Average Active Range Of Motion Research Articles

Triple suture fixation for displaced comminuted olecranon fracture with a stable ulnohumeral joint.

To report the outcome of a novel fixation technique using three high-strength sutures which is including articular buttress suture, cerclage suture, and tension band with off-loading triceps suture (triple suture fixation) in the treatment of displaced comminuted olecranon fracture with a stable ulnohumeral joint (Mayo type IIB). The rationale of using this technique is that the sutures have been used to stabilize multiple fracture fragments in all sides of the olecranon. Between July 2018 and July 2021, 10 patients (7 women, 3 men; mean age, 49.9years; mean follow-up duration, 27.8months) with Mayo type IIB olecranon fractures who underwent triple suture fixation were included in the study. The elbow was immobilized in a splint for 2weeks postoperatively. Range-of-motion exercises were initiated after splint removal and weight bearing was allowed at 6weeks postoperatively. Average active range of motion of the elbow was 145° of flexion (range, 135°-150°), 6.5° of extension (range, 0°-30°), 83° of supination (range, 70°-85°), and 77.5° of pronation (range, 70°-80°). Mean MEPS was 98.3 (range, 85-100) and DASH score was 3.1 (range, 0-10) at the final follow-up. Radiographic data at the final follow-up analyzed by paired t test demonstrated that there was no statistically significant difference of proximal olecranon height (OH), trochlear notch width (TW), and OH/TW ratio between postoperative treatment and normal side (p-value >.05). No complication of implant prominence, fixation failure, nonunion, infection or heterotopic ossification was found postoperatively. Breakage of drill bit occurred during drilling a distal oblique hole for articular buttress suture in one patient. The triple suture fixation is an effective treatment with low incidence of complications in treatment of Mayo type IIB olecranon fractures. Larger comparative studies are needed to confirm the value of such technique.

Pitfalls and suggestions for the treatment of open, comminuted fractures of the middle phalanx using custom-made dynamic external fixators: a retrospective case series

Background: The proximal interphalangeal joint (PIPJ) is a synovial joint prone to injury encompassing a wide spectrum of severity. In the setting of complicated injuries, dynamic external traction systems are considered to be the optimal treatment modality with numerous different Kirschner-wire configurations combined with rubber bands, springs, pulleys, or hinges being described. However, many of these pose significant technical challenges for the surgeon or are unwieldy to the patient emphasizing the need for simple, easy to construct, and well-tolerated modifications, which are equally effective in reducing the fracture and allowing early motion. Methods: The authors retrospectively analyzed prospectively collected data of 12 patients with open complex PIPJ fracture dislocations treated with a custom-made external fixator based on the one that was originally suggested by Suzuki et al. All patients were men with an average age of 55.1 yr (23 to 81). Injured digits involved four index, five middle, and three ring fingers. Results: The mean follow-up was 54.36 mo, and all patients healed without a second operation and returned to their jobs and preinjury level of activity. The average active range of motion of the PIPJ was 75.16±3.18 degrees, DIPJ was 69.33±14.7 degrees, and MCPJ was 88.75±1.97 degrees. Mean Quick Disabilities of Arm, Shoulder, and Hand (DASH)-Japan Society for Surgery of the Hand (JSSH) score at the final examination was 4.33±1.38 (range 2.3 to 6.8). The authors recorded five complications involving two rubber bands breaking, one pin-track infection, one rubber band-axial traction pin malposition, and one swan neck deformity, which were treated accordingly. Conclusions: One of the most crucial factors affecting outcome in this kind of injury is the appearance of the digit and functional results. None of the participants in this series had any complaint about the appearance of their fingers in the final examination, and 10 out of 12 judged the cosmetic result as very good. To the authors' knowledge, this report is one of the few that describes the functional outcome of pins and rubbers traction system (PRTS) application in complex fracture and fractures-dislocations with severe comminution of the middle phalanx and not only fractures related to the PIP joint. Level of Evidence: Level V.

