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Mamarelis G, Goldring MA, Srikantharajah D, Tytherleigh-Strong G. Superior Sternoclavicular Dislocation Treated with Costoclavicular Ligament Reconstruction Using Autograft: A Case Report. JBJS Case Connect 2023; 13:01709767-202309000-00030. [PMID: 37535769 DOI: 10.2106/jbjs.cc.23.00192] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
CASE We describe a case of a traumatic superior dislocation of the sternoclavicular joint (SCJ) due to an isolated rupture of the costoclavicular ligament (CCL). A magnetic resonance imaging (MRI) scan demonstrated the CCL rupture with preservation of the anterior and posterior SCJ ligaments. This was successfully treated with an isolated hamstring tendon reconstruction of the CCL, resulting in a satisfactory outcome at 1 year after the procedure. CONCLUSION Isolated CCL reconstruction with a hamstring tendon in a patient with a superior SCJ dislocation provided a satisfactory outcome.
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Tytherleigh-Strong G, Cuthbert R, Poutoglidou F, Tang Q. Magnetic Resonance Imaging in the Management of Significantly Displaced Adolescent Posterior Sternoclavicular Joint Injuries. J Pediatr Orthop 2023; 43:e374-e382. [PMID: 36863880 DOI: 10.1097/bpo.0000000000002378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND Computed tomography (CT) scans are the standard imaging modality for the diagnosis and treatment guide for adolescent posterior sternoclavicular joint (SCJ) injuries. However, the medial clavicular physis is not visualized and it is not possible to differentiate between a true SCJ dislocation and a physeal injury (PI). An magnetic resonance imaging (MRI) scan can visualize the bone and the physis. METHODS We treated a series of patients with adolescent posterior SCJ injuries diagnosed on CT scan. Patients underwent an MRI scan to differentiate between a true SCJ dislocation and a PI and to further differentiate between a PI with or without residual medial end clavicular bone contact. Patients with a true SCJ dislocation and a PI with no contact underwent an open reduction and fixation. Patients with a PI with contact were treated nonoperatively with repeat CT scans at 1 and 3 months. At final follow-up SCJ clinical function was assessed using Quick-DASH, Rockwood, modified Constant, and single assessment numeric evaluation (SANE) scores. RESULTS Thirteen patients (2 female and 11 male) with an average age of 14.9 years (12 to 17) were included in the study. Twelve patients were available at final follow-up (mean 50 mo, 26 to 84). One patient had a true SCJ dislocation and 3 had an off-ended PI and were treated with an open reduction and fixation. Eight patients had a PI with residual bone contact and were treated nonoperatively. For these patients serial CT scans showed that the position was maintained, with a serial increase in callus formation and bone remodeling. The average follow-up was 42.9 months (24 to 62). At final follow-up the mean Quick-disabilities of the arm, shoulder and hand (DASH) was 0.4 (0 to 2.3), Rockwood was 15, modified Constant was 98.8 (89 to 100) and SANE was 99.5% (95 to 100). CONCLUSION In this case series of significantly displaced adolescent posterior SCJ injuries MRI scans allowed identification of true SCJ dislocations and off-ended PIs, which were successfully treated by open reduction, and PIs with residual physeal contact which were successfully treated nonoperatively. LEVEL OF EVIDENCE Level IV-case series.
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Affiliation(s)
- Graham Tytherleigh-Strong
- Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Hills Road, Cambridge, UK
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Tytherleigh-Strong G, Sabharwal S, Peryt A. Clinical Outcomes and Return to Sports After Open Reduction and Hamstring Tendon Autograft Reconstruction in Patients With Acute Traumatic First-Time Posterior Dislocation of the Sternoclavicular Joint. Am J Sports Med 2022; 50:3635-3642. [PMID: 36135350 DOI: 10.1177/03635465221124267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Traumatic posterior dislocations of the sternoclavicular joint (SCJ) are rare. Multiple case reports, case series, and systematic reviews have been published on the treatment of posterior SCJ dislocations. However, they have usually been of small numbers, described a variety of surgical techniques on a mixture of acute and chronic dislocations, and have not focused on functional recovery or return to sports. PURPOSE/HYPOTHESIS The purpose of this study was to assess the clinical outcomes and return to sports after SCJ open reduction and reconstruction using a hamstring tendon autograft in patients with an acute first-time traumatic posterior dislocation of the SCJ. We hypothesized that SCJ open reduction and reconstruction would result in high survivorship, good clinical outcomes, and a high rate of return to sports. STUDY DESIGN Case series; Level of evidence, 4. METHODS This study included all patients who underwent SCJ open reduction and reconstruction within 14 days of sustaining a first-time traumatic posteriorly dislocated SCJ, with a minimum 3-year follow-up. Patient-reported outcomes were assessed by the following scores: short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), Rockwood SCJ, modified Constant, and Single Assessment Numeric Evaluation (SANE). Survivorship was defined as no clinical failure, such as instability or recurrent dislocation, and no revision surgery. Return to sports was assessed using a customized questionnaire. RESULTS A total of 19 patients who underwent surgery were included, with a mean age of 30.8 years (range, 18-52 years). Seventeen patients were available at final follow-up at a mean 94.5 months (range, 37-155 months). At final follow-up, the mean scores were as follows: QuickDASH, 4.3 (range, 0-20.4); Rockwood, 13.9 (range, 12-15); modified Constant, 94.4 (range, 71-100); and SANE, 92.1 (range, 70-100). The construct survivorship was 96%. Of the 14 patients who participated in sports, 12 (86%) returned to their preinjury levels. CONCLUSION After an acute first-time traumatic posterior SCJ dislocation, open reduction and stabilization with a hamstring tendon autograft, undertaken within 14 days of injury, provides good clinical outcomes and high rates of survivorship and return to sports.
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Affiliation(s)
- Graham Tytherleigh-Strong
- Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge, UK
| | - Sanjeeve Sabharwal
- Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge, UK
| | - Adam Peryt
- Division of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
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Al-Hadithy N, Khokher ZH, Kang N, Rensburg LV, Tytherleigh-Strong G. The incidence of medial end clavicle fractures is higher than had previously been considered. Shoulder Elbow 2021; 13:600-604. [PMID: 34804208 PMCID: PMC8600667 DOI: 10.1177/1758573220923122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 04/05/2020] [Accepted: 04/06/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Previous X-ray epidemiological studies have estimated the incidence of medial end clavicle fractures to account for 2-3% of all clavicle fractures. MATERIALS AND METHODS At our institution X-rays of every patient attending the Emergency Department are reviewed at a Virtual Fracture Clinic by a Consultant Orthopaedic Surgeon. Patients with a fracture are referred to the Shoulder and Elbow Fracture Clinic. Patients without a fracture are contacted and, if there are on-going concerns, are referred to the Shoulder and Elbow Fracture Clinic. Over an 18-month period we identified every patient that attended our Emergency Department that had sustained a clavicle fracture. RESULTS In total 558 clavicle fractures were identified (139 (24.9%) - lateral, 360 (64.5%) - middle, 59 (10.6%) - medial). Of the 59 medial end fractures, 31 (52.5%) were identified on presentation at the Emergency Department, 13 (22%) at the Virtual Fracture Clinic, 6 (10.2%) on computed tomography scan at the Shoulder and Elbow Fracture Clinic and 9 (15.3%) were admitted directly to the trauma unit. CONCLUSION The results of this study suggest that the incidence of medial end clavicle fractures in the general population is higher than had previously been considered. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | | | | | | | - Graham Tytherleigh-Strong
- Graham Tytherleigh-Strong, Division of
Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals, Trust
Hills Road, Cambridge CB2 2QQ, UK.
