We report the management of the acquired claw-toe deformity in ten adults. Each patient developed a varying number of claw toes at a mean interval of six months after the time of injury. There was clinical evidence of an acute compartment syndrome in one case. The clawing occurred at the start of heel-rise in the stance phase of gait. At this stage the patients complained of increasing pain and pressure on the tips of the toes. The deformities were corrected by lengthening flexor hallucis longus and flexor digitorum longus alone or in combination. The presence of variable intertendinous digitations between the tendons of flexor hallucis longus and flexor digitorum longus means that in some cases release of flexor hallucis longus alone may correct clawing of lesser toes

We split 100 porcine flexor tendons into five groups of 20 tendons for repair. Three groups were repaired using the Pennington modified Kessler technique, the cruciate or the Savage technique, one using one new device per tendon and the other with two new devices per tendon. Half of the tendons received supplemental circumferential Silfverskiöld type B cross-stitch. The repairs were loaded to failure and a record made of their bulk, the force required to produce a 3 mm gap, the maximum force applied before failure and the stiffness. When only one device was used repairs were equivalent to the Pennington modified Kessler for all parameters except the force to produce a 3 mm gap when supplemented with a circumferential repair, which was equivalent to the cruciate. When two devices were used the repair strength was equivalent to the cruciate repair, and when the two-device repair was supplemented with a circumferential suture the force to produce a 3 mm gap was equivalent to that of the Savage six-strand technique

Seven pectoralis major transfers in children suffering from bilateral paralysis of elbow flexion due to arthrogryposis or to trauma are reported. A technique is described in which the muscle is mobilised from the clavicle to allow the tendon of insertion to be attached to the biceps tendon at the elbow. The biceps tendon was found to be present and could be mobilised forwards in all the arthrogrypotic elbows. Subjectively, the results were considered by patients or parents to be very good in six cases and fair in one. Elbow flexion power against gravity and against some resistance was achieved in all patients except one. The overall function was very good in one elbow, good in two, fair in three and poor in only one. The merits of the various procedures described for the restoration of elbow flexion in arthrogryposis are discussed. It is concluded that total pectoralis major transfer by the method described here has given the best results

We describe our experience in the reduction of dislocation of the hip secondary to developmental dysplasia using ultrasound-guided gradual reduction using flexion and abduction continuous traction (FACT-R). During a period of 13 years we treated 208 Suzuki type B or C complete dislocations of the hip in 202 children with a mean age of four months (0 to 11). The mean follow-up was 9.1 years (five to 16). The rate of reduction was 99.0%. There were no recurrent dislocations, and the rate of avascular necrosis of the femoral head was 1.0%. The rate of secondary surgery for residual acetabular dysplasia was 19.2%, and this was significantly higher in those children in whom the initial treatment was delayed or if other previous treatments had failed (p = 0.00045). The duration of FACT-R was significantly longer in severe dislocations (p = 0.001) or if previous treatments had failed (p = 0.018). . This new method of treatment is effective and safe in these difficult cases and offers outcomes comparable to or better than those of standard methods. Cite this article: Bone Joint J 2015;97-B:405–11

We analysed the axis of movement in the normal elbow during flexion in vivo using radiostereometric analysis (RSA). The results show an intraindividual variation in the inclination of the axis ranging from 2.1° to 14.3° in the frontal and from 1.6° to 9.8° in the horizontal plane analysed at 30° increments. The inclination of the mean axis of rotation varied within a range of 12.7° in the frontal and 4.6° in the horizontal plane. In both planes, the mean axes were located close to a line joining the centres of the trochlea and capitellum. The intra- and interindividual variations of the axes of flexion of the elbow were greater than previously reported. These factors should be considered in the development of elbow prostheses

