Aims

We evaluated clinical and radiographic outcomes of total shoulder arthroplasty (TSA) using the second-generation Trabecular Metal (TM) Glenoid component. The first generation component was withdrawn in 2005 after a series of failures were reported. Between 2009 and 2012, 40 consecutive patients with unilateral TSA using the second-generation component were enrolled in this clinical study. The mean age of the patients was 63.8 years (40 to 75) and the mean follow-up was 38 months (24 to 42).

In adults with brachial plexus injuries, lack of active external rotation at the shoulder is one of the most common residual deficits, significantly compromising upper limb function. There is a paucity of evidence to address this complex issue. We present our experience of isolated latissimus dorsi (LD) muscle transfer to achieve active external rotation. This is a retrospective review of 24 adult post-traumatic plexopathy patients who underwent isolated latissimus dorsi muscle transfer to restore external rotation of the shoulder between 1997 and 2010. All patients were male with a mean age of 34 years (21 to 57). All the patients underwent isolated LD muscle transfer using a standard technique to correct external rotational deficit. Outcome was assessed for improvement in active external rotation, arc of movement, muscle strength and return to work. The mean improvement in active external rotation from neutral was 24° (10° to 50°). The mean increase in arc of rotation was 52° (38° to 55°). Mean power of the external rotators was 3.5 Medical Research Council (MRC) grades (2 to 5).

A total of 21 patients (88%) were back in work by the time of last follow up. Of these, 13 had returned to their pre-injury occupation. Isolated latissimus dorsi muscle transfer provides a simple and reliable method of restoring useful active external rotation in adults with brachial plexus injuries with internal rotational deformity.

Cite this article: Bone Joint J 2013;95-B:660–3.

Although the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was designed, and has been validated, as a measure of disability in patients with disorders of the upper limb, the influence of those of the lower limb on disability as measured by the DASH score has not been assessed. The aim of this study was to investigate whether it exclusively measures disability associated with injuries to the upper limb. The Short Musculoskeletal Functional Assessment, a general musculoskeletal assessment instrument, was also completed by participants. Disability was compared in 206 participants, 84 with an injury to the upper limb, 73 with injury to the lower limb and 49 controls.

We found that the DASH score also measured disability in patients with injuries to the lower limb. Care must therefore be taken when attributing disability measured by the DASH score to injuries of the upper limb when problems are also present in the lower limb. Its inability to discriminate clearly between disability due to problems at these separate sites must be taken into account when using this instrument in clinical practice or research.

This retrospective study was designed to evaluate the outcomes of re-dislocation of the radial head after corrective osteotomy for chronic dislocation. A total of 12 children with a mean age of 11 years (5 to 16), with further dislocation of the radial head after corrective osteotomy of the forearm, were followed for a mean of five years (2 to 10). Re-operations were performed for radial head re-dislocation in six children, while the other six did not undergo re-operation (‘non-re-operation group’). The active range of movement (ROM) of their elbows was evaluated before and after the first operation, and at the most recent follow-up.

In the re-operation group, there were significant decreases in extension, pronation, and supination when comparing the ROM following the corrective osteotomy and following re-operation (p < 0.05).

The children who had not undergone re-operation achieved a better ROM than those who had undergone re-operation.

There was a significant difference in mean pronation (76° vs 0°) between the non- re-operation and the re-operation group (p = 0.002), and a trend towards increases in mean flexion (133° vs 111°), extension (0° vs 23°), and supination (62° vs 29°). We did not find a clear benefit for re-operation in children with a re-dislocation following corrective osteotomy for chronic dislocation of the radial head.

Cite this article: Bone Joint J 2015;97-B:1582–7.

Aims

We investigated changes in the axial alignment of the ipsilateral hip and knee after total hip arthroplasty (THA).

The February 2013 Trauma Roundup³⁶⁰ looks at: the risk of ankle fractures; absorbable implants; minimally invasive heel fracture fixation; pertrochanteric fractures; arthroplasty and intracapsular hip fractures; and extensor mechanism disruption.

