Aims. To systematically review the efficacy of split
Rotator cuff pathology is the main cause of shoulder pain and dysfunction in older adults. When a rotator cuff tear involves the subscapularis tendon, the symptoms are usually more severe and the prognosis after surgery must be guarded. Isolated subscapularis tears represent 18% of all rotator cuff tears and arthroscopic repair is a good alternative primary treatment. However, when the tendon is deemed irreparable,
Aims. Favourable short-term outcomes have been reported following latissimus dorsi
Aims. Since long-term outcome of teres major
Background:. Massive rotator cuff tear can cause functional disability due to instability and degenerative changes of the shoulder joint. In patients with massive irreparable rotator cuff tear,
Progressive collapsing foot deformity (PCFD) is a complex foot deformity with varying degrees of hindfoot valgus, forefoot abduction, forefoot varus, and collapse or hypermobility of the medial column. In its management, muscle and tendon balancing are important to address the deformity. Peroneus brevis is the primary evertor of the foot, and the strongest antagonist to the tibialis posterior. Moreover, peroneus longus is an important stabilizer of the medial column. To our knowledge, the role of peroneus brevis to peroneus longus
We reviewed 11 patients who had been treated between January 1986 and June 1994 for severe foot injuries by
Introduction:. Peroneal muscle weakness is a common pathology in foot and ankle surgery. Polio, charcot marie tooth disease and spina bifida are associated with varying degrees of peroneal muscle paralysis. Tibialis Posterior, an antagonist of the peroneal muscles, becomes pathologically dominant, causing foot adduction and contributes to cavus foot posture. Refunctioning the peroneus muscles would enhance stability in toe off and resist the deforming force of tibialis posterior. This study determines the feasibility of a novel
Purpose. This study aimed to objectively define gait derangements and changes before and after Tibialis Anterior
Although it is generally accepted that surgical treatment is the treatment of choice in chronic TA ruptures, therapeutic options are difficult. Traditional options include grafts (natural, allografts and synthetic grafts) and end to end repair. Natural grafts described include fascia lata and plantaris tendon. Synthetic materials such as Dacrongrafts, Marlex mesh and carbon fibers have been used. There are significant complications from graft and end to end repair. These include wound necrosis, delayed union, infection, foreign body reaction and devastating tissue loss. Also functional results are suboptimal after delayed reconstruction.
Objective: To assess the efficacy of split Tibialis Posterior
Latissimus dorsi
Common peroneal nerve (CPN) palsy has been reported to be the most frequent lower extremity palsy characterized by a supinated equinovarus foot deformity and foot drop. Dynamic tendon transposition represents the gold standard for surgical restoration of dorsiflexion of a permanently paralyzed foot. Between 1998 and 2005, we operated on 16 patients with traumatic complete CPN palsy. An osseous tunnel is drilled from anterior tibialis tendon (ATT) bony insertion through the cuneiform bones in the direction of the third cuneiform, through which the ATT is extracted and then pulled proximally under the extensor retinaculum. New ATT origin on the third cuneiform is therefore created. A double
Surgical repair of posterosuperior rotator cuff
tears has a poorer outcome and a higher rate of failure compared
with repairs of supraspinatus tears. In this prospective cohort
study 28 consecutive patients with an irreparable posterosuperior
rotator cuff tear after failed conservative or surgical treatment
underwent teres major
Introduction and Aims: The role of
Massive, irreparable rotator cuff tears occur in about 15% of patients with ruptures of the rotator cuff tendons. There is no consistently agreed management for irreparable rotator cuff tears, however, latissimus dorsi
Background: Neglected ruptures of the tendoachilles pose a difficult surgical problem. Intervening scar tissue has to be excised which cannot be repaired by end-to-end anastamosis. Several techniques for reconstruction of chronic ruptures have been described. The flexor hallucis longus (FHL)
Introduction. The delayed presentation of Achilles tendon rupture is common, and is a difficult problem to manage. A number of surgical techniques have been described to treat this problem. We describe the use of Flexor Hallucis Longus (FHL) transfer to augment the surgical reconstruction of the delayed presentation of achilles tendon rupture. Materials and Methods. Fourteen patients with chronic tendo-Achilles rupture, presenting between April 2008 and December 2010, underwent surgical reconstruction and FHL transfer. Surgery was performed employing standard operative techniques, with shortening of the Achilles tendon and FHL transfer into the calcaneum with a Biotenodesis screw (Arthrex). VISA-A scores were performed preoperatively and six months postoperatively. Complication data was collected by review of the electronic patient record and direct patient questioning. Results. One patient died of an unrelated cause shortly before outcome scoring, and another patient was excluded because casting in the preoperative period prevented accurate scoring, although he achieved a good post-treatment score. Analysis was therefore carried out on twelve patients. Eleven of the twelve patients had significant improvement in their VISA-A score, with a mean improvement in score of 30 (p < 0.05). There were no significant complications in any of the patients. Conclusion. Our results show that FHL transfer in the management of chronic Achilles tendon rupture is a good, safe and reliable technique. There is excellent improvement in the mean VISA-A score, with no significant complications. Our results support the use of FHL
Introduction and Aims: While successful long-term results have been shown for ligament reconstruction–tendon interposition arthroplasty for treatment of thumb basal joint osteoarthritis, the need for invasive ligament reconstruction has not been established. In this study we describe long-term results utilising the technique of tendon interposition arthroplasty with dynamic
Introduction: Tibialis anterior
The “Knot of Henry” was dissected in 16 embalmed cadaveric feet to reveal the complex interconnections between flexor hallucis longus (FHL) and flexor digi-torum longus (FDL) tendons. Three distinct anatomical patterns were observed. Tension was applied manually to FHL or FDL proximal to the Knot. Digit movement was different depending on the anatomical pattern. FHL or FDL