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Moya D, Aydin N, Yamamoto N, Simone JP, Robles PP, Tytherleigh-Strong G, Gobbato B, Kholinne E, Jeon IH. Current concepts in anterior glenohumeral instability: diagnosis and treatment. SICOT J 2021; 7:48. [PMID: 34519639 PMCID: PMC8439181 DOI: 10.1051/sicotj/2021048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 08/27/2021] [Indexed: 11/14/2022] Open
Abstract
The glenohumeral joint is the most dislocated articulation, accounting for more than 50% of all joint dislocations. The reason behind shoulder instability should be investigated in detail for successful management, and the treatment plan should be individualized for all patients. Several classification systems have been proposed for glenohumeral instability. A physical exam is mandatory no matter what classification system is used. When treating patients with anterior shoulder instability, surgeons need to be aware of the critical size of the bone loss, which is commonly seen. The glenoid track concept was clinically adopted, and the measurement of the glenoid track for surgical decision-making is recommended. Detailed assessment of existing soft tissue injury to the labrum, capsule, glenohumeral ligaments, and rotator cuff is also mandatory as their presence influences the surgical outcome. Rehabilitation, arthroscopic repair techniques, open Bankart procedure, capsular plication, remplissage, Latarjet technique, iliac crest, and other bone grafts offer the surgeon different treatment options according to the type of patient and the lesions to be treated. Three-dimensional (3D) technologies can help to evaluate glenoid and humeral defects. Patient-specific guides are low-cost surgical instruments and can be used in shoulder instability surgery. 3D printing will undoubtedly become an essential tool to achieve the best results in glenohumeral instability surgery.
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Affiliation(s)
- Daniel Moya
- Department of Orthopedic Surgery, Hospital Británico de Buenos Aires, C1280 AEB Buenos Aires, Argentina
| | - Nuri Aydin
- Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Department of Orthopedics and Traumatology, 34098 Istanbul, Turkey
| | - Nobuyuki Yamamoto
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, 980-8575 Sendai, Japan
| | - Juan Pablo Simone
- Department of Orthopaedic Surgery, Hospital Alemán de Buenos Aires, C1118 AAT Buenos Aires, Argentina
| | | | - Graham Tytherleigh-Strong
- Division of Orthopaedics, Addenbroke's Hospital, Cambridge University Hospitals Trust, CB2 0QQ Cambridge, United Kingdom
| | - Bruno Gobbato
- Department of Orthopaedic Surgery, Hospital Sao Jose, Jaraguá do Sul, SC 89251-830, Brazil
| | - Erica Kholinne
- Faculty of Medicine, Universitas Trisakti, Department of Orthopaedic Surgery, St Carolus Hospital, 10440 Jakarta, Indonesia
| | - In-Ho Jeon
- Department of Orthopaedics, University of Ulsan, College of Medicine, Asan Medical Center, 05505 Seoul, Korea
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Bardos A, Sabhrawal S, Tytherleigh-Strong G. Management of Vertical Sternal Fracture Nonunion in Elite-Level Athletes. Orthop J Sports Med 2021; 9:23259671211010804. [PMID: 34250172 PMCID: PMC8237216 DOI: 10.1177/23259671211010804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 02/09/2021] [Indexed: 11/25/2022] Open
Abstract
Background: Sternal fractures are rare, and they can be treated nonoperatively. Vertical
sternal fractures have rarely been reported. Purpose: To describe the management and surgical treatment of a series of elite-level
athletes who presented with symptomatic nonunions of a vertical sternal
fracture. Study Design: Case series; Level of evidence, 4. Methods: Patients with an established symptomatic nonunion of a vertical sternal
fracture, as diagnosed by computed tomography (CT) or magnetic resonance
imaging (MRI), underwent open reduction and internal fixation using
autologous bone graft and cannulated lag screws. The patients were assessed
preoperatively and at the final follow-up using the Rockwood
sternoclavicular joint (SCJ) score; Constant score; and shortened version of
the Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores. Bony
union was confirmed on postoperative CT scan. Results: Five patients (4 men and 1 woman) were included; all were national- or
international-level athletes (rugby, judo, show-jumping, and MotoGP). The
mean age at surgery was 23.4 years (range, 19-27 years), the mean time from
injury to referral was 13.6 months (range, 10-17 months), and the mean time
from injury to surgery was 15.8 months (range, 11-20 months). The mean
follow-up was 99.4 months (range, 25-168 months). There was a significant
improvement after surgery in the mean Rockwood SCJ score (from 12.6 to 14.8
[P < .05]), Constant score (from 84 to 96.4
[P < .05]; 80% met the minimal clinically important
difference [MCID] of 10.4 points), and QuickDASH (from 6.8 to 0.98
[P < .05]; 0% met the MCID of 15.9 points). Four of
the patients were able to return to sport at their preinjury level, and 1
patient retired for nonmedical reasons. All of the fractures had united on
the postoperative CT scan. There were no postoperative complications. Conclusion: Vertical fractures of the sternum are very rare and tend to behave clinically
like an avulsion fracture injury to the capsuloligamentous structure of the
inferior SCJ. The requirement of advanced imaging to diagnose this injury
means that the actual incidence and natural history are not known. For
high-demand athletes, early identification, surgical reduction, and fixation
are likely to achieve the best outcome.
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Affiliation(s)
- Andrea Bardos
- Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge, UK
| | - Sanjeeve Sabhrawal
- Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge, UK
| | - Graham Tytherleigh-Strong
- Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge, UK
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Tytherleigh-Strong G, Aresti N, Begum R. Revision guided suture-button bone block stabilization of the shoulder in the presence of significant retained glenoid metalwork. JSES Int 2020; 4:803-813. [PMID: 33345219 PMCID: PMC7738448 DOI: 10.1016/j.jseint.2020.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Aim Positioning and fixation of the bone block during revision anterior stabilization of the shoulder, in the presence of significant retained glenoid metalwork, can be challenging. We present the results of a series of patients who underwent a revision bone block procedure secured with double suture buttons using a drill guide system, the position of which was calculated from a preoperative computed tomography (CT) scan. Materials and methods We undertook a revision bone block stabilization of the shoulder, using a guided double suture-button fixation, in 10 patients with significant retained glenoid metalwork from previous procedures. A preoperative CT scan was used to determine a position for the guide to allow a safe drill trajectory that would avoid any retained metalwork. A coracoid transfer was undertaken in 4 patients and an Eden-Hybinette in 6. Patients were assessed preoperatively and at final follow-up clinically and using the Oxford Shoulder Instability Score and the Subjective Shoulder Value score. Bone block position and healing was assessed by a CT scan at 6 months. The median follow-up was 36 months (range, 24-47 months). Results There were 3 female and 7 male patients with a median age of 24.5 years (17-49 years). At final follow-up, the mean Oxford Shoulder Instability Score had decreased from 25.9 (range, 21-35) to 5.8 (range, 3-14) (P < .005). The mean Subjective Shoulder Value score had risen from 87.1 (range, 10-60) to 80 (range, 60-90) (P < .05). All of the patients considered their shoulder to be stable apart from 1 patient. There had been no redislocations. The bone block positioned in the glenoid lower quadrant had healed for all of the patients on CT at 6 months. Conclusion Guided suture-button fixation of the bone block during revision anterior stabilization of the shoulder, in the presence of significant retained glenoid metalwork, provides a satisfactory outcome in terms of shoulder stability, graft position, and healing.
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Affiliation(s)
- Graham Tytherleigh-Strong
- Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge, UK
| | - Nicholas Aresti
- Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge, UK
| | - Rumina Begum
- Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge, UK
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Tytherleigh-Strong G, Gill J, Mulligan A, Al-Hadithy N. Arthroscopic Excision Arthroplasty of the Sternoclavicular Joint for Osteoarthritis: A Case Series of 50 Patients. Arthroscopy 2020; 36:1223-1229. [PMID: 31862291 DOI: 10.1016/j.arthro.2019.12.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 12/06/2019] [Accepted: 12/08/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE to report the results of a consecutive series of 50 patients who underwent an arthroscopic excision of the sternoclavicular joint (SCJ) for primary osteoarthritis refractory to conservative treatment. METHODS We undertook an arthroscopic excision of the SCJ in 50 patients with primary osteoarthritis refractory to conservative treatment. This included an adequate course of physiotherapy and at least 1 ultrasound-guided cortisone injection. There were 26 female and 24 male patients and the mean age at the time of surgery was 54.5 years (range 39-72 years). Patients were assessed preoperatively and at final follow-up with the Constant, Rockwood SCJ, and Quick-DASH scores. The mean follow-up was 41.8 months (range 24-73 months). Surgery was undertaken as a day-case with no shoulder immobilization. RESULTS Forty-five patients were available at final-follow up. The median Constant score had increased from 55 (range 37-79) to 72 (range 38-92), Rockwood score from 6 (range 4-9) to 13 (range 4-15), and Quick-DASH 36 (range 18-69) to 12 (range 0-51). All of these changes were statistically significant (P < .0001). There were no complications and, specifically, no problems with joint instability. Forty-four of the 45 patients were pleased with the results of their surgery and indicated that they would be happy to have the procedure again. CONCLUSIONS The results of this study show that arthroscopic excision arthroplasty of the SCJ is a satisfactory treatment for primary SCJ osteoarthritis refractory to conservative treatment. LEVEL OF EVIDENCE Level IV case series.
