In this study, we discuss 68 cases in which peripheral nerve trunks were inadvertently divided by surgeons. Most of these accidents occurred in the course of planned operations. Delay in diagnosis and in effecting repair was common. We list the nerves particularly at risk and the operations in which special care is needed. We recommend steps to secure prompt diagnosis and early treatment.

Advanced 3D imaging and CT-based navigation have emerged as valuable tools to use in total knee arthroplasty (TKA), for both preoperative planning and the intraoperative execution of different philosophies of alignment. Preoperative planning using CT-based 3D imaging enables more accurate prediction of the size of components, enhancing surgical workflow and optimizing the precision of the positioning of components. Surgeons can assess alignment, osteophytes, and arthritic changes better. These scans provide improved insights into the patellofemoral joint and facilitate tibial sizing and the evaluation of implant-bone contact area in cementless TKA. Preoperative CT imaging is also required for the development of patient-specific instrumentation cutting guides, aiming to reduce intraoperative blood loss and improve the surgical technique in complex cases. Intraoperative CT-based navigation and haptic guidance facilitates precise execution of the preoperative plan, aiming for optimal positioning of the components and accurate alignment, as determined by the surgeon’s philosophy. It also helps reduce iatrogenic injury to the periarticular soft-tissue structures with subsequent reduction in the local and systemic inflammatory response, enhancing early outcomes. Despite the increased costs and radiation exposure associated with CT-based navigation, these many benefits have facilitated the adoption of imaged based robotic surgery into routine practice. Further research on ultra-low-dose CT scans and exploration of the possible translation of the use of 3D imaging into improved clinical outcomes are required to justify its broader implementation. Cite this article: Bone Joint J 2024;106-B(9):892–897

Percutaneous stabilisation of tibial fractures by locking plates has become an accepted form of osteosynthesis. A potential disadvantage of this technique is the risk of damage to the neurovascular bundles in the anterior and peroneal compartments. Our aim in this anatomical study was to examine the relationship of the deep peroneal nerve to a percutaneously-inserted Less Invasive Stabilisation System tibial plate in the lower limbs of 18 cadavers. Screws were inserted through stab incisions. The neurovascular bundle was dissected to reveal its relationship to the plate and screws.

In all cases, the deep peroneal nerve was in direct contact with the plate between the 11th and the 13th holes. In ten specimens the nerve crossed superficial to the plate, in six it was interposed between the plate and the bone and in the remaining two specimens it coursed at the edge of the plate.

Percutaneous insertion of plates with more than ten holes is not recommended because of the risk of injury to the neurovascular structures. When longer plates are required we suggest distal exposure so that the neurovascular bundle may be displayed and protected.

Vascular injuries during total hip arthroplasty (THA) are rare but when they occur, have serious consequences. These have traditionally been managed with open exploration and repair, but more recently there has been a trend towards percutaneous endovascular management.

We performed a systematic review of the literature to assess if this change in trend has led to an improvement in the overall reported rates of morbidity and mortality during the last 22 years in comparison with the reviews of the literature published previously.

We found a total of 61 articles describing 138 vascular injuries in 124 patients. Injuries because of a laceration were the most prevalent (n = 51, 44%) and the most common presenting feature, when recorded, was bleeding (n = 41, 53.3%). Delay in diagnosis was associated with the type of vascular lesion (p < 0.001) and the clinical presentation (p = 0.002).

Open exploration and repair was the most common form of management, however percutaneous endovascular intervention was used in one third of the injuries and more constantly during the last 13 years.

The main overall reported complications included death (n = 9, 7.3%), amputation (n = 2, 1.6%), and persistent ischaemia (n = 9, 7.3%). When compared with previous reviews there was a similar rate of mortality but lower rates of amputation and permanent disability, especially in patients managed by endovascular strategies.

Cite this article: Bone Joint J 2015;97-B:1447–55.

I never considered this to be a significant problem if it is noticed. (back to that later)

Aaron Rosenberg's report seems to have agreed, but at the last members meeting of the Knee Society, Boston, September 2009, others had experience that contradicted my view.

With their experience, ultimately the results were very substantially compromised. This video and presentation show you how to avoid a bad result, actually obtain a perfect result, if you or your student assistant, resident or fellow, bags the MCL.

There are three important points. (1) One needs to recognise the occurrence. (2) The setting is usually varus and so direct end-to-end repair cannot be depended upon. (3) Use of a semitendinosis tenodesis, together with an imperfect, distracted direct repair works perfectly well!

(1) Recognition: The setting is usually varus, but I have had one case in which the chief resident, working with the fellow succeeded in getting the MCL in a valgus knee! In this usually tight varus setting the key feature is that at some point in the case, before component placement, one notices that the exposure is all of a sudden better! Now, the guilty resident or just a passive assisting resident/fellow will usually disagree. The extension space is not so obviously lax, but the flexion space is. Secondly, you do not feel an intact ligament in flexion. And, to prove it I have had to do a little more exposure of the superficial MCL to show the tear. There are at least three mechanisms. Most common is a saw cut. Next is possibly injury with the scalpel or cutting cautery during exposure, and last is damage essentially pre-operatively by a very sharp medial osteophyte which has thoroughly abraded the ligament.

Laxity in full flexion is not necessarily obvious as the posterior capsular integrity helps hide the instability. Again, the really intact ligament is well felt, and in the situation of laceration, the tibia pulls forward more on the medial side, the medial flexion space opens, and what was usually a tight exposure gets suddenly better.

(2) When varus is the setting, I have found it impossible or at least uncomfortable to depend upon direct repair. When the soft tissues are needing to be released or simply undergoing more stress than usual and a lot more than on the lateral side, I see it as unwise to expect or depend upon only a medial repair to hold.

(3) The semitendinosis tenodesis has worked essentially perfectly in every one of my cases. These patients have had no post-operative instability and they have had better than average to extremely good ROM.

A presumably key point is not to alter the patient's post-operative regimen! And, to avoid some passive alteration of PT, I advise specifically that the surgeon or those in his/her team do not mention the occurrence to the patient, the family or the PT! I put the whole story in the op-note, and weeks later I will specifically tell the patient what the staple in place is all about.

I never considered this to be a significant problem if it is noticed. (back to that later)

Aaron Rosenberg's report seems to have agreed, but at the last members' meeting of the Knee Society, Boston, September 2009, others had experience that contradicted my view.

With some experience, ultimately the results were very substantially compromised. This video and presentation show you how to avoid a bad result, actually obtain a perfect result, if you or your student assistant, resident or fellow, bags the MCL.

There are three important points. (1) One needs to recognise the occurrence. (2) The setting is usually varus and so direct end-to-end repair cannot be depended upon. (3) Use of a semitendinosis tenodesis, together with an imperfect, distracted direct repair works perfectly well! (1)

Recognition: The setting is usually varus, but I have had one case in which the chief resident, working with the fellow succeeded in getting the MCL in a valgus knee! In this usually tight varus setting the key feature is that at some point in the case, before component placement, one notices that the exposure is all of a sudden better! Now, the guilty resident or just a passive assisting resident/fellow will usually disagree. The extension space is not so obviously lax, but the flexion space is. Secondly, you do not feel an intact ligament in flexion. And, to prove it I have had to do a little more exposure of the superficial MCL to show the tear. There are at least three mechanisms. Most common is a saw cut. Next is possibly injury with the scalpel or cutting cautery during exposure, and last is damage essentially pre-op by a very sharp medial osteophyte which has thoroughly abraded the ligament.

Laxity in full flexion is not necessarily obvious as the posterior capsular integrity helps hide the instability. Again, the really intact ligament is well felt, and in the situation of laceration, the tibia pulls forward more on the medial side, the medial flexion space opens, and what was usually a tight exposure gets suddenly better.

A presumably key point is not to alter the patient's post-operative regimen! And, to avoid some passive alteration of PT, I advise specifically that the surgeon or those in his/her team do not mention the occurrence to the patient, the family or the PT! I put the whole story in the op-note, and weeks later I will specifically tell the patient what the staple in place is all about.

To evaluate the functional outcome of open humerus diaphyseal fractures treated with the Three-stitch technique of antegrade humerus nailing. This is a retrospective study conducted at the Department of Orthopaedics in D. Y. Patil University, School of Medicine, Navi Mumbai, India. The study included 25 patients who were operated on from January 2019 to April 2021 and follow-ups done till May 2022. Inclusion criteria were adult patients with open humerus diaphyseal fractures (Gustilo-Anderson Classification). All patients with closed fractures, skeletally immature patients, and patients with associated head injury were excluded from the study. All patients were operated on with a minimally invasive Three-stitch technique for antegrade humerus nailing. All patients were evaluated based on DASH score. Out of the 25 patients included in the study, all patients showed complete union. The mean age of the patients was 40.4 years (range 23–66 years). The average period for consolidation of fracture was 10.56 weeks (range 8–14 weeks). The DASH score ranged from 0 to 15.8 with an average score of 2.96. Five patients reported complications with three patients of post-operative infection and delayed wound healing and two patients with screw loosening. All complications were resolved with proper wound care and the complete union was noted. None of the patients had an iatrogenic neurovascular injury. Three-stitch antegrade nailing technique is a novel method to treat diaphyseal humerus fractures and provides excellent results. It has various advantages such as minimal invasiveness, minimal injury to the rotator cuff, fewer infection rates, minimal iatrogenic injuries, and good functional outcomes. Therefore, this treatment modality can be effectively used for open humerus diaphyseal fractures

Several studies have evaluated the risk of peroneal nerve (PN) injuries in all-inside lateral meniscal repair using standard knee magnetic resonance imaging (MRI) with the 30 degrees flexed knee position which is different from the knee position during actual arthroscopic lateral meniscal repair. The point of concern is “Can the risk of PN injury using standard knee MRIs be accurately determined”. To evaluate and compare the risk of PN injury in all-inside lateral meniscal repair in relation to both borders of the popliteus tendon (PT) using MRIs of the two knee positions in the same patients. Using axial MRI studies with standard knee MRIs and figure-of-4 with joint fluid dilatation actual arthroscopic lateral meniscal repair position MRIs, direct lines were drawn simulating a straight all-inside meniscal repair device from the anteromedial and anterolateral portals to the medial and lateral borders of the PT. The distance from the tip of each line to the PN was measured. If a line touched or passed the PN, a potential risk of iatrogenic injury was noted and a new line was drawn from the same portal to the border of the PN. The danger area was measured from the first line to the new direct line along the joint capsule. In 28 adult patients, the closest distances from each line to the PN in standard knee MRI images were significantly shorter than arthroscopic position MRI images (all p-values < 0.05). All danger areas assessed in the actual arthroscopic position MRIs were included within the danger areas as assessed by the standard knee MRIs. We found that the standard knee MRIs can be used to determine the risk of peroneal nerve injury in arthroscopic lateral meniscal repair, although the risks are slightly overestimated

Background. Open subtalar arthrodesis has been associated with a moderate rate of non-union, as high 16.3%, and high rates of infection and nerve injury. Performing this operation arthroscopically serves to limit the disruption to the soft tissue envelope, improve union rates and reduce infection. Our study describes our outcomes and experience of this operation. Method. Retrospective review of all patients who underwent an arthroscopic subtalar arthrodesis between 2023 and 2008. We excluded patients undergoing concurrent adjacent joint arthrodesis. The primary aim was to report on rates of union. Secondary outcomes included reporting on conversion to open procedure, duration of surgery, infection, and iatrogenic injury to surrounding structures. Results. 135 patients were included in the final analysis. 129 patients (95.5%) achieved union. The median time to fusion was 98 days. All cases were performed through sinus tarsi portals. 38 cases were performed with an additional posterolateral portal. Most cases (107/77%) were performed with 2 screws. 3 cases (2.2%) were converted to open procedures. The median tourniquet time was 86 minutes but available in only 88 (65%) cases. There were 4 (2.9%) superficial infections and no deep infections. 1 patient sustained an injury to FHL and there were no reported nerve injuries. Conclusions. At present this is the largest series of arthroscopic subtalar arthrodeses. We demonstrate that this operation can achieve high rates of union with low rates of infection with an equally low likelihood of needing to convert to an open procedure with modest operative times. In our experience the addition of a posterolateral portal does not appear to increase the incidence of nerve injury and aids in the visualisation of all 3 facets

Recent literature has demonstrated that conventional arthroscopic techniques do not adequately visualise areas of predilection of pathology of the long head of biceps (LHB) tendon and are associated with a 30–50% rate of missed diagnoses. The aim of this study was to evaluate the safety, effectiveness and ease of performing biceps tenoscopy as a novel strategy for reducing the rate of missed diagnoses. Five forequarter amputation cadaver specimens were studied. The pressure in the anterior compartment was measured before and after surgical evaluation. Diagnostic glenohumeral arthroscopy was performed and the biceps tendon was tagged to mark the maximum length visualised by pulling the tendon into the joint. Biceps tenoscopy was performed using 3 different techniques (1. Flexible video-endoscopy, 2. Standard arthroscopy via Neviaser portal. 3. Standard arthroscope via antero-superior portal with retrograde instrumentation). Each was assessed for safety, ease of the procedure and whether the full length of the extra-articular part of the LHB tendon could be visualised. The t-test was used to compare the length of the LHB tendon visualised at standard glenohumeral arthroscopy vs that visualised at biceps tenoscopy. An open dissection was performed after the arthroscopic procedures to evaluate for an iatrogenic injury to local structures. Biceps tenoscopy allowed visualisation to the musculotendinous junction in all cases. The mean length of the tendon visualised was therefore significantly greater at biceps tenoscopy (104 mm) than at standard glenohumeral arthroscopy (33 mm) (mean difference 71 mm, p<0.0001). Biceps tenoscopy was safe with regards to compartment syndrome and there was no difference between pre- and post-operative pressure measurements (mean difference 0 mmHg, p=1). No iatrogenic injuries were identified at open dissection. Biceps tenoscopy allows excellent visualisation of the entire length of the LHB tendon and therefore has the potential to reduce the rate of missed diagnoses. This study did not demonstrate any risk of iatrogenic injury to important local structures or any risk of compartment syndrome. Clinical evaluation is required to further validate this technique

