Aims. The aim of this study was to investigate the potentially increased risk of dislocation in patients with neurological disease who sustain a femoral neck fracture, as it is unclear whether they should undergo total hip arthroplasty (THA) or hemiarthroplasty (HA). A secondary aim was to investgate whether dual-mobility components confer a reduced risk of dislocation in these patients. Methods. We undertook a longitudinal cohort study linking the Swedish Hip Arthroplasty Register with the National Patient Register, including patients with a neurological disease presenting with a femoral neck fracture and treated with HA, a conventional THA (cTHA) with femoral head size of ≤ 32 mm, or a dual-mobility component THA (DMC-THA) between 2005 and 2014. The dislocation rate at one- and three-year revision, reoperation, and mortality rates were recorded. Cox multivariate regression models were fitted to calculate adjusted hazard ratios (HRs). Results. A total of 9,638 patients with a neurological disease who also underwent unilateral arthroplasty for a femoral neck fracture were included in the study. The one-year dislocation rate was 3.7% after HA, 8.8% after cTHA < 32 mm), 5.9% after cTHA (= 32 mm), and 2.7% after DMC-THA. A higher risk of dislocation was associated with cTHA (< 32 mm) compared with HA (HR 1.90 (95% confidence interval (CI) 1.26 to 2.86); p = 0.002). There was no difference in the risk of dislocation with DMC-THA (HR 0.68 (95% CI 0.26 to 1.84); p = 0.451) or cTHA (= 32 mm) (HR 1.54 (95% CI 0.94 to 2.51); p = 0.083). There were no differences in the rate of reoperation and revision-free survival between the different types of prosthesis and sizes of femoral head. Conclusion. Patients with a neurological disease who sustain a femoral neck fracture have similar rates of dislocation after undergoing HA or DMC-THA. Most patients with a neurological disease are not eligible for THA and should thus undergo HA, whereas those eligible for THA could benefit from a DMC-THA. Cite this article: Bone Joint J 2022;104-B(1):134–141

Introduction. Postvoid residualurine (PVR) can be an unknown chronic disorder, but it can also occur after surgery. A pilot-study initiated in Elective Surgery Center, Silkeborg led to collaboration with a urologist to develop a flowchart regarding treatment of PVR. Depending on the severity, men with significant PVR volumes were either recommend follow up by general practitioner or referred to an urologist for further diagnose and/or treatment. Aim: to determine the prevalence of pre- and postoperative PVR in men >65 years undergoing orthopedic surgeries and associated risk factors. Method. A single-center, prospective cohort study. Male patients were consecutively included during one year from April 2022. Data was extracted from the electronic patient files: age, lower urinary tract symptoms (LUTS), co-morbidity (e.g. diabetes), type of surgery and anesthesia, opioid use, pre- and postoperative PVR. Result. 796 participants; 316 knee-, 276 hip-, 26 shoulder arthroplasties and 178 lower back spinal surgeries. 95% (755) were bladder scanned preoperatively. 12% (89) had PVR 150-300ml, and 3% (23) had PVR >300ml. There was a higher risk of preoperative PVR ≥150ml in patients reporting LUTS, OR 1.97(1.28;3.03), having known neurological disease, OR 3.09(1.41;6.74), and the risk increased with higher age, OR 1.08 per year (1.04;1.12). Diabetes and the type of surgery was not associated with higher risk of PVR. 72% (569) had a postoperative bladder scan. 15% (95%CI: 12-19%) (70) patients without PVR preoperatively had PVR ≥150ml postoperatively. Conclusion. Approximately 15% of the men had PVR ≥150ml preoperatively. Neurological disease was the most severe risk factor and secondary if reporting LUTS. As expected, the risk increased with age. Neither diabetes nor the type of surgery was associated with higher risk. 15% of men without preoperative PVR had PVR after surgery. It is not possible to conclude if it is transient or chronic but further studies are ongoing

