1. The normal vascular anatomy of flexor tendons and extensor tendons in the hind limb of the rabbit is outlined. A marked difference between a tendon in a sheath and a tendon with a paratenon is shown, the latter having a much better blood supply. 2. The vascular reaction in flexor tendon divided within a sheath is shown. 3. The revascularisation of free grafts is illustrated and the differences between tendon with sheath and tendon with paratenon are detailed. 4. Experiments are reported to show that the microcirculation within a "vascular" tendon can support a pedicle graft in the rabbit. Such pedicle grafts are shown to be inferior to free grafts of "avascular" tendon, but the vascularity within the pedicle tendon graft may be modified by "blocking" the surface with silastic tubing. 5. The implications of this work on tendon grafting are discussed, together with a review of additional experimental work in related fields

1. The form and distribution of the blood vessels within the adult human femoral head are described.

2. It has been found possible to delimit the proximal femoral epiphysis in mature years by reference to arterial form alone.

3. Two morphologically different sets of vessels are described interposed between the arterioles and venules of the bone marrow. One, a true capillary bed, lies mainly within the fat marrow; the other, constituted by sinusoids, lies within the red marrow. The departure of these findings from current views is noted.

4. A capillary system is described in relationship to the calcified zone of the articular cartilage.

5. No evidence has been found in support of the common belief that the circulation within the femoral head decreases quantitatively with advancing age.

1. The results of a study of the characteristics of the vessels found in forty-six human femoral heads during the growth period are described.

2. Of the three different sources of blood entering the human adult femoral head it was found that from birth to about three to four years the vessels of the ligamentum teres do not contribute to the nourishment of the head.

3. After the fourth year the metaphysial vessels decrease in importance until they finally disappear, leaving the head with only one source of blood through the lateral epiphysial vessels; the ligamentum teres is not yet contributing to the circulation of the head.

4. After about eight or nine years it was found that the vessels of the ligamentum teres contribute to the blood supply of the head while the metaphysial blood flow is still arrested.

5. Finally, at puberty, after a period of activity of the metaphysial vessels, epiphysial fusion takes place, bringing together the three sources of blood characteristic of the adult.

1. Vascular anatomical studies of the spine are described and the possibility of spread of infection from pelvis to spine through the paravertebral venous plexus is discussed.

2. Though a venous route does exist, our studies do not support the supposition that infection is likely to spread by this route; nor is there any clear clinical, pathological or anatomical evidence that such spread occurs.

3. Nineteen cases of pyogenic osteomyelitis of the spine are recorded, six of which followed urinary infections. The condition is compared with osteomyelitis as it occurs in the other bones of adults.

Aims

Dual plating of distal femoral fractures with medial and lateral implants has been performed to improve construct mechanics and alignment, in cases where isolated lateral plating would be insufficient. This may potentially compromise vascularity, paradoxically impairing healing. This study investigates effects of single versus dual plating on distal femoral vascularity.

A new method of vascularised tibial grafting has been developed for the treatment of avascular necrosis (AVN) of the talus and secondary osteoarthritis (OA) of the ankle. We used 40 cadavers to identify the vascular anatomy of the distal tibia in order to establish how to elevate a vascularised tibial graft safely. Between 2008 and 2012, eight patients (three male, five female, mean age 50 years; 26 to 68) with isolated AVN of the talus and 12 patients (four male, eight female, mean age 58 years; 23 to 76) with secondary OA underwent vascularised bone grafting from the distal tibia either to revascularise the talus or for arthrodesis. The radiological and clinical outcomes were evaluated at a mean follow-up of 31 months (24 to 62). The peri-malleolar arterial arch was confirmed in the cadaveric study. A vascularised bone graft could be elevated safely using the peri-malleolar pedicle. The clinical outcomes for the group with AVN of the talus assessed with the mean Mazur ankle grading scores, improved significantly from 39 points (21 to 48) pre-operatively to 81 points (73 to 90) at the final follow-up (p = 0.01). In all eight revascularisations, bone healing was obtained without progression to talar collapse, and union was established in 11 of 12 vascularised arthrodeses at a mean follow-up of 34 months (24 to 58). MRI showed revascularisation of the talus in all patients. . We conclude that a vascularised tibial graft can be used both for revascularisation of the talus and for the arthrodesis of the ankle in patients with OA secondary to AVN of the talus. Cite this article: Bone Joint J 2015; 97-B:802–8

