Scaphoid fractures accounts for approximately 15% of all fractures of hand and wrist. Proximal pole fractures represent 10–20% of scaphoid fractures. Non –operative treatment shows high incidence of non-union and avascular necrosis. Surgical intervention with bone graft is associated with better outcome. The aim of this study was to evaluate the radiological and functional outcome of management of proximal pole scaphoid non-union with internal fixation and bone grafting. We included 35 patients with proximal pole scaphoid non-union (2008–2015). All patients underwent antegrade headless compression screw fixation and bone grafting at King's College Hospital, London (except one, who was fixed with Kirschner wire). 33 patients had bone graft from distal radius and two from iliac crest. Postoperatively patients were treated in plaster for 6–8 weeks, followed by splinting for 4–6 weeks and hand physiotherapy. All the patients were analysed at the final follow-up using DASH score and x-rays. Mean age of the patients was 28 years (20–61) in 32 men and 3 women. We lost three patients (9%) to follow up. At a mean follow up of 16 weeks (12–18) twenty three patients (66%) achieved radiological union. All patients but three (91%) achieved good functional outcome at mean follow up of 14 weeks (10–16). A good functional outcome can be achieved with surgical fixation and bone graft in proximal pole scaphoid fractures non-union. Pre-operative fragmentation of proximal pole dictates type of fixation (screw or k wire or no fixation). There was no difference in outcome whether graft was harvested from distal radius or iliac crest

The aim of our study is to investigate the natural history of scaphoid non-union. Factors affecting the outcome of scaphoid fracture non-union surgery were assessed using data collected retrospectively from 785 cases treated at 18 centres throughout the UK. All cases had undergone this surgery before October 2014, ensuring a minimum period of 2 years between surgery and data collection from the medical records. Smoking status significantly influenced the union rate of 94 proximal pole (non-smokers = 71%, smokers = 44%, p < 0.05) but not waist (non-smokers = 73% non-unions. Type of bone graft did not affect the union rate of the 282 waist nonunions (iliac crest = 69%; non-vascular distal radius = 75% and vascularised distal radius = 70%: P=0.35), but did influence the union rate of the 98 proximal pole nonunions (iliac crest = 58%; non-vascular distal radius = 58% and vascularised distal radius = 82%: P=0.004). Time interval between fracture and non-union surgery did not affect the union rate of 121 proximal pole nonunions (3–6 months = 56%; 6–12 months = 76%; 1–2 years = 69%; 2+years = 54%: P=0.5), but did influence the union rate of 303 nonunions of the waist (3–6 months = 80%; 6–12 months = 82%; 1–2 years = 65%; 2+years = 55%: P=0.02). Non-unions of the proximal pole appear to be influenced by smoking status and bone graft type, whereas non-unions of the scaphoid are influenced by the time to non-union surgery

A key component to the success of total knee replacement is the health and integrity of the extensor mechanism. While there are issues related to the patella, such as fracture, dislocation, subluxation, clunk due to peripatellar fibrosis and anterior knee pain, the overall integrity of the extensor mechanism is of tantamount importance in providing an excellent functional outcome. During total knee replacement it is of utmost importance to preserve the anatomic insertion of the patellar tendon on the tibial tubercle. However, after total knee replacement, a fall or extreme osteoporosis of the patella may cause a rupture of the patellar tendon, distally or proximally, and possibly the quadriceps tendon off of the proximal pole of the patella. Simple repairs of the patellar tendon avulsion may involve use of the semitendonosis and gracilis tendons along with primary repair of the tendon. Usually, patella infera develops after such a repair affecting overall strength and function. For severe disruptions of the extensor mechanism that are accompanied by a significant extensor lag, autologous tissue repair may not be possible. Thus, there are three techniques for reconstruction of this difficult problem: Extensor mechanism allograft with bone-patellar tendon-patella-quadriceps tendon, extensor mechanism allograft with os calcis-Achilles tendon construct and Marlex-mesh reconstruction for patellar tendon avulsion. The key to success of extensor mechanism allograft is proper tensioning of the allograft at full extensor and immobilisation for 6 weeks. Rosenberg's early experience showed that the allograft works best placed at maximum tension in extension. Rubash has described the use of the os calcis-Achilles tendon which does not utilise a patellar substitute. Hansen has recently described excellent results with the use of Marlex mesh to act as a structural reinforcement to the patellar tendon when it is avulsed

