Purpose of the study: Proximal fractures of the humerus account for 10% of fractures in persons aged over 65 years. There is no optimal treatment. The goal of surgery is to restore joint congruency, preserve vascular supply, and allow functional recovery. We describe the results obtained with a surgical technique designed to meet these goals. Material and methods: Fifteen 3-fragment fractures of the proximal humerus were treated with transosseous suture. Mean age of patients was 58 years. Eighty-six percent of the patients were female. Follow-up was 18 months on average. The patients were placed in a lounge chair position for the deltopectoral or transdeltoid approach. For this type of fracture, the humeral head is displaced medially or laterally, so that care must be taken to ensure the realignment in the sagittal and coronal planes. The DASH and Constant scores were noted for the operated and non-operated shoulders. Signs of bone healing were noted on the plain x-rays. Results: The mean DASH was 12, mean Constant score for the operated shoulder was 80 versus 90 for the other shoulder. The mean neck-shaft angle was 139°. There was one case of lost reduction but with a good final result. There was one case converted to arthroplasty. Discussion: This technique is in line with the current trend for biological preservation minimising the aggression to the humeral head blood supply. There was no risk of migration with the fixation material used and no need to remove implants. Conclusion: Transosseous suture of proximal fractures of the humerus is a mini-invasive method which provides good functional results avoiding voluminous metal implants, known to be costly and source of complications. The incidence of avascular necrosis of the humeral head is low, in agreement with the international literature

Aims. Complete ruptures of the ulnar collateral ligament (UCL) of the thumb are a common injury, yet little is known about their current management in the UK. The objective of this study was to assess the way complete UCL ruptures are managed in the UK. Methods. We carried out a multicentre, survey-based cross-sectional study in 37 UK centres over a 16-month period from June 2022 to September 2023. The survey results were analyzed descriptively. Results. A total of 37 centres participated, of which nine were tertiary referral hand centres and 28 were district general hospitals. There was a total of 112 respondents (69 surgeons and 43 hand therapists). The strongest influence on the decision to offer surgery was the lack of a firm ‘endpoint’ to stressing the metacarpophalangeal joint (MCPJ) in either full extension or with the MCPJ in 30° of flexion. There was variability in whether additional imaging was used in managing acute UCL injuries, with 46% routinely using additional imaging while 54% did not. The use of a bone anchor was by far the most common surgical option for reconstructing an acute ligament avulsion (97%, n = 67) with a transosseous suture used by 3% (n = 2). The most common duration of immobilization for those managed conservatively was six weeks (58%, n = 65) and four weeks (30%, n = 34). Most surgeons (87%, n = 60) and hand therapists (95%, n = 41) would consider randomizing patients with complete UCL ruptures in a future clinical trial. Conclusion. The management of complete UCL ruptures in the UK is highly variable in certain areas, and there is a willingness for clinical trials on this subject. Cite this article: Bone Jt Open 2024;5(8):708–714

Abstract. Background. We know that tears of the Triangular fibrocartilage complex (TFCC) can cause DRUJ instability and ulnar sided wrist pain. This study shows the clinical result of patients who had arthroscopic transosseous repair of the TFCC tear with DRUJ instability. Arthroscopic repair of TFCC tear is a promising, minimally invasive surgical technique especially in patients with DRUJ instability. Materials and methods. Fifteen patients who underwent TFCC one tunnel repair form 2018–2021 were reviewed retrospectively in hospital. The proximal component of TFCC was repaired through arthroscopic one- tunnel transosseous suture technique. VAS score for pain, wrist range of motion, grip strength and post operative complications were evaluated and each patient was rated according to the DASH score. Results. The patients had a TFCC tear confirmed on MRI and was confirmed on arthroscopy by doing a hook test. The patients were followed up for 6 months. Twelve patients had normal stability of DRUJ and three patients showed mild laxity compared with the contralateral side. The mean VAS score reduced from 4.7 to 0.8 (P=0.001) and grip strength increased significantly. The quick DASH score (P=0.001)also showed significant functional improvement. No surgical related complications occurred. Conclusions. Arthroscopic one tunnel transosseous TFCC foveal repair can be an excellent and safe method for repair of TFCC tear with DRUJ instability. Its a good treatment option in terms of reliable pain relief, functional improvement and reestablishment of DRUJ stability

