Limited Flexion Research Articles

Lowering of the Patella — prevention and treatment of a rare complication during leg lengthening: a case report

Background. Changes in the level of the patella position are a well-known complication of knee replacement, reconstruction of the anterior cruciate ligament, high tibial osteotomy and consequences of injuries. However, this problem has not been disclosed in the literature in relation to distraction osteogenesis using the Ilizarov method. The aim of the study is to describe such a rare iatrogenic complication as patella baja during limb lengthening by the Ilizarov method using a clinical case as an example. Case description. In 2017, a 17-year-old teenager was injured in a head-on collision of cars at high speed. The patient was diagnosed with an open fracture of the left femur and fibula and tibia of the left leg. He was treated in another clinic using the Ilizarov apparatus for osteosynthesis of the femur, tibia and proximal osteotomy of the tibia to move the bone to fill the distal bone defect. At the end of the treatment, the patient had a moderate limitation of the knee flexion (180-80°). In 2018, the patient was admitted to our clinic due to osteomyelitis at the level of the consolidated fracture. A new resection of the osteomyelitis lesion and proximal osteotomy for bifocal osteogenesis were performed. During the treatment, limitation of knee flexion (180-120°) was developed and radiographic signs of low position of the patella were obtained. Given the progression of patella baja (the Caton-Deschamps index = 0.51), we were forced to return the patient to the operating room to restore the correct height of the patella. Conclusions. The presented clinical case emphasizes the need for a more thorough assessment of the patella height after surgical treatment on the proximal tibia using the Ilizarov method. It is also noted that it is important to conduct a control MRI, which allows for a more detailed study of the initial position of the anterior tibial tubercle. In our case, early detection of complications allowed us to achieve complete recovery without any consequences.

Partial weight-bearing and range of motion limitation significantly reduce the loads at medial meniscus posterior root repair sutures in a cadaveric biomechanical model.

The aim of this study was to investigate the influence of medial meniscus posterior root avulsion (MMPRA) before and after surgical treatment on the biomechanics of the knee joint, including suture repair forces during daily and crutch-assisted gait movements. MMPRA were investigated in eight human cadaver knee joint specimens by a dynamic knee joint simulator with daily (normal gait, gait with additional rotational movement, standing up, sitting down) and rehabilitation-associated movements (crutch-assisted gait with limited flexion range of motion [30°] and 30% [toe-touch weight-bearing, TTWB] and 50% of body weight [partial weight-bearing, PWB]) with simulated physiologic muscle forces. Each specimen was tested in intact, torn and repaired (transtibial suture) state. The biomechanical parameters were: medial mean contact pressure and area, knee joint kinematics, medial displacement of the posterior meniscus horn and loading on the anchoring suture. Significant reduction of the contact area due to the avulsion was observed in all movements except for PWB and sitting down. MMPRA repair significantly increased the contact areas during all movements, bringing them to levels statistically indistinguishable from the initial state. MMPRA resulted in a medial displacement up to 12.8 mm (sitting down) and could be reattached with a residual displacement ranging from 0.7 mm (PWB) to 5.7 mm (standing up), all significantly (p < 0.001) reduced compared to the torn state. The mean peak anchoring suture load increased from TTWB (77 N), PWB (91 N) to normal gait (194 N), gait rotation (207 N), sitting (201 N; p < 0.01) and to standing up (232 N; p = 0.03). Surgical treatment of MMPRA allows restoration of physiological knee joint biomechanics. Crutch-assisted movements reduce the loading of the repair suture, thus likewise the risk for failure. From a biomechanical point of view, crutch-assisted movements are recommended for the early rehabilitation phase after MMPRA repair. Level V.

Efficacy Comparison of Low Level Laser Treatment with Muscle Energy Procedure Among Diabetic Patients Suffering from Frozen Shoulder

