Background

Nonsurgical treatment of Acromioclavicular joint dislocations is well established. Most patients treated conservatively do well, however, some of them develop persistent symptoms. We have used two different surgical reconstruction techniques for Chronic ACJ dislocation stabilization. The study evaluates the effectiveness of a braided polyester prosthetic ligament and modified Weaver-Dunn reconstruction methods.

Data were collected on patients undergoing subacromial decompression (SAD) in our routine practice from 1998 to 2004. All patients had clinical signs of subacromial pain and had failed conservative treatment. Tears were not repaired. Data on age, gender, arm dominance and presence of cuff tear at operation were recorded. At six months post-operatively, patients were assessed with the Constant Score (CS). Data were analysed using multiple linear regression. Data on 427 patients were collected, 168 having rotator cuff tears. The mean age was 55.41 years (SD 12.00). There were 233 women and 191 men. There were no significant gender differences between the two groups (x2=2.34, df=1, p=0.13). The group with cuff tears were significantly older by 10.24 years (p< 0.001, 8.10 to 12.38). Power of the study was 90% at the 5% significance level. Multiple linear regression showed that gender, age and presence of a cuff tear all had a significant effect on the CS. Gender B = 5.52 (1.99 to 9.06) p = 0.002 Age B = −0.31 (−0.48 to −0.15) p < 0.001 Cuff tear B = −5.51 (−9.48 to −1.55) p = 0.007 Hand dominance and the side operated upon had no significant effect. We found that in patients with symptomatic shoulders, who had failed conservative treatment and undergone an SAD, the CS at six months follow up was lower in those who had a cuff tear. There was increased tear prevalence in slightly older patients, and these scored on average 5.5 (1.5 to 9.5) points less than expected on the CS, p = 0.007, after allowing for age and gender. We believe that the surgeon should discuss with the patient whether a 5.5 points lower score is enough of a difference to warrant a formal rotator cuff repair rather than debridement and SAD alone, and a joint decision should be made.

The NHS Plan (2000) identified the need for change in the way patients are asked to give consent for surgery to make the process more explicit. A new NHS operation consent form was introduced in April 2002 following the Bristol enquiry into deaths associated with Cardiac Surgery.

Methods: We have addressed the obtaining of consent for surgery as an evidence-based exercise. The published literature has been reviewed and we have attempted to accurately quantify the success rates for surgery, complication rates and poor outcomes in order to identify what the likely benefits and risks are for our common operations –

Shoulder – Arthroscopic Sub-Acromial Decompression, Anterior stabilisation, Rotator Cuff repair, excision lateral end of clavicle and Shoulder Arthroplasty.

Evidence was therefore been categorised into 4 levels:

National & International published results

Results: We have taken the standard NHS Consent Form and modified it in a printed format to present to the patient a clearer description of the anticipated outcome from their surgery (with percentages). This evidence based consent form was evaluated in a combined prospective and retrospective survey of 60 patients who attended our pre-operative assessment clinic. We will present the results of the survey and demonstrate the standardised Consent Forms.

Conclusions: The majority of the information the patient wished to know was Level 4 evidence!

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.

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

Background: Total elbow prostheses are broadly classified into linked and the unlinked categories. We have looked at long-term results of unlinked Kudo 5 total elbow replacement used in the treatment of patients with rheumatoid arthritis in 2 hospitals.

Methods: 87 Kudo 5 Total elbow replacements in 70 patients with adult rheumatoid arthritis were performed at Wexham Park Hospital, Slough and City Hospital, Nottingham by 2 specialist elbow surgeons, the senior authors. 16 patients had died and 8 patients were lost to follow up. 62 elbow replacements in 46 patients were evaluated at a mean follow up of 79 months [29–137 months] using the Mayo Clinic Performance Index. Postoperative radiographs were also reviewed for loosening using standard anteroposterior and lateral films

Results: Preoperatively 6 had moderate pain and 56 had severe pain. Postoperatively the pain was rated as none or mild by 58 and moderate by 4. The average Mayo Elbow Score improved from 37 preoperatively to 86 postoperatively. The mean arc of flexion/extension improved from 60 to 99 degrees. There were 14 complications including ulnar neuropraxia, fracture, dislocation, triceps rupture and loosening. 4 cases were revised, 2 for aseptic and 2 for septic loosening. Postoperative radiographs showed 5 cases with loosening around the ulna component.

