Recently concerns have been raised as to the effect of intra-articular radio-frequency energy on axillary nerve function. In our unit 120 shrinkage procedures have been performed with 5 intra-operative contractions of deltoid and no axillary nerve palsy. In this study we aimed to identify and quantify any changes in axillary nerve function following capsular shrinkage. Needle electrodes were inserted into the deltoid muscle of 10 patients undergoing radio-frequency capsular shrinkage and 3 patients having diagnostic arthroscopy. Recordings of Compound Muscle Action Potentials (CMAPs) were made following pre-operative magnetic coil stimulation of the axillary nerve. The nerve was then monitored during operation. At the end of the procedure, a further recording of CMAP following axillary nerve stimulation was made to allow comparison with initial readings. We have shown:. Low amplitude stimulations of the axillary nerve in 6 of the 10 patients undergoing shrinkage. Increase in latency of the axillary nerve was noted in some patients including the controls. Increase in latency was independent of time spent performing shrinkage. We have concluded:-. Stimulation of the axillary nerve occurs frequently during capsular shrinkage. This axillary nerve stimulation cannot be causally related to the application of radio-frequency energy. Increased latency may occur due to cooling of the nerve by extravasated irrigation fluid. Nerve monitoring is recommended during the training of surgeons new to this technique. We would like to acknowledge the Magstim Company for their assistance with this project

The axillary nerve injuries most commonly are observed after trauma such as contusion-stretch, gunshot wound, laceration and iatrogenic injuries. Two of the most commons causes seem to be the glenohumeral dislocation and the proximal humerus fractures. The axillary nerve may sustain a simple contusion, or its terminal elements may be avulsed from the deltoid muscle. Compressive neuropathy in the quadrilateral space also has been reported (quadrilateral space syndrome, Calhill and Palmer, 1983). The axillary nerve injuries incidence represents less than 1% of all nerve injuries. Aim: The purpose of this study was to analyze outcome in patients, who presented with injuries to the axillary nerve. Material and methods: We report a series of 15 cases of axillary nerve lesions, which were operated between 1995 and 2002. These injuries resulted from shoulder injury either with or without fracture and or dislocation. Patients were operated between 3 to 6 months after trauma and an anterior deltopectoral approach was usually followed during surgery. The follow up period ranged from 1 to 8 years. Results: The results were considered as satisfactory in 11 out of 15 axillary nerve lesions. According to clinical examination, of the function of the shoulder and the muscle strength the results were classified as excellent in 5 cases, good in 6 cases and poor in 4 cases. Conclusions: If indicated, nerve repair can lead to useful function in carefully selected patients

Purpose: We have sometimes observed paralysis of the long portion of the triceps in patients operated after traumatic damage to the axillary nerve. In anatomy textbooks, the motor branch of the long portion of the triceps arises from the radial nerve within the triceps. We studied the position of the motor branch of the long portion of the triceps in order to better detail its origin. Material and methods: Group I: this group included nine patients with trauma-induced lesions of the axillary nerve associated with clinical involvement of the long portion of the triceps. Group II: this group was composed of 20 cadaver specimens of the secondary posterior trunks. Group III: fif-teen approaches to the subclavian plexus with dissection of the secondary posterior trunk. Lesions to the axillary nerve were retrieved from the operation reports in group I. The origin of the motor branch of the long portion of the triceps was identified in group II. The same origin was identified by neurostimulation in group III. Results: In group I there were six lesions of the axillary nerve situated a mean 10 mm from the division of the secondary posterior trunk and three lesions of the secondary posterior trunk. There were four type IV lesions and five type V lesions. In group II, the motor branch of the long portion of the triceps arose a mean 6 mm from the division of the secondary posterior trunk in 13 cases, at the division in five cases, and 10 mm downstream in two cases, but never from the radial nerve. In group III, the branch of long portion of the triceps arose a men 4.5 mm from the division of the secondary posterior trunk in 11 cases, and at the division in four cases, but never from the radial nerve. Discussion: In patients with trauma to the axillary nerve with paralysis of the long portion of the triceps, lesions to the axillary nerve occur proximally and are severe. In our study, the motor branch of the long portion of the triceps always arose from the axillary nerve or the secondary posterior branch. This shows that paralysis of the long portion of the triceps is a sign of poor prognosis in patients with traumatic lesions to the axillary nerve. This association is for us an element in favour of a proximal and serious lesion to the axillary nerve. Conclusion: Involvement of the long portion of the triceps must be searched for in patients with traumatic lesions to the axillary nerve. Paralysis of the long portion of the triceps is a sign of a serious lesion requiring early surgical repair before two months

