Aims. There remains a lack of consensus regarding the management of chronic anterior sternoclavicular joint (SCJ) instability. This study aimed to assess whether a standardized treatment algorithm (incorporating physiotherapy and surgery and based on the presence of trauma) could successfully guide management and reduce the number needing surgery. Methods. Patients with chronic anterior SCJ instability managed between April 2007 and April 2019 with a standardized treatment algorithm were divided into non-traumatic (offered physiotherapy) and traumatic (offered surgery) groups and evaluated at discharge. Subsequently, midterm outcomes were assessed via a postal questionnaire with a subjective SCJ stability score, Oxford Shoulder Instability Score (OSIS, adapted for the SCJ), and pain visual analogue scale (VAS), with analysis on an intention-to-treat basis. Results. A total of 47 patients (50 SCJs, three bilateral) responded for 75% return rate. Of these, 31 SCJs were treated with physiotherapy and 19 with surgery. Overall, 96% (48/50) achieved a stable SCJ, with 60% (30/50) achieving unrestricted function. In terms of outcomes, 82% (41/50) recorded good-to-excellent OSIS scores (84% (26/31) physiotherapy, 79% (15/19) surgery), and 76% (38/50) reported low pain VAS scores at final follow-up. Complications of the total surgical cohort included a 19% (5/27) revision rate, 11% (3/27) frozen shoulder, and 4% (1/27) scar sensitivity. Conclusion. This is the largest midterm series reporting chronic anterior SCJ instability outcomes when managed according to a standardized treatment algorithm that emphasizes the importance of appropriate patient selection for either physiotherapy or surgery, based on a history of trauma. All but two patients achieved a stable SCJ, with stability maintained at a median of 70 months (11 to 116) for the physiotherapy group and 87 months (6 to 144) for the surgery group. Cite this article: Bone Jt Open 2022;3(10):815–825

Instability is the reason for revision of a primary total knee replacement (TKR) in 20% of patients. To date, the diagnosis of instability has been based on the patient’s symptoms and a subjective clinical assessment. We assessed whether a measured standardised forced leg extension could be used to quantify instability. A total of 25 patients (11 male/14 female, mean age 70 years; 49 to 85) who were to undergo a revision TKR for instability of a primary implant were assessed with a Nottingham rig pre-operatively and then at six and 26 weeks post-operatively. Output was quantified (in revolutions per minute (rpm)) by accelerating a stationary flywheel. A control group of 183 patients (71 male/112 female, mean age 69 years) who had undergone primary TKR were evaluated for comparison. . Pre-operatively, all 25 patients with instability exhibited a distinctive pattern of reduction in ‘mid-push’ speed. The mean reduction was 55 rpm (. sd. 33.2). Post-operatively, no patient exhibited this pattern and the reduction in ‘mid-push’ speed was 0 rpm. The change between pre- and post-operative assessment was significant (p < 0.001). No patients in the control group exhibited this pattern at any of the intervals assessed. The between-groups difference was also significant (p < 0.001). This suggests that a quantitative diagnostic test to assess the unstable primary TKR could be developed. Cite this article: Bone Joint J 2014;96-B:1339–43

Background: Stress radiography and more recently magnetic resonance imaging have been used to study the integrity of lateral ankle ligaments in chronic symptomatic instability after injury. Aim: Our aim was to see if magnetic resonance imaging was as good as examination under anaesthesia and stress radiography, for diagnosing injury to the lateral ankle ligaments. Study Design: Cross-over study. Methods: Fifty eight patients, 47 men and 11 women, were included in the study. These were athletes or military personnel with symptomatic instability of the ankle after injury. This cohort of patients had MRI scans, stress radiographs and arthroscopic treatment of their ankle. Integrity of the calcaneo-fibular ligament (CFL) was recorded arthroscopically. The sensitivity, specificity, positive and negative predictive value of MRI and stress views, in assessing integrity of the CFL, were compared against the arthroscopic findings which was considered to be the gold standard. Results: Stress radiography under anaesthesia and MRI has sensitivities of 94% and 47% and specificities of 98% and 83% for diagnosing injury to the CFL, respectively. Stress radiography has a higher accuracy in diagnosing CFL injuries as compared to MRI. Conclusion: The results of this study casts doubt on the efficacy of MRI in the diagnosis of serious ankle ligament injuries

