Aims. The Precice intramedullary limb-lengthening system has demonstrated significant benefits over external fixation lengthening methods, leading to a paradigm shift in limb lengthening. This study compares outcomes following antegrade and retrograde femoral lengthening in both adolescent and adult patients. Patients and Methods. A retrospective review of prospectively collected data was undertaken of a consecutive series of 107 femoral lengthening operations in 92 patients. In total, 73 antegrade nails and 34 retrograde nails were inserted. Outcome was assessed by the regenerate healing index (HI), hip and knee range of movement (ROM), and the presence of any complications. Results. The mean lengthening was 4.65 cm (1.5 to 8) in the antegrade group and 4.64 cm (1.6 to 8) in the retrograde group. Of the 107 lengthenings, 100 had sufficient datapoints to calculate the mean HI. This was 31.6 days/cm (15 to 108). There was a trend toward a lower (better) HI with an antegrade nail and better outcomes in adolescent patients, but these were not statistically significant. Hip and knee ROM was maintained and/or improved following commencement of femoral lengthening in 44 patients (60%) of antegrade nails and 13 patients (38%) of retrograde nails. In female patients, loss of movement occurred both earlier and following less total length achieved. Minor implant complications included locking bolt migration and in one patient deformity of the nail, but no implant failed to lengthen and there were no deep infections. Three patients had delayed union, five patients required surgical intervention for joint contracture. Conclusion. This study confirms excellent results in femoral lengthening with antegrade and retrograde Precice nails. There is a trend for better healing and less restriction in hip and knee movement following antegrade nails. There are clinical scenarios, that mandate the use of a retrograde nail. However, when these are not present, we recommend the use of antegrade nailing. Cite this article: Bone Joint J 2019;101-B:1168–1176

Currently, the consensus regarding subscapularis tendon repair during a reverse total shoulder arthroplasty (rTSA) is to do so if it is possible. Repair is thought to decrease the risk of dislocation and improve internal rotation but may also increase stiffness and improvement in internal rotation may be of subclinical benefit. Aim is to retrospectively evaluate the outcomes of rTSA, with or without a subscapularis tendon repair. We completed a retrospective review of 51 participants (25 without and 26 with subscapularis repair) who received rTSR by a single-surgeon using a single-implant. Three patient reported outcome measures (PROM) were assessed pre-operatively and post-operative at twelve months, as well as range of movement (ROM) and plain radiographs. Statistical analysis utilized unpaired t tests for parametric variables and Mann-Whitney U test for nonparametric variables. External Rotation ROM pre-operatively was the only variable with a significance difference (p=0.02) with the subscapularis tendon repaired group having a greater range. Pre- and post-operative abduction (p=0.72 & 0.58), forward flexion (p=0.67 & 0.34), ASES (p=0.0.06 & 0.78), Oxford (p=0.0.27 & 0.73) and post-operative external rotation (p=0.17). Greater external rotation ROM pre-operatively may be indicative of the ability to repair the subscapularis tendon intra-operatively. However, repair does not seem to improve clinical outcome at 12 months. There was no difference of the PROMs and AROMs between the subscapularis repaired and not repaired groups for any of the variables at the pre-operative or 12 month post operative with the exception of the external rotation ROM pre-operatively. We can conclude that from PROM or AROM perspective there is no difference if the tendon is repaired or not in a rTSR and indeed the patients without the repair may have improved outcomes at 12 months

We have previously reported on the medium-term outcomes following a non-operative protocol of a short period of splinting followed by early movement to treat simple dislocations of the elbow. We undertook extended follow up of our original patient study group to determine whether the excellent results previously reported were maintained in the very long-term. A secondary question was to determine the rate and need for any late surgical intervention. We attempted to contact all patients in the original patient study group. Patients were requested to complete the Oxford elbow score (OES), the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and a validated patient satisfaction questionnaire. Patients were requested to attend a face-to-face assessment where they underwent a clinical examination including neurovascular assessment, range-of-motion and an assessment of ligamentous stability. Seventy-one patients (65%) from the original patient study group agreed to participate in the study. The mean duration of follow-up was 19.3 years. At final follow-up patients reported excellent functional outcome scores and a preserved functional range of movement in the injured elbows. The mean DASH score was 5.22 points and the mean Oxford Elbow Score was 91.6 points. The mean satisfaction score was 90.9 points. Our study shows that the excellent outcomes following treatment with a protocol of a short period of splinting and early movement remain excellent and are maintained into the very long term. These findings support our hypothesis that this treatment protocol is appropriate and suitable for most patients with simple dislocations of the elbow. The role for primary ligamentous repair for this patient group should be carefully considered. Work to more clearly define the anticipated benefits of surgery for specific patient groups or injury patterns would help to support informed decision making

