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The Bone & Joint Journal
Vol. 95-B, Issue 9 | Pages 1158 - 1164
1 Sep 2013
Ahmad Z Siddiqui N Malik SS Abdus-Samee M Tytherleigh-Strong G Rushton N

Lateral epicondylitis, or ’tennis elbow’, is a common condition that usually affects patients between 35 and 55 years of age. It is generally self-limiting, but in some patients it may continue to cause persistent symptoms, which can be refractory to treatment. This review discusses the mechanism of disease, symptoms and signs, investigations, current management protocols and potential new treatments.

Cite this article: Bone Joint J 2013;95-B:1158–64.


Bone & Joint 360
Vol. 2, Issue 4 | Pages 35 - 35
1 Aug 2013
Tytherleigh-Strong G


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_8 | Pages 7 - 7
1 Feb 2013
Griffiths D Young L Obi N Nikolaou S Tytherleigh-Strong G Van Rensburg L
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The current standard for treatment of humeral shaft fractures is in a functional humeral brace. Aims: To further assess the union rate for this mode of treatment and to delineate and any fracture type less likely to go on to union.

Retrospective radiographic and clinical review of 199 consecutive acute adult humeral shaft fractures. 43 operated on acutely (including all open fractures). Remaining 156 fractures treated in a humeral brace. Non union was determined as delayed fracture fixation or no evidence of union at 1 year. Union rate 82.9% with 88.5% follow-up. 16 of the 24 non unions were proximal third (all but one spiral/oblique): 71.4% union rate. Middle third fractures 87.3% and distal third shaft fractures 88.9 % union rate. Union rate of fractures with 3+ parts inclusive of all regions of the shaft was 95.6%.

The union rate in this study is not as high as has previously been reported for functional brace treatment. A lower threshold for intervention in proximal third spiral/oblique humeral shaft fractures may be indicated. Fracture site comminution is a very good prognostic indicator.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_1 | Pages 215 - 215
1 Jan 2013
Ahmad Z Wardale J Henson F Brooks R Tytherleigh-Strong G Noorani A Siddiqui N Rushton N
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Introduction

Massive rotator cuff repairs have up to 60% failure rate and repair of a chronic repair can have up to 40% failure rate. With this in mind, new methodologies are being to being developed to overcome this problem. The use of tendon augmentation grafts is one of them. Prior attempts have shown equivocal or poorer outcomes to control repairs. Aims and objectives: The specific aim of these expereiments was to test how well ovine tendon cells would take to a specific biological augmentation graft (Ligamimetic), and wheter tissue engineering techniques would enhance this.

Method

Tendon cells harvested from ovine tendons will be cultured, exposed to the tendon augmentation graft, and analysed to see how well it takes to the tendon cells. We have conducted a 21 day experiment, sampling at days 7, 14, and 21. The experiment will look in sheep tendon cells:1. Platelet rich plasma: A comparison of the effects of platelet rich plasma to cell adherence, cell proliferation, and collagen production. Mesenchymal stem cell: A comparison of the effects of mesenchymal stem cells to the material on cell adherence, cell proliferation, and collagen production.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_1 | Pages 216 - 216
1 Jan 2013
Ahmad Z Wardale J Henson F Brooks R Tytherleigh-Strong G Noorani A Siddiqui N Rushton N
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Introduction

Rotator cuff tears remain a problem, with massive tears having a failure rate of repair reported of up to 60%, despite advances in surgical techniques. Tissue engineering techniques offers the possibility of regenerating damaged tendon tissue to a pre-injury state. We explore these techniques by implanting two novel tendon augmentation grafts with use of platelet rich plasma (PRP) in sheep.

Methods

A total of 24 sheep were operated on, with the infraspinatus being surgically cut from its attachment to the humeral head. Each tendon was repaired using suture anchors and an interpositional implant according to 4 groups: (1) Empty control, (2) Novel collagen fibre implant with PRP (3) A novel collagen sponge implant (4) and the collagen sponge with PRP. The sheep were killed at 12 weeks and the implant site harvested and its histology evaluated.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIX | Pages 181 - 181
1 Sep 2012
Ollivere B Rollins K Elliott K Das A Johnston P Tytherleigh-Strong G
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Purpose

The evolution of locked anatomical clavicular plating in combination with evidence to suggest that fixation of clavicle fractures yields better outcome to conservative treatments has led to an increasing trend towards operative management. There is no evidence however to compare early fixation with delayed reconstruction for symptomatic non- or mal-union. We hypothesize that early intervention yields better functional results to delayed fixation.

