Purpose of the study: Proximal fractures of the humerus account for 10% of fractures in persons aged over 65 years. There is no optimal treatment. The goal of surgery is to restore joint congruency, preserve vascular supply, and allow functional recovery. We describe the results obtained with a surgical technique designed to meet these goals. Material and methods: Fifteen 3-fragment fractures of the proximal humerus were treated with transosseous suture. Mean age of patients was 58 years. Eighty-six percent of the patients were female. Follow-up was 18 months on average. The patients were placed in a lounge chair position for the deltopectoral or transdeltoid approach. For this type of fracture, the humeral head is displaced medially or laterally, so that care must be taken to ensure the realignment in the sagittal and coronal planes. The DASH and Constant scores were noted for the operated and non-operated shoulders. Signs of bone healing were noted on the plain x-rays. Results: The mean DASH was 12, mean Constant score for the operated shoulder was 80 versus 90 for the other shoulder. The mean neck-shaft angle was 139°. There was one case of lost reduction but with a good final result. There was one case converted to arthroplasty. Discussion: This technique is in line with the current trend for biological preservation minimising the aggression to the humeral head blood supply. There was no risk of migration with the fixation material used and no need to remove implants. Conclusion: Transosseous suture of proximal fractures of the humerus is a mini-invasive method which provides good functional results avoiding voluminous metal implants, known to be costly and source of complications. The incidence of avascular necrosis of the humeral head is low, in agreement with the international literature

Aims. Complete ruptures of the ulnar collateral ligament (UCL) of the thumb are a common injury, yet little is known about their current management in the UK. The objective of this study was to assess the way complete UCL ruptures are managed in the UK. Methods. We carried out a multicentre, survey-based cross-sectional study in 37 UK centres over a 16-month period from June 2022 to September 2023. The survey results were analyzed descriptively. Results. A total of 37 centres participated, of which nine were tertiary referral hand centres and 28 were district general hospitals. There was a total of 112 respondents (69 surgeons and 43 hand therapists). The strongest influence on the decision to offer surgery was the lack of a firm ‘endpoint’ to stressing the metacarpophalangeal joint (MCPJ) in either full extension or with the MCPJ in 30° of flexion. There was variability in whether additional imaging was used in managing acute UCL injuries, with 46% routinely using additional imaging while 54% did not. The use of a bone anchor was by far the most common surgical option for reconstructing an acute ligament avulsion (97%, n = 67) with a transosseous suture used by 3% (n = 2). The most common duration of immobilization for those managed conservatively was six weeks (58%, n = 65) and four weeks (30%, n = 34). Most surgeons (87%, n = 60) and hand therapists (95%, n = 41) would consider randomizing patients with complete UCL ruptures in a future clinical trial. Conclusion. The management of complete UCL ruptures in the UK is highly variable in certain areas, and there is a willingness for clinical trials on this subject. Cite this article: Bone Jt Open 2024;5(8):708–714

Operative fixation is the treatment of choice for a rupture of the distal tendon of biceps. A variety of techniques have been described including transosseous sutures and suture anchors. The poor quality of the bone of the radial tuberosity might affect the load to failure of the tendon repair in early rehabilitation. The aim of this study was to determine the loads to failure of different techniques of fixation and to investigate their association with the bone mineral density of the radial tuberosity. Peripheral quantitative computed tomography was carried out to measure the trabecular and cortical bone mineral density of the radial tuberosity in 40 cadaver specimens. The loads to failure in four different techniques of fixation were determined. The Endobutton-based method showed the highest failure load at 270 N (. sd. 22) (p < 0.05). The mean failure load of the transosseous suture technique was 210 N (. sd. 66) and that of the TwinFix-QuickT 5.0 mm was 57 N (. sd. 22), significantly lower than those of all other repairs (p < 0.05). No significant correlation was seen between bone mineral density and loads to failure. The transosseous technique is an easy and cost-saving procedure for fixation of the distal biceps tendon. TwinFix-QuickT 5.0 mm had significantly lower failure loads, which might affect early rehabilitation, particularly in older patients

Abstract. Background. We know that tears of the Triangular fibrocartilage complex (TFCC) can cause DRUJ instability and ulnar sided wrist pain. This study shows the clinical result of patients who had arthroscopic transosseous repair of the TFCC tear with DRUJ instability. Arthroscopic repair of TFCC tear is a promising, minimally invasive surgical technique especially in patients with DRUJ instability. Materials and methods. Fifteen patients who underwent TFCC one tunnel repair form 2018–2021 were reviewed retrospectively in hospital. The proximal component of TFCC was repaired through arthroscopic one- tunnel transosseous suture technique. VAS score for pain, wrist range of motion, grip strength and post operative complications were evaluated and each patient was rated according to the DASH score. Results. The patients had a TFCC tear confirmed on MRI and was confirmed on arthroscopy by doing a hook test. The patients were followed up for 6 months. Twelve patients had normal stability of DRUJ and three patients showed mild laxity compared with the contralateral side. The mean VAS score reduced from 4.7 to 0.8 (P=0.001) and grip strength increased significantly. The quick DASH score (P=0.001)also showed significant functional improvement. No surgical related complications occurred. Conclusions. Arthroscopic one tunnel transosseous TFCC foveal repair can be an excellent and safe method for repair of TFCC tear with DRUJ instability. Its a good treatment option in terms of reliable pain relief, functional improvement and reestablishment of DRUJ stability

Introduction. Although tension band wiring fixation of patellar fracture has been the most widely used technique, the metal implants related complications including implant loosening, postoperative pain are very common and additional surgeries are often necessary. Hypothesis. A totally metal free technique of transosseous suturing method could outperform the traditional fixation technique. Materials & Methods. A total of 25 patients (mean age of 59.60 years) with displaced patellar fracture treated by transosseous suturing technique were compared with a 1:1 matched historical control group who underwent modified tension band wiring fixation of patellar fracture. Union time, union rate, operation time, number of procedures, mean hospitalization days and the complications were compared between cases and controls. Results. Union time (8.43 ±2.92 weeks versus 8.64 ±2.82 weeks) and operation time (69.00 ±19.31 versus 64.89 ±14.27 minutes) were not different between two groups. Mean hospitalization days (4.04 ±1.40 versus 5.76 ±1.50 days; P < 0.001), number of procedures and the frequency of complications were significantly lower among transosseous suturing group (P< 0.001). Conclusions. Transosseous suturing technique is safe and effective in the transverse or comminuted fractures of patella. The complication rate is significantly lower than that of conventional tension band wiring technique

This in-vitro study evaluated the influence of ligament tensioning and the effectiveness of lateral collateral ligament (LCL) repair using transosseous sutures on the initial kinematics and stability of the elbow. Six fresh upper-extremities were mounted in a motion simulator with tracking system, which enabled both passive and simulated active elbow flexion. The intact elbow was tested then the LCL was sectioned from its humeral origin and repaired with a transosseous suture technique. Locking sutures were placed in the LCL and passed through a humeral bone tunnel entering at the centre of curvature of the capitellum with exit holes in the lateral epicondyle. An actuator pulled on the sutures to achieve 20, 40 and 60 N of LCL repair tension and the sutures were then secured. The dependent variable of this study was the motion pathways of the ulna relative to the humerus. The data were analyzed using a two-way, repeated-measures ANOVA with relevant post-hoc paired t-tests. With the arm oriented in the horizontal position under varus gravity loading, the repairs tracked in greater valgus than the intact LCL regardless of the repair tension. The larger the initial repair tension, the more the elbows tracked in valgus. Initial tension of 60 N was statistically different than the intact LCL with the forearm in pronation (p=0.04). Both the 40 and 60 N initial tensions were statistically different than the intact LCL with the forearm in supination (p< 0.01). Repair of the LCL using transosseous sutures effectively restores the varus stability of the elbow. The initial tension of LCL repairs affects the kinematics of the elbow, with a tendency to over-tighten the ligament and pull the elbow into valgus. These data suggest that acute repair of the LCL should be performed using a transosseous suture technique, and that a tension of 20N or perhaps less is sufficient to restore stability

Aims: The evaluation of blood supply of the humeral head in displaced 4-part Òvalgus impactedÒ fractures of the proximal humerus. Methods: 14 patients with acute 4-part valgus impacted fractures of the proximal humerus (9 women and 5 men, average age 43,6 years) were included in the study. The average impaction angle was 42.4û and the lateral displacement of the humeral head between 1–7 mm. Preoperative angiography of the proximal humerus was performed 6 to 12 hours after admission. Fracture þxation was achieved with transosseous suturing of the tuberosities to each other, to the metaphysis and to the articular part of the humeral head avoiding any use of hard material. Postoperative angiography was performed 8 to 10 weeks after the operation. Results: Digital angiographic image processing, using the segmentation technique, showed no statistical difference in the supply of the humeral head before and after the operation. The average blank number of small vessels and the overall area of blood supply (vessels/mm2 ) were about the same (p< 0.01) in 13 patients and no signs of avascular necrosis were seen 18–20 months after the operation. Partial avascular necrosis was seen in one case with 7 mm lateral displacement. Conclusions: Although the small number of cases, transosseous suturing þxation of 4-part valgus impacted fractures seems to preserve the remaining blood supply of the humeral head. The incidence of avascular necrosis is higher in cases with severe lateral displacement

