Recently concerns have been raised as to the effect of intra-articular radio-frequency energy on
The
Purpose: We have sometimes observed paralysis of the long portion of the triceps in patients operated after traumatic damage to the
We have assessed the final strength of the deltoid in 121 patients who had repair of isolated or combined lesions of the
Rupture of the pectoralis major (PM) tendon is a rare yet severe injury. Several techniques have been described for PM fixation including a transosseus technique, when cortical buttons are placed at the superior, middle and inferior PM tendon insertion positions. The concern with this technique is the risk that bicortical drilling poses to the
Abstract. Nerve transfer has become a common and often effective reconstructive strategy for proximal and complex peripheral nerve injuries of the upper limb. This case-based discussion explores the principles and potential benefits of nerve transfer surgery and offers in-depth discussion of several established and valuable techniques including: motor transfer for elbow flexion after musculocutaneous nerve injury, deltoid reanimation for
Abstract. Objective. Radial to
The August 2023 Shoulder & Elbow Roundup360 looks at: Motor control or strengthening exercises for rotator cuff-related shoulder pain? A multi-arm randomized controlled trial; Does the choice of antibiotic prophylaxis influence reoperation rate in primary shoulder arthroplasty?; Common shoulder injuries in sport: grading the evidence; The use of medial support screw was associated with
Aims. Resection of the proximal humerus for the primary malignant bone
tumour sometimes requires en bloc resection of the
deltoid. However, there is no information in the literature which
helps a surgeon decide whether to preserve the deltoid or not. The
aim of this study was to determine whether retaining the deltoid
at the time of resection would increase the rate of local recurrence.
We also sought to identify the variables that persuade expert surgeons
to choose a deltoid sparing rather than deltoid resecting procedure. Patients and Methods. We reviewed 45 patients who had undergone resection of a primary
malignant tumour of the proximal humerus. There were 29 in the deltoid
sparing group and 16 in the deltoid resecting group. Imaging studies
were reviewed to assess tumour extension and soft-tissue involvement.
The presence of a fat rim separating the tumour from the deltoid
on MRI was particularly noted. The cumulative probability of local
recurrence was calculated in a competing risk scenario. Results. There was no significant difference (adjusted p = 0.89) in the
cumulative probability of local recurrence between the deltoid sparing
(7%, 95% confidence interval (CI) 1 to 20) and the deltoid resecting
group (26%, 95% CI 8 to 50). Patients were more likely to be selected
for a deltoid sparing procedure if they presented with a small tumour
(p = 0.0064) with less bone involvement (p = 0.032) and a continuous
fat rim on MRI (p = 0.002) and if the
We reviewed 101 patients with injuries of the
terminal branches of the infraclavicular brachial plexus sustained between
1997 and 2009. Four patterns of injury were identified: 1) anterior
glenohumeral dislocation (n = 55), in which the axillary and ulnar
nerves were most commonly injured, but the
Residual muscle weakness in obstetric brachial plexus palsy results in soft-tissue contractures which limit the functional range of movement and lead to progressive glenoid dysplasia and joint instability. We describe the results of surgical treatment in 98 patients (mean age 2.5 years, 0.5 to 9.0) for the correction of active abduction of the shoulder. The patients underwent transfer of the latissimus dorsi and teres major muscles, release of contractures of subscapularis pectoralis major and minor, and
Physiological studies have revealed that the central nervous system controls groups of muscle fibers in a very efficient manner. Within a single skeletal muscle, the central nervous system independently controls individual muscle segments to produce a particular motor outcome. Mechanomyographic studies on the deltoid muscle have revealed that the deltoid muscle, commonly described as having three anatomical segments, is composed of at least seven functional muscle segments, which all have the potential to be at an important level independently coordinated by the central nervous system.[. 1. ] In this study we tried to anatomically describe and quantify these different functional segments within the deltoid muscle, based on the branching out pattern of the
Analysis of orthopaedic malpractice claims has shown that highest impact allegations (highest payment dollars per claim) were those that were related to failure to protect anatomic structures in surgical fields. The prevalence of subclinical peripheral neurologic deficit following reverse and anatomic shoulder arthroplasty has been reported to be 47% and 4%, respectively. We propose the following five rules in order to avoid neurovascular injury during shoulder arthroplasty cases:. Pre-operative planning would assure a smooth operation without intra-operative difficulties. Adequate planning would include appropriate imaging, obtaining previous operative reports, complete pre-operative neurovascular examination and requesting the necessary operative equipment. Tug test: It is crucial to palpate the
In reverse shoulder arthroplasty (RSA), a high complication rate is noted in the international literature (24.7%), and limited local literature is available. The complications in our developing health system, with high HIV, tuberculosis and metabolic syndrome prevalence may be different from that in developed health systems where the literature largely emanates from. The aim of this study is to describe the complications and complication rate following RSA in a South African cohort. An analytical, cross-sectional study was done where all patients’ who received RSA over an 11 year period at a tertiary hospital were evaluated. One-hundred-and-twenty-six primary RSA patients met the inclusion criteria and a detailed retrospective evaluation of their demographics, clinical variables and complication associated with their shoulder arthroplasty were assessed. All fracture, revision and tumour resection arthroplasties were excluded, and a minimum of 6 months follow up was required. A primary RSA complication rate of 19.0% (24/126) was noted, with the most complications occurring after 90 days at 54.2% (13/24). Instability was the predominant delayed complication at 61.5% (8/13) and sepsis being the most common in the early days at 45.5% (5/11). Haematoma formation, hardware failure and
A fracture of the tuberosity is associated with 16% of anterior glenohumeral dislocations. Manipulation of these injuries in the emergency department is safe with less than 1% risk of fracture propagation. However, there is a risk of associated neurological injury, recurrent instability and displacement of the greater tuberosity fragment. The risks and outcomes of these complications have not previously been reported. The purpose of this study was to establish the incidence and outcome of complications associated with this pattern of injury. We reviewed 339 consecutive glenohumeral dislocations with associated greater tuberosity fractures from a prospective trauma database. Documentation and radiographs were studied and the incidence of neurovascular compromise, greater tuberosity fragment migration and intervention and recurrent instability recorded. The mean age was 61 years (range, 18–96) with a female preponderance (140:199 male:female). At presentation 24% (n=78) patients had a nerve injury, with
Proximal humeral fractures are common fractures that may lead to severe functional disability. In open reduction and internal fixation of these fractures deltopectoral approach is pereferred by many surgeons being an internervous plane and because of familiarity. However when this aprroach is used extensive soft tissue dissection is inevitable and control of the commonly displaced tuberculum majus fragment which is displaced posterolateraly is difficult. In this prospective study we compared deltopectoral and lateral deltoid splitting approach by using the same fixation material. Between October 2005 and March 2007 42 patients were included in the study group. In Group A a lateral deltoid split approch and in Group B deltopectoral approach was used. Group A consisted of 22 cases; mean age 60.95 (26–90 years old); 12 female and 10 male, Group B 20 cases; mean age 56.9 (24–86 years old); 13 female, 7 male. Philos locking plate fixation (Synthes) was used in every case. When deltoid split approach was used
Introduction. Osteoarthritis of the glenohumeral joint leads to global degeneration of the shoulder and often results in humeral or glenoid osteophytes. It is established that the axillary neurovascular bundle is in close proximity to the glenohumeral capsule. Similar to other compressive neuropathies, osteophytic impingement of the
Fractures of the proximal humerus can offer a difficult surgical challenge particularly if they occur in elderly patients and/or are a complex fracture configuration. Much of the morbidity of the surgery relates to the extensile delto-pectoral approach traditionally used for operative treatment of these fractures. A minimally invasive technique for approaching these fractures has was developed using a proximal deltoid split approach at the anterior edge of the deltoid and sliding a precontoured proximal humeral locking plate submuscularly after provisional fracture reduction. This technique was tested in a cadaver model to identify “safe” and “at risk” holes in the plate for percutaneous fixation in relation to the
The patterns of nerve and associated skeletal injury were reviewed in 84 patients referred to the brachial plexus service who had damage predominantly to the infraclavicular brachial plexus and its branches. Patients fell into four categories: 1. Anterior glenohumeral dislocation (46 cases); 2. ‘Occult’ shoulder dislocation or scapular fracture (17 cases); 3. Humeral neck fracture (11 cases); 4. Arm hyperextension (9 cases). The axillary (38/46) and ulnar (36/46) nerves were most commonly injured as a result of glenohumeral dislocation. The
Plate fixation of the proximal humerus fractures may now be more desirable with the use of a biological approach by limiting surgical insult and allowing accelerated rehabilitation by a solid fixation. To evaluate the safety and efficacy of minimally invasive plating of the proximal humerus using validated disease-specific measures. During a period of one year, thirty patients were operated with use of the LCP proximal humerus plate (Synthes) through a 3cm lateral deltoid splitting approach and a second 2 cm incision at the deltoid insertion. The
