Ali Noorani - Academia.edu (original) (raw)

Papers by Ali Noorani

British Journal of Surgery

Foot & ankle specialist, 2010

Plantar fasciitis is the most common cause of plantar heel pain. The condition is potentially sel... more Plantar fasciitis is the most common cause of plantar heel pain. The condition is potentially self-limiting and can respond to conservative treatment, but patients may opt for surgery if the treatments fail. Surgical intervention is associated with potential complications. This study set out to explore the efficacy of the specific nonsurgical intervention offered to treatment-resistant cases in a local clinical setting. The technique involves image intensifier-guided injection of corticosteroid and local anesthetic agents under general anesthesia. Nineteen patients with recalcitrant plantar fasciitis of over 12 months' duration received injections. A simple follow-up questionnaire was given to patients after the procedure that focused on their subjective opinion of any change in their pain. They were also asked if the injection had solved their problems with heel pain. The improvements that the patients reported were found to be statistically significant (P = .012).

Journal of orthopaedic surgery (Hong Kong), 2013

The failure rate of rotator cuff repair is high. Regenerative techniques using material scaffolds... more The failure rate of rotator cuff repair is high. Regenerative techniques using material scaffolds, stem cells, and growth factors help augment repair and regenerate tissue. We reviewed the literature of various regenerative techniques in terms of (1) enhancing the repair process, (2) tissue regeneration, (3) mechanical strength, and (4) clinical outcome.

Shoulder & Elbow, 2014

Background: There is a paucity of data available with respect to outcome on long contoured lockin... more Background: There is a paucity of data available with respect to outcome on long contoured locking plate fixation for proximal humerus fractures with distal fracture extension. Methods: Thirty-four patients with traumatic proximal humerus fractures with distal extension underwent fixation with long contoured locking plates. Twenty-five patients (74%) were included in the study: one patient died, two patients had unrelated illnesses resulting in them being unable to complete follow-up assessment and six were lost to follow-up. Patients' case notes and radiographs were retrospectively reviewed, and patients were contacted to assess functional outcome using the Visual Analogue Scale (VAS) for pain, Disabilities of the Arm, Shoulder and Hand (DASH) score, Oxford Shoulder Score (OSS) and Stanmore Percentage of Normal Shoulder Assessment (SPONSA). Results: Mean follow-up was 27 months (range 11 months to 60 months). Mean pain at final follow-up was 3.6 [95% confidence interval (CI) ¼ 2.5 to 4.8] with only four patients having residual pain greater than 5 on the VAS scale. Mean DASH score was 41.2 (95% CI ¼ 32.0 to 50.4), mean OSS was 29.1 (95% CI ¼ 24.3 to 33.9) and mean SPONSA was 63.9% (95% CI ¼ 50.8 to 77.2). There was one wound infection. Three patients had non-unions that required bone grafting and revision internal fixation. Conclusions: We feel long contoured locking plates represent a useful treatment option for complex proximal humerus fractures Keywords Long contoured locking plates, proximal humerus fractures, PHILOS plate Date

Shoulder & Elbow, 2012

We present a case of extreme glenohumeral dysmorphism with pain and arthropathy which benefited f... more We present a case of extreme glenohumeral dysmorphism with pain and arthropathy which benefited from a Computer-Aided Design and Computer-Aided Manufacture (CADCAM) 'Piggy-Back' reverse total shoulder arthroplasty.

