Patient-reported outcomes (PROs) capture data related to patients' perception of their health... more Patient-reported outcomes (PROs) capture data related to patients' perception of their health status and aspects of health care delivery. In parallel, digital innovations have advanced the administration, storage, processing, and accessibility of PROs, allowing these data to become actively incorporated in day-to-day clinical practice along the entire patient care pathway. Further, the emergence of shared decision making, where patients are engaged in informed treatment selection aligned with their preferences, values, and needs, can be realized by PROs and technology. This technology-enabled, data-driven approach provides insights which, when actioned, can enhance musculoskeletal care of patients and populations, while enriching the clinician-patient experience of decision making. In this review, we provide an overview of the opportunities enabled by PROs and technology for the cycle of orthopedic care.
In 1991 15% of the UK population that travelled abroad required medical assistance. We have been ... more In 1991 15% of the UK population that travelled abroad required medical assistance. We have been treating more patients with lower limb injuries requiring repatriation via aircraft. Recommendations from Airlines were unavailable. 357 Consultants replied to a questionnaire about transportation of patients with a lower limb injury wearing a plaster cast. There was no consensus on safe transportation of these patients. No scientific data is available on the dynamics of transportation of patients with lower limb trauma. In order to assess the safest method of transportation an experiment was conducted. Ethical committee approval was granted. Five volunteers wearing above leg plaster casts were placed in a decompression chamber. The effects on anterior compartment pressures, Doppler venous return, ambient pressure between plaster and skin were assessed in different positions with and without plasters being split. In the normal population we have shown a trebling of intracompartmental pre...
The functions of the subclavius muscle (SM) are described as stabilization of the sternoclavicula... more The functions of the subclavius muscle (SM) are described as stabilization of the sternoclavicular joint (SCJ) and resisting elevation of the lateral end of the clavicle. During systematic cadaveric dissections, we observed additional fibrous structures, previously described as variants of the anatomy, extending from the SM and inserting into the coracoid process (CP). Due to the high incidence of these structures in our dissections, we hypothesized that the attachment at the CP is more common than appreciated and that, as a corollary, the function of the SM was (or has been) more complex than simply depressing the clavicle and generating stability at the SCJ. For our investigation, fifty‐two upper extremities of 26 human cadavers were dissected. The SM was demonstrated from costal to clavicular attachment. We documented additional fibrous structures apparently derived from the SM inserting into the CP. Measurements of the length of the SM, the length of its attachment, and the leng...
Frontiers in Bioengineering and Biotechnology, 2016
Background Re-attachment of tendon to bone is challenging with surgical repair failing in up to 9... more Background Re-attachment of tendon to bone is challenging with surgical repair failing in up to 90% of cases. Poor biological healing is common and characterised by the formation of weak scar tissue. Previous work has demonstrated that decellularised allogenic demineralised bone matrix (DBM) regenerates a physiologic enthesis. Xenografts offer a more cost-effective option but concerns over their immunogenicity have been raised. We hypothesised that augmentation of a healing tendon-bone interface with DBM incorporated with autologous mesenchymal stem cells (MSCs) would result in improved function, and restoration of the native enthesis, with no difference between xenogenic and allogenic scaffolds. Methods Using an ovine model of tendon-bone retraction the patellar tendon was detached and a complete distal tendon defect measuring 1 cm was created. Suture anchors were used to reattach the shortened tendon and xenogenic DBM + MSCs (n=5) and allogenic DBM + MSCs (n=5) were used to bridge the defect. Functional recovery was assessed every 3 weeks and DBM incorporation into the tendon and its effect on enthesis regeneration was measured using histomorphometry. Results By 12 weeks, DBM augmentation resulted in significantly improved functional weight bearing with no failures in either group. Compared to xenogenic DBM, allogenic DBM was associated with significantly higher functional weight bearing at 6 (P=0.047), 9 (P=0.028) and 12 weeks (P=0.009). This was accompanied by a more direct type of enthesis characterised by significantly more fibrocartilage and mineralised fibrocartilage. Xenograft was also associated with an immunogenic reaction despite preoperative decellularisation. Conclusion This study shows that DBM enhances tendon-bone healing and may reduce the high failure rates associated with surgery. An immunogenic reaction, and inferior biomechanical and histological results were also associated with the use of xenograft. Allogenic DBM with autologous MSCs may be a suitable scaffold for the enhancement of tendon-bone healing in the clinical setting. Disclosures Funded by IKC PoC grant awarded by the University of Leeds Ethical approval Granted by the study institution (University College London)
