Avulsion of the proximal hamstring tendon from the ischial tuberosity is an uncommon but significant injury. Recent literature has highlighted that functional results are superior with surgical repair over non-surgical treatment. Limited data exists regarding the optimal rehabilitation regime in post-operative patients. The aim of this study was to investigate the early interim patient outcomes following repair of proximal hamstring tendon avulsions between a traditionally conservative versus an accelerated rehabilitation regimen. In this prospective randomised controlled trial (RCT) 50 patients underwent proximal hamstring tendon avulsion repair, and were randomised to either a braced, partial weight-bearing (PWB) rehabilitation regime (CR = 25) or an accelerated, unbraced, immediate full weight-bearing (FWB) regime (AR group; n = 25). Patients were evaluated preoperatively and at 3 months after surgery, using the Lower Extremity Functional Scale (LEFS), Perth Hamstring Assessment Tool (PHAT), visual analog pain scale (VASP), Tegner score, and 12-item Short Survey Form (SF-12). Patients also filled in a diary questioning postoperative pain at rest from Day 2, until week 6 after surgery. Primary analysis was by per protocol and based on linear mixed models. Both groups, with respect to patient and characteristics were matched at baseline. Over three months, five complications were reported (AR = 3, CR = 2). At 3 months post-surgery, significant improvements (p<0.001) were observed in both groups for all outcomes except the SF-12 MCS (P = 0.623) and the Tegner (P = 0.119). There were no significant between-group differences from baseline to 3 months for any outcomes, except for the SF-12 PCS, which showed significant effects favouring the AR regime (effect size [ES], 0.76; 95% CI, 1.2-13.2; P = .02). Early outcomes in an accelerated rehabilitation regimen following surgical repair of proximal hamstring tendon avulsions, was comparable to a traditionally conservative rehabilitation pathway, and resulted in better physical health-related quality of life scores at 3 months post-surgery. Further long term follow up and functional assessment planned as part of this study

Fibular head avulsion fractures represent a significant injury to the posterolateral corner of the knee. There is a high rate of concomitant injuries including rupture of the cruciate ligaments. Surgical fixation is indicated to restore stability, protect repaired or reconstructed cruciate ligaments and possibly decrease the likelihood of degenerative change. The current presentation describes a novel technique which provides secure fixation to the fibular head, restoring integrity of the posterolateral ligament complex and facilitating early motion. We also present a case series of our experience by a single surgeon at our tertiary referral center. Twenty patients underwent open reduction and internal fixation between 2006 and 2016 using a large fragment cannulated screw and soft tissue washer inserted obliquely from the proximal fibula to tibia. Fixation was augmented with suture repair of the lateral collateral ligament and biceps tendon. The orientation of the fracture was assessed based on preoperative imaging. Repair / reconstruction of concomitant injuries was performed during the same procedure. Early range of motion was initiated at 2 weeks postoperatively under physical therapy guidance. All patients returned for clinical and radiographic assessment (average 3.5 years). All fractures went on to bony union. There were no reoperations for recurrent instability. All patients regained functional range of motion with mean extension of 0.94 degrees and mean flexion of 121.4 degrees. Two patients underwent hardware removal. One patient developed a late local infection, which occurred greater than 5 years after surgery. Eleven patients underwent postoperative varus stress radiographs which demonstrated less than 1 mm difference between the operated and contralateral side. Fracture morphology typically demonstrated an oblique pattern in the coronal plane and a transverse pattern in the sagittal plane. This study represents a novel surgical technique for the repair of fibular head avulsion fractures with a large fragment cannulated screw placed obliquely from the fibula to tibia. Fixation is augmented with a soft tissue washer and suture repair. Our results suggest that this technique allows for early range of motion with maintenance of reduction, high rates of union, and excellent postoperative stability

To investigate the effectiveness of avulsion fracture of tibial insertion of posterior cruciate ligament using the safe postero-medial approach through analyzing the clinical and radiographic outcomes. We treated 14 cases of acute PCL tibial avulsion fracture with “safe postero-medial approach”. The PCL and avulsion bony fragment was fixed with 1 cannuated screw and washer. The patients were assessed clinically and radiographically at 3 months, 6 months, and 12 months. Clinical examination for each visit included assessment of the knee range of motion, using goniometer and the posterior drawer test. The patients were evaluated according to the Lysholm and Tegner rating scales. Patients were followed-up for 12 to 16 months. X-ray showed that satisfactory reducdtion and bony healing was achieved in all cases. There was no neurovascular complication. All patients had negative posterior drawer tests. Excellent outcomes were reported by all patients with the Lysholm score system. And there was no signicant difference between the Tegner scores before injury and last follow-up. Surgical treatment of acute tibial avulsion fracture of the PCL with this approach can restore the stability and fuction of the joint safely in most patients without neurovascular complication. Therefore “safe postero-medial approach” may be suitable for the treatment of isolated tibial avulsion fracture of the PCL

