Simon Lambert

Plate osteosynthesis of diaphyseal fractures of the radius and ulna

Between January 1980 and December 1989, 133 consecutive patients were treated for a fracture of the shaft of one or both forearm bones (134 forearms in total). All fractures were stabilized with AO/ASIF 3.5 mm stainless-steel dynamic compression plates. The 1 year follow-up rate was 99 per cent; the long-term follow-up rate was 92 per cent (the mean long-term follow-up was 10.2 years (range, 2.7-15.2)) so there were 96 men and 35 women, with an average age of 37.5 years (range, 16-63). Twenty-two per cent of the forearms had open fractures, 26 per cent of patients had sustained multiple injuries and 19 per cent had a head injury. One hundred and twenty-seven of 132 forearms (96.2 per cent) underwent problem-free consolidation before 6 months. Two delayed unions and two non-unions required reoperation. There was one superficial infection in a patient with a closed fracture. Plates were removed from 70 patients (53 per cent) at a mean of 33.1 months (range, 8-122) after the first operation. In this group, there were three refractures (4.3 per cent) occurring at a mean of 8.7 months (range, 0-14) after plate removal. This study confirms the safety and efficacy of plate osteosynthesis in forearm shaft fractures: a high union rate and low complication rate can be anticipated. The data presented form the most reliable information on this subject currently available with the longest and highest rate of follow up of a sufficient number of patients using a single implant system in a single institution.

Operative management of the stiff elbow: Sequential arthrolysis based on a transhumeral approach

Between December 1990 and September 1993, 26 consecutive patients (27 elbows) were treated for elbow contractures. We used a modified transhumeral approach supplemented by a limited lateral approach with or without a limited medial approach according to the correction gained after each step of the procedure. Eleven posttraumatic, 6 degenerative, and 10 miscellaneous contractures were evaluated. The mean follow-up was 30 months. Statistically significant improvement in the range of motion was obtained for all groups of patients; the mean flexion-extension arc of motion increased from 66 degrees to 100 degrees for the posttraumatic contractures, from 79 degrees to 102 degrees for the degenerative contractures, and from 85 degrees to 121 degrees for a miscellaneous group of contractures. Relief of pain was not an issue in the posttraumatic group; it was not significant for the degenerative group but was significant for the miscellaneous group. Flexion and extension force were maintained, and no joint was made unstable. Complications included three transient ulnar neuropathies and one tardy ulnar nerve palsy. The technique presented offers the advantage of virtually unlimited exposure of the joint in a stepwise manner, dictated by the intraoperative assessment of joint motion combined with preservation of the medial and lateral collateral ligament complexes and all relevant muscle insertions and origins. The concept is applicable to contractures of differing cause and can be adapted to the specific needs of the patient.

Path analysis of factors for functional outcome at one year in 463 proximal humeral fractures

BACKGROUND Path analysis methods were used to test the prognostic value of 10 patient-related and treatment-related factors on the 1-year functional outcome of 463 proximal humeral fractures measured using the Constant score. Complex inter-relationships between these factors were also evaluated. MATERIALS AND METHODS Data were collected from a prospective cohort study that included 3 operative groups repaired using nail or plate fixation and 1 nonoperative group. From the available information, various factors potentially having a direct influence on the functional Constant score were identified. The process of creating a hypothetical causal path diagram was undertaken to order the factors in a sequence of associations or cause-and-effect relationships. RESULTS Our final multivariable regression model for the 1-year Constant score included the 6 factors of age, sex, treatment, occurrence of intraoperative and local post-treatment complications, and anatomic restoration. Being a woman aged older than 40 years, treated with a locking proximal humeral plate (LPHP), having experienced intraoperative and local post-treatment complications, and varus deformity of more than 30° were negative predictors of the Constant score (ie, poor shoulder function 1 year after treatment initiation). Three factors, the dominant side fractured and the Neer and AO fracture type, showed only significant association on intermediate factors. The presence of concomitant disease did not show any significant direct or indirect effect. A final pathway outlines these associations and inter-relationships. CONCLUSION Prevention of local complications, in particular those leading to severe varus deviation, appears essential to improve shoulder function after a proximal humeral fracture.

