Chronic massive irreparable rotator cuff tears represent a treatment challenge and the optimal surgical technique remains controversial. Superior capsular reconstruction (SCR) has been proposed as a means to provide superior stability to the glenohumeral joint, thus facilitating restoration of shoulder function. However, despite the growing use of SCR there is a paucity of data evaluating the outcomes when performed using a dermal allograft. The purpose of this study was to (1) report the overall survival rate (reoperation and clinical failure) of SCR (2) evaluate for pre-operative factors predicting reoperation and clinical failure.

From January 1, 2015 to November 31, 2017, 65 patients were diagnosed with irreparable rotator cuff tears and consented for a superior capsular reconstruction. These surgeries were performed by 6 surgeons, all fellowship trained in either sports or shoulder and elbow fellowships. Outcomes were graded as excellent, satisfactory, or unsatisfactory using the modified Neer scale. An unsatisfactory result was defined as a clinical “failure”. The Kaplan-Meier survival models were created to analyze reoperation-free and failure-free survival for the entire group. The reconstruction was performed using a dermal allograft. There were 31 patients excluded due to insufficient follow-up (< 6 months), leaving 34 included in this study. The mean follow-up was 12 months (range, 6–23). The average number of prior surgeries was 0.91 (range, 0–5), with 52.9% of patients receiving a prior rotator cuff repair and 38.2% of patients with a prior non-rotator cuff arthroscopy procedure.

The one and two-year survival-free of surgery was 64% and 44% and the one and two-year survival free of failure was 34% and 16% following SCR, respectively. For the patients that underwent a reoperation, 62.5% (n= 5/8) underwent reverse shoulder replacements, 25% (n= 2/8) latissimus dorsi tendon transfers, and 12.5% (n= 1/8) a diagnostic arthroscopy. The average period between the primary and revision surgery was 10.2 months (range, 2.1–18.5). All but two patients (75%, n= 6/8) had at least one surgery prior to the SCR. There were 14/34 (41.2%) patients who experienced pain, weakness, and restricted range of motion. These patients were defined as clinical failures with an unsatisfactory grading on Neer's criteria. Previous surgery predicted reoperation (80% vs 43%, p = 0.03). Female gender predicted clinical failure (100% vs 43%, p < 0 .01).

Superior Capsule Reconstruction performed for large to massive rotator cuff tears has a high rate of persistent pain and limited function leading to clinical failure in 65% (n= 22/34) of patients. The rate of failure is increased in revision cases, female gender and increased Goutallier fatty infiltration of the infraspinatus. Narrowed indications are recommended given the surgical complexity and high rate of early failure.

Glenoid bone loss is not an uncommon challenge in both primary shoulder arthroplasty surgery and revision surgery. Walch described the classification of glenoid morphology and this has led to an understanding of the expanded role for bone grafting, patient-specific implants and reverse prostheses. While bone grafting of the glenoid in conventional arthroplasty has been shown to be successful in some patients it is more routinely used in combination with reverse prostheses. More recently, augmented glenoid components have been developed for both conventional and reverse arthroplasty, though follow-up is insufficient to confirm their durability at this time.

After shoulder arthroplasty many pain generators may continue to play a role and these might otherwise be missed in a patient where the post-operative radiograph looks fine. Such conditions might include pain from an adjacent location such as the AC joint, or stress fracture of the acromion with reverse prostheses. Unrecognised infection or rotator cuff tear are also factors to consider. Moreover, anxiety and depression may be relevant to the outcome of shoulder arthroplasty.

Age is the most accurate surrogate for bone density and poor bone density is the reason for many fracture repairs to fail. Hemiarthroplasty has demonstrated consistently inconsistent results in terms for restoration of function. Most recently, with the evolution of reverse prostheses, prospective studies which are, in many cases, randomised and Level 2, have clearly shown reverse prostheses to be the most consistently reliable treatment in the patient noted above. It is with a high degree of certainty that we can inform such a patient that their function will be restored and their pain minimal with such treatment.

Background

Partial humeral head resurfacing using a stemless implant is a bone-conserving option in treatment of focal chondral defects. We report our experience using the Arthrosurface HemiCAP® device.

Aims

To study the outcomes of DVR plating for distal radius fractures.

A retrospective review of 51 consecutive patients undergoing fixation of Scaphoid fractures by two surgeons in a single institution was conducted. Twenty-four patients were treated with a Herbert screw and twenty-seven with an Acutrak screw. This included six patients who underwent acute fixation, three in each group. The remaining cases were for the treatment of non-union and delayed union.

