Reverse total shoulder replacement (RTSR) depends on adequate deltoid function for a successful outcome. However, the anterior deltoid and/or axillary nerve may be damaged due to prior procedures or injury. The purpose of this study was to determine the compensatory muscle forces required for scapular plane elevation following RTSR when the anterior deltoid is deficient. The soft tissues were removed from six cadaver shoulders, except for tendon attachments. After implantation of the RTSR, the shoulders were mounted on a custom-made shoulder simulator to determine the mean force in each muscle required to achieve 30° and 60° of scapular plane elevation. Two conditions were tested: 1) Control with an absent supraspinatus and infraspinatus; and 2) Control with anterior deltoid deficiency. Anterior deltoid deficiency resulted in a mean increase of 195% in subscapularis force at 30° when compared with the control (p = 0.02). At 60°, the subscapularis force increased a mean of 82% (p < 0.001) and the middle deltoid force increased a mean of 26% (p = 0.04). Scapular plane elevation may still be possible following an RTSR in the setting of anterior deltoid deficiency. When the anterior deltoid is deficient, there is a compensatory increase in the force required by the subscapularis and middle deltoid. Attempts to preserve the subscapularis, if present, might maximise post-operative function

1. The results of electrodiagnostic tests reveal the level and progress of nerve lesions. 2. The findings in a myopathic lesion are: a) a normal SD curve; b) no fibrillation on the E.M.G.; c) on volition a full interference pattern-because motor units have not been lost, but only muscle fibres within the units; d) the action potentials are short in duration, polyphasic and of low amplitude; e) conduction times are normal. 3. In peripheral nerve affections these findings are evidence of denervation: a) a sluggish response to a long duration current; b) a kinked SD curve; c) fibrillation at rest on the E.M.G.; d) a reduced interference pattern of motor unit action potentials on volition; e) a preponderance of polyphasic action potentials of long and short duration; f) slowing of conduction times. 4. Evidence of reinnervation is given by: a) a kink in the SD curve; b) the appearance of a response in the muscle to nerve stimulation; c) a progressive increase in conduction velocity; d) the appearance of polyphasic action potentials on volition; e) fibrillation becoming more difficult to detect. 5. The following findings suggest a lesion of the anterior horn cell: a) difficulty in detecting fibrillation, and a relatively normal SD curve in the presence of marked wasting. (Intact axons have "mopped up" denervated fibres.) b) Marked reduction in interference pattern with ‘giant units’. c) Normal conduction velocity

Aims

Following cast removal for nonoperatively treated distal radius fractures, rehabilitation facilitated by advice leaflet and advice video were compared to a course of face-to-face therapy.

Using general practitioner records and hospital notes and through direct telephone conversation with patients, we investigated the accuracy of nine patient-reported complications gathered from a self-completed questionnaire after elective joint replacement surgery of the hip and knee. A total of 402 post-discharge complications were reported after 8546 elective operations that were undertaken within a three-year period. These were reported by 136 men and 240 women with a mean age of 71.8 years (34 to 93). A total of 319 reported complications (79.4%; 95% confidence interval 75.4 to 83.3) were confirmed to be correct. High rates of correct reporting were demonstrated for infection (94.5%) and the need for further surgery (100%), whereas the rates of reporting deep-vein thrombosis (DVT), pulmonary embolism, myocardial infarction and stroke were lower (75% to 84.2%). Dislocation, peri-prosthetic fractures and nerve palsy had modest rates of correct reporting (36% to 57.1%). More patients who had knee surgery delivered incorrect reports of dislocation (p = 0.001) and DVT (p = 0.013). Despite these variations, it appears that post-operative complications may form part of a larger patient-reported outcome programme after elective joint replacement surgery

One of the interesting aspects of spinal pathology having an important bearing on the treatment of backache is that the spine acts as an integrated whole and that damage sustained by one part frequently injures other structures in the spinal column. Thus disc degeneration may be associated with an extrusion of nuclear material; it may initiate degenerative changes in the posterior joints; it may predispose to tears of the posterior spinal ligaments; or it may give rise eventually to all of these lesions, any one of which may produce backache with or without sciatica. The sciatica may be referred pain or may be produced by nerve root pressure. Nerve root pressure in such instances is commonly due to an extrusion of nuclear material, but it may also be due to pressure on the nerve root within the foramen by a "squashed" disc or by a subluxated posterior joint. Radiographs are of great value in the diagnosis of disc degeneration and they are of greater value in the assessment of the secondary effects that have taken place. With the use of bending films evidence of early degenerative changes may be obtained, tears of the supraspinous ligament can be detected, and abnormal movements of the posterior joints can be seen. Careful study of the antero-posterior and lateral projections will reveal evidence of subluxation of the posterior joints, chip fractures and degenerative arthritis in the zygapophysial articulations, and will clearly demonstrate overriding of the facets. The investigation of subjective phenomena, such as backache, is fraught with many difficulties and it must be preceded by an investigation of the anatomy of the part and the anatomical variations, the normal and abnormal physiology and the pathological lesions that occur. Many of these changes of course may have no clinical significance, but it is only when armed with the knowledge of what may occur that we can tackle the problem of low back pain on a logical basis

