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
The Mangled Extremity Severity
An objective technological solution for tracking adherence to at-home shoulder physiotherapy is important for improving patient engagement and rehabilitation outcomes, but remains a significant challenge. The aim of this research was to evaluate performance of machine-learning (ML) methodologies for detecting and classifying inertial data collected during in-clinic and at-home shoulder physiotherapy exercise. A smartwatch was used to collect inertial data from 42 patients performing shoulder physiotherapy exercises for rotator cuff injuries in both in-clinic and at-home settings. A two-stage ML approach was used to detect out-of-distribution (OOD) data (to remove non-exercise data) and subsequently for classification of exercises. We evaluated the performance impact of grouping exercises by motion type, inclusion of non-exercise data for algorithm training, and a patient-specific approach to exercise classification. Algorithm performance was evaluated using both in-clinic and at-home data.Aims
Methods
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). Three-month-old C57BL/6 J mice underwent a unilateral rotator cuff injury procedure. Mice were forced to run on a treadmill with the HIIT programme during the first to sixth weeks or seventh to 12th weeks after tendon tear surgery. To study the role of β3AR, SR59230A, a selective β3AR antagonist, was administered to mice ten minutes before each exercise through intraperitoneal injection. Supraspinatus muscle, interscapular brown fat, and inguinal subcutaneous white fat were harvested at the end of the 12th week after tendon tear and analyzed biomechanically, histologically, and biochemically.Aims
Methods
Rotator cuff (RC) tears are common musculoskeletal injuries which often require surgical intervention. Noninvasive pulsed electromagnetic field (PEMF) devices have been approved for treatment of long-bone fracture nonunions and as an adjunct to lumbar and cervical spine fusion surgery. This study aimed to assess the effect of continuous PEMF on postoperative RC healing in a rat RC repair model. A total of 30 Wistar rats underwent acute bilateral supraspinatus tear and repair. A miniaturized electromagnetic device (MED) was implanted at the right shoulder and generated focused PEMF therapy. The animals’ left shoulders served as controls. Biomechanical, histological, and bone properties were assessed at three and six weeks.Aims
Methods
To evaluate if union of clavicle fractures can be predicted at six weeks post-injury by the presence of bridging callus on ultrasound. Adult patients managed nonoperatively with a displaced mid-shaft clavicle were recruited prospectively. Ultrasound evaluation of the fracture was undertaken to determine if sonographic bridging callus was present. Clinical risk factors at six weeks were used to stratify patients at high risk of nonunion with a combination of Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) ≥ 40, fracture movement on examination, or absence of callus on radiograph.Aims
Methods
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
The purpose of this study was to compare the
outcome and complications of endoscopic versus open
release for the treatment of de Quervain’s tenosynovitis. Patients
with this condition were randomised to undergo either endoscopic (n
= 27) or open release (n = 25). Visual Analogue Scale (VAS) pain
and Disabilities of Arm, Shoulder, and Hand (DASH)
Aims. We performed a systematic review of the literature to determine
whether earlier surgical repair of acute rotator cuff tear (ARCT)
leads to superior post-operative clinical outcomes. Methods. The MEDLINE, Embase, CINAHL, Web of Science, Cochrane Libraries,
controlled-trials.com and clinicaltrials.gov databases were searched
using the terms: ‘rotator cuff’, or ‘supraspinatus’, or ‘infraspinatus’,
or ‘teres minor’, or ‘subscapularis’ AND ‘surgery’ or ‘repair’.
This gave a total of 15 833 articles. After deletion of duplicates
and the review of abstracts and full texts by two independent assessors,
15 studies reporting time to surgery for ARCT repair were included.
