Aim:. Right-Handed Girls With Rt-Ais Measured Using Holtain Equipment Have Upper Arm Length Asymmetry (Right-Minus-Left) Which Is: 1) Relatively Longer On Scoliosis Curve Convexity; 2) Significantly Associated With Scoliosis Curve Severity (Cobb Angle And Apical Vertebral Rotation); And 3) Transient, Decreasing With Age And Years After Menarche [1,2]. The Aim Is To Test Whether The Right Upper Arm Length Relative Overgrowth And Spinal Deformity Severity Were Associated With Right Or Left Upper Arm Length Size-For-Age. Method:. 94 Right-Handed Girls With Rt-Ais, Age 11–18 Years, (Mean Cobb Angle 46 Degrees, Range 10–102 Degrees), Were Evaluated Using A Harpenden Anthropometer For Upper Arm Length Asymmetry, Plotted Against Right And Left Upper Arm Length Standard Deviation Scores (Sds), Calculated From 378 Normal Girls, Age 11–18 Years. Results:. The Findings Show That Upper Arm Length Asymmetry Correlates Significantly With Right, But Not Left, Upper Arm Length Sds (Right Arm Spearman's Rho=0.330 P=0.001; Left Arm Rho=−0.013 P=0.902), And With No Other Limb Or Trunk Skeletal Region Sds. Cobb Angle And Avr Also Correlate Significantly With Right, But Not Left, Upper Arm Length Sds. Discussion:. The Abnormal Asymmetry Of Upper Arm Lengths Results From Relative Overgrowth Of Right Upper Arm. We Suggest This Asymmetry Results From An Abnormal Asymmetry Process (Eg Neurogenic) With Growth Velocity That Together Also Initiate The Trunk Deformity, Wherein Additional Factors Contribute To Scoliosis Progression Such As Upright Posture, Melatonin-Signalling Dysfunction And Osteopenia. The Right Upper Arm Length Overgrowth May Provide A Sentinel Of The Relative Anterior Spinal Overgrowth. Conflict Of Interest Statement: No conflict of interest

Aims. Slipped upper femoral epiphysis (SUFE) has well documented biochemical and mechanical risk factors. Femoral and acetabular morphologies seem to be equally important. Acetabular retroversion has a low prevalence in asymptomatic adults. Hips with dysplasia, osteoarthritis, and Perthes’ disease, however, have higher rates, ranging from 18% to 48%. The aim of our study was to assess the prevalence of acetabular retroversion in patients presenting with SUFE using both validated radiological signs and tomographical measurements. Methods. A retrospective review of all SUFE surgical cases presenting to the Royal Children’s Hospital, Melbourne, Australia, from 2012 to 2019 were evaluated. Preoperative plain radiographs were assessed for slip angle, validated radiological signs of retroversion, and standardized postoperative CT scans were used to assess cranial and mid-acetabular version. Results. In all, 116 SUFEs presented in 107 patients who underwent surgical intervention; 47 (52%) were male, with a mean age of 12.7 years (7.5 to 16.6). Complete radiological data was available for 91 patients (99 hips) with adequate axial CT imaging of both hips. Overall, 82 patients (82%) underwent pinning in situ (PIS), with subcapital realignment surgery (SRS) performed in 17 patients (18%) (slip angles > 75°). Contralateral prophylactic PIS was performed in 72 patients (87%). On the slip side, 62 patients (68%) had one or more radiological sign of retroversion. Tomographical acetabular retroversion was more pronounced cranially than caudally of the acetabulum on both the affected side and the contralateral side (p < 0.001) as expected in the normal population. Increasing severity of the slip was found to be directly proportional to the degree of reduction in cranial and central acetabular version (p < 0.05) in the SUFE hips. Conclusion. Acetabular retroversion is more prevalent in patients with SUFE than previously reported, and have been shown be correlated to the severity of the slip presentation. The presence of radiological signs of acetabular retroversion could be used to justify prophylactic contralateral pinning. Cite this article: Bone Jt Open 2022;3(2):158–164

