Constant Scoring Research Articles

Shoulder impingement syndrome: outcome of arthroscopic subacromial decompression.

To describe the outcome of cases with subacromial impingement syndrome managed with arthroscopic subacromial decompression. Quasi-experimental study. Section of Orthopaedics, Department of Surgery, The Aga Khan University Hospital, Karachi from April 2005 to March 2006. Thirty patients with impingement syndrome who underwent arthroscopic subacromial decompression after failed conservative treatment were included. The Constant and Murley shoulder scoring system was used for the clinical assessment of pain and function pre-operatively and 1, 6 and 24 weeks postoperatively. The postoperatively significant improvement was observed in the Constant and Murley scores in all the patients (by mean 40 points, p < 0.01), which was progressive over six months. Lower scores were noted in patients over 40 years of age, with advanced stage of impingement and partial tears of the rotator cuff. Arthroscopic subacromial decompression was effective in reducing pain and improving function in the studied patients with subacromial impingement syndrome.

Technique of Kirschner Wire Reduction and Fixation of Displaced Two-Part Valgus Angulated Proximal Humerus Fractures at the Surgical Neck

This article describes the technique of closed reduction with percutaneous fixation using Kirschner wires in helping the reduction of two-part valgus angulated and displaced proximal humerus fractures at the surgical neck. Traditional open reduction may lead to more accurate anatomic reduction; however, extensive tissue dissection increases the risk of avascular necrosis. Thus, closed reduction of unstable fracture mostly required forceful reduction maneuvers, which can harm the vascular supply and increase hematoma formation. Reduction of the fractured sides can easily be performed by engaging Kirschner -wires with a joystick method and fixation can be secured by using threaded pins. Thirty-six consecutive patients with displaced, two-part, valgus-angulated proximal humerus fractures at the surgical neck were treated by this method. The patients were followed for an average of 38 months. All fractures healed. According to the Constant scoring system, 21 patients (58%) had excellent, 9 patients (25%) had good, and 6 patients (17%) had fair results. The technique of closed reduction with a joystick method and percutaneous fixation is regarded as a reasonable treatment alternative in displaced two-part valgus angulated proximal humerus fracture.

Evolution of Nonoperatively Treated Symptomatic Isolated Full-Thickness Supraspinatus Tears

The natural history of small, symptomatic rotator cuff tears is currently unclear. The purpose of the present study was to assess the clinical and structural outcomes for a consecutive series of patients with symptomatic, isolated full-thickness supraspinatus tears who had been offered rotator cuff repair but declined operative treatment. In the study period, twenty-four patients with isolated full-thickness supraspinatus tears that had been diagnosed by means of magnetic resonance arthrography were offered rotator cuff repair and elected nonoperative treatment. The twenty men and four women had an average age of fifty-two years at the time of diagnosis. At a median of forty-two months after the diagnosis, all patients were reexamined clinically according to the Constant and Murley scoring system and all shoulders underwent standard magnetic resonance imaging. At the time of follow-up, the mean subjective shoulder score was 74% of that for a normal shoulder and the mean Constant score was 75 points (relative Constant score, 86%). The mean rotator cuff tear size did not change significantly over time (95% confidence interval, 0.51 to 1.12). In two shoulders, the tear was no longer detectable on magnetic resonance imaging, in nine shoulders the tear was smaller than it had been at the time of the initial diagnosis, in nine patients the tear had not changed, and in six patients the tear had increased in size. There was a slight but significant progression of fatty muscle infiltration of the supraspinatus, but no patient had fatty infiltration beyond stage 2 at the time of the latest follow-up (95% confidence interval, 0% to 14%). In a consecutive series of patients who had been offered repair of an isolated, symptomatic supraspinatus tear, the refusal of operative treatment resulted in surprisingly high clinical patient satisfaction and no increase of the average size of the rotator cuff tear 3.5 years after the recommendation of operative repair. This study confirms that the size of small rotator cuff tears does not invariably increase over a limited period of time. Distinguishing tears that will increase in size from those that will not needs further study.

