Purpose

The aim of this study was to report the outcomes of a series of patients with clavicle fracture non-union who had undergone open reduction and internal fixation using a contoured locking plate without the use of distant bone graft.

Introduction

Sling immobilization of the upper limb may affect balance. Computerized dynamic posturography (CDP) provides a validated, objective assessment of balance control and postural stability under dynamic test conditions. We tested the balance of individuals with a shoulder stabilization sling (SSS) using an Equitest Machine to objectively assess imbalance wearing a sling.

Introduction

The majority of radial head fractures may be treated successfully by conservative means and they are often considered a benign injury. However, approximately 25% of Mason type II fractures will not have a good long term result. Pain and stiffness can be a problem and this may be a significant complaint in young active patients with pain at end range of motion.

Title

3D distribution of cortical bone thickness in the proximal humerus, implications for fracture management.

Background

Reverse Geometry shoulder replacement requires fixation of a base plate (called a metaglene) to the glenoid to which a convex glenosphere is attached. Most systems use screws to achieve this fixation. The suprascapular nerve passes close to the glenoid and is known to be at risk of injury when devices and sutures are inserted into the glenoid. We investigate the risk posed to the suprascapular nerve by placement of metaglene fixation screws.

Purpose

Locking plates are widely used in clinical practice for the surgical treatment of complex proximal humerus fractures, especially in osteoporotic bone. The aim of this study is to assess the biomechanical influence of the infero-medial locking screws on maintaining reduction of the fragments in a proximal humerus fracture.

Introduction

Fractures of the proximal humerus represent a major osteoporotic burden. Recent developments in CT imaging have emphasized the importance of cortical bone thickness distribution in the prevention and management of fragility fractures. We aimed to experimentally define the CT density of cortical bone in the proximal humerus for building cortical geometry maps.

The cervical spine exhibits the greatest range of motion amongst the spinal segments due to its tri-planar components of movement. As a result, measurement of movements has proved difficult. A variety of methods have been used in an attempt to measure these movements but none have provided satisfactory triplanar data.

This paper uses the Zebris ultrasonic 3-D motion analysis system to measure flexion, extension, range of lateral bending and range of axial rotation in five similar male and five similar female subjects with no history of neck injuries. The subjects were tested unrestrained and in soft and hard collars, as well as in Philadelphia, Miami J and Minerva orthoses.

Results show that the Minerva is the most stable construct for restriction of movement in all planes in both groups (p< 0.001 vs. all groups (p=0.01 vs. Philadelphia in female extension), ANOVA). In the male group, the standard hard collar provides the second best resistance to flexion, lateral bending and axial rotation. The female group showed no one orthosis in second place overall. Looking at these results allows ranking of the measured orthoses in order of their three-dimensional stability. Furthermore, they validate the Zebris as a reliable and safe method of measurement of the complex movements of the cervical spine with low intersubject variability.

In conclusion, this paper, for the first time presents reproducible data incorporating the composite triplanar movements of the cervical spine thus allowing comparative analysis of the three-dimensional construct stability of the studied orthoses. In addition, these results validate the use of the Zebris system for measurement of cervical spine motion.

Background: The advent of locking plates used in the treatment of fractures of the surgical neck of the humerus has led to an increased use of internal fixation for these injuries. At present there are few large studies which have evaluated their success and potential factors which may contribute to any negative result.

Materials and Methods: We retrospectively reviewed 57 consecutive patients who were treated with internal fixation of 2,3 and 4-part fractures of the proximal humerus over a 3 year period with a minimum follow-up of 6 months. The MacKenzie (antero-superior) approach was used in all cases and fixation was achieved using either the PHILOS or Arthrex locking plates. Patients were assessed by a thorough chart review and at regular post-operative clinics for pain, range of motion, return to work/activity, smoking and alcohol intake and overall compliance with rehabilitation regime. X-rays were graded on the quality of initial reduction and maintenance of position. Primary end-points included union of fracture and need for additional operative procedures.

