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Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_III | Pages 332 - 332
1 Sep 2005
Maritz N Ligthelm L Lourens P Buys S Moolman Z
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Introduction and Aims: To establish how effective conservative treatment is for rotator cuff impingement. To look at the clinical presentation and the factors that influences the outcome. Method: A retrospective study of 189 patients, who attended the Upper Limb Clinic, was done. The response to physiotherapy and cortisone injections was noted. We also looked at the shape of the acromion and tried to correlate it with effectiveness of conservative treatment. Results: All patients had either a positive Neer or Hawkins sign. What is more significant is that in 123 patients internal rotation was markedly restricted to the 10. th. dorsal vertebrae or less. One hundred and nineteen patients received a sub-acromial cortisone injection. It was repeated in 52 patients, and 25 patients received a third injection. Forty-four patients needed surgery. Therefore, conservative treatment was effective in 83% of cases. Of the group who was operated on, only nine patients had a large spur and only 12 patients had a Bigliani Type-III acromion. It does not seem as if the spur is the main cause for impingement. Conclusion: Conservative treatment is very effective in the treatment of rotator cuff impingement. However, we believe that the right exercise program is of essence. Stretching the posterior capsule of the shoulder joint and increasing the internal rotation, which are the two most important initial exercises, should be concentrated on. Thereafter the depressor muscles, like sub-scapularis and infra-spinatus must be strengthened


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_13 | Pages 14 - 14
1 Nov 2015
Romeo A
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Total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) are excellent surgical options for individuals with shoulder arthritis, providing good to excellent results in the vast majority of patients. Complications are rare, but can be devastating for both the patient and surgeon. An uncommon, but extremely problematic complication following shoulder arthroplasty is shoulder stiffness. While substantial literature discussing post-arthroplasty stiffness is available for other joints such as the hip, knee, and elbow, there is a paucity of research available discussing this complication in the shoulder. As noted in multiple reviews, diminished range of motion following TSA or RSA may be due to a number of factors, including pre-operative diagnosis of proximal humerus fracture, inadequate post-operative rehabilitation, implant-related factors such as malpositioning and/or inappropriate-sized implants, and heterotopic ossification. Often, pathology leading to post-arthroplasty stiffness involves scarring of the long head of the biceps tendon, rotator cuff impingement, as well as cuff tendonitis. Periprosthetic joint infection (PJI) is also important to recognise, and may be difficult to diagnose, especially in cases of Propionibacterium acnes infections. Importantly, PJI may present with stiffness as well as instability, and thus a high index of suspicion with a low threshold to aspirate is necessary in these challenging patients. Treatment of patients with stiffness following arthroplasty is challenging, and may involve arthroscopic intervention with or without manipulation, as well as manipulation under anesthesia alone. This paper will discuss the etiology, work-up, and treatment of patients with shoulder stiffness following TSA and RSA


Orthopaedic Proceedings
Vol. 84-B, Issue SUPP_I | Pages - 89
1 Mar 2002
Viljoen J Osman S
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Two surgeons performed arthroscopic subacromial decompression (ASD) on 302 shoulders between January 1995 and January 1999. The mean age of patients was 49.6 years (28 to 81). The mean follow-up period was 36 months (4 to 62). Evaluated using the modified UCLA scoring system, 91% of patients had a good to excellent result at short-term follow-up. However, patients reviewed for two years or longer showed a 98% successful outcome. The commonest delay in improvement was stiffness, with six patients requiring surgical intervention. Early mobilisation with posterior capsular stretching is recommended. Careful clinical assessment of patients with chronic rotator cuff impingement and accurate identification of arthroscopic impingement signs ensures a successful outcome. Our study confirms other reports that ASD leads to good results in carefully selected patients


