We present the electromyographic (EMG) results ten years after open decompression of the median nerve at the wrist and compare them with the clinical and functional outcomes as judged by Levine’s Questionnaire. This retrospective study evaluated 115 patients who had undergone carpal tunnel decompression at a mean of 10.47 years (9.24 to 11.36) previously. A positive EMG diagnosis was found in 77 patients (67%), including those who were asymptomatic at ten years. It is necessary to include both clinical and functional results as well as electromyographic testing in the long-term evaluation of patients who have undergone carpal tunnel decompression particularly in those in whom revision surgery is being considered. In doubtful cases or when there are differing outcomes, self-administered scales such as Levine’s Questionnaire should prevail over EMG results when deciding on the need for revision surgery

Aims

The optimal choice of management for proximal humerus fractures (PHFs) has been increasingly discussed in the literature, and this work aimed to answer the following questions: 1) what are the incidence rates of PHF in the geriatric population in the USA; 2) what is the mortality rate after PHF in the elderly population, specifically for distinct treatment procedures; and 3) what factors influence the mortality rate?

Aims

The aim of this study was to create artificial intelligence (AI) software with the purpose of providing a second opinion to physicians to support distal radius fracture (DRF) detection, and to compare the accuracy of fracture detection of physicians with and without software support.

Aims

Rotator cuff tear (RCT) is the leading cause of shoulder pain, primarily associated with age-related tendon degeneration. This study aimed to elucidate the potential differential gene expressions in tendons across different age groups, and to investigate their roles in tendon degeneration.

Aims

Rotator cuff muscle atrophy and fatty infiltration affect the clinical outcomes of rotator cuff tear patients. However, there is no effective treatment for fatty infiltration at this time. High-intensity interval training (HIIT) helps to activate beige adipose tissue. The goal of this study was to test the role of HIIT in improving muscle quality in a rotator cuff tear model via the β3 adrenergic receptor (β3AR).

Aims

This study aimed to define the histopathology of degenerated humeral head cartilage and synovial inflammation of the glenohumeral joint in patients with omarthrosis (OmA) and cuff tear arthropathy (CTA). Additionally, the potential of immunohistochemical tissue biomarkers in reflecting the degeneration status of humeral head cartilage was evaluated.

Aims

To evaluate if union of clavicle fractures can be predicted at six weeks post-injury by the presence of bridging callus on ultrasound.

We reviewed the outcome of arthroscopic stabilisation of anterior glenohumeral instability in young adults using the transglenoid suture technique. A questionnaire was sent to 455 consecutive patients who had undergone this procedure between 1992 and 2000. Of these, 312 patients (68.5%) with 313 affected shoulders and a mean age of 20 years (18 to 28) responded. Outcome was determined by the number of re-dislocations or, in patients who had not re-dislocated, by the disease-specific quality of life as measured by the Western Ontario Shoulder Instability index. During a mean follow-up of 6.4 years (1 to 14), 177 patients (56%) sustained a re-dislocation, including 70 who required a further operation. In 136 patients (44%) who reported neither re-dislocation nor re-operation, the index scores were good (median 90.4%; 28.9% to 100%). No significant peri- or pre-operative predictors of re-dislocation or re-operation were found. We found a high rate of re-dislocation after transglenoid suture repair in young, physically active patients

We investigated the clinical response to arthroscopic synovectomy in patients with undifferentiated chronic monoarthritis (UCMA) of the wrist. Arthroscopic synovectomy was performed on 20 wrists in 20 patients with UCMA of the wrist who had not responded to non-steroidal anti-inflammatory drugs. The mean duration of symptoms at the time of surgery was 4.3 months (3 to 7) and the mean follow-up was 51.8 months (24 to 94). Inflamed synovium was completely removed from the radiocarpal, midcarpal and distal radioulnar joints using more portals than normal. After surgery, nine patients had early remission of synovitis and 11 with uncontrolled synovitis received antirheumatic medication. Overall, there was significant improvement in terms of pain relief, range of movement and Mayo score. Radiological deterioration was seen in five patients who were diagnosed as having rheumatoid arthritis during the follow-up period. Lymphoid follicles and severe lymphocyte infiltration were seen more often in synovial biopsies from patients with uncontrolled synovitis. These results suggest that arthroscopic synovectomy provides pain relief and functional improvement, and allows rapid resolution of synovitis in about half of patients with UCMA of the wrist

A total of 92 patients with symptoms for over six months due to subacromial impingement of the shoulder, who were being treated with physiotherapy, were included in this study. While continuing with physiotherapy they waited a further six months for surgery. They were divided into three groups based on the following four clinical and radiological criteria: temporary benefit following steroid injection, pain in the mid-arc of abduction, a consistently positive Hawkins test and radiological evidence of impingement. Group A fulfilled all four criteria, group B three criteria and group C two criteria. A total of nine patients improved while waiting for surgery and were excluded, leaving 83 who underwent arthroscopic subacromial decompression (SAD). The new Oxford shoulder score was recorded pre-operatively and at three and 12 months post-operatively. A total of 51 patients (group A) had a significant improvement in the mean shoulder score from 18 (13 to 22) pre-operatively to 38 (35 to 42) at three months (p < 0.001). The mean score in this group was significantly better than in group B (21 patients) and C (11 patients) at this time. At one year patients in all groups showed improvement in scores, but patients in group A had a higher mean score (p = 0.01). At one year patients in groups A and B did better than those in group C (p = 0.01). Arthroscopic SAD is a beneficial intervention in selected patients. The four criteria could help identify patients in whom it is likely to be most effective

We identified ten patients who underwent arthroscopic revision of anterior shoulder stabilisation between 1999 and 2005. Their results were compared with 15 patients, matched for age and gender, who had a primary arthroscopic stabilisation during the same period. At a mean follow-up of 37 and 36 months, respectively, the scores for pain and shoulder function improved significantly between the pre-operative and follow-up visits in both groups (p = 0.002), with no significant difference between them (p = 0.4). The UCLA and Rowe shoulder scores improved significantly (p = 0.004 and p = 0.002, respectively), with no statistically significant differences between groups (p = 0.6). Kaplan-Meier analysis for time to recurrent instability showed no differences between the groups (p = 0.2). These results suggest that arthroscopic revision anterior shoulder stabilisation is as reliable as primary arthroscopic stabilisation for patients who have had previous open surgery for recurrent anterior instability

Objectives

Indocyanine green (ICG) fluorescence angiography is an emerging technique that can provide detailed anatomical information during surgery. The purpose of this study is to determine whether ICG fluorescence angiography can be used to evaluate the blood flow of the rotator cuff tendon in the clinical setting.

There is no simple method available to identify patients who will develop recurrent instability after an arthroscopic Bankart procedure and who would be better served by an open operation. We carried out a prospective case-control study of 131 consecutive unselected patients with recurrent anterior shoulder instability who underwent this procedure using suture anchors. At follow-up after a mean of 31.2 months (24 to 52) 19 (14.5%) had recurrent instability. The following risk factors were identified: patient age under 20 years at the time of surgery; involvement in competitive or contact sports or those involving forced overhead activity; shoulder hyperlaxity; a Hill-Sachs lesion present on an anteroposterior radiograph of the shoulder in external rotation and/or loss of the sclerotic inferior glenoid contour. These factors were integrated in a 10-point pre-operative instability severity index score and tested retrospectively on the same population. Patients with a score over 6 points had an unacceptable recurrence risk of 70% (p < 0.001). On this basis we believe that an arthroscopic Bankart repair is contraindicated in these patients, to whom we now suggest a Bristow-Latarjet procedure instead

We retrospectively reviewed 26 patients who underwent reconstruction of the shoulder for a medial rotation contracture after birth injury of the brachial plexus. Of these, 13 patients with a mean age of 5.8 years (2.8 to 12.9) received an injection of botulinum toxin type A into the pectoralis major as a surgical adjunct. They were matched with 13 patients with a mean age of 4.0 years (1.9 to 7.2) who underwent an identical operation before the introduction of botulinum toxin therapy to our unit. Pre-operatively, there was no significant difference (p = 0.093) in the modified Gilbert shoulder scores for the two groups. Post-operatively, the patients who received the botulinum toxin had significantly better Gilbert shoulder scores (p = 0.012) at a mean follow-up of three years (1.5 to 9.8). It appears that botulinum toxin type A produces benefits which are sustained beyond the period for which the toxin is recognised to be active. We suggest that by temporarily weakening some of the power of medial rotation, afferent signals to the brain are reduced and cortical recruitment for the injured nerves is improved

The transfer of part of the ulnar nerve to the musculocutaneous nerve, first described by Oberlin, can restore flexion of the elbow following brachial plexus injury. In this study we evaluated the additional benefits and effectiveness of quantitative electrodiagnosis to select a donor fascicle. Eight patients who had undergone transfer of a simple fascicle of the ulnar nerve to the motor branch of the musculocutaneous nerve were evaluated. In two early patients electrodiagnosis had not been used. In the remaining six patients, however, all fascicles of the ulnar nerve were separated and electrodiagnosis was performed after stimulation with a commercially available electromyographic system. In these procedures, recording electrodes were placed in flexor carpi ulnaris and the first dorsal interosseous. A single fascicle in the flexor carpi ulnaris in which a high amplitude had been recorded was selected as a donor and transferred to the musculocutaneous nerve. In the two patients who had not undergone electrodiagnosis, the recovery of biceps proved insufficient for normal use. Conversely, in the six patients in whom quantitative electrodiagnosis was used, elbow flexion recovered to an M4 level. Quantitative intra-operative electrodiagnosis is an effective method of selecting a favourable donor fascicle during the Oberlin procedure. Moreover, fascicles showing a high-amplitude in reading flexor carpi ulnaris are donor nerves that can restore normal elbow flexion without intrinsic loss

Necrotising soft-tissue infections (NSTIs) of the upper limb are uncommon, but potentially life-threatening. We used a national database to investigate the risk factors for amputation of the limb and death. . We extracted data from the Japanese Diagnosis Procedure Combination database on 116 patients (79 men and 37 women) who had a NSTI of the upper extremity between 2007 and 2010. The overall in-hospital mortality was 15.5%. Univariate analysis of in-hospital mortality showed that the significant variables were age (p = 0.015), liver dysfunction (p = 0.005), renal dysfunction (P < 0.001), altered consciousness (p = 0.049), and sepsis (p = 0.021). Logistic regression analysis showed that the factors associated with death in hospital were age over 70 years (Odds Ratio (OR) 6.6; 95% confidence interval (CI) 1.5 to 28.2; p = 0.011) and renal dysfunction (OR 15.4; 95% CI 3.8 to 62.8; p < 0.001). Univariate analysis of limb amputation showed that the significant variables were diabetes (p = 0.017) mellitus and sepsis (p = 0.001). Multivariable logistic regression analysis showed that the factors related to limb amputation were sepsis (OR 1.8; 95% CI 1.5 to 24.0; p = 0.013) and diabetes mellitus (OR 1.6; 95% CI 1.1 to 21.1; p = 0.038). . For NSTIs of the upper extremity, advanced age and renal dysfunction are both associated with a higher rate of in-hospital mortality. Sepsis and diabetes mellitus are both associated with a higher rate of amputation. Cite this article: Bone Joint J 2014;96-B:1530–4

