The musculoskeletal (MSK) profiles of water polo players and other overhead athletes has been shown to relate to injury and throwing performance (TP). There have been no robust studies conducted on the MSK profiles and the variables affecting TP amongst female, adolescent, elite water polo players. A prospective quantitative cohort design was conducted amongst eighty-three female adolescent, elite water polo players (range 14–19 years). All participants filled out the Kerlan-Jobe Orthopaedic Clinic questionnaire, followed by a battery of screening tests aimed to identify possible MSK factors affecting TP. Pain provocation tests, range of motion (ROM), upward scapula rotation (USR), strength and pectoralis minor length measurements were all included. Participants also performed throwing speed (TS) and throwing accuracy (TA) tests. All the data collected were grouped together and analysed using SPSS 28.0. The condition for statistical significance was set as p <0.05. Multi-collinearity was tested for among variables to find out inter-variable correlations. Finally, a multiple regression analysis was performed. The mean KJOC score was 82.55 ± 14.96. 26.5% tested positive for at least one of the impingement tests. The MSK profile revealed decreased internal rotation ROM, increased external rotation ROM, a downwardly rotated scapula, weak external rotators, weak serratus anterior strength, strong lower trapezius and gluteus medius strength and a shorter pectoralis minor length all on the dominant side. Age, pectoralis minor length, upper trapezius and serratus anterior strength as well as upward scapula rotation were all positively correlated with TS, while sitting height, upper trapezius and serratus anterior strength and glenohumeral internal rotation ROM were positively correlated with TA. Multiple MSK parameters were found to be related to TS and TA in elite, adolescent water polo players.
The Latarjet procedure is a well described method to stabilize anterior shoulder instability. There are concerns of high complication rates, one of these being a painful shoulder without instability due to screw irritation. The arthroscopic changes in the shoulder at time of screw removal compared to those pre-Latarjet have not been described in the literature. We conducted a retrospective review of arthroscopic videos between 2015 and 2022 of 17 patients at the time of their Latarjet screw removal and where available (n=13) compared them to arthroscopic findings at time of index Latarjet. Instability was an exclusion criterion. X-rays prior to screw removal were assessed independently by two observers blinded to patient details for lysis of the graft. Arthroscopic assessment of the anatomy and pathological changes were made by two shoulder surgeons via mutual consensus. An intraclass correlation coefficient (ICC) was analyzed as a measure for the inter-observer reliability for the radiographs. Our cohort had an average age of 21.5±7.7 years and an average period of 16.2±13.1 months between pre- and post-arthroscopy. At screw removal all patients had an inflamed subscapularis muscle with 88% associated musculotendinous tears and 59% had a pathological posterior labrum. Worsening in the condition of subscapularis muscle (93%), humeral (31%) and glenoid (31%) cartilage was found when compared to pre-Latarjet arthroscopes. Three failures of capsular repair were seen, two of these when only one anchor was used. X-ray review demonstrated 79% of patients had graft lysis. Excellent inter-rater reliability was observed with an ICC value of 0.82. Our results show a high rate of pathological change in the subscapularis muscle, glenoid labrum and articular cartilage in the stable but painful Latarjet. 79% of patients had graft lysis with prominent screws on X-ray.
Orthopaedic training in Southern Africa is largely focused on trauma, although elective procedures, such as knee arthroscopy are increasing. This is especially true in the private sector where most trainees will practice. The primary aim of this study was to assess the arthroscopic competency of orthopaedic trainees in a setting of limited resources. A prospective observational cohort study was carried out. Orthopaedic trainees of a Southern African university hospital performed basic arthroscopy on a knee model. Their surgical competency was assessed by two surgeons proficient in arthroscopy using the modified Basic Knee Arthroscopy Skill Scoring System (mBAKSSS).Abstract
Background
Methods
Total Shoulder Arthroplasty (TSA) is a solution to fixing shoulder complications and restoring normal shoulder functionality. Shoulder arthritis is one of the common indicators of TSA. Studies suggest that 15% and 7% of the total Rheumatoid Arthritis (RA) and Osteoarthritis (OA) patients respectively, in sub-Saharan Africa, have degenerated shoulders. These patients are implanted with a Total Shoulder Prosthesis (TSP). There are limited literature available on the morphometric features of African shoulders. Previous studies have indicated that differences in shoulder surface geometry of the European and African populations, exists. This study aims at identifying the structural differences of the humeral articulating surfaces between South African and Swiss data sets. The South African data set included the Computerised Tomography (CT) scans of cadavers sourced from the University of Cape Town and the Swiss data set included the cadaver CT scans obtained from the SICAS Medical Image Repository. Sixty reconstructed models of humerus were generated from these scans of 30 (bilateral) healthy cadavers (15 South African and 15 Swiss) using Mimics®. The humeral articulating surfaces were separated from the shaft by performing in-silico surgery using SOLIDWORKS®, according to the guidelines provided orthopaedic surgeons. A Matlab code was generated to determine the superior-inferior (S-I) and the anterior-posterior (A-P) circular diameter and the peak points (PPs) of the articulating surfaces. The PPs were defined as the highest point on the articulating surface, which is most likely to be in contact with the glenoid. The S-I diameter was found to be significantly greater (p<0.01) than the A-P diameter for both the data sets (average difference = 5.02mm). Both the average A-P and S-I diameter for the Swiss data set were significantly larger (p = 0.02 and p = 0.03) than the South African data set by 2.36 mm and 2.70 mm respectively. The PPs were found to lie at an off-set from the origin. in case of the Swiss data set the average PP lie on the superior-posterior (S-P) quadrant and for the South African data set the average PP was found to lie on the anterior-inferior (A-I) quadrant. The A-P variation on the position of PP was highly significant (p = 0.003). The results obtained in this study sheds light on the observed morphological variations between the South African and Swiss data sets. The observed circular diameter values are similar to the literature. The observed results suggest that the average TSP needed for the Swiss data set would have been larger than the ones needed for the South African data set. PP is a novel feature which has not been studied extensively. The fact that the average Swiss data set PP lie in the S-P quadrant might suggest that these humeral heads are more retroverted and superiorly tilted when compared to the South African data set. These morphometric variations can play a major role in post-TSA kinematics. The future scope of this study is to highlight other morphometric variations, if any, for the gleno-humeral articulating surfaces.
