Aims

We have evaluated the survivorship, outcomes, and failures of an interlocking, reconstruction-mode stem-sideplate implant used to preserve the native hip joint and achieve proximal fixation when there is little residual femur during large endoprosthetic reconstruction of the distal femur.

We prospectively studied the use of intercostal EMG monitoring as an indicator of the accuracy of the placement of pedicle screws in the thoracic spine. We investigated 95 thoracic pedicles in 17 patients. Before insertion of the screw, the surgeon recorded his assessment of the integrity of the pedicle track. We then stimulated the track using a K-wire pedicle probe connected to a constant current stimulator. A compound muscle action potential (CMAP) was recorded from the appropriate intercostal or abdominal muscles. Postoperative CT was performed to establish the position of the screw. The stimulus intensity required to evoke a muscle response was correlated with the position of the screw on the CT scan. There were eight unrecognised breaches of the pedicle. Using 7.0 mA as a threshold, the sensitivity of EMG was 0.50 in detecting a breached pedicle and the specificity was 0.83. Thoracic pedicle screws were accurately placed in more than 90% of patients. EMG monitoring did not significantly improve the reliability of placement of the screw

We have assessed the efficacy of free nerve grafts in 90 cases of brachial plexus injury. Relatively good recovery of the elbow flexor and extensor muscles and of those of the shoulder girdle was found but recovery of the flexors and extensors of the forearm and of the intrinsic muscles of the hand was extremely poor. Poor results were found when spinal nerve roots seemed normal to the touch and appeared intact but had abnormal somatosensory evoked potentials or myelography. Recovery of the deltoid and infraspinatus muscles was better when injury had occurred to the circumflex and suprascapular nerves rather than to the plexus itself, perhaps because these nerves were explored in their entirety to determine the presence of multiple lesions. It is important to visualise the entire nerve thoroughly to assess the overall condition. Thorough exploration of the plexus and the use of intraoperative recording of somatosensory evoked potentials are essential

We performed bilateral femoral shortening operations on 15 skeletally mature patients (11 women and four men). Their mean height pre-operatively was 193.5 cm and they were shortened by 5 to 9 cm. We used a subtrochanteric Z-osteotomy with an AO condylar plate in 11 patients, and mid-diaphyseal osteotomy with an intramedullary locking nail in four. After an average follow-up of 8.1 years, isokinetic muscle testing showed that muscle strength was reduced bilaterally in five patients. The strength ratio between hamstrings and quadriceps muscles was normal in all those treated by subtrochanteric shortening; in those shortened at the mid-shaft the quadriceps was relatively weaker. The result was rated as excellent by 11 patients, very good by three, and good by one

1. Volkmann's ischaemia of the lower limb is more common in adults than in children and occurs with sufficient frequency after injuries of the femur, knee and leg to warrant a more determined effort to prevent it. 2. The first and most essential step is to recognise the early signs of ischaemic damage. Incision of the deep fascia may then save the threatened underlying muscle, though it may also be necessary to seek for and evacuate a haematoma beneath the muscle. When the femoral or popliteal artery is injured, exploration and repair may be imperative. 3. The treatment of established ischaemic contracture is by whatever measures are necessary to correct the deformity. These are lengthening of shortened tendons, or excision of them if they are involved in dense fibrosis at the periphery of the ischaemic mass; and excision of all totally destroyed muscle. Amputation may be necessary

1. Musculoplastic stump correction is a method of physiological preparation of all the elements of the stump–muscles, bone, vessels and nerves–so as to establish the best relations between them. It removes the cause of existing circulatory disorders by creating active muscular movements. 2. In all cases stump pains, even those of causalgic character, have been eliminated. We attribute this to the attainment of normal muscular tension, and we believe that many phantom sensations and pains are caused by cramped and retracted muscles. 3. Active muscular work produces increased arterial inflow, as has been shown by arteriography, and also eliminates venous stasis in the end of the stump by restoration of the muscle pump mechanism. 4. Stumps prepared in the way described become painless and warm and their muscles become strong

