Sub-Acromial Decompression (SAD) for impingement has a failure rate of 5–20%. We used MRI to see whether SAD failure is associated with muscle wasting or fatty degeneration in the rotator cuff. Fifty one patients with impingement were assessed using MRI pre- and post-op. Following arthroscopic SAD, seven patients with cuff tears were excluded. This study reviews the pre-op and 6 month post-op MRIs of the remaining 44 patients (25 males; 19 females) and also 17 additional MRIs obtained at three years post-op. MRI assessment was performed by an experienced radiologist using Zanetti’s muscle bulk assessment with values expressed as standard deviations from an age matched mean and Goutallier’s fatty degeneration assessment graded 0 to 4. There was a wide range of pre-op muscle bulk values (SupraSpinatus minus;2.4 to +3.4; SubScapularis minus;2.1 to +4.8; and InfraSpinatus/ Teres Minor minus;1.1 to +5.7). Comparing post-op with pre-op there was a gradual trend towards a reduced muscle bulk for each muscle after surgery but to a limited extent only (< 0.5SD). Pre-op fatty degeneration of SS and IS was grade 2 in about a half with a mild increase with time post-op (SS pre=50%, 6/12 and 3 years=59%; IS pre=45%, 6/12=43% and 3 years=59%). There was a similar age distribution for grades 1 and 2. Only three of the patients were a clinical failure at 6 months but this increased to five of the 17 patients scanned at 3 years. Predicting these failures was not possible based on the pre-op MRI data. The high initial success of SAD was not accompanied by an overall increase in muscle bulk or quality of the muscle at 6 months. The progressive loss of muscle bulk and quality over 3 years was accompanied by an increased clinical failure rate.

Aim: To assess the outcome of arthroscopic subacromial decompression on rotator cuff muscles

Material: 44 patients with impingement syndrome and intact rotator cuffs were recruited 3 years ago. All were followed up 6 months after surgery and 17 were selected randomly to attended after 3 years.

Methods: All patients prior to surgery underwent:

Clinical examination.

Constant Scoring.

Cybex testing of the rotator cuff muscles.

MRI scans.

Arthroscopic examination followed by arthroscopic SAD.

Standard post-op rehab.

Tests were repeated at 6 months, and in 17 patients again 3 years after surgery.

Results: 1– 41patients (93.18%) improved subjectively at 6 months, and 12 (out of 17) were still satisfied after3 years. 3- Impingement signs disappeared in 41 patients at 6 months and in 13 out of 17 at three years. 4- Average increase in Constant score was 18 points at 6 months and 4 points at 3 years. Pain ADL Pos. ROM Power Total Pre-op mean 5.71 5.23 5.23 25.45 8.76 50.38 Post-op mean 11.67 8.04 8.14 38.05 20.9 86.8 3 years mean 10.91 8.02 7.83 42.78 16.6 86.14 5-Dynamometer (Cybex) Muscle testing: Average power in Watts Abduct Adduct Int. Rot. Ext. Rot. Int. Rot. Ext. Rotation at side at side at 90abduct at 90abduct Pre-op 40.01 61.3 38.2 23.12 32.56 27.78 6/12 postop 54.78 76.6 51.93 36.34 40.74 39.19 3 years p.o. 52.65 69.98 52.77 38.55 40.78 36.21

Conclusions

SAD still provides good pain relief

Muscle power increases post-operative but tends to plateau or slightly decrease after 3 years

Dynamic muscle power measurement is recommended for accurate assessment.

Other Cybex measurements (Torque) had little relation to clinical outcome.

Constant score does not accurately assess changes in muscle power.

The Halder Nail was introduced into the UK in 1994 and the inventor has recently reported his results (Halder et al, 2001¹). Our unit has used the Halder humeral nail since 1997 for the management of traumatic and pathological fractures of the proximal humerus.

Methods: We conducted a retrospective cohort study of all patients undergoing Halder nailing from March 1997 to February 2001. 50 patients were included with a follow up of 3 months to 4 years. Fractures were classified into trauma related and pathological. Trauma related fractures were subdivided into 2-, 3- and 4-part fractures of the surgical neck, and humeral shaft fractures. Post-operative Constant scores were obtained for 34 patients.

Results: Thirty-two female and 18 male patients were included with a mean age of 69 years. There were 6 humeral shaft fractures; 13 2-part; 7 3-part and 9 4-part humeral neck fractures. There were 15 cases of nailing in pathological bone.

Trauma Cases: Of the 35 trauma related fractures there were 15 cases of non-union, and 12 cases of delayed union (time to union > 3 months). Postoperative radiographs demonstrated good reduction in 27of these 35 cases. The nail was removed in 16 cases due to impingement problems at the shoulder. Four patients subsequently required a hemiarthroplasty or dynamic compression plating following nail removal. In addition there were 6 cases of trio wire protrusion and 2 cases of broken wires. Of the 28 patients on whom post-op Constant scores had been obtained 8 scored 60% or above, 11 scored 40–59% and 9 scored 39% or less.

Pathological Cases: There were 8 cases of established pathological fractures and 7 cases of prophylactic nailing in pathological bone. Good postoperative reduction was demonstrated in 14 of the 15 patients. There were 2 cases of wound infection and 2 cases of nail impingement. 13 of the 15 patients reported good pain relief following fixation.

Conclusion: Despite good radiographic reduction following Halder nailing, non-union, delayed union and nail impingement were common in the trauma group. However the Halder nail did provide reliable and immediate pain relief and stability of the bone to allow healing in patients with pathological humeral fractures.

Aim: To investigate the effect of Arthroscopic Subacromial Decompression and rehabilitation on rotator cuff muscle strength and function.

Material: 24 patients with primary impingement syndrome and intact rotator cuffs were recruited. 8 further patients were excluded due to pathologies found at arthroscopy.

Methods: All recruited patients prior to surgery underwent: 1- Through clinical examination. 2-Constant Scoring. 3- Detailed Cybex dynamometer testing of the rotator cuff muscles of both shoulders in six different positions with the same range and for power, speed and torque. 4- MRI scans. 5- Full arthroscopic examination followed by a routine arthroscopic SAD. 6-Standard post-op rehab programme.

All tests were repeated at the minimum of 6 (average 6.3) months after the operation.

Results:

CLINICAL

- 23 (95.83%) improved subjectively, and were back to their normal daily routines.

- The average improvement in VAS scoring was an average of 3.5 (2–7))

- Impingement signs disappeared in 23 patients (95.83%)

- Average increase in Constant score was 23 points, from 53.5 to 76.5.Average pain increased from 7.5 to 9, ADL from 5.5 to 6, hand position from 7 to 8, range of motion from 21.5 to 37 & power from 9 to 17. Dynamometer Muscle testing (All measurement of power was done in watts)

A-Abduction power increased from an average of 14.5 to 32.9, Adduction from 17 to 42

b- At maximal adduction internal rotators increased from 25.5 to 34.55, external rotators from 20.25 to 30.85 and

c- At 90° abduction the internal rotators increased from 19.55 to 31.3, and the external rotators from 16.6 to 21.95

Conclusions:

-ASD provides good pain relief

-Most patients return to work before the end of 6 months period; however there seems to be a tendency for further improvement after the 6 months period.

- Muscle power increases post-operative but with individual variation

-Dynamic Power assessment is preferable to the Constant Score method, as power is measured in Watts, and can test below 90° of elevation.

-Power measurement is the only parameter directly related to the clinical outcome of ASD.