We have examined the
We investigated the effect of delay before nerve repair on neuropathic pain after injury to the brachial plexus. We studied 148 patients, 85 prospectively and 63 retrospectively. The mean number of avulsed spinal nerves was 3.2 (1 to 5). Pain was measured by a linear visual analogue scale and by the peripheral nerve injury scale. Early repair was more effective than delayed repair in the
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
The integrity of the spinal accessory nerve is fundamental to thoracoscapular function and essential for scapulohumeral rhythm. This nerve is vulnerable along its superficial course. This study assessed the delay in diagnosis and referral for management of damage to this nerve, clarified its anatomical course and function, and documented the results of repair. From examination of our records, 111 patients with lesions of the spinal accessory nerve were treated between 1984 and 2007. In 89 patients (80.2%) the damage was iatropathic. Recognition and referral were seldom made by the surgeon responsible for the injury, leading to a marked delay in instituting treatment. Most referrals were made for painful loss of shoulder function. The clinical diagnosis is straightforward. There is a characteristic downward and lateral displacement of the scapula, with narrowing of the inferior scapulohumeral angle and loss of function, with pain commonly present. In all, 80 nerves were explored and 65 were repaired. The course of the spinal accessory nerve in relation to the sternocleidomastoid muscle was constant, with branches from the cervical plexus rarely conveying motor fibres. Damage to the nerve was predominantly posterior to this muscle. Despite the delay, the results of repair were surprising, with early
Linburg-Comstock syndrome is characterised by an anomalous tendon slip from the flexor pollicis longus to the flexor digitorum profundus, usually of the index finger. An incidence as high as 60% to 70% has been reported. Post-traumatic inflammation of inter-tendinous connections between the flexor pollicis longus and flexor digitorum profundus, usually of the index finger, may cause unexplained chronic pain in the distal forearm. A total of 11 patients (eight females, three males), mean age 29.1 years (14 to 47) with a clinical diagnosis of Linburg-Comstock syndrome underwent surgical release of the inter-tendinous connection. The mean follow-up was for 27 months (2 to 48). Ten patients reported excellent
Replacement of the shoulder in juvenile idiopathic arthritis is not often performed and there have been no published series to date. We present nine glenohumeral hemiarthroplasties in eight patients with systemic or polyarticular juvenile idiopathic arthritis. The mean follow-up was six years (59 to 89 months). The mean age at the time of surgery was 32 years. Surgery took place at a mean of 27 years after diagnosis. The results indicated excellent
The Acclaim total elbow replacement is a modular system which allows implantation in both unlinked and linked modes. The results of the use of this implant in primary total elbow replacement in 36 patients, operated on between July 2000 and August 2002, are presented at a mean follow-up of 36 months (24 to 49). Only one patient did not have good
Between 1976 and 2004, 38 revision arthroplasties (35 patients) were performed for aseptic loosening of the humeral component. The mean interval from primary arthroplasty to revision was 7.1 years (0.4 to 16.6). A total of 35 shoulders (32 patients) were available for review at a mean follow-up of seven years (2 to 19.3). Pre-operatively, 34 patients (97%) had moderate or severe pain; at final follow-up, 29 (83%) had no or only mild pain (p <
0.0001). The mean active abduction improved from 88° to 107° (p <
0.01); and the mean external rotation from 37° to 46° (p = 0.27). Excellent or satisfactory results were achieved in 25 patients (71%) according to the modified Neer rating system. Humeral components were cemented in 29, with ingrowth implants used in nine cases. There were 19 of standard length and 17 were longer (two were custom replacements and are not included). Bone grafting was required for defects in 11 humeri. Only two glenoid components were left unrevised. Intra-operative complications included cement extrusion in eight cases, fracture of the shaft of the humerus is two and of the tuberosity in four. There were four re-operations, one for recurrent humeral loosening, with 89% survival free of re-operations at ten years. Revision surgery for aseptic loosening of the humeral component provides reliable pain
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 scores were 46.7 (39.0 to 61.0) and 85.4 (52.0 to 96.0), respectively (p <
0.001). The mean patient satisfaction score was 90%. There were two failures, one due to a ruptured ligament after one year and the other due to deep-seated infection. The MR scan at the final follow-up confirmed intact and thickened bands in 15 of 17 patients. This technique of augmentation gives consistent
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
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
