334 pathology affecting shoulder function, prior to injury. Men accounted 93 with average age 25.4 years, and women 39 with average age 34.2 years. All underwent conservative management with standard protocols and the fracture was united. The length and relative shortening of the united clavicle were assessed on a standardised posteroanterior chest x-ray. Intra- and Inter-observer reliability of measurements were assessed. Clinical outcome was evaluated with the Constant score. Mean follow-up was 30 months. Results: Clavicular shortening following fracture union was 11.4 mm on average (range 3–25 mm), and was encountered in 120 patients. Intra- and inter-observer variability of measurements were not significant. Fracture healing time averaged 10 weeks (range 6–20 weeks) and 5.3% of patients presented delayed union. Thirtyfour patients (25.8%) were unsatisfied with the result. The mean Constant score was 84 (range 62–100). Forty patients were having pain, and 21 had shoulder function impairment. Shortening >14mm was statistically associated with unsatisfactory results. Conclusion: Clavicle is an important element in the integral functional mobility of the shoulder and malunion after fracture could lead to unsatisfactory results. We describe a simple, reliable method of Clavicular length-shortening evaluation and we report the results following successful conservative management. Identification of those patients likely to have poor results after conservative treatment, would give the opportunity for alternative treatment modalities. Further prospective randomised trials are necessary. At least one of the authors is receiving or has received material benefits or support from a commercial source.
COMBINED ORTHOPAEDIC ASSOCIATIONS humeral nail used for fixation of difficult fractures of humerus. Method: In Airedale NHS Trust and Calderdale hospitals, 282 patients were treated for displaced humeral fractures. The new nail called Halder Humeral Nail (HHN) was inserted from the olecranon roof proximally towards the head of humerus. It had a specialised locking system by opening of a trio wire at the proximal head of humerus and distally near the elbow the nail was locked with the help of a screw on a plate. Patients were mobilised immediately after surgery in a polysling. Results: At six weeks, 95% of patients were pain free and could perform daily activities comfortably. Average post-operative Constance score was 74.7. Complications included proximal migration of the nail and the trio wire in seven cases; six patients had non-union and one patient had infection. Breakage of trio wire was seen in five cases. This resulted in modification of the nail by introducing an additional screw to lock at proximal humerus around the trio wires. Conclusion: We concluded that stable internal fixation and a good fracture union could be achieved by this new HHN, especially in a displaced humeral fracture, even in poor quality bone with fracture at different level. Pain-free movements, and early recovery was possible without damaging the rotator cuff and risking the axillary nerve. One or more of the listed authors are receiving or have received benefits or support from a recognised academic body for the pursuance of the study.
OUTCOME OF SHOULDER HEMIARTHROPLASTY FOR DISPLACED COMPLEX PROXIMAL HUMERAL FRACTURES R.S. Page1, C.M. Robinson2, C. Court-Brown2, R.M.F. Hill2 and A. Wakefield2 1 The Geelong Hospital, Geelong, Australia, 2The Royal Infirmary Of Edinburgh, Edinburgh, United Kingdom
Introduction and Aims: The aim was to prospectively assess shoulder hemiarthroplasty for un-reconstructable proximal humeral fractures at a minimum of 12 months and identify factors that aid prognosis. Method: Inclusion criteria were patients with a displaced fracture requiring shoulder hemiarthroplasty. Constant scoring was done at a minimum follow-up of one year. Patients were treated using a Neer or Osteonics prosthesis, the decision for hemiarthroplasty being made at the time of surgery. Post-operative management was standardised. An independent functional assessment, record review establishing a physiological index according to co-morbidities, and radiological analysis were carried out. Survival analysis was performed for one and five-year results and data was analysed by linear regression to identify prognostic factors. Results: From 163 patients there were 138 fitting the criteria, 42 males and 96 females, average age of 68.5 (range 30–90) years and follow-up of 6.3 (range 1–15) years. The fracture pattern was three and four part in 133 cases and five head split fractures; 58 were associated with dislocation. Survival was 96.4 percent at one year and 93.6 percent at five years, with no significant difference between prostheses. There were eight revisions, (one deep infection, four dislocations and three peri-prosthetic fractures), by 12 months. The average Constant score was 67.1 at one year. Conclusion: Prognostic factors on presentation were age of the patient and their physiological index, and at three months any complication, the position of the implant, tuberosity union and persistent neurological deficit. Overall optimum outcome was in patients aged 55 to 60, with minimal co-morbidities and uncomplicated recovery. None of the authors is receiving any financial benefit or support from any source.