The morphology of the proximal part of the humerus varies largely. Morphometric features characterizing the three-dimensional geometry of the proximal humerus have revealed a wide difference within individuals. These parameters include head size, radius of curvature, inclination angle, retroversion angle, offsets and neck-shaft angle. Different implant designs have been adapted so as to make provision for these anatomical variations. However, the optimal design criteria are yet to be established. Implant design is one of the main factors determining the success of Total Shoulder Arthroplasty (TSA) since slight modifications in the implant anatomy could have significant biomechanical effects. Therefore, this study investigates the three-dimensional morphometric parameters of the South African proximal humerus which will serve as a basis for designing a new Total Shoulder Prosthesis for the South African population. Sixteen South African (SA) fresh cadaveric humeri (8 left, 8 right; 8 paired) were used in this study. The data consisted of 6 men and 2 women with ages ranging from 32 to 55 years (43.13 ±8.51). The humeri were scanned using a Computer Tomography (CT) scanner. The Digital Imaging and Communications in Medicine (DICOM) files from the CT data were imported into medical modelling software, MIMICS for reconstruction. The 3D reconstructed model of the humeri as an STL file was used for further processing. The STL data were generated as a cloud of points in a CAD software, SolidWorks. These were then remodeled by defining the detailed Referential Geometric Entities (RGEs) describing the anatomical characteristics. Anatomical reference points were defined for the anatomical neck plane, the epiphyseal sphere and the metaphyseal cylinder. Also, axes were defined which comprises of the humeral head axis and the metaphyseal axis. Thereafter, the posterior offsets medial offsets and the inclination angles were measured based on the RGEs. The posterior offset varied from 0.07 mm to 2.87 mm (mean 1.20 mm), the medial offset varied from 4.40 mm to 8.45 mm (mean 6.50 mm) while the inclination angle varied from 114.00º to 133.87º (mean 121.05º) The outcome of the study showed that the shape and dimensions of the proximal humerus varies distinctively. The articular surface is not a perfect sphere and differs independently with respect to the inclination angles. In addition, variations were noticeable in the medial and lateral offsets. The morphometric data on the African shoulder is very limited and this study will significantly contribute to the shoulder data repository for the SA population. The morphometric parameters measured in this study will be useful in designing a South African shoulder prosthesis that mimics the native shoulder hence eliminating post-surgical complications.
The aim of this study was to investigate the
relationship between the geometry of the proximal femur and the incidence
of intra-operative fracture during uncemented total hip arthroplasty
(THA). We studied the pre-operative CT scans of 100 patients undergoing
THA with an uncemented femoral component. We measured the anteroposterior
and mediolateral dimensions at the level of division of the femoral
neck to calculate the aspect ratio of the femur. Wide variations
in the shape of the femur were observed, from round, to very narrow
elliptic. The femurs of women were narrower than those of men (p
<
0.0001) and small femurs were also narrower than large ones.