Achieving deep flexion after total knee replacement remains a challenge. In this study we compared the soft-tissue tension and tibiofemoral force in a mobile-bearing posterior cruciate ligament-sacrificing total knee replacement, using equal flexion and extension gaps, and with the gaps increased by 2 mm each. The tests were conducted during passive movement in five cadaver knees, and measurements of strain were made simultaneously in the collateral ligaments. The tibiofemoral force was measured using a customised mini-force plate in the tibial tray. Measurements of collateral ligament strain were not very sensitive to changes in the gap ratio, but tibiofemoral force measurements were. Tibiofemoral force was decreased by a mean of 40% (. sd. 10.7) after 90° of knee flexion when the flexion gap was increased by 2 mm. Increasing the extension gap by 2 mm affected the force only in full extension. Because increasing the range of flexion after total knee replacement beyond 110° is a widely-held goal, small increases in the flexion gap warrant further investigation

We describe a symptomatic, progressive restriction of knee flexion due to an accessory quadriceps femoris in a nine-year-old girl. There was no history or findings of post-injection fibrosis, nor any obvious swelling of the affected quadriceps. At arthroscopy no intra-articular pathology was found. An accessory ‘quinticeps femoris’ was diagnosed by ultrasonography and MRI. Following excision of the muscle and tendon full flexion of the knee was regained and there was no recurrence of the contracture

We present a system for treatment by controlled motion after repair of flexor tendons in the hand. This Washington regimen incorporates both controlled active extension against passive flexion by rubber band and the use of controlled passive extension and flexion. We utilise the Brooke Army Hospital modification of the rubber band passive flexion splint; this provides for maximal excursion of the tendon with full passive flexion of the finger. The 66 patients (78 fingers) who form the basis of this study all sustained complete laceration of the flexor profundus and superficialis tendons in "no man's land". Results were evaluated by the Strickland formula of total active motion (TAM) of the proximal and distal interphalangeal joints. Sixty-two fingers (80%) were rated "excellent", 14 fingers (18%) were "good", two fingers (2%) were "fair", none was rated "poor". Our regimen of controlled motion rehabilitation has also been applied with equal success to cases of flexor tendon grafting

Aims. Animal models have been developed that allow simulation of post-traumatic joint contracture. One such model involves contracture-forming surgery followed by surgical capsular release. This model allows testing of antifibrotic agents, such as rosiglitazone. Methods. A total of 20 rabbits underwent contracture-forming surgery. Eight weeks later, the animals underwent a surgical capsular release. Ten animals received rosiglitazone (intramuscular initially, then orally). The animals were sacrificed following 16 weeks of free cage mobilisation. The joints were tested biomechanically, and the posterior capsule was assessed histologically and via genetic microarray analysis. Results. There was no significant difference in post-traumatic contracture between the rosiglitazone and control groups (33° (standard deviation (. sd. ) 11) vs 37° (. sd. 14), respectively; p = 0.4). There was no difference in number or percentage of myofibroblasts. Importantly, there were ten genes and 17 pathways that were significantly modulated by rosiglitazone in the posterior capsule. Discussion. Rosiglitazone significantly altered the genetic expression of the posterior capsular tissue in a rabbit model, with ten genes and 17 pathways demonstrating significant modulation. However, there was no significant effect on biomechanical or histological properties. Cite this article: M. P. Abdel. Effectiveness of rosiglitazone in reducing flexion contracture in a rabbit model of arthrofibrosis with surgical capsular release: A biomechanical, histological, and genetic analysis. Bone Joint Res 2016;5:11–17. doi: 10.1302/2046-3758.51.2000593

Total knee replacement and high tibial osteotomy are common orthopaedic operations with low complication rates. Such surgery is in close proximity to the popliteal artery (PA), the behaviour of which during flexion of the knee is poorly understood. We used Duplex ultrasonography to determine the distance of the PA from the posterior tibial surface at 0° and 90° of flexion in 100 knees. When the knee was flexed the PA was closer to the posterior tibial surface at 1 to 1.5 cm below the joint line in 24% and at 1.5 to 2 cm below the joint line in 15%. There was a high branching anterior tibal artery in 6% of knees. We provide an anatomical account to help to explain our findings by using cadaver dissections, arteriography and static MRI studies

