Background

Nonsurgical treatment of Acromioclavicular joint dislocations is well established. Most patients treated conservatively do well, however, some of them develop persistent symptoms. We have used two different surgical reconstruction techniques for Chronic ACJ dislocation stabilization. The study evaluates the effectiveness of a braided polyester prosthetic ligament and modified Weaver-Dunn reconstruction methods.

Introduction

The Constant Score (CS) and the Oxford Shoulder Score (OSS) are shoulder scoring systems routinely used in the UK. Patients with Acromio-Clavicular Joint (ACJ) and Sterno-Clavicular Joint (SCJ) injuries and those with clavicle fractures tend to be younger and more active than those with other shoulder pathologies. While the CS takes into account the recreational outcomes for such patients the weighting is very small. We developed the Nottingham Clavicle Score (NCS) specifically for this group of patients.

Introduction

Health Economists in Denmark have recently reported low and delayed return to work for patients treated for Sub-Acromial Impingement syndrome (SAIS) by Arthroscopic Sub-Acromial Decompression (ASAD). Surgeons however are reporting that patients achieve good pain relief and a high standard of activities of daily living (ADL) after surgery.

Introduction

The conservative management of Sub-Acromial Impingement Syndrome (SAIS) of the shoulder includes both physiotherapy treatment and subacromial injection with local anaesthetic and steroids. The outcome from injection treatment has rarely been evaluated scientifically.

Metastatic osteosarcoma is seen in 10-20% of patients at initial presentation with the lung the most common site of metastasis. Historically, prognosis has been poor. We studied trends in survival in our small developed nation and aimed to identify correlations between the survival rate and three factors: newer chemotherapy, advances in radiological imaging and a more aggressive approach adopted by cardiothoracic surgeons for lung metastases.

Our national bone tumour registry was used to identify patients at the age of 18 or under, who presented with metastatic disease at initial diagnosis between 1933 and 2006. There were 30 patients identified. Kaplan-Meier analysis was used to determine survival rates and univariate analysis was performed using the Cox regression proportional hazards model.

Median survival has improved over the last 50 years; highlighted by the ‘Kotz’ eras demonstrating incremental improvement with more effective chemotherapy agents (p=0.004), and a current 5-year survival of 16%. Aggressive primary and metastatic surgery also show improving trends in survival. Three patients have survived beyond five years. The introduction of computerised tomography scanning has led to an increase in the prevalence of metastases at initial diagnosis.

Metastatic osteosarcoma remains with a very poor prognostic factor, however, aggressive management has been shown to prolong survival.

Metastatic osteosarcoma is seen in 10-20% of patients at initial presentation with the lung the most common site of metastasis. Historically, prognosis has been poor. We studied trends in survival in our small developed nation and aimed to identify correlations between the survival rate and three factors: newer chemotherapy, advances in radiological imaging and a more aggressive approach adopted by cardiothoracic surgeons for lung metastases.

Our national bone tumour registry was used to identify patients at the age of 18 or under, who presented with metastatic disease at initial diagnosis between 1933 and 2006. There were 30 patients identified. Kaplan-Meier analysis was used to determine survival rates and univariate analysis was performed using the Cox regression proportional hazards model.

Median survival has improved over the last 50 years; highlighted by the ‘Kotz’ eras demonstrating incremental improvement with more effective chemotherapy agents (p=0.004), and a current 5-year survival of 16%. Aggressive primary and metastatic surgery also show improving trends in survival. Three patients have survived beyond 5 years. The introduction of computerised tomography scanning has led to an increase in the prevalence of metastases at initial diagnosis.

Metastatic osteosarcoma remains with a very poor prognostic factor, however, aggressive management has been shown to prolong survival.

Most common current surgical treatment options for cuff tear arthropathy (CTA) are hemiarthroplasty and reverse total shoulder replacement. At our unit we have been using Reverse Total shoulder replacement (TSR) for CTA patients since 2001. We present our results of Reverse TSR in 64 patients (single surgeon) with a mean follow up of 2 years (Range 1 to 8 years). There were 45 males and 19 females in the study with a mean age of 70 years. Preoperative and postoperative Constant scores were collected by a team of specialist shoulder physiotherapists. Preoperatively plain radiographs were used to evaluate the severity of arthritis and bone stock availability.