Based on Ilizarov's law of tension-stress principle, distraction histogenesis technique has been widely applied in orthopaedic surgery for decades. Derived from this technique, cranial bone transport technique was mainly used for treating cranial deformities and calvarial defects. Recent studies reported that there are dense short vascular connections between skull marrow and meninges for immune cells trafficking, highlighting complex and tight association between skull and brain. Alzheimer's disease (AD) is a progressive neurodegenerative disease and the most common cause of dementia without effective therapy. Meningeal lymphatics have been recognized as an important mediator in neurological diseases. The augmentation of meningeal lymphatic drainage might be a promising therapeutic target for AD. Our proof-of-concept study has indicated that cranial bone transport can promote ischemic stroke recovery via modulating meningeal lymphatic drainage function, providing a rationale for treating AD using cranial bone maneuver (CBM). This study aims to investigate the effects of CBM on AD and to further explore the potential mechanisms. Transgenic 5xFAD mice model was used in this study. After osteotomy, a bone flap was used to perform CBM without damaging the dura. Open filed test, novel object recognition test and Barn's maze test were used to evaluate neurological functions of 5xFAD mice after CBM treatment. Congo red and immunofluorescence staining were used to evaluate amyloid depositions and Aβ plaques in different brain regions. Lymphangiogenesis and the level of VEGF-C were examined after CBM treatment. OVA-A647 was intra-cisterna-magna injected to evaluate meningeal lymphatic drainage function after CBM treatment. CBM significantly improved memory functions and reduced amyloid depositions and Aβ plaques in the hippocampus of 5xFAD mice. A significant increase of meningeal lymphatic vessels in superior sagittal sinus and transverse sinus, and the upregulation of VEGF-C in meninges were observed in 5xFAD mice treated with CBM. Moreover, CBM remarkably enhanced meningeal lymphatic drainage function in 5xFAD mice (n=5-16 mice/group for all studies). CBM may promote meningeal lymphangiogenesis and lymphatic drainage function through VEGF-C-VEGFR3 pathway, and further reduce amyloid depositions and Aβ plaques and alleviate memory deficits in AD

Aim. Patient quality of life (QoL) in untreated bone infection was compared to other chronic conditions and stratified by disease severity. Method. Patients referred for treatment of osteomyelitis (including fracture related infection) were identified prospectively between 2019 and 2023. Patients with confirmed infection completed the EuroQol EQ-5D-5L questionnaire. Clinicians blinded to EQ-index score, grouped patients according to JS-BACH Classification into ‘Uncomplicated’, ‘Complex’ or ‘Limited treatment options’. A systematic review of the literature was performed of other conditions that have been stratified using EQ-index score. Results. 257 patients were referred, and 219 had suspected osteomyelitis. 196 patients had long bone infection and reported an average EQ-index score of 0.455 (SD 0.343). 23 patients with pelvic osteomyelitis had an average EQ-index score of 0.098 (SD 0.308). Compared to other chronic conditions, patients with long-bone osteomyelitis had worse QoL when compared to different types of malignancy (including bladder, oropharyngeal, colorectal, thyroid and myeloma), cardiorespiratory disease (including asthma, COPD and ischaemic heart disease), psychiatric conditions (including depression, pain and anxiety), endocrine disorders (including diabetes mellitus), neurological conditions (including Parkinson's disease, chronic pain and radiculopathy) and musculoskeletal conditions (including osteogenesis imperfecta, fibrous dysplasia and x-linked hypophosphataemic rickets). QoL in long-bone infection was similar to conditions such as Prada-Willi syndrome, Crohn's disease and juvenile idiopathic arthritis. Patients who had a history of stroke or multiple sclerosis reported worse QoL scores compared to long-bone infection. Patients who had pelvic osteomyelitis gave significantly lower QoL scores when compared to all other conditions that were available for comparison in the literature. In long bone infection, 41 cases (21.0%) were classified as ‘Uncomplicated’, 136 (69.4%) as ‘Complex’ and 19 (9.7%) as ‘Limited treatment options available’. Within classification stratification, patients with ‘Uncomplicated’ long bone infections reported a mean EQ-index score of 0.618 (SD 0.227) which was significantly higher compared to ‘Complex’ (EQ-index: 0.410 SD 0.359, p=0.004) and ‘Limited treatment options available’ (EQ-index: 0.400 SD 0.346, p=0.007). Conclusions. Bone and joint infections have a significant impact on patient quality of life. It is much worse when compared to other common chronic conditions, including malignancy, cardiovascular and neurological diseases. This has not been previously reported but may focus attention on the need for more investment in this patient group