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Affiliation(s)
- Graham Tytherleigh-Strong
- Division of Orthopaedics, Addenbrookes Hospital, Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom.
| | - James Gill
- Division of Orthopaedics, Addenbrookes Hospital, Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom
| | - Alex Mulligan
- Division of Orthopaedics, Addenbrookes Hospital, Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom
| | - Nawfal Al-Hadithy
- Division of Orthopaedics, Addenbrookes Hospital, Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom
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Karia M, Al-Hadithy N, Tytherleigh-Strong G. Recurrent acromioclavicular joint dislocation with an associated coracoid fracture following acromioclavicular joint reconstruction. Ann R Coll Surg Engl 2020; 102:e136-e140. [PMID: 32326733 DOI: 10.1308/rcsann.2020.0051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Acromioclavicular joint injuries are common and account for up to 12% of all shoulder girdle injuries and have been reported as being as high as 50% in sports-related shoulder injuries. While the majority of acromioclavicular joint dislocations can be treated non-operatively, there are certain injury configurations, which can include high-grade dislocations in overhead athletes, where surgery may be indicated. The surgical management of acromioclavicular joint instability has moved towards recreating the action of the coracoclavicular ligaments by resuspending the clavicle on to the coracoid. Multiple techniques using high-strength sutures, synthetic ligaments, tendon allografts or autografts passed either around or through the coracoid process have been described. However, an unusual, but significant, complication associated with these techniques is an iatrogenic fracture of the coracoid process. We report the case of a patient with an iatrogenic coracoid fracture following two failed acromioclavicular joint resuspensory reconstructions using a synthetic ligament. This injury was successfully treated with an autologous hamstring graft reconstruction, initially protected with a hook plate.
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Affiliation(s)
- M Karia
- Hillingdon Hospital, Uxbridge, UK
| | | | - G Tytherleigh-Strong
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Gill J, Tytherleigh-Strong G. Osteochondritis dissecans with associated secondary chondromatosis in an adolescent shoulder. Shoulder Elbow 2019; 11:275-281. [PMID: 31316588 PMCID: PMC6620793 DOI: 10.1177/1758573217751653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 12/09/2017] [Accepted: 12/11/2017] [Indexed: 11/15/2022]
Abstract
Osteochondritis dissecans (OCD) of the humeral head is rare and usually occurs in adolescents. Secondary synovial chondromatosis occasionally occurs in the shoulder but has only been reported twice in an adolescent. We describe the case and management of an adolescent male who presented with features of OCD and secondary chondromatosis in his shoulder occurring simultaneously.
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Affiliation(s)
| | - Graham Tytherleigh-Strong
- Graham Tytherleigh-Strong, Division of Orthopaedics, Addenbrooke’s Hospital, Cambridge University Hospitals Trust, Cambridge CB2 2QQ, UK.
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11
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Titchener A, See A, Van Rensburg L, Tytherleigh-Strong G. Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees. J Shoulder Elbow Surg 2019; 28:e97-e103. [PMID: 30454930 DOI: 10.1016/j.jse.2018.08.047] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 08/24/2018] [Accepted: 08/29/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study assessed whether treating medial end clavicular fractures using an inverted distal clavicle locking plate, twisted through 90° around its axis, would allow for a less invasive surgical approach and improve screw trajectory insertion. MATERIALS AND METHODS We searched the databases of the 2 senior authors for patients who had sustained an acute, displaced fracture of the medial end of the clavicle and had undergone operative fixation using an inverted distal clavicle plate contoured through 90°. Through an inferior incision, a contoured locking plate was positioned on the anterior surface of the medial end of the clavicle. Up to 8 unicortical screws were inserted from anterior to posterior through the medial end of the plate. The lateral end was contoured and fixed to the superior clavicular surface. The patients were assessed preoperatively and at 1 month, 4 months, and final follow-up. Preoperative and postoperative plain x-ray images and computed tomography scans were reviewed. RESULTS The study included 8 patients (average age, 31.3 years; range, 15-59 years) with displaced fractures who underwent fixation. The median follow-up time was 30.5 months (range, 24-45 months). All patients reached clinical and radiographic union at 4 months. The mean 11-item version of the Disabilities of the Arm, Shoulder, and Hand score was 0.6 (range, 0-2.3). All of the patients had returned to their preinjury level of sport and activity. None of the patients had a complication. CONCLUSION Contouring an inverted distal clavicle plate through 90° may improve fixation options by allowing access to the anterior clavicle when treating medial clavicular fractures.
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Affiliation(s)
- Andrew Titchener
- Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge, UK
| | - Abbas See
- Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge, UK
| | - Lee Van Rensburg
- Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge, UK
| | - Graham Tytherleigh-Strong
- Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge, UK.
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Tytherleigh-Strong G, Mulligan A. Arthroscopic All-Intra-articular Revision Eden-Hybinette Procedure for Recurrent Instability After Coracoid Transfer. Arthrosc Tech 2019; 8:e121-e130. [PMID: 30899663 PMCID: PMC6410421 DOI: 10.1016/j.eats.2018.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 10/19/2018] [Indexed: 02/03/2023] Open
Abstract
Failure, in the form of recurrent shoulder instability, following a coracoid transfer procedure presents a challenging problem. Successful treatment with a revision Eden-Hybinette procedure, by both an open and arthroscopic approach using screws to secure the bone graft, has previously been reported. However, both the open and arthroscopic approach have required careful dissection through the distorted soft-tissue anatomy in the anterior compartment in front of subscapularis to gain access to the front of the glenoid through a muscle split. In this article, we describe a modification of an arthroscopic Eden-Hybinette technique that is undertaken intra-articularly and only requires portals through the rotator interval. This technique avoids having to undertake any extra-articular dissection in the anterior compartment and can address potential problems with retained metalwork and pre-existing anchor voids within the glenoid. In this Technical Note, we describe and highlight the pearls and pitfalls of an all-intra-articular arthroscopic revision Eden-Hybinette procedure.
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Affiliation(s)
- Graham Tytherleigh-Strong
- Address correspondence to Graham Tytherleigh-Strong, F.R.C.S.(Orth.), F.F.S.E.M.(U.K.), Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge CB2 2QQ, United Kingdom
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Mulligan A, Tytherleigh-Strong G. Heterotopic ossification after superior capsular reconstruction. J Shoulder Elbow Surg 2018; 27:e380-e386. [PMID: 30446233 DOI: 10.1016/j.jse.2018.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 08/13/2018] [Accepted: 08/19/2018] [Indexed: 02/01/2023]
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Cardim D, Robba C, Matta B, Tytherleigh-Strong G, Kang N, Schmidt B, Donnelly J, Calviello L, Smielewski P, Czosnyka M. Cerebrovascular assessment of patients undergoing shoulder surgery in beach chair position using a multiparameter transcranial Doppler approach. J Clin Monit Comput 2018; 33:615-625. [PMID: 30328561 PMCID: PMC6602988 DOI: 10.1007/s10877-018-0211-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 10/10/2018] [Indexed: 01/25/2023]
Abstract
Although the beach-chair position (BCP) is widely used during shoulder surgery, it has been reported to associate with a reduction in cerebral blood flow, oxygenation, and risk of brain ischaemia. We assessed cerebral haemodynamics using a multiparameter transcranial Doppler-derived approach in patients undergoing shoulder surgery. 23 anaesthetised patients (propofol (2 mg/kg)) without history of neurologic pathology undergoing elective shoulder surgery were included. Arterial blood pressure (ABP, monitored with a finger-cuff plethysmograph calibrated at the auditory meatus level) and cerebral blood flow velocity (FV, monitored in the middle cerebral artery) were recorded in supine and in BCP. All subjects underwent interscalene block ipsilateral to the side of FV measurement. We evaluated non-invasive intracranial pressure (nICP) and cerebral perfusion pressure (nCPP) calculated with a black-box mathematical model; critical closing pressure (CrCP); diastolic closing margin (DCM—pressure reserve available to avoid diastolic flow cessation); cerebral autoregulation index (Mxa); pulsatility index (PI). Significant changes occured for DCM [mean decrease of 6.43 mm Hg (p = 0.01)] and PI [mean increase of 0.11 (p = 0.05)]. ABP, FV, nICP, nCPP and CrCP showed a decreasing trend. Cerebral autoregulation was dysfunctional (Mxa > 0.3) and PI deviated from normal ranges (PI > 0.8) in both phases. ABP and nCPP values were low (< 60 mm Hg) in both phases. Changes between phases did not result in CrCP reaching diastolic ABP, therefore DCM did not reach critical values (≤ 0 mm Hg). BCP resulted in significant cerebral haemodynamic changes. If left untreated, reduction in cerebral blood flow may result in brain ischaemia and post-operative neurologic deficit.
