Cerebral Palsy (CP) is a group of disorders that affect movement and posture caused by injury to the developing brain. While prematurity and low birth weight are common causes in developed countries, birth asphyxia, kernicterus, and infections have been identified as predominant aetiologies in Africa. There is, however, very little information on the aetiology of CP in South Africa. The purpose of this study was to determine the aetiology, severity, and topographical distribution of CP in children undergoing orthopaedic surgery at our tertiary paediatric unit. A retrospective folder review was performed for patients with CP that underwent orthopaedic surgery from July 2018 to June 2022. Data was collected on perinatal circumstances, aetiology or risk factors for developing CP, severity of disability as classified by the Gross Motor Function Classification Scale (GMFCS) and topographical distribution. Descriptive analysis was performed. Two-hundred-and-thirty-four patients were included in the analysis. No specific aetiology could be identified in 51 (21.9%) patients. Hypoxic ischaemic encephalopathy (HIE) accounted for 23.6% of patients and was the most common aetiology across the different categories except for patients graded as GMFCS 2, in whom prematurity was the most common aetiology. Congenital brain malformations (10.5%) and cerebral infections, including HIV encephalopathy (11.4%) were the next most frequent aetiologies, followed by prematurity (7.6%), ischaemic stroke (6.8%) and intraventricular haemorrhage (6.3%). Fifty-two percent of patients were classified as GMFCS 4 or 5. There was a predominance of quadriplegic patients (37%) compared to hemiplegics (29%), diplegics (30%) and monoplegics (4%). Most patients undergoing orthopaedic surgery for musculoskeletal sequelae of CP were severely disabled quadriplegic patients in whom HIE was the predominant cause of CP. This emphasises the need for intervention at a primary care level to decrease the incidence of this frequently preventable condition

Purpose. Fracture-related infection (FRI) is an important complication related to orthopaedic trauma. Although the scientific interest with respect to the diagnosis and treatment of FRI is increasing, data on the microbiological epidemiology remains limited. Therefore, the primary aim of this study was to evaluate the microbiological epidemiology related to FRI, including the association with clinical symptoms and antimicrobial susceptibility data. The secondary aim was to analyze whether there was a relationship between the time to onset of infection and the microbiological etiology of FRI. Methods. Over a five-year period, FRI patients treated at the University Hospitals of Leuven, Belgium, were retrospectively included. The microbiological etiology and antimicrobial susceptibility data were analyzed. Patients were classified as having an early (<2 weeks after implantation), delayed (2–10 weeks) or late-onset (> 10 weeks) FRI. Results. One hundred ninety-one patients with 194 FRIs, mainly involving the tibia (23.7%) and femur (18.6%), were included. Staphylococcus aureus was the most frequently isolated pathogen, regardless of time to onset (n=61; 31.4%), followed by S. epidermidis (n=50; 25.8%) and non-epidermidis coagulase-negative staphylococci (n=35; 18.0%). Polymicrobial infections (n=49; 25.3%), mainly involving Gram-negative bacilli (n=32; 65.3%), were less common than monomicrobial infections (n=138; 71.1%). Virulent pathogens in monomicrobial FRIs were more likely to cause pus or purulent discharge (n=45;54.9%; p=0.002) and fistulas (n=21;25.6%; p=0.030). Susceptibility to piperacillin/tazobactam for GNB was 75.9%. Vancomycin covered 100% of Gram-positive cocci. Conclusion. The high frequency of polymicrobial infections, including Enterobacterales and enterococci, should be considered when choosing an empirical regimen, especially for early FRI. However, since antibiotic stewardship is the cornerstone of good antibiotic practice, overuse and misuse of broad-spectrum empiric therapy should be avoided at all costs. Large multicenter prospective studies are necessary to gain more insight into the added value of (broad) empirical antibiotic therapy

Aims. Advances in surgical technique and implant design may influence the incidence and mechanism of failure resulting in revision total hip arthroplasty (rTHA). The purpose of the current study was to characterize aetiologies requiring rTHA, and to determine whether temporal changes existed in these aetiologies over a ten-year period. Methods. All rTHAs performed at a single institution from 2009 to 2019 were identified. Demographic information and mode of implant failure was obtained for all patients. Data for rTHA were stratified into two time periods to assess for temporal changes: 2009 to 2013, and 2014 to 2019. Operative reports, radiological imaging, and current procedural terminology (CPT) codes were cross-checked to ensure the accurate classification of revision aetiology for each patient. Results. In all, 2,924 patients with a mean age of 64.6 years (17 to 96) were identified. There were 1,563 (53.5%) female patients, and the majority of patients were Caucasian (n = 2,362, 80.8%). The three most frequent rTHA aetiologies were infection (27.2%), aseptic loosening (25.2%), and wear (15.2%). The frequency of rTHA for adverse local tissue reaction (ALTR) was significantly greater from 2014 to 2019 (4.7% vs 10.0%; p < 0.001), while the frequency of aseptic loosening was significantly greater from 2009 to 2013 (28.6% vs 21.9%; p < 0.001). Conclusion. Periprosthetic joint infection was the most common cause for rTHA in the current cohort of patients. Complications associated with ALTR necessitating rTHA was more frequent between 2014 to 2019, while aseptic loosening necessitating rTHA was significantly more frequent between 2009 to 2013. Optimizing protocols for prevention and management of infection and ALTR after THA may help to avoid additional financial burden to institutions and healthcare systems. Cite this article: Bone Joint Open 2020;2(1):16–21

Flat-top talus (FTT) is a complication well-known to those treating clubfoot. Despite varying anecdotal opinions, its association with different treatments, especially the Ponseti method, remains uncertain. This systematic review aimed to establish the aetiology and prevalence of FTT, as well as detailing management strategies and their efficacy. A systematic review was conducted according to PRISMA guidelines to search for articles using MEDLINE, EMBASE and Web of Science until November 2021. Studies with original data relevant to one of three questions were included: 1) Possible aetiology 2) Prevalence following different treatments 3) Management strategies and their outcomes. 32 original studies were included, with a total of 1473 clubfeet. FTT may be a pre-existing feature of the pathoanatomy of some clubfeet as well as a sequela of treatment. It can be a radiological artefact due to positioning or other residual deformity. The Ponseti method is associated with a higher percentage of radiologically normal tali (57%) than both surgical methods (52%) and non-Ponseti casting (29%). Only one study was identified that reported outcomes after surgical treatment for FTT (anterior distal tibial hemiepiphysiodesis). The cause of FTT remains unclear. It is seen after all treatment methods but the rate is lowest following Ponseti casting. Guided growth may be an effective treatment. Key words:. Clubfoot, Flat-top talus, Ponseti method, guided growth. Disclosures: The authors have no relevant disclosures

Aims. The glenohumeral joint is the most frequently dislocated articulation, but possibly due to the lower prevalence of posterior shoulder dislocations, approximately 50% to 79% of posterior glenohumeral dislocations are missed at initial presentation. The aim of this study was to systematically evaluate the most recent evidence involving the aetiology of posterior glenohumeral dislocations, as well as the diagnosis and treatment. Materials and Methods. A systematic search was conducted using PubMed (MEDLINE), Web of Science, Embase, and Cochrane (January 1997 to September 2017), with references from articles also evaluated. Studies reporting patients who experienced an acute posterior glenohumeral joint subluxation and/or dislocation, as well as the aetiology of posterior glenohumeral dislocations, were included. Results. A total of 54 studies met the inclusion criteria. In total, 182 patients were included in this analysis; study sizes ranged from one to 66 patients, with a mean age of 44.2 years (. sd. 13.7). There was a higher proportion of male patients. In all, 216 shoulders were included with 148 unilateral injuries and 34 bilateral. Seizures were implicated in 38% of patients (n = 69), with falls, road traffic accidents, electric shock, and iatrogenic reasons also described. Time to diagnosis varied across studies from immediate up to a delay of 25 years. Multiple associated injuries are described. Conclusion. This review provides an up-to-date insight into the aetiology of posterior shoulder dislocations. Our results showed that seizures were most commonly implicated. Overall, reduction was achieved via open means in the majority of shoulders. We also found that delayed diagnosis is common