Abstract. Background. Anterior cruciate ligament (ACL) injuries with coinciding posterolateral tibial plateau (PLTP) depression fractures are rare. According to the most up to date literature, addressing the PLTP is crucial in preventing failure of the ACL. However, the surgical management of these injuries pose a great challenge to orthopaedic surgeons, given the anatomical location of the depressed PTP fragment. We report a case of a 17-year-old patient presenting to our department with this injury and describe a novel fixation method, that has not been described in the literature. Surgical Technique. A standard 2-portal arthroscopy is used to visualise the fractures. The PLTP is addressed first. With the combined use of arthroscopy and fluoroscopy, a guide pin is triangulated from the anteromedial aspect of the tibia, towards the depressed plateau fragment. Once the guide pin is approximately 1cm from the centre of the fragment, it is over-drilled with a cannulated drill, and simultaneously bluntly punched up to its original anatomical location. Bone graft is then used to fill the void, supported by two subchondral screws. Both fluoroscopy and arthroscopy are used to confirm adequacy of fixation. Finally, the tibial spine avulsion fracture is repaired arthroscopically using the standard suture bridging technique. Conclusion. We describe a novel, one-stage, minimally invasive approach that addresses both the ACL injury and PLTP fracture. We highlight the advantages of utilising this approach and functional outcomes

Purpose. Rectus femoris avulsion (RFA) injuries in paediatric patients are currently managed conservatively. However, the proximal attachment of the rectus femoris muscle lies in a critical zone in the hip joint with attachments to the anterior hip capsule and anterior inferior iliac spine. Violent avulsions therefore could cause damage to the adjacent acetabular labrum and articular cartilage initiating a process leading to early degenerative changes in the hip. To date, the association between rectus avulsions and labral tears has not been studied. Method. The complete medical records of patients who were presented to McMaster University Medical Center with rectus femoris avulsions between 1983 and 2008 who were between the ages of 2 and 18 were identified. Patients were included if they had documented plain radiographs and magnetic resonance arthrography images of their hip. MRIs were reviewed by an independent musculoskeletal radiologist blinded from the history of the patients. Results. 16 patients were identified in the database with rectus femoris avulsions diagnosed on plain radiograph and 7 were included in the study with documented MRIs. The average age of patients was 13 (Range 7–16). All injuries occurred during sports activity with 43% occurred during running, 29% with kicking during soccer and during skating acceleration while playing hockey. One patient had a concurrent sartorius avulsion. All patients with rectus femoris avulsions had labral tears identified on MRI in the zone adjacent to rectus insertion. All patients were treated conservatively. Clinical records suggested 72% of patients were still limping and 86% were experiencing residual pain at last follow-up. Conclusion. Patients with rectus femoris avulsions may be at risk for concurrent traumatic labral tears. These patients should be assessed for labral pathology including a clinical examination and MRI arthrography. Level of Evidence: Level IV

Aims

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

Background. Adductor muscle and tendon injuries are commonly seen in sport. Complete adductor avulsions have been described and can be managed non-operatively or operatively. A rare variant of this injury is the complete avulsion of the adductor complex with the pectineus and rectus abdominus amounting to a complete sleeve avulsion from the pubis. This is a severe injury that is increasingly recognised due to improved imaging and lower diagnostic threshold. Purpose. We describe the surgical management of twelve athletes with this severe injury. Study design. Prospective case series - Level of evidence, 4. Methods. All the injuries were prospectively collected onto our institutional pelvic sports injury database. This series summarises the outcome in twelve consecutive cases where surgery was undertaken after presentation with an acute avulsion (6–34 days) in athletes. The procedure comprised anatomical reattachment of the avulsed tissues with mesh reinforcement of the inguinal wall in seven patients. An independent physiotherapist reviewed all patients. Results. One patient developed a superficial wound infection treated with antibiotics. Transient complaints of local numbness were common but all twelve sportsmen returned to high-level sport (five elite) at an average of thirteen weeks (10–21 weeks). Conclusion. Awareness of the possibility of this complex injury is important and there should be a low threshold for investigation. In elite athletes operative intervention is associated with good clinical outcomes and successful return to sport

