Objectives: A stable shoulder is essential for proper elbow and hand function after oncologic resection of the shoulder girdle. We describe a surgical technique for replacing the shoulder joint capsule using synthetic mesh after resections of the shoulder girdle that resulted in gross intraoperative instability of the shoulder joint. Methods: 68 patients who underwent shoulder girdle resection between 1989 and 2006 were identified in our prospective database. This report focuses on nine patients whose shoulder joint was reconstructed with synthetic mesh. All patients were followed on a 3 monthly basis. Shoulder joint instability was determined from clinical records, database and radiographs. Results: Nine patients underwent shoulder joint reconstruction with synthetic mesh. One patient underwent a shoulder disarticulation within 30 days of the index surgery and was excluded from this rapport. No dislocations were noted during follow-up (range 3–48 months). Radiographs revealed an average vertical displacement of the humeral head compared to its original position of 0.7 cm (range 0–1.7 cm). There were two surgical complications. In one patient the humeral prosthesis migrated proximally and eroded through the skin requiring additional surgery. In another case erosion of the distal clavicle was noted. This was biopsied and foreign body reaction identified. Conclusions: Joint instability following major resections of the shoulder girdle is a source of morbidity and affects the function of the salvaged limb. Synthetic capsular reconstruction using Marlex mesh is a useful adjunct in patients where insufficient shoulder musculature and joint capsule remains after resection to allow for stable suspension of the upper limb

Wear of polymeric glenoid components has been identified as a cause of loosening and failure of shoulder implants1,2 in vivo. A small number of shoulder joint simulators have been built for in vitro wear testing, however none have been capable of testing with physiological motion patterns in three axes and with physiological loading. The Newcastle Shoulder Wear Simulator was designed with three axes of motion, which are programmable so that different activities of daily living might be replicated. The simulator uses three pneumatic cylinders with integral position encoders to move five shoulder prostheses simultaneously in the flexion-extension, abduction-adduction, and internal-external rotation axes. Axial loading is applied with pneumatic cylinders supplied from a pneumatic proportional valve via a manifold, which also supplies a sixth static control station. In order to establish if that the machine can actually perform as intended, commissioning trials were conducted replicating lifting a 0.5 Kg weight to head height as a daily living activity. During the commissioning trials JRI Orthopaedics Reverse VAIOS shoulder prostheses were tested in 50% bovine serum at ambient temperature. The results show that the shoulder joint wear simulator can satisfactorily reproduce a daily living activity deliberately selected for having a large range of motion and loading. Other daily activities, such as drinking from a mug, are less demanding in the ranges of motion and loading and represent no difficulty in being reproduced on the simulator. Now successfully commissioned, this new multi-station shoulder wear simulator can wear test current and new designs of shoulder prosthesis in vitro

Introduction: Despite a multitude of reports detailing the management of infected hips and knees with or without arthroplasty, only little information is available on how to deal with infected shoulders. Besides primary haematogenous infection, the increasing number of surgical procedures (infiltration, arthroscopy, ORIF, total- or hemi arthroplasty) confront the orthopaedic surgeon increasingly with this devastating complication. Our goal is to present our experience with the use of a cement spacer in the treatment of infected shoulder joints. Material and Methods: Between 1995 and 2005 9 patients were diagnosed with deep shoulder infection. The study includes 5 women and 4 men. The mean age at the time of diagnosis of the infection was 65 years (range, 51–78 years). Only 2 patient had had no prior surgery of the shoulder. 5 patients had an infection of a shoulder arthroplasty and 2 patients had been treated with ORIF for fracture. All of the patients underwent resection the humeral head or retrieval of the arthroplasty with large debridement followed by implantation of an antibiotic impregnated polymethyl methacrylate spacer. After a mean duration of two months of antibiotics and after normalisation of the CRP a delayed reimplantation of a prosthesis was performed in 6 patients. One patient is awaiting arthroplasty, while two patients are satisfied with the functional result obtained with the spacer and do not want further surgery. Results: None of the patients developed recurrent infection at an average follow-up time of 36 months. Shoulder function was judged objectively and subjectively to be at least satisfactory in all of the patients. Conclusions: Staged treatment of infected shoulders using antibiotic impregnated polymethyl methacrylate spacers showed in our small group of patients, good and reproducible results. The individually moulded and fitted spacer filling the joint cavity and restoring the normal anatomy of the shoulder after joint debridement makes secondary procedures much easier. In the cases of exchange prosthetic reconstruction no recurrent infection has been experienced and all of the patients have substantial pain relief and an adequate shoulder function. Based on this experience the authors think that staged treatment and the use of a cement spacer in infected shoulder joints is a valid approach

