We have assessed the influence of isolated and combined rotational malunion of the radius and ulna on the rotation of the forearm. Osteotomies were made in both the radius and the ulna at the mid-diaphyseal level of five cadaver forearms and stabilised with intramedullary metal implants. Malunion about the axis of the respective forearm bone was produced at intervals of 10°. The ranges of pronation and supination were recorded by a potentiometer under computer control. We examined rotational malunions of 10° to 80° of either the radius or ulna alone and combined rotational malunions of 20° to 60° of both the radius and ulna. Malunion of the ulna in supination had little effect on rotation of the forearm. Malunion of either the radius or of the ulna in pronation gave a moderate reduction of rotation of the forearm. By contrast, malunion of the radius in supination markedly reduced rotation of the forearm, especially with malunion greater than 60°. Combined rotational malunion produced contrasting results. A combination of rotational malunion of the radius and ulna in the same direction had an effect similar to that of an isolated malunion of the radius. A combination in the opposite direction gave the largest limitation of the range of movement. Clinically, rotational malunion may be isolated or part of a complex angular/rotational deformity and rotational malunion may lead to marked impairment of rotation of the forearm. A reproducible method for assessing rotational malunion is therefore needed

The aim of this study is to assess the discrepancy between weight bearing long leg radiographs and supine MRI alignment. There is currently increasing interest in the use of MRI to assess knee alignment and develop custom made cutting blocks utilising this data. However in almost all units MRI scans are performed supine and it is recognised that knee alignment can alter with weight bearing. 46 patients underwent MRI scans as pre-operative planning for Biomet signature total knee replacement and the measure of varus or valgus deformity on MRI was obtained from the plan produced by Biomet Signature software system. 41 of these patients had long leg weight bearing radiographs performed. 37 of these radiographs were amenable to measuring the knee alignment on the picture archiving and communication system (PACS). These measurements were performed by two assessors and inter-observer reliability was satisfactory. There was a significant difference between the alignment as measured on supine MRI compared with weight bearing long leg films. In knee arthroplasty one of the aims is to correct the biomechanical axis of the knee and one of the appeals of custom made cutting blocks is that this can be achieved more easily. However it is important to realise that alignment is not a static value and thus correcting supine alignment may not necessarily result in correction of weight bearing alignment

Intra-Discal Vacuum Phenomenon (IDVP) represents an intradiscal nitrogen gas accumulation where a cavity opens in a supine position, lowering intra-discal pressure and generating a bubble. IDVP has been observed in up to 20% of elderly patients and reported in almost 50% of chronic LBP patients. With a highly accurate detection on CT, its significance lacks clarity and consideration within normative data. IDVP occurs with patterns of lumbar and/or lumbopelvic morphology and associated diagnoses. Over-60s population based sample of 2020 unrelated CT abdomen scans without acute spinal presentations, with sagittal reconstructions, inclusive of T12 to femoral heads, were analyzed for IDVP and pelvic incidence (PI). Subjects with diagnostic morphological associations of the lumbar spine, including previous fracture, autofusion, transitional vertebra and listhesis, were selected out and analyzed separately. Subjects were then equally grouped into low, medium and high PI. Prevalence of lumbar spine IDVP is 41.3%. 125 cases were excluded. 1603 subjects yielded 663 IDVP. This was increased in severity towards the lumbosacral junction (L1L2 9.4%, L2L3 10.9%, L3L4 13.7%, L4L5 19.9%, L5S1 28.5%) and those with low PI, while distribution was more even with high PI. 292 had positive diagnostic associations, which were more likely to occur at the level of isthmic spondylolisthesis, adjacent to a previous fracture or suprajacent to lumbosacral transitional vertebra (p<0.05). This study has identified normative values for prevalence and severity of IDVP in a normal aging population. Morphological patterns that influence the pattern of IVDP such as pelvic incidence and diagnostic associations provide novel insights to the function of the aging spine