Femoroacetabular impingement causes pain in the hip in young adults and may predispose to the development of osteoarthritis. Genetic factors are important in the aetiology of osteoarthritis of the hip and may have a role in that of femoroacetabular impingement. We compared 96 siblings of 64 patients treated for primary impingement with a spouse control group of 77 individuals. All the subjects were screened clinically and radiologically using a standardised protocol for the presence of cam and pincer deformities and osteoarthritis. The siblings of those patients with a cam deformity had a relative risk of 2.8 of having the same deformity (66 of 160 siblings hips versus 23 of 154 control hips, p < 0.00001). The siblings of those patients with a pincer deformity had a relative risk of 2.0 of having the same deformity (43 of 116 sibling hips versus 29 of 154 control hips, p = 0.001). Bilateral deformity occurred more often in the siblings (42 of 96 siblings versus 13 of 77 control subjects, relative risk 2.6, p = 0.0002). The prevalence of clinical features in those hips with abnormal morphology was also greater in the sibling group compared with the control group (41 of 109 sibling hips versus 7 of 46 control hips, relative risk 2.5, p = 0.007). In 11 sibling hips there was grade-2 osteoarthritis according to Kellgren and Lawrence versus none in the control group (p = 0.002). Genetic influences are important in the aetiology of primary femoroacetabular impingement. This risk appears to be manifested through not only abnormal joint morphology, but also through other factors which may modulate progression of the disease

Objectives. A successful outcome following treatment of nonunion requires the correct identification of all of the underlying cause(s) and addressing them appropriately. The aim of this study was to assess the distribution and frequency of causative factors in a consecutive cohort of nonunion patients in order to optimise the management strategy for individual patients presenting with nonunion. Methods. Causes of the nonunion were divided into four categories: mechanical; infection; dead bone with a gap; and host. Prospective and retrospective data of 100 consecutive patients who had undergone surgery for long bone fracture nonunion were analysed. Results. A total of 31% of patients had a single attributable cause, 55% had two causes, 14% had three causes and 1% had all four. Of those (31%) with only a single attributable cause, half were due to a mechanical factor and a quarter had dead bone with a gap. Mechanical causation was found in 59% of all patients, dead bone and a gap was present in 47%, host factors in 43% and infection was a causative factor in 38% of patients. In all, three of 58 patients (5%) thought to be aseptic and two of nine (22%) suspected of possible infection were found to be infected. A total of 100% of previously treated patients no longer considered to have ongoing infection, had multiple positive microbiology results. Conclusion. Two thirds of patients had multiple contributing factors for their nonunion and 5% had entirely unexpected infection. This study highlights the importance of identifying all of the aetiological factors and routinely testing tissue for infection in treating nonunion. It raises key points regarding the inadequacy of a purely radiographic nonunion classification system and the variety of different definitions for atrophic nonunion in the current mainstream classifications used for nonunion. Cite this article: L. Mills, J. Tsang, G. Hopper, G. Keenan, A. H. R. W. Simpson. The multifactorial aetiology of fracture nonunion and the importance of searching for latent infection. Bone Joint Res 2016;5:512–519. DOI: 10.1302/2046-3758.510.BJR-2016-0138

1. During a fifteen-year period a clinical, radiological and in some cases a surgical study has been made of 319 patients suffering from spondylolisthesis–that is, forward slipping of one lumbar vertebra on another or forward sagging of the whole lumbar spine in relation to the sacrum. 2. The five etiological factors are described, and the cases are assigned to five groups according to the factor responsible for the slip. In every case slipping is permitted by a lesion of the apparatus which normally resists the forward thrust of the lower lumbar spine–that is, the hook of the neural arch composed of the pedicle, the pars interarticularis and the inferior articular facet engaging caudally over the superior articular facet of the vertebra below. 3. In Group I (congenital spondylolisthesis–sixty-six cases) the lesion is a congenital defect of the facets. In Group II (spondylolytic spondylolisthesis–164 cases) the lesion occurs in the region of the pars interarticularis and is either an elongation of the bone or a break in continuity. There are reasons for thinking that the lesion is caused by stress over a long period rather than by acute injury or by a congenital anomaly of ossification. In Group IV (degenerative spondylolisthesis–eighty cases) the lesion of the facets is degenerative. There are no good grounds for thinking that an abnormality of the angle between the facets and the pedicles is the primary lesion behind the degenerative change. 4. Group III and V comprise few cases. In the former (traumatic spondylolisthesis–three cases) the lesion–a fracture of the neural arch–is caused by a single severe injury. In Group V (pathological spondylolisthesis–six cases) the slipping is caused by weakness of bone from various causes. 5. A full description is given of the etiological and biomechanical features of each group. A special investigation has been made into the etiological factors in degenerative spondylolisthesis. 6. The incidence of involvement of nerve tissues is highest in degenerative spondylolisthesis; the most severe degrees of slip are found in congenital spondylolisthesis

1 . Current theories of the etiology of chondromalacia patellae do not explain satisfactorily either its great frequency or its common site of origin on the medial patellar facet. 2. The etiology can be more logically explained by the presence of a ridge on the upper anterior border of the cartilage of the medial femoral condyle, in most knees. This ridge, consisting of cartilage, or cartilage and bone, varies considerably in height and, in normal knee joint movement, causes considerable friction on the medial patellar facet. 3. The degenerative changes were found to be greater in the presence of the larger ridges, and–because of longer wear and tear–in the older patients. 4. This study indicates that chondromalacia was more severe in women than in men, and in patients overweight. Although the activity of the individual and the power of the quadriceps mechanism must play an extremely important part in this condition, it was not possible to assess this. 5. Two factors previously considered to be important in the etiology of this condition, namely, the length of the patellar tendon and Wiberg's Type III patellar shape, have not been confirmed in this study. 6. Resulting from the present investigation certain precautions are suggested in rehabilitation after operations on the knee, and a surgical method for discouraging the progress of this common, and sometimes disabling, condition has been devised

Stiffness after TKR is a frustrating complication that has many possible causes. Though the definition of stiffness has changed over the years, most would agree that flexion > 75 degrees and a 15-degree lack of extension constitutes stiffness. This presentation will focus upon the potential causes of a stiff TKR, intra-operative tips, the post-operative evaluation and management, and the results of revision for a stiff TKR. The management of this potentially unsatisfying situation begins pre-operatively with guidance of the patient's expectations; it is well-known that pre-operative stiffness is strongly correlated with post-operative lack of motion. At the time of surgery, osteophytes must be removed and the components properly sised and aligned and rotated. Soft-tissue balancing must be attained in both the flexion/extension and varus/valgus planes. One must avoid overstuffing the tibio-femoral and/or patello-femoral compartments with an inadequate bone resection. Despite these surgical measures and adequate pain control and rehabilitation, certain patients will continue to frustrate our best efforts. These patients likely have a biological predisposition for formation of scar tissue. Other potential causes for the stiff TKR include complex regional pain syndrome or joint infection. Close followup of a patient's progress is crucial for the success in return of ROM. Should motion plateau early in the recovery phase, the patient should be evaluated for manipulation under anesthesia. At our institution, most manipulations are performed within 3 months post-operative under an epidural anesthetic; patients will stay overnight for continuous epidural pain relief and immediate aggressive PT. The results of re-operations for a stiff TKR are variable due to the multiple etiologies. A clear cause of stiffness such as component malposition, malrotation or overstuffing of the joint has a greater chance of regaining motion than arthrofibrosis without a clear cause. Although surgical treatment with open arthrolysis, isolated component or complete revision can be used to improve TKR motion, results have been variable and additional procedures are often necessary

Aims

Avascular femoral head necrosis in the context of gymnastics is a rare but serious complication, appearing similar to Perthes’ disease but occurring later during adolescence. Based on 3D CT animations, we propose repetitive impact between the main supplying vessels on the posterolateral femoral neck and the posterior acetabular wall in hyperextension and external rotation as a possible cause of direct vascular damage, and subsequent femoral head necrosis in three adolescent female gymnasts we are reporting on.

