Aims

The use and variety of stemless humeral components in anatomical total shoulder arthroplasty (TSA) have proliferated since their advent in 2004. Early outcomes are reassuring but independent mid-term results are scarce. This independent study reports a consecutive series of 143 Eclipse stemless shoulder prostheses with a minimum five-year (5 to 10) follow-up.

Aims

Our aim was to investigate the prevalence of Propionibacterium (P.) acnes in the subcutaneous fat and capsule of patients undergoing shoulder surgery for frozen shoulder or instability.

Aims

Despite the expansion of arthroscopic surgery of the shoulder, the open deltopectoral approach is increasingly used for the fixation of fractures and arthroplasty of the shoulder. The anatomy of the terminal branches of the posterior circumflex humeral artery (PCHA) has not been described before. We undertook an investigation to correct this omission.

Pain is a common presenting symptom of patients with shoulder conditions, yet there has been little work done to accurately describe its distribution and nature.

We studied all patients attending the Royal Devon and Exeter Hospital shoulder clinic from August 2012 – 2013. Patients completed a questionnaire detailing their Oxford Shoulder Score and a validated neuropathic pain questionnaire. Patients were given diagrams to draw on their perceived location of pain or abnormal sensation.

We analysed all patients with frozen shoulder (48), osteoarthritis (37) and rotator cuff arthropathy (17).

We found that neuropathic pain is common in patients with shoulder conditions identified in 39% of OA patients, 42% with rotator cuff arthropathy and 57% with frozen shoulder. Pain outside the shoulder was reported in over 50% of patients, commonly the forearm, hand, neck and chest. Frozen shoulder was especially associated with pain outside of the shoulder with 39% describing symptoms in the neck or chest, 21% into the forearm and 18% into the hand. Interestingly, neuropathic pain radiating down the arm was not described in the rotator cuff arthropathy group.

The high prevalence of neuropathic symptoms and pain felt outside the shoulder aids diagnosis and more accurately identifies these conditions.

Despite the expansion of arthroscopic surgery of the shoulder, the open deltopectoral approach to the shoulder is still frequently used, for example in fracture fixation and shoulder replacement. However, it is sometimes accompanied by unexpected bleeding. The cephalic vein is the landmark for the deltopectoral interval, yet its intimate relationship with the deltoid artery, and the anatomical variations in that structure, have not previously been documented.

In this study the vascular anatomy encountered during 100 consecutive elective deltopectoral approaches was recorded and the common variants described. Two common variants of the deltoid artery were encountered. In type I (71%) it crosses the interval and tunnels into the deltoid muscle without encountering the cephalic vein. However, in type II (21%) it crosses the interval, reaches the cephalic vein and then runs down, medial to and behind it, giving off several small arterial branches that return back across the interval to the pectoralis major. Several minor variations were also seen (8%).

These variations in the deltoid artery have not previously been described and may lead to confusion and unexpected bleeding during this standard anterior surgical approach to the shoulder.

Cite this article: Bone Joint J 2013;95-B:657–9.

The Delto-pectoral approach is the workhorse of the shoulder surgeon, but surprisingly the common variants of the cephalic vein and deltoid artery have not been documented. The vascular anatomy encountered during one hundred primary elective delto-pectoral approaches was documented and common variants described.

Two common variants are described. A type I (71%), whereby the deltoid artery crosses the interval and inserts directly in to the deltoid musculature. In this variant the surgeon is unlikely to encounter any vessels crossing the interval apart from the deltoid artery itself. In a type II pattern (21%) the deltoid artery runs parallel to the cephalic vein on the deltoid surface and is highly likely to give off medial branches (95%) that cross the interval, as well as medial tributaries to the cephalic vein (38%).

Knowledge of the two common variants will aid the surgeon when dissecting the delto-pectoral approach and highlights that these vessels crossing the interval are likely to be arterial, rather than venous. This study allows the surgeon to recognize these variations and reproduce bloodless, safe and efficient surgery.

Background: Our Trust consists of two separate hospitals with duplicated Orthopaedic services at both sites. Sterile Services were centralised to one site in February 2006. Various problems were encountered leading to cancelled cases. What have been the financial implications of these cancellations?

