Introduction and Aims Back pain patients usually demand more time in clinic. A significant proportion of this time is spent in performing clinical examination. It has been recognised that detailed history of symptoms is the backbone in reaching the diagnosis and deciding the management plan for patients with lower back pain and/or radiculopathy. The aim of the study was to look at 1) Contributions from History and Examination. 2) Does Clinical Examination add any further information not identified from history?. Method A prospective, blinded study was carried out to determine the usefulness of history and clinical examination, individually to reach the diagnosis and plan the management. 75 consecutive lower back pain and/or radiculopathy patients were included in the study. Two orthopaedic registrars saw all the patients. One took detailed history and the other registrar performed clinical examination. Both registrars based on their information arrived at a provisional diagnosis. A consultant also took history and examined these patients. MRI scan was done as per clinical indication. Results The data was analysed using standard statistics software. In all patients history suggested the possible diagnosis. Clinical examination did not add any further information to alter the course of management, which was planned for the patient. Clinical examination did not show any further information that was not identified in the MRI scan. Conclusion Clinical examination does not add to the body of information available from history. Clinical examination does not add any further information not available on the scan. Clinical examination should be performed for patients considered for surgery to document the findings; here both subjective and objective assessment should be performed. Examination is not a useful screening tool

Introduction. As modern day lifestyle is becoming more active so is the incidence of meniscal injuries on rise. An injury to the meniscus is a common orthopedic problem with the incidence of meniscal injury resulting in meniscectomy of 61 per 100,000 populations per year. The common practice in diagnosis of the meniscal injury involves clinical examination followed by radiological or arthroscopic confirmation. The clinical tests commonly performed are joint line tenderness (JLT), McMurray's Test (Non-weight bearing test) and Childress Test (Weight Bearing Test). Aim. In our study, we performed the comparative analysis of the validity parameters for components of clinical examination in form of Joint line tenderness, McMurray's test and Childress Test. Methodology. A retrospective analysis was performed on the database established using Orchard Sports Injury Classification System-8. Codes KC2 and KC3 (Meniscal injuries) were identified for single examiner for duration from 2004–2007. Out of 88 patients considered for the study, 62 patients were stratified in whom only clinical examination was performed followed by arthroscopic evaluation. The validity parameters considered were accuracy, specificity, sensitivity, positive predictive value (PPV) and negative predictive value (NPV). Results. Joint line tenderness had accuracy of 85.47%, sensitivity of 89.09%, and specificity of 57.14%, PPV of 94.23% and NPV of 40%. McMurray's test yielded a accuracy of 88.7%, sensitivity of 89.65%, specificity of 75%, PPV of 98.11%, NPV of 33.33% while Childress test accurately predicted meniscal injury 87.09% and was sensitive for 94.73% with specificity of 40%, PPV of 94.73% and NPV of 40%. Conclusion. We can summarise that though the JLT, McMurray's Test and Childress Test provide a variable yet effective diagnostic value, all through can provide a composite diagnostic yield improving the outcome of clinical examination in meniscal injuries

Introduction. Meniscal injuries are very common cause of knee pain and resultant attendance to the orthopaedics or sports medicine clinics. The current protocol stands at clinical examination at first contact and establishing a diagnosis with clinical indicators like joint line tenderness, McMurray's, Apley's and weight-bearing test for meniscal pathology followed by MRI scan to confirm the diagnosis. Either surgical or conservative management follows this. We aim to assess clinical examination alone provide sufficient evidence for further management of meniscal injury and does a role of MRI scan exist to corroborate the findings. Methodology. We retrospectively studied 88 patients attending the sports medicine clinic for the duration 2004–2007 examined by senior clinical assessor. We investigated the co-relation of the clinical and MRI findings to validate if there exists an actual clinical justification to use MRI scan in every patient. We divided the data in further subsets of 57 patients in whom both clinical examination and MRI scan were performed and were validated by arthroscopy. The data obtained was analysed for parameters of accuracy, sensitivity, specificity, positive predictive value [PPV] and negative predictive value [NPV]. Results. The comparison of clinical examination against MRI scans alone in 88 patients provided a accuracy of 81.81%, sensitivity of 95.77% and specificity of 23.52%. The assessment revealed that clinical examination yielded accuracy of 89.47%, sensitivity of 96%, specificity of 42 %, PPV of 92%, NPV of 60% while MRI scan was 87.70% accurate, 86% sensitive, with specificity of 100%, PPV of 100%, NPV of 57.14%. Conclusion. From the results yielded by the study we can conclude that in experienced hands the clinical examination is as robust as MRI scan for meniscal injury of knee and can negate the need for MRI scan to be performed in every painful knee with suspicious meniscal injury

The purpose of the study was to assess the accuracy of clinical examination to diagnose meniscal injury. Internal Derangement of Knee is one of the most common conditions encountered in routine orthopaedic practice. The ultimate outcome depends upon timely management based on correct diagnosis. There are various tools available to diagnose this condition, mainly clinical examination, MRI & Arthroscopy. The individual method needs to be evaluated on the basis of merits and demerits depending upon the cost, time spent waiting for results and the degree of accuracy it provides. The study was carried out retrospectively by looking at case notes of 98 patients, who had arthroscopy of the knees with or without MRI. An attempt was made to establish the correlation between the arthroscopic diagnosis and the clinical signs looked for to diagnose meniscal injury. The result of the study showed that although the accuracy to diagnose the internal derangement prior to arthroscopy was fairly high, poor documentation of clinical examination findings, defeated the purpose of the assessment of accuracy. From patient’s management point of view, it appears that Arthroscopy & MRI have become indispensable tools in the evaluation of the injured knee. They can provide the physician and patient pre treatment prognosis. However they must be utilized as a complimentary to (not instead of) clinical evaluation and judgment. They become less cost-effective if used in a less responsible manner without the appropriate first-line investigations i.e. accurate clinical examination

Introduction and Aims: Back pain patients usually demand more time in clinic. A significant proportion of this time is spent in performing clinical examination. It has been recognised that a detailed history of symptoms is the backbone in reaching the diagnosis and deciding the management plan for patients with lower back pain and/or radiculopathy. Method: A prospective, blinded study was carried out to determine the usefulness of history and clinical examination, individually, to reach the diagnosis and plan the management. Sixty consecutive lower back pain and/or radiculopathy patients were included in the study. All the patients were seen by two orthopaedic registrars. Detailed history was taken by one and clinical examination was performed by the other registrar. A provisional diagnosis was made by both registrars based on their information. A consultant also took history and examined these patients. MRI scan was done as per clinical indication. Results: The gathered information was analysed using standard statistics software. The data indicates that clinical examination on its own was non-contributory in reaching diagnosis and plan the management. All information obtained by history alone correlated well with MRI results. The full results and cost implications will be discussed. Conclusion: Routine clinical examination of spine can be omitted without compromising the patient care, where clear history is available to reach diagnosis and plan the management. Clinical examination should be performed on those patients who need surgery to document the pre-operative neurology

The aim of this trial was to assess the clinical examination findings commonly used for the ACL deficient knee. For reliability testing and criterion validation 102 patients with ACL injuries were assessed by a single observer, 35 by a second observer and 47 again by the initial observer. For construct and criterion validation 30 patients were assessed pre-operatively and a mean of 1.7 years after ACL reconstruction. The Lysholm 11, Tegner and Cincinnati outcome measures were assessed along with instrumented knee laxity (Stryker test), the one hop test (OHT) and graded tests (including anterior draw, Lachman test, quality of end point, and pivot shift test). The outcome measures were found to be reliable except the Cincinnati system. All examination findings were of unsatisfactory reliability, with the exception of the OHT and the Stryker test. Construct validation revealed a significant improvement in all outcome measure scores and examination findings following ACL reconstruction. Criterion validation revealed that of the examination findings only the OHT had a satisfactory correlation with the symptom of giving way and the Lysholm/Tegner measures. Comparison of the difference between the desired and actual Tegner activity levels with the examination findings revealed an improvement in all levels of correlation. With the exception of the OHT, the clinical examination findings used for the ACL deficient knee are unreliable and correlate poorly with the functional outcome of the patient. They may, however, have some benefit in assessment of deficiency of the anatomical structures and the findings should be presented individually, rather than forming part of the functional assessment of the patient

Background. Thoracolumbar fractures are the most common spinal injuries resulting from blunt trauma. Missed spinal injuries can have serious consequences. Objective. Our objectives were to determine the utility of trauma series chest and abdomen computed tomographs for detecting clinically unrecognised vertebral fractures and to analyse those missed on clinical examination. The aim was to identify an ‘at-risk’ patient group with negative clinical examination warranting evaluation with CT screening. Material and Methods. We evaluated all computed tomography of the chest and/or abdominal that was undertaken for blunt trauma at our trauma centre from April 2009 to April 2010. Data was gathered from both CT scans and medical notes to capture demographics, mechanism of injury, fracture site and configuration. Key points were the clinical suspicion of vertebral fractures prior to CT request and identifying ‘at-risk’ patient group with factors contributing to difficulty in clinical interpretation. Results. There were a total of 303 patients in the year who underwent CT scan for blunt trauma. 51(16.8%) had a thoracolumbar vertebral fracture. There were 8 women and 43 men a mean age of 45.2 years. There were 29 (56.8%) stable and 22 (43.2%) unstable fractures. Out of the 51 total fracture patients, only 17(33.3%) had been clinically anticipated with a positive clinical examination. In the 22 unstable fractures, only 11 (50%) were expected and had clinically recorded correlating positive examination findings. Conclusion. A combination of both clinical examination and CT screening based on mechanism will likely be required to ensure adequate sensitivity with an acceptable specificity for the diagnosis of clinically significant injuries of the TL spine

Clinical decision-making could be difficult when Magnetic resonance imaging (MRI) is used for the diagnosis of knee injuries. We retrospectively studied 565 knee arthroscopies done between 2002 and 2005, 110 of which had suspected ligamentous injuries, evaluated clinically, with MRI and subsequently by arthroscopy. The aim of the study was to know the extent of correlation of clinical, MRI features with arthroscopy and whether MRI could be justifiably used to deny an arthroscopy. All patients with a strongly suggestive history were examined in the clinic by experienced orthopaedic surgeons and MRI was requested. Clinical examination was repeated under anaesthesia by the operating surgeon who not necessarily had examined the patient initially. The clinical and arthroscopy findings were recorded systematically. 3 Radiology consultants of varying musculoskeletal experience reported the MRI films. The clinical and MRI findings were compared with arthroscopy for the extent of correlation. We observed that overall Sensitivity of MRI for meniscal injuries was 73%, being more for medial than lateral and 86% for cruciate ligament injuries. Clinical examination had a sensitivity of 33% and a specificity of 93% for meniscal injuries, sensitivity of 86% and specificity of 100% for cruciate injuries. MRI was not able to demonstrate synovial plicae in 13 knees and chondral defects in 3 knees. 96 Knees, which were normal clinically, were found to have meniscal tears on MRI in 65 and subsequently confirmed by arthroscopy in 39. We conclude that an accurately performed clinical examination with positive signs alone, will be justified for arthroscopy and a negative MRI will not be a sufficient evidence to deny an arthroscopy. Also the reporting will largely depend on the quality of information provided by the clinician, technical factors and the musculoskeletal experience of the person reporting the films

With the increasing availability of magnetic resonance imaging, there is potentially less emphasis being placed on making a definitive clinical diagnosis. Changes in the undergraduate curriculum have also reduced the emphasis on orthopaedic clinical evaluation. This aim of this study was to evaluate the predictability of clinical examination alone in comparison with arthroscopic findings in 50 consecutive patients presenting for arthroscopy to our service. Four trainees examined each patient; each examiner was blinded to the clinical diagnosis made by their colleagues. All patients were examined in the ward and subsequently underwent examination under anaesthesia and arthroscopy. Of the tests for meniscal injuries joint line tenderness was the most sensitive (77%) and specific (68%). Apley’s and McMurray’s test while specific (92%, 98%) lacked sensitivity (9%, 30%). Overall the tests for anterior cruciate ligament (ACL) disruption were more reliable than the tests for meniscal injuries. The anterior drawer and Lachmann tests had high specificity (90%, 75%) and sensitivity. The pivot shift test also had very high specificity (75%) and sensitivity (98%) for detecting ACL injuries. These data demonstrate that joint line tenderness is the most reliable sign of menis-cal injury. In the absence of joint line tenderness Apley & McMurray’s tests have little role in routine clinical examination. Clinical tests and signs of ACL deficiency are consistently reliable in diagnosing ACL rupture

Introduction: Diagnosis of rotator cuff tears by clinical examination and MRI is not always accurate. If the extent of the tear could be predicted pre-operatively, both the patient and the surgeon would be better equipped for the subsequent operation and rehabilitation. Aim: To assess the accuracy of clinical examination and MRI in detecting the presence of rotator cuff tears. Method and Results: Retrospective analysis of 86 patients with symptoms and signs of rotator cuff disease. All underwent clinical examination of the shoulder followed by an MRI scan. The diagnosis was confirmed intra-operatively. Sensitivity of clinical examination for all tears was 69%, with a specificity of 64% and a positive predictive value of 80%. Individual sensitivities were as follows: grade I 50%, II 76%, III 100%. MRI had a sensitivity of 82.8% for all tears, specificity of 57% and a positive predictive value of 80%. Individual sensitivities: I 69%, II 90%, III 100%. Conclusion: In some patients clinical examination remains uncertain, MRI is helpful but the diagnosis is not always reliable

The aim of this study is to assess the accuracy of clinical examination of the knee compared to MRI and Arthroscopy in diagnosing significant internal derangement. We performed a retrospective analysis on 245 patients who underwent an MRI of the knee over a two-year period. The MRI diagnoses were compared with both clinical and arthroscopic findings. There were 169 male and 76 female patients with an average age of 33 years. A history of significant trauma was seen in 98 (40%) patients. The commonest clinical diagnosis was isolated medial meniscal tear (25%). Anterior cruciate ligament (ACL) tear was diagnosed in 8% and lateral meniscal tear in 7% of cases. No definite clinical diagnosis could be reached in 32% of patients. MRI showed no significant abnormality in 103 (42%) patients. Medial meniscal tear was noted in 47 (19%), ACL tear in 20 (8%) and lateral meniscal tear in 10 (4%) of the MRI scans. 96 patients (39%) proceeded to arthroscopy after their MRI scans. The mean time from MRI scan to arthroscopy was 181 days. The MRI and arthroscopy findings were in complete agreement in 90 (94%) patients. Of the 6 patients whose MRI findings did not correlate with arthroscopy, 4 showed meniscal tears not seen at surgery and two diagnosed ACL ruptures subsequently shown to be normal at arthroscopy. Three of the 4 meniscal tears were of the inferior surface of the posterior horn of the medial meniscus and one of the inferior surface of the lateral meniscus. The films were reviewed independently by three experienced MR radiologists all of whom confidently diagnosed a tear in each case. Clinical examination alone is not satisfactory in the diagnosis of knee injuries. MRI is a highly sensitive tool for diagnosis. Injuries that are commonly missed at arthroscopy can be diagnosed easily with MRI

Physical examination is critical to formation of a differential diagnosis in patients with ulnar-sided wrist pain. Although the specificity and sensitivity of some of those tests have been reported in the literature, the prevalence of positive findings of those provocative maneuvers has not been reported. The aim of the study is to find the prevalence of positive findings of the most commonly performed tests for ulnar sided wrist pain in a population presenting to UE surgeon clinics, and to correlate those findings with wrist arthroscopy findings.

Patients with ulnar sided wrist pain were identified from a prospective database of patients presented with wrist pain from September 2014. Prevalence of positive findings for the following tests were gathered: ECU synergy test, ECU instability test (Ice cream and Fly Swatter), Lunotriquetral ballottement, Kleinman shear, triquetrum tenderness, triquetrum compression test, triquetral-hamate tenderness, pisotriquetral shuck test, ulnar fovea test, ulnocarpal impaction (UCI) maneuver, UCI maneuver with fovea pressure (ulnar carpal plus test), piano key sign. A subgroup was then created for those who underwent wrist arthroscopy, and analysis of the sensitivities, the specificities and the predictive values of these provocative tests was carried out with correlation to arthroscopic finding.

Prevalence of ECU instability tests was t 1.13% (ice cream scoop) and 1.5% (fly swatter). Lunotriquetral ballottement test's positive findings range from 4.91% (excessive laxity) to 14.34% (pain reproducing symptoms. The Kleinman shear test yielded pain in 13.58% of patients, and instability in only 2.26%. Triquetrum compression test reproduces pain in 32.83% of patients, and triquetral-hamate tenderness reproduced pain in 13.21%. Pisotriquetral grind test yields 15.85% positive findings for pain, and 10.57% for crepitus with radioulnar translation. The ulnar fovea test revealed pain in 69.05% of cases. The UCI maneuver yielded pain in 70.19%. The UCI maneuver plus ulnar fovea test reproduced pain in 80.38% of cases. Finally, the piano key sign yields positive finding in 2.64% of cases.

For patients who underwent surgery, sensitivities, specificities and predictive values were calculated based on arthroscopic findings. The lunotriquetral ballottement test has 59.6% sensitivity, 39.6% specificity, 20.3% positive predictive value and 85.4% negative predictive value. The sensitivity of Kleinman test was 62.4%, the specificity was 41.3%, the positive predictive value was 23.5%, and the negative predictive value was 83.2%. The sensitivity of fovea test was 94.3%, the specificity was 82.5%, the positive predictive value was 89.5% and the negative predictive value was 92.3%. The UCI maneuver plus ulnar fovea test has 96.5% sensitivity, 80.7% specificity 86.4% positive predictive value, and 95.3% negative predictive value.