Instability is a common indication for revision total hip arthroplasty (THA). However, even after the initial revision, some patients continue to have recurrent dislocations. This study investigates those at risk for recurrent dislocation after revision THA for instability at a single institution. Between 2009 and 2019, 163 patients underwent revision THA for instability at a single institution. Thirty-three of these patients required re-revision THA due to recurrent dislocation. Cox proportional hazard models with death as a competing event were used to analyze risk factors, including prosthesis sizing and alignment. Paired t-tests or Wilcoxon signed rank tests were used to assess patient outcomes (Veterans RAND 12 (VR-12) physical score, VR-12 mental score, Harris Hip Score, and hip disability and osteoarthritis outcome score for joint replacement). Duration of follow-up until either re-revision or final follow-up was a mean of 45.3 ± 38.2 months. The 1-year cumulative incidence for recurrent dislocation after revision was 8.7%, which increased to 19.6% at 5 years and 32.9% at 10 years postoperatively. In the multivariable analysis, high ASA score [HR 2.71], being underweight (BMI<18 kg/m. 2. ) [HR 36.26] or overweight/obese (BMI>25 kg/m. 2. ) [HR 4.31], use of specialized liners [HR 5.51–10.71], lumbopelvic stiffness [HR 6.29], and postoperative abductor weakness [HR 7.20] were significant risk factors for recurrent dislocation. Increasing the cup size decreased the dislocation risk [HR 0.89]. The dual mobility construct did not affect the risk for recurrent dislocation in univariate or multivariable analyses. VR-12 physical and HHS (pain and function) scores improved postoperatively at midterm. Patients requiring revision THA for instability are at risk for recurrent dislocation. Higher ASA scores, abnormal BMI, use of special liners, lumbopelvic stiffness, and postoperative abductor weakness are significant risk factors for re-dislocation

Introduction. Genu valgum is a common presentation in paediatric patients with congenital limb deformities. The aim of this study is to assess the outcome of guided growth surgery in paediatric patients referred via our physiotherapy pathway with isolated genu valgum and associated patellar instability. Materials & Methods. Patients were identified from our prospective patellar instability database. Inclusion criteria was acquired or congenital genu valgum associated with patellar instability in skeletally immature patients. The mechanical lateral-distal femoral angle was assessed on long leg alignment radiographs (mLDFA <85 degrees). Surgical treatment was the placement of a guided growth plate (PediPlate, OrthoPediatrics, USA) on the medial distal femoral physis (hemi-epiphysiodesis). KOOS-child scores were collected pre-operatively and post-operatively (minimum at 6 months). Results. Eleven patients (seven female) with mean age of 12(range 5–15) were identified. Five patients had congenital talipes equinovarus(CTEV), one fibular hemimelia, one di-George syndrome, one septic growth arrest and three had idiopathic genu valgum. Pre- and post-operative KOOS-child scores showed overall improvement: 58(range 36–68) to 88(65–99) and knee symptoms subscores: 64(43–71) to 96(68–100) p<0.01, t-test. Mean follow-up was 10 months (range 3–23). No subsequent dislocations/subluxations occurred during follow-up. Conclusions. Guided growth surgery is an effective way of treating symptomatic patellar instability in skeletally immature patients with genu valgum in the absence of other structural pathology. It was most common in our cohort in patients with unilateral CTEV. We would recommend to screen syndromic and congenital limb deformity patients for patellar instability symptoms in the presence of genu valgum

Patellar dislocation is a common presentation with a clear management pathway. Sometimes, however, what a patient experiences as the patella dislocating may, in fact, be ACL insufficiency. We reviewed case notes and imaging of 315 consecutive ACL reconstructions, collecting data on the date and mechanism of injury, time to MRI, and reconstruction. We noted cases initially diagnosed as patellar dislocation. 25 of 315 (7.9%) patients were initially diagnosed with a patellar dislocation. Subsequently, however, MRI scans revealed no evidence of patellar dislocation and instead showed ACL rupture with pathognomonic pivot-shift bony oedema. The false patella dislocation group were 32% female and had an average age of 25; the rest of the group average age was 27.1 and there were a lower proportion of females; 21%. The false patella instability patients had a median waiting time of 412 days from injury to operation (range: 70-2445 days), compared to 392 days (range: 9 – 4212 days) for rest of the patients. 5 of the remaining 290 had MRIs showing patella oedema with medial patello-femoral ligament injury in addition to their ACL rupture. From our literature search this is a new finding which shows that ACL rupture can present with symptoms suggestive of patellar dislocation. These findings raise the risk that there are a group of people who have been diagnosed with patellar instability who instead have ACL insufficiency and so are at risk of meniscal and chondral damage. Further research should analyse those diagnosed with patellar instability to quantify missed ACL injuries