Abstract. Background. Fracture dislocation of the knee involves disruption of two or more knee ligaments with associated tibial plateau fracture. If these injuries are not evaluated swiftly, can result in a limb-threatening injury. The aim of this study is to look at the clinical outcomes of a single surgeon case series at a major trauma centre. Methods. Prospectively collected data was analysed for a 5-year period. Primary outcome measures used were International Knee Documented Committee(IKDC) score and Knee Injury & Osteoarthritis Outcome Score(KOOS). The secondary outcome measures include Tegner activity scale, knee range of movements & complications. Results. 23 patients were presented with the mean age was 37 years(17–74). 14% of patients sustained vascular injury & 19% had common peroneal nerve injury. Priority was given for early total repair/reconstruction with fracture fixation within 3 weeks where feasible (90% of patients), and if not, a staged approach was adopted. The mean IKDC score was 67 & KOOS was 73. The mean postoperative Tegner Activity Scale was 3.6 with mean flexion of 115(90–130). We observed some patterns of tibial plateau fractures are associated with similar patterns of ligamentous injuries. The anterio-medial rim fractures (52%) were associated with PCL, ACL & avulsion injuries of posterio-lateral corner structures. Most of the neurovascular injuries happened in this group. The other recognisable pattern was posterio-medial fractures, which were associated with ACL avulsion injury. Conclusion. To our knowledge, this is the first kind of study to report some fracture patterns that can be associated with particular ligamentous injuries

Acute metatarsal fractures are a common extremity injury. While surgery may be recommended to reduce the risk of nonunion or symptomatic malunion, most fractures are treated with nonoperative management. However, there is significant variability between practitioners with no consensus among clinicians on the most effective nonoperative protocol, despite how common the form of treatment. This systematic review identified published conservative treatment modalities for acute metatarsal fractures and compares their non-union rate, chronic pain, and length of recovery, with the objective of identifying a best-practices algorithm. Searches of CINAHL, EMBASE, MEDLINE, and CENTRAL identified clinical studies, level IV or greater in LOE, addressing non-operative management strategies for metatarsal fractures. Two reviewers independently screened the titles, abstracts, and full texts, extracting data from eligible studies. Reported outcome measures and complications were descriptively analyzed. Studies were excluded if a rehabilitation program outlining length of immobilization, weight-bearing and/or strengthening approaches was not reported. A total of 12 studies (8 RCTs and 4 PCs), from the 2411 studies that were eligible for title screening, satisfied inclusion criteria. They comprised a total of 610 patients with acute metatarsal fractures, with a mean age of 40.2 years (range, 15 – 82). There were 6 studies that investigated avulsion fractures, 2 studies on true Jones fractures, and 4 studies with mixed fracture types. Studies assessed a variety of treatment modalities including: WB and NWB casts, elasticated support bandages, hard-sole shoes, plaster slippers, metatarsal shoe casts, and air cast boots. Most studies investigated the outcomes of NWB casts and elasticated support bandages. The NWB short leg cast had no reported non-unions, delayed-unions, or refractures for avulsion fractures. In true Jones fractures, there was an average non-union rate of 23.6% (range, 5.6 – 27.8%), delayed-union rate of 11.8% (range, 5.6 – 18.8%), and refracture rate of 3% (range, 0 – 5.6%). Overall, the average AOFAS score was 87.2 (range, 84 – 91.7) and the average VAS score was 83.7 (range, 75 – 93). The elasticated support bandage had an average non-union rate of 3.4% (range, 0 – 12%), and delayed-union rate of 3.8% for acute avulsion fractures, with no reported refractures. No included study arm investigated outcomes of elasticated support bandages for the true Jones fracture. The average AOFAS score for elasticated support bandages was 93.5 (range, 90 – 100). The average VAS score was 88.9 (range, 90 – 100). Most acute metatarsal fractures heal well, with good-to-excellent functional outcomes and moderate-to-high patient satisfaction. Conservative strategies for avulsion fractures are highly successful and based on this data the authors recommend patients undergo a schedule that involves 3 – 4 weeks in an elasticated support bandage, short leg cast, or equivalent, and WB thereafter as tolerated, with return-to-activity after clinical union. Despite poorer conservative outcomes for true Jones fractures, patients should undergo 8 weeks in a NWB short leg cast, followed by a walking cast or hard-sole shoe for an additional 4 – 6 weeks, or until clinical union. However, surgical consultation is recommended

