This study was to evaluate the stability of a delta keel tibial tray using a block prosthesis and to determine whether a long intramedullary stem is a necessary adjunct to augment construct stability. An experimental technique was used employing strain gauges and deflection transducers to assess the stiffness and principle strains conferred to human cadaveric tibiae under various axial loading conditions.

As a control measure, tests were conducted in the absence of any bone loss, and repeated in a simulated bone defect treated with a metal block. The latter was analysed with and without augmentation of the tibial tray with an intramedullary stem. With axial loading of 2000N, the tray and block configuration resulted in 21% less proximal bone strain than the tray alone. The combined tray, block and stem resulted in 35% less proximal bone strain than the tray alone. Using the tray and block produced 1.06 times more deflection of the tibial tray and using the tray, block and stem 1.03 times more deflection of the tibial tray than the tray alone in the absence of a bony defect.

There was no statistical difference in overall construct stability (p < 0.05) despite the large strain-offsetting effect recorded using the tibial tray in conjunction with the block and stem

These results suggest that isolated bone defects that can be dealt with using a single block and modern standard tibial tray may not require additional supplementation with a long intramedullary stem.

This paper looks at technical details and other issues in 30 primary total hip arthroplasty procedures performed through a direct lateral exposure in which the skin incision was limited according to the preoperatively templated acetabular component external diameter (D), using a formula D/2 + 1cm. All patients were positioned in the lateral decubitis position and stabilised with a vacuum beanbag.

Unpaired t-tests were used to determine difference in outcome between these patients and those operated on conventionally. No differences were noted between the two groups with regard to preoperative diagnosis, Oxford Hip Score, Harris Hip Score, demographic details, and body mass index. No statistically significant differences were noted with regard to operation time, blood loss, postoperative narcotic requirements, time to mobilise, length of hospital stay, postoperative complications and six-week postoperative Harris Hip and Oxford Hip functional outcome scores.

The mini-incision technique does not appear to carry short-term advantages for the patients. We did not encounter technical problems, but the mini-exposure does create technical challenges that could potentially have an adverse effect on the ultimate outcome. We do not advocate its use.

This paper retrospectively reviews the type and outcome of shoulder surgery in 61 professional rugby players (mean age 24.7 years). All competed at provincial level or higher, with 20 competing internationally. Forty-three of the patients played the position of forward, while 33 played back. Most shoulders (41) were on the dominant side. Ten players had multiple procedures and over a seven-year period 76 procedures were performed. The procedures included 16 Latarjets, four arthroscopic stabilisations, four SLAP repairs, four arthroscopic shoulder decompressions, three biceps tenodeses, three HAGL repairs, two revision Latarjets, one posterior Bankart, one pectoralis major repair, one Weaver-Dunn and four combination procedures.

All but two players returned to their previous level of competition. The mean time to return to full contact participation was 3.6 months (1 to 12). The time to return was one month for an arthroscopic Mumford and six months for a stabilisation procedure.

The outcome of the shoulder Delta prosthesis in 22 men and nine women was prospectively studied. The mean age was 74 years (62 to 86). Indications for surgery were cuff deficient arthritis (18), fracture malunion (three), ‘pseudo-paralysis’ (six) and failed total prostheses (four). The mean preoperative Constant score of 39 increased to 69 (10 to 39) at 33 months postoperatively, with the major increases in the scores for active forward elevation and pain relief. The subjective satisfaction was 79%. Although this was a small series with a short follow-up, early results seem satisfactory.

In this prospective study of partial articular supraspinatus tendon avulsion (PASTA) lesions treated arthroscopically by an ‘all inside’ method, 12 patients (nine men and three women) with a mean age of 31 years (22 to 36) were followed up for a mean of 16 months (8 to 32). The deep partial rotator cuff tears were usually viewed from the glenohumeral joint side. Viewing the subacromial space usually revealed an entirely normal cuff with no sign of subacromial impingement. With the arthro-scope in the glenohumeral joint, the footprint area of the supraspinatus tendon was prepared and one or two anchors, each preloaded with two sutures, were passed through the rotator cuff into the footprint area of the greater tuberosity. The sutures attached to these anchors were passed through the tendon and tied in the subacromial space.