A nationwide study of Perthes’ disease in Norway was undertaken over a five-year period from January 1996. There were 425 patients registered, which represents a mean annual incidence of 9.2 per 100 000 in subjects under 15 years of age, and an occurrence rate of 1:714 for the country as a whole. There were marked regional variations. The lowest incidence was found in the northern region (5.4 per 100 000 per year) and the highest in the central and western regions (10.8 and 11.3 per 100 000 per year, respectively). There was a trend towards a higher incidence in urban (9.5 per 100 000 per year) compared with rural areas (8.9 per 100 000 per year). The mean age at onset was 5.8 years (1.3 to 15.2) and the male:female ratio was 3.3:1. We compared 402 patients with a matched control group of non-affected children (n = 1 025 952) from the Norwegian Medical Birth Registry and analysed maternal data (age at delivery, parity, duration of pregnancy), birth length and weight, birth presentation, head circumference, ponderal index and the presence of congenital anomalies. Children with Perthes’ disease were significantly shorter at birth and had an increased frequency of congenital anomalies. Applying Sartwell’s log-normal model of incubation periods to the distribution of age at onset of Perthes’ disease showed a good fit to the log-normal curve. Our findings point toward a single cause, either genetic or environmental, acting prenatally in the aetiology of Perthes’ disease

The aim of school screening is to identify most or all the individuals with unrecognized idiopathic scoliosis (IS) at an early stage when a less invasive treatment is more effective. The present study summarises the contribution of school screening in research of IS epidemiology, natural history and aetiology. In addition, school screening is a unique tool for research of IS in humans, as in most published articles, all aetiopathogenetic factors are studied in animals and not in humans. Such contribution is beyond the original aim of school screening but is very important to expand our knowledge and adequately understand the pathogenesis of IS. The role of biological factors such as the menarche, the lateralization of the brain, the handedness, the thoracic cage, the intervertebral disc, the melatonin secretion, as well as the role of environmental factors such as the light and the impact of the geographical latitude in IS prevalence were studied in children referred from school screening. The present study provides evidence to support that school screening programs should be continued not only for early detection of IS but also as a basis for epidemiological surveys until we learn much more about the aetiology of IS

The purpose of this study was to identify aetiological that may determine prognosis in ulnar nerve lesions and to evaluate the role of non-operative treatment. 148 consecutive patients (100 male) with 170 electrophysiologically proven (by nerve conduction and electromyography) ulnar nerve lesions were identified from the departmental records. Patient details, symptoms, known aetiology and treatment profile were recorded. Each patient was then contacted by telephone and/or questionnaire 1–6 (median 3. 8) years following electrodiagnosis to determine clinical progress and outcome. In patients with sensory symptoms alone or non-progressive painless motor symptoms, non-operative treatment was commenced. This involved advice on activity modifications and protection with a tubipad bandage or night spin. 12. 9% and 8. 8% of lesions were due to injury and intra-operative pressure respectively. Other causes included deformity and/or synovitis from arthritis of the elbow, repeated pressure, medial epicondylitis and benign space occupying lesions. 58. 2% were idiopathic with no clinical aetiological factor. 22 patients had expected bilateral lesions whereas 15 had contralateral lesions that were not symptomatic. 89. 4% and 4. 7% of lesions occurred at the elbow and wrist respectively. 83% of patients received non-operative first line treatment. 21% of these required operative intervention following further clinical and electrophysiological assessment. Partial or complete recovery occurred in 80%, 67% and 52% of the intra-operative, idiopathic and injury cases respectively (P< 0. 05). We conclude lesions of the ulnar nerve predominate in males and can be treated non-operatively providing clinical and electrophysiological monitoring is possible. Bilaterality is not uncommon and should be excluded. Lesions due to injury have a worse prognosis than those caused by direct continuous or repeated pressure or where no aetiological factor exists

Introduction: Femoroacetabular impingement (FAI) causes pain in young adults and osteoarthritis. Genetic factors are important in the aetiology of osteoarthritis. We aimed to investigate the extent to which FAI has an underlying genetic basis, by studying the siblings of patients undergoing surgery for FAI and comparing them with controls. Methods: 66 patients (probands, 29 male, 37 female, mean age 39.1 years) treated surgically for FAI provided siblings for the study. Probands were classified as having cam, pincer or mixed FAI. 101 siblings (55 male, 56 female, mean age 38.2 years) were recruited. The control group consisted of their 77 partners and was age and gender-matched. All subjects were assessed clinically and radiologically (standardised AP Pelvic and cross-table lateral radiographs of each hip). Radiographs were scored for the presence of osteoarthritis, and morphological abnormalities. Participants were classified as:. Normal morphology, no clinical features. Abnormal morphology, no clinical features. Abnormal morphology, clinical signs but no symptoms. Abnormal morphology with symptoms and signs. Osteoarthritis. Results: The sibling relative risks were significant for groups b, c, and d (ranging between 2–5, p< 0.01). Pro-bands and siblings shared the same pattern of abnormal morphology. Gender specificity was apparent: pincer abnormalities common in sisters but not in brothers. The brothers of probands with cam deformities almost universally demonstrated the same deformity, but only 50% of sisters did. Discussion: Genetic influences are important in the aetiology of FAI. Whether the morphological abnormality is determined at conception or by an inherited predisposition to an acquired event during development warrants further study. Symptoms are variable, indicating a spectrum of disease progression. These cohorts present an opportunity to prospectively study the natural history of the condition, improve understanding of the mechanisms and pathology, and potentially to be recruited into clinical trials

1. Chondromalacia of the patella starts most frequently on the medial facet. 2. The anatomy of the medial femoral condyle is described, including the rim at its superior border, and the different arrangement at the upper border of the lateral femoral condyle. 3. Rubbing of the medial patellar facet on the rim at the upper border of the medial femoral condyle can explain in part the etiology of chondromalacia

A five-year prospective trial involving 120 patients was undertaken to investigate the aetiology and treatment of coccydynia. The cause lies in some localised musculoskeletal abnormality in the coccygeal region. Lumbosacral disc prolapse is not a significant factor. The condition is genuine and distressing and we found no evidence of neurosis in our patients. Physiotherapy was of little help in treatment but 60% of patients responded to local injections of corticosteroid and local anaesthesia. Manipulation and injection was even more successful and cured about 85%. Coccygectomy was required in almost 20% and had a success rate of over 90%

Introduction: Femoroacetabular impingement (FAI) is an important cause of hip pain in young adults and a precursor to osteoarthritis. Genetic factors are important in the aetiology of osteoarthritis of the hip. From a research perspective, FAI is an example of how subtle morphological abnormality results in a predictable pattern of cartilage damage, and thereby offers great potential as a model to study early degenerative disease. Although many causes of FAI are described, the vast majority of patients give no history of previous hip disease. The purpose of this study was to investigate the extent to which FAI has an underlying genetic basis, by studying the siblings of patients undergoing surgery for FAI and comparing them with controls. Methods: 66 patients (probands, 29 male, 37 female, mean age 39.1 years) treated surgically for FAI provided siblings for the study. These patients were classified as having cam, pincer or mixed FAI. 101 siblings (55 male, 56 female, mean age 38.2 years) were recruited. The control group consisted of the 77 partners of those siblings (40 male, 37 female, mean age 41.9 years). All subjects underwent clinical (interview, examination, and hip scores) and radiological assessment (standardised AP Pelvic and cross-table lateral radiographs of each hip). Radiographs were scored for the presence of osteoarthritis, and cam- and pincer-type abnormalities. Results: Participants were classified as a) Normal morphology with no clinical features, b) Abnormal morphology but no clinical features c) Abnormal morphology with clinical signs but no symptoms, and d) Abnormal morphology with symptoms and signs. The sibling relative risks were significant for groups b, c, and d, supporting the hypothesis of an underlying genetic predisposition to FAI. Siblings usually demonstrated the same type of abnormal morphology as the proband. Gender specificity was apparent however, with pincer abnormalities which were usually apparent in female probands being common in sisters but less common in brothers. The brothers of probands with cam deformities almost universally demonstrated the same deformity, although only 50% of sisters did so. Discussion: Genetic influences are important in the aetiology of FAI. Whether the morphological abnormality is determined at conception or by an inherited predisposition to an acquired event during maturity warrants further study. We have identified a spectrum of disease with a proportion of siblings with abnormal morphology currently asymptomatic. These cohorts present an opportunity to prospectively study the natural history of the condition, improve our understanding of the mechanisms and pathology in early degenerative disease, and potentially to be recruited into clinical trials of surgical and adjuvant treatments

