The document discusses the classification and treatment of AC joint injuries. It notes that the Rockwood classification of these injuries using radiographs alone has limitations. For grade III separations, the literature finds comparable results between operative and non-operative treatments, though complications are more common with surgery. For high-demand athletes, ongoing symptoms are reported in a high percentage even with minor grades of injury. The document outlines surgical procedures for AC joint injuries, including coracoclavicular ligament reconstruction techniques, and notes the author's experience with the LARS ligament reconstruction.
On April 9th 2013 took place at Vall d’Hebron Institut de Recerca (VHIR) the seminar ‘Multi-stage, multimodal approaches for regenerative stroke therapies’, conducted by Pr. Aurel Popa-Wagner, PhD, Professor of Experimental Neurology at the Department of Neurology and Head of the Research Department.
Every six minutes a stroke occurs in Spain, the first cause of death in women and the second for men. In the world, it is estimated that there are 4.5 million deaths a year from stroke. Almost one in four men and nearly one in five women aged 45 years can expect to have a stroke if they live to their 85th year. It is estimated that by 2023 there will be an absolute increase in the number of patients experiencing a first ever stroke of about 30% compared with 1983.
It is known that intracellular vessel occlusion has a strong age dependency. As long as aging is an important risk factor for stroke, aged animals are being used in the laboratory because of its relevance in clinical rehabilitation and cellular studies. In addition, Pr. Aurel Popa-Wagner and his research group have shown that potential mechanisms for self-repair also operate in the post-ischemic aged brain. Young and aged animals affected by stroke differ in their post-stroke response, being more pronounced at 14 days post-stroke, where downregulated genes decrease in young rats and increases in aged rats, and the opposite occurs with the upregulated genes.
Referring to therapy, Pr. Aurel Popa-Wagner and his research group concluded that including both physical methods and methods of cellular therapy is more effective for improving recovery of function in aged rats after stroke than therapies aimed at only a single target system. This is, for example, combining neurogenesis, functional in the subventricular zone of the adult brain, with G-CSF (stem cell mobilisator granulocyte-colony stimulating factor), significantly effective in treatment of aged rats after stroke due to that it reduces the mortality rate in rats. In the first post-stroke hours, induced hypothermia with hydrogen sulfide diminish inflammation and improve neurorehabilitation in aged rats by simultaneously targeting multiple points of intervention. This technique could have a higher probability of success in treating the illness, as the Pr. Popa-Wagner affirms. The next step in post-stroke therapy, according to the speaker, might be the combination of nanotherapy with cell therapy.
On April 9th 2013 took place at Vall d’Hebron Institut de Recerca (VHIR) the seminar ‘Multi-stage, multimodal approaches for regenerative stroke therapies’, conducted by Pr. Aurel Popa-Wagner, PhD, Professor of Experimental Neurology at the Department of Neurology and Head of the Research Department.
Every six minutes a stroke occurs in Spain, the first cause of death in women and the second for men. In the world, it is estimated that there are 4.5 million deaths a year from stroke. Almost one in four men and nearly one in five women aged 45 years can expect to have a stroke if they live to their 85th year. It is estimated that by 2023 there will be an absolute increase in the number of patients experiencing a first ever stroke of about 30% compared with 1983.
It is known that intracellular vessel occlusion has a strong age dependency. As long as aging is an important risk factor for stroke, aged animals are being used in the laboratory because of its relevance in clinical rehabilitation and cellular studies. In addition, Pr. Aurel Popa-Wagner and his research group have shown that potential mechanisms for self-repair also operate in the post-ischemic aged brain. Young and aged animals affected by stroke differ in their post-stroke response, being more pronounced at 14 days post-stroke, where downregulated genes decrease in young rats and increases in aged rats, and the opposite occurs with the upregulated genes.
Referring to therapy, Pr. Aurel Popa-Wagner and his research group concluded that including both physical methods and methods of cellular therapy is more effective for improving recovery of function in aged rats after stroke than therapies aimed at only a single target system. This is, for example, combining neurogenesis, functional in the subventricular zone of the adult brain, with G-CSF (stem cell mobilisator granulocyte-colony stimulating factor), significantly effective in treatment of aged rats after stroke due to that it reduces the mortality rate in rats. In the first post-stroke hours, induced hypothermia with hydrogen sulfide diminish inflammation and improve neurorehabilitation in aged rats by simultaneously targeting multiple points of intervention. This technique could have a higher probability of success in treating the illness, as the Pr. Popa-Wagner affirms. The next step in post-stroke therapy, according to the speaker, might be the combination of nanotherapy with cell therapy.