Introduction. Instability remains a common complication following total hip arthroplasty (THA) and continues to account for the highest percentage of revisions in numerous registries. Many risk factors have been described, yet a patient-specific risk assessment tool remains elusive. The purpose of this study was to apply a machine learning algorithm to develop a patient-specific risk score capable of dynamic adjustment based on operative decisions. Methods. 22,086 THA performed between 1998–2018 were evaluated. 632 THA sustained a postoperative dislocation (2.9%). Patients were robustly characterized based on non-modifiable factors: demographics, THA indication, spinal disease, spine surgery, neurologic disease, connective tissue disease; and modifiable operative decisions: surgical approach, femoral head size, acetabular liner (standard/elevated/constrained/dual-mobility). Models were built with a binary outcome (event/no event) at 1-year and 5-year postoperatively. Inverse Probability Censoring Weighting accounted for censoring bias. An ensemble algorithm was created that included Generalized Linear Model, Generalized Additive Model, Lasso Penalized Regression, Kernel-Based Support Vector Machines, Random Forest and Optimized Gradient Boosting Machine. Convex combination of weights minimized the negative binomial log-likelihood loss function. Ten-fold cross-validation accounted for the rarity of dislocation events. Results. The 1-year model achieved an area under the curve (AUC)=0.63, sensitivity=70%, specificity=50%, positive predictive value (PPV)=3% and negative predictive value (NPV)=99%. The 5-year model achieved an AUC=0.62, sensitivity=69%, specificity=51%, PPV=7% and NPV=97%. All cohort-level accuracy metrics performed better than chance. The two most influential predictors in the model were surgical approach and acetabular liner. Conclusions. This machine learning algorithm demonstrates high sensitivity and NPV, suggesting screening tool utility. The model is strengthened by a multivariable dataset portending differential dislocation risk. Two modifiable variables (approach and acetabular liner) were the most influential in dislocation risk. Calculator utilization in “app” form could enable individualized risk prognostication. Furthermore, algorithm development through machine learning facilitates perpetual model performance enhancement with future data input

The neurogenic clubfoot is composed of several deformities – such as cavus and equinus, hind foot varus, supination and adduction of the forefoot – which develop due to the neurological disease leading to muscle imbalance. Whereas over-activity and spasticity occur after damage of the central nervous system, flaccid paralysis is the result of damage of the spinal motor neuron or the nerve itself. Local overload at the lateral border of the foot, poor stability and small supporting area may interfere with function and hence require treatment of the deformity. The primary aim is a functioning foot. Treatment options are conservative means or surgical procedures. Insoles are applied to correct the foot position: a lateral support forces the foot into valgus and pronation being effective only when loaded and worn in reinforced shoes. They can also be used to distribute pressure in case of local overload and sores. An individually manufactured foot orthosis provides more stability. If the forces are still overly big, the lever arm of an ankle foot orthosis is required. Surgical procedures may be carried out in addition to or instead of conservative means. Skeletal surgery should not be performed early because the neurological disease persists despite the local correction and increases the risk for recurrences. Stiffening of the foot needs to be avoided in order to preserve function. Stiffness due to cavus is reduced by a Steindler release of the plantar fascia. Equinus should not be overstressed. If necessary, it is corrected by heel cord lengthening resulting in a persistent loss of force, or by aponeurotomy maintaining force but being less efficient to gain length. To balance supination, split or complete transfer corrects the pull of hyperactive anterior or posterior tibial muscles. Lacking skeletal deformation is a prerequisite for these soft tissue procedures. Thus their presence requires bony correction alone or in addition to soft tissue surgery. The varus of the os calcis is best corrected by an original or modified Dwyer valgus osteotomy. Cavus, supination and adduction deformity can all be corrected at the midfoot. These procedures preserve mobility and hence function of the foot. Severely contracted feet, however, may need corrective fusions. Nevertheless, stiffness is badly tolerated. An alternative is application of an external fixater of the Ilizarov type to correct the skeletal deformity and followed by an additional corrective osteotomy. Botulinum toxin A paralysing a muscle for three months can be used to switch off overactive anterior or posterior tibial muscles in order to delay surgery or to prevent pull out after transfer. Application of casts to stretch overly short muscles can help to keep the deformity under control, but they need to be followed by splints in order to avoid early recurrence

Aims

To map literature on prognostic factors related to outcomes of revision total knee arthroplasty (rTKA), to identify extensively studied factors and to guide future research into what domains need further exploration.