Orthopaedic Proceedings
Vol. 84-B, Issue SUPP_I | Pages 78 - 78
1 Mar 2002
Viljoen J
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From January 1995 to January 1999, the author performed arthroscopic subacromial decompression (ASD) on 220 patients. The mean age of patients was 47.4 years (28 to 72). The follow-up period ranged from 4 to 60 months. The modified UCLA scoring system was used to evaluate patients at four months and again at 24 to 60 months. At short-term follow-up, 91% of patients achieved good to excellent results. However, patients reviewed for two years or longer showed a 98% successful outcome. Stiffness was commonly the last thing to improve, and three patients required surgical intervention. Early mobilisation with posterior capsular stretching is recommended. Careful clinical assessment of patients with chronic rotator cuff impingement and accurate identification of arthroscopic impingement signs ensures a successful outcome. This study confirms other reports that ASD produces good results in carefully-selected patients


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_1 | Pages 9 - 9
1 Jan 2014
Jayakumar P Hartmann C Eastwood D
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Aim. To review the natural history of upper limb osteochondromas and assess their functional effect. Materials. We performed a retrospective casenote review of a consecutive patient cohort presenting between 1997–2012 with upper limb osteochondromas. Indications for surgical intervention were noted and considered to be cosmetic, functional (including pain relief) and ‘prophylactic’ in terms of deformity prevention. All patients were invited to complete questionnaires for the PODCI, DASH, OSS and MHS scores. Results. We identified 102 patients (62 male: 40 female; mean age = 13.3 years; range 3–31 years). 84 patients had multiple exostoses whilst 18 had a solitary lesion. 52 patients had shoulder girdle involvement (scapula, clavicle and proximal humerus), 51 forearm (Masada I (n=31) Masada II (n=9) Masada III (n=11)), and 38 hand involvement. 46/102 patients had concurrent lower limb lesions. 56 operative procedures were performed primarily for functional benefit. Shoulder girdle procedures (n=21) improved pressure related pain, scapular pseudowinging/dyskinesia and cuff impingement. Forearm procedures (n=35) were performed for functional and prophylactic reasons and involved excision with ulnar lengthening and radial deformity correction (n=15, Masada I), realignment osteotomy or radial head excision for subluxation (n=7, Masada II) and excision with internal fixation of concomitant osteotomy (n=13, Masada I/III). No hand surgery was performed. Radial head dislocations are associated with large ulnar lesions causing shortening > 0.15 total ulnar length. Osteochondromas of the upper limb are generally well tolerated: functional effects were most commonly present in lesions involving the forearm but significant patient benefit was noted following shoulder girdle procedures. The scoring systems used failed to discriminate well between the various procedures used and the perceived benefit. Conclusion:. Patient outcomes are related to surgical indications. Currently available PROMs are either inappropriate Qs (DASH) and/or non-validated (OSS, MHS) and/or non-specific (PODCI*) only 8 parameters for the upper extremity. Better-validated measures may be required. Level of evidence: IV


Orthopaedic Proceedings
Vol. 85-B, Issue SUPP_II | Pages 143 - 143
1 Feb 2003
Maritz N Ligthelm L Lourens P Buys S Moolman Z
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Our retrospective study of 189 patients aimed to establish the efficacy of conservative treatment for rotator cuff impingement and also to assess the clinical presentation and the factors that influence the outcome. We noted patients’ response to physiotherapy and cortisone injections. We looked at the shape of the acromion and tried to correlate it with effectiveness of conservative treatment. All patients had either a positive Neer or Hawkins sign. In 123 patients internal rotation was markedly restricted. Subacromial cortisone injections were administered to 119 patients. The injection was repeated once in 52 patients and twice in 25. Surgery was necessary in 44 patients. In other words, conservative treatment was effective in 83%. Only 12 of the patients who underwent surgery had a Bigliani type-III acromion and only nine had a large spur. An appropriate exercise programme is critical if conservative treatment is to be effective. It should focus first on stretching the posterior capsule of the shoulder joint and increasing internal rotation, and subsequently on strengthening the subscapularis and infraspinatus muscles. We believe it is the imbalance of muscle power rather than the acromial spur that is the major cause of impingement