Aims: The aim of the study was to investigate the cap-suloligamentous structures of the shoulder joint and their association with rotator cuff tendons. Methods: Twenty seven alcohol-formalin-glycerol þxed right shoulder joints (age range 65 Ð 78 years) were investigated. The Ligg. coracohumerale, coracoglenoidale, glenohumeralia, semicirculare humeri and gleno-capsulare were dissected in þne detail. To visualise the rotator interval, the Processus coracoideus was cut at its base and moved together with the Ligg. coracohumerale and coracoglenoidale posteriorly. The analysis of the ligamentous structures and their relations with the rotator cuff tendons was performed. Results: The Lig. coracohumerale originated from Processus coracoideus and Lig. coracoglenoidale. It inserted into the Lig.semicirculare humeri Ð a capsular ligament spread between Tubercula minus et majus. Lig. glenocapsulare originated posterior to the Tuberculum supragle-noidale and inserted into the Lig. semicirculare humeri. The Mm. supra- and infraspinatus inserted into the Lig. semicirculare humeri. The anterior capsule was strengthened in addition to the three Ligg. glenohumeralia with a Lig. glenohumerale spirale. It originated from the Tuberculum infraglenoidale, coursed craniolaterally and inserted together with the M. subscapularis tendon at the Tuberculum minus. Conclusions: The shoulder joint capsule is strengthened with the Ligg. coracohumerale, coracoglenoidale, glenohumeralia superior, medium, inferior et spirale and Ligg. semicirculare humeri et glenocapsulare. The close relation of the ligamentous structures with the tendons of the rotator cuff brings a new insight into the different glenohumeral pathologies

The numbers of anatomic total shoulder joint replacements (ATSR) is increasing during the past years with encouraging clinical results. However, the survivorship of ATSR is lower as compared to total knee and hip replacements. Although the reasons for revision surgery are multifactorial, wear-associated problems like loosening are well-known causes for long-term failure of ATSR. Furthermore there is lack of valid experimental wear tests for ATSR. Therefore the purpose of this study was to define experimental wear testing parameters for ATSR and to perform a wear study comparing ceramic and metallic humeral heads. Kinetic and kinematic data were adopted from in-vivo loading measurements of the shoulder joint (. orthoload.com. ) and from several clinical studies on shoulder joint kinematics. As activity an ab/adduction motion of 0 to 90° in combination with an ante/retroversion while lifting a load of 2 kg has been chosen. Also a superior-inferior translation of the humeral head has been considered. The wear assessment was performed using a force controlled AMTI joint simulator for 3×10. 6. cycles (Fig. 1) and polyethylene wear has been assed gravimetrically. The studied ATSR (Turon. TM. , DJO Surgical, USA) resulted in a polyethylene wear rate of 62.75 ± 1.60 mg/10. 6. cycles in combination with metallic heads. The ceramic heads significantly reduced the wear rate by 26.7 % to 45.99 ± 1.31 mg/10. 6. (p<0.01). The wear scars dimensions were in good agreement to clinical retrievals. This study is the first that experimentally studied the wear behavior of ATSR based on clinical and biomechanical data under load controlled conditions. In term of wear the analyzed ATSR could clearly benefit from ceramic humeral heads. However, in comparison to experimental wear studies of total knee and hip replacements the wear rate of the studied ATSR was relatively high. Therefore further research may focus on optimized wear conditions of ATSR and the hereby described method may serve as a tool to evaluate a wear optimization process

