Loss Of Flexion Research Articles

The Results of Single Bundle Versus Double Bundle ACL Reconstruction Surgery, a Retrospective Study and Review of Literature.

Objective:The purpose of this study was to evaluate the results of single bundle and double bundle surgical techniques for anterior cruciate ligament (ACL) reconstruction.Methods:In this study, all single bundle and double bundle ACL reconstruction surgeries that were done in our university hospital from January 2008 to December 2012 were enrolled. All patients were followed at 2,6,12, 24 weeks and 1 a 2 years post operatively. On last follow up all patients were evaluated by clinical examination, KT-1000 and Lysholm questionnaire.Results:Seventy five patients were operated using single bundle and eighty five patients with double bundle technique. Fifty seven percent of patients in single bundle and 80% of patients in double bundle group had experienced pain during follow-up period. None of cases had knee extension or flexion loss. The average side to side differences using KT-1000 was 3.5 ± 0.38 (2.9-4.1) millimeters in single bundle group and 3.39 ± 0.39 (2.8-4) millimeters in double bundle group. These results showed no significant difference between two groups (P= 0.31). Lysholm score improved significantly in both groups, but there was no significant difference between them.Conclusion:According to this study the clinical results of single bundle ACL reconstruction was similar to double bundle reconstruction in short term follow up. Further studies are needed to evaluate the long term results.

The Iliotibial Band Transfer Restores Extensor Function after Quadricepsplasty for Knee Stiffness

Introduction: Retractile fibrosis of the quadriceps is a physical and social handicap in children, and often results from a past history of quadriceps intramuscular injection. The aim of this study was to evaluate the therapeutic results of fibrous quadriceps treated by distal quadricepsplasty using a transferring Iliotibial band (TITB) to prevent kin necrosis by Incision Z-Plasty. Materials and Methods: This is a descriptive retrospective 21-year study from 1984 to 2005, including 103 children (113 knees) less than 9 years old. Clinical were: all of patients knee flexion loss of motion 113 (100%), without associated Genu recurvatum or Dislocation of the patella. Results: The pre-operative range of flexion varied from 5° to 32° with a mean range of 22.5°. The post-operative range was 75° to 140°. The improvement in the range of flexion varied from 5° to 140° with a mean gain of 95°. At the final follow-up, the mean active flexion was 123.5° (85 to 140). The final mean gain in movement was 97.6° (25 to 135). The mean pre-operative ROM was 37.9° (0° to 35°). The mean ROM achieved at operation was 115.9° (75° to 140°). Mean flexion ROM after surgery was 77.7°. Mean flexion increased from 77.7° to 108.5° following postoperative rehabilitation or a mean gain of 30.7°. Author was performed Incision Z-Plasty for 34 knees, all of them (100%) with good result, and without incision necrosis. Conclusion:Quadriceps contracture is a condition quadriceps is contracted due to various causes. Various surgical options are available based on location of contracture, age, cause and duration of the contracture. Transfering Iliotibial band to Quadriceps after Quadripsplasty and Incision Z-Plasty with postoperative good result.

Screw Fixation of Lateral Condyle Fractures: Results of Treatment.

Fixation of lateral condyle distal humeral fractures has traditionally been achieved with K-wires. Screw fixation provides the advantage of compression across the fracture site, but the results of screw fixation and risk of iatrogenic physeal damage are not well defined. This study was designed to evaluate the efficacy of screw fixation for lateral condyle fractures. A retrospective study of patients with lateral condyle elbow fractures treated using screw fixation at a single institution was undertaken. Patients 12 years and younger with isolated fractures were included. Clinical notes were examined for residual symptoms, alignment, range of motion, and complications. Radiographs were reviewed for healing and growth arrest. Ninety-six patients who were treated over a 7-year period met inclusion criteria. Mean patient age was 5.8 years (range, 2 to 12 y). Fifty-four patients required open reduction; 42 patients underwent a closed reduction. Mean follow-up was 28.1 weeks (range, 4.9 to 417 wk). The overall complication rate was 19% and was 5% when lateral overgrowth was excluded as a complication. Initial fracture union was achieved in 99% of patients. One patient required revision fixation with a bone graft. Hardware was symptomatic with prominence or loss of flexion in 4% of patients. There were no cases of growth arrest or alterations of the carrying angle. For patients with final follow-up >12 months, the mean extension loss was 2 degrees (range, 0 to 25 degrees) and the mean loss of flexion was 8 degrees (range, 0 to 25 degrees). Screw fixation of lateral condyle fractures results in satisfactory union with a low risk of complications at early follow-up.

