29 cases of complex elbow injuries were reviewed at a mean period of 15 months. Outcome measures included MEPS and DASH score. Patients who had defined early surgery were significantly better than those in whom surgery was delayed. We concluded that Management of complex elbow injuries can be improved by early definitive surgery. The magnitude and type of soft tissue injuries should be identified. MRI scans should be liberally used for this purpose. We believe that early, adequate and appropriate management of soft tissue injuries including use of articulated external fixator for early mobilisation improves the outcome of complex elbow injuries.

Contoured locking plates are commonly used to fix the proximal humerus fractures. Their long-term results are unknown. We present long-term radiological and functional outcome of three and four part fractures of the proximal humerus treated with PHILOS plate.

We prospectively analysed 53 consecutive three and four part proximal humerus fractures treated with PHILOS plate between 2002 and 2007. Patients were assessed using Oxford Shoulder Score and DASH score. 44 fractures (21 three part and 23 four part) were available at the final follow up.

At a mean follow-up of 8.5 years (6.4 years–10.8 years) the average Oxford Shoulder Score was 43.9 (range 23–48) and the average DASH score was 7.7 (range 0–36.7). 30% of patients required re-operation (five for hemiarthroplasty, three for impingement syndrome, five for removal of implant). Avascular necrosis (AVN) developed in 10 patients, of which only three required hemiarthroplasty. All except one patient were satisfied with the result of their operation.

Our study supports the use of locking plates for the treatment of three and four part proximal humeral fractures. In spite of some patients requiring secondary surgical intervention in the first few years, the function of the shoulder continues to improve and in the long term patients were satisfied with the outcome. An important finding of our study is that the post-traumatic AVN of humeral head does not necessarily need major surgical intervention. We believe that the possibility of avascular necrosis should not be a major determinant in the choice of surgical treatment of proximal humeral fractures.

Introduction

The purpose of this study was to assess the rate of revision subacromial decompression and identify different pathologies.

Tightrope fixation is known method for reconstructing acromioclavicular joint and the presence of good bone stock around the two drillholes is the most important determining factor for preventing failure.

Introduction

Parathyroid hormone-related peptide (PTHrP) has been shown to be an important regulator of bone remodelling1. The aim of this study was to investigate the effect of the N-terminal domain of PTHrP (1–36) on osteogenic and angiogenic gene expression in human osteoblasts (HOB) and human bone marrow stromal cells (hBMSCs).

Hypothesis

Recurrent shoulder dislocation is associated with bony defect of the glenoid rim, commonly seen along with bankart tear - a soft tissue injury of glenoid labrum. This cadaveric study compares the bone block effect of coracoid transfer using using two common techniques, Classical Latarjet technique and the Congruent-Arc Latarjet. We hypothesized that the force needed to dislocate the shoulder would be greater in Congruent Arc technique than the Classical Latarjet, because of increased contact surface area as a result of greater linear dimensions.

Introduction: Radial styloidectomy as procedure has gained recognition over the last 60 years since its initial description for scaphoid nonunions. It is a recognised procedure in the treatment of distal radioscaphoid joint arthritis on its own or as an adjunct to another carpal procedure. There has been a debate regarding the length of styloid osteotomy and the risk of instability due to the damage of volar ligaments.

Aim: We set out to evaluate the anatomical variation of the volar ligament attachments

Methods: We performed dissection of 22 wrists in 11 embalmed cadavers (7 females, 4 males). Using dorsal approach we dissected down to the wrist and then to the volar ligaments. Measurements were taken from the tip of the radial styloid to the insertion of the volar ligaments, using digital vernier callipers. Measurements were carried out by two assessors and intra-observer and inter-observer variations were not found to be significant.

Results: Average age was 86.8 years (range 81–94). The average length of the volar ligament was found to be 7.19mm (range 5.37–10.01). No significant side dependant variation in measure was found. Predictably volar ligament length in females was found slightly lower compared to males.

