Introduction. High-volume image guided injections (HVIGI) followed by structured rehabilitation have been shown to be effective in various musculoskeletal conditions including Achilles tendinopathy and shoulder impingement syndrome. The aim was to explore the effect of a HVIGI in Hoffa's fat pad impingement, a common cause of anterior knee pain. Materials and Methods. 100 consecutive subjects who received a HVIGI followed by a standardised physiotherapy rehabilitation regime for Hoffa's fat pad impingement (diagnosed using clinical history, examination and magnetic resonance imaging) at one specialist MSK centre were sent a follow-up questionnaire. The questionnaire collected demographics, symptom length and the percentage improvement in symptoms following the HVIGI. All had received HVIGI consisting of 10ml of 0.5% Marcaine and 50mg of hydrocortisone followed by a structured rehabilitation programme with a focus on lower limb alignment control, flexibility, hip and knee strengthening in line with best practice. Data was analysed using SPSS version 20 at this interim stage; data collection is continuing. Results. The response rate at this point is currently 28%. Of the twenty-six subjects (9 female; 19 male; average age 37.8 ± 13.4) who completed the questionnaire 82% had had anterior knee pain symptoms for >6 months prior to receiving a HVIGI. The average percentage improvement in anterior knee pain was 45 ± 36.5% (range 0–100%). 48% of subjects reported a >6 month improvement in symptoms. No adverse effects were reported and no subject required anytime off work. Discussion. HVIGI with a structured rehabilitation programme should be considered in the short term management of Hoffa's fat pad impingement. Future research should be prospective, to improve the response rate, and consider longer term outcomes

In patients with developmental dysplasia of the hip (DDH) chronic joint dislocation induces remodeling of the soft tissue with contractures, muscle atrophy, especially of the hip abductors muscles, leading to severe motor dysfunction, pain and disability (1). The aim pf the present work is to explore if a correct positioning of the prosthetic implants through 3D skeletal modeling surgical planning technologies and an adequate customized rehabilitation can be beneficial for patients with DDH in improving functional performance. The project included two branches: a methodology branch of software development for the muscular efficiency calculation, which was inserted in the Hip-Op surgical planning system (2), developed at IOR to allow surgical planning for patients with complex hip joint impairment; and a clinical branch which involved the use of the developed software as part of a clinical multicentric randomized trial. 50 patients with DDH were randomized in two groups: a simple surgical planning group and an advanced surgical planning with muscular study group. The latter followed a customized rehabilitation program for the strenghtening of hip abductor muscles. All patients were assessed before surgery (T0) and at 3 (T1) and 6 months (T2) postoperatively using clinical outcome (WOMAC, HHS, ROM, MMT, SF12, 10mt WT) and instrumental measures (Dynamometric MT). Pre- and post-operative musculoskeletal parameters obtained by the software (i.e., leg length discrepancy, hip abductor muscle lengths and lever arms) using Hip-Op during the surgical planning were considered. One Way ANOVA for ROM measurement showed a significant improvement at T2 in patients included in experimental group, as well as WOMAC, HHS and SF12 score. The Dynamometric MT score showed significant differences between at T2 (p<0.009). Spearman's rank correlation coefficients showed a significant correlation between both pre- and post-operative abductors lever arm (mm) and hip abductor muscle strength at T2 (ρ = −0.55 pre-op and ρ = −0.51 post-op, p p<0.012 and p<0.02 respectively) and between the operated pre-postoperative leg length variation (mm) and the hip abductor muscle strength (ρ = −0.55, p p<0.013). Results so far obtained showed an improvement of functional outcomes in patients undergoing hip replacement surgery who followed therapeutic diagnostic pathway sincluding a preoperative planning including the assessment of the abductiors lever arm and a dedicated rehabilitation program for the strenghtening of abductios. Particularly interesting is the inverse relationship between the strength of the hip abductor muscles and the variation of the postoperative abductor lever arm

