Eyiyemi O. Pearse

A new technique for stabilizing adolescent posteriorly displaced physeal medial clavicular fractures

BACKGROUND Adolescent posteriorly displaced physeal injuries of the medial clavicle are uncommon. Up to 50% of conservatively treated patients remain symptomatic, and late surgery is hazardous. Stability is rarely achieved with closed or open reduction alone, and internal fixation is usually required. Previously described options for fixation achieve stability of the medial clavicle by securing it to the intact epiphysis. Because the epiphyseal fragment is small, fixation is achieved using sutures or wires. This relies on the size and structural integrity of the medial fragment, which in our experience can be variable. We hypothesized that a novel technique of operative stabilization of these injuries, which does not require fixation to the epiphyseal fragment and uses no metalwork, is safe and effective in treating these injuries. MATERIALS AND METHODS The operative technique involves suturing the medial clavicle to the anterior platysmal and periosteal layer using absorbable sutures passed through drill holes in the medial clavicle. Patients were assessed clinically an average of 9 months after surgery. RESULTS We treated 7 patients with this method. There were no intraoperative complications. All patients were pain-free and symptom-free and had a full range of movement at follow-up. All patients had returned to their preinjury level of sports. CONCLUSIONS We recommend this technique for treating these uncommon injuries. It is simple, safe, and reproducible and it produces good results.

Metallosis and cutaneous metal pigmentation in a reverse shoulder replacement

Metallosis with an associated cutaneous pigmentation as a result of metal dispersion has not been reported in the literature. A case is described in a patient who developed an extensive metallosis that presented with cutaneous pigmentation 8 years after a reverse shoulder replacement.

An unusual cause of subacromial impingement: a collagenous fibroma in the bursa.

A previously fit and well 23-year-old right-handed female patient developed pain spontaneously in her right shoulder. Initially the pain was poorly localized and relatively mild; however, within a week it was severe enough to prompt an attendance at the accident and emergency department. She was assessed clinically. Radiographs were taken and a diagnosis of impingement syndrome was made. She was offered a steroid injection but declined this. The patient was referred for physiotherapy which consisted of cuff strengthening Thera-Band exercises. She put up with this for a few months, but found that this made her shoulder worse. Eventually, the patient consulted her general practitioner who referred her to the specialist shoulder unit for an opinion. The patient presented to our unit 8 months after the onset of her symptoms with right shoulder pain which was felt in the deltoid area and had severe night pain. She was taking tramadol and diclofenac regularly and had discontinued her course in midwifery due to the severity of her symptoms. The examination findings were of mild acromioclavicular joint tenderness. She had pain on active shoulder abduction from 80 to 180 and provocation tests for cuff pain (Jobe’s supraspinatus test and Hawkin’s impingement sign) were positive. Provocation tests for

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.

Arthroscopic Posterior Stabilization of the Shoulder Using a Percutaneous Knotless Mattress Suture Technique

Posterior shoulder instability is far less common than anterior instability, and its arthroscopic treatment can be technically demanding. We describe a percutaneous arthroscopic technique for posterior shoulder stabilization using mattress sutures and knotless anchors. Spinal needles are used to pass the sutures percutaneously in a mattress fashion. Knotless anchors are used to secure the sutures under the labrum. These anchors can be used without cannulas, giving easier access to the posterior glenoid. This procedure is simple, cost-effective, and safe, avoiding the presence of both knots and suture strands in contact with the humeral head.

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.

Arthroscopic Posterior Glenoid Fracture Fixation Using Knotless Suture Anchors

Shoulder instability after a posterior glenoid rim fracture is rare and potentially difficult pathology to treat. Operative techniques often involve a large dissection to view the fragments resulting in local soft tissue injury. Internal fixation is often achieved with interfragmentary screws; however, this may not be possible with small or multifragmentary fracture patterns. We describe an arthroscopic technique for posterior glenoid rim fracture fixation using knotless suture anchors. These anchors can be inserted without cannulas allowing easier access to the posterior glenoid. This procedure is simple, safe, and offers good visualization of the glenohumeral joint whilst avoiding the detrimental effects of larger surgical dissection.

A Percutaneous Knotless Technique for SLAP Repair

We describe a percutaneous technique for repair of type II SLAP lesions. Through the Neviaser portal, a spinal needle is used to pass a FiberStick suture (Arthrex, Naples, FL) through the labrum to create 2 mattress sutures that are secured with PushLock anchors (Arthrex). This technique is simple, reproducible, and knotless and requires no cannulas. At the end of the procedure, minimal suture material remains in the joint.

