Aims. The ulna is an extremely rare location for primary bone tumours of the elbow in paediatrics. Although several reconstruction options are available, the optimal reconstruction method is still unknown due to the rarity of proximal ulna tumours. In this study, we report the outcomes of osteoarticular ulna allograft for the reconstruction of proximal ulna tumours. Methods. Medical profiles of 13 patients, who between March 2004 and November 2021 underwent osteoarticular ulna allograft reconstruction after the resection of the proximal ulna tumour, were retrospectively reviewed. The outcomes were measured clinically by the assessment of elbow range of motion (ROM), stability, and function, and radiologically by the assessment of allograft-host junction union, recurrence, and joint degeneration. The elbow function was assessed objectively by the Musculoskeletal Tumor Society (MSTS) score and subjectively by the Toronto Extremity Salvage Score (TESS) and Mayo Elbow Performance Score (MEPS) questionnaire. Results. The mean follow-up of patients was 60.3 months (SD 28.5). The mean elbow flexion-extension ROM was 95.8° (SD 21). The mean MSTS of the patients was 84.4 (SD 8.2), the mean TESS was 83.8 (SD 6.7), and the mean MEPS was 79.2 (SD 11.5). All the patients had radiological union at the osteotomy site. Symptomatic osteoarthritic change was observed in three patients (23%), one of whom ended up with elbow joint fusion. Two patients (15.4%) had recurrence during the follow-up period. Surgical complications included two allograft fractures, two plate fractures, three medial instabilities, and two infections. Conclusion. Osteoarticular ulna allograft reconstruction provides acceptable functional outcomes. Despite a high rate of complications, it is still a valuable reconstruction method, particularly in skeletally immature patients who need their distal humerus physis for the rest of hand growth. Cite this article: Bone Jt Open 2024;5(9):749–757

Aims

The aim of this study was to determine the clinical outcomes and factors contributing to failure of transposition osteotomy of the acetabulum (TOA), a type of spherical periacetabular osteotomy, for advanced osteoarthritis secondary to hip dysplasia.

The April 2023 Foot & Ankle Roundup³⁶⁰ looks at: Outcomes following a two-stage revision total ankle arthroplasty for periprosthetic joint infection; Temporary bridge plate fixation and joint motion after an unstable Lisfranc injury; Outcomes of fusion in type II os naviculare; Total ankle arthroplasty versus arthrodesis for end-stage ankle osteoarthritis; Normal saline for plantar fasciitis: placebo or therapeutic?; Distraction arthroplasty for ankle osteoarthritis: does it work?; Let there be movement: ankle arthroplasty after previous fusion; Morbidity and mortality after diabetic Charcot foot arthropathy.

Aims

The optimal management of posterior malleolar ankle fractures, a prevalent type of ankle trauma, is essential for improved prognosis. However, there remains a debate over the most effective surgical approach, particularly between screw and plate fixation methods. This study aims to investigate the differences in outcomes associated with these fixation techniques.

Aims

Therapeutic agents that prevent chondrocyte loss, extracellular matrix (ECM) degradation, and osteoarthritis (OA) progression are required. The expression level of epidermal growth factor (EGF)-like repeats and discoidin I-like domains-containing protein 3 (EDIL3) in damaged human cartilage is significantly higher than in undamaged cartilage. However, the effect of EDIL3 on cartilage is still unknown.

Aims. Osteoarticular reconstruction of the distal femur in childhood has the advantage of preserving the tibial physis. However, due to the small size of the distal femur, matching the host bone with an osteoarticular allograft is challenging. In this study, we compared the outcomes and complications of a resurfaced allograft-prosthesis composite (rAPC) with those of an osteoarticular allograft to reconstruct the distal femur in children. Methods. A retrospective analysis of 33 skeletally immature children with a malignant tumour of the distal femur, who underwent resection and reconstruction with a rAPC (n = 15) or osteoarticular allograft (n = 18), was conducted. The median age of the patients was ten years (interquartile range (IQR) 9 to 11) in the osteoarticular allograft group and nine years (IQR 8 to 10) in the rAPC group (p = 0.781). The median follow-up of the patients was seven years (IQR 4 to 8) in the osteoarticular allograft group and six years (IQR 3 to 7) in the rAPC group (p = 0.483). Limb function was evaluated using the Musculoskeletal Tumor Society (MSTS) score. Results. At final follow-up, the knee was unstable in 9/18 patients (50%) in the osteoarticular allograft group and 2/15 patients (13%) in the rAPC group (p = 0.026). The median range of motion (ROM) of the knee was 117° (IQR 115° to 120°) in the osteoarticular allograft group and 100° (IQR 95° to 105°) in the rAPC group (p < 0.001). The median MSTS score was 25 (IQR 23 to 26) in the osteoarticular allograft group and 28 (IQR 26 to 29) in the rAPC group (p = 0.007). Osteoarthritic change was detected in 11/18 patients (61%) in the osteoarticular allograft group and in 4/15 (26%) patients in the rAPC group (p = 0.048). Conclusion. In our series, a resurfaced allograft-prosthesis composite provided better knee stability and function, with a lower rate of osteoarthritis; an osteoarticular allograft was associated with better knee ROM. Cite this article: Bone Joint J 2022;104-B(10):1174–1179