Conclusions: The long-term results using the Kudo 5 elbow prosthesis in patients with rheumatoid arthritis are acceptable and comparable to other series reported of this implant. To date this is the largest series reported with the longest follow up using this implant.

We aimed to test the biomechanically predicted hypothesis that in massive rotator cuff tears irreparable by conventional methods the newly developed Nottingham Augmentation Device (NAD) would provide greater functional improvement than that gained from the gold standard of arthroscopic subacromial decompression. Thirty patients treated between 2001 and 2004 were assessed by pre- and six month post-operative Constant scoring. Fifteen underwent open acromioplasty and cuff reconstruction using the NAD (mean age 67.3), while 15 underwent a standard arthroscopic decompression (mean age 67.4). The two groups were matched retrospectively based on size of cuff tear, age and sex. Data was analysed using the student’s t-test at the 95% confidence interval. Both groups displayed a statistically significant increase in Constant score after surgery. The mean increase for NAD patients was 18.7 points compared with 17.6 points for those undergoing arthroscopic decompression. However there was no significant difference between the two groups’ improvement and this was even so in the power sub-category, where increased benefit was predicted with the NAD. The NAD requires greater surgical access, operating time and peri-operative analgesia, and no active mobilisation for six weeks. The arthroscopic technique is minimal access, rapid, involves no prosthesis or foreign body insertion and allows immediate mobilisation. However, with clear biomechanical benefits of the NAD seen in vitro, our results may simply reflect cuff tears in an older population group with irreversible tissue changes and less rehabilitative potential. A randomised prospective trial in a younger patient group with more acute tears and less tissue atrophy would appear the next step in determining the NAD’s place in the management of massive rotator cuff tears.

Background: Total elbow prostheses are broadly classified into linked and the unlinked categories. We have looked at long-term results of unlinked Kudo 5 total elbow replacement used in the treatment of patients with rheumatoid arthritis in 2 hospitals.

Methods: 87 Kudo 5 Total elbow replacements in 70 patients with adult rheumatoid arthritis were performed at Wexham Park Hospital, Slough and City Hospital, Nottingham by 2 specialist elbow surgeons, the senior authors.

16 patients had died and 8 patients were lost to follow up. 62 elbow replacements in 46 patients were evaluated at a mean follow up of 79 months [29–137 months] using the Mayo Clinic Performance Index. Postoperative radiographs were also reviewed for loosening using standard anteroposterior and lateral films.

Results: Preoperatively 6 had moderate pain and 56 had severe pain. Postoperatively the pain was rated as none or mild by 58 and moderate by 4. The average Mayo Elbow Score improved from 37 preoperatively to 86 postoperatively. The mean arc of flexion/extension improved from 60 to 99 degrees. There were 14 complications including ulnar neuropraxia, fracture, dislocation, triceps rupture and loosening. 4 cases were revised, 2 for aseptic and 2 for septic loosening. Postoperative radiographs showed 5 cases with loosening around the ulna component.

Conclusions: The long-term results using the Kudo 5 elbow prosthesis in patients with rheumatoid arthritis are acceptable and comparable to other series reported of this implant. To date this is the largest series reported with the longest follow up using this implant.

Introduction: This study investigates the survival (and radiological loosening) rates of prostheses following uncemented Total Shoulder Arthroplasties (TSAs) focusing on the glenoid baseplate fixation.