There were no significant differences between the two groups in terms of age, side of injury, and mechanism of injury. Fractures were classified as proximal, middle and distal thirds of the Scaphoid and there was no significant difference between the groups regarding the types of fractures treated. The only significant difference between the groups was the time from injury to fixation when considering the cases of delayed union and non union which was greater in the Herbert screw group (7.5 months vs 4 months p=<0.05).

There was no significant difference in outcome between the two methods of fixation. Union rates for all cases were 79% for Herbert screws and 81% for Acutrak screws and 82% and 83% respectively when only considering the delayed union/non-union procedures. There was no difference in terms of time to union, further surgery or clinical outcome between the two groups. The Acutrak screw required removal in five patients and the Herbert screw in two due to symptoms from screw prominence. This was not statistically significant.

In conclusion there is no significant difference in surgical outcome between these two methods of fixation for Scaphoid fractures. The authors feel that this supports the view that biological factors are more important than the method of fixation in obtaining union of Scaphoid fractures.

Introduction: The osteotomy in shoulder arthroplasty is based on the assumption that the resected articular segment corresponds to a segment of a sphere oriented, identically, in inclination and retroversion to the original humeral head(1). A previous report has suggested that the traditional osteotomy technique performed along the antero-superior part of the anatomical neck does not accurately replicate inclination and retroversion of the humeral head(2). We hypothesize that a simulated osteotomy performed along the antero-inferior anatomical neck resects a portion of the humeral head similarly oriented to the original head in terms of inclination and retroversion, and, more closely matches head diameter and radius of curvature when compared to the traditional osteotomy approach.

Methods: Twenty-eight fresh frozen cadaveric full arms were dissected free of soft tissue. Lines, points and surfaces were identified on each specimen. A Microscribe digitizer was used to digitize the points and lines. Data were imported into Rhinoceros NURBS modelling software and graphically modelled. The following parameters were used to describe the humeral head geometry: the longitudinal and axial radii of curvature (RoC) of the articular surface; the inclination angle (ƒÑ) and retroversion angle (ƒÒ). To simulate the traditional osteotomy, a plane was constructed using points at the anterior portion of the anatomical neck. The new osteotomy plane was formed using points at the antero-inferior anatomical neck. Paired Student’s t-test was used to compare techniques.

Results: No differences were found between the axial RoC of the resected segment for the new technique (22.5mm) when compared to the original head (22.5mm); a difference was found for the old osteotomy technique (23.0mm). In the coronal plane, no differences were found for the RoC of both the new and traditional techniques when compared to the original head. The axial and coronal diameters of the osteotomized surface were significantly different for both techniques. However, the mean difference between the axial and coronal diameters for the new technique was 2.4mm and, for the traditional technique, 3.2mm. Significant differences in retroversion of the resected surface were found when the new osteotomy technique (24.5deg) and traditional technique (40.5deg) were compared to the original head (29.0deg). Further, significant differences in inclination were found, when the new osteotomy technique (129.5deg) and traditional technique (132.1deg) were compared to the original head inclination (136.9deg).

Discussion: This study found that an osteotomy performed along the anteroinferior part of the anatomical neck removes an articular segment that is more spherical than a segment removed by the traditional osteotomy approach. Although significantly different from the original head, the retroversion associated with the new technique more closely matches the anatomy when compared to the traditional technique. The new osteotomy decreased the inclination angle by 7 degrees. This finding is unlikely to be clinically relevant. Cadaveric studies will reveal the accuracy of an anatomical reconstruction using the novel osteotomy approach.

Purpose of the study: Posterior glenoid erosio is a common finging in patients with degenerative joint disease of the shoulder. Anterior release is usually recommended, almost always with correction of the glenoid retroversion. There is no real consensus on the gravity of these posterior lesions nor on the appropriate attitude. The purpose of this study was to define the limitations of asymmetrical reaming during correction of excessive glenoid retroversion during total shoulder arthroplasty.

Material and methods: Five fresh cadaver shoulders were used. The size of the glenoid cavity and the humeral head were measured to select the optimal size for the glenoid implant. The scapula was embedded in resin. Posterior glenoid erosion was created by reaming to simulate wear producing retroversion greater than 15°. A control computed tomography (CT) was obtained to verify the lesion. The glenoid cavity was then prepared in the same manner as for prosthesis implantation, restoring neutral version to enable implantation of the prosthetic component of the size initially determined. A second CT was obtained to confirm the correction of the retroversion.

