Introduction

Unstable dorsal fracture/dislocation of PIP joint is a complex injury and difficult to treat. Different treatment methods have been described with varying results. We describe a novel technique to combine fracture fixation with volar plate repair using micro anchor suture.

Displaced two- to four-part fractures of the proximal humerus pose a difficult therapeutic challenge. We report the results of internal fixation of these fractures in a case series of 50 patients with a locking plate system. All fractures united with no failure of fixation. The mean constant score was 79. One patient developed avascular necrosis.

Internal fixation with locking plate system in healthy active patients, disregarding their age, is a reliable method of treating displaced proximal humerus fractures. The tuberosities should be restored anatomically prior to plate application. Surgical expertise in treating shoulder conditions is essential for good functional outcome.

Introduction

Symptomatic neglected and displaced three- and four-part proximal humeral fractures are often difficult to reconstruct. Replacement has been reported to give poor functional outcome and hence is not the ideal treatment option. We report our results of secondary reconstruction of these difficult fractures with a locking plate system.

Aim: To evaluate the radiographs of proximal humeral fractures in an attempt to define a diagnostic sign as a predictor of four-part fracture. Diagnostic sign The normal humeral head articular surface points towards the glenoid. We describe our ‘sunset’ sign as ‘articular surface of humeral head pointing away from the glenoid and tilted upwards, in the presence of a displaced greater tuberosity fracture’. We postulate that a patient with proximal humerus fracture showing this sign has four-part fracture until proved otherwise.

Materials and Methods: Between 2002 and 2006, 80 consecutive patients underwent open reduction and internal fixation of their proximal humeral fractures in our Shoulder unit. We reviewed their preoperative radiographs and operative notes retrospectively. The AP radiograph was evaluated independently by three observers who were blinded to the operative diagnosis. The presence of ‘sunset’ sign was recorded. A consensus review was performed for evaluation purpose. The findings were then correlated with the operative findings. With 95% confidence interval we calculated the sensitivity, specificity, and positive and negative predictive values for our diagnostic sign.

Results: Thirty patients displayed ‘sunset’sign in their radiograph. Of these 28 had confirmed four-part fractures operatively. The positive predictive value of ‘sunset’ sign in diagnosis of four-part fracture was 93%. The specificity and sensitivity were 95% and 78% respectively. The sensitivity was affected by 8 patients with four part fractures with displaced articular head fragment which had dropped either medially or posteriorly. There were substantial interobserver and intraobserver agreement as measured by kappa coefficient (0.62 and 0.70)

Conclusion: Our results suggest that in patients with proximal humeral fractures, the presence of ‘sunset’sign in the anteroposterior radiograph is a reliable indicator of four-part fracture.

Background: Avascular necrosis is a well recognised complication of displaced proximal humeral fractures irrespective of conservative and operative treatment. The reported rate of AVN with open reduction and internal fixation varies from 22 to 40%. The aim of our study was to look at the functional outcome and the incidence of AVN with operative treatment using locking plate with a minimum 3 year follow up.

Materials and methods: We retrospectively reviewed a consecutive series of 50 patients with displaced proximal humerus fractures treated with ORIF from 2002 to 2004. All patients were operated by the two senior authors employing anterior deltopectoral approach, indirect reduction, secure suture repair of the tuberosities and fixation with locking plate. The minimum follow up was 3 years. There were 9 two-part, 19 three-part and 22 four-part fractures. Their average age was 63 years. All patients were assessed objectively with Constant score and subjectively with Oxford questionnaire by an independent observer. Fracture healing and complications were recorded.

Results: 47 patients were available for follow-up. All fractures united. The average Constant score was 84. Their mean Oxford score was 16. There was no infection or metal work failure. One patient fractured below the plate after a fall but went onto uneventful union. 4 of 47 patients (8.5%) developed avascular necrosis. Three were four-part fracture and one was two-part fracture. Three patients underwent hemiarthroplasty of shoulder with good functional recovery. One patient declined further operative intervention due to low level of symptoms.

Conclusion: Indirect reduction and secure fixation of the tuberosities onto the humeral head with a locking plate is a reliable technique of treating displaced proximal humeral fractures. Our experience of avascular necrosis in only 8.5% of these fractures is much lower than any reported series after open surgery.

Introduction: The current accepted clinical tests to confirm rotator cuff tears include a triad of weakness in resisted external rotation, pain on impingement, and weakness on supraspinatus testing (Empty can test). A combination of two of the above in a patient over 60 years also suggests a cuff tear. We present a new simple clinical test, to diagnose rotator cuff tears. ‘Lateral Jobe test’: The lateral Jobe test consists of the patient holding their arms in 90 degrees abduction in the coronal plane with the elbows flexed 90 degrees and the hands pointing inferiorly with the thumbs directed medially. A positive test consists of pain or weakness on resisting downward pressure on the arms or an inability to perform the test.

