Nonsurgical treatment of Acromioclavicular joint dislocations is well established. Most patients treated conservatively do well, however, some of them develop persistent symptoms. We have used two different surgical reconstruction techniques for Chronic ACJ dislocation stabilization. The study evaluates the effectiveness of a braided polyester prosthetic ligament and modified Weaver-Dunn reconstruction methods. 55 patients (mean age 42) with Chronic Acromioclavicular joint dislocation were included in this study. They were treated either by a modified Weaver-Dunn method or a braided polyester prosthetic ligament. Patients were assessed using Oxford shoulder score preoperatively and a minimum of 12 months postoperatively.Background
Methods
The Constant Score (CS) and the Oxford Shoulder Score (OSS) are shoulder scoring systems routinely used in the UK. Patients with Acromio-Clavicular Joint (ACJ) and Sterno-Clavicular Joint (SCJ) injuries and those with clavicle fractures tend to be younger and more active than those with other shoulder pathologies. While the CS takes into account the recreational outcomes for such patients the weighting is very small. We developed the Nottingham Clavicle Score (NCS) specifically for this group of patients. We recruited 70 patients into a cohort study in which pre-operative and 6 month post-operative evaluations of outcome were reviewed using the CS, the OSS the Imatani Score (IS) and the EQ-5D scores which were compared with the NCS. Reliability was assessed using Cronbach's alpha. Reproducibility of the NCS was assessed using the test/re-test method. Each of the 10 items of the NCS was evaluated for their sensitivity and contribution to the total score of 100. Validity was examined by correlations between the NCS and the CS, OSS, IS and EQ-5D scores pre-operatively and post-operatively.Introduction
Methods
Health Economists in Denmark have recently reported low and delayed return to work for patients treated for Sub-Acromial Impingement syndrome (SAIS) by Arthroscopic Sub-Acromial Decompression (ASAD). Surgeons however are reporting that patients achieve good pain relief and a high standard of activities of daily living (ADL) after surgery. To evaluate the effectiveness of ASAD for patients with SAIS and correlate clinical outcome with rate of return to work.Introduction
Aim
The conservative management of Sub-Acromial Impingement Syndrome (SAIS) of the shoulder includes both physiotherapy treatment and subacromial injection with local anaesthetic and steroids. The outcome from injection treatment has rarely been evaluated scientifically. Patients attending a designated shoulder clinic and diagnosed by an experienced shoulder surgeon as having a SAIS between January 2009 and December 2011 were considered for inclusion in the study. 67 of 86 patients screened completed the study (3 did not meet inclusion criteria; 9 declined to participate; 3 lost to follow-up; 4 developed frozen shoulder syndrome). Each patient had a pre-injection Oxford Shoulder Score (OSS) and was given one subacromial injection of 10ml 0.25% levobupivacaine(Chirocaine) + 40 mg triamcinolone(Kenalog) through the posterior route. Radiograph imaging was also assessed. Follow-up was carried out at 6 to 12 weeks post injection when OSS was repeated. A 6 month follow-up assessment to assess if the patient's improvement in functionality and absence of symptoms indicated that a subacromial decompression operation was not necessary. The percentage of patients showing improvement in OSS was calculated and the difference in OSS pre- and post-injection assessed using a Wilcoxon Signed Rank test.Introduction
Methods
Metastatic osteosarcoma is seen in 10-20% of patients at initial presentation with the lung the most common site of metastasis. Historically, prognosis has been poor. We studied trends in survival in our small developed nation and aimed to identify correlations between the survival rate and three factors: newer chemotherapy, advances in radiological imaging and a more aggressive approach adopted by cardiothoracic surgeons for lung metastases. Our national bone tumour registry was used to identify patients at the age of 18 or under, who presented with metastatic disease at initial diagnosis between 1933 and 2006. There were 30 patients identified. Kaplan-Meier analysis was used to determine survival rates and univariate analysis was performed using the Cox regression proportional hazards model. Median survival has improved over the last 50 years; highlighted by the ‘Kotz’ eras demonstrating incremental improvement with more effective chemotherapy agents (p=0.004), and a current 5-year survival of 16%. Aggressive primary and metastatic surgery also show improving trends in survival. Three patients have survived beyond five years. The introduction of computerised tomography scanning has led to an increase in the prevalence of metastases at initial diagnosis. Metastatic osteosarcoma remains with a very poor prognostic factor, however, aggressive management has been shown to prolong survival.