Purpose: The objective of the study was to perform a prospective evaluation of thermal capsulorraphy for the treatment of multidirectional instability of the shoulder. Summary of Methods: Over a period of two years, 19 patients with multidirectional instability were treated with thermal shrinkage. Fifteen patients had involuntary dislocation and four voluntary. The predominant direction of instability was anterior/inferior in 10, posterior in 5 and multiple directions in 4. Patients were followed for a minimum of two years or until surgical failure and recurrence of symptomatology. Postoperatively patients were immobilised in a sling for a period of 3 weeks and were reviewed at 6 weeks and 3, 6, 9 and 12 months and then at six monthly intervals. The Western Ontario shoulder Instability Index was used as a clinical outcome measure as well as subjective and objective evaluation of patient’s function, range of motion, pain and instability. Results: Nine patients had recurrence of their instability occurring at an average of nine months following their surgical procedure (range 7–14 months). One patient had
Introduction and purpose: Different neurovascular structures may be damaged when making arthroscopic portals to the shoulder joint. The description of new portals poses new challenges. The goal of the present study is to provide an update on the anatomic vasculonervous responses of the current approaches to shoulder arthroscopy. Materials and methods: 16 fresh cadavers were systematically dissected. The most usual arthroscopic portals were marked and, then, the dissection started on a plane-to-plane basis. Relationships were identified and distances were measured to the most important neurovascular elements with a standard caliber (accuracy: 0.5mm). Results: The portals studied and the structures at risk were the following:. * Posterior portal: anterior branch of the
Abstract. Background/Objectives. The incidence of reverse total shoulder replacement (rTSR) implantation is increasing globally, but apprehension exists regarding complications and associated challenges. We retrospectively analysed the senior author's series of rTSR from a tertiary centre using the VAIOS shoulder system, a modular 4th generation implant. We hypothesised that the revision rTSR cohort would have less favourable outcomes and more complications. Methods. 114 patients underwent rTSR with the VAIOS system, over 7 years. The primary outcome was implant survival. Secondary outcomes were Oxford shoulder scores (OSS), radiographic analysis (scapular notching, tuberosity osteolysis, and periprosthetic radiolucent lines) and complications. Results. There were 55 Primary rTSR, 31 Revision rTSR and 28 Trauma rTSR. Implant survival: Primary rTSR- 0 revisions, average 3.35-year follow-up. Revision rTSR-1 revision (4.17%), average 3.52-year follow-up. Trauma rTSR- 1 revision (3.57%), average 4.56-year follow-up OSS: Average OSS improved from 15.39 to 33.8 (Primary rTSR) and from 15.11 to 29.1 (Revision rTSR). Average post-operative OSS for the Trauma rTSR was 31.4 Radiological analysis and complications: Low incidence of scapular notching One hairline fracture below the tip of stem, noted incidentally, which required no treatment. One periprosthetic fracture after alcohol related fall. Treated non-surgically One joint infection requiring two-stage revision to rTSR. One dislocation noted at 2 year follow up. This patient had undergone nerve grafting within 6 months of rTSR for
The standard approach is through the deltopectoral interval. Among patients with prior incisions, one makes every effort to either utilise the old incision or to incorporate it into a longer incision that will allow one to approach the deltopectoral interval and retract the deltoid laterally. The deltopectoral interval is most easily developed just distal to the clavicle, where there is a natural infraclavicular triangle of fat that separates the deltoid and pectoralis major muscles even in very scarred or stiff shoulders. Typically, the deltoid is retracted laterally leaving the cephalic vein on the medial aspect of the exposure. The anterior border of the deltoid is mobilised from the clavicle to its insertion on the humerus. The anterior portion of the deltoid insertion together with the more distal periosteum of the humerus may be elevated slightly. The next step is to identify the plane between the conjoined tendon group and the subscapularis muscle. Dissection in this area must be done very carefully due to the close proximity of the neurovascular group, the
Abstract. Introduction. Local anaesthetic injections are regularly used for perioperative pain relief for shoulder arthroscopies. In our practice all shoulder arthroscopies were performed under general aneasthesia supplemented by perioperative subacromial local anaesthetic injections or landmark guided
Reverse total shoulder replacement (RTSR) depends
on adequate deltoid function for a successful outcome. However, the
anterior deltoid and/or
After establishing anatomical feasibility, functional reconstruction to replace the anterolateral part of the deltoid was performed in 20 consecutive patients with irreversible deltoid paralysis using the sternoclavicular portion of the pectoralis major muscle. The indication for reconstruction was deltoid deficiency combined with massive rotator cuff tear in 11 patients, brachial plexus palsy in seven, and an isolated
Latissimus dorsi tendon transfer (LDTT) is technically
challenging. In order to clarify the local structural anatomy, we undertook
a morphometric study using six complete cadavers (12 shoulders).
Measurements were made from the tendon to the nearby neurovascular
structures with the arm in two positions: flexed and internally
rotated, and adducted in neutral rotation. The tendon was then transferred
and measurements were taken from the edge of the tendon to a reference
point on the humeral head in order to assess the effect of a novel
two-stage release on the excursion of the tendon. With the shoulder flexed and internally rotated, the mean distances
between the superior tendon edge and the radial
Although new locking plates allows for secure fixation of osteoporotic fractures in the proximal humerus, extensive soft tissue dissection is needed for their insertion. We report on a prospective clinical trial of the first thirty patients treated with plating of the proximal humerus though a minimally invasive percutaneous approach. All fractures healed within the first 6 months with no avascular necrosis or
Patients with pain and loss of shoulder function
due to nonunion of a fracture of the proximal third of the humerus may
benefit from reverse total shoulder replacement. This paper reports
a prospective, multicentre study, involving three hospitals and
three surgeons, of 35 patients (28 women, seven men) with a mean
age of 69 years (46 to 83) who underwent a reverse total shoulder
replacement for the treatment of nonunion of a fracture of the proximal humerus.
Using Checchia’s classification, nine nonunions were type I, eight
as type II, 12 as type III and six as type IV. The mean follow-up
was 51 months (24 to 99). Post-operatively, the patients had a significant
decrease in pain (p <
0.001), and a significant improvement in
flexion, abduction, external rotation and Constant score (p <
0.001), but not in internal rotation. A total of nine complications
were recorded in seven patients: six dislocations, one glenoid loosening
in a patient who had previously suffered dislocation, one transitory
paresis of the
Proximal humerus is the common site for primary bone malignancies that surgical treatment consists of wide excision of the tumor and reconstruction with tumor resection prosthesis or allograft. The ultimate function of the shoulder depends on the degree of sacrification of adjacent structures. Thirty-two patients with primary malignancies have been treated by wide excision and endoprosthetic replacement by senior author between 1989–2005 12 patients were female, 20 patients were male, mean age was 26,6 years (range 7–69 years). Histological diagnosis was 14 osteosarcoma, 4 Ewing’s sarcoma, 4 chondrosarcoma, 3 parosteal sarcoma, 4 giant cell tumor, 1 aneurysmal bone cyst, 2 synovial sarcoma. Synovial sarcoma, osteosarcoma and Ewing’s sarcoma patients received neoadjuvant chemotherapy prior to excision. Mean follow-up was 50,4 months (range 6–153 months). Oncologic results were 20 patients NED (no evidence of disease), 2 patients AWD (alive with disease), 10 patients DOD (died of disease). Functional outcome was scored according to Musculo-Skeletal System Tumor Society (MSTS) rating scale, 7 patients were excellent, 22 patients were good and 3 patients were poor. Regarding complications 2 patients developed local recurrence, 2 patients had superficial infection. Infected cases were treated by systemic antibiotic treatment. All patients had dexterity of the hand and elbow. Regarding shoulder abduction and forward flexion, 7 patients whose deltoid muscle and
Background: The Inferior Glenohumeral Ligament (IGHL) has a well known mechanical and propioceptive relevance in shoulder stability. The interrelation of the IGHL anatomical disposition and innervation has not actually been described. The studys purpose was to determine the IGHL innervation patterns and relate them to dislocation. Material &
methods: Forty-five embalmed and 16 fresh-frozen human cadaveric shoulders were studied. Massons Trichrome staining was used to detail the intra-ligamentous nerve fibre arrangements. Neural behaviour of the articular nerves was studied dynamically at the apprehension position and while anteroinferior dislocation of the shoulder joint was performed. Results: The anatomy of the IGHL was clearly defined. However, in 7 out of 61 cases the anterior band was only a slight thickening of the ligament. It averaged 34 mm (range, 28 to 46 mm) in length. The posterior band was only seen in 40.98 % of the cases. The
Treatment of proximal humerus fractures (PHF) is controversial in many respects, including the choice of surgical approach for fixation when using a locking plate. The classic deltopectoral (DP) approach is believed to increase the risk of avascular necrosis while making access to the greater tuberosity more difficult. The deltoid split (DS) approach was developed to respect minimally invasive surgery principles. The purpose of the present study (NCT-00612391) was to compare outcomes of PHF treated by DP and DS approaches in terms of function (Q-DASH, Constant score), quality of life (SF12), and complications in a prospective randomized multicenter study. From 2007 to 2016, all patients meeting the inclusion/exclusion criteria in two University Trauma Centers were invited to participate in the study. Inclusion criteria were: PHF Neer II/III, isolated injury, skeletal maturity, speaking French or English, available for follow-up (FU), and ability to fill questionnaires. Exclusion criteria: Pre-existing pathology to the limb, patient-refusing or too ill to undergo surgery, patient needing another type of treatment (nail, arthroplasty),
