Purpose of the study: Idiopathic scoliosis is a tridimensional deformation of the spine. For an overall description of the deformation, it is important to determine the exact deformation in each dimension to identify the topography and amplitude of the curvatures as well as the sagittal balance and vertebral rotation. Scoliosis is actually a deformation of the thoracic cage, which could be considered as its fourth dimension. The purpose of this study was to measure thoracic parameters, particularly thoracic volume, as a function of spinal curvature and growth in children. The goal was to better describe the deformation and difference in comparison with the normal population. Material and methods: In this prospective study, The Orten (Lyon) optical acquisition system was used to fashion a corset for 130 patients (110 girls, 20 boys, aged 4–16 years) with idiopathic scoliosis. The volume, circumference, anteroposterior and frontal diameters as well as the lengths T1–T12 and sternum were noted. These data were confronted with the clinical growth parameters: age, height in the upright and sitting position, body length, body weight, body mass index. Thoracic curvatures were measured using the Cobb system (15–45°). The vertebral rotation component was noted. In order to compare these pathological data with those observed in a normal population, the same optical acquisition protocol was performed in a control group of 65 girls and 61 boys free of thoracic deformation. Results: There was no significant difference in thoracic volume relative to the different growth parameters between the control group and the scoliosis group (Wilcoxon test: p=0.056). There was a correlation between thoracic volume (3–17 dm3) and age: boys r=0.75 and girls r=0.74. At about 4 years, thoracic volume was on average 33% of volume attained at puberty and at 10 years, 55%. These reference points were true for girls and for boys in the scoliosis and the control groups. The following relationships between thoracic measurements and sitting height were found to remain unchanged during growth: frontal diameter is about 30% of sitting height; anteroposterior diameter is equal to the length of the sternum and is about 20% of sitting height. Discussion and conclusion: The Orton optical acquisition system can be used to describe quantitatively the deformation of the thoracic cage caused by scoliosis. There was however no significant difference in thoracic volume between the normal controls and the scoliosis children with a curvature < 45°. Major scoliosis leads to deformation of the vertebral bodies and thus the thorax. This fourth dimension of the deformation should be taken into consideration when establishing the treatment by corset or surgery. This study described the thoracic parameters observed during growth in children with mild to moderate scoliosis. A later study on more severe forms will complete these data and enable an objective assessment of the thoracic deformation

Aims. Most patients with advanced malignancy suffer bone metastases, which pose a significant challenge to orthopaedic services and burden to the health economy. This study aimed to assess adherence to the British Orthopaedic Oncology Society (BOOS)/British Orthopaedic Association (BOA) guidelines on patients with metastatic bone disease (MBD) in the UK. Methods. A prospective, multicentre, national collaborative audit was designed and delivered by a trainee-led collaborative group. Data were collected over three months (1 April 2021 to 30 June 2021) for all patients presenting with MBD. A data collection tool allowed investigators at each hospital to compare practice against guidelines. Data were collated and analyzed centrally to quantify compliance from 84 hospitals in the UK for a total of 1,137 patients who were eligible for inclusion. Results. A total of 846 patients with pelvic and appendicular MBD were analyzed, after excluding those with only spinal metastatic disease. A designated MBD lead was not present in 39% of centres (33/84). Adequate radiographs were not performed in 19% of patients (160/846), and 29% (247/846) did not have an up-to-date CT of thorax, abdomen, and pelvis to stage their disease. Compliance was low obtaining an oncological opinion (69%; 584/846) and prognosis estimations (38%; 223/846). Surgery was performed in 38% of patients (319/846), with the rates of up-to-date radiological investigations and oncology input with prognosis below the expected standard. Of the 25% (215/846) presenting with a solitary metastasis, a tertiary opinion from a MBD centre and biopsy was sought in 60% (130/215). Conclusion. Current practice in the UK does not comply with national guidelines, especially regarding investigations prior to surgery and for patients with solitary metastases. This study highlights the need for investment and improvement in care. The recent publication of British Orthopaedic Association Standards for Trauma (BOAST) defines auditable standards to drive these improvements for this vulnerable patient group. Cite this article: Bone Joint J 2023;105-B(10):1115–1122