Proximal humeral fractures treated with an intramedullary cage and plate: clinical and radiographic outcomes at a minimum of 1 year postoperatively

Proximal humeral fractures are common injuries. Although certain fracture types may benefit from surgery including open reduction-internal fixation (ORIF), the optimal method for fixation is unclear. Newer implant designs that improve healing by minimizing hardware failure and recurrent fracture displacement may optimize clinical outcomes. Over a 27-month period, 37 consecutive patients with proximal humeral fractures were treated by a single surgeon with a lateral humeral plate through which an intramedullary nitinol cage was inserted. Additional screws were placed through the tuberosities and cage as required. Fractures were classified by both the Neer classification and angulation or displacement in the coronal plane. At most recent follow-up, radiographic results, patient-reported outcome measurements, range of motion, complications, and reoperations were recorded. Thirty-one patients had a minimum of 1 year of clinical and radiographic follow-up. The average follow-up period was 91 weeks. By use of the Neer classification, there were 4 two-part, 21 three-part, and 6 four-part fractures. Twenty-one fractures were displaced in valgus and 10 in varus. Outcome measurements at most recent follow-up demonstrated an average American Shoulder and Elbow Surgeons score of 68; Single Assessment Numeric Evaluation score of 70; Quick Disabilities of the Arm, Shoulder and Hand score of 27; Veterans RAND-12 Physical Component Score of 37 and Mental Component Score of 51; Constant score of 55; Patient-Reported Outcomes Measurement Information System score of 29; and Oxford Shoulder Score of 23. Average active range of motion showed forward elevation of 134°, abduction of 91°, external rotation with the arm at the side of 30° (range, -10° to 60°), and internal rotation with the arm at the side to L1 (range, T6-S4). There were 11 complications (35%), including 2 cases of axillary nerve neurapraxia that resolved and 4 cases of avascular necrosis (13%). Unplanned reoperations were performed in 6 patients (19%). One patient underwent revision for loose hardware removal, 1 patient underwent revision ORIF after a fall, and 4 patients required component removal and revision to shoulder arthroplasty. No screw cutout or varus head collapse occurred. The management of proximal humeral fractures remains challenging. Our results demonstrate similar fracture healing, clinical improvement, and complication rates compared with conventional ORIF with screws and a side plate. At 1 year of follow-up, there were low rates of recurrent fracture displacement and screw cutout. There was a higher-than-expected rate of avascular necrosis as compared with other studies using a similar fixation construct. Larger studies and longer follow-up may demonstrate decreased rates of revision surgery and superior outcomes. Additional studies may determine whether this fixation method is superior to others for proximal humeral fractures.

Conversion to Extension Contracture as a Means of Correction of Severe Flexion Contracture of the PIP Joint Using a Modified Dynamic External Fixator.

Background: This is a retrospective case series investigating the outcomes using a dynamic external fixator (DEF) for treatment on severe flexion contractures at the proximal interphalangeal (PIP) joint. Severe flexion contractures of the PIP joint occurring after multiple operations and neglected over a long period of time are difficult to treat. The recurrence of contracture, even after successful treatment, is inevitable in patients with severe cases. In this study, we defined the severity of PIP joint contracture based on the active range of motion (ROM), soft tissue condition, and duration of the contracture. We also illustrated the strategy, results, and complications of using a DEF with rubber bands in these severe cases. Methods: We studied 11 fingers of 10 patients with PIP joint contracture treated by DEF. These were fixed at a small arc and neglected for an average 4.1 years (range, 1-9 years). The temporal Kirshner wire (K-wire) fixation after achieving an extension via DEF was maintained for 9.1 weeks on average. We retrospectively reviewed the results of these patients with an average 2-year follow-up. Results: Our method yielded favorable results upon retrospective evaluation. The average active ROM of the affected PIP joint improved from 90/96° to 34/83° with a functional arc and good patient satisfaction. The elastic force induced by strong rubber bands was safe and effective. The first step of joint space widening was the key to obtaining a successful joint extension afterwards. Serious progression of osteoarthritis at the PIP joint and pin-site fracture were a complication in each one case. Conclusions: In this study, we evaluate the surgical strategy of using DEFs powered by elastic torque from rubber bands to treat severe cases of flexion contractures of fingers. We first created extension contracture intentionally, followed by promoting flexion movement during follow-up in this group of patients.

Anterior Locking Plate Osteosynthesis of Patellar Factures - Analysis of Complications and Functional Outcome.

