Background

Adhesive capsulitis (frozen shoulder) is a debilitating condition affecting 2–5% of the adult population. Its aetiology is still unclear and there is no consensus on the most effective treatment. The aim of this retrospective study was to investigate the mid-term functional outcome of one specific treatment protocol.

Unstable fractures of the distal tibia are being increasingly treated by open reduction and internal fixation using pre-contoured locking plates. Functional outcome following this type of fixation has not been reported previously.

The aim of this study was to functionally assess patients following MIPO fixation of distal tibial fractures.

Case notes of 26 patients treated at a single centre were reviewed. The fracture type, fixation technique, complications, time to union and subsequent treatment were documented. All patients returned for functional scoring using the validated American Academy of Orthopedic Surgeons (AAOS) foot and ankle core score.

Twenty-six consecutive patients were treated between 2002-2005. The majority were male, and 5 were open fractures. There were 13 AO type A, 4 type B and 9 type C fractures. Mean follow up was 20 months. Average time from injury to surgery was 2.5 days. All fractures were treated by a MIPO technique. A pre-contoured distal locking plate was used for the distal tibial reconstruction. Secondary surgical procedures e.g. 2nd look, delayed primary closure, or skin grafting were necessary in 3 cases. The fibula was plated in 60% of cases. Four patients developed wound infections requiring antibiotics, and all resolved. The commonest rehabilitation regime was 6 weeks non weight bearing in plaster. Mean time to union was 18 weeks. There were 3 cases of delayed union, requiring bone grafting. One patient required removal of the plate due to local irritation, and one required a broken screw to be removed. Mean range of movement was 10 degrees dorsiflexion, 30 plantarflexion. The mean normalised AAOS foot and ankle core score was 41 (SD +/− 8).

We conclude that MIPO fixation of distal tibial fractures is a safe and effective method of treatment. Functional outcome does not significantly differ from that of the general population.

Introduction: The surgical management of proximal humeral fractures continues to be an unsolved problem for the orthopaedic surgeon. Disagreement remains over how best to fix the more challenging complex fractures in younger patients where the ultimate goals of treatment are restoration of a painless shoulder, adequate function, and preservation of humeral head viability.

The PHILOS plate attempts to improve on previously designed implants by preserving the biological integrity of the humeral head articular fragment. The minimally invasive technique minimises soft tissue damage whilst at the same time securing the reduction using multiple locking screws with angular stability, thus allowing early mobilisation.

Methods: Retrospective review of the notes and x-ray images of 54 fractures treated with the PHILOS plate between Jan 2000 and Aug 2005. Data including baseline demographics, the presence of any complications and the need for reoperation were collected. In addition 43 (81%) patients were contacted and Oxford (OSS) and Disabilities of the Arm, Shoulder and Hand (DASH) scores were calculated to assess functional recovery. All patients were contacted at a minimum of 6 months following fixation with an average follow up of 18 months (Range 6–41 months)

We also present a cost analysis relating to the use of the PHILOS plate in practice.

Results: 54 fractures in 53 patients (25F:28M). Average age 54.4. There were 26 2-part, 15 3-part and 13 4-part fractures. A total of 11 (20%) patients had complications of which 7 (13%) required reoperation. These complications included deep infection (3 cases), AVN (4), Non Union (3) and plate impingement (1).

Mean OSS and DASH at follow up were 24.8 (S.D 11.6) and 28.0 (S.D 26.9) respectively. Worse scores were seen in those patients who had complications (OSS 39.4 Vs 22.6, DASH 58.2 Vs 23.4) although this difference was not statistically significant. There was also a trend for poorer scores with increasing fracture complexity and better scores in those patients operated upon by surgeons with a specific interest in the upper limb and in patients whose surgeon had performed more than 5 fixations.

Conclusion: Our series reports a much higher complication rate (20%) than that previously published. Whilst those patients who do not suffer complications reported good functional outcomes the presence of postoperative complications was associated with poorer results. Outcomes following surgery were affected by patient, implant and surgeon related factors. Given the high rate of serious complications and their detrimental affect on outcome surgeons should give serious consideration to the appropriateness of using such implants. To clarify these issues, further prospective randomised trials are needed.

Introduction We have evaluated the early outcome of arthroscopic excision of the distal clavicle (Mumford procedure) for acromioclavicular joint pathology.

