Pedicle Subtraction Osteotomy in Lateral Position: A New Strategy for Correcting Severe Thoracolumbar Kyphosis Combined with Hip Flexion Contracture in Ankylosing Spondylitis

ObjectiveTo describe spinal osteotomy in lateral position, which might be a new strategy for correcting thoracolumbar kyphotic deformity combined with severe hip flexion contracture, and to present two cases in which this method was successfully performed.MethodsSpinal osteotomies in lateral position were performed in two patients with severe thoracolumbar kyphosis combined with hip flexion contracture, which was not suitable for operation in the prone position. Case 1: a 33‐year‐old female AS patient still had severe hip flexion contracture due to poor rehabilitation after total hip replacement (THR). The range of movement of the hip was only about 15° in right and 10° in left. Pre‐operativethoracic kyphosis (TK), thoracolumbar kyphosis (TLK), lumbar lordosis (LL), and sagittal vertical axis (SVA) were 52.4°, 49.1°, 42.7°, and 315 mm, respectively. Pedicle subtraction osteotomy (PSO) at L3 was performed in the lateral position. The eggshell procedure was used during osteotomy. Case 2: a 45‐year‐old male AS patient presented coexisting rigid thoracolumbar kyphosis and hip flexion contracture. The range of movement of the hip was only about 20° in right and 25° in left. Pre‐operativeTK, TLK, LL and SVA were 34.9°, 66.8°, 58.8° and 290.8 mm, respectively. PSO at L₂ was performed in lateral position. The eggshell procedure was also used.ResultsSagittal malalignments of both patients were greatly improved. For case 1, the total operation time was 5.5 h. The blood loss was 1500 mL and the amount of allogeneic blood transfusion was 1580 mL during the operation. SVA was reduced to 127 mm and LL decreased from preoperative 42.7° to −28.4°. The correction angle through L₃ was 34.7° and the correction angle through the osteotomy segment was 62.9°. For case 2, the duration of surgery was 6.5 h. The operative blood loss was 2000 mL and the total amount of blood transfusion was 2020 mL. SVA was reduced to 209.8 mm and LL decreased from preoperative 58.8° to 9.2°.The correction angle through L₂ was 37.1° and the correction angle through the osteotomy segment was 55°. No intra‐operative or post‐operative complications were observed. Six months after PSO, case 1 had good posture for standing and sitting. The case 2 underwent bilateral THRs nine months after PSO.ConclusionPSO could be performed in the lateral position successfully. For AS patients who cannot be placed in the prone position due to coexisting severe thoracolumbar kyphosis and hip flexion contracture, performing spinal osteotomy in the lateral position as the first step is an alternative.     

Evaluation of Tension at Median and Ulnar Nerve Repairs at the Wrist in a Cadaveric Model

Background: Median and ulnar nerve lacerations at the wrist are often combined with zone 5 tendon injury. The inability to provide early range of motion leads to increased adhesions. Current therapy protocols recommend the wrist be held in 30° of flexion post operatively to protect the nerve repair. However, if tension and elongation across the nerve repair stay under a critical level in less wrist flexion, postoperative splinting in more extension could allow for better tendon excursion and less adhesions. Methods: Six cadaveric specimens were used. After appropriate dissection, the median and ulnar nerves were transected and repaired with a single 10-0 nylon suture. The wrist was ranged from 30° flexion to 45° extension to see if the repair would fail. Next, an epineural repair was accomplished with 9-0 nylon suture. The percent elongation along the nerve repair was measured at set increments from 30° flexion to 45° extension. Results: In all 6 specimens, median and ulnar nerve repairs with a single 10-0 nylon suture did not fail with wrist range of motion from 30° flexion to 45° extension. Mean percent elongation stayed under critical levels in up to 30° of extension. Conclusions: Both median and ulnar nerve repairs stayed under critical levels of tension and elongation in up to 30° of wrist extension. We believe it is possible to be more aggressive with wrist positioning in wrist level median and ulnar nerve repairs.     

