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Lewis TL, Robinson PW, Ray R, Dearden PMC, Goff TAJ, Watt C, Lam P. Five-Year Follow-up of Third-Generation Percutaneous Chevron and Akin Osteotomies (PECA) for Hallux Valgus. Foot Ankle Int 2023; 44:104-117. [PMID: 36692121 DOI: 10.1177/10711007221146195] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 01/25/2023]
Abstract
BACKGROUND Recent large studies of third-generation minimally invasive hallux valgus surgery (MIS) have demonstrated significant improvement in clinical and radiologic outcomes. It remains unknown whether these clinical and radiologic outcomes are maintained in the medium to long term. The aim of this study was to investigate the minimum 5-year clinical and radiologic outcomes following third-generation MIS hallux valgus surgery in the hands of a high-volume MIS surgeon. METHODS A retrospective observational single highly experienced MIS surgeon case series of consecutive patients undergoing primary isolated third-generation percutaneous chevron and Akin osteotomies (PECA) for hallux valgus with a minimum 60-month clinical and radiographic follow-up. Primary outcome was radiographic assessment of the hallux valgus angle (HVA) and intermetatarsal angle (IMA) preoperatively, 6 months, and ≥60 months following PECA. Secondary outcomes included the Manchester-Oxford Foot Questionnaire, patient satisfaction, EuroQol-5D visual analog scale and the visual analog scale for pain. RESULTS Between 2012 and 2014, 126 consecutive feet underwent isolated third-generation PECA, with complete data available for 78 (61.9%) feet. The median follow-up was 65.0 (IQR 64-69; range 60-88) months. There was a significant improvement in radiographic deformity correction; the median IMA improved from 12.0 degrees (interquartile range [IQR]: 10.8-14.2) to 6.0 degrees (IQR: 4.2-7.3) (P < .001), and the median HVA improved from 27.2 degrees (IQR: 20.6-34.4) to 7.2 degrees (IQR: 3.4-11.6). Median MOXFQ Index score at ≥60-month follow-up was 2.3 (IQR: 0.0-7.8). The radiographic recurrence rate (defined as HVA >15 degrees) was 7.7% at final follow-up. The complication rate was 4.8%. CONCLUSION Radiologic deformity correction for the 78 feet we were able to follow that had third-generation PECA performed by a single highly experienced MIS surgeon was found to be maintained at a mean follow-up of average 66.8 months, with a radiographic recurrence rate of 7.7%. Clinical PROMs and patient satisfaction levels were high and comparable to other third-generation studies with shorter duration of follow-up. LEVEL OF EVIDENCE Level IV, retrospective cohort study.
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Affiliation(s)
- Thomas L Lewis
- King's Foot and Ankle Unit, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Peter W Robinson
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, United Kingdom
| | - Robbie Ray
- King's Foot and Ankle Unit, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Thomas A J Goff
- Mid Yorkshire Hospitals NHS Trust, Wakefield, United Kingdom
| | - Clare Watt
- Orthopaedic and Arthritis Specialist Centre, Chatswood, Sydney, Australia
| | - Peter Lam
- Orthopaedic and Arthritis Specialist Centre, Chatswood, Sydney, Australia
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Lewis TL, Robinson PW, Ray R, Goff TAJ, Dearden PMC, Whitehouse MR, Lam P, Dracopoulos G. The Learning Curve of Third-Generation Percutaneous Chevron and Akin Osteotomy (PECA) for Hallux Valgus. J Foot Ankle Surg 2022; 62:162-167. [PMID: 35868982 DOI: 10.1053/j.jfas.2022.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 01/20/2022] [Revised: 06/10/2022] [Accepted: 06/11/2022] [Indexed: 02/03/2023]
Abstract
The learning curve to reach technical proficiency for third-generation percutaneous or minimally invasive chevron and Akin osteotomies (PECA/MICA) is recognized to be steep however it is poorly defined in the literature. This study is a retrospective review of the first 58 consecutive PECA cases of a single surgeon. The primary outcome was the number of cases required to reach technical proficiency as defined by the operation time. Secondary outcomes included radiation exposure, radiographic deformity correction, and complication rates. Between November 2017 and March 2019, 61 consecutive PECA cases were performed with outcome data available for 58 of these (95%). Technical proficiency was reached after 38 cases. Operation time and radiation exposure significantly decreased after this transition point (p < .05). There was no difference in complication rate or radiographic deformity correction regardless of position along the learning curve (p > .05). In conclusion, the mean number of cases required to reach technical proficiency in third-generation PECA is 38 cases. The complication rate does not correlate to the number of cases performed, therefore surgeons interested in learning minimally invasive surgery can be reassured that there is unlikely to be an additional risk of harm to a patient during the learning curve.