Studies were grouped based on time to surgery <
3 months (group
A, seven studies), or >
3 months (group B, eight studies). Weighted
means were calculated and compared using Student’s t-test. . Results. Group B had a significantly higher pre-operative Constant score
(CS) (p <
0.001), range of movement in external rotation (p =
0.003) and abduction (p <
0.001) compared with group A. Both
groups showed clinical improvement with surgical repair; group A
had a significantly improved Constant
We assessed the short- to mid-term survival of
metallic press-fit radial head prostheses in patients with radial
head fractures and acute traumatic instability of the elbow. The medical records of 42 patients (16 males, 26 females) with
a mean age of 56 years (23 to 85) with acute unstable elbow injuries,
including a fracture of the radial head requiring metallic replacement
of the radial head, were reviewed retrospectively. Survival of the
prosthesis was assessed from the radiographs of 37 patients after
a mean follow-up of 50 months (12 to 107). The functional results
of 31 patients were assessed using range-of-movement, Mayo elbow
performance
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
The combination of an irreparable tear of the rotator cuff and destructive arthritis of the shoulder joint may cause severe pain, disability and loss of independence in the aged. Standard anatomical shoulder replacements depend on a functioning rotator cuff, and hence may fail in the presence of tears in the cuff. Many designs of non-anatomical constrained or semi-constrained prostheses have been developed for cuff tear arthropathy, but have proved unsatisfactory and were abandoned. The DePuy Delta III reverse prosthesis, designed by Grammont, medialises and stabilises the centre of rotation of the shoulder joint and has shown early promise. This study evaluated the mid-term clinical and radiological results of this arthroplasty in a consecutive series of 50 shoulders in 43 patients with a painful pseudoparalysis due to an irreparable cuff tear and destructive arthritis, performed over a period of seven years by a single surgeon. A follow-up of 98% was achieved, with a mean duration of 39 months (8 to 81). The mean age of the patients at the time of surgery was 81 years (59 to 95). The female to male ratio was 5:1. During the seven years, six patients died of natural causes. The clinical outcome was assessed using the American Shoulder and Elbow
A total of 159 patients (84 women and 75 men,
mean age of 53 (20 to 87)) with subacromial impingement were randomised
to treatment with subacromial injections using lidocaine with one
of hyaluronic acid (51 patients), corticosteroid (53 patients) or
placebo (55 patients). Patients were followed up for 26 weeks. The
primary outcome was pain on a visual analogue score (VAS), and secondary
outcomes included the Constant Murley
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. Methods. A systematic review of the literature was performed identifying all RCTs that compared surgical and non-surgical management of fractures of the proximal humerus. Meta-analysis of clinical outcomes was performed where possible. Subgroup analysis based on the type of fracture, and a sensitivity analysis based on the type of surgical intervention, were also performed. Results. Seven studies including 528 patients were included. The overall meta-analysis found that there was no difference in clinical outcomes. However, subgroup and sensitivity analyses found improved patient outcomes for more complex fractures managed surgically. Four-part fractures that underwent surgery had improved long-term health utility
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
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
We have carried out a prospective double-blind randomised controlled trial to compare the efficacy of a single subacromial injection of the non-steroidal anti-inflammatory drug, tenoxicam, with a single injection of methylprednisolone in patients with subacromial impingement. A total of 58 patients were randomly allocated into two groups. Group A received 40 mg of methylprednisolone and group B 20 mg of tenoxicam as a subacromial injection along with lignocaine. The Constant-Murley shoulder
We have investigated the mid-term outcome of total shoulder replacement using a keeled cemented glenoid component and a modern cementing technique with regard to the causes of failure and loosening of the components. Between 1997 and 2003 we performed 96 total shoulder replacements on 88 patients, 24 men and 64 women with a mean age of 69.7 years (31 to 82). The minimum follow-up was five years and at the time of review 87 shoulders (77 patients) were examined at a mean follow-up of 89.1 months (60 to 127). Cumulative survival curves were generated with re-operations (accomplished and planned), survivorship of the proshesis, loosening of the glenoid (defined as tilt >
5° or subsidence >
5 mm), the presence of radiolucent lines and a Constant
This study reports the clinical and sonographic
outcome of arthroscopic rotator cuff repair in patients aged ≥ 70 years
and aimed to determine factors associated with re-tear. A total
of 69 consecutive repairs were performed in 68 patients with a mean
age of 77 years (70 to 86). Constant-Murley
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
Our aim in this prospective study was to evaluate the outcome of total shoulder replacement in the treatment of young and middle-aged active patients with primary glenohumeral osteoarthritis. We reviewed 21 patients (21 shoulders) with a mean age of 55 years (37 to 60). The mean follow-up was seven years (5 to 9). The same anatomical, third-generation, cemented implant had been used in all patients. All the patients were evaluated radiologically and clinically using the Constant and Murley