Latissimus dorsi anterior to major transfers have been advocated in the setting of loss of external rotation and elevation in conjunction with reverse shoulder replacement. Reverse shoulder replacement is a prosthesis specifically designed for shoulders with poor rotator cuff function. In the vast majority of cases, some teres minor function at the minimum is maintained in shoulders destined for a reverse shoulder replacement. However, in certain circumstances there is complete loss of any external rotation, and a muscle transfer can be performed in order to restore some external rotation function. A reverse shoulder replacement in the absence of any rotator cuff function goes into obligate internal rotation with elevation. A minimum of external rotation strength is necessary in order to maintain the arm in normal rotation. The first tip is patient selection. Physical examination of active external rotation, external rotation strength and forward elevation should be just performed. A latissimus transfer is indicated in patients who cannot maintain their arm in neutral to at least a few degrees of external rotation. A lag sign is another physical examination finding which can indicate complete loss of rotator cuff function. The latissimus dorsi transfer is performed by first identifying and releasing the latissimus from its insertion on the anterior humerus. The arthroplasty is performed. The passage for the latissimus muscle is developed carefully and being mindful of the
Reverse shoulder arthroplasty is becoming a frequent treatment of choice for patients with shoulder disorders. Complication rates after reverse shoulder arthroplasty may be three-fold that of conventional total shoulder arthroplasty especially in high risk patient populations and diagnoses like revision arthroplasty, fracture sequelae, and severe glenoid bone loss. Complications include component malposition, stiffness, neurological injury, infection, dislocation or instability, acromial or scapular spine fractures, scapular notching, and loosening of implants. Recognition of preoperative risk factors and appropriate 3D planning are essential in optimizing patient outcome and intraoperative success. Failure of reverse shoulder arthroplasty is a significant challenge requiring appropriate diagnosis of the failure mode. The most common neurological injuries involve the brachial plexus and the
Shoulder arthritis in the young adult is a deceptive title. The literature is filled with articles that separate outcomes based on an arbitrary age threshold and attempt to provide recommendations for management and even potential criteria for implanting one strategy over another using age as the primary determinant. However, under the age of 50, as few as one out of five patients will have arthritis that can be accurately classified as osteoarthritis. Other conditions such as post-traumatic arthritis, post-surgical arthritis including capsulorrhaphy arthropathy, and rheumatoid arthritis create a mosaic of pathologic bone and soft tissue changes in our younger patients that distort the conclusions regarding “shoulder arthritis” in the young adult. In addition, we are now seeing more patients with unique conditions that are still poorly understood, including arthritis of the pharmacologically performance-enhanced shoulder. Early arthritis in the young adult is often recognised at the time of arthroscopic surgery performed for other preoperative indications. Palliative treatment is the first option, which equals “debridement.” If the procedure fails to resolve the symptoms, and the symptoms can be localised to an intra-articular source, then additional treatment options may include a variety of cartilage restoration procedures that have been developed primarily for the knee and then subsequently used in the shoulder, including microfracture, and osteochondral grafting. The results of these treatments have been rarely reported with only case series and expert opinion to support their use. When arthritis is moderate or severe in young adults, non-arthroplasty interventions have included arthroscopic capsular release, debridement, acromioplasty, distal clavicle resection, microfracture, osteophyte debridement,
Optimal surgical management of proximal humeral fractures remains controversial. We report our experience and the study on our surgical technique for proximal humeral fractures and fracture-dislocations using locking plates in conjunction with calcium sulphate augmentation and tuberosity repair using high strength sutures. We used the extended deltoid-splitting approach for fracture patterns involving displacement of both lesser and greater tuberosities and for fracture-dislocations. We retrospectively analysed 22 proximal humeral fractures in 21 patients. 10 were male and 11 female with an average age of 64.6 years (Range 37 to 77). Average follow-up was 24 months. Fractures were classified according to Neer and Hertel systems. Pre-operative radiographs and CT scans in three and four-part fractures were done to assess the displacement and medial calcar length for predicting the humeral head vascularity. According to the Neer classification, there were 5 two-part, 6 three-part, 5 four-part fractures and 6 fracture-dislocations (2 anterior and 4 posterior). Results were assessed clinically with DASH scores, modified Constant & Murley scores and serial post-operative radiographs. The mean DASH score was 16.18 and modified Constant & Murley score was 64.04 at the last follow-up. 18 out of 22 cases achieved good clinical outcome. All the fractures united with no evidence of infection, failure of fixation, malunion, tuberosity failure, avascular necrosis or adverse reaction to calcium sulphate bone substitute. There was no evidence of
Non-operative management has frequently been adopted for closed injuries of the infraclavicular brachial plexus and its branches in the belief that spontaneous recovery is likely to occur, and surgical exploration is performed only if recovery has not occurred in the expected time. This paper correlates the clinical and electrophysiological features with the operative findings in six patients with such injuries. The
The scapula is a rare site for a primary bone tumour. Only a small number of series have studied patient outcomes after treatment. Previous studies have shown a high rate of recurrence, with functional outcomes determined by the preservation of the glenohumeral joint and deltoid. The purpose of the current study was to report the outcome of patients who had undergone tumour resection that included the scapula. We reviewed 61 patients (37 male, 24 female; mean age 42 years (SD 19)) who had undergone resection of the scapula. The most common resection was type 2 (n = 34) according to the Tikhoff-Linberg classification, or type S1A (n = 35) on the Enneking classification.Aims
Methods
Opinion varies as to the incidence of nerve lesions in anterior dislocation of the shoulder after low-velocity trauma. Most studies are retrospective or do not use EMG. We have investigated the incidence and the clinical consequences of nerve lesions in a prospective study by clinical and electrophysiological examination. Axonal loss was seen in 48% of 77 patients. The
We describe 11 cases of posterior fracture-dislocation of the shoulder that required open reduction and fixation. Difficulties with access through anterior approaches led us to use the superior subacromial approach. This is an extension of the approach often used to expose the rotator cuff; the joint is opened by splitting the supraspinatus tendon 5 mm behind the cuff interval. The glenoid, proximal humerus and any fracture fragments can be seen from above, allowing reduction of the dislocation and osteosynthesis to be performed with minimal risk of damage to the humeral head and its blood supply. The proximity of the
We reviewed 28 patients with brachial plexus lesions caused by shoulder dislocation. Contrary to most other reports, we found that the neurological lesions involved the infraclavicular and the supraclavicular brachial plexus. With supraclavicular lesions the involvement was always of the suprascapular nerve, and this always recovered spontaneously. Isolated
Traumatic rupture of the tendon of the subscapularis muscle was documented as an isolated lesion in the shoulders of 16 men. The injury was caused either by forceful hyperextension or external rotation of the adducted arm. The patients complained of anterior shoulder pain and weakness of the arm when it was used above and below the shoulder level. They did not experience shoulder instability. The injured shoulders exhibited increased external rotation and decreased strength of internal rotation. A simple clinical manoeuvre called the 'lift-off test', reliably diagnosed or excluded clinically relevant rupture of the subscapularis tendon. Confirmation of the clinical diagnosis was best achieved by ultrasonography or MRI, but arthrography or CT arthrography were also useful. Surgical exploration confirmed the diagnosis in every case. Repair of the ruptured tendon was technically demanding and required good exposure to identify and protect the
Displaced proximal Humeral fractures at Inverclyde Royal Hospital prior to 2008 were previously treated with the antegrade Acumed Polaris Proximal Humeral, predominantly in 2 part fractures. The Philos plate was introduced in 2008, initially being used to treat select non unions, and then expanded to acute fractures. The aim of this study was to assess time to union and complications in the lower volume District General setting comparing to published outcomes. From February 2008 – January 2011, 20 patients were identified. Age range 49–75 (mean 61.2) years, 8 male; 12 female. Left 9, Right 11 Neers 2 part 35%; 3 35%; 4 30%. 16 (80%) were performed in acute fractures with 4 for non-unions, 3 of which were previous polaris nail fixations. 2 patients were lost to follow up after 6/52 but were progressing well. Union was confirmed radiologically and clinically in all but 2 remaining patients (10%), one of whom suffered a significant complication of plate fracture, the second treated with revision for painful non union. 2 other significant complications were observed: transient
In 45 patients we assessed the functional results and complications for three different reconstructive procedures after resection of primary tumors of the proximal humerus. An osteoarticular allograft was used in 11, a clavicula pro humero operation in 15 and a tumour prosthesis in 19. The glenoid was resected with the proximal humerus in 25 patients. The
We conducted a prospective evaluation of patients with anterior dislocation of the shoulder associated with a fracture of the greater tuberosity. Thirty-four anterior dislocations of the shoulder with greater tuberosity fractures were reviewed with a minimum follow-up of one year from the time of injury. Eight required open reduction. The final outcome with regard to pain, range of movements, and function was assessed in 34 patients. In open reduction, there were five good results, one fair, one poor and one patient died. In the non-operative group, results were good in 11 patients, fair in eight, poor in one, not assessed in five and one patient died. Two patients have died in this series, one in the open reduction group. Associated injuries are:
Our purpose was to study the functional outcome and electrophysiologically to assess the axially nerve function in patients who have undergone surgery using a deltoid-splitting approach to treat complex proximal humeral fractures. This was a prospective observational study and was carried out in the Shoulder injury clinic at a university teaching hospital. Over a one-year period we treated fourteen locally-resident patients (median age 59 years) who presented with a three- or four-part proximal humeral fracture. All patients were treated using the extended deltoid-splitting approach, with open reduction, bone grafting and plate osteosynthesis. All patients were prospectively reviewed and underwent functional testing using the DASH, Constant and SF-36 scores as well as spring balance testing of deltoid power, and dynamic muscle function testing. At one year after surgery, all patients underwent EMG and nerve latency studies to assess
Complications in internal fixation of proximal humeral fractures can lead to an unsatisfactory outcome. We retrospectively reviewed 22 patients at a mean follow-up of 13 months (range 3–30). The average age was 58 years (36–86) in 10 male and 12 female patients. The mechanism of injury involved a simple fall in 17, MCA in 3, assault in 1 and metastasis in 1. The operation was performed at a mean of 11 days after the injury (range 1–29). There were 12 3-part, 6 2-part, 2 4-part fractures, 1 fracture dislocation and 1 pathological fracture. Only 13 out of 22 patients (59%) did not develop any complications. We had hardware problems in 5 patients including hardware pull-out, plate prominence, screw penetration, loosening or breakage. 2 wound infections, 1
Although, reverse shoulder arthroplasty has initially been introduced for rotator cuff arthropathy, its application has been expanded on fracture sequelae, chronic dislocations and even comminuted fractures of the humeral head in elderly patients. The purpose of this study is to present our experience and the mid-term clinical results of this type prosthesis. Between 2006 and 2008 16 reverse shoulder arthroplasties have been carried out in our department. Fourteen patients were female and 2 male with an average age of 72.4 years (55–81). Eleven patients had true rotator cuff arthropathy, 3 malunion of 4-part fractures, one chronic anterior shoulder dislocation and finally one patient had bilateral chronic posterior shoulder dislocation. In 2 cases we used the Delta prosthesis and in a further 14 cases the Aquealis Arthroplasty. Routine postoperative follow up was at 3,6,12 and 24 months and included plain radiographic control and clinical evaluation with the Constant Shoulder Score. All patients report significant pain relief and an average improvement of the Constant Score from 40.5 to 72.3. Two patients had anterior dislocation of the prosthesis 4 days postoperatively and we proceeded to the application of a 9 mm metal spacer and bigger polyethylene size. In one patient neuroapraxia of the
Although, reverse shoulder arthroplasty has initially been introduced for rotator cuff arthropathy, its application has been expanded on fracture sequelae, chronic dislocations and even comminuted fractures of the humeral head in elderly patients. The purpose of this study is to present our experience and the mid-term clinical results of this type prosthesis. Between 2006 and 2008 16 reverse shoulder arthroplasties have been carried out in our department. Fourteen patients were female and 2 male with an average age of 72.4 years (55–81). Eleven patients had true rotator cuff arthropathy, 3 malunion of 4-part fractures, one chronic anterior shoulder dislocation and finally one patient had bilateral chronic posterior shoulder dislocation. In 2 cases we used the Delta prosthesis and in a further 14 cases the Aquealis Arthroplasty. Routine postoperative follow up was at 3,6,12 and 24 months and included plain radiographic control and clinical evaluation with the Constant Shoulder Score. All patients report significant pain relief and an average improvement of the Constant Score from 40.5 to 72.3. Two patients had anterior dislocation of the prosthesis 4 days postoperatively and we proceeded to the application of a 9 mm metal spacer and bigger polyethylene size. In one patient neuroapraxia of the
Shoulder injury related to vaccine administration (SIRVA) is a prolonged episode of shoulder dysfunction that commences within 24 to 48 hours of a vaccination. Symptoms include a combination of shoulder pain, stiffness, and weakness. There has been a recent rapid increase in reported cases of SIRVA within the literature, particularly in adults, and is likely related to the mass vaccination programmes associated with COVID-19 and influenza. The pathophysiology is not certain, but placement of the vaccination in the subdeltoid bursa or other pericapsular tissue has been suggested to result in an inflammatory capsular process. It has been hypothesized that this is associated with a vaccine injection site that is “too high” and predisposes to the development of SIRVA. Nerve conduction studies are routinely normal, but further imaging can reveal deep-deltoid collections, rotator cuff tendinopathy and tears, or subacromial subdeltoid bursitis. However, all of these are common findings within a general asymptomatic population. Medicolegal claims in the UK, based on an incorrect injection site, are unlikely to meet the legal threshold to determine liability. Cite this article:
To evaluate the incidence of early complications and operative events during shoulder arthroscopy. A prospective study of 134 consecutive shoulder arthroscopies, performed using lateral decubitus position, by the same team, with 6 months minimum follow up. During 11 months period we performed 80 shoulder arthroscopies in male and 54 in female patients with mean age 48.6 years (15–82 years). Shoulder pathology that we treated was: 74 rotator cuff repair, 37 shoulder instability, 11 frozen shoulder, 9 calcifying tendonitis, 2 SLAP lesion and 1 debridement. We have well-placed 476 anchors and 63 side to side sutures. We experience 4 early complications in total (2.98%): 1 anterior interosseous nerve paresis, that fully recovered 6 weeks post op, 1 motor and sensor ulnar nerve paresis that has not fully recovered 4 months post op, 1 sensor ulnar nerve paresis that has not fully recovered 5 months post op and 1 septic shoulder arthritis that was treated with arthroscopic lavage and intravenous antibiotics and has not shown recurrence 11 months post op. Operative events: 5 (1.05%) anchor slippage, 3 (0.63%) anchor breakage, 5 (0.53%) suture slippage from anchors, 5 (3.73%) instrument breakage, 5 (0.53%) knot loosening or suture breakage. Shoulder arthroscopy is a quite safe but technically demanding operation. Early complications occur in low rate, but due to technical difficulties operative events occur more frequently, without affecting the final outcome of the operation. Although
Introduction and Aims: The purpose of this study was to analyse the results of a new intramedullary retrograde humeral nail used for fixation of difficult fractures of humerus. Method: In Airedale NHS Trust and Calderdale hospitals, 282 patients were treated for displaced humeral fractures. The new nail called Halder Humeral Nail (HHN) was inserted from the olecranon roof proximally towards the head of humerus. It had a specialised locking system by opening of a trio wire at the proximal head of humerus and distally near the elbow the nail was locked with the help of a screw on a plate. Patients were mobilised immediately after surgery in a polysling. Results: At six weeks, 95% of patients were pain free and could perform daily activities comfortably. Average post-operative Constance score was 74.7. Complications included proximal migration of the nail and the trio wire in seven cases; six patients had non-union and one patient had infection. Breakage of trio wire was seen in five cases. This resulted in modification of the nail by introducing an additional screw to lock at proximal humerus around the trio wires. Conclusion: We concluded that stable internal fixation and a good fracture union could be achieved by this new HHN, especially in a displaced humeral fracture, even in poor quality bone with fracture at different level. Pain-free movements, and early recovery was possible without damaging the rotator cuff and risking the
Purpose: To audit the improvement in function gained in patients with cuff tear arthropathy (CTA) using the reversed geometry delta 3 prosthesis and to balance this against operative and postoperative complications encountered. Method: 20 consecutive patients with CTA were assessed using the ASES and Constant scores pre and postoperatively. Results: All patients reported a marked improvement in post-operative pain relief. Average elevation increased from 49° to 102°. Function improved significantly. On the downside this is a technically difficult procedure in a group of patients whose average age was 81 (73–91) but whose biological age was higher. Technical difficulties arise from access to the glenoid, in particular to the inferior margin of the glenoid through a deltoid splitting approach. For this reason the surgical approach was changed to an extended deltopectoral approach with a large inferior capsular release after looping the
Purpose: To evaluate the short to medium term outcome of fifty-four consecutive patients (58 shoulders) treated exclusively with radiofrequency capsular shrinkage for atraumatic instability. Methods: Twenty-three men and thirty-one women (35 shoulders) with a mean age of twenty-four years (range, 14 to 53), who failed a 12 months course of physiotherapy. Instability was multidirectional in 26 patients (29 shoulders), antero-inferior in 24 patients (25 shoulders) and postero-inferior in 4 patients. Results: The Rowe score improved from 33.1 to 74.1 points at thirty-two months (range, 19 to 48) (p<
0.001). Instability recurred in 20 of 58 (34.5%) shoulders. Recurrent instability was related to the type of instability (10 of 13 shoulders for voluntary instability, 10 of 33 shoulders for involuntary instability and none of 12 shoulders for instability pain, p<
0.001) and previous instability surgery (7 of 10 shoulders, p<
0.01). Outcome was not related to the direction of instability, type of radiofrequency probe, age or ligamentous laxity. Two patients had a transient reduction in sensation in the