Over the long term, the results of the insertion of a Grammont inverted shoulder prothesis are unknown. The present study reports survivorship curves and the role of the initial aetiology in patients re-examined after 5 to 10 years. Patients and methods Eighty prostheses (for 77 patients) were implanted between 1992 and 1998: 66 cases of massive cuff tear arthropathy (MCTA) and 24 cases for another aetiology (mainly rheumatoid arthritis and revision). At the time of follow-up, 18 patients had died and 2 could not be traced. The remaining patients (57 representing 60 prostheses) were seen by an independent examiner. The minimum follow-up was 5 years. The average follow-up was 69,6 months. Kaplan-Meir survivorship curves for the 60 prostheses were established in order to show the probability of failure as defined by: revision of the prothesis, glenoid loosening, and a functional level< 30 points according to the Constant score. Results The survivorship curves were as follow:. - for non revision of the prosthesis at 10 years: 91% overall; after 9 years: 95% for MCTA, and 77 % for the others aetiologies. This difference was statistically significant (p< 0,01) ; 6 implants were revised: 3 for MCTA and 3 for other aetiologies. - for non glenoid loosening at 10 years: 84 % overall ; after 7 years: 91% for MCTA and 77% for other aetiologies. This difference was statistically significant (p< 0,05). In addition to the cases of replaced implants mentioned above there was a case of glenoid loosening after 8 years follow-up in a patient aged 92. -for Constant score < 30 at 10 years: 58 % overall. The punctual survivorship rate was significantly different in function of the aetiology, at 6 years ; but this was no longer the case after 7 years. Discussion. According to revision of the prosthesis, there is a clear rupture in the survivorship curve about 3 years after insertion in aetiologies other than MCTA. This suggests that Grammont inverted total shoulder arthroplasty is not appropriate in these aetiologies (particularly in cases of rheumatoid arthritis). According to Constant score < 30, there is a clear rupture in the survivorship curve about 7 years after insertion specially in MCTA cases. This suggests that inverted protheses should be used only in cases with severe handicap and only in patients aged over 75

The purpose of this study was to identify aetiological factors that may determine prognosis in ulnar nerve lesions at the elbow and to evaluate the role of non-operative treatment. One hundred and thirty consecutive patients (92 male) with 152 electrophysiologically proven (by nerve conduction and electromyography) ulnar nerve lesions at the elbow were identified from the departmental records. Patient details, symptoms, known aetiology and treatment profile were recorded. Each patient was then contacted by telephone and / or questionnaire between one and six years after electrodiagnosis to determine clinical progress and outcome. In patients with sensory symptoms alone or non-progressive painless motor symptoms, non-operative treatment was commenced. This involved advice on activity modification and protection with a tubipad bandage or night splint with continued clinical and electrophysiological surveillance. Sixty-one percent of lesions were idiopathic with no clinical aetiological factor. Defined causes included deformity and/or synovitis from arthritis of the elbow (11.2%), injudicious intra-operative pressure (9.2%), injury/trauma (8.5%) repeated pressure (4.1%), medial epicondylitis (2.9%) and benign space occupying lesions (2.9%). Twenty-two patients had expected bilateral lesions whereas 15 had contralateral lesions that were not symptomatic. Eighty-three percent of patients received non-operative first line treatment. Twenty-one percent of these required operative intervention (simple decompression) following further clinical and electrophysiological assessment. Partial or complete recovery occurred in 88%, 80%, 67% and 52% of the arthritis, intra-operative, idiopathic and injury cases respectively (P< 0.05). We conclude lesions of the ulnar nerve at the elbow predominate in males and the majority can be treated non-operatively providing clinical and electrophysiological monitoring is possible. Bilaterality is not uncommon and should be excluded. Lesions due to injury have a worse prognosis than those caused by arthritis of the elbow, direct continuous or repeated pressure or where no aetiological factor exists

Surfing is a popular UK water-sport. Recommendations for protective gear are based on studies abroad from trauma from large waves and reef breaks which may not be relevant in the UK. This study assesses the aetiology of UK surfing injuries in order to assist treatment and provide formative recommendations on protective equipment. Data was collected from UK surf clubs via an online survey. 130 individuals reported 335 injuries. M:F ratio 85:45, median age 28 (range 17–65). Head injuries were the most common (24%) followed by foot and ankle (19%). Surfers collided most often with their own boards (31%) followed by rocks/coral (15%), the sea (11%) and other surf boards (10%). Lacerations were the commonest injury (31%); followed by bruises/ black-eyes (24%) and joint/ligament sprains (15%). Concussions (5%), fractures (3%) and teeth injuries (1%) were rare. Less than 1/3 of all injuries required professional medical attention, 2 required operative intervention. Surfing injuries in the UK are common but usually minor. Serious head injuries (fractures and concussions) are rare. There is insufficient evidence to warrant the routine use of protective helmets whilst surfing in the UK, although protective head and foot gear may be considered when surfing the rarer reef/ rock breaks

Introduction: This is a prospective study of a series of consecutive cases of Os Odontoideum focussing on CT and MRI data. Both congenital and post-traumatic aetiologies have been proposed in the literature. This can lead to confusion in a medico-legal and clinical setting. Methods: Radiological, CT and MRI data from 26 consecutive cases of cranio-cervical anomalies were collected prospectively. Demographic details, the presence of any recent or remote traumatic aetiology and the clinical presentation were obtained from the medical record. A reconstructed mid-sagittal CT was examined for the thickness of the arch of C1, the size and location of the Os and the morphology of the atlantodens joint. The presence of any cord impression or signal change was obtained from the MRI. Results: 18 cases of Os Odontoideum were identified. Only one had a history of significant trauma remote from presentation. All adults had an abnormal archdens joint configuration (the ‘Jigsaw’ sign) with one exception. The atlantodens ratio was significantly greater in all cases of Os odontoideum indicating a relatively thickened anterior arch of the atlas. One case of non-union of a dens fracture presenting five or more years after the injury was identified in this series. Neither in this case nor two cases of transverse ligament rupture and two cases of Ossiculum terminale, was a thickened arch or an abnormal atlantodens joint observed. 12 of the cases presented after traumatic injury to the neck. In only three of these was there any abnormal neurological signs. Conclusions: Os Odontoideum has a characteristic appearance of the anterior C1 arch and the atlantodens joint as viewed on CT. These radiological signs are not observed after dens fractures. They may be taken to indicate a congenital aetiology for the condition. Patients with Os odontoideum are able to tolerate moderate to severe levels of injury without sustaining significant acute cord damage

At the apex of an idiopathic scoliotic curve there is a greater proportion of "slow twitch" muscle fibres in multifidus on the convex as compared to the concave side. To determine whether this represents a primary muscular imbalance relevant to the aetiology of idiopathic scoliosis or merely a secondary change, the lengths of multifidus on opposite sides of the curve were measured. Multifidus is shorter on the convex side. This is consistent with the theory of primary muscular imbalance, in which the more tonically acting muscle with its higher proportion of "slow twitch" fibres contracts and shortens as the deformity is produced. The paradox of multifidus being shorter on the convex rather than on the concave side is explained by consideration of its action

A study of the natural history and aetiology of deep vein thrombosis in 499 patients after total hip replacement is presented. Deep vein thrombosis was diagnosed by scanning the leg for 125Iodine-labelled fibrinogen for a period of 14 to 18 days and by ascending phlebography. It has been shown that deep vein thrombosis occurs ater than in patients who have undergone abdominal operations, and the risk period is longer. The peak of onset of thrombosis is on the fourth day after the hip replacement. Attempts at prophylaxis using subcutaneous heparin or intermittent pneumatic compression of the calves delay the appearance of thrombosis. Analysis of possible aetiology factors shows that the age of the patient, the degenerative disease of the hip, the surgical approach, and under-transfusion of blood, all have a significant effect on the incidence of thrombosis

Aims

Despite numerous studies on periprosthetic joint infections (PJI), there are no robust data on the risk factors and timing of metachronous infections. This study was performed to answer the following questions: 1) Is there any difference of manifestation time of metachronous PJIs between different localizations of multiple artificial joints? 2) Can we identify any specific risk factor for metachronous PJIs for different localizations of multiple artificial joints?