Patients with an intra-operative fracture of the calcar had smaller
and narrower femurs than those without a fracture (p <
0.05)
and the implanted Corail stems were smaller in those with a fracture
(mean size 9 The variability of the shape of the femoral neck at the level
of division contributes to the understanding of the causation of
intra-operative fractures in uncemented THA. Cite this article:
The treatment goals in diaphyseal radius fractures are to regain and maintain length and rotational stability. Open reduction and plating remains the gold standard but carries the inherent problems of soft tissue disruption and periosteal stripping. Intramedullary nailing offers advantages of minimally invasive surgery and minimal soft tissue trauma. The purpose of this study is to describe the results of locked intramedullary nailing for adult gunshot diaphyseal radius fractures. A retrospective review of clinical and radiological records was performed on patients with intramedullary nailing of isolated gunshot radius fractures between 2009 and 2013.Purpose of study:
Methods:
Injuries inflicted by gunshot wounds (GSW) are an immense financial burden on the South African healthcare system. The cost of treating an abdominal GSW has previously been estimated at R30 000 per patient. No study has been conducted to estimate the financial burden from an orthopaedic perspective. To estimate the average cost of treating GSW victims requiring orthopedic interventions in a South African tertiary level hospital.Background:
Objective:
To investigate the incidence of post-operative ulna nerve symptoms in total elbow arthroplasty after full in-situ release. A retrospective review was completed of the medical records of eighty-three consecutive primary total elbow arthroplasties (TEA) performed between 2003 and 2012. Data analysed included the presence of pre-operative ulnar nerve (UN) symptoms, history of prior UN transposition, intra-operative management of the UN and presence of post-operative symptoms.Aim:
Methods:
To measure compliance with the Trauma Unit guideline relating to the early application of the Thomas splint in patients with a femur shaft fracture on clinical examination. Retrospective review of clinical and radiological records of patients presenting from 01 January 2012 to 31 December 2012 at a Level 1 Trauma Unit.Objectives:
Design:
To investigate the clinical outcomes of elbows with post-traumatic stiffness treated by open surgical release. A retrospective review was completed on thirty-five consecutively managed patients who underwent an open elbow release for post-traumatic stiffness between 2007 and 2012. Pre-operative and post-operative range of motion (ROM), pain scores and functional outcomes were recorded.Aim:
Methods:
The presence of an L5 transverse process fracture is reported in many texts to be a marker of pelvis fracture instability. There is paucity of literature to support this view. Available studies have been performed on patients who were already known to have a pelvis fracture. No study has attempted to document the presence of this lesion in the absence of a pelvis fracture. Primary aim: To identify the correlation between the presence of a L5 transverse process fracture and an unstable pelvic ring injury. Secondary aim: To establish whether a L5 transverse process fracture can occur in the absence of a pelvis fracture. We conducted a retrospective review of all CT scans performed in patients who presented to a Level 1 Trauma Unit for blunt abdomino-pelvic trauma between January 1, 2012 and August 28, 2013. A total of 203 patients met our inclusion criteria.Purpose of study:
Methods:
Computerised Tomographic Angiography (CTA) is less invasive than conventional angiography. It is our perception that CTAs are being requested and performed too frequently at our institution without correct indications. We assessed the number of CTAs that were done, the percentage of vascular injuries sustained and whether correct indications were followed when requesting CTAs. A review of records of the radiology department to determine the number of CTAs done for suspected extremity vascular injuries from January to December 2012. Inclusion criteria were CTAs performed during this period for suspected vascular injuries in fractures and dislocations and extremity gunshot wounds. A retrospective chart review was performed to determine the mechanism of injury, clinical picture (pulses, temperature, capillary refill and neurology), indications for and results of the CTA.Purpose of study
Methodology
Hypoplasia of the glenoid is a rare condition caused by incomplete ossification of the postero-inferior aspect of the developing glenoid. It may be isolated or associated with a more generalised condition. The clinical symptomatology is variable depending on the age at time of presentation. We performed a retrospective chart review of patients who presented with shoulder complaints, and in whom a radiographic diagnosis of glenoid hypoplasia had been made. From January 2002 to December 2012, 8 patients (9 shoulders) with radiological signs of glenoid hypoplasia were identified. The mean age at presentation was 39 years (range 23 to 77) and the mean symptom duration was 12.5 months (range 1 to 48).Introduction
Materials and Methods
To compare radiological and clinical outcomes between triceps-detaching and triceps-sparing approaches in total elbow arthroplasty, with specific focus on cementing technique and post-operative range of motion. A retrospective review was completed of medical records and radiographs of 56 consecutively managed patients who underwent a primary total elbow arthroplasty between 2000 and 2012 at a tertiary hospital. Rheumatoid Arthritis was the predominant pathology (47/56). Data analysed included patient demographics, range of motion pre-operatively and at various stages post-operatively, approach utilized, operative time and complications. Cementing technique was graded as adequate, marginal or inadequate according to Morrey's criteria.Aim
Methods
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 tendon transfers, capsular release and osteotomies. We compared the outcomes in patients who had arthroscopic release only and those who also underwent a tendon transfer. We retrospectively reviewed the clinical records of all patients with OBPI presenting to our unit in the years 2002–2012 who underwent surgical procedures for the treatment of an IR contracture of the shoulder. Increase in range of external rotation (ER) in adduction and abduction intra-operatively was recorded. At follow-up, active ER, the Mallet score, presence of an ER contracture and the “drop-arm” sign was recorded.Purpose of study