Aims. Cartilage injuries rarely heal spontaneously and often require surgical intervention, leading to the formation of biomechanically inferior fibrous tissue. This study aimed to evaluate the possible effect of amelogenin on the healing process of a large osteochondral injury (OCI) in a rat model. Methods. A reproducible large OCI was created in the right leg femoral trochlea of 93 rats. The OCIs were treated with 0.1, 0.5, 1.0, 2.5, or 5.0 μg/μl recombinant human amelogenin protein (rHAM. +. ) dissolved in propylene glycol alginate (PGA) carrier, or with PGA carrier alone. The degree of healing was evaluated 12 weeks after treatment by morphometric analysis and histological evaluation. Cell recruitment to the site of injury as well as the origin of the migrating cells were assessed four days after treatment with 0.5 μg/μl rHAM. +. using immunohistochemistry and immunofluorescence. Results. A total of 12 weeks after treatment, 0.5 μg/μl rHAM. +. brought about significant repair of the subchondral bone and cartilage. Increased expression of proteoglycan and type II collagen and decreased expression of type I collagen were revealed at the surface of the defect, and an elevated level of type X collagen at the newly developed tide mark region. Conversely, the control group showed osteoarthritic alterations. Recruitment of cells expressing the mesenchymal stem cell (MSC) markers CD105 and STRO-1, from adjacent bone marrow toward the OCI, was noted four days after treatment. Conclusion. We found that 0.5 μg/μl rHAM. +. induced in vivo healing of injured articular cartilage and subchondral bone in a rat model, preventing the destructive post-traumatic osteoarthritic changes seen in control OCIs, through paracrine recruitment of cells a few days after treatment. Cite this article: Bone Joint Res 2023;12(10):615–623

Aim. Mesenchymal stem cells (MSCs) have several properties that may support their use as an early treatment option for osteoarthritis (OA). This study investigated the role of multiple injections of allogeneic bone marrow-derived stem cells (BMSCs) to alleviate the progression of osteoarthritic changes in the various structures of the mature rabbit knee in an anterior cruciate ligament (ACL)-deficient OA model. Materials and Methods. Two months after bilateral section of the ACL of Japanese white rabbits aged nine months or more, either phosphate buffered saline (PBS) or 1 x 10. 6. MSCs were injected into the knee joint in single or three consecutive doses. After two months, the articular cartilage and meniscus were assessed macroscopically, histologically, and immunohistochemically using collagen I and II. Results. Within the PBS injection (control group), typical progressive degenerative changes were revealed in the various knee structures. In the single MSC injection (single group), osteoarthritic changes were attenuated, but still appeared, especially in the medial compartments involving fibrillation of the articular cartilage, osteophyte formation in the medial plateau, and longitudinal tear of the meniscus. In the multiple-injections group, the smoothness and texture of the articular cartilage and meniscus were improved. Histologically, absence or reduction in matrix staining and cellularity were noticeable in the control and single-injection groups, respectively, in contrast to the multiple-injections group, which showed good intensity of matrix staining and chondrocyte distribution in the various cartilage zones. Osteoarthritis Research Society International (OARSI) scoring showed significantly better results in the multiple-injections group than in the other groups. Immunohistochemically, collagen I existed superficially in the medial femoral condyle in the single group, while collagen II was more evident in the multiple-injections group than the single-injection group. Conclusion. A single injection of MSCs was not enough to restore the condition of osteoarthritic joints. This is in contrast to multiple injections of MSCs, which had the ability to replace lost cells, as well as reducing inflammation. Cite this article: Bone Joint J 2019;101-B:824–831