Introduction. Early clinical examination combined with MRI following a high ankle sprain allows accurate diagnosis of syndesmosis instability. However, patients often present late, and for chronic injuries clinical assessment is less reliable. Furthermore, in many centres MRI may be not be readily available. The aims of the current study were to define MRI characteristics associated with syndesmosis instability, and to determine whether MRI patterns differed according to time from injury. Methods. Retrospectively, patients with an unstable ligamentous syndesmosis injury requiring fixation were identified from the logbooks of two fellowship trained foot and ankle surgeons over a five-year period. After exclusion criteria (fibula fracture or absence of an MRI report by a consultant radiologist), 164 patients (mean age 30.7) were available. Associations between MRI characteristics and time to MRI were examined using Pearson's chi-square tests or Fisher's exact tests (significance set at p< 0.05). Results. Overall, 100% of scans detected a syndesmosis injury if performed acutely (within 6 weeks of injury), falling to 83% if performed after 12 weeks (p=0.001). In the acute group, 93.5% of patients had evidence of at least one of either PITFL injury (78.7%), posterior malleolus bone oedema (60.2%), or a posterior malleolus fracture (15.7%). In 20% of patients with a posterior malleolus bone bruise or fracture, the PITFL was reported as normal. The incidence of posterior malleolus bone bruising and fracture did not significantly differ according to time. Conclusion. For unstable ligamentous syndesmosis injuries, MRI becomes less sensitive over time. Importantly, posterior malleolus bone oedema or fracture may be the only evidence of a posterior injury. Failure to recognise instability may lead to inappropriate management of the patient, long term pain and arthritis. We therefore advocate early MRI as it becomes more difficult to ‘grade’ the injury if delayed

Recurrent patellar instability is a common problem and there are multiple demographic and pathoanatomic risk factors that predispose patients to dislocating their patella. The most common of these is trochlear dysplasia. In cases of severe trochlear dysplasia associated with patellar instability, a sulcus deepening trochleoplasty combined with a medial patellofemoral ligament reconstruction (MPFLR) may be indicated. Unaddressed trochlear pathology has been associated with failure and poor post-operative outcomes after stabilization. The purpose of this study is to report the clinical outcome of patients having undergone a trochleoplasty and MPFLR for recurrent lateral patellofemoral instability in the setting of high-grade trochlear dysplasia at a mean of 2 years follow-up. A prospectively collected database was used to identify 46 patients (14 bilateral) who underwent a combined primary MPFLR and trochleoplasty for recurrent patellar instability with high-grade trochlear dysplasia between August 2013 and July 2021. A single surgeon performed a thin flap trochleoplasty using a lateral para-patellar approach with lateral retinaculum lengthening in all 60 cases. A tibial tubercle osteotomy (TTO) was performed concomitantly in seven knees (11.7%) and the MPFLR was performed with a gracilis tendon autograft in 22%, an allograft tendon in 27% and a quadriceps tendon autograft in 57% of cases. Patients were assessed post-operatively at three weeks and three, six, 12 and 24 months. The primary outcome was the Banff Patellar Instability Instrument 2.0 (BPII 2.0) and secondary outcomes were incidence of recurrent instability, complications and reoperations. The mean age was 22.2 years (range, 13 to 45), 76.7% of patients were female, the mean BMI was 25.03 and the prevalence of a positive Beighton score (>4/9) was 40%. The mean follow-up was 24.3 (range, 6 to 67.7) months and only one patient was lost to follow-up before one year post-operatively. The BPII 2.0 improved significantly from a mean of 27.3 pre-operatively to 61.1 at six months (p < 0 .01) and further slight improvement to a mean of 62.1 at 12 months and 65.6 at 24 months post-operatively. Only one patient (1.6%) experienced a single event of subluxation without frank dislocation at nine months. There were three reoperations (5%): one for removal of the TTO screws and prominent chondral nail, one for second-look arthroscopy for persistent J-sign and one for mechanical symptoms associated with overgrowth of a lateral condyle cartilage repair with a bioscaffold. There were no other complications. In this patient cohort, combined MPFLR and trochleoplasty for recurrent patellar instability with severe trochlear dysplasia led to significant improvement of patient reported outcome scores and no recurrence of patellar dislocation at a mean of 2 years. Furthermore, in this series the procedure demonstrated a low rate (5%) of complications and reoperations