Rupture of the pectoralis major (PM) tendon is a rare yet severe injury. Several techniques have been described for PM fixation including a transosseus technique, when cortical buttons are placed at the superior, middle and inferior PM tendon insertion positions. The concern with this technique is the risk that bicortical drilling poses to the axillary nerve as it courses posteriorly to the humerus. This cadaveric study investigates the proximity of the posterior branch of the axillary nerve to the drill positions for transosseus PM tendon repair. Drills were placed through the humerus at the superior, middle and inferior insertions of the PM tendon and the distance between these positions and the axillary nerve, which had previously been marked, was measured using computed tomography (CT) imaging. This investigation demonstrates that the superior border of PM tendon insertion is the fixation position that poses the highest risk of damage to the axillary nerve. Caution should be used when performing bicortical drilling during cortical button PM tendon repair, especially when drilling at the superior border of the PM insertion. We describe ‘safe’ and ‘danger’ zones for transosseus drilling of the humerus reflecting the risk posed to the axillary nerve

Abstract. Objective. Radial to axillary nerve and spinal accessory (XI) to suprascapular nerve (SSN) transfers are standard procedures to restore function after C5 brachial plexus dysfunction. The anterior approach to the SSN may miss concomitant pathology at the suprascapular notch and sacrifices lateral trapezius function, resulting in poor restoration of shoulder external rotation. A posterior approach allows decompression and visualisation of the SSN at the notch and distal coaptation of the medial XI branch. The medial triceps has a double fascicle structure that may be coapted to both the anterior and posterior division of the axillary nerve, whilst preserving the stabilising effect of the long head of triceps at the glenohumeral joint. Reinnervation of two shoulder abductors and two external rotators may confer advantages over previous approaches with improved external rotation range of motion and strength. Methods. Review of the clinical outcomes of 22 patients who underwent a double nerve transfer from XI and radial nerves. Motor strength was evaluated using the MRC scale and grade 4 was defined as the threshold for success. Results. 18/22 patients had adequate follow-up (Mean: 29.5 months). Of these, 72.2% achieved ≥grade 4 power of shoulder abduction and a mean range of motion of 103°. 64.7% achieved ≥grade 4 external rotation with a mean range of motion of 99.6°. Conclusions. The results suggest the use of the combined nerve transfer for restoration of shoulder function via a posterior approach, involving the medial head branch of triceps to the axillary nerve and the XI to SSN

Physiological studies have revealed that the central nervous system controls groups of muscle fibers in a very efficient manner. Within a single skeletal muscle, the central nervous system independently controls individual muscle segments to produce a particular motor outcome. Mechanomyographic studies on the deltoid muscle have revealed that the deltoid muscle, commonly described as having three anatomical segments, is composed of at least seven functional muscle segments, which all have the potential to be at an important level independently coordinated by the central nervous system.[. 1. ] In this study we tried to anatomically describe and quantify these different functional segments within the deltoid muscle, based on the branching out pattern of the axillary nerve. Forty-four deltoids of 22 embalmed adult cadavers, were analyzed. The axillary nerve was carefully dissected together with his anterior and posterior branch upon invasion into the muscle. According to the pattern of fiber distribution and their fascial embalmment, we then carefully splitted the deltoid muscle into different portions each being innervated by a major branch of the axillary nerve. The position and volume of each segment in relation to the whole muscle was derived. In 3 cases the axillary nerve branched out in 8 major divisions. In 22 out of 44 cases (50%), the axillary nerve branched out in 7 principal parts. A branching out pattern of 6 major divisions occurred in 14 out of 44 cases. Finally we found a division in 5 major branches in 5 of the specimens. In general, both posterior and anterior peripheral segments seemed to have the largest volume. In nearly all (93%) cases, the central segments were smaller in weight and volume compared to the more peripheral segments. Based on the innervation pattern of the deltoid muscle a segmentation in 5 up to 8 major segments seem to be found. This confirms from anatomical point of view earlier reports of functional differentiation within the deltoid muscle

