Introduction. Acute poliomyelitis is a very rare disease in western countries, however the remnant of the pathology can be find among the adult patients. In poliomyelitis, sensation is normal and patients may suffer from painful etiologies. Total knee arthroplasty (TKA) with non-hinged or semi hinged prosthesis systems may be a good options to relief the pain in poliomyelitic patients, however the knee remains unstable. Using the hinged system implant may be the good option to resolve the late. Although the main concern in case of hinged implant usage is the mechanical stress which is directly transferred to the bone surface in contact with the implant. This may leads to implant mobilization and consequently failure. Methods and Materials. From 2004 to 2014, 14 TKA were performed in poliomyelitic patients with secondary knee pain. All patients were presented with extensor compartment hyposthenia and reduced antigravity function. In all patients a third generation rotating hinged knees (RHK) implant system (Zimmer, Warsaw, IN, USA) was applied. Bilateral TKA was performed in only one case. The mean age at the time of surgery was 56 years (ranged 48–77). Mean follow-up was 60 months (24–112). Results Due to post-operative infection, one patient underwent knee arthrodesis and excluded from the study. In one case, patellar fracture occurred 3 month following the surgery and treated non-surgically. Pain relief was observed in all patients following the surgery without any major complication. Mean objective score according to knee society knee scoring system was improved from 28 (16–51) preoperatively to 79 (72–88) postoperatively. Mean functional score was improved from 24 (5–35) preoperatively to 66 (50–70) postoperatively. At last follow up the mean range of motion was 90° (75°−100°). Following radiographic control at last follow-up all implants was stable without any sign of failure such as mobilization, radiolucency line or osteolysis. Conclusion. Providing stable knee implant system is the most important factor in addition to pain relief in case of poliomyelitic patients with knee pain. In our experience, third generation RHK supplied satisfactory clinical results in poliomyelitic patients supplying good implant stability without interfere with existing intrinsic stability of the lower limb. We believe that good results were achieved due to particular specification of RHK implant including mild 3° of hyperextension and weight distribution mode in which 95% transfer to polyethylene insert and only 5% to hinged compartment that help to restore the stability in such a particular patients also in case of late post-polio syndrome

Background. In poliomyelitis; hand to knee gait is the sum of quadriceps weakness and fixed knee flexion deformity. Limb shortening is another added problem. Usually, each problem is attacked separately; with variable end results and complication rates for each procedure. Patients and methods. 22 patients (16–46 y.); with poliomyelitis with hand to knee gait due to fixed knee flexion deformity of mild to moderate degree (10–400); and limb shortening of 4.5–9.5 cm., were managed simultaneously by a single operation. A distal femoral metaphyseal anterior closing wedge (recurvatum) corrective osteotomy was done to treat acutely the fixed knee flexion deformity(and subsequently hand to knee gait). A modified Wagner or Orthofix frame was applied as a mono-plane mono-axial lengthening device to stabilize the osteotomy and to lengthen the short limb. Lengthening was started in all cases two weeks post-operatively. Results. All cases showed full correction of the deformity with elimination of the hand to knee gait problem and all showed the desired limb length equalization. The femora were lengthened to an average of 6.4 cm.(= 21 % of original femoral bone length), range of lengthening was: 4–9 cm. (= 11–26 %). The average healing index was 37 days per centimeter (with a range of 31 to 53 days per centimeter.). Conclusion. Simultaneous management of hand to knee and limb shortening could be achieved by a single osteotomy which is used to extend the knee acutely and for distraction two weeks later using a mono-lateral frame. Results were good, complications were few and accepted and the procedure is well tolerated by the patients

Background. In poliomyelitis; hand to knee gait is the sum of quadriceps weakness and fixed knee flexion deformity. Limb shortening is another added problem. Usually, each problem is attacked separately; with variable end results and complication rates for each procedure. Patients and methods. 22 patients (16–46 y.); with poliomyelitis with hand to knee gait due to fixed knee flexion deformity of mild to moderate degree (10–400); and limb shortening of 4.5–9.5 cm., were managed simultaneously by a single operation. A distal femoral metaphyseal anterior closing wedge (recurvatum) corrective osteotomy was done to treat acutely the fixed knee flexion deformity(and subsequently hand to knee gait). A modified Wagner or Orthofix frame was applied as a mono-plane mono-axial lengthening device to stabilize the osteotomy and to lengthen the short limb. Lengthening was started in all cases two weeks post-operatively. Results. All cases showed full correction of the deformity with elimination of the hand to knee gait problem and all showed - the desired - limb length equalization. The femora were lengthened to an average of 6.4 cm.(= 21% of original femoral bone length), range of lengthening was: 4–9 cm. (= 11–26%). The average healing index was 37 days per centimeter (with a range of 31 to 53 days per centimeter.). Conclusion. Simultaneous management of hand to knee and limb shortening could be achieved by a single osteotomy which is used to extend the knee acutely and for distraction two weeks later using a mono-lateral frame. Results were good, complications were few and accepted and the procedure is well tolerated by the patients

