Botulinum toxin A (BoNT-A) is a substance that requires repeated application due to its effectiveness being lost 12–16 weeks post application. Performing these intra-muscular injections under anesthesia reduces pain and distress during applications, ensuring effective and successful functional results. This study evaluates motor development of patients undergoing 3 or more repeated BoNT-A application in a tertiary pediatric hospital and the safety as well as effect of 3 different types of anesthesia. 75 children with cerebral palsy who underwent BoNT-A application at least three times consecutively with 6-month intervals and a total of 320 procedures admitted between January 2008 and January 2018 were retrospectively examined. Gross Motor Function Classification System (GMFCS) was employed in motor development evaluation. To observe the improvement in motor development, those with 2-1-0 level decreases in GMFCS classes were grouped and compared in terms of birth time, birth weight, cerebral palsy type and first BoNT-A application age. The 3 types of anesthesia methods (sedation analgesia, larengeal mask anesthesia (LMA) and inhalation mask anesthesia) applied during the procedures were compared in terms of sedation, procedure, recovery and total operation room time. The mean age of the children for all procedures was 45.51 ± 22.40 months. As a result of procedures, significant motor development was observed in 60 (80%) patients (p <0,000∗). No significant difference was observed when the children with cerebral palsy whose GMFCS declined in the form of level 2, 1 and unchanged were compared in terms of first application age, birth weight and gestational age. It was found that 106 (33.1%) were applied sevoflurane with anesthesia mask, 103 (32.1%) were administered sevoflurane with laryngeal mask, and 111 (34.6%) were sedation-analgesia. Only 10 out of 320 procedures were seen to develop side effects (8 vomiting, 2 bronchospasm). In the patients who underwent sedation analgesia during the first 3 BoNT-A procedures, the duration of recovery and total operating room time was seen to be significantly shorter than the others, while there was no difference between the anesthesia methods in the 4th and subsequent procedures. Regardless of the type of anesthesia, the recovery and total operating room times of those having undergone 6 or more procedures were longer than those with less than 6 procedures (p <0.009, p <0.016, respectively). As conclusion, repeated BoNT-A applications in children with CP provides progress in motor steps, it can be applied safely and effectively under anesthesia. Sedation analgesia application provides easier recovery compared to general anesthesia with LMA and mask only in the first three applications. However, recovery time increases with 4 and more repeated applications as the number of applications increases

Abstract. Objectives. Single-event multilevel surgery (SEMLS) is the standard orthopaedic treatment for gait abnormalities in children with diplegic cerebral palsy (CP). The primary aim of this study was to report the long-term functional mobility of these patients after surgery. The secondary aim was to assess the relationship between functional mobility and quality of life (QoL). Methods. Patients were included if they met the following criteria: 1) diplegic CP; 2) Gross Motor Function Classification System (GMFCS) I to III; 3) SEMLS at age ≤ 18. A total of 61 patients, mean age at surgery 11 years eight months (SD 2y 5m), were included. A mean of eight years (SD 3y 10m) after SEMLS, patients were contacted and asked to complete the Functional Mobility Scale (FMS) questionnaire over the telephone and given a weblink to complete an online version of the CP QOL Teen. FMS was recorded for all patients and CP QOL Teen for 23 patients (38%). Results. Of patients graded GMFCS I and II preoperatively, at long-term follow-up the proportion walking independently at home, school/work and in the community was 71% (20/28), 57% (16/28) and 57% (16/28), respectively. Of patients graded GMFCS III preoperatively, at long-term follow-up 82% (27/33) and 76% (25/33) were walking either independently or with an assistive device at home and school/work, respectively, while over community distances 61% (20/33) required a wheelchair. The only significant association between QoL and functional mobility was better ‘feelings about function’ in patients with better home FMS scores (r=0.55; 95% confidence interval 0.15 to 0.79; p=0.01). Conclusion. The majority of children maintained their preoperative level of functional mobility at long-term follow-up after SEMLS. Despite the favourable functional mobility, there was little evidence to establish a link between functional status and quality of life