Total hip replacement (THR) after acetabular fracture presents unique challenges to the orthopaedic surgeon. The majority of patients can be treated with a standard THR, resulting in a very reasonable outcome. Technical challenges however include infection, residual pelvic deformity, acetabular bone loss with ununited fractures, osteonecrosis of bone fragments, retained metalwork, heterotopic ossification, dealing with the sciatic nerve, and the difficulties of obtaining long-term acetabular component fixation. Indications for an acute THR include young patients with both femoral head and acetabular involvement with severe comminution that cannot be reconstructed, and the elderly, with severe bony comminution. The outcomes of THR for established post-traumatic arthritis include excellent pain relief and functional improvements. The use of modern implants and alternative bearing surfaces should improve outcomes further. Cite this article: Bone Joint J 2013;95-B, Supple A:11–16

Aims

Recent total knee arthroplasty (TKA) designs have featured more anatomical morphologies and shorter tibial keels. However, several reports have raised concerns about the impact of these modifications on implant longevity. The aim of this study was to report the early performance of a modern, cemented TKA design.

Aims

Time to treatment initiation (TTI) is generally defined as the time from the histological diagnosis of malignancy to the initiation of first definitive treatment. There is no consensus on the impact of TTI on the overall survival in patients with a soft-tissue sarcoma. The purpose of this study was to determine if an increased TTI is associated with overall survival in patients with a soft-tissue sarcoma, and to identify the factors associated with a prolonged TTI.

Post-traumatic elbow stiffness is a disabling condition that remains challenging for upper limb surgeons. Open elbow arthrolysis is commonly used for the treatment of stiff elbow when conservative therapy has failed. Multiple questions commonly arise from surgeons who deal with this disease. These include whether the patient has post-traumatic stiff elbow, how to evaluate the problem, when surgery is appropriate, how to perform an excellent arthrolysis, what the optimal postoperative rehabilitation is, and how to prevent or reduce the incidence of complications. Following these questions, this review provides an update and overview of post-traumatic elbow stiffness with respect to the diagnosis, preoperative evaluation, arthrolysis strategies, postoperative rehabilitation, and prevention of complications, aiming to provide a complete diagnosis and treatment path.

Cite this article: Bone Joint Open 2020;1-9:576–584.

We describe a case of sciatic endometriosis in a 25-year-old woman diagnosed by MRI and histology with no evidence of intrapelvic disease. The presentation, diagnosis and management of this rare condition are described. Early diagnosis and treatment are important to prevent irreversible damage to the sciatic nerve

Objectives. In order to elucidate the influence of sympathetic nerves on lumbar radiculopathy, we investigated whether sympathectomy attenuated pain behaviour and altered the electrical properties of the dorsal root ganglion (DRG) neurons in a rat model of lumbar root constriction. Methods. Sprague-Dawley rats were divided into three experimental groups. In the root constriction group, the left L5 spinal nerve root was ligated proximal to the DRG as a lumbar radiculopathy model. In the root constriction + sympathectomy group, sympathectomy was performed after the root constriction procedure. In the control group, no procedures were performed. In order to evaluate the pain relief effect of sympathectomy, behavioural analysis using mechanical and thermal stimulation was performed. In order to evaluate the excitability of the DRG neurons, we recorded action potentials of the isolated single DRG neuron by the whole-cell patch-clamp method. Results. In behavioural analysis, sympathectomy attenuated the mechanical allodynia and thermal hyperalgesia caused by lumbar root constriction. In electrophysiological analysis, single isolated DRG neurons with root constriction exhibited lower threshold current, more depolarised resting membrane potential, prolonged action potential duration, and more depolarisation frequency. These hyperexcitable alterations caused by root constriction were significantly attenuated in rats treated with surgical sympathectomy. Conclusion. The present results suggest that sympathectomy attenuates lumbar radicular pain resulting from root constriction by altering the electrical property of the DRG neuron itself. Thus, the sympathetic nervous system was closely associated with lumbar radicular pain, and suppressing the activity of the sympathetic nervous system may therefore lead to pain relief

Aims

Restarting planned surgery during the COVID-19 pandemic is a clinical and societal priority, but it is unknown whether it can be done safely and include high-risk or complex cases. We developed a Surgical Prioritization and Allocation Guide (SPAG). Here, we validate its effectiveness and safety in COVID-free sites.