We report a surgical technique for arthroplasty of the deformed hip after poliomyelitis. A fifty three year old man presented to our unit with a long-standing history of hip problems since contracting poliomyelitis at the age of two. Unusually, both of his hips were affected. He had been operated on twice for his right hip. This had left him with a deformed upper femur with significant shortening. The right hip was sub-luxed on presentation; this was due to a markedly dysplastic acetabulum. The polio and subluxation meant his muscles were weak and stretched. Like other authors, we were keen to achieve a stable hip. The senior author felt that a fully constrained socket would carry the following disadvantages:. Reduced range of movement. It would be difficult to fit a constrained socket into the small amount of pelvic bone available. Constrained sockets are more likely to loosen. An alternative approach, using a large diameter unconstrained metal on metal articulation, was employed; stability was achieved with the large head and the relatively small socket still preserved bone stock. The components chosen were a 52mm MMT, Birmingham acetabular resurfacing prosthetic, articulating with a 46mm chromium cobalt head. A fluted stem CAD CAM (computer aided design, computer aided manufacture) femoral prosthesis was used, as he needed to fully weight-bear from the outset, because of the weakness in his left leg. He has a good, pain-free range of movement. This represents a novel solution for arthroplasty in hips surrounded by weakened musculature. It avoids dramatic limitation of movement whilst minimising the bone stock loss and risk of dislocation. The patient is delighted with the medium term results

A 51 years old female who experienced difficulty in gait ambulation due to secondary osteoarthritis of knee showed knee instability caused by paralysis associated with poliomyelitis and scoliosis. At the first medical examination, right knee range of motion was 0° to 90°, and spino malleolar distance (SMD) showed 72cm for the right leg, 78cm for the left leg, and the bilateral comparison of SMD indicated the leg length discrepancy of 6cm. The patient has a history of surgeries with an anterior – posterior instrument for the treatment of scoliosis, and with Langenskiöld method for the paralyzed right knee at the age of seventeen. The patient also experienced varus degeneration at the age of twenty seven, which was surgically treated with high tibial osteotomy. In this case, a reoperation of her right knee was performed due to the reoccurrence of the knee pain. Preoperative planning was performed using Patient-matched instrument (Signature; Biomet) which was created based on computed tomography data. Each part of osteotomy followed the resection guide by Signature, and a total knee arthroplasty was carried out using the Rotating Hinge Knee System (Zimmer, warsaw. Inc). Two week after the operation, the patient showed the ability to walk without any assistance, and has been in a good condition

Predictions of lower limb growth are based upon historical data, collected from patients who had coexistent poliomyelitis. By utilising standardised longitudinal prospective European data, our objective was to generate superior estimates for the age and rate at which lower limb skeletal maturity is reached; thus improving the timing of epiphysiodesis, for the management of leg length discrepancy. The Avon Longitudinal Study of Parents and Children of the 90s (ALSPAC) is a longitudinal cohort study of children recruited antenatally 2. Using a previously validated Multiplier Method, a sequence of leg length multipliers were calculated for each child. 15,458 individuals were recruited to the ALSPAC study; and of those whose growth was measured, 52% were boys and 48% girls, each with an average of eight recording episodes. 25,828 leg length multiplier (LLM) values were calculated with final recordings taken at a mean age of 15.5 years. From this data, the age at which girls reach skeletal maturity (LLM=1) is 11 months later than previously calculated and for boys nearly 9 months earlier. With nearly 4000 more children recruited in this cohort than preceding studies, this study brings increased power to future leg length calculations

Aims

Total hip arthroplasty (THA) in patients with post-polio residual paralysis (PPRP) is challenging. Despite relief in pain after THA, pre-existing muscle imbalance and altered gait may cause persistence of difficulty in walking. The associated soft tissue contractures not only imbalances the pelvis, but also poses the risk of dislocation, accelerated polyethylene liner wear, and early loosening.

