Surgeons need to be able to measure angles and distances in three dimensions in the planning and assessment of knee replacement. Computed tomography (CT) offers the accuracy needed but involves greater radiation exposure to patients than traditional long-leg standing radiographs, which give very little information outside the plane of the image.

There is considerable variation in CT radiation doses between research centres, scanning protocols and individual scanners, and ethics committees are rightly demanding more consistency in this area.

By refining the CT scanning protocol we have reduced the effective radiation dose received by the patient down to the equivalent of one long-leg standing radiograph. Because of this, it will be more acceptable to obtain the three-dimensional data set produced by CT scanning. Surgeons will be able to document the impact of implant position on outcome with greater precision.

Aims. As an alternative to external fixators, intramedullary lengthening nails (ILNs) can be employed for distraction osteogenesis. While previous studies have demonstrated that typical complications of external devices, such as soft-tissue tethering, and pin site infection can be avoided with ILNs, there is a lack of studies that exclusively investigated tibial distraction osteogenesis with motorized ILNs inserted via an antegrade approach. Methods. A total of 58 patients (median age 17 years (interquartile range (IQR) 15 to 21)) treated by unilateral tibial distraction osteogenesis for a median leg length discrepancy of 41 mm (IQR 34 to 53), and nine patients with disproportionate short stature treated by bilateral simultaneous tibial distraction osteogenesis, with magnetically controlled motorized ILNs inserted via an antegrade approach, were retrospectively analyzed. The median follow-up was 37 months (IQR 30 to 51). Outcome measurements were accuracy, precision, reliability, bone healing, complications, and patient-reported outcome assessed by the Limb Deformity-Scoliosis Research Society Score (LD-SRS-30). Results. A median tibial distraction of 44 mm (IQR 31 to 49) was achieved with a mean distraction index of 0.5 mm/day (standard deviation 0.13) and median consolidation index of 41.2 days/cm (IQR 34 to 51). Accuracy, precision, and reliability were 91%, 92%, and 97%, respectively. New temporary range of motion limitations occurred in 51% of segments (34/67). Distraction-related equinus deformity treated by Achilles tendon lengthening was the most common major complication recorded in 16% of segments (11/67). In 95% of patients (55/58) the distraction goal was achieved with 42% unplanned additional interventions per segment (28/67). The median postoperative LD-SRS-30 score was 4.0 (IQR 3.6 to 4.3). Conclusion. Tibial distraction osteogenesis using motorized ILNs inserted via an antegrade approach appears to be a reliable and precise procedure. Temporary joint stiffness of the knee or ankle should be expected in up to every second patient. A high rate and wide range of complications of variable severity should be anticipated. Cite this article: Bone Joint J 2024;106-B(3):293–302

Aims. The increase in prescription opioid misuse and dependence is now a public health crisis in the UK. It is recognized as a whole-person problem that involves both the medical and the psychosocial needs of patients. Analyzing aspects of pathophysiology, emotional health, and social wellbeing associated with persistent opioid use after injury may inform safe and effective alleviation of pain while minimizing risk of misuse or dependence. Our objectives were to investigate patient factors associated with opioid use two to four weeks and six to nine months after an upper limb fracture. Methods. A total of 734 patients recovering from an isolated upper limb fracture were recruited in this study. Opioid prescription was documented retrospectively for the period preceding the injury, and prospectively at the two- to four-week post-injury visit and six- to nine-month post-injury visit. Bivariate and multivariate analysis sought factors associated with opioid prescription from demographics, injury-specific data, Patient Reported Outcome Measurement Instrumentation System (PROMIS), Depression computer adaptive test (CAT), PROMIS Anxiety CAT, PROMIS Instrumental Support CAT, the Pain Catastrophizing Scale (PCS), the Pain Self-efficacy Questionnaire (PSEQ-2), Tampa Scale for Kinesiophobia (TSK-11), and measures that investigate levels of social support. Results. A new prescription of opioids two to four weeks after injury was independently associated with less social support (odds ratio (OR) 0.26, p < 0.001), less instrumental support (OR 0.91, p < 0.001), and greater symptoms of anxiety (OR 1.1, p < 0.001). A new prescription of opioids six to nine months after injury was independently associated with less instrumental support (OR 0.9, p < 0.001) and greater symptoms of anxiety (OR 1.1, p < 0.001). Conclusion. This study demonstrates that potentially modifiable psychosocial factors are associated with increased acute and chronic opioid prescriptions following upper limb fracture. Surgeons prescribing opioids for upper limb fractures should be made aware of the screening and management of emotional and social health. Cite this article: Bone Jt Open 2021;2(2):119–124