We reviewed 19 patients (30 feet) with congenital vertical talus treated surgically between 1987 and 1999, 22 of them by the same surgeon. The etiological diagnosis was idiopathic in seven patients. Six patients had associated congenital abnormalities (four arthrogryposis, two digitotalar dysmorphism) and six had associated neurological abnormalities (three microcephalic, three spinal dysraphism). Only two patients had surgery after the age of 18 months. The mean age at surgery was 14.7 months (6 to 51). In 15 feet a two-stage procedure was performed. Lengthening of the extensor tendons, notably tibialis anterior, was followed six weeks later by posterior release. In 15 feet a one-stage procedure was done, with no lengthening of the extensors or transfer of tibialis anterior. The Kidner procedure was done in seven feet, but the tibialis posterior was never found to be subluxed and the procedure was abandoned. The calcaneocuboid joint was opened and pinned in eight feet. The peroneal tendons required lengthening in eight feet. At a mean follow-up of 5.8 years (2 to 13.5), results were excellent in 17 feet (normal forefoot and hind-foot). Results were good in seven feet (normal radiographs, normal hindfoot, but pronated forefoot). In four feet the result was fair (valgus hindfoot with a plantarflexion angle of the talus more than 35(). In one patient, the results in both feet were poor (uncorrected). All seven good results followed a two-stage procedure. We concluded that this was due to relative weakening of the lengthened tibialis anterior to the peroneus longus. Where necessary, plantarflexion of the talus should be corrected at operation, and this should be correlated with intra-operative fluoroscopy. Adequate reduction of the navicula inferomedially on the talar head obviates the need for
The equinovarus hind foot deformity is one of the most common deformities in children with spastic paralysis and is usually secondary to cerebral palsy. Split posterior tibialis
To describe and analyze the mid-term functional outcomes of a large series of patients who underwent the Hoffer procedure for brachial plexus birth palsy (BPBP). All patients who underwent the Hoffer procedure with minimum two-year follow-up were retrospectively reviewed. Active shoulder range of movement (ROM), aggregate modified Mallet classification scores, Hospital for Sick Children Active Movement Scale (AMS) scores, and/or Toronto Test Scores were used to assess functional outcomes. Subgroup analysis based on age and level of injury was performed. Risk factors for subsequent humeral derotational osteotomy and other complications were also assessed. A total of 107 patients, average age 3.9 years (1.6 to 13) and 59% female, were included in the study with mean 68 months (24 to 194) follow-up.Aims
Methods
Flat foot due to rupture of the tibialis posterior tendon has not previously been described in children. We present three young patients who developed unilateral pes planus after old undiagnosed lacerations of the
Introduction:. Reverse total shoulder arthroplasty (RTSA) has become an accepted surgical treatment for patients with severe deficiency of the rotator cuff. Despite the utility of RTSA in managing difficult shoulder problems, humeral rotation does not reliably improve and may even worsen following RTSA. Several approaches to increase active external rotation (aER) postoperatively have been proposed including the use of concomitant latissimus dorsi
Inability to actively supinate the forearm makes common activities of daily living and certain vocational activities awkward or impossible to perform. A total of 11 patients with deficient supination of the arm underwent transfer of the tendon of flexor carpi ulnaris to the split tendon of brachioradialis with its bony insertion into the radial styloid left intact. Active supination beyond neutral rotation was a mean of 37.2° (25° to 49.5°) at a minimum follow-up of three years, representing a significant improvement (95% confidence interval 25 to 50, p <
0.001). Functional evaluation of the hand after this transfer showed excellent and good results in ten patients and fair in one. The split tendon of brachioradialis as an insertion for transfer of the flexor carpi ulnaris appears to provide adequate supination of the forearm without altering the available pronation and avoids the domination of wrist extension sometimes associated with transfers of the flexor carpi ulnaris to the radial extensors of the wrist.
Among the most popular techniques for the management of radial nerve palsy is the transfer of the Pronator Teres (PT) to the Extensor Carpi Radialis Brevis (ECRB), of the Flexor Carpi Radialis (FCR) to the Extensor Digitorum Communis (EDC) and of the Palmaris Longus (PL) to rerouted Extensor Pollicis Longus (EPL). This retrospective study was undertaken to assess the outcome of flexor carpi radialis transfer in the treatment of radial nerve palsy. Twenty patients with a mean age of 36 years were included in this study. Surgical management, as described above, was decided since all patients had irreparable damage to the nerve. Parameters that were assessed included range of wrist motion, dynamic power of wrist flexion and extension, and radial and ulnar deviation and function. The average follow-up was 4.5 years. Compared to a control group of 10 volunteers of similar characteristics, all patients achieved a functional range of motion and satisfactory power of wrist motion. All patients returned to their previous occupation. Transfer of Flexor Carpi Radialis tendon for irreparable radial nerve palsy yields satisfactory results. Therefore, it can be expected that patients will obtain a functional range of motion as well as an adequate strength of motion.
Residual club foot (CTEV) is a challenging deformity which may require transfer of the tibialis anterior tendon to a more lateral position. The senior author has developed a modified SPLATT for residual forefoot supination in CTEV. We describe the SPLATT procedure and evaluate clinical and radiological outcomes of 11 patients(14 feet) (mean follow up 6.6 years; range 5.5–8.9) (mean age 6.9 years; range 2.9–10.0). Two patients had cerebral palsy, 1 spina bifida and 1 juvenile rheumatoid arthritis, the remaining 7 patients were ideopathic. Outcome measures based on patient centred assessment of function and foot appearance, by using the patient applied assessments of Chesney, Utukuri and Laaveg &
Ponsetti (there is increasing recognition that doctor-centred or radiograph-based scoring systems do not tally well with patient satisfaction). Objective assessment of outcome was provided by measurement of certain radiological parameters on the immediate pre-operative and the follow up weight-bearing radiographs (1st ray angle, talar-1st metatarsal angle, talar-2nd metatarsal angle, talo-calcaneal angle). The calcaneal line passing through the medial 1/3 of the cuboid or medial to the fourth metatarsal was also noted. The Blecks grade was recorded (pre-op 100% moderate-severe; post-op 88% mild-moderate). Parents assessed outcome based upon ‘best level of activity’, functional limitation and willingness to recommend treatment to others. Mean Chesney score at the time of follow up was 12.3 (8 to 15); mean Utukuri score was 15.8 (10 to 24); Laaveg and Ponsetti score was 81.5 (67 to 95). The best activity level achievable was ‘unlimited’ in 4 patients, ‘football’ in 4 patients, ‘running’ in 1 and limited by an associated condition in 2 patients (1 juvenile rheumatoid arthritis; 1 cerebral palsy related spastic paraparesis). All patients/parents indicated that they would undergo the same procedure again. One patient had delayed wound healing treated successfully with dressings. The 1st ray angle pre-operatively was 61.2°(range 50–70°), post-operatively it was 62.1°(range 50–81°). The talar-1st metatarsal angle was 28.8°(range 15–44°) pre-operatively and 19.1°(range 4–34°) post-operatively. The pre and post–operative talar-2nd metatarsal angles were 22.5°(range 0–35°) and 12.3(range 0–29°) respectively, the talo-calcaneal angle was 17.5°(range 10–35°) and 13.7(range 5–20°) respectively. The pre and postoperative lateral talo-calcaneal angles were 34.5°(range 25–40°) and 30.6(range 13–45°). The recognition that patient orientated subjective assessment is gaining in acceptance, and confirm patient satisfaction with function, cosmesis and pain levels with the SPLATT procedure. More traditional radiological outcome measures also confirm that the modified SPLATT is a safe, effective and acceptable procedure.