Frozen shoulder incidence in diabetic patient is twice as high as normal controls. There are various conventional as well as electrotherapies for its treatment within which low-level laser therapy versus muscle energy technique are well debated for efficacy in diabetic patients frozen shoulder. Objective: Comparative analysis of effectiveness of low-level laser therapy and muscle energy technique among diabetic patients with frozen shoulder. The study design was comparative study. The Place and Duration of Study was Department of Orthopaedic, Indus Medical College, Tando Muhammad Khan from 1st January 2023 to 30th June 2023. Methods: One hundred and twenty patients who were having diabetes mellitus (type 1 and type 2) and suffering from frozen shoulders were enrolled. The conventional therapeutic exercise included exercises like pendulum, arm overhead, finger wall ladder, twisting arm outwards, overhead pulley, cross-body reach exercises, hand behind-back exercise and outward rotation exercise. Muscle energy technique was administered in cases where restriction in shoulder flexion, as well as abduction, external rotation was observed. Results: There were 59% females and 41% males with majority being within the age group of 45-65 years. It was observed that there was a significant variance between pain scores at pretreatment and post treatment stages with highest value decrease observed in muscle energy technique group II. The ROM was least improved in control group only treated through conventional protocol. Conclusions: The Muscle energy technique is slightly more effective than low-level laser therapy technique in terms of pain, inflammation reduction and angular movements.

Effect of improving asymmetry through self-myofascial release in adolescent soccer player with hypomobility syndrome hip: A randomized controlled trial.

Hypomobility syndrome (HMS), or limited hip range of motion (ROM), is often reported in adolescents who train heavily. This study was aimed to investigate the impact of traditional static stretching (STR) and self-myofascial release (MFR) in adolescents with HMS hip. This study was a randomized controlled trial. Adolescent athletes with HMS hip were grouped as 23 STR and 23 MFR. Foam rolling was employed as the training method for MFR. Both interventions were performed twice a day for 20 minutes in 6 weeks. The training was filmed and distributed via the mobile video. Self-assessed Copenhagen Hip & Groin Outcome Score, ROM, strength, and hop tests were measured before and after the interventions. The healthy side without limitations was designated as non-HMS (nHMS) and taken as reference value. The study participants had limitations in flexion (FLX), abduction (ABD), internal rotation (IR), and external rotation (ER). The ROM of STR group was recovered to nHMS level. The FLX and ABD of MFR group was also recovered, however the IR and ER had lower angles compared to nHMS. MFR FLX, ABD, ER strength, and single hop test were restored like that of nHMS, however STR group was substantially lower than nHMS despite the improvements. Both groups depicted lower pre-intervention Copenhagen Hip & Groin Outcome Score subscale activities daily living, sport, and physical activity compared to nHMS. Activities daily living and physical activity were improved to healthy levels after the intervention, however sport was lower than that of nHMS. Both STR and MFR had impact on hip mobility and hip self-assessment score. Furthermore, MFR had strength improvements in FLX, ABD, and ER. However, the improvements in MFR group regarding triples, crossover hops, and self-assessed sports were limited. Therefore, STR and MFR are effective in improving not only ROM but also muscle function asymmetry in HMS hip.

Synovial hemangioma presenting with chronic painful infrapatellar mass: a case report

BackgroundSynovial hemangiomas are rare benign vascular anomalies surrounded by a synovial lining and were first described by Bouchut in 1856. These neoplasms can develop in the intra-articular region, resulting in effusions and knee pain. However, their cause remains unknown. Prompt diagnosis and intervention are critical to prevent chondral damage. Histopathological examination is used to achieve the diagnosis, which is often delayed because of a lack of specific clinical signs. This report describes a unique case in which a painful infrapatellar mass was diagnosed as a synovial hemangioma. The absence of typical magnetic resonance imaging (MRI) findings highlights the importance of arthroscopic excision for diagnosis and symptom relief.Case presentationA 20-year-old woman presented with persistent anterior left knee pain that became exacerbated when she climbed stairs. Despite previous pain management and physical therapy, she developed a painful lump beneath her patella that worsened over time. She had also undergone arthrocentesis, but this did not relieve her pain. Physical examination revealed a palpable, immobile 5-cm mass along the patellar tendon with limited knee flexion and extension and normal ligament stability. T1-weighted fat-saturated MRI of the left knee with gadolinium-based contrast revealed a lobulated intra-articular mass in Hoffa’s fat pad that resembled a soft tissue chondroma. A biopsy of the mass was performed to provide histopathological evidence, confirming the benign nature of the mass. The subsequent excisional arthroscopy, combined with incision enlargement for mass removal, confirmed the histopathologic diagnosis of synovial hemangioma based on the presence of numerous dilated blood vessels and venous proliferation within sections of the synovium. Recovery was complete, and no residual tumor was detected on follow-up MRI after 1 year.ConclusionThis case study emphasizes the importance of arthroscopic excision over open surgery for patients with synovial hemangioma. The minimally invasive nature of arthroscopy combined with the well-encapsulated nature and location of the mass facilitates complete resection.