The establishment of a suitable animal model of repair of the rotator cuff is difficult since the presence of a true rotator cuff anatomically appears to be restricted almost exclusively to advanced primates. Our observational study describes the healing process after repair of the cuff in a primate model. Lesions were prepared and repaired in eight ‘middle-aged’ baboons. Two each were killed at four, eight, 12 and 15 weeks post-operatively. The bone-tendon repair zones were assessed macroscopically and histologically. Healing of the baboon supraspinatus involved a sequence of stages resulting in the reestablishment of the bone-tendon junction. It was not uniform and occurred more rapidly at the sites of suture fixation than between them. Four weeks after repair the bone-tendon healing was immature. Whereas macroscopically the repair appeared to be healed at eight weeks, the Sharpey fibres holding the repair together did not appear in any considerable number before 12 weeks. By 15 weeks, the bone-tendon junction was almost, but not quite mature. Our results support the use of a post-operative rehabilitation programme in man which protects the surgical repair for at least 12 to 15 weeks in order to allow maturation of tendon-to-bone healing

Ankle lateral ligament complex injury is common. Traditional ‘Brostrum’ repair, performed either open or arthroscopically, still has a protracted post-operative period. The ‘Internal Brace’ provides a scaffold for the ligament repair and acts as a ‘check-rein’ preventing further injury. 16 patients with ankle instability and injury to the Anterior-Talo-Fibular-Ligament (ATFL) confirmed on MRI were identified. All had completed a period of conservative treatment. All had symptoms of pain in the region of the ATFL and described a feeling of instability. Surgery was performed under general anaesthetic and regional popliteal block. Anterior ankle arthroscopy demonstrated a positive ‘drive through’ in all cases. The ATFL was absent and in the majority replaced by incompetent scar. Scar tissue was removed from the anterior aspect of the ankle allowing visualisation of the fibula and lateral talar neck. Using the Internal Brace system (Arthrex), a 3.5mm swivel-lock with fibre-tape was placed into the fibula. With the ankle in plantar flexion, to allow appropriate tensioning, the distal end of the fibre-tape was secured to the talar neck, at a 45 degree angle, with a 4.75mm biotenodesis screw. The patient was placed into a moon-boot for 7–10 days and mobilised fully weight-bearing. Pre-op score, using EDQ-5, MOXFQ, AOFAS and visual analogue scores, with post-op PROMS were performed. All patients reported improvement in their symptoms at 6 week visit. The majority were back to normal activities at 12 weeks. The few that were not, had missed physiotherapy appointments for various reasons. There were no infections and no implant failures. Arthroscopy allows direct visualisation for accurate placement of the Internal Brace. Post-operatively recovery is expedited due to the stability provided by the ‘Brace’, permitting a more aggressive rehabilitation programme. The greatest potential is arguably for the elite athlete, where an accelerated return to full activity has significant occupational implications

Biomechanical interpretations of bone adaptation in biological reconstructions following bone tumors would be crucial for orthopedic oncologists, particularly if based on quantitative observations. This would help to plan for surgical treatments, rehabilitative programs and communication with the patients. In particular, outcomes of the Capanna technique, which combines bone allograft and vascularized fibula autograft, lead to stable and durable reconstructions [1, 2], and different remodeling patterns have been described [3] as a response to mechanical loading. However, there are several events that are not understood and require a biomechanical interpretation, as the evolution patterns can evolve towards conditions that threaten the strength of the reconstruction. We aimed to (i) analyze the biomechanical adaptation of a femoral reconstruction after Ewing sarcoma, in terms of morphological and densitometric evolution of bone from CT data, internal loads acting on the bone during movement, mechanical competence of the reconstruction, and (ii) relate in-progress bone resorption to the mechanical stimulus induced by different motor activities. Eight CT datasets of a patient (8 yrs at surgery using the Capanna technique) during 76-month follow-up were available. The evolution of bone morphology, density and moments of inertia was quantified. At the last control, the patient underwent gait analysis (walking, chair rise/sit, stair ascent/descent, squat). We created a multiscale musculoskeletal and finite element model from CT scans and motion analysis data at the end of follow-up, using state-of-the-art modeling workflows [4, 5], to analyze muscle and joint loads, and to compare the mechanical competence of the reconstructed bone with the contralateral limb, in the current real condition and in a possible revision surgery that removed proximal screws. Although there were no reconstruction complications and osteo-fusion with intense remodeling between allograft and autograft was shown, there was a progressive decrease in allograft cortical thickness and density. There were strategies of muscle coordination that led to differences in joint loads between limbs more marked in more demanding motor activities, and generally larger in the contralateral limb. The operated femur presented a markedly low ratio of physiological strain due to load-sharing with the metal implant, particularly in the lateral aspect. A possible revision surgery removing the three most proximal screws would help restore a physiological strain configuration, while the safety of the reconstruction would not be threatened. We suggest that bone resorption is related to load-sharing and to the internal forces exerted during movement, and the mechanical stimulus should be improved by adopting modifications in the surgical treatment and by promoting physical therapy aimed at specific muscle strengthening