To determine the outcome after the Semi-tendinosis tendon was used in reconstruction of the Medial Patella-femoral ligament using a fixed dynamic stabilising structure. The Adductor Magnus tendon insertion at the Adductor tubercle of the medial femoral condyle was used as a dynamic and fixed stabilising point preventing patella subluxation. This is a constant landmark in most patients and eliminates the need to find the isometric stabilisation point of the Medial Patella-femoral ligament. The Semi-tendinosus tendon was routed from its distal tibia attachment through a drill hole in the patella from distal to proximal. It was then transferred sub-vastus around the Adductor Magnus femoral attachment and sutured back onto itself at the inferior patella pole. It was tensioned at 30 degrees of knee flexion. Between 2004 and 2011 forty knees were reconstructed using the Semi-tendinosus tendon combined with an extra-synovial lateral release. All had failed conservative therapy for repeated patella instability. Post-operatively the patients followed a strict rehabilitation protocol. At follow-up the patients were questioned for any symptoms of patella instability or dislocation. Any complications of the surgery were documented. Patients were examined for any signs of patella apprehension or abnormal patella tracking.Purpose of the study
Method
An inability to extend the hallux following trauma is most often observed after direct laceration to the Extensor Hallucis Longus [EHL]. Primary repair, subsequent splinting and appropriate rehabilitation best deal with this type of injury. Damage to either the EHL muscle belly or the motor nerve to EHL are uncommon causes of the dropped hallux and present difficult reconstructive problems. Damage to the motor nerve branch to EHL in isolation is an uncommon problem and as far as we are aware surgery to address this pathology has not previously been described in the literature. This problem can occur after a penetrating injury, high tibial osteotomy or intramedullary nailing of a fractured tibia. We describe the operative procedure, technique and outcome in two cases of extensor hallucis longus to extensor digitorum communis (EDC) transfer to overcome this problem. A longitudinal skin incision is made just lateral to the tibia in the distal anterior part of the leg. The extensor retinaculum is divided and the EHL tendon identified and divided just distal to the EHL musculotendinous junction. The extensor digitorum communis (EDC) is then identified and the proximal stump of EHL woven into the EDC. A Pulvertaft weave technique is used and secured with 3/0 Ethibond suture. The appropriate amount of tension is placed on the repair by simulating weight bearing on the foot, ensuring the great toe remains in the neutral position. The extensor retinaculum is then repaired with 2/0 Vicryl and the skin closed with interrupted nylon sutures. The wound is infiltrated with 0.5% Marcaine to aid postoperative pain relief. A protected active motion rehabilitation program follows the surgery. We have used this technique in two cases, both have regained active extension of the hallux.
FHL transfer for management of chronic Achilles' tendon ruptures is done both open and endoscopically. But there are no published studies comparing open and endoscopic results. Our study aims to compare them and determine the suitability of these methods. Fourteen patients were treated endoscopically while 26 with an open technique. Of the 26, fourteen had an open Achilles tendon repair and FHL transfer while 12 has only open FHL transfer. All the endoscopic patients had only an FHL transfer. We compared demographics, complications of the procedure, recovery times, return to work and strength after 1 year. We noted ATRS at 6 months and 1 year for all three groups. We also conducted an MRI scan of three patients each of the three groups to determine the state of Achilles tendon and FHL tendon after 1 year of surgery.Abstract
Introduction
Materials and methods
Specific brace-fitting complications in idiopathic congenital talipes equinovarus (CTEV) have been rarely described in published series, and usually focus on non-compliance. Our primary aim was to compare the rate of persistent pressure sores in patients fitted with Markell boots and Mitchell boots. Our additional aims were to describe the frequency of other brace fitting complications and identify age trends in these complications. A retrospective analysis of medical files of 247 idiopathic CTEV patients born between 01/01/2010 - 01/01/2021 was performed. Data was collected using a REDCap database. Pressure sores of sufficient severity for clinician to recommend time out of brace occurred in 22.9% of Mitchell boot and 12.6% of Markell boot patients (X. 2. =6.9, p=0.009). The overall rate of bracing complications was 51.4%. 33.2% of parents admitted to bracing non-compliance and 31.2% of patients required re-casting during the bracing period for relapse. For patients with a minimum follow-up of age 6 years, 44.2% required tibialis anterior
The December 2023 Children’s orthopaedics Roundup. 360. looks at: A comprehensive nonoperative treatment protocol for developmental dysplasia of the hip in infants; How common are refractures in childhood?; Femoral nailing for paediatric femoral shaft fracture in children aged eight to ten years; Who benefits from allowing the physis to grow in slipped capital femoral epiphysis?; Paediatric patients with an extremity bone tumour: a secondary analysis of the PARITY trial data; Split tibial
Background. Iatrogenic hallux varus is a rare complication after hallux valgus surgery. Operative treatment comprises a wide variety of techniques, of which the reversed transfer of the abductor hallucis tendon is the most recent described technique. Methods. This paper will present the long-term clinical results of the reversed transfer of the abductor hallucis longus. Therefore, we performed a prospective clinical observational study on 16 female patients. Our hypothesis is that the
Aims. Multiple secondary surgical procedures of the shoulder, such as soft-tissue releases,
Rotator cuff tears are the most common cause of shoulder disability, affecting 10% of the population under 60 and 40% of those aged 70 and above. Massive irreparable rotator cuff tears account for 30% of all tears and their management continues to be an orthopaedic challenge. Traditional surgical techniques, that is,
Purpose of study. Internal rotation (IR) contracture of the shoulder is a frequent complication of obstetric brachial plexus injury, even in the face of full neurological recovery. Surgical procedures to treat this complication include
Introduction. It has been postulated that a mild clubfoot does better than a severe clubfoot no matter what treatment course is taken. There have been previous efforts to classify clubfoot. For units worldwide that use the Ponseti Method of clubfoot management, the Pirani scoring system is widely used. This scoring system has previously been shown to predict the number of plasters required to gain correction. Our study aimed to investigate whether the Pirani score gave an indication of longer-term outcome using tibialis anterior