The Constant score improved from a preoperative mean of 72 to a postoperative mean of 91. The greatest increase was in power and overhead motion, especially abduction and external rotation.

PASTA lesions are difficult to diagnose, even with MRI. The ‘all inside’ method of arthroscopic repair obviates the need to detach intact fibres.

This study reviews the use of intramedullary fibular allograft in treating nonunion of the humeral neck in 11 patients. Nine women and two men with a mean age of 76 years (63 to 89) were followed up for a mean of 61 months (14 to 72). The nonunion was exposed through a deltopectoral approach and fibular allograft was inserted across the fracture site. As the fibula is a very dense cortical bone, a T-plate could then be applied to the humerus with the screws directed into the intra-medullary fibular peg. Supplementary corticocancellous bone from the iliac crest was used. Bony union was achieved in every case. The preoperative mean Constant score was 26 and the postoperative mean Constant score was 75. The most notable improvement was in patients’ ability to elevate the arm actively. Decreases in pain levels were observed but were less dramatic than the increases in function.

In a retrospective review, 38 consecutive Workers’ Compensation (WC) patients undergoing primary total knee arthroplasty (TKA) were matched to a cohort of non-WC patients for demographics and preoperative diagnosis. Outcome measures included the Knee Society Score (KSS), the Oxford Knee Score, the McGrory Modified Knee Score (MMKS), patient satisfaction and number of postoperative clinic visits. Unpaired t-tests were used to determine differences in outcomes. Pre-operative KSS, pain and flexion range as measured by KSS, and Oxford scores displayed no statistical differences. The differences in the two groups at six weeks was significant in respect of KSS (p =0.0005) pain as measured by KSS (p =0.015), and flexion range (p =0.012). At six months similar results were noted in pain as measured by KSS (p =0.018), Oxford scores (p =0.005) and flexion range (p =0.035), but KSS function was not significant (p =0.073). One-year Oxford scores (p =0.013) and flexion range (p =0.013) were statistically significant, as were MMKS (p =0.001), patient expectations (p =0.030), perceived quality of life (p =0.009), and number of postoperative clinic visits (p =0.003).

The short-term outcomes of primary TKA in patients receiving workers’ compensation benefits are inferior to those obtained by non-workers’ compensation patients. Workers’ compensation patients are seen more often for postoperative follow-up, which we would attribute to the persistence of subjective complaints following primary TKA.

The results of arthroscopic repair of tears of the sub-scapularis tendon in nine men and six women, ranging in age from 53 to 73 years, were followed up at a mean of 14 months (6 to 24). Three were complete tears, six 50%-tears and six 30%-tears. In seven patients there were associated tears of the supraspinatus and infraspinatus tendons, which were repaired arthroscopically during the same procedure.

In each case the subscapularis tear was identified. In most patients a biceps tenotomy was necessary. The subscapularis footprint was prepared and the tendon was repaired using one or two anchors, each with two sutures, depending on the size of the tear. The mean pre-operative and postoperative Constant scores were 48 and 88 respectively.

In most patients, power returned to almost normal and pain was almost completely relieved. Arthroscopic subscapularis repair is a relatively new procedure and seems to give good results.

In this study, 40 patients who underwent total hip arthroplasty (THA) and had a history of previous steroid injections were compared retrospectively with 40 carefully matched patients who underwent THA in the same period but had never received steroid injections. The development of sepsis under standard care was one of the outcome measures. This occurred in 20% of steroid patients within the first 36 months after THA, compared to 0% in the control group. Further, in a detailed analysis of Harris and Oxford scores, patients treated with steroid had a higher incidence of night pain, more severe pain, and greater loss of function in activities of daily living at one year. There were two revisions for deep infection in the steroid and control groups.