Rib fractures (RF) represent the most common bone fracture after blunt trauma, occurring in 10–20% of all trauma patients and leading to concomitant injuries of the inner organs in severe cases. However, a standardized classification system for serial rib fractures (SRF) does still not exist. Basic knowledge about the facture pattern of SRF would help to predict organ damage, support forensic medical examinations, and provide data for in vitro and in silico studies regarding the thoracic stability. The purpose of our study was therefore to identify specific SRF patterns after blunt chest trauma. All SRF cases (≥3 subsequent RF) between mid-2008 and end of 2015 were extracted from the CT database of our University Hospital (n=383). Fractures were assigned to anterior, antero-lateral, lateral, postero-lateral, and posterior location within the transverse plane (36° each) using an angular measuring technique (reliability ±2°). Rib level, fracture type (transverse, oblique, multifragment, infracted), as well as degree of dislocation (none, </≥ rib width) were recorded and each related to the cause of accident. In total, 3747 RF were identified (9.7 per patient, ranging from 3 (n=25) to 33 (n=1)). On average, most RF occurred in crush/burying injuries (15.9, n=13) and pedestrian accidents (12.2, n=14), least in car/truck accidents (8.8, n=76). Altogether, RF gradually increased from rib 1 (n=140) towards rib 5 (n=517) and then decreased towards rib 12 (n=49), showing a bell-shaped distribution. More RF were detected on the left thorax (n=2027) than on the right (n=1720). Overall, most RF were found in the lateral (33%) and postero-lateral (29%) segment. Posterior RF mostly occurred in the lower thorax (63%), whereas anterior (100%), antero-lateral (87%), and lateral (63%) RF mostly appeared in the upper thorax. RF were distributed symmetrically to the sagittal plane, showing a hotspot (up to 98 RF) at rib levels 4 to 7 in the lateral segment and rib level 5 in the antero-lateral segment. In the car/truck accident group, 47% of all RF were in the lateral segment, in case of frontal collision (n=24) even 60%. Fall injuries (n=141) entailed mostly postero-lateral RF (35%). In case of falls >3 m (n=45), 48% more RF were detected on the left thorax compared to the right. CPR related SRF (n=33) showed a distinct fracture pattern, since 70% of all RF were located antero-laterally. Infractions were the most observed fracture type (44%), followed by oblique (25%) and transverse (18%) fractures, while 46% of all RF were dislocated (15% ≥ rib width). SRF show distinct fracture patterns depending on the cause of accident. Additional data should be collected to confirm our results and to establish a SRF classification system

An international Consensus Group has by a Delphi approach identified the topic of host factors affecting pin site infection to be one of the top 10 priorities in external fixator management. The aim of this study was to report the frequency of studies reporting on specific host factors as a significant association with pin site infection. Host factors to be assessed was: age, smoking, BMI and any comorbidity, diabetes, in particular. The intention was an ethological review, data was extracted if feasible, however no meta-analysis was performed. A systematic literature search was performed according to the PRISMA-guidelines. The protocol was registered before data extraction in PROSPERO. The search string was based on the PICO criterias. A logic grid with key concept and index terms was made. A search string was built assisted by a librarian. The literature search was executed in three electronic bibliographic databases, including Embase MEDLINE (1111 hits) and CINAHL (2066 hits) via Ovid and Cochrane Library CENTRAL (387 hits). Inclusion criteria: external fixation, >1 pin site infection, host factor of interest, peer-reviewed journal. Exclusion criteria: Not written in English, German, Danish, Swedish, or Norwegian, animal or cadaveric studies, location on head, neck, spine, cranium or thorax, editorials or conference abstract. The screening process was done using Covidence. A total of 3564 titles found. 3162 excluded by title and abstract screening. 140 assessed for full text eligibility. 11 studies included for data extraction. The included studies all had a retrospective design. Three identified as case-control studies. Generally the included studies was assessed to have a high risk of bias. A significant associations between pin site infection for following host factors: a) increased HbA1C level in diabetic patients; b) congestive heart failure in diabetic patients; c) less co-morbidity; d) preoperative osteomyelitis was found individually. This systematic literature search identified a surprisingly low number of studies examining for risk of pin site infection and host factors. Thus, this review most of all serves to demonstrate a gap of evidence about correlation between host factors and risk of pin site infection, and further studies are warranted

