Of a consecutive series of 70 babies with obstetric traction injury to the brachial plexus we were able to review 40 who had had only conservative treatment. We found that if recovery in the upper roots had not started by three months of age then, at follow-up there was a significant residual functional deficit. In a further 22 babies who showed no recovery of the upper roots by three months, exploration and sural nerve grafting were performed; 20 of these children were reviewed at one year. Good recovery of the deltoid was seen in 80% and of the biceps in 55%, while 25% had good external rotation at the shoulder. We conclude that if there is disruption of the upper roots with no sign of recovery at three months, grafting of these roots provides the best chance of useful recovery

We treated 12 shoulders in ten patients with irreparable rotator-cuff tears by transfer of the latissimus dorsi. There were nine men and one woman. Their average age was 64.0 years and the average follow-up was 35.6 months (26 to 42). The results were excellent in four shoulders, good in four, fair in one, and poor in three. Active forward flexion improved from a preoperative average of 99° to a postoperative average of 135°. Osteoarthritic changes appeared in five shoulders and proximal migration of the humeral head progressed in six. EMG revealed that nine of the 12 transferred muscles showed activity which was synergistic with the supraspinatus on external rotation with abduction. We conclude that latissimus dorsi transfer can be effective in restoring shoulder function after massive irreparable tears of the rotator cuff

We report four patients with a mean age of 17 years (14 to 22) with external rotation injuries of the knee in slight flexion. Radiographs showed a small fragment in the area of the lateral femoral condyle. At operation, the fragment, consisting of the femoral insertion of the popliteus, was anatomically reduced and fixed. At a mean follow-up of 35 months all the knees had an excellent function score. An isolated lesion of the popliteus often presents as a tendon avulsion whereas major damage to the posterolateral corner of the knee involves combined ligamentous injuries. In patients with an acute haemarthrosis and lateral pain in a stable knee, the diagnosis of isolated avulsion of the popliteus tendon should be suspected. Arthroscopy with special attention to the lateral gutter is indicated. We advise anatomical reduction and fixation of the fragment to prevent possible long-term effects on other posterolateral structures

Aims

This study investigates head-neck taper corrosion with varying head size in a novel hip simulator instrumented to measure corrosion related electrical activity under torsional loads.

Aims

The direct anterior approach (DAA) for total hip arthroplasty (THA) has potential advantages over other approaches and is most commonly performed with the patient in the supine position. We describe a technique for DAA THA with the patient in the lateral decubitus position and report the early clinical and radiological outcomes, the characteristics of the learning curve, and perioperative complications.

Evaluating musculoskeletal conditions of the lower limb and understanding the pathophysiology of complex bone kinematics is challenging. Static images do not take into account the dynamic component of relative bone motion and muscle activation. Fluoroscopy and dynamic MRI have important limitations. Dynamic CT (4D-CT) is an emerging alternative that combines high spatial and temporal resolution, with an increased availability in clinical practice. 4D-CT allows simultaneous visualization of bone morphology and joint kinematics. This unique combination makes it an ideal tool to evaluate functional disorders of the musculoskeletal system. In the lower limb, 4D-CT has been used to diagnose femoroacetabular impingement, patellofemoral, ankle and subtalar joint instability, or reduced range of motion. 4D-CT has also been used to demonstrate the effect of surgery, mainly on patellar instability. 4D-CT will need further research and validation before it can be widely used in clinical practice. We believe, however, it is here to stay, and will become a reference in the diagnosis of lower limb conditions and the evaluation of treatment options.

Cite this article: Bone Joint J 2021;103-B(5):822–827.

We report the results in 33 patients who had nerve grafting of the axillary or the suprascapular nerve or of both. There were 32 men and one woman; their mean age was 21 years and the average interval between injury and operation was three months. At a mean follow-up of 27 months, the deltoid had recovered to M3 or better in 23 of 30 patients (77%) and the infraspinatus in 18 of 25 patients (72%). Shoulder elevation had reached 120° or more in 27 patients (82%), with external rotation of 30° or more in 27 (82%). Twenty-six patients (79%) could reach to the top of their head with their hand. Recovery of muscle strength, range of movement and shoulder function were satisfactory when surgery was performed within four months of the injury. Early exploration and nerve grafting can lead to a good functional recovery, but thorough exploration and careful repair of both nerves are essential

Aims

Pelvic tilt (PT) can significantly change the functional orientation of the acetabular component and may differ markedly between patients undergoing total hip arthroplasty (THA). Patients with stiff spines who have little change in PT are considered at high risk for instability following THA. Femoral component position also contributes to the limits of impingement-free range of motion (ROM), but has been less studied. Little is known about the impact of combined anteversion on risk of impingement with changing pelvic position.

