Aims. This study aimed to use intraoperative free electromyography to examine how the placement of a retractor at different positions along the anterior acetabular wall may affect the femoral nerve during total hip arthroplasty (THA) when undertaken using the direct anterior approach (THA-DAA). Methods. Intraoperative free electromyography was performed during primary THA-DAA in 82 patients (94 hips). The highest position of the anterior acetabular wall was defined as the “12 o’clock” position (middle position) when the patient was in supine position. After exposure of the acetabulum, a retractor was sequentially placed at the ten, 11, 12, one, and two o’clock positions (right hip; from superior to inferior positions). Action potentials in the femoral nerve were monitored with each placement, and the incidence of positive reactions (defined as explosive, frequent, or continuous action potentials, indicating that the nerve was being compressed) were recorded as the primary outcome. Secondary outcomes included the incidence of positive reactions caused by removing the femoral head, and by placing a retractor during femoral exposure; and the incidence of femoral nerve palsy, as detected using manual testing of the strength of the quadriceps muscle. Results. Positive reactions were significantly less frequent when the retractor was placed at the ten (15/94; 16.0%), 11 (12/94; 12.8%), or 12 o’clock positions (19/94; 20.2%), than at the one (37/94; 39.4%) or two o’clock positions (39/94; 41.5%) (p < 0.050). Positive reactions also occurred when the femoral head was removed (28/94; 29.8%), and when a retractor was placed around the proximal femur (34/94; 36.2%) or medial femur (27/94; 28.7%) during femoral exposure. After surgery, no patient had reduced strength in the quadriceps muscle. Conclusion. Placing the anterior acetabular retractor at the one or two o’clock positions (right hip; inferior positions) during THA-DAA can increase the rate of electromyographic signal changes in the femoral nerve. Thus, placing a retractor in these positions may increased the risk of the development of a femoral nerve palsy. Cite this article: Bone Joint J 2022;104-B(2):193–199

Upper limb amputations, ranging from transhumeral to partial hand, can be devastating for patients, their families, and society. Modern paradigm shifts have focused on reconstructive options after upper extremity limb loss, rather than considering the amputation an ablative procedure. Surgical advancements such as targeted muscle reinnervation and regenerative peripheral nerve interface, in combination with technological development of modern prosthetics, have expanded options for patients after amputation. In the near future, advances such as osseointegration, implantable myoelectric sensors, and implantable nerve cuffs may become more widely used and may expand the options for prosthetic integration, myoelectric signal detection, and restoration of sensation. This review summarizes the current advancements in surgical techniques and prosthetics for upper limb amputees.

Cite this article: Bone Joint J 2021;103-B(3):430–439.

Aims

We aimed to address the question on whether there is a place for shoulder stabilization surgery in patients who had voluntary posterior instability starting in childhood and adolescence, and later becoming involuntary and uncontrollable.

Aims

The purpose of this study was to determine the functional outcome and implant survivorship of mobile-bearing total ankle arthroplasty (TAA) performed by a single surgeon.

The aim of this study was to examine the loading of the other joints of the lower limb in patients with unilateral osteoarthritis (OA) of the knee. We recruited 20 patients with no other symptoms or deformity in the lower limbs from a consecutive cohort of patients awaiting knee replacement. Gait analysis and electromyographic recordings were performed to determine moments at both knees and hips, and contraction patterns in the medial and lateral quadriceps and hamstrings bilaterally. The speed of gait was reduced in the group with OA compared with the controls, but there were only minor differences in stance times between the limbs. Patients with OA of the knee had significant increases in adduction moment impulse at both knees and the contralateral hip (adjusted p-values: affected knee: p < 0.01, unaffected knee p = 0.048, contralateral hip p = 0.03), and significantly increased muscular co-contraction bilaterally compared with controls (all comparisons for co-contraction, p < 0.01). The other major weight-bearing joints are at risk from abnormal biomechanics in patients with unilateral OA of the knee. Cite this article: Bone Joint J 2013;95-B:348–53