Non-identical presentations of Intra-Articular Anterior Cruciate Ligament Ganglion Cysts: A report of two cases and review of literature

An uncommon cystic, tumor-like lesion of uncertain origin, an anterior cruciate ligament ganglion is encircled by dense connective tissue that is filled with a gelatinous fluid. Ganglion cysts and ACL mucoid degeneration may coexist. The size and location of the lesion determine how the lesion presents clinically. Two examples of ganglion cysts originating from the anterior cruciate ligament are presented here; one exhibits a painful restriction of flexion, while the other presents with chronic pain that is not related to motion restriction. With MRI, this uncommon clinical disease can be identified. It can be distinguished by magnetic resonance imaging (MRI) from pigmented villonodular synovitis, synovial sarcoma, mucoid degeneration of the ACL, and localized synovitis. It can be treated by arthroscopic cyst debridement or aspiration assisted by CT or USG. ACL damage must be prevented with caution. Following arthroscopic cyst debridement, both patients experienced a complete functional recovery. Conclusion: Although uncommon, ganglion cysts of the ACL should be considered a differential diagnosis for knee discomfort. Diagnosis is confirmed by MRI evaluation. Good clinical results can be achieved by arthroscopic debridement of cysts without causing ligament damage.

Incorrectly healed supracondylar humerus fracture : That will grow out later on?!

The supracondylar humerus fracture is the most frequent fracture of the elbow region during the growth period. The peak age is around 5years. Extension fractures predominate. The clinical diagnostics are supplemented by X‑ray images in two projections. Growth-associated spontaneous corrections of posttraumatic deformities rarely occur. The goal of treatment is therefore the active transformation of every displaced fracture into a nondisplaced stably fixed fracture.If this is not successful, the consequences of healing in amalalignment can be, e.g., restriction of elbow flexion due to remaining antecurvation or cubitus varus. Combinations are often present. The causes include technical problems with reduction and retention but also misjudgement of the X‑ray findings, ignorance of the growth prognosis or inadequate verification of whether the treatment goal has been achieved.Unsatisfactory treatment results should be corrected as early as possible. This can be done primarily before bony healing is completed or secondarily as acorrective osteotomy at any later point in time. The earlier the correction of the malalignment is performed, the greater the chances of a complete restoration to the original condition. Depending on the type and extent of the deformity various techniques for corrective osteotomy are suggested in the literature.

Combined assessment of acetabular coverage and femoral head-neck shapes predicts osteoarthritis progression after periacetabular osteotomy.

Postoperative osteoarthritis (OA) progression is a major determinant of failure after curved periacetabular osteotomy (CPO). A large postoperative combination angle, i.e., the combination of computed tomography-based anterior center edge and alpha angles, is associated with femoroacetabular impingement after CPO, but its association with postoperative OA progression is unclear. We aimed to identify the anatomical parameters that can lead to OA progression after CPO and the impact of the combination angle on the same. We included 90 hips that were subjected to CPO at our center between March 2013 and March 2018. Seventeen hips showed OA progression with an increase in the Tönnis classification after surgery; 73 hips showed no progression. Radiographic anatomical parameters, including the lateral and anterior center edge angles, femoral and acetabular anteversion, and combination angle, and clinical outcomes, including modified Harris Hip Scores (mHHSs), postoperative anterior impingement, and range of motion, were compared between the two groups. Statistical significance was set at P < 0.05. Postoperative OA progression was significantly affected by preoperative OA evidence (P = 0.017), acetabular anteversion < 5.0° (P = 0.003), and a combination angle > 107.0° (P = 0.025). Patients with radiographic OA progression were associated with poor mHHSs (P = 0.017) and high frequencies of anterior impingement with a limited hip flexion and internal rotation angle. OA progression after CPO may be associated with preoperative evidence of OA and postoperative acetabular retroversion as well as a large combination angle. Surgeons should focus on the potential effects of preoperative OA grades, postoperative reduction in acetabular anteversion, and postoperative combination angle.