Of 935 consecutive patients referred with shoulder pain, 50 fitted the criteria for primary frozen shoulder. Twelve patients who failed to improve after conservative treatment and manipulation had excision of the coracohumeral ligament and the rotator interval of the capsule. The specimens were examined histologically, using special stains for collagen. Immunocytochemistry was performed with monoclonal antibodies against leucocyte common antigen (LCA, CD45) and a macrophage/synovial antigen (PGMI, CD68) to assess the inflammatory component, and vimentin and smooth-muscle actin to evaluate fibroblasts and myofibroblasts. Our histological and immunocytochemical findings show that the pathological process is active fibroblastic proliferation, accompanied by some transformation to a smooth muscle phenotype (myofibroblasts). The fibroblasts lay down collagen which appears as a thick nodular band or fleshy mass. These appearances are very similar to those in Dupuytren's disease of the hand, with no inflammation and no synovial involvement. The contracture acts as a check-rein against external rotation, causing loss of both active and passive movement

Long posterior wall (LPW) Charnley acetabular implants are widely used as it is believed that the LPW helps to prevent dislocation. This has, however, not been proven statistically. In a preliminary study of these implants removed at revision marked erosion of the LPW was frequently seen, indicating that repetitive impingement may occur. The influence of the long posterior wall was therefore investigated mathematically. LPW and standard sockets were found to be equally likely to dislocate provided that the standard socket was anteverted 5 degrees more than the LPW socket. With simulated external rotation, LPW sockets impinge 30% earlier than standard sockets. When impingement occurs a torque is applied to the components, which increases the shear stresses at the cement-bone interface. The torques, although not large enough to dislodge the socket immediately, are repetitive and so may contribute to loosening. The LPW socket can generate twice as much torque as the standard socket and therefore is more likely to loosen

We used laser Doppler flowmetry (LDF) with a high energy (20 mW) laser to measure perfusion of the femoral head intraoperatively in 32 hips. The surgical procedure was joint debridement requiring dislocation or subluxation of the hip. The laser probe was placed within the anterosuperior quadrant of the femoral head. Blood flow was monitored in specific positions of the hip before and after dislocation or subluxation. With the femoral head reduced, external rotation, both in extension and flexion, caused a reduction of blood flow. During subluxation or dislocation, it was impaired when the posterosuperior femoral neck was allowed to rest on the posterior acetabular rim. A pulsatile signal returned when the hip was reduced, or was taken out of extreme positions when dislocated. After the final reduction, the signal amplitudes were first slightly lower (12%) compared with the initial value but tended to be restored to the initial levels within 30 minutes. Most of the changes in the signal can be explained by compromise of the extraosseous branches of the medial femoral circumflex artery and are reversible. Our study shows that LDF provides proof for the clinical observation that perfusion of the femoral head is maintained after dislocation if specific surgical precautions are followed

In six unloaded cadaver knees we used MRI to determine the shapes of the articular surfaces and their relative movements. These were confirmed by dissection. Medially, the femoral condyle in sagittal section is composed of the arcs of two circles and that of the tibia of two angled flats. The anterior facets articulate in extension. At about 20° the femur ‘rocks’ to articulate through the posterior facets. The medial femoral condyle does not move anteroposteriorly with flexion to 110°. Laterally, the femoral condyle is composed entirely, or almost entirely, of a single circular facet similar in radius and arc to the posterior medial facet. The tibia is roughly flat. The femur tends to roll backwards with flexion. The combination during flexion of no antero-posterior movement medially (i.e., sliding) and backward rolling (combined with sliding) laterally equates to internal rotation of the tibia around a medial axis with flexion. About 5° of this rotation may be obligatory from 0° to 10° flexion; thereafter little rotation occurs to at least 45°. Total rotation at 110° is about 20°, most if not all of which can be suppressed by applying external rotation to the tibia at 90°