The best algorithm, measurements, and criteria for screening children with Down syndrome for upper cervical instability are controversial. Many authors have recommended obtaining flexion and extension views. We noted that patients who require surgical stabilization due to myelopathy or cord compression typically have grossly abnormal radiographic measurements on the neutral upright lateral cervical spine radiograph (NUL). This study was designed to determine whether a full series of cervical spine images including flexion/extension lateral radiographs (FEL) was important to avoid missing upper cervical instability. This is a retrospective evaluation of cervical spine images obtained between 2006 and 2012 for the purposes of “screening” children with Down syndrome for evidence of instability. The atlanto-dental interval, space available for cord, and basion axial interval were measured on all films. The Weisel-Rothman measurement was made in the FEL series. Clinical outcome of those with abnormal measurements were reviewed. Sensitivity, specificity, positive and negative predictive values of NUL and FEL x-rays for identifying clinically significant cervical spine instability were calculated. Two-hundred and forty cervical spine series in 213 patients with Down syndrome between the ages of four months and 25 years were reviewed. One hundred and seventy-two children had a NUL view, and 88 of these patients also had FEL views. Only one of 88 patients was found to have an abnormal ADI (≥6mm), SAC (≤14mm), or BAI (>12mm) on an FEL series that did not have an abnormal measurement on the NUL. This patient had no evidence of cord compression or myelopathy. Obtaining a single NUL x-ray is an efficient method for radiographic screening of cervical spine instability. Further evaluation may be required if abnormal measurements are identified on the NUL x-ray. We also propose new “normal” values for the common radiographic measurements used in assessing risk of cervical spine instability in patients with Down syndrome

In multilevel posterior cervical instrumented fusions, extending the fusion across the cervico-thoracic junction at T1 or T2 (CTJ) has been associated with decreased rate of re-operation and pseudarthrosis but with longer surgical time and increased blood loss. The impact on patient reported outcomes (PROs) remains unclear. The primary objective was to determine whether extending the fusion through the CTJ influenced PROs at 3 and 12 months after surgery. Secondary objectives were to compare the number of patients reaching the minimally clinically important difference (MCID) for the PROs and mJOA, operative time duration, intra-operative blood loss (IOBL), length of stay (LOS), discharge disposition, adverse events (AEs), re-operation within 12 months of the surgery, and patient satisfaction. This is a retrospective analysis of prospectively collected data from a multicenter observational cohort study of patients with degenerative cervical myelopathy. Patients who underwent a posterior instrumented fusion of 4 levels of greater (between C2-T2) between January 2015 and October 2020 with 12 months follow-up were included. PROS (NDI, EQ5D, SF-12 PCS and MCS, NRS arm and neck pain) and mJOA were compared using ANCOVA, adjusted for baseline differences. Patient demographics, comorbidities and surgical details were abstracted. Percentafe of patient reaching MCID for these outcomes was compared using chi-square test. Operative duration, IOBL, AEs, re-operation, discharge disposittion, LOS and satisfaction were compared using chi-square test for categorical variables and independent samples t-tests for continuous variables. A total of 206 patients were included in this study (105 patients not crossing the CTJ and 101 crossing the CTJ). Patients who underwent a construct extending through the CTJ were more likely to be female and had worse baseline EQ5D and NDI scores (p> 0.05). When adjusted for baseline difference, there was no statistically significant difference between the two groups for the PROs and mJOA at 3 and 12 months. Surgical duration was longer (p 0.05). Satisfaction with the surgery was high in both groups but significantly different at 12 months (80% versus 72%, p= 0.042 for the group not crossing the CTJ and the group crossing the CTJ, respectively). The percentage of patients reaching MCID for the NDI score was 55% in the non-crossing group versus 69% in the group extending through the CTJ (p= 0.06). Up to 12 months after the surgery, there was no statistically significant differences in PROs between posterior construct extended to or not extended to the upper thoracic spine. The adverse event profile did not differ significantly, but longer surgical time and blood loss were associated with construct extending across the CTJ

Prophylactic pinning of the contralateral hip in unilateral Slipped Upper Femoral Epiphysis (SUFE) persists as a source of debate with the majority of surgeons selecting this option in a proportion of patients whom they regard as at increased risk of a subsequent slip. Universal prophylactic pinning was introduced in our region in 2005 after an audit of ten years local practice identified 25% of unilateral cases presented with a subsequent slip. This study reports our experience between 2005 and 2020. In this prospective study, 44 patients presented with 55 affected hips compared with 60 patients with 67 affected hips in the original study. Two patients were excluded as their initial slip had not been treated in our unit. Of the 42 hips seven were bilateral, 34 of the 35 unilateral hips underwent prophylactic pinning. The one exception subsequently underwent prophylactic pinning due to developing pain. Consistent with our original series, at a minimum follow up of 13 months there have been no complications of infection, fracture, chondrolysis or avascular necrosis subsequent to prophylactic pinning. Over 25 years 70 patients have undergone prophylactic pinning without complication. On the premise that 25% of our unpinned hips presented with subsequent slips before instituting our policy we estimate that we have prevented 17 subsequent slips over 25 years including the consequences which can be significant. We continue to advocate universal prophylactic pinning as an effective and safe practice in the management of SUFE