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Affiliation(s)
- T L Lewis
- King's Foot and Ankle Unit, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - P W Robinson
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, United Kingdom.
| | - R Ray
- King's Foot and Ankle Unit, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - T A J Goff
- Mid Yorkshire Hospitals NHS Trust, Wakefield, United Kingdom
| | | | - M R Whitehouse
- Musculoskeletal Research Unit, Bristol Medical School, Southmead Hospital, University of Bristol, Bristol, United Kingdom; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, England
| | - P Lam
- Orthopaedic and Arthritis Specialist Centre, Chatswood, Sydney, Australia
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Ray R, Lewis TL, Robinson P, Dearden PMC, Goff TAJ, Watt C, Lam P. Valgus Second Toe Deformity Treated With a Percutaneous Extracapsular Closing-Wedge Osteotomy of the Proximal Phalanx. Foot Ankle Int 2022; 43:1157-1166. [PMID: 35652729 DOI: 10.1177/10711007221095506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 02/01/2023]
Abstract
BACKGROUND Coronal and sagittal plane deformities of the lesser toes are common yet challenging to treat. Traditional open releases and translational Weil osteotomies can be unpredictable and lead to postoperative stiffness. We present the results of a percutaneous closing wedge extracapsular osteotomy of the proximal phalanx to treat valgus deformity of the second toe. METHODS Thirty-one patients underwent 40 percutaneous osteotomies at a median age of 58.6±9.4 years. Using a small dorsomedial incision, a percutaneous proximal metaphyseal medial closing-wedge extracapsular osteotomy of the second toe is performed, leaving the dorsolateral cortex intact. An irrigated low-speed, high-torque 2- × 8-mm burr is used under image guidance. The osteotomy is then closed to correct deformity and taped for 2 weeks. Patient-reported outcomes and weightbearing radiographs were obtained. RESULTS Questionnaire data was available for 89.7% (n=35) of cases. Most cases (91.4%) were either satisfied or extremely satisfied with the procedure. Radiographs were available for 90.0% of osteotomies, with a median length from surgery to radiographic follow-up of 1.6 years (range 0.5-6.3; SD ±1.5). Median second-toe valgus angle (STVA) decreased from 16.2±10.7 degrees to 5.0±7.0 degrees (P < .001) at final follow-up. All osteotomies united with no delayed union. There were no wound complications or infections. We found 2 cases of radiographic recurrence. CONCLUSION Percutaneous proximal phalanx base metaphyseal closing wedge extracapsular osteotomies of lesser toes to correct coronal plane deformity is useful adjunct to first-ray corrective surgery and is associated with high levels of patient satisfaction. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Robbie Ray
- Princess Royal University Hospital, King's College NHS Foundation Trust, London, United Kingdom.,King's Foot and Ankle Unit, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Thomas L Lewis
- King's Foot and Ankle Unit, King's College Hospital NHS Foundation Trust, London, United Kingdom.,Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Peter Robinson
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, United Kingdom
| | | | - Thomas A J Goff
- Mid Yorkshire Hospitals NHS Trust, Wakefield, United Kingdom
| | - Clare Watt
- Orthopaedic and Arthritis Specialist Centre, Chatswood, Sydney, Australia
| | - Peter Lam
- Orthopaedic and Arthritis Specialist Centre, Chatswood, Sydney, Australia
