Keywords

Shoulder; dislocation; instability; skeletal immaturity; arthroscopic Bankart repair; outcomes

Introduction

There are over 110 special tests described in the literature for clinical examination of the shoulder, but there is no general consensus as to which of these are the most appropriate to use. Individual opinion appears to dictate clinical practice. Rationalising which tests and clinical signs are the most useful would not only be helpful for trainees, but would also improve day to day practice and promote better communication and understanding between clinicians.

Aims

To determine whether a correlation exists between the clinical symptoms and signs of impingement, and the severity of the lesions seen at bursoscopy.

Aims

To describe the distribution and clinical presentation of SLAP tears in rugby players, and time taken for return to sport.

Introduction

We present an all arthroscopic technique for modified Weaver Dunn reconstruction of symptomatic chronic type III acromioclavicular joint injuries.

Introduction: Between June 2005 and September 2007, ten male athletes underwent repair of the pectoralis major tendon using a new double row surgical technique whereby employing three bone anchors to produce a large foot print of the pectoralis major tendon. Here, we present our new surgical technique for the repair of the pectoralis major tendon with the results.

Patients: The mean age was 33.9 years (23–46 years) and the average follow up was 20.3 months (12–39). The mean time between surgery and the original injury was 11.6 weeks (1–48 weeks). We used the visual analogue scale for determining the level of satisfaction with regards to cosmesis and pain. Also, the patients were asked them about their subjective loss of strength.

Results: Eight patients were in pain prior to surgery and all patients were unsatisfied with the appearance of their chest. The average loss of strength was 75% pre-operatively. At the final follow up, none of the patients complained of any pain while pushing things away from their body; nine patients had no pain on moving their arm across the chest whilst one patient reported mild pain. Nine were satisfied with the appearance and the average regain in strength was around 90%. One patient developed a deep infection requiring a further washout and antibiotics. No re-rupture was seen amongst our patients. Hence, we conclude that satisfactory results can be achieved with this new technique.

Introduction: Significant internal rotation limitation is thought to be due to posterior capsular thickening and therefore adding a posterior release to the anterior and inferior releases seems sensible. However, this is technically more difficult.

Aims: To assess the overall outcome of arthroscopic capsular release and to establish whether inclusion of a posterior capsular release has an additional beneficial.

Methods: 48 patients with primary or secondary frozen shoulder in whom conservative physiotherapy had failed were included. 27 had an anterior and inferior release only, whilst the 21 included a posterior release. All data was collected prospectively.

Results: Aetiology of the frozen shoulder was primary (22), diabetic (7), post-traumatic (7) and post-operative (11). There a highly significant improvement in Constant score (P < 0.001) and range of motion (P< 0.001) by 5 months in both groups. The mean satisfaction score (minimum 1 and maximum 10) was 7 post-operatively. There was no significant difference in Constant Score between the two groups (P = 0.56) and no significant difference in the improvement of the range of motion, in particular internal rotation (P=0.35).

Conclusion: There was an overall rapid significant improvement following arthroscopic capsular release, but no significant difference in the overall outcome with the addition of a posterior release.

Clinical relevance: Adding a posterior release to an arthroscopic capsulectomy does not seem to add any significant benefit to the outcome.

We document intra-articular pathology in collision athletes with shoulder instability and describe the ‘collision shoulder’ – a direct impact without dislocation, with unusual labral injury, significant intra-articular pathology and neurology. 183 collision athletes were treated for labral injuries in 3 centres. Details of injury mechanism and intra-articular pathology at surgery were recorded. Premier league and International (Elite) comprised 72 players. A tackle was implicated in 52% of injuries and 65% had a dislocation. The mechanism of injury was ABduction External Rotation (ABER) in 45%, direct impact 36%, abduction only 8% and axial load 6%. Dislocation occurred in 51% of shoulders with ABER mechanism. A Bankart lesion was found in 79% of these shoulders; Hill-Sachs in 58% and Bony Bankart in 26%. Inferoposterior labral tears were present in only 11%, Superior Labral Antero-Posterior (SLAP) lesions in 32% and partial injury to the rotator cuff in 32%. In those sustaining a direct impact to the shoulder, 61% did not document dislocation, had a high incidence of inferoposterior labral involvement (50%), neurological symptoms (32%), but a low incidence of Bankart (33%), Hill-Sachs (22%) and Bony Bankart (11%) lesions. The mechanism did not affect incidence of superior labral/SLAP tears (18%), or capsular tears (including Humeral Avulsion of Glenohumeral Ligaments – HAGL) – 15%. Elite athletes had less dislocations (43% vs 74%) irrespective of mechanism, but were 40% more likely to have neurology, posteroinferior labral, cartilaginous or capsular injuries. They had twice the incidence of Bony Bankart and rotator cuff lesions and 5 times more SLAP/superior labral tears. Collision athletes with shoulder instability have a wide spectrum of pathoanatomy of the labrum and frequent associated intra-articular lesions. Significant injury often occurs in the Elite athlete and those sustaining a direct hit without dislocation (the ‘Collision Shoulder’).