Arthritis of the hip is a relatively common problem in patients with neuromuscular disorders due to muscle imbalance around the hip from weakness, paralysis, contractures and spasticity. Neuromuscular disorders such as cerebral palsy, Parkinson's disease, poliomyelitis, previous cerebrovascular accident (CVA) and Charcot arthropathy have been considered by many to be contraindications to total hip arthroplasty (THA). The presence of certain anatomic abnormalities (excessive femoral anteversion, acetabular dysplasia, leg length discrepancy (LLD) and coax valga) and significant soft tissue contractures, muscle imbalance, and muscular weakness make THA a challenging surgical procedure in this patient population, and can predispose to dislocation and poor functional outcome following surgery. THA can, however, result in substantial pain relief and functional improvement, and can be safely performed, provided certain technical considerations are addressed. The patient's motor strength and functional status (ambulatory vs. “sitter”) should be carefully assessed preoperatively, since both of these factors may affect the choice of surgical approach and component position. Significant soft tissue contractures should be released at the time of surgery. Although these can be frequently performed “open”, percutaneous adductor tenotomy is occasionally necessary for patients with significant adduction contractures. Patients requiring significant soft tissue releases may benefit from 6 weeks of bracing to allow soft tissues to heal in appropriately and minimise risk of dislocation during this period of time. Use of modular femoral components that allow for correction of excessive femoral anteversion, should be considered in patients with coexistent dysplasia and neuromuscular disease (i.e., CP or polio). Large femoral head components should also be considered in patients with increased risk factors for dislocation. Despite their obvious theoretical advantages, the use of large head metal on metal THAs should be used with extreme caution in view of growing concerns about these devices. Although constrained acetabular liners are associated with an increased risk of mechanical failure, their use should be strongly considered in patients with significant motor weakness or major soft tissue deficiencies. Meticulous soft tissue closure of the capsule of the hip is recommended, especially when performing THA through a posterior approach. Patients with neuromuscular disorders associated with spasticity and involuntary movements need to be optimally treated medically prior to and indefinitely after THA. There are limited reports of outcomes following THA in patients with neuromuscular disorders, however, some generalizations based on underlying diagnosis can be made. Patients with cerebral palsy and polio frequently have acetabular dysplasia, excessive femoral anteversion and LLD, and although durability does not seem to be a major concern, dislocation and instability is relatively common and needs to be addressed. Durability and instability do not appear to be major concerns in patients with Parkinson's disease, however, these patients have frequent medical complications perioperatively and have deterioration in function over time due to the progressive nature of their underlying disorder. Patients with previous CVA also appear to have acceptable durability and dislocation risk, but are at high risk of developing heterotopic ossification postoperatively. Patients with Charcot arthropathy or myelodysplasia are at high risk of instability and appear to have limited functional improvement following THA. As a result, the consensus of opinion is that THA is contraindicated in these patients

56 patients who had undergone lower limb lengthening in accordance with Ilizarov principles in 61 bone segments were retrospectively studied and functional outcomes were evaluated by 5 different assessment systems. There were 17 cases of congenial bone deficiencies, 11 post poliomyelitis, 11 post traumatic, 8 post infection, and 9 miscellaneous cases. The average lengthening was 7.6 centimeters (3–14). Among the 46 patients who had reached skeletal maturity at the time of study,79% had reached their lengthening goal. 10 patients had still open physes and would require further equalization procedures. There were 40 side effects (complications and obstacles) and 37 problems. 27 cases required additional surgery to treat the complications. Major complications were most commonly seen in congenital femoral lengthening cases. The functional outcome as evaluated by the five different assessment systems revealed improvement in almost all aspects. The improvement in esthetic appearance of the limb and shoe -wear, walking, sporting activities, and limp were the most common reasons for satisfaction as observed in 89% of the cases