THE ‘CLAVICLE’ HOOK PLATE IN THE TREATMENT OF ACROMIOCLAVICULAR DISLOCATION AND DISTAL CLAVICLE FRACTURES A. Barrow, B.H. Barrow and M. Radziejowski University of the Witwatersrand, Johannesburg, South Africa
Introduction and Aims: Acromioclavicular dislocations and fractures of the distal clavicle present a challenging problem for the treating surgeon. The use of a new specifically designed implant was investigated. A hooked-shaped plate with fixation to the distal clavicle and ‘hook’ placement under the posterior acromion was used. Method: The procedure was carried out on eight patients. In five patients the injury was a fractured distal clavicle. In three cases an acromioclavicular dislocation was treated. In all cases the time to returning to a functional capacity was analysed. The eventual functional result was indexed from the time of fracture union or complete stabilisation of the dislocations. Results: All five fractures went on to anatomical union. The three dislocations were all stabilised with no instability or subluxation. In two cases patients complained of impingement symptoms with decreased overhead functional capacity. In both cases the patients regained a full and pain-free range of movement after removal of the implant. Conclusion: This new implant provides an acceptable alternative in the management of distal clavicle fractures and acromioclavicular dislocations. The complication of impingement is encountered, but this appears to be treatable by removal of the implant after fracture union or joint stabilisation. At least one of the authors is receiving or has received material benefits or support from a commercial source.
EFFECTS OF DIFFERENT SUTURE TECHNIQUES ON REATTACHMENT OF THE TUBEROSITIES OF THE HUMERUS FOLLOWING HEMI-ARTHROPLASTY FOR FOUR-PART FRACTURE R.B. Abu-Rajab, I.G. Kelly, A.C. Nicol and B. Stansfield Glasgow Royal Infirmary, Glasgow and Bioengineering Department, Strathclyde University, Glasgow, UK
Introduction and Aims: The purpose of this study was to evaluate the effect on movement under load of different techniques of reattachment of the humeral tuberosities following four-part proximal humeral fracture. Method: Biomechanical test sawbones were used. Fourpart fracture was simulated and a cemented Neer3 prosthesis inserted. Three different techniques of reattachment of the tuberosities were used: 1) tuberosities attached to the shaft, and to each other through the lateral fins in the prosthesis with one cerclage suture through the anterior hole in the prosthesis; 2) as one without cerclage suture; 3) tuberosities attached to the prosthesis and to the shaft. All methods used a number five ethibond suture. Both tuberosities and the shaft had multiple markers attached. Two digital cameras formed an orthogonal photogrammetric system, allowing all segments to be tracked in a 3-D axis system. Humeri were incrementally loaded in abduction using an Instron machine, to a minimum 1200N, and sequential photographs taken. Photographic data was analysed to give 3-D linear and angular motions of all segments with respect to the anatomically relevant humeral axis, allowing intertuberosity and tuberosity-shaft displacement to be measured. Results: Techniques one and two were the most stable constructs with technique three, allowing greater separation of fragments and angular movement. True intertuberosity separation at the midpoint of the tuberosities was significantly greater using technique three (p<0.05). The cerclage suture used in technique two added no further stability to the fixation. Conclusion: Our model suggests that the most effective and simplest technique of reattachment involves suturing the tuberosities to each other, as well as to the shaft of the humerus. The cerclage suture appears to add little to the fixation in abduction, although the literature would suggest it may have a role in resisting rotatory movements. At least one of the authors is receiving or has received material benefits or support from a commercial source.
FIXATION OF DISTAL BICEPS RUPTURES USING THE ENDOBUTTON: A MODIFIED TECHNIQUE C. Roberts, P. Duke, M. Mitchell and M. Ross AOA Brisbane, Australia
Introduction and Aims: Distal biceps ruptures are an uncommon injury. They represent approximately three percent of all biceps ruptures. Intervention was popularised by Boyd and Anderson who described a two-incision technique. Improved outcome has been achieved with stronger fixation allowing early mobilisation. Method: All patients who underwent operative fixation of distal biceps ruptures by the senior two authors were identified. All patients were clinically reviewed at a minimum of six months from surgery. Functional outcomes scores in the form of Patient Rated Elbow Evaluation (PREE) and DASH scores were assessed. The operative technique utilised the Endobutton (Smith and Nephew) and is a substantial modification of that published by Bain,G et al. Results: Thirty-one patients were identified. All patients were male with an average age of 47 years. Average delay to surgery was 24 days. There were no postoperative complications and no repeat ruptures. Thirty patients have returned Patient Rated Elbow Evaluation (PREE) forms with an average score of eight. Cybex testing demonstrates good return of strength when compared to the uninjured side. Conclusion: Fixation of distal biceps ruptures using this modified Endobutton technique is a safe and effective method. At least one of the authors is receiving or has received material benefits or support from a commercial source. J BONE JOINT SURG [BR] 2005; 87-B:SUPP III
INTERNAL FIXATION OF HUMERAL FRACTURES WITH A NEW INTRAMEDULLARY RETROGRADE NAIL D.J. Beard, S.V. Sonanis, J.A. Chapman and S.C. Halder Airedale NHS
Introduction and Aims: The purpose of this study was to analyse the results of a new intramedullary retrograde