INTRODUCTION. Metal-on-metal hip resurfacing arthroplasty (MoMHRA) is a surgical option in the treatment of end-stage hip disease. The measurement of systemic levels of metal ions gives an insight into the wear occurring and is advocated by regulatory bodies as routine practice in the assessment of resurfaced hips. However, the acceptable upper levels of Chromium (Cr) and Cobalt (Co) ions concentration with clinical significance still have to be established. The aim of this study is to address this issue in unilateral and bilateral resurfaced hips. METHODS. 453 patients with unilateral MoMHRA and 139 patients with bilateral MoMHRA at >12 months postoperative were retrospectively identified from an independent hip specialist's database. Routine metal ion levels were measured at last follow-up (ICPMS protocol). Radiological assessment included measurement of acetabular component orientation using EBRA, calculation of contact patch to rim (CPR) distance, and evaluation for any adverse X-ray findings. The cohort was divided into the well functioning group (Group A) and the non-well functioning group (Group B). A well functioning resurfacing gad to fulfil all of the following criteria (bilateral patients had to fulfil criteria for both hips): no patient reported hip complaints, no surgeon detected clinical findings, HHS> 95, CPR distance> 10mm, no abnormal radiological findings and no further operation scheduled. Upper levels (acceptable limits) of Cr/Co were considered to be represented by the top margin of the box-whisker plot [upper limit = 75. th. quartile value + (1.5 x interquartile range)] in Group A. RESULTS. 251 unilateral MoMHRAs patients (55%) and 58 patients with bilateral MoMHRAs (42%) comprised Group A. The majority of males were in Group A compared to the majority of females who belonged in Group B (p<0.001); subsequently Group A patients had bigger size components (p<0.001). Unilateral Group A [Cr: 2.0 µg/l (SD: 1.5)/ Co: 1.8µg/l (SD: 1.2)] patients had significantly lower ions than Group B [Cr: 7.3µg/l (SD: 17.3)/ Co: 6.6µg/l (SD: 18.1)] patients (p <0.001). Similarly, Group A bilateral patients [Cr: 3.8µg/l (SD: 2.7)/ Co: 2.8µg/l (SD: 1.9)] had significantly lower ions that Group B [Cr: 10.7µg/l (SD: 16)/ Co: 8.5µg/l (SD: 15.8)]. The upper levels (safe were: Cr: 4.6µg/l / Co: 4.0µg/l for unilateral MoMHRAs and Cr: 7.4µg/l / Co: 5.0µg/l for bilateral MoMHRAs. Unilateral MoMHRAs had significantly higher ion levels compared to bilateral patients (p <0.001). Sensitivity and specificity of these upper levels in predicting poor function were respectively 25% and 95% for Cr and 22% and 96% for Co. DISCUSSION. The findings of this study suggest that both unilaterally and bilaterally resurfaced patients with well functioning implants have low metal ion levels with upper levels of Cr: 4.6µg/l / Co: 4.0µg/l for unilateral MoMHRAs and Cr: 7.4µg/l / Co: 5.0µg/l for bilateral MoMHRAs These results indicate that the upper acceptable limit of metal ion levels in resurfaced hips is lower than the previously MHRA recommended threshold, however the study was conducted with very low tolerance for what was considered a clinically problematic hip. Well-functioning bilateral resurfacing have higher ion levels compared to well-functioning unilateral resurfacing

Introduction and Aims: Odontoid fractures are quite common in the elderly following minor falls. As there are a few articulations in the upper cervical spine, degeneration in any one particular joint may affect the biomechanics of loading of the upper cervical spine. We aimed to analyse the pattern and relationship of odontoid fractures to the upper cervical spine osteoarthritis in the elderly. Method: Between July 1999 and March 2003, 185 patients had CT scan of the cervical spine for cervical spine injuries. Twenty-three out of 47 patients over the age of 70 years had odontoid fractures. The CT scan pictures of these patients were studied to analyse the type of fracture and its displacement, the severity of osteoarthritis in each articulation in the upper cervical spine, namely lateral atlantoaxial, atlantooccipital, atlantoodontoid and subaxial facetal joints, evaluation of osteopenia in the dens-body junction and in the body and odontoid process of the axis, and calcification of the ligaments. Results: Twenty-one of the 23 patients had Type II odontoid fracture with posterior displacement in seven (33.3%) and posterior angulation in nine (42.8%) patients. In these patients with Type II dens fracture, the atlantodens interval was obliterated in 19 (90.48%) patients, with only two of them (9.52%) having lateral atlantoaxial osteoarthritis. Conclusion: Type II fracture is the commonest odontoid fracture in the elderly. Posterior displacement of the fracture is common in elderly, unlike the younger population. There is a significant relationship between the upper cervical spine osteoarthritis, apart from osteopenia, to the incidence of Type II odontoid fractures. Significant atlantoodontoid osteoarthritis in the presence of normal lateral atlantoaxial joints increases the risk of sustaining Type II odontoid fracture