Deficiency in the gluteus medius and minimus abductor muscles is a well-recognised cause of hip pain and considerable disability. These patients present a management challenge, with no established consensus for surgical intervention. Whiteside in 2012 described a surgical technique for gluteus maximus
Massive posterosuperior cuff tears (mRCT) retracted to the glenoid are surgically challenging and often associated with high retear rates. Primary repair is a less-favourable option and other salvage procedures such as SCR and
Complications such as implant loosening, infection, periprosthetic fracture or instability may lead to revision arthroplasty procedures. There is limited literature comparing single-stage and two-stage revision shoulder arthroplasty. This study aims to compare clinical outcomes and cost benefit between single-stage and two-stage revision procedures. Thirty-one revision procedures (mean age 72+/-7, 15 males and 16 females) performed between 2016 and 2021 were included (27 revision RSA, 2 revision TSA, 2 failed ORIFs). Two-stage procedures were carried out 4-6 weeks apart. Single-stage procedures included debridement, implant removal and washout, followed by re-prep, re-drape and reconstruction with new instrumentations. Clinical parameters including length of stay, VAS, patient satisfaction was recorded preoperatively and at mean 12-months follow up. Cost benefit analysis were performed. Seven revisions were two-stage procedures and 24 were single-stage procedures. There were 5 infections in the two-stage group vs 14 in the single-stage group. We noted two cases of unstable RSA and 8 other causes for single-stage revision. Majority of the revisions were complex procedures requiring significant glenoid and/or humeral allografts and
Tendinopathy can commonly occur around the foot and ankle resulting in isolated rupture, debilitating pain and degenerative foot deformity. The pathophysiology and key cells involved are not fully understood. This is partly because the dense collagen matrix that surrounds relatively few resident cells limits the ability of previous techniques to identify and target those cells of interest. In this study, we apply novel single cell RNA sequencing (CITE-Seq) techniques to healthy and tendinopathic foot/ankle tendons. For the first time we have identified multiple sub-populations of cells in human tendons. These findings challenge the view that there is a single principal tendon cell type and open new avenues for further study. Healthy tendon samples were obtained from patients undergoing
The foot and ankle are very commonly affected in various paralytic conditions. Paralysis of different muscles acting on the foot results in characteristic gait aberrations. The gait abnormalities are a result of one or more of the consequences of paralysis including: loss of function, muscle imbalance, deformity and instability of joints. The aims of treatment of the paralysed foot and ankle are to: make the foot plantigrade, restore active dorsiflexion during the swing phase of gait (if this is not possible then prevent the foot from ‘dropping’ into plantar flexion during swing), ensure that the ankle and subtalar joints are stable throughout the stance phase of gait, facilitate a powerful push-off at the terminal part of the stance phase (if this is not possible, at least prevent a calcaneal hitch in terminal stance). The specific aims of treatment in each patient depend on the pattern and the severity of paralysis that is present and hence the aims are likely to vary. In order to determine what treatment options are available in a particular patient, it is imperative that a careful clinical assessment of the foot is done. Based on the clinical assessment, these questions need to be answered before planning treatment: What are the muscles that are paralysed What is the power of each muscle that is functioning? Is there muscle imbalance at the ankle, subtalar or midtarsal joints that has either already produced a deformity or has the potential to produce a deformity in future? Are there any muscles of grade V power that can be spared for a
Abstract. Introduction. Derby technique for posterolateral corner (PLC) reconstruction uses a doubled gracilis autograft to reconstruct the popliteo-fibular ligament (PFL) and a split biceps
This pilot study reports the clinical outcomes
of a combination of partial subscapularis
Introduction. Flexor Hallucis Longus (FHL)
Introduction The role of
Abstract. Background. Traumatic knee dislocations are devastating injuries and there is no single best accepted treatment. Treatment needs to be customised to the patient taking into consideration injury to the knee; associated neurovascular and systemic injuries. Objective. This study looked at functional outcome of a single surgeon case series of patients who underwent surgical management of their knee dislocation. Methods. Seventy patients with knee dislocation were treated with multi-ligament reconstruction at a major trauma centre. Acute surgical repair and reconstruction with fracture fixation within 3 weeks was preferred unless the patient was too unstable (Injury severity score>16). PCL was primarily braced and reconstructed subsequently, if required. Outcome was collected prospectively using IKDC score, KOOS and Tegner score. Results. The mean age of the patients was 35yrs (17–74), 53 males and 17 females. 5 patients had CPN injury (7%), 3 had vascular injury (4.2%), 2 had combined CPN and vascular injury (2.8%). Acute surgical treatment was done in 48 patients while 10 had staged reconstruction. 22 patients had delayed reconstruction. The mean follow-up period was 4.8 years (1–12 yrs). According to the IKDC score 67% of the patients had near-normal knee function. The mean Tegner activity scale postoperatively was 4.5 (preinjury 6.5) and the mean KOOS score was 75.3. Four patients had stiffness and needed arthroscopic arthrolysis, two patients had a residual foot drop from the original injury and needed
Abstract. Objectives. Achilles tendon ruptures are common in the UK, with data demonstrating a significant rise in incidence over the past years. Chronic Achilles ruptures have been less well defined in literature, and repair techniques vary significantly. A surge in publications reporting various management options for chronic Achilles ruptures has necessitated a review that systematically maps and summarises current evidence regarding treatments and identifies areas for future research. This scoping review aims to improve knowledge of various treatment strategies and their associated outcomes, thereby aiding clinicians in optimising treatment protocols. Methods. The Arksey and O'Malley, Levac and Peters frameworks were used. A computer-based search in PubMed, Embase, Emcare, Cinahl, ISI Web of Science and Scopus was performed for articles reporting the treatment of chronic Achilles ruptures. Two reviewers independently performed title/abstract and full text screening according to a pre-defined selection criteria. Results. A total of 747 articles were identified, of which 73 were finally included. Various management strategies were described with flexor hallucis longus