Among the provocative tests, the prevalence of positive findings is low in the majority of those maneuvers. The exceptions are the fovea test, the UCI maneuver, and the UCI plus maneuver. With regard to the sensitivity and the specificity of those tests, the current study reproduces the numbers reported in the literature. Of those patients who underwent wrist arthroscopy, the tests are better at predicting at the absence of injury rather than at predicting its presence

Introduction. There are over 110 special tests described in the literature for clinical examination of the shoulder, but there is no general consensus as to which of these are the most appropriate to use. Individual opinion appears to dictate clinical practice. Rationalising which tests and clinical signs are the most useful would not only be helpful for trainees, but would also improve day to day practice and promote better communication and understanding between clinicians. Methodology. We sent a questionnaire survey to all shoulder surgeons in the UK (BESS members), asking which clinical tests each surgeon found most helpful in diagnosing specific shoulder pathologies; namely sub-acromial impingement, biceps tendonitis, rotator cuff tears and instability; both anterior and posterior. Results. For impingement; Hawkins-Kennedy and Neer's tests were used by the majority of respondents, with 50% also routinely performing Neer's injection test. For frozen shoulder; the shoulder quadrant test was the commonest used, followed by loss of passive range of motion and loss of external rotation. For biceps tendonitis; Speed's and Yergason's tests were by far the commonest used. For rotator cuff tears the commonest signs were; the Napoleon belly press, Hornblower's sign, Gerber's sign, Jobe's sign and Codman's drop arm sign. For instability; the apprehension test, the Gerber-Ganz drawer test, load and shift test and Jobe's relocation test were the commonest used, with the jerk test also popular for posterior instability. We are also currently assessing how individuals actually perform these tests, and whether they are as the original authors described them. Conclusion. Our results demonstrated some variation in which tests were being used, but with an increased preference for certain tests. Interestingly a large number of respondents commented that the history was of paramount importance and that clinical signs should only substantiate the clinician's diagnosis

Disorders of human joints manifest during dynamic movement, yet no objective tools are widely available for clinicians to assess or diagnose abnormal joint motion during functional activity. Machine learning tools have supported advances in many applications for image interpretation and understanding and have the potential to enable clinically and economically practical methods for objective assessment of human joint mechanics. We performed a study using convolutional neural networks to autonomously segment radiographic images of knee replacements and to determine the potential for autonomous measurement of knee kinematics. The autonomously segmented images provided superior kinematic measurements for both femur and tibia implant components. We believe this is an encouraging first step towards realization of a completely autonomous capability to accurately quantify dynamic joint motion using a clinically and economically practical methodology.

Objective: The aim of this study was to show the effect of a universal (all neonates) ultrasound screening in newborns on the incidence of operative treatment of hip dysplasia. Materials: A retrospective study was performed and all newborns of the county Tyrol (Austria) between 1978 and 1998 (8257 births / year ((range: 7766 – 8858)) were reviewed regarding hip dysplasia and following hip surgeries. Between 1978 and 1983 clinical examination alone was performed to detect hip dysplasia. Between 1983 and 1988 an ultrasound screening programme according to Graf was initiated in our county. Between 1988 and 1998 ultrasound screening was performed in all newborns. Hence two observation periods were determined: 1978–1983 and 1993–1998. The time period between 1983 and 1993 was excluded to minimize bias and learning curve regarding the initiation of the ultrasound screening programme. A retrospective comparative analysis of the two observation periods regarding surgical treatment and costs caused by hip dysplasia was performed. During the observation period indication for surgery did not change, however new treatment techniques were introduced. Patients with neuromuscular and Perthes diseases were excluded. According to age dependent surgical procedures three patient samples were determined: Group A: 0–1.5 years, Group B: 1.5–15 years and Group C: 15–35 years. Results: Comparison of the two observation periods showed no influence on the number of interventions for dysplastic hips in group C (pelvic osteotomies and VDROs). In group A, a decrease of hip reductions was seen from 25.6±3.2 to 7.0± 1.4 cases per year. In group B, there was a decrease of operative procedures for dysplastic hips from 18.0±3.2 to 3.4±1.3 interventions per year. Since the introduction of universal hip ultrasound screening the decrease of the total number of interventions for all groups was 78.6%. Comparison of costs of the two observation periods showed an increase of all costs caused by DDH and CDH of 57.000 euro/ year for the time period between 1993 and 1998 which was mainly caused by the ultrasound screening programme. There was a significant reduction of costs regarding operative and non operative treatment for dysplastic hips from 410.000 euro (1978–1983) to 117.00 euro (1993–1998). Conclusion: Initially there were higher costs caused by the screening method, but on the other hand total number and costs for operative and nonoperative treatment of dysplastic hips were significantly reduced by the universal ultrasound screening programme. In our mind patient’s and family distress and pain related to interventions performed for CDH and DDH justify the slight increase of costs caused by the universal screening programme. We therefore recommend universal hip ultrasound screening for neonates

Introduction: To guide one’s surgical options if conservative treatment in metatarsalgia fails, a good understanding of the anatomy and the biomechanics of a normal forefoot is primordial. The recognition of a so-called ideal morphotype may serve as a guide, through technical or other means (clinical examination, X-rays, baropodometry,..), to obtain a calculated and subtle reconstruction of all the symptomatic elements. Material and Methods: Between 2000 and 2005, 68 patients were operated by the same surgeon and were all, but five, reviewed retrospectively by an independent examiner. The study of the 184 osteotomies performed (of which 177 Weil osteotomies), made use of clinical, and radiological computerised analysis. Results: We have not been able to find a significant correlation between a harmonious curve of Maestro and postoperative recurrence or transfert metatarsalgia. Discussion: The cause of transfert metatarsalgia is often hard to find. Known, and so evitable, are important shortening and a fault in the preoperative adjustment. Despite a precise preoperative planning and a perfectly performed surgical technique, the surgeon sometimes encounters the development of plantar callosities beneath metatarsal heads adjacent to the operated ones. Lots of variables are still unknown or not recognised: mobility at the Lisfranc, gastrocnemius retraction. We have noted a significant relationship between the preoperative (in-)stability and the risk of developing transfert metatarsalgia (p-value = 0.03). A metatarso-phalangeal articulation, unstable in the preop setting, has 0.36 times less the risk of leading to this complication than if the operation was performed on a stable articulation preoperatively. A stable articulation would so be an indirect sign of a good tolerance by the adjacent rays. Conclusion: One can question if the reconstruction of an architectural harmonious forefoot using the ideal curve of Maestro at any price is necessary, since we were not able do demonstrate a guaranteed postoperative pain relief. A respect of the so-called ideal morphotype of the forefoot on the dorsoplantar upright X-rays seems insufficient in the assurance of a balanced distribution of plantar pressures postoperatively. Certainly, this morphotype most probably avoids an elevated rate of complications, but may not be considered as the only criteria to be achieved. The clinical examination stays the most essential element. Only the preoperatively symptomatic and unstable metatarsals should probably undergo this osteotomy

Objective evaluations of resident performance can be difficult to simulate. A novel competency based surgical OSCE was developed to evaluate surgical skill. The goal of this study was to test the construct validity comparing previously validated Ottawa scores (O-scores) and Orthopaedic in-training evaluation scores (OITE).

An OSCE designed to simulate typical general orthopaedic surgical cases was developed to evaluate resident surgical performance. Post-graduate year (PGY) 3–5 trainees have an encounter (interview and physical exam) with a standardized patient and perform a correlating surgery on a cadaver. Examiners evaluate all components of the treatment plan and provide an overall score on the OSCE and also provide an O-score on overall surgical performance. Convergent and divergent validity was assessed comparing OSCE scores to O-scores and OITE scores. SPSS was used for statistical analysis. ANOVA was used to compare PGY averages and Pearson correlation coefficients were calculated to compare OSCE versus O-score and OITE scores.

A total of 96 simulated surgical cases were evaluated over a 3 year period for 24 trainees. There was a significant difference in OSCE scores based on year of training. (PGY3 − 6.06/15, PGY4 − 8.16/15 and PGY5 − 11.14/15, p < 0 .001). OSCE and O-scores demonstrated a strong positive correlation of +0.89 while OSCE and OITE scores demonstrated a moderate positive correlation of 0.68.

OSCE scores demonstrated strong convergent and moderate divergent correlation. A positive trajectory based on level of training and stronger correlations with established, validated scores supports the construct validity of the novel surgical OSCE.

We analysed follow-up data from 18 486 primary total hip arthroplasties performed between 1967 and 2001 to assess the validity of clinical procedures in diagnosing loosening of prosthetic components. Sensitivity, specificity and predictive values were estimated with the radiological definition of loose or not loose as the ‘gold standard’.

The prevalence of acetabular loosening increased from 0.6% to 13.9% during the period of the study and that of femoral loosening from 0.9% to 12.1%. Sensitivities and positive predictive values were low, suggesting that clinical procedures could not replace radiological assessment in the identification of loose prostheses. Specificities and negative predictive values were constantly above 0.86. The possibility of there being a prosthesis which is not loose in asymptomatic patients was consequently very high, particularly during the first five to six years after operation.

The necessity of periodic clinical and radiological follow-up examinations of asymptomatic patients during the first five to six years after operation remains questionable. Symptomatic patients, however, require radiological assessment.

Scaphoid fractures are rare injuries in the pediatric population. A clinical and radiographic review over a six-year period at our institution revealed ninety-nine suspected scaphoid fractures. All of these patients presented with post-traumatic tenderness in the anatomic snuffbox and were treated with thumb spica cast immobilization. Only 9% of these patients demonstrated radiographic evidence of scaphoid fracture on initial presentation. At subsequent follow-up, six additional patients revealed radiographic evidence of scaphoid fracture. Positive predictive value of snuffbox tenderness for scaphoid fracture was 6% for patients with initially normal radiographs.

To review the clinical and radiographic results of suspected pediatric scaphoid fractures, as well as to determine the predictive value of anatomic snuffbox tenderness for occult fracture.

Pediatric scaphoid fractures are rare injuries that were found to be non-displaced and to involve the waist and distal scaphoid in most cases. Snuffbox tenderness had a positive predictive value of 6% in the identification of occult fracture.

In cases of suspected scaphoid fracture and normal radiographs, reliance on anatomic snuffbox tenderness alone will result in unnecessary immobilization in the majority of children.

Ninety-nine potential injuries were identified. Average age was 13.9 years. Although all patients in this group had tenderness in the snuffbox, only nine of the original x-rays revealed a true scaphoid fracture. The ninety “clinical scaphoid fractures” were immobilized for twenty-three days on average. Of these, only six demonstrated future radiographic evidence of fracture. No injuries required surgery for non-union.

All pediatric scaphoid fractures that were diagnosed clinically or radiographically at our institution between 1998 and 2003 were reviewed. Initial and follow-up radiographs were examined for evidence of fracture.

Given the sequelae of untreated scaphoid fractures in adults, tenderness in the snuffbox has been used to diagnose “clinical scaphoid fractures”. Although never validated in children, this test continues to be used in this population. As the natural history of scaphoid fracture in children is more favorable than in adults, reliance on snuffbox tenderness alone has resulted in the over-treatment of this injury.

Background:

Glomus tumours of the hand are rare benign vascular tumours. The literature shows a limited number of case series with few patients treated over several years.

Between 1978 and 1997 all newborns in the Austrian province of Tyrol were reviewed regarding hip dysplasia and related surgery. This involved a mean of 8257 births per year (7766 to 8858). Two observation periods were determined: 1978 to 1982 (clinical examination alone) and 1993 to 1997 (clinical examination and universal ultrasound screening). A retrospective analysis compared the number and cost of interventions due to hip dysplasia in three patient age groups: A, 0 to < 1.5 years; B, ≥ 1.5 to < 15 years; and C, ≥ 15 to < 35 years.

In group A, there was a decrease in hip reductions from a mean of 25.2 (sd 2.8) to 7.0 (sd 1.4) cases per year. In group B, operative procedures decreased from a mean of 17.8 (sd 3.5) to 2.6 (sd 1.3) per year. There was a 75.9% decrease in the total number of interventions for groups A and B.

An increase of €57 000 in the overall cost per year for the second period (1993 to 1997) was seen, mainly due to the screening programme. However, there was a marked reduction in costs of all surgical and non-surgical treatments for dysplastic hips from €410 000 (1978 to 1982) to €117 000 (1993 to 1997). We believe the small proportional increase in costs of the universal ultrasound screening programme is justifiable as it was associated with a reduction in the number of non-surgical and surgical interventions. We therefore recommend universal hip ultrasound screening for neonates.

1. Twenty-one cases of congenital dislocation of the hip were found on examination of 1,881 consecutive neonates on the first day of life, giving an incidence of eleven per 1,000 live births.

2. Insignificant high-pitched "clicks" were noted in 10 per cent of newborn children.

3. Conversion of half of the patients with hip dislocation to normal occurred during the first post-natal week.

4. Joint laxity was not a feature of the newborn with congenital dislocation of the hip.

5. Oestradiol, oestrone and oestriol were estimated in twenty-fourhour urine samples collected from sixteen patients with congenital dislocation of the hip and nineteen matched controls during the first six days of life. No significant differences in oestrogen output between the two groups were found.

6. The hypothesis that congenital dislocation of the hip is a result of an inborn error of oestrogen metabolism in the newborn is not supported.

Pelvic x-ray is a routine part of the primary survey of Advanced Trauma Life Support (ATLS) guidelines. However, pelvic CT is the gold standard in the diagnosis of pelvic fractures. This study aims to confirm the safety of a modified ATLS algorithm omitting pelvic x-ray in hemodynamically stable polytraumatized patients with clinically stable pelvis, in favour of later pelvic CT scan.

A retrospective analysis of polytraumatized patients in our emergency room was conducted between 2005 and 2006. Inclusion criteria were blunt abdominal trauma, initial hemodynamic stability and clinically stable pelvis. We excluded patients requiring immediate intervention.

We reviewed the records of 452 patients. 91 fulfilled inclusion criteria (56% male, mean age 45 years). 43% were road traffic accidents and 47% falls. In 68/91 (75%) patients, both pelvic x-ray and CT examination were performed; the remainder had only pelvic CT. In 6/68 (9%) patients, pelvic fracture was diagnosed by pelvic x-ray. None false positive pelvic x-ray was detected. In 3/68 (4%) cases a fracture was missed in the pelvic x-ray, but confirmed on CT. 5 (56%) were classified type A fractures, and another 4 (44%) B 2.1 in computed tomography (AO classification). One A 2.1 fracture was found in a clinically stable patient who only received CT scan (1/23).

In hemodynamically stable patients with clinically stable pelvis, x-ray sensitivity is only 67% and it may safely be omitted in favor of a pelvic CT examination. The results support the safety and utility of our modified ATLS algorithm

The aim of this study was to compare the results of physical examination and magnetic resonance arthrography (MRA) in the diagnosis of superior labrum anterior posterior (SLAP) lesions of the shoulder. A review of all patients seen in 2005–2006 with an arthroscopically confirmed SLAP lesion was undertaken (n =22). Prior to surgery all patients had been examined prospectively by an upper limb physiotherapy practitioner and had then undergone MRA. All scans were undertaken and reported upon by an experienced consultant radiologist, specialising in musculo-skeletal conditions. A combination of 4 clinical tests were used to diagnose a SLAP lesion, these being O’Brien’s, pain provocation, bicep load and the crank test. To confirm a SLAP lesion a minimum of 2 of the above tests had to be positive. The sensitivity of each test in isolation and in combination and MRA sensitivity was determined and values statistically analysed for significance. The sensitivity of each isolated test was as follows: O’Brien’s = 82%, pain provocation = 86%, bicep load = 55% and the crank test = 68%. Using a combination of 2 or more positive tests was 95% sensitive, whereas MRA had a sensitivity of 64%. Using the McNemar test there was a statistically significant assosciation between positive clinical testing and negative MRA findings in the same patient (p< 0.05). The results would suggest that it may be advantageous to use a combination of physical tests rather than 1 test in isolation when examining a patient with a suspected SLAP lesion. The study would also suggest that even in the absence of radiological findings, in patients with a relevant history and strongly positive clinical signs, arthroscopic assessment may be indicated.

The aim of this study was first, to determine whether CT scans undertaken to identify serious injury to the viscera were of use in detecting clinically unrecognised fractures of the thoracolumbar vertebrae, and second, to identify patients at risk of ‘missed injury’. . We retrospectively analysed CT scans of the chest and abdomen performed for blunt injury to the torso in 303 patients. These proved to be positive for thoracic and intra-abdominal injuries in only 2% and 1.3% of cases, respectively. However, 51 (16.8%) showed a fracture of the thoracolumbar vertebrae and these constituted our subset for study. There were eight women and 43 men with mean age of 45.2 years (15 to 94). There were 29 (57%) stable and 22 (43%) unstable fractures. Only 17 fractures (33.3%) had been anticipated after clinical examination. Of the 22 unstable fractures, 11 (50%) were anticipated. Thus, within the whole group of 303 patients, an unstable spinal injury was missed in 11 patients (3.6%); no harm resulted as they were all protected until the spine had been cleared. A subset analysis revealed that patients with a high Injury Severity Score, a low Glasgow Coma Scale and haemodynamic instability were most likely to have a significant fracture in the absence of positive clinical findings. This is the group at greatest risk. Clinical examination alone cannot detect significant fractures of the thoracolumbar spine. It should be combined with CT imaging to reduce the risk of missed injury

The assortment of primary operative techniques starts with posterior release and ends with the most sophisticated ones such as complete subtalar release. The proper selection of one of them is a key to success and has to be done on the basis of clinical and radiographic parameters.

Posterior release: The indication for this procedure is determined by persistent equinus. On AP and lateral radiographs the normal talocalcaneal angle is visible AP greater than 20; lateral greater than 35 degrees). On the lateral radiograph in corrected equinus or standing, the angle between the calcaneus and tibia should be smaller than 80 degrees. A physical examination con- firms equinus position more precisely. Attention should be paid to the possibility of iatrogenic rocker bottom deformity. In such cases posterior release should be combined with dorsal release of the calcaneocuboid and talonavicular joint.

Posteromedial release: Clinical indications for this procedure are hindfoot equinus and varus and passively corrected medial spin measured with a bimalleolar angle less than 85 degrees. This angle should be checked during surgery when the posteromedial release is completed. If overcorrection is not achieved, the procedure has to be extended in sequence to lateral release or complete subtalar release. Radiographic indications are as follows: diminished talocalcaneal angle on AP (less than 20 degrees) and/or on lateral radiographs (less than 35 degrees), as well as partial overlap of the talus and calcaneus on AP radiographs.

Posteromedial-lateral, posterolateral-medial and partial subtalar release: Indications for these techniques are the same as for posteromedial release. The difference concerns the not corrigible medial spin. The decision about which technique should be used is made before surgery, but its conversion during surgery to another one is possible and depends on obstacles appearing during release. Intraoperative radiographs may help in making the decision.

Complete subtalar release: The clinical indication for this technique is primarily stiff varus and medial spin. The selection of this procedure may be the result of the primary decision or incomplete correction after less extensive procedures. To overcome the obstacles, the talocalcaneal interosseous ligament must be completely cut. Radiographic indications are the same as for posteromedial- lateral or partial subtalar release. Complete overlapping of the talus and calcaneus on AP radiograph inclines the surgeon to choose this method.

