We evaluated the clinical results and complications after extra-articular resection of the distal femur and/or proximal tibia and reconstruction with a tumour endoprosthesis (MUTARS) in 59 patients (mean age 33 years (11 to 74)) with malignant bone or soft-tissue tumours. According to a Kaplan–Meier analysis, limb survival was 76% (95% confidence interval (CI) 64.1 to 88.5) after a mean follow-up of 4.7 years (one month to 17 years). Peri-prosthetic infection was the most common indication for subsequent amputation (eight patients). Survival of the prosthesis without revision was 48% (95% CI 34.8 to 62.0) at two years and 25% (95% CI 11.1 to 39.9) at five years post-operatively. Failure of the prosthesis was due to deep infection in 22 patients (37%), aseptic loosening in ten patients (17%), and peri-prosthetic fracture in six patients (10%). Wear of the bearings made a minor revision necessary in 12 patients (20%). The mean Musculoskeletal Tumor Society score was 23 (10 to 29). An extensor lag > 10° was noted in ten patients (17%). These results suggest that limb salvage after extra-articular resection with a tumour prosthesis can achieve good functional results in most patients, although the rates of complications and subsequent amputation are higher than in patients treated with intra-articular resection. Cite this article: Bone Joint J 2013;95-B:1425–31

The surgical care of extra-articular distal tibial fractures remains controversial. This study looks at the radiological outcomes of distal tibial fractures treated with either a direct medial or anterolateral plate, with or without plating of the fibula, to assess the outcome and complications associated with these 2 approaches. This is a retrospective review of 80 patients with distal tibial extra-articular fractures, treated with an open reduction and plating, between 2008 and 2019 at Glasgow Royal Infirmary. Case notes and x-rays were reviewed. Of those tibial fractures fixed with only a medial plate, 78% united (28/36), 5% (2/36) had a non-union and 17% (6/36) a malunion. In the group treated with a combination of medial tibial and fibular plating, the figures were; 71% (15/21), 19% (4/21) and 10% (2/21). However, in the group treated with anterolateral plating of the tibia alone, only 53% (8/15) united, with a 20% (3/15) non-union and 13% (2/15) malunion rate. Additionally in this group, there were 2 patients (13%) with loss of fracture reduction within the first two months of fracture fixation, requiring revision surgery. Interestingly, of the 8 patients treated with anterolateral tibial and fibular plating, 88% (7/8) showed full union and only one (12%) had a non-union, with no malunions is this group. It would appear that medial tibial and a combination of medial tibial and fibular plating, have superior outcomes compared to anterolateral plating. Results suggest, if anterolateral plating is done, this should be augmented by fixation of the fibular fracture as well

Aims. Intra-articular (IA) tumours around the knee are treated with extra-articular (EA) resection, which is associated with poor functional outcomes. We aim to evaluate the accuracy of MRI in predicting IA involvement around the knee. Methods. We identified 63 cases of high-grade sarcomas in or around the distal femur that underwent an EA resection from a prospectively maintained database (January 1996 to April 2020). Suspicion of IA disease was noted in 52 cases, six had IA pathological fracture, two had an effusion, two had prior surgical intervention (curettage/IA intervention), and one had an osseous metastasis in the proximal tibia. To ascertain validity, two musculoskeletal radiologists (R1, R2) reviewed the preoperative imaging (MRI) of 63 consecutive cases on two occasions six weeks apart. The radiological criteria for IA disease comprised evidence of tumour extension within the suprapatellar pouch, intercondylar notch, extension along medial/lateral retinaculum, and presence of IA fracture. The radiological predictions were then confirmed with the final histopathology of the resected specimens. Results. The resection histology revealed 23 cases (36.5%) showing IA disease involvement compared with 40 cases without (62%). The intraobserver variability of R1 was 0.85 (p < 0.001) compared to R2 with κ = 0.21 (p = 0.007). The interobserver variability was κ = 0.264 (p = 0.003). Knee effusion was found to be the most sensitive indicator of IA involvement, with a sensitivity of 91.3% but specificity of only 35%. However, when combined with a pathological fracture, this rose to 97.5% and 100% when disease was visible in Hoffa’s fat pad. Conclusion. MRI imaging can sometimes overestimate IA joint involvement and needs to be correlated with clinical signs. In the light of our findings, we would recommend EA resections when imaging shows effusion combined with either disease in Hoffa’s fat pad or retinaculum, or pathological fractures. Cite this article: Bone Joint J 2023;105-B(6):696–701

This annotation considers the place of extra-articular reconstruction in the treatment of anterior cruciate ligament (ACL) deficiency. Extra-articular reconstruction has been employed over the last century to address ACL deficiency. However, the technique has not gained favour, primarily due to residual instability and the subsequent development of degenerative changes in the lateral compartment of the knee. Thus intra-articular reconstruction has become the technique of choice. However, intra-articular reconstruction does not restore normal knee kinematics. Some authors have recommended extra-articular reconstruction in conjunction with an intra-articular technique. . The anatomy and biomechanics of the anterolateral structures of the knee remain largely undetermined. Further studies to establish the structure and function of the anterolateral structures may lead to more anatomical extra-articular reconstruction techniques that supplement intra-articular reconstruction. This might reduce residual pivot shift after an intra-articular reconstruction and thus improve the post-operative kinematics of the knee.

Abstract. Introduction. The aim of this study was to determine if elite athletes could return to professional sport after MCL or PLC reconstruction using LARS ligaments and to demonstrate the safety and efficacy of LARS by reporting sport longevity, subsequent surgeries and complications. Methods. A retrospective review of all extra-articular knee ligament reconstructions in elite athletes utilising LARS ligaments by 3 knee surgeons between January 2013 and October 2020 was undertaken. Return to play (RTP) was defined as competing at professional level or national/ international level in amateur sport. Results. Sixty-four (84.2%) MCL and 12 (15.8%) PLC reconstructions utilising LARS in elite athletes were included. 52 (68.4%) underwent concomitant cruciate(s) reconstruction. The mean age was 25.1 years (SD +/− 4.50. Most were football (35, 46.1%) or rugby players (35, 46.1%). Sixty-seven athletes (88.2%) RTP with 65 (97.0%) of these playing at the same or higher Tegner level. 56 (83.6%) and 20 (57.1%) were still playing at 2 and 5 years post-surgery. Six (7.9%) players (5 of whom RTP) required further surgery relating to the LARS / metalwork and there was one case of adverse local inflammatory reaction to the synthetic material. There was one MCL re-rupture, sustained 4 years after RTP. Conclusion. Utilising LARS in extra-articular knee ligament reconstructions allows 88.2% of athletes, with a variety of knee ligament injuries, to return to elite sport. The low morbidity rates coupled with 57% of athletes still playing 5 years post-surgery suggests the LARS is safe and effective in these cases

Introduction. To determine if elite athletes can return to professional sport after MCL or posterolateral (PLC) reconstruction using LARS ligaments. The secondary aims are to demonstrate the safety and efficacy of LARS by reporting sport longevity, subsequent surgeries, and complications. Methods. A retrospective review of all extra-articular knee ligament reconstructions, utilising a LARS synthetic ligament, by 3 sports knee surgeons between 2013 and 2020 was undertaken. All elite athletes aged over 16 years and a minimum of 2 years post reconstruction were included. No LARS were used for ACL reconstructions, and they were excluded if a LARS ligament was used for a PCL reconstruction. Return to play (RTP) was defined as competing at professional level or national/ international level in amateur sport. Results. Sixty-four (84.2%) MCL reconstructions and 12 (15.8%) PLC reconstructions were included. 52 (68.4%) underwent concomitant autograft cruciate(s) reconstruction including 6 (7.8%) bicruciate reconstructions. The mean age was 25.1 years (SD +/− 4.50). 35 (46.1%) were footballers and 35 (46.1%) were rugby players. Sixty-seven athletes (88.2%) returned to elite sport, 7 (9.2%) did not RTP and RTP status was unknown for 2 (2.6%) (Figure 1). 65 out of 67 (97.0%) RTP at the same/higher Tegner level. 56 (83.6%) and 20 (57.1%) were still playing at 2- and 5-years post-surgery Six (7.9%) players required further surgery due to irritation from the metal fixation implants. One had an inflammation adjacent to the synthetic material at the femoral end and the other cases involved the tibial staples. All six cases were able to RTP. One athlete, following bicruciate /MCL surgery had the LARS removed due to laxity. There was one MCL re-rupture, sustained while jumping, 4 years after returning to football. Conclusions. Utilising LARS in extra-articular knee ligament reconstructions allows 88.2% of athletes with a variety of knee ligament injuries to return to elite sport. The results compare well regarding RTP, complication, and revision rates with the published evidence for other types of MCL and PLC grafts. This, coupled with 57% of athletes still playing 5 years post-surgery suggests the LARS is safe and effective in these cases. For any figures or tables, please contact authors directly

