Aims. The eccentric glenosphere was principally introduced into reverse shoulder arthroplasty to reduce the incidence of scapular notching. There is only limited information about the influence of its design on deltoid power and joint reaction forces. The aim of our study was to investigate how the diameter and eccentricity of the glenosphere affect the biomechanics of the deltoid and the resultant joint reaction forces. . Methods. Different sizes of glenosphere and eccentricity were serially tested in ten cadaveric shoulders using a custom shoulder movement simulator. Results. Increasing the diameter of the glenosphere alone did not alter the deltoid moment arm. However, using an eccentric glenosphere increased the moment arm of the deltoid, lowered the joint reaction force and required less deltoid force to generate movement. Conclusion. Eccentricity is an independent variable which increases deltoid efficiency and lowers joint reaction forces in a reverse shoulder arthroplasty. Cite this article: Bone Joint J 2016;98-B:218–23

Aims

The aim of this study was to identify risk factors for recurrent instability of the shoulder and assess the ability to return to sport in patients with engaging Hill-Sachs lesions treated with arthroscopic Bankart repair and Hill-Sachs remplissage (ABR-HSR).

We suggest that different mechanisms underlie joint pain at rest and on movement in osteoarthritis and that separate assessment of these two features with a visual analogue scale (VAS) offers better information about the likely effect of a total knee replacement (TKR) on pain. The risk of persistent pain after TKR may relate to the degree of central sensitisation before surgery, which might be assessed by determining the pain threshold to an electrical stimulus created by a special tool, the Pain Matcher. Assessments were performed in 69 patients scheduled for TKR. At 18 months after operation, separate assessment of pain at rest and with movement was again carried out using a VAS in order to enable comparison of pre- and post-operative measurements. A less favourable outcome in terms of pain relief was observed for patients with a high pre-operative VAS score for pain at rest and a low pain threshold, both features which may reflect a central sensitisation mechanism

Arthritis of the wrist is a painful disabling condition that has various causes and presentations. The traditional treatment has been a total wrist fusion at a price of the elimination of movement. However, forms of treatment which allow the preservation of movement are now preferred. Modern arthroplasties of the wrist are still not sufficiently robust to meet the demands of many patients, nor do they restore normal kinematics of the wrist. A preferable compromise may be selective excision and partial fusion of the wrist using knowledge of the aetiology and pattern of degenerative change to identify which joints can be sacrificed and which can be preserved. . This article provides an overview of the treatment options available for patients with arthritis of the wrist and an algorithm for selecting an appropriate surgical strategy. Cite this article: Bone Joint J 2015;97-B:1303–8

The purpose of this study was to evaluate whether concerns about the release of metal ions in metal-on-metal total hip replacements (THR) should be extended to patients with metal-bearing total disc replacements (TDR). Cobalt and chromium levels in whole blood and serum were measured in ten patients with a single-level TDR after a mean follow-up of 34.5 months (13 to 61) using inductively-coupled plasma mass spectrometry. These metal ion levels were compared with pre-operative control levels in 81 patients and with metal ion levels 12 months after metal-on-metal THR (n = 21) and resurfacing hip replacement (n = 36). Flexion-extension radiographs were used to verify movement of the TDR. Cobalt levels in whole blood and serum were significantly lower in the TDR group than in either the THR (p = 0.007) or the resurfacing group (p < 0.001). Both chromium levels were also significantly lower after TDR versus hip resurfacing (p < 0.001), whereas compared with THR this difference was only significant for serum levels (p = 0.008). All metal ion levels in the THR and resurfacing groups were significantly higher than in the control group (p < 0.001). In the TDR group only cobalt in whole blood appeared to be significantly higher (p < 0.001). The median range of movement of the TDR was 15.5° (10° to 22°). These results suggest that there is minimal cause for concern about high metal ion concentrations after TDR, as the levels appear to be only moderately elevated. However, spinal surgeons using a metal-on-metal TDR should still be aware of concerns expressed in the hip replacement literature about toxicity from elevated metal ion levels, and inform their patients appropriately

