Aims. Spinopelvic mobility plays an important role in functional acetabular component position following total hip arthroplasty (THA). The primary aim of this study was to determine if spinopelvic hypermobility persists or resolves following THA. Our second aim was to identify patient demographic or radiological factors associated with hypermobility and resolution of hypermobility after THA. Methods. This study investigated patients with preoperative posterior hypermobility, defined as a change in sacral slope (SS) from standing to sitting (ΔSS. stand-sit. ) ≥ 30°. Radiological spinopelvic parameters, including SS, pelvic incidence (PI), lumbar lordosis (LL), PI-LL mismatch, anterior pelvic plane tilt (APPt), and spinopelvic tilt (SPT), were measured on preoperative imaging, and at six weeks and a minimum of one year postoperatively. The severity of bilateral hip osteoarthritis (OA) was graded using Kellgren-Lawrence criteria. Results. A total of 136 patients were identified as having preoperative spinopelvic hypermobility. At one year after THA, 95% (129/136) of patients were no longer categorized as hypermobile on standing and sitting radiographs (ΔSS. stand-sit. < 30°). Mean ΔSS. stand-sit. decreased from 36.4° (SD 5.1°) at baseline to 21.4° (SD 6.6°) at one year (p < 0.001). Mean SS. seated. increased from baseline (11.4° (SD 8.8°)) to one year after THA by 11.5° (SD 7.4°) (p < 0.001), which correlates to an 8.5° (SD 5.5°) mean decrease in seated functional cup anteversion. Contralateral hip OA was the only radiological predictor of hypermobility persisting at one year after surgery. The overall reoperation rate was 1.5%. Conclusion. Spinopelvic hypermobility was found to resolve in the majority (95%) of patients one year after THA. The increase in SS. seated. was clinically significant, suggesting that current target recommendations for the hypermobile patient (decreased anteversion and inclination) should be revisited. Cite this article: Bone Joint J 2021;103-B(12):1766–1773

Hypermobility is an acknowledged risk factor for patellar instability. In this case control study the influence of hypermobility on clinical outcome following medial patellofemoral ligament (MPFL) reconstruction for patellar instability was studied. A total of 25 patients with hypermobility as determined by the Beighton criteria were assessed and compared with a control group of 50 patients who were matched for age, gender, indication for surgery and degree of trochlear dysplasia. The patients with hypermobility had a Beighton Score of ≥ 6; the control patients had a score of < 4. All patients underwent MPFL reconstruction performed using semitendinosus autograft and a standardised arthroscopically controlled technique. The mean age of the patients was 25 years (17 to 49) and the mean follow-up was 15 months (6 to 30). Patients with hypermobility had a significant improvement in function following surgery, with reasonable rates of satisfaction, perceived improvement, willingness to repeat and likelihood of recommendation. Functional improvements were significantly less than in control patients (p < 0.01). Joint hypermobility is not a contraindication to MPFL reconstruction although caution is recommended in managing the expectations of patients with hypermobility before consideration of surgery

Thirty-seven patients have been reviewed after arthrodesis of the ankle in order to determine the reduction of dorsiflexion and plantarflexion of the foot, the incidence of tarsal hypermobility and its relevance to the clinical results of this procedure. Radiological methods of measuring movements in the foot and tarsus are described and applied to patients who had a normal foot on the opposite side which could be used as a control. Our findings suggest that tarsal hypermobility is not as common as has hitherto been supposed and that a stiff foot with minor radiological degenerative changes in the tarsal joints is quite compatible with an excellent result