Metastatic osteosarcoma is seen in 10-20% of patients at initial presentation with the lung the most common site of metastasis. Historically, prognosis has been poor. We studied trends in survival in our small developed nation and aimed to identify correlations between the survival rate and three factors: newer chemotherapy, advances in radiological imaging and a more aggressive approach adopted by cardiothoracic surgeons for lung metastases. Our national bone tumour registry was used to identify patients at the age of 18 or under, who presented with metastatic disease at initial diagnosis between 1933 and 2006. There were 30 patients identified. Kaplan-Meier analysis was used to determine survival rates and univariate analysis was performed using the Cox regression proportional hazards model. Median survival has improved over the last 50 years; highlighted by the ‘Kotz’ eras demonstrating incremental improvement with more effective chemotherapy agents (p=0.004), and a current 5-year survival of 16%. Aggressive primary and metastatic surgery also show improving trends in survival. Three patients have survived beyond 5 years. The introduction of computerised tomography scanning has led to an increase in the prevalence of metastases at initial diagnosis. Metastatic osteosarcoma remains with a very poor prognostic factor, however, aggressive management has been shown to prolong survival.
Most common current surgical treatment options for cuff tear arthropathy (CTA) are hemiarthroplasty and reverse total shoulder replacement. At our unit we have been using Reverse Total shoulder replacement (TSR) for CTA patients since 2001. We present our results of Reverse TSR in 64 patients (single surgeon) with a mean follow up of 2 years (Range 1 to 8 years). There were 45 males and 19 females in the study with a mean age of 70 years. Preoperative and postoperative Constant scores were collected by a team of specialist shoulder physiotherapists. Preoperatively plain radiographs were used to evaluate the severity of arthritis and bone stock availability. 90% patients showed an improvement in the Constant score post operatively. The mean improvement in Constant score was 25 points. The mean Pain Score (max 15) improved from 6.3 to 11.8; the mean ADL Score (max 20) improved from 6.8 to 12.3; the mean Range of Motion score (max 40) improved from 10.8 to 20.2; but the mean Power Score (max 25) only improved from 0.9 to 4.9. The differences in improvement were statistically significant in each category. A total 6 patients (10%) required 10 revision surgeries for various reasons. Two patients dislocated anteriorly who were treated by open reduction. Two patients required revision of the glenoid component due to loosening after a mean of 2 years. One patient required revision of the humeral component with strut grafting secondary to severe osteolysis. Only one patient required revision of both humeral and glenoid components secondary to malpositioning. Three patients died for reasons unconnected with their shoulder problems and surgery. Radiographic analysis at the latest follow up (mean 24 months) showed inferior glenoid notching in 40% cases. Heterotrophic ossification was not seen in our series. We conclude that reverse TSR is a viable option for treatment of cuff tear arthropathy however glenoid loosening and scapular notching remains an issue.
Shoulder instability is a common cause of morbidity amongst Professional Rugby Union players. This study explores whether the risk of shoulder dislocation is associated with innate shoulder laxity. A randomised controlled study was completed in which all the Premiership Rugby Clubs in England were visited in 2006. 169 professional rugby players (mean age 25.1 years) with no history of instability in either shoulder were assessed and 46 injured players with one shoulder with a history of Bankart lesion or dislocation (mean age 27.5 years) also took part in this study. Shoulder laxity was measured by dynamic ultrasound. Anterior, posterior and inferior translations were measured in both shoulders for healthy players and the uninjured shoulder only for injured players.Objective
Methods
From August 2009, all doctors were subject to the European Working Time Directive (EWTD) restrictions of 48 hours of work per week. Changes to rota patterns have been introduced over the last two years to accommodate for these impending changes, sacrificing ‘normal working hours’ training opportunities for out-of-hours service provision. We have analysed the elogbook data to establish whether operative experience has been affected. A survey of trainees (ST3-8) was performed in February 2009 to establish shift patterns in units around the UK. All operative data entered into the elogbook during 2008 at these units was analysed according to type of shift (24hr on call with normal work the following day, 24hr on call then off next working day, or shifts including nights). 66% of units relied on traditional 24hrs on call in February 2009. When compared with these units, trainees working shifts had 18% less operative experience (564 to 471 operations) over the six years of training, with a 51% reduction in elective experience (288 to 140 operations). In the mid years of training, between ST3-5, operative experience fell from 418 to 302 operations (25% reduction) when shifts were introduced. This national data reflects the situation in UK hospitals in 2009, prior to the implementation of a maximum of 48 hours. It is expected that most hospitals will need to convert to shift-type working patterns to fall within the law. This could have significant implications for elective orthopaedic training in the UK.