Methods
Rotator cuff tears are among the most common and debilitating
upper extremity injuries. Chronic cuff tears result in atrophy and
an infiltration of fat into the muscle, a condition commonly referred
to as ‘fatty degeneration’. While stem cell therapies hold promise
for the treatment of cuff tears, a suitable immunodeficient animal
model that could be used to study human or other xenograft-based
therapies for the treatment of rotator cuff injuries had not previously
been identified. A full-thickness, massive supraspinatus and infraspinatus tear
was induced in adult T-cell deficient rats. We hypothesised that,
compared with controls, 28 days after inducing a tear we would observe
a decrease in muscle force production, an accumulation of type IIB
fibres, and an upregulation in the expression of genes involved
with muscle atrophy, fibrosis and inflammation.Objectives
Methods
Dislocation is one of the most common orthopaedic complications after primary total hip replacement (THR). The reported dislocation rate in elective THR is 5–8%. This number increases up to 22% for THR done for neck of femur fractures. Due to the reported increase in dislocation for trauma, some surgeons prefer to do a hemi-arthroplasty or open reduction and internal fixation (ORIF). Hemi-arthroplasty is known to have poorer functional outcomes. Failure of ORIF is as high as 43%, and revision of failed ORIF to THR has reported dislocation rates of up to 42%. A retrospective review of all THR done for neck of femur fractures during 2006–2011 was undertaken. The patients in our institution who are considered for a THR must have an active life-style. Records were reviewed for delay to surgery, surgical approaches, articulations, bearing surfaces, follow up periods and cemented versus uncemented implants. We excluded all pathological fractures, extra-capsular fractures, failed ORIF, patients with incomplete data and patients with a follow-up period less than 3 months. Hip dislocation was the end-point of the review and we did not study other causes of revision e.g. loosening of components or infection.Introduction
Materials and methods
We aim to determine the amputation rate and identify predictors of outcome in patients with tibial fractures and associated popliteal artery injuries at a level 1 trauma unit draining a large geographical region. All patients with popliteal artery injuries and tibial fractures treated at a level 1 trauma unit between 1999 and 2010 were assessed retrospectively regarding amputation rates and prognostic factors and tested for significance with a Z-test of proportions.Purpose
Material and methods
Resurfacing of the glenohumeral joint has gained popularity since its first introduction in 1958. Advantages of resurfacing over conventional shoulder arthroplasty include preservation of humeral bone stock, closer replication of individual anatomy, reduction of periprosthetic fracture risk, non-violation of medullary canal, and ease of revision to a stemmed component if needed. We reviewed a group of patients with arthrosis of the glenohumeral joint who underwent humeral resurfacing, and who were at a minimum of two years post surgery. From January 2000 to March 2011, 51 humeral resurfacing procedures were performed in 49 patients. Patients were contacted for review, and assessed using patient reported outcome measures. An Oxford Shoulder score as well as a subjective satisfaction and outcome questionnaire was completed, as well as details regarding further surgery or revision. 2 patients had died, 11 patients were not contactable, and in 4 the medical files had been lost. In the remaining 32 shoulders, the average follow-up was 5.9 years. The mean age at time of surgery was 62.3 years (range 36 to 84).Introduction
Materials and Methods
To review the union rates, outcomes and complications of angular stable plating of lateral third clavicle fractures. Between 2007 and 2010 angular stable plates were used in the fixation for seventeen patients with displaced lateral third clavicle fractures (Allman Group II, Type 2). These were identified from surgical log books and operation codes. The surgical and clinical notes as well as X-rays were reviewed. The patients were contacted telephonically. An Oxford Shoulder Score and questions relating to plate removal, scar pain and return to activities were asked. Three patients were not contactable.Purpose:
Method:
Total elbow replacement (TER) is one of the surgical options for treatment of severe haemophilic arthropathy of the elbow. There are only a few small series described in the literature. The goal of our study was to evaluate our cases and add these data to the known literature. A retrospective analysis of a series of 8 TER's (5 patients) was performed. Patients were seen in clinic and evaluated by physical examination, a VAS score for pain, the Mayo Elbow Performance Score (MEPS, 100 points=excellent) and X-rays of the affected elbow. Mean follow-up was 91 (4–236) months, and 103 months when we excluded a patient with only 4 months follow-up. Primary diagnosis was Hemophilia type A in 4 and von Willebrand disease in 1 patient. 2 patients were positive for Hepatitis C and 3 for HIV. Mean age at primary surgery was 46.7 (31.8–63.1) years.Purpose of study:
Methods:
Interposition arthroplasty is a salvage procedure for patients with severe osteoarthritis of the elbow where conservative treatment failed. It is mostly performed in younger patients where total joint replacement is contraindicated and an arthrodesis is unattractive. Although one of the oldest reconstructive options for elbow arthritis, the procedure is not without complications. There are only a few case series described in the literature. The purpose of our study is to review our cases and report their outcome. We retrospectively reviewed 18 consecutive cases of interposition arthroplasty between 2001 and 2010. 2 cases were excluded due to incomplete records. The mean patient age was 41.3 (19.4–58.6) years at time of surgery. The primary diagnosis was post-traumatic osteoarthritis in 11 cases and inflammatory osteoarthritis in 5 cases. The mean follow up was 4.7 (0.4–10) years. Pre- and post-operative pain and function was evaluated using the Visual Analogue Scale (VAS) and Mayo Elbow Performance Score (MEPS). The complications and the number of re-operations and revisions were recorded.Purpose:
Method.