Aims. Lumbar fusion is known to reduce the variation in pelvic tilt between standing and sitting. A flexible lumbo-pelvic unit increases the stability of total hip arthroplasty (THA) when seated by increasing anterior clearance and acetabular anteversion, thereby preventing impingement of the prosthesis. Lumbar fusion may eliminate this protective pelvic movement. The effect of lumbar fusion on the stability of total hip arthroplasty has not previously been investigated. Patients and Methods. The Medicare database was searched for patients who had undergone THA and spinal fusion between 2005 and 2012. PearlDiver software was used to query the database by the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedural code for primary THA and lumbar spinal fusion. Patients who had undergone both lumbar fusion and THA were then divided into three groups: 1 to 2 levels, 3 to 7 levels and 8+ levels of fusion. The rate of dislocation in each group was established using ICD-9-CM codes. Patients who underwent THA without spinal fusion were used as a control group. Statistical significant difference between groups was tested using the chi-squared test, and significance set at p < 0.05. Results. At one-year follow-up, 14 747 patients were found to have had a THA after lumbar spinal fusion (12 079 1 to 2 levels, 2594 3 to 7 levels, 74 8+ levels). The control group consisted of 839 004 patients. The dislocation rate in the control group was 1.55%. A higher rate of dislocation was found in patients with a spinal fusion of 1 to 2 levels (2.96%, p < 0.0001) and 3 to 7 levels (4.12%, p < 0.0001). Patients with 3 to 7 levels of fusion had a higher rate of dislocation than patients with 1 to 2 levels of fusion (odds ratio (OR) = 1.60, p < 0.0001). When groups were matched for age and gender to the unfused cohort, patients with 1 to 2 levels of fusion had an OR of 1.93 (95% confidence interval (CI) 1.42 to 2.32, p < 0.001), and those with 3 to 7 levels of fusion an OR of 2.77 (CI 2.04 to 4.80, p < 0.001) for dislocation. Conclusion. Patients with a previous history of lumbar spinal fusion have a significantly higher rate of dislocation of their THA than age- and gender-matched patients without a lumbar spinal fusion. Cite this article: Bone Joint J 2017;99-B:585–91

We report the use of a free vascularised iliac bone graft in the treatment of 21 patients (19 men and 2 women) with an avascular nonunion of the scaphoid in which conventional bone grafting had previously failed. The mean age of the patients was 32 years (23 to 46) and the dominant wrist was affected in 14. The mean interval from fracture to the vascularised bone grafting was 39 months (9 to 62). Pre-operative MRI showed no contrast enhancement in the proximal fragment in any patient. Fracture union was assessed radiologically or with CT scans if the radiological appearances were inconclusive. At a mean follow-up of 5.6 years (2 to 11) union was obtained in 16 patients. The remaining five patients with a persistent nonunion continued to experience pain, reduced grip strength and limited range of wrist movement. In the successfully treated patients the grip strength and range of movement did not recover to match the uninjured side. Prevention of progressive carpal collapse, the absence of donor site morbidity, good subjective results and pain relief, justifies this procedure in the treatment of recalcitrant nonunion of the scaphoid

We performed a prospective, randomised trial to evaluate the outcome after surgery of displaced, unstable fractures of the distal radius. A total of 280 consecutive patients were enrolled in a prospective database and 88 identified who met the inclusion criteria for surgery. They were randomised to receive either bridging external fixation with supplementary Kirschner-wire fixation or volar-locked plating with screws. Both groups were similar in terms of age, gender, hand dominance, fracture pattern, socio-economic status and medical co-morbidities. Although the patients treated by volar plating had a statistically significant early improvement in the range of movement of the wrist, this advantage diminished with time and in absolute terms the difference in range of movement was clinically unimportant. Radiologically, there were no clinically significant differences in the reductions, although more patients with AO/OTA (Orthopaedic Trauma Association) type C fractures were allocated to the external fixation group. The function at one year was similar in the two groups. No clear advantage could be demonstrated with either treatment but fewer re-operations were required in the external fixation group