90% patients showed an improvement in the Constant score post operatively. The mean improvement in Constant score was 25 points. The mean Pain Score (max 15) improved from 6.3 to 11.8; the mean ADL Score (max 20) improved from 6.8 to 12.3; the mean Range of Motion score (max 40) improved from 10.8 to 20.2; but the mean Power Score (max 25) only improved from 0.9 to 4.9. The differences in improvement were statistically significant in each category. A total 6 patients (10%) required 10 revision surgeries for various reasons. Two patients dislocated anteriorly who were treated by open reduction. Two patients required revision of the glenoid component due to loosening after a mean of 2 years. One patient required revision of the humeral component with strut grafting secondary to severe osteolysis. Only one patient required revision of both humeral and glenoid components secondary to malpositioning. Three patients died for reasons unconnected with their shoulder problems and surgery. Radiographic analysis at the latest follow up (mean 24 months) showed inferior glenoid notching in 40% cases. Heterotrophic ossification was not seen in our series.

We conclude that reverse TSR is a viable option for treatment of cuff tear arthropathy however glenoid loosening and scapular notching remains an issue.

Objective

Shoulder instability is a common cause of morbidity amongst Professional Rugby Union players. This study explores whether the risk of shoulder dislocation is associated with innate shoulder laxity.

From August 2009, all doctors were subject to the European Working Time Directive (EWTD) restrictions of 48 hours of work per week. Changes to rota patterns have been introduced over the last two years to accommodate for these impending changes, sacrificing ‘normal working hours’ training opportunities for out-of-hours service provision. We have analysed the elogbook data to establish whether operative experience has been affected.

A survey of trainees (ST3-8) was performed in February 2009 to establish shift patterns in units around the UK. All operative data entered into the elogbook during 2008 at these units was analysed according to type of shift (24hr on call with normal work the following day, 24hr on call then off next working day, or shifts including nights).

66% of units relied on traditional 24hrs on call in February 2009. When compared with these units, trainees working shifts had 18% less operative experience (564 to 471 operations) over the six years of training, with a 51% reduction in elective experience (288 to 140 operations). In the mid years of training, between ST3-5, operative experience fell from 418 to 302 operations (25% reduction) when shifts were introduced.

This national data reflects the situation in UK hospitals in 2009, prior to the implementation of a maximum of 48 hours. It is expected that most hospitals will need to convert to shift-type working patterns to fall within the law. This could have significant implications for elective orthopaedic training in the UK.

Introduction: Injury to the distal third of the axillary artery is well recognised as a complication of proximal humeral fractures. However the risk of iatrogenic injury at shoulder surgery has not, to date, been fully appreciated.

Patients: Four female patients aged 59 and over who suffered iatrogenic injury to the axillary artery at the time of shoulder surgery are reported. Two occurred during surgery for planned elective shoulder arthroplasty, while two occurred while treating elderly patients who had previously sustained a 3 part proximal humeral fracture. In all 4 cases the injury probably started as an avulsion of the anterior or posterior humeral circumflex vessels.

Results: Vascular surgeons were called in urgently to help with the management of all 4 cases. In two cases the axillary artery was found to have extensive atheroma, was frail and, after initial attempts at end-to-end repair, it became clear that a reversed vein graft was required. Three patients had a satisfactory outcome after reconstruction, while one patient who had previously had local radiotherapy for malignancy, but was now disease free, developed a completely ischaemic upper limb and required a forequarter amputation to save her life.

Message: The axillary artery can be very frail in the elderly, is often diseased with atheroma, and is vulnerable to iatrogenic injury at surgery. If injury occurs at surgery, small bulldog clamps should be applied to the cut ends and a vascular surgeon should be called immediately. A temporary arterial shunt should be considered urgently to provide an early return of vascularisation to the limb and to prevent serious complications. The axillary artery is very difficult to repair, and, in our experience may require a vein graft. In addition, distal clearance of the main brachial artery with a Fogarty catheter which is an essential part of the management.

An online survey has been carried out to evaluate the compliance with the OCAP learning tools, and the availability of clinical experience to early years’ trainees in Trauma and Orthopaedics in 2007–8. Three surveys were planned over the year, and we present the results from the first two surveys. Over the initial eight month period, 335 trainees in Trauma and Orthopaedic posts responded. There was considerable variation in the proportion of responses from different deaneries, and it was felt this reflected differences in the use of the two logbooks available (FHI or ISCP).