Abstract. Objective. To assess the prevalence of acetabular retroversion in patients presenting with Slipped Upper Femoral Epiphysis using both validated radiological signs and CT-angle measurements. Methods. A retrospective review of all cases involving surgical management for acute SUFE presenting to the Royal Children's Hospital, Melbourne were assessed from 2012–2018. Pre-operative plain radiographs were assessed for slip angle, validated radiological signs of retroversion (post wall/crossover/ischial spine sign) and standardised post-operative CT Scans were used to assess cranial and mid-acetabular version. Results. 116 SUFEs presented in 107 patients who underwent surgical intervention; 47 females and 60 boys, with an average age of 12.7 years (range 7.5–16.6 years). Complete radiological data was available for 91 patients (99 hips) with adequate axial CT imaging of both hips. 82% patients underwent pinning in situ (PIS) with subcapital realignment surgery (SRS) performed in 18% (slip angles >75°). Contralateral prophylactic hip PIS was performed in 72 patients (87%). On the slip side, 68% of patients had 1 or more radiological signs of retroversion in the slipped hip, with 60% on the contralateral side. The mean cranial and mid-acetabular version measurements were −8°(range −30 – 8°) and 10.5°(range −10 – 25°), respectively. Conclusions. Acetabular retroversion is rare in the normal population with studies reports ranging from 0–7%. This study showed an increased prevalence of 68% in SUFE patients, which is likely to be a primary anatomical abnormality, subsequently increasing the shear forces across the proximal femoral growth plate due to superior over-coverage. The resulting CAM lesion from SUFE in combination with the pincer lesion due to retroversion can lead to premature hip impingement and degeneration. Further larger studies are required to assess if acetabular retroversion is a true risk factor, and its role in helping guide management including prophylactic pinning. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Purpose: We present the midterm results of conservative treatment of upper (atlas and axis) cervical spine injuries and we propose a CT-based radiological follow-up study. Material and Methods: In a 12 year period (1990–2001), 45 patients (33 male and 12 female) with a mean age 37.2 years (range 15–75) were presented with an acute injury of the upper cervical spine. There were 19 fractures of the atlas (8 Jefferson’s fractures, 6 isolated lateral mass fractures and 5 posterior arch fractures) and 26 axial fractures (12 odontoid fractures, types I–III according to Anderson’s classification and 14 traumatic spondylolisthesis, types I–II according to Effendi classification). Twenty (20) patients were immobilized using halo-vest and 25 Minerva orthosis. Two (2) patients presented with Brown-Sequard syndrome. All patients were retrospectively reviewed and had clinical and radiological follow-up study (plain films and CT spiral reconstruction films). Mean follow-up was 6.2 years. Mean immobilization time was 3.8 months range. Results: Patients with incomplete neurological lesion did not recover. One patient with an isolated atlas lateral mass fracture, developed a hemiparesis during his hospitalization, which was partially resolved. In the final follow-up study, all patients presented a stable upper cervical spine, on the dynamic flexion/extension plain films. In the final CT spiral reconstruction films, fracture line was evident in 12 patients (27%), while atlantoaxial joint incongruity was obvious in 5 patients. Seven (7) patients (16%) complained for residual neck pain and stiffness and presented reduced range of motion. Conclusion: Conservative treatment of atlantoaxial injuries is effective and offers a stable upper cervical spine. Solid fracture union is not always present. CT spiral reconstruction is very helpful in detecting transverse ligament efficacy and atlantoaxial joint incongruity

