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Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_I | Pages 59 - 59
1 Jan 2011
Shalaby S Morgan G Hanna M Hafez M Nakhla A Abbas A Zaman T Saavedra E Tross S
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Shockwave treatment in our unit is provided in conjunction with our Urological colleagues. Shock Wave Therapy has been used as a last option in patients with difficult and chronic Orthopaedic conditions with an informed consent for all patients.

Material and Methods: 28 patients from Ealing Hospital and West Middlesex Hospital were referred to The Lithotripsy unit at Charing Cross Hospital for Shock wave therapy.

Patients were consented by the Orthopaedic surgeon and the treatment was administered by urologist

The cases included:

4 Humeral fractures: 1 Case in HIV +ve 19 years old

5 Femoral non-union: 1 case bilateral in Osteogenesis imperfecta

4 Tibial non-union: 1 Recurent Fracture in 65 years old man

2 Osteochondritis of the Talus

2 Osteochondritis of the knee

4 Scaphoid fractures: 1 case had been fixed and grafted.

Medial Epicondyle fracture non union

5th Metacarpal Fracture

Trochanteric Bursitis

Tennis Elbow

4 Planter fasciitis

– The Shock wave Machine used is Storz SLX – F2 Electromagnetic shock wave generator which focus the shock wave low energy high frequency in focal zone with no harm to other tissues. Frequency 4 htz = 4 shockwave/sec

– Energy level 1–3 generate pressure value in the focal area of 5–30 megapascal

– Size of focal zone 9X 50 mm or 6X 28 mm

– Total shock wave applied per session 2000 to 3000 shock

– large focus and small focus were used in fracture of large bones and small bones respectively. Most of cases required 2–3 session with 4–6 weeks interval.

– in Soft tissue Treatment Less energy was used and patients required 1 to 2 sessions.

Results: There was complete resolution of symptoms in the 4 cases of soft tissues.

– Clinical and radiological union in 3 of the 4 Humeral Fracture including HIV+ve and in 2 of 3 tibial fracture and 1 of 2 scaphoid.

– 50% pain relief in Psedo arthrosis

– Union is promoted by Cellular stimulation and pain relief is by unknown mechanism but explained by increase vascularity and neuro-modulation.

– None of the patient’s have so far required subsequent operative interventions, several had residual symptoms.

Discussion: Shock wave therapy is a new consevative treatment modality used in orthopaedic as the last option before surgery but there is a need for RCT.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_II | Pages 216 - 216
1 Jul 2008
Venkateswaran B Montgomery A Zaman T Even T Copeland S Levy O
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The purpose of this study is to report the 1 to 5 year results of arthroscopic Rotator Cuff repairs.

Between November 2001 to May 2003, 115 consecutive patients were operated (73 males and 42 females) with arthroscopic repair. 13 patients were lost to follow up, leaving 102 patients available for follow up. Patients were evaluated using the Constant score, satisfaction levels and ultrasound scan to evaluate cuff integrity. Failures were defined as dissatisfied patients and those who had had a re-operation. Re-tear rate was recorded.

The mean follow up time was 23.8 months (range 12–61). Mean age was 57.3 years (range 23–78). 47% had a history of trauma. There were 107 patients (95.5%) with full thickness tears and 5 (4.5%) had partial thickness tears. Of the full thickness tears, 8 (7.6%) were massive in size, 36 (34%) large, 44 (41.5%) medium and 18(17%) small. Isolated Supraspinatus (SSP) tear was recorded in 83.5% and subscapularis tear in 7 %. A combination of SSP tear with infraspinatus and teres minor was found in 9.6%.

86% had Acromioplasty (ASD) with or without an AC joint excision arthroplasty. Two patients had Bankart repairs in addition at the time of cuff repair.

The mean pre op Constant score was 40.9 points (95% CI 37.3 to 44.5), which had improved to 84.8 (CI 82.2 to 86.9) at last follow-up. 78% returned to same work and 82% returned to pre injury leisure activity. There were 20 re-tears (19.6%). eight of the 102 patients were not satisfied. Five of these patients had revision operation.