This study aims to compare the outcomes of Volar locking plating (VLP) versus percutaneous Kirschner wires (K-wire) fixation for surgical management of distal radius fractures. We systematically searched multiple databases, including MEDLINE for randomized controlled trials (RCTs) comparing outcomes of VLP fixation and K-wire for treatment of distal radius fracture in adults. The methodological quality of each study was assessed by the Cochrane Risk of Bias tool. Patient-reported outcomes, functional outcomes, and complications at 1 year follow up were evaluated. Meta-analysis was performed using random-effects models and results presented as risk ratios (RRs) or mean differences (MDs) with 95% confidence interval (CI). 13 RCTs with 1336 participants met the inclusion criteria. Disabilities of the Arm, Shoulder and Hand (DASH) scores were significantly better for VLP fixation (MD= 2.15; 95% CI, 0.56-3.74; P = 0.01; I2=23%). No significant difference between the two procedures for grip strength measured in kilograms (MD= −3.84; 95% CI,-8.42-0.74; P = 0.10; I2=52%) and Patient-Rated Wrist Evaluation (PRWE) scores (MD= −0.06; 95% CI,-0.87-0.75; P = 0.89; I2=0%). K-wire treatment yielded significantly improved extension (MD= −4.30; P=0.04) but with no differences in flexion, pronation, supination, and radial deviation (P >0.05). The risk of complications and rate of reoperation were similar for the two procedures (P >0.05). This meta-analysis suggests that VLP fixation improves DASH score at 12 months follow up, however, the difference is small and unlikely to be clinically important. Existing literature does not provide sufficient evidence to demonstrate the superiority of either VLP or K-wire treatment in terms of patient-reported outcomes, functional outcomes, and complications

Standard fixation for intra-articular distal humerus fracture is open reduction and internal fixation (ORIF). However, high energy fractures of the distal humerus are often accompanied with soft tissue injuries and or vascular injuries which limits the use of internal fixation. In our report, we describe a highly complex distal humerus fracture that showed promising healing via a ring external fixator. A 26-year-old man sustained a Gustillo Anderson Grade IIIB intra-articular distal humerus fracture of the non-dominant limb with bone loss at the lateral column. The injury was managed with aggressive wound debridement and cross elbow stabilization via a hinged ring external fixator. Post operative wound managed with foam dressing. Post-operatively, early controlled mobilization of elbow commenced. Fracture union achieved by 9 weeks and frame removed once fracture united. No surgical site infection or non-union observed throughout follow up. At 2 years follow up, flexion - extension of elbow is 20°- 100°, forearm supination 65°, forearm pronation 60° with no significant valgus or varus deformity. The extent of normal anatomic restoration in elbow fracture fixation determines the quality of elbow function with most common complication being elbow stiffness. Ring fixator is a non-invasive external device which provides firm stabilization of fracture while allowing for adequate soft tissue management. It provides continuous axial micro-movements in the frame which promotes callus formation while avoiding translation or angulation between the fragments. In appropriate frame design, they allow for early rehabilitation of joint where normal range of motion can be allowed in controlled manner immediately post-fixation. Functional outcome of elbow fracture from ring external fixation is comparable to ORIF due to better rehabilitation and lower complications. Ring external fixator in our patient achieved acceptable functional outcome and fracture alignment meanwhile the fracture was not complicated with common complications seen in ORIF. In conclusion, ring external fixator is as effective as ORIF in treating complex distal humeral fractures and should be considered for definitive fixation in such fractures