Posterior dislocation of the shoulder is an unusual injury and there is often much delay before the diagnosis is made. Nevertheless, if the condition is borne in mind when examining the patient and studying the X-ray films the diagnosis should not be missed. A single antero-posterior radiograph of the shoulder joint is inadequate. For the radiologist a pair of stereoscopic films is desirable; but for routine emergency work in hospital other projections are necessary. A vertical view should be taken, either with the limb abducted and the tube in the axilla, or with the tube above the shoulder and a curved cassette in the axilla. When this is impossible a profile or posterior oblique view of the scapula may be substituted

The glenohumeral joint is an important joint with large mobility of the human upper extremity. In shoulder arthroplasty patients often has an unsatisfactory outcome. In order to understand the biomechanical complexity of the shoulder, a novel computer controlled experimental shoulder simulator with an innovative muscle control were constructed. The main component of the simulator includes the active pneumatic muscles to replicate the deltoid and the rotator-cuff function and two springs as passive muscle. The aim of this study is to evaluate the impact of a variation of shoulder joint geometries on shoulder biomechanics in the basis of motion analysis. The radius of the glenoid cavity varied from 28–33mm with 2.5mm increment while the radius the humeral head are varied from 20.1–25.1 with 2.5mm increment. The “teach-in” function of the simulator allows an operator to assign the movement to the simulator where the lengths of the pneumatic muscles are recorded. Then the simulator repeats the assigned movement according to the recorded muscles length. The daily living activities includes abduction/adduction, internal/external rotation with adducted arm, and circumduction. The results show promising repeatability of the simulator with minor deviation. However, damage on the surface of the humeral head has been found which should be further studied for both shoulder behavior investigation and the shoulder simulator optimisation. Therefore, this study is a decent initial study toward the verification of the simulator and lead to a better understanding of shoulder biomechanical behavior to cope with the clinical problems in the future

The purpose of this paper is to call attention to the anterior bone block method of Hybbinette-Eden for recurrent dislocation of the shoulder joint. 1. The operative technique is not difficult, and the after-treatment is short and relatively agreeable for the patient. 2. Sixty of our own cases are described, with four recurrences. The recurrences all occurred as the result of real trauma. In a total of 128 Scandinavian cases there were eight recurrences—that is 6·3 per cent. 3. In our opinion, based on the observations of radiography, arthrography, and operation, it is the compression fracture of the head of the humerus which deserves the name "essential lesion." Destruction of the anterior rim of the glenoid may be very slight, or entirely lacking. No false joint cavity or rupture big enough to receive the head of the humerus was ever observed by arthrography or by inspection during operative exploration. Recurrent dislocation is an intracapsular subluxation, which occurs when the anterior rim of the glenoid slides into the hollow in the humeral head

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 axillary nerve and posterior circumflex artery 3.4 cm (range: 1.4 – 5); cutaneous branch of the axillary nerve 6.3 cm (range: 3.8 – 8.3), suprascapular nerve 2.8 cm (range: 2.1–3.3). * Anterosuperior portal: main branch of the musculocutaneous nerve 6.5 cm (range: 3.8 – 11). * Lateral subacromial portal: axillary nerve and posterior circumflex artery 3.7 cm (range: 2– 5.5). * Anteroinferior subaxillary portal 4 cm (range: 3.1 –6). * Supraspinatus portal: suprascapular nerve 3.2 cm (range: 2.4 – 4). Conclusions: Although the crucial elements at risk when performing a shoulder arthroscopy are multiple, the axillary and suprascapular nerves were the most vulnerable structures to the different approaches. In spite of the presence of the “safe areas” described above, the neurovascular bundle was frequently affected by passage through the anteroinferior subaxillary portal. The results suggest that the use of this portal is not safe for routine arthroscopic practice

Aim

Clavicular osteotomy was described as an adjunct to deltopectoral approach for improved exposure of the glenohumeral joint. This study aims to present contemporary outcomes and complications associated with the routine use of clavicular osteotomy by a single surgeon in a regional setting within New Zealand.

