Introduction

An additional pathology should be considered for Achillodynia differentials – the intratendinous tear (ITT) – for which we describe symptoms, ultrasound findings and co-presenting pathology.

Hip arthroscopy is becoming more popular. A literature review demonstrated paucity of published papers reporting the outcome of hip arthroscopy in teenagers without developmental dysplasia of the hip. Our aim was to record the type of lesions found and report the outcome and level of satisfaction following hip arthroscopy in teenagers.

From 2002 to 2008, 96 hip arthroscopies were undertaken in 76 patients. Pre-operative and two-week, six-week and current post-operative assessments were performed using the modified Harris hip score (HHS) and the Non Arthritic Hip Score (NAHS). In addition, a satisfaction survey was completed at their most recent review.

Patients enrolled in the study were under the age of 20. Patients with a history of developmental dysplasia of the hip, Perthes disease and arthritis were excluded from the study. Patients had at least a six-month follow-up from their surgery.

Our study cohort comprised 53 males and 43 females with an average age of 17 years old (range 13 to 19 years). The average duration of follow up was 19 months (range 3 to 75 months). There were 41 left and 54 right-sided hip arthroscopies. There were five re-operations. The average duration of hip traction was 19 minutes (range 6 to 47 minutes).

We found pathology in all hips that underwent arthroscopy. We report a significant improvement in MHHS and NAHS at six weeks and current review (p-value <0.01). Sixty-two percent of patients had returned to sport at the previous level of competition, 32% of patients returned to sport at a lower level of competition and 5% patients did not return to sport. Overall, 84% of patients were satisfied following their hip arthroscopy and 91% would have the surgery again if they had to. There were five re-operations.

Our study has revealed a range of intra articular hip pathologies amenable to surgical treatment using hip arthroscopy. We have observed a significant improvement in hip scores; with up to 94% of patients returning to sport in the short term with high satisfaction levels. Long term follow up of this group is ongoing.

Introduction: Distal third fractures of the clavicle account for approximately 10–15% of clavicle fractures. Non union rates following conservative management can be as high as 30%. Many techniques have been described, including external fixation, k-wire fixation, and most recently, hook plate fixation. Non-absorbable sutures, and slings have also been utilised. All of these techniques are associated with complications. In addition, Hook plates require a second operation to remove the plate. This study reports the results of a simple technique using a PDS loop in the fixation of Neer type 2 fractures of the clavicle, performed in our institution.

Methods: Twelve patients with Neer type 2 fractures operated by a single surgeon over three years were included in the study. The mean age was 45 (14 to 63). There were 7 male and 5 female patients. Standard postoperative protocols were followed in all patients. A 1.5 PDS cord looped around the coracoid was used to hold the reduced medial clavicular shaft fragment. Patients were followed up postoperatively at two, six and twelve weeks. Final outcomes were assessed using radiographs and the Oxford and DASH scoring systems at twelve months.

Results: Ten fractures united within twelve weeks. All of these patients returned to their pre-injury activity level. There were two non unions, both in non compliant patients. One of these non unions remained asymptomatic and one patient was lost to follow up. The mean Oxford score at 12 months was 14.25 (range 12 to 16) and the mean DASH score was 5 (4–7).

Conclusion: We conclude that this technique is safe, simple and cost effective. It achieves high rates of union without the need for implant removal. As with other techniques, proper patient selection is essential. We recommend this technique as an excellent treatment option when dealing with these notoriously difficult fractures.

Femero acetabular impingement is a common casue of hip and groin pain. Its presence can be expected from clinical examination and confirmed with appropriate imaging. Treatment of the CAM lesion has been well described by Ganz et al and the open treatment of this condition has been shown to be effective. However, there is significant morbidity associoated with this surgery. Arthroscopic treatment of the CAM lesion and also pincer impingement can be safely performed and the techniques will be shown.

We will detail our experience in performing over 500 arthroscopies for femero acetabular impingement. This will be a visual demonstration of the techniques we use on a day to day basis.

