Proximal humeral fractures are common and often occur in osteoporotic bone. Suture fixation utilises the rotator cuff tendons as well as bone providing adequate stability and avoids complications associated with metalwork insertion. Surgical exposure was via a delto-pectoral approach with minimal dissection of the fracture site. Initially a 2 suture technique was utilized with heavy ethibond sutures passed through drill holes either side of the bicipital groove; however, because of concerns about varus instability the technique now uses a third suture placed laterally acting as a tension band to prevent varus collapse. Patients with Neer 2 and 3 part fractures treated with suture fixation were assessed clinically (using the Constant score) and radiologically at a mean of 27 months post fracture. To date 24 patients have been studied. The average age of the patients in our series was 70.2. All fractures progressed to union with no cases of radiological avascular necrosis. We had 2 cases of mal-union (-one varus and one valgus-), both with a 2-suture technique. One patient had early loss of fixation; re-exploration was performed with stability conferred by a third lateral suture. Active abduction > 120o was achieved in 9 patients with a mean Constant score of 72 compared to 89 on the un-injured contra-lateral side. We have demonstrated that suture fixation of displaced proximal humeral fractures is an effective alternative to fixation using metalwork. The advantages are that minimal soft tissue stripping of the fracture site is required and the potential problems associated with metalwork insertion into osteoporotic bone are avoided. Following one case of varus mal-union with a 2-suture technique we now routinely use a third suture to act as a lateral tension band

Passive and active elbow flexion was performed in eight cadaveric arms to determine the effect of Type 1 coronoid fractures and suture repair on kinematics. Testing was performed in ligamentously intact and MCL deficient elbows; with radial head arthroplasty (RHA); with an intact coronoid, following a Type 1 fracture, and with suture repair of the coronoid. There was an alteration in elbow kinematics and stability following Type 1 coronoid fractures that was not corrected with coronoid repair. Suture fixation of the coronoid is probably unnecessary if the lateral ligaments are repaired and the radial head is repaired or replaced. To determine the effect of fixation of Type 1 coronoid fractures on elbow stability and kinematics in ligamentously intact and medial collateral ligament (MCL) deficient elbows with radial head arthroplasty (RHA). Type 1 coronoid fractures cause changes in elbow kinematics and stability that are not corrected with suture repair. Suture fixation of Type 1 coronoid fractures is probably unnecessary if the lateral ligaments are repaired and the radial head is repaired or replaced. With intact ligaments, there was an increase in valgus angulation following a Type 1 coronoid fracture (p< 0.05) that was not corrected with fixation. With MCL deficiency, there was no change in valgus angulation for all coronoid states. For both ligament states, there was an increase maximum varus-valgus laxity after a Type 1 coronoid fracture with forearm pronation (p=0.03) that was not corrected with fixation (p=0.4). Kinematic data was collected from eight cadaveric arms during passive and simulated active elbow motion. The protocol was performed in stable and MCL deficient elbows with RHA. Testing occurred with the coronoid intact, following Type 1 coronoid fracture, and with suture repair of the fracture. Valgus angulation and maximum varus-valgus laxity were measured. With intact ligaments, Type 1 coronoid fractures cause an alteration in elbow kinematics and laxity that is not corrected with suture fixation. With MCL disruption, Type 1 coronoid fractures have no effect on elbow kinematics and a small effect on laxity that is not corrected with coronoid repair. Funding: Research and Institutional Support received from Wright Medical Technologies. Please contact author for graphs and/or diagrams

We describe the technique of open reduction and fixation of displaced 2 and 3 part proximal humeral fracture, in which, two ‘figure of 8’ heavy braided sutures are passed through drill holes deep to the bicipital groove and passed through the fracture fragments and the cuff in a tension band fashion. A series of 12 patients, with a mean age of 65 years (range: 44–75 years), were reviewed at an average of 16 months (range: 4–18 months) after fracture fixation. The patients were assessed clinically, and radiographic evaluation of fracture healing, avascular necrosis and malunion was performed. Any complications of treatment were noted. All fractures united with no evidence of avascular necrosis. There was some varus deformity in two cases. There was one early loss of reduction but stability was re-established at re-exploration. Good or excellent clinical results were obtained in 10 patients according to the Constant score. Active abduction > 120° was achieved in 75% (nine patients). Paired suture fixation is an effective means of achieving stabilisation after open reduction of displaced two and three part proximal humeral fractures, with a low rate of non-union while preserving a good functional range of motion. The advantages of this technique are the minimal soft tissue stripping and the avoidance of complications associated with metalwork

