Pain is a common presenting symptom of patients with shoulder conditions, yet there has been little work done to accurately describe its distribution and nature.

We studied all patients attending the Royal Devon and Exeter Hospital shoulder clinic from August 2012 – 2013. Patients completed a questionnaire detailing their Oxford Shoulder Score and a validated neuropathic pain questionnaire. Patients were given diagrams to draw on their perceived location of pain or abnormal sensation.

We analysed all patients with frozen shoulder (48), osteoarthritis (37) and rotator cuff arthropathy (17).

We found that neuropathic pain is common in patients with shoulder conditions identified in 39% of OA patients, 42% with rotator cuff arthropathy and 57% with frozen shoulder. Pain outside the shoulder was reported in over 50% of patients, commonly the forearm, hand, neck and chest. Frozen shoulder was especially associated with pain outside of the shoulder with 39% describing symptoms in the neck or chest, 21% into the forearm and 18% into the hand. Interestingly, neuropathic pain radiating down the arm was not described in the rotator cuff arthropathy group.

The high prevalence of neuropathic symptoms and pain felt outside the shoulder aids diagnosis and more accurately identifies these conditions.

The Delto-pectoral approach is the workhorse of the shoulder surgeon, but surprisingly the common variants of the cephalic vein and deltoid artery have not been documented. The vascular anatomy encountered during one hundred primary elective delto-pectoral approaches was documented and common variants described.

Two common variants are described. A type I (71%), whereby the deltoid artery crosses the interval and inserts directly in to the deltoid musculature. In this variant the surgeon is unlikely to encounter any vessels crossing the interval apart from the deltoid artery itself. In a type II pattern (21%) the deltoid artery runs parallel to the cephalic vein on the deltoid surface and is highly likely to give off medial branches (95%) that cross the interval, as well as medial tributaries to the cephalic vein (38%).

Knowledge of the two common variants will aid the surgeon when dissecting the delto-pectoral approach and highlights that these vessels crossing the interval are likely to be arterial, rather than venous. This study allows the surgeon to recognize these variations and reproduce bloodless, safe and efficient surgery.

Background: Our Trust consists of two separate hospitals with duplicated Orthopaedic services at both sites. Sterile Services were centralised to one site in February 2006. Various problems were encountered leading to cancelled cases. What have been the financial implications of these cancellations?

It is difficult to estimate the true cost to the Trust for a cancelled case. Each cancelled case is a ‘slot’ on an operating list that has not been filled. There are regular Waiting List Initiative (WLI) Lists – the number of these have increased. Could an empty slot on a regular list have been filled by a WLI case? Would the cost of the WLI case theoretically performed in the empty slot be the cost of the cancelled case? The model is basic and has many assumptions. Patients are allocated a slot on a WLI list for a variety of reasons, however with enough numbers and across enough time, the true cost must be somewhere near these figures.

Method: Every cancelled case coded as “Surgical Equipment: checking/malfunction/unavailable” between April 2006 and Mar 2008 (2 financial years).

The total number of WLI cases in the same period and the total cost of those cases.

Results: There were 239 cancelled cases for Sterile Services reasons across Trust April 2006 – March 2008. During the same period, there were 1,566 Waiting List Initiative

Cases Cost: £3,234,000 (£2,065 per case)

Conclusions: If all of the cancelled slots had been filled by WLI cases this would have avoided a total cost to the Trust of £493,535

We present a retrospective analysis of 50 cases of cuff tear arthropathy, treated over past seven year period by use of reverse geometry shoulder prosthesis. 98% follow-up was achieved with average follow up of 3 years. Mean (SD) age was 81.3 (9.2) years and female to male ratio was 5:1. Six patients had bilateral reverse geometry shoulder replacements. Patients were assessed with preoperative Oxford and American Shoulder and Elbow Scores Society score (pre-op ASES) and post-operative American Shoulder and Elbow Society Score (post-op ASES), Oxford, Constant and SF36 scores. Mean pre-op ASES was 22.29 (95%CI: 9.1 – 37.9) and post-op ASES score was 65.2 (95%CI: 48.5 – 81.9), (P< 0.001, Paired t-test). Mean post operative Oxford score was 27.25 (95% CI: 18.4 – 27.6). Mean post operative Constant score was 63.2 (95% CI: 52.6 – 79.6). X-ray review was performed to assess scapular notching and Sirveaux score was used to grade extent of notching. 11 patients had Sirveaux grade 0, 5 had grade 1, 6 had grade 2, 12 had grade 3 and 8 had grade 4 notching. Intra-operative complications included 2 glenoid fractures. Post-operative complications included 2 acromion fractures and 2 episodes of subsidence with dislocation. None of the patients developed post operative haematoma. There was one episode of infection in one patient that required further surgery. Iteration of approach with increasing experience over the years will be discussed. Ours is the biggest series of reverse geometry prosthesis used for irreparable rotator cuff tear arthropathy published so far in the literature and our results have shown superior results in terms of improvement in function and complications. We conclude reverse geometry shoulder replacement provides reasonable improvement in pain and function in elderly population with massive cuff tear arthropathy of shoulder.