The spectrum of pathoanatomy in collision athletes with shoulder instability is wide, with a high incidence of extended labral lesions and associated intra-articular injuries. The ‘collision shoulder’ describes an injury sustained by direct impact to the shoulder without dislocation, but with extensive labral damage and a high incidence of other intra-articular pathology and neurological symptoms.

One hundred and eighty-three collision athletes (rugby and rugby league) were treated for labral injuries related to their sport in three different centres. Details of the mechanism of injury and findings at surgery were recorded. Only 60% of athletes in the series presented following a documented dislocation or subluxation episode of the shoulder. An additional pattern of injury was recognised in the remaining athletes involving a direct impact injury to the shoulder. In these athletes the clinical symptoms and signs were less specific but there was a high incidence of ‘dead arm’ at the time of injury (72%).

The spectrum of pathology in this series was wide with a high incidence of associated intra-articular lesions. In those athletes with an impact type of injury without dislocation there was more extensive labral pathology with a high incidence of posterior labral tears (50%). The incidence of associated chondral lesions was similarly very high but significant bony pathology was less common than in the dislocation group (11 % versus 26%). Elite athletes had less frank dislocations but were more likely to sustain neurological injury, posterior labral tears, SLAP lesions and cartilaginous and capsular injuries.

The incidence of all lesions in this series of collision athletes is higher than those previously published. These lesions often occurred in the absence of a frank dislocation (the ‘collision shoulder). It is important to anticipate additional pathology when planning definitive management in these patients, with surgery tailored to the specific lesions found. The athlete with an impact type of injury without dislocation can do well following surgery, with a high rate of return to contact sport, either at the same or a higher level.

Aims To describe the distribution, clinical presentation of SLAP tears in rugby players, and time taken for return to sport.

Method A retrospective review of 51 shoulder arthroscopies performed on professional rugby players over a 35 month period was carried out. All patients diagnosed with a SLAP lesion at arthroscopy were identified. Each patient’s records were reviewed to record age, injury side, mechanism of injury, clinical diagnosis, investigations and results, management, and return to play.

Results The incidence of SLAP tears was 35%. All 18 patients were male with an average age of 27yrs. There were 11 isolated SLAP tears (61%), 3 SLAP tears associated with a Bankart lesion (17%), 2 SLAP tears associated with a posterior labral lesion (11%) and 2 SLAP tears associated with an anterior and posterior labral injury (11%). Of the 18 SLAP tears, 14 (78%) were Type 2, 3(17%) were Type 3 and 1(5%) was Type 4. All patients recalled a specific heavy tackle with fall onto the lateral aspect of shoulder. No patient sustained a complete dislocation. None of the patients presented with symptoms of instability. MR Arthrograms were performed in 17 of the 18 patients. SLAP tears were detected in 13 patients (76%). All patients underwent arthroscopic reconstruction within 6 months post injury. At Arthroscopy 7 patients (39%) were found to have associated injuries. Preoperatively 11% of patients were satisfied with their shoulder. By 6 months post surgery 89% of patients were satisfied and 95% were back to their previous activity level. Patients with isolated SLAP tears returned to sports at an average of 2.6 months post surgery.

Conclusion SLAP tears are a common injury in rugby players with shoulder pain following injury. These can often be diagnosed with MR arthrography. Arthroscopic repair is associated with excellent results and early return to sports.