Orthopaedic Proceedings
Vol. 84-B, Issue SUPP_I | Pages - 90
1 Mar 2002
de Beer J van Rooyen K Harvie R
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Painful conditions of the acromioclavicular (AC) joint are common in South Africa, particularly among sportsmen. These conditions are often treated by open excision of the distal end of the clavicle, but an arthroscopic procedure offers many advantages. From February 1994 to February 2000, we performed 138 procedures. The mean age of patients ({71% men and 29% women) was 29 years (19 to 53). In cases of rotator cuff impingement, arthroscopic acromioplasty was followed by clavicular excision via the subacromial route. With a normal acromion and rotator cuff the AC joint was approached through two superior AC portals, avoiding removal of the AC ligaments. In all cases a standard 3.5-mm arthroscope was placed in one portal for viewing and the mechanical shaver inserted through the other. About 7 mm to 8mm of bone was removed from the clavicle. Patients were in hospital for about a day and 87% were discharged the same day. The mean follow-up time was 34 months (2 months to 4 years). Patient satisfaction was high in 32%, fair in 60% and poor in 8%. Most patients (92%) returned to all previous sports and activities. We concluded that the arthroscopic Mumford procedure is at least as successful as its open equivalent. It can be done as an outpatient procedure and permits a rapid return to activities. Cosmesis is excellent and stability of the AC joint is preserved


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_11 | Pages 175 - 175
1 Jul 2014
Razmjou H Gunnis G Holtby R
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Summary. Data of 663 patients with three different pathologies were examined. We found that using patients with significant symptoms and functional difficulty in the opposite shoulder will not bias the results of observational studies if outcomes are based on routine disability measures such as ASES or Constant-Murley scores. Introduction. Recently, using patients with bilateral limb problems as independent cases has raised concerns in orthopaedic research due to violating the assumption of independence. If observations are too similar in characteristics, they become highly correlated which leads to lowering the variance and biasing the results. Type of pathology (impingement, cuff tear, osteoarthritis) and aging are expected to affect the incidence of bilateral shoulder complaints and should be considered when examining potential bias in this area. In addition, the impact of dominant side pathology has not been investigated primarily in patients with shoulder problems. The objectives of this study were: 1) to examine the incidence of bilateral shoulder complaints and pathology on the dominant side in patients with impingement syndrome, rotator cuff tear and osteoarthritis of the glenohumeral joint, 2) to explore the role of sex and age in developing bilateral shoulder complaints, and 3) to examine the impact of bilaterality and hand dominance on pre and one year post-operative disability. Patients and Methods. This study involved review of data of patients with a diagnosis of impingement syndrome, rotator cuff tears and osteoarthritis (OA) of the gleno-humeral joint who had undergone surgery and had returned for their one year follow-up. Two outcome measures were used; the American Shoulder & Elbow Surgeons (ASES) and the Constant Murley score (CMS). Results. Data of 663 patients (317 females; 269 impingement syndrome, 290 rotator cuff tear, 104 osteoarthritis) were included in the analysis. There was a difference in the incidence of bilateral symptoms in patients with different pathologies: osteoarthritis 46%, impingement 26%, and rotator cuff tears 23% (p<0.0001). The incidence of dominant side involvement was 70%, 68% and 50% in patients with rotator cuff tear, impingement syndrome and osteoarthritis (p=0.003). Neither bilaterality nor dominant arm pathology had a negative impact on disability (p>0.05). Discussion/Conclusion. Type of pathology and aging affect the incidence of bilateral shoulder symptoms. Rotator cuff related pathologies affect the dominant side more frequently. The most interesting finding of this study was related to lack of influence of bilateral symptoms or dominant side pathology on reported disability in three different pathology groups with different prevalence of disease


Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_II | Pages 170 - 170
1 Apr 2005
Venkateswaran B Zaman T Even T Kapila A Bargava A Copeland S Levy O
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Aim: Despite many studies the implications of perfusion and blood flow abnormalities in the rotator cuff (RC) in vivo are not clearly understood. Laser Doppler Flowmetry (LDF) is an established technique for the measurement of perfusion in tissue, which has been applied in animal and human studies. This study aims to evaluate Laser Doppler Flowmetry (LDF) as a technique for the assessment of blood flow in the normal and diseased RC. Methods: With Ethics committee approval and informed consent patients undergoing arthroscopy for impingement or cuff tear (diseased cuff) and instability (normal cuff – BO) were recruited. Following diagnostic arthroscopy and bursoscopy measurements of the LDF in the RC tear were made at 6 points. Five of these were in the cuff over a 4 cm. 2 are from the insertion at the greater tuberosity and one in the deep surface. Diseased RC were sub grouped into mild (B1), moderate (B2) and severe (*B3 – cuff tear) impingement grades (Copeland – Levy Classification). The arthroscopy, grading, and probe placement were made by the senior authors. LDF flux (LDFf) was recorded over 30 seconds at each measurement point. The mean of these readings was then calculated (LDF flux – an arbitrary unit of measurement of the perfusion). Results: 35 patients were recruited. 210 measurements were recorded, in 6 anatomical locations. The mean LDFf was 34.1 in diseased RC and 55.3 in normal RC (p=0.0002). The mean LDFf was 52.2 in severe (RC tear) impingement and 30.3 in mild and moderate impingement’s (p< 0.0001). The LDFf was lowest in the moderate grade with a significant increase at the edges of a cuff tear. Conclusion: Preliminary recording of LDFf show changes are in keeping with current knowledge of the pathology. LDFf decreases with advancing impingement. There is an increase in LDFf at the edges of RC tears. This might reflect a reparative response


Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_III | Pages 384 - 384
1 Sep 2005
Levy O Venkateswaran B Zaman T Even T Kapila A Bhargava A Copeland S
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Introduction: Laser Doppler Flowmetry (LDF) is an established technique for the measurement of perfusion in tissues, which has been applied in animal and human studies. Despite many studies the implications of perfusion and blood flow abnormalities in the rotator cuff (RC) in vivo are not clearly understood. This study aims to assess the blood flow in the normal and diseased RC using Laser Doppler Flowmetry (LDF) technique. Methods: With Ethics approval and informed consent patients undergoing arthroscopy for impingement or cuff tear (diseased cuff) or for shoulder instability (normal cuff) were recruited. Following diagnostic arthroscopy and bursoscopy measurements of the blood flux in the RC using the LDF were made at 6 points. Five of these were in the cuff over a 4 cm. 2. area from the insertion at the greater tuberosity (A,E – @ Tuberosity level, C-Muscelotendinous junction, B,D – between the two) and one (F) in the deep surface. Diseased RC were subgrouped into mild (B1), moderate (B2) and severe (B3- cuff tear) impingement grades (Copeland-Levy Classification). The arthroscopy, grading, and probe placement were made by the two senior authors. LDF flux (unit of measurement of the perfusion – LDFf) was recorded over 30 seconds at each measurement point. The mean of these readings was calculated. Results: 56 patients were recruited. 35 Males (62.5%) and 21 Females (37.5%). 336 measurements were recorded. The observed mean LDFf was 32.8 (27.4–38.1; 95% CI) , 25.4 (22.4–28.5) and 43.1 (37.8–48.4; 95% CI) For Normal, Impingement and Tear cases, respectively (p< 0.0001, One-way ANOVA). The LDFf was lowest in the Impingement without tear grade (B2) with a statistically significant increase at the edges of a cuff tear. Conclusion: Preliminary recordings of LDF show changes are in keeping with current knowledge of the pathology. LDFf decreases with advancing impingement, being least affected in the musculotendinous junction. There is a substantial increase in LDFf at the edges of RC tears. This might reflect an attempted reparative response


Bone & Joint Research
Vol. 8, Issue 3 | Pages 118 - 125
1 Mar 2019
Doi N Izaki T Miyake S Shibata T Ishimatsu T Shibata Y Yamamoto T

Objectives

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

Methods

Twenty-six patients were evaluated from October 2016 to December 2017. The participants were categorized into three groups based on their diagnoses: the rotator cuff tear group; normal rotator cuff group; and adhesive capsulitis group. After establishing a posterior standard viewing portal, intravenous administration of ICG at 0.2 mg/kg body weight was performed, and fluorescence images were recorded. The time from injection of the drug to the beginning of enhancement of the observed area was measured. The hypovascular area in the rotator cuff was evaluated, and the ratio of the hypovascular area to the anterolateral area of the rotator cuff tendon was calculated (hypovascular area ratio).