Purpose: The objective of the study was to determine the changes in the driving pattern – especially the capacity to use the steering wheel after carpal tunnel surgery so that recommendation for suitability to return back to driving can be made.

Methods Used: A computerised driving simulator normally used for driving assessment of drivers with disability at the regional mobility centre at the Wrightington Hospital was used to assess the patient’s driving. Static and dynamic steering torque was measured before and at 2 & 6 weeks after carpal tunnel release in 25 patients using the static assessment rig. Driving reaction time was also studied in these patients.

Results: There was decrease from preoperative static steering torque to that at 2 weeks postoperatively but the dynamic steering torque did not differ in most cases. By 6 to 8 weeks postoperatively, the mean torque values for static and dynamic steering capacity had significantly improved. The driving reaction times at preoperative assessment did not differ significantly from the post operative ones at all times.

Conclusion: Although at 2 weeks postoperatively the ability to use the operated hand for static steering had not returned in most patients, their overall steering capacity was not affected as suggested by their unaffected dynamic steering time and the reaction time.

Purpose: We report a locally invasive tenosynovial haemangioma infiltrating the flexor digitorum sublimis of the non dominant little finger in a sixteen year old student which was excised with part of the sublimis tendon and the A2 pulley.

Patients and Methods: Haemangiomata developing in the hand in relation to tendon and the tenosynovium (tendon sheath) are very rare. To our knowledge only three cases have been described arising in relation to the tenosynovium of the tendons of the hand only one of which showed infiltration of the underlying tendon. We report the case of a sixteen year old right hand dominant student who presented to her family doctor with a swelling on her left little finger. A magnetic resonance scan was arranged which confirmed a soft tissue lesion between the flexor tendons and the proximal phalanx of the left little finger with appearance similar to giant cell tumour of the tendon sheath. Surgical exploration demonstrated a dark red fleshy tumour that appeared to infiltrate the flexor digitorum ublimes tendon, and extend around either side of the proximal phalanx. For complete excision of the lesion the infiltrated sublimis tendon and a part of the A2 pulley were sacrificed. There was no resultant bowstringing of the profundus tendon.

Histologically the tenosynovium was expanded by a vascular lesion consisting of dilated, thin-walled vascular channels within fibrous tissue The appearances were those of a synovial haemangioma of the tenosynovium of the flexor tendons

Conclusion: Our case illustrates the pitfalls in diagnosis and the invasive potential of a synovial haemangioma which in our case had infiltrated the flexor sublimis tendon and the area around the A2 pulley. A complete surgical excision is critical to prevent recurrence.

Introduction and Aims: The aim was to prospectively assess shoulder hemiarthroplasty for un-reconstructable proximal humeral fractures at a minimum of 12 months and identify factors that aid prognosis.

Method: Inclusion criteria were patients with a displaced fracture requiring shoulder hemiarthroplasty. Constant scoring was done at a minimum follow-up of one year. Patients were treated using a Neer or Osteonics prosthesis, the decision for hemiarthroplasty being made at the time of surgery. Post-operative management was standardised. An independent functional assessment, record review establishing a physiological index according to co-morbidities, and radiological analysis were carried out. Survival analysis was performed for one and five-year results and data was analysed by linear regression to identify prognostic factors.

Results: From 163 patients there were 138 fitting the criteria, 42 males and 96 females, average age of 68.5 (range 30–90) years and follow-up of 6.3 (range 1–15) years. The fracture pattern was three and four part in 133 cases and five head split fractures; 58 were associated with dislocation. Survival was 96.4 percent at one year and 93.6 percent at five years, with no significant difference between prostheses. There were eight revisions, (one deep infection, four dislocations and three peri-prosthetic fractures), by 12 months. The average Constant score was 67.1 at one year.

Conclusion: Prognostic factors on presentation were age of the patient and their physiological index, and at three months any complication, the position of the implant, tuberosity union and persistent neurological deficit. Overall optimum outcome was in patients aged 55 to 60, with minimal co-morbidities and uncomplicated recovery.

Introduction and Aims: The aim was to assess the efficacy of current arthroscopic knotting techniques with commonly used suture materials.