Arthroscopic cuff repair shows high satisfaction rate (92%) and good functional results with 20% re-tear rate, while offering all the advantages of arthroscopic surgery.


The Journal of Bone & Joint Surgery British Volume
Vol. 90-B, Issue 7 | Pages 893 - 898
1 Jul 2008
Levy O Relwani J Zaman T Even T Venkateswaran B Copeland S

The aim of this study was to define the microcirculation of the normal rotator cuff during arthroscopic surgery and investigate whether it is altered in diseased cuff tissue.

Blood flow was measured intra-operatively by laser Doppler flowmetry. We investigated six different zones of each rotator cuff during the arthroscopic examination of 56 consecutive patients undergoing investigation for impingement, cuff tears or instability; there were 336 measurements overall.

The mean laser Doppler flowmetry flux was significantly higher at the edges of the tear in torn cuffs (43.1, 95% confidence interval (CI) 37.8 to 48.4) compared with normal cuffs (32.8, 95% CI 27.4 to 38.1; p = 0.0089). It was significantly lower across all anatomical locations in cuffs with impingement (25.4, 95% CI 22.4 to 28.5) compared with normal cuffs (p = 0.0196), and significantly lower in cuffs with impingement compared with torn cuffs (p < 0.0001).

Laser Doppler flowmetry analysis of the rotator cuff blood supply indicated a significant difference between the vascularity of the normal and the pathological rotator cuff. We were unable to demonstrate a functional hypoperfusion area or so-called ‘critical zone’ in the normal cuff. The measured flux decreases with advancing impingement, but there is a substantial increase at the edges of rotator cuff tears. This might reflect an attempt at repair.


Orthopaedic Proceedings
Vol. 88-B, Issue SUPP_II | Pages 345 - 345
1 May 2006
Levy O Venkateswaran B Montgomery A Zaman T Even T Copeland S
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Arthroscopic Rotator cuff repair is gaining popularity in recent years; however, the results of arthroscopic repairs are yet to be reported. Between November 2001 to May 2003, 115 consecutive patients were operated (73 males and 42 females) with arthroscopic repair. 13 patients were lost to follow up, leaving 102 patients available for follow up.

The mean follow up time was 23.8 months (range 12–61). There were 107 patients (95.5%) with full thickness tears and 5 (4.5%) had partial thickness tears. Of the full thickness tears, 8 (7.6%) were massive in size, 36 (34%) large, 44 (41.5%) medium and 18(17%) small.

Mean age was 57.3 years (range 23–78). 47% had a history of trauma.

Mainly Supraspinatus (SSP) tear was recorded in 83.5% and isolated subscapularis tear in 7%. A combination of SSP tear with infraspinatus and teres minor minor (posterior tear) was found in 9.6%.

86% had Acromioplasty (ASD) with or without an AC joint excision arthroplasty. Two patients had Bankart repairs in addition at the time of cuff repair.

Patients were evaluated using the Constant score, satisfaction levels and ultrasound scan to evaluate cuff integrity. Failures were defined as dissatisfied patients and those who had had a re-operation. Re-tear rate was recorded.

The mean pre op Constant score was 40.9 points (95% CI 37.3 to 44.5), which had improved to 84.8 (CI 82.2 to 86.9) at last follow-up. 78% returned to same work and 82% returned to pre injury leisure activity. There were 20 ultrasound demonstrated re-tears (19.6%). However, the majority of patients with radiological re-tears had good function, pain relief and were satisfied. Eight of the 102 patients were not satisfied. Five of these patients had revision operation.

Arthroscopic cuff repair shows high satisfaction rate (92%) and good functional results while offering all the advantages of arthroscopic surgery.


Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_III | Pages 384 - 384
1 Sep 2005
Levy O Venkateswaran B Zaman T Even T Kapila A Bhargava A Copeland S
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Introduction: Laser Doppler Flowmetry (LDF) is an established technique for the measurement of perfusion in tissues, which has been applied in animal and human studies. Despite many studies the implications of perfusion and blood flow abnormalities in the rotator cuff (RC) in vivo are not clearly understood. This study aims to assess the blood flow in the normal and diseased RC using Laser Doppler Flowmetry (LDF) technique.

Methods: With Ethics approval and informed consent patients undergoing arthroscopy for impingement or cuff tear (diseased cuff) or for shoulder instability (normal cuff) were recruited. Following diagnostic arthroscopy and bursoscopy measurements of the blood flux in the RC using the LDF were made at 6 points. Five of these were in the cuff over a 4 cm2 area from the insertion at the greater tuberosity (A,E – @ Tuberosity level, C-Muscelotendinous junction, B,D – between the two) and one (F) in the deep surface. Diseased RC were subgrouped into mild (B1), moderate (B2) and severe (B3- cuff tear) impingement grades (Copeland-Levy Classification). The arthroscopy, grading, and probe placement were made by the two senior authors. LDF flux (unit of measurement of the perfusion – LDFf) was recorded over 30 seconds at each measurement point. The mean of these readings was calculated.

Results: 56 patients were recruited. 35 Males (62.5%) and 21 Females (37.5%).

336 measurements were recorded.

The observed mean LDFf was 32.8 (27.4–38.1; 95% CI) , 25.4 (22.4–28.5) and 43.1 (37.8–48.4; 95% CI) For Normal, Impingement and Tear cases, respectively (p< 0.0001, One-way ANOVA).

The LDFf was lowest in the Impingement without tear grade (B2) with a statistically significant increase at the edges of a cuff tear.

Conclusion: Preliminary recordings of LDF show changes are in keeping with current knowledge of the pathology. LDFf decreases with advancing impingement, being least affected in the musculotendinous junction. There is a substantial increase in LDFf at the edges of RC tears. This might reflect an attempted reparative response.


Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_II | Pages 170 - 170
1 Apr 2005
Venkateswaran B Zaman T Even T Kapila A Bargava A Copeland S Levy O
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Aim: Despite many studies the implications of perfusion and blood flow abnormalities in the rotator cuff (RC) in vivo are not clearly understood. Laser Doppler Flowmetry (LDF) is an established technique for the measurement of perfusion in tissue, which has been applied in animal and human studies. This study aims to evaluate Laser Doppler Flowmetry (LDF) as a technique for the assessment of blood flow in the normal and diseased RC.

Methods: With Ethics committee approval and informed consent patients undergoing arthroscopy for impingement or cuff tear (diseased cuff) and instability (normal cuff – BO) were recruited. Following diagnostic arthroscopy and bursoscopy measurements of the LDF in the RC tear were made at 6 points. Five of these were in the cuff over a 4 cm. 2 are from the insertion at the greater tuberosity and one in the deep surface.

Diseased RC were sub grouped into mild (B1), moderate (B2) and severe (*B3 – cuff tear) impingement grades (Copeland – Levy Classification). The arthroscopy, grading, and probe placement were made by the senior authors. LDF flux (LDFf) was recorded over 30 seconds at each measurement point. The mean of these readings was then calculated (LDF flux – an arbitrary unit of measurement of the perfusion).

Results: 35 patients were recruited. 210 measurements were recorded, in 6 anatomical locations. The mean LDFf was 34.1 in diseased RC and 55.3 in normal RC (p=0.0002). The mean LDFf was 52.2 in severe (RC tear) impingement and 30.3 in mild and moderate impingement’s (p< 0.0001).

The LDFf was lowest in the moderate grade with a significant increase at the edges of a cuff tear.

Conclusion: Preliminary recording of LDFf show changes are in keeping with current knowledge of the pathology. LDFf decreases with advancing impingement. There is an increase in LDFf at the edges of RC tears. This might reflect a reparative response.