Aims. The aim of this study was to investigate the feasibility of application of a 3D-printed megaprosthesis with hemiarthroplasty design for defects of the distal humerus or proximal ulna following tumour resection. Methods. From June 2018 to January 2020, 13 patients with aggressive or malignant tumours involving the distal humerus (n = 8) or proximal ulna (n = 5) were treated by en bloc resection and reconstruction with a 3D-printed megaprosthesis with hemiarthroplasty, designed in our centre. In this paper, we summarize the baseline and operative data, oncological outcome, complication profiles, and functional status of these patients. Results. Preparation of the prosthesis was a mean of 8.0 days (SD 1.5), during which time no patients experienced tumour progression. The mean operating time and intraoperative blood loss were 158.1 minutes (SD 67.6) and 176.9 ml (SD 187.8), respectively. All of the prostheses were implanted successfully. During a mean follow-up of 25.7 months (SD 7.8), no patients died, but four had complications (two superficial wound problems, one temporary palsy of radial nerve, and one dislocation). No aseptic loosening, structural failure, infection, heterotopic ossification, or degenerative arthritis was seen in this study. The mean flexion of the elbow was 119.6° (SD 15.9°) and the mean extension lag was 11.9° (SD 13.8°). The mean Musculoskeletal Tumor Society 93 score and Mayo Elbow Performance Score were 28.4 (SD 0.9) and 97.7 (SD 4.4), respectively. Conclusion. The custom-made, 3D-printed megaprosthesis with hemiarthroplasty is a feasible option for functional reconstruction after resection of a tumour in the distal humerus or proximal ulna. Cite this article: Bone Joint J 2022;104-B(6):747–757

The treatment of osteonecrosis of the femoral head (FHN) is controversial. It mainly occurs in young patients in whom total hip replacement is best avoided because of an increased risk of revision. The objective of this long-term follow-up study was to evaluate the outcome of intertrochanteric flexion osteotomy as a hip joint preserving operation for FHN. Over a 19-year period we carried out 70 intertrochanteric flexion osteotomies for FHN in 64 patients. The mean follow-up was 10.4 years (3.0 to 20.3). The overall mean Harris hip score increased from 51 points preoperatively to 71 points postoperatively. Six patients (9%) developed early postoperative complications. A total of 19 hips (27%) underwent total hip arthroplasty at a mean of 8.7 years after osteotomy. The five-year survival rate was 90%. Survival rates of hips in Ficat stage 2 were higher than those in stages 3 or 4. Hips with a preoperative necrotic angle of < 200° had a better survival probability than those with a necrotic angle > 200°. Our findings suggest that flexion osteotomy is a safe and effective procedure in Ficat stage 2 and 3 FHN, preferably with a necrotic angle of < 200°

We have studied the concept of posterior condylar offset and the importance of its restoration on the maximum range of knee flexion after posterior-cruciate-ligament-retaining total knee replacement (TKR). We measured the difference in the posterior condylar offset before and one year after operation in 69 patients who had undergone a primary cruciate-sacrificing mobile bearing TKR by one surgeon using the same implant and a standardised operating technique. In all the patients true pre- and post-operative lateral radiographs had been taken. The mean pre- and post-operative posterior condylar offset was 25.9 mm (21 to 35) and 26.9 mm (21 to 34), respectively. The mean difference in posterior condylar offset was + 1 mm (−6 to +5). The mean pre-operative knee flexion was 111° (62° to 146°) and at one year postoperatively, it was 107° (51° to 137°). There was no statistical correlation between the change in knee flexion and the difference in the posterior condylar offset after TKR (Pearson correlation coefficient r = −0.06, p = 0.69)

Aims. One of the main causes of tibial revision surgery for total knee arthroplasty is aseptic loosening. Therefore, stable fixation between the tibial component and the cement, and between the tibial component and the bone, is essential. A factor that could influence the implant stability is the implant design, with its different variations. In an existing implant system, the tibial component was modified by adding cement pockets. The aim of this experimental in vitro study was to investigate whether additional cement pockets on the underside of the tibial component could improve implant stability. The relative motion between implant and bone, the maximum pull-out force, the tibial cement mantle, and a possible path from the bone marrow to the metal-cement interface were determined. Methods. A tibial component with (group S: Attune S+) and without (group A: Attune) additional cement pockets was implanted in 15 fresh-frozen human leg pairs. The relative motion was determined under dynamic loading (extension-flexion 20° to 50°, load-level 1,200 to 2,100 N) with subsequent determination of the maximum pull-out force. In addition, the cement mantle was analyzed radiologically for possible defects, the tibia base cement adhesion, and preoperative bone mineral density (BMD). Results. The BMD showed no statistically significant difference between both groups. Group A showed for all load levels significantly higher maximum relative motion compared to group S for 20° and 50° flexion. Group S improved the maximum failure load significantly compared to group A without additional cement pockets. Group S showed a significantly increased cement adhesion compared to group A. The cement penetration and cement mantle defect analysis showed no significant differences between both groups. Conclusion. From a biomechanical point of view, the additional cement pockets of the component have improved the fixation performance of the implant. Cite this article: Bone Joint Res 2022;11(4):229–238