Methods: ALL uncemented TSAs inserted in one shoulder unit from 1989 to 2001 were entered onto a database prospectively and the patients monitored to death or failure of the implant, resulting in revision surgery. Over 80% of the surviving implants were monitored on sequential radiographs and the radiological loosening rate was observed. 273 TSAs have been monitored – 193 with a porous coated glenoid baseplate and 80 with a hydroxyapatite coating on top of the porous coating.

Results: The Survival rates (%) of the non-HA coated baseplates at 1 to 12 years using the Life Table Method were:− 97, 93, 89, 83, 83, 81, 79, 79, 77, 75, 75 & 75% respectively. The Survival rates for the HA coated glenoid base-plates at 1 to 4 years were 100, 97, 93, & 93% respectively. Failures were predominantly due to mechanical loosening and glenoid disassembly with only 3 cases of infection documented. Thus by 4 years there was a statistically significant improvement in survival of the glenoids. Survival rates were further reduced when radiological loosening was taken into account. The earlier series was analysed to assess the survival of prostheses inserted for RA and OA. The survival rates at 5 and 10 years were 78% & 70% for OA and 96% and 88% for RA.

Discussion & Conclusions: This Life Table analysis confirms the early benefit from the use of hydroxy-apatite coating of the glenoid implant of a TSA. Further improvements, particularly in relation to reducing further the small risk of disassembly are underway.

Introduction: Inflammatory or degenerative processes of glenohumeral joint lead to pain and restriction of movements of the shoulder. As with the treatment of disabling arthritis in the other large joints, prosthetic replacement of the glenohumeral joint has gained in popularity because of its efficacy in relieving pain. Several designs for the total shoulder replacement (TSR) prostheses are currently used for the cemented and cementless implantation. The uncemented prostheses were developed in order to achieve a “biological” fixation of the implant to the adjacent bone. No survivorship data exists to compare these devices to the original TSR prostheses for cemented implantation, although this information is crucial for the decision making regarding their use. We present the long term survival rates of the Bio-Modular TSR prosthesis for uncemented implantation.

Methods:The Bio-Modular TSR prosthesis was implanted in 90 patients between 1989–1994 (15 men and 75 women, mean age 61 years, range 19–92 years). This prosthesis was the first to use an anatomical, offset humeral head, based on the study on the bony anatomy of the upper humerus. The mean follow-up period was 8.8 years. Survivorship analysis, according to the method described by Murray et al. and based on Rothman’s formula for the confidence limits determination, was used for the outcome evaluation of all the prostheses studied. The criterion for failure in this series was are-operation on the shoulder with a removal of part or all of the prosthesis.

Results: The ten-year cumulative survival rates of the Bio-Modular prosthesis was 71.7%.

The main cause for this low survivorship rate is the low survivorship of this prosthesis among patients with primary osteoarthritis, 61.4% ten years survivorship. Conversely among the patients with rheumatoid arthritis the ten years survivorship was considerably higher (86.9%). The main cause of failure of this prosthesis was related to the glenoid component and was either due to aseptic glenoid component loosening (in 54% of the failed cases) or a failure (uncoupling) of the polyethylene bearing liner in 17% of failed cases. Furthermore about 70% of the failed cases occurred during the first four postoperative years showing an overall four years cumulative survivorship rate of 80.9%.

Discussion: The survivorship data presented here indicate that the use of the Bio-Modular TSR prosthesis in patients with osteoarthritis produces less favorable results, comparing to the classical (Neer II) cemented designs. Therefore, the use of this prosthesis in patients with osteoarthritis should be reconsidered. But the higher survival of the prosthesis in the patients with rheumatoid arthritis suggests its safe use in the rheumatoid patients.

Purpose: To analyse preliminary outcomes of a new synthetic ligament used for reconstructing coraco-clavicular ligament in acromio-clavicular joint disruption.

Methods: Patients who underwent acromio-clavicular joint stabilisation using Nottingham Surgilig were followed up at average of 40 months (range 6–80 months) post operation. Apart from clinical and radiological assessment, the Constant-Murley scoring system and the Imatani scores were also used to measure outcome.