Previous studies have demonstrated the benefits of arthroscopic arthrolysis in relieving pain and improving motion in arthritic elbows, but none have reported the specific functional recovery. This study aims to review the functional outcome and patient satisfaction in a series of patients who underwent arthroscopic elbow arthrolysis for intrinsic stiffness, pain and arthritis not suitable for arthroplasty. Twenty six patients who underwent arthroscopic arthrolysis over a three year period were included. All patients were manual workers or strength athletes. All had pain and stiffness secondary to primary or secondary arthritis, with or without loose bodies. Pre- and post-operative evaluation included the Elbow Functional Assessment score, patient satisfaction and return to work and sports. The mean follow up period was 22 months. Function improved significantly in 87% with overall improvement in the Elbow Functional Assessment score from a preoperative score of 48 to a postoperative score of 84 (p< 0.05). All except three patients returned to their desired level of activity by 3 months postoperatively. Pain improved in 91%, mechanical symptoms in 80%, stiffness in all except one. The arc of elbow movement improved from 106° to 124° with a mean gain in elbow extension of 13°. Mayo elbow performance index also significantly improved postoperatively. Overall, 87% patients were very satisfied with the outcome. We conclude that the arthroscopic arthrolysis improves elbow function and returns patients to their desired level of activity, as well as improving range of motion and pain in patients with intrinsic elbow stiffness and pain.

We present an all arthroscopic technique for modified Weaver Dunn reconstruction of symptomatic chronic type III ACJ joint injuries. Over a one year period we performed 12 all arthroscopic modified Weaver-Dunn procedures. All patients had failed non-operative management for at least 6 months. The technique involved excision of the lateral end of clavicle, stabilisation with a suture cerclage technique from 2 anchors placed in the base of the coracoid and coracoacromial ligament transfer from the acromion to lateral end of clavicle. Post-operatively the patients were immobilised for six weeks, followed by an active rehabilitation programme and return to work and sports at 3 months. We have currently performed this technique in 12 patients, all male. The average age at operation was 25.8yrs at a mean interval of 11 months post injury. The mean Constant score preoperatively was 49 (44–54). The mean 3 month postoperative Constant score was 88.6 (84–96). There have been no complications, and the 2 professional sportsmen within our cohort returned to full contact at 3 months. Due to an irreducible clavicle, one patient required an open excision of lateral clavicle, with the rest of the procedure performed arthroscopically. Arthroscopic Weaver-Dunn has a number of advantages over the corresponding open procedure. It avoids the detachment of deltoid needed to gain exposure and also the morbidity from the wound. From our experience is that it enables patients to regain their function more rapidly with an earlier return to sporting activities. The early results from our initial experience have been excellent, with no complications. With this technique an anatomic reconstruction can be achieved with excellent cosmesis, low morbidity and potentially accelerated rehabilitation.

The diagnosis of subacromial impingement of the shoulder is generally a clinical diagnosis, with no well defined diagnostic criteria. A number of tests have been described. Neer and Hawkins signs are the most common with reported sensitivities for subacromial impingement of 75% and 92% respectively.

The senior author was taught another impingement test by Mr S Copeland during his Fellowship in Reading, UK. The Copeland Impingement test is an extension of the Neer’s impingement sign, where abduction in the scapula plane with the shoulder in internal rotation causes mid-arc pain which is abolished with abduction in external rotation.

In a retrospective study we analysed the clinical data of twenty-nine patients diagnosed with subacromial impingement of the shoulder. The diagnosis was determined by the clinician’s final diagnosis. This was based on the clinical findings and response to a subacromial injection (Neer’s Test). The clinical tests included were: Hawkin’s test, Mid-arc impingement pain, Neer’s sign, Neer’s test and the Copeland impingement test. The sensitivity and specificity of each test was determined and the values statistically analysed for any significance.

The Copeland test was the most sensitive, with 95% sensitivity. Using the Wilcoxon’s signed ranks test the Copeland test was significantly more sensitive than the Neer’s and Hawkin’s tests for subacromial impingement.

In conclusion the Copeland test is an effective clinical test in the diagnosis of subacromial impingement and more sensitive than the traditional tests.

Avascular necrosis (AVN) of the humeral head is an extremely disabling condition (Gerber et al, JSES 1998. 7(6):586–90). The results of stemmed arthroplasty for this condition are good, with Hattrup and Cofield reporting 79% subjective improvement at nine years (JSES 2000;9:177–82). This study reports the outcomes of surface replacement shoulder arthroplasties for AVN over a 16 year period. Between 1986 and 2001 twenty-seven arthroplasties were performed in patients with advanced avascular necrosis of the humeral head. All patients had secondary degenerative changes. AVN was secondary to corticosteriods and trauma in most cases.

The mean age of the patients was 60 years (range 35 to 86). These included 16 hemiarthroplasties and 7 total shoulder arthroplasties. All prostheses were of the Copeland Surface Replacement Arthroplasty (CSRA) type.