Aims. Despite the expansion of arthroscopic surgery of the shoulder, the open deltopectoral approach is increasingly used for the fixation of fractures and arthroplasty of the shoulder. The anatomy of the terminal branches of the posterior circumflex humeral artery (PCHA) has not been described before. We undertook an investigation to correct this omission. Patients and Methods. The vascular anatomy encountered during 100 consecutive elective deltopectoral approaches was recorded, and the common variants of the terminal branches of the PCHA are described. Results. In total, 92 patients (92%) had a terminal branch that crossed the space between the deltoid and the proximal humerus and which was therefore vulnerable to tearing or avulsion during the insertion of the blade of a retractor during the deltopectoral approach to the shoulder. In 75 patients (75%) there was a single vessel, in 16 (16%) a double vessel and in one a triple vessel. Conclusion. The relationship of these vessels to the landmark of the tendon of the insertion of pectoralis major into the proximal humerus is described. Damage to these previously undocumented branches can cause persistent bleeding leading to prolonged surgery and post-operative haematoma and infection, as well as poor visualisation during the procedure. Cite this article: Bone Joint J 2016;98-B:1395–8

Aims

The aim of this study was to reassess the rate of neurological, psoas-related, and abdominal complications associated with L4-L5 lateral lumbar interbody fusion (LLIF) undertaken using a standardized preoperative assessment and surgical technique.

Despite the expansion of arthroscopic surgery of the shoulder, the open deltopectoral approach to the shoulder is still frequently used, for example in fracture fixation and shoulder replacement. However, it is sometimes accompanied by unexpected bleeding. The cephalic vein is the landmark for the deltopectoral interval, yet its intimate relationship with the deltoid artery, and the anatomical variations in that structure, have not previously been documented. In this study the vascular anatomy encountered during 100 consecutive elective deltopectoral approaches was recorded and the common variants described. Two common variants of the deltoid artery were encountered. In type I (71%) it crosses the interval and tunnels into the deltoid muscle without encountering the cephalic vein. However, in type II (21%) it crosses the interval, reaches the cephalic vein and then runs down, medial to and behind it, giving off several small arterial branches that return back across the interval to the pectoralis major. Several minor variations were also seen (8%). These variations in the deltoid artery have not previously been described and may lead to confusion and unexpected bleeding during this standard anterior surgical approach to the shoulder. Cite this article: Bone Joint J 2013;95-B:657–9

The use of an osteocutaneous free fibular graft as a single-stage reconstructive procedure for composite tissue loss is increasingly common. Detailed anatomical study in cadavers of the blood supply to the graft demonstrates cutaneous arteries arising from the peroneal artery and then passing along the posterior surface of the lateral intermuscular septum. These vessels pierce the crural fascia and then ramify to supply the skin. Knowledge of the vascular anatomy of the skin overlying the fibula is essential to the success of the graft

1. Three new cases of injury to main arteries at orthopaedic operations are described, and a follow-up of two previously described cases is given. The rarity of these accidents is a credit to those engaged in orthopaedic surgery, for many orthopaedic operations are done very close to great vessels, and often under the bloodless conditions of a tourniquet. Nevertheless, it is well to have the risk of great vessel injury in mind because such an accident, although rare, may be a serious threat to life or limb. 2. It is important to repair the damaged artery rather than ligate it because the risk to the growth or viability of the limb is lessened. 3. The aim should be a return to full function with as near normal a vascular anatomy as possible