Method Forty-one patients with acromioclavicular joint pathology underwent arthroscopic distal clavicle resections between 2002 and 2004. Preoperatively, all patients had acromioclavicular joint tenderness, 90% had a positive horizontal adduction test and 62% had a positive O’Brien’s AC compression test. All provocative signs were abolished on re-examination after acromio-clavicular joint injection. Surgery was indicated with failure of conservative management. Surgery was performed through a subacromial approach to the acromio-clavicular joint, using a Acromionizer (Smith-Nephew Dyonics, Andover, MA) burr through the anterosuperior portal. A supplementary Neviaser portal was used in 9 cases. Patients were clinically assessed at average of 18 months post surgery (range; 9–36). Functional rating was obtained with the Constant Score, WORC score and the Oxford Score. Results

Thirty-five patients (85%) reported none or minimal pain. 81% were negative for provocative AC signs. Internal rotation increased by average of 5 vertebrae levels. The Constant, the WORC and Oxford Scores were improved by 23 points, 674 points and 16 points respectively (p< 0.05). 71% reported good or excellent function by the 3^rd post-operative month.

Conclusion The arthroscopic Mumford procedure effectively treats acromioclavicular joint pathology. The procedure has low associated morbidity and high patient satisfaction.

Aims: To compare two protocols of early mobilisation for minimally displaced radial head fractures through a single-blinded, prospective randomised trial. Methods: Sixty patients were randomly allocated to either immediate active mobilisation or 5-day delay before active mobilisation was commenced. Patients were reviewed at 7 days, 4 weeks and 3 months after injuries. A blinded observer assessed each patient. Results: All fractures united by the third month. At the end of 7days, the mobilisation group had less pain (VAS 6 vs 7.6, p=0.002); greater ßexion (mean 112û vs 98û, p=0.0004); greater strength in supination (p< 0.001) and better elbow function (Morrey Score 54 vs 43, p=0.005). By the fourth week, both groups were comparable in all parameters and improvement continued into the third month. Mean limit of extension at the third month were 2.3û in the immediate mobilisation group and 1.8û in the delayed group (NS). All had excellent function on the basis of the Morrey Score. Conclusions: Immediate mobilisation did not adversely affect the outcome; the patients had less pain and better elbow function at one week post-injury. Pain, ranges of movement and function were similar by the fourth week post-injury.

Aims: Nonunion in long bone fractures is rare in the skeletally immature. We report the outcome of a series of patients treated for tibial bone loss and non-union at average follow-up of 52 months. Methods: Nine children aged 18 months to 17 years were treated. Three patients had established non-union ranging from 7 months to 6 years, three had bone loss (1–6cm), and three had fractures in which non-union was anticipated (1 Gustilo IIIb and 2 Tcherne IIIñs). Treatment involved wound excision for open fractures, debridement of devascularised bone and stabilisation with monolateral þxators (2 patients) and circular þxators (7 patients). Five patients had unifocal treatment; four had multifocal treatment (3 bone transports). Treatment time ranged from 3 to 12 months, and was not related to the complexity of treatment. Functional outcome was measured using the Short Musculoskeletal Functional Assessment (SMFA). Results: At the latest follow-up (average 52 months), the mean range of knee motion was 3–125û and mean ankle range was 13û dorsißexion, 35û plantarßexion. Physeal arrest was present in three children (limb length discrepancy 2–4cm) but with no deformity. Functional outcome revealed a ÒDysfunction IndexÒ of 0–19% (ave. 7%) and a ÒBother IndexÒ of 0–16% (ave. 6%). Conclusions: Limb salvage of severe tibial fractures in which nonunion were established or anticipated were worthwhile. Good function can be obtained. The duration of treatment was not related to the complexity of treatment but was increased by leaving sterile but avascular bone unexcised

Traumatic knee dislocations are rare but devastating injuries. We have evaluated the clinical results of ligament repair and reconstruction. Knee dislocation was defined as an acute event that produced multidirectional instability with at least 2 of the 4 major ligaments disrupted.

Twenty-one patients with 22 knee dislocations presented between 1994 and 2001. There was one vascular and one common peroneal nerve injury. Eight (38%) patients were treated in the acute period (< 14 days), 5 (24%) had reconstructions within 1 year of injury. The remainder were late reconstructions. The patients were evaluated at mean follow-up of 32 months (11 to 77). This included ROM measurement, clinical and instrumented ligament laxity testing. Posterior stress view with 10kg weight was used to evaluate the PCL reconstruction. Function was evaluated using the IKDC chart, the Lysholm Score, the Tegner Activity Level, the Knee Outcome Survey and WOMAC.

