Foot pain and related problems are quite common in the community. It is reported that 24% of individuals older than 45 experienced foot pain. Also, it is stated that at least two thirds of individuals experiences moderate physical disability due to foot problems. In the absence of evaluation of risk factors such as limited ankle dorsiflexion in the early period of the diseases (Plantar fasciitis, Achilles Tendinopathy e.g.) and the lack of mobile systems with portable remote access, foot pain becomes refractory/chronic foot pain, secondary pathologies and ends with workload of 1., 2. and 3rd level healthcare services. In the literature, manuel and dijital methods have been used to analyze the ankle range of motion (ROM). These studies are generally based on placing protractors on the image and / or angle detection from inclination measurement by using the gyroscope sensor of the mobile device. Some of these applications are effective and they are designed to be suitable for measuring in a clinical setting by a physician or physiotherapist. To the best of our knowledge, there is no system developed to measure real-time ankle ROM remotely with collaboration of the patients. In this research, we proposed to develop an ankle ROM analyze system with smart phone application that can be used comfortably by subjects. We present a case of a 22-year-old male with a symptomatic pes planus. The mobile application, which was used for data collection, was designed and implemented for Android devices. Initially, before the mobile application home page is opened, a consent page was submitted to the acceptance of individual within the scope of Law (KVKK) data privacy. Then, the participant was asked to state his sociodemographic characteristics [age, gender, height, weight] and dominant side. No history of foot-ankle injury, trauma, and surgery was recorded. Activity pain of the foot was 6 according to visual anolog scale (VAS) in the mobile application. His ankle dorsiflexion was 15 ° by manuel goniometer. Besides, server was responsible for storing the collected data and ROM measurement. ROM was calculated by processing the foot video which was sent through the mobile application. During the processing phase, a segmentation model was used which was trained with image process and deep learning methods. With the developed system, we obtained the manual goniometric measurement result with 2 degrees deviation. As the application is calibrated, it is expected to approach the actual measurement of ROM. We can conclude that mobile app-goniometer result in dorsiflexion measurement is a novel promising evaluation method for ankle ROM. it will be easy and practical to detect and monitor risk factor of the diseases, decrease medical costs, provide health services in rural areas, and contribution to life quality and to reduce the workload on physicians and physiotherapist

Intraoperative range of motion (ROM) radiographs are routinely taken during scaphoidectomy and four corner fusion surgery (S4CF) at our institution. It is not known if intraoperative ROM predicts postoperative ROM. We hypothesize that patients with a greater intra-operativeROM would have an improved postoperative ROM at one year, but that this arc would be less than that achieved intra- operatively. We retrospectively reviewed 56 patients that had undergone S4CF at our institution in the past 10 years. Patients less than 18, those who underwent the procedure for reasons other than arthritis, those less than one year from surgery, and those that had since undergone wrist arthrodesis were excluded. Intraoperative ROM was measured from fluoroscopic images taken in flexion and extension at the time of surgery. Patients that met criteria were then invited to take part in a virtual assessment and their ROM was measured using a goniometer. T-tests were used to measure differences between intraoperative and postoperative ROM, Pearson Correlation was used to measure associations, and linear regression was conducted to assess whether intraoperative ROM predicts postoperative ROM. Nineteen patients, two of whom had bilateral surgery, agreed to participate. Mean age was 54 and 14 were male and 5 were male. In the majority, surgical indication was scapholunate advanced collapse; however, two of the participants had scaphoid nonunion advanced collapse. No difference was observed between intraoperative and postoperative flexion. On average there was an increase of seven degrees of extension and 12° arc of motion postoperatively with p values reaching significance Correlation between intr-operative and postoperative ROM did not reach statistical significance for flexion, extension, or arc of motion. There were no statistically significant correlations between intraoperative and postoperative ROM. Intraoperative ROM radiographs are not useful at predicting postoperative ROM. Postoperative extension and arc of motion did increase from that measured intraoperatively

As the field of hip arthroscopy continues to develop, functional measures and testing become increasingly important in patient selection, managing patient expectations prior to surgery, and physical readiness for return to athletic participation. The Hip Sport Test (HST) was developed to assess strength, coordination, agility, and range of motion prior to and following hip arthroscopy as a functional assessment. However, the relationship between HST and hip strength, range of motion, and hip-specific patient reported outcome (PRO) measures have not been investigated. The purpose of this study was to evaluate the correlation between the HST scores and measurements of hip strength and range of motion prior to undergoing hip arthroscopy. Between September 2009 and January 2017, patients aged 18-40 who underwent primary hip arthroscopy for the treatment of femoroacetabular impingement with available pre-operative HST, dynamometry, range of motion, and functional scores (mHHS, WOMAC, HOS-SSS) were identified. Patients were excluded if they were 40 years old, had a Tegner activity score < 7, or did not have HST and dynamometry evaluations within one week of each other. Muscle strength scores were compared between affected and unaffected side to establish a percent difference with a positive score indicating a weaker affected limb and a negative score indicating a stronger affected limb. Correlations were made between HST and strength testing, range of motion, and PROs. A total of 350 patients met inclusion criteria. The average age was 26.9 ± 6.5 years, with 34% females and 36% professional athletes. Total and component HST scores were significantly associated with measure of strength most strongly for flexion (rs = −0.20, p < 0 .001), extension (rs = −0.24, p<.001) and external rotation (rs = −0.20, p < 0 .001). Lateral and diagonal agility, components of HST, were also significantly associated with muscle strength imbalances between internal rotation versus external rotation (rs = −0.18, p=0.01) and flexion versus extension (rs = 0.12, p=0.03). In terms of range of motion, a significant correlation was detected between HST and internal rotation (rs = −0.19, p < 0 .001). Both the total and component HST scores were positively correlated with pre-operative mHHS, WOMAC, and HOS-SSS (p<.001 for all rs). The Hip Sport Test correlates with strength, range of motion, and PROs in the preoperative setting of hip arthroscopy. This test alone and in combination with other diagnostic examinations can provide valuable information about initial hip function and patient prognosis

Aims. In computer simulations, the shape of the range of motion (ROM) of a stem with a cylindrical neck design will be a perfect cone. However, many modern stems have rectangular/oval-shaped necks. We hypothesized that the rectangular/oval stem neck will affect the shape of the ROM and the prosthetic impingement. Methods. Total hip arthroplasty (THA) motion while standing and sitting was simulated using a MATLAB model (one stem with a cylindrical neck and one stem with a rectangular neck). The primary predictor was the geometry of the neck (cylindrical vs rectangular) and the main outcome was the shape of ROM based on the prosthetic impingement between the neck and the liner. The secondary outcome was the difference in the ROM provided by each neck geometry and the effect of the pelvic tilt on this ROM. Multiple regression was used to analyze the data. Results. The stem with a rectangular neck has increased internal and external rotation with a quatrefoil cross-section compared to a cone in a cylindrical neck. Modification of the cup orientation and pelvic tilt affected the direction of projection of the cone or quatrefoil shape. The mean increase in internal rotation with a rectangular neck was 3.4° (0° to 7.9°; p < 0.001); for external rotation, it was 2.8° (0.5° to 7.8°; p < 0.001). Conclusion. Our study shows the importance of attention to femoral implant design for the assessment of prosthetic impingement. Any universal mathematical model or computer simulation that ignores each stem’s unique neck geometry will provide inaccurate predictions of prosthetic impingement. Cite this article: Bone Joint Res 2021;10(12):780–789

Aims. We aimed to assess the reliability and validity of OpenPose, a posture estimation algorithm, for measurement of knee range of motion after total knee arthroplasty (TKA), in comparison to radiography and goniometry. Methods. In this prospective observational study, we analyzed 35 primary TKAs (24 patients) for knee osteoarthritis. We measured the knee angles in flexion and extension using OpenPose, radiography, and goniometry. We assessed the test-retest reliability of each method using intraclass correlation coefficient (1,1). We evaluated the ability to estimate other measurement values from the OpenPose value using linear regression analysis. We used intraclass correlation coefficients (2,1) and Bland–Altman analyses to evaluate the agreement and error between radiography and the other measurements. Results. OpenPose had excellent test-retest reliability (intraclass correlation coefficient (1,1) = 1.000). The R. 2. of all regression models indicated large correlations (0.747 to 0.927). In the flexion position, the intraclass correlation coefficients (2,1) of OpenPose indicated excellent agreement (0.953) with radiography. In the extension position, the intraclass correlation coefficients (2,1) indicated good agreement of OpenPose and radiography (0.815) and moderate agreement of goniometry with radiography (0.593). OpenPose had no systematic error in the flexion position, and a 2.3° fixed error in the extension position, compared to radiography. Conclusion. OpenPose is a reliable and valid tool for measuring flexion and extension positions after TKA. It has better accuracy than goniometry, especially in the extension position. Accurate measurement values can be obtained with low error, high reproducibility, and no contact, independent of the examiner’s skills. Cite this article: Bone Joint Res 2023;12(5):313–320

Abstract. Objectives. Impingement in total hip replacements (THRs), including bone-on-bone impingement, can lead to complications such as dislocation and loosening. The aim of this study was to investigate how the location of the anterior inferior iliac spine (AIIS) affected the range of motion before impingement. Methods. A cohort of 25 CT scans (50 hips) were assessed and nine hips were selected with a range of AIIS locations relative to the hip joint centre. The selected CT Scans were converted to solid models (ScanIP) and THR components (DePuy Synthes) were virtually implanted (Solidworks). Flexion angles of 100⁰, 110⁰, and 120⁰ were applied to the femur, each followed by internal rotation to the point of impingement. The lateral, superior and anterior extent of the AIIS from the Centre of Rotation (CoR) of the hip was measured and its effect on the range of motion was recorded. Results. There was found to be a significant (p<0.05) inverse relationship between the ROM of the THR and the lateral measure of the AIIS. Of the three measures, the lateral AIIS measure showed the strongest relationship with ROM to impingement (R=0.73) with the anterior and superior measures resulting in R values of 0.41 and 0.56 respectively. For every millimetre lateral the AIIS location, there was typically a loss of 1.2° of range of motion. With increasing lateralisation, the AIIS was positioned more directly over the femur, thereby reducing the ROM in the THR during high flexion positions. No soft tissue was included in the models which would have affected the ROM. Conclusions. The results from this study have shown that the lateral measure of the AIIS could be a predictor for bone-on-bone impingement. To build confidence, wider study of AIIS location variation is needed, as well as analysis under impingement prone activities of daily living. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

There are a variety of sizes currently available for reverse total shoulder arthroplasty (RTSA) implant systems. Common sizing options include a smaller 36 to 38 mm or a larger 40 to 42 mm glenosphere, and are typically selected based on surgeon preference or patient size. Previous studies have only evaluated the abduction and adduction range of motion within a single plane of elevation, providing a limited view of the joint's possible range of motion. The purpose of this study was to use computer modeling to evaluate the abduction and adduction range of motion across multiple planes of elevation for a range of glenosphere sizes. Computed tomography images of four cadaveric specimens (age: 54 ± 24 years) were used to obtain the osseous anatomy to be utilised in the model. Solid-body motion studies of the RTSA models were constructed with varying glenosphere diameters of 33, 36, 39, 42, and 45 mm in Solidworks (Dassault Systems, US). The implant components were scaled, while maintaining a consistent centre of rotation. Simulations encompassing the full range of abduction and adduction were conducted for the planes of elevation between −15˚ and 135˚ at 15˚ intervals, with the motion of the humerus being constrained in neutral internal-external rotation throughout all planes. Angles of elevation were obtained utilising the humeral long axis and the RTSA centre of rotation. Statistical analysis was performed using repeated measures ANOVA. Glenosphere diameter was found to significantly affect the adduction range of motion (p=0.043), in which the largest size provided approximately 17˚ more adduction range of motion than the smallest. However, abduction range of motion was not found to be significantly affected through the alteration of glenosphere size (p=0.449). The plane of elevation was not found to significantly affect abduction or abduction (p=0.585 & p=0.225, respectively). Increasing glenosphere diameter resulted in an increased adduction range of motion when averaged across the tested planes of elevation; however the observed influence on abduction was not significant. These are similar to the trends observed in the previous single plane of elevation studies. These findings illustrate the importance of implant sizing related to range of motion. Further studies are required to determine the influence of glenosphere size on internal and external range of motion

Range of Motion (ROM) assessments are routinely used during joint replacement to evaluate joint stability before, during and after surgery to ensure the effective restoration of patient biomechanics. This study aimed to quantify axial torque in the femur during ROM assessment in total hip arthroplasty to define performance criteria against which hip instruments can be verified. Longer term, this information may provide the ability to quantitatively assess joint stability, extending to quantitation of bone preparation and quality. Joint loads measured with strain-gaged instruments in five cadaveric femurs prepared using posterior approach were analysed. Variables such as surgeon-evaluator, trial offset and specimen leg and weight were used to define 13 individual setups and paired with surgeon appraisal of joint tension for each setup. Peak torque loads were then identified for specific motions within the ROM assessment. The largest torque measured in most setups was observed during maximum extension and external rotation of the joint, with a peak torque of 13Nm recorded in a specimen weighing 98kg. The largest torque range (19.4Nm) was also recorded in this specimen. Other motions within the trial reduction showed clear peaks in applied torque but with lower magnitude. Relationships between peak torque, torque range and specimen weight produced an R2 value greater than 0.65. The data indicated that key influencers of torsional loads during ROM were patient weight, joint tension and limb motion. This correlation with patient weight should be further investigated and highlights the need for population representation during cadaveric evaluation. Although this study considered a small sample size, consistent patterns were seen across several users and specimens. Follow-up studies should aim to increase the number of surgeon-evaluators and further vary specimen size and weight. Consideration should also be given to alternative surgical approaches such as the Direct Anterior Approach

Nearly one quarter of ankle fractures have a recognized syndesmosis injury. An intact syndesmosis ligament complex stabilizes the distal tibio-fibular joint while allowing small, physiologic amounts of relative motion. When injured, malreduction of the syndesmosis has been found to be the most important independent factor that contributes to inferior functional outcomes. Despite this, significant variability in surgical treatment remains. This may be due to a poor understanding of normal dynamic syndesmosis motion and the resultant impact of static and dynamic fixation on post-injury syndesmosis kinematics. As the syndesmosis is a dynamic structure, conventional CT static images do not provide a complete picture of syndesmosis position, giving potentially misleading results. Dynamic CT technology has the ability to image joints in real time, as they are moved through a range-of-motion (ROM). The aim of this study was to determine if syndesmosis position changes significantly throughout ankle range of motion, thus warranting further investigation with dynamic CT. This is an a priori planned subgroup analysis of a larger multicentre randomized clinical trial, in which patients with AO-OTA 44-C injuries were randomized to either Tightrope or screw fixation. Bilateral ankle CT scans were performed at 1 year post-injury, while patients moved from maximal dorsiflexion (DF) to maximal plantar flexion (PF). In the uninjured ankles, three measurements were taken at one cm proximal to the ankle joint line in maximal DF and maximal PF: Anterior (ASD), middle (MSD), and posterior (PSD) syndesmosis distance, in order to determine normal syndesmosis position. Paired samples t-tests compared measurements taken at maximal DF and maximal PF. Twelve patients (eight male, six female) were included, with a mean age of 44 years (±13years). The mean maximal DF achieved was 1-degree (± 7-degrees), whereas the mean maximal PF was 47-degrees (± 8-degrees). The ASD in DF was 3.0mm (± 1.1mm) versus 1.9mm (± 0.8mm) in PF (p<0.01). The MSD in DF was 3.3mm (±1.1mm) versus 2.3mm (±0.9mm) in PF (p<0.01). The PSD in DF was 5.3mm (±1.5mm) versus 4.6mm (±1.9mm) in PF (p<0.01). These values are consistent with the range of normal parameters previously reported in the literature, however this is the first study to report the ankle position at which these measurements are acquired and that there is a significant change in syndesmosis measurements based on ankle position. Normal syndesmosis position changes in uninjured ankles significantly throughout range of motion. This motion may contribute to the variation in normal anatomy previously reported and controversies surrounding quantifying anatomic reduction after injury, as the ankle position is not routinely standardized, but rather static measurements are taken at patient-selected ankle positions. Dynamic CT is a promising modality to quantify normal ankle kinematics, in order to better understand normal syndesmosis motion. This information will help optimize assessment of reduction methods and potentially improve patient outcomes. Future directions include side-to-side comparison using dynamic CT analysis in healthy volunteers

Introduction. The reliability of currently available proximal humeral fracture classi?cation systems has been shown to be poor, giving rise to the question whether a more objective measure entails improved predictability of surgical outcome. This study aims to apply a novel software system to predict the functional range of motion of the glenohumeral joint after proximal humeral fracture. Method. Using a validated system that simulates bone-determined range of motion of spheroidal joints such as the shoulder joint, we categorically analysed a consecutive series of 79 proximal humeral fractures. Morphological properties of the proximal humerus fractures were related to simulated bone-determined range of motion. Results. The interobserver variability of range of motion assessment using our system showed excellent agreement (0.798). Maximal glenohumeral abduction and forward ?exion of intra-articular fractures were 34.3±6.6 SE and 60.7±12.4 SE degrees. For fractures with a displaced greater tuberosity abduction was 75.0±5.9 SE and forward flexion was 118.2±4.9 SE degrees, whilst for fractures where both tuberosities had been displaced they were 60.0±10.9 SE and 69.6±13.4 SE degrees respectively. For non-intra articular fractures without displaced tuberosities movements were 89.3±3.3 SE and 122.6±3.4 SE degrees respectively. The head inclination angle was positively correlated with maximum abduction (0.362, p = 0.014). Offset was negatively correlated with maximum abduction, but not statistically signi?cant (0.834, p = 0.087). Conclusion. This study has demonstrated a novel and effective tool allowing the prediction of functional motion after proximal humeral fracture based on bone anatomy. The study demonstrates that intra-articular fractures generally have the worst prognosis with regards to bone-determined ROM. Fractures with displaced tuberosities show more motion limitations for abduction than for forward ?exion. A reduced head inclination angle is a strong predictor of limited bone-determined range of motion for all types of proximal humerus fractures

Introduction: Cervical range of motion is affected by a wide variety of pathologies and is routinely measured in clinical assessment of the neck. It is therefore crucial to use a method that is both accurate and reliable but that is also non-invasive and inexpensive. This study assessed cervical range of motion using different methods of measurement, namely the universal goniometer and the cervical range of motion (CROM) goniometer. These methods were then compared with each other. In addition, we were interested in determining whether a single component of neck movement is representative of total cervical range of motion. Methods: 50 healthy subjects between the ages of 18–87 with no shoulder or spine pathology were asked to perform six active neck movements, flexion, extension, lateral flexion and axial rotation while the movements were measured first using the universal goniometer and then with the CROM goniometer. The CROM goniometer has been shown previously to have excellent validity and reliability. The researchers were trained to use the measuring techniques prior to data collection. All measurements were performed by the same researcher for each subject and the two researchers alternated between subjects. Results: Comparison between the universal goniometer and the CROM goniometer was performed using Bland and Altman plots. This revealed that 60.6% of universal goniometer readings were within ±5° of the CROM reading; however 31.6% of readings differed by > ±5° and 7.8% differed by > ±10°. The interobserver variance was calculated and there was excellent agreement between the two researchers for both the universal goniometer and CROM goniometer, with an intraclass correlation coefficient of ≥0.80 for every movement. Extension was the most predictive of total neck movement (Pearson coefficient 0.643, p < 0.001). This continues to be the case even when the negative effect of age on range of motion is taken into account. Discussion: The finding that extension was the most representative neck movement has implications for the assessment of cervical motion. Accordingly, if a single neck movement is measured to represent total range of motion, extension should be used. The comparison between the CROM and universal goniometer demonstrated that the majority of goniometer readings were within 5° of the CROM result; however, this was not consistently the case. Given that the CROM is a valid and reliable method of measuring neck movement, the inconsistency between the goniometer and CROM can be taken as inaccuracy on the part of the universal goniometer. As the interobserver variance is excellent one can assume that these results are reproducible and that the errors observed are a true reflection of the limitations of the device

Introduction: Subject to recent literature citing a reduction in ankle range of motion predisposing to ankle fractures in children, we decided prospectively to analyse the passive range of motion in children presenting to our fracture clinic with simple distal radial metaphyseal fractures treated conservatively in cast. The range of motion was assessed by two observers, and measured using a goniometer in 80 patients. (42 radial fractures and 38 controls) The controls were recruited from children presenting with lower limb injuries and with no prior history of an upper limb injury or neuromuscular condition. The fractures were as a result of simple falls onto the outstretched hand with definite radiological and clinical findings. The range of motion in the contralateral limb was assessed. Both groups showed an equal distribution of dominant and non-dominant limbs. Results: Both groups were well matched with an average age of 10 and 10.3 years fracture group and control group respectively, and gender 55% male fracture group and 52.5% control group. The m injured group showed a passive range of motion of 1680, whereas the control group showed a higher range of motion of 1820, a difference of 140 (p< . 005 student t-test). A third blinded independent observer of 20 children assessed Intra and interobserver error, and no observer was noted to have higher or lower readings. Conclusion: Children with radial fractures have a lower passive range of motion of their wrists than Controls. This may contribute to the aetiology of wrist fractures in a paediatric population. An possible explanation may be as cited in original work that children who sustain fractures have less mobility around their joints due to reduced elasticity in their musculoskeletal framework. Simple passive stretching of fracture prone joints should therefore be advised