Complete or nearly complete disruption of the attachment of the gluteus is seen in 10–20% of cases at the time of THA. Special attention is needed to identify the lesion at the time of surgery because the avulsion often is visible only after a thickened hypertrophic trochanteric bursa is removed. From 1/1/09 to 12/31/13, 525 primary hip replacements were performed by a single surgeon. After all total hip components were implanted, the greater trochanteric bursa was removed, and the gluteus medius and minimus attachments to the greater trochanter were visualised and palpated. Ninety-five hips (95 patients) were found to have damage to the muscle attachments to bone. Fifty-four hips had mild damage consisting of splits in the tendon, but no frank avulsion of abductor tendon from their bone attachments. None of these cases had severe atrophy of the abductor muscles, but all had partial fatty infiltration. All hips with this mild lesion had repair of the tendons with #5 Ticron sutures to repair the tendon bundles together, and drill holes through bone to anchor the repair to the greater trochanter. Forty-one hips had severe damage with complete or nearly complete avulsion of the gluteus medius and minimus muscles from their attachments to the greater trochanter. Thirty-five of these hips had partial fatty infiltration of the abductor muscles, but all responded to electrical stimulation. The surface of the greater trochanter was denuded of soft tissue with a rongeur, the muscles were repaired with five-seven #5 Ticron mattress sutures passed through drill holes in the greater trochanter, and a gluteus maximus flap was transferred to the posterior third of the greater trochanter and sutured under the vastus lateralis. Six hips had complete detachment of the gluteus medius and minimus muscles, severe atrophy of the muscles, and poor response of the muscles to electrical stimulation. The gluteus medius and minimus muscles were sutured to the greater trochanter, and gluteus maximus flap was transferred as in the group with functioning gluteus medius and minimus muscles. Postoperatively, patients were instructed to protect the hip for 8 weeks, then abductor exercises were started. The normal hips all had negative Trendelenburg tests at 2 and 5 years postoperative with mild lateral hip pain reported by 11 patients at 2 years, and 12 patients at 5 years. In the group of 54 with mild abductor tendon damage that were treated with simple repair, positive Trendelenburg test was found in 5 hips at 2 years and in 8 hips at 5 years. Lateral hip pain was reported in 7 hips at 2 years, and in 22 at 5 years. In the group of 35 hips with severe avulsion but good muscle tissue, who underwent repair with gluteus maximus flap transfer, all had good abduction against gravity and negative Trendelenburg tests at 2 and 5 years postoperative, and none had lateral hip pain. Of the 6 hips with complete avulsion and poor muscle who underwent abductor muscle repair and gluteus maximus flap transfer, all had weak abduction against gravity, mildly positive Trendelenburg sign, and mild lateral hip pain at 2 and 5 years postoperative. Abductor avulsion is uncommon but not rare, and is detected during THA only by direct examination of the tendon and removal of the trochanteric bursa. Simple repair of mild abductor tendon damage did not prevent progressive abductor weakness in some hips; and the increase in number of patients with lateral hip pain from 2 to 5 years suggests progressive deterioration. Augmentation of the repair with a gluteus maximus flap appears to provide a stable reconstruction of the abductor muscles, and seemed to restore abductor function in the hips with functioning muscles

The extracortical single-button (SB) inlay repair is one of the most preferred distal biceps tendon repair techniques. However, specific complications such as neurovascular injury and non-anatomic repairs have led to the development of techniques that utilize intracortical double-button (DB) fixation. To compare the biomechanical stability of the extracortical SB repair with the anatomical DB repair technique. Controlled laboratory study. The distal biceps tendon was transected in 18 cadaveric elbows from 9 donors. One elbow of each donor was randomly assigned to the extracortical SBor anatomical DB group. Both groups were cyclically loaded with 60N over 1000 cycles between 90° of flexion and full extension. The elbow was then fixed in 90° of flexion and the repair construct loaded to failure. Gap-formation and construct stiffness during cyclic loading, and ultimate load to failure was analysed. After 1000 cycles, the anatomical DB technique compared with the extracortical SB technique showed significantly less gap-formation (mean difference 1.2 mm; p=0.017) and significantly more construct stiffness (mean difference 31 N/mm; p=0.023). Ultimate load to failure was not significantly different comparing both groups (SB, 277 N ±92 vs. DB, 285 N ±135; p=0.859). The failure mode in the anatomical DB group was significantly different compared with the extracortical SB technique (p=0.002) and was due to fracture avulsion of the BicepsButton in 7 out of 9 specimens (vs. none in SB group). Our study shows that the intracortical DB technique produces equivalent or superior biomechanical performance to the SB technique. The DB repair technique reduces the risk of nerve injury and better restores the anatomical footprint of biceps tendon. The DB technique may offer a clinically viable alternative to the SB repair technique

