Total knee arthroplasty (TKA) is recognised as an effective treatment for end-staged knee osteoarthritis. Up to 20% of these patients is unfortunately unsatisfied due to anterior knee pain from unknown origin (Bourne and al. 2010). The aim of this study is to compare knee 3D kinematics during gait of patients with anterior knee pain after TKA to an asymptomatic TKA group. Our hypothesis is that the painful TKA group would exhibit known kinematics characteristics during gait that increase patellofemoral (PF) stresses (i.e. dynamic flexion contracture, valgus alignment, valgus collapse or a quick internal tibial rotation movement) compared to the TKA asymptomatic group.

Thirty-eight patients (45 knees) were recruited 12–24 months post-surgery done by one of three experienced orthopaedic surgeons (31 unilateral TKA and seven bilateral TKA, all using the same knee implant). Patients were divided according to their KOOS pain score (with a cut-off at 6/20 to be included in the painful group). The KOOS questionnaire was also used to assess activities of daily living, symptoms, sports and quality of life. A complete clinical and radiological work up was done on the painful group to exclude those with known explanation for pain (i.e. loosening, malrotation, infection and clinical instability). 3D knee kinematics during treadmill walking was captured and computed using the KneeKGTM system.

For the painful and asymptomatic groups, demographic results show respectively: age of 64.4 ± 7.6 and 69.8 ± 8.3 years, BMI of 31.9 ± 5.0 and 28.1 ± 3.6 kg.m−2, speed of 1.8 ± 0.6 and 1.67 ± 0.5 miles/h., and 50% of women in each group. Only age and BMI showed to be statistically different between groups. The painful TKA group exhibited a valgus alignment when walking (at initial contact and during stance, p<0.001). No significant difference has been put forward for the flexion/extension and internal/external tibial rotation.

Since a higher valgus alignment increases the Q angle, which lateralise the patella and increases PF stresses, results provide new insight on origin of symptoms. Conservative treatments for PF pain syndrome have shown to address the valgus alignment and improve symptoms, therefore the next step will be to assess the impact on pain level and alignment during gait of a personalised conservative management for the painful TKA group. Additionally, a study assessing the change in the radiological and dynamic alignment from pre to post surgery could bring valuable insight on the impact of surgical procedure on anterior knee pain.

Purpose: Gait analysis has become an innovative approach to assess the biomechanical adaptations due to an ACL injury. However, interpreting the large amount of data collected often requires an expert. Therefore, there is a need to develop an automatic method capable to distinguish kinetic pattern of an ACL deficient patients from an asymptomatic population.

Method: 26 ACL deficient patients and 30 asymptomatic participants took part in a treadmill gait analysis. 3D ground reaction forces (vertical, medio-lateral and anterior-posterior) were collected using the ADAL 3D treadmill. Features were extracted from the 3D ground reaction forces as a function of time and then classified by the nearest neighbour rule using a wavelet decomposition method. The classification method was tested on our data base of 56 participants.

Results: The proposed classification method obtained an accuracy of 90%. The classification accuracy per class was higher for the ACL deficient group allowing classifying correctly 25 out of 26 ACL deficient patient. 25 out of the 30 asymptomatic participants were properly classified.

Conclusion: This study shows that an automatic objective computer method could be used in a clinical setting to help diagnose an anterior cruciate ligament injury during a gait analysis evaluation. Future studies should apply this method on a larger database including data from patients with other musculoskeletal pathologies to help diagnose other injuries.

Introduction and objective: Distal biceps tendon ruptures commonly occur in the dominant arm of male between 40 and 60 years of age. The degenerative tendon avulses from the radial tuberosity. Conservative treatment results in decreased flexion and supination strength. Surgical reattachment is the treatment of choice and several surgical approaches and fixation devices have been proposed. The purpose of this study was to compare the results of two different techniques.

Materials and Methods: Twenty-four consecutive patients with distal biceps tendon ruptures were randomly assigned to one of two treatment groups: 12 using 2 biodegradable anchors through a modified 2-incision technique (group A) and 12 patients underwent distal biceps repair using an Endobutton^® (Acufex Smith & Nephew, Andover MA) using a single transverse anterior incision (group B). All patients were male. Average age was 40 (33–57) in groupA and 42 (29–59) in group B. The rupture was located in the dominant arm in 6 patients in groupA and 7 in group B.

The interval between injury and surgery was similar in both groups (< 12 days). Postoperative protocol and rehabilitation was the same in both groups. Full range of motion as tolerated was allowed two week after surgery.