A previous study done in our unit showed good results in terms of union, stability and function following 2-suture repair of proximal humeral fractures. Healing took place usually with a mild degree of varus angulation but one failure of this technique when the fracture slipped into varus prompted us to re-evaluate our technique. The addition of a third (lateral) suture to the repair has been used as routine following this. A prospective series of 24 patients with displaced Neer 2 and 3 part proximal humeral fractures was studied. The patients were reviewed at a mean of 22.5 months post fixation. The patients were reviewed clinically and graded according to the Constant Shoulder Score to assess range of movement, power, function and pain. This was compared to the contralateral uninjured shoulder. Radiographic evaluation of fracture union, avascular necrosis and malunion was performed, and any complications of treatment were noted. There were 24 2- and 3-part fractures. All the fractures united with no radiological evidence of avascular necrosis. At follow-up there was a mean Constant Score of 71.05 compared with a mean score of 84.5 on the uninjured contralateral shoulder. Active abduction of > 120° was achieved in 9 patients. Intraoperative stability in the varus/valgus plane was noted to be better. All patients were satisfied with the results; the problem of instability in the coronal plane has not been a problem and the fractures have healed with no varus mal-union. There have been no additional complications with this technique compared to the 2-suture method. We have successfully achieved stability after open reduction and suture fixation of 2- and 3-oart fractures of the proximal humerus. Following one case of varus instability using a 2 suture technique,. We have routinely supplemented this with a third (lateral) suture. There have been no additional complications using this method, the angulation of the fractures once healed are improved and none of the repairs have had a problem with varus slip

Purpose of the study: We describe a new modified arthroscopic technique of surgically treating avulsion fractures of the tibial eminence using the Scorpion device (Arthrex, Naples, FL).

Methods and results: A 57 year-old female who sustained a type II fracture of the tibial spine was treated with arthroscopic fracture fixation using the Scorpion device to place a whip stitch into the substance of the anterior cruciate ligament (ACL). Tibial tunnels were made on the anteromedial aspect of the tibia using the Acufex ACL guide (Smith and Nephew, Mansfield, MA) and the sutures were passed through these tunnels and tied over a bony bridge. At 6 months after surgery, the patient was asymptomatic and had returned to her daily activities. She had regained full range of movement and had a clinically stable knee, confirmed on KT 2000 arthrometer. Radiographs showed anatomic reduction and fracture union.

Conclusion: The Scorpion device which is commonly used in arthroscopic shoulder surgery provides significant advantages as it can be used arthroscopically to place a whip stitch in the substance of the ACL. The hook at its end can be used to retrieve suture loop from the joint, thus reducing instrumentation and operating time. It is a user friendly arthroscopic technique that restores the necessary tension in the ACL, provides stable fracture fixation, and also results in a cosmetic end result.

Akins original description of his osteotomy did not describe the use of any metal work. Today the osteotomy is most commonly held and fixed with either a staple or screw. We describe the results obtained with a simple suture technique. Methods Data was collected prospectively on 125 patients undergoing an Akin osteotomy. Hallux valgus (HV) and intermetatarsal (IM) angles pre and postoperatively were recorded. Patients were reviewed at 6 week follow up. Cost analysis was also performed comparing different fixation types.

111 of the patients were female and 14 male. The average age at time of surgery was 49 years. 104 cases were in conjunction with hallux valgus correction while 21 cases were for hallux interphalangeus. The mean preoperative HV angle was 33.3 degrees (range 22 to 53), and the IM angle 13.3 degrees (range 9 to 25). At the 6 week follow up all patients had shown signs of radiological union. The postoperative HV angle was 12.4 degrees (range 7 to 17) and the IM angle 6.4 degrees (range 5 to 11). All patients maintained their correction. There were no complications, infections or fixation problems. All patients were satisfied with their surgery and would have it repeated again. The suture technique was the most cost effective method.

We describe a quick, easy, implant free method of fixing the Akin osteotomy. There is no need for metalwork removal and in today's world of austerity and the current climate of widespread budget constraints we describe a cost effective method which is clinically just as effective as methods requiring a staple or screw.