Methods

Between August 2006 and May 2010, 97 patients were managed with operative fixation for their clavicular fracture. Sixty eight with initial fixation and 29 delayed fixation for clavicular non- or mal-union. Patients were prospectively followed up to radiographic union, and outcomes were measured with the Oxford Shoulder Score, QuickDASH, EQ5D and a patient interview. Mean follow-up was to 30 months. All patients were managed with Acumed anatomical clavicular plates.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_I | Pages 118 - 118
1 Mar 2009
Tytherleigh-Strong G Smith RC Getgood A
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Aim: To characterise the reasons for failure following primary surgical stabilisation, the indications and the results of surgery in a subgroup of patients undergoing revision arthroscopic shoulder stabilisation.

Methods: All patients who underwent revision shoulder stabilisation over a 3 year period were included in the study. Information about the index procedure, imaging and the findings at arthroscopy were used to characterise the mechanism of failure. Patients were assessed clinically and WOSI scored at 6 and 12 months and then annually.

Results: Thirty-six patients were reviewed. Twenty underwent an arthroscopic (AR) and 15 underwent an open (OR) revision procedure. The AR index procedures were 15 arthroscopic (4 suture-anchor, 10 thermal shrinkage, 1 unknown) and 5 open (3 Bankart, 2 Putti-Platt). The OR index procedures were arthroscopic 10 (4 suture-anchor, 3 transglenoid, 2 thermal shrinkage) and 6 open (4 Bankart, 2 Putti-Platt). Soft-tissue failure was the primary mechanism in all AR cases (4 further trauma, 7 inappropriate primary procedure, 3 missed pathology, 6 technical error). The OR primary mechanism of failure was bone loss 12 (4 epileptic) and soft-tissue failure 3. At AR follow-up of 25.8 months (10–45) there had been 1 re-dislocation and 1 subluxation, mean WOSI 298 (68–517). There had been no OR re-dislocations at 22.5 months (10–42) follow-up, mean WOSI 313 (76–621).

Conclusion: Recurrent instability following surgical stabilisation maybe due to bone loss or soft-tissue failure (further trauma, inappropriate primary procedure, missed pathology, technical error). Revision arthroscopic surgery maybe indicated in soft tissue failure cases and can produce acceptable medium term results.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_II | Pages 360 - 360
1 Jul 2008
Smith RC Tytherleigh-Strong G
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Aim: To characterise the reasons for failure following primary surgical stabilisation in a group of patients considered suitable to undergo revision surgical stabilisation using arthroscopic techniques.

Methods: Patients presenting to our institution following failure of a primary shoulder stabilisation who underwent a revision arthroscopic stabilisation were reviewed. Information about the index procedure, imaging and the findings at arthroscopy were used to characterise the mechanism of failure. Shoulders were assessed pre-op by clinical examination and the WOSI score. At the time of arthroscopy patients proceeded to an appropriate stabilisation procedure using either a suture anchor or a modified transglenoid technique. Shoulders underwent a standard rehabilitation protocol and were reviewed at 6 weeks and then 6 monthly.

Results: Twenty patients underwent a revision arthroscopic stabilisation and were included in the study. Index procedures were arthroscopic stabilisation 4, thermal shrinkage 10 (un-repaired Bankart in 6), open Bankart 2, Putti-Platt 2, unknown procedure 2. Time from index procedure to re-dislocation ranged from 3 months to 7 years. The mechanism of failure was due to soft-tissue problems in all cases and could be grouped into four different categories. Further trauma 4 Inappropriate primary procedure 7 Missed pathology 3 Technical error 6 At early follow up of 6 – 42 months following revision arthroscopic stabilisation 1 patient re-dislocated at 12 months due to further trauma.