The purpose of this paper is to report on the use of a
Aims. Flexor hallucis longus (FHL)
Aims. To evaluate the donor site morbidity and tendon morphology after harvesting whole length, full-thickness peroneus longus tendon (PLT) proximal to the lateral malleolus for ligament reconstructions or
Introduction: In orthopaedic surgery,
In recently, reverse shoulder arthroplasty for rotator cuff deficient arthritis is widely used in the world. However, a high complication rate was reported and worried about long-term results after reverse shoulder arthroplasty. From 2001, we performed a novel strategy for these cases such as rotator cuff reconstruction w/ or w/o muscle transfer and a humeral head replacement with using smallest head to decrease joint volume. The aim of this study was to investigate with clinical outcomes after this surgery more than two years follow-up. Materials & methods. Fifty six shoulders underwent humeral head replacement (HHR) with or without
Fixation of
Most of the controversy surrounding management of the adult acquired flatfoot deformity revolves around the correction of Stage 2 deformity. Stage 1 deformity, uncommonly corrected surgically, involves tenosynovitis with preservation of tendon length and absence of structural deformity. Attempts at tenosynovectomy in light of structural deformity leads to operative failure, found in 10% of Teasdall and Johnson's 1992 patient population. Thus, with tenosynovectomy rarely becoming an operative situation, Stage 2 deformity becomes the mainstay of operative treatment of the adult flatfoot. Stage 2 deformity patients present with swelling medially, the inability to do a single heel raise, with a passively correctable subtalar joint. The tendon is functionally torn. In recent years, authors have subdivided Stage 2 deformity even further into A and B subcategories, where A involves less than 50% uncovering of the talonavicular joint, and B patients more than 50%. Recently, Anderson has added a C subtype, which may be applied to either A and B patients, in patients who have forefoot varus. Thus, Stage 2 patients suffer from pain that begins medially and progresses to the subfibular region over time. Most important, recognition of the continued sub classification in Stage 2 disease echoes the fact that this disorder is on a continuum, challenging the surgeon to recognize subtleties that, if unrecognized, lead to a poor patient outcome. The mainstay of treatment in Stage 2 disease is the medial slide calcaneal osteotomy, which realigns the hindfoot axis reducing valgus, improves the medial arch, protects the FDL
Pediatric hand surgery in general requires special considerations and this is even more true when planning surgery in children with CP. It is important for the surgeon to realize that the functional problems these children exhibit have their cause in a brain damage which is not amenable to hand surgical treatment. Therefore it is crucial to carefully analyze each child’s impairment including the voluntary motor control and the child’s specific needs before endeavoring into surgery. Associated impairments, such as mental retardation, nutritional problems, epilepsy, dystonia or severe sensory deficits may influence decision-making, but the crucial factor is often the child’s own wish for an improved function. A child that completely neglects his or her extremity is usually not helped by surgery, at least not in an attempt to get a better hand function. Hand surgery in CP mainly comes down to three techniques: 1. Reducing strength in spastic muscles by release operation, either at the origin of the muscle, at the insertion or as a fractional lengthening at the musculo-tendinous junction, 2. Increasing strength in weak antagonists by
Chronic massive irreparable rotator cuff tears represent a treatment challenge and the optimal surgical technique remains controversial. Superior capsular reconstruction (SCR) has been proposed as a means to provide superior stability to the glenohumeral joint, thus facilitating restoration of shoulder function. However, despite the growing use of SCR there is a paucity of data evaluating the outcomes when performed using a dermal allograft. The purpose of this study was to (1) report the overall survival rate (reoperation and clinical failure) of SCR (2) evaluate for pre-operative factors predicting reoperation and clinical failure. From January 1, 2015 to November 31, 2017, 65 patients were diagnosed with irreparable rotator cuff tears and consented for a superior capsular reconstruction. These surgeries were performed by 6 surgeons, all fellowship trained in either sports or shoulder and elbow fellowships. Outcomes were graded as excellent, satisfactory, or unsatisfactory using the modified Neer scale. An unsatisfactory result was defined as a clinical “failure”. The Kaplan-Meier survival models were created to analyze reoperation-free and failure-free survival for the entire group. The reconstruction was performed using a dermal allograft. There were 31 patients excluded due to insufficient follow-up (< 6 months), leaving 34 included in this study. The mean follow-up was 12 months (range, 6–23). The average number of prior surgeries was 0.91 (range, 0–5), with 52.9% of patients receiving a prior rotator cuff repair and 38.2% of patients with a prior non-rotator cuff arthroscopy procedure. The one and two-year survival-free of surgery was 64% and 44% and the one and two-year survival free of failure was 34% and 16% following SCR, respectively. For the patients that underwent a reoperation, 62.5% (n= 5/8) underwent reverse shoulder replacements, 25% (n= 2/8) latissimus dorsi
The interosseous route remains popular for tibialis posterior
Posterior tibial tendon dysfunction is a well-recognised condition. It commonly occurs in middle aged overweight women. In contrast to most tendon pathology, the tendon is still often intact and the tendon is stretched rather than completely ruptured. The diagnosis can be made on clinical grounds. Clinical features include acquired flatfoot deformity, inability to perform a single heel raise, ‘too many toes’ sign and loss of inversion power with the foot in forced plantarflexion. Disease is staged into four stages, Stage II is the most common presentation. Treatment options for Stage I are non-operatively including rest and antiinflammatories. Surgical treatment for this is required if this fails or progresses to next stage. Treatment for Stage II disease is most commonly a
Purpose. Management of massive, degenerative, and irreparable rotator cuff tears is challenging. Excessive re-tear rates and poor clinical outcome after standard repair have led to alternative methods of treatment.