Introduction. Sheffield Children's Hospital specialises in limb lengthening for children. Soft tissue contracture and loss of range of motion at the knee and ankle are common complications. This review aims to look at therapeutic techniques used by the therapy team to manage these issues. Materials & Methods. A retrospective case review of therapy notes was performed of femoral and tibial lengthening's over the last 3 years. Included were children having long bone lengthening with an iIntramedullary nail, circular frame or mono-lateral rail. Patients excluded were any external fixators crossing the knee/ankle joints. Results. 20 tibial and 25 femoral lengthening's met the inclusion criteria. Pathologies included, complex fractures, limb deficiency, post septic necrosis and other congenital conditions leading to growth disturbance. All patients had issues with loss of motion at some point during the lengthening process. The knee and foot/ankle were equally affected. Numerous risk factors were identified across the cohort. Treatment provided included splinting, serial casting, bolt on shoes, exercise therapy, electrical muscle stimulation and passive stretching. Conclusions. Loss of motion in lower limb joints was common. Patients at higher risk were those with abnormal anatomy, larger target lengthening's, poor compliance or lack of access to local services. Therapy played a significant role in managing joint motion during treatment. However, limitations were noted. No one treatment option gave preferential outcomes, selection of treatment needed to be patient specific. Future research should look at guidelines to aid timely input and avoid secondary complications

Introduction. Selection of an optimum thickness of polyethylene insert in total knee arthroplasty (TKA) is important for the good stability and range of motion (ROM). The purpose of this study is to investigate the amount of change of ROM as the thickness of trial insert increase. Material and Method. The study included 86 patients with 115 knees undergoing TKA from October 2012 to February 2014. There were 17 men and 69 women with an average age of 75±8 (58–92) years. The implants posterior stabilized knee (Scorpio NRG, Stryker) was used and all prostheses were fixed with cement. The ROM was measured by the goniometer under the general anesthesia at the time of operation in increments of 1°. Preoperative flexion angle was measured by passively flexing the patient's hip 90 degrees and allowing the weight of the leg to flex the knee joint (Lee et al 1998). Extension angle was measured by holding the heel and raising the leg by another examiner. During TKA, flexion and extension angle was measured in a similar manner when each insert trial (8, 10, 12, and 15mm) was inserted. After the wound closure and removing the draping, ROM was measured again. Statistical analysis of range of motion was performed using a paired t-test to determine significance. Results. Preoperative extension angle was-11.8±7.5°and flexion angle was 125.4±14.9 °. postoperative extension angle after removing drapes was −5.0±3.4°and flexion angle was126.4±8.8°. Although extension angle was improved statistically (p<0.001), flexion angle was not improved. Intraoperative extension and flexion angle that were measured with the same thick insert trial as the polyethylene insert finally selected was −3.7±3.0°and 120.8±9.8°respectively. The thickness of polyethylene insert finally set was 8mm (28knees), 10mm (58knee), 12mm (24 knee), and 15mm (5knee). The amount of deficit in extension ROM by changing the trial inserts those were measured intraoperatively were 2.5±2.2° (n=112, 8 to 10mm, p<0.01), 3.2±2.8° (n=80, 10 to 12mm, p< 0.01), and 4.7±2.5° (n=15, 12 to 15mm, p<0.01). Flexion angle was 0.6±4.3° (8 to 10mm, n.s), 1.5±4.0° (10 to 12mm, p=0.002), 2.6±4.0° (12 to 15mm, p=0.025). Discussion. Although it is important to select a sufficient thick polyethylene insert to prevent postoperative instability, excessive thick polyethylene can decrease ROM especially extension. In many type of prosthesis, thickness of polyethylene insert differs every 2 mm is prepared. In the current study, if the thickness of polyethylene is increased 2mm (8 to10mm and 10 to 12mm) or 3mm (12 to15mm), extension and flexion angle was decreased 2.5–4.7°and 0.6–2.6°respectively

Aims. Pelvic tilt (PT) can significantly change the functional orientation of the acetabular component and may differ markedly between patients undergoing total hip arthroplasty (THA). Patients with stiff spines who have little change in PT are considered at high risk for instability following THA. Femoral component position also contributes to the limits of impingement-free range of motion (ROM), but has been less studied. Little is known about the impact of combined anteversion on risk of impingement with changing pelvic position. Methods. We used a virtual hip ROM (vROM) tool to investigate whether there is an ideal functional combined anteversion for reduced risk of hip impingement. We collected PT information from functional lateral radiographs (standing and sitting) and a supine CT scan, which was then input into the vROM tool. We developed a novel vROM scoring system, considering both seated flexion and standing extension manoeuvres, to quantify whether hips had limited ROM and then correlated the vROM score to component position. Results. The vast majority of THA planned with standing combined anteversion between 30° to 50° and sitting combined anteversion between 45° to 65° had a vROM score > 99%, while the majority of vROM scores less than 99% were outside of this zone. The range of PT in supine, standing, and sitting positions varied widely between patients. Patients who had little change in PT from standing to sitting positions had decreased hip vROM. Conclusion. It has been shown previously that an individual’s unique spinopelvic alignment influences functional cup anteversion. But functional combined anteversion, which also considers stem position, should be used to identify an ideal THA position for impingement-free ROM. We found a functional combined anteversion zone for THA that may be used moving forward to place total hip components. Cite this article: Bone Jt Open 2021;2(10):834–841

Purpose. This study was to investigate the effect of posterior tibial slope (PTS) on the kinematics in the cruciate-retaining total knee arthroplasty (CR-TKA) using 2- to 3- dimensional registration technique. Material & Methods. A total of 75 knees in 58 patients were recruited and categorized into the following two groups according to PTS. Group A was categorized PTS under 7degrees (n = 33) and group B was categorized PTS over 7 degrees (n = 42). The average age of group A and group B at the time of fluoroscopic surveillance date was 73.5 ± 7.4 years and 74.3 ± 4.5 years, respectively and the average follow-up period from operation date to fluoroscopic surveillance date was 13.8 ± 9.3 months and 16.7 ± 8.6 months, respectively. In vivo kinematics during sequential deep knee bending under weight-bearing condition were evaluated using fluoroscopic image analysis and 2- to 3- dimensional registration technique. Range of motion (ROM), axial rotation, anteroposterior (AP) translations of medial and lateral nearest points of the femoral component relative to the tibial component were measured and compared between the two groups. The nearest points were determined by calculating the closest distance between the surfaces of femoral component model and the axial plane of coordinate system of the tibial component. We defined external rotation and anterior translation as positive. P values under 0.05 was defined as statistically significant. Results. The mean PTS in group A and B were 5.5 ± 1.4°and 9.9 ± 1.9°, respectively. There was no statistically significant difference in the degrees of axial rotation from 0° to 110° of flexion between the two groups (4.9 ± 4.2° vs 5.2 ± 4.2°, p > 0.05), respectively. The hyperextension of group B were significantly larger than group A (−2.3 ± 6.6°vs −9.8 ± 8.7°, p <0.05). The ROM of group B were significantly larger than group A (118.7 ± 10.8°vs 128.7 ± 17.7°, p <0.05). However, there was no significant difference in the maximum flexion between the two groups (116.4 ±10.8°vs 118.9±14.5°, p >0.05), respectively. In terms of AP translation, medial nearest points were located significantly more posterior at 0°, 10°, 30°, 40° of flexion in group B compared to group A. There was no significant difference in the location of lateral nearest points between the two groups during all knee range of motion. Discussion/Conclusion. The results shown in this study demonstrated that the PTS influenced the kinematics and ROM under weight-bearing condition in CR-TKA. The large PTS induced great posterior displacement of medial nearest points during early flexion phase and increased hyperextension between the femoral and tibial components

The incidence of first metatarsophalangeal joint (MTPJ) stiffness following bunion surgery varies in the literature from 2% to 60%. The causes include pre-existing degenerative joint disease, infection, chronic regional pain syndrome (Type 1), joint incongruence and avascular necrosis. The aim of this study was to establish whether closure of the capsule influences the range of motion in the first MTPJ. We performed a cadaveric study using a ‘Y’ shaped medial capsulotomy as our model. A mid-medial approach was performed on ten cadaveric feet, exposing the medial capsule of the 1st MTPJ. The range of motion of the 1st MTPJ was recorded, and a ‘Y’ shaped capsulotomy performed. The capsule was then closed in neutral, full plantar flexion, and full dorsi flexion and the range of motion recorded. When the capsule was closed with the first MTPJ at the limit of plantar flexion there was a mean loss of 13.7° of dorsi-flexion (range 12°–15°, p< 0.01) compared with the pre-capsulotomy range of motion. When the capsule was closed in dorsi-flexion there was a mean loss of 9.3° of plantar flexion (range 0°–20°, p< 0.05). There was no change in range of motion when the capsule was closed in neutral. Capsular closure can influence first MPTJ motion. Care should therefore be taken during capsular repair. Closure in extremes of extension or flexion, as advocated in some techniques such as the Mitchell osteotomy, should be avoided

Purpose: The purpose of this historical prospective study was to compare the pre and post-operative range of motion (ROM) and quality of life outcomes 6 months post-operatively in patients with partial and full-thickness tears of the rotator cuff. Methods: Data of 90 consecutive patients diagnosed with partial thickness tear (PTT) who had undergone decompression and or acromiploasty were compared with 90 patients (age and gender-matched) who had undergone repair of a full-thickness tear (FTT). The outcomes were objective pre and post-operative range of motion (ROM) in 5 directions and three patient-derived outcome measures; one disease-specific, the Western Ontario Rotator Cuff Index, and two shoulder specific measures: the American Shoulder & Elbow Surgeons standardized shoulder assessment form and, the Constant-Murley. A statistical paired t-test analysis was conducted between change (pre vs. 6 months) in ROM and QOL scores to examine the impact of severity on improvement between the 2 groups. Results: Forty-three females and 47 males in each group (180 subjects in total) were included in the analysis. The mean age was 54.8 and 54.9 for the PTT and FTT groups respectively. The PTT group was significantly stiffer in pre-operative passive flexion (p=0.010), abduction (p=0.022) and active external rotation at 0 degree of abduction (p=0.040). The 6-month WORC, ASES, and relative Constant all showed significant improvement in quality of life in both groups (p< 0.0001). There was a statistically significant difference in passive external rotation at 0 degrees of abduction between groups with FTT group being stiffer than the PTT group (p=0.019) post-operatively. Change in ROM was not significantly different in all other directions. Conclusions: The intent of this study was to compare the pre-operative and rate of improvement in two groups of patients suffering from different severity of pathology. The results indicate that quality of life improves significantly regardless of the extent of tear (partial thickness vs. full thickness). Patients with FTT may require a longer time to improve their range of motion in external rotation

Purpose. The remplissage procedure may be performed as an adjunct to Bankart repair to address an engaging Hill-Sachs defect. Clinically, it has been reported that the remplissage procedure improves joint stability but that it may also restrict shoulder range of motion. The purpose of this biomechanical study was to examine the effects of the remplissage procedure on shoulder motion and stability. We hypothesized that the remplissage procedure would improve stability and prevent engagement but may have a deleterious effect on motion. Method. Eight cadaveric forequarters were mounted on a custom biomechanical testing apparatus which applied simulated loads independently to the rotator cuff muscles and to the anterior, middle and posterior deltoid. The testing conditions included: intact shoulder, Bankart defect, Bankart repair, 2 Hill-Sachs defects (15%, 30%) with and without remplissage. Joint range of motion and translation were recorded with an optical tracking system. Outcomes measured were internal-external rotation range of motion in adduction and 90 combined abduction, extension range of motion and stability, quantified in terms of joint stiffness and engagement, in abduction. Results. With a 15% Hill-Sachs defect, the remplissage significantly reduced internal-external rotation in adduction (15.111.1, p=0.039), but not in abduction (7.79.0, p=0.380). In a 30% Hill-Sachs defect, the remplissage procedure significantly reduced internal-external rotation in adduction (19.57.8, p=0.001), and in abduction (12.28.6, p=0.03). The remplissage procedure significantly enhanced stability in the 15% Hill-Sachs defect (4.74.0 N/mm, p=0.038), and in the 30% defect (3.93.2 N/mm, P=0.030) compared to the unrepaired defect. All of the unrepaired 30% defects engaged and the remplissage procedure successfully eliminated engagement in each case. However, impingement of the repair on the posterior glenoid with paradoxical posterior pivoting of the humeral head was observed in 50% of the specimens. Conclusion. The remplissage procedure significantly augmented a Bankart repair in 15% and 30% Hill-Sachs defects and, in 30% Hill-Sachs defects, the remplissage successfully prevented engagement of the defect. The remplissage procedure, however, did significantly reduced shoulder internal-external rotation range of motion as reported clinically, and was also found to reduce extension in the two defect groups. During extension the intra-articular soft tissue bumper created by the remplissage procedure was found to impinge on the posterior glenoid rim and cause pivoting, which produced non-physiologic glenohumeral joint distraction. Therefore, the remplissage procedure stabilized the joint to a significantly greater degree than did a Bankart repair alone; however, it also significantly reduced shoulder range of motion

Aims. Total knee arthroplasty (TKA) may provoke ankle symptoms. The aim of this study was to validate the impact of the preoperative mechanical tibiofemoral angle (mTFA), the talar tilt (TT) on ankle symptoms after TKA, and assess changes in the range of motion (ROM) of the subtalar joint, foot posture, and ankle laxity. Methods. Patients who underwent TKA from September 2020 to September 2021 were prospectively included. Inclusion criteria were primary end-stage osteoarthritis (Kellgren-Lawrence stage IV) of the knee. Exclusion criteria were missed follow-up visit, post-traumatic pathologies of the foot, and neurological disorders. Radiological angles measured included the mTFA, hindfoot alignment view angle, and TT. The Foot Function Index (FFI) score was assessed. Gait analyses were conducted to measure mediolateral changes of the gait line and ankle laxity was tested using an ankle arthrometer. All parameters were acquired one week pre- and three months postoperatively. Results. A total of 69 patients (varus n = 45; valgus n = 24) underwent TKA and completed the postoperative follow-up visit. Of these, 16 patients (23.2%) reported the onset or progression of ankle symptoms. Varus patients with increased ankle symptoms after TKA had a significantly higher pre- and postoperative TT. Valgus patients with ankle symptoms after TKA showed a pathologically lateralized gait line which could not be corrected through TKA. Patients who reported increased ankle pain neither had a decreased ROM of the subtalar joint nor increased ankle laxity following TKA. The preoperative mTFA did not correlate with the postoperative FFI (r = 0.037; p = 0.759). Conclusion. Approximately one-quarter of the patients developed ankle pain after TKA. If patients complain about ankle symptoms after TKA, standing radiographs of the ankle and a gait analysis could help in detecting a malaligned TT or a pathological gait. Cite this article: Bone Joint J 2023;105-B(11):1159–1167

Introduction: Range of motion (ROM) is an important measure of the success of knee Arthroplasty. The extent to which pain relief contributes to improvements in knee ROM in total knee Arthroplasty (TKA) patients is unknown. This prospective study assessed the separate effects of pain abolition and surgery on ROM in a group of 141-osteoathritic patient’s undergoing TKA. Pain had a significant inhibitory effect on knee ROM. Improvements in ROM following TKA may be primarily due to pain relief. Methods: 141 randomly selected patients underwent LCS total knee arthroplasty (De Puy). A single surgeon performed all operations, using an identical surgical technique. Passive flexion and extension were measured when awake, under anaesthesia, and post-operatively under anaesthesia. Paired t-tests were used to test for significant differences between the measurements. Independent samples t-tests were used to test for significant differences between the changes in flexion, extension and ROM between the time points tested. Results:. When awake the mean flexion was 116.8°, extension 3.8°, and ROM 113.0°. When anaesthetised pre-op, the flexion was 130.2°, extension 0.8°, and ROM 129.4°. When anaesthetised post-op the flexion was 133.8°, extension 0.2°, and the ROM 133.5°. Knee flexion (p < 0.0001) and range of motion (p < 0.0001) were significantly greater and knee extension (p < 0.0001) was significantly reduced following anaesthesia only. A further significant increase in knee flexion (p < 0.0001) and range of motion (p = 0.00014) was observed post –operatively under anaesthetic. However knee extension did not significantly increase further (p = 0.29). The average improvement in range of motion once anaesthetised was 16.4° (SD = 13.1°) with the majority of this improvement due to an increase of flexion (average increase of 13.4° (SD = 11.9°) rather than an increase in extension (average increase of 3.0° (SD = 4.2°). The combined effect of surgery and anaesthetic was 20.5° (SD = 12.3°), with the majority of this improvement due to an increase of flexion (average increase of 17° (SD = 8.5°) rather than an increase in extension (average increase of 3.6° (SD = 6.0°). Discussion: Pain abolition resulted in a mean increase of 16.4° in the range of motion, and both TKA combined with pain abolition further increased significantly the range of motion to a mean of 20.5°. This study suggests that improvements in ROM following total knee arthroplasty are primarily due to reduction in the symptoms of pain and that other factors such as surgical technique and prosthesis design can further increase ROM. Future studies should record the measurements of passive flexion, extension and range of motion in the anaesthetised patient, as this will allow objective assessment of changes in range of movement

The influence of amount of tibial posterior slope changes on joint gap and postoperative range of motion was investigated in 35 patients undergoing unicompartmental knee arthroplasty (UKA). Component gap between the medial tibial osteotomy surface and the femoral trial prosthesis was measured throughout the range of motion using a tensor. The mean tibial posterior slope decreased from 10.2 to 7.3 degrees. Increased tibial slope change was positively correlated with component gap differences of 90° −10°, 120° −10°, and 135° −10° and negatively correlated with postoperative extension angle. Increasing tibial slope should be avoided to achieve full extension angle after UKA

Aim. To compare radiological and clinical outcomes between triceps-detaching and triceps-sparing approaches in total elbow arthroplasty, with specific focus on cementing technique and post-operative range of motion. Methods. A retrospective review was completed of medical records and radiographs of 56 consecutively managed patients who underwent a primary total elbow arthroplasty between 2000 and 2012 at a tertiary hospital. Rheumatoid Arthritis was the predominant pathology (47/56). Data analysed included patient demographics, range of motion pre-operatively and at various stages post-operatively, approach utilized, operative time and complications. Cementing technique was graded as adequate, marginal or inadequate according to Morrey's criteria. Results. 12 patients were lost to follow-up or had incomplete records, leaving 44 patients for analysis. 15 patients had a triceps-sparing approach, and 29 had a variation of a triceps-detaching approach. Average follow-up was 56.1 months. Flexion range of motion in the triceps-sparing group improved from 25°–122° (±19.6°) pre-op to 10°–140° (±22.5°) at final follow-up, and in the triceps-detaching group from 41°–104° (± 22.2°) pre-op to 27°–129° (±35.0°) at final follow-up. Tourniquet time averaged 85.4 (±17.0) minutes for the triceps-sparing group and 96.1 (±22.6) minutes for the triceps-detaching group. The complication rate in the triceps-sparing group was 13.3%, and included one olecranon fracture and one case of superficial wound sepsis. The complication rate for the triceps-detaching group was 24.1%, and included one patient with persistent ulnar nerve symptoms requiring transposition, one medial condyle fracture and five triceps ruptures. Three patients who had attempted repairs of the rupture developed deep infections requiring multiple further surgeries. Cementing technique was adequate in 91.7% in the triceps-sparing group and in 70.6% in the triceps-detaching group and marginal in the remainder of the cohort. Conclusion. A triceps-sparing approach results in a predictable improvement in range of motion with no compromise of the cement mantle. NO DISCLOSURES