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Lewis TL, Ray R, Robinson P, Dearden PMC, Goff TJ, Watt C, Lam P. Percutaneous Chevron and Akin (PECA) Osteotomies for Severe Hallux Valgus Deformity With Mean 3-Year Follow-up. Foot Ankle Int 2021; 42:1231-1240. [PMID: 34111991 DOI: 10.1177/10711007211008498] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients with severe hallux valgus deformity present technical and operative challenges with high rates of recurrence and residual deformity. The clinical and radiologic outcomes of percutaneous surgery for severe hallux valgus are not known. METHODS A retrospective review of consecutive patients with a hallux valgus angle (HVA) >40 degrees or intermetatarsal angle (IMA) >20 degrees who underwent third-generation percutaneous chevron and Akin osteotomy (PECA) for hallux valgus deformity correction. RESULTS Between December 2012 and August 2019, 59 feet in 50 patients underwent PECA. Preoperative and follow-up radiographic data were available for 53 feet (89.8%). Postoperative clinical patient-reported outcome measures and satisfaction results were available for 51 feet (86.4%). The mean clinical and radiographic follow-up was 3.1 years and the mean postoperative Manchester-Oxford Foot Questionnaire Index score was 15.1. There was a statistically significant improvement (P < .001) in both IMA and HVA following surgery (IMA 17.5-5.1 degrees; HVA 44.1-11.5 degrees). All patients reported they were satisfied with their outcome, with 76.8% reporting they were highly satisfied. The hallux valgus recurrence rate was 7.5%. CONCLUSION Percutaneous surgery for severe hallux valgus deformity can achieve a large deformity correction, patient satisfaction, and quality of life, with reasonable rates of residual deformity and low rates of recurrence. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Thomas L Lewis
- King's College Foot and Ankle Unit, King's College NHS Foundation Trust, London, United Kingdom
| | - Robbie Ray
- King's College Foot and Ankle Unit, King's College NHS Foundation Trust, London, United Kingdom
| | - Peter Robinson
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, United Kingdom
| | | | - Thomas J Goff
- Mid Yorkshire Hospitals NHS Trust, Wakefield, United Kingdom
| | - Clare Watt
- Orthopaedic and Arthritis Specialist Centre, Chatswood, Sydney, Australia
| | - Peter Lam
- Orthopaedic and Arthritis Specialist Centre, Chatswood, Sydney, Australia
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Lewis TL, Goff TAJ, Ray R, Varrall CR, Robinson PW, Fogarty K, Chang A, Dhaliwal J, Dearden PMC, Wines A. Randomized Controlled Trial of Topical Skin Adhesive vs Nylon Sutures for Incision Closure in Forefoot Surgery. Foot Ankle Int 2021; 42:1106-1114. [PMID: 33870760 DOI: 10.1177/10711007211002501] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND There are many options for incision closure in forefoot surgery. The aim of this study was to compare topical skin adhesive (2-octyl-cyanoacrylate) to simple interrupted nylon sutures. METHODS A prospective randomized controlled trial comparing topical skin adhesive (TSA) and nylon sutures (NSs) for elective open forefoot surgery. Primary outcome was Hollander Wound Evaluation Scale (HWES) assessed 2 weeks following surgery. Secondary objectives included time taken for wound closure, wound assessment, patient satisfaction with wound cosmesis, incision pain, and infection rate. RESULTS Between January and December 2018, 84 feet (70 patients) underwent hallux valgus scarf/Akin osteotomy or first metatarsophalangeal arthrodesis and were randomized to receive either intervention (topical skin adhesive) or control (3/0 nylon sutures). We found worse HWES scores when using TSA compared to NSs (1.07 vs 0.60). Incision closure time was slower for TSA (mean, 272 vs 229 seconds). At 2 weeks postoperatively, wound care was faster for TSA (mean 71 secs) vs NSs (mean 120), and patient-reported pain was less with TSA (visual analog scale: TSA 1.2 vs NSs 2.1). A high degree of overall patient satisfaction was reported in both groups, without significant difference. CONCLUSION Closure of elective forefoot surgery incisions with topical skin adhesive or interrupted nylon sutures offers high satisfaction rates, low pain scores, and low complications. However, topical skin adhesive was associated with more inflammation and areas of wound separation compared to nylon sutures. We recommend the use of sutures for wound closure in forefoot surgery. LEVEL OF EVIDENCE Level I, randomized controlled trial.
