Many of the questionnaire based scoring systems (i.e. Rowe score) require some form of clinical assessment. These clinical components can be very difficult to perform on a large scale particularly when a patient lives a long distance from clinic. We have attempted to counter this problem by asking the patient to asses their own range of motion. The aim of this study was to test the agreement between patient and clinician measured shoulder external rotation range using a photo based self-assessment tool.

Fifty-one professional and semi-professional rugby players were recruited to assess shoulder external rotation range. Each player was presented with a photo based shoulder external rotation range self-assessment tool, which featured four photos of progressive shoulder external rotation in 2 positions, 900 abduction (150, 300, 450 & 600 of external rotation) and 00 abduction (700, 800, 900 & 1000 of external rotation). The players were asked to perform active external rotation in these two positions and mark the image which best matched their maximal external rotation. The player was then independently assessed using the same tool, by a clinician.

The difference between the player's and the clinician's assessment was analysed using a weighted Kappa test. The Kappa for the shoulder external rotation in 900 abduction was 0.75 and 0.71 for left and right respectively, and 0.57 and 0.55 for shoulder external rotation in 00 abduction. Thus, the strength of agreement between the player's and clinician's assessment of shoulder external rotation is good in 900 abduction and moderate in 00 abduction.

These results demonstrate that the photo-based shoulder external rotation range self-assessment tool is a very useful addition to researchers' and clinicians' toolkits and may be most useful when a patient lives a great distance from/or is unable to attend a clinic.

After meniscetomy there is an increased risk of tibiofemoral arthritis. In recent times there has been an increased emphasis on preservation of healthy meniscal tissue. When this cannot be achieved some patients may benefit from allograft transplantation. This aims to restore meniscal function and so limit pain and the development of arthritis. This is an evolving area with controversy surrounding patient selection, tissue harvesting and sterilisation, longterm outcome and overall efficacy.

Twenty-eight patients have undergone 30 meniscal transplants beginning in 2001. All transplants have been performed by the senior author. The mean age at surgery was 37.7 years (range 20–51), there were 16 males and 12 females. At the time of the index operation nine patients underwent additional procedures on the same knee. All patients are scored using recognised knee scoring systems including the Oxford, IKDC and Lysholm scores. All patients are being followed up regularly with clinical assessment and repeat scores.

To date the average follow up is 34.3 months (range 6–84). There have been 12 patients requiring further arthroscopy (three with complete meniscal transplant failure). The average increases in Lysholm, Oxford and IKDC scores were 10.7, 7.6 and 8.6 respectively.

Lack of donors is the current limitation to performing transplants in Brisbane. 61 patients are currently awaiting suitable menisci and in the last 12 months there have been only three donors. A national registry may address this issue but raises problems related to uniform retrieval, storage, sizing and availability. Early results are encouraging with the majority of patients experiencing pain relief and improvement of function over time.

Purpose: With the advent of the locking precontoured proximal humerus plate, fixation of three- and four-part proximal humerus fractures has become an attractive option. The purpose of this study was to report the surgical and functional outcomes of locked plate fixation verses hemiarthroplasty in these fractures.

Methods: This study included 56 patients with three-part and four-part proximal humerus fractures from 2002–2005 with a mean follow-up time of 35 months. The mean patient age was 58.8 years for the ORIF group (n=42) and 68.7 years for hemiarthroplasty group (n=14). IRB approval was obtained and functional outcomes questionnaires were sent out with an invitation to return to the office for a physical exam. Range of Motion (ROM), the Constant score, the American Shoulder and Elbow Surgeons score (ASES), the Simple Shoulder Test (SST), the Euroqol EQ-50, a visual analog pain scale (VAS), and the UCLA shoulder score were used to evaluate the patients.