Introduction/Aim. Mid-flexion instability is a well-documented, but often poorly understood cause of failure of TKA. NAVIO robotic-assisted TKA (RA-TKA) offers a novel, integrative approach as a planning, execution as well as an evaluation tool in TKA surgery. RA-TKA provides a hybrid planning technique of measured resection and gap balancing- generating a predictive soft-tissue balance model, prior to making cuts. Concurrently, the system uses a semi-active robot to facilitate both the execution and verification of the plan, as it pertains to both the static and dynamic anatomy. The goal of this study was to assess the ability of the NAVIO RA-TKA to plan, execute and deliver an individualized approach to the soft-tissue balance of the knee, specifically in the “mid-flexion” arc of motion. Materials and Methods. Between May and September 2018, 50 patients underwent NAVIO RA-TKA. Baseline demographics were collected, including age, gender, BMI, and range of motion. The NAVIO imageless technique was used to plan the procedure, including: surface-mapping of the static anatomy; objective assessment of the dynamic, soft-tissue anatomy; and then application of a hybrid of measured-resection and gap-balancing technique. Medial and lateral gaps as predicted by the software were recorded throughout the entire arc of motion at 15° increments. After executing the plan and placing the components, actual medial and lateral gaps were recorded throughout the arc of motion. Results. In the assessment of coronal-plane balance, the average deviation from the predicted plan between 0–90° was 0.9mm in both the medial and lateral compartments (range 0.5–1.2mm). In the mid-flexion arc (15–75°), final soft-tissue stability was within 1.0mm of the predictive plan (range 0.9–1.2mm). Discussion/Conclusions. In this study, NAVIO RA-TKA demonstrated a highly accurate and reproducible surgical technique to plan, execute and verify a balanced a soft-tissue envelope in TKA. Objective soft-tissue balancing of the TKA can now be performed, including the mid-flexion arc of motion. Further analysis can determine if these objective measurements will translate into improved patient-reported outcome scores

Introduction Range of motion (ROM) is an important measure of outcome. A better understanding of the factors influencing ROM is important when counselling patients undergoing TKA. Aim The aim of the study was to prospectively evaluate the influence of a number of selected variables on knee flexion at one year using the same prosthesis in a single surgeon series. Patients and Methods 170 patients (57 males; 113 females) undergoing TKA were prospectively evaluated. The following data was recorded for each patient: age, gender, primary diagnosis, direction and magnitude of the preoperative axial deformity, BMI, cement use, preoperative and one year Oxford Knee Scores (OKS), the active and passive range of motion (ROM) preoperatively, at the end of surgery and at three month and one year review. Results Average flexion values at each stage were as follows: preoperative (1110), end of surgery (1200), three months (1030) and one year (1070). There was a significant loss of flexion following TKA. The improvement between three months and one year however proved significant. Multiple regression analysis revealed that preoperative flexion was the strongest predictor of one-year flexion. Increasing age was also found to have a significant influence on final flexion. Gender, BMI, pre-operative OKS and cement use had no significant influence on final flexion. Patients tend to migrate towards a middle range of flexion i.e. those with poor flexion gain movement whilst those with good flexion tend to lose motion. Conclusions Preoperative flexion is the strongest predictor of final flexion following TKA

Aim: This study aims to establish whether or not mobile bearing TKR delivers the often stated benefits improved function and range of motion when compared to its fixed bearing equivalent. Methods and Results: A total of 357 patients undergoing TKR were randomly allocated to receive either a Mobile Bearing (181 knees) or a Fixed Bearing (176 knees) PSTKR. Further subrandomisation into patella resurfacing or retention was performed for both designs. All knees were scored using standard tools (Oxford, AKSS and SF12) preoperatively and at intervals postoperatively by independent observers. The range of motion increased from an average of 96 deg. (pre-op) to an average of 109 deg. at 1 year post-op for both the fixed and mobile bearing design. The management of the patella had no effect in either group. The knee society and knee function scores increased equally for both the fixed bearing and mobile bearing knees with no differences noted. Conclusion: There were no measurable differences in range of motion and clinical outcome scores at 1 year post-op for a mobile bearing design over its fixed bearing equivalent. It is likely that any potential advantages of a mobile bearing design will manifest in longevity rather than function

Introduction. There is uncertainty about the relationship between improvement in range of motion (ROM) and functional outcome or patient satisfaction after total hip arthroplasty (THA). Using data from a prospective multi-centre study we investigated this relationship. Methods. We recorded the Oxford Hip Score (OHS), Merle d'Aubigne and Postel score (MDA) and range of motion (ROM) preoperatively and at one and five years and a patient satisfaction questionnaire at five years. Complete 5 year data were available for 342 patients. Results. Improvement in ROM between one and five years was significant but minimal (p=0.005, year 1: mean 191(0–280), year 5: mean 191(70–300). Both absolute ROM (year 1, r=0.27; year 5, r=0.40) and ROM gain (r=0.45, 0.59) had a significant linear correlation (p=0.000). ROM improvement and MDA gain at five years had the best association and predicted 34% of the variability of the model. Absolute and ROM gain both had a linear correlation with OHS gain (p=0.001), but their predictive value was poor. ROM gain predicted OHS gain better than absolute ROM (year 1, r= 0.22 vs 0.10; year 5, r= 0.23 vs 0.09). The strongest association was between ROM gain and OHS gain at 5 years that explained 5% of the variability. There was no difference in absolute or ROM gain between those who were satisfied and not with surgery. Conclusion. There was minimal improvement in ROM after first year. ROM predicted surgeon reported assessment but not patient reported outcome. Relative gain predicted OHS improvement better than absolute ROM but did not affect patient satisfaction. It may be unnecessary to review patients in person to assess ROM after THA

Introduction: Gait analysis studies of patients following ankle arthrodesis have demonstrated a functional gait, largely due to tarsal hypermobility compensating for lost tibio-talar motion. We present a prospective radiographic study comparing the pre and post-operative range of motion of the foot following ankle arthrodesis. In this study, we introduce a radiographic technique using reliable anatomic landmarks to measure sagittal range of motion of the foot after ankle arthrodesis. Materials and Methods: Between 2002 and 2007, we performed 154 arthrodesis procedures of the ankle. Patients were suitable for inclusion in this study if an isolated arthrodesis of the ankle was performed for post traumatic arthritis with a minimum of 1 year follow-up without any additional hindfoot operations. Preoperative and post-operative passive plantar flexion and dorsiflexion radiographs were obtained in a standardized fashion. Anatomic landmarks were then used to measure and compare tibio-talar, mid-tarsal, and subtalar movement. Results: There were 48 patients who met the inclusion criteria for this study. Preoperatively, the mean measured motion was as follows: total sagittal motion 35o, tibio-talar motion18o, mid-tarsal (transverse tarsal + naviculo cuneiform + tarsometatarsal joints) motion 12o (34% of pre-op sagittal arc), subtalar motion 5.5o (15% of pre-op sagittal arc), and mid-tarsal + subtalar motion 17.5o (49% of pre-operative sagittal motion). These changed post operatively to a mean motion as follows: total sagittal motion 18.5o, (52% of preoperative sagittal motion), mid-tarsal motion 10o (28% of pre-op sagittal arc), subtalar motion 10.5o (27% of pre-op sagittal arc), and mid-tarsal + subtalar motion 20.5o (54% of pre-operative sagittal motion). Discussion: This study presents an accurate and reproducible means of measuring the sagittal plane range of motion of the hindfoot and ankle, and documents the presence of increased motion in the subtalar and talonavicular joints after ankle arthrodesis

The 3D interplay between femoral component placement on contact stresses and range of motion of hip resurfacing was investigated with a hip model. Pre- and post-operative contours of the bone geometry and the gluteus medius were obtained from grey-value CT-segmentations. The joint contact forces and stresses were simulated for variations in component placement during a normal gait. The effect of component placement on range of motion was determined with a collision model. The contact forces were not increased with optimal component placement due to the compensatory effect of the medialisation of the center of rotation. However, the total range of motion decreased by 33%. Accumulative displacements of the femoral and acetabular center of rotation could increase the contact stresses between 5–24%. Inclining and anteverting the socket further increased the contact stresses between 6–11%. Increased socket inclination and anteversion in combination with shortening of the neck were associated with extremely high contact stresses. The effect of femoral offset restoration on range of motion was significantly higher than the effect of socket positioning. In conclusion, displacement of the femoral center of rotation in the lateral direction is at least as important for failure of hip resurfacings as socket malpositioning

We hypothesize that tethering adhesions of the quadriceps muscle are the major pathological structures responsible for a limited range of motion in the stiff arthritic knee. Forty-two modified quadriceps muscle releases were performed on 24 patients with advanced osteoarthritis scheduled for total knee arthroplasty. The ranges of motion were documented intraoperatively both before and immediately after the release. Passive flexion improved significantly in all patients (mean, 32.4 degrees of improvement, P < .001) following a modified quadriceps release, despite any presence of osteophytes or severe deformities. These results strongly implicate adhesions of the quadriceps muscle to the underlying femur, which prevent the distal excursion of the quadriceps tendon, as the restrictive pathology preventing deep flexion in patients with osteoarthritis

The human hip capsule is a heterogeneous structure contributing greatly to the stability of this joint. A posterior approach to the hip necessarily sacrifices the ischio-femoral ligament but the decision to release the ilio-femoral and pubo-femoral ligaments remains at the discretion of the surgeon. This mechanical study aims to demonstrate that these anterior capsular structures, when left intact, may limit the external rotational range of motion when the variables of femoral offset, leg length and neck version are adjusted at the time of surgery. A dry bone pelvis-femur model was prepared and registered with the Stryker iNstride Hip Navigation software. A cemented 28 HDPE contemporary cup was inserted at 45° inclination with 20° of anteversion and a revision modular stem implanted in the femoral medullary canal. Artificial ilio-femoral and pubo-femoral ligaments were then prepared from plastinated rubber fabric and mounted in their anatomical positions. Using this model, a range of restoration body sizes was sequentially introduced to vary the offset. The rotational range of motion was then assessed. Repeat measurements were made using + 10mm length bodies across the same offset range. Finally, assessments of rotational range of motion were made using the 19mm body alone while varying neck lengths and degrees of version were trialled. All measurements of external rotation were taken in a position of 0° hip flexion and 0° abduction, as determined using the Stryker iNstride Hip Navigation System. As femoral offset was increased using our model, there was a progressive loss of external rotation. This consistent restriction of external rotation was further accentuated when +10mm length bodies were trialled across the same range of offsets. When a standard 19mm restoration body was placed and a range of heads trialled, it was again found that increasing neck length consistently correlated with a reduction in external rotation. Varying the restoration neck version with a standard head, it was found that increasing retroversion correlated with an increase in the external rotational range of motion. The findings of this mechanical study suggest a progressive limitation of hip external rotation with increasing femoral offset and leg length when the anterior capsular structures are intact. Such findings are of importance in pre-operative planning as they suggest that increases in these variables may significantly limit a patient’s range of external rotation unless the anterior hip capsule is released. Such considerations must of course be balanced against the potential to destabilise the hip if too extensive a soft tissue release is performed. The artificial model used in this study is intended to approximate the human hip and its ligaments. The absolute values for rotational range of motion measured using the Stryker hip navigation system are less significant than the overall trend which they suggest. A patient-based study is now planned to further test these findings

Abstract. Introduction. Persistent medial laxity increases the risk of failure for ACL reconstruction. To address this, multiple reconstruction techniques have been created. To date, no single strand reconstruction constructs have been able to restore both valgus and rotational stability. In response to this, a novel single strand Short Isometric Construct (SIC) MCL reconstruction was developed. Methods. Eight fresh-frozen cadaveric specimens were tested in three states: 1) intact 2) after sMCL and dMCL transection, and 3) after SIC MCL reconstruction. In each state, four loading conditions were applied at varying flexion angles: 90N anterior drawer, 5Nm tibial external rotation torque, 8Nm valgus torque, and combined 90N anterior drawer plus 5Nm tibial external rotation torque. Results. Transection of the sMCL and dMCL resulted in increased laxity with external rotation torque, valgus torque, and combined anterior drawer plus external rotation. SIC MCL reconstruction restored external rotation and valgus stability to intact levels throughout all degrees of flexion. In the combined test SIC MCL reconstruction also restored stability to intact levels for both anterior distraction and external rotation throughout the range of motion. No significant differences were noted between intact and SIC reconstruction. Conclusion. The single-limb short isometric construct (SIC) MCL reconstruction restored native valgus and rotatory stability to a sMCL- and dMCL-deficient knee in biomechanical testing

Introduction: Experimental studies in anatomic full size hip models indicate that larger femoral heads offer potential in providing greater hip range of motion and joint stability. We studied the effects of increasing head diameter from 28mm to 36 mm in total hip replacement (THR) on the range of flexion and abduction. Methods: 243 patients who underwent primary total hip replacement with S ROM prosthesis between July 1996 and June 2004 were studied. 151 patients (77 male and 74 female) underwent THR with 28 mm head and 92 patients (38 male and 54 female) underwent THR with 36 mm head. The range of flexion and abduction were studied and statistical analysis was performed using the Student t-test. We monitored the dislocation rate in both groups. Results: The mean flexion is 87.0 for the 28 mm group and 89.6 for the 36 mm group. The mean abduction is 27.77 and 27.98 for 28mm and 36mm groups respectively. Even though there is a slight increase in the mean flexion and abduction from the 28mm to 36mm group, this increase in not found to be statistically significant. For flexion (2.6 (−0.85 to 3.2); p=0.377), and for abduction (0.02 (−2.37 to 1.94); p=0.847). Three hips dislocated in the 28mm group (2%) but none of the hips in 36mm group has dislocated. Discussion: Even though experimental studies indicate improvement in range of motion with increasing head diameter in THR, this effect is not reflected in our clinical study. But there is improvement in the joint stability by using a prosthesis with larger head diameter as evidenced by a reduction in the dislocation rate

Distal radius fractures (DRF) are the most common fracture type in all age groups combined. Unstable DRF may be surgically managed with volar or dorsal plate fixation. Dorsal plating has traditionally been associated with decreased range of motion (ROM). However, this assumption has not been recently assessed to determine whether functional ROM is achievable (approximately 54o of flexion and 60o of extension) with recent advances in lower profile dorsal plate design. The aim of this study was therefore to compare ROM and patient reported outcome measures between volar and dorsal plating methods for DRF. A meta-analysis was performed to directly compare ROM and DASH scores between dorsal and volar plate fixation for DRF. Separate literature searches for each plating method were performed using MedLine and EMBase on January 28, 2018. Exclusion criteria consisted of non-English articles, basic science articles, animal/cadaver studies, case studies/series, combined operative approaches, papers published more than 20 years ago and paediatric studies. Only articles with at least one year patient follow-up and a) ROM and AO distal radius fracture classification, or b) DASH scores were included. Raw data was extracted from all articles that met inclusion criteria to compile a comprehensive dataset for analysis. Descriptive statistics with z-score comparison for AO classification or a two-tailed independent samples t-test for ROM and DASH scores for dorsal versus volar plating were performed. Significance was defined as p < 0 .05. After rigorous screening, 6 dorsal plating and 43 volar plating articles met inclusion criteria for ROM/AO classification versus 6 dorsal plating and 44 volar plating articles for DASH scores. The weighted means of flexion (dorsal 54.9o, SD 9.3, n=257, volar 61.3o, SD 11.5, n=1906) and extension (dorsal 60.0o, SD 12, n=257, volar 62.8o, SD 11.4, n=1906) were statistically significantly different (both p < 0 .001) between the two plating methods. The volar plating group had a significantly higher proportion of AO type C fractures (dorsal 0.5, n =169, volar 0.6, n=1246, p < 0 .001). The weighted means of reported DASH scores were not significantly different between dorsal (14.01, SD 14.8) versus volar (13.6, SD 12.8) plating (p=0.54). Though mean wrist flexion and extension were statistically different between the dorsal versus volar plating methods, the difference between group means was less than 5o, which is unlikely to be clinically significant. Additionally, we did not find a significant difference in DASH scores between the two plating methods. Taken together, these findings imply that the statistical difference in ROM outcomes are likely not clinically significant and should therefore not dictate choice of plating method for fixation of DRF

Introduction: Experimental studies in anatomic full size hip models indicate that larger femoral heads offer potential in providing greater hip range of motion and joint stability. We studied the effects of increasing head diameter from 28mm to 36 mm in total hip replacement (THR) on the range of flexion and abduction. Methods: 243 patients who underwent primary total hip replacement with S ROM prosthesis between July 1996 and June 2004 were studied. 151 patients (77 male and 74 female) underwent THR with 28 mm head and 92 patients (38 male and 54 female) underwent THR with 36 mm head. The range of flexion and abduction were studied and statistical analysis was performed using the Student t-test. We monitored the dislocation rate in both groups. Results: The mean flexion is 87.0 for the 28 mm group and 89.6 for the 36 mm group. The mean abduction is 27.77 and 27.98 for 28mm and 36mm groups respectively. Even though there is a slight increase in the mean flexion and abduction from the 28mm to 36mm group, this increase in not found to be statistically significant. For flexion (2.6 (−0.85 to 3.2); p=0.377), and for abduction (0.02 (−2.37 to 1.94); p=0.847). Three hips dislocated in the 28mm group (2%) but none of the hips in 36mm group has dislocated. Discussion: Even though experimental studies indicate improvement in range of motion with increasing head diameter in THR, this effect is not reflected in our clinical study. But there is improvement in the joint stability by using a prosthesis with larger head diameter as evidenced by a reduction in the dislocation rate

Aim: To study the outcome of the total excision of the clavicle focusing on the mobility of the upper limb. Material and Method: We performed total claviculectomy in five patients with a neoplasm of the clavicle. This operation is requiring because there is a high risk of severe neurovascular damage due to the close vicinity of major neural and vascular elements. The growth was always excised en block with the clavicle to avoid local recurrence. Specimens were sent for histology, microbiology and genetic studies. Results: Our patients had no complications so they could start rehabilitation soon. An abnormal scapular rhythm was noticed during shoulder abduction but normal motion was restored with exercises. The patients restored normal shoulder range of motion, they had no pain and there was no cosmetic problem. All patients were found and examined after 38±24 months. They maintained the excellent initial result and all they had returned to their former jobs and activities. Discussion and Conclusions: Surgery for primary tumors of bone aims on the patient’s survival and on the sparing of a functioning limb. Any skepticism about total cla-viculectomy is not justified as this procedure, often followed by adjuvant treatments, gives the patient a chance to save his life while exercise helps restoring the normal mobility and function of the upper limb. The clavicle provides the insertion fields for several muscles, suspends and supports the arm. Our cases show that this bone is an accessory to the skeleton and its absence does not cause any functional problems

Background. Patient satisfaction after total knee arthroplasty (TKA) has been lower than after a similar procedure, total hip arthroplasty. Poor subjective outcomes after TKA may be partially explained by abnormal kinematics patterns after TKA. The purpose of this study was to analyse rotational kinematics patterns in knees that had undergone posterior stabilized (PS)-TKA, and to clarify the relationships between rotational kinematics patterns and patient satisfaction, as well as between rotational kinematics patterns and knee function. Materials & Methods. A total of 49 osteoarthritis knees after primary PS-TKA (NexGen LPS-Flex fixed bearing knee system) were included in this study; deformed valgus, severe flexion contractures, and highly unstable knees were excluded. We used a computer navigation system and measured knee kinematics after each surgery was completed. A single investigator gently applied a manual range of motion from full extension to flexion. The angle of the internal rotation of the tibia was measured automatically at 0º, 30º, 45º, 60º, and 90º, along with maximum extension and flexion. We categorized the post-operative rotational kinematics patterns for individual cases, focusing on the initial knee flexion from 0–30º. Type A corresponded to an increased internal rotation angle of the tibia during the initial knee flexion (screw home-like movement). Type B corresponded to an increased external or an unchanged rotation angle of the tibia. We examined the range of motion (ROM) at 6 months after surgery and assessed the 2011 Knee Society Score (2011 KSS) at ≥1 year following surgery. Statistical analysis. The difference between the two groups was compared using a Wilcoxon rank sum test. Analyses were performed with JMP statistical software v8.0 (SAS Institute). A p-value of <0.05 was regarded as significant. Results. The tibia exhibited an average of 5º of internal rotation at initial knee flexion. The type A kinematics pattern achieved a better ROM and functional activity score (2011 KSS) than the type B kinematics pattern. Discussion. Modern TKA implants have been designed to reproduce normal knee kinematics to achieve better patient satisfaction and knee function. However, few reports have described the relationship between the rotational kinematics patterns at initial knee flexion and patient satisfaction. In our study, the type A postoperative rotational kinematics pattern (screw home-like movement) had better ROM and functional activity score than the type B kinematics pattern. The movement toward the internal rotation of the tibia during initial knee flexion might be important in achieving better clinical results after PS-TKA

