Aims. Long-term outcomes following the use of human dermal allografts in the treatment of symptomatic irreparable rotator cuff tears are not known. The aim of this study was to evaluate these outcomes, and to investigate whether this would be a good form of treatment in young patients in whom a reverse shoulder arthroplasty should ideally be avoided. Methods. This prospective study included 47 shoulders in 45 patients who underwent an open reconstruction of the rotator cuff using an interposition GraftJacket allograft to bridge irreparable cuff tears, between January 2007 and November 2011. The Oxford Shoulder Score (OSS), pain score, and range of motion (ROM) were recorded preoperatively and at one year and a mean of 9.1 years (7.0 to 12.5) postoperatively. Results. There was significant improvement in the mean OSS from 24.7 (SD 5.4) preoperatively to 42.0 (SD 6.3) at one year, and this improvement was maintained at 9.1 years (p < 0.001), with a score of 42.8 (SD 6.8). Similar significant improvements in the pain score were seen and maintained at the final follow-up from 6.1 (SD 1.6) to 2.1 (SD 2.3) (p < 0.001). There were also significant improvements in the ROM of the shoulder, and patient satisfaction was high. Conclusion. The use of an interposition human dermal allograft in patients with an irreparable rotator cuff tear leads to good outcomes that are maintained at a mean of nine years postoperatively. Cite this article: Bone Joint J 2022;104-B(1):91–96

The management of patients with massive irreparable rotator cuff tears (RCT) has traditionally proved challenging. This prospective study was undertaken with the aim to assess the overall functional outcome following the use of human dermal allograft in the reconstruction of massive irreparable RCT. 15 patients were included in the study, having a median age of 63 years. All patients underwent open reconstruction of massive irreparable RCT. None of the selected patients had evidence of significant gleno-humeral arthritis. All patients were evaluated pre- and post- operatively by the treating surgeon, and followed up for 12 months. The same physiotherapy protocol was prescribed for all patients. Initial and follow-up assessments were done at regular intervals using the Oxford and quick-DASH scoring systems. A very high patient satisfaction rate, with substantial improvement in pain and function was noted. There was substantial improvement in Oxford shoulder score from a mean of 23.3 to 8.7 (p<0.01), and a similar improvement in mean quick-DASH score from 50.3 to 23.0 (p<0.01). Of the 15 patients, 11 had an improvement of >10 in Oxford score, with these reporting a score of <10 after 12 months. None of the patients had any significant complications because of the surgery, and none had a deterioration in Oxford score from their pre-operative status. We found that Human dermal allograft is a very effective tool in the repair of massive irreparable RCT, with excellent follow-up results after one year

Shoulder istability is an increasing problem in the natonal rugby league. Arthroscopic stabilisation has become an acceptable form of treatment for this instability. This study details the results of surgery to 32 elite contact athletes from one NRL club— the North Queensland Cowboys. Thirty-two cases of shoulder stabilisation have been performed on the players from the North Queensland Cowboys since 2003. A case series presentation of these procedures and follow up shall be detailed. Thirty-two cases of instability surgery have been performed on North Queensland Elite Rugby League players. Five procedures were open, two bilateral and five for posterior instability. Two recurrences have been seen in the arthroscopically reconstructed group. The first developed a HAGL at his subsequent instability episode and required open repair. The second case was a player with significant ligament instability he eventually underwent bilateral open reconstruction. Arthroscipic stabilisation is an acceptable option for elite rugby league players; recurrence rates are low, range of motion loses are reduced and earlier return to play occurs, when compared to open stabilisation