In Europe wide exhibition on ancient diseases in skeletal and mummified remains are scarce. In the last Congress of the EBJIS held last year in Barcelona a small sample of old infection diseases were showed. Until now, only in the specifically meetings of paleopathology it is possible to see some examples of this archaeological pieces. The knowledge of the frequency, prevalence and evolution of the most important infections that use to affect at bone across the time could be important to evaluate the health status of the population. From February to August 2009 is been open in the Egyptian Museum of Barcelona a wide exhibition of archaeological pieces that shows a wide range of abnormalities and diseases in skeletal and mummified remains. More than 150 pieces belongings at 35 different institutions around the World are shows to the public. Among theses, 58 pieces are present in the Infection Area; they cover a wide range of time in the Mankind History, from the Neolithic Period to the end of the XIX century. We present a sample of the most important pieces of this ambit as poliomyelitis, Hanssen disease, treponematosis, tuberculosis, brucellosis, pyogenic osteomyelitis in diaphysis of long bones and in the spine, hidatidic cists. The diagnoses of some of them are evaluated by molecular evidence. We also shows the mummies of two children, one with tuberculosis and the other with triquinosis, and an adult mummy from the Tiwanaku Culture possible affected of treponematosis

Between 1997 and 2003, five patients with acquired knee flexion contractures were treated by gradual soft tissue distraction using the Ilizarov external fixator. Two patients presented following burns, two following septic arthritis of the knee and one after poliomyelitis. The mean age was 8.2 years (5 to 12). All patients had a fixed flexion contracture of the knee of 90°. The mean duration of fixator application was 4 months. No soft tissue releases or bony surgical procedures were performed. When the external fixator was removed, the mean residual knee flexion deformity was 2°. Follow-up after removal of the fixator averaged 5 months. The mean loss of correction was 15° (0° to 30°). Two patients developed mild pin-tract sepsis, which was successfully treated with oral antibiotics. Compared to preoperative status, energy-efficient mobility was markedly improved in all patients

Grice-Green subtalar arthrodesis was initially reported to correct valgus hindfoot deformities in patients with poliomyelitis. Nowadays, the indications of the Grice-Green arthrodesis have been significally broadened. The aim of this study is to analyse the indications of treatment and evaluate the results of the Grice-Green arthrodesis in children. During the period 1986–2006, 17 children with valgus hindfoot deformities were treated in our department. In 12 of them the procedure was performed in both feet and in the rest (5 patients) unilaterally. The mean age at operation was 8.8 years. The most common group of patients suffered from cerebral palsy (10 patients), followed by the patients suffering from myelomeningocele (4 patients), 2 patients suffered from overcorrection following treatment of congenital equinovarus and one patient from Charcot Marie Tooth disease. In neine patients the operation was combined with Achilles tendon lengthening, capsulotomies, tendon transfers, tendonotomies, and Evans arthrodesis. In all operations bone graft from the tibia or the fibula was used. Postoperatively a balow knee non weightbearing cast was applied for 8 weeks followed by a weightbearing cast for 4 weeks. The results were avaluated according to Alman and Zimbies criteria. The mean follow up of the patients was 4.2 years. The results in 24 feet were considered excellent and in 5 cases satisfactory. In all cases subtalar arthrodesis was achieved. Grice-Green arthrodesis is a very useful operative technique for the correction of severe valgus hindfoot deformities in children. The results of the technique are usually good and the operation does not influence the normal growth of the foot. An accurate preoperative planning and a good surgical technique is neccesary for good results

Purpose: We reviewed retrospectively 27 ankle arthrodesis procedures performed from 1990 to 2001 to assess the mid-term outcome. These patients had had on average 1.5 ankle interventions before the arthrodesis. Mean follow-up was seven years. Material and methods: The arthrodeses were performed for posttraumatic degeneration (n=21), sequelae of septic arthritis (n=3), poliomyelitis (n=2), and rheumatoid arthritis (n=1). Forty-four percent of the patients had osteoarthritis of the subtalar joint. The transfibular approach was used for 21 patients and an external fixation for five. One woman was treated with a 90 LC-DCP 4.5 plate. Results: Union was achieved in 13 weeks. There were three cases of wound necrosis (11%), two cases of superficial infection 7%) and one case each of axonotomesis of the posterior tibial nerve (3%) and malunion (3%) which required revision for insertion of a transplantar screw. Using the AOFAS system, the mean function score at last follow-up 88.4/92 compared with 42/92. Eighty-eight percent of the patients were satisfied. At last follow-up, 75% of patients had signs of active subtalar osteoarthritis. Three patients were symptomatic. Conclusion: Ankle arthrodesis is a good indication for symptomatic osteoarthritis of the ankle joint despite that it in the long-term it accelerates the development of degenerative disease in the subjacent articulations