Diagnostic interpretation error of paediatric musculoskeletal (MSK) radiographs can lead to late presentation of injuries that subsequently require more invasive surgical interventions with increased risks of morbidity. We aimed to determine the radiograph factors that resulted in diagnostic interpretation challenges for emergency physicians reviewing pediatric MSK radiographs. Emergency physicians provided diagnostic interpretations on 1,850 pediatric MSK radiographs via their participation in a web-based education platform. From this data, we derived interpretation difficulty scores for each radiograph using item response theory. We classified each radiograph by body region, diagnosis (fracture/dislocation absent or present), and, where applicable, the specific fracture location(s) and morphology(ies). We compared the interpretation difficulty scores by diagnosis, fracture location, and morphology. An expert panel reviewed the 65 most commonly misdiagnosed radiographs without a fracture/dislocation to identify normal imaging findings that were commonly mistaken for fractures. We included data from 244 emergency physicians, which resulted in 185,653 unique radiograph interpretations, 42,689 (23.0%) of which were diagnostic errors. For humerus, elbow, forearm, wrist, femur, knee, tibia-fibula radiographs, those without a fracture had higher interpretation difficulty scores relative to those with a fracture; the opposite was true for the hand, pelvis, foot, and ankle radiographs (p < 0 .004 for all comparisons). The descriptive review demonstrated that specific normal anatomy, overlapping bones, and external artefact from muscle or skin folds were often mistaken for fractures. There was a significant difference in difficulty score by anatomic locations of the fracture in the elbow, pelvis, and ankle (p < 0 .004 for all comparisons). Ankle and elbow growth plate, fibular avulsion, and humerus condylar were more difficult to diagnose than other fracture patterns (p < 0 .004 for all comparisons). We identified actionable learning opportunities in paediatric MSK radiograph interpretation for emergency physicians. We will use this information to design targeted education to referring emergency physicians and their trainees with an aim to decrease delayed and missed paediatric MSK injuries

Diagnostic interpretation error of paediatric musculoskeletal (MSK) radiographs can lead to late presentation of injuries that subsequently require more invasive surgical interventions with increased risks of morbidity. We aimed to determine the radiograph factors that resulted in diagnostic interpretation challenges for emergency physicians reviewing pediatric MSK radiographs. Emergency physicians provided diagnostic interpretations on 1,850 pediatric MSK radiographs via their participation in a web-based education platform. From this data, we derived interpretation difficulty scores for each radiograph using item response theory. We classified each radiograph by body region, diagnosis (fracture/dislocation absent or present), and, where applicable, the specific fracture location(s) and morphology(ies). We compared the interpretation difficulty scores by diagnosis, fracture location, and morphology. An expert panel reviewed the 65 most commonly misdiagnosed radiographs without a fracture/dislocation to identify normal imaging findings that were commonly mistaken for fractures. We included data from 244 emergency physicians, which resulted in 185,653 unique radiograph interpretations, 42,689 (23.0%) of which were diagnostic errors. For humerus, elbow, forearm, wrist, femur, knee, tibia-fibula radiographs, those without a fracture had higher interpretation difficulty scores relative to those with a fracture; the opposite was true for the hand, pelvis, foot, and ankle radiographs (p < 0 .004 for all comparisons). The descriptive review demonstrated that specific normal anatomy, overlapping bones, and external artefact from muscle or skin folds were often mistaken for fractures. There was a significant difference in difficulty score by anatomic locations of the fracture in the elbow, pelvis, and ankle (p < 0 .004 for all comparisons). Ankle and elbow growth plate, fibular avulsion, and humerus condylar were more difficult to diagnose than other fracture patterns (p < 0 .004 for all comparisons). We identified actionable learning opportunities in paediatric MSK radiograph interpretation for emergency physicians. We will use this information to design targeted education to referring emergency physicians and their trainees with an aim to decrease delayed and missed paediatric MSK injuries

