Rockwood classified acromioclavicular (AC) joint injuries by displacement of the joint on radiogr... more Rockwood classified acromioclavicular (AC) joint injuries by displacement of the joint on radiographs. This classification has driven the management dogma of acute AC dislocation. The correlation between Rockwood grade and symptoms has not been described in acute injury. This study assesses that relationship. This series included 77 patients with acute AC joint injury (<6 weeks), treated between 2006 and 2015. Objective and patient-reported measures enabled correlation between clinical measures and Rockwood grade. The mean age was 32 years (±11.86; range 17-59 years); 88% were male. Forty-four per cent were professional athletes and 43% suffered injury during rugby. The mean time from injury to presentation was 2 weeks (±1.64; range 0-5 weeks). There was poor correlation between Rockwood classification and pain (visual analogue scale) ( r = 0.05; p = 0.752). Poor correlation was noted between Rockwood grade and functional deficit (elevation ( r = 0.18; p = 0.275), abduction ( r =...
Over the past 20 years the design of the surface replacement prostheses has evolved, butthe basic... more Over the past 20 years the design of the surface replacement prostheses has evolved, butthe basic concept and design of surface replacement, minimalremoval of bone and cementless ¢xation, has remained constant.The indications and surgical technique have been re¢ned during this period.The surface replacement prosthesis has demonstrated results at least equal to those of conventional stemmed prostheses suggesting that the humeral component does not need a stem or cement for ¢xation. In this paper, we discuss the evolution and development of surface replacement of the shoulder, describe the indications and surgical technique and present the results of the Copeland surface-replacement arthroplasty.
The aim of this study is to establish the sensitivity and specificity of MRA in the investigation... more The aim of this study is to establish the sensitivity and specificity of MRA in the investigation of patients with traumatic anterior shoulder dislocations. A retrospective analysis of consecutive patients undergoing both magnetic resonance arthrography and arthroscopic assessment after a traumatic anterior shoulder dislocation between January 2011 and 2014 was performed. Demographic data were collected from electronic records. Images were interpreted by 8 musculoskeletal radiologists and patients were treated by 8 consultant orthopaedic surgeons. Arthroscopic findings were obtained from surgical notes and these findings were used as a reference for MRA. The sensitivity, specificity, and positive predictive value were calculated for the different injuries. Sixty-nine patients underwent both an MRA and shoulder arthroscopy during the study period; however, clinical notes were unavailable in 9 patients. Fifty-three patients (88 %) were male, the mean age was 28 years (range 18 to 50) ...
Background The aim of this systematic review was to evaluate the effectiveness of rehabilitation ... more Background The aim of this systematic review was to evaluate the effectiveness of rehabilitation programmes following surgical repair of the rotator cuff with emphasis upon length of immobilisation and timing of introduction of load. Methods An electronic search of CENTRAL, MEDLINE and PEDro was undertaken to August 2014 and supplemented by hand searching. Randomised controlled trials were included, quality appraised using the PEDro scale and synthesised via meta-analysis or narrative synthesis, based upon levels of evidence, where appropriate. Results Twelve studies were included. There is strong evidence that early initiation of rehabilitation does not adversely affect clinical outcome but there is a marginally higher, statistically non-significant, incidence of tendon re-tear (OR 1.3; 95% CI 0.72 to 2.2). There is strong evidence that initiation of functional loading early in the rehabilitation programme does not adversely affect clinical outcome. Discussion Concern about early i...
Background: The short head of biceps brachii has been the subject of little investigation when co... more Background: The short head of biceps brachii has been the subject of little investigation when compared to the long head or distal biceps tendons. The aim of this study was to dissect and describe the origin and proximal portion of the short head of biceps brachii. Materials and Methods: Three left and two right (n=5) fresh-frozen human cadaver shoulders were dissected and the proximal short head was measured and photographed. Results: The origin of the short head of biceps consisted of muscle fibres attaching directly to the tip of the coracoid process, with a thin, tendinous aponeurosis covering its anterior surface, rather than a true tendon as previously described. Conclusion: The short head of biceps does not attach to the coracoid process via a true tendon. These findings have implications for procedures that utilise the short head of biceps.
Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2012
Capsular tear with complete labrum detachment (type III lesion) was the most frequent surgical fi... more Capsular tear with complete labrum detachment (type III lesion) was the most frequent surgical finding. Minor Bony Bankart lesions (Ͻ25%) were found in 19 cases. 75 cases (75%) of osteochondral Hill-Sachs lesions and 15 cases (15%) of bone HillSachs lesions were identified. We treated 2 cases of Humeral Avulsion of Glenohumeral ligament (HAGL) with arhtoscopic and mini open technique. According to the Rowe scale we obtained excellent and good results for 96% (74 cases) of the patients treated with the Suture Anchor Technique and in 87% (20 cases) of the patients treated with the Transglenoid technique. Return to sport was allowed after the 4th month, being at pre-injury level for all cases. The average time was 5.3 months (4-7). Discussion and conclusion: Many studies have shown a high percentage of redislocation after non-surgical treatment. Younger patients and practicing contact sports, over head sports or sports of high speed (snow skiing, motocross) increase this risk. The best time to treat shoulder instability is after the first episode; tissues are in better condition, which allows for anatomic repair. Technically it is easier to liberate and reduce the structures with minimal capsular plication. Excellent results are obtained, with early return to sport at pre-injury level. There is a clear tendency to better results with the Suture Anchor Technique.
Background: Symptomatic Acromioclavicular (AC) dislocations have historically been surgically tre... more Background: Symptomatic Acromioclavicular (AC) dislocations have historically been surgically treated with Coracoclavicular (CC) ligament reconstruction with transfer of the Coracoacromial (CA) ligament. Tensioning the CA ligament is the key to success. Methods: Seventeen patients with chronic, symptomatic Type III AC joint or acute Type IV and V injuries were treated surgically. The distal clavicle was resected and stabilized with CC ligament reconstruction using the CA ligament. The CA ligament was passed into the medullary canal and tensioned, using a modified 'docking' technique. Average follow-up was 29 months (range 12-57). Results: Postoperative ASES and pain significantly improved in all patients (p = 0.001). Radiographically, 16 (94%) maintained reduction, and only 1 (6%) had a recurrent dislocation when he returned to karate 3 months postoperatively. His ultimate clinical outcome was excellent. Conclusion: The docking procedure allows for tensioning of the transferred CA ligament and healing of the ligament in an intramedullary bone tunnel. Excellent clinical results were achieved, decreasing the risk of recurrent distal clavicle instability.
Acute compartment syndrome after muscle rupture, although rare, is a limb threatening condition, ... more Acute compartment syndrome after muscle rupture, although rare, is a limb threatening condition, which warrants emergency treatment. The case of acute compartment syndrome secondary to a gastrocnemius muscle tear of the right lower leg, in a non-athlete is reported. To our knowledge, this is the only description of acute compartment syndrome due to muscle rupture in a non-athlete.
Shoulder injuries in rugby players are common, but the mechanisms of injury are less well underst... more Shoulder injuries in rugby players are common, but the mechanisms of injury are less well understood. This study aims to elucidate common mechanisms of injury and identify the patterns of injury they produce. Twenty-four elite rugby players, referred to the senior author for diagnosis and management of shoulder injuries, were selected. Videos of the injuries were independently reviewed by rugby-medical experts to describe the mechanisms of injury. The mechanisms reported were collated and analysed to determine the level of agreement between reviewers and conclude an overall description of injury mechanisms. The authors identified three mechanisms of shoulder injury from the video analysis. These are the &amp;amp;amp;amp;amp;amp;amp;amp;#39;Try-Scorer&amp;amp;amp;amp;amp;amp;amp;amp;#39;, characterised by hyperflexion of the outstretched arm such as when scoring a try; the &amp;amp;amp;amp;amp;amp;amp;amp;#39;Tackler&amp;amp;amp;amp;amp;amp;amp;amp;#39;, extension of the abducted arm behind the player while tackling; and the &amp;amp;amp;amp;amp;amp;amp;amp;#39;Direct Impact&amp;amp;amp;amp;amp;amp;amp;amp;#39;, a direct blow to the arm or shoulder when held by the side in neutral or slight adduction. The Try Scorer and Tackler mechanisms both involve a levering force on the glenohumeral joint (GHJ). These mechanisms predominantly cause GHJ dislocation, with Bankart, reverse Bankart and superior labrum anterior-posterior tears. The Try-Scorer Mechanism also caused the majority (83%) of rotator cuff tears. The Direct Hit mechanism resulted in GHJ dislocation and labral injury in 37.5% of players and was most likely to cause acromioclavicular joint dislocation and scapula fractures, injuries that were not seen with the other mechanisms. Greater understanding of the mechanisms involved in rugby shoulder injury is useful in understanding the pathological injuries, guiding treatment and rehabilitation and aiding the development of injury-prevention methods.
