Aims

After the initial correction of congenital talipes equinovarus (CTEV) using the Ponseti method, a subsequent dynamic deformity is often managed by transfer of the tendon of tibialis anterior (TATT) to the lateral cuneiform. Many surgeons believe the lateral cuneiform should be ossified before surgery is undertaken. This study quantifies the ossification process of the lateral cuneiform in children with CTEV between one and three years of age.

Aims

The glenohumeral joint is the most frequently dislocated articulation, but possibly due to the lower prevalence of posterior shoulder dislocations, approximately 50% to 79% of posterior glenohumeral dislocations are missed at initial presentation. The aim of this study was to systematically evaluate the most recent evidence involving the aetiology of posterior glenohumeral dislocations, as well as the diagnosis and treatment.

Aims

In patients with a rotator cuff tear, tear pattern and tendon involvement are known risk factors for the development of pseudoparalysis of the shoulder. It remains unclear, however, why similar tears often have very different functional consequences. The present study hypothesizes that individual shoulder anatomy, specifically the moment arms (MAs) of the rotator cuff (RC) and the deltoid muscle, as well as their relative recruitment during shoulder abduction, plays a central role in pseudoparalysis.

Patients with neuromuscular imbalance who require total hip arthroplasty (THA) present particular technical problems due to altered anatomy, abnormal bone stock, muscular imbalance and problems of rehabilitation.

In this systematic review, we studied articles dealing with THA in patients with neuromuscular imbalance, published before April 2017. We recorded the demographics of the patients and the type of neuromuscular pathology, the indication for surgery, surgical approach, concomitant soft-tissue releases, the type of implant and bearing, pain and functional outcome as well as complications and survival.

Recent advances in THA technology allow for successful outcomes in these patients. Our review suggests excellent benefits for pain relief and good functional outcome might be expected with a modest risk of complication.

Cite this article: Bone Joint J 2018;100-B(1 Supple A):17–21.

Aims

Single-event multilevel surgery (SEMLS) has been used as an effective intervention in children with bilateral spastic cerebral palsy (BSCP) for 30 years. To date there is no evidence for SEMLS in adults with BSCP and the intervention remains focus of debate.

Aims

The aim of the study was to develop a quantitative scoring system to predict whether a large-to-massive rotator cuff tear was arthroscopically reparable prior to surgery.

Flexor digitorum longus transfer and medial displacement calcaneal osteotomy is a well-recognised form of treatment for stage II posterior tibial tendon dysfunction. Although excellent short- and medium-term results have been reported, the long-term outcome is unknown. We reviewed the clinical outcome of 31 patients with a symptomatic flexible flat-foot deformity who underwent this procedure between 1994 and 1996. There were 21 women and ten men with a mean age of 54.3 years (42 to 70). The mean follow-up was 15.2 years (11.4 to 16.5). All scores improved significantly (p < 0.001). The mean American Orthopedic Foot and Ankle Society (AOFAS) score improved from 48.4 pre-operatively to 90.3 (54 to 100) at the final follow-up. The mean pain component improved from 12.3 to 35.2 (20 to 40). The mean function score improved from 35.2 to 45.6 (30 to 50). The mean visual analogue score for pain improved from 7.3 to 1.3 (0 to 6). The mean Short Form-36 physical component score was 40.6 (sd 8.9), and this showed a significant correlation with the mean AOFAS score (r = 0.68, p = 0.005). A total of 27 patients (87%) were pain free and functioning well at the final follow-up. We believe that flexor digitorum longus transfer and calcaneal osteotomy provides long-term pain relief and satisfactory function in the treatment of stage II posterior tibial tendon dysfunction.

Cite this article: Bone Joint J 2015;97-B:346–52.

A total of seven patients (six men and one woman) with a defect in the Achilles tendon and overlying soft tissue underwent reconstruction using either a composite radial forearm flap (n = 3) or an anterolateral thigh flap (n = 4). The Achilles tendons were reconstructed using chimeric palmaris longus (n = 2) or tensor fascia lata (n = 2) flaps or transfer of the flexor hallucis longus tendon (n = 3). Surgical parameters such as the rate of complications and the time between the initial repair and flap surgery were analysed. Function was measured objectively by recording the circumference of the calf, the isometric strength of the plantar flexors and the range of movement of the ankle. The Achilles tendon Total Rupture Score (ATRS) questionnaire was used as a patient-reported outcome measure. Most patients had undergone several previous operations to the Achilles tendon prior to flap surgery. The mean time to flap surgery was 14.3 months (2.1 to 40.7).

