C Michael Robinson

The University of Edinburgh, Edinburgh, Scotland, United Kingdom

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Publications (31)81.8 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: The glenohumeral joint provides greater freedom of motion than any other joint in the body at the expense of decreased stability. Shoulder instability can occur in overhead throwing athletes (chronic, overuse injuries) but more commonly occurs in contact athletes (acute traumatic dislocations). Our understanding of the anatomy and pathologic entities has evolved significantly since initial descriptions of shoulder instability and this has facilitated an evolving repertoire of treatment options. This article reviews the functional anatomy and biomechanics of shoulder stability and outlines the bony and soft tissue lesions associated with shoulder instability in the athlete.
    Clinics in Sports Medicine 10/2013; 32(4):607-624. · 2.38 Impact Factor
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    ABSTRACT: An association between coracoid fracture and glenohumeral instability with both a seizure disorder and the subsequent development of coracoid nonunion has not previously been recognized. This is clinically important as patients with a seizure disorder and glenohumeral instability frequently require a primary osseous reconstructive procedure, such as coracoid osteotomy and transfer to the anterior glenoid rim (the Bristow-Latarjet procedure), to address glenoid osseous deficiency. We report on coracoid fracture nonunion in five patients with a seizure disorder and anterior glenohumeral instability and discuss the implications for surgical treatment. Coracoid fracture was specifically sought on three-dimensional reconstructions of computed tomography scans in a consecutive series of 234 patients presenting to our unit with recurrent anterior instability. In addition to demographic data, we specifically sought information on any history of shoulder injury, the mechanism of injury, or previous seizure activity in these patients. In patients with a coracoid fracture or nonunion viewed to be at high risk of failure with a soft-tissue procedure, an open osseous reconstructive procedure was performed. The type of operative procedure was determined by the location of the nonunion. We identified six coracoid fracture nonunions in association with anterior glenohumeral instability in five patients (mean age, 26.8 years; range, twenty-four to thirty years). All patients had instability occurring in association with seizures. In the four shoulders with the anatomic location of the coracoid nonunion at its so-called elbow, a standard Bristow-Latarjet procedure was performed. In the two shoulders in which the nonunion was more distal, an Eden-Hybbinette procedure was performed. We recommend having a high index of suspicion of coracoid fracture when treating patients with a seizure disorder who have anterior glenohumeral instability. In these patients, preoperative computed tomographic images allow the diagnosis of a coracoid nonunion to be made prior to surgery and help to determine whether there is sufficient intact coracoid bone to allow a Bristow-Latarjet procedure to be performed.
    The Journal of Bone and Joint Surgery 04/2012; 94(7):e40. · 3.23 Impact Factor
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    ABSTRACT: Recent innovations have greatly increased the range of proximal humeral fractures that are amenable to open reduction and plate fixation.The optimum technique for some of the more complex fracture patterns is not yet fully refined.This article aims to describe the recent advances in the treatment of complex proximal humeral fractures by open reduction and locking plate fixation, focusing particularly on the indications for surgery, the operative techniques, and the expected outcomes after treatment.
    Journal of orthopaedic trauma 10/2011; 25(10):618-29. · 1.78 Impact Factor
  • C Michael Robinson, Matthew Seah, M Adeel Akhtar
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    ABSTRACT: Posterior glenohumeral dislocation is less common than anterior dislocation, and less is known about its epidemiology, functional outcome, and complications. The purposes of this study were to determine the epidemiology and demographics of posterior dislocations and to assess the risk of recurrence and the functional outcome after treatment. We performed a retrospective review of a prospective audit of the cases of 112 patients who sustained 120 posterior glenohumeral dislocations. Patients were treated with relocation, immobilization, and then physical therapy. Functional outcome was assessed with the Western Ontario Shoulder Instability Index (WOSI) and the limb-specific Disabilities of the Arm, Shoulder and Hand score (DASH) during the two years after the dislocation. The prevalence of posterior dislocation was 1.1 per 100,000 population per year, with peaks in male patients between twenty and forty-nine years old, and in the elderly patients over seventy years old. Most dislocations (67%) were produced by a traumatic accident, with most of the remainder produced by seizures. Twenty patients (twenty-three shoulders) developed recurrent instability. On survival analysis, 17.7% (95% confidence interval, 10.8% to 24.6%) of the shoulders developed recurrent instability within the first year. On multivariable analysis, an age of less than forty years, dislocation during a seizure, and a large reverse Hill-Sachs lesion (>1.5 cm3) were predictive of recurrent instability. Small persistent functional deficits were detected with the WOSI and DASH at two years. The prevalence of posterior dislocation is low. The most common complication after this injury is recurrent instability, which occurs at an early stage in 17.7% of shoulders within the first year after dislocation. The risk is highest in patients who are less than forty years old, sustain the dislocation during a seizure, and have a large humeral head defect. The risk is lower for most patients who sustain the injury from a traumatic accident, especially if they are older and have a small anterior humeral head defect. There are persistent deficits of shoulder function within the first two years after the injury.