The aim of this study was to determine the functional outcome and rate of re-tears following mini-open repair of symptomatic large and massive tears of the rotator cuff using a two-row technique. The 24 patients included in the study were assessed prospectively before and at a mean of 27 months (18 to 53) after surgery using the Constant and the Oxford Shoulder
We present the outcome of 47 Souter-Strathclyde replacements of the elbow with a mean follow-up of 82 months (12 to 129). The clinical results were assessed using a condition-specific outcome measure. The mean total
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
We developed a questionnaire to assess patient-reported outcome after surgery of the elbow from interviews with patients. Initially, 17 possible items with five response options were included. A prospective study of 104 patients (107 elbow operations) was carried out to analyse the underlying factor structure, dimensionality, internal and test-retest reliability, construct validity and responsiveness of the questionnaire items. This was compared with the Mayo Elbow performance
Scapulothoracic fusion (STF) for painful winging
of the scapula in neuromuscular disorders can provide effective pain
relief and functional improvement, but there is little information
comparing outcomes between patients with dystrophic and non-dystrophic
conditions. We performed a retrospective review of 42 STFs in 34
patients with dystrophic and non-dystrophic conditions using a multifilament
trans-scapular, subcostal cable technique supported by a dorsal
one-third semi-tubular plate. There were 16 males and 18 females
with a mean age of 30 years (15 to 75) and a mean follow-up of 5.0
years (2.0 to 10.6). The mean Oxford shoulder
Radial osteotomy is currently advocated for patients
with Lichtman’s stages II and IIIA of Kienböck’s disease; its place
in the treatment of patients with stage IIIB disease remains controversial.
The purpose of this study was to evaluate the medium-term results
of this procedure and to compare the outcome in patients with stage
IIIB disease and those with earlier stages (II and IIIA). A total
of 18 patients (18 osteotomies) were evaluated both clinically and radiologically
at a mean follow-up of 10.3 years (4 to 18). Range of movement,
grip strength and pain improved significantly in all patients; the
functional
We have undertaken a prospective clinical and radiological analysis of 124 shoulder arthroplasties (113 patients) carried out for osteoarthritis. The clinical results showed improvement in the absolute Constant
Total shoulder replacement is a successful procedure for degenerative or some inflammatory diseases of the shoulder. However, fixation of the glenoid seems to be the main weakness with a high rate of loosening. The results using all-polyethylene components have been better than those using metal-backed components. We describe our experience with 35 consecutive total shoulder replacements using a new metal-backed glenoid component with a mean follow-up of 75.4 months (48 to 154). Our implant differs from others because of its mechanism of fixation. It has a convex metal-backed bone interface and the main stabilising factor is a large hollow central peg. The patients were evaulated with standard radiographs and with the Constant
We compared the long-term function of subscapularis after the Latarjet procedure using two surgical approaches. We treated 102 patients (106 shoulders) with a mean age of 26.8 years (15 to 51) with involuntary unidirectional recurrent instability. The operation was carried out through an L-shaped incision with trans-section of the upper two-thirds of the muscle in 69 cases and with a subscapularis split in 37. All clinical results were assessed by the Rowe and the Duplay
We have developed an illustrated questionnaire, the Hand20, comprising 20 short and easy-to-understand questions to assess disorders of the upper limb. We have examined the usefulness of this questionnaire by comparing reliability, validity, responsiveness and the level of missing data with those of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. A series of 431 patients with disorders of the upper limb completed the Hand20 and the Japanese version of the DASH (DASH-JSSH) questionnaire. The norms for Hand20
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
Fractures of the proximal humerus can lead to malalignment of the humeral head, necrosis and post-traumatic osteoarthritis. In such cases surface replacement might be a promising option. A total of 28 shoulders with glenohumeral arthritis subsequent to a fracture underwent surface replacement arthroplasty of the humeral head in patients with a mean age of 60 years (35 to 83). On the basis of the inclination of the impacted head, post-traumatic arthritis was divided into three types: type 1, an impacted fracture of the head in an anatomical position (seven cases); type 2, a valgus impacted fracture (13 cases); type 3, a varus impacted fracture (eight cases). The outcome was measured by means of the Constant
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
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
We present the long-term outcome, at a median of 18 years (12.8 to 23.5) of open posterior bone block stabilisation for recurrent posterior instability of the shoulder in a heterogenous group of 11 patients previously reported on in 2001 at a median follow-up of six years. We found that five (45%) would not have chosen the operation again, and that four (36%) had further posterior dislocation. Clinical outcome was significantly worse after 18 years than after six years of follow-up (median Rowe
We have previously described the short-term outcome of the use of reverse shoulder arthroplasty in the treatment of acute complex proximal humeral fractures in the elderly. We now report the clinical and radiological outcome of 36 fractures at a mean of 6.6 years (1 to 16). Previously, at a mean follow-up of 6 years (1 to 12) the mean Constant