Bilateral Shoulder Dysfunction Related to the Lung Resection Area After Thoracotomy.

This study aimed to investigate the mobility, pain, and disability of the shoulders after different pulmonary surgical procedures.It is a cross-sectional prospective study. A total of 38 patients who underwent lung surgery via thoracotomy (mean age = 57 ± 10 years) were evaluated in the preoperative period, and first and second postoperative days were assessed for range of motion of shoulder; pain intensity; and application of the Shoulder Pain and Disability Index questionnaire. This study compared the 3 days of evaluation, and the subgroups according to the resection area (biopsy/nodulectomy, lung segmentectomy and lobectomy).There was a decrease of flexion (153° ± 16°–98° ± 23°), abduction (151° ± 20°–126° ± 38°), and increased Shoulder Pain and Disability Index (2.4–44.3) in the shoulder ipsilateral to surgery from the preoperative to the first postoperative day (P < 0.05). There was a greater loss of ipsilateral flexion and abduction in the lobectomy subgroup (P < 0.05), and decreased abduction of the contralateral shoulder in the lung segmentectomy and lobectomy subgroups (P < 0.05).After pulmonary surgery, there is bilateral impairment in shoulder range of motion, with greater limitation on ipsilateral shoulder, and larger resections.

Pressing fixation of mallet finger fractures with the end of a K-wire (a new fixation technique for mallet fractures)

AimThe aim of this study was to describe and evaluate a surgical technique for the treatment of mallet finger fractures using a K-wire stabilization of the distal interphalangeal (DIP) joint and another K-wire pressing the bone fragment. MethodsBetween June 2007 and March 2014, 41 patients (28 men, 13 women) with isolated closed mallet finger fracture were treated using two K-wires. In the cohort, the mean joint surface involvement was 44.3% (range: 28–62%). With a mean period of 23.6 months, patient follow-up lasted 13–34 months. The fingers were evaluated for loss of extension and flexion of the (DIP) joints. The results were graded using Crawford's criteria. ResultsUnion of all fractures took place at an average of 5.5 weeks after the surgical procedure. Average extension lag was 4°, and active flexion 71°. According to the Crawford rating scale, 35 fingers were excellent, four were good, one was fair, and one was poor. ConclusionsPressing fixation of the bone fragment with the end of a K-wire was a useful technique in the treatment of mallet finger fractures. Type of study/level of evidenceTherapeutic IV.

Influence of preoperative factors on the gain in flexion after total knee arthroplasty

Final flexion mobility after a total knee arthroplasty is an important factor in patient comfort. Some patients gain in flexion mobility, others do not. Is it possible to identify the clinical factors related to the patient that predicted the final gain in flexion? Materials and methodsA multicenter retrospective study directed by the Société française de la hanche et du genou (SFHG) was conducted on 1601 cases of total knee arthroplasty that had presented no complications and a minimal follow-up of 2 years. The gain in flexion was assessed by the difference between the preoperative and the final range of flexion. The range of the gain in flexion was tested based on eight factors: age, gender, etiology, body mass index, frontal deformity, preoperative flexum deformity and four levels of preoperative mobility: < 90°, 90°–109°, 110°–129°, and ≥ 130°. ResultsA mean gain in flexion of 8.4°±14° was found for the overall series. In 66% of cases, we found an increase of flexion and in 19% a loss of flexion. In cases with BMI higher than 35, varus deformity with an HKA angle<166°, or flessum greater than 5°, the gain in flexion was significantly higher. A significantly different gain in flexion (P<0.0001) was found in the four levels of preoperative flexion: the greatest gain in flexion was found in the “<90°” group, then this gain was less in the next two groups, to become a significant decrease in the “≥130°” group. A decrease in flexion was noted in 51% of the cases in the latter group. Other factors such as age, sex, and etiology had no influence on the gain in flexion. DiscussionAfter TKA, a gain in flexion was often noted. The amount of gain depended on the preoperative range of flexion: the lower this level was, the more flexion increased. The presence of a varus deformity, morbid obesity, or flessum was associated with greater gain in flexion, even if the final flexion was lower than the mean flexion in the overall population. The search for these factors made it possible to predict a gain in flexion and discuss this with the patient. Level of evidenceLevel IV. Multicenter retrospective study.