Poster 352: Histopathological Etiology of Mucoid Degeneration of the Anterior Cruciate Ligament

Objectives: Mucoid degeneration of the anterior cruciate ligament (ACL) is an uncommon clinical condition with reported prevalence below 0.5%. There is a paucity of histopathological description in the literature, which has limited our understanding of the underlying pathophysiology. Such limited understanding has resulted in treatment options limited to mechanical debridement rather than biologic interventions to prevent development or progression of mucoid degeneration. The purpose of this study is to define the histopathology of mucoid degeneration of the ACL to better guide future biologic and surgical management options. Methods: This is a case control study where a retrospective series of 10 patients were identified to have mucoid degeneration of the ACL from 2002 to 2023. They were evaluated and treated by two senior attending orthopedic sports medicine surgeons. Magnetic resonance images (MRI) were evaluated for multiple anatomic and morphometric measures. Tissue samples were obtained at the time of arthroscopic partial debridement of the ACL for all patients. Intra-operative ACL samples and cadaveric control tissues were prepared for histologic examination of microstructure and composition, and gene expression using multiplex transcriptional profiling. For the gene expression analysis RNA was isolated from archived formalin-fixed and paraffin-embedded (FFPE) sections. Three consecutive 6mm sections were pooled to generate one RNA sample and total RNA was extracted using a High Pure FFPET RNA Isolation Kit per the manufacturer’s protocol and stored at -80°C until further analysis. RNA concentration and integrity was evaluated using an Agilent BioAnalyzer 2100 and a corrected input of 50ng of total RNA was used for NanoString analyses using the NanoString nCounter® Human Fibrosis V2 Panel for multiplex molecular analysis of 770 genes. Analysis was performed using nSolver 4.0 Software and only probes with counts above background were included following the manufacturer instructions. Results: All 10 patients reported pain and limited knee flexion. MRI exhibited a bulbous appearance of the ACL. There was an increased posterior tibial slope (PTS), narrow notch width index, and increased signal intensity of the ACL. Medial meniscus tear and cartilage degeneration were reported with high prevalence. The histological analysis showed significant differences in the architecture of the tissue compared with normal ACL controls, with disorganized collagen matrix and increased glycosaminoglycan content. NanoString analysis demonstrated a total of 155 differentially expressed genes (DEGs) between the mucoid degeneration and control groups after adjustments for multiple comparisons (p&lt;0.05), with the top 20 DEGs summarized in Table 1. Among all the DEGs identified the 5 most upregulated ones include Fibronectin 1 (FN1), COL5A1, COL6A3, COL3A1 and COL1A2. There were also significant differences in the pathway scores for epithelial-to-mesenchymal transition (EMT), Extracellular matrix Degradation and Synthesis, Collagen Biosynthesis, Focal Adhesion Kinase, PDGF Signaling and PI3K-Akt (Fig. 1). The histology findings demonstrate distinct changes in the structure and composition of the ACL, and we hypothesize that repetitive microtrauma of the ACL may lead to cumulative damage that ultimately results in mucoid degeneration. Increased posterior tibial slope and narrow notch width index may contribute to cumulative loading of the ligament and subsequent mucoid degeneration. Identification of biomechanical risk factors may help to identify high risk patients. Associated injury of the medial meniscus and medial compartment cartilage also suggests that mucoid degeneration of the ACL may be part of an early degenerative process in the knee. Conclusions: Mucoid degeneration of the ACL is an uncommon condition that may represent the result of repetitive microtrauma to the ligament. Current interventions address the condition after it has progressed to an irreversible biological state. By defining the cellular and molecular mechanism(s) of the condition, we aim to broaden treatment options to potentially identify biologic interventions. The association of mucoid degeneration and medial compartment osteoarthritis suggests that patients may benefit from earlier interventions. [Figure: see text][Figure: see text]

Ring-Embedded Finger Over Proximal Interphalangeal Joint with Preserved Neurovascularization: A Case Report and Literature Review.

We present a unique case of a 45-year-old man with his right middle finger embedded with rings. Limited finger flexion was noted because of flexor tendon injury caused by the dorsal migration of the embedded ring through joint. The rings were removed under anesthesia, resulting in the resolution of swelling and recover of osseous structure. Follow-up examinations revealed no residual edema or numbness, indicating preserved neurovascularization, despite the dorsal migration of the ring. Our unique case reveals continuous finger ring migration without compromising neurovascular bundles, with review of 30 cases emphasizing the importance of psychiatric consultation. Timely intervention yielded nearly half of patients achieving full recovery.