Aims

Previous studies have suggested that selenium as a trace element is involved in bone health, but findings related to the specific effect of selenium on bone health remain inconclusive. Thus, we performed a meta-analysis by including all the relevant studies to elucidate the association between selenium status (dietary intake or serum selenium) and bone health indicators (bone mineral density (BMD), osteoporosis (OP), or fracture).

Aims

The aim of this investigation was to compare risk of infection in both cemented and uncemented hemiarthroplasty (HA) as well as in total hip arthroplasty (THA) following femoral neck fracture.

Aims

Patients with femoral neck fractures (FNFs) treated with total hip arthroplasty (THA) have an almost ten-fold increased risk of dislocation compared to patients undergoing elective THA. The surgical approach influences the risk of dislocation. To date, the influence of differing head sizes and dual-mobility components (DMCs) on the risk of dislocation has not been well studied.

Introduction. Reports cite up to 20% of total knee arthroplasty (TKA) patients are not satisfied. Recent focus on alignment and balance has perhaps overshadowed kinematics as a key determinant of outcomes. Some propose that reproducing the native knee kinematics of lateral-pivot motion in early flexion during walking will enact optimal TKA outcomes. The purpose of this study was to determine if intra-operative kinematic patterns correlate with patient function, pain and satisfaction after TKA. Methods. A retrospective review of consecutive TKA's performed by two surgeons was performed. After final components were implanted and balanced, sensor-embedded tibial trials were inserted and kinematic patterns were recorded through range-of-motion. Femoro-tibial contact points were recorded at four distinct flexion points (0°, 45°, 90° and full flexion). Center of rotation kinematic patterns were calculated and categorized as medial pivot, lateral pivot or translation at each measurement range via established criteria. Knees with lateral (L) pivot in early flexion between 0 and 45 ° and medial (M) pivot beyond 90°, regardless of the mid-flexion pivot pattern, formed the experimental group designated as LXM. All other patterns were designated non-LXM and formed the control group. Modern, validated clinical outcome measures (Knee Society Score, EQ5D, UCLA) were obtained preoperatively and at minimum one-year postoperatively. Results. 185 consecutive TKAs were analyzed and 33 were excluded due to sensor device malfunction, atypical hardware, unresurfaced patella, surgery at a non-study hospital, early infection, aseptic loosening revision, ipsilateral hip disease, or subsequent neurologic disease or death unrelated to the index TKA resulting in a final sample size of 152 patients. Twelve patients (7.9%) were lost to minimum one-year follow-up, and two were excluded from analysis due to outlier values. Seventy-five percent of the final sample was female. Mean age, height, weight, and BMI were 63.6 years, 167.0 cm, 94.5 kg, and 33.9, respectively. Patients in the LXM group tended to be slightly older (66 vs. 63 years, p = 0.062) and had fewer months of follow-up (18.3 vs. 21.6 months, p = 0.030). Controlling for age and follow-up, patients with the LXM kinematic pattern demonstrated better postoperative function scores (mean 74.6 vs. 66.3 points, p = 0.032) and greater functional improvement from preoperative baseline (mean 40.3 vs. 30.0 points, p = 0.001). The LXM kinematic pattern also was associated with greater improvement in the Knee Society objective score (mean 39.6 vs. 32.3 points, p = 0.053). There was a trend for LXM to demonstrate greater improvement in satisfaction (mean 20.1 vs. 17.3 points, p 0.086). EQ-5D health care quality of life and UCLA activity level score were unrelated to kinematic pattern. Conclusion. TKA patients with a lateral pivot kinematic pattern in the early range of motion and a medial pattern in high flexion beyond 90-degrees demonstrated superior functional outcomes and objective clinical knee scores. This supports the premise that TKA kinematic patterns that replicate native knee kinematics unique to certain degrees of flexion will have optimal function, improved clinical outcome, and less pain

