The treatment of patients with arthritis of the glenohumeral joint with an associated massive irreparable cuff tear is challenging. Since these patients usually have proximal migration of the humerus, the CTA extended head allows a surface with a low coefficient of friction to articulate with the acromion.

Between 2001 and 2006 a total of 48 patients with arthritis of the shoulder joint associated with a massive cuff tear, were treated with a CTA head. The indications for use being Seebauer Type 1a and 1b appearances on x-ray and active abduction of the arm to more than 60° with appropriate analgesia. Preoperatively, a Constant score and an ASES pain and function score were completed as well as standard radiological assessment. These were repeated at follow up. Paired t tests were carried out for all the variables. A Kaplan-Meier survival analysis was performed.

Follow up varied between 2 and 8 years. Improvements in pain, function and all movement parameters were significant at p< 0.001. There was no change in the strength component. Survival analysis showed 94% survival at 8 years (95% CL 8%) there were 2 revisions and 5 deaths. Radiological assessment at follow up revealed no evidence of humeral stem loosening. In 5 (17%) cases however there was evidence of erosion in the surface of the acromion and in 13 (45%) erosion of the glenoid. Finally one component was also seen to have subluxed anteriorly.

This head design has been in use for a number of years. To date there appears to be no reported outcome of their use. This series shows that in an appropriately selected patient a satisfactory clinical outcome can be maintained in the short to medium term. The presence of erosion of the glenoid but also the under surface of the acromion does require continuing monitoring.

We aim to establish the likely functional scores following different types of surgery for bone tumours. All living patients who had undergone treatment for a bone tumour were contacted and invited to complete a TESS self-report questionnaire. The TESS contains 32 items of day-to-day activities which the patient scores themselves against. The final score is a percentage, with 100% being ‘normal’. The project was approved by the local ethical committee.

723 responses were obtained from just over 1000 letters that were sent. Thirty seven sets of data were incomplete leaving a total of 686. There were 369 males and 317 females, with an average age of 49 (range 15 to 93). The mean interval from their initial operation was 12 years (range 1 to 42). 590 of the procedures were in the lower limb and 96 in the upper limb. 126 patients had an amputation and 560 limb salvage (82%).

Mean scores obtained for each procedure were: EPR mid-femur 86%; EPR distal femur 77%; EPR proximal tibia 74%; EPR proximal humerus 71%; EPR proximal femur 71%; Below knee amputation 70%; EPR total femur 63%; Disarticulation of the hip 61%; Above knee amputation 60%; Hindquarter amputation 57%; EPR pelvis 54%.

Younger patients had much better scores (80% for those under 30 vs. 69% for those over 30, p< 0.0001) than those over 30. Additionally, the scores for those that had had an amputation following a EPR procedure were no worse than those who had had an amputation originally. Significantly, EPR proximal tibia was better than AKA (78% vs. 67% p = 0.0003), as was EPR distal femur (80% vs. 67% p < 0.0001).

This data from a large series is helpful in indicating likely outcomes following surgical treatment of sarcomas, both for patients and surgeons.