Conclusion: Recurrent instability following surgical stabilisation maybe due to soft-tissue failure. Soft-tissue failure can be subdivided into further trauma, inappropriate primary procedure, missed pathology and technical error. Cases within these subdivisions may be suitable for revision surgery using arthroscopic techniques.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_I | Pages 51 - 51
1 Mar 2008
Changoor A Tytherleigh-Strong G Runciman J Hurtig M Miniaci A
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Two fixation devices for rotator cuff repair were compared in a sheep model. Surgical transection of the supra-spinatus tendon insertion was repaired using metallic OBL suture anchors or Suretac II anchors. Twelve weeks postoperatively the repair site was assessed using histology, polarized light microscopy and biomechanical testing. No important differences were found between these two repair methods.

The purpose of this study was to compare traditional rotator cuff fixation devices with bioabsorbable press-fit tacks.

Sixteen sheep were assigned to OBL (n=8) or Suretac (n=8) treatment groups. Four sheep shoulder joints were used as unoperated controls. Treated sheep underwent general anesthesia and a lateral arthrotomy using aseptic technique to allow transection of the supraspinatus tendon insertion. The tendon-bone interface was repaired with two fixation devices according to the manufacturer’s directions. After recovery from anesthesia the sheep were maintained in small pens for twelve weeks. After sacrifice, muscle-tendon-bone blocks were prepared for mechanical testing. The specimen underwent a preload of 25N, followed by cyclic loading (10–50N x10), then loading at 480mm/min until failure. The remaining bone-tendon interface was fixed, embedded in plastic and 100μ undecalcified histological sections were cut, polished and stained.

All tendons had healed to the humerus and the repair site was two to three times larger than unoperated controls. There were no significant differences between the two treatment groups with respect to maximum load, modulus, and energy per unit area. Histological analysis is ongoing.

These data suggest that these two fixation methods are functionally equivalent in this model. Press-fit fixation devices do not knot tying and they can be inserted arthroscopically so they are a convenient fixation method.

This study confirms that press fit anchors and metallic anchors with sutures are equivalent for repair of bone-tendon interfaces.

Funding: Smith & Nephew supplied the fixation devices for this project. Thanks to Deb McWade for technical assistance.


The Journal of Bone & Joint Surgery British Volume
Vol. 89-B, Issue 1 | Pages 143 - 143
1 Jan 2007
Tytherleigh-Strong G


The Journal of Bone & Joint Surgery British Volume
Vol. 88-B, Issue 7 | Pages 860 - 864
1 Jul 2006
McCullough CJ Remedios D Tytherleigh-Strong G Hua J Walker PS

Between June 1991 and January 1995, 42 hydroxyapatite-coated CAD-CAM femoral components were inserted in 25 patients with inflammatory polyarthropathy, 21 of whom had juvenile idiopathic arthritis. Their mean age was 21 years (11 to 35). All the patients were reviewed clinically and radiologically at one, three and five years. At the final review at a mean of 11.2 years (8 to 13) 37 hips in 23 patients were available for assessment.

A total of four femoral components (9.5%) had failed, of which two were radiologically loose and two were revised. The four failed components were in patients aged 16 years or less at the time of surgery. Hydroxyapatite-coated customised femoral components give excellent medium- to long-term results in skeletally-mature young adults with inflammatory polyarthropathy. Patients aged less than 16 years at the time of surgery have a risk of 28.5% of failure of the femoral component at approximately ten years.


Orthopaedic Proceedings
Vol. 85-B, Issue SUPP_II | Pages 121 - 121
1 Feb 2003
Tytherleigh-Strong G Sforza C Levy O Copeland S
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To assess the indication and role of shoulder arthroscopy for the problem shoulder arthroplasty.

Between 1995–2000, 28 patients who had excessive pain or limitation of motion following a shoulder arthroplasty underwent arthroscopy. A pre-operative diagnosis was made in 13 out of the 28 patients.

