Flexion Deficit Research Articles

To Manipulate or Not? Management of Pediatric Knee Arthrofibrosis Following Operative Fixation of Tibial Spine Fractures

ObjectivesKnee arthrofibrosis is a common complication after surgical fixation of tibial spine fractures. However, there is no standardized treatment modality for resultant arthrofibrosis, with some surgeons electing for non-operative management, while others prefer manipulation under anesthesia with a possible arthroscopic lysis of adhesions, if indicated. To better understand indications and outcomes from these treatment modalities for arthrofibrosis, we examined patients treated by both approaches. MethodsWe performed a multicenter retrospective case series of patients with arthrofibrosis after tibial spine fracture surgery. Arthrofibrosis was defined as loss of knee extension ≥ 10.0° and/or knee flexion ≥ 25.0° compared to the contralateral, uninjured knee at three months following index surgery. Patients were organized into two cohorts: non-operative and operative treatment. Data was collected for demographics, fracture classification, concomitant injuries, treatment timeline, and knee range of motion. ResultsThere were 16 patients in the operative group and 10 patients in the non-operative group. At the time of diagnosis, the operative group had a mean 10° larger flexion deficit compared to the non-operative group. Both treatment modalities resulted in similar ranges of motion at terminal evaluation. Final flexion was recorded as 130° in the operative group and 127° in the non-operative group. Final extension deficits were 3° in both cohorts. ConclusionsOperative and non-operative treatment modalities can be effective in management of knee arthrofibrosis after fixation of tibial spine fractures. Non-operative treatment may be more suitable for milder range of motion deficits, but further research is necessary to guide clinical practice. Level of EvidenceLevel IV, Case Series;

Increased rate of surgery for loss of motion following anterior cruciate ligament reconstruction during COVID-19

ObjectivesTo investigate the incidence and risk factors associated with loss of motion after anterior cruciate ligament reconstruction (ACLR) during the coronavirus disease 2019 pandemic (COVID-19). MethodsA retrospective review of patients undergoing primary ACLR between March 2017 and November 2022 by a senior high-volume orthopaedic surgeon was performed. Exclusion criteria included revision ACLR, multiligamentous knee surgery, and age <14 years. The COVID-19 group was categorized according to the United States Centers for Disease Control Public Health Emergency declaration dates (January 31, 2020–May 11, 2023). To minimize confounding variables associated with the early stages of COVID-19, patients who underwent ACLR between December 1, 2019 and February 29, 2020 were excluded. Loss of motion was defined using the International Knee Documentation Committee criteria for loss of motion of the knee (i.e. an extension deficit >5° or flexion deficit >15° compared to the contralateral knee) 3–12 months after ACLR or as requiring surgery to restore motion within 12 months of ACLR. ResultsA total of 336 individuals who underwent 352 primary ACLRs (164 pre-COVID-19, 188 during COVID-19) were included (mean age: 25.2 ​± ​10.6 years, 44% female). The overall rate of postoperative loss of motion was 15% (n = 53), and 9% (n = 31) required surgery to restore motion within 12 months of ACLR. More patients underwent surgery for loss of motion during COVID-19 compared to pre-COVID-19, which was statistically significant (12% (n = 23) vs 5% (n = 8), respectively, P = 0.02). However, a statistically significant difference in the rate of loss of motion was not detected (18% (n = 33) vs 12% (n = 20), respectively, P = 0.16). A statistically significant increased median time from injury to ACLR was observed during COVID-19 compared to pre-COVID-19 (55 vs 37 days, P <0.01). More patients were unable to achieve terminal extension (0°) at minimum 9 months postoperatively during COVID-19 compared to pre-COVID-19 (10% vs 3%, P = 0.04) and motion was worse at this interval (0°–136° vs −2°–138°, P <0.01). ConclusionSurgery for loss of motion following ACLR was more common during COVID-19. Decreased access to elective medical care, changed activity level, psychological effects, or COVID-19 itself may explain the increased rate of surgery for loss of motion during COVID-19. Level of evidenceCase series; level IV.

