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.

Aim

Review causes of anchor fixation failures in patients who underwent arthroscopic rotator cuff repair.

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: The aim of our study was to review the massive rotator cuff tears that were repaired arthroscopically and evaluate the clinical results in respect to repair integrity as well as the effect on the progression of osteoarthritis.

Materials and Methods: We reviewed 56 (39 male,17 female) consecutive patients who underwent arthroscopic repair of their massive rotator cuff tears using biodegradable anchors by the senior author. The technique relies on the suspension bridge principal as described by S.Burkhart (1997). The mean age was 68.2 years (30–86) with most patients between 75 and 85 years. The mean follow up was 31months (24–41). Objective evaluation was done using the Constant score and subjective with the Oxford score. Osteoarthritis was investigated with radiographs and repair integrity with ultrasound. SPSS 16 for Windows was used for the statistical analysis of out results.

Results: 93% of the patients had good (11%) or excellent results according to the Oxford score and 91% had Constant score over 75. The improvement in the scores was significant statistically in all parameters (p=0.000, p for strength=0.001). Thirteen patients had postoperative OA, but this was not correlated with the results or the improvement and 11/13 had excellent Oxford scores and Constant scores over75. Seventeen patients had a re-tear which was not correlated with the results or the improvement and 15/17 had excellent Oxford scores and Constant scores over 75. Seven patients had both osteoarthritis and retear but again improvement and results were not affected.

Conclusion: Arthroscopic repair of massive rotator cuff tears has excellent clinical results regardless of the development of osteoarthritis or the repair integrity and should be the first line of treatment.

Aim: Retrospective evaluation of the clinical results of arthroscopic capsulolabral stabilisation using suture anchors with a mattress technique.

Materials and Methods: Sixty five consecutive procedures in sixty-two patients (50 male, 12 female) with mean age of 38 years (14–66) underwent capsulolabral stabilisation by the senior author between 2005 and 2008. There was a history of dislocation in 38 shoulders (58.4%), 16(42.6%) had recurrent and 6 bilateral instability, 27 patients (41.5% shoulders) presented with pain. Thirteen patients had gradual onset and 14 after an injury. The mean follow up was 29 months (14–54).

Results: Arthroscopic findings included three patients (5%) with glenoid bone loss more than 15%, Hill Sachs lesions greater than 20% in eighteen patients (27.6%) and six cases where the torn labrum was partially absent. Three shoulders had a panlabral tear (4.4%). A mean of 2.3 (1–4) anchors were used. The mean Rowe score was 92.3 (30–100) with 90% excellent or good and the mean Oxford Score was 41(16–48) with 89% excellent or good. All heavy manual workers returned to work in a mean of 15.4 weeks. Four professional athletes are back to preinjury level in a mean of twenty weeks. There were two (3%) failures with redislocation.

Conclusion: Reinforcement of labral repair with capsule plication is an effective means to treat shoulder instability with a 97% success rate and no exclusion criteria.

Aim: To describe a new radiological sign after rupture of the thumb ulnar collateral ligament.

Introduction: Rupture of the thumb ulnar collateral ligament is a commonly missed injury, with delayed diagnosis leading to considerable morbidity. Stress radiographs and MRI scans have been used to diagnose chronic (gamekeepers thumb) or acute (skiers thumb) injuries to this ligament. The former often causes discomfort and the latter are often not readily available. We describe a new radiological sign seen on the lateral radiographs of the thumb, which has previously not been described in the literature. The ‘sag sign’ is volar subluxation of the proximal phalanx in relation to the metacarpal at the metacarpal phalangeal joint

Method: Between 2001–2006, radiographs of nineteen patients who had undergone repair of thumb ulnar collateral ligaments were retrospectively reviewed. There were 12 male and 7 female patients with an average age of 44. These were compared to a control group of normal thumb radiographs. The ‘sag sign’ was present on all the lateral radiographs of thumbs with ulnar collateral ligament tears. Once the ligament was repaired, the metacarpophalangeal joint alignment returned to normal. The sign was validated by senior house officers and registrars in orthopaedics training.