International Journal of Shoulder Surgery, 2012

} Muscle activation patterns in patients with recurrent shoulder instability } Symptomatic chroni... more } Muscle activation patterns in patients with recurrent shoulder instability } Symptomatic chronic long head of biceps rupture: Surgical results } Does age or gender of the patient influence the outcome of type II superior labrum anterior and posterior repair? } Surgical treatment of lateral clavicle fractures associated with complete coracoclavicular ligament disruption: Clinico-radiological outcomes of acromioclavicular joint sparing and spanning implants } Septic failure is not a septic loosening: A case report of a failed shoulder prosthesis } Locking plates for displaced fractures of the lateral end of clavicle: Potential pitfalls } Improved clinical utility in clavicle fracture decision-making with true orthogonal radiographs C o n t e n t s ABSTRACT Purpose: The aim of this study is to present muscle patterns observed with the direction of instability in a series of patients presenting with recurrent shoulder instability. Materials and Methods: A retrospective review was carried out on shoulder instability cases referred for fine wire dynamic electromyography (DEMG) studies at a specialist upper limb centre between 1981 and 2003. An experienced consultant clinical neurophysiologist performed dual needle insertion into four muscles (pectoralis major (PM), latissimus dorsi (LD), anterior deltoid (AD) and infraspinatus ) in shoulders that were suspected to have increased or suppressed activation of muscles that could be contributing to the instability. Raw EMG signals were obtained while subjects performed simple uniplanar movements of the shoulder. The presence or absence of muscle activation was noted and compared to clinical diagnosis and direction of instability. Results: A total of 140 (26.6%) shoulders were referred for fine wire EMG, and 131 studies were completed. Of the shoulders tested, 122 shoulders (93%) were identified as having abnormal patterns and nine had normal patterns. PM was found to be more active in 60% of shoulders presenting with anterior instability. LD was found to be more active in 81% of shoulders with anterior instability and 80% with posterior instability. AD was found to be more active in 22% of shoulders with anterior instability and 18% with posterior instability. IS was found to be inappropriately inactive in only 3% of shoulders with anterior instability but in 25% with posterior instability. Clinical assessment identified 93% of cases suspected to have muscle patterning, but the specificity of the clinical assessment was only correct in 11% of cases.

International Journal of Shoulder Surgery, 2012

Background and Purpose:The Stanmore Percentage of Normal Shoulder Assessment (SPONSA) is a patien... more Background and Purpose:The Stanmore Percentage of Normal Shoulder Assessment (SPONSA) is a patient-reported outcome measure (PROM). The score assesses pain, range of movement, strength, stability and function of the shoulder. The aim of this work was to formally validate the SPONSA. Materials and Methods: Validation of this score was carried out by measuring reproducibility, construct validity and sensitivity to change. Time to completion was also recorded. The Oxford Shoulder Score (OSS) and Constant Score (CS) were used for comparison. These assessments were performed with 61 individuals undergoing shoulder interventions. Results: There was excellent preoperative reproducibility in both intra-and inter-observer groups. The SPONSA had a 0.79 correlation with the OSS and 0.78 with the CS. The overall effect size of the SPONSA was 0.72, which was comparable to OSS (0.65) and greater than CS (0.34), implying equal or better sensitivity to change. Conclusions: The SPONSA is practical and quick to perform and also a reproducible and a sensitive instrument. This simple PROM is a commendable addition to the existing validated scoring methods for the shoulder. Level of Evidence: I;; testing of previously developed diagnostic criteria on consecutive patients (with universally applied reference "gold" standard).

International Journal of Shoulder Surgery, 2011

Latissimus dorsi tendon transfers are increasingly being used around the shoulder. We aim to asse... more Latissimus dorsi tendon transfers are increasingly being used around the shoulder. We aim to assess any improvement in pain and function following a latissimus dorsi tendon transfer for massive, irreparable postero-superior cuff deficiency. At our institution, between 1996 and 2009, 38 latissimus dorsi tendon transfer procedures were performed. Sixteen of these were for massive irreparable rotator cuff deficiency associated with pain and impaired function. All patients were evaluated by means of interview or postal questionnaire and case note review. Pain and function were assessed using the Stanmore percentage of normal shoulder assessment (SPONSA) score, visual analogue scale and Oxford Shoulder Score. Forward elevation was also assessed and a significant improvement was thought to correlate with the success of the procedure at stabilizing the humeral head upon elevation. Mean follow-up time was 70 months. There was a significant reduction in pain on the visual analogue scale from 6.4 to 3.4 (P < 0.05), an improved SPONSA score from 32.5 to 57.5 (P < 0.05), and an improved Oxford Shoulder Score from 40.75 to 29.6 (P < 0.05). Forward elevation improved from 40° preoperatively to 75° postoperatively (P < 0.05). Our results add to the body of evidence that latissimus dorsi tendon transfers for irreparable postero-superior cuff deficiency in selected patients reduce pain and improve shoulder function in the medium term. Level 4.