Abstract. Introduction. Anterolateral procedures can reduce the risk of re-rupture after ACL reconstruction in high risk patients however, this effectiveness has never been evaluated in elite athletes. The purpose of this study was to evaluate the effectiveness of lateral extra-articular tenodesis in reducing revision rates in ACL reconstructions in elite athletes. Methodology. A consecutive cohort of elite athletes between 2005 and 2018 undergoing ACLR reconstruction with or without modified Lemaire lateral extra-articular tenodesis were analysed. A minimum of 2 years of follow-up was required. The association between the use of LET and ACL graft failure was evaluated with univariate and multivariate logistic regression models. Results. 455 elite athletes (83% male; 22.5±4.7 years) underwent primary ACL reconstruction with (n=117) or without (n=338) a LET procedure. Overall, 36 athletes (7.9%) experienced ACL graft failure including 32 (9.5%) reconstructions without a LET and 4 (3.4%) with a LET. Utilization of LET during primary ACL reconstruction reduced the risk of graft failure by 2.8 times with 16.5 athletes needing to be treated with LET to prevent a single ACL graft failure. Multivariate models showed that LET significantly reduced the risk of graft rupture (RR=0.325; p=.029) as compared to ACL reconstruction alone after controlling for age at ACL reconstruction and gender. Including graft type in the model did not significantly change the risk profile. Conclusion. The addition of LET in elite athletes undergoing primary ACL reconstruction reduced the risk of undergoing revision by 2.8 times

Abstract. Background. Performing lateral extra-articular tenodesis (LET) with ACL reconstruction may conflict with the ACLR femoral tunnel. Methods. 12 fresh-frozen cadaveric knees were used: at 120 flexion, an 8mm ACLR femoral tunnel was drilled in the anteromedial bundle position via the anteromedial portal. A modified Lemaire LET was performed using a 1 cm-wide iliotibial band strip left attached to Gerdy's tubercle. The LET femoral fixation point was identified 10mm proximal / 5 mm posterior to the LCL femoral attachment, and a 2.4-mm guide wire was drilled, aiming at 0, 10, 20, or 30 degrees anteriorly in the axial plane, and at 0, 10, or 20 degrees proximally in the coronal plane. The relationship between the LET drilling guide wire and the ACLR femoral tunnel reamer was recorded for each combination. When collision with the femoral tunnel was recorded, the LET wire depth was measured. Results. Tunnel conflict occurred at a mean LET wire depth of 23.6 mm (15–33 mm). No correlation existed between LET wire depth and LET drilling orientation (r=0.066; p=0.67). Drilling angle in the axial plane was significantly associated with the occurrence of tunnel conflict (P < .001). However, no such association was detected when comparing the drilling angle in the coronal plane (P=0.267). Conclusion. Conflict occurred at as little as 15 mm depth. When longer implants are used, the orientation should be at least 30 degrees anterior in the axial plane. Clinical Relevance. This study provides important information for surgeons performing LET in combination with ACLR

Extra-articular deformity may be present in patients requiring TKA. Underlying causes include trauma, metabolic bone disease, congenital deformity, or prior osteotomy. Patients with intra-articular deformity have a combination of intra-articular bone loss and concomitant ligament contraction which can be managed in the standard fashion. In these cases establishing appropriate limb alignment and management of bone loss coincide well with the standard ligament balancing employed to provide a stable knee. However, if extra-articular deformity is not corrected extra-articularly, it must be corrected by a compensatory distal femoral or proximal tibial resection to reproduce appropriate limb alignment. Complex instabilities may result from this type of wedge resection because it occurs between the proximal and distal attachments of the collateral ligaments and so produces asymmetrical ligament length alterations. Femoral compensatory wedge resection for extra-articular deformity produces extension instability without affecting the flexion gap and so femoral deformities are POTENTIALLY more difficult to correct than tibial deformities where the compensatory tibial cut influences flexion AND extension equally. Lack of access to the intramedullary canal (as well as increased complexity of producing appropriately placed bone cuts) may be managed with computer guidance or patient specific instruments. The closer a deformity is to the knee, the greater its importance and the effect on the surgical correction. This is a directly proportional relationship, so that as the apex of the deformity moves from juxta-articular to more distant, the amount of corrective wedge needed to re-align the limb decreases proportionally. Rotatory deformities most commonly effect extensor mechanism tracking. The effect is similar to any other deformity in that proximity to the knee and increases the likelihood that it will have a significant local effect. In general, these deformities may be clinically, and radiographically more subtle and so must be searched for. They should be managed by restoring normal rotational parameters of the bone or by appropriate compensation of component rotation relative to the bone. As the need for prosthetic constraint increases due to ligament imbalance or deficiency, intramedullary stems may be required. Their use may be compromised by the presence of the deformity. The younger the patient and the more severe the deformity the more likely I am to treat the deformity by correction at the site of the deformity rather than compensating with abnormal bone resections. The older the patient and the milder the deformity (or the amount of correction required) the more intra-articular correction +/− increased TKA constraint is feasible

Deformity can be associated with significant bone loss, ligament laxity, soft-tissue contractures, distortion of long bone morphology, and extra-articular deformity. Correction of varus, valgus, or flexion deformity requires soft tissue releases in conjunction with bone cuts perpendicular to the long axes of the femur and tibia. Cruciate-retaining or -substituting implants can be used based on surgeon preference if the ligaments are well balanced. However, in presence of severe deformity, additional measures may be warranted to achieve alignment and balance. TKA then becomes a more challenging proposition and may require the surgeon to perform extensive releases, adjunct osteotomies and deploy more constrained implants. Merely enhancing constraint in the implant, however, without attending to releases and extra-articular correction may not suffice. Pre-operative planning, i.e., whether intra-articular correction alone will suffice or extra-articular correction is required, will be highlighted. Surgical principles and methods of performing large releases, reduction osteotomy, lateral epicondylar sliding osteotomy, sliding medial condylar osteotomy, and closed wedge diaphyseal/metaphyseal osteotomy concomitantly with TKA will be illustrated with examples. Results of a large series of TKA with extra-articular deformity resulting from coronal bowing of femoral or tibial diaphysis, malunited fractures, prior osteotomies, and stress fractures will be presented. The techniques reported can successfully restore alignment, pain-free motion, and stability without necessarily using more constrained implants

Extra-articular deformity may be present in patients requiring TKA. Underlying causes include trauma, metabolic bone disease, congenital deformity, or prior osteotomy. Patients with intra-articular deformity can have a combination of intra-articular bone loss and concomitant ligament contraction which can be managed in the standard fashion. In these cases establishing appropriate limb alignment and management of bone loss coincide well with the standard ligament balancing employed to provide a stable knee. However, if extra-articular deformity is not corrected extra-articularly, it must be corrected by a compensatory distal femoral or proximal tibial resection to reproduce appropriate limb alignment. Complex instabilities may result from this type of wedge resection because it occurs between the proximal and distal attachments of the collateral ligaments and so produces asymmetrical ligament length alterations. Femoral compensatory wedge resection for extra-articular deformity produces extension instability without affecting the flexion gap and so femoral deformities are POTENTIALLY more difficult to correct than tibial deformities where the compensatory tibial cut influences flexion AND extension equally. Lack of access to the intramedullary canal (as well as increased complexity of producing appropriately placed bone cuts) may be managed with computer guidance or patient specific instruments. The closer a deformity is to the knee, the greater its importance and the effect on the surgical correction. This is a directly proportional relationship, so that as the apex of the deformity moves from juxta-articular to more distant, the amount of corrective wedge needed to re-align the limb decreases proportionally. Rotatory deformities are complex and most commonly effect extensor mechanism tracking. In general the effect is similar to any other deformity in that proximity to the knee increases the likelihood that it will have a significant local effect. In general, these deformities are clinically, and radiographically more subtle and so must be searched for. They should be managed by an attempt to restore normal rotational parameters of the bone itself or appropriate compensation of component rotation in relation to the bone. As prosthetic constraint increases one may need to use intramedullary stems. Their use may be compromised by the deformity. Finally, the younger the patient and the more severe the deformity the more likely I am to treat the deformity by correction at the site of the deformity rather than compensating with abnormal bone resections. The older the patient and the milder the deformity (or the amount of wedge correction required) the more likely I am to manage the deformity with intra-articular correction and increased TKA constraint