Double versus Single Tightropes in Patients with Acromioclavicular Joint Dislocations

We read with interest the paper by Tsiouri et al. [1]. The authors presented their experience of the use of the Tightrope implant for the stabilization of acute and chronic acromioclavicular joint dislocations and lateral clavicle fractures in 40 patients. They reported a ‘disappointingly’ high rate of failure of 19% (nine patients) and, as a result, the authors concluded that the Tightrope alone is not adequate to stabilize the acromioclavicluar joint. In their conclusion, the authors stated that they were unable to identify any specific factor that contributed to failure and therefore have ceased using the Tightrope implant. We considered that it was important to highlight several factors that, in our opinion, significantly contributed to the failure rate presented in this series. The original description of the technique [2,3] advised on the use of the procedure for acute injuries defined as dislocations sustained less than 4 weeks before the operation. The procedure is not advised for use in cases of chronic dislocation and, in our institution, we use a Modified Weaver–Dunn procedure (i.e. a biological reconstruction of the coracoclavicular ligaments) for such cases. The authors have chosen to ignore this advice. First, their cut off for defining an injury as acute is 6 weeks rather than 4 weeks. This would imply that a significant (but unspecified in their paper) number of patients underwent surgery between 4 weeks and 6 weeks post injury. Second, the authors have chosen to treat 13 chronic cases with a mean time to surgery of 13 weeks. The authors have therefore reported an extremely small series of patients treated appropriately: at most, this numbers 18 in total but, in reality, because several ‘acute’ patients are likely to have had operations after the 4-week window, the number of appropriately treated patients is likely to be much less than this. Four of the nine failures occurred in patients with chronic injuries. It is not possible to determine from the data presented in their paper how many of the remaining five failures occurred when operations took place more than 4 weeks after the injuries. One of the five failures in the acute group was attributed to infection. To our knowledge, infection is not the exclusive domain of this technique. Two of the five failures in the acute group were stable asymptomatic subluxations. It has also been our experience that such radiological subluxations are minor, of no cosmetic concern, entirely asymptomatic and nonprogressive. We do not consider such cases as failures of the technique. The remaining two of the five failures in the acute group failed by ‘cutting out’. Cut out usually results from an error with the positioning of the drill hole: the drill hole is either placed too anteriorly or posteriorly in the clavicle or too medially or laterally in the coracoid and this leaves a thin cortical shell through which the implant can cut out. In our series of 50 cases [3], all failures bar one were the result of a technical error. Failure as a result of technical error is probably more likely with the use of two separate drill holes There are other concerns with their paper. Although the authors wrote ‘Postoperative immobilization was limited to 4 weeks in a sling’, they pointed out in their results section that there was a significant rate of noncompliance, with an average of only 3 weeks in a sling after the operation and as little as 0 weeks! This also questions the compliance with return to physical activity and sport. The failure rate reported by Bain et al. [4] arose as a result of allowing patients to return to physical activity immediately after surgery and therefore cannot be considered as a failure of technique but of rehabilitation. The authors did not indicate how many of their failures complied with postoperative rehabilitation instructions and it is not certain how many of their patients fall into the category of failure of rehabilitation rather than failure of technique. Another concern is the statistical analysis used to identify relationships between failure and factors such as type of injury, chronicity, use of single or double Tightrope, etc. The number of patients in their series is extremely small and this makes the risk of a type II error (i.e. failure to reject the null hypothesis when there really is a difference) very high and the statement that they found no significant correlation unreliable. Finally, we have concerns about the attention to detail in their paper. The name of the author of the original description of the technique is spelled incorrectly in two of the three references in their paper. We can conclude from the data presented that, of 31 cases presented in their paper, 13 chronic cases were treated contrary to the recommendation in the description of the original technique. Of the remaining 18, an unspecified number were treated outside the recommended 4-week window and an unspecified number were not compliant with their rehabilitation. Two of these 18 patients (11%) failed as a result of a technical error, which may have been made more likely by the authors’ use of a double drill hole and double implant technique. Given the authors’ choice to disregard important recommendations made in the original description of the technique, we think it wise that they no longer use the technique. However, we would suggest that their paper is not representative of the results when the manufacturer’s advice is followed by a skilled arthroscopist.

A novel technique for internal fixation of a complex radial head fracture

The internal fixation of a transverse shear fracture through the radial head of a 31-year-old female is described. This unusual fracture pattern has not been previously described in the literature and presented an operative challenge. A novel technique was employed using suture anchors to securely re-attach the sheared fragment of bone without damaging the articular surface of the radial head. The patient made a full recovery with restoration of a full range of motion at the elbow, and radiological evidence of union with no signs of avascular necrosis at 6 months.