Purpose: Surgical prosthetic treatment of excentred degeneration of the shoulder joint has long been limited to simple humeral prostheses. Inverted total shoulder arthroplasty (ITSA) using the Grammont system appears to provide real improvement. What is the comparative outcome? Does the Grammont prosthesis give constant results? Is the simple humeral prosthesis still indicated for selected cases? In order to respond to these questions, we reviewed 84 patients who had undergone surgery between 1986 and 2000 for implantation of 52 simple humeral prostheses (mean follow-up 7.1 years) and 32 ITSA (mean follow-up 4.3 years). Material and methods: Between 1986 and 1995, all patients with excentred degeneration of the shoulder joint were treated with a simple humeral prosthesis (36 cases). Between 1995 and 2000, either ITSA or simple humeral prosthesis (16 cases) was used. For the ITSA, indications were limited to excentred degeneration in patients aged over 70 years with a painful pseudoparalytic shoulder or contraindication for a simple prosthesis (alteration of the acromiocorocoid vault or the subscapular area). Simple prostheses were used either when an ITSA could not be implanted (patient too young, overly deteriorated glenoid, deltoid insufficiency) or when there was a preferential indication (excentred degeneration in young patients < 65 years, preservation of active motion, Favard type 1 or 2 glenoid…). Results: For the simple humeral prosthesis series (1986–1995): the Constant score improved from 16.4 preoperatively to 489.6 postoperatively; radiographically there were one humeral loosening, three superior migrations, and three glenoid degenerations; three revision procedures were required. For the ITSA: the Constant score improved from 14.2 preoperatively to 61.6 postoperatively; radiographically there was one humeral loosening; 32% glenoid alterations in Nérot grades 3 and 4; one revision procedure was required. For the later simple humeral protheses (1995–2000): the Constant score improved from 18.2 preoperatively to 56.4 postoperatively (60.2 excluding cases with a simple prosthesis due to contraindication of an ITSA); radiologically there were one superior migration and two glenoid deteriorations. Discussion: For a given indication, the results with the ITSA were better than with the simple prosthesis (p < 0.001). However, excluding salvage procedures where the ITSA could not be used, simple prostheses inserted for precise indications provided results nearly equivalent to the ITSA (p < 0.05) with less uncertainty concerning the future. For us, the inverted total shoulder prosthesis and the simple humeral prosthesis share indications for surgical repair of excentred degeneration of the shoulder joint

Purpose: The purpose of our work was to study the effects of sequential arthroscopic section of the anterior capsule of the shoulder joint using an experimental model of retractile capsulitis induced by heat treatment. Material and methods: Twelve cadaver shoulders were studied. Passive mobility was initially normal. Anterior capsule retraction was first created under arthroscopic control (Arthrocare® generator, power 2). Twelve programmed sequential sections were then performed successively using the thermal probe (Arthrocare®, power 9) on: the coracohumeral ligament (CHL) and the superior glenohumeral ligament (SGHL), the middle gleno-humeral ligament (MGHL), the inferior glenohumeral ligament (IGHL), and the intra-articular portion of the subscapular muscle tendon (SST). The posterior capsule was not studied. At each step, motion was measured independently by two operators. At the end of the sequence, the articulation was opened to verify the sections as was the absence of any injury to noble structures. Results: Measures were reproducible (mean difference 5° between two series). The sections were correctly achieved. Macroscopically, there were no injuries to noble structures. The role of the different elements studied were as follows: — rotator interval (CHL, SGHL): gain in RE1 (mean 40°) and RE2 (mean 35°) (greater than loss during retraaction; — IGHL: gain in elevation (mean 33°); — IGHL and rotator interval: potentialisation of gain in FE2 (mean 41°) and elevation (mean 50°); — MGHL: moderate increase in external rotation at 45° antepulsion and elevation (mean 20°); —SST: discrete gain in RE1 (10°) but risk of dislocation (n=1). Discussion: Our model was reproducible. Section of the anterior capsule by a thermal method did not produce macroscopic injury to neighboring tissues. Our study pointed out the preeminent importance of sectioning the rotator interval for recovering external rotation. This section, combined with section of the IGHL has a potentialsing effect. The limitation of our study is the absence of examination of the posterior capsule