Objective. The aim of this study was to assess the results of combined arthroscopically assisted posterior cruciate ligament reconstruction and open reconstruction of the posterolateral corner in patients with chronic (3 months or more) symptomatic instability and pain. Patients & methods. A retrospective analysis of all the patients who had a combined reconstruction of the posterior cruciate ligament and the posterolateral corner between 1996 and 2003 was carried out. Nineteen patients who had the combined reconstruction were identified from the database. All the patients were assessed pre- and post-operatively by physical examination and three different ligament rating scores. All the patients also had weight bearing radiographs, MRI scans and an examination under anaesthesia and arthroscopy pre-operatively. The PCL reconstruction was performed using an arthroscopically assisted single anterolateral bundle technique and the posterolateral corner structures were reconstructed using an open Larson type of tenodesis. Results. Pre-operatively all the patients had a grade III posterior sag and demonstrated more than 20 degrees of external rotation as compared to the opposite normal knee on the Dial test. The average follow-up was 66.8 months (range 24 -108). Post-operatively 7 patients had no residual posterior sag, 11 patients had a grade I posterior sag and 1 patient had a grade II posterior sag. Five of the 19 patients demonstrated minimal residual posterolateral laxity. The Lysholm score improved from a mean of 41.2 to 76.5 (P=0.0001) and the Tegner score from a mean of 2.6 to 6.4 (p=0.0001). Conclusions. We conclude that while a combined reconstruction of chronic posterior cruciate ligament and posterolateral corner instability does not restore complete anatomical stability, improvement in symptoms and function demonstrate its value in these difficult injuries

Introduction. Midcarpal instability is an uncommon but troublesome problem. Patients have loss of dynamic control of the wrist in pronation and ulnar deviation due to laxity of the volar wrist ligaments that is often congenital or due to minor trauma. For those in whom conservative measures fail, open ligament reconstruction or fusions have been described. Aim. We prospectively studied a series of fourteen patients who underwent arthroscopic thermal capsular shrinkage for midcarpal instability. Methods. All patients were assessed clinically and by fluoroscopy and arthroscopy to confirm the diagnosis. Wrist arthroscopy with four portals was performed and monopolar radiofrequency capsular shrinkage was performed using a 2.3mm probe. Post-operatively the wrist was immobilised in a splint for 6 weeks. Results. Fourteen wrists in eleven patients were treated. Mean length of follow-up was 44 months. Symptoms of instability never occurred in three wrists and rarely occurred in eleven. The patient's subjective overall assessment of the wrist was ‘much better’ in ten wrists, ‘better’ for one wrist and ‘worse’ for three wrists. These three cases had persistent pain but improvement of instability symptoms. Two of these cases belonged to the same patient who had Ehlers Danlos syndrome. All patients were satisfied with the outcome and would have the same procedure again. The mean pre-operative DASH score was 35.2 and 17.1 at the most recent follow-up. Mean flexion decreased by 25% and mean extension by 17%. There were no significant complications. Conclusion. Capsular shrinkage is an effective procedure for midcarpal instability. Although there are some concerns regarding deterioration of results over time as seen in shoulder instability, these mid-term results show that this is currently not a problem

We identified a series of 128 patients who had unilateral open reconstruction of the anterior cruciate ligament (ACL) by a single surgeon between 1993 and 2000. In all, 79 patients were reviewed clinically and radiologically eight to 15 years after surgery. Assessment included measurement of the Lysholm and Tegner scores, the ACL quality-of-life score and the Short Form-12 score, as well as the International Knee Documentation Committee clinical assessment, measurement of laxity by the KT-1000 arthrometer, a single-leg hop test and standardised radiography of both knees using the uninjured knee as a control. Of the injured knees, 46 (57%) had definite radiological evidence of osteoarthritis (Kellgren-Lawrence grade 2 or 3), with a mean difference between the injured and non-injured knees of 1.2 grades. The median ACL quality-of-life score was 80 (interquartile range (IQR) 60 to 90), the Lysholm score 84 (IQR 74 to 95), the Short Form-12 physical component score 54 (IQR 49 to 56) and the mean Hop Index 0.94 (0.52 to 1.52). In total 58 patients were graded as normal, 20 as nearly normal and one as abnormal on the KT-1000 assessment and pivot-shift testing. Taking the worst-case scenario of assuming all non-attenders (n = 48), two septic failures and one identified unstable knee found at review to be failures, the failure rate was 40%. Only two of the patients reviewed stated that they would not have similar surgery again. Open reconstruction of the ACL gives good, durable functional results, but with a high rate of radiologically evident osteoarthritis