Results: Twenty patients underwent this operation and data was available on 19 of them. These patients had their operation after an average of 18 months following injury, during which period they had conservative treatment, except in 2 cases where a Weaver Dunn operation was performed initially.

The mean Constant score was 88 (s.d. 12). The mean Imatani score was 86 (s.d. 16). Most patients were satisfied with the operation (90%). There was one case of rupture through the central portion of the Surgilig, and following extensive laboratory analysis, the ligament has been modified since. One patient had a fracture of his coracoid while lifting heavy weights. In 4 patients there was clinical and radiological evidence of loosening of the screw but only 1 complained of this being a problem.

Conclusion: This is an initial medium term outcome analysis of the Nottingham Surgilig. Our results are promising and justify further use and evaluation of this relatively new technique.

We report the results of a method of reconstructing massive rotator cuff (RC) tears and reinforcing the repaired RC tendons with re-tensioning of the cuff to effect reconstruction of tears which were previously considered non-repairable.

Methods A consecutive series of 37 patients (19 men) with a mean age of 61 years (range 45–80) are reported. Mean duration of pre-op symptoms was 19 (4–36) months and the mean pre-op Constant Score (CS) was 41. Insertion involved anchoring the device to the undersurface of the retracted RC tendon with Ethibond sutures, passing the other end of the device through a tunnel under the greater tuberosity and anchoring the device, under tension, to the proximal humerus with 1 or 2 screws. The proximal fixation is similar to “spot-welding” while the distal fixation is a “flexible plate” fixation.

Results The follow-up mean CS (minimum 10/12 post-op) was 54. There has been one deep infection. Two had MRI confirmed re-rupture of the RC. One case of a stiff shoulder required manipulation. This embroidered polyester augmentation device is resistant to re-tears and integrates well with medium term re-centering of the humeral head which had been superiorly displaced pre-op.

We describe a surgical procedure used to achieve glenothoracic fusion after one-stage radical, near total scapulectomy for primary or secondary malignant lesions in six patients. The aim was complete excision of the lesion and preservation of the glenoid to provide a fulcrum for movement of the arm.

Post-operative assessment involved determination of the range of movement and the application of the Musculoskeletal Tumour Society score and the Constant score to evaluate function. The results showed that a functional range of movement was attainable despite such radical surgery, although there was a considerable reduction in power and ability to lift.

Introduction: The aim of this paper is to biomechanically evaluate its stabilisation properties of a new retrograde device used in the þxation of proximal humeral fractures and to assess the effect of Bone Mineral Density (BMD) on its intramedullary þxation. The device incorporates a trio wire at the proximal end instead of a conventional proximal locking screw relying on it for proximal humeral segment stability. Methods: Eight fresh frozen human humeri were harvested from post mortem specimens and evaluated for Bone Mineral Density (BMD). The long axis of the nail and the rotational axis of the humerus were perfectly aligned. A 2-mm perpendicular osteotomy (fracture), 3cm distal to the distal margin of the medial joint surface represented the most rotationally unstable proximal humeral fracture. The proximal end was loaded for torque at a rate of 10û/sec. All testing was halted at failure (10% drop in recorded load). Results: The mean torque hold at failure was 1.51 ± 0.56, median 1.4 Nm-1. The mean rotation observed at failure was 32.2û ± 21.43û, median 34.3û. No signiþcant relationship was identiþed between proximal humeral bone mineral density and Failure of torque hold with the use of this particular device. Conclusions: Biomechanical data from previous similar studies are based on highly variable testing conþgurations. True comparisons are difþcult to obtain. This study shows that the trio wires deform with minimal torque. The Nail is weak in torsional control when compared to other implants available for the treatment of proximal humeral fractures.

This study investigates the survival (with gross radiological loosening) rates of prostheses following uncemented Total Shoulder Arthroplasties (TSAs) focusing on the glenoid baseplate fixation.