We have studied patients with Joint Hypermobility Syndrome (JHS) admitted to the Royal National Orthopaedic Hospital (RNOH) for a three-week in-patient rehabilitation programme. Ten patients were investigated at the start and end of this programme, and so far eight patients have been followed up at three months review. Postural stability was measured using a force plate, and the path of the centre of force (CoF) was tracked while patients were asked to attempt a series of more challenging tasks: double leg stance with eyes open and then with eyes closed, followed by single leg stance with eyes open and closed. Patients also completed a number of questionnaires at the same time points. We found the results of the double stance eyes closed test of postural stability to be the most informative. The ellipse area (EA) containing 95% of the points of the path of the CoF decreased from 21.5 + 14.8 cm2 to 9.0 + 11.5 cm2 over the course of the in-patient programme. In the eight patients followed up at three months, EA has remained the same (9.6 + 14.6 cm2). We conclude that the effects of the exercise programme and advice on subsequent exercise can be maintained over three months

Rehabilitation systems based on inertial measurement units (IMU) and bio-feedbacks are increasingly used in many different settings for patients with neurological disorders such as Parkinson disease or balance impairment, and more recently for functional recover after orthopedic surgical interventions or injuries especially concerning the lower limb. These systems claim to provide a more controlled and correct execution of the motion exercises to be performed within the rehabilitation programs, hopefully resulting in a better outcomes with respect to the traditional direct support of a physical therapists. In particular recruitment of specific muscles during the exercise is expression of its correct and finalized execution. The objective of this study was to compare muscular activation patterns of relevant lower limb muscles during different exercises performed with traditional rehabilitation and with a new validated system based on IMU and biofeedback (Riablo, Corehab, Trento, Italy). Twelve healthy subjects (mean age 28.1 ± 3.9, BMI 21.8± 2.1) were evaluated in a rehabilitation center. Muscular activation pattern of gluteus maximum, gluteus medium, rectus femoris and biceps femoris was recorded through surface EMG (Cometa; Milan) during six different motion tasks: hip abduction in standing position, lunge, hip flexion with extended knee in standing position, lateral lunge, hip abduction with extended knee in lateral decubitus, squat. Subjects performed 10 repetitions of each task for a total of 100 repetitions per motion task, with and without Riablo System as well as during standard rehabilitation. An additional IMU was positioned on the shank in order to detect beginning and end of each repetition. A single threshold algorithm was used to identify muscle activation timing. During hip abduction in standing position, gluteus maximum and rectus femoris showed a better and longer activation pattern while using Riablo compared to traditional rehabilitation. Gluteus medium showed a similar activation pattern whereas biceps femoris showed no activation from 30% to 80% using Riablo. During squat, rectus femoris and biceps femoris had a similar activation pattern with and without Riablo whereas gluteus maximum and gluteus medium showed a better activation pattern while using Riablo. The recent development of innovative rehabilitation systems meets the need of manageable, reliable and efficient instruments able to reduce rehabilitation costs but with the same good clinical outcomes. Muscular activation patterns of relevant lower limb muscles during selected motion tasks reveal their correct execution. The use of this new rehabilitation system based on IMU and biofeedback seems to allow a more selective and effective muscular recruitment, likely due to the more correct and controlled execution of the exercise, particularly for the identification and interdiction of possible compensation mechanisms