This is a retrospective review of the results of the Acclaim total elbow replacement in 11 older patients aged ≥ 65 years with primary osteoarthritis of the elbow, with a mean follow-up of 57.6 months (30 to 86.4). Significant reductions in pain and improvement in range of movement and function were recorded. Radiological review revealed two patients with 1 mm lucencies in a single zone, and one patient with 1 mm lucencies in two zones. No components required revision. There were no deep infections, dislocations or mechanical failures. Complications included one intra-operative medial condylar fracture and one post-operative transient ulnar neuropathy, which resolved. This study demonstrates that the Acclaim prosthesis provides good symptomatic
We describe the results of Copeland surface replacement shoulder arthroplasty using the mark III prosthesis in patients over 80 years of age. End-stage arthritis of the shoulder is a source of significant pain and debilitating functional loss in the elderly. An arthroplasty offers good
We describe 20 patients, aged between 43 and 88 years, with delayed nerve palsy or deepening of an initial palsy caused by arterial injury from low-energy injuries to the shoulder. The onset of palsy ranged from immediately after the injury to four months later. There was progression in all the patients with an initial partial nerve palsy. Pain was severe in 18 patients, in 16 of whom it presented as neurostenalgia and in two as causalgia. Dislocation of the shoulder or fracture of the proximal humerus occurred in 16 patients. There was soft-tissue crushing in two and prolonged unconsciousness from alcoholic intoxication in another two. Decompression of the plexus and repair of the arterial injury brought swift
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 score (maximum 100) before the operation was 47.21 and improved to 79.92 (p <
0.001). The mean pain score (maximum 50) improved from 21.41 to 46.70 (p <
0.001) and the mean functional component of the score (maximum 30) from 11.19 to 18.65 (p <
0.001). There was negligible change in the score for the range of movement although a significant improvement in mean flexion from 124° to 136° was noted (p <
0.001). Revision surgery was required in four patients, for dislocation, wound dehiscence and early infection in one, late infection in two and aseptic loosening in one. The cumulative survival was 75% at nine years for all causes of failure and 97% at ten years for aseptic loosening alone. Our study demonstrates the value of the Souter-Strathclyde total elbow arthroplasty in providing
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 Score, 19 elbows were satisfactory, nine were excellent and ten good. The median total score had improved from 35 points (20 to 75) before the primary arthroplasty to 85 points (40 to 100) at the latest follow-up. There was a marked
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
We report the use of a free vascularised iliac bone graft in the treatment of 21 patients (19 men and 2 women) with an avascular nonunion of the scaphoid in which conventional bone grafting had previously failed. The mean age of the patients was 32 years (23 to 46) and the dominant wrist was affected in 14. The mean interval from fracture to the vascularised bone grafting was 39 months (9 to 62). Pre-operative MRI showed no contrast enhancement in the proximal fragment in any patient. Fracture union was assessed radiologically or with CT scans if the radiological appearances were inconclusive. At a mean follow-up of 5.6 years (2 to 11) union was obtained in 16 patients. The remaining five patients with a persistent nonunion continued to experience pain, reduced grip strength and limited range of wrist movement. In the successfully treated patients the grip strength and range of movement did not recover to match the uninjured side. Prevention of progressive carpal collapse, the absence of donor site morbidity, good subjective results and pain
The Souter-Strathclyde prosthesis was used in 52 revisions of total elbow replacements (TERs) between August 1986 and May 1997. Of these, 50, carried out in 45 patients, were prospectively followed for a mean of 53 months (14 to 139). The procedure produced reliable
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
We have carried out a retrospective review of 11 Souter-Strathclyde primary total elbow arthroplasties in ten patients with osteoarthritis, over a period of nine years. The diagnosis was primary osteoarthritis in nine elbows and post-traumatic arthritis in two. The mean follow-up was 68 months (15 to 117). Although no patient was symptomatic, radiological review revealed evidence of loosening affecting three humeral and two ulnar components, one of which subsequently failed and was revised at 97 months. There were no dislocations, deep infections or mechanical failures. Complications included two superficial wound infections and two neurapraxias of the ulnar nerve which resolved. This study shows that the unlinked Souter-Strathclyde total elbow arthroplasty can be considered for patients with osteoarthritis and gives good symptomatic