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Affiliation(s)
- Danilo Cardim
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK. .,Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Vancouver, Canada. .,Vancouver General Hospital, 899 W 12th Ave, Room 2469, Vancouver, V5Z 1M9, Canada.
| | - Chiara Robba
- Neurosciences Critical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Department of Neuroscience, University of Genoa, Genoa, Italy.,Department of Anaesthesia and Intensive Care, San Martino Policlinico Hospital, Genoa, Italy
| | - Basil Matta
- Neurosciences Critical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Department of Anaesthesia, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Graham Tytherleigh-Strong
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Niel Kang
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Bernhard Schmidt
- Department of Neurology, University Hospital Chemnitz, Chemnitz, Germany
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Leanne Calviello
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
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15
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Abstract
The sternoclavicular joint (SCJ) is an integral part of the shoulder girdle that connects the upper limb to the axial skeleton. Swelling of the SCJ is commonly due to trauma, degeneration, infections and other disease processes that affect synovial joints. This review also focuses on uncommon conditions that could affect the SCJ, including SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome, Friedrich’s disease and Tietze syndrome. The scope of this review is limited to the analysis of the current evidence on the various conditions affecting the SCJ and also to provide an algorithm to manage these conditions.
Cite this article: EFORT Open Rev 2018;3:471-484. DOI: 10.1302/2058-5241.3.170078
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Affiliation(s)
| | - Shahbaz Ahmed
- Pulvertaft Hand Centre, Royal Derby Hospital, Derby, UK
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16
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Tytherleigh-Strong G, Pecheva M, Titchener A. Treatment of First-Time Traumatic Anterior Dislocation of the Sternoclavicular Joint With Surgical Repair of the Anterior Capsule Augmented With Internal Bracing. Orthop J Sports Med 2018; 6:2325967118783717. [PMID: 30046630 PMCID: PMC6055321 DOI: 10.1177/2325967118783717] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Traumatic anterior dislocations of the sternoclavicular joint (SCJ) are rare. Although they can usually be treated by a closed reduction, the reported subsequent recurrence rate is 50%. Purpose To determine whether further instability after first-time traumatic anterior dislocation would be prevented by a minimally invasive open repair of the anterior SCJ capsule, augmented with internal bracing. Study Design Case series; Level of evidence, 4. Methods Open repair of the anterior SCJ capsule was completed on a series of patients who had sustained a first-time traumatic anterior dislocation of the SCJ. Patients with preexisting SCJ instability and recurrent dislocations were excluded. Through a transverse incision, the anterior SCJ capsule was repaired and plicated by use of sutures. The repair was then protected by use of an internal brace, bridging between the sternum and the medial end of the clavicle. Results Six patients (4 males, 2 females) with a mean age of 28.3 years were included. Four patients underwent surgery within 4 weeks of their dislocation, and 2 patients had ongoing symptoms of instability but had not had a further dislocation. The median follow-up was 28.2 months (range, 24-35 months). At the most recent follow-up, none of the patients had sustained further dislocation or episode of instability, and their SCJs appeared stable. The mean abbreviated Disabilities of the Arm, Shoulder and Hand (QuickDASH) score was 2.3 (range, 0-4.5). Conclusion The medium-term results of this case series suggest that after first-time dislocation, surgical repair of the anterior SCJ capsule augmented with internal bracing can prevent recurrent instability. This may be an attractive option for individuals involved in higher risk activities, as the operative management of recurrent anterior SCJ instability usually requires a figure-of-8 tendon reconstruction, which carries a significantly higher morbidity.
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Affiliation(s)
- Graham Tytherleigh-Strong
- Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge, UK
| | - Mira Pecheva
- Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge, UK
| | - Andrew Titchener
- Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge, UK
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17
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Domos P, Tytherleigh-Strong G, Van Rensburg L. Increased wound complication with intramedullary screw fixation of clavicle fractures: Is it thermal necrosis? J Orthop Surg (Hong Kong) 2018; 25:2309499017739482. [PMID: 29129131 DOI: 10.1177/2309499017739482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Adult mid-shaft clavicle fractures are common injuries. For displaced fractures, open reduction with plate or intramedullary (IM) fixation is the widely used techniques. All methods have their own potential drawbacks, especially related to local soft tissue complications. There is little information about outcome and management of local wound complications after clavicle fracture fixations. METHODS Ninety-seven patients underwent open reduction and internal fixation, 17 were treated with IM screw fixation and 80 with plate fixation. Wound complication occurred in eight patients (8.2%) and rates differed significantly between IM and plate fixations (29.4% vs. 3.8%). Patients were assessed on average 58.3 months with visual analogue pain scores (VASs), Oxford Shoulder Score (OSS), and QuickDash (QD) score. RESULTS Five patients had wound breakdown and three patients had wound erythema. In seven patients with stable fixation, it was possible to "dress and suppress" with average 3 weeks of oral antibiotics. One patient had unstable fixation and required longer antibiotic treatment with early screw removal. One patient developed a chronic discharging wound, requiring debridement and later plate removal. At final follow-up, all wounds remained healed, bony union was achieved in all. The average scores were: VAS 1, OSS 46, and QD 4.5. CONCLUSIONS Good function with dry healed wound and united clavicle can be achieved. Further studies are required to investigate the difference in soft tissue complication rates, which may be due to the IM technique of retrograde drilling with a guide wire and due to aseptic thermal bone necrosis, rather than true infection.
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Affiliation(s)
- Peter Domos
- 1 Department of Trauma and Orthopaedics, Royal Free Hospital NHS Foundation Trust, London, UK
| | - Graham Tytherleigh-Strong
- 2 Department of Trauma and Orthopaedics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Lee Van Rensburg
- 2 Department of Trauma and Orthopaedics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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18
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Tytherleigh-Strong G, Rashid A, Lawrence C, Morrissey D. Arthroscopic Sternoclavicular Joint Diskectomy for Acute and Chronic Tears. Arthroscopy 2017; 33:1965-1970. [PMID: 28847575 DOI: 10.1016/j.arthro.2017.06.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 05/07/2017] [Accepted: 06/17/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To describe the results and functional scores in a group of patients who underwent arthroscopic excision of a symptomatic sternoclavicular joint (SCJ) disk tear with a minimum follow-up period of 2 years. METHODS Between April 2010 and December 2014, 14 patients underwent arthroscopic excision of a torn SCJ disk. Patients whose intended surgery was an isolated diskectomy and underwent that surgery only, with no additional procedure, were included. The minimum follow-up period was 24 months. All patients underwent an arthroscopic SCJ diskectomy. Postoperatively, no immobilization was required, and the patients were encouraged to mobilize as pain permitted. The patients were assessed preoperatively and at final follow-up with the visual analog scale score for pain, Rockwood score, and QuickDASH (short version of the Disabilities of the Arm, Shoulder and Hand questionnaire) score. RESULTS The average age at surgery was 29.4 years (range, 19-39 years). Ten of the patients had been symptom free before a specific incident, after which SCJ symptoms developed. The other 4 patients reported a gradual onset of symptoms and were considered to have chronic tears. The average duration of symptoms was 22.8 months (range, 6-48 months). At a mean follow-up of 33.4 months (range, 24-59 months), a significant improvement in the Rockwood score was noted, from 7 (range, 5-9; standard deviation [SD], 1.4) to 13.6 (range, 9-15; SD, 1.9) (P = .001) (minimal clinically important difference not described). The mean QuickDASH score improved from 23.7 points (range, 6.8-40.9 points; SD, 11.8 points) to 8 points (range, 0-29.5 points; SD, 9 points) (P = .0024) (minimal clinically important difference, 13.4 points). There were no reported complications and specifically no instability. CONCLUSIONS The results of this series suggest that arthroscopic SCJ diskectomy is a safe and reproducible procedure for the treatment of patients with symptomatic SCJ disk tears. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Graham Tytherleigh-Strong
- Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, England.