Purpose: The evaluation of blood supply of the humeral head in displaced 4-part “valgus impacted” fractures with digital angiographic image processing. Material-Methods: 14 patients with acute 4-part valgus impacted fractures of the proximal humerus (9 women and 5 men, average age 43,6 years) were included in the study. The average impaction angle was 42.4o and the lateral displacement of the humeral head between 1–7 mm. Preoperative angiography of the proximal humerus was performed 6 to 12 hours after admission. Fixation of the fracture was achieved with in situ transosseous suturing fixation of the tuberosities to each other, to the metaphysis and to the articular part of the humeral head avoiding any reduction maneuvers and use of hard material. Postoperative angiography was performed 8 to 10 weeks after the operation. Results: Digital angiographic image processing, using the segmentation technique, showed no statistical difference in the supply of the humeral head before and after the operation. The average blank number of small vessels and the overall area of blood supply (vessels/mm2) were about the same in 13 patients and no signs of avascular necrosis were seen 18–20 months after the operation. Partial avascular necrosis was seen in one case with 7 mm lateral displacement. Conclusions: Although the small number of cases, in situ transosseous suturing fixation of the 4-part valgus impacted fractures seems to preserve the remaining blood supply of the humeral head. The incidence of avascular necrosis is higher in cases with severe lateral displacement

Rotator cuff tendons are typically reattached to the proximal humerus using either transosseous sutures or suture anchors. Their primary mode of failure is at the tendon bone interface 1. Surgical adhesives are used to bond cartilage, tendons and bone, and to close wounds. In an attempt to increase the tendon-bone interface we investigated the addition of a novel adhesive secreted from a species of Australian frog (Notaden bennetti) 2 to different methods of rotator cuff repair. Forty two fresh frozen sheep infraspinatus tendons were repaired using 3 different techniques: transosseous sutures; two Mitek RC Quickanchors with 1 suture per anchor and two Opus Magnum anchors with 1 suture per anchor all using a mattress stitch configuration. In each group 7 shoulders were repaired with the addition of a small amount of frog glue to the infraspinatus footprint while 7 were used as control with no adhesive. Mechanical testing was performed using a mechanical tensile testing machine. The strongest construct in the control groups was the Mitek suture anchors (mean 86±5 N) followed by the Opus suture anchor (69±6N) and transosseous repair (50±6N). This proved significant (p< 0.05) between both metallic anchors and the transosseous repair.{BR}The addition of frog glue resulted in a significant increase in load to failure and total energy required until failure in all repair techniques (p< 0.01). There was a 2 fold increase in load to failure of both the Opus Magnum (143±8N) and Mitek RC Fastin (165N±20 N) anchors while the transosseous repair (86± 8 N) had a 1.7 fold increase in its load to failure. This data suggests that:. suture anchor fixation is a stronger construct requiring a larger amount of total force to fail than transosseous repair using a one suture repair technique, that. the addition of an adhesive to the tendon-bone interface significantly enhances both ultimate load and total energy required to failure in all repair types. The unique properties of this frog glue (strong, flexible, sets in water and biocompatibility) may ultimately lead to the production of a useful adjunct for rotator cuff repair in humans

Aim: To define the contact force and contact area at the glenoid labrum-bone interface between suture sites in an open transosseous Bankart repair, and to assess how these contact parameters are altered by tying adjacent sutures to each other. Methods: Twelve capsulolabral avulsion lesions were created in fresh-frozen human shoulder specimens and were repaired using a standard transosseous suture technique. The contact forces and contact areas were measured at the labrum-bone interface between sutures before and after repair. Using the free suture ends, either a single or double strand knot was then tied between adjacent suture sites and the contact parameters were measured again. Results: The contact forces and contact areas under the soft tissue bridges between transosseous sutures were mildly increased during repair (before repair: average force=5.53g, area=2.25mm. 2. ; after repair: force=11.7g, area=3.13mm. 2. ). However, both the contact forces and areas increased significantly when a single or double strand of suture was tied over the soft tissue bridge. The double strand technique resulted in a significantly greater increase in contact forces and areas than the single strand technique (single strand average force=70.1g, area=6.75mm. 2. ; double strand average force=95.15g, area=8.0mm. 2. p< 0.05). Conclusions: The contact parameters between labrum and bone in a Bankart repair were increased when the suture strands from adjacent transosseous repair sites were linked. Increasing contact force or contact area may improve healing at the bone-soft tissue interface, and may reduce the risk of “spot welding” repairs. This, in turn, may reduce the failure rate of Bankart repairs

Introduction and Aims: Suture anchors allow consistent reattachment of tendons and ligaments to bone. Many options are available. The purpose of this study was to compare the initial strength of two rotator cuff repair techniques. The hypothesis was that rotator cuff repair strength with anchors would be inferior to transosseous sutures. Method: Eight paired shoulders with a standardised supraspinatus defect were randomised to bioabsorbable nonsuture-based anchor or transosseous suture repair. Each specimen was then subjected to a stepwise cyclic loading protocol, utilising a custom-designed loading apparatus. Repair site migration was measured using an optical measurement system, consisting of a digital camera and custom software. Mode of failure, number of cycles and load to failure were measured for 50% (5 mm) and 100% (10 mm) loss of repair. These results were correlated with bone mineral density, age and gender. Statistical analysis utilised paired t-tests and Pearson correlations. Results: The anchors failed at the anchor-tendon interface, whereas the sutures failed through the sutures. Mean values for 50 percent loss of repair were 206 ± 88 cycles and 44 ± 15 N for the sutures, and 1193 ± 252 cycles and 156 ± 20 N for the anchors (p< 0.05). The corresponding values for 100 percent loss of repair were 2458 ± 379 cycles and 294 ± 27 N for the sutures, and 2292 ± 333 cycles and 263 ± 28 N for the anchors (p> 0.05). These results may be due to the relative less deformability of the anchors. This may be relevant clinically, as in the early post-operative period, while tendon healing to bone is occurring, anchors may offer improved strength, allowing improved initial healing. Strength was unaffected by bone quality. This may be attributed to each repair failing primarily through the repair construct or at the anchor-tendon interface, and not through bone. Strengths of this study include the use of paired specimens, the stepwise cyclic loading protocol, as well as increased accuracy of our measurement system. Limitations include the use of an in vitro model, as well as a simulated, standardised rotator cuff tear. Conclusion: Repair strength with anchors was superior to sutures. Strength was unaffected by bone quality. Anchors facilitate an arthroscopic procedure, decrease operative time, and may allow a faster post-operative recovery. This study has described a new high-resolution method of measuring tendon repair failure and may be useful in future studies

The February 2023 Wrist & Hand Roundup³⁶⁰ looks at: ‘Self-care’ protocol for minimally displaced distal radius fractures; Treatment strategies for acute Seymour fractures in children and adolescents: including crushed open fractures; Routinely collected outcomes of proximal row carpectomy; Moving minor hand surgeries in the office-based procedure room: a population-based trend analysis; A comparison between robotic-assisted scaphoid screw fixation and a freehand technique for acute scaphoid fracture: a randomized, controlled trial; Factors associated with conversion to surgical release after a steroid injection in patients with a trigger finger; Two modern total wrist arthroplasties: a randomized comparison; Triangular fibrocartilage complex suture repair reliable even in ulnar styloid nonunion.

Despite being one of the most common injuries around the elbow, the optimal treatment of olecranon fractures is far from established and stimulates debate among both general orthopaedic trauma surgeons and upper limb specialists. It is almost universally accepted that stable non-displaced fractures can be safely treated nonoperatively with minimal specialist input. Internal fixation is recommended for the vast majority of displaced fractures, with a range of techniques and implants to choose from. However, there is concern regarding the complication rates, largely related to symptomatic metalwork resulting in high rates of implant removal. As the number of elderly patients sustaining these injuries increases, we are becoming more aware of the issues associated with fixation in osteoporotic bone and the often fragile soft-tissue envelope in this group. Given this, there is evidence to support an increasing role for nonoperative management in this high-risk demographic group, even in those presenting with displaced and/or multifragmentary fracture patterns. This review summarizes the available literature to date, focusing predominantly on the management techniques and available implants for stable fractures of the olecranon. It also offers some insights into the potential avenues for future research, in the hope of addressing some of the pertinent questions that remain unanswered.

Cite this article: Bone Joint J 2023;105-B(2):112–123.