Central Tendon Tenotomy for Management of Extrinsic Extensor Tightness of the Hand: Surgical Technique and Case Reports.

We present a 67-year-old woman with long finger extrinsic extensor tightness and a 56-year-old man with limited index finger flexion due to extrinsic extensor tightness secondary to tendon transfers for radial nerve palsy. Both patients underwent prior surgical procedures that led to limited range of motion (ROM). Subsequently, they elected for central tendon tenotomy (CTT), which demonstrated postoperative ROM improvement and satisfactory patient outcomes. Surgical management of extrinsic extensor tendon tightness of the hand is generally addressed by performing tenolysis to improve tendon excursion. We present a novel and simple technique of CTT with pertinent anatomy, descriptive cases, and a cadaveric video.

Modified volar approach for proximal row carpectomy

ObjectivesProximal row carpectomy is a well-accepted surgical procedure for the management of traumatic and degenerative wrist pathologies. It is routinely performed through a dorsal approach; a volar surgical access was presented in order to enable concomitant carpal tunnel release and avoid flexion limitation or disabilities caused by adhesions of the dorsal capsule and extensor tendons. We propose a modification to the volar approach, with detailed description of skin incision (reproducing the standard palmar access to the scaphoid), capsular section (beginning with a longitudinal cut radial to flexor carpi radialis tendon and prolonged transversally along the radio-lunate joint) and sequence of carpal bone removal (starting with the scaphoid rather than the lunate). Materials and methodsThe patients who underwent surgical treatment with modified volar proximal row carpectomy between 1992 and 2015 were enrolled in a retrospective analysis. ResultsWe report postoperative improvement in both the Mayo Wrist score and total active range of motion in 38 patients, in line with the outcomes of dorsal proximal row carpectomy. ConclusionsThe modified volar approach is highly recommended when better visualization and access to proximal carpal bones are needed (particularly useful for inveterate perilunate dislocations), moreover if concomitant carpal tunnel syndrome or extensor tendon pathologies are present.

Os supratrochleare anterius: a very rare clinical case and review of literature.

The accessory bones around the elbow are very rare variant structures, present in approximately 0.7% of cases. They can cause diagnostic problems and can be mistaken for pathological structures, especially when pain and limitation of elbow movements are present and a trauma can be traced in the patient's history. They are of different nature, either presenting within muscle tendons as sesamoids (brachialis and triceps brachii muscles) or presenting intra-articularly probably as separated or accessory ossification centres. The least common is the os supratrochleare anterius. We present a case of a young male, featuring chronic blocking and 20° limited flexion of his right elbow, which bothered him during his occupation as a locksmith. In history, he suffered minor trauma to the elbow 20 years ago. X-ray and CT showed a large ossicle in the coronoid fossa of the humerus. The ossicle was surgically extracted in small pieces. The patient left satisfied with no mention of complaints. The os supratrochleare anterius is a very rare accessory bone of the elbow, located in the coronoid fossa of the humerus which can mimic many pathological states, and limit movements and causing pain around the elbow.

A 3UPS/S Spherical Parallel Manipulator Designed for Robot-Assisted Hand Rehabilitation after Stroke

Hand dysfunction is a common symptom in stroke patients. This paper presents a robotic device which assists the rehabilitation process in order to reduce the need of physical therapy, i.e., a 3UPS/S parallel robotic device is employed for repetitive robot-assisted rehabilitation. Euler angle representation was used to solve the robot’s inverse kinematics. The robot’s joint space and rotational workspace were determined for two scenarios. In the first scenario, the workspace was obtained considering the actuator’s stroke limitations, while in the second scenario, the workspace was determined by adding a second condition, i.e., the range of motion of the spherical joints. Singularity analysis was performed using the geometric algebra approach. The robot was manufactured using additive manufacturing technology. The solution of the inverse kinematic problem was employed to control the robot. The robot can perform a full range of motion during wrist ulnar deviation and radial deviation motions, with the exception of limited wrist flexion and extension motions. The robot has singular configurations within its workspace. Although the spherical joints have roles in reducing the workspace, the primary causes are actuator selection, radii of the base and moving platforms, and the length of the central leg. These factors can be considered to improve the workspace. Singularity can be avoided by carefully selecting the rotation of the moving platform about the Z-axis and avoiding same leg lengths.