This review compares the outcomes and complication rates of three surgical strategies used for the management of symptomatic os acromiale. The purpose of this study was to help guide best practice recommendations. A systematic review of nine prospective studies, seven retrospective studies, and three case studies published across ten countries between 1993 and 2018 was performed. Adult patients (i.e., ≥ 18 years of age) with a symptomatic os acromiale that failed nonoperative management were included in this review. Surgical techniques utilized within the included studies include excision, acromioplasty, and open reduction and internal fixation (ORIF). The primary outcomes of interest included patient satisfaction and return to activity. Range of motion and several standardized outcome measurement tools were also included in the final analysis. Patient satisfaction was highest in the excision and ORIF groups, with 92% and 82% of patients reporting good to excellent postoperative results, respectively, compared to 63% in the acromioplasty group. All three patient groups experienced improved postoperative objective scores (i.e., patient-reported outcome scores and active range of motion). The excision group experienced a complication rate of 1%, while the acromioplasty group experienced a complication rate of 11% and the ORIF group a rate of 67%. This study reports on the largest sample of patients who have undergone surgical treatment for a symptomatic os acromiale. We have demonstrated that excision of the os with repair of the deltoid resulted in the best clinical outcomes with the least complications. In healthy adult patients with a large os fragment and a normal rotator cuff, surgical fixation may provide increased preservation of deltoid function while offering good patient satisfaction. Such patients should be aware that they are at increased risk of requiring a second procedure due to symptomatic hardware following ORIF

In light of recent regulatory initiatives, medical devices now require additional clinical evidence to prove their safety and efficacy. At the same time, patients' own assessment of their devices' function and performance has gained in importance. The collection of these data allows for a more comprehensive picture of clinical outcomes and complications following total knee arthroplasty (TKA). These trends have led researchers to search for new methods of acquiring, interpreting and disseminating patient-reported outcome measurements (PROMs). The current study assesses the feasibility of a digital platform for collecting PROMs that was recently adapted for TKA patients. It sought to determine patient engagement, survey completion rates, and satisfaction with this platform. Eighty-two patients (mean age, 63.7 years, 59% females) scheduled for TKA were enrolled from one US and six UK sites between January 12, 2018 and April 30, 2018. Patients were supplied with a mobile application (app) that collects a variety of PROMs, including four domains based on the Patient-Reported Outcome Information System (PROMIS™): physical function, depression, pain interference and pain behavior. The platform electronically administers questionnaires using computer-adaptive tests (CATs), which reduce the burden on patients by tailoring follow-up questions to account for their previous answers. Satisfaction with the app was assessed in subset of patients who evaluated its ease-of-use (n=45), likelihood that they would recommend it to family/friends (n=35), and whether they successfully used the information it provided during their recovery (n=31). These scores were taken on a 1 to 10 (worst to best) scale. Patients demonstrated regular engagement with the platform, with 73% using the app at least once a week. Weekly engagement remained high throughout the seven-week post-operative period (Figure 1). There was a 69% completion rate of all PROMIS™ CAT surveys during the study. The four PROMIS™ CAT domains had similar survey completion rates (Figure 2). The subset of patients queried regarding their satisfaction with the app gave it favorable mean scores for ease-of-use (8.8), likelihood to recommend to a family member or friend (8.1), and their success at using its information to improve their recovery (7.4). Initial results support this digital platform's potential for successfully and efficiently collecting large volumes of PROMs. Patients reported high levels of engagement and satisfaction. For any figures or tables, please contact authors directly

Aims

Chronic osteomyelitis (COM) of the lower limb in adults can be surgically managed by either limb reconstruction or amputation. This scoping review aims to map the outcomes used in studies surgically managing COM in order to aid future development of a core outcome set.

Aims

Distraction osteogenesis with intramedullary lengthening devices has undergone rapid development in the past decade with implant enhancement. In this first single-centre matched-pair analysis we focus on the comparison of treatment with the PRECICE and STRYDE intramedullary lengthening devices and aim to clarify any clinical and radiological differences.

