Henry B. Colaço

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 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.

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.

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.

Does the DVR® plate restore bony anatomy following distal radius fractures?

INTRODUCTION Fractures of the distal radius are common. Malreduced fractures are associated with residual functional deficiency. There has been a trend over the last few years for using fixed angle volar locking plates to surgically stabilise this injury. Our unit uses the DVR® plate (DePuy, Warsaw, IN, US). Nevertheless, it is unknown whether the normal bony anatomy is recreated or merely restored to acceptable limits with its usage. The aim of this study was to evaluate the reduction achieved compared with an uninjured population and pre-existing quoted ‘normal’ values. Furthermore, we wanted to identify the percentage of cases that were reduced to acceptable limits, and determine whether the grade of the surgeon and fracture type was a confounding influence on this reduction. METHODS A retrospective review of the 3-month postoperative radiography of 48 eligible patients who underwent open reduction and internal fixation of a distal radius fracture with a DVR® plate was undertaken. RESULTS Volar tilt, radial length and inclination were different to quoted normal values (p<0.01). Despite this, these parameters fell within acceptable limits in 46 cases; this was not influenced by fracture type or grade of operating surgeon. CONCLUSIONS The DVR® plate restores the bony anatomy to within acceptable limits in the majority of patients who have sustained a fracture of the distal radius although of all parameters investigated, the widest variability is seen in volar tilt.

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.

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.