Graham Tytherleigh-Strong

Rotator cuff disease.

The important role played by the rotator cuff in the stability and movement of the glenohumeral joint make it susceptible to damage and injury in patients of all age groups. A number of extrinsic and intrinsic mechanisms have been described for the development of rotator cuff disease, although it is more likely that the actual etiology in any one individual is multifactorial. The key to successful management in a particular patient is an accurate diagnosis of the underlying cause by thorough clinical examination and the use of appropriate investigations. The mainstay of treatment of patients with rotator cuff disease is nonoperative. Surgical intervention is usually considered only after failure of at least 6 months of conservative therapy. However, there are a few situations where early surgical intervention is indicated.

Nonoperative treatment of humeral shaft fractures revisited

PURPOSE The purpose of this study was to examine the union rate of humeral shaft fractures treated nonoperatively and to establish whether a particular fracture type is more likely to go on to nonunion. METHODS Radiographs and patient records of 207 humeral shaft fractures occurring during 5 years were retrospectively reviewed. All patients were initially managed nonoperatively and placed in a U-slab on diagnosis in the emergency department; this was converted to a functional humeral brace at 7 to 10 days after injury. Fracture location, morphology and comminution were assessed radiologically. Union was defined as the absence of pain and movement at the fracture site in the presence of radiographic callus formation. Nonunion was defined as no evidence of bone union by 1 year after injury or fractures requiring delayed fixation, defined as operative fixation undertaken more than 6 weeks after injury. RESULTS The study included 138 humeral shaft fracture patients; 18 patients (11%) were lost to follow-up, and 24 went on to nonunion, giving an overall union rate of 83%. Of the 24 nonunions, 15 underwent delayed operative fixation at an average of 8.3 months after injury. The union rate for proximal-third fractures was 76% compared with 88% for middle-third fractures and 85% for distal-third fractures. Comminuted fractures (defined as 3+ parts) had a 89% union rate regardless of position. CONCLUSION A lower threshold for surgical intervention may be considered in proximal-third, two-part spiral-oblique humeral shaft fractures. Brace therapy can be the optimal treatment regimen, but it is not the only option.

Arthroscopic Excision of the Sternoclavicular Joint for the Treatment of Sternoclavicular Osteoarthritis

PURPOSE To report the results of a series of 10 patients who underwent an arthroscopic excision of the sternoclavicular joint (SCJ) for osteoarthritis refractory to conservative treatment. METHODS We undertook an arthroscopic excision of the SCJ in 10 patients with osteoarthritis. There were 7 female and 3 male patients with a mean age at surgery of 53 years (range, 42 to 62 years). Patients were assessed preoperatively and at follow-up with the Constant score and the Rockwood SCJ scoring system. The mean follow-up was 28 months (range, 17 to 41 months; SD, 8.1 months). Surgery was undertaken as a day case with no shoulder immobilization. RESULTS All of the patients had regained their preoperative or full range of movement within 2 weeks of surgery. At most recent follow-up, 7 patients had no pain and 3 had slight pain with activity. The median Constant score had increased from 64.5 (range, 41 to 77) to 83 (range, 61 to 95), and the median Rockwood score had increased from 6 (range, 4 to 7) to 13.5 (range, 9 to 15) (maximum, 15). On the basis of these findings, the clinical results were rated as excellent (13 to 15) in 7 patients, good (10 to 12) in 2, and fair (7 to 9) in 1. There were no complications and, specifically, no problems with joint stability. CONCLUSIONS The results of this study show that arthroscopic SCJ excision is a satisfactory treatment for SCJ osteoarthritis refractory to conservative measures. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Arthroscopy of the Sternoclavicular Joint

Traditionally, an open approach has been required to undertake any surgical intervention for intra-articular sternoclavicular joint pathology. This in itself carries a certain operative morbidity, including damage to the underlying mediastinal structures and damage to the sternoclavicular and costoclavicular ligaments, with subsequent joint instability and unsightly scarring. This technical note describes an arthroscopic approach to the sternoclavicular joint that reduces this morbidity. The evolution of the technique including the rationale for portal placement and the angle of instrument insertion is explained. Experience of over 50 arthroscopic procedures including diagnostic arthroscopy, discectomy, excision of loose bodies, and washout and debridement after infection and excision of the medial end of the clavicle for osteoarthritis is detailed.

BESS/BOA Patient Care Pathways: Traumatic anterior shoulder instability.

Definition Anterior traumatic shoulder instability can be defined as excessive anterior translation of the humeral head on the glenoid fossa caused primarily by a traumatic event. This results in symptoms including pain, discomfort, subluxation or dislocation. This has also been referred to as Type 1 instability (Figure 1) on the Stanmore triangle of instability.1 Figure 1. Stanmore classification of shoulder instability. Shared decision-making The General Medical Council’s ‘Good Medical Practice guide2 clearly states in the section on working in partnership with patients that doctors should: Listen to patients and respond to their concerns and preferences. Give patients the information they want or need in a way they can understand. Respect patients’ right to reach decisions with the doctor about their treatment and care. Support patients in caring for themselves to improve and maintain their health. This can only be achieved by direct consultation between the patient and their treating clinician. Decisions about treatment taken without such direct consultation between patient and treating clinician are not appropriate, as they do not adhere to principles of good medical practice.