An online survey has been carried out to evaluate the compliance with the OCAP learning tools, and the availability of clinical experience to early years’ trainees in Trauma and Orthopaedics in 2007–8. Three surveys were planned over the year, and we present the results from the first two surveys. Over the initial eight month period, 335 trainees in Trauma and Orthopaedic posts responded. There was considerable variation in the proportion of responses from different deaneries, and it was felt this reflected differences in the use of the two logbooks available (FHI or ISCP). Respondents were FTSTAs (50%), ST1s (11%) and ST2s (29%). The respondents reported their operative experience was poor with low numbers of index procedures – the median values being 2 DHS, 1 Hemiarthroplasty and 0 for Ankle ORIFs performed as the lead surgeon in the first 4 months, rising to 3, 1 and 1 respectively in the second. As an assistant the numbers were 3, 4 and 3. FTSTAs had done more procedures as lead surgeon. It is not clear whether this reflects motivation, or whether they are trainees who were unable to secure training posts due to seniority and were already more experienced. Many posts were entirely ward based. Improvements in meetings with Assigned Educational Supervisors were noted, as was the use of the learning agreements, and with registration rates with the ISCP. There was considerable variation between posts, hospitals and deaneries, and a tool was developed to summarise this data to be post-, trainee-, and duration-specific. Summaries of each post were distributed to Training Program Directors, Heads of School, and the SAC. Although some improvement has occurred, further rounds of the survey are necessary to ensure that this continues. The next round will commence in September 2008 to complete twelve months of data.
Shoulder instability is a common cause of morbidity amongst Professional Rugby Union players. This study explores whether the risk of shoulder dislocation is associated with innate shoulder laxity. A prospective, randomised controlled study was completed in which all the Premiership Rugby Clubs in England were visited. 169 professional rugby players with no history of instability in either shoulder and 46 players with one shoulder with clinical instability symptoms were assessed. Shoulder laxity was measured by clinical evaluation, questionnaires and ultrasound. Anterior, posterior and inferior translation was measured in both shoulders for healthy players and the uninjured shoulder only for injured players. The results showed there was no significant difference between the left (anterior: mean 2.92 +/− 1.15 mm; posterior: mean 5.10 +/− 1.75 mm; inferior: mean 3.08 +/− 1.00 mm) and right (anterior: mean 3.07 +/− 1.14 mm; posterior: mean 4.87 +/− 1.61 mm; inferior: mean 2.91 +/− 0.99 mm) shoulders in healthy players (P >
0.05). The comparison between healthy shoulders (anterior: mean 3.00 +/− 1.15 mm; posterior: mean 4.99 +/− 1.68 mm; inferior: mean 3.00 +/− 1.00 mm) from healthy players and the uninjured shoulder (anterior: mean 4.16 +/− 1.70 mm; posterior: mean 6.16 +/− 3.04 mm; inferior: mean 3.42 +/− 1.18 mm) from injured players identified that players with unstable shoulders have a significantly higher shoulder translation in their normal shoulder than healthy players (P <
0.05). This is the first study looking at laxity and the risk of shoulder dislocations in sportsmen involved in a high contact sport. These results support the hypothesis that rugby players with “lax” shoulders are more likely to sustain a dislocation or subluxation injury to one of these lax shoulders in their sport.