Between 1997 and 2002, seven talipes equino varus deformities in six patients were treated using gradual distraction and correction with the Ilizarov external fixator. Three patients had poliomyelitis, four patients had neglected clubfeet and two patients had relapsed club-feet. The mean age of patients was 13.3 years (5 to 21) and the mean duration of fixator application was 3.25 months. When the plantigrade position was achieved the fixator was removed and a below-knee walking cast was applied. Four months after fixator removal, additional bony correction surgery (triple arthrodesis) was done in three patients. At the time of fixator removal, a plantigrade foot was achieved in all patients. The mean follow-up time from surgery was 26 months. Pin-tract sepsis in two patients was treated effectively with oral antibiotics. Other complications included meta-tarsophalangeal subluxation from flexor tendon contractures in one foot. There have been no recurrences of deformities. Compared to preoperative status, gait was subjectively improved in all patients. Correction of the deformity in the patients who had a triple arthrodesis of the foot was achieved with less bone loss than in patients who had undergone a primary triple arthrodesis. These results suggest that treatment with Ilizarov frames is effective in the management of neglected and relapsed clubfoot deformities

Arthritis of the hip is a relatively common problem in patients with neuromuscular disorders due to muscle imbalance around the hip from weakness, paralysis, contractures and spasticity. Neuromuscular disorders such as cerebral palsy, Parkinson's disease, poliomyelitis, previous cerebrovascular accident (CVA) and Charcot arthropathy have been considered by many to be relative contraindications to total hip arthroplasty (THA). The presence of certain anatomic abnormalities (excessive femoral anteversion, acetabular dysplasia, leg length discrepancy (LLD) and coax valga) and significant soft tissue contractures, muscle imbalance, and muscular weakness make THA a challenging surgical procedure in this patient population, and can predispose to dislocation and poor functional outcome following surgery. THA can, however, result in substantial pain relief and functional improvement in patients with significant hip arthritis and neuromuscular disorders, and can be safely performed, provided certain technical considerations are addressed. The patient's motor strength and functional status (ambulatory vs. “sitter”) should be carefully assessed pre-operatively, since both of these factors may affect the choice of surgical approach and component position. Significant soft tissue contractures should be released at the time of surgery. Although these can be frequently performed “open”, percutaneous adductor tenotomy is occasionally necessary for patients with significant adduction contractures. Patients requiring significant soft tissue releases may benefit from 6 weeks of bracing to allow soft tissues to heal appropriately and minimise risk of dislocation during this period of time. Use of modular femoral components that allow for correction of excessive femoral anteversion, should be considered in patients with coexistent dysplasia and neuromuscular disease (i.e. CP or polio). Large femoral head components should also be considered in patients with increased risk factors for dislocation. Despite their obvious theoretical advantages, the use of large head metal on metal THAs should be used with extreme caution in view of growing concerns about these devices. Although constrained acetabular liners are associated with an increased risk of mechanical failure, their use should be strongly considered in patients with significant motor weakness or major soft tissue deficiencies. Meticulous soft tissue closure of the capsule of the hip is recommended, especially when performing THA through a posterior approach. Patients with neuromuscular disorders associated with spasticity and involuntary movements need to be optimally treated medically prior to and indefinitely after THA. There are limited reports of outcomes following THA in patients with neuromuscular disorders, however some generalisations based on underlying diagnosis can be made. Patients with cerebral palsy and polio frequently have acetabular dysplasia, excessive femoral anteversion and LLD, and although durability does not seem to be a major concern, dislocation and instability is relatively common and needs to be addressed. Durability and instability do not appear to be major concerns in patients with Parkinson's disease, however, these patients have frequent medical complications perioperatively and have deterioration in function over time due to the progressive nature of their underlying disorder. Patients with previous CVA also appear to have acceptable durability and dislocation risk, but are at high risk of developing heterotopic ossification postoperatively. Patients with Charcot arthropathy or myelodysplasia are at high risk of instability and appear to have limited functional improvement following THA. As a result, the consensus of opinion is that THA is contraindicated in patients with Charcot arthropathy and myelodysplasia