Aims. Delayed diagnosis is a well-known complication of a Monteggia fracture-dislocation. If left untreated, the dislocated radial head later becomes symptomatic. The purposes of this study were firstly, to evaluate the clinical and radiological results of open reduction of the radial head and secondly, to identify the factors that may affect the outcome of this procedure. Materials and Methods. This retrospective study evaluated 30 children with a chronic Monteggia lesion. There were 18 boys and 12 girls with a mean age of 7.4 years (4 to 13) at the time of open reduction. The mean interval to surgery, after the initial fracture, was 23.4 months (6 to 120). Clinical grading used a Kim modified elbow score: radiological outcome was recorded. The effect of the patient’s age, gender, duration from initial injury, Bado classification, and annular ligament reconstruction were analyzed. The mean follow-up was 42.2 months (15 to 20). Results. The Kim elbow scores evaluated at the last clinic visit were excellent in 23 patients, good in three, fair in two, and poor in two. A majority of the patients were found to have significant improvement of elbow flexion (p < 0.001). Six met the criteria of a fair radiological outcome; four of these were operated on more than 24 months after the initial injury, and three had surgery after the age of 11. Univariate analysis failed to find any factor that was significantly associated with a fair or poor outcome. Conclusion. Good clinical and radiological outcomes can be expected in most patients. Osteoarthritic changes were associated with age > 11 years and/or a delay of treatment of > 24 months. However, no statistically significant factor could be identified which correlated with an unfavourable outcome. Cite this article: Bone Joint J 2018;100-B:1117–24

We evaluated the long-term results of a modified Spitzy shelf operation for secondary osteoarthritis in 119 hips with a mean follow-up of 23.8 years. The mean age of the patients at the time of surgery was 25 years. Preoperative osteoarthritic change, the age at operation and shelf height were important factors in determining the outcome. Of the 61 hips in the pre-stage (three) and the initial stage (58) of osteoarthritis, 53 (87%) had good results, compared with only 30 (51%) of 58 hips with advanced osteoarthritis. Of the latter, 72% of those aged less than 25 years had good results compared with only 40% of patients aged over 25 years. The shelf height in the group with good results was significantly lower than in those with poor results. This operation is a safe procedure and indicated for acetabular dysplasia or subluxation of the hip with early osteoarthritic change in patients aged less than 25 years

We report the outcome at a mean of 93 months (73 to 110) of 71 patients with an acute fracture of the scaphoid who were randomised to Herbert screw fixation (35) or below-elbow plaster cast immobilisation (36). These 71 patients represent the majority of a randomised series of 88 patients whose short-term outcome has previously been reported. Those patients available for later review were similar in age, gender and hand dominance. There was no statistical difference in symptoms and disability as assessed by the mean Patient Evaluation Measure (p = 0.4), or mean Patient-Rated Wrist Evaluation (p = 0.9), the mean range of movement of the wrist (p = 0.4), mean grip strength (p = 0.8), or mean pinch strength (p = 0.4). Radiographs were available from the final review for 59 patients. Osteoarthritic changes were seen in the scaphotrapezial and radioscaphoid joints in eight (13.5%) and six patients (10.2%), respectively. Three patients had asymptomatic lucency surrounding the screw. One non-operatively treated patient developed nonunion with avascular necrosis. In five patients who were treated non-operatively (16%) there was an abnormal scapholunate angle ( > 60°), but in four of these patients this finding was asymptomatic. No medium-term difference in function or radiological outcome was identified between the two treatment groups

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

We report the long-term results of 51 pelvic osteotomies in 43 patients with a mean follow-up of 15 years (13 to 20). The mean age of the patients was 28 years (14 to 46). At review three patients were lost to follow-up, and six had received a total hip arthroplasty. Of 48 hips, 42 (88%) were preserved, with good to excellent clinical results in 27 (64%). Pre-operatively, 41 (80%) of the treated hips had shown no sign of osteoarthritis. Thirty-one (65%) hips showed no progression of osteoarthritis after follow-up for 15 years. Significant negative factors for good long-term results were the presence of osteoarthritic changes and a fair or poor clinical score pre-operatively. Pelvic reorientation osteotomy for symptomatic hip dysplasia can give satisfactory and reproducible long-term clinical results

Aims

To clarify the mid-term results of transposition osteotomy of the acetabulum (TOA), a type of spherical periacetabular osteotomy, combined with structural allograft bone grafting for severe hip dysplasia.

The February 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: Trends in management of paediatric distal radius buckle fractures; Pelvic osteotomy in patients with previous sacral-alar-iliac fixation; Sacral-alar-iliac fixation in patients with previous pelvic osteotomy; Idiopathic toe walking: an update on natural history, diagnosis, and treatment; A prediction model for treatment decisions in distal radial physeal injuries: a multicentre retrospective study; Angular deformities after percutaneous epiphysiodesis for leg length discrepancy; MRI assessment of anterior coverage is predictive of future radiological coverage; Predictive scoring for recurrent patellar instability after a first-time patellar dislocation.