Injury Extra, 2012

Purpose: We review the complications and survivorship of surgery for metastatic bone disease. Bon... more Purpose: We review the complications and survivorship of surgery for metastatic bone disease. Bone is the most common site of metastatic disease. Skeletal complications include pain and pathological fractures. Surgery aims to provide stable painless mobility with fixation or replacement. Current literature has few treatment studies. We present a consecutive series of patients with pathological lesions that required surgery.

Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2012

Purpose: To conduct a systematic review of the current evidence for the effects of stem cells on ... more Purpose: To conduct a systematic review of the current evidence for the effects of stem cells on tendon-healing in preclinical studies and human studies. Methods: A systematic search of the PubMed, • SINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane, and Embase databases was performed for stem cells and tendons with their associated terminology. Data validity was assessed, and data were collected on the outcomes of trials. Results: A total of 27 preclinical studies and 5 clinical studies met the inclusion criteria. Preclinical studies have shown that Stem cells are able"To~"5TiTvrve~3n7n:lTfr^^ when placed into a new tendon environment, leadirig^loje.generation and bicimechanicai benefit to the tendon. Studies have been reported showing that stem cell therapy can be~enhanced oyTnolecuiar signanng~adjunct, mechanical stimulation of cells, and the use of augmentation delivery devices. Studies have also shown alternatives to the standard method of bone marrow-derived mesenchymal stem cell therapy. Of the 5 human studies, only 1 was a randomized controlled trial, which showed that skin-derived tendon cells had a greater clinical benefit than autologous plasma. One cohort study showed the benefit of stem cells in rotator cuff tears and another in lateral epicondylitis. Two of the human studies showed how stem cells were successfully extracted from the humerus and, when tagged with insulin, became tendon cells. Conclusions: The current evidence shows that stem cells can have a positive effect on tendon healing. This is most likely because stem cells have regeneration potential, producing tissue that is similar to the preinjury state, but the results can be variable. The use of adjuncts such as molecular signaling, mechanical stimulation, and augmentation devices can potentially enhance stem cell therapy. Initial clinical trials are promising, with adjuncts for stem cell therapy in development. Level of Evidence: Level IV, systematic review of Level H-IV studies.

Annals of The Royal College of Surgeons of England, 2012

INTRODUCTION Brodie's abscess is a form of subacute osteomyelitis characterised by a low grade py... more INTRODUCTION Brodie's abscess is a form of subacute osteomyelitis characterised by a low grade pyogenic abscess found most commonly in the metaphysis. One rare form found in children crosses the physeal growth plate and into the epiphysis. Due to the rarity of this subtype and apprehension associated with treatment of the transphyseal abscess, no clear guidance exists on its management. CASE HISTORY We present a case of delayed diagnosis of Brodie's abscess crossing the physis in a 14-year-old boy. He gave a one-year history of pain in the right knee and early x-rays had shown lucent areas in the tibia. However, these were only noted to be significant at presentation one year later. We also describe an improvised minimally invasive and atraumatic technique of modifying a laminar suction catheter for accessing and draining the abscess. CONCLUSIONS From our experience and reports in the literature it is clear that antibiotic treatment is generally advocated with varying degrees of surgical intervention. Outcomes are largely favourable. Nevertheless, initial drainage allows samples to be sent for microbiological and histological assessment to aid subsequent management and may prevent subsequent leg length discrepancy from failed conservative treatment. We believe that management of a transphyseal abscess must include early drainage and a prolonged course of antibiotics. The antibiotic choice and duration will be governed by culture results and local policy but is commonly given for up to six weeks in the literature and must include one antistaphylococcal drug.