Introduction and Aims: The aim of this study was to evaluate the role of Whole Body MR (WBMR) in the staging of Musculo Skeletal (MSK) tumors, on a premise that a single study might present an alternative to the traditional imaging. Method: Forty-two patients were referred for MR evaluation for primary bone or soft tissue sarcomas. These studies were done between October 2001 and April 2003. Each patient had a WBMR, Localised MR, CXR and CT Thorax, and bone scan. Results: In 42 patients screened, 32 had a primary malignant musculo skeletal tumor. There were 14 primary bone tumors and 18 soft tissue sarcomas. Of the 32 patients concordance between WBMR imaging and the other staging modalities was identified in 27 patients. Discordance was identified in five patients. Two lesions were identified on WBMR and not seen on other imaging modalities. Two lesions not identified by WBMR, subsequently seen on CT thorax. One lesion was not seen on WBMR but seen on localised MR. Eight of the 32 patients had pulmonary metastases. In these patients concordance between the WBMR and CT Thorax was identified in five of eight patients and discordance was identified in three of eight patients where nodules were identified on CT Thorax and not on WBMR. Four patients were noted to have osseous metastases, all seen on WBMR. One bone scan failed to pick up metastasis seen on WBMR. One patient was identified as having a soft tissue metastasis on Whole Body MR, which was not identified on the conventional CT Thorax. Case studies:. Case 1: Metastatic Leiomyosarcoma. Case 2: Metastatic Ewings sarcoma. Case 3: Metastatic Epithelioid sarcoma. Conclusion: Whole body MR Scanning techniques allow whole body imaging in as little as eight minutes. It is a useful technique in staging and assessing total tumor burden, but still should be performed in conjunction with a CT Thorax

A self-control ratio, the spine-pelvis index (SPI), was proposed for the assessment of patients with adolescent idiopathic scoliosis (AIS) in this study. The aim was to evaluate the disproportionate growth between the spine and pelvis in these patients using SPI. A total of 64 female patients with thoracic AIS were randomly enrolled between December 2010 and October 2012 (mean age 13 years, standard deviation (. sd. ) 2.17; 9 to 18) and a further 73 healthy female patients with a mean age of 12.4 years (mean age 12.4 years, . sd. 2.24; 9 to 18), were randomly selected from a normal control database at our centre. The radiographic parameters measured included length of spine (LOS), height of spine (HOS), length of thoracic vertebrae (LOT), height of thoracic vertebrae (HOT), width of pelvis (WOP), height of pelvis (HOP) and width of thorax (WOT). SPI was defined as the ratio LOS/HOP. The SPI and LOT/HOP in patients with AIS showed a significant increase when compared with normal girls (p < 0.001 and p < 0.001 respectively), implying an abnormal pattern of growth of the spine relative to the pelvis in patients with AIS. . No significant difference in SPI was found in different age groups in the control group, making the SPI an age-independent parameter with a mean value of 2.219 (2.164 to 2.239). We also found that the SPI was not related to maturity in the control group. . This study, for the first time, used a self-control ratio to confirm the disproportionate patterns of growth of the spine and pelvis in patients with thoracic AIS, highlighting that the SPI is not affected by age or maturity. Cite this article: Bone Joint J 2015;97-B:1668–74

Aims. Flail chest from a blunt injury to the thorax is associated with significant morbidity and mortality. Its management globally is predominantly non-operative; however, there are an increasing number of centres which undertake surgical stabilisation. The aim of this meta-analysis was to compare the efficacy of this approach with that of non-operative management. Patients and Methods. A systematic search of the literature was carried out to identify randomised controlled trials (RCTs) which compared the clinical outcome of patients with a traumatic flail chest treated by surgical stabilisation of any kind with that of non-operative management. Results. Of 1273 papers identified, three RCTs reported the results of 123 patients with a flail chest. Surgical stabilisation was associated with a two thirds reduction in the incidence of pneumonia when compared with non-operative management (risk ratio 0.36, 95% confidence interval (CI) 0.15 to 0.85, p = 0.02). The duration of mechanical ventilation (mean difference -6.30 days, 95% CI -12.16 to -0.43, p = 0.04) and length of stay in an intensive care unit (mean difference -6.46 days, 95% CI 9.73 to -3.19, p = 0.0001) were significantly shorter in the operative group, as was the overall length of stay in hospital (mean difference -11.39, 95% CI -12.39 to -10.38, p < 0.0001). Conclusion. Surgical stabilisation for a traumatic flail chest is associated with significant clinical benefits in this meta-analysis of three relatively small RCTs. Cite this article: Bone Joint J 2016;98-B:1119–25