The purpose of this study was to establish whether exploration and neurolysis is an effective method of treating neuropathic pain in patients with a sciatic nerve palsy after total hip replacement (THR). A total of 56 patients who had undergone this surgery at our hospital between September 1999 and September 2010 were retrospectively identified. There were 42 women and 14 men with a mean age at exploration of 61.2 years (28 to 80). The sciatic nerve palsy had been sustained by 46 of the patients during a primary THR, five during a revision THR and five patients during hip resurfacing. The mean pre-operative visual analogue scale (VAS) pain score was 7.59 (2 to 10), the mean post-operative VAS was 3.77 (0 to 10), with a resulting mean improvement of 3.82 (0 to 10). The pre- and post-neurolysis VAS scores were significantly different (p < 0.001). Based on the findings of our study, we recommend this form of surgery over conservative management in patients with neuropathic pain associated with a sciatic nerve palsy after THR.

Cite this article: Bone Joint J 2013;95-B:20–2.

The current indications for functional restoration of extension of the knee following quadriceps resection or loss require reappraisal. The contribution of pedicled and free functional muscle transfer is likely to be over-emphasised in many studies, with good functional outcomes predominantly reported only in the context of cases with residual quadriceps function. In cases with total quadriceps resection or loss, all forms of reconstruction perform poorly. Furthermore, in smaller resections with loss of two or fewer components of the quadriceps, minimal impairment of function occurs in the absence of functional reconstruction, suggesting that functional restoration may not be warranted. Thus there is a paradox in the current approach to quadriceps reconstruction, in that small resections are likely to be over-treated and large resections remain under-treated.

This review suggests a shift is required in the approach and rationale for reconstructing functional extension of the knee after quadriceps resection or loss. A classification based on current evidence is suggested that emphasises more clearly the indications and rationale for functional transfers.

We present the electromyographic (EMG) results ten years after open decompression of the median nerve at the wrist and compare them with the clinical and functional outcomes as judged by Levine’s Questionnaire. This retrospective study evaluated 115 patients who had undergone carpal tunnel decompression at a mean of 10.47 years (9.24 to 11.36) previously. A positive EMG diagnosis was found in 77 patients (67%), including those who were asymptomatic at ten years. It is necessary to include both clinical and functional results as well as electromyographic testing in the long-term evaluation of patients who have undergone carpal tunnel decompression particularly in those in whom revision surgery is being considered. In doubtful cases or when there are differing outcomes, self-administered scales such as Levine’s Questionnaire should prevail over EMG results when deciding on the need for revision surgery

We describe a 23-year-old woman with neuritis ossificans involving the tibial, common peroneal and lateral sural nerves. She presented with chronic debilitating posterior knee pain. An MRI scan showed masses in these nerves, biopsy of which revealed a histological diagnosis of neuritis ossificans. Treatment with OxyContin and Neurotin for two years resulted in resolution of symptoms. Follow-up MRI demonstrated a resolution of two of the three masses. There was a persistent area of ossification without associated oedema in the common peroneal nerve. Neuritis ossificans has the histological appearance of myositis ossificans and follows a similar clinical course. The success of conservative treatment in this case suggests that the potential complications of surgical excision can be avoided.

The transfer of part of the ulnar nerve to the musculocutaneous nerve, first described by Oberlin, can restore flexion of the elbow following brachial plexus injury. In this study we evaluated the additional benefits and effectiveness of quantitative electrodiagnosis to select a donor fascicle. Eight patients who had undergone transfer of a simple fascicle of the ulnar nerve to the motor branch of the musculocutaneous nerve were evaluated. In two early patients electrodiagnosis had not been used. In the remaining six patients, however, all fascicles of the ulnar nerve were separated and electrodiagnosis was performed after stimulation with a commercially available electromyographic system. In these procedures, recording electrodes were placed in flexor carpi ulnaris and the first dorsal interosseous. A single fascicle in the flexor carpi ulnaris in which a high amplitude had been recorded was selected as a donor and transferred to the musculocutaneous nerve. In the two patients who had not undergone electrodiagnosis, the recovery of biceps proved insufficient for normal use. Conversely, in the six patients in whom quantitative electrodiagnosis was used, elbow flexion recovered to an M4 level. Quantitative intra-operative electrodiagnosis is an effective method of selecting a favourable donor fascicle during the Oberlin procedure. Moreover, fascicles showing a high-amplitude in reading flexor carpi ulnaris are donor nerves that can restore normal elbow flexion without intrinsic loss