Introduction: Injury to the distal third of the axillary artery is well recognised as a complication of proximal humeral fractures. However the risk of iatrogenic injury at shoulder surgery has not, to date, been fully appreciated. Patients: Four female patients aged 59 and over who suffered iatrogenic injury to the axillary artery at the time of shoulder surgery are reported. Two occurred during surgery for planned elective shoulder arthroplasty, while two occurred while treating elderly patients who had previously sustained a 3 part proximal humeral fracture. In all 4 cases the injury probably started as an avulsion of the anterior or posterior humeral circumflex vessels. Results: Vascular surgeons were called in urgently to help with the management of all 4 cases. In two cases the axillary artery was found to have extensive atheroma, was frail and, after initial attempts at end-to-end repair, it became clear that a reversed vein graft was required. Three patients had a satisfactory outcome after reconstruction, while one patient who had previously had local radiotherapy for malignancy, but was now disease free, developed a completely ischaemic upper limb and required a forequarter amputation to save her life. Message: The axillary artery can be very frail in the elderly, is often diseased with atheroma, and is vulnerable to iatrogenic injury at surgery. If injury occurs at surgery, small bulldog clamps should be applied to the cut ends and a vascular surgeon should be called immediately. A temporary arterial shunt should be considered urgently to provide an early return of vascularisation to the limb and to prevent serious complications. The axillary artery is very difficult to repair, and, in our experience may require a vein graft. In addition, distal clearance of the main brachial artery with a Fogarty catheter which is an essential part of the management

Controversy remains regarding the optimal treatment for iatrogenic injury to the medial collateral ligament (MCL) during primary total knee arthroplasty (TKA). Some authors have recommended converting to a prosthesis that provides varus/valgus constraint while others have recommended primary repair. In this study we report the results of a 45 patients who sustained intra-operative MCL injuries during primary TKA that were treated with primary repair. Of 3922 consecutive primary TKA there were 48 (1.2%) intra-operative MCL lacerations or avulsions. One patient was lost and one died before 24-month follow-up. All but one patient underwent primary repair with placement of components without varus/valgus constraint. This left 45 knees with a mean follow up of 89 months (range, 24 – 214 months). The mean HSS knee scores increased from 47 to 85 points (p<0.001). No patients had subjective complaints of instability. No patients had excessive varus/valgus laxity when tested in full extension and 30 degrees of flexion. The range of motion at the time of final follow-up averaged 110 degrees (range, 85 – 130 degrees). Five knees required treatment for stiffness with 4 knees undergoing manipulation under anesthesia and 1 knee undergoing open lysis of adhesions with polyethylene articular surface exchange. Two knees underwent revision for aseptic loosening of the tibial component. In the three knees that underwent open revision, the MCL was noted to be in continuity and without laxity. Primary repair with 6 weeks of post-operative hinged bracing after iatrogenic injury to the MCL during primary TKA was successful at preventing instability although stiffness was seen in approximately 10% of patients. The increased morbidity associated with implantation of a semi-constrained or constrained implant may be unwarranted in this situation

Controversy remains regarding the optimal treatment for iatrogenic injury to the medial collateral ligament (MCL) during primary total knee arthroplasty (TKA). Some authors have recommended converting to a prosthesis that provides varus/valgus constraint while others have recommended primary repair. In this study, we report the results of 45 patients who sustained intra-operative MCL injuries during primary TKA that were treated with primary repair. Of 3922 consecutive primary TKA there were 48 (1.2%) intra-operative MCL lacerations or avulsions. One patient was lost and one died before 24 months follow up. All but one patient underwent primary repair with placement of components without varus/valgus constraint. This left 45 knees with a mean follow up of 89 months (range, 24 to 214 months). The mean HSS knee scores increased from 47 to 85 points (p<0.001). No patients had subjective complaints of instability. No patients had excessive varus/valgus laxity when tested in full extension and 30 degrees of flexion. The range of motion at the time of final follow-up averaged 110 degrees (range, 85 to 130 degrees). Five knees required treatment for stiffness with 4 knees undergoing manipulation under anaesthesia and 1 knee undergoing open lysis of adhesions with polyethylene articular surface exchange. Two knees underwent revision for aseptic loosening of the tibial component. In the three knees that underwent open revision, the MCL was noted to be in continuity and without laxity. Primary repair with 6 weeks of post-operative hinged bracing after iatrogenic injury to the MCL during primary TKA was successful at preventing instability although stiffness was seen in approximately 10% of patients. The increased morbidity associated with implantation of a semi-constrained or constrained implant may be unwarranted in this situation

Controversy remains regarding the optimal treatment for iatrogenic injury to the medial collateral ligament (MCL) during primary total knee arthroplasty (TKA). Some authors have recommended converting to a prosthesis that provides varus/valgus constraint while others have recommended primary repair. In this study we report the results of a 45 patients who sustained intraoperative MCL injuries during primary TKA that were treated with primary repair. Of 3922 consecutive primary TKA there were 48 (1.2%) intraoperative MCL lacerations or avulsions. One patient was lost and one died before 24 months follow up. All but one patient underwent primary repair with placement of components without varus/valgus constraint. This left 45 knees with a mean follow up of 89 months (range, 24–200). The mean HSS knee scores increased from 46.8 to 84.8 points (p<0.001). No patients had subjective complaints of instability. No patients had excessive varus/valgus laxity when tested in full extension and 30 degrees of flexion. The range of motion at the time of final follow-up averaged 110 degrees (range, 85 degrees to 130 degrees). Five knees required treatment for stiffness with 4 knees undergoing manipulation under anesthesia and 1 knee undergoing open lysis of adhesions with polyethylene articular surface exchange. Two knees underwent revision for aseptic loosening of the tibial component. In the three knees that underwent open revision, the MCL was noted to be in continuity and without laxity. Primary repair with 6 weeks of postoperative hinged bracing after iatrogenic injury to the MCL during primary TKA was successful at preventing instability although stiffness was seen in approximately 10% of patients. The increased morbidity associated with implantation of a semiconstrained or constrained implant may be unwarranted in this situation

Objective:. To observe the incidence of intra-operative vascular injuries during anterior cervical decompression and fusion (ACDF). Secondly, management and monitoring of the outcome post vascular injury during ACDF. Methods:. This a prospective study. A review of all spinal patients' records was performed from June 2006 to April 2011. A comprehensive literature review was also utilized. Inclusion criteria – all patients had ACDF post trauma. All non-traumatic cases were excluded. Results:. The study consisted of 55 patients; 15 were females and 40 were males. The age distribution was 23–65 years. Two patients were excluded due to non-traumatic causes. Of the remaining 53 patients, four sustained intra-operative vascular injuries during ACDF surgery. All 4 patients had corpectomies, and one case was an iatrogenic injury. The commonly injured vessel during the ACDF surgery was the left vertebral artery. Haemostatic control was achieved via tamponade and haemostatic agents. The left common carotid was iatrogenically injured in one case and was treated by microvascular repair. Three patients were treated with antiplatelet therapy for three months duration. The patient with an iatrogenic injury was treated with anticoagulation therapy for three months duration. All computerized tomographic angiograms at three months follow up illustrated patent vessels. Conclusion:. There is an increased incidence of intra operative vascular injuries during ACDF associated with corpectomies. It is essential to be aware of the low incidence of intra operative arterial injury during ACDF and to have a management approach, such as tamponade or microvascular repair. Anticoagulation and antiplatelet therapy is effective in decreasing the complications of vascular injuries post ACDF

Introduction and Aims: The Lateral Femoral Cutaneous Nerve is placed at risk of iatrogenic injury in the dual incision minimally invasive approach THA. A number of trials have indicated rates of injury up to 30%. This clinical and cadaver study examined the morphology of the nerve in 101 cadaver specimens and in 78 dual incision THA patients. Method: One hundred and one lateral femoral cutaneous nerves of the thigh were dissected in fresh and formalin embalmed specimens. Dissection was limited to the anterior thigh and the branch pattern of the LFCN recorded. Dual incision patients were followed prospectively and examined with regard to LFCN paraesthesia. Results: Despite the variability of the nerve, three basic morphologic patterns emerged. Approximately 55% had a major medial trunk and smaller lateral branch, 30% involved two distinct large branches and 15% had a trifurcation or other pattern. In our clinical series, over 30% of patients experienced paraesthesia and some experienced a burning dysaesthesia in the distribution of the LFCN. Conclusion: Iatrogenic injury to the LFCN is relatively common in the dual incision minimally invasive THA and patients must be informed of such a risk. Based on this study we have slightly modified our incision and approach

Intramedullary tibial nailing was performed in ten paired cadavers and the insertion of a medial-to-lateral proximal oblique locking screw was simulated in each specimen. Anatomical dissection was undertaken to determine the relationship of the common peroneal nerve to the cross-screw. The common peroneal nerve was contacted directly in four tibiae and the cross-screw was a mean of 2.6 mm (1.0 to 10.7) away from the nerve in the remaining 16. Iatrogenic injury to the common peroneal nerve by medial-to-lateral proximal oblique locking screws is therefore a significant risk during tibial nailing

Introduction. Soft tissue releases are often required to correct deformity and achieve gap balance in total knee arthroplasty (TKA). However, the process of releasing soft tissues can be subjective and highly variable and is often perceived as an ‘art’ in TKA surgery. Releasing soft tissues also increases the risk of iatrogenic injury and may be detrimental to the mechanically sensitive afferent nerve fibers which participate in the regulation of knee joint stability. Measured resection TKA approaches typically rely on making bone cuts based off of generic alignment strategies and then releasing soft tissue afterwards to balance gaps. Conversely, gap-balancing techniques allow for pre-emptive adjustment of bone resections to achieve knee balance thereby potentially reducing the amount of ligament releases required. No study to our knowledge has compared the rates of soft tissue release in these two techniques, however. The objective of this study was, therefore, to compare the rates of soft tissue releases required to achieve a balanced knee in tibial-first gap-balancing versus femur-first measured-resection techniques in robotic assisted TKA, and to compare with release rates reported in the literature for conventional, measured resection TKA [1]. Methods. The number and type of soft tissue releases were documented and reviewed in 615 robotic-assisted gap-balancing and 76 robotic-assisted measured-resection TKAs as part of a multicenter study. In the robotic-assisted gap balancing group, a robotic tensioner was inserted into the knee after the tibial resection and the soft tissue envelope was characterized throughout flexion under computer-controlled tension (fig-1). Femoral bone resections were then planned using predictive ligament balance gap profiles throughout the range of motion (fig-2), and executed with a miniature robotic cutting-guide. Soft tissue releases were stratified as a function of the coronal deformity relative to the mechanical axis (varus knees: >1° varus; valgus knees: >1°). Rates of releases were compared between the two groups and to the literature data using the Fischer's exact test. Results. The overall rate of soft tissue release was significantly lower in the robotic gap-balancing group, with 31% of knees requiring one or more releases versus 50% (p=0.001) in the robotic measured resection group and 66% (p<0.001) for conventional measured resection (table-1) [1]. When comparing as a function of coronal deformity, the difference in release rates for robotic gap-balancing was significant when compared to the conventional TKA literature data (p<0.0001) for all deformity categories, but only for varus and valgus deformities for robotic measured resection with the numbers available (varus: 33% vs 50%, p=0.010; neutral 11% vs 50%, p=0.088, valgus 27% vs 53%, p=0.048). Discussion. Robotic-assisted tibial-first gap-balancing techniques allow surgeons to plan and adjust femoral resections to achieve a desired gap balance throughout motion, prior to making any femoral resections. Thus, gap balance can be achieved through adjustment of bone resections, which is accurate to 1mm/degree with robotics, rather than through manual releasing soft tissues which is subjective and less precise. These results demonstrated that the overall rate of soft tissue release is reduced when performing TKA with predictive gap-balancing and a robotic tensioning system. For any figures or tables, please contact authors directly

Aims. We set out to determine if there is a difference in perioperative outcomes between early and delayed surgery in paediatric supracondylar humeral fractures in the absence of vascular compromise through a systematic review and meta-analysis. Materials and Methods. A literature search was performed, with search outputs screened for studies meeting the inclusion criteria. The groups of early surgery (ES) and delayed surgery (DS) were classified by study authors. The primary outcome measure was open reduction requirement. Meta-analysis was performed in the presence of sufficient study homogeneity. Individual study risk of bias was assessed using the Risk of Bias in Non-Randomised Studies – of Interventions (ROBINS-I) criteria, with the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria used to evaluate outcomes independently. Results. A total of 12 studies met the inclusion criteria (1735 fractures). Pooled mean time to surgery from injury was and 10.7 hours for ES and 91.8 hours for DS. On meta-analysis there was no significant difference between ES versus DS for the outcome of open reduction requirement. There was also no significant difference for the outcomes: Iatrogenic nerve injury, pin site infection, and re-operation. The quality of evidence for all the individual outcomes was low or very low. Conclusions. There is no evidence that delaying supracondylar fracture surgery negatively influences outcomes in the absence of vascular compromise. There are, however, notable limitations to the existing available literature

Aims

Management of displaced paediatric supracondylar elbow fractures remains widely debated and actual practice is unclear. This national trainee collaboration aimed to evaluate surgical and postoperative management of these injuries across the UK.