Conclusion: Based on a standard 3–4mm radial styloidectomy recommended we do not feel that there would be any compromise of the volar wrist ligaments.

We performed a prospective cohort study to investigate the comparability of subjective and objective assessment scores of shoulder function following surgery for rotator cuff pathology.

A consecutive series of 372 patients underwent surgery for rotator cuff disorders with post-operative follow up over 24 months. 248 patients only had subacromial decompression, whereas 124 patients had rotator cuff repair additionally (93 arthroscopic; 31 open). Assessments were made pre-operatively, and at 3, 6, 12, and 24 months post-operatively using the Disabilities of the Arm, Shoulder, and Hand (DASH) score; Oxford Shoulder Questionnaire (OSQ); and the Constant score, which was used as a reference. Standardisation calculations were performed to convert all scores into a 0 to 100 scale, with 100 representing a normal shoulder. The student’s t test was used to compare the mean score for each subjective tool (DASH and OSQ) with the objective score (Constant) at each time point. Pearson’s Correlation coefficient was used to analyse the changes with time post-operatively. The statistical tests were used for the individual surgery types as well as all surgeries collectively. The relationship between the DASH and the Constant score was strongly correlated in all types of surgery.

The relationship between the Oxford and Constant scores was similar, except in the open rotator cuff repair group. There was no statistical difference between the mean DASH and Constant scores for all interventions at any time point. A significant difference was seen between the mean Oxford and Constant scores for at least one time point in all but the open rotator cuff repair group.

We demonstrate that the DASH and Oxford scoring systems would be useful substitutes for the Constant score, eliminating the need for a trained investigator and specialist equipment required to perform the Constant score with the associated cost benefits.

We performed a prospective audit to investigate the comparability of subjective and objective assessment scores of shoulder function following surgery for rotator cuff pathology. A consecutive series of 372 patients underwent surgery for rotator cuff disorders with post-operative follow up over 24 months. 248 patients solely underwent subacromial decompression, whereas 124 had additional rotator cuff repair (93 arthroscopic; 31 open).

Assessments were made pre-operatively, and at 3, 6, 12, and 24 post-operative months using the Disabilities of the Arm, Shoulder, and Hand (DASH) score; Oxford Shoulder Questionnaire (OSQ); and the Constant score, which was used as a reference. Standardisation calculations were performed to convert all scores into a 0 to 100 scale, with 100 representing a normal shoulder. The student’s t-test was used to compare the mean score for each subjective tool (DASH and OSQ) with the objective score (Constant) at each time point. Correlation coefficients (Pearson’s) were used to analyse the changes with time (post-operative course). Each statistical test was used for all surgeries collectively and for the individual surgery types.

The relationship between the DASH and the Constant score was robust in all types of surgery. The relationship between the Oxford and Constant was generally robust, except in the open rotator cuff group. There was no statistical difference between the mean DASH and Constant scores for all interventions at each time point. A significant difference was seen between the mean Oxford and Constant scores for at least one time point in all but the open rotator cuff repair group.

We demonstrate the DASH and Oxford scoring systems would be useful substitutes for the Constant score, obviating the need for the trained investigator and specialist equipment required to perform the Constant score, alongside the associated cost benefits. Further it provides evidence of service, aids appraisal and revalidation.

Introduction: We performed a prospective cohort study to investigate the comparability of subjective and objective assessment scores of shoulder function following surgery for rotator cuff pathology.

