Purpose of study. Internal rotation (IR) contracture of the shoulder is a frequent complication of obstetric brachial plexus injury, even in the face of full neurological recovery. Surgical procedures to treat this complication include tendon transfers, capsular release and osteotomies. We compared the outcomes in patients who had arthroscopic release only and those who also underwent a tendon transfer. Methods. We retrospectively reviewed the clinical records of all patients with OBPI presenting to our unit in the years 2002–2012 who underwent surgical procedures for the treatment of an IR contracture of the shoulder. Increase in range of external rotation (ER) in adduction and abduction intra-operatively was recorded. At follow-up, active ER, the Mallet score, presence of an ER contracture and the “drop-arm” sign was recorded. Results. 25 procedures were performed in 22 patients. Mean intra-operative gain in ER was greatest in those patients who had simultaneous arthroscopic release and a tendon transfer (83.3° and 60.5° in adduction and abduction respectively). This group had the greatest average range of active ER at follow up (47.5°), the lowest incidence of a “drop-arm” sign (14%), but also the highest incidence of ER contracture (75%). Patients who underwent arthroscopic anterior shoulder release only, had the highest average Mallet score at final follow up (17.1 compared to 16.3 in the scope and tendon transfer group), 45% incidence of a “drop-arm” sign and also the lowest incidence of ER contracture (32%). General satisfaction was greatest in the scope plus tendon transfer group. Conclusion. Patients who had arthroscopic release and tendon transfer had better ER range and power but more severe ER contractures than patients who underwent arthroscopic release only. Patient satisfaction and Mallet scores were comparable between the two groups and therefore bring into question the need for early tendon transfer in these patients. NO DISCLOSURES

Aims. Traditionally, total hip arthroplasty (THA) templating has been performed on anteroposterior (AP) pelvis radiographs. Recently, additional AP hip radiographs have been recommended for accurate measurement of the femoral offset (FO). To verify this claim, this study aimed to establish quantitative data of the measurement error of the FO in relation to leg position and X-ray source position using a newly developed geometric model and clinical data. Methods. We analyzed the FOs measured on AP hip and pelvis radiographs in a prospective consecutive series of 55 patients undergoing unilateral primary THA for hip osteoarthritis. To determine sample size, a power analysis was performed. Patients’ position and X-ray beam setting followed a standardized protocol to achieve reproducible projections. All images were calibrated with the KingMark calibration system. In addition, a geometric model was created to evaluate both the effects of leg position (rotation and abduction/adduction) and the effects of X-ray source position on FO measurement. Results. The mean FOs measured on AP hip and pelvis radiographs were 38.0 mm (SD 6.4) and 36.6 mm (SD 6.3) (p < 0.001), respectively. Radiological view had a smaller effect on FO measurement than inaccurate leg positioning. The model showed a non-linear relationship between projected FO and femoral neck orientation; at 30° external neck rotation (with reference to the detector plane), a true FO of 40 mm was underestimated by up to 20% (7.8 mm). With a neutral to mild external neck rotation (≤ 15°), the underestimation was less than 7% (2.7 mm). The effect of abduction and adduction was negligible. Conclusion. For routine THA templating, an AP pelvis radiograph remains the gold standard. Only patients with femoral neck malrotation > 15° on the AP pelvis view, e.g. due to external rotation contracture, should receive further imaging. Options include an additional AP hip view with elevation of the entire affected hip to align the femoral neck more parallel to the detector, or a CT scan in more severe cases. Cite this article: Bone Jt Open 2022;3(10):795–803