Aims. Periacetabular osteotomy (PAO) is an established treatment for acetabular dysplasia. It has also been proposed as a treatment for patients with acetabular retroversion. By reviewing a large cohort, we aimed to test whether outcome is equivalent for both types of morphology and identify factors that influenced outcome. Methods. A single-centre, retrospective cohort study was performed on patients with acetabular retroversion treated with PAO (n = 62 hips). Acetabular retroversion was diagnosed clinically and radiologically (presence of a crossover sign, posterior wall sign, lateral centre-edge angle (LCEA) between 20° and 35°). Outcomes were compared with a control group of patients undergoing PAO for dysplasia (LCEA < 20°; n = 86 hips). Femoral version was recorded. Patient-reported outcome measures (PROMs), complications, and reoperation rates were measured. Results. The mean Non-Arthritic Hip Score (NAHS) preoperatively was 58.6 (SD 16.1) for the dysplastic hips and 52.5 (SD 12.7) for the retroverted hips (p = 0.145). Postoperatively, mean NAHS was 83.0 (SD 16.9) and 76.7 (SD 17.9) for dysplastic and retroverted hips respectively (p = 0.041). Difference between pre- and postoperative NAHS was slightly lower in the retroverted hips (18.3 (SD 22.1)) compared to the dysplastic hips (25.2 (SD 15.2); p = 0.230). At mean 3.5 years’ follow-up (SD 1.9), one hip needed a revision PAO and no hips were converted to total hip arthroplasty (THA) in the retroversion group. In the control group, six hips (7.0%) were revised to THA. No differences in complications (p = 0.106) or in reoperation rate (p = 0.087) were seen. Negative predictors of outcome for patients undergoing surgery for retroversion were female sex, obesity, hypermobility, and severely decreased femoral anteversion. Conclusion. A PAO is an effective surgical intervention for acetabular retroversion and produces similar improvements when used to treat dysplasia. Femoral version should be routinely assessed in these patients and when extremely low (< 0°), as an additional procedure to address this abnormality may be necessary. Females with signs of hypermobility should also be consulted of the likely guarded improvement. Cite this article: Bone Jt Open 2021;2(9):757–764

Aims. The effectiveness of total hip arthroplasty (THA) for patients with no or minimal radiological signs of osteoarthritis (OA) is unclear. In this study, we aimed to: 1) assess the outcome of such patients; 2) identify patient comorbidities and CT or MRI findings which predicted outcome; and 3) compare their outcome to the expected outcome of THA for hip OA. Methods. Adult patients undergoing THA for hip pain, with no or minimal radiological features of OA (Tönnis grading scale ≤ 1), were identified from a consecutive series of 1,925 THAs. Exclusion criteria were: inflammatory arthritis; osteonecrosis of the femoral head; prior trauma or infection; and patients without minimum one-year follow-up and patient-reported outcome measures (PROMs). The primary outcome measure was the Oxford Hip Score (OHS). Secondary outcome measures were EuroQol-visual analogue scale (EQ-VAS), University of California and Los Angeles (UCLA) scale, and patient satisfaction on a validated three-point ‘better’, ‘same’, or ‘worse’ scale. Results. A total of 107 patients with a median age of 41 years (IQR 18 to 73) were included, with mean follow-up of 6.0 years (SD 3.1). All patients underwent a diagnostic hip injection as a decision aid. Median postoperative OHS was 34 (IQR 28 to 42), with 36 patients (33%) achieving a patient-acceptable symptom state (OHS ≥ 42), lower than THA patients in international registries (40 to 43 points). Secondary outcomes were UCLA of 6 (4 to 8) and EQ-VAS of 73 (51 to 80); 91/102 patients (89%) felt ‘better’ and would ‘undergo surgery again'. Patients with chronic pain syndrome or hypermobility had lower OHS than patients without comorbidities (-6 points, p < 0.006). Overall, 84 patients had a CT and 34 patients an MRI. Patients with subchondral cysts (OHS 42 (37 to 45) vs 35 (26 to 36); p = 0.014) or joint space narrowing on CT (OHS 42 (IQR 37 to 44) vs 35 (26 to 36); p = 0.022) had higher function. Conclusion. Despite high satisfaction levels, patients undergoing THA with minimal or no radiological OA had lower postoperative function than typical THA patients. We recommend obtaining low-dose CT imaging and a diagnostic hip injection to aid decision-making. Cite this article: Bone Jt Open 2025;6(3):328–335