Acute syndesmotic ankle injuries continue to impose a diagnostic dilemma and it remains unclear whether weighbearing or external rotation should be exerted rotation during the imaging process. Therefore, we aimed to implement both axial load (weightbearing) and external rotation in the assessment of a clinical cohort of patients with syndesmotic ankle injuries syndesmotic using weightbearing CT imaging. In this retrospective comparative cohort study, patients with an acute syndesmotic ankle injury were analyzed using a WBCT (N= 20; Mean age= 31,64 years; SD= 14,07. Inclusion criteria were an MRI confirmed syndesmotic ankle injury imaged by a bilateral WBCT of the ankle during weightbearing and combined weightbearing-external rotation. Exclusion criteria consisted of fracture associated syndesmotic ankle injuries. Three-dimensional (3D) models were generated from the CT slices. Tibiofibular displacement and Talar Rotation was quantified using automated3D measurements (Anterior TibioFibular Distance (ATFD), Alpha Angle, Posterior TibioFibular Distance (PTFD) and Talar Rotation (TR) Angle) in comparison to a cohort of non-injured ankles. Results. The difference in neutral-stressed Alpha° and ATFD showed a significant difference between patients with a syndesmotic ankle lesion and healthy ankles (P = 0.046 and P = 0.039, respectively) The difference in neutral-stressed PTFD and TR° did not show a significant difference between patients with a syndesmotic ankle lesion and healthy ankles (P = 0.492; P = 0.152, respectively). Conclusion. Application of combined weightbearing-external rotation reveals a dynamic anterior tibiofibular widening in patients with syndesmotic ankle injuries. This study provides the first insights based on 3D measurements to support the potential relevance of applying external rotation during WBCT imaging. However, to what extent certain displacement patterns are associated with syndesmotic instability and thus require operative treatment strategies has yet to be determined in future studies

Introduction. Patients with metastatic spinal cord compression (MSCC) or unstable spinal lesions warrant early surgical consultation. In multiple myeloma, chemotherapy and radiotherapy have the potential to decompress the spinal canal effectively in the presence of epidural lesions. Mechanical stability conferred by bracing may potentiate intraosseous and extraosseous bone formation, thus increasing spinal stability. This study aims to review the role of non-operative management in myeloma patients with a high degree of spinal instability, in a specialist tertiary centre. Methods. Retrospective analysis of a prospectively collected database of 83 patients with unstable myelomatous lesions of the spine, defined by a Spinal Instability Neoplastic Score (SINS) of 13–18. Data collected include patient demographics, systemic treatment, neurological status, radiological presence of cord compression, most unstable vertebral level and presence of intraosseous and extraosseous bone formation. Post-treatment scores were calculated based on follow-up imaging which was carried out at 2 weeks for cord compression and 12 weeks for spinal instability. A paired t-test was used to identify any significant difference between pre- and post-treatment SINS and linear regression was used to assess the association between variables and the change in SINS. Results. A significant reduction in SINS was observed from a pre-treatment average score of 14 to a score of 9, following treatment for myeloma (p<0.001). A higher initial score and a younger age were associated with a larger overall reduction in SINS (p<0.001 and p=0.02 respectively). No single variable (bisphosphates, chemotherapy, radiotherapy and steroids) had a significant association with SINS reduction. 25 (30%) patients had spinal cord compression, all of which showed radiological resolution of cord compression at 2 weeks. No patients developed neurological deterioration during treatment and all patients had an improvement in their pain scores. 64 (77%) patients had evidence of intraosseous and/or extraosseous bone formation on their follow-up scan. Conclusion. Non-operative management in the form of bracing and systemic therapy is a safe and effective treatment for spinal instability and spinal cord compression in myeloma. Treatment of unstable myelomatous lesions of the spine with or without cord compression should not follow traditional guidelines for MSCC. The decision to adopt a non-operative approach in this cohort of patients should ideally be made in a tertiary centre with expertise in multiple myeloma and in a multidisciplinary setting