American Heart Journal, 2002

} Muscle activation patterns in patients with recurrent shoulder instability } Symptomatic chroni... more } Muscle activation patterns in patients with recurrent shoulder instability } Symptomatic chronic long head of biceps rupture: Surgical results } Does age or gender of the patient influence the outcome of type II superior labrum anterior and posterior repair? } Surgical treatment of lateral clavicle fractures associated with complete coracoclavicular ligament disruption: Clinico-radiological outcomes of acromioclavicular joint sparing and spanning implants } Septic failure is not a septic loosening: A case report of a failed shoulder prosthesis } Locking plates for displaced fractures of the lateral end of clavicle: Potential pitfalls } Improved clinical utility in clavicle fracture decision-making with true orthogonal radiographs C o n t e n t s ABSTRACT Purpose: The aim of this study is to present muscle patterns observed with the direction of instability in a series of patients presenting with recurrent shoulder instability. Materials and Methods: A retrospective review was carried out on shoulder instability cases referred for fine wire dynamic electromyography (DEMG) studies at a specialist upper limb centre between 1981 and 2003. An experienced consultant clinical neurophysiologist performed dual needle insertion into four muscles (pectoralis major (PM), latissimus dorsi (LD), anterior deltoid (AD) and infraspinatus ) in shoulders that were suspected to have increased or suppressed activation of muscles that could be contributing to the instability. Raw EMG signals were obtained while subjects performed simple uniplanar movements of the shoulder. The presence or absence of muscle activation was noted and compared to clinical diagnosis and direction of instability. Results: A total of 140 (26.6%) shoulders were referred for fine wire EMG, and 131 studies were completed. Of the shoulders tested, 122 shoulders (93%) were identified as having abnormal patterns and nine had normal patterns. PM was found to be more active in 60% of shoulders presenting with anterior instability. LD was found to be more active in 81% of shoulders with anterior instability and 80% with posterior instability. AD was found to be more active in 22% of shoulders with anterior instability and 18% with posterior instability. IS was found to be inappropriately inactive in only 3% of shoulders with anterior instability but in 25% with posterior instability. Clinical assessment identified 93% of cases suspected to have muscle patterning, but the specificity of the clinical assessment was only correct in 11% of cases.

British Journal of Surgery

Foot & ankle specialist, 2010

Plantar fasciitis is the most common cause of plantar heel pain. The condition is potentially sel... more Plantar fasciitis is the most common cause of plantar heel pain. The condition is potentially self-limiting and can respond to conservative treatment, but patients may opt for surgery if the treatments fail. Surgical intervention is associated with potential complications. This study set out to explore the efficacy of the specific nonsurgical intervention offered to treatment-resistant cases in a local clinical setting. The technique involves image intensifier-guided injection of corticosteroid and local anesthetic agents under general anesthesia. Nineteen patients with recalcitrant plantar fasciitis of over 12 months' duration received injections. A simple follow-up questionnaire was given to patients after the procedure that focused on their subjective opinion of any change in their pain. They were also asked if the injection had solved their problems with heel pain. The improvements that the patients reported were found to be statistically significant (P = .012).

Journal of orthopaedic surgery (Hong Kong), 2013

The failure rate of rotator cuff repair is high. Regenerative techniques using material scaffolds... more The failure rate of rotator cuff repair is high. Regenerative techniques using material scaffolds, stem cells, and growth factors help augment repair and regenerate tissue. We reviewed the literature of various regenerative techniques in terms of (1) enhancing the repair process, (2) tissue regeneration, (3) mechanical strength, and (4) clinical outcome.