There is a large amount of evidence available about the relative merits of unicompartmental and total knee arthroplasty (UKA and TKA). Based on the same evidence, different people draw different conclusions and as a result, there is great variability in the usage of UKA.

The revision rate of UKA is much higher than TKA and so some surgeons conclude that UKA should not be performed. Other surgeons believe that the main reason for the high revision rate is that UKA is easy to revise and, therefore, the threshold for revision is low. They also believe that UKA has many advantages over TKA such as a faster recovery, lower morbidity and mortality and better function. They therefore conclude that UKA should be undertaken whenever appropriate.

The solution to this argument is to minimise the revision rate of UKA, thereby addressing the main disadvantage of UKA. The evidence suggests that this will be achieved if surgeons use UKA for at least 20% of their knee arthroplasties and use implants that are appropriate for these broad indications.

Cite this article: Bone Joint J 2015;97-B(10 Suppl A):3–8.

A total of 56 male patients with a displaced intracapsular fracture of the hip and a mean age of 81 years (62 to 94), were randomised to be treated with either a cemented hemiarthroplasty (the Exeter Trauma Stem) or reduction and internal fixation using the Targon Femoral Plate. All surviving patients were reviewed one year after the injury, at which time restoration of function and pain in the hip was assessed. There was no statistically significant difference in mortality between the two groups (7/26; 26.9% for hemiarthroplasty vs 10/30; 33.3% for internal fixation). No patient treated with a hemiarthroplasty required further surgery, but eight patients treated by internal fixation did (p = 0.005), five requiring hemiarthroplasty and three requiring total hip arthroplasty. Those treated by internal fixation had significantly more pain (p = 0.02). The restoration of mobility and independence were similar in the two groups.

These results indicate that cemented hemiarthroplasty gives better results than internal fixation in elderly men with a displaced intracapsular fracture of the hip.

Cite this article: Bone Joint J 2015;97-B:992–6.

The purpose of this study was to determine patient-reported outcomes of patients with mild to moderate developmental dysplasia of the hip (DDH) and femoroacetabular impingement (FAI) undergoing arthroscopy of the hip in the treatment of chondrolabral pathology. A total of 28 patients with a centre-edge angle between 15° and 19° were identified from an institutional database. Their mean age was 34 years (18 to 53), with 12 female and 16 male patients. All underwent labral treatment and concomitant correction of FAI. There were nine reoperations, with two patients requiring revision arthroscopy, two requiring periacetabular osteotomy and five needing total hip arthroplasty.

Patients who required further major surgery were more likely to be older, male, and to have more severe DDH with a larger alpha angle and decreased joint space.

At a mean follow-up of 42 months (24 to 89), the mean modified Harris hip score improved from 59 (20 to 98) to 82 (45 to 100; p < 0.001). The mean Western Ontario and McMaster Universities Osteoarthritis Index score improved from 30 (1 to 61) to 16 (0 to 43; p < 0.001). Median patient satisfaction was 9.0/10 (1 to 10). Patients reported excellent improvement in function following arthroscopy of the hip.

This study shows that with proper patient selection, arthroscopy of the hip can be successful in the young patient with mild to moderate DDH and FAI.

Cite this article: Bone Joint J 2015;97-B:1316–21.

Hip fracture is a common injury associated with high mortality, long-term disability and huge socio-economic burden. Yet there has been relatively little research into best treatment, and evidence that has been generated has often been criticised for its poor quality. Here, we discuss the advances made towards overcoming these criticisms and the future directions for hip fracture research: how co-ordinating existing national infrastructures and use of now established clinical research networks will likely go some way towards overcoming the practical and financial challenges of conducting large trials. We highlight the importance of large collaborative pragmatic trials to inform decision/policy makers and the progress made towards reaching a consensus on a core outcome set to facilitate data pooling for evidence synthesis and meta-analysis.

These advances and future directions are a priority in order to establish the high-quality evidence base required for this important group of patients.

Cite this article: Bone Joint J 2015;97-B:875–9.