Percutaneous Achilles tenotomy is an integral part of the Ponseti technique. Though considered as a simple procedure, many authors have reported serious neurovascular complications that include iatrogenic injury to the lesser saphenous vein, the posterior tibial neurovascular bundle, the sural artery and pseudoaneurysm formation. The authors describe the results of their new tenotomy technique, the ‘Posterior to Anterior Controlled’ (PAC) technique in an attempt to eliminate such complications. This is a prospective study. Infants < 1 year of age with idiopathic clubfoot were taken up for the Ponseti technique of correction. Tenotomy was performed by the ‘PAC’ technique under local anaesthesia if passive dorsiflexion was found to be < 15 degrees. Outcome measures included completeness of the tenotomy (by ultrasonography), improvement in the equinus angle and occurrence of neurovascular complications. 40 clubfeet in 22 patients underwent ‘PAC’ tenotomy. The mean age was 3.5 months. The tenotomy was found to be complete in all cases. The equinus angle improved by an average of 78.5 degrees (range 70–95 degrees), which was statistically significant (p < 0.05, students t test). Mild soakage of the cast with blood was noted in 21 (52.5%) cases. No neurovascular complication was noted. The average follow-up was 12.2 months (range 9–18 months). The ‘PAC’ tenotomy virtually eliminates the possibility of neurovascular damage, maintains the percutaneous nature of the procedure, is easy to learn and can be performed even by relatively inexperienced surgeons safely and effectively as an office procedure under local anaesthesia

We reviewed the outcome, at a mean follow-up of 14 months, of 21 two-column fractures of the acetabulum treated by operation through one or two non-extensile approaches. Eighteen procedures resulted in reduction of the articular surfaces to within 3 mm. The blood loss and operating time when two combined non-extensile approaches were used were similar to those reported for extended acetabular approaches. The incidence of heterotopic ossification which limited joint motion was low, and the average Harris hip score was 81 points. The use of non-extensile approaches for acetabular fractures in which both columns are involved avoids iatrogenic injury to the abductors, and reduces the incidence of complications

Equinus contracture of the ankle due to a tight Gastrocnemius has been implicated in the pathogenesis of a number of foot and ankle conditions. There are numerous described procedures for release of the Gastrocnemius such as the Strayer procedure. Our indications for release are in patients with a symptomatic forefoot and an equinus contracture of 5 degrees or more in extension as defined by the Silfverskiöld test. The release is usually combined with a reconstructive procedure. The advantages of our technique are its simplicity, excellent visualisation of the tendon and sural nerve, good wound healing and patient comfort post-operatively. The procedure can be performed without tourniquet. A 2.5cm incision is made over the medial calf, just distal to the Gastrocnemius muscle indentation. The deep fascia is incised and the edge of the tendon can be visualised. Blunt digital dissection is performed on either side of the tendon to develop a plane. A metal Cusco speculum is inserted to visualise the full width of the tendon. The tenotomy is performed starting medially and the last 5mm of the lateral tendon is left uncut. This reduces the chance of iatrogenic injury to the nerve. The tendon bridge can be left if correction is sufficient, otherwise passive dorsiflexion of the ankle results in completion. Post-operatively, patients are able to mobilise fully with crutches and passive ankle physiotherapy is commenced immediately. We performed 22 MAGS procedures in 17 patients. There were no Sural nerve injuries and no wound complications. All patients were delighted with cosmesis. Average pre-operative equinus contracture with the leg extended was 18 degrees. Average intra-operative correction of 24 degrees was obtained and at 3 months follow-up, all patients were able to dorsiflex past neutral

Aims

This systematic review aimed to summarize the full range of complications reported following ankle arthroscopy and the frequency at which they occur.

MIS (minimally invasive surgery) aims to improve cosmesis and facilitate early recovery by using a small skin incision with minimal soft tissue disruption. When using MIS in the forefoot, there is concern about neurovascular and tendon damage and cutaneous burns. The aim of this anatomical study was to identify the structures at risk with the proposed MIS techniques and to determine the frequency of iatrogenic injury. Materials and Methods. 10 paired normal cadaver feet were used. All procedures were performed using a mini C-arm in a cadaveric lab by 2 surgeons: 1 consultant who has attended a cadaveric MIS course but does not perform MIS in his regular practice (8 feet), and 1 registrar who was supervised by the same consultant (2 feet). In each foot, the surgeon performed a lateral release, a MICA (minimally invasive chevron and Akin) procedure for the correction of hallux valgus, and a minimally invasive DMO (distal metatarsal extra-articular osteotomy) procedure. Each foot was then dissected and photographed to identify any neurovascular or tendon injury. Results. The dorsal medial cutaneous and the plantar interdigital nerves were intact in all specimens. There was no obvious damage to the arterial plexus supplying the first metatarsal head. No flexor or extensor tendon injuries were identified. There is a significant learning curve to performing the osteotomy cuts in the desired plane. In the DMO, the dissection also revealed some intact soft tissue at the osteotomy site indicating that the metatarsal heads were not truly floating. Discussion. Although there has been concern regarding neurovascular and tendon injury, our findings indicate minimal risk, which is consistent with reports in the literature. This study also reflects the learning curve. Conclusion. We suggest that training on cadaveric specimens may be advantageous, particularly, with regard to the plane of the osteotomy

Aim: The retrospective evaluation of external fixation as a treatment of choice for fractures of humeral diaphysis. Material – Method: 24 patients with an equal number of fractures of humerus diaphysis (21 closed, 3 open) were treated with external fixation. Time to bony union, the seriousness and type of complications, the clinical, radiological and functional outcome were evaluated. The minimum time of follow up was six months. Results: Excellent 20, good 2, fair 1, poor 1. The cause of fair and poor results was limitation of shoulder motion. 22 fractures united within 2–5 months. Complications were 2 cases of non-union, 3 pin-track infections, 3 remanipulations. There was no case of deep infection at the fracture site and no iatrogenic injury of the radial nerve. Conclusion: The external fixation, used in the treatment of humerus fractures, is a semi-interventional method, easy to apply, well-tolerated by the patient and with very good functional results. It a very good alternative of both the conservative treatment and internal fixation

The June 2023 Knee Roundup³⁶⁰ looks at: Cementless total knee arthroplasty is associated with early aseptic loosening in a large national database; Is cementless total knee arthroplasty safe in females aged over 75 years?; Could novel radiological findings help identify aseptic tibial loosening?; The Attune cementless versus LCS arthroplasty at introduction; Return to work following total knee arthroplasty and unicompartmental knee arthroplasty; Complications and downsides of the robotic total knee arthroplasty; Mid-flexion instability in kinematic alignment better with posterior-stabilized and medial-stabilized implants?; Patellar resurfacing does not improve outcomes in modern knees.

Aims: Distal humeral shaft fractures are difficult to treat by antegrade humeral nails. In this study we have used a new retrograde nail to treat these fractures. Methods and Material: Since 1997 we have treated 15 extra articular fractures using this device. The nail is introduced through the roof of the olecranon fossa, thus leaving the rotator cuff of the shoulder free from any iatrogenic injury. Proximal rotational stability is maintained by a unique ‘Trio Wire’, which passes through the nail and fans out in the head of the humerus. Distal rotational stability is maintained by the transverse plate. Results: In all cases early pain relief was obtained with return of shoulder and elbow functions. By 6 weeks 98% of patients could perform the majority of daily tasks. No significant complication was noted except a loss of extension of the elbow by 10–15 degrees. Conclusion: This new nail provides stable fixation of difficult distal humeral fractures, even in cases with poor bone quality. Early pain relief with a rapid return of shoulder and elbow functions denote a successful outcome of these operations

The August 2023 Wrist & Hand Roundup360 looks at: Complications and patient-reported outcomes after trapeziectomy with a Weilby sling: a cohort study; Swelling, stiffness, and dysfunction following proximal interphalangeal joint sprains; Utility of preoperative MRI for assessing proximal fragment vascularity in scaphoid nonunion; Complications and outcomes of operative treatment for acute perilunate injuries: a systematic review; The position of the median nerve in relation to the palmaris longus tendon at the wrist: a study of 784 MR images; Basal fractures of the ulnar styloid? A randomized controlled trial; Proximal row carpectomy versus four-corner arthrodesis in SLAC and SNAC wrist; Managing cold intolerance after hand injury: a systematic review.

Ten patients who suffered iatrogenic injury to a vertebral artery during anterior cervical decompression were reviewed to assess the mechanisms of injury, their operative management, and the subsequent outcome. All had been undergoing a partial vertebral body resection for spondylitic radiculopathy or myelopathy (4), tumour (2), ossification of the posterior longitudinal ligament (1), nonunion of a fracture (2), or osteomyelitis (1). The use of an air drill had been responsible for most injuries. The final control of haemorrhage had been by tamponade (3), direct exposure and electrocoagulation (1), transosseous suture (2), open suture (1), or open placement of a haemostatic clip (3). Five patients had postoperative neurological deficits, but most of them resolved. We found direct arterial exposure and control to be safe, quick and reliable. Careful use of the air drill, particularly in pathologically weakened bone, as in infection or tumour, is essential. Arterial injury is best avoided by a thorough knowledge of the anatomical relationships of the artery, the spinal canal, and the vertebral body

The August 2024 Trauma Roundup³⁶⁰ looks at: Does topical vancomycin prevent fracture-related infections in closed fractures undergoing open reduction and internal fixation? A randomized controlled trial; Is postoperative splinting advantageous after upper limb fracture surgery?; Does suprapatellar nailing resolve knee pain?; Locking versus non-locking plate fixation in comminuted talar neck fractures: a biomechanical study using cadaveric specimens; Revolutionizing recovery metrics: PROMIS versus SMFA in orthopaedic trauma care; Dorsal hook plating of patella fractures: reliable fixation and satisfactory outcomes; The impact of obesity on subtrochanteric femur fracture outcomes; Low-dose NSAIDs (ketorolac) and cytokine modulation in orthopaedic polytrauma: a detailed analysis.

Introduction: Vascular injuries associated with limb bone fractures are relatively uncommon. Aim: To determine the mechanisms of injury and evaluate the outcome of combined orthopaedic and vascular injuries. Method: A retrospective review of all patients with vascular injury associated with limb bone fractures between January 1992 and July 2006 was performed. Data collected included demographic details, clinical presentation, assessment, management and outcome. Results: Of 22,340 fractures treated during the 14 years period 36 patients sustained a vascular injury that required surgical intervention. Of those, 18 patients (50%) had a concomitant fractures or other orthopaedic injury this group form the basis of the audit. The median age was 31.1 (range 3–80) years, and 66% were male. Road traffic accidents accounted for 12 injuries (66%), other accidents 4(22%), iatrogenic injury 1(6%), and 1 gunshot injury (6%). Four patients had an associated nerve injury with varying severity. Skeletal fixation preceded vascular repair in most of the cases. Peroperative arterial shunting was not used in any patient. The primary vascular procedures included end-to-end anastamosis 2(11%), bypass grafting 1(6%), interposition vein grafts 8(43%), vein patch 1(6%), direct arterial repair 2(11%), ligation 2(11%), primary amputation 1(6%), reposition of normal course of artery 1(6%). During a 17 months follow-up period, the upper and lower limb preservation rate was 100 and 89%, respectively. Nine patients (50%) were symptom free; three patients (16.6%) had a neurological deficit. Conclusion: Vascular injury is uncommon in the orthopaedic patients. High suspicion and early intervention is essential to optimise outcome and function

The axillary nerve injuries most commonly are observed after trauma such as contusion-stretch, gunshot wound, laceration and iatrogenic injuries. Two of the most commons causes seem to be the glenohumeral dislocation and the proximal humerus fractures. The axillary nerve may sustain a simple contusion, or its terminal elements may be avulsed from the deltoid muscle. Compressive neuropathy in the quadrilateral space also has been reported (quadrilateral space syndrome, Calhill and Palmer, 1983). The axillary nerve injuries incidence represents less than 1% of all nerve injuries. Aim: The purpose of this study was to analyze outcome in patients, who presented with injuries to the axillary nerve. Material and methods: We report a series of 15 cases of axillary nerve lesions, which were operated between 1995 and 2002. These injuries resulted from shoulder injury either with or without fracture and or dislocation. Patients were operated between 3 to 6 months after trauma and an anterior deltopectoral approach was usually followed during surgery. The follow up period ranged from 1 to 8 years. Results: The results were considered as satisfactory in 11 out of 15 axillary nerve lesions. According to clinical examination, of the function of the shoulder and the muscle strength the results were classified as excellent in 5 cases, good in 6 cases and poor in 4 cases. Conclusions: If indicated, nerve repair can lead to useful function in carefully selected patients

Aims

Staphylococcus aureus is a major cause of septic arthritis, and in vitro studies suggest α haemolysin (Hla) is responsible for chondrocyte death. We used an in vivo murine joint model to compare inoculation with wild type S. aureus 8325-4 with a Hla-deficient strain DU1090 on chondrocyte viability, tissue histology, and joint biomechanics. The aim was to compare the actions of S. aureus Hla alone with those of the animal’s immune response to infection.