Purpose: The purpose of this work was to compare outcome after hemiarthroplasty and after inverted arthroplasty for the treatment of excentred degeneration of the shoulder joint. Material and methods: This multicentric study inclued 136 patients, 110 women and 26 men, mean age 72.4 years (range 55 – 86 years) with 142 shoulder prostheses. Among the 142 shoulders operated on, 62 underwent Aequalis hemiarthroplasty and 80 inverted arthroplasty. The preoperative handicap was more severe in the hemiarthroplasty group (Constant score 26) than in the inverted arthroplasty group (Constant score 23). Results: Clinical and radiological follow-up data were collected at a mean follow-up of 44 months for the Aequalis prostheses and at 45 months for the inverted prostheses. There were seven failures requiring five revision procedures: three in the hemiarthroplasty group and four in the inverted arthroplasty group. The differences between the hemi- and inverted arthroplasty groups concerned the Constant score, which was significantly better in the inverted prostheses (65.5) than in the hemiarthroplasties (46.1), for all subscores. Active elevation was 138° for the inverted prostheses and 97° for the Aequalis prostheses (p < 0.01). Mean external rotation in position 1 was 22° for the Aequalis prostheses and 11° for the inverted prostheses (p < 0.01) with no difference in elevation rotation. These results remained equivalent and significant over time, even beyond five years. Radiographically, there was one case with an anomalous humeral component (impaction) in the inverted group. For the inverted prostheses, there were three migrations that have not been revised to date and three partial screw loosenings. The main problem was the development of notches in the scapular column observed in 50% of the cases including 20% which reached the lower screw. For the Aequalis prostheses, the main problem was deterioration of the acromial vault observed in 50% of the cases leading to altered function. Discussion: Inverted prostheses provide clearly better mid-term results, even after five years. With hemiarthroplasty there is a long-term risk of vault wear. The long-term course of the inverted prostheses is worrisome due to the notches in the scapular column and the stress on the fixation. These prostheses should be used preferably for old persons with a deteriorated vault

Aims

Despite recent advances in arthroscopic rotator cuff repair, re-tear rates remain high. New methods to improve healing rates following rotator cuff repair must be sought. Our primary objective was to determine if adjunctive bone marrow stimulation with channelling five to seven days prior to arthroscopic cuff repair would lead to higher Western Ontario Rotator Cuff (WORC) scores at 24 months postoperatively compared with no channelling.

Summary—Fifty-two cases of exposure of the glenoid labrum are recorded. Fifty-one operations with anterior exposure, followed by capsular reefing and shortening of the subscapularis, were successful. One operation with superior exposure, and without capsular reefing or shortening of the subscapularis, was unsuccessful.

Our objective was to determine the plasma levels of substance P (SP) in patients with postoperative stiffness after arthroscopic rotator cuff repair.

Plasma samples were obtained at 15 months from surgery from 2 groups of patients who underwent arthroscopic repair of a rotator cuff tear. In Group 1, 30 subjects (14 men and 16 women, mean age: 64.6 years, range 47 to 78) with shoulder stiffness 15 months after arthroscopic rotator cuff repair were recruited. In Group 2, 30 patients (11 men and 19 women, mean age: 57.8 years, range 45 to 77) were evaluated 15 months after successful arthroscopic rotator cuff repair. Immunoassays were performed with commercially available assay kits to detect the plasma levels of SP.