Materials and Methods: A consecutive series of 372 patients underwent surgery for rotator cuff disorders with post-operative follow up over 24 months. 248 patients solely underwent subacromial decompression, whereas 124 had additional rotator cuff repair (93 arthroscopic; 31 open). Assessments were made pre-operatively, and at 3, 6, 12, and 24 post-operative months using the Disabilities of the Arm, Shoulder, and Hand (DASH) score; Oxford Shoulder Questionnaire (OSQ); and the Constant score, which was used as a reference. Standardisation calculations were performed to convert all scores into a 0 to 100 scale, with 100 representing a normal shoulder. The student’s t test was used to compare the mean score for each subjective tool (DASH and OSQ) with the objective score (Constant) at each time point. Correlation coefficients (Pearson’s) were used to analyse the changes with time (post-operative course). Each statistical test was used for all surgeries collectively and for the individual surgery types.

Results: The relationship between the DASH and the Constant score was robust in all types of surgery. The relationship between the Oxford and Constant was generally robust, except in the open rotator cuff group. There was no statistical difference between the mean DASH and Constant scores for all interventions at each time point. A significant difference was seen between the mean Oxford and Constant scores for at least one time point in all but the open rotator cuff repair group.

Conclusion: We demonstrate the DASH and Oxford scoring systems would be useful substitutes for the Constant score, obviating the need for the trained investigator and specialist equipment required to perform the Constant score, alongside the associated cost benefits.

Complex proximal humerus fractures have been described as the unsolved fracture. Review of literature shows a variety of treatment methods and results. We present the results of a prospective study of 47 complex proximal humerus fractures treated by PHILOS (Proximal Humeral Internal Locking System) plate. The aim of this study was to assess the effectiveness of the PHILOS plate in the surgical treatment of Neer’s type 3 & 4 fractures.

We operated upon 47 patients (mean age 56yrs) between March 2002 and January 2006 for fixation of 3 part (28 patients) and 4 part (19 patients) fractures at a level 1 trauma centre. An independent observer reviewed patients at 6 monthly intervals for clinical and radiological assessment. Outcome measures included DASH and Constant scores.

42 patients were available for follow up, which ranged from 12–66 (average 24.4) months. Recovery of movements, and relief in pain was satisfactory in most of the patients, but the strength of shoulder did not recover fully in any patient. There were two failures in our series, one due to breakage of plate and another due to non-union; both treated successfully by revision. 4 patients (8%) had radiological signs of avascular necrosis of humeral head but only 2 of them were symptomatic requiring further treatment. Pain due to impingement was noted in several patients leading to removal of plate (6 patients) and subacromial decompression (3 patients). We encountered the problem of cold welding and distortion of screw heads, while removing the plate. The broken plate was subjected to biomechanical and metallurgical analysis, which revealed that the plate is inherently weak at the site of failure.

We concluded that in spite of the above-mentioned complications, the PHILOS plate is a reliable implant to fix 3 and 4 part proximal humeral fractures. We were particularly impressed with the satisfactory results of fixation in 4 part fractures. However, we are not convinced about its strength. The plate may cause impingement in some patients necessitating its removal later on, which itself may not be easy.

Level of Evidence: Therapeutic study, level IV (case series).

Objective: An open procedure has long been the gold standard for the repair of rotator cuff tears. Increasingly arthroscopic repair is taking the place of open surgery. This study is a comparative analysis of open and arthroscopic rotator cuff repair.

Methodology: 113 (57 female, 56 male; mean age 58 years) consecutive patients undergoing rotator cuff repair performed between 2003 and 2006 in one centre were studied prospectively. 92 were arthroscopic (48 female, 44 male; mean age 57 years) whilst 21 used a mini-open technique (9 female, 12 male; mean age 62). The determinant for which procedure was employed was solely clinical, whereby tears greater than 30mm dictated an open procedure. Assessments were made using the Oxford Shoulder Questionnaire (OSQ), DASH and Constant Scores pre-operatively, at three and six post-operative months, and six-monthly thereafter. Correlation coefficients (Pearson’s) were used to analyse and compare the post-operative course for each intervention, and the student’s t test was used to compare the mean scores for each treatment at each time point.