Arthritis of the hip is a relatively common problem in patients with neuromuscular disorders due to muscle imbalance around the hip from weakness, paralysis, contractures and spasticity. Neuromuscular disorders such as cerebral palsy, Parkinson's disease, poliomyelitis, previous cerebrovascular accident (CVA) and Charcot arthropathy have been considered by many to be relative contraindications to total hip arthroplasty (THA). The presence of certain anatomic abnormalities (excessive femoral anteversion, acetabular dysplasia, leg length discrepancy (LLD) and coax valga) and significant soft tissue contractures, muscle imbalance, and muscular weakness make THA a challenging surgical procedure in this patient population, and can predispose to dislocation and poor functional outcome following surgery. THA can, however, result in substantial pain relief and functional improvement in patients with significant hip arthritis and neuromuscular disorders, and can be safely performed, provided certain technical considerations are addressed. The patient's motor strength and functional status (ambulatory vs. “sitter”) should be carefully assessed pre-operatively, since both of these factors may affect the choice of surgical approach and component position. Significant soft tissue contractures should be released at the time of surgery. Although these can be frequently performed “open,” percutaneous adductor tenotomy is occasionally necessary for patients with significant adduction contractures. Patients requiring significant soft tissue releases may benefit from 6 weeks of bracing to allow soft tissues to heal in appropriately and minimize risk of dislocation during this period of time. Use of modular femoral components that allow for correction of excessive femoral anteversion, should be considered in patients with coexistent dysplasia and neuromuscular disease (i.e. CP or polio). Large femoral head components should also be considered in patients with increased risk factors for dislocation. Despite their obvious theoretical advantages, the use of large head metal on metal THAs should be used with extreme caution in view of growing concerns about these devices. Although constrained acetabular liners are associated with an increased risk of mechanical failure, their use should be strongly considered in patients with significant motor weakness or major soft tissue deficiencies. Meticulous soft tissue closure of the capsule of the hip is recommended, especially when performing THA through a posterior approach. Patients with neuromuscular disorders associated with spasticity and involuntary movements need to be optimally treated medically prior to and indefinitely after THA. There are limited reports of outcomes following THA in patients with neuromuscular disorders, however some generalisations based on underlying diagnosis can be made. Patients with cerebral palsy and polio frequently have acetabular dysplasia, excessive femoral anteversion and LLD, and although durability does not seem to be a major concern, dislocation and instability is relatively common and needs to be addressed. Durability and instability do not appear to be major concerns in patients with Parkinsons disease, however, these patients have frequent medical complications perioperatively and have deterioration in function over time due to the progressive nature of their underlying disorder. Patients with previous CVA also appear to have acceptable durability and dislocation risk, but are at high risk of developing heterotopic ossification post-operatively. Patients with Charcot arthropathy or myelodysplasia are at high risk of instability and appear to have limited functional improvement following THA. As a result, the consensus of opinion is that THA is contraindicated in patients with Charcot arthropathy and myelodysplasia

The purpose of this study was to analyse a potential correlation of arthrofibrosis (AF) and femoral rotational mal-alignment in total knee arthroplasty (TKA). We hypothesized an increased internal mal-rotation of the femoral component leading to unphysiological kinematic motion of the arthroplastic knee joint. These repetitive microtrauma may then induce increased synovial hyperplasia leading to arthrofibrosis. Arthrofibrosis is an ill-defined entity that results in unsatisfactory outcome following TKA. Biological and mechanical factors have been suggested as etiology, but specific causes have not been identified. Methods: From a cohort of 3058 mobile bearing TKA 44 (1.4%) cases were diagnosed with arthrofibrosis, of which 38 (86%) cases underwent clinical examination and CT investigation to determine femoral component rotation taking the transepicondylar (TEA) axis as reference point. A control group with 38 well functioning TKA was compared. Results: Increased internal mal-rotation of the femoral component of 5.0° in the AF group (reference to the TEA) was highly significant (p < 0.001) ranging from 10°IR to 1°ER compared with the control group (0.0° parallel to TEA, 4°IR to 5°ER). Men younger than average for index TKA in this center with a decreased BMI, previous knee surgery (particularly correcting osteoto-mies), poliomyelitis, and OA had an increased risk of developing arthrofibrosis. PCL retaining or sacrificing, patella resurfacing or retaining had no increased prevalence for AF. Rheumatoid patients had a decreased risk of developing arthrofibrosis . Conclusion: The correlation of AF to femoral component internal mal-rotation was statistically significant (p < 0.001). These results confirm that unphysiological kinematics in TKA appear to be a major etiopathological factor for arthrofibrosis (AF). In this study femoral component internal mal-rotation has shown to be a significant risk factor in the development of arthrofibrosis. We, therefore, recommend consideration of early CT evaluation in cases with AF and, when internally mal-rotated, revision of the femoral component. This study has been cleared by the Ethical Committee, University of Zurich, Switzerland