    The Journal of Bone and Joint Surgery 09/2011; 93(17):1605-13. · 3.23 Impact Factor
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    C Michael Robinson, Dominic Inman, Sally-Anne Phillips
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    ABSTRACT: Fractures and nonunions in which there is a varus deformity of the humeral head producing posterinferior subluxation of the articular surface are increasingly recognized as an important subgroup of proximal humeral fractures. Operative open reduction and internal fixation of these injuries is often recommended when the varus deformity is severe. We describe a simple technique to assist in the open reduction and locking plate stabilization of this challenging and complex fracture subtype using tools and implants that are readily available in most modern orthopaedic trauma operating rooms.
    Journal of orthopaedic trauma 07/2011; 25(10):634-40. · 1.78 Impact Factor
  • Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 10/2010; 19(7):1105-14. · 1.93 Impact Factor
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    Simon M Johnson, C Michael Robinson
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    ABSTRACT: Generalized ligamentous hyperlaxity and glenohumeral joint instability are common conditions that exhibit a spectrum of diverse clinical forms and may coexist in the same patient. No single diagnostic test can confirm the presence of these disorders, and a careful clinical assessment is important. Unlike patients with traumatic shoulder instability, patients with hyperlaxity and instability are more likely to experience episodes of recurrent subluxation than they are to have recurrent dislocation. They are more likely to have instability in more than one anatomic plane, and they usually do not have the soft-tissue and osseous lesions associated with traumatic instability. Shoulder symptoms in a patient with hyperlaxity are not always due to instability; other pathological conditions may coexist, with rotator cuff impingement being the most common. Most patients with hyperlaxity have a reduction in instability symptoms after nonoperative treatment, including physical therapy, activity modification, and additional psychological support when necessary. Operative treatment provides reproducibly good results for patients with hyperlaxity who do not respond to a prolonged program of nonoperative measures. Open inferior capsular shift remains the gold standard of operative treatment, although arthroscopic capsular shift and plication procedures are now producing comparable results. Thermal capsulorrhaphy is associated with unacceptably high failure rates and postoperative complications and cannot be recommended as a treatment.
    The Journal of Bone and Joint Surgery 06/2010; 92(6):1545-57. · 3.23 Impact Factor
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    ABSTRACT: This is an overview of the current literature on malunion after midshaft clavicle fracture. Anatomy, trauma mechanism, classification, incidence, symptoms, prevention, and treatment options are all discussed. The conclusion is that clavicle malunion is a distinct clinical entity that can be treated successfully.
    Acta Orthopaedica 04/2010; 81(3):273-9. · 2.74 Impact Factor
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    ABSTRACT: Cerebral emboli have been detected during intramedullary orthopaedic procedures. The quantity of emboli produced and their clinical effects are currently not known. This study aimed to quantify the intra-operative cerebral embolic load using transcranial Doppler ultrasound during the intramedullary stabilisation of femoral and tibial diaphyseal fractures. Clinical cognitive function was also assessed after surgery and any relationship to the cerebral embolic load determined. Prospective cohort study of 20 patients with femoral or tibial diaphyseal fractures treated with reamed intramedullary nailing. The intra-operative cerebral embolic load was measured using transcranial Doppler ultrasound of the middle meningeal artery. Cognitive function was assessed 3 days after surgery using a range of validated neuropsychological tests. The cognitive results were compared to predicted scores matched for age and intelligence quotient as is the standard method of cognitive assessment after trauma. Four patients had detectable cerebral emboli with counts of only 2, 3, 3, and 9 respectively. A significantly poorer than predicted cognitive score occurred in immediate and delayed memory recall tests. However there was no significant difference in any cognitive function score between those patients who had detectable cerebral emboli and those who did not. Small numbers of cerebral emboli were detected during intramedullary stabilisation of lower limb long bone fractures but with no apparent cognitive effect. This poor correlation is similar to recent studies performed on arthroplasty patients and also conforms to the extensive cardiac surgery literature which would indicate that such low levels of systemic embolisation are unlikely to consistently produce cerebral clinical effects.