Effects of Judet Quadricepsplasty in the Treatment of Post‐traumatic Extension Contracture of the Knee

ObjectiveTo investigate the clinical outcomes and the affecting factors of Judet''s quadricepsplasty on the stiffness of post‐traumatic knee flexion.MethodsA retrospective survey was analyzed from June 2015 to October 2018. A total of 15 patients (eight males, seven females; mean age, 48.27 years) with extension contracture of the knee were treated by Judet''s quadricepsplasty. All cases were injuries induced by fracture trauma. The mean interval between the initial procedure and quadricepsplasty was 56.2 months (range, 13–276 months). The knee range of motion (ROM) was assessed with a goniometer. The results of the procedure were analyzed by measuring the degrees of flexion of the operated knees at different time points (before, immediately after, and late postoperatively). We evaluated Hospital for Special Surgery (HSS) score, Judet''s criteria, change in the degree of knee flexion, and complications.ResultsAll patients were followed up for 14 to 47 months, with an average of 31.53 months. The degree of flexion increased from 23.33° (range, 10°–50°) preoperatively to 107.33° (range, 100°–125°) intraoperatively, followed by a slight fall in the range of flexion in the late postoperative period, which reached an average of 95.33° (range, 60°–115°) in the last follow‐up. The knee joint function was assessed according to the Judet''s criteria, eight cases (53.33%) achieved excellent results, six (40%) good, one (6.67%) fair, and zero (0.00%) poor results at final follow‐up. The long‐term excellent and good rate was 93.33%. The range of flexion of the knee during operation and at the last time of follow‐up was better than that before surgery (P < 0.001). The final flexion was significantly lower than that measured at immediate postoperative (P < 0.001). The mean postoperative HSS score for the entire group was 93.73 (range, 89–96). Fifteen excellent results were obtained according to the HSS knee score. Skin infection was seen in one patient (6.67%). There were no complications such as deep sepsis, intraoperative rupture of the quadriceps tendon, fracture of the lateral femoral condyle, skin dehiscence.ConclusionJudet quadricepsplasty is an effective method to treat knee extension contracture and improve knee range of motion (ROM). It should be performed by an experienced orthopaedic surgeon and followed by physiotherapy with continuous passive motion (CPM). The knee ROM obtained with the surgery has an excellent long‐term effect.     

Monolateral external fixation for the progressive correction of neurological spastic knee flexion contracture in children

The purpose of this study was to report the results of the surgical treatment of spastic knee flexion contracture using tenotomy and progressive correction by external fixator–distractor devices. The study design involved a prospective observational study of 16 knees in nine patients with spastic flexion contracture greater than 30°. Treatment was indicated for both ambulatory and nonambulatory patients; and, in the latter group when sitting or personal hygiene was compromised. The average age was 11.6 years (range 10–17). Five of the patients were male and four female. There was one case of hemiplegia (11.1%), two cases of paraplegia (22.2%), and six cases of quadriplegia (66.7%). Six patients retained some walking capacity, while three had none. In all cases, distal lengthening of the hamstrings was carried out. A monolateral fixator with a gradual correction device was applied for a period of 4.8 weeks. The average follow-up was 26.6 months. The preoperative straight-leg raise was 55°. The popliteal angle was 58° preoperatively (range 30–80°), 8.5° on removal of the fixator, and 20° at the end of the follow-up. Complications: There were no superficial or deep infections, and no fractures or distal sensory–motor alterations. There was one case of arthrodiatasis of the knee (6.3%) which was resolved when the fixator was removed, and 11 cases of pin-track infection (68.7%) which were resolved with local care and oral antibiotics. To conclude, spastic knee flexion contracture can be treated gradually with monolateral external fixator with distraction devices, and with distraction modules which prevent acute stretching of the posterior neurovascular structures of the knee.     

Walking ability in patients with arthrogryposis multiplex congenita

Background:

Arthrogryposis multiplex congenita (AMC) is a multiple joint condition which affects both lower and upper extremities and thus affects ambulation. Multiple surgeries are needed to correct limb deformity in order to promote walking. The objective of this study is to identify the most critical residual deformity that diminishes the ambulatory status.

Materials and Methods:

51 patients were included in this study, 14 patients were nonambulatory. The mean age at first surgery was 4.1 years (range 2-16 years). The mean length of followup was 44.0 months (range 22-168 months). Type of procedures and number of operations, residual deformity and walking ability were recorded. Residual deformity including hip flexion contracture more than 30°, knee flexion contracture more than 30°, scoliosis, hip dysplasia or dislocation, knee extension contracture or recurvatum, active motion of hips and knees and upper limb involvement were evaluated. Statistical analysis was done to evaluate factors that were statistically significant to affect walking ability in AMC patients.