This powerpoint is intended to give an overview of observation of knee to undergraduate first year students. Students should not forget to do overall comprehensive observation of posture and other body parts before focusing the observation locally at the knee joint.
Multidirectional instability of the shoulder 2014Lennard Funk
Multidirectional Instability is still a term that is used for a number of patients with shoulder instabiliity. In this lecture I discuss the confusion in definitions, applications and my understanding and management of this complex group of patients.
Low Grade Infection after Shoulder SurgeryLennard Funk
Young male patients are at greatest risk for low-grade infections following arthroscopic and open non-arthroplasty shoulder surgery. Propionibacterium acnes was the most prevalent organism. Patients presented with classical post-operative frozen shoulder symptoms, resistant to usual treatments. 80% of patients with negative cultures improved with empirical treatment.
Arthroscopically assisted latissimus dorsi transfer is a viable option for treatment of patients in their 50s to 70s, without arthritis of the glenohumeral joint, who suffer from massive postero-superior rotator cuff tears that are not amendable to primary repair or that have failed previous repair attempts.
Clinical reasoning is one of the pillars for good physiotherapy practice. It is an integral component of evidence based practice. It is a thought process that develops over time in a clinician. The first step is to start thinking of a clinical problem.
The lecture is delivered to first year physiotherapy students at Kathmandu University School of Medical Sciences, Nepal. The students will continue with case discussion using similar model proposed by Mark Jones and Darren Rivett in his book. Further real cases and the cases in Mark Jones will be discussed in the subsequent classes over the Bachelor of Physiotherapy course.
This powerpoint is intended to give an overview of observation of knee to undergraduate first year students. Students should not forget to do overall comprehensive observation of posture and other body parts before focusing the observation locally at the knee joint.
Multidirectional instability of the shoulder 2014Lennard Funk
Multidirectional Instability is still a term that is used for a number of patients with shoulder instabiliity. In this lecture I discuss the confusion in definitions, applications and my understanding and management of this complex group of patients.
Low Grade Infection after Shoulder SurgeryLennard Funk
Young male patients are at greatest risk for low-grade infections following arthroscopic and open non-arthroplasty shoulder surgery. Propionibacterium acnes was the most prevalent organism. Patients presented with classical post-operative frozen shoulder symptoms, resistant to usual treatments. 80% of patients with negative cultures improved with empirical treatment.
Arthroscopically assisted latissimus dorsi transfer is a viable option for treatment of patients in their 50s to 70s, without arthritis of the glenohumeral joint, who suffer from massive postero-superior rotator cuff tears that are not amendable to primary repair or that have failed previous repair attempts.
Clinical reasoning is one of the pillars for good physiotherapy practice. It is an integral component of evidence based practice. It is a thought process that develops over time in a clinician. The first step is to start thinking of a clinical problem.
The lecture is delivered to first year physiotherapy students at Kathmandu University School of Medical Sciences, Nepal. The students will continue with case discussion using similar model proposed by Mark Jones and Darren Rivett in his book. Further real cases and the cases in Mark Jones will be discussed in the subsequent classes over the Bachelor of Physiotherapy course.
Rotator Cuff Update 2022 for Medbelle Len Funk.pptxLennard Funk
the common questions patients will ask once they have had a scan and a tear has been reported, particularly if they have had no injury of trauma, they ask what caused my tear. If I have a tear what can you do to fix it, it’s got to be fixed. How can I get better if it is not fixed. I have already had physiotherapy and that didn’t fix it so how will more physiotherapy. Some patients who are not keen on surgery, do I really need to have an operation. I have not had an injury.
there are multiple options thrown into the mix here which we need to consider for an individual patient.
The below illustration shows a very rough decision making tool that I would use in determining surgical or treatment options for particular patients.
A younger patient who has both pain and weakness with a massive cuff tear, if it is partially repairable a biological augment would be suitable.
If their predominant weakness is external rotation i.e. a positive Hornblower sign but good elevation, a lat dorsi tendon transfer.
For an older patient who has a predominant weakness but no significant pain, deltoid rehabilitation programme is indicated.
If they do have pain, a suprascapular nerve procedure such as an ablation would be beneficial.
For those that have significant pain and weakness with failed non-operative options, a reverse shoulder replacement would be the best option.
The balloon as we said, has a very limited place and this is for the older patient with slight loss of function and pain with higher demands.
For those that have more significant pain and elevation weakness, a superior capsular reconstruction would be my preferred option.