It is difficult to estimate the true cost to the Trust for a cancelled case. Each cancelled case is a ‘slot’ on an operating list that has not been filled. There are regular Waiting List Initiative (WLI) Lists – the number of these have increased. Could an empty slot on a regular list have been filled by a WLI case? Would the cost of the WLI case theoretically performed in the empty slot be the cost of the cancelled case? The model is basic and has many assumptions. Patients are allocated a slot on a WLI list for a variety of reasons, however with enough numbers and across enough time, the true cost must be somewhere near these figures.

Method: Every cancelled case coded as “Surgical Equipment: checking/malfunction/unavailable” between April 2006 and Mar 2008 (2 financial years).

The total number of WLI cases in the same period and the total cost of those cases.

Results: There were 239 cancelled cases for Sterile Services reasons across Trust April 2006 – March 2008. During the same period, there were 1,566 Waiting List Initiative

Cases Cost: £3,234,000 (£2,065 per case)

Conclusions: If all of the cancelled slots had been filled by WLI cases this would have avoided a total cost to the Trust of £493,535

The combination of an irreparable tear of the rotator cuff and destructive arthritis of the shoulder joint may cause severe pain, disability and loss of independence in the aged. Standard anatomical shoulder replacements depend on a functioning rotator cuff, and hence may fail in the presence of tears in the cuff. Many designs of non-anatomical constrained or semi-constrained prostheses have been developed for cuff tear arthropathy, but have proved unsatisfactory and were abandoned. The DePuy Delta III reverse prosthesis, designed by Grammont, medialises and stabilises the centre of rotation of the shoulder joint and has shown early promise. This study evaluated the mid-term clinical and radiological results of this arthroplasty in a consecutive series of 50 shoulders in 43 patients with a painful pseudoparalysis due to an irreparable cuff tear and destructive arthritis, performed over a period of seven years by a single surgeon. A follow-up of 98% was achieved, with a mean duration of 39 months (8 to 81). The mean age of the patients at the time of surgery was 81 years (59 to 95). The female to male ratio was 5:1. During the seven years, six patients died of natural causes. The clinical outcome was assessed using the American Shoulder and Elbow score, the Oxford Shoulder Score and the Short-form 36 score. A radiological review was performed using the Sirveaux score for scapular notching.

The mean American Shoulder and Elbow score was 19 (95% confidence interval (CI) 14 to 23) pre-operatively, and 65 (95% CI 48 to 82) (paired t-test, p < 0.001) at final follow-up. The mean Oxford score was 44 (95% CI 40 to 51) pre-operatively and 23 (95% CI 18 to 28) (paired t-test, p < 0.001) at final follow-up.

The mean maximum elevation improved from 55° pre-operatively to 105° at final follow-up. There were seven complications during the whole series, although only four patients required further surgery.

We present a retrospective analysis of 50 cases of cuff tear arthropathy, treated over past seven year period by use of reverse geometry shoulder prosthesis. 98% follow-up was achieved with average follow up of 3 years. Mean (SD) age was 81.3 (9.2) years and female to male ratio was 5:1. Six patients had bilateral reverse geometry shoulder replacements. Patients were assessed with preoperative Oxford and American Shoulder and Elbow Scores Society score (pre-op ASES) and post-operative American Shoulder and Elbow Society Score (post-op ASES), Oxford, Constant and SF36 scores. Mean pre-op ASES was 22.29 (95%CI: 9.1 – 37.9) and post-op ASES score was 65.2 (95%CI: 48.5 – 81.9), (P< 0.001, Paired t-test). Mean post operative Oxford score was 27.25 (95% CI: 18.4 – 27.6). Mean post operative Constant score was 63.2 (95% CI: 52.6 – 79.6). X-ray review was performed to assess scapular notching and Sirveaux score was used to grade extent of notching. 11 patients had Sirveaux grade 0, 5 had grade 1, 6 had grade 2, 12 had grade 3 and 8 had grade 4 notching. Intra-operative complications included 2 glenoid fractures. Post-operative complications included 2 acromion fractures and 2 episodes of subsidence with dislocation. None of the patients developed post operative haematoma. There was one episode of infection in one patient that required further surgery. Iteration of approach with increasing experience over the years will be discussed. Ours is the biggest series of reverse geometry prosthesis used for irreparable rotator cuff tear arthropathy published so far in the literature and our results have shown superior results in terms of improvement in function and complications. We conclude reverse geometry shoulder replacement provides reasonable improvement in pain and function in elderly population with massive cuff tear arthropathy of shoulder.

