Khalid D. Mohammed

Upper-limb surgery for tetraplegia

We reviewed the results of reconstruction of 97 upper limbs in a consecutive series of 57 tetraplegic patients, treated from 1982 to 1990. Of these, 49 had functional and eight had cosmetic reconstructions. The principal functional objectives were to provide active elbow extension, hook grip, and key pinch. Elbow extension was provided in 34 limbs, using deltoid-to-triceps transfer. Hook grip was provided in 58 limbs, mostly using extensor carpi radialis longus to flexor pollicis longus transfer, and key pinch in 68, mostly using brachioradialis to flexor pollicis longus transfer. Many other procedures were employed. At an average follow-up of 37 months, 70% had good or excellent subjective results, and objective measurements of function compared favourably with other series. Revisions were required for 11 active transfers and three tenodeses, while complications included rupture of anastomoses and problems with thumb interphalangeal joint stabilisation and wound healing. We report a reliable clinical method for differentiating between the activity of extensor carpi radialis longus and brevis and describe a successful new split flexor pollicis longus tenodesis for stabilising the thumb interphalangeal joint. Bilateral simultaneous surgery gave generally better results than did unilateral surgery.

A review of national shoulder and elbow joint replacement registries.

BACKGROUND The aim was to review the funding, organization, data handling, outcome measurements, and findings from existing national shoulder and elbow joint replacement registries; to consider the possibility of pooling data between registries; and to consider wether a pan european registry might be feasible. MATERIALS AND METHODS Web sites, annual reports, and publications from ongoing national registries were searched using Google, PubMed, and links from other registries. Representatives from each registry were contacted. RESULTS Between 1994 and 2004, 6 shoulder registries and 5 elbow registries were established, and by the end of 2009, the shoulder registries included between 2498 and 7113 replacements and the elbow registries between 267 and 1457 replacements. The registries were initiated by orthopedic societies and funded by the government or by levies on implant manufacturers. In some countries, data reporting and patient consent are required. Completeness is assessed by comparing data with the national health authority. All registries use implant survival as the primary outcome. Some registries use patient-reported outcomes as a secondary outcome. CONCLUSIONS A registry offers many advantages; however, adequate long-term funding and completeness remain a challenge. It is unlikely that large-scale international registries can be implemented, but more countries should be encouraged to establish registries and, by adopting compatible processes, data could be pooled between national registries, adding considerably to their power and usefulness.

Biomechanical Performance of Bankart Repairs in a Human Cadaveric Shoulder Model

The objective of this study was to develop a method to evaluate the biomechanical performance of Bankart repairs in a human cadaveric shoulder in a clinically relevant orientation. Twenty fresh-frozen human cadaveric shoulder girdles were used to compare the biomechanical performance of intact anteroinferior capsulolabral complexes with the biomechanical performance of three Bankart lesion reconstruction techniques. Repairs were performed on surgically created Bankart lesions. Evaluations were performed with the shoulders in glenohumeral abduction and external rotation. The repair techniques employed interosseous sutures, Mitek GII suture anchors, or Acufex T-Fix devices. The suture material used in all repairs was No. 2 Ti-Cron. The biomechanical performance of the three reconstruction techniques did not differ, but each was significantly inferior compared with that of the intact shoulder samples. The interosseous repairs failed by suture pullout through soft tissue. Repairs in the Mitek GII group failed by pullout of the suture anchors, suture breakage, or pullout of the suture through soft tissue. Repairs in the T-Fix group failed by pullout of the suture through soft tissue or failure of the polymer portion of the T-Fix suture.

Tendon Transfer Surgery for People With Tetraplegia: An Overview

After cervical spinal cord injury, the loss of upper limb function is common. This affects an individuals ability to perform activities of daily living and participate in previous life roles. There are surgical procedures that can restore some of the upper limb function lost after cervical spinal cord injury. Tendon transfer surgery has been performed in the tetraplegic population since the early 1970s. The goals of surgery are to provide a person with tetraplegia with active elbow extension, wrist extension (if absent), and sufficient pinch and/or grip strength to perform activities of daily living without the need for adaptive equipment or orthoses. These procedures are suitable for a specific group, usually with spinal cord impairment of C4-8, with explicit components of motor and sensory loss. Comprehensive team assessments of current functioning, environment, and personal circumstances are important to ensure success of any procedure. Rehabilitation after tendon transfer surgery involves immobilization for tendon healing followed by specific, targeted therapy based on motor learning and goal-orientated training. Outcomes of tendon transfer surgery are not limited to the improvements in an individuals strength, function, and performance of activities but have much greater life affects, especially with regard to well-being, employment, and participation. This article will provide an overview of the aims of surgery, preoperative assessment, common procedures, postoperative rehabilitation strategies, and outcomes based on clinical experience and international published literature.