We aimed to test the biomechanically predicted hypothesis that in massive rotator cuff tears irreparable by conventional methods the newly developed Nottingham Augmentation Device (NAD) would provide greater functional improvement than that gained from the gold standard of arthroscopic subacromial decompression. Thirty patients treated between 2001 and 2004 were assessed by pre- and six month post-operative Constant scoring. Fifteen underwent open acromioplasty and cuff reconstruction using the NAD (mean age 67.3), while 15 underwent a standard arthroscopic decompression (mean age 67.4). The two groups were matched retrospectively based on size of cuff tear, age and sex. Data was analysed using the student’s t-test at the 95% confidence interval. Both groups displayed a statistically significant increase in Constant score after surgery. The mean increase for NAD patients was 18.7 points compared with 17.6 points for those undergoing arthroscopic decompression. However there was no significant difference between the two groups’ improvement and this was even so in the power sub-category, where increased benefit was predicted with the NAD. The NAD requires greater surgical access, operating time and peri-operative analgesia, and no active mobilisation for six weeks. The arthroscopic technique is minimal access, rapid, involves no prosthesis or foreign body insertion and allows immediate mobilisation. However, with clear biomechanical benefits of the NAD seen in vitro, our results may simply reflect cuff tears in an older population group with irreversible tissue changes and less rehabilitative potential. A randomised prospective trial in a younger patient group with more acute tears and less tissue atrophy would appear the next step in determining the NAD’s place in the management of massive rotator cuff tears.
The results have also been analysed for each part of the Constant Score – Pain, Activities of Daily Living, Range of Movement and Strength and these will be presented.
Significant differences were identified between the 3 methods of “Strength” measurement, highlighing the need for a uniform method of carrying out the CS.
Transmitted and polarised light microscopy has been used in all cases.
The main cause for this low survivorship rate is the low survivorship of this prosthesis among patients with primary osteoarthritis, 61.4% ten years survivorship. Conversely among the patients with rheumatoid arthritis the ten years survivorship was considerably higher (86.9%). The main cause of failure of this prosthesis was related to the glenoid component and was either due to aseptic glenoid component loosening (in 54% of the failed cases) or a failure (uncoupling) of the polyethylene bearing liner in 17% of failed cases. Furthermore about 70% of the failed cases occurred during the first four postoperative years showing an overall four years cumulative survivorship rate of 80.9%.
The mean Constant score was 88 (s.d. 12). The mean Imatani score was 86 (s.d. 16). Most patients were satisfied with the operation (90%). There was one case of rupture through the central portion of the Surgilig, and following extensive laboratory analysis, the ligament has been modified since. One patient had a fracture of his coracoid while lifting heavy weights. In 4 patients there was clinical and radiological evidence of loosening of the screw but only 1 complained of this being a problem.
The Nottingham Hood is a polyester soft tissue reinforcement device for the treatment of weakened or torn rotator cuff tendons (RCTs). The device was introduced in 1987 and has undergone a number of modifications from a close weave polyester modified aortic vascular graft (Mark 1) to an embroidered trefoil shape (Mark 4 – Pearsall’s Ltd) which has now been available since 2000. While this device has been under development it has been used on a named patient basis for 10 years on humanitarian grounds as an alternative treatment option for patients with massive RCTs. Approximately 30 Nottingham Hoods have been inserted over the past 10 years. This study investigates the histological changes and ingrowth associated with this device. Four patients who have had the Nottingham Hood inserted for massive RCTs have had re-operations for various reasons on five occasions. Excised material from the rotator cuff has been subjected to histological investigation. Excised biopsy material has been obtained 6 weeks, 6, 9 &
12 months and 14 years following implantation. Transmitted and polarised light microscopy has been used in all cases. At 6 weeks birefringent clear material similar to suture material was identified, invested by fibrin and occasional red cells i.e. old thrombus. The fibrin was partly calcified and insinuated between bundles of the meshwork material. No true ingrowth of material was seen at this stage. At 6 months the material was seen macroscopically to be covered with collagenous material, rather like fascia which interdigitated closely with the embedded polyester material. At 14 years the mesh appeared to be invested, sandwich-like into a collagenous fascia-like structure with dense hyaline bands of collagen. Some fibrin was also present between the fibrils and a low grade foreign body giant cell response with light chronic inflammation. The local synovium showed detritic synovitis. The histological features show that there is an early organisational response to the insertion of the new tissue, which is then accompanied by long-term incorporation into host tissues by fibrosis and scarring. A small fibrin and foreign body response lingers on. This long-term follow-up assessment provides evidence that long-term implantation of polyester as reinforcement for the rotator cuff tendons is not associated with serious biological problems. However the problem of stretching of the repaired rotator cuff muscles does occur and needs to be considered in more depth.
