Current concepts in the surgical management of adolescent idiopathic scoliosis.

Adolescent idiopathic scoliosis (AIS) is a complex 3D deformity of the spine. Its prevalence is between 2% and 3% in the general population, with almost 10% of patients requiring some form of treatment and up to 0.1% undergoing surgery. The cosmetic aspect of the deformity is the biggest concern to the patient and is often accompanied by psychosocial distress. In addition, severe curves can cause cardiopulmonary distress. With proven benefits from surgery, the aims of treatment are to improve the cosmetic and functional outcomes. Obtaining correction in the coronal plane is not the only important endpoint anymore. With better understanding of spinal biomechanics and the long-term effects of multiplanar imbalance, we now know that sagittal balance is equally, if not more, important. Better correction of deformities has also been facilitated by an improvement in the design of implants and a better understanding of metallurgy. Understanding the unique character of each deformity is important. In addition, using the most appropriate implant and applying all the principles of correction in a bespoke manner is important to achieve optimum correction. In this article, we review the current concepts in AIS surgery. Cite this article: Bone Joint J 2018;100-B:415-24.

Anterior cruciate ligament insufficiency: does delay in index surgery affect outcome in recreational athletes.

The aim of the study was to see if delay in anterior cruciate ligament (ACL) reconstruction affects post-reconstruction outcome in recreational athletes. Sixty-two recreational athletes who had arthroscopic ACL reconstructions using quadruple hamstring grafts between 1997 and 2000 were retrospectively evaluated. Patients with less than 2 years' follow-up, those with multi-ligament injuries, reconstructions for previous failed repairs, those whose injury date was unknown, those with pre-injury Tegner activity level greater than 7 (competitive athletes) and those lost to follow-up were all excluded. Forty-six patients (38 males) were entered. The mean follow up was 38 months and the mean time from injury to index ACL reconstruction was 27 months. Apart from two revisions there were no other significant complications. Forty-one (89%) patients were evaluated in a review clinic. There was a significant improvement in the post-reconstruction Lysholm scores and an improvement in the Tegner scores. The Spearman's correlation coefficient between postoperative Lysholm score and the delay until surgery was -0.18 and the correlation coefficient between postoperative Tegner scores and the delay until surgery was 0.14. Thirty-five patients returned to sporting activity. Thirty-seven rated their knee as being normal or nearly normal and 35 said that their knee function was as they had expected it to be. Late ACL reconstruction does not adversely affect the outcome in recreational athletes. ACL reconstruction should be offered to these patients as there is a significant improvement in the knee function and patients are satisfied with the results.

Fractures of the distal third of the clavicle treated by hook plating.

We retrospectively assessed the union and shoulder function following hook plate fixation in 18 patients with Neer type 2 fractures of the lateral end of the clavicle. The average age was 40 (range 22-62) years, and the mean follow-up was 25 (range 6-48) months. Fifteen patients had acute fractures and the rest were non-unions. Complications included two non-unions, one following a deep infection. There were no iatrogenic fractures. Acromial osteolysis was seen in five patients who had their plates in situ. The average pain score at rest was 1 (range 0-4), and the average pain score on abduction was 2.2 (range 0-5). The average Constant score was 88.5 (range 63-100). Patients were asked to rate their shoulder function; three rated it as normal, 11 as nearly normal and one as not normal. Hook plate fixation appears to be a valuable method of stabilising Neer type 2 fractures of the clavicle, resulting in high union rates and good shoulder function. These plates need to be removed after union to prevent acromial osteolysis.

Scaphoid non-union: the role of vascularized grafting in recalcitrant non-unions of the scaphoid.

Achieving union using conventional grafts has a high chance of failure in patients with recalcitrant non-union (persistent pseudarthrosis) of the scaphoid bone, an avascular proximal fragment and previous failed surgeries because of poor host bed vascularity. Eleven patients with long-standing non-union were treated with vascularized pedicle bone grafting and supplementary corticocancellous grafting. Five had screw fixation and six were fixed with K-wires. The average age of the patients was 28 years, average duration of the non-union was 39 months and mean radiological follow-up was 32 months. There were no significant skeletal complications, although two patients developed neuromata. At review, only six of the 11 non-unions were united. Whilst this is a difficult clinical problem and achieving union is a formidable challenge, we believe that there is a role for such extensive surgery in order to achieve good postoperative function.

In scaphoid non-union, does the source of graft affect outcome? Iliac crest versus distal end of radius bone graft.

Iliac crest bone grafts are sometimes preferred to other bone grafts for the treatment of non-unions of fractures of the scaphoid as they are claimed to have better osteogenic potential and biomechanical properties. We retrospectively studied a consecutive cohort of 68 symptomatic established scaphoid non-unions treated by bone grafting. An iliac crest graft was used in 44 cases and a distal radius graft in the other 24. The two treatment groups were comparable in terms of location of the fracture, duration of the non-union and the fixation implants used. Overall union was achieved in 45 of the 68 patients (66%) and the union rate was not influenced by the type of bone graft used. Twenty-nine of the 44 treated with iliac crest bone graft (66%) and 16 of the 24 (67%) treated with distal radial graft united. Donor site pain over the iliac crest was present in nine of the 44 patients in this group.

Wrist fusion versus limited carpal fusion in advanced Kienbock's disease.

We treated 18 patients with advanced Kienbock's disease surgically. Six had total wrist fusions and 12 had limited carpal fusions. The average age was 39.6 yrs and the average follow up was 61.8 months and 66.8 months respectively. The visual analogue pain scores, the patient satisfaction scores and the SF 12 were better in the total wrist fusion group. The DASH (Disabilities of the Arm, Shoulder and Hand) scores, the range of movement and the grip strengths were better in the limited carpal fusions group but this was not statistically significant. Four patients with limited carpal fusions had a non-union that required revising. We believe that total wrist fusion should be offered earlier to patients with advanced stages of the disease, as there are less surgical failures, more satisfied patients, better post operative pain scores and consistent long-term results with less potential for further deterioration with time as compared to other treatment methods.