Glenoid bone grafting in reverse total shoulder arthroplasty (RTSA) has emerged as an effective method of restoring bone stock in the presence of complex glenoid bone loss, yet there is limited published evidence on efficacy. The aim of this study was to conduct an analysis of clinical and radiographic outcomes associated with glenoid bone grafting in primary RTSA. Patients who underwent a primary RTSA with glenoid bone grafting were retrospectively identified from the databases of two senior shoulder surgeons. Inclusion criteria included minimum of 12 months clinical and/or radiographical follow up. Patients underwent preoperative clinical and radiographic assessment. Graft characteristics (source, type, preparation), range of movement (ROM), patient-reported outcome measures (Oxford Shoulder Scores [OSS]), and complications were recorded. Radiographic imaging was used to analyse implant stability, graft incorporation, and notching by two independent reviewers. Between 2013 and 2021, a total of 53 primary RTSA procedures (48 patients) with glenoid bone grafting were identified. Humeral head autograft was used in 51 (96%) of cases. Femoral head allograft was utilised in two cases. Depending on the morphology of glenoid bone loss, a combination of structural (corticocancellous) and non-structural (cancellous) grafts were used to restore glenoid bone stock and the joint line. All grafts were incorporated at review. The mean post-operative OSS was significantly higher than the pre-operative OSS (40 vs. 22, p < 0.001). ROM was significantly improved post-operatively. One patient is being investigated for residual activity-related shoulder pain. This patient also experienced scapular notching resulting in the fracturing of the inferior screw. One patient experienced recurrent dislocations but was not revised. Overall, at short term follow up, glenoid bone grafting was effective in addressing glenoid bone loss with excellent functional and clinical outcomes when used for complex bone loss in primary RTSA. The graft incorporation rate was high, with an associated low complication rate

Introduction. Despite the rising popularity of 1st carpometacarpal joint (CMCJ) arthrodesis as one of the surgical options for basilar thumb arthritis, the available literature on this is poor. This study aims to investigate post-operative pinch and grip strength following 1st CMCJ arthrodesis, at a minimum of 1 year follow-up. Complication rates, range of motion and patient reported scores were also evaluated. Methods. A retrospective cohort (2012–2020) was used, which included patients who had arthrodesis performed by the Hands surgeons at Counties Manukau DHB. In a 15 minute visit, we took the measurements using our standard dynamometer and pinch gauge, and collected three questionnaires [QuickDASH, PRWHE, PEM]. For analysis, we compared our results to the preoperative measures, contralateral hand, and to a previous study on a similar cohort looking at thumb strength following trapeziectomy. Results. 42 arthrodesis were performed, and 24 were available for follow-up. The average follow-up time was 77 months and the average age was 51 years old. Overall, we found a statistically significant improvement in thumb strength following surgery. Mean preoperative grip strength was 21.4kg and 32.5kg postoperatively (= +11kg). Preoperative pinch strength was 5.5kg and 7kg postoperatively (= +1.5kg). These results were significantly higher compared to the trapeziectomy cohort. We also found an improvement in 1st CMCJ ROM post-operatively. 7 complications were reported (29.1%). 4 were metalware-related and 3 were non-union. QuickDASH score significantly improved from a median of 42.95 to 12.5 while PRWHE from 67.5 to 14.5. Overall patient satisfaction was 87.4%. Conclusion. 1st CMCJ arthrodesis leads to an improvement in thumb function, pain and range of movement and results in high patient satisfaction, and therefore should be recommended for younger patients who need a pain-free and strong thumb

Cryocompression therapy is a non-invasive and non-pharmacological modality used in managing acute post-operative inflammation and pain. A prospective, randomised controlled trial (RCT) was undertaken to evaluate the effectiveness of a post-operative cryocompression protocol using the Game Ready™ (GR) device versus usual care on recovery following total knee arthroplasty (TKA). A single centre RCT was conducted with 70 TKAs (68 patients) randomised to a 2-week intervention period consisting of treatment with GR cryocompression (n=33, 33.3% males) or a usual care protocol of ice with static compression using tubigrip (n=35, 54.3% males). Knee range of movement (ROM) (flexion and extension), a visual analogue pain score (VAS) and limb circumference were documented at day 1, 2 and 14, as well as 6 and 12 weeks post-surgery. ROM was also recorded at day 90, while medication use and length of hospital stay were documented. Patient reported outcome measures (PROMs) including the KOOS and patient satisfaction questionnaire were employed. The GR group demonstrated 2.3° more (p=0.05) knee extension ROM overall, as well as 2. 8° more at day 1 (p=0.048), 3.8° at day 14 (p=0.007) and 5.4° at 3 months (p=0.017). There were no group differences (p>0.05) observed in pain (VAS), flexion ROM, limb circumference, opioid use or other PROMs. Across the full cohort, higher pain levels resulted in increased opioid intake (p=0.002), older patients used significantly less opioids (p<0.001) and males reported significantly less pain (VAS) than females (p=0.048). Using GR following TKA is a safe, non-invasive tool that can be used to aid in the post-operative recovery period. Patients using the GR cryocompression device gained significantly more extension ROM compared to the conventional ice with compression group, despite no other group differences