All uncemented TSAs inserted in one shoulder unit from 1989 to 2001 were entered onto a database prospectively and the patients monitored to death or failure of the implant, resulting in revision surgery. Over 80% of the surviving implants were monitored on sequential radiographs and the radiological loosening rate was observed. 273 TSAs have been monitored – 193 with a porous coated glenoid baseplate and 80 with a hydroxyapatite coating on top of the porous coating.

The Survival rates (%) of the non-HA coated base-plates at 1 to 12 years using the Life Table Method were:- 97, 93, 89, 83, 83, 81, 79, 79, 77, 75, 75 & 75% respectively. The Survival rates for the HA coated glenoid baseplates at 1 to 4 years were 100, 97, 93, & 93% respectively. Failures were predominantly due to mechanical loosening and glenoid disassembly with only 3 cases of infection documented. Thus by 4 years there was a statistically significant improvement in survival of the glenoids. Survival rates were further reduced when radiological loosening was taken into account. The earlier series was analysed to assess the survival of prostheses inserted for RA and OA. The survival rates at 5 & 10 years were 78% & 70% for OA and 96% & 88% for RA.

This Life Table analysis confirms the early benefit from the use of hydroxyapatite coating of the glenoid implant of a TSA. Further improvements, particularly in relation to reducing further the small risk of disassembly are underway.

This paper reports two studies of uncemented (UC) shoulder arthroplasty – one directed at UC humeral stems (Study 1) and the second at UC glenoid components (Study 2).

In Study 1, 160 consecutive UC humeral stems were inserted between 1989 and 1995. Three types of stem were used – Biomodular, modified Biomodular and Nottingham. At a mean follow-up of 4.3 years 18 shoulders were lost to follow-up. Of the remaining 142 shoulders radiographs from routine follow-up appointments at 6 months,1,2,3,5,7 & 9 years were reviewed together with a clinical follow-up of the patients.

In Study 2 a survival analysis was carried out on a consecutive series of 222 UC glenoid components inserted between 1989 and 1998 at a mean follow-up of over 5 years. Survival was defined as a prosthesis remaining in situ in a live patient. Six types of UC glenoid component were used – Copeland/Zimmer(non HA), stndard Biomodular, low-profile Biomodular, Nottingham prototype, Nottingham and Nottingham with HA.

In Study 1, radiological follow-up indicated 3 stems(2%) showed definite loosening (all related to deep infection) – all were revised. Six stems (4%) showed probable loosening but were asymptomatic.

In Study 2, for the whole series a survival table was created which identified a survival at 2; 5 and 10 years respectively of 92%; 75% and 66%. The later prosthesis designs performed best. A radiological analysis of all shoulders is currently in progress. This audit of outcome has indicated that hydroxyapatite has been beneficial but further long-term studies are required.

Steroids are known to have an adverse effect on the blood glucose levels in diabetics. Intra-articular steroids are commonly used in Orthopaedic and Rheumatology practice. However we have failed to identify any studies to date that have been carried out on the short-term effect of intra-articular steroids in diabetics who are taking insulin. This study was carried out to establish the effects of intra-articular (IA) steroid injections on the blood glucose levels and insulin requirements for insulin dependant diabetic patients treated for a “Frozen Shoulder”.

Methods: Insulin-dependant diabetic patients suffering from a “Frozen Shoulder” who were referred to our out patient clinics were recruited prospectively for this study. Each patient received 40 mg of long acting steroid plus 9 mls of 0.5% Marcain injected intra-articularly into the glenohumeral joint. They were each asked to record their subsequent blood glucose levels and insulin requirements on a form, four times a day for seven days post injection. Each patient was seen again at 6 weeks and, when appropriate, they were offered a second intra-articular injection according to the recommendations of Jacobs et al¹ (1991).

Results: Fifteen patients were recruited into the study. All patients reported a disturbance of their blood glucose control in the post injection period lasting for a variable period up to seven days. Approximately one third of patients found it necessary to increase their daily insulin requirements during the first two days after the injection.