Introduction. Numerous risk factors have been identified for patellar tendinopathy (PT), often in small population studies. The aim was to use an online questionnaire internationally to generate a large database and identify significant risk factors. Materials and Methods. Subjects were recruited from England, Spain and Italy with the questionnaire available in all three languages, with the questionnaire previously having been validated by Morton et al. (2014) as to be suitable for self-administration. The questionnaire can be viewed at: . http://patellartendinopathyquestionnaire.blogspot.co.uk/. (English), . http://tendinopatiarotuliana.blogspot.co.uk/. (Spanish) and . http://tendinopatiarotulea.blogspot.co.uk/. (Italian). All data was anonymised and password protected. 825 data sets were collected with 23.4% having clinically diagnosed PT. Results. Eight risk factors were included in the analysis based on a purposeful selection procedure: gender, hours of training, hamstring flexibility, previous patellar tendon rupture, previous knee injury, current/previous back pain, family history and age. To be female was found to be positively associated with PT, suggesting being female is protective (odds ratio (OR) = 0.70, 95% CI: 0.49–1.00, p=0.05). As hours of training increased the association with PT became stronger so that training >20 hours a week had a very significant OR of 8.94 (95%CI: 4.68–17.08, p<0.05), the most significant OR calculated. There was an association between a previous knee injury and PT (OR=2.10, 95% CI: 1.45–3.04, p<0.05) and having self-reported flexible hamstrings suggested some protection from PT (OR=0.61, 95% CI0.38–0.97, p=0.04). There was a trend towards association for back pain (OR=1.45, 95% CI: 0.99–2.14, p=0.06) and a family history of tendon problems (OR=1.51, 95% CI: 0.96–2.37, p=0.08). Discussion. Risk factors have been identified that are potentially modifiable in order to inform prevention and rehabilitation programmes; future research is required to establish causal relationships. Certain risk factors require investigation as they are not currently recognised in the literature

Knee ligament injury is one of the most frequent sport injuries and ligament reconstruction has been used to restore the structural stability of the joint. Cycling exercises have been shown to be safe for anterior cruciate ligament (ACL) reconstruction and are thus often prescribed in the rehabilitation of patients after ligament reconstruction. However, whether it is safe for posterior cruciate ligament (PCL) reconstruction remains unclear. Considering the structural roles of the PCL, backward cycling may be more suitable for rehabilitation in PCL reconstruction. However, no study has documented the differences in the effects on the knee kinematics between forward and backward pedaling. Therefore, the current study aimed to measure and compare the arthrokinematics of the tibiofemoral joint between forward and backward pedaling using a biplane fluoroscope-to- computed tomography (CT) registration method. Eight healthy young adults participated in the current study with informed written consent. Each subject performed forward and backward pedaling with an average resistance of 20 Nm, while the motion of the left knee was monitored simultaneously by a biplane fluoroscope (ALLURA XPER FD, Philips) at 30 fps and a 14-camera stereophotogrammetry system (Vicon, OMG, UK) at 120 Hz. Before the motion experiment, the knee was CT and magnetic resonance scanned, which enabled the reconstruction of the bones and articular cartilage. The bone models were registered to the fluoroscopic images using a volumetric model-based fluoroscopy-to-CT registration method, giving the 3-D poses of the bones. The bone poses were then used to calculate the rigid-body kinematics of the joint and the arthrokinematics of the articular cartilage. In this study, the top dead center of the crank was defined as 0° so forward pedaling sequence would begin from 0° to 360°. Compared with forward pedaling, for crank angles from 0° to 180°, backward pedaling showed significantly more tibial external rotation. Moreover, both the joint center and contact positions in the lateral compartment were more anterior while the contact positions in the medial compartment was more posterior, during backward pedaling. For crank angles from 180° to 360°, the above-observed phenomena were generally reversed, except for the anterior-posterior component of the contact positions in the medial compartment. Forward and backward pedaling displayed significant differences in the internal/external rotations while the rotations in the sagittal and frontal planes were similar. Compared with forward cycling, the greater tibial external rotation for crank angles from 0° to 180° during backward pedaling appeared to be the main reason for the more anterior contact positions in the lateral compartment and more posterior contact positions in the medial compartment. Even though knee angular motions during forward and backward pedaling were largely similar in the sagittal and frontal planes, significant differences existed in the other components with different contact patterns. The current results suggest that different pedaling direction may be used in rehabilitation programs for better treatment outcome in future clinical applications