Purpose and Background:. To compare static and dynamic lumbar intervertebral ranges of motion (IV-RoM) in patients with chronic, nonspecific low back pain with upper and lower cut off values derived from healthy controls when variability and measurement errors were reduced. Measurements from functional radiographs suffer from high variability and measurement errors, making cut off values for excessive or insufficient motion problematical. This study compared maximum lumbar IV-RoM and maximum IV-RoM at any point in continuous motion sequences in patients with chronic, non-specific back pain with upper and lower cut off values for L2 to L5 from matched controls using quantitative fluoroscopy, where variation and measurement errors were reduced. Methods and Results:. Participants underwent passive recumbent examinations in the sagittal and coronal planes. Values based on were developed for both maximum and continuous motion in controls (n=40). Fishers exact test was used to analyse proportions of patients whose IV-RoMs exceeded reference values. For maximum IV-RoM in patients, there were no statistically significant differences between groups for the lower value. Only flexion at L4/5 significantly exceeded the upper value (p=0.03). For continuous IV-RoM, left L3/4 (p=0.01) and right L4/5 (p=0.01) were significantly below the lower cut off values. Both flexion L4/5 (p=0.05) and left L3/4 (p=0.01) were significantly above the upper cut off values. Conclusions:. Controlling variability and reducing errors allowed meaningful upper and lower cut off values to be produced for both static and dynamic IV-RoM and may lead to better treatment decisions for those with suspected inter-vertebral stiffness or hypermobility

Historically avoidance of avascular necrosis (AVN) has been the primary objective in the management of an acute unstable slipped upper femoral epiphysis (SUFE). When achieved through pinning in situ it was invariably associated with significant malunion. With increasing appreciation of the consequences of femoroacetabular impingement, modern techniques aim to correct deformity and avoid AVN. Exactly what constitutes an acute unstable SUFE is a source of debate but should represent 5–10% of all cases. This audit reviewed cases over the past 25 years treated in one region. Of 89 patients with 113 slips, 21 hips were recorded as unstable. During this period the management has evolved from closed reduction and stabilization through pinning in situ, to open reduction. Radiographic outcomes following these three treatment methods were compared with record of any subsequent surgery in the form of osteotomy or total hip arthroplasty. Currently the lowest reported incidence of AVN in patients with an acute unstable slip is associated with the Parsch technique which combines open arthrotomy, digital reduction and screw fixation. Early outcomes with this technique are in accordance with those reported in the literature and represents a significant improvement in outcome when compared to earlier techniques used in the management of the severe unstable SUFE

Anterior spinal pathology of the upper thoracic (T2–T4) segment is rare. The surgical approach is still controversial. Anterior week approach with partial osteotomy of the sternum or high latero-posterior thoracotomy are insufficient to approach this segment. The purpose of this study is to present our experience with sternotomy as a approach in the surgical treatment of anterior spinal pathology to the upper thoracic (T2–T4) segment. Material and methods: Between 2000–2004 nine patients with anterior spinal pathology in the upper thoracic segment were surgically treated. From all patients 5 were male and 4 female. The age ranged from 52 to 62 years. The anterior spinal pathology localisation was in 5 patients in T2; in 2 pt. in T2 and 2 pt. in both T2 and T3. The diagnosis in all patients was done by protocol wich included: careful neurological examination; standard radiographic films (AP and lateral view); CT; MRI; bone scan and other routine investigations. Neurologic status (deficit) was evaluated by modified Frankel Scale (M.F.S.). There were one patient grade A2; 4 patients with grade B; 3 pt. as a grade 3 and one grade D1. Sternotomy as a approach was used in all patients to expose the upper thoracic (T2–T4) segment. Corpectomy, extirpation of the local tumors mass; decompression of the spinal canal and neural elements was done. The defect between T1-T3-4 was bridged with three-cortical iliac crest bone graft. In 7 cases fixation with anterior plate was done. Histologically in 2 pt. was found metastasis of carcinoma of thyroid grand foliculocellulare type; in 4 pt. solitary plasmocytoma; in two pt. giant cell tumor and in one patient invasive chondroma. All patients after surgery were transferred to the Oncology Center for other aditional treatment. Neurological recovery was registered in all patients expect one who died 2 months after surgery. The patient with grade A2 and one of grade B recovered to grade D1; one patient of grade B recovered to grade C and two of grade B and patients of grade C and D recovered to grade E. The solid fusion happened in all patient expect one who died. Conclusion:. Sternotomy is a safe approach to the upper thoracic T2–T4 segment with possibility of direct visualisation of pathologic process and radical extirpation of the tumorous mass. Early decompression of the spinal canal and neural elements by corpectomy and manolatory for neurologic recovery