Hypermobility Spectrum Disorder (HSD or hEDS) is attributed to a collagen abnormality associated with excessive joint flexibility. Approximately 90% of females with hip dysplasia have hypermobility. Manifestations of hypermobility in various body systems are unique to every patient, affecting different tissues of the body with varying degrees of severity. Our purposes were to identify the manifestations of hypermobility across multiple body systems and to study the recognition of hypermobility in the medical literature of multiple specialties over multiple decades. A literature search of the major medical disciplines for key words associated with HSD was performed. These specialties included gastroenterology, gynecology, neurology, psychiatry, oral-maxillofacial surgery, cardiology, and orthopaedic surgery. A specialty-specific impact factor (IF) score was calculated as the percentage of research articles that referenced hypermobility as a comorbidity over all articles within that specialty. Statistical differences were identified using single factor ANOVA with significance determined at p<0.05. We reviewed many published, specialty-specific manifestations of hypermobility, and describe them. All six non-orthopaedic specialties demonstrated a continually increasing relative IF ratio throughout the study period with a peak impact average of 0.22 (p<0.05 compared with other time ranges). There was a 93.3% overall increase in IF scores from the 1992–1998 period to the most recent period examined (p<0.05). Hypermobility is increasingly recognized as a significant health issue in multiple disciplines. Since dysplasia is associated with approximately 40% of all primary total hip arthroplasty cases, understanding the multi-system manifestations, and broad impact of hypermobility on patients, is relevant for every hip surgeon. We are expanding our research into other medical disciplines, including urology, ophthalmology, dermatology, clinical psychology, and others

The October 2023 Sports Roundup. 360. looks at: Extensor mechanism disruption in the treatment of dislocated and multiligament knee injuries; Treatment of knee osteoarthritis with injection of stem cells; Corticosteroid injection plus exercise or exercise alone as adjuvants for patients with plantar fasciitis?; Generalized joint hypermobility and a second ACL injury?; The VISA-A ((sedentary) questionnaire for Achilles tendinopathy?

Greater trochanteric pain syndrome (GTPS) is a common and disabling hip condition. Hypermobility has been suggested as a possible cause of GTPS. The purpose of this study was to report the prevalence of hypermobility and to investigate its impact on hip-related function and awareness in patients with GTPS. This cross-sectional study was based on a cohort of patients diagnosed with GTPS in the 2013–2015 period. Hypermobility was investigated with the Beighton Score and defined by a cut-off score ≥5. Data on patients' current hip function and awareness were collected with the questionnaires the Copenhagen Hip and Groin Outcome Score and the Forgotten Joint Score. A total of 612 patients with GTPS were identified based on the diagnosis system; out of those, 390 patients were assessed for eligibility, and 145 (37%) were included. The prevalence of hypermobility within this cohort was estimated to be 11% (95% confidence interval (CI): 3–26%) for males and 25% (95% CI: 17–34%) for females. No significant association was found between hypermobility and self- reported hip function and awareness. We recommend that future studies of GTPS will include hypermobility and investigate the consequences of hypermobility among patients with GTPS

The presence of hip osteoarthritis is associated with abnormal spinopelvic characteristics. This study aims to determine whether the pre-operative, pathological spinopelvic characteristics “normalize” at 1-year post-THA. This is a prospective, longitudinal, case-control matched cohort study. Forty-seven patients underwent pre- and post- (at one-year) THA assessments. This group was matched (age, sex, BMI) with 47 controls/volunteers with well-functioning hips. All participants underwent clinical and radiographic assessments including lateral radiographs in standing, upright-seated and deep-flexed-seated positions. Spinopelvic characteristics included change in lumbar lordosis (ΔLL), pelvic tilt (ΔPT) and hip flexion (pelvic-femoral angle, ΔPFA) when moving from the standing to each of the seated positions. Spinopelvic hypermobility was defined as ΔPT>30° between standing and upright-seated positions. Pre-THA, patients illustrated less hip flexion (ΔPFA −54.8°±17.1° vs. −68.5°± 9.5°, p<0.001), greater pelvic tilt (ΔPT 22.0°±13.5° vs. 12.7°±8.1°, p<0.001) and greater lumbar movements (ΔLL −22.7°±15.5° vs. −15.4°±10.9°, p=0.015) transitioning from standing to upright-seated. Post-THA, these differences were no longer present (ΔPFApost −65.8°±12.5°, p=0.256; ΔPTpost 14.3°±9.5°, p=0.429; ΔLLpost −15.3°±10.6°, p=0.966). The higher prevalence of pre-operative spinopelvic hypermobility in patients compared to controls (21.3% vs. 0.0%; p=0.009), was not longer present post-THA (6.4% vs. 0.0%; p=0.194). Similar results were found moving from standing to deep-seated position post-THA. Pre-operative, spinopelvic characteristics that contribute to abnormal mechanics can normalize post-THA following improvement in hip flexion. This leads to patients having the expected hip-, pelvic- and spinal flexion as per demographically-matched controls, thus potentially eliminating abnormal mechanics that contribute to the development/exacerbation of hip-spine syndrome