We present a retrospective review of 50 cases of cuff tear arthropathy treated over past seven years by the use of reverse geometry shoulder prosthesis. 98% follow-up was achieved with average follow up of 3.04 years. Mean age was 81.3 (SD 9.2) years, female to male ratio was 5:1 and seven patients had bilateral procedures. Pre-operatively patients were assessed with American Shoulder and Elbow Surgeons Scores (ASES) and Oxford Scores and pos-operatively with ASES, Oxford and Constant scores. SF36 score was used to assess functional health status. Mean pre-op ASES was 22.29 (95%CI: 9.1 – 37.9) and post-op ASES score was 65.2 (95%CI: 48.5 – 81.9), (P< 0.001, Paired t-test). Mean post-operative Oxford score was 27.25 (95% CI: 18.4 – 27.6) and mean post operative Constant score was 63.2 (95% CI: 52.6 – 79.6). Sirveaux score was used to grade extent of glenoid notching on AP and lateral glenohumeral views, that showed 69% had notched. Complications included two acromion fractures, two episodes of subsidence with dislocation, one episode of infection and one patient with unexplained pain in axilla. We found reverse geometry shoulder replacement provides reasonable improvement in pain and function in elderly patients with massive cuff tear arthropathy.

We present a retrospective analysis of 50 cases of cuff tear arthropathy, treated over a seven year period by use of reverse geometry shoulder prosthesis. 98% follow-up was achieved with average follow up of 3 years. Mean (SD) age was 81.3 (9.2) years and female to male ratio was 5:1. Six patients had bilateral reverse geometry shoulder replacements. Patients were assessed with pre-operative American Shoulder and Elbow Score (pre-op ASES) and post-operative American Shoulder and Elbow Scores (post-op ASES), Oxford, Constant and SF36 scores. Mean pre-op ASES was 22.29 (95%CI: 9.1 – 37.9) and post-op ASES score was 65.2 (95%CI: 48.5 – 81.9), (P< 0.001, Paired t-test). Mean post operative Oxford score was 27.25 (95% CI: 18.4 – 27.6). Mean post operative Constant score was 63.2 (95% CI: 52.6 – 79.6). X-ray review was performed to assess scapular notching and Sirveaux score was used to grade extent of notching. 11 patients had Sirveaux grade 0, 5 had grade 1, 6 had grade 2, 12 had grade 3 and 8 had grade 4 notching. Intra-operative complications included 2 glenoid fractures. Post-operative complications included 2 acromion fractures and 2 episodes of subsidence with dislocation. None of the patients developed post operative haematoma. There was one episode of infection in one patient that required further surgery. Iteration of approach with increasing experience over the years will be discussed. Ours is the biggest series of reverse geometry prosthesis used for irreparable rotator cuff tear arthropathy published so far in the literature and our results have shown superior results in terms of improvement in function and complications. We recommend reverse geometry shoulder replacement is the way forward to treat irreparable cuff tear arthropathy of shoulder.

The aim of this study was to determine the biomechanical behavior of two different implants used in the fixation of proximal humerus fractures. The two implants in this study are specifically designed for the fixation of proximal humerus fractures and both utilize the concept of fixed angle locking screws. Bone densitometry was performed prior to fracture production and fixation. A reproducible three-part fracture was created in paired human cadaveric bone and then fixed using the locking screw implants. Stress/strain curves for the bone-implant construct were created for loads applied in cantilever bending and torsion to determine the relative stiffness below the yield point. Following this each construct was tested to failure with a valgus bending load.

The locking nail implant provided a significantly stiffer construct in torsion, valgus, extension and flexion at loads below failure threshold. The valgus load to failure was significantly higher for the nail. The mode of failure was different between implants.

We describe a patient with cerebral palsy, of normal intelligence, who could not walk but who by the age of 16 had been successfully managed with a staged bilateral total hip arthroplasty using a constrained liner.

We describe three patients who developed meralgia paraesthetica after the use of a well-padded and care-fully-placed patient-positioning device in total hip replacement.