1. A study has been made of the blood supply of the human patella. There are two main systems, one penetrating the middle third of the anterior surface and the other entering the lower pole of the bone behind the patellar ligament. 2. The relationship between these findings and the complication of avascular necrosis of the upper fragment of the patella after fracture is discussed. Forty-one cases of necrosis after operation have been studied and notes made on the pathological, clinical and radiological evolution of the condition. Whatever the severity of the ischaemic necrosis the prognosis was not substantially affected and good function was observed in all knees six months after injury. 3. The surgical implications of the vascular anatomy are discussed. It is pointed out that surgical intervention may damage the blood vessels entering the anterior surface of the bone and that circumferential repair of patellar fractures may strangle the vessels in their peripatellar course. 4. If removal of one-half of the patella after a transverse fracture is indicated, vascular studies indicate that the upper fragment should be removed

Aims

This study investigated the effects of transcatheter arterial embolization (TAE) on pain, function, and quality of life in people with early-stage symptomatic knee osteoarthritis (OA) compared to a sham procedure.

The October 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: Outcomes of open reduction in children with developmental hip dislocation: a multicentre experience over a decade; A torn discoid lateral meniscus impacts lower-limb alignment regardless of age; Who benefits from allowing the physis to grow in slipped capital femoral epiphysis?; Consensus guidelines on the management of musculoskeletal infection affecting children in the UK; Diagnosis of developmental dysplasia of the hip by ultrasound imaging using deep learning; Outcomes at a mean of 13 years after proximal humeral fracture during adolescence; Clubfeet treated according to Ponseti at four years; Controlled ankle movement boot provides improved outcomes with lower complications than short leg walking cast.

Aims

Open tibial fractures are limb-threatening injuries. While limb loss is rare in children, deep infection and nonunion rates of up to 15% and 8% are reported, respectively. We manage these injuries in a similar manner to those in adults, with a combined orthoplastic approach, often involving the use of vascularised free flaps. We report the orthopaedic and plastic surgical outcomes of a consecutive series of patients over a five-year period, which includes the largest cohort of free flaps for trauma in children to date.

Aims

To evaluate the perioperative complications associated with total en bloc spondylectomy (TES) in patients with spinal tumours, based on the extent and level of tumour resection.

Objectives

As well as debridement and irrigation, soft-tissue coverage, and osseous stabilization, systemic antibiotic prophylaxis is considered the benchmark in the management of open fractures and considerably reduces the risk of subsequent fracture-related infections (FRI). The direct application of antibiotics in the surgical field (local antibiotics) has been used for decades as additional prophylaxis in open fractures, although definitive evidence confirming a beneficial effect is scarce. The purpose of the present study was to review the clinical evidence regarding the effect of prophylactic application of local antibiotics in open limb fractures.

Aims

This multicentre, retrospective study aimed to improve our knowledge of primary pyogenic spinal infections in children by analyzing a large consecutive case series.

Aims

This retrospective cohort study compared the results of vascularised and non-vascularised anterior sliding tibial grafts for the treatment of osteoarthritis (OA)of the ankle secondary to osteonecrosis of the talus.

In spite of extensive accounts describing the blood supply to the femoral head, the prediction of avascular necrosis is elusive. Current opinion emphasises the contributions of the superior retinacular artery but may not explain the clinical outcome in many situations, including intramedullary nailing of the femur and resurfacing of the hip. We considered that significant additional contribution to the vascularity of the femoral head may exist. A total of 14 fresh-frozen hips were dissected and the medial circumflex femoral artery was cannulated in the femoral triangle. On the test side, this vessel was ligated, with the femoral head receiving its blood supply from the inferior vincular artery alone. Gadolinium contrast-enhanced MRI was then performed simultaneously on both control and test specimens. Polyurethane was injected, and gross dissection of the specimens was performed to confirm the extraosseous anatomy and the injection of contrast. The inferior vincular artery was found in every specimen and had a significant contribution to the vascularity of the femoral head. The head was divided into four quadrants: medial (0), superior (1), lateral (2) and inferior (3). In our study specimens the inferior vincular artery contributed a mean of 56% (25% to 90%) of blood flow in quadrant 0, 34% (14% to 80%) of quadrant 1, 37% (18% to 48%) of quadrant 2 and 68% (20% to 98%) in quadrant 3. Extensive intra-osseous anastomoses existed between the superior retinacular arteries, the inferior vincular artery and the subfoveal plexus.