Functional outcome of closed fractures of proximal humerus managed by Joshi’s external stabilizing system

Background:Proximal humeral fractures account for 4–5% of all fractures; most of them involving elderly and osteoporotic people. 1 51% of such fractures are displaced. Two Fractures with minimal displacement, regardless of the number of fracture lines, can be treated with closed reduction and early mobilization, but anatomical reduction in displaced fractures is difficult to obtain and the incidence of pseudarthrosis is high 3-5. We evaluated the functional results of closed Neer's 2- and 3-part proximal humerus fractures treated by Joshi's external stabilizing system.Materials and Methods:Sixteen patients with proximal humeral fractures were managed from 2008 to 2010 by Joshi's stabilizing external fixation. They were 10 males and 6 females, with a mean age of 57.5 years. Based on Neer's classification, there were eleven 3-part fractures and five 2-part fractures. The mechanism of injuries included seven road traffic accidents and nine fall. Shoulder mobilization exercises were started within 1 week after stabilization with JESS. External fixation was removed after the evidence of union (6–8 weeks). Pain was evaluated by visual analogue scale (VAS) and shoulder range of motion was evaluated by Constant Scoring System. Followup was done at 4 weeks, 8 weeks, 12 weeks, and then at every 4 weeks.Results:Mean followup was of 20.5 months (range 9-30 months). Postoperative mean VAS score and Constant Score of patients was 2.1 (±0.73) and 78.1 (±9.61) at an average followup of 6 months. Mean duration for union was 6.5 (±1.18) weeks. One case of K-wire loosening and one case of pin tract infection were the complications noted.Conclusion:External fixation by JESS is an alternative option to treat Neer's 2 and 3 part proximal humerus fractures with good results.

The effectivenes of the of the acromioplasty in the treatment of subacromial impingement syndrome of the shoulder

The aim of this study is to evaluate the effectiveness of anterior open acromioplasty in patients with subacromial impingement syndrome of the shoulder in which there is no response to conservative treatment. Anterior open acromioplasty was performed on 56 patients diagnosed with subacromial impingement syndrome. We have called patients for the control. We evaluated the patients according to the Constant shoulder scoring system and VAS (Visual Analogue Scale), at rest, at night and during activity. We also evaluated and recorded range of motion of the shoulder and muscle strength. In two patients (3.6%) the result was moderate; in five patients (8.9%) the result was good and in 49 patients (87.5%) the result was perfect. The mean Constant score was 87 (51-100). In two patients (3.5%) there was light pain at rest and at night, and moderate pain during motion. In three patients (5.3%) we detected moderate pain only during motion. In 51 patients (91.2%) there was no pain at all. Acromioplasty has a positive effect on the treatment of pain, active range of motion and muscle strength in daily living activities in the treatment of subacromial impingement syndrome. J. Exp. Clin. Med., 2012; 29:20-22

Management of proximal humeral Neer 3-part and 4-part fracture dislocations with anatomic reconstruction locking plate

Objective To analyze the therapeutic effect of open reduction with internal fixation (ORIF) and anatomic reconstruction locking plate in treatment of Neer 3-part and 4-part fracture dislocations of proximal humerus. Methods The study involved 30 patients with Neer 3-part and 4-part fracture dislocations treated with anatomic reconstruction locking plate from September 2004 to December 2007.Twenty patients had complete follow-up data.The treatment methods included locking proximal humeral plate (LPHP) in seven patients and proximal humeral internal locking system (PHILOS) in 13.There were 15 males and five females,at age range of 29-84 years (average 52.5 years),including nine patients younger than 65 years and 11 older than 65 years.According to Neer classification,there were 15 patients with 3-part fracture dislocations including 12 anterior and three posterior dislocations and five patients with 4-part fracture dislocations including four anterior and one posterior dislocations. VAS and Constant scoring system were adopted to evaluate the shoulder joint function postoperatively. Results All 20 patients were followed up for 36-71 months ( average 51 months),which showed avascular necrosis of humeral head in six patients (30％),plating loosening in two,screw penetration in six,nonunion in two and infection in two.The mean visual analogue score (VAS) was 2.55 poiuts and the mean Constant score for the shoulder was 80.8.According to the Neer shoulder functional evaluation standard,eight patients were graded as excellent,six as good,three as fair and three as poor,with excellence rate of 70％.Conclusions Although the anatomic reconstruction locking plate and ORIF can cause a high incidence of avascular necrosis of humeral head in the treatment of Neer 3-part and 4-part fracture dislocations of proximal humerus,especially for the patients older than 65 years.However,there is no obvious correlation between necrosis of humeral head and shoulder function.Clinically,the method could be selected on the ba-sis of individual condition of the patients. Key words: Shoulder fractures; Fracture fixation, internal; Shoulder dislocation