Introduction:. Implant dislocations are often caused by implant or bone impingement, and less impingement is critical to prevent dislocations. Several reports demonstrated that greater femoral offset delayed bony impingement and led to an improved range of motion (ROM) after THA. Therefore, an increase in the femoral offset may improve ROM and decrease implant dislocation. The aim of this study was to clarify the effect of the femoral offset in avoiding component or bony impingement after total hip arthroplasty (THA). Methods:. Seventy-eight patients underwent THA with a Pinnacle cup and Summit stem (DePuy). Intraoperative kinematic analysis was performed with a navigation system, which was used to obtain intraoperative range of motion (ROM) measurements during trial insertion of stems of 2 different offset lengths with the same head size. Further, ROM was also measured after actual component insertion. Results:. Maximal ROM was independent of the femoral offset of the stem in each patient (Figure 1). Further, we measured the intraoperative maximal ROM corresponding to high offset stems of 2 different lengths (stem sizes 1–3; + 6 mm, stem sizes 4–9; +8 mm), and compared the maximal ROMs between the standard- and high-offset stems. There were no statistically significant differences (Figure 2). These results indicate that an excessive offset length of the stem may not affect ROM. We also analyzed the correlation between femoral offset length and ROM, and found that the range of external rotation was significantly greater in patients with greater femoral offset (RR = 0.36, P = 0.02) (Figure 3). However, we could not show any correlation for the ROM values in the other planes of motion. Discussions:. Summit stem is available in 9 different sizes with standard offset lengths ranging from 36.0 mm to 44.0 mm. The average offset of Summit stem was larger than other stems. These differences in offset length could be the reason why the high offset stem did not change maximal ROM in our study. Further, the summit stem employs 2 different types of high offset lengths (+6 mm and +8 mm). We did not find any difference in maximal ROM even after using the +8 mm high offset stem. Our results indicated that even the Summit standard offset stem might have enough femoral offset to avoid implant/bone impingement. However, several reports showed that increasing stem offset increased the bending moment on the prosthesis and increased the strain in the medial cortex, and may lead to early failure of the femoral component. Nevertheless, selection of the offset stem should be performed carefully to prevent offset complications

Four-Corner Fusions (4CF) and Proximal Row Carpectomies (PRC) are common procedures utilized to treat carpal pathologies and radial sided wrist pain. Usually, the range of motion (ROM) and grip strength (GS) is affected by such conditions. Literature quotes significant reduction in ROM (50–60%) and grip strength (GS) (80% of normal) with PRC and 4CF. This study aims to determine the correlation between pre-operative ROM and GS and post-operative ROM and GS for patients with wrist pain undergoing PRC or 4CF. We hypothesize that ROM between pre-operative and post-operative patients does not change, but GS improves. Data from a prospective database of patients with wrist pain was searched to identify patients who have undergone PRC or 4CF with one year follow-up completed in the past two years. 17 such participants were identified. The diagnosis, pre-operative ROM in flexion, extension, radial deviation, ulnar deviation, pronation and supination, as well as GS at time of surgery and at six months and one year follow up were identified and assessed. The data was analysed to determine correlation between pre-and postoperative ROM and GS. The analysis was subdivided to compare patients treated with PRC versus patients with 4CF. No significant difference between pre- and post-operative ROM was detected, except in flexion at 6 months post-operatively. The average flexion was significantly lower at 6 months (p=0.0251) compared to pre-operative levels. Average flexion pre-operatively and at 6 and 12 months was found to be 46.6 (SD=15), 34.3 (SD=13.3), 51.2 (SD=21.5) respectively. Extension was at 41.4 (SD=15.3) pre-operatively and at 33.4 (SD=12.8) and 42.1 (SD=15.5) at 6 and 12 months post-operatively. Similarly, radial and ulnar deviation averages pre-operatively and at 6 and 12 months post-operatively were found to be 11.33 (SD=5.9), 11.9 (SD=4.5), 16 (SD=8.2) [radial deviation] and 24.1 (SD=8.3), 21.4 (SD=7.3), 26 (SD=12.8) [ulnar deviation]. No significant difference was found in GS at 6 months post-operative. However, significant difference at 12 months post-operatively was observed with an average GS of 28.4 kg (SD=12.8) [p=0.0385]. Average GS pre-operatively and at 6 months was 15.8 kg (SD=9.7) and 17.3 kg (SD=8.9) respectively. This study provides an insight on ROM and GS after PRC and 4CF. It shows that patients do not gain or lose ROM after surgery. As expected, GS improves with treatment as the pain diminishes. It is interesting to note that flexion gets worse at 6 months post-operatively before it bounces back to pre-operative levels

In this prospectively randomized study, we compared the changes in the range of motion (ROM) in posterior cruciate ligament-retaining (PCLR) (n=50) and -sacrificing (PCLS) (n=50) total knee arthroplasties during the perioperative period. The median ROM in PCLR prostheses was 122.5° preoperatively, 120.0° intraoperatively, and 100.0° at discharge, and 115.0°, 120.0°, and 95.0°, respectively, in PCLS. The designs did not differ statistically in each period (p> 0.05). Both designs showed significant correlations between the preoperative and intraoperative ROM, and between the preoperative and discharge ROM. Only the PCLS showed a significant correlation between the intraoperative and discharge ROM. Since the PCL tenses with flexion, the degree of preoperative degeneration, intraoperative recession, and postoperative tension of the PCL may have played a major role in the results. The PCLS design has an advantage in rehabilitation planning because of the predictable changes in the ROM during the perioperative period, although the acquired average ROM at discharge did not differ statistically

Introduction: ROM after TKA can be influenced by multi-factors such as preoperative range of motion, body habitus, implant design, intraoperative surgical technique, and postoperative rehabilitation. Recently many implant manufacturers have made modifications to traditional total knee designs to improved maximal knee flexion and range of motion. Some posterior cruciate ligament (PCL) stabilized total knee prostheses that incorporate design features intended to improve knee kinematics in high flexion were introduced and the use of these prostheses has attracted attention. Recently in the cruciate retaining (CR) prosthesis, high-flexion knee (CR-Flex) and gender-specified prosthesis were designed to allow a greater and safer flexion after TKA. The aim of this study was to evaluate the effect of cruciate retaining typed different femoral component design on knee range of motion using a computerized navigation system. Materials & method: 30 patients who underwent primary TKA because of primary osteoarthritis were included. EM navigation system was used in all cases. After tibia and femoral cutting using standard CR cutting block, standard fixed bearing CR knee (NexGen CR, Zimmer, Warsaw, IN) trial was inserted. If surgeon is satisfactory with alignment, stability and ligament balancing, the maximal knee extension and flexion was recorded using gravity by navigation system. Then, high-flexion fixed bearing CR knees(NexGen CR-Flex and Gender solution NexGen CR-Flex knee, Zimmer, Warsaw, IN) trial was inserted after additional posterior cutting. The maximal knee extension and flexion was evaluated exactly same way. Results: Preoperative mean varus deformity was 10.52°. The mean flexion contracture was 7.52±6.81° and further flexion 129.9±7.94°. The average intraoperative maximal flexion of NexGen CR was 133.5±5.35° (125–146°) and that of hyper-flexion design were 135.5±5.77°(125–147°) in Nexgen CR-Flex and 136.1±5.76°(126–146°) in Gender knee. All knees showed greater than 125° of flexion regardless of the implant design. All knees can achieve physiologic leg alignment and nearly full extension of the knee after operation. Conclusion: Hyper flexion designs showed subtle increase in mean maximal flexion and overall range of motion of the knee compared with the standard design, when it measured using navigation system intraoperatively. But clinically, it is not certain that these differences can lead to significant improvement of range of motion

The aim of this study was to investigate the pre-operative factors predicting the knee range of motion during stair ascending and descending a year after total knee arthroplasty. The pre-operative and one year post-operative results of fifty six patients with osteoarthritis were analysed. Range of knee motion during stair ascent and descent was recorded using electrogoniometry. Pre-operative measures were grouped in three different domains; the Demographic Domain with age and Body Mass Index (BMI), the Body Function Domain with knee range of motion in long sitting (ROMsit), Knee extensor moment, Pain on a Visual Analogue Scale and the stiffness component of the Western Ontario McMaster University Osteoarthritis Index (WOMAC) and thirdly the Psychosocial Domain with the Tampa scale for ‘fear of movement’ (TSK) and the sense of helplessness due to pain. Hierarchical Multiple Regression was used to analyse the relative importance of measures grouped into the three domain blocks on range of motion of the operated knee during stair ascent and descent. Model 1 contained domain block 1, model 2 included domain blocks 1 and 2 and model 3 included domain blocks 1,2 and 3. Learned helplessness was a significant predicting factor for stair descent (beta; −0.538, p=0.025) while for stair ascent, age (beta 0.375, p=0.005) and ROMsit (beta 0.365, p=0.021) were significant predicting variables. These results show that postoperative stair ascent and descent are predicted by different pre-operative factors. For stair ascent the demographic factors age and function factor ROM are important, while for stair descent, only the addition of the psychosocial factors in model 3 resulted in a significant change. These results indicate that treatment of patients with end-stage osteoarthritis should not only be aimed at improving range of motion of the knee but should also take into account psychosocial variables such as a sense of helplessness due to pain

Introduction: A femoral stem with a modular neck can optimize the range of motion (ROM). The hip’s maximal rotational ranges were evaluated with three different modular neck versions. Methods: This study included 52 primary implantations of a short cementless anatomical modular stem using navigation control. ROM was measured using the sagittal femoral and the anterior pelvic plane as references. Once the cup and stem were implanted, three different neck versions (retroverted: −7°, neutral: 0, and anteverted: +7°) were used. A dynamic test measured the maximal ROM for each patient and neck version. Simultaneously, the surgeon evaluated the stability and the absence of posterior impingement. Results: The average rotational range in extension was 72° for a retroverted neck, 71° for a neutral neck and 76° for an anteverted neck. This difference was not clinically significant. The equilibrium of the rotational ranges appeared better with a retroverted neck (average center: −6°) than with a neutral neck (average center: −8°) or an anteverted neck (average center: −13°) (p< 0,001). The equilibrium of the rotational range correlated with the femoral stem anteversion (r=−0.70, p< 0.001) and with the combined anteversion (r=−0.74, p< 0.001). Finally, an anteverted neck was used in 3 cases, a neutral neck in 25 cases and a retroverted neck in 24 cases. The surgeon’s final neck version choice obtained the best equilibrium in 60% of cases. Discussion/Conclusion: The study showed that balancing the hip rotational ranges may be a helpful operative test when choosing a modular neck without a navigation system

Distal radius fractures (DRF) are the most common fracture type in all age groups combined. Unstable DRF may be surgically managed with volar or dorsal plate fixation. Dorsal plating has traditionally been associated with decreased range of motion (ROM). However, this assumption has not been recently assessed to determine whether functional ROM is achievable (approximately 54 degrees of flexion and 60 degrees of extension) with recent advances in lower profile dorsal plate design. The aim of this study was therefore to compare ROM and patient reported outcome measures between volar and dorsal plating methods for DRF. A meta-analysis was performed to directly compare ROM and Disabilities of Arm, Shoulder and Hand (DASH) scores between dorsal and volar plate fixation for DRF. Separate literature searches for each plating method were performed using MedLine and EMBase on January 28, 2018. Exclusion criteria consisted of non-English articles, basic science articles, animal/cadaver studies, case studies/series, combined operative approaches, papers published more than 20 years ago and paediatric studies. Only articles with at least one year patient follow-up and a) ROM and AO-OTA distal radius fracture classification, or b) DASH scores were included. Raw data was extracted from all articles that met inclusion criteria to compile a comprehensive dataset for analysis. Descriptive statistics with z-score comparison for AO-OTA classification or a two-tailed independent samples t-tests for ROM and DASH scores for dorsal versus volar plating were performed. Significance was defined as p < 0 .05. After rigorous screening, six dorsal plating and 43 volar plating articles met inclusion criteria for ROM/AO-OTA classification versus six dorsal plating and 44 volar plating articles for DASH scores. The weighted means of flexion (dorsal 54.9 degrees, SD 9.3, n=257, volar 61.3 degrees, SD 11.5, n=1906) and extension (dorsal 60 degrees, SD 12, n=257, volar 62.8 degrees, SD 11.4, n=1906) were significantly different (both p < 0 .001) between the two plating methods. The volar plating group had a significantly higher proportion of type C fractures (dorsal 0.5, n =169, volar 0.6, n=1246, p < 0 .001). The weighted means of reported DASH scores were not significantly different between dorsal (14, SD 14.8) versus volar (13.6, SD 12.8) plating (p=0.54). Though mean wrist flexion and extension were statistically different between the dorsal versus volar plating methods, the difference between group means was less than 5-degrees, which is unlikely to be clinically significant. Additionally, there was no significant difference in DASH scores between the two plating methods. Taken together, these findings imply that the statistical difference in ROM outcomes are likely not clinically significant and should therefore not dictate choice of plating method for fixation of DRF

We sought to validate a method of measuring the range of motion of knees on radiographs as part of a new system of “Virtual Knee Clinics”. The range of motion of 52 knees in 45 patients were first obtained clinically with goniometers and compared to radiographs of these patients' knees in full active flexion and extension. Four methods of plotting the range of motion on the radiographs were compared. The intra-class correlation coefficient (ICC) for inter-rater reliability using the goniometer was very high; ICC=0.90 in extension and 0.85 in flexion. The best ICC for radiographic measurement in extension was 0.86 indicating substantial agreement and best ICC in flexion was 0.95 (method 4). ICC for intra-rater reliability was 0.98 for extension and 0.99 for flexion on radiographic measurements. Measuring range of motion of the knee has never previously been validated in the literature. This study has allowed us to set up a “Virtual Knee Clinic,” combining postal questionnaires and radiographic measurements as a surrogate for knee function. We aim to maintain high quality patient surveillance following knee arthroplasty, reduce our new to follow-up ratios in line with Department of Health guidelines and improve patient satisfaction through reduced travel to hospital outpatients

Purpose of the study: The theoretical advantage of a disc prosthesis compared with fusion is to preserve spinal mobility. The purpose of our study was to determine the relationship, at nine years follow-up, between range of motion and clinical outcome after lumbar disc replacement. Material and methods: This retrospective analysis concerned the clinical and radiographic outcome observed in 38 patients who had undergone one- or two-stage disc replacement surgery (51 implanted prostheses). Mean follow-up was 8.6 years (range 6.9–10.7). Clinical outcome was assessed with the Stauffer-Coventry modified score (SCM), the Oswestry score (ODQ) and a visual analog scale (VAS) for lumbar and radicular pain. Flexion-extension range of motion (ROM) was measured on the upright films (Cobb method) at last follow-up. Each clinical element was compared with the ROM (Spearman coefficient of correlation). Two groups of patients were distinguished: high (> 5°) and low ≤ 5°) ROM for comparison with the Mann-Whitney test. Results: The Spearman coefficient of correlation disclosed a weak to moderate but statistically significant association between ROM, lumbar VAS (r=−0.35, p=0.034), ODQ (r=−0.33, p=0.046), SCM (r=0.42, p=0.0095); but no significant correlation between ROM and radicular VAS (r=−0.12,p=0.48). Patients with greater ROM had better clinical results and ODQ (mean difference 6.3 points, p=0.031) and SCM (mean difference 2.2 points, p=0.017); but no significant difference between the preoperative characteristics in each group (age, sex, weight, surgical history, lumbar and radicular pain, ODQ and SCM). Discussion: There are no data in the literature comparing range of motion and clinical outcome after lumbar disc replacement. The present study demonstrated a weak to moderate but statistically significant relationship (r=0.35) between range of flexion-extension motion and clinical outcome at nine years. In addition, patients with lesser ROM (< 5°) have slightly less favorable results compared with those with greater ROM (> 5°). This study suggests the preservation of motion has a positive effect on mid-term clinical outcome. Conclusion: These results need to be confirmed with long-term prospective data comparing discal prosthesis with fusion and non-surgical treatment in order to demonstrate the usefulness of preserving motion on the quality of the clinical outcome

Background Context: Total disc replacement (TDR) gained enormous popularity as a treatment option for symptomatic degenerative disc disease in the last few years. But the impact of the prosthesis design on the segmental biomechanics in most instances still remains unclear. As TDR results in a distraction of the capsuloligamentous structures, the disc height seems to be of crucial importance for the further biomechanical function of the operated level. Yet the biomechanical role of disc height after TDR still remains unclear. Purpose: The purpose of study was to evaluate the influence of prosthesis height after total disc replacement on: 1) the sagittal balance and 2) the range of motion. Study design: A radiological and an in-vitro biomechanical study. Method: 6 human, lumbar spines L4–L5 were tested in vitro.The segmental lordosis of the specimen were measured on plain radiographs and the range of motion was measured for all six degrees of freedom with a previously described spine tester. The segmental lordosis and the range of motion at level L4–L5 was evaluated for following settings: 1) intact state 2) after implantation of a prosthesis with 5mm endplate 3) after implantation of a prosthesis with 7mm endplate. The prosthesis used was a prototyp and had a constrained design with a ball and socket principle. Results: Even the implantation of the lowest possible prosthesis height (5mm endplate) resulted in an increase of segmental lordosis (intact: 6.9; 5mm endplate: 8.8; p=0,027). Using a higher prosthesis (7mm endplate) further increased the segmental lordosis (10.5, p=0.041). The implantation of the lowest prosthesis resulted in significant increase of movement capability compared to the intact status for flexion-extension (8.6 vs 11.4; p=0.046) and axial rotation (2.9 vs 5.1; p=0.028). Lateral bending did not changed significantly (9.4 vs 8.6; p=0.345). The implantation of the higher prosthesis (7mm endplate) resulted in similar movement capability compared to intact status for flexion-extension (8.4 vs 8.6; p=0.116) and axial rotation (3.3 vs 2.9; p=0.600). Lateral bending decreased significantly compared to the intact status (5.1 vs 8.6; p=0.028). Conclusion: Total disc replacement with the lowest prosthesis height inherently increases segmental lordosis. Further increase of disc height results in a significant enhancement of segmental lordosis by decreasing the range of motion for all three degrees of freedom. Yet, methods for scheduling the ideal disc height preoperatively, to provide a physiological lordosis thereby maintaining physiological range of motion postoperatively, seems not to be established already

Background. With the projected 673% increase in total knee arthroplasties (TKA) through the year 2030 in the United States alone, arthrofibrosis will become one of the more commonly encountered challenges in orthopaedic surgery. Methods. After obtaining Institutional Review Board approval we retrospectively reviewed the results of 19 patients with a mean age at the time of surgery of 55.4 years (41–83) who underwent arthroscopic lysis of adhesions (ALOA) for arthrofibrosis at a minimum of 3 months after primary total knee arthroplasty by a single surgeon (SJC) at a single institution. All patients underwent a standardized adhesiolysis in the operating room. All patients had a minimum of 6 months follow up. All patients underwent arthroscopic lysis of adhersions for restricted range of motion (ROM) after failing aggressive physical therapy. We defined restriction in ROM as any extension lag >5°, and flexion ≤90°. Eight patients underwent manipulation under anesthesia for ROM less than 90° after ALOA. Results. Preoperative ROM was compared to ROM measured at most recent follow up. The mean knee arc of motion improved by 17° (p=0.0402), the mean flexion arc improved from 17° (p=0.0263) and the number of patients with flexion less than or equal to 90° decreased from 13 patients to 6 patients (p=0.0049). There were no patients that required polyethylene exchange, no periprosthetic joint infections or intraoperative fractures and no patients who suffered deep vein thrombosis as a result of the procedure. Conclusion. We conclude that arthroscopic lysis of adhesions for treatment of arthrofibrosis after total knee arthroplasty is a safe and effective way to improve post-operative range of motion

Reverse total shoulder replacement is a viable surgical option for Cuff Tear Arthropathy. Short term results have been promising. Longer term follow-up has demonstrated a high rate of scapular notching. This is attributed to mechanical impingement between the humeral cup and scapular neck when the arm is fully adducted. The long term sequelae of scapular notching are unclear but there is concern that it may compromise fixation of the glenoid component and affect functional outcomes. Design modifications to address this problem include the newly available eccentric glenospheres and larger diameter glenospheres. These glenospheres are designed to offer greater ranges of motion and theoretically may reduce the risk of impingement and notching. The purpose of this biomechanical study is to demonstrate the difference in range of motions with each design of glenosphere. To our knowledge there is no published literature evaluating this design differences. The SMR (Lima Orthotec) reverse total shoulder prothesis was implanted into a synthetic bone model (Sawbones, Pacific Laboratories, Vashon, Washington). Four different types of glenospheres (Standard 36 mm, Eccentric 36 mm, Standard 44 mm, Eccentric 44 mm) were then implanted into the same model which was fixed on a measurement table. The precision coordinate measurement device (FARO-Arm, SO6/Rev22, FARO Technologies Inc., Lake Mary, Florida) was used to establish the centres of rotation and ranges of motion. To date, the collection of data has just been completed, but the data are yet to be analysed. In conclusion, this is a biomechanical study evaluating the ranges of motion and risk of notching, comparing different designs of glenospheres in Reverse Total Shoulder Joint Replacement

