Subacromial bursa fibrosis are linked to rotator cuff lesion with shoulder stiffness; however, the mechanism underlying this shoulder disorder remain elusive. MicroRNA-29s (miR-29s) are emerging fibrosis inhibitor targeting fibrogenic matrices during tissue fibrosis. This study is aimed to investigate clinical relevance and function of miR-29 signalling to subacromial bursa homeostasis in shoulder stiffness. Subacromial bursa in patients with rotator cuff lesion with or without shoulder stiffness who required open acromioplasty were harvested for assessing fibrosis histopathology using Manson's trichrome staining. Expressions of proinflammatory cytokines, fibrotic matrices, and miR-29s were quantified using RT-PCR and in situ hybridization. Range of motion and pain scores of the stiffness group were higher than those of non-stiffness group. Upregulated proinflammatory cytokines (IL-1β, IL-6, and TNF-α) and fibrotic matrices (collagen 1α1, 3α1, and 4α1) but decreased miR-29a and b expression existed in the stiffness group. Affected tissues exhibited severe fibrotic matrix accumulation, synovial hyperangiogenesis, hyperplasia, and strong miR-29a transcripts. In vitro, IL-1β rather than IL-6 and TNF-α decreased miR-29a expression of subacromial bursa fibroblasts. miR-29a knockdown escalated fibrotic matrix expression, whereas forced miR-29a expression alleviated the IL-1β-induced fibrotic matrix expression. Of interest, miR-29a transgenic mice displayed moderate responses to supraspinatus and infraspinatus tenotomy-induce fibrosis and gait irregularity of affected shoulders. Weak miR-29 signalling causes excessive fibrosis and remodelling in subacromial bursa and ultimately increases the prevalence of shoulder stiffness. This study reveals a new mechanistic underlying shoulder stiffness and highlights that sustained miR-29a potentially ameliorates the severity and function of stiff shoulder

Shoulder septic arthritis is uncommon and frequently misdiagnosed, resulting in severe consequences. This study evaluated the demographics, bacteriological profile, antibiotic susceptibility, treatment regimens, and clinical outcomes. This is a 10-year retrospective observational analysis of 30 patients (20 males and 10 females) who were treated for septic arthritis of the shoulder. The data collecting process utilised clinical records, laboratory archives, and x-ray archives. We gathered demographic information, pre- and post-intervention clinical data, serum biochemical markers, and the results of imaging examinations. All patients had a surgical arthrotomy and joint debridement in the operating room, and specimens were taken for culture and sensitivity testing. The specimens were cultivated for at least seventy-two hours. Shoulder joint ranges of motion, comorbidities, and the presence of osteomyelitis were assessed clinically to determine the outcome. All statistical analyses were conducted using the STATA 17 statistical software. Analysis of correlation between categorical variables was performed using the chi-squared test. The majority of the study patients were black Africans (97%). The age range of the group was from 8 days to 17 years. At presentation, 33% of patients had a low-grade fever, whereas the majority (60%) had normal body temperature. The average length of symptoms was 3.9 days (ranged from 1 day to 15 days), and the majority of patients had an increased white cell count (83%) and C-reactive protein (98%). There was accumulation of fluid in the joint of all individuals who received shoulder ultrasound imaging. We noted a significant incidence of gram-positive cocci, which were mostly susceptible to first-line antibiotics. Shoulder stiffness affected 63% of patients and chronic osteomyelitis affected 50% of individuals. Neither the severity nor the duration of the symptoms was related to an increased risk of osteomyelitis. The results of this study revealed that the clinical characteristics and bacterial profile of septic arthritis of the shoulder conform to typical patterns. The likelihood of osteomyelitis and an unfavourable prognosis is considerable