Tension band wiring is the standard procedure for patellar fractures, but is associated with a high rate of implant related complications and implant failure. Tension band wiring may fail, especially with multifragmentary and comminuted fractures. Plate fixation of complex patellar fractures seems to be superior to wiring, both clinically and biomechanically. The aim of this study was to evaluate complications after locking plate fixation in patellar fractures two years after surgery and to access the functional outcome. As part of a prospective case series, all patients who had received locking plate fixation of a patellar fracture between April 2013 and May 2018 were clinically examined two years postoperatively and potential complications were evaluated. A total of 38 patients aged 19 - 87 years were included. Complications occurred in a total of five patients (13%), including one reactive prepatellar bursitis, one chronic infection and loss of reduction due to a dislocated pole fragment in three cases. The average active range of motion of the affected knee joint two years postoperatively was 133°. The Tegner activity scale score reached 3 points, the Lysholm score 95 points and the Kujala score 95 points. With an overall relatively low complication rate and good clinical outcome, dislocated distal pole fragments are a common complication after plate fixation of patellar fractures. If preoperative diagnostic testing shows a pole fragment, a modified hook-plate can be used, with the possibility of fixing the pole fragment.

Results of Latissimus Dorsi Transfer using a Tendinous Allograft through a Single Deltopectoral Approach for Irreparable Posterosuperior Rotator Cuff Tears.

Objective The primary aim of the present study is to evaluate the functional results of a modification to the latissimus dorsi (LD) transfer around the shoulder for irreparable posterosuperior rotator cuff tears. The secondary aim is to evaluate variables that might influence the outcomes. Surgical Technique Through a single deltopectoral approach, the LD tendon is detached, reinforced, and elongated with a tendinous allograft, transferred around the humerus, and fixed superolaterally to the greater tuberosity and anteriorly to the subscapularis. Methods Retrospective functional evaluation of 16 cases. The average follow-up was 21 months (12–47). The postoperative results (at last follow-up) were compared with the preoperative ones, as well as to other pre, intra, and postoperative variables. Results All (but one) patients were satisfied. Average University of California, Los Angeles (UCLA) score increased from 11.6 (8–16) to 27.3 (17–30) ( p < 0.001). Improvements of shoulder pain, function, and strength achieved statistical significance ( p < 0.001). Nonetheless, normal strength was never restored. Average active range of motion improved as follows: forward elevation, from 106° (60–140°) to 145° (130–160°) ( p < 0.001); external rotation from 30° (0° to 60°) to 54° (40–70°) ( p < 0.001); and internal rotation from L1 (gluteus to T7) to T10 (T12–T3) ( p < 0.05). No complication has occurred. Preoperative pseudoparesis was reverted in all the six cases in which it was present. None of the variables analyzed influenced the outcomes, including pseudoparesis. Conclusions At early follow-up, this technique is safe and effective at recovering from pseudoparesis and at improving shoulder pain, function, and strength.

Surgical and Protocolized Management of Distal Radius Nonunion

Abstract Introduction Nonunion of the distal radius is an extremely rare and serious complication with unpredictable outcomes. The aim of the present study is to analyze the radiological and functional results after a protocolized surgical treatment. Material and Methods A retrospective review of case series of patients with diagnosis of nonunion of the distal radius surgically treated from 2010 to 2016. The diagnosis of nonunion was made at 6 months without signs of consolidation. According to computed tomography (CT) scan images, we propose a classification of this complication as type I: no deformity or mild deformity, with subchondral metaphyseal bone stock beneath lunate facet greater than 10 mm, with no degenerative changes at the distal radioulnar joint (DRUJ); type II: moderate deformity or degenerative changes in the DRUJ, distinguishing between IIA and IIB based on the subchondral metaphyseal bone stock; and type III: degenerative changes at the midcarpal joint. In all cases, a reconstructive technique consisting of volar locking plate osteosynthesis with autologous tailored iliac crest graft was performed, hence none of the cases were classified as type III. Results In total, six cases were included. Mean follow-up: 58 months (range: 30–108 months). Consolidation was achieved in a mean period of 5 months (range: 3–9 months). Average active range of motion: flexion: 54° (range: 10°–80°); extension: 40° (range: 10°–85°); supination: 82.5° (range: 75°–85°); pronation 80° (range: 55–85°); radial deviation: 15° (range: 5°–20°); and ulnar deviation 15° (range: 5–20°). Mean strength: 24.15 Kg (6.9–35 Kg). The average score on the Visual Analog Scale (VAS) at rest was of 0.6 (0–2), and with movement, it was of 1.8 (0–4). The mean postoperative score on the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was of 18.48 (range: 0–50.8). Average radial height: 9.65 mm (range: 7–12 mm); average radial angulation: 17° (10°–20°); volar tilt: 8.36° (range: 0.2°–21°); average ulnar variance: 1.52 mm (range: 0–3.5 mm). Complications: persistent nonunion, superficial wound infection, acquired residual ulnar club hand deformity, radiocarpal arthritis, and midcarpal arthritis. Nevertheless, no salvage techniques were needed or requested during the follow-up, with all patients in an active work situation or living an active life in complete normality. Conclusions The protocolized surgical treatment of pseudoarthrosis of the the distal radius, based on our proposed classification, offers good functional outcomes in the long-term follow-up.