Distal biceps tendon ruptures are uncommon injuries with only around 300 cases reported in the li... more Distal biceps tendon ruptures are uncommon injuries with only around 300 cases reported in the literature. Current management tends to favour anatomical reinsertion of the tendon into the radial tuberosity, especially in young and active individuals. These injuries are commonly repaired using either a single anterior incision with suture anchors or the Boyd-Anderson dual incision technique. We report the use of a bioabsorbable interference screw for the repair of distal biceps tendon rupture using a minimal incision technique. In this technique the avulsed tendon and a bioabsorbable screw are secured in a drill hole on the radial tuberosity using whip stitch and fibre wire sutures according to Biotenodesis system guidelines. The technique described requires minimal volar dissection that is associated with a reduced number of synostosis and posterior interosseous nerve injuries. The bioabsorbable interference screw has all the advantages of being biodegradable and has been shown to have greater pullout strength than suture anchors. It is also a reasonable alternative to titanium screws in terms of primary fixation strength. The strong fixation provided allows early active motion and return to previous activities as seen in our case.
Background: The aim of this systematic review was to evaluate the effectiveness of rehabilitation... more Background: The aim of this systematic review was to evaluate the effectiveness of rehabilitation programmes following surgical repair of the rotator cuff with emphasis upon length of immobilisation and timing of introduction of load. Methods: An electronic search of CENTRAL, MEDLINE and PEDro was undertaken to August 2014 and supplemented by hand searching. Randomised controlled trials were included, quality appraised using the PEDro scale and synthesised via meta-analysis or narrative synthesis, based upon levels of evidence, where appropriate. Results: Twelve studies were included. There is strong evidence that early initiation of rehabilitation does not adversely affect clinical outcome but there is a marginally higher, statistically non-significant, incidence of tendon re-tear (OR 1.3; 95% CI 0.72 to 2.2). There is strong evidence that initiation of functional loading early in the rehabilitation programme does not adversely affect clinical outcome. Discussion: Concern about early initiation of rehabilitation and introduction of gradual functional load does not appear warranted but this should be considered in a context of potential for Type II error. There is further need to evaluate approaches that foster early initiation of rehabilitation and gradual introduction of functional load as well as considering key outcomes such as return to work.
Rockwood classified acromioclavicular (AC) joint injuries by displacement of the joint on radiogr... more Rockwood classified acromioclavicular (AC) joint injuries by displacement of the joint on radiographs. This classification has driven the management dogma of acute AC dislocation. The correlation between Rockwood grade and symptoms has not been described in acute injury. This study assesses that relationship. This series included 77 patients with acute AC joint injury (<6 weeks), treated between 2006 and 2015. Objective and patient-reported measures enabled correlation between clinical measures and Rockwood grade. The mean age was 32 years (±11.86; range 17-59 years); 88% were male. Forty-four per cent were professional athletes and 43% suffered injury during rugby. The mean time from injury to presentation was 2 weeks (±1.64; range 0-5 weeks). There was poor correlation between Rockwood classification and pain (visual analogue scale) ( r = 0.05; p = 0.752). Poor correlation was noted between Rockwood grade and functional deficit (elevation ( r = 0.18; p = 0.275), abduction ( r =...
Over the past 20 years the design of the surface replacement prostheses has evolved, butthe basic... more Over the past 20 years the design of the surface replacement prostheses has evolved, butthe basic concept and design of surface replacement, minimalremoval of bone and cementless ¢xation, has remained constant.The indications and surgical technique have been re¢ned during this period.The surface replacement prosthesis has demonstrated results at least equal to those of conventional stemmed prostheses suggesting that the humeral component does not need a stem or cement for ¢xation. In this paper, we discuss the evolution and development of surface replacement of the shoulder, describe the indications and surgical technique and present the results of the Copeland surface-replacement arthroplasty.
The aim of this study is to establish the sensitivity and specificity of MRA in the investigation... more The aim of this study is to establish the sensitivity and specificity of MRA in the investigation of patients with traumatic anterior shoulder dislocations. A retrospective analysis of consecutive patients undergoing both magnetic resonance arthrography and arthroscopic assessment after a traumatic anterior shoulder dislocation between January 2011 and 2014 was performed. Demographic data were collected from electronic records. Images were interpreted by 8 musculoskeletal radiologists and patients were treated by 8 consultant orthopaedic surgeons. Arthroscopic findings were obtained from surgical notes and these findings were used as a reference for MRA. The sensitivity, specificity, and positive predictive value were calculated for the different injuries. Sixty-nine patients underwent both an MRA and shoulder arthroscopy during the study period; however, clinical notes were unavailable in 9 patients. Fifty-three patients (88 %) were male, the mean age was 28 years (range 18 to 50) ...