Anterior cruciate ligament deficiency (ACLD) affects the performance of walking in some patients (non-copers) while copers are able to minimize the effects via proper musculoskeletal compensations. Since many daily activities are more challenging than level walking, e.g., obstacle-crossing, it is not clear whether copers are able to cope with such a challenging task. A successful and safe obstacle-crossing requires not only sufficient foot clearance of the swing limb, but also the stability of the body provided mainly by the stance limb. Failure to meet these demands may lead to falls owing to loss of balance or tripping over obstacles. The purpose of the current study was to identify the motor deficits and/or biomechanical strategies in coper and non-coper ACLD patients when crossing obstacles of different heights for a better function assessment. Ten coper and ten non-coper ACLD patients were recruited in the current study. The non-coper ACLD subjects were those who had not been able to return to their pre-injury level activities, had at least once giving way during the last six months and their Lysholm knee scale was less than 70 [1]. Each subject walked and crossed obstacles of heights of 10%, 20% and 30% of their leg lengths at a self-selected pace. Kinematic and kinetic data were measured with a 7-camera motion analysis system (Vicon, Oxford Metrics, U.K.) and two force plates (AMTI, U.S.A.). The leading and trailing toe clearances were calculated as the vertical distances between the toe markers and the obstacle when the toe was directly above the obstacle. Joint angles of both limbs, and joint moments of the stance limb, were calculated. Peak extensor moments at the knee during stance phase and the corresponding joint angles were extracted for statistical analysis. A 3 by 2, 2-way mixed-model analysis of variance with one between-subject factor (group) and one within-subject factor (obstacle height) was performed (α=0.05). SAS version 9.2 was used for all statistical analysis. Compared with the copers, significantly reduced leading and trailing toe clearances were found in the non-coper group (P<0.05). The non-copers showed significantly decreased peak extensor moments (P<0.05) and flexion angle at the affected knee during the stance phase before leading limb crossing (P<0.05). Distinctive gait patterns were identified in coper and non-coper patients with unilateral anterior cruciate ligament deficiency during obstacle crossing. During the stance phase before the un-affected leading limb crossing, the non-copers showed significantly reduced flexion and peak extensor moments at the affected knee (i.e., quadriceps avoidance), primarily owing to the impaired stability at the affected knee. The significantly reduced leading and trailing toe clearances in the non-coper group indicate that the non-coper ACLD patients are at a higher risk of tripping over the obstacle, and may have difficulty in regaining balance owing to the unstable ACLD knee. Advanced rehabilitation program or reconstruction of the ACL is suggested for the non-coper group

Introduction. This study sought to determine whether the functional outcome of two common spinal operations could be improved by a programme of post-operative rehabilitation and/or an educational booklet each compared with usual care. Methods. This was a multi-centre, factorial, randomised controlled trial on the post operative management of spinal surgery patients, with randomisation stratified by surgeon and operative procedure. The study compared the effectiveness of a rehabilitation programme and an education booklet for the postoperative management of patients undergoing discectomy or lateral nerve root decompression surgery, each compared with “usual care” using a 2 × 2 factorial design, randomising patient to four groups; rehabilitation-only, booklet-only, rehabilitation-plus-booklet, and usual care only. The primary outcome measure was the Oswestry Disability Index (ODI) at 12 months, with secondary outcomes including visual analogue scale measures of back and leg pain. An economic analysis was also performed. Results. 338 patients were recruited into the study with outcomes preformed pre-operatively, and postoperatively at 6 weeks, 3, 6, 9 and 12 months post-operatively. At the one year review the effect of rehabilitation on ODI was −2.7 (95% CI −6.8 to 1.5) and the effect of booklet was 2.7 (95% CI −1.5 to 6.9). There were no significant differences in costs or outcomes associated with either intervention and neither intervention was cost-effective. Discussion. This study found that neither intervention had a significant impact on long term outcome or cost. There was some evidence to suggest that the impact of the interventions was different between patients undergoing discectomy and those having spinal decompression. Conflicts of Interest. None. Source of Funding. Arthritis Research UK. Previously presented at International Society for the Study of the Lumbar Spine 2011