Introduction Both congenital and acquired aetiologies for Os Odontoideum have been proposed leading to confusion in a medico-legal setting. No large series with CT and MRI features has been reported. Methods Clinical, radiological, CT and MRI data from 25 cases of cranio-cervical anomalies (including 18 with Os Odontoideum) was collected prospectively. The hypothesis that Os Odontoideum is associated with signs of dysplasia such as arch hypertrophy (as quantified by the arch-peg ratio) and a ‘jigsaw’ like atlanto-dens joint configuration was tested. Results Only one of 18 cases with Os Odontoideum gave a history of remote trauma. None of the cases with other post traumatic conditions showed arch hypertrophy or dysplasia of the joint. Os Odontoideum was associated with two distinctive features on mid-sagittal CT reconstruction: arch hypertrophy and the presence of a ‘jigsaw sign’. A quantitative definition of arch hypertrophy (an arch/ peg ratio greater than 0.5) provided a sensitive and specific test for Os Odontoideum. This was further enhanced in combination with the jigsaw sign to give a test accuracy of 97%. Motor changes with MRI signs of cord damage were observed in one of 12 cases associated with trauma. Conclusions The lack of a history of remote trauma and the dyplastic atlanto-dens joint seen on CT are more suggestive of a congenital than a post-traumatic aetiology for Os Odontoideum. Patients with Os odontoideum are able to tolerate moderate to severe levels of injury without sustaining significant acute cord damage

1. Breech malposition and hormonal joint laxity produce atraumatic posterior dislocations in the hip joints of young rabbits. 2. Experimental studies were shown to cause the development of a limbus and other softtissue changes similar to those found in human congenital dislocations. 3. The development of femoral retroversion and anteversion in the presence of joint laxity is described. 4. The co-existence of breech malposition and hormonal joint laxity in utero, and their importance as prime factors in the etiology of congenital dislocation of the hip, are discussed

1. Peroneal spastic flat foot is a term loosely and often inaccurately used to describe rigid valgus feet developing from widely different causes. 2. The most common causes are two anomalies of the bones of the tarsus—the calcaneonavicular bar, and the talocalcaneal bridge. The first was described in 1921 by Sloman and in 1927 by Badgley; the other is described for the first time in this paper as an etiological factor in rigid flat foot though it has been recognised by anatomists for fifty years as a skeletal variation. The term peroneal spastic flat foot, as applied to these cases, is inaccurate since there is no spasm of the peroneal muscles. The deformity is a fixed structural deformity due to anomalous bone structure, and the apparent spasm of peroneal muscles is in reality an adaptive shortening. A better term would be rigid flat foot due to talocalcaneal bridge or calcaneonavicular bar. 3. The smaller group of patients who suffer from inflammatory lesions of the tarsal joints, chiefly due to rheumatoid arthritis, do in fact develop valgus deformity from peroneal spasm. The resemblance between the two groups is superficial and it is limited to the apparent similarity of the deformity. Though it might be justifiable to designate this type as peroneal spastic flat foot, it would be better to use the more accurate title—arthritic flat foot with peroneal spasm. 4. Lipping of the upper margin of the talonavicular joint strongly suggests the existence of one or other of the congenital anomalies. Both anomalies are visualised only by special radiological projections

A sibling risk study that shows a statistically significant increase in risk for anteromedial osteoarthritis of the knee. Anteromedial osteoarthritis is a distinct phenotype of osteoarthritis. Previous studies have shown a genetic aetiology to both hip and knee osteoarthritis. The aim of this study was to determine the sibling risk of antero-medial osteoarthritis of the knee. We conducted a retrospective cohort study of 132 probands with primary anteromedial osteoarthritis, who had undergone unicompartmental arthroplasty. Sibling were identified as having symptomatic knee problems by postal Oxford Knee Score (OKS). A positive OKS was defined as an OKS+/− 2SD of the mean of the proband group. Sibling spouses were used as controls. Those siblings & spouses that were symptomatic from the OKS were invited to undergo Knee X-rays, to look for radiological signs of osteoarthritis. Osteoarthritis was diagnosed as greater than Grade II on the Kell-gren Lawrence classification. The pattern of disease was noted and it was considered if the sibling were suitable for a unicompartmental knee arthroplasty. The prevalence and sibling risk of anteromedial osteoarthritis was determined using a randomly selected single sibling per proband family. The prevalence was determined in the 103 single proband sibling pairs. There was a statistically significant risk within the sibling group P= 0.024 using the Chi square test. The relative risk of anteromedial osteoarthritis was. 3.21(95% CI 1.08 to 9.17). Genetic factors play a major role in the development of anteromedial osteoarthritis

Slipped upper femoral epiphysis (SUFE) is a condition, which affects the immature hip joint. Many theories have been postulated as to its underlying aetiology however; its exact cause is, as yet unknown. The final common pathway appears to be failure of the of the growth plate to resist shearing forces, giving rise to displacement of the femoral head. We hypothesized that the lubricating ability of the synovial fluid in hip joints of children with SUFE was defective, thereby allowing increasing shear forces on the physis to occur, so that when the joint is loaded it will fail at its weakest point, namely the capital epiphysis. Aim: The aim of this study was to establish a biomechanical porcine cadaveric model to study SUFE and use this model to determine how defective joint lubrication may increase the probability of SUFE. Methods: Using immature porcine femurs and a custom-made rig, a torsional load was applied about an axis perpendicular to the growth plate in order to cause the femur to fail along the growth plate. The Hounsefield testing machine applied a tensile load and recorded the associated elongation. From these figures the torque applied to the femoral head and the associated angular rotation could be computed. Using Weibel analysis we were able to determine the probability of SUFE occurring for a range of synovial fluid coefficients of friction, a range of joint reaction forces and neck-shaft angles. Results: We found that it is possible to induce a SUFE in an immature porcine loaded hip joint and that there was an increased probability of slip with increased coefficient of friction of synovial fluid, increased percentage body weight and increased neck-shaft angle. Conclusion: Defective lubrication may be a key underlying aetiological factor responsible for SUFE

A prospective study was made of 119 children with transient synovitis or any other cause for synovial effusion and elevated intra-articular pressure. During a follow-up of one year not one case of Perthes' disease was diagnosed and the late clinical and radiographic changes were minimal with moderate overgrowth of the femoral head in 33% and widening of the joint space in 14.2%. Our results do not support the widely accepted concept that Perthes' disease develops as a result of the period of elevated intra-articular pressure found in transient synovitis. Further research into this and Perthes' disease should follow the premise that they are two different diseases without any aetiological connection

1. The clinical features of hyperostosis cranii are briefly reviewed. In large series of cases the syndrome has been found to occur almost entirely in females. 2. In recent studies of dystrophia myotonica, it is apparent that hyperostosis cranii is one of the variable features of the disorder. This disease occurs equally among males and females and the hyperostosis cranii also is distributed equally among males and females. 3. Hyperostosis cranii also occurs in patients with Morgagni's syndrome, with acromegaly, and as "senile hyperostosis.". 4. The etiology of hyperostosis is still a matter for speculation. More recent studies have focused attention on the endocrine system, and it seems probable, in view of the sex distribution in dystrophia myotonica, that the key to the problem may be found in this disorder. 5. In dystrophia myotonica the characteristic skull changes are hyperostosis cranii, a small pituitary fossa, excessive sinus formation and prognathism. These are acromegaloid changes. Gonadal atrophy is a common feature and endocrine study suggests that the endocrine defect is primarily a failure of the androgenic function of the adrenals and the testes. 6. In rodents and in humans ablation of the gonads leads to overactivity of gonadotrophic cells and, at times, of somatotrophic cells. Sometimes pituitary tumours develop. 7. Acromegaloid features may occur in eunuchs, and it is likely that the acromegaloid changes in dystrophia myotonica are of the same order from overactivity of growth hormone. 8. In animals excess of growth hormone produces thickening of the skull. 9. In dystrophia myotonica, acromegaly, and Morgagni's syndrome, it is suggested that hyperostosis cranii is an expression of unrestrained activity of growth hormone