Inherent disadvantages of reverse shoulder arthroplasty designs based on the Grammont concept hav... more Inherent disadvantages of reverse shoulder arthroplasty designs based on the Grammont concept have raised a renewed interest in less-medialised designs and techniques. The aim of this study was to evaluate the outcome of reverse shoulder arthroplasty (RSA) with the fully-constrained, less-medialised, Bayley-Walker prosthesis performed for the treatment of rotator-cuff-deficient shoulders with glenohumeral arthritis. A total of 97 arthroplasties in 92 patients (53 women and 44 men, mean age 67 years (standard deviation (sd) 10, (49 to 85)) were retrospectively reviewed at a mean follow-up of 50 months ((sd 25) (24 to 96)). The mean Oxford shoulder score and subjective shoulder value improved from 47 (sd 9) and 24 points (sd 18) respectively before surgery to 28 (sd 11) and 61 (sd 24) points after surgery (p < 0.001). The mean pain at rest decreased from 5.3 (sd 2.8) to 1.5 (sd 2.3) (p < 0.001). The mean active forward elevation and external rotation increased from 42(°)(sd 30) ...
The sternoclavicular joint (SCJ) is a pivotal articulation in the linked system of the upper limb... more The sternoclavicular joint (SCJ) is a pivotal articulation in the linked system of the upper limb girdle, providing load-bearing in compression while resisting displacement in tension or distraction at the manubrium sterni. The SCJ and acromioclavicular joint (ACJ) both have a small surface area of contact protected by an intra-articular fibrocartilaginous disc and are supported by strong extrinsic and intrinsic capsular ligaments. The function of load-sharing in the upper limb by bulky periscapular and thoracobrachial muscles is extremely important to the longevity of both joints. Ligamentous and capsular laxity changes with age, exposing both joints to greater strain, which may explain the rising incidence of arthritis in both with age. The incidence of arthritis in the SCJ is less than that in the ACJ, suggesting that the extrinsic ligaments of the SCJ provide greater stability than the coracoclavicular ligaments of the ACJ. Instability of the SCJ is rare and can be difficult to ...
Journal of Bone and Joint Surgery - British Volume, 2012
Scapulothoracic fusion (STF) for painful winging of the scapula in neuromuscular disorders can pr... more Scapulothoracic fusion (STF) for painful winging of the scapula in neuromuscular disorders can provide effective pain relief and functional improvement, but there is little information comparing outcomes between patients with dystrophic and non-dystrophic conditions. We performed a retrospective review of 42 STFs in 34 patients with dystrophic and non-dystrophic conditions using a multifilament trans-scapular, subcostal cable technique supported by a dorsal one-third semi-tubular plate. There were 16 males and 18 females with a mean age of 30 years (15 to 75) and a mean follow-up of 5.0 years (2.0 to 10.6). The mean Oxford shoulder score improved from 20 (4 to 39) to 31 (4 to 48). Patients with non-dystrophic conditions had lower overall functional scores but achieved greater improvements following STF. The mean active forward elevation increased from 59° (20° to 90°) to 97° (30° to 150°), and abduction from 51° (10° to 90°) to 83° (30° to 130°) with a greater range of movement achi...
Journal of Bone and Joint Surgery - British Volume, 2012
There is little information about the management of peri-prosthetic fracture of the humerus after... more There is little information about the management of peri-prosthetic fracture of the humerus after total shoulder replacement (TSR). This is a retrospective review of 22 patients who underwent a revision of their original shoulder replacement for peri-prosthetic fracture of the humerus with bone loss and/or loose components. There were 20 women and two men with a mean age of 75 years (61 to 90) and a mean follow-up 42 months (12 to 91): 16 of these had undergone a previous revision TSR. Of the 22 patients, 12 were treated with a long-stemmed humeral component that bypassed the fracture. All their fractures united after a mean of 27 weeks (13 to 94). Eight patients underwent resection of the proximal humerus with endoprosthetic replacement to the level of the fracture. Two patients were managed with a clam-shell prosthesis that retained the original components. The mean Oxford shoulder score (OSS) of the original TSRs before peri-prosthetic fracture was 33 (14 to 48). The mean OSS aft...