We performed a prospective, randomised study on 57 patients older than 60 years of age with unstable, extra-articular fractures of the distal radius to compare the outcome of immobilisation in a cast alone with that using supplementary, percutaneous pinning. Patients treated by percutaneous wires had a statistically significant improvement in dorsal angulation (mean 7°), radial length (mean 3 mm) and radial inclination (mean 3 mm) at one year. However, there was no significant difference in functional outcome in terms of pain, range of movement, grip strength, activities of daily living and the SF-36 score except for an improved range of movement in ulnar deviation in the percutaneous wire group. One patient developed a pin-track infection which required removal of the wires at two weeks. We conclude that percutaneous pinning of unstable, extra-articular fractures of the distal radius provides only a marginal improvement in the radiological parameters compared with immobilisation in a cast alone. This does not correlate with an improved functional outcome in a low-demand, elderly population

Introduction. Restoration of mechanical axis is one of the main aims during Total Knee Arthroplasty (TKA) surgery. Treatment of osteoarthritis (OA) of the knee with extra-articular deformity either in femur or in tibia poses a technical challenge in achieving this aim. Insufficient correction of axis is associated with poor clinical outcome of total knee arthroplasty (TKA). Extra-articular deformity can either be addressed with compensatory intra-articular bone resection at the time of TKA or correctional osteotomy prior to or at the time of TKA. Patients & Methods & Results. We present our experience of treating 7 patients with knee arthritis (9 knees) and significant extra-articular deformity. Two patients had OA knee with severe valgus deformity in tibia from recurrent stress fractures. One was treated with one-stage corrective osteotomy and long stem modular TKA. The other had deformity correction with two level tibial osteotomy with intramedullary nail and modular long stem TKA later. Both required tibial tubercle osteotomy during TKA. Two patients with bilateral OA knees and significant varus deformity had sequential deformity correction with Taylor Spatial Frame (TSF) followed by TKA on one side and a single stage intra-articular correction during TKA on the other. Three patients with knee OA and associated deformity (femoral - two pt., tibia one pt.) had symptom resolution with just correction of malaligment with Taylor Spatial Frame (TSF) and did not require TKA. Conclusion. Complex extra-articular femoral or tibial deformities may require proper limb realignment prior to TKA. Our series supports all three approaches to correcting significant extra-articular deformity with knee OA. Each case should be considered individually and planned accordingly

Introduction. Bone tumours rarely involve the joint surface as cartilage is thought to be a good barrier to tumour spread. When the tumour does cross the surface the surgeon is faced with the dilemma of whether to amputate the limb, resect it without reconstruction or reconstruct with an implant. This paper aims to investigate the oncological and functional outcomes of patients undergoing an extra-articular resection and reconstruction with an endoprosthesis. Method. 3100 patients have been seen in ROH with primary bone tumours. Patients were identified who had an extra-articular resection considered pre-operatively and the notes and imaging was reviewed. This group was subdivided into a group who did have an extra-articular resection (EAR) and those who either had an amputation or traditional through joint resection. The outcomes of the three groups (group 1 = no joint involvement, group 2 = EAR considered but not done and group 3 = EAR) were then compared in terms of oncological outcome, surgical margins and complications. Results. EAR was considered in 94 cases (3%) usually due to either obvious tumour or joint effusion on initial imaging. Of these 94 cases an EAR was undertaken in 66 cases and not in 28 cases. There was no difference in age, site distribution, diagnosis between the groups. The mean size of the tumour was smaller in the EAR group. The percentage of wide margins achieved was significantly smaller in the EAR group and risk of local recurrent disease was greater in the EAR group but mainly in patients with chondrosarcoma. There was no difference in patient survival between the groups. Conclusions. EAR gives acceptable oncological and functional results but has significantly higher rates of locally recurrent disease in patients with chondrosarcoma

Aims. The aims of this retrospective study were to determine the incidence of extra-articular deformities (EADs), and determine their effect on postoperative alignment in knees undergoing mobile-bearing, medial unicompartmental knee arthroplasty (UKA). Patients and Methods. Limb mechanical alignment (hip-knee-ankle angle), coronal bowing of the femoral shaft and proximal tibia vara or medial proximal tibial angle (MPTA) were measured on standing, full-length hip-to-ankle radiographs of 162 patients who underwent 200 mobile-bearing, medial UKAs. Results. Incidence of EAD was 7.5% for coronal femoral bowing of >5°, 67% for proximal tibia vara of >3° (MPTA<87°) and 24.5% for proximal tibia vara of >6° (MPTA<84°). Mean postoperative HKA angle achieved in knees with femoral bowing ≤5° was significantly greater when compared to knees with femoral bowing >5° (p=0.04); in knees with proximal tibia vara ≤3° was significantly greater when compared to knees with proximal tibia vara >3° (p=0.0001) and when compared to knees with proximal tibia vara >6° (p=0.0001). Conclusion. Extra-articular deformities are frequently seen in patients undergoing mobile-bearing medial UKAs, especially in knees with varus deformity>10°. Presence of an EAD significantly affects postoperative mechanical limb alignment achieved when compared to limbs without EAD and may increase the risk of limbs being placed in varus>3° postoperatively. Clinical Relevance. Since the presence of an EAD, especially in knees with varus deformity>10°, may increase the risk of limbs being placed in varus>3° postoperatively and may affect long-term clinical and implant survival outcomes, UKR in such knees should be performed with caution

The aim of this review is to evaluate the current available literature evidencing on peri-articular hip endoscopy (the third compartment). A comprehensive approach has been set on reports dealing with endoscopic surgery for recalcitrant trochanteric bursitis, snapping hip (or coxa-saltans; external and internal), gluteus medius and minimus tears and endoscopy (or arthroscopy) after total hip arthroplasty. This information can be used to trigger further research, innovation and education in extra-articular hip endoscopy

Total knee arthroplasty becomes more challenging when knee arthritis is associated with an extra-articular deformity of the femur or tibia. We evaluated the outcome of navigated total knee arthroplasty in a large series of arthritic knees with extra-articular deformity. We retrospectively reviewed the records of 950 patients who had undergone navigated TKA between January 2005 and February 2008. There were 40 extra-articular deformities in 34 patients, with bilateral involvement in 6 patients which were included in the study. Twenty-two limbs had deformity in the femur and the tibia had deformity in 18 limbs. There were 24 females and 10 males with a mean age of 63.1 years (range, 46–80 years). The etiologies included malunited fractures (13 patients), stress fractures (4 patients), post high tibial osteotomy (3 patients), and excessive coronal bowing (14 patients). The mean femoral extra-articular deformity in the coronal plane was 9.3° varus (range, 24° varus to 2.8° varus) and the mean tibial extra-articular deformity in the coronal plane was 6.3° varus (range, 20° varus to 8.5° valgus). Three limbs underwent simultaneous corrective osteotomy and the rest were treated with intra-articular correction during computer-assisted total knee arthroplasty. The limb alignment changed from a mean of 166.7° preoperatively to 179.1° postoperatively. At a mean follow-up of 26.4 months, the Knee Society knee score improved from a mean pre-operative score of 49.7 points to 90.4 points postoperatively; function score improved from 47.3 points to 84.9 points. The results of our study indicate that computer-assisted total knee arthroplasty is a useful alternative to conventional total knee arthroplasty for knee arthritis with extraarticular deformity where accurate restoration of limb alignment may be challenging due to the presence of a deformed tibia or femur or in the presence of hardware