A key component to the success of total knee replacement is the health and integrity of the extensor mechanism. While there are issues related to the patella, such as fracture, dislocation, subluxation, clunk due to peripatellar fibrosis and anterior knee pain, the overall integrity of the extensor mechanism is of tantamount importance in providing an excellent functional outcome. During total knee replacement it is of utmost importance to preserve the anatomic insertion of the patellar tendon on the tibial tubercle. However, after total knee replacement, a fall or extreme osteoporosis of the patella may cause a rupture of the patellar tendon, distally or proximally, and possibly the quadriceps tendon off of the proximal pole of the patella. Simple repairs of the patellar tendon avulsion may involve use of the semitendonosis and gracilis tendons along with primary repair of the tendon. Usually, patella infera develops after such a repair affecting overall strength and function. For severe disruptions of the extensor mechanism that are accompanied by a significant extensor lag, autologous tissue repair may not be possible. Thus, there are three techniques for reconstruction of this difficult problem: Extensor mechanism allograft with bone-patellar tendon-patella-quadriceps tendon, extensor mechanism allograft with os calcis-Achilles tendon construct and Marlex-mesh reconstruction for patellar tendon avulsion. The key to success of extensor mechanism allograft is proper tensioning of the allograft at full extensor and immobilisation for 6 weeks. Rosenberg's early experience showed that the allograft works best placed at maximum tension in extension. Rubash has described the use of the os calsis-Achilles tendon which does not utilise a patellar substitute. Hansen has recently described excellent results with the use of Marlex mesh to act as a structural reinforcement to the patellar tendon when it is avulsed

Purpose of study. To study the effect of different shoes and orthotics have on patellar tendon tensile forces. Patellar tendinopathy is an overuse injury that affects tennis players and in high impact sports like basketball, volleyball and running has an incidence of 20%. The tensile forces in the patellar tendon can be reliably measured with an intratendinously placed fibre optic tube and wireless transmission device allows for dynamic testing. The biggest strain differentials have been confirmed in jumps from 30cm height. Tennis is played on 3 major different court surfaces and there is a variety of commercially designed tennis shoes on the market. Materials and methods. 6 male tennis players, ages 18–49 were enrolled for this study. A fibre optic cannula was placed in the middle of the proximal pole of patella tendon from lateral to medial direction in the dominant knee. The patellar tendon tensile forces deform the fibre optic cannula in turn modulating the light signal passing through the optic cannula. The drag in the fibre optic sensor signal was used to measure the tensile forces in the patellar tendon. MLTS 700 goniometer were utilized to measure and record the amount of flexion with each jump to standardize results for different shoes and orthotics. Results. The results of patellar tendon tensile forces measurements for different players, different shoes and orthotics showed no trend or statistical difference for any particular shoe or orthotic. Conclusions. Fibre optic measurements of the effect of different shoes on patellar tendon tensile forces did not show a distinct advantage for any shoe above another. 1 DISCLOSURE