Abstract. Objectives. Neonatal motor development transitions from initially spontaneous to later increasingly complex voluntary movements. A delay in transitioning may indicate cerebral palsy (CP). The general movement optimality score (GMOS) evaluates infant movement variety and is used to diagnose CP, but depends on specialized physiotherapists, is time-consuming, and is subject to inter-observer differences. We hypothesised that an objective means of quantifying movements in young infants using motion tracking data may provide a more consistent early diagnosis of CP and reduce the burden on healthcare systems. This study assessed lower limb kinematic and muscle force variances during neonatal infant kicking movements, and determined that movement variances were associated with GMOS scores, and therefore CP. Methods. Electromagnetic motion tracking data (Polhemus) was collected from neonatal infants performing kicking movements (min 50° knee extension-flexion, <2 seconds) in the supine position over 7 minutes. Tracking data from lower limb anatomical landmarks (midfoot inferior, lateral malleolus, lateral knee epicondyle, ASIS, sacrum) were applied to subject-scaled musculoskeletal models (Gait2354_simbody, OpenSim). Inverse kinematics and static optimisation were applied to estimate lower limb kinematics (knee flexion, hip flexion, hip adduction) and muscle forces (quadriceps femoris, biceps femoris) for isolated kicks. Functional principal component analysis (fPCA) was carried out to reduce kicking kinematic and muscle force waveforms to PC scores capturing ‘modes’ of variance. GMOS scores (lower scores = reduced variety of movement) were collected in parallel with motion capture by a trained operator and specialised physiotherapist. Pearson's correlations were performed to assess if the standard deviation (SD) of kinematic and muscle force waveform PC scores, representing the intra-subject variance of movement or muscle activation, were associated with the GMOS scores. Results. The study compared GMOS scores, kinematics, and muscle force variances from a total of 26 infants with a mean corrected gestational age of 39.7 (±3.34) weeks and GMOS scores between 21 and 40. There was a significant association between the SD of the PC scores for knee flexion and the GMOS scores (PC1: R = 0.59, p = 0.002; PC2: R = 0.49, p = 0.011; PC3: R = 0.56, p = 0.003). The three PCs captured variances of the overall flexion magnitude (66% variance explained), early-to-late kick knee extension (20%), and continual to biphasic kicking (6%). For hip flexion, only the SD of PC1 correlated with GMOS scores (PC1: R = 0.52, p = 0.0068), which captured the variance of the overall flexion magnitude (81%). For the biceps femoris, the SD of PC1 and PC3 associated with GMOS scores (PC1: R = 0.50, p = 0.002; PC3: R = 0.45, p = 0.03), which captured the variance of the overall bicep force magnitude (79%) and early-to-late kick bicep activation (8%). Conclusions. Infants with reduced motor development as scored in the GMOS displayed reduced variances of knee and hip flexion and biceps femoris activation across kicking cycles. These findings suggest that combining objectively measured movement variances with existing classification methods could facilitate the development of more consistent and accurate diagnostic tools for early detection of CP. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction and Objective. Clinically, it is considered that spastic muscles of patients with cerebral palsy (CP) are shortened, and produce higher force in shorter muscle lengths. Yet, direct quantification of spastic muscles’ forces is rare. Remarkably, previous intraoperative tests in which muscle forces are measured directly as a function of joint angle showed for spastic gracilis (GRA) that its passive forces are low, and only a small percentage of its maximum active force is measured in flexed knee positions. However, the relationship of force characteristics of spastic GRA with its muscle-tendon unit length (l. MTU. ) is unknown. Combining intraoperative experiments with participants’ musculoskeletal models developed based on their gait analyses, we aimed to test if spastic GRA muscle (1) operates at short l. MTU. compared to that of typically developing (TD) children, and exerts higher (2) passive and (3) active forces at shorter lengths, within gait-relevant l. MTU. range. Materials and Methods. Ten limbs of seven children with CP (GMFCS-II) were tested. Pre-surgery, gait analyses were conducted. Intraoperatively, isometric spastic GRA distal forces were measured in ten hip-knee joint angle combinations, in two conditions: (i) passive state and (ii) maximal activation of the GRA exclusively. In OpenSim, gait_2392 model was used for each limb to calculate l. MTU. 's per each hip and knee angle combination and the gait-relevant l. MTU. range, and to analyze gait relevant spastic muscle force - l. MTU. data. l. MTU. values were normalized for the participants’ thigh lengths. Two-way ANOVA was used to compare the patients’ l. MTU. to those of the seven age-matched TD children to test the first hypothesis. In order to test the second and the third hypotheses, Spearman's rank correlation coefficient (ρ) was calculated to seek a correlation between the muscle's operational length (represented by mean l. MTU. within gait cycle) and muscular force characteristics (the percent force at shortest l. MTU. of peak force, either in passive or in active conditions) within gait-relevant l. MTU. range. Results. ANOVA showed that l. MTU. 's of spastic GRA are shorter (on average by 15.4%) compared to those of TD. At the shortest gait-relevant l. MTU. , the GRA passive force was 84.6 (13.7)% of the peak passive force; and the active force was 55.8 (33.9)% of the peak active force. Passive state forces show an increase at longer lengths, whereas active state force characteristics vary in a patient-specific way. Spearman's rank correlation indicated weak correlations between muscle's operational length and muscular force characteristics (ρ= −0.30 P= 0.40, and ρ= −0.27 P= 0.45, for passive and active states, respectively). Therefore, only the first hypothesis was confirmed. Conclusions. Novel muscle force - l. MTU. data for spastic GRA were obtained using intraoperative data and modelling combined. The modelling showed in concert with the clinical considerations that spastic GRA may be a shortened muscle. However, because the model does not distinguish the muscle-belly and tendon lengths, it cannot isolate shorter muscle belly length and how this compares to the data of TD children remains unknown. Moreover, the absence of a strong correlation between shorter operational muscle length and higher force production either in passive or in active conditions highlights the influence of other factors (e.g., muscle structural proteins, and muscle mechanical characteristics including intermuscular interactions etc.) on the pathology rather than ascribing it solely to the length of a spastic muscle itself