Assessment of Tendon Graft Rings for A2 and A4 Hand Pulley Reconstruction: N/A - Not a clinical study

Simultaneous loss of the of the A-2 and A-4 pulleys can cause significant bowstringing of the flexor digitorum profundus. Pulley repair is commonly done with a palmaris tendon loop about the proximal or middle phalanx. The number of loops and the location of the loops can effect the degree of bowstringing. The purpose of this study was to investigate whether repair of the A2 pulley alone in a digit having A2 and A4 pulley incompetence could lead to a good functional outcome and to determine the number of graft rings necessary for proper repair. A motorized apparatus was constructed using potentiometers to measure angular rotation of the digit as a function of tendon excursion. After control (undamaged pulleys) testing, we recorded finger angular rotation as a function of tendon excursion of eleven cadaveric fingers after the following interventions: 1) complete excision of A2 and A4 pulley, 2) repair of distal part of the A2 pulley with one ring of tendon graft, 3) repair of the A2 pulley with two rings of tendon graft, 4) repair of the A2 pulley with two rings of tendon graft and the A4 pulley with one ring. The loss of flexion at full tendon excursion was measured both at the PIP and MCP joint and was calculated as a percentage loss as compared to controls. The loss of the A-2 and A-4 pulleys caused a loss of 32% angular excursion at the MCP joint and 19.6% at the PIP joint. At the PIP joint One ring showed a 14% loss in PIP rotational angle compared to control, 2 rings showed a 17% decrease while the use of three rings, that is, two at A2 and one at A4, had a decrease of 5%. At the MCP joint, with one ring, the decrease in rotational angle was 12% with a second ring 16% whereas with the 3 ring scenario it was 14%. There is significant loss of rotation at both the MCP and PIP associated with loss of the A-2 and A-4 pulley. A double loop at the proximal phalanx fostered no advantage to the single loop. This may involve issues of increased tendon drag. The best reconstruction was the 2 plus 1 pulley reconstruction. The study indicates clinically that in cases of loss of both the A-2 and A-4 pulley, reconstruction of both pulleys should be considered.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Hip Strength Deficits in Patients With Symptomatic Femoroacetabular Impingement and Labral Tears

To determine the prevalence of hip strength deficits in a consecutive cohort of patients with unilateral femoroacetabular impingement (FAI) compared with the asymptomatic contralateral hip. Fifty consecutive patients undergoing hip arthroscopy for symptomatic FAI underwent preoperative hip strength dynamometer measurements and were included in the study. Manual isometric hip strength measurements were performed with a handheld dynamometer and included measurements of various hip strengths (flexion, extension, adduction, abduction, internal rotation, and external rotation). Weakness greater than or equal to 10% for any given measurement was defined as a strength deficit in this study. Clinical data including age, gender, size of labral tear, and preoperative outcome scores were recorded. Outcome scores included the modified Harris Hip Score and Short Form 12Physical Component. The mean age of patients in the study was 32.0 years (range, 18.1 to 49.8 years). There were 32 male and 18 female patients. Hip abduction strength deficits were seen in 46% of patients and flexion strength deficits in 42% of patients. An 8% decrease in strength of the involved hip was seen in flexion, and an 8.7% decrease was seen in abduction. Patients with hip flexion strength deficits had a loss of function (mean modified Harris Hip Score, 57.8 v 66.1; P= .021) and larger labral tears (mean, 39 mm v 28 mm; P= .003). Hip flexion strength deficits correlated with loss of hip flexion (r= 0.373, P= .008). Hip strength deficits were common in patients presenting with unilateral symptomatic FAI and occurred most commonly in hip abduction and flexion. Strength deficits in hip flexion were associated with decreased function, loss of motion, and larger labral tears in patients with FAI and labral tears. Level IV, prognostic case series.