The mean extension deficit was 6.8 degrees (0–25) and mean flexion deficit was 8.6 degrees (0–20). Of the ACL reconstructions, 4 knees had 0–3mm side-to-side difference, 15 knees had 3–5mm and 1 knee had 6–10mm. Of the PCL reconstructions, 2 were within 3–5mm of side-to-side difference, 9 knees were 6-10mm and 4 were more than 10mm. Posterolateral corner repair/reconstructions appeared durable. None of the knees were IKDC Grade A, 8 knees were Grade B, 9 were as Grade C and 5 were Grade D. The mean Lysholm Score was 81 (66–100) and the mean Tegner Activity Level was 4.9 (1–7). The mean Knee Outcome Survey score was 75 (41–99). Acutely treated knees had better scores than late reconstructions.

Our study has demonstrated good function in the operatively treated knee dislocations at 1–7 years. Nearly all had few problems with daily activities. The ability to return to high-demand sports and heavy manual labour was less predictable.

Aim: We investigated the accuracy of clinical signs for the diagnosis of rotator cuff disease.

Methods: Fifty patients with history of rotator cuff disease (subacromial impingement syndrome or rotator cuff tear) were examined by two observers to determine the accuracy of clinical tests for the condition. The observers were a consultant (cons.) with an established shoulder practice and a senior registrar (reg.) with an interest in shoulder surgery. The clinical signs evaluated include the painful arc, the drop arm test, Neer’s sign and Hawkins’ sign. For rotator cuff pathology we evaluated the strength of abduction initiation and at 90 degrees abduction for supraspinatus, Speed’s and Yergason’s tests for biceps, strength of shoulder external rotation for infraspinatus and the Gerber lift-off test for subscapularis. We compared our clinical accuracy against a positive subacromial injection test for impingement syndrome, and the findings of rotator cuff tears at arthroscopy.

Results: The consultant and the registrar did not differ significantly in their assessments (paired t-test, p> 0.05). The highly sensitive tests have poor specificity. The most sensitive tests for impingement syndrome were the Hawkins’ sign (cons: 100%, reg: 97%) and the Neer’s sign (cons: 94%, reg: 81%). The Hawkins’ sign also had high negative and positive predictive values. The painful arc and the drop arm tests both had low sensitivity and specificity. Testing the supraspinatus strength at 90 degrees abduction was more sensitive for full thickness cuff tear than testing strength of abduction initiation (cons: 100% vs 67%; reg: 90% vs 50%). These tests were poor at differentiating partial thickness tears from full thickness tears.

Conclusion: The Neer’s and Hawkins’ signs were the most sensitive for impingement syndrome. Testing the supraspinatus at 90 degrees abduction was more sensitive than abduction initiation for full thickness supraspinatus tear.

We investigated the accuracy of clinical signs for the diagnosis of rotator cuff disease. Fifty patients with history suggestive of rotator cuff disease (subacromial impingement syndrome or rotator cuff tear) were examined by two observers to determine the accuracy of commonly used clinical tests for the condition. The observers were a consultant (cons.) with an established shoulder practice and a senior registrar (reg.) with an interest in shoulder surgery. The clinical signs of impingement syndrome we evaluated include the painful arc, the drop arm test, Neer’s sign and Hawkins’ sign. For rotator cuff pathology we evaluated the strength of abduction initiation and at 90 degrees abduction for supraspinatus, Speed’s and Yergason’s tests for biceps, strength of shoulder external rotation for infraspinatus and the Gerber lift-off test for subscapularis. We compared our clinical accuracy against a positive subacromial injection test for impingement syndrome, and the findings of rotator cuff tears at arthroscopy.

The consultant and the registrar did not differ significantly in their assessments (paired t-test, p> 0.05). The highly sensitive tests have poor specificity. The most sensitive tests for impingement syndrome were the Hawkins’ sign (cons:100%, reg: 97%) and the Neer’s sign (cons: 94%, reg: 81%). The Hawkins’ sign also had high negative and positive predictive values. The painful arc and the drop arm tests both had low sensitivity and specificity. Testing the supraspinatus strength at 90 degrees abduction was more sensitive for full thickness cuff tear than testing strength of abduction initiation (cons: 100% vs 67%; reg: 90% vs 50%). These tests were poor at differentiating partial thickness tears from full thickness tears.

Our findings echoed the conclusions of other papers in that the Neer’s and Hawkins’ signs are the most sensitive for impingement syndrome. Testing the supraspinatus at 90 degrees abduction was more sensitive than abduction initiation for full thickness supraspinatus tear.