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
Arthrodesis of the wrist is a standard operation which is indicated for severe rheumatoid arthritis in which destruction is too advanced for more conservative procedures, or after failure of previous surgery. We have developed an L-shaped plate designed for this purpose. It provides rigid internal fixation with the wrist in the neutral position and utilises bone grafts obtained from the distal ulna and the carpal bones. We have carried out 29 successful fusions between 1992 and 1995. In all 29 patients synovectomy and resection of the head of the ulna were performed; 11 also had reconstruction of ruptured extensor tendons. All the patients obtained bony union, pain
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
We report a prospective study of the effects of extracorporeal shock-wave therapy in 195 patients with chronic calcifying tendinitis. In part A 80 patients with chronic symptoms were randomly assigned to a control and three subgroups which had different treatment by low-energy and high-energy shock waves. In part B 115 patients had either one or two high-energy sessions. We recorded subjective, functional and radiological findings at six months after treatment. The results showed energy-dependent success, with
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
Between 1986 and 1994, 13 patients with mobile painful arthritic elbows were treated by distraction interposition arthroplasty using fascia lata. The mean period of follow-up was 63 months. An elbow distractor/fixator was applied for three to four weeks to separate the articular surfaces and to protect the fascial graft. Nine of the 13 patients (69%) had satisfactory
We studied 57 patients with isolated lunotriquetral injuries treated by arthrodesis, direct ligament repair, or ligament reconstruction. The outcomes were compared by using written questionnaires, the Disabilities of the Arm, Shoulder and Hand (DASH) score, range of movement, strength, morbidity and rates of reoperation. Isolated lunotriquetral injury was confirmed by arthroscopy or arthrotomy. The mean age of the patients was 30.7 years (15.4 to 53.7) and the injuries were subacute or chronic in 98.2%. Eight patients underwent lunotriquetral reconstruction using a distally-based strip of the tendon of extensor carpi ulnaris, 27 had lunotriquetral repair and 22 had lunotriquetral arthrodesis. The mean follow-up was 9.5 years (2 to 22). The probability of remaining free from complications at five years was 68.6% for reconstruction, 13.5% for repair, and less than 1% for arthrodesis. Of the lunotriquetral arthrodeses, 40.9% developed nonunion and 22.7% developed ulnocarpal impaction. The probability of not requiring further surgery at five years was 68.6% for reconstruction, 23.3% for repair and 21.8% for arthrodesis. The DASH scores for each group were not significantly different. Objective improvements in strength and movement, subjective indicators of pain
We have reviewed 66 consecutive Souter-Strathclyde arthroplasties of the elbow implanted in 59 patients between 1982 and 1993. Thirteen patients (15 elbows) (19.6%) died. Sixteen elbows (24.2%) were revised, six for aseptic loosening (9%), four (6%) because of fracture or loosening after a fracture, three (4.5%) for infection and three (4.5%) for dislocation. Four patients refused to attend for review. In 33 elbows with a follow-up of 93 months (60 to 167) complete
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. 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 score and Nirschl
staging of lateral epicondylitis. Follow-up was continued for total
of six months, with assessment at one week, four weeks, 12 weeks
and six months.Objectives
Methods
The purpose of this study was to compare the
outcome and complications of endoscopic We conclude that endoscopic release for de Quervain’s tenosynovitis
seems to provide earlier improvement after surgery, with fewer superficial
radial nerve complications and greater scar satisfaction, when compared
with open release. Cite this article:
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 score improved from 43 (18 to 78) pre-operatively
to 65 (30 to 86) post-operatively (p <
0.001). The median post-operative
VAS (0 to 100) for pain decreased from 63 (0 to 96) pre-operatively to
5 (0 to 56) post-operatively (p <
0.001). In conclusion, teres major transfer effectively restores function
and relieves pain in patients with irreparable posterosuperior rotator
cuff tears and leads to an overall clinical improvement in a relatively
young and active patient group with limited treatment options. Cite this article:
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 score and a visual analogue scale, respectively. The greatest
improvement was obtained in the stiffest elbows: nine patients with
a pre-operative ROM <
30° achieved a mean post-operative ROM
of 92° (55° to 125°). This study demonstrates that in patients with
a stiff elbow after injury, good results may be obtained after open
elbow arthrolysis without using passive stretching during rehabilitation.