Background. Spastic muscles of patients with cerebral palsy (CP) are considered structurally as shortened muscles, that produce high force in short muscle lengths. Yet, previous intraoperative studies in which muscles’ forces are measured directly as a function of joint angle showed consistently that spastic knee flexor muscles produce a low percentage of their maximum force in flexed knee positions. They also showed effects of epimuscular myofascial force transmission (EMFT): simultaneous activation of different muscles elevated target muscle's force. However, quantification of spastic muscle's force - muscle-tendon unit length (l. MTU. ) data during gait is lacking. Aim. Combining intraoperative experiments with participants’ musculoskeletal models developed based on their gait analyses, we aimed to test the following hypotheses: activated spastic semitendinosus (ST) muscle (1) operates at short l. MTU. 's during gait, forces are (2) low at short l. MTU. 's and (3) increase by co-activating other muscles. Methods. Ten limbs of seven children with CP (GMFCS-II) were tested. Pre-surgery, gait analyses were conducted. Intraoperatively, isometric spastic ST distal forces were measured in ten hip-knee joint angle combinations, in two conditions: (i) activation of the ST individually and (ii) simultaneously with the gracilis, biceps femoris, and rectus femoris muscles endorsing EMFT. In OpenSim, gait_2392 model was used for each limb to (a) calculate l. MTU. per each hip and knee angle combination and the gait relevant l. MTU. range, and (b) analyze gait relevant spastic muscle force - l. MTU. data. Two-way ANOVA was used to compare the patients’ l. MTU. to those of the seven age-matched typically developing (TD) children. l. MTU. values were normalized for the participants’ thigh length. (a) was used to test hypothesis (1) and (b) to test hypotheses (2) and (3): in condition (i), the percent of peak force exerted at the shortest l. MTU. calculated per limb was used as a metric for (2). In condition (ii), mean percent change in muscle force calculated within gait-relevant l. MTU. range was used as a metric for (3). Results. Modeling showed that l. MTU. of spastic ST during gait is shorter on average by 14.1% compared to TD. The ST active force at the shortest gait-relevant l. MTU. was 68.6 (20.6)% (39.9–99.2%) of the peak force. Simultaneous activation of other muscles caused substantial increases in force (minimally by 11.1%, up to several folds, with an exception for one limb). Therefore, only the first and third hypotheses were confirmed. Conclusion. The modeling showed in concert with the clinical considerations that spastic ST may be a shortened muscle that produces high force in short muscle lengths. However, this contrasts intraoperative data, which shows only low forces in flexed knee positions. Note that, the model does not distinguish the muscle-belly and tendon lengths. Therefore, it cannot isolate shorter muscle length and how this compares to the data of TD children remains unknown. Yet, the effects of co-activation of other muscles shown intraoperatively to cause an increase of the spastic ST's force are observed also in muscle force - l. MTU. data characterizing gait. Therefore, if indeed spastic ST produces high forces in short muscle-belly lengths alone, elevated forces due to co-activation of other muscles may be considered as a contributor to the patients’ pathological gait. Otherwise, such EMFT effect may be the main determinant of the pathological condition