Analysis of orthopaedic malpractice claims has shown that highest impact allegations (highest payment dollars per claim) were those that were related to failure to protect anatomic structures in surgical fields. The prevalence of subclinical peripheral neurologic deficit following reverse and anatomic shoulder arthroplasty has been reported to be 47% and 4%, respectively. We propose the following five rules in order to avoid neurovascular injury during shoulder arthroplasty cases:. Pre-operative planning would assure a smooth operation without intra-operative difficulties. Adequate planning would include appropriate imaging, obtaining previous operative reports, complete pre-operative neurovascular examination and requesting the necessary operative equipment. Tug test: It is crucial to palpate the axillary nerve and be aware of its location. The tug test is a systematic technique for locating and protecting the axillary nerve. Neuromonitoring has been utilised in shoulder surgery in the past. Nagda et al showed that nerve alerts during shoulder arthroplasty occurred 56.7% of the time and 50% of the events were with the arm in abduction, external rotation and extension; 76.7% of signals returned to normal with retractor removal and change in arm positioning. We recommend removing all retractors and returning the arm to neutral position several times during surgery, especially during the glenoid exposure when the arm is in abduction and external rotation. Newer commercially available nerve stimulators are extremely useful in locating and protecting neurovascular structures. We recommend brachial plexus exploration and axillary nerve dissection with the aid of a nerve stimulator in all revision cases. Availability of a nerve/microvascular surgeon as an assistant in revision cases for brachial plexus exploration using a microscope is crucial for successful revision surgery

In reverse shoulder arthroplasty (RSA), a high complication rate is noted in the international literature (24.7%), and limited local literature is available. The complications in our developing health system, with high HIV, tuberculosis and metabolic syndrome prevalence may be different from that in developed health systems where the literature largely emanates from. The aim of this study is to describe the complications and complication rate following RSA in a South African cohort. An analytical, cross-sectional study was done where all patients’ who received RSA over an 11 year period at a tertiary hospital were evaluated. One-hundred-and-twenty-six primary RSA patients met the inclusion criteria and a detailed retrospective evaluation of their demographics, clinical variables and complication associated with their shoulder arthroplasty were assessed. All fracture, revision and tumour resection arthroplasties were excluded, and a minimum of 6 months follow up was required. A primary RSA complication rate of 19.0% (24/126) was noted, with the most complications occurring after 90 days at 54.2% (13/24). Instability was the predominant delayed complication at 61.5% (8/13) and sepsis being the most common in the early days at 45.5% (5/11). Haematoma formation, hardware failure and axillary nerve injury were also noted at 4.2% each (1/24). Keeping in mind the immense difference in socioeconomical status and patient demographics in a third world country the RSA complication rate in this study correlates with the known international consensus. This also proves that RSA is still a suitable option for rotator cuff arthropathy and glenohumeral osteoarthritis even in an economically constrained environment like South Africa

