We assessed the functional outcome following fracture of the tibial plateau in 63 consecutive patients. Fifty-one patients were treated by internal fixation, five by combined internal and external fixation and seven non-operatively. Measurements of joint movement and muscle function were made using a muscle dynamometer at three, six and 12 months following injury. Thirteen patients (21%) had a residual flexion contracture at one year. Only nine (14%) patients achieved normal quadriceps muscle strength at 12 months, while 19 (30%) achieved normal hamstring muscle strength. Recovery was significantly slower in patients older than 40 years of age. We conclude that there is significant impairment of movement and muscle function after fracture of the tibial plateau and that the majority of patients have not fully recovered one year after injury

Aims. The objective of this study was to compare early postoperative functional outcomes and time to hospital discharge between conventional jig-based total knee arthroplasty (TKA) and robotic-arm assisted TKA. Patients and Methods. This prospective cohort study included 40 consecutive patients undergoing conventional jig-based TKA followed by 40 consecutive patients receiving robotic-arm assisted TKA. All surgical procedures were performed by a single surgeon using the medial parapatellar approach with identical implant designs and standardized postoperative inpatient rehabilitation. Inpatient functional outcomes and time to hospital discharge were collected in all study patients. Results. There were no systematic differences in baseline characteristics between the conventional jig-based TKA and robotic-arm assisted TKA treatment groups with respect to age (p = 0.32), gender (p = 0.50), body mass index (p = 0.17), American Society of Anesthesiologists score (p = 0.88), and preoperative haemoglobin level (p = 0.82). Robotic-arm assisted TKA was associated with reduced postoperative pain (p < 0.001), decreased analgesia requirements (p < 0.001), decreased reduction in postoperative haemoglobin levels (p < 0.001), shorter time to straight leg raise (p < 0.001), decreased number of physiotherapy sessions (p < 0.001) and improved maximum knee flexion at discharge (p < 0.001) compared with conventional jig-based TKA. Median time to hospital discharge in robotic-arm assisted TKA was 77 hours (interquartile range (IQR) 74 to 81) compared with 105 hours (IQR 98 to 126) in conventional jig-based TKA (p < 0.001). Conclusion. Robotic-arm assisted TKA was associated with decreased pain, improved early functional recovery and reduced time to hospital discharge compared with conventional jig-based TKA. Cite this article: Bone Joint J 2018;100-B:930–7

Aims

The aim of the HIPGEN consortium is to develop the first cell therapy product for hip fracture patients using PLacental-eXpanded (PLX-PAD) stromal cells.

Aims. Torus fractures of the distal radius are the most common fractures in children. The NICE non-complex fracture guidelines recently concluded that bandaging was probably the optimal treatment for these injuries. However, across the UK current treatment varies widely due to a lack of evidence underpinning the guidelines. The Forearm Fracture Recovery in Children Evaluation (FORCE) trial evaluates the effect of a soft bandage and immediate discharge compared with rigid immobilization. Methods. FORCE is a multicentre, parallel group randomized controlled equivalence trial. The primary outcome is the Wong-Baker FACES pain score at three days after randomization and the primary analysis of this outcome will use a multivariate linear regression model to compare the two groups. Secondary outcomes are measured at one and seven days, and three and six-weeks post-randomization and include the Patient Reported Outcome Measurement Information System (PROMIS) upper extremity limb score, EuroQoL EQ-5D-Y, analgesia use, school absence, complications, and healthcare resource use. The planned statistical and health economic analyses for this trial are described here. The FORCE trial protocol has been published separately. Conclusion. This paper provides details of the planned analyses for this trial, and will reduce the risks of outcome reporting bias and data driven results. Cite this article: Bone Joint Open 2020;1-6:205–213

1 . The extensor digitorum longus of the rabbit was partly denervated by section of one of its two nerve branches and examined histologically for evidence of sprouting of new fibres. 2. Sections from material fixed two and three days after operation showed terminal bundles in which varying numbers of axons and motor end-plates have degenerated. This supports the concept that the motor unit is not confined to single groups of neighbouring muscle fibres, but innervates fibres scattered throughout the muscle. 3. New fine fibres branching from intact intramuscular axons to reinnervate denervated muscle fibres were observed as early as four days after operation. 4. Such new fibres were most numerous in the early weeks after operation and their numbers then declined. Two months after operation no small fibres or simple end-plates were seen. 5. No new fibres were seen in areas of the muscle containing only denervated nerve fibres. The new fibres were formed only under the stimulus of proximity to the degenerating ones. 6. The relationship of these findings to the mechanism of recovery of human muscle affected by poliomyelitis is discussed