Thirty-five patients with habitual dislocation of the patella in flexion were reviewed; eight were bilaterally affected. Each had undergone quadricepsplasty with an average follow-up of 6 years 9 months. Bands or contractures, most commonly in vastus lateralis, the iliotibial tract and rectus femoris were seen in each. Redislocation was seen in 12 knees. At review, 79% of the knees were normal. Quadriceps lengthening is an essential part of treatment and must be performed proximally. Causes for failure include reformation of contractures and failure to correct the initial abnormality fully

One of the objectives of knee replacement is to correct flexion deformity, the frequent consequence of rheumatoid arthritis and osteoarthritis. A review of 697 primary and revision replacements carried out between 1969 and 1985 and followed up from 1 to 16 years found that such deformity was present in 61% of knees before the primary operation. Replacement reduced this to 17% and the improvement was usually maintained. The deformity was present in only 21% of the replacements which required revision and the second operation reduced this to 8%. Flexion contractures affected rheumatoid knees more often and more seriously than osteoarthritic knees, but arthroplasty was more successful in correcting the deformity in the former. All of the 11 types of prosthesis used achieved some degree of correction, but the Walldius hinge and the variants of the Freeman condylar design were the most successful. Surprisingly, the best outcome, in terms of pain and reduced need for revision, was found in the rheumatoid knees most seriously deformed before operation, but this association was absent in the osteoarthritic knees. Postoperative deformity in knees without pain or extreme weakness did not appear to influence the patients' ability to walk or to use stairs or a chair, as measured by unexacting tests in the clinic

We report three complete ruptures and one partial rupture of the flexor pollicis longus tendon in association with the insertion of a volar plate for the treatment of fracture of the distal radius. Rupture was associated with the chronic use of steroids

We report the results of transfer of the long toe flexors and lengthening of the calcaneal tendon in 33 patients with equinovarus deformity requiring orthoses after a stroke. Review of 29 patients more than two years after surgery showed that 21 were able to walk without an orthosis. Equinovarus deformity had recurred in six patients and hammer toe in 11, but walking ability without bracing was still better in seven of these. Results are improved by the release of the short toe flexors

We report the case of a child with cerebral palsy and spastic diplegia treated for bilateral fixed flexion of the knee by bilateral hamstring lengthening. An attempt to straighten the legs from 90 degrees to 20 degrees flexion damaged the sciatic nerve. There are no objective means of estimating how much deformity can be reduced safely. We present a method of calculating the extra strain in the sciatic nerve produced by reducing a flexion deformity. The result, combined with clinical judgement, provides guidelines for safe corrective surgery

We have studied the kinematics of the knee in the sagittal plane, using a four-bar linkage as model, and assuming that a "neutral fibre" in each ligament remains isometric throughout flexion. We devised a computer program to calculate the distance separating any pair of points, one on each bone, for various cruciate attachments at various angles of flexion. The parameters for the linkage in four cadaveric knees were obtained by marking the centre of attachment of the cruciate ligaments with tacks and taking lateral radiographs. The movements of the bones were then calculated, in the computer model, for various attachments of "replacement" ligament fibres, the distance between the attachment sites being plotted against the angle of flexion. It was then possible to define zones around the isometric attachment points within which changes in length would be predictable. Our results show that the position of the femoral sites of attachment of both anterior and posterior cruciate replacement was more critical than that of the tibial attachments