We present a retrospective review of 50 cases of cuff tear arthropathy treated over past seven years by the use of reverse geometry shoulder prosthesis. 98% follow-up was achieved with average follow up of 3.04 years. Mean age was 81.3 (SD 9.2) years, female to male ratio was 5:1 and seven patients had bilateral procedures. Pre-operatively patients were assessed with American Shoulder and Elbow Surgeons Scores (ASES) and Oxford Scores and pos-operatively with ASES, Oxford and Constant scores. SF36 score was used to assess functional health status. Mean pre-op ASES was 22.29 (95%CI: 9.1 – 37.9) and post-op ASES score was 65.2 (95%CI: 48.5 – 81.9), (P< 0.001, Paired t-test). Mean post-operative Oxford score was 27.25 (95% CI: 18.4 – 27.6) and mean post operative Constant score was 63.2 (95% CI: 52.6 – 79.6). Sirveaux score was used to grade extent of glenoid notching on AP and lateral glenohumeral views, that showed 69% had notched. Complications included two acromion fractures, two episodes of subsidence with dislocation, one episode of infection and one patient with unexplained pain in axilla. We found reverse geometry shoulder replacement provides reasonable improvement in pain and function in elderly patients with massive cuff tear arthropathy.

We present a retrospective analysis of 50 cases of cuff tear arthropathy, treated over a seven year period by use of reverse geometry shoulder prosthesis. 98% follow-up was achieved with average follow up of 3 years. Mean (SD) age was 81.3 (9.2) years and female to male ratio was 5:1. Six patients had bilateral reverse geometry shoulder replacements. Patients were assessed with pre-operative American Shoulder and Elbow Score (pre-op ASES) and post-operative American Shoulder and Elbow Scores (post-op ASES), Oxford, Constant and SF36 scores. Mean pre-op ASES was 22.29 (95%CI: 9.1 – 37.9) and post-op ASES score was 65.2 (95%CI: 48.5 – 81.9), (P< 0.001, Paired t-test). Mean post operative Oxford score was 27.25 (95% CI: 18.4 – 27.6). Mean post operative Constant score was 63.2 (95% CI: 52.6 – 79.6). X-ray review was performed to assess scapular notching and Sirveaux score was used to grade extent of notching. 11 patients had Sirveaux grade 0, 5 had grade 1, 6 had grade 2, 12 had grade 3 and 8 had grade 4 notching. Intra-operative complications included 2 glenoid fractures. Post-operative complications included 2 acromion fractures and 2 episodes of subsidence with dislocation. None of the patients developed post operative haematoma. There was one episode of infection in one patient that required further surgery. Iteration of approach with increasing experience over the years will be discussed. Ours is the biggest series of reverse geometry prosthesis used for irreparable rotator cuff tear arthropathy published so far in the literature and our results have shown superior results in terms of improvement in function and complications. We recommend reverse geometry shoulder replacement is the way forward to treat irreparable cuff tear arthropathy of shoulder.

The aim of this study was to determine the biomechanical behavior of two different implants used in the fixation of proximal humerus fractures. The two implants in this study are specifically designed for the fixation of proximal humerus fractures and both utilize the concept of fixed angle locking screws. Bone densitometry was performed prior to fracture production and fixation. A reproducible three-part fracture was created in paired human cadaveric bone and then fixed using the locking screw implants. Stress/strain curves for the bone-implant construct were created for loads applied in cantilever bending and torsion to determine the relative stiffness below the yield point. Following this each construct was tested to failure with a valgus bending load.

The locking nail implant provided a significantly stiffer construct in torsion, valgus, extension and flexion at loads below failure threshold. The valgus load to failure was significantly higher for the nail. The mode of failure was different between implants.