Outcome of proximal interphalangeal joint replacement with pyrocarbon implants: a long-term longitudinal follow-up study.

The aim of this study was to compare the short-, mid-, and long-term results of pyrocarbon PIPJ arthroplasty. Twenty-seven consecutive patients (9 males, 18 females) had arthroplasty for 32 pyrocarbon PIPJ prostheses. Two patients (two joints) were lost for follow-up. Four implants were removed during follow-up. Fifteen patients (18 implants) were available for a long-term follow-up assessment on average 9.7 (9-10.8) years postoperatively and seven patients with eight implants had telephone interviews to calculate the implant survival and complications. Of the 15 patients who came to the latest follow-up, 12 (14 implants) passed each of the three follow-up visits for short-term (ø 19months), mid-term (ø 54months), and long-term follow-up (ø 9.8years) to compare functional and radiological parameters longitudinally. In total, seven of the 30 joints (23%) required a revision surgery, all within the first 2years postoperatively, including three arthrodesis due to early infection or dislocation, and one distal component removal due to primary loosening. Three patients required soft tissue revisions. The implant survival after 9years was 87%. There was minimal pain at rest throughout the 9-year follow-up analysis; pain with activity was rated 1.9 at the short-term assessment, 1.5 at mid-term, and 1.6 at long-term. The average active range of motion was at short-, mid-, and long-term examination 49°, 50°, and 48° and grip strength averaged 24, 24, and 21kg, respectively. The DASH score was stable with 35, 36, and 33 points. At the long-term follow-up, all evaluated implants showed radiological signs of implant loosening or migration. According to the PIP joint outcome score, 57% resulted finally in a "good" outcome. Pyrocarbon PIPJ arthroplasty has a risk of early complications necessitating revision surgeries. In spite of radiological implant migration, good pain relief, grip strength, and high quality-of-life ratings are stable for a long time.

Antibiotic cement spacer retention for chronic shoulder infection after minimum 2-year follow-up

The treatment of periprosthetic shoulder infections and proximal humerus osteomyelitis is challenging. The outcomes of antibiotic cement spacer retention are poorly defined in the literature. The purpose of this study was to review long-term functional and patient-reported outcomes data of patients with retained antibiotic cement spacers. We predict reasonable functional outcomes and minimal pain. We identified 22 patients of the senior author who have been treated with definitive antibiotic spacer placement. All patients were originally offered a 2-stage revision and declined. Twelve patients had a minimum follow-up of 2 years and were included in our cohort. Mean age was 70.7 (range 59-81), 8/12 patients were female, and the average body mass index was 27.8 (range = 17-45). Functional outcome assessments included the Standardized Shoulder Assessment Form, the Quick Disabilities of the Arm, Shoulder, and Hand Score (QuickDASH), and visual analog scale (VAS) along with clinical range of motion examination. Thepatients were followed up for a mean of 5.6 years. Eight patients had spacer placement for chronic shoulder arthroplasty infections, whereas 4 patients had spacer placement for chronic osteomyelitis of the proximal humerus. No patients were currently being treated with suppressive antibiotics. One patient had negative cultures at the time of antibiotic spacer placement. The most common organisms were Cutibacterium acnes (6), Staphylococcus epidermidis (6), and methicillin-resistant Staphylococcus aureus (4), with 4 patients growing more than 1 species. The average ASES score was 54 (range = 27-73), QuickDASH was 45 (range = 14-89), and VAS score 2.8 (range = 0-8). Average active range of motion was 68° of forward elevation and 35° of external rotation. Retention of antibiotic cement spacer is a viable option in the treatment algorithm for chronic shoulder infections. Long-term antibiotic cement spacer may be considered for those patients who are unwilling or unable to undergo a 2-stage revision. Patients can expect a reasonable amount of function and little to no pain with an antibiotic cement spacer.

Pins and rubbers traction system for fractures of the proximal interphalangeal joint.