A fracture of the tuberosity is associated with 16% of anterior glenohumeral dislocations. Manipulation of these injuries in the emergency department is safe with less than 1% risk of fracture propagation. However, there is a risk of associated neurological injury, recurrent instability and displacement of the greater tuberosity fragment. The risks and outcomes of these complications have not previously been reported. The purpose of this study was to establish the incidence and outcome of complications associated with this pattern of injury. We reviewed 339 consecutive glenohumeral dislocations with associated greater tuberosity fractures from a prospective trauma database. Documentation and radiographs were studied and the incidence of neurovascular compromise, greater tuberosity fragment migration and intervention and recurrent instability recorded. The mean age was 61 years (range, 18–96) with a female preponderance (140:199 male:female). At presentation 24% (n=78) patients had a nerve injury, with axillary nerve being most common (n=43, 55%). Of those patients with nerve injuries 15 (19%) did not resolve. Greater tuberosity displacement >5mm was observed in 36% (n=123) of patients with 40 undergoing acute surgery, the remainder did not due to comorbidities or patient choice. Persistent displacement after reduction accounted for 60 cases, later displacement within 6 weeks occurred in 63 patients. Recurrent instability occurred in 4 (1%) patients. Patient reported outcomes were poor with average EQ5D being 0.73, QDASH score of 16 and Oxford Shoulder Score of 41. Anterior glenohumeral dislocation with associated greater tuberosity fracture is common with poor long term patient reported outcomes. Our results demonstrate there is a high rate of neurological deficits at presentation with the majority resolving spontaneously. Recurrent instability is rare. Late tuberosity fragment displacement occurs in 18% of patients and regular follow-up for 6 weeks is recommended to detect this

Proximal humeral fractures are common fractures that may lead to severe functional disability. In open reduction and internal fixation of these fractures deltopectoral approach is pereferred by many surgeons being an internervous plane and because of familiarity. However when this aprroach is used extensive soft tissue dissection is inevitable and control of the commonly displaced tuberculum majus fragment which is displaced posterolateraly is difficult. In this prospective study we compared deltopectoral and lateral deltoid splitting approach by using the same fixation material. Between October 2005 and March 2007 42 patients were included in the study group. In Group A a lateral deltoid split approch and in Group B deltopectoral approach was used. Group A consisted of 22 cases; mean age 60.95 (26–90 years old); 12 female and 10 male, Group B 20 cases; mean age 56.9 (24–86 years old); 13 female, 7 male. Philos locking plate fixation (Synthes) was used in every case. When deltoid split approach was used axillary nerve was explored and protected, a C-arm was used in every case. Functional results and compications were compared at the follow up visits. When radiological results were compared the reduction of head and tubercular fragments were better in deltoid splitting approach. The Constant score was better in Group A at an earlier time period 68.9 vs 58.4 (p< 0.01). At the 6th month follow up the difference between Constant scores was not significant, 85.9 vs 85.2 (p> 0.05). Axillary nerve lesion due to lateral deltoid split exposure was not observed in any of the cases. Lateral deltoid split exposure with identification and protection of the axillary nerve facilitates 270 degrees control of the head and tubercular fragments in AO/ASIF type B and C fractures. Additional fixation of tubercular fragments by sutures passed through cuff tendons and fixed to the plate helps to maintain the reduction. Compared to double incision minimal invasive approach a shother plate is used without any inadvertant risk to the axillary nerve. Better Constant scores are achieved at an earlier time. We recommend this technique in AO/ASIF type B and C fractures