Introduction. Autologous chondrocyte implantation (ACI) is contra-indicated in a joint rendered unstable by a ruptured anterior cruciate ligament (ACL). We present our experience of ACI repair with ACL reconstruction. Methods. Patients underwent arthroscopic examination and cartilage harvesting of the knee. A second operation was undertaken approximately six weeks later to repair the ruptured ACL with hamstring graft or Bone patella-Bone (BPB) and to implant the chondrocytes via formal arthrotomy. Three groups were assessed: Group 1: Simultaneous ACL Reconstruction and ACI; Group 2: Previous ACL Reconstruction with subsequent ACI repair; Group 3: Previously proven partial or complete ACL rupture, deemed stable and not treated with reconstruction with ACI procedure subsequently. Patients then underwent a graduated rehabilitation program and were reviewed using three functional measurements: Bentley functional scale, the modified Cincinnati rating system, and pain measured on a visual analogue scale. All patients also underwent formal clinical examination at review. Results. Those who underwent simultaneous ACL Reconstruction and ACI had a 47% improvement in Bentley functional scale, 36% improvement in visual analogue score and 38% improvement in the modified Cincinnati rating system. This is in contrast to only a 15% improvement in the modified Cincinnati rating system, 30% improvement in Bentley functional scale, and 32% improvement in visual analogue score in patients who had ACI repair after previous ACL reconstruction. 68% of patients who had the procedures simultaneously rated their outcome as excellent/good and 27% felt it was a failure. In contrast 38% of patients rated their outcome as a failure if they had ACI repair without reconstruction of ACL rupture. Conclusion. Symptomatic cartilage defects and ACL deficiency may co-exist in many patients and represent a treatment challenge. Our results suggest that a combined ACL and ACI repair is a viable option in this group of patients and should reduce the anaesthetic and operative risks of a two-stage repair. Patients with complete rupture of ACL despite being deemed stable performed poorly at review and our study suggests all complete ruptures regardless of stability should be treated with a reconstruction when performing an autologous chondrocyte implantation

Aim. To identify differences in hip muscle strength, knee valgus during a single leg squat (SLS),and function between subjects with Greater Trochanter Pain Syndrome (GTPS) and healthy(H) subjects. To determine associations between pain, function, hip strength and SLS in GPTS subjects. Study Design: Observational study of 14 (3 male 11 female) PFP patients (mean symptom duration 17 months), matched for age height and weight with 14 healthy (H) subjects, All subjects fulfilled specific inclusion and exclusion criteria. Appropriate Ethical approval was obtained. Measures for both groups were Knee valgus angle during SLS using 2D motion capture and SiliconCoach software for measurement of knee valgus angles, hip abduction, internal and external rotation muscle strength using hand held dynamometry, visual analogue scale for pain. Lower Extremity Functional Scale (LEFS). All measures were taken on the affected leg for GPTS subjects and matched for the equivalent leg in healthy group. Strength was reported as a percentage of body weight. SiliconCoach was reliable for intra-rater reliability of knee valgus angle (ICC.996). Results. There were no significant differences in age, height and weight (p=.85,.57,.51 respectively). Significant differences existed in hip abduction strength p=.005(GPTS13.72 (7.65), H21.49 (5.55)) and LEFS p=0.001(GPTS 57.28(16.55), H76.92(4.44)). There were no significant differences in internal and external rotation and knee valgus angles p=.509, p=.505, p=.159 respectively. There was a negative correlation between pain and function r=.879) p=0.001) and a moderate positive correlation between function and hip abduction strength r=.428 (p=.127). This preliminary study shows that patients with GPTS have reduced strength in hip abductor musculature when compared to healthy subjects. This may be due to pain inhibition; however the true causes of pain need to be determined. Pain and to a lesser extent hip abductor strength appears to have an effect on function in GPTS patients. In summary the results indicate that hip abductor muscle strengthening and management strategies to reduce pain should be included in the rehabilitation programmes of patients with GPTS. Further research with larger numbers of subjects should be developed to investigate this subject