The average follow up period was 6 years (range 1 to 13). The average preoperative Constant score was 17. This improved to 74 at follow-up. Forward flexion improved from 63 degrees preoperatively to 133 degrees at follow-up. Abduction improved from 49 degrees to 118 degrees. External rotation improved from −3 degrees to 61 degrees. Pain scores improved from 0 to 11.7, using a 15 point visual analogue scale. 81% of patients had slight and no difficulty performing their routine activities of daily living. The remaining 19% still had some difficulty with routine activities. Four of the patients performed regular overhead activity and recorded some difficulty in doing this, whereas they had great difficulty pre-operatively. There were no cases of loosening. No difference was seen in any of the results between the hemi-arthroplasty and total shoulder replacement patients.

Surface replacement arthroplasty is a suitable procedure for degenerative disease secondary to AVN of the humeral head, with results similar to stemmed prostheses. It has the advantage of preserving bone stock.

Purpose: The aims of this study were to describe our technique and outcome of arthroscopic repair of small rotator cuff tears.

Methods: The technique involves two screw-in anchors placed into the footprint area, linked with a double-loop No. 1 Polydioxanone suture. It is quick and simple, providing a similar fixation to other commonly used methods. Between 1999 and 2001, 20 repairs were performed using this technique in patients with rotator cuff tears < 2cm in size. Prospective follow-up was conducted on these patients. Mean age was 56.5yrs (range 37–72yrs) with 10 males and 10 females (8 left and 12 right sided cuff tears).

Results: Mean follow-up period was 13mths (range 10–28mths). Constant scores improved from preoperative mean 34 (range 22–53) to postoperative mean 85 (range 76–96). Pain scores (/15) improved from preoperative mean 3.7 to postoperative mean 13.4. All regained full range of movement. All were satisfied with the operation. There was an average 90% subjective improvement. There were no complications.

Conclusion: Arthroscopic rotator cuff repair for small tears produces satisfactory results using this technique.

Purpose: The Subacromial bursa is the largest bursa in the body. In 1934 Codman described the presence of Subacromial plicae, similar to the suprapatellar plicae found in the knee. This anatomical finding was again described by Strizak et al. in 1982. It is recognised that plicae in the knee can cause anterior knee pain with impingement against the patella in young people. We investigate the possibility that a similar situation exists with plicae of the Subacromial bursa. The aims of this study were to document the incidence of bursal plicae seen at bursoscopy during arthroscopic Subacromial decompressions of the shoulder, and to assess whether there is any pattern to the occurrence of these plicae, and the relation to impingement lesions seen at bursoscopy.

Methods: A review of all patients undergoing Arthroscopic Subacromial Decompression (ASD) of the shoulder between January 1996 and July 2001.

Results: A total of 2043 ASD procedures were performed in the study period. Of these, the number of plicae found was 130, with an incidence of 6.4%. There was a strong age predilection, with a significantly higher incidence in younger age groups. There was no difference between males and females.

Where a plica was present the impingement lesion seen on the cuff side was significantly greater than the lesion seen on the acromial side (p< 0.0001). This suggests that the impingement might be due to the plica itself.

Conclusions: This study is the first to describe the presence of Subacromial plicae in living subjects and correlates with previous anatomical studies. The younger age predominance correlates with the findings of plicae in the knee. Our findings suggest that Subacromial plica may be a cause of impingement in young patients.

Introduction: Shoulder arthroplasty is generally a successful procedure. However, in a small percentage excessive pain or limitation of motion, does occur. We examine the role of arthroscopy in the diagnosis and treatment of these patients.

Methods and Results: Between 1995–2000, 29 patients who had excessive pain or limitation of motion following arthroplasty underwent arthroscopy. Time between procedures was 37.3 months (range 4–95).

Impingement syndrome confirmed and successfully treated by ASD in 10, a rotator cuff tear in 3. Loose bodies removed in 1. Arthroscopic washout was performed in 1 patient for acute septic joint. 6 of 7 with capsular fibrosis underwent a successful arthroscopic capsular release. Loose or worn components were found in 4, a florid synovitis in 1, loose cement in another and in 1 no abnormality could be found.

Discussion: Arthroscopy is a useful tool for diagnosis and treatment of painful or stiff shoulder arthroplasty. However, it leads to a number of technical difficulties. Orientation within the joint is often hindered as the reflection from the prosthesis makes it difficult to differentiate between the real and mirror images of the tissues and arthroscopic instruments. Access is often compromised in stiff shoulders.

Conclusion: Arthroscopy following shoulder arthroplasty is useful for the diagnosis and treatment of pain and loss of motion in selected patients, but can be technically difficult. Diagnostic arthroscopy following shoulder arthroplasty should be considered for patients suffering from pain in whom no cause could be found using less invasive investigations.