The treatment of patients with osteoarthritis of the knee and associated extra-articular deformity of the leg is challenging. Current teaching recognises two possible approaches: (1) a total knee replacement (TKR) with intra-articular bone resections to correct the malalignment or (2) an extra-articular osteotomy to correct the malalignment together with a TKR (either simultaneously or staged). However, a number of these patients only have unicompartmental knee osteoarthritis and, in the absence of an extra-articular deformity would be ideal candidates for joint preserving surgery such as unicompartmental knee replacement (UKR) given its superior functional outcome and lower cost relative to a TKR [1). We report four cases of medial unicondylar knee replacement, with a simultaneous extra-articular osteotomy to correct deformity, using novel 3D printed patient-specific guides (Embody, UK) (see Figure 1). The procedure was successful in all four patients, and there were no complications. A mean increase in the Oxford knee score of 9.5, and in the EQ5D VAS of 15 was observed. To our knowledge this is the first report of combined osteotomy and unicompartmental knee replacement for the treatment of extra-articular deformity and knee osteoarthritis. This technically challenging procedure is made possible by a novel 3D printed patient-specific guide which controls osteotomy position, degree of deformity correction (multi-plane if required), and orientates the saw-cuts for the unicompartmental prosthesis according to the corrected leg alignment. Using 3D printed surgical guides to perform operations not previously possible represents a paradigm shift in knee surgery. We suggest that this joint preserving approach should be considered the preferred treatment option for suitable patients

Introduction. Arthritic knees requiring total knee replacement may present with additional deformities located along the femur or tibia away from the articular region. These deformities may be congenital, developmental, associated with metabolic bone disease, or acquired as a result of malunited fractures or previous advocated for arthritic knee with ipsilateral extra-articular deformity. Methods. We undertook retrospective study to evaluate the results of total knee arthroplasty in arthritic knee with extra-articular deformity in 26 knees (24 patients). Sixteen deformities were in tibia and ten deformities were in femur. All patients underwent total knee arthroplasty with intraarticular bone resection and soft tissue balancing. Results. Average period of follow up was 30 months. Average preoperative arc of motion was 57.5 degrees, which improved to 102.5 degrees. The average preoperative knee society knee score 23.5 points, which improved to an average of 91.3 points at the time of last follow up. The average functional score was 27.0 points, which improved to average of 88.0 points. There were no complications such as infection, ligament instability or component loosening. Conclusion. Intra-articular bone resection is an effective procedure for management of arthritic knees with extra-articular deformity

1. One hundred and forty-two cases of extra-articular arthrodesis of quiescent tuberculous hips with fibrous ankylosis have been reviewed. 2. The methods used were the ilio-femoral graft with and without osteotomy, and the ischio-femoral graft by the Brittain or Foley technique. 3. Success occurs more frequently when the grafting operation is combined with or followed by a femoral osteotomy. 4. It is suggested that this success is due largely to the increased immobilisation afforded by the osteotomy. 5. It appears that equally good results can be obtained with either an ilio-femoral or an ischio-femoral graft in these cases provided that an upper femoral osteotomy is also carried out, preferably at or soon after the grafting operation. 6. An upper femoral osteotomy will frequently convert an unsuccessful extra-articular hip graft into a successful one without further grafting

We treated 31 feet in 17 children with myelomeningocele by extra-articular subtalar arthrodesis. Two patients were lost to follow-up. In the rest, we assessed the correction of valgus deformity and the growth of the tarsal bones. At operation the mean age of the eight girls and nine boys was 6.3 years (3 to 9). At a mean follow-up period of 5.5 years (3 to 9) patients were evaluated clinically and radiologically. We assessed calcaneal growth by calculating the ratio of calcaneal and naviculo-metatarsal longitudinal length on the preoperative and follow-up lateral radiographs. Results of valgus correction were good in 19 feet. In eight they were unsatisfactory owing to progressive valgus of the ankle. Orthotic fitting was difficult and pressure sores over the medial malleolus often developed. Four of the patients underwent further correction by distal tibial osteotomy. The growth ratio was increased in 15 feet, remained the same in seven and decreased in five. Extra-articular subtalar arthrodesis produced satisfactory partial correction of a complex valgus deformity and stability of the hindfoot, and did not have a detrimental effect on the growth of the calcaneus

Osteochondral fractures of the talus are uncommon. They are classified according to Berndt and Harty, as progressing in severity through four stages. This classification, however, does not address extra-articular extrusion of the osteochondral fragment. We report an osteochondral lesion of the talar dome which presented as an extruded extra-articular fragment in a closed injury of the ankle. This type of lesion may offer a continuation to the four original stages. Clinicians should be aware that this pattern of fracture can occur, and thus allow a more accurate diagnosis and the provision of some aid in the treatment of these injuries

Aim: To analyse retrospectively patients after subtalar extra-articular arthrodesis in CP patients. Material and methods: The operation was designed to correct pronated valgus foot. Followed cohort involved 43 patients with 72 affected and operated feet. Subtalar arthrodesis was based on insertion of bicortical graft obtained from iliac wing in the corrected position of the foot. Immobilisation in POP cast continued for 6 weeks postoperatively. Patients were followed clinically and radiographically in standing position before the operation, and after that at regular intervals. Clinical examination involved estimation of heel valgus, foot-prints, videodocumentation. Lateral talo-calcaneal angle (TC) and calcaneal-bottom angle (CB) were measured on radiographs. Moreover qualitative-descriptive classification was used (good, fair, poor). Results: The median of preoperative TC angle was 44,5° at right foot and 48,0° at left foot. The median of postoperative angle changed to 29,5° at right foot and 29,0° at left foot. The difference in TC angles before and after operation was statistically significant. The median of preoperative CB angle was 7,5° at right foot and 7,0° at left foot. The median of postoperative CB angle was 10,5° at right foot and 7,5° at left foot. The difference in CB angles before and after operation was not statistically significant. Operation failed in two cases due to collapse or migration of the graft. Significant improvement in this study was found in 59 (82%) of cases. Discussion: Plenty of reports concerning the use of classical Grice-Green operation in different modifications were reported. This study is based on the use of bicortical cortico-cancellous graft, which provided good stability as well as a smooth incorporation to the neighbouring bones. The correction in TC angle dominated over change in CB angle. Conclusion: Subtalar extra-articular arthrodesis showed in mid-term follow up very good results

Aims. The aim of this study was to assess hypertrophy of the extra-articular tendon of the long head of biceps (LHB) in patients with a rotator cuff tear. Patients and Methods. The study involved 638 shoulders in 334 patients (175 men, 159 women, mean age 62.6 years; 25 to 81) with unilateral symptomatic rotator cuff tears. The cross-sectional area (CSA) of the LHB tendon in the bicipital groove was measured pre-operatively in both shoulders using ultrasound. There were 154 asymptomatic rotator cuff tears in the contralateral shoulder. Comparisons were made between those with a symptomatic tear, an asymptomatic tear and those with no rotator cuff tear. In the affected shoulders, the CSAs were compared in relation to the location and size of the rotator cuff tear. . Results. The mean CSA was 21.0 mm. 2 . (4 to 71) in those with a symptomatic rotator cuff tear, 19.9 mm. 2. (4 to 75) in those with an asymptomatic rotator cuff tear and 14.1 mm. 2 . (5 to 43) in those with no rotator cuff tear. The mean CSA in patients with both symptomatic and asymptomatic rotator cuff tears was significantly larger than in those with no rotator cuff tear (p < 0.001). In the affected shoulders, there were significant differences between patients with more than a medium sized posterosuperior cuff tear and those with an antero-superior cuff tear. . Conclusion . Regardless of the symptoms, there was significant hypertrophy of the extra-articular LHB tendon in patients with a rotator cuff tear. The values were significantly related to the size of the tear. Cite this article: Bone Joint J 2017;99-B:806–11

Aims

The aim of this study was to determine the immediate post-fixation stability of a distal tibial fracture fixed with an intramedullary nail using a biomechanical model. This was used as a surrogate for immediate weight-bearing postoperatively. The goal was to help inform postoperative protocols.