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Affiliation(s)
- Thomas L Lewis
- King's Foot and Ankle Unit, King's College NHS Foundation Trust, Orpington, UK
| | | | - Robbie Ray
- King's Foot and Ankle Unit, King's College NHS Foundation Trust, Orpington, UK
| | | | | | - Karen Fogarty
- North Sydney Orthopaedic and Sports Medicine Centre, Wollstonecraft, Australia
| | - Alice Chang
- Bankstown-Lidcombe Hospital, Bankstown, Australia
| | | | | | - Andrew Wines
- North Sydney Orthopaedic and Sports Medicine Centre, Wollstonecraft, Australia
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Lewis TL, Ray R, Robinson P, Dearden PMC, Goff TJ, Gordon D, Lam P. Letter Regarding: Biomechanical Comparison of 2 Common Techniques of Minimally Invasive Hallux Valgus Correction. Foot Ankle Int 2021; 42:381-382. [PMID: 33689502 DOI: 10.1177/1071100721992753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Dearden PMC, Ray RI, Robinson PW, Varrall CR, Goff TJ, Fogarty KA, Wines AP. Clinical and Radiological Outcomes of Forefoot Offloading Versus Rigid Flat Shoes in Patients Undergoing Surgery of the First Ray. Foot Ankle Int 2019; 40:1189-1194. [PMID: 31303022 DOI: 10.1177/1071100719858621] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND It is common clinical practice to use either flat or reverse camber shoes to protect the foot for up to 6 weeks after surgery for hallux valgus or hallux rigidus. To date there is a paucity of evidence as to whether there is any difference between these 2 postoperative shoes, in either patient satisfaction or clinical outcomes. METHODS One hundred consecutive patients undergoing scarf/Akin osteotomies or first metatarsophalangeal joint (MTPJ) arthrodesis were recruited. Patients were randomized 50:50 to either flat or reverse camber postoperative shoes. Patients undergoing ancillary lesser toe procedures were not excluded. Patient satisfaction was assessed by visual analog scale (VAS) pain score and Likert satisfaction survey. Radiographic outcomes were reviewed at 1 year observing differences in fusion rates or deformity recurrence. There were 47 patients in the reverse cam and 43 in the flat shoe group. No difference in primary forefoot operation, additional operation, age at surgery, or preop VAS pain score was seen. RESULTS At 6 weeks, there was no significant difference in postop VAS pain score. The flat shoe group was significantly more likely to be satisfied with their general mobility (86.0% vs 61.7%; P = .01) and with their stability in the shoe (90.7% vs 69.6%; P = .03). No significant difference was seen between groups for nonunion or hallux valgus recurrence rates. CONCLUSION Both forms of postoperative footwear were effective in enabling patients to mobilize and in preventing adverse outcomes. Patients were more likely to be satisfied with a flat postoperative shoe due to improved stability and ease of mobilizing. The results of this study aid surgeon decision making for postoperative footwear in forefoot surgery. LEVEL OF EVIDENCE Level II, prospective randomized controlled trial.