We aimed to assess the short and medium term complications of patients who had undergone Latarjet procedures. We also compared this to a group of patients who over a similar period underwent an open Bankhart procedure to assess the complication profiles between the two groups. We retrospectively reviewed the notes and X-rays of all patients identified by surgical log books and or operation codes for instability. Eighty seven patients (88 shoulders) underwent Latarjet procedures between 2002 and 2010. Patients were phoned to obtain a telephonic Oxford shoulder score. There were 44 patients with 46 shoulders in the open Bankhart group.Purpose:
Method:
Unstable pelvic ring injuries usually occur in polytrauma patients and are associated with high mortality and morbidity. Percutaneous screw fixation of sacro-iliac joint dislocations, fracture-dislocations and sacral fractures is a well-recognised technique first described by Routt and is increasingly gaining popularity. This method is biomechanically comparable to open reduction and internal fixation with plates and screws but offers the advantages of minimally invasive surgical techniques. It is however a technically demanding procedure with reported complications including hardware failure, misplacement of screws, nerve injury and poor posterior reduction. The purpose of the study is to report clinical results of patients treated with closed reduction and percutaneous ilio-sacral screw fixation for unstable pelvic ring fractures by a single surgeon. A review of prospectively collected data was performed on all patients who had percutaneous sacro-iliac fixation between 2009 and 2012. Thirty five percutaneus sacro-iliac screws were inserted in 30 patients with a mean age of 25.6 years (range 17–62). Fracture types included 10 AO type B, and 20 AO type C. The mean follow-up period was 11.6 months (range 3–38). The complications assessed were screw misplacement, neurovascular complications, hardware breakage and loss of reduction.Purpose of study
Methods
The purpose of this study was to follow up a cohort of South African doctors who had previously failed a validated musculoskeletal assessment tool, to examine the effect of a two-month Orthopaedic internship rotation on musculoskeletal competency. A validated competency examination in orthopaedic medicine was used as the assessment tool. Topics included fractures and dislocations, arthritis, basic anatomy and emergencies that require immediate referral to an orthopaedic surgeon. The questionnaire consists of twenty-five short-answer questions. A validated answer key and scoring system were used to mark the questionnaire. In a previous study, we found that 91 per cent of South African doctors in our study group, at the start of their internship, failed to demonstrate basic competency on the examination. We concluded that medical school preparation in orthopaedic medicine in South Africa is inadequate. We reapplied the examination at the end of 2011 to a study group of seventy-six first and second-year interns, to assess whether a two-month orthopaedic rotation during internship had a significant effect on musculoskeletal competency.Purpose
Methods
The outcomes of conservatively managed minimally displaced isolated greater tuberosity fractures are sparsely reported and the aim of this study was to look at the outcome of these fractures. Twenty-seven patients who had sustained a greater tuberosity fracture were identified. They were all managed by a single surgeon. All patients had a regime of initial immobilisation for 3 weeks followed by physiotherapy and range of motion exercises. They were all x-rayed at 1 week and 3 weeks after injury to monitor for any displacement. Four fractures occurred with an anterior dislocation. In seven patients the fracture was not visible on x-ray but was diagnosed on Ultrasound or MRI. Twenty-three of 27 patients were available for follow-up. For this follow up, the patients were telephonically contacted and the Oxford Shoulder Score (OSS) was completed to assess their outcome.Purpose of study
patients and methods
The addition of interlocking screws to intramedullary nails adds greatly to the stability of these constructs, yet the placement of distal screws accounts for a significant proportion of the total fluoroscopy and operative times. The Sureshot® (Smith and Nephew™) is a computerised system that allows placement of distal screws without fluoroscopy by using electromagnetic guided imagery. The purpose of this study is to compare traditional free-hand technique to the Sureshot® technique in terms of operating time, radiation dose and accuracy. Between September 2011 and March 2012 we prospectively randomised 66 consecutive patients presenting to us with femur shaft fractures requiring intramedullary nails to either free-hand (n=33) or Sureshot® assisted (n=28) distal locking. Fractures warranting only one distal locking screw, or those requiring retrograde or cephalo-medullary nailing, were excluded. Five patients' data was not suitable for analysis. The two groups were assessed for distal locking time, distal locking radiation and accuracy of distal locking.Purpose of study
Methods