We will demonstrate different degrees of rim lesions, labral tears, labral repairs, acetabular rim excision, femero osteochondroplasty, checking impingement and intra-operative techniques for confirming position of resection.

In the future this technique will be widley used to treat FAI by a greater number of surgeons.

We propose a grading system for contrast free MRI images of tennis elbow and evaluate the inter and intra observer variability of their interpretation.

Methods: Three senior orthopaedic surgeons were asked to blindly grade 0.2T dedicated extremity contrast free MRI images of elbows of patients who presented with varying degrees of symptomatic tennis elbow.

Our proposed grading system of 1 to 5 based on the pattern around the common extensor tendon was used.

Images of the symptomatic and contralateral non symptomatic elbows were graded blindly twice with an interval of 1 month by each surgeon.

Each surgeon graded 176 MRI images twice.

The grades were subsequently grouped into (I) grades 1 to 2 and (II) grades 3 to 5

Results: With regards to the intra observer agreement, consultant A showed 90.1% agreement, consultant B showed 90.6% agreement and consultant C 96.0% agreement. The mean intra observer agreement rate was 92.2%.

The inter observer agreement between consultant A and B was 82.46%, between A and C 67.1% and between B and C 80.1%.

It was also noted that there were systematic differences to the inter observer variability. Consultant A graded the images 3 to 5 on both occasions 52.9% of the time, consultant B graded 3 to 5 on both occasions 37.8% of the time and consultant C graded 3 to 5 on both occasions 23.3% of the time.

Conclusion: The intra observer agreement rate is high. There is however a greater inter observer variation but this variation is consistent. We suggest that the inter observer differences can be improved by (1) reducing the grades to positive or negative and (2) by group reeducation of the observers.

External rotation of the shoulder is commonly measured in two ways, with the arm adducted or with the arm abducted to 90°. The measurement forms an important part of the assessment of shoulder function, but has been shown to be unreliable. Following the observation that, with the arm adducted, the range of external rotation alters according to the exact position of the arm in the sagittal plane, we conducted a study to quantify the effect on the range of external rotation of a small increment in forward flexion (15°).

With the arm first in a vertical position and then in 15° of forward flexion, external rotation was measured in 40 asymptomatic and 20 ‘frozen’ shoulders. With forward flexion, the range of external rotation decreased by a mean of 16.9° in the asymptomatic and 13.5° in the ‘frozen’ shoulders.

We postulate that some of the variation is a function of scapular positioning. With arm flexion, the scapula protracts, resulting in alteration in glenoid version. However, some difference is due also to alteration in soft tissue tension in the two arm positions.

The sagittal position of the arm affects the range of external rotation of the adducted shoulder. This variation in measurement may affect the scores of certain outcome measures.

Aims – to describe the modifications in technique and outcome of the Latarjet procedure.

Methods – 46 patients were operated on over a six year period. The modifications included a change in orientation of the coracoid bone block and the addition of capsular closure. The procedures were performed by one surgeon for instability associated with antero-inferior glenoid loss. A Walch-Duplay score for instability was produced for each patient at follow-up. All patients had radiological evaluation.

Results – all patients were male with 33 participating at rugby union at a competitive level. The average number of pre-operative dislocations was 5 (range 2 to 20). The average follow-up was 38 months (minimum 6 months). Only one patient had recurrent instability. 31 returned to sport at the same level. The Walch-Duplay scores were as follows; excellent 70%, good 25%, mild 3.75% and poor 1.25%. There were the following complications; 2 fibrous unions (excellent outcome), 3 broken screws (excellent outcome) and two fixation failures (due to patient non compliance). There was no decrease in the range of internal rotation, 8 patients had mild restriction in forward flexion (average 5°) and 20 patients had mildly reduced external rotation at 90° abduction (average 5°). All but one patient (recurrent dislocation) rated their outcome as excellent and would have the operation again.