Shoulder & Elbow, 2014

Background: There is a paucity of data available with respect to outcome on long contoured lockin... more Background: There is a paucity of data available with respect to outcome on long contoured locking plate fixation for proximal humerus fractures with distal fracture extension. Methods: Thirty-four patients with traumatic proximal humerus fractures with distal extension underwent fixation with long contoured locking plates. Twenty-five patients (74%) were included in the study: one patient died, two patients had unrelated illnesses resulting in them being unable to complete follow-up assessment and six were lost to follow-up. Patients' case notes and radiographs were retrospectively reviewed, and patients were contacted to assess functional outcome using the Visual Analogue Scale (VAS) for pain, Disabilities of the Arm, Shoulder and Hand (DASH) score, Oxford Shoulder Score (OSS) and Stanmore Percentage of Normal Shoulder Assessment (SPONSA). Results: Mean follow-up was 27 months (range 11 months to 60 months). Mean pain at final follow-up was 3.6 [95% confidence interval (CI) ¼ 2.5 to 4.8] with only four patients having residual pain greater than 5 on the VAS scale. Mean DASH score was 41.2 (95% CI ¼ 32.0 to 50.4), mean OSS was 29.1 (95% CI ¼ 24.3 to 33.9) and mean SPONSA was 63.9% (95% CI ¼ 50.8 to 77.2). There was one wound infection. Three patients had non-unions that required bone grafting and revision internal fixation. Conclusions: We feel long contoured locking plates represent a useful treatment option for complex proximal humerus fractures Keywords Long contoured locking plates, proximal humerus fractures, PHILOS plate Date

Shoulder & Elbow, 2012

We present a case of extreme glenohumeral dysmorphism with pain and arthropathy which benefited f... more We present a case of extreme glenohumeral dysmorphism with pain and arthropathy which benefited from a Computer-Aided Design and Computer-Aided Manufacture (CADCAM) 'Piggy-Back' reverse total shoulder arthroplasty.

International Journal of Shoulder Surgery, 2012

} Muscle activation patterns in patients with recurrent shoulder instability } Symptomatic chroni... more } Muscle activation patterns in patients with recurrent shoulder instability } Symptomatic chronic long head of biceps rupture: Surgical results } Does age or gender of the patient influence the outcome of type II superior labrum anterior and posterior repair? } Surgical treatment of lateral clavicle fractures associated with complete coracoclavicular ligament disruption: Clinico-radiological outcomes of acromioclavicular joint sparing and spanning implants } Septic failure is not a septic loosening: A case report of a failed shoulder prosthesis } Locking plates for displaced fractures of the lateral end of clavicle: Potential pitfalls } Improved clinical utility in clavicle fracture decision-making with true orthogonal radiographs C o n t e n t s ABSTRACT Purpose: The aim of this study is to present muscle patterns observed with the direction of instability in a series of patients presenting with recurrent shoulder instability. Materials and Methods: A retrospective review was carried out on shoulder instability cases referred for fine wire dynamic electromyography (DEMG) studies at a specialist upper limb centre between 1981 and 2003. An experienced consultant clinical neurophysiologist performed dual needle insertion into four muscles (pectoralis major (PM), latissimus dorsi (LD), anterior deltoid (AD) and infraspinatus ) in shoulders that were suspected to have increased or suppressed activation of muscles that could be contributing to the instability. Raw EMG signals were obtained while subjects performed simple uniplanar movements of the shoulder. The presence or absence of muscle activation was noted and compared to clinical diagnosis and direction of instability. Results: A total of 140 (26.6%) shoulders were referred for fine wire EMG, and 131 studies were completed. Of the shoulders tested, 122 shoulders (93%) were identified as having abnormal patterns and nine had normal patterns. PM was found to be more active in 60% of shoulders presenting with anterior instability. LD was found to be more active in 81% of shoulders with anterior instability and 80% with posterior instability. AD was found to be more active in 22% of shoulders with anterior instability and 18% with posterior instability. IS was found to be inappropriately inactive in only 3% of shoulders with anterior instability but in 25% with posterior instability. Clinical assessment identified 93% of cases suspected to have muscle patterning, but the specificity of the clinical assessment was only correct in 11% of cases.