Aims. This study reviews the use of a titanium mesh cage (TMC) as an adjunct to intramedullary nail or plate reconstruction of an extra-articular segmental long bone defect. Patients and Methods. A total of 17 patients (aged 17 to 61 years) treated for a segmental long bone defect by nail or plate fixation and an adjunctive TMC were included. The bone defects treated were in the tibia (nine), femur (six), radius (one), and humerus (one). The mean length of the segmental bone defect was 8.4 cm (2.2 to 13); the mean length of the titanium mesh cage was 8.3 cm (2.6 to 13). The clinical and radiological records of the patients were analyzed retrospectively. Results. The mean time to follow-up was 55 months (12 to 126). Overall, 16 (94%) of the patients achieved radiological filling of their bony defect and united to the native bone ends proximally and distally, resulting in a functioning limb. Complications included device failure in two patients (12%), infection in two (12%), and wound dehiscence in one (6%). Four patients (24%) required secondary surgery, four (24%) had a residual limb-length discrepancy, and one (6%) had a residual angular limb deformity. Conclusion. A titanium mesh cage is a useful adjunct in the treatment of an extra-articular segmental defect in a long bone. Cite this article: Bone Joint J 2018;100-B:646–51

We describe a consecutive series of five patients with bone or soft-tissue sarcomas of the elbow and intra-articular extension treated by complex soft tissue, allograft bone and prosthetic joint replacement after wide extra-articular en bloc excision. All had a pedicled myocutaneous latissimus dorsi rotation flap for soft-tissue cover and reconstruction of the triceps. Wide negative surgical margins were obtained in all five patients. No local wound complications or infections were seen. There were no local recurrences at a mean follow-up of 60 months (20 to 105). The functional results were excellent in four patients and good in one. Longer term follow-up is necessary to confirm the durability of the elbow reconstruction

Primary synovial chondromatosis, defined by Jaffe (1951), is a rare, benign arthropathy, of unknown aetiology, distinguished by the chondroid metaplasia of the synovial membrane of the joint, bursa or tendon sheath, which leads to the formation of loose bodies, usually intra-articular. It is characteristically monoarticular and the knee, hip and elbow are the joints most commonly affected. The shoulder is a rare localisation and the extra-articular involvement even rarer, with only few cases presented in the literature. The diagnosis is possibilited by the clinical examination and by the confirmation of the presence of multiple intra-articular loose bodies by roentgenographic studies and magnetic resonance (MR). The treatment is always surgical. Malignant degeneration of synovial chondromatosis into chondrosarcoma is described, although rare. We report an exceptionally rare case of synovial osteochondromatosis of the shoulder with combined intra and extra-articular involvement in a 28 years old female patient, former athlete. She presented with a five-year history of shoulder pain and slight limitation of motion. Radiographic examination and magnetic resonance imaging led us to the diagnosis of synovial chondromatosis of the shoulder. The patient underwent arthroscopic removal of the intra-articular loose bodies and partial synovectomy. The subscapularis recess was then identified through an anterior deltopectoral incision and multiple loose bodies were removed from within. Primary synovial chondromatosis of the shoulder is rare (5% of the cases) and the involvement of the extra-articular shoulder site is even rarer. Bloom and colleagues reported ten cases involving the shoulder in a meta-analysis of 191 synovial chondromatosis cases. The arthroscopic removal of the loose bodies combined with the partial sinovectomy has demonstrated efficacy and low recurrence rates, allowing excellent visualization of the joint, decreased morbidity and early functional return. Nevertheless, we think that this approach may become insufficient when the extra-articular involvement is verified

Aims. The aim of this study was to report a single surgeon series of consecutive patients with moderate hallux valgus managed with a percutaneous extra-articular reverse-L chevron (PERC) osteotomy. . Patients and Methods. A total of 38 patients underwent 45 procedures. There were 35 women and three men. The mean age of the patients was 48 years (17 to 69). An additional percutaneous Akin osteotomy was performed in 37 feet and percutaneous lateral capsular release was performed in 22 feet. Clinical and radiological assessments included the type of forefoot, range of movement, the American Orthopedic Foot and Ankle (AOFAS) score, a subjective rating and radiological parameters. . The mean follow-up was 59.1 months (45.9 to 75.2). No patients were lost to follow-up. Results. The mean AOFAS score increased from 62.5 (30 to 80) pre-operatively to 97.1 (75 to 100) post-operatively. A total of 37 patients (97%) were satisfied. At the last follow up there was a statistically significant decrease in the hallux valgus angle, the intermetatarsal angle and the proximal articular set angle. The range of movement of the first metatarsophalangeal joint improved significantly.. There was more improvement in the range of movement in patients who had fixation of the osteotomy of the proximal phalanx. Conclusion. Preliminary results of this percutaneous approach are promising. This technique is reliable and reproducible. Its main asset is that it maintains an excellent range of movement. Take home message: The PERC osteotomy procedure is an effective approach for surgical management of moderate hallux valgus which combines the benefits of percutaneous surgery with the versatility of the chevron osteotomy whilst maintaining excellent first MTPJ range of motion. Cite this article: Bone Joint J 2016;98-B:365–73

Aims: The aim of this study is to compare open Bankart procedure and arthroscopic extra-articular stabilization of the shoulder in patients with anterior instability. Material and Methods: 236 patients with recurrent anterior shoulder instability were treated surgically between 1992 and 2002. Open Bankart procedure was performed in 177 patients, mean age 29 years (range 17–67), and arthroscopic extra-articular stabilization in 59 patients, mean age 27 years (range 14–45). Single surgeon was performed all surgery. Follow-up for open surgery was from 2 to10 years, and for arthroscopic stabilization from 12 to 60 months. Results: Constant score for Bankart procedure was 90 points and for arthroscopic stabilization was 96 points. Five patients (2.8%) had re-dislocation after open procedure and three patients (5,1%) after arthroscopic stabilization. Conclusion: Open Bankart is more reliable than arthroscopic stabilisation of the shoulder. However, arthroscopic stabilisation has more advantages; better ROM, better function and cosmesis, lesser morbidity and small violation of normal anatomy

Aim. The aim of this study was to compare the cost-effectiveness of intramedullary nail fixation and ‘locking’ plate fixation in the treatment of extra-articular fractures of the distal tibia. Patients and Methods. An economic evaluation was conducted from the perspective of the United Kingdom National Health Service (NHS) and personal social services (PSS), based on evidence from the Fixation of Distal Tibia Fractures (UK FixDT) multicentre parallel trial. Data from 321 patients were available for analysis. Costs were collected prospectively over the 12-month follow-up period using trial case report forms and participant-completed questionnaires. Cost-effectiveness was reported in terms of incremental cost per quality adjusted life year (QALY) gained, and net monetary benefit. Sensitivity analyses were conducted to test the robustness of cost-effectiveness estimates. Results. Mean NHS and PSS costs were significantly lower for patients treated with an intramedullary nail than for those treated with a locking plate (-£970, 95% confidence interval (CI) -1685 to -256; p = 0.05). There was a small increase in QALYs gained in the nail fixation group (0.01, 95% CI -0.03 to 0.06; p = 0.52). The probability of cost-effectiveness for nail fixation exceeded 90% at cost-effectiveness thresholds as low as £15 000 per additional QALY. The cost-effectiveness results remained robust to several sensitivity analyses. Conclusion. This trial-based economic evaluation suggests that nail fixation is a cost-effective alternative to locking plate fixation. Cite this article: Bone Joint J 2018;100-B:624–33

1. A study is presented of 286 extra-articular subtalar arthrodeses done during the years 1958 to 1965 on 258 patients with pes calcaneo-valgus, pes planovalgus, pes varus or flail foot. 2. Certain changes in the surgical technique originally presented by Grice have been made. We have applied the arthrodesis not only to valgus feet but also to varus feet, and we have described the details of the surgical technique as used on the varus foot. 3. In none of our cases was there failure of fusion or reabsorption of the graft. The unsatisfactory results (239 per cent) were caused by residual varus or valgus deformity of the foot