The February 2024 Shoulder & Elbow Roundup³⁶⁰ looks at: Does indomethacin prevent heterotopic ossification following elbow fracture fixation?; Arthroscopic capsular shift in atraumatic shoulder joint instability; Ultrasound-guided lavage with corticosteroid injection versus sham; Combined surgical and exercise-based interventions following primary traumatic anterior shoulder dislocation: a systematic review and meta-analysis; Are vascularized fibula autografts a long-lasting reconstruction after intercalary resection of the humerus for primary bone tumours?; Anatomical versus reverse total shoulder arthroplasty with limited forward elevation; Tension band or plate fixation for simple displaced olecranon fractures?; Is long-term follow-up and monitoring in shoulder and elbow arthroplasty needed?

The October 2023 Wrist & Hand Roundup³⁶⁰ looks at: Distal radius fracture management: surgeon factors markedly influence decision-making; Fracture-dislocation of the radiocarpal joint: bony and capsuloligamentar management, outcomes, and long-term complications; Exploring the role of artificial intelligence chatbot in the management of scaphoid fractures; Role of ultrasonography for evaluation of nerve recovery in repaired median nerve lacerations; Four weeks versus six weeks of immobilization in a cast following closed reduction for displaced distal radial fractures in adult patients: a multicentre randomized controlled trial; Rehabilitation following flexor tendon injury in Zone 2: a randomized controlled study; On the road again: return to driving following minor hand surgery; Open versus single- or dual-portal endoscopic carpal tunnel release: a meta-analysis of randomized controlled trials.

Aims

To examine the long-term outcome of arthrodesis of the hip undertaken in a paediatric population in treating painful arthritis of the hip. In our patient population, most of whom live rurally in hilly terrain and have limited healthcare access and resources, hip arthrodesis has been an important surgical option for the monoarticular painful hip in a child.

Aims

The aims of this study were to validate the Forgotten Joint Score-12 (FJS-12) in the postoperative evaluation of periacetabular osteotomy (PAO), identify factors associated with joint awareness after PAO, and determine the FJS-12 threshold for patient-acceptable symptom state (PASS).

Aims

Pigment epithelium-derived factor (PEDF) is known to induce several types of tissue regeneration by activating tissue-specific stem cells. Here, we investigated the therapeutic potential of PEDF 29-mer peptide in the damaged articular cartilage (AC) in rat osteoarthritis (OA).

1 . Two cases of chronic progressive dislocation of the talo-navicular joints are discussed. 2. Radiographs are presented showing the development of the lesions over a period of eighteen years. 3. It is thought that the lesion is caused by laxity of ligaments and subsequent osteoarthritic changes

The precise localisation of osteoarthritic changes is crucial for selective surgical treatment. Single photon-emission CT-CT (SPECT-CT) combines both morphological and biological information. We hypothesised that SPECT-CT increased the intra- and interobserver reliability to localise increased uptake compared with traditional evaluation of CT and bone scanning together. We evaluated 20 consecutive patients with pain of uncertain origin in the foot and ankle by radiography and SPECT-CT, available as fused SPECT-CT, and by separate bone scanning and CT. Five observers assessed the presence or absence of arthritis. The images were blinded and randomly ordered. They were evaluated twice at an interval of six weeks. Kappa and multirater kappa values were calculated. The mean intraobserver reliability for SPECT-CT was excellent (κ = 0.86; 95% CI 0.81 to 0.88) and significantly higher than that for CT and bone scanning together. SPECT-CT had significantly higher interobserver agreement, especially when evaluating the naviculocuneiform and tarsometatarsal joints. SPECT-CT is useful in localising active arthritis especially in areas where the number and configuration of joints are complex

We report the long-term results of the Matti-Russe operation for pseudarthrosis of the scaphoid in 100 cases, reported previously by Mulder in 1968. Clinical results for 77 patients and radiographic data for 74 were reviewed at 22 to 34.8 years after surgery. In general, there was satisfactory relief of pain and stiffness but some patients had limitation of motion and reduced grip-strength, with usually slight osteoarthritic changes. There was poor correlation between subjective, objective, and radiographic results but 88% of the patients were satisfied with their results

We reviewed 31 patients at a mean of five years after mallet deformity of the finger had been treated with a thermoplastic splint. Intra-articular fractures were present in 35% of patients. Osteoarthritic changes had developed in 48%, most in association with fracture, and 29% had a swan-neck deformity. There was a loss of extension greater than 10° in 35%; the average deficit at the interphalangeal joint was 8.3° and the average flexion arc was 48.5°. Despite these findings, patient satisfaction was generally high, with little evidence of functional impairment