Introduction. Although tension band wiring fixation of patellar fracture has been the most widely used technique, the metal implants related complications including implant loosening, postoperative pain are very common and additional surgeries are often necessary. Hypothesis. A totally metal free technique of transosseous suturing method could outperform the traditional fixation technique. Materials & Methods. A total of 25 patients (mean age of 59.60 years) with displaced patellar fracture treated by transosseous suturing technique were compared with a 1:1 matched historical control group who underwent modified tension band wiring fixation of patellar fracture. Union time, union rate, operation time, number of procedures, mean hospitalization days and the complications were compared between cases and controls. Results. Union time (8.43 ±2.92 weeks versus 8.64 ±2.82 weeks) and operation time (69.00 ±19.31 versus 64.89 ±14.27 minutes) were not different between two groups. Mean hospitalization days (4.04 ±1.40 versus 5.76 ±1.50 days; P < 0.001), number of procedures and the frequency of complications were significantly lower among transosseous suturing group (P< 0.001). Conclusions. Transosseous suturing technique is safe and effective in the transverse or comminuted fractures of patella. The complication rate is significantly lower than that of conventional tension band wiring technique

This in-vitro study evaluated the influence of ligament tensioning and the effectiveness of lateral collateral ligament (LCL) repair using transosseous sutures on the initial kinematics and stability of the elbow. Six fresh upper-extremities were mounted in a motion simulator with tracking system, which enabled both passive and simulated active elbow flexion. The intact elbow was tested then the LCL was sectioned from its humeral origin and repaired with a transosseous suture technique. Locking sutures were placed in the LCL and passed through a humeral bone tunnel entering at the centre of curvature of the capitellum with exit holes in the lateral epicondyle. An actuator pulled on the sutures to achieve 20, 40 and 60 N of LCL repair tension and the sutures were then secured. The dependent variable of this study was the motion pathways of the ulna relative to the humerus. The data were analyzed using a two-way, repeated-measures ANOVA with relevant post-hoc paired t-tests. With the arm oriented in the horizontal position under varus gravity loading, the repairs tracked in greater valgus than the intact LCL regardless of the repair tension. The larger the initial repair tension, the more the elbows tracked in valgus. Initial tension of 60 N was statistically different than the intact LCL with the forearm in pronation (p=0.04). Both the 40 and 60 N initial tensions were statistically different than the intact LCL with the forearm in supination (p< 0.01). Repair of the LCL using transosseous sutures effectively restores the varus stability of the elbow. The initial tension of LCL repairs affects the kinematics of the elbow, with a tendency to over-tighten the ligament and pull the elbow into valgus. These data suggest that acute repair of the LCL should be performed using a transosseous suture technique, and that a tension of 20N or perhaps less is sufficient to restore stability

Aims: The evaluation of blood supply of the humeral head in displaced 4-part Òvalgus impactedÒ fractures of the proximal humerus. Methods: 14 patients with acute 4-part valgus impacted fractures of the proximal humerus (9 women and 5 men, average age 43,6 years) were included in the study. The average impaction angle was 42.4û and the lateral displacement of the humeral head between 1–7 mm. Preoperative angiography of the proximal humerus was performed 6 to 12 hours after admission. Fracture þxation was achieved with transosseous suturing of the tuberosities to each other, to the metaphysis and to the articular part of the humeral head avoiding any use of hard material. Postoperative angiography was performed 8 to 10 weeks after the operation. Results: Digital angiographic image processing, using the segmentation technique, showed no statistical difference in the supply of the humeral head before and after the operation. The average blank number of small vessels and the overall area of blood supply (vessels/mm2 ) were about the same (p< 0.01) in 13 patients and no signs of avascular necrosis were seen 18–20 months after the operation. Partial avascular necrosis was seen in one case with 7 mm lateral displacement. Conclusions: Although the small number of cases, transosseous suturing þxation of 4-part valgus impacted fractures seems to preserve the remaining blood supply of the humeral head. The incidence of avascular necrosis is higher in cases with severe lateral displacement