Like athletes, musicians are vulnerable to musculoskeletal
injuries that can be career ending or have a severe negative financial
impact. All ages are affected, with a peak incidence in the third
and fourth decades. Women are slightly more likely to be affected
than men. It is incumbent upon orthopaedic surgeons to be able to
complete a thorough physical assessment, be aware of the risk factors
associated with musculoskeletal symptoms in musicians, and have
a detailed knowledge of the specific syndromes they suffer and their
appropriate treatment. In this paper we review the common hand injuries that afflict
musicians and discuss their treatment. Cite this article:
The sternoclavicular joint (SCJ) is a pivotal
articulation in the linked system of the upper limb girdle, providing
load-bearing in compression while resisting displacement in tension
or distraction at the manubrium sterni. The SCJ and acromioclavicular
joint (ACJ) both have a small surface area of contact protected
by an intra-articular fibrocartilaginous disc and are supported
by strong extrinsic and intrinsic capsular ligaments. The function
of load-sharing in the upper limb by bulky periscapular and thoracobrachial
muscles is extremely important to the longevity of both joints.
Ligamentous and capsular laxity changes with age, exposing both
joints to greater strain, which may explain the rising incidence
of arthritis in both with age. The incidence of arthritis in the
SCJ is less than that in the ACJ, suggesting that the extrinsic
ligaments of the SCJ provide greater stability than the coracoclavicular
ligaments of the ACJ. Instability of the SCJ is rare and can be difficult to distinguish
from medial clavicular physeal or metaphyseal fracture-separation:
cross-sectional imaging is often required. The distinction is important
because the treatment options and outcomes of treatment are dissimilar,
whereas the treatment and outcomes of ACJ separation and fracture
of the lateral clavicle can be similar. Proper recognition and treatment
of traumatic instability is vital as these injuries may be life-threatening.
Instability of the SCJ does not always require surgical intervention.
An accurate diagnosis is required before surgery can be considered,
and we recommend the use of the Stanmore instability triangle. Most
poor outcomes result from a failure to recognise the underlying
pathology. There is a natural reluctance for orthopaedic surgeons to operate
in this area owing to unfamiliarity with, and the close proximity
of, the related vascular structures, but the interposed sternohyoid
and sternothyroid muscles are rarely injured and provide a clear
boundary to the medial retroclavicular space, as well as an anatomical
barrier to unsafe intervention. This review presents current concepts of instability of the SCJ,
describes the relevant surgical anatomy, provides a framework for
diagnosis and management, including physiotherapy, and discusses
the technical challenges of operative intervention. Cite this article:
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.
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 score improved significantly after surgery, whereas ranges of movement and grip strength were maintained at the pre-operative levels. Progression of arthritis in the radiocapitate joint was observed in three patients, but their outcomes were not significantly different from those without progression of arthritis. Proximal row carpectomy with capsular interposition arthroplasty is a reasonable option for the treatment of patients with advanced arthritis of the wrist.