Introduction: Several studies have looked at accuracy of thoracic pedicle screw placement, both in vivo and on cadavers, using fluoroscopy, image guidance, and anatomical landmarks. To our knowledge the upper thoracic spine (T1-T6) has not been specifically studied in the context of screw insertion and placement accuracy without the use of either image guidance or fluoroscopy. Our objective was to study the accuracy of placement of upper thoracic screws without the use of fluoroscopy, and report on implant related complications. Methods: A single surgeon inserted a total of 60 screws in 13 consecutive non-scoliotic spine patients. These 60 screws were the first to be placed in the high thoracic spine in our institution. All previous surgeries used only a hook or wire technique for the upper thoracic spine. The most common diagnosis in our patient population was trauma. All screws were inserted using a modified Roy-Camille technique. Post operative axial computed tomography (CT) images were obtained for each patient and analyzed by an independent senior radiologist for placement accuracy. Furthermore we reviewed the operative records of each patient to record any implant related complications. Results: No pedicle screw misplacements were found in 61.5% of the patients. Fifty three out of the 60 screws were placed correctly within all the pedicle margins. The overall pedicle screw placement accuracy was 88.3% using our modified Roy-Camille technique. Five medial and 2 lateral violations were noted in the 7 misplaced screws. One of the 7 misplaced screws was considered to be a marginal violation. No implant related complications were noted. Furthermore, no learning curve effect was noted as far as misplacement pattern was concerned. Conclusion: We found that inserting pedicle screws in the upper thoracic spine based solely on anatomical landmarks was safe with an accuracy comparable to that of published studies on image guided surgery at the thoracic level

Preoperative talar valgus deformity increases the technical difficulty of total ankle replacement (TAR) and is associated with an increased failure rate. Deformity of ≥15° has been reported to be a contraindication to arthroplasty. The goal of the present study was to determine whether the operative procedures and clinical outcomes of TAR for treatment of end-stage ankle arthritis were comparable for patients with preoperative talar valgus deformity of ≥15° as compared to those with <15°. We will describe the evolving surgical technique being utilized to tackle these challenging cases.

Fifty ankles with preoperative coronal-plane tibiotalar valgus deformity of ≥15° “valgus” group) and 50 ankles with valgus deformity of <15° (“control” group) underwent TAR. The cohorts were similar with respect to demographics and components used. All TARs were performed by a single surgeon. The mean duration of clinical follow-up was 5.5 years (minimum two years). Preoperative and postoperative radiographic measurements of coronal-plane deformity, Ankle Osteoarthritis Scale (AOS) scores and Short Form (SF)-36 scores were prospectively recorded. All ancillary (intraoperative) and secondary procedures, complications and measurements were collected.

The AOS pain and disability subscale scores decreased significantly in both groups. The improvement in AOS and SF-36 scores did not differ significantly between the groups at the time of the final follow-up. The valgus group underwent more ancillary procedures during the index surgery (80% vs 26%). Tibio-talar deformity improved significantly toward a normal weight-bearing axis in the valgus group. Secondary postoperative procedures were more common in the valgus group (36%) than the controls (20%). Overall, re-operation was not associated with poorer patient outcome scores. Metal component revision surgery occurred in seven patients (three valgus and four controls). These revisions included two deep infections (2%), one in each group, which were converted to hindfoot fusions. Therefore, 94% of the valgus group retained their original components at final follow-up

Thus far, this is the largest reported study that specifically evaluates TAR with significant preoperative valgus alignment, in addition to having the longest follow-up. Satisfactory midterm results were achieved in patients with valgus mal-alignment of ≥15°. The valgus cohort required more procedures during and after their TAR, as well as receiving more novel techniques to balance their TAR. Whilst longer term studies are needed, valgus coronal-plane alignment of ≥15° should not be considered an absolute contraindication to TAR if the associated deformities are addressed.