All techniques mentioned can be extended to the correction of forefoot adduction. A metatarsal first ray angle lower than 70 degrees is indicated for correction. For small children, the opening of the cuneonavicular and first cuneometatarsal joint with a slight transposition of the tibialis anterior is preferred. In older children, open wedge osteotomy of the medial cuneiform is done. For correction of calcaneocuboid displacement, no open reduction is performed even if a +2 displacement of the cuboid is seen on AP radiograph, because self-existent reduction occurred. However, closed stabilisation of this joint by K-wire is performed. A stable subtalar complex can be rotated as a block during partial or complete subtalar release.

Introduction

The available scoring methods and outcome analysis methods in lower extremity skeletal trauma with vascular injuries are not always specific. Biochemical parameters like venous blood lactate, bicarbonate and serum CPK (at the time of admission and serial monitoring) were measured to assess whether they supplement clinical parameters in predicting limb salvageability in lower extremity skeletal trauma with vascular injuries. Materials and methods: 74 adult patients with long bone fracture of lower limb associated with vascular injury (open and closed) were included in the study group. Patients with significant head injury (who cannot provide informed consent) and those with mangled extremities (MESS score>8) were excluded.

Aims. To analyze whether the addition of risk-based criteria to clinical examination-based selective ultrasound screening would increase the rates of early detected cases of developmental dysplasia of the hip (DDH) and decrease the rate of late detected cases. Methods. A systematic review with meta-analysis was performed. The initial search was performed in the PubMed, Scopus, and Web of Science databases in November 2021. The following search terms were used: (hip) AND (ultrasound) AND (luxation or dysplasia) AND (newborn or neonate or congenital). Results. A total of 25 studies were included. In 19 studies, newborns were selected for ultrasound based on both risk factors and clinical examination. In six studies, newborns were selected for ultrasound based on only clinical examination. We did not find evidence indicating that there are differences in the incidence of early- and late-detected DDH, or in the incidence of nonoperatively treated DDH between the risk-based and clinical examination-based groups. The pooled incidence of operatively treated DDH was slightly lower in the risk-based group (0.5 (95% confidence interval (CI) 0.3 to 0.7)) compared with the clinical examination group (0.9 per 1,000 newborns, (95% CI 0.7 to 1.0)). Conclusion. The use of risk factors in conjunction with clinical examination in the selective ultrasound screening of DDH might lead to fewer operatively treated cases of DDH. However, more studies are needed before stronger conclusions can be drawn. Cite this article: Bone Joint J 2023;105-B(3):247–253

Nonunions occur in situations with interrupted fracture healing process and indicate conditions where the fracture has no potential to heal without further intervention. Per definition, no healing is detected nine months post operation and there is no visible progress of healing over the last three months. The classification of nonunions as hypertrophic, oligotrophic, atrophic and pseudoarthosis, as well as aseptic or septic, identifies mechanical and biological requirements for fracture healing that have not been met. The overall treatment strategy comprises identification and elimination of the problems. However, current clinical methods to determine the state of healing are based on highly subjective radiographic evaluation or clinical examination. A data collection telemetric system for objective continuous measurement of the load carried by a bridging smart implant was developed to assess the mechanical stability and monitor bone healing in complicated fracture situations. The first results from a clinical trial show that the system is capable to offer early warning of nonunions or poor fracture healing. Nonunions are often multifactorial in nature and not just related to a biomechanical problem. Their successful treatment requires consideration of both biological and mechanical aspects. Disturbed vascularity and stability are the most important factors. Infection could be another complicating factor resulting in unpredictable long-time treatment. New technologies for monitoring of fracture healing in addition to radiographic evaluation and clinical examination seem to be promising for early detection of nonunions

Aims. The purpose of this study was to evaluate the mid-term outcomes of autologous matrix-induced chondrogenesis (AMIC) for the treatment of larger cartilage lesions and deformity correction in hips suffering from symptomatic femoroacetabular impingement (FAI). Methods. This single-centre study focused on a cohort of 24 patients with cam- or pincer-type FAI, full-thickness femoral or acetabular chondral lesions, or osteochondral lesions ≥ 2 cm. 2. , who underwent surgical hip dislocation for FAI correction in combination with AMIC between March 2009 and February 2016. Baseline data were retrospectively obtained from patient files. Mid-term outcomes were prospectively collected at a follow-up in 2020: cartilage repair tissue quality was evaluated by MRI using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. Patient-reported outcome measures (PROMs) included the Oxford Hip Score (OHS) and Core Outcome Measure Index (COMI). Clinical examination included range of motion, impingement tests, and pain. Results. A total of 12 hips from 11 patients were included (ten males, one female, mean age 26.8 years (SD 5.0), mean follow-up 6.2 years (SD 5.2 months)). The mean postoperative MOCART score was 66.3 (SD 16.3). None of the patients required conversion to total hip arthroplasty. Two patients had anterior impingement. External hip rotation was moderately limited in four patients. There was a correlation between MOCART and follow-up time (r. s. = -0.61; p = 0.035), but not with initial cartilage damage, age, BMI, or imaging time delay before surgery. PROMs improved significantly: OHS from 37.4 to 42.7 (p = 0.014) and COMI from 4.1 to 1.6 (p = 0.025). There was no correlation between MOCART and PROMs. Conclusion. Based on the reported mid-term results, we consider AMIC as an encouraging treatment option for large cartilage lesions of the hip. Nonetheless, the clinical evidence of AMIC in FAI patients remains to be determined, ideally in the context of randomized controlled trials. Cite this article: Bone Joint J 2024;106-B(5 Supple B):32–39

Aims. The ‘pink, pulseless hand’ is often used to describe the clinical situation in which a child with a supracondylar fracture of the humerus has normal distal perfusion in the absence of a palpable peripheral pulse. The management guidelines are based on the assessment of perfusion, which is difficult to undertake and poorly evaluated objectively. The aim of this study was to review the available literature in order to explore the techniques available for the preoperative clinical assessment of perfusion in these patients and to evaluate the clinical implications. Methods. A systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered prospectively with the International Prospective Register of Systematic Reviews. Databases were explored in June 2022 with the search terms (pulseless OR dysvascular OR ischaemic OR perfused OR vascular injury) AND supracondylar AND (fracture OR fractures). Results. A total of 573 papers were identified as being suitable for further study, and 25 met the inclusion criteria for detailed analysis. These studies included a total of 504 patients with a perfused, pulseless limb associated with a supracondylar humeral fracture. Clinical examination included skin colour (23 studies (92%)), temperature (16 studies (64%)), and capillary refill time (13 studies (52%)). Other investigations included peripheral oxygen saturation (SaO2) (six studies (24%)), ultrasound (US) (14 (56%)), and CT angiogram (two studies (8.0%)). The parameters of ‘normal perfusion’ were often not objectively defined. The time to surgery ranged from 1.5 to 12 hours. A total of 412 patients (82%) were definitively treated with closed or open reduction and fixation, and 92 (18%) required vascular intervention, ranging from simple release of entrapped vessels to vascular grafts. Conclusion. The description of the vascular assessment of the patient with a supracondylar humeral fracture and a pulseless limb in the literature is variable, with few objective criteria being used to define perfusion. The evidence base for decision-making is limited, and further research is required. We were able, however, to make some recommendations about objective criteria for the assessment of these patients, and we suggest that these are performed frequently to allow the detection of any deterioration of perfusion. Cite this article: Bone Joint J 2023;105-B(3):231–238

Abstract. Introduction. MRI scanning is the establish method of defining intra- and extra-articular diagnoses of patients with non-arthritic knee problems. Discrepancies in reporting have been noted in previous historic studies and anecdotally. The aim of this study was to analyse the reporting of intra-articular pathology and discrepancies in knee MRI reports by two clinician groups, consultant radiologists and consultant knee surgeons in a district hospital setting. Methods. A retrospective case-controlled cohort study was conducted using data collected from an outpatient physiotherapy-led knee clinic. Seventy-four patients in the cohort were referred for an MRI scan of their knee(s) following a clinical examination and history. MRI reports from both the consultant knee surgeon and the radiologist were entered into a database with other clinical details. Reports were analysed to determine number of diagnoses and degree of agreement. Each report was deemed to either completely agree, completely disagree or partially agree. Results. 87 knees were scanned in total. Of the 87 reports, 14% (n=12) completely agreed. 45% of the reports (n=39) partially agreed and 41% (n=36) completely disagreed. Of the reports which partially agreed 79% (n=31) had a percentage agreement of ≤ 50%. Conclusions. This study reveals major discrepancies in knee MRI reporting by two clinician groups. This has greatest clinical impact on non-surgical clinicians and those with limited MRI reviewing experience who are reliant on reports to describe diagnoses to patients and determining management plans. More research is required to determine the reasons for these differences and measures to mitigate them

Background. Iatrogenic hallux varus is a rare complication after hallux valgus surgery. Operative treatment comprises a wide variety of techniques, of which the reversed transfer of the abductor hallucis tendon is the most recent described technique. Methods. This paper will present the long-term clinical results of the reversed transfer of the abductor hallucis longus. Therefore, we performed a prospective clinical observational study on 16 female patients. Our hypothesis is that the tendon transfer will persist in a good alignment and patient satisfaction on long term. There is a 100% follow-up rate with a range from 10 to 101 months. Patients were subjected to a clinical examination, three questionnaires and their general satisfaction. Results. Out of 16 patients, at time of follow-up, we found a positive correlation between the subjective outcome score and alignment (r = 0.59), and between the general satisfaction and alignment (r = 0.77). Based on the general satisfaction we achieved a success satisfaction rate of 69% (11 patients). The other 31% (5 patients) patient group was only satisfied with major reservations or not satisfied at all. The two most invalidating complications were a coronal or sagittal malalignment or the combination of both. Conclusion. Our results suggest that the reverse abductor hallucis tendon transfer is a good technique to treat a supple iatrogenic hallux varus with an observed success satisfaction rate of 69% at a mean follow-up time of 48 (range 10–101) months. However, patients should be informed that on the long-term loss of correction is possible

Over 500 supracondylar humerus fractures (SCHF) are treated at our institution each year. Our standard post-operative pathway includes a 3-week visit for splint removal, wire removal, and radiographs. Subsequent follow-up occurs at 12 weeks for a clinical examination. In an effort to minimize unnecessary follow-up visits, we investigated whether photographs and/or patient-reported outcome measure (PROM) scores could identify patients who do not need routine 3-month in-person follow-up. At the 3-month visit, 248 SCHF patients (mean 6.2 yrs; 0.75-11yrs) had bilateral elbow motion (ROM) and carrying angles measured; and photographs documenting frontal and sagittal alignment of both injured and uninjured upper extremities, in both maximum elbow flexion and extension. Two independent assessors made the same measurements off the clinical photographs to compare these with the clinical measurements. Two PROMs: Self-Assessment Questionnaire (SAQ: 0 best to 14 worst) and QuickDASH (0 best to 100 worst) were completed at the 3-month visit. Inter-rater reliability of the photograph measurements was excellent (Kappa: 0.88-0.93), but weakly concordant with clinical measurements (carrying angle Kappa=0.51;max flexion Kappa=0.68;max extension Kappa=0.64). SAQ moderately correlated with QuickDASH (Kappa=0.59) and performed better at identifying patients with abnormalities. SAQ score ≥ 4 identified patients meeting 3-month follow-up criteria, with sensitivity: 36.1%; specificity: 96.8% and negative-predictive-value (NPV): 87%. We did not find that photographs were reliable. Although SAQ-score has high NPV, a more sensitive fracture-specific PROM is needed to identify patients who do not need a 3-month follow-up visit

Introduction. Autologous Matrix Induced Chondrogenesis (AMIC) for surgical treatment of osteochondral lesions of the talus (OCLT) has shown excellent clinical and radiological results at short term follow up two years after surgery. However, no mid-term follow up data is available. Aim. 1. To evaluate the clinical outcome after AMIC-aided reconstruction of osteochondral lesions of the talus at a minimum follow up time of five years. 2. To evaluate the morphology and quality of the regenerated cartilage by magnetic resonance imaging (MRI) at on at a minimum follow up time of five years. Methods. Seventeen patients prospectively underwent surgery receiving a AMIC-aided repair of OCLT consisting of debridement, autologous grafting, and sealing of the defect with a collagen scaffold (Chondro-Gide, Geistlich Surgery, Wolhusen, Switzerland). Clinical and radiological assessment was performed before and after a minimum of 60 months after surgery (average 78 months, range, 60–120). Clinical examination included the American Orthopaedic Foot & Ankle Society (AOFAS) ankle score and the Visual Analogue Scale (VAS). Radiological imaging consisted of MRI. The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was applied. Results. The AOFAS ankle score improved significantly from a mean of 60 points preoperatively (range, 17–79) to 91 points (range, 70–100) postoperatively (p< 0.01). The preoperative pain score averaged a VAS of 5 (range, 2–8), improving to an average of 1.1 (range 0–8) (p< 0.01). The MOCART score for cartilage repair tissue on postoperative MRI averaged 71 points (range, 50–90). Conclusion. The AMIC-procedure is safe for the treatment of OCLT with overall good clinical and magnetic resonance imaging results at five years follow up

We have previously reported on the medium-term outcomes following a non-operative protocol of a short period of splinting followed by early movement to treat simple dislocations of the elbow. We undertook extended follow up of our original patient study group to determine whether the excellent results previously reported were maintained in the very long-term. A secondary question was to determine the rate and need for any late surgical intervention. We attempted to contact all patients in the original patient study group. Patients were requested to complete the Oxford elbow score (OES), the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and a validated patient satisfaction questionnaire. Patients were requested to attend a face-to-face assessment where they underwent a clinical examination including neurovascular assessment, range-of-motion and an assessment of ligamentous stability. Seventy-one patients (65%) from the original patient study group agreed to participate in the study. The mean duration of follow-up was 19.3 years. At final follow-up patients reported excellent functional outcome scores and a preserved functional range of movement in the injured elbows. The mean DASH score was 5.22 points and the mean Oxford Elbow Score was 91.6 points. The mean satisfaction score was 90.9 points. Our study shows that the excellent outcomes following treatment with a protocol of a short period of splinting and early movement remain excellent and are maintained into the very long term. These findings support our hypothesis that this treatment protocol is appropriate and suitable for most patients with simple dislocations of the elbow. The role for primary ligamentous repair for this patient group should be carefully considered. Work to more clearly define the anticipated benefits of surgery for specific patient groups or injury patterns would help to support informed decision making

Background. Cauda equina syndrome (CES) is a spinal condition requiring emergency spinal surgery once diagnosed. The patient-reported symptoms are often subtle and none have been shown to be sensitive or specific in confirming CES. Magnetic resonance image (MRI) is the diagnostic gold standard, and guidelines recommend MRI access within 24-hours of symptom presentation. Limited sequence MRI scans (sagittal T2 sequences of the whole spine) have been shown to successfully identify patients with scan-positive CES despite reducing the duration of an MRI. The aim of this audit was to examine utilisation of same-day MRI requests by spinal practitioners from a newly operational same-day emergency care spinal unit over the two-year period. Methods and results. Data was routinely collected over the two-year period and retrospectively reviewed. Data extraction occurred for cases of suspected CES with a same-day scan. Data extraction included type of MRI scan (lumbar/ whole spine/ CES protocol); outcome (admission/ discharge); final diagnosis. After clinical examination, only 258 (24% of 1085) suspected CES cases were identified and scanned within 24 hours, 58% (n=149) of which were with CES limited sequence scans. Only 12% (n=30) demonstrated scan- positive CES resulting in surgery within 24-hours. MRI same-day requests increased between 2020 (n=81, 21%) and 2021 (n=177, 26%), although utilisation of limited sequence scans improved (n=39, 48% in 2020; n=109, 62% in 2021). Conclusion. Limited sequence MRI scans are a time- and cost-saving means of providing screening for those with suspected CES. Improved utility was demonstrated over the 2-year period by the spinal practitioners. Conflicts of interest: No conflicts of interest. Sources of funding: No sources of funding

In absence of available quantitative measures, the assessment of fracture healing based on clinical examination and X-rays remains a subjective matter. Lacking reliable information on the state of healing, rehabilitation is hardly individualized and mostly follows non evidence-based protocols building on common guidelines and personal experience. Measurement of fracture stiffness has been demonstrated as a valid outcome measure for the maturity of the repair tissue but so far has not found its way to clinical application outside the research space. However, with the recent technological advancements and trends towards digital health care, this seems about to change with new generations of instrumented implants – often unfortunately termed “smart implants” – being developed as medical devices. The AO Fracture Monitor is a novel, active, implantable sensor system designed to provide an objective measure for the assessment of fracture healing progression (1). It consists of an implantable sensor that is attached to conventional locking plates and continuously measures implant load during physiological weight bearing. Data is recorded and processed in real-time on the implant, from where it is wirelessly transmitted to a cloud application via the patient's smartphone. Thus, the system allows for timely, remote and X-ray free provision of feedback upon the mechanical competence of the repair tissue to support therapeutic decision making and individualized aftercare. The device has been developed according to medical device standards and underwent extensive verification and validation, including an in-vivo study in an ovine tibial osteotomy model, that confirmed the device's capability to depict the course of fracture healing as well as its long-term technical performance. Currently a multi-center clinical investigation is underway to demonstrate clinical safety of the novel implant system. Rendering the progression of bone fracture healing assessable, the AO Fracture Monitor carries potential to enhance today's postoperative care of fracture patients

The use of rotating hinge (RH) prostheses for severe primary as well as revision arthroplasty is widely established. Aim of this study was to investigate long term results of a new RH prosthesis (EnduRo®, B Braun, Germany), which uses carbon-fiber reinforced poly-ether-ether-ketone (CFR PEEK) as a new bearing material, first time used in knee arthroplasty. Fifty-six consecutive patients, who received the EnduRo® RH prosthesis were included in this prospective study: 21 patients (37.5%) received the prosthesis as a primary total knee arthroplasty (TKA) and 35 patients (62.5%) underwent revision total knee arthroplasties (rTKA). Clinical and radiographic examinations were performed preoperatively as well as postoperatively after 3 and 12 months and annually thereafter. Min. Follow up was 7 and mean follow up 9,3 years. Clinical examination included Knee Society Score (KSS), Western Ontario and McMaster Osteoarthritis Index (WOMAC), Oxford Knee Score (OKS), and range of motion (ROM). Competing risk analysis was assessed for survival with respect to indication and failure mode. KSS, WOMAC, OKS, and ROM significantly improved from the preoperative to the follow up investigations (p < 0.0001). There was no difference in clinical outcome between the primary and the revision group. The overall cumulative incidence for revision for any reason was 23.6% and the cumulative incidence for complications associated with failure of the prothesis was 5.6% at 7 years, respectively. Complications occurred more frequently in the revision group (p = 0.002). The evaluated RH prosthesis provided reliable and durable results with a minimum follow-up of 7 years. Prosthesis survival was successful considering the complexity of cases. The use of this RH system in primary patients showed high survival rates. Long-term functional and clinical results proved to be satisfying in both revision and primary cases. No adverse events were associated with the new bearing material CFR-PEEK

