Introduction. At Sheffield Children's Hospital, treatment of leg length discrepancy is a common procedure. Historically, this has been done with external fixators. With the development in intramedullary technology, internal nails have become the preferred modality for long bone lengthening in the adolescent population. However, it is important to review whether this technology practically reduces the known challenges seen and if it brings any new issues. Therefore, the aim of this review is to retrospectively evaluate the therapeutic challenges of 16 fit-bone intramedullary femoral lengthening's at Sheffield Children's Hospital between 2021–2022. Materials & Methods. The international classification of function (ICF) framework was used to differentiate outcomes. The patient's therapy notes were retrospectively reviewed for themes around structural, activity and participation limitation. The findings were grouped for analysis and the main themes presented. Results. There were 8 males, mean age 17.4 years (range 17–18) and 8 females, mean age 15.9 years (range 14–18). 5 right and 11 left femurs were lengthened. Underlying pathology varied amongst the 16 patients. All patients went into a hinged knee brace post operatively. Structural limitations included: pain, fixed flexion deformity of the knee, loss of knee flexion, quadriceps muscle lag, muscle spasms and gluteal weakness. The primary activity limitation was reduced weight bearing with altered gait pattern. Participation limitations included reduced school attendance and involvement in activities with peers. Access to Physiotherapy from local services varied dramatically. Five of the cohort have completed treatment. Conclusions. Anecdotally, intramedullary femoral lengthening nails have perceived benefits for families compared to external fixators in the adolescent population. However, there remain musculoskeletal and psychosocial outcomes requiring therapeutic management throughout the lengthening process and beyond. Therefore, quantifying these outcomes is essential for measuring the impact on each patient for comparison. To interpret these themes, we need to evaluate the outcomes objectively, this was not done consistently in this review. Future research should look at outcome measures that are sensitive to all aspects of the ICF. With an aim of improving the therapeutic treatment provided and the overall outcome for the children treated

Introduction. We propose that Total Hip Replacement with correction of fixed flexion deformity of the hip and exaggerated lumbar lordosis will result in relief of symptoms from spinal stenosis, possibly avoiding a spinal surgery. A sequence of patients with this dual pathology has been assessed to examine this and suggest a possible management algorithm. Materials and methods. A retrospective study of 19 patients who presented with dual pathology was performed and the patients were assessed with regards to pre and post-operative symptoms, walking distance, and neurological status. Results. There were 17 patients with improvement in the spinal stenotic symptoms following hip replacement to an extent that none required spinal surgery. There were two patients who had spinal surgery after THR, at varying lengths following hip replacements as their spinal stenotic symptoms worsened over time, and had lateral spinal stenosis on MRI. Discussion. In advanced hip osteoarthritis, a fixed flexion deformity may develop at the hip leading to an exaggerated lumbar lordosis in erect posture. In the presence of co-existing spinal stenosis, the exaggerated lumbar lordosis may worsen the spinal stenotic symptoms while standing and walking. Cadaveric & Radiological studies have shown that canal narrowing occurs with increased lordosis/ extension in the lumbar spine. Our findings suggest that when central lumbar spinal stenosis coexists with bilateral hip arthritis and FFD at the hip, THR should be offered first. Successful hip surgery for arthritis correcting significant fixed flexion deformity would lessen the lumbar lordosis, thus correcting the excessive pathological narrowing. If a patient is fit enough, simultaneous bilateral THR via an anterior type of approach makes surgical correction of FFD easier. Although it has been suggested in the literature that patients with spinal stenosis have a increased risk of neurological impairment following THR, we did not find any clear association