Our objective was to determine the plasma levels of substance P (SP) in patients with postoperative stiffness after arthroscopic rotator cuff repair. Plasma samples were obtained at 15 months from surgery from 2 groups of patients who underwent arthroscopic repair of a rotator cuff tear. In Group 1, 30 subjects (14 men and 16 women, mean age: 64.6 years, range 47 to 78) with shoulder stiffness 15 months after arthroscopic rotator cuff repair were recruited. In Group 2, 30 patients (11 men and 19 women, mean age: 57.8 years, range 45 to 77) were evaluated 15 months after successful arthroscopic rotator cuff repair. Immunoassays were performed with commercially available assay kits to detect the plasma levels of SP. The mean plasma levels of SP in patients with postoperative stiffness were significantly greater than those in the control group (81.06 ± 27.76 versus 23.49 ± 5.64, P < 0.05). The plasma concentrations of substance P in patients with shoulder stiffness after arthroscopic rotator cuff repair are higher compared to plasma levels of SP in patients with a good postoperative outcome. The neuronal upregulation of SP shown in the plasma of patients with post operative shoulder stiffness may underlay not only the symptoms of adhesive capsulitis, but also its development

Total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) are excellent surgical options for individuals with shoulder arthritis, providing good to excellent results in the vast majority of patients. Complications are rare, but can be devastating for both the patient and surgeon. An uncommon, but extremely problematic complication following shoulder arthroplasty is shoulder stiffness. While substantial literature discussing post-arthroplasty stiffness is available for other joints such as the hip, knee, and elbow, there is a paucity of research available discussing this complication in the shoulder. As noted in multiple reviews, diminished range of motion following TSA or RSA may be due to a number of factors, including pre-operative diagnosis of proximal humerus fracture, inadequate post-operative rehabilitation, implant-related factors such as malpositioning and/or inappropriate-sized implants, and heterotopic ossification. Often, pathology leading to post-arthroplasty stiffness involves scarring of the long head of the biceps tendon, rotator cuff impingement, as well as cuff tendonitis. Periprosthetic joint infection (PJI) is also important to recognise, and may be difficult to diagnose, especially in cases of Propionibacterium acnes infections. Importantly, PJI may present with stiffness as well as instability, and thus a high index of suspicion with a low threshold to aspirate is necessary in these challenging patients. Treatment of patients with stiffness following arthroplasty is challenging, and may involve arthroscopic intervention with or without manipulation, as well as manipulation under anesthesia alone. This paper will discuss the etiology, work-up, and treatment of patients with shoulder stiffness following TSA and RSA

Surgeries for reverse total shoulder arthroplasty (RTSA) significantly increased in the last ten years. Initially developed to treat patients with cuff tear arthropathy (CTA) and pseudoparalysis, wider indications for RTSA were described, especially complex proximal humerus fractures. We previously demonstrated in patients with CTA a different sequence of muscular activation than in normal shoulder, with a decrease in deltoid activation, a significant increase of upper trapezius activation and slight utility of the latissimus dorsi. There is no biomechanical study describing the muscular activity in patients with RTSA for fractures. The aim of this work is to describe the in vivo action of RTSA in patients with complex fractures of the proximal humerus. We conducted an observational prospective cohort study comparing 9 patients with RTSA for complex humerus fracture (surgery more than 6 months, healed tuberosities and rehabilitation process achieved) and 10 controls with normal shoulder function. Assessment consisted in a synchronized analysis of range of motion (ROM) and muscular activity on electromyography (EMG) with the use of 7 bipolar cutaneous electrodes, 38 reflective markers and 8 motion-recording cameras. Electromyographic results were standardized and presented in muscular activity (RMS) adjusted with maximal isometric contractions according to the direction tested. Five basic movements were evaluated (flexion, abduction, neutral external rotation, external rotation in 90° of abduction and internal rotation in 90° of abduction). Student t-test were used for comparative descriptive analysis (p < 0,05). The overall range of motion with RTSA is very good, but lower than the control group: flexion 155.6 ± 10 vs 172.2 ± 13.9, p<0.05, external rotation at 90° 55.6 ± 25 vs 85.6 ± 8.8, p<0,05, internal rotation at 90° 37.8 ± 15.6 vs 52.2 ± 12, p<0,05. The three heads of the deltoid are more stressed during flexion and abduction in the RTSA group (p. The increased use of the 3 deltoid chiefs does not support the hypothesis proposed by Grammont when the RTSA is performed for a complex proximal humerus fracture. This can be explained by the reduced dispalcement of the rotation center of the shoulder in these patients compared to those with CTA. These patients also didn't present shoulder stiffness before the fracture. The maximal muscle activity of the trapezius in flexion and of the latissimus dorsi in flexion and abduction had not been described to date. These new findings will help develop better targeted rehabilitation programs. In addition, the significant role of the latissimus dorsi must question the risks of its transfer (L'Episcopo procedure) to compensate for external rotation deficits