We aimed to evaluate the clinical results using the pins and rubbers traction system (PRTS) as described by Suzuki et al. for unstable intra-articular fractures of the proximal interphalangeal (PIP) joint and to assess the efficacy and the indication of the technique of the PRTS. Thirty-nine fingers in 39 patients (mean age 46.0 years) with unstable fractures of the PIP joint were treated by the PRTS. The mean interval between injury and surgery was 30.8 days. Active and passive exercise of range of motion of all fingers was started immediately after surgery. Radiographic and clinical results were evaluated at the final examination. The mean period the PRTS was applied was 6.4 weeks. The mean follow-up period was 8.9 months. Anatomical union was obtained in all patients. No joint instability, no malunion, nor osteomyelitis was observed. At the final examination, the average active range of motion of the PIP joint was 74.6°. The average Visual Analogue Scale for pain and Quick Disability of Arm, Shoulder, and Hand score were 1.2 and 3.2, respectively. The current study demonstrated good results of the PRTS for unstable intra-articular fractures of the PIP joint. Furthermore, satisfactory results were obtained in cases of an incomplete amputation at the PIP joint, a pathological fracture due to bone tumor, and an osteochondral defect due to comminuted fracture of the proximal phalangeal head, where costal osteochondral bone was transplanted. From this study, the PRTS is recommended as a useful treatment because it is widely effective for various unstable fractures of the PIP joint.

Surgical release for tubercular elbow stiffness.

BackgroundFor decades, tuberculosis (TB) has posed a great threat to people worldwide. Bone and joint TB is one of the most common types of extrapulmonary TB, with elbow TB comprising a small proportion of these cases. The treatment for elbow stiffness associated with TB has been rarely reported.Patients and methodsWe retrospectively analyzed six patients (four females and two males) with tubercular elbow stiffness during a 7-year period. All of them received open arthrolysis and hinged external fixation to restore functional extension, flexion, supination and pronation. Mayo Elbow Performance Score (MEPS) and range of motion (ROM) were evaluated preoperatively and at final follow-up.ResultsAt final follow-up after surgery, we evaluated the average active ROM, which was 111.7° (90°–135°). The average extension was 11.7° (0°–30°), while the average flexion was 123.3° (115°–135°). At the same time, the average supination was increased to 70° (40°–90°) and the average pronation was increased to 68.3° (45°–80°). The MEPS was elevated to 92.5 (85–100). Three patients displayed complications and were treated and cured with dressing changes and antibiotics.ConclusionOpen arthrolysis and hinged external fixation are useful for the treatment of non-traumatic elbow stiffness with TB.

Dynamic external traction combined with internal fixation for treatment of comminuted intra-articular fractures of the base of the thumb proximal phalanx

Objective To document the efficacy of our modified dynamic external traction system that is applied concomitantly with internal fixation for comminuted fractures at the base of thumb proximal phalanx. Methods From March 2009 to July 2014, 7 cases of comminuted fractures at the base of thumb proximal phalanx with metacarpophalangeal(MP) joint involvement (AO type C fractures) were treated with open or close reduction and internal fixation. Meanwhile a dynamic external traction system was applied. Postoperative exercise started early.Range of motion of the MP joint, pinch strength and postoperative complications were evaluated. Results Postoperative follow-up period ranged from 13 to 32 months, with an average of 18 months. The mean plaster splint immobilization time was 7.7 days (range, 3 to 14 days). The external fixator was removed at 4.3 weeks on average (range, 4 to 6 weeks). The internal fixation hardware removal time was 7.2 weeks postoperatively on average (range, 6 to 9 weeks). All the patients were able to return to their original jobs. The average active range of motion for the MP joint of the thumb was 8.6° (range, 5° to 10°) extension and 42.4° (range, 35° to 50°) flexion. Mean pinch strength was 89% of that of the contralateral side. According to the upper extremity functional evaluation criteria issued by the Hand Surgery Society of the Chinese Medical Association, the results were rated as excellent in 5 cases and good in 2 cases. Conclusion Dynamic external traction system combined with internal fixation can provide reliable fracture fixation and allow early mobilization of the MP joint. The variable traction force can effectively maintain joint stability during movement and reduce adhesion and contracture of the joint. Key words: Thumb; Finger phalanges; Intra-articular fractures; Dynamic traction

Knee salvage in revision arthroplasty after massive bone loss of the femur condyles (≥Engh III) with a single-modular-hinged knee revision implant.

