Massive posterosuperior cuff tears (mRCT) retracted to the glenoid are surgically challenging and often associated with high retear rates. Primary repair is a less-favourable option and other salvage procedures such as SCR and tendon transfers are used. This study presents clinical and radiological outcomes of muscle advancement technique for repair of mRCT.

Sixty-one patients (mean age 57±6, 77% males and 23% females) (66 shoulders) underwent all-arthroscopic rotator cuff repair that included supraspinatus and infraspinatus subperiosteal dissection off scapular bony fossae, lateral advancement of tendon laminae, and tension-free double-layer Lasso Loop repair to footprint.

Pre-and post-operative range of motion (ROM), cuff strength, VAS, Constant, ASES, and UCLA scores were assessed. Radiologic assessment included modified Patte and Goutallier classifications. All patients had MRI at 6 months to evaluate healing and integrity of repair was assessed using Sugaya classification with Sugaya 4 and 5 considered retears.

Advanced fatty degeneration (Goutallier 3-4) was present in 44% and 20% of supraspinatus and infraspinatus. Tendon retraction was to the level of or medial to glenoid in 22%, and just lateral in 66%. 50.8% mRCT extended to teres minor. Subscapularis was partially torn (Lafosse 1-3) in 46% and completely torn (Lafosse 4-5) in 20%.

At mean follow-up (52.4 weeks), a significant increase in ROM, Relative Cuff Strength (from 57% to 90% compared to contralateral side), VAS (from 4 ±2.5 to 1±1.7), Constant (50±17.8 to 74 ±13.0), ASES (52 ±17.5 to 87 ±14.9), and UCLA (16± 4.9 to 30 ±4.9) scores were noted. There were six retears (10%), one failure due to P. acnes infection. 93% returned to pre-injury work and 89% of cases returned to pre-injury sport. Satisfaction rate was 96%.

Muscle advancement technique for mRCT is a viable option with low retear rates, restoration of ROM, strength, and excellent functional outcomes.

Acromioclavicular joint (ACJ) dislocations is a common disorder amongst our population for which numerous techniques have been described. It is thought that by using this novel technique combining a CC and AC repair with a reconstruction will result in high maintenance of anatomical reduction and functional results.

12 consecutive patients ACJ dislocations were included. An open superior clavicular approach is used. Firstly, the CC ligaments are repaired after which a CC reconstruction is performed using a tendon allograft. Secondly, the AC ligaments are repaired using an internal brace construct combined with a tendon allograft reconstruction (Figure 1).

The acute:chronic ratio was 6:6. Only IIIB, IV and V AC-joint dislocations were included. The Constant-Murley Score improved from 27.6 (8.0 – 56.5) up to 61.5 (42.0 – 92.0) at 12 months of follow up. Besides one frozen shoulder from which the patient recovered spontaneously no complications were observed with this technique. The CCD was reduced from 18.7 mm (13.0 – 24.0) to 10.0 mm (6.0 – 16.0) and 10.5 mm (8.0 – 14.0) respectively 12 weeks and 12 months postoperatively.

There is some evidence, suggesting to address as well as the vertical (coracoclavicular (CC) ligaments) as the horizontal (acromioclavicular (AC) ligaments) direction of instability. This study supports addressing both entities however comparative studies discriminating chronic as acute cases should be conducted to further clarify this ongoing debate on treating ACJ instability.

This study describes a novel technique to treat acute and chronic Rockwood stage IIIB – IV ACJ dislocations with promising short-term clinical and radiological results. This suggests that the combined repair and reconstruction of the AC and CC ligaments is a safe procedure with low complication risk in experienced hands. Addressing the vertical as well as horizontal stability in ACJ dislocation is considered key to accomplish optimal long-term results.

Introduction

Bilateral total knee arthroplasty (TKA) results in substantial perioperative blood loss with increased morbidity. Tranexamic acid (TXA) administration in either intravenous or topical form has been found to be effective in reducing perioperative blood loss. The objective of the present study was to compare the efficacy of topical versus intravenous TXA in reducing perioperative blood loss.

Introduction

Objective was to assess clinical results of treatment of Infected Non Union (INU) of long bones, using Antibiotic Cement Impregnated Nail (ACIN), a single or two staged approach, Stage 1 - Debridement, eradication of infection, primary stabilization with (ACIN). 2nd Stage - Definitive stabilization and early rehabilitation.

