Aims. Total hip arthroplasty (THA) in patients with post-polio residual paralysis (PPRP) is challenging. Despite relief in pain after THA, pre-existing muscle imbalance and altered gait may cause persistence of difficulty in walking. The associated soft tissue contractures not only imbalances the pelvis, but also poses the risk of dislocation, accelerated polyethylene liner wear, and early loosening. Methods. In all, ten hips in ten patients with PPRP with fixed pelvic obliquity who underwent THA as per an algorithmic approach in two centres from January 2014 to March 2018 were followed-up for a minimum of two years (2 to 6). All patients required one or more additional soft tissue procedures in a pre-determined sequence to correct the pelvic obliquity. All were invited for the latest clinical and radiological assessment. Results. The mean Harris Hip Score at the latest follow-up was 79.2 (68 to 90). There was significant improvement in the coronal pelvic obliquity from 16.6. o. (SD 7.9. o. ) to 1.8. o. (SD 2.4. o. ; p < 0.001). Radiographs of all ten hips showed stable prostheses with no signs of loosening or migration, regardless of whether paralytic or non-paralytic hip was replaced. No complications, including dislocation or infection related to the surgery, were observed in any patient. The subtrochanteric shortening osteotomy done in two patients had united by nine months. Conclusion. Simultaneous correction of soft tissue contractures is necessary for obtaining a stable hip with balanced pelvis while treating hip arthritis by THA in patients with PPRP and fixed pelvic obliquity. Cite this article: Bone Jt Open 2021;2(9):696–704

Aims. The aim of this study was to explore the prognostic factors for postoperative neurological recovery and survival in patients with complete paralysis due to neoplastic epidural spinal cord compression. Patients and Methods. The medical records of 135 patients with complete paralysis due to neoplastic cord compression were retrospectively reviewed. Potential factors including the timing of surgery, muscular tone, and tumour characteristics were analyzed in relation to neurological recovery using logistical regression analysis. The association between neurological recovery and survival was analyzed using a Cox model. A nomogram was formulated to predict recovery. Results. A total of 52 patients (38.5%) achieved American Spinal Injury Association Impairment Scale (AIS) D or E recovery postoperatively. The timing of surgery (p = 0.003) was found to be significant in univariate analysis. In multivariate analysis, surgery within one week was associated with better neurological recovery than surgery within three weeks (p = 0.002), with a trend towards being associated with a better neurological recovery than surgery within one to two weeks (p = 0.597) and two to three weeks (p = 0.055). Age (p = 0.039) and muscle tone (p = 0.018) were also significant predictors. In Cox regression analysis, good neurological recovery (p = 0.004), benign tumours (p = 0.039), and primary tumours (p = 0.005) were associated with longer survival. Calibration graphs showed that the nomogram did well with an ideal model. The bootstrap-corrected C-index for neurological recovery was 0.72. Conclusion. In patients with complete paralysis due to neoplastic spinal cord compression, whose treatment is delayed for more than 48 hours from the onset of symptoms, surgery within one week is still beneficial. Surgery undertaken at this time may still offer neurological recovery and longer survival. The identification of the association between these factors and neurological recovery may help guide treatment for these patients. Cite this article: Bone Joint J 2019;101-B:872–879

1. Forty-five cases of zoster paralysis, not involving the cranial nerves, are detailed. These include eighteen cases not previously published. Of these eighteen patients, one-third were referred for an orthopaedic opinion. 2. Complete or almost full recovery occurred within a year in two-thirds of the patients. Permanent paralysis occurred in one-sixth of the patients studied. 3. Muscles that failed to recover were mainly or wholly supplied from single segments of the spinal cord; so the prognosis must be guarded in those cases in which such muscles are completely paralysed. 4. Various phenomena occurring in zoster paralysis are discussed

We report the case of an eight-month-old girl who presented with a poliomyelitis-like paralysis in her left upper limb caused by enterovirus 71 infection. She recovered useful function after nerve transfers performed six months after the onset of paralysis. Early neurotisation can be used successfully in the treatment of poliomyelitis-like paralysis in children

1. The distribution of the permanent paresis and paralysis in the muscles of 203 lower limbs affected by poliomyelitis is analysed and related to the destruction of motor nerve cells in the grey matter of the lumbo-sacral cord. 2. The tibialis anterior and tibialis posterior and the long muscles of the toes are more often paralysed than paretic; these muscles are innervated by short motor cell columns. Muscles such as the hip flexors and hip adductors that are more often paretic than paralysed are innervated by long cell columns. 3. Muscles innervated by the upper lumbar spinal segments are more frequently affected than those innervated by the sarcal segments. This agrees with the segmental incidence of motor cell destruction found in poliomyelitic spinal cords. 4. Each muscle or muscle group is associated in paralysis with other specific muscles. For instance, the long toe extensors with the peronei and the calf muscles (triceps surae) with the biceps femoris. Associated muscles are innervated by adjacent motor cell columns. The probability of recovery in a paralysed muscle can be determined by reference to the degree of involvement in its associated muscles. 5. The distribution of the paralysis in an individual lower limb is determined by the site and size of foci of motor cell destruction. The cell loss in certain common patterns of paralysis is described. 6. The practical application of these findings is discussed