Postoperative stiffness (POS) of the shoulder may occur after an apparently successful reconstruction of a rotator cuff tear. The role of the peripheral nervous system in tissue healing has only recently been recognized. We determined the plasma levels of SP in patients with postoperative stiffness after arthroscopic repair of a rotator cuff tear, and compared them with those in patients with a good outcome after arthroscopic rotator cuff repair. Plasma samples were obtained at 15 months from surgery from 2 groups of patients who underwent arthroscopic repair of a rotator cuff tear. In Group 1, 30 subjects (14 men and 16 women, mean age: 64.6 years, range 47 to 78) with shoulder stiffness 15 months after arthroscopic rotator cuff repair were recruited. In Group 2, 30 patients (11 men and 19 women, mean age: 57.8 years, range 45 to 77) were evaluated 15 months after successful arthroscopic rotator cuff repair. Immunoassays were performed with commercially available assay kits to detect the plasma levels of SP. Statistical analysis were performed with Wilcoxon Sign Rank test. Significance was set at P< 0.05. The concentrations of the neuropeptide SP in sera were measurable in all patients. Patients with postoperative stiffness had statistically significant greater plasma levels of SP than patients in whom arthroscopic repair of rotator cuff tears had resulted in a good outcome (P < 0.05). Postoperative stiffness (POS) of the shoulder may occur after an apparently successful reconstruction of a rotator cuff tear. An increased amount of SP in the subacromial bursa has been correlated with the pain caused by rotator cuff disease. SP stimulates DNA synthesis in fibroblasts, which are the cellular components of the adhesive capsulitis of the shoulder. Also, SP is a pain transmitter peptide, and pain may cause a secondary muscular and/or capsular contracture. Our results show that the plasma concentrations of substance P in patients with shoulder stiffness after arthroscopic rotator cuff repair are higher compared to plasma levels of SP in patients with a good postoperative outcome. We cannot determine the cause of POS in our patients, but the findings of this study suggest a possible neuronal role in the pathophysiology of POS after arthroscopic repair of rotator cuff tears. The knowledge of the pathophysiological role of sensory nerve peptides in tissue repair in these patients could open new therapeutic options to manage conditions of the musculo-skeletal system with impaired tissue-nervous system interaction

Aims

Fractures of the humeral shaft represent 3% to 5% of all fractures. The most common treatment for isolated humeral diaphysis fractures in the UK is non-operative using functional bracing, which carries a low risk of complications, but is associated with a longer healing time and a greater risk of nonunion than surgery. There is an increasing trend to surgical treatment, which may lead to quicker functional recovery and lower rates of fracture nonunion than functional bracing. However, surgery carries inherent risk, including infection, bleeding, and nerve damage. The aim of this trial is to evaluate the clinical and cost-effectiveness of functional bracing compared to surgical fixation for the treatment of humeral shaft fractures.

Aims

Mechanical stimulation is a key factor in the development and healing of tendon-bone insertion. Treadmill training is an important rehabilitation treatment. This study aims to investigate the benefits of treadmill training initiated on postoperative day 7 for tendon-bone insertion healing.