Introduction. Chronic ankle instability is a common condition that can be effectively treated with arthroscopic lateral ankle ligament reconstruction to restore ankle stability and function. The aim of this study was to assess the functional outcomes of arthroscopic lateral ligament reconstruction using the MOXFQ, VAS, and EQ5D patient-reported outcome measures (PROMs). Methods. This prospective series included 38 patients who underwent arthroscopic lateral ligament reconstruction for chronic ankle instability between December 2019 and April 2022. All patients completed the MOXFQ, VAS, and EQ5D PROMs preoperatively, as well as at6, and 12 months postoperatively. The MOXFQ is a disease-specific PROM that assesses foot and ankle function, while the VAS measures pain and the EQ5D evaluates health-related quality of life. Results. At the 12-month follow-up, the mean MOXFQ Index score had improved significantly from 53.3 ± 23.1 preoperatively to 16.0 ±21.1 (p < 0.001). Similarly, the mean VAS score had improved from 36.2 ± 22.4 preoperatively to 14.7 ± 15.0 (p < 0.001), and the meanEQ5D score had improved from 0.55 ± 0.26 preoperatively to 0.87 ± 0.12 (p < 0.001). No major complications were observed. Conclusion. Arthroscopic lateral ligament reconstruction is an effective treatment for chronic ankle instability, with significant improvements in clinical and health-related quality of life outcomes

One-fourth of all ankle trauma involve injury to the syndesmotic ankle complex, which may lead to syndesmotic instability and/or posttraumatic ankle osteoarthritis in the long term if left untreated. The diagnosis of these injuries still poses a deceitful challenge, as MRI scans lack physiologic weightbearing and plain weightbearing radiographs are subject to beam rotation and lack 3D information. Weightbearing cone-beam CT (WBCT) overcomes these challenges by imaging both ankles during bipedal stance, but ongoingdebate remains whether these should be taken under weightbearing conditions and/or during application of external rotation stress. The aim of this study is study therefore to compare both conditions in the assessment of syndesmotic ankle injuries using WBCT imaging combined with 3D measurement techniques. In this retrospective study, 21 patients with an acute ankle injury were analyzed using a WBCT. Patients with confirmed syndesmotic ligament injury on MRI were included, while fracture associated syndesmotic injuries were excluded. WBCT imaging was performed in weightbearing and combined weightbearing-external rotation. In the latter, the patient was asked to internally rotate the shin until pain (VAS>8/10) or a maximal range of motion was encountered. 3D models were developed from the CT slices, whereafter. The following 3D measurements were calculated using a custom-made Matlab® script; Anterior tibiofibular distance (AFTD), Alpha angle, posterior Tibiofibular distance (PFTD) and Talar rotation (TR) in comparison to the contralateral non-injured ankle. The difference in neutral-stressed Alpha angle and AFTD were significant between patients with a syndesmotic ankle lesion and contralateral control (P=0.046 and P=0.039, respectively). There was no significant difference in neutral-stressed PFTD and TR angle. Combined weightbearing-external rotation during CT scanning revealed an increased AFTD in patients with syndesmotic ligament injuries. Based on this study, application of external rotation during WBCT scans could enhance the diagnostic accuracy of subtle syndesmotic instability