Open surgical release for contractures of the elbow.

Compared with arthroscopic release, open release is more commonly used for the treatment of stiff elbow. Flexion is recovered by releasing posterior tethering soft-tissue structures and by removing anterior impingement between the coronoid and/or radial head and the distal humerus. Extension is improved by releasing anterior soft-tissue tethers and by removing impingement between the olecranon tip and the olecranon fossa. Open elbow release is most commonly performed via ligament-sparing approaches. Ulnar nerve identification and transposition is recommended in the presence of nerve dysfunction or when correction of significant loss of elbow flexion is anticipated. Long-term improvement in flexion and extension can be expected with proper patient selection. Less predictable results are obtained in adolescent patients and in those with underlying traumatic brain injury.

Free muscle transfer for challenging and rare upper limb disorders

Free innervated muscle transfer (FMT) achieves functional restoration following not only traumatic brachial plexus injury, but also intractable rare upper limb disorders, such Hopkins' syndrome, myoplasia in arthrogryposis and radition neuropathy. I introduce our current experience of FMT for these disorders. Hopkins syndrome is a rare cause of poliomyelitis-like paralysis affecting one or more extremities after an acute attack of asthma. The exact etiology of Hopkins syndrome is not known. Two children developed acute asthma followed by complete flaccid paralysis of the the upper extremity. They underwent staged reconstruction using FMT. Rigorous postoperative physiotherapy was carried out to achieve a good functional outcome. At recent follow-up, they were able to effectively use the reconstructed hand for most of their daily activities. They had good control and could perform 2-handed activities. The selection of a suitable operative treatment and suitable donor nerves is critical, and there are no clear guidelines in the literature. FMT can be effectively employed in similar cases to restore grasping function. Arthrogryposis is a collective term applied to a variety of different syndromes characterized by nonprogressive, multiple joint contractures present at birth due to neurogenic, myopathic (amyoplasia), or connective-tissue disorders. The most serious impairment of amyoplasia in the upper extremity is an inability to flex the elbow due to extension contracture of the elbow. The ability to flex one elbow is essential to enable a child to become functionally independent with self-feeding and self-care of the face and hair; extension of the other elbow is necessary for independent toileting. Active elbow flexion is the definitive goal of surgical intervention. Multiple procedures, including triceps transfer, pectoralis major transfer, latissimus dorsi transfer, and the Steindler flexorplasty, have been used to provide active elbow flexion in patients with arthrogryposis. However, these conventional procedures do not always provide satisfactory long-term function and may result in a decreased arc of elbow flexion and in flexion contracture because of weakness of the donor muscles. We present the long-term results of a functioning free muscle transfer with use of the gracilis muscle for restoration of elbow flexion in three patients with arthrogryposis. Radiation-induced brachial plexopathy is a delayed complication of radiation treatment for tumors involving the neck and chest area and is progressive. A 56 year-old woman presented to us with loss of elbow flexion and weak wrist and finger extension 15 years after she received external beam radiation to the left chest, axilla, and supraclavicular region for the treatment of breast cancer. She was managed with a gracilis free muscle transfer for elbow flexion and hand prehension. By 2 years after surgery she regained elbow range of motion of 40 to 110 degrees and improved her hand function. She was able to perform her activities of daily living. Her Disabilities of the Arm, Shoulder, and Hand Score improved from 56 to 20.

Complex proximal ulna fractures: outcomes of surgical treatment.