    Injury 05/2009; 40(7):742-5. · 1.93 Impact Factor
  • C Michael Robinson, Kar H Teoh, Alex Baker, Lawrence Bell
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    ABSTRACT: Fractures of the lesser tuberosity are rare injuries, and little is known of their epidemiology. Operative treatment is generally recommended for displaced fractures; however, the outcome of this method of treatment has not previously been studied. The aims of our study were to determine the approximate incidence of lesser tuberosity fractures, as well as the functional outcome following operative treatment in a consecutive series of patients. Over an eight-year period, we studied the demographic details of a consecutive series of twenty-two adult patients who had a fracture of the lesser tuberosity. We used age and sex-specific local census data to estimate the annual incidence of this injury in our local population. Seventeen of the original cohort of twenty-two patients, who were medically fit and had a displaced (two-part) fracture, were treated with open reduction and internal fixation of the fracture. We assessed the outcome using the Short Form-36 (SF-36) general health measure, the Constant score, and the Disabilities of the Arm, Shoulder and Hand (DASH) score. The estimated annual incidence of these fractures was low at 0.46 per 100,000 population per year during the study period. There were fifteen men and seven women, with a median age of forty-three years. There was an even distribution of fractures across the age cohorts, and most fractures were sustained from a high-energy transfer mechanism. The median Constant score was 95 points at two years, and the median DASH score was 12 points at two years after the injury. Most patients regained nearly normal range of motion in the affected shoulder by three months. One patient had development of posttraumatic shoulder stiffness, which responded to arthroscopic release. All patients who were in regular employment prior to the injury returned to their jobs within six months. There were no significant differences between each component of the SF-36 at two years compared with age and sex-matched controls. A lesser tuberosity fracture, without an associated humeral head or greater tuberosity fracture, is a rare injury. Open reduction and internal fixation provides excellent restoration of function and range of shoulder movement, with a low risk of complications.
    The Journal of Bone and Joint Surgery 04/2009; 91(3):512-20. · 3.23 Impact Factor
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    ABSTRACT: Undisplaced fractures of both the diaphysis and the lateral end of the clavicle have a high rate of union, and the functional outcomes are good after nonoperative treatment. Nonoperative treatment of displaced shaft fractures may be associated with a higher rate of nonunion and functional deficits than previously reported. However, it remains difficult to predict which patients will have these complications. Since a satisfactory functional outcome may be obtained after operative treatment of a clavicular nonunion or malunion, there is currently considerable debate about the benefits of primary operative treatment of these injuries. Displaced lateral-end fractures have a higher risk of nonunion after nonoperative treatment than do shaft fractures. However, nonunion is difficult to predict and may be asymptomatic in elderly individuals. The results of operative treatment are more unpredictable than they are for shaft fractures.
    The Journal of Bone and Joint Surgery 03/2009; 91(2):447-60. · 3.23 Impact Factor
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    ABSTRACT: The extended deltoid-splitting approach was developed as an alternative to the deltopectoral approach in the treatment of three- and four-part proximal humeral fractures. The aim of our prospective study was to determine whether this approach was associated with evidence of nerve injury, functional deficits or other complications in these cases, during the first year following reconstruction. Over a 1-year-period, we treated 14 people (median age 59 years) with open reduction and plate fixation using the extended deltoid-splitting approach. All were prospectively reviewed clinically and radiologically during the first year after surgery. Functional testing involved three scoring systems, spring balance testing of deltoid power, dynamic muscle function testing and, at 1 year, electrophysiological assessment of axillary nerve function. Of the 14 fractures, 13 united without complications and with comparatively minor residual functional deficits. Of these 13 cases, 1 showed slight neurogenic change in the anterior deltoid but no evidence of anterior deltoid paralysis. In the remaining case, osteonecrosis of the humeral head developed 9 months after surgery and functional scores were poor, but without evidence of nerve injury on electrophysiological testing. This technique is a useful alternative in the treatment of complex proximal humeral fractures, providing good access for reduction and implant placement without adverse effects.