Should We Repair Rotator Cuff Tears OPN 2017.pdfLennard Funk
Lennard Funk & Puneet Monga
Prepared for Orthopaedic Product News, 2017
Rotator cuff disease is very common. There is as much enthusiastic discussion and debate on its management as there was 80 years ago when Codman (1937) first described the pathology and surgical management. There is great variation amongst surgeons as to the management of rotator cuff tears biased by experience and their understanding of the literature, skills levels and regional variations. There has been a lot of research done on the pathology, non-operative and operative treatments over the last two decades. Also, over the last decade there have been massive strides in the development of new surgical techniques and technologies. However, despite these advances there is as much discussion and debate!
Superior Capsular Reconstruction Outcomes Wrightington 2020Lennard Funk
Hariharan Mohan, Jagwant Singh, Michael Walton, Lennard Funk, Puneet Monga
Cautious optimism following SCR may be offered to this challenging subset of patients with symptomatic irreparable rotator cuff tears. It is likely that the relatively low re-operation rates can be further improved by considering the negative prognostic factors in defining indications for surgery. Further studies with longer term followup are recommended.
Isolated scapula pain is uncommon, but very difficult to diagnose and manage. In this presentation I run through the known causes and an approach to the diagnosis, in order to guide best treatment.
The Incidence of Traumatic Posterior and Combined Labral Tears in Patients Un...Lennard Funk
Presentation at ISAKOS, 2019
There were 442 primary arthroscopic labral repair procedures performed over the three-year period. The total cohort had a mean age of 25.91±9.09 years (range, 14-67 years) and consisted of 89.6% males. There was no significant difference in mean age or gender between the isolated anterior, posterior or combined groups (p=0.383 and p=0.541, respectively).
• Of the 442 patients who underwent a shoulder labral repair, isolated anterior labral pathology occurred in 52.9% (n=234), with posterior and combined labral tears accounting for 16.3% (n=72) and 30.8%, respectively (n=136) (Table 3).
• Patients were stratified as either sporting or non-sporting; 74.9% of patients were categorised as sporting (n=331) and had a mean age of 24.91±5.69 years, which was significantly lower than the mean age of 35.40±11.94 years in the non-sporting population (p<0.001). In the non-sporting population 68.5% (n=76) of patients had isolated anterior labral tears with 12.6% (n=14) posterior and 18.9% (n=21) combined. In the sporting population isolated anterior labral tears accounted for 47.7% (n=158), posterior 17.5% (n=58) and combined labral tears 34.7% (n=115). The sporting population had a significantly greater proportion of posterior and combined labral tears with the non-sporting population a significantly greater proportion of anterior labral tears (p=0.013).
• Rugby players had the greatest incidence of shoulder instability within the sporting cohort accounting for 231 cases. Of the 231 cases, 47.2% were isolated anterior labral tears, 12.6% isolated posterior and 40.3% combined lesions.
Posterior and combined shoulder labral tears are more prevalent than previously reported in the civilian population. The rates are higher in young, sporting populations and especially in contact sports such as rugby.
Pectoralis major allograft reconstructionLennard Funk
Presentation at ISAKOS, 2019
We performed a total of 142 pectoralis major repairs over a ten year period, of which 19 required allograft reconstruction. Of these 19 patients, 11 were available for response. All 11 patients were male with a mean age of 38.3 years (21 to 48 years). The mean time between injury and surgery was 12.2 months (4 to 30 months). Ten patients (91%) were unable to perform their previous level of work pre-operatively, with all patients returning to pre-injury occupation levels post-operatively.
The main complaint prior to surgery was pain on pushing and moving the affected arm across the body, which improved in nine patients (82%), with no improvement reported in two patients. Strength improved significantly post-operatively, with only three patients reporting no improvement (paired t-test p=0.01). Six patients reported an improvement in cosmesis (50%).
Hydrodistention is a treatment for frozen shoulder (FS) that is gaining popularity again. However, no large, long-term outcome data has been published yet. Our aims were to evaluate hydrodistension for the treatment of primary frozen shoulder (FS) in a large cohort of patients with long follow-up period.
We present a case series of eighty-nine patients (36 males and 53 females) with a mean age of 52 years (33-73). Eleven (12.4%) had disease associations. We excluded post-operative secondary stiff shoulders. The mean volume injected was 33.7ml (16-66). 36/89 (40%) had capsular rupture. Six (6.7%) had adverse effects. The mean follow-up was 104.5 weeks (8-238).