To review the results of plating of various fracture patterns of proximal ulna fractures including isolated olecranon fractures, olecranon fractures combined with a coronoid fracture, and olecranon fractures combined with a coronoid and radial head fracture. The study included 38 patients with either an isolated olecranon fracture or combined injuries, all treated with open reduction and internal fixation of the olecranon. Other procedures were performed as needed, including radial head fixation or arthroplasty, fixation of the coronoid, and repair of the lateral collateral ligament complex. There were 27 men and 11 women with an average age of 49 years. Clinical and radiographic assessment was obtained at an average follow-up time of 15 and 8.4 months, respectively. All fractures healed within 5 months. The average arc of ulnohumeral motion was 91° (range 0°-140°); average pronation-supination arc was 128° (range 0°-180°). Subgroup analysis showed a statistically significant lower rotational motion arc in patients with associated radial head (73°) or coronoid fractures (68°) compared to isolated olecranon fractures. All other parameters including ulnohumeral motion, complication rate, and revision rate were similar among the groups. A stable, functional elbow can be restored in most patients with proximal ulna fractures treated with open reduction and internal fixation. Loss of full flexion is likely with high-energy trauma, complex fracture patterns, and concomitant injuries. Fracture patterns involving the coronoid and/or the radial head are associated with restricted forearm rotation. III.

The Importance of Patient Sex in the Outcomes of Anterior Cruciate Ligament Reconstructions

Background: One of the well-studied epidemiological phenomena of anterior cruciate ligament (ACL) injuries is the 2- to 9-fold increase in the relative risk of ACL rupture in female athletes compared with male athletes. However, the influence of patient sex on the outcome after ACL reconstruction remains unclear, with some authors reporting inferior outcomes in females and others noting no significant difference. Purpose: To provide a comprehensive systematic review and meta-analysis to examine the possible association between patient sex and the subjective and objective outcomes after ACL reconstruction. Methods: This study was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All studies that reported clinical outcomes after ACL reconstruction in males and females independently were included in the review. A quantitative random-effects meta-analysis was performed to compare outcomes between sexes. For outcomes with considerable heterogeneity, meta-regression was used to identify potential moderators. Articles were evaluated qualitatively when quantitative data were not reported. Results: A total of 135 publications were included in the review. Females had inferior outcomes in instrumented laxity (standardized mean difference [SMD], 0.24; 95% CI, 0.11-0.37), revision rate (relative risk [RR], 1.15; 95% CI, 1.02-1.28), Lysholm score (SMD, −0.33; 95% CI, −0.55 to −0.11), Tegner activity scale (SMD, −0.37; 95% CI, −0.49 to −0.24), and incidence of not returning to sports (RR, 1.12; 95% CI, 1.04-1.21), all of which were statistically significant. Other outcomes were comparable between sexes, including anterior drawer test, Lachman test, pivot-shift test, timed single-legged hop test, single-legged hop test, quadriceps testing, hamstring testing, extension loss, flexion loss, development of cyclops lesion, and International Knee Documentation Committee (IKDC) knee examination score. Females and males were equally likely to develop anterior knee pain and osteoarthritis after ACL reconstruction. The graft rupture and graft failure rates did not differ significantly between sexes. Conclusion: There were comparable or inferior results for females compared with males in all outcomes analyzed. No statistically significant sex difference was identified in most of the objective parameters. However, subjective and functional outcomes, including Lysholm score, Tegner activity scale, and ability to return to sports, have been shown to be poorer in females.

