Injuries to the quadriceps muscle group are common in athletes performing high-speed running and kicking sports. The complex anatomy of the rectus femoris puts it at greatest risk of injury. There is variability in prognosis in the literature, with reinjury rates as high as 67% in the severe graded proximal tear. Studies have highlighted that athletes can reinjure after nonoperative management, and some benefit may be derived from surgical repair to restore function and return to sport (RTS). This injury is potentially career-threatening in the elite-level athlete, and we aim to highlight the key recent literature on interventions to restore strength and function to allow early RTS while reducing the risk of injury recurrence. This article reviews the optimal diagnostic strategies and classification of quadriceps injuries. We highlight the unique anatomy of each injury on MRI and the outcomes of both nonoperative and operative treatment, providing an evidence-based management framework for athletes.

Cite this article: Bone Joint J 2023;105-B(12):1244–1251.

Biochemical markers of bone-turnover have long been used to complement the radiological assessment of patients with metabolic bone disease. Their implementation in daily clinical practice has been helpful in the understanding of the pathogenesis of osteoporosis, the selection of the optimal dose and the understanding of the progression of the onset and resolution of treatment. Since they are derived from both cortical and trabecular bone, they reflect the metabolic activity of the entire skeleton rather than that of individual cells or the process of mineralisation. Quantitative changes in skeletal-turnover can be assessed easily and non-invasively by the measurement of bone-turnover markers. They are commonly subdivided into three categories; 1) bone-resorption markers, 2) osteoclast regulatory proteins and 3) bone-formation markers. Because of the rapidly accumulating new knowledge of bone matrix biochemistry, attempts have been made to use them in the interpretation and characterisation of various stages of the healing of fractures. Early knowledge of the individual progress of a fracture could help to avoid delayed or nonunion by enabling modification of the host’s biological response. The levels of bone-turnover markers vary throughout the course of fracture repair with their rates of change being dependent on the size of the fracture and the time that it will take to heal. However, their short-term biological variability, the relatively low bone specificity exerted, given that the production and destruction of collagen is not limited to bone, as well as the influence of the host’s metabolism on their concentration, produce considerable intra- and inter-individual variability in their interpretation. Despite this, the possible role of bone-turnover markers in the assessment of progression to union, the risks of delayed or nonunion and the impact of innovations to accelerate fracture healing must not be ignored

The literature on fracture repair has been reviewed. The traditional concepts of delayed and nonunion have been examined in terms of the phased and balanced anabolic and catabolic responses in bone repair. The role of medical manipulation of these inter-related responses in the fracture healing have been considered

High energy fractures of the pelvis are a challenging problem both in the immediate post-injury phase and later when definitive fixation is undertaken. No single management algorithm can be applied because of associated injuries and the wide variety of trauma systems that have evolved around the world. Initial management is aimed at saving life and this is most likely to be achieved with an approach that seeks to identify and treat life-threatening injuries in order of priority. Early mortality after a pelvic fracture is most commonly due to major haemorrhage or catastrophic brain injury. In this article we review the role of pelvic binders, angiographic embolisation, pelvic packing, early internal fixation and blood transfusion with regard to controlling haemorrhage. Definitive fixation seeks to prevent deformity and reduce complications. We believe this should be undertaken by specialist surgeons in a hospital resourced, equipped and staffed to manage the whole spectrum of major trauma. We describe the most common modes of internal fixation by injury type and review the factors that influence delayed mortality, adverse functional outcome, sexual dysfunction and venous thromboembolism