Purpose: The evaluation of blood supply of the humeral head in displaced 4-part “valgus impacted” fractures with digital angiographic image processing. Material-Methods: 14 patients with acute 4-part valgus impacted fractures of the proximal humerus (9 women and 5 men, average age 43,6 years) were included in the study. The average impaction angle was 42.4o and the lateral displacement of the humeral head between 1–7 mm. Preoperative angiography of the proximal humerus was performed 6 to 12 hours after admission. Fixation of the fracture was achieved with in situ transosseous suturing fixation of the tuberosities to each other, to the metaphysis and to the articular part of the humeral head avoiding any reduction maneuvers and use of hard material. Postoperative angiography was performed 8 to 10 weeks after the operation. Results: Digital angiographic image processing, using the segmentation technique, showed no statistical difference in the supply of the humeral head before and after the operation. The average blank number of small vessels and the overall area of blood supply (vessels/mm2) were about the same in 13 patients and no signs of avascular necrosis were seen 18–20 months after the operation. Partial avascular necrosis was seen in one case with 7 mm lateral displacement. Conclusions: Although the small number of cases, in situ transosseous suturing fixation of the 4-part valgus impacted fractures seems to preserve the remaining blood supply of the humeral head. The incidence of avascular necrosis is higher in cases with severe lateral displacement

Rotator cuff tendons are typically reattached to the proximal humerus using either transosseous sutures or suture anchors. Their primary mode of failure is at the tendon bone interface 1. Surgical adhesives are used to bond cartilage, tendons and bone, and to close wounds. In an attempt to increase the tendon-bone interface we investigated the addition of a novel adhesive secreted from a species of Australian frog (Notaden bennetti) 2 to different methods of rotator cuff repair. Forty two fresh frozen sheep infraspinatus tendons were repaired using 3 different techniques: transosseous sutures; two Mitek RC Quickanchors with 1 suture per anchor and two Opus Magnum anchors with 1 suture per anchor all using a mattress stitch configuration. In each group 7 shoulders were repaired with the addition of a small amount of frog glue to the infraspinatus footprint while 7 were used as control with no adhesive. Mechanical testing was performed using a mechanical tensile testing machine. The strongest construct in the control groups was the Mitek suture anchors (mean 86±5 N) followed by the Opus suture anchor (69±6N) and transosseous repair (50±6N). This proved significant (p< 0.05) between both metallic anchors and the transosseous repair.{BR}The addition of frog glue resulted in a significant increase in load to failure and total energy required until failure in all repair techniques (p< 0.01). There was a 2 fold increase in load to failure of both the Opus Magnum (143±8N) and Mitek RC Fastin (165N±20 N) anchors while the transosseous repair (86± 8 N) had a 1.7 fold increase in its load to failure. This data suggests that:. suture anchor fixation is a stronger construct requiring a larger amount of total force to fail than transosseous repair using a one suture repair technique, that. the addition of an adhesive to the tendon-bone interface significantly enhances both ultimate load and total energy required to failure in all repair types. The unique properties of this frog glue (strong, flexible, sets in water and biocompatibility) may ultimately lead to the production of a useful adjunct for rotator cuff repair in humans

Aim: To define the contact force and contact area at the glenoid labrum-bone interface between suture sites in an open transosseous Bankart repair, and to assess how these contact parameters are altered by tying adjacent sutures to each other. Methods: Twelve capsulolabral avulsion lesions were created in fresh-frozen human shoulder specimens and were repaired using a standard transosseous suture technique. The contact forces and contact areas were measured at the labrum-bone interface between sutures before and after repair. Using the free suture ends, either a single or double strand knot was then tied between adjacent suture sites and the contact parameters were measured again. Results: The contact forces and contact areas under the soft tissue bridges between transosseous sutures were mildly increased during repair (before repair: average force=5.53g, area=2.25mm. 2. ; after repair: force=11.7g, area=3.13mm. 2. ). However, both the contact forces and areas increased significantly when a single or double strand of suture was tied over the soft tissue bridge. The double strand technique resulted in a significantly greater increase in contact forces and areas than the single strand technique (single strand average force=70.1g, area=6.75mm. 2. ; double strand average force=95.15g, area=8.0mm. 2. p< 0.05). Conclusions: The contact parameters between labrum and bone in a Bankart repair were increased when the suture strands from adjacent transosseous repair sites were linked. Increasing contact force or contact area may improve healing at the bone-soft tissue interface, and may reduce the risk of “spot welding” repairs. This, in turn, may reduce the failure rate of Bankart repairs