    Injury 01/2009; 40(2):181-5. · 1.93 Impact Factor
  • Paul J Jenkins, Kate Slade, James S Huntley, C Michael Robinson
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    ABSTRACT: Clinical examination of suspected scaphoid fractures is sensitive, but not specific, and initial plain radiographs lack sensitivity. A variety of second-line imaging techniques have been proposed to improve immediate diagnosis and reduce overtreatment. Different sample populations and methods of reporting test performance have made side-by-side comparison difficult. The aim of this study is to describe the epidemiology of clinically suspected scaphoid fracture and determine the prevalence of true fracture. These data are used to compare second-line imaging techniques in our population. 200 consecutive patients attending a trauma service with clinically suspected scaphoid fracture were followed through diagnosis to discharge. The prevalence of true fracture was 16% and was associated with male sex and injury playing sport. Magnetic resonance imaging has the best diagnostic performance, with the added benefit of soft tissue evaluation, but was the most expensive option. Ultrasound examination was least effective in detecting true fractures. Future studies should further evaluate the clinical and economic sequelae of overtreatment of suspected fractures. Clinicians should examine alternatives to "empirical" treatment without definite diagnosis based on their local facilities and patient demographics.
    Injury 08/2008; 39(7):768-74. · 1.93 Impact Factor
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    ABSTRACT: Anterior dislocation of the glenohumeral joint in younger patients is associated with a high risk of recurrence and persistent functional deficits. The aim of this study was to assess the efficacy of a primary arthroscopic Bankart repair, while controlling for the therapeutic effects produced by the arthroscopic intervention and joint lavage. In a single-center, double-blind clinical trial, eighty-eight adult patients under thirty-five years of age who had sustained a primary anterior glenohumeral dislocation were randomized to receive either an arthroscopic examination and joint lavage alone or together with an anatomic repair of the Bankart lesion. Assessment of the rate of recurrent instability, functional outcome (with use of three scores), range of movement, patient satisfaction, direct health-service costs, and treatment complications was completed for eighty-four of these patients (forty-two in each group) during the subsequent two years. In the two years after the primary dislocation, the risk of a further dislocation was reduced by 76% and the risk of all recurrent instability was reduced by 82% in the Bankart repair group compared with the group that had arthroscopy and lavage alone. The functional scores were also better (p < 0.05), the treatment costs were lower (p = 0.012), and patient satisfaction was higher (p < 0.001) after arthroscopic repair. The improved functional outcome appeared to be mediated through the prevention of instability since the functional outcome in patients with stable shoulders was similar, irrespective of the initial treatment allocation. The patients who had a Bankart repair and played contact sports were also more likely to have returned to their sport at two years (relative risk = 3.4, p = 0.007). Following a first-time anterior dislocation of the shoulder, there is a marked treatment benefit from primary arthroscopic repair of a Bankart lesion, which is distinct from the so-called background therapeutic effect of the arthroscopic examination and lavage of the joint. However, primary repair does not appear to confer a functional benefit to patients with a stable shoulder at two years after the dislocation.
    The Journal of Bone and Joint Surgery 05/2008; 90(4):708-21. · 3.23 Impact Factor
  • Martin J Mitchell, Andrew C Gray, C Michael Robinson
    Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 01/2008; 17(2):e1-3. · 1.93 Impact Factor
  • C Michael Robinson, Lukman Khan, Adeel Akhtar, Roger Whittaker
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    ABSTRACT: The recent technological developments in implant design and the wider availability of bone graft substitutes have stimulated a renaissance in the operative treatment of complex proximal humeral fractures. However, one of the remaining problems of the operative treatment of these injuries has been the limited surgical access to the posterior aspect of the shoulder afforded by the deltopectoral approach. In this article, we describe a novel extended deltoid-splitting approach, in which the area traversed by the axillary nerve is identified and protected during the surgery. We feel that this approach provides enhanced surgical exposure and offers a useful alternative to the deltopectoral approach in the operative treatment of 3- and 4-part proximal humeral fractures.