We report the long-term clinical and radiological outcomes of the Aequalis total shoulder replacement with a cemented all-polyethylene flat-back keeled glenoid component implanted for primary osteoarthritis between 1991 and 2003 in nine European centres. A total of 226 shoulders in 210 patients were retrospectively reviewed at a mean of 122.7 months (61 to 219) or at revision. Clinical outcome was assessed using the Constant
We prospectively evaluated 61 patients treated arthroscopically for anterior instability of the shoulder at a mean follow-up of 44.5 months (24 to 100) using the Rowe scale. Those with post-operative dislocation or subluxation were considered to be failures. Logistic regression analysis was used to identify patients at increased risk of recurrence in order to develop a suitable selection system. The mean Rowe
In order to compare the outcome from surgical repair and physiotherapy, 103 patients with symptomatic small and medium-sized tears of the rotator cuff were randomly allocated to one of the two approaches. The primary outcome measure was the Constant
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
There are no long-term published results on the survival of a third-generation cemented total shoulder replacement. We describe a clinical and radiological study of the Aequalis total shoulder replacement for a minimum of ten years. Between September 1996 and May 1998, 39 consecutive patients underwent a primary cemented total shoulder replacement using this prosthesis. Data were collected prospectively on all patients each year, for a minimum of ten years, or until death or failure of the prosthesis. At a follow-up of at least ten years, 12 patients had died with the prosthesis intact and two had emigrated, leaving 25 available for clinical review. Of these, 13 had rheumatoid arthritis and 12 osteoarthritis. One refused radiological review leaving 24 with fresh radiographs. Survivorship at ten years was 100% for the humeral component and 92% for the glenoid component. The incidence of lucent lines was low. No humeral component was thought to be at risk and only two glenoid components. The osteoarthritic group gained a mean 65° in forward flexion and their Constant
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
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
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
Transfer of pectoralis major has evolved as the most favoured option for the management of the difficult problem of irreparable tears of subscapularis. We describe our experience with this technique in 30 patients divided into three groups. Group I comprised 11 patients with a failed procedure for instability of the shoulder, group II included eight with a failed shoulder replacement and group III, 11 with a massive tear of the rotator cuff. All underwent transfer of the sternal head of pectoralis major to restore the function of subscapularis. At the latest follow-up pain had improved in seven of the 11 patients in groups I and III, but in only one of eight in group II. The subjective shoulder
Although the outcome of fractures of the distal radius is traditionally assessed using objective clinical variables such as grip strength and range of movement of the wrist, the extent to which they reflect function and outcomes of importance for the patient is uncertain. This may cause considerable inconsistencies in the assessment of outcome using current
We report the outcome of a modified Bankart procedure using suture anchors in 31 patients (31 shoulders) with a mean follow-up of 11 years (10 to 15). The mean age of the patients was 28 years (16 to 39). At follow-up, the mean Rowe
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
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
In a prospective randomised trial of calcifying tendinitis of the rotator cuff, we compared the efficacy of dual treatment sessions delivering 2500 extracorporeal shock waves at either high- or low-energy, via an electromagnetic generator under fluoroscopic guidance. Patients were eligible for the study if they had more than a three-month history of calcifying tendinitis of the rotator cuff, with calcification measuring 10 mm or more in maximum dimension. The primary outcome measure was the change in the Constant and Murley
We studied retrospectively the results of revision arthroplasty of the elbow using a linked Coonrad-Morrey implant in 23 patients (24 elbows) after a mean follow-up period of 55 months. According to the Mayo Elbow Performance
We describe the results of surgical treatment in a prospective study of 183 consecutive cases of subluxation (101) and dislocation (82) of the shoulder secondary to obstetric brachial plexus palsy between 1995 and 2000. Neurological recovery was rated ‘good’ or ‘useful’ in all children, whose lesions fell into groups 1, 2 or 3 of the Narakas classification. The mean age at operation was 47 months (3 to 204). The mean follow-up was 40 months (24 to 124). The mean gain in function was 3.6 levels (9.4 to 13) using the Mallet
We describe a method for stabilising the distal radioulnar joint using a double breasted slip of extensor retinaculum. This is a retrospective series of 30 patients with a painful wrist secondary to instability of the distal radioulnar joint. The results were assessed by a modified Mayo
Between 1990 and 1996 we performed 20 consecutive ulnohumeral arthroplasties for primary osteoarthritis of the elbow. The outcome was assessed using the Disabilities of Arm, Shoulder and Hand
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
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
We treated surgically 16 shoulders with an isolated traumatic rupture of the subscapularis tendon over a six-year period. Nine patients had a total and seven a partial tear of the subscapularis tendon. Repair was undertaken through a small deltopectoral groove approach. The mean Constant
The outcome of an anatomical shoulder replacement
depends on an intact rotator cuff. In 1981 Grammont designed a novel
large-head reverse shoulder replacement for patients with cuff deficiency.