Introduction. Traditionally it has been thought that the use of a small diameter femoral head in conjunction with a posterior surgical approach would result in a high rate of dislocation. We present the results of a consecutive series of 350 total hip replacements performed using a 22mm femoral head and a standard posterior approach, with prospective data collection. Objective. To determine the outcome of total hip replacement using small diameter heads via a standard posterior approach. Methods. Between March 2000 and April 2005, 319 patients underwent 350 total hip replacements with a small diameter 22mm head under the care of four different consultants, using a standard posterior approach. All patients underwent annual clinical and radiological review. All of the femoral implants were cemented modular polished triple-tapered C-stems (Depuy Ltd.) and all of the acetabular components were cemented UHMW-polyethylene components with long posterior walls. Palacos-R cement (Heraeus GMBH) containing gentamicin was used in all cases, with a third generation cementing technique. A standard posterior approach was used in all cases, with direct repair of the short external rotators, but without the use of transosseous sutures. Results. There were 245 female and 105 male patients, with 198 right-sided operations, 152 left with 31 patients undergoing staged bilateral operations. The average age at the time of surgery was 69.2 years (range 25–92 years). Five patients (6 THRs0 were lost to follow-up and 101 patients (29%) died during the study. The average duration of follow-up for surviving patients is 128 months (108 – 169 months). Five acetabular components have been revised for aseptic loosening associated with a high wear rate, and 4 are currently loose. There were three peri-prosthetic femoral fractures treated by internal fixation, and two temporary nerve palsies. Four femoral components were revised at the time of revision of a loose acetabulum, but none were loose. There has been no aseptic loosening of any femoral components and there were no cases of deep infection. The average acetabular abduction angle was 43.2 degrees (30–62) and the average femoral offset was 46mm (35–54). Five patients suffered dislocations, 3 female and 2 male, 2 right-sided and 3 left. Average age was 70 (60–85), average offset was 44.6mm (40–48). Four occurred on a single occasion only and were stable on reduction and only one required further surgery for recurrent dislocations, with application of a PLAD. Extended, skirted femoral heads had been used in four of these cases, reducing the head/neck ratio (p<0.5). Conclusions. Total hip replacement using small diameter femoral heads and a posterior approach has provided excellent results and implant longevity, with a low complication rate. Dislocation occurred in five cases and was associated with the use of an extended head. When using a posterior surgical approach the use of extended heads should be avoided, with high offset stems and standard heads being used in preference in order to achieve the correct length and offset, whilst maintaining the maximum head/neck ratio

Objective: There is no non-invasive gold standard for measuring gap formation following rotator cuff repair; re-tears are reported both on MRI and Ultrasound. We present a novel RSA technique using a combination of 1mm tantalum beads and metal sutures to allow monitoring of gap formation following rotator cuff repair. Methodology: We carried out ten open rotator cuff repairs with using trans-osseous sutures on patients with moderate to massive tears. During surgery RSA markers were inserted into the shoulder to allow postoperative monitoring of the repair. These markers took the form of 1mm RSA tantalum beads in the greater tuberosity, distal to the repair site, and three metal sutures in tendon, proximal to the repair site. Direct measurements of the distance between the markers each side of the repair were taken intra-operatively (T=O). RSA images were taken of the repair immediately postoperatively (T=1–2 hours), day 3, 2 weeks, 3 months and 1 year post-operatively. Ultrasound imaging was performed at the same intervals by consultant musculo-skeletal radiologists blinded to the RSA data. Results: At the 3 month stage post-operatively RSA data shows an increase in the average gap between the 2 sets of markers, with considerable variation between patients (5mm to 19mm). Conclusion: The results are highly suggestive of gap formation in the repair. The greatest increase in gap formation has been seen between 2 weeks and 3 months. During this time patients come out of their abduction arm sling and commence physiotherapy. It may be that due to excessive loading on the repair before it has fully healed has causes failure in some cases

Ten patients who suffered iatrogenic injury to a vertebral artery during anterior cervical decompression were reviewed to assess the mechanisms of injury, their operative management, and the subsequent outcome. All had been undergoing a partial vertebral body resection for spondylitic radiculopathy or myelopathy (4), tumour (2), ossification of the posterior longitudinal ligament (1), nonunion of a fracture (2), or osteomyelitis (1). The use of an air drill had been responsible for most injuries. The final control of haemorrhage had been by tamponade (3), direct exposure and electrocoagulation (1), transosseous suture (2), open suture (1), or open placement of a haemostatic clip (3). Five patients had postoperative neurological deficits, but most of them resolved. We found direct arterial exposure and control to be safe, quick and reliable. Careful use of the air drill, particularly in pathologically weakened bone, as in infection or tumour, is essential. Arterial injury is best avoided by a thorough knowledge of the anatomical relationships of the artery, the spinal canal, and the vertebral body

Purpose: The purpose of this study is to report the preliminary outcomes after open reduction and internal fixation of displaced proximal humerus fractures with a new device called “Da Vinci System. ®. (Arthrex)”. It is a triangle-shaped titanium cage whose opposite faces are pierced and represents the evolution of a triangle-shaped bone block technique performed in a previous series of 33 patients. Material and methods: Between May 2005 and May 2008 we treated 54 patients (26 males and 28 females), even though we included in our study 36 patients who had a minimum follow-up of 12 months. The mean age was 60.3 years. The fractures were classified according to Neer. According to the technique, the Authors position the correct size titanium cage into the metaepiphysis, so that the fragments are reduced upon the cage and are stabilized with a minimal osteosynthesis by Kirschner wires, titanium screws or transosseous sutures. Results: The functional results were evaluated by the Constant score; with a mean follow-up of 22 months (minimum 12, maximum 36 months), the results were excellent or good in 34 cases, bad in 1 case; the mean active anterior elevation was 165 degrees, while in one case a polar necrosis is present but clinical asymptomatic. All fractures but one healed; in one case, 80 days after the operation, we had a deep infection treated with a self-customed cement spacer. Discussion: Surgical management of displaced proximal humerus fractures is still a challenge to surgeons. Optimal fixation system remains controversial, especially in complex fractures with instable fragments and osteoporotic bone. The Authors underline it is important to reconstruct the medial part of the surgical neck, to fill the bone defect, and to provide stable osteosynthesis. The “Da Vinci System” is an interesting innovation to treat difficult problems such as fracture fragments reconstruction and stability, metaphyseal bone loss and proximal humerus revascularization

We have studied the mechanical properties of several current techniques of tendon-to-bone suture employed in rotator-cuff repair. Non-absorbable braided polyester and absorbable polyglactin and polyglycolic acid sutures best combined ultimate tensile strength and stiffness. Polyglyconate and polydioxanone sutures failed only at high loads, but elongated considerably under moderate loads. We then compared the mechanical properties of nine different techniques of tendon grasping, using 159 normal infraspinatus tendons from sheep. The most commonly used simple stitch was mechanically poor: repairs with two or four such stitches failed at 184 N and 208 N respectively. A new modification of the Mason-Allen suture technique improved the ultimate tensile strength to 359 N for two stitches. Finally, we studied the mechanical properties of several methods of anchorage to bone using typically osteoporotic specimens. Single and even double transosseous sutures and suture anchor fixation both failed at low tensile loads (about 140 N). The use of a 2 mm thick, plate-like augmentation device improved the failure strength to 329 N. The mechanical properties of many current repair techniques are poor and can be greatly improved by using good materials, an improved tendon-grasping suture, and augmentation at the bone attachment

Introduction: The development of the ilioinguinal approach by the pioneering work of Letournel in 1965 has transformed the treatment of acetabular fractures. To date, this approach has been well established and few modifications have been described of the original approach. However, this approach is difficult, takes long time for exposure and closure of abdominal layers. The aim of this article is to report a modification of the approach which the authors have found particularly useful. Material and Method: Cadaveric dissection showed that it was easier to detach the inguinal ligament from the anterior superior iliac spine and reflect the anterior abdominal wall as one layer, than by the classical approach through layers of the anterior abdominal wall. Closure was also simpler, in the cadaver, with the entire anterior abdominal wall reattaching satisfactorily by a single transosseous suture. The rest of the approach, including division of iliopectineal fascia and developing the three windows remains the same as in the original approach. Results: To date, three acetabular fractures have been reduced and fixed using this modification. Besides substantially speeding up the exposure and closure, this approach allows superior distal visualization of the anterior column and wall, and the impression of rather less bleeding. No complications developed with the three cases treated through this modified approach, and specifically, there have been no hernias, nor has the lateral femoral cutaneous nerve of the thigh been damaged. Discussion: This small study demonstrates a modification to a classic approach that seems to be both safe and fast We hope that further experience will also show reduction in problems associated with wound healing. Further work in progress may also show that femoral venous flow is less impeded by this approach as retraction is not against the unyielding inguinal ligament