Abstract. Objectives. Neonatal motor development transitions from initially spontaneous to later increasingly complex voluntary movements. A delay in transitioning may indicate cerebral palsy (CP). The general movement optimality score (GMOS) evaluates infant movement variety and is used to diagnose CP, but depends on specialized physiotherapists, is time-consuming, and is subject to inter-observer differences. We hypothesised that an objective means of quantifying movements in young infants using motion tracking data may provide a more consistent early diagnosis of CP and reduce the burden on healthcare systems. This study assessed lower limb kinematic and muscle force variances during neonatal infant kicking movements, and determined that movement variances were associated with GMOS scores, and therefore CP. Methods. Electromagnetic motion tracking data (Polhemus) was collected from neonatal infants performing kicking movements (min 50° knee extension-flexion, <2 seconds) in the supine position over 7 minutes. Tracking data from lower limb anatomical landmarks (midfoot inferior, lateral malleolus, lateral knee epicondyle, ASIS, sacrum) were applied to subject-scaled musculoskeletal models (Gait2354_simbody, OpenSim). Inverse kinematics and static optimisation were applied to estimate lower limb kinematics (knee flexion, hip flexion, hip adduction) and muscle forces (quadriceps femoris, biceps femoris) for isolated kicks. Functional principal component analysis (fPCA) was carried out to reduce kicking kinematic and muscle force waveforms to PC scores capturing ‘modes’ of variance. GMOS scores (lower scores = reduced variety of movement) were collected in parallel with motion capture by a trained operator and specialised physiotherapist. Pearson's correlations were performed to assess if the standard deviation (SD) of kinematic and muscle force waveform PC scores, representing the intra-subject variance of movement or muscle activation, were associated with the GMOS scores. Results. The study compared GMOS scores, kinematics, and muscle force variances from a total of 26 infants with a mean corrected gestational age of 39.7 (±3.34) weeks and GMOS scores between 21 and 40. There was a significant association between the SD of the PC scores for knee flexion and the GMOS scores (PC1: R = 0.59, p = 0.002; PC2: R = 0.49, p = 0.011; PC3: R = 0.56, p = 0.003). The three PCs captured variances of the overall flexion magnitude (66% variance explained), early-to-late kick knee extension (20%), and continual to biphasic kicking (6%). For hip flexion, only the SD of PC1 correlated with GMOS scores (PC1: R = 0.52, p = 0.0068), which captured the variance of the overall flexion magnitude (81%). For the biceps femoris, the SD of PC1 and PC3 associated with GMOS scores (PC1: R = 0.50, p = 0.002; PC3: R = 0.45, p = 0.03), which captured the variance of the overall bicep force magnitude (79%) and early-to-late kick bicep activation (8%). Conclusions. Infants with reduced motor development as scored in the GMOS displayed reduced variances of knee and hip flexion and biceps femoris activation across kicking cycles. These findings suggest that combining objectively measured movement variances with existing classification methods could facilitate the development of more consistent and accurate diagnostic tools for early detection of CP. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Appropriate in vivo models can be used to understand atrophic non-union pathophysiology. In these models, X-ray assessment is essential and a reliable good quality images are vital in order to detect any hidden callus formation or deficiency. However, the radiographic results are often variable and highly dependent on rotation and positioning from the detector/film. Therefore, standardised A-P and lateral x-ray views are essential for providing a full radiological picture and for reliably assessing the degree of fracture union. We established and evaluated a method for standardised imaging of the lower limb and for reliably obtaining two perpendicular views (e.g. true A-P and true lateral views). The normal position of fibula in murine models is posterolateral to the tibia, therefore, a proper technique must show fibula in both views. In order to obtain the correct position, the knee joint and ankle joints were flexed to 90 degrees and the foot was placed in a perpendicular direction with the x-ray film. To achieve this, a leg holder was made and used to hold the foot and the knee while the body was in the supine position. Lateral views were obtained by putting the foot parallel to the x-ray film. Adult Wister rat cadavers were used and serial x-rays were taken. A-P view in supine position showed the upper part of the fibula clearly, however, there was an unavoidable degree of external rotation in the whole lower limb, and the lower part of the fibula appeared behind the tibia. Therefore, a true A-P view whilst the body was in the supine position was difficult. To overcome this, a P-A view of the leg was performed with the body prone position, this allowed both upper and lower parts of the fibula to appear clearly in both views. This method provides two true perpendicular views (P-A and lateral) and helped to optimise radiological assessment

Summary. Application of RSA in supine and standing positions allows pelvic fracture stability to be measured more accurately than current techniques. RSA may enable a better understanding of these injuries. Introduction. The in vivo stability of the pelvic ring after fracture stabilisation remains unknown. Plain radiographs have a low accuracy in diagnosing loss of fracture reduction over time. Radiostereometric analysis (RSA) is an accurate imaging measurement method that has previously been applied to measure the healing of other fractures. This pilot study investigated the potential application of RSA in supine and standing positions to measure pelvic fracture stability over time and under weightbearing load. Methods. Five patients with a similar type C pelvic ring disruption who were all operated on using the same surgical technique and had RSA markers inserted at the time of surgery. All five patients had a unilateral comminuted sacral fracture lateral to the sacral foramina treated with posterior plating and pubic rami fractures stabilised by external fixation for six weeks. All patients were mobilised partial weight bearing after regaining leg control. RSA examinations at 2, 4, 12, 26 and 52 weeks included three radiographic pairs taken in supine, standing and supine positions at each time point. Two additional RSA examinations were performed the day prior and post pin removal at 6 weeks. Results. All patients ambulated before the 2 week follow-up and progressed uneventfully. At latest follow-up, there were no complications. Minimal displacements (translations less than 0.3mm and rotations less than 0.5°) were recorded between the supine exams pre and post standing at 2 weeks. Hence, the supine examination was found to be a reliable position to measure the migration of the ilium over time. No loss of reduction was identifiable on plain radiographs over time. At 52 weeks, in contrast to plain radiographic results, RSA measurements revealed that one patient had a fracture migration greater than 4mm. Such large displacements could result in sacral nerve root transection, leading to devastating consequences, such as incontinence, for patients whose sacral fractures are through or medial to the sacral foramina. In one patient, the migration recorded for the apparent uninjured posterior complex side exceeded the migration of the injured side suggesting an unrecognised bilateral injury. Comparative RSA examinations pre and post external fixator removal demonstrated that in three patients the injured hemipelvis migrated greater than 2mm after the removal of the external fixator, which may be indicative that the fixator was removed prematurely. Discussion and Conclusion. The application of RSA allows accurate measurement of pelvic fracture stability which is difficult, if not impossible, to identify and quantify with any other imaging techniques. Hence, RSA has the capacity to enable a better understanding of pelvic ring injuries and optimise their treatment