Purpose: The objective of this study was to analyze the clinical results of arthroscopic release for the treatment of shoulder stiffness and to report the results according to etiology. Method: Thirty cases were reviewed in 29 patients with a mean age of 48 years [range, 25–75]. The mean time from diagnosis to surgery was 37.5 months [range, 6–120]. The stiffness was considered idiopathic (i.e. frozen shoulder) (10 cases), post-traumatic (eight cases) or post-surgical (12 cases). The release consisted of 14 rotator interval resections, four anterior capsulotomies, 20 anterior and inferior capsulotomies, three tenotomies of the superior portion of the subscapularis, and 11 biceps tenotomies or tenodeses. In 26 cases, associated extra-articular procedures were also performed, including 22 subacromial bursectomies and four acromioplasties. Patients were reviewed at a mean follow-up of 44 months [range, 12–99]. Results: Eighty-nine percent were satisfied or very satisfied. The mean Subjective Shoulder Value was 76%. The mean Constant score increased from 40 ± 13 points preoperatively to 74 ± 16 points postoperatively (p< 0.05). Conclusion: Arthroscopic shoulder release is effective for pain relief and improved function. The recovery of motion is better in idiopathic stiffness (i.e. frozen shoulder) than in post-traumatic and post-surgical stiffness. Resection of the rotator interval seems effective to restore external rotation and elevation

Introduction. Rotator cuff healing after an arthroscopic repair is discussible because of the high incidence of failures. Among biologic augmentations currently used, platelet-rich plasma (PRP) is one of the most applied, supposed to enhance and accelerate the healing process in different musculoskeletal disorders. However, the evidence supporting its successful administration is still lacking, especially in the field of the rotator cuff repair. Our purpose is to clarify if the recovery is accelerated and the integrity of repaired construct is increased in patients undergoing PRP injections after arthroscopic repair of the rotator cuff. Patients & Methods. Thirty-eight patients with full-thickness rotator cuff tears have been enrolled after they had been informed about the use of PRP and the timing of its application postoperatively. Seventeen patients underwent arthroscopic rotator cuff repair and PRP injections (3 injections at 10 days each other), 21 underwent arthroscopic rotator cuff repair without PRP injections. Outcomes were assessed preoperatively, at 3, 6, 12, and minimum 16 months after surgery (average 17.7 +/− 1.7 months). Constant system, the University of California at Los Angeles (UCLA) system and a Visual Analogue Scale (VAS) scale were used; range of motion and strength in all planes were also assessed. The healing of the repair was assessed at magnetic resonance imaging at a minimum follow up of 6 months from surgery. All patients had the same rehabilitation protocol. Results. Platelet-rich plasma gel application after to arthroscopic rotator cuff tear repairs did not accelerate recovery with respect to pain, range of motion, strength, functional scores, or overall satisfaction as compared with conventional repair at any time point. There was no difference between the 2 groups after 3, 6, 12, months and at final follow up. The follow-up MRI showed no significant difference in the healing rate of the rotator cuff tear. In addition, magnetic resonance imaging, at a minimum of 6 months after surgery, demonstrated a retear rate of 23.5 % in the PRP group and 19% in the conventional group, there was no statistical significance between the groups (P = .658). Discussion/Conclusion. Although PRP application after arthroscopic repair of the rotator cuff has no effects on clinical recovery and structural integrity, it reduces the postoperative occurrence of shoulder stiffness. Further studies should support these findings