Active range of motion, Mayo Elbow Performance Score (MEPS), pain, strength (Dexter isokinetic testing), patient satisfaction, operative time and elbow radiographs were evaluated at 12 months postoperatively. The mean follow-up was 17 months (range, 12–34).

Results: Average operative time (minutes):50 (group A) and 42 (group B). There were no complications in group B. Two patients in group A had a transient posterior interosseous nerve neurapraxia with spontaneous full recovery after 3 months, and other one developed symptomatic heterotopic bone formation and synostosis was resected. There was no statistical significant difference in MEPS score, range of motion, time to return to work or strength between both groups. All patients in both groups were satisfied with their final result and eventually returned to their pre-injury activity level without sequelae after 12.2 (group A) and 10.3 (group B) weeks.

Conclusion: Functional results of the two techniques studied were similar. Anterior approach showed lesser complications and less time off work than 2-incision technique. Endobutton^® single approach assisted tecnique should be considered the gold standard procedure for distal biceps tendon repair due to its shorter operative time and lower morbidity. However, we need series with a longer follow-up to confirm these results.

Introduction: Ankle arthrodesis is still a surgical technique, which implies compensations with a higher range of motion from the neighbouring joints (knee-tarsus). The aim of this study is to compare and analyze the functional results of large outcome ankle arthrodesis through both kinetic and kinematical motion study and plantar support study.

Material and Methods: We studied 19 patients (17 males and 2 females) with post-traumatic ankle arthrodesis (15 right side and 4 left side) with a minimum follow up of three years (3–9 years). No other lower extremity pathologies were associated. Average age was 37 years (23–56 y.o) and average weight 84,5 kg (54–117 Kg).

We performed physical (including body mass index, BMI), functional and image examination (X-Rays and CT scan). In order to objectify the results we used SF-36, AOFAS scale (max 90 points) and Mazur scale (max 97 points). Kinetic parameters of motion with two force plates (Kistler, Switzerland) and pedography (Emed, Novel, Munich, Germany) were obtained. Kinematic data were obtained with a 3-D video analysis system (Clima system, STT, San Sebastian, Spain). A statistical descriptive study was performed to know the grade of patients’ satisfaction and to analyze the range of motion (ROM) and reaction force of the limbs. Both sides were compared.

Results: results obtained with Mazur scale were 49,26 points (14 – 83), 49,89 points AOFAS scale (22 – 84), 85,79 points SF-36 (85 – 109). Pain score (VAS) was 4.1 points. BMI over 30 points was found six patients. Image analysis of all patients showed an adequate fracture consolidation and a correct ankle position. Kinematical study expressed a lower ROM in the fusion ankle than in the healthy one, basically due to the neighbouring joints movement compensation. Regarding motion parameters we only found differences at the anterior-posterior force switch direction point (41,67% of the healthy foot step and 50,37% in the fusion foot step). Support time was greater in fusion ankle than in healthy one. Midfoot and centre forefoot pressures resulted greater in fusion feet.

Conclusion: Patients with ankle arthrodesis presented often overweight. They show a good subjective outcome in the quality life scales and few mechanical alterations despite of the low score of the ankle and pain specific rating scales.

Aim: To assess the functional and occupational outcome of open elbow arthrolysis for post-traumatic contractures.

Materials and Methods: Prospective evaluation of 60 consecutive cases (86% male,14%female) of post-traumatic extrinsic elbow stiffness. Average age was 37 years (24–48). Moderate to high physical demand at work in 96% of cases. 56% of cases involved the right side.

Open arthrolysis (column procedure) trough a lateral (72%) or posterior (28%) approach followed a minimum rehabilitation period of 6 months post original injury. In 8 cases, an anterior transposition of the ulnar nerve was required. Patients received postoperative analgesia with Bupivacaine 0,0125% trough an indwelling catheter. No chemical or radiotherapy ectopic calcification prophylaxis was used. Postoperative complications, range of motion, X-ray evaluation, time to return to work, activity level and workers’ compensation were evaluated at the end of follow-up (24 months, range 12–36).

Results: Complications occurred in 14% of cases. Two patients required revision surgery for ectopic calcifications restricting prono-supination. The flexo-extension (FE) arc of motion improved from 49 ° to 115 ° and that of prono-supination (PS) from 100 ° to 158 ° The results were found to be statistically significant for FE (p= 0.054) and PS (p> 0,00001).

