The gait pattern of five amputees was recorded by visual observation and also by a quantitative measurement system. The results were compared with the gait pattern predicted from biomechanical analysis. Visual observation was found to be an unreliable clinical skill. The observers recorded only 22.2% of the predicted gait deviations and were unable to comment on 15.6% of all the required observations. The gait parameters which were difficult to assess visually, namely step length and step time, are considered by most workers to be of particular value as diagnostic clinical indicators in gait assessment. The measurement system used was accurate in recording gait deviations and picked up 3.4 times as many deviations as visual observation. This report demonstrates the inadequacy of visual observation as a diagnostic method and emphasises the need for measurements

Guided growth is commonly performed by placing an extra-periosteal two-hole plate across the growth plate with one epiphyseal and one metaphyseal screw. Recent work by Keshet et al. (2019) investigated the efficacy of the removal of the metaphyseal screw only (“sleeper plate”) after correction. They concluded the practice to be unnecessary as only 19% of patient show recurrence of deformity. The aim of this study is to examine the incidence of rebound and undesired bony in-growth of the plate (“tethering”) after metaphyseal screw removal only.

In this retrospective case series, patient data on 144 plates inserted around the knee was obtained. Plates still in situ (n=69) at time of study and full hardware removal (n=50) were excluded. The remaining 25 plates had a metaphyseal screw only removed after deformity correction. We analyzed the rate of re-bound, tethering and maintenance of correction in two age groups at latest follow-up for a mean of 3.5 years (1.25 to five). Fisher's exact test with Freeman-Halton extension was used to analyze the two by three contingency table.

Twenty-five plates were identified as “sleeper plates” in our series. 13 plates (52%) maintained the achieved correction after a mean of 21 months (four to 39), nine plates (36%) required screw re-insertion due to rebound after a mean of 22 months (12-48) from screw removal, and four plates (16%) showed tethering with undesired continuation of guided growth after a mean of 14 months (seven to 22) from screw removal. Younger patients (years at time of plate insertion) had higher rates of rebound and tethering (p=.0112, Fisher's exact test). All Tethering occurred in titanium plates, none occurred in steel plates.

The sleeper plate is an acceptable treatment strategy for coronal deformities around the knee. Rebounding and tethering are potential outcomes that occur in younger patients and should be disclosed to patients; titanium plates may increase the risk of tethering, however further long-term follow-up is needed. We stress the importance of close post-operative follow up to identify tethering early and prevent over correction.

The sleeper plate technique is a viable option in younger children with congenital abnormalities, however, continued monitoring of alignment is necessary after screw removal to check for rebound and tethering.

Aims. The primary aim of this study was to evaluate the performance and safety of magnetically controlled growth rods in the treatment of early onset scoliosis. Secondary aims were to evaluate the clinical outcome, the rate of further surgery, the rate of complications, and the durability of correction. Patients and Methods. We undertook an observational prospective cohort study of children with early onset scoliosis, who were recruited over a one-year period and followed up for a minimum of two years. Magnetically controlled rods were introduced in a standardized manner with distractions performed three-monthly thereafter. Adverse events which were both related and unrelated to the device were recorded. Ten children, for whom relevant key data points (such as demographic information, growth parameters, Cobb angles, and functional outcomes) were available, were recruited and followed up over the period of the study. There were five boys and five girls. Their mean age was 6.2 years (2.5 to 10). Results. The mean coronal Cobb angle improved from 57.6° (40° to 81°) preoperatively, 32.8° (28° to 46°) postoperatively, and 41° (19° to 57°) at two years. Five children had an adverse event, with four requiring return to theatre, but none were related to the device. There were no neurological complications or infections. No devices failed. One child developed a proximal junctional kyphosis. The mean gain in spinal column height from T1 to S1 was 45.4 mm (24 to 81) over the period of the study. Conclusion. Magnetically controlled growth rods provide an alternative solution to traditional growing rods in the surgical management of children with early onset scoliosis, supporting growth of the spine while controlling curve progression. Their use has clear psychosocial and economic benefits, with the reduction of the need for repeat surgery as required with traditional growing rods. Cite this article: Bone Joint J 2018;100-B:507–15