The indications for lumbar discectomy are pain and neurological dysfunction. This paper considers the extent and timing of neurological recovery following spinal decompression

Aims. The primary aim of this study was to investigate the effect of an enhanced recovery program (ERP) on the short-term functional outcome after total hip arthroplasty (THA). Secondary outcomes included its effect on rates of dislocation and mortality. . Patients and Methods. Data were gathered on 1161 patients undergoing primary THA which included 611 patients treated with traditional rehabilitation and 550 treated with an ERP. . Results. The ERP was shown to be a significant independent factor which shortened length of stay (LOS) by a mean of 1.5 days (95% confidence interval (CI) 1.3 to 1.8, p < 0.001) after adjusting for confounding variables. The rates of dislocation (traditional 1.03% vs ERP 0.91%, p = 0.84) and mortality (1.5% vs 0.6%, p = 0.14) one year post-operatively were not significantly different. Both groups showed significant improvement in Harris Hip Score (42.8 vs 41.5) at 12 to 18 months post-operatively and there was no significant difference in the magnitude of improvement on univariate (p = 0.09) and multivariate analysis (p = 0.35). There was no significant difference in any of the eight domain scores of the Short-Form - 36 general health surveys post-operatively (p > 0.38). . Conclusion . We conclude that an ERP after THA shortens LOS by a mean of 1.5 days and does not increase the rate of complications post-operatively. It gives equivalent functional outcomes to a traditional rehabilitation pathway. Take home message: ERP reduces LOS after THA in comparison to traditional rehabilitation, without adversely affecting functional outcomes, dislocation rates or mortality. Cite this article: Bone Joint J 2016;98-B:475–82

Evidence is presented to support the contention that after slipping of the upper femoral epiphysis there is a potential for the bony epiphysis to grow back to its pre-slipped position. A suggestion is made as to how this recovery may occur

We have reviewed 59 patients with injury to the spinal cord to assess the predictive value of the sparing of sensation to pin prick in determining motor recovery in segments which initially had MRC grade-0 power. There were 35 tetraplegics (18 complete, 17 incomplete) and 24 paraplegics (19 complete, 5 incomplete), and the mean follow-up was 29.6 months. A total of 114 motor segments initially had grade-0 power but sparing of sensation to pin prick in the corresponding dermatome. Of these, 97 (85%) had return of functional power (≥ grade 3) at follow-up. There were 479 motor segments with grade-0 power but no sparing of sensation to pin prick and of these only six (1.3%) had return of functional power. Both of the above associations were statistically significant (chi-squared test, p < 0.0001). After injury to the spinal cord, the preservation of sensation to pin prick in a motor segment with grade-0 power indicated an 85% chance of motor recovery to at least grade 3

The suppression of the immediate postmeniscectomy synovial reaction by a potent prostaglandin inhibitor (flurbiprofen 400 mg daily) resulted in significantly less knee pain and swelling in 50 patients compared to 50 age-matched controls taking a simple analgesic (paracetamol 4 g daily) (P less than 0.001), thus enhancing recovery by three to four weeks. In the patients undergoing partial meniscectomy knee function was restored by 27 days, a figure comparable with endoscopic methods

Skeletal muscle grafts, when thawed after freezing, can be used to repair peripheral nerves. This method was used after transection of the median nerve in the upper arm in marmosets. Examination at 28 days showed total denervation of flexor carpi radialis; at 150 days electrophysiological evidence of recovery of nerve conduction across the graft and of muscle activation was seen. Sections at this time showed nerve fibres and new functional neuromuscular junctions in the muscle. It is concluded that effective reinnervation of target muscles is possible after peripheral nerve repair using skeletal muscle autografts

Opinion varies as to the incidence of nerve lesions in anterior dislocation of the shoulder after low-velocity trauma. Most studies are retrospective or do not use EMG. We have investigated the incidence and the clinical consequences of nerve lesions in a prospective study by clinical and electrophysiological examination. Axonal loss was seen in 48% of 77 patients. The axillary nerve was most frequently involved (42%). Although recovery as judged by EMG and muscle strength was almost complete, function of the shoulder was significantly impaired in patients with lesions of the axillary and suprascapular nerves. Unfavourable prognostic factors are increasing age and the presence of a haematoma. It is not necessary to carry out EMG routinely; an adequate programme of physiotherapy is important. In patients with a severe paresis, EMG is essential after three weeks

Most posterior hindfoot procedures have been described with the patient positioned prone. This affords excellent access to posterior hindfoot structures but has several disadvantages for the management of the airway, the requirement for an endotracheal tube in all patients, difficulty with ventilation and an increased risk of pressure injuries, especially with regard to reduced ocular perfusion.