Methods: Between Sep 2006 and Jan 2007, a consecutive series of 175 patients with painful shoulders who were about to undergo arthroscopic treatment of their shoulders were reviewed prospectively. Their average age was 53 years. There were 97 males and 78 females. Those with fracture or previous surgery were excluded. They were examined preoperatively by two independent orthopaedic surgeons for four tests, the lateral Jobe and the triad of combination examinations mentioned above. They were blinded to the provisional diagnosis. The results of the all the clinical tests were validated against arthroscopic findings.

Results: Of the 175 patients, 102 patients had rotator cuff tear confirmed arthroscopically. 91 patients had positive ‘Lateral Jobe test’ of which 83 had rotator cuff tear (positive predictive value 91%). When compared against the combination of three clinical signs namely impingment sign, weak resisted external rotation and positive empty can test, the Lateral Jobe test had a higher sensitivity (81 vs. 58%) and negative predictive value (77 vs. 60%). The specificity of both was similar at 89 and 88% respectively.

Conclusion: The lateral Jobe test is a simple single test to diagnose rotator cuff tears.

We review our results of arthroscopic capsular plication in patients with ligamentous laxity that had developed symptoms of instability after a traumatic event. Between 2004 and 2005, 115 patients with traumatic injury to their shoulder underwent arthroscopic stabilization and repair of their shoulder. Of these, twelve patients had ligamentous laxity and had their capsule plicated as a means to stabilize their shoulder. All had failed three months of biofeedback physiotherapy. The mean age of the patients was 29 years (range 17 to 46). The average time interval between date of injury and surgery was 21 months. They were reviewed retrospectively with a minimum follow up of 2 yeats. The functional outcome was assessed by Constant scoring system and Rowe score. At arthroscopy, capsular plication with a south to north direction would be fashioned with #1 PDS sutures. In multidirectional instability, the inferior and posterior capsule would be plicated as well. If the labrum was torn, this and the capsule would be repaired together. The repair was reinforced with rotator interval closure. Postoperatively the arm was rested in sling for four weeks followed by gradual mobilization. At a minimum follow up of two years, all twelve shoulders became stable. There were 8 excellent, 3 good and one fair result as graded by modified Rowe score. Re-arthroscopy in the patient with fair result showed good capsular repair and presence of scar tissue in the subacromial space. All patients rated their shoulder as normal. Ten patients returned to their preinjury level of competitive sport. Two patients returned to sport but at a lower level voluntarily. Arthroscopic capsular plication appears to be a safe and reliable technique in stabilizing shoulders in patients with ligamentous laxity. This form of repair should be offered to this group of patients if treatment with biofeedback physiotherapy fails.

Aim: To evaluate the radiographs of proximal humeral fractures in an attempt to define a diagnostic sign as a predictor of four-part fracture.

Diagnostic sign: The normal humeral head articular surface points towards the glenoid. We describe our ‘sunset’ sign as ‘articular surface of humeral head pointing away from the glenoid and tilted upwards, in the presence of a displaced greater tuberosity fracture’. We postulate that a patient with proximal humerus fracture showing this sign has four-part fracture until proved otherwise.

Materials and Methods: Between 2002 and 2006, 80 consecutive patients underwent open reduction and internal fixation of their proximal humeral fractures in our Shoulder unit. We reviewed their preoperative radiographs and operative notes retrospectively. 79 patients were included in the study as one patient’s pre-operative radiograph was not available.

The AP radiograph was evaluated independently by three observers who were blinded to the identity of the patients and their operative diagnosis. The presence of ‘sunset’ sign was recorded. There was 90% inter-observer agreement. In the remaining 10%, a consensus review was performed as to the presence of sign for evaluation purpose. The findings were then correlated with the operative findings to confirm whether they were four-part fractures or not. With 95% confidence interval we calculated the sensitivity, specificity, and positive and negative predictive values for our diagnostic sign.

Results: 30 out of 79 patients displayed ‘sunset’sign in their preoperative radiograph. Of these 28 had confirmed four-part fractures operatively. The positive predictive value of ‘sunset’ sign in diagnosis the four-part fracture was 93%. The specificity and sensitivity were 95% and 78% respectively. The sensitivity was affected by 8 patients with four part fractures with displaced articular head fragment which had dropped either medially or posteriorly.