Introduction and Aims: Suture anchors allow consistent reattachment of tendons and ligaments to bone. Many options are available. The purpose of this study was to compare the initial strength of two rotator cuff repair techniques. The hypothesis was that rotator cuff repair strength with anchors would be inferior to transosseous sutures. Method: Eight paired shoulders with a standardised supraspinatus defect were randomised to bioabsorbable nonsuture-based anchor or transosseous suture repair. Each specimen was then subjected to a stepwise cyclic loading protocol, utilising a custom-designed loading apparatus. Repair site migration was measured using an optical measurement system, consisting of a digital camera and custom software. Mode of failure, number of cycles and load to failure were measured for 50% (5 mm) and 100% (10 mm) loss of repair. These results were correlated with bone mineral density, age and gender. Statistical analysis utilised paired t-tests and Pearson correlations. Results: The anchors failed at the anchor-tendon interface, whereas the sutures failed through the sutures. Mean values for 50 percent loss of repair were 206 ± 88 cycles and 44 ± 15 N for the sutures, and 1193 ± 252 cycles and 156 ± 20 N for the anchors (p< 0.05). The corresponding values for 100 percent loss of repair were 2458 ± 379 cycles and 294 ± 27 N for the sutures, and 2292 ± 333 cycles and 263 ± 28 N for the anchors (p> 0.05). These results may be due to the relative less deformability of the anchors. This may be relevant clinically, as in the early post-operative period, while tendon healing to bone is occurring, anchors may offer improved strength, allowing improved initial healing. Strength was unaffected by bone quality. This may be attributed to each repair failing primarily through the repair construct or at the anchor-tendon interface, and not through bone. Strengths of this study include the use of paired specimens, the stepwise cyclic loading protocol, as well as increased accuracy of our measurement system. Limitations include the use of an in vitro model, as well as a simulated, standardised rotator cuff tear. Conclusion: Repair strength with anchors was superior to sutures. Strength was unaffected by bone quality. Anchors facilitate an arthroscopic procedure, decrease operative time, and may allow a faster post-operative recovery. This study has described a new high-resolution method of measuring tendon repair failure and may be useful in future studies

Introduction. Traditionally it has been thought that the use of a small diameter femoral head in conjunction with a posterior surgical approach would result in a high rate of dislocation. We present the results of a consecutive series of 350 total hip replacements performed using a 22mm femoral head and a standard posterior approach, with prospective data collection. Objective. To determine the outcome of total hip replacement using small diameter heads via a standard posterior approach. Methods. Between March 2000 and April 2005, 319 patients underwent 350 total hip replacements with a small diameter 22mm head under the care of four different consultants, using a standard posterior approach. All patients underwent annual clinical and radiological review. All of the femoral implants were cemented modular polished triple-tapered C-stems (Depuy Ltd.) and all of the acetabular components were cemented UHMW-polyethylene components with long posterior walls. Palacos-R cement (Heraeus GMBH) containing gentamicin was used in all cases, with a third generation cementing technique. A standard posterior approach was used in all cases, with direct repair of the short external rotators, but without the use of transosseous sutures. Results. There were 245 female and 105 male patients, with 198 right-sided operations, 152 left with 31 patients undergoing staged bilateral operations. The average age at the time of surgery was 69.2 years (range 25–92 years). Five patients (6 THRs0 were lost to follow-up and 101 patients (29%) died during the study. The average duration of follow-up for surviving patients is 128 months (108 – 169 months). Five acetabular components have been revised for aseptic loosening associated with a high wear rate, and 4 are currently loose. There were three peri-prosthetic femoral fractures treated by internal fixation, and two temporary nerve palsies. Four femoral components were revised at the time of revision of a loose acetabulum, but none were loose. There has been no aseptic loosening of any femoral components and there were no cases of deep infection. The average acetabular abduction angle was 43.2 degrees (30–62) and the average femoral offset was 46mm (35–54). Five patients suffered dislocations, 3 female and 2 male, 2 right-sided and 3 left. Average age was 70 (60–85), average offset was 44.6mm (40–48). Four occurred on a single occasion only and were stable on reduction and only one required further surgery for recurrent dislocations, with application of a PLAD. Extended, skirted femoral heads had been used in four of these cases, reducing the head/neck ratio (p<0.5). Conclusions. Total hip replacement using small diameter femoral heads and a posterior approach has provided excellent results and implant longevity, with a low complication rate. Dislocation occurred in five cases and was associated with the use of an extended head. When using a posterior surgical approach the use of extended heads should be avoided, with high offset stems and standard heads being used in preference in order to achieve the correct length and offset, whilst maintaining the maximum head/neck ratio