Acute scaphoid fractures are commonly treated with cast for 8–12 weeks. With this prolonged period of immobilisation patients can encounter joint stiffness and muscle wasting requiring extensive physiotherapy. Despite best practice, these fractures also pose a risk of non-union and suboptimal function. Fracture location, duration of time lost from work and impairment in activities of daily living are key factors in scaphoid fracture management. The aim of our study was to compare percutaneous screw fixation of the scaphoid with other operative fixation techniques. Parameters documented were length of conservative treatment, mechanism of injury, post-op complications and patient satisfaction levels with each technique using a standardised questionnaire. Economic benefit was also measured by examining time to return to work, number of x-rays and outpatient visits required per treatment group. In this study, 76 patients requiring operative scaphoid fixation were evaluated. 27 patients underwent percutaneous fixation. Waist fractures accounted for 66% (n= 18), proximal pole fractures 33% (n=8) and distal pole fractures 4% (n=1). There were 16 non-displaced fractures (59%) and 11 displaced fractures (41%). The average length of conservative treatment was 77 days (range: 2–256 days). Within the percutaneous group 2 patients developed non-union. We did not encounter any wound infection or superficial radial nerve damage. Patients treated with early percutaneous fixation had highest satisfaction levels, returned to work earlier and required less follow-up (P< 0.001). In conclusion percutaneous screw fixation provides earlier bone union and avoids the need for prolonged immobilisation when compared to other treatment modalities. The economic benefit of early percutaneous fixation must also be considered when managing patients with scaphoid fractures.
Seven patients with osteochondral defects of the humeral head were treated over a 3 year period (2002–2005). In six of the patients the diagnosis was made incidentally at time of arthroscopy with the seventh patient being diagnosed preoperatively. There were 5 males and 2 females with an average age of 48 years. Four patients had a history of trauma. The preoperative diagnosis was impingement in 5, supraspinatus partial thickness tear in one and an osteochondral defect in the seventh. Ultrasound revealed a supraspinatus partial thickness tear in one, fluid in the biceps grove in one, and was normal in the other 5. One patient had a MRI which showed a SLAP lesion. All patients had conservative treatment with subacromial injection with 2 patients having complete relief of pain, 2 having almost complete relief, and the other 4 having improvement but not complete relief of pain. Only 2 of the patients had a minor reduction in movement. At arthroscopy the osteochondral defect measured 1x 1 cm in four cases and 1 x 1,5 cm in the other 3. In all patients the osteochondral defect was debrided and the exposed bone abraded. Four patients had an acromioplasty, one had an acromioplasty and excision of the AC joint, one had a debridement only and the seventh patient had an acromioplasty, SLAP repair and debridement of a partial thickness supraspinatus tear. The follow-up averaged 24 months (6–58). The VAS improved from an average of 6,4 preoperatively to 1,2 postoperatively and the ASES improved from 47 preoperatively to 85 postoperatively. All patients were happy to have had the procedure. In conclusion, debridement and abrasion of osteochondral defect was an effective treatment in this series. Acromioplasty should be added when indicated.
Five patients with entrapment of the suprascapular nerve treated in a 7 year period (2000–2006) were reviewed. There were 4 males and 1 female with an average age of 35 years (15–59). The patients presented with non-specfic pain around the scapula and shoulder. Four of the patients had marked wasting and weakness of the supraspinatus and infraspinatus muscles. One patient had congenital non-union of the clavicles. One patient was a competitive pole vaulter but there was no apparent aetiological factor in the other 3. The diagnosis was confirmed with nerve conduction studies in all the patients. All underwent MRI scan which was normal in 4 patients and showed a cyst in the spinoglenoid notch in the 5th. Four patients had an open release of the suprascapular nerve, the patients whose MRI showed a cyst was found at surgery to have an abnormal vessel compressing the nerve. One patient had an arthroscopic release of the suprascapular nerve. Four patients were available for follow-up. The follow-up averaged 22 months (6–58). All patients had complete relief of pain and almost complete recovery of strength. In conclusion, the diagnosis of suprascapular nerve entrapment must be entertained when patients present with non-specific periscapular pain and wasting of the supraspnatus and infraspinatus muscles. MRI must be done to rule out cysts. Surgical release is successful and can be done arthroscopically.
Proximal humeral locked plates have been advocated as an improved option for treating displaced proximal humeral fractures. After a number of failures using other methods we moved to this option in 2003. We reviewed all patients treated with this method, since we started in 2004. 16 patients were available for follow up. Using the Simple Shoulder Test and the Oxford Shoulder Score we assessed their level of function and pain. X-rays were checked for loss of fixation and union. The average follow up was 13 months post-surgery; the average age was 61 years. Using Neer’s classification, seven had 2 part fractures, seven had 3 part fractures and two had 4 part fractures. All fractures united and the patients reported good shoulder function. None had loss of fixation. There were no cases of sepsis. There were two patients awaiting hardware removal and one patient has already had removal for subacromial impingement. The results in this limited series compare favourably with the reported literature and we had no loss of fixation compared to our previous treatment.