We describe use of the ‘recovery position’, which affords equivalent access to the posterior aspect of the ankle and hindfoot without the morbidity associated with the prone position. A laryngeal mask rather than endotracheal tube may be used in most patients. In this annotation we describe this technique, which offers a safe and simple alternative method of positioning patients for posterior hindfoot and ankle surgery.

Cite this article: Bone Joint J 2013;95-B:1317–19.

We undertook a trial on 60 patients with AO 31A2 fractures of the hip who were randomised after stabilisation of the fracture into two equal groups, one of which received post-operative treatment using a non-invasive interactive neurostimulation device and the other with a sham device. All other aspects of their rehabilitation were the same. The treatment was continued for ten days after operation.

Outcome measurements included the use of a visual analogue scale for pain, the brief pain inventory and Ketorolac for post-operative control of pain, and an overall assessment of outcome by the surgeon. There were significantly better results for the patients receiving treatment by active electrical stimulation (repeated measures analysis of variance, p < 0.001). The findings of this pilot trial justify a larger study to determine if these results are more generally applicable.

We investigated the predictive value of intra-operative neurophysiological investigations in obstetric brachial plexus injuries. Between January 2005 and June 2011 a total of 32 infants of 206 referred to our unit underwent exploration of the plexus, including neurolysis. The findings from intra-operative electromyography, sensory evoked potentials across the lesion and gross muscular response to stimulation were evaluated. A total of 22 infants underwent neurolysis alone and ten had microsurgical reconstruction. Of the former, one was lost to follow-up, one had glenoplasty and three had subsequent nerve reconstructions. Of the remaining 17 infants with neurolysis, 13 (76%) achieved a modified Mallet score > 13 at a mean age of 3.5 years (0.75 to 6.25). Subluxation or dislocation of the shoulder is a major confounding factor. The positive predictive value and sensitivity of the intra-operative EMG for C5 were 100% and 85.7%, respectively, in infants without concurrent shoulder pathology. The positive and negative predictive values, sensitivity and specificity of the three investigations combined were 77%, 100%, 100% and 57%, respectively.

In all, 20 infants underwent neurolysis alone for C6 and three had reconstruction. All of the former and one of the latter achieved biceps function of Raimondi grade 5. The positive and negative predictive values, sensitivity and specificity of electromyography for C6 were 65%, 71%, 87% and 42%, respectively.

Our method is effective in evaluating the prognosis of C5 lesion. Neurolysis is preferred for C6 lesions.

Cite this article: Bone Joint J 2013;95-B:699–705.

An elderly woman presented with a pathological fracture of the right humerus. Progressive dissolution of the shaft of this bone took place over six months. No cause could be established and the patient refused biopsy. With only simple splintage for treatment the humeral shaft gradually reformed and re-ossified over a period of two years. The patient has been under review for four and a half years and no further pathology has come to light. The cause of the osteolysis remains obscure.

We analysed the influence of the timing of surgery (< 48 hours, group 1, 21 patients vs > 48 hours, group 2, 14 patients) on the neurological outcome and restoration of mobility in 35 incomplete tetra- and paraplegic patients with metastatic spinal-cord compression.

Pain and neurological symptoms were assessed using the American Spinal Injury Association impairment scale. More improvement was found in group 1 than in group 2 when comparing the pre-operative findings with those both immediately post-operatively (p = 0.021) and those at follow-up at four to six weeks (p = 0.010). In group 1 the number of pre-operatively mobile patients increased from 17 (81%) to 19 patients (90%) whereas the number of mobile patients in group 2 changed from nine (64%) to ten (71%).

These results suggest that early surgical treatment in patients with metastatic spinal-cord compression gives a better neurological outcome even in a palliative situation.