The integrity of the spinal accessory nerve is fundamental to thoracoscapular function and essential for scapulohumeral rhythm. This nerve is vulnerable along its superficial course. This study assessed the delay in diagnosis and referral for management of damage to this nerve, clarified its anatomical course and function, and documented the results of repair. From examination of our records, 111 patients with lesions of the spinal accessory nerve were treated between 1984 and 2007. In 89 patients (80.2%) the damage was iatropathic. Recognition and referral were seldom made by the surgeon responsible for the injury, leading to a marked delay in instituting treatment. Most referrals were made for painful loss of shoulder function. The clinical diagnosis is straightforward. There is a characteristic downward and lateral displacement of the scapula, with narrowing of the inferior scapulohumeral angle and loss of function, with pain commonly present. In all, 80 nerves were explored and 65 were repaired. The course of the spinal accessory nerve in relation to the sternocleidomastoid muscle was constant, with branches from the cervical plexus rarely conveying motor fibres. Damage to the nerve was predominantly posterior to this muscle.

Despite the delay, the results of repair were surprising, with early relief of pain, implying a neuropathic source, which preceded generally good recovery of muscle function.

This study assessed if transfer of the extensor hallucis longus is a valid alternative treatment to split transfer of the tibialis anterior tendon in adult hemiplegic patients without overactivity of the tibialis anterior.

One group of 15 patients had overactivity of tibialis anterior in the swing phase, and underwent the split transfer. A further group of 14 patients had no overactivity of tibialis anterior, and underwent transfer of extensor hallucis longus. All patients had lengthening of the tendo Achillis and tenotomies of the toe flexors. All were evaluated clinically and by three-dimensional gait analysis pre- and at one year after surgery. At this time both groups showed significant reduction of disability in walking. Gait speed, stride length and paretic propulsion had improved significantly in both groups. Dorsiflexion in the swing phase, the step length of the healthy limb and the step width improved in both groups, but only reached statistical significance in the patients with transfer of the extensor hallucis longus. There were no differences between the groups at one year after operation.

When combined with lengthening of the tendo Achillis, transfer of the extensor hallucis longus can be a valid alternative to split transfer of the tibialis anterior tendon to correct equinovarus foot deformity in patients without overactivity of tibialis anterior.

An internal rotation contracture is a common complication of obstetric brachial plexus palsy. We describe the operative treatment of seven children with a recurrent internal rotation contracture of the shoulder following earlier corrective surgery which included subscapularis slide and latissimus dorsi transfer. We performed z-lengthening of the tendon of the subscapularis muscle and transferred the lower trapezius muscle to the infraspinatus tendon. Two years postoperatively the mean gain in active external rotation was 47.1°, which increased to 54.3° at four years.

Lengthening of the tendon of subcapularis and lower trapezius transfer to infraspinatus improved the range of active external rotation in patients who had previously had surgery for an internal rotation contracture.

Ulnar neuropathy presents as a complication in 5% to 10% of total elbow replacements, but subsequent ulnar neurolysis is rarely performed. Little information is available on the surgical management of persistent ulnar neuropathy after elbow replacement. We describe our experience with the surgical management of this problem.

Of 1607 total elbow replacements performed at our institution between January 1969 and December 2004, eight patients (0.5%) had a further operation for persistent or progressive ulnar neuropathy. At a mean follow-up of 9.2 years (3.1 to 21.7) six were clinically improved and satisfied with their outcome, although, only four had complete recovery. When transposition was performed on a previously untransposed nerve the rate of recovery was 75%, but this was reduced to 25% if the nerve had been transposed at the time of the replacement.

Hallux rigidus was first described in 1887. Many aetiological factors have been postulated, but none has been supported by scientific evidence. We have examined the static and dynamic imbalances in the first metatarsophalangeal joint which we postulated could be the cause of this condition. We performed a finite-element analysis study on a male subject and calculated a mathematical model of the joint when subjected to both normal and abnormal physiological loads.

The results gave statistically significant evidence for an increase in tension of the plantar fascia as the cause of abnormal stress on the articular cartilage rather than mismatch of the articular surfaces or subclinical muscle contractures. Our study indicated a clinical potential cause of hallux rigidus and challenged the many aetiological theories. It could influence the choice of surgical procedure for the treatment of early grades of hallux rigidus.