Results:

At the latest followup, 31 patients were community ambulators, 3 patients were household ambulators, 3 patients were nonfunctional ambulatory, and 14 patients were nonambulatory. There were an average of 4.3 surgeries per patient. Statistical analysis of all factors was done and the results were significant with a P < 0.037 in knee flexion contracture >30 degrees with odds ratio of 4.58. Hip flexion contracture >30° was a trend toward significant with a P value of 0.058 and odds ratio of 4.53. Multivariate analysis showed that knee flexion contracture was significant with 4.58 (95% CI 1.01-20.6).

Conclusion:

AMC is a rare disease that causes disability, requiring multiple surgeries to correct deformities. Our study showed that residual knee flexion contracture was associated with nonambulatory status of patients with AMC.     

A Comparative Study between Conservative and Surgical Treatments of Triangular Fibrocartilage Complex Injury of the Wrist with Distal Radius Fractures

BackgroundTriangular fibrocartilage complex (TFCC) injury is common in distal radius fractures. The purpose of this study was to compare the conservative and surgical treatments of TFCC injury of the wrist associated with distal radius fractures.MethodsA retrospective study was conducted on 39 patients who received treatment for TFCC injury with distal radius fractures. All patients were treated using a volar locking plate for distal radius fractures. Twenty-six patients who received conservative treatment for TFCC through long arm splinting were classified into group 1, and 13 patients who received surgical treatment for TFCC were classified into group 2. The splint was maintained for 6 weeks in both groups. For clinical evaluation, the range of motion (ROM) of the wrist joint, patient-rated wrist evaluation (PRWE) score, Disabilities of the Arm, Shoulder and Hand (DASH) score, and grip strength were measured. Distal radioulnar joint (DRUJ) stability was evaluated through a stress load test and graded between grade 0 and 3 intraoperatively after fixation and at the final follow-up.ResultsIn group 1, the average DASH score was 11.1 ± 4.4, the average PRWE score was 10.2 ± 4.6, the grip strength was 89.4% relative to the unaffected side, the average ROM of the wrist joint was 65° ± 7.0° for extension, 51.5° ± 8.1° for flexion, 86° ± 5.1° for supination, and 85° ± 5.2° for pronation, and DRUJ stability at the final follow-up was grade 0 in 58.62%, grade 1 in 31.03%, grade 2 in 10.34%, and grade 3 in 0%. In group 2, the average DASH score was 13 ± 5.0, the average PRWE score was 12.4 ± 3.7, the grip strength was 87.3% relative to the unaffected side, and the average ROM of the wrist joint was 60° ± 9.8° for extension, 53.1° ± 7.0° for flexion, 85° ± 5.3° for supination, and 86.8° ± 4.5° for pronation. At the final follow-up, DRUJ stability was grade 0 in 66.67%, grade 1 in 25%, grade 2 in 8.3%, and grade 3 in 0%. The 2 groups showed no statistically significant differences in DASH score, PREW score, grip strength, ROM, and final follow-up DRUJ stability.ConclusionsThere were no statistically significant differences in the clinical outcomes between the surgical and conservative treatment groups. Therefore, when normal radiological indices are achieved after treatment of distal radius fractures, DRUJ stability can be obtained by conservative treatment.     

Dorsal fracture-dislocations of the proximal interphalangeal joint: evaluation of closed reduction and percutaneous Kirschner wire pinning

Background

The purpose of this study is to evaluate the outcome of closed reduction and percutaneous Kirschner wire pinning in acute dorsal fracture-dislocations of the proximal interphalangeal (PIP) joint.

Methods

Eight men and one woman were treated with closed reduction and percutaneous Kirschner wire pinning by one orthopaedic surgeon. The ring finger was injured in six patients, the small finger in two patients and the middle finger in one patient. The mean joint surface involvement was 36 % (range, 26–49 %). The Kirschner wires were removed after an average of 28 days (range, 24–37 days).

Results

All patients demonstrated a painless, but fusiform, swollen PIP joint after a mean follow-up of 6.5 months. The average flexion of the PIP joint was 106° (range, 80–110), and the average extension of the PIP joint was 4° short of full extension (range, 10 hyperextension–15 flexion contracture). All patients had a concentrically reduced PIP joint with a healed fracture on radiographs. Two patients had radiographic evidence of degenerative changes, but were asymptomatic. One patient developed a superficial pin track infection, which quickly resolved with a short course of antibiotics, and avascular necrosis affecting one of the condyles of the proximal phalanx.