Introduction: The Constant Score Functional Assessment (CS) is now the standard method of assessing shoulder disability in Europe. It has been observed that CS values decrease with age and attempts have been made in Canada (Constant, 1986), Germany (Tempelhof, 1999), Switzerland (Gerber, 1992) and US (Romeo, 2002) to produce national norms. Unfortunately the methods used for measuring the “Strength” category of the CS have varied. This study aimed to establish UK norms. Methods: 200 patients stratified for age over 50 were invited to take part in this study for which Local Ethics Committee approval had been obtained. Of these 200, 46 patients (21 males) attended and all attendees had a CS carried out with the “Strength” measurement made in 3 ways – 1) maximum force using a fixed spring balance – FSB(max); 2) maximum force using a Nottingham myometer – M(max); 3) mean force from 2 to 4 seconds using a Nottingham myometer – M(mean). Results: The results for the 25 females and 21 males using M(mean) show a general trend of decreasing Constant Score with increasing age for the left and right shoulders of both the male and female subjects. There were some outliers, particularly in the female results, which were reflected in widened 95% confidence intervals. Paired student t-tests found statistically significant differences between M(mean) and FSB (max) results (left, p<
0.01; right, p=0.013) and M(mean) and M(max) (left, p<
0.01; right, p<
0.01). Discussion: The results confirm deterioration in the CS with age in both men and women. Constant Score values from our study differ from previous studies, with up to 15 points difference between our results and those from Romeo 2002. Significant differences were identified between the 3 methods of “Strength” measurement, highlighting the need for a uniform method of carrying out the CS. Conclusion: The UK pattern of deteriorating CS with age mirrors that seen in other countries but the values are different. These differences are significant and make it necessary to reconsider the use of the corrected CS. It is probably wiser to use the uncorrected CS but refer to normal values as a guide for the expected CS at different ages.
Introduction: This study was designed to investigate which parameters of the Constant Score are most influenced by the presence of a Rotator Cuff Tear (RCT). Methods: 28 patients attending the Shoulder Clinic took part in this study for which Ethics approval had been obtained. Strength measurements were assessed in three ways: 1) maximum force using a fixed spring balance (FSB) 2) maximum force using the Nottingham Mecmesin Myometer 3) mean force during 2nd to 4th seconds using Nottingham Myometer. The CS assessor was blind to the volunteer’s history and state of their rotator cuff. Ultrasonography was used to establish the presence of a full-thickness RCT. Results: The CS values for the left and right shoulders were analysed separately. No statistically significant difference (p>
0.05) was found between shoulders with a RCT and without a RCT in the pain, ADL and ROM parameters. Left shoulders with a RCT scored significantly different strength scores to those without (p<
0.05) but this significance was not seen in the right shoulders (p>
0.05). Shoulder strength measurements were highest with the FSB and lowest when measured using the mean force. Discussion: The results obtained so far suggest that a shoulder with a full-thickness tear of the RC may obtain a significantly lower strength score than a normal shoulder. It does not suggest that any of the other three parameters of the CS can indicate the presence of a tear. Conclusion: A reduction of shoulder strength alone might be a good indicator of a full-thickness RCT. However, this study indicates the importance of standardising the method of shoulder strength assessment for the Constant Score.
Steroids are known to have an adverse effect on the blood glucose levels in diabetics. Intra-articular steroids are commonly used in Orthopaedic and Rheumatology practice. However we have failed to identify any studies to date that have been carried out on the short-term effect of intra-articular steroids in diabetics who are taking insulin. This study was carried out to establish the effects of intra-articular (IA) steroid injections on the blood glucose levels and insulin requirements for insulin dependant diabetic patients treated for a “Frozen Shoulder”.
This paper reports two studies of uncemented (UC) shoulder arthroplasty – one directed at UC humeral stems (Study 1) and the second at UC glenoid components (Study 2). In Study 1, 160 consecutive UC humeral stems were inserted between 1989 and 1995. Three types of stem were used – Biomodular, modified Biomodular and Nottingham. At a mean follow-up of 4.3 years 18 shoulders were lost to follow-up. Of the remaining 142 shoulders radiographs from routine follow-up appointments at 6 months,1,2,3,5,7 &
9 years were reviewed together with a clinical follow-up of the patients. In Study 2 a survival analysis was carried out on a consecutive series of 222 UC glenoid components inserted between 1989 and 1998 at a mean follow-up of over 5 years. Survival was defined as a prosthesis remaining in situ in a live patient. Six types of UC glenoid component were used – Copeland/Zimmer(non HA), stndard Biomodular, low-profile Biomodular, Nottingham prototype, Nottingham and Nottingham with HA. In Study 1, radiological follow-up indicated 3 stems(2%) showed definite loosening (all related to deep infection) – all were revised. Six stems (4%) showed probable loosening but were asymptomatic. In Study 2, for the whole series a survival table was created which identified a survival at 2; 5 and 10 years respectively of 92%; 75% and 66%. The later prosthesis designs performed best. A radiological analysis of all shoulders is currently in progress. This audit of outcome has indicated that hydroxyapatite has been beneficial but further long-term studies are required.