We report the outcome at a mean of 93 months (73 to 110) of 71 patients with an acute fracture of the scaphoid who were randomised to Herbert screw fixation (35) or below-elbow plaster cast immobilisation (36). These 71 patients represent the majority of a randomised series of 88 patients whose short-term outcome has previously been reported. Those patients available for later review were similar in age, gender and hand dominance. There was no statistical difference in symptoms and disability as assessed by the mean Patient Evaluation Measure (p = 0.4), or mean Patient-Rated Wrist Evaluation (p = 0.9), the mean range of movement of the wrist (p = 0.4), mean grip strength (p = 0.8), or mean pinch strength (p = 0.4). Radiographs were available from the final review for 59 patients. Osteoarthritic changes were seen in the scaphotrapezial and radioscaphoid joints in eight (13.5%) and six patients (10.2%), respectively. Three patients had asymptomatic lucency surrounding the screw. One non-operatively treated patient developed nonunion with avascular necrosis. In five patients who were treated non-operatively (16%) there was an abnormal scapholunate angle ( > 60°), but in four of these patients this finding was asymptomatic. No medium-term difference in function or radiological outcome was identified between the two treatment groups

Spinal accessory nerve palsy leads to painful disability of the shoulder, carrying an uncertain prognosis. We reviewed the long-term outcome in 16 patients who were treated for pain, weakness of active elevation and asymmetry of the shoulder and the neck due to chronic paralysis of the trapezius muscle, as a result of nerve palsy. Of four patients who were treated conservatively, none regained satisfactory function, although two became pain-free. The other 12 patients were treated operatively with transfer of the levator scapulae to the acromion and the rhomboid muscles to the infraspinatus fossa (the Eden-Lange procedure). At a mean follow-up of 32 years, the clinical outcome of the operatively treated patients was excellent in nine, fair in two, and poor in one patient, as determined by the Constant score. Pain was adequately relieved in 11 and overhead function was restored in nine patients. Pre-operative electromyography had been carried out in four patients. In two, who eventually had a poor outcome, a concomitant long thoracic and dorsal scapular nerve lesion had been present. The Eden-Lange procedure gives very satisfactory long-term results for the treatment of isolated paralysis of trapezius. In the presence of an additional serratus anterior palsy or weak rhomboid muscles, the procedure is less successful in restoring shoulder function

There is little published information on the health impact of frozen shoulder. The purpose of this study was to assess the functional and health-related quality of life outcomes following arthroscopic capsular release (ACR) for contracture of the shoulder. Between January 2010 and January 2012 all patients who had failed non-operative treatment including anti-inflammatory medication, physiotherapy and glenohumeral joint injections for contracture of the shoulder and who subsequently underwent an ACR were enrolled in the study. A total of 100 patients were eligible; 68 underwent ACR alone and 32 had ACR with a subacromial decompression (ASD). ACR resulted in a highly significant improvement in the range of movement and functional outcome, as measured by the Oxford shoulder score and EuroQol EQ-5D index. The mean cost of a quality-adjusted life year (QALY) for an ACR and ACR with an ASD was £2563 and £3189, respectively. . ACR is thus a cost-effective procedure that can restore relatively normal function and health-related quality of life in most patients with a contracture of the shoulder within six months after surgery; and the beneficial effects are not related to the duration of the presenting symptoms. Cite this article: Bone Joint J 2013;95-B:942–6

There have been few reports in the literature of total elbow arthroplasty extending beyond 10 to 15 years. We reviewed 40 patients (41 elbows) with a mean age of 56 years (19 to 83) who had undergone a Coonrad/Coonrad-Morrey elbow arthroplasty by one surgeon for various diagnoses between 1974 and 1994. Surgical selection excluded patients with previous elbow infection or who refused to accept a sedentary level of elbow activity postoperatively. Objective data were collected from charts, radiographs, clinical photographs and supplemented by the referring orthopaedic surgeons’ records and radiographs if health or distance prevented a patient from returning for final review. Subjective outcome was defined by patient satisfaction. Of the 41 elbows, 21 were functional between 10 and 14 years after operation, ten between 15 and 19 years and ten between 20 and 31 years. There were 14 complications and 13 revisions, but no cases of acute infection, or permanent removal of any implant

Over a seven-year period we treated a consecutive series of 58 patients, 20 men and 38 women with a mean age of 66 years (21 to 87) who had an acute complex anterior fracture-dislocation of the proximal humerus. Two patterns of injury are proposed for study based upon a prospective assessment of the pattern of soft-tissue and bony injury and the degree of devascularisation of the humeral head. In 23 patients, the head had retained capsular attachments and arterial back-bleeding (type-I injury), whereas in 35 patients the head was devoid of significant soft-tissue attachments with no active arterial bleeding (type-II injury). Following treatment by open reduction and internal fixation, only two of 23 patients with type-I injuries developed radiological evidence of osteonecrosis of the humeral head, compared with four of seven patients with type-II injuries. A policy of primary treatment by open reduction and internal fixation of type-I injuries is justified, whereas most elderly patients (aged 60 years or over) with type-II injuries are best treated by hemiarthroplasty. The best treatment for younger patients (aged under 60 years) who sustain type-II injuries is controversial and an individualised approach to their management is advocated

Aims

Plating displaced proximal humeral fractures is associated with a high rate of screw perforation. Dynamization of the proximal screws might prevent these complications. The aim of this study was to develop and evaluate a new gliding screw concept for plating proximal humeral fractures biomechanically.

This study provides recommendations on the position of the implant in reverse shoulder replacement in order to minimise scapular notching and osteophyte formation. Radiographs from 151 patients who underwent primary reverse shoulder replacement with a single prosthesis were analysed at a mean follow-up of 28.3 months (24 to 44) for notching, osteophytes, the position of the glenoid baseplate, the overhang of the glenosphere, and the prosthesis scapular neck angle (PSNA). A total of 20 patients (13.2%) had a notch (16 Grade 1 and four Grade 2) and 47 (31.1%) had an osteophyte. In patients without either notching or an osteophyte the baseplate was found to be positioned lower on the glenoid, with greater overhang of the glenosphere and a lower PSNA than those with notching and an osteophyte. Female patients had a higher rate of notching than males (13.3% vs 13.0%) but a lower rate of osteophyte formation (22.9% vs 50.0%), even though the baseplate was positioned significantly lower on the glenoid in females (p = 0.009) and each had a similar mean overhang of the glenosphere. Based on these findings we make recommendations on the placement of the implant in both male and female patients to avoid notching and osteophyte formation. Cite this article: Bone Joint J 2013;95-B:530–5

We compared six patients with a mean age of 70 years (49 to 80) with severe bilateral, painful glenohumeral joint destruction who underwent a single-stage bilateral total shoulder replacement, with eight patients of mean age 61 years (22 to 89) who underwent bilateral total shoulder replacement in two stages, at a mean interval of 18 months (6 to 43). The overall function, pain and strength improved significantly in both groups. The subjective shoulder value, relative Constant score, active external rotation and the strength were improved significantly more in the single-stage group. Active elevation, abduction and overall function improved, significantly more in the single-stage group. Both the total duration of hospitalisation and the time off work per shoulder were substantially shorter in the single-stage group. The overall rate of complication was lower in the single-stage group. Our findings indicated that single-stage bilateral total shoulder replacement yielded significantly better clinical results with shorter hospitalisation and rehabilitation than staged replacement, and was not associated with any increase in complications

In adults with brachial plexus injuries, lack of active external rotation at the shoulder is one of the most common residual deficits, significantly compromising upper limb function. There is a paucity of evidence to address this complex issue. We present our experience of isolated latissimus dorsi (LD) muscle transfer to achieve active external rotation. This is a retrospective review of 24 adult post-traumatic plexopathy patients who underwent isolated latissimus dorsi muscle transfer to restore external rotation of the shoulder between 1997 and 2010. All patients were male with a mean age of 34 years (21 to 57). All the patients underwent isolated LD muscle transfer using a standard technique to correct external rotational deficit. Outcome was assessed for improvement in active external rotation, arc of movement, muscle strength and return to work. The mean improvement in active external rotation from neutral was 24° (10° to 50°). The mean increase in arc of rotation was 52° (38° to 55°). Mean power of the external rotators was 3.5 Medical Research Council (MRC) grades (2 to 5). A total of 21 patients (88%) were back in work by the time of last follow up. Of these, 13 had returned to their pre-injury occupation. Isolated latissimus dorsi muscle transfer provides a simple and reliable method of restoring useful active external rotation in adults with brachial plexus injuries with internal rotational deformity. Cite this article: Bone Joint J 2013;95-B:660–3

Dislocation of the shoulder may occur during seizures in epileptics and other patients who have convulsions. Following the initial injury, recurrent instability is common owing to a tendency to develop large bony abnormalities of the humeral head and glenoid and a susceptibility to further seizures. Assessment is difficult and diagnosis may be missed, resulting in chronic locked dislocations with protracted morbidity. Many patients have medical comorbidities, and successful treatment requires a multidisciplinary approach addressing the underlying seizure disorder in addition to the shoulder pathology. The use of bony augmentation procedures may have improved the outcomes after surgical intervention, but currently there is no evidence-based consensus to guide treatment. This review outlines the epidemiology and pathoanatomy of seizure-related instability, summarising the currently-favoured options for treatment, and their results

This study was performed to determine whether pure cancellous bone graft and Kirschner (K-) wire fixation were sufficient to achieve bony union and restore alignment in scaphoid nonunion. A total of 65 patients who underwent cancellous bone graft and K-wire fixation were included in this study. The series included 61 men and four women with a mean age of 34 years (15 to 72) and mean delay to surgery of 28.7 months (3 to 240). The patients were divided into an unstable group (A) and stable group (B) depending on the pre-operative radiographs. Unstable nonunion was defined as a lateral intrascaphoid angle > 45°, or a radiolunate angle > 10°. There were 34 cases in group A and 31 cases in group B. Bony union was achieved in 30 patients (88.2%) in group A, and in 26 (83.9%) in group B (p = 0.439). Comparison of the post-operative radiographs between the two groups showed no significant differences in lateral intrascaphoid angle (p = 0.657) and scaphoid length (p = 0.670) and height (p = 0.193). The radiolunate angle was significantly different (p = 0.020) but the mean value in both groups was < 10°. Comparison of the dorsiflexion and palmar flexion of movement of the wrist and the mean Mayo wrist score at the final clinical visit in each group showed no significant difference (p = 0.190, p = 0.587 and p = 0.265, respectively). Cancellous bone graft and K-wire fixation were effective in the treatment of stable and unstable scaphoid nonunion. Cite this article: Bone Joint J 2013;95-B:809–14