INTRODUCTION. The purpose of TKA is to restore normal kinematics and functioning to diseased knees. The purpose of this study was to determine whether intraoperative kinematic data are correlated with minimum one-year outcomes following primary TKA. METHODS. We reviewed data on 185 consecutive primary TKAs in which sensor-embedded tibial trials were used to evaluate kinematic patterns following traditional ligament balancing. Procedures were performed by two board-certified arthroplasty surgeons. The same implant design and surgical approach was used for all knees. Contact locations on the medial and lateral condyles were recorded for each patient at 0°, 45° and 90° of flexion, and full flexion. Vector equations were created by contact locations on the medial and lateral sides and the vector intersections determined the center of rotation between each measurement position. Center of rotation was calculated as the average of vector intersections at 0 to 45°, 45 to 90°, and 90° to full flexion. If the average center of rotation was between 16 and 1000 mm of the contact location on the medial side it was considered a medial pivot knee. Knees were also classified as medial (16 to 200 mm on medial side), lateral (16 to 200 mm on lateral side), translating (> 200 mm medially or laterally), and other (< 16 mm on both medial and lateral sides). The new Knee Society Scoring System (KSSO objective score, KSSS satisfaction score, KSSF function score), the EQ-5D™ Health Status Index, and the University of California Los Angeles (UCLA) Activity Level Score were measured preoperatively and at minimum one-year follow-up (average 20.4 months). RESULTS. Thirty-three TKAs were excluded to eliminate potential bias due to sensor device malfunction, atypical hardware, unresurfaced patella, surgery at a non-study hospital, or early postoperative infection, revision due to aseptic loosening, ipsilateral hip disease, and subsequent neurologic disease or death unrelated to the index TKA, resulting in a final sample size of 152 knees. Twelve (7.9%) patients were lost to follow-up, and two were excluded due to outlier values for average center of rotation. Seventy-five percent of the final sample was female. Mean age and BMI were 63.6 years 33.9, respectively. Average center of rotation ranged from −1017 to 1562 mm with negative signifying the lateral side. Medial pivot knees comprised 40% (55) of the total sample. Sex, age, height, surgeon, implant side, and implant type were unrelated to pivot classification. Patient weight (100.2 vs. 90.9 kg; p = 0.012) and BMI (35.5 vs. 32.8; p = 0.044) were greater in medial pivot knees. Controlling for BMI, KSSO, KSSF, KSSS, EQ5D, UCLA, and pain scores at latest follow-up did not differ in medial and non-medial pivot knees (p ≥ 0.151). The amount of improvement in outcomes from preoperative baseline also did not differ in medial and non-medial pivot knees (p ≥ 0.161). Outcomes did not vary among knees with translating medial, lateral, and other pivots (p ≥ 0.065). DISCUSSION. Our results suggest that a medial pivot kinematic pattern may not be a substantial governor of clinical success

Aim: The aim of the study is to present our experience in the treatment of intertrochanteric fractures in high-risk elderly patients, using regional anaesthesia, and assess the method. Material and methods: During the last 3 years, we treated 39 patients (15 men, 24 women) mean age 89.7 yrs, range 71–100 yrs, using external fixation. Three at least of the following diseases co-existed: coronary disease, hypertension, neurological disease, respiratory disease, diabetes melitus, obesity. Mean time of the procedure was 20 minutes. Results: 1) All fractures were united. 2) Pin-track infection in 9 paients.3) Four patients died during their hospitalization from pathological reasons. Conclusions: The use of external fixation in high-risk elderly patients, is a secure and reliable method of treatment. It lasts a short time with no blood loss, provides a stable osteosynthesis, and permits early mobilization and rehabilitation. A drawback of the method is the pin-track infection