Introduction. We have previously published limb lengthening using external fixation in pathological bone diseases. We would like to report a case series of femoral lengthening using the PRECICE system in a similar pathological group especially looking at it's feasibility and complications. Materials and Methods. This is a case series of four patients, two patients with osteogenesis imperfecta and two with Ollier's disease, who underwent femoral lengthening via distraction osteogenesis using the PRECICE intramedullary nail system. It was a retrospective study from a prospective database from clinical records and radiographs. Results. The mean age at the time of surgery was 15.5 years, the mean preoperative leg length discrepancy was 30mm, and the mean distraction distance achieved was 28.75mm. Since these patients were of shorter heigh, limb lengthening was considered. All 4 patients had successful insertion of the nail. The outcomes noted from the 4 patients are collated, with several complications occurring including delayed femoral union, fixed flexion deformity of the hip, persisting pain and quadriceps weakness. Those with Ollier's disease underwent an increased rate of distraction to prevent premature healing. The implications of long-term bisphosphonate therapy in OI are discussed with regards to the risk of delayed femoral union and intra-operative fracture. Conclusions. Intramedullary femoral lengthening in pathological bone disease is possible, but the surgeon needs to give attention to certain details. The regenerate formation is based on the background pathology irrespective of the hardware used. There is much more compliance with the nail technique

Flexion contractures are a common finding in an end-stage arthritic knee, occurring in up to 60% of patients undergoing total knee arthroplasty. Fixed flexion deformities may result from posterior capsular scarring, osteophyte formation, and bony impingement. It is essential to correct this deformity at the time of total knee arthroplasty, as a residual flexion contracture will result in joint overload and abnormal gait mechanics. This may translate to a slower walking velocity, shorter stride length, and pain. This presentation will discuss a systematic way of dealing with flexion contractures to ensure that the total knee arthroplasty will achieve full extension. The surgical technique for treating fixed flexion deformity about the knee includes release of the posterior cruciate ligament, posterior capsular release, adequate distal femoral bone resection, and removal of osteophytes. Postoperatively, attention must be divided between obtaining maximal flexion and full extension. Should a flexion contracture be noted upon the postoperative visit, additional measures should be taken to address it

Flexion contractures are a common finding in an end-stage arthritic knee, occurring in up to 60% of patients undergoing total knee arthroplasty. Fixed flexion deformities may result from posterior capsular scarring, osteophyte formation, and bony impingement. It is essential to correct this deformity at the time of total knee arthroplasty, as a residual flexion contracture will result in joint overload and abnormal gait mechanics. This may translate to a slower walking velocity, shorter stride length, and pain. This presentation will discuss a systematic way of dealing with flexion contractures to ensure that the total knee arthroplasty will achieve full extension. The surgical technique for treating fixed flexion deformity about the knee includes release of the posterior cruciate ligament, posterior capsular release, adequate distal femoral bone resection, and removal of osteophytes. Post-operatively, attention must be divided between obtaining maximal flexion and full extension. Should a flexion contracture be noted upon the post-operative visit, additional measures should be taken to address it

Introduction. Total knee arthroplasty is the standard treatment for advanced knee osteoarthritis. Patient-specific instrument (PSI)has been reported by several authors using different techniques produced by implant companies. The implant manufacturers produce PSI exclusively for their own knee implants and for easy straightforward cases. However, the PSI has become very expensive and unusable as a universal or an open platform. In addition, planning the implant is done by technicians and not by surgeons and needs long waiting time before surgery (6 weeks). Methods. We proposed a new technique which is a device and method for preparing a knee joint in a patient undergoing TKA surgery of any knee implant (prosthesis). The device is patient specific, based on a method comprised of image-based 3D preoperative planning (CT, MRI or computed X-ray) to design the templates (PSI) that are used to perform the knee surgery by converting them to physical templates using computer-aided manufacturing such as computer numerical control (CNC) or additive-manufacturing technologies. The device and method are used for preparing a knee joint in a universal and open-platform fashion for any currently available knee implant. Results. All patient-specific implants and any knee implant could be produced. The technique was applied on NExGen implant (Zimmer)on 21 patients, PFC implant (Depuy, J & J) on 5 patients, Scorpio NRG implant (Stryker) on 24 patients and SLK Evo implant (Implant International) on 81 patients. The >15 degrees varus gave a mean of 10.44 degrees in 56.67% of cases and the <15 degrees varus gave a mean of 24.04 degrees in 43.33% of cases. The total varus of 5–30 degrees gave a mean of 16.33 degrees in 90.9% of cases and the total valgus of 20–40 gave a mean of 25 degrees in 9.1% of cases. The fixed flexion deformity of < 20 degrees gave a mean of 9.4 degrees in 75.3% of cases while the fixed flexion deformity of >20 gave a mean of 31.87 degrees in 24.7% of cases. Discussion. The system is based on CT images, generic data of implant sizes, average bone geometry and standard TKA parameters for bone cutting, mechanical axis and rotation (e.g., zero-degree coronal cut, adjustable posterior slope, femoral flexion, epicondylar axis, no notching or overhang, etc.). The method of planning and completing virtual surgery of TKA includes several steps based on 3D reconstruction and segmentation of computed tomography (CT) or MRI scan data. The universal device and method are suitable to be used for any commercially and currently available knee implant. They are used for all on-shelf implants and all patient-specific instruments. The device is specifically designed for TKA and the planning is based on the 3D files of a universal TKA prosthesis. There are four standard sizes of the universal TKA prosthesis which were built depending on the average bone geometry. These 4 sizes are 55, 60, 65 and 70 mm. These sizes are consistent with the six most common implants available today: NexGen Zimmer, PFC Depuy, Sigma Knee, Triathlon Stryker, Vanguard Biomet, and Smith & Nephew Proflex. However, for extreme cases, one size above or below the maximum and minimum range can be used. The device has 2 parts: a femoral part and a tibial part, both of which are independent of any commercially available knee implant