We reviewed the results of a selective à la carte soft-tissue release operation for recurrent or residual deformity after initial conservative treatment for idiopathic clubfoot by the Ponseti method. Recurrent or residual deformity occurred in 13 (19 feet) of 33 patients (48 feet; 40%). The mean age at surgery was 2.3 years (1.3 to 4) and the mean follow-up was 3.6 years (2 to 5.3). The mean Pirani score had improved from 2.8 to 1.1 points, and the clinical and radiological results were satisfactory in all patients. However, six of the 13 patients (9 of 19 feet) had required further surgery in the form of tibial derotation osteotomy, split anterior tibialis
We reviewed the outcome of distal chevron metatarsal osteotomy without
Various surgical treatment were reported on rheumatoid shoulder. However, there were no recommended surgeries in the Japanese 2. nd. basic published text of rheumatoid disease. We had performed total shoulder arthroplasty(TSA) and humeral head replacement (HHR) in patient with Rheumatoid shoulder from 1992. The aim of this study was to compare the outcome of humeral head replacement, 2. nd. generation TSA and 3. rd. generation TSA in patients followed more than 5 years with rheumatoid shoulder. Material & Method. From 1992–2007, we performed shoulder arthroplasty in 42 shoulders in 40 patients. Six cases were not able to follow due to die and lost. All 36 shoulders in 34 patients could be followed with x-ray examinations more than 5 years. Averaged follow-up period was 8.6 years (range 5–14.5). HHR with intact cuff performed in 10 shoulders, 2. nd. generation TSA with intact cuff in 10, 3. rd. generation TSA in intact cuff in 10 and HHR with muscle
Our aim was to determine whether the length and function of the flexor carpi ulnaris muscle were affected by separating it from its soft tissue connections. We measured the length of flexor carpi ulnaris before and after its dissection in ten patients with cerebral palsy. After tenotomy, tetanic contraction shortened the muscle by a mean of 8 mm. Subsequent dissection to separate it from all soft tissue connections, resulted in a further mean shortening of 17 mm (p <
0.001). This indicated that the dissected connective tissue had been strong enough to maintain the length of the contracting muscle. Passive extension of the wrist still lengthened the muscle after tenotomy, whereas this excursion significantly decreased after subsequent dissection. We conclude that the connective tissue envelope, which may be dissected during
Purpose of the study: A stiff shoulder in internal rotation is a classical complication of obstetrical injury to the brachial plexus. The condition generally associates glenohumeral dysplasia. In 2003, Pearl proposed arthroscopic release of the shoulder, with or without latissimus dorsi transfer as an alternative to an open procedure. We report a series of 13 patients who underwent this procedure. Material and method: From 2004 to 2007, 13 children aged 1 to 11 years (range 3.5) underwent surgery. The procedure was an arthroscopic tenotomy of the intra-articular portion of the subscapularis associated with release of the anterior capsuloligament structures without
We have reviewed 38 surgically treated cases of spontaneous posterior interosseous nerve palsy in 38 patients with a mean age of 43 years (13 to 68) in order to identify clinical factors associated with its prognosis. Interfascicular neurolysis was performed at a mean of 13 months (1 to 187) after the onset of symptoms. The mean follow-up was 21 months (5.5 to 221). Medical Research Council muscle power of more than grade 4 was considered to be a good result. A further 12 cases in ten patients were treated conservatively and assessed similarly. Of the 30 cases treated surgically with available outcome data, the result of interfascicular neurolysis was significantly better in patients <
50 years old (younger group (18 nerves); good: 13 nerves (72%), poor: five nerves (28%)) than in cases >
50 years old (older group (12 nerves); good: one nerve (8%), poor: 11 nerves (92%)) (p <
0.001). A pre-operative period of less than seven months was also associated with a good result in the younger group (p = 0.01). The older group had a poor result regardless of the pre-operative delay. Our recommended therapeutic approach therefore is to perform interfascicular neurolysis if the patient is <
50 years of age, and the pre-operative delay is <
seven months. If the patient is >
50 years of age with no sign of recovery for seven months, or in the younger group with a pre-operative delay of more than a year, we advise interfascicular neurolysis together with
Purpose: Mal-tracking or dislocation of the patella is often the result of abnormal anatomy. Understanding the abnormal anatomy will clarify the treatment options available. The common anatomical causes of dislocation range from the valgus knee with an elevated ‘Q’ angle to patella alta with a hypo-plastic trochlea, to external tibial torsion, resulting in an excessive ‘Q’ angle. External tibial torsion results in symptoms ranging from patello-femoral pain to subluxation or dislocation. Many patients are asymptomatic prior to an injury. The decision to correct the underlying anatomical abnormality is often a difficult one. Methods: A retrospective study of 232 rotational HTO’s in 221 patients operated on between 1990 and 2003 was conducted. The pre-operative degree of external tibial torsion and ‘Q’ angle was noted as well as the degree of rotation. The extent, if any patello-femoral pathology, was noted. Assessment was carried out using the HSS scoring system and Lysholm score.|Notation was made of prior surgery to the knee ranging from arthroscopy to patella
Transfer of pectoralis major has evolved as the most favoured option for the management of the difficult problem of irreparable tears of subscapularis. We describe our experience with this technique in 30 patients divided into three groups. Group I comprised 11 patients with a failed procedure for instability of the shoulder, group II included eight with a failed shoulder replacement and group III, 11 with a massive tear of the rotator cuff. All underwent transfer of the sternal head of pectoralis major to restore the function of subscapularis. At the latest follow-up pain had improved in seven of the 11 patients in groups I and III, but in only one of eight in group II. The subjective shoulder score improved in seven patients in group I, in one in group II and in six in group III. The mean Constant score improved from 40.9 points (28 to 50) in group I, 32.9 (17 to 47) in group II and 28.7 (20 to 42) in group III pre-operatively to 60.8 (28 to 89), 41.9 (24 to 73) and 52.3 (24 to 78), respectively. Failure of the
The surgical treatment of chronic Achilles tendon ruptures is essential to restore the normal gait pattern. There are a variety of surgical techniques described, including primary repair, augmentation with
Introduction: Cavus deformity of the foot is defined as equinus (plantar flexion) of the forefoot in relation to the hind foot. In 1/2–3/4 of the children an underlying disease could be diagnosed, usually neuromuscular in origin. Pathomechanism. Gradual developing deformity caused by muscular imbalance, the intrinsic muscles of the foot being weaker as well as the foot dorsiflexors. Main deformities are: claw toes, flexion of the first metatarsal, heel varus and equinus. The deformities will become more rigid with increasing growth and/or progression of the underlying disease. Symptoms are: shoefitting problems, pain, callosities under the forefoot and lateral border, clumsiness during gait and running, tripping. Predominant ages are 8 – 12. Diagnosis: The primary goal is to establish or role out an underlying disease before adequate treatment can be applied. The examination should focus on detailed muscle function and joint mobility. Standardised standing X-ray examination and EMG is often needed for diagnosis and to evaluate muscles to be transferred. Treatment: Moulded insoles, shoe modifications and AFOs are symptomatic. Preventing progression is important. In flexible feet
The recent advance of drug therapy for RA tends to replace preventive surgery, for example synovectomy. A rupture of a dorsal extensor tendon of the hand is an absolute indication for surgery, however. Such tendon ruptures are usually treated by tendon reconstruction and synovectomy of wrist joint. At our department, reconstructive surgery was administered with synovectomy for extensor tendon ruptures of the hand in 97 hands for 86 patients until June 2005. Recently, however, we occasionally encounter ruptures of extensor tendons not associated with severe synovitis. To treat such tendon ruptures, we usually administer