Objective: There is no non-invasive gold standard for measuring gap formation following rotator cuff repair; re-tears are reported both on MRI and Ultrasound. We present a novel RSA technique using a combination of 1mm tantalum beads and metal sutures to allow monitoring of gap formation following rotator cuff repair. Methodology: We carried out ten open rotator cuff repairs with using trans-osseous sutures on patients with moderate to massive tears. During surgery RSA markers were inserted into the shoulder to allow postoperative monitoring of the repair. These markers took the form of 1mm RSA tantalum beads in the greater tuberosity, distal to the repair site, and three metal sutures in tendon, proximal to the repair site. Direct measurements of the distance between the markers each side of the repair were taken intra-operatively (T=O). RSA images were taken of the repair immediately postoperatively (T=1–2 hours), day 3, 2 weeks, 3 months and 1 year post-operatively. Ultrasound imaging was performed at the same intervals by consultant musculo-skeletal radiologists blinded to the RSA data. Results: At the 3 month stage post-operatively RSA data shows an increase in the average gap between the 2 sets of markers, with considerable variation between patients (5mm to 19mm). Conclusion: The results are highly suggestive of gap formation in the repair. The greatest increase in gap formation has been seen between 2 weeks and 3 months. During this time patients come out of their abduction arm sling and commence physiotherapy. It may be that due to excessive loading on the repair before it has fully healed has causes failure in some cases

Purpose: The purpose of this study is to report the preliminary outcomes after open reduction and internal fixation of displaced proximal humerus fractures with a new device called “Da Vinci System. ®. (Arthrex)”. It is a triangle-shaped titanium cage whose opposite faces are pierced and represents the evolution of a triangle-shaped bone block technique performed in a previous series of 33 patients. Material and methods: Between May 2005 and May 2008 we treated 54 patients (26 males and 28 females), even though we included in our study 36 patients who had a minimum follow-up of 12 months. The mean age was 60.3 years. The fractures were classified according to Neer. According to the technique, the Authors position the correct size titanium cage into the metaepiphysis, so that the fragments are reduced upon the cage and are stabilized with a minimal osteosynthesis by Kirschner wires, titanium screws or transosseous sutures. Results: The functional results were evaluated by the Constant score; with a mean follow-up of 22 months (minimum 12, maximum 36 months), the results were excellent or good in 34 cases, bad in 1 case; the mean active anterior elevation was 165 degrees, while in one case a polar necrosis is present but clinical asymptomatic. All fractures but one healed; in one case, 80 days after the operation, we had a deep infection treated with a self-customed cement spacer. Discussion: Surgical management of displaced proximal humerus fractures is still a challenge to surgeons. Optimal fixation system remains controversial, especially in complex fractures with instable fragments and osteoporotic bone. The Authors underline it is important to reconstruct the medial part of the surgical neck, to fill the bone defect, and to provide stable osteosynthesis. The “Da Vinci System” is an interesting innovation to treat difficult problems such as fracture fragments reconstruction and stability, metaphyseal bone loss and proximal humerus revascularization