There is some evidence to suggest that outcomes of THA in patients with minimal radiographic osteoarthritis may not be associated with predictable outcomes. The aim of this study was to:. Assess the outcome of patients with hip pain who underwent THA with no or minimal radiographic signs of osteoarthritis,. Identify patient comorbidities and multiplanar imaging findings which are predictive of outcome,. Compare the outcome in these patients to the expected outcome of THA in hip OA. A retrospective review of 107 hips (102 patients, 90F:12M, median age 40.6, IQR 35.1–45.8 years, range 18–73) were included for analysis. Plain radiographs were evaluated using the Tonnis grading scale of hip OA. Outcome measures were all-cause revision; iHOT12; EQ-5D; Oxford Hip Score; UCLA Activity Scale; and whether THA had resulted in the patient's hip pain and function being Better/Same/Worse. The median Oxford Hip Score was 33.3 (IQR 13.9, range 13–48), and 36/107 (33.6%) hips achieved an OHS≥42. There was no association between primary hip diagnosis and post-operative PROMs. A total of 91 of the 102 patients (89.2%, 93 hips) reported that their hip pain and function was Better than prior to THA and would have the surgery again, 7 patients (6.8%, 10 hips) felt the Same, and 4 patients (3.9%, 4 hips) felt Worse and would not have the surgery again. Younger patients undergoing total hip arthroplasty with no or minimal radiographic osteoarthritis had lower postoperative Oxford Hip Scores than the general population; though most felt symptomatically better and knowing what they know now, would have surgery again. Those with chronic pain syndrome or hypermobility were likely to benefit less. Those with subchondral cysts or joint space narrowing on CT imaging were more likely to achieve higher functional scores and satisfaction

Introduction. The mechanisms of how spinal arthrodesis (SA) affects patient function after total hip replacement (THA) remain unclear. The objectives of this study were to a) Determine how outcome post-THA compares between patients with- and without-SA, b) Characterize sagittal pelvic changes that occur when moving between different functional positions, and test for differences between patients with- and without-SA, and c) Assess whether differences in sagittal pelvic dynamics are associated with outcome post-THA. Patients/Materials & Methods. Forty-two patients with THA-SA (60 hips) were case-control matched for age, gender, BMI with 42 THA-only patients (60 hips). All presented for review where outcome, PROMs [including Oxford-Hip-Score(OHS)] and 4 radiographs of the pelvis and spino-pelvic complex in 3 positions (supine, standing, deep-seated) were obtained. Cup orientation and various spino-pelvic parameters [including pelvic tilt (PT) and Pelvic-Femoral-Angle (PFA)] were measured. The difference in PT between standing and seated allowed for patient classification based on spino-pelvic mobility into normal (±10–30°), stiff (<±10°) or hypermobile (>±30°). Results. The THA-SA group had inferior PROMs (OHS: 33vs.43; P<0.001) and more complications (12vs.3; p=0.01), especially dislocation (5vs.0) than the THA-only group. No difference in change of PT between supine and standing positions was detected between groups. When standing, THA-SA patients had greater PT (24°vs.17°; p=0.01) and the hip was more extended (194°vs.185°; P<0.001). THA-SA patients were 4 times more likely to have spino-pelvic hypermobility with anterior tilting of their pelvis. Of all biomechanical parameters, only spino-pelvic hypermobility was associated with significant inferior PROMs (OHS:35; p=0.04) and was also present in dislocating hips that required revision despite optimum cup orientation. Discussion. In patients with SA who have undergone a THA, the presence of spino-pelvic hypermobility is associated with an inferior outcome and leads to hip instability secondary to anterior impingement when deep seated (anterior tilt functionally retroverting cup). For those patients, current implant positioning may not be sufficient to avoid dislocation. Conclusion. THA in the presence of a SA is associated with inferior outcomes and higher complication rates. We recommend that assessing spino-pelvic mobility should form an integral part of pre-operative assessment in patients with SA due for a THA