Massive bone loss of the femur condyles in revision arthroplasty often requires modular-hinged revision implants to restore a stable joint situation. In the present series, the outcome after knee revision surgery using a single modular-hinged revision implant in patients with severe bone defects (>Engh III) is investigated. Sixty patients with severe bone defects (≥Engh III) after failed primary and revision knee arthroplasty were included. Medium follow-up was 47 (range 10-84) months after knee revision surgery. Medium patient age was 70 (range 33-87) years at the time of surgery. An average of 2.3 prior knee operations per patient was performed. 70% of the patients required the knee revision implant after two-stage revision because of a deep implant infection. Estimated 5year extremity survival was 95 and 65% implant survival. Reasons for implant revision in decreasing order were reinfection (30%), aseptic loosening (13%), and periprosthetic fracture (9.8%). The average active range of motion in the knee joint was 88° (range 40°-115°) for flexion. An extension deficit of a mean of -6° was (range -50-5° hyper-extension) observed. Patient age influenced the functional results significantly in terms of reduced walking distances and decreased modified WOMAC score. In consideration of this complex study, population acceptable functional results can be achieved using a modular knee revision endoprosthesis. In younger patients (<60years), satisfying results in terms of walking ability and overall satisfactory can be expected. The outcome in older multimorbid patients is worse. Yet, operation in these patients can be feasible to restore enough mobility for daily household activities.

Heterotopic Vascularized Joint Transfer in Mutilating Hand Injuries.

In cases of mutilating hand injuries, the primary goal is recovery of prehensile function. This is particularly true in the case of joints, which are extremely difficult to replace or reconstruct adequately when damaged. Heterotopic vascularized joint transfer is indicated when salvageable joints are available for transfer to a more functionally optimal position on the hand. Seven cases of mutilating hand injuries treated with heterotopic vascularized joint transfers from 2003 to 2012 were retrospectively identified. All patients sustained severe metacarpophalangeal joint (MPJ) or proximal interphalangeal joint (PIPJ) damage that threatened recovery of optimal hand function. All patients were men, with an average age of 34.7 years. Operative, perioperative, and postoperative details including final active range of motion were collected and analyzed. Seven joints were taken from nonsalvageable amputated digits: 4 from the amputated parts, and 3 from the proximal stumps. Five joints were transferred as free flaps requiring microvascular anastomosis, and 2 were transferred on neurovascular pedicles. One joint was lost due to vasospasm. Average active range of motion was 68.3° for homojoint transfers (MPJ to MPJ, PIPJ to PIPJ), and 35° for heterojoint transfers. All but 1 patient were able to achieve tripod pinch; the remaining patient achieved only side-to-side pinch. Heterotopic vascularized joint transfer is a useful technique to consider in cases of mutilating hand injuries. Improved recovery of prehensile function can be achieved with thoughtful design and execution, followed by proper patient education and rehabilitation.

Biological Reconstruction for Children with Osteosarcoma Around the Knee

Limb salvage in children with primary malignant bone tumours around the knee is challenging, with considerations such as shortening, bone and joint remodeling and high functional demands of active children. The ultimate aim for reconstruction is restoring a stable, painless and mobile joint. With improved survival rates from chemotherapy, reconstructive techniques should ideally last the child's lifespan. We adopted a biological approach by preserving the patients' native joint, with bony defects bridged by fibula grafts supplemented by autoclaved bone grafts infused with bone marrow. We conducted this retrospective review to determine if we were able to meet our objectives of reconstruction. A retrospective review of children with osteogenic sarcoma involving the distal femur or proximal tibia treated at our institution was done. Patients aged 13 years and below at the time of surgery who had undergone a limb salvage procedure that preserved the knee joint were included. Nine patients were identified, 3 males and 6 females. The average age was 10.0 years (range, 7 to 13 years) at the time of surgery. Seven had tumours involving the distal femur while 2 had tumours involving the proximal tibia. There were no cases of local recurrence. Four of the 9 patients died from metastatic disease, the 5 surviving patients have no evidence of disease, and the average follow-up for survivors was 13.2 years. The average active range of motion for the knee joint was 96° (range, 50° to 130°). The average Musculoskeletal Tumour Society (MSTS) score was 26.3 (range, 23 to 30). We have observed this technique of limb salvage offers satisfactory limb function with long-term follow-up.