Fibular Hemimelia is not just a fibular anomaly but there is entire limb involvement with varied expression in each segment. Factors which we have considered in treatment are the amount of fibula present, percentage of shortening, tibial and leg deformity and foot deformity. Residual or recurrent foot deformity is the prime reason for unsatisfactory results, so we have used Paley's classification which takes into consideration foot deformity. Our series is of 29 cases, Paley type I-7, Type II-6, Type III-16 and none of type IV. Tibial lengthening (+/−) bow correction was performed in 28 cases. Supramalleolar osteotomy was done in 4 cases. In foot, soft tissue release only was done in 6 cases and soft tissue release with osteotomy (subtalar or calcaneal) was done in 14 cases. Amputation was done in 2 cases. Age ranged from 11 months to 16 years. Mean follow up was 4.2 years. Mean lengthening was 3.5 cm. Desires lengthening was achieved in 21/29 cases and plantigrade foot was achieved in 16/29 cases. Complications faced were recurrence of foot deformity, knee valgus, knee fixed flexion deformity, knee subluxation and pin tract problems. Less than 3 rays and more than 25 cm of limb length discrepancy were poor prognostic factors. We had 7 excellent, 16 good and 6 poor results. To conclude, it is difficult to achieve the aim of plantigrade foot and limb length equality in all cases but radical surgery with foot correction and tibial lengthening can give good results.

Patient's non acceptance of a bulky external fixator, the incidence of fractures of the regenerate, muscle transfixion giving rise to contractures especially in the Tendo Achilles, increased index of consolidation and the frequency of infections has made Limb lengthening with external fixators alone unpopular.

In a retrospective study, we evaluated the technique of limb lengthening over a sub muscular plate combined with Ilizarov external fixator as an alternative to external fixator alone and whether the combined procedure is successful in reducing the external fixator period. 15 patients (14 with length discrepancy in the lower limb and 1 with low stature) and a total of 16 limbs (15 tibiae and 1 femur) were lengthened over a sub muscular plate fixed on the proximal segment followed by corticotomy and application of external fixator. Lengthening was achieved at 1 mm/day followed by distal segment fixation with three or four screws on reaching the target length. The pre operative target length was successfully achieved in all patients at a mean of 4.4 cm (2.2 to 6.5 cm). The mean duration of external fixation was 59.2 days (33 to 107 days) with the mean external fixation index at 16.7 days/cm (10.95 to 23.78). Infection complicated the procedure in two patients and one patient had mild Tendo Achilles contracture. Lengthening over a plate drastically reduces the time external fixator needs to worn and is preferred by patients to limb lengthening over an external fixator alone. patient Lengthening over a plate provides an alternative method for limb lengthening, can be applied to children with open physes and to deformed bones.

[Lengthening over a Plate]

Using patient-oriented outcome measures, we examined twenty-six patients following surgical repair of clavicular nonunion. Patient satisfaction was high, and there was only a minor degree of residual disability (mean DASH score 14.5, SF-36 scores within normal range). Time from injury to surgical repair did not influence results.

Using modern, patient-oriented limb-specific outcome measures, we sought to determine the effect of time to repair on patient satisfaction following surgical fixation of nonunion of the clavicular shaft.

As measured by the DASH and SF-36, patient satisfaction was high following clavicular nonunion repair with only minor degrees of residual disability. Time to repair did not have a significant effect on outcome.

Previous reports of clavicular nonunion repair have concentrated on radiographic or surgeon-based criteria. Our study shows that successful clavicular nonunion repair effectively restores upper extremity function and general health status to near-normal levels.

We identified twenty-six patients who had undergone open reduction, internal fixation of a nonunion of the clavicular shaft. There were sixteen men and ten women, with a mean age of forty-four years (range thirty to seventy-one years). The mean duration of nonunion was 1.9 years with a range from four months to thirty-one years. All patients underwent fixation with a plate, and 73% of patients also underwent iliac crest bone grafting. Two nonunions required revision surgery for healing: twenty-four healed after the index procedure. We assessed patient outcome using standard history and physical, radiographs, and the DASH and SF-36 outcome instruments. The mean DASH score (0 = perfect, 100 = complete disability, “normal” = 10) was 14.5 (range 0 to 58), indicating good restoration of upper extremity function with mild residual disability. SF-36 scores were within the normal range. There was no significant difference in DASH or SF-36 scores between those fixed “early” (< six months) and those repaired “late” (> six months), p=0.30, p=0.78, respectively.

Using patient-oriented outcome measures, we examined twenty-six patients following surgical repair of clavicular nonunion. Patient satisfaction was high, and there was only a minor degree of residual disability (mean DASH score 14.5, SF-36 scores within normal range). Time from injury to surgical repair did not influence results.

Percutaneous repair of the ruptured tendo Achillis has a low rate of failure and negligible complications with the wound, but the sural nerve may be damaged.

We reviewed 96 patients who had an acute percutaneous repair done by a single surgeon at district general hospital between January 1998 to April 2004. The mean follow up was 27 months. The repair is carried out using six stab incisions over the posterolateral aspect of the tendon. The procedure can be carried out under local anaesthesia. All patients were put in a below knee cast after the operation. Cast was changed at 4 weeks keeping the foot in plantigrade position. The mean period of immobilization was 8 weeks.

They returned to work at 12 weeks and to sport at 16. One developed a minor wound infection and another complex regional pain syndrome type II. There were 2 injuries to the sural nerve. There were no late reruptures. This technique is simple to undertake and has a low rate of complications. We present one of the largest series reported in literature.