Between October 2006 and September 2007, eight consecutive patients with syndesmotic diastasis of the ankle had Tight Rope suture –endobutton fixation. We present our early results following this fixation. There were 3 males and 5 females with a mean age of 42 years (range 21 – 67). All were followed up for a mean of 7 months. Five patients had right side involvement. Majority were twisting injuries. These patients were compared with a cohort group (10 patients) who had diastasis screw fixation for similar fractures during the same period. Results: The mean post operative Olerud & Molander ankle subjective score was 86 points. The tourniquet time was significantly less in endobutton group compared to the diastasis screw group(mean of 56 minutes vs. 72 minutes). There was some difference in time to mobilisation between the two groups (mean of 10 days). The endobutton group patients were able to return to work and leisure activities earlier (mean of 4 weeks) compared to the diastasis group. Range of motion was similar in both groups. There were fewer complications in both groups with superficial infection and stiffness being the most common. Both groups were satisfied with the fixation. Advantages of Tight rope fixation: The tourniquet time was reduced; there was no need for 2nd operation with its attendant risks. Earlier mobilisation was possible leading to early return to work and leisure activities. We recommend the use of this new suture endobutton fixation for ankle diastasis with promising early functional results. Further prospective studies are needed to evaluate this new type of fixation device

Abstract. Background. Aim of this study is to determine the difference between re-operation rates after conventional Methods of fixation of patella fractures using Metallic implants and novel technique of all suture fixation using Ethibond or fiber tape. Methods. This is a retrospective comparative analysis involving 62 patients who had a transverse patellar fracture and underwent surgery between January 2013 to December 2021. Selected patients were divided, based on different fixation methods used, into four groups - TBW group, CC screw group, Encirclage group and Suture Fixation Group. Patients were followed till bone union was evident on radiographs. Number of patients in Metallic implant group undergoing repeat operation were compared with the patients who underwent patella fracture fixation using all suture technique. Mean and standard deviation (SD) were calculated for all continuous variables. Mean of the two groups was compared using unpaired t-test. Results. TBW was the most common method of fixation used in 41(66.1%) patients. 7 patients each underwent surgery using CC screw, Encirclage +/− TBW, and suture fixation respectively. Bone union was seen in about 85% of patients in all the groups suggesting all treatment modalities lead to good fracture healing. 15 patients(36.6%) of patients in TBW group and 3 patients(42.9%) in encirclage group had implant removal because of hardware-related complications (p<0.001). None of the patient who underwent All suture Fixation underwent re-operation. Conclusion. The results suggest that Suture fixation of patellar fractures is a valid treatment modality giving excellent results with similar bone union rates without any complications

Abstract. Introduction. All-tissue quadriceps tendon (QT) is becoming an increasingly popular alternative to hamstrings tendon (HT) and bone-tendon-bone (BTB) autograft for anterior cruciate ligament (ACL) reconstruction. The relatively short graft length however dictates that one, or both, ends rely on suture fixation. The strength of this construct is therefore extremely important. This study evaluates whether the use of a novel fixation technique can improve the tensile properties of the construct compared to a Krackow suture, and a looped tendon (suture free) gold standard. Methods. Eighteen porcine flexor tendons were tested, across three groups; suture-tape Krackow, looped tendon, and the novel ‘strain suture’. Biomechanical testing simulated the different stages of ACL graft preparation and loading (60N preload for 10 minutes, 10 cycles from 10N to 75N, and 1000 cycles from 100N to 400N). Elongation and load to failure were recorded, and stiffness calculated for each construct. Results. The mean elongation was significantly improved for the strain suture compared to the suture tape Krackow for preload, 10 cycle and 1000 cycle testing protocols respectively (1.36mm vs 4.93mm, p<001; 0.60mm vs 2.72mm, p<0.001; 2.95mm vs 29.08mm, p<0.001). Compared with the looped tendon, the strain suture demonstrated similar results for preload and 10 cycle elongation, but greater elongation during the 1000 cycle stage. Stiffness of the latter two constructs was similar. Conclusions. Augmentation of the suture fixation using this novel technique provides a construct that is significantly superior to currently practised suture techniques, and similar in elongation and stiffness to a looped graft