1. Ten patients with neurological evidence of damage to the intrathecal sacral nerve roots of the cauda equina by verified lumbar disc prolapse are described. 2. The nature of the bladder paralysis has been investigated by cystometry and the findings contrasted with published opinions. 3. The prognosis of the bladder paralysis has been established by review up to six years after removal of the disc prolapse. No evidence of recovery of complete bladder paralysis has been found, but the consequences of persistent bladder paralysis have been much less severe than previous reports have stated. Reasons have been suggested for this. 4. Principles of recognition and management of bladder paralysis due to cauda equina lesions have been stated and methods suggested

Purpose: The serratus anterior, innervated by the Charles Bell nerve, contributes to dynamic abduction and elevation of the shoulder by stabilising the scapula on the thorax. Abduction and elevation beyond 90° or movement of the spinal border of the scapula is impossible in case of serratus anterior paralysis. Material and methods: This series included 16 patients with traumatic damage to the Charles Bell nerve leading to unique paralysis of the serratus anterior. Mean age of the patients at diagnosis was 27.5 years. Nine patients underwent scapulothoracic arthrodesis or scapulopexia and seven patients were not operated due to spontaneous total or partial recovery. Results: Initial elevation in the non operated group was 125°. At five years elevation was 145°, Constant score was 85, and shoulder abduction force was 12 kg (83% of the contralateral force). Final outcome was very good in four patients, good in one, fair in one and poor in one (the fair and poor outcomes involved severe pain for one and major loss of force for the other). Preoperative elevation in the operated group was 95°, reaching 104° at last follow-up. At four years, elevation was 104°, Constant score was 75, and shoulder abduction force was 9 kg (72% of the contralateral force). One case of infection required revision and healed satisfactorily. Outcome was very good in six patients and good in three. Discussion: Several types of treatment can be proposed: non-surgical care, muscle transfer basically with the pectoralis major, and scapulothoracic arthrodesis. The principal series reported in the literature on scapulothoracic arthrodesis concern patients with fascioscapulohumeral dystrophy and are not comparable with our series. It would be possible to compare our patients with series of post-trauma paralysis using muscle transfer which have given good results for mobility but limited improvement in global muscle force. In our patients, scapulothoracic arthrodesis gave good results in terms of muscle force, pain and overall shoulder function; mobility was fixed by the position of the scapula in the arthrodesis. We advocate this method for the treatment of serratus anterior paralysis mainly in manual labourers

We have reviewed 26 patients treated by trapezius transfer for deltoid paralysis due to brachial plexus injury or old poliomyelitis. We assessed the power of shoulder abduction and the tendency for subluxation. There were good results in 16 patients (60%); five were fair and five poor. Trapezius transfer appears to give reasonable results in the salvage of abductor paralysis of the shoulder

Purpose: Radial paralysis is a major complication of humeral shaft fractures. In most cases, the paralysis is regressive but in certain patients surgical repair is required to achieve full neurological recovery. We reviewed retrospectively our patients to determine the causes of non-recovery and evaluate the efficacy of different treatments. Material and methods: Thirty patients were operated between 1990 and 1997 for radial nerve paralysis that was observed immediately after trauma or developed secondarily. Mean follow-up after surgery was 6.3 years. There were 22 men and 8 women, 16 right side and 14 left side. Mean delay from injury to surgery was four months (0–730 days). Elements that could be involved in radial paralysis were noted: type of fracture, level of the fracture, treatment, approach, material used. There were ten cases with non-union. Neurological recovery at three years was assessed with muscle tests and with the Alnot criteria. An electrical recording was also made in certain patients. Surgery involved neurolysis in 23 cases, nerve grafts in five and tendon transfers in two. Results: Outcome was very good and good in 22 patients, good in one and could not be evaluated in one (tendon transfer). There were three failures (two neurolysis and one graft) and two patients were lost to follow-up. After neurolysis, mean delay to recovery was seven months; it was 15 months after nerve grafts. Recovery always occurred proximally to distally. Discussion: Radial paralysis after femoral shaft fracture regresses spontaneously in 76% to 89% of the cases, depending on the series. There is a predominance in the 20 to 30 year age range. Several factors could be involved in radial paralysis (fracture of the distal third of the humerus, spiral fracture, plate fixation, nonunion). The anterolateral approach allows a better exposure of the nerve. Unlike other authors, we do no advocate exploration of the injured nerve during surgical treatment of the fracture because it is most difficult to determine the potential for recovery of a continuous nerve. Conclusion: The risk of radial nerve paralysis is greatest for spiral fracture of the distal third of the humerus. In such cases, it may be useful to explore the nerve during the primary procedure and insert a plate. For other cases, we prefer to wait for spontaneous nerve recovery. If reinnervation is not observed at 100 days, we undertake exploration