Results: Radiological review of the ORIF group showed union in 41 patients and avascular necrosis (AVN) in one patient who underwent subsequent hemiarthroplasty. Plate removal was performed in 1 patient after three months from the initial surgery, because of impingement symptoms. The scores of Euroqol EQ-50 (73±24 vs. 63.2±21, p=0.169) and VAS (2±2 vs. 3.1±2.8, p=0.135) were not statistically significant. Validated functional scores are given below.

Function ORIF Hemiarthroplasty p-value (ANOVA)

Conclusion and Significance: Open reduction with internal fixation of three- and four-part proximal humerus fractures using a locking proximal humerus plate provides stable fixation that encourages bony healing and allows for early range of motion and also better functional results, and satisfaction when compared to hemiarthroplasty.

We have an aggressive approach to meniscal repair, including repairing tears other than those classically suited to repair. Elite athletes represent the subgroup of patients who place the most demand on the menisci and as a result, place maximum stress on any meniscal repair. Here we present the medium to long-term outcome of meniscal repair (inside-out) in the elite athlete.

42 elite athletes underwent 45 meniscal repairs between January 1990 and July 1997 were identified from a prospective database. All repairs were performed using an arthroscopically assisted inside-out technique. All patients returned a completed questionnaire (Lysholm and IKDC) to determine their current function and any symptoms or interventions that we were unaware of. 67% medial and 33% lateral menisci were repaired (3 patients had both medial and lateral menisci repaired). 83.3% of these repairs were associated with simultaneous ACL reconstruction. The average time from injury to surgery was 11 months (range 0–45 months). Follow-up time was a mean of 8.5 years (range 5.4 to 12.6 years).

In general, function was good with an average Lysholm and subjective IKDC scores of 89.6 and 85.4 respectively. 81% of patients returned to their main sport and most to a similar level at a mean time of 10.4 months post-repair. We identified 11 definite failures, 10 medial and 1 lateral meniscus that ultimately required arthroscopic excision, this represents a 24% failure rate. We identified one further patient who had possible failed repairs, giving a worse case failure rate of 26.7% at a mean of 42 months post surgery. However, 7 of these failures were associated with a further injury, and 2 of the 7 failures ruptured their ACL reconstruction. Therefore the repairs had healed and were torn with reinjury. In this series medial meniscal repairs were Significantly more likely to fail than lateral meniscal repairs, with a failure rate of 36.4% and 5.6% respectively (p< 0.05).

This series reflects an aggressive approach to meniscal repair with repair of tears in a high demand elite group of patients. Despite this, on a worst case analysis 73% were intact at a mean of 8.5 years post repair. We conclude that meniscal repair and healing is possible and that most patients can return to preinjury level of activity.

This study reports our long-term results of arthroscopically assisted meniscal suture using an inside-out technique.

Between January 1990 and July 1997, 112 patients underwent 121 meniscal repairs in 112 knees. The average follow-up is 8.7 years (range 5.4 to 12.9 years). Repairs consisted of interrupted sutures using 2.0 PDS. Sutures were placed arthroscopically using a suture shuttle system and tied behind the capsule after making a small postero-medial or posterolateral incision. The meniscus and bed was prepared using a Rasp or hand-held instruments. Fibrin clot techniques were not used. 79% of patients had associated ACL reconstruction in addition to meniscal suture. All surgery was carried out by our senior author (PTM). Rehabilitation involved non-weight-bearing in an extension splint for 3 weeks and partial weight-bearing for a further 3 weeks followed by a progressive rehabilitation programme.

The average age at surgery was 23.9 years (range 12.2 to 57.7 years). The average time from injury to surgery was 13.5 months (range 0 to 60 months). There were 74 males and 38 females. 51% of patients were professional or semi-professional athletes. Repair involved 79 medial menisci, 42 lateral menisci. The average number of sutures used was 3.8 (range 1 to 12). Operative findings and procedure were entered prospectively into a database. Patients were assessed clinically until recovery and long-term follow-up consisted of a detailed postal questionnaire.