At a mean follow-up of 32.3 months (12.1 to 59.6) the circumference of the calf on the operated lower limb was reduced by a mean of 1.9 cm (sd 0.74) compared with the contralateral limb (p = 0.042). The mean strength of the plantar flexors on the operated lower limb was reduced to 88.9% of that of the contralateral limb (p = 0.043). There was no significant difference in the range of movement between the two sides (p = 0.317). The mean ATRS score was 72 points (sd 20.0). One patient who had an initial successful reconstruction developed a skin defect of the composite flap 12 months after free flap surgery and this resulted in recurrent infections, culminating in transtibial amputation 44 months after reconstruction.

These otherwise indicate that reconstruction of the Achilles tendon combined with flap cover results in a successful and functional reconstruction.

Cite this article: Bone Joint J 2015;97-B:215–20.

Aims

We aimed to identify the pattern of nerve injury associated with paediatric supracondylar fractures of the humerus.

Aims

Single event multilevel surgery (SEMLS) has been shown to improve gait in children with cerebral palsy (CP). However, there is limited evidence regarding long-term outcomes and factors influencing them.

We conducted an anatomical study to determine the best technique for transfer of the anterior interosseous nerve (AIN) for the treatment of proximal ulnar nerve injuries. The AIN, ulnar nerve, and associated branches were dissected in 24 cadaver arms. The number of branches of the AIN and length available for transfer were measured. The nerve was divided just proximal to its termination in pronator quadratus and transferred to the ulnar nerve through the shortest available route. Separation of the deep and superficial branches of the ulnar nerve by blunt dissection alone, was also assessed. The mean number of AIN branches was 4.8 (3 to 8) and the mean length of the nerve available for transfer was 72 mm (41 to 106). The transferred nerve reached the ulnar nerve most distally when placed dorsal to flexor digitorum profundus (FDP). We therefore conclude that the AIN should be passed dorsal to FDP, and that the deep and superficial branches of the ulnar nerve require approximately 30 mm of blunt dissection and 20 mm of sharp dissection from the point of bifurcation to the site of the anastomosis.

The use of this technique for transfer of the AIN should improve the outcome for patients with proximal ulnar nerve injuries.

Cite this article: Bone Joint J 2014;96-B:789–94.

Dislocation of the acromioclavicular joint is a relatively common injury and a number of surgical interventions have been described for its treatment. Recently, a synthetic ligament device has become available and been successfully used, however, like other non-native solutions, a compromise must be reached when choosing non-anatomical locations for their placement. This cadaveric study aimed to assess the effect of different clavicular anchorage points for the Lockdown device on the reduction of acromioclavicular joint dislocations, and suggest an optimal location. We also assessed whether further stability is provided using a coracoacromial ligament transfer (a modified Neviaser technique). The acromioclavicular joint was exposed on seven fresh-frozen cadaveric shoulders. The joint was reconstructed using the Lockdown implant using four different clavicular anchorage points and reduction was measured. The coracoacromial ligament was then transferred to the lateral end of the clavicle, and the joint re-assessed. If the Lockdown ligament was secured at the level of the conoid tubercle, the acromioclavicular joint could be reduced anatomically in all cases. If placed medial or 2 cm lateral, the joint was irreducible. If the Lockdown was placed 1 cm lateral to the conoid tubercle, the joint could be reduced with difficulty in four cases. Correct placement of the Lockdown device is crucial to allow anatomical joint reduction. Even when the Lockdown was placed over the conoid tubercle, anterior clavicle displacement remained but this could be controlled using a coracoacromial ligament transfer.

Cite this article: Bone Joint J 2015;97-B:1657–61.

Injuries to the limb are the most frequent cause of permanent disability following combat wounds. We reviewed the medical records of 450 soldiers to determine the type of upper limb nerve injuries sustained, the rate of remaining motor and sensory deficits at final follow-up, and the type of Army disability ratings granted. Of 189 soldiers with an injury of the upper limb, 70 had nerve-related trauma. There were 62 men and eight women with a mean age of 25 years (18 to 49). Disabilities due to nerve injuries were associated with loss of function, neuropathic pain or both. The mean nerve-related disability was 26% (0% to 70%), accounting for over one-half of this cohort’s cumulative disability. Patients injured in an explosion had higher disability ratings than those injured by gunshot. The ulnar nerve was most commonly injured, but most disability was associated with radial nerve trauma. In terms of the final outcome, at military discharge 59 subjects (84%) experienced persistent weakness, 48 (69%) had a persistent sensory deficit and 17 (24%) experienced chronic pain from scar-related or neuropathic pain. Nerve injury was the cause of frequent and substantial disability in our cohort of wounded soldiers.

Cite this article: Bone Joint J 2014;96-B:254–8.