Distal clavicle fractures have a significant non-union rate, and are often managed operatively. Many of the fixation devices used have a high complication rate or require removal. An arthroscopic technique using the Tightrope device (Arthrex) has been used in our institution. We aimed to describe our initial results.

Eighteen cases were identified retrospectively, and the notes and radiographs reviewed. Twelve patients were male, six female, with mean age 33 years. All fractures were displaced, lateral to the coraco-clavicular ligament complex: six showed marked comminution. Mean follow-up was thirteen weeks. Fifteen fractures united, with a mean radiological time to union of 8 weeks (range 6-13 weeks). There were three surgical complications. In one, the clavicular button was not seated correctly on bone, and early failure required revision surgery. In another, there was inadequate reduction, radiographic non-union at five months and subsequent device failure. In the last, there was radiographic non-union, but the patient was asymptomatic.

The arthroscopic tightrope device provides minimally invasive stabilisation and reliable union. The complications seen were related to incorrect technique, and anticipate the complication rate to diminish as the technique is developed. We recommend the use of this technique for the stabilisation of distal clavicle fractures.

Introduction: Since the first repair of coracoclavicular ligament complex in 1886 there have been more than sixty operative procedures described in the literature. Open methods of reduction and stabilization of AC joint are associated with increased morbidity and violation to the surrounding soft tissue and result in less cosmetic scar and possibly a further surgery to remove the hardware. We propose an arthroscopic technique using Tightrope (Arthrex) to reduce and stabilize the joint with low morbidity.

Materials and Methods: We reviewed 26 (21 male, 5 female) consecutive patient’s (notes, radiographs and Oxford shoulder score) who underwent arthroscopic stabilization of AC joint. The average age was 33 years (min.22, max.53). The average period from injury to surgery was nine days. The primary indication for surgery was grade IV to VI injuries and grade III injuries in upper extremity athletes and workers with the need for overhead activities. Patient’s satisfaction and functional improvement were observed.

Results: Short-term preliminary results are encouraging and show an excellent functional outcome without significant residual pain. We had four radiological recurrences of the deformity, two of which were completely asymptomatic, one associated with painless clicking and one requested revision surgery (same technique) to improve cosmesis. There were no infections or neurovascular injury in this series.

Conclusion: This method of surgically stabilizing the AC joint is minimally invasive, done as a day case and yielding satisfactory results. Among the advantages of the technique are that it does not require specific expensive instrumentation and offers the possibility of visualizing the glenohumeral joint for associated lesions. However, there is a learning curve and experience with arthroscopic procedures is essential.

The aim of this study was to compare the results of physical examination and magnetic resonance arthrography (MRA) in the diagnosis of superior labrum anterior posterior (SLAP) lesions of the shoulder. A review of all patients seen in 2005–2006 with an arthroscopically confirmed SLAP lesion was undertaken (n =22). Prior to surgery all patients had been examined prospectively by an upper limb physiotherapy practitioner and had then undergone MRA. All scans were undertaken and reported upon by an experienced consultant radiologist, specialising in musculo-skeletal conditions. A combination of 4 clinical tests were used to diagnose a SLAP lesion, these being O’Brien’s, pain provocation, bicep load and the crank test. To confirm a SLAP lesion a minimum of 2 of the above tests had to be positive. The sensitivity of each test in isolation and in combination and MRA sensitivity was determined and values statistically analysed for significance. The sensitivity of each isolated test was as follows: O’Brien’s = 82%, pain provocation = 86%, bicep load = 55% and the crank test = 68%. Using a combination of 2 or more positive tests was 95% sensitive, whereas MRA had a sensitivity of 64%. Using the McNemar test there was a statistically significant assosciation between positive clinical testing and negative MRA findings in the same patient (p< 0.05). The results would suggest that it may be advantageous to use a combination of physical tests rather than 1 test in isolation when examining a patient with a suspected SLAP lesion. The study would also suggest that even in the absence of radiological findings, in patients with a relevant history and strongly positive clinical signs, arthroscopic assessment may be indicated.

Distal biceps tendon ruptures are uncommon with a reported incidence of 1.24 per 100,000 per year.

They typically occur in males in the fourth decade.

Operative treatment has been shown to improve functional outcomes in the treatment of distal biceps tendon ruptures. A variety of surgical techniques have been described, usually using the dual incision Boyd-Anderson approach.

We report a series of 10 patients with 10 tendon ruptures treated using a single incision volar approach and using the Arthrex Biotenodesis screw to reattach the tendon to the radial tuberosity.

This method has been previously described in only one case report.

All ten patients underwent clinical assessment using the Mayo Elbow Performance Score (MEPS) and functional assessment using the DASH scoring system. The power was assessed isokinetically using the Nottingham Myometer.

Based on the MEPS and DASH grading system all patients achieved a good or excellent result.

In our experience reattachment of the distal biceps tendon using a single incision approach and Arthrex Biotenodesis screw is a new technique which gives a good functional outcome.