Decortication and plate osteosynthesis for nonunion of the clavicle

Between 1968 and 1995, 37 patients with ununited fractures of the clavicle were treated by decortication and plate osteosynthesis. Thirty-two (86%) were failures of union of fractures of the middle third. Thirty-four (92%) patients had post-traumatic nonunion or delayed union. Sixteen (43%) patients had undergone primary operative treatment. Autogenous cancellous bone graft was used in 24 (65%) patients with atrophic nonunion. Nine tricortical, iliac crest, intercalary grafts were used for segmental bone loss equal to or greater than 15 mm. At the end of treatment, union had been achieved in 35 (95%) cases. At a mean follow-up of 8.6 years (range 13 months to 17 years), 32 (86%) patients had no symptoms and had a full range of motion of the shoulder. Decortication with plate osteosynthesis is a reliable, durable technique for the management of symptomatic, ununited fractures of the clavicle.

The deltoid extension lag sign for diagnosis and grading of axillary nerve palsy

The deltoid extension lag sign has been developed to avoid the pitfalls confounding the diagnosis of an axillary nerve lesion. The physician elevates the arm into a position of near full extension. The patient is asked to attempt active maintenance of this position. If the deltoid is weak, the arm will drop. In five patients with traumatic axillary nerve palsy after anterior dislocation of the shoulder, the deltoid extension lag sign was used to evaluate the functional status of the deltoid muscle. The magnitude of the angular drop, or lag, of the arm was a precise indicator of the functional status and recovery of the deltoid. The sign proved to be objective and reproducible, allowing confident assessment of deltoid function and when repeated over time allowed precise follow-up of deltoid recovery.

Augmentation of Rotator Cuff Repair With Soft Tissue Scaffolds

Background Tears of the rotator cuff are one of the most common tendon disorders. Treatment often includes surgical repair, but the rate of failure to gain or maintain healing has been reported to be as high as 94%. This has been substantially attributed to the inadequate capacity of tendon to heal once damaged, particularly to bone at the enthesis. A number of strategies have been developed to improve tendon-bone healing, tendon-tendon healing, and tendon regeneration. Scaffolds have received considerable attention for replacement, reconstruction, or reinforcement of tendon defects but may not possess situation-specific or durable mechanical and biological characteristics. Purpose To provide an overview of the biology of tendon-bone healing and the current scaffolds used to augment rotator cuff repairs. Study Design Systematic review; Level of evidence, 4. Methods A preliminary literature search of MEDLINE and Embase databases was performed using the terms rotator cuff scaffolds, rotator cuff augmentation, allografts for rotator cuff repair, xenografts for rotator cuff repair, and synthetic grafts for rotator cuff repair. Results The search identified 438 unique articles. Of these, 214 articles were irrelevant to the topic and were therefore excluded. This left a total of 224 studies that were suitable for analysis. Conclusion A number of novel biomaterials have been developed into biologically and mechanically favorable scaffolds. Few clinical trials have examined their effect on tendon-bone healing in well-designed, long-term follow-up studies with appropriate control groups. While there is still considerable work to be done before scaffolds are introduced into routine clinical practice, there does appear to be a clear indication for their use as an interpositional graft for large and massive retracted rotator cuff tears and when repairing a poor-quality degenerative tendon.