Malformation and hypoplasia of the clavicle can result in pain, impaired function, restricted sho... more Malformation and hypoplasia of the clavicle can result in pain, impaired function, restricted shoulder movement, subjective feeling of instability, and cosmetic deformity. There are no reports of clavicle lengthening by osteotomy and distraction osteogenesis (DO). This is a retrospective review of 5 patients (7 clavicles) who underwent clavicle lengthening by DO using a monolateral external fixator for clavicular hypoplasia. There were 3 males and 2 females with the mean age of 15 years (9 to 23 y) and mean follow-up of 35 months (12 to 66 mo). Preoperative diagnoses included Klippel-Feil syndrome, cleidocranial dysplasia with hemihypertrophy and torticollis, congenital myopathy and Noonans syndrome, and obstetric brachial plexus injury. Mean length gained was 31 mm (15 to 41 mm) that represents an average of 24.7% of overall bone length. Mean time in fixator was 174 days (161 to 263 d) and mean external fixation index was 56 d/cm. Two patients required internal fixation after fixator removal to consolidate union and 1 required additional internal fixation for atrophic regeneration. Mean preoperative oxford shoulder score improved from 28.5 to 41 and all patients were extremely satisfied with their result. Two patients developed pin-site infections. Clavicular lengthening by DO for congenital clavicular hypoplasia is a previously unreported technique that enables gradual correction of deformity without risking brachial plexus traction injury after acute correction. It has the potential to improve shoulder pain, function, range of movement, and cosmesis. Distraction ≥25% of overall bone length may require additional plate fixation to consolidate union. Level IV-therapeutic study.
Interfragmental ischaemia is a prerequisite for the initiation of the inflammatory and immunologi... more Interfragmental ischaemia is a prerequisite for the initiation of the inflammatory and immunological response to fracturing of bone.Intrafragmental ischaemia is inevitable: the extent of the initial ischaemic insult does not, however, directly relate to the outcome for healing of the fracture zones and avascular necrosis of the humeral head. The survival of distal regions of fragments with critical perfusion may be the result of a type of inosculation (blood vessel contact), which establishes reperfusion before either revascularization or neo-angiogenesis has occurred.Periosteum has a poorly defined role in fracture healing in the proximal humerus. The metaphyseal periosteal perfusion may have a profound effect, as yet undefined, on the healing of most metaphyseal fractures of the proximal humerus, and may be disturbed further by inadvertent surgical manipulation.The metaphysis can be considered as a 'torus' or ring of bone, its surface covered by periosteum antero- and post...
Deep prosthetic infection is a potentially devastating complication after total elbow arthroplast... more Deep prosthetic infection is a potentially devastating complication after total elbow arthroplasty, with an incidence of up to 12%. This study examined the demographics, microbiologic profile, and outcomes of infected total elbow arthroplasty treated with 2-stage revision in a tertiary referral unit. We identified 19 consecutive patients (mean age, 65 years) undergoing revision arthroplasty for deep prosthetic infection. All patients underwent a first-stage procedure with removal of implants, débridement, and insertion of an antibiotic-loaded cement spacer, followed by at least 6 weeks of intravenous antibiotics. Fourteen patients required a second-stage revision. Five patients did not undergo a second-stage procedure because of patient choice (n = 2), medical or surgical risk factors (n = 2), and death from an unrelated cause (n = 1). Of the 19 patients undergoing a first-stage procedure, 16 (84%) remained infection free, and 11 of the 14 patients (79%) undergoing reimplantation of...