Introduction. The purpose of the present study was to identify risk factors for lag-screw cut-out following osteosynthesis of intertrochanteric fractures. Materials and methods. The study was a case-control study using a sex and age matched control group. The fractures were classified according to Evans and OTA/AO classifications. Operative treatment was performed using dynamic hip-screw or cephalomedullary nailing systems. All patients were followed for at least 3–4 months postoperatively. The following risk factors were assessed: fracture type, quality of reduction by blinded assessment using a visual analogue scale, tip-apex distance (TAD) according to Baumgaertner, lag-screw positioning and other relevant additional risk factors in terms of walking ability, osteoporosis, cardio-vascular disease, neurological disease, diabetes, obesity, alcohol consumption and smoking. Results. 35 cases with lag-screw cut-out and 122 controls without cut-out, 124 women with a mean age of 84.9 (range: 51–95) years and 33 men with a mean age of 82.3 (range: 67–94) years were identified. Cut-out were significantly more frequent in OTA/AO type 31-A3 fractures (odds ratio (OR) 4.13; 95% CI: 1.50–11.36). The quality of reduction was significantly related to the risk of cut-out. The mean TAD was 26.5 mm in the case group and 21 mm in the control group. This difference was significant (chi square test p=0.046). Assessment of the lag-screw positioning showed that a central/central (OR 0.18; 95 % CI: 0.11–0.30) or central/inferior (OR 0.14; 95 % CI: 0.03–0.63) position was associated with a reduced risk for cut-out. None of the additional risk factors included in this study seemed to have any influence on the results. Conclusion. This study showed that fracture type, quality of reduction, TAD and lag-screw positioning were the most important risk factors for cut-out

Aims

Platelet-rich plasma (PRP) intra-articular injections may provide a simple and minimally invasive treatment for early-stage knee osteoarthritis (OA). This has led to an increase in its adoption as a treatment for knee OA, although there is uncertainty about its efficacy and benefit. We hypothesized that patients with early-stage symptomatic knee OA who receive multiple PRP injections will have better clinical outcomes than those receiving single PRP or placebo injections.

Osteoarthritis (OA) is a degenerative disease resulting from progressive joint destruction caused by many factors. Its pathogenesis is complex and has not been elucidated to date. Advanced glycation end products (AGEs) are a series of irreversible and stable macromolecular complexes formed by reducing sugar with protein, lipid, and nucleic acid through a non-enzymatic glycosylation reaction (Maillard reaction). They are an important indicator of the degree of ageing. Currently, it is considered that AGEs accumulation in vivo is a molecular basis of age-induced OA, and AGEs production and accumulation in vivo is one of the important reasons for the induction and acceleration of the pathological changes of OA. In recent years, it has been found that AGEs are involved in a variety of pathological processes of OA, including extracellular matrix degradation, chondrocyte apoptosis, and autophagy. Clearly, AGEs play an important role in regulating the expression of OA-related genes and maintaining the chondrocyte phenotype and the stability of the intra-articular environment. This article reviews the latest research results of AGEs in a variety of pathological processes of OA, to provide a new direction for the study of OA pathogenesis and a new target for prevention and treatment.

Cite this article: Bone Joint Res 2022;11(5):292–300.

Introduction: Patients with cerebral palsy or other neurological diseases have a high incidence of foot deformities, limiting the mobility and quality of life for these patients. We analyzed the results of surgical correction and determined the optimal treatment for the main deformities. Material and Methods: We analysed retrospectively the results of surgical correction of foot deformities. 87 Patients were treated between 1995 and 2003. We have actual data from 51 Patients (59%) with 68 feet treated. Mean follow up time is 4,25 years. We had 23 Patients with neurogenic clubfoot, 16 with flatfoot, 25 with pes equinus, 2 pes cavus and 2 hallux valgus. Of these patients 73% were able to walk before surgery. Results: For the quality of life we evaluated pain, problems while walking and problems with ulcers with a Visual Analogue Scale (0–10). Pain decreased from 4,01 to 1,58 (p< 0.001), Problems with walking improved from 6,87 to 3,31 (p< 0.001), Problems with ulcers improved from 3,79 to 1,35 (p< 0.001). Maximum walking time increased from a mean of 17 minutes to 52 minutes (p< 0.001). The level of mobility was increased in 34%. These results were the basis for the analysis of the best treatment for each deformity. For each group (neurogenic clubfoot, flatfoot and equinus) the best and poorest patients were selected and analysed. What was the diagnosis, indication for surgery, mobility and expectations of the patient before the surgery compared with the outcome. Discussion: Surgical reconstruction of neurogenic foot deformities shows very good results. Essential is a muscular balancing to achieve long lasting results. Regular physiotherapy and night orthoses can improve the outcome