Instability of the sternoclavicular joint: Current concepts in classification, treatment and outcomes

The sternoclavicular joint (SCJ) is a pivotal articulation in the linked system of the upper limb girdle, providing load-bearing in compression while resisting displacement in tension or distraction at the manubrium sterni. The SCJ and acromioclavicular joint (ACJ) both have a small surface area of contact protected by an intra-articular fibrocartilaginous disc and are supported by strong extrinsic and intrinsic capsular ligaments. The function of load-sharing in the upper limb by bulky periscapular and thoracobrachial muscles is extremely important to the longevity of both joints. Ligamentous and capsular laxity changes with age, exposing both joints to greater strain, which may explain the rising incidence of arthritis in both with age. The incidence of arthritis in the SCJ is less than that in the ACJ, suggesting that the extrinsic ligaments of the SCJ provide greater stability than the coracoclavicular ligaments of the ACJ. Instability of the SCJ is rare and can be difficult to distinguish from medial clavicular physeal or metaphyseal fracture-separation: cross-sectional imaging is often required. The distinction is important because the treatment options and outcomes of treatment are dissimilar, whereas the treatment and outcomes of ACJ separation and fracture of the lateral clavicle can be similar. Proper recognition and treatment of traumatic instability is vital as these injuries may be life-threatening. Instability of the SCJ does not always require surgical intervention. An accurate diagnosis is required before surgery can be considered, and we recommend the use of the Stanmore instability triangle. Most poor outcomes result from a failure to recognise the underlying pathology. There is a natural reluctance for orthopaedic surgeons to operate in this area owing to unfamiliarity with, and the close proximity of, the related vascular structures, but the interposed sternohyoid and sternothyroid muscles are rarely injured and provide a clear boundary to the medial retroclavicular space, as well as an anatomical barrier to unsafe intervention. This review presents current concepts of instability of the SCJ, describes the relevant surgical anatomy, provides a framework for diagnosis and management, including physiotherapy, and discusses the technical challenges of operative intervention. Cite this article: Bone Joint J 2013;95-B:721–31.The sternoclavicular joint (SCJ) is a pivotal articulation in the linked system of the upper limb girdle, providing load-bearing in compression while resisting displacement in tension or distraction at the manubrium sterni. The SCJ and acromioclavicular joint (ACJ) both have a small surface area of contact protected by an intra-articular fibrocartilaginous disc and are supported by strong extrinsic and intrinsic capsular ligaments. The function of load-sharing in the upper limb by bulky periscapular and thoracobrachial muscles is extremely important to the longevity of both joints. Ligamentous and capsular laxity changes with age, exposing both joints to greater strain, which may explain the rising incidence of arthritis in both with age. The incidence of arthritis in the SCJ is less than that in the ACJ, suggesting that the extrinsic ligaments of the SCJ provide greater stability than the coracoclavicular ligaments of the ACJ. Instability of the SCJ is rare and can be difficult to distinguish from medial clavicular physeal or metaphyseal fracture-separation: cross-sectional imaging is often required. The distinction is important because the treatment options and outcomes of treatment are dissimilar, whereas the treatment and outcomes of ACJ separation and fracture of the lateral clavicle can be similar. Proper recognition and treatment of traumatic instability is vital as these injuries may be life-threatening. Instability of the SCJ does not always require surgical intervention. An accurate diagnosis is required before surgery can be considered, and we recommend the use of the Stanmore instability triangle. Most poor outcomes result from a failure to recognise the underlying pathology. There is a natural reluctance for orthopaedic surgeons to operate in this area owing to unfamiliarity with, and the close proximity of, the related vascular structures, but the interposed sternohyoid and sternothyroid muscles are rarely injured and provide a clear boundary to the medial retroclavicular space, as well as an anatomical barrier to unsafe intervention. This review presents current concepts of instability of the SCJ, describes the relevant surgical anatomy, provides a framework for diagnosis and management, including physiotherapy, and discusses the technical challenges of operative intervention.

Validation of the Stanmore percentage of normal shoulder assessment.