The patellofemoral joint is an important source of symptoms in osteoarthritis of the knee. We have used a newly designed surgical model of patellar strengthening to induce osteoarthritis in BALB/c mice and to establish markers by investigating the relationship between osteoarthritis and synovial levels of matrix metalloproteinases (MMPs). Osteoarthritis was induced by using this microsurgical technique under direct vision without involving the cavity of the knee. Degeneration of cartilage was assessed by the Mankin score and synovial tissue was used to determine the mRNA expression levels of MMPs. Irrigation fluid from the knee was used to measure the concentrations of MMP-3 and MMP-9. Analysis of cartilage degeneration was correlated with the levels of expression of MMP. After operation the patellofemoral joint showed evidence of mild osteoarthritis at eight weeks and further degenerative changes by 12 weeks. The level of synovial MMP-9 mRNA correlated with the Mankin score at eight weeks, but not at 12 weeks. The levels of MMP-2, MMP-3 and MMP-14 mRNA correlated with the Mankin score at 12 weeks. An increase in MMP-3 was observed from four weeks up to 16 weeks. MMP-9 was notably increased at eight weeks, but the concentration at 16 weeks had decreased to the level observed at four weeks. Our observations suggest that MMP-2, MMP-3 and MMP-14 could be used as markers of the progression of osteoarthritic change

1. A study of normal and osteoarthritic hyaline cartilage has been made with the electron microscope and x-ray diffraction. 2. Normal cartilage consists of a three-dimensional network of collagen fibrils with no preferred orientation, surrounded by a matrix containing polysaccharide. 3. In the osteoarthritic joint the collagen fibrils show definite orientation and a decreased proportion of ground substance. X-ray diffraction confirms this and shows the orientation to be at right angles to the surface of the femoral head. 4. Tensional forces across the joint may explain why osteoarthritic changes first appear in the non-weight-bearing area of the joint

It has been suggested that arthrodesis of the ankle leads to osteoarthritis of the joints of the ipsilateral hind- and midfoot. We believe these studies overlooked the presence of osteoarthritic changes in these joints before the arthrodesis. We reviewed the pre-operative radiographs of 70 patients with osteoarthritis of the ankle who underwent 71 ankle arthrodeses (one was bilateral). The talonavicular, calcaneocuboid, subtalar and naviculocuneiform joints were given an osteoarthritis score according to Kellgren and Lawrence. The mean age at operation was 54.9 years and the most common indication was for post-traumatic osteoarthritis (52 cases). A total of 68 patients showed pre-existing arthritis in either the hind- or mid-foot, with the subtalar joint the most commonly affected. Ipsilateral hind- and mid-foot arthritis is almost universally present in patients with arthritis of the ankle requiring arthrodesis. The presence of such changes may not be a consequence of this arthrodesis

Aims

The primary aim of this study was to describe long-term patient-reported outcomes after ulna shortening osteotomy for ulna impaction syndrome.

The anterior centre-edge (VCA) angle quantifies the anterior cover of the femoral head, and angles of less than 20° are considered abnormal. We have measured the VCA angles in hips without osteoarthritic changes. We took bilateral false-profile radiographs of nine female and 30 male cadavers without signs of osteoarthritis. The mean age at the time of death was 72 years (46 to 92). The mean VCA angle was 32.8° (17.7 to 53.6). The SD was 7.9°. Our findings suggest that the threshold of abnormality of the VCA angle may be slightly lower than previously thought. This information may be useful in counselling patients with asymptomatic acetabular dysplasia

We studied 37 patients with varus osteoarthritis of the knee to determine the influence of the bone mineral density (BMD) on the varus deformity. There were 15 men (21 knees) and 22 women (38 knees). The mean age of the men was 69 years and of the women 68 years. BMD was measured in the L1–L4 spinal region using dual X-ray absorptiometry. In the women a low level of BMD was associated with varus deformity originating at the proximal tibia, but a high level was predominantly linked with deformity originating in the joint space. Similar findings were obtained in the men. Our results suggest that a low BMD predisposes to trabecular microfractures and consequently increased stress on the articular cartilage. A low BMD does not preclude osteoarthritic change in the knee

We describe the outcome at a mean follow-up of 8.75 years (7.6 to 9.8) of seven patients who had undergone osteochondral autologous transplantation for full-thickness cartilage defects of the shoulder between 1998 and 2000. These patients have been described previously at a mean of 32.6 months when eight were included. One patient has been lost to follow-up. The outcome was assessed by the Constant shoulder score and the Lysholm knee score to assess any donor-site morbidity. Standard radiographs and MR scores were obtained and compared with the pre-operative findings and the results from the previous review. No patient required any further surgery on the shoulder. The mean Constant score improved significantly until the final follow-up (p = 0.018). The Lysholm score remained excellent throughout. There was a significant progression of osteoarthritic changes from the initial surgery to the first and final follow-up but this did not appear to be related to the size of the defect, the number of cylinders required or the Constant score (p = 0.016). MRI showed that all except one patient had a congruent joint surface at the defect with full bony integration of all osteochondral cylinders. The results have remained satisfactory over a longer period with very good objective and subjective findings