Journal of shoulder and elbow surgery, Jan 27, 2017
Sprengel deformity is a rare congenital shoulder girdle anomaly characterized by scapula malposit... more Sprengel deformity is a rare congenital shoulder girdle anomaly characterized by scapula malposition, periscapular muscle atrophy, and limited shoulder movement. Traditionally, it has been managed by omovertebral bar excision and muscle transplantation procedures guided by age and Cavendish grade. We present a unique observation in humans: a case series with Sprengel deformity possessing a cleithrum, an ancestral remnant of shoulder girdle development found in archaic bony fish. Nine patients presented with so-called Sprengel deformity to a tertiary referral shoulder clinic. All were assessed clinically and radiologically with scapular radiographs and computed tomography or magnetic resonance imaging scans. The clinical and radiologic features were classified according to Cavendish and Rigault systems, respectively, and the scapular ratio was assessed. All patients were assigned grade 4 on the Cavendish scale. Six were grade 2 and 3 were grade 3 on the Rigault scale. The distinguish...
The current study describes several surgical techniques for the treatment of the reverse Hill - S... more The current study describes several surgical techniques for the treatment of the reverse Hill - Sachs lesion after posterior shoulder dislocation; we also aimed to present long term results followed for a minimum of five years. This study is a prospective case series of 17 patients who were treated in our clinic between 2008 and 2011. Patients with a defect size smaller than 25% of the articular surface were treated conservatively. An endoprosthesis of the glenohumeral joint was implanted in patients with a defect size bigger than 40%. All remaining patients were treated by a variety of operative techniques, depending on the quality of the bone and size of the defect. Twelve of seventeen patients had a defect size of the humeral articular surface between 25% and 40% with a mean age of 39 years. Depending on the defect size these patients were treated with retrograde chondral elevation, antegrade cylindrical graft or a graft of the iliac bone crest with an open approach. All the proc...
Background: The success of rotator cuff repair is primarily dependent on tendon-bone healing. Fai... more Background: The success of rotator cuff repair is primarily dependent on tendon-bone healing. Failure is common because weak scar tissue replaces the native enthesis, rendering it prone to reruptures. A demineralized bone matrix (DBM) consists of a network of collagen fibers that provide a sustained release of growth factors such as bone morphogenetic proteins. Previous studies have demonstrated that it can regenerate a fibrocartilaginous enthesis. Hypothesis: The use of a DBM and mesenchymal stem cells (MSCs) at the healing enthesis will result in a higher bone mineral density at the tendon insertion and will enhance the regeneration of a morphologically superior enthesis when compared with an acellular human dermal matrix. Study Design: Controlled laboratory study. Methods: Eighteen female Wistar rats underwent unilateral detachment of the supraspinatus tendon. Three weeks later, tendon repair was carried out in animals randomized into 3 groups: group 1 received augmentation of th...
Background Flail shoulder can occur following a brachial plexus injury and is characterized by pa... more Background Flail shoulder can occur following a brachial plexus injury and is characterized by painful subluxation of the glenohumeral joint and the inability to independently position the hand in space. The present study aimed to report the clinical outcomes following glenohumeral arthrodesis for late reconstruction of flail shoulder in patients with traumatic supraclavicular brachial plexus palsy. Methods Seven patients were included in the present study and were followed-up for a mean of 98 months (range 27 months to 197 months). The mean age at the time of surgery was 48 years (range 28 years to 80 years) and the mean time to surgery from injury was 5 years (range 2.5 years to 8 years). Results Six patients achieved bony union with a mean time to fusion of 4.7 months (range 2 months to 8 months). Non-union occurred in one case. The mean Oxford Shoulder Score improved from 11 pre-operatively (range 4 to 16) to 27 postoperatively (range 16 to 40) ( p = 0.016), and the mean Subject...
Epileptic seizures can cause shoulder dislocation, recurrent instability and eventually arthritis... more Epileptic seizures can cause shoulder dislocation, recurrent instability and eventually arthritis. The purpose of this study was to report the results, complications and rate of revision surgery following anatomical shoulder arthroplasty in epileptic patients with instability arthropathy. A consecutive series of eight patients with epilepsy underwent anatomical shoulder arthroplasty for recurrent shoulder instability and were retrospectively reviewed after a mean of 4.7 years (range, 2-7.5 years). These included three total shoulder replacements and five humeral resurfacing hemiarthroplasty procedures. Mean age of the cohort was 33 years (range, 17-44). All patients experienced post-operative grand mal seizures. Two patients with hemiarthroplasty required further surgery due to painful glenoid erosion. No residual cases of instability were noted. Mean active forward elevation and external rotation improved following surgery. The Oxford Shoulder Score improved from 15 pre-operatively...