Abstract. Introduction. Historic MCL reconstruction techniques focused on the superficial MCL to restore valgus stability while overlooking tibial external rotation and the deep MCL. This study assessed the ability of a contemporary medial collateral ligament (MCL) reconstruction and a deep MCL (dMCL) reconstruction to restore rotational and valgus knee stability. Methods. Six pairs fresh-frozen cadaveric knee specimens with intact soft tissue were tested in four states: 1) intact 2) after sMCL and dMCL sectioning, 3) contemporary MCL reconstruction (LaPrade et al), and 4) dMCL reconstruction. In each state, four loading conditions were applied at varying flexion angles: 8Nm valgus torque, 5Nm tibial external rotation torque, 90N anterior drawer, and combined 90N anterior drawer plus 5Nm tibial external rotation torque. Results. Transection of the sMCL and dMCL resulted in increased laxity with valgus torque, external rotation torque, and combined anterior drawer plus external rotation. dMCL reconstruction restored external rotation stability to intact levels throughout all degrees of flexion but did not restore valgus stability at any flexion angle. Contemporary MCL reconstruction restored valgus and external rotation stability at 0° and 20° and valgus stability at 40°. In the combined anterior drawer plus tibial external rotation trial, the dMCL restored stability at 20° and improved stability between 40° and 90° flexion. Conversely, the contemporary MCL reconstruction did not restore stability at any degree of flexion. Conclusion. Deep MCL reconstruction restored rotational stability to the knee throughout range of motion but not valgus stability. The contemporary MCL reconstruction restored stability only near full extension

Introduction. Several reports demonstrated the overcoverage of the anterior acetabulum. Anterior CE angle over 46°may be a probable risk factor for pincer FAI syndrome after a rotational acetabular osteotomy. In addition, a highly anteverted femoral neck, reported as a risk factor for posterior impingement, has been found in DDH patients. These findings indicate proper acetabular reorientation is essential to avoid anterior or posterior impingement after periacetabular osteotomy (PAO). The aim of this study was to evaluate the relationship between acetabular three-dimensional (3D) alignment reorientation and clinical range of motion (ROM) after periacetabular osteotomy (PAO). Methods. A total of 53 patients who underwent curved PAO (CPO) for DDH from January 2014 to April 2017 were selected. Three (5.7%) of them were lost to follow-up. Therefore, the data from 58 hips, contributed by 50 patients (44 women and 6 men), were included in the analysis. Pre- and postoperative computed tomography (CT) scans from the pelvis to the knee joint were performed and transferred to a 3D template software (Zed Hip; Lexi, Tokyo, Japan). The pelvic plane axis was defined according to the functional pelvic plane. The pre- and postoperative lateral and anterior 3D center-edge (CE) angles were measured on the coronal and sagittal views through the center of the femoral head. The pre- and postoperative 3D center-edge (CE) angles and femoral anteversion were measured and compared with clinical outcomes, including postoperative ROM. Results. The radiographical outcomes of our study are demonstrated in Figure 1. The mean values of pre- and postoperative lateral CE angles were 12.6º±8.7 and 30.2º±9.7, respectively (p<0.001), and mean pre- and postoperative anterior CE angles were 42.4º±15.3 and 63.9º±12.1, respectively (p<0.001). Both CE angles were significantly improved. The correlation between pre- and postoperative acetabular coverage and postoperative ROM was evaluated. Postoperative abduction and internal rotation ROM were significantly associated with postoperative lateral CE angles (abduction; p < 0.001, internal rotation; p = 0.028); flexion and internal rotation ROM was significantly associated with postoperative anterior CE angles (flexion; p < 0.001, internal rotation; p = 0.028). Femoral anteversion was negatively correlated with postoperative abduction (p = 0.017) and external rotation (p = 0.047) ROM (Table 1). Postoperative abduction ROM was strongly positively correlated with femoral anteversion, whereas postoperative external rotation was strongly negatively correlated (Table 2). The total anteversion was strongly correlated with pre- or postoperative ROMs during flexion and internal rotation ROM (Table 2). Conclusion. Postoperativeanterior acetabular coverage may affect internal rotation ROM more than the lateral coverage. Therefore, the direction of acetabular reorientation should be carefully determined according to 3D alignment during PAO. For any figures or tables, please contact the authors directly

Introduction. Arthrofibrosis following total knee arthroplasty (TKA) is a complex and multifactorial complication that may require manipulation under anesthesia (MUA). However, patient and surgical factors that potentially influence the development of knee stiffness following TKA are not fully understood. The purpose of this study was to identify patient and surgical factors that may influence arthrofibrosis following TKA by assessing a cohort of patient that underwent MUA and comparing them to a matched cohort of patients without arthrofibrosis. Methods. The joints registry of a university hospital was searched for patient that underwent MUA following primary TKA between 2004 and 2013. Demographic and surgical information was obtained from the electronic medical record including range of motion (ROM), comorbidities and timing of MUA. Patients who underwent MUA were then double-matched by baseline (prior to primary TKA) knee ROM to patients who underwent primary TKA without postoperative arthrofibrosis during the same time period. Results. Fifty-two patients (56 TKAs, 71% female, mean BMI 32.2kg/m2) underwent MUA after TKA during the study period. MUA was performed a mean of 13.6 weeks after primary TKA. Study patient were then double-matched by baseline flexion (mean 107º±2º) to 111 patients (112 TKAs) with a similar mean baseline flexion (104º±2º, p=0.138). Patient requiring MUA were younger (mean age 56 vs. 64 years, p<0.001), had more comorbidities (5 vs. 3, p<0.001), and a higher number of previous knee surgery (56% vs. 21%, p<0.001) compared with controls. The risk for requiring MUA following primary TKA was significantly higher (2.4, p<0.001) in patient with previous knee surgery (arthroscopy for meniscal pathology, ACL reconstruction, osteotomies). Tourniquet time, length of stay, number of physical therapy sessions, blood loss >50 mL and any complication during the hospital stay were not found to be associated with increased risk of requiring MUA. Discussion. Younger patients with more comorbidities and a history of previous knee surgery were found to have significantly higher risk for developing arthrofibrosis and requiring MUA after primary TKA in the current study. Patients with this risk profile need to counseled regarding the risk for arthrofibrosis possibly requiring MUA after primary TKA

Background:. Few clinical hip score include toe-reach motion after THA (put-on-socks, nail-cutting). Some reports have shown whether THA patients can put on socks or not in daily activity, and not shown how they can do it. The purpose of this study is to investigate real pattern of put-on-socks motion in daily activities after THA, and to evaluate safe range of motion for prevention of hip dislocation. Materials and Methods:. Reviewing clinical chart, we investigated highly frequent pattern in wearing socks motion that would cause hip dislocation in ADL in 100 patients with normal lower extremities except for hip joint more than one year after THA, then, we classified the motion pattern. Using an optical 3-D motion analysis (MAC3D system, Motion Analysis, USA), we measured necessary angle of the hip in 10 THA subjects (mean age at operation 61 years old) one year postoperatively, while the patients make such frequent patterns of movement as above. Simultaneously, individual 3-dimensional skeletal model was reconstructed from CT data and implant CAD data. Driving 3-D skeletal model combined with motion analysis data on display (Zed Hip, LEXI), we calculated angle from posture that hip flexion angle was maximum during wearing-socks motion to impingement point (implant and/or bone) for each direction. ALL joint angle was defined as “zero” in supine position. Results:. Resulting from clinical chart, high incident pattern of the motion was “Leg raising pattern” (26%), and “Trunk flexion pattern” (23%) (Figure 1). For above two pattern of the socks-wearing motion, 3-D motion analysis showed that maximum hip flexion angle was 85 ± 13 degrees for leg raising pattern, 88 ± 14 degrees for trunk flexion pattern. Hip angle of abduction/adduction or external/internal rotation was within mean 15 degrees during each motion. 3-D model simulation combined with motion data showed that 39 ± 15 degrees, 33 ± 9.7 degrees for direction of hip flection, 34 ± 17 degrees, 32 ± 11 degrees for direction of hip adduction and 78 ± 21 degrees, 51 ± 21 degrees for direction of hip internal rotation from posture on maximum hip flexion angle to impingement point for each motion, respectively. All cases showed safe range of more than 20 degrees for all direction and impingement occurred between cup and stem in all cases (Figure 2, 3). Discussion:. Recently, there have been trend to decrease limitation of motion in ADL after THA. Safe range of motion without impingement have been enlarged resulting from development of implant design, proper alignment and operative technique. This study showed safe range without impingement in frequent socks-wearing pattern in daily living among THA patients one year after surgery. More research for motion in ADL can lead to remove postoperative restrictions in THA patients

Currently, the consensus regarding subscapularis tendon repair during a reverse total shoulder arthroplasty (rTSA) is to do so if it is possible. Repair is thought to decrease the risk of dislocation and improve internal rotation but may also increase stiffness and improvement in internal rotation may be of subclinical benefit. Aim is to retrospectively evaluate the outcomes of rTSA, with or without a subscapularis tendon repair.

We completed a retrospective review of 51 participants (25 without and 26 with subscapularis repair) who received rTSR by a single-surgeon using a single-implant. Three patient reported outcome measures (PROM) were assessed pre-operatively and post-operative at twelve months, as well as range of movement (ROM) and plain radiographs. Statistical analysis utilized unpaired t tests for parametric variables and Mann-Whitney U test for nonparametric variables.

External Rotation ROM pre-operatively was the only variable with a significance difference (p=0.02) with the subscapularis tendon repaired group having a greater range. Pre- and post-operative abduction (p=0.72 & 0.58), forward flexion (p=0.67 & 0.34), ASES (p=0.0.06 & 0.78), Oxford (p=0.0.27 & 0.73) and post-operative external rotation (p=0.17)

Greater external rotation ROM pre-operatively may be indicative of the ability to repair the subscapularis tendon intra-operatively. However, repair does not seem to improve clinical outcome at 12 months.

There was no difference of the PROMs and AROMs between the subscapularis repaired and not repaired groups for any of the variables at the pre-operative or 12 month post operative with the exception of the external rotation ROM pre-operatively. We can conclude that from PROM or AROM perspective there is no difference if the tendon is repaired or not in a rTSR and indeed the patients without the repair may have improved outcomes at 12 months.

The function of the shoulder joint has traditionally been evaluated based on range of motion (ROM) in predefined anatomical planes and also by using functional scores, which assessed shoulder function based on the ability to conduct certain activities of daily living (ADLs). However, measuring ROM only in terms of flexion-extension, abduction-adduction and internal-external rotation may under-account for the 3-dimensional mobility of the shoulder joint. Furthermore, functional scores, such as the Oxford shoulder score or American shoulder and elbow surgeons (ASES) score, are subjective measures and are not an accurate assessment of shoulder joint function. In this study, we proposed the use of the globe model of the shoulder joint which can be used to provide an objective measure of the global ROM and also function of the shoulder joint – termed the Global and Functional arc of motion (GAM and FAM). Thirty-three young, healthy male patients (23.7 ± 1.5 years) were recruited and tasked to perform eight ADLs and a full humeral circumduction movement which represented their active global ROM. Reflective markers were placed in accordance to the International Society of Biomechanics (ISB) and optical-based motion capture cameras were used to track relative motion of the dominant humerus with respect to the thorax (i.e. thoracohumeral motion). The GAM and FAM were generated by plotting the thoracohumeral on a spherical coordinate system during global ROM and the eight ADLs respectively. Shoulder joint global ROM and function were quantified by calculating the area enclosed by the closed loop of GAM and FAM respectively. The spherical coordinate system, or more commonly referred to as the globe model, describes thoracohumeral movement using plane of elevation (POE), angle of elevation (AOE) and rotation. In our model, POE and AOE represents longitude and latitude of the globe respectively, and rotation is depicted using a red-green-blue (RGB) colour scale. Overall, subject's GAM of the shoulder joint covered an area of 4.64 ± 0.48 units2 compared to only 1.12 ± 0.26 units2 for the FAM. Subjects only required 24.4 ± 5.7 % of their global shoulder ROM for basic daily functioning. Studies that reduced shoulder joint movement into planar movements (i.e. sagittal, coronal and rotation) do not account for the 3-dimensional nature of the joint and doing so may overestimate the requirement of the shoulder joint for ADLs relative to its ROM in each plane. While others have attempted to use the globe model, such studies tend to reduce the globe into its descriptive angles (i.e. POE, AOE and rotation), reducing its intuitiveness. In contrast, by keeping an intact globe, the proposed globe model was more intuitive and yet capable of quantifying both shoulder joint global ROM and function. Doing so, we found that young healthy subjects only required approximately a quarter of their global ROM of the shoulder joint to complete the most common daily tasks, which was significantly less than what was previously reported

Decreased head-neck ratio diameter and component malposition in total hip arthroplasty are factors known to result in impingement, increased rates of dislocation, wear and failure. In addition to these complications, impingement of the femoral neck on the acetabular component of a hip resurfacing may result in femoral neck fracture and loosening of the acetabular component. Little is known regarding the optimum femoral and acetabular hip resurfacing component position to avoid impingement. In the first part of this study we analysed the radiographic component position of 131 consecutive hip resurfacings. In the second part the effect of three component variables on the range of motion to impingement were analysed using a dry bone model:. Inclination of the acetabular cup. Version of the acetabular cup. Femoral head-neck diameter ratio. The mean femoral-stem shaft angle in the first part of the study was 138° (range 121° to 158°). The mean acetabular inclination angle was 45° (range 30° to 63°). This wide range in position mirrors that described in the literature. The dry bone study revealed an optimum acetabular cup inclination tending towards 50° and an anteversion of 25°. A large diameter femoral head relative to the femoral neck resulted in a greater range of motion to impingement. A fine balance however exists, to remove a minimum amount of pelvic bone to accommodate a larger acetabular component with an ‘oversized’ femoral component. The acetabular resurfacing cup positions described allow the greatest range of physiological hip movement. New technology and improvements to existing equipment and techniques will hopefully lead to more accurate placement of hip resurfacing components minimising the risk of impingement and its complications in this high demand group of patients

4 years of follow-up study on 27 patients who had biological reverse total shoulder replacement 12 patients who had Bio-RSA by using Tonier Aequalis reversed implants with bone graft extracted from the head of humerus before humeral shaft was prepared. The average age of this group of patients is 77. The average pre-operative shoulder abduction on the affected side is 52 degrees and forward flexion of 90 degrees. Indication for surgery in all those cases are due to cuff tear. The average post-operative abduction is 90 degrees and forward flexion of 97 degrees. The average follow-up period is 9 months with a range from 4 to 18 months. Two patients from this group failed to make an improvement in the range of their shoulder movements post-operatively. 15 underwent Bio-RSA by using Delta XTEND reverse shoulder system without bone graft. The average age of this group of patients is 73. The average pre-operative shoulder abduction is 35 degrees and forward flexion of 37 degrees. Indication for surgery again in most of the cases is due to cuff tear, except one case was due to proximal humeral fracture. The average post-operative abduction is 96 degrees and forward flexion of 101 degrees. The average follow-up period is 19 months with a range of 4–42 months. Only one patient failed to make an improvement post-operatively. This is the patient who had Bio-RSA due to a proximal humeral fracture. 6 patients out of this group also had previous resurfacing which has failed in comparison to the bone graft group which none had previous resurfacing surgery. Conclusion. Overall, the average post-operative range of movements in both groups is not very significant different. Bio-RSA without bone graft seems to make a larger improvement when compared with per-operative range of motion. Howver, whether a much longer follow-up period and younger patients have an impact on the outcome is debatable

Dislocation remains a major early complication after total hip arthroplasty (THA), and range of motion (ROM) before impingement is important in joint stability. Factors contributing to dislocation include design specific factors such as head-neck ratio, surgeon-related factors such as component placement, and patient-related factors such as bony anatomy. To study the relative importance of these factors, we analysed the effects of patient anatomy, implant design, and component orientation on hip ROM. Femoral and acetabular geometry were extracted from CT scans of 20 hips. CAD models of four different THA component designs were virtually implanted in the 3D-CT reconstructed anatomic models. The major design differences were in head-neck ratio and neck-stem angle. A previously reported contact detection model (D’Lima, J Orthop Research 2008) was used to measure restriction in hip ROM due to prosthetic or bony impingement. The following patient parameters were measured on plain AP radiographs: acetabular inclination, acetabular depth ratio, the arc-length between the tip of greater trochanter and ilium, and the arc-length between lesser trochanter and ischium. Multiple linear regression was used to determine correlation between radiographic parameters and hip ROM in flexion, extension, adduction, abduction, and external rotation. Mean head size was 51 ± 2mm, mean anatomic acetabular inclination was 41° ± 2, and mean acetabular depth ratio was 460 ± 60. When the cup and stem were implanted for best fit to the anatomy, mean hip ROM was 125° ± 8 (flexion), 57° ± 17 (extension), 29° ± 13 (adduction), 69° ± 7 (abduction), and 42° ± 13 (external rotation). Implanting the cup in “optimal” surgical alignment of 45° abduction and 20° anteversion reduced mean hip flexion, extension and abduction and increased adduction. Subject-to-subject variation was substantially greater than variation between CAD designs (differences in head-neck ratio) or component orientation (between ideal and anatomic). Hip flexion correlated moderately with acetabular abduction angle and the angle of the flare of the iliac wing (R2 = 0.59, p = 0.03). Hip abduction correlated moderately with the angle of the flare of the iliac wing and the length of the arc from the tip of the greater trochanter to the ilium (R2 = 0.50, p = 0.05). A universal cup position that permits optimal range of motion in all patients may not be valid. Since patient-related factors overshadowed implant design, cup position should be tailored to the individual patient. Preoperative radiographs can help predict postoperative hip ROM although not as accurately as 3D-CT reconstructions. These results may lead to enhancements in surgical navigation techniques

Introduction: In general a loose-balanced total knee arthroplasty (TKA) are believed to gain good postoperative range of motion (ROM), however, too much laxity is thought to be a cause for persistent pain and catastrophic long-term results. Materials and methods: We measured the antero-posterior and medio-lateral laxity to evaluate the influence of stability after cruciate-retaining TKA on ROM, pain score in Knee Society score and Functional score at 4–7 years after the operation. Twenty-one knees in 15 patients with an average age of 68 years (range, 58–78) who had a PCL retaining TKA for osteoarthrosis were examined (YS-4, 16 knees; AGC-S, 5 knees). There were 12 women and 3 men. Anteroposterior laxity was examined using a KT 2000 arthrometer at 30-degree knee flexion. Mediolateral laxity was examined at full extension with manual stress x-rays. Results: Average ROM was 112 degrees (range, 90–140 degrees), antero-posterior laxity was 9.7 mm (range, 2–27 mm) and mediolateral laxity was 10.6 degrees (range, 5–22 degrees). Knee Society pain score was 47 (range, 10–50) and Functional score was 82 (range, 40–100). No significant difference in ROM and clinical scores were noted between the lax and the stable knees. Correlations between ROM and anteroposterior or medio-lateral laxity were not significant (P = 0.55, P = 0.05, respectively; Spearman’s correlation efficient). Discussion and conclusion: A loose-balanced TKA did not gain good post-operative ROM. No parameters suggested that lax knees got better flexion angle, worse pain score and functional score than stable knees

Introduction. Reverse total shoulder arthroplasty (RTSA) can partially restore lost range of motion (ROM). Active motion restoration is largely a function of RTSA joint constraint, limiting impingement, and muscle recruitment; however, it may also be a function of implant design. The aim of this computational study was to examine the effects of implant design parameters, such as neck-shaft (N-S) angle and glenoid lateralization, on impingement-free global circumduction range of motion (GC-ROM). GC-ROM summarizes the characteristically complex, wide-ranging envelope of glenohumeral motion into a single quantity for ease of comparison. Methods. Nine computational models were used to investigate implant parameters. The parameters examined were N-S angles of 135°, 145°, and 155° in combination with glenoid lateralizations (0, 5, and 10 mm). Static positioning of the humerus was defined by an elevation direction angle, elevation angle, and rotation. The humerus was rotated from the neutral position (0° of rotation and elevation), and then elevated in different elevation directions until impingement was detected. Abduction occurred at an elevation direction angle of 0°, while flexion and extension occurred at elevation direction angles of 90° and −90°, respectively. Elevation direction angles ranged from −180° to 180°. Elevation ranged from 0° and 180°. Rotations ranged from −45° to 90°, where negative and positive rotations represented external and internal rotation, respectively. For each rotation angle, a plot of maximum elevation in each elevation plane was created using polar coordinates (radius = elevation, angle = elevation direction). The area enclosed by the resulting points, normalized with respect to the implant with a 145° N-S angle and 5 mm lateralization, was calculated. The sum of these areas defined the GC-ROM. Results. Figure 1 depicts the maximum ROM curves at each angle of rotation for a 145° N-S angle humeral implant with 5 mm of glenoid lateralization. Table 1 shows the normalized areas within the maximum ROM curves for each implant configuration at each angle of rotation, where 0% indicates that the corresponding angle of rotation could not be achieved without impingement. The effect of varying N-S angle (constant lateralization of 5 mm) and lateralization (constant N-S angle of 145°) is shown for 0° rotation (Figures 2A and 2B, respectively). Conclusions. In general, increasing glenoid lateralization increases GC-ROM; however, the unintuitive poor performance of all 10 mm lateralized configurations at rotations of −90° highlights the complex relationships between implant parameters and ROM. Interestingly, the 135° N-S implant had greater flexion and extension ROM, while the 155° N-S implant had greater abduction ROM, suggesting that there are trade-offs between N-S angles pertaining to the elevation direction in which maximum elevation is obtained. The results of this study highlight the need to incorporate multi-directional motion when assessing the effect of varying implant parameters on the impingement-free GC-ROM. Future studies will include the application of the presented technique to a broader range of implant and surgical parameters

Introduction. Reverse Total Shoulder Arthroplasty (rTSA) is an efficient treatment, to relieve from pain and to increase function. However, scapular notching remains a serious issue and post-operative range of motion (ROM) presents many variations. No study compared implant positioning, different implant combinations, different implant sizes on different types of patient representative to undergo for rTSA, on glenohumeral ROM in every degree of freedom. Material and Methods. From a CT-scan database classified by a senior surgeon, CT-exams were analysed by a custom software Glenosys® (Imascap®, Brest, France). Different glenoid implants types and positioning were combined to different humerus implant types. Range of motion was automatically computed. Patients with an impingement in initialisation position were excluded from the statistical analysis. To validate those measures, a validation bench was printed in 3D to analyse different configurations. Results. 25 patients were included; 50 configurations were realised per patient. The validation bench on 5 configurations retrieved an error of 1,5° ± 0,88°. The impingement rate and ROM were improved using lateralised glenoid implant types, inferior positioning glenoid implant types, 42mm glenospheres, decreased Neck Shaft Angles for humerus implants and humerus inset. Conclusion. Impingement in resting arm at side position and ROM can be maximised with an adequate implant choice. A surgical planning software could assist the surgeon to choose the best configuration for each patient to maximise the post-operative outcome (scapular notching and global range of motion)

Recently, several smartphone applications (apps) have been developed and validated for ankle ROM measurement tools like the universal goniometer. This is the first innovative study introduces a new smartphone application to measure ankle joint ROM as a remote solution. This study aimed to assess the correlation between smartphone ROM and universal goniometer measurements, and also report the evaluation of the DijiA app by users.