Introduction. Direct anterior approach (DAA) total hip arthroplasty (THA) has been reported to improve early outcomes as compared to posterior approach THA up to 6 weeks post-operatively. However, very few detailed results have been reported within the first 6 weeks. In this study we investigate the effect of surgical approach on THA outcome via weekly assessment. Methods. Patients undergoing THA for primary osteoarthritis were prospectively enrolled. Data was collected pre-operatively and post-operatively at weekly intervals for 6 weeks. Outcome scores and additional functional measures were compared using unpaired t-test, effect size, and Pearson correlation coefficients. Results. 111 patients (55 DAA and 56 posterior approach) were enrolled. There was no significant difference (p>0.05) in pre-surgical Patient Reported Outcome Measurement Information System (PROMIS) Pain interference and Physical Function scores, VAS Pain, and Modified Harris Hip Scores (mHHS). Post-operatively, the DAA group had decreased length of stay [1.4 vs 2.2 days, p=0.0002] and increased distance walked on postoperative day 1 and 2 [95 vs 52 ft, p=0.011 and 251 vs. 163 ft, p=0.0004, respectively]. The DAA group had lower VAS pain scores [p<0.05] and required less day 1 and total narcotics [59 vs 80 morphine equivalents, p=0.029 and 138 vs 190, p=0.01, respectively]. The DAA cohort had improved PROMIS Physical Function scores and mHHS up to 5 weeks post- operatively. Anterior approach patients discontinued their assistive device 8 days earlier [p=0.01], left home 3 days earlier [p=0.001], and drove a car 5 days earlier [p=0.016] compared to posterior patients. Conclusion. Patients undergoing DAA THA had significantly shorter length of stay, improved mobilization, decreased narcotic requirements and improved inpatient VAS pain scores compared to mini-posterior THA. Furthermore, DAA patients discontinued their assistive device, left their home, and drove a car sooner than posterior approach patients. The significant improvement in physical function seen with DAA THA persisted up to 5 weeks post-operatively

Objective. The optimal dosage and timing of tranexamic acid in total hip arthroplasty (THA) still is undetermined. Previous studies showed the hyper-fibrinolysis would last for 18 hours after surgery. The study aimed to examine the efficacy and safety of multiple bolus of intravenous TXA on hidden blood loss and inflammation response following primary THA. Methods. 150 patients were randomly divided into three groups to receive single bolus of 20 mg/kg IV-TXA before skin incision (Group A), or another bolus of 1 g IV-TXA 3 hours later (Group B), or another two boluses of 1g IV-TXA 3 hours and 6 hours later (Group C). All patients received a standard perioperative enhanced recovery protocol. The primary outcomes was hidden blood loss. Other outcome measurements such as hemoglobin level, total blood loss, transfusion rate, inflammation markers (CRP, IL-6), VAS pain score, length of hospital stay (LOH) and venous thromboembolism (VTE) were also compared. Results. The hidden blood loss in group C was 402.13 ± 225.97 ml, which was less than that in group A (679.28±277.16 ml, p< 0.001) and group B (560.62±295.22 ml, p= 0.010). However, such difference was not detected between group A and B (p= 0.072). The mean value of total blood loss in group A, B and C were 1090.78±251.41, 979.42±247.89, 768.71±180.19 ml, respectively, with a significant intergroup difference (p <0.001). The Hb drop on postoperative day (POD) 3 in group A, B and C was 30.82±6.31, 27.16±6.83, 21.98±3.72 g/L, and the difference between groups was significant (p <0.001). Only one patients received red blood cell transfusion. The mean level of CRP in group C was lower than that in group A and B on POD 2 (p= 0.000, p= 0.034), POD 3 (p= 0.000, p= 0.014). The serum level of IL-6 in group C was lower than group A on POD 1, POD 2 and POD 3 (p=0.017, p=0.023, p= 0.005; respectively). The patients in group C had slightly less postoperative pain. The LOH in group C was shorter than those in group A (p= 0.023). No episodes of VTE or other adverse events occurred in any patient. Conclusion. Multiple boluses of IV-TXA can effectively reduce hidden blood loss following primary THA. What is the most important is that, by adding another boluses of IV-TXA, patients can gain a smaller decline of Hb, less postoperative inflammation response, less pain and shorter length of hospital stay