Locked anatomic plate fixation in displaced clavicular fractures

We aimed to evaluate the results and complications of open reduction and internal fixation by locked anatomic plates in adult midshaft clavicular fractures. Sixteen patients (11 males, 5 females; mean age: 39.6 years) who underwent open reduction and internal fixation with locked anatomic plate for displaced-comminuted midshaft clavicular fractures and were followed-up for at least one year were reviewed retrospectively. Complications in the early and late postoperative periods and functional scores according to the Constant and DASH scoring systems from the latest follow-up were evaluated. Mean follow-up period was 24.6 (range: 12 to 52) months and mean union time was 13.3 (range: 10 to 23) weeks. None of the patients had superficial and/or deep infections in the early postoperative period or neurovascular complications. Two (12.5%) patients had implant irritation. In two (12.5%) patients, implant failure was detected in the late postoperative period. Delayed union was suspected in these patients and they were operated with longer plate and grafting in the 4th month. At the final follow-up, none of the patients had nonunion or malunion and the mean Constant and DASH scores were 85.5 and 12.8, respectively. Constant scores in patients with complications (p=0.007) and DASH scores in patients with no complications (p=0.001) were significantly lower. Fixation with locked anatomic plates in displaced midshaft clavicular fractures has lower complication rates. Possible postoperative complications are generally associated with implant irritation and failure. These problems can be avoided with the development in implant technology and new implant designs.

Clinical Effect of Acute Complete Acromioclavicular Joint Dislocation Treated with Micro-Movable and Anatomical Acromioclavicular Plate

Objectives: We evaluated the long-term clinical results of acute complete acromioclavicular dislocations treated with micro-movable and anatomical acromioclavicular plate.Methods: Open reduction and internal fixation was performed using the MAAP in 16 patients (10 males, 6 females; mean age 36 years; range16 to 63 years) with acute complete acromioclavicular joint dislocation. Radiographic evaluations were routinely conducted every 3 weeks until 3 months postoperatively. The MAAP were removed under local anesthesia after 3 months postoperatively. We evaluated the functional results by using the constant scoring system and radiological results in the last follow-up time. The mean follow up was 26 months (range 16 to 38 months).Results: The mean Constant score was 94 (range, 78 to 100). The results were excellent in 12 patients (75.0%), good in 3 patients (18.8%) and satisfactory in 1patient (6.2%). Three patients with scores of 80 to 90 had mild pain during activity, but have not affected the shoulder range of motion. One patient has both some pain and limited range of motion of shoulder joint. All patients but one have returned to their preoperative work without any limitations. Compared to the contralateral side, radiography showed anatomical reposition in the vertical plane in 14 cases, slight loss of reduction in 2 older patients.Conclusion: We recommend the MAAP fixation for surgical treatment of acute complete acromioclavicular joint dislocation as it could provide satisfactory shoulder functions and clinical results, with lower complication rate. However, it is necessary to continue to observe the clinical effects of this fixation technique.

A new technique of arthroscopic fixation using double anchors for SLAP lesions

The aim of this study was to evaluate the clinical and structural outcome of the new fixation technique of type-II SLAP repair using double anchors compared with conventional method. Twenty-eight patients with 29 shoulders, who were followed up for at least 1 year after surgery, were enrolled. Fourteen shoulders were treated using the new technique (group 1), and 15 shoulders using the conventional technique (group 2). The clinical outcomes were evaluated using two different functional scores, the pain VAS and range of motion. The postoperative labral integrity was determined by magnetic resonance imaging at 1 year after surgery. At postoperative 6 months, all functional scores of group 1 were superior to group 2, particularly in pain VAS and Constant Scoring System. All ranges of motion in group 1 showed a better result than in group 2, particularly in forward flexion and external rotation at 90° abduction (88° ± 4.8 in group 1 and 84° ± 9.2 in group 2, P = 0.03). At postoperative 12 months and the last visit, all functional scores in group 1 were superior to those in group 2 and all external rotations at 90° of abduction in group 1 showed significantly better results than those of group 2. All patients in group 1 showed complete healing of the repaired SLAP lesion but one patient in group 2 showed partial detachments on the MRI. This new technique provides anatomical restoration of a SLAP lesion and yields successful clinical and structural outcomes at a short-term follow-up. Randomized controlled trials, level II.