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 score. No patients required revision. In one a tear of the supraspinatus tendon occurred. Overall, 20 patients (95%) were either very satisfied (n = 18) or satisfied (n = 2) with the outcome. Significant differences (p <
0.0001) were found for all categories of the Constant and Murley score pre- and post-operatively. The mean Constant and Murley score increased from 24.1 points (10 to 45) to 64.5 points (39 to 93), and the relative score from 30.4% (11% to 50%) to 83% (54% to 116%). No clinical or radiological signs of loosening of the implant were seen. For young and middle-aged patients with osteoarthritis, third-generation total shoulder replacement is a viable method of treatment with a low rate of complications and excellent results in the mid-term.
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 score improved from a mean of 49.2 (24 to 80) pre-operatively to 60.8 (34 to 95) post-operatively (p = 0.0006) in the diabetic patients, and from 46.4 (23 to 90) pre-operatively to 65.2 (25 to 100) post-operatively (p = 0.0003) in the non-diabetic patients at six months. This was significantly greater (p = 0.0002) in non-diabetic patients (18.8) than in diabetics (11.6). There was no significant change in the mean mental component of the Short-Form 12, but the mean physical component increased from 35 to 41 in non-diabetics (p = 0.0001), and from 37 to 39 (p = 0.15) in diabetics. These trends were observed at one year. Patients with diabetes showed improvement of pain and function following arthroscopic rotator cuff repair in the short term, but less than their non-diabetic counterparts.
Contracture of the collateral ligaments is considered to be an important factor in post-traumatic stiffness of the elbow. We reviewed the results of isolated release of the medial collateral ligament in a series of 14 patients with post-traumatic loss of elbow flexion treated between 1998 and 2002. There were nine women and five men with a mean age of 45 years (17 to 76). They were reviewed at a mean follow-up of 25 months (9 to 48). The operation was performed through a longitudinal posteromedial incision centred over the ulnar nerve. After decompression of the ulnar nerve, release of the medial collateral ligament was done sequentially starting with the posterior bundle and the transverse component of the ligament, with measurement of the arc of movement after each step. If full flexion was not achieved the posterior half of the anterior bundle of the medial collateral ligament was released. At the latest follow-up, the mean flexion of the elbow improved significantly from 96° (85° to 115°) pre-operatively to 130° (110° to 150°) at final follow-up (p = 0.001). The mean extension improved significantly from 43° (5° to 90°) pre-operatively to 22° (5° to 40°) at final follow-up (p = 0.003). There was a significant improvement in the functional outcome. The mean Broberg and Morrey score increased from a mean of 54 points (29.5 to 85) pre-operatively to 87 points (57 to 99) at final follow-up (p <
0.001). All the patients had normal elbow stability. Our results indicate that partial surgical release of the medial collateral ligament is associated with improved range of movement of the elbow in patients with post-traumatic stiffness, but was less effective in controlling pain.
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 score improved in seven patients in group I, in one in group II and in six in group III. The mean Constant score improved from 40.9 points (28 to 50) in group I, 32.9 (17 to 47) in group II and 28.7 (20 to 42) in group III pre-operatively to 60.8 (28 to 89), 41.9 (24 to 73) and 52.3 (24 to 78), respectively. Failure of the tendon transfer was highest in group II and was associated with pre-operative anterior subluxation of the humeral head. We conclude that in patients with irreparable rupture of subscapularis after shoulder replacement there is a high risk of failure of transfer of p?ctoralis major, particularly if there is pre-operative anterior subluxation of the humeral head.