Background: Extra-articular fractures of the distal radius in children are most often treated with closed reduction and cast immobilization. The purpose of this retrospective study was to evaluate long term (> 12 years follow-up) objective and subjective outcomes in a consecutive series of pediatric patients treated with closed reduction with standardized outcome instruments. We hypothesized that children treated with closed reduction and cast immobilization have little or no objective functional impairment in later life and therefore subjective factors are the strongest determinants of outcome. Methods: Twenty-seven patients with an average age at time of injury of 9 years (range, five to sixteen years) were evaluated at an average of twenty-one years (range, twelve to twenty seven years) after injury (patients aged 21 to 39) after closed reduction of an extra-articular distal radius fracture. Patients were evaluated using 2 physician-based evaluation instruments (modified Mayo wrist score; MMWS, and the Sarmiento modification of the Gartland and Werley score; MGWS) and an upper extremity-specific health status questionnaire (Disabilities of the Arm, Shoulder and Hand; DASH) questionnaire. Radiographic measurements were also made. Multivariable analysis of variance and multiple linear regression modelling were used to identify the degree to which various factors affect variability in the scores derived with these measures. Results: All fractures had healed without significant loss of alignment. Final functional results according to the MGWS were rated as excellent or good in all patients. The average MMWS score was 90 points, and the median DASH score was 0 points. Twenty patients (74%) considered themselves pain free. Bivariate analysis revealed pain -as rated according to scales used in the MMWS- and age at time of injury to be correlated with DASH scores, with pain as the only independent predictor of patient-based outcome in multivariable analysis. This explains almost three quarters of the variability in DASH scores. Pain, range of motion, and radiographic measurement of radial length correlated with the physician based scoring system MMWS;. Conclusions: Twenty-one years after injury 96% of patients have a satisfactory outcome according to physician-based MMWS categorical ratings and patient-based DASH scores. It is remarkable that pain explained 74% of the variation in DASH scores. Perhaps when there is very little impairment, subjective factors are more important determinants of disability

Of 23 children (35 feet) with cerebral palsy who had undergone a Grice extra-articular subtalar arthrodesis for a valgus hindfoot between 1976 and 1981, we reviewed 17 (26 feet), at a mean of 20 years (17 years 3 months to 22 years 4 months) after operation. Seven were quadriplegic, eight spastic diplegic, and two hemiplegic. They were all able to walk at the time of operation. Thirteen patients (20 feet) were pleased with the Grice procedure, 13 had no pain and 15 (23 feet) were still able to walk. The clinical results were satisfactory for most feet. Radiography showed that the results had been maintained over time but 14 feet developed a mean ankle valgus of 11° (6 to 18) with a compensatory hindfoot varus in 12 feet. No deformity of the talus or arthritis of adjacent joints was noted. The Grice procedure gives good long-term results in children with cerebral palsy

Objective: To evaluate the clinical and radiological outcome of an intra-articular bone-patellar tendon-bone (B-PT-B) anterior cruciate ligament reconstruction in combination with an extra-articular tenodesis (Lemaire procedure), at very long term follow-up. Methods: Out of a total of 148 patients, 100 were available for clinical and/or radiological evaluation in 2006. The minimum follow-up is 21 years with a mean of 24.5 years. Outcome parameters included objective (IKDC) and subjective (KOOS) clinical scores, and radiographs (standing, TELOS). Results: 84% of the patients were very satisfied or satisfied. The objective IKDC classification was: A=17%, B=41%, C=34%, D=8%. In 2006, 27% had narrowing < 50% (C) and 27% had narrowing > 50% (D). Onset of osteoarthritis correlated with medial meniscus status and medial femoral chondral defects. Knees with a preserved (healthy or sutured) medial meniscus had a significantly (p< 0.05) better radiological outcome. 24% had narrowing < 50% (C) and 12% had narrowing > 50% (D). Risk factors for osteoarthritis were: medial meniscectomy, residual laxity, age at intervention and femoral chondral defects. Conclusion: The outcome of anterior cruciate ligament reconstruction using a B-PT-B in combination with extra-articular tenodesis is satisfactory in the very long term, in knees with a preserved medial meniscus and normal cartilage

Limb-sparing surgery has become the preferred surgical treatment of malignant bone tumours of the knee. In patients with intra-articular extension of their tumour, extra-articular limb sparing surgery can prevent the knee from amputation. In a retrospective study between January 1985 and December 2007, we performed 34 extra-articular tumour resections of the knee-joint for a bone- or soft tissue tumour in the distal femur or proximal tibia with (suspect) intra-articular tumour extension into the knee on MRI. Contra-indications were extension of the tumour into the extensor mechanism and/or tumour involvement of the neurovascular bundle. Osteosarcoma (23/34) was the most common primary malignancy. Mean age was 36 years (17–70) and the mean follow up was 9 years (1–19). Patient survival rates at 5 years and 10 years are 78% and 58% respectively, mean patient survival was 47 months (8–211). In 12 (35%) patients, the primary implanted prosthesis failed during follow up. Prosthetic survival rates including minor revision surgery were 63% at 5 years and 36% at 10 years. Six (18%) patients had local recurrence of their malignancy, 5 of them in the popliteal fossa. Local recurrence was significantly correlated with marginal margins (P< 0.05). Fifteen patients had major complications (44%) mainly deep infection in proximal tibia resections and aseptic loosening in distal femur resections. Aseptic loosening was significantly correlated with non HA-coated stems (P< 0.05). Functional outcome scores according to MSTS (mean 81, (65–93)) and TESS (mean 85, (56–98)) of survivors are good. Our results suggest that extra-articular tumour resections of the knee-joint can provide a functional endoprosthesis and can be an alternative for primary amputation. However it is a technical demanding procedure with acceptable local recurrence and high complication rates in patients with, in general, poor survival

A new technique is described for extra-articular subtalar arthrodesis; it combines the main elements of the Batchelor and the Grice procedures. Results were reviewed after a minimum of three years. Of the 25 feet treated 24 had solid fusion and had maintained the operative correction of the valgus deformity; the one non-union was due to deep infection

We describe 129 patients with disabling instability of the knee due to deficiency of the anterior cruciate ligament. They were treated by replacement of the ligament with a Leeds-Keio prosthesis supplemented by an extra-articular MacIntosh lateral substitution reconstruction. After an average period of 71 months a satisfactory outcome was found in only 60% of knees. Nine had required revision because of recurrent instability and the pivot-shift sign had become positive in 40% of patients. In our opinion the long-term results are unsatisfactory when compared with those obtained using a graft from the medial third of the patellar tendon supplemented with a MacIntosh extra-articular tenodesis

Many methods of reconstruction for ACL deficiency have been described, but little is known about their biomechanical properties. We examined extra-articular (EA), intra-articular (IA) and combined (EA+IA) reconstructions in ten cadaver knees after the ACL had been ruptured by the performance of a rapid anterior drawer movement. Stability at each stage before and after rupture and reconstruction was tested by anterior drawer, Lachman, varus-valgus and tibial rotation tests. Both IA and IA+EA reconstructions restored normal stability, while EA reconstructions improved stability but did not restore it to normal. The addition of an EA procedure to an IA procedure made no difference to knee stability. We conclude that in cases of isolated ACL deficiency there is no biomechanical basis for EA reconstruction, either alone or in addition to an IA reconstruction