International Journal of Shoulder Surgery, 2012

Background and Purpose:The Stanmore Percentage of Normal Shoulder Assessment (SPONSA) is a patien... more Background and Purpose:The Stanmore Percentage of Normal Shoulder Assessment (SPONSA) is a patient-reported outcome measure (PROM). The score assesses pain, range of movement, strength, stability and function of the shoulder. The aim of this work was to formally validate the SPONSA. Materials and Methods: Validation of this score was carried out by measuring reproducibility, construct validity and sensitivity to change. Time to completion was also recorded. The Oxford Shoulder Score (OSS) and Constant Score (CS) were used for comparison. These assessments were performed with 61 individuals undergoing shoulder interventions. Results: There was excellent preoperative reproducibility in both intra-and inter-observer groups. The SPONSA had a 0.79 correlation with the OSS and 0.78 with the CS. The overall effect size of the SPONSA was 0.72, which was comparable to OSS (0.65) and greater than CS (0.34), implying equal or better sensitivity to change. Conclusions: The SPONSA is practical and quick to perform and also a reproducible and a sensitive instrument. This simple PROM is a commendable addition to the existing validated scoring methods for the shoulder. Level of Evidence: I;; testing of previously developed diagnostic criteria on consecutive patients (with universally applied reference "gold" standard).

International Journal of Shoulder Surgery, 2011

Latissimus dorsi tendon transfers are increasingly being used around the shoulder. We aim to asse... more Latissimus dorsi tendon transfers are increasingly being used around the shoulder. We aim to assess any improvement in pain and function following a latissimus dorsi tendon transfer for massive, irreparable postero-superior cuff deficiency. At our institution, between 1996 and 2009, 38 latissimus dorsi tendon transfer procedures were performed. Sixteen of these were for massive irreparable rotator cuff deficiency associated with pain and impaired function. All patients were evaluated by means of interview or postal questionnaire and case note review. Pain and function were assessed using the Stanmore percentage of normal shoulder assessment (SPONSA) score, visual analogue scale and Oxford Shoulder Score. Forward elevation was also assessed and a significant improvement was thought to correlate with the success of the procedure at stabilizing the humeral head upon elevation. Mean follow-up time was 70 months. There was a significant reduction in pain on the visual analogue scale from 6.4 to 3.4 (P < 0.05), an improved SPONSA score from 32.5 to 57.5 (P < 0.05), and an improved Oxford Shoulder Score from 40.75 to 29.6 (P < 0.05). Forward elevation improved from 40° preoperatively to 75° postoperatively (P < 0.05). Our results add to the body of evidence that latissimus dorsi tendon transfers for irreparable postero-superior cuff deficiency in selected patients reduce pain and improve shoulder function in the medium term. Level 4.

Injury Extra, 2012

Purpose: We review the complications and survivorship of surgery for metastatic bone disease. Bon... more Purpose: We review the complications and survivorship of surgery for metastatic bone disease. Bone is the most common site of metastatic disease. Skeletal complications include pain and pathological fractures. Surgery aims to provide stable painless mobility with fixation or replacement. Current literature has few treatment studies. We present a consecutive series of patients with pathological lesions that required surgery.

Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2012

Purpose: To conduct a systematic review of the current evidence for the effects of stem cells on ... more Purpose: To conduct a systematic review of the current evidence for the effects of stem cells on tendon-healing in preclinical studies and human studies. Methods: A systematic search of the PubMed, • SINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane, and Embase databases was performed for stem cells and tendons with their associated terminology. Data validity was assessed, and data were collected on the outcomes of trials. Results: A total of 27 preclinical studies and 5 clinical studies met the inclusion criteria. Preclinical studies have shown that Stem cells are able"To~"5TiTvrve~3n7n:lTfr^^ when placed into a new tendon environment, leadirig^loje.generation and bicimechanicai benefit to the tendon. Studies have been reported showing that stem cell therapy can be~enhanced oyTnolecuiar signanng~adjunct, mechanical stimulation of cells, and the use of augmentation delivery devices. Studies have also shown alternatives to the standard method of bone marrow-derived mesenchymal stem cell therapy. Of the 5 human studies, only 1 was a randomized controlled trial, which showed that skin-derived tendon cells had a greater clinical benefit than autologous plasma. One cohort study showed the benefit of stem cells in rotator cuff tears and another in lateral epicondylitis. Two of the human studies showed how stem cells were successfully extracted from the humerus and, when tagged with insulin, became tendon cells. Conclusions: The current evidence shows that stem cells can have a positive effect on tendon healing. This is most likely because stem cells have regeneration potential, producing tissue that is similar to the preinjury state, but the results can be variable. The use of adjuncts such as molecular signaling, mechanical stimulation, and augmentation devices can potentially enhance stem cell therapy. Initial clinical trials are promising, with adjuncts for stem cell therapy in development. Level of Evidence: Level IV, systematic review of Level H-IV studies.