Midshaft clavicle fractures can be classified into simple or complex/comminuted. The hardest fracture to treat is the severely comminuted and displaced fracture. We retrospectively compared 286 consecutive operatively treated simple (2 and 3 part) fractures with the more complex comminuted (>=4 part) midshaft clavicle fractures, looking at outcome, complication rate and union rate. Between 2008 and 2010 the senior author operated on 286 displaced midshaft clavicle fractures using a plate and screws. In this cohort there were 173 simple (2 and 3 part) fractures and 99 complex (>=4 part) fractures. The operation was performed through a limited incision technique and was standardized. All fractures were fixed with at least 3 screws on either side of the comminution. All patients were up until radiological and clinical union. A standardized questionnaire was used to assess patient satisfaction, return to work, sport and outcome at each postoperative visit. All complications were documented. All fractures eventually went onto union. There were 242 males and 44 females with the average age being 33. The complex fractures had a larger scar, took longer to return to normal motion, work and sport, and took on average 10 weeks to unite compared to 6 weeks in the simple fractures. The infection rate in the simple fractures was 1% and in the complex fractures was 2%. The big difference was the incidence of non union in the complex fractures of 10% compared to 1%; the other main difference was postoperative shoulder stiffness of 3% at 3 months in the complex fractures compared to 1 % in the simple fractures. Plate elevation/irritation was also more prevalent in the complex fractures of 10% compared to 3%. This study clearly shows there is a higher complication rate in complex fractures. Particular attention must be placed on surgical technique and anatomical reduction of these difficult fractures followed closely by postoperative rehabilitation. Future studies of clavicle fractures should specify the type of fracture being treated to give a better understanding of the potential outcome

Introduction: Treatment of proximal humeral fractures is still controversial. Conservative treatment may result in malunion and shoulder stiffness. We present our experience with displaced or comminuted fractures of the proximal humerus treated by closed or open “minimal invasive osteosynthesis” or by open reduction and using of fixed plates or by hemiarthroplasty. Patients and Methods: This study consists of 189 Pts. (18–89 year old, mean 58.5Y) followed for 2–10 years (mean 5.5Y), treated by closed reduction and percutaneous pinning (79), ORIF and minimal osteosynthesis (27), ORIF with rigid plates (17), ORIF by LCP plates (10), ORIF by proximal humeral nail (5) or by hemiarthroplasty (51). Patients were evaluated by the UCLH and by Constant’s shoulder grading score systems and radiographs. Results: Overall results were excellent and good in 85% of patients with 2 and 3 parts fractures of the proximal humerus treated by “minimal osteosynthesis” techniques, with some better results in less comminuted fractures. 26/32 Pts with 4 part fractures treated surgically had good functional results. The other 8 had poor results and 4 of them developed AVN of the humeral head. 75% of the patients treated by hemiarthroplasty had satisfactory results. They were almost free of pain, but had only a moderate improvement in shoulder motion (active abduction or flexion of 30–90 degrees in 38/51). Conclusions: “Minimal osteosynthesis” by K.W. techniques, lag screws, rush pins or proximal humeral nail, by closed or open reduction, remains as the first optional treatment of complex fractures of the shoulder, even in young patients with a 4 part fracture. ORIF by conventional plates may be used in young patients and by LCP (locked compression plates) in osteoporotic or comminuted fractures of older patients. In the elderly, hemiarthroplasty seems to be the treatment of choice

We evaluated the results of Cementless Surface Replacement Arthroplasty (CSRA) of the shoulder in 67 patients with advanced glenohumeral destruction who have an intact rotator cuff. Between november 2002 and december 2008, 70 CSRA (32 Copeland/ Biomet and 38 SMRR/ Lima) were implanted in 67 patients. A deltopectoral approach was used in 34 cases and an anterosuperior approach in 36 cases. Patients were assessed using Constant score, a patient satisfaction score and a detailed radiographic analysis. The mean follow up was 3.4 years (range 1 to 7.5 years). The mean Constant score improved preoperatively from 17.6 points (range 2–55) to an average postoperative score of 66.1 (range 13–91). The pain score improved from 1.13 points (range 0–6) to 12.3 points (range 3–15). The forward flexion and external rotation improved from 71° (range 20 to 140) and 0° (range −40 to +45) to 143° (range 60 to180) and 34.4° (range −20 to +60) respectively. Complications included: 1 subscapularis detachment, 5 secondary rotator cuff tear, 1sepsis, 3 patients with shoulder stiffness. No shift in implant position was observed. 11 humeral components developed radiolucencies at the prosthesis-bone interface. The radiographic analysis involved a system of dividing the prosthesis/bone interface into 5 zones. The best clinical results were significantly achieved in patients with necrosis compared with osteoarthritis (Constant Score, ant. elevation, ext. Rotation). Using regression analysis we found that changes in the head-shaft angle position of the implant (valgus/varus placement of the CSRA) significantly predicted the age and sex adjusted Constant score. When the inclination angle of the humeral head decreases, the adjusted Constant score increases. In the same model, we also found that the lateral offset of the humerus significantly predicted the adjusted Constant score. When the lateral offset of the humerus decreases, the adjusted Constant score increases. The medialization of the glenoid significantly and negatively predicted the Constant score. Conclusion. CSRA of the shoulder outcomes have been comparable with those of stemmed arthroplasties. Radiolucent lines occur with follow up and most of the time located in the S1 area. Glenoid wear and humeral head lateralization negatively impact the clinical score. Cementless Shoulder resurfacing is a viable alternative to conventional shoulder arthroplasty