Conclusions

In agreement with previous studies, closed reduction and percutaneous Kirschner wire pinning in dorsal fracture-dislocations of the PIP joint is a minimally invasive and simple technique which appears to give satisfactory outcomes in the short to intermediate term.     

Experiences with pins and rubber band traction in the treatment of proximal interphalangeal joint contracture

BACKGROUND:

Proximal interphalangeal joint (PIPJ) contracture is a difficult problem to treat regardless of etiology. Although numerous interventions have been recommended, published results are mediocre at best.

OBJECTIVE:

The authors describe their experience and results of using a modification of pins and rubber band traction (PRBT) – applying a dynamic extension apparatus to a contracted PIPJ using the constant traction force in a stretched rubber (elastic) band.

METHOD:

A retrospective review of patients treated with this method was performed, and the results are presented. The technique itself is described, and clinical photographs illustrate the method.

RESULTS:

Mean PIPJ flexion contracture before PRBT was 82° (range 60° to 110°). The full correction of eight contracted PIPJs in seven patients was achieved, in a mean of 17.8 days (range 14 to 31 days). At one month postremoval of PRBT, the mean PIPJ flexion contracture was 22.8° (range 0° to 46°).

DISCUSSION:

The method is compared with previously described methods of PIPJ contracture correction, whether surgical or splinting; the latter may be static, dynamic or a combination of the two. The results of previously published studies are discussed and compared with the method described.

CONCLUSION:

The present method is a powerful and effective simplification of a previously described method of correcting PIPJ contractures. This technique is simple, ‘low-tech’ and can be applied under local anesthetic; the authors believe it offers a useful adjunct to surgical release.     

Anterior tibial plateau fracture: An often missed injury

Background:

In most classifications of tibial plateau fractures, including one used most widely-Schatzker classification, fractures are described as a combination of medial and lateral condyle, primarily in the sagittal plane. Coronal component of these fractures, affecting the posterior tibial condyle is now well recognized. What is not described is anterior coronal component of the fracture, what we are calling “anterior tibial condyle fracture”. These fractures are often missed on routine antero-posterior and lateral knee X-rays due to an overlap between the fracture and the normal bone.

Materials and Methods:

Eight cases of anterior tibial condyle fractures with posterior subluxation of the tibia, six of which were missed by the initial surgeon and two referred to us early, are described. Two of the six late cases and both the early ones were operated. Reconstruction of the anterior condyle and posterior cruciate ligament reconstruction was done. Primary outcome measures such as union of the fracture, residual flexion deformity, range of motion and stability were studied at the end of 6 months.

Results:

All operated fractures united. There was no posterior sag in any. In those presenting late and were operated, the flexion deformity got corrected in all (average from 15° to 0°) and mean flexion achieved was 100° (range: 80-120°). In those presenting early and were operated, there was no flexion deformity at 6 months and a mean flexion achieved was 115° (range: 100-130°). None of the operated patients had instability.

Conclusion:

This article attempts to highlight that this injury is often missed. They should be suspected, diagnosed early and treated by reconstruction of anterior condyle, posterior cruciate ligament reconstruction.     

Errors in visual estimation of flexion contractures during total knee arthroplasty

AIM: To quantify and reduce the errors in visual estimation of knee flexion contractures during total knee arthroplasty (TKA).METHODS: This study was divided into two parts: Quantification of error and reduction of error. To quantify error, 3 orthopedic surgeons visually estimated preoperative knee flexion contractures from lateral digital images of 23 patients prior to and after surgical draping. A repeated-measure analysis of variance was used to compare the estimated angles prior to and following the placement of the surgical drapes with the true knee angle measured with a long-arm goniometer. In an effort to reduce the error of visual estimation, a dual set of inclinometers was developed to improve intra-operative measurement of knee flexion contracture during TKA. A single surgeon performed 6 knee extension measurements with the device during 146 consecutive TKA cases. Three measurements were taken with the desired tibial liner trial thickness, and 3 were taken with a trial that was 2 mm thicker. An intraclass correlation coefficient (ICC) was calculated to assess the test-retest reliability for the 3 measurements taken with the desired liner thickness, and a paired t test was used to determine if the knee extension measurements differed when a thicker tibial trial liner was placed.RESULTS: The surgeons significantly overestimated flexion contractures in 23 TKAs prior to draping and significantly underestimated the contractures after draping (actual knee angle = 6.1° ± 6.4°, pre-drape estimate = 6.9° ± 6.8°, post-drape estimate = 4.3° ± 6.1°, P = 0.003). Following the development and application of the measurement devices, the measurements were highly reliable (ICC = 0.98), and the device indicated that 2.7° ± 2.2° of knee extension was lost with the insertion of a 2 mm thicker tibial liner. The device failed to detect a difference in knee extension angle with the insertion of the 2 mm thicker liner in 9/146 cases (6.2%).CONCLUSION: We determined the amount of error associated with visual estimation of knee flexion contractures, and developed a simple, reliable device and method to improve feedback related to sagittal alignment during TKA.     