Aims. This study of patients with osteoarthritis (OA) of the hip aimed to: 1) characterize the contribution of the hip, spinopelvic complex, and lumbar spine when moving from the standing to the sitting position; 2) assess whether abnormal spinopelvic mobility is associated with worse symptoms; and 3) identify whether spinopelvic mobility can be predicted from static anatomical radiological parameters. Patients and Methods. A total of 122 patients with end-stage OA of the hip awaiting total hip arthroplasty (THA) were prospectively studied. Patient-reported outcome measures (PROMs; Oxford Hip Score, Oswestry Disability Index, and Veterans RAND 12-Item Health Survey Score) and clinical data were collected. Sagittal spinopelvic mobility was calculated as the change from the standing to sitting position using the lumbar lordosis angle (LL), sacral slope (SS), pelvic tilt (PT), pelvic-femoral angle (PFA), and acetabular anteinclination (AI) from lateral radiographs. The interaction of the different parameters was assessed. PROMs were compared between patients with normal spinopelvic mobility (10° ≤ ∆PT ≤ 30°) or abnormal spinopelvic mobility (stiff: ∆PT < ± 10°; hypermobile: ∆PT > ± 30°). Multiple regression and receiver operating characteristic (ROC) curve analyses were used to test for possible predictors of spinopelvic mobility. Results. Standing to sitting, the hip flexed by a mean of 57° (. sd. 17°), the pelvis tilted backwards by a mean of 20° (. sd. 12°), and the lumbar spine flexed by a mean of 20° (. sd. 14°); strong correlations were detected. There was no difference in PROMs between patients in the different spinopelvic mobility groups. Maximum hip flexion, standing PT, and standing AI were independent predictors of spinopelvic mobility (R. 2. = 0.42). The combined thresholds for standing was PT ≥ 13° and hip flexion ≥ 88° in the clinical examination, and had 90% sensitivity and 63% specificity of predicting spinopelvic stiffness, while SS ≥ 42° had 84% sensitivity and 67% specificity of predicting spinopelvic hypermobility. Conclusion. The hip, on average, accounts for three-quarters of the standing-to-sitting movement, but there is great variation. Abnormal spinopelvic mobility cannot be screened with PROMs. However, clinical and standing radiological features can predict spinopelvic mobility with good enough accuracy, allowing them to be used as reliable screening tools. Cite this article: Bone Joint J 2019;101-B:902–909

Progressive collapsing foot deformity (PCFD) is a complex foot deformity with varying degrees of hindfoot valgus, forefoot abduction, forefoot varus, and collapse or hypermobility of the medial column. In its management, muscle and tendon balancing are important to address the deformity. Peroneus brevis is the primary evertor of the foot, and the strongest antagonist to the tibialis posterior. Moreover, peroneus longus is an important stabilizer of the medial column. To our knowledge, the role of peroneus brevis to peroneus longus tendon transfer in cases of PCFD has not been reported. This study evaluates patient reported outcomes including pain scores and any associated surgical complications for patients with PCFD undergoing isolated peroneus brevis to longus tendon transfer and gastrocnemius recession. Patients with symptomatic PCFD who had failed non-operative treatment, and underwent isolated soft tissue correction with peroneus brevis to longus tendon transfer and gastrocnemius recession were included. Procedures were performed by a single surgeon at a large University affiliated teaching hospital between January 1 2016 to March 31 2021. Patients younger than 18 years old, or undergoing surgical correction for PCFD which included osseous correction were excluded. Patient demographics, medical comorbidities, procedures performed, and pre and post-operative patient related outcomes were collected via medical chart review and using the appropriate questionnaires. Outcomes assessed included Visual Analogue Scale (VAS) for foot and ankle pain as well as sinus tarsi pain (0-10), patient reported outcomes on EQ-5D, and documented complications. Statistical analysis was utilized to report change in VAS and EQ-5D outcomes using a paired t-test. Statistical significance was noted with p<0.05. We analysed 43 feet in 39 adults who fulfilled the inclusion criteria. Mean age was 55.4 ± 14.5 years old. The patient reported outcome mean results and statistical analysis are shown in Table one below. Mean pre and post-operative foot and ankle VAS pain was 6.73, and 3.13 respectively with a mean difference of 3.6 (p<0.001, 95% CI 2.6, 4.6). Mean pre and post-operative sinus tarsi VAS pain was 6.03 and 3.88, respectively with a mean difference of 2.1 (p<0.001, 95% CI 0.9, 3.4). Mean pre and post-operative EQ-5D Pain scores were 2.19 and 1.83 respectively with a mean difference of 0.4 (p=0.008, 95% CI 0.1, 0.6). Mean follow up time was 18.8 ± 18.4 months. Peroneus brevis to longus tendon transfer and gastrocnemius recession in the management of symptomatic progressive collapsing foot deformity significantly improved sinus tarsi and overall foot and ankle pain. Most EQ-5D scores improved, but did not reach statistically significant values with the exception of the pain score. This may have been limited by our cohort size. To our knowledge, this is the first report in the literature describing clinical results in the form of patient reported outcomes following treatment with this combination of isolated soft tissue procedures for the treatment of PCFD. For any figures or tables, please contact the authors directly