To compare the effect of standard non-offset and offset humeral heads on early glenoid loosening. From 2002–2004 in a prospective study, 12 patients with osteoarthritis and intact rotator cuff had a TSR with an offset humeral head matching normal anatomy. Five tantalum markers were introduced into the scapula and acromion, spaced widely apart; four markers were placed in a pegged glenoid component. RSA radiographs were taken postoperatively, three, six, twelve months. The micromotion of this offset head group was compared with a baseline series of TSRs with standard non offset humeral head implants which had previously been measured over 24 months. At 24 months, the largest segment translation for the offset head group was in the anterior/posterior direction with a mean of 0.24mm, the standard head group mean was 0.61mm, t=1.3,P=0.21. Proximal/distal translation gave means of 0.51mm (standard head) and 0.17mm (offset head), t=1.3,P=0.21. Medial/lateral translation was smallest for the offset group with mean 0.16mm this is less than half the standard group mean 0.57mm and is significant, t=1.4,P=0.19. The largest rotation was anteversion/retroversion with a mean of 1.50 (offset) compared to 4.40 (standard), t=2.3, P=0.04. Varus/valgus tilt differed significantly with means 0.90 (offset) and 2.50 (standard), t=3.8,P=0.001; and finally anterior/posterior tilt had smallest means of 0.70 (offset) and 1.00 (standard), t=1.2,P=0.25. Maximum total point motion was also significantly different at 24 months, means of 0.66mm (offset) compared to 1.65mm (standard), t=2.3,P=0.04. Early migration occurs in both groups of pegged components. A principal component micromotion index illustrates the complexity of micromotion. Offset heads move significantly less than the standard type, the significant differences in MTPM movement and in rotation (varus/valgus tilt) suggest that the offset head may decrease eccentric loading

Although few published papers assess the results of revision total shoulder replacement for painful hemi-arthroplasty with a functional rotator cuff, surgical outcome is accepted as being poor. Our experience suggests that results are poor if a well-fixed humeral stem is revised to correct version, and if a non-functional rotator cuff is not alternatively managed. We identified fifteen patients with painful hemi-arthroplasty and a suspected functional rotator cuff that underwent revision total shoulder replacement at Wrightington hospital over a ten year period. The aetiology comprised osteoarthritis (seven), inflammatory arthritis (five), trauma (two) and avascular necrosis (one). The average time interval to revision surgery was 44.5 months. Humeral head size was up-sized in two and down-sized in seven cases at revision surgery. Three cases underwent iliac crest autografting for glenoid deficiency. Four cases underwent humeral stem revision for incorrect version. The average surgical time for primary total shoulder replacement at Wrightington hospital is 80 minutes while the average time for these revision total shoulder replacements was 105 minutes. Four patients had an unsatisfactory outcome according to Neer’s criteria due to an intra-operative greater tuberosity fracture (one), an intra-operative humeral shaft fracture (one) and a non-functional rotator cuff (two), one of which was revised to an extended head prosthesis with good outcome. Surgical time for revision and primary total shoulder replacement did not differ significantly if humeral stem revision or glenoid augmentation was not indicated. Oversized humeral head components may cause pain due to overstuffing the joint and soft tissues. Revision total shoulder replacement for hemi-arthroplasty with incorrect prosthetic version cannot guarantee an improved outcome. Significant glenoid deficiencies can be effectively managed by iliac crest bone grafting at revision total shoulder replacement. Rotator cuff deficient patients should be managed with alternative prostheses.

Introduction and Aims: The aim was to assess the efficacy of current arthroscopic knotting techniques with commonly used suture materials.

Method: A Hounsfield tensiometer with 1000N load cell, strain rate 25mm/min, bar separation of 7.5mm under standard temperature and pressure was used. Suture materials used, 2 Ethibond, 1 PDS and 1 Panacryl. The knotting techniques compared were the Tennessee slider, Tautline hitch, Duncan Loop, SMC knot and Surgeon’s knot. Two surgeons tied each 10 times using a suture passer and standardised knot technique. Each knot was tested to failure on 10 sequential experiments. Suture material strength was tested in isolation, tested to failure using the different knots then repeated after suture immersion in normal (0.9%) saline.

Results: Ultimate strength of the suture material and the knotting techniques were assessed. The mode of failure, slip or suture material fracture was also investigated. The 2 Ethibond had higher ultimate strength than either 1 PDS or 1 Panacryl. The Tautline hitch and Surgeon’s knot had significantly lower slip rates, with superior internal security than the other knotting techniques (P less than 0.002). The Tennessee slider, Duncan Loop and SMC knots had low security and slipped in more than 50 percent of experiments. There was no difference after saline soaking. The number of additional half hitches required for maximum knot holding capacity was consistently three, confirming previous findings.