Aim. The diagnosis of prosthetic joint infection (PJI) is challenging and relies on a combination of parameters. However, the currently recommended diagnostic algorithms have not been validated for patients with recent surgery, dislocation or other events associated with a local inflammatory response. As a result, these algorithms are not safely applicable offhand in such conditions. Calprotectin is a leukocyte protein that has been shown to be a reliable biomarker of PJI. The purpose of this study was to evaluate the use of calprotectin to rule out PJI within 3 months after surgery or dislocation. Method. We included patients who underwent arthroplasty revision surgery at our institution within 3 months after any event causing inflammation. Calprotectin was measured using a lateral-flow assay. European Bone and Joint Infection Society (EBJIS) criteria were used as gold standard. The diagnostic accuracy of calprotectin was calculated. Results. Twenty-two patients (14 females, 8 males) with a mean age of 65.1 ± 12.3 years with 13 total hip (THA) and 9 total knee arthroplasties (TKA) were included. There were 4 instances of possible early-onset acute infection, 4 dislocations, 2 patella tendon ruptures, 1 local tissue reaction to the sutures, 4 cases of early loosening, 2 component breakages and 1 avulsion of a polyethylene patella button. Using the EBJIS criteria, PJI was confirmed postoperatively in 12 cases. With a cut-off at 50mg/L, the calprotectin lateral flow test was positive in 10 cases. This results in a sensitivity of the calprotectin test of 0.75, a specificity of 0.9, positive and negative predictive values of 0.9 and 0.75, respectively, and a positive and negative likelihood ratio of 7.5 and 0.28, respectively. Conclusions. Aggravating the difficulties of ruling out PJI prior to revision surgery, local inflammation can be caused by some conditions in which the widely accepted PJI definition criteria cannot be applied. Nevertheless, an accurate diagnosis of PJI is just as crucial in these situations as it is in planned revision surgery. This study suggests that calprotectin is a promising diagnostic parameter for ruling out PJI in such cases. The calprotectin lateral-flow assay is readily applicable at the beginning of the procedure, yielding results that can assist in the decision whether to perform septic revision or aseptic partial or component exchange within 15 minutes, and with an overall accuracy of 81.8%

Introduction. The hip hemiarthroplasty in posterior approach is a common surgical procedure at the femoral neck fractures in the elderly patients. However, the postoperative hip precautions to avoid the risk of dislocations are impeditive for early recovery after surgery. We used MIS posterior approach lately known as conjoined tendon preserving posterior (CPP) approach, considering its enhancement of joint stability, and examined the intraoperative and postoperative complications, retrospectively. Methods. We performed hip hemiarthroplasty using CPP approach in 30 patients, and hip hemiarthroplasty using conventional posterior approach in 30 patients, and both group using lateral position with the conventional posterior skin incision. The conjoined tendon (periformis, obturator internus, and superior/inferior gemellus tendon) was preserved and the obturator externus tendon was incised in CPP approach without any hip precautions postoperatively. The conjoined tendon was incised in conventional approach using hip abduction pillow postoperatively. Results. There was no difference between CPP approach group and conventional approach group in the mean age of patients (81.8 years, and 80.3 years, respectively), and in the mean operative time (68.8 minutes, and 64.9 minutes, respectively). In 4 cases of CPP approach, the avulsion fracture at femoral attachment of the conjoined tendon occured during hip reduction manoeuvres. No dislocations occured in both groups in the follow-up period (2 years). Discussion. Lately, the number of hip surgery in muscle sparing approach is increasing. However, in general, MIS approach induces the intraoperative complications, and requires the skillful procedure. The hip reduction manoeuvres would be more difficult in the CPP approach, than in conventional posterior approach, because the preserved conjoined tendon would inhibit hip reduction, considering those avulsion fractures of the femoral attachment. Nevertheless, CPP approach did not require no extended time compared to conventional approach, and no postoperative hip precautions. Due to these results, CPP approach could be a good MIS procedure including early recovery after surgery based on the enhancement of joint stability, excluding the difficulties in hip reduction manoeuvres. We could not show the difference in dislocation rate between two groups, because of small numbers. We are planning to increase the number of patients in the future study

Avulsion of the abductor muscles of the hip may cause severe limp and pain. Limited literature is available on treatment approaches for this problem, and each has shortcomings. This study describes a muscle transfer technique to treat complete irreparable avulsion of the hip abductor muscles and tendons. Ten adult cadaver specimens were dissected to determine nerve and blood supply point of entry in the gluteus maximus and tensor fascia lata (TFL) and evaluate the feasibility and safety of transferring these muscles to substitute for the gluteus medius and minimus. In this technique, the anterior portion of the gluteus maximus and the entire TFL are mobilised and transferred to the greater trochanter such that the muscle fiber direction of the transferred muscles closely matches that of the gluteus medius and minimus. Five patients (five hips) were treated for primary irreparable disruption of the hip abductor muscles using this technique between January 2008 and April 2011. All patients had severe or moderate pain, severe abductor limp, and positive Trendelenburg sign. Patients were evaluated for pain and function at a mean of 28 months (range, 18–60 months) after surgery. All patients could actively abduct 3 months post-operatively. At 1 year post-operatively, three patients had no hip pain, two had mild pain that did not limit their activity, three had no limp, and one had mild limp. One patient fell, fractured his greater trochanter, and has persistent limp and abduction weakness. The anterior portion of the gluteus maximus and the TFL can be transferred to the greater trochanter to substitute for abductor deficiency. In this small series, the surgical procedure was reproducible and effective; further studies with more patients and longer follow-up are needed to confirm this