This study assessed the role of Ilizarov technique, using soft tissue distraction, in correction of radial club hand deformities. Five patients (6 deformities) with grade IV radial hemimelia (radial aplasia) were studied. There were three boys and two girls aged 2 to 8 years. One boy had bilateral involvement with TAR syndrome. One girl had bilateral involvement with VATER syndrome. One other boy had unilateral involvement with Holt Oram syndrome. The thumb was absent in three cases and hypoplastic in one case. The preoperative deformity measured 95 degrees (range 60–105 degrees). This was corrected using gradual soft tissue distraction with an Ilizarov fixator. Complete correction of the hand deformity was achieved over a period of 4–6 weeks. In two hands, rebalancing
Introduction: Children with clubfoot treated by the Ponseti method of clubfoot management require anterior tibialis
Introduction We report the experience of a district general hospital foot and ankle service, in performing a modified excision arthroplasty and
We studied a cohort of 26 diabetic patients with chronic ulceration under the first metatarsal head treated by a modified Jones extensor hallucis longus and a flexor hallucis longus transfer. If the first metatarsal was still plantar flexed following these two transfers, a peroneus longus to the peroneus brevis
Chronic infections and ulceration around the tendo Achillis are difficult to manage. Split-skin grafts do not survive even on healthy exposed tendon. Refractory cases may require plastic surgical intervention with the use of free flaps. Patients with significant vascular disease are not suitable for such techniques. Flexor hallucis longus tendon transfer is an established treatment for chronic ruptures of the tendo Achillis. We report the successful treatment of an infected tendo Achillis with excision and reconstruction with flexor hallucis longus transfer. The muscle belly of this tendon allowed later skin grafting while the
A radial nerve palsy complicates 1.8 to 17% (mean 11%) diaphyseal humeral fractures (13.7% in our series of 156 humeral fractures and nonunions treated by external fixation – Tsiagadigui, 2000). In about 75%, it is a primary lesion, related to the fracture before any attempt at treatment. In 60%, the fracture, most commonly with an oblique fracture line, involves the middle third. In children, a supracondylar fracture may be complicated by radial nerve palsy. Most nerve lesions correspond to neurapraxia or axonotmesis, due to traction or compression associated with bone angular deformity. Unfrequently, the nerve is impaled or severed by bone fragments, or may be trapped within the fracture in case of a spiral oblique middle or distal third humeral fracture with lateral displacement of the distal fragment. Iatrogenic injury during internal fixation or entrapment within periosteal callus are occasionally observed. The classical indications for early radial nerve exploration include open fractures requiring surgical debridement, or fractures with vascular compromise, or when the osteosynthesis is done by a plate. In all other cases, we recommend to investigate the integrity of the radial nerve by echography. In the absence of discontinuity, spontaneous neurological recovery is likely to occur and is monitored clinically and by electromyography; prevention of joint contracture is done by physiotherapy and by a wrist splint, maintaining the joint in slight dorsiflexion. In case of persistent palsy, neurolysis is indicated several months after the initial injury, the precise delay depending on the level of the fracture. Palliative treatment by
The most commonly used surgical techniques used to treat recurrent or habitual patellar dislocation in the child do not specifically address the patella alta, one of the major causes of patellar dislocation. Twelve knees in eight patients had a lowering of the patella by total
We hypothesised that a minimally invasive peroneus
brevis
Introduction and Aims: External tibial torsion associated with an increased ‘Q’ angle is an important factor in recurrent patella instability. It is surgically correctable with a rotational osteotomy of the proximal tibia above the patella tendon insertion. This technique ‘normalises’ the extensor mechanics and produces better results than patella
Purpose: The synovectomy-reaxation-stabilisation (SRS) procedure classically involves tenosynovectomy of the extensors, articulr synovectomy, partial deinnervation of the wrist, and
Reverse total shoulder arthroplasty (RTSA) was designed to treat the cuff-deficient shoulder with arthritis and irreparable rotator cuff tears of the supraspinatus and infraspinatus tendons. The results of RTSA in this patient population have been very good and reliable in the majority of cases. However, it has also been reported that patients whose rotator cuff tear involves the supraspinatus, infraspinatus and teres minor and who demonstrate a ‘horn-blower's sign’ do very poorly if a muscle transfer is not performed to improve external rotation in these shoulders in abduction. The loss of the teres minor in these patients results in grave difficulty for the patient attempting to perform their activities of daily living even if they can obtain reasonable good forward flexion. The muscle transfer that is most commonly used for these select patients is a latissmus dorsi
The Cobb Stainsby forefoot arthroplasty for claw and hammer toes combines excision arthroplasty (Stainsby) with extensor
Introduction. Definition-in this presentation, the discussion will not include reparable cuff deficiency, as this is handled with standard arthroplasty techniques combined with cuff repair. Factors that affect decision-making. Kinematics-fixed fulcrum or not. Bone loss. Deltoid integrity. Coracoacromial arch integrity. Age. Activity level. Options. Hemiarthroplasty. “ Extended head” hemiarthroplasty. Arthroplasty +
The Ponseti method of clubfoot management requires a period of bracing in order to maintain correction. This study compared the effectiveness of ankle foot orthoses and Denis Browne boots and bar in the prevention of recurrence following successful initial management. Between 2001 and 2003, 45 children (69 feet) with idiopathic clubfeet achieved full correction following Ponseti casting with or without a tenotomy, of whom 17 (30 clubfeet) were braced with an ankle foot orthosis while 28 (39 clubfeet) were prescribed with Denis Browne boots and bar. The groups were similar in age, gender, number of casts and tenotomy rates. The mean follow-up was 60 months (50 to 72) in the ankle foot orthosis group and 47 months (36 to 60) in the group with boots and bars. Recurrence requiring additional treatment occurred in 25 of 30 (83%) of the ankle foot orthosis group and 12 of 39 (31%) of the group with boots and bars (p <
0.001). Additional procedures included repeat tenotomy (four in the ankle foot orthosis group and five in the group treated with boot and bars), limited posterior release with or without
Introduction. Patients with neglected rupture of the Achilles tendon typically present with weakness and reduced function rather than pain. Shortening of the musculotendinous unit and atrophy of the muscle belly in chronic rupture potentially leads to poorer recovery following
Children with spinal dysraphism can develop various musculoskeletal deformities, necessitating a range of orthopaedic interventions, causing significant morbidity, and making considerable demands on resources. This systematic review aimed to identify what outcome measures have been reported in the literature for children with spinal dysraphism who undergo orthopaedic interventions involving the lower limbs. A PROSPERO-registered systematic literature review was performed following PRISMA guidelines. All relevant studies published until January 2023 were identified. Individual outcomes and outcome measurement tools were extracted verbatim. The measurement tools were assessed for reliability and validity, and all outcomes were grouped according to the Outcome Measures Recommended for use in Randomized Clinical Trials (OMERACT) filters.Aims
Methods
The December 2022 Foot & Ankle Roundup360 looks at: Evans calcaneal osteotomy and multiplanar correction in flat foot deformity; Inflammatory biomarkers in tibialis posterior tendon dysfunction; Takedown of ankle fusions and conversion to total ankle arthroplasty; Surgical incision closure with three different materials; Absorbable sutures are not inferior to nonabsorbable sutures for tendo Achilles repair; Zadek’s osteotomy is a reliable technique for treating Haglund’s syndrome; How to best assess patient limitations after acute Achilles tendon injury; Advances in the management of infected nonunion of the foot and ankle.