Introduction: The development of the ilioinguinal approach by the pioneering work of Letournel in 1965 has transformed the treatment of acetabular fractures. To date, this approach has been well established and few modifications have been described of the original approach. However, this approach is difficult, takes long time for exposure and closure of abdominal layers. The aim of this article is to report a modification of the approach which the authors have found particularly useful. Material and Method: Cadaveric dissection showed that it was easier to detach the inguinal ligament from the anterior superior iliac spine and reflect the anterior abdominal wall as one layer, than by the classical approach through layers of the anterior abdominal wall. Closure was also simpler, in the cadaver, with the entire anterior abdominal wall reattaching satisfactorily by a single transosseous suture. The rest of the approach, including division of iliopectineal fascia and developing the three windows remains the same as in the original approach. Results: To date, three acetabular fractures have been reduced and fixed using this modification. Besides substantially speeding up the exposure and closure, this approach allows superior distal visualization of the anterior column and wall, and the impression of rather less bleeding. No complications developed with the three cases treated through this modified approach, and specifically, there have been no hernias, nor has the lateral femoral cutaneous nerve of the thigh been damaged. Discussion: This small study demonstrates a modification to a classic approach that seems to be both safe and fast We hope that further experience will also show reduction in problems associated with wound healing. Further work in progress may also show that femoral venous flow is less impeded by this approach as retraction is not against the unyielding inguinal ligament

A prospective study of early operative treatment of unstable elbow dislocations using a surgical algorithm, we present the early results of nine such injuries including five terrible triads of the elbow and four elbows which redislocated in plaster. All except two were high energy injuries. The lateral collateral ligament complex was found to be avulsed proximally in all cases and was reattached using a bone anchor. The common extensor origin was also torn to a variable extent in all cases and was repaired end to end. In the terrible triads, the coronoid fracture as fixed with a transosseous suture and the radial head reconstructed or, in one case with gross comminution, replaced. In the four redislocations, full stability was only restored when the medial collateral ligament was also reattached. Mobilization without a hinged external fixator was allowed from day one, but the elbows were protected in a hinged splint in between exercise sessions. Patients were assessed for stability, ROM, and functional disability using the DASH score at an average of 12 months. No elbows redislocated post-operatively and no patients complained of instability. Mean extension was 18° (95% CI 7° – 28°), flexion 131° (124° – 137°), pronation 76° (56° – 96°), and supination 82° (75° – 90°). Mean DASH score was 14.6 (95% CI 0.7 – 28.5) though this result was skewed by one patient who developed RSD and had a DASH score of 67.2. This was however the only complication. Early operative intervention with reconstruction of unstable elbow dislocations, including the terrible triad, prevents the poor results which are commonly found following non-operative treatment of such injuries. An external fixator is not usually required in the acute setting

Aims: The evaluation of outcome of 4-part valgus impacted fractures of the proximal humerus after reconstruction with stable transosseous suturing þxation and early postoperative passive motion. Methods: 51 patients, 33 women and 18 men (average age 49,5 years) with displaced 4-part Òvalgus impactedÒ fractures of the proximal humerus, were treated operatively in the last 10 years (1991–2001). Stable þxation of the tuberosities to each other, to the metaphysis and to the articular part of the humeral head, was achieved with non-absorbable (Ethibon No 5) sutures, avoiding any use of hard material. Early passive motion with pendulum exercises was applied to all patients at the 2nd postoperative day, followed by active assisted exercises after the 4th to 6th postoperative week, and þnal strengthening exercises after the 2nd to 3rd postoperative month. Results: Long term results (mean follow up period 5.6 years), were evaluated according to Constant-Murley Scoring System. 42 patients (82.3%) had very good result (Constant score > 80) without pain and satisfactory motion (160û forward elevation, 50û to 80û external rotation and internal rotation up to T12). The incidence of avascular necrosis was 3,9%. Complications developed in 6 patients: 1 malunion of the great tuberosity, 3 heterotopic ossiþcations and 2 nonunions revised to hemi-arthroplasty and plate osteo-synthesis plus bone grafting. Conclusions: Advantages of this minimally invasive technique are: shorter operative time, no use of hardware, less soft tissue damage, low incidence of avascular necrosis, stable osteosynthesis with tension band effect, and adequate rotator cuff repair, allowing for early joint motion