Neonatal brachial plexus palsy (NBPP) is frequently associated with internal rotation contractures of the shoulder as a result of muscle imbalance due to muscle fattening and/or fibrosis which favour the internal rotation of the shoulder. Botulinum toxin A (BTX-A) injection in the subscapularis (SC) muscle could weaken the SC and thereby restore muscle balance. The purpose of this study was to assess the effect of intra muscular injection of BTX-A in the SC on the passive external rotation and the need for external rotation surgery in NBPP patients after BTX-A injection. A prospective comparative study was performed with 93 patients with progressive internal rotation contractures. Al patients underwent an MRI to determine the percentage of the humeral head anterior to the glenoid (PHHA) and glenoid version. Patients younger than 48 months old and with a minimum deformity (PHHA> =35%) or moderate deformity (PHHA< 35%) were included. Patients with a severe deformity or complete posterior dislocation were excluded. Fifteen consecutive patients were injected with BTX-A (2 U/kg body weight, botox. ®. ) at two sites of the SC of the affected shoulder immediately after the MRI under general anesthesia. Seventy eight patients were included as a control group before the new BTX-A treatment was introduced. The passive external rotation was measured pre-MRI and at follow-up. The indication for external rotation surgery was determined after the MRI was performed. No adverse events were observed. Pre-MRI, the mean passive external rotation in adduction in the BTX-A group was −5° (SE 8°) and in the control group 3° (SE 3°). In the BTX-A group, the mean passive external rotation in adduction increased with 53° (95% CI 31°–74°, p< 0.001) compared to the control group. After stratification the beneficial effect of BTX-A was observed in patients with a minimum deformity (54°, 95% CI 37°–71°, p< 0.001), but this was not significant in patients with a moderate deformity (47°, 95% CI −20°−115°, p=0.13) compared to the control group. The patients in the BTX-A group were less frequently indicated for external rotation surgery compared the control group (27% vs. 89%, p< 0.001). The maximum effect of BTX-A injection was observed at a mean follow-up of 3 months (SE 1). The control group was followed for a mean of 7 months (SE 0.4) to observe the natural history of internal rotation contractures. The groups were comparable regarding type of lesion, primary treatment, age, PHHA, glenoid version and passive external rotation pre-MRI (p 0.09–0.74). BTX-A injections in the SC of NBPP patients reduce internal rotation contractures. This effect was mainly observed in patients with a minimum glenohumeral deformity. Restoration of muscle balance could prevent further glenohumeral deformation and could prevent external rotation surgery

Internal rotation contracture/tightness presents a functional problem for the patient and a technical challenge for the surgeon performing total shoulder arthroplasty most commonly occurring in cases of osteoarthritis. Internal rotation contractures result from a number of physiologic and biomechanical conditions. Osteophytes, which form around the head and neck of the humerus and glenoid provide a mechanical block to external rotation, which occurs over time. The inability to pass through a full excursion of external rotation tightens the anterior capsular structures over time and causes a contracture of the musculotendinous units (subscapularis and pectoralis major), responsible for internal rotation. The osteophytes themselves also change the vector of pull of the internal rotators and cause them to be “tented” anteriorly. Hence the issues causing an internal rotation contracture and inhibiting external rotation following total shoulder arthroplasty include a mechanical bone block, diminished tissue compliance and abnormal tendon excursion. Management of this problem has frequently been focused predominantly on fractional lengthening the subscapularis tendon, but all components must be addressed at the time of surgery to make sure that a functional range of motion in external rotation can be achieved following reconstruction. This video details the assessment of each of these components and their management. Surgical technique includes: resection of all obstructive osteophytes which block rotation and which cause abnormal tendon excursion; adequate head removal and shaping to provide restoration of an anatomical arc of curvature of the humeral head in continuity with the metaphyseal support base, adequate release of upper pectoralis major tendon tightness, release of capsular contractures and adhesions about the subscapularis muscle and tendon; and fractional lengthening of the subscapularis muscle-tendon itself to allow adequate healthy reattachment of the subscapularis tendon to the more superior aspects of the rotator cuff without allowing anterior instability to occur. Attention to the myotendinous junction rather than thinning the tendon itself has proven to be important in achieving a healthy tendon attachment without significant attenuation. Appropriate seating of the humeral head in anatomic version is also important to prevent unnatural distention of the anterior structures. These surgical techniques should help the surgeon provide an anatomic restoration of motion and function