It is customary to analyse scoliosis as a mechanical failure: first there is a straight spine (=normal), then an habitual and collapsing posture (=disease) and finally, structural remodelling (Hueter-Volkmann effect = scoliosis). This hypothesis makes two practical predictions:. There is a disease process causing the pathological posture. The purpose of gatherings such as this is to identify this pathology, thus far without success. Early diagnosis will permit early non-operative treatment which will halt or reverse the remodelling and reduce the occurrence of severe deformity and the need for corrective spinal surgery. The failure of school scoliosis screening to achieve this end is well documented, but the consequence for the underlying hypothesis has not been analysed. Screening failed, not because it was unable to detect scoliosis, but because scoliosis did not behave as the hypothesis predicted. Disease process: All theories presume some form of neurological or muscular deficit as the final pathway but while the variety is wide, e.g. (historically) anterior poliomyelitis; more recently proprioceptive defect, melatonin or calmodulin disorder, there is no clear evidence for such a deficit in adolescent idiopathic scoliosis (AIS). Of 1342 screening referrals to this centre, 10 had a neurological diagnosis (most of which were already known to the patients) and 598 had radiologically confirmed AIS. In contrast, 1707 referrals to the general clinics included 410 syndromic cases and 420 AIS. Patients with a neurological problem, by and large, find their own way to medical attention. The hypothesis does not explain the natural history or the aetiology, and awkward observations, such as the association with growth (. Goldberg et al . Spine. 18. (5):. 529. –535.1993. , . Eur Spine J. 2. :. 29. –36.1993. and, most recently, . Ylikoski M. . Journal of Pediatric Orthopaedics B. 14. :. 320. –324, . 2005. ) or the higher incidence in ballet dancers (. Warren et al. . New England Journal of Medicine. 314. (21):. 1348. –1353. 1986. ) and rhythmic gymnasts (. Tanchev et al. . Spine. 25. (11):. 1367. –1372. 2000. ) are ignored. Screening: Screening programmes (e.g. . Goldberg et al., . Spine. 20. (12):. 1368. –1374, . 1995. ) showed that there was no precise demarcation between “scoliosis” and “normal,” and that there was no benefit in terms of the need for surgical correction from screening or bracing, (. Goldberg et al. . Spine. 26. (1):. 42. –47, . 2001. ). Discussion: his information has been in the public domain for some years and, in the meanwhile, there have been huge advances in biology and medicine which must have relevance. When the predictions of a hypothesis are not confirmed, that hypothesis must at least be re-examined, and it is not necessary to wait until a replacement can be suggested. The undisputed aspects of scoliosis, such as association with growth rate and maturation, lateralisation, gender predominance, normal distribution of Cobb angle and asymmetry over the wider population, essential health and normality of those with even severe deformity, increased incidence in other conditions, all suggest a different model. This is an opportune time to pause and reconsider the underlying model of scoliosis in the light of what we have learned about scoliosis and what is now known in other disciplines about how morphology is determined and evolved

Primary total knee arthroplasty (TKA) is a reliable procedure with reproducible long-term results. Nevertheless, there are conditions related to the type of patient or local conditions of the knee that can make it a difficult procedure. The most common scenarios that make it difficult are discussed in this review. These include patients with many previous operations and incisions, and those with severe coronal deformities, genu recurvatum, a stiff knee, extra-articular deformities and those who have previously undergone osteotomy around the knee and those with chronic dislocation of the patella.

Each condition is analysed according to the characteristics of the patient, the pre-operative planning and the reported outcomes.

When approaching the difficult primary TKA surgeons should use a systematic approach, which begins with the review of the existing literature for each specific clinical situation.

Cite this article: Bone Joint J 2015;97-B(10 Suppl A):30–9.

The April 2014 Research Roundup³⁶⁰ looks at: scientific writing needed in orthopaedic papers; antiseptics and osteoblasts; thromboembolic management in orthopaedic patients; nicotine and obesity in post-operative complications; defining the “Patient Acceptable Symptom State”; and cheap and nasty implants of poor quality.