Summary Statement. We present a simple and useful geometrical equation system to carry out the pre-operative planning and intra-operative assessments for total knee arthroplasty. These methods are extremely helpful in severely deformed lower limbs. Introduction. Total knee arthroplasty is a highly successful surgery for most of the patients with knee osteoarthritis. With commercial instruments and jigs, most surgeons can correct the deformity and provided satisfactory results. However, in cases with severe extra-articular deformity, the instruments may mislead surgeons in making judgment of the true mechanical axis. We developed a geometrical equation system for pre-operative planning and intra-operative measurement to perform correct bony cuts and achieve good post-operative axis. Patients & Methods. From 2008 to 2012, twenty-four patients with severe extra-articular deformities of low limbs underwent total knee arthroplasties for osteoarthritis. The deformities included malunion of femoral or tibial shafts with angulation, non-union of femoral supracondylar fractures, failed high tibia osteotomies, severe bowing of femurs, and other post-traumatic sequelae. The intra-medullary or extra-medullary guide devices were not possible to provide correct axis in these cases. For pre-operative planning, we analyzed the deformities on triple-film scanography and standing anterior-posterior and lateral X-ray films. The angles needed to be corrected in coronal and sagittal planes were measured. A geometrical equation system was applied to calculate the thickness of the proximal tibia cut and distal femoral cut. If the flexion contracture was presented, the degree of necessary elevation of joint line was also calculated. Intra-operatively, the degree of rotation of anterior and posterior femoral cuts was assessed after proximal tibial and distal femoral cuts. The sizes of prosthesis were judged according to the balance between flexion and extension gaps. A 3-in-1 jig was used for chamfering of the femur. After fine-tuning of bony cuts and balancing of soft tissue, the prostheses were cemented. The conventional intra-medullary and extra-medullary guiding devices were not used during the whole procedure. Results. All of the patients achieved satisfactory results in the aspect of pain relief and functional outcomes. All patients had good post-operative axis in coronal plane (varus or valgus deformity < 3 degrees). Twenty-two patients (92%) achieved good sagittal alignments (deformity < 3 degrees). The results were compatible with those in the patient population without those severe deformities. There was no major complication among these patients. Discussion/Conclusion. In this series, we present a simple and useful geometrical equation system to carry out the pre-operative planning and intra-operative assessments for total knee arthroplasty. These methods are extremely helpful in severely deformed lower limbs. Optimal post-operative alignments were achieved in this series and no major complication was found

Using finely reconstructed helical pelvis CT scans of ninety-three cases and image analysis software, we define the “Safe Zone” for the extra-articular placement of screws during internal fixation of the acetabulum, using a Stoppa approach. Screws should be at most: 11mm from the top of the Sciatic notch, 23mm from the tip of the Ischial Spine, and at most 5mm posterior to the top of the Obturator canal, along the pelvic brim. The purpose of this study was to identify a “safe zone” in the inner pelvis, to allow extra-articular screw placement using the Stoppa approach. Acetabulum internal fixation screws can safely (extra-articular position) be placed through the Stoppa approach using three identifiable landmarks. Surgeons can use these identifiable anatomic landmarks for the safe placement of screws along the inner aspect of the acetabulum. Study Population: males:females 47%:53%, mean age: 51,3yrs (18–88). Reference measurements (means): Femoral Head (FH): 45,5mm (36–6), Inter-SI joint:177,9mm (102–34). Safe distance to joint: 1) from Sciatic notch: 11mm; 2) from Ischial Spine: 23mm; 3) from Obturator roof: 5mm. The Ischial Spine Distance (ISD) showed clustering (p< 0.05) into two groups according to Femoral Head diameter: FH< 47mm: Safe ISD=23mm ; FH≥47mm: Safe IS=28mm. Ninety-three Helical Pelvis CT scans with fine reconstruction were done between July 1, 1999-June 30, 2000. Axial images were analyzed using GE Vox Tool® v.3.0.3 image analysis software. The femoral head diameter and the Inter-SI joint distance were used as reference. The distance between three identifiable bony landmarks and the point which would allow the placement of a 4mm screw outside the hip joint were measured. Inter and Intra-observer reliability study showed a difference < 1mm in > 90% of cases. Surgical approaches which avoid extensive dissection and manipulation of the gluteal musculature are gaining in popularity. The Stoppa is such an approach which gives access to the medial acetabular wall and to the inner pelvis from the SI joint to the symphysis along the pelvic brim. This blind approach does not allow visualisation of the joint and confirmation of screw placement. The present paper offers surgeons these reference points

Aim: To evaluate time of union and functional recovery of the shoulder joint in humeral shaft fractures treated with antegrade intramedullary nailing. Methods: During 1998–2002, 29 patients (16 male and 13 female, mean age 43.7 years) with humeral shaft fractures underwent antegrade, proximal locked, intramedullary nailing. A modified extra-articular entry point, 1 cm below the greater tuberosity, was used to avoid rotator cuff damage. The nail, after accurate measurement of its length and proximal metaphysis enlargement up to 10 mm, was impacted into the narrow, cone-shaped, distal part of the humerus, without the necessity of distal screw interlocking. Passive motion of the shoulder joint was initiated from the 2nd postoperative day and active assisted exercises after the 2nd postoperative week. Results: Mean follow up period was 27 months. Solid callus formation was noted in all fractures, between the 14th and 18th postoperative week. No cases of intra-operative fractures, nerve irritation, rotational instability, nail migration and loss of distal impaction were noted. Mean Constant-Murley score was 93 points at the 16th postoperative week. Conclusion: Antegrade intramedullary nailing is a reliable and beneficial procedure for the treatment of humeral shaft fractures, regarding union and functional recovery of the arm. The extra-articular entry point should be preferred to avoid rotator cuff and articular surfaces damage whereas the accurate measurement of the nail length and the firm impaction of it at the olecranon fossa makes distally interlocking unnecessary, decreasing significantly the overall operative time and the associated complications

Arthrolysis and dynamic splinting have been used in the treatment of elbow contractures, but there is no standardised protocol for treatment of severe contractures with an arc of flexion < 30°. We present our results of radical arthrolysis with twin incisions with the use of a monolateral hinged fixator to treat very severe extra-articular contracture of the elbow. This retrospective study included 26 patients (15 males and 11 females) with a mean age of 30 years (12 to 60). The mean duration of stiffness was 9.1 months (5.4 to 18) with mean follow-up of 5.2 years (3.5 to 9.4). The mean pre-operative arc of movement was 15.6° (0° to 30°), with mean pre-operative flexion of 64.1° (30° to 120°) and mean pre-operative extension of 52.1° (10° to 90°). Post-operatively the mean arc improved to 102.4° (60° to 135°), the mean flexion improved to 119.1° (90° to 140°) and mean extension improved to 16.8° (0° to 30°) (p < 0.001). The Mayo elbow score improved from a mean of 45 (30 to 65) to 89 (75 to 100) points, and 13 had excellent, nine had good, three had fair and one had a poor result. We had one case of severe instability and one wound dehiscence which responded well to treatment. One case had deep infection with poor results which responded well to treatment. Our findings indicate that this method is very effective in the treatment of severe elbow contracture; however, a randomised controlled study is necessary for further evaluation

Purpose of the study: Reconstruction of the anterior cruciate ligament (ACL) has become a common procedure. We compared two randomized series: intra-articular (Kenneth-Jones) versus intra- and extra-articular (MacInJones). Material and methods: From January 1995 through March 1998, 73 knees were treated surgically for differential medial laxity measured at 7 to 12 mm on passive stress x-rays in 20° flexion. Group 1 (ACL reconstruction alone) included 34 patients (aged 27.1±7.5 years). Group 2 (ACL reconstruction plus extra-articular plasty) included 29 patients (aged 28.5±12 years). Function was scored 72% in group 1 and 68% in group 2 at mean seven years follow-up (102 and 93 months follow-up respectively). Anterior laxity was measured radiographically and with KT-1000 and the position of the tunnels was assessed according to Aglietti. Results: According to the IKDC, functional outcome was 83.9±3.1 in group 1 and 83.3±3.6 in group 2. The overall IKDC classification was 0A, 57.8% B, 26.3% C, and 15.7% D for group 1 and 58% A, 52.9% B, 29.4% C, and 11.7% D for group 2. The pivot-shift test was negative in 61.1% of group 1 knees (27.7% grade 1 and 11.1% grade 2) and negative in 83.3% of group 2 knees (16.6% grade 1). In group 1, the radiological drawer showed 46.09% improvement in the differential laxity for the medial compartment and 41% for lateral compartment. In group 2 the corresponding improvements were 44.8% and 44.6%. There was no difference in tunnel position between the two groups. Discussion: The two-year results of this series did not provide any evidence favoring a clear advantage of complementary lateral plasty. At seven years follow-up, the pivot-shift test appeared to favor associated lateral plasty (p=0.09), but with no significant difference in laxity for the two compartments. Conclusion: Anterior laxity was only incompletely controlled by both reconstruction techniques. In this context of relatively limited laxity (7–12 mm initially), at seven years follow-up there was no certain advantage of complementary lateral extra-articular plasty in combination with ACL reconstruction