There is a lack of high-quality research investigating outcomes of Ponseti-treated idiopathic clubfeet and correlation with relapse. This study assessed clinical and quality of life (QoL) outcomes using a standardized core outcome set (COS), comparing children with and without relapse. A total of 11 international centres participated in this institutional review board-approved observational study. Data including demographics, information regarding presentation, treatment, and details of subsequent relapse and management were collected between 1 June 2022 and 30 June 2023 from consecutive clinic patients who had a minimum five-year follow-up. The clubfoot COS incorporating 31 parameters was used. A regression model assessed relationships between baseline variables and outcomes (clinical/QoL).Aims
Methods
To analyze the short-term outcome of two types of total wrist arthroplasty (TWA) in terms of wrist function, migration, and periprosthetic bone behaviour. A total of 40 patients suffering from non-rheumatoid wrist arthritis were enrolled in a randomized controlled trial comparing the ReMotion and Motec TWAs. Patient-rated and functional outcomes, radiological changes, blood metal ion levels, migration measured by model-based radiostereometric analysis (RSA), bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA), complications, loosening, and revision rates at two years were compared.Aims
Methods
There are many reasons for muscle imbalance around the foot and ankle but the most common is some form of neuromuscular disease. The etiology is obviously very important in the decision making of treatment options. One should be aware of the progression pattern of the disease or condition. The simplest imbalances to treat are those secondary to a static condition. The initial goal is to determine what force couples are available, what can be used, is it an in phase, or out of phase muscle you want to transfer. Next is to determine if there are any contractures that will have to be addressed and equally important whether there are fixed skeletal deformities present. No
Introduction:. The cavovarus foot is a complex deformity caused by muscle imbalance, soft-tissue contracture and secondary bony abnormality. It is a combination of hindfoot, midfoot and forefoot deformity and the decision making process for surgical management can be difficult. The process of deciding which combination of procedures is required is often poorly understood. We present an algorithm to assist with this decision making. Methods:. We have analysed a single surgeon's experience of cavovarus foot correction, from a consecutive series of 50 patients over 5 years, to develop an algorithm to guide operative decision making. Cases included cavovarus deformity secondary to cerebral palsy, Friedreich's ataxia, Charcot Marie Tooth disease, post-traumatic contracture, post-cerebrovascular accident, iatrogenic post-surgery and physiological cavus. We have taken a systematic approach to each component of the deformity in order to generate the algorithm. Results:. To assist in rationalising the traditional ‘a-la-carte’ approach, our algorithm describes what we believe are the indications for a variety of surgical interventions, including soft tissue contracture release, osteotomies of the hindfoot, midfoot and forefoot,
The February 2023 Shoulder & Elbow Roundup360 looks at: Arthroscopic capsular release or manipulation under anaesthesia for frozen shoulder?; Distal biceps repair through a single incision?; Distal biceps tendon ruptures: diagnostic strategy through physical examination; Postoperative multimodal opioid-sparing protocol vs standard opioid prescribing after knee or shoulder arthroscopy: a randomized clinical trial; Graft healing is more important than graft technique in massive rotator cuff tear; Subscapularis tenotomy versus peel after anatomic shoulder arthroplasty; Previous rotator cuff repair increases the risk of revision surgery for periprosthetic joint infection after reverse shoulder arthroplasty; Conservative versus operative treatment of acromial and scapular spine fractures following reverse total shoulder arthroplasty.
Crossover second toe deformity is a multiplanar deformity derived from multiple etiologies with the common endpoint of metatarsophalangeal joint instability. The stability of the joint is compromised through laxity of the volar plate, secondary rupture of the lateral collateral ligament, and ultimately dorsal subluxation or dislocation of the metatarsophalangeal joint. The digital malalignment often includes a hammertoe deformity, but should not be confused with a routine clawtoe. Elimination of alternative diagnoses relies on precise palpation to negate Morton's neuroma, 2nd metatarsalgia, Freiberg's infraction, and 2nd metatarsal stress fracture. Radiographs assist in the diagnosis in not only eliminating the above mentioned differential diagnoses, but also in evaluating confounding anatomic variables such as hallux valgus, metatarsus primus varus, and metatarsal length. These variables may necessitate additional osteotomies in conjunction with ligament reconstruction to minimise recurrence. Operative intervention has revealed long term failure of secondary ligament reconstruction, mandating
There are numerous causes of cavovarus feet, the most common of which are the hereditary motor and sensory peripheral neuropathies. Regardless of the underlying aetiology, cavovarus feet are caused by muscle imbalance. Often the imbalance is between a relatively strong tibialis posterior acting against a weaker peroneus brevis, and a relatively weak tibialis anterior being over powered by peroneus longus. Intrinsic muscle weakness and gastro-soleal tightness is common. After the failure of non-operative management, flexible deformity can be corrected with a combination of
Increasingly often diagnosed by sophisticated investigation, rotator cuff disease may be treated conservatively or surgically. Surgical options are decompression alone, decompression and debridement, partial rotator cuff repair, full reconstruction,