Results: The average age of patients was 63 years (range 19–91) with a preponderance of women (29:18 female: male). Average follow-up was 8 months. Ten (18%) patients were classified as problem drinkers, and 13 (22%) were smokers. Four patients were initially treated by a trial of conservative management which later failed, necessitating surgical intervention. Fifty three fractures (93%) went on to achieve union within 6 months of injury. Nine patients (15%) required an additional operation: 5 conversions to hemiarthroplasty for pain relief and 4 removals of metal for loss of screw fixation or impingement. There was no increased need for re-operation in alcoholics, but there was a 50% increase in the need for additional operations in smokers.

Discussion: To our knowledge, this study represents the largest cohort of patients treated with a fixed-angle locking plate for a fracture of the surgical neck of humerus. The use of the locking plate has led to improved union rates and good functional outcomes in the treatment of these often problematic fractures. Although these fractures tend to occur more often in alcoholics, union rates and need for re-operation are not affected. Smoking is a significant a risk factor for the need for re-operation and non-union.

Arthroscopic rotator cuff repair has evolved significantly in the last decade and has become a standard treatment. Satisfactory results of arthroscopic subacromial decompression (ASD) in the treatment of rotator cuff tears have also been reported (1). The aim of this study was to compare the outcome following arthroscopic repair versus decompression alone in patients with small & medium rotator cuff tears (Classification of Post, Silver & Singh (2). There were 114 patients in the ASD group and 96 in the Arthroscopic rotator cuff repair group (RCR). The groups were statistically comparable in terms of patient age & gender. Clinical follow-up was performed at a minimum of 12 months post -operatively (average 36 months). The average Post-op Constant score was 69.8 for the ASD group and 86.4 for the RCR group. The average post-op pain score (S.D) in the ASD group was 10.9 (± 4.3) and in the RCR group was 13.6 (± 3.1). Post operative strength was 7.6 (± 3.6) in the ASD group and 16.7 (± 5.4) in the RCR group.26 patients (22.8%) in the ASD group and 3 (3.3%) of the RCR group required futher surgery. Patient satisfaction (maximum 10 points) was 7.4% in the ASD group and 8.9 (± 1.4) in the RCR. The results of this study support arthroscopic rotator cuff repair. Shoulder strength is improved and there is significant reduction in the need for revision surgery.

We describe the results of Copeland surface replacement shoulder arthroplasty using the mark III prosthesis in patients over 80 years of age. End-stage arthritis of the shoulder is a source of significant pain and debilitating functional loss in the elderly. An arthroplasty offers good relief of pain and may allow the patient to maintain independence. The risk-benefit ratio of shoulder replacement may be felt to be too high in an elderly age group, but there is no published evidence to support this theory. We have assessed whether the procedure was as reliable and safe as previously seen in a younger cohort of patients. Between 1993 and 2003, 213 Copeland surface replacement arthroplasty procedures were performed in our unit, of which 29 (13.6%) were undertaken in patients over the age of 80. This group of patients was followed up for a mean of 4.5 years (2.1 to 9.3). Their mean age was 84.3 years (81 to 93), the mean operating time was 40 minutes (30 to 45) and the mean in-patient stay was five days (2 to 21). There were no peri-operative deaths or significant complications. The mean Constant score adjusted for age and gender, improved from 15.1% to 77%. Copeland surface replacement shoulder arthroplasty may be performed with minimal morbidity and rapid rehabilitation in the elderly.

Ulna Styloid Fractures have been historically dismissed as a relatively benign injury. However recent clinical and biomechanical research has suggested that primary repair of displaced ulna styloid avulsion fractures is advised as a means of stabilizing the radioulnar joint and preventing the disability associated with chronic radioulnar joint instability.

Optimum fixation method was examined in this study using a human cadaveric model. A custom jig was designed to allow testing in radial/ulna deviation in varying degrees of wrist flexion and extension. Universal materials testing device was used to apply a maximum load of 150 N. Eight pairs of cadaveric wrists were tested. Constructs tested were 1.6mm K-wire fixation, Tension Band wiring and Screw Fixation. Fracture displacement was measured using a venire micrometer.