The study included 22 healthy university students (14F/8M; 20.68±1.72 years) admitted to Yeditepe University. Fourty four feet was measured by both the universal goniometer (UG) and DijiA app. The datas were analyzed through using the intraclass correlation coefficient (ICC). The DijiA app was evaluated by usability testing with representative users.

Pearson correlation coefficient test showed moderate correlation between the DijiA and UG for dorsiflexion (DF) and plantar flexion (PF) measurements (Pearson correlation coefficient: r=0.323, for DF; r=0.435 for PF 95% confidence interval). The application usability was found as high with 76.5 average score and users liked it.

The DijiA app may be a more convenient and easy way to measure ankle DF and PF-ROM than UG. It can be used to evaluate ROM in clinical practice or home using as a personal smartphone.

We sought to evaluate the early post-operative active range-of-motion (AROM) between robotic-assisted total knee arthroplasty (raTKA) and conventional TKA (cTKA). A secondary data analysis on a global prospective cohort study was performed. A propensity score method was used to select a matched control of cTKA from the same database using 1:1 ratio, based on age, sex, BMI, and comorbidity index. This resulted in 216 raTKA and cTKA matched cases. Multivariable longitudinal regression was used to evaluate difference in ROM over time and values are reported as least squares means (95% confidence interval). The longitudinal model tested the treatment effect (raTKA vs cTKA), time effect, and their interaction with control on covariance of patients ‘s age, sex, BMI, comorbidity and pre-operative flexion. Logistic regression was used to analyze the active flexion level at one month (cut by 90°) and three months (cut by 110°).

At one-month postoperative the raTKA cases had more AROM for flexion by an average of 5.54 degrees (p<0.001). There was no difference at three months (p=0.228). The raTKA group had a greater improvement from pre-operative values at both one-month, with an average 7.07° (3.6°, 10.5°, p<0.001) more improvement, and at three-months with an average improvement of 4° more (1.61°, 7.24°, p=0.0115). AROM for extension was lower overall in the raTKA group by an average of 0.44° (p=0.029). The raTKA patients had higher odds of achieving ≥90° of flexion at one-month (OR 2.15, 95% CI 1.16, 3.99).

raTKA resulted in greater AROM flexion gains in the early postoperative period than cTKA. Additional research is needed to understand if these earlier gains in AROM are associated with improved patient satisfaction and continued improvements with time.

Purpose: The “Hill-Sachs Remplissage” (HSR) is a procedure used in the treatment of anterior shoulder instability associated with an engaging Hill-Sachs (HS) defect. It consists of an arthroscopic capsulotenodesis of the posterior capsule and infraspinatus tendon within the defect. There is currently no evidence that the capsule and tendon heal in the humeral bone defect. Our hypotheses were. that the capsulotenodesis heals in the HS defect and fills at least 50% of its area; and,. that limitation of range of motion compared to the non-operated shoulder would be minimal. Method: Prospective clinical study. Inclusion criteria:. recurrent anterior shoulder instability;. engaging HS lesion. Exclusion criteria:. glenoid bone loss;. rotator cuff tear. Twenty-nine patients underwent an arthroscopic Bankart repair plus HSR. Clinical assessment at a mean follow up of 13.1 months (range 6 to 32 months) consisted of a structured interview and detailed physical examination including range of motion compare to the contralateral shoulder and instability signs. Range of motion was analyzed in two groups according to length of follow-up, Group 1 with less than 12 months follow-up (14 patients); and Group 2 with greater than 12 months follow-up (15 patients). Either a CT arthrogram (25 patients) or an Arthro-MRI (2 patient) was performed at a minimum of six months postoperatively. Four orthopaedic surgeons analyzed the images independently to determine the percentage of healing of the capsulotenodesis. Results: There was no recurrence of instability at the latest follow-up. There was no statistically significant deficit in forward elevation in either group. Group 1 patients had statistically significant mean deficits as compared to the contralateral side of 15 degrees of external rotation in adduction (ER1), 15 degrees of external rotation at 90 degrees of abduction (ER2), and 1.1 points of internal rotation in adduction according to the Constant score system (ER1). Group 2 patients had statistically significant mean deficits of 4 degrees of ER1 and 11 degrees of ER2, with no significant difference in IR1. There was healing of the capsulotenodesis within the bone defect in all twenty-seven patients. The bone defect was filled more than 75% of its surface in 22 of 29 patients (76%). The remaining seven had between 50 and 75% filling (24%). There was no defect filling of less than 50% in this study. Conclusion: We demonstrated greater than 50% HS defect filling in all patients in our series after an arthroscopic “Hill-Sachs Remplissage” and filling > 75% in 22 of 29 (76%). Modest deficits of external rotation were demonstrated at greater than 12 months follow-up. While these results suggest that the technical goal of HS defect filling is achievable, longer term studies are necessary to establish whether there is an association between the rate of healing, the functional impairment of external rotation and clinical outcomes

Introduction. After total hip arthroplasty, dislocation is one of the most frequent serious early complications. This occurs in part due to impingement (catching and leverage of the neck-cup on the inlay/cup border). Impingement may also negatively impact long-term outcomes. Materials and Methods. A preliminary model for an optimised hip endoprosthesis system was developed to offer a mechanical solution to avoid impingement and dislocation. A computer-supported range of motion simulation using parameters of cup anteversion and inclination as well as torsion and CCD shaft angle was then performed to localise areas of anterior and posterior impingement of typical acetabular cups. Results. Through isolation of the two main trajectories of motion, and modifications with corresponding gaps to the inlay/cup areas as well as oppositional banking in the abduction/adduction plane, the combination of a snap-fit acetabular cup with reduced cup profile was the result: the “bidirectional total hip prosthesis.”. Under standardised parameters, the ranges of impingement for typical implants are not directly opposite one another (at 180°), but are found instead at an angle of 108.3°. Conclusion. Complications such as dislocation and impingement may possibly be avoided with the bidirectional total hip prosthesis. Typical implantation parameters yield an implant design with rotational asymmetry. [Fig. 1, 2]

INTRODUCTION: Range of motion following TKA is a commonly assessed and important outcome parameter. The reported knee ROM is often measured using manual goniometers. The accuracy of goniometer in measuring ROM of the knee is not known. We compared the knee ROM measured with a manual goniometer and compared that to measurements obtained from computer assisted navigation system. METHODS: This prospective ongoing study has so far recruited 60 patients (71 knees) undergoing TKA by a single surgeon. Measurements of the ROM were performed intraoperatively using a 14 inch 360° Nexgen Baseline® goniometer, validated by physical therapists, and the Stryker knee navigation system. ™. Consistent anatomical landmarks were used to obtain flexion and extension measurements. Each goniometer and navigation measurement was performed twice by the same reader. RESULTS: Goniometer was more inaccurate in measuring the knee ROM than the navigation. There was a 5.07° difference between two measurements obtained with the goniometer compared to a mean discrepancy of 1.15° using the navigation system. Further, the ROM measured by navigation was on average 13.9° larger than that measured by the goniometer. BMI affected the ROM recording obtained by both the goniometer and the navigation system. DISCUSSION AND CONCLUSION: This study indicates that goniometer is not an accurate tool for measurements of knee ROM as there is a marked discrepancy between two goniometer readings. The navigation system seemed to produce more consistent, but markedly higher, readings than a manual goniometer. Reported results on knee ROM in the literature need to be interpreted with caution and scrutinized for potential inaccuracy of the measuring tool

Background:. For the past four decades controversy surrounds the decision to retain or sacrifice the posterior cruciate ligament during a total knee arthroplasty. To our knowledge no study has been done to describe the effect of releasing the PCL on the range of motion of the knee. Study design:. Case series. Methods:. Computer navigation data (Brainlab) was obtained intra-operatively from thirty patients at total knee arthroplasty. Coronal alignment, maximal passive knee extension and maximal passive flexion was captured before and after release of the PCL. Results:. Releasing the posterior cruciate ligament led to an increase in maximal extension in all patients (av 3,6°) and a decrease in coronal deformity in 63%. The surprising finding was an increase in maximal knee flexion (av 5°, range 0 to 10°.) The increase in maximal flexion was statistically significant. Conclusion:. Sacrificing the posterior cruciate ligament alters the kinematics of the knee and the resultant increase in knee flexion might explain why cruciate sacrificing total knee arthroplasty has superior flexion compared to cruciate retaining designs

The Dynesys is a flexible posterior stabilization system that is designed to preserve intersegmental kinematics and reduce loading at the facet joints. The purpose of this study was to determine if the length of the Dynesys spacer has an effect on range of motion (ROM) at the implanted level. Spacer length was found to significantly affect ROM in all three loading directions with and without a follower preload. The longer spacer increased ROM and the shorter spacer decreased ROM, largely due to differences in segmental compression between the two. The Dynesys, a flexible posterior stabilization system that provides an alternative to fusion, is designed to preserve intersegmental kinematics and alleviate loading at the facet joints. Recent biomechanical evidence suggests that motion with Dynesys is less than the intact spine (Schmoelz, 2003). The purpose of this investigation was to determine if the length of the Dynesys spacer contributes to differences in range of motion (ROM) at the implanted level. Ten cadaveric lumbar spine segments (L2-L5) were tested by applying a pure moment of ±7.5Nm in three directions of loading with and without a follower preload of 600N. Test conditions included: intact, injury at L3-L4, Dynesys at L3-L4 (standard spacer), long spacer (+2mm), and short spacer (−2mm). Intervertebral rotations were measured using an optoelectronic camera. Pressure sensors placed inside the joint capsules measured facet loads. Statistical significance was determined using repeated measures ANOVA. Spacer length had a significant effect on ROM in all three loading directions with and without a follower preload. Initial contact loads within the facet joints were 150% and 64% that of the standard spacer for the short and long spacer, respectively. The magnitude of distraction of the segment affects ROM. Shorter spacers increased segmental compression of the intervertebral disc and facet joints and therefore reduced ROM. With a follower preload, the segment is further compressed and ROM is further reduced. The results contribute to an understanding of the design of such implants and could help guide future research. Funding: Synos Foundation, Switzerland, National Science and Engineering Research Council of Canada (NSERC). Please contact author for table or diagram

To determine the effect of altering tibial slope on the two-year range of motion (ROM) of patients undergoing condylar total knee replacements (TKR). A single surgeon performed 74 primary cemented posterior stabilised tri-compartmental TKR’s on 56 patients (19 male, 37 female) with mean age of 67.1 years, height 66.7in., weight 187.4 lb, and BMI 29.58 kg/m2. 51 had osteoarthritis, and five had rheumatoid arthritis. A standard surgical technique was employed utilising flexion axis localisation to position the femoral components. Patients were followed for two years minimum using outcome measures and x-rays. Knees where tibial slope was restored to a degree angle equal to, or slightly greater than, their pre-op slope (group 1) were compared to knees where tibial slope was decreased (group 2). The average 2 year post-op ROM in Group 1 was significantly greater than that of Group 2 (129.3 degrees vs. 120.5 degrees, p=.001). The average pre-op to post-op increase in ROM in Group 1 was significantly greater than Group 2 (38.1 degrees vs.27.7 degrees, p=.003). Correlational analysis revealed that restoration of pre-op tibial slope was the primary determinant of post-op ROM, followed by pre-op ROM, then weight and BMI (each to significance of p< 0.05). Restoration of tibial slope clearly produced increased ROM in this study. Using one standard slope cut for every tibia may prevent many patients from achieving their maximum potential ROM

Introduction Fixed flexion deformity (FFD) represents a challenge during total knee arthroplasty (TKA). Furthermore, controversy exists as to the fate of FFD following TKA. Aims The aims of this study were to determine how fixed flexion behaves in relation to surgery, factors that may influence or correlate with FFD both preoperatively and following TKA and the effect of FFD on outcome at one year. Patients and Methods 133 patients (41 males; 92 females) undergoing TKA were prospectively studied. The following data was recorded for each patient: age, gender, primary diagnosis, direction and magnitude of the pre-operative axial deformity, BMI, preoperative and one year Oxford Knee Scores (OKS), the active and passive range of motion (ROM) preoperatively, at the end of surgery and at three month and one year review. FFD was defined as forced passive extension (FPE) greater than zero degrees. Results Sixty-six patients (50%) had a preoperative FFD (mean, 60). At the end of surgery, this measured 10, 80 at 3 months and 40 at one year. When comparing those with a preoperative FFD to those with no FFD, there was no significant difference when assessing age, BMI or preoperative OKS. Preoperative FFD was significantly more common in males although there was no significant difference in the magnitude of FFD at any stage between males and females. There was a significant improvement in FFD at one year. Patients with a preoperative FFD were found to have significantly less flexion both preoperatively and at one year. When comparing those with FFD at one year to those with no FFD, those with FFD were significantly older and had significantly less flexion. There was no significant difference in BMI, OKS or gender. Conclusions There is a definite trend when assessing the change in FFD with time. Correction at the time of surgery would appear to be important. Residual FFD is associated with reduced flexion at one year

Many of the questionnaire based scoring systems (i.e. Rowe score) require some form of clinical assessment. These clinical components can be very difficult to perform on a large scale particularly when a patient lives a long distance from clinic. We have attempted to counter this problem by asking the patient to asses their own range of motion. The aim of this study was to test the agreement between patient and clinician measured shoulder external rotation range using a photo based self-assessment tool. Fifty-one professional and semi-professional rugby players were recruited to assess shoulder external rotation range. Each player was presented with a photo based shoulder external rotation range self-assessment tool, which featured four photos of progressive shoulder external rotation in 2 positions, 900 abduction (150, 300, 450 & 600 of external rotation) and 00 abduction (700, 800, 900 & 1000 of external rotation). The players were asked to perform active external rotation in these two positions and mark the image which best matched their maximal external rotation. The player was then independently assessed using the same tool, by a clinician. The difference between the player's and the clinician's assessment was analysed using a weighted Kappa test. The Kappa for the shoulder external rotation in 900 abduction was 0.75 and 0.71 for left and right respectively, and 0.57 and 0.55 for shoulder external rotation in 00 abduction. Thus, the strength of agreement between the player's and clinician's assessment of shoulder external rotation is good in 900 abduction and moderate in 00 abduction. These results demonstrate that the photo-based shoulder external rotation range self-assessment tool is a very useful addition to researchers' and clinicians' toolkits and may be most useful when a patient lives a great distance from/or is unable to attend a clinic

Purpose. The effects of Acetabular Rim Osteophytes (ARO) in Total Hip Arthroplasty (THA), has not been quantified. During THA their presence and location is variable, and the effect on post-operative Range of Motion (ROM) is unknown. The purpose of this study was to evaluate the ROM of a modern hip implant in five cadaver models utilizing computerized virtual surgery, and to analyze the effect of AROs given their location on the acetabulum, and position of the prosthesis during motion. Method. CT scans of five cadaveric pelvises and femurs were used to create 3-D Models. Surgery, using virtual Stryker components was then performed to restore the natural anatomic offset and leg length. ROM to impingement was evaluated for each model in eight vectors: flexion/extension, internal/external rotation, abduction/adduction, and 90 degrees of flexion with internal/external rotation. An Osteophyte Impingement Model was then created by elevating the natural acetabular rim by 10 millimeters circumferentially in each virtual cadaver pelvis. Using the same THA components, ROM was then evaluated in this pelvic model and compared to the cadaveric models. Results. ROM in the Osteophyte Impingement Model yielded a statistically significant decrease in five of the eight vectors tested, when compared to the Cadaveric Model: Flexion, Extension, External Rotation, Flexion to 90 degrees with Internal Rotation, and Flexion to 90 degrees with External Rotation. Only 3 of these 5 vectors were within normal human physiological ROM: Flexion, External Rotation, and Flexion to 90 degrees with Internal Rotation. The osteophyte model yielded a decrease in absolute ROM in the following: Flexion to 101 vs 113 degrees (p= 0.03), External Rotation to 30.4 vs 49.5 degrees (p= 0.01), and Flexion to 90 degrees with Internal Rotation 16.7 vs 31.6 degrees (p=0.01). When mapped on the acetabulum of right-sided hip, with the 12 o'clock position as the superior pole of the acetabulum, impingement on the osteophyte was noted at the following locations: with Flexion, and Flexion to 90 degrees with Internal Rotation, impinged was noted between 1 and 2 o'clock on the acetabulum. In External Rotation impinged occurred between 7 and 8 o'clock on the acetabulum. Conclusion. This study showed that a 10 millimeter osteophyte can potentially decrease range of motion and lead to impingement in THA in certain planes of motions: Flexion, External Rotation and Flexion to 90 degrees with Internal Rotation. The location of this impingement is between the 1 and 2 o'clock in Flexion, and Flexion to 90 degrees with Internal Rotation. In External Rotation, the impingement will occur between the 7 and 8 o'clock. The above applies to a right-sided acetabulum, the left side will demonstrate the mirror image of this impingement: Between the 10 to 11 o'clock, and 4 to 5 o'clock positions respectively. Osteophytes 10 millimeters or more in height at these positions should be carefully evaluated intra-operatively and removed safely if possible

Polyethylene contact stresses have been shown to correlate with wear in total hip arthroplasty (THA). Several liner designs have been introduced in an attempt to increase stability or reduce impingement and increase range of motion. This study analyzed the effect of liner design on range of motion (ROM) and PE contact stresses in a finite element model (FEM). FEMs of four liner designs were generated: Generic was modelled as a simple hemisphere, Chamfer had a wide chamfer on the inner edge of the liner to increase ROM, Highwall had an extended lip to increase stability, and Anteverted created a 20° anteversion with lat-eralisation of the centre of rotation. With the liners in varying positions of abduction and anteversion, physiologic loads were applied through the femoral head. Hip ROM was measured by rotating the head and neck in different directions until prosthetic impingement. Significant differences in ROM were seen relative to the Generic liner. Chamfer increased ROM by mean 16%. Highwall reduced ROM by mean 12%. Anteverted increased flexion by 17% but decreased extension, abduction, and external rotation. Contact stresses were also significantly affected by liner design and acetabular orientation. Overall for the same acetabular position, contact stresses were higher for Chamfer and lower for Highwall and Anteverted. These results underline the complex interaction between cup design, hip stability, range of motion and contact stresses. Design features that increase stability tend to reduce contact stresses and ROM, while those features that increase ROM, tend to increase contact stresses. This data can help the surgeon match liner design to specific patient requirements