The Halder Nail was introduced into the UK in 1994 and the inventor has recently reported his results (Halder et al, 2001
Current design guidelines for the front end of motor vehicles aim to reduce tibial fractures but this may be at the expense of an increased risk of injury to the knee itself . The purpose of this study was to describe the type of knee injuries and group characteristics of those sustaining them with a view to initiating a more detailed research project in injuries to the lower limb. The medical records of all patients aged 16 years and over presenting to the Accident &
Emergency (A&
E) Department at University Hospital Nottingham with a knee injury sustained in a road traffic accident between April 1992 and December 1998 were identified and reviewed. In a total of 374 patients, 178 sustained significant knee injuries, requiring admission to hospital. 78% of these sustained a fracture, with fracture of the tibial plateau being most common. 22% of patients sustained ligamentous injury. Almost 50% of patients received operative treatment during the first month after injury. Current legislation may be responsible for placing pedestrians at more risk from knee injuries. An understanding of the mechanism of knee injury compared with tibial fracture is important and recommendations for prevention of injury can then be instituted.
A research programme has been directed at the mechanism by which car occupants sustain ankle and hind-foot injuries. The severe injuries that are most associated with long term disability and high socio-economic cost have been investigated. Although seat belts and air bags have had a beneficial effect on injuries to most body regions including pelvic, femur and knee injuries, no protective effect has been demonstrated for below knee injuries. Only by understanding the mechanism of injuries to the leg below the knee will it be possible to design improved protection in the future. Twenty three post mortem human surrogate (PMHS) limbs were impacted using a test set up that was developed to simulate the loading conditions seen in a frontal collision in 3 different positions – A, B &
C. The impactor head (5cm x 10cm wide), was instrumented with an accelerometer and linear potentiometer. The impacting force was generated using a bungee-powered sled mounted on steel bearings. Three PMHS legs were tested In Position A (impactor head centred in line with the tibial axis), 9 PMHS legs were tested in Position B (impactor head centred on the anterior tibial margin) and 11 PMHS legs were tested in Position C (impactor head centred 2.5cm anterior to the anterior tibial margin). Active dorsiflexion was simulated through the Achilles tendon and prior to the application of Achilles tension a tibial pre-load (500 to1500N) was applied via a ‘jacking-plate’ applied to the proximal end of the tibia. During impact testing, bone failure (fractures) occurred at impact loads of 5.7+/−1.9 kN (resultant tibial failure load 6.4+/−1.9 kN) and the following injuries were generated: 9 intra-articular calcaneal fractures; 1 talar neck and 2 talar body fractures; 3 intra-articular distal tibial (pilon) fractures; 2 malleolar fractures; 3 soft tissue injuries and in 3 cases there was no detectable injury. The impact test conditions were replicated with a Hybrid III leg in a first attempt at developing injury risk functions for the dummy. This study has demonstrated the importance of preload through muscle tension in addition to the intrinsic properties of PMHS specimens in the generation of severe ankle and hindfoot injury.
Thermal shrinkage of the shoulder capsule requires postoperative joint immobilisation with the humeral head centred in the glenoid fossa for optimal proprioceptive recovery. Routinely applied commercial slings hold the arm internally rotated and lengthen the posterior capsule. The aim of our study was to develop and test the clinical effectiveness of a splint that would maintain the shoulder in an optimal position of neutral rotation after posterior capsular shrinkage. To our knowledge, no splint has been described for this purpose. We developed a new design fabricating the splint using thermoplastic material. The design was then modified to ensure ease of fitting and patient comfort. The custom-made splint is fashioned preoperatively and fitted in the operating room after the dressings are applied. Our study group consisted of 18 cases of multidirectional or posterior shoulder instability who were splinted for a period of three weeks after thermal capsular shrinkage. The comfort and compliance of the splint were assessed using a patient questionnaire. Constant scores for the study group were retrospectively compared with a similar patient group managed with a ‘polysling’.