Extensor Pollicis Longus Ruptures Following Distal Radius Osteotomy

Introduction Extensor tendon ruptures may occur from closed as well as open treatment of distal radius fractures. Although rare, surgical corrections of malunited distal radii with volar osteotomy may carry a potential risk of rupture of the extensor tendons, most commonly the extensor pollicis longus (EPL). To investigate the etiology and pathological process involved in these complications, we had surgeons from multiple centers contribute cases for evaluation. Materials and Methods In this case series, we included patients with EPL ruptures who underwent distal radius osteotomies performed through a volar approach. Data was pooled from multiple surgical centers and compiled. Demographics, initial injury parameters, imaging studies, pre- and postoperative examination, intra-operative findings, surgical technique, and patient outcomes were compared and analyzed. Pre- and postoperative radiographs were evaluated and compared. Results Six cases from five surgeons in four institutions were evaluated. Length of follow-up ranged from one to over four years. Initial injuries included intra- and extra-articular fractures. All patients were initially treated with cast immobilization. Every patient in the study had limitation of range of motion preoperatively, most with primary loss of flexion. All malunions were healed in extension (20° to 60°) and with shortening. During the reconstructive operation deformity correction in the sagittal plane was 25° to 55°. All osteotomies were fixed with volar locking plates with autologous bone graft, except for one patient who received calcium phosphate-based bone-void filler. Postoperative X-rays suggested prominent osteotomy resection edges, osteophytes, or dorsal bony prominence due to healed callous. Every osteotomy united during the follow-up period. Average time from osteotomy to EPL rupture was 10 weeks [2 to 17 weeks]. Two patients initially refused to undergo tendon transfers. One was pleased with the outcome despite the ruptured EPL. The other patient ruptured two other extensor tendons and then underwent tendon transfers with good results. One patient ruptured the transferred tendon as well after two months and underwent successful tendon grafting. Conclusion Although extensor tendon ruptures following distal radius volar osteotomies are rare, they are a known complication of these corrective surgical procedures. In the absence of screw prominence, it is likely that dorsal callus, prominent osteotomy resection edges and osteophytes may attribute to attritional rupture of the EPL tendon.

Proposition of a protocol to evaluate upper-extremity functional deficits and compensation mechanisms: application to elbow contracture

ObjectiveInstrumented gait analysis is widely acceptedas an objective assessment of lower-extremity function. Conversely, upper-extremity function suffers from lack of objective evaluation. The present paper aims at proposing a protocol to be used to clinically and objectively evaluate upper-extremity function whatever the pathological joint. Secondly, it aims at better understanding the consequences on upper-extremity function and the compensation mechanisms induced by elbow contracture. Elbow contracture was simulated in this study by using a brace. DesignTwelve healthy subjects followed an instrumented3D movement analysis while performing 11 daily life movements. The movements were performed with 3 differentelbow contracture conditions, simulated by wearing an adjustable elbow brace. ResultsThe proposed protocol was successful in creatinga wide range of motion at all the upper-extremity joints. The activity-related range of motion and the mean range of motion computed on the whole set of daily life movements were effective in evaluating the severity of elbow contracture. The lack of elbow flexion was compensated by trunk flexion, hand flexion and radial deviation, and combined movement of shoulder flexion, abduction, and humeral internal rotation. Deficit in elbow extension was mainly compensated by the use of trunk flexion. ConclusionsA protocol could be proposed for the objectiveevaluation of upper-extremity function. Its application to elbow contracture suggests that loss of elbow flexion affects more movements than loss of elbow extension.

开放复位并修复Bankart损伤治疗陈旧性肩关节前脱位(附6例病例分析)