A total of 12 epileptic patients (14 shoulders) with recurrent seizures and anterior dislocations of the shoulder underwent a Latarjet procedure and were reviewed at a mean of 8.3 years (1 to 20) post-operatively. Mean forward flexion decreased from 165° (100° to 180°) to 160° (90° to 180°) (p = 0.5) and mean external rotation from 54° (10° to 90°) to 43° (5° to 75°) (p = 0.058). The mean Rowe score was 76 (35 to 100) at the final follow-up. Radiologically, all shoulders showed a glenoid-rim defect and Hill-Sachs lesions pre-operatively. Osteo-arthritic changes of the glenohumeral joint were observed in five shoulders (36%) pre-operatively and in eight shoulders (57%) post-operatively. Re-dislocation during a seizure occurred in six shoulders (43%). Five of these patients underwent revision surgery using a bone buttress from the iliac crest and two of these patients re-dislocated due to a new seizure. . Due to the unacceptably high rate of re-dislocation after surgery in these patients, the most important means of reducing the incidence of further dislocation is the medical management of the seizures. The Latarjet procedure should be reserved for the well-controlled patient with epilepsy who has recurrent anterior dislocation of the shoulder during activities of daily living

The purpose of this study was to assess the clinical and radiological outcomes of dorsal intercarpal ligament capsulodesis for the treatment of static scapholunate instability at a minimum follow-up of four years. A total of 59 patients who underwent capsulodesis for this condition were included in a retrospective analysis after a mean of 8.25 years (4.3 to 12). A total of eight patients underwent a salvage procedure at a mean of 2.33 years (0.67 to 7.6) and were excluded. The mean range of extension/flexion was 88° (15° to 135°) and of ulnar/radial deviation was 38° (0° to 75°) at final follow-up. The mean Disabilities of the Arm Shoulder and Hand (DASH) score and Mayo wrist scores were 28 (0 to 85) and 61 (0 to 90), respectively. After significant improvement immediately post-operatively (p < 0.001 and p = 0.001, respectively), the mean scapholunate and radiolunate angles deteriorated to 70° (40° to 90°) and 8° (-15° to 25°), respectively, at final follow-up, which were not significantly different from their pre-operative values (p = 0.6 and p = 0.4, respectively). The mean carpal height index decreased significantly from 1.53 (1.38 to 1.65) to 1.48 (1.29 to 1.65) indicating progressive carpal collapse (p < 0.001); 40 patients (78%) had radiological evidence of degenerative arthritis. Capsulodesis did not maintain carpal reduction over time. Although the consequent ongoing scapholunate instability resulted in early arthritic degeneration, most patients had acceptable long-term function of the wrist

There is little information about the management of peri-prosthetic fracture of the humerus after total shoulder replacement (TSR). This is a retrospective review of 22 patients who underwent a revision of their original shoulder replacement for peri-prosthetic fracture of the humerus with bone loss and/or loose components. There were 20 women and two men with a mean age of 75 years (61 to 90) and a mean follow-up 42 months (12 to 91): 16 of these had undergone a previous revision TSR. Of the 22 patients, 12 were treated with a long-stemmed humeral component that bypassed the fracture. All their fractures united after a mean of 27 weeks (13 to 94). Eight patients underwent resection of the proximal humerus with endoprosthetic replacement to the level of the fracture. Two patients were managed with a clam-shell prosthesis that retained the original components. The mean Oxford shoulder score (OSS) of the original TSRs before peri-prosthetic fracture was 33 (14 to 48). The mean OSS after revision for fracture was 25 (9 to 31). Kaplan-Meier survival using re-intervention for any reason as the endpoint was 91% (95% confidence interval (CI) 68 to 98) and 60% (95% CI 30 to 80) at one and five years, respectively. There were two revisions for dislocation of the humeral head, one open reduction for modular humeral component dissociation, one internal fixation for nonunion, one trimming of a prominent screw and one re-cementation for aseptic loosening complicated by infection, ultimately requiring excision arthroplasty. Two patients sustained nerve palsies. Revision TSR after a peri-prosthetic humeral fracture associated with bone loss and/or loose components is a salvage procedure that can provide a stable platform for elbow and hand function. Good rates of union can be achieved using a stem that bypasses the fracture. There is a high rate of complications and function is not as good as with the original replacement

Between March 1994 and June 2003, 80 patients with brachial plexus palsy underwent a trapezius transfer. There were 11 women and 69 men with a mean age of 31 years (18 to 69). Before operation a full evaluation of muscle function in the affected arm was carried out. A completely flail arm was found in 37 patients (46%). Some peripheral function in the elbow and hand was seen in 43 (54%). No patient had full active movement of the elbow in combination with adequate function of the hand. Patients were followed up for a mean of 2.4 years (0.8 to 8). We performed the operations according to Saha’s technique, with a modification in the last 22 cases. We demonstrated a difference in the results according to the pre-operative status of the muscles and the operative technique. The transfer resulted in an increase of function in all patients and in 74 (95%) a decrease in multidirectional instability of the shoulder. The mean increase in active abduction was from 6° (0 to 45) to 34° (5 to 90) at the last review. The mean forward flexion increased from 12° (0 to 85) to 30° (5 to 90). Abduction (41°) and especially forward flexion (43°) were greater when some residual function of the pectoralis major remained (n = 32). The best results were achieved in those patients with most pre-operative power of the biceps, coracobrachialis and triceps muscles (n = 7), with a mean of 42° of abduction and 56° of forward flexion. Active abduction (28°) and forward flexion (19°) were much less in completely flail shoulders (n = 34). Comparison of the 19 patients with the Saha technique and the 15 with the modified procedure, all with complete paralysis, showed the latter operation to be superior in improving shoulder stability. In all cases a decrease in instability was achieved and inferior subluxation was abolished. The results after trapezius transfer depend on the pre-operative pattern of paralysis and the operative technique. Better results can be achieved in patients who have some function of the biceps, coracobrachialis, pectoralis major and triceps muscles compared with those who have a complete palsy. A simple modification of the operation ensures a decrease in joint instability and an increase in function

Between 1996 and 2008, nine patients with severe post-traumatic arthritis underwent revision of a failed interposition arthroplasty of the elbow with a further interposition procedure using an allograft of tendo Achillis at a mean of 5.6 years (0.7 to 13.1) after the initial procedure. There were eight men and one woman with a mean age of 47 years (36 to 56). The mean follow-up was 4.7 years (2 to 8). The mean Mayo Elbow Performance score improved from 49 (15 to 65) pre-operatively to 73 (55 to 95) (p = 0.04). The mean Disability of the Arm, Shoulder and Hand score was 26 (7 to 42). One patient was unavailable for clinical follow-up and one underwent total elbow replacement three months post-operatively. Of the remaining patients, one had an excellent, two had good, three fair and one a poor result. Subjectively, five of the nine patients were satisfied. Four continued manual labour. Revision interposition arthroplasty is an option for young, active patients with severe post-traumatic arthritis who require both mobility and durability of the elbow

The outcome of surgery in patients with medial epicondylitis of the elbow is less favourable in those with co-existent symptoms from the ulnar nerve. We wanted to know whether we could successfully treat such patients by using musculofascial lengthening of the flexor-pronator origin with simultaneous deep transposition of the ulnar nerve. We retrospectively reviewed 19 patients who were treated in this way. Seven had grade I and 12 had grade IIa ulnar neuropathy. At a mean follow-up of 38 months (24 to 48), the mean visual analogue scale pain scores improved from 3.7 to 0.3 at rest, from 6.6 to 2.1 with activities of daily living, and from 7.9 to 2.3 at work or sports, and the mean disabilities of the arm, shoulder and hand scores improved from 42.2 to 23.5. These results suggest that this technique can be effective in treating patients with medial epicondylitis and coexistent ulnar nerve symptoms

We performed a prospective, randomised trial on 106 patients to compare the effects of local corticosteroid injections with physiotherapy as advocated by Cyriax in the treatment of tennis elbow. The main outcome measures were the severity of pain, pain provoked by resisted dorsiflexion of the wrist, and patient satisfaction. At six weeks 22 of 53 patients in the injection group were free from pain compared with only three in the physiotherapy group. In the corticosteroid-treated group 26 patients had no pain on resisted dorsiflexion of the wrist compared with only three in the physiotherapy group. Thirty-five patients who had injections and 14 who had physiotherapy were satisfied with the outcome of treatment at six weeks. At the final assessment there were 18 excellent and 18 good results in the corticosteroid group and one excellent and 12 good results in the physiotherapy group. There was a significant increase in grip strength in both groups but those with injections had a significantly better result. After one year there were no significant differences between the two groups. Half of the patients, however, had received only the initial treatment, 20% had had combined therapy and 30% had had surgery. We conclude that at six weeks, treatment with corticosteroid injections was more effective than Cyriax physiotherapy and we recommend it because of its rapid action, reduction of pain and absence of side-effects

Displaced fractures of the lateral end of the clavicle in young patients have a high incidence of nonunion and a poor functional outcome after conservative management. Operative treatment is therefore usually recommended. However, current techniques may be associated with complications which require removal of the fixation device. We have evaluated the functional and radiological outcomes using a novel technique of open reduction and internal fixation. A series of 16 patients under 60 years of age with displaced fractures of the lateral end were treated by open reduction and fixation using a twin coracoclavicular endobutton technique. They were followed up for the first year after their injury. At one year the mean Constant score was 87.1 and the median Disabilities of the Arm, Shoulder and Hand score was 3.3. All fractures had united, except in one patient who developed an asymptomatic fibrous union. One patient had post-traumatic stiffness of the shoulder, which resolved with physiotherapy. None required re-operation. This technique produces good functional and radiological outcomes with a low prevalence of complications and routine implant removal is not necessary

The treatment of a chronic posterior dislocation of the shoulder is often determined by the size of the associated impression fracture of the humeral head. Our hypothesis was that patients with a chronic unreduced posterior dislocation of the shoulder and a defect in the humeral head involving between 25% to 50% of the articular surface, would do better if reconstructed with an allograft from the femoral head rather than treated by a non-anatomical reconstruction. We reviewed ten men and three women with a mean age of 42 years (36 to 51) at a mean follow-up of 54 months (41 to 64) who had this procedure. At follow-up, nine had no pain or restriction of activities of daily living. Their mean Constant-Murley shoulder score was 86.8 (43 to 98). No patient had symptoms of instability of the shoulder. Reconstruction of the defect in the humeral head with an allograft provides good pain relief, stability and function for patients with a locked, chronic posterior dislocation where the defect involves between 25% and 50% of the circumference of the articular surface

Restoration of hand function is rarely achieved after a complete closed traction lesion of the supraclavicular brachial plexus. We describe the injury, treatment, rehabilitation and long-term results of two patients who regained good function of the upper limb and useful function in the hand after such an injury. Successful repairs were performed within six days of injury. Tinel’s sign proved accurate in predicting the ruptures and the distribution of pain was accurate in predicting avulsion. The severe pain that began on the day of injury resolved with the onset of muscle function. Recovery of muscle function preceded recovery of sensation. Recovery of the function of C and Aδ fibres was the slowest of all