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Affiliation(s)
- Paul M C Dearden
- Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds, UK
| | - Robbie I Ray
- Sydney Orthopaedic Foot and Ankle Research Institute, Wollstonecraft, NSW, Australia
| | - Peter W Robinson
- Sydney Orthopaedic Foot and Ankle Research Institute, Wollstonecraft, NSW, Australia
| | - Caroline R Varrall
- Sydney Orthopaedic Foot and Ankle Research Institute, Wollstonecraft, NSW, Australia
| | - Thomas J Goff
- Sydney Orthopaedic Foot and Ankle Research Institute, Wollstonecraft, NSW, Australia
| | - Karren A Fogarty
- Sydney Orthopaedic Foot and Ankle Research Institute, Wollstonecraft, NSW, Australia
| | - Andrew P Wines
- Sydney Orthopaedic Foot and Ankle Research Institute, Wollstonecraft, NSW, Australia
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Bryant H, Dearden PMC, Harwood PJ, Wood TJ, Sharma HK. Ionising radiation exposure in patients with circular frame treatment of distal tibial fractures. Injury 2015; 46:1597-600. [PMID: 25986665 DOI: 10.1016/j.injury.2015.03.020] [Citation(s) in RCA: 2] [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: 11/07/2014] [Revised: 01/26/2015] [Accepted: 03/05/2015] [Indexed: 02/02/2023]
Abstract
Total radiation exposure accumulated during circular frame treatment of distal tibial fractures was quantified in 47 patients treated by a single surgeon from February 2007 until Oct 2010. The radiation exposures for all relevant radiology procedures for the distal tibial injury were included to estimate the radiation risk to the patient. The median time of treatment in the frame was 169 days (range 105-368 days). Patients underwent a median of 13 sets of plain radiographs; at least one intra operative exposure and 16 patients underwent CT scanning. The median total effective dose per patient from time of injury to discharge was 0.025mSv (interquartile range 0.013-0.162 and minimum to maximum 0.01-0.53). The only variable shown to be an independent predictor of cumulative radiation dose on multivariate analysis was the use of CT scanning. This was associated with a 13-fold increase in overall exposure. Radiation exposure during treatment of distal tibial fractures with a circular frame in this group was well within accepted safe limits. The fact that use of CT was the only significant predictor of overall exposure serves as a reminder to individually assess the risk and utility of radiological investigations on an individual basis. This is consistent with the UK legal requirements for justification of all X-ray imaging, as set out in the Ionising Radiation (Medical Exposure) Regulations 2000 [1].
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Affiliation(s)
- H Bryant
- Department of Orthopaedics and Trauma, Hull Royal Infirmary, Hull, UK.
| | - P M C Dearden
- Department of Orthopaedics and Trauma, Hull Royal Infirmary, Hull, UK
| | - P J Harwood
- Department of Orthopaedics and Trauma, Leeds General Infirmary, Leeds, UK
| | - T J Wood
- Radiation Physics Department, Queen's Centre for Oncology and Haematology, Castle Hill Hospital, Hull, UK and Department of Engineering, Faculty of Science, University of Hull, Hull, UK
| | - H K Sharma
- Department of Orthopaedics and Trauma, Hull Royal Infirmary, Hull, UK
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Abstract
We present a case of distal clavicle osteolysis following treatment of a chronic acromioclavicular joint dislocation with a synthetic ligament. The relevant literature is reviewed and discussed.
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Affiliation(s)
- Paul M. C. Dearden
- Department of Trauma and Orthopaedic Surgery, Lincoln County Hospital, Greetwell Road, Lincoln, LN2 5QY Lincolnshire, United Kingdom
| | - Nicholas A. Ferran
- Department of Trauma and Orthopaedic Surgery, Lincoln County Hospital, Greetwell Road, Lincoln, LN2 5QY Lincolnshire, United Kingdom
| | - Emyr W. Morris
- Department of Trauma and Orthopaedic Surgery, Lincoln County Hospital, Greetwell Road, Lincoln, LN2 5QY Lincolnshire, United Kingdom
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Dearden PMC, Ferran NA, Maqsood M. A modified Weaver-Dunn procedure without need for internal fixation. Acta Orthop Belg 2010; 76:120-123. [PMID: 20306976] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
The shoulder as the most mobile joint in the body has a complex anatomy providing it with an increased range of motion, at the expense of its stability. The complex of ligaments and tendons around the acromioclavicular joint (ACJ) is prone to injury especially during sporting activity or following falls onto the apex of the shoulder. The original classification of ACJ dislocations having been modified by Rockwood suggests that types III to VI injuries may benefit from surgical intervention. Many procedures have been described to correct the deformity in the ACJ and to reestablish its ligamentous support. We describe a modification to the Weaver-Dunn procedure, which aims to establish a stable reduction with bone-to-bone healing, provided by bone plug fixation with Ethibond suture.
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