In 20% of cases, patients returned to their previous job with some restrictions (33% disability) and 12% changed to a less physically demanding occupation.

Conclusions: Open arthrolysis is an effective surgical procedure to improve mobility in post-traumatic stiff elbows. It is indicated when the joint interline is preserved. Good functional and occupational outcome in a high percentage of case in the working population was observed.

Objective: The purpose of this study was to determine which factors may influence in the outcome of the surgical treatment of Carpal Tunnel Syndrome (CTS).

Material and Methods: During 2005, 175 patients were treated with the diagnosis of CTS by open carpal release (short palmar incision) without ligament reconstruction. 113 cases were selected: 39 males and 74 females, with an average age of 41 years (21 to 64 years) and a follow-up of 24 months (12–36 months). The dominant hand was treated in 58%. The subcutaneous cellular tissue (SCT) was sutured in 14% and 11% were immobilized with a cast for 2 weeks after surgery.

We considered factors such as: systemic conditions, functional work requirement, preoperative time, surgical technique, and their correlation with complications, clinical outcome and time to return to work and activity level.

Results: Complications: 41% pillar pain, 9% suture dehiscence, 3,5% ulnar neuritis, 1,7% trigger finger, 1,7% reflex sympathetic dystrophy, and 1,8% wound infection. 5 patients were re-operated. Complications rate due to surgery was 3,5% after 12 months of follow-up. The average time out of work was 9 weeks (2–43 weeks) and was higher (13 weeks) in patients with post-operative immobilization. All patients, except one, returned to their previous activity level. History of systemic conditions and dominance had not influence on the final outcome. The suture of the SCT and the postoperative immobilization showed lower wound dehiscence and pillar pain cases.

Conclusions: The surgical treatment of the CTS provides good clinical and labour results. Patients with suture of the SCT and cast immobilization show less post-operative surgical complications.

Objective: The purpose of this study was to compare the functional and workers compensation results of displaced intra-articular distal radius fractures treated with three diferent type of treatments.

Material and Methods: A randomized prospective study to evaluate 70 patients with displaced intraarticular distal radius fractures. The mean age were 40 years (range, 22–65 years) and all patients were medium or high level workers (40% dominant-hand). Three randomized groups were treated: 19 patients with close reduction and a cast (group 1); 24 patients with close reduction, percutaneous fixation with Kw and a cast (group 2); and 27 patiens with close reduction and external fixation and Kw (group 3).

Postoperative complications, pain (visual analogue scale), clinical and functional outcome based on DASH score, grip strength, X-ray evaluation, time to return to work and activity level were evaluated and compared at 3, 6 and 12 months of prospective follow-up.

Results: Consolidation was obtained in all cases at 7 weeks. Results at 12 months of follow-up: Pain evaluation score: 2.3 (group 1), 2.9 (group 2) and 1.5 (group 3); mean lost of ROM was 11° (group 1), 11° (group 2) and 23.9° (group 3); mean DASH score was 7 (group 1), 29 (group 2) and 12 (group 3). Average lost of pinch strength was 18.3% (group 1), 23% (group 2) and 35% (group 3). Non-aceptable X-ray parameters: 65% (group 1), 35% (group 2) and 50% (group 3).

Re-operations: 10% (group 1), 7.6% (group 2) and 14.8% (group 3). The average time to return to work (weeks) was 12 (group 1), 14 (group 2) and 19.3 (group 3). All patients return to the work and activity level they had before injury.

Conclusions: Similar results were obtained in the three groups at 12 months but better clinical results for the conservative group (group 1) at 3 and 6 months of FU. The orthopaedic treatment achieved better functional results with lesser lost of ROM, time out of work, more grip strength and better DASH score. Percutaneous fixation achieve better X-ray results at the end of FU with lesser re-operations. The functional and clinical outcomes after one year still are unknown. Hence, more and longer studies are required to confirm these results.

Aim: Total Wrist fusion is the main procedure for treatment of postraumatic and degenerative wrist osteoarthritis. During the last decade, midcarpal fusion has become more and more popular as it preserves motion. The purpose of this study was to compare the functional and workers compensation results of both treatments on active workers.

Material and Methods: A prospective study to evaluate 77 patients (76 male and 1 female) who underwent wrist fusion, between 2002 to 2006, with an average of 28 months of follow-up (range, 12–58 months) were made. The mean age were 32 years (range, 25–48 years) and all patients were medium or high level workers with postraumatic and degenerative wrist osteoarthritis. The aethiology in 67% of the patients was SNAC wrist. Right hand was involved in 65% of the patients.