Using the transverse processes of fresh porcine lumbar spines as an experimental model we evaluated the heat generated by a rotating burr of a high-speed drill in cutting the bone. The temperature at the drilled site reached 174°C with a diamond burr and 77°C with a steel burr. With water irrigation at a flow rate of 540 ml/hr an effective reduction in the temperature was achieved whereas irrigation with water at 180 ml/hr was much less effective. There was a significant negative correlation between the thickness of the residual bone and the temperature measured at its undersurface adjacent to the drilling site (p < 0.001). Our data suggest that tissues neighbouring the drilled bone, especially nerve roots, can be damaged by the heat generated from the tip of a high-speed drill. Nerve-root palsy, one of the most common complications of cervical spinal surgery, may be caused by thermal damage to nerve roots arising in this manner

We present a novel use for an adult proximal humeral locking plate. In our case an 18-year-old female with cerebral palsy sustained a peri-prosthetic fracture of a blade plate previously inserted for a femoral osteotomy. Treatment was revision using a long proximal humeral locking plate. She had a successful outcome. We present the history and operative management. The female had a history of quadriplegic cerebral palsy, asthma, diabetes mellitus and congenital heart disease. She had a gastrostomy tube for enteral feeding. She was on nutritional supplements, baclofen, Omeprazole and movicol. She is looked after by her parents and requires a wheelchair for mobility. She is unable to communicate. Surgical History: Right adductor tenotomy, aged 11. Femoral Derotation Osteotomy & Dega Acetabular Osteotomy, aged 13. Right distal hamstring and knee capsule release, aged 14. Admitted to A&E (aged 18); unwitnessed fall. Painful, swollen, deformed thigh with crepitus. Xrays demonstrated peri- prosthetic fracture below blade plate. No specific equipment available to revise. Decision made to use PHILOS (Synthes, UK). GA, antibiotics, supine on table. Lateral approach. Plate removed after excising overgrown bone. Reduced and held. 10hole PHILOS applied. Near anatomical reduction. Secure fixation with locking screws proximally away from blade plate defect. Blood loss 800ml. 5 days in hospital. Sequential fracture clinic review. Wound healed well. Fracture healed on Xray at 11 months and discharged. To our knowledge this is the first reported use of a PHILOS plate for this specific fracture. The complexity of this case and underlying neurological disorder deemed long blade plate revision unsuitable. Fracture rates after femoral derotation osteotomies rare. 5/157 and 1/58 in the two largest studies to date. Conservative measures were the main recommendation. We have demonstrated a straightforward method for revision fixation with an excellent outcome. It would be recommended as an alternative to other surgeons in this position