Healing of the subscapularis, documented by ultrasound, following total shoulder arthroplasty was examined in thirty shoulders. All had marked improvement in pain, SST, and ASES scores. Four subscapularis tears were identified but only one patient had a positive abdominal compression test, 7/26 patients had a positive compression test despite an intact cuff, and 4/7 patients had a significant internal rotation contracture. The abdominal compression test was not accurate in detecting sub-scapularis tears. There was a significant false positive rate, which may be related to a lack of internal rotation. Overall, the outcome was excellent and not related to the status of the subscapularis. Very little information is available on healing of the subscapularis after shoulder arthroplasty. The purpose of this study was to document the subscapularis healing rate and relate it to post-operative function and the abdominal compression test. Thirty consecutive shoulders (twenty-three patients) s/p total shoulder replacement had standardized pre- and post-operative examinations including quantitative strength assessment and specific subscapularis testing. Ultrasound (validated for postop accuracy) was performed to document tendon healing. All thirty shoulders had marked improvements in pain, SST, and ASES scores. Four subscapularis tears were identified but only one patient had a positive abdominal compression test. Seven out of twenty-six patients had a positive compression test despite an intact cuff. Four of seven patients had a significant internal rotation contracture. Neither the status of the subscapularis nor a positive compression test appeared to affect outcome. Although specific subscapularis tests are often positive, only a small percentage of subscapularis tendons appear to retear after shoulder arthroplasty. The abdominal compression test is not accurate in detecting subscapularis tears post arthroplasty. There is a significant false positive rate, which may be related to a lack of internal rotation. However, overall outcome of shoulder arthroplasty was excellent and did not appear to be dependant on the status of the subscapularis

Introduction: Leg length and offset restoration are known to improve function after total hip arthroplasty, and to minimize the risk of dislocation and limp. Anatomic data of the hip are needed to determine specifications for prosthesis design that restore patient hip anatomy more closely. Furthermore, femoral off-set values calculated on X-Rays may be inaccurate in case of external rotational contracture or high femoral ante-version. The goal of this study was to determine three-dimensional morphological data of the hip in case of primary osteoarthritis, especially for femoral off-set. Material and Method: 223 hips with primary osteoarthritis have been analysed using a CT-scan and a specific software (HIP-PLAN. ®. ) that allows image post-processing for re-orienting the pelvis or the femur to a standardized orientation. Femoral and acetabular anteversions were measured. The planar (2D) and three-dimensional (3D) values of femoral offset were determined. 3D values were measured as the distance between the femoral head centre and the diaphyseal femur axis; 2D values were calculated as the projection of this distance on the frontal plan. Results: Measurements precision was good with correlation scores ranging between 0.91 and 0.99. Mean acetabular anteversion angle was 26° +/−6.6° when measured in the Anterior Pelvic Plane and 21.9° +/−6.6° in the frontal plane according to the method of Murray. Mean femoral anteversion was 21.9° +/−9.4 according to the method of Murphy. The Sum of acetabular and femoral anteversion was found to be out of the safe zone regarding dislocation risk in 47% of patients. Mean 3D femoral off-set was found to be 42.2 mm+/− 5, significantly increased by 3.5 mm +/− 2.5 when compared to the 2D femoral off-set values. Femoral off-set was above 45mm in 31% of cases and higher than 50 mm in 12% of cases. The tip of the great trochanter was located higher than the femoral head centre, at a mean distance of about 9 mm. Discussion: When measured on X-rays, femoral off-set may be significantly under-estimated. This error is probably due to the external rotational contracture of the hip induced by osteoarthritis. If the implants are positioned using the anatomical preoperative anteversion angles, 47% of patients would not be in the safe zone regarding posterior dislocation risk. Conclusions: Planar measurement using X-Rays underestimates significantly the femoral off-set. Neck and head modularity may be useful to achieve simultaneous restoration of femoral off-set and leg length in 12 to 31% of cases