| | - Abbas Rashid
- Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, England
| | - Christopher Lawrence
- Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, England
| | - David Morrissey
- Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, England
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19
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Abstract
Osteoarthritis changes at the sternoclavicular joint (SCJ) have been shown to be present on computed tomography in more than 90% of people over the age of 60 years. Although usually asymptomatic, when symptoms do occur, they can be very debilitating. Most patients respond favorably to conservative treatment, but there is a small cohort of patients who continue to be symptomatic despite adequate conservative treatment. Surgical management with an open SCJ excision has been shown to give satisfactory results. However, probably due to concerns with regard to damage to the mediastinal structures, instability, and scarring, there is a high threshold for surgery. Arthroscopic SCJ excision has been shown to achieve similar results to an open procedure while avoiding some of the risks. In this Technical Note, we describe the indications, imaging, and the technique of an arthroscopic excision of the SCJ.
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Affiliation(s)
- Graham Tytherleigh-Strong
- Address correspondence to Graham Tytherleigh-Strong, F.R.C.S.(Orth), F.F.S.E.M.(UK), Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Cambridge CB2 2QQ, U.K.Division of OrthopaedicsAddenbrooke's HospitalCambridge University Hospitals TrustCambridgeCB2 2QQU.K.
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20
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Gill JR, Morrissey DI, Van Rensburg L, Tytherleigh-Strong G. Sternoclavicular joint osteophytosis: a difficult diagnosis to swallow. BMJ Case Rep 2017; 2017:bcr-2016-219053. [PMID: 28687685 DOI: 10.1136/bcr-2016-219053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Unexplained dysphagia requires prompt investigation to rule out a possible underlying malignancy. We describe the case of a 60-year-old man who presented to his family practitioner with a 1-year history of increasing dysphagia with associated pain over the front of his chest. He was referred on to an ear, nose and throat specialist where no obvious laryngeal pathology was found at direct laryngoscopy, but an 'indentation' of the right anterior larynx, which increased with external pressure on the sternoclavicular joint (SCJ), was noted. A subsequent CT scan of his neck demonstrated osteoarthritis of the right SCJ with an abnormally large posterior osteophyte. The patient was subsequently referred on to an orthopaedic surgeon specialising in SCJ surgery and underwent an arthroscopic excision of his right SCJ. Soon after surgery, the patient's dysphagia had settled and his symptoms remain resolved 1 year post surgery.
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Affiliation(s)
- James Ritchie Gill
- Trauma and Orthopaedics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - David I Morrissey
- Trauma and Orthopaedics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Lee Van Rensburg
- Trauma and Orthopaedics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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21
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Tytherleigh-Strong G, Rashid A, Lawrence C, Morrissey D. Arthroscopic Intra-articular Disk Excision of the Sternoclavicular Joint. Arthrosc Tech 2017; 6:e599-e605. [PMID: 28706805 PMCID: PMC5495580 DOI: 10.1016/j.eats.2017.01.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 01/05/2017] [Indexed: 02/03/2023] Open
Abstract
The sternoclavicular joint (SCJ) has a complete intra-articular disk that can be damaged either as a result of trauma or as part of ongoing degenerative joint disease. Although often asymptomatic, SCJ disk tears may lead to mechanical symptoms and pain. Previously, isolated symptomatic SCJ disk tears have only occasionally been mentioned in the literature with a few associated case reports of diskectomy by open arthrotomy. With improved imaging and availability of magnetic resonance imaging scans and the advent of SCJ arthroscopy it is now possible to treat symptomatic SCJ disk tears by arthroscopic excision. In this Technical Note, we describe the diagnosis of a torn SCJ disk and the technique of arthroscopic excision of a torn SCJ disk.
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Affiliation(s)
- Graham Tytherleigh-Strong
- Address correspondence to Graham Tytherleigh-Strong, F.R.C.S. (Orth.), F.F.E.S.M. (U.K.), Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospital Trust, Hills Road, Cambridge CB2 2QQ, UK.Division of OrthopaedicsAddenbrooke's HospitalCambridge University Hospital TrustHills RoadCambridgeCB2 2QQUK
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22
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Rashid A, Lawrence C, Tytherleigh-Strong G. Surgical treatment of a concurrent type 5 acromioclavicular joint dislocation and a failed anterior glenohumeral joint stabilization. Shoulder Elbow 2016; 8:258-63. [PMID: 27660658 PMCID: PMC5023054 DOI: 10.1177/1758573216658436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 06/04/2016] [Indexed: 11/15/2022]
Abstract
Traumatic glenohumeral joint dislocation and acromioclavicular joint subluxations tend to occur in young active males. Use of the coracoid process either as a transfer in recurrent instability or in suspensory reconstructions of the coracoclavicular ligaments have gained popularity. However this requires careful consideration in the event of concomitant injuries if they both require surgery.
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Affiliation(s)
| | | | - Graham Tytherleigh-Strong
- Graham Tytherleigh-Strong, Cambridge Shoulder & Elbow Unit, Addenbrookes Hospital, Hills Road, Cambridge CB2 0QQ, UK.
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23
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Brownson P, Donaldson O, Fox M, Rees JL, Rangan A, Jaggi A, Tytherleigh-Strong G, McBernie J, Thomas M, Kulkarni R. BESS/BOA Patient Care Pathways: Traumatic anterior shoulder instability. Shoulder Elbow 2015; 7:214-26. [PMID: 27582981 PMCID: PMC4935160 DOI: 10.1177/1758573215585656] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Peter Brownson
- Peter Brownson, The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Thomas Drive, Liverpool L14 3LB, UK. Tel.: 0151 282 6447
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24
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Ali E, Griffiths D, Obi N, Tytherleigh-Strong G, Van Rensburg L. Nonoperative treatment of humeral shaft fractures revisited. J Shoulder Elbow Surg 2015; 24:210-4. [PMID: 25088479 DOI: 10.1016/j.jse.2014.05.009] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Revised: 04/17/2014] [Accepted: 05/04/2014] [Indexed: 02/01/2023]
Abstract
PURPOSE The purpose of this study was to examine the union rate of humeral shaft fractures treated nonoperatively and to establish whether a particular fracture type is more likely to go on to nonunion. METHODS Radiographs and patient records of 207 humeral shaft fractures occurring during 5 years were retrospectively reviewed. All patients were initially managed nonoperatively and placed in a U-slab on diagnosis in the emergency department; this was converted to a functional humeral brace at 7 to 10 days after injury. Fracture location, morphology and comminution were assessed radiologically. Union was defined as the absence of pain and movement at the fracture site in the presence of radiographic callus formation. Nonunion was defined as no evidence of bone union by 1 year after injury or fractures requiring delayed fixation, defined as operative fixation undertaken more than 6 weeks after injury. RESULTS The study included 138 humeral shaft fracture patients; 18 patients (11%) were lost to follow-up, and 24 went on to nonunion, giving an overall union rate of 83%. Of the 24 nonunions, 15 underwent delayed operative fixation at an average of 8.3 months after injury. The union rate for proximal-third fractures was 76% compared with 88% for middle-third fractures and 85% for distal-third fractures. Comminuted fractures (defined as 3+ parts) had a 89% union rate regardless of position. CONCLUSION A lower threshold for surgical intervention may be considered in proximal-third, two-part spiral-oblique humeral shaft fractures. Brace therapy can be the optimal treatment regimen, but it is not the only option.