Introduction. Enhanced Recovery Protocol (ERP) for elective total hip or total knee replacement has become the gold standard. The main principles are to reduce bleeding, both with a tranexamic acid infusion and local injection of adrenaline, and to reduce the risk of postoperative thrombo-embolic complications by early mobilisation, enabled by local anaesthetic infiltration at time of surgery. The aim of this study is to evaluate the impact of the ERP. Methods. A retrospective review was performed including all patients who underwent primary hip or knee arthroplasty surgery between January 2011 and December 2013. The ERP was implemented in our department in August 2012 thus creating two cohorts; the traditional postoperative group and those undergoing ERP. Outcome measurements of length of stay, postoperative transfusion, thrombo-embolic complications and number of re-admissions were assessed. Results. 1262 patients were included. The traditional group contained a total of 632 patients and the ERP group contained 630 patients. The number of patients receiving a blood transfusion postoperatively significantly decreased from 50 (7.9%) to 27 (4.3%) (p value <0.05). There was no statistical difference in postoperative thrombo-embolic events. The length of stay was reduced from 5.5 days to 4.8 days (P value <0.05). There was no difference in the number of re-admissions. Conclusion. ERP has led to a significant decrease in transfusions after elective arthroplasty surgery, without increasing the incidence of thrombo-embolic events. Furthermore it has significantly reduced the length of stay which has obvious cost implications. This study agrees with the current literature in that enhanced recovery should indeed be the gold standard for elective arthroplasty procedures

Beside spine and pelvis surgery, computer-assisted guidance systems are not used frequently for musculoskeletal injuries. Main reason is the dependence on a fixed reference array that must be firmly attached to all moving parts. We investigated a novel fluoroscopy-based image guidance system in orthopaedic trauma surgery that uses a different technique. This was a prospective, not randomised single centre case series at a level I trauma centre. 45 patients with 46 injuries (foot 12, shoulder 10, long bones 7, hand and wrist 7, ankle 7, spine and pelvis 4) were included. Different surgical procedures were examined following the basic principles of the AO/ASIF. Main outcome measurements were the number of trials for implant placement, total surgery time, usability via user questionnaire and system failure rate. Furthermore we wanted to test the ability of the new system to be integrated in existing surgical workflows. In all cases, the trajectory function was used, inserting a total of 56 guided implants. The trajectory was the most popular feature used by surgeons (n=43, 93.5%), followed by the length measurement tool (n=29, 63%) and the bending function (n=17, 37%). The functions could be freely activated by the performing surgeon. The system failed when used in pelvic and spinal injuries, resulting in a total failure rate of 6.5% (n=3) of all included cases. The overall usability was rated as good, scoring 84.3%. This study examined the clinical application of a fluoroscopy-based image guidance system for different musculoskeletal injuries. Its major advantage is the high integrability in the accustomed surgical workflow and its connectivity with existing technical equipment. It can hardly be compared to known navigation solutions, since instruments are not tracked and fixed reference arrays are not required. Expected advantages should be explored in randomised studies

The Birmingham hip resurfacing (Smith & Nephew, Tennessee) (BHR) has been used in younger more active patients. Aim. We report on our experience of 206 BHR procedures in patients aged 50 years or less with a minimum ten year follow-up. Clinical outcome scores, body mass index (BMI), gender and age were analysed to investigate resurfacing outcomes. Methods. 200 patients (158 males and 42 females) with an average operation age of 43.33 years (SD ±5.66) were investigated. There were 6 bilateral procedures The mean follow-up period was 12.44 years (SD ±1.71). The arthroplasties were completed between April 1999 and December 2002 by one surgeon. Data and outcome measurements were collected prospectively and analysed retrospectively. We evaluated Harris Hip Scores, Short Form-36 (SF-36v2) Scores, Tegner Activity Score Scores and McMaster Universities Osteoarthritis Index Scores (WOMAC) comparatively at preoperative, six month and yearly intervals. Results. In 1 patient the implant was in situ at the time of death. Revision was carried out in 5 hips (2.4%) at a mean time period of 3.2 years (0–8) post-operatively. Failure was due to femoral neck fracture, acetabular loosening and avascular necrosis of the femoral head, leading to loosening. Kaplan-Meier analysis showed survivorship of 97.6%. The mean Harris Hip scores (paired t-test, p<0.05) improved significantly from 55.58 preoperatively to 91.33 at 15 years. The mean SF-36v2 physical scores (paired t-test, p<0.05) improved significantly from 32.70 preoperatively to 43.75 at 15 years. WOMAC total scores (paired t-test, p<0.05) improved significantly from 44.37 preoperatively to 14.67 at 15 years. Conclusion. In this demanding group of patients, without any restrictions to physical activity, the results of this procedure at 10 years are most encouraging. However, concerns remain in relation to the effect of elevated metal ions, tissue sensitivities, and anatomical variations, such as hip dysplasia, which may impact on function and success