We present a retrospective study of 25 patients treated by open arthrolysis of the elbow for post-traumatic stiffness. The mean follow-up was for 7.8 years (5 to 10.8). The range of movement of the elbow, pain scores and functional outcomes were recorded pre- and postoperatively. An improvement in the mean range of movement from 55° (0° to 95°) to 105° (55° to 135°) was obtained in our patients at one year. This improvement was maintained over the mean follow-up period of 7.8 years (5 to 10.8). Improvement in pain, function and patient satisfaction was recorded in 23 of the 25 patients at final follow-up. On the basis of this study, we believe that the results of open arthrolysis for post-traumatic stiffness of the elbow are durable over the medium term

Aims

To achieve the functional benefits of the direct anterior (DA) approach and the fixation benefits of cemented replacement, this study combined the two techniques posing the following questions: does the limited access of the DA approach adversely affect the cement technique?; and does such a cementing technique reduce the incidence of cementless complications?

This is a retrospective study of six children with ununited scaphoid fractures treated conservatively. Their mean age was 12.8 years (9.7 to 16.3). Five had no early treatment. Radiological signs of nonunion were found at a mean of 4.6 months (3 to 7) after injury. Treatment consisted of cast immobilisation until clinical and radiological union. The mean clinical and radiological follow-up was for 67 months (17 to 90). We assessed the symptoms, the range of movement of the wrist and the grip strength to calculate the Modified Mayo Wrist score. The fracture united in all patients after a mean period of immobilisation of 5.3 months (3 to 7). Five patients were pain free; one had mild pain. All returned to regular activities, and had a range of movement and grip strength within 25% of normal, resulting in an excellent Modified Mayo Wrist score. Prolonged treatment with cast immobilisation resulted in union of the fracture and an excellent Modified Wrist Score in all patients

Aims. Since redesign of the Oxford phase III mobile-bearing unicompartmental knee arthroplasty (UKA) femoral component to a twin-peg design, there has not been a direct comparison to total knee arthroplasty (TKA). Thus, we explored differences between the two cohorts. Patients and Methods . A total of 168 patients (201 knees) underwent medial UKA with the Oxford Partial Knee Twin-Peg. These patients were compared with a randomly selected group of 177 patients (189 knees) with primary Vanguard TKA. Patient demographics, Knee Society (KS) scores and range of movement (ROM) were compared between the two cohorts. Additionally, revision, re-operation and manipulation under anaesthesia rates were analysed. Results. The mean follow-up for UKA and TKA groups was 5.4 and 5.5 years, respectively. Six TKA (3.2%) versus three UKAs (1.5%) were revised which was not significant (p = 0.269). Manipulation was more frequent after TKA (16; 8.5%) versus none in the UKA group (p <  0.001). UKA patients had higher post-operative KS function scores versus TKA patients (78 versus 66, p < 0.001) with a trend toward greater improvement, but there was no difference in ROM and KS clinical improvement (p = 0.382 and 0.420, respectively). Conclusion. We found fewer manipulations, and higher functional outcomes for patients treated with medial mobile-bearing UKA compared with TKA. TKA had twice the revision rate as UKA although this did not reach statistical significance with the numbers available. . Cite this article: Bone Joint J 2016;98-B(10 Suppl B):28–33

Aims. Radial head arthroplasty (RHA) may be used in the treatment of non-reconstructable radial head fractures. The aim of this study was to evaluate the mid-term clinical and radiographic results of RHA. Patients and Methods. Between 2002 and 2014, 77 RHAs were implanted in 54 men and 23 women with either acute injuries (54) or with traumatic sequelae (23) of a fracture of the radial head. Four designs of RHA were used, including the Guepar (Small Bone Innovations (SBi)/Stryker; 36), Evolutive (Aston Medical; 24), rHead RECON (SBi/Stryker; ten) or rHead STANDARD (SBi/Stryker; 7) prostheses. The mean follow-up was 74.0 months (standard deviation (. sd. ) 38.6; 24 to 141). The indication for further surgery, range of movement, mean Mayo Elbow Performance (MEP) score, quick Disabilities of the Arm, Shoulder and Hand (quickDASH) score, osteolysis and positioning of the implant were also assessed according to the design, and acute or delayed use. Results. The mean MEP and quickDASH scores were 90.2 (. sd. 14; 45 to 100), and 14.0 points (. sd. 12; 1.2 to 52.5), respectively. There were no significant differences between RHA performed in acute or delayed fashion. There were 30 re-operations (19 with, and 11 without removal of the implant) during the first three post-operative years. Painful loosening was the primary indication for removal in 14 patients. Short-stemmed prostheses (16 mm to 22 mm in length) were also associated with an increased risk of painful loosening (odds ratio 3.54 (1.02 to 12.2), p = 0.045). Radiocapitellar instability was the primary indication for re-operation with retention of the implant (5). The overall survival of the RHA, free from re-operation, was 60.8% (. sd. 5.7%) at ten years. Conclusion. Bipolar and press-fit RHA gives unsatisfactory mid-term outcomes in the treatment of acute fractures of the radial head or their sequelae. The outcome may vary according to the design of the implant. The rate of re-operation during the first three years is predictive of the long-term survival in tight-fitting RHAs. Cite this article: Bone Joint J 2017;99-B1197–1203