In an unselected series of 55 cases of slipped capital femoral epiphysis (SCFE) we observed an incidence of 25% of epiphyseal reduction, mostly unintentional. Reduction indicated physeal instability and was associated with an effusion, detected by sonography on admission, and inability to bear weight. The true prevalence of instability may be higher since an effusion was noted in 33 cases (60%) on the initial sonographic assessment. Serial radiographs showed reduction in 12 (22%), with an average change of 15.1 degrees in the head-neck angle. Serial sonography showed reduction in 7 out of 20 cases (35%), with an average change of 3.7 mm in displacement. In two cases reduction was seen on sonography but not on radiography. Of the hips which showed subsequent reduction, 12 had had a bone scan on admission; three showed initial epiphyseal avascularity but only one progressed to symptomatic avascular necrosis. All stable hips had normal epiphyseal vascularity on the initial bone scan. This indicates the importance of injury from the initial displacement in causing avascular necrosis, rather than effusion, vascular compromise or iatrogenic injury from gentle repositioning. Physeal instability in SCFE is common and should be assessed clinically on admission. It is indicated by joint effusion or inability to bear weight. A slip is very unlikely to be unstable in a child able to bear weight and with no sonographic effusion

Aims

Both anatomical and reverse total shoulder arthroplasty (aTSA and rTSA) provide functional improvements. A reported benefit of aTSA is better range of motion (ROM). However, it is not clear which procedure provides better outcomes in patients with limited foward elevation (FE). The aim of this study was to compare the outcome of aTSA and rTSA in patients with glenohumeral osteoarthritis (OA), an intact rotator cuff, and limited FE.

Introduction:. A surgical hip dislocation provides circumferential access to the femoral head and is essential in the treatment pediatric and adult hip disease. Iatrogenic injury to the femoral head blood supply during a surgical may result in the osteonecrosis of the femoral head. In order to reduce vessel injury and incidence of AVN, the Greater Trochanteric Osteotomy (GTO) was developed and popularized by Ganz. The downside of this approach is the increased morbidity associated with the GTO including non-union in 8% and painful hardware requiring removal in 20% of patients. (reference) Recent studies performed at our institution have mapped the extra-osseous course of the medial femoral circumflex artery and provide surgical guidelines for a vessel preserving posterolateral approach. In this cadaveric model using Gadolinium enhanced MRI, we investigate whether standardized alterations in the postero-lateral surgical approach may reliably preserve femoral head vascularity during a posterior surgical hip dislocation. Methods:. In 8 cadaveric specimens the senior author (ES) performed a surgical hip dislocation through the posterolateral approach with surgical modifications designed to protect the superior and inferior retinacular arteries. In every specimen the same surgical alterations were made using a ruler: the Quadratus Femoris myotomy occurred 2.5 cm off its trochanteric insertion, the piriformis tenotomy occurred at its insertion and extended obliquely leaving a 2 cm cuff of conjoin tendon (inferior gemellus), and the Obturator Externus (OE) was myotomized 2 cm off its trochanteric insertion. (Figure 1) For the capsulotomy, the incision started on the posterior femoral neck directly beneath the cut obturator externus tendon and extending posteriorly to the acetabulum. Superior and inferior extensions of the capsulotomy ran parallel to the acetabular rim creating a T-shaped capsulotomy. After the surgical dislocation was complete, the medial femoral circumflex artery (MFCA) was cannulated and Gadolinium-enhanced MRI performed in order to assess intra-osseous femoral head perfusion and compared to the gadolinium femoral head perfusion of the contra-lateral hip as a non-operative control. Gross-dissection after polyurethane latex injection in the cannulated MFCA was performed to validate MRI findings and to assess for vessel integrity after the surgical dislocation. Results:. In 8 cadaveric specimens MRI quantification of femoral head perfusion was 94.3% and femoral head-neck junction perfusion was 93.5% compared to the non-operative control. (Figure 2) Gross dissection after latex injection into the MFCA demonstrated intact superior and inferior retinacular arteries in all 8 specimens. (Figure 3). Discussion and Conclusions:. In this study, perfusion to the femoral head and head-neck junction is preserved following posterior surgical dislocation through the postero-lateral approach. These preliminary findings suggest that specific surgical modifications can protect and reliably maintain vascularity to the femoral head after surgical hip dislocation. This approach may benefit hip resurfacing and potentially decease risk of femoral neck fracture secondary to osteonecrosis. In addition this may allow a vascular preserving surgical hip dislocation to be performed without the need for a GTO

Aims: To identify the incidence of neurological deþcit and functional outcome following displaced acetabular fractures. Methods: We carried out a prospective study of 136 patients who underwent skeletal stabilization of displaced acetabular fractures. Patients with sciatic nerve injuries were identiþed, assessed and followed up clinically. Routine EMG and nerve conduction studies were performed post-operatively on all cases with clinical proven neurological lesions to correlate the level, severity of the lesion and monitor progress of recovery. Results: 27 patients (19.8%) have neurological deþcit identiþed preoperatively. In 12 patients where the femoral heads were dislocated posteriorly. 20 were male and 7 were female. The mean age was 33.8 years (range 16–66). 15 patients had associated injuries but none of the patients had injury to the spinal cord. The mean ISS was 12.6 (range 9–34). The mean follow up was 3.4 years (range 1.5–6 years). 13 patients with complete drop foot at presentation. 9 patients had EMG proven double crush lesion. 3 patients had ipsilateral knee injury. 2 patients had intraopearative iatrogenic injury. All 9 patients with double crush syndrome have no improvement in function. Conclusions: Acetabular fractures associated with sciatic nerve injuries are devastating injuries with signiþcant long term morbidity. 50% patients showed improvement with time. Identiþcation of double crush lesion is vital as it is associated with poorer functional recovery as compared to single lesion

Displaced fractures of the distal humerus are very difficult to treat. Numerous techniques have been developed for internal fixation, e.g. plating, Rush nail fixation, IM nailing etc. Results are not very good in majority of the cases. Conventional ‘antigrade’ nailing sometimes may not be suitable for these types of fractures. This new nail is inserted by a close retrograde technique using a special interlocking system to avoid axillary nerve and rotator cuff damage. This nail also allows stable fixation of these distal fractures via a plate welded its distal end, which maintain the rotational stability. Since 1997 we have treated 15 displaced extra particular fractures using this device. 12 of them were widely displaced fractures, some comminuted, and 3 were pathological fractures. The nail is introduced through the roof of the olecranon fossa, thus leaving the rotator cuff of the shoulder free from any iatrogenic injury. Proximal rotational stability is maintained by a unique ‘Trio Wire’, which passes through the nail and fans out in the head of the humerus. Distal rotational stability is maintained by the transverse plate. In all cases early pain relief was obtained with return of shoulder and elbow functions. By 6 weeks 98% of patients could perform the majority of daily tasks. No significant complication was noted except a loss of extension of the elbow by 10–15 degrees. This new nail provides stable fixation of difficult distal humeral fractures, even in cases with poor bone quality. Early pain relief with a rapid return of shoulder and elbow functions denote a successful outcome of these operations

This study investigates and defines the topographic anatomy of the medial femoral circumflex artery (MFCA) terminal branches supplying the femoral head (FH). Gross dissection of 14 fresh–frozen cadaveric hips was undertaken to determine the extra and intracapsular course of the MFCA’s terminal branches. A constant branch arising from the transverse MFCA (inferior retinacular artery; IRA) penetrates the capsule at the level of the anteroinferior neck, then courses obliquely within the fibrous prolongation of the capsule wall (inferior retinacula of Weitbrecht), elevated from the neck, to the posteroinferior femoral head–neck junction. This vessel has a mean of five (three to nine) terminal branches, of which the majority penetrate posteriorly. Branches from the ascending MFCA entered the femoral capsular attachment posteriorly, running deep to the synovium, through the neck, and terminating in two branches. The deep MFCA penetrates the posterosuperior femoral capsular. Once intracapsular, it divides into a mean of six (four to nine) terminal branches running deep to the synovium, within the superior retinacula of Weitbrecht of which 80% are posterior. Our study defines the exact anatomical location of the vessels, arising from the MFCA and supplying the FH. The IRA is in an elevated position from the femoral neck and may be protected from injury during fracture of the femoral neck. We present vascular ‘danger zones’ that may help avoid iatrogenic vascular injury during surgical interventions about the hip. Cite this article: Bone Joint J 2015;97-B:1204–13

A radial nerve palsy complicates 1.8 to 17% (mean 11%) diaphyseal humeral fractures (13.7% in our series of 156 humeral fractures and nonunions treated by external fixation – Tsiagadigui, 2000). In about 75%, it is a primary lesion, related to the fracture before any attempt at treatment. In 60%, the fracture, most commonly with an oblique fracture line, involves the middle third. In children, a supracondylar fracture may be complicated by radial nerve palsy. Most nerve lesions correspond to neurapraxia or axonotmesis, due to traction or compression associated with bone angular deformity. Unfrequently, the nerve is impaled or severed by bone fragments, or may be trapped within the fracture in case of a spiral oblique middle or distal third humeral fracture with lateral displacement of the distal fragment. Iatrogenic injury during internal fixation or entrapment within periosteal callus are occasionally observed. The classical indications for early radial nerve exploration include open fractures requiring surgical debridement, or fractures with vascular compromise, or when the osteosynthesis is done by a plate. In all other cases, we recommend to investigate the integrity of the radial nerve by echography. In the absence of discontinuity, spontaneous neurological recovery is likely to occur and is monitored clinically and by electromyography; prevention of joint contracture is done by physiotherapy and by a wrist splint, maintaining the joint in slight dorsiflexion. In case of persistent palsy, neurolysis is indicated several months after the initial injury, the precise delay depending on the level of the fracture. Palliative treatment by tendon transfers offers in cases of persistent palsy excellent functional results. Tendon transfers may be indicated early after the fracture, in case of an irreparable radial nerve lesion

Purpose: Inadequate disc fragment excision, suboptimal bony decompression of the lateral recess, and persistent foraminal and far lateral compressive lesions are the most common cited causes for persistent radiculopathy after lumbar decompressive surgery. This study examines the utility of continous intraoperative monitoring of electromyographic (EMG) nerve root potentials during decompression of lumbar radiculopathy using a proprietary neurophysiological EMG monitoring system (Neurovision; Nuvasive; San Diego, CA). Methods: A prospective, non-blinded, non-randomized study was undertaken in 43 patients with symptomatic lumbar radiculopathy and weakness undergoing decompressive surgery. All had previously failed conservative therapy. Preoperative and postoperative data for neurological strength examination, EMG amplitudes, VAS scores for radiculopathy were recorded. Continuous EMG nerve root potentials were monitored and recorded during surgery. Results: At the time of surgery, 39 of 43 patients demonstrated measurable asymmetric EMG amplitudes. Of these 39, 30 patients had clinical strength improvements. Intraoperative EMG improvements were seen in 21 of these 30 patients with an overall sensitivity of 70%. Of 9 patients who did not improve in strength, 8 demonstrated no improvement or worsening on EMG for a specificity of 89%. Overall, EMG nerve root monitoring had a positive predictive value of 95.5% and a negative predictive value of 47.1% with regards to strength improvement. 3 cases had worsened transient weakness that resolved within 3 months. In detecting such injury, EMG was 100% sensitive, 97% specific with a positive predictive value of 75% and a negative predictive value of 98%. Conclusions: Use of intraoperative EMG nerve root surveillance may provide a useful adjunct in determining the adequacy of decompression during surgery of compressive lumbar radiculopathy and may help to predict the degree of motor improvement. Although a rare complication, EMG is particularly sensitive at detecting iatrogenic injury to the nerve root during surgery

Supracondylar humeral fractures are the most common elbow injury in children, usually sustained from a fall on the outstretched hand. Iatrogenic ulnarnerve injury is not uncommon following cross K wiring. NNH is the number of cases needed to treat in order to have one adverse outcome. A systemic review was undertaken to calculate relative risks, risk difference and number needed to harm following management of supracon-dylar fractures with cross or lateral K wires. It was found that there was one iatrogenic ulnar nerve injury for every twenty-seven cases that were managed with crossed K wires. The aim of this study was to calculate the number of cross K wiring of supracondylar fractures of the humerus that would need to be performed for one iatrogenic ulnar nerve injury to occur. Iatrogenic ulnarnerve injury is not uncommon following cross K wiring of supracondylar fractures of the humerus. To date there are no clinical trials showing the benefit of cross K wiring over lateral K wiring in the management of supracondylar fractures of the humerus in children. If it can be confirmed that lateral K wiring is as effective as crossed K wiring, iatrogenic ulnar nerve injury can be avoided. A systematic review of iatrogenic ulnar nerve injuries following management of supracondylar fractures was conducted. The databases MEDLINE 1966 – present, EMBASE 1980 – present, CINAHL 1982 – present, CDSR, and DARE were searched along with a meticulous search of the Journal of Paediatric Orthopaedics from 1998 to 2004. Of the two hundred and forty-eight papers identified, only thirty-six met the inclusion criteria. The papers where both lateral crossed K wires were used as treatment were identified for calculating relative rates, risk difference and number needed to harm. NNH was 7.69. When a sensitivity analysis removing two studies that had five subjects or fewer and a 100% ulnar nerve injury rate was peformed, the NNH was 27.7. In other words, there was one iatrogenic ulnar nerve injury for every twenty-seven cases that were managed with crossed K wires