We reviewed the outcome in 24 children with bilateral spastic cerebral palsy aged seven years or younger for whom surgery was recommended between 1999 and 2005 following gait analysis. A total of 13 children (operative group) had surgery and the remaining 11 (control group) did not, for family or administrative reasons. The operative group had at least two post-operative gait analyses at yearly intervals, with eight children having a third and six children a fourth. The control group had a second analysis after a mean interval of 1.5 years (95% confidence interval 1.1 to 1.9). In the operative group, the Gillette gait index, the ranges of movement in the lower limb joint and knee extension in stance improved following surgery, and this was maintained overall at the second post-operative analysis. The minimum knee flexion in stance in the control group increased between analyses.

These results suggest that surgical intervention in selected children can result in improvements in gait and function in the short to medium term compared with non-operative management.

The aim of this study was to define the microcirculation of the normal rotator cuff during arthroscopic surgery and investigate whether it is altered in diseased cuff tissue.

Blood flow was measured intra-operatively by laser Doppler flowmetry. We investigated six different zones of each rotator cuff during the arthroscopic examination of 56 consecutive patients undergoing investigation for impingement, cuff tears or instability; there were 336 measurements overall.

The mean laser Doppler flowmetry flux was significantly higher at the edges of the tear in torn cuffs (43.1, 95% confidence interval (CI) 37.8 to 48.4) compared with normal cuffs (32.8, 95% CI 27.4 to 38.1; p = 0.0089). It was significantly lower across all anatomical locations in cuffs with impingement (25.4, 95% CI 22.4 to 28.5) compared with normal cuffs (p = 0.0196), and significantly lower in cuffs with impingement compared with torn cuffs (p < 0.0001).

Laser Doppler flowmetry analysis of the rotator cuff blood supply indicated a significant difference between the vascularity of the normal and the pathological rotator cuff. We were unable to demonstrate a functional hypoperfusion area or so-called ‘critical zone’ in the normal cuff. The measured flux decreases with advancing impingement, but there is a substantial increase at the edges of rotator cuff tears. This might reflect an attempt at repair.

After establishing anatomical feasibility, functional reconstruction to replace the anterolateral part of the deltoid was performed in 20 consecutive patients with irreversible deltoid paralysis using the sternoclavicular portion of the pectoralis major muscle. The indication for reconstruction was deltoid deficiency combined with massive rotator cuff tear in 11 patients, brachial plexus palsy in seven, and an isolated axillary nerve lesion in two. All patients were followed clinically and radiologically for a mean of 70 months (24 to 125). The mean gender-adjusted Constant score increased from 28% (15% to 54%) to 51% (19% to 83%). Forward elevation improved by a mean of 37°, abduction by 30° and external rotation by 9°.

The pectoralis inverse plasty may be used as a salvage procedure in irreversible deltoid deficiency, providing subjectively satisfying results. Active forward elevation and abduction can be significantly improved.

Reversed shoulder prostheses are increasingly being used for the treatment of glenohumeral arthropathy associated with a deficient rotator cuff. These non-anatomical implants attempt to balance the joint forces by means of a semi-constrained articular surface and a medialised centre of rotation. A finite element model was used to compare a reversed prosthesis with an anatomical implant. Active abduction was simulated from 0° to 150° of elevation. With the anatomical prosthesis, the joint force almost reached the equivalence of body weight. The joint force was half this for the reversed prosthesis. The direction of force was much more vertically aligned for the reverse prosthesis, in the first 90° of abduction. With the reversed prosthesis, abduction was possible without rotator cuff muscles and required 20% less deltoid force to achieve it.

This force analysis confirms the potential mechanical advantage of reversed prostheses when rotator cuff muscles are deficient.

Neuralgic amyotrophy is an uncommon condition characterised by the acute onset of severe pain in the shoulder and arm, followed by weakness and atrophy of the affected muscles, and sensory loss as the pain subsides. The diversity of its clinical manifestations means that it may present to a variety of different specialties within medicine. This article describes the epidemiology, aetiopathogenesis, clinical features, differential diagnoses, investigations, treatment, course and prognosis of the condition.