Conclusion: The Tautline hitch is recommended due to internal security, tying characteristics and overall knot strength. Whichever knot is selected, three additional alternating half hitches to obtain consistent security is strongly supported.

Aim of Study To assess the efficacy of commonly used sutures materials with commonly described arthroscopic knotting techniques in as close a physiological pattern as possible.

Methods The investigation was carried out in three phases. Initially the ultimate strength of the suture material was tested. Materials compared were 1PDS, 2 Ethibond, 1 Panacryl The suture was then tested to failure by two surgeons comparing five different knotting techniques. Knots tested were Tennessee slider, Duncan loop, SMC, Tautline hitch, and Surgeons knot. Finally the test was repeated after soaking the suture with normal saline.

Results As expected, 2 ethibond has a higher ultimate strength than either 1 PDS or 1 Panacryl. The Tautline hitch and Surgeon’s knot had a significantly lower slippage rate when compared to the other knotting techniques. (P value < 0.002). The Tennessee slider, Duncan Loop and SMC knots slipped in > 50% of experiments. No difference was observed when the suture material had been soaked in normal saline. The number of half hitches required to provide maximum knot holding capacity was 3, confirming previous experimental findings by other investigators.

Conclusions Tautline hitch is recommended for use with all suture materials due to low slippage rates, ease of tying, ease of sliding and overall high knot strength.

Aim: Patients with advanced rheumatoid arthritis who were managed with ipsilateral shoulder and elbow arthroplasties were reviewed to determine appropriate sequence of surgery, operative technique and the functional outcome.

Methods: Between 1992 and 2002, twenty-two patients underwent ipsilateral elbow and shoulder arthroplasties. Nineteen patients were available for final review. Clinical and radiological assessments were done on these patients.

Results: Twenty-four upper limbs in nineteen patients were reviewed. Mean age at final follow-up was 61.1 years (49.9 to 73.3yrs; SD 8.2). Mean duration of follow-up from the last operation was 55.5 months (12 to 129.3m; SD 33.5). The average interval between the operations was 40.1 months; it was 41.2 months when elbow operated first and 38.7 months when shoulder was operated first. This difference was not significant (p=0.82). All movements showed significant improvement after respective joint replacements. There was a significantly greater improvement in external rotation of the shoulder when it was operated first (p=0.48). The average improvement in Constant-Murley scores was 28.8 points; with no statistically significant difference between either sequence of operations (p=0.49). However, there was statistically significant improvement in the average Mayo elbow performance score after the elbow arthroplasty when it was operated first (p=0.03).

Two patients needed conversion of shoulder hemi-arthroplasty to total shoulder replacement due to subsequent erosion of the glenoid. One elbow replacement was revised because of recurrent dislocations. There were four patients who developed ulnar neuropathy, of which two were permanent. There were no peri-prosthetic fractures in this series. One patient needed custom-made short-stemmed shoulder prosthesis due to the presence of a long-stemmed humeral component of total elbow prosthesis in situ.

Conclusion: Ipsilateral shoulder and elbow replacements significantly improve pain and function of the limb, when there is advanced arthritis. The joint that appears clinically and radiologically worse should be replaced first. However if both the joints are equally involved we feel that elbow should be replaced first as the functional improvement seems to be better. Careful preoperative planning is required in choosing the type and size of prosthesis, to avoid potential complications.

Introduction The aim of this study was to investigate the potential of impaction bone grafting for the restoration of glenoid bone stock in revision shoulder arthroplasty.

Methods There was significant osteolysis around the glenoid component in four rheumatoid patients who underwent revision shoulder arthroplasty using this technique. The criteria was a contained or containable defect. Femoral head allograft and iliac crest autograft harvested at the time of revision were used. Pre and post-operative radiographs, tomograms and fluoroscopic views aided in bone-stock analysis. Images were analysed for osteolysis, graft survival, incorporation and component loosening. Patients were followed using Constant-Murley scoring pre-operatively, and at a minimum of 12 months. The average patient age was 56 years (range 42 to 76), with three females and one male patient.