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Affiliation(s)
- Erden Ali
- Department of Trauma and Orthopaedic Surgery, Addenbrooke's Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK; Magdalene College, University of Cambridge, Cambridge, UK.
| | - Dylan Griffiths
- Department of Trauma and Orthopaedic Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Nnamdi Obi
- Department of Trauma and Orthopaedic Surgery, Addenbrooke's Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Graham Tytherleigh-Strong
- Department of Trauma and Orthopaedic Surgery, Addenbrooke's Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
| | - Lee Van Rensburg
- Department of Trauma and Orthopaedic Surgery, Addenbrooke's Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK
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25
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Imam S, Low AK, Tytherleigh-Strong G. Sternoclavicular Joint Arthritis: Arthroscopic and Open Resection. OPER TECHN SPORT MED 2014. [DOI: 10.1053/j.otsm.2014.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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27
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Ahmad Z, Brooks R, Kang SN, Weaver H, Nunney I, Tytherleigh-Strong G, Rushton N. The effect of platelet-rich plasma on clinical outcomes in lateral epicondylitis. Arthroscopy 2013; 29:1851-62. [PMID: 24060428 DOI: 10.1016/j.arthro.2013.07.272] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 07/24/2013] [Indexed: 02/06/2023]
Abstract
PURPOSE To evaluate the evidence for application of platelet-rich plasma (PRP) in lateral epicondylitis. METHODS We carried out a systematic review of the current evidence on the effects of PRP in lateral epicondylitis on clinical outcomes. We performed a comprehensive search of the PubMed, Medline, Cochrane, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Embase databases using various combinations of the commercial names of each PRP preparation and "lateral epicondylitis" (with its associated terms), looking specifically at human studies. Data validity was assessed and collected on clinical outcome. RESULTS Nine studies met the inclusion criteria, of which 5 were randomized controlled trials. Two cohort studies showed that PRP improved clinical satisfaction scores. One case-control study showed that PRP yielded a significantly greater improvement in symptoms compared with bupivacaine. Two randomized controlled trials compared the effect of injections of PRP and blood. Only 1 of the studies noted a significant difference at the 6-week time point. Three randomized controlled trials compared corticosteroids with PRP. Two of the smaller trials, which had follow-up periods of 6 weeks and 3 months, showed no significant difference between treatment groups. The largest randomized controlled trial found that PRP had significant benefit compared with corticosteroids with regard to pain and Disabilities of the Arm, Shoulder and Hand scores at 1- and 2-year time points. CONCLUSIONS This review highlights the limited but evolving evidence for the use of PRP in lateral epicondylitis; however, further research is required to understand the concentration and preparation that facilitate the best clinical outcome. Characterizing the timing of the intervention would optimize the health economics behind the decision to treat for the patient and health care provider. LEVEL OF EVIDENCE Level III, systematic review of Level I to III studies.
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Affiliation(s)
- Zafar Ahmad
- Department of Orthopaedics, Norfolk and Norwich University Hospital, Norwich, England.
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28
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Abstract
Lateral epicondylitis, or ’tennis elbow’, is a common condition that usually affects patients between 35 and 55 years of age. It is generally self-limiting, but in some patients it may continue to cause persistent symptoms, which can be refractory to treatment. This review discusses the mechanism of disease, symptoms and signs, investigations, current management protocols and potential new treatments. Cite this article: Bone Joint J 2013;95-B:1158–64.
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Affiliation(s)
- Z. Ahmad
- Norfolk and Norwich University Hospital, Department
of Orthopaedics, Colney Lane, Norwich
NR4 7UR, UK
| | - N. Siddiqui
- Princess Alexandra Hospital, Brisbane
Hand and Upper Limb Unit, Woolloongabba, Brisbane 4002, Australia
| | - S. S. Malik
- Ipswich Hospital, Ipswich
Heath Road, Ipswich, Suffolk
IP4 5PD, UK
| | - M. Abdus-Samee
- University Hospital Lewisham, Lewisham
Healthcare NHS Trust, Lewisham High Street, London SE13
6LH, UK
| | | | - N. Rushton
- Orthopaedic Research Unit, University
of Cambridge, Box 180, Addenbrookes
Hospital, Hills Road, Cambridge
CB2 0QQ, UK
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Tytherleigh-Strong G, Griffith D. Arthroscopic excision of the sternoclavicular joint for the treatment of sternoclavicular osteoarthritis. Arthroscopy 2013; 29:1487-91. [PMID: 23910004 DOI: 10.1016/j.arthro.2013.05.029] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 05/28/2013] [Accepted: 05/30/2013] [Indexed: 02/06/2023]
Abstract
PURPOSE To report the results of a series of 10 patients who underwent an arthroscopic excision of the sternoclavicular joint (SCJ) for osteoarthritis refractory to conservative treatment. METHODS We undertook an arthroscopic excision of the SCJ in 10 patients with osteoarthritis. There were 7 female and 3 male patients with a mean age at surgery of 53 years (range, 42 to 62 years). Patients were assessed preoperatively and at follow-up with the Constant score and the Rockwood SCJ scoring system. The mean follow-up was 28 months (range, 17 to 41 months; SD, 8.1 months). Surgery was undertaken as a day case with no shoulder immobilization. RESULTS All of the patients had regained their preoperative or full range of movement within 2 weeks of surgery. At most recent follow-up, 7 patients had no pain and 3 had slight pain with activity. The median Constant score had increased from 64.5 (range, 41 to 77) to 83 (range, 61 to 95), and the median Rockwood score had increased from 6 (range, 4 to 7) to 13.5 (range, 9 to 15) (maximum, 15). On the basis of these findings, the clinical results were rated as excellent (13 to 15) in 7 patients, good (10 to 12) in 2, and fair (7 to 9) in 1. There were no complications and, specifically, no problems with joint stability. CONCLUSIONS The results of this study show that arthroscopic SCJ excision is a satisfactory treatment for SCJ osteoarthritis refractory to conservative measures. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Graham Tytherleigh-Strong
- Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Teaching Hospital Trust, Hills Road, Cambridge, England.
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Ahmad Z, Henson F, Wardale J, Noorani A, Tytherleigh-Strong G, Rushton N. Review article: Regenerative techniques for repair of rotator cuff tears. J Orthop Surg (Hong Kong) 2013; 21:226-31. [PMID: 24014790 DOI: 10.1177/230949901302100223] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The failure rate of rotator cuff repair is high. Regenerative techniques using material scaffolds, stem cells, and growth factors help augment repair and regenerate tissue. We reviewed the literature of various regenerative techniques in terms of (1) enhancing the repair process, (2) tissue regeneration, (3) mechanical strength, and (4) clinical outcome.
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Affiliation(s)
- Zafar Ahmad
- Department of Orthopaedics, Norfolk and Norwich University Hospital, Norwich, United Kingdom
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Abstract
Traditionally, an open approach has been required to undertake any surgical intervention for intra-articular sternoclavicular joint pathology. This in itself carries a certain operative morbidity, including damage to the underlying mediastinal structures and damage to the sternoclavicular and costoclavicular ligaments, with subsequent joint instability and unsightly scarring. This technical note describes an arthroscopic approach to the sternoclavicular joint that reduces this morbidity. The evolution of the technique including the rationale for portal placement and the angle of instrument insertion is explained. Experience of over 50 arthroscopic procedures including diagnostic arthroscopy, discectomy, excision of loose bodies, and washout and debridement after infection and excision of the medial end of the clavicle for osteoarthritis is detailed.
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Affiliation(s)
- Graham Tytherleigh-Strong
- Address correspondence to Graham Tytherleigh-Strong, F.R.C.S.(Orth), DSportMed, F.F.S.E.M., Cambridge University Hospital Trust, Orthopaedics & Trauma, Addenbrooke's Hospital, Hills Road, Cambridge, Cambs CB2 2QQ, England.
