A total of 11 patients with combined traumatic injuries of the brachial plexus and spinal cord were reviewed retrospectively. Brachial plexus paralysis in such dual injuries tends to be diagnosed and treated late and the prognosis is usually poor. The associated injuries, which were all on the same side as the plexus lesion, were to the head (nine cases), shoulder girdle (five), thorax (nine) and upper limb (seven). These other injuries were responsible for the delayed diagnosis of brachial plexus paralysis and the poor prognosis was probably because of the delay in starting treatment and the severity of the associated injuries. When such injuries are detected in patients with spinal cord trauma, it is important to consider the possibility of involvement of the brachial plexus

We prospectively examined the physical and imaging findings, including MRI, of 23 patients with spontaneous osteonecrosis of the knee after obtaining informed consent to acquire tissue specimens at surgery. There were four men and 19 women, with a mean age of 67.5 years (58 to 77). Plain radiographs were designated as stages 1, 2, 3 or 4 according to the classification of Koshino. Five knees were classified as stage 1, five as stage 2, seven as stage 3 and six as stage 4. The histological specimens were stained with haematoxylin and eosin and tetrachrome. In the early stages of the condition, a subchondral fracture was noted in the absence of any features of osteonecrosis, whereas in advanced stages, osteonecrotic lesions were confined to the area distal to the site of the fracture which showed impaired healing. In such cases, formation of cartilage and fibrous tissue, occurred indicating delayed or nonunion. These findings strongly suggest that the histopathology at each stage of spontaneous osteonecrosis is characterised by different types of repair reaction for subchondral fractures

1. In the first 1600 of the series of peripheral nerve injuries treated during the years 1940-45 at the Peripheral Nerve Injuries Unit, Oxford, 52 per cent. were due to penetrating wounds, and 6 per cent. of these involved the brachial plexus. 2. A specific method of grouping and grading recovery is described: Group I—lesions of the roots and trunk of C.5, 6; Group II—lesions of the posterior cord; Group III—lesions of C.8, T.1, and the medial cord. 3. The recovery of cases in Group I was good, in Group II fair, and in Group III poor. 4. The brachial plexus was explored on twenty-two occasions. Only in four instances was there interruption of continuity—which is in striking contrast with the frequency in more distal degenerative nerve lesions in open wounds. 5. There is no evidence to suggest that neurolysis influenced motor or sensory recovery, but on one occasion it relieved persistent pain in the limb. In general the correlation between operative findings and prognosis was not precise. 6. With one exception, no recovery of consequence took place in the small muscles of the hand after a lesion in continuity, although galvanic stimulation to all paralysed muscles had been given regularly. 7. There is evidence to suggest that innervation of the biceps may not always be limited to C.5 and 6 and that in a proportion of cases C.7 may make a substantial contribution. 8. In five cases (12 per cent.) Horner's syndrome was present; the causation is discussed. 9. In every case of damage to a main vessel there was a marked tendency to joint stiffness, particularly in the hand, but on one occasion only was there evidence of ischaemic changes in the muscles and nerves. 10. The good spontaneous recovery which occurred in Groups I and II; the poor recovery in Group III even in cases where there was an apparently favourable lesion in continuity; the rarity with which division of nerves was found at operation; and the discouraging results of repair in three cases; make it necessary to conclude that routine exploration of open wounds of the brachial plexus is neither profitable nor justifiable

We have investigated the outcome of arthroscopic revision surgery for recurrent instability of the shoulder after failed primary anterior stabilisation. We identified 40 patients with failed primary open or arthroscopic anterior stabilisation of the shoulder who had been treated by revision arthroscopic capsulolabral reconstruction and followed up for a mean of 36 months (12 to 87). There were 34 men and six women with a mean age of 33.1 years (15 to 48). Details of the patients, the technique of the primary procedure, the operative findings at revision and the clinical outcome were evaluated by reviewing the medical records, physical examination and the use of the Western Ontario shoulder instability index score, the American Shoulder and Elbow Surgeons score and the health status questionnaire 12. Recurrent instability persisted in four patients after the revision arthroscopic procedure. At the final follow-up, the mean American Shoulder and Elbow Surgeons score was 81.1 (17.5 to 99.5) and the mean Western Ontario shoulder instability index score was 68.2 (20 to 98.2). Quality-of-life scoring showed good to excellent results in most patients. Arthroscopic revision capsulolabral reconstruction can provide a satisfactory outcome in selected patients for recurrent instability of the shoulder provided that no large Hill-Sachs lesion is present

Aims

To evaluate safety outcomes and patient satisfaction of the re-introduction of elective orthopaedic surgery on ‘green’ (non-COVID-19) sites during the COVID-19 pandemic.