We describe the longer term clinical and radiological findings in a prospectively followed series of 49 rheumatoid patients (58 shoulders) who had undergone Neer II total shoulder replacement. The early and intermediate results have been published previously. At a mean follow-up of 19.8 years (16.5 to 23.8) 14 shoulders survived. Proximal migration of the humeral component was associated with progressive loosening of the glenoid and humeral components, but was independent of the state of the rotator cuff at the time of operation. Despite these changes the range of movement was preserved. Most patients had little or no pain in the shoulder, could sleep undisturbed and could attend to personal hygiene and grooming

Between September 1993 and September 1996, we performed 34 Kudo 5 total elbow replacements in 31 rheumatoid patients. All 22 surviving patients were reviewed at a mean of 11.9 years (10 to 14). Their mean age was 56 years (37 to 78) at the time of operation. All had Larsen grade IV or V rheumatoid changes on X-ray. Nine (three bilateral replacements and six unilateral) had died from unrelated causes. One who had died before ten years underwent revision for dislocation. Of the 22 total elbow replacements reviewed six had required revision, four for aseptic loosening (one humeral and three ulnar) and two for infection. Post-operatively, one patient had neuropraxia of the ulnar nerve and one of the radial nerve. Two patients had valgus tilting of the ulnar component. With revision as the endpoint, the mean survival time for the prosthesis was 11.3 years (95% confidence interval (10 to 13) and the estimated survival of the prosthesis at 12 years according to Kaplan-Meier survival analysis was 74% (95% confidence interval 0.53 to 0.91). Of the 16 surviving implants, ten were free from pain, four had mild pain and two moderate. The mean arc of flexion/extension of the elbow was 106° (65° to 130°) with pronation/supination of 90° (30° to 150°) with the joint at 90° of flexion. The mean Mayo elbow performance score was 82 (60 to 100) with five excellent, ten good and one fair result. Good long-term results can be expected using the Kudo 5 total elbow replacement in patients with rheumatoid disease, with a low incidence of loosening of the components

Between 1998 and 2007, 22 patients with fractures of the scapula had operative treatment more than three weeks after injury. The indications for operation included displaced intra-articular fractures, medialisation of the glenohumeral joint, angular deformity, or displaced double lesions of the superior shoulder suspensory complex. Radiological and functional outcomes were obtained for 16 of 22 patients. Disabilities of the Arm, Shoulder, Hand (DASH) and Short form-36 scores were collected for 14 patients who were operated on after March 2002. The mean delay from injury to surgery was 30 days (21 to 57). The mean follow-up was for 27 months (12 to 72). At the last review the mean DASH score was 14 (0 to 41). Of the 16 patients with follow-up, 13 returned to their previous employment and recreational activities without restrictions. No wound complications, infection or nonunion occurred. Malunion of the scapula can be prevented by surgical treatment of fractures in patients with delayed presentation. Surgery is safe, effective, and gives acceptable functional results

We prospectively studied 26 consecutive patients with clinically documented sensory or motor deficiency of a peripheral nerve due to trauma or entrapment using ultrasound, and in 19 cases surgical exploration of the nerves was undertaken. The ultrasonographic diagnoses were correlated with neurological examination and the surgical findings. Reliable visualisation of injured nerves on ultrasonography was achieved in all patients. Axonal swelling and hypoechogenity of the nerve was diagnosed in 15 cases, loss of continuity of a nerve bundle in 17, the formation of a neuroma of a stump in six, and partial laceration of a nerve with loss of the normal fascicular pattern in five. The ultrasonographic findings were confirmed at operation in those who had surgery. Ultrasound may be used for the evaluation of peripheral nerve injuries in the upper limb. High-resolution ultrasound can show the exact location, extent and type of lesion, yielding important information that might not be obtainable by other diagnostic aids

A prospective series of 32 cases with tuberculosis of the hand and wrist is presented. The mean age of the patients was 23.9 years (3 to 65), 12 had bony disease and 20 primarily soft-tissue involvement. The metacarpal of the little finger was the most commonly involved bone. Pain and swelling were the usual presenting features and discharging sinuses were seen in three cases. All patients were given anti-tubercular chemotherapy with four drugs. Operative treatment in the form of open or arthroscopic debridement, or incision and drainage of abscesses, was performed in those cases where no response was seen after eight weeks of ATT. Hand function was evaluated by the modified score of Green and O’Brien. The mean was 58.3 (25 to 80) before treatment and 90.5 (80 to 95) at the end. The mean follow-up was for 22.4 months (6 to 43). Conservative treatment was successful in 24 patients (75%). Eight who did not respond to chemotherapy within eight weeks required surgery. Although tuberculosis of hand has a varied presentation, the majority of lesions respond to conservative treatment

This study was performed to review the safety and outcome of total shoulder replacements in patients who are ≥ 80 years of age. A total of 50 total shoulder replacements in 44 patients at a mean age of 82 years (80 to 89) were studied. Their health and shoulder status, the operation and post-operative course were analysed, including pain, movement, patient satisfaction, medical and surgical complications, radiographs, the need for revision surgery, and implant and patient survival. A total of 27 patients had an ASA classification of III or IV and medical abnormalities were common. Of the 13 shoulders with bony deficiency of the glenoid, nine required grafting. The duration of hospital stay was prolonged and blood transfusions were common. There were no peri-operative deaths. The mean follow-up was for 5.5 years (2 to 12). Pain was significantly reduced (p < 0.001) and movement improved in active elevation and both external and internal rotation (p < 0.001). Using the Neer scale for assessing outcome, 40 (80%) shoulders had an excellent or satisfactory result. There were medical or surgical complications in 17 cases. Four shoulders developed radiological evidence of loosened glenoid components, and three of these had a poor outcome. Three other shoulders required revision, two for instability. By the time of this review 39 of the patients had died from unrelated causes at a mean of 7.5 years (0.8 to 16.4) after surgery. Total shoulder replacement is a relatively effective treatment in this elderly group of patients. However, there is a requirement for more intense patient care in the peri-operative period, and non-fatal medical or surgical complications are common. Most of these elderly patients will have a comfortable functional shoulder for the rest of their lives

In a prospective randomised study we compared the results of arthroscopic subacromial bursectomy alone with debridement of the subacromial bursa followed by acromioplasty. A total of 57 patients with a mean age of 47 years (31 to 60) suffering from primary subacromial impingement without a rupture of the rotator cuff who had failed previous conservative treatment were entered into the trial. The type of acromion was classified according to Bigliani. Patients were assessed at follow-up using the Constant score, the simple shoulder test and visual analogue scores for pain and functional impairment. One patient was lost to follow-up. At a mean follow-up of 2.5 years (1 to 5) both bursectomy and acromioplasty gave good clinical results. No statistically significant differences were found between the two treatments. The type of acromion and severity of symptoms had a greater influence on the clinical outcome than the type of treatment. As a result, we believe that primary subacromial impingement syndrome is largely an intrinsic degenerative condition rather than an extrinsic mechanical disorder

We reviewed the outcome of 28 patients who had been treated using the Aequalis fracture prosthesis for an acute fracture of the proximal humerus at a mean follow-up of 39.3 months (24 to 63). The mean age of the patients at the time of the fracture was 66.3 years (38 to 80). The mean Constant score was 68.2 (37 to 84) for the operated shoulder, which represented 89.5% of the mean score for the uninjured side (p < 0.001). The quality of the reconstruction as shown on the immediate post-operative radiographs was categorised into three types, anatomical, acceptable, and unacceptable, depending on the position of the tuberosities relative to the prosthetic head and the humeral shaft. Anatomical reconstruction was associated with a higher mean Constant score as well as higher mean values of anterior forward elevation, abduction and external rotation than the other types, but the differences were not statistically significant (p > 0.231). A total of 18 patients had active anterior elevation ≥150°. Their mean active abduction and external rotation were 163.6° and 31.3°, respectively. In seven of the 28 patients, the mean active anterior elevation, abduction and external rotation were 130.7°, 129.2° and 22.8°, respectively. In all, 12 patients were very satisfied with the results, 12 were satisfied, two were dissatisfied and two were disappointed; 26 reported no or only mild pain while only two had moderate pain. In five patients proximal migration of the humeral head was shown on the anteroposterior radiographs of the shoulder. No evidence of loosening was found in any prosthesis

We have investigated the outcome of arthroscopic revision surgery for recurrent instability of the shoulder after failed primary anterior stabilisation. We identified 40 patients with failed primary open or arthroscopic anterior stabilisation of the shoulder who had been treated by revision arthroscopic capsulolabral reconstruction and followed up for a mean of 36 months (12 to 87). There were 34 men and six women with a mean age of 33.1 years (15 to 48). Details of the patients, the technique of the primary procedure, the operative findings at revision and the clinical outcome were evaluated by reviewing the medical records, physical examination and the use of the Western Ontario shoulder instability index score, the American Shoulder and Elbow Surgeons score and the health status questionnaire 12. Recurrent instability persisted in four patients after the revision arthroscopic procedure. At the final follow-up, the mean American Shoulder and Elbow Surgeons score was 81.1 (17.5 to 99.5) and the mean Western Ontario shoulder instability index score was 68.2 (20 to 98.2). Quality-of-life scoring showed good to excellent results in most patients. Arthroscopic revision capsulolabral reconstruction can provide a satisfactory outcome in selected patients for recurrent instability of the shoulder provided that no large Hill-Sachs lesion is present

We have examined the accuracy of 143 consecutive ultrasound scans of patients who subsequently underwent shoulder arthroscopy for rotator-cuff disease. All the scans and subsequent surgery were performed by an orthopaedic surgeon using a portable ultrasound scanner in a one-stop clinic. There were 78 full thickness tears which we confirmed by surgery or MRI. Three moderate-size tears were assessed as partial-thickness at ultrasound scan (false negative) giving a sensitivity of 96.2%. One partially torn and two intact cuffs were over-diagnosed as small full-thickness tears by ultrasound scan (false positive) giving a specificity of 95.4%. This gave a positive predictive value of 96.2% and a negative predictive value of 95.4%. Estimation of tear size was more accurate for large and massive tears at 96.5% than for moderate (88.8%) and small tears (91.6%). These results are equivalent to those obtained by several studies undertaken by experienced radiologists. We conclude that ultrasound imaging of the shoulder performed by a sufficiently-trained orthopaedic surgeon is a reliable time-saving practice to identify rotator-cuff integrity

A consecutive series of 372 patients who underwent surgery for disorders of the rotator cuff involving arthroscopic subacromial decompression and open or arthroscopic repairs of the cuff were prospectively investigated as to the comparability of subjective and objective assessment scores of shoulder function. Assessments were made before operation and at 3, 6, 12, 18 and 24 months after surgery using the Disabilities of the Arm, Shoulder, and Hand score, the Oxford shoulder score and the Constant-Murley score, which was used as a reference. All scores were standardised to a scale of 0 to 100 for comparison. Statistical analysis compared the post-operative course and the mean score for the subjective Disabilities to the Arm, Shoulder and Hand score and Oxford shoulder score, with the objective Constant score at each interval. A strong correlation was evident between both subjective scores and the Constant score. We concluded that both the subjective scores would be useful substitutes for the Constant score, obviating the need for a trained investigator and the specialist equipment required to perform the Constant score