Conclusion: IA steroid injections cause disturbance of the blood glucose control in insulin dependant diabetics. Patients must be warned regarding this side effect when IA steroid injections are given.

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.

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

Conclusions:

-ASD provides good pain relief

Aim: To assess shoulder proprioception before and after a new surgical treatment for multi-directional instability.

Methods: A pilot study assessing shoulder proprioception in asymptomatic controls (n=6), pre-operative patients (n=7) awaiting surgery for multidirectional instability (having failed rehabilitation) and post-operative patients (n=7) having undergone thermo-capsular shrinkage and rehabilitation. Data were obtained using the Proprioception Assessment System developed at our centre following a standardised protocol to record threshold to detection of passive movement (TTDPM) and reproduction of passive position (RPP) in three positions of rotation.

Results: For controls, TTDPM at 0 degrees, +30 degrees and −30 degrees was 1.08 degrees ± 1.05 degrees, 1.75 degrees ± 1.80 degrees and 1.61 degrees ± 1.68 degrees respectively. In the pre-operative group the asymptomatic shoulders had values of 2.48 degrees ± 2.22 degrees, 2.14 degrees ± 1.59 degrees and 1.51 degrees ± 0.87degrees and the symptomatic shoulders 8.59 degrees ± 12.96 degrees, 6.89 degrees ± 6.36 degrees and 4.4 degrees ± 3.45 degrees respectively. In the post-operative group, asymptomatic shoulders had values of 2.09 degrees ± 1.25 degrees, 2.31 degrees ± 1.30 degrees and 2.30 degrees ± 1.31 degrees and symptomatic shoulders 2.15 degrees ± 1.30 degrees, 2.54 degrees ± 1.43 degrees and 2.89 degrees ± 2.12 degrees respectively. With respect to RPP, controls had values at 0 degrees, +30 degrees and –30 degrees of 2.49 degrees ± 1.02 degrees, 2.58 degrees ± 1.13degrees and 2.72 degrees ± 2.11 degrees. In the pre-operative group, the results for asymptomatic shoulders were 2.48 degrees ± 0.68 degrees, 0.87 degrees ± 0.51 degrees and 3.44 degrees ± 2.41 degrees and for symptomatic shoulders 5.63 degrees ± 2.05 degrees, 3.17 degrees ± 2.05 degrees and 7.56 degrees ± 6.10 degrees respectively. In the post-operative group, the results for asymptomatic shoulders were 2.85 degrees ± 1.13 degrees, 3.78 degrees ± 1.94 degrees and 2.55 degrees ± 2.11 degrees and for symptomatic shoulders 2.28 degrees ± 0.81 degrees, 5.40 degrees ± 5.91 degrees and 3.62 degrees ± 1.63 degrees respectively.

Conclusions: There were no differences between shoulders in controls and post-operative patients. Despite the small numbers, the pre-operative patients showed significant differences (p< 0.05) between shoulders in two of the six test protocols. Post-operative shoulders had means similar to controls suggesting thermo-capsular shrinkage may help regain shoulder proprioception after injuries.

The aimof this study was to assess proprioception in multi-directional instability of the shoulder before and after a new surgical treatment.

A cross-sectional pilot study assessing shoulder proprioception in asymptomatic controls (n=6), pre-operative patients (n=7) awaiting surgery for atraumatic, multidirectional instability having failed a comprehensive rehabilitation programme and post-operative patients (n=7) having undergone thermo-capsular shrinkage of the shoulder and post-operative rehabilitation. Data were obtained using the Proprioception Assessment System developed at this centre following a standardised protocol to record both threshold to detection of passive movement (TTDPM) and reproduction of passive position (RPP) in three positions of rotation. Means and standard deviations are presented.

