A comparison of simple and complex single-row versus transosseous-equivalent double-row repair techniques for full-thickness rotator cuff tears: a systematic review and meta-analysis.

BACKGROUND: Rotator cuff injuries have traditionally been managed by either single-row or double-row arthroscopic repair techniques. Complex single-row techniques have recently been proposed as a biomechanically stronger alternative treatment option. However, no rigorous meta-analysis has evaluated the effectiveness of complex single-row against double-row repair. This meta-analysis aims to evaluate clinical outcomes in patients with full-thickness rotator cuff injuries treated with both simple and complex single-row, as well as transosseous-equivalent (TOE) double-row procedures. METHODS: An up-to-date literature search was performed using the predefined search strategy. All studies that met the inclusion criteria were assessed for methodological quality and included in the meta-analysis. Pain, functional scores, range of motion, and retear rate were all considered in the study. CONCLUSION: The results of our meta-analysis suggest that there is no significant difference between complex single-row and TOE double-row procedures in any of the observed outcomes. At this point in time, the available comparative data between simple single-row and TOE double-row repair techniques are limited. Further high-quality studies are required to assess the clinical outcomes and cost-effectiveness of these different techniques.

The influence of age and unreported symptoms on the Oxford Shoulder Score.

BACKGROUND: One potential limitation of interpreting the Oxford Shoulder Score (OSS) in longitudinal studies is that the observed score may be influenced by age and other variables, which may change over time. The purpose of the present study was to investigate the influence of increasing age and unreported non-shoulder upper limb and neck symptoms on the OSS. METHODS: We collected OSS data from a sample of our ethnically diverse local population. All subjects indicated whether they suffered from any neck, shoulder, elbow or wrist symptoms for which they had not sought a medical opinion. Those reporting no symptoms formed the asymptomatic group. RESULTS: We found a significant decline in OSS with increasing age in the whole study population, as well as in both the asymptomatic and symptomatic groups with previously unreported symptoms: Spearman correlation coefficient = -0.27, -0.28 and -0.33 respectively (p < 0.001). The median OSS in the asymptomatic group was 48 [interquartile range (IQR) 48 to 48]. This was significantly higher than the symptomatic group, with a median OSS of 46 (IQR 40 to 47) (p < 0.001). CONCLUSIONS: We found the OSS to be affected by non-shoulder upper-limb and neck pathology as well as age. Within the limitations of the OSS, the differences we found do not exceed the minimal important change.

ACL graft compression: a method to allow reduced tunnel sizes in ACL reconstruction.

PURPOSE: A common problem during ACL reconstruction is asymmetry of proximal-distal graft diameter leading to tunnel upsizing and graft-tunnel mismatch. Compression downsizing provides a graft of uniform size, allowing easy passage into a smaller tunnel. The purpose of this study was to quantify the graft compression technique and its effects on graft biomechanics and stability. It was hypothesised that compression downsizing would significantly reduce cross-sectional area (CSA); that no significant changes in graft biomechanics would occur; graft fixation stability would be improved. METHOD: Sixty-eight non-irradiated peroneus longus (PL) tendons were investigated. Twenty were halved and paired into ten four-strand grafts, 20 strands were compressed by 0.5-1 mm diameter and changes in CSA recorded using an alginate mould technique. The following properties were compared with 20 control strands: cyclic strain when loaded 70-220 N for 1000 cycles; stiffness; ultimate tensile load and stress; Young's modulus. 24 PL tendons were quadrupled into grafts, 12 were compressed and all 24 were submerged in Ringer's solution at 37 °C and the CSA recorded over 12 h. Twelve compressed and 12 control quadrupled grafts were mounted in porcine femurs, placed in Ringer's solution for 12 h at 37 °C and graft displacement at the bone tunnel aperture recorded under cyclic loading. RESULTS: Mean decreases in CSA of 31% under a stress of 471 kPa and 21% under a stress of 447 kPa were observed for doubled and quadrupled grafts, respectively. Compressed grafts re-expanded by 19% over 12 h compared to 2% for controls. No significant differences were observed between compressed and control grafts in the biomechanical properties and graft stability; mean cyclic displacements were 0.3 mm for both groups. CONCLUSIONS: No detrimental biomechanical effects of graft compression on allograft PL tendons were observed. Following compression, the grafts significantly increased in size during in vitro joint simulation. No significant difference was observed in graft stability between groups. Graft compression did not cause adverse mechanical effects in vitro. Smaller tunnels for compressed grafts reduce bone loss and ease anatomical placement.

