Subacromial impingement syndrome: management challenges.

The painful shoulder is the most common condition seen in specialist shoulder clinics. It is often associated with lack of range of motion and reduced shoulder function. Lack of sleep and difficulties in performing basic daily life activities are common findings. Subacromial Impingement Syndrome (SAIS) has been considered as the most common cause of shoulder pain since it was described in 1852. Charles Neer, in 1972, described the presence of a "proliferative spur and ridge" on the undersurface of the acromion, which needs to be removed to improve the symptoms (acromioplasty). Neer's "impingement" hegemony was undisputed for at least 30 years. A more extensive knowledge of the pathogenesis of SAIS, however, has led authors to challenge the role of "impingement" in the shoulder pain and the role of surgical intervention. The aim of this review was to understand if there is still a role for surgical decompression in patients with SAIS. A literature review was performed in PubMed, PEDro, Embase, and the Cochrane Central Register of Controlled Trials using impingement, subacromial space, rotator cuff tears, tendinopathy, and tendinitis as key words. Randomized clinical trials (RCTs) with long-term follow-up comparing surgical intervention and conservative treatments in SAIS were preferred; however, prospective articles studying the outcome of surgical decompression and physiotherapy were also included. The majority of the studies showed no difference in the outcome between patients randomized to surgical decompression or conservative management. However, some studies reported better results after surgery, especially in the long term. Interpretation of the results is very difficult as most of the studies are of poor quality and have short follow-up. In our opinion, the type of subacromial lesion needs to be considered; this may offer an explanation to the difference in severity of symptoms and to the varying degrees of response to certain treatments, including surgery. Further studies are mandatory to better understand the role of surgery in SAIS.

A patient-derived Constant-Murley score is comparable to a clinician-derived score.

BACKGROUND: Although there are many advantages to patient-based assessment for musculoskeletal conditions, one common problem is that many of these assessments are perceived to be subjective. To overcome this limitation for patient-based shoulder evaluation, we developed a modified Constant-Murley score that allows patients to complete subjective and objective sections of the score. QUESTIONS/PURPOSES: The purpose of our study was to assess the reliability of the new patient-based Constant-Murley score questionnaire by comparing composite scores and subscores obtained with those obtained using the standard physician-based Constant-Murley questionnaire in the same group of patients. METHODS: Between August and October 2000, all patients having shoulder surgery in our institute were invited to participate in this study; 58 of 61 (95%) opted to do so and completed the patient-based questionnaire at preoperative and postoperative assessments. The clinician-based Constant-Murley score was performed by a clinician who was blinded to the corresponding patient-based questionnaire. Patients underwent various procedures ranging from manipulation under anesthesia and arthroscopic procedures to reverse shoulder arthroplasty. RESULTS: The mean patient-based and the clinician-based Constant-Murley scores were 47 (SD = 19.5; range, 4-90; N = 108) and 48 (SD = 19.9; range, 4-90; N = 108) points respectively. The mean difference was -1.3 (SD = 3; range, -11 to 8; N = 108) points. The new patient-based Constant-Murley score questionnaire reproduced the patient-based method and had substantial to almost perfect agreement with it for the composite score and various subgroups. CONCLUSIONS: These results suggest that a patient-based questionnaire can be used interchangeably with or in place of a clinician-based Constant-Murley score. These results apply to subjective and objective items of the Constant-Murley score.

Percutaneous K-wire buttress technique for displaced radial neck fracture.

Radial neck fractures are uncommon injuries in adults and more often found in children, where they account for 5-8.5% of elbow injuries. It is generally agreed that an angulation of less than 30 degrees is acceptable. However, anything greater than this should be improved in an attempt to restore normal anatomy and maximize the range of movement. We describe our management of a radial neck fracture in a young lady which was significantly angulated, resulting in a restriction of movements. Attempts at a closed reduction failed and hence we proceeded with percutaneous reduction and buttressing with a K-wire. Post-operatively the patient regained a full range of movements with normal elbow function. We outline our surgical technique, which has not been previously described. We suggest that it is a safe and easy option in cases of failed closed reduction and should be considered prior to proceeding with an open reduction.

"Put your 'extended' finger on the bleeder": the use of direct pressure from the shaver blade to achieve hemostasis.

Maintaining good hemostasis is vital to ensure clear vision during arthroscopic surgery. This is most commonly achieved with electrocautery or radiofrequency devices. Another technique involves temporarily increasing the arthroscopic fluid inflow pressure to tamponade the bleeding. Unfortunately, both of these methods are not without risks or limitations and may involve extra costs. Our technique involves the use of the barrel end of the shaver blade to apply direct pressure on the bleeding vessel for 3 seconds to stop the bleeding. This is a simple, time-efficient, and cost-effective method of achieving hemostasis.

The active elevation lag sign and the triangle sign: new clinical signs of trapezius palsy.