This study was performed at Assiut University, Assiut, Egypt. Anterior distal femoral hemiepiphysiodesis (ADFH) using intra-articular plates for the correction of paediatric fixed knee flexion deformities (FKFD) has two main documented complications: postoperative knee pain and implant loosening. This study describes a biomechanical analysis and a preliminary report of a novel extra-articular technique for ADFH. Sixteen femoral sawbones were osteotomized at the level of the distal femoral physis and fixed by rail frames to allow linear distraction simulating longitudinal growth. Each sawbone was tested twice: first using the conventional technique with medial and lateral parapatellar eight plates (group A) and then with the plates inserted in the proposed novel location at the most anterior part of the medial and lateral surfaces of the femoral condyles with screws in the coronal plane (group B). Gradual distraction was performed, and the resulting angular correction was measured. Strain gauges were attached to the plates, and the amount of strain (and equivalent stress) over the plates was recorded. This technique was then applied to 9 paediatric FKFDs of different aetiologies. The preoperative FKFD and the amount of subsequent angular correction were measured. The amount of angular correction was higher in group B at 5, 10-, and 15-mm of distraction (p<0.001). The maximum and overall stresses measured throughout the distraction process were higher in group A (p<0.001). The mean FKFD improved from 24 ± 9° preoperatively to 9 ± 7° after 10 ± 3° months (p<0.001). The correction rate was 1.81 ± 0.65° per month. During ADFH, the fixation of the eight plates in the coronal plane at the anterior part of the femoral condyles may produce greater correction and lower stresses over the implants as compared to the conventional technique. Preliminary results from our initial series seem to support the effectiveness of this technique with respect to the degree of angular correction achieved

Radial head fractures with fragment displacement should be reduced and fixed, when classified as Mason II type injuries. We describe a method of arthroscopic fixation which is performed as a day case trauma surgery, and compare the results with a more traditional fixation approach, in a case controlled manner. We prospectively reviewed six Mason II radial head fractures which were treated using an arthroscopic reduction and fixation technique. The technique allows the fracture to be mobilised, reduced, and anatomically fixed using headless screws. All arthroscopic surgeries were conducted as day-cases. We retrospectively collected age and sex matched cases of open reduction and fixation of Mason II fractures using headless screws. The arthroscopic cases required less analgesia, shorter hospital admissions, and had fewer complications. The averaged final range of follow-up, at 1 year post-operation was 15 to 140 degrees in the arthroscopic group and 35 to 120 degrees in the open group. The Mayo Elbow Performance Score was 95/100 and 90/100 respectively. No acute complications were noted in the arthroscopic group, and a radial nerve neuropraxia [n=1], superficial wound infection [n=1], and loose screw [n=1]. Two patients of the arthroscopic group required secondary motion gaining operations [n=1 arthroscopic anterior capsulectomy for a fixed flexion contracture of 35 degrees, and n=1 loss of supination requiring and arthroscopic radial scar excision]. Three patients in the open group required secondary surgery [n=2 arthroscopic anterior capsulectomy for fixed flexion deformities, and n=1 arthroscopic anterior capsulectomy for fixed flexion deformities, and n=1 arthroscopic radial head excision for prominent screws, loss of forearm rotation, and radiocapitellar arthrosis pain]. The technique of arthroscopic fixation of Mason II radial head fractures appears to be valid, with respect to anatomical restoration of the fracture, minimal hospital admission, reduction in analgesia requirement, fewer complications, and a decreased need for secondary surgery