Introduction. Osteoarthritis of the glenohumeral joint leads to global degeneration of the shoulder and often results in humeral or glenoid osteophytes. It is established that the axillary neurovascular bundle is in close proximity to the glenohumeral capsule. Similar to other compressive neuropathies, osteophytic impingement of the axillary nerve could result in axillary nerve symptoms. The purpose of this study was to compare the proximity of the axillary neurovascular bundle to the inferior humerus in shoulders to determine distance of the neurovascular bundle as the osteophyte (goat's beard) of glenohumeral osteoarthritis develops. Methods. In this IRB approved study, preoperative MRI's of 98 shoulders (89 patients) with primary osteoarthritis (OA group) were compared to 91 shoulders (86 patients) with anterior instability (Control group). For MRI measurements (mm) two coronal-oblique T1 or proton density weighted images were selected for each patient located at 5 and 6 o'clock position of the glenoid in the parasagittal plane. Humeral head diameter to standardize the glenohumeral measurements, size of the spurs, and 6 measurements between osseus structures and axillary neurovascular bundle were obtained on each image using a calibrated measurement system (Stryker Office PACS Power Viewer). Level of significance was set at p>.05. Results. Since results were both significant at 5 and 6 o'clock, for clarity we will only give the results at 6 o'clock. Humeral head osteophytes were present in 52% (51/86) of arthritic patients with an average size of 9.90 mm (range 0–24.31). Distance between humeral head or inferior osteophyte and neurovascular bundle was significantly decreased (p<0.05) in the OA group, 19.74 mm (range 2.80–35.12) compared to the control group 23.8 mm (14.25–31.89). If we compare the same distance between the Control group, OA group with a spur and OA group without a spur, the difference is only significant between the Control group and OA with spur. (p<0.05) In non-arthritic patients, the neurovascular bundle was closest to the inferior glenoid rim in all patients (91/91). By contrast, the neurovascular bundle was closest to the humeral head in 26.5% (26/98) of arthritic patients. Among these 26 patients, a large humeral head osteophyte was present in 96% (25/26). The neurovascular bundle distance and humeral head osteophyte size were inversely correlated (r=−0.45 at 5 o'clock, r=−0.546 at 6 o'clock) in the arthritic group (p<0.05). Discussion. The axillary neurovascular bundle was significantly closer to the osseous structures (humerus) in arthritic patients compared to non-arthritic patients (p<0.05). The neurovascular bundle was significantly closer to the bone when there was a humeral osteophyte, and the distance was inversely proportional to humeral osteophyte size (p<0.05). This study indicates humeral osteophytes are capable of encroaching on the axillary nerve. Axillary nerve entrapment may be a contributing and treatable factor of pain in patients with glenohumeral osteoarthritis

Fractures of the proximal humerus can offer a difficult surgical challenge particularly if they occur in elderly patients and/or are a complex fracture configuration. Much of the morbidity of the surgery relates to the extensile delto-pectoral approach traditionally used for operative treatment of these fractures. A minimally invasive technique for approaching these fractures has was developed using a proximal deltoid split approach at the anterior edge of the deltoid and sliding a precontoured proximal humeral locking plate submuscularly after provisional fracture reduction. This technique was tested in a cadaver model to identify “safe” and “at risk” holes in the plate for percutaneous fixation in relation to the axillary nerve. A case series of eighteen patients who had surgery using this technique were reviewed. All patients achieved acceptable reductions and went on to unite without any signs of AVN or implant failure. One patient had a transient sensory disturbance in an axillary nerve distribution post op. One patient has asymptomatic fibrous union of the greater tuberosity. Minimally invasive plate fixation using a lateral deltoid split approach is technically possible with excellent results. The danger zone around the axillary nerve has been identified and should be avoided with percutaneous fixation utilising this procedure. A jig to allow accurate MIPO fixation has been developed

The patterns of nerve and associated skeletal injury were reviewed in 84 patients referred to the brachial plexus service who had damage predominantly to the infraclavicular brachial plexus and its branches. Patients fell into four categories: 1. Anterior glenohumeral dislocation (46 cases); 2. ‘Occult’ shoulder dislocation or scapular fracture (17 cases); 3. Humeral neck fracture (11 cases); 4. Arm hyperextension (9 cases). The axillary (38/46) and ulnar (36/46) nerves were most commonly injured as a result of glenohumeral dislocation. The axillary nerve was ruptured in only 2 patients who had suffered high energy trauma. Ulnar nerve recovery was often incomplete. ‘Occult’ dislocation refers to patients who had no recorded shoulder dislocation but the history was suggestive that dislocation had occurred with spontaneous reduction. These patients and those with scapular fractures had a similar pattern of nerve involvement to those with known dislocation, but the axillary nerve was ruptured in 11 of 17 cases. In cases of humeral neck fracture, nerve injury resulted from medial displacement of the humeral shaft. Surgery was performed in 7 cases to reduce and fix the fracture. Arm hyperextension cases were characterised by injury to the musculocutaneous nerve, with the nerve being ruptured in 8 of 9. Five had humeral shaft fracture or elbow dislocation. There was variable involvement of the median and radial nerves, with the ulnar nerve being least affected. Most cases of infraclavicular brachial plexus injury associated with shoulder dislocation can be managed without operation. Early nerve exploration and repair should be considered for:. Axillary nerve palsy without recorded shoulder dislocation or in association with fracture of the scapula. Musculocutaneous nerve palsy with median and/or radial nerve palsy. Urgent operation is necessary for nerve injury resulting from fracture of the humeral neck to relieve ongoing pressure on the nerves