Knee alignment is a fundamental measurement in the assessment, monitoring and surgical management of patients with OA. In spite of extensive research into the consequences of malalignment, there is a lack of data regarding the potential variation between supine and standing (functional) conditions. The purpose of this study was to explore this relationship in asymptomatic, osteoarthritic and prosthetic knees. Our hypothesis was that the change in alignment of these three groups would be different. Infrared position capture was used to assess knee alignment for 30 asymptomatic controls and 31 patients with OA, before and after TKA. Coronal and sagittal mechanical femorotibial (MFT) angles in extension (negative values varus/hyperextension) were measured supine and in bi-pedal stance and changes analysed using a paired t-test. To quantify this change in 3D, vector plots of ankle centre displacement relative to the knee centre were produced. Alignment in both planes changed significantly from supine to standing for all three groups, most frequently towards relative varus and extension. In the coronal plane, the mean±SD(°) of the supine/standing MFT angles was 0.1±2.5/−1.1±3.7 for asymptomatic (p=0.001), −2.5±5.7/−3.6±6.0 for osteoarthritic (p=0.009) and −0.7±1.4/ −2.5±2.0 for prosthetic knees (p<0.001). In the sagittal plane, the mean±SD(°) of the supine/standing MFT angles was −1.7±3.3/−5.5±4.9 for asymptomatic (p<0.001), 7.7±7.1/1.8±7.7 for osteoarthritic (p<0.001) and 6.8±5.1/1.4±7.6 for prosthetic knees (p<0.001). The vector plots showed that the trend of relative varus and extension in stance was similar in overall magnitude and direction between the groups. The similarities between each group did not support our hypothesis. The consistent kinematic pattern for different knee types suggests that soft tissue restraints rather than underlying joint deformity may be more influential in dynamic control of alignment from lying to standing. This potential change should be considered when positioning TKA components on supine limbs as post-operative functional alignment may be different

The management of displaced forearm diaphyseal fractures in adults is predominantly operative. Anatomical reduction is necessary to infer optimal motion and strength. The authors have observed an intraoperative technique where passive pronosupination is examined to assess quality of reduction as a surrogate marker for active movement. We aimed to assess the value of this technique, but intentionally malreducing a simulated diaphyseal fracture of a radius in a cadaveric model, and measuring the effect on pronosupination. A single cadaveric arm was prepared and pronation/supination was examined according to American Academy of Orthopaedic Surgeons guidance. A Henry approach was then performed and a transverse osteotomy achieved in the radial diaphysis. A volar locking plate was used to hold the radius in progressive amounts of translation and rotation, with pronosupaintion measured with a goniometer. The radius could be grossly malreduced with no effect on pronation and supination until the extremes of deformity. The forearm showed more tolerance with rotational malreduction than translation. Passive pronation was more sensitive for malreduction than supination. The use of passive pronosupination to assess quality of reduction is misleading