We describe the outcome at a mean follow-up of 8.75 years (7.6 to 9.8) of seven patients who had undergone osteochondral autologous transplantation for full-thickness cartilage defects of the shoulder between 1998 and 2000. These patients have been described previously at a mean of 32.6 months when eight were included. One patient has been lost to follow-up. The outcome was assessed by the Constant shoulder score and the Lysholm knee score to assess any donor-site morbidity. Standard radiographs and MR scores were obtained and compared with the pre-operative findings and the results from the previous review. No patient required any further surgery on the shoulder. The mean Constant score improved significantly until the final follow-up (p = 0.018). The Lysholm score remained excellent throughout. There was a significant progression of osteoarthritic changes from the initial surgery to the first and final follow-up but this did not appear to be related to the size of the defect, the number of cylinders required or the Constant score (p = 0.016). MRI showed that all except one patient had a congruent joint surface at the defect with full bony integration of all osteochondral cylinders. The results have remained satisfactory over a longer period with very good objective and subjective findings

Hand function was evaluated in 105 patients who had been operated on in early infancy for brachial plexus birth palsy. The mean follow-up after surgery was for 13.4 years (5.0 to 31.5). Fine sensation, stereognosis, grip and pinch strength and the Raimondi scale were recorded. Fine sensation was normal in 34 of 49 patients (69%) with C5–6 injury, 15 of 31 (48%) with C5–7 and in 8 of 25 (32%) with total injury. Loss of protective sensation or absent sensation was noted in some palmar areas of the hand in 12 of 105 patients (11%). Normal stereognosis was recorded in 88 of the 105 patients (84%), whereas only 9 of the 105 (9%) had normal grip strength. The mean Raimondi scale scores were 4.57 (3 to 5) (C5–6), 4.26 (1 to 5) (C5–7) and 2.16 (0 to 5) in patients with total injury. The location of impaired sensation was related to the distribution of the root injury. Avulsion type of injury correlated with poor recovery of hand function

While frequently discussed as a standard treatment for the management of an infected shoulder replacement, there is little information on the outcome of two-stage re-implantation. We examined the outcome of 17 consecutive patients (19 shoulders) who were treated between 1995 and 2004 with a two-stage re-implantation for the treatment of a deep-infection after shoulder replacement. All 19 shoulders were followed for a minimum of two years or until the time of further revision surgery. The mean clinical follow-up was for 35 months (24 to 80). The mean radiological follow-up was 27 months (7 to 80). There were two excellent results, four satisfactory and 13 unsatisfactory. In 12 of the 19 shoulders (63%) infection was considered to be eradicated. The mean pain score improved from 4.2 (3 to 5 (out of 5)) to 1.8 (1 to 4). The mean elevation improved from 42° (0° to 140°) to 89° (0° to 165°), mean external rotation from 30° (0° to 90°) to 43° (0° to 90°), and mean internal rotation from the sacrum to L5. There were 14 complications. Our study suggests that two-stage re-implantation for an infected shoulder replacement is associated with a high rate of unsatisfactory results, marginal success at eradicating infection and a high complication rate

We prospectively reviewed 14 patients with deficiency of the proximal pole of the scaphoid who were treated by rib osteochondral replacement arthroplasty. Improvement in wrist function occurred in all except one patient with enhanced grip strength, less pain and maintenance of wrist movement. In 13 patients wrist function was rated as good or excellent according to the modified wrist function score of Green and O’Brien. The mean pre-operative score of 54 (35 to 80) rose to 79 (50 to 90) at review at a mean of 64 months (27 to 103). Carpal alignment did not deteriorate in any patient and there were no cases of nonunion or significant complications. This procedure can restore the mechanical integrity of the proximal pole of the scaphoid satisfactorily and maintain wrist movement while avoiding the potential complications of alternative replacement arthroplasty techniques and problems associated with vascularised grafts and salvage techniques

We retrospectively identified 18 consecutive patients with synovial chrondromatosis of the shoulder who had arthroscopic treatment between 1989 and 2004. Of these, 15 were available for review at a mean follow-up of 5.3 years (2.3 to 16.5). There were seven patients with primary synovial chondromatosis, but for the remainder, the condition was a result of secondary causes. The mean Constant score showed that pain and activities of daily living were the most affected categories, being only 57% and 65% of the values of the normal side. Surgery resulted in a significant improvement in the mean Constant score in these domains from 8.9 (4 to 15) to 11.3 (2 to 15) and from 12.9 (5 to 20) to 18.7 (11 to 20), respectively (unpaired t-test, p = 0.04 and p < 0.0001, respectively). Movement and strength were not significantly affected. Osteoarthritis was present in eight patients at presentation and in 11 at the final review. Recurrence of the disease with new loose bodies occurred in two patients from the primary group at an interval of three and 12 years post-operatively. In nine patients, loose bodies were also present in the bicipital groove; seven of these underwent an open bicipital debridement and tenodesis. We found that arthroscopic debridement of the glenohumeral joint and open debridement and tenodesis of the long head of biceps, when indicated, are safe and effective in relieving symptoms at medium-term review

We describe 14 patients who underwent transfer of latissimus dorsi using a new technique through a single-incision. Their mean age was 61 years (47 to 76) and the mean follow-up was 32 months (19 to 42). The mean Constant score improved from 46.5 to 74.6 points. The mean active flexion increased from 119° to 170°, mean abduction from 118° to 169° and mean external rotation from 19° to 33°. The Hornblower sign remained positive in three patients (23%) as did the external rotation lag sign also in three patients (23%). No patient had a positive drop-arm sign at follow-up. No significant difference was noted between the mean pre- and postoperative acromiohumeral distance as seen on radiographs. An increased grade of osteoarthritis was found in three patients (23%). Electromyographic analysis showed activity of the transferred muscle in all patients

We have examined the relief from pain and the functional outcome in 18 patients who underwent resection arthroplasty of the shoulder as a salvage operation between 1988 and 2002. The indications included failed shoulder replacement in 17, with infection in 13, and chronic septic arthritis in one. The mean follow-up was 8.3 years (2.5 to 16.6). Two intra-operative fractures of the humerus occurred, both of which healed. The level of pain was significantly decreased (t-test, p < 0.001) but five patients continued to have moderate to severe pain. The mean active elevation was 70° (0° to 150°) postoperatively and represented an improvement from 39° (0° to 140°) (t-test, p = 0.003), but internal and external rotation were hardly changed. The mean number of positive answers on the 12-question Simple Shoulder Test was 3.1 (0 to 12) but the shoulder was generally comfortable when the arm was positioned at rest by the side. The mean post-operative American Shoulder and Elbow Surgeon’s score was 36 (8 to 73). Despite applying this procedure principally to failed shoulder replacements, the results were similar to those reported in the literature for patients after severe fracture-dislocation. Reduction of pain is possible in one half to two-thirds of patients. The outcome of this operation in providing relief from pain cannot be guaranteed, but the shoulder is usually comfortable at rest, albeit with profound functional limitations

Sixteen patients who underwent a revision operation for nonunion of fractures of the distal humerus following previous internal fixation were reviewed at a mean follow-up of 39 months (8 to 69). The Mayo elbow performance score was excellent in 11, good in two, fair in two and poor in one. In 15 patients union was achieved and in one with an infected nonunion a subsequent bone graft was necessary in order to obtain union. Age, gender, a history of smoking, mechanism of the injury and the AO classification of the initial fracture did not correlate with the development of nonunion. In 12 patients (75%), the initial fixation was assessed as being suboptimal. The primary surgery was regarded as adequate in only three patients. Our findings suggest that the most important determinant of nonunion of a distal humeral fracture after surgery is the adequacy of fixation

We have undertaken an in vivo assessment of the tissue metabolism and cellular activity in torn tendons of the rotator cuff. Cellular oxygen consumption was measured in 13 patients undergoing mini-open repair of small, medium, large and massive full-thickness tears. Measurements were also taken from three control patients who were undergoing open stabilisation of the shoulder with grossly normal tendons. The level of oxygen and nitrous oxide was measured amperometrically using silver needle microelectrodes at the apex of the tear and 1.5 cm from its edge. With nitrous oxide indicating the degree of perfusion, oxygen consumption was calculated at each location to reflect cellular activity. All of the torn tendons had lower levels of cellular activity than the control group. This activity was lower still in the tissue nearest to the edge of the tear with the larger tears showing the lowest activity. This indicated reduced levels of tissue metabolism and infers a reduction in tendon viability. Our findings suggest that surgical repair of torn tendons of the rotator-cuff should include the more proximal, viable tissue, and may help to explain the high rate of re-rupture seen in larger tears

We have performed a form of lunate replacement arthroplasty, which included excision of the lunate and insertion of a vascularised radial bone flap wrapped in pronator quadratus, for stage IIIB or stage IV Kienböck’s disease, in 41 patients who have been followed up for more than three years. All patients reported an improvement in their symptoms, and 20 of the 41 became free of pain after the operation. Extension and flexion of the wrist were increased by a mean of 9° and 6°, respectively (p < 0.05). The radioscaphoid angle and the carpal height ratio were not significantly changed and only minimal deterioration was observed due to degenerative change. The size, density or location of the inserted bone did not change with time. A vascularised radial bone flap wrapped in pronator quadratus can be a reliable treatment option for advanced Kienböck’s disease, when the pedicled bone and muscle envelope acts as a stable spacer for the excised lunate

We describe a new method of stabilising a painful unstable sternoclavicular joint using the sternocleidomastoid tendon and passing it through the medial clavicle and onto the manubrium sternum. This method is simple, reproducible and avoids the potential risks of reefing the joint to the first rib. The technique was used in seven cases of sternoclavicular joint instability in six patients who were reviewed at a mean of 39.7 months (15 to 63). Instability was markedly reduced or eliminated in all cases, but in one there was occasional persistant subluxation. There were minor scar complications after two procedures and one patient had transient ulnar neuritis. This procedure provides satisfactory results in the medium term

We reviewed 20 patients who had undergone a Coonrad-Morrey total elbow arthroplasty after resection of a primary or metastatic tumour from the elbow or distal humerus between 1980 and 2002. Eighteen patients underwent reconstruction for palliative treatment with restoration of function after intralesional surgery and two after excision of a primary bone tumour. The mean follow-up was 30 months (1 to 192). Five patients (25%) were alive at the final follow-up; 14 (70%) had died of their disease and one of unrelated causes. Local control was achieved in 15 patients (75%). The mean Mayo Elbow Performance Score improved from 22 (5 to 45) to 75 points (55 to 95). Four reconstructions (20%) failed and required revision. Seven patients (35%) had early complications, the most frequent being nerve injury (25%). There were no infections or wound complications although 18 patients (90%) had radiotherapy, chemotherapy or both. The Coonrad-Morrey total elbow arthroplasty provides good relief from pain and a good functional outcome after resection of tumours of the elbow. The rates of complications involving local recurrence of tumour (25%) and nerve injury (25%) are of concern