We reviewed 31 consecutive patients with Friedreich’s ataxia and scoliosis. There were 24 males and seven females with a mean age at presentation of 15.5 years (8.6 to 30.8) and a mean curve of 51° (13° to 140°). A total of 12 patients had thoracic curvatures, 11 had thoracolumbar and eight had double thoracic/lumbar. Two patients had long thoracolumbar collapsing scoliosis with pelvic obliquity and four had hyperkyphosis. Left-sided thoracic curves in nine patients (45%) and increased thoracic kyphosis differentiated these deformities from adolescent idiopathic scoliosis. There were 17 patients who underwent a posterior instrumented spinal fusion at mean age of 13.35 years, which achieved and maintained good correction of the deformity. Post-operative complications included one death due to cardiorespiratory failure, one revision to address nonunion and four patients with proximal junctional kyphosis who did not need extension of the fusion. There were no neurological complications and no wound infections. The rate of progression of the scoliosis in children kept under simple observation and those treated with bracing was less for lumbar curves during bracing and similar for thoracic curves. The scoliosis progressed in seven of nine children initially treated with a brace who later required surgery. Two patients presented after skeletal maturity with balanced curves not requiring correction. Three patients with severe deformities who would benefit from corrective surgery had significant cardiac co-morbidities

Aims. Magnetically controlled growing rod (MCGR) systems use non-invasive spinal lengthening for the surgical treatment of early-onset scoliosis (EOS). The primary aim of this study was to evaluate the performance of these devices in the prevention of progression of the deformity. A secondary aim was to record the rate of complications. Patients and Methods. An observational study of 31 consecutive children with EOS, of whom 15 were male, who were treated between December 2011 and October 2017 was undertaken. Their mean age was 7.7 years (2 to 14). The mean follow-up was 47 months (24 to 69). Distractions were completed using the tailgating technique. The primary outcome measure was correction of the radiographic deformity. Secondary outcomes were growth, functional outcomes and complication rates. Results. The mean Cobb angle was 54° (14° to 91°) preoperatively and 37° (11° to 69°) at the latest follow-up (p < 0.001). The mean thoracic kyphosis (TK) was 45° (10° to 89°) preoperatively and 42° (9° to 84°) at the latest follow-up. The mean T1–S1 height increased from 287 mm (209 to 378) to 338 mm (240 to 427) (p < 0.001) and the mean sagittal balance reduced from 68 mm (-76 to 1470) preoperatively to 18 mm (-32 to 166) at the latest follow-up. The mean coronal balance was 3 mm (-336 to 64) preoperatively and 8 mm (-144 to 64) at the latest follow-up. The mean increase in weight and sitting and standing height at the latest follow-up was 45%, 10% and 15%, respectively. The mean Activity Scale for Kids (ASKp) scores increased in all domains, with only personal care and standing skills being significant at the latest follow-up (p = 0.02, p = 0.03). The improvements in Cobb angle, TK and T1-S1 heights were not related to gender, the aetiology of the EOS, or whether the procedure was primary or conversion from a conventional growing rod system. A total of 21 children developed 23 complications at a rate of 0.23 per patient per year. Seven developed MCGR-specific complications. Complications developed at a mean of 38 months (3 to 67) after the initial surgery and required 22 further procedures. Children who developed a complication were more likely to be younger, have syndromic EOS, and have a single-rod construct (6.9 versus 9.3 years, p = 0.034). Conclusion. The progression of EOS can be controlled using MCGRs allowing growth and improved function. Younger and syndromic children are more likely to develop complications following surgery. Cite this article: Bone Joint J 2018;100-B:1187–1200

