Aims

Improvements in the evaluation of outcome after nerve transfers are required. The assessment of force using the Medical Research Council (MRC) grades (0 to 5) is not suitable for this purpose. A ceiling effect is encountered within MRC grade 4/5 rendering this tool insensitive. Our aim was to show how the strength of flexion of the elbow could be assessed in patients who have undergone a re-innervation procedure using a continuous measurement scale.

Introduction

The purpose of this study was to assess the rate of revision subacromial decompression and identify different pathologies.

The Ponseti and French taping methods have reduced the incidence of major surgery in congenital idiopathic clubfoot but incur a significant burden of care, including heel-cord tenotomy. We developed a non-operative regime to reduce treatment intensity without affecting outcome. We treated 402 primary idiopathic clubfeet in patients aged < three months who presented between September 1991 and August 2008. Their Harrold and Walker grades were 6.0% mild, 25.6% moderate and 68.4% severe. All underwent a dynamic outpatient taping regime over five weeks based on Ponseti manipulation, modified Jones strapping and home exercises. Feet with residual equinus (six feet, 1.5%) or relapse within six months (83 feet, 20.9%) underwent one to three additional tapings. Correction was maintained with below-knee splints, exercises and shoes. The clinical outcome at three years of age (385 feet, 95.8% follow-up) showed that taping alone corrected 357 feet (92.7%, ‘good’). Late relapses or failure of taping required limited posterior release in 20 feet (5.2%, ‘fair’) or posteromedial release in eight feet (2.1%, ‘poor’). The long-term (> 10 years) outcomes in 44 feet (23.8% follow-up) were assessed by the Laaveg–Ponseti method as excellent (23 feet, 52.3%), good (17 feet, 38.6%), fair (three feet, 6.8%) or poor (one foot, 2.3%). These compare favourably with published long-term results of the Ponseti or French methods. This dynamic taping regime is a simple non-operative method that delivers improved medium-term and promising long-term results.

Cite this article: Bone Joint J 2013;95-B:271–8.

Background: Paget’s disease of the sacrum is rare. A monostotic lesion in the sacrum is reported. A case with an unusual presentation is discussed.

Introduction: A 53 years old man was referred to our unit with a 5–6 months history of abdomen discomfort and tenesmus.

He had a history of low back pain and was noted to have an area of increasing numbness over the left buttock. A prominence of the left sacroiliac region was noticed and on rectal examination a bony hard mass was palpable posteriorly.

A plain x-ray of the pelvis showed a gross expansion and enlargement of the sacrum with lucent area and widespread new bone formation.

Biochemical test revealed a raised alkaline phosphatase level.

A MRI scan reported a large tumour arising from the sacrum. with a differential of chordoma, paget’s sarcoma or an osteochondroma.

In addition a bone scan reported raised uptake in the pelvis.

An open incision biopsy was performed and the histology report was consistent with appearance of paget’s disease with no evidence of sarcoma.

Interestingly the patient symptoms improved after the biopsy. He was commenced on biphosphonates. A surveillance scan is to be performed in due course.

Conclusion: This case was unusual in terms of clinical presentation and location.

Furthermore even the most sophisticated imaging modalities may fail to establish the diagnosis and biopsy is then necessary. This should always be performed in specialized centers, in order to minimise complications.