Accurate and reproducible measurement of three-dimensional shoulder kinematics would contribute to better understanding shoulder mechanics, and therefore to better diagnosing and treating shoulder pathologies. Current techniques of 3D kinematics analysis use external markers (acromial cluster or scapula locator) or medical imaging (MRI or CT-Scan). However those methods present some drawbacks such as skin movements for external markers or cost and irradiation for imaging techniques. The EOS low dose biplanar X-Rays system can be used to track the scapula, humerus and thorax for different arm elevation positions. The aim of this study is to propose a novel method to study scapulo-thoracic kinematics from biplanar X-rays and to assess its reliability during abduction in the scapular plane. This study is based on the EOS™ system (EOS Imaging, Paris, France), which allows acquisition of 2 calibrated, low dose, orthogonal radiographs with the subject standing at 30 to 40° angle of coronal rotation to the plane of one of the X-ray beams, in order to limit superimposition with the ribcage and spine. Seven abduction positions in the scapular plane were maintained by the subjects for 10 seconds, during X-ray acquisition. Between two positions, the subjects returned at rest position. Arm elevations were approximately 0, 10, 20, 30, 60, 90 and 150° (position 1 to 7). Six subjects were enrolled to perform a reproducibility study based on the 3D reconstructions of 2 experienced observers three times each. For each subject, a personalised 3D reconstruction of the scapula was created. The observer digitises clearly visible anatomical landmarks on both stereoradiographs for each arm position. These landmarks are used to make a first adjustment of a parameterised 3D model of the scapula. This provides a pre-personalised model of the subject's scapula which is then rigidly registered on each pair of X-rays until its retroprojection fits best on the contours that are visible on the X-rays. The thorax coordinate system (CS) was built following the ISB (International Society of Biomechanics) recommendations. The CS associated to the scapula was a glenoid centred CS based on the ellipse which fit on the glenoid rim on the 3D model of scapula. Scapular CS orientation and translation in the thorax CS was calculated following a Y,X,Z angle sequence for each position. Each 3D reconstruction of the scapula was performed in approximately 30 minutes. The most reproducible rotation was upward/downward rotation (along X axis) with a 95% confidence interval (95% CI) from 2.71° to 3.61°. Internal/external rotation and anterior/posterior tilting were comprised respectively between 5.18° to 8.01° and 5.50° to 7.23° (CI 95%). The most reproducible translation was superior-inferior translation (along Y axis) with a 95% CI from 1.22mm to 2.46mm. Translation along X axis (antero-posterior) and Z axis (medio-lateral) were comprised respectively between 2.49mm to 4.26mm and 2.47mm to 3.30mm (CI 95%). We presented a new technique for 3D functional quantitative analysis of the scapulo-thoracic joint. This technique can be used with confidence; uncertainty of the measures seems acceptable compared to the literature. Main advantages of this technique are the very low dose irradiation compared to the CT-Scan and the possibility to study arm elevation above 120°

Aims. The aims of this study were to evaluate the long-term outcome of surgery for bone or soft-tissue metastases from renal cell carcinoma (RCC) and to determine factors that affect prognosis. Patients and Methods. Between 1993 and 2014, 58 patients underwent surgery for bone or soft-tissue metastases from RCC at our hospital. There were 46 men and 12 women with a mean age of 60 years (25 to 84). The mean follow-up period was 52 months (1 to 257). The surgical sites included the spine (33 patients), appendicular skeleton (ten patients), pelvis (eight patients), thorax (four patients), and soft tissue (three patients). The surgical procedures were en bloc metastasectomy in 46 patients (including 33 patients of total en bloc spondylectomy (TES)) and intralesional curettage in 12 patients. These patients were retrospectively evaluated for factors associated with prognosis. Results. The one-, three-, five-, ten-, and 15-year overall survival (OS) rates were 89%, 75%, 62%, 48%, and 25%, respectively. The median survival time (MST) was 127 months for en bloc metastasectomy and 54 months for intralesional curettage and bone grafting. The median survival time was 127 months for the spine, 140 months for lesions of the appendicular skeleton, and 54 months for the pelvis. Multivariate analysis showed that non-clear cell type RCC and metastases to more than two sites were independent risk factors for a poor prognosis. Conclusion. Patients with bone or soft-tissue metastases from a RCC have a reasonable prognosis, making surgical resection a viable option even in patients in whom the metastases are advanced. Cite this article: Bone Joint J 2018;100-B:1241–8