The average Lysholm scores were 86.4, with 59% excellent, 16% good, 17% fair and 8% poor. IKDC subjective scores averaged 82.0, with 40% excellent, 21% good, 27% fair and 12% poor. Confirmed failure of meniscal repair (as indicated by MRI or re-arthros-copy) has been identified in 11.8% of patients. A further 10.8% have a probable failure based on a recurrence of mechanical symptoms. Of the failures 73% were professional or semi-professional sportsman. Their average return to sport after surgery was 9.5 months (range 3 to 18 months). Failure was reported at an average of 29.3 months after surgery (range 0 to 84 months).

With an aggressive approach towards meniscal preservation we have achieved a success rate of 77.4% at an average follow-up of 8.7 years.

The majority of these tears are vertical posterior horn or large bucket handle and associated with an ACL reconstruction. The majority of patients are young and involved in a high level of sporting activity.

Introduction and Aims: Treatment options for medial gonarthrosis include high tibial osteotomy (HTO). There has been a shift towards opening wedge techniques partially due a perceived higher complication rate with closing wedge techniques. This has not been our experience and we describe the outcome of a large series of closing wedge HTOs.

Method: We reviewed the case records of 313 patients who underwent a total of 374 closing wedge high tibial osteotomies by three surgeons for medial compartment gonarthrosis between 1989 and 2003. The mean outpatient follow-up was 16 months and the mean time post-surgery was 66 months. We identified any post-operative complications and the early clinical outcome including those known to have proceeded to joint replacement. The mean age of patient was 52 years (range 19–72). In all patients a laterally based wedge, mean size nine degrees (range 4–18), was excised and the osteotomy stabilised with one or two stepped staples.

Results: Outcome following closing wedge osteotomy was generally good, only six percent of patients complained of continuing knee pain, although not at a level that required further intervention. Symptoms in 3.5% of knees deteriorated and required total knee replacement at a mean of 63 months (range 16–112) following osteotomy. No intra-operative difficulties were encountered with these replacements. The complication rate was acceptable with an overall rate of 7.8%. One patient required revision shortly after surgery due to inadequate initial correction and one developed a transient peroneal nerve neuropraxia. There were no other neurovascular or intra-operative complications recorded. All the osteotomies united, although nine patients had delayed union, taking a mean of five months for their osteotomies to unite. Other complications included: five patients who had staples removed due to irritation, one who developed a stitch abscess and one who developed a deep wound infection. Two knees had a reduced ROM and required an MUA. In addition, six patients developed symptomatic DVTs, three with pulmonary emboli, but there were no deaths.

Conclusion: In our experience, closing wedge osteotomy for medial gonarthrosis is a safe and reliable procedure with a good early outcome and an acceptable complication rate of 7.8% in this series, with a low incidence of serious complications that compares favourably with the quoted complication rates for opening wedge techniques.

This study reports our long-term results of arthroscopically assisted meniscal suture using an inside-out technique.

Between January 1990 and July 1997, 112 patients underwent 121 meniscal repairs in 112 knees. The average follow up is 8.7 years (range 5.4 to 12.9 years). Repairs consisted of interrupted sutures using 2.0 PDS. Sutures were placed arthroscopically using a suture shuttle system and tied behind the capsule after making a small posteromedial or posterolateral incision. The meniscus and bed was prepared using a Rasp or hand-held instruments. Fibrin clot techniques were not used. 79% of patients had associated ACL reconstruction in addition to meniscal suture. All surgery was carried out by our senior author (PTM). Rehabilitation involved non-weight bearing in an extension splint for 3 weeks and partial weight bearing for a further 3 weeks followed by a progressive rehabilitation program.

The average age at surgery was 23.9 years (range 12.2 to 57.7 years). The average time from injury to surgery was 13.5 months (range 0 to 60 months). There were 74 males and 38 females. 51% of patients were professional or semi-professional athletes. Repair involved 79 medial menisci, 42 lateral menisci. The average number of sutures used was 3.8 (range 1 to 12). Operative findings and procedure were entered prospectively into a database. Patients were assessed clinically until recovery and long-term follow up consisted of a detailed postal questionnaire.