Post traumatic myositisossificans is a benign condition of heterotropic ossification of unknown aetiology which typically is related to trauma from a single blow or repeated episodes of microtrauma. We describe an unusual case of myositis ossificans which developed as a complication at the donor site for hamstring autologous graft used in open anterior and posterior cruciate repair and posterolateral corner reconstruction in a 15 year old girl. Case report: A 15 year old girl sustained a closed traumatic dislocation of her left knee when she fell from a trampoline. She underwent emergency manipulation under anaesthetic and closed reduction followed by MRI scan which showed a complete disruption of the lateral collateral ligament complex, posterolateral corner injury, complete tears of the anterior and posterior cruciate ligaments and a partial tear of the medial collateral ligament. 13 days later she had an open reconstruction of her anterior and posterior cruciate ligaments with allograft and a repair of popliteus and lateral structures with Larson reinforcement with controlateral hamstring autologous graft. Eight months following open reconstruction the patient represented to her primary care practitioner with a painful lump in the postero-medial controlateral right thigh. MRI study showed that there was a lobulated hypervascular appearance with a thin enhancing rim of low signal on all sequences indicating calcification. An xray revealed a calcified mass consistent with the diagnosis of myositis ossificans. Discussion and conclusion: To date we have found no reported cases of myositis ossificans occurring as a result of surgery to harvest hamstring autograft in the setting of ligament reconstruction about the knee. We believe that this is an unusual complication of the donor site which needs awareness amongst clinicians involved in primary and revision cruciate ligament reconstruction. We suggest that a management strategy of surveillance for this lesion is appropriate and excision biopsy should be reserved for specific indications such as malignant features on imaging or mass effect

The surgical treatment of three- and four-part fractures of the proximal humerus in osteoporotic bone is difficult and there is no consensus as to which technique leads to the best outcome in elderly patients. Between 1998 and 2004 we treated 76 patients aged over 70 years with three- or four-part fractures by percutaneous reduction and internal fixation using the Humerusblock.

A displacement of the tuberosity of > 5 mm and an angulation of > 30° of the head fragment were the indications for surgery.

Of the patients 50 (51 fractures) were available for follow-up after a mean of 33.8 months (5.8 to 81). The absolute, age-related and side-related Constant scores were recorded. Of the 51 fractures, 46 (90.2%) healed primarily. Re-displacement of fragments or migration of Kirschner wires was seen in five cases. Necrosis of the humeral head developed in four patients. In three patients a secondary arthroplasty had to be performed, in two because of re-displacement and in one for necrosis of the head. There was one case of deep infection which required a further operation and one of delayed healing.

The mean Constant score of the patients with a three-part fracture was 61.2 points (35 to 87) which was 84.9% of the score for the non-injured arm. In four-part fractures it was 49.5 points (18 to 87) or 68.5% of the score for the non-injured arm.

The Humerusblock technique can provide a comfortable and mobile shoulder in elderly patients and is a satisfactory alternative to replacement and traditional techniques of internal fixation.