Background. The procedures of total elbow and shoulder replacements increased 6% to 13% annually from 1993 to 2007 with revision-related burden increasing from 4.5% to 7%. The revisions of the shoulder and elbow prostheses due to aseptic loosening, periprosthetic fractures, infections have led to the use of standard or custom-made implants due to significant bone loss. This study reports our experience in the management of complicated primary and revisions of total shoulder and elbow replacements with significant humeral bone loss and in metabolic diseases of the elbow and shoulder treated with bone resection using The Mosaic Humeral Replacement System. Patients and Materials. A total of 20 patients underwent total elbow or shoulder arthroplasty using the Mosaic Humeral Replacement System (Biomet, UK). The Mosaic system was used in 8 shoulder arthroplasties (Group A) and in 12 elbow arthroplasties (Group B). The underlying pathologis in Group A included 2 malunited proximal humerus fracture, 1 humeral osteomyelitis, 1 shoulder chondrosarcoma, 1 aggressive Gigantic Cell Tumor with prosthetic fracture, 2 metastatic lytic lesion, and 1 failed fixation of non-union proximal humerus. Figure 1 shows Mosaic implant after complex fracture of proximal humerus. Reasons for Mosaic arthroplasty in Group B included 3 humeral component revisions due to periprosthetic fracture, 1 prosthesis breaking-up with fractures, 1 revision of loose Souter Strathclyde prosthesis, 1 loose prosthesis due to infection, 1 highly comminuted elbow fracture, 1 aseptic loosening of humeral component of total elbow replacement, 3 revision of total elbow replacement due loosening and 1 pathological distal humerus fracture due to metastasis. Figure 2&3 shows pre- and post-operative Mosaic implant following complex periprosthetic fracture of distal humerus. Clinical Observation/Discussion. The Mosaic Humeral Replacement System is a complete system for complex revision, salvage/oncology, and complex humeral fractures. It is a completely modular system which can be adapted to different patient anatomies and indications. It has been designed to face several surgical challenges, including reattaching soft tissues, properly tensioning the glenohumeral joint and restoring joint function. It is a cost-effective procedure with the benefits of a custom made humeral component in a standard tray. Our study shows that good results can be achieved with this form of treatment. Radiological assessment of all patients showed a satisfactory position of the implant with appropriate margin of bony resection. One patient with proximal and another one with distal humeral Mosaic replacement had late infection. One patient had aseptic loosening 3 years after distal humeral replacement. Most of the patients had satisfactory improvement in range of movement and chronic pain. While primary clinical observations and imaging results indicate acceptable results with Mosaic arthroplasty; a realistic assessment can only be achieved in long-term using the appropriate outcome measures. At the present we continue to regularly assess the patients clinically and radiologically and by means of Liverpool elbow score for distal and Quick- DASH for proximal Mosaic Humeral Replacement System and plan to report the long-term results in due time

We have been using 3-dimensional CAD software for preoperative planning as a desktop tool daily. In ordinary cases, proper size stems and cups can be decided without much labor but in our population, many arthritic hip cases have dysplastic condition and they often come to see us for hip replacement after severe defects were created over the acetabulum. It is often the case that has Crowe's type III, IV hips with leg length difference. For those cases preoperative planning using 3D CAD is a very powerful tool. Although we only have 2-dimensional display with our computer during preoperative planning, 3 dimensional geometries are not so difficult to be understood, because we can turn the objects with the mouse and can observer from different directions. We can also display their sections and can peep inside of the geometries. It is quite natural desire that a surgeon wishes to see the planed geometries as a 3-dimensional materials. For some complicated cases, we had prepared plastic model and observed at the theater for better understanding. When we ask for a model service, each model costs $2,500. We also have small scale desk top rapid processing tool too, however it takes 2 days to make one side of pelvis. Observation of the geometries using 3-dimensional display can be its substitute without much cost and without taking much time. The problem of using 3D display had been the special goggle to mask either eye alternatively. In the present paper, we have used a 3D display which has micro arrays of powerful prism to deriver different image for each eye without using any goggle. Method. After preoperative planning, 2 images were prepared for right eye and left eye giving 2-3 degree's parallax. These images were encoded into a special AVI file for 3-dimensional display. To keep fingers away from the device, several scenes were selected and 3-dimensional slide show was endlessly shown during the surgery. Result. Cup geometries with screws had been prepared and cup position with screws direction were very useful. The edge of acetabulum and cup edge are well compared then could obtain a better cup alignment. Screws are said to be safe if they were inserted in upper posterior quadrant. However so long as the cluster cup was used, when the cup was given 30 degrees anterior rotation, 25 mm screw was still acceptable using CAT angiography. Conclusion. Three dimensional display without goggle was a useful tool to observe preoperative planning inside the operation theater