Clinical and radiographic outcome of tension band suture fixation for displaced olecranon fractures

BackgroundTension band wire fixation (TBW) is a well-described method for treating displaced olecranon fractures. Further surgery is often needed due to wound breakdown or prominent hardware. An all-suture technique has recently been described as an alternative to TBW but radiographic and clinical outcome are not well established. The aim of this single-center retrospective cohort study was to evaluate outcome after treatment with all-suture technique for simple displaced olecranon fractures.MethodsA retrospective review of olecranon fractures in patients (> 18 years) treated for displaced olecranon fractures with tension band suture fixation (TBSF) between February and August 2019 was performed in our facility. Primary outcome was revision surgery, which was assessed four years after surgery. Clinical and radiographical follow-up was performed at two weeks, six weeks, three months and six months to assess union rate, fracture displacement, range of motion (ROM), Quick-DASH and Oxford Elbow Score.ResultsA total of 24 patients were included. Median age was 64 years [IQR:39–73], 9 patients were male and median ASA score was 2 [IQR:1–2]. 15 fractures were Mayo type 2 A and 9 type 2B with minor comminution. At four-year follow-up, three patients had died. None of the remaining 21 patients had undergone revision surgery. At six months, the median Quick-DASH and Oxford Elbow Score were 2.3 [IQR:0-4.5] and 47 [IQR:46–48], respectively. Median elbow extension and flexion deficits were 0° [IQR:0-2.25] and 0° [IQR:0–0], respectively. Radiographic union was achieved in all patients. In two cases radiographic loss of reduction and malunion was observed but both patients were asymptomatic and had no functional deficits. One patient refractured the elbow due to a second trauma and was reoperated.ConclusionsTBSF is a promising technique for Mayo type 2 A and 2B fractures with minor comminution. There were no revision surgeries within the first four years. We found good functional outcomes and a high union rate.

Arthroscopic fibroarthrolysis and mobilization under anesthesia is a simple, reproducible, and satisfactory method for the treatment of patients with severe post-traumatic arthrofibrosis of the knee

ObjectiveTo evaluate the range of motion (ROM) of the knee in patients with severe post-traumatic knee arthrofibrosis after being treated with arthroscopic fibroarthrolysis (AFA) and manipulation under anesthesia (MUA). MethodsCase series of patients with severe post-traumatic knee arthrofibrosis who underwent AFL+MUA in a national referral center. The primary outcome to be assessed was ROM before and after surgery and then at 3-month intervals until a minimum follow-up of one year was completed. Results51 patients were included. The main injuries preceding the stiffness were tibial plateau fracture (37.3%), distal femur fracture (27.5%), and femoral shaft fracture (15.7%). Forty-five patients had severe flexion deficits with a median preoperative flexion of 70°. Intraoperative flexion significantly improved to 110°. Significant loss of flexion was observed at 3 and 6 months, however, patients regained ROM in the 9 and 12-month follow-ups. At discharge, 80% of the patients achieved flexion of 90° or more. There were 4 intraoperative complications and 3 reinterventions were performed. ConclusionAFA+MUA can help patients with severe post-traumatic knee arthrofibrosis to recover ROM in most cases. However, this procedure is not without risks and complications, therefore, careful consideration should be given to its indication and execution.

ACL Reconstruction Using Quadrupled Semitendinosus Versus Double-Stranded Semitendinosus and Gracilis Autograft: 2-Year Results From a Prospective Randomized Controlled Study

Background: A disadvantage of using hamstring tendon autograft consisting of the semitendinosus and gracilis tendons for anterior cruciate ligament reconstruction is pain from tendon harvesting and persistent hamstring weakness. In the tendon-sparing all-inside technique, a quadrupled semitendinosus graft and adjustable-loop cortical fixation are suggested to give less postoperative flexion deficits while displaying overall similar clinical results to the traditional hamstring technique. However, there are a limited number of high-quality studies comparing these techniques with inconsistent results. Purpose: To investigate differences between the all-inside (quadrupled semitendinosus) and traditional hamstring (double-stranded semitendinosus and gracilis) technique regarding (1) self-reported function, (2) hamstring strength, and (3) knee laxity. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 98 patients were randomized to either the all-inside or the traditional hamstring technique. Perioperatively, duration of surgery and graft size were obtained. The International Knee Documentation Committee 2000 Subjective Knee Form score, Knee injury and Osteoarthritis Outcome Score, Tegner Activity Scale score, knee laxity (KT-1000 arthrometer side-to-side difference and pivot shift), range of motion, isokinetic knee strength, and hop test score were collected preoperatively and 2 years postoperatively. Return-to-sport readiness was evaluated 9 months postoperatively. Results: A total of 89 patients completed 2-year follow-up, 45 patients with the all-inside technique and 44 patients with the traditional hamstring technique. There were no significant differences between groups in any of the outcome measures 2 years after surgery, but there was a tendency in the all-inside group toward having increased anterior translation (mean, 3.6 mm vs 2.7 mm), a higher number of revision surgeries (5 patients vs 2 patients), and more patients having +1 and +2 pivot-shift values (29 vs 18 patients) when compared with the traditional group. Conclusion: The all-inside technique yields equivalent results to the traditional hamstring technique 2 years after surgery and should be considered a reliable technique to use for ACL reconstruction. Sparing the gracilis tendon does not lead to less persistent hamstring weakness. Long-term follow-up is needed to further determine whether the tendency of increased anterior translation seen at 2 years postoperatively will lead to a higher risk of graft failure.