Osteoarthritis of the first metatarsophalangeal (MTP1) joint is a common disorder in elderly, resulting in pain and disability. Arthrodesis of this joint shows satisfactory results, with relieve of pain in approximately 85% of the patients. However, the compensation mechanism for loss of motion in the MTP1 joint after MTP1 arthrodesis is unknown. A reduced compensation mechanism of the foot may explain the disappointing result of MTP1 arthrodesis in the remaining 15% of the patients. This study was conducted to elucidate this compensation mechanism. We hypothesize that the ankle and forefoot are responsible for compensation after MTP1 arthrodesis. Gait was evaluated in eight patients with arthrodesis of the MTP1 joint (10 feet) and twelve healthy controls (21 feet) by using a sixteen-camera Vicon-system. The four-segmental, validated Oxford-Foot-Model was used to investigate differences in range of motion of the hindfoot-tibia, forefoot-hindfoot and hallux-forefoot segment during stance. For statistical analysis, the unpaired t-test with Bonferroni correction (p<0.0125) was performed. No differences in spatiotemporal parameters were observed between both groups. In the frontal plane, MTP1 arthrodesis decreased the range of motion in midstance, while an increased range of motion was observed in terminal stance for the hindfoot relative to the tibia in the transversal plane. Subsequently range of motion in the forefoot in preswing was increased. This resulted in less eversion in the hindfoot during midstance, increased internal rotation of the hindfoot during terminal stance and more supination in the forefoot during preswing in the MTP1 arthrodesis group. Motion of the hallux was restricted in the loading response (i.e. plantar flexion) and terminal stance (i.e. dorsiflexion). As hypothesized, both the ankle and the forefoot are responsible for compensation after MTP1 arthrodesis, because arthrodesis causes less eversion and increased internal rotation of the hindfoot and increased supination of the forefoot. As expected, both dorsiflexion and plantar flexion of the hallux was restricted due to arthrodesis. These findings suggest a gait pattern in which the lateral arch of the foot is more loaded and the stiff hallux is avoided during the stance phase of gait. Our results indicate that proper motion of the forefoot and ankle joint is important when considering arthrodesis of the MTP1 joint. Therefore, we emphasize careful assessment the range of motion in the forefoot and ankle joint in the pre-operative situation, since patients with a decreased range of motion in the forefoot and ankle joint have a less functioning compensation mechanism. We currently perform a study to evaluate the strength of the positive correlation between the pre-operative range of motion in the forefoot and ankle joint and the clinical outcome

Restoration of anatomy is paramount in total hip arthroplasty (THA) to optimise function and stability. Leg-length discrepancy of ≥10mm is poorly tolerated and can be the subject of litigation. We routinely use a multimodal protocol to optimise soft tissue balancing which involves pre-operative templating, leg-length measurement supine and in the lateral position after positioning, and the use of an intra-operative leg-length measurement device to ensure optimisation of leg-length. We have analysed the results of our protocol in restoring leg-length in primary THA. Radiological leg-length was measured in a consecutive series of 50 patients who had THA for unilateral arthritis by an independent observer pre- and post-operatively using validated methods utilising radiological software. The measurements pre- and post-operative were compared. Patients with bilateral hip arthritis and poor imaging were excluded. Leg-length was successfully restored to within 5.0mm of the target leg-length in 84.0% of patients (mean +0.7mm (95% CI +0.2 to +1.1)). The other 14.0% of patients were restored to within 5.1–8.0mm (mean +2.2mm (95% CI −2.7 to +7.1)) and 2.0% of patients were restored to within 8.1–10.0mm. Leg length was accurately restored across the subset of patients within a narrow range of either side of the mean target leg length. Intra-operative measurement of leg length can be difficult but is vital in ensuring appropriate restoration of leg-length. We recommend a similar multimodal protocol to ensure restoration of leg-length within narrow limits to maximise function and patient satisfaction

3D imaging is commonly employed in the surgical planning and management of bony deformity. The advent of desktop 3D printing now allows rapid in-house production of specific anatomical models to facilitate surgical planning. The aim of this pilot study was to evaluate the feasibility of creating 3D printed models in a university hospital setting. For requested cases of interest, CT DICOM images on the local NHS Picture Archive System were anonymised and transferred. Images were then segmented into 3D models of the bones, cleaned to remove artefacts, and orientated for printing with preservation of the regions of interest. The models were printed in polylactic acid (PLA), a biodegradable thermoplastic, on the CubeX Duo 3D printer. PLA models were produced for 4 clinical cases; a complex forearm deformity as a result of malunited childhood fracture, a pelvic discontinuity with severe acetabular deficiency following explantation of an infected total hip replacement, a chronically dislocated radial head causing complex elbow deformity as a result of a severe skeletal dysplasia, and a preoperative model of a deficient proximal tibia as a result of a severe tibia fracture. The models materially influenced clinical decision making, surgical intervention planning and required equipment. In the case of forearm an articulating model was constructed allowing the site of impingement between radius and ulnar to be identified, an osteotomy was practiced on multiple models allowing elimination of the block to supination. This has not previously been described in literature. The acetabulum model allowed pre-contouring of a posterior column plate which was then sterilised and eliminated a time consuming intraoperative step. While once specialist and expensive, in house 3D printing is now economically viable and a helpful tool in the management of complex patients