Respondents were FTSTAs (50%), ST1s (11%) and ST2s (29%). The respondents reported their operative experience was poor with low numbers of index procedures – the median values being 2 DHS, 1 Hemiarthroplasty and 0 for Ankle ORIFs performed as the lead surgeon in the first 4 months, rising to 3, 1 and 1 respectively in the second. As an assistant the numbers were 3, 4 and 3. FTSTAs had done more procedures as lead surgeon. It is not clear whether this reflects motivation, or whether they are trainees who were unable to secure training posts due to seniority and were already more experienced. Many posts were entirely ward based.

Improvements in meetings with Assigned Educational Supervisors were noted, as was the use of the learning agreements, and with registration rates with the ISCP. There was considerable variation between posts, hospitals and deaneries, and a tool was developed to summarise this data to be post-, trainee-, and duration-specific. Summaries of each post were distributed to Training Program Directors, Heads of School, and the SAC. Although some improvement has occurred, further rounds of the survey are necessary to ensure that this continues. The next round will commence in September 2008 to complete twelve months of data.

Shoulder instability is a common cause of morbidity amongst Professional Rugby Union players. This study explores whether the risk of shoulder dislocation is associated with innate shoulder laxity. A prospective, randomised controlled study was completed in which all the Premiership Rugby Clubs in England were visited. 169 professional rugby players with no history of instability in either shoulder and 46 players with one shoulder with clinical instability symptoms were assessed. Shoulder laxity was measured by clinical evaluation, questionnaires and ultrasound. Anterior, posterior and inferior translation was measured in both shoulders for healthy players and the uninjured shoulder only for injured players. The results showed there was no significant difference between the left (anterior: mean 2.92 +/− 1.15 mm; posterior: mean 5.10 +/− 1.75 mm; inferior: mean 3.08 +/− 1.00 mm) and right (anterior: mean 3.07 +/− 1.14 mm; posterior: mean 4.87 +/− 1.61 mm; inferior: mean 2.91 +/− 0.99 mm) shoulders in healthy players (P > 0.05). The comparison between healthy shoulders (anterior: mean 3.00 +/− 1.15 mm; posterior: mean 4.99 +/− 1.68 mm; inferior: mean 3.00 +/− 1.00 mm) from healthy players and the uninjured shoulder (anterior: mean 4.16 +/− 1.70 mm; posterior: mean 6.16 +/− 3.04 mm; inferior: mean 3.42 +/− 1.18 mm) from injured players identified that players with unstable shoulders have a significantly higher shoulder translation in their normal shoulder than healthy players (P < 0.05). This is the first study looking at laxity and the risk of shoulder dislocations in sportsmen involved in a high contact sport. These results support the hypothesis that rugby players with “lax” shoulders are more likely to sustain a dislocation or subluxation injury to one of these lax shoulders in their sport.

Introduction: Upper limb injuries in road traffic accidents (RTAs) have been sparsely investigated and poorly understood. The purpose of this study was to obtain more specific information on upper limb injuries sustained by front seat occupants in car accidents with a view to identifying injuries that are a priority for prevention and further research.

Methods: With ethical approval and after obtaining identification of cases from the Transport and Research Laboratory the appropriate hospital records and radiographs were reviewed. Data were analysed to identify the frequency and severity of upper limb injuries, the mechanism of injury and the impairment sustained in accordance with the American Medical Association guide. The costs of management of the upper limb injury and that for the patient in total were calculated.

Results: Sixty cases were reviewed (29 male), aged 18–83 years (mean 45 years). There were 19 clavicle fractures of which 17 were right sided, two requiring operative intervention. These injuries were attributed to a “seat-belt” effect. The mean upper limb Abbreviated Injury Score was 1.9 and the overall Injury Severity Score ranged from 1 to 50 (median 12.3). Upper extremity sensory deficit ranged from 0 to 9% and motor deficit 0 to 22.5% giving up to 5% sensory and 13.5% motor “whole person impairment”. The wrist generally suffered a poorer functional outcome compared with the elbow. The mean estimated treatment cost for upper limb management was £2,200 compared with a total injury treatment cost of £11,000 per person.