Results: Displacement on forced radial deviation was maximum in neutral wrist position in all construct configurations. Displacement was minimized in 20 degrees wrist flexion. The optimum fixation method was 2 k-wires with tension band wiring. This study would suggest that the optimum fixation for ulna styloid fractures is a Tension band-wiring construct. If non-operative treatment is used we suggest that the wrist is immobilized in a position of wrist flexion to reduce tension on the ulna carpal ligament and prevent fracture displacement.

The Extensor Digitorum Brevis is an easily visualised superficial muscle present on the dorsolateral aspect of the foot. It is innervated by the terminal branches of L5. Wasting of this muscle has been described as a sign of L5 radiculopathy, however its specificity and sensitivity as a clinical sign in patients with disc disease has never been assessed to the best of our knowledge.

The purpose of our study was to determine the effectiveness of this sign in patients with a know L5 radiculopathy. We included three groups of patients, which were prospectively assessed by a blinded single examiner. Group A were patients with a clinical L5 radiculopathy confirmed on MRI, Group B were patients with a clinical a S1 radiculopathy confirmed on MRI and Group C were a control group. There were 20 patients in each group, 10 male and 10 female, mean age 38 years (range 19 – 57 years). Our inclusion criteria were leg pain greater than 6 weeks, we excluded and patient with a history of previous disc disease or foot surgery. A positive sign was defined as a gross clinical wasting of the extensor digitorum brevis compared to the opposite foot.

The sign was negative in all 20 patients in the control group. The sign was positive in 12 patients (60%) with L5 radiculopathy and only one patient (5%) with S1 radiculopathy. Fishers exact test confirmed statistical significance between the two groups with a p value of < 0.05.

We conclude that this easily performed objective clinical sign, when used inpatients with leg pain, is highly specific in determining the pressure of an L5 root involvement.

Two hundred patients with Adhesive Capsulitis according to Codman’s criteria were treated with manipulation under anaesthetic and hydraulic distension by the senior author. The procedure and subsequent rehabilitation was uniform for all patients. The average age at time of procedure was sixty years (range 36–91 years). Follow-up was performed using a self-assessment booklet which we devised to examine outcome in the following areas: Pain Visual Analogue Score, Ten Activities of Daily Living, Ability to Sleep & Lie on Affected Shoulder, Range of Motion and overall satisfaction. The average length of follow-up was sixty-two months (range 12–125 months). One hundred and forty-five patients were available for follow-up and completed the assessment correctly.

Results: There were no operative complications in this group. Pain was significantly decreased from a mean pre-operative pain visual analogue score of 7.9 to 1.4 post-operatively. Shoulder pain causing difficulty sleeping was reduced from 85% of patients pre-operatively to 15% post-operatively. Range of motion was assessed in comparison to pre-operative values of the affected side and current values of the unaffected side. Regarding patient satisfaction 90% of patients were improved post-operatively, 7.5% unchanged and 1.5% felt that their symptoms were worse following the procedure. The procedure was well tolerated and 97% of patients would have the procedure again. Patients who had the procedure within nine months following onset of symptoms had better long-term range of motion and functional outcome than those who had a greater delay in treatment. Our results indicate manipulation and hydraulic distension is a safe effective treatment for adhesive capsulitis and that a more favourable outcome is achieved if it is performed at an early stage.

The pathogenesis of frozen shoulder remains unclear. Fibroblast proliferation has been implicated in the pathogenesis with subsequent fibrosis of the capsule. We studied patients undergoing manipulation under anaesthesia for frozen shoulder. All fitted Codman’s criteria for the diagnosis. Normal saline was injected and then aspirated from 14 patients undergoing manipulation under anaesthesia for treatment of frozen shoulder and from 15 patients undergoing shoulder arthroscopy for other pathology. Human fibroblasts were cultured from sections of human anterior abdominal wall obtained from patients undergoing elective surgery. The effect of frozen shoulder aspirate versus normal control on human fibroblast proliferation and apoptosis was measured. Cellular proliferation was determined using the Promega celltitre 96TM non-radioactive cell proliferation assay.