Over one year a bio-absorbable corkscrew was used in 19 rotator cuff repairs in 17 patients (10 men and seven women) with a mean age of 52 years (25 to 68). Seven were partial thickness tears. The 12 full thickness tears involved only the supraspinatus in all but four patients. Open surgery was performed on these four patients, who had an isolated subscapularis tear, an isolated teres minor tear, a combined supraspinatus and infraspinatus tear and a combined supraspinatus, infraspinatus and subscapularis tear. The remaining patients underwent arthroscopic repair. All patients had an acromioplasty and 13 had the acromioclavicular joint excised. Two patients had a concomitant SLAP repair. One corkscrew was used in 10 cases, two in six and three in two. The mean follow-up was 8 months (3 to 24). The mean Constant score at follow-up was 80. There were five complications (26%) in which the corkscrew or a fragment of it came loose in the subacromial space. Two patients required further surgery to remove the corkscrew. The corkscrew was found to be a useful device for rotator cuff repairs, but the complication rate was high.
Of 81 elbow replacements performed over a seven-year period, 11 were total elbow revision (TER) procedures, which were done on two men and nine women with a mean age of 61 years (40 to 70). Seven of the patients had rheumatoid arthritis, three had post-traumatic osteoarthritis and one had haemophilia. The reason for revision was aseptic loosening in eight patients and aseptic loosening with fracture in the other three. The prostheses revised were the Souter in eight patients, the Kudo in one, the GSB I in one and the Dee in one. In revision TER, one long stem Souter prosthesis was used, two Pretoria, one GSB 3 and seven Morrey. The mean time from primary to revision TER was 10 years (2 to 31). At a mean follow-up of 30 months (6 to 48), all except one patient were pain-free and the arc of flexion had increased by 30°. Complications included one dislocation, one radial nerve palsy, which recovered after six months, and one aseptic loosening. There were no cases of sepsis. Revision TER is a technically demanding procedure with a high risk of complications. In this series patient satisfaction was high. Our policy is to use a hinged prosthesis, preferably the Morrey, in revision TER.
This study looks at the outcomes of 112 full thickness rotator cuff tears treated by arthroscopic decompression, without repair of the rotator cuff, from 1994. The decision not to repair the tear was taken only if four criteria were met. First, if there was no clinical weakness on manual testing of the individual rotator cuff muscles, secondly, if there was full abduction, thirdly, if there was no riding up of the humeral head on the anteroposterior radiograph and fourthly, if there was well-developed ‘cable’ on arthroscopic visualisation of the rotator cuff. The mean age of the patients, 38% of whom were men, was 62 years (47 to 83). In 44% the right shoulder was operated on. There were 32% type-II acromions and 68% type-III. There were 58% C2 tears and 42% C3 tears. All had arthroscopic acromioplasty and acromioclavicular joint excision. Later, three required an open acromioclavicular joint excision with one open cuff repair. At a mean follow-up time of 71 months (11 to 110), the clinical and surgical notes and radiographs were reviewed and a modified Simple Shoulder Test (SST) used to evaluate outcomes by telephone. The mean postoperative SST was 11.5 out of 12 (3 to 12). Complete relief was reported in 84% of cases. These subjective results suggest that, with careful selection, not all full thickness tears of the rotator cuff need repair.
We retrospectively reviewed the results of 21 patients (22 shoulders) who had surgery for os acromiale. The mean age of the 6 men and 15 women was 52 years. The dominant side was involved in 10 patients. The duration of symptoms ranged from one month to 13 years. Ten patients had a history of recent trauma. All presented with tenderness over the site of the os and signs of impingement. In three patients, signs of weakness suggested a rotator cuff tear, and three patients had tenderness over the acromioclavicular joint. Rotator cuff tears, four partial and eight full thickness, were present in 12 cases. Surgery included excision of the os in nine cases and fixation in 13. Ancillary procedures included acro-mioclavicular joint excision (eight), rotator cuff repair (eight), cuff debridement (three) and biceps tenodesis (one). At follow-up, which ranged from 5 months to 6 years, Constant and American Shoulder and Elbow Surgeons’ scores were assessed. The presence of a deltoid defect was noted and deltoid strength was measured. The mean Constant score at follow-up was 77. Deltoid strength was notably reduced in abduction but not in forward flexion. There were no cases of sepsis. Five cases required further surgery. In three, this involved removal of metal, but persistent pain necessitated one subsequent rotator cuff repair and one arthroscopic debridement of the subacromial space. The outcome of both fixation and excision was satisfactory, but the reoperation rate was higher in patients who underwent fixation. We advise arthroscopic excision of meso-acromion in the absence of a full thickness rotator cuff tear.