To prevent insufficiency of the triceps after total elbow arthroplasty, we have, since 2008, used a triceps-sparing ulnar approach. This study evaluates the clinical results and post-operative alignment of the prosthesis using this approach.

We reviewed 25 elbows in 23 patients. There were five men and 18 women with a mean age of 69 years (54 to 83). There were 18 elbows with rheumatoid arthritis, six with a fracture or pseudoarthrosis and one elbow with osteoarthritis.

Post-operative complications included one intra-operative fracture, one elbow with heterotopic ossification, one transient ulnar nerve palsy, and one elbow with skin necrosis, but no elbow was affected by insufficiency of the triceps.

Patients were followed for a mean of 42 months (24 to 77). The mean post-operative Japanese Orthopaedic Association Elbow Score was 90.8 (51 to 100) and the mean Mayo Elbow Performance score 93.8 (65 to 100). The mean post-operative flexion/extension of the elbow was 135°/-8°. The Manual Muscle Testing score of the triceps was 5 in 23 elbows and 2 in two elbows (one patient). The mean alignment of the implants examined by 3D-CT was 2.8° pronation (standard deviation (sd) 5.5), 0.3° valgus (sd 2.7), and 0.7° extension (sd 3.2) for the humeral component, and 9.3° pronation (sd 9.7), 0.3° valgus (sd 4.0), and 8.6° extension (sd 3.1) for the ulnar component. There was no radiolucent line or loosening of the implants on the final radiographs.

The triceps-sparing ulnar approach allows satisfactory alignment of the implants, is effective in preventing post-operative triceps insufficiency, and gives satisfactory short-term results.

Cite this article: 2015;97-B:1096–1101.

In this paper we propose a new classification of neurogenic peri-articular heterotopic ossification (HO) of the hip based on three-dimensional (3D) CT, with the aim of improving pre-operative planning for its excision.

A total of 55 patients (73 hips) with clinically significant HO after either traumatic brain or spinal cord injury were assessed by 3D-CT scanning, and the results compared with the intra-operative findings.

At operation, the gross pathological anatomy of the HO as identified by 3D-CT imaging was confirmed as affecting the peri-articular hip muscles to a greater or lesser extent. We identified seven patterns of involvement: four basic (anterior, medial, posterior and lateral) and three mixed (anteromedial, posterolateral and circumferential). Excellent intra- and inter-observer agreement, with kappa values > 0.8, confirmed the reproducibility of the classification system.

We describe the different surgical approaches used to excise the HO which were guided by the 3D-CT findings. Resection was always successful.

3D-CT imaging, complemented in some cases by angiography, allows the surgeon to define the 3D anatomy of the HO accurately and to plan its surgical excision with precision.

Cite this article: Bone Joint J 2015; 97-B:899–904.

The August 2012 Shoulder & Elbow Roundup³⁶⁰ looks at: platelet-rich fibrin matrix and the torn rotator cuff; ultrasound, trainees, and ducks out of water; the torn rotator cuff and conservative treatment; Bankart repair and subsequent degenerative change; proprioception after shoulder replacement; surgery for a terrible triad, with reasonable short-term results; and the WORC Index.

The April 2015 Foot & Ankle Roundup³⁶⁰ looks at: Plantar pressures linked to radiographs; Strength training for ankle instability?; Is weight loss good for your feet?; Diabetes and foot surgery complications; Tantalum for failed ankle arthroplasty?; Steroids, costs and Morton’s neuroma; Ankle arthritis and subtalar joint

The interaction between the lumbosacral spine and the pelvis is dynamically related to positional change, and may be complicated by co-existing pathology. This review summarises the current literature examining the effect of sagittal spinal deformity on pelvic and acetabular orientation during total hip arthroplasty (THA) and provides recommendations to aid in placement of the acetabular component for patients with co-existing spinal pathology or long spinal fusions. Pre-operatively, patients can be divided into four categories based on the flexibility and sagittal balance of the spine. Using this information as a guide, placement of the acetabular component can be optimal based on the type and significance of co-existing spinal deformity.