Deficiency of the anterior cruciate ligament (ACL) is a common disorder which can lead to changes in lifestyle. We followed 59 patients who had had arthroscopic reconstruction of the ACL using a central-third patellar-tendon autograft for seven years to assess the long-term effectiveness of recent advances in reconstruction of the ACL. The standard criteria for evaluation of the International Knee Documentation Committee, the Lysholm knee score and measurements using the KT 1000 arthrometer all showed satisfactory results. Deterioration in the clinical performance after seven years was associated with osteoarthritic changes and correlated with chronic ligament injuries and meniscectomy. There were three traumatic and three spontaneous ruptures. We believe that the procedure can be successful, but remain concerned about failure of the graft and osteoarthritis. The results raise questions about the best time to operate and suggest that early surgery may reduce the risk of osteoarthritis

We treated 12 shoulders in ten patients with irreparable rotator-cuff tears by transfer of the latissimus dorsi. There were nine men and one woman. Their average age was 64.0 years and the average follow-up was 35.6 months (26 to 42). The results were excellent in four shoulders, good in four, fair in one, and poor in three. Active forward flexion improved from a preoperative average of 99° to a postoperative average of 135°. Osteoarthritic changes appeared in five shoulders and proximal migration of the humeral head progressed in six. EMG revealed that nine of the 12 transferred muscles showed activity which was synergistic with the supraspinatus on external rotation with abduction. We conclude that latissimus dorsi transfer can be effective in restoring shoulder function after massive irreparable tears of the rotator cuff

Recognized anatomic variations that lead to patella instability include patella alta and trochlea dysplasia. Lateralization of the extensor mechanism relative to the trochlea is often considered to be a contributing factor; however, controversy remains as to the degree this contributes to instability and how this should be measured. As the tibial tuberosity-trochlear groove (TT-TG) is one of most common imaging measurements to assess lateralization of the extensor mechanism, it is important to understand its strengths and weaknesses. Care needs to be taken while interpreting the TT-TG value as it is affected by many factors. Medializing tibial tubercle osteotomy is sometimes used to correct the TT-TG, but may not truly address the underlying anatomical problem. This review set out to determine whether the TT-TG distance sufficiently summarizes the pathoanatomy, and if this assists with planning of surgery in patellar instability.

Cite this article: Bone Jt Open 2022;3(3):268–274.

A total of 60 children and adolescents with rupture of the anterior cruciate ligament (ACL) was seen between 1980 and 1990. Observation of the 23 patients who were treated conservatively revealed that the natural history of the injury resulted in severe instability and poor function of the knee. Associated meniscal tears were present in 15 knees. Three osteochondral fractures occurred and osteoarthritic changes developed in ten knees. In 1990 therefore we introduced reconstruction of the ACL with a four-strand hamstring graft using an anatomical placement with transphyseal tunnels and anchorage well away from the growth plate. Over a period of nine years, 47 knees underwent reconstruction. The mean follow-up was 49 months (12 to 96). No child suffered physeal damage or leg-length discrepancy. The results were satisfactory in 77% and there was little difference between patients treated before the adolescent growth spurt and those treated during or after this time. These results, however, were not as good as those seen in adults during the same period

1. A study has been made of the treatment of recurrent dislocation of the patella in 106 knees in seventy-six patients. 2. In young adults in whom degenerative changes in the knee were not severe at the time of operation transplant of the tibial tubercle gave the best results. 3. In older patients and in those in whom osteoarthritic changes were present in the knee transplant of the tibial tubercle was unsatisfactory, but patellectomy with rerouting of the quadriceps mechanism gave fair results. 4. Tibial tubercle transplant is contra-indicated in children because it may give a recurvatum deformity. 5. When the dislocation is permanent, operation may be unnecessary, but if it becomes inevitable simple patellectomy is the best procedure. 6. The results of plastic operations on the quadriceps expansion and of supracondylar femoral osteotomy are bad. 7. No operation can give consistently good results because the knee is usually congenitally weak, often as part of generalised ligamentous laxity