Purpose: Functional outcome after shoulder arthrodesis was evaluated to assess indications for the treatment of posttraumatic partial and total brachial plexus paralysis in adults. Material and methods: Twenty-seven patients who underwent glenohumeral arthrodesis for posttraumatic brachial plexus paralysis were reviewed. Eleven had radicular paralysis (C5, C6 and C5, C6, C7) and sixteen total paralysis. All patients recovered active elbow flexion. Shoulder reinnervation had failed in eleven patients. Before the arthrodesis, 22 patients could no use their paralysed limb. Mean time between direct neurological surgery and arthrodesis was 30 months for partial paralyses and 20 months for total paralyses. Glenohumeal screw fixation was used for the arthrodesis which was associated with an external fixation in 21. Results: Mean postoperative follow-up was 70 months. There were two cases of non-union which fused after revision and three cases of humerus fracture which occurred during the first six months after surgery. Pain related to inferior subluxation improved in six patients. There was no significant difference between the two groups for position of the fusion, or postoperative active motion (60° flexion, 60° abduction, 45° internal rotation and 7 to −9° external rotation). There was a significant difference in force which was greater for superior paralyses (11 kgf versus 7 kgf in flexion, 12 kfg versus 7 kgf in abduction, 6 kgf versus 2 kgf in external rotation and 11 kgf versus 4 kgf in internal rotation). The same was true for hand movement. The differences were statistically correlated with force of the pectoralis major. Conclusion: Glenohumeral arthrodesis provides significant improvement in function in patients with supraclavicular brachial plexus paralysis, even with a paralytic hand. Arthrodesis also allows reorienting surgical reinnervation to other functions such as hand movement. Shoulder force and hand movement are directly correlated with force of the pectoralis major

We treated 31 patients with non-traumatic paralysis of the posterior interosseous nerve over 15 years. There were 10 men and 21 women of mean age 40.3 years (17 to 71). Six were managed conservatively, and 25 by operation. In 14 patients entrapment occurred at the supinator, including three who had double compression at both the entrance and exit from the muscle. In four it was caused by a ganglion, in one by a lipoma, in one by a dislocated radial head and in two by a marked constriction in the nerve of unknown cause. The remaining three patients were retrospectively diagnosed as having neuralgic amyotrophy, the only observable change at operation being slight oedema of the nerve. Paralysis recovered in 24 out of the 25 patients at between 2 to 18 months (mean 5.6) after operation, and the one failure was treated later by tendon transfer

1 . A case is described in which complete transposition of the latissimus dorsi muscle with its neurovascular pedicle was performed to compensate for complete paralysis of the triceps and partial paralysis of the posterior part of the deltoid muscle. 2. Muscle necrosis did not occur to any significant degree. 3. Strong substitute triceps function was achieved

We have reported that most of lower cervical cord injury patients had either improved or remained the same neurology following early operative stabilization done in our hospital. However, a few patients deteriorated with ascending paralysis in acute stage. Purpose of this paper is to present such cases and discuss the outcomes. Methods: 1) We have analyzed 10 pts of acute lower cervical cord injury who had deteriorated neurologic symptom ascending above C4 and complicated with respiratory quadriplegia. They accounted for 3.7 % out of 271 patients with bony injury. 2) They were 8 males and 2 females, aged 17~76, injury type C5/6 fracture-dislocation (Fx/Dx) in 4, C6/7 Fx/Dx in 4, C7/T1 in 1, and one C5 flexion tear drop Fx. 3) 2 patients were treated conservatively and 8 had operative reduction and fusion with careful technique. Results: 1) All patients had complete quadriplegia. 2) 3 pts could not wean out of ventilator and other 2 of them eventually died. 3) Paralysis started to ascend in 3 days after injury needed ventilator in 24 hours thereafter. 4) 2 out of 10 patients underwent an excessive distraction being treated conservatively. 8 patients had operative fixation for bony injuries, 7 of them obtained solid spine with single operation, but one had redislocated in a few days after the operation and received restabilisation surgery. Conclusion: 1) There are a few patients of acute lower cervical injury with complete quadriplegia deteriorated neurology ascending paralysis with respiratory distress. 2) Comparing to other cases an operative treatment would not a cause of such neurologic deterioration. 3) In most cases paralysis of diaphragm was passing symptom, but quite a few patients(1%) could not wean off ventilator. 4) Cause of ascending paralysis in such injury could not be identified definitely, therefore careful observation and prompt treatment such as tracheotomy should be recommended