Subscapularis Function and Structural Integrity After Arthroscopic Repair of Isolated Subscapularis Tears

Background: Results of arthroscopic repair of isolated subscapularis tendon tears have not been widely studied. A detailed evaluation of subscapularis function with subscapularis strength quantification has not been performed to date. Purpose: To evaluate postoperative subscapularis muscle function and to assess the clinical outcome and structural tendon integrity with postoperative magnetic resonance imaging after arthroscopic repair of isolated subscapularis tears. Study Design: Case series; Level of evidence, 4. Methods: In a prospective study, isolated subscapularis tendon tears in 21 patients were treated with an all-arthroscopic repair. The average age of the study population was 43 years. The mean interval between trauma and surgery was 5.8 months. In 19 patients, a traumatic event caused the onset of symptoms. Subscapularis muscle function was assessed with specific clinical tests and the Constant scoring system. Postoperative subscapularis strength was evaluated with a custom-made electronic force measurement plate. All patients underwent postoperative magnetic resonance imaging to assess structural integrity of the repair. Results: The average duration of follow-up was 27 months. The Constant score increased from 50 points preoperatively to 82 points postoperatively (P < .01). Most positive preoperative lift-off and belly-press tests were reversed by surgery, with a rate of 5 (24%) persistent positive tests after surgery. In operated shoulders, subscapularis strength in the belly-press (65 vs 87 N; P < .05) and the lift-off position (44 vs 68 N; P < .05) was significantly reduced compared with the contralateral shoulder. Magnetic resonance imaging revealed an intact repair in 20 patients. Atrophy of the upper subscapularis muscle portion was present in about one-fourth of the patients and in all patients with a positive postoperative belly-press test. Conclusion: Arthroscopic repair of isolated subscapularis tendon tears achieves substantial improvement of shoulder function and a low rerupture rate. Despite excellent clinical results, a significant postoperative subscapularis strength deficit compared with the contralateral shoulder persists that can be quantified with use of the force measurement plate. Atrophy of the upper subscapularis muscle is present in 25% of the patients in the postoperative course.

Mittelfristige Ergebnisse der operativen Behandlung bei Claviculaosteitis

Osteitis of the clavicle is rare and not well described in the international literature. We describe a concept of surgical treatment with medium-term observations. A total of 22 patients (12 women, 10 men; BMI Ø24.6kg/m(2), age Ø48years) with osteitis of the clavicle were included in the series. The treatment regime consisted of a surgical approach. Data collection was prospective. Data gathered preoperatively and at follow-up included clinical examination, laboratory findings, radiographs and the Constant scoring system. The mean follow-up period was 13.3 (3-53) months. The described surgical concept was able to permanently eliminate infection in all cases studied. Surgical revisions were required in six patients. The average Constant score showed a significant increase from 66 to 84 at follow-up. Patients also showed good functional results after total resection of the clavicle. The reported treatment regime provides reliable results in terms of eliminating infection with good clinical results. Neighboring joints were frequently also involved in the infection and needed to be surgically addressed.

How repaired rotator cuff function influences Constant scoring

The function level influence of an intact rotator cuff on the unweighted Constant score and its corresponding items is unknown. The aim of this study was to evaluate this contribution. The hypothesis was that the shoulder muscles other than the rotator cuff ones ensure a "basic" shoulder function level that is improved by the rotator cuff depending on its fatty degeneration index (FDI) MATERIAL AND METHODS: This study was based on a continuous series of 29 non-osteoarthritic shoulders whose sutured rotator cuff tears remained intact after 9 years of follow-up. The preoperative FDI was 0.9 (0-2) and 1.26 (0.2-2.2) at the final follow-up. The Constant score was 76.85 at the final follow-up (range 42-93). There was a strong negative correlation between preoperative and follow-up FDI's and all the Constant scores at the final follow-up. Linear regression analysis was performed. The two linear regression lines were superimposed. For a given FDI value, all Constant scores were lower when linear regression was based on preoperative FDI scores that included postoperative deterioration of the FDI. The two linear regression lines converged as the FDI increased and intersected at an FDI of 2.25. Thus, the impact of intact repaired rotator cuff function was null when the FDI was above 2.25, leaving other shoulder muscles (including the deltoid), to ensure "basic" shoulder function at a Constant score of approximately 62 points. The "basic" shoulder function found in this study is supported by the similar Constant scores found in reverse shoulder prostheses, and in painless shoulders with full thickness rotator cuff tears. The deltoid and the shoulder muscles other than the rotator cuff seem to be responsible for "basic" shoulder function and represent 60% of the unweighted Constant score. The lower the FDI, the more the function of an intact repaired cuff improves this "basic" function level. Level IV.