Aim: The evaluation of outcome of 4-part valgus impacted fractures of the proximal humerus after reconstruction with stable transosseous suturing fixation. Methods: 52 patients (34 female, 18 male, mean age 49,5y) with displaced 4-part “valgus impacted” fractures of the proximal humerus, were operatively treated between 1993–2002. The average impaction angle was 42.4° and the lateral displacement of the humeral head between 1–7 mm. In situ, stable fixation of the tuberosities to each other, to the articular part of the humeral head and to the metaphysis at a level below the top of the head, was achieved with heavy non-absorbable sutures, avoiding reduction maneuvers and any use of hard material. Early passive motion with pendulum exercises was applied at the 2nd postoperative day, followed by active assisted exercises after the 6th postoperative week and final strengthening exercises after the 3rd postoperative month. Results: Long term results (mean follow up 5.6 years), were evaluated according to Constant-Murley Scoring System. 45 patients (86.5%) had very good result (Constant score > 80) without pain and satisfactory motion (up to 160° forward elevation, 60° to 80° external rotation and internal rotation up to T12). The incidence of avascular necrosis was 5.7 %. Complications developed in 6 patients: 1 malunion of the great tuberosity, 3 heterotopic ossifications and 2 nonunions revised to hemi-arthroplasty and plate osteosynthesis respectively. Conclusions: Advantages of this minimally invasive technique are shorter operative time, no use of hardware, less soft tissue damage, low incidence of avascular necrosis, stable fixation with tension band effect and adequate rotator cuff repair, allowing for early joint motion

There is no non-invasive gold standard for measuring gap formation following rotator cuff repair; re-tears are reported both on MRI and Ultrasound. Roentgen Stereophotogrammetric Analysis (RSA) has previously been used to monitor microscopic migration of markers in rigid bodies. We present a novel RSA technique using a combination of 1mm tantalum beads and metal sutures to allow accurate monitoring of gap formation following rotator cuff repair. The RSA system combines a commercially made calibration cage with software developed at Imperial College. We verified the RSA system by analysing a movable glass phantom and comparing the data with precise physical measurements of the same object: it identified a 2mm distraction of the phantom to within 0.05mm. In vitro work involved cadaveric human shoulders. We placed three 1mm RSA tantalum beads in the greater tuberosity and three metal sutures in supraspinatus tendon. We then created a tear in supraspinatus at its insertion into the greater tuberosity. We were able to show that RSA images taken before and after the tear correlated closely with direct measurements. The processed data demonstrated movement associated with gap formation. We have performed two open rotator cuff repairs using trans-osseous sutures. During surgery RSA markers were inserted into the shoulder to allow post-operative monitoring of the repair (guided by the in vitro work). Direct measurements of the distance between markers each side of the repair were taken intra-operatively (T=O). RSA images were taken immediately post-operatively (T=1 hours), day 3, day 14, and day 84. The RSA data suggests gapping of typically 3mm may have occurred at the repair sites in both patients. Ultrasound imaging was performed at the same intervals by consultant musculoskeletal radiologists blinded to the RSA data. Preliminary results correlating the two modalities suggest that ultrasound can visualise gap formation accurately even immediately post-operatively