Conclusions: The study demonstrates the significance of upper limb injuries in road traffic accidents and the data has been used in conjunction with crash dynamics data to formulate recommendations for future car safety and further research.

We aimed to test the biomechanically predicted hypothesis that in massive rotator cuff tears irreparable by conventional methods the newly developed Nottingham Augmentation Device (NAD) would provide greater functional improvement than that gained from the gold standard of arthroscopic subacromial decompression. Thirty patients treated between 2001 and 2004 were assessed by pre- and six month post-operative Constant scoring. Fifteen underwent open acromioplasty and cuff reconstruction using the NAD (mean age 67.3), while 15 underwent a standard arthroscopic decompression (mean age 67.4). The two groups were matched retrospectively based on size of cuff tear, age and sex. Data was analysed using the student’s t-test at the 95% confidence interval. Both groups displayed a statistically significant increase in Constant score after surgery. The mean increase for NAD patients was 18.7 points compared with 17.6 points for those undergoing arthroscopic decompression. However there was no significant difference between the two groups’ improvement and this was even so in the power sub-category, where increased benefit was predicted with the NAD. The NAD requires greater surgical access, operating time and peri-operative analgesia, and no active mobilisation for six weeks. The arthroscopic technique is minimal access, rapid, involves no prosthesis or foreign body insertion and allows immediate mobilisation. However, with clear biomechanical benefits of the NAD seen in vitro, our results may simply reflect cuff tears in an older population group with irreversible tissue changes and less rehabilitative potential. A randomised prospective trial in a younger patient group with more acute tears and less tissue atrophy would appear the next step in determining the NAD’s place in the management of massive rotator cuff tears.

Introduction The Constant-Murley Score is the functional score currently recommended by the British Shoulder and Elbow Society and by the European Society for Surgery of the Shoulder and Elbow. Normal Values for shoulder assessment are imperative for the diagnosis of pathology and measurement of treatment outcome. Normal values for the UK are currently not known. Several techniques have been described for the assessment for strength and measurement of this paraemeter differs between published series.

Patients and method 122 patients over 50 (62 male) attended a GP surgery for a Constant Score measurement. Constant Score was assessed using three techniques for strength measurement: maximum strength with myometer (Mmax), mean strength with myometer (Mmean) and maximum strength with fixed spring balance (FSB).

Results Maximum strength values measured by myometer or fixed spring balance were very similar with a mean difference of 0.5 (less than the calibration of a spring balance). Mean strength measurements were consistently lower than maximum strength measurements with a mean difference of 3 points. Age and sex both significantly affected Constant Score (P< 0.001, P< 0.001). Constant Score falls by 0.4 points per year over 50. Males have a score 8 points greater than females.

Conclusions Constant Score decreases predictably with age in the UK. Methods of strength assessment are not the same. A uniform method of shoulder strength assessment or correction for method is required to allow meaningful comparisons between series.

Introduction: The Constant Score Functional Assessment (CS) is now the standard method of assessing shoulder disability in Europe. Previous studies have indicated that the CS values associated with a full-thickness rotator cuff tear (RCT) are lower than for normal shoulders. This study was designed to investigate which parameters of the CS were most influenced by the presence of a RCT. As ultrasonograpy has now been shown to have a high accuracy for diagnosing full-thickness RCTs it was used to establish the diagnosis.

Methods: 28 patients attending the Shoulder Clinic were invited to take part in this study for which Local Ethics Committee approval had been obtained. The majority of patients had a painful shoulder on at least one side. All patients had a CS carried out with the “Strength” measurement made in 3 ways – 1) maximum force using a fixed spring balance – FSB(max); 2) maximum force using a commercial myometer – M(max); 3) mean force from 2 to 4 seconds using a commcercial Myometer – M(mean). The CS was measured with no knowledge of the patient’s history or diagnosis and blinded to the state of the rotator cuff. The patients were then assessed using ultrasonograpy of the shoulder (Diasus with an 8–16MHz head) to establish the presence of a full-thickness RCT.

Results: The CS Values for the left and right shoulders have been analysed separately.

The results have also been analysed for each part of the Constant Score – Pain, Activities of Daily Living, Range of Movement and Strength and these will be presented.