Introduction: Management of displaced comminuted fractures of the proximal humerus in the elderly is still controversial. Conservative treatment may result in severe disability due to malunion and shoulder stiffness. Rigid fixation of these fractures by plates may offer stability in anatomic position, but requires in most cases extensive soft tissue exposure and may result in a relatively high incidence of avascular necrosis of the humeral head. Therefore, many authors are today of the opinion that hemiarthroplasty of the shoulder joint in such fractures is preferable to rigid fixation. This study reviews our experience with hemiartroplasty of the shouldere in elderly patients with comminuted fractures of the proximal humerus. Material & Methods: This study consists of 39 Pts. (27F, 12M; 72–89 year old, mean 76.5Y; 12 with 3 parts fractures and 27 with 4 parts fracture) treated by hemiarthroplasty of the proximal humerus. Patients were followed for 2–8 years (mean 4Y), and evaluated by the Neer‘s shoulder grading score and radiographs. Results: 74% of the patients treated by hemiarthroplasty had satisfactory results. They were almost free of pain, but most of them had only a moderate improvement in shoulder motion (active abduction or flexion of 110–130 degrees were observed in 4/39, of 90–110 degrees in 7/39, of 50–90 degrees in 17/39 and of 30–50 degrees in 11/29). Conclusions: Based on this study it seems that pain relief by hemiarthroplasty may be achieved in most older patients with comminuted fractures of the proximal humerus, but the gain in shoulder function is relatively limited

Between 1972 and 2002 74 patients were treated under the combined care of the orthopaedic oncology service and lymphoma clinic with primary bone lymphoma. We reviewed the seventeen cases affecting the upper limb (23%). Of the seventeen patients nine remain alive. Assessment of the patient’s clinical presentation, histopathological definition, treatment and function outcome was made. The nine survivors were assessed clinically and with the Oxford shoulder score and the Toronto extremity salvage score. Average time from first presentation to diagnosis was 7 months. All seventeen were diagnosed as a B –cell non-Hodgkin’s lymphoma, fifteen cases were high grade and two cases were low grade. The scapula was involved in six, humerus eight and clavicle three cases. Seven patients sustained pathological fractures three of which were at presentation; of these two were treated surgically. Eight patients have subsequently died of their disease. Functional outcome in surviving patients after medical treatment was very good with average TESS score of 79% (52%–99%) and OSS of 27 (12–52). The presentation of lymphoma of the shoulder girdle may mimic benign shoulder conditions and lead to a delay in radiological and histopathological diagnosis. Pathological fracture is a common presentation and complication of treatment, however these fractures have a high chance of healing with medical treatment alone. Although shoulder stiffness remains a problem following medical treatment, overall upper limb function is good. There is little evidence that these patients require surgery in the short to medium term