Method: A Hounsfield tensiometer with 1000N load cell, strain rate 25mm/min, bar separation of 7.5mm under standard temperature and pressure was used. Suture materials used, 2 Ethibond, 1 PDS and 1 Panacryl. The knotting techniques compared were the Tennessee slider, Tautline hitch, Duncan Loop, SMC knot and Surgeon’s knot. Two surgeons tied each 10 times using a suture passer and standardised knot technique. Each knot was tested to failure on 10 sequential experiments. Suture material strength was tested in isolation, tested to failure using the different knots then repeated after suture immersion in normal (0.9%) saline.

Results: Ultimate strength of the suture material and the knotting techniques were assessed. The mode of failure, slip or suture material fracture was also investigated. The 2 Ethibond had higher ultimate strength than either 1 PDS or 1 Panacryl. The Tautline hitch and Surgeon’s knot had significantly lower slip rates, with superior internal security than the other knotting techniques (P less than 0.002). The Tennessee slider, Duncan Loop and SMC knots had low security and slipped in more than 50 percent of experiments. There was no difference after saline soaking. The number of additional half hitches required for maximum knot holding capacity was consistently three, confirming previous findings.

Conclusion: The Tautline hitch is recommended due to internal security, tying characteristics and overall knot strength. Whichever knot is selected, three additional alternating half hitches to obtain consistent security is strongly supported.

Introduction The aim of this study was to assess shoulder hemiarthroplasty for non-reconstructable proximal humeral fractures at a minimum of 12 months and identify factors that aid prognosis.

Methods Patients with a displaced fracture requiring shoulder hemiarthroplasty were studied. Patients were treated using the Neer or Osteonics prosthesis and the decision for hemiarthroplasty was made at the time of surgery. Post-operative management was standardised. An independent functional assessment, record review creating a physiological index on co-morbidities, and a radiological analysis were carried out. Survival analysis was performed for one and five year results and data was analysed by linear regression to identify prognostic factors. From 163 patients there were 138 fitting the criteria, 42 males and 96 females, average age of 68.5 (range 30 to 90) years and follow-up of 6.3 (range 1 to 15) years. The fracture pattern was three or four part in 133 cases and five head split fractures; 58 were associated with dislocation.

Results Survival was 96.4% one year and 93.6% five years, with no significant difference between prostheses. There were eight revisions, (one deep infection, four dislocations and three peri-prosthetic fractures), by 12 months. The average Constant score was 67.1 at one year. Prognostic factors at presentation were patient age and physiological index. At three months factors were implant position, tuberosity union, persistent neurological deficit and any complication.

Conclusion Overall optimum outcome was in patients aged 55 to 60, with minimal co-morbidities and an uncomplicated recovery.

In relation to the conduct of this study, one or more of the authors is in receipt of a research grant from a non-commercial source.

Introduction The aim of this study was to assess the efficacy of current arthroscopic knotting techniques with commonly used suture materials.

Methods A Hounsfield tensiometer with a 1000N load cell, strain rate of 25 mm/min, bar separation of 7.5 mm was used under standard temperature and pressure. Suture materials were those in common use; 2 Ethibond, 1 PDS and 1 Panacryl. The knotting techniques compared were the Tennessee slider, Tautline hitch, Duncan Loop, SMC knot and the Surgeon’s knot. Two surgeons tied each knot 10 times using a suture passer and standardised knot technique. Each knot was tested to failure on 10 sequential experiments. Suture material strength was tested alone, tested to failure using the different knots and after suture immersion in normal saline. The ultimate strength of the suture material and of the various knotting techniques were assessed. The mode of failure, slip or suture material fractured was also investigated.

Results The 2 Ethibond had superior strength compared to 1 PDS or 1 Panacryl. The Tautline hitch and Surgeon’s knot had a significantly lower slip rate, with superior internal security than the other knotting techniques (p < 0.002). The Tennessee slider, Duncan Loop and SMC knots slipped in more than 50% of experiments. No difference was observed after soaking in normal saline. The number of additional half hitches required for maximum knot holding was consistently three, confirming previous findings.

Conclusions The Tautline hitch is recommended with its superior internal security, tying characteristics and overall knot strength. Whichever arthroscopic knot is selected, the addition of three alternating half hitches for consistent security and reliability is strongly supported.

Introduction The aim of this study was to investigate the potential of impaction bone grafting for the restoration of glenoid bone stock in revision shoulder arthroplasty.

