Introduction: Treatment strategies for management of proximal humeral fractures are assisted by an understanding of the fracture morphology, and in particular the viability of the humeral head. Although widely accepted, the AO and Neer classification systems show poor interobserver reproducibility, and generally do not provide a basis to guide treatment regimens. Hertel described a comprehensive binary (Lego) classification system, which defines fracture plane and parts, as well as incorporating calcar length, attachment and angulation that is vital in predicting humeral head ischemia. The sequential numerical form of the classification makes it complex, and prone to categorisation error. Sandow has extended this to a more descriptive system by naming proximal humeral parts (H-head, G-Greater Tuberosity, L-lesser Tuberosity, S-shaft), recording the fracture plane, and optionally incorporating calcar length and head angulation or displacement.: The aim of this study was to compare the inter- and intraobserver reliability of this new classification system with the AO and Neer Classification, and its usefulness as a guide to management.

Patients and Methods: 49 proximal humeral fractures in 49 consecutive patients treated at the department of orthopaedics and trauma, Royal Adelaide Hospital were identified in the period of July 2007 till January 2008. All fractures of the proximal humerus were examined using AP, lateral and axial radiographs. Three independent reviewers, looking specifically at interobserver correlation and the indication of humeral head viability, classified the fractures using the AO, Neer and “HGLS Classification”.

Results: The median age of patients was 72 (range 50 to 85). Based on the interobserver correlation analysis, the AO (κ-value 0.47) and Neer κ-value (0.44) classification systems were graded as poor and were consistent with values published in articles in the past. The HGLS Classification” showed good interobserver agreement for all three examiners (κ-value 0.73). Similar κ-values were also seen for intraobserver agreement.

Conclusion: While the parts system of Neer and AO-system can still provide a general impression of the fracture form, the “HGLS classification” for proximal humeral fractures provided a more precise description of the fracture pattern which has important prognostic and therapeutic implications. It is quick to apply and easy to use as it does not require the memorising of a numerical classification. Our study showed a good reliability for the classification system, however further studies seem necessary to assess validity of the HGLS-system.

Treatment strategies for the management of proximal humeral fractures are assisted by an understanding of the fracture morphology and, in particular, the viability of the humeral head. Although widely accepted, the AO and Neer classification systems show poor interobserver reproducibility and generally do not provide a basis to guide treatment. The aim of this study was to compare the interobserver and intraobserver reliability of a new classification system with the AO and Neer classifications and review its usefulness as a guide to management.

Hertel described a comprehensive binary (Lego) classification system, which defines fracture planes and parts, as well as incorporating calcar length, attachment and angulation. This facilitates predicting humeral head ischemia; however the sequential numerical form of the classification makes it complex and prone to categorisation error. Sandow has extended this to a more descriptive system by naming proximal humeral parts (H-head, G-greater tuberosity, L-lesser tuberosity, S-shaft), recording the fracture plane and optionally incorporating calcar length and head angulation or displacement.

50 proximal humeral fractures in 50 patients treated at the Department of Orthopaedics and Trauma, Royal Adelaide Hospital, were identified from the period of July 2007 to January 2008. All fractures of the proximal humerus were examined using AP, lateral and axial radiographs. Three independent reviewers classified the fractures using the AO, Neer and “HGLS Classification”. The findings were analysed specifically for intra/interobserver correlation and the indications for humeral head viability.

The median age of patients was 72 (range 50 to 85). Based on the interobserver correlation analysis, the AO and Neer Classification systems were graded as poor. The ‘HGLS’ Classification showed good interobserver agreement for all three examiners and more consistently provided guidelines for management based on humeral head viability.

While the parts system of Neer can still provide a general impression of the fracture form, the “HGLS classification” for proximal humeral fractures provided a more precise description of the fracture pattern which has important prognostic and therapeutic implications. It is quick to apply and easy to use as it does not require memorisation of a numerical classification and can help to understand fracture patterns and thus aid planning of a reduction and fixation strategy. Good interobserver correlation makes it a useful tool for communication between surgeons.

INTRODUCTION: In irreparable rotator cuff tear associated with pseudoparalysis, inverse prostheses have shown to be able to restore overhead elevation and strength. If the rotator cuff disease involves the teres minor muscle, pseudoparalysis in external rotation can adversely affect function and functional outcome of inverse arthroplasty. The goal of our study was to evaluate the outcome of inverse total shoulder arthroplasty combined with latissimus dorsi transfer for combined pseudoparalysis in elevation and external rotation.

MATERIAL AND METHODS: From 1998 till 2005, we retrospectively analyzed 11 shoulders in 10 patients with at a mean follow up of 20 months. All 11 shoulders had a massive rotator cuff tear with fatty degeneration of the posterosuperior cuff including teres minor exceeding stage 2 according to Goutallier and an average osteoarthritis grade 2 according to Samilson and Prieto Data assessment included pre- and postoperative clinical examination and Constant Score as well as standard radiographs.

RESULTS At follow up, subjective shoulder value increased from 27% to 68%, Constant Score improved significantly from 48% to 94%, flexion from 106° to 141°, abduction from 95° to 150° and strength from 0.2 to 4.9 (p< 0.05). Although no gain was seen in active external rotation in adduction, a significant loss of external lag was noted from 47° to 9° (p< 0.05). All patients were able to perform overhead activities with increase in functional use of the arm (p< 0.05). Complication requiring revision included postoperative infection in one and hematoma in another case.