Objective: we present the long-term behavior of polyethylene’s insert in acetabular implants ARC2F. Materials and Methods: from 1989 to 1995, 668 THA’s were implanted. Mean patients age was 54 years (28–75). The preoperative diagnosis included: primary OA 501 cases, post-traumatic arthritis 24, hip dysplasia 112, AVN 31. In all cases Omnifit femoral stem with proximal HA coating and ARC2F acetabular component were used. 165 patients (182 arthroplasties) were lost to follow-up. The average time of observation was 15 years (13–18.5). Results: all THA’s performed well without signs of wear at 10 years. No implant was revised during the first decade because of mechanical loosening. Since then, during the 13th – 14th year, a significant number of patients appeared with symptoms of polyethylene’s massive destruction and significant osteolysis at the femoral and acetabular side of the arthroplasty. We recalled all patients that could be found. Totally, 178 from 486 THA’s had similar radiographic signs of wear. Only 33 of all these had initial wrong orientation of the cup. Conclusion: despite the excellent early and middle-term results, ARC2F shows rapid and massive wear of the insert after 12 years, probably because of degeneration and loss of polyethylene’s structural integrity due to the method of sterilization. We suggest to recall and inspect all the patients which have this kind of implant more than 12 years

Introduction & Purpose of Study. The purpose of the present study was to evaluate the clinical, radiographic and histologic results with the Zweymueller total hip arthroplasty (THA) and metal-on-metal articulation. Material and Methods. Between 1994–2003, 380 patients received 415 third-generation Zweymueller-Plus THA with SL-stem and Bicon screw socket for hip osteoarthritis. Ten (5.15%) patients did not return for their last follow-up evaluation for reasons unrelated to their hip operation. This study reports on 217 THAs with follow up more than 60 months. The 217 THAs were implanted in 194 patients (143 women and 51 men), aged 55 ± 9 years, (25–70 years). The most common diagnosis for THA was primary osteoarthritis (48%) followed by secondary osteoarthritis due to developmental hip dysplasia (44%). Results. The follow-up was 77 ±17 months, (60 – 112 months). From the 217 THAs, 14 (6.4%) hips were revised for any reason; the socket in 5(2.3%) and the SL-stem in 9(4.1%) hips. The preoperative Harris hip score of 45±19 was improved to 96 ± 4 postoperatively. 95% of the patients were satisfied or very satisfied with the result of the operation. Revision was made in a total 14(4.6%) hips because of different reasons. The aseptic revision rate was 5%: 4(1.8%) Bicon cups and 7(3%) SL-stems were revised for aseptic loosening. The septic revision rate was 1.4% (3 THAs) and was due to Staph aureus. Periarticular ossification was observed in 32(17%) of the hips (5% Brooker grades III and IV), however without associated disability. The histological examination revealed mild metalosis (Mirra grades 1 and 2) in all revised hips. The cumulative survival for any reason (95% C.I.) was 90% (97% to 71%). The aseptic survival was 91% (97–72%) [95% CI); and specifically for the Bicon socket it was 98 % (100 to 92%); and for the SL-stem 93% (98% to 74%)[CI 95%]. The survival for the men and women was 78.9% and 94.4% respectively (log rank test: chi square P= 0.25). A significant, not statistically significant observation was that men showed lower survival for the stem than women (78.9 vs. 97.5%). Conclusion. This study showed that the medium-term results of Zweymueller total hip arthroplasty with metal-on-metal articulation were inferior particularly for the SL-stem to those obtained with the conventional Zweymueller total hip arthroplasty with polyethylene-ceramic articulation. This could be due either to allergic or mechanical (Sikomet Alloy) reasons

The movements of the carpal bones during the scaphoid shift test were evaluated radiographically in 60 wrists. The clinical results were graded according to the degree of subluxation of the scaphoid and pain on the dorsum of the wrist. Lateral radiographs at rest and under stress were taken and the relative movements of the scaphoid with respect to the radius and lunate, and the rotation of the scaphoid and lunate were calculated.