A prospective study of early operative treatment of unstable elbow dislocations using a surgical algorithm, we present the early results of nine such injuries including five terrible triads of the elbow and four elbows which redislocated in plaster. All except two were high energy injuries. The lateral collateral ligament complex was found to be avulsed proximally in all cases and was reattached using a bone anchor. The common extensor origin was also torn to a variable extent in all cases and was repaired end to end. In the terrible triads, the coronoid fracture as fixed with a transosseous suture and the radial head reconstructed or, in one case with gross comminution, replaced. In the four redislocations, full stability was only restored when the medial collateral ligament was also reattached. Mobilization without a hinged external fixator was allowed from day one, but the elbows were protected in a hinged splint in between exercise sessions. Patients were assessed for stability, ROM, and functional disability using the DASH score at an average of 12 months. No elbows redislocated post-operatively and no patients complained of instability. Mean extension was 18° (95% CI 7° – 28°), flexion 131° (124° – 137°), pronation 76° (56° – 96°), and supination 82° (75° – 90°). Mean DASH score was 14.6 (95% CI 0.7 – 28.5) though this result was skewed by one patient who developed RSD and had a DASH score of 67.2. This was however the only complication. Early operative intervention with reconstruction of unstable elbow dislocations, including the terrible triad, prevents the poor results which are commonly found following non-operative treatment of such injuries. An external fixator is not usually required in the acute setting

Dislocation following total hip arthroplasty (THA) is a well-known and potentially devastating complication. Clinicians have used many strategies in attempts to prevent dislocation since the introduction of THA. While the importance of postoperative care cannot be ignored, particular emphasis has been placed on preoperative planning in the prevention of dislocation. The strategies have progressed from more traditional approaches, including modular implants, the size of the femoral head, and augmentation of the offset, to newer concepts, including patient-specific component positioning combined with computer navigation, robotics, and the use of dual-mobility implants. As clinicians continue to pursue improved outcomes and reduced complications, these concepts will lay the foundation for future innovation in THA and ultimately improved outcomes.

Cite this article: Bone Joint J 2022;104-B(1):8–11.

Aims: The evaluation of outcome of 4-part valgus impacted fractures of the proximal humerus after reconstruction with stable transosseous suturing þxation and early postoperative passive motion. Methods: 51 patients, 33 women and 18 men (average age 49,5 years) with displaced 4-part Òvalgus impactedÒ fractures of the proximal humerus, were treated operatively in the last 10 years (1991–2001). Stable þxation of the tuberosities to each other, to the metaphysis and to the articular part of the humeral head, was achieved with non-absorbable (Ethibon No 5) sutures, avoiding any use of hard material. Early passive motion with pendulum exercises was applied to all patients at the 2nd postoperative day, followed by active assisted exercises after the 4th to 6th postoperative week, and þnal strengthening exercises after the 2nd to 3rd postoperative month. Results: Long term results (mean follow up period 5.6 years), were evaluated according to Constant-Murley Scoring System. 42 patients (82.3%) had very good result (Constant score > 80) without pain and satisfactory motion (160û forward elevation, 50û to 80û external rotation and internal rotation up to T12). The incidence of avascular necrosis was 3,9%. Complications developed in 6 patients: 1 malunion of the great tuberosity, 3 heterotopic ossiþcations and 2 nonunions revised to hemi-arthroplasty and plate osteo-synthesis plus bone grafting. Conclusions: Advantages of this minimally invasive technique are: shorter operative time, no use of hardware, less soft tissue damage, low incidence of avascular necrosis, stable osteosynthesis with tension band effect, and adequate rotator cuff repair, allowing for early joint motion

Aim: The evaluation of outcome of 4-part valgus impacted fractures of the proximal humerus after reconstruction with stable transosseous suturing fixation. Methods: 52 patients (34 female, 18 male, mean age 49,5y) with displaced 4-part “valgus impacted” fractures of the proximal humerus, were operatively treated between 1993–2002. The average impaction angle was 42.4° and the lateral displacement of the humeral head between 1–7 mm. In situ, stable fixation of the tuberosities to each other, to the articular part of the humeral head and to the metaphysis at a level below the top of the head, was achieved with heavy non-absorbable sutures, avoiding reduction maneuvers and any use of hard material. Early passive motion with pendulum exercises was applied at the 2nd postoperative day, followed by active assisted exercises after the 6th postoperative week and final strengthening exercises after the 3rd postoperative month. Results: Long term results (mean follow up 5.6 years), were evaluated according to Constant-Murley Scoring System. 45 patients (86.5%) had very good result (Constant score > 80) without pain and satisfactory motion (up to 160° forward elevation, 60° to 80° external rotation and internal rotation up to T12). The incidence of avascular necrosis was 5.7 %. Complications developed in 6 patients: 1 malunion of the great tuberosity, 3 heterotopic ossifications and 2 nonunions revised to hemi-arthroplasty and plate osteosynthesis respectively. Conclusions: Advantages of this minimally invasive technique are shorter operative time, no use of hardware, less soft tissue damage, low incidence of avascular necrosis, stable fixation with tension band effect and adequate rotator cuff repair, allowing for early joint motion

There is no non-invasive gold standard for measuring gap formation following rotator cuff repair; re-tears are reported both on MRI and Ultrasound. Roentgen Stereophotogrammetric Analysis (RSA) has previously been used to monitor microscopic migration of markers in rigid bodies. We present a novel RSA technique using a combination of 1mm tantalum beads and metal sutures to allow accurate monitoring of gap formation following rotator cuff repair. The RSA system combines a commercially made calibration cage with software developed at Imperial College. We verified the RSA system by analysing a movable glass phantom and comparing the data with precise physical measurements of the same object: it identified a 2mm distraction of the phantom to within 0.05mm. In vitro work involved cadaveric human shoulders. We placed three 1mm RSA tantalum beads in the greater tuberosity and three metal sutures in supraspinatus tendon. We then created a tear in supraspinatus at its insertion into the greater tuberosity. We were able to show that RSA images taken before and after the tear correlated closely with direct measurements. The processed data demonstrated movement associated with gap formation. We have performed two open rotator cuff repairs using trans-osseous sutures. During surgery RSA markers were inserted into the shoulder to allow post-operative monitoring of the repair (guided by the in vitro work). Direct measurements of the distance between markers each side of the repair were taken intra-operatively (T=O). RSA images were taken immediately post-operatively (T=1 hours), day 3, day 14, and day 84. The RSA data suggests gapping of typically 3mm may have occurred at the repair sites in both patients. Ultrasound imaging was performed at the same intervals by consultant musculoskeletal radiologists blinded to the RSA data. Preliminary results correlating the two modalities suggest that ultrasound can visualise gap formation accurately even immediately post-operatively

Aims

Stemless humeral implants have been developed to overcome stem-related complications in total shoulder arthroplasty (TSA). However, stemless implant designs may hypothetically result in less stable initial fixation, potentially affecting long-term survival. The aim of this study is to investigate early fixation and migration patterns of the stemless humeral component of the Simpliciti Shoulder System and to evaluate clinical outcomes.

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

Introduction. Avulsion of abductors from hip is a debilitating complication after total hip arthroplasty performed through a trans-gluteal approach. It results in intractable pain, Trendelenberg limp and instability of the hip. Techniques described for repairing these abductor tears including direct trans osseous repairs, endoscopic repair techniques, Achilles tendon allograft, Gluteus Maximus and Vastus Lateralis muscle transfers. The aim of our study was to assess improvement in pain, limp and abductor strength in patients operated upon surgically for confirmed abductor avulsion using a modified trans osseous repair and augmentation of repair with a Graft Jacket allograft acellular human dermal matrix (Graft jacket; Wright Medical Technology, Arlington, TN). Patients and Methods. In this prospective study we include 18 consecutive patients with hip abductor avulsions following a primary total hip arthroplasty through Hardinge approach for osteoarthritis. All the patients presented with pain around lateral aspect of hip, walking with a significant Trendelenberg limp and used a crutch or a stick in the opposite hand. Diagnosis was made by clinical examination and confirmed by MRI scans. Surgical Technique. Surgical procedure was through lateral approach using the old scar to mobilise combined aponeurosis of the Gluteal Medius and Gluteus Minimus from the bony bed on the ilium to permit advancement onto the trochanter. The conjoint Gluteus Medius and Minimus insertion was affixed to the greater trochanter with No.5 non absorbable trans-osseous suture using a Krackow stitch through a series of transverse tunnels made in anterior aspect of greater trochanter. An on lay augmentation (Fig. 1) of the osseo-tendinous junction was performed using a Graft Jacket matrix of 4 × 7 cms in size after rehydration according to the manufacturer's instructions. Results. At mean follow up of 22 months (15–34 months), pain improved in all patients with mean VAS score improving from 8.25 to 2.33 (p value-0.05). All the patients had improvement in their abductor strength with MRC grade 4 out of 5 in 16 patients and 3 out of 5 in 2 patients. Trendelenberg sign disappeared in all but two. Mean Harris hip score improved from 34.05 to 81.26 (p value-0.001). All patients had improvement in gait except mild noticeable limp in two patients.13 patients did not use any walking aids and five felt more secure using a walking stick in the contralateral hand. The mean SF-36 Physical component score was 53.47 and Mental component score was 56.07. Conclusions. The procedure is safe and associated with high patient satisfaction, without the morbidity of tendon or muscle transfers. The Graft Jacket Matrix provides biological bridging between the hip abductors and its insertion into greater trochanter. It provides a biological scaffold for cellular and vascular in-growth and constructive tissue remodelling. The described procedure appears to enhance the mechanical strength of repaired tendon immediately following surgery. The Graft Jacket allograft matrix has already been used successfully in rotator cuff repairs of shoulder and has showed encouraging results. The early success of this new procedure warrants further study with more patients, longer follow-up and possibly histological study of retrieved specimens