Post total knee arthroplasty, mid flexion instability can be described as a stable knee in full extension but as soon as knee starts bending instability is noticed and the knee becomes stable again at 90° of flexion. Mid flexion instability should not be confused with the true flexion instability. Such instability may be not be recognized in most cases because of subtleness of the nature of complaints of the patient. Soft tissue tension should be equal not only medio-laterally but also in antero-posterior alignment. The knee needs to be balanced in the complete arc of motion. To understand this it should be remembered that main stabilizer of the knee in extension is the posterior capsule and in flexion are the collateral ligaments. Main factors contributing to Mid Flexion instability are:. 1. Over release of anterior part of Medial Collateral Ligament (which is a stabilizer from 30° to 60° of motion). 2. Femoral-tibial articular geometry - Malposition of the implant in relation to the epicondyles so that collateral ligaments won't be isometric. 3. Over release of anterior part of Medial Collateral Ligament (which is a stabilizer between 30° to 60° of motion. 4. Tibial post-femoral box geometry. In a fixed flexion deformity, suitable posterior release should be matched with the collateral frame before taking extra-distal femoral cuts. Every 2 mm of additional distal femoral cut causes mid flexion instability of 2 to 3° as was seen in a cadaveric study. It is important to understand the interplay between posterior structures and collateral structures. Normally collateral structures have some laxity at 5° flexion but at 0° knees are locked mainly because of the tension of the posterior structures. We have classified mid flexion instability in three types:. Type I: Over-released MCL and Normalised Posterior capsule. Type II: MCL Normal, but Posterior capsule is tight / insufficiently released and to balance this disparity distal femur cut is increased. Type III: A Combination of above two conditions with MCL and Postero-medial Capsule both having laxity e.g. in a FFD with varus. It is a retro-prospective study. 411 patients with 600 knees were subjected to the study to assess mid-flexion instability in patients with primary Total Knee Arthroplasty. Follow was over a period of 5 years. Of the 600 TKA 60 were LCS prosthesis, 90 were PFC RP, 200 were PFC sigma and rest 250 were Stryker Scorpio. All patients were assessed by clinical and radiological evaluation. X-rays were taken in 0°, 30°, 60°. Arthrograms were also done to assess alignment of the joints. Fluroscopic studies were done in select few cases. Knee society score was noted for each patient and compared with pre-operative data. Mid Flexion instability in a newer concept, the causes of which and further management protocols needs to be worked out. Mid Flexion instability is a failure to release the tight posterior capsule in a fixed flexion deformity. Over release of anterior MCL will result in mid flexion instability but in this situation knee may be unstable even at 90°

A patient in his thirties developed synovitis with grade 4 chondrolysis and a stiff knee with a fixed flexion deformity between three and six years following PLC and PCL reconstruction using LARS (Ligament Augmentation and Reconstruction System, Corin). There was histologic evidence of foreign body reaction, the knee was painful, swollen and stiff. We did not use any further LARS ligaments for soft tissue reconstructions of the kneein our practice. We commenced a recall programme for all 83 patients patients who underwent a soft tissue knee reconstruction using LARS. Of those contacted, 41 replied (49%) and 16 patients had symptoms (19%) and were investigated further with XRay, MRI and arthroscopy as indicated. We discovered a total of five patients had histologically proven synovitis with foreign body reactions (6%), three of whom had life-changing symptomatic pain, swelling and stiffness with degenerate changes (3.6%). These patients had undergone various reconstructions, including a) PLC only, b) ACL and PCL, c) PCL and PLC and d) ACL, PCL and PLC. A further single case of massive bone cyst formation was noted, following PCL reconstruction using LARS (1.2%)