Dorsal displacement of the scaphoid with respect to the radius was significantly associated with the clinical grade of subluxation. There was correlation between the amount of pain and the displacement of the scaphoid from the lunate, but not from the radius. The wrists with a painful shift test had greater relative displacement of the scaphoid from the lunate than those with painless subluxation.

These observations support the view that pain associated with subluxation of the scaphoid during the shift test is a significant finding, and that radiographic analysis of the test may confirm a positive result when dynamic scaphoid instability is suspected.

Of 42 patients with resolvingscoliosis, 34 were followed up for more than 25 infantile idiopathicyears. Twenty had been primarily treated in a plaster bed and 14 by physiotherapy. The mean angle of the curve at presentation was 17° and at follow-up it was 5°. No patient had significant progression of the scoliosis during the growth spurt. When adults few had back pain or an increased disability score and there was no interference with work or social activities. The rib-vertebra angle difference proved to be an essential radiological sign when distinguishing resolving from progressive infantile idiopathic scoliosis. There was no advantage of plaster over physiotherapy with regard to either the time to resolution or the functional outcome. Treatment of resolving infantile idiopathic scoliosis in a plaster bed is therefore now outdated.

Introduction

A recent retrospective study of distal femoral physeal fractures (DFPFs) suggested closed manipulation alone has a high incidence of re-displacement, malunion or physeal bar formation. The paper concluded that all displaced DFPFs require internal fixation, and breaching the physis with k-wires is safe. We agree that hyper-extension/flexion injuries need stabilisation using k-wires but, in our experience, purely valgus/varus deformities can be successfully managed by manipulation under anaesthesia (MUA) and a moulded cylinder cast.

In biomaterial engineering the surface of an implant can influence cell differentiation, adhesion and affinity towards the implant. Increased bone marrow derived mesenchymal stromal cell (BMSC) differentiation towards bone forming osteoblasts, on contact with an implant, can improve osteointegration. The process of micropatterning has been shown to improve osteointegration in polymers, but there are few reports surrounding ceramics.

The purpose of this study was to establish a co-culture of BMSCs with osteoclast progenitor cells and to observe the response to micropatterned zirconia toughened alumina (ZTA) ceramics with 30 µm diameter pits. The aim was to establish if the pits were specifically bioactive towards osteogenesis or were generally bioactive and would also stimulate osteoclastogenesis that could potentially lead to osteolysis.

We demonstrate specific bioactivity of micropits towards osteogenesis with more nodule formation and less osteoclastogenesis. This may have a role when designing ceramic orthopaedic implants.

Introduction

Deciding the acetabular cup inclination and anteversion is an important step in total hip arthroplasty. Despite numerous studies focusing on enhancement of precise positioning into anatomical safe zone, problem remains regarding which is the “optimal anteversion” and what is the proper anatomical reference during the surgery.

Post-discharge surveillance of surgical site infection is necessary if accurate rates of infection following surgery are to be available. We undertook a prospective study of 376 knee and hip replacements in 366 patients in order to estimate the rate of orthopaedic surgical site infection in the community. The inpatient infection was 3.1% and the post-discharge infection rate was 2.1%. We concluded that the use of telephone interviews of patients to identify the group at highest risk of having a surgical site infection (those who think they have an infection) with rapid follow-up by a professional trained to diagnose infection according to agreed criteria is an effective method of identifying infection after discharge from hospital.

Introduction: Some patients with collapsed osteonecrosis of the femoral head do not need any specific treatment because of mild symptoms or disability. The general features of this patient population were evaluated.

Materials and Methods: Forty-five cases of collapsed osteonecrosis of the femoral head in 38 patients were included in this study. These patients visited outpatient clinics for the first time from January 1996 to December 2002. In all cases, pain developed at least 3 years before the last follow-up, but no specific treatment was necessary. There were 27 men and 11 women. The mean age at the onset of pain was 41 years (range, 17 to 72 years). The duration from the onset of pain to the last follow-up was 36 to 167 months (mean, 73 months). The general and radiological features were evaluated.