Patient-reported outcomes (PROs) capture data related to patients' perception of their health... more Patient-reported outcomes (PROs) capture data related to patients' perception of their health status and aspects of health care delivery. In parallel, digital innovations have advanced the administration, storage, processing, and accessibility of PROs, allowing these data to become actively incorporated in day-to-day clinical practice along the entire patient care pathway. Further, the emergence of shared decision making, where patients are engaged in informed treatment selection aligned with their preferences, values, and needs, can be realized by PROs and technology. This technology-enabled, data-driven approach provides insights which, when actioned, can enhance musculoskeletal care of patients and populations, while enriching the clinician-patient experience of decision making. In this review, we provide an overview of the opportunities enabled by PROs and technology for the cycle of orthopedic care.
In 1991 15% of the UK population that travelled abroad required medical assistance. We have been ... more In 1991 15% of the UK population that travelled abroad required medical assistance. We have been treating more patients with lower limb injuries requiring repatriation via aircraft. Recommendations from Airlines were unavailable. 357 Consultants replied to a questionnaire about transportation of patients with a lower limb injury wearing a plaster cast. There was no consensus on safe transportation of these patients. No scientific data is available on the dynamics of transportation of patients with lower limb trauma. In order to assess the safest method of transportation an experiment was conducted. Ethical committee approval was granted. Five volunteers wearing above leg plaster casts were placed in a decompression chamber. The effects on anterior compartment pressures, Doppler venous return, ambient pressure between plaster and skin were assessed in different positions with and without plasters being split. In the normal population we have shown a trebling of intracompartmental pre...
The functions of the subclavius muscle (SM) are described as stabilization of the sternoclavicula... more The functions of the subclavius muscle (SM) are described as stabilization of the sternoclavicular joint (SCJ) and resisting elevation of the lateral end of the clavicle. During systematic cadaveric dissections, we observed additional fibrous structures, previously described as variants of the anatomy, extending from the SM and inserting into the coracoid process (CP). Due to the high incidence of these structures in our dissections, we hypothesized that the attachment at the CP is more common than appreciated and that, as a corollary, the function of the SM was (or has been) more complex than simply depressing the clavicle and generating stability at the SCJ. For our investigation, fifty‐two upper extremities of 26 human cadavers were dissected. The SM was demonstrated from costal to clavicular attachment. We documented additional fibrous structures apparently derived from the SM inserting into the CP. Measurements of the length of the SM, the length of its attachment, and the leng...
Frontiers in Bioengineering and Biotechnology, 2016
Background Re-attachment of tendon to bone is challenging with surgical repair failing in up to 9... more Background Re-attachment of tendon to bone is challenging with surgical repair failing in up to 90% of cases. Poor biological healing is common and characterised by the formation of weak scar tissue. Previous work has demonstrated that decellularised allogenic demineralised bone matrix (DBM) regenerates a physiologic enthesis. Xenografts offer a more cost-effective option but concerns over their immunogenicity have been raised. We hypothesised that augmentation of a healing tendon-bone interface with DBM incorporated with autologous mesenchymal stem cells (MSCs) would result in improved function, and restoration of the native enthesis, with no difference between xenogenic and allogenic scaffolds. Methods Using an ovine model of tendon-bone retraction the patellar tendon was detached and a complete distal tendon defect measuring 1 cm was created. Suture anchors were used to reattach the shortened tendon and xenogenic DBM + MSCs (n=5) and allogenic DBM + MSCs (n=5) were used to bridge the defect. Functional recovery was assessed every 3 weeks and DBM incorporation into the tendon and its effect on enthesis regeneration was measured using histomorphometry. Results By 12 weeks, DBM augmentation resulted in significantly improved functional weight bearing with no failures in either group. Compared to xenogenic DBM, allogenic DBM was associated with significantly higher functional weight bearing at 6 (P=0.047), 9 (P=0.028) and 12 weeks (P=0.009). This was accompanied by a more direct type of enthesis characterised by significantly more fibrocartilage and mineralised fibrocartilage. Xenograft was also associated with an immunogenic reaction despite preoperative decellularisation. Conclusion This study shows that DBM enhances tendon-bone healing and may reduce the high failure rates associated with surgery. An immunogenic reaction, and inferior biomechanical and histological results were also associated with the use of xenograft. Allogenic DBM with autologous MSCs may be a suitable scaffold for the enhancement of tendon-bone healing in the clinical setting. Disclosures Funded by IKC PoC grant awarded by the University of Leeds Ethical approval Granted by the study institution (University College London)