This study was carried out to investigate the outcome of rotator cuff repair surgery in 14 centres in th UK in a randomised controlled trial. It also looked at a comparison of a long-acting absorbable suture (Panacyrl) and a non-absorbabable suture (Ethibond). All patients were treated with open repair of their rotator cuff tear with modified Mason-Allen sutures used in 83% of cases. One hundred and fifty-nine patients were included in the analysis. patients had Constant scores carried out pre-operatively, six and 12 months as well as ultrasound real time dynamic scans at eight weeks, six and 12 months. Constant pain scores, total constant scores and re-tear rates were measured. There was a significant improvement in the Constant score after rotator cuff repair surgery. However for large tears, the re-tear rate at six months is approximately 50%. Despite this high retear rate there was still a good benefit from surgery. Is the improvement in those cases with a re-tear a consequence of the sub-acromial decompression (SAD) and what would have been the outcome with an ASD alone?
The aim of this study was to assess the results of bone ingrowth into the glenoid component of one design of Total Shoulder Arthroplasty (TSA) in which hydroxyapatite (HA) coating of the glenoid baseplate was introduced since 1997. Glenoid loosening is one of the most important complications of both cemented and uncemented TSA. Between May 1993 and April 1997 over 140 uncemented, porous coated, metal backed glenoid component were used in our Unit. By 1997 it had become clear that a significant number of these glenoid components had developed mechanical loosening and some required revision. We therefore started using an HA coated glenoid component for our TSAs from April 1997. One hundred and seventy-four shoulder arthroplasty procedures were performed between April 1997 and October 1999 of which 37 were TSAs using the HA coated uncemented glenoid. The indications included osteoarthritis (22), rheumatoid arthritis (nine), revision TSA (three), avascular necrosis (two) and cuff arthropathy with cuff reconstruction (one). The minimum follow-up was 18 months. The X rays were evaluated using the MLS (Migration, Lucent lines, Screw problems) system, which had been developed and reported previously. This system of evaluation has been shown to be reproducible for assessment of glenoid fixation. There was one case in which the glenoid liner became displaced and had to be replaced. Our early results at a mean FU of approximately 2 years show an improved radiological fixation compared with those glenoids inserted without HA.
Shoulder surgery is associated with moderate to severe post-operative pain. A pain free post-operative period is desirable and appreciated by both patients and therapists and is essential for early rehabilitation. Analgesia can be provided either locally or systemically or by combining the two. A prospective, randomised double blind study was designed to assess the effectiveness of an existing postoperative local analgesic method: using Marcaine through subacromial catheter. Thirty-nine patients were included in the trial. All patients had simple arthroscopic subacromial decompression and no additional pathology to the shoulder. At the end of the operation a standard epidural catheter was inserted into the subacromial space under visual control. Sixteen patients had 0.25% Bupivacaine and 23 patients had normal Saline given in 10 ml boluses six hourly, until required. All patients had access to conventional pain relief (paracetamol, non-steroids, minor opioids, morphine). VAS scores were taken before and one hour after the study bolus was given. In addition the patients were assessed for quality of sleep, opinion about the analgesia provided by the catheter and VAS of pain prior to and post physiotherapy sessions. The physiotherapist also recorded the active forward flexion of the operated shoulder. The number of doses required and all additional analgesic medication were recorded. The use of subacromial local anaesthetic provides significantly better pain relief (P=0.029). However, patients with subacromial local anaesthetic
Patients suffering from generalised convulsions may dislocate their shoulders either anteriorly or posteriorly. Those with anterior dislocation are likely to have recurrent episodes because of secondary bony damage to the anterior rim of the glenoid and head of the humerus. In such patients there is high rate of failure of the standard soft-tissue stabilisation procedures. We have therefore devised a bone buttress operation in which autograft or allograft is secured to the deficient anterior glenoid and shaped to form an extension of its articular surface. We report our experience in 14 patients with grandmal epilepsy and recurrent anterior dislocation of the shoulder. After the bone buttress operation there were no further dislocations and all patients were satisfied despite a small restriction in their range of movement. We believe this to be the operation of choice for patients with this difficult problem.