Background. Administration of Botulinum toxin type A (BTX-A) in patients with spastic cerebral palsy aims to improve mobility by increasing joint range of motion and decreasing passive resistance. However, our recent animal experiments indicated that BTX-A can decrease muscle”s length range of force exertion (Lrange), and increase its passive forces and extracellular matrix (ECM) collagen content. Moreover, BTX-A injected into the tibialis anterior (TA) was shown to spread into non-injected synergistic muscles in the whole anterior crural compartment. These effects that contradict the treatment aims deserve further investigation. Aim. To test in a rat model if: (1) BTX-A injected into the medial and lateral gastrocnemius (GM&GL) muscles spreads into the synergistic soleus (SOL) as well as antagonistic TA and extensor digitorum longus (EDL). (2) The muscles exposed show a wider Lrange, decreased muscle passive force and reduced ECM collagen. Methods. 2×0.1U/20µl of BTX-A (BTX-A group, n=6) or only 2×20µl of saline (Control group, n=6) were prepared and each was injected into the mid-belly of the GM and GL separately. 5 days post injection, forces of all muscles were measured in passive state and also on activation. The GM&GL length was changed whereas; all other muscles were kept at constant length. After biomechanical testing, the muscles were histologically analyzed using Gomori trichrome stain to detect ECM collagen. Two-way ANOVA (factors: GM&GL length and animal group) was used to assess BTX-A effects on forces, and the Kruskal-Wallis test was used to test the change in proportion of collagenous tissue for each muscle. Differences were considered significant at p<0.05. Results. Injected muscles: ANOVA showed significant main effects of both factors on GM&GL total forces and a significant interaction. Force reductions are more pronounced at shorter lengths (increase from 80.8% to 88.4% with decreasing length). Lrange decreased (by 24.1%). ANOVA showed significant main effects of only muscle length on GM&GL passive forces and no significant interaction. Non-injected muscles: ANOVA showed significant main effects of both factors (for SOL), or only of BTX-A (for TA and EDL) only on muscle total forces, but no significant interaction. Force drops for the SOL (89.8%) and anterior crural muscles (57.0% and 51.0% for TA and EDL) do indicate spread of BTX-A intra- and extra-compartmentally. Histological analyses showed increased ECM collagen contents of BTX-A group for the GM&GL, TA, and EDL. Conclusion. Narrowed Lrange and increased ECM collagen content are not in accord with the clinical purpose of the treatment. BTX-A did not reduce passive forces, but did not cause an increase either. Remarkably, the results show that BTX-A leakage is a major issue that can affect muscles of even antagonistic muscle compartments. Hence, our animal experiments indicate much more complex BTX-A effects than considered, which requires further testing in patients

Objectives. There are various pin-in-plaster methods for treating fractures of the distal radius. The purpose of this study is to introduce a modified technique of ‘pin in plaster’. Methods. Fifty-four patients with fractures of the distal radius were followed for one year post-operatively. Patients were excluded if they had type B fractures according to AO classification, multiple injuries or pathological fractures, and were treated more than seven days after injury. Range of movement and functional results were evaluated at three and six months and one and two years post-operatively. Radiographic parameters including radial inclination, tilt, and height, were measured pre- and post-operatively. Results. The average radial tilt was 10.6° of volar flexion and radial height was 10.2 mm at the sixth month post-operatively. Three cases of pin tract infection were recorded, all of which were treated successfully with oral antibiotics. There were no cases of pin loosening. A total of 73 patients underwent surgery, and three cases of radial nerve irritation were recorded at the time of cast removal. All radial nerve palsies resolved at the six-month follow-up. There were no cases of median nerve compression or carpal tunnel syndrome, and no cases of tendon injury. Conclusion. Our modified technique is effective to restore anatomic congruity and maintain reduction in fractures of the distal radius. Cite this article: Bone Joint Res 2015;4:176–180