Discussion – recurrent instability due to bone loss is a difficult problem that is not amenable to traditional stability soft tissue procedures. We feel that the Latar-jet procedure confers excellent stability and produces excellent subjective and objective outcomes

Aim: To study the role of total elbow replacement in the management of distal humeral fractures in elderly patients.

Patients and methods: Between 1995 and 2003, 25 consecutive patients with fractures of the distal humerus were treated by primary total elbow replacement using the Coonrad-Morrey prosthesis. All surgeries were performed by one of the senior authors in two centers in South Wales. There were 18 females and 7 males and none of them had inflammatory or degenerative arthritis of the elbow. The mean age at the time of injury was 78 years (68–84). According to the AO classification, 16 patients had suffered a C3 injury, five type B3 and three type A3. One fracture was unclassified. The mean time to follow-up was 4 years (1–9 years).

Results: At follow-up 19 patients (76%) reported no pain, five (20%) had mild pain with activity and one had mild pain at rest. The mean flexion arc was 28 degrees to 105 degrees. The mean supination was 69 degrees (50–90) and pronation 70 degrees (50–80). No elbow was unstable. Mean Mayo elbow performance score was 71.5(25–100). Four patients (16%) developed ulnar neuropraxia following surgery that improved with time, 2 patients developed superficial wound infection (staphylococcus aureus), which was treated with antibiotics only. None of the above elbows required revision to date. Radiological evaluation revealed only one patient with a radio-lucent line at the cement -bone interface. It was between 1 and 2mm in length, was present on the initial postoperative radiograph and was non-progressive at the time of follow-up.

Conclusion: Primary total elbow arthroplasty is an acceptable option for the management of comminuted fractures of the distal humerus in elderly patients when the configuration of the fracture and the quality of the bone make reconstruction difficult.

Purpose of study: A retrospective review of treatment for this often very difficult problem in old people with osteoporotic bone.

Description of methods: Number of patients reviewed: 11 (9 females, 2 males). Age: 63 – 89 (average 76). Follow-up: 14 – 72 months (average 61)

The operative method was similar in all cases: the non-union was exposed through a delto pectoral approached and fibular allograft was inserted across the fracture site. As the fibula is a very dense cortical bone a T-plate could then be applied to the humerus with the screws directed into the intramedullary fibular peg. Cortico-cancellous bone from the Iliac crest was supplemented.

Results: Bony union was achieved in every case.

Pre-operative constant scores: Average 26

Post-operative constant scores: Average 75

The most significant increase in constant score was the ability to actively elevate the arm. Decrease in pain levels did play a role but was not as dramatic as the increase in function.

Discussion: In this very difficult problem of non-union of the proximal humerus, mostly in elderly people with osteo-porotic bone where internal fixation is a major problem, supplementing the fixation with an intramedullary fibular peg achieved excellent results.

Over 40 months, 264 arthroscopic rotator cuff repairs were assessed prospectively. Preoperatively all patients were assessed using a modified Constant score and Visual Analogue Pain Scale (VAPS). The mean age at surgery was 59 years (19 to 83). In 151 cases (62%) the shoulders were on the dominant side. All patients underwent postoperative ultrasonography to assess cuff integrity at three weeks. Twenty-two patients were lost to follow-up. Of the rest, 210 were clinically reviewed and Constant scores produced. The remaining 32 were assessed using the VAPS and a subjective satisfaction questionnaire.

The Constant score improved by a mean of 29.6, with 166 patients (69%) reporting complete resolution of pain. The subjective outcome was rated excellent by 162 patients, good by 55, moderate by 20 and poor by five. There were 13 retears, 11 of which were identified on the three-week ultrasound. When four of these were revised, two required subscapularis repair. Importantly, five patients with retears had excellent subjective outcome. Complications were five superficial infections, 13 cases of transient neuritis following interscalene nerve blocks, four cases of bursitis, which required debridement and suture removal, and two anchor pull-outs. The overall reoperation rate was 4%.

Arthroscopic rotator cuff repair offers excellent objective and subjective outcomes, particularly pain relief. Ultrasonography at three weeks is a good indicator of whether or not a repair has taken.