Anterior surgical approaches for total hip arthroplasty (THA) have increased popularity due to expected faster recovery and less pain. However, the direct anterior approach (Heuter approach which has been popularised by Matta) has been associated with a higher rate of early revisions than other approaches due to femoral component loosening and fractures. It is also noted to have a long learning curve and other unique complications like anterior femoral cutaneous and femoral nerve injuries. Most surgeons performing this approach will require the use of an expensive special operating table. An alternative to the direct anterior approach is the anterior-based muscle-sparing approach. It is also known as the modified Watson-Jones approach, anterolateral muscle-sparing approach, minimally invasive anterolateral approach and the Röttinger approach. With this technique, the hip joint is approached through the muscle interval between the tensor fascia lata and the gluteal muscles, as opposed to the direct anterior approach which is between the sartorius and rectus femoris and the tensor fascia lata. This approach places the femoral nerve at less risk for injury. I perform this technique in the lateral decubitus position, but it can also be performed in the supine position. An inexpensive home-made laminated L-shaped board is clamped on end of table allowing the ipsilateral leg to extend, adduct, and externally rotate during the femoral preparation. This approach for THA has been reported to produce excellent results. One study reports a complication rate of 0.6% femoral fracture rate and 0.4% revision rate for femoral stem loosening. In a prospective randomised trial looking at the learning curve with new approach, the anterior-based muscle-sparing anterior approach had lower complications than a direct anterior approach. The complications and mean operative time with this approach are reported to be no different than a direct lateral approach. Since this surgical approach is not through an internervous interval, a concern is that this may result in a permanent functional defect as result of injury to the superior gluteal nerve. At a median follow-up of 9.3 months, a MRI study showed 42% of patients with this approach had fat replacement of the tensor fascia lata, which is thought to be irreversible. The clinical significance remains unclear, and inconsequential in my experience. A comparison MRI study showed that there was more damage and atrophy to the gluteus medius muscle with a direct lateral approach at 3 and 12 months. My anecdotal experience is that there is faster recovery and less early pain with this approach. A study of the first 57 patients I performed showed significantly less pain and faster recovery in the first six weeks in patients performed with the anterior-based muscle-sparing approach when compared to a matched cohort of THA patients performed with a direct lateral approach. From 2004 to 2017, I have performed 1308 total hip replacements with the anterior-based muscle sparing approach. Alternatively, I will use the direct lateral approach for patients with stiff hips with significant flexion and/or external rotation contractures where I anticipate difficulty with femoral exposure, osteoporotic femurs due to increased risk of intraoperative trochanteric fractures, previously operated hips with scarring or retained hardware, and Crowe III-IV dysplastic hips when there may be a need for a femoral shortening or derotational osteotomy. Complications have been very infrequent. This approach is a viable alternative to the direct anterior approach for patients desiring a fast recovery. The anterior-based muscle-sparing approach is the approach that I currently use for all outpatient total hip surgeries

Alignment of total joint replacement in the valgus knee can be done readily with intramedullary alignment and hand-held instruments. Intramedullary alignment instruments usually are used for the femoral resection. The distal femoral surfaces are resected at a valgus angle of 5 degrees. A medialised entry point is advised because the distal femur curves toward valgus in the valgus knee, and the distal surface of the medial femoral condyle is used as reference for distal femoral resection. In the valgus knee, the anteroposterior axis is especially important as a reliable landmark for rotational alignment of the femoral surface cuts because the posterior femoral condyles are in valgus malalignment, and are unreliable for alignment. Rotational alignment of the distal femoral cutting guide is adjusted to resect the anterior and posterior surfaces perpendicular to the anteroposterior axis of the femur. In the valgus knee this almost always results in much greater resection from the medial than from the lateral condyle. Intramedullary alignment instruments are used to resect the proximal tibial surface perpendicular to its long axis. Like the femoral resection, resection of the proximal tibial surface is based on the height of the intact medial bone surface. After correction of the deformity, ligament adjustment is almost always necessary in the valgus knee. Stability is assessed first in flexion by holding the knee at 90 degrees and maximally internally rotating the extremity to stress the medial side of the knee, then maximally externally rotating the extremity to evaluate the lateral side of the knee. Medial opening greater than 4mm, and lateral opening greater than 5mm, is considered abnormally lax, and a very tight lateral side that does not open at all with varus stress is considered to be abnormally tight. Stability is assessed in full extension by applying varus and valgus stress to the knees. Medial opening greater than 2mm is considered to be abnormally lax, and a very tight lateral side that does not open at all with varus stress is considered to be too tight. Release of tight structures should be done in a conservative manner. In some cases, direct release from bone attachment is best (popliteus tendon); in others, release with pie-crusting technique is safe and effective. In knees that are too tight laterally in flexion, but not in extension, the LCL is released in continuity with the periosteum and synovial attachments to the bone. When this lateral tightness is associated with internal rotational contracture, the popliteus tendon attachment to the femur is also released. The iliotibial band and lateral posterior capsule should not be released in this situation because they provide lateral stability only in extension. The only structures that provide passive stability in flexion are the LCL and the popliteus tendon complex, so knees that are tight laterally in flexion and extension have popliteus tendon or LCL release (or both). Stability is tested after adjusting tibial thickness to restore ligament tightness on the lateral side of the knee. Additional releases are done only as necessary to achieve ligament balance. Any remaining lateral ligament tightness usually occurs in the extended position only, and is addressed by releasing the iliotibial band first, then the lateral posterior capsule, if needed. The iliotibial band is approached subcutaneously and released extrasynovially, leaving its proximal and distal ends attached to the synovial membrane. In knees initially too tight laterally in extension, but not in flexion, the LCL and popliteus tendon are left intact, and the iliotibial band is released. If this does not loosen the knee enough laterally, the lateral posterior capsule is released. The LCL and popliteus tendon rarely, if ever, are released in this type of knee. Finally, the tibial component thickness is adjusted to achieve proper balance between the medial and lateral sides of the knee. Anteroposterior stability and femoral rollback are assessed, and posterior cruciate substitution is done, if necessary, to achieve acceptable posterior stability