Fixation of Long Oblique and Spiral Metacarpal Shaft Fractures With Intramedullary Screw and Cerclage Wires

Introduction: Long oblique and spiral metacarpal shaft fractures are length-unstable fracture patterns susceptible to malrotation and shortening. We expand the use of intramedullary screw fixation for traditional length-unstable fracture patterns including long oblique and spiral with cerclage wire augmentation. Materials and Methods: Surgical technique of intramedullary screws for long oblique and spiral metacarpal shaft fractures, augmented with cerclage wires, is described. Case series of patients who underwent this technique over a 3-year period from 2 surgeons at a single institution were evaluated. The inclusion criteria included patients who underwent this technique with long oblique or spiral metacarpal shaft fractures. The exclusion criteria included open injuries, and base or neck fractures. Results: A total of 8 patients were included with an average age at surgery 42 years old (range, 25 to 70). Six of the 8 patients achieved full range of motion at the time of final follow-up. One patient had ~5 to 10-degree deficit in both flexion and extension, and the other had 20-degree loss in both flexion and extension. The follow-up averaged 62 days (range, 25 to 144 days). There were no patients with nonunion, malunion, hardware failure, or postoperative fracture subsidence or malrotation. The average time to union was 6.1 weeks (range, 3.5 to 12.4 wks). Conclusions: This hybrid technique expands the use of intramedullary screws to traditional length-unstable fractures including long oblique and spiral patterns. Patients demonstrate return to full range of motion, union approximately in 6 weeks, with minimal complications following this minimally invasive technique.

Outcomes of an All-Soft Tissue Fixation Technique for Reconstruction of the Medial Patellofemoral Complex Using Double-Bundle Quadriceps Tendon Autograft for Recurrent Patellar Dislocation in Skeletally Immature Patients.

Patellar fracture, femoral physis injury, and recurrent instability are concerning complications in medial patellofemoral ligament (MPFL) reconstruction (MPFLR) techniques for recurrent patellar dislocation in children and adolescents. To evaluate the outcomes of an anatomic all-soft tissue fixation technique for reconstruction of the medial patellofemoral complex (MPFC) using a double-bundle quadriceps tendon (QT) autograft for recurrent patellar dislocation in skeletally immature patients. Case series; Level of evidence, 4. This retrospective study involved 24 skeletally immature patients (24 knees; 16 women and 8 men; age range, 9.5-15 years) with recurrent patellar dislocation who underwent MPFC reconstruction using a double-bundle QT autograft between September 2018 and January 2021. Only soft tissue suture fixation was used on the femoral and patellar sides of the 2 bundles of the QT. Radiographs, computed tomography, and magnetic resonance imaging were used to evaluate physeal status, lower limb alignment, patellar height and tilt, trochlear morphology, tibial tubercle-trochlear groove distance, and any associated knee pathology. Functional outcomes were assessed with the Kujala score, the visual analog scale (VAS) for pain, and the grading system of Insall et al.22. The mean follow-up time was 40 ± 9.6 months (range, 28-56 months). At the final follow-up, the Kujala and VAS pain scores showed a significant improvement versus preoperative scores (P < .001), and the passive lateral patellar glide showed a significant reduction (P < .001). All patients had negative apprehension and J signs. Of the 24 patients, 23 regained full range of motion, while 1 patient had a knee flexion deficit. The patellar tilt angle improved significantly at the final follow-up (P < .001). There was no patellar fracture, femoral physis injury, or recurrence of patellar dislocation. According to the grading system of Insall et al, the results were excellent in 15 knees (62.5%), good in 8 knees (33.3%), fair in 1 knee (4.2%), and no knees showed poor results. Reconstruction of the MPFC using a double-bundle QT autograft with an all-soft tissue fixation technique was an effective method for treating patellar instability in skeletally immature patients.