Introduction. Upper femoral fractures include intra and extra-capsular fracture (ECF). For intra-capsular fracture (ICF), hemi-arthroplasty (HA) is the most commonly used treatment. Interest in total hip arthroplasty (THA) is growing because THA yields less revision (4% versus 7%) associated to better functional results despite higher dislocation rate (9% versus 3%). Regarding ECF, internal fixation is the reference treatment. THA could represent a relevant alternative. This study evaluates the efficiency of THA using dual mobility cup (THA-DMC) as treatment of these fractures specially in elderly patients. Material and method. 70 patients were operated on for upper femoral fractures with Quattro THA-DMC between May 2012 and October 2013. Minimum follow-up is one year. Seven surgeons in 4 institutions were involved. Data collected were: age, gender, type of fracture, surgical approach, mortality, revision rate and dislocation rate. Results. Seventy patients were included. 83.3 % were women. Mean age was 82.8 (51–99). 43% were ECF and 57% ICF. Postero-lateral approach represented 51% of cases, trans-trochanteric 43% and Hardinge 6%. Mortality rate was 10%. One dislocation (1.4%) occurred at one month postoperative treated by closed reduction. No revision was performed. Discussion. Even though THA is widely used to treat ICF, two recent meta-analyses concluded that THAs bring better survivorship as well as better functional results despite a higher dislocation rates. THA-DMC is a way to decrease dislocation risk as confirmed by our study. There is a lack of studies published on the treatment of ECF, precluding a proper assessment. Conclusion. Given the studies identified, the gold standard in the treatment of ICF is moving toward THA. THA-DMC could overcome the higher dislocation rate observed with standard THA

The purpose of this study was to determine the oblique plane deformity in slipped upper femoral epiphysis. A retrospective radiographic review was undertaken in patients admitted with a slipped upper femoral epiphysis between March 2008 and October 2010. Patients in whom a CT scan had been performed in addition to plain radiographs were assessed further. Angular deformity in the coronal and sagittal planes were measured by the angle formed between the femoral neck and a line perpendicular to the physis on the AP pelvic radiograph and the axial CT scan respectively. The magnitude and direction of the resultant deformity was defined in the oblique plane. Additional demographic data (gender, age, side, procedure and complications) was collected. Seven girls, average age of 12 (range 10 – 13) and 6 boys, average age of 13 (range 10 – 15) were identified. The slip was bilateral in 2, left sided in 6 and right sided in 5 cases. Two patients were pinned in situ, 8 had surgical dislocation performed to facilitate reduction prior to pinning and 3 patients had secondary procedures performed following in situ pinning. The average angulation in the oblique posteroinferior plane (25 degrees) was less than in the coronal (30 degrees) and the sagittal planes (62 degrees). The average magnitude was 67mm (range 31 – 88). CT is useful adjunct particularly when a frog legged lateral view is not possible because of pain or the fear of further displacement. Determination of the deformity in the oblique plane may aid in positioning of the screw during in situ pinning and may be helpful in identifying patients in whom pinning maybe difficult

Introduction. Lesions of the upper extremities, and especially of the hands, are the most common form of occupational injury in the agricultural and industrial sectors [1]. When the grip strength and the way of its development are relevant, it would be very useful to be able to rely on an instrumental procedure, in support of the clinical examination, for both clinical and legal purposes. The possibility of differentiating between healthy subjects and patients affected by disabilities of the upper extremities, using parameters based on force-time curves for handgrip tests, was investigated with the aim to obtain objective and comprehensive outcome, useful to support the clinical evaluation. Materials and Methods. The reference group consisted of 151 subjects examined for occupational trauma of the upper limbs, all with a dominant right arm, who had suffered an occupational injury. The 74% of the injuries affected the hand. A further 648 healthy people were enrolled as the control group. Grip strength was measured with an electronic dynamometer. The signals acquired with the dynamometer were subdivided into 5 characteristic phases [2]: first reaction, explosive contraction, isometric contraction, release and relaxation. The maximum force, the ratio between the maximum force exerted by the two arms and an index related to the explosive muscle power and the ability to maintain maximum voluntary contraction were calculated. Percentage variations of each parameter, as compared to a threshold value, were taken into account and an overall value (T) was calculated, representing the sum of these variations. Result and Discussion. This acquisition system was shown to be reliable and easy to use, and the test could be administered simply and fairly rapidly. The findings in the control group were comparable to those reported in the literature [3–4]. A negative value of T invariably identified a subject with a disability. By associating assessment of T with those of the specific indexes, other subjects with a clinical disability were identified. The use of the parameters we describe makes it possible not only to assess the maximum force of the handgrip but also how it is exerted and maintained, thus providing a more reliable method of differentiating between normal function and impairment and what it is more obtaining an objective and comprehensive outcome, which sensitivity is useful to support clinical evaluation. The proposed functional tests could offer the clinician a possible diagnostic aid, providing a method that can describe the motor skill on the basis of objective parameters. In view of its good sensitivity (0.99%) and specificity (0.84%), relatively rapid execution and the low cost of the tools, it could be usefully adopted in the clinical setting