Purpose: Correction of residual clubfoot deformities remains a great surgical challenge, and treatment failure is not uncommon. Open surgical reconstruction often leads to more scarring, risk of neurovascular injury, and a stiff foot. The Ilizarov external fixator allows for osseous realignment without open incisions. The Taylor spatial frame (TSF) is a relatively new external fixator that is capable of simultaneous six-axis deformity correction. Our method applies the Ponseti principles of clubfoot correction to a two-stage TSF correction (i.e., varus and internal rotation correction and then equinus correction). The Ponseti type 1 frame is programmed to correct varus and internal rotation first and then equinus. The Ponseti type 2 frame follows the same sequence as the type 1 frame but includes a final phase in which the foot ring is cut on two sides to allow separate correction of forefoot cavus and adductus. We present our initial multicenter experience with this Ponseti-inspired method. Methods: During a five-year period, seventeen patients (22 feet) were treated for residual clubfoot deformities with the TSF. Nine patients had idiopathic clubfoot, five had arthrogryposis, one had myelomeningocele, one had developmental clubfoot, and one had clubfoot associated with fibular hemimelia. Eight boys and nine girls were treated. The average age was 6.5 years (age range, 1.75–15 years). Equinus, internal rotation, and varus were addressed in nine patients (Ponseti type 1 frame), equinus, internal rotation, and forefoot deformity (adduction and/or cavus) in six patients (Ponseti type 2 frame), and equinus only in two patients. All patients underwent correction with standard two-ring frames using a long bone program. Results: All frames were removed after an average of 3.6 months (range, 3–8 months). One patient had under correction of residual equinus, but all others achieved full correction of deformities. Complications included superficial pin site infection in nine patients, talar subluxation in one patient, and subluxation of the first metatarsophalangeal joint in two patients. Infections were successfully treated with oral antibiotics. The one case of talar subluxation was reduced by the residual TSF program. The subluxated great toe was pinned in a separate surgery in two cases. Conclusions: We believe that the Ponseti sequence of correction can be applied to older children with residual club-foot deformities even if they have previously undergone surgery. Our method with the TSF is a safe, accurate (computer-based), and effective treatment. It does not require open surgery, so the potential for scarring is minimized. It also allows for any subsequent treatments as needed. Significance: The Ponseti-inspired method of residual club-foot deformity correction with the TSF is accurate and is a viable alternative to repeat open surgical procedures

Objective: The aim of this study was to assess the results of combined arthroscopically assisted posterior cruciate ligament reconstruction and open reconstruction of the posterolateral corner in patients with chronic (3 months or more) symptomatic instability and pain. Patients & Methods: A retrospective analysis of all the patients who had a combined reconstruction of the posterior cruciate ligament and the posterolateral corner between 1996 and 2003 was carried out. Nineteen patients who had the combined reconstruction were identified from the database. All the patients were assessed pre and post-operatively by physical examination and three different ligament rating scores. All the patients also had weight bearing radiographs, MRI scans and an examination under anaesthesia and arthroscopy pre-operatively. The PCL reconstruction was performed using an arthroscopically assisted single anterolateral bundle technique and the posterolateral corner structures were reconstructed using an open Larson type of tenodesis. Results: Pre-operatively all the patients had a grade III posterior sag and demonstrated more than 20 degrees of external rotation as compared to the opposite normal knee on the Dial test. The average follow up was 66.8 months (range 24–108). Post-operatively 7 patients had no residual posterior sag, 11 patients had a grade I posterior sag and 1 patient had a grade II posterior sag. Five of the 19 patients demonstrated minimal residual posterolateral laxity. The Lysholm score improved from a mean of 41.2 to 76.5 (P=0.0001) and the Tegner score from a mean of 2.6 to 6.4 (p=0.0001). Conclusions: We conclude that while a combined reconstruction of chronic posterior cruciate ligament and pos-terolateral corner instability does not restore complete anatomical stability, improvement in symptoms and function demonstrate its value in these difficult injuries

We identified ten patients who underwent arthroscopic revision of anterior shoulder stabilisation between 1999 and 2005. Their results were compared with 15 patients, matched for age and gender, who had a primary arthroscopic stabilisation during the same period.

At a mean follow-up of 37 and 36 months, respectively, the scores for pain and shoulder function improved significantly between the pre-operative and follow-up visits in both groups (p = 0.002), with no significant difference between them (p = 0.4). The UCLA and Rowe shoulder scores improved significantly (p = 0.004 and p = 0.002, respectively), with no statistically significant differences between groups (p = 0.6). Kaplan-Meier analysis for time to recurrent instability showed no differences between the groups (p = 0.2).

