It is difficult to establish the diagnosis of an injured shoulder if only one radiographic projection is used. We have compared two lateral projections, the Neer trans-scapular and the apical oblique in 80 patients; the radiographs were presented randomly to 10 casualty officers and nine radiologists. The apical oblique view was found to permit more accurate diagnosis of fractures and of dislocation by both groups.

Purpose of the study: Hemi-arthroplasty, osteosynthesis, and ball-and-socket implants provide well-known results for the management of displaced joint fractures of the proximal humerus in elderly subjects. The purpose of this work was to assess the reversed Grammont prosthesis for these indications.

Material and methods: From 1993 to 1999, eighteen Delta III prostheses were implanted by the same operator in recent trauma victims. The patients, 17 women and one man, mean age 75 years, presented four-fragment fractures (n=15) or fracture dislocation (n=3). The dominant side was involved in nine cases. These patients presented infiltrative rotator cuff tendinopathy (n=4), type 1 diabetes mellitus (n=2), exogenosis (n=2), morbid obestity (n=2), homelessness (n=2), and dementia (n=2). Surgery was performed under general anesthesia in the semi-sitting position via a trapezodeltoid approach without acromion osteotomy and with 20° humeral implant retroversion in all cases except one, cemented in 17 cases. The tubercles could be reinserted in four patients. Rehabilitation was not always possible. The Constant score and the anteroposterior and Lamy lateral views were used to assess clinical and radiographic outcome.

Results: There were two deaths, so the analysis included 16 shoulders. Complications were: shoulder-hand syndrome (n=1), early deep Acinetobacter infection with revision and preservation of the arthroplasty (n=1), anterior dislocation at one month due to voluntary 10° anterotation of the humeral stem requiring reorientation (n=1). At mean follow-up of 85 months, the Constant score was 60, with a weighted score of 83%. The results were not influenced by reinsertion of the tubercles and were considered good for pain and activity, fair for strength, and disappointing for rotations. The x-rays did not reveal any sign of humeral loosening. There was one lucent line between the glenoid and the metaglenoid, four cases with pillar notches, and nine infraglenoid ossifications.

Discussion and conclusion: For displaced joint fractures of the proximal humerus, endomedullary osteosynthesis and the ball-and-socket implant have shown their efficacy as an alternative to hemiarthroplasty. The reverted prosthesis also appears to be a valid therapeutic option for elderly persons with osteoporotic bone compromising the reinsertion of the tubercules. This option enables good results for pain, activity, strenth and active mobility except for rotation, with only five signs of gravity for the glenoid with one involving the glenoid and none the humerus at 85 months follow-up. These results should be further confirmed with a larger series and longer follow-up.

Purpose: The three dimensional position of the tuberosity and the tension of the rotator cuff influence the structural changes of the rotator cuff and their influence on clinical results of reversed trauma prostheses.

We propose this technique with it of a biological support, the fractured humeral head, adequately modeled, in order to give again the just tension to the cuff

Method: from February 2007 and February 2009 we treated 29 patients with a reversed trauma prostehes, in 7 cases we have practiced the bony necktie, for giving a support to the correct reconstruction of the tuberosity. The patients have an average of 71,5 years and was evaluated with Constant score and radiographic study with mean follow-up of 18,6 months

Results: Improvement of postoperative Constant score and radiographic good results were correlated with satisfactory subjective results. However, these results will have to be confirmed with more cases and later revision

Conclusion: Tuberosity position and healing is critical for clinical and radiographic outcome in shoulder arthroplasty in trauma. In particular the rate resorption of the tuberosity in Reverse Trauma Prostheses still is elevated. we propose a new surgical technical in order to give again the just position to the tuberosity fractured and therefore to give tension to the rotator cuff

Purpose: The risk of recurrence and progression to chronic instability after a first episode of anteromedial shoulder dislocation is high in young patients. Risk assessment has varied in published reports but is constantly high in subjects aged less than 25 years. The injuries occurring during the first episode are poorly identified and rarely treated. We thus propose an arthroscopic assessment for young subjects with sports activities to identify lesions and achieve stabilisation after the first dislocation. The purpose of this work was to report the lesions observed and present our surgical protocol.