Stiffness is an uncommon but potentially debilitating complication following total knee replacement (TKR). The treatment of this condition remains difficult and controversial. We present the results of 13 patients who underwent open arthrolysis for stiffness. The mean time between TKR and arthrolysis was 14 months. The mean follow-up was 7.2 years (2 to 10). The mean range of movement prior to arthrolysis was 55°. This increased to 91°, six months after arthrolysis (p < 0.005). The improved range of movement was maintained during the follow-up period. No patient has required revision of their components. We have found arthrolysis to be a useful and successful approach to post-TKR stiffness

Objectives. Osteosynthesis of anterior pubic ramus fractures using one large-diameter screw can be challenging in terms of both surgical procedure and fixation stability. Small-fragment screws have the advantage of following the pelvic cortex and being more flexible. The aim of the present study was to biomechanically compare retrograde intramedullary fixation of the superior pubic ramus using either one large- or two small-diameter screws. Materials and Methods. A total of 12 human cadaveric hemipelvises were analysed in a matched pair study design. Bone mineral density of the specimens was 68 mgHA/cm. 3. (standard deviation (. sd). 52). The anterior pelvic ring fracture was fixed with either one 7.3 mm cannulated screw (Group 1) or two 3.5 mm pelvic cortex screws (Group 2). Progressively increasing cyclic axial loading was applied through the acetabulum. Relative movements in terms of interfragmentary displacement and gap angle at the fracture site were evaluated by means of optical movement tracking. The Wilcoxon signed-rank test was applied to identify significant differences between the groups. Results. Initial axial construct stiffness was not significantly different between the groups (p = 0.463). Interfragmentary displacement and gap angle at the fracture site were also not statistically significantly different between the groups throughout the evaluated cycles (p ⩾ 0.249). Similarly, cycles to failure were not statistically different between Group 1 (8438, . sd. 6968) and Group 2 (10 213, . sd. 10 334), p = 0.379. Failure mode in both groups was characterised by screw cutting through the cancellous bone. Conclusion. From a biomechanical point of view, pubic ramus stabilisation with either one large or two small fragment screw osteosynthesis is comparable in osteoporotic bone. However, the two-screw fixation technique is less demanding as the smaller screws deflect at the cortical margins. Cite this article: Y. P. Acklin, I. Zderic, S. Grechenig, R. G. Richards, P. Schmitz, B. Gueorguiev. Are two retrograde 3.5 mm screws superior to one 7.3 mm screw for anterior pelvic ring fixation in bones with low bone mineral density? Bone Joint Res 2017;6:8–13. DOI: 10.1302/2046-3758.61.BJR-2016-0261

We performed a comprehensive systematic review of the literature to examine the role of hemiarthroplasty in the early management of fractures of the proximal humerus. In all, 16 studies dealing with 810 hemiarthroplasties in 808 patients with a mean age of 67.7 years (22 to 91) and a mean follow-up of 3.7 years (0.66 to 14) met the inclusion criteria. Most of the fractures were four-part fractures or fracture-dislocations. Several types of prosthesis were used. Early passive movement on the day after surgery and active movement after union of the tuberosities at about six weeks was described in most cases. The mean active anterior elevation was to 105.7° (10° to 180°) and the mean abduction to 92.4° (15° to 170°). The incidence of superficial and deep infection was 1.55% and 0.64%, respectively. Complications related to the fixation and healing of the tuberosities were observed in 86 of 771 cases (11.15%). The estimated incidence of heterotopic ossification was 8.8% and that of proximal migration of the humeral head 6.8%. The mean Constant score was 56.63 (11 to 98). At the final follow-up, no pain or only mild pain was experienced by most patients, but marked limitation of function persisted