To determine the radiological signs and the ease of diagnosis on different views, we reviewed true antero-posterior, axillary and supraspinatus outlet views of 26 shoulders with os acromiale. The anteroposterior view shows sclerosis and ‘double oval’. The supraspinatus outlet view shows a ‘double’ acromion. The axillary view demonstrates the site of the pseudarthrosis and size of the os. The os acromiale was visible on the anteroposterior view in 25 cases, on the supraspinatus outlet in 20 cases and on the axillary view in 17 cases. It was visible in at least two views in 25 of the cases. The os was more often evident on the anteroposterior view, but more clearly seen on the axillary. A radiologist reported on 13 of the X-rays and missed the diagnoses in nine cases. In two cases, the surgeon missed the radiological diagnosis. There were 20 meso-acromions and two pre-acromions.
In this retrospective radiographic review, we compared the adequacy of reduction of 18 femoral fractures treated by retrograde and 35 fractures treated by pro-grade nailing. The groups were similar with regard to age, gender and side of the fracture. In the prograde group, there were eight fractures of type A5, 25 of type A3 and two of type C2. In the retrograde group there were two type-A2 fractures, 14 type-A3 and two type-C2. On the Winquist classification there were eight group-0, two group-1, two group-3 and 23 group-4 fractures in the prograde group, and two group-0, one group-3 and 15 group-4 fractures in the retrograde group. We measured the lateral femoral angle (LFA) from the anatomical axis to assess alignment postoperatively. We considered an LFA value of 83( normal and LFA values between 78( and 88( acceptable. The LFA was greater than 88( in 3% of the prograde group and in 6% of the retrograde group. In the prograde and retrograde groups, 86% and 83% of the nails respectively were in the acceptable range. In both groups, the LFA was less than 78( in 11%. There was shift of more than 1 cm in 17% of the prograde and in 44% of the retrograde groups. Recurvatum of more than 5( was seen in 31%( of prograde and 22% of retrograde nailings. In the retrograde group, 67% of nails were distal to the femoral notch on the lateral radiograph and were deemed to be proud. We concluded that prograde and retrograde nailing of distal third femur fractures gave comparable results in terms of alignment, but that recurvatum could be problematic with prograde nailing and that shift and proud nails were a concern with retrograde nailing. The clinical significance of these results has still to be determined.
This paper highlights the fact that full length labral tears are a cause of instability in posterior fracture-dislocations of the hip. From July 1994 to March 2001, 133 consecutive posterior fracture-dislocations of the hip were surgically treated. On admission, all patients were initially subjected to closed reduction, and in some cases skeletal or skin traction was applied. Pelvic radiographs were taken to confirm relocation, and CT done to look for intra-articular bone fragments. Intra-operative findings and surgical technique were recorded. Redislocation occurred in eight patients, whose surgical notes were reviewed to determine the cause. Despite 9 kg of skeletal traction, one patients’s hip redislocated the day after closed reduction. In the other seven, redislocation occurred postoperatively. The time to redislocation varied from one day to 16 weeks, and because redislocation was sometimes painless, not all patients reported it immediately. Two patients, whose radiographs showed very small fragments at the superior-posterior position, would normally have been treated conservatively. On one, surgery was performed because the fragment was lodged at the weight-bearing area of the joint. The hip of the other redislocated on skeletal traction the day after closed reduction. At surgery, it was noted that both patients had extensive soft tissue stripping and full length tears of the labrum. The other six patients had clear posterior wall fractures requiring surgical reconstruction. The fragments were often attached to the capsule but were too small to fix with screws, so buttress plating was used alone. Full-length labral tears in posterior dislocations of the hip cause instability, and failure to address this adequately at surgery may result in redislocation.
We treated 133 traumatic posterior dislocations surgically between July 1994 and March 2001. In 16 patients, labral tears had occurred. Operating on posterior hip dislocations, initially we fixated the posterior wall with screws and/or buttress plate, depending on the size of the fragment, and did suture the torn labrum, relying rather on the buttress plate or intact posterior wall for stability. We began repairing the torn labrum when we realised that any small fragments still attached to the labrum simply pull out from under the buttress plate, allowing the hip to redislocate. Once the wall has been reconstructed, interrupted sutures are passed through the labrum, with the hip internally rotated to prevent shortening of the capsule when sutures are tied. A one-third tubular plate is placed over the sutures lying on the posterior wall and fixed with screws. The sutures are then tied individually over the plate. Postoperatively the patient is kept in bed for six weeks, with the hip abducted and knee extended. Seven patients in whom the labrum was not repaired experienced redislocation. We performed second operations on two of them, repositioning the plates and reconstructing the posterior wall, but redislocation again occurred. The redislocated femoral heads were damaged because they rubbed against the plate and screws. In the other nine patients, we sutured the labrum, and in a 3 month to 2.5 year follow-up, no redislocation has occurred. . Labral repair restores stability, and tying interrupted sutures over a buttress plate is an easy and effective method of repair.