Posterolateral rotatory instability (PLRI) is the most common type of elbow instability. It is caused by an insufficiency of the lateral ligamentous complex, which consists mainly of the radial collateral ligament (RCL) and the lateral ulnar collateral ligament (LUCL). Investigate the influence of serial sectioning of the lateral ligamentous complex on elbow stability in a cadaveric model of PLRI. Kinematics of six fresh frozen cadaveric elbow specimens were measured by digitizing anatomical marks with a Microscribe 3DLX digitizing system (Revware Inc, Raleigh, NC). Each specimen was tested under four conditions: Intact, LUCL tear, LUCL and RCL tear, and complete Tear (LUCL, RCL and capsule tear). Each specimen was tested in 30°, 60° and 90° elbow flexion angles. Varus- laxity was measured in supination, pronation, and neutral forearm rotation positions and total forearm rotation was measured with 0.3 Nm of torque. Statistical significant differences between the conditions were detected using a two-way ANOVA with Tukey's post-hoc test. The radial head dislocated in all specimens in LUCL and RCL tear and Comp but not in LUCL tear. Total forearm ROM did not increase form intact to LUCL tear (p>0.05) but significantly increased in LUCL and RCL tear (p=0.0002) and complete tear (p<0.0001) in all flexion angles. Additionally, ROM in LUCL tear significantly differed from LUCL and RCL tear and complete tear (p=0.0027 and p=0.0002). A similar trend was seen with the varus angle. While there was a significant difference when the intact condition was compared to both the LUCLand RCL tear and complete tear conditions (p<0.0001 and p<0.0001), there was no difference between the intact and LUCL tear conditions. LUCL tear alone is not sufficient to cause instability and increase ROM and varus angle, meanwhile the increase of ROM and varus angle with additional capsular tear was not significant compared to LUCL and RCL tear. The increase of ROM after LUCL and RCL tear is an unknown symptom of PLRI

Background. Recent studies have suggested that full-limb radiographs are more accurate and sensitive than short film radiographs for pre-operative measurement of the anatomical angles required to achieve optimal knee alignment in Total Knee Arthroplasty (TKA). However, there are drawbacks associated with their use including excess radiation to the pelvic organs, the need for specialised radiography equipment and increased cost. Given these drawbacks, we compared the use of MRI scans, a commonly performed pre-operative investigation, with short film knee radiographs for measurement of knee alignment. Objective. To investigate whether knee alignment measurements made on MRI scans correlate with those measured on short film knee radiographs in patients with osteoarthritic knees. Methods. We retrospectively reviewed short film knee radiographs and MRI scans of 50 patients with knee osteoarthritis. The plain radiographs had to be performed whilst weight bearing. The MRI scans were performed supine and non-weight bearing. The exclusion criteria included previous trauma to the knee, previous TKA and previous fracture of the lower limb. 4 angle measurements defined by The American Knee Society: alpha, beta, sigma and gamma were measured using each of the 2 modalities. Kolmogorov-Smirnov and two- tailed paired t-tests were used for statistical analysis of the results. Pearson correlation coefficient was used for the measure of dependence. Results. The alpha, beta, sigma and gamma angles obtained using the MR images were different to those obtained using short film weight bearing knee radiographs by −3°± 1° (p < 0.001), 1° ± 3° (p=0.002), 1° ± 3° (p=0.047) and 1° ± 4° (p=0.113) respectively. There was a weak correlation between the MRI based method and the radiographic method in measuring all 4 angles. Conclusions. Our results have shown that the angular measurements performed on MR images should be interpreted with caution as they may vary depending on the MRI slice selected for evaluation. The differences observed and the weak correlation between the 2 modalities may be due to the different scopes used for determining the femoral or tibial axes. The measurements obtained using the plain radiographs were interpreted using a single 2D projection of a 3D structure. However, the measurements of the MR images were evaluated using a 2D image of a slice through a 3D structure. In conclusion, the use of MRI scans for pre-operative planning in TKA may not be advisable at this stage as the angular measurements obtained using the MR images were poorly correlated to those obtained using plain radiographs