We compared the initial strength of two techniques for repair of rotator cuff tears. Eight paired cadaveric shoulders with a standardized supraspinatus defect were studied. A transosseous suture and anchor repair was conducted on each side. Specimens were tested under cyclic loading, while fixation was monitored with an optical tracking technique. Mode of failure, number of cycles and load to failure were measured for 50% (5 mm) and 100% (10 mm) loss of repair. Anchors provide improved repair strength at 50% repair loss, in comparison to sutures (p< 0.05). Strength was unaffected by bone mineral density, age and gender. The purpose of this study was to compare the initial strength of two rotator cuff repair techniques. Repair strength with anchors was superior to sutures. Strength was unaffected by bone quality. Anchors, enabling a quicker, less invasive arthroscopic repair, offer improved fixation over sutures, which are more time consuming and invasive. Eight paired shoulders with a standardized supra-spinatus defect were randomized to anchor or suture repair, and subjected to cyclic loading. Repair migration was measured using a digital camera. Failure mode, cycles and load were measured for 50% and 100% loss of repair. Results were correlated with bone mineral density, age and gender. The anchors failed at the anchor-tendon interface, whereas the sutures failed through the sutures. Mean values for 50% loss of repair were 205.6 ± 87.5 cycles and 43.8 ± 14.8 N for the sutures, and 1192.5 ± 251.7 cycles and 156.3 ± 19.9 N for the anchors (p< 0.05). The corresponding values for 100% loss of repair were 2457.5 ± 378.6 cycles and 293.8 ± 27.4 N for the sutures, and 2291.9 ± 332.9 cycles and 262.5 ± 28.0 N for the anchors (p> 0.05). These results did not correlate with bone quality. This study has demonstrated that anchors provide improved repair strength, in comparison to sutures. This may be due to the relative less deformability of the anchors. Repair strength did not correlate with bone quality. This may be attributed to each repair failing primarily through the repair construct or at the anchor-tendon interface, and not through bone

Introduction and purpose: The treatment of proximal humerus fractures is still controversial in terms of the surgical approach to be used and even of whether surgery is indeed necessary or not. The purpose of this study is to assess the functional result and the patients’ perception of their general health condition after treatment of displaced humerus fractures by means of transosseous sutures with or without the support of modified Ender nails. Materials and methods: The study comprised a series of 40 patients (mean age: 66.21 years); 82% females /18% males. The patients had the following fracture types: 27% had two-part fractures, 60% had three-part fractures and 12% had four-part fractures and fracture-dislocations. The mean follow-up was 55.83 months (12.83-97). The final functional evaluation was carried out using the Constant score and the health perception was measured on the EuroQol-5D scale. All patients were submitted to a final radiological exam (AP and profile radiographs on the scapular plane). Results: The mean value obtained on the Constant Scale was 74.18 in the involved arm and 84.06 in the contralateral one. As regards pain, the mean obtained was 12.57, while the value for forward arm elevation was 8.24. When comparing two age groups (> 70 vis-á-vis < 70 year olds) a significant difference was obtained with respect to Constant Scale’s global value (p 0.022). Furthermore, a significant difference was detected between the result of the EuroQol-5D scale, the global result of the Constant Scale (p 0.061), abduction (p 0.05), internal rotation (p 0.05) and strength (p 0.007). The rate of postop complications was 6% (2 surgical wound haematomas). The final radiological control revealed losses in reduction and necrosis in 9.37% and 3.03% of patients respectively. Conclusions: (1) Good global functional results on he Constant Scale. (2) Significant differences in functional results based on patients’ age. (3) Difference in quality of life perceptions on the basis of the amount of mobility and strength obtained postoperatively. (4) Low complications rate

Introduction: A secure repair of the subscapularis represents an integral part of any surgery involving the anterior approach to the shoulder. Dysfunction of the subscapularis leads not only to poor functional results but also to anterior joint instability which is potentially untreatable. We have devised a new technique of double row fixation of the subscapularis using two suture anchors. Aim: To evaluate the biomechanical strength of this double row technique against the established methods of simple suturing and transosseous repair techniques. Method: Twenty matched pairs of human cadaveric shoulders were allocated into 3 groups. Group 1 consisted of 10 shoulders repaired with the double row technique. This involved incising the subscapularis along the bicipital groove and a lesser tuberosity osteotomy carried out leaving the subscapularis attached to a thin island of bone. A suture anchor (Twinfix) was then inserted just medial to the osteotomy site and the tendon repaired to bone using two horizontal mattress sutures. A second anchor was inserted laterally to supplement the repair with two simple suture knots. The remaining 10 contralateral shoulders were allocated equally between groups 2 and 3. In group 2, the subscapularis was divided longitudinally 1cm medial to the bicipital groove and repaired with simple interrupted suture knots. In group 3, the subscapularis was incised at its insertion to lesser tuberosity and the tendon repaired to the osteotomy site by multiple transosseous sutures through drill holes in the anterior humeral cortex. The suture material used in all three groups was identical and consisted of an ultra high molecular weight poly-ethylene suture (Ultrabraid). To simulate the direction of pull of the subscapularis, the testing block was tilted 45 degrees while a vertically applied distraction force was applied. A custom made jig was used to measure the amount of displacement in response to a gradually applied load. All specimens were tested to failure. The mode of failure of each fixational construct was recorded. Results: The load to failure was found to be significantly higher in the double row repair technique compared to simple suturing and transosseous methods. Simple suturing failed by suture cutting out of soft tissue and tranosseous repair failed by a combination of the suture cutting out through bone and soft tissue. Conclusion: This new double row technique is simple to perform and preliminary biomechanical testing has shown this to be superior in terms of fixational strength compared to established methods. Additional advantages of this technique which have not been taken into account in this in vitro study include non violation of the subscapularis tendon with bone to bone healing

Aim: The aim of the study was to investigate the influence of bone density of the greater tuberosity on mechanical strength of different bone anchors for rotator cuff surgery. Especially in osteopenic bone the metal bone anchors and transosseus sutures are still the “gold-standard” in rotator cuff surgery. Material and Methods: Four bone anchors, each standing for a specific group of bone anchor, and two suture materials were tested. One of them was the metallic Super Revo screw 5.0 (Linvatec), the absorbable screw Spiralok 5.0 (Mitek), the absorbable press-fit anchor Bioknotless RC (Mitek) and the absorbable Ultrasorb RC (Linvatec). The suture materials tested was the well known V-37 (Ethicon) and the new Orthocord (Mitek) both USP 2. All fixations systems were tested on a) 6 pairs of fresh-frozen human shoulders from young adults (range 20–50 yrs.) and b) 6 pairs of fresh frozen human shoulders from elderly (range 60–93 yrs.). Cyclic loading was performed, as it was considered the best way to simulate the postoperative conditions in a manner similar to those used in prior studies until the system failed. The maximum tensile strength, the failure mode, and the displacement of the fixation device (system displacement) under load at the first cycle at 75 N and at the maximum tensile strength were recorded. Results: The absorbable Spiralok 5 mm screw anchor showed the highest failure load with a mean of 171 N in osteopenic bone. The suture material Orthocord and V-37 had the lowest mechanical strength in osteopenic bone with a mean of 125 N resp. 114 N. The remaining anchors had an almost identical failure load with means of 150 N (Super Revo 5 mm and Bioknotless RC) and 151 N (Ultrasorb RC). No statistical significance was found though. Comparing the mechanical strength of each fixation system in healthy and osteopenic bone no statistical significant difference was found except for the V-37 suture. In healthy bone the failure load of V-37 suture had a mean of 204 N and in osteopenic bone of 114 N. Discussion: The absorbable Spiralok 5 mm screw showed a good performance in healthy and osteopenic bone when compared with standard bone anchor like the titan Super Revo 5 mm screw or transosseous sutures. Absorbable anchors have certain advantages, besides that usually they are more expensive. They can easily be overdrilled in case of rupture of the suture material, and they do not interfere during later revision surgery or for imaging studies such as magnetic resonance imaging