The goal for arthroscopic stabilization of anterior glenohumeral instability is to achieve an outcome equivalent to or better than open procedures. A number of arthroscopic procedures have been advocated to reestablish continuity of the inferior glenohumeral ligament complex (IGHLC) with the glenoid. Implantable suture anchors were developed to avoid the problems associated with arthroscopic staple capsulorrhaphy like iatrogenic injury of the glenoid or humeral surface, loosening and migration of the staple. The preferred techniques are easy implantable suture anchors made of titanium (Fastak). Our experience suggests, that if proper selection criteria are employed, normal patients and overhead-athletes may benefit from the advantages of an arthroscopic repair without accepting an increased risk for recurrence. From 4/96 to 10/00 we performed a prospective analysis of 242 shoulders, who underwent arthroscopic shoulder stabilization with FASTak-(n = 159) Panalok-(n = 26) and Sure-tac suture anchors (n = 57) in our clinic. The patients were re-examined with a follow-up of at least 12 months. The best results were in the FASTak-group. After 2 years 4.7% suffered a redislocation. 28.6% (2 patients) needed a revision, but none of the shoulders required a second open stabilization. The reason for redislocation or sub-luxation were traumatic injuries, participating in contact sports or in one case a generalized ligamentous laxity. The Rowe score was 83.1 ± 20.9 points. There was a high satisfaction of the patients with the operative result and 60.9% could go back to their pre-op sports level. At 24-months follow-up this study demonstrates good results of arthroscopic shoulder stabilisation with FASTak suture anchors. In combination with the LACS-Procedure or the Electro thermally assisted capsular shift (ETACS) not only the capsular detachment but also the capsular redundancy may be adressed and a lower failure rate can be expected

The December 2013 Shoulder & Elbow Roundup. 360 . looks at: Platelet-rich plasma; Arthroscopic treatment of sternoclavicular joint osteoarthritis; Synchronous arthrolysis and cuff repair; Arthroscopic arthrolysis; Regional blockade in the beach chair; Recurrent instability; Avoiding iatrogenic nerve injury in elbow arthroscopy; and Complex reconstruction of total elbow revisions

The advent of modular porous metal augments has ushered in a new form of treatment for acetabular bone loss. The function of an augment can be seen as reducing the size of a defect or reconstituting the anterosuperior/posteroinferior columns and/or allowing supplementary fixation. Depending on the function of the augment, the surgeon can decide on the sequence of introduction of the hemispherical shell, before or after the augment. Augments should always, however, be used with cement to form a unit with the acetabular component. Given their versatility, augments also allow the use of a hemispherical shell in a position that restores the centre of rotation and biomechanics of the hip. Progressive shedding or the appearance of metal debris is a particular finding with augments and, with other radiological signs of failure, should be recognized on serial radiographs. Mid- to long-term outcomes in studies reporting the use of augments with hemispherical shells in revision total hip arthroplasty have shown rates of survival of > 90%. However, a higher risk of failure has been reported when augments have been used for patients with chronic pelvic discontinuity.

Cite this article: Bone Joint J 2024;106-B(4):312–318.

Purpose: Meralgia paraesthetica is usually caused by entrapment of the lateral femoral cutaneous nerve (LFCN) at the inguinal ligament. We present our experience with 114 patients who underwent surgical management for meralgia paraesthetica. Material: We reviewed 114 patients (48 men, 66 women, five bilateral cases) who underwent surgery for meralgia paraesthetica between 1987 and 1999; local anaesthesia was used for neurolysis in most cases. We identified five aetiologies: idiopathic (n=69, three bilateral), abdominal surgery (n=19), iliac graft harvesting (n=12, one bilateral), hip surgery (n=7), trauma (n=7, one bilateral). Methods: We analysed outcome at more than two years follow-up for the entire series and by aetiology using a standard 12-point evaluation scale accounting for residual pain, sensorial disorders, and patient satisfaction. Results: The overall results were good, mean score 9/12 (range 1–12). Ninety-two patients were very satisfied or satisfied. Among the 27 patients who were not satisfied, five developed recurrence. Mean time to full pain relief was 70 days (range 1 – 364 days). Recovery of thigh sensitivity was noted at 128 days (range 1 – 364). Discussion: The essential criteria of poor prognosis were duration of the meralgia before surgery and its aetiology. Neurolysis of an LFCN injured by trauma or iliac graft harvesting provided less satisfactory results (scores 7 and 6 respectively) than for idopathic meralgia paraesthetica or abdominal-surgery injury (scores 9 and 10 respectively). Eight of the neurolysis procedures in this series did not provide satisfactory results (score 5). Conclusion: Neurolysis appears to be the surgical treatment of choice for mearlgia paraesthetica. In skilled hands, neurolysis can be performed under local anaesthesia, although certain difficulties can be encountered: obesity, modified anatomy due to prior operations, nerve variability (frequent). Knowledge of these different elements is essential not only to achieve neurolysis but also prevent iatrogenic injury

Injuries to the quadriceps muscle group are common in athletes performing high-speed running and kicking sports. The complex anatomy of the rectus femoris puts it at greatest risk of injury. There is variability in prognosis in the literature, with reinjury rates as high as 67% in the severe graded proximal tear. Studies have highlighted that athletes can reinjure after nonoperative management, and some benefit may be derived from surgical repair to restore function and return to sport (RTS). This injury is potentially career-threatening in the elite-level athlete, and we aim to highlight the key recent literature on interventions to restore strength and function to allow early RTS while reducing the risk of injury recurrence. This article reviews the optimal diagnostic strategies and classification of quadriceps injuries. We highlight the unique anatomy of each injury on MRI and the outcomes of both nonoperative and operative treatment, providing an evidence-based management framework for athletes.

Cite this article: Bone Joint J 2023;105-B(12):1244–1251.

Aims

To identify the incidence and risk factors for five-year same-site recurrent disc herniation (sRDH) after primary single-level lumbar discectomy. Secondary outcome was the incidence and risk factors for five-year sRDH reoperation.

Aims

The optimal management of posterior malleolar ankle fractures, a prevalent type of ankle trauma, is essential for improved prognosis. However, there remains a debate over the most effective surgical approach, particularly between screw and plate fixation methods. This study aims to investigate the differences in outcomes associated with these fixation techniques.

There has been a marked increase in the number of hip arthroscopies performed over the past 16 years, primarily in the management of femoroacetabular impingement (FAI). Insights into the pathoanatomy of FAI, and high-level evidence supporting the clinical effectiveness of arthroscopy in the management of FAI, have fuelled this trend. Arthroscopic management of labral tears with repair may have superior results compared with debridement, and there is now emerging evidence to support reconstructive options where repair is not possible. In situations where an interportal capsulotomy is performed to facilitate access, data now support closure of the capsule in selective cases where there is an increased risk of postoperative instability. Preoperative planning is an integral component of bony corrective surgery in FAI, and this has evolved to include computer-planned resection. However, the benefit of this remains controversial. Hip instability is now widely accepted, and diagnostic criteria and treatment are becoming increasingly refined. Instability can also be present with FAI or develop as a result of FAI treatment. In this annotation, we outline major current controversies relating to decision-making in hip arthroscopy for FAI.

Cite this article: Bone Joint J 2022;104-B(5):532–540.

Aims

The aim of the HIPGEN consortium is to develop the first cell therapy product for hip fracture patients using PLacental-eXpanded (PLX-PAD) stromal cells.

Despite being one of the most common injuries around the elbow, the optimal treatment of olecranon fractures is far from established and stimulates debate among both general orthopaedic trauma surgeons and upper limb specialists. It is almost universally accepted that stable non-displaced fractures can be safely treated nonoperatively with minimal specialist input. Internal fixation is recommended for the vast majority of displaced fractures, with a range of techniques and implants to choose from. However, there is concern regarding the complication rates, largely related to symptomatic metalwork resulting in high rates of implant removal. As the number of elderly patients sustaining these injuries increases, we are becoming more aware of the issues associated with fixation in osteoporotic bone and the often fragile soft-tissue envelope in this group. Given this, there is evidence to support an increasing role for nonoperative management in this high-risk demographic group, even in those presenting with displaced and/or multifragmentary fracture patterns. This review summarizes the available literature to date, focusing predominantly on the management techniques and available implants for stable fractures of the olecranon. It also offers some insights into the potential avenues for future research, in the hope of addressing some of the pertinent questions that remain unanswered.

Cite this article: Bone Joint J 2023;105-B(2):112–123.

Introduction: This study aimed to analyse immunohis-tochemically the proteolysis of Amyloid Precursor Protein (APP) using Caspase-3-mediated APP proteolytic peptide (CMAP), beta-Amyloid (Aβ) and Active Caspase-3 in post-mortem human specimens in acute and chronic compressive myelopathy. Compressive myelopathy, occurring through traumatic fracture/dislocation of vertebrae, iatrogenic injury, cervical spondylotic myelopathy (CSM), or metastatic tumour, causes much socio-economic and emotional disability for patients as well as physical consequences. In such conditions, APP is recognised as an early and specifi c marker of axonal injury. The proteolysis of APP in both acute and chronic compressive myelopathy has not yet been described. Studies analysing axonal injury after brain trauma suggest a role for Caspase-3 in the cleavage of APP. 1. In addition, Caspase-3-mediated cleavage of APP has been found to be associated with the formation of Aβ, a neurotoxic protein thought to contribute to cell death in Alzheimer’s disease. 2. Furthermore, A? may subsequently encourage activation of Caspases −2, −3, and −6, the major effector molecules in apoptosis. 2. The current study addressed two hypotheses; that APP provides a substrate for the Caspase-3 enzyme, and, that this event is associated with Aβ production in the compressed spinal cord. Methods: Spinal cord material from 17 patients with documented SCI was analysed. The spatial distribution of cellular immunoreactivity was qualitatively assessed in injury due to trauma (n=5), iatrogenic event (n=1), CSM (n=6) and metastatic tumour (n=5). Morphological, immunohistochemical and immunofl uorescent techniques were used to investigate APP proteolysis. Results: Caspase-3, APP, CMAP and Aβ were present in anterior horn cells of the grey matter and axons of the white matter. An association was found between neuronal immunoreactivity and that of axons in motor tracts. Dual-immunolabelling revealed axonal co-localisation of CMAP with Aβ and Caspase-3 with Aβ. Although CMAP was present in axons which were immunoposi-tive for APP, an inverse relationship was found as each marker was limited to its own, distinct region, consistent with the theory that CMAP actively cleaves APP. In neurons, co-localisation occurred between Caspase-3 and Aβ, and CMAP with Aβ. No neuronal co-localisation was shown between CMAP and APP in the acute and chronic state. Discussion: Caspase-3 appears likely to contribute to the proteolytic cleavage of APP in compressive myelop-athy. CMAP was associated with the production of Aβ as demonstrated using single and dual immunolabelling. Furthermore, evidence is given for the association of Caspase-3 itself with the neurotoxic peptide, Aβ. It is possible that activation of Caspase-3 via these secondary mechanisms may trigger the advancement of the apoptotic cascade with the subsequent demise of the cell

Introduction: Reconstruction of ruptured anterior cruciate ligament is a commonly performed orthopaedic procedure. There are many ways of reconstructing this ligament. One method of doing so is to harvest a tendon graft from the hamstring muscles and use it as part of the reconstruction. The tendon is usually harvested by passing a tendon stripper along the length of the tendon from an anterior knee incision. The semitendinosus and the gracilis are the hamstring muscles whose tendons are used for this. A recent case study reported injury to the sciatic nerve during the harvest of semitendinosus graft. Although morbidity arising from iatrogenic injury to nerves at the anterior aspect of the knee has been well documented, little has been written about the relationship of the sciatic nerve to the semitendinosus and gracilis in the posterior thigh. This study proposes to look at this anatomical relationship. Method: 20 legs on ten cadavers underwent the same dissection to expose the semitendinosus tendon, gracilis tendon and the sciatic nerve while maintaining their anatomical relationships. In all cases the gracilis lay further away from the sciatic nerve than the semiten-dinosus tendon. As the semitendinosus tendon was in between the semitendinosus and the sciatic nerve in all instances it was decided not to measure the distance between gracilis and the sciatic nerve. The distance between the closest point of the sciatic nerve to the tendon of semitendinosus was measured at the joint line and at intervals of 20 mm from the joint line. Results: In 45 % of the subjects the sciatic nerve and the semitendinosus tendon gradually moved further apart as the measurements were taken more proximally in the leg. In 10 % they consistently moved apart from 6 cm from the joint line onwards. In another 10% they moved consistently apart from the 8cm from the joint line measurement and in 15 % they moved apart consistently from 12 cm from the joint line. In the remaining 20 % the sciatic nerve and the semitendinosus tendon did not consistently move apart from each other until after 14 cm from the joint line. In one subject (a female of small stature) it was noted that the semitendinosus muscle lay almost directly upon the sciatic nerve. In 6 subjects the minimum distance between the sciatic nerve and the semitendinosus tendon was less than 18mm. In one subject the distance between the sciatic nerve and the semitendinosus tendon was found to be 10 mm at the closest point and remained in close proximity for a further 4 cm. Conclusion: In 55 % of our patients the sciatic nerve did not consistently move further away from the semi-tendinosus tendon as it was measured more proximally. In some subjects the minimum distance between the nerve and the tendon was less than 2 cm. Both these facts would put the sciatic nerve at risk during tendon harvesting if the tendon stripper were to move outside of the tendon during the procedure