Results Glenoid component survivorship pre-revision averaged 9.5 years (range 8 to 12). The pre-operative Constant-Murley average was 11 (range 4 to 20) versus 64 post-operatively, a significant improvement over an average follow-up of 19.5 months (range 12 to 40). Radiological assessment demonstrated all grafts had incorporated with minimal subsidence and no radio-lucency at the graft-bone interface. Two of the glenoid components demonstrated static lucency at the component-graft interface, but no component movement on serial x-rays. In both patients the significant improvement in functional was maintained.

Conclusions To our knowledge this technique has not been described in glenoid component revision. It successfully provided bone for glenoid component insertion. This would not have been possible using standard techniques. The early results for this technique are encouraging and justify the continued application and follow-up of glenoid impaction grafting.

Introduction The aim of this study was to assess the efficacy of current arthroscopic knotting techniques with commonly used suture materials.

Methods A Hounsfield tensiometer with a 1000N load cell, strain rate of 25 mm/min, bar separation of 7.5 mm was used under standard temperature and pressure. Suture materials were those in common use; 2 Ethibond, 1 PDS and 1 Panacryl. The knotting techniques compared were the Tennessee slider, Tautline hitch, Duncan Loop, SMC knot and the Surgeon’s knot. Two surgeons tied each knot 10 times using a suture passer and standardised knot technique. Each knot was tested to failure on 10 sequential experiments. Suture material strength was tested alone, tested to failure using the different knots and after suture immersion in normal saline. The ultimate strength of the suture material and of the various knotting techniques were assessed. The mode of failure, slip or suture material fractured was also investigated.

Results The 2 Ethibond had superior strength compared to 1 PDS or 1 Panacryl. The Tautline hitch and Surgeon’s knot had a significantly lower slip rate, with superior internal security than the other knotting techniques (p < 0.002). The Tennessee slider, Duncan Loop and SMC knots slipped in more than 50% of experiments. No difference was observed after soaking in normal saline. The number of additional half hitches required for maximum knot holding was consistently three, confirming previous findings.

Conclusions The Tautline hitch is recommended with its superior internal security, tying characteristics and overall knot strength. Whichever arthroscopic knot is selected, the addition of three alternating half hitches for consistent security and reliability is strongly supported.

87 patients (51 male, 36 female; mean age 57, range 30 to 82) underwent arthroscopic subacromial decompression (SAD) and were followed up for one year. We calculated the ASES, the Constant, the DASH Disability/ Symptom, and the SF-36 Physical Function scores.

All the scores improved throughout the follow-up period, although the SF36 score showed less marked improvement. Comparing the preoperative and one year values there were significant improvements at one year (p < 0.001) for the three upper-limb-specific scoring systems (ASES, Constant and DASH), and for the SF36, but less so (p = 0.001). Comparing the 6 months and one year scores there were significant improvements in the ASES, Constant and DASH scores, but not in the SF36 score. This suggests that improvement may still be continuing at one year.

No significant differences in the postoperative scores for the four acromion operative appearance groups (normal, minor scuffing, marked damage, bare bone areas) were found, or for the operative cuff appearance groups (normal, minor scuffing, partial tear, full thickness tear, massive cuff tear).

We also asked for the patients’ assessment of their outcome at one year, using a satisfaction visual analogue scale (VAS), and two category selection questions relating to satisfaction and to perceived room for further improvement respectively. Patients were coded as successes or failures on their responses to the VAS and the two questions. There seems to be an association with cuff appearance and success or failure as determined by the response to the room for improvement question. More specifically, this difference seems to be due the infraspinatus. A normal infraspinatus is associated with a successful outcome as perceived by the patient.

In conclusion, with SAD recovery may not be complete at one year. The three limb-specific scores are equally useful in monitoring progress, whereas the more general SF36 score is less useful. The state of the acromion or cuff does not have an effect on outcome as measured by the commonly used scores. The appearance of the infraspinatus may be predictive of success as measured by the patient.