Purpose of the study: The purpose of this study was to determine the feasibility and reproducibility of a new arthroscopic procedure combining a Bristow-Latarjet lock with Bankart reinsertion of the lambrum. Material and methods: Forty-seven consecutive patients with significant bone defects in the glenoid and a deficient capsule were treated arthroscopically: arthroscopic Bankart had failed in six. The procedure was performed exclusively arthroscopically using a special instrumentation: after its osteotomy and identification of the axiallary nerve, the coracoids was passed through the subcapular muscle with its tendon; the block was fixed on the scapular neck after 90° lateral rotation so as to prolong the natural concavity of the glenoid. Anchors and sutures were then used to refix the capsule and the labrum onto the glenoid border, leaving the block in an extra-articular position. Follow-up included a physical examination and standard x-rays at 45, 90 and 180 days; 31 patients had a postoperative scan. Three independent operators read the images. Results: The procedure was completed arthroscopically in 41 of 47 patients (8%); conversion to a deltopectoral approach was required for six patients (12%). The
Purpose of the study: Optimal management of proximal fractures of the humerus remains a subject of debate. We conducted a prospective epidemiological study to identify injuries encountered, determine the reproducibility of reference classifications and their pertinence for therapeutic decision making. Material and methods: All patients presenting a proximal fracture of the humerus admitted to a teaching hospital from November 2007 to November 2008 were included using a standardised computer form. A CT-scan was obtained if necessary. Fractures were classified by three senior observers (CP, GM, AR) according to the Neer and AO classifications. Results: Two hundred forty-seven fractures were collected in 75 men (30%) and 172 women (70%), mean age 66 years (18–97). There were 112 fractures on the dominant side (45%). Two patients had vessel injury and one an associated injury of the brachial plexus. One patient had an isolated injury to the
Of 545 consecutive patients with anterior shoulder dislocations, 108 (20%) were aged 60 years or more at the time of injury. We reviewed and radiographed 95 of these elderly patients after a mean follow-up of 7.1 years.
Displaced fractures of the distal humerus are very difficult to treat. Numerous techniques have been developed for internal fixation, e.g. plating, Rush nail fixation, IM nailing etc. Results are not very good in majority of the cases. Conventional ‘antigrade’ nailing sometimes may not be suitable for these types of fractures. This new nail is inserted by a close retrograde technique using a special interlocking system to avoid
Both our own experience with antegrade nailing of the humerus and reports in the literature have made us aware of some of the drawbacks of this technique. Invasion of the intact shoulder is associated with damage to the rotator cuff and possible ectopic calcification, resulting in subacromial impingement. The ‘blind’ percutaneous placement of the top locking screw may endanger the
Background. Acute anterior dislocation of the glenohumeral joint may be complicated by injury to neighboring structures. These injuries are best considered a spectrum of injury ranging from an isolated dislocation (unifocal injury), through injuries associated with either nerve or osteoligamentous injury (bifocal injury), to injuries where there is evidence of both nerve and osteoligamentous injury. The latter combination has previously been described as the “terrible triad,” although we prefer the term “trifocal,” recognizing that this is the more severe end of an injury spectrum and avoiding confusion with the terrible triad of the elbow. We evaluated the prevalence and risk factors for nerve and osteoligamentous injuries associated with an acute anterior glenohumeral dislocation in a large consecutive series of patients treated in our Unit. Materials and Methods. 3626 consecutive adults (mean age 48yrs) with primary traumatic anterior shoulder dislocation treated at our unit were included. All patients were interviewed and examined by an orthopaedic trauma surgeon and underwent radiological assessment within a week of injury. Where rotator cuff injury or radiologically-occult greater tuberosity fracture was suspected, urgent ultrasonography was used. Deficits in neurovascular function were assessed clinically, with electrophysiological testing reserved for equivocal cases. Results. Unifocal injuries occurred in 2228 (61.4%) of patients. There was a bimodal distribution in the prevalence of these injuries, with peaks in the 20–29 age cohort (34.4% patients) and after the age of 60 years (23.0% patients). Of the 1120 (30.9%) patients with bifocal dislocations, 920 (82.1%) patients had an associated osteotendinous injury and 200 (17.9%) patients had an associated nerve injury. Trifocal injuries occurred in 278 (7.7%) of cases. In bifocal and trifocal injuries, rotator cuff tears and fractures of the greater tuberosity or glenoid were the most frequent osteotendinous injuries. The
Acute trauma and repetitive nicrotrauma connected with certain athletic activities are oftenmentioned when describing the etiology of nerve entrapment syndromes. According to the literature it is obvious that nerve entrapment syndromes in athletes are not as rare as they were once considered to be. Certain sports or physical activities have been mentioned that lead to specific nerve entrapment syndromes – for example, cyclist’s palsy and bowler’s thumb. Unlike nerve entrapment syndromes, vascular and neurovascular syndromes in athletes seem to be more common and have been described in greater detail, while nerve entrapment syndromes in athletes have been reported only recently. To support this contention, I present currently available information about nerve entrapment syndromes in athletes. For each syndrome possible cause of compression, clinical symptoms and signs, and the most effective treatment is presented. On the upper extremity are described: spinal accessory nerve, thoracic outlet syndrome, brachial plexus, long thoracic nerve, suprascapular
Introduction: Clinically evident neurological injury of the operated limb after total shoulder arthroplasty is not uncommon. The purpose of this prospective study was to determine the incidence of subclinical neurological lesions after reverse shoulder arthroplasty and anatomic shoulder arthroplasty (group control), and to correlate its occurrence to postoperative lengthening of the arm. Method: We included all patients needing a total shoulder arthroplasty either anatomic or reversed. Each patient underwent a pre- and postoperative electromyography (EMG). This study focused on the clinical, radiological and EMG evaluation, with a measure of the lengthening of the arm in case of reversed shoulder arthroplasty according to a protocol previously validated. Result: Between November 2007 and February 2009, we collected 41 patients (42 prostheses), including 23 anatomic (group 1) and 19 reverse (group 2) primary shoulder arthroplasties. The 2 groups were similar according to mean age, comorbidity, male/female ratio and nerve conduction abnormalities on EMG performed on an average of 10 days before surgery. Control EMG realized at an average of 3.6 weeks postoperatively showed in group 1, a plexus lesion due to an intra-operative complication. In group 2, we noticed 9 recent neurological damages (45% of cases) involving mainly the
The current evidence comparing the two most common approaches for reverse total shoulder arthroplasty (rTSA), the deltopectoral and anterosuperior approach, is limited. This study aims to compare the rate of loosening, instability, and implant survival between the two approaches for rTSA using data from the Dutch National Arthroplasty Registry with a minimum follow-up of five years. All patients in the registry who underwent a primary rTSA between January 2014 and December 2016 using an anterosuperior or deltopectoral approach were included, with a minimum follow-up of five years. Cox and logistic regression models were used to assess the association between the approach and the implant survival, instability, and glenoid loosening, independent of confounders.Aims
Methods
Repair of large rotator cuff tears can be a demanding technical exercise, particularly when patients are elderly and tissue quality for repair is poor. In 25 patients we have used a method of tying rotator cuff sutures over a screw fixation post at the level of the surgical neck to secure the torn cuff to the greater tuberosity while healing occured. This study reports the results of these patients. 25 patients (27 shoulders) of average age 68.5 years were reviewed at an average of 22 months post surgery (range 3– 52 months). 4 patients (6 shoulders) were workers compensation injuries. The Constant method of shoulder assessment and visual analogue pain scores were used. Constant scores improved from an average of 30.6 pre-operatively to 75.2 post operatively. Pain scores improved from an average of 7.2 pre-operatively to 2.2 post operatively. Over 80 % of patients reported being very satisfied with the results of their procedure. 2 patients reported being unsatisfied with their procedure. Workers compensation patients had poorer results for pain and function than the group average but still reported good satisfaction with the procedure. 4 complications occurred. 2 patients had re- tears of their cuff after falls. One was repaired with side to side suturing and the other was re-repaired to the post. 1 wound infection occurred requiring arthroscopic shoulder lavage and final removal of the implant. This shoulder subsequently healed with good function. One patient had significant shoulder pain requiring surgery and removal of the fixation post. There were no other cases of screw irritation and no
Purpose: Desmoid tumours are uncommon in the axillary region. We report the clinical course in seven patients operated for desmoid tumours of the axillary region. Material and methods: Our series included two women and five men. Mean age was 52 years (39–60). One tumour was in the trapesium, two were in the retroplexic, two in the axillary fossa, one in the deltoid and one in the upper part of the arm. Biopsy and magnetic resonance imaging were obtained in all patients. Surgical margins were in healthy tissue in five cases; resection was limited to intratumoural tissue in one. The
The purpose was to evaluate the results of reverse shoulder arthroplasty (RSA) in proximal humerus fracture sequelae (FS). Multicenter retrospective series of forty-five consecutive patients operated between 1995 and 2003. Types of FS included: cephalic collapse and necrosis (n=8), chronic locked dislocation (n=5), surgical neck nonunion (n=7), severe malunion (twenty), and isolated greater tuberosity malunion (n=3). Twenty-six patients had surgical treatment of the initial fracture and seventeen had non-surgical treatment; thirty-three Delta and ten Aequalis reverse prosthesis were implanted. Mean age at surgery was seventy-three years (range, fifty-seven to eighty-six). Forty-three patients were available for clinical and radiologic evaluation with a mean follow-up of thirty-nine months (range, twenty-four to ninety-five). Nine re-operations (21%) and ten complications (23%) were encountered, including four infections (leading to two resection-arthroplasties), two instabilities, one glenoid fracture (converted to hemiarthroplasty) and one