We studied 11 patients (14 elbows) with gross rheumatoid deformity of the elbow, treated by total arthroplasty using the Kudo type-5 unlinked prosthesis, and who were evaluated between five and 11 years after operation. Massive bone defects were augmented by autogenous bone grafts. There were no major complications such as infection, subluxation or loosening. In most elbows relief from pain and stability were achieved. The results, according to the Mayo Elbow Performance Score, were excellent in eight, good in five and fair in one. In most elbows there was minimal or no resorption of the grafted bone. There were no radiolucent lines around the stems of the cementless components. This study shows that even highly unstable rheumatoid elbows can be replaced successfully using an unlinked prosthesis, with augmentation by grafting for major defects of bone

We retrospectively reviewed 21 patients (22 shoulders) who presented with deep infection after surgery to the shoulder, 17 having previously undergone hemiarthroplasty and five open repair of the rotator cuff. Nine shoulders had undergone previous surgical attempts to eradicate their infection. The diagnosis of infection was based on a combination of clinical suspicion (16 shoulders), positive frozen sections (> 5 polymorphonuclear leukocytes per high-power field) at the time of revision (15 shoulders), positive intra-operative cultures (18 shoulders) or the pre-operative radiological appearances. The patients were treated by an extensive debridement, intravenous antibiotics, and conversion to a reverse shoulder prosthesis in either a single- (10 shoulders) or a two-stage (12 shoulders) procedure. At a mean follow-up of 43 months (25 to 66) there was no evidence of recurrent infection. All outcome measures showed statistically significant improvements. Mean abduction improved from 36.1° (. sd. 27.8) pre-operatively to 75.7° (. sd. 36.0) (p < 0.0001), the mean forward flexion from 43.1° (. sd. 33.5) to 79.5° (. sd. 43.2) (p = 0.0003), and mean external rotation from 10.2° (. sd. 18.7) to 25.4° (. sd. 23.5) (p = 0.0037). There was no statistically significant difference in any outcome between the single-stage and the two-stage group

We compared the quantitative electromyographic activity of the elbow flexors during four exercises (forced inspiration, forced expiration, trunk flexion and attempted elbow flexion), following intercostal nerve transfer to the musculocutaneous nerve in 32 patients who had sustained root avulsion brachial plexus injuries. Quantitative electromyographic evaluation of the mean and maximum amplitude was repeated three times for each exercise. We found that mean and maximum elbow flexor activity was highest during trunk flexion, followed by attempted elbow flexion, forced inspiration and finally forced expiration. The difference between each group was significant (p < 0.001), with the exception of the difference between trunk flexion and attempted elbow flexion. Consequently, we recommend trunk flexion exercises to aid rehabilitation following intercostal nerve transfer

We have conducted a prospective study to assess the mid-term clinical results following arthroscopic repair of the rotator cuff. Patients were evaluated using the Constant score, subjective satisfaction levels and post-operative ultrasound scans. Of 115 consecutive patients who underwent arthroscopic repair of the rotator cuff at our institution, 102 were available for follow-up. The mean period of follow-up was for 35.8 months (24 to 73). The mean age of the patients was 57.3 years (23 to 78). There were 18 small (≤ 1 cm in diameter), 44 medium (1 cm to 3 cm in diameter), 34 large (3 cm to 5 cm in diameter) and six massive (> 5 cm in diameter) tears. There was a statistically significant increase in the size of the tear with increasing age (p = 0.0048). The mean pre-operative Constant score was 41.4 points (95% confidence interval, 37.9 to 44.9), which improved to 84.5 (95% confidence interval, 82.2 to 86.9). A significant inverse association (p = 0.0074), was observed between the size of the tear and the post-operative Constant score, with patients having smaller tears attaining higher Constant scores after repair. Post-operatively, 80 patients (78.4%) were able to resume their occupations and 84 (82.4%) returned to their pre-injury leisure activities. Only eight (7.8%) of 102 patients were not satisfied with the outcome. Recurrent tears were detected by ultrasound in 19 (18.6%) patients, and were generally smaller than the original ones. Patients with recurrent tears experienced a mean improvement of 31.6 points (95% confidence interval, 23.6 to 39.6) in their post-operative Constant scores. Those with intact repairs had significantly improved (p < 0.0001) Constant scores (mean improvement 46.3 points, 95% confidence interval, 41.9 to 50.6). Patient satisfaction was high in 94 cases (92%), irrespective of the outcome of the Constant score. Recurrent tears appear to be linked to age-related degeneration. Arthroscopic repair of the rotator cuff leads to high rates of satisfaction (92%) and good functional results, albeit with a recurrence rate of 18.6% (19 of 102)

We divided 309 patients with an inflammatory arthritis who had undergone primary elbow replacement using the Souter-Strathclyde implant into two groups according to their age. The mean follow-up in the older group (mean age 64 years) was 7.3 years while in the younger patients (mean age 42 years) it was 12 years. Survivorship for three different failure end-points (revision, revision because of aseptic loosening of the humeral component, and gross loosening of the humeral implant), was compared in both groups. Our findings showed that there was no significant difference in the incidence of loosening when young rheumatoid patients were compared with an older age group

We describe the intermediate results of lateral ligamentous repair or reconstruction for posterolateral rotatory instability of the elbow. Between 1986 and 1999, we performed 12 direct repairs and 33 ligament reconstructions with a tendon autograft. One patient was lost to follow-up and 44 were retrospectively studied at a mean of six years (2 to 15). Surgery restored stability in all except five patients. In two the elbow became stable after a second procedure. The mean post-operative Mayo elbow performance score was 85 points (60 to 100). The result was classified as excellent in 19, good in 13, fair in seven and poor in five patients. Thirty-eight patients (86%) were subjectively satisfied with the outcome of the operation. Better results were obtained in patients with a post-traumatic aetiology (p = 0.03), those with subjective symptoms of instability at presentation (p = 0.006) and those who had an augmented reconstruction using a tendon graft (p = 0.04). Reconstruction using a tendon graft seems to provide better results than ligament repair and the results do not seem to deteriorate with time. The outcome of this procedure is less predictable in patients with no subjective instability

We studied 21 patients with a spontaneous palsy of the anterior interosseous nerve. There were 11 men and 10 women with a mean age at onset of 39 years (17 to 65). Pain around the elbow or another region (forearm, shoulder, upper arm, systemic arthralgia) was present in 17 patients and typically lasted for two to three weeks. It had settled within six weeks in every case. In ten cases the palsy developed as the pain settled. A complete palsy of flexor pollicis longus and flexor digitorum profundus to the index finger was seen in 13 cases and an isolated palsy of flexor pollicis longus in five. All patients were treated without operation. The mean time to initial muscle contraction was nine months (2 to 18) in palsy of the flexor digitorum profundus to the index finger, and ten months (1 to 24) for a complete palsy of flexor pollicis longus. An improvement in muscle strength to British Medical Research Council grade 4 or better was seen in all 15 patients with a complete palsy of the flexor digitorum profundus and in 16 of 18 with a complete palsy of flexor pollicis longus. There was no significant correlation between the duration of pain and either the time to initial muscle contraction or final muscle strength. Prolonged pain was not always associated with a poor outcome but the age of the patient when the palsy developed was strongly correlated. Recovery occurred within 12 months in patients under the age of 40 years who achieved a final British Medical Research Council grade of 4 or better. Surgical decompression does not appear to be indicated for young patients with this condition

We present the outcome of the treatment of chronic post-traumatic contractures of the proximal interphalangeal joint by gradual distraction correction using an external fixator. A total of 30 consecutive patients with a mean age of 34 years (17 to 54) had distraction for a mean of 16 days (10 to 22). The fixator was removed after a mean of 29 days (16 to 40). Assessment at a mean of 34 months (18 to 54) after completion of treatment showed that the mean active range of movement had significantly increased by 63° (30° to 90°; p < 0.001). The mean active extension gained was 47° (30° to 75°). Patients aged less than 40 years fared slightly better with a mean gain in active range of movement of 65° (30° to 90°) compared with those aged more than 40 years, who had a mean gain in active range of movement of 55° (30° to 70°) but the difference was not statistically significant (p = 0.148). The use of joint distraction to correct chronic flexion contracture of the proximal interphalangeal joint is a minimally-invasive and effective method of treatment

We describe a technique of soft-tissue reconstruction which is effective for the treatment of chronic lunotriquetral instability. Part of extensor carpi ulnaris is harvested with its distal attachment preserved. It is passed through two drill holes in the triquetrum and sutured to itself. This stabilises the ulnar side of the wrist. We have reviewed 46 patients who underwent this procedure for post-traumatic lunotriquetral instability with clinical signs suggestive of ulnar-sided carpal instability. Standard radiographs were normal. All patients had pre-operative arthroscopy of the wrist at which dynamic lunotriquetral instability was demonstrated. A clinical rating system for the wrist by the Mayo clinic was used to measure the outcome. In 19 patients the result was excellent, in ten good, in 11 satisfactory and in six poor. On questioning, 40 (87%) patients said that surgery had substantially improved the condition and that they would recommend the operation. However, six (13%) were unhappy with the outcome and would not undergo the procedure again for a similar problem. There were six complications, five of which related to pisotriquetral problems. The mean follow-up was 39.1 months (6 to 100). We believe that tenodesis of extensor carpi ulnaris is a very satisfactory procedure for isolated, chronic post-traumatic lunotriquetral instability in selected patients. In those with associated pathology, the symptoms were improved, but the results were less predictable

Excision is not a suitable treatment for all comminuted fractures of the radial head. In elbows where instability can be predicted, a replacement arthroplasty of the radial head is more effective. The aim of this paper was to present the medium-term results of the Judet floating radial head prosthesis. This operation was performed on 14 patients between 1992 and 2003, of whom 12 were reviewed at a mean follow-up of five years and three months (1 to 12 years). The outcome was assessed using the Mayo elbow performance score and a modified Disability of Arm Shoulder Hand (DASH) questionnaire. There were six excellent results, four good, one fair and one poor, as graded by the Mayo score. The mean DASH score was 23.9/100 (0 to 65.8/100). The only significant complication occurred in one patient who developed a severe complex regional pain syndrome. There were no patients with secondary instability of the elbow, implant loosening, cubitus valgus, osteoporosis of the capitellum, or pain in the forearm and wrist. Our experience, combined with that of other authors using this device, has encouraged us to continue using the Judet prosthesis in comminuted fractures of the elbow where instability is a potential problem

We present six patients with chronic dislocation of the elbow who were treated by primary semiconstrained total elbow arthroplasty. All were women with a mean age of 65 years (51 to 76), the mean interval between dislocation and surgery was 17 weeks (5 to 52) and the mean follow-up 58 months (24 to 123). The most dramatic improvement was in function. The mean American Shoulder and Elbow Surgeon score was 5.2 times better (p < 0.001) and the mean total range of movement increased from 33° to 121° (p < 0.001) after operation. Three patients developed wear of polyethylene. One required revision for a periprosthetic fracture, and another required a bushing exchange. Primary semiconstrained elbow arthroplasty provides significant, predictable functional improvement. Potential solutions for wear of polyethylene include a different operative technique or design of implant. Despite the high incidence of such wear, total elbow arthroplasty should be considered as a viable treatment option for chronic dislocation of the elbow in elderly patients