Overlaying Classifiers: A Practical Approach to Optimal Scoring

The Receiver Operating Characteristic (ROC) curve is one of the most widely used visual tools to evaluate performance of scoring functions regarding their capacities to discriminate between two populations. It is the goal of this paper to propose a statistical learning method for constructing a scoring function with nearly optimal ROC curve. In this bipartite setup, the target is known to be the regression function up to an increasing transform, and solving the optimization problem boils down to recovering the collection of level sets of the latter, which we interpret here as a continuum of imbricated classification problems. We propose a discretization approach, consisting of building a finite sequence of N classifiers by constrained empirical risk minimization and then constructing a piecewise constant scoring function s N (x) by overlaying the resulting classifiers. Given the functional nature of the ROC criterion, the accuracy of the ranking induced by s N (x) can be conceived in a variety of ways, depending on the distance chosen for measuring closeness to the optimal curve in the ROC space. By relating the ROC curve of the resulting scoring function to piecewise linear approximates of the optimal ROC curve, we establish the consistency of the method as well as rate bounds to control its generalization ability in sup -norm. Eventually, we also highlight the fact that, as a byproduct, the algorithm proposed provides an accurate estimate of the optimal ROC curve.

Coracoclavicular ligament repair and screw fixation in acromioclavicular dislocations

We evaluated the long-term results of acromioclavicular dislocations treated with coracoclavicular fixation using a cancellous screw. Coracoclavicular fixation was performed using the modified Bosworth technique in 32 patients (24 males, 8 females; mean age 35 years; range 19 to 58 years) with acromioclavicular dislocations. According to the Rockwood classification, seven patients had type III, nine patients had type IV, 13 patients had type V, and three patients had type VI dislocations. Following repair of the coracoclavicular ligament, fixation was performed with a cancellous screw in all but two patients in whom a cortical screw was used. These two patients developed redislocation due to screw cut out and underwent reoperation with cancellous screw fixation and were not included in the final assessments. The screws were removed under local anesthesia after eight weeks postoperatively. The patients were evaluated for cosmetic appearance, functional status, pain, localized tenderness, articular range of motion, and with the functional Constant scoring system. The mean follow up was 3.1 years (range 1 to 8 years). The mean Constant score was 98 (range 92 to 100). The results were excellent in 26 patients (86.7%) and good in four patients (13.3%). There was subluxation of the acromioclavicular joint in one patient (3.3%). The alignment of the acromioclavicular joint was normal in the remaining patients. None of the patients showed joint degeneration. All patients were pain-free and achieved full range of motion. With ease of application, low complication rate, and low rate of acromioclavicular joint arthrosis, the modified Bosworth technique is an effective surgical method in providing satisfactory shoulder function in acromioclavicular dislocations.