Such has been the success of this replacement that it has led to
a rapid expansion of the indications. We performed a systematic
review of the literature to evaluate the functional outcome of each
indication for the reverse shoulder replacement. Secondary outcome
measures of range of movement, pain
In a prospective, randomised study on the repair of tears of the rotator cuff we compared the clinical results of two suture techniques for which different suture materials were used. We prospectively randomised 100 patients with tears of the rotator cuff into two groups. Group 1 had transosseous repair with No. 3 Ethibond using modified Mason-Allen sutures and group 2 had transosseous repair with 1.0 mm polydioxanone cord using modified Kessler sutures. After 24 to 30 months the patients were evaluated clinically using the Constant
We performed a double-blind, randomised controlled trial to assess the effectiveness of a continuous-infusion brachial plexus block with levobupivacaine compared with that of a standard single injection for the management of post-operative pain after surgery on the shoulder. Eight patients were randomised to receive a pre-operative brachial plexus block using 30 ml of levobupivacaine 0.5% with adrenaline 1:200 000 followed by insertion of a 20-gauge polyamide catheter. This was connected to a disposable elastometric pump, set immediately after surgery to administer a continuous flow of levobupivacaine 0.25% at a rate of 5 ml per hour. The other eight patients were randomised to receive only the initial injection of 30 ml. The study was double-blinded with the aid of sham catheters and clamped pumps. All patients were given regular paracetamol and were prescribed morphine through a patient-controlled analgesia pump. Motor and sensory block assessments, visual analogue scale pain
The different attributes of the Patient Evaluation Measure (PEM) questionnaire were investigated in 80 patients with a fracture of the scaphoid. Assessments were made at 2, 8, 12, 26 and 52 weeks. Reliability was assessed by measurement of the internal consistency of the different questions in 275 completed PEM forms. Cronbach’s alpha, which needs to lie between 0.7 and 0.9, was 0.9 for the PEM. Pain, tenderness, swelling, wrist movement and grip strength correlated with the PEM
Diabetes mellitus is recognised as a risk factor
for carpal tunnel syndrome. The response to treatment is unclear,
and may be poorer than in non-diabetic patients. Previous randomised
studies of interventions for carpal tunnel syndrome have specifically
excluded diabetic patients. The aim of this study was to investigate
the epidemiology of carpal tunnel syndrome in diabetic patients,
and compare the outcome of carpal tunnel decompression with non-diabetic
patients. The primary endpoint was improvement in the QuickDASH
score. The prevalence of diabetes mellitus was 11.3% (176 of 1564).
