Aims

The purpose of this study was to develop a convolutional neural network (CNN) for fracture detection, classification, and identification of greater tuberosity displacement ≥ 1 cm, neck-shaft angle (NSA) ≤ 100°, shaft translation, and articular fracture involvement, on plain radiographs.

Aims

We aimed to address the question on whether there is a place for shoulder stabilization surgery in patients who had voluntary posterior instability starting in childhood and adolescence, and later becoming involuntary and uncontrollable.

Introduction. Glenoid inclination, defined as the angle formed by the intersection of a line made of the most superior and inferior points of the glenoid and a line formed by the supraspinatus fossa, has been postulated to impact the mechanical advantage of the rotator cuff in shoulder abduction. An increase in glenoid inclination has previously been reported in patients with massive rotator cuff tears and multiple studies have correlated rotator cuff tears to an increase of the critical shoulder angle, an angle comprised of both the glenoid inclination and acromical index. Glenoid inclination is best measured by the B-angle as it has been shown to be both an accurate and reliable. The purpose of this study was to determine the correlation of glenoid inclination and the presence of degenerative rotator cuff tears. Methods. Data was prospectively collected for study patients assigned to one of two groups. The tear group consisted of patients with degenerative, atraumatic rotator cuff tears, confirmed by MRI and the control group consisted of healthy volunteers without shoulder pain. Inclusion criteria for both groups included age 45 or older. Exclusion criteria included history of previous shoulder surgery, previous patient-recalled injury to the shoulder, presence of glenoid weak, and previous humerus or glenoid fracture. Patients were also excluded from the control group if any shoulder pain or history of rotator cuff disease was present. All patients had standard anterior/posterior shoulder radiographs taken and glenoid inclination was digitally measured with Viztek OpalRad PACS software (Konica Minolta, Tokyo, Japan). The beta angle was measured to determine the glenoid inclincation. Statistical analysis was performed using SPSS version 23 (IBM, Aramonk, NY). Patient age and glenoid inclination were examined with the Shapiro-Wilk test of normality and then compared with student t tests. Gender distribution was compared with chi square test. A p-value of 0.05 was used to represent significance. Results. The study included 26 patients in the tear group and 23 patients in the control group. There was no difference in the age of the two groups (57 vs 54, p=0.292) or gender distribution (p=0.774). The average glenoid inclination was 11.18 (SD=2.67) degrees for the tear group and 5.97 (SD=2.55) degrees for the control group. This difference was statistically significant (p<0.001). Discussion. Glenoid inclination is significantly increased in patients with degenerative rotator cuff tears compared to healthy controls. Tendon overload secondary to increased glenoid inclination may be the primary anatomical factor contributing to the development of degenerative rotator cuff tears

Newer irreversible oral anticoagulants such as rivaroxaban, a direct factor 10a inhibitor, are increasingly employed to prevent thromboembolic events in atrial fibrillation (AF) patients, and to manage venous thromboembolism (VTE). Unlike warfarin, these agents require no monitoring and involve infrequent dose adjustment. We report the case of a patient treated with rivaroxaban for AF. Patient presented with unprovoked sudden onset right shoulder pain which clinically resembled shoulder haemarthrosis. A single case was anonymised and retrospectively reviewed through examination of clinical and radiographic data. A 70 year old female with known AF presented to Accident and Emergency with sudden onset of right shoulder pain and limited movement, which developed over one hour. The pain was constant, localised to the shoulder and without trauma. Past medical history included severe aortic regurgitation and associated thoracic aortic aneurysm, heart failure, atrial fibrillation and hypertension. Observations were normal upon admission with no haemodynamic compromise or pyrexia. Examining the right shoulder demonstrated distension of shoulder joint capsule, tenderness and a reduced range of movement. Temperature and neurovascular status in the right arm were normal. Investigations upon admission included an INR of 1.2. An anteroposterior right shoulder radiograph showed no evidence of fracture. Patient was managed conservatively with simple oral analgesia. Importantly, rivaroxaban was withheld for 5 days and symptoms resolved. Warfarin therapy was subsequently commenced instead as treatment for AF. Patient was discharged one week later and seen in clinic two weeks post-discharge. A full recovery occurred and with a full range of movement in the right shoulder. In the UK, current National Institute for Health and Care Excellence (NICE) guidelines recommend the use of factor 10a inhibitors, for prevention of stroke in AF patients, and following elective total hip and knee replacement operations to prevent VTE. In turn, rivaroxaban is increasingly prescribed as first line therapy. Whereas warfarin has a documented association with haemarthrosis, there is no primary literature evaluating the incidence of factor 10a therapy associated haemarthrosis. In our case, the unprovoked shoulder haemarthrosis resolved following rivaroxaban cessation. In comparison with warfarin, rivaroxaban is irreversible. With warfarin and a high INR, vitamin K can be used to reverse the anticoagulation. There is no equivalent for rivaroxaban. We suggest further studies into incidence of haemarthrosis associated with oral anticoagulant therapy be undertaken, and treating physicians be aware of such complication