This study aimed to quantify the relationship between passive tension of rotator cuff repair and arm position intraoperatively and to examine the effect of the passive tension on gap formation in cadaveric rotator cuff repairs. Five patients undergoing open surgical reconstruction of the rotator cuff were recruited. The operations were performed by a single surgeon using a standardised technique, which was acromioplasty, minimal debridement, mobilisation of tissue, bone troughs and transosseous suture tunnels. A Differential Variable Reluctance Transducer (DVRT) was placed at the apex of the debrided tendon. An in situ calibration was performed to relate the output from the DVRT to actual tension in the tendon. The tension generated was recorded as the supraspinatus tendon was advanced into a bone trough and secured. The relationship between arm position and repair tension was measured, by simultaneously collecting data from the DVRT and a calibrated goniometer. Particular attention was paid to the three standard positions of post-operative immobilisation; full adduction with internal rotation, neutral rotation with a 30° abduction wedge and ninety degrees of abduction. Five cadaveric shoulders were used for the creation of standardised rotator cuff tears which were then repaired using the technique described above. The difference in tension measured between full adduction and 30° abduction was statically applied for twenty four hours and the gap formation measured. Repair tension increased with advancement of the supraspinatus tendon into the bone trough. Abduction reduced the repair load, this was observed mainly in the first 30° of abduction. The mean reduction in load by 30° of abduction was 34 N. Twenty four hours of 34N static loading caused gap formation in each cadaveric rotator cuff repairs, the mean was 9.2 mm. Rotator cuff repairs tension can be reduced by postoperative immobilisation in 30° abduction. The change in tension with full adduction was caused gap formation in cadaveric rotator cuff repairs

Introduction. Avulsion of abductors from hip is a debilitating complication after total hip arthroplasty performed through a trans-gluteal approach. It results in intractable pain, Trendelenberg limp and instability of the hip. Techniques described for repairing these abductor tears including direct trans osseous repairs, endoscopic repair techniques, Achilles tendon allograft, Gluteus Maximus and Vastus Lateralis muscle transfers. The aim of our study was to assess improvement in pain, limp and abductor strength in patients operated upon surgically for confirmed abductor avulsion using a modified trans osseous repair and augmentation of repair with a Graft Jacket allograft acellular human dermal matrix (Graft jacket; Wright Medical Technology, Arlington, TN). Patients and Methods. In this prospective study we include 18 consecutive patients with hip abductor avulsions following a primary total hip arthroplasty through Hardinge approach for osteoarthritis. All the patients presented with pain around lateral aspect of hip, walking with a significant Trendelenberg limp and used a crutch or a stick in the opposite hand. Diagnosis was made by clinical examination and confirmed by MRI scans. Surgical Technique. Surgical procedure was through lateral approach using the old scar to mobilise combined aponeurosis of the Gluteal Medius and Gluteus Minimus from the bony bed on the ilium to permit advancement onto the trochanter. The conjoint Gluteus Medius and Minimus insertion was affixed to the greater trochanter with No.5 non absorbable trans-osseous suture using a Krackow stitch through a series of transverse tunnels made in anterior aspect of greater trochanter. An on lay augmentation (Fig. 1) of the osseo-tendinous junction was performed using a Graft Jacket matrix of 4 × 7 cms in size after rehydration according to the manufacturer's instructions. Results. At mean follow up of 22 months (15–34 months), pain improved in all patients with mean VAS score improving from 8.25 to 2.33 (p value-0.05). All the patients had improvement in their abductor strength with MRC grade 4 out of 5 in 16 patients and 3 out of 5 in 2 patients. Trendelenberg sign disappeared in all but two. Mean Harris hip score improved from 34.05 to 81.26 (p value-0.001). All patients had improvement in gait except mild noticeable limp in two patients.13 patients did not use any walking aids and five felt more secure using a walking stick in the contralateral hand. The mean SF-36 Physical component score was 53.47 and Mental component score was 56.07. Conclusions. The procedure is safe and associated with high patient satisfaction, without the morbidity of tendon or muscle transfers. The Graft Jacket Matrix provides biological bridging between the hip abductors and its insertion into greater trochanter. It provides a biological scaffold for cellular and vascular in-growth and constructive tissue remodelling. The described procedure appears to enhance the mechanical strength of repaired tendon immediately following surgery. The Graft Jacket allograft matrix has already been used successfully in rotator cuff repairs of shoulder and has showed encouraging results. The early success of this new procedure warrants further study with more patients, longer follow-up and possibly histological study of retrieved specimens