Acute scaphoid fractures are commonly treated with cast for 8–12 weeks. With this prolonged period of immobilisation patients can encounter joint stiffness and muscle wasting requiring extensive physiotherapy. Despite best practice, these fractures also pose a risk of non-union and suboptimal function. Fracture location, duration of time lost from work and impairment in activities of daily living are key factors in scaphoid fracture management. The aim of our study was to compare percutaneous screw fixation of the scaphoid with other operative fixation techniques. Parameters documented were length of conservative treatment, mechanism of injury, post-op complications and patient satisfaction levels with each technique using a standardised questionnaire. Economic benefit was also measured by examining time to return to work, number of x-rays and outpatient visits required per treatment group. In this study, 76 patients requiring operative scaphoid fixation were evaluated. 27 patients underwent percutaneous fixation. Waist fractures accounted for 66% (n= 18), proximal pole fractures 33% (n=8) and distal pole fractures 4% (n=1). There were 16 non-displaced fractures (59%) and 11 displaced fractures (41%). The average length of conservative treatment was 77 days (range: 2–256 days). Within the percutaneous group 2 patients developed non-union. We did not encounter any wound infection or superficial radial nerve damage. Patients treated with early percutaneous fixation had highest satisfaction levels, returned to work earlier and required less follow-up (P< 0.001). In conclusion percutaneous screw fixation provides earlier bone union and avoids the need for prolonged immobilisation when compared to other treatment modalities. The economic benefit of early percutaneous fixation must also be considered when managing patients with scaphoid fractures

The LCS RPS knee system is based on the successful LCS mobile bearing prosthesis, and has been introduced with the intention of improving post-operative knee flexion. The aim of this study is to report a high incidence of significant patellofemoral crepitus when this prosthesis is used without patella resurfacing. A successful arthroscopic technique to treat this complication will be described. We present a retrospective review of a single surgeon series of LCS RPS knee arthroplasty. All procedures were performed using a standard technique with cemented components. The patella was not resurfaced in any of the presented cases. The knee society score, patellofemoral score (Baldini et al, 2006), BMI, range of motion, and post-operative radiographs were obtained for all patients. In addition the presence of patellofemoral crepitus was assessed and rated as either none, mild (for limited ROM), moderate (throughout entire ROM), or severe(catching/clunk). An arthroscopic technique to treat this complication was developed. A total of 56 patients were reviewed at a mean follow-up of 16 months (range 9–22). The mean age at time of operation was 70 (range 50–87), and mean BMI was 29 (range 18–42). A lateral release was performed in 7 cases (12%). Mean knee society score was 77 (range 35–92), patellofemoral score 73 (range 25–100), and ROM 115 degrees (range 85–135). Significantly, patellofemoral crepitus was severe in 12 (21%) patients, moderate in 21 (37%), mild in 15 (26%), and absent in 9 (16%). In 4 patients arthroscopic resection of the proximal pole of the patella has resulted in complete resolution of severe crepitus with increases in patellofemoral (mean 25) and knee society (mean 7) scores, and, ROM (mean 15 degrees). One of these patients at 6 month follow-up has reported return of moderate crepitus. Similar resolution of crepitus has been seen in 3 cases which were revised to resurface the patella. As part of this ongoing study a non-randomised comparison group who received patellar resurfacing at the primary procedure has produced no cases of moderate or severe crepitus. In conclusion patella resurfacing is required when using the LCS RPS prosthesis to prevent an unacceptably high rate of moderate to severe patellofemoral crepitus. Both arthroscopic patelloplasty and revision to resurface the patella have resulted in resolution of this problem. Potential biomechanical causes for this problem will be presented

We reviewed 234 benign solitary schwannomas treated between 1984 and 2004. The mean age of the patients was 45.2 years (11 to 82). There were 170 tumours (73%) in the upper limb, of which 94 (40%) arose from the brachial plexus or other nerves within the posterior triangle of the neck. Six (2.6%) were located within muscle or bone. Four patients (1.7%) presented with tetraparesis due to an intraspinal extension.

There were 198 primary referrals (19 of whom had a needle biopsy in the referring unit) and in these patients the tumour was excised. After having surgery or an open biopsy at another hospital, a further 36 patients were seen because of increased neurological deficit, pain or incomplete excision. In these, a nerve repair was performed in 18 and treatment for pain or paralysis was offered to another 14.

A tender mass was found in 194 (98%) of the primary referrals. A Tinel-like sign was recorded in 155 (81%). Persistent spontaneous pain occurred in 60 (31%) of the 194 with tender mass, impairment of cutaneous sensibility in 39 (20%), and muscle weakness in 24 (12%).

After apparently adequate excision, two tumours recurred. No case of malignant transformation was seen.