Introduction: The treatment of fractures of the proximal humerus is still controversial. Conservative treatment may result in severe disability due to malunion and shoulder stiffness. Open reduction and rigid fixation requires extensive soft tissue exposure, which may results in a high incidence of avascular necrosis of the proximal humerus. We present our experience with “minimal invasive” surgical techniques of such fractures. Materials & Methods: This study consists of 128 Pts. (52 M, 76 F, 18–84 year old, mean 53.5Y) followed for 2–7 years (mean 3.5Y), treated by closed reduction and percutaneous pinning (55), by ORIF and minimal osteosynthesis by screws (27), by ORIF with rigid plates (7), and by hemiarthroplasty of the proximal humerus (39). Patients were evaluated by the Neer’s shoulder grading score and radiographs. Results: Overall results were excellent and good in 85% of patients with 2, and 3 parts fractures of the proximal humerus treated by “minimal invasive” fixation techniques, with some better results in less comminuted fractures. 9/14 young patients with 4 part fractures had good functional results. The other 5 patients had poor results and 3 of them developed AVN of the humeral head. 75% of the patients treated by hemiarthroplasty had satisfactory results. They were almost free of pain, but most of them had only a moderate improvement in shoulder motion. Discussion: Based on this study it seems that “minimal osteosynthesis” by K.W. techniques, lag screws or rush pins, by closed or open reduction, remains as the first optional treatment of complex fractures of the shoulder, even in young patients with a 4 part fracture. In the elderly, hemiarthroplasty should be considered in such pathology as the treatment of choice

Purpose: The purpose of this study was to analyse the factors affecting outcome after prosthesis implantation for osteonecrosis of the humerus in order to ascertain details concerning the indications for humerus or total prostheses in this condition. Material and methods: Forty-seven women and 27 men, mean age 57 years with osteonecrosis of the humerus underwent surgery for implantation of 80 shoulder prostheses. According to the Arlet and Ficat classification as modified by Cruess there were five grade II, fifteen grade III, 41 grade IV and fourteen grade V shoulders, with five unclassifiable shoulders. there were 14 supraspinatus tears and five infraspinatus tears. The 26 total shoulder prostheses and 54 humeral prostheses were reviewed at a mean 47 months follow-up. Pre-operative x-rays were available for 65 shoulders and postoperative x-rays for 58. Results: The subjective outcome was considered good irrespective of the grade (very satisfied 60%, satisfied 30%, dissatisfied 4%). The mean postoperative Constant score was 70 ± 15. The preoperative score was lower for more advanced disease but the difference was not significant at postoperative assessment. The total prosthesis provided better results in grade V shoulders and the hemiprosthesis in grade II and III shoulders. The result of the humeral prostheses depended on the grade of necrosis. The postoperative Constant score was lower for advanced necrosis with lower scores for motion, force and pain (which was not influenced by age). At last follow-up, 31% of the x-rays revealed a significant narrowing of the glenoid-head space. The clinical outcome was significantly less satisfactory for all Constant scores. Rotator cuff tears, preoperative stiffness favoured glenoid wear. Tears of both cuff tendons led to poor outcome. Bone collapse with impaction of the head into the glenoid and medialisation of the humerus was a significant factor predictive of less satisfactory outcome. Discussion: The grade of necrosis is a determining factor for indications for humerus or total shoulder arthroplasty for the treatment of osteonecrosis. Our objective results lead us to recommend a humeral prosthesis for grade II and III patients and a total shoulder arthroplasty for grade V patients. For grade IV patients, the choice depends on patient age, shoulder stiffness, the status of the cuff, and most importantly, collapsus of the head of the humerus with impaction-medialisation of the humerus