Summary Statement. We measured scapulothoracic motions during humeral abduction with different humeral rotations in healthy subjects and whole cadaver models and clarified that humeral rotation significantly influenced scapular kinematics. Introduction. Scapular dyskinesis has been observed in various shoulder disorders such as impingement syndrome or rotator cuff tears. However, the relationship between scapular kinematics and humeral positions remains unclear. We hypothesised that humeral rotation would influence scapular motions during humeral abduction and measured scapular motion relative to the thorax in the healthy subjects and whole cadavers. Methods. Healthy Subjects: Twenty-four shoulders of twelve healthy subjects without shoulder disorders were enrolled. Three electromagnetic sensors were attached on the skin over the sternum, scapula and humerus. Scapular motions during scapular plane abduction (abduction) were measured. The measurements were performed with four hand positions, palm up, thumb up, palm down and thumb down. The elbow was kept extended in all measurements. Each measurement took 5 seconds and repeated three times. Cadavers: Twelve shoulders from 6 fresh whole cadavers were used. A cadaver was set in sitting position on a wooden chair without interrupting scapular motions. Electromagnetic sensors were attached on the thorax, scapula and humerus rigidly with transcortical pins. The elbow was kept in extended position by holding the forearm and the arm was moved passively. The measurements were performed during scapular plane abduction and scapular kinematics were measured in four hand positions, 1: thumb up, 2; palm up, 3; palm down, 4; thumb down as well as the healthy subjects. Each measurement took 5 seconds and repeated three times. Data Analysis: The coordinate system and rotation angles of the thorax, scapula and humerus were decided following ISB recommendation. A one-way analysis of variance was used to test the differences in 4 arm positions. Dunnet's multiple post hoc tests were used to identify the difference between thumb up model (neutral rotation) and other three arm positions. Results. Scapular posterior tilt increased during palm up abduction (healthy subjects −2.0° to 0.1°, cadaver −3.2° to −1.4° at 120° of abduction). During thumb-down abduction, scapular posterior tilt decreased (healthy subjects −4.1° to −8.0° at 110° of abduction, cadaver −3.2° to −8.6° at 120° of abduction) and scapular upward rotation increased (healthy subjects 21.0° to 26.1° at 110° of abduction, cadaver 25.3° to 31.1° at 120° of abduction). Thumb down abduction demonstrated no significant difference from thumb up position. Discussion. Scapular motions measured in healthy subjects and cadaver models showed similar patterns indicating that surface markers on the healthy subjects could track scapular motions successfully as bone markers in cadaver models. Humeral external rotation increased scapular posterior tilt and humeral internal rotation increased scapular anterior tilt and upward rotation. This suggests that position of the greater and lesser tuberosity and tension of the joint capsule caused scapular tilt and scapular upward rotation. Kinematic changes caused by humeral rotations were observed in earlier phase of abduction in healthy subjects than in cadaver models. This suggests that healthy subjects set scapular position beforehand not to increase subacromial pressure. Conclusion. Humeral rotation significantly influenced scapular kinematics. Assessment for these patterns is important for evaluation of shoulder pathology associated with abnormal scapular kinematics

Background. Bone lesions in Ewing's sarcoma (ES/PNET) have been traditionally diagnosed with bone Scan. PET-scan is emerging as a promising investigative modality for detection of metastatic lesions. In this prospective study, we compare the utility of both to detect the metastatic sites. Methods. One hundred and seventy five histologically proven cases of ESPNET from 2004-2009 were prospectively staged with bone scan and PET-scan with Breath- hold CT scan- thorax. The diagnostic value of PET-scan to pick up metastatic lesions was compared with bone scan. Results. The site of primary disease was axial in 62(35.4 %) patients, appendicular in 94(53.7 %) patients, and extraskeletal in 19 (10.8 %) patients. 24(13.7 %) patients were metastatic at presentation, while 151(86.2 %) patients had localized disease. In all patients with localized disease, bone scan did not detect any lesion other than that detected on PET-scan. In metastatic patients, PET-scan detected 12 patients with lymph node involvement which were not detected by bone scan, 10 patients were found to have lung metastasis by PET scan with breath-hold CT thorax, bony metastases were seen in two patients where the number and site of lesions were same in both PET and bone scan. In 19 patients with extraskeletal PNET, PET scan detected primary lesion in all while the bone scan was non-avid in any of these. Conclusion. PET- Scan was able to detect all the bony lesions picked up by bone scan at baseline in newly diagnosed patients of PNET/ES. Furthermore, PET-scan was able to detect extra-skeletal sites of metastases. We conclude that PET scan may obviate the need of bone scan in the diagnostic work up of patients with Ewing's sarcoma