Aims

The aim of this study was to analyse the effect of altered viewing perspectives on the measurement of the glenopolar angle (GPA) and the differences between these measurements made on 3D CT reconstructions and anteroposterior (AP) scapular view radiographs.

In this study, we describe a morphological classification for greater tuberosity fractures of the proximal humerus. We divided these fractures into three types: avulsion, split and depression. We retrospectively reviewed all shoulder radiographs showing isolated greater tuberosity fractures in a Level I trauma centre between July 2007 and July 2012. We identified 199 cases where records and radiographs were reviewed and included 79 men and 120 women with a mean age of 58 years (23 to 96). The morphological classification was applied to the first 139 cases by three reviewers on two occasions using the Kappa statistic and compared with the AO and Neer classifications. The inter- and intra-observer reliability of the morphological classification was 0.73 to 0.77 and 0.69 to 0.86, respectively. This was superior to the Neer (0.31 to 0.35/0.54 to 0.63) and AO (0.30 to 0.32/0.59 to 0.65) classifications. The distribution of avulsion, split and depression type fractures was 39%, 41%, and 20%, respectively. This classification of greater tuberosity fractures is more reliable than the Neer or AO classifications. These distinct fracture morphologies are likely to have implications in terms of pathophysiology and surgical technique. Cite this article: Bone Joint J 2014;96-B:646–51

The October 2013 Shoulder & Elbow Roundup³⁶⁰ looks at: Deltoid impairment not necessarily a contra-indication for shoulder arthroplasty; The tricky radiograph; Not so asymptomatic cuff tears; Total shoulder arthroplasty: kinder on the glenoid; Barbotage for calcific tendonitis; What happens to the arthritic glenoid?; Two screws a screw too few?; Sloppy hinge best for elbow arthroplasty.

The glenopolar angle assesses the rotational alignment of the glenoid and may provide prognostic information and aid the management of scapula fractures. We have analysed the effect of the anteroposterior (AP) shoulder radiograph rotational offset on the glenopolar angle in a laboratory setting and used this to assess the accuracy of shoulder imaging employed in routine clinical practice. Fluoroscopic imaging was performed on 25 non-paired scapulae tagged with 2 mm steel spheres to determine the orientation of true AP views. The glenopolar angle was measured on all the bony specimens rotated at 10° increments. The mean glenopolar angle measured on the bone specimens in rotations between 0° and 20° and thereafter was found to be significantly different (p < 0.001). We also obtained the AP radiographs of the uninjured shoulder of 30 patients treated for fractures at our centre and found that none fitted the criteria of a true AP shoulder radiograph. The mean angular offset from the true AP view was 38° (10° to 65°) for this cohort. Radiological AP shoulder views may not fully project the normal anatomy of the scapular body and the measured glenopolar angle. The absence of a true AP view may compromise the clinical management of a scapular fracture. Cite this article: Bone Joint J 2013;95-B:1114–20