Introduction. Angular deformities of the distal femur can be corrected by opening, closing and neutral wedge techniques. Opening wedge (OW) and closing wedge (CW) are popular and well described in the literature. CW and OW techniques lead to leg length difference whereas the advantage of neutral wedge (NW) technique has several unique advantages. NW technique maintains limb length, wedge taken from the closing side is utilised on the opening side and since the angular correction is only half of the measured wedge on either side, translation of distal fragment is minimum. Leg lengths are not altered with this technique hence a useful technique in large deformities. We found no reports of clinical outcomes using NW technique. We present a technique of performing external fixator assisted NW correction of large valgus and varus deformities of distal femur and dual plating and discuss the results. Materials & Methods. We have treated 20 (22 limbs – 2 patients requiring staged bilateral corrections) patients for distal femoral varus and valgus deformities with CWDFO between 2019 and 2022. Out of these 4 patients (5 limbs) requiring large corrections of distal femoral angular deformities were treated with Neutral Wedge (NW) technique. 3 patients (four limbs) had distal femoral valgus deformity and one distal femoral varus deformity. Indication for NW technique is an angular deformity (varus or valgus of distal femur) requiring > 12 mm opening/closing wedge correction. We approached the closing side first and marked out the half of the calculated wedge with K – wires in a uniplanar fashion. Then an external fixator with two Schanz screws is applied on the opposite side, inserting the distal screw parallel to the articular surface and the proximal screw 6–7 cm proximal to the first pin and at right angles to the femoral shaft mechanical axis. Then the measured wedge is removed and carefully saved. External fixator is now used to close the wedge and over correct, creating an appropriate opening wedge on the opposite side. A Tomofix (Depuoy Synthes) plate is applied on the closing side with two screws proximal to osteotomy and two distally (to be completed later). Next the osteotomy on the opposite side is exposed, the graft is inserted. mLDFA is measured under image intensifier to confirm satisfactory correction. Closing wedge side fixation is then completed followed by fixation of opposite side with a Tomofix or a locking plate. Results. 3 patients (4 limbs) had genu valgum due to constitutional causes and one was a case of distal femoral varus from a fracture. Preoperative mLDFA ranged from 70–75° and in one case of varus deformity it was 103°. We achieved satisfactory correction of mLDFA in (85–90°) in 4 limbs and one measured 91°. Femoral length was not altered. JLCA was not affected post correction. Patients were allowed to weight bear for transfers for the first six weeks and full weight bearing was allowed at six weeks with crutches until healing of osteotomy. All osteotomies healed at 16–18 weeks (average 16.8 weeks). Patients regained full range of movement. We routinely recommend removal of metal work to facilitate future knee replacement if one is needed. Follow up ranged from 4 months to 2 yrs. Irritation from metal work was noted in 2 patients and resolved after removing the plates at 9 months post-surgery. Conclusions. NWDFO is a good option for large corrections. We describe a technique that facilitates accurate correction of deformity in these complex cases. Osteotomy heals predictably with uniplanar osteotomy and dual plate fixation. Metal work might cause irritation like other osteotomy and plating techniques in this location

Introduction. Knee arthroplasty provides not only pain relief but also an improvement in function and range of movement. Limited joint mobility (LJM), secondary to peri-articular connective tissues stiffness, is a common complication of diabetes mellitus. We therefore examined functional outcome post-total knee arthroplasty (TKA) in a cohort of subjects with and without diabetes mellitus. Method. The effect of TKA on indices of knee function (fixed flexion, maximum flexion, total ROM and knee society score) was examined in 367 subjects with type 2 diabetes and 367 subjects without diabetes. The groups were matched for age, sex, BMI and functional movement at baseline. Participants were examined at baseline (pre-operatively), 1, 5 and 10 years post-TKA. Results. There was no significant difference in fixed flexion, maximal flexion or total range of movement between the two groups at baseline. At 1 year the group with diabetes had a significantly lower maximal flexion (p < 0.001), total range of movement (p < 0.001) and Knee Society Score (p = 0.034). At 5 years post-arthroplasty a significant increase was observed in fixed flexion (p = 0.026) as well as a significant decrease in maximal flexion (p = 0.001) and total range of movement (p = 0.004) in the diabetic group. Ten years post-arthroplasty yielded similar results. Conclusion. Within one-year post-arthroplasty people with diabetes develop a poorer range of movement compared to controls. Between one to five years post-procedure a significant fixed flexion deformity occurred in those with diabetes. A sustained deterioration was observed up to 10 years post-procedure. This study is the first to demonstrate that the pre-operative presence of diabetes mellitus leads to a worse functional outcome post-knee arthroplasty