Introduction. Children with early-onset scoliosis (EOS) with rib hump chest-wall distortion or fused/absent ribs have thoracic insufficiency syndrome (TIS). Commonly, respiration is adversely affected by loss of lung volume from chest-wall constriction and clinical loss of active rib cage expansion. The dynamic thoracic components of diaphragm or rib cage lung expansion during respiration is poorly characterised by radiograph or CT scan. Pulmonary function tests indicate only hemithorax performance. Dynamic lung MRI, however, can visualise both chest-wall and diaphragm motion, allowing assessment of each individual hemithorax performance, so that a dynamic classification system of the thoracic function can be developed. Methods. Ten patients with TIS underwent dynamic lung MRI testing as part of the routine clinical preoperative work-up. Each hemithorax was graded: 1=intact motion of both chest wall and diaphragm; 2=primarily loss of chest-wall motion with minimal diaphragm abnormality; 3=substantial loss of diaphragm excursion with minimal loss or compensatory hyperkinesis of chest wall; and 4=substantial loss of both diaphragm and chest-wall motion. The grades for each hemithorax were added and averaged to form the thoracic function score. Ranges of scores were grouped into levels of clinical thoracic performance: level I (score 1–1·5); level II (>1·5–2·5); level III (>2·5–3·5); and level IV(>3·5–4·0). Results. Of nine patients with EOS, two were level I, three were level II, and four were level III. In four patients there was marked posterior obstruction of diaphragmatic excursion by soft-tissue organs. One patient with hypoplastic thorax without scoliosis was level II. Conclusions. Thoracic function index is a new thoracic performance approach based on dynamic lung MRI that has potential to identify biomechanical abnormalities of the thorax in EOS that cause restrictive lung disease. This index could provide insight into how to reverse the abnormality with new types of surgeries. Posterior obstructive blockade of the diaphragm is identified as a new cause for restrictive lung disease in EOS

The function of the shoulder joint has traditionally been evaluated based on range of motion (ROM) in predefined anatomical planes and also by using functional scores, which assessed shoulder function based on the ability to conduct certain activities of daily living (ADLs). However, measuring ROM only in terms of flexion-extension, abduction-adduction and internal-external rotation may under-account for the 3-dimensional mobility of the shoulder joint. Furthermore, functional scores, such as the Oxford shoulder score or American shoulder and elbow surgeons (ASES) score, are subjective measures and are not an accurate assessment of shoulder joint function. In this study, we proposed the use of the globe model of the shoulder joint which can be used to provide an objective measure of the global ROM and also function of the shoulder joint – termed the Global and Functional arc of motion (GAM and FAM). Thirty-three young, healthy male patients (23.7 ± 1.5 years) were recruited and tasked to perform eight ADLs and a full humeral circumduction movement which represented their active global ROM. Reflective markers were placed in accordance to the International Society of Biomechanics (ISB) and optical-based motion capture cameras were used to track relative motion of the dominant humerus with respect to the thorax (i.e. thoracohumeral motion). The GAM and FAM were generated by plotting the thoracohumeral on a spherical coordinate system during global ROM and the eight ADLs respectively. Shoulder joint global ROM and function were quantified by calculating the area enclosed by the closed loop of GAM and FAM respectively. The spherical coordinate system, or more commonly referred to as the globe model, describes thoracohumeral movement using plane of elevation (POE), angle of elevation (AOE) and rotation. In our model, POE and AOE represents longitude and latitude of the globe respectively, and rotation is depicted using a red-green-blue (RGB) colour scale. Overall, subject's GAM of the shoulder joint covered an area of 4.64 ± 0.48 units2 compared to only 1.12 ± 0.26 units2 for the FAM. Subjects only required 24.4 ± 5.7 % of their global shoulder ROM for basic daily functioning. Studies that reduced shoulder joint movement into planar movements (i.e. sagittal, coronal and rotation) do not account for the 3-dimensional nature of the joint and doing so may overestimate the requirement of the shoulder joint for ADLs relative to its ROM in each plane. While others have attempted to use the globe model, such studies tend to reduce the globe into its descriptive angles (i.e. POE, AOE and rotation), reducing its intuitiveness. In contrast, by keeping an intact globe, the proposed globe model was more intuitive and yet capable of quantifying both shoulder joint global ROM and function. Doing so, we found that young healthy subjects only required approximately a quarter of their global ROM of the shoulder joint to complete the most common daily tasks, which was significantly less than what was previously reported