Results: Strong correlation was demonstrated between the rates of recovery with each surgery (Constant r=0.94; DASH r=0.96; OSQ r=0.94). Although the absolute scores were better for the arthroscopic group at each time-point with all assessment tools, these differences were statistically significant only pre-operatively with each score, and at one year with the Constant score.

Conclusion: Whilst the open repair group had poorer scores pre-operatively reflecting an initial difference in tear severity, the rates of improvement were identical with either treatment modality, as were the one year outcomes measured with the OSQ and DASH. This study demonstrates arthroscopic rotator cuff repair to be comparable with open, although we acknowledge that at one year a significant difference was evident with the Constant score.

To investigate the comparability of subjective and objective scores of shoulder function following surgery for rotator cuff pathology. From 2003 to 2006, 333 patients undergoing surgery for rotator cuff disorders were followed prospectively. 220 (66%) underwent solely subacromial decompression, whilst 113 (34%) had additional rotator cuff repair (92 arthroscopic; 21 mini-open). Assessments were made pre-operatively and six-monthly thereafter using the DASH score; Oxford Shoulder Questionnaire (OSQ); and Constant score, which was used as a reference. Standardisation calculations were used to convert all scores to a 0 to 100 scale (100 representing a normal shoulder). The student’s t test was used to compare the mean score for each subjective tool (DASH and OSQ) with the objective score (Constant). Correlation coefficients (Pearson’s) were used to analyse the post-operative course measured with subjective and objective tools for each intervention. Each statistical test was used for all surgeries collectively and the individual surgery types. There was no difference between the mean DASH and Constant scores. A significant difference was seen between the Oxford and Constant scores for at least one time point in each treatment group. Strong correlation was demonstrated between both subjective scores and the Constant. The mean Pearson correlation coefficient comparing the DASH and Constant was 0.96, whilst that for the Oxford and Constant was 0.89. The DASH and Constant scores provided identical results in terms of absolute values at a given time point, and with respect to rates of recovery. The relationship between the Oxford and Constant was less robust. In this study the DASH and Constant scores were indistinguishable, justifying the use of only the former for follow-up, obviating the need for a trained investigator required to perform a Constant score.

To compare the effectivity of arthroscopic and open stabilisation of the shoulder. Between 2003 and 2006, 100 patients (20 female, 80 male; mean age 32 years) undergoing glenohumeral stabilisation were followed prospectively. 28 were open (3 female, 25 male; mean age 30.7 years), 72 arthroscopic (17 female, 55 male; mean age 32.0 years). Assessments were made using the Constant, DASH, and Carter-Rowe (CR) scores, as well as the Oxford Shoulder Instability Questionnaire (OSIQ) pre-operatively, at three and six post-operative months, and six-monthly thereafter. The student’s t test was used to compare the mean scores at each time point. Correlation coefficients (Pearson’s) were used to compare the postoperative course with either intervention. In general the open group performed marginally less well than did the arthroscopic. However, the DASH score demonstrated less consistency both in this relationship, and the rate of post-operative recovery when compared with the other scoring systems. In the open surgery group the DASH revealed a deterioration from the pre-operative score at six months before subsequent improvement; in the arthroscopic group, this deterioration occurred at three months. However, these differences were not statistically significant regardless of the assessment tool employed. Strong correlation was demonstrated between the rates of recovery following either surgery (Constant r=0.99; OSIQ r=1.00; CR r=0.94). Again, this was not supported by the DASH (r= −0.868). The rates of improvement were identical with either treatment when measured with the Constant, OSIQ, and CR, whilst the DASH score yielded inconsistent results. No significant difference could be shown between open and arthroscopic surgery at any individual time point regardless of the assessment tool employed. We suggest that open and arthroscopic surgeries yield very similar outcomes.

Four part (Neer’s) proximal humeral fractures if treated by fixation are prone to develop avascular necrosis of humeral head; requiring further treatment and possible reoperation. This has led to the popularity of hemiarthroplasty as the primary treatment in these fractures. Since the availability of contoured locking compression plate (PHILOS) in our unit, we have treated most of the 4 part proximal humeral fractures by internal fixation. The aim of this study was to assess the usefulness of the PHILOS plate in the treatment of these fractures.