Since 1996 more than one million metal-on-metal articulations have been implanted worldwide. Adverse reactions to metal debris are escalating. Here we present an algorithmic approach to patient management. The general approach to all arthroplasty patients returning for follow-up begins with a detailed history, querying for pain, discomfort or compromise of function. Symptomatic patients should be evaluated for intra-articular and extra-articular causes of pain. In large head MoM arthroplasty, aseptic loosening may be the source of pain and is frequently difficult to diagnose. Sepsis should be ruled out as a source of pain. Plain radiographs are evaluated to rule out loosening and osteolysis, and assess component position. Laboratory evaluation commences with erythrocyte sedimentation rate and C-reactive protein, which may be elevated. Serum metal ions should be assessed by an approved facility. Aspiration, with manual cell count and culture/sensitivity should be performed, with cloudy to creamy fluid with predominance of monocytes often indicative of failure. Imaging should include ultrasound or metal artifact reduction sequence MRI, specifically evaluating for fluid collections and/or masses about the hip. If adverse reaction to metal debris is suspected then revision to metal or ceramic-on-polyethylene is indicated and can be successful. Delay may be associated with extensive soft-tissue damage and hence poor clinical outcome

Complex regional pain syndrome is characterised by an exaggerated response to injury in a limb with intense prolonged pain, vasomotor disturbance, delayed functional recovery and trophic changes. This review describes the current knowledge of the condition and outlines the methods of treatment available with particular emphasis on the knee

Hip implant retrieval analysis is the most important source of insight into the performance of new materials and designs of hip arthroplasties. Even the most rigorous in vitro testing will not accurately simulate the behavior of implant materials and new designs of prosthetic arthroplasties. Retrieval analysis has revealed such factors as the effects of gamma-in-air sterilisation of polyethylene, fatigue failure mechanisms of polymethylmethacrylate bone cement, fretting corrosion of Morse taper junctions, third body wear effects of both hard-on-hard and hard-on-soft bearing couples, and the effects of impingement of components on the full spectrum of bearing surfaces, none of which was predicted by pre-implantation in vitro testing of these materials and combinations. The temporal sequence of the retrieval process is approximately six years from first implantation through retrieval analysis, laboratory investigation, and publication of results, and thus, in addition to rigorous clinical evaluation, represents the true development and insight cycle for new designs and materials.

This paper reviews the current literature concerning the main clinical factors which can impair the healing of fractures and makes recommendations on avoiding or minimising these in order to optimise the outcome for patients. The clinical implications are described.

Most proximal humeral fractures are stable injuries of the ageing population, and can be successfully treated non-operatively. The management of the smaller number of more complex displaced fractures is more controversial and new fixation techniques have greatly increased the range of fractures that may benefit from surgery.

This article explores current concepts in the classification and clinical aspects of these injuries, reviewing the indications, innovations and outcomes for the most common methods of treatment.

Although mechanical stabilisation has been a hallmark of orthopaedic surgical management, orthobiologics are now playing an increasing role. Platelet-rich plasma (PRP) is a volume of plasma fraction of autologous blood having platelet concentrations above baseline. The platelet α granules are rich in growth factors that play an essential role in tissue healing, such as transforming growth factor-β, vascular endothelial growth factor, and platelet-derived growth factor. PRP is used in various surgical fields to enhance bone and soft-tissue healing by placing supraphysiological concentrations of autologous platelets at the site of tissue damage. The easily obtainable PRP and its possible beneficial outcome hold promise for new regenerative treatment approaches.

The aim of this literature review was to describe the bioactivities of PRP, to elucidate the different techniques for PRP preparation, to review animal and human studies, to evaluate the evidence regarding the use of PRP in trauma and orthopaedic surgery, to clarify risks, and to provide guidance for future research.

We performed a systematic review of the optimal management of septic arthritis in children as recommended in the current English literature using MEDLINE, EMBASE, CINAHL, the Cochrane Library and reference lists of retrieved articles without date restrictions up to 31 January 2009. From 2236 citations, 227 relevant full-text articles were screened in detail; 154 papers fulfilled the inclusion criteria, from which conclusions were drawn on the management of infected joints in children.

Our review showed that no single investigation, including joint aspiration, is sufficiently reliable to diagnose conclusively joint infection. The roles of aspiration, arthrotomy and arthroscopy in treatment are not clear cut, and the ideal duration of antibiotic therapy is not yet fully defined. These issues are discussed. Further large-scale, multi-centre studies are needed to delineate the optimal management of paediatric septic arthritis.