Proximal interphalangeal joint replacement with an unconstrained pyrocarbon prosthesis (Ascension®): a long-term follow-up

There have been limited publications that report long-term outcomes of pyrocarbon implants. This report describes both clinical and radiographic long-term results for patients who have been treated with pyrocarbon proximal interphalangeal implants. Thirteen implants in ten patients are reported for an average follow-up of 8.3 years (range 6.2-9.3). All patients were suffering from degenerative joint disease. Five of the 13 digits were free of pain, the remaining eight digits had mild to moderate pain (visual analogue scale 2-5). The average active range of motion was 58° (SD 19°) at latest examination. X-ray results were unremarkable in six digits with an acceptable position of the prosthesis. However, in seven patients significant radiolucent lines (≥ 1 mm) were observed. Three prostheses demonstrated a migration of the proximal component, and one a subsidence of the distal component. Our study does not support the use of this implant for treatment of osteoarthritis of the finger joint owing to high complication rates and limited range of motion.

Improve reconstructed metacarpophalangeal joint function with second toe transplantation after curved osteotomy under the metatarsal head cartilage

Objective To investigate the technique and clinical results of curved osteotomy under the metatarsal head's cartilage for improving reconstructed metacarpophalangeal joint function of fingers with second toe transplantation. Methods There were total 21 cases with 21 digits. During second toe transplantation with the metatarsophalangeal joint, the bottom of the second metatarsal head was incised. Then a curved osteotomy were carried out on about 5.0 mm under the metatarsal head's cartilage until the passive range of motion could be 90°.Longitudinal or cross-Kirschner wires were used to fix the joint.Finally,the conventional methods were used to reconstruct the blood supply, movement and nerves. Results All 21 digits of the 21 cases survived uneventfully.The follow-up time was ranged from 6 to 24 months.Their average passive range of motion of the reconstructed metacarpophalangeal joint was 75°,ranging from 65° to 85°.The average active range of motion was 65°, ranging from 45° to 80°. Postoperative X-ray revealed fracture healed well without joint degeneration. Conclusion Curved osteotomy under the metatarsal head's cartilage is an effective way to improve active and passive activities function of the reconstructed metacarpophalangeal joint with second toe transplantation. Key words: Metacarpophalangeal joint ; Reconstruction ; Metatarsals ; Microsurgery ; Osteotomy

Outcomes of Open and Arthroscopic Subscapularis Repairs (SS-18)

Introduction Injury to the subscapularis tendon can be a cause of significant shoulder dysfunction. Diagnosis can be complex and therefore may be delayed. There is minimal literature on outcomes seen after subscapularis repair but some studies suggest shoulder function after rotator cuff repair is poorer in the setting of subscapularis repair. We present one-year minimum follow-up of a series of both arthroscopic and open subscapularis repairs. Methods We retrospectively reviewed 39 patients with one year follow-up after open or arthroscopic repair of a full-thickness subscapularis tear. Tear size (upper third, upper half, or entire subscapularis tendon) and pattern were recorded and any concomitant procedures documented. Preoperative and postoperative physical exams were completed including range of motion and the presence or absence of an abnormal stomach press. ASES and Constant scores were completed at 1 year by 24 of the total 39 patients. Results An open repair was performed in 17 patients and an arthroscopic repair in 22 patients. Average follow-up was 29 months (range 12-75 months). At most recent postoperative follow-up, the average active range of motion was forward elevation to 140 degrees, external rotation to 53 degrees, and internal rotation to T10. There was no significant difference in postoperative motion between open and arthroscopic repairs. Of those patients with an abnormal stomach press preoperatively, 48% continued to demonstrate an abnormal stomach press at latest follow-up. In those completing subjective outcome scores, the average ASES score was 76 and average Constant score was 73. There was no difference in range of motion, ASES, or Constant scores based on size of tear. Conclusion Outcomes of open and arthroscopic subscapularis repairs were equivalent. In addition, tear size was not predictive of outcome suggesting even complete subscapularis tears may do well after either open or arthroscopic repair. Though a complete repair was performed in all patients, nearly half of patients with an abnormal stomach press preoperatively were unable to perform a normal test postoperatively. Injury to the subscapularis tendon can be a cause of significant shoulder dysfunction. Diagnosis can be complex and therefore may be delayed. There is minimal literature on outcomes seen after subscapularis repair but some studies suggest shoulder function after rotator cuff repair is poorer in the setting of subscapularis repair. We present one-year minimum follow-up of a series of both arthroscopic and open subscapularis repairs. We retrospectively reviewed 39 patients with one year follow-up after open or arthroscopic repair of a full-thickness subscapularis tear. Tear size (upper third, upper half, or entire subscapularis tendon) and pattern were recorded and any concomitant procedures documented. Preoperative and postoperative physical exams were completed including range of motion and the presence or absence of an abnormal stomach press. ASES and Constant scores were completed at 1 year by 24 of the total 39 patients. An open repair was performed in 17 patients and an arthroscopic repair in 22 patients. Average follow-up was 29 months (range 12-75 months). At most recent postoperative follow-up, the average active range of motion was forward elevation to 140 degrees, external rotation to 53 degrees, and internal rotation to T10. There was no significant difference in postoperative motion between open and arthroscopic repairs. Of those patients with an abnormal stomach press preoperatively, 48% continued to demonstrate an abnormal stomach press at latest follow-up. In those completing subjective outcome scores, the average ASES score was 76 and average Constant score was 73. There was no difference in range of motion, ASES, or Constant scores based on size of tear. Outcomes of open and arthroscopic subscapularis repairs were equivalent. In addition, tear size was not predictive of outcome suggesting even complete subscapularis tears may do well after either open or arthroscopic repair. Though a complete repair was performed in all patients, nearly half of patients with an abnormal stomach press preoperatively were unable to perform a normal test postoperatively.