The Bernese periacetabular osteotomy (PAO) is a well-established procedure in the management of symptomatic hip dysplasia. The associated Smith-Petersen exposure offers excellent visualization of the acetabulum and control of acetabular osteotomy and mobilization. The traditional exposure of the true pelvis involves osteotomy of the iliac wing in order to mobilize the sartorial and inguinal ligament insertion. However, full osteotomy of the iliac spine may necessitate screw fixation if a relatively large segment of bone is included. A known complication with screw fixation of the iliac wing osteotomy involves failure of fixation and screw back out. Moreover, the screw may be irritative to the patient even in the setting of adequate fixation. A larger osteotomy may also injure the lateral femoral cutaneous nerve as it travels near the anterior superior spine. To minimize the risk of these potential complications, a wafer osteotomy may be used to develop a sleeve of tissue involving the sartorial insertion. Markings may be made so that the curvilinear incision is centered about the anterior-superior iliac spine (ASIS). The sartorial sleeve also mobilizes the entirety of the lateral femoral cutaneous nerve medially as it runs and branches to varying degrees in a fatty tissue layer in the tensor-sartorius interval directly beneath the subcutaneous layer, thereby affording protection throughout the procedure. When the ASIS is first osteotomized as a several millimeter-thick mobile fragment and reflected, the sartorius attachment to the mobile fragment of the wafer osteotomy may be preserved. Furthermore, the wafer osteotomy may be re-fixed to the stable pelvis during closure with simple heavy suture fixation alone, avoiding screw insertion or associated removal. Because only a wafer or bone is taken during the spine osteotomy, more bone is available at the ASIS for fixation of the mobile fragment after repositioning. In this technical note, we describe the wafer osteotomy technique in further detail. For any figures or tables, please contact authors directly

The aim of our biomechanical study was to find out whether the prosthetic design, especially of the metaphyseal part, and the type of tuberosity fixation influences the primary stability in shoulder arthroplasty. Materials and Methods: 16 fresh frozen human cadaveric humeri were dissected until only the rotator cuff remained. A four-part fracture was simulated by osteotomy. In a first step two types of shoulder prosthesis (open stem versus closed stem) were used. The Tornier Aequalis prosthesis (open stem) using suture fixation and the Mathys Affinis fracture prosthesis (closed stem) using cable fixation were implanted according to standard techniques. The specimens were then loaded into a servo-pneumatic testing device in 25° of abduction. In 20 consecutive cycles traction of 40 Newton was alternating exerted on the subscapularis and infraspinatus tendon, while a continuous force of 40 Newton was exerted on the greater tuberosity to simulate the pull of the m. supraspinatus. The motion of the fragments was recorded by 2 high speed cameras. The following parameters were investigated : Failure of osteosynthesis, intertuberosity motion, motion lesser tuberosity-shaft, motion greater tuberosity-shaft, motion metaphysis-shaft. After completing the first series the cable fixation exposed to be more stable. In a second series we compared cable versus suture fixation in the Affinis fracture prosthesis to find out whether the stability was depending on the prosthesis design. Results:. Series 1: The intertuberosity motion was significantly lower in the cable prosthesis. The tuberosity-shaft motion was significantly lower in the cable group for greater and lesser tuberosity. The metaphysis - shaft motion did not significantly differ in both groups. Series 2: The intertuberosity motion was significant lower when the tuberosities were fixed by cable. The tuberosity-shaft motion was significantly lower when cable fixation was used. The metaphysis-shaft motion was not significantly diverse. Conclusion: Highest primary stability of tuberosity fixation in trauma-arthroplasty of the shoulder was measured in cable fixation and closed stem. We proved that the kind of fixation was the most important factor determing the stability. Metaphyseal design was less important

We present a case series of patients who underwent 3 or 4 part proximal humerus fracture fixation using an intra-osseous suture technique. 18 patients are included in the study with follow up data obtained ranging from 1 to 4 years. Oxford Shoulder Scores (OSS) and range of movement measurements were taken for all patients. The mean OSS for the group was 50/60 with a mean forward flexion of 140°, abduction of 132°, external rotation of 48° and internal rotation to the level 10. th. thoracic vertebra. Three patients developed adhesive capsulitis, 2 requiring subsequent arthroscopic release. This data compares favourably to outcomes reported in the literature with hemiarthroplasty or locking plate fixation. An activity based costing analysis estimated that the treatment costs for proximal humerus fractures was approximately £2,055 when performing a soft tissue reconstruction, £3,114 when using a locking plate and £4,679 when performing a hemiarthroplasty. This demonstrates a significant financial saving when using intra-osseous fixation compared to other fixation techniques. We advocate the use of the intra-osseous suture fixation technique for certain 3 and 4 part fractures. It gives good functional outcomes, significant cost savings and potentially makes revision procedures easier when compared to other fixation techniques