Objectives. The goals of this study were: 1) to determine if high-fat diet (HFD) feeding in female mice would negatively impact biomechanical and histologic consequences on the Achilles tendon and quadriceps muscle; and 2) to investigate whether exercise and branched-chain amino acid (BCAA) supplementation would affect these parameters or attenuate any negative consequences resulting from HFD consumption. Methods. We examined the effects of 16 weeks of 60% HFD feeding, voluntary exercise (free choice wheel running) and BCAA administration in female C57BL/6 mice. The Achilles tendons and quadriceps muscles were removed at the end of the experiment and assessed histologically and biomechanically. Results. HFD feeding significantly decreased the Achilles tendon modulus without histological alterations. BCAA administration significantly decreased the stiffness of Achilles tendons in the exercised normal diet mice. Exercise partially ameliorated both the weight gain and glucose levels in the HFD-fed mice, led to a significant decrease in the maximum load of the Achilles tendon, and an increase in the average fibril diameter of the quadriceps femoris muscle. There were significant correlations between body weight and several biomechanical properties, demonstrating the importance of controlling obesity for maintaining healthy tendon properties. . Conclusions. In summary, this study showed a significant impact of obesity and body weight on tendon biomechanical properties with limited effects of exercise and BCAAs. Cite this article: Bone Joint Res 2013;2:186–92

Aims

We aimed to address the question on whether there is a place for shoulder stabilization surgery in patients who had voluntary posterior instability starting in childhood and adolescence, and later becoming involuntary and uncontrollable.

An experimental model was established to investigate the possibility of repairing cervical nerve roots avulsed from the spinal cord, as occurs in traction injuries of the brachial plexus. In five sheep the C6 root was avulsed and the ventral root was reattached using freeze-thawed muscle as a short graft (0.5 cm). Recovery was assessed after one year by electrophysiology and histology. Stimulation of the root produced muscle contractions in four out of five sheep. Action potentials were recorded distal to the grafts in all five sheep. Histological examination showed regenerated fibres in the ventral roots in all cases. These fibres could be traced distally to the brachial plexus. Our study confirms that motor fibres can regenerate out of the spinal cord into the ventral roots and reinnervate muscles, and suggests that reimplantation of avulsed roots is a surgical option in selected cases of traction injury of the brachial plexus

Four different experiments were performed to study the healing of a large, non-vascularised, diaphyseal, bone segment in adult cats. In the first experiment, a 4 cm segment of tibia with its periosteum was excised and replaced in its bed. The other experiments were similar, except that in the second, the periosteum of the segment was removed, in the third its medullary canal was blocked with a Silastic rod, and in the last group the segment was isolated from its muscle bed by a Silastic sheet. The reparative processes were quantified by estimating the resorption index, the cortical new bone formation index, the callus encasement index, and the osteocyte count. Bone resorption and apposition occurred in the segment even when the periosteum was absent or the medullary canal was blocked, with osseous union at both ends by eight to 12 weeks, provided the segment was not isolated from its muscle bed. Thus, the muscle bed played a significant role in these reparative processes

Spinal accessory nerve palsy leads to painful disability of the shoulder, carrying an uncertain prognosis. We reviewed the long-term outcome in 16 patients who were treated for pain, weakness of active elevation and asymmetry of the shoulder and the neck due to chronic paralysis of the trapezius muscle, as a result of nerve palsy. Of four patients who were treated conservatively, none regained satisfactory function, although two became pain-free. The other 12 patients were treated operatively with transfer of the levator scapulae to the acromion and the rhomboid muscles to the infraspinatus fossa (the Eden-Lange procedure). At a mean follow-up of 32 years, the clinical outcome of the operatively treated patients was excellent in nine, fair in two, and poor in one patient, as determined by the Constant score. Pain was adequately relieved in 11 and overhead function was restored in nine patients. Pre-operative electromyography had been carried out in four patients. In two, who eventually had a poor outcome, a concomitant long thoracic and dorsal scapular nerve lesion had been present. The Eden-Lange procedure gives very satisfactory long-term results for the treatment of isolated paralysis of trapezius. In the presence of an additional serratus anterior palsy or weak rhomboid muscles, the procedure is less successful in restoring shoulder function

