Introduction/aims

Anterior cruciate ligament (ACL) reconstruction is now routinely performed arthroscopically. However, there are only a few centres in the UK which offer this procedure as a day case. We aimed to assess the clinical outcomes of day case ACL reconstruction using a tourniquet-less pump regulated procedure.

Treatments of Chronic Acromioclavicular joint dislocation are controversial. Many procedures have been described in the past for the management of them. Treatment modalities have changed with increasing understanding of the nature of the problem, patient expectations and the biomechanics of the joint

Introduction

Extensor digitorum brevis (EDB) transfer is a useful method for treating chronic ankle instability in selected patients. It adds strength to the anterolateral capsule and provides proprioceptive feedback to functionally unstable ankles.

Treatments of Chronic Acromioclavicular joint dislocation are controversial. Many procedures have been described in the past for the management of them. Treatment modalities have changed with increasing understanding of the nature of the problem, patient expectations and the biomechanics of the joint

To assess the functional outcome of the chronic AC joint dislocations treated by modified Weaver-Dunn procedure combined with Acromioclavicular joint augmentation.

We treated 54 patients with chronic AC joint dislocation by modified Weaver-Dunn procedure with additional AC joint augmentation. We used tight rope system in 20 patients, Mersilene tape in 22 patients and no 5 Ethibond in 12 patients.

This Study was done between Jan 2003 to Jan2012. Mean follow up was 20 months, mean age of the patients was 35, and male to female distribution was 48:6. We assessed them clinically and radio logically during their follow up. All patients were back to their occupation. 80% are back to their pre injury sporting activity level. The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 10.2 points. One patient had a failure of augmentation device.

Our study shows that chronic symptomatic AC joint dislocations, (Rockwood types III to V,) Managed with modified modified Weaver-Dunn procedure with augmentation are showing good short term results. Significant improvement in the patient satisfaction, early return to work and radiological appearance

Introduction: Glenohumeral arthritis secondary to chronic cuff deficiency not only leads to serious compromise in shoulder function but also poses a surgical challenge. There is no consensus regarding management of this problem although different arthroplasty options have been tried with variable results. We present our experience with managing this difficult problem using a shoulder resurfacing and subscapularis Z-plasty in order to improve shoulder movements, pain and function.

Patient and Methods: This study was conducted on 30-patients with rotator cuff arthropathy operated by a single surgeon at a district general hospital. There were 21 female and 9 male patients with mean age 73 years (range 62–85 years). The average duration of symptoms prior to treatment was 5.45 years (range 2–15 years). Twenty patients had uncemented shoulder resurfacing while remaining ten patients had cemented resurfacing procedure. The mean follow-up was 21 months (range 36–18 months). The patients were assessed at 3 months, 6 months, 12 months and 24 months postoperatively with European Society for shoulder and Elbow Surgery Score (ESSES) and radiograph at each visit.

Results: The ESSES score significantly improved from a mean of 47.5 preoperatively to 77.5 postoperatively, with most improvement being in subjective scoring (pain and ADL) followed by improvement in external rotation and forward flexion movement due to lengthening of subscapularis by Z-plasty. The VAS score for pain improved from average 7.4 preoperatively to 0.9 at 6 months postoperatively. On subjective scoring most patients reported good to excellent result at 6 months following surgery. There was no difference in outcome scores between cemented and uncemented resurfacing groups. No intraoperative or postoperative complications were encountered.

Our early results with shoulder resurfacing in management of rotator cuff arthropathy are encouraging. This bone conserving surgery may serve as an alternative to major procedures like reverse shoulder arthroplasty in selected group of patients.

AIM: The purpose of this retrospective study was to assess the results of a novel surgical technique for chronic lateral ankle instability using dynamic extensor digitorum brevis (EDB) muscle transfer.

METHODS: 15 patients underwent dynamic EDB muscle transfer for symptomatic chronic lateral ankle instability. All patients were quite fit and physically very active. 9 male and 6 female patients, mean age 27 (range, 22–32) were operated by single surgeon (ALP) between March 2003 and August 2005. All patients had standard procedure involving proximal transfer of the origin of EDB muscle whilst preserving its neuro-vascular pedicle. All patients went through a standard post-operative physiotherapy protocol including pro-prioceptive training. Mean follow-up was 24 months (range, 12–36 months). The mean functional Karlsson scores improved from 26.5 before surgery to 86.5 at 12 months after surgery. At follow-up, all patients had normal range of ankle movements and were functionally stable. All patients regained their pre-injury activity level at 12 months after surgery. There were no early or late complications in our series.