Os acromiale is a developmental defect caused by failure of fusion of the anterior epiphysis of the acromion between the ages of 22 and 25. The prevalence of os acromiale in the general population ranges from 1.4% to 15%. Os acromiale has been reported as a contributory factor to shoulder impingement symptoms and rotator cuff injuries, despite being a common incidental observation. In this retrospective study, we examined the prevalence of os acromiale in black African patients with shoulder pain. We retrospectively reviewed the clinical records, radiographs, and magnetic resonance imaging (MRI) scans of 119 patients who presented with atraumatic and minor traumatic shoulder pain at a single institution over a one-year period. Anteroposterior, scapula Y-view, and axillary view plain images were initially evaluated for the presence of os acromiale, and this was corroborated with axial MRI image findings. Patients with verified os acromiale had their medical records reviewed to determine their first complaint and the results of their clinical examination and imaging examination. Radiographs and MRI on 24 patients (20%) revealed an osacromiale. This cohort had a mean age of 59.2 years, and there were significantly more females (65%) than males. Meso-acromion was identified as the most prevalent type (n=11), followed by pre-os acromion (n=7). All patients underwent bilateral shoulder x-rays, and 45 percent of patients were found to have bilateral meso- acromion. Most patients (70%) were reported to have unstable os acromiale with subacromial impingement symptoms, and nine patients (36%) had confirmed rotator cuff tears based on clinical and Mri findings. Surgery was necessary for 47% of the 24 patients with confirmed Os acromiale (arthroscopic surgery, n=7; open surgery, n=1) in order to treat their symptoms. The prevalence of os acromiale in our African patients with atraumatic shoulder symptoms is greater than that reported in the general population. Os acromiale is a rare condition that should always be considered when evaluating shoulder pain patients

Introduction. Early clinical examination combined with MRI following a high ankle sprain allows accurate diagnosis of syndesmosis instability. However, patients often present late, and for chronic injuries clinical assessment is less reliable. Furthermore, in many centres MRI may be not be readily available. The aims of the current study were to define MRI characteristics associated with syndesmosis instability, and to determine whether MRI patterns differed according to time from injury. Methods. Retrospectively, patients with an unstable ligamentous syndesmosis injury requiring fixation were identified from the logbooks of two fellowship trained foot and ankle surgeons over a five-year period. After exclusion criteria (fibula fracture or absence of an MRI report by a consultant radiologist), 164 patients (mean age 30.7) were available. Associations between MRI characteristics and time to MRI were examined using Pearson's chi-square tests or Fisher's exact tests (significance set at p< 0.05). Results. Overall, 100% of scans detected a syndesmosis injury if performed acutely (within 6 weeks of injury), falling to 83% if performed after 12 weeks (p=0.001). In the acute group, 93.5% of patients had evidence of at least one of either PITFL injury (78.7%), posterior malleolus bone oedema (60.2%), or a posterior malleolus fracture (15.7%). In 20% of patients with a posterior malleolus bone bruise or fracture, the PITFL was reported as normal. The incidence of posterior malleolus bone bruising and fracture did not significantly differ according to time. Conclusion. For unstable ligamentous syndesmosis injuries, MRI becomes less sensitive over time. Importantly, posterior malleolus bone oedema or fracture may be the only evidence of a posterior injury. Failure to recognise instability may lead to inappropriate management of the patient, long term pain and arthritis. We therefore advocate early MRI as it becomes more difficult to ‘grade’ the injury if delayed

The direct anterior approach (DAA) is a popular minimally invasive approach for total hip arthroplasty (THA). It usually involves ligation of the lateral femoral circumflex artery's ascending branch (a-LFCA), which contributes to the perfusion of the tensor fasciae latae (TFL) muscle. Periarticular muscle status and clinical outcome were assessed after DAA-THA after a-LFCA preservation versus ligation. We evaluated surgical records of 161 patients undergoing DAA-THA with tentative preservation of the a-LFCA by the senior author between May and November 2021. Among 92 eligible patients, 33 (35 hips) featured successful preservation, of which 20 (22 hips, 13 female) participated in the study. From 59 patients with ligated a-LFCA, 26 (27 hips, 15 female) were enrolled, constituting the control group. MRI and clinical examinations were performed at 17–26 months to analyze volume and fatty infiltration of the TFL, gluteus medius and gluteus minimus muscles relative to the contralateral non-THA hip (15 preserved, 18 ligated). Clinical and radiographic data was retrospectively extracted from patient files. Patient-reported outcomes (PROMs) were added from the THA registry. There was a relative difference in TFL muscle volume of -6.27 cm. 3. (−9.89%, p=0.018) after a-LFCA preservation versus -8.6 cm. 3. (=11.62%, p=0.002) after ligation, without group differences (p>0.340). a-LFCA preservation showed lower relative TFL fatty infiltration (p=0.10). Gluteal muscle status was similar between sides and groups. Coxa valga morphology was more frequent in a-LFCA preservation (83%) than ligation (17%). Clinical outcomes showed high patient satisfaction in both groups, without difference in PROMs, but less anterolateral soft-tissue swelling after a-LFCA preservation (p<0.001). Despite excellent clinical results in both groups, preservation of the a-LFCA was associated with less TFL fatty infiltration and soft tissue swelling. Provided there is no compromise of intraoperative access we recommend a-LFCA preservation for DAA-THA

Tenotomy of the iliopsoas tendon has been described as an effective procedure to treat refractive groin pain induced by iliopsoas tendinitis. However, the procedure forces the rectus femoris to act as the primary hip flexor and little is known about the long-term effects of this procedure on the peri-articular muscle envelope (PAME). Studies suggest that iliopsoas tenotomy results in atrophy of the iliopsoas and decreased hip flexion strength with poorer outcomes, increasing the susceptibility for secondary tendinopathy. The aim of this study is to describe changes in the PAME following psoas release. All patients who presented for clinical examination at our hospital between 2016 and 2021 were retrospectively reviewed. Patients who presented after psoas tenotomy with groin pain and who were unable to actively lift the leg against gravity, were included. Pelvic MRI was taken. Qualitative muscle evaluation was done with the Quartile classification system. Quantitative muscle evaluation was done by establishing the cross-sectional area (CSA). Two independent observers evaluated the ipsi- and contralateral PAME twice. The muscles were evaluated on the level: iliacus, psoas, gluteus minimus-medius-maximus, rectus femoris, tensor fasciae lata, piriformis, obturator externus and internus. For the qualitative evaluation, the intra- and inter-observer reliability was calculated by using kappastatistics. A Bland-Altman analysis was used to evaluate the intra- and inter-observer reliability for the quantitative evaluation. The Wilcoxon test was used to evaluate the changes between the ipsi- and contra-lateral side. 17 patients were included in the study. Following psoas tenotomy, CSA reduced in the ipsilateral gluteus maximus, if compared with the contralateral side. Fatty degeneration occurred in the tensor fascia latae. Both CSA reduction and fatty degeneration was seen for psoas, iliacus, gluteus minimus, piriformis, obturator externus and internus. No CSA reduction and fatty degeneration was seen for gluteus medius and rectus femoris. Conclusions/Discussion. Following psoas tenotomy, the PAME of the hip shows atrophy and fatty degeneration. These changes can lead to detrimental functional problems and may be associated with debilitating rectus femoris tendinopathy. In patients with psoas tendinopathy, some caution is advised when considering an iliopsoas tenotomy

In 2010, we published results of Ponseti versus primary posteromedial release (PMR) for congenital talipes equinovarus (CTEV) in 51 prospective patients. This study reports outcomes at a median of 15 years from original treatment. We followed 51 patients at a median of 15 years (range 13–17 years) following treatment of CTEV with either Ponseti method (25 patients; 38 feet) or PMR (26 patients; 42 feet). Thirty-eight patientsd were contacted and 33 participated in clinical review (65%), comprising patient reported outcomes, clinical examination, 3-D gait analysis and plantar pressures. Sixteen of 38 Ponseti treated feet (42%) and 20 of 42 PMR treated feet (48%) had undergone further surgery. The PMR treated feet were more likely to have osteotomies and intra- articular surgeries (16 vs 5 feet, p<0.05). Of the 33 patients reviewed with multimodal assessment, the Ponseti group demonstrated better scores on the Dimeglio (5.8 vs 7.0, p<0.05), the Disease Specific Instrument (80 vs 65.6, p<0.05), the Functional Disability Inventory (1.1 vs 5.0, p<0.05) and the AAOS Foot & Ankle Questionnaire (52.2 vs. 46.6, p < 0.05), as well as improved total sagittal ankle range of motion in gait, ankle plantarflexion range at toe off and calf power generation. The primary PMR group displayed higher lateral midfoot and forefoot pressures. Whilst numbers of repeat surgical interventions following Ponseti treatment and primary PMR were similar, the PMR treated feet had greater numbers of osteotomies and intra-articular surgeries. Outcomes were improved at a median of 15 years for functional data for the Ponseti method versus PMR, with advantages seen in the Ponseti group over several domains. This study provides the most comprehensive evaluation of outcomes close to skeletal maturity in prospective cohorts, reinforcing the Ponseti Method as the initial treatment of choice for idiopathic clubfeet

Magnetic resonance imaging (MRI) is the gold standard for the diagnosis of the pathologies affecting the glenohumeral joint and the rotator cuff diseases. MRI allows to highlight anatomic discontinuities of both muscles and tendons. However, MRI diagnostic accuracy has not proven to be highly sensitive in distinguishing between a partial-thickness tear and a full-thickness rotator cuff tear. The purpose of this study was to determine if MRI under axial traction can be helpful in increasing MRI sensitivity to identify partial-thickness rotator cuff tears. The study included 10 patients (4 males and 6 females) who had clinical examination and MRI suggesting a partial-thickness rotator cuff tear. They were candidates for shoulder arthroscopy because of persistent symptoms after at least three months of conservative treatment. The patients underwent a new MRI (under axial traction: MRI-AT) with a 4-kg weight applied to the affected arm. Then the patients underwent arthroscopy to confirm the diagnosis. Patients with a suspected full-thickness rotator cuff tear were excluded from the study. Patients’ average age was 52.4 years, and the dominant side was affected in 77.7% of the cases. Preoperative Constant-Murley Score was 57. MRI-AT showed that 3 patients were affected by a complete tear of the rotator cuff, 3 patients by a partial-thickness rotator cuff tear and 4 patients had no lesion. The analysis of data showed that: under axial traction the subacromial space increased by 0,2 mm (P value = 0,001075), the superior glenohumeral space decreased by 2.4 mm (P value = 0,07414), the inferior glenohumeral space increased by 0.3 mm (P value = 0,02942), the acromial angle decreased by 1.9° (P value = 0,0002104) and the acromion-glenohumeral angle decreased by 0.3° (P-value = 0,01974). Two experienced evaluators analyzed previous standard MRI and MRI-AT scans in a double-blinded fashion, with inter-rater evaluation of all the images and measures. Intraclass correlation coefficient (ICC) has been utilized to assess the reliability of the measures performed by different operators. ICC always resulted in more than 0.7, showing a high concordance among values in the same group. A comparative evaluation between standard MRI and MRI-AT has been conducted to highlight possible discrepancies and this has been compared to intraoperative findings. Concordance of the values was 89% between standard MRI and MRI-AT and 100% between MRI under axial traction and intraoperative findings. This study showed a high correlation between the diagnosis achieved with MRI-AT and the intraoperative arthroscopic findings. The use of MRI-AT in clinical practice may improve the diagnostic sensitivity of this method to detect a partial-thickness rotator cuff tear

Aim. Treatment algorithms for fracture-related nonunion depend on the presence or absence of bacterial infection. However, the manifestation of septic nonunion varies. Low-grade infections, unlike manifest infections, lack clinical signs of infection and present similarly to aseptic nonunion. The clinical importance of low-grade infection in nonunion is not entirely clear. Therefore, the aim of this study was to evaluate the clinical relevance of low-grade infection in the development and management of femoral or tibial nonunion. Method. A prospective, multicenter clinical study enrolled patients with nonunion and regular healed fractures. Preoperatively, complete blood count without differential, C-reactive protein (CRP), and procalcitonin were obtained, clinical signs of infection were recorded, and a suspected septic or aseptic diagnosis was made based on history and clinical examination. During surgical nonunion revision or routine implant removal, tissue samples were collected for microbiology and histopathology, and osteosynthesis material for sonication. Nonunion patients were followed for 12 months. Definitive diagnosis of “septic” or “aseptic” nonunion was made according to diagnostic criteria for fracture-related infection, considering the results of any further revision surgery during follow-up. Results. 34 patients with regular healed fractures were included. 62 nonunion patients were diagnosed as aseptic, 22 with manifest, and 23 with low-grade infection. The positive predictive value was 88% and the negative predictive value 72% for the suspected diagnosis. The nonunion groups had significantly higher CRP levels than the regular healer group. Differentiation between septic and aseptic nonunion based on blood values was not possible. Low-grade infection demonstrated less frequently histopathologic signs of infection than manifest infection (22% vs. 50%, p=0.048), with 15% of regular healers having histopathologic signs of infection. Cutibacterium acnes was less present in manifest compared to low-grade infection (p=0.042). Healing rates for septic nonunion involving C. acnes were significantly lower for manifest infection (20%) than for low-grade infection (100%, p=0.002). Patients with low-grade infection were treated with systemic antibiotics less frequently than patients with manifest infection (p=0.026), with no significant difference in healing rate (83% vs. 64%), which was slightly lower for low-grade infection than for aseptic nonunion (90%). Conclusions. Low-grade infections play a significant role in nonunion development and are difficult to diagnose preoperatively due to the lack of clinical signs of infection and unremarkable blood counts. However, our results imply that for low-grade infections, antibiotic therapy may not always be mandatory to heal the nonunion. This study was supported by the German Social Accident Insurance (FF-FR0276)

Spinal deformations are posture dependent. Official data from the Netherlands show that youth are encountering increasing problems with the musculoskeletal system (>40% back pain, and sport injury proneness). Prolonged sloth and slumped sitting postures are causative factors. Dutch youth are “champion sitting” in Europe. The effects of sitting on the development of posture and function of locomotion (stiffness) during growth have only been reported clearly in classic textbooks (in German) of practical anatomy and orthopaedics. Research with relevant clinical examinations is being done to understand epidemiological data on the increasing posture-dependent problems. A cohort of adolescents (15–18 years) in secondary school was assessed for sagittal postural deviations while bending. 248 children completed a questionnaire, and tests were done on neuromuscular tightness. The femorotibial angle was used to measure hamstring tightness. Measurement of the dorsiflexion of the foot was used to assess the tightness of calf muscles and Achilles tendons. All adolescents were photographed laterally while performing the finger–floor test (used to test flexibility), assessed as a knockout test: “Can you reach the floor or not?” The spinal profiles while bending were classified as abnormal arcuate or angular kyphosis. Hamstring tightness was present in 62.1% of the cohort in both legs, and in 18.2% unilaterally. Achilles tendon tightness was present bilaterally in 59.3%, and unilaterally in 19.4%. Activities with presence of stiffness (finger–floor distance), in descending order, were football, running, no sports, field hockey, tennis, dance, and gymnastics. 93.5% of the soccer players had tight hamstrings in both legs compared with none of those performing gymnastics. The correlation of the finger–floor test with tight hamstrings was 73.2%. For sagittal bending deformities, the correlation between form and function deficits cannot be made yet. 80 of 248 spines were rated by the examiners as having deformed flexion. Since Andry (1741) and at the zenith of continental orthopaedics and anatomy around 1900, the prolonged flexed positions of a young spine were indicated as being the main cause of deformity by overload and shear loads on immature discs and cartilage, preventing normal development of the discs. Nachemson proved that the intradiscal pressure in sitting adults was extremely high, so it follows that children must also be at risk. Evidence suggests that youth, generally because of their sedentary and “screenful lifestyle”, will encounter serious problems in growth, manifesting as incongruent neuro-osseous growth (Roth), serious neuromuscular tightness (being prone to injury), and spinal deformations, leading to pain

There is no consensus regarding the optimum frequency of ultrasound for monitoring the response to Pavlik harness (PH) treatment in developmental dysplasia of hip (DDH). The purpose of our study was to determine if a limited-frequency hip ultrasound (USS) assessment in children undergoing PH treatment for DDH had an adverse effect on treatment outcomes when compared to traditional comprehensive ultrasound monitoring. This study was a single-center non-inferiority randomized controlled trial. Children aged less than six months of age with dislocated, dislocatable and stable dysplastic hips undergoing a standardized treatment program with a PH were randomized, once stability had been achieved, to our current standard USS monitoring protocol (every clinic visit) or to a limited-frequency ultrasound protocol (USS only until hip stability and then end of treatment). Groups were compared based on alpha angle at the end of treatment, acetabular indices (AI) and IHDI grade on follow up radiographs at one-year post harness and complication rates. The premise was that if there were no differences in these outcomes, either protocol could be deemed safe and effective. One hundred patients were recruited to the study; after exclusions, 42 patients completed the standard protocol (SP) and 36 completed the limited protocol (LP). There was no significant difference between the mean age between both groups at follow up x-ray (SP: 17.8 months; LP: 16.6 months; p=0.26). There was no difference between the groups in mean alpha angle at the end of treatment (SP: 69°; LP: 68.1°: p=0.25). There was no significant difference in the mean right AI at follow up (SP: 23.1°; LP: 22.0°; p=0.26), nor on the left (SP:23.3°; LP 22.8°; p=0.59). All hips in both groups were IHDI grade 1 at follow up. The only complication was one femoral nerve palsy in the SP group. In addition, the LP group underwent a 60% reduction in USS use once stable. We found that once dysplastic or dislocated hips were reduced and stable on USS, a limited- frequency ultrasound protocol was not associated with an inferior complication or radiographic outcome profile compared to a standardized PH treatment pathway. Our study supports reducing the frequency of ultrasound assessment during PH treatment of hip dysplasia. Minimizing the need for expensive, time-consuming and in-person health care interventions is critical to reducing health care costs, improving patient experience and assists the move to remote care. Removing the need for USS assessment at every PH check will expand care to centers where USS is not routinely available and will facilitate the establishment of virtual care clinics where clinical examination may be performed remotely