Plate fixation of the proximal humerus fractures may now be more desirable with the use of a biological approach by limiting surgical insult and allowing accelerated rehabilitation by a solid fixation. To evaluate the safety and efficacy of minimally invasive plating of the proximal humerus using validated disease-specific measures. During a period of one year, thirty patients were operated with use of the LCP proximal humerus plate (Synthes) through a 3cm lateral deltoid splitting approach and a second 2 cm incision at the deltoid insertion. The axillary nerve was palped and easily protected during insertion. Only two-part (N=22) and three-part impacted valgus type (N=8) were included in this study since they can be reduced indirectly thru this percutaneous technique. The average follow-up was thirteen months (eight to twenty months). All patients had the Constant and DASH evaluations. All fractures healed within the first six months with no loss of correction. The surgical technique was found easy by all surgeons, the axillary nerve was palpated and protect with this new technique. No infection or avascular necrosis were seen. No axillary nerve deficit was identified. At the last follow-up (average nineteen months, twelve months minimum), the median Constant score was sixty-eight points, with an age ajusted score of seventy-six. The mean DASH score was twenty-seven points. Only age was independently predictive of both the Constant and DASH functional scores. Patients improved until one year of follow up. Percutaneous insertion of a locking proximal humerus plate is safe and produces gives good early functional and radiologic outcomes. Recuperation from a proximal humerus fracture can be seen until one year

Purpose: The objective of the study was to perform a prospective evaluation of thermal capsulorraphy for the treatment of multidirectional instability of the shoulder. Summary of Methods: Over a period of two years, 19 patients with multidirectional instability were treated with thermal shrinkage. Fifteen patients had involuntary dislocation and four voluntary. The predominant direction of instability was anterior/inferior in 10, posterior in 5 and multiple directions in 4. Patients were followed for a minimum of two years or until surgical failure and recurrence of symptomatology. Postoperatively patients were immobilised in a sling for a period of 3 weeks and were reviewed at 6 weeks and 3, 6, 9 and 12 months and then at six monthly intervals. The Western Ontario shoulder Instability Index was used as a clinical outcome measure as well as subjective and objective evaluation of patient’s function, range of motion, pain and instability. Results: Nine patients had recurrence of their instability occurring at an average of nine months following their surgical procedure (range 7–14 months). One patient had axillary nerve dysfunction postoperatively with difficulty in abducting the shoulder. Three patients had sensory dysaesthesia related to the axillary nerve territory. All neurological subjective evaluations recovered within 9 months. Four of five patients with a predominantly posterior direction to their instability failed this surgical procedure. Only 2 of 10 (20%) with predominantly anterior instability failed. Conclusion: Analysis of patients with multidirectional laxity determined that thermal capsulorraphy had a high failure rate (9/19, 47%) with associated significant postoperative complications including axillary nerve dysaesthesias and stiffness