To reveal if patient reported knee-related pain, function, quality of life, general health and satisfaction at one year after primary total knee arthroplasty (TKA) is different between patients not being subject to revision surgery and those having had early treatment with open debridement and exchange of the tibial insert for postoperative PJI. The Swedish Knee Arthroplasty Register was used to identify 50 patients in the region of Skane that had a primary TKA during the years 2008 – 2012 and within 6 months were revised with open debridement and exchange of the tibial insert due to suspected or verified PJI. Only patients without further revisions were included. Patient reported outcome measurements (PROM) were obtained preoperatively and 1 year postoperatively and included knee related pain, function, quality of life using the Knee injury and Osteoarthritis Outcome Score (KOOS), general health using the EQ-VAS as well as satisfaction with the surgery. The scores were compared to those reported by 3,913 patients having a TKA during the same time but not revised during the first year. Welch's t-test and the Chi2-test were used in statistical analysis. Compared to the controls the infected patients were older (mean age 72 vs 69 years, p = 0.04) and were more morbid (ASA 3; 14/50 patients vs 14%, p = 0.02). The preoperative PROM data were similar. Complete 1 year PROM data was available for 31 of the patients. Those patients reported somewhat worse outcome one year postoperatively than the controls with statistically and clinically significant differences in general health (mean 61 vs 76, p=0.002), KOOS ADL (mean 65 vs 76, p=0.03) and knee related quality of life (mean 51 vs 63, p=0.02) with large variations on individual level. Just over half of the patients (17/29) treated for PJI were very satisfied or satisfied with the surgery compared to 79% of the controls. Patients treated with open debridement and exchange of the tibial insert due to early PJI after primary TKA reported less beneficial postoperative outcome than those without revision surgery during the first postoperative year but with large individual variations

Aim. (1) To determine whether any difference exists in AVN risk between surgical reduction [Fish] or pinning-in-situ [PIS] of severe slips. (2) To review the different classifications of SUFE in relation to AVN. Materials and Methods. 56 children presented with slipped upper femoral epiphysis (SUFE) from 1998 to 2008; 29 males, 27 females; mean age 12.8 years. The Loder & Southwick classifications were used. All slips were treated surgically. The mild and moderate groups were treated with a single pin-in-situ. The severe group had either surgical reduction [Fish femoral neck osteotomy], alternatively a single pin-in-situ, randomised by day of admission. Avascular necrosis of the femoral head (AVN) was the primary outcome measurement. Results. There were seven cases of AVN (12.5%). 2/41 in the stable group developed AVN compared to 5/15 in the unstable group, statistically significant [Chi-Square P=0.001]. No patient in the mild group, one out of seven in the moderate group, and six out of 22 in the severe group developed AVN. In the severe slip group, the AVN rate in the PIS group was 40%, after Fish osteotomy it was 23.5%. This is not statistically significant, but the trend favours surgical reduction. Conclusion and Significance. (1) Surgical reduction by Fish osteotomy is no riskier for AVN than pinning in situ for severe SUFE. Surgical reduction should therefore be performed to avoid gross deformity in these cases. (2) We have confirmed that the stability and the severity of the slip at presentation are the best indicators for predicting AVN

