Puneet Monga

Stiffness after Arthroscopic Shoulder Surgery: Incidence, Management and Classification

Background Stiffness after arthroscopic shoulder surgery is of significant concern to the patient, surgeon and therapist. The present study aimed to investigate the natural history of stiffness after shoulder arthroscopic procedures. Methods Postoperative recovery of range of motion (ROM) in patients who underwent 234 consecutive arthroscopic procedures over a 1-year period was reviewed. The time needed to regain full ROM was recorded for every patient. Stiffness was graded from 0 to 3 depending on the loss of movements as compared to the opposite side. Results Postoperative ROM returned to normal in 63% of patients within 3 months, 94% of patients within 6 months, 96% of patients within 9 months and 97% of patients within 1 year after surgery. Stiffness was graded as a loss of ROM compared to the contralateral shoulder, with less than a third loss as grade 1, one third to two-thirds loss as grade 2 and more than two thirds loss as grade 3. Some 85% patients with Grade 1 stiffness recovered complete ROM at 6 months, whereas only 43% of grade 2/3 stiffness returned to normal at 6 months. Only four patients required further active intervention for recovery from stiffness. Risk of developing stiffness was related to the pre-operative diagnosis. Conclusions Although, minor (grade 1) stiffness after shoulder surgery occurs commonly despite early mobilization rehabilitation protocols; it resolves rapidly without further surgical intervention in a majority of the patients.

The unicortical sternoclavicular joint reconstruction using synthetic graft

Sternoclavicular joint injuries represent 5% of all injuries to the shoulder complex. We report a safe and reproducible technique for reconstruction of anterior sternoclavicular joint dislocations, employing a synthetic graft using a unicortical technique with minimal dissection anterior to the joint.

Three dimensional scapular prints for evaluating glenoid morphology: An exploratory study

Background Computerised Tomography (CT) scans are conventionally employed to assess the glenoid morphology prior to total shoulder arthroplasty (TSA). This study explores the role of three-dimensional (3D) models for assessing glenoid morphology. Methods CT scans of 32 patients scheduled for TSA were reconstructed to scapular models using customised software and a desktop 3D printer. The size and aspect ratios were maintained. Glenoid version, glenoid maximum height and width, and the maximum acromion antero-posterior (AP) length were compared between the models and CT scans. Results The models were an accurate qualitative reflection of scapular anatomy. The average retroversion in 3D models was 8.19°±30.8° compared to 10.26°±42.5° in scan images. The mean difference was 2.07°±24.6° (p=0.408). However, the mean absolute error was 5.02°±12.3°. The mean difference of the glenoid maximum width and the acromion maximum AP length was 0.22±3.33mm (p=0.862) and 0.32±14.12mm (p=0.213) respectively. However, the mean difference was significant for the glenoid maximum height measuring 3.67±12.04mm with p=0.004. The correlation between the examiners was high for all parameters, with intraclass correlation ranging between 0.94 and 0.99. Conclusion 3D printing technology promises to be a useful tool for preoperative planning with accurate reproduction of transverse plane anatomy. 3D prints represent superior definition of reconstructed anatomical measures such as glenoid height as compared to conventional CT Scans.

Surgical reconstruction of unrepairable pectoralis major rupture using tendo-achilles allograft:

Rupture of the pectoralis major remains an infrequent injury, although, recently, it has been reported more commonly as a result of the expansion and increasing popularity of competitive sports, as well as developments in sports medicine. A number of surgical repair techniques have been described for direct repair in the acute setting. However, on occasion, the pectoralis major muscle is so retracted that a tension-free direct repair is not possible. We describe a technique for allograft reconstruction of the pectoralis major, with our preliminary outcomes, where it is found or anticipated that a direct repair is not possible.

Surgery for the fractured clavicle: factors predicting nonunion

BACKGROUND This study identifies the reasons for failure after plate osteosynthesis of midshaft clavicle fractures, complication rates, and time to radiographic union. METHODS A retrospective review of 84 consecutive patients who had undergone surgical fixation for a midshaft clavicle fracture was performed. RESULTS There were 82 patients who were included for analysis and operated on by 11 different surgeons using a mixture of locking (63%) and nonlocking (37%) plates. The rate of osteosynthesis failure was 12.2%. A logistical regression analysis found that failure of osteosynthesis had no relationship to type of plate used (P = .82), gender (P = .42), number of proximal (P = .96) or distal (P = .63) screws to the fracture, or length of plate (P = .42). Smoking was found to be the only risk factor (P = .02) that increased failure rates after midshaft clavicle osteosynthesis. CONCLUSION Smoking was the only identifiable risk factor to increase failure rates in clavicle osteosynthesis. Preoperative counseling can identify those at increased risk of implant failure and can help improve clinical results by implementing a smoking cessation plan.

SLAP Lesions Part II: Acute Lesion Versus Chronic Lesion Resulting from Repetitive Motion (or Microtrauma)

SLAP lesions can occur as a result of two discreet mechanisms. An acute SLAP tear may result from a traumatic superior compression force during a fall or a traumatic inferior pull to the arm. A chronic SLAP tear, in contrast, may result from repetitive overhead activity. Such overuse and repetitive microtrauma is commonly seen in overhead athletes. Clinical presentation of an acute SLAP tear is usually a sudden onset pain following an acute traumatic episode versus an insidious onset of symptoms in a chronic tear, which is exacerbated by repetitive overhead movements.

Shoulder Pathology in Sports

Sports injuries are on the increase, with the increasing interest and involvement in sports around the world. In Europe there is a large diversity of sports, with many sports being more prominent in certain countries. Although injury pathology is similar (e.g. a labral tear), the injury mechanisms are often unique to that sport and the rehabilitation and demands are also unique to the sport. In this Instructional Course chapter, we hope to show you some examples of this and highlight some unique and important current issues in the sports shoulder in 2014.