Aims. To assess if older symptomatic children with club foot deformity differ in perceived disability and foot function during gait, depending on initial treatment with Ponseti or surgery, compared to a control group. Second aim was to investigate correlations between foot function during gait and perceived disability in this population. Methods. In all, 73 children with idiopathic club foot were included: 31 children treated with the Ponseti method (mean age 8.3 years; 24 male; 20 bilaterally affected, 13 left and 18 right sides analyzed), and 42 treated with primary surgical correction (mean age 11.6 years; 28 male; 23 bilaterally affected, 18 left and 24 right sides analyzed). Foot function data was collected during walking gait and included Oxford Foot Model kinematics (Foot Profile Score and the range of movement and average position of each part of the foot) and plantar pressure (peak pressure in five areas of the foot). Oxford Ankle Foot Questionnaire, Disease Specific Index for club foot, Paediatric Quality of Life Inventory 4.0 were also collected. The gait data were compared between the two club foot groups and compared to control data. The gait data were also correlated with the data extracted from the questionnaires. Results. Our findings suggest that symptomatic children with club foot deformity present with similar degrees of gait deviations and perceived disability regardless of whether they had previously been treated with the Ponseti Method or surgery. The presence of sagittal and coronal plane hindfoot deformity and coronal plane forefoot deformity were associated with higher levels of perceived disability, regardless of their initial treatment. Conclusion. This is the first paper to compare outcomes between Ponseti and surgery in a symptomatic older club foot population seeking further treatment. It is also the first paper to correlate foot function during gait and perceived disability to establish a link between deformity and subjective outcomes. Cite this article: Bone Joint Open 2020;1-7:384–391

Purpose of the Study:. Spontaneous intraarticular haemorrhages are the most frequent bleeding episodes encountered in the haemophiliac population, causing pain, joint deformity and arthropathy. Chronic haemophiliac arthropathy is characterised by persistent joint swelling, proliferative synovitis, and damage to or loss of articular cartilage. Elimination of the synovitis is the key to prevention of recurrent intraarticular haemorrhages and joint damage. The purpose of the study was to investigate the indications for, and outcome of, radioactive synoviorthesis for haemophiliac arthropathy. Methods:. A retrospective study was done to assess the results of 12 intra-articular injections of radioactive Yttrium-90 colloid, performed in 10 patients from November 1993 to December 2006. Patients were referred by the Haematology Unit if they had a target joint, as defined as >2 bleeds into the same joint in the preceding 6 months. Follow up was conducted at 6 monthly intervals, assessing clinical and radiological outcomes. The radiological involvement of the target joint, the pre- and post-treatment range of movement, presence of synovitis and bleeding events were compared from presentation to that at follow up. Range of movement of each target joint was assessed and compared to that at follow-up. Results:. The average age at time of injection was 10.6 years (range 6–15). The duration of follow-up was 35 months (range 6 to 60 months). The involved joints had an average of 2 bleeds each in the 6 months preceding the injection (24 events). Following Yttrium injection only 1 out of 12 joints had a bleed in the subsequent 6 months (1 event). Synovitis of the target joint resolved in 11 of 12 joints. Nine target joints (75%) showed a favourable improvement in range of movement. Those with a favourable radiological score had a better clinical outcome, but even those with a poor score showed improvement. Conclusion:. In this study, intra-articular injection of radioactive Yttrium-90 colloid was shown to:. –. Significantly reduce bleeding events in a Haemophiliac cohort. –. Resolve synovitis in 11 out of 12 joints with haemophiliac arthropathy. –. Improve range of movement in the majority of patients. –. This was best in those with a better radiological appearance at presentation. –. Those with a poorer radiological grade also showed some improvement suggesting that while results are less certain, patients may still benefit from the intervention