DISCUSSION: Ankle sprains are the most common injuries sustained during sports and physical exercise. Treatment is usually conservative because most of these injuries heal without consequence. However, symptomatic chronic lateral ankle instability is a difficult problem to treat and several surgical techniques have been described. EDB muscle not only acts as a dynamic substitute for the deficient ligament but also overcomes the problem of over-tightening of the ligament leading to restricted supination.

CONCLUSION: Dynamic EDB muscle transfer is a safe, clinically effective and reliable surgical option for symptomatic chronic lateral ankle instability.

The aim was to demonstrate that day case Anterior Cruciate Ligament (ACL) reconstruction, without the use of a tourniquet, is clinically effective, cost effective, safe and “patient choice” procedure.

Fifty patients who underwent day case, arthroscopic, ACL reconstruction without the use of a tourniquet, but using saline and epinephrine, pump regulated, irrigation. The same surgeon performed each case for the period May 2003 to April 2005. Seven patients had their tendons reconstructed with the use of patellar tendon grafts, the remainder, 43 patients, had hamstring tendon grafts. The study included 6 women and 44 men. This prospective study assessed cost effectiveness, clinical efficacy by measuring post-operative pain and postoperative results and finally whether this procedure remained the “patient choice”. The mean age was 30.6 years, (range 16 – 46). In addition to assessing level of immediate post operative pain the patients were also assessed at two weeks and six weeks for pain, range of movement, swelling and for the occurrence of any early post-operative complications.

We were able to show that there was a significant cost benefit, approximately one third to a half in comparison to other local surgeons; that the study was clinically effective and that there were no reported early complications; and that all 50 patients would choose to have the surgery again as a day case procedure with this technique.

We would like to present day case ACL reconstruction without the use of a tourniquet, as a safe option for the carefully selected patient.

This is a report of 30 patients who underwent arthroscopic, Anterior Cruciate Ligament (ACL) reconstruction without the use of a tourniquet, but using saline and epinephrine, pump regulated, irrigation. Each case was performed as a day case by the same surgeon for the period May 2003 to December 2004. 5 patients had their tendons reconstructed with the use of patellar tendon grafts, the remainder, 25 patients, had hamstring tendon grafts. The study included 4 women and 26 men. This prospective study assessed cost effectiveness, clinical efficacy by measuring post-operative pain and post-operative results and finally whether this procedure remained the “patient choice”. The mean age was 30.6 years, (range 17 – 46). In addition to assessing level of immediate post operative pain the patients were also assessed at two weeks and six weeks for pain, range of movement, swelling and for the occurrence of any early post-operative complications. We were able to show that there was a significant cost benefit, approximately one third to a half in comparison to other local surgeons; that the study was clinically effective and that there were no reported early complications; and that all 30 patients would choose to have the surgery again as a day case procedure with this technique. We would like to present day case ACL reconstruction as a safe option for the carefully selected patient and as a procedure that could perhaps be included in the orthopaedic basket for day case surgery in the UK.

Introduction. Acute distal biceps rupture can be a devastating injury and surgical repair offers the only real chance of full recovery. We report on a new surgical technique in which the use of suture anchors and a modified de-tensioning suture was employed to protect the repair in the early post operative recovery period and aid early rehabilitation and return to full pre-injury activity.

Materials & Methods. Using the standard anterior incision the distal biceps tendon was approximated to the radial tuberosity using two Mitek sutures and a sliding stitch. Using 2-0 Vicryl, de-tensioning sutures were used to attach the medial and lateral sides of the tendon to the underlying brachialis muscle. Post-operative recovery encouraged isometric contractions as early as 24 hours and after 2 weeks allowed flexion and extension with gravity eliminated. Six weeks onwards full active movement commenced with gradual increase in stretching and strengthening exercise.

Results. 14 patients underwent this procedure and all returned to pre-injury activity levels within 9 months. Follow up (6–14 months) demonstrated all had regained pre-injury levels of strength in flexion and supination.

Discussion. Using two suture anchors, it is suggested that load bearing strength is greater than the trans-osseous method, providing even tension is applied to both anchors. This can be achieved using a sliding stitch. De-tensioning sutures restore the isometric pull on biceps in the early phase and protects the repair.

Conclusion. All cases operated on in this way have made excellent recoveries and have returned to full pre-injury levels of activity. We therefore recommend this technique as a way of enhancing rehabilitation in what can be a devastating injury for the active sporting individual

Pectoralis major tendon rupture is a relatively rare injury, resulting from violent, eccentric contraction of the muscle. Over fifty percent of these injuries occur in athletes classically in weight-lifters during bench press. In this study, thirteen cases of distal rupture of the pectoralis major muscle in athletes are presented. All patients underwent surgical repair.