The stabilising effects on the glenohumeral joint of each of the rotator-cuff muscles and of the biceps were studied with the arm in abduction and external rotation in 13 cadaver shoulders. The muscles were loaded one at a time with forces proportional to their cross-sectional areas. We recorded the positions of the humeral head before and after the application to the humerus of an anterior force of 1.5 kg. When the capsule was intact, the anterior displacement with the subscapularis loaded was significantly larger than with the other muscles loaded (p = 0.0009). With the capsule vented, the displacement with the biceps loaded was significantly smaller than that with the subscapularis loaded (p = 0.0052). After creating an imitation Bankart lesion, the displacement with the biceps loaded was significantly less than with any of the rotator-cuff muscles loaded (p = 0.0132). We conclude that in the intact shoulder, the subscapularis is the least important anterior stabiliser, and that the biceps becomes more important than the rotator-cuff muscles as stability from the capsuloligamentous structure decreases. Strengthening of the biceps as well as the rotator-cuff muscles should be part of the rehabilitation programme for anterior shoulder instability

We have measured anterior and posterior displacement in 563 normal knees and 487 knees with chronic deficiency of the anterior cruciate ligament (ACL). We performed stress radiography using a simple apparatus which maintained the knee at 20° of flexion while a 9 kg load was applied. There was no significant difference in posterior translation dependent on the condition of the ACL. Measurement of anterior translation in the medial compartment proved to be more reliable than in the lateral compartment for the diagnosis of rupture of the ACL, with better specificity, sensitivity and predictive values. We have classified anterior laxity based on the differential anterior translation of the medial compartment and identified four grades in each of which we can further distinguish four subgrades for laxity of the lateral compartment. Within each of these subgroups, either internal or external rotation may dominate and sometimes there is a major translation of both compartments. Radiological evaluation of displacement of the knee in 20° of flexion provides conclusive evidence of rupture of the ACL. A detailed study of pathological displacement is the basis for a classification of laxity. It is then possible to decide for each type of laxity, the surgical treatment which is specifically adapted to the lesion, and to define a reference value for judging outcome

We made a prospective study of 58 consecutive Neer II total shoulder replacements in 49 rheumatoid patients. Cemented glenoid and press-fit humeral components had been used. After a mean follow-up of 9.5 years (7 to 13), 11 patients (15 shoulders) had died, one shoulder had been arthrodesed and five patients (five shoulders) had been lost to follow-up. Of the remaining 37 shoulders 29 were painfree or had only slight discomfort, four had pain on unusual activity, and four had moderate or severe pain. There were satisfactory improvements in the mean range of active elevation (53° to 75°) and external rotation (5° to 38°); satisfactory performance of the activities of daily living had been maintained throughout follow-up. Radiographs showed loosening in ten shoulders of nine glenoid and nine humeral components but of these only three had significant symptoms. Three loose glenoid components and two loose humeral components required revision. We consider that the Neer total shoulder replacement provides a reasonable medium to long-term outcome in rheumatoid arthritis, but recommend that the humeral component should be routinely cemented

Axial radiographs were obtained under valgus and external rotation stress at 45° of knee flexion with and without contraction of the quadriceps muscle in order to assess the dynamics of patellar subluxation or dislocation. The radiography was performed on 82 knees in 61 patients with patellofemoral instability, and on 44 normal knees. The lateral patellofemoral angle and the congruence angle were measured and compared with the conventional Merchant views. Both parameters showed greater differences between symptomatic and normal knees on the stress radiographs obtained without quadriceps contraction. There was a major difference in the lateral patellofemoral angles between the groups, which clearly distinguished symptomatic knees from normal controls. Congruence angles on stress radiography had a significant correlation with the functional scores obtained after a period of conservative treatment and a positive correlation with the frequency of patellar subluxation. When the quadriceps contracted, two patterns of patellar shift were observed. While the patella reduced into the trochlear groove in all normal knees and about 70% of the symptomatic knees, contraction of the quadriceps caused further subluxation of the patella in the remaining symptomatic knees. All the knee joints which showed this displacement failed to respond to conservative treatment and eventually required surgical treatment. Thus, this technique of stress radiography is a simple, cost-effective and useful method of evaluating patellar instability and predicting the prognosis

Aims

We compared the clinical outcomes of curved intertrochanteric varus osteotomy (CVO) with bone impaction grafting (BIG) with CVO alone for the treatment of osteonecrosis of the femoral head (ONFH).