From 1982 to 1987 we treated 85 extra-articular comminuted distal third humeral fractures in adults with prefabricated plastic braces. Of these, 15% were open fractures and 18% had initial peripheral nerve injury. On average, the sleeve was applied 12 days after injury and used for 10 weeks. There was 96% union, with no infections. All nerve injuries resolved or were improving at the latest examination. At union there was varus deformity averaging 9 degrees in 81% of patients, but loss of range of movement was minimal and functional results were good

Background. To establish relative fixation strengths of a single lateral locking plate, a double locking plate, and a tibial nail in treatment of proximal tibial extra-articular fractures. Methods. Three groups of composite tibial synthetic bones consisting of 5 specimens per group were included; lateral plating (LP) using a LCP-PLT (locking compression plate-proximal lateral tibia), double plating (DP) using a LCP-PLT and a LCP-MPT (locking compression plate-medial proximal tibia), and intramedullary nailing (IN) using an ETN (expert tibial nail). To simulate a comminuted fracture model, a gap osteotomy measuring 1 cm was cut 8 cm below the joint. For each tibia, a minimal preload of 100N was applied before loading to failure. A vertical load was applied at 25mm/min until tibia failure. Results. For axial loading, fixation strength of DP (14387.3N, SD=1852.1) was 17.5% greater than that of LP (12249.3N, SD=1371.6), and 60% less than that of IN (22879.6N, SD=1578.8) (p<0.001). For ultimate displacement in axial loading, similar results were observed for LP (5.74mm, SD=1.01) and DP (4.45mm, SD=0.96), with a larger displacement for IN (5.84mm, SD=0.99). Conclusion. In biomechanical testing of a comminuted proximal tibial fracture model, DP proved stronger than LP in terms of ultimate strength. IN proved strongest; however, DP may be an acceptable alternative for minimally invasive osteosynthesis, which may be technically difficult to fix using a nail

We describe 74 patients with disabling instability of the knee due to isolated anterior cruciate deficiency. None responded to conservative measures or correction of internal derangements. All patients were treated by replacement of the anterior cruciate ligament with the medial third of the patellar tendon as a free graft, supplemented by an extra-articular MacIntosh lateral reconstruction. A satisfactory outcome was found in 93% of knees after an average of 70 months follow-up. Cast immobilisation after operation, the interval between injury and reconstruction, the age of the patient and the severity of symptoms before reconstruction had no significant effect on the final outcome

The comparability of studies of extra-articular proximal femur fractures is compromised by the lack of a widely accepted, simple classification system with clinical and prognostic relevance. The aim of the study is to define the complication profile as well as differences relating to age, gender and survival rate of simple trochanteric fractures (typ 1), intertrochanteric comminute (typ 2) and subtrochanteric fractures (typ 3). The records of 335 consecutive patients were analysed prospectively. Patients had a mean follow-up of 10 (0–56) months, and were treated operatively with three intramedullary nailing systems. Simple trochanteric fractures (n=67) show only wound healing problems (1.5%). Median age is m/f 76.4(45–98) years/82.7(39–101), and the two-year survival rate is m/f 50.3%/84.9%. Intertrochanteric comminute fractures (n=204) demonstrate the highest complication rates (25%) with 9.7% femur head perforations, 3.5% other hardware related problems and 11.8% wound healing problems. Median age is m/f 72.5(41–94) years/83.6(54–100), survival rate is m/f 92.7%/66.5%. We observe a complication rate of 17.0% in subtrochanteric fractures (n=64), no femur head perforation but 9.1 % other hardware problems and 7.8% wound healing problems. Median age is m/f 61.1(24–91) years/81.6(38–99), surviving rate is m/f 92.3%/67.9%. The overall complication rate is nearly twice as high in females compared to males (19% versus 10%). The 3 types of proximal extraarticular femur fractures show diferrences in epidemiological data such as median age and surviving rates. Furthermore intramedullary nail osteosynthesis of extraarticular proximal femur fractures lead to different complication patterns in simple trochanteric fractures, in comparison to inter-trochanteric comminuted fractures and subtrochanteric fractures. The recommended surgical treatment in Type 1 fractures leads to a low complication rate. Type 3 fractures exhibit an acceptable complication level; pseudarthrosis and intraoperative shaft fissures as well as wound healings problems are the main complications. Type 2 fractures represent fractures whose treatment is problematic, with the highest complication rate of hardware-related problems (13.2%), including femoral head perforation (9.7%), and the highest number of wound healing complications (11.8%), more than a third of which are infections

Purpose: To compare the functional outcome and quality-of-life following a displaced extra-articular proximal humerus fracture treated with open reduction and locking plate fixation versus non-operative management. To provide preliminary data for a subsequent prospective clinical trial. Method: Eligible subjects were identified through retrospective searches of a large emergency department admission database and the orthopaedic trauma database. All subjects ages . 3. 55 treated for a proximal humerus fracture between 2002 to 2005 were invited to participate. The Disabilities of Arm, Shoulder, and Hand (DASH), Health Utilities Index Mark 3 (HUI), Euroqol-5D (EQ-5D), and the SF-36 questionnaires were mailed to all eligible subjects. Initial radiographs were reviewed using the AO/OTA classification system. Only patients with A3, B1, B2, or B3 fractures were included. Results: Thiry-four subjects were included: 15 were treated with sling immobilization and 19 with locked plate ORIF. The non-operative group was approximately seven years older (mean age 74 versus 67, p = 0.046). DASH scores were similar between the groups: ORIF 26.6 ± 24 and Sling 26.5 ± 20. The 95% CI surrounding the 0.01 point difference (−16.0 to 15.9) slightly exceeds the 13 point cutoff for the instrument’s measurement error (minimal detectable change). Using univariable analysis, no statistically significant differences in health state values were detected. The mean HUI value for the ORIF group was 0.68 versus 0.75 for the sling (p=0.48). Mean EQ-5D values were 0.77 for the ORIF group and 0.80 for the sling group (p=0.73). The SF-36 PCS scores were also similar between the two groups: ORIF 41.1 versus Sling 39.8 (p=0.77). When controlling for age and pre-injury function, a 0.09 point difference in HUI values was detected favouring the sling treatment (p=0.036). No differences in DASH, EQ-5D, or SF-36 PCS scores were detected using regression models. Conclusion: The results of this small cohort suggest, for extra-articular fractures, the functional and quality of life outcomes may be similar between the two interventions. No trial comparing locked plate fixation and non-operative management has been reported. A total of 96 subjects will be needed for a prospective clinical trial comparing the two treatments (DASH difference 15, 80% power, 0.05 two-sided alpha)

Purpose of the study: For medial osteoarthritis with chronic anterior laxity, we propose an original technique combining subtraction osteotomy and extra-articular ligmentoplasty using the lateral quarter of the patellar tendon. Material and methods: WE report a retrospective review of 29 patients (11 males/18 females) aged 29–51 years treated from May 1996 to October 2002. Time from rupture of the anterior cruciate ligament (ACL) and the operation was 17.5 years (range 13–22 years). These patients had had 52 prior operations (more than one per knee). All presented functional instability, a positive pivot test, and anterior laxity measured at 8 mm on average (range 5–10 mm) on KT1000. Pain in the medial compartment was observed in all patients with osteoarthritis noted grade II in 7, grade III in 18 and grade IV in 4. Radological varus measured 5–15°. Lateral subtraction osteotomy fixed with a plate was performed in combination with a patellar tendon autograft using the lateral quarter of the patellar tendon. Immediate mobilization with complete weight bearing was the rule. Results: A mean 5–year follow-up (range 18 months to 9 years). According to the IKDC subjective score, 26 patients were satisfied or very satisfied and 22 of them had resumed their sports activities. Instability persisted in one patient and pain in two. Varus was corrected in three patients but the medial degradation progressed. Anterior laxity measured with KT1000 was 1–6 mm (mean 2 mm). The pivot test was positive in one knee, negative in 18 and revealed slight displacement in 10. Excluding the radiological aspect, the overall IKDC score was 2A, 21B, 6C, 1D. Conclusion: This combined method is particularly interesting for stabilizing chronic ACL instability causing secondary medial degeneration. It treats two conditions with the same approach with an acceptable rate of satisfaction