Introduction and purpose: Different neurovascular structures may be damaged when making arthroscopic portals to the shoulder joint. The description of new portals poses new challenges. The goal of the present study is to provide an update on the anatomic vasculonervous responses of the current approaches to shoulder arthroscopy. Materials and methods: 16 fresh cadavers were systematically dissected. The most usual arthroscopic portals were marked and, then, the dissection started on a plane-to-plane basis. Relationships were identified and distances were measured to the most important neurovascular elements with a standard caliber (accuracy: 0.5mm). Results: The portals studied and the structures at risk were the following:. * Posterior portal: anterior branch of the axillary nerve and posterior circumflex artery 3.4 cm (range: 1.4 – 5); cutaneous branch of the axillary nerve 6.3 cm (range: 3.8 – 8.3), suprascapular nerve 2.8 cm (range: 2.1–3.3). * Anterosuperior portal: main branch of the musculocutaneous nerve 6.5 cm (range: 3.8 – 11). * Lateral subacromial portal: axillary nerve and posterior circumflex artery 3.7 cm (range: 2– 5.5). * Anteroinferior subaxillary portal 4 cm (range: 3.1 –6). * Supraspinatus portal: suprascapular nerve 3.2 cm (range: 2.4 – 4). Conclusions: Although the crucial elements at risk when performing a shoulder arthroscopy are multiple, the axillary and suprascapular nerves were the most vulnerable structures to the different approaches. In spite of the presence of the “safe areas” described above, the neurovascular bundle was frequently affected by passage through the anteroinferior subaxillary portal. The results suggest that the use of this portal is not safe for routine arthroscopic practice

The standard approach is through the deltopectoral interval. Among patients with prior incisions, one makes every effort to either utilise the old incision or to incorporate it into a longer incision that will allow one to approach the deltopectoral interval and retract the deltoid laterally. The deltopectoral interval is most easily developed just distal to the clavicle, where there is a natural infraclavicular triangle of fat that separates the deltoid and pectoralis major muscles even in very scarred or stiff shoulders. Typically, the deltoid is retracted laterally leaving the cephalic vein on the medial aspect of the exposure. The anterior border of the deltoid is mobilised from the clavicle to its insertion on the humerus. The anterior portion of the deltoid insertion together with the more distal periosteum of the humerus may be elevated slightly. The next step is to identify the plane between the conjoined tendon group and the subscapularis muscle. Dissection in this area must be done very carefully due to the close proximity of the neurovascular group, the axillary nerve, and the musculocutaneous nerve. Scar is then released from around the base of the coracoid. The subacromial space is freed of scar and the shoulder is examined for range of motion. Particularly among patients with prior rotator cuff surgery, there may be severe scarring in the subacromial space. Internal rotation of the arm with dissection between the remaining rotator cuff and deltoid is critical to develop this plane. If external rotation is less than 30 degrees, one can consider incising the subscapularis off bone rather than through its tendinous substance. For every 1 cm that the subscapularis is advanced medially, one gains approximately 20 to 30 degrees of external rotation. The rotator interval between the subscapularis and supraspinatus is then incised. This release is then continued inferiorly to incise the inferior shoulder capsule from the neck of the humerus. This is performed by proceeding from anterior to posterior with progressive external rotation of the humerus staying directly on the bone with electrocautery and great care to protect the axillary nerve. The key for glenoid exposure as well as improvement in motion is deltoid mobilization, a large inferior capsular release, aggressive humeral head cut and osteophyte removal