Aim: Displaced intrarticular fractures and fracture-dislocations of the proximal humerus usually need operative treatment. The results of shoulder hemiartroplasty for the treatment of neglected fractures and fracture-dislocations are presented. Material – Method: 9 shoulder hemiartroplasties with modular head was used for the treatment of 5 neglected comminuted fractures and 4 fracture-dislocations of the proximal humerus. They were 5 females and 4 males with a mean age of 58 years, which were followed-up for a mean period of 4 years. The time between the injury and the operation varied from 2 to 8 months. The main indications was pain, loss of shoulder movement in relatively young patients. The tuberosities were found and extensively mobilized. The prosthesis was inserted with cement and the tuberosities were reattached to the shaft. Results: Main follow up was 4 years (2–8). The results were assessed according the modified UCLA score and were found excellent in 2, satisfactory in 4 and poor in z cases. Pain has improved in 7 cases and the mean postoperative elevation was 90? (20?–130?). External and internal rotation was significally improved. 5 patients presented satisfactory muscle strength and were able to perform satisfyingly the daily activities. Constant score rated from 50 to 80. The presence of a dislocation did not affect the final outcome. On the contrary the displacement of the tuberosities was decisive, and it was combined with greater scaring of the soft tissues and greater loss of motion. One patient developed transient palsy of the
Introduction: The combined fractures of the clavicle (or A-C dislocation) and the scapular neck are complex injuries related to high energy trauma. Their management varies depending on the degree of instability and the presence of neurovascular complications. We evaluated the results of the treatment given to this rare injury. Material and Method: During a five year period (1997–2001) we treated 12 patients with floating shoulder. The injury was in all cases the result of severe road traffic accident. Nine patients were males and three females with age ranging from 20 to 51 years. Seven patients had injured the right shoulder, the remaining five having injured the left one. Eight patients had additional injuries (chest in four, head in two, fracture of the T4 with complete paraplegia in one, chest and abdominal in one). Three patients had neurovascular complications and were operated upon. Two of them with vascular injury were operated ungently and had arterial graft and stabilization of the clavicle or the A-C joint with tension band. The third patient with only neurological injury (axillary and suprascapular nerves) had similar stabilization of his clavicle. The remaining nine patients with minor displacement of the fractures and stable shoulder girdle were managed conservatively. Results: We reexamined eleven patients. The mean follow-up period was 19 months (8–56 months). In nine patients-including the three operated-the fractures had healed in satisfactory position. In the remaining two the fracture of the scapular neck was malunited, resulting in loss of shoulder normal configuration and restriction of shoulder elevation. In two of the operated patients the coexistence of neurological injury resulted in poor functional outcome. The third one-with the axillary and suprascapular nerve injury-improved in relation to the
Aims: Treatment options for proximal humeral fractures are not very clear, specially in osteoporotic bones. Non operative treatment if on one hand leads to unpredicted and poor outcomes, the operative treatment on the other hand leads to devascularization of fractured fragments and implant failure leading to unacceptable results. Newer interlocking plates, which are applied with minimum soft tissue stripping of fractured fragments and better fixation abilities seems a promising alternative. We present our experience with such plates. Patients and Methods: Over a period of two years 2002 and 2003, we used 50 plates to treat Neer’s two and three parts and surgical neck of humerus fractures. We reviewed our clinical results with PHILOS plates, which is in interlocking plate. Average age was 34 (24–82). 21 Male and 29 Females. We followed them clinically and radiologically for healing. The shoulder function was assesses with DASH scoring system. The DASH system questionnaire was filled by patients before the fracture and after healing of the fractures. We used a regimen of progressive rehabilitation of shoulder from immediate post operative period. All the complications including union issues, shoulder function, wound problems, nerve injuries, infection and implant failure were noted. Two different techniques were used to fix the fracture with the plate. Statistical analysis was performed on the data collected through DASH questionnaires along with multivariate and univariate analysis and t-tests. Results: We were able to follow all the patients who filled the pre fracture and post healing DASH system questioner. X-rays and clinical findings were available for all the patients in the study. All the patients united with average length of 6 weeks (5–12 weeks). All the fractures united. There were no deep infections; however, two patients had to have a week of oral antibiotics for superficial wound infection. There were no permanent nerve injuries. Eight patients had transient
Purpose: Early results of MI treatment of proximal humeral fractures in mainly osteoporotic bone stock using the NCB®-PH plate showed promising results reaching 62 points (86% of age related normal value) in Constant Score 6 months postoperatively (Roederer et al., submitted, 2006). The purpose of this study was to analyze the long-term results focusing on functional outcome and complications. Methods: So far out of a total number of 90 cases we have gained the data of 35 patients (24 women, 11 men; age 68 in the mean) who sustained fractures of the proximal humerus treated MI with the NCB-PH® plate (Zimmer Company, Winterthur, Switzerland). In 16 cases (46%) osteoporosis has been diagnosed pre-operatively. Radiological follow-up in two planes and functional outcome is assessed clinically (ROM) and using visual analogue scale (VAS) for pain and function, Constant Score and a modified adl score (activities of daily living). Results: Average ROM (in degree) for anteversion was 101, glenohumeral abduction 87, external rotation 31 and internal rotation 81. Average VAS for pain was 1, 9 points (10 = worst) and for function 6, 4 points (10 = best). Average Constant Score was 65 points, average adl score was 16 points (30 = best). Between 6 and 12 months postoperatively one case (2, 9%) of sintering of the humeral head and one case (2, 9%) of avascular necrosis was detected. In 3 cases (9%) of reversed impingement we performed total removal of hardware. Four younger patients (11%; age 60 in the average) underwent the same procedure demanding it though not suffering of limited ROM or pain. Conclusion and Significance: In the early results NCB-PH® proved to be an effective MI method of treatment of fractures of the humeral head in the elderly patient with mainly osteoporotic bone stock. The 1 year follow up data show further functional improvement (approx. 5% of Constant Score). The complication rate remains low (5/35 = 14%). Especially, no cases of lesions of the
One of the major long term problems of total shoulder replacement is loosening of the glenoid component. Since 1997 we have been using atmospheric pressure to drive cement into the interstices of the glenoid trabecular bone by lowering the intraosseous pressure. This is achieved by introducing a wide bore needle into the base of the coracoid process and attaching it to surgical suction. During this period approximately 200 Tornier Aequalis shoulder replacements were performed by the senior author. For the purpose of this detailed study 20 consecutive cases were studied. Good exposure of the glenoid is achieved using an extended approach and aggressive surgical releases. The surface is prepared according to the manufacturers recommendation. The base of the coracoid is now exposed and drilled with a 3.5mm AO drill bit, angled so as not to collide with the keel of the glenoid component. A Verres needle is hammered into the glenoid at this point and connected to a separate, second suction apparatus, placed on high suction during final lavage, cement insertion and cement curing. Blood and lavage fluid can be seen to be sucked from the glenoid during preparation and cementation. Standard true antero-posterior radiographs were taken by the same experienced radiographer in the plane of the glenoid face two days following surgery, and at 3 months and one year. A Mitotoyu digital microcalliper with a resolution of 0.1mm was used to determine the depth of cement intrusion and presence of lucent lines. Three independent observers measured each radiograph. Analysis of interobserver error shows agreement between observers. For assessment the glenoid was divided into five zones – Superior flange; superior slope of keel; base of keel; inferior slope of keel; inferior flange. No patient had a complete lucent line around the glenoid component. Four patients had a single zone lucent line (ranging from 1.1mm to 1.7mm) None of these patients had a lucent line around the keel, and those four areas of lucency under the superior or inferior flange were more likely due to incomplete removal of articular cartilage than a failure of cement technique. The reported prevalence of glenoid lucent lines varies from 22% to 89%. The significance of glenoid lucent lines is controversial but several studies have reported a direct relationship between the presence of radiolucent lines and the development of loosening of cemented components. Secure cement technique is more difficult in the shoulder than in the knee or hip. Access is tighter, bleeding more difficult to control and peroxide should not be contemplated because of close proximity of the