Current practice of BHS members in the treatment of osteonecrosis of the femoral head in adults.

INTRODUCTION: The management of osteonecrosis (ON) of the femoral head remains controversial. It is unclear the extent to which non-arthroplasty procedures are used and there has been no previous report of the trends in operative management of ON in the UK. Our objective is to report current trends in management of ON of the femoral head amongst specialist hip surgeons in the UK. METHODS: A single-stage internet-based survey was e-mailed to 352 eligible members of the British Hip Society (BHS). This consisted of 10 question stems including 16 hypothetical clinical scenarios with imaging. RESULTS: 115 active Consultant members of the BHS completed the survey. For symptomatic pre-collapse ON we found core decompression (CD) was the most common operative intervention and for post-collapse ON we found that total hip arthroplasty (THA) was the most common operative intervention. We found no difference in the rate of operative intervention between 24 and 48-year-old patients at any stage of ON but joint preserving procedures were more often selected for the younger patient and arthroplasty for the older patient. Surgeons were more likely to offer arthroplasty to a 48-year-old patient at an earlier stage of disease. CONCLUSIONS: Our respondents would offer different operative interventions dependent on stage of ON and patient age. Core decompression (CD) and arthroplasty were common but variation in treatment options offered suggests a lack of consensus amongst UK hip surgeons. We suggest that further research such as a prospective RCT is needed to gain consensus on management of this condition.

Quantification of the articular view of the elbow afforded by standard portals using 30° arthroscopy.

BACKGROUND: The present study quantifies the field of view (FOV) from standard arthroscopy portals and aims to identify anatomical regions where the FOV is limited. METHODS: Eleven cadaveric elbows were examined through standard anteromedial, anterolateral and posterior portals. The FOV was marked with dye using a spinal needle. The articular surfaces were then exposed and the percentage FOV seen was calculated. FOV percentage areas were compared using a Student's t-test (JMP, version 10, SAS Institute Inc., Cary, NC, USA). P < 0.05 was considered statistically significant. RESULTS: The mean (SD) FOV percentage area seen from the anteromedial portal and anterolateral portal was 91.69% (3.63%) and 92.03% (3.93%), respectively, for the anterior humerus articular surface. There was no significant difference in the mean FOV percentage area seen from the anteromedial and anterolateral portals (p = 0.99). The mean (SD) FOV percentage area of the posterior humerus articular surface was 84.69% (2.28%). The mean (SD) FOV percentage area seen of the radial head and trochlear was 16.05% (2.66%) and 4.14% (1.76%), respectively. CONCLUSIONS: The present study is the first to quantify the FOV of elbow arthroscopy. The majority of the anterior and posterior humerus articular surface can be seen through standard portals. The limitations in FOV are primarily confined to the radial head and trochlear notch.

Biomechanical properties of bovine tendon xenografts treated with a modern processing method.