This study investigated the anatomical relationship between the clavicle and its adjacent vascular structures, in order to define safe zones, in terms of distance and direction, for drilling of the clavicle during osteosynthesis using a plate and screws following a fracture. We used reconstructed three-dimensional CT arteriograms of the head, neck and shoulder region. The results have enabled us to divide the clavicle into three zones based on the proximity and relationship of the vascular structures adjacent to it. The results show that at the medial end of the clavicle the subclavian vessels are situated behind it, with the vein intimately related to it. In some scans the vein was opposed to the posterior cortex of the clavicle. At the middle one-third of the clavicle the artery and vein are a mean of 17.02 mm (5.4 to 26.8) and 12.45 mm (5 to 26.1) from the clavicle, respectively, and at a mean angle of 50° (12 to 80) and 70° (38 to 100), respectively, to the horizontal. At the lateral end of the clavicle the artery and vein are at mean distances of 63.4 mm (46.8 to 96.5) and 75.67 mm (50 to 109), respectively. An appreciation of the information gathered from this study will help minimise the risk of inadvertent iatrogenic vascular injury during plating of the clavicle

Introduction and Objectives: This study was designed to analyze the results of treatment of proximal humeral fractures using the Hoffman external fixator, evaluated using the Neer classification and Constant scale. Materials and Methods: From January 1987 to June 1996, a total of 53 patients with proximal fractures of the humerus were treated using external fixation. Two of these cases had multiple injuries and died in the intensive care unit (ICU). For this reason, follow-up was done of the remaining 51 cases. There were 34 males (67%) and 17 females (33%). Average age was 52 years (range: 26–80). It is important to note that, of this group, 21 patients had multiple injuries in addition to the fracture of the humerus. There were 7 with craneoencephalic trauma, 11 with thoracic trauma, 3 with abdominal trauma, and 12 with fractures of other extremities. Eleven (20.7%) of the patients required admission to the ICU. Most frequent aetiologies were automobile accident in 31 cases (61%), accidental fall in 15 cases (29%), and other causes in 5 cases (10%). No significant difference was found based on the side that was affected. Fracture types in this study were as follows: Type III displaced fracture, 2 parts: 23 cases (45%); type IV displaced fractures, 3 and 4 parts: 15 cases (27%); type V displaced fractures of 3 and 4 parts: 10 cases (20%); type VI fractures of 3 and 4 parts with anterior luxation, 3 cases (8%) (Table 1). Three fractures were open Grade II or Grade III fractures (Couchoix), and 2 with associated comminuted fractures of the ipsilateral humerus. Results: Clinical development was assessed in the 51 cases at an average of 20 months after removal of the external fixator (maximum 6 years). * Pain: Average score 11.3 *Daily-life activities: Average score 14.7 points out of a maximum 20 points; 80% of patients achieved activity similar to pre-fracture levels. * Mobility: Average score was 24.6 out of 40. * Strength: Average score was 17 points. Overall average score for all patients out of 100 points on Constant’s scale was 67.7. Complications included local infection of the wound at the screw site in 4 cases, all of which were proximal screws. Algodystrophy was present in 3 patients. Three patients presented subacromial conflict after consolidation. No surgical iatrogenic injuries to vascular or nervous tissues were noted. Subjective results: Patients showed good acceptance of the external fixator due to the fact that it caused them little incapacity during treatment. Discussion and Conclusions: External fixation is a quick and simple method which avoids entering the arm and affords similar results. As a minimally-invasive treatment technique, in case of failure, any other method may be used, including replacement arthroplasty, since passive movement of the shoulder is maintained from the beginning

This review provides a concise outline of the advances made in the care of patients and to the quality of life after a traumatic spinal cord injury (SCI) over the last century. Despite these improvements reversal of the neurological injury is not yet possible. Instead, current treatment is limited to providing symptomatic relief, avoiding secondary insults and preventing additional sequelae. However, with an ever-advancing technology and deeper understanding of the damaged spinal cord, this appears increasingly conceivable. A brief synopsis of the most prominent challenges facing both clinicians and research scientists in developing functional treatments for a progressively complex injury are presented. Moreover, the multiple mechanisms by which damage propagates many months after the original injury requires a multifaceted approach to ameliorate the human spinal cord. We discuss potential methods to protect the spinal cord from damage, and to manipulate the inherent inhibition of the spinal cord to regeneration and repair. Although acute and chronic SCI share common final pathways resulting in cell death and neurological deficits, the underlying putative mechanisms of chronic SCI and the treatments are not covered in this review.

Aims

Arthroplasty has become increasingly popular to treat end-stage ankle arthritis. Iatrogenic posterior neurovascular and tendinous injury have been described from saw cuts. However, it is hypothesized that posterior ankle structures could be damaged by inserting tibial guide pins too deeply and be a potential cause of residual hindfoot pain.

The optimal method for the management of neglected traumatic bifacetal dislocation of the subaxial cervical spine has not been established. We treated four patients in whom the mean delay between injury and presentation was four months (1 to 5). There were two dislocations at the C5-6 level and one each at C4-5 and C3-4. The mean age of the patients was 48.2 years (27 to 60). Each patient presented with neck pain and restricted movement of the cervical spine. Three of the four had a myelopathy. We carried out a two-stage procedure under the same anaesthetic. First, a posterior soft-tissue release and partial facetectomy were undertaken. This allowed partial reduction of the dislocation which was then supplemented by interspinous wiring and corticocancellous graft. Next, through an anterior approach, discectomy, tricortical bone grafting and anterior cervical plating were carried out. All the patients achieved a nearly anatomical reduction and sagittal alignment. The mean follow-up was 2.6 years (1 to 4). The myelopathy settled completely in the three patients who had a pre-operative neurological deficit. There was no graft dislodgement or graft-related problems. Bony fusion occurred in all patients and a satisfactory reduction was maintained. The posteroanterior procedure for neglected traumatic bifacetal dislocation of the subaxial cervical spine is a good method of achieving sagittal alignment with less risk of iatrogenic neurological injury, a reduced operating time, decreased blood loss, and a shorter hospital stay compared with other procedures

Introduction. Revision for instability has supplanted revision for aseptic loosening and revision for osteolysis since the advent of improved polyethylene inserts with changes in both sterilization techniques and cross-linking. Having the ability to judiciously choose a higher level of constraint may be beneficial in complex primary total knee arthroplasty (TKA) scenarios which can not be balanced through traditional surgical methods. The purpose of this work was to investigate short term outcomes and survivorship in cases where a greater stabilizing insert was used with a posterior stabalizing (PS) femur to address instability in flexion or extension. Methods. Two high volume TKA centers retrospectively reviewed cases in which a greater stabilizer insert was used with a primary PS knee system. The studied insert had +/− 2 degrees of varus-valgus coronal restraint as opposed the standard with no coronal constraint. The study inserts had 7 degrees of transverse plane rotational freedom. The inserts were used when extension balance was not achieved despite the usual soft tissue releases and a thicker insert resulted in a flexion contracture statically during the procedure. This situation typically occurred in the following patient groups: valgus knees with medial collateral (MCL) stretching, iatrogenic MCL injury, varus knees with lateral ligament complex stretching, the “double-varus” knee, and patients with a previous high tibial osteotomy. Intra-operatively patients were taken through a range of motion and trial implants were then placed. A cruciate retaining trial insert was then used to assess stability so that a true assessment could be made of ligament balance. Bone cuts were checked before ligament release. The usual releases were then performed to achieve balance including subperiosteal releases medially and laterally and pie-crusting when indicated. Repeat trial reductions were then performed once the final implants were cemented in place again using the cruciate retaining insert. If the soft tissue releases did not achieve balance and a thicker insert resulted in a flexion contracture then the greater stabilizer insert was selected over the PS insert. Knee Society Score and plain radiographs were collected at pre-op, 2 year and 5 year follow-up. Results. One hundred seventy two cases with 2 year minimum follow-up and 41 cases with 5 year minimum follow up were assessed. All patients had good to excellent Knee Society Scores with good range of motion and pain relief. There were no aseptic revisions of the TKA's over this period. Specifically, there were no revisions for loosening, osteolysis, instability, or post breakage. Conclusions. A more stabilized tibial post insert which provides valgus-varus constraint but permits rotational freedom may provide needed stability in select primary situations without predisposing to early post failure or implant loosening or lysis

Introduction: Injuries to the urinary tract are a well known complication in patients with pelvic trauma. A severe urological injury frequently results in adverse long term outcome and prolonged disability. We present a review of the results of management of urological injury and the impact on final outcome in patients with pelvic fractures. Patients: Out of 554 patients admitted to our center with pelvic fracture, 39 with injury to the urinary tract were identified – 8 females and 31 males (study group). The mean age of the patients was 30.9 yrs (range 15 to 71 yrs) and the mean ISS was 12.9 (range 9 to 22). Two patients had a skin wound communicating with fracture hematoma. Seven (18 %) had upper tract injury, 6 (15.4 %) had extraperitoneal bladder rupture, 9 (23.1 %) had intraperitoneal rupture, 3 (7.6 %) had bladder neck injury and 14 (35.9 %) had urethral injury. The mechanism and type of injury, initial management, timing of urological intervention, orthopaedic procedure complications and long term result in terms of incontinence, stricture and sexual dysfunction were assessed. All patients were assessed based on Orthopaedic, urological and the Euroqol (EQ5D) generic health questionnaire and compared to age and sex matched control group of 47 patients with similar pelvic injuries and ISS but no urological injury. The mean follow up period was 2.3 years. Results: Upper urinary tract injuries: All were managed nonoperatively and had a uniformly good outcome except one patient who had a traumatic renal vein thrombosis and required nephrectomy. Three had acetabular fractures (one ant column and 2 both column fractures) and 4 had pelvic ring injuries (2 AP, 2 LC). Six were operated with av. time delay between injury and surgery being 7.1 days. We consider the urological injury related to the general trauma rather than the specific pelvic injury. Lower tract injuries: 14 out of 15 patients with bladder rupture had a repair of bladder within 24 hours of arrival at our center. One with a small extra-peritoneal tear was managed nonoperatively. Seven had LC injury, 6 had ARC and 2 had acetabular fractures (both column). One of the acetabulum fractures was managed by fixation and bladder repair on the day of arrival and the other had secondary congruence, which was not operated. Pelvic ring injuries were managed by internal and/or external fixation as appropriate. The average time delay between injury and surgery was 1.8 days. One patient with AP2 fracture died after 3 weeks due to severity of associated visceral injuries. Three patients reported failure of erection. All three patients with bladder neck injury had an APC fracture. Two were managed by immediate repair (day 1 and day 2) and had normal continence. One repair was delayed due to delay in transfer and was done on the 4th day. He developed faecal and urinary incontinence and loss of sexual function. Thirteen males had urethral injury – average age 37 yrs (range 19 to 70 years). Five had APC and five LC pelvic ring injuries, three had acetabular fractures. Three patients had a primary urethrostomy for a gap defect and two of these developed erectile dysfunction. Two were referred late to our center and were managed by continent urinary diversion. The rest had a catheter railroaded to maintain alignment of the two urethral ends and delayed repair was done for three patients. One patient in this group had sexual dysfunction while 5 developed a stricture. The only female patient with urethral injury had an open tilt fracture associated with urethral tear. The control group had 7 acetabular fractures, 19 AP compression, 17 lateral compression injuries and 4 vertical shear injuries. Four were managed nonoperatively. None of these had an open fracture. The average time delay between injury and surgery was 2.2 days. We found no significant difference between the study and the control group in the outcome on comparing patients with upper tract and bladder injuries but the urethral injury group had a poorer result in all 5 parameters of the EQ5D. Conclusions: Upper tract and bladder injuries in the context of pelvic trauma can be successfully managed as described, they do not add significant morbidity compared to the control group. In contrast urethral injuries significantly affected the outcome after pelvic fracture in terms of general health and return to normal function. Early management with primary alignment at the time of pelvic stabilisation and a delayed repair if required produced good results. A high index of suspicion and routine retrograde urethrograms would reduce risk of missed or iatrogenic injury. A team approach is required to achieve optimum results

The majority of studies reporting sensitivity and specificity data for imaging modalities and physical examination tests for long head of biceps (LHB) tendon pathology use arthroscopy as the gold standard. However, there is little published data to validate this as an appropriate benchmark. The aim of this study was to determine the maximum length of the LHB tendon that can be seen at glenohumeral arthroscopy and whether it allows adequate visualisation of common sites of pathology. Seven female cadaveric specimens were studied. Mean age was 74 years (range 44–96 years). Each specimen underwent arthroscopy in lateral decubitus (LD) and beach chair (BC) positions. The LBH-tendon was tagged with a suture placed with a spinal needle marking the intra-articular length and the maximum excursions achieved using a hook and a grasper in both LD and BC positions. T-tests were used to compare data. The mean intra-articular and extra-articular lengths of the tendon were 23.9 mm and 82.3 mm respectively. The mean length of tendon that could be visualised by pulling it into the joint with a hook was significantly less than with a grasper (LD: hook 29.9 mm, grasper 33.9 mm, mean difference 4 mm, p=0.0032. BC: hook 32.7 mm, grasper 37.6 mm, mean difference 4.9 mm, p=0.0001). Using the BC position allowed visualisation of a significantly greater length than the LD position when using either a hook (mean difference 2.86 mm, p=0.0327) or a grasper (mean difference 3.7 mm, p=0.0077). The mean length of the extra-articular part of the tendon visualised using a hook was 6 mm in LD and 8.9 mm in BC. The maximum length of the extra-articular portion visualised using this technique was 14 mm (17%). Pulling the tendon into the joint with a hook does not allow adequate visualisation of common distal sites of pathology in either LD or BC. Although the BC position allows a significantly greater proportion of the tendon to be visualised this represents a numerically small value and is not likely to be clinically significant. The use of a grasper also allowed greater excursion but results in iatrogenic tendon injury which precludes its use. The reported incidence of pathology in Denard zone C (distal to subscapularis) is 80% and in our study it was not possible to evaluate this zone even by using a grasper or maximum manual force to increase excursion. This is consistent with the extremely high rate of missed diagnoses reported in the literature. Surgeons should be aware that the technique of pulling the LHB-tendon into the joint is inadequate for visualising distal pathology and results in a high rate of missed diagnoses. Furthermore, efforts to achieve greater excursion by “optimum” limb positioning intra-operatively do not confer an important clinical advantage and are probably unnecessary

Aims

Spinal deformity surgery carries the risk of neurological injury. Neurophysiological monitoring allows early identification of intraoperative cord injury which enables early intervention resulting in a better prognosis. Although multimodal monitoring is the ideal, resource constraints make surgeon-directed intraoperative transcranial motor evoked potential (TcMEP) monitoring a useful compromise. Our experience using surgeon-directed TcMEP is presented in terms of viability, safety, and efficacy.