Introduction: The treatment of symptomatic rotator cuff rupture is a common therapeutic challenge in our ageing population with high functional demands. We reviewed our results of arthroscopic treatment (introduced in our department in October 2005) and compared the outcome with that of open repair. Material and Methods: The 73 patients of the open group were operated between October 1998 and October 2006. Treatment consisted of classic open repair done by a parasagital incision with transosseous sutures in 69 and titanium anchors in 4 cases. All patients were immobilised in an abduction splint for 6 weeks and only passive exercises were performed during this period. Strengthening exercises were allowed after 3 month. The arthroscopic group included 30 patients operated between October 2005 and June 2008. A single row repair using 1–3 titanium anchors was performed via 3 to 5 incisions. The abduction splint was used for 4 weeks and strengthening exercises were allowed after 2 month. Standard x-rays in 3 planes were performed praeop, postop and at the latest follow up examination. A praeop MRI was done in all cases. Clinical examination used the non age adapted Constant score and complications were recorded. Results: Follow up was possible for 29 men and 36 women with a mean age of 57 years (35 to 78) in the open versus 15 men and 13 women with a mean age of 59 years (44 to 74) in the arthroscopic group. Mean follow up averaged 36 month (3–102) in the open and 15 month (3–35) in the arthroscopic group. One tendon was affected in 45% versus 75%, two tendons in 45% versus 25% and three tendons in 10% versus 0% in the open and arthroscopic groups. The mean Constant score could be improved from 50 (29–68) praeop to 71 (39–97) postop in the open and 52 (28–62) praeop to 80 (45–98) postop in the arthroscopic group. If only one and two tendon ruptures were recorded in the open group the mean postop Constant score was 76. Four complications were encountered in the open group. One patient had to be revised due to deep infection and one because of wound healing problems. Two cases of frozen shoulder could be managed conservatively. In the arthroscopic group one patient showed a temporal irritation of the ulnar nerve and another a frozen shoulder. Both cases could be managed conservatively. Conclusion: Short to mid term results showed no difference in clinical outcome comparing open and arthroscopic procedures. The higher mean postop Constant score of the arthroscopic group was mainly due to the lager tears sizes of the open group. Advantages of the arthroscopic procedure are the possibility of faster rehabilitation and that the operation seems less prone to infection and wound healing problems

Purpose: Short-term results of surgical repair of subscapularis tears are well known. The purpose of this study was to assess long-term outcome after surgical repair of 21 full-thickness tears of the subscapularis. Material and methods: Inclusion criteria were subscapularis tear (n=21) which were isolated (n=9) or associated with a supraspinatus tear (n=11) without intraspinatus tears. The subscapularis was reinserted by transosseous fixation in fifteen cases and with a trapezeal flap in six. The supraspinatus was repaired by transosseous suture. Function (Constant score) was assessed preoperatively, at one and three years, and at last follow-up (nine years, range six to fifteen years). We also noted radiographic changes (subacromial height, osteoarthritis using the Samilson classification, anterior dislocation of the humeral head). Fatty degeneration (FD) of the cuff was assessed on pre-operative scans and at last follow-up. Arthroscan, performed at one year and ultrasonography performed at last follow-up were used to assess cuff continuity. Results: The rough Constant score was 45.2 (12–93.5) preoperatively, 67.5 (20–95) at one and three years and 59.45 (20–95) at last follow-up. At last follow-up, the Constant score was significantly better than preoperatively (improved pain score). There was only one case of repeated tear (repaired supraspinatus). At last follow-up we noted six anterior dislocations. The subacromial space remained unchanged (9.5 mm). Glenohumeral osteoarthritis developed in fourteen cases (2 Samilson class 3) including eight de novo degenerations. FD of repaired subscapularis tendons was 0.8 (0–4) preoperatively and 1.64 (1–4) at last follow-up. FD of unrepaired subscapularis tendons treated with a trapezeal flap worsened (2.2 to 2.7). FD of the supraspinatus and infraspinatus (0.5 preoperatively) worsened one stage. At last follow-up, the Constant score was lower in the presence of anterior dislocation of the humeral head (p=0.013). Development of anterior dislocation of the humeral head was correlated with major preoperative FD of the subscapularis (cut-off between 1.5 and 2, p=0.01). There was a correlation between more FD of the infraspinatus and the presence of anterior dislocation of the humeral head. Among the trapezeal flaps, there were only two good results (Constant scores 74 and 75) in patients with FD of the subscapularis scored 1.5 preoperatively. Conclusion: Functional and radiographic outcome after cuff repair or palliation with a trapezeal flap for subscapularis tears associated or not with supraspinatus tears is not satisfactory unless the fatty degeneration of the subscapularis is low preoperatively (δ 1.5)

Purpose of the study: Old tears of the subscapular muscle situated in the glenoid area are not accessible to direct repair and require locoregional muscle plasty. The clavicular portion of the pectoralis major can be used for reconstruction. The purpose of this study was to describe the operative technique and examine short-term outcome. Material and methods: Five patients, mean age 54 years (45–71 years) with an irreparable tear of the subscapularis in the glenoid area with fatty degeneration greater than grade two in the Goutallier classification were treated. Four had had previous surgery for acromioplasty associated with rotator cuff repair in two or implantation of a humeral prosthesis in one. The preoperative Constant score was 27.5 (mean, range = 8.5–54) due to invalidating pain, limited active mobility and reduced muscle force. Gerber’s lift-off test was positive for those patients for whom it could be performed. Plain x-rays evidenced anterior subdislocation of the humeral head in one case. Subscapular reconstruction was achieved using the entire clavicular portion of the pectoralis major which was dissected and sectioned at its distal insertion on the humerus then reinserted by transosseous suture onto the lesser tuberosity. The rehabilitation program started with active and passive mobility against gravity within a few days of surgery using biofeedback contraction of the muscle flap then active contractions two months postoperatively. Patients were reviewed at a mean 19 months (6–42 months) for clinical and radiological assessment. Results: Four patients had a painless shoulder with a negative lift-off test. The gain in active mobility was predominantly achieved with anterior elevation and abduction. Muscle force was weak leading to a low overall Constant score at revision (mean = 50, range = 30–63). Radiographically, the humeral head was centered exactly as on the preoperative films. There were no cases with a new anterior subdislocation nor an aggravation of a former subdislocation. Functional outcome was better in cases with a unique tear of the subscapularis. Discussion and conclusion: Open surgery is used for primary repair of recent tears of the subscapularis. This technique gives 80 p. 100 good and very good results. In case of symptomatic acromioclavicular osteoarthtisis, better long-term results can be obtained by using a tendodesis of the long biceps and resecting the lateral centimeter of the clavicle. In case of irreparable tears in the glenoid area, reconstruction by transfer of the clavicular portion of the pectoralis major can produce a stable painless shoulder with improved active moblity and normal clinical tests. This method provides anterior stability of the glenohumeral articulation and prevents any anterior subdislocation of the humeral head, thus protecting the joint from secondary degeneration

Purpose of the study: Reinsertion of the brachial biceps on the radial tubercle has been an effective method for recovering cyclic supination. Several surgical techniques have been proposed but only one clinical evaluation of operated patients has been published. We report the first study of a clinical and magnetic resonance imaging (MRI) assessment of brachial biceps reinsertion in the anatomic position using an anchorage system. The purpose of this work ws to determine whether the reinserted biceps remains inserted and to analyze the zone of insertion. Material and methods: Nine manual laborers underwent surgery between 1999 and 2003 for repair of a ruptured brachial biceps by reinsertion on an anchor. The patients were reviewed by an independent operator (measurement of force and flexion). A 3-Tesla MRI machine was used to evaluate the position of the reinserted biceps. Reinsertion was performed within 5 days of injury (range 3–9 days) using the same technique of anchorage in the radial tubercle in all cases. A longitudinal incision measuring 3–5 cm along the medial border of the radial brachial was made to localize the ruptured biceps and the radial tubercle and drill two or three insertion holes for the anchors. The suture threads were used to bring the brachial biceps tendon progressively to the anchor used as a pulley before knotting. The patients were immobilized for three weeks, limiting flexion to 0–90°, then 45–130° the three following weeks. Results: For the nine patients, there were no cases of sepsis nor radioulnar synostosis. Three cases of calcification were noted and to cases of nervous complications which resolved totally. Six patients, mean age 44.8 years (range 34–54 years) (two patients had moved away from the region) were reviewed at mean 19.2 months (range 10–33 months). Force at maximum flexion was 94.6% of the opposite side (range 58–131.5%). Repeated supination was somewhat bothersome for two patients. None of the patients complained of work impairment and all resumed their activity at the same level within 4.6 months on average. The MRI analysis (available in five patients) demonstrated that the reinserted tendon was in contact with the bone and that ther was a visible bone-tendon junction: the anterior and posterior borders of the tendon, as well as the fivers, showed a regular configuration. The terminal part of the tendon was enlarged in 3/5 cases. The tendon signal from the last 3 cm was variable: low intensity signal on T1 and T2 sequences or discrete high intensity signal on T1 and T2. There was no evidence of peritendinous effusion. At the time of the MRI evaluation, the anchors had not been resorbed. Discussion: Several studies have reported the usefulness of reinserting the branchial biceps in manual laborers. The half-approach techniques, especially by anchorage, avoid the double-approach, enabling less traumatic reinsertion. The branches of the radial nerve must be carefully identified (we observed only resolutive cases of nervous deficit). Nevertheless, this type of reinsertion has not been evaluated. There is no proof that the reinserted biceps remains in an anatomic position. Our MRI findings are in favor of continuing the single-strand suture technique since the evidence demonstrated the validity of this type of transosseous suture

Aims

Acute distal biceps tendon repair reduces fatigue-related pain and minimizes loss of supination of the forearm and strength of flexion of the elbow. We report the short- and long-term outcome following repair using fixation with a cortical button techqniue.

