Traumatic injuries to the sternoclavicular joint (SCJ) are uncommon representing only 3% of all injuries to the shoulder girdle. Acutely, the majority are managed non-operatively with physiotherapy rehabilitation. However, if there is evidence of neurovascular compromise emergency reduction is indicated. There is no consensus on treatment of SCJ dislocations and subluxations that remain symptomatic after conservative treatment. Multiple surgical techniques have been described to alleviate this problem. These include resection of the medial end of the clavicle and various stabilization techniques using Kirschner wires, muscle tendon (subclavius, sternocleidomastoid, semi-tendinosus and palmaris longus) and synthetic materials (Dacron). However, all techniques have reported problems in terms of pain, decreased range of movement and a relatively high complication rate. We report a new technique using a LARS® ligament (Ligament Augmentation and Reconstruction System) with good early post-operative results. 5 symptomatic SCJ dislocations were repaired over a 3 year period. The operations were conducted by the same surgeon and at the same unit. The patients were on average 20 years old (17–22). Mean follow up time was 21 months (9–41). Functional assessment was made using the DASH (Disabilities of the Arm, Shoulder and Hand) and the OSS (Oxford Shoulder Score) outcome measures. An improvement between pre- and post-operative scoring was observed in both DASH median 51.7 (24.2–75.0) v 13.7 (8.3–20.8) (p=0.024) and OSS 20.6 (15–32) v 41.8 (39–47) (p<0.001). One patient had a pneumothorax intra-operatively but this resolved with conservative treatment. There were no long term complications experienced during follow up.
Poor outcome in ACL reconstruction is often related to tunnel position. This study investigates the use of surgical navigation to improve outcome. Improving accuracy of tunnel position will lead to improved outcome. In a prospective randomised controlled trial 60 ACL plasties with quadruple-loop semi-tendinosus and gracilis tendon were randomised to either standard instrumentation or computer assisted guides to position the tibial and femoral tunnels. The results were evaluated on clinical outcome based on IKDC laxity measurements and radiologic assessment of anterior drawer at 150 and 200N as well as radiological assessment of the tunnel positions. No complications were observed in either group. IKDC laxity was level A in 22 knees in the conventional group (average 1.5 mm (0-6) at 200N) compared with 26 navigated knees (average laxity 1.3mm (0-5)). Laxity was less than 2 mm in 96.7% of the navigated group (83% in conventional group). The variability of laxity in the navigated group was significantly less than the conventional group, with the standard deviation of the navigated group being smaller than the conventional group standard deviation (p = 0.0003 at 150N and 0.0005 at 200N TELOS). A significant difference (p=0.03) was found between the groups in the ATB value characterising the sagittal position of the tibial tunnel (negative ATB values imply graft impingement in extension). In the conventional group mean ATB was -1.2 (-5-+4) while it was 0.4 (0 - 3) in Group II. There were no negative ATB values in the Navigated Group. The use of computer assisted navigation creates a more consistently accurate tibial tunnel position than using conventional techniques. It is suggested that this should reduce impingement and improve graft longevity.
Since the recognition of chronic exertional compartment syndrome (CECS) of the leg as a cause of exercise-induced leg pain was made in the 1950s, there has been no universally accepted diagnostic pressure. A 1997 review found 16 papers from 1962 to 1990, which have differing diagnostic criteria. The threshold pressure used at DMRC Headley Court is based on the work of Allen and Barnes from 1986, where in a patient with a suitable history, a dynamic pressure in the exercising muscle compartment above 50 mmHg is diagnostic. We present the data gathered at DMRC Headley Court during the first year of the new protocol on dynamic pressure testing, from May 2007. The new exercise protocol involved exercising patients using a representative military task: the combat fitness test (CFT) using a 15 kg Bergen on a treadmill, set at 6.5 km/h with zero incline. During this period, we performed 151 intra-compartmental pressure studies in 76 patients. 120 were successful in 68 patients, with 31 technical failures. Patients complained of exercise-induced leg pain on performing the CFT and pointed to the muscles in either the anterior or deep posterior muscle compartments and these were exclusively tested with invasive studies. No patients complained of symptoms in the lateral or superficial posterior compartments and therefore neither was tested. The majority were performed in the anterior leg compartment (110 successful), with a few (9 successful) in the deep posterior compartment, and there was only one complication with a posterior tibial artery puncture. The mean age of patient was 28.9 years (SD 6.7). In 119 compartment studies, the mean pressure was 97.8 mmHg (SD 31.7). This data is normally distributed (Shapiro Wilk test, W=0.98 p=0.125). In summary, we present the data using the CFT as the exercise protocol in patients who give a history compatible with CECS and have symptoms of leg pain during exercise. This data has a mean of approximately 100 mmHg, which is double that of the diagnostic criteria of Allen and Barnes, who used running as the exercise protocol. The presence of a weighted bergen as well as the stride and gait pattern used during the loaded march may be contributory factors in explaining why the pressures are higher compared to other forms of exercise. Further work is ongoing with determining the intracom-partmental muscle pressure in normal subjects with no history of exertional leg pain performing the CFT.