Characterization of the Relative Change in Objective and Subjective Metrics by Baselining Patients Who Have Wearable Technology Before Total Knee Arthroplasty

BackgroundWearable sensors and associated supporting technologies (ie, patient applications) can provide both objective (joint position, step counts, etc.) and subjective data (ie, pain scores and patient-reported outcome measures) to track a patient’s episode of care. Establishing a subjective and objective baseline of a patient’s experience may arguably be beneficial for multiple reasons, including setting recovery expectations for the patient and demonstrating the effectiveness or success of the intervention. MethodsIn this pilot study, we characterized a subset of patients (n = 82 from 7 surgeons) using a wearable sensor system at least 6 days before total knee arthroplasty and provided postsurgical data up to 50 days postintervention. The 5-day average before surgery for total step counts (activity), achieved flexion and extension on a progress test (functional limit) and visual analog scale daily pain score were calculated. The difference from baseline was then calculated for each patient for each day postsurgery and reported as averages. ResultsOn average, a patient will experience a relative deficit of 4,000 steps immediately following surgery that will return to near-baseline levels 50 days postintervention. A 30° deficit in flexion and a 10° deficit in extension will return at a similar rate as steps. Relative pain scores will worsen with an increase of approximately 3 points immediately following surgery. However, pain will decrease by 2 points relative to baseline between 40 and 50 days. ConclusionsThe results of this pilot study demonstrate a method to baseline a patient’s presurgical subjective and objective data and to provide a reference for postsurgical recovery expectations. Applications for these data include benchmarking for evaluating intervention success as well as setting patient expectations.

Moment arm and torque generating capacity of semitendinosus following tendon harvesting for anterior cruciate ligament reconstruction: A simulation study.

Altered semitendinosus (ST) morphology and distal tendon insertion following anterior cruciate ligament reconstruction (ACLR) may reduce knee flexion torque generating capacity of the hamstrings via impaired ST force generation and/or moment arm. This study used a computational musculoskeletal model to simulate mechanical consequences of tendon harvest for ACLR on ST function by modeling changes in ST muscle tendon insertion point, moment arm, and torque generating capacity across a physiological range of motion. Simulated ST function was then compared between ACLR and uninjured contralateral limbs. Magnetic resonance imaging from 18 individuals with unilateral history of ACLR involving a hamstring autograft was used to analyse bilateral hamstring muscle (ST, semimembranosus, bicep femoris long head and short head) morphology and distal ST tendon insertion. The ACLR cohort was sub-grouped into those with and without ST regeneration. For each participant with ST regeneration (n = 7), a personalized musculoskeletal model was created including postoperative remodeling of ST using OpenSim 4.1. Knee flexion and internal rotation moment arms and torque generating capacities of hamstrings were evaluated. Bilateral differences were calculated with an asymmetry index (%) ([unaffected limb-affected limb]/[unaffected limb + affected limb]*100%). Smaller moment arms or knee torques within injured compared to uninjured contralateral limbs were considered a deficit. Compared to uninjured contralateral limbs, ACLR limbs with tendon regeneration (n = 7) had minor reductions in knee flexion (5.80% [95% confidence interval (CI) = 3.97-7.62]) and internal rotation (4.92% [95% CI = 2.77-7.07]) moment arms. Decoupled from muscle morphology, altered ST moment arms in ACLR limbs with tendon regeneration resulted in negligible deficits in knee flexion (1.20% [95% CI = 0.34-2.06]) and internal rotation (0.24% [95% CI = 0.22-0.26]) torque generating capacity compared to uninjured contralateral limbs. Coupled with muscle morphology, ACLR limbs with tendon regeneration had substantial deficits in knee flexion (19.32% [95% CI = 18.35-20.28]) and internal rotation (15.49% [95% CI = 14.56-16.41]) torques compared to uninjured contralateral limbs. Personalized musculoskeletal models with measures of ST distal insertion and muscle morphology provided unique insights into post-ACLR ST and hamstring function. Deficits in knee flexor and internal rotation moment arms and torque generating capacities were evident in those with ACLR even when tendon regeneration occurred. Future studies may wish to implement this framework in personalized musculoskeletal models following ACLR to better understand individual muscle function for injury prevention and treatment evaluation.