Material and methods: Between February 2002 and March 2003, we included fifteen patients in a prospective study. All patients were aged 17–25 years at the first episode of traumatic anteromedial dislocation of the shoulder. The patients were informed of the “usual” orthpaedic treatment and of the risk of recurrence. We proposed an arthroscopic assessment of their lesions and concomitant treatment. All patients accepted this therapeutic alternative. All procedures were performed by the same operator within ten days of dislocation. Patients were immobilised for 21 days with an elbow to body brace followed by rehabilitation in an outpatient setting, avoiding external rotation for 21 days. The Duplay score was determined.

Results: In this prospective series of patients, we identified a haematoma, a Malgaigne notch, and disinsertion of the anteroinferior capsulolabral complex in all patients. We were unable to find any glenoid or ligament injury on the humerus. The cuff was intact in all patients except one who had a deep wound of the supraspinatus. Lesion suture with resorbable anchors was satisfactory in 14 patients. We have not observed any recurrences. Physical examination did not disclose any apprehension and there has been no case of altered external rotation (< 5).

Conclusion: Considering the major risk of recurrent dislocation after a first episode in these young patients, we have studied an alternative to orthopaedic treatment. All patients accepted the proposed arthroscopic treatment. All patients presented capsulolabral detachment which was easily treated. At last follow-up, all patients have recovered a pain-free stable shoulder. This was a small series with a short follow-up so these results must be considered with caution. They are nevertheless very encouraging.

Gunshot injuries to the shoulder are rare and difficult to manage. We present a case series of seven patients who sustained a severe shoulder injury to the non-dominant side as a result of a self-inflicted gunshot wound. We describe the injury as ‘suicide shoulder’ caused by upward and outward movement of the gun barrel as the trigger is pulled. All patients were male, with a mean age of 32 years (21 to 48). All were treated at the time of injury with initial repeated debridement, and within four weeks either by hemiarthroplasty (four patients) or arthrodesis (three patients). The hemiarthroplasty failed in one patient after 20 years due to infection and an arthrodesis was attempted, which also failed due to infection. Overall follow-up was for a mean of 26 months (12 to 44). All four hemiarthroplasty implants were removed with no feasible reconstruction ultimately possible, resulting in a poor functional outcome and no return to work. In contrast, all three primary arthrodeses eventually united, with two patients requiring revision plating and grafting. These patients returned to work with a good functional outcome. We recommend arthrodesis rather than replacement as the treatment of choice for this challenging injury.

Cite this article: Bone Joint J 2013;95-B:820–4.

Introduction. Anterior shoulder instability results in labral and osseous glenoid injuries. With a large osseous defect, there is a risk of recurrent dislocation of the joint, and therefore the patient must undergo surgical correction. An MRI evaluation of the patient helps to assess the soft tissue injury. Currently, the volumetric three-dimensional (3D) reconstructed CT image is the standard for measuring glenoid bone loss and the glenoid index. However, it has the disadvantage of exposing the patient to radiation and additional expenses. This study aims to compare the values of the glenoid index using MRI and CT. Method. The present study was a two-year cross-sectional study of patients with shoulder pain, trauma, and dislocation in a tertiary hospital in Karnataka. The sagittal proton density (PD) section of the glenoid and enface 3D reconstructed images of the scapula were used to calculate glenoid bone loss and the glenoid index. The baseline data were analyzed using descriptive statistics, and the Chi-square test was used to test the association of various complications with selected variables of interest. Result. The glenoid index calculated in the current study using 3D volumetric CT images and MR sagittal PD images was 0.95±0.01 and 0.95±0.01, respectively. The CT and MRI glenoid bone loss was 5.41±0.65% and 5.38±0.65%, respectively. When compared, the glenoid index and bone loss calculated by MRI and CT revealed a high correlation and significance with a p-value of <0.001. Conclusions. The study concluded that MRI is a reliable method for glenoid measurement. The sagittal PD sequence combined with an enface glenoid makes it possible to identify osseous defects linked to glenohumeral joint damage and dislocation. The values derived from 3D CT are identical to the glenoid index and bone loss determined using the sagittal PD sequence in MRI