We prospectively reviewed 21 patients (mean age 57 yrs) operated between March 2002 and January 2006 at a level 1 trauma centre, using 3/5 hole PHILOS plate for fixation. An independent observer reviewed them postoperatively at 6 monthly intervals for clinical and radiological assessment. Outcome measures included DASH and Constant score. A SPECT/bone scan was done in appropriate cases.

18 patients were available for follow up, which ranged from 12–66 (average 24.4) months. Recovery of movements and relief in pain was satisfactory in most of the patients with mean Constant score of 63 points (range 37 to 95) and DASH score of 20 points (range 15–78) at last follow up.. We encountered a few complications including non-union (1); implant breakage (1) and impingement (4). Only one patient in our series required hemiarthroplasty; out of two who developed symptomatic avascular necrosis. Patient satisfaction was high in spite of moderate Constant score. Removal of PHILOS plate was difficult in some cases due to problem of cold welding and distortion of screw heads. The broken plate was subjected to biomechanical and metallurgical analysis, which revealed that the plate is inherently weak at the site of failure.

Our series is comparatively small to draw any firm conclusions but we feel that with the availability of better implants, there is a case to consider the fixation rather than arthroplasty as the primary treatment of 4 part proximal humeral fractures.

Level of evidence: Therapeutic study – Level IV (prospective case series)

Proximal humeral fractures are common injuries but there is no general agreement on the best method for fixing unstable and displaced 3 & 4 part fractures. A new implant – Proximal Humeral Internal Locking System (PHILOS) – has recently been introduced to fix these fractures. The aim of this study was to assess the effectiveness of the PHILOS plate in the surgical treatment of these fractures.

We operated upon 36 patients between March 2002 and December 2004. 33 of them were available for follow up, which ranged from 12–45 months. Assessment at follow up included radiological review, Constant and DASH scoring.

While recovery of movements and relief in pain was satisfactory, the strength of shoulder did not recover fully in any patient. There were two failures in our series, one due to breakage of plate. 4 patients have shown radiological signs of avascular necrosis of humeral head. The plate was removed in 4 patients due to impingement and / or mechanical block in abduction. Another 2 patients had to undergo arthroscopic subacromial decompression for the same reasons. We encountered the problem of cold welding and distortion of screw heads, while removing the PHILOS plate.

The broken plate was subjected to biomechanical and metallurgical analysis, which revealed that the plate is inherently weak at the site of failure.

The PHILOS plate does have inherent advantages over other implants for fixation of 3 and 4 part proximal humeral fractures but we are not convinced about its strength. Design of its proximal screws also appears less than satisfactory. The plate may cause impingement in some patients necessitating its removal later on, which itself may not be easy.

We have reviewed the management and outcome of ununited fractures of the humerus in a specialist limb reconstruction unit. A retrospective study conducted at Kings College Hospital, including referrals during the period September 1994 to present. There were 47 cases of humeral non-union, (14 proximal, 25 diaphyseal and eight distal). The time of referral from injury ranged from two months to eight years, with one patient referred after 37 years. 38 of the 47 patients had undergone an average of 1.08 operations prior to referral. Treatment aimed to achieve alignment, stability and stimulation. Methods were as follows: Proximal fractures [14]: nine Locked Compression Plate (LCP), five Dynamic Compression Plate (DCP). Autologous bone graft alone [eight], Bone Morphogenic Protein (BMP – Osigraft) alone [three], both bone graft and BMP [three]. 13 have united. One is under treatment. Mean time to union was six months. Diaphyseal fractures [25]: 12 LCP, four DCP, five Intramedullary (IM) nail, one Ilizarov frame and one required observation only. Autologous bone graft alone [17], BMP alone [two], both bone graft and BMP [three]. 23 have united. One patient awaits surgery. One patient declined surgery. Mean time to union was four months. Distal fractures [eight]: four LCP, two DCP, two Ilizarov frames. Autologous bone graft alone [seven], both bone graft and BMP [one]. Seven have united. One is under treatment. Mean time to union was seven months. Open reduction and appropriate stabilisation, together with the stimulus of autologus bone graft and/or BMP consistently resulted in healing of ununited fracture of the humerus. Many treatment methods were employed. It is not clear whether it was the treatment method or the accumulated experience of the Limb Reconstruction Unit, which was responsible for a high success rate comparable to, or better than, published results.