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Limb salvage for pelvic sarcomas involving the acetabulum is a major surgical challenge. There remains no consensus about what is the optimum type of reconstruction after resection of the tumour. The aim of this study was to evaluate the surgical outcomes in these patients according to the methods of periacetabular reconstruction.

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The aim of the study was to analyze the results of primary tendon reinsertion in acute and chronic distal triceps tendon ruptures (DTTRs) in the general population.

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The aim of this study was to evaluate the outcome of Monteggia-like lesions at midterm follow-up and to determine whether the surgical treatment of the radial head influences the clinical and radiological results.

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The aims of this study were to evaluate the abductor function in moderate and severe slipped capital femoral epiphysis (SCFE), comparing the results of a corrective osteotomy at the base of the femoral neck and osteoplasty with 1) in situ epiphysiodesis for mild SCFE, 2) contralateral unaffected hips, and 3) hips from healthy individuals.

Dislocation of the acromioclavicular joint is a relatively common injury and a number of surgical interventions have been described for its treatment. Recently, a synthetic ligament device has become available and been successfully used, however, like other non-native solutions, a compromise must be reached when choosing non-anatomical locations for their placement. This cadaveric study aimed to assess the effect of different clavicular anchorage points for the Lockdown device on the reduction of acromioclavicular joint dislocations, and suggest an optimal location. We also assessed whether further stability is provided using a coracoacromial ligament transfer (a modified Neviaser technique). The acromioclavicular joint was exposed on seven fresh-frozen cadaveric shoulders. The joint was reconstructed using the Lockdown implant using four different clavicular anchorage points and reduction was measured. The coracoacromial ligament was then transferred to the lateral end of the clavicle, and the joint re-assessed. If the Lockdown ligament was secured at the level of the conoid tubercle, the acromioclavicular joint could be reduced anatomically in all cases. If placed medial or 2 cm lateral, the joint was irreducible. If the Lockdown was placed 1 cm lateral to the conoid tubercle, the joint could be reduced with difficulty in four cases. Correct placement of the Lockdown device is crucial to allow anatomical joint reduction. Even when the Lockdown was placed over the conoid tubercle, anterior clavicle displacement remained but this could be controlled using a coracoacromial ligament transfer.

Cite this article: Bone Joint J 2015;97-B:1657–61.

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Radial head arthroplasty (RHA) may be used in the treatment of non-reconstructable radial head fractures. The aim of this study was to evaluate the mid-term clinical and radiographic results of RHA.

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Revision total elbow arthroplasty (TEA) is often challenging. The aim of this study was to report on the clinical and radiological results of revision arthroplasty of the elbow with the Latitude TEA.

After establishing anatomical feasibility, functional reconstruction to replace the anterolateral part of the deltoid was performed in 20 consecutive patients with irreversible deltoid paralysis using the sternoclavicular portion of the pectoralis major muscle. The indication for reconstruction was deltoid deficiency combined with massive rotator cuff tear in 11 patients, brachial plexus palsy in seven, and an isolated axillary nerve lesion in two. All patients were followed clinically and radiologically for a mean of 70 months (24 to 125). The mean gender-adjusted Constant score increased from 28% (15% to 54%) to 51% (19% to 83%). Forward elevation improved by a mean of 37°, abduction by 30° and external rotation by 9°.

The pectoralis inverse plasty may be used as a salvage procedure in irreversible deltoid deficiency, providing subjectively satisfying results. Active forward elevation and abduction can be significantly improved.

In a prospective, randomised study on the repair of tears of the rotator cuff we compared the clinical results of two suture techniques for which different suture materials were used.

We prospectively randomised 100 patients with tears of the rotator cuff into two groups. Group 1 had transosseous repair with No. 3 Ethibond using modified Mason-Allen sutures and group 2 had transosseous repair with 1.0 mm polydioxanone cord using modified Kessler sutures. After 24 to 30 months the patients were evaluated clinically using the Constant score and by ultrasonography.

Of the 100 patients, 92 completed the study. No significant statistical difference was seen between the two groups: Constant score, 91% vs 92%; rate of further tear, 18% vs 22%; and revision, 4% vs 4%. In cases of further tear the outcome in group 2 did not differ from that for the intact repairs (91% vs 91%), but in group 1 it was significantly worse (94% vs 77%, p = 0.005).

Overall, seven patients had complications which required revision surgery, in four for pain (two in each group) and in three for infection (two in group 1 and one in group 2).

The aim of this study was to evaluate the ten-year clinical and functional outcome of hip resurfacing and to compare it with that of cementless hip arthroplasty in patients under the age of 55 years.

Between 1999 and 2002, 80 patients were enrolled into the study: 24 were randomised (11 to hip resurfacing, 13 to total hip arthroplasty), 18 refused hip resurfacing and chose cementless total hip arthroplasty with a 32 mm bearing, and 38 insisted on resurfacing. The mean follow-up for all patients was 12.1 years (10 to 14).

Patients were assessed clinically and radiologically at one year, five years and ten years. Outcome measures included EuroQol EQ5D, Oxford, Harris hip, University of California Los Angeles and University College Hospital functional scores.

No differences were seen between the two groups in the Oxford or Harris hip scores or in the quality of life scores. Despite a similar aspiration to activity pre-operatively, a higher proportion of patients with a hip resurfacing were running and involved in sport and heavy manual labour after ten years.

We found significantly higher function scores in patients who had undergone hip resurfacing than in those with a cementless hip arthroplasty at ten years. This suggests a functional advantage for hip resurfacing. There were no other attendant problems.

Cite this article: Bone Joint J 2015; 97-B:617–22.

Unlinked, linked and convertible total elbow arthroplasties (TEAs) are currently available. This study is the first to report the clinical results of the convertible Latitude TEA. This was a retrospective study of a consecutive cohort of 63 patients (69 primary TEAs) with a mean age of 60 years (23 to 87). Between 2006 and 2008 a total of 19 men and 50 women underwent surgery. The mean follow-up was 43 months (8 to 84). The range of movement, function and pain all improved six months post-operatively and either continued to improve slightly or reached a plateau thereafter. The complication rate is similar to that reported for other TEA systems. No loosening was seen. Remarkable is the disengagement of the radial head component in 13 TEAs (31%) with a radial head component implanted.

Implantation of both the linked and the unlinked versions of the Latitude TEA results in improvement of function and decreased pain, and shows high patient satisfaction at mid-term follow-up.

Cite this article: Bone Joint J 2015; 97-B:681–8.

Intact abductors of the hip play a crucial role in preventing limping and are known to be damaged through the direct lateral approach. The extent of trauma to the abductors after revision total hip replacement (THR) is unknown. The aim of this prospective study was to compare the pre- and post-operative status of the gluteus medius muscle after revision THR. We prospectively compared changes in the muscle and limping in 30 patients who were awaiting aseptic revision THR and 15 patients undergoing primary THR. The direct lateral approach as described by Hardinge was used for all patients. MRI scans of the gluteus medius and functional analyses were recorded pre-operatively and six months post-operatively. The overall mean fatty degeneration of the gluteus medius increased from 35.8% (1.1 to 98.8) pre-operatively to 41% (1.5 to 99.8) after multiple revision THRs (p = 0.03). There was a similar pattern after primary THR, but with considerably less muscle damage (p = 0.001), indicating progressive muscle damage. Despite an increased incidence of a positive Trendelenburg sign following revision surgery (p = 0.03) there was no relationship between the cumulative fatty degeneration in the gluteus medius and a positive Trendelenburg sign (p = 0.26). The changes associated with other surgical approaches to the hip warrant investigation.