CONCLUSION: Irreparable rupture of the posterosuperior rotator cuff involving with pseudoparalysis of elevation and external rotation,, the implantation of an inverse prosthesis combined with latissimus dorsi transfer can increase active range of motion and substantially improve functional external rotation, as opposed to the published results of the inverse prosthesis alone, which do not improve active external rotation.

INTRODUCTION: Full thickness rotator cuff tears have been associated with changes of the anterior acromion. In a previous study we also documented differences in lateral extension of the acromion in rotator cuff tears compared with shoulders with intact cuffs. It was the purpose of this study to verify in a prospective examination, whether presence or absence of rotator cuff tearing in a precisely defined population is quantitatively related to the degree of lateral extension of the acromion.

MATERIAL AND METHODS: 59 consecutive patients between 60 and 70 years and hospitalized for reasons other than shoulder pathologies were entered into a prospective study. All 110 shoulders without previous operations, major trauma or rheumatoid arthritis were examined radiographically and with ultrasonography by two independent examiners.

RESULTS: 67 cuffs were intact, 28 showed a cuff tendinopathy, 17 a full thickness tearing. The acromion index for shoulder with rotator cuff tear was 0.75, for tendinopathy 0.68 and for normal cuffs 0.65. The differences between rotator cuff tears and the other two groups was significant (p< 0.05). The acromion index was not related to gender or osteoarthritis. An acromion index of < 0.77 had a positive predictive value of > 70%. An acromion index of < 0.7 predicted an absence of rotator cuff tearing with an accuracy of 97%. Interobserver agreement of the assessment was excellent with 88%.

CONCLUSION: The relationship between rotator cuff tears and a large extension of the acromion can be used to predict the presence of rotator cuff tears in shoulders between ages 60 and 70. A cause-effect relation is probable and will be studied further.

Introduction: Surgical treatment of glenohumeral joint pathologies with both hemiarthroplasty and total shoulder arthroplasty have shown good results. Although techniques and designs have improved, patients do undergo revision surgery. Complications like chronic instability, inadequate function of the rotator cuff, infection and early component loosening become compromising on the result of shoulder arthroplasty. Revision surgery with the reverse Delta-III prosthesis is a promising treatment modality. The goal of this study was to evaluate the outcome of revision arthroplasty with Delta-III prosthesis after failed primary shoulder arthroplasty.

Material and methods: From 1996 till 2001, we retrospectively analysed 24 patients who underwent revision arthroplasty with a Delta-III-Prosthesis. Out of them 17 had been operated with a hemiarthroplasty and 7 with a total shoulder arthroplasty for different pathologies. Data assessment included pre- and postoperative subjective shoulder value and Constant score. Standard radiographs were performed at time of follow-up.

Results: At average follow-up time of 39 months, patient showed a significant pre- to postoperative gain in subjective shoulder value, relative constant score, active range of motion and strength together with reduction of pain (p< 0.05). No difference was seen in the outcome, if revision arthroplasty was performed after hemiarthro-plasty or total shoulder replacement. Complications were observed in more than 30% of the cases.

Conclusion: In case of failure of primary shoulder arthroplasty, revision with an inverse Delta-III prosthesis is a good treatment option. Good functional results are observed at short to mid term follow up. This outcome though is slightly compromised by a relatively high complication rate.

Introduction: Structural failure of a rotator cuff repair, if associated with pain and severe dysfunction, represents a treatment challenge. Depending on the size of the retear ,the degree of fatty degeneration of the involved muscles, retraction of the musculotendinous unit, as well as age and activity level of the patient, treatment options include re-repair, re-repair with tendon transfer, glenohumeral arthrodesis and inverse total shoulder (Delta) prosthesis. The purpose of this study was to review the outcome of treatment of failed rotator cuff repairs and to compare the results of the four most important types of treatments.

Material and methods: From 1991 till 2002, we retrospectively analysed 80 patients, who underwent revision surgery of the shoulder after failed primary cuff repair. Out of them, 33 had a rerepair, 15 were treated with a delta prosthesis, 17 with a latissimus dorsi-and 15 with a pectoralis major-transfer. Data assessment included pre- and postoperative Constant Score and complication rate. Average follow-up time was 51 months.

Results: After rerepair of the rotator cuff, patients showed a significant gain in subjective shoulder value, rel. Constant Score and reduction of pain(p< 0.05), but range of motion and strength remained unchandged. After additional latissimus-dorsi-or pectoralis major-transfer no significant gain was seen in either subjective shoulder value, nor rel. Constant Score. After Implantation of delta prosthesis, significant improvement was seen in subjective shoulder value, relative Constant score, range of motion and strength (p< 0.05). These improvements were significantly better than in the other groups (p< 0.05). Complication rate was the highest in the delta group.

Conclusion: After failed rotator cuff repair, attempts of rerepair allow good subjective results by reducing pain and maintaining range of motion. Although range of motion is maintained after additional latissimus dorsi-and pectoralis major-transfer, subjective and objective results are not satisfying. After implantation of a delta prosthesis, very good subjective and objective outcome can be predicted, although results are slightly compromised by the high complication rate.