There were no differences between shoulders in controls and post-operative patients. Despite the small numbers, pre-operative patients showed significant differences (p< 0.05) between shoulders in 2 of the 6 test protocols. Post-operative shoulders had means similar to controls suggesting thermo-capsular shrinkage may help regain shoulder proprioception after injury.

Thermal shrinkage of the shoulder capsule requires postoperative joint immobilisation with the humeral head centred in the glenoid fossa for optimal proprioceptive recovery. Routinely applied commercial slings hold the arm internally rotated and lengthen the posterior capsule. The aim of our study was to develop and test the clinical effectiveness of a splint that would maintain the shoulder in an optimal position of neutral rotation after posterior capsular shrinkage.

To our knowledge, no splint has been described for this purpose. We developed a new design fabricating the splint using thermoplastic material. The design was then modified to ensure ease of fitting and patient comfort.

The custom-made splint is fashioned preoperatively and fitted in the operating room after the dressings are applied. Our study group consisted of 18 cases of multidirectional or posterior shoulder instability who were splinted for a period of three weeks after thermal capsular shrinkage. The comfort and compliance of the splint were assessed using a patient questionnaire. Constant scores for the study group were retrospectively compared with a similar patient group managed with a ‘polysling’.

The aim of this study was to assess the results of bone ingrowth into the glenoid component of one design of Total Shoulder Arthroplasty (TSA) in which hydroxyapatite (HA) coating of the glenoid baseplate was introduced since 1997.

Glenoid loosening is one of the most important complications of both cemented and uncemented TSA. Between May 1993 and April 1997 over 140 uncemented, porous coated, metal backed glenoid component were used in our Unit. By 1997 it had become clear that a significant number of these glenoid components had developed mechanical loosening and some required revision. We therefore started using an HA coated glenoid component for our TSAs from April 1997.

One hundred and seventy-four shoulder arthroplasty procedures were performed between April 1997 and October 1999 of which 37 were TSAs using the HA coated uncemented glenoid. The indications included osteoarthritis (22), rheumatoid arthritis (nine), revision TSA (three), avascular necrosis (two) and cuff arthropathy with cuff reconstruction (one). The minimum follow-up was 18 months. The X rays were evaluated using the MLS (Migration, Lucent lines, Screw problems) system, which had been developed and reported previously. This system of evaluation has been shown to be reproducible for assessment of glenoid fixation.

There was one case in which the glenoid liner became displaced and had to be replaced. Our early results at a mean FU of approximately 2 years show an improved radiological fixation compared with those glenoids inserted without HA.

Patients suffering from generalised convulsions may dislocate their shoulders either anteriorly or posteriorly. Those with anterior dislocation are likely to have recurrent episodes because of secondary bony damage to the anterior rim of the glenoid and head of the humerus. In such patients there is high rate of failure of the standard soft-tissue stabilisation procedures. We have therefore devised a bone buttress operation in which autograft or allograft is secured to the deficient anterior glenoid and shaped to form an extension of its articular surface. We report our experience in 14 patients with grandmal epilepsy and recurrent anterior dislocation of the shoulder. After the bone buttress operation there were no further dislocations and all patients were satisfied despite a small restriction in their range of movement. We believe this to be the operation of choice for patients with this difficult problem.

We made a prospective study of 241 Charnley total hip replacements performed between 1968 and 1974. In 1990, we reviewed 92 patients with 103 hips (96.3% of surviving hips) at a mean follow-up of 17.6 years (15 to 20.6) The clinical results were excellent, with Charnley scores of 4 or more for pain in 95% of the patients, for function in 73% and for movement in 93%. Of the whole series, 8.3% had been revised, and Kaplan-Meier survival analysis showed a probability of revision at 20 years of 10.7%. These results are similar to those from the few other series with extended follow-up, and make it difficult to justify the present widespread use of uncemented hip prostheses. It would seem that some aspects of the design of the first-generation Charnley stem were beneficial for long-term survival of the arthroplasty. We found no correlation between the clinical results and radiological loosening on the Harris scale.