Introduction: Growing pains are a common complaint in school age children, but no definite organic causes have been identified. An association between musculoskeletal pain and joint laxity has been proposed. This study therefore investigates the relationship between growing pains and joint hypermobility in children. Materials and Methods: Thirty three children with growing pains and thirty one controls of similar age and sex were recruited from outpatient clinics of a specialist paediatric hospital. Joint hypermobility was assessed in each group using the Beighton score. A Beighton score of greater than or equal to 4 out of 9 was considered hypermobile. Results: The median Beighton scores were 6 for the study group and 0 for the control group. 93.3% of the study group had a Beighton score of equal to or greater than 4, compared to 22.6% of the control group. There was a highly significant difference in Beighton score between the two groups (P< 0.0001), with an estimated difference of 4 points 95% CI 4–6. Discussion and Conclusion: A link between joint hyper-mobility and musculoskeletal symptoms has been demonstrated in adults. There is also some evidence that hypermobile children are more likely to experience musculoskeletal pain, particularly articular, but the extent to which joint hypermobility is related to growing pains specifically has been poorly defined. We have investigated a selective population of children with growing pains and have shown them to be significantly more hypermobile than the control children. The aetiology of growing pains remains unclear. While the growing pains will get better, in view of the possible association of joint hypermobility and other musculoskeletal complains, these children should be carefully assessed for joint laxity

To quantify the prevalence of Generalized Joint Hypermobility (GJH), aka Hypermobility Spectrum Disorder, in adult patients presenting with hip pain to a sub-specialty hip practice, this 4-year, prospective, observational study evaluated correlations with clinical, demographic, and baseline outcomes. 1,004 consecutive new hip patients (390 males, 614 females) were evaluated for GJH using the Beighton 9-point physical exam criteria and the Hakim-Grahame 5-item history questionnaire. Diagnosis, age, sex and race were tested as predictors of GJH. Patient reported outcomes from iHOT-12 and a modified Harris Hip Score (mHHS) were also assessed. There were 333 patients presenting with hip dysplasia over this period. Hip dysplasia (DDH) patients without osteoarthritis (OA) had a significantly elevated prevalence of GJH (77.9%) compared to non-dysplastic hip patients (32.8%, p<0.0001) or to patients with DDH+OA (35.7%, p<0.0001). The prevalence of GJH was significantly higher in females (OR=4.2, 95% CI: 3.2 to 5.5, p<0.0001) and inversely proportional to age. Hispanic patients presented with significantly lower prevalence of GJH compared with other races (p<0.05). GJH was not a predictor of patient-reported outcomes scores (p=0.51 for iHOT-12 and p=0.44 for mHHS). During the course of this study, we successfully performed our first PAO procedure on an outpatient basis (February 2019). That is currently our standard practice. With a strong correlation observed between hypermobility and developmental dysplasia of the hip (DDH), further research is warranted to explore the genetic basis and significance of this association