Background The aim of this systematic review was to evaluate the effectiveness of rehabilitation ... more Background The aim of this systematic review was to evaluate the effectiveness of rehabilitation programmes following surgical repair of the rotator cuff with emphasis upon length of immobilisation and timing of introduction of load. Methods An electronic search of CENTRAL, MEDLINE and PEDro was undertaken to August 2014 and supplemented by hand searching. Randomised controlled trials were included, quality appraised using the PEDro scale and synthesised via meta-analysis or narrative synthesis, based upon levels of evidence, where appropriate. Results Twelve studies were included. There is strong evidence that early initiation of rehabilitation does not adversely affect clinical outcome but there is a marginally higher, statistically non-significant, incidence of tendon re-tear (OR 1.3; 95% CI 0.72 to 2.2). There is strong evidence that initiation of functional loading early in the rehabilitation programme does not adversely affect clinical outcome. Discussion Concern about early i...
Background: The short head of biceps brachii has been the subject of little investigation when co... more Background: The short head of biceps brachii has been the subject of little investigation when compared to the long head or distal biceps tendons. The aim of this study was to dissect and describe the origin and proximal portion of the short head of biceps brachii. Materials and Methods: Three left and two right (n=5) fresh-frozen human cadaver shoulders were dissected and the proximal short head was measured and photographed. Results: The origin of the short head of biceps consisted of muscle fibres attaching directly to the tip of the coracoid process, with a thin, tendinous aponeurosis covering its anterior surface, rather than a true tendon as previously described. Conclusion: The short head of biceps does not attach to the coracoid process via a true tendon. These findings have implications for procedures that utilise the short head of biceps.
Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2012
Capsular tear with complete labrum detachment (type III lesion) was the most frequent surgical fi... more Capsular tear with complete labrum detachment (type III lesion) was the most frequent surgical finding. Minor Bony Bankart lesions (Ͻ25%) were found in 19 cases. 75 cases (75%) of osteochondral Hill-Sachs lesions and 15 cases (15%) of bone HillSachs lesions were identified. We treated 2 cases of Humeral Avulsion of Glenohumeral ligament (HAGL) with arhtoscopic and mini open technique. According to the Rowe scale we obtained excellent and good results for 96% (74 cases) of the patients treated with the Suture Anchor Technique and in 87% (20 cases) of the patients treated with the Transglenoid technique. Return to sport was allowed after the 4th month, being at pre-injury level for all cases. The average time was 5.3 months (4-7). Discussion and conclusion: Many studies have shown a high percentage of redislocation after non-surgical treatment. Younger patients and practicing contact sports, over head sports or sports of high speed (snow skiing, motocross) increase this risk. The best time to treat shoulder instability is after the first episode; tissues are in better condition, which allows for anatomic repair. Technically it is easier to liberate and reduce the structures with minimal capsular plication. Excellent results are obtained, with early return to sport at pre-injury level. There is a clear tendency to better results with the Suture Anchor Technique.
Background: Symptomatic Acromioclavicular (AC) dislocations have historically been surgically tre... more Background: Symptomatic Acromioclavicular (AC) dislocations have historically been surgically treated with Coracoclavicular (CC) ligament reconstruction with transfer of the Coracoacromial (CA) ligament. Tensioning the CA ligament is the key to success. Methods: Seventeen patients with chronic, symptomatic Type III AC joint or acute Type IV and V injuries were treated surgically. The distal clavicle was resected and stabilized with CC ligament reconstruction using the CA ligament. The CA ligament was passed into the medullary canal and tensioned, using a modified 'docking' technique. Average follow-up was 29 months (range 12-57). Results: Postoperative ASES and pain significantly improved in all patients (p = 0.001). Radiographically, 16 (94%) maintained reduction, and only 1 (6%) had a recurrent dislocation when he returned to karate 3 months postoperatively. His ultimate clinical outcome was excellent. Conclusion: The docking procedure allows for tensioning of the transferred CA ligament and healing of the ligament in an intramedullary bone tunnel. Excellent clinical results were achieved, decreasing the risk of recurrent distal clavicle instability.
