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

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. The trapezio-metacarpal joint (TMCJ) is subject to constant multiplanar forces and is stabilised by the bony anatomy and ligamentous structures. Ligament reconstruction can correct the hypermobility and potentially prevent osteoarthritis. Eaton and Littler proposed a surgical technique to reconstruct the volar ligamentous support of this joint. In our cadaveric biomechanical study, we aimed to evaluate the resultant effect of this technique on the mobility of the thumb metacarpal. Materials and method. Seventeen cadaveric hands were prepared and placed on a custom-made jig. Movements at the trapeziometacarpal joint were created using weights. Static digital photographs were taken with intact anterior oblique (AOL) and ulnar collateral ligaments(UCL) and compared with those taken after sectioning these ligaments and following Eaton-Littler reconstructive technique. The photographic records were analyzed using Scion. Image™. Paired T-test was used to establish statistical significance with a p<0.05. Results. AOL and UCL stabilised the TMCJ in extension. Division of these ligaments produced a significant degree of subluxation of the metacarpal at this joint with the thumb in a neutral position. Reconstruction of the ligamentous supports, using the Eaton-Littler technique, reduced the degree of extension. Conclusion. The primary stabilising ligament of the TMCJ is a subject of debate. Our study objectively evaluates the effect of reconstruction of AOL and UCL on various movements at the TMCJ comparing with sectioned and unsectioned specimens. It confirms the role AOL and UCL in resisting extension and utility of the Eaton-Littler procedure in decreasing hyperextension at this joint. This may have clinical utility in traumatic injury and degenerative laxity, by reducing pain and potentially slowing or even preventing the progression of osteoarthritis

Introduction. The viscoelastic cervical disk prosthesis CP-ESP is an innovative one-piece deformable but cohesive interbody spacer. It is an evolution of the LP-ESP lumbar disk implanted since 2006. The implant provides 6 full degrees of freedom including shock absorption. The design allows a limitation for rotation and translation with resistance to motion (elastic return property) aimed at avoiding overload of the posterior facets. The rotation center can vary freely during motion. It thus differs substantially from current prostheses. This study reports the clinical results of a prospective observational study series of 89 patients who are representative of the current use of the ESP implant since 2012. The radiological results are focused on the evolution of the mean center of rotation (MCR) as an additional information to the range of motion (ROM) for the evaluation of the quality of spine movement. Materials and Methods. 89 patients (33 males, mean age 45 years [28–60], 107 implants) were included for an open, prospective and non-randomized study between October 2012 and December 2015. One level patients were at C3C4 (3), C4C5 (3), C5C6 (41) C6C7 (24) C7T1 (1). Two levels patients were C4C5/C5C6 (3), C5C6/C6C7 (12), C6C7/C7D1 (1) and 3 levels C4C5/C5C6/C6C7 (1). Results. Clinical data were obtained preoperatively and at 3, 6, 12 and 24 months (mean ± SD): . Neck VAS:. 5,85±2,24. 2,34±1,95. 1,42±1,54. 2,25±1,75. 2,1±1,1. Arm VAS:. 6,5±1,95. 2,22±1,95. 1,5±2,0. 3±2,78. 1±2,5. NDI (%):. 55,8±15,2. 29,5±17. 18,9±15. 31±13. 21±11. SF 36 PCS (%):. 31±22,5. 50±14,9. 65±8,4. 44±12,8. 54±12. SF 36 MCS (%):. 32±13,9. 51±10,9. 69±8,5. 54±6,7. 59±8. We did not observe local ossifications. One case of side level degeneration was observed after 12 months in a C5C6 mono-segmental disk replacement (retrospectively this patient was a good case for a double initial implantation). To date the patient has not been re-operated. Two cases were revised (one C5C6 implant for bone ingrowth failure at 6 months and one C4C5 case for painful hypermobility in a globally stiff spine). Range of motion was obtained after 6 months and maintained at 24 months. Radiological study of the location of the mean center of rotation at the prosthesis level and adjacent disks demonstrated the adaptation ability of the implant. Conclusion. The concept of the ESP prosthesis is different from that of the “first generation” articulated devices currently used in the cervical spine. This study reports encouraging clinical results about pain, function and kinematic behavior. An interesting point is the evolution of the Mean Centers of Rotation in the. post-operative course. This adaptation ability is one of the main features as we need to consider the mean and long term evolution of the global cervical posture and mobility after a cervical disc replacement. Additional studies and longer patient follow-up are needed to assess long-term reliability of this innovative implant