The Tuberculous Synovitis of the Elbow: A Misunderstood Entity

We present the case of a 7-year-old child with a history of tuberculosis exposure, admitted to the pediatric surgery department due to a chronic swelling of the right elbow persisting for 3 years. Despite being afebrile, the patient experienced unspecified weight loss. Clinical examination revealed a painful fluctuating swelling of the right elbow, limited flexion, and a 12-degree valgus deformity of the ulna. Laboratory tests showed an elevated CRP level indicative of an inflammatory process. Standard radiographs exhibited soft tissue hypertrophy without bone lesions. MRI demonstrated synovial hypertrophy of the right elbow joint with adjacent bone marrow infiltration and deformation of the distal humerus. Biopsy revealed nonspecific chronic synovitis. Surgical removal of the synovial mass was performed, and histopathological examination revealed features suggestive of tuberculosis. Extension studies for tuberculosis were negative. The patient was treated with antituberculous therapy and physiotherapy, leading to the regression of symptoms. This case highlights the diagnostic utility of MRI in detecting synovial hypertrophy and bone marrow infiltration in cases of chronic elbow swelling, especially in the context of tuberculosis exposure.

The relationship of limited mobility of the cervical spinewith postural and mental reactions of students

Introduction: Previous studies have found that, in addition to the general factors for the occurrence of pain and reduced mobility of the cervical spine, the use of electronic devices promotes these, the excessive use of which can also lead to the occurrence of depressive symptoms in students. The aim of this study was to determine the mobility limitation of the cervical spine in students with reported neck pain, to determine the degree of disability and depression due to neck pain, to determine the correlation of mobility limitation of the cervical spine with the degree of disability and depression of students, and to determine the correlation of the degree of disability with the degree of depression. Methods: The research was conducted as a cross-sectional study from May to July 2021 at the University of Zenica in four faculties. The study used the General Questionnaire and two standardized questionnaires to assess disability due to neck pain (Index of Disability due to Neck Pain) and the degree of depression (patient health questionnaire). Results: A total of 147 students with reported neck pain participated in the study. A limitation of mobility was found in 30.6% of the students in flexion, 25.2% in rotation, 23.8% in lateral flexion, and 20.4% on extension. Mild disability due to neck pain was found in 58.5% of students, moderate in 23.8%, and severe in 2.7%. 45.6% of the students had mild depression, 18.4% had moderate depression, and 5.4% had severe depression.Conclusion: Restricted flexion and rotation are more common than restricted lateral flexion and extension of the cervical spine. About half of the students who reported neck pain had a mild degree of disability and mild depression. A strong positive correlation was found between the degree of disability and depression in students with neck pain.

ISOLATED CONGENITAL GENU RECURVATUM A CASE SERIES

Congenital Genu Recurvatum (CGR) is a rare anomaly which can be diagnosed prenatally via imaging or following birth by a physical examination. With an incidence of 1 in 100,000 live births, CGR is defined as a pathological degree of hyperextension of the knee joint accompanied by limited flexion. CGR may occur in isolation or in association with other birth defects such as talipes equinovarus and a congenital dislocation of the hip joint. In severe cases of CGR, contracture of the quadriceps tendon does not permit reduction. At the other end of the severity spectrum, where the dislocated knee yields to reduction through manual manipulation, conservative treatment with serial Plaster of Paris (POP) casting of the joint in the reduced position has demonstrated excellent outcome. Newborn babies born in our institution during the period 2019-2022 with isolated unilateral congenital dislocation of knee joint managed conservatively is followed up till 3 months. Based on our experience, we conclude that serial casting is has shown excellent functional outcomes in patients with grade 3 isolated congenital genu recurvatum managed by manipulation and serial casting

Limited preoperative forward flexion does not impact outcomes between anatomic or reverse shoulder arthroplasty for primary glenohumeral arthritis