Mini-open versus extended open release for severe carpal tunnel syndrome

Background

This study aims to compare surgical outcomes of severe carpal tunnel syndrome (CTS) treated with mini-incision versus extensile release.

Methods

The method employed in this study was a retrospective review of patients with severe CTS, defined by electrophysiologic studies showing non-recordable distal sensory latency of the median nerve. Patients underwent either a mini-incision (2 cm) release of the transverse carpal ligament (group 1) or extensile release proximal to the wrist flexion crease (group 2). Exclusion criteria included prior carpal tunnel release, use of muscle flap, multiple concurrent procedures, or a prior diagnosis of peripheral neuropathy. Group 1 included 70 wrists (40 females, 30 males). Group 2 included 64 wrists (35 females, 29 males). Reported outcomes included pre- and post-operative grip strength as well as Boston Carpal Tunnel Questionnaires (BCTQ).

Results

Patients in group 1 had a 22.6 % increase in grip strength postoperatively (4.5 months ± 5.0), while patients in group 2 had a 59.3 % increase (10.0 months ± 6.9). BCTQ surveys from group 1 (n = 46) demonstrated a symptom severity score of 12.93 and functional status score of 9.39 at an average follow-up of 41.9 ± 10.6 months. Group 2 (n = 42) surveys demonstrated averages of 12.88 and 9.10 at 43.1 ± 11.6 months. One patient in the mini-incision cohort required revision surgery after 2 years, while no patient in the extended release cohort underwent revision.

Conclusion

No significant differences between the two procedures with regard to patient-rated symptom severity or functional status outcomes were found. Both techniques were demonstrated to be effective treatment options for severe CTS.     

Isolated dorsal approach for the treatment of neglected volar metacarpophalangeal joint dislocations

Here, we present the clinical and radiological results of three neglected volar metacarpophalangeal dislocations in 2 patients, which were treated with open reductions 10 and 24 mo after the dislocations. There was a mean of a 20°(range 10°-30°) limitation of extension and a 53.3°(range 30°-70°) limitation of flexion preoperatively. Postoperatively, there was no limitation of extension(at 8 and 12 mo) in any of the fingers. In terms of flexion, one finger had full function, one had a 10° and the last one had a 30° limitation of flexion. Two of the fingers presented anesthesia preoperatively, which improved to hypesthesia postoperatively. One finger had hypesthesia, which improved postoperatively. During surgery, a ruptured dorsal capsule was found to have interposed into the joint, making closed reduction impossible. Our experience with these two patients demonstrated that, even in neglected cases, open reduction using an isolated dorsal approach may result in satisfactory clinical andradiological outcomes.     

Can Combining Femoral and Acetabular Morphology Parameters Improve the Characterization of Femoroacetabular Impingement?