Chronic instability of the acromioclavicular joint is relatively common and normally occurs following a fall onto the point of the shoulder. Reconstruction of the joint (Weaver-Dunn procedure) is often required in service personnel, and numerous methods of fixation have been used, including vicryl tape, PDS loops and the use of a hook plate. Many of these operative methods require a second operation to remove the plates and/or screws, and are associated with a failure rate of up to 30%. The ‘Surgilig’ was designed as a method of revision for failed Weaver-Dunn procedures. However this study evaluates its use in the primary operation. We prospectively followed up the Modified Weaver Dunn procedures using surgilig. The post-operative x-rays were reviewed at six weeks, 3 months and then 6 months when the patients were discharged to assess the radiological success of the procedure. We have performed this procedure in 11 patients. Of the eight patients that have reached the six month postoperative time so far, at which they would be discharged from clinic follow-up, none have had radiological failure of the fixation. One patient even had weight-bearing x-rays taken at 6 weeks, with no detrimental effect. Even though a small study, the initial results for primary fixation of acromioclavicular joint disruption with surgilig are extremely encouraging. The study suggests that surgilig should continue to be used in its current role. As patient numbers increase, a follow-up study should be conducted to evaluate these preliminary findings.
Failure of fracture healing is a significant problem, resulting in considerable morbidity and financial costs to the NHS. It is also a major complication of ballistic injuries. We reviewed our experience in the management of non-union by revision of fracture fixation and use of Bone Morphogenic Protein at Ministry of Defence Hospital Unit Frimley Park. Bone Morphogenic Proteins have been identified as promoting osteogenesis and have been used to stimulate bone growth in fracture revision surgery and spinal surgery. BMP’s are a subgroup of the TGF-β family and consist of at least 20 different subtypes of which BMP 2 and BMP 7 are commercially available. Current preparations include a solution for application to a gel matrix and as a powder for reconstitution to a paste for implantation to the fracture site. Costs per graft are in the region of £2,000. BMPs have been used at Frimley Park since 2005 in the management of 12 patients with established non-union. These included fractures of 4 femurs, 5 humerai, 2 clavicles and 1 metatarsal. Early results are encouraging and support continued use of BMP’s in fracture revision surgery for established non-union. Non-union remains a difficult problem and even with this treatment there was a significant failure rate, often associated with failure of fixation.
The aim of this study was to use motion analysis to study a surgeon’s learning curve for an arthroscopic Bankart repair on a training model in a skills laboratory. Six fellowship trained lower limb surgeons unfamiliar with advanced shoulder arthroscopy performed an arthroscopic Bankart repair on an ALEX shoulder model. Standardised training was given and then an electromagnetic tracking system used to objectively assess hand movements, distance travelled by hands and time taken while the surgeons performed the technique. The arthroscopic repair was repeated three times on four consecutive occasions by each surgeon giving a total of 72 repair episodes. Analysis revealed improvement of all outcome parameters with less hand movements, less distance travelled and less time to complete the task. This study objectively demonstrates a learning curve for arthroscopic Bankart suture in a skills laboratory. It indicates the potential benefits of practicing aspects of arthroscopic techniques in a skills centre on appropriately selected models.
Fracture dislocations of the elbow are complex injuries that have a significant risk of long term instability and loss of function. The more severe injuries are fortunately rare and the published series are relatively small. This in turn means that there is less precise evidence and guidance as to the optimal treatment. With the improvements in the understanding of this injury we consider that the prognosis is not necessarily as poor as has been previously reported and we have attempted to quantify this in a prospective, single surgeon series with standard surgical and rehabilitation protocols using dedicated upper limb physiotherapists.