Minimally invasive (MIS) screw fixation for Hangman's fracture can decrease iatrogenic soft-tissue injury compared with conventional open approach, but increase the risk of instrumentation-related complications due to lack of anatomical landmarks. With the advantages, the intra-operative three-dimensional fluoroscopy-based navigation (ITFN) system seems to be an inherent partner for MIS techniques. The purpose of this study was to evaluate the accuracy and feasibility of MIS techniques incorporating with ITFN for treating Hangman's fracture. 20 patients with Hangman's fracture underwent C2-C3 pedicle screw fixation using ITFN. 6 patients used MIS technique, with the other 14 patients using conventional open technique. Preoperative visual analogue score (VAS) was 5.7±1.4 in CAOS-MIS group and 5.5±0.9 in CAOS-open group. Operative time, blood loss and postoperative neurovascular complications were recorded. The accuracy of screw positions was studied by postoperative CT scan. All patients were followed up for at least 6 months and the fusion status was ascertained by dynamic radiographs. The average operative time was 134.2±8.0 min in CAOS-MIS group and 139.3±25.8 min in CAOS-open group, and there was no significant difference between the two (p&gt;0.01). The blood loss was 66.7±25.8 ml in CAOS-MIS group and 250.0±141.4 ml in CAOS-open group. Statistical difference existed with CAOS-MIS group significant less than CAOS-open group (p&lt;0.01). A total of 80 screws were inserted. No screw-related neurovascular injury was observed. Post-operative CT scan revealed 83.3% (20/24) screws of grade 1 and 16.7% screws of grade 2 (4/24) in CAOS-MIS group, meanwhile 89.3% screws of grade 1 (50/56) and 10.7% screws of grade 2 (6/56) in CAOS-open group. There was no grade 3 screw detected. Fisher's exact test showed there was no statistical difference between these two groups (p&gt;0.01). There was no statistical difference in pre-operative VAS between these two groups (p&gt;0.01). Compared with the CAOS-open group (1.7±0.6), neck pain VAS at 6-month follow-up in CAOS-MIS group (0.3±0.5) was significantly lower (p&lt;0.01). Solid fusion was demonstrated in all the cases by dynamic radiographs. So it is feasible and safe for percutaneous minimally invasive C2-C3 pedicle screw fixation for Hangman's fracture using intra-operative three-dimensional fluoroscopy-based navigation, which can also decrease the incidence of post-operative neck pain

The treatment of supracondylar humeral fractures in children continues to evolve. The currently fashionable treatment for displaced fractures is closed reduction and the insertion of at least two K-wires. This usually requires the patient to have a second surgery to remove the K-wires, and may result in significant scarring. The senior author has used the straight arm method to treat displaced supracondylar fractures. We have reviewed the long term results of seven children treated by the straight arm method. No patient had a scar, no patient had a cubitus varus and all children regained a full range of movement. This method offers excellent results with no risk of iatrogenic nerve injury, scarring, or second surgery

This report reviews the long-term results of treating acetabula with unusually severe problems, such as pelvic discontinuity or major column loss after failed total hip arthroplasty (THA) and reconstruction problems. Loss of acetabular bone stock results from removal of bone during the original procedure, prosthetic failure, and osteolysis. In massive structural failure, the acetabular rim, quadrilateral plate, and associated columns become deficient. At worst, this may be combined with pelvic discontinuity and disruption of the ilium and ischium. Prosthetic protrusio may result from fixation loss and be associated with scarring of the femoral vessels, femoral nerve, ureter and bowel. A variety of implants has been used to in ace-tabular reconstruction. The results are often poor because of insufficient bone stock to support the implant. In a consecutive series of 251 THA revisions done between 1988 and 1996, 17 patients were treated for major pelvic column loss, pelvic discontinuity or both. In five patients, a posterolateral approach without trochanteric osteotomy was used. The extensile triradiate approach with ilioinguinal extension was used in 12 patients in whom severe prosthetic protrusio increased the risk of intrapelvic iatrogenic injury. A long anterior column pelvic plate was applied. A posteriorly placed AO 4.5-mm pelvic reconstruction plate with 10 to 12 holes was used in nine cases of pelvic discontinuity and in five cases of posterior column bone loss. This plate extended from the most inferior extent of the ischium across the wall of the posterior column to a point high on the ilium. Anterior column fixation was done in eight of nine cases of pelvic discontinuity and all three cases of anterior column deficiency. This called for an 8 to 12-hole 3.5-mm AO pelvic reconstruction plate that extended from the pubic symphysis across the pelvic rim. This spanned the anterior column defect, ranging from 4 cm to 8 cm, to the medial wall of the ilium. Bulk allograft was used in 16 of the 17 patients. The patient in whom allograft was not used had pelvic discontinuity following pelvic irradiation. Whole pelvic acetabular transplants were used in seven with severe bone loss or following resection for chondrosarcoma and the other for pigmented or villonodular synovitis. Posterior segmental acetabular allograft was used in two cases of posterior column absence. Femoral heads were used in two posterior column defects, three pelvic discontinuities with anterior column defect, and two anterior column defects. Acetabular components were cemented in six of seven whole bulk ace-tabular transplants, six of nine pelvic discontinuities and two anterior column defects. Cemented implants were classified as loose if there was a complete radiolucent line at the bone cement interface, measurable component migration or measurable change in position. Uncemented acetabular components were considered loose if component migration had occurred or screws had broken. Pelvic plates were considered loose if there was measurable migration or change in plate position or if fixation screws had backed out or broken. Radiographic union was considered present when bridging callus or trabecular bone was visible across the discontinuity site. Junctional healing was considered probable when radiographs did not show obvious signs of failure. Grafts were considered unhealed if there was obvious displacement, bone gaps or hardware breakage. Seven of the nine patients with pelvic discontinuity had late evidence of healing of the fracture and allograft consolidation. One underwent removal of the graft at three weeks after developing acute postoperative infection: early junctional healing of a whole bulk acetabular allograft required an osteotomy to break up the interface. Another patient, who underwent removal of the graft and implant at three months for chronic infection, had consolidation of a whole bulk ace-tabular allograft. One patient underwent revision of a pressfitted acetabular component at 60 months, and the pelvic discontinuity was solidly united. In a fourth patient, explored at 124 months for loosening of a cemented cup, there was near complete dissolution of the graft posterior acetabular wall and a loose posterior pelvic plate. In a patient with pelvic discontinuity after radiation therapy for uterine carcinoma, satisfactory healing of the pelvic discontinuity was confirmed at 32 months, when excisional arthroplasty for late chronic infection followed urinary sepsis. Seven patients had major column loss with severe cavitary defects. Consolidation of the allograft was noted in all seven within the first 12 months of follow-up. Revision (47%) was required for infection in three patients, implant loosening in four, and recurrent implant dislocation in one. The four loose cups were revised to a cemented all-polyethylene component. All four implants had been placed on less than 50% host bone. None of the four has required subsequent revision. Dislocation postoperatively occurred in eight patients. In six, the extensile triradiate approach had been used. This approach led to dislocation in 50%. The main reasons for using the extensile triradiate approach were to avoid catastrophic injuries by direct exposure of vital structures and to allow stable anterior column plate fixation. In that no neurovascular injuries occurred and stable durable allograft consolidation and healing of pelvic discontinuity took place, these goals were largely met. Three patients developed late sciatic palsy. In one, plaster immobilisation had possibly caused direct pressure over the fibular head and led to chronic peroneal palsy. The other two underwent additional exploration of the sciatic nerve for late entrapment caused by migration of screws from the posterior column plate. Two patients developed bladder infections postoperatively. Another developed superficial phlebitis of the lower leg. Acetabular revision for loosening was necessary in three of seven cementless implants, while only two of 10 cemented implants failed. The acetabular component should be cemented into the allograft when more than 50% of the prosthetic interface is non-viable. Virtually all graft material, including dense cortical grafts, may ultimately fail if used for implant fixation. Patients should be told about the inevitable risks. However, techniques used led to stable healing of the pelvic discontinuity in most cases. Long pelvic plates that securely stabilise the pelvis and allografts carefully opposed to host bone may explain the relative success in this series

Sacroiliac screw fixation is the method of choice for the definitive treatment of unstable posterior pelvic ring injuries; however this technique is demanding and associated with a high risk of iatrogenic neurovascular damage. We therefore evaluated the outcome, complications, surgical and fluoroscopy time for unstable posterior pelvic ring injuries managed with a transiliac locked compression plate. 23 patients were managed with a transiliac locked compression plate for unstable posterior pelvic injuries at a Level I Trauma Center. 21 patients were available for follow up after an average of 30 months and outcome evaluation was performed with the Pelvic Outcome Score, which is composed of a clinical, radiological, and social integration part. The overall outcome for the pelvic outcome score was excellent in 47.6% (10 patients), good in 19% (4 patients), fair in 28.6% (6 patients) and poor in 4.8% (1 patient). 15 out of 21 patients (71.4%) returned to their normal life, 3 patients (14.3%) were limited at work, and 3 patients (14.3%) were not able to return to work due to their disabilities. The social status was unchanged to the preinjury status in 19 patients (90.5%). 13 patients (62%) stated no changes in spare time and sports activities; 4 patients (19%) had minor and another 4 patients (19%) had major restrictions. The average operation time was 101 min and intraoperative fluoroscopic time averaged 74.2 sec. No iatrogenic neurovascular injuries were observed. Posterior percutaneous plate osteosynthesis may be a good alternative to sacral screw fixation because it is quick, safe, and associated with a good functional outcome

Purpose: Due to its proximity to the glenohumeral joint, the suprascapular nerve may be at risk of iatrogenic nerve injury during arthroscopic labral repair. Our primary objective is to evaluate the risk of suprascapular nerve injury during standard drilling techniques utilized in arthroscopic superior labral repairs. Secondarily, we evaluated the correlation between this risk and scapular size. Method: Forty-two cadaveric shoulders were dissected to isolate their scapulae. A surgical drill and guide was used to create suture anchor holes in 3 locations in the superior rim of the glenoids as typically done in arthroscopic superior labral repairs. The orientation of these drill holes correspond to common shoulder arthroscopic portals. The suprascapular nerve was then dissected from the suprascapular notch to the spinoglenoid notch. The presence of drill perforations through the medial cortex of the glenoid vault was recorded along with the corresponding hole depth and distance to the suprascapular nerve. Results: Medial glenoid vault perforations occurred in 8/21(38%) cadavers with a total of 18/126(14%) perforations. The suprascapular nerve was in line of the drill path in 5/18(28%) perforations. Female specimens and smaller scapulae had a statistically higher risk of having a perforation (p< 0.05). Conclusion: The results of this anatomic study suggest that there is a substantial risk of medial glenoid vault perforation. When a perforation does occur, the suprascapular nerve appears to be at high risk for injury especially with more posterior drill holes. The risk is significantly higher in females and in smaller scapulae

Post-traumatic elbow stiffness is a disabling condition that remains challenging for upper limb surgeons. Open elbow arthrolysis is commonly used for the treatment of stiff elbow when conservative therapy has failed. Multiple questions commonly arise from surgeons who deal with this disease. These include whether the patient has post-traumatic stiff elbow, how to evaluate the problem, when surgery is appropriate, how to perform an excellent arthrolysis, what the optimal postoperative rehabilitation is, and how to prevent or reduce the incidence of complications. Following these questions, this review provides an update and overview of post-traumatic elbow stiffness with respect to the diagnosis, preoperative evaluation, arthrolysis strategies, postoperative rehabilitation, and prevention of complications, aiming to provide a complete diagnosis and treatment path.

Cite this article: Bone Joint Open 2020;1-9:576–584.

Aims

Guided growth has been used to treat coxa valga for cerebral palsy (CP) children. However, there has been no study on the optimal position of screw application. In this paper we have investigated the influence of screw position on the outcomes of guided growth.