The aim of this study was to evaluate prospectively the outcome following arthroscopic Bankart repair using two types of suture anchors, absorbable and non-absorbable. Patients with a diagnosis of recurrent traumatic anterior instability of the shoulder, seen between April 2000 and June 2003 in a single unit, were considered for inclusion in the study. Patients were assessed pre-operatively and post-operatively using a subjective patient related outcome measurement tool (Oxford instability score), a visual analogue scale for pain and instability (VAS Pain and VAS instability) and a quality of life questionnaire (SF-12). The incidence of recurrent instability and the level of sporting ability were recorded. Patients were randomised to undergo surgical repair with either non-absorbable or absorbable anchors. 130 patients were included in the study. 6 patients were lost to follow-up and 124 patients (95%) completed the study. Both types of anchors were highly effective. There were no differences in the rate of recurrence or any of the scores between the two. Four patients in the non-absorbable group and 3 in the absorbable group experienced further episodes of dislocation after a traumatic event. The rate of redislocation in the whole series was therefore, 5.6%. In addition, 4 patients, all of them in the absorbable group (4%) described ongoing symptoms of instability but no true dislocations. 85% of the patients have returned to their previous level of sporting activity. There are no differences in the outcome of Arthroscopic Bankart repair using either absorbable or non-absorbable anchors. Both are highly effective, showing a redislocation rate of 5.6%

Introduction. Objective was to assess clinical results of treatment of Infected Non Union (INU) of long bones, using Antibiotic Cement Impregnated Nail (ACIN), a single or two staged approach, Stage 1 - Debridement, eradication of infection, primary stabilization with (ACIN). 2nd Stage - Definitive stabilization and early rehabilitation. Methods. 185 cases of infected non-union of long bones from Jan 2002 to Jan 2009 were treated in this hospital. 46 females and 139 males, age varied from 17–65 years (Avg. 40). Tibia was the commonest bone to be affected, followed by femur & humerus. The control of infection was by debridement, antibiotic cement impregnated K-nail (ACIN) insertion with or without Ilizarov ring fixator application, second stage treatment by definitive internal fixation and bone grafting was done if required. Average duration of follow up, was 26 months (14–58 months). Main outcome measurements were assessment of bone healing, functional outcome, healing time and complications. Results. Out of the 185 cases treated in our institute 174 (93.7%) patients achieved union at an average of 8 months. 2 limbs with non union tibia fractures were amputed on demand by patients, 2 limbs developed severe edema, 7 patients did not achieve union, inspite of repeated procedures. Infection was controlled early especially in Type 1 non unions. 5 patients had persistent infection though mild inspite of 2 or 3 surgeries of exploration and curettage. Discussion and conclusion. The two staged procedure described gives satisfactory results. Antibiotic and cement impregnated nails and beads achieve good infection control without any complications and reduce the healing time. Ilizarov fixator helps in stabilization, compression, deformity correction at the same time and plays a significant role in the path to union. Fixator should be removed as early as possible to avoid restriction of movements

Purpose. To examine measurement properties of four disability outcomes in patients with advanced osteoarthritis of the glenohumeral joint. Methods. This was a prospective longitudinal study of patients with advanced osteoarthritis of the glenohumeral joint who underwent a Total Shoulder Arthroplasty (TSA) and were followed for 6 months. Four measures [Western Ontario Osteoarthritis Shoulder (WOOS) Index, the American Shoulder and Elbow Surgeons (ASES) assessment, Constant-Murley score (CMS), and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH)] were completed 2-3 weeks before surgery and at 6 months after surgery. Results. Seventy-seven patients (average age: 66, range 35 to 86, 60% women, 40% men) participated in the study. The Cronbach's Coefficient Alpha of subjective measures was high at 0.91, 0.86, and 0.83 for WOOS, ASES, and QuickDASH respectively. All measures were able to discriminate between men and women's levels of disability at p< 0.05. Correlations between pre-operative scores were moderate (0.59 to -0.79) and slightly increased post-operatively (0.61 to -0.87). All measures were sensitive in detecting change in the disability status over a period of 6 months. Conclusion. All four disability measures were reliable and valid for use in patients with advanced osteoarthritis of the glenohumeral joint. Outcome measurement in busy clinics can be facilitated by choosing valid and reliable measures that have the advantage of simplicity for use by patients and clinicians. The consensus-based standards for selection of outcome measures have been developed for hip and knee arthritis and need to take place for the shoulder joint. Developing consensus by an international group of experts will improve consistency in using outcome measures in patients with shoulder problems

