Following arthroscopic arthrolysis for frozen shoulder, steroid injections may become necessary to improve ongoing pain and facilitate stretching exercises. The aim of this study was to evaluate the rate of steroid injections needed post-arthroscopic arthrolysis of frozen shoulder. Case series review carried out in a District General Hospital in UK. 30 consecutive patients who had arthroscopic arthrolysis under the care of the senior author were included. Patients’ records were analysed to identify the number of steroid injections administered post-operatively. 11 males and 19 females were examined, aged 46–83 years old (mean 56.1). 7 patients were diabetic. 10 patients (33.3%) received steroid injections post-operatively, with 8 of them receiving the injection within the first 6 post-operative months. The average post-operative time of steroid injection was 9.8 months. There was no association between diabetes and administration of a post-operative steroid injection P>0.01. Following arthroscopic arthrolysis a substantial proportion of patients may require one or more steroid injections to help pain and facilitate stretching exercises and physiotherapy. This study showed that 1 in 3 frozen shoulders treated with arthroscopic arthrolysis may need a subsequent steroid injection in the first year post surgery. Patients should be counselled preoperatively with regards to that, and be warned that arthroscopic arthrolysis is only the first step in the treatment pathway leading to recovery. Blackpool Victoria Hospital Orthopaedic Department

Abstract. Background. Traumatic knee dislocations are devastating injuries and there is no single best accepted treatment. Treatment needs to be customised to the patient taking into consideration injury to the knee; associated neurovascular and systemic injuries. Objective. This study looked at functional outcome of a single surgeon case series of patients who underwent surgical management of their knee dislocation. Methods. Seventy patients with knee dislocation were treated with multi-ligament reconstruction at a major trauma centre. Acute surgical repair and reconstruction with fracture fixation within 3 weeks was preferred unless the patient was too unstable (Injury severity score>16). PCL was primarily braced and reconstructed subsequently, if required. Outcome was collected prospectively using IKDC score, KOOS and Tegner score. Results. The mean age of the patients was 35yrs (17–74), 53 males and 17 females. 5 patients had CPN injury (7%), 3 had vascular injury (4.2%), 2 had combined CPN and vascular injury (2.8%). Acute surgical treatment was done in 48 patients while 10 had staged reconstruction. 22 patients had delayed reconstruction. The mean follow-up period was 4.8 years (1–12 yrs). According to the IKDC score 67% of the patients had near-normal knee function. The mean Tegner activity scale postoperatively was 4.5 (preinjury 6.5) and the mean KOOS score was 75.3. Four patients had stiffness and needed arthroscopic arthrolysis, two patients had a residual foot drop from the original injury and needed tendon transfer. Conclusion. Traumatic knee dislocation is a challenging problem but good outcomes can be achieved by surgical management

Aim. Over the last 15 years there has been a series of publications reporting the beneficial effects of elbow arthrolysis, with considerable variation in operative technique and post-operative management. Many advocate the use of passive stretching techniques in the early post-operative period if range of motion fails to improve satisfactorily. The purpose of this study was to assess our results of open elbow arthrolysis in patients who did not receive any passive stretching after discharge from hospital. Methods. Prospectively collected data of 55 patients with a minimum follow-up of 1 year after arthrolysis were analysed. All procedures were performed by the same surgeon (LR), achieving as much improvement in elbow motion as possible at operation. All patients had continuous brachial plexus blocks and continual passive motion for 2-3 days post-operatively but none received any passive stretching after discharge. At review, a senior physiotherapist (BD) formally assessed all the patients. Results. All patients' arc of movement improved from 68 degrees to 104 degrees (flexion 18 degrees/extension 23 degrees). Upper limb function (Disabilities of the Arm, Shoulder and Hand score) improved by 50%. Pain decreased from 20 to 9, measured with a Visual Analogue Score. The greatest improvement in motion was obtained in the stiffest elbows - 7 patients with an arc of 30 degrees or less pre-operatively achieved an arc of 100 degrees by the time of the last review. Conclusions. Good results of open arthrolysis for post-traumatic elbow stiffness can be achieved with continuous brachial plexus blocks and continual passive motion for 2-3 days post-operatively. There appears to be little evidence to support treatment with passive stretching techniques after discharge from hospital, as our results are similar to other reported series