Physical findings and surgical technique are described. Magnetic resonance imaging was used in the diagnosis of all patients and intra-operative findings correlated with the reported scans in eleven patients with minor differences in two patients. During follow up examination, six patients had excellent results, six had good results and one had a fair result. Eleven patients could return to sports activity at their preoperative level.

Among our patients we emphasize that of an orthopaedic resident who suffered a rupture of his pectoralis major tendon as an unusual complication of closed manipulation of an anterior shoulder dislocation.

According to the literature and our experience, we suggest that only surgical repair of the pectoralis major rupture will result in complete recovery and restoration of the full strength of the muscle which is essential for the active athlete.

Introduction and Aims: Pectoralis major tendon rupture is a relatively rare injury, resulting from violent, eccentric contraction of the muscle. Over 50percent of these injuries occur in athletes, classically in weight-lifters during bench press.

Method: In this study, 13 cases of rupture of the pectoralis major muscle in athletes are presented. All patients underwent surgical repair. Physical findings and surgical technique are described. Magnetic resonance imaging was used in the diagnosis of all patients. Intra-operative findings correlated with the reported scans in 11 patients with minor differences in two patients.

Results: During follow-up examination, six patients had excellent results, six had good results and one had a fair result. Eleven patients could return to sports activity at their pre-operative level.

Among our patients we emphasise that of an orthopaedic resident who suffered a rupture of his pectoralis major tendon as an unusual complication of closed manipulation of an anterior shoulder dislocation.

Conclusion: According to the literature and our experience, we suggest that only surgical repair of the pectoralis major rupture will result in complete recovery and restoration of the full strength of the muscle, which is essential for the active athlete.

Full thickness defects of articular cartilage have a poor capacity for biological repair and often progress to osteoarthritis. Various surgical techniques have been developed to overcome the inability of chondrocytes to heal injured cartilage. Arthroscopic lavage and debridement offer temporary symptomatic relief whereas marrow-stimulating techniques like drilling, microfracture and abrasion arthroplasty yield poor quality fibro-cartilage that is incapable of withstanding the mechanical stresses to which healthy articular cartilage is subjected.

We present our experience using the osteochondral graft transfer technique in the treatment of isolated Outerbridge grade 4 lesions of the knee. The study includes nineteen patients with a mean age of 29 years (range 17 to 40) presenting with symptomatic lesions of the knee with a mean defect size of 2.4cm (0.8 to 6). At a mean follow-up of 20 months (6 to 40) our results showed a significant improvement in patient function by a mean of 46 points or a 23% mean improvement as assessed by the Knee Society Score (P< 0.0001; One sample t-test). Similarly there was significant improvement in the Brittberg scores with a mean improvement by 2 clinical grades (p< 0.0001; Wilcoxon Rank test). Quality of life scores as measured by the Short Form 36 were dramatically improved by a mean of 24 points (p< 0.0001; Wilcoxon Rank test). In addition, there was significant reduction in pain post-operatively (p< 0.0001; Wilcoxon Rank test) with patients describing a mean improvement of 6 points as measured on the visual analogue chart. A significant number of patients (84.2%) were able to return to active sporting levels by 6 months (p< 0.0001;McNemar Change test).

The results of the osteochondral graft transfer technique, at relatively short-term follow-up, are encouraging with a high percentage of subjective satisfaction. This procedure proved to be a reliable and valid solution for treating isolated osteochondral defects of the knee, providing functional and durable cartilage that is critical to joint function.

Impingement is a major part of the pathological complex of degenerative osteoarthritis of the elbow. It can be seriously disabling causing symptoms of pain, locking, swelling and reduced range of motion. Various surgical techniques, both arthroscopic as well as open, have been described which aim to remove the offending osteophytes and loose bodies in an attempt to improve elbow function.

Our study includes thirteen patients with a mean age of the 54 years (34 to 68) who underwent debridement arthroplasty of the elbow for degenerative arthritis using a modification of the Outerbridge-Kashiwagi trans-olecranon technique. This approach allows excision of posterior osteophytes, adequate clearance of the olecranon fossa,

removal of anterior coronoid osteophytes and loose bodies via a trans-olecranon fenestration and when required permits decompression of the ulnar nerve in the cubital tunnel.

At a mean follow-up of 37 months (3 to 96) the Mayo scores improved by a mean of 36 points with performance indices being rated as excellent in 5, good in 5 and fair in 3. Pain scores improved by a mean of 4 grades (2 to 8). The mean improvement in the flexion-extension arc was 28 (0 to 55). There was one complication of transient ulnar nerve neuritis, which responded to non-operative measures.

Though limited by the lack of a control group we were able to show the effectiveness and reliability of our technique in producing lasting benefit in improving range of motion and relieving pain in degenerative osteoarthritis of the elbow.