Frozen shoulder is commonly encountered in general
orthopaedic practice. It may arise spontaneously without an obvious
predisposing cause, or be associated with a variety of local or
systemic disorders. Diagnosis is based upon the recognition of the
characteristic features of the pain, and selective limitation of
passive external rotation. The macroscopic and histological features
of the capsular contracture are well-defined, but the underlying
pathological processes remain poorly understood. It may cause protracted
disability, and imposes a considerable burden on health service
resources. Most patients are still managed by physiotherapy in primary
care, and only the more refractory cases are referred for specialist
intervention. Targeted therapy is not possible and treatment remains predominantly
symptomatic. However, over the last ten years, more active interventions
that may shorten the clinical course, such as capsular distension
arthrography and arthroscopic capsular release, have become more popular. This review describes the clinical and pathological features
of frozen shoulder. We also outline the current treatment options,
review the published results and present our own treatment algorithm.
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 scores improved significantly (pre-operative
visual analogue scale (VAS) of 7.2 ( Cite this article:
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 Score, the Simple Shoulder Test and a visual analogue scale. All the scores improved and there was no loosening, no polyethylene-glenoid disassembly and no other implant-related complications. We conclude that a metal-backed glenoid component is a good option in total shoulder replacement with no worse results than of those using a cemented all-polyethylene prosthesis.
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 score was 58.5; this was reduced to 53 points with the further follow-up. A total of 23 patients (63%) had radiological evidence of loosening of the glenoid component. Nevertheless, only one patient had aseptic loosening of the baseplate at 12 years’ follow-up. The reduction in the mean Constant score with longer follow-up and the further development of scapular notching is worrying. New developments in design, bearing surfaces and surgical technique, and further follow-up, will determine whether reverse shoulder arthroplasty has a place in the management of complex proximal humeral fractures in the elderly.
This study evaluates the position of the long
head of biceps tendon using ultrasound following simple tenotomy,
in patients with arthroscopically repaired rotator cuff tears. In total, 52 patients with a mean age of 60.7 years (45 to 75)
underwent arthroscopic repair of the rotator cuff and simple tenotomy
of the long head of biceps tendon. At two years post-operatively,
ultrasound revealed that the tendon was inside the bicipital groove
in 43 patients (82.7%) and outside in nine (17.3%); in six of these
it was lying just outside the groove and in the remaining three
(5.8%) it was in a remote position with a positive Popeye Sign.
A dynamic ultrasound scan revealed that the tenotomised tendons
had adhered to the surrounding tissues (autotenodesis).The initial
condition of the tendon influenced its final position (p <
0.0005).
The presence of a Popeye sign was statistically influenced by the
pre-operative co-existence of supraspinatus and subscapularis tears (p
<
0.0001). It appears that the natural history of the tenotomised long head
of biceps tendon is to tenodese itself inside or just outside the
bicipital groove, while its pre-operative condition and coexistent
subscapularis tears play a significant role in the occurrence of
a Popeye sign.
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.
The Motec cementless modular metal-on-metal ball-and-socket
wrist arthroplasty was implanted in 16 wrists with scaphoid nonunion
advanced collapse (SNAC; grades 3 or 4) and 14 wrists with scapholunate
advanced collapse (SLAC) in 30 patients (20 men) with severe (grades
3 or 4) post-traumatic osteoarthritis of the wrist. The mean age of
the patients was 52 years (31 to 71). All prostheses integrated
well radiologically. At a mean follow-up of 3.2 years (1.1 to 6.1)
no luxation or implant breakage occurred. Two wrists were converted
to an arthrodesis for persistent pain. Loosening occurred in one
further wrist at five years post-operatively. The remainder demonstrated close
bone–implant contact. The clinical results were good, with markedly
decreased Disabilities of the Arm Shoulder and Hand (DASH) and pain
scores, and increased movement and grip strength. No patient used
analgesics and most had returned to work. Good short-term function was achieved using this wrist arthroplasty
in a high-demand group of patients with post-traumatic osteoarthritis.
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.
Bone loss involving articular surface is a challenging
problem faced by the orthopaedic surgeon. In the hand and wrist,
there are articular defects that are amenable to autograft reconstruction
when primary fixation is not possible. In this article, the surgical
techniques and clinical outcomes of articular reconstructions in
the hand and wrist using non-vascularised osteochondral autografts
are reviewed.