All-Arthroscopic Latissimus Dorsi Transfer.

Massive irreparable rotator cuff tears are often associated with severe functional impairment and disabling pain. One viable treatment option is a latissimus dorsi tendon transfer. We propose an all-arthroscopic technique that we believe avoids insult to the deltoid musculature while reducing morbidity from open harvest of the tendon. The operation is performed with the patient in the lateral decubitus position, by use of a combination of viewing and working portals in the axilla. The initial viewing portal is placed along the anterior belly of the latissimus muscle in the axilla. The latissimus and teres major are identified, as is the thoracodorsal neurovascular pedicle. The tendons are carefully separated, and the inferior and superior borders of the latissimus are whipstitched using a suture passer, which helps facilitate subsequent mobilization of the muscle. The interval deep to the deltoid and superficial to the teres minor is developed into a subdeltoid tunnel for arthroscopic tendon transfer. The latissimus tendon is then transferred and stabilized arthroscopically to the supraspinatus footprint with suture anchors. Our preliminary data suggest that this surgical technique results in improvement in pain, range of motion, and function.

All-Arthroscopic Technique for Reconstruction of Acute Acromioclavicular Joint Dislocations.

Acromioclavicular joint dislocations are a common injury particularly among contact sports players. There has been an increasing trend toward arthroscopic management of these injuries. To date, these reconstructions have primarily addressed superoinferior instability by reconstructing the coracoclavicular ligaments. We describe an all-arthroscopic technique for reconstruction of the coracoclavicular ligaments using Arthrex ABS TightRopes (Arthrex, Naples, FL), with additional stabilization of the superior acromioclavicular joint capsule using an anchor-based suture bridge to address anteroposterior instability.

Digital photography for assessment of shoulder range of motion: A novel clinical and research tool.

PURPOSE: Maintenance of a pain-free functional range of motion is the aim of surgery for shoulder trauma. The aim of this study was to show that the range of motion can be accurately assessed using digital photographs. MATERIALS AND METHODS: We reviewed 17 patients who had undergone surgery for shoulder trauma. Each patient's range of motion was assessed by two physicians and two physiotherapists. Digital photographs were taken of each patient at their functional limit. Photographs were assessed by two physicians and two physiotherapists, and by an external physician who had no previous contact with the patients. RESULTS: Inter-observer and intra-observer reliability trials showed excellent correlation of results. There was no significant difference between observer's results, or between results of physical examination and photographic examination. CONCLUSIONS: Digital photography is a viable adjunct to assessment of range of motion of the shoulder. This has positive implications both clinically, and for shoulder research. LEVEL OF EVIDENCE: Level 3.

Conservative treatment of the distal radius fracture using thermoplastic splint: pilot study results.

INTRODUCTION: Fractures of the distal radius are common accounting for approximately one-sixth of all fractures treated in the emergency room. This study reviews a series of patients with stable distal radius fractures who have been treated with thermoplastic splint. METHODS: This study was undertaken between November 2009 and May 2010 in a single orthopaedic fracture outpatient clinic. All patients had undisplaced or minimally displaced distal radius fractures. Children and open fractures were excluded. Patients had been reviewed in the outpatients with radiographs on 1, 2, 6 and 12 weeks after injury. Skin condition and satisfaction were assessed on splint removal. Radiological parameters of radial inclination, radial length and palmer tilt were measured. RESULTS: In total, 26 patients were treated with the splint. The average age of the patients was 45.1 (range, 21-73), and male/female ratio was 12:14. On average, the splint was removed at 5.1 weeks (mode = 6 weeks). The right- to left-side ratio was 11:15. Eleven of those fractures were on the dominant side. There was no significant difference in the radiological outcomes pre- and post-splinting. Nearly all patients had been satisfied with the splint. Two patients had minor cast complications whilst 23 patients were able to shower whilst in splint. CONCLUSION: Patients treated with thermoplastic splint showed no deterioration in their radiological outcomes. Nearly all the patients had been satisfied with the splint.

Nonoperative modalities to treat symptomatic cervical spondylosis.

Cervical spondylosis is a common and disabling condition. It is generally felt that the initial management should be nonoperative, and these modalities include physiotherapy, analgesia and selective nerve root injections. Surgery should be reserved for moderate to severe myelopathy patients who have failed a period of conservative treatment and patients whose symptoms are not adequately controlled by nonoperative means. A review of the literature supporting various modalities of conservative management is presented, and it is concluded that although effective, nonoperative treatment is labour intensive, requiring regular review and careful selection of medications and physical therapy on a case by case basis.

A quantitative assessment of facial protection systems in elective hip arthroplasty.