目的：大多数陈旧性肩关节前脱位大多采取切开复位同时不同方式内固定的方法治疗，我们在切开复位的同时对关节囊和关节盂加固修复而放弃贯穿关节间内固定以早期活动减少关节粘连和僵硬，本研究目的就是评估其疗效。方法：6例平均伤后11周的陈旧的肩关节前脱位的病人，给予手术切开复位并行盂唇-关节囊修复加强，术后肩关节外展功能位支架固定，随访8月后进行临床功能和影像学检查按Rowe和Zarin标准评估疗效。结果：全部病人按Rowe和Zarin标准评分，平均83分，3例评为优，2例良，1例一般。所有病例胜任日常活动，伴轻微疼痛或无疼痛，前举平均丧失20˚，外旋丧失20˚，内旋平均丧失2个椎体水平。结论：对陈旧性肩关节前脱位切开复位的同时盂唇-关节囊加固修复的手术方法可取得较好疗效，值得应用推广。 Object: Open reduction with different fixation operations has been introduced for most chronic shoulder anterior dislocation. However, open reduction and simultaneous Bankart lesion repair without the joint fixation were used in our study. The aim was to evaluate the outcomes of our method. Methods: Six patients with chronic anterior dislocation of shoulder underwent open re-duction and capsulolabral complex repair after an average delay of 11 weeks after injury. Early motion was allowed the day after surgery in the function position. Then the clinical and radio-graphic results were analyzed at a mean follow-up of 8 months according to Rowe and Zarin’s cri-teria. Results: The average Rowe and Zarin’s score was 83 points. Three out of six shoulders were graded as excellent, two as good and one as fair. All patients were able to complete their daily ac-tivities with either mild or no pain. Anterior active forward flexion loss averaged 20˚, external active rotation loss averaged 20˚ and internal active rotation loss averaged 2 vertebral body levels. Conclusion: The results show that the overall prognosis for this method of operation is more fa-vorable than the previous methods and we recommend open reduction and capsulolabral complex repair for the treatment of old anterior shoulder dislocation.

Unusual Orthopaedic Injuries from the World's Most Popular Sport.

When it comes to numbers of participants and spectators, there’s little doubt that soccer is the world’s most popular sport. It makes sense, then, that soccer sees its share of musculoskeletal injuries. The majority of soccer injuries affect the feet and legs, with sprains, strains, and ligament injuries of the knees and ankles being the most common. This month’s “Case Connections” focuses on the diagnosis and treatment of four not-so-common soccer injuries. In the December 10, 2014, JBJS Case Connector, Huri et al. present the case of a teenage professional soccer player with a chronic rupture of the rectus femoris muscle. The initial injury had occurred two years earlier when he kicked another player’s foot instead of the ball. Nonoperative approaches had not facilitated a return to running or kicking. At the time of presentation, doctors noted a prominence on the right thigh that was suggestive of a proximal rupture and distal displacement of the rectus femoris muscle. At an isokinetic speed of 240°/sec, the knee extension strength difference between the injured and normal limbs was 40%; pain prevented the patient from being tested at other isokinetic speeds. MRI of the thigh revealed extensive soft-tissue edema and a complete avulsion of the reflected head of the rectus femoris. Figure 1 shows the rupture location preoperatively and intraoperatively. Fig. 1 Arrows indicate the location of the rectus femoris rupture preoperatively (top) and intraoperatively (bottom). Intraoperatively, surgeons moved the muscle belly proximally as far as possible …

Hip Stiffness Patterns in Lumbar Flexion- or Extension-Based Movement Syndromes

ObjectiveTo determine whether a relationship exists between sagittal plane hip range of motion loss and sagittal plane lumbar Movement System Impairment (MSI) categories in patients with low back pain (LBP). DesignCorrelational study. SettingUniversity outpatient physical therapy clinic. ParticipantsSubjects (N=40) with LBP. InterventionsNot applicable. Main Outcome MeasuresClassification into a flexion- or extension-based lumbar MSI category, and bilateral passive hip flexion and extension range of motion testing. Using predefined criteria, subjects in each MSI category were subclassified into 1 of 3 hip stiffness categories: (1) a considerable loss of either flexion or extension (pattern A); (2) a considerable loss of both flexion and extension (pattern B); or (3) minimally limited flexion or extension (pattern C). ResultsPattern A occurred in 23 (57.5%) subjects, with the primary direction of hip motion loss agreeing with the MSI category 78.3% of the time (φ=.56; P=.007). Pattern B occurred in 10 (25%) subjects, with the primary direction of hip motion loss agreeing with the MSI category 70% of the time (φ=.47; P=.197). Pattern C occurred in 7 (17.5%) subjects, with the primary direction of hip motion limitation agreeing with the MSI category 42.9% of the time (φ=−.40; P=.290). ConclusionsConsiderable unidirectional hip motion loss in the sagittal plane was a common finding among subjects with LBP and yielded a strong positive relationship with the same direction MSI category. These results may inform future studies investigating whether treatment of hip stiffness patterns could improve outcomes in LBP management.