Purpose:. To describe a plating technique for the Lapidus procedure as an alternative to the traditional screw fixation technique. To look at the complications experienced during the Lapidus procedure and to find possible solutions to prevent these complications. Methods:. A retrospective study of 34 Lapidus procedures in 26 patients (8 bilateral) between 2006 and 2009 was performed. All were done with a plating technique and a primary bone graft. The indications were:. metatarsus primus varus. hypermobility. degenerative TMT joint. Results:. The average intermetatarsal angle pre-operatively was 17.1° and this was reduced to 6,4° post – operatively. The complications experienced were:. post –operative metal removal = 6. transfer metatarsalgia = 1. hallux varus = 1. screw breakage = 1. delayed union = 1. non-union = 1. Conclusion:. The plating technique for the Lapidus procedure gives stable fixation and the outcome compares well with other methods of fixation

Hallux valgus continues to frustrate foot and ankle surgeons the world over. The condition is mostly clear in its aetiology but unclear in its pathogenesis. The key, as in all surgery, is decision making, patient selection and to have many surgical options available. The key things to consider are: joint congruency, the presence of arthritis, the presence of metatarsus adductus, the intermetatarsal angle, the hallux valgus angle and the presence of interphalangeal deformity. I consider true hypermobility of the first ray and Achilles tendon tightness to be less important factors. Patient expectations are particularly important as most patients with hallux valgus are women who want to wear high-heeled shoes!. The most successful operations consist of a combination of soft tissue and bony procedures. The most common error in bunion surgery, in my opinion, is the use of a procedure with inadequate power to correct the deformity. When the joint is markedly arthritic and deformed an arthrodesis is the procedure of choice. I will discuss the above points in the lecture

Orthopaedic problems are common in patients with Ehlers-Danlos Syndrome (EDS). Articular hypermobility can be particularly disabling leading to instability in the appendicular skeleton. We present a case of an EDS patient presenting with knee pain and instability. It highlights important lessons to be learned when considering joint replacement in this patient group. A 51 year old lady with EDS underwent a posterior cruciate retaining total knee replacement for pain and instability. She dislocated her knee replacement three months post-operatively after a fall. Her knee was reduced at her local emergency department causing injury to the popliteal artery. She required urgent popliteal artery repair and fasciotomies. The common peroneal nerve was also irreversibly damaged by the dislocation. She has since had one further dislocation and is now awaiting revision surgery. When considering total knee replacement (TKR) in EDS, the patient must be warned of the inferior results compared to TKR for other causes. The increased risk of complications must be explained and a more constrained TKR design considered to address the inherent joint laxity. The potential consequences of a dislocated TKR can be disastrous and therefore relocation must be performed in a controlled environment in the operating theatre

Patella instability is a common problem with many surgical options. We prospectively evaluated the results of medial patella femoral ligament (MPFL) reconstruction with an autogenous gracilis or semitendinous graft. With a minimum follow up of one year patients were reviewed using the Kujala scoring system. Twenty MPFL reconstructions were performed on seventeen patients over a two year period, from January 2004 to December 2005. There were 13 females and 4 males. Three patients had bilateral involvement. Thirteen patients had a lateral release with their MPFL reconstruction and three had a distal realignment procedure as well to correct their patella instability. The mean follow up was 17 months (range 12 to 26 months). The average age was 25 years old at operation (range 13 to 47) and the average age of their first dislocation was 16 (range 0-35). Nine patients had previous surgical treatment for patella instability. The average hypermobility score in the patients was 5/9 and six patients scored 9/9. At follow up 18 out of 20 patients (90%) had stable tracking with no further subluxations/dislocations. Of the two with unstable tracking, one had a stable patella before falling several times onto her knee. An MRI confirmed the ligament was intact but a type 2 trochlear dysplasia was present and a Bereiter trochleoplasty was subsequently performed. The other patient described no frank dislocation but instead subluxations. Eighteen of the twenty reconstructions (90%) achieved a stable patella. Overall Kujala scores increased by a third