Aims

High-grade dysplastic spondylolisthesis is a disabling disorder for which many different operative techniques have been described. The aim of this study is to evaluate Scoliosis Research Society 22-item (SRS-22r) scores, global balance, and regional spino-pelvic alignment from two to 25 years after surgery for high-grade dysplastic spondylolisthesis using an all-posterior partial reduction, transfixation technique.

To determine the bony outcomes of patients treated at our Institution after sustaining femur fracture and arterial injury, due to gunshot, in the ipsilateral limb, studied over a four-year period. The database at the Department of Vascular Surgery at our Institution was searched for cases that had sustained both arterial injury and femur fracture of the ipsilateral leg. Their case notes and X-rays were reviewed for the following:. Time line from injury to discharge. Procedure performed. Duration of external fixation. Complications (infection, iatrogenic vascular injury, amputation,. bony union achieved). Incidence of fasciotomy. During the period from 2002 to the end of 2005 there were 12 patients who qualified to be included in the audit group. Three of the 12 (25%) had to undergo a primary amputation upon arrival. The other nine cases underwent surgery. One of these received an intra-medullary device, another skeletal traction and the rest external fixation following the vascular surgery. Five of the 7 external fixation devices were converted to an intramedullary device in due course. All nine cases went on to union. There were no reported cases of iatrogenic vascular repair disruption. Of the 12, only three cases reported any infection. One case developed severe osteomyelitis of the femur. Primary vascular repair with temporary external fixation that was later converted into an intramedullary device (within 14 days) provided satisfactory results

Reduction and K-wiring is the most popular form of treating displaced supracondylar fractures of the humerus. Complications including redisplacement of the fracture, cubitus varus, iatrogenic nerve injuries and pin tract infection have been reported following surgery. For successful outcome with K-wiring of supracondylar fractures, strict adherence to protocols and surgical expertise are necessary. We have treated these fractures in straight arm traction since 1995, and the purpose of this study was to audit our practice. Between January 1995 and December 2000, 112 children with a closed displaced supracondylar fracture of the humerus, without neurovascular deficit, were managed by straight arm traction for a mean duration of 22 days. Final outcome was assessed using clinical (flex-ion-extension arc, carrying angle and residual rotational deformity) and radiographical (metaphyseal-diaphyseal angle and Humero-Capitellar angle) criteria. Our outcomes were compared with those of the recent large studies reporting results of surgical treatment. 71 (63%) patients had excellent, 33 (29%) patients good, 5 (4.4%) patients fair, and 3 (2.6%) patients poor outcome. All patients with fair or poor outcomes were older than 10 years. Elevated straight-arm traction is safe and effective in children younger than 10 years. It can be effectively used in an environment that has provision of paediatric medical care and general orthopaedic expertise with outcomes comparable to those fractures treated surgically in specialist centres

The position of the gastrocnemius tendon relative to the calcaneus and fibular head distance may be different in children with cerebral palsy (CP) when compared to normal children. However, no such data is available. Usually, palpation of the muscle bellies or previous experience of the operating surgeon is employed to place the surgical incision. Inaccurate localisation may cause incorrect incision and a risk of iatrogenic damage to the vital structures (i.e. sural nerve). The aim of our study is to compare gastrocnemius muscle length in-vivo between paretic and unaffected children and suggest a formula to localise muscle-tendon junction. Ten children with di/hemiplegia (seven females and three males; mean age 8y 7mo, range 2–14y) were recruited. None of them had received any conventional medical treatment. An equal number of age/sex matched, typically developing children (mean age 9y 1mo, range 4–14y) were recruited. Participants lay prone on an examination plinth with their feet hanging from its edge. Sagittal-plane ultrasound scanning of the gastrocnemius muscle at rest was performed to measure the length of gastrocnemius bellies. We also measured the heights, lower leg lengths, thigh lengths and leg lengths. At similar age, the lower leg lengths in CP patients were shorter than normal children. Similarly, gastrocnemius medial (GM) muscles were shorter in CP children when compared to similar aged normal children. In CP children, the GM muscle and lower leg ratio ranges between 35 to 50% with an average ratio of 45%. When compared to leg length, the ratio is 22%. Using these figures we created a formula that may be used clinically to identify the tendon for open or endoscopic lengthening and also to make simple and accurate localisation of GM-tendon junction for surgical access. This minimizes the risk of iatrogenic neurovascular injuries and decreases the length of the surgical incision

Ankle arthroscopy is generally performed through anterior portals and provides good access to the anterior aspect of the ankle joint. However, the structure of the talus and the anatomical confines of the ankle joint limit access to posterior structures via this approach. Developments in the technique of posterior ankle arthroscopy have determined the appropriate site for portals with minimal risk of iatrogenic neurovascular injury. This facilitates treatment of conditions such as flexor hallucis longus (FHL) release, excision of os trigonum for posterior impingement, treatment of retro-calcaneal bursitis and treatment of ankle and subtalar joint pathology. Posterior ankle arthroscopy is a relatively new technique and has recently been adopted by the senior author. This study was performed to explore the benefits and limitations of this procedure and to identify early post operative results. We describe our experience of this technique in treating 9 patients with varied posterior ankle pathology. 2 patients had excision of os trigonum; 2 had FHL release; 1 had both excision of os trigonum and FHL release; 3 had curettage for posterior osteochondral defect (OCD) of the talus; and 1 had resection of Haglund’s deformity. The mean pre-operative AOFAS scores (Ankle-Hindfoot Scale) was 73 (range 47 to 85). The mean post operative AOFAS score at 3 months was 82 (range 75 to 87). 4 patients had recent surgery and await follow up. There were no complications. Two cases exposed the limitations of this procedure: Incomplete resection of (i) a Haglund’s deformity required conversion to an open excision and (ii) a posteromedial OCD lesion will require further anterior ankle arthroscopy due to inadequate exposure. We conclude that for the experienced arthroscopic surgeon this is a safe technique that facilitates treatment of a variety of ankle and hindfoot problems that would otherwise require open procedures

Early percutaneous pin fixation after closed reduction is the treatment of choice for displaced distal humerus fractures. Our purpose was to study the outcome of closed reduction and external fixation more than 1 week after injury. Material and methods: Ninety-one children with fractures of the distal humerus were treated more than 7 days after injury (range 7 – 65 days, average 10,5 days). The average age at the time of surgery was 6,7 years (range 3,3 – 16,1years). 63 were male. All had 1–3 previous unsuccessful closed or\and open reductions in another clinic. Twelve had iatrogenic nerve injury. Our method consists of applying the Ilizarov’ apparatus in the proximal humerus for primary transolecranon traction and close reduction using image intensifier. After reduction two crossed K-wires were passed through the condyles and final fixator was constructed. The K-wire from olecranon was removed. Postoperative fixation was done for 3 – 6 weeks. Elbow motion was started 2–3 days after surgery. Results: The results depended on the severity of the fracture and time after injury. All fractures went on to union. Good and excellent results (no deformity or contracture) occurred in 95 % of 59 patients with transcondylar fractures (AO classification type A2 and A3) and 7–16 days after injury. Of twenty patients with transcondylar fractures (AO classification A2 and A3) and more than 17 days 85% had similar result. Three children required eventual supracondylar osteotomy because of progressive rotational-varus deformity. Of twelve children with T- of Y- fractures (AO C1, C2, or C3) three (25%) had poor Results: Conclusion: Late reduction with external fixation was accomplished with anatomic reduction and good functional outcome and allowed early motion of the elbow

Aims: Removal of metal implants after complete fracture healing is controversial. Potential negative aspects of indwelling implants such as stress shielding, metal release, allergies, limitations for later surgical procedures contrast with high cost. Furthermore, knowledge about indication, timing and complications remains very limited. Purpose of this study was to analyse published reports on indication, timing and complications of forearm plate removal. Methods: 14 studies (1984 to 2002), including 635 cases of forearm plate removal, were analysed for indication, timing and complications. Results: While 69.1% of the patients were asymptomatic, 30.9% complained of tenderness, barometric pain, implant prominence and bone infections. The average total frequency of complications was 24.0 (11.8–40)%: Iatrogenic nerve injuries occurred in 11.5 (2.0Ð29.1)%, followed by refractures in 7.7 (2.0–26.1)%, wound infections in 6.8 (4.8–11.5)% and hypertrophic scars in up to 9.1%. However, e.g. the increased forearm refracture rate turned out to be clearly associated with the use of 4.5mm DC plates, plate removal after less than 12 months, poor anatomic reduction and open fractures. Conclusions: Considering the identiþed risk factors, forearm plate removal can be performed with a low complication rate. Since the present analysis is based on a few heterogeneous retrospective studies, major prospective clinical studies are required to acquire representative data to þnally answer the question whether to remove the implant or not. However, leaving metal implants in young patients is necessarily associated with disadvantageous biomechanical properties, inevitable metal release and may interfere with later bone surgical procedures

Abstract

The medial malleolus, once believed to be the primary stabilizer of the ankle, has been the topic of conflicting clinical and biomechanical data for many decades. Despite the relevant surgical anatomy being understood for almost 40 years, the optimal treatment of medial malleolar fractures remains unclear, whether the injury occurs in isolation or as part of an unstable bi- or trimalleolar fracture configuration. Traditional teaching recommends open reduction and fixation of medial malleolar fractures that are part of an unstable injury. However, there is recent evidence to suggest that nonoperative management of well-reduced fractures may result in equivalent outcomes, but without the morbidity associated with surgery. This review gives an update on the relevant anatomy and classification systems for medial malleolar fractures and an overview of the current literature regarding their management, including surgical approaches and the choice of implants.

Cite this article: Bone Joint J 2019;101-B:512–521.

Introduction: For a period of 7 years were treated in Emergency Hospital Pirogov 205 patients with humeral shaft fracture (HSF)–125 with interlocking nailing (ILN), 80 with AO plates, these include 55 delayed unions (DU) and nonunions (NU). Material and methods: We treated 15 DU (2–4 months), 19 NU after conservative treatment (4–12 months), 15 NU after operative treatment and 6 recalcitrant NU. 23 of the cases were men at the average age of 43.9 (18–74) and 32–women, at the average age of 64.7 (43–88). NU according to Weber-Cech were–2 hypertrophic, 18 olygotrophic and 20 atrophic, as 7 of them were infected. The initial trauma in 14 cases was high energy. The most common predisposing factors at DU are: poor bone contact–distraction 11 cases, soft tissue interposition 8 cases. At NU after conservative treatment: soft tissue interposition 13 cases and inadequate vascularity–severe injury 6 cases, and at NU after operative treatment: mechanical instability–inadequate fixation 18 cases and excessive soft tissue striping 11 cases. The usual contributing factors are: metabolic bone disease 23 cases; obesity 18 cases; poor functional level 14 cases; smoking 14 cases; advanced age 11 cases. Osteosynthesis with AO plate were 23 cases and the remaining 32–interlocking nails. Bone grafting was done in 23 cases, decortications in 12 cases, and channel reaming–in 20 cases. Results: All the cases that were treated with AO plates consolidated for the average period of 103 days (70–150) and the cases with interlocking nails (with the exception of 3–9%) for the average period of 108 days (160–240). As post-operative complications we had 6 (26%) cases of iatrogenic neurological injury with plate ostheosynthesis, 3 (10%) cases of shoulder impingements with ILN, one case of shaft fracture and infection in both methods. The patients were followed for minimum 12 months after bone union–clinical and X-ray examinations (12–60) months. We rated the final functional result according to Rommens score: excellent–29, very good–13, good–8, satisfactory–2, bad–3. Conclusion: We think that DU are more appropriate for interlocking nailing. The cases that NU are a result of unsuccessful conservative treatment, because intramedullary channel was obstructed, is better to be treated by ostheosynthesis with plate. And the contrary–it is suitable to replace ostheosynthesis with AO plate with interlocking nails after extraction of the implants in addition to bone grafting

Aims

We aimed to evaluate the health-related quality of life (HRQoL) in children with supracondylar humeral fractures (SCHFs), who were treated following the recommendations of the Paediatric Comprehensive AO Classification, and to assess if HRQoL was associated with AO fracture classification, or fixation with a lateral external fixator compared with closed reduction and percutaneous pinning (CRPP).

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The aim of this study was to compare the incidence of anterior knee pain after antegrade tibial nailing using suprapatellar and infrapatellar surgical approaches

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The objectives of this study were to compare postoperative pain, analgesia requirements, inpatient functional rehabilitation, time to hospital discharge, and complications in patients undergoing conventional jig-based unicompartmental knee arthroplasty (UKA) versus robotic-arm assisted UKA.

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Anterior cruciate ligament (ACL) and multiligament knee (MLK) injuries increase the risk of development of knee osteoarthritis and eventual need for total knee arthroplasty (TKA). There are limited data regarding implant use and outcomes in these patients. The aim of this study was to compare the use of constrained implants and outcomes among patients undergoing TKA with a history of prior knee ligament reconstruction (PKLR) versus a matched cohort of patients undergoing TKA with no history of PKLR.

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Plate and screw fixation has been the standard treatment for painful conditions of the wrist in non-rheumatoid patients in recent decades. We investigated the complications, re-operations, and final outcome in a consecutive series of patients who underwent wrist arthrodesis for non-inflammatory arthritis.

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Anatomical atlases document classical safe corridors for the placement of transosseous fine wires through the calcaneum during circular frame external fixation. During this process, the posterior tibial neurovascular bundle (PTNVB) is placed at risk, though this has not been previously quantified. We describe a cadaveric study to investigate a safe technique for posterolateral to anteromedial fine wire insertion through the body of the calcaneum.