Inherent disadvantages of reverse shoulder arthroplasty designs based on the Grammont concept hav... more Inherent disadvantages of reverse shoulder arthroplasty designs based on the Grammont concept have raised a renewed interest in less-medialised designs and techniques. The aim of this study was to evaluate the outcome of reverse shoulder arthroplasty (RSA) with the fully-constrained, less-medialised, Bayley-Walker prosthesis performed for the treatment of rotator-cuff-deficient shoulders with glenohumeral arthritis. A total of 97 arthroplasties in 92 patients (53 women and 44 men, mean age 67 years (standard deviation (sd) 10, (49 to 85)) were retrospectively reviewed at a mean follow-up of 50 months ((sd 25) (24 to 96)). The mean Oxford shoulder score and subjective shoulder value improved from 47 (sd 9) and 24 points (sd 18) respectively before surgery to 28 (sd 11) and 61 (sd 24) points after surgery (p < 0.001). The mean pain at rest decreased from 5.3 (sd 2.8) to 1.5 (sd 2.3) (p < 0.001). The mean active forward elevation and external rotation increased from 42(°)(sd 30) ...
The sternoclavicular joint (SCJ) is a pivotal articulation in the linked system of the upper limb... more The sternoclavicular joint (SCJ) is a pivotal articulation in the linked system of the upper limb girdle, providing load-bearing in compression while resisting displacement in tension or distraction at the manubrium sterni. The SCJ and acromioclavicular joint (ACJ) both have a small surface area of contact protected by an intra-articular fibrocartilaginous disc and are supported by strong extrinsic and intrinsic capsular ligaments. The function of load-sharing in the upper limb by bulky periscapular and thoracobrachial muscles is extremely important to the longevity of both joints. Ligamentous and capsular laxity changes with age, exposing both joints to greater strain, which may explain the rising incidence of arthritis in both with age. The incidence of arthritis in the SCJ is less than that in the ACJ, suggesting that the extrinsic ligaments of the SCJ provide greater stability than the coracoclavicular ligaments of the ACJ. Instability of the SCJ is rare and can be difficult to ...
Journal of Bone and Joint Surgery - British Volume, 2012
Scapulothoracic fusion (STF) for painful winging of the scapula in neuromuscular disorders can pr... more Scapulothoracic fusion (STF) for painful winging of the scapula in neuromuscular disorders can provide effective pain relief and functional improvement, but there is little information comparing outcomes between patients with dystrophic and non-dystrophic conditions. We performed a retrospective review of 42 STFs in 34 patients with dystrophic and non-dystrophic conditions using a multifilament trans-scapular, subcostal cable technique supported by a dorsal one-third semi-tubular plate. There were 16 males and 18 females with a mean age of 30 years (15 to 75) and a mean follow-up of 5.0 years (2.0 to 10.6). The mean Oxford shoulder score improved from 20 (4 to 39) to 31 (4 to 48). Patients with non-dystrophic conditions had lower overall functional scores but achieved greater improvements following STF. The mean active forward elevation increased from 59° (20° to 90°) to 97° (30° to 150°), and abduction from 51° (10° to 90°) to 83° (30° to 130°) with a greater range of movement achi...
Journal of Bone and Joint Surgery - British Volume, 2012
There is little information about the management of peri-prosthetic fracture of the humerus after... more There is little information about the management of peri-prosthetic fracture of the humerus after total shoulder replacement (TSR). This is a retrospective review of 22 patients who underwent a revision of their original shoulder replacement for peri-prosthetic fracture of the humerus with bone loss and/or loose components. There were 20 women and two men with a mean age of 75 years (61 to 90) and a mean follow-up 42 months (12 to 91): 16 of these had undergone a previous revision TSR. Of the 22 patients, 12 were treated with a long-stemmed humeral component that bypassed the fracture. All their fractures united after a mean of 27 weeks (13 to 94). Eight patients underwent resection of the proximal humerus with endoprosthetic replacement to the level of the fracture. Two patients were managed with a clam-shell prosthesis that retained the original components. The mean Oxford shoulder score (OSS) of the original TSRs before peri-prosthetic fracture was 33 (14 to 48). The mean OSS aft...