Acute compartment syndrome after muscle rupture, although rare, is a limb threatening condition, ... more Acute compartment syndrome after muscle rupture, although rare, is a limb threatening condition, which warrants emergency treatment. The case of acute compartment syndrome secondary to a gastrocnemius muscle tear of the right lower leg, in a non-athlete is reported. To our knowledge, this is the only description of acute compartment syndrome due to muscle rupture in a non-athlete.
Shoulder injuries in rugby players are common, but the mechanisms of injury are less well underst... more Shoulder injuries in rugby players are common, but the mechanisms of injury are less well understood. This study aims to elucidate common mechanisms of injury and identify the patterns of injury they produce. Twenty-four elite rugby players, referred to the senior author for diagnosis and management of shoulder injuries, were selected. Videos of the injuries were independently reviewed by rugby-medical experts to describe the mechanisms of injury. The mechanisms reported were collated and analysed to determine the level of agreement between reviewers and conclude an overall description of injury mechanisms. The authors identified three mechanisms of shoulder injury from the video analysis. These are the &amp;amp;amp;amp;amp;amp;amp;amp;#39;Try-Scorer&amp;amp;amp;amp;amp;amp;amp;amp;#39;, characterised by hyperflexion of the outstretched arm such as when scoring a try; the &amp;amp;amp;amp;amp;amp;amp;amp;#39;Tackler&amp;amp;amp;amp;amp;amp;amp;amp;#39;, extension of the abducted arm behind the player while tackling; and the &amp;amp;amp;amp;amp;amp;amp;amp;#39;Direct Impact&amp;amp;amp;amp;amp;amp;amp;amp;#39;, a direct blow to the arm or shoulder when held by the side in neutral or slight adduction. The Try Scorer and Tackler mechanisms both involve a levering force on the glenohumeral joint (GHJ). These mechanisms predominantly cause GHJ dislocation, with Bankart, reverse Bankart and superior labrum anterior-posterior tears. The Try-Scorer Mechanism also caused the majority (83%) of rotator cuff tears. The Direct Hit mechanism resulted in GHJ dislocation and labral injury in 37.5% of players and was most likely to cause acromioclavicular joint dislocation and scapula fractures, injuries that were not seen with the other mechanisms. Greater understanding of the mechanisms involved in rugby shoulder injury is useful in understanding the pathological injuries, guiding treatment and rehabilitation and aiding the development of injury-prevention methods.
Distal biceps tendon ruptures are uncommon injuries with only around 300 cases reported in the li... more Distal biceps tendon ruptures are uncommon injuries with only around 300 cases reported in the literature. Current management tends to favour anatomical reinsertion of the tendon into the radial tuberosity, especially in young and active individuals. These injuries are commonly repaired using either a single anterior incision with suture anchors or the Boyd-Anderson dual incision technique. We report the use of a bioabsorbable interference screw for the repair of distal biceps tendon rupture using a minimal incision technique. In this technique the avulsed tendon and a bioabsorbable screw are secured in a drill hole on the radial tuberosity using whip stitch and fibre wire sutures according to Biotenodesis system guidelines. The technique described requires minimal volar dissection that is associated with a reduced number of synostosis and posterior interosseous nerve injuries. The bioabsorbable interference screw has all the advantages of being biodegradable and has been shown to have greater pullout strength than suture anchors. It is also a reasonable alternative to titanium screws in terms of primary fixation strength. The strong fixation provided allows early active motion and return to previous activities as seen in our case.
Background: The aim of this systematic review was to evaluate the effectiveness of rehabilitation... more Background: The aim of this systematic review was to evaluate the effectiveness of rehabilitation programmes following surgical repair of the rotator cuff with emphasis upon length of immobilisation and timing of introduction of load. Methods: An electronic search of CENTRAL, MEDLINE and PEDro was undertaken to August 2014 and supplemented by hand searching. Randomised controlled trials were included, quality appraised using the PEDro scale and synthesised via meta-analysis or narrative synthesis, based upon levels of evidence, where appropriate. Results: Twelve studies were included. There is strong evidence that early initiation of rehabilitation does not adversely affect clinical outcome but there is a marginally higher, statistically non-significant, incidence of tendon re-tear (OR 1.3; 95% CI 0.72 to 2.2). There is strong evidence that initiation of functional loading early in the rehabilitation programme does not adversely affect clinical outcome. Discussion: Concern about early initiation of rehabilitation and introduction of gradual functional load does not appear warranted but this should be considered in a context of potential for Type II error. There is further need to evaluate approaches that foster early initiation of rehabilitation and gradual introduction of functional load as well as considering key outcomes such as return to work.
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Papers by L. Funk