Annals of The Royal College of Surgeons of England, 2012

INTRODUCTION Brodie's abscess is a form of subacute osteomyelitis characterised by a low grade py... more INTRODUCTION Brodie's abscess is a form of subacute osteomyelitis characterised by a low grade pyogenic abscess found most commonly in the metaphysis. One rare form found in children crosses the physeal growth plate and into the epiphysis. Due to the rarity of this subtype and apprehension associated with treatment of the transphyseal abscess, no clear guidance exists on its management. CASE HISTORY We present a case of delayed diagnosis of Brodie's abscess crossing the physis in a 14-year-old boy. He gave a one-year history of pain in the right knee and early x-rays had shown lucent areas in the tibia. However, these were only noted to be significant at presentation one year later. We also describe an improvised minimally invasive and atraumatic technique of modifying a laminar suction catheter for accessing and draining the abscess. CONCLUSIONS From our experience and reports in the literature it is clear that antibiotic treatment is generally advocated with varying degrees of surgical intervention. Outcomes are largely favourable. Nevertheless, initial drainage allows samples to be sent for microbiological and histological assessment to aid subsequent management and may prevent subsequent leg length discrepancy from failed conservative treatment. We believe that management of a transphyseal abscess must include early drainage and a prolonged course of antibiotics. The antibiotic choice and duration will be governed by culture results and local policy but is commonly given for up to six weeks in the literature and must include one antistaphylococcal drug.

American Heart Journal, 2002

} Muscle activation patterns in patients with recurrent shoulder instability } Symptomatic chroni... more } Muscle activation patterns in patients with recurrent shoulder instability } Symptomatic chronic long head of biceps rupture: Surgical results } Does age or gender of the patient influence the outcome of type II superior labrum anterior and posterior repair? } Surgical treatment of lateral clavicle fractures associated with complete coracoclavicular ligament disruption: Clinico-radiological outcomes of acromioclavicular joint sparing and spanning implants } Septic failure is not a septic loosening: A case report of a failed shoulder prosthesis } Locking plates for displaced fractures of the lateral end of clavicle: Potential pitfalls } Improved clinical utility in clavicle fracture decision-making with true orthogonal radiographs C o n t e n t s ABSTRACT Purpose: The aim of this study is to present muscle patterns observed with the direction of instability in a series of patients presenting with recurrent shoulder instability. Materials and Methods: A retrospective review was carried out on shoulder instability cases referred for fine wire dynamic electromyography (DEMG) studies at a specialist upper limb centre between 1981 and 2003. An experienced consultant clinical neurophysiologist performed dual needle insertion into four muscles (pectoralis major (PM), latissimus dorsi (LD), anterior deltoid (AD) and infraspinatus ) in shoulders that were suspected to have increased or suppressed activation of muscles that could be contributing to the instability. Raw EMG signals were obtained while subjects performed simple uniplanar movements of the shoulder. The presence or absence of muscle activation was noted and compared to clinical diagnosis and direction of instability. Results: A total of 140 (26.6%) shoulders were referred for fine wire EMG, and 131 studies were completed. Of the shoulders tested, 122 shoulders (93%) were identified as having abnormal patterns and nine had normal patterns. PM was found to be more active in 60% of shoulders presenting with anterior instability. LD was found to be more active in 81% of shoulders with anterior instability and 80% with posterior instability. AD was found to be more active in 22% of shoulders with anterior instability and 18% with posterior instability. IS was found to be inappropriately inactive in only 3% of shoulders with anterior instability but in 25% with posterior instability. Clinical assessment identified 93% of cases suspected to have muscle patterning, but the specificity of the clinical assessment was only correct in 11% of cases.