The mean plasma levels of SP in patients with postoperative stiffness were significantly greater than those in the control group (81.06 ± 27.76 versus 23.49 ± 5.64, P < 0.05).

The plasma concentrations of substance P in patients with shoulder stiffness after arthroscopic rotator cuff repair are higher compared to plasma levels of SP in patients with a good postoperative outcome. The neuronal upregulation of SP shown in the plasma of patients with post operative shoulder stiffness may underlay not only the symptoms of adhesive capsulitis, but also its development.

Our aim was to determine the prevalence of shoulder symptoms in patients with type I compared to type 2 diabetes mellitus and evaluate the clinical presentation of patients diagnosed with adhesive capsulitis. This was a retrospective case-note review of 164 diabetic patients treated for shoulder symptoms from 1996 to 2007. Diabeta 3 for relevant Diabetic data. We used ANOVA, Tukey HSD, Chi-Square and Fisher’s Exact tests.

The incidence of treated shoulder patients in diabetic population: 1.04%. 86 males; 78 females. Average age 58 years (22 – 83). DM Type I 34% (46/136); Type II 66% (90/136). Mean duration of DM at presentation: 10 years (1–33). Mean HbA1c at presentation 8.3%. Retinopathy 16% (19/90); Neuropathy 12% (12/88).

The diagnoses were: Impingement 101 (62%); Adhesive Capsulitis 35 (21%); Cuff tear 17 (10%); Arthritis 11 (7%).

Mean recorded pre-treatment ROM: Impingement (flexion 117°, abduction 103°, ER 36°); Adhesive Capsulitis (flexion 90°, abduction 75°, ER 12°); Cuff tear (flexion 109°, abduction 95°, ER 45°); Arthritis (flexion 67°, abduction 93°, ER 18°).

Adhesive Capsulitis was significantly related to: HbA1c (9.9%); p< 0.001, Type I DM; p< 0.003, Duration of DM (average 17.5 yrs); p< 0.03.

An interesting statistically significant (p< 0.003) correlation was found between Type 2 DM and Impingement Syndrome.

Treatments included: Injection (53), MUA (49), Arthroscopy (99), Open Surgery (56). 82% patients satisfactorily discharged (mild/no pain and improved ROM: flexion > 150°, abduction > 150° and ER > 50°) after an average 3.4 months. Three referred to pain clinic, sixteen patients didn’t attend their follow-up appointment and seven died. Eleven relapsed (eight adhesive capsulitis).

Persistent symptoms were more common in Diabetic patients with adhesive capsulitis, which was found to be significantly related to Type I DM, its duration and control (HbA1c levels). Type II Diabetics are more likely to be affected with impingement syndrome. Close liaison with the Diabetology Department is essential for effective treatment of Diabetic Shoulder pathology.

We report our experience with glenohumeral arthrodesis as a salvage procedure for epilepsy-related recurrent shoulder instability. A total of six patients with epilepsy underwent shoulder fusion for recurrent instability and were followed up for a mean of 39 months (12 to 79). The mean age at the time of surgery was 31 years (22 to 38). Arthrodesis was performed after a mean of four previous stabilisation attempts (0 to 11) in all but one patient in whom the procedure was used as a primary treatment. All patients achieved bony union, with a mean time to fusion of 2.8 months (2 to 7). There were no cases of re-dislocation. One revision was undertaken for loosening of the metalwork, and then healed satisfactorily. An increase was noted in the mean subjective shoulder value, which improved from 37 (5 to 50) pre-operatively to 42 (20 to 70) post-operatively although it decreased in two patients. The mean Oxford shoulder instability score improved from 13 pre-operatively (7 to 21) to 24 post-operatively (13 to 36). In our series, glenohumeral arthrodesis eliminated recurrent instability and improved functional outcome. Fusion surgery should therefore be considered in this patient population. However, since the majority of patients are young and active, they should be comprehensively counselled pre-operatively given the functional deficit that results from the procedure.

Cite this article: Bone Joint J 2014;96-B:1525–9.