Conclusion: Our results suggest that in patients with proximal humeral fractures, the presence of ‘sunset’sign in the anteroposterior radiograph is a reliable indicator of four-part fracture.

Introduction: Analysis of the ages at the time of surgery of all patients undergoing primary hip and knee replacement in a UK District General Hospital setting over a period of 13 years

Method: Retrospective study of all cases of primary hip and knee replacements performed at our institution between 1993 and 2005.

Results: A total of 4703 patients had primary total joint replacement in this period. This includes 2591 hip replacements and 2112 knee replacements. The ratio of females to males was 2:1

The average age of primary hip replacement patient was 70 years. (male patients 68 years and 71 years in females.) Over the 13 year period, the average age of male patients was noted to decline steadily from 71 in 1993 to 66 in 2003. But the average age of female patients remained constant at around 71 years.

The number of patients below age 60 years undergoing hip replacement procedures was analysed. Only 8% of patients were under 60 years of age in 1993 rising to 23% in 2005. Between 2000 and 2005 this figure was at or above 20%.

Surface hip replacement was started at our hospital in 1999. The number of patients treated with surface hip replacement as a proportion of all primary hip procedures has increased to 32% in 2005. The average age of these patients was 57 years. The sex difference was approximately 1:1 as compared to 1:2 in total hip replacement.

The average age of primary knee replacement patients was 73 years, 72 yrs for males and 73 yrs for females. No change in average age was noted over the period. The proportion of patients under age of 60 years varied between 4 and 9%

Conclusion: The average age of male patients having primary hip replacement in the UK is declining and the proportion of young males undergoing hip replacement is increasing. Unless there has been a change in the incidence of osteoarthritis, these observations may reflect either a change in surgical selection criteria possibly associated with the success of surface replacement or else patients’ demand for early intervention. No changes have been observed in the age of patients undergoing knee replacement.

Introduction: Symptomatic neglected and displaced three and four-part proximal humeral fractures are often difficult to reconstruct. Replacements has been reported to give poor functional outcome and hence not the ideal treatment option. We report our results of secondary reconstruction of these difficult fractures with a locking plate system.

Material and Methods: Between 2003 and 2005, 15 healthy active patients with displaced three to four-part fractures underwent revision/secondary open reduction and internal fixation with a locking plate system (Philos, Stratec UK Ltd). Ten patients had delayed presentation. Three patients had failed previous internal fixation. One patient had non-union and one had malunited fracture. Their average age was 63 years. Objective assessment was measured by the Constant score, subjective assessment by the Oxford questionnaire. The mean follow-up was 14 months.

Surgical technique: In revision cases, the fracture was approached through the same incision. All metal work was removed. Careful attention was given to restore the normal anatomy of humeral head with correct placement of the tuberosities. Reduction was held with Ticron sutures through the rotator cuff followed by fixation with the locking plate. Two patients required arthroscopic repair of their labral tears. The shoulder was immobilised in a sling for four weeks followed by gradual mobilisation program.

Results: All fractures united. No failure of fixation was observed. The mean Constant score was 73. The pain component improved from 3 preoperatively to 14 at follow up. The average range of flexion was 1100, abduction of 950 and external rotation of 350. All patients had good to excellent subjective outcome. We encountered poor rotator cuff function in one patient.

Conclusion: Successful reconstruction of three and four part proximal humeral fractrures is possible. Anatomical restoration of humeral head and tuberosities prior to plate fixation is essential for good outcome.

Aim: To evaluate the results of internal fixation of displaced proximal humeral fractures with a locking plate system.

Material and Methods: Between 2002 and 2003, 126 patients presented to our shoulder unit with proximal humeral fractures. Of these, 22 healthy active patients with displaced two to four-part fractures underwent open reduction and internal fixation with a locking compression plate system (Philos, Stratec UK Ltd). Their average age was sixty-two years. They were evaluated clinically and radiologically at 4, 12, 26 weeks or until union. Objective assessment was measured by the Constant scoring system, subjective assessment by the Oxford shoulder questionnaire.

Surgical Technique: Through an anterior deltopectoral approach, the fracture was reduced. A titanium plate designed to contour over the lateral aspect of the humeral head was applied with minimum of five locking screws in head fragment and three in the humeral shaft. Tuberosities approximation was reinforced with Ticron sutures through the rotator cuff and the holes in the plate. The shoulder was immobilised in a sling for two weeks followed by gradual mobilisation program with the physiotherapist.