Based on the incidence of pain and infectious complications in the first postoperative year, and pending completion of the study, we provisionally suggest that steroid injection of hips may be ill advised in patients who are likely candidates for future THA.

Purpose: The purpose of this study was to analyse outcome of shoulder prostheses after radiotherapy, to define a specific clinicoradiological entity, and evaluate incidence of complications.

Material and methods: Fourteen shoulder prostheses were implanted in 13 women who had been treated for breast cancer with complementary radiotherapy and one man treated for Hodgkin’s lymphoma. The time from radiothearpy to implantation was 16 years, seven months. Two forms were identified on the preoperative x-rays: seven cases with typical avascular osteonecrosis according to the Arlet and Ficat classification, and seven cases with a radiographic presentation of arthritis or degenerative disease. Humeral prostheses were used in five cases and a total shoulder arthroplasty in nine.

Results: Four implants had to be removed, three for sepsis, and five patients required revision surgery. The mean postoperative Constant score for the ten prostheses still in place was 53.1 points with a mean elevation of 111° at three years seven months follow-up. The gain in pain score was 8.5 points with a mean result of 10.9 points. The results were different depending on the initial radiological form, with less favourable outcome observed in typical osteonecrosis.

Discussion: This study demonstrated a particular radio-clinical entity independent of classical osteonecrosis of the humeral head. The surgical procedure was more difficult and the outcome was less satisfactory than in the classical forms with a high rate of complications.

The proximity of neural structures to the coracoclavicular ligaments limits the amount of coracoid process that can be harvested. The purpose of this study of 100 dry human scapulae was to define the anatomic limitations.

We found the mean measurement of the horizontal arm of the coracoid process anterior to the conoid tubercle was 21.5 mm (SD 0.9 mm). In 10% of the scapulae, it was larger than 30 mm. In 66%, the posterior aspect of the conoid fused with the vertical ramus and the lateral lip of the suprascapular notch.

This amount of coracoid appears to be large enough to expand the glenoid vault, and to hold two AO small fragment screws. It can be safely harvested if the conoid ligament is respected. Partial sacrifice of the trapezoid ligament is unavoidable, but does not compromise coracoclavicular stability. If the coracoid osteotomy is extended medial to the conoid tubercle it encroaches on the vertical ramus of the coracoid and can damage the suprascapular nerve. Posterior advancement of the osteotomy can extend onto the anterosuperior glenoid.

We evaluated the clinical outcome of arthroscopic labroplasty in 56 patients treated for shoulder instability owing to ligamentous laxity.

In our technique, the antero-inferior labral capsular complex is detached and mobilised from the glenoid. It is advanced superiorly and plicated to create a new labrum, retensioning the capsule and decreasing the articular volume. Usually, a rotator interval plication is also added. Postoperatively, patients wear an adduction sling for three weeks, but movement is permitted within pain limits.

The mean time to follow-up, when patients were clinically reviewed and assessed on the Walch-Du Play score, was 26 months (12 to 74). No intra-operative complications or nerve injuries were encountered. There was a single failure with frank redislocation. The mean Walch-Du Play score was 88/100 (10 to 100).

Redundant capsule and a hypoplastic labrum are common in unstable shoulders owing to ligamentous laxity. The labroplasty creates a ‘bumper’ and addresses the excess of capsule. In our short-term experience, this arthroscopic technique is superior to the open capsular shift.

Between 1996 and 2001 we used a modification of the Latarjet procedure to treat 70 patients with bony insufficiency of the glenoid. Our modification involves detaching a long piece of coracoid and rotating it to match its concave inferior surface with the surface of the glenoid. The coracoid graft is placed extra-articularly and the capsule repaired with bone anchors to the edge of the glenoid.

Postoperatively no sling is applied and rehabilitation is started early.

At a mean of 24 months (9 to 72) patients were clinically reviewed and assessed on the Walch-Du Play score. The results were excellent in 68%, moderate in 6% and poor in 1%. There were no redislocations.