Malformation and hypoplasia of the clavicle can result in pain, impaired function, restricted sho... more Malformation and hypoplasia of the clavicle can result in pain, impaired function, restricted shoulder movement, subjective feeling of instability, and cosmetic deformity. There are no reports of clavicle lengthening by osteotomy and distraction osteogenesis (DO). This is a retrospective review of 5 patients (7 clavicles) who underwent clavicle lengthening by DO using a monolateral external fixator for clavicular hypoplasia. There were 3 males and 2 females with the mean age of 15 years (9 to 23 y) and mean follow-up of 35 months (12 to 66 mo). Preoperative diagnoses included Klippel-Feil syndrome, cleidocranial dysplasia with hemihypertrophy and torticollis, congenital myopathy and Noonans syndrome, and obstetric brachial plexus injury. Mean length gained was 31 mm (15 to 41 mm) that represents an average of 24.7% of overall bone length. Mean time in fixator was 174 days (161 to 263 d) and mean external fixation index was 56 d/cm. Two patients required internal fixation after fixator removal to consolidate union and 1 required additional internal fixation for atrophic regeneration. Mean preoperative oxford shoulder score improved from 28.5 to 41 and all patients were extremely satisfied with their result. Two patients developed pin-site infections. Clavicular lengthening by DO for congenital clavicular hypoplasia is a previously unreported technique that enables gradual correction of deformity without risking brachial plexus traction injury after acute correction. It has the potential to improve shoulder pain, function, range of movement, and cosmesis. Distraction ≥25% of overall bone length may require additional plate fixation to consolidate union. Level IV-therapeutic study.
Interfragmental ischaemia is a prerequisite for the initiation of the inflammatory and immunologi... more Interfragmental ischaemia is a prerequisite for the initiation of the inflammatory and immunological response to fracturing of bone.Intrafragmental ischaemia is inevitable: the extent of the initial ischaemic insult does not, however, directly relate to the outcome for healing of the fracture zones and avascular necrosis of the humeral head. The survival of distal regions of fragments with critical perfusion may be the result of a type of inosculation (blood vessel contact), which establishes reperfusion before either revascularization or neo-angiogenesis has occurred.Periosteum has a poorly defined role in fracture healing in the proximal humerus. The metaphyseal periosteal perfusion may have a profound effect, as yet undefined, on the healing of most metaphyseal fractures of the proximal humerus, and may be disturbed further by inadvertent surgical manipulation.The metaphysis can be considered as a 'torus' or ring of bone, its surface covered by periosteum antero- and post...
Deep prosthetic infection is a potentially devastating complication after total elbow arthroplast... more Deep prosthetic infection is a potentially devastating complication after total elbow arthroplasty, with an incidence of up to 12%. This study examined the demographics, microbiologic profile, and outcomes of infected total elbow arthroplasty treated with 2-stage revision in a tertiary referral unit. We identified 19 consecutive patients (mean age, 65 years) undergoing revision arthroplasty for deep prosthetic infection. All patients underwent a first-stage procedure with removal of implants, débridement, and insertion of an antibiotic-loaded cement spacer, followed by at least 6 weeks of intravenous antibiotics. Fourteen patients required a second-stage revision. Five patients did not undergo a second-stage procedure because of patient choice (n = 2), medical or surgical risk factors (n = 2), and death from an unrelated cause (n = 1). Of the 19 patients undergoing a first-stage procedure, 16 (84%) remained infection free, and 11 of the 14 patients (79%) undergoing reimplantation of...
Journal of shoulder and elbow surgery, Jan 27, 2017
Sprengel deformity is a rare congenital shoulder girdle anomaly characterized by scapula malposit... more Sprengel deformity is a rare congenital shoulder girdle anomaly characterized by scapula malposition, periscapular muscle atrophy, and limited shoulder movement. Traditionally, it has been managed by omovertebral bar excision and muscle transplantation procedures guided by age and Cavendish grade. We present a unique observation in humans: a case series with Sprengel deformity possessing a cleithrum, an ancestral remnant of shoulder girdle development found in archaic bony fish. Nine patients presented with so-called Sprengel deformity to a tertiary referral shoulder clinic. All were assessed clinically and radiologically with scapular radiographs and computed tomography or magnetic resonance imaging scans. The clinical and radiologic features were classified according to Cavendish and Rigault systems, respectively, and the scapular ratio was assessed. All patients were assigned grade 4 on the Cavendish scale. Six were grade 2 and 3 were grade 3 on the Rigault scale. The distinguish...