Surgical treatment of chronic locked posterior dislocation of the shoulder

Objective To evaluate the results of management of chronic locked posterior dislocation of the shoulder by surgical reduction with bone graft to restore joint surface of the humeral head. Methods From March 2002 to April 2008, 18 patients were treated for chronic locked posterior dislocation of the shoulder. They all were treated surgically to reduce the shoulder and restore humeral head joint surface with large bone graft. Mean time between trauma and surgery was 5 months. Preoperative CT scan confirmed shoulder posterior dislocation and a reverae Hill-Sachs lesion in all 18 patients, 8 of them with bone loss from 20% to 25% and 10 within 25% to 45%. scored for the Constant score (CS) and UCLA score at follow up. Results Postoperatively the patients were followed up for 1 to 4 years, with an average of 2.6 years. Shoulder function was evaluated using the Constant score and UCLA score. According Constant scoring 7 cases were rated as excellent, 9 cases as good, 1 case as fair and 1 case as poor. The average rate of excellent and good results was 88.8%. Only 1 case had stiff shoulder, but no recurrent dislocation occurred. UCLA score was 35 for the highest and 13 for the lowest, the mean being 30. Conclusion Open reduction and bone grafting resulted in good midterm results for the patients with traumatic chronic locked posterior dislocation of the shoulder. Key words: Shoulder dislocation; Wounds and injuries; Bone transplantation; Surgical procedures; operative

Locking compression plate fixation for treatment of distal clavicle fractures

Objective To investigate the application of locking compressing plate (LCP) for the treatment of distal clavicle fractures. Methods From January 2008 to February 2009, 13 cases of Neer type II distal clavicle fractures were treated with open reduction and internal fixation using an LCP. Postoperatively the shoulder functions were evaluated using Constant scoring system. Results Postoperatively 11 cases were followed up, while 2 cases were lost to follow up. The follow up period ranged from 3 to 14 months. Primary wound healing was achieved in all cases. There was no delayed union, nonunion or malunion. Constant scores ranged 84 to 94, with an average of 90. Conclusion Fixation of distal clavicle fracture with LCP provides a new and promising technique to treat distal clavicle fractures. Key words: Clavicle; Fractures; bone; Fracture fixation; internal

Treatment of proximal humeral fractures with locking pate the importance of medial support

Objective To evaluate the results of locking plate fixation for the treatment of proximal humeral fractures and the effect of medial support of the humeral head. Methods From February 2003 to March 2008, 37 cases of proximal humeral fractures were treated. There were 15 males and 22 females. The age of this group ranged from 21 to 81 years, with an average of 65.6 years. There were 8 patients who were younger than 60 and 29 older than 60. Causes of the fractures included falling from bicycles in 22 cases, falling from a height in 9 cases and traffic accident in 6 cases. According to Neer classification, there were 13 cases of two-part fractures, 20 cases of three-part and 4 cases of four-part fracture. All the fractures were treated with locking plate (Proximal Humeral Internal Locking System, PHILOS ). Results Postoperatively 33 cases were followed up for 12 to 48 months with an average of 18.6 months. Four cases were lost to follow up. Bone union was achieved in all cases, with the mean healing period of 10 weeks. According to Constant scoring, the excellent and good result rate was 81.8%. Conclusion Locking plate is an effective implant for treating proximal humeral fractures. Mechanical support of inferior-medial region in the humeral head to maintain the reduction and less soft tissue striping of the fracture site are important for the success of the surgery. Key words: Humeral fractures; poximal; Fracture fixation; internal; Locking plate

Factors affecting results of patients with humeral proximal end fractures undergoing primary hemiarthroplasty: A retrospective study in 42 patients

Aim Our study reports long-term results and factors related to patient satisfaction in the case of primary hemiarthroplasty for humeral proximal end fractures. Patients and methods We retrospectively evaluated 42 patients with humeral proximal end fractures who underwent primary hemiarthroplasty in our clinic from February 1994 to March 2004. Of the 42 patients, 14 (33%) were male and 28 (67%) female. The mean age was 68.9 ± 5.57 years (age range: 59–81 years). The mean follow-up period was 78.8 ± 26.6 months (range: 48–118 months). We evaluated the following parameters: fracture type according to the Neer classification, the time interval between the fracture and the operation, postoperative radiological examination, the Neer outcome assessment criteria for patient satisfaction and functions, according to the Constant and Murley Scoring (CMS) system. Results We found good-to-excellent outcomes in 36 (85.7%) and poor outcome in six (14.3%) patients according to the Neer criteria. The average values for CMS score, anterior elevation and external rotation were 73.59 ± 17.95 (25–94), 121.30 ± 42.99° (range: 30–170°) and 30° (range: 0–80°), respectively. The patients who had been operated in the early period (within 2 weeks) had better functional outcomes ( p < 0.001) and had significant pain relief. There was a strong positive correlation between the humeral offset (distance between the head and the tuberosities) and the degree of elevation ( r = 0.872, p < 0.001). There was a strong negative correlation between the height of the humeral head and the degree of elevation ( r = −0.853, p < 0.001). Conclusion In humeral proximal end fractures, primary hemiarthroplasty in the early period with the anatomic reconstruction of bone and soft tissues of the shoulder joint and long-term regular rehabilitation programme are important factors contributing to increased patient satisfaction.