The results were most satisfactory in this group of patients, most of whom participated in contact sports, where soft tissue procedures (e.g., open and arthroscopic Bankarts) carry unacceptable failure rates.

The capsular shift procedure is done to treat instability due to ligamentous laxity. Usually there is no traumatic avulsion of the labroligamentous tissues.

In surgical repair the anterior labrum is separated from the glenoid. The labrum and attached ligaments are shifted superiorly and attached with bone anchors to the decorticated glenoid. The labrum and ligaments are rolled into a soft tissue ‘bumper’ (we refer to this as labroplasty). Arthroscopic rotator interval plication is added to the procedure.

For six months to six years we followed up 67 patients treated between 1994 and 2000. There were two cases of recurrent subluxation (3%). Patient satisfaction was high.

The acromion is a bony process that juts out from the lateral end of the scapular spine. It is continuous with the blade and the spinous process. The process is rectangular, and carries a facet for the clavicle. Inferiorly is sited the subacromial bursa. Inferior encroachment or displacement of the acromion can result in impingement.

The aim of this osteological study was to assess the presence of acromial displacement and variations predisposing to compaction of the subacromial space. Using the method described by Morrison and Bigliana, we assessed the scapulae of 128 men and women ranging from 35 to 92 years of age. We found a flat acromion in 30%, no hook in 48%, a small hook in 18% and a large hook in 4%. The presence of a hook was associated with a subacromial facet and a large hook with glenoid erosion.

This study confirms the presence of four types of acromion.

We discuss aspects of glenohumeral instability and rotator cuff tears in a clinically orientated approach, presenting a new way of quantifying structural bone loss from the anterior glenoid and defining the Glenoid Index as an indicator of the appropriate surgical approach to address anterior instability.

Repair of the rotator cuff depends on viable and functional muscular tissue. We discuss the potential for repair of the supraspinatus tendon in relation to the tangent sign, fat infiltration and retraction. Comparing MRI and arthroscopic findings, we highlight pitfalls in the diagnosis and repair of the subscapularis tendon.

Painful conditions of the acromioclavicular (AC) joint are common in South Africa, particularly among sportsmen. These conditions are often treated by open excision of the distal end of the clavicle, but an arthroscopic procedure offers many advantages.

From February 1994 to February 2000, we performed 138 procedures. The mean age of patients ({71% men and 29% women) was 29 years (19 to 53). In cases of rotator cuff impingement, arthroscopic acromioplasty was followed by clavicular excision via the subacromial route. With a normal acromion and rotator cuff the AC joint was approached through two superior AC portals, avoiding removal of the AC ligaments. In all cases a standard 3.5-mm arthroscope was placed in one portal for viewing and the mechanical shaver inserted through the other. About 7 mm to 8mm of bone was removed from the clavicle. Patients were in hospital for about a day and 87% were discharged the same day.

The mean follow-up time was 34 months (2 months to 4 years). Patient satisfaction was high in 32%, fair in 60% and poor in 8%. Most patients (92%) returned to all previous sports and activities.

We concluded that the arthroscopic Mumford procedure is at least as successful as its open equivalent. It can be done as an outpatient procedure and permits a rapid return to activities. Cosmesis is excellent and stability of the AC joint is preserved.

The rotator cuff is sited on the anatomical neck of the humerus and is formed by the insertion of the supraspinatus (SP), infraspinatus (IS), teres minor (TM) and subscapularis. All play a vital role in the movement of the glenohumeral joint, and the anatomy is of critical importance in arthroscopic rotator cuff repair. We undertook an osteological and gross anatomical dissection study of the insertion mechanism of these tendons, in particular the SP .