The average Lysholm scores were 86.4, with 59% excellent, 16% good, 17% fair and 8% poor. IKDC subjective scores averaged 82.0, with 40% excellent, 21% good, 27% fair and 12% poor. Confirmed failure of meniscal repair (as indicated by MRI or re-arthroscopy) has been identified in 11.8% of patients. A further 10.8% have a probable failure based on a recurrence of mechanical symptoms. Of the failures 73 % were professional or semi-professional sportsman. There average return to sport after surgery was 9.5 months (range 3 to 18 months). Failure was reported at an average of 29.3 months after surgery (range 0 to 84 months).

With an aggressive approach towards meniscal preservation we have achieved a success rate of 77.4% at an average follow-up of 8.7 years. The majority of these tears are vertical posterior horn or large bucket handle and associated with an ACL reconstruction. The majority of patients are young and involved in a high level of sporting activity.

Introduction Concentric interference screw placement has been proposed as having potentially better biological graft integration than eccentric interference screw placement during soft tissue ACL reconstruction. The purpose of this study was to determine whether a wedge shaped concentric screw was at least equivalent to an eccentric screw in stiffness, yield load, ultimate load and mode of failure.

Methods Seven matched pairs of human cadaveric tendon in porcine tibia with titanium wedge shaped screws were randomly allocated to either the eccentric or concentric groups. Bone tunnels were drilled 45° to the long axis of the tibia, akin to standard ACL reconstruction. Tendon diameter was matched to tunnel diameter and a screw one millimetre larger than tunnel diameter was inserted. An Instrom machine was used to pull in the line of the tendon. Tendons were inspected after construct disassembly.

Results The concentric screw configuration showed significantly higher stiffness (p< 0.0085), yield load (p< 0.0135) and ultimate load (p< 0.0075). The mode of failure in the eccentric screw position was slippage at the screw tendon interface in all cases. In the concentric group 88% of cases had a breakage in the tendon and 13% of cases had slippage at the tendon bone interface. However, it was observed during construct disassembly that there was more macroscopic damage to the tendon substance in the concentric group. Failure was mostly by tendon breakage, which reflects the strongest fixation possible with the tendon being the weakest link in the system.

Conclusions Concentric interference screw fixation of soft tissue graft offers superior fixation in single pullout mode when compared to eccentric interference screw fixation.

Introduction Transcondylar fixation has recently been offered as an alternative method of femoral fixation in soft tissue ACL reconstructions. It provides the advantages of avoiding intra-articular hardware and of achieving full circumferential contact of soft tissue to bone for graft integration. This paper presents a series of hamstring ACL reconstructions using femoral transcondylar fixation in a short-term retrospective clinical review.

Methods Over a six month period the senior author performed a total of 50 hamstring anterior cruciate ligament reconstruction procedures using the femoral transcondylar fixation, 80% of these patients were available for review. The patient series consisted of 24 males and 16 females with average age of 29.9 years (range 14.4 to 54.5) at the time of surgery. Patients were assessed by clinical review, questionnaires (Lysholm and IKDC) and KT 1000 measurement at 30 lbs. Follow-up ranged from 12 to 16 months post-operatively with an average of 13.3 months.

Results The Lysholm scores mean was 83.9, which graded 75% of patients as good or excellent. Of the remaining patients 15% were fair and 10% graded their knee as poor. This was different from the IKDC patient questionnaire (subjective assessment) where 59% of patients categorised their knee as good or excellent. There were 70% of patients who rated their result poor or fair with respect to pain, and 52% of patients who rated their result poor or fair with respect to swelling. However, 67% of patients rated their knee good or excellent with respect to stability and function. Clinical laxity testing demonstrated a mean increase in translation of two millimetres (−3.3 to 5.3) in the index knee as compared to the opposite knee. On objective clinical tests, 97% of patients were normal or nearly normal with four percent being abnormal due to a passive motion deficit. There were no complications within the group and specifically no complications related to the transfix implant. No patient had pain, tenderness or crepitus around the iliotibial band.