Diabetic patients were more likely to have severe neurophysiological
findings at presentation. Patients with diabetes had poorer QuickDASH
scores at one year post-operatively (p = 0.028), although the mean
difference was lower than the minimal clinically important difference
for this
We carried out a prospective, randomised controlled trial on two groups of 40 patients with painful calcific tendonitis and a mean age of 48.4 years (32.5 to 67.3). All were to undergo arthroscopic removal of the calcific deposit within six months after randomisation. The 40 patients in group I received ultrasound-guided needling followed by high-energy shock-wave therapy and the 40 in group II had shock-wave therapy alone. In both groups one treatment consisting of 2500 impulses of shock waves with an energy flux density of 0.36 mJ/mm. 2. was applied. The clinical and radiological outcome was assessed using the 100-point Constant shoulder
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
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
There are few reports in the literature of the diagnosis and treatment of the infected shoulder arthroplasty. Most deal with resection arthroplasty and two-stage exchange surgery. We present our results of one-stage exchange operation as treatment for the infected shoulder arthroplasty. Our group comprised 16 patients (ten men, six women) with 16 infected arthroplasties. By the time of follow-up, two patients had died (mean 5.8 years), two could not be located and three had already undergone revision surgery. Nine patients were thus available for clinical examination and assessment. The infections were largely caused by staphylococci, Propionibacterium species and streptococci. Two were early infections (within three months of surgery) and 14 were late infections. The mean follow-up was 5.8 years (13 months to 13.25 years) when the mean Constant-Murley
This is a prospective study of 107 repairs of obstetric brachial plexus palsy carried out between January 1990 and December 1999. The results in 100 children are presented. In partial lesions operation was advised when paralysis of abduction of the shoulder and of flexion of the elbow persisted after the age of three months and neurophysiological investigations predicted a poor prognosis. Operation was carried out earlier at about two months in complete lesions showing no sign of clinical recovery and with unfavourable neurophysiological investigations. Twelve children presented at the age of 12 months or more; in three more repair was undertaken after earlier unsuccessful neurolysis. The median age at operation was four months, the mean seven months and a total of 237 spinal nerves were repaired. The mean duration of follow-up after operation was 85 months (30 to 152). Good results were obtained in 33% of repairs of C5, in 55% of C6, in 24% of C7 and in 57% of operations on C8 and T1. No statistical difference was seen between a repair of C5 by graft or nerve transfer. Posterior dislocation of the shoulder was observed in 30 cases. All were successfully relocated after the age of one year. In these children the results of repairs of C5 were reduced by a mean of 0.8 on the Gilbert
Surgical repair of posterosuperior rotator cuff
tears has a poorer outcome and a higher rate of failure compared
with repairs of supraspinatus tears. In this prospective cohort
study 28 consecutive patients with an irreparable posterosuperior
rotator cuff tear after failed conservative or surgical treatment
underwent teres major tendon transfer. Their mean age was 60 years
(48 to 71) and the mean follow-up was 25 months (12 to 80). The
mean active abduction improved from 79° (0° to 150°) pre-operatively
to 105° (20° to 180°) post-operatively (p = 0.011). The mean active
external rotation in 90° abduction improved from 25° (0° to 70°)
pre-operatively to 55° (0° to 90°) post-operatively (p <
0.001).
The mean Constant
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
Lateral clavicular physeal injuries in adolescents
are frequently misinterpreted as acromioclavicular dislocations. There
are currently no clear guidelines for the management of these relatively
rare injuries. Non-operative treatment can result in a cosmetic
deformity, warranting resection of the non-remodelled original lateral
clavicle. However, fixation with Kirschner (K)-wires may be associated
with infection and/or prominent metalwork. We report our experience
with a small series of such cases. Between October 2008 and October 2011 five patients with lateral
clavicular physeal fractures (types III, IV and V) presented to
our unit. There were four boys and one girl with a mean age of 12.8
years (9 to 14). Four fractures were significantly displaced and
treated operatively using a tension band suture technique. One grade
III fracture was treated conservatively. The mean follow-up was
26 months (6 to 42). All patients made an uncomplicated recovery. The mean time to
discharge was three months. The QuickDASH
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
We report the effectiveness of revision of total
elbow replacement by re-cementing. Between 1982 and 2004, 53 elbows
in 52 patients were treated with re-cementing of a total elbow replacement
into part or all of the existing cement mantle or into the debrided
host-bone interface, without the use of structural bone augmentation
or a custom prosthesis. The original implant revision was still in
situ and functional in 42 of 53 elbows (79%) at a mean of
94.5 months (26 to 266) after surgery. In 31 of these 42 elbows
(74%) the Mayo Elbow Performance
The use of passive stretching of the elbow after
arthrolysis is controversial. We report the results of open arthrolysis in
81 patients. Prospectively collected outcome data with a minimum
follow-up of one year were analysed. All patients had sustained
an intra-articular fracture initially and all procedures were performed
by the same surgeon under continuous brachial plexus block anaesthesia
and with continuous passive movement (CPM) used post-operatively
for two to three days. CPM was used to maintain the movement achieved
during surgery and passive stretching was not used at any time.
A senior physiotherapist assessed all the patients at regular intervals.