BACKGROUND: Spinal accessory nerve palsy causing trapezius dysfunction can lead to significant disability. Diagnosis is frequently delayed or inaccurate leading to inappropriate treatment. METHODS: We describe new clinical signs for trapezius muscle dysfunction and palsy, and accessory nerve palsy, viz. The Active Elevation Lag sign and the Triangle sign. These signs help to differentiate between scapular winging due to trapezius dysfunction and that due to serratus anterior dysfunction. The signs are based on the principle that the deficiency of trapezius function causes an ;active forward elevation lag' with compensatory spinal hyperextension, and lead to the Triangle sign in the prone position, whereas no such lag is found in patients with pure serratus anterior dysfunction. Video recordings of clinical examination of 10 patients, 5 with isolated spinal accessory nerve palsy and 5 with long thoracic nerve palsy (confirmed by neurophysiology studies) were blinded and reviewed by 8 assessors. RESULTS: Of the total of 80 readings, 100% sensitivity and 95% specificity were found, in correlation with the diagnosis confirmed by neurophysiology studies, with positive predictive value of 95% and negative predictive value of 100%. CONCLUSION: These are simple clinical signs, easy to perform which are useful in diagnosing trapezius weakness in clinical practice. LEVEL OF EVIDENCE: Level 2-1; Evidence obtained from well-designed controlled trials without randomization.

Distal oblique first metatarsal osteotomy in grade 3 hallux rigidus: a long-term followup.

BACKGROUND: While some studies have demonstrated that metatarsus primus elevatus in hallux rigidus is an uncommon secondary change rather than a causative factor, we believe it is, in fact, more common. We advocate surgical treatment if the first ray is elevated beyond normal range, thereby acting as a decompression realignment osteotomy. MATERIALS AND METHODS: We analyzed patients operated between June 1994 and December 1996. Oblique distal osteotomy of the first metatarsal was performed in 20 patients. A retrospective review of clinical and radiological outcomes was performed including an AOFAS score and patient satisfaction scale. The postoperative ROM was evaluated with lateral radiographs in maximum plantar/dorsiflexion. The average followup was 11.1 (range, 8.7 to 13.6) years. RESULTS: One case of metatarsalgia was the only postoperative complication. The average AOFAS score increased from 44 (range, 14 to 68) to 82 (range, 80 to 100). Good to excellent results were achieved in 19 patients. The mean passive dorsiflexion of the first MTP joint improved from 8 degrees (range, 5 degrees to 10 degrees) to 44 degrees (range, 15 degrees to 55 degrees). No patient underwent subsequent surgery. CONCLUSION: The oblique osteotomy is a safe and reliable procedure for treatment of painful hallux rigidus. In our experience, it yields good and excellent results with high patient satisfaction and low complication rates.

Spinal manifestations in a patient with congenital insensitivity to pain.

Spinal manifestations in congenital insensitivity to pain are relatively uncommon and easily misdiagnosed. We report on a patient with absent protective pain sensation, who developed spinal neuropathic arthropathy. At age 11 years, he presented with a destructive lesion at the L1-L2 level, causing him tingling sensation in both lower limbs. He was treated with combined anteroposterior spinal fusion from T12 to L3 and had full recovery. Five years later, he presented with a long history of clicking in his low back, muscle weakness and paresthesia in both lower extremities during walking, and evidence of Charcot arthropathy at the L4-L5 level, resulting in junctional kyphosis and canal narrowing. Posterior spinal arthrodesis from L3 to the sacrum was performed, due to lack of patient and parental consent for combined anterior decompression/posterior fusion. The patient resumed normal muscle function and his previous level of activities. Spinal complications should be anticipated in this condition and create diagnostic and therapeutic dilemmas. However, surgical management can produce favorable clinical results.

The use of chondrogide membrane in autologous chondrocyte implantation.

UNLABELLED: Autologous chondrocyte implantation is a new technique for the treatment of chondral defects in the knee. The exact procedure involved is continuously being developed with the ultimate aim of achieving hyaline cartilage regeneration. We present the outcome of our series of 31 patients, focussing on the use of the chondrogide membrane in the implantation process. Assessment is presented both in the form of arthroscopic appearance at approximately 1 year, and in the form of clinical outcome measures at 1 year and at 2 years after the second stage of the procedure. CONCLUSION: the use of chondrogide membrane in the fixation of cells during the implantation process is associated with satisfactory clinical outcome and does not appear to show evidence of hypertrophy at one-year arthroscopy, as compared to periosteum.

Osteosarcoma associated with diamond-blackfan anaemia: a case of a child receiving growth hormone therapy.

PURPOSE: Diamond-Blackfan anaemia (DBA) is a rare pure congenital red cell aplasia, usually presenting in infancy or early childhood. The literature suggests a predisposition to haemopoietic malignancy but in addition solid tumours have been reported, with five cases of osteosarcoma described. PATIENT: A sixth case of a 12-year-old girl with DBA who developed an osteosarcoma of the distal femur is presented. RESULTS: She was treated with methotrexate followed by tumour excision and distal femoral replacement. The patient is currently alive with multiple pulmonary metastases. DISCUSSION: We discuss the association between the administration of growth hormone and future development of malignancy in patients with DBA.