Aims: The study aimed at analyzing the outcome of femoral components in patients with total hip replacement following osteonecrosis of the femoral head with regard to the associated factor of the osteonecrosis. Methods: We reviewed 41 patients with 55 cementless total hip replacements operated for advanced osteonecrosis. According to etiology of the osteonecrosis patients were divided into two groups. The first group included 17 cases with osteonecrosis without a systemic disease and the second group 38 cases with osteonecrosis associated with a systemic disease (alcohol abuse, corticosteroid medication, sickle-cell-disease). Results: The follow-up was on average 6.4 years (range, 2 to 12.8). Eight stem revisions had to be performed, all of them were in the patients with a systemic disease. Ten-year survival rates with femoral revision as the endpoint were in the first group 100%, and in the systemic disease group 68% (p=0.03). Conclusion: The data of this retrospective study supports the notion that the aetiology of osteonecrosis might has an influence on the survival of the femoral component

We report four patients who showed hundreds of brilliant white loose bodies at arthroscopy of the knee after a short history of pain and crepitus. Histological, historical and clinical evidence is presented which indicates that the aetiology of this condition is the culture of chondrocytes in synovial fluid. It is suggested that reversal of the usually accepted order of events in synovial osteochondromatosis could provide a better and unified explanation for both that condition and multiple loose bodies. The term 'snow storm knee' is proposed to describe the dramatic picture seen at arthroscopy

We have shown that stress fractures can be induced in the tibial diaphysis of an animal model by the repeated application of non-traumatic impulsive loads. The right hind limbs of 31 rabbits were loaded for three to nine weeks and changes in the bone were monitored by radiography and bone scintigraphy. The presence of stress fractures was confirmed histologically in some cases. Most animals sustained a stress fracture within six weeks and there was a positive correspondence between scintigraphic change and radiological evidence. Microscopic damage was evident at the sites of positive bone scans. The progression, location, and time of onset of stress fractures in this animal model were similar to those in clinical reports, making the model a useful one for the study of the aetiology of stress fractures

Introduction: To determine the aetiology of peripheral nerve injuries presenting to a specialist centre, identify the management strategies employed and discuss the functional outcome achieved. Methods: Retrospective review of all children referred to this hospital between 1996–2003 with an acquired nerve injury. Obstetrical brachial plexus palsy was excluded. Results: 100 nerve injuries (94 patients) were identified. The mean age was 9.9yrs (0.5–16yrs). 81 injuries involved the upper limb, 19 the lower limb. Most were due to low energy trauma and associated with fractures or their surgical management. 16% presented with autonomic sympathetic dysfunction, 10% with neuropathic pain. 43 patients underwent at least one surgical procedure. The operation was classified diagnostic in 5 (no surgically remediable lesion identified), therapeutic in 33 (surgical procedure could be expected to aid recovery) and reconstructive in 5 (no improvement in nerve function could be achieved; functional improvement achieved by other means). Excellent functional outcome only occurred in conservatively treated cases and in some treated by neurolysis. Nerve grafts and direct repairs were associated with good outcomes. Delayed surgery was associated with fair outcomes. Discussion: Peripheral nerve injuries in children as in adults require careful, prompt attention to obtain the best outcome. Iatropathic injuries must be acknowledged

Heritable thrombophilic disorders have been proposed as one of the causes for Legg-Calvé-Perthes disease. A total of 62 patients diagnosed with this disease between 1988 and 1997 and 50 controls were screened for thrombophilia. The incidence and relationship of thrombophilia to the severity of the disease were evaluated. One patient and none of the controls had protein S deficiency. One of the control group and one of the patients had protein C deficiency with the latter child also having a combined deficiency with a mutant factor V gene. The number of children with a mutant factor V gene, protein C deficiency, who were homozygous for the C 677T polymorphism of methylenetetra-hydrofolate reductase or were heterozygous for mutant G20210A prothrombin did not differ statistically in the study and the control groups. No patient had antithrombin deficiency or positive lupus anticoagulant. We found no correlation between thrombophilia and the extent of the disease. The most common risk factors for arteriovenous thromboembolism showed no statistical significance in our patients compared with the control group or with the general population. These data do not confirm an aetiological role for thrombophilia in Perthes’ disease

Introduction:. Recent studies have concluded that gender influences hip morphology at the time of surgery as well as dysplastic development of the hip. This may lead to a particular choice of implant including stem design and/or neck modularity. In this study we hypothesized that not only gender but also morphotype and etiology (primary osteoarthritis versus aseptic osteonecrosis) may be a significant factor to predict the anatomy of the hip at the time of total hip arthroplasty (THA). Methods:. We reviewed 690 patients undergoing THA for primary arthritis (OA) or avascular osteonecrosis (AVN) between April 2000 and June 2005 and stratified each into three groups based on their anatomic constitution: endomorph (EN), ectomorph (ECT), or mesomorph (ME) (determined by the ratio: pelvic width/total leg length measured on full-length X-rays). Two independent observers measured twice four parameters on preoperative CT scan: neck-shaft-angle angle (NSA), femoral offset value (FO), helitorsion (Ht) value and femoral neck anteversion (Av). Results:. No significant difference were observed between men and women for the four parameters with respectively: NSA (129.29° ± 5.6 versus 129.3° ± 5.7), Av (20.3° ± 8.6 versus 20.27° ± 8.6), FO (19.7 mm ± 3.98 versus 19.74 mm ± 3.98) and Ht (19.97° ± 12.2 for men and 19.94° ± 12.3). Significant difference were found for NSA: 130.1° ± 5.8 for ECT, 129.55° ± 6 for MES and 128.2° ± 5,1 for EN with p < 0.01. For Av, the values were: 18.9° ± 8.7 for ECT, 20.74° ± 8.1 for MES and 21.2° ± 8.95 for EN (p < 0.01). For FO the values were 19.1 mm ± 3.9 for ECT, 19.7 ± 4 for MES and and 20.44 mm ± 3.93 for EN (p < 0.01). No difference was found for Ht between the 3 groups. A significant difference was found between patients suffering from OA and AVN: mean NSA was 130.36° ± 8.79 for OA patients versus 127.35° ± 8.38 for those who had an AVN (p < 0.01). A value was 17.06° ± 8.1 for OA and 23.7 ± 7.89 for AVN (p < 0.01). FO value was 18.72 mm ± 3.71 for OA versus 20.75 mm ± 4.15 for AVN (p <0.01). And Ht was 18.94° ± 9.64 for OA and 21.05° ± 14.5 for AVN patients (p < 0.01). Discussion and conclusion:. Patients with short and wide morphotype (endomorph) had, irrespective of gender, lower values of NSA with greater anterversion and offset values, whereas patients with long and narrow morphotype (ectomorph) had higher values of NSA and smaller Av and FO (figure 1). In the same time patients suffering from AVN have lower NSA angle, lower Av, smaller FO and Ht (figure 2). Femoral stem design should allow the consideration of these differences to optimize the reconstruction of the hip at the time of THA including pre-operative and intra-operative modularity