Introduction and Objective. Scapholunate instability is the most common cause of carpal instability. When this instability is left untreated, the mechanical relationship between the carpal bones is permanently disrupted, resulting in progressive degenerative changes in the radiocarpal and midcarpal joints. Different tenodesis methods are used in the treatment of acute or early chronic reducible scapholunate instability, where arthritis has not developed yet and the scapholunate ligament cannot be repaired. Although it has been reported that pain is reduced in the early follow up in clinical studies with these methods, radiological results differ between studies. The deterioration of these radiological parameters is associated with wrist osteoarthritis as previously stated. Therefore, more studies are needed to determine the tenodesis method that will improve the wrist biomechanics better and will last longer. In our study, two new tenodesis methods, spiral antipronation tenodesis, and anatomic front and back reconstruction (ANAFAB) were radiologically compared with triple ligament tenodesis (TLT), in the cadaver wrists. Materials and Methods. The study was carried out on a total of 16 fresh frozen cadaver wrists. Samples were randomly allocated to the groups treated with 3 different scapholunate instability treatment methods. These are TLT (n: 6), spiral antipronation tenodesis (n: 5) and ANAFAB tenodesis (n: 5) groups. In all samples SLIL, DCSS, STT, DIC, RSC and LRL ligaments were cut in the same way to create scapholunate instability. Wrist CT scans were taken on the samples in 4 different states, in intact, after the ligaments were cut, after the reconstruction and after the movement cycle. In all of these 4 states, wrist CTs were taken in 6 different wrist positions. For every state and every position through tomography images; Scapholunate (SL) distance, Scapholunate (SL) angle, Radioscaphoid (RS) angle, Radiolunate (RL) angle, Capitolunate (CL) angle, Dorsal scaphoid translation (Dt) measurements were made. Results. Scapholunate distances means were different between intact and cut states only in neutral and clenched fist positions for all groups (p values <0.001). Mean differences were similar between the groups (p > 0.100). In neutral position, for SL center distance, mean difference between cut and reconstruction states were not different between the groups (p=0.497) but it was noted that only TLT group could not restore to the intact state. In neutral position, for SL angle, compared with the cut state, TLT and ANAFAB significantly reduced the angle (TLT: 20° (p=0.005), ANAFAB: 28° (p<0.001)) whereas antipronation tenodesis could not (13°, p=0.080). In clenched fist position, for SL angle, compared with the intact state, only ANAFAB group restored the angle, TLT and antipronation groups were significantly worse than the intact state (TLT: p<0.001, antipronation: p=0.001). In clenched fist position, for RL angle, compared with the intact state, ANAFAB and TLT groups restored the angle but antipronation group was significantly worse than the intact state (p<0.001). In neutral position, for RS angle, compared with the cut state, only ANAFAB significantly reduced the angle (11°, p<0.001) whereas TLT and antipronation groups could not (TLT: 6° (p=0.567), antipronasyon: 4° (p=0.128). Conclusions. In the presence of severe scapholunate instability in which a several number of secondary stabilizers are injured, the ANAFAB tenodesis method may be preferred to the classical method, TLT tenodesis. The results of spiral antipronation tenodesis were not better than the TLT

Abstract. Objectives. The study aims to determine whether an arthroscopic ligament reconstruction is necessary to relieve clinical ankle instability symptoms in patients with an MRI scan showing medial or lateral ligament tear. Methods. This was a single centre retrospective case series study of 25 patients with ankle instability and ligament tear on MRI scan who had undergone arthroscopic procedures from January 2015 to December 2018. Patients were followed up for an average period of 3 years postoperatively to check for any recurrence of symptoms. Results. Of the 25 patients, 23 had ATFL tear on MRI scan, and 2 had deltoid ligament tear. Examination under anaesthesia was stable in 13 patients and unstable in 12 patients. The majority of the patients (76%) had a simple arthroscopic ankle debridement and no ligament repair. Six patients needed Brostrom repair. Conclusions. Our study has shown that in patients with MRI proven ligament tear and clinical instability, a ligament reconstruction was unnecessary in most patients. The instability symptoms of patients were relieved by simple ankle arthroscopic debridement