The optimal management of rotationally-unstable ankle fractures involving the posterior malleolus remains controversial. Standard practice involves trans-syndesmotic fixation (TSF), however, recent attention has been paid to the indirect reduction of the syndesmosis by repairing small posterior malleolar fracture avulsion fragments, if present, using open reduction internal fixation. Posterior malleolus fixation (PMF) may obviate the need for TSF. Given the limited evidence and diversity in surgical treatment options for rotationally-unstable ankle fractures with ankle syndesmosis and posterior malleolar involvement, we sought to assess the research landscape and identify knowledge gaps to address with future clinical trials. We performed a scoping review to investigate rotational ankle fractures with posterior malleolar involvement, utilizing the framework originally described by Arksey and O'Malley. We searched the English language literature using the Ovid Medline and Embase databases. All study types investigating rotationally-unstable ankle fractures with posterior malleolus involvement were categorized into defined themes and descriptive statistics were used to summarize methods and results of each study. A total of 279 articles published from 1988 to 2018 were reviewed, and 70 articles were included in the final analysis. The literature consists of studies examining the surgical treatment strategies for PMF (n=21 studies, 30%), prognosis of rotational ankle fractures with posterior malleolar involvement (n=16 studies, 23%), biomechanics and fracture pattern of these injuries (n=13 studies, 19%), surgical approach and pertinent anatomy for fixation of posterior malleolus fractures (n=12 studies, 17%), and lastly surgical treatment of syndesmotic injuries with PMF compared to TSF (n=4 studies, 6%). Uncontrolled case series of single treatment made up the majority of all clinical studies (n=44 studies, 63%), whereas controlled study designs were the next most common (n=16 studies, 23%). Majority of research in this field has been conducted in the past eight years (n=52 studies, 74%). Despite increasing concern and debate among the global orthopaedic community regarding rotationally-unstable ankle fractures with syndesmosis and posterior malleolar involvement, and an increasing trend towards PMF, optimal treatment remains unclear when comparing TSF to PMF. Current research priorities are to (1) define the specific injury pattern for which PMF adequately stabilizes the syndesmosis, and (2) conduct a randomized clinical trial comparing PMF to TSF with the assistance of the orthopaedic community at large with well-defined clinical outcomes

Introduction. Avulsion of abductors from hip is a debilitating complication after total hip arthroplasty performed through a trans-gluteal approach. It results in intractable pain, Trendelenberg limp and instability of the hip. Techniques described for repairing these abductor tears including direct trans osseous repairs, endoscopic repair techniques, Achilles tendon allograft, Gluteus Maximus and Vastus Lateralis muscle transfers. The aim of our study was to assess improvement in pain, limp and abductor strength in patients operated upon surgically for confirmed abductor avulsion using a modified trans osseous repair and augmentation of repair with a Graft Jacket allograft acellular human dermal matrix (Graft jacket; Wright Medical Technology, Arlington, TN). Patients and Methods. In this prospective study we include 18 consecutive patients with hip abductor avulsions following a primary total hip arthroplasty through Hardinge approach for osteoarthritis. All the patients presented with pain around lateral aspect of hip, walking with a significant Trendelenberg limp and used a crutch or a stick in the opposite hand. Diagnosis was made by clinical examination and confirmed by MRI scans. Surgical Technique. Surgical procedure was through lateral approach using the old scar to mobilise combined aponeurosis of the Gluteal Medius and Gluteus Minimus from the bony bed on the ilium to permit advancement onto the trochanter. The conjoint Gluteus Medius and Minimus insertion was affixed to the greater trochanter with No.5 non absorbable trans-osseous suture using a Krackow stitch through a series of transverse tunnels made in anterior aspect of greater trochanter. An on lay augmentation (Fig. 1) of the osseo-tendinous junction was performed using a Graft Jacket matrix of 4 × 7 cms in size after rehydration according to the manufacturer's instructions. Results. At mean follow up of 22 months (15–34 months), pain improved in all patients with mean VAS score improving from 8.25 to 2.33 (p value-0.05). All the patients had improvement in their abductor strength with MRC grade 4 out of 5 in 16 patients and 3 out of 5 in 2 patients. Trendelenberg sign disappeared in all but two. Mean Harris hip score improved from 34.05 to 81.26 (p value-0.001). All patients had improvement in gait except mild noticeable limp in two patients.13 patients did not use any walking aids and five felt more secure using a walking stick in the contralateral hand. The mean SF-36 Physical component score was 53.47 and Mental component score was 56.07. Conclusions. The procedure is safe and associated with high patient satisfaction, without the morbidity of tendon or muscle transfers. The Graft Jacket Matrix provides biological bridging between the hip abductors and its insertion into greater trochanter. It provides a biological scaffold for cellular and vascular in-growth and constructive tissue remodelling. The described procedure appears to enhance the mechanical strength of repaired tendon immediately following surgery. The Graft Jacket allograft matrix has already been used successfully in rotator cuff repairs of shoulder and has showed encouraging results. The early success of this new procedure warrants further study with more patients, longer follow-up and possibly histological study of retrieved specimens