Introduction: Range of motion is an invariable outcome -measure in studies on total knee arthroplasty (TKA) and other knee surgery. Concluding that a certain change in motion equals a corresponding change in outcome may be invalid if true accuracy of current measuring techniques is unknown. This is integral to many studies. Surprisingly little has been done to validate these techniques. Methods: Maximum extension and flexion were measured in 32 TKAs by four independent observers using three common techniques: visual estimate (VE), pocket and universal goniometers (PG and UG). Lateral radiographs in reproducible positions were measured using computer analysis, providing a gold standard for comparison with clinical measurements. The correlation coefficients and coefficients of reliability were calculated. Results: There were no significant differences between observers using any method. Significant differences were found between each technique and radiographic measure (paired t-test, p< 0.001). Correlation coefficients were lower for extension estimates (0.76–0.80) than flexion (0.91–0.96). Coefficients of repeatability varied from 11.6 degrees to 12.1 degrees for extension measurements and from 13.8 degrees to 19.2 degrees for flexion measurements, with UG being the most accurate. The VE accuracy approached that of UG only at easily visualised angles such as 90 degrees. The coefficient of repeatability for radiographic measure was significantly lower at 2.9 degrees. Conclusions: Clinical measurements of range of motion vary significantly from radiographic measurement, with the computer assisted radiographic measurement providing high reliability as the gold standard. UG is most accurate, followed by PG and VE. However, coefficients of repeatability were surprisingly large, indicating the degree of accuracy of each measurement technique and the necessary magnitude of difference for this to be outside measurement error. This has relevance for all outcome studies and everyday clinical practice

Background. Data on varus-valgus and rotational profiles can be obtained during navigated total knee arthroplasty (TKA). Such intraoperative kinematic data might provide instructive clinical information for refinement of surgical techniques, as well as information on the anticipated postoperative clinical outcomes. However, few studies have compared intraoperative kinematics and pre- and postoperative clinical outcomes; therefore, the clinical implications of intraoperative kinematics remain unclear. In clinical practice, subjects with better femorotibial rotation in the flexed position often achieve favorable postoperative range of motion (ROM); however, no objective data have been reported to prove this clinical impression. Hence, the present study aimed to investigate the correlation between intraoperative rotation and pre- and postoperative flexion angles. Materials and Methods. Twenty-six patients with varus osteoarthritis undergoing navigated posterior-stabilized TKA (Triathlon, Stryker, Mahwah, NJ) were enrolled in this study. An image-free navigation system (Stryker 4.0 image-free computer navigation system; Stryker) was used for the operation. Registration was performed after minimum soft tissue release and osteophyte removal. Then, maximum internal and external rotational stress was manually applied on the knee with maximum extension and 90° flexion by the same surgeon, and the rotational angles were recorded using the navigation system. After knee implantation, the same rotational stress was applied and the rotational angles were recorded again. In addition, ROM was measured before surgery and at 1 month after surgery. The correlation between the amount of pre- and postoperative tibial rotation and ROM was statistically evaluated. Results. The amount of tibial rotation at registration was positively correlated with that after surgery (p < 0.05). Although the amount of tibial rotation at maximum extension was not correlated with ROM, the amount of rotation at 90° flexion at registration was positively correlated with pre- and postoperative ROM (p < 0.05). Moreover, the amount of tibial rotation at 90° flexion was positively correlated with postoperative ROM (p < 0.05). Conclusion. It is well known that preoperative ROM affects postoperative ROM. Our results showed that better tibial rotation at 90° flexion predicts favorable postoperative ROM, suggesting that flexibility of the surrounding soft tissues as well as the quadriceps muscles is an important factor for obtaining better ROM. Further evaluation of navigation-based kinematics during TKA surgery may provide useful information on ROM

Limitations of the range of motion (ROM) of total hip prostheses lead to impingement causing dislocation and material failure. Due to wear, the femoral head penetrates polyethylene (PE)-sockets by about 0,1 mm/year (ceramic on PE) and 0,2–0,6 mm/year (metal on PE). Wear rate increases with steep acetabular cup position. In contrast to polyethylene, wear of alumina-ceramic cups appears to be independent from inclination angle and is only about 0,001 mm/year. Wear and design features may restrict the artificial joint mobility. The purpose of this study is to determine the effects of head penetration on ROM in relation to different cup positions. Computer simulation was carried out with a three-dimensional CAD-program. 3-D models of modular cup, spherical head, and stem with cylindrical neck and 12/14 taper were generated. The femoral head was shifted 0, 1, 2, and 5 mm towards the pole of the cup. According to mean direction of penetration measured in retrieved PE-sockets, femoral head was also moved 0, 1, 2, and 5 mm in vertical direction. The joint motions were measured at different cup positions. The study demonstrates that ROM is clearly reduced by increasing head penetration. After 2 mm penetration, e.g. maximum flexion is reduced by approx. 15° at 45° cup inclination. Restriction of flexion is more pronounced in the vertical penetration path. If the socket is placed in more horizontal position, less ROM of flexion, extension and abduction is observed. With steeper cup positions ROM of flexion increases but, as well as risk of dislocation, wear and penetration rate of PE sockets increase. Modern hip prostheses should provide sufficient joint movements, precise implant positioning and low wear bearing couples avoiding penetration of femoral head. Additionally, design aspects like liner geometry, head-neck ratio have to be considered preventing impingement, dislocation or early failure by aseptic loosening

1) INTRODUCTION. Total knee arthroplasty (TKA) is one of the most common orthopaedic procedures performed, and is projected to exponentially increase over the next 20 years. As primary TKA cases increase, so does the frequency of revisions. The primary goals for all TKA cases include alleviating pain and improving overall knee function. The objective of this study was to evaluate the change in outcomes as measured by the Knee Society Score (KSS) between primary and revision TKA systems. 2) METHODS. This data was collected as part of three prospective, post-market, multicenter studies comparing preoperative to 6-week data. Patients were stratified into two groups based on type of single radius knee device; Posteriorly Stabilized (PS) group and Total Stabilizer (TS) group. Early clinical outcomes based on the KSS and operative data were used to compare groups. 3) RESULTS. The KSS was compared to determine the amount of improvement in revision vs. primary cases. Within the KSS Pain/Motion section, the improvement in range of motion was greatest in the TS revision group (change of 8°) in comparison to the primary PS group (change of 3°), as well as a significant decrease in pain classification. The KSS Functional scores improved significantly more in the revision group compared to the primary group. 4) DISCUSSION and CONCLUSION. Studies have determined that revision TKAs have lower rates of functional outcomes, leading to a decreasing trend in KSS. This trend can be correlated to increased difficulty of the surgical technique due to increased bone loss and anatomical changes, as well as a higher constraint in revision TKA devices. The design of a single radius knee revision system addresses these issues with revision TKA and has been shown to have comparable KSS evaluations to patients receiving primary single radius TKAs

Background. It is known that severe cases of intervertebral disc (IVD) disease may lead to the loss of natural intervertebral height, which can cause radiating pain throughout the lower back and legs. To this point, surgeons perform lumbar fusion using interbody cages, posterior instrumentation and bone graft to fuse adjacent vertebrae together, thus restoring the intervertebral height and alleviating the pain. However, this surgical procedure greatly decreases the range of motion (ROM) of the treated segment, mainly caused by high cage stiffness. Additive manufacturing can be an interesting tool to reduce the cage's elastic modulus (E), by adding porosity (P) in its design. A porous cage may lead to an improved osteointegration since there is more volume in which bone can grow. This work aims to develop a finite element model (FEM) of the L4-L5 functional spinal unit (FSU) and investigate the loss of ROM induced by solid and porous cages. Materials and Methods. The Intact-FEM of L4-L5 was created, which considered the vertebrae, IVD and ligaments with their respective material properties. 1. The model was validated by comparing its ROM with that of other studies. Moments of 10 Nm were applied on top of L4 while the bottom of L5 was fixed to simulate flexion, extension, lateral bending and axial rotation. 2. The lumbar cages, posterior instrumentation and bone graft were then modelled to create the Cage-FEMs. Titanium was chosen for the instrumentation and cages. Cages with different stiffness were considered to represent porous structures. The solid cage had the highest modulus (E. 0. =110 GPa, P. 0. =0%) whereas the porous cages were simulated by lowering the modulus (E. 1. =32.8 GPa, P. 1. =55%; E. 2. =13.9 GPa, P. 2. =76%; E. 3. =5.52 GPa, P. 3. =89%; E. 4. =0.604 GPa, P. 4. =98%), following the literature. 3. The IVD was removed in Cage-FEMs to allow the implant's insertion [Fig. 1] and the previous loading scenarios were simulated to assess the effects of cage porosity on ROM. Results. The Intact-FEM presents acceptable ROM according to experimental and numerical studies, as shown by the red line in Figure 2. After insertion, lower ROM values in Cage-FEMs are measured for each physiological movement [Fig. 3]. In addition, highly porous cages have greater ROM, especially in axial rotation. Discussion. Significant reduction of ROM is expected after cage insertion because the main goal of interbody fusion is to allow bone growth. As such, the procedure's success is highly dependent on segmental stability, which is achieved by using cages in combination with bone graft and posterior instrumentation. Furthermore, higher cage porosities seem to affect the FSU. In fact, ROM increases more as the cage modulus approaches that of the cancellous bone (E. canc-bone. =0.2 GPa. 1. ). Next step will be to assess the effects of cage design on the L4-L5 FSU mechanical behavior and stress distribution. To conclude, additive manufacturing offers promising possibilities regarding implant optimization, being able to create porous cages, thus reducing their stiffness. For any figures or tables, please contact the authors directly

At a minimum of one year after operation, we studied 64 patients with 86 total hip arthroplasties (THA) by standard anteroposterior hip and pelvic radiographs and measurement of range of motion and of isometric abduction strength. The femoral offset correlated positively with the range of abduction (p = 0.046). Abduction strength correlated positively with both femoral offset (p = 0.0001) and the length of the abductor lever arm (p = 0.005). Using multiple regression, abduction strength correlated with height (p = 0.017), gender (p = 0.0005), range of flexion (p = 0.047) and the abductor lever arm (p = 0.060). Our findings suggest that greater femoral offset after THA allows both an increased range of abduction and greater abductor strength

The purpose of this study was to compare the post operative ROM of patients randomised between SRA and 28mm THA. Restoration of normal ROM has been proposed as an advantage of hip resurfacing (SRA) over THA and is due to the use of larger diameter femoral heads. However, the head-neck diameter ratio, which is an important factor governing ROM, would in theory allow more ROM with THA (28mm head/14mm neck = ratio 2:1) versus SRA (approximate ratio 1.3–2.0:1). Patients were randomised between SRA and THA. Osseous landmarks were identified with a marker pen. Both ASIS served as the reference line for the pelvis position. Digital photographs of hip motion were taken and a blinded rater (with respect to the side and type of surgery) performed range of motion testing on the operated and normal side. Pre-study validation of ROM measurement method with a software program revealed high intra and inter observer reliability. Sixty SRA and sixty-two THA were evaluated at minimum follow-up of twelve months. Preoperative ROM and demographic data were similar for both groups. No significant differences (p> 0.05) were found in the total arc of motion (SRA=204.2°, THA=196.5°), arc of rotation (SRA=47.7°, THA=44.3°), flexion-extension arc (SRA=118.1, THA=120.1), abduction-adduction arc (SRA=43.1°, THA=42.9°). In theory, ROM should have been greater in THA. Fear of instability may have limited ROM recovery potential in THA. Since pre operative soft tissue contracture is an important factor influencing post operative ROM, the complete capsular release performed during SRA may have been an advantage of this technique

Introduction:. Dual mobility total hip arthroplasty (DM-THA) allows for very large femoral head size, which may be beneficial for hip range of motion (ROM). No clinical study has objectively compared ROM in patients with DM-THA and large (36-mm head) total hip arthroplasty (36-THA). The aim of this prospective case-control study is to test the hypotheses that DM-THA provides superior hip ROM compared to 36-THA by dynamic radiography, and that surgical approach (posterolateral [PL] versus modified anterolateral [AL]) has effect on post-operative hip ROM. Materials and Methods:. Sixteen patients (11 males, 5 females) who had undergone DM-THA with a minimum follow up of one year were age, sex and body mass index (BMI) matched to twenty patients (12 males, 8 females) with 36-THA, all operated upon by the senior author. Maximum hip-trunk flexion, extension and total hip-trunk ROM was calculated on standing lateral digital radiographs of the lower lumbar spine, pelvis and hip, using commercially available software (TraumaCad®, BrainLab, Munich, Germany) from three upright positions; standing neutral, standing with maximum hip flexion and standing with maximum hip extension. Contributions to motion from lumbo-sacral spine (LSS) and pelvic tilt were calculated and subtracted from hip-trunk measurements to quantify true hip flexion, extension and total true hip ROM. Statistical analysis (SPSS software, Chicago, IL) was performed on all radiographic measurements to detect difference in ROM between DM-THA and 36-THA, and to detect difference in ROM between THAs performed through posterolateral (THA-PL) and anterolateral (THA-AL) approaches. Results:. There was no significant difference in age, sex and BMI between groups (p > 0.05). In DM-THA versus 36-THA, hip-trunk flexion (118° +15.3° vs. 112.75° +16.44°), hip-trunk extension (20.88° +6.72° vs. 21.00° +6.00°) and total hip-trunk ROM (139.50° +17.86° vs. 133.75° +16.29°) revealed no statistically significant difference between groups (p > 0.05). Similarly, true hip flexion (100.63° +14.77° vs. 99.85° + 13.55°), extension (12.75 + 6.01° vs. 12.20 + 3.71°) and total true hip ROM (113.38° +19.28° vs. 112.05° +14.84°) did not show statistically significant difference between groups (p > 0.05). No significant difference in true hip flexion or extension existed between THA-PL and THA-AL (p > 0.05). There was no significant difference in total hip-trunk and total true hip ROM between males and females (p > 0.05). Patients with degenerative/stiff LSS (LSS ROM <15°) exhibited significant reduction in hip-trunk total ROM (130.62° +15.97°) compared to patients with flexible (ROM >15°) LSS (144.27° +15.56°) (p = 0.015), without any significant reduction in true total hip ROM (112.81° +16.59° vs. 112.40° +17.46, respectively) (p = 0.943). Conclusion:. DM-THA does not provide superior ROM compared to 36-THA as evidenced by dynamic radiography. PL/AL surgical approach, with presumptive violation of hip extensors/flexors, does not affect post-operative hip extension/flexion, respectively. THA patients with flexible LSS may exhibit apparent increased hip ROM due to compensatory movement at the LSS, rather than an actual increase in true hip ROM

Purpose: Our purpose was to evaluate why some patients achieve excellent range of motion (ROM) following total knee arthroplasty (TKA) and to determine its relation to outcome. Methods: We evaluated 618 primary unilateral TKA’s for osteoarthritis from a prospective arthroplasty database using a single implant design. 209 TKA’s with ROM greater than 120 degrees at one year follow-up were compared to 409 TKA’s with ROM less than 120 degrees to determine if age, BMI, gender, ASA class, and preop ROM differed between the two groups. Knee society and oxford knee scores were also compared both preoperatively and at one year follow-up using independent samples t-test. A multiple logistical regression analysis was performed to determine predictors of ROM. Results: Preoperative ROM was higher (115 vs 106, p< 0.0001), BMI was lower (30.7 vs 32.9. p< 0.0001), and there was a higher proportion of males (p< 0.0001) in those patients with exceptional ROM at one year (> 120 degrees). Knee Society Score (93.7 vs 87.8, p< 0.0001) and Oxford Knee Score (20.4 vs 24.4, p< 0.0001) were superior in the exceptional ROM group at one year follow-up. In multiple logistic regression, only preoperative ROM (p< 0.0001) was a significant predictor of postoperative flexion range. Conclusions: Body habitus may play a role in our ability to achieve exceptional flexion following TKA. Implant design has historically favoured male anatomy which may influence exceptional flexion range. Preoperative ROM still seems to be the biggest predictor of postoperative ROM. Perhaps timely surgical intervention, pre-habilitation and implant design choice can influence our ability to achieve exceptional ROM following TKA

Introduction. Postoperative knee flexion is an important indicator of success in total knee arthroplasty (TKA). Factors influencing the postoperative range of motion (ROM) were reported to be preoperative ROM, primary indication, height of postoperative joint line, patellar thickness, postoperative pain and rehabilitation. In this study, we aimed to identify the relationship between preoperative hip ROMs and postoperative knee flexion through reviewing the TKA results in Japanese patients. Patients & Methods. We retrospectively reviewed primary TKAs 55 knees in 55 patients (33 left and 22 right) between April 2012 and March 2013 inclusive. The patients were 11 men and 44 women, with a mean age of 76.7 years. Preoperative hip ROMs and perioperative knee flexion were measured by using goniometer. Hip ROMs were flexion, extension, abduction, adduction, external rotation; ER, internal rotation; IR and total rotation; TR (The total rotation added up ER and IR.). Hip ROMs were measured passively, with the pelvis was fixed manually. Postoperative knee flexion was measured in the fourth week. The patients were classified according to the good group (28 knees), the postoperative knee flexion was more than 125 degrees; and the poor group (27 knees), less than 120 degrees. We compared preoperative hip ROMs in each groups. Multiple regression analysis and Single regression analysis were used for comparison between preoperative hip ROMs and postoperative knee flexion. For comparisons between paired groups we used Wilcoxon test, between unpaired groups Mann-Whitney U test. A p value of less than 0.05 was considered significant. Results. Knee flexion of all patients did not have significant changes before and after the operation (p=0.09). Although the good group was a similar result (p=0.94), the poor group significantly decreased after the operation (p=0.01). (Table 1) The linear combination of hip ER and hip IR explained 28% (R. 2. = 0.28, p=0.0008) of the variance in postoperative knee flexion. The correlation coefficient of postoperative knee flexion and preoperative flexion was 0.41 (p=0.0017), and postoperative knee flexion and hip IR was 0.27(p=0.048), and postoperative knee flexion and hip TR was 0.35(p=0.008). There were only a low correlation between hip ROMs and postoperative knee flexion. (Table 2) As for the hip ER and hip IR, there were no significant differences between good group and poor group, however there was a significant difference for the hip TR between the two groups (p=0.013).(Figure 1). Discussion. The mean postoperative flexion of our patients was 122.4°, with a loss of 2.4° flexion but postoperative flexion was improved on equality with preoperative flexion. There was a positive correlation between preoperative and postoperative flexion. This study also showed that there was a positive correlation between postoperative flexion and preoperative hip TR. A new finding is that there was a significant difference for the hip TR between good group and poor group. These finding may imply that biarticular muscles of origin around hip joint participate with the postoperative flexion. We conclude that it is important for TKAs to evaluate hip ROMs

Introduction. Today, there is no clear consensus as to the amplitude of movement of the “normal hip”. Knowing the necessary joint mobility for everyday life is important to understand different pathologies and to better plan their treatments. Moreover, determining the hip range of motion (ROM) is one of the key points of its clinical examination. Unfortunately this process may lack precision because of movement of other joints around the pelvis. Our goal was to perform a preliminary study based on the coupling of MRI and optical motion capture to define precisely the necessary hip joint mobility for everyday tasks and to assess the accuracy of the hip ROM clinical exam. Methods. MRI was carried out on 4 healthy volunteers (mean age, 28 years). A morphological analysis was performed to assess any bony abnormalities. Two motion capture sessions were conducted: one aimed at recording routine activities (stand-to-sit, lie down, lace the shoes while seated, pick an object on the floor while seated or standing) known to be painful or prone to implant failures. During the second session, a hip clinical exam was performed successively by 2 orthopedists (2 and 12 years' experience), while the motion of the subjects was simultaneously recorded (Fig.1). These sequences were captured: 1) supine: maximal flexion, maximal IR/ER with hip flexed 90°, maximal abduction; 2) seated: maximal IR/ER with hip and knee flexed 90°. A hand held goniometer was used by clinicians to measure hip angles in those different positions. Hip joint kinematics was computed from the markers trajectories using a validated optimized fitting algorithm which accounted for skin motion artifacts (accuracy: translational error≍0.5 mm, rotational error <3°). The resulting computed motions were applied to patient-specific hip joint 3D models reconstructed from their MRI data (Fig. 2). Hip angles were determined at each point of the motion thanks to two bone coordinate systems (pelvis and femur). The orthopedist's results were compared. Results. All subject's hips were morphologically normal. For all movements, a minimum of 95° hip flexion was required (mean range 95°–107°), lacing the shoes and lying down being the more demanding. Abduction/adduction and IR/ER remained low (± 20°) and variable across subjects. Regarding the clinical exam, the error made by the clinicians varied in the range of ± 10°, except for the flexion and abduction where the error was higher (flexion: mean 9.5°, range −7°–22°; abduction: mean 19.5°, range: 8–32°). No significant differences between the errors made by the two examiners were noted (mean error for each examiner: 7.4° vs. 8.4°). Conclusion. Daily activities of a “normal hip” involve intensive hip flexion, which could explain why such motion can yield hip pain or possible implant failure. This information should be considered in the surgical planning and prosthesis design when restoring patient mobility and stability. The clinical exam seems to be a precise method for determining hip passive motion, if extra care is taken to stabilize the pelvis during flexion and abduction to prevent overestimation of the ROM. Further studies including more subjects are required before attesting the accuracy of this test