Aims. This cross-sectional study aimed to investigate the in vivo ankle kinetic alterations in patients with concomitant chronic ankle instability (CAI) and osteochondral lesion of the talus (OLT), which may offer opportunities for clinician intervention in treatment and rehabilitation. Methods. A total of 16 subjects with CAI (eight without OLT and eight with OLT) and eight healthy subjects underwent gait analysis in a stair descent setting. Inverse dynamic analysis was applied to ground reaction forces and marker trajectories using the AnyBody Modeling System. One-dimensional statistical parametric mapping was performed to compare ankle joint reaction force and joint moment curve among groups. Results. The patients with OLT showed significantly increased dorsiflexion moment in the ankle joint compared with healthy subjects during 38.2% to 40.9% of the gait cycle, and increased eversion moment in the ankle joint compared with patients without OLT during 25.5% to 27.6% of the gait cycle. Compared with healthy subjects, the patients with OLT showed increased anterior force during 42% to 43% of the gait cycle, and maximal medial force (p = 0.005, ηp2 = 0.399). Conclusion. The patients with concomitant CAI and OLT exhibit increased dorsiflexion and eversion moment, as well as increased anterior and medial ankle joint reaction force during stair descent, compared with patients with CAI but without OLT and healthy subjects, respectively. Thus, a rehabilitative regimen targeting excessive ankle dorsiflexion and eversion moment may help to reduce ankle joint loading. Cite this article: Bone Joint Res 2024;13(12):716–724

Abstract. Introduction. Previous research has shown that, notwithstanding ligament healing, properly selected MCL reconstruction can restore normal knee stability after MCL rupture. The hypothesis of this work was that it is possible to restore knee stability (particularly valgus and AMRI) with simplified and/or less-invasive MCL reconstruction methods. Methods. Nine unpaired human knees were cleaned of skin and fat, then digitization screws and optical trackers were attached to the femur and tibia. A Polaris stereo camera measured knee kinematics across 0. o. -100. o. flexion when the knee was unloaded then with 90N anterior-posterior force, 9Nm varus-valgus moment, 5Nm internal-external rotation, and external+anterior (AMRI) loading. The test was conducted for the following knee conditions: intact, injured: transected superficial and deep MCL (sMCL and dMCL), and five reconstructions: (long sMCL, long sMCL+dMCL, dMCL, short sMCL+dMCL, short sMCL), all based on the medial epicondyle isometric point and using 8mm tape as a graft, with long sMCL 60mm below the joint line (anatomical), short sMCL 30mm, dMCL 10mm (anatomical). Results. No significant changes were found in anterior or posterior translation, or varus at any stage. MCL deficiency caused increased valgus, external rotation and AMRI instabilities. All reconstructions restored valgus stability. The isolated long sMCL allowed residual external rotation and AMRI instability, while the short sMCL did stabilise AMRI. Both 2-strand reconstructions (dMCL+sMCL) restored stability. Conclusion. All tested techniques, except long sMCL, restored valgus and AMRI stability of the knee. The single femoral tunnel is satisfactory for both the dMCL and sMCL grafts

Aims. Instability is a common cause of failure after total hip arthroplasty. A novel reverse total hip has been developed, with a femoral cup and acetabular ball, creating enhanced mechanical stability. The purpose of this study was to assess the implant fixation using radiostereometric analysis (RSA), and the clinical safety and efficacy of this novel design. Methods. Patients with end-stage osteoarthritis were enrolled in a prospective cohort at a single centre. The cohort consisted of 11 females and 11 males with mean age of 70.6 years (SD 3.5) and BMI of 31.0 kg/m. 2. (SD 5.7). Implant fixation was evaluated using RSA as well as Western Ontario and McMaster Universities Osteoarthritis Index, Harris Hip Score, Oxford Hip Score, Hip disability and Osteoarthritis Outcome Score, 38-item Short Form survey, and EuroQol five-dimension health questionnaire scores at two-year follow-up. At least one acetabular screw was used in all cases. RSA markers were inserted into the innominate bone and proximal femur with imaging at six weeks (baseline) and six, 12, and 24 months. Independent-samples t-tests were used to compare to published thresholds. Results. Mean acetabular subsidence from baseline to 24 months was 0.087 mm (SD 0.152), below the critical threshold of 0.2 mm (p = 0.005). Mean femoral subsidence from baseline to 24 months was -0.002 mm (SD 0.194), below the published reference of 0.5 mm (p < 0.001). There was significant improvement in patient-reported outcome measures at 24 months with good to excellent results. Conclusion. RSA analysis demonstrates excellent fixation with a predicted low risk of revision at ten years of this novel reverse total hip system. Clinical outcomes were consistent with safe and effective hip replacement prostheses. Cite this article: Bone Jt Open 2023;4(5):385–392