Results: Proliferation of human fibroblasts was significantly increased in the cells treated with aspirate obtained from frozen shoulder patients versus both negative control (growth medium only) and control (normal shoulder aspirate) at concentrations of 105, 25% and 50%. This increase in proliferation was in a dose dependent manner, with the most significant increase seen in cells treated with a 505 concentration of frozen shoulder aspirate. Apoptosis was unregulated at all concentrations of shoulder aspirate, but only achieves statistical significance at 255 and 505 concentrations.

Conclusion: This study supports the hypothesis that frozen shoulder results from alteration in fibroblast regulation. Pharmacological modulation of fibroblast proliferation may be a potential therapeutic option.

Surgical correction of spinal deformity in patients with neural axis abnormalities has established risks of causing further neurological injury. It is necessary to identify individuals with a predisposition for such abnormalities before treatment is instituted.

Objective: Examination of the association between idiopathic scoliosis and underlying neural axis abnormalities in the infantile and juvenile age groups.

Design: Retrospective chart and radiographic review.

Subjects: Ninety-four (36 infantile, 58 juvenile) consecutive patients with non-congenital scoliosis under the age of eleven years.

Outcome measures: These consisted of the MRI findings, neurological examination, associated curve morphology and necessity for neurosurgical intervention or surgical curve correction.

Results: Approximately 25% of patients presenting as idiopathic juvenile scoliosis had underlying neural axis abnormalities. No patient with apparent infantile idiopathic scoliosis had an abnormal spinal MRI scan. Using the Z score for independent proportions, there was a statistically significant difference between infantile and juvenile scoliosis and the presence of an underlying neural axis abnormality (Z score of 2.089, equivalent to p< 0.02).

Conclusions: We advocate routine MR spinal imaging in all patients with juvenile idiopathic scoliosis. In infantile idiopathic scoliosis, to avoid unnecessary general anaesthetics, one should image the spinal canal only when clinically indicated

Introduction: Five occipitocervical implant systems were compared biomechanically in vitro using nondestructive testing.

Methods: A composite material model of the occiput and upper cervical spine was developed and validated. The specimens were tested using an in-vitro purpose build test rig. Instrumentation was from the occiput to C5 and included five constructs in current clinical use. Biomechanical testing parameters included axial rotation, flexion/extension and lateral bending. Nondestructive pure moments were applied to C5 using a system of cables and pulleys loaded by a materials testing machine (Hounsfield Ltd. UK) Angular displacement of the specimen under load was measured using the Zebris System (Zebris Medizintechnik, GMBH, Germany) which collects and stores three-dimensional space co-ordinates by means of attached ultrasonic markers. Mean maximum angular displacement was calculated from a series of five test cycles for each construct. Statistical significance was determined using a one-way analysis of variance (ANOVA) combined with a LDS test at 95% confidence.

Results: Statistically significant differences were shown in the initial stiffness of current implant constructs used for stabilization of the occipitocervical junction. The Zebris system was also validated as an accurate and efficient 3-D motion analysis for cervical spine biomechanical research.

Cervical orthoses are currently used in the pre-hospital stabilization of trauma patients and also as part of the definitive non-operative treatment of injuries of the cervical spine. The construct stability of orthoses is compromised by virtue of the fact that the cervical spine exhibits the greatest range of movement amongst the spinal segments and also because of the complex composite nature of neck movements.

To date, data has been difficult to attain comparing the various orthoses, in the various planes of movement of the cervical spine. Various methods including the use of inclinometers, goniometers, radiography, computerized tomography and cineroentgenography have been used in an attempt to measure these movements but none have provided satisfactory triplanar data.

This paper uses the Zebris ultrasonic 3-D motion analysis system to measure flexion, extension, range of lateral bending and range of axial rotation in five similar male and five similar female subjects with no history of neck injuries. The subjects were tested in a soft and hard collar, Philadelphia, Miami J and Minerva.