Purpose: The purpose of this study was to analyse results of the inverted shoulder prosthesis (Grammont Delta III prosthesis) for surgical treatment of malignant tumours of the upper portion of the humerus in twelve patients. Material and methods: Twelve patients were treated in two centres (six patients each). There were five women and seven men, mean age 51 years (34–69). Seven had a primary tumour and five had a unique secondary tumour. All tumours were implanted after Malawer I resection (IA four case and IB two cases), with an autologous bone graft using resected irradiated bone. All resections were wide as needed for healthy margins. Resection extended to the lower fourth of the humerus in four cases, to between the lower fourth and third in six cases and to the upper third or less in two cases. Ten patients were reviewed at a mean follow-up of 22 months (7–60) to assess clinical function (Constant score) and radiographic results. Two patients with a unique secondary tumour died within the six months following surgery due to progression of the primary tumour. Results: The mean Constant score was 58.75 (30–81.1). Weighted for age and gender, the result was 70.3% (32.6–82). Five sedentary patients were able to resume their former activities (1/2). Radiographically, there were two resorptions of the autograft, two glenoid lucent lines that did not progress, four notches in the column, and three Sneppen 1 calcifications. Mechanically, there were no prosthesis dislocations in patients whose resection extended to the lower fourth of the humerus, four dislocations in the one-fourth one-third group (2/6) and two dislocation in the upper group (2/2). Discussion, conclusion: Functional and radiographic outcome after anatomic prosthesis implantation for surgical treatment of malignant tumours of the upper portion of the humerus was directly related to the status of the rotator cuff. The Grammont Delta III inverted prosthesis provided satisfactory functional and radiographic results in this indication after Malawer I resection, irrespective of the rotator cuff sacrifice. The risk of prosthesis instability appeared to be related to the extent of the humeral resection required for cancerological cure. For patients who undergo resection of one third or more of the humerus, muscle plasty should be associated

Left-right skeletal length asymmetries in upper limbs related to curve side have been detected with adolescent thoracic idiopathic scoliosis (AIS). In school screening referrals with thoracic scoliosis we find apical vertebral rotation (AVR, Perdriolle) is associated significantly with upper arm length asymmetry. Sixty-nine of 218 consecutive adolescent patients referred routinely during 1988–1999 had idiopathic thoracic scoliosis of whom 61 had left and right upper arm lengths measured with a Holtain anthropometer (right curves 49, left curves 12, mean age 14.9 years, girls 38 postmenarcheal 34, boys 23). The controls are 278 normal girls and 281 boys (11–18 years, mean age 13.5 years). The mean value for Cobb angle is 18 degrees (range 4–42 degrees), AVR 13 (range 0–34 degrees), Cobb angle (CA) and AVR are each positively associated with upper arm length asymmetry (p=0.001 & p< 0.0001 respectively) and after correcting for each of Cobb side, apical level, sex and handedness, AVR and upper arm length asymmetry are still significantly associated (p=0.004 ANOVA). Partial correlation analysis shows AVR is associated with upper arm length asymmetry after controlling for CA (p=0.033); but not CA and upper arm length asymmetry after controlling for AVR (p=0.595). The reason why a larger AVR to the right is associated with a relatively longer right upper arm is unknown. Possibilities include neuromuscular and skeletal mechanisms, the latter relative concave overgrowth of neurocentral synchondrosis and/or of periapical ribs. We suggest consideration be given to combining convex vertebral body stapling (Betz) with concave periapical rib resection (Sevastik and Xiong) for right thoracic AIS in girls

Meniscal knee designs are unlike conventional surface replacement designs as they have two moving surfaces between the polyethylene and the metal tibial tray. This means the sliding distance is shared over two surfaces. This study was performed to assess the damage to both surfaces and whether the concept of wear sharing exists in knee prostheses of these designs. Although 22 meniscal bearings from both the designs of knee prosthesis of the Minns design were collected, 4 pairs of bearings (2 from each design of the Minns knee) were examined in detail as it was felt they represented the range of damage features seen in the explanted samples. These samples were examined for wear and damage on both the upper and lower polyethylene surfaces. In both designs of bearings, the wear was significantly less extensive on all the lower surfaces examined. The roughness of the burnished areas on the upper surface was always less than any of the lower surfaces of the same bearing. Even the specimens with gross wear and delamination damage on the upper surface has no corresponding damage on the lower surface. Only one specimen had wear on the lower surface of the dovetail retention bar, usually no wear was seen on this surface indicating the main weight-bearing area is the lower flat surface of both designs of bearings, and that the sliding distance is shared during use thus reducing the wear factor for both surfaces in use