Avulsion fractures of the tip of the olecranon are a common traumatic injury. Kirshner-wire fixation (1.6mm) with a figure of eight tension band wire (1.25mm) remains the most popular technique. Hardware removal mat be required in up to 80% of cases. Modern suture materials have very high tensile strength coupled with excellent usability. In this study we compare a repair using 1.6mm k-wires with a 1.25mm surgical steel, against a repair that uses two strands of 2 fibrewire.

Twelve Pairs of cadaveric arms were harvested. A standard olecranon osteotomy was performed to mimic an avulsion fracture. In each pair one was fixed using standard technique, 2 × 1.6mm transcortical ?-wire plus figure of 8 loop of 1.25mm wire. The other fixed with the same ?-wires with a tension band suture of 2.0 fibrewire (two loops, one figure of 8 and one simple loop). The triceps tendon was cyclically loaded (10-120 Newtons) to simulate full active motion 2200 cycles. Fracture gap was measured with the ‘Smart Capture’ motion analysis system. The arm was fixed at 90 degrees and triceps tendon was loaded until fixation failure, ultimate load to failure and mode of failure was noted.

The average gap formation at the fracture site for the suture group was 0.91mm, in the wire group 0.96mm, no specimen in either group produced a significant gap after cyclical loading. Mean load to failure for the suture group was 1069 Newtons (SD=120N) and in the wire group 820 Newtons (SD=235N).

Both types of fixation allow full early mobilisation without gap formation. The Suture group has a significantly higher load to failure (p=0.002, t-test). Tension Band suture allows a lower profile fixation, potentially reducing the frequency of wound complications and hardware removal.

The Ilizarov technique can be used to achieve bony union in high energy trauma and in non-union. There is much interest in the augmentation of bone healing using growth factors, GPS II collects the patients own platelets into a highly concentrated formula. Activated platelets release growth factors that may stimulate fracture healing.

We used the GPS II system in 13 cases of either high-energy trauma (2 cases) of non-union (11 cases) treated with the Ilizarov Circular frame in our institution. The group included two tibial fractures, eight tibial, one femoral and two ulnar non-unions. The minimum follow up of a year. The average age of the patient was 45 (22–66). We observed complications and measured time to clinical and radiological union from the start of treatment with circular frame.

No complications associated with GPS. One patient had an infection remotely in the limb resulting in amputation. All fractures and non-unions went on to solid bony union. The average time to radiological union was 21 weeks (range 13–36 weeks). Frame removal in these cases was 6.5 months (range 4–10 months). No patient underwent any further surgical intervention.

This pilot study features a heterogenous group of patients in which it is difficult to assess the role of GPS II. The use of GPS II, however, was uncomplicated in our study. The use of GPS II may act as a adjuvant therapy in the treatment of high energy trauma and non-union treated with the Ilizarov technique. Furthers studies are required to investigate the efficacy of GPS II in the management of non-union.

Disruption of the coraco-clavicular ligaments may be associated with either dislocation of the AC joint or fracture of the distal clavicle. If sufficient displacement occurs, functional disability results. Traditional techniques have required a bra-strap incision and often require late removal of the metalwork. The Tightrope syndesmosis repair system was adapted to be used arthroscopically to reduce and hold the clavicle enabling healing of the ligaments and any associated fracture using a minimally invasive technique but ensuring accurate reduction and secure stabilisation.

Between December 2004 and November 2006, 21 patients with acute injuries to the corac-clavicular ligaments in our institution were treated using this system. As the system was in evolution the majority were treated arthroscopically and a few using an “open” technique. All had either the acromio-clavicular joint reduced or a distal clavicle fracture reduced and stabilised using the Tightrope Syndesmosis Repair system. The system had been modified from that commercially available for use in the ankle with the consent of the manufacturer (Arthrex, Naples, Fla).

All patients were evaluated at a minimum of 6 months (range 6–32 months) post operatively using the DASH, ASES and Constant scores The mean ASES score was 95, the mean Constant score was 94, and the mean DASH score was 2.5. There were no complications and two patient required removal of the clavicle endobutton.

The authors conclude that this new technique is a safe, simple, cosmetically acceptable and reproducible method of reducing and stabilising the distal clavicle allowing for healing of either the coraco-clavicular ligaments or the distal clavicle