Various authors have linked hypermobility at the trapeziometacarpal joint to future development of arthritis. When examining hypermobility, the anterior oblique ligament (AOL) and ulnar collateral ligament (UCL) are the two most important supporting structures. Literature suggests that reconstructive techniques to correct the hypermobility can prevent subsequent development of osteoarthritis. Eaton and Littler proposed a surgical technique to reconstruct the ligamentous support of this joint in 1973. This cadaveric biomechanical study aimed to evaluate the resultant effect on the mobility of the thumb metacarpal following this reconstructive technique. Seventeen cadaveric hands were prepared and strategically placed on a jig. Movements at the trapeziometacarpal joint were created artificially. Static digital photographs were taken with intact AOL and UCL at trapeziometacarpal joint (controls), for later comparison with those after sectioning of these ligaments and following Eaton-Littler reconstructive technique. The photographic records were analyzed using Scion.Image. Statistical analysis was performed using Minitab. A paired T-test was used to establish statistical relevance. Results confirmed that the AOL and UCL had a major role in limiting excessive motion at the trapeziometacarpal joint, principally in extension. Division of these ligaments produced a significant degree of subluxation of the metacarpal at this joint with thumb in neutral position (p-value = 0.013). Reconstruction of the ligamentous support using the Eaton-Littler technique reduced the degree of extension available (p-value = 0.005). This study confirmed the important role of the AOL and UCL in maintaining trapeziometacarpal joint stability, and that the Eaton-Littler reconstructive technique reduces the degree of hyperextension at this joint

Degenerative spondylolisthesis is consistently responsible for narrowing of the spinal canal, but only in a part of the cases it causes lateral or central stenosis. The presence, type and severity of stenosis is related to several factors, such as the constitutional dimensions of the spinal canal, the orientation and severity of degenerative changes of the facet joints, and the amount of vertebral slipping. The type of stenosis, that is whether stenosis is central or lateral, depends on the orientation of the articular processes, and the length of the pedicles. Usually stenosis is lateral initially and central in later stages. Instability, that is hypermobility on flexion-extension adiographs is one of the main characteristics of degenerative spondylolisthesis. However, in many cases there is no appreciable hypermobility of the slipped vertebra. We consider the latter condition as a potential instability, which can become a manifest instability as a result of surgery, or when destabilizing factors unable to destabilize a normal vertebra intervene, such as disc degeneration or severe degenerative changes of the facet joints. There is no indication for surgery in patients with no significant symptoms. In patients with an unstable motion segment who have only back pain it is usually sufficient to perform a fusion alone if stenosis is mild and asymptomatic. Neural decompression should be performed if stenosis is severe. Bilateral laminotomy, or even total laminectomy, may be carried out with no concomitant fusion in patients with mild olisthesis, no vertebral hypermobility on functional radiographs, mild central stenosis or any degree of isolated lateral stenosis, and mild or no back pain. The indications for monolateral laminotomy with no fusion are: moderate central stenosis in elderly patients with unilateral symptoms; lateral stenosis only on one side; and unilateral additional pathology, such as a synovial cyst. Patients with moderate or severe olisthesis, vertebral hypermobility even of mild degree, and/or severe central stenosis and chronic back pain should undergo decompression and fusion. The association of an arthrodesis allows decompression of the neural structures as widely as necessary. Posterolateral instrumented fusion, using pedicle screw fixation, is the most common procedure, that can be done at multiple level when olisthesis is present at more than one level. In both cases it requires no, or a short, postoperative immobilization Posterolateral fusion may be replaced by PLIF. This procedure, associated with pedicle screw instrumentation, gives excellent results and a high rate of solid fusion. The devices inserted in the disc space are normally represented by cages filled with bone chips. An alternative are the use of blocks of porous tantalum (hedrocel), the stiffness of which is very similar to that of subchondral bone. We are using blocks of hedrocel since 3 years with excellent results in terms of intersomatic fusion. In 20 cases followed for at least 2 years we never observed mobilization of the implant or loosening of the pedicle screws, and we almost consistently found a tight union between the implant and the adjacent vertebrae

As it remains unproven that hypermobility of the first tarsometatarsal joint (TMTJ-1) is a significant factor in hallux valgus deformity, the necessity for including arthrodesis of TMTJ-1 as part of a surgical correction of a hallux valgus is questionable. In order to evaluate the role of this arthrodesis on the long-term outcome of hallux valgus surgery, a prospective, blinded, randomised study with long-term follow-up was performed, comparing the Lapidus procedure (which includes such an arthrodesis) with a simple Hohmann distal closing wedge metatarsal osteotomy. The study cohort comprised 101 feet in 87 patients: 50 feet were treated with a Hohmann procedure and 51 with a Lapidus procedure. Hypermobility of TMTJ-1 was assessed pre-operatively by clinical examination. After a mean of 9.25 years (7.25 to 11.42), 91 feet in 77 patients were available for follow-up. There was no difference in clinical or radiological outcome between the two procedures. Also, there was no difference in outcome between the two procedures in the subgroup clinically assessed as hypermobile. This study does not support the theory that a hallux valgus deformity in a patient with a clinically assessed hypermobile TMTJ-1 joint requires fusion of the first tarso-metatarsal joint. Cite this article: Bone Joint J 2013;95-B:1222–6