Introduction. Hip abductor tendon tears have been referred to as “rotator cuff tears of the hip,” and are a recognized etiology for persistent, often progressive, lateral hip pain, weakness, and limp. Multiple repair techniques and salvage procedures for abductor tendon tears have been reported in the literature; however, re-tear remains a frequent complication following surgical repair. This study compares the short-term outcomes of open abductor tendon repairs with decortication and suture fixation (DSF) compared to a modified technique repair into a bone trough (BT), to determine best surgical results for large abductor tendon avulsions. Additionally, surgical treatment of small tears versus large tears was examined. Methods. The outcomes of 37 consecutive hip abductor tendon repairs treated between January 2009 and December 2017 were retrospectively reviewed. Large tears were defined as detachment of 33–100% of the gluteus medius insertion. There were 15 DSF and 10 BT cases. Postoperative pain, ability to perform single leg stance, hip abduction, and Trendelenburg lurch, were examined. Small tears (12 cases) were defined as having no gluteus medius avulsion from the trochanteric insertion and were comprised of longitudinal tears (repaired side-by-side) and isolated gluteus minimus tears (repaired by tenodesis to the overlying gluteus medius). Standard statistical analyses were utilized. Type I error for all analyses was set at α=0.05. Results. When comparing large tear repair outcomes, repairs into a BT had superior outcomes to repairs with DSF: 0 (BT) versus 6 (DSF, 40%) failure rate (p<0.05), and greater reductions in pain at one-year post surgery (Δ VAS: BT, −5.70±0.97 | DSF: −2.73±0.69; p<0.01), ability to perform a single leg stance and hip abduction (90% and 100% vs 47% and 73%) (p<0.05). Clinical strength ratings were higher for repairs into a BT, but this did not reach statistical significance. When comparing large to small tear repair outcomes, small tears were found to have lower VAS pain scores and higher clinical strength ratings during both the pre-op and 1-year post-op time points (p<0.05). A higher percentage of those with small tears were able to perform a single leg stance and hip abduction (100%) compared to those with large tears (64% and 78% respectively) (p<0.05). A significantly higher frequency of residual lurch was also observed for those with large tears; 56% compared to small tears at 0%. Conclusions. Utilizing a BT repair significantly improved surgical results for large abductor tendon avulsions. Level of evidence: Therapeutic level IV case series

Purpose: The aim of this study was to evaluate the arthroscopic findings and treatment of chronic shoulder pain after minimally displaced greater tuberosity (GT) fractures. Material and Methods: Arthroscopy was performed in 12 patients (8m, 4f; mean age of 36 years) with more than 6 months of shoulder pain after sustaining a minimally displaced GT fracture (inferior to 5 mms). 4 cases were associated with anterior shoulder dislocation. Results: Varied pathologic findings, some of them unsuspected, were observed in all cases, both at subacromial and glenohumeral level:. 5 cases of subacromial impingement secondary to protrusion of the proximal portion of the GT; 2 of them associated with Pasta lesion. 3 cases of unstable – non united bony fragments at subacromial level. 4 cases of isolated Pasta lesions, 2 pure tendinous and 2 “bony” with unstable osteocondral fragments. All lesions were arthroscopically treated: GT tuber-oplasty, repair of Pasta lesions, suture fixation of GT fragments. After minimum follow-up of one year, Constant and Simple Shoulder Test scores were significantly improved. Conclusions: Arthroscopy proved to be very useful to assess the varied etiologic factors for chronic shoulder pain in undisplaced GT fractures. Arthroscopic techniques are effective in managing GT malunions and tendinous and bony Pasta lesions