Objectives: Behind armour blunt trauma (BABT) to the thorax results from motion of the body wall arising from the defeat of high-energy projectiles by body armour. NATO predicts that BABT will increase in future conflicts. This study aims to define biomechanical tolerance levels for BABT to the lateral thorax. Methods: Terminally anaesthetised pigs (n=19) were subjected to 4 levels of severity of BABT (Table). Two types of armour plates were used. Group 1 were subjected to a 7.62 mm round (INIBA armour) whilst group 2 was subjected to a 12.7 mm round (EBA armour) the latter group being further subdivided by the presence or absence of two thicknesses of trauma attenuating backing (TAB). Accelerometers were attached to the pleural aspect of ribs 7, 8 and 9 mid-way between the spine and the sternum. Results: Outcome was assessed by classifying severity of injury, in terms of mortality, into 3 groups – survivors (animals surviving to 6 h post-impact), early (0–30 min) and late deaths (> 30 min–6 h). The peak acceleration values were obtained from the accelerometer closest to the point of impact. Mean peak acceleration was significantly higher in the early death group (1070 km/s. 2. ) compared to survivors (591 km/s. 2. ) (p< 0.05). There were 6 early deaths, 5 late deaths and 8 survivors. In terms of outcome Group 1 represented the lowest threat with 5 survivors and 1 late death. The animals in Group 2 with no TAB fared worst with 2 early deaths, one late death and no survivors. Deaths were due to respiratory failure/apnoea (n=4), pneumothorax (n=2), haemothorax (n=1), respiratory failure/pulmonary contusion (n=3) and ventricular fibrillation (n=1). Conclusions: Peak acceleration of the body wall may be used to rank the outcome following BABT. There is a significant difference in peak acceleration at the extremes of the injury scale

To date the principal focus of the mechanism of cervical spine fracture has been directed towards head/neck circumference and vertebral geometric dimensions. However the role of other measurements, including chest circumference and neck length, in a standard cervical fracture population has not yet been studied in detail. Cervical fractures often involve flexion/extension type mechanisms of injury, with the head and cervical spine flexing/extending, using the thorax as an end point of contact. Thus, the thorax may play an important role in neck injuries. Study design: We prospectively studied all patients with cervical spine fractures who were admitted to the National Spinal Injuries Unit from 1 July 2000 to 1 March 2001. Anthropometrical measurement of head circumference, neck circumference, chest circumference, and neck length were analysed. Ages ranged from 18 to 55 years, and all patients with concomitant cervical pathology were excluded from the study. Mechanism of injury involved flexion/extension type injuries in all cases; those with direct axial loading were excluded. A control group of 40 patients (age 18–50 years) involved in high velocity trauma with associated long bone fractures, in whom cervical injury was suspected, but who were without any cervical fracture, or associated pathology, were similarly measured. Results: Our analysis revealed a statistically significant increase in chest size in the male control group versus the male fracture group (97.89 cm versus 94.19 cm, P < 0.05, Student’s t-test). There was a correspondingly significant increase in chest circumference between the female controls versus the female fracture group (92.33 cm versus 88.88 cm, P < 0.05, Student’s t-test). Our results revealed no statistical difference in head circumference, neck circumference, or neck length between each of the groupings. These results indicate a proportionately larger chest may be a protective factor in cervical spine fractures

Aims

The objective of this study was to compare simulated range of motion (ROM) for reverse total shoulder arthroplasty (rTSA) with and without adjustment for scapulothoracic orientation in a global reference system. We hypothesized that values for simulated ROM in preoperative planning software with and without adjustment for scapulothoracic orientation would be significantly different.

This study examines the case of a spondylodiscitis in the thoracic spine caused by MRSA which led to two orthopaedic surgeries followed by rehabilitation. A 72.6 year old woman suffered a cutaneous infection with herpes zoster on the right dorsal thorax – 2 weeks later she presented a sepsis by MSSA. 2 month later she lamented sever pain in the thoracic column. She were hospitalized presenting a sepsis by MRSA. One month later it was found an infectious spondylodiscitis from thoracic vertebra T 8 to T 11 with destruction of the intervertebral spaces. To eliminate the infection and stabilize the dorsal column she was undertaken an first orthopaedic surgery by dorsal decompression and dorsal spondylodesis from T 6 – L 2; intraoperative microbiology: MRSA. 3 month later she was undertaken a second surgery by a lateral transthoracic decompression and intervertebral stabilization from T 9 – T 10 with tricortical bone chips and inlay of sponge with Calcibon and Gentamycin. The following rehabilitation took her to a reasonable result. The cost of the first treatment with dorsal stabilization was € 17.694,24, the second surgery was € 13.678,88; the cost of both rehabilitations was € 4.160,00. The finally costs for the whole treatment for the insurance was € 47,442,62. This retrospective case report shows the high costs for a treatment of spondylodiscitis caused by MRSA, not taking in consideration the harm and prolonged pain of the patient