The aim of our study was to assess, for the first time in a large study, whether there are radiological features of the acromioclavicular joint (ACJ) which vary with age or between genders and side. Clinical experience suggested that there was no clear correlation between the radiological features and symptoms arising from the ACJ. Therefore we also aimed to test the null hypothesis that there are no consistent radiological features which correspond with the need for surgical excision of the ACJ. We analysed 240 shoulder radiographs, divided into male and female, left and right shoulders, and decades from 20 to 80 years inclusive. At the ACJ the presence of sclerosis, osteophytes, cysts and lysis were recorded, and the width of the joint measured. These same parameters were assessed on the pre-operative radiographs for a group of 100 patients by a blinded observer. Fifty had undergone ASD (arthroscopic subacromial decompression), and 50 ASD with ACJ excision. These two groups were age matched. Statistical analyses were performed. There was no statistical difference between any of the parameters for gender or side however with increasing age there was a significantly increased incidence of joint space narrowing and increased features of osteoarthrosis. When comparing the matched ASD and the ACJ excision groups it was found that the presence of medial sclerosis (p = 0.016) and superior clavicular osteophytes (p = 0.016) were more common in the ACJ excision group. We concluded that there is a change in the radiological features of the ACJ with increasing age but not between sides or gender. The null hypothesis is upheld. Only 2 parameters, namely medial acromial sclerosis and superior clavicular osteophytes, are radiological features which correlate with a symptomatic acromioclavicular joint. These have poor sensitivity and specificity and therefore should not be used as a test

We have carried out a prospective double-blind randomised controlled trial to compare the efficacy of a single subacromial injection of the non-steroidal anti-inflammatory drug, tenoxicam, with a single injection of methylprednisolone in patients with subacromial impingement. A total of 58 patients were randomly allocated into two groups. Group A received 40 mg of methylprednisolone and group B 20 mg of tenoxicam as a subacromial injection along with lignocaine. The Constant-Murley shoulder score was used as the primary outcome measure and the Disability of Arm, Shoulder and Hand (DASH) and the Oxford Shoulder Score (OSS) as secondary measures. Six weeks after injection the improvement in the Constant-Murley score was significantly greater in the methylprednisolone group (p = 0.003) than in the tenoxicam group. The improvement in the DASH score was greater in the steroid group and the difference was statistically significant and consistent two (p < 0.01), four (p < 0.01) and six weeks (p < 0.020) after the injection. The improvement in the OSS was consistently greater in the steroid group than in the tenoxicam group. Although the difference was statistically significant at two (p < 0.001) and four (p = 0.003) weeks after the injection, it was not at six weeks (p = 0.055). Subacromial injection of tenoxicam does not offer an equivalent outcome to subacromial injection of corticosteroid at six weeks. Corticosteroid is significantly better than tenoxicam for improving shoulder function in tendonitis of the rotator cuff after six weeks.

In 100 patients the fulcrum axis which is the line connecting the anterior tip of the coracoid and the posterolateral angle of the acromion, was used to position true anteroposterior radiographs of the shoulder. This method was then compared with the conventional radiological technique in a further 100 patients.

Three orthopaedic surgeons counted the number of images without overlap between the humeral head and glenoid and calculated the amount of the glenoid surface visible in each radiograph. The analysis was repeated for intraobserver reliability. The learning curves of both techniques were studied.

The amount of free visible glenoid space was significantly higher using the fulcrum-axis method (64 vs 31) and the comparable glenoid size increased significantly (8.56 vs 6.47). Thus the accuracy of the anteroposterior radiographs of the shoulder is impaired by using this technique. The intra and interobserver reliability showed a high consistency. No learning curve was observed for either technique.