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Wijeratna MD, Turmezei TD, Tytherleigh-Strong G. Novel assessment of the sternoclavicular joint with computed tomography for planning interventional approach. Skeletal Radiol 2013; 42:473-8. [PMID: 22933016 DOI: 10.1007/s00256-012-1502-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 07/01/2012] [Accepted: 08/06/2012] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To describe the plane of the sternoclavicular joint (SCJ) to aid planning of instrument orientation during invasive procedures. METHODS Computed tomography (CT) images of 80 consecutive patients aged 25 to 40 years with appropriate chest imaging series were retrospectively reviewed. Patients with a previous median sternotomy, fused manubriosternal joint or fracture were excluded. The medial clavicle was found to vary greatly in its anatomy such that a representative morphology could not be described. The manubrium was found to be a more consistent structure and was examined in more detail. The angulation of the SCJ was measured in three orthogonal planes using CT multiplanar reformats. Each SCJ (160 in total) was assessed for transverse, coronal, and sagittal angulation of the central manubrial articular surface in respect to the long axis of the manubrial body using a newly devised measurement technique. RESULTS The mean angles (± standard deviation) of the SCJs were 62.4 ± 9.7° to the transverse plane, 149.3 ± 7.3° to the coronal plane and 69.8 ± 7.5 to the sagittal plane. There was no significant difference in transverse (p = 0.41) or sagittal (p = 0.60) angulation between sides, however there was a significant difference for the coronal plane (p = 0.04). No significant differences were noted between the sexes in any plane. CONCLUSIONS Increasing use of invasive diagnostic and treatment techniques dictate that a safe approach to the joint should be used to reduce the risk of iatrogenic injury. This study adds to existing knowledge of SCJ anatomy and its variation within the population. Understanding this can minimize the risk to adjacent structures when approaching the SCJ with injection needles or arthroscopic instruments.
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Affiliation(s)
- Malin D Wijeratna
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals, Hills Road, Cambridge, CB2 0QQ, UK.
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Jassim S, Ollivere B, Getgood A, Tytherleigh-Strong G. P17.09 Patient perceptions of doctors’ attire: how ‘bare below the elbows’ has impacted on the doctor-patient relationship. J Hosp Infect 2010. [DOI: 10.1016/s0195-6701(10)60183-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Miniaci A, Tytherleigh-Strong G. Fixation of unstable osteochondritis dissecans lesions of the knee using arthroscopic autogenous osteochondral grafting (mosaicplasty). Arthroscopy 2007; 23:845-51. [PMID: 17681206 DOI: 10.1016/j.arthro.2007.02.017] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2005] [Revised: 02/11/2007] [Accepted: 02/14/2007] [Indexed: 02/02/2023]
Abstract
PURPOSE A number of surgical techniques have been described for the operative fixation of an unstable osteochondritis dissecans (OCD) lesion in the knee that has failed appropriate nonoperative management. However, no one technique has been universally successful. We report the results of a new fixation technique for unstable OCD lesions using arthroscopic autogenous osteochondral grafting (mosaicplasty). METHODS Twenty patients with OCD lesions (16 International Cartilage Repair Society [ICRS] OCD type II, 3 ICRS OCD type III, and 1 ICRS OCD type IV) who had failed an appropriate course of nonoperative management underwent autogenous osteochondral grafting. The OCD lesions were assessed arthroscopically and then fixed in situ by using multiple 4.5-mm osteochondral dowel grafts harvested from the edges of the femoral trochlea. The lesion was initially fixed with an osteochondral graft passing through the center of the fragment and then stabilized by using further grafts inserted around its periphery. RESULTS Preoperative International Knee Documentation Committee scores assessed 5 patients as nearly normal, 8 as abnormal, and 7 as severely abnormal. At the 18-month follow-up, all of the knees were scored as normal. The average preoperative visual analog pain score out of 10 was 8.3, which was reduced to 0.8 at 6 months and to 0 at 1 year after surgery. Serial magnetic resonance imaging scans showed healing of the bony part of the lesion in all of the knees 6 months after surgery and continuous articular cartilage healing at 9 months. CONCLUSIONS Autogenous osteochondral grafting of unstable OCD lesions in the knee is a reliable and minimally invasive technique that provides a stable biologic fixation using autogenous bone graft and has few complications. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Anthony Miniaci
- Sports Medicine Program, Division of Surgery, University of Toronto, Toronto, Ontario, Canada
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McCullough CJ, Remedios D, Tytherleigh-Strong G, Hua J, Walker PS. The use of hydroxyapatite-coated CAD-CAM femoral components in adolescents and young adults with inflammatory polyarthropathy. ACTA ACUST UNITED AC 2006; 88:860-4. [PMID: 16798985 DOI: 10.1302/0301-620x.88b7.17046] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Between June 1991 and January 1995, 42 hydroxyapatite-coated CAD-CAM femoral components were inserted in 25 patients with inflammatory polyarthropathy, 21 of whom had juvenile idiopathic arthritis. Their mean age was 21 years (11 to 35). All the patients were reviewed clinically and radiologically at one, three and five years. At the final review at a mean of 11.2 years (8 to 13) 37 hips in 23 patients were available for assessment. A total of four femoral components (9.5%) had failed, of which two were radiologically loose and two were revised. The four failed components were in patients aged 16 years or less at the time of surgery. Hydroxyapatite-coated customised femoral components give excellent medium- to long-term results in skeletally-mature young adults with inflammatory polyarthropathy. Patients aged less than 16 years at the time of surgery have a risk of 28.5% of failure of the femoral component at approximately ten years.
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Affiliation(s)
- C J McCullough
- The North West London Hospitals, NHS Trust, Northwick Park Hospital, Watford Road, Harrow, Middlesex HA1 3UJ, UK.
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Abstract
PURPOSE The aim of this study was to assess whether intra-articular hyaluronan viscosupplementation after osteochondral grafting (mosaic arthroplasty) of the knee allowed better graft integration and function in a sheep model. TYPE OF STUDY Experimental study. METHODS Twelve adult sheep underwent a mosaic arthroplasty procedure to a standardized osteochondral defect on the medial femoral condyle. One week after surgery the animals were randomized to receive a course of weekly intra-articular injections for 5 weeks of either sodium-hyaluronate solution 25 mg/2.5 mL (HA group) or of a 2.5 mL buffer solution (control group). Synovial fluid samples were taken preoperatively, preceding each injection, and at 8 and 12 weeks. The animals were euthanized at 12 weeks, the knees dissected out, and biomechanical and histologic assessments were made. RESULTS There was no difference in the synovial fluid leukocyte or total protein concentration between the groups, but the hyaluronan concentration was statistically higher in the HA group. Aggregate moduli of the articular surface were statistically higher in the graft articular cartilage in the HA group than in the control group, as were the sulphated glycosaminoglycan levels. Histologic assessment found more articular cartilage flow in the HA group, whereas there was more interstitial tissue present in the interstices between the grafts in the control group. CONCLUSIONS Results from this study suggest that hyaluronan viscosupplementation following osteochondral grafting does convey some beneficial effects on graft cartilage in the early postoperative period in an ovine model. CLINICAL RELEVANCE This study suggests that, in the early postoperative period, hyaluronan supplementation improves articular cartilage survival after osteochondral grafting.
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Affiliation(s)
- Graham Tytherleigh-Strong
- Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Teaching Hospitals Trust, Cambridge, England.
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Abstract
We studied 24 patients with 44 phocomelic upper limbs. Only 11 limbs could be grouped in the classification system of Frantz and O' Rahilly. The non-classifiable limbs were further studied and their characteristics identified. It is confirmed that phocomelia is not an intercalary defect.
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Abstract
Two cases of bacterial adductor myositis that presented as painful hips in boys aged 4 and 9 years are reported. Clinically, there was severe pain and a high pyrexia, a raised C-reactive protein and positive blood cultures but a negative hip ultrasound. Urgent magnetic resonance imaging demonstrated changes throughout the adductor muscles in keeping with bacterial myositis. Both boys settled with intravenous antibiotic therapy. We propose that magnetic resonance imaging is a valuable tool in the assessment of infection around the hip and should be indicated when other investigations have excluded a septic arthritis but the child remains unwell.