BackgroundFemoroacetabular impingement (FAI) presupposes a dynamic interaction of the proximal femur and acetabulum producing clinical symptoms and chondrolabral damage. Currently, FAI classification is based on alpha angle and center-edge angle measurements in a single plane. However, acetabular and femoral version and neck-shaft angle also influence FAI. Furthermore, each of these parameters has a reciprocal interaction with the others; for example, a shallow acetabulum delays impingement of the femoral head with the acetabular rim.Questions/purposesWe introduce the new parameter “omega zone,” which combines five parameters into one: the alpha and center-edge angles, acetabular and femoral version, and neck-shaft angle. We sought to determine whether the omega zone could differentiate patients with FAI from (1) normal control subjects (alpha < 55°), but also from (2) control subjects with elevated alpha angles (≥ 55°).MethodsWe evaluated CT data of 20 hips of male patients with symptomatic cam-type FAI and of 35 male hips extracted from 110 anonymized CT scans for vascular diagnosis. We excluded hips with osteoarthritis, developmental dysplasia, or coxa profunda (center-edge angle 20°–45° on AP pelvic view or corresponding coronal CT views). With dedicated software, femoral and pelvic orientation was standardized; we tested the omega zone in four hip positions in three distinct groups: patients with cam-type FAI (alpha > 60°) and control subjects with normal (< 55°) and high alpha angles (≥ 55°).ResultsThe omega zone was smaller in patients with cam-type FAI than normal control subjects (alpha angle < 55°) at 60° and 90° of flexion (mean, 12%; 95% confidence interval [CI], 7–17; p = 0.008; Cohen’s d = 9%; 95% CI, 4–13; p = 0.003). Furthermore, the omega zone was smaller in all positions in patients with cam-type FAI than control subjects with high alpha angles (0° p = 0.017, 30° p = 0.004, 60° p = 0.004, 90° p = 0.007). In contrast, the omega zone did not differ between control subjects with normal or high alpha angles. In all hips, the omega zone decreased with flexion, corresponding to a decrease in remaining impingement-free motion with flexion.ConclusionsThe omega zone visualizes and quantifies the interaction of the proximal femur and acetabulum. The omega zone differed between patients with cam-type FAI and control subjects with high alpha angles (≥ 55°), who could not be distinguished based on alpha angle alone. For hip-preserving surgery, it can help surgeons decide whether to address the femur, the acetabulum, or both.

Level of Evidence

Level III, diagnostic study.     

Ten- to 14-Year Results of a High-Flex Rotating Platform Knee Implant: A Follow-Up Report of a Prospective Cohort

BackgroundHigh-flex posterior stabilised rotating platform (PSRP) implant was introduced to provide for deep knee flexion. Few short-term results have been reported, but there are no long-term outcomes reported.MethodsWe prospectively followed 48 patients (53 knees) implanted with one such design. Inclusion criteria for implantation were patients with good pre-operative flexion and wishing to perform activities requiring deep knee flexion post-operatively, with femorotibial varus angle < 15° and having good flexion stability at trialling stage. Previously, we reported their outcomes at 2–6 years (FU-1). We now report their functional and radiological results at a minimum follow-up of 10 years (FU-2) in 39 patients (43 knees); 5 patients having died and 4 lost to follow-up.ResultsThe mean pre-operative flexion of 124° improved to 130° at FU-1 and to 134° at FU-2. Flexion of 130° or more was seen in 59.6% knees at FU-1 and 74.42% knees at FU-2. At FU-2 mean Knee score was 90.5 and Function score was 67.8. Incidence of patellofemoral symptoms increased from 7.7% at FU-1 to 11.36% at FU-2. There were no cases of bearing spin out, osteolysis or revision surgeries.ConclusionAt a minimum 10-year follow-up, high-flexion PSRP design in selected patients yielded 100% survival. We recorded good knee flexion and knee society scores, with no case of spin out, implant loosening, osteolysis or revision surgery. Although deep knee flexion improved at longer follow-up, its use in ADL had reduced due to other age-related factors. There was increased incidence of patellofemoral symptoms.     

Anatomic Repair of the Central Slip with Anchor Suture Augmentation for Treatment of Established Boutonniere Deformity

BackgroudThe rupture of the central slip of an extensor tendon of a finger causes a boutonniere (or buttonhole) deformity, characterized by pathologic flexion at the proximal interphalangeal (PIP) joint and hyperextension at the distal interphalangeal (DIP) joint. Currently, there are no standard treatment guidelines for this deformity. This study aimed to report clinical results of surgery to correct chronic boutonniere deformity.MethodsThis retrospective case series was conducted between January 2010 and December 2018 and only 13 patients with trauma-induced chronic deformity were included. After excision of elongated scar tissue, a direct anatomic end-to-end repair using a loop suture technique with supplemental suture anchor augmentation was conducted. Total active motion was assessed before and after surgery and self-satisfaction scores were collected from phone surveys.ResultsAll patients presented with Burton stage I deformities defined as supple and passively correctable joints. The initial mean extension lag of the PIP joint (43.5°) was improved by an average of 21.9° at the final follow-up (p < 0.001). The mean hyperextension of the DIP joint averaged 19.2° and improved by 0.8° flexion contracture (p < 0.001). The average total active motion was 220.4° (range, 160°–260°). Based on the Souter''s criteria, 69.2% (9/13) of the patients had good results. Only 1 patient reported fair outcome and 23.1% (3/13) reported poor outcome. The average Strickland formula score was 70 (range, 28.6–97.1). In total, 10 patients (77%) had excellent or good results. Of 10 patients contacted by phone, self-reported satisfaction score was very satisfied in 2, satisfied in 3, average in 3, poor in 1, and very poor in 1. Three patients reported a relapse of the deformity during range of motion exercises, 1 of whom underwent revision surgery. One patient complained of PIP joint flexion limitation, and 2 complained of DIP joint flexion limitation at final follow-up.ConclusionsIn chronic boutonniere deformity, central slip reconstruction with anchor suture augmentation can be an easily applicable surgical option, which offers fair to excellent outcome in 77% of the cases. The risk of residual extension lag and recurrence of deformity should be discussed prior to surgery.     