Introduction: The treatment of fractures of the proximal humerus is still controversial. Conservative treatment may result in severe disability due to malunion and shoulder stiffness. Open reduction and rigid fixation requires extensive soft tissue exposure, which may result in a high incidence of avascular necrosis of the proximal humerus. Today, many authors are in the opinion that “minimal osteosynthesis” of such fractures is preferable to rigid fixation. It may be achieved by K.W. techniques, lag screws, rush pins, percutaneous pinning or percutaneous external fixation. This study reviews our experience with comminuted fractures of the proximal humerus treated by different minimal invasive techniques of fixation, using functional evaluation and radiological assessment. Materials and methods: This study consists of 76 patients with comminuted fractures of the proximal humerus (33 M, 44 F, 18–89 year old, mean 52/5Y) with follow-up of 2–6 years (mean 3.5Y). They were treated by minimal invasive surgical techniques: 53 of them by closed reduction and percutaneous pinning and the remaining 23 by ORIF and minimal osteosynthesis. All patients were evaluated by Neer’s shoulder grading score and radiographs. Results: Overall results were excellent and good in 85% of patients with 2, and 3 parts fractures of the proximal humerus, treated either by closed or open minimal osteosynthesis techniques, with some better results in less comminuted fractures. 9/13 (69%) of young patients with 4 part fractures treated by closed percutaneous minimal fixation had good functional results. In four other patients the clinical results were poor and two of them developed AVN of the humeral head. 5/8 (62.5%) of young patients with 4 part fractures treated by ORIF and minimal fixation had good functional results. In three other patients the clinical results were poor and one of them developed AVN of the humeral head. Conclusions: Based on this study it seems that “minimal osteosynthesis” by K.W. techniques and by lag screws, by closed or open reduction, remains as the first optional treatment of complex fractures of the shoulder, even in young patients with a 4 part fracture

Rotator cuff pathology is common in orthopaedic patients. However, there are still debates about the best way of treating those patients. We present the clinical experience from our Unit. We present 85 patients who had arthroscopic or arthroscopically assisted shoulder surgery for full thickness rotator cuff tears between 1994 and 2001. Their medical records and radiological investigations were reviewed, and the management as well as the outcome of their treatment were recorded. The aim was to review those patients and determine if optimum assessment and management was implemented to them. There were 47 male and 38 female patients with average age 58.8 years and weight 79.9 kg, 32 of the patients reported trauma prior to their symptoms. 63 patients had MRI scan and they had average 2.6 years of symptoms and 2.4 steroid injections before their operative management. 27 patients had arthroscopic and 58 mini open rotator cuff repair. From those with recorded pain management 32 patients had interscalene block and 21 infiltration with local anaesthetic. Their average hospital stay was 1.4 and 1.8 days for the arthroscopic and mini open repairs respectively. In 69 (77.7%) patients the result was considered overall satisfactory; 8 (9.4%) patients had temporary shoulder stiffness and/or pain, which were treated conservatively with steroid injections and physiotherapy. 11 (12.9%) of the patients required reoperation, 5 from which required cuff resuturing and 4 manipulations under anaesthetic for postoperative stiffness. 3 patients (3.5%) had other than shoulder complications including CVA, chest infection, and CTS. Rotator cuff surgery remains a challenge where often the working surgical plan is altered intraoperatively and tissue quality is of major importance for the final outcome. Arthroscopy has reduced patient’s hospital stay and rehabilitation time. However, a not durable repair, or postoperative stiffness can be a potential risk complicating the surgical result. In this study it is demonstrated that treatment of patients with rotator cuff disease is still a challenge, time in hospital is reduced with arthroscopic management, but the overall risk for reoperation/MUA either for not durable previous repair or postoperative stiffness was still quite high (12.9%)

Shoulder movements from neutral into flexion, extension, abduction, adduction and external rotation are easily measured with a goniometer. In the neutral position, the glenohumeral ligaments, which act as the reins of the joint, limit movement and are symmetrically relaxed. The torso obstructs internal rotation with the arm adducted at the side and the full range of movement cannot be attained. The torso is cleared when the shoulder is abducted, usually to 90°. However, this degree of abduction places the shoulder within the painful arc of impingement and may influence the degree of internal rotation. Further, owing to shoulder joint stiffness, some patients may not be able to abduct the shoulder to 90°. Because of these problems, it has become internationally accepted to measure internal rotation in the near-neutral position by determining the vertebral level behind the back to which the thumb can reach. We assessed 200 symptomatic and asymptomatic shoulders to determine the correlation between the ‘hand behind back’ and angular measurements of internal rotation at 90° or 30° of abduction