Results: The retroversion was corrected in all cases. At least one point of the implant penetrated the glenoid wall in all cases. In three cases, four points were outside the wall. In one case, reaming caused a fracture of the anterior glenoid rim. Finally, in one case, the size of the implant had to be reduced to avoid an oversized implant.

Discussion: The limitations for asymmetrical reaming to correct for posterior wear yet leave enough bone stock for implantation of a glenoid prosthesis are not defined. This study shows that asymmetrical reaming of the anterior rim of the glenoid cavity cannot satisfactorily correct for glenoid retroverson greater than 15° because of the frailness of the anterior wall and the risk the points will penetrate the rim. These complications compromise the primary stablity of the prosthesis and probably secondary short-term and mid-term stability.

Conclusion: If the glenoid retroversion is excessive (> 15°), it would be advisable to graft the posterior defect.

Introduction: Restoration of original humeral head geometry in shoulder arthroplasty is a necessary requirement and may have a bearing on the longevity of the implant. Modern, adaptable, prosthetic components are believed to allow restoration of the individual’s proximal humeral anatomy, provided a precise osteotomy of the humeral head at the level of the anatomical neck is performed. The osteotomy and reconstruction of the humeral head is based on the assumption that the resected articular segment corresponds to a segment of a sphere oriented, identically, in inclination and retroversion to the original humeral head. Resection, along the mid-anterior portion of the cartilage/calcar border, is understood to create a surface that enables a prosthetic component to be mounted, retroverted and inclinated to the same degree as the original head geometry. The objective of this study was to determine the degree of variation in humeral head retroversion relative to the superior and inferior borders of the proximal humeral articular surface.

Methods: Twenty-eight fresh frozen human cadaveric full arms were dissected free of soft tissue to expose the proximal humerus. The distal end of the humeral shaft was potted in PMMA and fixed rigidly in a custom–built jig. The following points and lines were identified and marked on each specimen:

the circumference of the anatomical neck;

A Microscribe 3D-X digitizer was used to digitize the points and lines. The data for each humerus were imported into Rhinoceros NURBS modelling software and graphically represented. The constructed graphical model was used to divide the articular portion of the humeral head into six equal sections in the axial plane. The retroversion angle, relative to the epicondyles, was calculated for each section.

Results: A linear decrease in retroversion angle was noted from the most superior to most inferior point on the proximal humeral articular surface. The retroversion angle was greatest at the level of the insertion of the supraspinatus tendon (34.2deg +/−13.7deg) and least at the inferior cartilage/calcar interface (24.3deg +/−10.2deg).

Discussion: Accurate recovery of humeral head geometry is a requirement in order to achieve good function. The variability in retroversion, as it relates to its point of measurement, may effect the accuracy of pre-operative assessment of a patient’s humeral head geometry as well as the osteotomy during shoulder arthroplasty, and, thus, may impact on joint range of motion and stability post-operatively. Further investigation is warranted.

Carpal tunnel syndrome is the commonest nerve entrapment syndrome. There is still controversy over the method of anaesthesia for this procedure. There have been many studies to show the effectiveness of local infiltration anaesthesia. However, patients do not always tolerate it, as one of the disadvantages of local anaesthetic is pain on infiltration. Experimental studies have shown that warming local anaesthetic can reduce the pain of injection in normal subjects. The aim of our study is to assess the effect of warming local anaesthetic for carpal tunnel surgery.

We conducted a prospective randomised controlled trial. Sample size was calculated. The study group consisted of patients undergoing carpal tunnel surgery. The treatment group received local anaesthetic at 37°C, the control group at room temperature. Patients were asked to indicate the degree of discomfort on a visual analogue scale (0 to 100).

There was a significant reduction in pain scores in the treatment group. Warming the local anaesthetic produced a mean visual analogue score of 13.8 versus 43 for the control group. These results were statistically significant (p< 0.05).

Many carpal tunnel releases are performed under General Anaesthetic . One of the main reasons cited was poor patient tolerance to local anaesthetic infiltration due to pain. Our results show a significant reduction in the reported pain by warming the local anaesthetic for carpal tunnel release. We suggest that warming local anaesthetic should be best practice for anaesthesia in carpal tunnel release.