We describe a new a technique for reconstructiing the ulnar collateral ligament (UCL) of the elbow, and test this new technique biomechanically comparing it with an established technique. The UCL is commonly injured in the throwing athlete. We describe a reconstruction using semi-tendinosis allograft with humeral fixation by interference knot. 30 fresh frozen cadaveric arms were harvested and amputated at the mid-humerus. Soft tissue was stripped to the level of the elbow sparing the UCL. The native ligament was ruptured in a materials testing machine (Bionix 858, MTS) by placing a rotational torque on the humerus, with the elbow was fixed at a right angle. Load to failure and stiffness were noted. These arms were randomly assigned to be reconstructed with one of three techniques: 1. Palmaris longus allograft with docking technique humeral fixation 2. Palmaris longus allograft with interference knot humeral fixation 3. Semitendinosis allograft with interference knot humeral fixation The techniques were then tested in the materials testing machine, load to failure and stiffness were noted. Group 1: load to failure 13.31 N/m (+/− 4.2) and stiffness 19.4 N/mm. Group 2: load to failure 13.86 N/m (+/− 5.5) and stiffness 19.1 N/mm. Group 3: load to failure 20.57 (+/− 7.4) and stiffness 20.4 N/mm. The semitendinosis interference technique had a significantly higher strength (p< 0.005) but was not significantly stiffer. None of the techniques approached the strength or stiffness of the native ligament: load to failure 34.2 N/mm and stiffness 45.3N/mm. A new technique to reconstruct the UCL of the elbow uses interference knot fixation in the humeral tunnel. When a palmaris longus allograft is used this technique has a similar biomechanical profile to the established docking technique. When semi-tendinosis is used this technique is significantly stronger and may result in earlier rehabilitation in the clinical setting.

To study the outcome of complex proximal humeral fracture sequelae (Type 3 & 4) treated with the Delta III Total Shoulder Replacement (TSR) Prosthesis. This is a prospective outcome study involving 10 patients mean age (71.5 yrs). All patients failed conservative treatment of proximal humeral fractures. Mean time from injury to surgery was 10.5 (+/− 11.5) months. All patients underwent a Delta III TSR via McKenzie approach by a single surgeon. Patients were assessed clinically with Constant scores, asked whether they were satisfied, and radiologically with plain film radiographs. Since last review one patient has died. Mean time at follow up was 20.8 months post-operation (12 “32 months). Three patients had undergone early revision for dislocation. Since last review two patients have developed deep infection, one treated with washout and suction drain, one with removal of prosthesis. One patient has a clinical diagnosis of complex regional pain syndrome. Three patients are very happy with the outcome of surgery, one is happy, one unhappy and four very unhappy. The mean pre-operative Constant scores was 8.9 (2–15), at first review 44.4 (15–96) and now 35.8 (4–76). The mean pain score on a visual analogue scale (0–10) was 3.6 (0–10). Radiographs showed no progressive notching of the glenoid in any patient. Mean flexion was 93 degrees (10,170), mean abduction 61 degrees (10,100) and mean external rotation was “1 degrees (−20,20).

This is a new technique for treating proximal humeral fracture sequelae. Some individual results are excellent. There has been a high complication rate and a significant rate of poor results. At this time we cannot recommend the reverse geometry prosthesis for the treatment of proximal humeral fracture sequelae.

Purpose of Study Disruption of the coraco-clavicular ligaments may be associated with either dislocation of the Acromioclavicular joint or fracture of the distal clavicle. If sufficient displacement occurs functional disability results. Traditional techniques have required a bra-strap incision and often require late removal of the metalwork. The Tightrope syndesmosis repair system was adapted to be used arthroscopically to reduce and hold the clavicle enabling healing of the ligaments and any associated fracture using a minimally invasive technique but ensuring accurate reduction and secure stabilisation. Between December 2004 and September 2005 20 patients with injuries to the coraco-clavicular ligaments were treated using this system. As the system was in evolution a the majority were treated arthroscopically and a few using an “open” technique. All had either the acromio-clavicular joint reduced or a distal clavicle fracture reduced and stabilised using the Tightrope Syndesmosis Repair system. The system had been modified from that commercially available for use in the ankle with the consent of the manufacturer (Arthrex, Naples, Fla).

Results All patients were evaluated at a minimum of 6 months post operatively using the DASH, ASES and Constant scores The mean ASES score was 94, the mean Constant score was 90, the mean DASH score was 5 One patient had failure of the metalwork due to malposition, this was revised successfully using the Tightrope and one had a transient adhesive capsulitis. There were no other complications and no patient required removal of the metalwork.

Conclusions The authors conclude that this new technique is a safe, simple, cosmetically acceptable and reproducible method of reducing and stabilising the distal clavicle allowing for healing of either the coraco-clavicular ligaments or the distal clavicle.

The aim of this study is to assess the clinical outcome following latissiumus dorsi transfer for massive irreparable tears of the rotator cuff.

Between 1996 and 2002 seven patients with massive irreparable rotator cuff tears were treated by transfer of the latissimus dorsi by a single surgeon. Their mean age at time of surgery was 65 years. Five patients were female, five were primary procedures and two were revisions. Patients were assessed with MRI pre-operatively; the decision to plan a transfer was made clinically.

At time of operation all were found to massive irreparable tears of the cuff including Supraspinatus and Infraspinatus, Subscapularis was intact in all cases. Five of the transfers were implanted to a bone trough, one was sutured to a tendon stump, and one was augmented with a Teflon patch.

Mean time to follow up was 21 months. All patients were assessed by the lead author or by his Specialist Registrar. Six patients had a good result, one had a poor result this was a revision procedure resulting in deltoid origin detachment.

Functional outcome significantly improved post-transfer. Constant score 62.1% vs 36.1% (p< 0.0005, Paired t-test), Pain was also significantly reduced post-transfer, both when active 7.1 vs. 2.2 p (< 0.005) and when at rest 3.7 vs. 1.2 (p< 0.005).