These results suggest that arthroscopic revision anterior shoulder stabilisation is as reliable as primary arthroscopic stabilisation for patients who have had previous open surgery for recurrent anterior instability.

Posterolateral rotatory instability is the most common type of symptomatic chronic instability of the elbow. In this condition the forearm complex rotates externally in relation to the humerus, causing posterior subluxation or dislocation of the radial head. The lateral ligament complex, radial head and coronoid process are important constraints to posterolateral rotatory instability, and their disruption is involved in the pathogenesis of this condition. The diagnosis relies on a high index of clinical suspicion, active and passive apprehension tests, and examination under anaesthesia. Surgical treatment has given consistently successful results. Open reconstruction of the lateral ligaments with a tendon graft has been the procedure of choice, with arthroscopic techniques emerging as a potential alternative

We have assessed the clinical and radiological outcome of traumatic knee injuries resulting in open reconstruction of the posterior cruciate ligament using synthetic ligaments at the University of Toronto, Ontario. Pre and post-operative stress radiographs at 30 and 90 degrees were performed, along with IKDC, Lysholm and Tegner scoring. Between 1995 and 2002, 11 patients were operated on. The average time to surgery was 42.3 months (range 1 to 252 months). The average age at time of surgery was 34.1 (26 – 48). The length of follow up ranged from 6 to 87 months. IKDC scoring showed that no patient returned to normal. 5 were nearly normal, 4 abnormal and 2 severely abnormal. The average Lysholm score was 83 (58 – 95). 2 scored excellent, 6 good, 2 fair and 1 poor. The average Tegner score pre-injury was 6.3, prior to surgery 1.8 and post-operatively 3.9 (twice weekly jogging). Stress radiographs showed a decrease in antero-posterior laxity at 30 and 90 degrees although statistical significance was not achieved (p = 0.229 and 0.474 respectively). We conclude that PCL reconstruction restores the normal biomechanics of the knee allowing a more normal function. The synthetic ligament allowed early weight bearing and range of movement mobilisation. The Tegner scores showed a considerable improvement from pre to post-operative values. The stress radiographs showed a decrease in the antero-posterior laxity. Although the IKDC scores did not show any normal knees post-operatively, this was expected due to the severity of the initial injuries. The authors recommend the use of synthetic ligaments to reconstruct the PCL

We report a retrospective analysis of the results of combined arthroscopically-assisted posterior cruciate ligament reconstruction and open reconstruction of the posterolateral corner in 19 patients with chronic (three or more months) symptomatic instability and pain in the knee. All the operations were performed between 1996 and 2003 and all the patients were assessed pre- and post-operatively by physical examination and by applying three different ligament rating scores. All also had weight-bearing radiographs, MR scans and an examination under anaesthesia and arthroscopy pre-operatively. The posterior cruciate ligament reconstruction was performed using an arthroscopically-assisted single anterolateral bundle technique and the posterolateral corner structures were reconstructed using an open Larson type of tenodesis. The mean follow up was 66.8 months (24 to 110). Pre-operatively, all the patients had a grade III posterior sag according to Clancy and demonstrated more than 20° of external rotation compared with the opposite normal knee on the Dial test. Post-operatively, seven patients (37%) had no residual posterior sag, 11 (58%) had a grade I posterior sag and one (5%) had a grade II posterior sag. In five patients (26%) there was persistent minimal posterolateral laxity. The Lysholm score improved from a mean of 41.2 (28 to 53) to 76.5 (57 to 100) (p = 0.0001) and the Tegner score from a mean of 2.6 (1 to 4) to 6.4 (4 to 9) (p = 0.0001). We conclude that while a combined reconstruction of chronic posterior cruciate ligament and posterolateral corner instability improves the function of the knee, it does not restore complete stability