Knee flexion contracture impacts functional mobility in children with cerebral palsy with various degree of involvement: a cross-sectional register study of 2,838 individuals

Background and purpose — The impact of knee flexion contracture (KFC) on function in cerebral palsy (CP) is not clear. We studied KFC, functional mobility, and their association in children with CP.Subjects and methods — From the Swedish national CP register, 2,838 children were defined into 3 groups: no (≤ 4°), mild (5–14°), and severe (≥ 15°) KFC on physical examination. The Functional Mobility Scale (FMS) levels were categorized: using wheelchair (level 1), using assistive devices (level 2–4), walking independently (level 5–6). Standing and transfer ability and Gross Motor Function Classification (GMFCS) were assessed.Results — Of the 2,838 children, 73% had no, 14% mild, and 13% severe KFC. KFC increased from 7% at GMFCS level I to 71% at level V. FMS assessment (n = 2,838) revealed around 2/3 were walking independently and 1/3 used a wheelchair. With mild KFC (no KFC as reference), the odds ratio for FMS level 1 versus FMS level 5–6 at distances of 5, 50, and 500 meters, was 9, 9, and 8 respectively. Correspondingly, with severe KFC, the odds ratio was 170, 260, and 217. In no, mild, and severe KFC 14%, 47%, and 77% could stand with support and 11%, 25%, and 33% could transfer with support.Interpretation — Knee flexion contracture is common in children with CP and the severity of KFC impacts function. The proportion of children with KFC rose with increased GMFCS level, reduced functional mobility, and decreased standing and transfer ability. Therefore, early identification and adequate treatment of progressive KFC is important.

Knee flexion contracture is a common problem in children with cerebral palsy (CP) (Miller 2005, Cloodt et al. 2018). Due to muscle imbalance, short and spastic hamstring muscles, and prolonged sitting posture, knee flexion contracture may develop and often progresses in adolescence (Miller 2005, Rodda et al. 2006). Although the exact impact of knee flexion contracture and its contribution to the development of flexed knee gait is still not fully understood, it is associated with progressive deterioration of gait in the ambulating child (Bell et al. 2002, Rodda et al. 2006) and it results in difficulties maintaining functional standing, sitting, and transfer in non-ambulatory children (Miller 2005, Cloodt et al. 2018). In addition, knee flexion contracture generates increased forces on the knee joint, which may cause pain (Rodda et al. 2006, Steele et al. 2012, Schmidt et al. 2020).Prevention of knee flexion contracture has not been thoroughly studied, and physiotherapy treatment and focal spasticity reduction have been attempted without convincing effect (Hägglund et al. 2005, Galey et al. 2017). In ambulatory children, there are several reports of improvement of gait pattern and knee flexion contracture after orthopedic surgery (Ma et al. 2006, Rodda et al. 2006, Stout et al. 2008, Taylor et al. 2016). These studies are limited mainly to children in Gross Motor Function Classification System (GMFCS) level I–III, and occasionally level IV, and varies across age groups as well as according to the surgery performed (Ma et al. 2006, Rodda et al. 2006, Stout et al. 2008, Taylor et al. 2016).The Functional Mobility Scale (FMS), the Pediatric Outcomes Data Collection Instrument (PODCI), and the Gross Motor Function Measure dimension D (GMFM D) are often used to assess function after orthopedic surgery; all three instruments describe how the child actually moves in daily life, and not necessarily what his or her capacity is (Russell 1993, Daltroy et al. 1998, Graham et al. 2004).Knee flexion contracture is easy to assess by physical examination; however, there are limited reports on the prevalence of knee flexion contracture and distribution of functional mobility in larger cohorts of children with CP at all GMFCS levels (Rodby-Bousquet and Hägglund 2010, Cloodt et al. 2018). We studied knee flexion contracture, functional mobility, and their association in children with CP. We assumed that the presence and severity of knee flexion contracture contributes to decreased physical function in children with CP.     