Knee dislocations are a rare but serious cause of trauma. The aim of this study was to establish current demographics and injury patterns/associations in multi-ligament (MLI) knee injuries in the United Kingdom. A National survey was sent out to trauma & orthopaedic trainees using the British Orthopaedic Trainees Association sources in 2018. Contributors were asked to retrospectively collect a data for a minimum of 5 cases of knee dislocation, or multi-ligament knee injury, between January 2014 and December 2016. Data was collected regarding injury patterns and surgical reconstructions. 73 cases were available for analysis across 11 acute care NHS Trusts. 77% were male. Mean age was 31.9 (SD 12.4; range 16–69). Mean Body Mass Index (BMI) was 28.3 (SD 7.0; range 19–52). Early (<3 weeks) reconstruction was performed in 53% with 9 (23%) patients under-going procedures for arthrofibrosis. Late (>12 weeks) reconstruction took place in 37% with one (3.7%) patient under-going arthroscopic arthrolysis. 4% had delayed surgery (3–12 weeks) and 5% had early intervention with delayed ACL reconstruction. For injuries involving 3 or more ligament injuries graft choices were ipsilateral hamstring (38%), bone-patella tendon-bone (20%), allograft (20%), contralateral hamstring (17%) and synthetic grafts in 18%. Multi-ligament knee injuries are increasingly being managed early with definitive reconstructions. This is despite significant risk of arthrofibrosis with early surgery. Ipsilateral and contralateral hamstring grafts make up the bulk of graft choice however allograft (20%) and synthetic grafts (18%) remain popular

Background. The meniscal deficient knee often exists in the setting of associated pathology including instability, malalignment and chondral injury. Meniscal allograft transplantation (MAT) is established to be a reliable option in restoring function and treating symptoms. The aim of this study was to establish the role of MAT as part of a staged approach to treatment of the previously menisectomised knee. Methods. This prospective study included all patients that underwent arthroscopic MAT at our institution between 2010 to 2017. Fresh frozen allograft was utilised using a soft tissue fixation technique. Further data was collected for index surgical procedures before and after MAT. Data for pre and post-operative Knee Injury and osteoarthritis outcome scores (KOOS), Tegner scores, graft survival, reoperation rates, patient satisfaction and MRI extrusion measurements were collected and details of any further surgical intervention and / or complications also documented. Results. Twenty seven MAT procedures were performed in 26 patients. Sixteen patients underwent lateral MAT and 11 patients medial. Ten patients underwent ACL reconstruction, three ACI and two, osteotomy in the pre-MAT phase. A further seven patients underwent ACI within the post-operative phase. The post-operative mean KOOS scores improved significantly in all subscales as did Tegner scores. Graft survival was 100%, satisfaction rate 92%, and mean meniscal extrusion 3.04mm. Post operatively, three patients required meniscal repair and a single patient partial menisectomy of graft. Two patients underwent arthroscopic arthrolysis following MAT. Conclusions. This series highlights the multifactorial profile of the meniscal deficient knee and the role of MAT as a safe and reliable technique in the staged and comprehensive biologic treatment available to minimise symptoms and maximise outcomes

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

Stiffness after knee arthroplasty is an important complication that the orthopaedic surgeon must be prepared to manage. In some cases, patients have a low-pain threshold or unidentifiable etiologic findings with no clinical indicators of septic or aseptic failure, and no radiographic evidence of mechanical complications. Psychosocial issues are important to consider, such as patient motivation and etiologic findings related to a worker's compensation claim. For patients who fail to achieve satisfactory ROM after TKA with no identifiable cause, treatment options may be categorised as non-surgical and surgical interventions. Non-surgical interventions would be physical therapy and pharmaceutical control for pain management. Surgical interventions include non-invasive options such as manipulation under anesthesia, and invasive options such as arthroscopy and mini-arthrotomy. Manipulation under anesthesia is indicated in the TKA that has less than 90° ROM after six weeks, no progression or regression in ROM. A modified technique has evolved for patients with persistent stiffness after standard-technique manipulation. The modified technique uses epidural anesthesia continued for post-operative analgesia, hospital stay of 1–3 days, CPM for 2–3 days, and daily PT. Continuous epidural infusion with local anesthetic is administered to provide complete analgesia, but allows muscle activation to be maintained during the hospital stay. Although open revision is sometimes required, arthroscopic management may be an effective alternative in certain instances, and also is helpful in diagnosis and treatment of other conditions of the knee that include prosthetic loosening and failure, retained cement, loose bodies, and sub-clinical infections. However, the painful TKA without evidence of significant intra-articular pathologic findings does not always respond well to arthroscopic management. Another option is open arthrotomy, done mainly to excise scar tissue. A synovectomy may be done as well. The polyethylene insert may be removed and an examination of the posterior cruciate ligament (PCL) performed. If the PCL is tight, it can be released and the existing components may be retained. Sometimes the polyethylene liner may be exchanged to a lipped insert to maintain stability. Revision surgery represents another option of treatment that can provide improved results whether manipulation or arthroscopic debridement has been done (14). Revision of one or all components combined with arthrolysis continues to have a role in improvement of ROM and outcomes in the stiff TKA