Information was collected prospectively recording function and stability. All patients were assessed with the Mayo clinic elbow score and the AAOS Disability of the Arm Shoulder and Hand score (DASH).
All fractures had united and there were no cases of migration or failure of metal fixation devices. There were no cases of symptomatic instability and no patient had signs of instability when assessed at clinically. A mean flexion arc of 106 degrees was recorded (range 60–145) with a mean extension limit of 23 degrees (range 0–40). Pronation and supination arcs were recorded with a mean of 127 degrees of rotation (range 0–160) There were no reoperations for infection or instability amongst this group of patients Mayo clinic performance index for the elbow produced a mean score of 91.5 with a range of 85–100 which equates to a good or excellent outcome for all patients.
Stability of the elbow joint is provided primarily by the integrity of the ulno humeral articulation. Secondary contributions to stability are provided by the radio-capitelar joint and the medial collateral ligament complex. Lesser contributions are provided by the lateral ligament and the joint capsule. A dislocation which is complicated by an injury to one of these main stabilising structures will have a greater risk of instability and recurrent dislocation. Poor outcomes have been noted to occur with both coronoid fractures and significant radial head fractures. There is a group of patients with a more severe injury within this spectrum who have a pattern of injury which leads to gross instability. This “unhappy triad” is a dislocation where there is an associated coronoid fracture, a radial head fracture and complete disruption of the medial collateral ligament complex. These severe injuries tend to present to a specialist after significant delay with recurrent dislocation following failure of initial management. Three cases will be presented to illustrate the anatomical considerations and management strategies for this pattern of injury by immediate reconstruction, hinged external fixation or elbow replacement.
Treatment regimes for malignant disease have improved significantly in recent years leading to improved survival after diagnosis of primary and Metastatic disease. Against this background we have reviewed the activity in a district general hospital offering a spinal service to evaluate the efficacy of surgery in metastatic disease. Materials and Methods: Retrospective casenote review of patients identified through theatre records over a 3 year period. 27 patients were identified as having surgery for spinal tumours, of whom 24 were for metastatic disease. All presented with pain and/or signs of acute cord compression and had an intervention on an urgent or emergency basis by one of three spinal surgeons. Results: Of the 24 patients with metastases, the primary tumours were breast (7), lung(7), prostate(2), renal(2), bladder(1), clear cell (1), colon(1), thyroid(1) and unknown (2). The operations performed were: spinal decompression or vertebrectomy and stabilisation(18), stabilisation without decompression(4), decompression alone (1), biopsy only (1). Mean survival after surgery was 9.4 months (range 0–42 months) with a poorer outcome in those with pulmonary and renal disease. 7 patients remain alive with a mean follow up of 21 months. Symptomatic improvement was recorded in 19 / 24 patients in terms of pain control and/or restoration of function. There were 4 perioperative deaths of which none were due to complications of surgery. Discussion: Patients with terminal diseases are challenging to treat as they require multidisciplinary input both in hospital and in the community. Good results can be achieved for both symptom control and pain relief by surgical intervention for spinal metastases if appropriate early referral is made to a spinal surgeon. We have found that with the general improvements in survival with malignancy an aggressive surgical regime of decompression or vertebrectomy with spinal stabilisation can be supported.
Day case Anterior Cruciate Ligament (ACL) reconstruction has recently become accepted as a safe and reliable technique. One major advantage of day case procedures is the reduction of cancellations due to bed availability leading to a more predictable admission for the patient. Traditionally this advantage has not always been available to service personnel due to the combined problems of distance from the hospital and lack of a suitable and safe environment for discharge. These problems can be overcome by the close cooperation with the local Medical Reception Station. During 2000 a total of 29 day case ACL reconstructions were performed. There were no cancellations for non-clinical reasons. Of these 29, 12 were performed on service personnel of whom 8 were based at a significant distance from the hospital. A total of 6 patients were treated via the Medical Reception Station (MRS) for overnight stay after the operation. There were no significant complications at the MRS and all patients have returned to normal duty. There were no postoperative complications in this group of patients. We suggest that the advantages of day surgery can be extended to servicemen by the use of the MRS as a temporary accommodation. This should prevent soldiers operations from being cancelled and reduce time away from operational units. This practice could be extended to all aspects of surgery suitable for day case procedures.