Insufficiency of the lateral collateral ligamentous complex causes posterolateral rotatory instability (PLRI). During reconstruction surgery the joint capsule is repaired, but its biomechanical influence on elbow stability has not been described. We hypothesized that capsular repair reduces ROM and varus angle after reconstruction of the lateral collateral complex. Six fresh frozen cadaveric elbow specimens were used. Varus laxity in supination, pronation and neutral forearm rotation with 1 Nm load and forearm rotaitonal range of motion (ROM) with 0.3 Nm torque were measured using a Microscribe 3DLX digitizing system (Revware Inc, Raleigh, NC). Each specimen was tested under four different conditions: Intact, Complete Tear with LUCL, RCL and capsule tear, LUCL/RCL reconstruction + capsule repair and LUCL/RCL reconstruction only. Reconstruction was performed according to the docking technique (Jones, JSES, 2013) and the capsule was repaired with mattress sutures. Each condition was tested in 30°, 60° and 90° elbow flexion. A two-way ANOVA with Tukey's post-hoc test was used to detect statistical differences between the conditions. Total ROM of the forearm significantly increased in all flexion angles from intact to Complete tear (p<0.001). ROM was restored to normal in 30° and 60° elbow flexion in both reconstruction conditions (p>0.05). LUCL/RCL Reconstruction + capsule repair in 90° elbow flexion was associated with a significantly lower ROM compared to intact (p=0.0003) and reconstruction without capsule repair (p=0.015). Varus angle increased significantly from intact to complete tear (p<0.0001) and restored to normal in both reconstruction conditions (p>0.05) in 30° and 60° elbow flexion. In contrast varus angle was significantly lower in 90° elbow flexion in both reconstruction conditions compared to intact (both p<0.0001). Reconstruction of the lateral collateral complex restores elbow stability, ROM and varus laxity independent of capsular repair. Over tightening of the elbow joint occurred in 90° elbow flexion, which was aggravated by capsular repair. Over all capsular repair can be performed without negatively affecting elbow joint mobility

Children with cerebral palsy (CP) often present femoral bone deformities not accounted for in generic musculoskeletal models [1,2]. MRI-based models can be used to include subject-specific muscle paths [3,4], although this is a time-demanding process. Recently, non-rigid deformation techniques have been used to transform generic bone geometry, including muscle points, onto personalized bones [5]. However, it is still unknown to what extent such an approximation of subject-specific detail affects calculated hip contact forces (HCFs) during gait in CP children. Seven children diagnosed with diplegic CP walked independently at self-selected speed. 3D marker trajectories were captured using Vicon (Oxford Metrics, UK) and force data was measured using two AMTI force platforms (Watertown, MA). MR-images were acquired (Philips Ingenia 1.5T) of all subjects lying supine. Firstly, a generic model [6] was scaled using the marker positions of a static pose. Secondly, a MRI-model containing the subject-specific bone structures and muscle paths of all hip and upper leg muscles was created [3]. Thirdly, the generic femur and pelvis geometries and muscle points were transformed onto the image-based femur and pelvis using an advanced non-rigid deformation procedure (Materialise N.V.). For all models, further analyses were performed in OpenSim 3.1 [7]. A kalman smoother procedure was used to calculate joint angles [8]. Muscle forces were calculated using a static optimization minimizing the sum of squared muscle activities. Next, HCFs were calculated and normalized to body weight (BW). First and second peak HCFs were determined and used for a Kruskal-Wallis test to determine differences between models. In case of a significant difference, a post-hoc rank-based multiple comparison test with Bonferonni adjustment was used. Further, average absolute differences in muscle points between the models was calculated, as well as average differences in moment arm lengths (MALs), reflecting muscle function. Where the scaled generic muscle points differed on average 2.49cm from the MRI points, the non-rigidly deformed points differed 1.54cm from the MRI muscle points. Specifically, the tensor fascia latae differed most between the deformed and MRI models (11.7cm). When considering MALs, the gluteii muscles present an altered function for the generic and deformed models compared to the MRI model for all degrees of freedom of the hip at the time of both HCF peaks. The differences between models resulted in a significantly increased second peak HCF for the MRI models compared to the generic models (first peak average HCF: 3.88BW, 3.95BW and 4.90BW; second peak average HCF: 3.03BW, 4.89BW and 5.32BW for the generic, MRI and non-rigidly deformed models respectively). Although not significantly different, the deformed models calculated slightly increased HCFs compare to the MRI models. The generic models underestimated HCFs compared to the MRI models, while the non-rigidly deformed models slightly overestimated HCFs. However, differences between the deformed and MRI models in terms of muscle points and MALs remain, specifically for the gluteii muscles. Therefore, further user-guided modification of the model based on MR-images will be necessary