Range of motion (ROM) is a well recognised outcome measure following total knee arthroplasty (TKA). Reduced knee flexion can lead to poor outcome after TKA and therefore identification at an early stage is important as it may provide a window for intervention with targeted physiotherapy, closer follow-up and in resistant cases possible manipulation or arthrolysis. ROM combines both flexion and extension and in contrast to flexion, fewer studies have recognised the importance of a lack of full extension or fixed flexion deformity (FFD) following TKA. A residual FFD can increase energy cost, decrease velocity during ambulation and result in pain with knee scores more likely to be diminished than if knee extension was normal. Recognition and early detection of FFD is therefore important. Methods of assessment include by visual estimation or goniometric measurement of knee flexion angle. While goniometers are inexpensive, easy to use and provide more accurate than visual estimates of angles, they have been shown to exhibit poor inter-observer reliability. Therefore they may not be sensitive enough to consistently identify FFD and therefore distinguish between grading systems based on absolute angular limits. The aim of this study was to investigate the accuracy of standard clinical ROM measurement techniques following TKA and determine their reliability for recognising FFD. Ethical approval was obtained for this study. Thirty patients who were six weeks following TKA had their knee ROM measured. An infrared (IR) tracking system (±1°accuracy) that had been validated against an electro-goniometer was used to give a “true” measurement of the lower limb sagittal alignment with the knee fully extended and maximally flexed while the patient was supine. The patients were also assessed independently by experienced arthroplasty practitioners using a standardised goniometric measurement technique. For goniometric clinically-measured flexion (Clin. flex). and extension (Clin. ext. ) linear models were generated using IR-measured flexion and extension (IR. flex. and IR. ext. ), BMI and gender as covariables. Data for extension were categorised in none, moderate and severe postoperative FFD as per Ritter et al. 2007 and agreement in classification between the two methods was assessed using the Kappa statistic. For the linear models for Clin. flex. and Clin. ext. neither BMI nor gender were significant variables. Therefore the final models were:. Clin. flex. = 0.54 + 0.66∗IR. flex. (r. 2. adj. = 0.521). Clin. ext. = 0.23 + 0.50∗IR. ext. (r. 2. adj. = 0.247). The model for Clin. flex. showed that the IR and clinical measurements coincided at approximately 90° so that for every 10° increase in flexion above 90° clinical measurement only increased by 7° but for every 10° decrease in flexion below 90° clinical measurement only decreased by 7°. The model for Clin. ext. showed that the IR and clinical measurements coincided at approximately 0° so that for every 10° increase in FFD angle, clinical measurement only increased by 5° but if the knee went into hyperextension this would be underestimated by the clinical measure. In identifying FFD there was moderate agreement between the two measurements (κ = 0.44). Clinically nine patients were assessed as having FFD but the IR measurements showed 18 patients having FFD, of which nine patients were not identified clinically. When assessing knee ROM following joint arthroplasty manual goniometric measurements provided a poor estimate of the range when compared to the “true” angle as measured with a validated IR measurement tool. When the knee was held in maximum flexion there was a tendency to both underestimate and overestimate the true angle. However when the knee was held in extension there was a tendency to underestimate which we believe is important as it would underreport both the frequency and magnitude of FFD. In our study, 18 patients had a moderate FFD as identified by the IR system, only half of which were identified by goniometer measurement alone. Studies of comparisons of both visual and manual goniometry measurements of the knee in maximum flexion with lateral radiographs have shown most errors involved an underestimate of true flexion. It has been concluded that it was safer to underestimate knee flexion angle as it would result in higher pick up rate of cases being performing less well. In contrast however, underestimation while in extension is less desirable as it fails to pick-up FFD which may have benefited from intervention had they been identified. It is known that residual FFD can increase energy cost and decrease velocity during ambulation with pain and functional knee scores more likely to be reduced. Recognition and early detection is therefore important. With the use of more accurate systems to identify and measure FFD, such as the one used for this study may in turn allow more timely treatment and therefore hopefully improved outcomes