Aims

The primary aim of this study was to assess the feasibility of recruiting and retaining patients to a patient-blinded randomized controlled trial comparing corticosteroid injection (CSI) to autologous protein solution (APS) injection for the treatment of subacromial shoulder pain in a community care setting. The study focused on recruitment rates and retention of participants throughout, and collected data on the interventions’ safety and efficacy.

Aims

This study aims to determine the rate of and risk factors for total knee arthroplasty (TKA) after operative management of tibial plateau fractures (TPFs) in older adults.

Introduction. Acromioclavicular dislocation (ACD) is frequent, at 8% of all shoulder traumas. Management in grade III lesions remains controversial. The present study assessed objective and subjective results at medium-term follow-up (mean, 60 months; range, 12—120 mo) in 27 patients managed by Ligastic® ligament reconstruction for acute dislocation. Patients and Methods. This is a multicenter, multi-surgeon retrospective study. Between 1998 and 2006, 59 patients were operated on for grade III or IV ACD, in one teaching hospital (Lille, France) and one general hospital (Tourcoing, France). Follow-up was performed by an indepen- dent (non-operator) observer. The 27 acute cases followed up underwent comparative bilateral radioclinical shoulder examination. Initial X-ray assessment found 14 grade-III (52%) and 13 grade-IV (48%) dislocations using Patte's classification. Results. Mean Constant score was significantly lower on the operated side (82.44 vs 90.04; p < 0.05). Specific strength analysis, on the other hand, showed no significant difference with the contralateral shoulder. Coracoclavicular distance was significantly greater on the operated side (p < 0.05), with and without traction. Periprosthetic osteolysis was found in 24% of cases, and seemed to worsen over follow-up. There were no cases of fracture on osteolysis. There were no cases of sepsis or of implant intolerance. Four patients, however, required surgical revision. Conclusion. In light of literature findings and our own experience, surgery is not to be recom- mended in grade-III ACD, and the authors have given up use of this device in this group due to the rate of associated osteolysis. Level of evidence. Level IV

In this prospective analysis of the sonographic findings of asymptomatic shoulders to determine the prevalence of rotator cuff lesions in black patients over the age of 40 years, we examined 106 black patients. Patients with shoulder trauma were excluded. Bilateral sonography was done on the subscapularis, supra-spinatus and infraspinatus insertions of 66 men and 50 women (mean age 52.8 years). The tears were measured and classed as partial or full thickness tears. In 33 patients, there was a history of previous trauma, but they were asymptomatic at the time of the examination. The pain score for the whole group was 1.3 on an analogue scale of 5, which means that pain is present intermittently but no medication is necessary. In 34 patients there were 42 cuff lesions. The largest (3.5 cm) was in a 73-year-old. In 17 shoulders the tear measured more than 1 cm, and in 13 shoulders the tear was partial. There was almost no weakness of subscapularis, supra-spinatus and infraspinatus muscles. We concluded that asymptomatic rotator cuff tears are as common in the black population as in the Caucasian population

Introduction and Aims: A prospective analysis of the sonographic findings of asymptomatic shoulders in black patients over 40 years of age, to determine the prevalence of rotator cuff lesions in this group. Method: Physical examination and bilateral sonograms were performed on 106 black patients, who visited the Trauma Clinic. Patients with shoulder trauma were excluded. Scans were made of sub-scapularis, supra-spinatus and infra-spinatus insertions. The size of the tears were measured in millimetres and divided in partially and full thickness tears. Results: There were 66 male and 50 female patients. Mean age 52.8 years. Thirty-three patients had a history of previous trauma, but were asymptomatic at the time of the examination. The pain score for the whole group was 1.3 on an analogue scale of five, which means that pain is present now and then, but no medication is necessary. Forty-two cuff lesions were present in 34 patients. The biggest lesion (3.5 cm) was in a 73-year old patient. In 17 shoulders, the tear was more than one cm and in 13 shoulders it was a partial tear. There was almost no weakness of sub-scapularis, supra-spinatus and infra-spinatus. Conclusion: Asymptomatic rotator cuff tears were as common in the black population as in the Caucasian population. The symptoms present are mild and the patients experienced it as normal. Weakness as such may not be a problem in patients with a rotator cuff tear. Weakness may become a problem if the tear increases in size. Pain may become a problem when the shoulder becomes unstable