Long-term patient satisfaction and functional outcome 8–11 years after subacromial decompression

The aim of this investigation was to evaluate the long-term outcome of arthroscopic subacromial decompression (ASD) in patients with primary impingement syndrome stage II and early stage III. Ninety-five patients (105 shoulders, 48 female), mean age 54 years (range 26-69), who had undergone surgery between 1996 and 1999, were included. Pain intensity during activity and at rest, patient satisfaction, active range of motion (ROM), muscular strength and shoulder function using the Constant score were evaluated. Fifty-three (50%) shoulders were pain-free (Visual Analogue Scale < or = 10 mm) during activity and 72 (68%) shoulders were pain-free at rest. Sixty-one (58%) patients stated that they were very satisfied and 27 (25%) were quite satisfied with regard to their current shoulder function. Shoulders were divided into Group 1: Pain-free patients (n = 53), Group 2: Patients with shoulder pain and no arthropathy (n = 41) and Group 3: Patients with shoulder pain and arthropathy (n = 11). The groups had average active ROM of 157 degrees, 135 degrees and 117 degrees, respectively, in abduction and 97 degrees, 79 degrees, and 68 degrees in external rotation. The average strength in elevation in the scapular plane was 7.4, 5.8 and 3.9 kg, respectively, whereas the mean value in external rotation was 8.4, 7.9 and 5.3 kg, respectively. The Constant score had a mean value of 87, 69 and 59 points in the three groups, respectively. Eleven shoulders have undergone re-operation, one after a new trauma. We conclude that ASD is a valuable procedure. Patients expressed a high degree of satisfaction with shoulder function 8-11 years after ASD.

Chemoprotection of Flexor Tendon Repairs Using Botulinum Toxin

After flexor tendon repair, tendon gapping or rupture may be replaced by joint stiffness and poor function. After surgical repair of injured flexor tendons, botulinum toxin type A was injected into the forearm flexor muscles. This selectively decreased the force of muscle contraction. During this period of partial muscle denervation, patients could generate enough force to allow for early active mobilization (with its attendant benefits) but insufficient force to induce gapping or rupture of the repaired tendon. Eighteen adult patients with zone 2 flexor tendon injuries (34 digits) were studied prospectively for up to 3 years. Tendons were repaired using the modified Kessler technique and marked with stainless steel wire. Botulinum toxin was injected into the appropriate proximal flexor muscle belly under localizing electromyographic control. A matched cohort consisted of 53 patients (104 digits). Results were assessed according to range of joint motion (Kleinert and Verdan criteria) and electromyographic and radiologic studies. Ninety-four percent had excellent results and 6 percent of digits had good results. There were no patients with fair or poor results. Average active range of motion was 244 degrees at 18 months. No gapping or ruptures occurred and no tenolyses were required. The control group of matched controls (modified Kessler repair; no botulinum injection) showed that 81 percent of digits had excellent results, 6 percent had good results, 8 percent had fair results, and 6 percent had poor results. Botulinum toxin injection statistically significantly improves the results of flexor tendon repair. The authors have termed this technique "chemoprotection" of flexor tendon repairs.