Thirty-eight patients were treated with scaphoid excision and 4-corner fusion using dorsal circular plate. Thirty-nine patients were treated with total wrist fusion using one single, dorsal, precontoured and tapered plate for osteosynthesis and third carpometacarpal joint (CMCJ-3) was included. All patients were immobilised in a cast for 4 weeks after surgery.

Postoperative complications, pain (visual analogue scale), clinical and functional outcome based on Green and O’Brien score, grip strength, X-ray evaluation, time to return to work and activity level were evaluated and compared.

Results: Consolidation was obtained in all cases at 10 weeks. Pain evaluation score was 19,2 (4-corner) and 13,8 (total fusion) on post-op time. The mean modified Mayo wrist score was 70,4 (4-corner) and 69 (total wrist). Average lost of pinch strength was 43% (4corner) and 21% (total fusion). 2 patients with 4-corner fusion required total wrist arthrodesis. Three cases who had a total wrist fusion, required implant removal.

The average time to return to work was 17 weeks (4-corner) and 16,2 weeks (total fusion). All patients return to work. Twelve percent of four-corner fusion and 72% of total wrist fusion return to the same work level with restrictions (until 33% of activity). Twenty-two percent of 4-corner fusion and 28% of total wrist fusion were unable to return to their previous activity level, performing lower intensity work activities. Overall satisfaction was high in both groups with 85% (4corner) and 93% (total fusion).

Conclusion: Both fusion techniques allows an effective stabilization, maintaining the bone stock and eliminate wrist pain with fast return to work.

Total wrist fusion had less surgical failures, better level of satisfaction, lesser lost of force than 4-corner fusion, with less potential for further deterioration with time. However, 4-corner fusion allows return to work with a similar activity level and preserve a functional range of motion in patients with high levels of activity.

Introduction and purpose: The purpose of this study was to assess the functional results of ankle arthrodesis as a treatment of posttraumatic sequelae.

Materials and methods: We carried out a retrospective study from the 1st of January 2000 to the 31st of December of 2005 with a total of 55 patients that underwent posttraumatic ankle arthrodesis, with a mean follow-up of 5 years (range: 1–7 years). The mean age of the patients was 40 years (range: 18–61). There were 52 men and 3 women, the right side (40) predominated over the left (15). Seventy-eight percent of trauma sustained was high-energy with a predominance of fracture of the tibial pilon (type C3 fractures on the AO classification). There were 35% open fractures. The predominant type of surgical technique performed used cannulated screws without any iliac crest grafts. The mean time from surgery to discharge was 9 months (range 4–19).

Results: Repeat arthrodesis was necessary in 16% and an infrapatellar amputation was necessary in 1 case. Only 1 patient returned to their workplace without limitations, the rest were discharged to a medical board for sequelae. The use of crutches/insoles and subjective assessment of pain were related to a lateral tibiotalar angle greater than 90° and varus deformity.

Conclusions: Tibiotalar arthrodesis is a useful rescue technique in patients with severe posttraumatic ankle sequelae. It eliminates pain and increases stability but is the cause of a significant loss of function of the lower limb.

Introduction and purpose: The non-reestablishment of normal scaphoid anatomy is related to instability, loss of function and secondary arthritis. The most appropriate treatment for unstable non-unions with scaphoid deformity is the use of a trapezium-shaped bone graft and internal fixation. We present our experience and the results obtained by treatment of this condition.

Materials and methods: We retrospectively studied 35 patients (34 males and 1 female) with unstable scaphoid non-union treated by curettage, trapezium-shaped iliac crest bone graft and internal fixation, with a mean follow-up of 24 months (range: 12–52 months). Mean age of the patients was 29.8 years (range: 18–52) and all had medium to high functionally demanding jobs. In 48% of cases it was the dominant wrist that underwent surgery. In 3 cases there was a previous history of union of scaphoid fracture. To fixate the graft different devices were used: metal cannulated screws (54%), Kirschner wires (22%) and biodegradable screws (22%). Growth factors were used in 5 cases (PRP) and the wrist was immobilized for 8 weeks. We assessed complications, range of movement, union on x-ray, Green and O’Brien’s scale and return to work at the end of follow-up.