Proximal humeral non-unions are uncommon, but when they occur they are disabling and often present a surgical challenge.

We have treated 55 cases of proximal humeral fractures by internal fixation from March 2002 to March 2004. Of these, 18 were non-unions out of which 16 were treated using AO Cannulated blade plate and bone grafting. Results of these patients are presented in this report.

14 out of 16 were available for follow up, which ranged from 18–30 months. Patients were regularly reviewed clinically and radiologically and had constant and DASH scoring at final follow up. Average Constant score was 64 and DASH score was 35.3. Range of movement recovered to 50% or more in every patient but only 3 had full range of movements. Maximum recovery in the strength of shoulder muscles measured with myometer was about 75% as compared to other side. Although X-rays showed sound bony healing in all but one case, none of the patients was completely symptom free at final review. However, they were all satisfied with the outcome of their operation.

Stable internal fixation is the key to success of surgical treatment of non-unions. We are satisfied with the usefulness of AO cannulated blade plate in providing a rigid fixation in our cases. However, it is difficult to achieve perfect results in terms of pain relief and recovery of normal function due to various reasons, which would be highlighted in our presentation. The report would also discuss the technical difficulties encountered in using this implant.

The purpose of the study was to define the anatomy of the distal biceps tendon and it’s attachment to the proximal radius (bicipital tuberosity). Distal ruptures of the biceps tendon are not uncommon. Surgical treatment needs an understanding of the precise anatomy of the distal biceps tendon and it’s insertion; of which there are no reports in the literature.

Eighty cadaver elbows were dissected. Six were damaged, hence they were excluded from the study. The skin over the cadaver elbows was removed. The distal biceps tendon was dissected and followed to it’s insertion on to the bicipital tuberosity. Measurements of tendon dimensions were taken at the elbow joint and at it’s insertion.

The whole distal biceps tendon twists in a predictable manner. The tendon fibres too change orientation. The tendon inserts on the posterior margin of the bicipital tuberosity in a thin C-shaped manner. All the biceps insertions had a significantly large bursa associated with it.

Both the biceps tendon and it’s intra-tendinous fibres twist. This has biomechanical implications. The dimensions of the biceps tendon at the elbow and at it’s insertion affect the biomechanics. The insertion into bone in a thin C shaped fashion has connotations on methods of repair.

Introduction and Aims: To explore the variability of tendon slips, insertions and juncturae tendinae (JT) of extensor digitorum communis (EDC) and extensor digiti quinti proprius (EDQP).

Method: The extensor tendons to digits three, four and five (middle, ring and little fingers respectively) were dissected in 49 adult preserved cadaver hands.

Results: The most common patterns of tendon slip origin/insertion were:

the insertion of two slips from EDQP into digit five (84%);

Whereas variations are not uncommon (Von Schroeder & Botte, 2001), it is the more constant features (presence or absence) which are of surgical relevance and which our study emphasises.

Conclusion: We conclude that the ulnar EDQP slip can be safely and easily harvested as a free tendon graft without any consequential loss of extension of little finger and with minimal surgical trauma. It also follows that rupture of the radial side of the extensor hood of the middle finger predisposes to ulnar subluxation of the middle finger EDC, and we describe two such clinical cases.