Introduction. Curved varus intertrochanteric osteotomy of the femur is an excellent and minimally invasive method for the treatment of osteonecrosis of the femoral head or osteoarthritis of the hip for joint preservation. However, the early postoperative complications of this procedure may be due to separation at the osteotomy site and an increase in varus angle due to early partial weight bearing. Methods. We modified the curved varus intertrochanteric osteotomy of the femur by performing an additional rotation. Regarding the surgical technique, curved varus osteotomy is performed at an angle of 30 degrees to the femoral shaft and an additional rotational osteotomy is also performed at an angle of 15 or 20 degrees to the osteotomy plane. Partial weight bearing with one-third body weight is permitted 3 weeks after surgery. Results. Curved varus intertrochanteric osteotomy of the femur was designed for developmental dysplastic hip by Nishio in 1969 and reported to have good outcomes in 1971. An important feature of this method is that the incidence of high riding of the greater trochanter or shortening of leg length is less than that in varus intertrochanteric osteotomy. Moreover, good contact at the osteotomy site and less lateral shift of the femoral shaft is observed. However, we have experienced a case of separation at the osteotomy site and increase of the varus angle in our hospital. Previous reports recommended that partial weight bearing with one-third body weight should be initiated after 5 weeks and full weight bearing after 6 months because the contact area is decreased at the osteotomy site by varus osteotomy. The post-operative recovery of the patients with total hip arthroplasty is rapid, therefore, we must consider important issues such as initiating the rehabilitation program early and reducing the duration of hospitalization. As per our experience, we think that partial weight bearing with one-third body weight should be initiated at 3 weeks. At the osteotomy site, we rotated the nearest bone segment to move it such that it intersects the proximal and distal bone cortex. Therefore, the osteotomy site will be stabilized and will have the ability to endure load. Another feature of this technique is that the partial removal of the necrotic area leads to an increase in the healthy load-bearing area. A limitation of this method is that an angle of an additional rotation is up to 30 degrees, because the joint capsule cannot be incised circumferentially and the short external rotator tendons should also be preserved. Conclusion. Modified curved varus intertrochanteric osteotomy is a useful method for the prevention of increased degree of a varus angle as well as for obtaining more intact area of femoral head in osteonecrosis

Aim. To determine differences in knee valgus angles produced during a single leg squat and hip muscle strength between healthy subjects and patients with patellofemoral pain (PFP). To determine correlations between variables of hip muscle strength, knee valgus angle and pain. Study design: Observational study of 20 (8 male 12 female) healthy (H) subjects, matched for age height and weight with 20 (8 male 12 female) PFP patients (mean symptom duration 46.75 weeks). All subjects fulfilled specific inclusion and exclusion criteria. Appropriate Ethical approval was obtained. Measures for both groups were Knee valgus angle during a single leg squat using 2D motion capture and SiliconCoach software for measurement of knee valgus angles, hip abduction, internal and external rotation muscle strength using hand held dynamometry, visual analogue scale for pain. Strength was reported as a percentage of body weight. All measures were taken on the affected leg for PFP subjects and matched for the equivalent leg in healthy group. SiliconCoach was determined to be reliable for intra-rater reliability of knee valgus angle (ICC.996). Results. There were no significant differences in age, height and weight (p=.59,.51,.26 respectively). Significant differences existed in hip abduction strength p=.001(PFP 19.93(9.2), H 32.22(8.26)), Hip internal rotation p=0.001 (PFP 12.94(4.35), H 19.53(6.36)), Hip external rotation p=0.001(PFP 10.00(3.07), H 16.26 (4.62)), Knee Valgus Angles p=0.001(PFP 5.31(2.59), H 2.29 (2.35)). No correlations existed between any of the variables including pain. This preliminary study shows that patients with PFP have larger knee valgus angles when doing a single leg squat and significantly weaker hip muscle strength when compared to healthy subjects. The reason for larger knee angles during single leg squat could be hypothesised as being due to weak hip abductor muscles not sufficiently controlling the alignment of the femur. However no correlations were found for these measures, nor were they found for any of the other variables including pain level. In summary the results indicate that hip musculature strengthening of the rotators and abductors and measures to reduce knee valgus angle should be included in the rehabilitation programme of patients with PFP. Further research with larger numbers of subjects should be developed to investigate this subject