We performed eight osteochondral autologous transplantations from the knee joint to the shoulder. All patients (six men, two women; mean age 43.1 years) were documented prospectively. In each patient the stage of the osteochondral lesion was Outerbridge grade IV with a mean size of the affected area of 150 mm. 2. All patients were assessed by using the Constant score for the shoulder and the Lysholm score for the knee. Standard radiographs, magnetic resonance imaging and second-look arthroscopy were used to assess the presence of glenohumeral osteoarthritis and the integrity of the grafts. After a mean of 32.6 months (8 to 47), the mean Constant score increased significantly. Magnetic resonance imaging revealed good osseointegration of the osteochondral plugs and congruent articular cartilage at the transplantation site in all but one patient. Second-look arthroscopy performed in two cases revealed a macroscopically good integration of the autograft with an intact articular surface. Osteochondral autologous transplantation in the shoulder appears to offer good clinical results for treating full-thickness osteochondral lesions of the glenohumeral joint. However, our study suggests that the development of osteoarthritis and the progression of pre-existing osteoarthritic changes cannot be altered by this technique

We have observed damage to the labrum as a result of repetitive acetabular impingement in non-dysplastic hips, in which the femoral neck appears to abut against the acetabular labrum and a non-spherical femoral head to press against the labrum and adjacent cartilage. In both mechanisms anatomical variations of the proximal femur may be a factor. We have measured the orientation of the femoral neck and the offset of the head at various circumferential positions, using MRI data from volunteers with no osteoarthritic changes on standard radiographs. Compared with the control subjects, paired for gender and age, patients showed a significant reduction in mean femoral anteversion and mean head-neck offset on the anterior aspect of the neck. This was consistent with the site of symptomatic impingement in flexion and internal rotation, and with lesions of the adjacent rim. Furthermore, when stratified for gender and age, and compared with the control group, the mean femoral head-neck offset was significantly reduced in the lateral-to-anterior aspect of the neck for young men, and in the anterolateral-to-anterior aspect of the neck for older women. For patients suspected of having impingement of the rim, anatomical variations in the proximal femur should be considered as a possible cause

We reviewed 25 children who presented consecutively with voluntary (habitual) subluxation of the shoulder. Thirty-six shoulders were involved and symptoms had been present for an average period of 12 years. Eighteen children were managed by 'skillful neglect': all these had become fully active in the profession of their choice and were satisfied with the outcome. Two of them had required shoulder surgery in adult life but only after trauma. Seven children (ten shoulders) had undergone stabilising operations during childhood with the aim of preventing later degenerative arthritis. These patients were also active in their selected professions, but only three (five of the ten shoulders) had good results: two shoulders had recurrent instability, two were painful and one was stiff. None of the shoulders in either group had developed osteoarthritic changes. There was no association with emotional or psychiatric problems. We conclude that voluntary subluxation of the shoulder in children has a favourable prognosis and that there is no indication for surgical intervention during childhood

To investigate the effect of instability on the remodelling of a minor articular surface offset, we created a 0.5 mm coronal step-off of the medial femoral condyle in 12 New Zealand white rabbits and transected the anterior cruciate ligament (ACL). A control group of 12 rabbits had only ACL resection and the opposite knee was used as the non-operated control. The osteoarthritic changes at 6, 12 and 24 weeks after surgery were evaluated histologically. In addition, changes in the immunological detection of 3-B-3(-) and 7-D-4 chondroitin-6-sulphate epitopes were determined because of the previous association of such changes with repair of cartilage and early osteoarthritis. In the instability/step-off group there was rapidly progressing focal degeneration of cartilage on the high side of the defect, not seen in previous step-off studies in stable knees. The rest of the femoral condyles and the tibial plateaux of the instability/step-off group had moderate osteoarthritis similar to that of the instability group. 3-B-3(-) was detectable in the early and the intermediate stages of osteoarthritis but no staining was seen in the severely damaged cartilage zones. Immunoreactivity with 7-D-4 increased as degeneration progressed. Our findings have shown that even a minor surface offset may induce rapid degeneration of cartilage when the stability of the knee is compromised

A total of 90 patients with an isolated rupture of the anterior cruciate ligament (ACL) had a reconstruction using the ipsilateral patellar tendon secured with round-headed cannulated interference screws. Annual review for five years showed three failures of the graft (two traumatic and one atraumatic); none occurred after two years. Ten patients sustained a rupture of the contralateral ACL. At five years, 69% of those with surviving grafts continued to participate in moderate to strenuous activity. Using the International Knee Documentation Committee assessment, 90% reported their knee as being normal or nearly normal and had a median Lysholm knee score of 96 (64 to 100). Most patients (98%) had a pivot shift of grade 0 with the remaining 2% being grade 1; 90% of the group had a Lachman test of grade 0. The incidence of subsequent meniscectomy was similar in the reconstructed joint to that in the contralateral knee. Radiological examination was normal in 63 of 65 patients. Our study supports the view that reconstruction of the ACL is a reliable technique allowing full rehabilitation of the previously injured knee. In the presence of normal menisci there is a low incidence of osteoarthritic change despite continued participation in sporting activity

Aims

The aim of this prospective study was to assess the long-term clinical, radiological, functional, and quality of life (QoL)-related outcome of patients treated with the synthetic Ligament Advanced Reinforcement System (LARS) device for anterior cruciate ligament (ACL) rupture.

