Introduction The standard surgical practice for athletes with recurrent anterior shoulder instability who play contact or collision sports is to perform either the Bankart repair or Bristow procedure. The purpose of this study was to investigate the outcome of a combined Bankart and Bristow procedure for recurrent anterior shoulder instability in high contact and collision athletes.

Methods Ninety-one patients underwent 100 combined Bankart and Bristow procedures for anterior shoulder instability (nine bilateral cases). Combined procedures were indicated in athletes participating in contact and collision sports. We were able to follow-up 71% of cases (71 shoulders in 65 patients) at an average of 6.5 years after surgery (range 2.1 to 12.3 years). The average age at the time of surgery was 23 years (range 15 to 47 years). There were 63 males and only two females. All patients were participating in competitive level sport at the time of injury of which 76.1% was rugby. A Rowe rating was calculated for each patient.

Results Forty-four percent were graded excellent, 18% good, 27% fair and 11% poor. Overall 66% of athletes returned to their pre-injury level of sport or better, whilst 25% return to a lower level of their sport. Nine percent did not return to sport after surgery. This cohort included 37 professional or semi-professional players of whom 73% were able to return to their pre-morbid or a higher level of sport. Only six percent have experienced further dislocations since surgery. A further 12% have experienced shoulder subluxation and another 19% report feelings of insecurity. Four percent have required an additional procedure. Eighty-nine reported no or only mild limitation of function or discomfort and 87% were either very satisfied or satisfied with their outcome.

Conclusions The combined open Bankart repair and Bristow procedures gives good results in athletes who participate in contact and collision sports. It has proved to be a robust procedure in the long term, allowing almost 75% of professional and semi-professional athletes to return to the same level or higher of sporting participation.

Aim: To assess the prevalence of anterior knee pain after intramedullary nailing of the tibia and its socioeconomic impact.

Methods: A retrospective, study of 251 consecutive tibial intramedullary nailings in 248 patients, aged less than 60 years at the time of injury. The minimum follow-up period was five years and the patients were assessed using a questionnaire and the Lysholm knee score.

Results: The mean follow-up was 7.9 years. Anterior knee sensory disturbance was reported by 58% of patients. Anterior knee pain (AKP) was reported by 47%. This interfered with activities of daily living in 37%, work in 36% and sport in 57%. Pain on kneeling was mild in 54%, moderate in 34% and severe 12%. AKP improved with time in 73% patients and became worse in 4%. The Lysholm score rated 41% knees as excellent, 19% as good, 26% as fair and 14% as poor. Eighty-six percent of the patients returned to work. The presence of anterior knee pain prevented return to previous work in 10%. The type of work performed before and after injury respectively were; sedentary 26%/29%, walking-based 20%/27%, manual 38%/37%, heavy manual 16%/7%.

Conclusions: Anterior knee pain persisted in 47% of patients after intramedullary nailing of the tibia. There was some decrease in symptoms with time and the majority of patients were able to return to work. However, anterior knee pain caused a significant disability in a small number and all patients should be warned of this problem before this type of surgery.

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.

Aim: To quantify the effect of overhead sports on static scapular position.

Method: Three cohorts of young adults were evaluated: Swimmers (n=35), Tennis players (n=32) and Controls (n=33). Scapular position was determined using the method described by DiVita. Details of overhead activities, hand dominance and history of shoulder injuries were obtained by questionnaire. All measurements were performed by a single observer.

Results: DiVita’s normalised ratios in dominant shoulders were 1.57±0.09 for swimmers, 1.61±0.11 for tennis players and 1.57±0.12 for controls. For non-dominant shoulders, the ratios were 1.58±0.1.5, 1.59±0.13 and 1.63±0.13 respectively. There were no significant differences between groups. Within male subjects, there were no differences in scapular size between athletes and controls on either dominant or non-dominant sides. However, scapular distance was significantly greater in swimmers in both shoulders (dominant p=0.009, non-dominant p=0.028) and in the dominant shoulder in tennis players (p=0.037) when compared with controls. Female athletes showed no differences in scapular size when compared with controls but female swimmers had greater scapular sizes on their non-dominant sides when compared with controls (p=0.016).

Conclusions: There were measurable anthropometric differences between athletes and controls that supported our hypothesis of greater scapular distances in both shoulders in swimmers and in the dominant shoulder in tennis players when compared with controls. However, these were not borne out using a normalised ratio. DiVita’s method of assessing static scapula position is readily applicable to clinical and sporting settings and proved reproducible with minimal equipment. It may be worthy of further investigation.