The objective of this study is to compare three dimensional (3D) postoperative motion between metal and ceramic bipolar hip hemiarthroplasty for femoral neck fracture. Materials and Methods. This study was conducted with forty cases (20 cases of metal bipolar hemiarthroplasty (4 males, 16 females), 20 cases of ceramic bipolar hemiarthroplasty (2 males, 18 females)) from November 2012 to November 2014. Average age was 80.8±7.5 years for the metal bipolar group and 79.3±10.5 years for the ceramic bipolar group. We obtained motion pictures from standing position to maximum abduction in flexion by fluoroscopy then analyzed by 2D–3D image matching method. The motion range of the “Shell angle”, “Stem neck angle” and the “Stem neck and shell angle” has been compared between the metal bipolar group and the ceramic bipolar group (Fig. 1). Results. Metal bipolar showed greater variability of the Stem neck angle and Shell angle than ceramic bipolar. Six of the twenty cases reached unilateral oscillation angle of 37 degrees in metal bipolar. In other words, 30% of metal bipolar group revealed neck-shell impingement. No case reached oscillation angle of 58 degrees in ceramic bipolar group. There was no significant difference between the metal bipolar group and the ceramic bipolar group with respect to the difference of minimum and maximum angle of Stem neck angle (movement range of the stem neck) and Shell angle (movement range of the bipolar cup). On the other hand, difference of minimum and maximum angle of the Stem neck and shell angle (movement range of the inner head) was significantly greater in the metal bipolar group than the ceramic bipolar group. Movement, range of bipolar shell was significantly greater than that of inner head in both groups (Table 1). Discussion. The present study is the first report using 2D–3D image matching method in bipolar impingement. From the result of our study, bipolar shell moves greatly against the acetabular cartilage for both metal bipolar and ceramic bipolar, and the range of movement of the outer shell was significantly greater than the range of movement of the inner head. It indicates that most of the movement actually occurs between outer shell and acetabular cartilage, despite bipolar prosthesis having a double bearing function intrinsic to the design. Impingement between the shell and the stem neck was found six of twenty cases with metal bipolar group and no impingement occurred with ceramic bipolar group. The present results showed that the ceramic bipolar has the possibility to avoid the characteristic complications of the bipolar caused by the wear debris produced by impingement. In conclusion, the metal bipolar group's inner head's range of movement was greater than the ceramic bipolar group. The impingement between stem neck and shell occurred in the 30% of metal group patients. On the other hand, there were no impingement cases for the ceramic bipolar group. We expect good long term clinical result and expansion of the indication as the ceramic bipolar may reduce the typical bipolar related complication

Objective. To determine differences in fracture stability and functional outcome between synthetic bone graft and allograft/autograft with internal fixation of tibia plateau metaphyseal defects. Patient & Methods. Between 2007- 2008, 84 consecutive cases of internal fixation of tibia plateaux were identified from our theater logbook. 29 patients required additional autologous, allogenic bone graft, or synthetic bone graft substitute to ensure fracture stability. 5 patients were excluded due to lost to follow up leaving a cohort of 24 patients. Hydroxyapatite calcium carbonate synthetic bone graft was utilised in 14 patients (6 male and 8 female). Allograft/autograft were utilised in the remaining 10 patients (6 male and 4 female). All 24 patients had closed fractures, classified using the AO and Schatzker classification. Roentograms at presentation, post-operatively and regular follow-up till 12 months were analysed for maintenance of reduction, early and late subsidence of the articular surface. Functional outcomes such as knee range of movement and WOMAC Knee scores were compared between groups. Results. There was no significant statistical difference between groups for post-operative joint reduction, long term subsidence, and WOMAC scores. The degree of subsidence was not related to age or fracture severity. Maintenance of knee flexion was found to be better in the allograft/autograft group (p=0.015) when compared between groups. Multivariate analysis compared graft type, fracture severity, postoperative reduction, subsidence rate, range of movement and WOMAC score. The only finding was a statistical significant (p=0.025) association with the graft type and range of movement. Conclusion. Allograft/autograft may allow better recovery of long-term flexion, possibly due to reduced inflammatory response compared with synthetic bone graft. However, all other parameters such as maintenance of joint reduction and subjective outcome measures were comparable with the use of hydroxyapatite calcium carbonate bone graft. This study shows that synthetic bone graft is a suitable option in fixation of unstable tibia plateau fractures, avoiding risk of viral disease transmission with allograft and donor site morbidity associated with autograft

We undertook 37 reverse total shoulder replacements within a 2 yr period for chronic complex shoulder conditions. All cases were undertook by one of two upper limb consultant orthopaedic surgeons. At time of listing for operation, the decision as to whether to undertake a bony-increased offset reverse total shoulder was made. Retrospective data was collected on the need for analgesia at final follow up and range of movement. Of the 37 patients, 12 underwent BIO-RSA procedures. Indications for surgery was predominantly rotator cuff arthropathy (n=9) but two patients had severe OA and one had a complex proximal humeral fracture. The average age of the patient was 76.6 yrs (69–87 yrs) with a mean follow-up of 6.8 months (6 weeks to 1 yr). The remaining 25 patients were similar in terms of indication, with 18 patients with cuff tear arthropathies and 7 with severe OA. Average age was slightly lower at 74.9 years (50–85). In terms of range of movement, outcomes between the two groups were broadly similar; those receiving BIO-RSA having an active forward flexion of 90.5° (50–130°) and abduction 88.6° (40–160°). Both groups had excellent analgesic effect with 92% in each either being completely painfree (33.3% BIO-RSA and 44% RSA) or requiring only occasional analgesia. The vast majority of patients were either very satisfied or satisfied with the outcome of the surgery, with one patient in the BIO-RSA group being slightly dissatisfied and three in RSA group. If grafting is necessary, the use of BIO-RSA within this centre seems to have comparable results to those undergoing standard RSA