Conclusions The femoral transcondylar fixation used in soft tissue ACL reconstructions is a viable alternative to interference screw fixation. It delivers comparable results in the short term, and offers potential advantages. The technique is reliable, reproducible and safe, with no complications being reported in this study.

Introduction The standard surgical practice for athletes with recurrent anterior shoulder instability who play contact or collision sports is to perform either the Bankart repair or Bristow procedure. The purpose of this study was to investigate the outcome of a combined Bankart and Bristow procedure for recurrent anterior shoulder instability in high contact and collision athletes.

Methods Ninety-one patients underwent 100 combined Bankart and Bristow procedures for anterior shoulder instability (nine bilateral cases). Combined procedures were indicated in athletes participating in contact and collision sports. We were able to follow-up 71% of cases (71 shoulders in 65 patients) at an average of 6.5 years after surgery (range 2.1 to 12.3 years). The average age at the time of surgery was 23 years (range 15 to 47 years). There were 63 males and only two females. All patients were participating in competitive level sport at the time of injury of which 76.1% was rugby. A Rowe rating was calculated for each patient.

Results Forty-four percent were graded excellent, 18% good, 27% fair and 11% poor. Overall 66% of athletes returned to their pre-injury level of sport or better, whilst 25% return to a lower level of their sport. Nine percent did not return to sport after surgery. This cohort included 37 professional or semi-professional players of whom 73% were able to return to their pre-morbid or a higher level of sport. Only six percent have experienced further dislocations since surgery. A further 12% have experienced shoulder subluxation and another 19% report feelings of insecurity. Four percent have required an additional procedure. Eighty-nine reported no or only mild limitation of function or discomfort and 87% were either very satisfied or satisfied with their outcome.

Conclusions The combined open Bankart repair and Bristow procedures gives good results in athletes who participate in contact and collision sports. It has proved to be a robust procedure in the long term, allowing almost 75% of professional and semi-professional athletes to return to the same level or higher of sporting participation.

Introduction The gold standard technique for meniscal repair has been an inside-out technique. Current practice suggests that certain tears are incapable of healing although anecdotally this has not been our experience. This study reports our long-term results of an aggressive approach to meniscal preservation using an inside out technique.

Methods Between January 1990 and July 1997, 116 patients underwent 125 meniscal repairs in 116 knees. The average follow-up is 8.8 years (range 5.4 to 12.9). Repairs consisted of interrupted sutures using 2.0 PDS. Sutures were placed arthroscopically using a suture shuttle system and tied behind the capsule after making a small postero-medial or postero-lateral incision. The meniscus and bed was prepared using a Rasp or hand-held instruments. There were 49 left knees and 67 right knees in 77 males and 39 females. Repair involved 80 medial menisci and 45 lateral menisci. The average number of sutures used was 3.8 (range 1 to 12).

Results The average Lysholm scores were 86.0, with 54% excellent, 21% good, 17% fair and 8% poor. IKDC subjective scores averaged 81.5, with 39% excellent, 23% good, 25% fair and 13% poor. Failure of meniscal repair has been identified in 30% of patients. Of these two thirds were associated with a further significant injury. Of the failures 73% were professional or semi-professional athletes. The average time for return to sport after surgery was 9.5 months (range 3 to 18 months). Failure was reported at an average of 29.3 months after surgery (range 0 to 84 months).

Conclusions The long-term results of the meniscal suture using this arthroscopically assisted inside out technique in our unit are acceptable. In addition the majority of the failures have occurred in professional athletes. We would therefore expect our long term failure rate to be at the high end of the spectrum. These results are comparable to those using standard suturing techniques.