Introduction: Arthrodesis of the shoulder joint is appropriate for several conditions, including paralysis, degenerative disease, infection, and salvage of failed arthroplasty. Two common complications of shoulder fusion, non-union and unacceptable arm position, may reflect failure to achieve rigid fixation during the surgical procedure. Numerous fixation techniques have been described, including plate fixation, external fixation, and screw fixation. Aim: To compare the biomechanics of five fixation techniques of shoulder fusion in a human cadaveric model. Methods: Twenty-five shoulder fusions were carried out in fresh-frozen human cadaveric specimens with the following five techniques: screw fixation alone (n=5), external fixation alone (n=5), external fixation supplemented with screw fixation (n=5), single plate fixation (n=5), and double plate fixation (n=5). Each specimen was tested on a servo-hydraulic machine under repeated physiologic loads to determine the bending and torsional stiffness. Results: There was a statistically significant difference in bending and torsional stiffness between all five fixation techniques (ANOVA, p< 0.05). Normalised bending (B) and torsional (T) stiffness, in descending order, were: double plate (B=1.0, T=1.0), single plate (B=0.77, T=0.89), external-fixation with screws (B=0.68, T=0.74), external-fixation alone (B=0.40, T=0.53), and screws alone (B=0.13, T=0.26). Discussion & Conclusion: Statistically significant differences in bending and torsional stiffness have been identified using five different techniques of shoulder fusion. The risk of the most common complications of this surgical procedure, non-union and unacceptable arm position, may be minimised if these biomechanical findings are applied to surgical decision-making

Purpose: Difficult nonunions of the humerus are frequently treated with free vascularized bone, usually the fibula, but donor site morbidity from the lower leg can be significant. The lateral border of the scapula is a 7–12 cm tubular length of vascular bone that can be easily transferred to the humerus. Method: Nineteen established nonunions of the humerus, including mid-shaft (11), proximal (4), distal (3), and a failed shoulder fusion, were treated with a segment of scapula on a vascular pedicle. Patients (13 females, 6 males with average age of 63) had undergone 3 previous surgeries on average in attempts to heal the fracture. The time from injury to procedure averaged 28 months (range, 5–120 months). The surgical team consisted of an orthopedist and a plastic surgeon working simultaneously with the patient in a lateral position. The scapular graft was juxtaposed to the humerus through an axillary tunnel, then rigidly fixed with plate and screws and grafted with a calcium sulfate and bio-assayed demineralized bone matrix product (Allomatrix. ™. , Wright Medical Technology, Arlington TN). Results: All nonunions healed, achieving radiographic evidence of consolidation between 8–24 weeks (average, 13 weeks). One patient with a previously infected non-union had recurrent infection and required further surgery before healing. Another patient fractured through the mid-portion of the healed graft in a fall two years after surgery and was revised to an endoprosthesis. Patient-based Musculoskeletal Tumor Society scores averaged 83% at 41 months (range, 24–66). Conclusion: Pedicled transfer of the lateral border of scapula with circumflex scapular artery is an excellent choice for treating recalcitrant humeral nonunions. There were no complications at the donor site and all nonunions healed. Advantages of this procedure are:. Surgery time

The classification of complex fractures of the proximal humerus has long been an area of dispute reflecting an inability to agree on the anatomy of these injuries based on conventional X-rays alone. We demonstrated here that 3-dimensional CT reconstructions, when viewed in a systematic fashion, can yield superior understanding and an enhanced concurrence among observers as to the nature of these fractures. This has lead to a modification of the Neer classification diagram of proximal humeral fractures to reflect their true 3-dimensional anatomy. A 3-dimensional understanding is crucial in and of itself during any process of surgical reconstruction, but a 3-dimensional classification is additionally useful insofar as it informs other aspects of clinical decision making. For example, in a particular category of injury what if any surgery is indicated? In this regard one must first know the natural history of the specific fracture type without the benefit of operative intervention. Towards an answer to this basic question we have categorized non-operated proximal humeral fracture patients according to the new 3-dimensional classification and have followed their clinical progress. We present here the Natural History in unoperated patients with the types of Complex injuries who historically have been the ones commonly recommended to surgery. Results: Over an 8 year period, 63 Complex Fractures treated non-operatively were evaluated with standardized indices. We conclude that overall motion, function and pain status of Complex Fractures of proximal humerus treated conservatively is similar to that of a successful surgical Shoulder Fusion. Motion is considerably compromised but pain is minimal and functional status is acceptable to most patients. Contrary to common belief avascular necrosis is rare even in severely displaced injuries. Additional new observations concerning Valgus/Varus, Head Split, and rotational injuries will also be presented. Future studies based on this 3-dimensional classification system need to be done to compare these natural history results with various types of surgical interventions

Scapular instability is a disabling deformity that results in pain and influences the overall upper limb function ; for which scapular stabilization may be necessary. Aim: To review the results of this procedure. Methods: 9 patients who underwent this procedure could be contacted and were assessed. We used the Disability of Arm, shoulder and Hand score(DASH) and the constant score for shoulder function including subjective assessment of patients pain and overall satisfaction and radiographs for evidence of unionwith a mean age of 36 yrs(range 21–57 yrs), performed in the period between July 1996 and October 2002 with a mean follow up period of 35.7 months,(range 10–72 months).6 of them were primary procedures and two were revisions for failed primary stabilisation . The main pre-operative complaint of these patients was dragging pain, scapular winging, painful forward flexion and abduction and sense of instability. The underlying pathology was Fascio-scapulo-humeral dystrophy in 3, sprengels shoulder in 2,brachial plexus palsy in 1, following trapezius muscle excision in 1, residual winging following shoulder fusion in 1. The technique used for fusion was plate and wires in 6, Rush pin and wires in 2. All of them had bone grafting . At the last follow up the mean DASH score was 37 and the mean constant score was 74.67. All patients had mild or no pain,felt their scapula stable and were satisfied with the outcome. The main post operative complaint was wire breakage and migration that necessitated removal in 3 patients. We conclude that scapulothoracic fusion is a valuable procedure and can restore reasonable shoulder function and relieve pain in patients with scapular instability