Clinical and Functional Outcomes of Suture Versus Headless Screw Fixation for Tibial Eminence Fractures in Children

Background: Suture and screw fixations are widely used to treat tibial eminence fractures (TEFs). Although a few biomechanical and clinical studies have compared suture fixation (SF) and screw fixation in the treatment of TEFs in children, no comparative clinical studies are available regarding headless screw fixation (HSF). Purpose: To evaluate the clinical and functional outcomes of children with TEF who underwent SF and HSF. Study Design: Cohort study; Level of evidence, 3. Methods: The study included 24 patients treated with either SF (11 patients) or HSF (13 patients) within 1 month of TEF (type 2 or 3) without associated ligamentous and bone injury between 2015 and 2020. All patients were evaluated at a minimum 2-year follow-up in terms of Lysholm score, Tegner activity level, International Knee Documentation Committee subjective score, and isometric strength test. Knee stability was compared based on the Lachman test, pivot-shift test, and KT-1000 arthrometer side-to-side difference. Results: No significant differences were found between the 2 groups in terms of Lysholm score, Tegner activity level, and International Knee Documentation Committee subjective score at follow-up. All patients were able to resume their daily activities within 6 months after the injury. However, flexion deficits (6°-10°) were found in 2 patients in the SF group and 1 patient in the HSF group, and extension deficits (3°-5°) were found in 3 patients in the SF group and 1 patient in the HSF group, without significant intergroup difference. Stability based on the Lachman test, pivot-shift test, and KT-1000 arthrometer side-to-side difference was also similar between the 2 groups at follow-up. No statistically significant difference was found between the 2 groups in isometric tests performed. Conclusion: The present study is the first to compare the clinical and functional results of SF and HSF techniques. The HSF technique demonstrated comparable clinical and functional outcomes, suggesting its potential as an alternative to the SF technique.

Isolated Severing of the Long Flexor of the Thumb Following an Electrical Shock: A Case Report

We report a case of isolated severing of the FPL tendon following an electrical shock, A 24 -year-old male suffered from an electrical shock while work on home electrical circuit. The lesion was limited to the right hand, clinical exam showed a deficit of thumb flexion with multiple skin burn lesions, surgical exploration and repair we done after stabilization of the patient.

Asymmetric Deficit of Knee Flexion: An Occasional Symptom of Discoid Lateral Meniscus in Children.

A knee flexion deficit can be the unique symptom and sign of discoid lateral meniscus (DLM) in children. The aim of this study was to investigate the accuracy of this clinical sign. The hypothesis was that deficit of knee flexion was associated with anterior rim disinsertion and posteriorly fixed DLM. A retrospective, single-center study was conducted in a larger series of 114 operated knees for symptomatic DLM from 2007 to 2018. A focus was done on 9 knees with a deficit of knee flexion without snapping. History and clinical examination with grading of instability, preoperative magnetic resonance imaging, and arthroscopic findings were studied. Among 35 knees with DLM grade 3 of instability, 26 had an isolated extension deficit. Nine knees in 5 boys and 4 girls with a mean age of 9 years (range 6 to 12) had a flexion deficit. It was the only symptom of DLM in 6, and it was associated to extension deficit in 3. In the history, 8 knees were grade 2 (snapping knee) before evolving toward a flexion deficit. All had a complete DLM with posterocentral (n=7) or central (n=2) shift at magnetic resonance imaging analysis. All had DLM with posterior shift fixed during arthroscopic evaluation. Moreover, looking at the entire series, 1 knee was a false negative and had a full flexion despite a posterior and fixed DLM during arthroscopic evaluation. The sensitivity of asymmetrical knee flexion to predict posterior fixed DLM was 90%. An asymmetric deficit in knee flexion is highly suggestive of DLM with anterior detachment and fixed posterior meniscal shift (specificity and positive predictive value of 100%). Given this could be the only clinical sign of DLM, specific attention therefore must be paid in the assessment of knee flexion by measuring the distance between heel and bottom on both sides, especially in a knee without snapping currently but with a history of snapping (grade 3). Level III.

Relationship between Upper Limb Functional Assessment and Clinical Tests of Shoulder Mobility and Posture in Individuals Participating in Recreational Strength Training.