Arthrogryposis multiplex congenita is believed to be a specific clinical entity which is aetiologically unrelated to the "arthrogryposis-like" deformities of known neurological diseases such as myelomeningocele and myelodysplasia. The observation that the condition appeared to be three times as common in Melbourne, Australia, as in four centres in the United Kingdom (Wynne-Davies and Lloyd-Roberts 1976), prompted this survey of 132 patients: 73 from the United Kingdom, 34 from Australia and 25 from Wilmington, Delaware, USA. The survey aimed to established the same criteria for diagnosis in the three countries and to search for prenatal and genetic aetiological factors. It was shown that all centers treated more newborn children with this disorder during the 1960s than either before or after that period. All cases were sporadic and there was no family association with talipes equinovarus, congenital dislocation of the hip or hereditary neuromuscular disease. "Environmental" findings from all three centers were similar and it was concluded that arthrogryposis multiplex cogenita is a non-genetic disease of early pregnancy, associated with a variety of unfavourable intra-uterine factors. In addition, an unknown but possibly viral environmental agent may have been present to a significant extent only during recent decades and is now declining

The correction of axial deviation of the lower limbs in paediatric patients requires complete patient history and clinical examination. The correct approach to the deformity must consider:radiology,evolution,associated joint damage, neurologic diseases and surgical planning. Timing and choice of operation (osteotomy, assimetric epiphyseal distraction, hemiepiphysodesis, epiphysiodesis) are critical. Thirty-four paediatric patients with an average age of 10 years (range 2–18) were treated with a monolateral external fixator: 16 femoral osteotomies (nine post-traumatic, four congenital, one after radiotherapy for neoplastic diesease, one Ollier’s disease, one multiple exostosis) and 18 tibial osteotomies (eight congential, four post-traumatic, two multiple exostosis, two osteogenesis imperfecta, one neoplasm, one Ollier’s disease) were performed. The knowledge of normal physiologic values, angles and anatomical and mechanical axes are fundamentally important. In choosing which operation to perfom in patients with post-traumatic deviation, the controlateral limb, functional necessity, symptoms and possible compensation must be considered. External fixation appears to be necessary in the correction of lower limb deformities because of patient comfort in the femur, because it allows osteotomy in the apex of the deformity and because it is possible to perform lengthening and correction when necessary. We suggest performing lengthening and correction osteotomy at the same level when it is possible, whereas it is dangerous to perform it at the distal metaphyseal femur and distal third of the tibia

Purpose of the study: Management of the spinal neuroarthropathy of Charcot’s disease is recommended. Vertebral fusion should be extensive and often circumferential. The natural history of this disease, often diagnosed late, is poorly understood and the results of functional treatments not well studied. The purpose of this study was to describe the elements motivating surgical abstention and to analyse the natural course of the vertebral lesions. Material and methods: The diagnosis of spinal neuroarthropathy was established in seven patients from 1997 to 2007. Six has paraplegia and one female patient Friedrich ataxia. The initial neurological disease was known for 18 years on average before diagnosis of the spinal neuroarthropathy. The management decision was based on patient motivation, comorbid conditions, and successive functional, clinical and imaging assessments. The patients were classed by the progression of vertebral destruction. Four patients had a non-evolving destruction, two with a stable spine and two with spinal hypermobility. Results: The spinal stability, the absence of progression of the spinal neuroarthropathy, and in certain cases the presence of an ossification process were determining in deciding to abstain from surgery. Despite the collapse of the trunk, surgical abstention was decided for two patients basically because of the loss of spinal mobility resulting from the arthrodesis. For three other patients with progressing spinal lesions, the presence of comorbid factors (major risk of infection), patient refusal of the risk of temporary or definitive loss of function were the reasons surgery was decided against. Discussion: According to the literature, it is assumed that abstention from surgery will invariably lead to neurological or infectious complications and even patient death. We did not observe these events in our series. The major surgery exposes to a risk of failure; certain authors have reported a complication rate of 60% and others have had 40% repeat operations. The instability induced by the spinal neuroarthropathy can be considered providential by the patient. The fact that several patients declined surgery because of the fear of worsening their handicap after arthrodesis is noteworthy. Simulation with a rigid corset was determining. The spinal neuroarthropathy does not appear to be a continuous destructive process but its natural history is not well known. Predictive elements were not identified in this study. Conclusion: Charcot’s spinal neuroarthropathy is a challenging condition in frail patients. Disease progression, comorbid conditions, and multidisciplinary functional assessments are needed for adequate management and decision making