Reverse total shoulder arthroplasty (rTSA) can be used in complex cases when the glenoid requires reconstruction. In this study, a baseplate with composite bone autograft and a central trabecular titanium peg was implanted, and its migration was assessed for two years postoperatively using radiostereometric analysis (RSA). A total of 14 patients who underwent a rTSA with an autograft consented to participate. Of these, 11 had a primary rTSA using humeral head autograft and three had a revision rTSA with autograft harvested from the iliac crest. The mean age of the patients was 66 years (39 to 81). Tantalum beads were implanted in the scapula around the glenoid. RSA imaging (stereographic radiographs) was undertaken immediately postoperatively and at three, six, 12, and 24 months. Analysis was completed using model-based RSA software. Outcomes were collected preoperatively and at two years postoperatively, including the Oxford Shoulder Score, the American Shoulder and Elbow Score, and a visual analogue score for pain. A Constant score was also obtained for the assessment of strength and range of motion.Aims
Methods
Vascular compromise due to arterial injury is a rare but serious complication of a proximal humeral fracture. The aims of this study were to report its incidence in a large urban population, and to identify clinical and radiological factors which are associated with this complication. We also evaluated the results of the use of our protocol for the management of these injuries. A total of 3,497 adult patients with a proximal humeral fracture were managed between January 2015 and December 2022 in a single tertiary trauma centre. Their mean age was 66.7 years (18 to 103) and 2,510 (72%) were female. We compared the demographic data, clinical features, and configuration of those whose fracture was complicated by vascular compromise with those of the remaining patients. The incidence of vascular compromise was calculated from national population data, and predictive factors for its occurrence were investigated using univariate analysis.Aims
Methods
Introduction: Thermal shrinkage represents a major innovation in the evolving field of surgery for shoulder instability. The basic science of collagen fiber change has been studied in detailed and set the physical basis for mechanical properties change of the capsule. Animal models and clinical studies has been published for the last decade with short and mid-term results. A clinical application has proceeded basic knowledge in many respects and there is concern about the safety and efficacy of the procedure. Materials and Methods: Between February 1999 and January 2001, 25 patients, mean age 21.5 (range 16–28) were operated (single shoulder) for radiofrequency capsular shrinkage with VAPR device. In this group 2 high performance sportsmen (basketball and judo), 4 leisure sports activities (mainly basketball), 6 combat soldiers and 13 non related to sporting activities. In 5 of these patients arthroscopic Bankart repair was performed. In one case the procedure was performed after failure of capsular shift in an extreme hyperlax multidirectional instability and this patients was excluded from the study. Indication for surgery were: 1. Multidirectional instability with less than 3 frank dislocation. 2. Symptomatic subluxators with positive apprehension test after failed non-operative rehabilitation program. 3. High demands first dislocators sportsman with failure of non operative rehabilitation program. The arthroscopy was performed in sitting position with posterior and anterior portals as a day surgery or overnight hospitalization. Anterior portal was used for VAPR probe first and portals were switched if needed. All patients were immobilized in shoulder immobilizer for 6 weeks. Rehabilitation program was planed on individual basis and patients were instructed not to return to full contact sport or activities at least 6 months post operatively. Patients were checked at 2 and 6 weeks before commence rehabilitation and than at 3, 6, 24 months. Mean follow up was 17.6 months (range 6–27 m.). Results: Operation and postoperative course was uneventful and no complications were detected. All patients had normal
The outcomes following nonoperative management of minimally displaced greater tuberosity (GT) fractures, and the factors which influence patient experience, remain poorly defined. We assessed the early patient-derived outcomes following these injuries and examined the effect of a range of demographic- and injury-related variables on these outcomes. In total, 101 patients (53 female, 48 male) with a mean age of 50.9 years (19 to 76) with minimally displaced GT fractures were recruited to a prospective observational cohort study. During the first year after injury, patients underwent experiential assessment using the Disabilities of the Arm, Shoulder and Hand (DASH) score and assessment of associated injuries using MRI performed within two weeks of injury. The primary outcome was the one-year DASH score. Multivariate analysis was used to assess the effect of patient demographic factors, complications, and associated injuries, on outcome.Aims
Methods
The aim of this study was to report the incidence of implant-related complications, further operations, and their influence on the outcome in a series of patients who underwent primary reverse total shoulder arthroplasty (RTSA). The prospectively collected clinical and radiological data of 797 patients who underwent 854 primary RTSAs between January 2005 and August 2018 were analyzed. The hypothesis was that the presence of complications would adversely affect the outcome. Further procedures were defined as all necessary operations, including reoperations without change of components, and partial or total revisions. The clinical outcome was evaluated using the absolute and relative Constant Scores (aCS, rCS), the Subjective Shoulder Value (SSV) scores, range of motion, and pain.Aims
Methods
Open reduction and plate fixation (ORPF) for displaced proximal humerus fractures can achieve reliably good long-term outcomes. However, a minority of patients have persistent pain and stiffness after surgery and may benefit from open arthrolysis, subacromial decompression, and removal of metalwork (ADROM). The long-term results of ADROM remain unknown; we aimed to assess outcomes of patients undergoing this procedure for stiffness following ORPF, and assess predictors of poor outcome. Between 1998 and 2018, 424 consecutive patients were treated with primary ORPF for proximal humerus fracture. ADROM was offered to symptomatic patients with a healed fracture at six months postoperatively. Patients were followed up retrospectively with demographic data, fracture characteristics, and complications recorded. Active range of motion (aROM), Oxford Shoulder Score (OSS), and EuroQol five-dimension three-level questionnaire (EQ-5D-3L) were recorded preoperatively and postoperatively.Aims
Methods
The Mathys Affinis Short is the most frequently used stemless total shoulder prosthesis in the UK. The purpose of this prospective cohort study is to report the survivorship, clinical, and radiological outcomes of the first independent series of the Affinis Short prosthesis. From January 2011 to January 2019, a total of 141 Affinis Short prostheses were implanted in 127 patients by a single surgeon. Mean age at time of surgery was 68 (44 to 89). Minimum one year and maximum eight year follow-up (mean 3.7 years) was analyzed using the Oxford Shoulder Score (OSS) at latest follow-up. Kaplan-Meier survivorship analysis was performed with implant revision as the endpoint. Most recently performed radiographs were reviewed for component radiolucent lines (RLLs) and proximal humeral migration.Aims
Methods
The aim of this study was to identify risk factors for recurrent instability of the shoulder and assess the ability to return to sport in patients with engaging Hill-Sachs lesions treated with arthroscopic Bankart repair and Hill-Sachs remplissage (ABR-HSR). This retrospective study included 133 consecutive patients with a mean age of 30 years (14 to 69) who underwent ABR-HSR; 103 (77%) practiced sports before the instability of the shoulder. All had large/deep, engaging Hill-Sachs lesions (Calandra III). Patients were divided into two groups: A (n = 102) with minimal or no (< 10%) glenoid bone loss, and B (n = 31) with subcritical (10% to 20%) glenoid loss. A total of 19 patients (14%) had undergone a previous stabilization, which failed. The primary endpoint was recurrent instability, with a secondary outcome of the ability to return to sport.Aims
Methods
In order to determine whether and for whom serial radiological evaluation is necessary in one-part proximal humerus fractures, we set out to describe the clinical history and predictors of secondary displacement in patients sustaining these injuries. Between January 2014 and April 2016, all patients with an isolated, nonoperatively treated one-part proximal humerus fracture were prospectively followed up. Clinical and radiological evaluation took place at less than two, six, 12, and 52 weeks. Fracture configuration, bone quality, and comminution were determined on the initial radiographs. Fracture healing, secondary displacement, and treatment changes were recorded during follow-up.Aims
Patients and Methods
The glenohumeral joint is the most frequently dislocated articulation, but possibly due to the lower prevalence of posterior shoulder dislocations, approximately 50% to 79% of posterior glenohumeral dislocations are missed at initial presentation. The aim of this study was to systematically evaluate the most recent evidence involving the aetiology of posterior glenohumeral dislocations, as well as the diagnosis and treatment. A systematic search was conducted using PubMed (MEDLINE), Web of Science, Embase, and Cochrane (January 1997 to September 2017), with references from articles also evaluated. Studies reporting patients who experienced an acute posterior glenohumeral joint subluxation and/or dislocation, as well as the aetiology of posterior glenohumeral dislocations, were included.Aims
Materials and Methods
Aims
Patients and Methods
Since long-term outcome of teres major tendon transfer surgery
for irreparable posterosuperior rotator cuff (RC) tears is largely
unknown, the primary aim of this study was to evaluate the long-term
outcome of the teres major transfer. We also aimed to report on
the results of a cohort of patients with a similar indication for
surgery that underwent a latissimus dorsi tendon transfer. In this prospective cohort study, we reported on the long-term
results of 20 consecutive patients with a teres major tendon transfer
for irreparable massive posterosuperior RC tears. Additionally,
we reported on the results of the latissimus dorsi tendon transfer
(n = 19). The mean age was 60 years (47 to 77). Outcomes included
the Constant score (CS), and pain at rest and during movement using
the Visual Analogue Scale (VAS).Aims
Patients and Methods
Fractures and nonunions of the proximal humerus are increasingly treated by open reduction and internal fixation. The extended deltopectoral approach remains the most widely used for this purpose. However, it provides only limited exposure of the lateral and posterior aspects of the proximal humerus. We have previously described the alternative extended deltoid-splitting approach. In this paper we outline variations and extensions of this technique that we have developed in the management of further patients with these fractures.