Aims. We present the clinical and radiographic outcome of 81 children with Gartland type I to III supracondylar humeral fractures at a minimum follow-up of ten years (mean 12.1 years; 10.3 to 16.1) following injury. Patients and Methods. The clinical and functional outcomes are compared with normal age- and gender-matched individuals. The population-based study setting was first identified from the institutional registries; the rate of participation was 76%. Controls were randomly selected from Finnish National Population Registry. Results. According to Flynn's criteria, most fractures (75.3%) resulted in a satisfactory (“good or excellent”) outcome. Satisfactory recovery was achieved in 75.0% of type I fractures treated by closed splinting (p = 0.013). Type II fractures were associated with both satisfactory (57.7%) and unsatisfactory (42.3%) results, regardless of the type of treatment, although the numbers were small in the sub groups. Most type III fractures were treated operatively, and most (76%) had a satisfactory outcome according to Flynn’s criteria (p = 0.015). Compared with none among the normal subjects, flexion of the elbow was reduced by >  10° at long-term follow-up in 20 cases (24.7%, p < 0.001) and 9 (11.1%) had a reduced flexion of > 15° (p = 0.004). In patients who had sustained a type III fracture, the carrying angle was decreased by 35.7% (from 9.8° to 6.3°; p = 0.048). All patients achieved an excellent Mayo Elbow Performance Score (mean 96.4 points). Conclusion. The long-term outcome of extension-type supracondylar humeral fractures is generally good, but not exclusively benign, with the potential for long-term pain and ulnar nerve sensitivity, and a decrease in grip strength and range of movement in type II and type III fractures. Bony remodelling cannot be relied upon to correct any residual deformity. In particular, type II fractures have impaired long-term recovery and justify individual consideration in their treatment. Cite this article: Bone Joint J 2016;98-B:1410–17

Delayed rather than early reconstruction of the anterior cruciate ligament is the current recommended treatment for injury to this ligament since it is thought to give a better functional outcome. We randomised 105 consecutive patients with injury associated with chondral lesions no more severe than grades 1 and 2 and/or meniscal tears which only required trimming, to early (< two weeks) or delayed (> four to six weeks) reconstruction of the anterior cruciate ligament using a quadrupled hamstring graft. All operations were performed by a single surgeon and a standard rehabilitation regime was followed in both groups. The outcomes were assessed using the Lysholm score, the Tegner score and measurement of the range of movement. Stability was assessed by clinical tests and measurements taken with the KT-1000 arthrometer, with all testing performed by a blinded uninvolved experienced observer. A total of six patients were lost to follow-up, with 48 patients assigned to the delayed group and 51 to the early group. None was a competitive athlete. The mean interval between injury and the surgery was seven days (2 to 14) in the early group and 32 days (29 to 42) in the delayed group. The mean follow-up was 32 months (26 to 36). The results did not show a statistically significant difference for the Lysholm score (p = 0.86), Tegner activity score (p = 0.913) or the range of movement (p = 1). Similarly, no distinction could be made for stability testing by clinical examination (p = 0.56) and measurements with the KT-1000 arthrometer (p = 0.93). Reconstruction of the anterior cruciate ligament gave a similar clinical and functional outcome whether performed early (< two weeks) or late at four to six weeks after injury

Aims

The results of surgery for Dupuytren’s disease can be compromised by the potential for disease recurrence and loss of function. Selecting which patients will benefit from repeat surgery, when to operate, and what procedure to undertake requires judgement and an understanding of patient expectations and functional needs. We undertook this study to investigate patient outcomes and satisfaction following repeat limited fasciectomy for recurrent Dupuytren’s disease.