Xenograft tendons have been used in few human studies, with variable results. With the advent of novel tissue processing techniques, which may mitigate against an immune-mediated rejection response without adversely affecting mechanical properties, there may now be a clinical role for xenograft tendons, particularly in knee ligament reconstruction. We hypothesize that 'BioCleanse®' processed bovine extensor digitorum medialis (EDM) tendons exhibit favorable time-zero pre-implantation biomechanical characteristics when compared to both unprocessed bovine EDM tendons and BioCleanse® processed human cadaveric allograft tibialis anterior tendons. In this in vitro case controlled laboratory study, three groups of tendons underwent a 5-stage static loading test protocol: 15 BioCleanse® bovine (BCB), 15 fresh frozen unprocessed bovine (FFB), and 12 BioCleanse® human allograft (BCA) tendons. Cross-sectional area of the grafts was measured using an alginate molding technique, and tendons were mounted within an Instron® 5565 Materials Testing System using cryogenic clamps. BCB tendons displayed a higher ultimate tensile stress (p<0.05), with equivalent ultimate failure load, creep, and modulus of elasticity when compared to the FFB tendons (p>0.05). BCB tendons had an equivalent cross-sectional area to the BCA tendons (p>0.05) whilst exhibiting a greater failure load, ultimate tensile stress, less creep and a higher modulus of elasticity (p<0.05). The BioCleanse® process did not adversely affect the time-zero biomechanical properties of bovine xenograft EDM tendons. BioCleanse® processed bovine xenograft EDM tendons exhibited superior biomechanical characteristics when compared with BioCleanse® processed allograft tibialis anterior tendons. These findings support further investigation of xenograft tendons in orthopedic soft tissue reconstructive surgery.

Construct Validity, Assessment of the Learning Curve, and Experience of Using a Low-Cost Arthroscopic Surgical Simulator.

OBJECTIVE: We have developed a low-cost, portable shoulder simulator designed to train basic arthroscopic skills. This study aimed to establish the construct validity of the simulator by determining which parameters discriminated between experience levels and to assess the experience of using the simulator. DESIGN: Participants were given an introductory presentation and an untimed practice run of a 6-step triangulation task using hooks and rubber bands. A total of 6 consecutive attempts at the task were timed, and the number of times the participant looked at their hands during the task was recorded. Participants then completed a questionnaire on their experience of using the simulator. SETTING: St George's Hospital, London and the South West London Elective Orthopaedic Centre, Surrey. PARTICIPANTS: Medical students, trainee doctors and surgeons, and consultant surgeons were approached to use the simulator. Participation was voluntary and nonincentivized. In total, 7 orthopedic consultants, 12 trainee doctors (ranging from foundation year 1 to clinical fellow post-Certificate of Completion of Training), and 9 medical students were recruited. RESULTS: The average time for medical students to complete the task was 161 seconds, compared to 118 seconds for trainees, and 84 seconds for consultants. The average fastest time for medical students was 105 seconds, 73 seconds for trainees, and 52 seconds for consultants. Students were significantly slower than trainees (p = 0.026) and consultants (p = 0.001). However, times did not differ significantly between trainees and consultants. Consultants looked at their hands 0.7 times on average during the task compared with 2.8 and 3.4 times for trainees and students, respectively. More than 95% of participants found the exercise interesting and agreed or strongly agreed that the simulator was easy to use, easily portable, and well designed and constructed. DISCUSSION: This study has established construct validity of the simulator by demonstrating the ability to distinguish between surgical experience levels. The learning curve shows improvement in individuals with or without arthroscopic or surgical experience. Simulation is becoming increasingly important in the training of medical students and surgical trainees; this study has established that low-cost portable arthroscopic box trainers may play a significant role.

Simulation in shoulder surgery.

Simulation is a rapidly developing field in medical education. There is a growing need for trainee surgeons to acquire surgical skills in a cost-effective learning environment to improve patient safety and compensate for a reduction in training time and operative experience. Although simulation is not a replacement for traditional models of surgical training, and robust assessment metrics need to be validated before widespread use for accreditation, it is a useful adjunct that may ultimately lead to improving surgical outcomes for our patients.

Arthroscopic Conjoint Tendon Transfer: A Technique for Revision Anterior Shoulder Stabilization.