Between 1997 and 2007, 68 consecutive patients underwent replacement of the proximal humerus for tumour using a fixed-fulcrum massive endoprosthesis. Their mean age was 46 years (7 to 87). Ten patients were lost to follow-up and 16 patients died. The 42 surviving patients were assessed using the Musculoskeletal Tumor Society (MSTS) Score and the Toronto Extremity Salvage Score (TESS) at a mean follow-up of five years and 11 months (one year to ten years and nine months). The mean MSTS score was 72.3% (53.3% to 100%) and the mean TESS was 77.2% (58.6% to 100%). Four of 42 patients received a new constrained humeral liner to reduce the risk of dislocation. This subgroup had a mean MSTS score of 77.7% and a mean TESS of 80.0%. The dislocation rate for the original prosthesis was 25.9; none of the patients with the new liner had a dislocation at a mean of 14.5 months (12 to 18). Endoprosthetic replacement for tumours of the proximal humerus using this prosthesis is a reliable operation yielding good results without the documented problems of unconstrained prostheses. The performance of this prosthesis is expected to improve further with a new constrained humeral liner, which reduces the risk of dislocation.
Despite the expansion of arthroscopic surgery of the shoulder,
the open deltopectoral approach is increasingly used for the fixation
of fractures and arthroplasty of the shoulder. The anatomy of the
terminal branches of the posterior circumflex humeral artery (PCHA)
has not been described before. We undertook an investigation to
correct this omission. The vascular anatomy encountered during 100 consecutive elective
deltopectoral approaches was recorded, and the common variants of
the terminal branches of the PCHA are described.Aims
Patients and Methods
To analyse the influence of upper extremity trauma on the long-term
outcome of polytraumatised patients. A total of 629 multiply injured patients were included in a follow-up
study at least ten years after injury (mean age 26.5 years, standard
deviation 12.4). The extent of the patients’ injury was classified
using the Injury Severity Score. Outcome was measured using the
Hannover Score for Polytrauma Outcome (HASPOC), Short Form (SF)-12, rehabilitation
duration, and employment status. Outcomes for patients with and
without a fracture of the upper extremity were compared and analysed
with regard to specific fracture regions and any additional brachial
plexus lesion.Aims
Patients and Methods
We performed a comprehensive systematic review of the literature to examine the role of hemiarthroplasty in the early management of fractures of the proximal humerus. In all, 16 studies dealing with 810 hemiarthroplasties in 808 patients with a mean age of 67.7 years (22 to 91) and a mean follow-up of 3.7 years (0.66 to 14) met the inclusion criteria. Most of the fractures were four-part fractures or fracture-dislocations. Several types of prosthesis were used. Early passive movement on the day after surgery and active movement after union of the tuberosities at about six weeks was described in most cases. The mean active anterior elevation was to 105.7° (10° to 180°) and the mean abduction to 92.4° (15° to 170°). The incidence of superficial and deep infection was 1.55% and 0.64%, respectively. Complications related to the fixation and healing of the tuberosities were observed in 86 of 771 cases (11.15%). The estimated incidence of heterotopic ossification was 8.8% and that of proximal migration of the humeral head 6.8%. The mean Constant score was 56.63 (11 to 98). At the final follow-up, no pain or only mild pain was experienced by most patients, but marked limitation of function persisted.
Most proximal humeral fractures are stable injuries of the ageing population, and can be successfully treated non-operatively. The management of the smaller number of more complex displaced fractures is more controversial and new fixation techniques have greatly increased the range of fractures that may benefit from surgery. This article explores current concepts in the classification and clinical aspects of these injuries, reviewing the indications, innovations and outcomes for the most common methods of treatment.
We retrospectively reviewed the outcomes of 33
consecutive patients who had undergone an extra-articular, total or
partial scapulectomy for a malignant tumour of the shoulder girdle
between 1 July 2001 and 30 September 2013. Of these, 26 had tumours
which originated in the scapula or the adjacent soft tissue and
underwent a classic Tikhoff–Linberg procedure, while seven with
tumours arising from the proximal humerus were treated with a modified
Tikhoff-Linberg operation. We used a Ligament Advanced Reinforcement
System for soft-tissue reconstruction in nine patients, but not
in the other 24. The mean Musculoskeletal Tumor Society score (MSTS) was 17.6
(95% confidence interval (CI) 15.9 to 19.4); 17.6 (95% CI 15.5 to
19.6) after the classic Tikhoff–Linberg procedure and 18.1 (95%
CI 13.8 to 22.3) after the modified Tikhoff–Linberg procedure. Patients
who had undergone a LARS soft-tissue reconstruction had a mean score
of 18.6 (95% (CI) 13.9 to 22.4) compared with 17.2 (95% CI 15.5
to 19.0) for those who did not. The Tikhoff–Linberg procedure is a useful method for wide resection
of a malignant tumour of the shoulder girdle which helps to preserve
hand and elbow function. The method of soft-tissue reconstruction
has no effect on functional outcome. Cite this article:
A variety of operative techniques have been described as under
the term ‘Bristow-Latarjet’ procedure. This review aims to define
the original procedure, and compare the variation in techniques
described in the literature, assessing any effect on clinical outcomes. A systematic review of 24 studies was performed to compare specific
steps of the technique (coracoid osteotomy site, subscapularis approach,
orientation and position of coracoid graft fixation and fixation
method, additional labral and capsular repair) and detect any effect
this variability had on outcomes.Objectives
Materials and Methods
Between 1998 and 2007, 22 patients with fractures of the scapula had operative treatment more than three weeks after injury. The indications for operation included displaced intra-articular fractures, medialisation of the glenohumeral joint, angular deformity, or displaced double lesions of the superior shoulder suspensory complex. Radiological and functional outcomes were obtained for 16 of 22 patients. Disabilities of the Arm, Shoulder, Hand (DASH) and Short form-36 scores were collected for 14 patients who were operated on after March 2002. The mean delay from injury to surgery was 30 days (21 to 57). The mean follow-up was for 27 months (12 to 72). At the last review the mean DASH score was 14 (0 to 41). Of the 16 patients with follow-up, 13 returned to their previous employment and recreational activities without restrictions. No wound complications, infection or nonunion occurred. Malunion of the scapula can be prevented by surgical treatment of fractures in patients with delayed presentation. Surgery is safe, effective, and gives acceptable functional results.