Mean improvement in forward flexion was 165.4, abduction 111.6, external rotation was hand above head with elbow back (and internal rotation in extension to T12. Mean improvement in quickDASH score was 17.1 (p<0.001) and Constant Score was 70.0 (p<0.001). Mean improvement in VAS was 7.3 (p<0.001). No patients had night pain (p<0.001). Eighty-eight (99%) returned to their previous occupation. Seventy-six (85%) returned to their previous level of sport. Gender, previous intra-articular steroid injection, volume of the injectate, type of steroid used, capsular rupture and underlying aetiology had no impact on outcome.
1. 23/03/2013
ACJ Injury Rugby
Lennard Funk
1 2
3 4
Rockwood
Questions:
Classification
What is the Grade?
Should we operate?
Why?
When?
How?
5 6
1
2. 23/03/2013
What Grade?
We conclude that the classification of AC joint
injuries using a radiograph alone has limited
reliability and consistency in clinical practice.
7 8
Indications for Stabilisation Treatment?
Literature = Type 4, 5 & 6
Operative
Non-operative
When?
9 10
Ceccarelli et al. 2008 Bradley & Elkousy, Clin Sport Med, 2003
The only advantage to operative
intervention consistently borne out in the
From the literature evaluation, clinical results seem to be comparable
between the operative and the conservative treatments, literature is an increased probability of
but complications are more evident in the surgery group.
anatomic reduction.
Since there is not a preponderance of positive papers showing the benefits
There is no correlation between reduction
of a surgical technique over conservative therapy, the nonoperative treatment is
still considered a valid procedure in the grade III acromioclavicular separation.
and improvement in pain, strength, or
More prospective randomized studies using validated outcome measures are
needed to identify the suitable operation techniques for the acute injuries. motion, however.
11 12
2
3. 23/03/2013
Athletes Rangger et al. Orthopade 2002
Jun;31(6):587-90
High Demand Cox. Am J Sports Med, 1981
Following ACJ Dislocations:
30% of overhead athletes had 164 US Naval Cadets
to reduce sport
Ongoing symptoms at 6 months:
9% had to change sport
36% of Grade 1
Climbers and patients
performing strength training 48% of Grade 2
had to reduce their activities or Major in 13%
give up sports Minor in 35%
Altered activities in overhead 69% of Grade 3
ball sports
13 14
What about rugby? Indications
Often able to play
Unable to train • Symptoms(
Modern day expectations • Pa+ent(Demands(
– Work(demands(
– Society(demands(
• Overhead(Athlete(
15 16
Approach Surgical procedures
Acute Injury
< 1 week
Review
3 weeks
Coping Not Coping
Review
3 months Surgery
17 18
3
4. 23/03/2013
Coracoclavicular
Harris et al. AJSM 2000
Ligaments
Harris et. al. Am J Sports Med. 2000
Strength – 500N (+/- 134)
Stiffness – 103N/mm (+/-
30)
Uniaxial Tension 25mm/min
None of the reconstruction techniques analyzed
in the present study were able to restore the
normal mechanical function of the intact
coracoclavicular ligament complex
19 20
ACJ Ligaments
Fukuda et al. JBJSA. 1986
Dynamic Stability
Two thirds of the superior Delto-trapezial fascia
stability for lesser Fukuda et al. JBJSA. 1986: Copeland & Kessel.
Injury. 1980; DePalma. 1973; Urist. JBJS 1963.
displacements
90% the posterior stability
Lizaur et al. JBJS. 1994
21 22
My Experience
2001 2006
23 24
4
5. 23/03/2013
LARS Ligament (Corin) LARS Ligament
Braided Polyethylenetraphthalate
1500N tensile strength (30 LAC)
No reduction in mechanical resilience
after over 10 million wear cycles loaded
in torsion, traction and flexion [Fialka et al. 2005;
Vascularisation & Fibrous ingrowth -
Collagen Type 1 [Trieb et al. Eur Surg Res. 2004; Yu et al. 2005;
Pelletier & Durand]
25 26
3 weeks post-op LARS Ligament Outcomes
Wright & Funk, 2010. BESS
27 28
LARS Ligament Outcomes LARS Ligament Outcomes
All patients returned to their previous level of work & The median postoperative residual displacement of the ACJ
sports post LARS reconstruction in a mean time of 3 was 15%.
months
The mean patient satisfaction score was 93%
In one patient who did not follow the prescribed
rehabilitation protocol the reconstruction failed in the
early postoperative period.
29 30
5