The mean range of movement (ROM) improved from 69° to 109° and the
function and pain of the upper limb improved from 32 to 16 and from
20 to 10, as assessed by the Disabilities of the Arm Shoulder and
Hand
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
We have analysed the Constant-Murley (1987) assessment for 25 patients with shoulder pathology. We found the
We have developed a 12-item questionnaire for completion by patients presenting with shoulder instability. A prospective study of 92 patients was undertaken involving two assessments, approximately six months apart, performed in an outpatient department. Each patient completed the new questionnaire and the SF36 form. An orthopaedic surgeon completed the Constant shoulder
Ununited fractures of the scaphoid with extensive bone resorption are usually treated by bone grafting and internal fixation, using either an open or a minimally invasive technique. We studied the feasibility of percutaneous fixation without bone grafting in a consecutive series of 27 patients with established nonunion of an undisplaced fracture of the scaphoid and extensive local resorption of bone. They were treated by a single surgeon with rigid fixation alone, using a headless cannulated screw inserted through a volar percutaneous technique. Clinical examination, standard radiographs and CT confirmed that the fracture had united in all patients at a mean of 11.6 weeks (8 to 16), and that their functional
Objectives. Local corticosteroid infiltration is a common practice of treatment
for lateral epicondylitis. In recent studies no statistically significant
or clinically relevant results in favour of corticosteroid injections
were found. The injection of autologous blood has been reported
to be effective for both intermediate and long-term outcomes. It
is hypothesised that blood contains growth factors, which induce
the healing cascade. Methods. A total of 60 patients were included in this prospective randomised
study: 30 patients received 2 ml autologous blood drawn from contralateral
upper limb vein + 1 ml 0.5% bupivacaine, and 30 patients received
2 ml local corticosteroid + 1 ml 0.5% bupivacaine at the lateral
epicondyle. Outcome was measured using a pain
Operative release for entrapment of the suprascapular nerve was carried out in 35 patients. They were assessed at an average of 30 months (12 to 98) after operation using the functional shoulder
We compared the outcome of arthroscopic repair of the rotator cuff in 32 diabetic patients with the outcome in 32 non-diabetic patients matched for age, gender, size of tear and comorbidities. The Constant-Murley
Impingement syndrome in the shoulder has generally been considered to be a clinical condition of mechanical origin. However, anomalies exist between the pathology in the subacromial space and the degree of pain experienced. These may be explained by variations in the processing of nociceptive inputs between different patients. We investigated the evidence for augmented pain transmission (central sensitisation) in patients with impingement, and the relationship between pre-operative central sensitisation and the outcomes following arthroscopic subacromial decompression. We recruited 17 patients with unilateral impingement of the shoulder and 17 age- and gender-matched controls, all of whom underwent quantitative sensory testing to detect thresholds for mechanical stimuli, distinctions between sharp and blunt punctate stimuli, and heat pain. Additionally Oxford shoulder
We describe the clinical outcome of a technique of surgical augmentation of chronic massive tears of the rotator cuff using a polyester ligament (Dacron) in 21 symptomatic patients (14 men, seven women) with a mean age of 66.5 years (55.0 to 85.0). All patients had MRI and arthroscopic evidence of chronic massive tears. The clinical outcome was assessed using the Constant and Murley and patient satisfaction scores at a mean follow-up of 36 months (30 to 46). The polyester ligament (500 mm × 10 mm) was passed into the joint via the portal of Neviaser, medial to the tear through healthy cuff. The two ends of the ligament holding the cuff were passed through tunnels made in the proximal humerus at the footprint of the insertion of the cuff. The ligament was tied with a triple knot over the humeral cortex. All the patients remained free from pain (p <
0.001) with improvement in function (p <
0.001) and range of movement (p <
0.001). The mean pre-operative and post-operative Constant
Advanced osteoarthritis of the wrist or the distal articulation of the lunate with the capitate has traditionally been treated surgically by arthrodesis. In order to maintain movement, we performed proximal row carpectomy with capsular interposition arthroplasty as an alternative to arthrodesis in eight patients with advanced arthritis and retrospectively reviewed their clinical and radiographic outcomes after a mean follow-up of 41 months (13 to 53). The visual analogue scale (VAS) for pain at its worst and at rest, and the patient-rated wrist evaluation
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