Introduction: The success of cemenntless THA (total hip arthroplasty) mainly depends on the choices of stem, its size and accuracy of stem orientation. Selection of the optimal stem judging only by plain X-ray is not so easy. Because deformity varies in each case and it is impossible to obtain profile view of the hip. As osteoarthritic patients tend to develop external rotation contractures, radiographic position of the patients with correct rotation is very difficult. To override these problems, we have been using 3-D preoperative planning system. As for the stem selection, we have been mainly using Revelation stem, because it has a structure called lateral flare that provide proximal physiological load transfer. In the present study, the usefulness of our preoperative planning system especially for the determination of the size and stem orientation with Revelation stem. Materials and Method: Pre-operative planning was performed in 55 osteoarthritic hips in 50 patients (10 male and 40 females), and the mean age at the operation was 64.05 years old. The 3-dimensinal geometries of the femora femora were reconstructed from the CAT scan DICOM data. The geometry of femur and components were placed on the same coordinate. Cross-sectional images from many directions were observed, and the optimal location and the size of the stem were selected. According to the result, actual operations were done. Planed sizes and selected sizes at the surgeries were compared. For several patients, post-operative CAT scans were performed, then planed stem position and actual stem position were compared. Result: Stems preoperatively defined were used in 50hips (90.9%),1 size large ones were used in 2 hips (3.6%) and 1 size large ones were used in 3 hips (5.5%). Discussion: As Revelation stems have very high proximal fit-and-fill, the end point of the stem insertion is very definite. The characteristics made the accuracy of the preoperative planning. So it was not so difficult to perform THA according to the preoperative planning as it had been imagined

The use of two-dimensional plain X-rays for preoperative planning in total hip arthroplasty is unreliable. For example, in the presence of rotational hip contracture the lateral femoral off set can be significantly under-estimated. Pre-operative planning is of particular importance when using uncemented prostheses. The aim of this study was to determine the precision of a novel 3D CT-based preoperative planning methodology with the use of a cementless modular-neck femoral stem. Pre-operative computerised 3D planning was performed using HIP-PLAN® software for 223 patients undergoing THA with a cement-less cup and cement-less modular-neck stem. Components were chosen that best restored leg length and lateral off set. Postoperative anatomy was assessed by CT-scan and compared to the pre-operative plan. The implanted component was the same as the planned one in 86% of cases for the cup and 94% for the stem. There was no significant difference between the mean planned femoral anteversion (26.1° +/− 11.8) and the mean postoperative anteversion (26.9° +/− 14.1) (p=0.18), with good correlation between the two (coefficient 0.8). There was poor correlation, however, between the planned values and the actual post-operative values of acetabular cup anteversion (coefficient 0.17). The rotational centre of the hip was restored with a precision of 0.73mm +/3.5 horizontally and 1.2mm +/− 2 laterally. Limb length was restored with a precision of 0.3mm +/− 3.3 and femoral off set with a precision of 0.8mm +/− 3.1. There was no significant alteration in femoral off set (0.07mm, p=0.4) which was restored in 98% of cases. Almost all of the operative difficulties encountered were predicted pre-operatively. The precision of the three-dimensional pre-operative planning methodology investigated in this study is higher than that reported in the literature using two-dimensional X-ray templating. Cup navigation may be a useful adjunct to increase the accuracy of cup positioning