BackgroundAnatomic total shoulder arthroplasty (TSA) remains the treatment of choice for primary glenohumeral osteoarthritis with an intact rotator cuff (PGHOA). However, reverse total shoulder arthroplasty (RSA) has gained popularity as a primary procedure in selected patients who may be at risk for postoperative rotator cuff dysfunction or glenoid loosening. The purpose of this study was to compare short-term outcomes between TSA and RSA in patients with PGHOA and limited preoperative forward flexion (FF). MethodsA retrospective review was performed on a multi-institutional registry of patients to identify patients aged less than 80 years undergoing TSA or RSA for PGHOA with preoperative FF ≤ 90°. Forty-five TSAs were identified and matched by age and sex to 45 patients undergoing RSA. A subset of 22 TSAs and 24 RSAs with severely limited preoperative FF of ≤ 70° was also analyzed. Range of motion including FF, external rotation and internal rotation, strength, and patient-reported outcomes including visual analog scale pain score, Western Ontario Osteoarthritis of the Shoulder index score, Veterans RAND 12 mental score, American Shoulder and Elbow Surgeons score, and Constant-Murley score were evaluated at a minimum of 2 years postoperative. ResultsNo significant differences were observed in postoperative FF, external rotation, or strength measurements between groups. The limited FF TSA group achieved significantly improved internal rotation compared to the RSA group (L2 vs. L4, P < .002). No significant differences were observed between TSA and RSA in American Shoulder and Elbow Surgeons, visual analog scale, Constant, or Single Assessment Numeric Evaluation scores (P > .05) for both the overall comparison and subset of patients with FF of ≤ 70°. However, patients in the RSA cohort showed a significantly higher return to normal sporting activities than the TSA group. ConclusionPatients aged less than 80 years with PGHOA and limited preoperative FF achieve similar postoperative range of motion and patient-reported outcomes whether treated with TSA or RSA. Therefore, limited preoperative FF does not appear to be a major determinant of outcomes for PGHOA.

Screw versus Kirschner wire fixation for lateral humeral condyle fractures in children:a meta analysis

To compare screw versus Kirschner wire fixation in the treatment of lateral humeral condyle fractures in children. A systematic search was conducted in PubMed, Embase, the Cochrane library, Web of Science, China National Knowledge Internet(CNKI), Wanfang Datebase from in ception to February 2022. Studies comparing screws and Kirschner wire fixation in the treatment of lateral humeral condyle fractures in children were included. Outcome measures included and excluded by a set of inclusion and exclusion criteria and evaluated for their quality, their excellent and good rate of fracture healing, malunion, delayed union or nonunion, infection, limitation of elbow flexion or extension(>10°) were extracted and analyzed using software Rev Man 5.3. A total of 9 retrospective studies involving 647 patients were included, with 255 patients in the screw fixation group(including screw combined with Kirschner wire) and 392 patients in the Kirschner wire fixation group. Meta analysis showed the following:infection rate in the screw group was significantly lower than that in the Kirschner wire group[OR=0.22, 95%CI(0.09, 0.56), P=0.001]. There were no significant differences between the 2 groups in excellent and good rate of fracture healing, malunion rate(P>0.05). Subgroup analysis showed that infection rate in the screw-only group was significantly lower than that in the Kirschner wire group[OR=0.18, 95%CI(0.05, 0.65), P=0.009]. For lateral humeral condyle fractures, Screw fixation alone had a lower infection rate than kirschner wire fixation and screw combined with Kirschner wire fixation. There were no significant differences in the excellent and good rate of fracture healing, malunion. In terms of postoperative efficacy and safety of internal fixation, orthopaedic surgeons are more likely to recommend screws for fixation of lateral humeral condyle fractures in children.

Surgical procedures to improve hand function in tetraplegic patients: patient satisfaction and outcomes over a 20-year period.

The aim of the present study was to report our experience in the evolution in surgical strategy and patient satisfaction after upper limb reconstruction in tetraplegic patients. A total of 72 patients (114 upper limbs) underwent surgery between 1997 and 2017. Since April 2003, tenodesis of the extensor digitorum communis tendons was no longer performed because it limited wrist flexion, and two-stage operations to restore active grasp were replaced by one-stage procedures. In total, 34 patients (58 upper limbs) completed questionnaires about function and satisfaction at a mean follow-up of 14 years (range 4-24) since their first operation; 26 were satisfied, 30 would have the operation again and 31 benefitted from the surgery. Surgical procedures, such as tendon transfers, arthrodesis and tenodesis, can have a positive effect on patient-perceived function and satisfaction in the long term in most of these patients.Level of evidence: IV.