Subtalar distraction bone-block arthrodesis for malunited calcaneal fractures was performed in 31 patients (26 men, five women), with a mean age of 38.5 years. The mean time from injury to arthrodesis was 36 months. There were no cases of nonunion.

One patient had an early dislocation of the bone block requiring a repeat arthrodesis, and one had a soft-tissue infection. The mean AOFAS hindfoot score improved significantly from 23.5 before operation to 73.2 at a mean follow-up of 33 months (p > 0.001). Compared with the unaffected side, the talocalcaneal height was corrected by 61.8%, the talus-first metatarsal axis by 46.5%, the talar declination angle by 38.5% and the talocalcaneal angle by 35.4%. Dynamic pedobarography revealed a return to normal of the pressure distribution during roll-over and a more energetic gait. The distribution of local transfer of load correlated well with the AOFAS score. The amount of correction of the heel height correlated with a normal pattern of pressure transfer on the heel (p < 0.05).

Six normal cadaver lower limbs were mounted on a specially designed loading apparatus. Wires were used to simulate the five muscle bellies of the quadriceps, the ratio of their tensions having been determined from that of the anatomical cross-sectional areas of the muscles. A three-camera system was used to track the patella during knee movements from flexion to extension. The patellofemoral contact area was determined by pressure-sensitive film. The limb was loaded with and without tension on the wire which simulated the oblique part of the vastus medialis (VMO). Absence of VMO tension caused the patella to displace laterally (4.2 mm) and increased the load on the lateral patellar facet throughout the range of knee motion. When the tension on the wire simulating vastus lateralis was reduced by 40% to simulate the effect of a lateral release procedure, the abnormal kinematics caused by the absent VMO returned to normal.

1. In ten healthy young men an experimental paralysis of the supraspinatus muscle was induced with the aid of Xylocaine injected in or near the suprascapular nerve.

2. The completeness of the paralysis was checked by electromyography.

3. With the supraspinatus muscle completely eliminated, all subjects could move the arm against gravity through its full range in the shoulder joint, though the force and the power of endurance during abduction were diminished.

4. It is concluded that the role of the supraspinatus muscle is of a quantitative nature only.

Systemic factors are believed to be pivotal for the development of heterotopic ossification in severely-injured patients. In this study, cell cultures of putative target cells (human fibroblastic cells, osteoblastic cells (MG-63), and bone-marrow stromal cells (hBM)) were incubated with serum from ten consecutive polytraumatised patients taken from post-traumatic day 1 to day 21 and with serum from 12 healthy control subjects.

The serum from the polytraumatised patients significantly stimulated the proliferation of fibroblasts, MG-63 and of hBM cells. The activity of alkaline phosphatase in MG-63 and hBM cells was significantly decreased when exposed to the serum of the severely-injured patient. After three weeks in 3D cell cultures, matrix production and osteogenic gene expression of hBM cells were equal in the patient and control groups. However, the serum from the polytraumatised patients significantly decreased apoptosis of hBM cells compared with the control serum (4.3% vs 19.1%, p = 0.031).

Increased proliferation of osteoblastic cells and reduced apoptosis of osteoprogenitors may be responsible for increased osteogenesis in severely-injured patients.

Stable fixation of fractures of the distal radius can be achieved by using two 2.0 mm titanium plates placed on the radial and intermediate columns angled 50° to 70° apart. We describe our results with this method in a prospective series of 74 fractures (58 severely comminuted) in 73 consecutive patients.

Early postoperative mobilisation was possible in all except four wrists. All of the 73 patients, except two with other injuries, returned to work and daily activities with no limitations. The anatomical results were excellent or good in 72 patients and fair in one.

Our discussion includes details of important technical considerations based on an analysis of the specific complications which were seen early in the series.

We describe the functional results in 14 patients (7 men, 7 women) after subtotal scapulectomy for primary bone and soft-tissue tumours at a specialist musculoskeletal oncology unit. Eight had chondrosarcomas, two Ewing’s sarcomas, one aggressive fibromatosis and three soft-tissue sarcomas. The mean follow-up was 52 months (6 to 120). Analysis of residual symptoms and of range and strength of movement by physicians used the Musculoskeletal Tumour Society rating scale (MSTS). Physical disability was measured by the patients using the Toronto Extremity Salvage Score (TESS).

All 14 patients are still alive, two with systemic disease. Nine had more than 80% of their scapula resected but the glenohumeral joint was preserved in all cases. Eight had full movement and another two achieved 90° of flexion. The mean functional results were good to excellent in all except three patients (mean MSTS = 71.6 and TESS = 79.9). Two of these three patients had considerable pain as a result of brachial neuropathy.

Scapulectomy gives an excellent functional result if the glenohumeral joint is preserved. The rotator cuff could be removed without a severe functional deficit provided that the deltoid was reattached to the scapular remnant and the trapezius.

Thirty patients who had sustained a Colles' fracture at least four years previously were examined functionally and radiographically. Seventeen had a good radiological result and 13 were considered to have malunion. Functionally the displaced group performed significantly worse than the undisplaced group. We conclude that malunion of a Colles' fracture results in a weak, deformed, stiff and probably painful wrist.

Biochemical and histochemical studies have indicated that there is specific cellular activity in the region of the calcification front of articular cartilage implying that a regulation process takes place there. Using scanning and transmission electron microscopy and light microscopy to examine tissue sections of both undecalcified and decalcified articular cartilage in the region of the calcification front, we have looked at its morphology with particular reference to its cellular control. Our observations show that physiological calcification is an active process under cellular control and is related to the presence of extracellular membrane-bound matrix vesicles.