Background. The improvement of the rib cage deformity (RCD) after surgery correction has not been correlated in detail with the correction of vertebral axial rotation (AR). The loss of at the rib cage after correction has been never monitored. The hypothesis of this work was that the aesthetic improvement of RCD in adolescent idiopathic scoliosis (AIS) does not follow completely the reduction of thoracic AR after correction surgery. Moreover, lesser correction of thorax deformity could be expected in mature patients with more rigid curves. Methods. Multicenter prospective study of the modifications of the rib cage deformity in 24 patients operated because of AIS Lenke type 1A. RDC was assessed in the preoperative MRI exams including the thoracic perimeter. Vertebral AR was quantified by the RaSac angle. Anterior and posterior rib hump, and the translation of the sternum were measured in mm according to standard protocols. All these parameters were assessed in the immediate post-op period and 2-years after surgery using CT-scan axial slides. In all cases, a vertebral derotation technique performed by asymmetric rod bending was used. Immature (Risser 0–2) and mature (Risser 3–4) patients were compared. Results. Mean age of patients was 14±2 years. The preoperative curve magnitude was 56.2±8.3 Cobb degrees. RaSac at the apex was 27.2±2.8 degrees. There were 10 immature and 14 mature patients. There were no differences between the two groups in all the radiological measurements of the curves. Immature patients showed lesser posterior rib hump as compared to mature cases (14.9±4.1 mm versus 38.1±22.9; p<0.001). Postoperative vertebral AR was lesser in immature patients (2.0±1.2 versus 7.9±2.4 degrees) and increased slightly at 2-year check-up. The posterior rib hump showed also a slightly increased 2 years after surgery. In 18 cases (75%), a contralateral anterior rib hump less than 3 mm emerged after surgery that diminished but not disappeared at 2-year check-up. Conclusions. The rib cage deformity showed a lesser correction than the vertebral axial rotation. Besides this finding, immature patients showed more rib cage plasticity showing both greater modifications after surgery, and higher loss of correction during follow-up. Level of evidence. Level IV

Rotator cuff pathology is the main cause of shoulder pain and dysfunction in older adults. When a rotator cuff tear involves the subscapularis tendon, the symptoms are usually more severe and the prognosis after surgery must be guarded. Isolated subscapularis tears represent 18% of all rotator cuff tears and arthroscopic repair is a good alternative primary treatment. However, when the tendon is deemed irreparable, tendon transfers are the only option for younger or high-functioning patients. The aim of this review is to describe the indications, biomechanical principles, and outcomes which have been reported for tendon transfers, which are available for the treatment of irreparable subscapularis tears.

The best tendon to be transferred remains controversial. Pectoralis major transfer was described more than 30 years ago to treat patients with failed surgery for instability of the shoulder. It has subsequently been used extensively to manage irreparable subscapularis tendon tears in many clinical settings. Although pectoralis major reproduces the position and orientation of the subscapularis in the coronal plane, its position in the axial plane – anterior to the rib cage – is clearly different and does not allow it to function as an ideal transfer. Consistent relief of pain and moderate recovery of strength and function have been reported following the use of this transfer. In an attempt to improve on these results, latissimus dorsi tendon transfer was proposed as an alternative and the technique has evolved from an open to an arthroscopic procedure. Satisfactory relief of pain and improvements in functional shoulder scores have recently been reported following its use. Both pectoralis minor and upper trapezius transfers have also been used in these patients, but the outcomes that have been reported do not support their widespread use.

Cite this article: Bone Joint J 2024;106-B(9):970–977.

A retrospective analysis of all paediatric patients admitted to Camp Bastion Role 3 between June 2006 and March 2013 was conducted from the UK trauma database. Patient demographics, mechanism of injury, anatomical distribution of injury and treatment are described. Two hundred and ninety eight children were admitted, 225 males with a median age of 9 years old. The highest number of cases (78) was recorded in 2011. Overall there were 55 fatalities (85.6% male). Most injuries were by IED (68% of cases) with 74% requiring operative intervention. Seventy-four percent of casualties had three or more anatomical regional injuries. Whilst the most commonly injured region was the lower limb (78%), head injuries were seen in 41%, abdominal injuries in 48% and thorax injuries in 44%. Debridement (including amputations) (59.4%) and laparotomy (30.6%) were the commonest operations performed. Sixty percent of cases were in theatre within one hour of arrival. Amongst survivors the mean ISS score was 17 and amongst fatalities 43; NISS 22 and 51; RTS 5.45 and 2.91. Paediatric blast injuries represent a significant burden to medical facilities in contemporary conflict. Whilst limb injuries predominate, the proportion of head and torso injuries is higher than seen in adult blast injuries