Results show that the Minerva is significantly the most stable construct for restriction of movement in all planes in both groups (p< 0.002 vs. all groups, Student’s t-test), but more impressively in the female group. In the male group, the standard hard collar performs second best in flexion, lateral bending and axial rotation. In the female group, the second most stable orthosis is the Philadelphia in flexion/extension and the hard collar in lateral bending and axial rotation (p< 0.05 vs. next most stable in all cases, Student’s t-test). The soft collar in both groups offered only minimal resistance to movement in any plane, e. g. 45.07° vs. 46.45° extension vs. normal in males and 40.15° vs. 41.8° extension vs. normal in females.

Looking at these results together allows the ranking of the measured orthoses in order of the three-dimensional stability they offer. Furthermore, they validate the Zebris as a reliable and safe method of measurement of the complex movements of the cervical spine with low intersubject variability.

In conclusion, this paper, for the first time presents reproducible data incorporating the composite triplanar movements of the cervical spine thus allowing comparative analysis of the three-dimensional construct stability of the studied orthoses.

The pathogenesis of frozen shoulder remains unclear. Fibroblast proliferation has been implicated in the pathogenesis with subsequent fibrosis of the capsule. We studied patients undergoing manipulation under anaesthesia for frozen shoulder. All fitted Codman’s criteria for the diagnosis. Normal saline was injected and then aspirated from 15 patients undergoing manipulation under anaesthesia for treatment of frozen shoulder and from 15 patients undergoing shoulder arthroscopy for other pathology. Human fibroblasts were cultured from sections of human anterior abdominal wall obtained from patients undergoing elective surgery. The effect of frozen shoulder aspirate versus normal control on human fibroblast proliferation and apoptosis was measured. Cellular proliferation was determined using the Promega celltitre 96TM non-radioactive cell proliferation assay.

Proliferation of human fibroblasts was significantly increased in the cells treated with aspirate obtained from frozen shoulder patients versus both negative control (growth medium only) and control (normal shoulder aspirate) at concentrations of 105, 25% and 50%. This increase in proliferation was in a dose dependent manner, with the most significant increase seen in cells treated with a 505 concentration of frozen shoulder aspirate. Apoptosis was upregulated at all concentrations of shoulder aspirate, but only achieves statistical significance at 255 and 505 concentrations.

This study supports the hypothesis that frozen shoulder results from alteration in fibroblast regulation.

Introduction: Thromboembolic complications are common in both elective and trauma orthopaedic practice. Despite the many studies reported in the literature, there remain a number of unanswered questions regarding the use of thrombophylaxis. The aim of this study was to establish the current practice amongst Irish consultant orthopaedic surgeons regarding thromboprophylaxis.

Materials and Methods: A detailed confidential written questionaire was sent to all consultant orthopaedic surgeons in the republic of Ireland. Surgeons were asked to indicate the type of mechanical and chemothromboprophylaxis in the setting of total hip arthroplasty, knee arthroplasty and hip fracture. They were also questioned regarding 1) time of commencement of therapy 2) duration of therapy 3) method of diagnosis of DVT 4) Estimated incidence of mortality from pulmonary embolism in the last five years 5) Whether there was established protocol for DVT prophylaxis in their unit. 6) Reason for not using chemothromboprophylaxis if not used and 7) whether their method of treatment was influenced by anaesthetic concerns.

Results: The response rate was seventy percent. Over ninetyfive percent of surgeons used a combination of physical and chemical modalities. There was a wide variation between type of therapy, commencement time and duration of prophylaxis. There was a higher rate of intervention and duration of therapy in elective practice. A unit policy regarding thromboprophylaxis existed in a majority of hospitals (54.7%). Forty-seven per cent of respondents felt that there had been no post-operative mortality in their practice in the previous five years from pulmonary embolism. Twenty-six percent of respondents felt that anaesthetists influenced the type of prophylaxis used. The results of this survey shows that venous thromboembolism is regarded as a significant complication of orthopaedic surgery and that most orthopaedic surgeons take active steps to try and prevent its occurrence. There was a higher rate of intervention in this groug of surgeons compared to previous surveys of British orthopaedic surgeons. This may reflect a higher standard of care or a concern regarding the high rate of litigation in the republic of Ireland. However there is no consensus as to the optimum therapy which reflects the conflicting evidence available in the many publications on this subject.