Results: Risk factors included steroid therapy in 18, alcoholism in 16, other in 1 case; 10 cases had no risk factors (idiopathic). In 29 patients, both femoral heads were involved. Extent of the necrosis was 37 to 89 percent (mean, 62 percent). The amount of depression was 0.5 to 17 mm (mean, 2.2 mm).

Discussion: Steroid therapy was the most frequent risk factor in this patient population. In most cases, the amount of depression was less than 3 mm. Most patients remembered that the pain was most severe at its onset and improved over the next several months.

Introduction

Lisfranc joint injuries account for only 0.2% of all fractures but early diagnosis improves the chances of a better outcom]. Radiographic signs, such as diastasis (>2mm) of the 1–2 interspace, are subtle and. often missed, leading to a poorer outcome. We present a new radiographic sign, less likely to result in missed diagnoses. Null nypothesis: The intermetarsal angle remains unchanged in Lisfranc injuries.

Introduction

The prosthetic impingement occurs if the range of motion of the hip exceeds implant mobility or in case of component malorientation. This retrieval study was designed to assess the frequency and the risk factors of this phenomenon.

There are currently no agreed guidelines for the type and frequency of post spinal surgery neurological observations. This lack of an agreed standard can lead to the failure to adequately monitor cord function following surgery and thus neurological deficits can be missed. We have carried out an audit of the postoperative spinal observations against our agreed standards of care.

Standards of care:

All patients should have the frequency of required neuro obs documented in the post op instructions.

28 case notes were reviewed. 21 of these cases were scoliosis correction through anterior, posterior and combined approaches. 3 had disc replacements, 2 had decompression for metastatic cancer and one had fixa-tion of a fracture.

All patients failed to complete all standards fully. There was a lack of clear postoperative guidelines, failure to record neurological status in recovery, incomplete documentation of neurological state in HDU, failure to inform medical staff in presence of a neurological deficit and inadequate assessment of patient by medical staff. One patient returned to theatre for a foot drop, which is still only partially recovered.

We recommend the audit of current practice and implementation of locally agreed standards for the postoperative monitoring.

Introduction: The prosthetic impingement occurs if the range of motion of the hip exceeds implant mobility or in case of component malorientation. This phenomenon is rarely studied in the literature and most data have come from sporadic cases. This study was designed to assess the frequency and the risk factors of this phenomenon.

Material: The frequency and the severity of the impingement were calculated from a continuous series of 413 cups retrievals. These cups were examined macroscopically twice by two independent observers. The cam effect was noted as: absent, grade 1 (visible at gross inspection but measuring < 1 mm), grade 2 (notch measuring 1–3 mm), grade 3 (notch measuring > 3 mm). The risk factors were analyzed for 298 retrievals that had complete clinical charts.

Results: Among the 413 cups explants, the frequency of impingement was 51.3 percent (grade 3 in 12% and grade 2 in 24%). The impingement was the reason for removal in only 1.7 percent (only for hard bearings), meaning that impingement was mainly an unexpected event (98.3 percent). The impingement was more frequent when revisions were performed because of instability (80 percent; odd-ratio 4.2 (1.1–16.2)) than for loosening (52%) osteolysis (59%) or infection (38%) (p =.002). Likewise, impingement was more frequent when the sum of hip motion exceeded 200 degrees (sum of motion in the 6 degrees of freedom of the hip) (66% versus 45% if the sum was below 200°). The other risk factors were: use of heads with skirts (78% versus 55%), liner with an elevated rim (73% versus 55%), and head-neck ratio below 2.

Discusssion and conclusion: This study underlines the impingement is common when assessing cup retrievals (over 50 percent). One should be aware of impingement when performing hip replacement in patients having a high range of motion. This situation may require prostheses with a high head-neck ratio, as well as use of computer-assisted surgery. One should avoid liners with elevated rim as well as heads with skirts to prevent dislocation, particularly when other risk factors are detected.