In this case report a four-year-old girl with ulnar dimelia is described. She had six digits without mirror symmetry in her right hand. The first pre-axial digit was excised and true pollicisation performed for the second pre-axial digit. The arterial anatomy was abnormal but there was not symmetrical development of the arterial tree.

We determined the effect of the surgical approach on perfusion of the femoral head during hip resurfacing arthroplasty by measuring the concentration of cefuroxime in bone samples from the femoral head. A total of 20 operations were performed through either a transgluteal or an extended posterolateral approach.

The concentration of cefuroxime in bone was significantly greater when using the transgluteal approach (mean 15.7 mg/kg; 95% confidence interval 12.3 to 19.1) compared with that using the posterolateral approach (mean 5.6 mg/kg; 95% confidence interval 3.5 to 7.8; p < 0.001). In one patient, who had the operation through a posterolateral approach, cefuroxime was undetectable.

Using cefuroxime as an indirect measure of blood flow, the posterolateral approach was found to be associated with a significant reduction in the blood supply to the femoral head during resurfacing arthroplasty compared with the transgluteal approach.

The use of joint-preserving surgery of the hip has been largely abandoned since the introduction of total hip replacement. However, with the modification of such techniques as pelvic osteotomy, and the introduction of intracapsular procedures such as surgical hip dislocation and arthroscopy, previously unexpected options for the surgical treatment of sequelae of childhood conditions, including developmental dysplasia of the hip, slipped upper femoral epiphysis and Perthes’ disease, have become available. Moreover, femoroacetabular impingement has been identified as a significant aetiological factor in the development of osteoarthritis in many hips previously considered to suffer from primary osteoarthritis.

As mechanical causes of degenerative joint disease are now recognised earlier in the disease process, these techniques may be used to decelerate or even prevent progression to osteoarthritis. We review the recent development of these concepts and the associated surgical techniques.

Cite this article: Bone Joint J 2014;96-B:5–18.

We report a case of osteonecrosis of the femoral head in a young man who is a carrier of the prothrombin gene mutation. We suggest that an electrical injury to his lower limb may have triggered intravascular thrombosis as a result of this mutation with subsequent osteonecrosis of the femoral head. No case of osteonecrosis of the femoral head secondary to a distant electrical injury has previously been reported.

This paper summarises the current knowledge on the effects of medullary reaming of long-bone fractures. Following a review of intramedullary vascular physiology, the consequences for vascularity, the autograft effects, the generation of heat, and fat embolism are outlined. Also, alternative reaming techniques are described.

We have investigated the significance of the method of treatment on the oncological and functional outcomes and on the complications in 184 patients with soft-tissue sarcomas of the adductor compartment managed at three international centres. The overall survival at five years was 65% and was related to the grade at diagnosis and the size of the tumour. There was no difference in overall survival between the three centres. There was, however, a significant difference in local control with a rate of 28% in Centre 1 compared with 10% in Centre 2 and 5% in Centre 3.

The overall mean functional score using the Toronto Extremity Salvage Score in 70 patients was 77% but was significantly worse in patients with wound complications or high-grade tumours. The scores were not affected by the timing of radiotherapy or the use of muscle flaps.

This large series of soft-tissue sarcomas of the adductor compartment has shown that factors influencing survival do not vary across the international boundaries studied, but that methods of treatment affect complications, local recurrence and function.