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Affiliation(s)
- Simon Thomas
- Department of Orthopaedics, Royal Berkshire Hospital, Reading, UK
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Tytherleigh-Strong G, Gill J, Sforza G, Copeland S, Levy O. Reossification and fusion across the acromioclavicular joint after arthroscopic acromioplasty and distal clavicle resection. Arthroscopy 2001; 17:E36. [PMID: 11694940 DOI: 10.1053/jars.2001.26861] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Arthroscopic acromioplasty and distal clavicle resection has now become an accepted method of treatment for acromioclavicular (AC) joint arthritis. Complications following arthroscopic acromioplasty are relatively uncommon and include instrument breakage, hematoma, traction neuropathy, infection, acromial fracture, reflex sympathetic dystrophy, and recurrence of symptoms. Although heterotopic ossification within the soft tissues has also been reported, complete reossification of the resected clavicle has not. We report a case of reossification of the clavicle and fusion across the AC joint following arthroscopic acromioplasty and distal clavicle resection.
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Affiliation(s)
- G Tytherleigh-Strong
- Reading Shoulder Surgery Unit, Department of Orthopaedics, The Royal Berkshire Hospital, Reading, England
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Thomas S, Tytherleigh-Strong G, Dodds R. Pyomyositis of the iliacus muscle in a child. J Bone Joint Surg Br 2001; 83:619-20. [PMID: 11380145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
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Abstract
The important role played by the rotator cuff in the stability and movement of the glenohumeral joint make it susceptible to damage and injury in patients of all age groups. A number of extrinsic and intrinsic mechanisms have been described for the development of rotator cuff disease, although it is more likely that the actual etiology in any one individual is multifactorial. The key to successful management in a particular patient is an accurate diagnosis of the underlying cause by thorough clinical examination and the use of appropriate investigations. The mainstay of treatment of patients with rotator cuff disease is nonoperative. Surgical intervention is usually considered only after failure of at least 6 months of conservative therapy. However, there are a few situations where early surgical intervention is indicated.
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Affiliation(s)
- G Tytherleigh-Strong
- Sports Medicine Program, Division of Orthopaedics, Toronto Western Hospital, Toronto, Ontario, Canada
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Affiliation(s)
- G Tytherleigh-Strong
- Department of Orthopaedics, Wexham Park Hospital, Slough, Berkshire SL2 4HL, UK. g.t.-
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Handoll HH, Farrar MJ, McBirnie J, Tytherleigh-Strong G, Awal KA, Milne AA, Gillespie WJ. Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures. Cochrane Database Syst Rev 2000; 2021:CD000305. [PMID: 10796339 PMCID: PMC7043307 DOI: 10.1002/14651858.cd000305] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Hip fracture patients have a high risk of thromboembolic complications following surgical management. OBJECTIVES To examine the effects of heparin (unfractionated (U), and low molecular weight (LMW) heparins), and physical methods (compression stockings, calf or foot pumps) for prevention of deep venous thrombosis (DVT) and pulmonary embolism after surgery for hip fracture in the elderly. SEARCH STRATEGY We searched the Cochrane Musculoskeletal Injuries Group trials register, Medline, Embase, and reference lists of published papers and books. We contacted trialists and other workers in the field. Date of most recent search: September 1996. SELECTION CRITERIA Randomised and quasi-randomised trials evaluating the use of heparins and physical agents for prevention of DVT and pulmonary embolism in patients undergoing surgery for hip fracture. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed methodological quality and extracted data. Trials were grouped into four categories (heparin versus control, mechanical versus control, LMW heparin versus U heparin, and miscellaneous) and results pooled where possible. MAIN RESULTS The 26 included trials involved 2600 predominantly female and elderly patients. Overall, trial quality was disappointing. Ten trials involving 826 patients which compared U heparin with control, and four trials of 471 patients which compared LMW heparin with control, showed a reduction in the incidence of lower limb DVT (121/511 (24%) versus 203/519 (39%); Peto odds ratio 0.41; 95% confidence interval 0.31 to 0.55). There were insufficient data to confirm the efficacy of either agent in the prevention of pulmonary embolism. There was a non significant increase in overall mortality in the heparin group (46/420 (11%) versus 35/423 (8%); Peto odds ratio 1.39; 95% confidence interval 0. 86 to 2.23). Data were inadequate for all other outcomes including wound complications. There is insufficient evidence from five trials, involving 644 patients, to establish if LMW heparin was superior to U heparin. Most trials evaluating heparins had methodological defects. Four trials, involving 442 patients, testing mechanical pumping devices were also methodologically flawed, and so pooled results need to be viewed cautiously. Mechanical pumping devices may protect against DVT (12/202 (6%) versus 42/212 (19%); Peto odds ratio 0.24; 95% confidence interval 0.13 to 0.44). Although the limited data indicated a potential benefit, they were inadequate to establish any effect on the incidence of pulmonary embolism and overall mortality. Problems with skin abrasion and compliance were reported. REVIEWER'S CONCLUSIONS U and LMW heparins protect against lower limb DVT. There is insufficient evidence to confirm either protection against pulmonary embolism or overall benefit, or to distinguish between various applications of heparin. Foot and calf pumping devices appear to prevent DVT, may protect against pulmonary embolism, and reduce mortality, but compliance remains a problem. Good quality trials of mechanical methods as well as direct comparisons with heparin should be considered.
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Affiliation(s)
- H H Handoll
- Department of Orthopaedic Surgery, Clinical Research Unit, Princess Margaret Rose Orthopaedic Hospital, Edinburgh, UK, EH10 7ED.
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Stewart KJ, Tytherleigh-Strong G, Bharathwaj S, Quaba AA. The soft tissue management of children's open tibial fractures. J R Coll Surg Edinb 1999; 44:24-30. [PMID: 10079664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
A series of 49 children admitted with a diagnosis of open tibial fracture was reviewed with particular regard to soft tissue management. Injuries were grouped according to the Gustilo classification. Twenty-two patients had Grade I fractures, 11 Grade II and 16 Grade III (4 Grade IIIa, 11 Grade IIIb and one Grade IIIc). Patients were managed by early lavage and debridement under general anaesthesia, followed by immobilisation. Local transposition flaps were utilised in 10 patients and provided reliable soft tissue cover. A free tissue transfer was performed in only one patient. Complications appeared to be associated with delayed involvement by plastic surgeons.
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Affiliation(s)
- K J Stewart
- Department of Plastic and Reconstructive Surgery, Royal Hospital for Sick Children, Edinburgh, UK
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Abstract
We have analysed 249 consecutive fractures of the humeral shaft treated over a three-year period. The fractures were defined by their AO morphology, position, the age and gender of the patient and the mechanism of injury. Open fractures were classified using the Gustilo system and soft-tissue injury, and closed fractures using the Tscherne system. The fractures were classified as AO type A in 63.3%, type B in 26.2% and type C in 10.4%. Most (60%) occurred in the middle third of the diaphysis with 30% in the proximal and 10% in the distal third. The severity of the fracture and soft-tissue injury was greater with increasing injury severity. Less than 10% of the fractures were open. There was a bimodal age distribution with a peak in the third decade as a result of moderate to severe injury in men and a larger peak in the seventh decade after a simple fall in women.
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Affiliation(s)
| | - N. Walls
- Royal Infirmary of Edinburgh NHS Trust, Lauriston Place, Edinburgh EH3 9YW, UK
| | - M. M. McQueen
- Royal Infirmary of Edinburgh NHS Trust, Lauriston Place, Edinburgh EH3 9YW, UK
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Abstract
We have analysed 249 consecutive fractures of the humeral shaft treated over a three-year period. The fractures were defined by their AO morphology, position, the age and gender of the patient and the mechanism of injury. Open fractures were classified using the Gustilo system and soft-tissue injury, and closed fractures using the Tscherne system. The fractures were classified as AO type A in 63.3%, type B in 26.2% and type C in 10.4%. Most (60%) occurred in the middle third of the diaphysis with 30% in the proximal and 10% in the distal third. The severity of the fracture and soft-tissue injury was greater with increasing injury severity. Less than 10% of the fractures were open. There was a bimodal age distribution with a peak in the third decade as a result of moderate to severe injury in men and a larger peak in the seventh decade after a simple fall in women.
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