We present a simple seated dial test that can be used by a single examiner in the acute or chronic situation to diagnose posterolateral corner knee injury. In the acute setting a traditional prone dial test can be cumbersome and painful for patients. Therefore a supine technique can be utilised, however this requires an assistant in order to hold the knees together with the tibia in a reduced position. We therefore utilise a seated technique in which the patient sits with their knees flexed over the edge of the examination couch. The patient is then able to hold their knees together, negating the need for an assistant. The sensitivity of a dial test is improved if the knee is reduced and so with this technique the tibia will be held in the anatomical position by the examination couch. The patients' feet are grasped with both medial malleoli together and then an external rotation moment is exerted at 30 and 90 degrees of flexion measuring the thigh-foot angle or visualising the tibial tuberosities. A positive test being 10 degrees or more of increased external rotation in the affected knee. This test is similar to the Spin test however it relies on the tactile sensation of posterolateral tibial rotation. This can be difficult to elicit in the acute situation due to haemarthrosis. Simultaneous side-to-side comparison is also not possible. A further disadvantage of the Spin test is that it can only be performed at 90 degrees of flexion and so only applies in combined PCL and posterolateral corner repair. In conclusion we believe that this modification of the standard dial test is a simple to perform accurate method for assessing posterolateral corner knee injury in the acute and chronic setting

The study looked at early outcomes of 55 patients who underwent open reduction and internal fixation of distal radius fracture with a single variable angle volar locking plate (Variax, Stryker), by a single surgeon (GS), between May 2007 and December 2008. A retrospective review of notes and radiographs was performed. Twenty-nine women and 26 men were included. The mean age was 52 years. Mean follow up time was 3 months. The dominant wrist was involved in 38 patients. The mechanism of injury was of low energy in 38 patients and of high energy in 17 patients. All patients had comminuted fractures and 52 patients had intraarticular fractures. Seven patients underwent intraoperative carpal tunnel decompression. At latest follow up, active wrist motion averaged 37° extension, 40° flexion, 70° pronation, and 56° supination. Grip strength averaged 64% and pinch grip 77% of the contralateral wrist. Postoperative complications included one flexor pollicis longus rupture, one malunion and three patients with loosening of screws. There was a higher rate of complications seen in patients with high energy injuries. These early results suggest that volar plating with a variable angle plate is an effective treatment option, especially for complex intraarticular distal radius fractures. A medium term outcomes study of a larger number of patients is planned

We present a novel use for an adult proximal humeral locking plate. In our case an 18-year-old female with cerebral palsy sustained a peri-prosthetic fracture of a blade plate previously inserted for a femoral osteotomy. Treatment was revision using a long proximal humeral locking plate. She had a successful outcome. We present the history and operative management. The female had a history of quadriplegic cerebral palsy, asthma, diabetes mellitus and congenital heart disease. She had a gastrostomy tube for enteral feeding. She was on nutritional supplements, baclofen, Omeprazole and movicol. She is looked after by her parents and requires a wheelchair for mobility. She is unable to communicate. Surgical History: Right adductor tenotomy, aged 11. Femoral Derotation Osteotomy & Dega Acetabular Osteotomy, aged 13. Right distal hamstring and knee capsule release, aged 14. Admitted to A&E (aged 18); unwitnessed fall. Painful, swollen, deformed thigh with crepitus. Xrays demonstrated peri- prosthetic fracture below blade plate. No specific equipment available to revise. Decision made to use PHILOS (Synthes, UK). GA, antibiotics, supine on table. Lateral approach. Plate removed after excising overgrown bone. Reduced and held. 10hole PHILOS applied. Near anatomical reduction. Secure fixation with locking screws proximally away from blade plate defect. Blood loss 800ml. 5 days in hospital. Sequential fracture clinic review. Wound healed well. Fracture healed on Xray at 11 months and discharged. To our knowledge this is the first reported use of a PHILOS plate for this specific fracture. The complexity of this case and underlying neurological disorder deemed long blade plate revision unsuitable. Fracture rates after femoral derotation osteotomies rare. 5/157 and 1/58 in the two largest studies to date. Conservative measures were the main recommendation. We have demonstrated a straightforward method for revision fixation with an excellent outcome. It would be recommended as an alternative to other surgeons in this position