Conclusion: The sag sign is a reliable indicator of an underlying injury to the thumb ulnar collateral ligament. Many studies have looked at the radiological diagnosis of this commonly missed injury. Stress radiography and ultrasound require straining an injured thumb which can extend the lesion and cause discomfort. MRI and MR arthrography are both sensitive and specific, but are costly and time consuming. Our sign is evident on plain film, is easily available, and does not require additional apparatus.

We assessed a new knotless anchor system (Opus AutoCuff, ArthroCare Sports Medicine), which was designed to repair torn rotator cuffs. This knotless anchor winches cuff tissue into the bone with a mattress suture that is cinched into place without the need for knots. We reviewed patients who underwent arthroscopic repair with this technique with a minimum follow up of one year. This is prospective study of a consecutive series of the first one hundred patients who underwent arthroscopic cuff repair with the Autocuff system in 2005. Nine were lost to follow-up leaving ninety-one were available for review. All sizes of cuff tear were addressed and in all one hundred and eighty anchors were deployed. There were thirty seven men and sixty seven women with an average age of 69.4 years (range 36–85 years) Follow-up was by clinical assessment, cuff ultrasound and plain radiographs one year after surgery (12–20 months). Pain relief was described as good to excellent in 93% of patients and Constant scores improved by an average of 34 points with 48.5% being good to excellent, 39.4% fair and 12.1% poor. Nine anchors (5%) in eight patients had pulled out at one year, of which three were symptomatic. Suture repair poses varied points of weakness; loose knots, suture attrition and screw toggle all contribute to failure. We have shown that cuff repair by this method appears to be effective up to one year. It is important, however, to spread the tension of the repair with more than one anchor when treating larger tears.

Introduced in 2005, the Opus Magnum (Arthrocare) anchor has been used in our unit for repair of rotator cuff tears. It is a non-screw type anchor which relies on the deployment of wings locked in the subchondral bone. In order to evaluate whether these anchors migrate after implantation we undertook radiographic examination of their placement at intervals. We attempted to assess whether loss of fixation could be secondary to osteoporosis. Between 2005 and 2006, 106 patients (59 female, 47 male) aged 35–84 years (average age 62 years) underwent arthroscopic repair of rotator cuff tears with a total of 229 anchors. A review of radiographs taken at six weeks and 12 months post-insertion was undertaken. Cortical index of the proximal humeral diaphysis was measured from the AP radiograph indicating bone density; this involved measuring humeral width and medullary cavity diameter at a fixed point of 10cm below the greater tuberosity of the humerus. At six weeks follow-up there were no anchor pull-outs seen on radiographs. At 12 months follow-up 10 of the 229 anchors were found to have pulled out of the bone, equating to a failure rate of 4%. Of these seven of the 10 patients were asymptomatic. The average cortical index was found to be significantly lower in the failure group. Bone quality at the greater tuberosity of the humerus can be insufficient to withstand the tensions developed in newer anchor technology, leading to anchor migration. We present evidence that radiographs may be sufficient to influence the clinician’s choice of anchorage device. An economic estimation of bone density would be a helpful predictor of pull-out strength of suture anchors, essentially a low cortical index would indicate that these anchors are more likely to fail. A routine radiograph at 12 months would also identify the asymptomatic anchor failures.

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.

Aim: Review causes of anchor fixation failures in patients who underwent arthroscopic rotator cuff repair.

Methods: Between 2003 and 2006, 650 arthroscopic rotator cuff repairs were performed by the senior author. Of these, anchor fixation failure occurred in fifteen patients. A retrospective review was undertaken to find out the reasons for their failure.

Results: There were ten women and five men, age range 46–84 (mean age 64). Thirteen underwent repair with metallic knotless anchors (Arthrocare), and two with 5.5mm biodegradable screw anchors (Arthrotek). Knotless anchors were used to repair six massive, one large, three medium and three small tears. The two patients with biodegradable anchor repair had only small tears, each held with a single anchor. All but one failure was apparent at six weeks. One metallic anchor failed at four months. Twelve knotless anchors failed through pull-out and one broke. Both biodegradable anchors broke at the eyelet.

