Marcus Lee

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.

Conservative management versus open reduction and internal fixation for mid-shaft clavicle fractures in adults - The Clavicle Trial: study protocol for a multicentre randomized controlled trial

BackgroundClavicle fractures account for around 4% of all fractures and up to 44% of fractures of the shoulder girdle. Fractures of the middle third (or mid-shaft) account for approximately 80% of all clavicle fractures. Management of this group of fractures is often challenging and the outcome can be unsatisfactory. In particular it is not clear whether surgery produces better outcomes than non-surgical management. Currently there is much variation in the use of surgery and a lack of good quality evidence to inform our decision.Methods/DesignWe aim to undertake a multicentre randomised controlled trial evaluating the effectiveness and safety of conservative management versus open reduction and internal fixation for displaced mid-shaft clavicle fractures in adults. Surgical treatment will be performed using the Acumed clavicle fixation system. Conservative management will consist of immobilisation in a sling at the side in internal rotation for 6 weeks or until clinical or radiological union. We aim to recruit 300 patients. These patients will be followed-up for at least 9 months. The primary endpoint will be the rate of non-union at 3 months following treatment. Secondary endpoints will be limb function measured using the Constant-Murley Score and the Disabilities of the Arm, Shoulder and Hand (DASH) Score at 3 and 9 months post-operatively.DiscussionThis article presents the protocol for a multicentre randomised controlled trial. It gives extensive details of, and the basis for, the chosen methods, and describes the key measures taken to avoid bias and to ensure validity.Trial RegistrationUnited Kingdom Clinical Research Network ID: 8665. The date of registration of the trial is 07/09/2006. The date the first patient was recruited is 18/12/2007.

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.

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.

Surgical Intervention for Rheumatoid Arthritis and Complication Risks

Abstract There is a global trend toward a decline in surgical intervention for rheumatoid arthritis, over a similar period during which medical management has improved. However, surgery continues to play a role in the management of the disease as, while inflammation may vary, structural damage tends to be both cumulative and irreversible. Prosthetic joint arthroplasty is the most common surgical procedure for large joint involvement. Rheumatoid arthritis represents an independent risk factor in prosthetic joint infection, and greater experience of the surgeon with rheumatoid conditions correlates with improved patient outcomes.