Evaluation of patients with painful total knee replacement requires a thorough clinical examination and relevant investigations in order to reach a diagnosis. Awareness of the common and uncommon problems leading to painful total knee replacement is useful in the diagnostic approach. This review article aims to act as a guide to the evaluation of patients with painful total knee replacement.

Fractures of the proximal interphalangeal joint include a wide spectrum of injuries, from stable avulsion fractures to complex fracture-dislocations. Stability of the joint is paramount in determining the appropriate treatment, which should aim to facilitate early mobilisation and restoration of function.

Failure of bone repair is a challenging problem in the management of fractures. There is a limited supply of autologous bone grafts for treating nonunions, with associated morbidity after harvesting. There is need for a better source of cells for repair. Mesenchymal stem cells (MSCs) hold promise for healing of bone because of their capacity to differentiate into osteoblasts and their availability from a wide variety of sources. Our review aims to evaluate the available clinical evidence and recent progress in strategies which attempt to use autologous and heterologous MSCs in clinical practice, including genetically-modified MSCs and those grown on scaffolds. We have compared various procedures for isolating and expanding a sufficient number of MSCs for use in a clinical setting.

There are now a number of clinical studies which have shown that implantation of MSCs is an effective, safe and durable method for aiding the repair and regeneration of bone.

The management of patients with a painful total knee replacement requires careful assessment and a stepwise approach in order to diagnose the underlying pathology accurately. The management should include a multidisciplinary approach to the patient’s pain as well as addressing the underlying aetiology. Pain should be treated with appropriate analgesia, according to the analgesic ladder of the World Health Organisation. Special measures should be taken to identify and to treat any neuropathic pain. There are a number of intrinsic and extrinsic causes of a painful knee replacement which should be identified and treated early. Patients with unexplained pain and without any recognised pathology should be treated conservatively since they may improve over a period of time and rarely do so after a revision operation.

This paper describes the presence of tenodesis effects in normal physiology and explores the uses of operative tenodesis in surgery of the upper limb.

Coccydynia is a painful disorder characterised by coccygeal pain which is typically exaggerated by pressure. It remains an unsolved mystery because of the perceived unpredictability of the origin of the pain, some psychological traits that may be associated with the disorder, the presence of diverse treatment options, and varied outcomes. A more detailed classification based on the aetiology and pathoanatomy of coccydynia helps to identify patients who may benefit from conservative and surgical management.

This review focuses on the pathoanatomy, aetiology, clinical features, radiology, treatment and outcome of coccydynia.

The dismal outcome of tuberculosis of the spine in the pre-antibiotic era has improved significantly because of the use of potent antitubercular drugs, modern diagnostic aids and advances in surgical management. MRI allows the diagnosis of a tuberculous lesion, with a sensitivity of 100% and specificity of 88%, well before deformity develops. Neurological deficit and deformity are the worst complications of spinal tuberculosis. Patients treated conservatively show an increase in deformity of about 15°. In children, a kyphosis continues to increase with growth even after the lesion has healed. Tuberculosis of the spine is a medical disease which is not primarily treated surgically, but operation is required to prevent and treat the complications. Panvertebral lesions, therapeutically refractory disease, severe kyphosis, a developing neurological deficit, lack of improvement or deterioration are indications for surgery. Patients who present with a kyphosis of 60° or more, or one which is likely to progress, require anterior decompression, posterior shortening, posterior instrumented stabilisation and anterior and posterior bone grafting in the active stage of the disease. Late-onset paraplegia is best prevented rather than treated. The awareness and suspicion of an atypical presentation of spinal tuberculosis should be high in order to obtain a good outcome. Therapeutically refractory cases of tuberculosis of the spine are increasing in association with the presence of HIV and multidrug-resistant tuberculosis.