Discussion: It was anticipated that subjects with a RCT would be found to be weaker and have a reduced CS in an affected shoulder. This was found to be the case for the left shoulder but not for the right. The reasons for this will be discussed. The abnormally low CS for the normal right shoulders (Group 1) will also be explored.

Conclusion: The CS may be a valuable method of identifying those patients with a RCT. This study indicates that a more careful evaluation of “Strength” measurements still needs to be undertaken.

Introduction: The Constant Score Functional Assessment (CS) is now the standard method of assessing shoulder disability in Europe. It has been observed that the CS values decrease with age and attempts have been made in Canada (Constant, 1986), Germany (Tempelhof, 1999), Switzerland (Gerber, 1992) and US (Romeo, 2002) to produce national norms against which the subject’s Constant Score might be compared. Unfortunately the methods used for measuring the “Strength” category of the CS have varied and thus the results are not uniformly comparable. This study has used three methods of evaluating “Strength” for the CS in a randomised group of subjects aged over 50 in order to establish the UK norms.

Methods: 200 patients stratified for age over 50 were invited to take part in this study for which Local Ethics Committee approval had been obtained. Of these 200, 46 patients (21 males) attended and all attenders had a CS carried out with the “Strength” measurement made in 3 ways – 1) maximum force using a fixed spring balance – FSB(max); 2) maximum force using a commercial myometer – M(max); 3) mean force from 2 to 4 seconds using a commercial Myometer – M(mean). The CS values have been plotted for age and sex.

Results: The results for the 25 females and 21 males using M(mean) are shown below. The middle line represents the linear regression with the 95% Confidence Intervals above and below.

Discussion: The results confirm that there is a deterioration in the CS with age in both men and women. The outliers in three of the four graphs will be discussed and the analysis represented after removal of outliers for which there is a justification for exclusion. The differences between the left and right shoulders will be discussed.

Significant differences were identified between the 3 methods of “Strength” measurement, highlighing the need for a uniform method of carrying out the CS.

Conclusion: The UK pattern of deteriorating CS with age mirrors that seen in other countries but the values are different. These differences are significant and make it necessary to reconsider the use of the corrected CS. It is probably wiser to use the uncorrected CS but refer to normal values as a guide for the expected CS at different ages.

Introduction: Legislation driven & technology aided reductions in mortality have been documented over the past 10 years for road traffic accidents (RTAs). However many authors have noted an increasing morbidity as a result of serious lower limb injuries. In collaboration with the Transport Research Laboratory (TRL) a 2 stage research programme has been carried out on fresh frozen PHMS lower limbs. This programme, has culminated in a specific series of PMHS tests to reproduce the most disabling lower limb injuries seen in real world accident data. The authors aimed to establish force thresholds for failure (fracture) of the calcaneus, talus and tibial plafond in frontal and frontal offset RTAs. This data is considered essential to support new pan-European legislation for better lower limb protection structures in new motor vehicles which is currently under discussion.

Methods: A 5m bungee driven sled test facility capable of creating a validated and repeatable dynamic crash pulse was used to subject 15 PMHS lower limb specimens to, axial impact loading. The pulse was modelled on the accelerometer toe-pan recordings from a full-scale automotive crash test in frontal impact. To represent brake pedal intrusion at an impact velocity of up to 14ms⁻¹, a staggered double impact, delaying application of axial loading was used. Impact loading was achieved via a modelled brake pedal to the mid-foot. All specimens were preloaded through the Achilles tendon and by knee extension to simulate the plantar flexing response seen in the foot & ankle in driving simulator studies. Delaying the application of axial loading after the initial impact and sled deceleration effectively imparts momentum into the specimen, further preloading the foot and ankle and thus increasing pre-impact bracing. Transducer data were recorded using high frequency (20 & 100 KHz) capture systems (K-Trader and Prosig). High-speed cinematography enabled additional kinematic analysis. Each specimen was tested once only. Specimens were selected at random for five impact severity groups. All specimens underwent pre impact BMD evaluation using protocols previously designed for this type of work. Post impact analysis included X-rays and necropsy.

Results: The specimens used varied in BMD and age similar to specimens used in other centres for similar testing. In the 15 final test specimens 8 calcaneal fractures were generated, one with an additional talar neck fracture. Seven specimens did not sustain injury. Measured BMD did not appear to be a useful predictor of load to failure. Peak axial forces ranged from 5KN up to 14kN. Toe pan and foot accelerations up to 200g were generated.