This paper retrospectively reviews the type and outcome of shoulder surgery in 61 professional rugby players (mean age 24.7 years). All competed at provincial level or higher, with 20 competing internationally. Forty-three of the patients played the position of forward, while 33 played back. Most shoulders (41) were on the dominant side. Ten players had multiple procedures and over a seven-year period 76 procedures were performed. The procedures included 16 Latarjets, four arthroscopic stabilisations, four SLAP repairs, four arthroscopic shoulder decompressions, three biceps tenodeses, three HAGL repairs, two revision Latarjets, one posterior Bankart, one pectoralis major repair, one Weaver-Dunn and four combination procedures.

All but two players returned to their previous level of competition. The mean time to return to full contact participation was 3.6 months (1 to 12). The time to return was one month for an arthroscopic Mumford and six months for a stabilisation procedure.

The outcome of the shoulder Delta prosthesis in 22 men and nine women was prospectively studied. The mean age was 74 years (62 to 86). Indications for surgery were cuff deficient arthritis (18), fracture malunion (three), ‘pseudo-paralysis’ (six) and failed total prostheses (four). The mean preoperative Constant score of 39 increased to 69 (10 to 39) at 33 months postoperatively, with the major increases in the scores for active forward elevation and pain relief. The subjective satisfaction was 79%. Although this was a small series with a short follow-up, early results seem satisfactory.

Over a six-year period, one surgeon operated on 46 men with instability associated with antero-inferior glenoid loss. Thirty-three of them played rugby at a competitive level. The mean number of preoperative dislocations was five (2 to 22). Modifications included a change in orientation of the coracoid bone block and the addition of capsular closure.

A Walch-Duplay score for instability was calculated at follow-up. The mean follow-up was 38 months with a minimum of 6 months. Only one patient had recurrent instability. Thirty-one returned to sport at the same level. Walch-Duplay scores were excellent in 70%, good in 25%, mild in 3.75% and poor in 1.25%. Complications included two fibrous unions (excellent outcome), three broken screws (excellent outcome) and two fixation failures owing to patient non-compliance.

There was no decrease in the range of internal rotation. Eight patients had mild restriction in forward flexion (mean 5°) and 20 patients had mildly reduced external rotation at 90° abduction (mean 5°). All but one patient with recurrent dislocation rated the outcome excellent and would have the operation again. The Latarjet procedure confers outstanding stability and gives excellent subjective and objective outcomes.

In this prospective study of partial articular supraspinatus tendon avulsion (PASTA) lesions treated arthroscopically by an ‘all inside’ method, 12 patients (nine men and three women) with a mean age of 31 years (22 to 36) were followed up for a mean of 16 months (8 to 32). The deep partial rotator cuff tears were usually viewed from the glenohumeral joint side. Viewing the subacromial space usually revealed an entirely normal cuff with no sign of subacromial impingement. With the arthro-scope in the glenohumeral joint, the footprint area of the supraspinatus tendon was prepared and one or two anchors, each preloaded with two sutures, were passed through the rotator cuff into the footprint area of the greater tuberosity. The sutures attached to these anchors were passed through the tendon and tied in the subacromial space.

The Constant score improved from a preoperative mean of 72 to a postoperative mean of 91. The greatest increase was in power and overhead motion, especially abduction and external rotation.

PASTA lesions are difficult to diagnose, even with MRI. The ‘all inside’ method of arthroscopic repair obviates the need to detach intact fibres.

We reviewed 36 patients (39 shoulders) who had undergone arthroscopic Mumford procedure via a two superior portal technique for isolated acromioclavicular joint pain, using the Simple Shoulder Score (SSS) and a subjective outcome questionnaire, which included views about the cosmesis of the scars. The mean age of the 32 men and four women was 36 years (19 to 57) and 14 shoulders were on the dominant side. The mean follow-up was 22.7 months (14 to 47). Twenty-five patients reported a history of trauma, including six rugby injuries and five repetitive injuries sustained while bodybuilding.