Lateral meniscal failure and secondary valgus with lateral compartment arthrosis is quite common in the developed world. The varus knee is the common phenotype of the ‘jock’ of both genders, while the valgus knee is a common consequence of lateral meniscal tear, skiing or ‘catwalk’ life. Occurring more commonly in ‘flamingo’ phenotypes, lateral meniscal failure can be disabling, entirely preventing high heels being worn for instance. Indications. Lateral UKA is indicated for most valgus knees, and is substantially safer than TKA. ACL integrity is not essential in older people, as the patello-femoral mechanism is in line with the lateral compartment. Severe valgus with substantial bone loss is not a contraindication, if the deformity is simply angular. As long as there is not marked subluxation, fixed flexion deformity invariably corrects after notch osteophyte removal from femur and tibia. Combinations. Lateral UKA can be combined safely with PFJA: performed through a lateral approach, this is a safe and conservative procedure. ACL integrity is not essential – reconstruction can be undertaken simultaneously, if necessary. Combining lateral UKA with medial UKA is only rarely needed, and sometimes needs ACL reconstruction too. Adding a medial UKA in under 5 years usually results from overcorrection of the valgus. Mid Term Results, at a median of 7 years postop: Between 2005 to 2009, 64 knees in 58 patients had a lateral UKA using a device designed for the lateral compartment. This included 41 females and 17 males with a mean age of 71 years at the time of surgery (range 44–92). Thirty-nine patients underwent surgery on the right knee and 6 underwent bilateral procedures, of which four were performed under a single anesthetic. Primary lateral compartment osteoarthritis was the primary diagnosis in 63 cases with secondary osteoarthritis to a lateral tibial plateau fracture the indication in one patient. At 119 months follow up, the predicted cumulative survival was 0.97. With re-operation as an endpoint, 11% of patients within the study had undergone re-operation with a predicted cumulative survival of 0.81 at 119 months. This compares well with historic fixed bearing series. Preoperative OKS scores were available for 50 knees, scores were available for 63 knees at 9–48 months and 52 knees at 61–119 months post index operation. There was a significant improvement in the OKS between the preoperative scores (median 26 range 9–36) and early postoperative time points of 9–48 months, (median 42 range 23–48) (p<0.001). At the later postoperative time point of 61–119 months the score had been maintained (42 range 10–48). Conclusion. Lateral UKA is a small and safe procedure, with clinical outcomes that are equivalent to a medial UKA and are maintained at a median of 7 years postoperatively

The purpose of this study is to investigate the feasibility of surgical correction of moderate flexion deformity during total knee arthroplasty by recreating the posterior condylar recess following certain sequence of surgical principles without extra-resection of bone from the distal femur or proximal tibia. The hypothesized surgical protocol was applied in 52 consecutive primary TKAs with moderate flexion deformity. Preoperative and residual postoperative flexion deformity was recorded. Intraoperatively, extension and flexion gap widths were recorded before and after surgical correction. Fixed flexion deformity has improved from a preoperative mean value of 24.8±6.4 to a postoperative residual value of 3.2±1.8 (p value < 0.001). Extension and flexion gap widths have increased by a mean value of 3.8±0.4 mm and 4.1±0.7 mm respectively (p value < 0.005). There was no significant difference between the changes in the extension and flexion gaps. The original flexion/extension gap width mismatch (3.2±0.5mm) was compensated for by an upsized femoral component. The statistically significant changes has demonstrated the efficiency of the hypothesized surgical protocol for management of flexion deformity during TKA added to the benefits of bone conservation for future revision surgery, preservation of surface area for collateral attachments, and establishment of the joint line at the correct level