Introduction. Improvements in function after THA can be evaluated using validated health outcome surveys but studies have shown that PROMs are unreliable in following the progress of individuals. Formal gait lab analysis is expensive, time consuming and fixed in terms of location. Inertial Measurement Units (IMUs) containing accelerometers and gyroscopes can determine aspects of gait kinematics in a portable package and can be used in the outpatient setting (Figure 1). In this study multiple metrics describing gait were evaluated pre- and post THA and comparisons made with the normal population. Methods. The gait of 55 patients with monarthrodial hip arthrosis was measured pre-operatively and at one year post-surgery. Patients with medical co-morbidity or other condition affecting their gait were excluded. Six IMUs aligned in the sagittal plane were attached at the level of the anterior superior iliac spines, mid-thigh and mid-shank. Data was analysed using proprietary software (Figure 2). Each patient underwent a conventional THA using a posterolateral approach. An identical test was performed one year after surgery. 92 healthy individuals with a normal observed gait were used as controls. Results. In the pre-operative test the range of movement in the sagittal plane of both the ipsilateral hip (mean range 20.4) and the contra-lateral non-diseased hip (35.3 degrees) was reduced compared to the control group (40.5 degrees), (P<0.001). The pre-operative range of motion of both knees was also reduced compared with normal (P<0.001). Pelvic movement on the ipsilateral side was increased. After one year the range of movement of the ipsilateral hip significantly improved (Mean range 28.9 deg SD 6.6) but did not attain normal values (P<0.001). Movement measured in the contralateral hip reduced further from its pre-operative value with a mean difference of −5.25 degrees (95% CI −8.06 to −2.43). Measurements of the symmetry of movement were increased. Knee movement on both sides increased but not to normal values (p<0.001). In contradistinction, there was bilateral increased coronal movement at the thigh and calf a year after surgery. Discussion and Conclusion. Gait after routine THA does not return to normal on the ipsilateral or contralateral side. Pathology in one hip causes bilateral gait abnormality that can be quantified by movement at the pelvis, hip, thigh and knee. The ability of a patient to walk normally after surgery will depend on many factors including details of the hip operation such as accurate recreation of the biomechanics of the joint and physical therapy regimens. Advances in technology now allow assessment of gait in large number of patients in the clinic setting and will better allow us to establish the important factors to improve patients gait and thereby potentially improve further satisfaction and PROMS scores. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Introduction. Lewinnek's Safe-Zone gives recommendations only for cup placement in total hip arthroplasty while the orientation of the neck isn't considered. Furthermore the criteria for cup placement are not clearly defined and the ranges for cup orientation are considerably large. This study introduces new recommandations for the combined placement of both total hip components, when both, cup and stem, are considered. This defines the new dynamic combined safe-zone (cSafe-Zone) which gives clear directions for the optimal combined orientation of both components in order to maximize the intended range of movement (iROM) while reducing the risk for prosthetic impingement and dislocation. Material and Methods. The combined safe-zone outlines the area that encloses all component orientations that achieve the predefined iROM without prosthetic impingement. A computerized 3D-model of a total hip prosthesis was established that does systematically test all design parameters semi-automatically in order to identify those component positions that fulfill the predefined conditions. The analysis was carried out for straight stems, anatomic stems and short stems. The iROM is composed of basic movements like flexion/extension, internal/external rotation, ab/adduction and combination of these movements that the patient should reach and that are commonly accepted as physiologic hip movements. The orientation of the cup was varied between 20° and 70° of inclination and −10° of retro- to 40° anteversion. Stem antetorsion was tested from −10° retro- to 40°-antetorsion and CCD-angle from 110° to 150°. Head-size and head/neck ratio were additional parameters. Results. The new combined safe-zone has a dynamic location and has a polygonal outer boundary. It is smaller than Lewinnek's safe-zone. Its size and location within the cup inclination/anteversion diagram depends on the antetorsion and the CCD-angle of the stem. It can be demonstrated that a low-anteverted stem should be combined with a high-anteverted cup and vice versa, i.e. cup anteversion and stem antetorsion are linearly but inversely correlated. This is true for a straight stem as well as for anatomic and for short stems. The size of the cSafe-Zone is largest when the socket is radiographically anteverted between 20° and 25°. The neck/shaft-angle (CCD-angle) and the anatomic design do have a high impact on the preferred antetorsion of the stem. A straight 130°-CCD-stem is best implanted in about 15°+/−4degree of antetorsion while an anatomic 127°-CCD-stem can be implanted in a lower degree of antetorsion. Increasing the head/neck ratio increases the cSafe-Zone too and gives room for a lower cup inclination which increases the jumping distance. The optimal CCD-angle of a straight stem is 127°+/−3 degree. Conclusion. The new combined safe-zone (cSafe-zone) gives well-defined recommendations for cup and stem placement taking into account the dynamic interrelationship between cup and stem. In extending Lewinnek's recommendations it defines how both the cup and the stem should be oriented relative to each other and how the component's orientations are optimized in order to achieve the highest safety against prosthetic impingement while reaching the highest range of movement which is especially important for high-performance materials and in young and active patients