Background: An acromiohumeral interval narrower than six millimeters has been considered pathologic and strongly indicative for rotator cuff tears by numerous authors. This prospective study was conducted as an assessment of inter- and intraobserver variation in the radiographic measurement of the acromiohumeral interval and its critical value. Material and Methods: Thirty blinded, standardized anteroposterior shoulder radiographs were independently reviewed by five board certified orthopedic shoulder surgeons. The acromiohumeral distance, from the inferior anterior acromial aspect to the humeral head was measured in millimeters. The five investigators classified each film a second time in random order. Results: Finally the same 27 radiographs (90%) have been evaluated by five investigators at both examination time points. The results of three investigators showed significant intra-observer variation ranging from 4 to 11 millimeters for the same radiograph. Six investigator pairs showed significant inter-observer variation at both examination time points (p< 0.05). The maximum inter-observer difference for the same radiograph was 11 millimeters (ranging from 1 to 11, SD 0.3 – 4.2). Conclusion: In view of our results the assessment of the acromiohumeral interval using anteroposterior x-rays does not seem to be a reproducible method of measurement. Further investigations in combination with CT or MRI are necessary to ensure our findings

The aim of our study was to assess, for the first time in a large study, whether there are radiological features of the acromioclavicular joint (ACJ) which vary with age or between genders and side. Clinical experience suggested that there was no clear correlation between the radiological features and symptoms arising from the ACJ. Therefore we also aimed to test the null hypothesis that there are no consistent radiological features which correspond with the need for surgical excision of the ACJ. We analysed 240 shoulder radiographs, divided into male and female, left and right shoulders, and decades from 20 to 80 years inclusive. At the ACJ the presence of sclerosis, osteophytes and cysts were recorded, and the width and angle of the joint measured. These same parameters were assessed on the preoperative radiographs for a group of 100 patients by a blinded observer. Fifty had undergone ASD (arthroscopic subacromial decompression), and 50 ASD with ACJ excision. These two groups were age matched. Statistical analyses were performed. There was no statistical difference between any of the parameters for gender or side however with increasing age there was a significantly increased incidence of acromial sclerosis and joint space narrowing. When comparing the matched ASD and the ACJ excision groups it was found that the presence of medial sclerosis of the acromium (p = 0.016) and superior clavicular osteophytes (p = 0.016) were more common in the ACJ excision group. We concluded that there is a change in the radiological features of the ACJ with increasing age but not between sides or gender. The null hypothesis has been rejected. The presence of either medial sclerosis of the acromium, and superior clavicular osteophytes, are radiological features which correlate with a symptomatic acromioclavicular joint

Our aim in this prospective study was to evaluate the outcome of total shoulder replacement in the treatment of young and middle-aged active patients with primary glenohumeral osteoarthritis. We reviewed 21 patients (21 shoulders) with a mean age of 55 years (37 to 60). The mean follow-up was seven years (5 to 9). The same anatomical, third-generation, cemented implant had been used in all patients. All the patients were evaluated radiologically and clinically using the Constant and Murley score.

No patients required revision. In one a tear of the supraspinatus tendon occurred. Overall, 20 patients (95%) were either very satisfied (n = 18) or satisfied (n = 2) with the outcome. Significant differences (p < 0.0001) were found for all categories of the Constant and Murley score pre- and post-operatively. The mean Constant and Murley score increased from 24.1 points (10 to 45) to 64.5 points (39 to 93), and the relative score from 30.4% (11% to 50%) to 83% (54% to 116%). No clinical or radiological signs of loosening of the implant were seen.

For young and middle-aged patients with osteoarthritis, third-generation total shoulder replacement is a viable method of treatment with a low rate of complications and excellent results in the mid-term.