Children with cerebral palsy (CP) often present femoral bone deformities not accounted for in generic musculoskeletal models [1,2]. MRI-based models can be used to include subject-specific muscle paths [3,4], although this is a time-demanding process. Recently, non-rigid deformation techniques have been used to transform generic bone geometry, including muscle points, onto personalized bones [5]. However, it is still unknown to what extent such an approximation of subject-specific detail affects calculated hip contact forces (HCFs) during gait in CP children. Seven children diagnosed with diplegic CP walked independently at self-selected speed. 3D marker trajectories were captured using Vicon (Oxford Metrics, UK) and force data was measured using two AMTI force platforms (Watertown, MA). MR-images were acquired (Philips Ingenia 1.5T) of all subjects lying supine. Firstly, a generic model [6] was scaled using the marker positions of a static pose. Secondly, a MRI-model containing the subject-specific bone structures and muscle paths of all hip and upper leg muscles was created [3]. Thirdly, the generic femur and pelvis geometries and muscle points were transformed onto the image-based femur and pelvis using an advanced non-rigid deformation procedure (Materialise N.V.). For all models, further analyses were performed in OpenSim 3.1 [7]. A kalman smoother procedure was used to calculate joint angles [8]. Muscle forces were calculated using a static optimization minimizing the sum of squared muscle activities. Next, HCFs were calculated and normalized to body weight (BW). First and second peak HCFs were determined and used for a Kruskal-Wallis test to determine differences between models. In case of a significant difference, a post-hoc rank-based multiple comparison test with Bonferonni adjustment was used. Further, average absolute differences in muscle points between the models was calculated, as well as average differences in moment arm lengths (MALs), reflecting muscle function. Where the scaled generic muscle points differed on average 2.49cm from the MRI points, the non-rigidly deformed points differed 1.54cm from the MRI muscle points. Specifically, the tensor fascia latae differed most between the deformed and MRI models (11.7cm). When considering MALs, the gluteii muscles present an altered function for the generic and deformed models compared to the MRI model for all degrees of freedom of the hip at the time of both HCF peaks. The differences between models resulted in a significantly increased second peak HCF for the MRI models compared to the generic models (first peak average HCF: 3.88BW, 3.95BW and 4.90BW; second peak average HCF: 3.03BW, 4.89BW and 5.32BW for the generic, MRI and non-rigidly deformed models respectively). Although not significantly different, the deformed models calculated slightly increased HCFs compare to the MRI models. The generic models underestimated HCFs compared to the MRI models, while the non-rigidly deformed models slightly overestimated HCFs. However, differences between the deformed and MRI models in terms of muscle points and MALs remain, specifically for the gluteii muscles. Therefore, further user-guided modification of the model based on MR-images will be necessary

Instability following total hip arthroplasty (THA) is an unfortunately frequent and serious problem that requires thorough evaluation and preoperative planning before surgical intervention. Prevention through optimal index surgery is of great importance, as the management of an unstable THA is challenging even for an experienced joints surgeon. However, even after well-planned surgery, a significant incidence of recurrent instability still exists. Moreover leg-length discrepancy (LLD) after THA can pose a substantial problem for the orthopaedic surgeon. Such discrepancy has been associated with complications including nerve palsy, low back pain, and abnormal gait. Consequently we may use a big femoral head or increase femoral offset (FO) in unstable THA for avoiding LLD. However we do not know the relationship between FO and STT. The objective of this study is to assess hip instability of three different FOs in same patient undergoing THA during an operation. We performed 70 patients who had undergone unilateral THA using CT based navigation system at a single institution for advanced osteoarthoritis from May 2013 to May 2014. We used postero-lateral approach in all patients. After cup and stem implantation, we assessed soft tissue tensioning in THA during operation. Trial necks were categorized into one of three groups: standard femoral offset (sFO), high femoral offset (hFO, +4mm compared to sFO) and extensive high femoral offset (ehFO, +8 mm compared to sFO). We measured distance of lift-off about each of three femoral necks using CT based navigation system and a force gauge with hip flexed at 0 degrees and 30 degrees under a traction of lower extremity. Traction force was 40% of body weight. Forty patients had leg length restored to within +/− 3mm of the contralateral side by post-operative CT analysis. We examined these patients. Traction force was 214±41.1Nm. The distances of lift-off were 8.8±4.5mm (sFO), 7.4±4.1mm (eFO), 5.1±3.9mm (ehFO) with 0 degrees hip flexion and neutral abduction(Abd) / adduction(Add) and neutral internal rotation(IR)/ external rotation(ER). The distance of lift-off were 11.5±5.9mm (sFO),10.5±5.5mm (eFO),9.1±5.9mm (ehFO) with 30 degrees hip flexion and neutral Abd / Add and neutral IR/ER. Significant difference was observed between 0 degrees hip flexion and 30 degrees hip flexion on each FO (p<0.05). On changing the distance of lift-off, hFO to ehFO (2.2±1.6mm)was more stable than sFO to hFO (1.4±1.7mm)with 0degrees hip flexion.(p<0.05). On the other hands, hFO to ehFO (1.4±1.6mm) was more stable than sFO to hFO (1.0±1.3mm) with 30 degrees hip flexion. However, we did not find significant difference (p=0.18). Hip instability was found at 30 degrees hip flexion more than at 0 degrees hip flexion. We found that changing ehFO to sFO can lead to more stability improvement of soft tissue tensioning than sFO to eFO, especially at 0 degrees hip flexion. Whereas In a few cases, the distance of lift-off did not change with increasing femoral offset by 4mm. When you need more stability in THA without LLD, We recommend increasing FO by 8mm