    Journal of Orthopaedic Trauma 11/2007; 21(9):657-62. · 1.75 Impact Factor
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    C Michael Robinson, Adeel Akhtar, Martin Mitchell, Cole Beavis
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    ABSTRACT: Complex posterior fracture-dislocations of the shoulder are rare and often associated with poor long-term function regardless of the choice of treatment. The purposes of this study were to evaluate the epidemiology and pathological anatomy of posterior fracture-dislocations of the shoulder and to assess the clinical and radiographic outcomes of a specific treatment protocol of open reduction and internal fixation. We studied the demographic details of a consecutive series of twenty-six patients (twenty-eight shoulders in nineteen men and seven women with a mean age of fifty-three years) who sustained acute posterior dislocation of the humeral head with an associated Neer two, three, or four-part fracture. We used age and gender-specific local census data to assess the incidence of injury in our local population. All patients were treated by open relocation of the humeral head, bone-grafting of humeral head defects if they were causing residual shoulder instability, and internal fixation of the fracture. We recorded the prevalence of fracture complications that were clinically and radiographically apparent and assessed the functional outcome using three validated scoring systems (the Short Form-36 general health measure, the Disabilities of the Arm, Shoulder and Hand score, and the Constant score). The overall incidence of posterior fracture-dislocations was 0.6 per 100,000 population per year. The peak incidence was in middle-aged men, and most injuries were sustained during a seizure or a fall from a height. In all patients, there was a displaced primary fracture of the anatomic neck of the humerus, propagating from the area of an osteochondral fracture of the anterior aspect of the humeral head (a reverse Hill-Sachs lesion). We recognized three subtypes determined by the extent of the secondary fracture lines. At two years after surgery, the median Constant score was 83.5 points and the median Disabilities of the Arm, Shoulder and Hand score was 17.5 points. The eight components of the Short Form-36 score were not significantly different from those of age and sex-matched controls at two years. Acute complex posterior fracture-dislocations of the shoulder are rare, but they occur in patients who are younger than the majority of other patients who sustain a proximal humeral fracture. The use of open reduction and internal fixation to treat these fractures is associated with a relatively low risk of postoperative complications, and the functional outcome is generally favorable.
    The Journal of Bone and Joint Surgery 08/2007; 89(7):1454-66. · 3.23 Impact Factor
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    The Journal of Bone and Joint Surgery 06/2007; 89(5):1092-6. · 3.23 Impact Factor
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    ABSTRACT: The prevalence and risk factors for recurrent instability and functional impairment following a primary glenohumeral dislocation remain poorly defined in younger patients. We performed a prospective cohort study to evaluate these outcomes. We also aimed to produce guidelines for the design of future clinical trials, assessing the efficacy of interventions designed to improve the outcome after a primary dislocation. We performed a prospective cohort study of 252 patients ranging from fifteen to thirty-five years old who sustained an anterior glenohumeral dislocation and were treated with sling immobilization, followed by a physical therapy program. Patients received regular clinical follow-up to assess whether recurrent instability had developed. Functional assessments were made and were compared for two subgroups: those who had not had instability develop and those who had received operative stabilization to treat recurrent instability. On survival analysis, instability developed in 55.7% of the shoulders within the first two years after the primary dislocation and increased to 66.8% by the fifth year. The younger male patients were most at risk of instability, and 86.7% of all of the patients known to have recurrent instability had this complication develop within the first two years. A small but measurable degree of functional impairment was present at two years after the initial dislocation in most patients. Sample-size calculations revealed that a relatively small number of patients with a primary dislocation would be required in future clinical trials examining the effects of interventions designed to reduce the prevalence of recurrent instability and improve the functional outcome. Recurrent instability and deficits of shoulder function are common after primary nonoperative treatment of an anterior shoulder dislocation. There is substantial variation in the risk of instability, with younger males having the highest risk and females having a much lower risk. Future clinical trials to evaluate primary interventions should evaluate the prevalence of recurrent instability and functional deficits, with use of an assessment tool specifically for shoulder instability, during the first two years after the initial dislocation.
    The Journal of Bone and Joint Surgery 12/2006; 88(11):2326-36. · 3.23 Impact Factor
  • Anish K. Amin, C. Michael Robinson
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    ABSTRACT: Fractures and dislocations involving the shoulder girdle are common. If these injuries occur after high-energy trauma, initial assessment must follow Advanced Trauma Life Support™ (ATLS)™ guidelines to identify associated life-threatening injuries. Physical examination must include a thorough neurovascular assessment of the upper limb, with particular attention to the axillary nerve and brachial plexus because they are often damaged in injuries to the shoulder girdle. Knowledge of the relevant anatomy and accurate radiological evaluation help classify the severity of the fracture or dislocation. Classification of the injury helps guide treatment and indicate prognosis. Most fractures and dislocations of the shoulder girdle are managed with a brief period of immobilization followed by early, progressive mobilization of the entire upper limb to prevent stiffness. Surgical treatment is appropriate in some patients and various techniques are used to achieve reduction of the fracture or dislocation and maintain reduction by internal fixation. Complications may occur as a result of initial injury or after treatment of the fracture or dislocation.
    Surgery (Oxford) 01/2006; 24(12):415-420.