Revision anterior stabilization of the shoulder presents a challenge to the surgeon and carries a higher risk of recurrent dislocation than primary repair. The Latarjet procedure may be more reliable than revision soft-tissue repair but may not be indicated in patients without significant glenoid bone loss. We describe an arthroscopic technique of conjoint tendon transfer using a combination of suspensory and interference screw fixation for patients without significant glenoid bone loss (<15%). The arthroscopic approach to this procedure allows intra-articular visualization to assist in mobilization of the conjoint tendon, accurate bone tunnel placement, and subsequent labral repair. It avoids the additional steps of bone block preparation and the larger portals required for arthroscopic Latarjet techniques, in addition to eliminating potential complications due to coracoid bone block resorption.

Post-traumatic osteonecrosis of the proximal humerus.

Post-traumatic osteonecrosis of the proximal humerus represents a challenging problem to the surgeon. It is commonly seen following multi-fragmentary fractures of the proximal humerus which may affect the long-term functional recovery after such injuries. This review summarises the current evidence on risk factors, reasons why estimating its epidemiology is difficult, the vascular supply of the humeral head, classification, and management options.

The 30-year wait for treatment of an acutely painful knee.

A 63-year-old retired man presented to our clinic reporting a severely painful, localised knee pain present for around 30 years and associated with a spontaneous palpable lump. He was prompted to seek medical advice at this point because his symptoms were exacerbated when his young grandchildren bumped into the knee. While radiographs were unhelpful, ultrasonography revealed a well-defined, subcutaneous soft tissue mass at the anterior aspect of the knee. Surgical excision was performed as a day case. Histological examination of the mass showed a glomus tumour. This patient had suffered for many years as a result of this painful mass but full resolution of his pain occurred immediately after excision.

The accuracy of primary care teams in diagnosing disorders of the shoulder.

OBJECTIVE: The aim of this retrospective, observational study was to determine the accuracy of diagnoses given by a multitude of primary care services to patients referred to an orthopaedic upper limb surgeon with a focus towards shoulder pathology. METHODS: Records of all patients referred to a single upper limb surgeon over a 1-year period were reviewed. The diagnosis in the primary care setting was compared with the initial working diagnosis in the specialist clinic and against the final diagnosis following specialist investigation/intervention. RESULTS: 114 eligible patients were identified. General practitioners referred 35% of patients, musculoskeletal triage services referred 63% of patients and independent physiotherapists referred 2% of patients. It was found that 37% of patients were not given a diagnosis by the primary care team. When a diagnosis was given, accuracy was 50% (κ = 0.28) when correlated against that given by an orthopaedic upper limb surgeon. CONCLUSIONS: Our findings suggest that knowledge of shoulder conditions is limited amongst primary care practitioners. There does not appear to be any difference in accuracy between general practitioners and musculoskeletal triage services.

Factors influencing foundation programme choice among medical students.

OBJECTIVES: The advent of Modernising Medical Careers has replaced the traditional pre-registration house officer (PRHO) year and first year of senior house officer (SHO) training with a combined foundation programme. The aim of this study was to find out the factors influencing choice of foundation programme among medical students. DESIGN: Prospective survey. SETTING: Three medical schools based in England. MAIN OUTCOME MEASURES: A questionnaire was formulated containing the reasons for choosing a foundation programme with students asked to rank their choices. RESULTS: There were 46 replies. The most important factors identified were geographical location (score 154) and combination of specialties (score 178). The least important factors was the reputation of consultants (score 525) and opportunities for research (score 530). CONCLUSIONS: The factors influencing choice of foundation programme are not dissimilar to the choice of PRHO year despite the different emphasis in training which it offers.

Congenital clubfoot: a review.

Congenital clubfoot is a relatively common lower limb deformity that is increasingly managed by non-operative methods of serial manipulation and immobilization. This review looks at aetiology, examination techniques and severity scoring, and provides an overview of operative and non-operative methods of treatment.

Impingement of a fibroma of the extensor tendon sheath on the extensor retinaculum.

Deep lacerations to the forearm can cause impaired movement of the digits. This report describes the presentation and management of a self-harmer who presented with loss of motion of her ring finger. Surgical exploration unexpectedly demonstrated the cause to be a fibroma of the tendon sheath impinging on the extensor retinaculum. Full recovery was demonstrated at sixmonth review following removal of the lesion.