The SP inserts by a triple or quadruple mechanism. The ‘heel’ (medial) and capsule fuse, inserting into the anatomical neck proximal to the anterior facet of the greater humeral tubercle. The ‘foot arch’ inserts as a strong, flat, fibrous tendon into the facet. This area is cuboidal, rectangular, or ellipsoid, and measures 36 mm² to 64 mm². In about 5%, the insertion is fleshy (pitted), rendering it weaker than a tendinous attachment. The ‘toe’ lips over the edge of the facet laterally and fuses with the periosteum, fibres of the inter-transverse ligament and the IS. A proximal ‘hood’ of about 4 mm stretches down inferiorly and fuses with the periosteum of the humeral shaft. The subacromial or subdeltoid synovial bursa are sited laterally.

The IS and TM insert into the middle and posterior facets (225 mm and 36 mm²) at respective angles of 80° and 115°. The inferior portion of the TM facet is not fused with the shoulder capsule. The subscapularis inserts broadly into the lesser tubercle, and the superior fibres fuse with the shoulder capsule and intertransverse ligament. The insertion of the subscapularis does not contribute directly to the formation of the ‘hood’, which belongs exclusively to the SP, IP and TM.

This study confirms the complexity of the SP insertion and suggests that an unfavourable attachment or biomechanical anatomical malalignment may lead to eventual tendon/cuff degeneration.

We have long suspected that patients treated at our institution have narrower femoral canals than the literature suggests. This has implications when it comes to nail size and the question of using reamed or unreamed nails. Using CT analysis, we studied the morphology of the femoral isthmus.

We prospectively evaluated 30 men with a mean age of 26 years (20 to 35). Patients with previous femoral fractures were excluded from the study. A scanogram determined the level of the isthmus and axial cuts at this level accurately revealed canal size and shape.

We found a canal size of less than 12 mm in 62%. In a third of these, canal size was less than 11 mm. Axial cuts showed three types of femoral canals: 14 patients had thick femoral cortices and a narrow canal, seven had thin cortices and a wider canal, and nine had an oval canal, with the larger diameter in the sagittal plane.

If one adheres to the principle of reaming until cortical clutter is heard, the recommended 12-mm or 13-mm reamed femoral nail is not suitable for the majority of non-Caucasian men in our population. Larger nails may cause such complications as delayed union, nonunion and fracture. Smaller nails of 10-mm and 11-mm diameter result in satisfactory clinical and radiological outcomes.

The supraspinatus tendon (SP) often ruptures. Gray established that the tendinous insertion always attaches to the highest facet of the greater tubercle of the humerus. Our osteological study of 124 shoulders in men and women between the ages of 35 and 94 years refocuses on the humeral insertion of the SP in relation to infraspinatus (IS) and teres minor (TM).

We found type-I SFs (cubic) in 53 shoulders (43%) and type-II SFs (rectangular or oblong) in 21 (17%). Type-III (ellipsoid) SFs were present in 20 shoulders (16%) and type-IV (angulated or sloping) in 11 (9%). SFs were type V (with tuberosity) in 12 shoulders (10%) and type VI (pitted) in three (2%). The facet area of the SP, IP and TM varied from 49 mm, 225 mm and 36mm2. Of the three muscles, the IS facet was consistently the largest (p < 0.05) and shaped rectangularly.

The SP inserted in a cubic or rectangular facet format in 75% of people. SP facet-size may relate to tendon strength, degeneration and rupture. This information may contribute to the understanding of tears of the rotator cuff.

Traumatic atlanto-axial subluxation is a rare injury which may not be revealed on routine radiographs, especially when there is muscle spasm. We report on seven patients with atlanto-axial subluxation as a result of neck injury; only two of them had significant head injuries. Three patients presented with a neurological deficit attributable to the injury, one immediate and two with delayed onset. Traumatic atlanto-axial instability, occurring in an otherwise healthy patient, has a potential for neurological disaster; early consideration of operative treatment is indicated.

Isolated traumatic dislocation of the radial head in children is not as rare as sometimes supposed. Attention to detail in radiographic interpretation is the key to diagnosis. Early closed reduction and immobilisation in an above-elbow plaster in 90 degrees of flexion and full supination for three to six weeks is recommended. Seven cases are presented, two of which were treated operatively and had unsatisfactory results. The applied anatomy, management and complications are discussed.