Rotator cuff repair has excellent clinical outcomes but continues to be a challenge when it comes to large and massive tears as well as revision procedures. Reported symptomatic retear rates are still too high to be acceptable. The purpose of the present study was to evaluate the effectiveness of a combination of augmentation techniques consisting of microfractures of the greater tuberosity, extracellular matrix (ECM) patch graft and subsequent platelet concentrate (PC) subacromial injections in revision rotator cuff repair. The study was designed as a retrospective comparative study on prospectively collected data from a consecutive cohort of patients. All patients who underwent arthroscopic revision rotator cuff repair for symptomatic failure of previous posterosuperior rotator cuff repair were considered eligible for the study. Symptomatic failure had been diagnosed according to clinical examination and confirmed by magnetic resonance imaging (MRI). Structural integrity had been assessed on MRI and classified according to Sugaya classification. Only patients affected by stage IV-V were considered eligible. Tear reparability was confirmed during arthroscopy. Only patients with a minimum 2 years follow-up were included. Patients were divided in two groups. In group 1 (control group) a standard arthroscopic revision and microfractures of the greater tuberosity were performed; in group 2 (experimental group), microfractures of the greater tuberosity and a ECM patch graft were used to enhance tendon repair, followed by postoperative PC injections. Minimum follow-up was 12 months. Primary outcome was the Constant-Murley score (CMS) normalized for age and gender. Subjective outcome was assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) score in its short version (Quick-DASH). Tendon integrity was assessed with MRI at 6 months after surgery. Comparison between groups for all discrete variables at baseline and at follow-up was carried out with the Student's t-test for normally distributed data, otherwise Mann-Whitney U-test was used. Within-group differences (baseline vs follow-up) for discrete variables were analyzed by paired t-test, or by Wilcoxon signed-rank test in case of data with non-normal distribution. Differences for categorical variables were assessed by chi-squared test. Significance was considered for p values < 0.05. Forty patients were included in the study (20 patients for each group). The mean follow-up was 13 ± 1.6 months. No patients were lost at the follow up. Comparison between groups did not show significant differences for baseline characteristics. At follow-up, mean CMS was 80.7 ± 16.6 points in group 1 and 91.5 ± 11.5 points in group 2 (p= 0.022). Mean DASH score was 28.6 ± 21.6 points in group 1 and 20.1 ± 17.4 points in group 2 (p= 0.178). Post-operative MRI showed 6 healed shoulders in Group 1 and 16 healed shoulders in Group 2 (p<0.004). No postoperative complications were reported in both groups. The combination of microfractures of the greater tuberosity, ECM patch graft, and subsequent PC subacromial injections is an effective strategy in improving tendon healing rate

Background. FORECAST is a prospective longitudinal cohort study exploring mechanism-based prognostic factors for pain persistence in sciatica. Here, we share an update on this largest deeply-phenotyped primary care sciatica cohort. Methods/results. Our cohort includes 180 people with sciatica (score >4 on Stynes’ Sum Score), aged 18–85, within 3 months of symptom onset. Psychosocial factors, self-reported sensory profiling, clinical examination, quantitative sensory testing (QST), biological samples (blood and skin samples), and Magnetic Resonance Neurography of lumbar nerve roots were collected at baseline. Pain persistence was determined at three and twelve months with the Sciatica Bothersomeness Index (SBI) and a numeric pain rating scale (NRS) as primary outcomes. Recruitment nears completion, with 160 participants enrolled to date. 127 and 96 participants have completed 3 and 12 months follow-up respectively. Overall, 56% of our cohort are female, with a mean age (SD) of 54.14yrs (16.57). Ethnicity data approximates local populations. SBI at baseline was (median [IQR]) 13[10-17], and interim longitudinal data shows stepwise improvement at 3 and 12 months. Baseline ‘average’ pain intensity was 5.56 (2.15) for leg pain, and 4.14(2.82) for low back pain (LBP). Overall, pain scores decreased at 3 and 12 months, with greater reductions in leg pain than LBP at 12 months. However, around 55–80% and 40–65% of people reported persistent pain at 3 and 12 months respectively. Conclusion. Leg pain severity was moderate and higher than LBP at baseline. All primary outcome measures demonstrate improvement over time, however 40–65% of patients report persistent pain at 12 months. Conflicts of interest. LR: Paid facilitation of post-graduate courses internationally. SK, MT, FP, KM, WS, CP, CR, SC: No conflicts of interest. GC: Editor in Chief of Health Psychology Review. Director of board of directors, MentalCHealth Care setting NoordWestVlaanderen. JF: Copyright holder of ODI (Oswestry Disability Index). Served on a data monitoring committee for a clinical trial of 2 different surgical approaches to cervical disc herniation (FORVAD). Member of HTA Prioritisation Committee B: Inside hospital Care from 2015-February 2019. Member of HTA Interventional Procedures Panel from 2010–2015. Trustee and board member of 3 spine related charities – Back to Back; British Scoliosis Research Foundation and BackCare. Expert instructed by both claimant and defendant solicitors in negligence and person injury cases. GB: Paid consultancy (RNA-seq) with Ivy Farm and Coding.bio. ABS: Paid post-graduate lecturing internationally. Co-chair NeupSig sciatica working group (unpaid). Sources of funding. This project is funded by UKRI and Versus Arthritis as part of the UKRI Strategic Priorities Fund (SPF) Advanced Pain Discovery Platform (APDP), a co-funded initiative by UKRI (MRC, BBSRC, ESRC), Versus Arthritis, the Medical Research Foundation and Eli Lilly and Company Ltd (Grant MR/W027003/1). Additional funding has been received from the back to back charity to expand longitudinal components of the study. LR has received support with PhD fees from the CSP charitable trust. ABS is supported by a Wellcome Trust Clinical Career Development Fellowship. (222101/Z/20/Z). WS is partly funded through the National Institute for Health and Care Research (NIHR) Biomedical Research Centre at the South London and Maudsley NHS Foundation Trust and King's College London. FP is funded by a Dorothy Hodgkin Career Development Fellowship in Chemistry in association with Somerville College. GB is supported by the Wellcome Trust (223149/Z/21/Z) and Diabetes UK (19/0005984). GC and KRM are partly funded by UKRI and Versus Arthritis as part of the Advanced Pain Discovery Platform (APDP) PAINSTORM (MR/W002388/1). The UKRI and Versus Arhthritis (APDP) are the major funders of FORECAST. All other funders provided either some people support, or funded projects with legacy data that we reuse

Barriers to successful return to previous level of activity following Anterior Cruciate Ligament Recon-struction (ACLR) are multifactorial and recent research suggests that athletic performance deficits persist after completion of the rehabilitation course in a large percentage of patients. Thirty soccer athletes (26.9 ± 5.7 years old, male) with ACL injury were surgically treated with all-inside technique and semitendi-nosus tendon autograft. At 2 years from surgery, they were called back for clinical examination, self-reported psychological scores, and biomechanical outcomes (balance, strength, agility and velocity, and symmetry). Nonparametric statistical tests have been adopted for group comparisons in terms of age, concomitant presence of meniscus tear, injury on dominant leg, presence of knee laxity, presence of varus/valgus, body sides, and return to different levels of sports. Athletes with lower psychological scores showed lesser values in terms of power, resistance and neuromuscular activity as compared to the ones with good psychological scores that showed, instead, better self-reported outcomes (TLKS, CRSQ) and low fear of reinjury (TSK). In the athletes who had a functional deficit in at least one subtest, a safe return to sports could not have been recommended. Our findings confirmed that demographics, physical function, and psychological factors were related to playing the preinjury level sport at mean 2 years after surgery, sup-porting the notion that returning to sport after surgery is multifactorial. A strict qualitative and quantitative assessment of athletes’ status should be performed at different follow-ups after surgery to guarantee a safe and controlled RTP

Aims. The aim of this retrospective study was to determine if there are differences in short-term clinical outcomes among four different types of matrix-associated autologous chondrocyte transplantation (MACT). Methods. A total of 88 patients (mean age 34 years (SD 10.03), mean BMI 25 kg/m. 2. (SD 3.51)) with full-thickness chondral lesions of the tibiofemoral joint who underwent MACT were included in this study. Clinical examinations were performed preoperatively and 24 months after transplantation. Clinical outcomes were evaluated using the International Knee Documentation Committee (IKDC) Subjective Knee Form, the Brittberg score, the Tegner Activity Scale, and the visual analogue scale (VAS) for pain. The Kruskal-Wallis test by ranks was used to compare the clinical scores of the different transplant types. Results. The mean defect size of the tibiofemoral joint compartment was 4.28 cm. 2. (SD 1.70). In total, 11 patients (12.6%) underwent transplantation with Chondro-Gide (matrix-associated autologous chondrocyte implantation (MACI)), 40 patients (46.0%) with Hyalograft C (HYAFF), 21 patients (24.1%) with Cartilage Regeneration System (CaReS), and 15 patients (17.2%) with NOVOCART 3D. The mean IKDC Subjective Knee Form score improved from 35.71 (SD 6.44) preoperatively to 75.26 (SD 18.36) after 24 months postoperatively in the Hyalograft group, from 35.94 (SD 10.29) to 71.57 (SD 16.31) in the Chondro-Gide (MACI) group, from 37.06 (SD 5.42) to 71.49 (SD 6.76) in the NOVOCART 3D group, and from 45.05 (SD 15.83) to 70.33 (SD 19.65) in the CaReS group. Similar improvements were observed in the VAS and Brittberg scores. Conclusion. Two years postoperatively, there were no significant differences in terms of outcomes. Our data demonstrated that MACT, regardless of the implants used, resulted in good clinical improvement two years after transplantation for localized tibiofemoral defects. Cite this article: Bone Joint Res 2021;10(7):370–379

Aim. The diagnosis of septic arthritis mostly relies on clinical examination, several blood parameters including white blood cell count, C-reactive protein, sedimentation, and the analysis of the joint aspiration. However, the diagnosis can be difficult when the symptoms are vague and the information obtained from laboratory might be insufficient for definitive diagnosis. This study aimed to evaluate several ratios obtained from routine blood tests for a possible use in the diagnosis of septic arthritis. Method. The adult patients who were operated in our clinic due to septic arthritis between 2014–2020 were identified and retrospectively evaluated. The patients with any blood disorders or missing file information were excluded. A total of 36 patients were found to be eligible for inclusion. The control group included 40 patients without any sign of infection who underwent total knee arthroplasty due to knee osteoarthritis. Preoperative blood tests of each patients were examined. In addition to CRP and sedimentation values, neutrophil-lymphocyte, monocyte-lymphocyte, platelet-lymphocyte, and platelet count-mean platelet volume were calculated and receiving operating characteristics (ROC) curve analysis was made to determine the sensitivity, specificity and area under curve (AUC) values of these parameters. Results. The distribution of affected joint in septic arthritis group was as follow; 22 knees, 6 hips, 4 shoulders, 2 elbows, 1 wrist and 1 ankle. The cultures of joint aspiration yielded positive result in 19 patients while the cultures were negative in 17 patients. All of the analyzed parameters were significantly different between the groups (p<0.001). ROC curve analysis results are given in detail, in Table 1 and Figure 1. The AUC value was 97.3 when only CRP and sedimentation values were used but increased to 98.6 when neutrophile/ lymphocyte ratio was added and increased to 100 when all analyzed parameters were included. Conclusions. The analyzed parameters were found to increase the overall sensitivity and specificity when used together with acute phase reactants. However, when evaluated separately, CRP and sedimentation were still found as the most valuable parameters in the diagnosis of septic arthritis. In the diagnosis of septic arthritis, 35 mm/hr cut-off value for sedimentation and 10 mg/L cut-off value for CRP were found more sensitive and specific compared to standard laboratory cut-off values of 20 mm/hr and 5 mg/L. For any tables or figures, please contact the authors directly

Introduction and Objective. The surgical strategy for acetabular component revision is determined by available host bone stock. Acetabular bone deficiencies vary from cavitary or segmental defects to complete discontinuity. For segmental acetabular defects with more than 50% of the graft supporting the cup it is recommended the application of reinforcement ring or ilioischial antiprotrusio devices. Acetabular reconstruction with the use of the antiprotrusion cage (APC) and allografts represents a reliable procedure to manage severe periprosthetic deficiencies with highly successful long-term outcomes in revision arthroplasty. Objective. We present our experience, results, critical issues and technical innovations aimed at improving survival rates of antiprotrusio cages. Materials and Methods. From 2004 to 2019 we performed 69 revisions of the acetabulum using defrosted morcellized bone graft and the Burch Schneider anti-protrusion cage. The approach was direct lateral in 25 cases, direct anterior in 44. Patients were re-evaluated with standard radiography and clinical examination. Results. Eight patients died from causes not related to surgery, and two patients were not available for follow up. Five patients were reviewed for, respectively, non-osseointegration of the ring, post-traumatic loosening with rupture of the screws preceded by the appearance of supero-medial radiolucency, post-traumatic rupture of the distal flange, post-traumatic rupture of the cemented polyethylene-ceramic insert, and dislocation treated with new dual-mobility insert. Among these cases, the first three did not show macroscopic signs of osseointegration of the ring, and the only areas of stability were represented by the bone-cement contact at the holes in the ring. Although radiographic studies have shown fast remodeling of the bone graft and the implant survival range from 70% to 100% in the 10-year follow up, the actual osseointegration of the ring has yet to be clarified. To improve osseointegration of the currently available APC whose metal surface in contact with the bone is sandblasted, we combined the main features of the APC design long validated by surgical experience with the 3D-Metal Technology for high porosity of the external surface already applied to and validated with the press fit cups. The new APC design is produced with the 3D-Metal technology using Titanium alloy (Ti6Al4V ELI) that Improves fatigue resistance, primary stability and favorable environment for bone graft ingrowth. We preview the results of the first cases with short-term follow up. Conclusions. Acetabular reconstruction with impacted morcellized bone graft and APC is a current and reliable surgical technique that allows the restoration of bone loss with a high survival rate of the implant in the medium to long term. The new 3D Metal Cage is designed to offer high friction for the initial stability. The high porosity of the 3D Metal structure creates a favorable environment for bone growth, thus providing valid secondary fixation reproducing the results achieved with the 3D metal press fit cup

Introduction. Anterior tibial translation (ATT) is assessed in the acutely injured knee to investigate for ligamentous injury and rotational laxity. Specifically, there is a growing recognition of the significance of anterior medial rotary laxity (AMRI) as a crucial element in assessing knee stability. Anterior cruciate ligament (ACL) injuries are often accompanied with medial collateral ligament (MCL) damage. It has been suggested that Deep MCL (dMCL) fibres are a primary restraint in rotational displacement. This research aims to quantify the difference in rotational laxity of patients with ACL and MCL injuries to deem if the Feagin-Thomas test can robustly capture metrics of AMRI. 2. Methods. AMRI was assessed using the Feagin-Thomas test in 7 isolated ACL (iACL) injured participants, 3 combined ACL and superficial fibre MCL (sMCL) injuries, 5 combined ACL and deep fibre MCL injuries, and 21 healthy controls. Displacement values were recorded using an optical motion capture (OMC) system and bespoke processing pipeline which map and model the knee's anterior displacement values relative to the medial compartment. Since absolute values (mm) of rotational laxity vary dependant on the person, values were recorded as a proportion of the rotational laxity obtained from the subject's contralateral leg. Values were compared between each patient group using an ANOVA test and Tukey's honesty significant difference post hoc test. 3. Results. The healthy control group had a median proportion of 0.97 (3SF), whilst the iACL was 1.12 (3SF), a 12% increase in rotational laxity in the injured leg. The sMCL group yielded a result of 1.64 (3SF), a 64% increase in rotational laxity in the injured leg; finally, dMCL resulted in a proportion of rotational laxity of 1.90 (3SF), a 90% increase in rotational laxity [table 1]. Whilst all groups showed differences in the increase of rotational laxity, dMCL was significantly different from the healthy control group (P value 0.0041). 4. Conclusion. ACL injuries with MCL involvement led to an increase in anterior medial rotary laxity and this is more evident in patients where deep MCL fibres are involved. The Feagin-Thomas test appears to be sensitive in detecting differences in AMRI and should be considered when performing comprehensive clinical knee examination. For any figures or tables, please contact authors directly

Lisfranc injuries are uncommon and can be challenging to manage. There is considerable variation in opinion regarding the mode of operative treatment of these injuries, with some studies preferring primary arthrodesis over traditional open reduction and internal fixation (ORIF). We aim to assess the clinical and radiological outcomes of the patients treated with ORIF in our unit. This is a retrospective study, in which all 27 consecutive patients treated with ORIF between June 2013 and October 2018 by one surgeon were included with an average follow-up of 2.4 years. All patients underwent ORIF with joint-sparing surgery by a dorsal bridging plate (DBP) for the second and third tarsometatarsal (TMT) joint, and the first TMT joint was fixed with trans-articular screws. Patients had clinical examination and radiological assessment, and completed American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score and Foot Function Index (FFI) questionnaires. Our early results of 22 patients (5 lost to follow-up) showed that 16 (72%) patients were pain free, walking normally without aids, and wearing normal shoes and 68% were able to run or play sports. The mean AOFAS midfoot score was 78.1 (63–100) and the average FFI was 19.5 (0.6–34). Radiological assessment confirmed that only three patients had progression to posttraumatic arthritis at the TMT joints though only one of these was clinically symptomatic. Good clinical and radiological outcomes can be achieved by ORIF in Lisfranc injuries with joint-sparing surgery using DBP

The ankle radiograph is a commonly requested investigation as the ankle joint is commonly injured. Each radiograph exposes 0.01 mSv of radiation to the patient that is equivalent to 1.5 days of natural background radiation [1]. The aim of the clinical audit was to use the Ottawa Ankle Rule to attempt to reduce the number of ankle radiographs taken in patients with acute ankle injuries and hence reduce the dose of ionising radiation the patient receives. A retrospective audit was undertaken. 123 ankle radiograph requests and radiographs taken between May and July 2018 were evaluated. Each ankle radiograph request including patient history and clinical examination was graded against the Ottawa Ankle Rule. The rule states that 1 point(s) indicates radiograph series; (1) malleolar and/or midfoot pain; (1) tenderness over the posterior 6cm or tip of the lateral or medial malleolus (ankle); (1) tenderness over the navicular or the base of the fifth metatarsal (foot); (1) unable to take four steps both immediately and in the emergency department [2]. Patients who score 0 do not need radiograph series. Each radiograph was reviewed if a fracture was present or not. The clinical audit identified 14 true positives where the Ottawa Ankle Rule scored 1 and the patient had an ankle fracture, and 2 false negatives (sensitivity 88%). There were 81 false positives, and 23 true negatives (specificity 22%). Therefore, a total of 23/123 ankle radiographs were unnecessary which is equivalent to 34.5 days of background radiation. The negative predictive value of the Ottawa Ankle Rule in this audit was 92%. The low rate of Ottawa rule utilisation may unnecessarily cause patient harm that should be addressed. An educational intervention with physicians combined with integration of the Ottawa rule scoring in ankle radiograph requests is planned with re-audit in 6 months