Spinal accessory nerve palsy leads to painful disability of the shoulder, carrying an uncertain prognosis. We reviewed the long-term outcome in 16 patients who were treated for pain, weakness of active elevation and asymmetry of the shoulder and the neck due to chronic paralysis of the trapezius muscle, as a result of nerve palsy. Of four patients who were treated conservatively, none regained satisfactory function, although two became pain-free. The other 12 patients were treated operatively with transfer of the levator scapulae to the acromion and the rhomboid muscles to the infraspinatus fossa (the Eden-Lange procedure). At a mean follow-up of 32 years, the clinical outcome of the operatively treated patients was excellent in nine, fair in two, and poor in one patient, as determined by the Constant score. Pain was adequately relieved in 11 and overhead function was restored in nine patients. Pre-operative electromyography had been carried out in four patients. In two, who eventually had a poor outcome, a concomitant long thoracic and dorsal scapular nerve lesion had been present. The Eden-Lange procedure gives very satisfactory long-term results for the treatment of isolated paralysis of trapezius. In the presence of an additional serratus anterior palsy or weak rhomboid muscles, the procedure is less successful in restoring shoulder function

After brachial plexus injuries, and other forms of paralysis of the upper limb, even when residual paralysis is very grave indeed, and even when the limb is almost flail—a forearm which can project forwards by the construction of a bone-block behind the elbow, with arthrodesis of the shoulder when necessary; a hand with fingers in the form of a claw and a thumb which opposes them; and a wrist which may perhaps be arthrodesed, but which still better can flex or extend when the forearm is pronated or supinated; together with the wise use of such muscles as are likely to gain function; may enable a patient to do very much more than he can with an artificial limb

1. The arcade of Frohse, a fibrous arch over the posterior interosseous nerve, may well play a part in causing progressive paralysis of the posterior interosseous nerve, both with and without injury. 2. Paralysis of the muscles supplied by this nerve with no evidence of recovery after six weeks, either electromyographic or clinical, should be treated by exploration and splitting of the arcade of Frohse

Background: Paralysis of the crural nerve secondary to a compressive haematoma of the psoas in the pelvis is a well-known complication of anticoagulant therapy. This complication has also been described after hip or pelvic surgery. Its occurrence in a context of trauma is exceptional. Case report: A 16-year-old female adolescent sought emergency care for total deficit of knee extension. The patient had an enlarged painful knee subsequent to a skateboard fall. She reported knee trauma involving the patella and a direct shock to the homolateral hip, on the trochanter. Physical examination confirmed the knee and hip pain. Rest was advised. One and a half month after the accident, the patient again consulted for total deficit of active knee extension. The initial diagnosis suggested was posttraumatic rupture of the patellar tendon. An emergency MRI was normal, ruling out this diagnosis. More attentive physical examination revealed the presence of a complete paralysis of the quadriceps muscle by crural nerve palsy. MRI of the pelvic region revealed the presence of a voluminous haematoma of the psoas compressing the crural nerve. Emergency evacuation of the haematoma was performed. The patient underwent rehabilitation for one year and achieved progressive and complete recovery of the quadriceps function. An electromyogram obtained at one year was normal. Conclusion: This was an exceptional case of crural nerve palsy secondary to a posttraumatic haematoma of the psoas, with no notion of anticoagulation therapy. The initial knee injury was misinterpreted as involving a local patellar problem but in reality had caused a paralysis of the quadriceps muscle. MRI provided the diagnosis of psoas haematoma

Three patients referred for rehabilitation of brachial plexus lesions and two referred with leg weakness associated with sciatica were found to have conversion paralysis. The diagnosis was made by demonstrating normal motor nerve conduction to the clinically weak muscles. The weakness was treated by intensive physical rehabilitation with complete and sustained recovery in all cases

1. Sixteen cases of thenar paralysis are reviewed in which a bone graft was inserted between the first and second metacarpals to maintain fixed abduction and opposition of the thumb. 2. The technique of the operation is described and the causes of failure are discussed. 3. The operation is intended for those cases in which tendon transplantation to restore active opposition of the thumb is unsuitable. Rotation of the first metacarpal into full opposition is the most important feature of the operation

We report six patients with isolated paralysis of the infraspinatus and discuss the diagnosis, pathology, treatment, and outcome over a mean follow-up period of 33 months. Four patients were shown to have space-occupying lesions at the spinoglenoid notch by MRI or ultrasonography or both, and ganglia were confirmed and removed surgically in three, with good results. Ganglia at this site are not uncommon and should be included in the differential diagnosis of patients presenting with shoulder pain and weakness