Review article: Regenerative techniques for repair of rotator cuff tears

The failure rate of rotator cuff repair is high. Regenerative techniques using material scaffolds, stem cells, and growth factors help augment repair and regenerate tissue. We reviewed the literature of various regenerative techniques in terms of (1) enhancing the repair process, (2) tissue regeneration, (3) mechanical strength, and (4) clinical outcome.

The prevalence of osteoarthritis of the sternoclavicular joint on computed tomography.

BACKGROUND Symptomatic disorders around the sternoclavicular joint (SCJ) are relatively uncommon. Previous cadaveric and radiographic studies have suggested that asymptomatic osteoarthritic changes are relatively common, progressively increasing with age. The purpose of this study was to determine the prevalence of SCJ osteoarthritis in the general population using computed tomography (CT) scans. METHODS We assessed 464 SCJs in 232 patients undergoing a standardized axial CT scan of the thorax including both SCJs, across a range of ages from the second to tenth decade. The scans were undertaken for multiple clinical indications; however, none were obtained to investigate SCJ pathology. The predominant changes investigated were for the features associated with osteoarthritis including the presence of osteophytes, subchondral cysts, and subcortical sclerosis. RESULTS The CT scans of 244 SCJs (53%) in 137 patients (59%) showed at least 1 sign of osteoarthritis. No patients younger than 35 years had any features of osteoarthritis. Osteoarthritic changes were present in 89.6% of patients older than 50 years compared with 9.1% younger than this age. All patients above the age of 61 had at least 1 feature of osteoarthritic changes on at least 1 side of the SCJ. Increasing prevalence was noted with increasing age both in the percentage of SCJs showing any positive signs of osteoarthritis and in the severity of osteoarthritis. CONCLUSION SCJ osteoarthritis is a very common incidental finding on CT scans, particularly with increasing age. This should be taken into consideration when using a CT scan to assess a patient with symptomatic SCJ pathology.

Arthroscopic Intra-articular Disk Excision of the Sternoclavicular Joint

The sternoclavicular joint (SCJ) has a complete intra-articular disk that can be damaged either as a result of trauma or as part of ongoing degenerative joint disease. Although often asymptomatic, SCJ disk tears may lead to mechanical symptoms and pain. Previously, isolated symptomatic SCJ disk tears have only occasionally been mentioned in the literature with a few associated case reports of diskectomy by open arthrotomy. With improved imaging and availability of magnetic resonance imaging scans and the advent of SCJ arthroscopy it is now possible to treat symptomatic SCJ disk tears by arthroscopic excision. In this Technical Note, we describe the diagnosis of a torn SCJ disk and the technique of arthroscopic excision of a torn SCJ disk.

Subclavian vein thrombosis following acute internal fixation of a clavicular fracture

With the recent increase in popularity of early operative fixation for certain clavicular fracture configurations, it is important for orthopaedic surgeons to be mindful of the possible additional risk of thromboembolic complications that may arise as a consequence of an acute injury. We describe the case of a 41-year-old man who presented to our department with a left-sided, middle-third, displaced clavicular fracture. He underwent an acute open reduction and internal fixation, which was complicated by a postoperative subclavian vein thrombosis. This was treated with oral anticoagulation. The thrombus had completely resorbed by 3 months. Five months after surgery, the patient had a full range of movement of the left arm, with no swelling, after having completed a 4000-mile cycle ride. A review of the available literature suggests that the commonest and safest treatment for a subclavian vein thrombosis is subcutaneous unfractionated heparin followed by oral warfarin therapy. The present case report highlights the potential risk of upper limb thrombosis after acute osteo-synthesis of the clavicle and discusses the current evidence with respect to the treatment of upper limb venous thrombosis.

Arthroscopic Excision of the Sternoclavicular Joint

Osteoarthritis changes at the sternoclavicular joint (SCJ) have been shown to be present on computed tomography in more than 90% of people over the age of 60 years. Although usually asymptomatic, when symptoms do occur, they can be very debilitating. Most patients respond favorably to conservative treatment, but there is a small cohort of patients who continue to be symptomatic despite adequate conservative treatment. Surgical management with an open SCJ excision has been shown to give satisfactory results. However, probably due to concerns with regard to damage to the mediastinal structures, instability, and scarring, there is a high threshold for surgery. Arthroscopic SCJ excision has been shown to achieve similar results to an open procedure while avoiding some of the risks. In this Technical Note, we describe the indications, imaging, and the technique of an arthroscopic excision of the SCJ.