Methods There was significant osteolysis around the glenoid component in four rheumatoid patients who underwent revision shoulder arthroplasty using this technique. The criteria was a contained or containable defect. Femoral head allograft and iliac crest autograft harvested at the time of revision were used. Pre and post-operative radiographs, tomograms and fluoroscopic views aided in bone-stock analysis. Images were analysed for osteolysis, graft survival, incorporation and component loosening. Patients were followed using Constant-Murley scoring pre-operatively, and at a minimum of 12 months. The average patient age was 56 years (range 42 to 76), with three females and one male patient.

Results Glenoid component survivorship pre-revision averaged 9.5 years (range 8 to 12). The pre-operative Constant-Murley average was 11 (range 4 to 20) versus 64 post-operatively, a significant improvement over an average follow-up of 19.5 months (range 12 to 40). Radiological assessment demonstrated all grafts had incorporated with minimal subsidence and no radio-lucency at the graft-bone interface. Two of the glenoid components demonstrated static lucency at the component-graft interface, but no component movement on serial x-rays. In both patients the significant improvement in functional was maintained.

Conclusions To our knowledge this technique has not been described in glenoid component revision. It successfully provided bone for glenoid component insertion. This would not have been possible using standard techniques. The early results for this technique are encouraging and justify the continued application and follow-up of glenoid impaction grafting.

The composition and morphology of the glenoid are integral to the support of a glenoid component in total shoulder arthroplasty (TSA). This study was performed to identify the morphology of glenoid cavity in pre and post replacements in a cadaveric model.

Eleven normal cadaveric shoulders (Right – 5, Left – 6) were dissected down to the bone such that the glenoid labrum was left intact. Computerised Tomography (CT) scanning at 0.5 mm thickness was performed on each of the specimens in a standardised fashion to evaluate the morphology of the glenoid and glenoid medullary cavity. CT scanning was repeated after a mixture of cemented pegged and keeled glenoid components were inserted into all the specimens using standard instrumentation.

Five reproducible lengths (Body width), Posterior wall length, Anterior Wall length. Glenoid body length and corrected body width) and the retroversion angle of the glenoid were identified on the CT scans. These measurements were taken at the 25th, 50th and 75th percentiles of the height of each glenoid both pre and post replacements. Further post glenoid replacement CT scans were analysed for cement-fill of the glenoid cavity and cortical encroachment of the prosthesis.

There was significant correlation of all the measurements including the retroversion angle between the pre and post glenoid replacements at all levels. All but one pegged prosthesis had insufficient cement mantle or critical penetration or abutment at one of the pegs at least. Most often the penetration or cortical abutment was along the posterior wall. All keeled prosthesis had a sufficient cement mantle all around.

The designs of the glenoid prosthesis were satisfactory with some respects like radius of curvature, size and to a certain degree the shape. The margin of error for insertion of the pegged prosthesis was very narrow. Design changes are required in the glenoid component for better bony fixation.

Humeral hemi arthroplasty has become widely used as a form of surgical management for severe fractures. However there is still no consensus as to the role for prosthetic replacement in displaced proximal humeral fractures.

The aim was to assess shoulder hemi arthroplasty for un-reconstructable three and four part proximal humeral fractures at a minimum of twelve months and identify factors that guide to prognosis.

Criteria for inclusion were patients with a fracture that went onto shoulder hemi arthroplasty with Constant scoring at a minimum follow up of one year. Patients were treated using a Neer or Osteonics prosthesis, with the decision for hemi arthroplasty being made at the time of surgery. Post-operative management was standardised. An independent functional assessment, record review establishing a physiological index according to comorbidities, and a radiological analysis were carried out. A survival analysis was performed for the one and five year results and data was analysed by linear regression to identify prognostic factors.

Of 163 patients there were 138 fitting the criteria, 42 males and 96 females with an average age of 68.5 (range30–90) years and average follow up of 6.3 (range1–15) years. The fracture pattern was three or four part in 133 cases and 5 head split fractures; 58 were associated with a dislocation. Survival was 96.4% at 1 year and 93.6% at 5 years, with no significant difference between prostheses. There were 8 revisions, (1 deep infection, 4 dislocations and 3 peri-prosthetic fractures), most within 12 months. The average Constant score was 67.1 at one year.

Prognostic factors on presentation were the age of the patient and their physiological index. Factors at 3 months were any complication, the position of the implant, tuberosity union and persistent neurological deficit. Overall optimum outcome was gained by patients aged 55–60, with minimal comorbidities and an uncomplicated recovery.