Results: All fractures united with a mean healing time of fourteen weeks. There were no malunion, non-union or failure of fixation. The mean constant score was 78. The average range of flexion was 1330, abduction of 1250 and external rotation of 430. One patient had a significant fall three months after surgery and sustained an undisplaced fracture of shaft of humerus below the plate. Treated non operatively, both fractures went on to uneventful union.

Conclusions: Internal fixation with locking plate system in healthy active patients, disregarding their age, is a reliable method of treating displaced proximal humerus fractures. In our experience, the functional outcome of these patients was superior to those patients treated with hemiarthroplasty or intramedullary fixation.

Aim: To evaluate the results of arthroscopic repair of anterior and superior glenoid labral tears in the shoulder with metallic knotless suture anchors with an average follow up of 31 months.

Material and methods: Between 2000 and 2002, 55 patients with labral tears underwent arthroscopic repair with metallic knotless suture anchors (Mitek, Ethicon Ltd). Their average age was 36 years (range 16 to 67). Thirty-seven patients presented with anterior instability. Twenty-one patients presented with painful shoulder without instability. In the instability group there were eight acute dislocations and twenty-nine recurrent dislocations.

All patients underwent examination under anaesthesia, arthroscopic repair of labral tears using the metallic knotless suture anchors, thermal capsulorraphy and closure of the rotator interval. Subacromial decompression was performed when indicated. Rehabilitation consisted of sling immobilisation for four weeks followed by gradual strengthening program over three months with the physiotherapist. Contact sports were allowed at 1 year.

Evaluation: Patients were evaluated preoperatively and at the time of final follow-up using Constant score and Modified Rowe – Zarin score system.

Results: Three out of the thirty-seven patients in the instability group had recurrent dislocation. A fourth patient had pain with a positive anterior apprehension test thus making the overall recurrence rate of 11%. In the painful shoulder group, good and excellent results were recorded in twenty out of twenty-one patients (95%). Of the fifty five patients who had labral repair, five had poor functional outcome secondary to pain in their shoulder (9%). One patient had a fall and required further surgery to replace one dislodged anchor.

Conclusions: We found the metallic knotless suture anchor easy to use and stabilised the torn labrum well. The success rate for instability compares well with the published literature. However, we have some concern of our observation of early degenerative changes in some of our patients treated for recurrent dislocation.

The aim of the study was to determine the value of clinical assessment in the diagnosis of SLAP (Superior Labral Anterior Posterior) lesions of shoulder.

A retrospective clinical review of 48 patients who underwent arthroscopic stabilisation for SLAP (Snyder Type II to Type IV) lesions between 1997 and 2003 was undertaken. The patients were assessed preoperatively by the senior author using a combination of clinical tests including Neer’s impingement test, anterior apprehension test, compression rotation test, O’Brien, Speed, Gerber and Yergason tests.

The mean age of the patients was forty-four. Thirty-nine patients had persistent shoulder pain after injury. Seventeen were sport related. Pre operative diagnosis of SLAP was made in only eleven cases. We found the Neer impingement test positive in twenty-one, anterior apprehension test in twenty-six (sensitivity 54%), O’Brien test in twenty-three (sensitivity 48%), Compression rotation test in six and Speed’s test in five patients.

Our study does not support any single or combination clinical tests that can diagnose SLAP lesions with confidence. In a young patient with persisting shoulder pain after injury, positive anterior apprehension test should alert suspicion. Arthroscopic examination remains the most reliable assessment of the damaged labrum.

Aim: To compare and evaluate results following fixation of displaced clavicle fracture using three different plates.

Methods: Between 1994 and 2001, forty patients with displaced midclavicular fracture were plated with three different type of implants. The mean age of the patients was thirty-four years. Reconstruction Plate was used in twenty, 3.5 mm DCP in ten and 3.5mm LCDCP in ten. Twenty-eight fractures were multifragmentary. The interfragmentary screw technique was used in fifteen cases and one patient required bone grafting.

Evaluation: In this retrospective study, the patients’ shoulder function, rate of fracture union, and complications between the three different types of plate were evaluated and compared.

Results: Patients whose fracture was treated with DCP or LCDCP all achieved union within three months. One LCDCP lifted laterally after the patient went back to manual work within two weeks. Of the patients whose fracture was treated with reconstruction plate (20), only twelve united uneventfully within three months. Eight complications were recorded. Delayed union occurred in three, loss of fixation in two and the plate bent in the remaining three. All the complications were observed in multifragmentary fractures.

Conclusion: The more malleable reconstruction plate appeared to deform under load when used in the fixation of displaced multifragmentary clavicular fracture. We recommend the stronger LCDCP in this situation.