Fixed flexion contracture is often present in association with osteoarthritis of the knee and correction is one of the key surgical goals in total knee replacement. Surgical strategies to correct flexion contracture include removal of posterior osteophytes, posterior capsular release and additional distal femoral bone resection. Traditional teaching indicates 2 mm of additional distal femoral bone resection will correct 10 degrees of flexion deformity. However some studies have questioned this figure and removing excessive distal femoral bone results in elevation of the joint line, potentially causing patella baja, alteration in collateral ligament tension through the flexion arc and mid-flexion instability. The aim of our study is to determine the relationship between distal bone resection of the femur and passive knee extension in total knee arthroplasty. A cohort of 50 patients, undergoing total knee arthroplasty, was recruited. Following complete femoral and tibial bone preparation, to simulate the effect of distal femoral bone resection, augments of 2 mm increments (2 mm, 4 mm, 6 mm, 8 mm) were placed onto the trial femoral component. The degree of flexion contracture with each augment was measured using computer navigation. The results showed a 2 mm augment produced an average of 3.37 degrees of flexion deformity. A 4 mm augment led to an average of 6.68 degrees fixed flexion, whilst a 6 mm augment produced 11.38 degrees. To correct 10 degrees flexion deformity, an additional 6 mm distal femoral bone resection is required. In conclusion, additional distal femoral bone resection may not be as an effective strategy as previously believed to correct fixed flexion deformity in total knee arthroplasty

Fibular Hemimelia is not just a fibular anomaly but there is entire limb involvement with varied expression in each segment. Factors which we have considered in treatment are the amount of fibula present, percentage of shortening, tibial and leg deformity and foot deformity. Residual or recurrent foot deformity is the prime reason for unsatisfactory results, so we have used Paley's classification which takes into consideration foot deformity. Our series is of 29 cases, Paley type I-7, Type II-6, Type III-16 and none of type IV. Tibial lengthening (+/−) bow correction was performed in 28 cases. Supramalleolar osteotomy was done in 4 cases. In foot, soft tissue release only was done in 6 cases and soft tissue release with osteotomy (subtalar or calcaneal) was done in 14 cases. Amputation was done in 2 cases. Age ranged from 11 months to 16 years. Mean follow up was 4.2 years. Mean lengthening was 3.5 cm. Desires lengthening was achieved in 21/29 cases and plantigrade foot was achieved in 16/29 cases. Complications faced were recurrence of foot deformity, knee valgus, knee fixed flexion deformity, knee subluxation and pin tract problems. Less than 3 rays and more than 25 cm of limb length discrepancy were poor prognostic factors. We had 7 excellent, 16 good and 6 poor results. To conclude, it is difficult to achieve the aim of plantigrade foot and limb length equality in all cases but radical surgery with foot correction and tibial lengthening can give good results

Background. Evidence concerning the management of dorsal fracture dislocation (DFD) of the proximal interphalangeal joint (PIPJ) in the hand has been limited by small sample size and case heterogeneity within studies. This retrospective case control study examined clinical outcome of this specific subgroup managed by three different methods. Methods. Patients undergoing fixation of unstable DFD of the PIPJ between March 2005 and August 2011 were identified from theatre records. A retrospective review of case-notes and radiographs was undertaken to determine fracture characteristics, fixation methods and clinical outcomes. Results. 21 patients with DFD of the PIPJ were identified with a mean age of 40 years (range 22–65). The majority of patients were male (17/21, 81%) and the mean percentage articular surface involvement of fractures was 41% (Std. Dev. 11.3%). PIPJ DFD's were managed by reduction of the PIPJ and temporary transarticular K-wire fixation (12/21, 57%), hemi-hamate arthroplasty (7/21, 33%), or by open reduction and internal fixation (2/21,10%). PIPJ ROM following hemi-hamate arthroplasty was 65° (range 34–108°) and was greater than K-Wire fixation at 56. o. (range 9–85. o. ) (p = 0.82). Hemi-hamate arthroplasty and K-wire fixation resulted in fixed flexion deformity of 20° (range −12–52°) and 15° (range −6–50°) respectively (p = 0.61). Hand therapy data was available for one case undergoing ORIF with a post-operative ROM of 60° and 30° of fixed flexion. There was poor correlation between articular surface involvement and post-operative range of movement at the PIPJ (Co-efficient −0.16, p = 0.55). Conclusion. We present a relatively large series of outcomes following DFD of the PIPJ. We were unable to demonstrate any difference in post operative clinical outcomes between the fixation methods examined

