Objectives

Accurate characterisation of fractures is essential in fracture management trials. However, this is often hampered by poor inter-observer agreement. This article describes the practicalities of defining the fracture population, based on the Neer classification, within a pragmatic multicentre randomised controlled trial in which surgical treatment was compared with non-surgical treatment in adults with displaced fractures of the proximal humerus involving the surgical neck.

Dislocation of the acromioclavicular joint is a relatively common injury and a number of surgical interventions have been described for its treatment. Recently, a synthetic ligament device has become available and been successfully used, however, like other non-native solutions, a compromise must be reached when choosing non-anatomical locations for their placement. This cadaveric study aimed to assess the effect of different clavicular anchorage points for the Lockdown device on the reduction of acromioclavicular joint dislocations, and suggest an optimal location. We also assessed whether further stability is provided using a coracoacromial ligament transfer (a modified Neviaser technique). The acromioclavicular joint was exposed on seven fresh-frozen cadaveric shoulders. The joint was reconstructed using the Lockdown implant using four different clavicular anchorage points and reduction was measured. The coracoacromial ligament was then transferred to the lateral end of the clavicle, and the joint re-assessed. If the Lockdown ligament was secured at the level of the conoid tubercle, the acromioclavicular joint could be reduced anatomically in all cases. If placed medial or 2 cm lateral, the joint was irreducible. If the Lockdown was placed 1 cm lateral to the conoid tubercle, the joint could be reduced with difficulty in four cases. Correct placement of the Lockdown device is crucial to allow anatomical joint reduction. Even when the Lockdown was placed over the conoid tubercle, anterior clavicle displacement remained but this could be controlled using a coracoacromial ligament transfer.

Cite this article: Bone Joint J 2015;97-B:1657–61.

Introduction: Arthroscopic A.C.L. reconstruction using Semitendinosus (S.T.) and Gracilis (Gr.) tendons is a popular technique for the treatment of ACL deficient knees. It is common to find accessory tendinous bands (vinculae) arising from these two tendons when harvesting them. The implications are that extra care must be taken with the use of the tendon stripper if one is to avoid cutting the main tendon. Our clinical experience reveals that these connections are highly variable and, contrary to popular thinking, may be present beyond 10cm. proximally.

Aim: Our aim was to map these intertendinous connections and assess their variability using a cadaveric model. In particular we were interested to identify the presence of vinculae arising proximally beyond 10cm.

Procedure: We dissected the tendons of Gr. and S.T. of ten embalmed adult human cadaveric legs. Various vinculae from both tendons were identified and their origin and insertion mapped. All measurements were done using the tibial crest as a reference.

Results: We found that vinculae have a high variability. Bands were seen between tendons, connecting them to the popliteal fascia, sartorius, gastrognemis, pretibial and superficial fascia. Vinculae originated more than 10cm proximally from Semitendinosus and Gracilis in eight and two occasions respectively. There was a constant connection band between S.T. and the grastrocriernius fascia.

Conclusion: Our results confirm that vincular anatomy is more variable than previously reported. Surgeons should be aware of our new finding of vinculae commonly originating beyond 10cm. proximally. This work has prompted us to investigate the role of MRI for pre-operatively templating vinculae.