Background and Purpose: The Stanmore Percentage of Normal Shoulder Assessment (SPONSA) is a patient-reported outcome measure (PROM). The score assesses pain, range of movement, strength, stability and function of the shoulder. The aim of this work was to formally validate the SPONSA. Materials and Methods: Validation of this score was carried out by measuring reproducibility, construct validity and sensitivity to change. Time to completion was also recorded. The Oxford Shoulder Score (OSS) and Constant Score (CS) were used for comparison. These assessments were performed with 61 individuals undergoing shoulder interventions. Results: There was excellent preoperative reproducibility in both intra- and inter-observer groups. The SPONSA had a 0.79 correlation with the OSS and 0.78 with the CS. The overall effect size of the SPONSA was 0.72, which was comparable to OSS (0.65) and greater than CS (0.34), implying equal or better sensitivity to change. Conclusions: The SPONSA is practical and quick to perform and also a reproducible and a sensitive instrument. This simple PROM is a commendable addition to the existing validated scoring methods for the shoulder. Level of Evidence: I; testing of previously developed diagnostic criteria on consecutive patients (with universally applied reference “gold” standard).

Absence of avascular necrosis of the humeral head after post-traumatic rupture of the anterior and posterior humeral circumflex arteries : A case report

The vascularity of the proximal aspect of the humerus has recently been studied in detail2,6. The anterior humeral circumflex artery appears to be the main blood supply to the humeral head, while the posterior humeral circumflex artery has the most sizable anastomoses. The role of the intraosseous blood supply has been difficult to assess quantitatively, given the fact that no method has been developed to study the blood supply to the humeral head after complete obstruction of the major vessels. We recently examined a patient who had rupture of both circumflex arteries, as documented with angiography and operative observation, in association with a traumatic anterior dislocation of the shoulder. There was no evidence of avascular necrosis of the humeral head on radiographs or magnetic resonance images made eighteen months after the injury. A fifty-seven-year-old man, who was right-hand dominant and had no history of problems related to the shoulder, sustained a closed anterior subcoracoid dislocation of the right glenohumeral joint as the result of a fall (Fig. 1). Immediately after the injury, the patient had pain and numbness in the entire hand and forearm and was unable to flex or extend the elbow or to move the digits. On clinical testing, the flexors of the wrist and digits as well as the intrinsic muscles of the hand did not contract. Active flexion of the elbow was possible against gravity but not against manual resistance. There was numbness over the deltoid muscle and no clinical activity of that muscle. Anteroposterior radiograph of the right shoulder, showing a subcoracoid dislocation. With use of a Kocher maneuver and intravenous sedation, a closed reduction was achieved without difficulty. A …

Clinical outcome after reconstruction for sternoclavicular joint instability using a sternocleidomastoid tendon graft.

BACKGROUND Anterior instability of the sternoclavicular joint is uncommon and usually follows a benign course, although symptomatic patients may require surgical intervention. The optimal treatment for symptomatic instability of the sternoclavicular joint remains unclear. The aim of this study was to evaluate the clinical outcome after reconstruction of the sternoclavicular joint with use of a sternocleidomastoid tendon graft to treat chronic debilitating anterior instability of the sternoclavicular joint. METHODS Thirty-two patients underwent surgical reconstruction of the sternoclavicular joint for chronic debilitating anterior instability using the tendon of the sternal head of the ipsilateral sternocleidomastoid muscle and were followed for a mean of forty-four months. The etiology of instability was posttraumatic in fourteen patients, generalized hyperlaxity in seven patients, and degenerative instability in eleven patients. Outcome measures included the Oxford instability shoulder score, subjective shoulder value, pain rating, and postoperative grading of sternoclavicular joint stability. RESULTS Clinical scores and pain rating were similar for the three groups before surgery and improved significantly in all of the groups to the same extent after the surgery. At the time of the latest follow-up, eleven of fourteen patients in the posttraumatic group, six of seven patients in the generalized hyperlaxity group, and eight of eleven patients in the degenerative group reported the sternoclavicular joint as stable with no functional limitation. Two patients reported that the joint remained unstable. No other complications occurred. CONCLUSIONS Sternoclavicular joint reconstruction using a sternocleidomastoid tendon graft is safe and offers reliable pain relief and functional improvement for patients with chronic debilitating anterior instability of the sternoclavicular joint.