Reverse total shoulder arthroplasty (RTSA) provides a surgical alternative to conventional shoulder arthroplasty in the rotator cuff deficient shoulder. Short term data has shown consistent improvements in pain and function but higher complication and failure rates have also been reported. The aims of this study were to identify the early and late complications of RTSA, to establish the frequency of glenoid notching, and to assess the post-operative functional outcomes. 21 patients (22 joints) treated with RTSA at Glasgow Royal Infirmary (GRI) between April 2006 and October 2010 were retrospectively reviewed. Indications for surgery included cuff tear arthropathy, revision hemiarthroplasty and fracture malunion. Complication rates were obtained by analysis of follow up data from Bluespier and case notes. Glenoid notching was graded from x-rays by multiple observers using the Sirveaux classification. Outcome was assessed using the Oxford Shoulder Score (OSS) and range of motion (ROM). The complication rate associated with RTSA was 14.3%, effecting 3 patients. One dislocation and 1 ulnar nerve palsy occurred within 30 days post-op. A late complication was represented by 1 dislocation, which required revision. Glenoid notching occurred in 71.4% (15 of 21patients), though the majority had a low Sirveaux classification (grade 1 or 2). OSS increased post-operatively and showed a linear improvement with time (R. 2. = 0.81) and ROM increased significantly post-op compared with pre-op (p<0.001). The complication rate associated with RTSA at GRI was lower than that reported in literature and the outcome was good as defined by ROM and OSS. The rate of glenoid notching was higher than literature reports but the significance of this is unclear as notching may not be associated with loosening

Displaced proximal Humeral fractures at Inverclyde Royal Hospital prior to 2008 were previously treated with the antegrade Acumed Polaris Proximal Humeral, predominantly in 2 part fractures. The Philos plate was introduced in 2008, initially being used to treat select non unions, and then expanded to acute fractures. The aim of this study was to assess time to union and complications in the lower volume District General setting comparing to published outcomes. From February 2008 – January 2011, 20 patients were identified. Age range 49–75 (mean 61.2) years, 8 male; 12 female. Left 9, Right 11 Neers 2 part 35%; 3 35%; 4 30%. 16 (80%) were performed in acute fractures with 4 for non-unions, 3 of which were previous polaris nail fixations. 2 patients were lost to follow up after 6/52 but were progressing well. Union was confirmed radiologically and clinically in all but 2 remaining patients (10%), one of whom suffered a significant complication of plate fracture, the second treated with revision for painful non union. 2 other significant complications were observed: transient axillary nerve palsy and deep infection. Both of these patients recovered with delayed union observed in the infection case (52 weeks). Time to union range was 8–52 weeks (mean 17.1). The literature shows a high failure rate of up to 45% with intramedullary nail fixation and limited predominantly to 2 part fractures with risk of damage to the rotator cuff. This study shows a satisfactory union rate using the Philos of 90% with only 3 (15%) requiring further surgery for non-union, plate fracture and infection. 3 and 4 part fractures composed 65% of case load. Early results indicate satisfactory outcomes compared to current published literature

Olecranon fractures account for 20% of elbow fractures. Displaced fractures can be treated by several methods – Tension Band Wiring (TBW), Open Reduction and Internal Fixation with a plate (ORIF) or conservative measures. Studies from UK specialist centres have demonstrated infection rates of up to 15% and metal ware removal rates of up to 80%. In addition studies have shown that conservative treatment provides a good function and pain relief in the elderly and infirm. We aimed to look at all displaced olecranon fractures within our unit over a 4 year period and analyse their case notes for patient features, age stratification, treatment methods, complications and outcomes. We also aimed to compare our results to outcomes in studies published by specialist centres. All olecranon fractures admitted to our unit in calendar years 2007–2010 were identified from our trauma database. Case sheets were analysed for patient's age, co-morbidities, treatment, complications and outcome. X-rays were analysed to classify the fractures and assess outcome of treatment. 71 patients were identified, Male: Female = 33:38. Age range was 7–93, mean was 62.8 years. Treatment used – TBW 42 (59.1%), ORIF 9 (12.7%), and Conservative 20 (28.2%). In the surgical group of 51 patients there were 4 infections (7.8%). There were no incidences of nerve palsy. Metalware was removed in 15 patients (29.4%) – for TBW this was 11/42 (26.25%) and ORIF 4/9 (44.4%) – however the difference was not significant (p=0.06). The conservative group had no complications. In our study group we have demonstrated a lower infection rate and a far lower rate of metal ware removal than published studies. We have a high rate of patients treated conservatively who do well. Further work is being performed into the functional outcome of the whole group