When compared to magnetic resonance imaging (MRI), ultrasound (US) performed by experienced users is an inexpensive tool that has good sensitivity and specificity for diagnosing rotator cuff (RC) tears. However, many practitioners are now utilizing in-office US with little to no formal training as an adjunct to clinical evaluation in the management of RC pathology. The purpose of our study was to determine if US without formal training is effective in managing patients with a suspected RC tear. This was a single centre prospective observational study. Five fellowship-trained surgeons each examined 50 participants referred for a suspected RC tear (n= 250). Patients were screened prior to the consultation and were included if ≥ 40 years old, had an MRI of their affected shoulder, had failed conservative treatment of at least 6 months, and had ongoing pain and disability. Patients were excluded if they had glenohumeral instability, evidence of major joint trauma, or osteonecrosis. After routine clinical exam, surgeons recorded their treatment plan (“No Surgery”, “Uncertain”, or “Surgery”). Surgeons then performed an in-office diagnostic US followed by an MRI and documented their treatment plan after each imaging study. Interrater reliability was analyzed using a kappa statistic to compare clinical to ultrasound findings and ultrasound findings to MRI, normal and abnormal categorization of biceps, supraspinatus, and subscapularis. Following clinical assessment, the treatment plan was recorded as “No Surgery” in 90 (36%), “Uncertain” in 96 (39%) of cases, “Surgery” in 61 (25%) cases, and incomplete in 3 (2%). In-office US allowed resolution of 68 (71%) of uncertain cases with 227 (88%) of patients having a definitive treatment plan. No patients in the “No Surgery” group had a change in treatment plan. After MRI, 16 (6%) patients in the “No Surgery” crossed-over to the “Surgery” group after identification of full-thickness tears, larger than expected tears or alternate pathology (e.g., labral tear). The combination of clinical examination and in-office US may be an effective method in the initial management of patients with suspected rotator cuff pathology. Using this method, a definitive diagnosis and treatment plan was established in 88% of patients with the remaining 12% requiring an MRI. A small percentage (6%) of patients with larger than expected full-thickness rotator cuff tears and/or alternate glenohumeral pathology (e.g., labral tear) would be missed at initial evaluation

Purpose. Ultrasound of the neonatal and infantile hip is a useful tool in diagnosis and treatment of the developmental dysplasia of the hip (DDH), especially given the fact that numerous cases of DDH do not present any findings in the clinical examination. Methods. Between January 2014 and May 2020, 10536 (5273 neonates and infants, 53% girls, 47% boys) consecutive neonatal and infantile hip joints were studied using the Graf Hip Ultrasound method. Results. 607 hips were diagnosed as abnormal. 523 (5%) hip joints were type IIA, 18 (0.17%) were type ΙΙΒ, 19 (0.18%) were type ΙΙC, 33 (0.31%) were type ΙΙΙ and 14 (0.13%) were type IV. 72% of patients were girls, 55% of patients were firstborns, 35,7% presented breech, 8,2% had a positive family history of DDH, 6% were part of a multiple pregnancy, while 27,2% had no predisposing factor for the disease. Type ΙΙΑ hips were treated with follow- up only and had all matured (turned to normal- type I hips) within a trimester. Type ΙΙΒ και ΙΙC hips were treated using an abductor harness and were normal (type I) within three months. 35.7% of type ΙΙΙ were treated with an abductor harness and 64.3% with hip spica. All type IV hips were treated with hip spica. The duration of therapy for type III and type IV hips was 3 months. Conclusion. The early use of a hip ultrasound provides us with the ability to diagnose and treat DDH efficiently, resulting in a normal hip joint within the first months of life

Aims. The aim of this study was to review the value of accepting referrals for children with ‘clicky hips’ in a selective screening programme for hip dysplasia. Patients and Methods. A single-centre prospective database of all referrals to the hip clinic was examined to identify indication for referrals, diagnosis, and treatment. All patients referred received a standardized ultrasound scan and clinical examination by an orthopaedic consultant. Results. There were 5716 children referred to the orthopaedic hip clinic between 1 June 2014 and 26 September 2018. In all, 1754 children (30.1%) were referred due to ‘clicky hip’ with no additional risk factors or indications for ultrasound scan. A total of 123 children (7.1%) referred with ‘clicky hip’ and no additional risk factors or examination findings had an abnormal initial hip ultrasound, including 16 children (0.9%) with dysplastic hips. Of the 141 children who required treatment in a Pavlik harness during the study period, 23 (16%) had been referred with a ‘clicky hip’ and no additional risk factors or examination findings, including six children with Graf 3 or 4 hips. Conclusion. There is significant value in reviewing children with an isolated ‘clicky hip’. Many children who require treatment are referred to the orthopaedic service as ‘clicky hip’ with no additional risk factors. In a pragmatic pathway with a diverse population of clinicians performing baby checks, ‘clicky hip’ is an important indication for referral and should not be discarded. Cite this article: Bone Joint J 2019;101-B:635–638

Introduction. Clinical examination for stability in knee replacement involves the anterior drawer test. This test has been used to help in the diagnosis of flexion instability when used at 90 degrees and midflexion instability at 30 degrees. We sought to determine the inter-rater reliability of this test when compared to motion capture data. Methods. 10 subjects with previous knee repalcement were examined by four orthopedics knee repalcement surgeons in one setting. Each surgeon evaluated each subject in random order and was blinded from the results of the other surgeons. Each surgeon performed an anterior drawer test at 30 and 90 degrees and graded the instability as 0–5mm, 5–10mm or >10 mm. Anterior posterior translation was measured using motion capture. Results. At 30 degrees, the agreement between AP subjective rater score and measured AP laxity was poor for 3 of the 4 raters (Κ for observer A,B,C,D: 0.00, 0.0256, 0.5263, 0.3103). At 90 degrees, the agreement was also poor for 3 of the 4 raters (Κ for observer A,B,C,D: 0.0843, 0.6552, 0.2187, 0.0385). Inter-rater reliability was poor at 30 degrees for both the subjective rater score (Κ = 0.21, SE = 0.12, p = 0.0337) and the measured AP laxity (Κ=0.18, SE=0.1, p=0.0427). Inter-rater reliability was also poor at 90 degrees for both the subjective rater score (Κ = 0.04, SE = 0.10, p = 0.3568) and the measured AP laxity (Κ = 0.05, SE = 0.09, p = 0.2906). Conclusion. The anterior drawer test has poor inter rater reliability at both 30 and 90 degrees. It is unclear if this is from differences in technique of the examiners or form differences in pain or quadriceps function of the subjects. Instability should not be diagnosed strictly by this test and should involve a complete clinical picture of the patient

The primary objective of this study was to establish a safety profile for an all-arthroscopic anatomic glenoid reconstruction via iliac crest autograft augmentation for the treatment of shoulder instability with glenoid bone loss. Short-term clinical and radiological outcomes were also evaluated. This study involved a retrospective analysis of prospectively collected data for 14 patients (male 8, female 6) who were treated for shoulder instability with bone loss using autologous iliac crest bone graft between 2014 and 2018. Of 14 patients, 11 were available for follow-up. The safety profile was established by examining intra-operative and post-operative complications such as neurovascular injuries, infections, major bleeding, and subluxations. Assessment of pre-operative and post-operative Western Ontario Shoulder Instability (WOSI) index, radiographs, and CT scans comprised the evaluation of clinical and radiological outcomes. A good safety profile was observed. There was no occurrence of intraoperative complications, neurovascular injuries, adverse events, or major bleeding. One patient did develop an infection in the neurovascular injuries, adverse events, or major bleeding. One patient did develop an infection in the treated shoulder post-surgery. There were no subluxations or positive apprehension tests on clinical examination post-operatively. Short-term clinical outcomes were seen to be favorable WOSI scores at the most recent follow-up were significantly higher than pre-operative scores, with a mean increase of 39.6 ± 10.60 (p = 0.00055). The average follow-up for CT scan was 4.66 (SD± 2.33) months, where all patients showed bone graft union. Arthroscopic treatment of shoulder instability with bone loss via autologous iliac crest bone graft is shown to be a safe operative procedure that results in favorable short-term clinical and radiological outcomes. Further investigations must be done to evaluate the longevity of these positive health outcomes

Purpose: This research project compared the accuracy of 3 methods of meniscal injury diagnosis that are commonly employed in a clinical orthopaedics: Clinical examination, MRI and Arthroscopic surgery. Method: A retrospective review of charting was used to collect meniscal injury assessment data for 116 patients that had sustained an acute anterior cruciate ligament injury to one knee. Sixty-eight of the 116 patients had the presence of a meniscal lesion confirmed via surgery. Sensitivity and specificity of “hands on” clinical examination and MRI interpretation were determined using the results of arthroscopic surgery as the gold standard. Sensitivity and specificity of “hands on” clinical examination relative to MRI interpretation was also calculated. Finally, the findings of all three methods of meniscal evaluation were compared. Results: Accuracy testing demonstrated that the sensitivity and specificity of clinical examinations (0.54 / 0.81) was comparable to levels observed for MRI (0.69 / 0.70), and when directly comparing the findings of clinical examination against MRI, that there was a high level of agreement when a meniscal lesion was not present (specificity: 0.91), but a much lower level of agreement when a meniscal lesion was suspected (sensitivity: 0.54). In general, when comparing the findings from clinical examination, MRI, and arthroscopic surgery, complete agreement among all 3 methods of evaluation occurred in only 51% of the patients. Conclusion: Our results serve to highlight the inaccuracies associated with meniscal injury assessment when evaluating an acutely traumatized knee joint, and suggest that the incidence of secondary joint trauma following ligament injury may be under predicted

Adductor strain is a common injury among football players. The adductor muscle group contains the three adductor muscles. (adductor longus, magnus and brevis) Adductor longus muscle is a triangular-shaped long muscle. This muscle originates from the superior ramus of the pubic bone and inserted into the middle part of the linea aspera. Adductor longus muscle is the most commonly injured muscle of adductors. Sudden acceleration, jumping, stretching, and kicking the ball are common causes of an adductor injury. Adductor muscle strains can result in missed playing time for football players. We present a 26-year-old man soccer player with pain in the left groin and proximal thigh. The symptoms had started during training and after kicking the ball with left foot (dominant side), he felt an acute pain in the groin region and proximal thigh. Despite the injury, he managed to finish the training. The team physician examined the patient immediately after training. The range of motion of both hip joints was in normal ranges and mild pain with adduction. There was a palpable mass at the inner proximal thigh during contraction of adductor muscles. There was no history of groin pain or adductor problems before this injury. Conventional radiographs showed no osseous abnormalities. 36 hours after the injury, MRI revealed acute grade IIB strain in the left adductor longus muscle, including both superior and inferior parts of the muscle. A hematoma was observed in the superior part of the left adductor muscle, with a craniocaudal length of 42 millimeters. There was an adductor muscle strain with hyperintensity extending for a craniocaudal length of approximately 12 centimeters involving more than 50% crosses sectional diameter of the muscle belly. Conservative treatment started immediately, consisting of cold therapy and soft tissue massage. Compression of the injured tissue using a 15-cm elastic bandage roll is done to limit bleeding and provide support. Iced water machine (Game Ready) was used. The team physician examined the player every day and prescribed physiotherapy protocol daily. Additionally, short interval follow-up MRI is used to evaluate the injury. (After 7 and 14 days of the injury) No injection was performed. The player is able to return to play immediately, despite MRI's strain images. The player started straight running 5 days later and joined to team training 8 days later and played 90 minutes-league-match 12 days after injury without any pain. No injection was performed. The player is able to return to play immediately, despite MRI's strain images. The player started straight running 5 days later and joined to team training 8 days later and played 90 minutes-league-match 12 days after injury without any pain. MRI is a useful technique in diagnosing trauma in football players presenting with groin pain. In this case, to estimate time-to-return-to-play, MRI alone is not strong evidence. MRI is a good option for follow up, but anamnesis and clinical examination is not inferior to diagnostic imaging

Background. Cam morphology develops during adolescence and predisposes individuals to future hip pain and osteoarthritis. An improved understanding of cam development is required to determine whether the process is modifiable. Hypothesis/Purpose. The aim of this study was to characterise the risk factors, timing, and pathogenesis of cam formation. Study Design. Longitudinal prospective observational cohort study. Methods. Longitudinal observational cohort study over three years of individuals from football club academies and an age-matched control population, aged 9–18 years at baseline. Assessments include questionnaires, clinical examination, and MRI of both hips. Alpha angle and epiphyseal extension were measured on radial images. Results. Cohort comprised male academy footballers (121 at baseline and 78 at follow-up) and male and female controls (107 at baseline and 71 at follow-up). Mean change in cartilage alpha angle was 12.4° (SD 8.4) for footballers, 7.3° (SD 6.0) for male controls and 4.0° (SD 4.1) for female controls. A positive correlation was found between Physical Activity Questionnaire Score and change in cartilage alpha angle (coefficient 0.787, p=<0.001). The greatest change in cartilage alpha angle occurred in individuals aged 11–12 years at baseline, with no significant change after 14 years of age. A positive correlation between mean cartilage alpha angle and lateral epiphyseal extension was observed (r. 2. = 0.294, p=0.029). Conclusions. Males undertaking intense sporting activity during adolescence at greatest risk of developing cam morphology, but there is no significant change in hip morphology after 14 years of age. The findings are consistent with physiological adaptation and epiphyseal extension in response to hip loading during skeletal immaturity

Aim: We wanted to ascertain if clinical examination confers any additional benefit to secondary/targeted ultrasound screening of neonatal hips. Materials/Methods: Of the 30585 births (over a 6 year period) in the population served by our hospital, 2742 babies (8.96percent) were referred to the Hip Screening Clinic by the neonatologists and general practitioners. They were examined clinically and by US scans by the specialist consultants. The findings were documented prospectively. Of these, 1862 hips were normal on clinical examination, 841 hips tense (clinical examination inconclusive). Results: 233 hips were identified as abnormal by the US scans (Graf method). 106 (45percent) of these were normal on clinical examination. In 88 of the hips with abnormal US scans (38percent), clinical examination could not be performed reliably as the babies were tense. None of the hips identified as abnormal on clinical examination were normal on US scans. Conclusion/Discussion: US scanning of hips in at-risk babies by an experienced paediatric radiologist will identify all the abnormal hips. This will release the paediatric orthopaedic surgeon from routine clinical examination of all these babies. This time can be utilised for running other clinics. Babies found to have abnormal hips on US scanning may be seen by the orthopaedic surgeon for treatment and follow-up. Parents of babies with normal hip US scans may be reassured by a nurse practitioner or a paediatric physiotherapist. This should lead to better utilisation of resources and cost savings

Introduction. Patients with reduced lumbar spine mobility are at higher risk of dislocation after THA as their hips have to compensate for spinal stiffness. Therefore our study aimed to 1) Define the optimal protocol for identifying patients with mobile hips and stiff lumbar spines and 2) Determine clinical and standing radiographic parameters predicting high hip and reduced lumbar spine mobility. Methods. This prospective diagnostic cohort study followed 113 consecutive patients with end-stage hip osteoarthritis (OA) awaiting THA. Radiographic measurements were performed for the lumbar lordosis angle, pelvic tilt and pelvic-femoral angle on lateral radiographs in the standing, ‘relaxed-seated’ and ‘deep-seated’ (i.e. torso maximally leaning forward) position. A “hip user index” was calculated in order to quantify the contribution of the hip joint to the overall sagittal movement performed by the femur, pelvis and lumbar spine. Results. Radiographs in the relaxed-seated position had an accuracy of 56% (95%CI:46–65%) to detect patients with stiff lumbar spines, compared to a detected rate of 100% in the deep-seated position. The mean ‘hip user index’ was 63±12% and ten patients (9%) were hip users, having an index of 80% or more. A standing pelvic tilt of ≥18.5° was the only predictor for being a hip user with a sensitivity of 90% and specificity of 71% (AUC 0.83). Patients with a standing pelvic tilt ≥18.5° and an unbalanced spine with a flatback deformity had a 30xfold relative risk (95%-CI:4–226; p<0.001) of being a hip user. Conclusion. Patients awaiting THA and having high hip and reduced lumbar spine mobility can be screened for with lateral standing radiographs of the spinopelvic complex and a thorough clinical examination. If the initial screening is positive, radiographs in the deep-seated position allow for better identification of patients being ‘hip users’ compared to radiographs in the relaxed-seated position

Aim: We wanted to ascertain if clinical examination confers any additional benefit to secondary/targeted ultrasound screening of neonatal hips. Materials and Methods: Of the 30585 births (from 1997–2002) in the population served by our hospital, 2742 babies (8.96 percent) were referred to the Hip Screening Clinic by the neonatologists and general practitioners. They were examined clinically and by US scans by the specialist consultants. The findings were documented prospectively. Of these, 1862 hips were normal on clinical examination, 841 hips tense (clinical examination inconclusive). Results: 233 hips were identified as abnormal by the US scans (Graf method). 106 (45 percent) of these were normal on clinical examination. In 88 of the hips with abnormal US scans (38 percent), clinical examination could not be performed reliably as the babies were tense. None of the hips identified as abnormal on clinical examination were normal on US scans. Conclusion/Discussion: US scanning of hips in at-risk babies by an experienced paediatric radiologist will identify all the abnormal hips. This will release the paediatric orthopaedic surgeon from routine clinical examination of all these babies. This time can be utilised for running other clinics. Babies found to have abnormal hips on US scanning may be seen by the orthopaedic surgeon for treatment and follow-up. Parents of babies with normal hip US scans may be reassured by a nurse practitioner or a paediatric physiotherapist. This should lead to better utilisation of resources and cost savings