Discussion: The increasing strength of suture material has shifted the weak point away from the suture-tendon interface towards the anchor-bone interface. Arthroscopic techniques permit a wider age range of patients suitable for surgery, each with varying degrees of osteoporosis in the proximal humerus, increasing risk of anchor pull-out. Multiple anchor insertions to reduce stiff, retracted tears may also lead to weakening of the bone table in the footprint area of the greater tuberosity. Incomplete anchor deployment, commonly at the curved cortical bone edge of greater tuberosity can also lead to failure.

Conclusion: Anchors failed if tension in the repair exceeds the bones capacity to retain the anchor, if the anchor is incompletely deployed or if one anchor is stressed beyond its tension capability. We recommend that consideration is given to spreading the tension of the tissue repair amongst the anchors placed in the greater tuberosity.

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 suspension bridge principle relies on a firm fixation of the torn rotator cuff at the anterior and posterior margins of the greater tuberosity leaving a mobile section between the two points. In massive rotator cuff tears which cannot be approximated, a partial repair can be performed using the above principle. The aim of this study is to evaluate the functional and radiological results using the above technique with bio-absorbable anchors.

Materials and Methods: This is a prospective study of a consecutive series of 59 patients who were found intraoperatively to have a rotator cuff tear of greater than 5cm. There were 41 men and 18 women with an average age of 68 years (range). The average length of follow up was 16 months (12 to 26 months). Patients were assessed objectively with the Constant score, and subjectively with the Oxford questionnaire. Cuff integrity was evaluated using ultrasound.

Results: Using the Constant score, the outcome was excellent in 30(51.5%), fair in 24(40.5%) and poor in 5(8.5%). 55(93%) patients had an improvement in pain whilst all had increased movement. 51(86%) had improved activities of daily living, whilst 43(72.3%) had improvement in recreational activities. Ultrasound demonstrated the repair remained firmly anchored in position in 54 patients (91.5%). Five patients showed complete disruption and represented poor functional outcome. Patient satisfaction was 94.9%.

Conclusion: Our results confirm that a water tight repair is not necessary for a good functional outcome for massive irreparable tears. The biodegradable anchors have been shown to be holding the repairs well at medium term follow up. In patients with a massive irreparable rotator cuff tear, the suspension bridge principle is a valuable technique.

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: 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 functional results of rotator cuff function and integrity after arthroscopic excision of calcium and decompression with a minimum follow up of two years.

Methods Between 2002 and 2004, sixty consecutive patients with calcific tendinitis underwent arthroscopic excision of calcium and subacromial decompression. Their average age was 51 years (range 28 to 78). The male to female ratio was 2:3. All patients were retrospectively reviewed by an independent observer. Functional outcome was assessed objectively by Constant scoring system and subjectively by Oxford Shoulder Questionnaire. The integrity of the rotator cuff was assessed by ultrasound scan. (Sonosite). Operative technique After arthroscopic subacromial decompression, all calcific deposits were excised with an arthroscopic rotating blade. The resultant cuff defect was left to heal and no cuff repair was performed. Other intra-articular pathology including SLAP lesions were treated at the same time. Postoperatively, early mobilization of the shoulder was encouraged.

Results The mean Constant score at follow-up was 82 (range 63 to 100). Fifty-four patients (90%) had good or excellent results and six patients (10%) had a fair score. Ultrasound assessment showed intact rotator cuff with no residual defect in forty-three patients, partial thickness tears in twelve, and small full thickness tears in three. Two patients had recurrence of calcium. Only four of the fifteen patients who had ultrasound evidence of rotator cuff tear were symptomatic.

Conclusion Arthroscopic excision of calcium and subacromial decompression is an effective method of pain relief in calcific tendinitis of the shoulder. 75% of the rotator cuff appeared to have healed after two years. Of the remaining 25% patients who had a defect in their supraspinatus tendon, only 6% remain symptomatic.

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.