The upper limb is crucial for functioning in everyday life, thus comprehensive assessment is crucial for physically active people to monitor the effect of exercise and prevent injuries. The aim of this study was to analyse the relationship between upper limb function, shoulder mobility, and posture in individuals who participate in recreational strength training. Thirty-four subjects who engaged in strength training of the upper limbs were divided into two groups: Group 1 (exercise < 3 years) and Group 2 (exercise ≥ 3 years). Lateral scapular slide tests, head and clavicle posture evaluations, and shoulder mobility and closed kinetic chain tests were performed. Group 1 had a greater flexion deficit in both shoulders than Group 2. There was greater external rotation in the non-dominant shoulder and a greater score of the closed kinetic chain test in Group 2 compared to Group 1. There were no statistically significant differences between groups regarding scapula, clavicle, and head posture. The closed kinetic chain test was correlated with a scapula position and symmetry in shoulder flexion in Group 2. Long-term strength training of the upper limbs can be recommended to improve functional abilities in the closed kinetic chain, increase shoulder mobility, and reduce asymmetry.

ADJUNCT CPM THERAPY DOES NOT APPEAR TO IMPROVE THE ROM ACHIEVED AFTER MUA FOR STIFFNESS IN TOTAL KNEE ARTHROPLASTY

Stiffness is reported in up to 16% of patients after total knee replacement (TKR)1. Treatment of stiffness after TKR remains a challenge. Manipulation under anaesthesia (MUA) accounts for between 6%-36% of readmissions following TKR2,3. The outcomes of MUA remain variable/unpredictable. Post-operative CPM is used as an adjuvant to MUA, potentially offering improved ROM, however, remains the subject of debate. We report a retrospective study comparing MUA with and without post-operative CPM.In our institution patients undergoing MUA to receive CPM post-operatively. Owing to the COVID-19 pandemic hospital admissions were limited. During this period MUA procedures were undertaken without CPM. Two cohorts were included: 1) MUA + post-operative CPM 2) Daycase MUA. Patients’ demographics, pre-manipulation ROM, post-MUA ROM, and ROM at final follow-up were recorded.Between 2017-2022 126 patients underwent MUA and were admitted for CPM and 42 had daycase MUA. The median Age was 66.5 and 64% were female. 57% had extension deficit (&gt;5o), 70% had flexion deficit (&lt; 90o), and 37% had both. The mean Pre-operative ROM was 72.3o(SD:18.3o) vs. 68.5o(19.0o), ROM at MUA was 95.5o(SD:20.7o) vs 108.3o(SD:14.1o) [p&lt; 0.01], and at final follow-up 87.4o(SD:21.9o) vs. 92.1o(SD:18.2o) for daycase and CPM groups respectively. At final follow-up for the daycase and CPM groups respectively 10% vs. 7% improved, 29% vs. 13% maintained, and 57% vs. 79% regressed from the ROM achieved at MUA. The mean percentage of ROM gained at MUA maintained at final follow-up was 92%(SD:17) and 85%(SD:14)[p=0.03] for daycase and CPM groups respectively.There was no significant difference in ROM achieved at final follow-up despite the significantly greater improvement in ROM achieved at MUA for the CPM group. The CPM group lost a greater ROM after MUA (15% vs. 8%). We conclude that post-operative CPM does not improve ROM achieved after MUA.

Arthroscopic Dorsal Ligamentocapsulodesis in the Treatment of Occult Dorsal Wrist Ganglion Cysts Associated with Scapholunate Instability: Surgical Technique and Preliminary Clinical Results.

Background: This study aimed to evaluate our preliminary results and experience with the arthroscopic dorsal ligamentocapsulodesis in managing occult dorsal wrist ganglion cysts (ODGCs) associated with scapholunate (SL) instability. Methods: All patients who underwent arthroscopic dorsal ligamentocapsulodesis due to an ODGC with concomitant SL ligament tear were retrospectively reviewed. In addition to demographic data and length of follow-up, outcomes data that included range of motion, grip strength, modified Mayo wrist score (MMWS), complications and radiographs were collected. Results: The study included 18 patients (18 wrists; 10 female and 8 male). The mean age was 32 years (range: 19-48) and the mean follow-up was 34 months (range: 24-48). The mean preoperative extension deficit decreased from 5.5° (range: 0°-20°) to 2.7° (range: 0°-15°) at the final follow-up (p = 0.004). The mean preoperative flexion deficits decreased from 4.4° (range: 0°-15°) to 2.2° (range: 0°-10°) postoperatively (p = 0.003). The mean hand grip strength significantly increased from 27.7kg (range: 22-36) to 38.3kg (range: 31-46) at the final follow-up assessment (p < 0.001). The mean MMWS improved from 46 (range: 25-65) pre-operatively to 91 (range: 70-100) at the final follow-up (p = 0.0002). No major intra- or postoperative complications were observed. Conclusions: SL instability may have an important role in the aetiology of ODGCs, and arthroscopic dorsal ligamentocapsulodesis can provide pain relief and functional improvement without recurrence at the short- to mid-term follow-up in the treatment of ODGCs. Level of Evidence: Level IV (Therapeutic).