Assess the outcome of plating of lateral end clavicle fractures. Lateral end clavicle fractures can be treated both conservatively and surgically. Different surgical methods are available to stabilize lateral end clavicle fractures. We treated 15 lateral end clavicle fractures with plate fixations (4 AO ‘T’ plate and 11 ACUMED lateral clavicle plate) from September 2002 to December 2005. There were 12 males and 3 females and the mean age was 33.12 year (range 23–61). 3 were done for non-union and 13 for acute fractures. 2 non-unions were treated with AO ‘T’ plate and 1 with ACUMED lateral clavicle plate. 1 patient with non-union had bone grafting at the time of the procedure. Acute fractures were stabilized with in 3 weeks from the time of the injury. All fractures were Type 2 according to Neer classification of lateral end clavicle fractures. The cause of the injury was, simple fall (3), fall from pushbike (3), assault (3), sports/skate-board (3), and RTA (3). The senior author operated on all patients. The arm was immobilized in a sling for six weeks post operatively. The follow up ranged between 5 months to 36 months All but one fracture healed. 1 ‘T’ and 1 ACUMED plate was removed 7 months after the index procedure after fracture consolidation. There was no superficial or deep infection. Patients were assessed clinically with Constant and DASH scores; patient satisfaction with the procedure was also recorded and union assessed radiologically.. Lateral end clavicle fractures pose a challenge due to the small size of the distal fragment. In our experience plating of these fractures give satisfactory results. Oblique fracture patterns result in better fixation and union rates. The plate design and advantages of the ACUMED contoured distal clavicle plates are further discussed in the paper.

Purpose of Study Disruption of the coraco-clavicular ligaments may be associated with either dislocation of the Acromioclavicular joint or fracture of the distal clavicle. If sufficient displacement occurs functional disability results. Traditional techniques have required a bra-strap incision and often require late removal of the metalwork. The Tightrope syndesmosis repair system was adapted to be used arthroscopically to reduce and hold the clavicle enabling healing of the ligaments and any associated fracture using a minimally invasive technique but ensuring accurate reduction and secure stabilisation. Between December 2004 and September 2005 20 patients with injuries to the coraco-clavicular ligaments were treated using this system. As the system was in evolution a the majority were treated arthroscopically and a few using an “open” technique. All had either the acromio-clavicular joint reduced or a distal clavicle fracture reduced and stabilised using the Tightrope Syndesmosis Repair system. The system had been modified from that commercially available for use in the ankle with the consent of the manufacturer (Arthrex, Naples, Fla).

Results All patients were evaluated at a minimum of 6 months post operatively using the DASH, ASES and Constant scores The mean ASES score was 94, the mean Constant score was 90, the mean DASH score was 5 One patient had failure of the metalwork due to malposition, this was revised successfully using the Tightrope and one had a transient adhesive capsulitis. There were no other complications and no patient required removal of the metalwork.

Conclusions The authors conclude that this new technique is a safe, simple, cosmetically acceptable and reproducible method of reducing and stabilising the distal clavicle allowing for healing of either the coraco-clavicular ligaments or the distal clavicle.

Between 1993 and 1996, we undertook 35 Kudo 5 total elbow replacements in a consecutive series of 31 rheumatoid patients. A total of 25 patients (29 procedures) was evaluated at a mean follow-up of six years (5 to 7.5) using the Mayo Clinic performance index. In addition, all patients were assessed for loosening using standard anteroposterior and lateral radiographs.

At review, 19 elbows (65%) had either no pain or mild pain, ten (35%) had moderate pain and none had severe pain. The mean arc of flexion/extension was 94° (35 to 130) and supination/pronation was 128° (30 to 165).

A fracture of the medial epicondyle occurred during surgery in one patient. This was successfully treated with a single AO screw and a standard Kudo 5 implant was inserted. Postoperatively, there were no infections. One patient had a dislocation which was treated by closed reduction and five had neurapraxia of the ulnar nerve.

Radiologically, there was no evidence of loosening of the humeral component, but two ulnar components had progressive radiolucent lines suggestive of loosening. Two other ulnar components had incomplete and non-progressive radiolucent lines. With definite radiological loosening as the endpoint, the probability of survival of the Kudo 5 prosthesis at five years using the Kaplan-Meier method was 89%.

Aim: To study the long term results of rotator cuff repair in patients over the age of 65.

Introduction: Although some patients with rotator cuff tears are asymptomatic, the majority have a combination of pain, weakness and restricted function. Whilst this affects the lifestyle of all patients, in the elderly these symptoms can make the difference between independent living and the need for assistance or sheltered accommodation.

Method: The present study has looked at a consecutive series of 24 patients all of them over 65 years, who underwent rotator cuff surgery between 1993 and 1997. Outcome has been assessed using two validated scoring systems – the Oxford Shoulder Score (OSS) and the DASH questionnaire. All patients had an open subacromial decompression of their shoulders at the time of cuff repair. Two patients could not be contacted for follow up and were therefore excluded. One patient who had a hemiarthroplasty of the shoulder 3 years after rotator cuff repair was excluded as well.

The average follow up period was 6 years (range 4.5 – 9 years). The Oxford Shoulder Score revealed that 72% had good to excellent results, 16% remained unchanged and 12% were worse than prior to surgery. The corresponding DASH scores were 28% excellent, 40% good, 16% fair and 16% poor respectively. In addition 81% of patients were independent with daily activities, with 48% of them living alone and the remaining 33% living with their partners. Only 19% of patients needed significant help with their activities of daily living. These results were irrespective of whether surgery was performed on the dominant or non-dominant shoulder.

Conclusion: We would suggest that age itself should not be considered a contraindication to rotator cuff repair.

Between 1993 and 2002 7 allografts/joint replacement combinations have been used to treat massive bone loss at the elbow.

The original 4 procedures (2 humeral and 2 ulna allografts) used a standard Stanmore total elbow replacement. Of these the 2 humeral allografts failed and revision surgery was necessary. The 2 grafts on the ulna side of the joint remain in situ (average 6 years after surgery) with one of the patients subsequently having a primary joint replacement on the contra-lateral side.

More recently a further humeral and a further ulna allograft/joint replacement have been performed together with one patient having humeral and ulna allografts on both sides of the joint for extensive bone loss. In these cases the Coonrad-Morrey total elbow arthroplasty was used as the joint implant.

The philosophy behind the use of allografts is discussed and the management principles outlined. The possible reasons for failure of the early humerus allograft/joint replacement combinations is addressed and future developments considered.