Cite this article: Bone Joint J 2014;96-B:1618–22.

Damage to the cartilage of the distal radioulnar joint frequently leads to pain and limitation of movement, therefore repair of this joint cartilage would be highly desirable. The purpose of this study was to investigate the fixation of scaffold in cartilage defects of this joint as part of matrix-assisted regenerative autologous cartilage techniques. Two techniques of fixation of collagen scaffolds, one involving fibrin glue alone and one with fibrin glue and sutures, were compared in artificially created cartilage defects of the distal radioulnar joint in a human cadaver. After being subjected to continuous passive rotation, the methods of fixation were evaluated for cover of the defect and pull out force.

No statistically significant differences were found between the two techniques for either cover of the defect or integrity of the scaffold. However, a significantly increased mean pull out force was found for the combined procedure, 0.665 N (0.150 to 1.160) versus 0.242 N (0.060 to 0.730) for glue fixation (p = 0.001).

This suggests that although successful fixation of a collagen type I/III scaffold in a distal radioulnar joint cartilage defect is feasible with both forms of fixation, fixation with glue and sutures is preferable.

Cite this article: Bone Joint J 2014;96-B:508–12.

The practice of removing a well-fixed cementless femoral component is associated with high morbidity. Ceramic bearing couples are low wearing and their use minimises the risk of subsequent further revision due to the production of wear debris. A total of 165 revision hip replacements were performed, in which a polyethylene-lined acetabular component was revised to a new acetabular component with a ceramic liner, while retaining the well-fixed femoral component. A titanium sleeve was placed over the used femoral trunnion, to which a ceramic head was added. There were 100 alumina and 65 Delta bearing couples inserted.

The mean Harris hip score improved significantly from 71.3 (9.0 to 100.0) pre-operatively to 91.0 (41.0 to 100.0) at a mean follow up of 4.8 years (2.1 to 12.5) (p < 0.001). No patients reported squeaking of the hip.

There were two fractures of the ceramic head, both in alumina bearings. No liners were seen to fracture. No fractures were observed in components made of Delta ceramic. At 8.3 years post-operatively the survival with any cause of failure as the endpoint was 96.6% (95% confidence interval (CI) 85.7 to 99.3) for the acetabular component and 94.0% (95% CI 82.1 to 98.4) for the femoral component.

The technique of revising the acetabular component in the presence of a well-fixed femoral component with a ceramic head placed on a titanium sleeve over the used trunnion is a useful adjunct in revision hip practice. The use of Delta ceramic is recommended.

Cite this article: Bone Joint J 2013;95-B:333–8.

Microfracture is frequently used as the first line of treatment for the repair of traumatic cartilage defects. We present the clinical and histological results 18 months to two-years after treatment in a 26-year-old male with a post-traumatic chondral defect of the medial femoral condyle managed by microfracture covered with chondrotissue, a cell-free cartilage implant made of a resorbable polyglycolic acid felt and hyaluronic acid.

The direct anterior approach in total hip replacement anatomically offers the chance to minimise soft-tissue trauma because an intermuscular and internervous plane is explored. This motivated us to abandon our previously used transgluteal approach and to adopt the direct anterior approach for total hip replacement. Using MRI, we performed a retrospective comparative study of the direct anterior approach with the transgluteal approach. There were 25 patients in each group. At one year post-operatively all the patients underwent MRI of their replaced hips. A radiologist graded the changes in the soft-tissue signals in the abductor muscles. The groups were similar in terms of age, gender, body mass index, complexity of the reconstruction and absence of symptoms.

Detachment of the abductor insertion, partial tears and tendonitis of gluteus medius and minimus, the presence of peri-trochanteric bursal fluid and fatty atrophy of gluteus medius and minimus were significantly less pronounced and less frequent when the direct anterior approach was used. There was no significant difference in the findings regarding tensor fascia lata between the two approaches.

We conclude that use of the direct anterior approach results in a better soft-tissue response as assessed by MRI after total hip replacement. However, the impact on outcome needs to be evaluated further.

Fractures and nonunions of the proximal humerus are increasingly treated by open reduction and internal fixation. The extended deltopectoral approach remains the most widely used for this purpose. However, it provides only limited exposure of the lateral and posterior aspects of the proximal humerus. We have previously described the alternative extended deltoid-splitting approach. In this paper we outline variations and extensions of this technique that we have developed in the management of further patients with these fractures.

We describe the use of a vascularised periosteal patch onlay graft based on the 1,2 intercompartmental supraretinacular artery in the management of 11 patients (ten men, one woman) with chronic nonunion involving the proximal third of the scaphoid. The mean age of the patients was 31 years (21 to 45) with the dominant hand affected in eight. Six of the patients were smokers and three had undergone previous surgery to the scaphoid. All of the proximal fragments were avascular. The presence of union was assessed using longitudinal axis CT.

Only three patients progressed to union of the scaphoid and four required a salvage operation for a symptomatic nonunion. The remaining four patients with a persistent nonunion are asymptomatic with low pain scores, good grip strength and a functional range of wrist movement.

Although this technique has potential technical advantages over vascularised pedicled bone grafting, the rate of union has been disappointing and we do not recommend it as a method of treatment.

We compared time-dependent changes in the biomechanical properties of single-and double-row repair of a simulated acute tear of the rotator cuff in rabbits to determine the effect of the fixation techniques on the healing process.

A tear of the supraspinatus tendon was created in 80 rabbits which were separated into two equal groups. A single-row repair with two suture anchors was conducted in group 1 and a double-row repair with four suture anchors in group 2. A total of ten intact contralateral shoulder joints was used as a control group. Biomechanical testing was performed immediately post-operatively and at four and eight weeks, and histological analysis at four and eight weeks.

The mean load to failure in group 2 animals was greater than in group 1, but both groups remained lower than the control group at all intervals. Histological analysis showed similar healing properties at four and eight weeks in both groups, but a significantly larger number of healed tendon-bone interfaces were identified in group 2 than in group 1 at eight weeks (p < 0.012).

The ultimate load to failure increased with the number of suture anchors used immediately post-operatively, and at four and eight weeks. The increased load to failure at eight weeks seemed to be related to the increase in the surface area of healed tendon-to-bone in the double-row repair group.

The results of proximal humeral replacement following trauma are substantially worse than for osteoarthritis or rheumatoid arthritis. The stable reattachment of the lesser and greater tuberosity fragments to the rotator cuff and the restoration of shoulder biomechanics are difficult. In 1992 we developed a prosthesis designed to improve fixation of the tuberosity fragments in comminuted fractures of the proximal humerus. The implant enables fixation of the fragments to the shaft of the prosthesis and the diaphyseal fragment using screws, washers and a special toothed plate. Between 1992 and 2003 we used this technique in 50 of 76 patients referred to our institution for shoulder reconstruction after trauma. In the remaining 26, reconstruction with a prosthesis and nonabsorbable sutures was performed, as the tuberosity fragments were too small and too severely damaged to allow the use of screws and the toothed plate.

The Constant score two years post-operatively was a mean of 12 points better in the acute trauma group and 11 points better in the late post-traumatic group than in the classical suture group.

We recommend this technique in patients where the tuberosity fragments are large enough to allow fixation with screws, washers and a toothed plate.

We assessed the long-term results of 58 Souter-Strathclyde total elbow replacements in 49 patients with rheumatoid arthritis. The mean length of follow-up was 9.5 years (0.7 to 16.7). The mean pre-operative Mayo Elbow Performance Score was 30 (15 to 80) and at final follow-up was 82 (60 to 95). A total of 13 elbows (22.4%) were revised, ten (17.2%) for aseptic loosening, one (1.7%) for instability, one (1.7%) for secondary loosening after fracture, and one elbow (1.7%) was removed because of deep infection. The Kaplan-Meier survival rate was 70% and 53% at ten and 16 years, respectively. Failure of the ulnar component was found to be the main problem in relation to the loosening. Anterior transposition of the ulnar nerve had no influence on ulnar nerve paresthaesiae in these patients.

We compared six patients with a mean age of 70 years (49 to 80) with severe bilateral, painful glenohumeral joint destruction who underwent a single-stage bilateral total shoulder replacement, with eight patients of mean age 61 years (22 to 89) who underwent bilateral total shoulder replacement in two stages, at a mean interval of 18 months (6 to 43).

The overall function, pain and strength improved significantly in both groups. The subjective shoulder value, relative Constant score, active external rotation and the strength were improved significantly more in the single-stage group. Active elevation, abduction and overall function improved, significantly more in the single-stage group. Both the total duration of hospitalisation and the time off work per shoulder were substantially shorter in the single-stage group. The overall rate of complication was lower in the single-stage group.

Our findings indicated that single-stage bilateral total shoulder replacement yielded significantly better clinical results with shorter hospitalisation and rehabilitation than staged replacement, and was not associated with any increase in complications.