This paper reports a series of comparative tests in-vitro that examined how lateral meniscectomy and meniscal allografting affected tibio-femoral joint contact pressures. 8 Cadaver knees (age range 81 – 98 years) were loaded in axial compression in an Instron materials testing machine up to 700N for 10 seconds and pressure maps obtained from the lateral compartment using Fuji Prescale film inserted below the meniscus. This was repeated after meniscectomy, then after meniscal allografting with fixation by a bone plug for the insertional ligaments, plus peripheral sutures. Finally, the pressure when the allograft was secured by peripheral sutures alone was measured. Meniscectomy caused a significant increase in peak contact pressures (p=0.0002). Both of the reconstructive methods reduced the peak contact pressures significantly below that of the meniscectomised knee (p=0.0029 with bone block; p=0.0199 with sutures alone). A significant difference was not found between the peak contact pressures after the reconstructions and that of the intact knee (p=0.1721 with bone block; p=0.0910 with sutures alone). The peak pressures increased slightly when the allografts were converted from bone block to suture-only fixation (p=0.0349). The principal finding was that both of the meniscal allograft insertion techniques reduced the peak contact pressure significantly below that of the meniscectomised knee, so that it did not then differ significantly from the peak contact pressure in the intact knee. When the two fixation methods were compared, the loss of the bone plug attachment caused a small increase in peak pressure. This study suggests that meniscal allografting should have a chondroprotective effect and that there is a small advantage from adding bony fixation to suture fixation

Introduction. Syndesmosis injuries are significant injuries and require anatomical reduction. However, stabilisation of these injuries with syndesmosis screws carries specific complications and many surgeons advocate a second operation to remove the screw. Primary Tightrope suture fixation has been shown to be an effective treatment for syndesmotic injuries and avoids the need for a second operation. Materials and Methods. A retrospective audit identified patients who were treated for syndesmosis injuries over a two year period. Theatre and clinic costs were obtained to compare the cost of syndesmosis fixation using diastasis screws with the estimated cost of primary syndesmosis fixation using a Tightrope suture. Results. 79 patients received diastasis screw fixation of syndesmosis injuries between January 2007 and January 2009. The mean number of follow up clinic appointments was 3.7 following initial surgery, and 2.2 following diastasis screw removal. Allowing for device, theatre time and clinic appointment costs, and an estimated average of 4 follow up appointments following Tightrope syndesmosis fixation, primary fixation with this device could a saving of 34 theatre slots, 68 outpatient clinic appointments, and £12,138 per year at our hospital. Discussion. Biomechanical studies have demonstrated a reduction in normal tibiotalar external rotation with the presence of a diastasis screw, and there are several published reports of complications when these screws are retained. The Tightrope suture provides reduction of the syndesmosis whilst allowing normal physiological movement at the distal tibiofibular joint and negates the need for a second operation to remove the implant. In addition there may be improvements in foot and ankle scores and a faster return to work when these devices are used compared with traditional screw fixation. Conclusion. In addition to the patient benefits, our audit suggests that there may be significant financial benefits associated with primary syndesmosis fixation with Tightrope sutures

Introduction. In order to prepare hamstring autograft, suture fixation to the tendon is required to secure and handle the tendon during harvest and preparation. We use a simple, grasping suture which doesn't require suture of the tendon, thus saving time and avoiding violation of the graft itself. We present this technique, with results of mechanical testing compared to a standard whip suture, traditionally used to handle hamstring autograft. Methods and materials. Twelve uniform ovine flexor tendons were prepared. A number two braided polyester suture was used in all cases. Six tendons were prepared with a standard, non-locking whip-suture, maintaining uniformity of suture bite and working length between samples. Six tendons were prepared with the utility suture, also taking care to maintain uniformity. The suture was applied by tying the thread around the tendon with a single-throw granny knot then symmetrically wrapping the suture ends from proximal to distal and securing with another single throw, allowing compression of the tendon with longitudinal tension on the suture. All the samples were tested to failure in uniaxial tension in a materials testing machine. Peak load values and load/displacement curves were acquired and results analysed with a two-sample T-test assuming significance at P<0.05. Results. Modes of failure between the groups, as characterised by the load/displacement curves were quite distinct. Peak load to failure was lower in the utility suture group but all failures occurred when the suture snapped. Thus the peak load to failure of the suture/tendon construct exceeded the breaking strain of the suture material. Conclusion. The grasping utility suture described here is sufficiently strong to harvest and handle hamstring autograft without passing a needle through the graft, saving time and avoiding violation of the graft itself. The lower loads at failure, despite failure occurring due to suture snapping, may reflect differing knot orientation between groups