Purpose. The purpose of this study is to evaluate stiff knees which have a preoperative arc of motion (AOM) < 65 degrees and maximum flexion < 90 degrees under anesthesia for primary TKA. Material and Methods. We prospectively evaluated 25 knees, 20 patients, the follow up period was 5±3 years, OA 13, RA 10 and traumatic OA 2 knees. All case were medial para-patella approaches and snip was added in one knee operation, 23 PS-type and 2 constrain-type TKAs. Results. Preoperative and postoperative FTA were 185.3±8.4 and 174.2±2.8 degrees, α95.5±3.0, β88.6±2.1, γ4.1±2.9, σ83.8±3.0, CTA1.4±1.9 degrees. Soft tissue releases were performed in Clayton stage I 9, II 14 and III 2 knees, and additional resection for the posterior capsule 11, vastus intermedius 2 and ITT 4 knees and lateral release 4 knees. Additional bone cuts were performed in 19 knees including femur 14 knees and tibia 12 knees. Component gaps (20/30/40lb) of medial and lateral were 9.8±0.8/10.8±2.9/12.2±1.9 mm and 11.0±2.1/12.6±2.5/13.6±2.8 mm at 0 degrees, they were 11.4±2.8/13.5±3.6/15.8±4.1 mm and 12.5±2.7/15.1±3.8 /18.0±4.2 mm at 90 degrees. (Figure1) MCL avulsion was in 3 knees. AOMs in preoperative, perioperative, 1-year later and final observation were 45.0±16.5, 110.4±15.5, 110.8±18.4 and 113.4±18.2 degrees. (Figure2) Flexions were72.5±17.7, 104.0±14.0, 104.0±14.0 and 106.5±14.4 degrees. Extensions were −28.3±10.5, −6.0±7.5, −6.0±7.0 and −6.9±7.8 degrees. There were no statistical differences between perioperative and final AOM, flexion and extension, and between OA and RA. Discussion. AOM improved and remained after the surgeries. We evaluated soft tissue release and component gaps in 25 stiff knees when preoperative arc of motion (AOM) was < 65 degrees and maximum flexion < 90 degrees under anesthesia for primary TKA. There were no statistical differences between perioperative and final AOM, flexion and extension, and between OA and RA. For any figures or tables, please contact the authors directly

A key component to the success of total knee replacement is the health and integrity of the extensor mechanism. While there are issues related to the patella, such as fracture, dislocation, subluxation, clunk due to peripatellar fibrosis and anterior knee pain, the overall integrity of the extensor mechanism is of tantamount importance in providing an excellent functional outcome. During total knee replacement it is of utmost importance to preserve the anatomic insertion of the patellar tendon on the tibial tubercle. However, after total knee replacement, a fall or extreme osteoporosis of the patella may cause a rupture of the patellar tendon, distally or proximally, and possibly the quadriceps tendon off of the proximal pole of the patella. Simple repairs of the patellar tendon avulsion may involve use of the semitendonosis and gracilis tendons along with primary repair of the tendon. Usually, patella infera develops after such a repair affecting overall strength and function. For severe disruptions of the extensor mechanism that are accompanied by a significant extensor lag, autologous tissue repair may not be possible. Thus, there are three techniques for reconstruction of this difficult problem: Extensor mechanism allograft with bone-patellar tendon-patella-quadriceps tendon, extensor mechanism allograft with os calcis-Achilles tendon construct and Marlex-mesh reconstruction for patellar tendon avulsion. The key to success of extensor mechanism allograft is proper tensioning of the allograft at full extensor and immobilisation for 6 weeks. Rosenberg's early experience showed that the allograft works best placed at maximum tension in extension. Rubash has described the use of the os calcis-Achilles tendon which does not utilise a patellar substitute. Hansen has recently described excellent results with the use of Marlex mesh to act as a structural reinforcement to the patellar tendon when it is avulsed