The purpose of this study was to analyse the reason for failure of shoulder arthroplasties performed for osteoarthritis, looking specifically at factors associated with either hemi or total shoulder replacement.

Over an eight-year period over 80 consecutive patients undergoing a Global hemi-arthroplasty or total shoulder arthroplasty were looked at. All patients underwent at least two years of follow up. All patients were assessed pre and post operatively using the Constant and ASES scoring systems. A bio-engineer or physiotherapist performed these evaluations. X-rays were analysed for demarcation, loosening and glenoid erosion. Failure was defined as the need for revision surgery. Reasons for revision were predominately pain, loosening and instability. In these instances the differences between hemi and total joint arthroplasty were recorded. A distinct pattern was present with several early revisions being performed for continuing pain in the patient group who underwent hemi-arthroplasty.

In conclusion, this study supports total shoulder replacement as the operation of choice, in suitable patients, as compared to hemi-arthroplasty. This would appear to reduce the risk of the need for early revision on account of pain. This must be weighed against the potential for late glenoid loosening.

It has been proposed that scoring systems could be nationally used, initially on a secondary care level as a method of prioritising patients on waiting lists for hip and knee arthroplasty. If this were to be successful, scoring systems could be used as a way of tackling the ever increasing waiting list times for surgery which currently stand at around 15 months on the NHS.

I studied and compared the New Zealand and Oxford Hip and Knee Scores, collecting data from 79 patients over a period of seven weeks.

I found that generally, patients who scored highly were recommended for surgery; however I also found that in the group of patients recommended for surgery there was a wide range of scores obtained. There was also a great deal of overlap between the scores obtained by those who were recommended for surgery and those who were not. This means that it would be very difficult to predict a decision for an individual patient based purely on their scores. In addition, many confounding variables can affect the wide range of scores obtained.

I concluded that there was too much variation between the scores obtained by patients undergoing surgery to be able to consistently and fairly prioritise them. In order to implement the use of scoring systems in this country, nationally approved criteria and priority banding categories need to be established. Scoring systems need to be modified to be clearer and to cover more variables. Larger studies need to be conducted with more patients and over a longer period of time; and further work could be done into the proposal that GP’s could use these systems as a tool for referral to consultant out-patient clinics.

The study assesses the efficacy of commonly used suture materials with commonly described arthroscopic knotting techniques in as close a physiological pattern as possible.

The investigation was carried out in three phases. Initially the suture material strength was tested. The suture was then tested to failure using the different knotting techniques. Finally the test was repeated after soaking the suture with normal saline.

A Hounsfield tensometer was utilised with a load cell of 1000N, strain rate of 25mm/min, bar separation of 7.5mm and standard temperature and pressure. Suture material tested was 2 ethibond, 1 PDS and 1 Panacryl. Knotting techniques compared were the Tennessee slider, Tautline hitch, Duncan Loop, SMC knot and Surgeon’s knot. Two surgeons tied each knot 10 times after first becoming practiced with each technique. Each knot was tested to failure on 10 sequential experiments.

Ultimate strength of the suture material and of the knotting techniques was assessed. In addition the mode of failure, whether the knot slipped or suture material fractured was investigated.

As expected, 2 ethibond has a higher ultimate strength than either 1 PDS or 1 Panacryl. The Tautline hitch and Surgeon’s knot had a significantly lower slippage rate when compared to the other knotting techniques. (P value < 0.002). The Tennessee slider, Duncan Loop and SMC knots slipped in more than 50% of experiments. No difference was observed when the suture material had been soaked in normal saline. The number of half hitches required to provide maximum knot holding capacity was 3, confirming previous experimental findings by other investigators.

The Tautline hitch is recommended for use with all suture materials due to low slippage rates, ease of tying, ease of sliding and overall high knot strength

To measure any observed differences in migration and rotation between keeled and pegged glenoid components using roentgen stereo-photogrammetric analysis.