Abstract. Background/Objectives. The incidence of reverse total shoulder replacement (rTSR) implantation is increasing globally, but apprehension exists regarding complications and associated challenges. We retrospectively analysed the senior author's series of rTSR from a tertiary centre using the VAIOS shoulder system, a modular 4th generation implant. We hypothesised that the revision rTSR cohort would have less favourable outcomes and more complications. Methods. 114 patients underwent rTSR with the VAIOS system, over 7 years. The primary outcome was implant survival. Secondary outcomes were Oxford shoulder scores (OSS), radiographic analysis (scapular notching, tuberosity osteolysis, and periprosthetic radiolucent lines) and complications. Results. There were 55 Primary rTSR, 31 Revision rTSR and 28 Trauma rTSR. Implant survival: Primary rTSR- 0 revisions, average 3.35-year follow-up. Revision rTSR-1 revision (4.17%), average 3.52-year follow-up. Trauma rTSR- 1 revision (3.57%), average 4.56-year follow-up OSS: Average OSS improved from 15.39 to 33.8 (Primary rTSR) and from 15.11 to 29.1 (Revision rTSR). Average post-operative OSS for the Trauma rTSR was 31.4 Radiological analysis and complications: Low incidence of scapular notching One hairline fracture below the tip of stem, noted incidentally, which required no treatment. One periprosthetic fracture after alcohol related fall. Treated non-surgically One joint infection requiring two-stage revision to rTSR. One dislocation noted at 2 year follow up. This patient had undergone nerve grafting within 6 months of rTSR for axillary nerve injury sustained during the original fracture dislocation. One acromial fracture with tibial and distal humeral fracture after a fall. Conclusions. The 4th generation modular VAIOS implant is a reliable option for various indications. The revision rTSR cohort had favourable outcomes with low complication rates. In this series, early-to-medium term results suggest lower revision rates and good functional outcomes when compared to published reports. We plan to monitor long-term implant survivorship and patient reported outcomes. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

Abstract. Introduction. Local anaesthetic injections are regularly used for perioperative pain relief for shoulder arthroscopies. In our practice all shoulder arthroscopies were performed under general aneasthesia supplemented by perioperative subacromial local anaesthetic injections or landmark guided axillary nerve together with suprascapular nerve injections. We compared pain relief achieved with these two methods. We hypothesized that the selective nerve blocks would provide better post operative pain relief as described in literature. Methods. We conducted a retrospective cohort study on two patient groups with 17 patients each. Group one patients received 20mls 50:50 mixture of 1% lignocaine and 0.5% chirocaine injections before and after start of procedure and group two patients received 20 mls of chirocaine around the axillary and suprascapular nerves. VAS scores were collected at 1 and 4 hours and analgesia taken during the first 24 hours was recorded. Results. No significant difference in pain scores was noted but analgesia requirements in the nerve block group were higher. Conclusion. Landmark guided nerve blocks did not show any advantage over subacromial local anaesthetic in our study. This is in contrast to published literature and we believe subacromial injections are more reliable and reproducible. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Although new locking plates allows for secure fixation of osteoporotic fractures in the proximal humerus, extensive soft tissue dissection is needed for their insertion. We report on a prospective clinical trial of the first thirty patients treated with plating of the proximal humerus though a minimally invasive percutaneous approach. All fractures healed within the first 6 months with no avascular necrosis or axillary nerve injury. At the latest follow-up, the median Constant score was sixty-eight and the mean DASH score was twenty-seven. This study suggests that percutaneous plating can be a safe and effective method of fixation. To evaluate the safety and efficacy of minimally invasive plating of the proximal humerus using validated disease-specific measures. Percutaneous insertion of a locking proximal humerus plate is safe and produces good early functional and radiologic outcomes. Plate fixation of the proximal humerus fractures may now be more desirable with the use of a biological approach by limiting surgical insult and allowing accelerated rehabilitation. All fractures healed within the first six months with no loss of correction. Two reoperations were needed to remove intra-articular screws placed too long. No infection or avascular necrosis were seen. At the lastest follow-up, the median Constant score was sixty-eight points, with an age ajusted score of seventy-six. The mean DASH score was twenty-seven points. Only age was independantly predictive of both the Constant and DASH functional scores. During a period of one year, thirty patients were operated with use of the LCP proximal humerus plate (Synthes) through a 3cm lateral deltoid splitting approach and a second 2 cm incision at the deltoid insertion. The axillary nerve was palped and easily protected during insertion. Only two-part (N=22) and three-part impacted valgus type (N=8) were included in this study since they can be reduced indirectly thru this percutaneous technique. The average follow-up was thirteen months (eight to twenty months). All patients had the Constant and DASH evaluations