Special Report: The clinical limitations of surgery in high-level athletes have not been established. Rehabilitation protocols based on animal experiments may be misleading. Current rehabilitation protocols are based on clinical experience rather than experimental science. Fitness for return to sport requires functional goals to be achieved by each athlete. Three common injuries in rugby will be considered to illustrate criteria for safe return to sport: Anterior cruciate ligament reconstruction, open shoulder reconstruction for anterior instability and isolated posterior cruciate ligament injury treated non-operatively

We prospectively evaluated 61 patients treated arthroscopically for anterior instability of the shoulder at a mean follow-up of 44.5 months (24 to 100) using the Rowe scale. Those with post-operative dislocation or subluxation were considered to be failures. Logistic regression analysis was used to identify patients at increased risk of recurrence in order to develop a suitable selection system.

The mean Rowe score improved from 45 pre-operatively to 86 at follow-up (p < 0.001). At least one episode of post-operative instability occurred in 11 patients (18%), although their stability improved (p = 0.018), and only three required revision. Subjectively, eight patients were dissatisfied. Age younger than 28 years, ligamentous laxity, the presence of a fracture of the glenoid rim involving more than 15% of the articular surface, and post-operative participation in contact or overhead sports were associated with a higher risk of recurrence, and scored 1, 1, 5 and 1 point, respectively. Those patients with a total score of two or more points had a relative risk of recurrence of 43% and should be treated by open surgery.

We reviewed 15 patients, nine girls and six boys, with chronic anterior dislocation of the radial head which was treated by ulnar osteotomy, external fixation and open reconstruction of the elbow joint but without repair of the annular ligament. Their mean age was 9.5 years (5 to 15) and the mean interval between the injury and reconstruction was 22 months (2 months to 7 years). All radial heads remained reduced at a mean follow-up of 20 months (6 months to 5 years). Normal ranges of movement for flexion, extension, pronation and supination were unchanged in 96.1% (49/51) and worse in 3.9% (2/51). Limited ranges of movement were improved in 77.8% (7/9), unchanged in 11% (1/9) and further decreased in 11% (1/9).There were two superficial pin-track infections and two cases of delayed union but with no serious complications. Reconstruction of the radiocapitellar joint is easier using external fixation since accurate correction of the ulna can be determined empirically and active functional exercises started immediately. Only patients with a radial head of normal shape were selected for treatment by this method

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

Tunnel placement in Anterior Cruciate Ligament (ACL) reconstruction is the single most important variable that a surgeon can control in order to achieve a successful outcome. The femoral tunnel is more critical than the tibial. Audit tunnel positions after ACL reconstruction in a regional centre.We studied 114 patients undergoing primary isolated ACL reconstruction within a 12-month period. Case notes and radiographs were reviewed retrospectively. Tunnel position was assessed on lateral and AP radiographs of the knee. A review of literature established optimal tunnel position. Measurements of tunnel position were made according to the methods described by Jonsson. 16 surgeons (8 consultants and 8 registrars) performed 57 arthroscopic and 57 open reconstructions, using 24 hamstring and 90 bone-tendon-bone autografts. Femoral tunnel drilling was through the medial arthroscopic portal (24) or the tibial tunnel (90). 85 sets of radiographs were available for review (21 not performed post-operatively, 8 not found). In the sagittal plane, the femoral tunnel insertion should be within the posterior third along an extended Blumensaat’s line and the tibial tunnel between 41 and 49% along the tibial joint line from anterior to posterior. In the coronal plane, the tibial tunnel should exit between 41% and 49% along the tibial joint line, from medially. Our results showed that 65% of femoral tunnels were outside this position, 23% of the tibial tunnels out in the sagittal plane and 55% out coronally. Of those drilled through the medial portal, only 5% of the femoral tunnels were outside our recommended position. Clinical Governance demands that guidelines for best practice are established and that audit ensures these standards are met. Anatomical studies give useful data in determining acceptable standards, as demonstrated in our audit. To enable this it is imperative that post-operative radiographic assessment is performed routinely