Aims

The aim of this study was to assess orthopaedic oncologic patient morbidity resulting from COVID-19 related institutional delays and surgical shutdowns during the first wave of the pandemic in New York, USA.

We studied 1061 children with myelomeningocele, reviewing 3184 pelvic radiographs from 802 patients. Hip dislocation had occurred by the age of 11 years in 28% of children with a thoracic neurosegmental level, 30% of those with an L1/2 level, 36% of L3, 22% of L4, 7% of L5 and only 1% of those with sacral levels. Hip dislocation was not inevitable even when there was maximal muscle imbalance about the hip. The average hip flexion contracture in children aged 9 to 11 years was significantly greater in those with thoracic (22 degrees) and L1/2 (33 degrees) levels than in those with L4 (9 degrees), L5 (5 degrees) or sacral (4 degrees) levels. Our findings indicate that muscle imbalance is not a significant factor in the production of flexion deformity or dislocation of the hip; both are commonly seen in the absence of imbalance. The restoration of muscle balance should no longer be considered to be the principal aim of the management of the hip in children with myelomeningocele

We investigated the functional outcome in patients who underwent reverse shoulder replacement (RSR) after removal of a tumour of the proximal humerus. A total of 16 patients (ten women and six men) underwent this procedure between 1998 and 2011 in our hospital. Five patients died and one was lost to follow-up. Ten patients were available for review at a mean follow-up of 46 months (12 to 136). Eight patients had a primary and two patients a secondary bone tumour. At final follow up the mean range of active movement was: abduction 78° (30° to 150°); flexion 98° (45° to 180°); external rotation 32° (10° to 60°); internal rotation 51° (10° to 80°). The mean Musculoskeletal Tumor Society score was 77% (60% to 90%) and the mean Toronto Extremity Salvage Score was 70% (30% to 91%). Two patients had a superficial infection and one had a deep infection and underwent a two-stage revision procedure. In two patients there was loosening of the RSR; one dislocated twice. All patients had some degree of atrophy or pseudo-atrophy of the deltoid muscle. Use of a RSR in patients with a tumour of the proximal humerus gives acceptable results. Cite this article: Bone Joint J 2013;95-B:1551–5

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).

We have previously shown that prior exposure of rat hind limbs to ischaemia for five minutes and reperfusion for five minutes reduced the structural damage to skeletal muscle which followed a subsequent period of ischaemia for four hours and reperfusion for one hour. We have now examined the potential mechanisms by which this ischaemic preconditioning protocol may be effective in reducing damage to skeletal muscle induced by prolonged ischaemia and reperfusion. Prior exposure of the hindlimb to ischaemia for five minutes and reperfusion for five minutes did not prevent the fall in the ATP content of tibialis anterior which occurred after a subsequent period of ischaemia for four hours and reperfusion for one hour. Similarly, no effect of the preconditioning protocol was seen on the elevated muscle myeloperoxidase, indicative of an elevated neutrophil content, or abnormal muscle cation content. Reperfused ischaemic muscle was also found to have an increased content of heat-shock protein (HSP) 72, but the preconditioning protocol did not further increase the content of this or other HSPs indicating that it was not acting by increasing the expression of these cytoprotective proteins. The protective effects of preconditioning appeared to be mimicked by the infusion of adenosine to animals immediately before exposure to the four-hour period, indicating a potential mechanism by which skeletal muscle may be preconditioned to maintain structural viability