We examined the recovery of power in the muscles of the lower limb after fracture of the tibial diaphysis, using a Biodex dynamometer. Recovery in all muscle groups was rapid for 15 to 20 weeks following fracture after which it slowed. Two weeks after fracture the knee flexors and extensors have about 40% of normal power, which rises to 75% to 85% after one year. The dorsiflexors and plantar flexors of the ankle and the invertors and evertors of the subtalar joint are much weaker two weeks after injury, but at one year their mean power is more than that of the knee flexors and extensors.

Our findings showed that age, the mode of injury, fracture morphology, the presence of an open wound and the Tscherne grade of closed fractures correlated with muscle power. It is age, however, which mainly determines muscle recovery after fracture of the tibial diaphysis.

The aim of this study was to analyse the gait pattern, muscle force and functional outcome of patients who had undergone replacement of the proximal tibia for tumour and alloplastic reconstruction of the extensor mechanism using the patellar-loop technique.

Between February 1998 and December 2009, we carried out wide local excision of a primary sarcoma of the proximal tibia, proximal tibial replacement and reconstruction of the extensor mechanism using the patellar-loop technique in 18 patients. Of these, nine were available for evaluation after a mean of 11.6 years (0.5 to 21.6). The strength of the knee extensors was measured using an Isobex machine and gait analysis was undertaken in our gait assessment laboratory. Functional outcome was assessed using the American Knee Society (AKS) and Musculoskeletal Tumor Society (MSTS) scores.

The gait pattern of the patients differed in ground contact time, flexion heel strike, maximal flexion loading response and total sagittal plane excursion. The mean maximum active flexion was 91° (30° to 110°). The overall mean extensor lag was 1° (0° to 5°). The mean extensor muscle strength was 25.8% (8.3% to 90.3%) of that in the non-operated leg (p < 0.001). The mean functional scores were 68.7% (43.4% to 83.3%) (MSTS) and 71.1 (30 to 90) (AKS functional score).

In summary, the results show that reconstruction of the extensor mechanism using this technique gives good biomechanical and functional results. The patients’ gait pattern is close to normal, except for a somewhat stiff knee gait pattern. The strength of the extensor mechanism is reduced, but sufficient for walking.

Cite this article: Bone Joint J 2015;97-B:1063–9.

We evaluated the construct validity of the Musculoskeletal Tumour Society rating scale (Enneking score) as a functional measure for patients with sarcoma involving the upper limb. We compared the Enneking score by examining the correlation between two patient-derived outcome measures, the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire and the Medical Outcomes Study Short Form-36 (SF-36) as indicators of functional status in 40 patients with malignant or aggressive benign bone and soft-tissue tumours of the upper limb who had undergone surgical treatment.

The frequency distributions were similar among the three scoring systems. As for the validity, Spearman’s rank correlation coefficient of the Enneking score to the DASH questionnaire was −0.79 and that of the Enneking to the SF-36 subscales ranged from 0.38 to 0.60. Despite being a measure from the surgeon’s perspective, the Enneking score was shown to be a valid indicator of physical disability in patients with malignant or aggressive benign tumours of the upper limb and reflected their opinion.

We reviewed 57 adult patients at an average of 37 months after early internal fixation for displaced fractures of the distal humerus. Two-thirds had intercondylar (Muller type C) fractures, and one-third had articular comminution (type C3). A chevron olecranon osteotomy was used, with early active movement after fixation. Results were good or excellent in 76% with an average range of movement of 115 degrees. Early stable fixation by an experienced surgeon is recommended for these fractures.

We recorded compound muscle action potentials (CMAPs) from the diaphragm in 15 normal volunteers, nine patients with lesions of the lower cervical cord (C5 to C8), one completely quadriplegic patient (C6) and seven patients with lesions at a higher cervical level (C1 to C4). Transcranial magnetic stimulation and electrical stimulation of the phrenic nerve were carried out.

When the centre of the coil was placed on the interauricular line at a point 3 cm lateral to the vertex on the scalp, the CMAPs from the diaphragm had the largest amplitude and the shortest latency. There was no difference in the mean latency of the CMAPs recorded by transcranial magnetic stimulation in the normal volunteers and in the patients with lesions of the lower cervical cord. In the quadriplegic patient, the latency of the CMAPs was not delayed, but was prolonged in the patients with lesions at a higher level. Those evoked by electrical stimulation of the phrenic nerve were not prolonged in the patients with higher lesions.

Our findings suggest that the prolongation of the latency by transcranial magnetic stimulation reflects dysfunction of the higher cervical cord. The combination of transcranial magnetic stimulation and electrical stimulation of the phrenic nerve can detect the precise level of the lesion in the motor tract to the diaphragm.

We carried out a cross-sectional study in 51 patients (81 feet) with a clawed hallux in association with a cavus foot after a modified Robert Jones tendon transfer. The mean follow-up was 42 months (9 to 88). In all feet, concomitant procedures had been undertaken, such as extension osteotomy of the first metatarsal and transfer of the tendon of the peroneus longus to peroneus brevis, to correct the underlying foot deformity. All patients were evaluated clinically and radiologically.

The overall rate of patient satisfaction was 86%. The deformity of the hallux was corrected in 80 feet. Catching of the big toe when walking barefoot, transfer lesions and metatarsalgia, hallux flexus, hallux limitus and asymptomatic nonunion of the interphalangeal joint were the most frequent complications. Hallux limitus was more likely when elevation of the first ray occurred (p = 0.012). Additional transfer of the tendon of peroneus longus to peroneus brevis was a significant risk factor for elevation of the first metatarsal (p < 0.0001).

The deforming force of extensor hallucis longus is effectively eliminated by the Jones transfer, but the mechanics of the first metatarsophalangeal joint are altered. The muscle balance and stability of the entire first ray should be taken into consideration in the management of clawed hallux.