Introduction Spondylolysis and isthmic spondylolisthesis (IS) have both a familial and mechanical aetiology, yet the phenotypic expression of the familial aetiology is unknown except for the observation of spinal bifida occulta. Other posterior element abnormalities are unrecognised, and any facet joint orientation (FJO) abnormality at the effected level has been ignored because of presumed previous mechanical defunctioning by the pars defect. The recognition of multilevel sagittal FJO in L4/5 degenerative spondylolisthesis (DS), begs the question whether more proximal segment examination may reveal FJ variations in IS. Methods MRI scans were used to measure orientation of the FJ at L3/4, L4/5, and L5/S1 in 30 individuals with normal scans, and 30 patients with IS. The angular measurement recorded is in relation to the coronal plane. Repeated measures assessment confirmed method validity. Results Mean measurement of axial FJO at L3/4 and L4/5 was 51.1 and 42.5deg in normal subjects, and 45.2 and 35.0deg in IS. The more coronal angulation at the levels above a pars defect in IS was highly statistically significant (p=0.0006 & p=0.00002). At L5/S1 orientations were the same (39deg). Discussion Relative coronal FJO in the lumbar spine may be the phenotypic expression of the congenital aetiology of IS. The mechanism of effect may be increased stress concentration at the pars between or below coronally oriented FJs. These more coronal FJOs in IS also explain:- the common observation of retrolisthesis at L4/5 above IS when the L4/5 disc degenerates, lateral overhang of the L4/5 FJ to the L5 pedicle entry-point above an IS, and the exceptionally uncommon combination of DS at L4/5 and IS at L5/S1 when both disorders are independently common. This latter observation can be further explained by the generalization that DS occurs in those individual with sagittal lumbar facets, and that IS occurs in those with more coronal FJs

To retrospectively analyze the etiology and microbiological results of synovial fluid culture, periprosthetic tissue culture and sonication fluid culture in 74 episodes of prosthetic joint infection (PJI) in 66 patients treated at the Department for Orthopaedic Surgery in 5 years period. PJI was diagnosed according to the standard definition criteria (1). Conventional microbiological methods were used together with sonication of explanted prosthesis and sonication fluid culture. The results are presented in Table 1. Acute PJI were more common in female patients (72%), whereas delayed PJI occurred in both sexes equally. Surprisingly, among acute PJI streptococcal (especially Streptococcus agalactiae) PJI were as common as Staphylococcus aureus PJI; we also observed high percentage of polymicrobial PJI (26 % among acute PJI and 30 % among delayed PJI), whereas 6/21 (28.6%) were detected by sonication fluid culture only. Preoperative synovial fluid culture identified the pathogen in 91.3% of acute PJI and in 63.2% of delayed PJI. Sonication fluid culture identified causative pathogens in 85% of acute PJI and in 95% of delayed PJI. In acute PJI 24/34 (70.6%) patient had concordant microbiological results between standard cultures and sonication fluid cultures, whereas in 4/34 (11.7%) microorganisms were detected by sonication fluid culture only and in 6/34 (17.6%)by tissue culture only. 23/40 (57.5%)patients with delayed PJI had concordant microbiological results; in 3/40 (7.5%) pathogens were detected by sonication fluid culture only. We found sonication as very useful additional method in diagnostics of PJI, especially low grade PJI. At the same time we observed high percentage of positive and concordant mcrobiological results between all three microbiological methods in patients with acute PJI

We performed electrophysiological studies on both legs of 52 children, aged from 3 months to 15 years, with idiopathic club foot. In only nine (17%) was no abnormality found. Isolated peroneal nerve damage was seen in 14 (27%). Abnormality of both peroneal and posterior tibial nerves was found in five (10%). Four patients (8%) had evidence of isolated spinal-cord dysfunction, whereas combined spinal-cord and peripheral-nerve lesions were seen in 14 (27%). Six patients (11%) had variable neurogenic electrophysiological patterns. In 13 patients in whom the studies were repeated neither progression nor improvement of the electrophysiological parameters was observed. Pathological electrophysiological findings were found in 66% of conservatively-treated patients. In the 43 patients treated surgically, all 16 with fair and poor results had pathological electrophysiological findings and 12 required further operations. Multiplicity of the pathological findings was related to the severity of the deformity of the foot; normal studies represent a good prognostic sign. Electrophysiological studies are useful in idiopathic club foot with residual deformities after conservative or operative treatment. Our findings support the theory that muscle imbalance is an aetiological factor in idiopathic club foot

To evaluate the proportion of microbial associations causing PJI, diversity of their strains and impact on treatment failure after the removal of the hip implant and insertion of a spacer. Spectrum of pathogens in 189 cases of PJI was studied retrospectively. Strains were isolated from the joint aspirates, tissue samples and removed orthopedic devices. The cohort comprised 144 cases of PJI after primary THA and 45 cases after the hip replacement revision surgery. All patients underwent first stage of two-stage revision procedure which involves the removal of a hip implant, debridement of infected periprosthetic tissues and subsequent insertion of a bone cement spacer. There were 92 males and 97 females (median age of 57 yrs). Statistical analysis of the results was performed with GraphPad Prism 6.0 (California, USA). Microbial associations were detected in 28.6% (n=54) of PJI cases. Gram-positive bacteria prevailed in both groups with mono- and polymicrobial etiology. There were 52.5% of S. aureus isolates in monomicrobial group and 25% isolates in polymicrobial group (p=0.0002). This also included 8.4 and 20.6% isolates of MRSA, respectively (p<0.0001). CNS were detected in 20.1% of mono- and 27.9% of polymicrobial infection isolates, including about 40% of MRSE in both groups. Gram-negative pathogens accounted for 25.7% of isolates in polymicrobial group and 14.1% in monomicrobial group (p=0.022). Non-fermenting bacteria prevailed among Gram-negative strains presented in associations. Acinetobacter sp. and P. aeruginosa were identified in 7.4% (p=0.043) and 5.1% (p=0.56) of polymicrobial isolates. The percentage of treatment failure after the removal of the hip implant and insertion of a spacer was considerably higher (p<0.0001) in patients with polymicrobial than monomicrobial infection: 72.2 vs 25.2%, respectively. The proportion of isolates in microbial associations involving Gram-negative pathogens was 61.5% in patients with infection recurrence and 26.7% in patients with a successful outcome of the surgery (p=0.033). Microbial associations were found in 28.6% of PJI cases after hip arthroplasty. They posed a significant risk for treatment failure after removal of the hip implant and insertion of a spacer. The multidrug-resistant strains (MRSA, Acinetobacter sp. and P. aeruginosa) were often isolated in microbial associations. Our results suggest that further study of the risk factors for polymicrobial infection is necessary in patients with PJI. Identification of a patient group at high risk for developing polymicrobial PJI will allow prescription of empiric antimicrobial therapy in time, taking into account possible multi-resistant pathogens

The purpose of this study was to investigate the role that genetics play in the aetiology and symptomatology of full thickness tears of the rotator cuff. From a retrospective, cohort study of 205 patients diagnosed with full thickness rotator cuff tears, we determined, using ultrasound, the prevalence of full thickness tears in their 129 siblings. Using 150 spouses as controls, the relative risk of full thickness rotator cuff tear in siblings v controls was 2.42 (p< 0.0001, 95 % CI 1.77 to 3.31). The relative risk of symptomatic full thickness rotator cuff tear in siblings v controls was 4.65 (p< 0.0001, 95 % CI 2.42 to 8.63). The significantly increased risk for tears in siblings implies that genetic factors play a major role in the development of full thickness tears of the rotator cuff

Femoral head necrosis in the context of high impact gymnastics of young adolescents is rare but seems a more serious complication compared to a Perthes like necrosis.

Between 2017 and 2019, three young females aged from12 to 14 years were referred due incapacitating hip pain and severe collapsing femoral head necrosis. The indication of hip preserving surgery was based on the extent of the necrosis, presence of a vital lateral pillar and joint subluxation.

In one of our 3 cases total head involvement made THR necessary, which was performed elsewhere. In the remaining 2 cases, head reduction osteotomy plus periacetabular osteotomy led to a good and a fair result.

Repetitive impact between the main supplying vessels on the posterolateral femoral neck and the posterior acetabular wall in hyperextension/ external rotation could be the cause of severe femoral head necrosis in three adolescent female gymnasts we are reporting on. Supra-selective angiography or sonography may be helpful to improve indication. Targeted adaptation of training methods should be discussed. Due to the severe vascular insult, results have to be considered moderate.