Abstract. OBJECTIVES. Although surgical periacetabular osteotomy (PAO) for hip dysplasia aims to optimise acetabular coverage and restore hip function, it is unclear how surgery affects capsular mechanics and joint stability. The purpose was to examine how the reoriented acetabular coverage affects capsular mechanics and joint stability in dysplastic hips. METHODS. Twelve cadaveric dysplastic hips (n = 12) were denuded to the capsule and mounted onto a robotic tester. The robot positioned each hip in multiple flexion angles (Extension, Neutral 0°, Flexion 30°, Flexion 60°, Flexion 90°) and performed internal-external rotations and abduction-adduction to 5 Nm in each rotational or planar direction. Each hip underwent a PAO, preserving the capsule, and was retested postoperatively in the robot. Paired sample t-tests compared the range of motion before and after PAO surgery (CI = 95%). RESULTS. Pre-operatively, the dysplastic hips demonstrated large ranges of internal-external rotations and abduction-adduction motions throughout all flexion positions. Post-operatively, the PAO slackenend the anterosuperior capsule and tightened the inferior capsule. This increased external rotation in Flexion 60° and Flexion 90° (∆. ER. = +16 and +23%) but provided lateral coverage to decrease internal rotation at Flexion 90° (∆. IR. = –15%). The PAO also reduced abduction throughout, but increased adduction in Neutral 0°, Flexion 30°, and Flexion 60° (∆. ADD. = +34, +30%, +29% respectively). CONCLUSIONS. The PAO provided crucial osseous structural coverage to the femoral head, decreasing hypermobility and adverse loading at extreme hip flexion-extension. However, it also slackened the anterosuperior capsule and increased adduction and external rotation, which may lead to ischiofemoral impingement and adductor irritations. Capsular instability may be secondary to acetabular undercoverage, thus capsular alteration may be warranted for larger corrections or rotational osteotomies. To preserve native hip and delay joint degeneration, it is crucial to preserve capsule and elucidate amount of reorientation needed without causing iatrogenic instability. 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

Aims. The aims of the study were to determine the differences in spinopelvic mobility between a cohort of hip OA patients and a control group for the 1) standing to relaxed-seated and 2) standing to deep-seated task. Methods. A cohort of 40 patients with end-stage hip OA and a control group of 40 subjects, matched for age, gender and BMI were prospectively studied. Clinical data and lateral view radiographs in different positions were assessed. Sagittal spinopelvic mobility was calculated as the change when moving from the standing to relaxed-seated and standing to deep-seated positions for the lumbar lordosis angle, pelvic tilt and pelvic-femoral angle. Results. When moving from the standing to sitting position, hip OA patients demonstrated less hip flexion (52±18 vs. 69±11, p<0.001), an increased posterior pelvic tilt (23±13 vs. 12±9, p<0.001) and more flexion of the lumbar spine (22±15 vs. 14±11, p=0.01). Similarly, when moving from the standing to deep-seated position, hip OA patients demonstrated also less hip flexion (64±21 vs. 84±18, p<0.001), accompanied by a posterior and not an anterior pelvic tilt as in the control group (10±16 vs. −3±17, p<0.001). No difference could be found for lumbar spine flexion (40±15 vs. 43±13, p=0.28). The percentage of subjects with stiff spinopelvic mobility was significantly lower in the patient group (15% vs 48%; p=0.002) and there was a trend towards a higher percentage in spinopelvic hypermobility in patients (20% vs 2%; p=0.08). Conclusions. Decreased hip flexion due to OA leads to an increased posterior pelvic tilt when taking a relaxed-seated position. Less than 10° of posterior pelvic tilt from the standing to relaxed seated position (spinopelvic ‘stiffness’) is more frequent in controls without hip OA and results from hip mobility and not from stiffness of the lumbar spine