The mean SSS was 11.5 out of 12. Subjectively 25 shoulders were rated excellent, eight good, two moderate and four poor. In 31 shoulders (79.5%) pain resolved completely. Twenty-five patients considered small scars either very important or extremely important and 33 were either extremely happy or very happy with their scars.

Arthroscopic excision of the distal clavicle via superior portals preserves the capsule-ligamentous structures stabilising the acromioclavicular joint. The procedure gives an excellent subjective outcome. Those patients with a poorer subjective outcome were older, with an increased possibility of occult shoulder pathology.

This study reviews the use of intramedullary fibular allograft in treating nonunion of the humeral neck in 11 patients. Nine women and two men with a mean age of 76 years (63 to 89) were followed up for a mean of 61 months (14 to 72). The nonunion was exposed through a deltopectoral approach and fibular allograft was inserted across the fracture site. As the fibula is a very dense cortical bone, a T-plate could then be applied to the humerus with the screws directed into the intra-medullary fibular peg. Supplementary corticocancellous bone from the iliac crest was used. Bony union was achieved in every case. The preoperative mean Constant score was 26 and the postoperative mean Constant score was 75. The most notable improvement was in patients’ ability to elevate the arm actively. Decreases in pain levels were observed but were less dramatic than the increases in function.

The results of arthroscopic repair of tears of the sub-scapularis tendon in nine men and six women, ranging in age from 53 to 73 years, were followed up at a mean of 14 months (6 to 24). Three were complete tears, six 50%-tears and six 30%-tears. In seven patients there were associated tears of the supraspinatus and infraspinatus tendons, which were repaired arthroscopically during the same procedure.

In each case the subscapularis tear was identified. In most patients a biceps tenotomy was necessary. The subscapularis footprint was prepared and the tendon was repaired using one or two anchors, each with two sutures, depending on the size of the tear. The mean pre-operative and postoperative Constant scores were 48 and 88 respectively.

In most patients, power returned to almost normal and pain was almost completely relieved. Arthroscopic subscapularis repair is a relatively new procedure and seems to give good results.

Aim: To determine the complication rate following fixation of olecranon fractures in the elderly.

Method: A retrospective review of clinical notes and x-rays over a 4 year period at 3 district general hospitals in South Wales was performed. Only patients with isolated, displaced olecranon fractures over 65 years were included.

Results: 80 patients who underwent olecranon fixation were identified and reviewed. It was found that 80% of these underwent tension band wiring and the operations were performed in the majority by training grade surgeons. The overall complication rate was 37%. This included an infection rate of 13%, of which the majority required re-operation.2 patients required multiple procedures including olecranon excision and triceps advancement. Prominence of metalwork was a significant problem with removal of metalwork performed in 24% of patients.

Conclusion: In what is commonly regarded as a straightforward procedure carried out by training grade surgeons we found an unacceptable re-operation rate of 37%. It is our belief that olecranon fixation in the elderly is not a benign procedure and caution should be exercised when dealing with these injuries. We propose an alternative method of surgical treatment for these injuries.

The ‘Pi’ plate is an anatomical titanium plate recently introduced for the internal fixation of comminuted intra-articular distal radius fractures. We report our experience with this implant in a prospective series of twelve patients with an average age of thirty six years (range, 26–52 years).

A dorsal approach with release of the EPL tendon and extra-compartmental exposure of the radius between the second and fourth extensor compartments was employed in all cases. Iliac bone graft and a styloid K-wire were used to augment the plate fixation. Post-operatively, active mobilisation was started after wound healing. Wrist motion and grip strength measurements were made at six weeks, three months and six months by the therapist. At six months, patients recovered an average of 85% of range of movement compared with the opposite wrist, except for palmar flexion (65%). No loss of reduction was observed on follow-up radiographs. Complications were compartment syndrome, intraoperative EPL rupture and two cases of extensor tendonitis requiring implant removal.

The ‘Pi’ plate affords rigid fixation of distal radius fractures permitting early rehabilitation. It is however a demanding technique that is not without complications.