In a survey of 6000 children between 9 and 10 years of age, 122 were found to have unilateral or bilateral hallux valgus. These children were randomly assigned to no treatment or to the use of a foot orthosis. About three years later 93 again had radiography. The metatarsophalangeal joint angle had increased in both groups but more so in the treated group. During the study, hallux valgus developed in the unaffected feet of children with unilateral deformity, despite the use of the orthosis.
Using 26 cadaver shoulders, we produced a standard defect in the supraspinatus tendon and performed one of three types of repair. Their strength was found by testing in tension the force required to produce a gap of 3 mm, then 6 mm, and finally total disruption of the repair. The use of a polyethylene patch to spread the forces over the lateral bone surface and of extra sutures to grasp the tendon end raised by 2.6 times the load at which a 3 mm gap in the repair occurred and by 1.7 times the load to failure.
Four patients with pectoralis major ruptures underwent clinical and dynamometric assessment and one patient underwent late surgical repair. The operation is described. Dynamometry proved a useful and objective method of estimating the loss of strength and indicating patients who might benefit from surgical repair.
A survey of 6000 schoolchildren discovered 36 cases of unilateral and 60 cases of bilateral hallux valgus, defined as a metatarsophalangeal angle of more than 14.5 degrees, measured on standing radiographs. Metatarsus primus varus was found not only in the early stages of hallux valgus but in the unaffected feet of children with unilateral hallux valgus. Adduction of the first metatarsal is not due to differential growth of the cortices of the first metatarsal nor is it a consequence of malalignment of the metatarsocuneiform joint. The intermetatarsal angle did not correlate with the angle of metatarsus adductus nor with the intercuneiform angle.
The articular surface of the humeral head is usually described as facing posteromedially, making an angle of between 16 degrees and 35 degrees with the transepicondylar plane. At hemiarthroplasty the articular surface also appears to be offset posteriorly with respect to the humeral shaft. Coracoid impingement may occur if this offset is not accommodated. An analysis was made of 29 cadaveric humeri using an industrial co-ordinate measuring machine. The position of the centre of the head was defined with respect to the humeral shaft and transepicondylar plane. The humeral articular surface was found to be retroverted by 21.4 degrees and its centre offset posteriorly by 4.7 mm. Previous interpretation of retroversion did not take into account the posterior displacement, and this may be of importance in improving future prosthetic design.
In a prospective study, 60 patients with acute acromioclavicular dislocation were randomly allocated to treatment with a broad arm sling or to reduction and fixation with a coracoclavicular screw. Of these 54 were followed for four years. Conservatively-treated patients regained movement significantly more quickly and fully, returned to work and sport earlier and had fewer unsatisfactory results than those having early operation. For severe dislocations, with acromioclavicular displacement of 2 cm or more, early surgery produced better results. Conservative management is best for most acute dislocations, but younger patients with severe displacement may benefit from early reduction and stabilisation.
In a prospective study of the measurement of osteoporosis in patients with fracture of the femoral neck, we compared a histological with a radiological method. We found no significant correlation between histological planimetry and the radiological six metacarpal hand index in patients with either cervical or trochanteric fractures. This demonstrates that metacarpal morphometry cannot predict histological osteoporosis of the iliac crest.
A biomechanical study has been carried out on 20 cadaveric knees to investigate their load-absorbing mechanism. The impact load was applied using a weight falling onto the transected proximal femur and the force transmitted through the knee was measured at the transected distal tibia using a load transducer. The peak force transmitted increased as, sequentially, meniscus, articular cartilage and subchondral bone were damaged or removed. The most striking result was found in an implanted knee replacement where the transmitted force reached 180% of that in the intact knee. The results show that the joint has an impact-absorbing property in each segment and that in the osteoarthritic knee there is less absorption of shock than in the normal knee. The high impact force in an implanted knee suggests that microfractures of the cancellous bone might be expected and may produce loosening.
This paper reports a prospective study of 72 consecutive patients with fractures or fracture-dislocations of the upper end of the humerus, treated during 1981. Most were elderly and treatment was conservative. Of the 72 patients 64 were followed up for a period of six months. Observations were made on the type of fracture, the speed and pattern of recovery of shoulder movements, on the time of commencement of physiotherapy, and on its duration. We found that with conservative treatment alone, 94% of our patients had good or satisfactory results at six months from injury. The criteria for manipulation are discussed and the literature is reviewed.