Purpose: Infection after resection and total knee arthoplasty for malignant bone tumours in children is a serious complication which may compromise limb salvage. The purpose of this work was to study the aetiology, treatment and prognosis of this event. Material and methods: Among the 169 total knee arthroplasties performed for malignant bone tumours between 1981 and 1999, we selected 17 patients meeting the following criteria: proven infection with identified germ on deep samples or presence of a fistula more than two years after surgery. All of the patients had osteogenic sarcomas (excluding Ewing sarcomas which account for 30% of the tumours in this localisation). The bone tumour involved the femur (n=11) or the tibia (n=6) and required extraarticular (n=14) or transarticular (n=2) resection. Infections were primary (n=9) developing after the first operation, or secondary (n=8) to surgical revision in six, joint wound in one, or haematogeneous dissemination in one patient. The causal germ was identified in thirteen patients (76%) and was a staphylococcus in all cases. Treatment included systemic antibiotics and lavage (n=10), one-procedure change in prosthesis (n=3), removal of the implant with replacement by a spacer (n=2), surgical abstention (n=2), or amputation (n=1). Results: Mean follow-up was eight years (2 – 16 years). On the average, treatment of infection lasted 51 months and required a 3.9 surgical interventions. At last follow-up, infection was considered cured in 70% of the patients who were free of clinical or laboratory signs of infection without antibiotics for at least one year. The arthroplasty could be preserved in one-third of the cases (22% of the primary infections and 50% of the secondary infections). Another treatment, arthrodesis (n=6), Borggreve procedure (n=1), or amputation (n=4), was given in the other two-thirds. Discussion: The 10% complication rate observed here is in agreement with data in the literature. Development of primary infection is influenced more by the histology of the tumour and the presence of skin wounds (methotrexate) than by tumour site or type of resection. The diagnosis of primary infection is made late, often at the end of the postoperative chemotherapy protocol. Changing the implant is the ideal treatment. Secondary infection is characteristically less difficult to diagnose; infection is recognised earlier and the chances of preserving the implant are better

Purpose: The objective of this study was to analyze the clinical results of arthroscopic release for the treatment of shoulder stiffness and to report the results according to etiology. Method: Thirty cases were reviewed in 29 patients with a mean age of 48 years [range, 25–75]. The mean time from diagnosis to surgery was 37.5 months [range, 6–120]. The stiffness was considered idiopathic (i.e. frozen shoulder) (10 cases), post-traumatic (eight cases) or post-surgical (12 cases). The release consisted of 14 rotator interval resections, four anterior capsulotomies, 20 anterior and inferior capsulotomies, three tenotomies of the superior portion of the subscapularis, and 11 biceps tenotomies or tenodeses. In 26 cases, associated extra-articular procedures were also performed, including 22 subacromial bursectomies and four acromioplasties. Patients were reviewed at a mean follow-up of 44 months [range, 12–99]. Results: Eighty-nine percent were satisfied or very satisfied. The mean Subjective Shoulder Value was 76%. The mean Constant score increased from 40 ± 13 points preoperatively to 74 ± 16 points postoperatively (p< 0.05). Conclusion: Arthroscopic shoulder release is effective for pain relief and improved function. The recovery of motion is better in idiopathic stiffness (i.e. frozen shoulder) than in post-traumatic and post-surgical stiffness. Resection of the rotator interval seems effective to restore external rotation and elevation

1. An anatomical study of the bony structure of the pars interarticularis of the fourth and fifth lumbar vertebrae has been made in specimens from seven cadavers aged seventeen to sixty-seven. 2. Layers of cortical bone have been described antero-laterally and postero-medially which are thickest in the narrowest region of the pars. 3. In one specimen from a seventeen-year-old male, a healing fracture was found in the antero-lateral layer of cortical bone in the right neural arch of the fourth lumbar vertebra. 4. The stresses to which the pars is subject consist primarily of shear forces applied to the articular processes. The significance of these stresses to the etiology of spondylolysis is discussed

Purpose: Congenital idiopathic clubfoot is the most common musculoskeletal birth defect developing during the fetal period, but with no known etiology. MYH 2, 3, 7, and 8 are expressed embryonically or perinatally, the period during which congenital idiopathic clubfoot develops; are all components of Type II muscle, which is consistently decreased in clubfoot patients; and are associated with several muscle contracture syndromes that have associated clubfoot deformities. In this study, we hypothesized that mutations in embryonic and perinatal myosin genes could be associated with congenital idiopathic clubfoot. Methods: We screened the exons, splice sites, and predicted promoters of 24 bilateral congenital idiopathic clubfoot patients and 24 matched controls in MYH 1, 2, 3, and 8 via sequence-based analysis, and screened an additional 76 patients in each discovered SNP. Results: While many SNPs were found, none proved to be significantly associated with the phenotype of congenital idiopathic clubfoot. Also, no known mutations that cause distal arthrogryposis syndromes were found in the congenital idiopathic clubfoot patients. Conclusion: These findings demonstrate that congenital idiopathic clubfoot has a different pathophysiology than the clubfoot seen in distal arthrogryposis syndromes, and defects in myosin are most likely not directly responsible for the development of congenital clubfoot. Given the complexity of early myogenesis, many regulatory candidate genes remain that could cause defects in the hypaxial musculature that is invariably observed in congenital idiopathic clubfoot. Significance: This study further differentiates congenital idiopathic clubfoot as distinct from other complex genetic syndromes that can present with similar deformities, and thus facilitates further research to improve the clinical diagnosis and treatment of congenital idiopathic clubfoot

Object: To study the incidence, etiology and management of patients with neuralgia following Posterior Lumbar Interbody Fusion (PLIF). Design: A prospective study of 85 patients undergoing PLIF surgery from March 1996 to March 2001. Subjects: Seven of the 85 patients undergoing PLIF surgery developed new leg pain between three days and five months following surgery. Results: The incidence of neuralgia was 8%. In all the patients the post-surgical neuralgia was in a new distribution. MRI examination ruled out misplaced pedicle screws in all cases, but was otherwise unhelpful. One patient developed neuralgia five months post-operatively due to collapse of the cortico-cancellous graft and secondary foraminal narrowing. This was not relieved following surgical decompression. Four patients had neuralgia caused by relative stenosis of the exiting nerve (3) or the traversing nerve (1) which started between three days and two weeks after surgery. The pain was relieved in all four following surgical decompression. One patient had leg pain when lying down; standing and sitting relieved this. A loose lamina was found on exploring the wound. Her pain settled after surgery. One patient developed a spondylolisthesis at the level below a L4/5 PLIF four months after surgery. Her pain was eased by stabilization of the lower segment. Conclusions: MRI scans are not very helpful in these cases. Early exploration is recommended and gave good results in six of our seven cases

Object: To study the incidence, etiology and management of patients with neuralgia following Posterior Lumbar Interbody Fusion (PLIF). Design: A prospective study of 216 patients undergoing PLIF surgery from March 1996 to August 2003. Subjects: 16 of the 225 patients (7.1%) undergoing PLIF surgery developed new leg pain following surgery. Results In all patients, the distribution of the postoperative pain was different than the pre-operative pain. Nerve swelling with relative stenosis was the most common cause (9/16), followed by pedicular screw misplacement (2/16), nerve anomaly (2/16), loose posterior arch (2/16), and graft subsidence (1/16). Nine patients with nerve swelling complained of pain with no neurological findings. One responded to a root block and 6 to re-exploration and further decompression. The patients with misplaced screws woke up from surgery with pain and neurology. The pain responded to removal of screws in both. Two patients with loose posterior arches complained of leg pain while lying down only. These symptoms disappeared after excision of the arches. In 2 patients conjoint roots were found intra-operatively. Both developed post operative pain, which settled down in one. In one patient subsidence of an iliac graft caused pain a few months following surgery and did not respond to further decompression. Discussion: The overall incidence of post PLIF neuralgia was 7.1%, however by removing the whole facet, as performed in the last 122 patients, the incidence reduced from 9.7% (first 103 patients) to 4.9%. Based on our data we propose a classification system for Post PLIF Neuralgia, and a management plan. Using both, 11 of the 16 patients reported their leg pain disappeared, leaving only 5 patients with residual leg pain (< 3%). Key-stones in avoiding post PLIF neuralgia are generous decompression of the nerve roots, especially the lateral recess above the disc, total facetectomy and removal of graft pieces before closure