Although most peripheral nerve sheath tumours are benign, some are malignant. The management of malignant tumours usually involves wide excision and is facilitated by knowledge of the diagnosis prior to operation. Imaging modalities, including MRI, give anatomical information but do not distinguish between benign and malignant nerve tumours. We therefore introduced the use of ultrasound guided needle biopsy for suspected nerve tumours to our unit in 2004. Prior to this, excision biopsy was carried out in all cases. We aimed to review our experience with needle biopsy and determine whether it has an effective role in the management of peripheral nerve tumours. All patients who had a needle biopsy for suspected peripheral nerve tumours from January 2004 to December 2011 were identified from our tumour database and clinical notes reviewed. In all cases, biopsy was carried out under ultrasound guidance with local anaesthesia to obtain a 1mm core of tissue. From 25 patients reviewed, 21 (84%) had a successful biopsy. In 3 cases the biopsy was unable to be completed due to pain and in 1 patient insufficient tumour tissue was obtained. 1 patient had a temporary radial nerve palsy following needle biopsy which recovered fully. In biopsies that were successful, 19 (90%) showed a benign peripheral nerve tumour. Following diagnosis of a benign lesion, only 2 patients required to have surgical excision of the tumour due to pain. The remainder were managed non-operatively. In the 2 cases of malignant tumours detected by biopsy, a successful wide surgical excision was performed. Ultrasound guided core needle biopsy appears safe and gives a tissue diagnosis in most cases of suspected peripheral nerve tumours. In malignant cases it facilitates surgical planning, while most benign tumours could be managed non-operatively, therefore avoiding potential complications of nerve surgery

Olecranon fractures account for 20% of elbow fractures. Displaced fractures can be treated by several methods – Tension Band Wiring (TBW), Open Reduction and Internal Fixation with a plate (ORIF) or conservative measures. Studies from UK specialist centres have demonstrated infection rates of up to 15% and metalware removal rates of up to 80%. In addition studies have shown that conservative treatment provides good function and pain relief in the elderly and infirm. To look at all displaced olecranon fractures within our unit (the busiest district general hospital in Scotland) over a 4 year period and analyse for patient features, age stratification, identify treatment methods, complications and outcomes. To compare this to outcomes in studies published by specialist centres. All olecranon fractures admitted to our unit in calendar years 2007–2010 were identified from our trauma database. Case sheets were analysed for patient's age, co-morbidities, treatment, complications & outcome. Xrays were analysed to classify the fractures and assess outcome of treatment. 71 patients were identified, Male: Female = 33:38. Age range was 7–93. Mean 62.8. Treatment used – TBW 42 (59.1%), ORIF 9 (12.7%), Conservative 20 (28.2%). In the surgical group of 51 patients there were 4 infections (7.8%). There were no incidences of nerve palsy. Metalware was removed in 15 patients (29.4%) – for TBW this was 11/42 (26.25) and ORIF 4/9 (44.4%) – however the difference was not significant (p=0.06). The conservative group had no complications. In our study group we have demonstrated a lower infection rate and a far lower rate of metalware removal than published studies.?We have a high rate of patients treated conservatively who do well. Further work is being performed into the functional outcome of the whole group

Aims

We aimed to evaluate the temperature around the nerve root during drilling of the lamina and to determine whether irrigation during drilling can reduce the chance of nerve root injury.

Objectives

The aim of this study was to systematically review the literature on measurement of muscle strength in patients with femoroacetabular impingement (FAI) and other pathologies and to suggest guidelines to standardise protocols for future research in the field.