Aims. Our study aimed to 1) determine if there was a difference for the HOOS-PS score between patients with stiff/normal/hypermobile spinopelvic mobility and 2) to investigate if functional sagittal cup orientation affected patient reported outcome 1 year post-THA. Methods. This prospective diagnostic cohort study followed 100 consecutive patients having received unilateral THA for end-stage hip osteoarthritis. Pre- and 1-year postoperatively, patients underwent a standardized clinical examination, completed the HOOS-PS score and sagittal low-dose radiographs were acquired in the standing and relaxed-seated position. Radiographic measurements were performed for the lumbar-lordosis-angle, pelvic tilt (PT), pelvic-femoral-angle and cup ante-inclination. The HOOS-PS was compared between patients with stiff (ΔPT<±10°), normal (10°≤ΔPT≤30°) and hypermobile spinopelvic mobility (ΔPT>±30°). Results. Preoperatively, 16 patients demonstrated stiff, 70 normal and 14 hypermobile spinopelvic mobility without a difference in the HOOS-PS score (66±14/67±17/65±19;p=0.905). One year postoperatively, 43 patients demonstrated stiff, 51 normal and 6 hypermobile spinopelvic mobility. All postoperative hypermobile patients had normal spinopelvic mobility preoperatively and showed significantly worse HOOS-PS scores compared to patients with stiff or normal spinopelvic mobility (21±17/21±22/35±16;p=0.043). Postoperatively, patients with hypermobile spinopelvic mobility demonstrated no significant difference for the pelvic tilt in the standing position compared to the other two groups (19±8°/16±8°/19±4°;p=0.221), but a significantly lower sagittal cup ante-inclination (36±10°/36±9°/29±8°;p=0.046). Conclusion. The present study demonstrated that patients with normal preoperative and postoperative spinopelvic hypermobility show worse HOOS-PS scores than patients with stiff or normal spinopelvic mobility. The lower postoperative cup ante-inclination seems to force the pelvis to tilt more posteriorly when moving from the standing to seated position (spinopelvic hypermobility) in order to avoid anterior impingement. Thus, functional cup orientation in the sagittal plane seems to affect postoperative patient reported outcome

Spinopelvic mobility describes the change in lumbar lordosis and pelvic tilt from standing to sitting position. For 1° of posterior pelvic tilt, functional cup anteversion increases by 0.75° after total hip arthroplasty (THA). Thus, spinopelvic mobility is of high clinical relevance regarding the risk of implant impingement and dislocation. Our study aimed to 1) determine the proportion of OA-patients with stiff, normal or hypermobile spino-pelvic mobility and 2) to identify clinical or static standing radiographic parameters predicting spinopelvic mobility. This prospective diagnostic cohort study followed 122 consecutive patients with end-stage osteoarthritis awaiting THA. Preoperatively, the Oxford Hip Score, Oswestry Disability Index and Schober's test were assessed in a standardized clinical examination. Lateral view radiographs were taken of the lumbar spine, pelvis and proximal femur using EOS© in standing position and with femurs parallel to the floor in order to achieve a 90°-seated position. Radiographic measurements were performed for the lumbar lordosis angle (LL), sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI) and pelvic-femoral-angle (PFA). The difference in PT between standing and seated allowed for patient classification based on spino-pelvic mobility into stiff (±30°). From the standing to the sitting position, the pelvis tilted backwards by a mean of 19.6° (SD 11.6) and the hip was flexed by a mean of 57° (SD 17). Change in pelvic tilt correlated inversely with change in hip flexion. Spinopelvic mobility is highly variable in patients awaiting THA and we could not identify any clinical or static standing radiographic parameter predicting the change in pelvic tilt from standing to sitting position. In order to identify patients with stiff or hypermobile spinopelvic mobility, we recommend performing lateral view radiographs of the lumbar spine, pelvis and proximal femur in all patients awaiting THA. Thereafter, implants and combined cup inclination/anteversion can be individually chosen to minimize the risk of dislocation. No predictors could be identified. We recommend performing sitting and standing lateral view radiographs of the lumbar spine and pelvis to determine spinopelvic mobility in patients awaiting THA

Aims. Short, bone-conserving femoral components are increasingly used in total hip arthroplasty (THA). They are expected to allow tissue-conserving implantation and to render future revision surgery more straightforward but the long-term data on such components is limited. One such component is the global tissue-sparing (GTS) stem. Following the model for stepwise introduction of new orthopaedic implants, we evaluated early implant fixation and clinical outcome of this novel short-stem THA and compared it to that of a component with established good long-term clinical outcome. Methods. In total, 50 consecutive patients ≤ 70 years old with end-stage symptomatic osteo-arthritis were randomized to receive THA with the GTS stem or the conventional Taperloc stem using the anterior supine intermuscular approach by two experienced hip surgeons in two hospitals in the Netherlands. Primary outcome was implant migration. Patients were followed using routine clinical examination, patient reported outcome using Harris Hip Score (HHS), Hip Disability And Osteoarthritis Outcome Score (HOOS), EuroQol five-dimension questionnaire (EQ5D), and Roentgen Stereophotogrammetric Analysis (RSA) at three, six, 12, and 24 months. This study evaluated the two-year follow-up results. Results. In addition to the initial migration pattern of distal migration (subsidence, Y-translation) and retroversion (Y-rotation) also exhibited by the Taperloc stem, the GTS stem showed an initial migration pattern of varization (X-translation combined with Z-rotation) and posterior translation (Z-translation). However, all components stabilized aside from one Taperloc stem which became loose secondary to malposition and was later revised. Clinical outcomes and complications were not statistically significantly different with the numbers available. Conclusion. A substantially different and more extensive initial migration pattern was seen for the GTS stem compared to the Taperloc stem. Although implant stabilization was achieved, excellent long-term survival similar to that of the Taperloc stem should not be inferred. Especially in the absence of clinically proven relevant improvement, widespread usage should be postponed until long-term safety has been established. Cite this article: Bone Joint J 2020;102-B(6):699–708

Differences at motor control strategies to provide dynamic balance in various tasks in diabetic polyneuropatic (DPN) patients due to losing the lower extremity somatosensory information were reported in the literature. It has been stated that dynamics of center of mass (CoM) is controlled by center of pressure (CoP) during human upright standing and active daily movements. Indeed analyzing kinematic trajectories of joints unveil motor control strategies stabilizing CoM. Nevertheless, we hypothesized that imbalance disorders/CoM destabilization observed at DPN patients due to lack of tactile information about the base of support cannot be explained only by looking at joint kinematics, rather functional foot usage is proposed to be an important counterpart at controlling CoM. In this study, we included 14 DPN patients, who are diagnosed through clinical examination and electroneuromyography, and age matched 14 healthy subjects (HS) to identify control strategies in functional reach test (FRT). After measuring participants’ foot arch index (FAI) by a custom-made archmeter, they were tested by using a force plate, motion analysis system, surface electromyography and pressure pad, all working in synchronous during FRT. We analyzed data to determine effect of structural and functional foot pathologies due to neuropathy on patient performance and postural control estimating FAI, reach length (FR), FR to height (H) ratio (FR/H; normalized FR with respect to height), displacement of CoM and CoP in anteroposterior direction only, moment arm (MA, defined as the difference between CoP and CoM at the end of FRT), ankle, knee and hip joint angles computed at the sagittal plane for both extremities. Kinematic metrics included initial and final joint angles, defined with respect to start and end of reaching respectively. Further difference in the final and initial joint angles was defined as Δ. FAI was founded significantly lower in DPN patients (DPN: 0.3404; HS: 0.3643, p= <0.05). The patients’ FR, FR/H and absolute MA and displacement of CoM were significantly shorter than the control group (p= <0.05). Displacement of CoP between the two groups were not significant. Further we observed that CoM was lacking CoP in DPN patients (mean MA: +0.88 cm), while leading CoP in HS (mean MA: −1.59 cm) at the end of FRT. All initial angles were similar in two groups, however in DPN patients final right and left hip flexion angle (p=0.016 and p=0.028 respectively) and left ankle plantar flexion angle (p=0.04) were smaller than HS significantly. DPN patients had significantly less (p=0.029) hip flexion (mean at right hip angle, Δ=25.0°) compared to HS (Δ=33.53°) and ankle plantar flexion (DPN mean at right ankle angle, Δ=6.42°, HS mean Δ=9.07°; p=0.05). The results suggest that movement of both hip and ankle joints was limited simultaneously in DPN patients causing lack of CoM with respect to CoP at the end of reaching with significantly lower FAI. These results lead to the fact that cutaneous and joint somatosensory information from foot and ankle along with the structure of foot arch may play an important role in maintaining dynamic balance and performance of environmental context. In further studies, we expect to show that difference at control strategies in DPN patients due to restricted functional foot usage might be a good predictor of how neuropathy evolves to change biomechanical aspects of biped erect posture

Aims. This study of patients with osteoarthritis (OA) of the hip aimed to: 1) characterize the contribution of the hip, spinopelvic complex, and lumbar spine when moving from the standing to the sitting position; 2) assess whether abnormal spinopelvic mobility is associated with worse symptoms; and 3) identify whether spinopelvic mobility can be predicted from static anatomical radiological parameters. Patients and Methods. A total of 122 patients with end-stage OA of the hip awaiting total hip arthroplasty (THA) were prospectively studied. Patient-reported outcome measures (PROMs; Oxford Hip Score, Oswestry Disability Index, and Veterans RAND 12-Item Health Survey Score) and clinical data were collected. Sagittal spinopelvic mobility was calculated as the change from the standing to sitting position using the lumbar lordosis angle (LL), sacral slope (SS), pelvic tilt (PT), pelvic-femoral angle (PFA), and acetabular anteinclination (AI) from lateral radiographs. The interaction of the different parameters was assessed. PROMs were compared between patients with normal spinopelvic mobility (10° ≤ ∆PT ≤ 30°) or abnormal spinopelvic mobility (stiff: ∆PT < ± 10°; hypermobile: ∆PT > ± 30°). Multiple regression and receiver operating characteristic (ROC) curve analyses were used to test for possible predictors of spinopelvic mobility. Results. Standing to sitting, the hip flexed by a mean of 57° (. sd. 17°), the pelvis tilted backwards by a mean of 20° (. sd. 12°), and the lumbar spine flexed by a mean of 20° (. sd. 14°); strong correlations were detected. There was no difference in PROMs between patients in the different spinopelvic mobility groups. Maximum hip flexion, standing PT, and standing AI were independent predictors of spinopelvic mobility (R. 2. = 0.42). The combined thresholds for standing was PT ≥ 13° and hip flexion ≥ 88° in the clinical examination, and had 90% sensitivity and 63% specificity of predicting spinopelvic stiffness, while SS ≥ 42° had 84% sensitivity and 67% specificity of predicting spinopelvic hypermobility. Conclusion. The hip, on average, accounts for three-quarters of the standing-to-sitting movement, but there is great variation. Abnormal spinopelvic mobility cannot be screened with PROMs. However, clinical and standing radiological features can predict spinopelvic mobility with good enough accuracy, allowing them to be used as reliable screening tools. Cite this article: Bone Joint J 2019;101-B:902–909

Aim of study: To assess ankle dorsiflexion of operated pedes equinovari congenitales in both clinical examination and gait analysis. Introduction: Mac Kay subtalar release corrects mostly perfectly deformed feet. Operated feet show however stiffness not only in subtalar but as well as in ankle joint. The range of motion in ankle joint was not yet studied systematically at all. Gait analysis offers the possibility to follow the motion in ankle joint dynamically. Material: Thirty six consecutively operated feet were examined by clinical as well as by gait analysis examination. All were operated by Mac Kay procedure at least one year before examination (range 1–7 years). Feet were examined in lying and stance positions. Gait analysis was based on use of Oxford foot model (8 cameras motion capture system). Results: Dorsiflexion/plantiflexion of the foot estimated by clinical examination was compared with maximum dorsiflexion in phase of mid-stance (second rocker)/maximum plantiflexion in pre-swing phase (third rocker). Differences individually for each patients in dorsiflexion/plantiflexion were calculated. Mean of difference between dorsiflexion in clinical examination and dorsiflexion in gait analysis x = 14.3°. Mean of diference between plantiflexion in clinical examination and plantiflexion in gait analysis x= 5,4°. Using T-paired test these differences were found statistically significant (p=0,01). Normal maximum dorsiflexion of the children’ foot in gait analysis is about 20°. From this point 14 operated feet out from 36 did not fulfill this criterion. On the other hand only 4 operated feet showed in gait analysis dorsiflexion less than 10°. Discussion: Dorsiflexion of the foot is important for smooth gait. The diference between dates from clinical examination and dates from gait lab can be explained by weight - bearing force pushing the foot into dorsiflexion during second rocker or by secondary adaptive intrinsic bending of the foot. Conclusion: Operated feet showed moderate/severe stiffnes of ankle joint. Despite of it, the gait cycle was not significantly impaired

Of the 30585 births (from 1997–2002) in the population served by our NHS trust, 2742 babies (8.96%) were referred to the hip screening clinic by the neonatologists and general practitioners. They were examined clinically and by US scans by the specialist consultants. The findings were documented prospectively. 233 hips were identified as abnormal by ultrasound scans (Graf). 45% (106) of these were normal on clinical examination. None of the hips identified as abnormal on clinical examination were normal on US scans. In 38% (88) clinical examination could not be reliably performed as the babies were tense. Of the 1862 hips which were clinically normal, 106 (5.69%) had abnormal ultrasound findings. Furthermore, of the 841 babies who were tense on clinical examination, 88 (10.46%) babies had abnormal ultra-sonographic findings. Ultrasound scanning of hips in at-risk babies by an experienced paediatric radiologist will identify all the abnormal hips. This will release the paediatric orthopaedic surgeon from routine clinical examination of all these babies. This time can be utilised for running other clinics. Babies found to have abnormal hips on US scanning may be seen by the orthopaedic surgeon for treatment and follow-up. Parents of babies with normal hip US scans may be reassured by a nurse practitioner or a paediatric physiotherapist

The primary purpose of this study was to assess whether patients presenting with clinical graft laxity following primary anatomic anterior cruciate ligament (ACL) reconstruction using hamstring autograft reported a significant difference in disease-specific quality-of-life (QOL) as measured by the ACL-QOL questionnaire. Clinical ACL graft laxity was assessed in a cohort of 1134/1436 (79%) of eligible patients using the Lachman and Pivot-shift tests pre-operatively and at 12- and 24-months following ACL reconstruction. Post-operative ACL laxity was assessed by an orthopaedic surgeon and a physical therapist who were blinded to each other's examination. If there was a discrepancy between the clinical examination findings from these two assessors, then a third impartial examiner assessed the patient to ensure a grading consensus was reached. Patients completed the ACL-QOL questionnaire pre-operatively, and 12- and 24-months post-operatively. Descriptive statistics were used to assess patient demographics, rate of post-operative ACL graft laxity, surgical failures, and ACL-QOL scores. A Spearman rho correlation coefficient was utilised to assess the relationships between ACL-QOL scores and the Lachman and Pivot-shift tests at 24-months post-operative. An independent t-test was used to determine if there were differences in the ACL-QOL scores of subjects who sustained a graft failure compared to the intact graft group. ACL-QOL scores and post-operative laxity were assessed using a one-way analysis of variance (ANOVA). There were 70 graft failures (6.17%) in the 1134 patients assessed at 24-months. A total of 226 patients (19.9%) demonstrated 24-months post-operative ACL graft laxity. An isolated positive Lachman test was assessed in 146 patients (12.9%), an isolated positive Pivot-shift test was apparent in 14 patients (1.2%), and combined positive Lachman and Pivot-shift tests were assessed in 66 patients (5.8%) at 24-months post-operative. There was a statistically significant relationship between 24-month post-operative graft laxity and ACL-QOL scores (p < 0.001). Specifically, there was a significant correlation between the ACL-QOL and the Lachman test (rho = −0.20, p < 0.001) as well as the Pivot-shift test (rho = −0.22, p < 0.001). There was no significant difference between the scores collected from the graft failure group prior to failure occurring (mean = 74.38, SD = 18.61), and the intact graft group (mean = 73.97, SD = 21.51). At 24-months post-operative, the one-way ANOVA demonstrated a statistically significant difference between the ACL-QOL scores of the no laxity group (mean = 79.1, SD = 16.9) and the combined positive Lachman and Pivot-shift group (mean = 68.5, SD = 22.9), (p = 0, mean difference = 10.6). Two-years post ACL reconstruction, 19.9% of patients presented with clinical graft laxity. Post-operative graft laxity was significantly correlated with lower ACL-QOL scores. The difference in ACL-QOL scores for patients with an isolated positive Lachman or Pivot-shift test did not meet the threshold of a clinically meaningful difference. Patients with clinical laxity on both the Lachman and Pivot-shift tests demonstrated the lowest patient-reported ACL-QOL scores, and these results exceeded the minimal clinically important difference

Purpose. To clarify the true association with pathological DDH and ASC (asymmetrical skin crease). Method. Between 1. st. January 1995 and 31. st. December 2015 all paediatric referrals with suspected hip instability were assessed in a one-stop DDH clinic. All patients had clinical and sonographic assessment with results prospectively recorded onto a database. Result. Over this 21-year period, 103 cases were referred with ASC. Seventy were female and 33 male. The age distribution at initial assessment was bimodal with peaks at 3 and 9 months. Eighty-three cases (81% ) were referred with ASC, but the hip joints were normal on both clinical examination and sonography. Eighteen cases (17% ) were referred with ASC but had an additional risk factor. This group also had normal hips on both clinical examination and sonography. Of the 103 cases, only two had pathological DDH. Both were female and aged 3 and 10 months respectively. They had ASC, but in addition had unilateral limitation of hip abduction, a Galeazzi positive sign and a leg length discrepancy. Radiological assessment diagnosed unilateral irreducible hip dislocations in both cases. Statistical analysis calculated an overall sensitivity for ASC of 100% and a PPV of 1.94% . Conclusion. Public Health England NIPE guidelines state that ASC are a ‘screen positive sign’ and should be referred for expert assessment of the hip joints to exclude DDH. This study confirms the opinions of experts and systemic reviews that isolated ASC is an unreliable clinical sign in the diagnosis of pathological DDH. If the hip joint is clinically normal it is highly unlikely that there will be an association with pathological DDH. Routine radiological and sonographic imaging of the hip joints is unnecessary if there is no limitation of hip abduction and normal leg lengths (negative Galeazzi). National guidelines should reflect this

Purpose. There is concern that the positive predictive value (PPV) of neonatal screening for instability may have deteriorated over recent years, this study aims to evaluate this. Method. This is a prospective observational longitudinal study from 2012 – 2016. Patients that were referred from paediatric neonatal screening with hip instability (Ortolani / Barlow positive, clunks) were identified and underwent ultrasound and clinical examination in the one stop hip clinic by the senior author. Referrals were taken from a range of screeners from paediatric doctors to midwives and advanced neonatal practitioners. Syndromic or neurological dislocated hips were excluded. The outcome measures were the presence of a subluxated / dislocated hip on ultrasound as per Graf and Harcke classification and a positive provocative manoeuvre on examination. This allowed a PPV to be evaluated for both ultrasound and clinical examination. Results. 139 neonates were referred for a suspected dislocated or dislocatable hip from paediatric screening services. These were seen at a mean 14.0 days (95% C I, 12.28 to 15.72). 20 patients had a Graf type 4 hip on ultrasound and 5 had a positive provocative test on examination. This represents an ultrasound PPV of 14.4% and clinical exam PPV of 3.6% . This has deteriorated from 15 year data from our unit (PPV 24% clinical, 49% sonographic). Our overall surgical rate for DDH has increased to 1.07 per 1000, and our overall rate of open reductions has increased to 0.7 per 1000. This is based upon figures from 2012 – 2014. Conclusion. The PPV of screening has decreased over the last 5 years. The concern is too many screeners who, with regards screening the paediatric hip, are poorly trained, inexperienced, not adequately supervised. We need to learn the lessons of Sweden and ensure better quality screening by limiting screening to a small number of experienced practitioners

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To systematically review the efficacy of split tendon transfer surgery on gait-related outcomes for children and adolescents with cerebral palsy (CP) and spastic equinovarus foot deformity.