Sagittal stability of the knee is believed to be of significant importance following total knee arthroplasty. We examine four different knee designs at a minimum of twenty-four months postoperatively. Sagittal stability was measured at four degrees of flexion: 0°; 30°; 60°; and 90°, to examine the effect of design on mid-flexion stability. The knee designs included were: the rotating platform LCS design (DePuy); the cruciate sparing Triathlon system (Stryker); SAIPH system (Matortho, UK); and the medial rotating knee design, MRK (Matortho, UK). Following ethical approval, 64 cases were enrolled into the study, 22 male and 42 female. Inclusion criteria included: a minimum of 18 months from surgery; ability to flex beyond 90 degrees; and have no postoperative complications. 18 LCS, 18 MRK, 14 SAIPH and 14 Triathlon knee designs were analysed. Sagittal stability was measured using the KT1000 device. Active range of movement was measured using a hand held goniometer and recorded as was Oxford knee score, WOMAC knee score, SF12 and Kujala patellofemoral knee score. Mean follow-up was 33.7 months postoperative, with a mean age of 72 years. Mean weight was 82.7kgs and height 164cms. There was no significant difference in preoperative demographics between the groups. Mean active post-operative range of motion of the knee was from 2–113° with no significant difference between groups. Sagittal stability was similar in all four groups in full extension; however the MRK and SAIPH designs showed improved stability in the mid-range of flexion (30–90°). Patient satisfaction also showed a similar trend with MRK achieving better patient reported functional outcomes and satisfaction than that of the SAIPH, LCS and Triathlon systems. All four knee designs demonstrated good post-operative range of movement with comparative improvement of patient scores to other reported studies. The MRK and SAIPH knee design showed an improved mid-flexion sagittal stability with better patient reported satisfaction and functional scores

Whilst the use of reverse total shoulder arthroplasty is becoming more common for the treatment of rotator cuff arthropathy, there is still relatively little evidence with regards to its use in complex fractures of the proximal humerus in the elderly. It is increasingly felt to be of use in those patients in whom either internal fixation is not possible due to fracture configuration or bone quality, or in whom there is a rotator cuff deficiency. We report the outcomes of 14 patients with complex 3- or 4-part humeral fractures or delayed presentation of dislocation treated with reverse TSR. Patients were treated within a two year period from January 2011 to December 2013. The average age at time of operation was 75 (50–91 years) with a mean follow-up of 7 months (2–13 months). One patient moved out of area and one lost to follow-up two months following procedure. Reverse TSR was considered a salvage procedure for patients with comminuted proximal humeral fractures or those who presented with irreducible non-acute dislocations. At time of last follow-up all 14 patients were satisfied with the results of their operation and functionally independent with activities of daily living. Range of movement post-operatively was good with mean active forward extension 97° (70–150°) and abduction 101° (80–170°). 43% of patients were pain-free, whilst the remainder only required the use of occasional analgesia. No major post-operative complications were reported. Patients who underwent reverse TSR for dislocation fared better than for those with proximal humeral fractures. The mean active forward extension was 107.5° (90–150°) and abduction 112.5° (90–170°) in the dislocation group (n=5) compared with those who had a fracture in which the forward extension was 91.4° (70–120°) and abduction 95° (80–120°). The results of these patients demonstrate that reverse TSR should be considered in patients with complex proximal humeral fractures or delayed presentation of fractures. It seems to provide consistently excellent pain-relief for patients, with patients either reporting being pain-free or requiring only occasional analgesia. In addition, all patients treated were functionally independent following operation. Range of movement, particularly for those with dislocation, appear good. Further follow-up is required to ensure sustained results but early studies are encouraging