This paper reports two studies of uncemented (UC) shoulder arthroplasty – one directed at UC humeral stems (Study 1) and the second at UC glenoid components (Study 2). In Study 1, 160 consecutive UC humeral stems were inserted between 1989 and 1995. Three types of stem were used – Biomodular, modified Biomodular and Nottingham. At a mean follow-up of 4.3 years 18 shoulders were lost to follow-up. Of the remaining 142 shoulders radiographs from routine follow-up appointments at 6 months,1,2,3,5,7 & 9 years were reviewed together with a clinical follow-up of the patients. In Study 2 a survival analysis was carried out on a consecutive series of 222 UC glenoid components inserted between 1989 and 1998 at a mean follow-up of over 5 years. Survival was defined as a prosthesis remaining in situ in a live patient. Six types of UC glenoid component were used – Copeland/Zimmer(non HA), stndard Biomodular, low-profile Biomodular, Nottingham prototype, Nottingham and Nottingham with HA. In Study 1, radiological follow-up indicated 3 stems(2%) showed definite loosening (all related to deep infection) – all were revised. Six stems (4%) showed probable loosening but were asymptomatic. In Study 2, for the whole series a survival table was created which identified a survival at 2; 5 and 10 years respectively of 92%; 75% and 66%. The later prosthesis designs performed best. A radiological analysis of all shoulders is currently in progress. This audit of outcome has indicated that hydroxyapatite has been beneficial but further long-term studies are required

A powered, randomised control trial was instigated to evaluate the advantages of subacromial injection of Methylprednisolone over conservative treatment in the management of partial rotator cuff injuries of the shoulder. Consecutive patients with possible partial rotator cuff tears were reviewed at 1 week. Inclusion criteria for a diagnosis of partial rotator cuff tear included; traumatic mechanism, greater tuberosity tenderness, painful arc, and complete resolution of disability post-Bupivicaine block. Exclusion criteria included; age < 16 years, chronic shoulder disease, acromioclavicular tenderness, and abnormal shoulder radiograph. Patients were randomly allocated to receive either 1 immediate subacromial injection of 40mg Methylprednisolone (group S) or no injection (group N). Initial outcomes measured were; visual analogue pain score (0–10) and active abduction (nearest 5°), repeated at 3, 6, and 12 weeks. All patients were instructed in analgesia usage and given identical shoulder exercises. Of 279 patients reviewed over 3 years, 90 met the inclusion criteria (6/90 patients were lost to follow-up). 50 patients were randomised to group S, 40 to group N. Mean pain score improvement at 12 weeks was comparable (S=4.95, N=4.44) (p> 0.1, CI=0.16–0.86). In patients aged > 40 years group S had significantly higher mean improvement in abduction at completion (64.28°) compared to group N (34.63°) (p< 0.02, CI 1.29–58.01). Conversely in patients aged < 40 years group S had lower mean improvements in abduction (40.55°) compared to group N (77.73°), though this was not statistically significant (p=0.1, CI 2.06–72.29). Methylprednisolone injection is more efficacious than conservative treatment alone in some patients. This benefit appears age-dependent and consequently such treatment should be reserved for patients aged > 40 years

Reconstructing a shoulder fracture with an arthroplasty is analogous to solving a jigsaw puzzle. Before beginning the task of assembling the pieces of a puzzle, the final “picture” must be seen, as this will guide the proper location for the individual puzzle pieces. And, only when all the pieces are properly placed will the final picture be defined and recognised as a piece of art!. In the same way, following a three or four part displaced fracture of the shoulder, reassembly of the various pieces requires time and skilful appreciation of the three dimensional anatomy of bone, ligament and muscle. These tissues are like puzzle pieces which, when assembled according to the rules of anatomy and physiology, will lead to successful outcome measured by minimal pain and functional recovery of shoulder motion. This presentation will examine each of these puzzle pieces – the bone fragments, the muscle, and the ligaments – individually and functionally integrated. We will review their importance in the overall scheme of shoulder reconstruction following a complex fracture. The critical concerns of humeral length, humeral version and myofascial sleeve tension will be discussed in detail. It is the recognition of these anatomic and physiologic necessities, which allow the final shoulder radiograph and the patient, to indeed resemble a piece of art