Between 1995 and 2006, five intra-articular osteotomies of the head of the radius were performed in patients with symptomatic healed displaced articular fractures. Pre-operatively, all patients complained of persistent painful clicking on movement. Only patients with mild or no degenerative changes of the radial head and capitellum were considered for osteotomy. The operations were performed at a mean of 8.2 months (4 to 13) after injury and the patients were reviewed at a mean of 5.5 years (15 months to 12 years) after the osteotomy. The average Mayo Elbow Performance Index
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
We retrospectively reviewed 11 consecutive patients with an infected reverse shoulder prosthesis. Patients were assessed clinically and radiologically, and standard laboratory tests were carried out. Peroperative samples showed Propionbacterium acnes in seven, coagulase-negative Staphylococcus in five, methicillin-resistant staphylococcus aureus in one and Escherichia coli in one. Two multibacterial and nine monobacterial infections were seen. Post-operatively, patients were treated with intravenous cefazolin for at least three days and in all antibiotic therapy was given for at least three months. Severe pain (3 of 11) or severe limitation of function (3 of 11) are not necessarily seen. A fistula was present in eight, but function was not affected. All but one patient were considered free of infection after one-stage revision at a median follow-up of 24 months, and without antibiotic treatment for a minimum of six months. One patient had a persistent infection despite a second staged revision, but is now free of infection with a spacer. Complications included posterior dislocation in one, haematoma in one and a clavicular fracture in one. At the most recent follow-up the median post-operative Constant-Murley
We have compared the outcome of hemiarthroplasty of the shoulder in three distinct diagnostic groups, using survival analysis as used by the United Kingdom national joint registers, patient-reported outcome measures (PROMs) as recommended by Darzi in the 2008 NHS review, and transition and satisfaction questions. A total of 72 hemiarthroplasties, 19 for primary osteoarthritis (OA) with an intact rotator cuff, 22 for OA with a torn rotator cuff, and 31 for rheumatoid arthritis (RA), were followed up for between three and eight years. All the patients survived, with no revisions or dislocations and no significant radiological evidence of loosening. The mean new Oxford shoulder
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
Instability after arthroplasty of the shoulder
is difficult to correct surgically. Soft-tissue procedures and revision surgery
using unconstrained anatomical components are associated with a
high rate of failure. The purpose of this study was to determine
the results of revision of an unstable anatomical shoulder arthroplasty
to a reverse design prosthesis. Between 2004 and 2007, 33 unstable
anatomical shoulder arthroplasties were revised to a reverse design.
The mean age of the patients was 71 years (53 to 86) and their mean
follow-up was 42 months (25 to 71). The mean time to revision was
26 months (4 to 164). Pain
We reviewed 80 shoulders (77 patients) at a mean follow-up of 44 months after insertion of a Grammont inverted shoulder prosthesis. Three implants had failed and had been revised. The mean Constant
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
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
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)
After establishing anatomical feasibility, functional reconstruction to replace the anterolateral part of the deltoid was performed in 20 consecutive patients with irreversible deltoid paralysis using the sternoclavicular portion of the pectoralis major muscle. The indication for reconstruction was deltoid deficiency combined with massive rotator cuff tear in 11 patients, brachial plexus palsy in seven, and an isolated axillary nerve lesion in two. All patients were followed clinically and radiologically for a mean of 70 months (24 to 125). The mean gender-adjusted Constant
We performed eight osteochondral autologous transplantations from the knee joint to the shoulder. All patients (six men, two women; mean age 43.1 years) were documented prospectively. In each patient the stage of the osteochondral lesion was Outerbridge grade IV with a mean size of the affected area of 150 mm. 2. All patients were assessed by using the Constant
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
The results of proximal humeral replacement following trauma are substantially worse than for osteoarthritis or rheumatoid arthritis. The stable reattachment of the lesser and greater tuberosity fragments to the rotator cuff and the restoration of shoulder biomechanics are difficult. In 1992 we developed a prosthesis designed to improve fixation of the tuberosity fragments in comminuted fractures of the proximal humerus. The implant enables fixation of the fragments to the shaft of the prosthesis and the diaphyseal fragment using screws, washers and a special toothed plate. Between 1992 and 2003 we used this technique in 50 of 76 patients referred to our institution for shoulder reconstruction after trauma. In the remaining 26, reconstruction with a prosthesis and nonabsorbable sutures was performed, as the tuberosity fragments were too small and too severely damaged to allow the use of screws and the toothed plate. The Constant
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