We have previously shown that joint distraction and movement with a hinged external fixation device for 12 weeks was useful for repairing a large articular cartilage defect in a rabbit model. We have now investigated the results after six months and one year. The device was applied to 16 rabbits who underwent resection of the articular cartilage and subchondral bone from the entire tibial plateau. In group A (nine rabbits) the device was applied for six months. In group B (seven rabbits) it was in place for six months, after which it was removed and the animals were allowed to move freely for an additional six months. The cartilage remained sound in all rabbits. The areas of type II collagen-positive staining and repaired soft tissue were larger in group B than in group A. These findings provide evidence of long-term persistence of repaired cartilage with this technique and that weight-bearing has a positive effect on the quality of the cartilage.

We used a biodegradable mesh to convert an acetabular defect into a contained defect in six patients at total hip replacement. Their mean age was 61 years (46 to 69). The mean follow-up was 32 months (19 to 50). Before clinical use, the strength retention and hydrolytic in vitro degradation properties of the implants were studied in the laboratory over a two-year period. A successful clinical outcome was determined by the radiological findings and the Harris hip score.

All the patients had a satisfactory outcome and no mechanical failures or other complications were observed. No protrusion of any of the impacted grafts was observed beyond the mesh. According to our preliminary laboratory and clinical results the biodegradable mesh is suitable for augmenting uncontained acetabular defects in which the primary stability of the implanted acetabular component is provided by the host bone. In the case of defects of the acetabular floor this new application provides a safe method of preventing graft material from protruding excessively into the pelvis and the mesh seems to tolerate bone-impaction grafting in selected patients with primary and revision total hip replacement.

We have compared the energy expenditure during walking in three patients, aged between 51 and 55 years, with unilateral disarticulation of the hip when using the mechanical-controlled stance-phase control knee (Otto Bock 3R15) and the microprocessor-controlled pneumatic swing-phase control knee (Intelligent Prosthesis, IP). All had an endoskeletal hip disarticulation prosthesis with an Otto Bock 7E7 hip and a single-axis foot. The energy expenditure was measured when walking at speeds of 30, 50, and 70 m/min.

Two patients showed a decreased uptake of oxygen (energy expenditure per unit time, ml/kg/min) of between 10.3% and 39.6% when using the IP compared with the Otto Bock 3R15 at the same speeds. One did not show any significant difference in the uptake of oxygen at 30 m/min, but at 50 and 70 m/min, a decrease in uptake of between 10.5% and 11.6% was found when using the IP. The use of the IP decreased the energy expenditure of walking in these patients.

An understanding of the remodelling of tendon is crucial for the development of scientific methods of treatment and rehabilitation. This study tested the hypothesis that tendon adapts structurally in response to changes in functional loading. A novel model allowed manipulation of the mechanical environment of the patellar tendon in the presence of normal joint movement via the application of an adjustable external fixator mechanism between the patella and the tibia in sheep, while avoiding exposure of the patellar tendon itself. Stress shielding caused a significant reduction in the structural and material properties of stiffness (79%), ultimate load (69%), energy absorbed (61%), elastic modulus (76%) and ultimate stress (72%) of the tendon compared with controls. Compared with the material properties the structural properties exhibited better recovery after re-stressing with stiffness 97%, ultimate load 92%, energy absorbed 96%, elastic modulus 79% and ultimate stress 80%. The cross-sectional area of the re-stressed tendons was significantly greater than that of stress-shielded tendons.

The remodelling phenomena exhibited in this study are consistent with a putative feedback mechanism under strain control. This study provides a basis from which to explore the interactions of tendon remodelling and mechanical environment.