Overstuffing in total knee replacement: no effect on clinical outcomes or anterior knee pain

With total knee replacement (TKR), correct sizing and rotational alignment are essential for good clinical outcomes. Overstuffing may result in loss of flexion and adversely affect the outcome of TKR. The purpose of this study was to correlate overstuffing with patient reported clinical outcomes and anterior knee pain (AKP). Baseline and follow-up clinical and radiological data of 262 patients who had NexGen LPS posterior stabilized TKR without patellar resurfacing between 2008 and 2009 were prospectively collected. We measured anterior femoral offset, femoral diameter, and posterior condylar offset on the pre-operative and postoperative lateral non-weight bearing radiographs. Overstuffing was defined as an increase in pre-operative to postoperative values. Repeated measures analysis of variance (ANOVA) was used to analyse for differences from preoperative to postoperative WOMAC scores between patients with and without overstuffing. A total of 193 sets of lateral radiographs (preoperative and postoperative) were adequate for analysis. Anterior overstuffing was noted in 84 patients (43.5%), posterior overstuffing in 168 (87%), and total overstuffing in 155 patients (80%). Total WOMAC scores were similar in patients with and without anterior, posterior or total overstuffing (p = 0.11, p = 0.65, and p = 0.06, respectively). We found no relation between the presence of AKP with either anterior, posterior or total overstuffing (chi-square: p = 0.14, p = 0.24, and p = 0.54, respectively). We found no relation between radiological anteroposterior overstuffing with patient reported outcome measures or AKP.

Effect of the metastatic defect on the structural response and failure process of human vertebrae: An experimental study

BackgroundPathologic vertebral fractures are associated with intractable pain, loss of function and high morbidity in patients with metastatic spine disease. However, the failure mechanisms of vertebrae with lytic defects and the failed vertebrae's ability to retain load carrying capacity remain unclear. MethodsEighteen human thoracic and lumbar vertebrae with simulated uncontained bone defects were tested under compression-bending loads to failure. Failure was defined as 50% reduction in vertebral body height. The vertebrae were allowed to recover under load and re-tested to failure using the initial criteria. Repeated measure ANOVA was used to test for changes in strength and stiffness parameters. FindingsVertebral failure occurred via buckling and fracture of the cortex around the defect, followed by collapse of the defect region. Compared to the intact vertebrae, the failed vertebrae exhibited a significant loss in compressive strength (59%, p<0.001), stiffness (53%, p<0.05) and flexion (70%, p<0.01) strength. Significant reduction in anterior-posterior shear (strength (63%, p<0.01) and stiffness (67%, p<0.01)) and lateral bending strength (134%, p<0.05) were similarly recorded. In the intact vertebrae, apart from flexion strength (r2=0.63), both compressive and anterior-posterior shear strengths were weakly correlated with their stiffness parameters (r2=0.24 and r2=0.31). By contrast, in the failed vertebrae, these parameters were strongly correlated, (r2=0.91, r2=0.86, and r2=0.92, p<0.001 respectively). InterpretationFailure of the vertebral cortex at the defect site dominated the initiation and progression of vertebral failure with the vertebrae failing via a consolidation process of the vertebral bone. Once failed, the vertebrae showed remarkable loss of load carrying capacity.

Effect of Heterotopic Ossification on Hip Range of Motion and Clinical Outcome

The utility of heterotopic ossification (HO) classification systems is debatable. The range of motion and Harris hip score (HHS) were calculated in 104 patients with known HO after total hip arthroplasty and 208 matched controls without HO. The patients with HO were radiographically divided into high and low grade HO groups. There was no statistically significant association of HHS with high or low grade HO. High grade HO had a statistically significant 6° loss of terminal hip flexion, 4° loss of abduction, and 6° loss of internal rotation at the hip. The small changes in terminal hip range of motion and lack of association with HHS may be the result of false radiographic continuity resulting in an overestimation of the disability in high grade HO.