Neglected surgically intervened bilateral congenital dislocation of knee in an adolescent

Neglected bilateral congenital dislocation of knee is unusual. A 12 year old boy presented with inability to walk due to buckling of the knee. The symptoms were present since the child learnt walking. He preferred not to walk. Bilateral supracondylar femoral osteotomy was done at the age of 6 years. Patient had a fixed flexion deformity of both knees, 30° in the right (range of flexion from 30° to 45°) and 45° fixed flexion deformity in left knee respectively (range of flexion from 45° to 65°) when presented to us. The radiological examination revealed bilateral congenital dislocation of knee (CDK). No syndromic association was observed. He was planned for staged treatment. In stage I, the knee joints were distracted by Ilizarov ring fixators and this was followed by open reduction of both the knee joints in stage II. A bilateral supracondylar extension osteotomy was done 18 months after the previous surgery (stage III). The final followup visit at 4 years the patient presented with range of motion 5-100° and 5-80° on the right and left knee respectively with good functional outcome. The case is reported in view of lack of treatment guidelines for long standing neglected CDK in an adolescent child.     

Effect of partial and complete posterior cruciate ligament transection on medial meniscus: A biomechanical evaluation in a cadaveric model

Background:

The relationship between medial meniscus tear and posterior cruciate ligament (PCL) injury has not been exactly explained. We studied to investigate the biomechanical effect of partial and complete PCL transection on different parts of medial meniscus at different flexion angles under static loading conditions.

Materials and Methods:

Twelve fresh human cadaveric knee specimens were divided into four groups: PCL intact (PCL-I), anterolateral bundle transection (ALB-T), posteromedial bundle transection (PMB-T) and PCL complete transection (PCL-T) group. Strain on the anterior horn, body part and posterior horn of medial meniscus were measured under different axial compressive tibial loads (200-800 N) at 0°, 30°, 60° and 90° knee flexion in each groups respectively.

Results:

Compared with the PCL-I group, the PCL-T group had a higher strain on whole medial meniscus at 30°, 60° and 90° flexion in all loading conditions and at 0° flexion with 400, 600 and 800 N loads. In ALB-T group, strain on whole meniscus increased at 30°, 60° and 90° flexion under all loading conditions and at 0° flexion with 800 N only. PMB-T exihibited higher strain at 0° flexion with 400 N, 600 N and 800 N, while at 30° and 60° flexion with 800 N and at 90° flexion under all loading conditions.

Conclusions:

Partial PCL transection triggers strain concentration on medial meniscus and the effect is more pronounced with higher loading conditions at higher flexion angles.     

Reliability of radiographic measurements of knee motion following knee arthroplasty for use in a virtual knee clinic

INTRODUCTION

We sought to validate radiographic measurements of range of motion of the knee after arthroplasty as part of a new system of virtual clinics.

METHODS

The range of motion of 52 knees in 45 patients was obtained by 2 clinicians using standardised techniques and goniometers. Inter-rater reliability and intraclass correlation coefficients (ICCs) were calculated. Radiographs of these patients’ knees in full active flexion and extension were also used to calculate intra and inter-rater reliability compared with clinical measurements using four different methods for plotting angles on the radiographs.

RESULTS

The ICC for inter-rater reliability using the goniometer was very high. The ICC was 0.91 in extension and 0.85 in flexion while repeatability was 8.49° (-8.03–8.99°) in extension and 5.23° (-4.54–5.74°) in flexion. The best ICC for radiographic measurement in extension was 0.86, indicating ‘near perfect’ agreement, and repeatability was 5.43° (-4.04–6.12°). The best ICC in flexion was 0.95 and repeatability was 5.82° (-3.38–6.55°). The ICC for intrarater reliability was 0.98 for extension and 0.99 for flexion on radiographic measurements.

CONCLUSIONS

Validating the use of radiographs to reliably measure range of motion following knee arthroplasty has allowed us to set up a ‘virtual knee clinic’. Combining validated questionnaires and radiographic measurement of range of motion, we aim to maintain high quality patient surveillance following knee arthroplasty, reduce our ratio for new to follow-up patients in line with Department of Health guidelines and improve patient satisfaction through reduced travel to hospital outpatients.