POSTOPERATIVE CPM DOES NOT IMPROVE ROM ACHIEVED AFTER MUA FOR STIFFNESS IN TOTAL KNEE ARTHROPLASTY

AbstractObjectivesStiffness is reported in 4%–16% of patients after having undergone total knee replacement (TKR). Limitation to range of motion (ROM) can limit a patient's ability to undertake activities of daily living with a knee flexion of 83o, 93o, and 106o required to walk up stairs, sit on a chair, and tie one's shoelaces respectively. The treatment of stiffness after TKR remains a challenge. Many treatment options are described for treating the stiff TKR. In addition to physiotherapy the most employed of these is manipulation under anaesthesia (MUA). MUA accounts for up to 36% of readmissions following TKR. Though frequently undertaken the outcomes of MUA remain variable and unpredictable. CPM as an adjuvant therapy to MUA remains the subject of debate. Combining the use of CPM after MUA in theory adds the potential benefits of CPM to those of MUA potentially offering greater improvements in ROM. This paper reports a retrospective study comparing patients who underwent MUA with and without post-operative CPM.MethodsStandard practice in our institution is for patients undergoing MUA for stiff TKR to receive CPM for between 12–24hours post-operatively. Owing to the COVID-19 pandemic hospital admissions were limited. During this period several MUA procedures were undertaken without subsequent inpatient CPM. We retrospectively identified two cohorts of patients treated for stiff TKR: group 1) MUA + post-operative CPM 2) Daycase MUA. All patients had undergone initial physiotherapy to try and improve their ROM prior to proceeding to MUA. In addition to patients’ demographics pre-manipulation ROM, post-MUA ROM, and ROM at final follow-up were recorded for each patient.ResultsIn total 168 patients who had undergone MUA between 2017–2022 were identified with a median Age of 66.5 years and 64% female. 57% had extension deficit (&gt;5o), 70% had flexion deficit (&lt; 90o), and 37% had both. 42 had daycase MUA without CPM and the remaining 126 were admitted for post-operative CPM. The mean Pre-operative ROM was 72.3o (SD:18.3o) and 68.5o (19.0o) for the daycase and CPM groups respectively. The mean ROM recorded at MUA was 95.5o (SD:20.7o) and 108.3o (SD:14.1o) [p&lt;0.01] and at final follow-up was 87.4o (SD:21.9o) and 92.1o (SD:18.2o) for daycase and CPM groups respectively. At final follow-up for the daycase and CPM groups respectively 10% vs. 7% improved, 29% vs. 13% maintained, and 57% vs. 79% regressed from the ROM achieved at MUA. The mean percentage of ROM gained at MUA maintained at final follow-up was 92% (SD:17%) and 85% (SD:14%) [p=0.03] for daycase and CPM groups respectively.ConclusionOverall, there was no significant difference in ROM achieved at final follow-up despite the significantly greater improvement in ROM achieved at MUA for the CPM group. Analysis of the percentage ROM gained at MUA maintained at follow up showed that most patients regressed from ROM achieved at MUA in both groups with those in the CPM only maintaining 85% as opposed to 92% in the daycase patients. It is our observation that post-operative CPM does not improve ROM achieved after MUA as compared to MUA alone.Declaration of Interest(b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.

Tibialis Posterior Tendon Transfer for Foot Drop: Case Report

Irreparable sciatic nerve palsy is a cause of foot drop and resulting in absent or weak most of the muscles in leg. There may be dysfunctions of all tendons in the leg excepting Achilles tendon and plantaris tendon. The treatment of this atypical neurologic injury has not been defined. I reported a case of foot drop case of patient who presented with paralysis of the external popliteal sciatic nerve, The neurological exam revealed a deficit of the dorso flexion of the foot and hypoesthesia of the dorsal region of the foot concomitant with a section of the external popliteal sciatic nerve. tibialis posterior transfer gives good results in terms of normal gait, high patients, satisfaction with minimal donor site morbidity and low complication rate.