Clinical assessment of elbow deformity in children at present is mainly based on physical examination and plain X-ray images, which may be inaccurate if the elbow is not in fully supination; furthermore, the rotational deformity is even harder to be determined by such methods. Morrey suggested that the axis of rotation of the elbow joint can be simplified to a single axis. Based on such assumption, we are proposing a method to assess elbow deformity using rotational axis of the joint, and an optimized calculation algorithm is presented. The rotation axis of elbow in respective to the upper arm can be obtained from the motion tract of markers placed at the forearm. Cadaver study was done, in which three skeletal motion trackers were placed over both the anterior aspect of humerus, as well as distal ulna. Osteotomy was created at the supracondylar region of humerus through lateral approach, and the bone fragments were stabilized with a set of external skeletal fixator, leaving the soft tissue intact. The amount of deformity was created manually by adjusting the position of the distal fragment via skeletal fixator. Ultrasound 3D motion tracking system from Zebris® was used in this study, and the program was developed under the Matlab environment. Cycles of passive elbow flexion/extension motion were carried out for each set of deformity. The data were initially transformed to humerus coordinate, and since the upper arm was not absolutely stationary, its influence on the measured position of ulna was adjusted. With this adjusted data, a best fit plane that would include most of the ulna positions (MU) within a minimal distance was obtained. The rotation axis was calculated as the normal vector to this plane, and the carrying angle could subsequently be assessed according to the relationship between this axis and the x-axis on the xy-plane as well as on the xz-plane. Fresh frozen cadaver study was conducted in the Medical Simulation Center at Tzu-Chi University. After adjustment of the raw data to eliminate the influence of humerus motion, the ulna motion could be narrowed down from a band of 10mm to 3mm, with a significant smaller standard deviation. The rotation axis was obtained by the normal vector to the best fit plane. Two different approaches were attempted to find the plane. In the first method, the plane was obtained via least square method from the adjusted ulna positions, and the second method found the plane via RANSAC method. Calculations were repeated several times for each method, and the results showed a variation of 5 degrees in the first method and about 2 degrees in the second method. Rotational axis can be used to define the 3-dimensional deformity of elbow joint; however, it is difficult to obtain such axis accurately due to hypermobility and multi-directional motion of the shoulder joint. In this study, we have developed another method to assess the elbow deformity using motion analysis system instead of the conventional image studies, and this may be applicable clinically if the facility becomes more accessible in the future. (This research was supported by the project TCRD-TPE-99-30 granted by the Buddhist Tzu-Chi General Hospital, Taipei Branch)

Introduction. The published results of the use of a dual mobility cup to prevent instability in primary and revision total hip arthroplasty (THA) have established its efficacy. However, the monoblock, porous cobalt chromium cup design makes secure fixation difficult to achieve, limiting its use in patients with significant acetabular deformity or bone loss. Recently, a modular version of the dual mobility cup was introduced, consisting of a conventional porous shell with holes to allow augmented screw fixation, a highly polished modular metal liner, and a standard bipolar femoral head. The purpose of this report is to present its various indications, the surgical technique, and report our initial results. Methods. With IRB approval and FDA clearance, we implanted the modular dual mobility (MDM) cup in 15 patients undergoing primary and 5 patients undergoing revision THA deemed high risk for instability. Indications included septic and aseptic revision surgery, developmental hip dysplasia, avascular necrosis, recurrent dislocations, hemiarthroplasty conversion to THA, periprosthetic fracture, abductor insufficiency requiring augmented repair, and hypermobility from auto-immune inflammatory disease. Surgical Technique. The acetabulum is prepared in the standard fashion for implantation of a press-fit component. After implantation and possible screw augmentation, osteophytes are removed. A modular metal liner is manually inserted into the shell by lining up tines and then impacted into place. Concentric positioning must be confirmed. After standard femoral stem preparation, a dual-mobility head with multiple neck length options is easily assembled and placed on the trunion. The hip is then located and assessed for limb length, stability, and offset. Results. In the 15 primary THAs, successful implantation of the MDM construct was accomplished without issues related to the aforementioned technique. Adjunct screw fixation was utilized in 8 patients based on initial rim fit and bone quality. In all cases, the hip had to be manually dislocated because of increased stability. There were no peri-operative complications related to the MDM. In the 5 revision cases, insertion was possible in 4 of 5 patients. In 2 cases, the MDM liner was used in previously implanted, well-fixed and positioned metal acetabular shells compatible with the MDM insert. In 2 cases, the original metal cup was replaced with a shell compatible with the MDM insert. In the remaining patient, a failed hemi-resurfacing, the use of the MDM was abandoned because of impingement and excessive lengthening causing the inner trial head to disassociate from outer trial head. Discussion. The MDM cup offers a number of important features not available on the original dual mobility designs. These include the use of: 1) a conventional shell, inserted with familiar instrumentation; 2) a shell that can be used with either a highly cross-linked polyethylene liner or the modular polished metal liner; 3) conventional cancellous screws that makes possible augmented fixation in cases of significant bone loss or acetabular deformity. These features make possible the use of the dual mobility concept without the need to add to a hospital's cup inventory. The initial results in a variety of primary and revision conditions have been encouraging

Aims

To determine if the results of treatment of adolescents with coccydynia are similar to those found in adults. Adult patients with coccydynia may benefit from injection therapy or operative treatment. There is little data evaluating treatment results in adolescents. We have treated adolescent patients similarly to adults and compared the outcomes.