1. A study of late segmental collapse in twelve femoral heads shows that it may not develop until two and a half years after the fracture. 2. Until the articular surfaces had collapsed the patients usually had no symptoms. The fractures were united and there was no obvious radiographic evidence of ischaemic necrosis. 3. There was histological evidence that the whole of the femoral heads had been necrotic at one time. The term late segmental collapse is more appropriate than late segmental necrosis. 4. The blood vessels of the ligamentum teres played little or no part in revascularisation which, when it occurred, was almost entirely across the fracture line. 5. In only one femoral head was revascularisation approaching completion and apparently continuing. In the other eleven much of the head remained necrotic and the process appeared to have halted. 6. An increase in radiological density was caused by new bone laid down on unresorbed necrotic trabeculae and was most prominent behind the line of revascularisation when the process had halted. 7. Trabecular collapse was evident within dead bone. In ten of the femoral heads it occurred in the subchondral region and in four just beyond the junction of reossified and dead bone. 8. Osteoarthritic changes occurred in the cartilage covering revascularised bone at the periphery of the head, especially when collapse was severe

We treated 26 hips (24 consecutive patients) with residual dysplasia by a technique of incomplete triple pelvic osteotomy. The mean age of the patients was 21.6 years. The mean values for the pre-operative centre-edge angle of Wiberg, the refined centre-edge angle, the acetabular angle of Sharp, the modified acetabular angle and femoral head lateralisation were 7.7°, −3.1°, 49.3°, 53.2° and 17.2 mm, respectively. After a mean follow-up of 3.3 years they were 27.0°, 13.0°, 38.9°, 44.3° and 15.9 mm, respectively (p < 0.05). The osteoarthritic grading changed adversely in one hip. The mean pre-operative and latest Harris hip scores were 74.9 and 93.0, respectively (p < 0.05). This technique provides a stable osteotomy with maintenance of the posterior column which allows early mobilisation and minimal internal fixation. The technique is not complex and requires minimal blood transfusion. The use of an image intensifier is not necessary and harvesting of a subcristal bone graft avoids post-operative complications at the donor site

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).

1. The clinical and radiological results of seventy-one osteotomies for primary osteoarthritis of the hip performed with internal fixation have been examined two to eight years after operation. Advanced cases where osteotomy would have been purely a salvage procedure were excluded. 2. The hips were divided into two groups: one in a relatively early and the other in a later intermediate stage of the disease. The two criteria for inclusion in the "early" group were a) fiexion movement of 90 degrees or more, either with the patient conscious or completely relaxed under anaesthesia, and b) no collapse of bone seen in the radiograph. 3. The clinical results show that early osteotomy seldom fails to give relief of pain, which is closely correlated with improved function and a favourable assessment of the operation by the patient. A good range of flexion, not less than 70 degrees and frequently 90 degrees, is retained when the criteria mentioned above obtain. 4. The radiological assessment was based upon examination of the joint space, the cystic appearances and the degree of collapse of bone, if any, as seen in serial films. There was convincing evidence of regression indicating arrest of the arthritic process in 70 per cent of the "early" cases. 5. Regression after osteotomy appears to be a well-defined process which is more commonly observed and more complete when the osteotomy is performed sooner rather than at a later stage of the disease. With few exceptions a good radiological result is associated with a good clinical result. 6. Some of the possible causes of failure are discussed. Osteotomy is more likely to fail if delayed till stiffness is severe and collapse of bone has begun. Large cysts, rapid advance of the disease, and a valgus osteotomy in the presence of lateral subluxation may also prejudice the results. 7. This review offers good support for Nissen's suggestion that in primary osteoarthritis of the hip osteotomy should be performed early, while the joint is still mobile and capable of repair, in order to retain good function. 8. Relief from pain is not the only consideration in deciding when to operate; the prospects of arresting the disease and of stimulating a healing reaction in the disordered cancellous bone and articular cartilage by early osteotomy should always be kept in mind. 9. In many respects the findings of this review are complementary to those of Postel and Vaillant (1962) who reported excellent results from varus osteotomy of Pauwels' type in a series of cases of subluxation of the hip with pain but without frank secondary osteoarthritic change