Purpose. Management of massive, degenerative, and irreparable rotator cuff tears is challenging. Excessive re-tear rates and poor clinical outcome after standard repair have led to alternative methods of treatment. Tendon transfers and shoulder arthroplasty have had mixed results; both are invasive procedures with high potential morbidity. We began performing rotator cuff augmentation and replacement using GraftJacket allograft acellular human dermal matrix as a biologic minimally invasive alternative in this difficult population almost 6 years ago. This article highlights our preferred arthroscopic technique and early results. Method. From January 2004 to June 2007, 45 patients (36 men, 9 women) with massive rotator cuff tears were treated arthroscopically with the GraftJacket allograft. All patients completed a preoperative University of California, Los Angeles (UCLA) score. Follow-up was a minimum of 2 years (range, 24–68 months) and patients completed UCLA, Western Ontario Rotator Cuff (WORC), and American Shoulder and Elbow Surgeons (ASES) scores. Results. Analysis was performed using the 3 validated outcomes measurement scores. The mean UCLA score increased from 18.4 preoperatively to 27.5 postoperatively (P < .000). The average WORC score was 75.2, and the ASES score was 84.1 at the final follow-up. Conclusion. Evidence-based data to outline an algorithm for management of irreparable rotator cuff tears is being developed. We documented significant clinical improvement with arthroscopic rotator cuff reconstruction using the GraftJacket allograft acellular human dermal matrix. The procedure is safe and associated with high patient satisfaction, without the morbidity of tendon transfer or arthroplasty. For those few cases where further surgery is required, no bridges are burned. The early success of this procedure warrants further study with more patients, longer follow-up, and higher levels of evidence-based investigation

Management of open tibial fractures remains controversial. We hypothesised that unreamed intramedullary nail offers inherent advantages of nail as well as external fixation. We undertook a prospective randomised study to compare the results of management of open tibial fractures with either an external fixator or an undreamed intramedullary nail until fracture union or failure. Our study included 30 consecutive open tibial fractures (Gustilo I, II & IIIA) between 4 cm distal to knee and 4 cm proximal to ankle in skeletally mature adults, who presented to a level-1 trauma centre. Alternate patients were treated by either external fixation and unreamed nailing i.e. 15 in each group. Standard protocol for debridement and fixation was followed in all cases. All external fixators were removed at 6 weeks. All cases were followed up until fracture union, the main outcome measurement. 26 (87%) were males and 4 (13%) females; age range was 20-60 years (average 33.8). All fractures in both groups united. Time to union averaged 7.9 months for both groups. Incidence of wound problems, infection, hardware failure and delayed union were comparable. However, there was higher incidence of angular deformities and stiffness of knee and ankle in external fixation group, although not statistically significant. We found no statistically significant difference between unreamed intramedullary nailing and external fixation for the management of open tibial diaphyseal fractures, although ease of weight bearing as well as absence of angular deformities and joint stiffness were distinct advantages in the nail group. Therefore we recommend unreamed nail for Gustilo I, II and IIIA open tibial fractures

The Achilles tendon is the most commonly ruptured tendon in the body and yet its management remains controversial due to potential surgical complications. We believe that primary repair using LARS ligament augmentation, combined with early mobilisation will significantly reduce all these potential problems and lead to improved functional outcomes. Nine patients with acute Achilles tendon ruptures underwent primary repair using augmentation with a Ligament Augmentation and Reconstruction System (LARS) ligament. Day one postoperatively each patient was started on active range of motion exercises. Clinical parameters, isokinetic strength and outcome measurements (The American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score and Lower Extremity Functional Scale (LEFS) was utilised to assess pain and function, Tegner score to evaluate activity) were evaluated at an average follow-up of 17 months. Complications, if any, were also recorded. There were no re-ruptures and all patients returned to normal work (average time 9.2 weeks) and all but one returned to their previous level of recreational sporting activity (average time 20.8 weeks). The postoperative performance testing showed positive results with the mean decrease in calf circumference of affected leg was 1.0 cm (range, −0.5 to 2.0), and every patient was able to perform at least one heel-raise with the mean heel raise difference being −3.8 repetitions (range, −1 to −10 reps) when compared to the other leg. In terms of functional outcomes, all patients reported very good results. The mean AOFAS score postoperatively was 83.4% (range, 74% to 100%) and the mean LEFS score was 82.5% (range, 45 to 100%). The mean preoperative Tegner score was 4.75 (range, 2 to 8) and the postoperative score was 3.75 (range, 2 to 7). The results of our preliminary clinical series indicate that LARS ligament repair of acute Achilles tendon ruptures provides a reliable and effective technique for repair. It eliminates the need for graft harvesting, it decreases postoperative complications, but most importantly, patients have improved functional outcomes