We examined the effects of previous resection of the radial head and synovectomy on the outcome of subsequent total elbow arthroplasty in patients with rheumatoid arthritis. Fifteen elbows with a history of resection and synovectomy were compared with a control group of patients who had elbow arthroplasty with an implant of the same design. The mean age in both groups was 63 years. In the study group, resection of the radial head and synovectomy had been undertaken at a mean of 8.9 years before arthroplasty. The mean radiological follow-up for the 13 available patients in the study group was 5.89 years (0.3 to 11.0) and in the control group was 6.6 years (2.2 to 12.6). There were no revisions in either group. The mean Mayo elbow performance score improved from 29 to 96 in the study group, with similar improvement in the control group (28 to 87). The study group had excellent results in 13 elbows and good results in two. The control group had excellent results in seven and good results in six. Our experience indicates that previous resection of the radial head and synovectomy are not associated with an increased rate of revision following subsequent arthroplasty of the elbow. However, there was a higher rate of complication in the study group compared with the control group

We have studied cellular and vascular changes in different stages of full thickness tears of the rotator cuff. We examined biopsies from the supraspinatus tendon in 40 patients with chronic rotator cuff tears who were undergoing surgery and compared them with biopsies from four uninjured subscapularis tendons. Morphological and immunocytochemical methods using monoclonal antibodies directed against leucocytes, macrophages, mast cells, proliferative and vascular markers were used. Histological changes indicative of repair and inflammation were most evident in small sized rotator cuff tears with increased fibroblast cellularity and intimal hyperplasia, together with increased expression of leucocyte and vascular markers. These reparative and inflammatory changes diminished as the size of the rotator cuff tear increased. Marked oedema and degeneration was seen in large and massive tears, which more often showed chondroid metaplasia and amyloid deposition. There was no association between the age of the patient and the duration of symptoms. In contrast, large and massive tears showed no increase in the number of inflammatory cells and blood vessels. Small sized rotator cuff tears retained the greatest potential to heal, showing increased fibroblast cellularity, blood vessel proliferation and the presence of a significant inflammatory component. Tissue from large and massive tears is of such a degenerative nature that it may be a significant cause of re-rupture after surgical repair and could make healing improbable in this group

This study prospectively evaluated the outcome of manipulation under anaesthesia and hydrodilatation as treatments for adhesive capsulitis. A total of 36 patients (38 shoulders) were randomised to receive either method, with all patients being treated in stage II of the disease process. The mean age of the patients was 55.2 years (44 to 70) and the mean duration of symptoms was 33.7 weeks (12 to 76). Eighteen shoulders (17 patients) underwent manipulation under anaesthesia and 20 (19 patients) had hydrodilatation. There were three insulin-dependent diabetics in each group. The mean visual analogue score in the manipulation under anaesthesia group was 5.7 (3 to 8.5; n = 18) before treatment, 4.7 (0 to 8.5; n = 16) at two months (paired t-test p = 0.02), and 2.7 (0 to 9; n = 16) at six months (paired t-test, p = 0.0006). The mean score in the hydrodilatation group was 6.1 (4 to 10; n = 20) before treatment, 2.4 (0 to 8; n = 18) at two months (paired t-test, p = 0.001), and 1.7 (0 to 7; n = 18) at six months (paired t-test, p = 0.0006). The visual analogue scores in the hydrodilatation group were significantly better than in the manipulation under anaesthesia group over the six-month follow-up period (p < 0.0001). The mean Constant score in those manipulated was 36 (26 to 66) before treatment, 58.5 (24 to 90) at two months (paired t-test, p = 0.001) and 59.5 (23 to 85) at six months (paired t-test, p = 0.0006). In the hydrodilatation group it was 28.8 (18 to 55) before treatment, 57.4 (17 to 80) at two months (paired t-test, p = 0.0004) and 65.9 (28 to 92) at six months (paired t-test, p = 0.0005). The Constant scores in the hydrodilatation group were significantly better than in the manipulated group over the six-month period of follow-up (p = 0.02). The range of movement improved in all patients over the six months, but was not significantly different between the groups. At the final follow-up, 94% of patients (17 of 18) were satisfied or very satisfied after hydrodilatation compared with 81% (13 of 16) of those receiving a manipulation. Most of our patients were treated successfully, but those undergoing hydrodilatation did better than those who were manipulated

We reviewed the records and radiographs of 381 patients with rheumatoid arthritis who had undergone silastic metacarpophalangeal joint replacement during the past 17 years. The number of implants was 1336 in the course of 404 operations. Implant failure was defined as either revision or fracture of the implant as seen on radiography. At 17 years, the survivorship was 63%, although on radiographs two-thirds of the implants were seen to be broken. Factors which improved survival included soft-tissue balancing, crossed intrinsic transfer and realignment of the wrist. Surgery to the thumb and proximal interphalangeal joint had a deleterious effect and the use of grommets did not protect the implant from fracture

Objectives

The objective of this study was to perform a meta-analysis of all randomised controlled trials (RCTs) comparing surgical and non-surgical management of fractures of the proximal humerus, and to determine whether further analyses based on complexity of fracture, or the type of surgical intervention, produced disparate findings on patient outcomes.

We have examined 167 patients who had a hemiarthroplasty for three- and four-part fractures and fracture-dislocations of the head of the humerus in a multicentre study involving 12 Austrian hospitals. All patients were followed for more than a year. Anatomical healing of the tuberosity significantly influenced the outcome as measured by the Constant score and subjective patient satisfaction. With regard to pain, the outcome was generally satisfactory but only 41.9% of patients were able to flex the shoulder above 90°. The age of the patient and the type of prosthesis significantly influenced the healing of the tuberosity, but bone grafting did not. Achievement of healing of the tuberosity was inferior in institutions at which less than 15 hemiarthroplasties had been performed (Mann-Witney U test, p = 0.0001)

A vascularised bone-graft procedure from the base of the second metacarpal was performed in 14 patients with nonunion of the scaphoid. There were 11 men and three women with a mean age of 22 years. In eight patients, who had dorsiflexed intercalated segment instability (DISI), an open wedge was formed at the site of nonunion, and the vascular pedicle was grafted from the volar side. In the six patients without DISI, transplantation was carried out through the same dorsal skin incision. Complete bony union was obtained in all patients after a mean post-operative period of 10.2 weeks, and DISI was corrected in all affected patients. According to Cooney’s clinical scoring system, the results were excellent in five, good in six, and fair in three patients. Because of its technical simplicity and the limited dissection needed, the procedure should be considered for the primary surgical treatment of patients with nonunion of the scaphoid

We have compared the functional outcome after glenohumeral fusion for the sequelae of trauma to the brachial plexus between two groups of adult patients reviewed after a mean interval of 70 months. Group A (11 patients) had upper palsy with a functional hand and group B (16 patients) total palsy with a flail hand. All 27 patients had recovered active elbow flexion against resistance before shoulder fusion. Both groups showed increased functional capabilities after glenohumeral arthrodesis and a flail hand did not influence the post-operative active range of movement. The strength of pectoralis major is a significant prognostic factor in terms of ultimate excursion of the hand and of shoulder strength. Glenohumeral arthrodesis improves function in patients who have recovered active elbow flexion after brachial plexus palsy even when the hand remains paralysed

In 28 patients with a solitary diagnosis of instability of the trapeziometacarpal joint because of a rupture of the anterior oblique ligament, reconstruction was carried out using a slip of the tendon of flexor carpi radialis. We were able to review 26 patients. The results after a follow-up of four years seven months showed that most (87%) had significant relief from pain and symptoms. Seventeen were graded as good to excellent. The mean grip strength recovered to 86% of the contralateral side. Most patients (81%) felt that they had subjective improvement and would have undergone the operation again. A lesser functional result was seen in those who developed a flexion deformity because of overtightening of the reconstruction. Increased awareness of this lesion can lead to an early and clear diagnosis so that the patient may be advised adequately. We describe a specific, diagnostic, clinical test which we have used consistently and successfully

We describe an operation to relieve compression of the lateral antebrachial cutaneous nerve at the elbow. Between 1987 and 1997 we operated on seven patients, one with bilateral compression. In two the compression was associated with injury to biceps. A longitudinal or a transverse incision was carried out and the nerve was released from the deep fascia. Partial excision of the biceps aponeurosis was undertaken in the patients who did not have injury to biceps; some additional procedures were required for those patients with injuries. All patients had symptomatic relief

We treated 34 consecutive articular fractures of the proximal humerus in 33 patients with good bone quality by open reduction and internal fixation. Anatomical or nearly anatomical reduction was achieved in 30, at a mean follow-up of 63 months (25 to 131), complete or partial avascular necrosis had occurred in 12 cases (35%). Two patients subsequently underwent arthroplasty and six further patients required additional surgery. The 32 patients who did not require arthroplasty obtained a mean Constant score of 78 points or 89% of an age- and gender-matched normal score (66 points or 76% in the presence and 83 points or 96% in the absence of avascular necrosis (p < 0.0005)); 22 were painfree, and seven had mild pain and three moderate pain. The mean active anterior elevation was 156°. Internal fixation of complex fractures of the proximal humerus restored good shoulder function if avascular necrosis did not develop

We studied, retrospectively, 131 patients who had undergone an open operation for the carpal tunnel syndrome (CTS) in 229 hands. The symptoms were present on both sides in 59% of patients when first seen. Neurophysiological impairment of the median nerve was observed in 66% of the asymptomatic hands, and 73% of patients in this group developed symptoms of CTS after the opposite side had been operated on. Follow-up of patients with unilateral CTS showed that the subsequent development of disease in the unaffected hand is very common. We conclude that CTS is a bilateral disorder and that it becomes more evident as time passes. There is a correlation between the duration of symptoms and bilateral occurrence

We conducted a prospective, randomised, controlled trial of 45 patients (47 elbows), with tennis elbow, who underwent either a formal open release or a percutaneous tenotomy. All patients had pre- and post-operative assessment using the Disability of Arm, Shoulder and Hand (DASH) scoring system. Both groups were followed up for a minimum of 12 months. Statistical analyses using the Mann-Whitney U test and repeated measured ANOVA showed significant improvements for patient satisfaction (p = 0.012), time to return to work (p = 0.0001), improvements in DASH score (p = 0.001) and improvement in sporting activities (p = 0.046) in the percutaneous group. Those patients undergoing a percutaneous release returned to work on average three weeks earlier and improved significantly more quickly than those undergoing an open procedure. The percutaneous procedure is a quicker and simpler procedure to undertake and produces significantly better results

Patients with short congenital amputations below the elbow often function as if they have had a disarticulation of the elbow. We have reviewed the results in six patients who had lengthening of such stumps by the Ilizarov technique to improve the fitting of prostheses. The mean lengthening was 5.6 cm (3.4 to 8.4), and in two patients flexion contractures of the elbows were corrected simultaneously. Additional lateral distraction was used in one patient to provide a better surface on the stump. There were no major complications. All six patients were able to use their prosthesis at the latest follow-up after 39 to 78 months