Peripheral nerve injury is an uncommon but serious complication of hip surgery that can adversely affect the outcome. Several studies have described the use of electromyography and intra-operative sensory evoked potentials for early warning of nerve injury. We assessed the results of multimodal intra-operative monitoring during complex hip surgery. We retrospectively analysed data collected between 2001 and 2010 from 69 patients who underwent complex hip surgery by a single surgeon using multimodal intra-operative monitoring from a total pool of 7894 patients who underwent hip surgery during this period. In 24 (35%) procedures the surgeon was alerted to a possible lesion to the sciatic and/or femoral nerve. Alerts were observed most frequently during peri-acetabular osteotomy. The surgeon adapted his approach based on interpretation of the neurophysiological changes. From 69 monitored surgical procedures, there was only one true positive case of post-operative nerve injury. There were no false positives or false negatives, and the remaining 68 cases were all true negative. The sensitivity for predicting post-operative nerve injury was 100% and the specificity 100%. We conclude that it is possible and appropriate to use this method during complex hip surgery and it is effective for alerting the surgeon to the possibility of nerve injury

In a 41-year-old man, right-sided infraspinatus muscle weakness was associated with compression of the suprascapular nerve caused by a spinoglenoid ganglion cyst. The lesion was confirmed using electromyography and MRI. In addition, arthroscopy showed an incomplete discoid labrum. The free inner edge of the labrum was removed as in a meniscectomy of a discoid meniscus in the knee joint. Arthroscopic decompression of the cyst was performed through a juxtaglenoid capsulotomy which was left open. Neurological function recovered completely

Aims

The use of frozen tumour-bearing autograft combined with a vascularized fibular graft (VFG) represents a new technique for biological reconstruction of massive bone defect. We have compared the clinical outcomes between this technique and Capanna reconstruction.

A giant cell tumour is a primary lesion of bone of intermediate severity. Its histogenesis is unclear. In a few cases pulmonary metastases have been described. Multiple skeletal metastases in the absence of sarcomatous change have been observed. We present a case report of a 25-year-old woman with a recurrent giant cell tumour of the distal fibula. After a second recurrence and six years after the initial diagnosis, she rapidly developed multiple bony metastases. The outcome was fatal

A series of 26 children was referred to our specialist unit with a ‘pink pulseless hand’ following a supracondylar fracture of the distal humerus after a mean period of three months (4 days to 12 months) except for one referred after almost three years. They were followed up for a mean of 15.5 years (4 to 26). The neurovascular injuries and resulting impairment in function and salvage procedures were recorded. The mean age at presentation was 8.6 years (2 to 12). There were eight girls and 18 boys. Only four of the 26 patients had undergone immediate surgical exploration before referral and three of these four had a satisfactory outcome. In one child the brachial artery had been explored unsuccessfully at 48 hours. As a result 23 of the 26 children presented with established ischaemic contracture of the forearm and hand. Two responded to conservative stretching. In the remaining 21 the antecubital fossa was explored. The aim of surgery was to try to improve the function of the hand and forearm, to assess nerve, vessel and muscle damage, to relieve entrapment and to minimise future disturbance of growth. Based on our results we recommend urgent exploration of the vessels and nerves in a child with a ‘pink pulseless hand’, not relieved by reduction of a supracondylar fracture of the distal humerus and presenting with persistent and increasing pain suggestive of a deepening nerve lesion and critical ischaemia

1. This is a small series and patients have been treated in a variety of ways. Some impressions emerge, however, concerning the importance of initial trauma, the importance of the factor of heredity and the results of treatment. 2. More than 40 per cent of the patients in the series had an injury to the knee before symptoms began, which tends to support the traumatic theory. Twenty of the twenty-three patients who gave a past history of trauma had a lesion on the medial condyle, next to the intercondylar notch, and one patient of the three who had lesions on the lateral femoral condyle suffered from recurrent dislocation of the patella. 3. Although numerous examples have been reported in the literature of osteochondritis dissecans occurring in several members of a family, the family history of only one patient in this series suggested a familial tendency, and this was doubtful. It seems that patients showing a familial tendency are not commonly seen compared with the number of patients presenting with osteochondritis dissecans. 4. It is often stated that osteoarthritic changes will follow if part of the articular surface is lost, as in osteochondritis dissecans, and this belief has led to the school of thought which advocates restoration of the articular surface by reposition of the fragment. While there is no doubt that this method should be used if a large proportion of the weight-bearing surface of a femoral condyle is affected, the argument has less force if a small area is affected. It is interesting to find that of the five patients treated by replacement of a separated fragment four developed osteoarthritis, whereas in the first series only six patients out of the twenty-two developed such changes. Although these former had what appeared to be an accurate reposition of the fragment it is possible that a "step up" on the joint surface was produced, which gave rise to a more rapid deterioration of the articular cartilage. Accurate conclusions cannot be drawn from five patients, but it may be that attempts to reconstruct the articular surface of a femoral condyle can, over a long period of time, give worse results than simple removal of the lesion. 5. The group of patients treated conservatively gave encouraging results, and improved radiographic appearances were seen in most cases. There was also a notable absence of osteoarthritic changes and these results support the view that conservative treatment is indicated in adolescents and children