Objectives. Traumatic brachial plexus injury causes severe functional impairment of the arm. Elbow flexion is often affected. Nerve surgery or tendon transfers provide the only means to obtain improved elbow flexion. Unfortunately, the functionality of the arm often remains insufficient. Stem cell therapy could potentially improve muscle strength and avoid muscle-tendon transfer. This pilot study assesses the safety and regenerative potential of autologous bone marrow-derived mononuclear cell injection in partially denervated biceps. Methods. Nine brachial plexus patients with insufficient elbow flexion (i.e., partial denervation) received intramuscular escalating doses of autologous bone marrow-derived mononuclear cells, combined with tendon transfers. Effect parameters included biceps biopsies, motor unit analysis on needle electromyography and computerised muscle tomography, before and after cell therapy. Results. No adverse effects in vital signs, bone marrow aspiration sites, injection sites, or surgical wound were seen. After cell therapy there was a 52% decrease in muscle fibrosis (p = 0.01), an 80% increase in myofibre diameter (p = 0.007), a 50% increase in satellite cells (p = 0.045) and an 83% increase in capillary-to-myofibre ratio (p < 0.001) was shown. CT analysis demonstrated a 48% decrease in mean muscle density (p = 0.009). Motor unit analysis showed a mean increase of 36% in motor unit amplitude (p = 0.045), 22% increase in duration (p = 0.005) and 29% increase in number of phases (p = 0.002). Conclusions. Mononuclear cell injection in partly denervated muscle of brachial plexus patients is safe. The results suggest enhanced muscle reinnervation and regeneration. Cite this article: Bone Joint Res 2014;3:38–47

Aims

To compare the functional outcome, health-related quality of life (HRQoL), and satisfaction of patients who underwent primary total hip arthroplasty (THA) and a single debridement, antibiotics and implant retention (DAIR) procedure for deep infection, using either the transgluteal or the posterior surgical approach for both procedures.

Injuries to the hamstring muscle complex are common in athletes, accounting for between 12% and 26% of all injuries sustained during sporting activities. Acute hamstring injuries often occur during sports that involve repetitive kicking or high-speed sprinting, such as American football, soccer, rugby, and athletics. They are also common in watersports, including waterskiing and surfing. Hamstring injuries can be career-threatening in elite athletes and are associated with an estimated risk of recurrence in between 14% and 63% of patients. The variability in prognosis and treatment of the different injury patterns highlights the importance of prompt diagnosis with magnetic resonance imaging (MRI) in order to classify injuries accurately and plan the appropriate management.

Low-grade hamstring injuries may be treated with nonoperative measures including pain relief, eccentric lengthening exercises, and a graduated return to sport-specific activities. Nonoperative management is associated with highly variable times for convalescence and return to a pre-injury level of sporting function. Nonoperative management of high-grade hamstring injuries is associated with poor return to baseline function, residual muscle weakness and a high-risk of recurrence. Proximal hamstring avulsion injuries, high-grade musculotendinous tears, and chronic injuries with persistent weakness or functional compromise require surgical repair to enable return to a pre-injury level of sporting function and minimize the risk of recurrent injury.

This article reviews the optimal diagnostic imaging methods and common classification systems used to guide the treatment of hamstring injuries. In addition, the indications and outcomes for both nonoperative and operative treatment are analyzed to provide an evidence-based management framework for these patients.

Cite this article: Bone Joint J 2020;102-B(10):1281–1288.

Aims

Many surgeons choose to perform total knee arthroplasty (TKA) surgery with the aid of a tourniquet. A tourniquet is a device that fits around the leg and restricts blood flow to the limb. There is a need to understand whether tourniquets are safe, and if they benefit, or harm, patients. The aim of this study was to determine the benefits and harms of tourniquet use in TKA surgery.

Aims

This study, using a surgeon-maintained database, aimed to explore the risk factors for surgery-related complications in patients undergoing primary cervical spine surgery for degenerative diseases.

Aims

Despite the increase in the surgical repair of proximal hamstring tears, there exists a lack of consensus in the optimal timing for surgery. There is also disagreement on how partial tears managed surgically compare with complete tears repaired surgically. This study aims to compare the mid-term functional outcomes in, and operating time required for, complete and partial proximal hamstring avulsions, that are repaired both acutely and chronically.

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