Aims

The aim of this study was to describe a quantitative 3D CT method to measure rotator cuff muscle volume, atrophy, and balance in healthy controls and in three pathological shoulder cohorts.

Aims

The James Lind Alliance aims to bring patients, carers, and clinicians together to identify uncertainties regarding care. A Priority Setting Partnership was established by the British Association for Surgery of the Knee in conjunction with the James Lind Alliance to identify research priorities related to the assessment, management, and rehabilitation of patients with persistent symptoms after knee arthroplasty.

Purpose: This study was performed to assess the incidence of generalized ligament laxity in patients undergoing revision shoulder stabilization. Methods and Results: Prospective data was collected for 21 patients undergoing revision shoulder stabilization and 43 patients with clavicle fractures as a control group, between 2004 and 2009 under the care of orthopaedic surgeons at the Royal Infirmary of Edinburgh including demographic details, type of primary stabilization and causes of failure. Clinical examination was used to assess the ligament laxity using the Beighton score. Laxity is scored on a 0–9 scale. Scores of 4 or above are indicative of generalized ligament laxity. Brighton criteria is used to diagnose Benign Joint Hypermobility Syndrome (BJHS) and use signs and symptoms along with Beighton score. The most common primary procedure for shoulder instability was open stabilization in 15 patients (75%). The most common cause of failure was trauma in 14 patients (67%). The mean age was 29 years with a range from 22–58 years. There were 16 males and 5 females. The average Beighton score for patients undergoing revision shoulder stabilization was 2.8 with a range from 0–7. 13 patients (61%) in this group had a Beighton score of 4 or more as compared to 12 patients (27%) in the control group. This difference was statistically significant with a P value of 0.018. 11 patients (52%) fulfilled the Brighton criteria for BJHS. Conclusion: We found that there is a high incidence (61%) of generalized ligament laxity in patients undergoing revision shoulder stabilization. Trauma is a common (67%) cause of failure in these patients. Patients with generalized ligament laxity should be made aware about the high failure rate after shoulder stabilization at their primary surgery and appropriate advice about rehabilitation should be given

Aims

Outcome measures quantifying aspects of health in a precise, efficient, and user-friendly manner are in demand. Computer adaptive tests (CATs) may overcome the limitations of established fixed scales and be more adept at measuring outcomes in trauma. The primary objective of this review was to gain a comprehensive understanding of the psychometric properties of CATs compared with fixed-length scales in the assessment of outcome in patients who have suffered trauma of the upper limb. Study designs, outcome measures and methodological quality are defined, along with trends in investigation.

Objectives

Accurate characterisation of fractures is essential in fracture management trials. However, this is often hampered by poor inter-observer agreement. This article describes the practicalities of defining the fracture population, based on the Neer classification, within a pragmatic multicentre randomised controlled trial in which surgical treatment was compared with non-surgical treatment in adults with displaced fractures of the proximal humerus involving the surgical neck.

Aims

Fracture clinics are often characterised by the referral of large numbers of unselected patients with minor injuries not requiring investigation or intervention, long waiting times and recurrent unnecessary reviews. Our experience had been of an unsustainable system and we implemented a ‘Trauma Triage Clinic’ (TTC) in order to rationalise and regulate access to our fracture service. The British Orthopaedic Association’s guidelines have required a prospective evaluation of this change of practice, and we report our experience and results.