Elastofibroma dorsi is an uncommon, benign, slow-growing soft-tissue tumour of uncertain aetiology. It classically presents as an ill-defined mass at the inferior pole of the scapula with symptoms which include swelling, discomfort, snapping, stiffness and occasionally pain. We report the symptoms, function and outcome after treatment of 21 elastofibromas in 15 patients. All were diagnosed by MRI and early in the series four also underwent CT-guided biopsy to confirm the diagnosis. In all, 18 tumours were excised and three were observed. After excision, the mean visual analogue score for pain decreased from 4.6 (0 to 10) pre-operatively to 2.4 (0 to 8) post-operatively (p = 0.04). The mean shoulder function, at a mean follow-up of 4.2 years (3 months to 16 years), was 78.1% (30 to 100) using the Stanmore percentage of normal shoulder assessment scoring system. The mean range of forward flexion improved from 135° (70° to 180°) to 166° (100° to 180°) after excision (p = 0.005). In four patients a post-operative haematoma formed; one required evacuation. Three patients developed a post-operative seroma requiring needle aspiration and one developed a superficial infection which was treated with antibiotics. Our findings support previous reports suggesting that a pre-operative tissue diagnosis is not necessary in most cases since the lesion can be confidently diagnosed by MRI, when interpreted in the light of appropriate clinical findings. Surgical excision in symptomatic patients, is helpful. It has been suggested that elastofibroma is caused by a local tissue reaction and is not a true neoplastic process. A strong association has been noted between elastofibroma and repetitive use of the shoulder, which is supported by our findings

A prospective series of 32 cases with tuberculosis of the hand and wrist is presented. The mean age of the patients was 23.9 years (3 to 65), 12 had bony disease and 20 primarily soft-tissue involvement. The metacarpal of the little finger was the most commonly involved bone. Pain and swelling were the usual presenting features and discharging sinuses were seen in three cases. All patients were given anti-tubercular chemotherapy with four drugs. Operative treatment in the form of open or arthroscopic debridement, or incision and drainage of abscesses, was performed in those cases where no response was seen after eight weeks of ATT. Hand function was evaluated by the modified score of Green and O’Brien. The mean was 58.3 (25 to 80) before treatment and 90.5 (80 to 95) at the end. The mean follow-up was for 22.4 months (6 to 43). Conservative treatment was successful in 24 patients (75%). Eight who did not respond to chemotherapy within eight weeks required surgery. Although tuberculosis of hand has a varied presentation, the majority of lesions respond to conservative treatment

Advances in hip arthroscopy have renewed interest in the ligamentum teres. Considered by many to be a developmental vestige, it is now recognised as a significant potential source of pain and mechanical symptoms arising from the hip joint. Despite improvements in imaging, arthroscopy remains the optimum method of diagnosing lesions of the ligamentum teres. Several biological or mechanical roles have been proposed for the ligament. Unless these are disproved, the use of surgical procedures that sacrifice the ligamentum teres, as in surgical dislocation of the hip, should be carefully considered. This paper provides an update on the development, structure and function of the ligamentum teres, and discusses associated clinical implications

Aims

The goal of closed reduction (CR) in the treatment of developmental dysplasia of the hip (DDH) is to achieve and maintain concentricity of the femoral head in the acetabulum. However, concentric reduction is not immediately attainable in all hips and it remains controversial to what degree a non-concentric reduction is acceptable. This prospective study is aimed at investigating the dynamic evolution of the hip joint space after CR in DDH using MRI.

We describe a case of symptomatic focal femoral osteolysis around a screw hole distal to the hydroxyapatite-coated portion of a cannulated femoral component in a revision hip replacement. No locking screw had been inserted into this, the most proximal of the three distal holes for locking screws. The presence of polyethylene wear debris in the tissue excised from the lesion suggested that it had passed through the cannulated portion of the stem and out of the proximal unfilled distal locking hole, initiating an osteolytic reaction in an otherwise well-fixed stem. This case highlights an important design characteristic of such cannulated, uncemented femoral components. We recommend that the proximal aperture of these cannulated stems be occluded at implantation

Between 1998 and 2007, 22 patients with fractures of the scapula had operative treatment more than three weeks after injury. The indications for operation included displaced intra-articular fractures, medialisation of the glenohumeral joint, angular deformity, or displaced double lesions of the superior shoulder suspensory complex. Radiological and functional outcomes were obtained for 16 of 22 patients. Disabilities of the Arm, Shoulder, Hand (DASH) and Short form-36 scores were collected for 14 patients who were operated on after March 2002. The mean delay from injury to surgery was 30 days (21 to 57). The mean follow-up was for 27 months (12 to 72). At the last review the mean DASH score was 14 (0 to 41). Of the 16 patients with follow-up, 13 returned to their previous employment and recreational activities without restrictions. No wound complications, infection or nonunion occurred. Malunion of the scapula can be prevented by surgical treatment of fractures in patients with delayed presentation. Surgery is safe, effective, and gives acceptable functional results