Introduction. Knee arthroplasty provides not only pain relief but also an improvement in function and range of movement. Limited joint mobility (LJM), secondary to peri-articular connective tissues stiffness, is a common complication of diabetes mellitus. We therefore examined functional outcome post-total knee arthroplasty (TKA) in a cohort of subjects with and without diabetes mellitus. Method. The effect of TKA on indices of knee function (fixed flexion, maximum flexion, total ROM and knee society score) was examined in 367 subjects with type 2 diabetes and 367 subjects without diabetes. The groups were matched for age, sex, BMI and functional movement at baseline. Participants were examined at baseline (pre-operatively), 1, 5 and 10 years post-TKA. Results. There was no significant difference in fixed flexion, maximal flexion or total range of movement between the two groups at baseline. At 1 year the group with diabetes had a significantly lower maximal flexion (p < 0.001), total range of movement (p < 0.001) and Knee Society Score (p = 0.034). At 5 years post-arthroplasty a significant increase was observed in fixed flexion (p = 0.026) as well as a significant decrease in maximal flexion (p = 0.001) and total range of movement (p = 0.004) in the diabetic group. Ten years post-arthroplasty yielded similar results. Conclusion. Within one-year post-arthroplasty people with diabetes develop a poorer range of movement compared to controls. Between one to five years post-procedure a significant fixed flexion deformity occurred in those with diabetes. A sustained deterioration was observed up to 10 years post-procedure. This study is the first to demonstrate that the pre-operative presence of diabetes mellitus leads to a worse functional outcome post-knee arthroplasty

Hypothesis. This study demonstrates the utility of a modified postero-medial surgical approach to the knee in treating a series of patients with complex tibial plateau injuries with associated postero-medial shear fractures. Postero-medial shear fractures are under-appreciated and their clinical relevance have recently been characterised. Less invasive surgery and indirect reduction techniques are inadequate for treating these postero-medial coronal plane fractures. Methods. The approach includes an inverted ‘L’ shaped incision and reflection of the medial head of gastrocnemius, while protecting the neurovascular structures. This is a more extensile exposure than described by Trickey (1968). Our case series includes 8 females and 8 males. The average age is 53.1 years. The mechanism of injury included 7 RTAs, 5 fall from height, 1 industrial accident and 3 valgus injuries. All patients' schatzker grade 4, or above, fractures with a posteromedial split depression. Two were open, two had vascular compromise and one had neurological injury. Results. Average time to surgery was 6.4 days (range 0–12), operative time 142 mins (range 76–300), and length of stay 17.3 days (range 7–46). 11 patients were treated using the posrtero-medial approach alone and 5 were combined with an anterior approach. 2 patients suffered reduced range of movement requiring manipulation and physiotherapy, and 3 patients had a 5 degree fixed flexion deformity. 2 patients developed superficial wound infections treated with antibiotics alone. Anatomical reduction and fracture union was achieved in 13 patients; of the remaining 3 patients, 2 had unavoidable articular surface comminution, and 1 suffered antero-medial collapse and varus deformity. Conclusions. These are complex fractures to treat and this posterior surgical approach allows direct reduction and optimal positioning of plates to act as buttress devices. It can be extended across the midline to the postero-lateral corner and also allows excellent exposure of the popliteal vessels should concurrent vascular repair be required

Introduction. PIPJ replacement has become increasingly popular however, there is very little clinical data available apart from small studies and those from the originators of the prostheses. We present a review of our initial experience with the Acension. (c). Pyro-carbon PIP joint. Results. Data was collected from 62 joints in 39 patients with one patient lost to follow-up. Mean age was 61.6 years. 29 patients were female and 10 male. Mean follow up was 22.3 months (range 11 to 54). 7 patients or 11% needed further surgery. The majority were for stiffness with 3 operations for dislocation or component malposition. The total complication rate was 32%, again the biggest problem was stiffness. 4 joints have subluxed or dislocated, 2 had superficial infections. There was no statistical difference in the rate of complications compared to the operated finger or the pre-operative diagnosis. Post-operatively patients had a mean fixed flexion deformity of 19° and flexed to 76° (58° arc). However patients undergoing surgery following trauma do not do as well as the other groups with a decrease in ROM of 33°. Conclusions. Subjectively patients are returning low pain scores and the majority are pleased with the outcome of their surgery. There is however a high rate of complications and re-operations. This is in part due to the complexity of the cases as patients with inflammatory arthritis, following trauma or infection or those who are undergoing revision procedures often have decreased bone stock, erosions and more complex soft tissue balancing resulting in an increase in the complication rate. We have found the early results to be encouraging and, when successful, better than the short term results for arthrodesis or silastic implants. We intend to continue with the technique but believe patients should be kept under review