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Complete ruptures of the ulnar collateral ligament (UCL) of the thumb are a common injury, yet little is known about their current management in the UK. The objective of this study was to assess the way complete UCL ruptures are managed in the UK.

Purpose of study. Computerised Tomographic Angiography (CTA) is less invasive than conventional angiography. It is our perception that CTAs are being requested and performed too frequently at our institution without correct indications. We assessed the number of CTAs that were done, the percentage of vascular injuries sustained and whether correct indications were followed when requesting CTAs. Methodology. A review of records of the radiology department to determine the number of CTAs done for suspected extremity vascular injuries from January to December 2012. Inclusion criteria were CTAs performed during this period for suspected vascular injuries in fractures and dislocations and extremity gunshot wounds. A retrospective chart review was performed to determine the mechanism of injury, clinical picture (pulses, temperature, capillary refill and neurology), indications for and results of the CTA. Results. During this time 285 CTAs were performed of which 137 were suitable for analysis. One hundred and fifteen were males. The average age was 30.25 (range 14 to 86) years. Eighty six (62.77%) of the CTAs were normal. A further 4 patients showed no vascular injury, but with external compression of the vessels. The mechanism of injury was gunshot wounds in 58% of cases, motor vehicle accidents in 16.8% and pedestrian-motor vehicle accidents in 15%. 58.5% of cases with abnormal pulses had normal CTAs. Twenty one patients had normal pulses, but 5 of these had abnormal CTAs. Clinical assessment of peripheral pulse had a sensitivity of 81.5%, specificity of 34%, positive predictive value of 41.5% and negative predictive value of 76%. Conclusion. Thirty one (58.5%) of cases with abnormal pulses had normal CTAs, indicating that clinical examination is unreliable. Twenty one (15.3%) patients with normal pulses on clinical examination had CTAs performed. We believe CTAs are over-utilised due to availability rather than relying on serial clinical examination and non invasive testing. NO DISCLOSURES

Background Context. SPECT-CT is a hybrid imaging modality, which has become very well established in the diagnosis of inflammatory, vascular and malignant processes affecting the spine. However, little evidence exists on its application with degenerative pathologies. Purpose & Study Design. Systematic review on the use of SPECT-CT in the diagnosis of degenerative facet joint arthropathy. Patient Sample. 824 patients across 10 studies conducted over the last 6 years (2012 – 2018), with a mean age of 51.8 years old. All studies excluded patients with malignancy, infection or inflammatory aetiologies or those related to acute trauma. Only degenerative pathologies of the lumbar spine in an adult population were included. Methods. A systematic review of the literature available on the topic was conducted using the PubMed, Cochrane, Medline and Embase online databases of journal articles. Results. Five studies focused on SPECT-CT alone / versus CT. Two focused on SPECT-CT vs MRI, and three focussed on SPECT-CT guided facet joint injections. Of these 10 studies, seven concluded with results supporting SPECT CT's use, two reported discordance between SPECT-CT findings with those diagnosed from clinical examination / MRI scans, and one study's conclusions were equivocal. Conclusion. SPECT-CT shows promise as an imaging adjunct in assisting with the diagnosis and subsequent treatment of degenerative facet joint arthropathies. In patients whose MRI scans reveal multiple potential pain generators, SPECT-CT could help differentiate between clinically significant sources of pain and may even serve a purpose in guiding facet joint injections in patients with inconclusive MRI / CT scans. No conflicts of interest. No funding obtained

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The present study seeks to investigate the correlation of pubofemoral distances (PFD) to α angles, and hip displaceability status, defined as femoral head coverage (FHC) or FHC during manual provocation of the newborn hip < 50%.

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There is a lack of high-quality research investigating outcomes of Ponseti-treated idiopathic clubfeet and correlation with relapse. This study assessed clinical and quality of life (QoL) outcomes using a standardized core outcome set (COS), comparing children with and without relapse.

MRI scan for the knee joint has often been regarded to be the non invasive alternative to a diagnostic arthroscopy. MRI scan is routinely used to support the diagnosis for meniscal or ACL injuries prior to recommending arthroscopic examination and surgery. Identification of meniscal tears can be difficult to interpret and can be observer dependent as well as dependent upon the sensitivity of the scanner. Similar difficulties may exists in clinical examination as well. Our aim was to compare and correlate clinical, MRI and arthroscopic findings in the diagnosis of meniscal and Anterior Cruciate Ligament (ACL) Injuries. This was an observational study of 131 patients over 36 months who had both MRI and arthroscopic surgery. Our study showed clinical examination had better sensitivity (0.86 vs 0.76)and specificity(0.73 v/s 0.52) in comparing to MRI in diagnosis of medial menisceal injuries. similarly +predictive value and −predictive value were higher for clinical examination. whereas for lateral menisceal and ACL injuries there were marginal differences in sensitivity, specificity and predictive values. We conclude that carefully performed clinically examination can give equally or better diagnosis of meniscal and ACL injuries in comparison to MRI scan. MRI scan may be used to rule out such injuries rather than to diagnose them. MRI scan has much better negative predictive value than positive predictive value in both meniscal and ACL injuries diagnosis. When clinical signs and symptoms are inconclusive, performing MRI scan is likely to be more beneficial in avoiding unnecessary arthroscopic surgery. When clinical diagnosis is in favour of either meniscal or ACL injuries, performing MRI scan prior to Arthroscopic examination is unlikely to be of significance. MRI scan should not be used as a primary diagnostic tool in meniscal and ACL injuries

Introduction: A large number of patients with non-specific low back pain (NSLBP) are examined by physiotherapists. Physiotherapists ask their patient’s questions, as part of their clinical examination, however the reliability of the information elicited by these questions has never been examined. Methods: Following a Focus group with a sample of physiotherapists (n=30), and subsequent Delphi technique questionnaire, a list of questions and tests for the clinical examination to NSLBP was developed. The clinical examination list was then tested for item inter-tester reliability with 100 NSLBP patients and 16 physiotherapists. Patients were assessed by both physiotherapists on one day. Data were analysed using kappa coefficients for nominal data and weighted kappas for ordinal data. Results: The physiotherapists rated issues regarding the location and quality of pain with good levels of reliability, kappa values ranged from 0.49 to 0.64. Diurnal changes in pain and history of pain were also reliably ascertained (Kappa values ranging from 0.49 to 0.73), with symptoms other than pain demonstrating good reliability (values ranging from 0.50 to 0.77). Issues regarding the affect of psychosocial issues as barriers to recovery and the degree to which the patient’s pain was affecting their function were not as reliable (kappa values from 0.14 to 0.51). Conclusions: It is clear that whilst the questions typically used in the clinical examination of NSLBP are reliable when addressing simple issues relating to the report of symptoms, more complex issues are less reliable and further work is required to improve the reliability of the information obtained

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A national screening programme has existed in the UK for the diagnosis of developmental dysplasia of the hip (DDH) since 1969. However, every aspect of screening and treatment remains controversial. Screening programmes throughout the world vary enormously, and in the UK there is significant variation in screening practice and treatment pathways. We report the results of an attempt by the British Society for Children’s Orthopaedic Surgery (BSCOS) to identify a nationwide consensus for the management of DDH in order to unify treatment and suggest an approach for screening.

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There is no consensus regarding optimum timing and frequency of ultrasound (US) for monitoring response to Pavlik harness (PH) treatment in developmental dysplasia of the hip (DDH). The purpose of our study was to determine if a limited-frequency hip US assessment had an adverse effect on treatment outcomes compared to traditional comprehensive US monitoring.

Establish the positive predictive value of clinical examination predicted radicular level to MRI. To identify the value of the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) assessment tool in the assessment of patients presenting with radicular symptoms of lumbar spine source. 8 patients attending the ESP Orthopaedic triage service, presenting with radicular pain in which MRI is clinically indicated. Prospective study on patients attending ESP Orthopaedic triage service. Patients were clinically examined, both parts LANSS score was completed. Following the assessment a radicular level was selected. Following MRI the results were compared. Positive predicted values (PPV) for clinical examination and sensitivity and specificity of a LANSS score>12 was calculated. LANSS score. MRI report. PPV of 75% of therapist predicted level being same level or adjacent level to MRI stated level. 66% specificity and 100% sensitivity of patients in study with LANNS>12 having MRI evaluated radicular nerve root compression. This pilot suggests that clinical examination and the LANSS score is useful in establishing the presence of radicular nerve root compression. This evidence supports the need for further research

Many different clinical examinations are used to assess instability of the glenohumeral joint. Validation of these includes clinical data, follow-up, imaging, and arthroscopy. In spite of these many works, there currently exists no clear unique method for identifying and validation novel clinical examinations. The aim of this study was to use a computational tool to quantify the specificity of clinical examinations in assessing glenohumeral ligament (GHL) pathology. Five GHLs were modelled according to the literature [. 1. ]. Physiological kinematics data [. 2. ] were applied to simulate 23 clinical examination manoeuvres for the glenohumeral joint. Individual ligament forces were computed as a percentage of the total ligamentous restraint. The 0° abduction anterior-laxity test was most specific for the superior GHL (82.3%). The anterior apprehension in the coronal plane and 90° anterior-laxity tests were specific for the anterior band of the inferior GHL (abIGHL – 100%). Pure scapular plane abduction and the 90° abduction inferior-laxity tests were specific for the axillary pouch of the IGHL (apIGHL – 100%, 89.6%). Specific tests for posterior band of the IGHL were posterior apprehension (95.1%), 0° and 20° abduction posterior-laxity, and 30° to 45° flexion Norwood and Terry test (100% each). The middle GHL did not exhibit any exclusive loading pattern for any of the tests. A secondary insertional morphology was simulated with the abIGHL positioned at the 4 o’clock position as opposed to the 3 o’clock position [. 1. ,. 2. ,. 3. ]. Significant loading differences were computed for the same ligaments during the same tests. This study demonstrates the sensitivity of specific tests for individual GHLs, but provides the significant caveat that ligament loading is significantly influenced by normal anatomical variations

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The early diagnosis of cauda equina syndrome (CES) is crucial for a favourable outcome. Several studies have reported the use of an ultrasound scan of the bladder as an adjunct to assess the minimum post-void residual volume of urine (mPVR). However, variable mPVR values have been proposed as a threshold without consensus on a value for predicting CES among patients with relevant symptoms and signs. The aim of this study was to perform a meta-analysis and systematic review of the published evidence to identify a threshold mPVR value which would provide the highest diagnostic accuracy in patients in whom the diagnosis of CES is suspected.

We present the long term outcome from children with Legg-Calves-Perthes (LCPD) treated at our unit. Patients treated for LCPD were identified retrospectively from an orthopaedic database between 1990 and 2005. Patient demographics, clinical examination, treatment and Herring classification were recorded at initial presentation and treatment. Long-term clinical and radiological follow-up was also recorded. 85 patients were identified and 4 excluded due to insufficient data giving a total of 81 patients. Of these, 58 were male and 23 female. Average age range at presentation was 6.5 years (range 1.5–14 yrs). The side affected was 34 right, 35 left, 24 bilateral giving 93 hips in total. Time between presentation and diagnosis averaged 4.7 months (range 0–48 months). In patients with recorded clinical examination 87% had reduced abduction and 88% reduced internal rotation. Treatment was largely conservative with 12 hips (13%) undergoing surgery within the first 4 years of diagnosis. Radiographs were available for 71 hips. Herring classification was A-12, B-22, C-37. Long term follow up averaged 16 years (range 10–25 yrs). Stulberg grading was available in 67 hips; Grade I 13, Grade II 21, Grade III 19, Grade IV 18 and Grade V 6. There were ongoing issues (mostly pain) in 18 hips, 5 of which required a subsequent operation. No correlation was found between abduction and Stulberg grade (p-value = 0.7). A correlation was found between delay in diagnosis of ≥6 months and the need for a subsequent operation (p-value = 0.0408). The overall trend as expected showed that a better Herring classification generally led to a more favourable Stulberg classification. Range of motion was not predictive for Stulberg grade. The need for further surgical intervention for symptoms at long term follow up was 0.05%

Telehealth has the potential to change the way we approach patient care. From virtual consenting to reducing carbon emissions, costs, and waiting times, it is a powerful tool in our clinical armamentarium. There is mounting evidence that remote diagnostic evaluation and decision-making have reached an acceptable level of accuracy and can safely be adopted in orthopaedic surgery. Furthermore, patients’ and surgeons’ satisfaction with virtual appointments are comparable to in-person consultations. Challenges to the widespread use of telehealth should, however, be acknowledged and include the cost of installation, training, maintenance, and accessibility. It is also vital that clinicians are conscious of the medicolegal and ethical considerations surrounding the medium and adhere strictly to the relevant data protection legislation and storage framework. It remains to be seen how organizations harness the full spectrum of the technology to facilitate effective patient care.

Cite this article: Bone Joint J 2023;105-B(8):843–849.

Acute bone and joint infections in children are serious, and misdiagnosis can threaten limb and life. Most young children who present acutely with pain, limping, and/or loss of function have transient synovitis, which will resolve spontaneously within a few days. A minority will have a bone or joint infection. Clinicians are faced with a diagnostic challenge: children with transient synovitis can safely be sent home, but children with bone and joint infection require urgent treatment to avoid complications. Clinicians often respond to this challenge by using a series of rudimentary decision support tools, based on clinical, haematological, and biochemical parameters, to differentiate childhood osteoarticular infection from other diagnoses. However, these tools were developed without methodological expertise in diagnostic accuracy and do not consider the importance of imaging (ultrasound scan and MRI). There is wide variation in clinical practice with regard to the indications, choice, sequence, and timing of imaging. This variation is most likely due to the lack of evidence concerning the role of imaging in acute bone and joint infection in children. We describe the first steps of a large UK multicentre study, funded by the National Institute for Health Research, which seeks to integrate definitively the role of imaging into a decision support tool, developed with the assistance of individuals with expertise in the development of clinical prediction tools.

Cite this article: Bone Joint J 2023;105-B(3):227–229.

Background. There is a paucity of prognosis research in patients with neuropathic low back-related leg pain (LBLP) in primary care. Purpose. To investigate the clinical course and prognostic factors in primary care LBLP patients consulting with neuropathic pain (NP). Methods. LBLP patients in a primary-care cohort study (n=606) completed the self-report version of Leeds Assessment for Neurological Symptoms and Signs (s-LANSS, score of ≥12 indicates possible NP) at baseline and 4-months. Mixed effects models compared pain-intensity (highest of mean leg or mean back pain - 0–10 NRS at baseline, 4-months, 12-months and 3-years) between those with persistent NP (s-LANSS ≥12 at baseline and 4-months) and those without (s-LANSS ≥12 at baseline and <12 at 4-months). Univariable and multivariable binary logistic regression examined association between potential prognostic factors (chosen from baseline self-report questionnaires, clinical examination, MRI scan findings) and persistent NP. Multiple imputation was used to account for missing data. Results. 44% (72/164) of patients with NP at baseline had persistent NP at 4-months. Mean pain intensity of patients with persistent NP was higher at 4-months, 12-months and 3-years compared to those without. In univariable analysis, only pain self-efficacy was significantly associated with persistent NP (OR 0.98, 95% CI 0.96 to 0.998). In multivariable analysis, none of the 7 investigated factors were significantly associated with persistent NP. Conclusion. Patients with persistent NP were consistently worse-off up to 3-years follow-up compared to those without. It was difficult to identify those patients with NP at baseline who would have persistent NP at 4-months. No conflicts of interest. Sources of funding: Sarah Harrisson is a Clinical Doctoral Fellow funded through a National Institute for Health Research (NIHR) Research Professorship for Nadine Foster (NIHR-RP-011-015). Nadine Foster is a NIHR Senior Investigator. Kika Konstantinou is supported by a Higher Education Funding Council for England/ National Institute for Health Research Senior Clinical Lectureship. The views expressed in this publication are those of the author(s), not necessarily those of the NHS, NIHR or the Department of Health and Social Care. This work relates to an Education and Continued Professional Development (level 2) award by the Musculoskeletal Association of Chartered Physiotherapists to Sarah Harrisson (June 2016)

Aims

Frozen shoulder is a common, painful condition that results in impairment of function. Corticosteroid injections are commonly used for frozen shoulder and can be given as glenohumeral joint (GHJ) injection or suprascapular nerve block (SSNB). Both injection types have been shown to significantly improve shoulder pain and range of motion. It is not currently known which is superior in terms of relieving patients’ symptoms. This is the protocol for a randomized clinical trial to investigate the clinical effectiveness of corticosteroid injection given as either a GHJ injection or SSNB.

Aims

The aim of this study was to determine the consensus best practice approach for the investigation and management of children (aged 0 to 15 years) in the UK with musculoskeletal infection (including septic arthritis, osteomyelitis, pyomyositis, tenosynovitis, fasciitis, and discitis). This consensus can then be used to ensure consistent, safe care for children in UK hospitals and those elsewhere with similar healthcare systems.

Aims

Rates of reverse total shoulder arthroplasty (rTSA) continue to grow. Glenoid bone loss and deformity remains a technical challenge to the surgeon and may reduce improvements in patients’ outcomes. However, there is no consensus as to the optimal surgical technique to best reconstruct these patients’ anatomy. This review aims to compare the outcomes of glenoid bone grafting versus augmented glenoid prostheses in the management of glenoid bone loss in primary reverse total shoulder arthroplasty.

Aims

Developmental dysplasia of the hip (DDH) can be managed effectively with non-surgical interventions when diagnosed early. However, the likelihood of surgical intervention increases with a late presentation. Therefore, an effective screening programme is essential to prevent late diagnosis and reduce surgical morbidity in the population.