Purpose. To evaluate the clinical results of arthroscopic repair and open Ahlgren Larsson method in patients with chronic lateral ankle instability. Methods. We retrospectively evaluated 87 patients who were operated in our clinic between 2010 and 2018 with the diagnosis of chronic lateral ankle instability. 16 patients with osteochondral lesion, 5 patients with rheumatoid arthritis, 4 patients with ankle fractures of the same side, 2 patients with a history of active or previous malignancy were excluded. Preoperative and postoperative clinical evaluations were performed with AOFAS ankle-hindfoot score, FAOS and VAS scores. Results. Sixty patients with chronic lateral ankle instability were evaluated. 28 patients, treated with Ahlgren-Larsson method and 32 patients, treated with arthroscopic repair. 36 of the patients were female and 24 were male; the mean age of the arthroscopy group was 44 ± 9; the mean age of the open surgery group was 46 ± 11. There was no significant difference between the groups in terms of demographic features (age, sex, VKI). Postoperative clinical improvement was observed in both groups. There was no statistically significant difference between the groups in terms of functionality. However, there was a statistically significant difference in pain and satisfaction of VAS in favor of arthroscopy group. Conclusions. Ahlgren-Larsson method and arthroscopic repair technique are safe and effective for chronic lateral ankle instability. Arthroscopic technique may be preferred for pain and patient satisfaction as it is less invasive and less morbid

Instability currently represents the most frequent cause for revision total knee replacement. Instability can be primary from the standpoint of inadequately performed collateral and/or posterior cruciate ligament balancing during primary total knee replacement or it may be secondary to malalignment/loosening which can develop later progressive instability. Revision surgery must take into consideration any component malalignment that may have primarily contributed to instability. Care should be given to assessing collateral ligament integrity. This can be done during physical examination by radiological stress testing to see if the mediolateral stress of the knee comes to a good endpoint. If there is no sense of a palpable endpoint, then the surgeon must assume structural incompetency of the medial or lateral collateral ligament or both. In posterior cruciate retaining knees, anteroposterior instability must be assessed. For instability, most revisions will require a posterior cruciate substituting design or a constrained condylar design that is unlinked. However, if the patient displays considerable global instability, a linked, rotating platform constrained total knee replacement design will be required. Recent data has shown that the rotating hinges work quite well in restoring stability to the knee with maintenance of the clinical results over a considerable length of time. Intramedullary stems should be utilised in most cases when bone integrity is suspect and insufficient. Infection should be ruled out by aspiration and off of antibiotics prior to any revision operation, especially if loosening of the components represents the cause of instability. The surgeon should attempt to restore collateral ligament balance whenever possible as this yields the best clinical result

The best algorithm, measurements, and criteria for screening children with Down syndrome for upper cervical instability are controversial. Many authors have recommended obtaining flexion and extension views. We noted that patients who require surgical stabilization due to myelopathy or cord compression typically have grossly abnormal radiographic measurements on the neutral upright lateral cervical spine radiograph (NUL). This study was designed to determine whether a full series of cervical spine images including flexion/extension lateral radiographs (FEL) was important to avoid missing upper cervical instability. This is a retrospective evaluation of cervical spine images obtained between 2006 and 2012 for the purposes of “screening” children with Down syndrome for evidence of instability. The atlanto-dental interval, space available for cord, and basion axial interval were measured on all films. The Weisel-Rothman measurement was made in the FEL series. Clinical outcome of those with abnormal measurements were reviewed. Sensitivity, specificity, positive and negative predictive values of NUL and FEL x-rays for identifying clinically significant cervical spine instability were calculated. Two-hundred and forty cervical spine series in 213 patients with Down syndrome between the ages of four months and 25 years were reviewed. One hundred and seventy-two children had a NUL view, and 88 of these patients also had FEL views. Only one of 88 patients was found to have an abnormal ADI (≥6mm), SAC (≤14mm), or BAI (>12mm) on an FEL series that did not have an abnormal measurement on the NUL. This patient had no evidence of cord compression or myelopathy. Obtaining a single NUL x-ray is an efficient method for radiographic screening of cervical spine instability. Further evaluation may be required if abnormal measurements are identified on the NUL x-ray. We also propose new “normal” values for the common radiographic measurements used in assessing risk of cervical spine instability in patients with Down syndrome