The Effect of an Exercise Program on the Biomechanics of the Shoulder Girdle in Overhead Shooting in High-level Handball Players

Handball athletes are subjected to high loads, especially during the process of throwing or shooting overhead. These athletes often complain of pain and report unexplained loss of throwing velocity and throwing control. Shoulder dyskinesia and overuse syndrome have been identified as risk factors among elite handball athletes. Understanding the dynamics and kinematics of the throwing phase is vital for the exercise professional. This study evaluates the effect of an interventional exercise program on shoulder girdle biomechanics and overhead shooting. The sample consisted of 20 high level handball athletes from Greece. The athletes were divided into two groups: 10 in the study group, who were given the exercise program, and 10 in the control group, who only engaged in in-team handball training. Before and after the program, the following measurements were performed: a) angular measurements of abduction, adduction, flexion and extension of the shoulder; b) isokinetic evaluation of abduction flexion and adduction extension of the shoulder joint, at three angular velocities (60°/sec, 180°/sec and 300°/sec). Inferential statistics showed that there was a statistically significant difference in angular measurements with a reduction in range of motion for 10 of the study group. In the isokinetic assessment there was a statistically significant difference, in the 180°/sec velocities in flexion and extension, and in the deficit of flexion of both shoulders. In conclusion, the interventional exercise program had, to some extent, a beneficial effect on muscle strengthening of the shoulder girdle. The results of this study may suggest training guidelines, provide important information to exercise professionals, and provide feedback to handball athletes.

Discoid lateral meniscus instability in children: part I. A new grading system of instability to clarify natural history.

In young patients, the discoid lateral meniscus (DLM) usually becomes symptomatic at the time of peripheral rim instability of a complete discoid form. However, little is known about the natural history of meniscal instability. The aim was to detect hidden forms of presentation of instability using the history and clinical mechanical symptoms of instability. Retrospective study of 114 paediatric knees treated for DLM. A new clinical grading system for instability (stable, locked, snapping, blocked and unblocked knees) was defined and studied in combination with MRI and arthroscopic findings. One hundred seven DLMs (94%) showed instability due to edge detachment. Fifteen (13%) knees were stable (grade 0), 2 (2%) were grade 1, 57 (50%) were grade 2, 35 (31%) were grade 3 and 5 (4%) were grade 4. The cause of grade 3 was an extension deficit (26/35) or flexion deficit (9/35). Grade 1 or 2 correlated with limited detachment, unlike grade 3 or 4. The grade of instability never decreased, but rather increased in many knees during the natural history of DLM. A new presentation of DLM is presented: episodic locking phenomenon and blocked knee with flexion deficit. Clinicians should be wary of pseudo-improvement with the recovery of mobility after a period of the blocked knee, which may be due to a progression towards the ultimate degree of instability. Clinical grading of instability has clarified the natural history of DLM-associated tearing. III.

Clinical and radiological evaluation of surgical treatment of medial epicondyle fractures of humerus in children. A two-centre study

The present study analyses the outcome of open reduction and internal fixation (ORIF) of humerus medial epicondyle fracture with the use of Kirschner (K) wires, and determine the effect of elbow dislocation. The study included 112 patients operated on in 2005–2016. Of these, 81presented with an isolated medial epicondyle fracture (mean age 11.6 years), and 31 with an elbow dislocation (mean age 11.9 years). Out of 112 patients tested, 98 achieved an excellent treatment result, ten good and a mean Mayo Elbow Performance Score (MEPS); no significant differences were observed between dislocated and non-dislocated elbow groups. Those with an isolated medial epicondyle fracture demonstrated a mean flexion of 140.7° and extension deficit of 3.0°, while those with an elbow dislocation displayed a mean flexion of 134.5° and extension deficit 6.1°. The dislocation group demonstrated significantly greater extension and flexion deficits (p = 0.019, p < 0.001, respectively). One patient required revision surgery due to nonunion. Ulnar nerve function was normal in 110 patients: in the other two, it resolved spontaneously in one, and the nerve was transposed in the other. Medial elbow instability was found in seven patients: two with elbow dislocation and five without. ORIF with K wires is a safe procedure for treating medial epicondyle humeral fractures that yields good or very good results. Similar outcomes are observed between patients with and without dislocation according to MEPS; however, flexion and extension are more limited in the former group.