We aimed to assess the risk to surgeons of blood splatter during total hip arthroplasty. Hoods from personal protection systems used in 34 consecutive total hip replacements were collected and the area of blood splatter was measured and compared to goggles and visors. Thirty one primary THA's (13 cemented, 4 hybrid, 14 uncemented) and 3 revisions (1 hybrid, 2 uncemented) were collected. Splashes were detected on all of the masks with a mean of 034% cover. Splatter was greatest for the operating surgeon, followed by the first assistant, though the difference was not statistically significant. Operating personnel were at greater risk of contamination during uncemented arthroplasty (p < 0.0001; 95% CI). On average 50.60% and 45.40% of blood cover was outside the area protected by goggles and visors respectively. There was a significant difference between the Personal Protection Systems (PPS) and goggles (p = 0.0231; 95% CI) as well as between the PPS and visors (p = 0.0293; 95% CI).

Anterior cruciate ligament graft tensioning. Is the maximal sustained one-handed pull technique reproducible?

BACKGROUND: Tensioning of anterior cruciate ligament (ACL) reconstruction grafts affects the clinical outcome of the procedure. As yet, no consensus has been reached regarding the optimum initial tension in an ACL graft. Most surgeons rely on the maximal sustained one-handed pull technique for graft tension. We aim to determine if this technique is reproducible from patient to patient. FINDINGS: We created a device to simulate ACL reconstruction surgery using Ilizarov components and porcine flexor tendons. Six experienced ACL reconstruction surgeons volunteered to tension porcine grafts using the device to see if they could produce a consistent tension. None of the surgeons involved were able to accurately reproduce graft tension over a series of repeat trials. CONCLUSIONS: We conclude that the maximal sustained one-handed pull technique of ACL graft tensioning is not reproducible from trial to trial. We also conclude that the initial tension placed on an ACL graft varies from surgeon to surgeon.

Clavicle fractures: a comparison of five classification systems and their relationship to treatment outcomes.

We compared five classification systems for clavicle fractures. The aim of this study was to evaluate the prognostic value of each system. Over a two-year period we reviewed all new radiographs of the shoulder region and identified 487 clavicle fractures. Each radiograph was classified using five classification systems. We reviewed all subsequent X-rays and clinical records until the patient was discharged. We assessed each classification system's prognostic value in predicting delayed/non-union. Our data show that 79.3% of clavicle fractures occur in the middle third, 19.3% in the lateral third and 1.4% in the medial third. The overall prevalence of delayed/non-union was 7.3%, with 3.2% requiring operative management and 4.1% developing asymptomatic non-union. The incidence of non-union in the lateral third was 9.6%, but only 0.4% required operative management. Craig's classification had the greatest prognostic value for lateral third fractures, and Robinson's classification had the greatest prognostic value for middle third fractures. Fractures of the clavicle are common injuries but non-union is an uncommon occurrence. Non-union is more common in the lateral third, but we found these to be mostly asymptomatic. Middle third fractures are more likely to require operative fixation. Middle third fractures should be classified according to Robinson's classification system and lateral third fractures according to Craig's classification. We did not assess sufficient medial third fractures for the data to be significant.

Successful treatment of chronic osteomyelitis of the radius.

Chronic osteomyelitis is uncommon in the United Kingdom and Ireland. Current migration trends with an influx of people from less affluent nations may result in more cases of chronic osteomyelitis being seen in community and hospital practice. We report on a case of chronic osteomyelitis of the radius and document current treatment recommendations.

Irreducible Pulled Elbow in an Adolescent. A Case Report.

We present a case of pulled elbow in an adolescent patient that required open reduction.

The effects of freezing on the tensile properties of repaired porcine flexor tendon.

PURPOSE: When conducting complex testing of tendon repairs, it is essential that the samples are adequately preserved to prevent degradation. Freezing of samples is the most convenient method of preservation; however, there is no evidence in the literature to prove that freezing tendon before or after repair is acceptable. We aimed to prove that freezing tendons does not significantly alter the results of linear load-to-failure testing of tendon repairs. METHODS: After a power study, 150 tendons were harvested from porcine forelimbs and randomized into 5 groups of 30 tendons. After division, tendons were repaired using a Pennington modified core technique with a Silfverskiöld peripheral cross-stitch. Tendons in group 1 were divided, repaired, and tested within 3 hours postmortem. Tendons in group 2 were refrigerated at 4 degrees C for 24 hours prior to repair and testing. Tendons in group 3 were frozen at -25 degrees C for 3 months prior to repair and testing. Tendons in group 4 were frozen at -25 degrees C for 6 months prior to repair and testing. Tendons in group 5 were frozen at -25 degrees C for 6 months, repaired, refrozen for 1 month, and then tested. All repairs were linear load tested to ascertain the ultimate strength and force to produce 3-mm gap in the repair. RESULTS: Analysis of variance analysis of the results did not demonstrate any significant differences between groups. CONCLUSIONS: Freezing tendons both before and after suture repair is an acceptable method of preservation when investigating the force to produce 3-mm gap and ultimate strength of tendon repairs.