Discussion: This test method appears to predispose the calcaneus to injury. It failed to create either a Pilon fracture or an isolated talus fracture. Previous research investigating axial impact loading have applied a direct impact with varing levels of pre-load. They resulted in a range of injuries and suggested pre-loading reduced injury thresholds for talar and tibial injuries. This has not been our experience.

Conclusions: This data is invaluable, enabling thresholds for legislative car crash testing to be authoritatively stated and incorporated into national and international standards.

Introduction: The Nottingham Hood is a polyester soft tissue reinforcement device for the treatment of weakened or torn rotator cuff tendons (RCTs). The device was introduced in 1987 and has undergone a number of modifications from a close weave polyester modified aortic vascular graft (Mark 1) to an embroidered trefoil shape (Mark 4 – Pearsall’s Ltd) which has now been available since 2000. While this device has been under development it has been used on a named patient basis for 10 years on humanitarian grounds as an alternative treatment option for patients with massive RCTs. Approximately 30 Nottingham Hoods have been inserted over the past 10 years. This study investigates the histological changes and ingrowth associated with this device.

Methods: Four patients who have had the Nottingham Hood inserted for massive RCTs have had re-operations for various reasons on five occasions. Excised material from the rotator cuff has been subjected to histological investigation. Excised biopsy material has been obtained 6 weeks, 6, 9 & 12 months and 14 years following implantation.

Transmitted and polarised light microscopy has been used in all cases.

Results: At 6 weeks birefringent clear material similar to suture material was identified, invested by fibrin and occasional red cells i.e. old thrombus. The fibrin was partly calcified and insinuated between bundles of the meshwork material. No true ingrowth of material was seen at this stage. At 6 months the material was seen macroscopically to be covered with collagenous material, rather like fascia which interdigitated closely with the embedded polyester material. At 14 years the mesh appeared to be invested, sandwich-like into a collagenous fascia-like structure with dense hyaline bands of collagen. Some fibrin was also present between the fibrils and a low grade foreign body giant cell response with light chronic inflammation. The local synovium showed detritic synovitis.

Discussion: The histological features show that there is an early organisational response to the insertion of the new tissue, which is then accompanied by long-term incorporation into host tissues by fibrosis and scarring. A small fibrin and foreign body response lingers on.

Conclusion: This long-term follow-up assessment provides evidence that long-term implantation of polyester as reinforcement for the rotator cuff tendons is not associated with serious biological problems. However the problem of stretching of the repaired rotator cuff muscles does occur and needs to be considered in more depth.

Introduction: This study investigates the survival (and radiological loosening) rates of prostheses following uncemented Total Shoulder Arthroplasties (TSAs) focusing on the glenoid baseplate fixation.

Methods: ALL uncemented TSAs inserted in one shoulder unit from 1989 to 2001 were entered onto a database prospectively and the patients monitored to death or failure of the implant, resulting in revision surgery. Over 80% of the surviving implants were monitored on sequential radiographs and the radiological loosening rate was observed. 273 TSAs have been monitored – 193 with a porous coated glenoid baseplate and 80 with a hydroxyapatite coating on top of the porous coating.

Results: The Survival rates (%) of the non-HA coated baseplates at 1 to 12 years using the Life Table Method were:− 97, 93, 89, 83, 83, 81, 79, 79, 77, 75, 75 & 75% respectively. The Survival rates for the HA coated glenoid base-plates at 1 to 4 years were 100, 97, 93, & 93% respectively. Failures were predominantly due to mechanical loosening and glenoid disassembly with only 3 cases of infection documented. Thus by 4 years there was a statistically significant improvement in survival of the glenoids. Survival rates were further reduced when radiological loosening was taken into account. The earlier series was analysed to assess the survival of prostheses inserted for RA and OA. The survival rates at 5 and 10 years were 78% & 70% for OA and 96% and 88% for RA.

Discussion & Conclusions: This Life Table analysis confirms the early benefit from the use of hydroxy-apatite coating of the glenoid implant of a TSA. Further improvements, particularly in relation to reducing further the small risk of disassembly are underway.