Conclusion: These results are compatible with those published for Latissimus Dorsi Transfer. Latissimus Dorsi Transfer can be effective in restoring shoulder function and reducing pain following massive irreparable tears of the rotator cuff.

We report the outcome of 58 knees with anteromedial osteoarthritis in which the Oxford unicompartmental arthroplasty was inserted. These were performed in a district general hospital by three surgeons.

All the knees had only anteromedial disease, an intact anterior cruciate ligament and correctable varus. The indication for replacement in all cases was pain. The mean follow up was 24.5 months (6–48). Outcome was assessed by patient satisfaction and the Oxford knee score. Complications, revisions, time to mobility and time to return to work were also noted.

The average age of the 26 women and 23 men at time of operation was 65 years. 31 of the patients were very happy with the outcome, 12 were happy, 5 were unhappy, and one was very unhappy. Mean pre-operative Oxford knee score was 43 (27–53) this improved post-operatively to 18 (12–45) a significant improvement (p< 0.005, paired t-test). Time taken to mobility was an average of 36 hours (24–72), 24 of the patients were in full or part time employment at the time of operation, all returned to their former posts at an average of 6 weeks (2–24).

Three patients have ongoing pain and are booked for revision to TKR. One patient had a dislocated femoral component and required this to be revised twice with a meniscus change at the same time; this patient is now happy. 2 further patients had revision of the meniscus to a larger size for meniscal dislocation. One patient had an infection treated with debridement and antibiotics; infection settled. Our results show that there is a learning curve; all of the insert revision occurred early in the series. Patient selection is important, those with disease in other compartments have continuing pain. Appropriate selection of patients and good surgical technique are the key to obtaining a good outcome.

Aim: To show that the Delta III Total Shoulder Replacement (TSR) Prosthesis is an alternate treatment for complex proximal humeral fracture sequelae (Type 3 & 4)

Methods: This is a prospective outcome study involving 10 patients (mean age (71.5 yrs). All patients failed conservative treatment with a mean time to surgery of 10.5 (+/− 11.5) months and a mean follow up of 8.2 months (6–24mnths). All patients underwent a Delta III TSR via McKenzie approach by a single surgeon.

Patients were assessed with constant and age adjusted Constant scores, radiographs and subjective questionnaire and whether they were satisfied at 6 weeks, 3, 6, 12, 24 months.

Results: At 6 months, age adjusted Constant scores changed form a mean 8.9 (5.3) pre-op to 50.1 (20.9). Six patients were satisfied, 2 unsure and 2 unsatisfied; elevation improved the most, with external rotation the least affected. Age adjusted power increase by 40.4 %, with a subjective function (10 points) improving by 32.6 %. X-rays at 6 months showed two glenoid notches in contact with the inferior screws. Three patients underwent revision surgery (total 5 revisions) for acute post – operative dislocations – all had inserts changed. Intra-operative tension assessment (by means of anterior dislocation of the humerus) was found to be a useful test of stability. Revision surgery found to be a significant predictor of poorer function at 6 months. (p< 0.025). No stem failures noted. Significantly better constant scores achieved with shorter period of time from fracture to delta replacement (p< 0.045). A single wound infection was treated successfully with oral antibiotics.

Conclusion: The results of the Delta III TSR in this difficult group of patients, appear satisfactory in terms of patient satisfaction, subjective and objective functional assessment and 6 months prosthesis survival (100%), and appear to offer a better functional outcome than hemiarthroplasty.

This study aimed to quantify the relationship between passive tension of rotator cuff repair and arm position intraoperatively and to examine the effect of the passive tension on gap formation in cadaveric rotator cuff repairs.

Five patients undergoing open surgical reconstruction of the rotator cuff were recruited. The operations were performed by a single surgeon using a standardised technique, which was acromioplasty, minimal debridement, mobilisation of tissue, bone troughs and transosseous suture tunnels.

A Differential Variable Reluctance Transducer (DVRT) was placed at the apex of the debrided tendon. An in situ calibration was performed to relate the output from the DVRT to actual tension in the tendon. The tension generated was recorded as the supraspinatus tendon was advanced into a bone trough and secured.

The relationship between arm position and repair tension was measured, by simultaneously collecting data from the DVRT and a calibrated goniometer. Particular attention was paid to the three standard positions of post-operative immobilisation; full adduction with internal rotation, neutral rotation with a 30° abduction wedge and ninety degrees of abduction.

Five cadaveric shoulders were used for the creation of standardised rotator cuff tears which were then repaired using the technique described above. The difference in tension measured between full adduction and 30° abduction was statically applied for twenty four hours and the gap formation measured.

Repair tension increased with advancement of the supraspinatus tendon into the bone trough. Abduction reduced the repair load, this was observed mainly in the first 30° of abduction. The mean reduction in load by 30° of abduction was 34 N.

Twenty four hours of 34N static loading caused gap formation in each cadaveric rotator cuff repairs, the mean was 9.2 mm.

Rotator cuff repairs tension can be reduced by postoperative immobilisation in 30° abduction. The change in tension with full adduction was caused gap formation in cadaveric rotator cuff repairs.