The current study describes several surgical techniques for the treatment of the reverse Hill - S... more The current study describes several surgical techniques for the treatment of the reverse Hill - Sachs lesion after posterior shoulder dislocation; we also aimed to present long term results followed for a minimum of five years. This study is a prospective case series of 17 patients who were treated in our clinic between 2008 and 2011. Patients with a defect size smaller than 25% of the articular surface were treated conservatively. An endoprosthesis of the glenohumeral joint was implanted in patients with a defect size bigger than 40%. All remaining patients were treated by a variety of operative techniques, depending on the quality of the bone and size of the defect. Twelve of seventeen patients had a defect size of the humeral articular surface between 25% and 40% with a mean age of 39 years. Depending on the defect size these patients were treated with retrograde chondral elevation, antegrade cylindrical graft or a graft of the iliac bone crest with an open approach. All the proc...
Background: The success of rotator cuff repair is primarily dependent on tendon-bone healing. Fai... more Background: The success of rotator cuff repair is primarily dependent on tendon-bone healing. Failure is common because weak scar tissue replaces the native enthesis, rendering it prone to reruptures. A demineralized bone matrix (DBM) consists of a network of collagen fibers that provide a sustained release of growth factors such as bone morphogenetic proteins. Previous studies have demonstrated that it can regenerate a fibrocartilaginous enthesis. Hypothesis: The use of a DBM and mesenchymal stem cells (MSCs) at the healing enthesis will result in a higher bone mineral density at the tendon insertion and will enhance the regeneration of a morphologically superior enthesis when compared with an acellular human dermal matrix. Study Design: Controlled laboratory study. Methods: Eighteen female Wistar rats underwent unilateral detachment of the supraspinatus tendon. Three weeks later, tendon repair was carried out in animals randomized into 3 groups: group 1 received augmentation of th...
Background Flail shoulder can occur following a brachial plexus injury and is characterized by pa... more Background Flail shoulder can occur following a brachial plexus injury and is characterized by painful subluxation of the glenohumeral joint and the inability to independently position the hand in space. The present study aimed to report the clinical outcomes following glenohumeral arthrodesis for late reconstruction of flail shoulder in patients with traumatic supraclavicular brachial plexus palsy. Methods Seven patients were included in the present study and were followed-up for a mean of 98 months (range 27 months to 197 months). The mean age at the time of surgery was 48 years (range 28 years to 80 years) and the mean time to surgery from injury was 5 years (range 2.5 years to 8 years). Results Six patients achieved bony union with a mean time to fusion of 4.7 months (range 2 months to 8 months). Non-union occurred in one case. The mean Oxford Shoulder Score improved from 11 pre-operatively (range 4 to 16) to 27 postoperatively (range 16 to 40) ( p = 0.016), and the mean Subject...
Epileptic seizures can cause shoulder dislocation, recurrent instability and eventually arthritis... more Epileptic seizures can cause shoulder dislocation, recurrent instability and eventually arthritis. The purpose of this study was to report the results, complications and rate of revision surgery following anatomical shoulder arthroplasty in epileptic patients with instability arthropathy. A consecutive series of eight patients with epilepsy underwent anatomical shoulder arthroplasty for recurrent shoulder instability and were retrospectively reviewed after a mean of 4.7 years (range, 2-7.5 years). These included three total shoulder replacements and five humeral resurfacing hemiarthroplasty procedures. Mean age of the cohort was 33 years (range, 17-44). All patients experienced post-operative grand mal seizures. Two patients with hemiarthroplasty required further surgery due to painful glenoid erosion. No residual cases of instability were noted. Mean active forward elevation and external rotation improved following surgery. The Oxford Shoulder Score improved from 15 pre-operatively...
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Papers by Simon Lambert