Our aim was to determine if a tourniquet placed on the forearm has any advantage in clinical practice over the usual position on the upper arm. We randomised 50 patients who were undergoing an open operation for carpal tunnel syndrome under local anaesthesia into two groups. One had a tourniquet on the upper arm and the other on the forearm. The blood pressure, pulse, and level of pain were recorded at intervals of five minutes during the operation. The surgeons were also asked to evaluate the quality of the anaesthesia, the bloodless field, and the site of the tourniquet. The patients tolerated the tourniquet on the upper arm and forearm equally well. The surgeons had some difficulties when it was placed on the forearm. We therefore recommend placement of a tourniquet on the upper arm for operations on the hand and wrist which are carried out under local anaesthesia

Os acromiale is a rare anatomical abnormality and treatment is controversial. Our retrospective study analyses the outcome of excision, acromioplasty and bony fusion of the os acromiale when it is associated with a tear of the rotator cuff. After a mean follow-up of 41 months, 33 patients were radiologically and clinically assessed using the Constant score. The surgical procedure was to repair the rotator cuff together with excision of the os acromiale in six patients, acromioplasty in five, and fusion in 22. Of the 22 attempted fusions seven failed radiologically. The Constant scores were 82%, 81%, 81% and 84% for patients who had excision, acromioplasty, successful fusion and unsuccessful fusion respectively. There were no statistically significant differences. We conclude that a small mobile os acromiale can be resected, a large stable os acromiale treated by acromioplasty and a large unstable os acromiale by fusion to the acromion. Even without radiological fusion the clinical outcome can be good

Both idiopathic carpal tunnel syndrome (CTS) and Raynaud’s phenomenon (RP) are common, and may have similar clinical symptoms. The degree of their coexistence is uncertain. We have examined 30 patients, who were diagnosed clinically and electromyographically as having idiopathic CTS, for the presence of RP using a cold provocation test with photoplethysmography. The patients’ hands were exposed in water at 10°C for five minutes. A total of 18 patients (60%) was found to have RP; this is much greater than would be expected from the prevalence in the general population. Raynaud’s phenomenon should be considered when treating patients with CTS because of the possibility of coexistence and the similar symptoms of these two disorders

We analysed the results of arthroscopic synovectomy of the wrist in 18 patients (19 wrists) with rheumatoid arthritis who had not responded to conservative treatment. The patients’ symptoms were assessed using visual analogue scales for pain and satisfaction. Standard posteroanterior radiographs which were taken pre-operatively and at final follow-up were analysed using a modified Larsen scoring system (normal, 0; total destruction, 40). The mean follow-up period was 29.2 months (24 to 45). The mean pre-operative pain score was 8.58 which decreased to 3.58 one year after surgery and increased again to 4.42 at final follow-up. This suggested a gradual increase in pain with time. The mean satisfaction score was 6.26. The mean modified Larsen’s score was 9.8 pre-operatively and 13.9 at final follow-up, which demonstrated the slow progression of degenerative changes. Arthroscopic synovectomy for rheumatoid arthritis of the wrist allows effective pain relief and high patient satisfaction, although any prolonged benefits will require long-term follow-up

We present nine patients (five men and four women) who underwent surgical excision of clinically significant heterotopic ossification at the elbow. They also received perioperative radiation therapy using total doses between 600 and 1000 cGy. Five received fractionated radiotherapy, with two fractions of 500 cGy applied on the first two postoperative days, and the remaining four were irradiated with single doses of 600 and 700 cGy. After a mean period of observation of 7.7 months (6 to 13) none had radiological recurrence of heterotopic ossification and eight showed clinical improvement. Assessment of the functional outcome showed a mean improvement in the Morrey score from 33.3 to 84.5 points indicating a high therapeutic efficacy of prophylactic irradiation

We describe four women and two men who had persistent wrist pain and reduced function after minor operations on the dorsum, usually for ganglia. They had diffuse pain and paraesthesia over the dorsum of the wrist, thumb, index and middle fingers, which was worse and different from that before operation. They all had temporary relief of symptoms after block of the posterior interosseous nerve with bupivacaine. Later, excision of the terminal branches of the nerve at the wrist cured three patients completely and gave marked improvement in the other three, with no complications. Great care is required at operations on the dorsum of the wrist, but pain from a neuroma can be relieved by local excision

Seven patients with chronic insufficiency of the triceps were treated by either a rotation flap using anconeus (4) or an allograft of tendo Achillis (3). The latter procedure was selected for patients with a large defect in whom the anconeus muscle had been devitalised. Five disruptions were in patients who had previously undergone an elbow replacement. The patients were assessed for subjective satisfaction, pain, range of movement and strength, and the results were graded using the Mayo Elbow Performance Score (MEPS). The mean follow-up was for 33 months (9 to 63). One rotation flap failed six months after operation. At the most recent follow-up, the remaining six patients had no or slight pain, restoration of a functional arc of movement and normal or slightly decreased power of extension. All six were satisfied with the outcome and were able to resume their daily activities with no limitations other than those imposed by the previous elbow replacement. The final MEPS was 100 points in five patients and 75 in one

We report a controlled, prospective study to investigate the effect of treatment by low-energy extracorporeal shock waves on pain in tennis elbow. We assigned at random 100 patients who had had symptoms for more than 12 months to two groups to receive low-energy shock-wave therapy. Group I received a total of 3000 impulses of 0.08 mJ/mm. 2. and group II, the control group, 30 impulses. The patients were reviewed after 3, 6 and 24 weeks. There was significant alleviation of pain and improvement of function after treatment in group I in which there was a good or excellent outcome in 48% and an acceptable result in 42% at the final review, compared with 6% and 24%, respectively, in group II

We studied retrospectively a consecutive series of 547 shoulders in 529 patients undergoing operation for instability. In 41, the cause of instability was considered to be lateral avulsion of the capsule, including the inferior glenohumeral ligament, from the neck of the humerus, the HAGL lesion. In 35, the lesion was found at first exploration, whereas in six it was noted at revision of a previous failed procedure. In both groups, the patients were older on average than those with instability from other causes. Of the primary cases, in 33 (94.3%) the cause of the first dislocation was a violent injury; six (17.4%) had evidence of damage to the rotator cuff and/or the subscapularis. Only four (11.4%) had a Bankart lesion. In patients undergoing a primary operation in whom the cause of the first dislocation was a violent injury, who did not have a Bankart lesion and had no suggestion of multidirectional laxity, the incidence of HAGL was 39%

We treated 31 patients with non-traumatic paralysis of the posterior interosseous nerve over 15 years. There were 10 men and 21 women of mean age 40.3 years (17 to 71). Six were managed conservatively, and 25 by operation. In 14 patients entrapment occurred at the supinator, including three who had double compression at both the entrance and exit from the muscle. In four it was caused by a ganglion, in one by a lipoma, in one by a dislocated radial head and in two by a marked constriction in the nerve of unknown cause. The remaining three patients were retrospectively diagnosed as having neuralgic amyotrophy, the only observable change at operation being slight oedema of the nerve. Paralysis recovered in 24 out of the 25 patients at between 2 to 18 months (mean 5.6) after operation, and the one failure was treated later by tendon transfer

The diagnosis of chronic lesions of the rotator cuff is challenging. We have developed a new index to improve the sonographic diagnosis of chronic tears of the cuff. In a pilot study, we examined 50 asymptomatic healthy volunteers by ultrasound to establish the diameter of the rotator cuff in relation to the tendon of the long head of biceps. Subsequently, the index was calculated in 64 patients who had had shoulder pain for more than three months caused by clinically diagnosed lesions of the rotator cuff. The compensatory hypertrophy of the biceps tendon was quantified sonographically in relation to the diameter of the cuff. Comparison with the contralateral shoulder revealed a significantly higher biceps rotator-cuff ratio (p < 0.05) for patients with torn rotator cuffs. A ratio greater than 0.8 was considered pathological (index positive); the mean ratio in the control group was 0.43. The sensitivity of a positive index was 97.8%, the specificity 63.2%, the positive predictive value 86.3%, and the negative predictive value 92.4% in comparison with surgical findings. Use of the index improves sensitivity in the diagnosis of chronic tears of the cuff by ultrasound

In nine patients of median age 34 years who had sustained an amputation of the thumb at a median 24 (5 to 131) months previously, we lengthened the first metacarpal by 30 (17 to 36) mm. Seven amputations had been through the proximal phalanx and two through the metacarpal. The first two patients had autogenous grafting at a second stage, but the other seven had callotasis alone. In these patients the external fixators were removed at a median 189 (115 to 271) days after osteotomy. In six cases the adductor pollicis tendon was transferred proximally and the first web deepened. There was late fracture or palmar flexion of the callus in five patients, but this required further surgery in only one. Treatment was complete at 326 (140 to 489) days after osteotomy. The extended thumb retained its sensitivity; both grasp and key-pinch strength were satisfactory and only one patient felt that the result did not warrant the long course of treatment. Metacarpal lengthening by this method is a prolonged procedure, but provides a valuable alternative to more complex reconstructions

Between 1978 and 1986, 59 patients received a GSB III elbow prosthesis, six of them in both elbows. Rheumatoid arthritis (RA) was the underlying cause in 51 of the patients and post-traumatic osteoarthritis (PTOA) in eight. Of these, 24 patients (28 prostheses) have since died; two, both operated on bilaterally, had had their implants for more than ten years and had already been assessed for inclusion in the long-term follow-up. Two patients, each with one elbow prosthesis, have been lost to follow-up and three males who are still living (two with PTOA, one with juvenile RA) had their prosthesis removed before ten years had elapsed. The remaining 32 patients (28 RA, 4 PTOA) with 36 GSB III elbows were examined clinically and radiologically after a mean period of 13.5 years. Pain was considerably reduced in 91.6%. Mobility was increased by 37° in those with RA and by 67° in those with PTOA. There were three cases of aseptic loosening and three of deep infection. The main complication was disassembly of the prosthetic component in nine elbows (13.8%). This last group included two patients with postoperative fractures unrelated to the operative technique and one with neuropathic arthritis. Ulnar neuritis occurred in two patients. Since 87.7% of all the GSB III prostheses implanted in this period remained in situ, our results are comparable with those for hip and knee arthroplasty

Aims

The aim of this study was to compare the pain caused by the application of a tourniquet after exsanguination of the upper limb with that occurring after simple elevation.

Methods

Between 2005 and 2012, 50 patients (23 female, 27 male) with nonunion of the humeral shaft were included in this retrospective study. The mean age was 51.3 years (14 to 88). The patients had a mean of 1.5 prior operations (sd 1.2;1 to 8).

All patients were assessed according to a specific risk score in order to devise an optimal and individual therapy plan consistent with the Diamond Concept. In 32 cases (64%), a change in the osteosynthesis to an angular stable locking compression plate was performed. According to the individual risk an additional bone graft and/or bone morphogenetic protein-7 (BMP-7) were applied.