Results: Complete union was obtained in 68.6%, partial in 14.3% and incomplete in 17.1%. Four patients (13.8%) required repeat surgery: 2 four-corner arthrodesis, 1 a conventional graft and 1 a vascularized graft. The mean flexion-extension arc was 99.6°; radio-ulnar deviation was 48.6°. According to the modified Green-O’Brien scale, 93% of the patients had excellent to good results. Time off work after surgery was 21 weeks (9-50 weeks). Ninety-five percent of patients returned to their former job. There were no statistically significant differences with reference to the location of the non-union of the fixation used, although cannulated tapered screws had a lower union rate and a greater number of complications. The worst results were associated with previous surgery and signs of radiocarpal degeneration.

Conclusions: Restoration of normal scaphoid morphology by means of a trapezium-shaped graft results in good outcomes and allows an optimum return to work in manual workers. Previous surgery, signs of radiocarpal degeneration and voluminous implants cause the worst functional results. Even if complete union is not seen on x-rays, the functional result may be optimum.

AIM: The scaphoid resection with four-corner fusion is an effective procedure for treatment of postraumatic and degenerative wrist osteoarthritis. Few studies that evaluated the functional and workers compensation results are available in the literature. We presented the results of 4-corner fusion on active heavy labour workers.

MATERIAL AND METHODS: A prospective study to evaluate 38 patients (37 male and 1 female) who underwent 4-corner fusion, between 2002 to 2005, with an average of 24 months of follow-up (range, 12–48 months) were made. The mean age of the patients were 32 years (range, 25–48 years). All patients were heavy-labour workers. The aethiology in 77% of the patients was SNAC wrist. Dominant limb was involved in 65% of the patients. All patients were immobilised in a cast for 4 weeks after surgery. Patients were assessed clinically and radiographically. Functional analysis of grip and pinch strenght were performed.

RESULTS: Consolidation was obtained in all cases at 10 weeks. Pain evaluation score was 77 at pre-op and 19 on post-op time. The range of flexion – extension movement postoperative was 57°. Average lost of pinch strength was 25%. All patients return to work, 80% to the same activity level and 20% to a different work performing less strenuous activities. After surgery, the range time to return to work was 160 days.

CONCLUSION: The four-corner fusion allows an effective stabilization, maintaining the bone stock and eliminate wrist pain. This technique permit a fast return to work with a great level of satisfaction and preserve a functional range of motion with a minimum lost of force in heavy labour workers.

AIM: We present the results of scaphoid non-unions treated with open reduction, bone grafting and internal fixation with biodegradable implants on active heavy labour workers.

MATERIAL AND METHODS: Between 2002 to 2004, 20 patients with scaphoid non-unions were treated by open reduction, bone grafting and internal fixation using self-reinforced poly-L-lactic acid screws. The mean prospective follow-up was 24 months (range, 12–38 months). The mean age was 28 years (range, 18–42 years). All patients were male and heavy-labour workers.

The patients were assessed clinically (modified Mayo wrist score) and radiograhically. The grip and pinch strength were also studied.

RESULTS: We find 13 excellent results, good in 5 cases and poor in 2 cases. A Matti-Russe group patient was revised 6 months after the first intervention. Any fragment displacement, implant loosening or adverse reaction was found. Most of the patients (90%) return to the same work and the same level without complications.

CONCLUSION: Both groups are a good alternative for the scaphoid non-unions treatment. However, biodegradable implants disappears in the time, the removal are no necessary, facilitate the revision surgery, if necessary, and permitted MRI studies to evaluated the graft viability.

Introduction: We present our experience in the treatment of the aseptic necrosis of the femoral head with a vascularized iliac crest graft by means of a retrospective analysis of 25 hips (22 patients) subjected to surgery in our hospital between June 1993 and September 2002.

Materials and methods: There was a predominance of male patients (20 cases). In most patients the necrosis appeared in the left side. The most common predisposing factor was alcohol abuse (8 cases). All patients were subjected to a clinical (Harris score) and a radiological evaluation, and the evolution of their necrosis was assessed using the Ficat-Arlet system (as modified by ARCO) with a mean follow-up of 4 years.

Results: The average functional evaluation was of 87 points, with 76% of results in the excellent and good categories and 24% fair and poor. 40% of the hips underwent some kind of radiological deterioration (mean: 5.2 years). On the basis of the radiological evaluation criteria, 66% of patients evolved satisfactorily.

Conclusions: Our results are in line with those published in the literature. 60% of patients operated on showed no evidence of a radiological progression of the necrosis of the femoral head.