Acute traumatic brachialis rupture in a young rugby player: a case report

A 17-year-old boy, who played fullback for a local rugby club, was referred with pain and swelling in the front of his left elbow after being injured while playing. The mechanism of injury suggested a hyperextension injury to his elbow. While tackling, the opponent’s knee hit his extended forearm, and he felt severe pain in the front of his elbow and had a dead-arm feeling. Since then, he had been unable to move his left elbow and had severe pain. The patient did not receive any treatment immediately and presented to us a week after his injury with marked bruising and swelling around the antecubital area of his left elbow. The elbow was held in 20 flexion, and there was pain on any further active or passive movement. The biceps tendon was difficult to palpate because of the swelling. There was no distal neurovascular deficit. The patient had undergone an ultrasound examination of the elbow before he was referred. It showed a normal biceps tendon (Fig. 1) and suggested a possible rupture and hematoma of brachialis muscle measuring about 60 mm in length, 13 mm in breadth, and 29 mm in width, just below the midpoint (Fig. 2). Owing to the unusual nature of this injury, a magnetic resonance image (MRI) of the elbow was ordered to confirm the diagnosis. The MRI, which was done about 2 weeks after the injury, showed

Shoulder pain in primary care: frozen shoulder

BACKGROUND AND CONTEXT Frozen shoulder is a painful condition that follows a protracted clinical course. We aim to review the management of patients with a diagnosis of frozen shoulder who are referred for specialist orthopaedic evaluation against existing guidelines in primary care. ASSESSMENT OF PROBLEM Referrals and clinical records were reviewed for all patients referred for orthopaedic specialist assessment who received a specialist diagnosis of frozen shoulder. Diagnostic, investigation and management practices from a regional primary health care setting in New Zealand were compared with guideline-recommended management. RESULTS Eighty patients with frozen shoulder were referred for orthopaedic evaluation in the 13 month study period, mostly from general practice. Fifteen patients (19%) were identified as having a frozen shoulder in their medical referral. Most (99%) had received previous imaging. Seven patients (12%) had received guideline recommended treatment. STRATEGIES FOR IMPROVEMENT Education of all clinicians involved in patient management is important to ensure an understanding of the long natural history of frozen shoulder and provide reassurance that outcomes are generally excellent. HealthPathways now include more information regarding diagnosis, imaging and evidence-based management for frozen shoulder. LESSONS Frozen shoulder may be under-diagnosed among patients referred for orthopaedic review. Ultrasound imaging is commonly used and may identify occult and unrelated pathology in this age-group. When managed according to clinical guidelines, patients report significant clinical and functional improvement with most reporting 80% function compared with normal after 1 year. KEYWORDS Adhesive capsulitis; bursitis; injections; practice guideline; primary health care; ultrasound.

Identification of patients with cervical SCI suitable for early nerve transfer to achieve hand opening

Study design:Retrospective audit.Objectives:The objective of this study was to identify the proportion of patients with cervical spinal cord injury who would potentially benefit from nerve transfer surgery to gain active hand opening, and to determine when a safe nerve transfer decision can be made.Setting:Christchurch, New Zealand.Methods:Case note review of the first 12 months following acute cervical spinal cord injury (2007–2012). Neurological assessment at 6 weeks, 12 weeks and 1 year following injury.Results:Fifty-three patients had complete assessments and showed changes in the level of injury and severity of neurological injury between assessments. Forty-two percent of patients had motor complete C5–7 level injuries 12 weeks following injury and would benefit from consideration for nerve transfer to improve hand opening. Fewer (26%) would benefit 1 year following injury owing to a change in the neurological level of injury.Conclusions:Twelve-week neurological assessment identifies patients who may benefit from nerve transfer surgery. This enables referral for comprehensive upper limb assessment and reassessment of motor function to determine suitability for surgical intervention. Nerve transfer within the window of opportunity provides active hand opening for patients following cervical spinal cord injury.

Does the Beighton Score Correlate With Specific Measures of Shoulder Joint Laxity

Background: Evaluation of shoulder joint laxity is an important component of the shoulder examination, especially in the setting of shoulder instability. Measures of generalized joint laxity, particularly the Beighton score, are often recorded and used to help make management decisions in these cases. However, no evidence is available to show that the Beighton score corresponds to specific measures of shoulder joint laxity. Purpose: To assess the correlation between the Beighton score and validated measures of shoulder joint laxity. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 160 participants (age range, 16-35 years) with no history of shoulder joint abnormality were examined. The Beighton score, glenohumeral external rotation (standing and lying), glenohumeral abduction, and the sulcus sign were recorded. The relationship between the Beighton score and each measure of shoulder joint laxity was assessed. Results: A high proportion of participants (34%) had a Beighton score of 4 or higher. Rates of positive shoulder laxity tests were lower (11%-19%). A positive Beighton score was a poor predictor of abnormal shoulder laxity, with low sensitivity (range, 0.40-0.48) and low positive predictive values (range, 0.13-0.31). Spearman correlation coefficients demonstrated poor correlation between the Beighton score and all measures of shoulder joint laxity when assessed as continuous variables (range, 0.29-0.45). Conclusion: The Beighton score has poor correlation with specific measures of shoulder joint laxity and should not be considered equivalent to these tests as a method of clinical assessment.

Type IV acromioclavicular joint dislocation associated with a mid-shaft clavicle malunion

This reports presents the case of a combined clavicle fracture malunion and chronic Type IV acromioclavicular (AC) joint dislocation. The patient was seen acutely in the emergency department following a mountain bike accident at which time the clavicle fracture was identified and managed conservatively however the AC dislocation was not diagnosed. The patient presented 25 months following the injury with persistent pain and disability and was treated with clavicle osteotomy and AC stabilization. We document the clinical details, surgical treatment and outcome.