Introduction. The use of reverse total shoulder arthroplasty (RSA) is becoming increasingly common in the treatment of rotator cuff arthropathy. In recent years indications for use have expanded to include elderly patients in whom either internal fixation is not possible due to fracture configuration, poor bone quality, or presence of a rotator cuff deficiency. There is however relatively little evidence to support its use in these circumstances. Objective. This study aims to assess the viability of RSA as a salvage procedure in the treatment of complex proximal humeral fractures or irreducible dislocations, quantified in terms of functional outcome, complication rates and patient reported satisfaction. Methods. All patients presenting between January 2011 and December 2013 with a complex 3- or 4-part humeral fracture or a delayed presentation with an irreducible non-acute dislocation, treated with salvage RSA were eligible for inclusion. All operations were performed in a single centre by one of two specialist upper limb surgeons. Standard deltopectoral approach was performed. Tournier reverse fracture stem with two choices of inserts and graft hole in the stem with proximal hydroxyapatite coating was the implant of choice. All patients and underwent a standardised rehabilitation programme. Clinical outcome was measured at final follow up using (1) patient reported satisfaction, (2) clinician measured range of movement (3) complication rate. Results. A total of 16 patients were eligible for inclusion in this study. Mean age at time of operation was 72.8 years (41–91 years) with a mean follow-up of 7 months (2–13 months). At time of last follow-up 100 per cent of patients were satisfied with the results of their operation and functionally independent with activities of daily living. Mean oxford score was 39 (36–48). Range of movement post-operatively had a mean active forward extension 97° (70–150°) and abduction 101° (80–170°). 43% of patients were pain-free, whilst the remainder only required the use of occasional analgesia. One patient developed heterotrophic ossification post operatively and underwent surgical excision. One patient sustained a peri-prosthetic avulsion fracture at 18months treated non-operatively. Patients who underwent RSA for dislocation fared better than for those with proximal humeral fractures. The mean active forward extension was 107.5° (90–150°) and abduction 112.5° (90–170°) in the dislocation group (N=5) compared with those who had a fracture (N= 11) in which the forward extension was 91.4° (70–120°) and abduction 95° (80–120°). Conclusion. Reverse TSA should be considered in patients with complex proximal humeral fractures or delayed presentation with irreducible dislocation. Early results demonstrate good outcomes in terms of patient satisfaction, pain relief and preservation of function. These early result are encouraging however a further study with longer follow-up is required to confirm sustained benefit

The management of upper limb nonunions can be challenging and often with unpredictable outcomes. In the study we present the results of treatment of upper limb nonunions treated in our institution with BMP-7 biological enhancement. Between 2004 and 2011 all consecutive patients who met the inclusion criteria were followed up prospectively. Union was assessed with regular radiological assessment. At the final follow up clinical assessment included the disabilities of the Arm, Shoulder and Hand (DASH) score, range of movement and patient satisfaction. The mean follow up was 12 months (12–36). In total 42 patients met the inclusion criteria with a mean age of 47. Anatomical distribution of the nonunion sites included 19 cases of mid/proximal radius/ulna, 14 humerus, 6 distal radius and 3 clavicles. 5 patients had septic nonunion, 35 had atrophic nonunion, 11 had previous open fractures, and 10 had bone loss (range 1–3 cm). The mean number of operations performed and the mean time from injury to BMP application was 1.5 and 26 months, respectively. 40 patients had both clinical and radiological union whereas 2 had partial radiological union but a pain free range of motion. BMP was applied in isolation in 1 case and 41 cases the application was combined with autologous bone grafting. The range of movement of the affected limb, DASH score and patient satisfaction were optimum at the final follow up. This study supports the use of BMP-7 as a bone stimulating adjunct for the treatment of complex and challenging upper limb nonunions

We present the results of a bi-centre, retrospective study examining the clinical, functional and radiological outcomes of distal radius fracture fixation with the Aptus locking plates and Tri-Lock® variable angle locking screws. We assessed 61 patients with distal radius fractures with a minimum of six months follow-up. Functional assessment was made using the DASH score. We measured wrist range of movement and grip strength, and reviewed radiographs to assess restoration of anatomy, fracture union and complications. All fractures united within six weeks. Mean ranges of movement and grip strength were only mildly restricted compared to the normal wrist. The mean DASH score was 18.2. Seven patients had screws misplaced outside the distal radius although 3 of these remained asymptomatic. Five other patients developed minor complications. Variable angle locking systems benefit from flexibility of implant positioning and may allow enhanced inter-fragmentary reduction for accurate fixation of intra-articular fractures. However, variable-angle systems may lead to increased rates of screw misplacement