Cite this article: Bone Joint J 2015;97-B:1017–23.

In this study we quantified and characterised the return of functional mobility following open tibial fracture using the Hamlyn Mobility Score. A total of 20 patients who had undergone reconstruction following this fracture were reviewed at three-month intervals for one year. An ear-worn movement sensor was used to assess their mobility and gait. The Hamlyn Mobility Score and its constituent kinematic features were calculated longitudinally, allowing analysis of mobility during recovery and between patients with varying grades of fracture. The mean score improved throughout the study period. Patients with more severe fractures recovered at a slower rate; those with a grade I Gustilo-Anderson fracture completing most of their recovery within three months, those with a grade II fracture within six months and those with a grade III fracture within nine months.

Analysis of gait showed that the quality of walking continued to improve up to 12 months post-operatively, whereas the capacity to walk, as measured by the six-minute walking test, plateaued after six months.

Late complications occurred in two patients, in whom the trajectory of recovery deviated by > 0.5 standard deviations below that of the remaining patients. This is the first objective, longitudinal assessment of functional recovery in patients with an open tibial fracture, providing some clarification of the differences in prognosis and recovery associated with different grades of fracture.

Cite this article: Bone Joint J 2015; 97-B:1118–25.

Acetabular labral tears and associated intra-articular pathology of the hip have been recognised as a source of symptoms. However, it is now appreciated that there is a relatively high prevalence of asymptomatic labral tears. In this study, 70 young asymptomatic adult volunteers with a mean age of 26 years (19 to 41) were recruited and underwent three tesla non-arthrographic MR scans. There were 47 women (67.1%) and 23 men (32.9%).

Labral tears were found in 27 volunteers (38.6%); these were an isolated finding in 16 (22.9%) and were associated with other intra-articular pathology in the remaining 11 (15.7%) volunteers. Furthermore, five (7.1%) had intra-articular pathology without an associated labral tear.

Given the high prevalence of labral pathology in the asymptomatic population, it is important to confirm that a patient's symptoms are due to the demonstrated abnormalities when considering surgery.

Cite this article: Bone Joint J 2015;97-B:623–7.

Objectives

Local corticosteroid infiltration is a common practice of treatment for lateral epicondylitis. In recent studies no statistically significant or clinically relevant results in favour of corticosteroid injections were found. The injection of autologous blood has been reported to be effective for both intermediate and long-term outcomes. It is hypothesised that blood contains growth factors, which induce the healing cascade.

Talonavicular and subtalar joint fusion through a medial incision (modified triple arthrodesis) has become an increasingly popular technique for treating symptomatic flatfoot deformity caused by posterior tibial tendon dysfunction.

The purpose of this study was to look at its clinical and radiological mid- to long-term outcomes, including the rates of recurrent flatfoot deformity, nonunion and avascular necrosis of the dome of the talus.

A total of 84 patients (96 feet) with a symptomatic rigid flatfoot deformity caused by posterior tibial tendon dysfunction were treated using a modified triple arthrodesis. The mean age of the patients was 66 years (35 to 85) and the mean follow-up was 4.7 years (1 to 8.3). Both clinical and radiological outcomes were analysed retrospectively.

In 86 of the 95 feet (90.5%) for which radiographs were available, there was no loss of correction at final follow-up. In all, 14 feet (14.7%) needed secondary surgery, six for nonunion, two for avascular necrosis, five for progression of the flatfoot deformity and tibiotalar arthritis and one because of symptomatic overcorrection. The mean American Orthopaedic Foot and Ankle Society Hindfoot score (AOFAS score) at final follow-up was 67 (between 16 and 100) and the mean visual analogue score for pain 2.4 points (between 0 and 10).

In conclusion, modified triple arthrodesis provides reliable correction of deformity and a good clinical outcome at mid- to long-term follow-up, with nonunion as the most frequent complication. Avascular necrosis of the talus is a rare but serious complication of this technique.

Cite this article: Bone Joint J 2015; 97-B:668–74.