Treatment of Chest Wall Implosion Injuries Without Thoracotomy: Technique and Clinical Outcomes

Chest wall implosion injuries secondary to side impact are unusual but devastating injuries. The purpose of this series is to describe the clinical entity, present a surgical technique to reduce and repair the thoracic cage deformity without thoracotomy, and report outcomes in nine patients. Institutional review board approved retrospective case series, surgical technique. Level I Trauma Center. Twenty-two patients were admitted during 7-year period with thoracic cage implosion injuries and multiple segmental rib fractures from a side impact mechanism. All patients' required mechanical ventilation and had an implosion deformity along the posterolateral thoracic cage, pulmonary contusion, and clavicular fractures. Nine patients underwent repair of rib fractures through a paramidline posterior approach without thoracotomy using standard 2.4-mm titanium plates. Seven patients with similar fracture pattern treated nonoperatively were used as a historical control. Total intubation time, intensive care unit (ICU) length of stay (LOS), and final shoulder function using the Constant Murley scoring system were compared between the two groups. Average age, male to female ratio, and injury severe score were comparable for both cohorts (p > 0.6). Average follow-up was 16 months versus 12 months for the operative and nonoperative groups, respectively, (p = 0.11). In the operative group, 8 of 9 (89%) patients were extubated within 24 hours of surgery; 3 of 9 (33%) were extubated in the operating room. In the operative group, seven patients underwent internal fixation of the clavicle and progressed to union with a mean Constant score of 93. Nine patients had nonoperative treatment of the clavicle with a mean Constant score of 75 (p = 0.04). Total intubation time (1.9 days) was significantly shorter in the operative group than the nonoperative controls at 13.3 days (p < 0.01) and length of ICU stay was also shortened at 5.7 (4-8) days versus 16.7 (10-26) days, respectively, (p < 0.01). Chest wall implosion injuries with fixed deformities of the thoracic cage, multiple segmental rib fractures, and clavicular injury are a distinct clinical entity, which can be effectively managed with a posterior paramidline approach without thoracotomy. Reduction of the deformity and repair of the rib fractures led to a dramatic reduction in time to extubation, ICU LOS, and in-hospital complications including pneumonia and sepsis. Repair of the clavicular fracture appeared to be beneficial.

Comparison of arthroscopic capsular release in diabetic and idiopathic frozen shoulder patients

The clinical results of arthroscopic capsular release for frozen shoulder in diabetic (group 1) and idiopathic (group 2) patients were compared. Surgery was performed on 28 shoulders of 26 patients (24 women, 2 men) with frozen shoulder unresponsive to conservative treatment. The mean age was 50 (range 40-65). A total of 14 patients were included in group 1, and 12 were in group 2. The average duration of complaints was 10 and 7 months in groups 1 and 2, respectively. The evaluation of shoulder functions was made according to the University of California, Los Angeles (UCLA) and Constant Scoring Systems. Duration of complete pain relief and for regaining range of motion (ROM) after surgery were also noted in their final follow-up examination. The mean follow-up period was 48.5 and 60.2 months in group 1 and group 2, respectively. There was no significant difference between the two groups in terms of the postoperative duration of complete pain relief and that for regaining ROM (P > 0.05). The duration of complete pain relief was 2.6 and 2.5 months, and regaining of ROM was 1.6 and 1.5 months for groups 1 and 2, respectively. The postoperative UCLA and Constant scores had significant increases in both groups compared to the preoperative ones (P < 0.05). There was a significant difference between the groups in terms of Constant scores (P < 0.05) while there was no difference in terms of UCLA scores (P > 0.05). There was a statistically significant difference in shoulder abduction and internal rotation degrees between the groups (P < 0.05). The results of arthroscopic capsular release for frozen shoulder in diabetic patients had less good results in terms of range of motion and Constant-Score. There was no significant difference between the two groups in terms of the duration of pain relief and that of regaining the ROM.