Of the 13 patients who had a pre-operative diagnosis an impingement syndrome was confirmed and successfully treated by arthroscopic subacromial decompression in 10, a rotator cuff tear was confirmed and debrided in two and in one loose bodies removed. Of the 15 patients who did not have a pre-operative diagnosis a post-arthroplasty capsular fibrosis was found in seven, six undergoing a successful arthroscopic capsular release. Loose or worn components were found in four of the shoulders, a small cuff tear was identified in one, a florid synovitis was present in another, loose cement was found in a further patient and in one no abnormality could be found. During the procedures orientation within the joint was often hindered by the reflection from the prosthesis making it difficult to differentiate between the real and mirror images of both the tissues and arthroscopic instruments. Access was also often compromised.

Arthroscopy following shoulder arthroplasty is useful for the diagnosis and treatment of pain and loss of motion in selected patients, but can be technically demanding. Diagnostic arthroscopy following shoulder arthroplasty should be considered for patients suffering from pain in whom no cause can be found using less invasive investigations.


Orthopaedic Proceedings
Vol. 85-B, Issue SUPP_II | Pages 105 - 106
1 Feb 2003
Tytherleigh-Strong G Miniaci A
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To assess the use of autogenous osteochondral graft fixation (mosaicplasty) in unstable osteochondritis dissecans (OCD) lesions (Clanton type 2 and 3) of the knee.

Eleven patients with x-ray and N4R1 confirmed OCD lesion in their femoral condyle, that had remained symptomatic despite adequate conservative treatment, underwent arthroscopic mosaicplasty plug fixation of the lesion. The OCD lesions were all loose at operation and were all fixed rigidly in situ. using a number of autogenous 4. 5min osteochondral plugs harvested from the edge of the trochlear groove. The patients were prospectively assessed both clinically and by MRI scan at 3, 6 and 12 months and then six monthly. Average follow up was 2. 7 years (2 – 4. 1).

Prior to operation all patients had joint effusions and were experiencing pain limiting their activities. By 6 months post-operation the IKDC score had returned to normal in all cases and none of the patients had joint effusions or pain. Serial NHU scans documented healing of the osteochondral plugs and a continuous articular cartilage surface layer in all cases by 9 months.

Using mosaicplasty plug fixation we were able to obtain healing in all 1 1 unstable OCD lesions. The benefits of this technique are the ability to obtain rigid stabilization of the fragment using multiple plugs, stimulation of the subchondral blood supply and autogenous cancellous bone grafting. We conclude that mosaic-plasty plug fixation of unstable OCD lesions in the knee is a good technique and recommend its use.

Eleven patients with an unstable osteochondritis dissecans lesion (OCD) in their femoral condyle underwent in situ arthroscopic osteochondral graft fixation (mosaicplasty) of the lesion using a number of 4. 5min plugs harvested from the trochlear groove. By 6 months follow-up all of the patients were pain free with no joint effusion and by 9 months all had NW evidence of plug healing and continuous articular cartilage coverage. The benefits of this technique are the ability to obtain rigid stabilization, stimulation of the subchondral blood supply and cancellous bone grafting. We conclude that mosaic-plasty fixation of OCD lesions is a useful technique.


The Journal of Bone & Joint Surgery British Volume
Vol. 83-B, Issue 4 | Pages 619 - 621
1 May 2001
THOMAS S TYTHERLEIGH-STRONG G DODDS R


The Journal of Bone & Joint Surgery British Volume
Vol. 80-B, Issue 2 | Pages 249 - 253
1 Mar 1998
Tytherleigh-Strong G Walls N McQueen MM

We have analysed 249 consecutive fractures of the humeral shaft treated over a three-year period. The fractures were defined by their AO morphology, position, the age and gender of the patient and the mechanism of injury. Open fractures were classified using the Gustilo system and soft-tissue injury, and closed fractures using the Tscherne system.

The fractures were classified as AO type A in 63.3%, type B in 26.2% and type C in 10.4%. Most (60%) occurred in the middle third of the diaphysis with 30% in the proximal and 10% in the distal third. The severity of the fracture and soft-tissue injury was greater with increasing injury severity. Less than 10% of the fractures were open. There was a bimodal age distribution with a peak in the third decade as a result of moderate to severe injury in men and a larger peak in the seventh decade after a simple fall in women.