Successful ORIF of proximal humeral fractures requires a careful assessment of the patient factors (age/osteoporosis/functional expectations), accurate identification the fracture segments (head/shaft/tuberosities) and accessory factors which are of vascular and surgical relevance (length of posteromedial metaphyseal head extension, integrity of medial soft tissue hinge, head split segments, tuberosity/head segments impacted to-gether or distracted apart). Fixation of the fracture can be achieved by a number of techniques because of the multiple factors that often apply—numerous techniques are usually required of the surgeon. The principles of fixation require accurate restoration of the head and tuberosity orientation, fixation of the metaphyseal segments (tuberosities) results in a stable circular platform on which the head segment rests. Thus, the fixation of choice acts as a load sharing device not a load bearing device. This fixation is often augmented with tension band and circlage suture fixation. These concepts are especially applicable to the osteoporotic patient. The order of fixation requires that the medial hinge not be disrupted. If it is disrupted in the younger patient it requires fixation first. All tuberosity segments are tagged with ethibond sutures. The head and the largest tuberosity segment are reduced and held with k-wire or canulated scews, avoiding the central medullary canal entry point. If the head tuberosity segment is unstable in relation to the shaft, the fixation implant of choice (plate/intramedullary) is chosen and the head/tuberosity complex is reduced to the shaft. Depending on the fracture segments and the degree of comminution this may require compression of distraction. Post-op the patient is immobilised in external rotation to balance the cuff forces. If very rigid fixation is achieved then early mobilisation is undertaken to minimise the adhesions due to opening of the subdeltoid space. If fixation is tenuous movement is commenced a 3–4 weeks. AVN of the humeral head with good tuberosity head architecure can be salvaged. The diagnosis of AVN is determned at three months with a MRI and consideration given to Zolidronate therapy. Post-traumatic stiffness with good architecture can be salvaged with an arthroscopic capsular release

Displaced proximal humeral fractures are common fractures with high complication rate especially in osteoporotic elderly population. The purpose of our clinical prospective case series was to evaluate the Philos locking plate developed by AO/ASIF in surgical treatment of these difficult fractures. Between October 2005 and March 2007 42 patients were included in the study group. The patients were divided in two groups based on the age at the time of presentation. Group A consisted of patients younger than 65 years old; 14 male, 9 female; mean age 43.8 (24–63 years old) and group B were patients above the age 65; 16 female, 3 male; mean age 77.3(66–90 years old). All fractures were classified according to AO/ASIF classification and radilogical and functional outcomes were assesed. Mean follow up was 7.8 months. The mean Constant scres were 86.3(71–92) in group A and 84.7(68–92) in group B (p> 0.05). All fracture healed uneventfully and no implant failure was observed. Displacement of tuberculum majus fragment was observed in only one case. Avascular necrosis of the humeral was not observed in any case. This prospective study proved that when technical details are followed and supplementary suture fixation of the tubercular fragments to the plate is obtained locking plate fixation of these problem fractures in every age group has a very high radiological and functional success rate. Especially in fixation of osteoporotic fractures lack of fixation failure and initiation of early range of motion is a major advantage

Purpose: Injury to the distal radioulnar joint can result in ulna sided wrist pain and instability. Stabilisation of the distal radioulnar ligaments described by Adams and Berger uses a tendon graft run along the anatomical course of the distal radioulnar ligaments from the lip of the radial sigmoid notch to the fovea of the ulna. The graft wraps around the ulna head and is fixed with a simple suture; this can be challenging for the surgeon and requires a considerable length of tendon. The length of graft required could be reduced by fixing the graft directly to the ulna. Alternative fixation methods when the graft is short would include bone anchors and interference screws. We therefore compared the fixation strength achieved with simple suture, by bone anchor and by interference screw (Mini Bio-suture Tack and 3mm Biotenodesis interference screw, Arthrex, UK). Methods: Four ulna bones were harvested along with four corresponding tendons. Tendons were divided into 2mm wide strips and run through a 3.5mm hole in the ulna. Maximum load was measured after fixing the tendon with 1) simple suture, 2) a bone anchor, and 3) an interference screw. Paired data was tested with the paired T-test and Wilcoxon test. Results: Maximum load recorded was highest for the Mini Bio-Suture Tack bone anchor (99.28 ± 47.39) followed by the simple suture method (96.23 ± 24.14 N), and the Biotenodesis interference screw (46.90 ± 11.29). Differences approached significance when comparing simple suture fixation with interference screws (p=0.02/0.068). Conclusions: No study has investigated the use of interference screws to secure two tendons in one graft tunnel. Previous work using a single graft and a single tendon has consistently shown that interference screws are superior to other methods of fixation. However, when performing Adam’s procedure for stabilisation of the distal radioulnar joint suturing the tendon together or using a bone anchor provide the greatest fixation strength. This might be due to loss of the interference effect when placing two grafts in the tunnel