Objective: To evaluate if the complete resection of the femoral bump, in cam-type FAI increases the postoperative flexion and internal rotation. Material and Method: We reviewed 24 consecutive pre-operative and postoperative hip CT scans in 24 patients with FAI (22 male and 2 female, mean age 36.9 years) who underwent arthroscopic hip surgery for the removal of a bony prominence on the femoral neck-head junction. We measured the alpha angle in two places: in the classical location, in the mid plane of the femoral neck axis and proximally, in the same plane but in first quarter of the femoral neck height. Then we compared these results with the presence of a residual prominence diagnosed in the 3 dimensionally reconstructed images of the postoperative CT scan and the virtual range of motion of the 3D models using impaction detection software. Results: We found 7 cases with a residual bony prominence at the femoral neck-head junction in the 3D model of the proximal femur after the surgery. In this group the mean mid femoral neck alpha angle was significantly improved from 69.7° before the surgery to 48.3° (p=0.028), however the proximal alpha angle was not significantly improved 71.1° preoperative versus 62.7 (p=0.176) after the surgery. In the 17 patients without a residual bump, both alpha angles were improved, the mid alpha angle from 64.9° before the surgery to 40.76° (p=0.000) after the surgery and the proximal alpha angle from 65.8° to 38.4° (p=0.000). The range of motion of hip in the impaction detection software was also significantly improved in both groups, from flexion of 103° to 116° (p=0.001) in the group without a residual bump and from 102 to 118 (p=0.046) in the group with a residual bony prominence after the surgery. The internal rotation at 90° of flexion was also improved in both groups with a statistically significant difference (p=0.001 versus p=0.028 respectively). Conclusion: The complete arthroscopic resection of the femoral bump improves significantly the ranges of flex-ion and internal rotation in patients with cam-type FAI

The range of motion (ROM) after total knee arthroplasty (TKA) is one of the most important factors for patient satisfaction, especially in Asian countries. To enhance the knee flexion angle, “high-flexion” designs have been introduced in total knee prostheses. One of such design was a new design of femoral prosthesis, which increased the posterior cut on the bone by 2 mm and thickened the posterior condyle, allowing the posterior condylar radius to continue further. There were several reports on postoperative ROM of such “high-flexion” posterior-stabilized (PS) total knee prosthesis. However, there was no report on the postoperative ROM of “high-flexion” cruciate ligament retaining (CR) total knee prosthesis. The purpose of this study was to compare the ROM associated with standard and high-flexion posterior CR total knee prostheses. One hundred and fifty-one consecutive patients (176 knees) had CR total knee prosthesis. 89 knees had standard CR TKA (NexGen CR, Zimmer, Warsaw, IL), and 87 knees had high-flexion CR knee prostheses (NexGen CR-Flex, Zimmer, Warsaw, IL). Differences in the age, diagnosis, preoperative Knee Society Score (KSS), and preoperative ROM of the knee between two groups were not significant. At one year postoperatively, the patients were assessed clinically and radiographically. The mean postoperative KSS knee score was 96.2 points for the standard CR prosthesis group and 96.7 points for the high-flexion CR prosthesis group (p=0.464). The mean postoperative KSS function score was 83.4 points for the standard CR prosthesis group and 84.8 points for the high-flexion CR prosthesis group (p=0.446). The mean postoperative ROM was 110.8 degrees in the standard CR prosthesis group, and 114.0 degrees in high-flexion prosthesis group (p=0.236). No knee had aseptic loosening, revision, or osteolysis. Previous report showed that “high-flexion” PS design did not increase postoperative ROM compared to standard design. However, there was no report on the postoperative ROM of “high-flexion” CR total knee prosthesis. We found no significant differences between the standard CR group and “high-flexion” CR group with regard to ROM or clinical and radiographic parameters. However, in the cases which achieved high flexion, “high-flexion” design, which chamfered posterior femoral edge, can reduce the possibility of deformation from posterior contacts under lord. Therefore, the results of the current study suggested that “high-flexion” CR design is not the design that increase ROM significantly, but might be the safe design even when the knee achieved deep flexion

Introduction: In this study we have studied the range of motion within Dynesys treated discs and levels adjacent to flexible stabilisation. Dynesys was designed to offer physiological motion at the lumbar spine. An advantage which is superior to abolishing movements through spinal fusion. Methods: A cohort of 75 post-Dynesys patients had weight-bearing lateral lumbar spine x rays in flexion/extension positions. Evaluation was done through PACS™ digital software. Flexibility at individual disc level was measured as the differences between flexion/extension angles accurate to within 1°. Motion was evaluated at the index and immediate adjacent levels. Results: Patients with single level Dynesys had an average ROM of (3+/−4.7) at L5-S1 and (5.1+/−2.9) at the immediate adjacent level. Two levels Dynesys was associated with a ROM of 5+/−3.6 at L5-S1 & L4–5 and 3.5+/−1.8 at their immediate neighbour disc. Across three levels, Dynesys favoured a ROM of 5.3+/−2.5 at the operated sites and 1.6+/− 2 at the adjacent level. Discussion & Conclusion: This study is the first radiological research to confirm the flexibility of Dynesys. Controlled motion at the dynesys treated disc levels share to distribute global spinal movements. This will advantage the next disc segments and protects them from risk of developing “accelerated adjacent segment disease”

Ideally the hip arthroplasty should not be subject to bony or prosthetic impingement, in order to minimise complications and optimise outcomes. Modern 3d planning permits pre-operative simulation of the movements of the planned hip arthroplasty to check for such impingement. For this to be meaningful, however, it is necessary to know the range of movement (ROM) that should be simulated. Arbitrary “normal” values for hip ROM are of limited value in such simulations: it is well known that hip ROM is individualised for each patient. We have therefore developed a method to determine this individualised ROM using CT scans.

CT scans were performed on 14 cadaveric hips, and the images were segmented to create 3d virtual models. Using Matlab software, each virtual hip was moved in all potential directions to the point of bony impingement, thus defining an individualised impingement-free 3d ROM envelope. This was then compared with the actual ROM as directly measured from each cadaver using a high-resolution motion capture system.

For each hip, the ROM envelope free of bony impingement could be described from the CT and represented as a 3d shape. As expected, the directly measured ROM from the cadaver study for each hip was smaller than the CT-based prediction, owing to the presence of constraining soft tissues. However, for movements associated with hip dislocation (such as flexion with internal rotation), the cadaver measurements matched the CT prediction, to within 10°.

It is possible to determine an individual's range of clinically important hip movements from a CT scan. This method could therefore be used to create truly personalised movement simulation as part of pre-operative 3d surgical planning.

Purpose of the study: Little is known about the clinical profile of patients aged less than 65 years who present a large or massive rotator cuff tear. We hypothesized that this clinical profile depends on the type of tear. Material and method: This was a prospective descriptive multicentric study over a period of six months which included 112 patients aged less than 65 years, 66 men and 46 women, mean age 56.3 years (range 35–65) who had a large or massive rotator cuff tear. The Constant score and active and passive range of motion, subacromial height and fatty infiltration according to the Goutallier classification were noted. Patients were divided into four classes according to deficit in active elevation and external rotation: class A (n=55, no deficit), class B (n=19, deficient elevation alone), class C (n=28, deficient external rotation alone), class C (n=10, deficient elevation and external rotation). Results: These classes were not significantly different for age, sex-ratio, duration of symptoms, or presence of subscapular involvement. Trauma was involved more often in patients in class B and class D. The mean absolute Constant score was significantly lower in patients in class B (30.2) or D (23.5) than in class A (53.3) or C (44.7). The subacromial space was significantly narrower in group D (5 mm) than in the other groups. Fatty infiltration of the infraspinatus scores > II was significantly more common in groups C and D. Severe fatty degeneration of the subscapular (> II) was found in only eight shoulders and was not correlated with defective active elevation. Discussion: This study demonstrates that deficient external rotation is correlated with the type of tear but has little impact on the Constant score. Conversely, patients with deficient active elevation have a lower Constant score but do not exhibit characteristically different tears than patients without deficient active elevation. Thus, the management scheme should be no different in patients with deficient elevation than in patients with out deficient elevation, excepting cases with a major lesion of the subscapularis

INTRODUCTION

Femoral stem impingement can damage an acetabular liner, create polyethylene wear, and potentially lead to dislocation. To avoid component-to-component impingement, many surgeons aim to align acetabular cups based on the “Safe Zone” proposed by Lewinnek. However, a recent study indicates that the historical target values for cup inclination and anteversion defined by Lewinnek et al. may be useful but should not be considered a safe zone. The purpose of this study was to determine the effect of altering femoral head size on hip range-of-motion (ROM) to impingement.

Rotational acetabular osteotomy (RAO) for developmental dysplasia of the hip (DDH) may not restore normal hip range of motion (ROM) due to the inherent deformity of the hip and it may lead to femoro-acetabular impingement. The purpose of this study was to investigate morphological factors of the pelvis and femur influencing on simulated ROM after RAO with a fixed target for femoral head coverage. We retrospectively reviewed CT images of 52 DDHs with an average lateral centre edge angle (CEA) of 7.9° (−12° to 19°). After virtual RAO with 30° of lateral CEA and 55° of anterior CEA producing femoral head coverage similar to that of the normal hips, we measured simulated flexion ROM using pelvic and femoral computer models reconstructed from the CT images. Pelvic sagittal inclination, acetabular anteversion, lateral CEA, femoral neck anteversion, femoral neck shaft angle (FNSA), alpha angle and the position of the anterior inferior iliac spine (AIIS) were investigated as morphological factor. When the most prominent point of the AIIS existed more distally than the cranial tip of the acetabular joint line in a lateral view of the pelvis model in supine position, the subjects were defined as AIIS-Type1; the remaining subjects were defined as Type 2. There were 10 hips with Type 1 and 42 hips with Type 2 AIIS. The Kappa value of inter-observer reproducibility to classify AIIS was 0.82. Multiple regression analyses were performed to analyse the relationship between ROM and the morphological parameters. We also analysed the relationship between the probability of flexion ROM being less than 110° and the factors which influenced on flexion ROM. FNSA and AIIS-Type independently influenced on simulated flexion ROM after RAO (standard regression coefficient: −0.51 and 0.37, respectively. p&lt; 0.001). The multiple correlation coefficient was 0.68. Flexion ROM after RAO with a fixed femoral head coverage similar to that of the normal hips ranged from 95° to 141° with an average of 121°±8°. The probability of ROM being less than 110° was significantly higher in subjects with AIIS-Type 1 than in those with Type 2 (odds ratio: 13.3, p&lt;0.01). It was also significantly higher in subjects with more than 135° of FNSA than in those with less than 135° of FNSA (odds ratio: 9.5, p&lt;0.05). FNSA and the type of AIIS influenced on flexion ROM after RAO with approximately 40° of variation in spite of a fixed target for femoral head coverage. A large FNSA and a distal positioning of AIIS were independently associated with smaller flexion ROM after RAO

It is debatable whether high flexion total knee arthroplasty (TKA) designs will improve postoperative flexion, function or will diminish the need for manipulation under anesthesia (MUA). We retrospectively analyzed range of motion (ROM), flexion, Knee Society Score (KSS), and rate of MUA in a consecutive group of patients who underwent TKA with a conventional PS or a high flexion (HF) insert using identical surgical technique, implant design and postoperative care. Fifty TKAs with a standard posterior stabilized insert (PS) were matched with 50 who received a high flexion insert (HF) for patient’s age, gender, preoperative ROM, and KSS. The patient’s ROM and KSS were obtained at 6 weeks, 4 months, and 1 year postoperatively. The outcome variables (flexion, ROM, KSS and manipulation rate) in the two groups were compared using the generalized estimating equations method. A second analysis of patients with preoperative flexion equal or greater than 120 degrees was performed. The ROM, flexion, and patient reported KSS was similar in the PS and HF groups at each one of the time periods. The rate of MUA was also similar. Patients with a preoperative ROM of at least 120° showed similar results. Our study found that 1 year after surgery, patients who underwent TKA with a PS or a HF insert achieved similar flexion, ROM and function

The study aimed to determine how well recorded pain levels and range of motion relate to patients' reported levels of functional ability/disability pre- and post- total hip arthroplasty. Range of motion (ROM), Oxford Hip Score (OHS) and Self-Report Harris Hip Score (HHS) were recorded pre-operatively and 3 months post-total hip arthroplasty. Pearson's correlation coefficients were calculated to determine the strength of the relationships both pre- and post-operatively between ROM (calculated using the HHS scoring system) and scores on OHS and HHS and response relating to pain from the questionnaires (question 1 HHS and questions 1, 6, 8, 10, 11 and 12 of OHS) and overall scores. Only weak relationships were found between ROM and HHS pre- (r = 0.061, n = 99, p = 0.548) and post-operatively (r = 0.373, n = 66, p = 0.002). Similar results were found for OHS, and when ROM was substituted for flexion range. In contrast, strong correlations were found between OHS pain component and HHS pre- (r = -0.753, n = 107, p<0.001) and post-operatively (r = -0.836, n = 87, p<0.001). Strong correlations were also found between the OHS pain component correlated with the HHS functional component only (HHS with score for questions relating to pain deducted) pre- (r = -0.665, n = 107, p<0.001) and post-operatively (r = -0.688, n = 87, p<0.001). Similar results were found when the HHS pain component was correlated with OHS. In orthopaedic clinical practice ROM is routinely used to assess the success or failure of arthroplasty surgery. These results suggest that this should not be done. Instead, asking the patient the level of pain that they are experiencing may be a good determinant of level of function. The results of this study may aid the development of arthroplasty scoring systems which better assess patients' functional ability

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

Background

Recurrent instability and dislocation after total hip arthroplasty are difficult complications. In certain cases, a constrained acetabular device can address these issues. The purpose of this study is to report the midterm outcomes and survivorship of a single constrained liner device.

Aims

Accurate knowledge of the normal shoulder range of movement (ROM) is imperative for evaluating pathology and clinical success. However, in orthopaedic texts, the quoted normal shoulder ROM has significant variation. Furthermore we suspect there is a high incidence of intra and inter observer error during shoulder ROM examination.

The aims of our study were thus:

To perform a literature review and record the published values for normal shoulder ROM. Subsequently, to calculate the average of these published values.

To perform visual and goniometer measurement of shoulder ROM in 10 volunteers and assess the agreement between the two methods.

Aim: To investigate and compare the effects of two types of LCS total knee arthroplasty AP glide {(posterior cruciate is retained and the mobile bearing allows anteroposterior and well as rotational movement) and RP (in which posterior cruciate is sacrificed and the mobile bearing allows only rotational movement)} on joint proprioception and range of motion. Methods: 30 patients scheduled to undergo mobile bearing total knee arthroplasty were randomised to receive either a LCS AP glide or Rotating platform prosthesis. Clinical scores (Oxford knee score, American knee society score (AKSS), EuroQol), range of motion and proprioception were assessed prior to and at three and six months after the operation. Proprioception was assessed in terms of absolute error angle (mean difference between the target angle and the response angle). Student’s t-test was used to compare the mean of two groups (with a level of significance of p < 0.05). Results: Both groups were comparable in terms of pre-operative range of motion, oxford knee score, American knee society score, EuroQol score and proprioception. At 6 months there was significant improvement in the Oxford knee score, AKSS and EuroQol score in both groups (p< 0.001), but no difference was noted between the two groups with respect to these parameters. There was improvement in the proprioception (reduction in absolute error angle) in both groups though this was not significant statistically (p> 0.05). The mean active non-weight-bearing range of motion improved in both groups {AP glide group, (p< 0.05) and RP group, (p> 0.05)}. Conclusions: We did not find significant difference between AP glide and RP LCS knee arthroplasty in terms of improvement in proprioception and range of motion

Introduction. Lateralizing the center of rotation (COR) of reverse total shoulder arthroplasty (rTSA) has the potential to increase functional outcomes of the procedure, namely adduction range of motion (ROM). However, increased torque at the bone-implant interface as a result of lateralization may provoke early implant loosening, especially in situations where two, rather than four, fixation screws are used. The aim of this study was to utilize finite element (FE) models to investigate the effects of lateralization and the number of fixation screws on micromotion and adduction ROM. Methods. Four patient-specific scapular geometries were developed from CT data in 3D Slicer using a semi-automatic threshold technique. A generic glenoid component including the baseplate, a lateralization spacer, and four fixation screws was modelled as a monoblock. Screws were simplified as 4.5 mm diameter cylinders. The glenoid of each scapula was virtually reamed after which the glenoid component was placed. Models were meshed with quadratic tetrahedral elements with an edge length of 1.3 mm. The baseplate and lateralization spacer were assigned titanium material properties (E = 113.8 GPa and ν = 0.34). Screws were also assigned titanium material properties with a corrected elastic modulus (56.7 GPa) to account for omitted thread geometry. Cortical bone was assigned an elastic modulus of 17.5 GPa and Poisson's ratio of 0.3. Cancellous bone material properties in the region of the glenoid were assigned on an element-by-element basis using previously established equations to convert Hounsfield Units from the CT data to density and subsequently to elastic modulus [1]. Fixed displacement boundary conditions were applied to the medial border of each scapula. Contact was simulated as frictional (μ = 0.8) between bone and screws and frictionless between bone and baseplate/spacer. Compressive and superiorly-oriented shear loads of 686 N were applied to the baseplate/spacer. Lateralization of the COR up to 16 mm was simulated by applying the shear load further from the glenoid surface in 4 mm increments (Fig. 1A). All lateralization levels were simulated with four and two (superior and inferior) fixation screws. Absolute micromotion of the baseplate/spacer with respect to the glenoid surface was averaged across the back surface of the spacer and normalized to the baseline configuration considered to be 0 mm lateralization and four fixation screws. Adduction ROM was measured as the angle between the glenoid surface and the humeral stem when impingement of the humeral cup occurred (Fig. 1B). Results. Lateralization (p = 0.015) and reducing the number of fixation screws (p = 0.008) significantly increased micromotion (Fig. 2). Lateralization significantly increased adduction ROM (p = 0.001). Relationships between lateralization, the number of fixation screws, micromotion, and adduction ROM were shoulder-specific (Fig. 3). Conclusions. Lateralizing the COR of rTSA can improve functional outcomes of the procedure, however may compromise long-term survival of the implant by increasing micromotion. Our results indicate that the trade-offs of lateralizing should be considered on a patient-specific basis, taking into account factors such as quality and availability of bone stock

Aim: To investigate and compare the effects of two types of LCS total knee arthroplasty on joint proprioception and range of motion. Methods: 47 patients were randomised to receive either a LCS AP glide or Rotating platform prosthesis. Clinical scores (Oxford knee score, American knee society score, EuroQol), range of motion and proprioception were assessed prior to and at 3,6, and 12 months after the operation. Proprioception was assessed in terms of absolute error angle (mean difference between the target angle and the response angle). Knee angles were measured in degrees using an electromagnetic tracking device, Polhemus 3Space Fastrak that detected positions of sensors placed on the test limb. Student’s t-test was used to compare the mean of two groups (with a level of significance of p < 0.05). Results: Both groups were comparable in terms of pre-operative range of motion, oxford knee score, American knee society score, EuroQol score and proprioception. There was statistically significant improvement in the Oxford knee score, AKSS and EuroQol score in both groups (p< 0.001), but there was no difference between the groups with respect to these parameters. There was improvement in the proprioception (reduction in absolute error angle) in both groups though this was not significant statistically (p> 0.05). Conclusions: We did not find significant difference between AP glide and RP LCS knee arthroplasty in terms of improvement in proprioception and range of motion

Increasing knee flexion following total knee arthroplasty (TKA) has become an important outcome measure. Surgical technique is one factor that can influence knee motion. In this study, it was hypothesised that stripping of the posterior knee capsule could improve flexion and range of motion (ROM) following TKA. Patients who were undergoing TKA were prospectively randomised into two groups - one group (62 patients) were allocated stripping of the posterior knee capsule (PCS), the other group (66 patients) no stripping (no-PCS). The primary outcome was change in flexion and ROM compared to pre-operative measurements at three time points; after wound closure, 3months and 1year post-operatively. Secondary outcomes were absolute measurements of flexion, extension, ROM and complications. All operations were performed by a single surgeon using the same implant and technique. All patients received identical post-operative rehabilitation. There was a significant gain in flexion after wound closure in the PCS group (p=0.022), however there was no significant difference at 3months or 1year post-operatively. Absolute values of extension (p=0.008) and flexion (p=0.001) 3months post-operatively were significantly reduced for the PCS group. The absolute value of ROM was significantly higher for the no-PCS group at 3months (p=0.0002) and 1year (p=0.005). There were no significant difference in the rate of complications. Posterior capsular stripping causes a transient increase in flexion that does not persist post-operatively. We do not recommend routine stripping of the posterior knee capsule in patients undergoing TKA