Objective. To assess the long term functional and objective outcomes for 2 stage Dupuytrens contracture correction. Methods. Patients with severe contracture were offered a 2 stage correction. This involved application of external fixator to distract the contracture over the course of 2 weeks and subsequent partial fasciectomy (in primary contractures) and dermofasciectomy with full thickness skin graft (in recurrent contractures). A series of 54 corrections in 47 patients were identified. Of these, 6 were lost to follow-up, 1 deceased. Pre-operative total range of active movement (TRAM), total flexion contracture and PIP flexion contracture, Tubiana grade and DASH/Michigan Hand Scores were recorded and compared to post-operative data. Results. Mean age was 61 (range 43–90), 44 male, 10 females. The average duration of follow-up was 32 months (range 6–96). The mean fixed flexion deformity (FFD) in the PIPJ improved from 84 degrees (range 50–110, SD-12) to 30 degrees (range −5–90, SD-27) (p< 0.0001). Mean total flexion contracture improved from 123 degrees(range 50–210, SD-34) to 46 degrees (range 0–195, SD-50) (p< 0.0001). The mean TRAM improved from 70 degrees (range 10–140, SD-33) to 148 degrees (range 25–135, SD-52) (p< 0.0001). DASH scores improved from 32.0 to 27.6. Michigan hand scores improved from 68 to 76. There was no statistical difference in pre- and post-op hand scores. Complications include CRPS (8%), infection (6%), stiffness (4%), graft failure (4%), neurovascular injury (2%), fracture (4%). Conclusions. Long term follow-up of this two stage technique shows that the correction, range of movement and function is maintained. We consider that the complications rate is acceptable for these very severe deformities where amputation, joint fusions and total collateral ligament and volar plate release are the only other comparable surgical alternatives

Late presentation and rapid progression of Dupuytren's contracture significantly increases operating time, complications and likelihood of incomplete correction; however, surgical timing is usually more a function of waiting list length than of clinical criteria. We sought to measure the rate of progress of Dupuytren's contracture. All patients with Dupuytren's contracture referred to the sole Consultant Hand Surgeon for Highland Region between June 1997 and February 2003 were prospectively included. Fixed flexion deformities at each finger joint and thumb-index angle to the point of firm resistance to extension were recorded by a single observer (QGNC) at presentation and immediately pre-operatively. Of 151 participants 37% had a family history. There was a male predominance of 5:1, with bilaterality in 77% at presentation. Five percent had diabetes, 3% had epilepsy, 52% acknowledged tobacco habits and 24% regular alcohol in excess of recommended limits. Angular deterioration was observed in 52% of digits, over one quarter of this occurred at the small finger joints, where 58% of PIPJs progressed. Mean delay from presentation to surgery was 11 months (2-55.5). Mean age at presentation of 62 (16-86) years did not correlate with angular deformity at presentation or with velocity of deterioration or with manual/non-manual employment. Mean severity of deformity at presentation for manual (34°) was double non-manual workers (17°) although angular deterioration was faster in the non-manual group (3.8 cf 0.7°/month respectively). Similar speeds of deterioration were seen at MCPJ and PIPJ, speed of deterioration was 2.2°/month for each of the three ulnar digits. Speed of deterioration correlated (r=0.7) with severity of deformity at presentation for ring and small fingers. This study offers the first quantification of rate of deterioration in Dupuytren's contracture. This could be used as a waiting list tool to predict the delay before a digit is likely to pose increased surgical risk