Between 2000–2001 in a prospective randomised study, 20 patients with osteoarthritis had a TSR with roentgen stereo-photogrammetric analysis. Five tantalum markers were introduced into the scapula and acromion, spaced widely apart. Another 4 markers were placed in either a pegged or keeled glenoid component.

RSA radiographs were taken postoperatively, three, six, twelve and eighteen months. The radiographs were digitised and analysed using dedicated software (UmRSA). The relative movement of the glenoid with respect to the scapula was measured.

The largest translation for the keeled components was in the proximal/distal direction with a mean of 1.3mm, the pegged group mean was 0.27mm. This difference was significant, P = 0.001. Both other translation axes showed no significant difference between the two component types. Medial/lateral migration gave means of 0.38mm(keel) and 0.52mm(peg) and the anterior/ posterior translation with means of 0.54mm(keel) and 0.41mm(peg). Maximal total point motion mean values at 18 months were 2.6mm for keeled and 1.1mm for pegged glenoid components. This difference was also significant P=0.001

The largest rotation was anterior/posterior tilt with means of 3.5°(keel) and 1.1°(peg) this difference was significant p=0.005; varus/valgus tilt with a mean of 3.2°(keel) compared to 20(peg) was again, significant P = 0.002. and finally anteversion/retroversion means were 3.3°(keel) and 2.7°(peg). Multivariate analysis identified 2 principal components from the keeled data each accounting for 35% of the variation in the data. The first included transverse and saggital translation together with rotation about the longitudinal axis; the second component consisted of translation on the longitudinal axis with rotation about the transverse axis.

Between 1992 and 2000, 120 shoulder arthroplasties have been inserted in patients with osteoarthritis at this hospital. Shoulder function was assessed using the ASES patient self-evaluation form and the Constant-Murley clinical index as well as evaluation including routine measurements of shoulder motion and pain. The mean follow-up was 4.4years (2 to 10years).

Movement, pain and both shoulder function scores significantly improved after operation with t-test values significant at P< 0.001 level. Three sub-groups of primary osteoarthritis (OA), avascular necrosis (AVN) and post traumatic arthritis (PTA) were analysed separately. Although each group was significantly improved after arthroplasty the AVN and PTA patients had significantly poorer results than OA patients for pain and the functional scores, except the AVN group for the Constant Murley score. General linear model analysis indicated that both Constant-Murley and ASES shoulder function scores were shown to be sensitive to change after treatment and that improvement was maintained for up to 8 years post-operation.

Kaplan-Meier analysis showed a significant difference in survival between the 3 sub-groups of OA, PTA and AVN with 5 of 16 PTA operations needing revision. This was reflected in function measurement with PTA values 20 points lower in both clinical (P=0.014) and self assessed functional status (P=0.004).

At each visit a true AP radiograph was taken. Radiological lucency was graded using the method of Matsen. The humeral components were inserted without cement and there were no signs of loosening. Just four components had lucency at one of 7 zones. There was a noticeably higher incidence of glenoid lucency, Proportional hazards analysis was used to model the hazard rate of glenoids at risk. A hazard model for the glenoid components consisted of only one variable – presence or absence of glenoid erosion noted at operation. The model is significant (P= 0.02) with erosion having a hazard rate 6 times greater than that if not eroded.

All tibial shaft fractures treated at one hospital during a five-year period were studied in a prospective trial. Ninety-one displaced fractures in adults were treated using a conservative policy that included early bone grafting when indicated. Sound bony union was obtained in all cases. Those that healed primarily took on average 16.3 weeks whereas the 24 per cent that required bone grafts took 35.1 weeks. The number of complications, most of which were minor, was considered acceptable. It is concluded that provided early bone grafting is performed when necessary, a basically conservative policy of treatment is satisfactory; bony union of all displaced tibial fractures is achieved in a reasonable period of time.