The deltopectoral approach is a common approach for Shoulder joint replacements where a normal subscapularis tendon is divided. Despite meticulous attention to the subscapular repair, suboptimal return of function was found on clinical examination in 92% of patients (Miller S L: Journal of Shoulder & Elbow Surgery. 12(1): 29–34, February 2003). Therefore the aim was to study the integrity of the Subscapularis tendon in patients with Shoulder joint Replacements both clinical and ultrasound examination

Methods: A cohort of 25 subjects who had undergone Copeland Shoulder replacements through deltopectoral approach were included. All patients had same technique of tendon-to-tendon repair and postoperative rehabilitation. After ethics committee approval subjects were evaluated prospectively with Lift off test, Belly press test and the Constant score. Average follow-up was 29.6 months. An experienced Radiologist performed the Ultrasound examination

Results: Ultrasound examination showed 8 % (2 of 25) had full thickness rupture of subscapularis with 44% (11 of 25) showed mild to moderate atrophy of subscapularis muscle and 12%(3 of 25) severe atrophy. 20%(5 of 25) had Lift off test and Belly press test positive. 40%(10 of 25) had either or both of these tests positive. 60%(15 of 25) had clinical or radiological evidence of reduced function (Fisher exact test, P < 0.01). Constant score are 37.5 with full thickness tears compared to 59.4 with intact subsapularis tendon

Conclusion: Subscapularis tendon function following shoulder replacement had received poor attention. It is deficient in over 60% of patients with joint replacement through Deltopectoral approach with tendon-to-tendon repair. We therefore conclude for this study that alternative techniques of subscapularis tendon repair or alternative approaches to the shoulder joint need to be considered to improve the functional outcome in these patients

Scientific Background The Coracoid process of scapula is a principal landmark in shoulder surgery. Brachial plexus is at risk of injury during surgery around the coracoid, e.g. Weaver-Dunn procedure. Magnetic resonance imaging is the method of choice for evaluating the anatomy and pathology of the brachial plexus and has good resolution compared to Computed tomography or Ultrasound (Ref: 1).

Aim The aim was to study the proximity of brachial plexus to coracoid process in various Shoulder positions. The objective was to define the position of safety for operating around the coracoid.

Methods With Ethics Committee approval, twelve healthy volunteers (men with average age of thirtyfive years) were recruited. Exclusion criteria included previous shoulder injury or operations, known contra-indication for MRI examination and children. An open Magnetic Resonance Scanner (1.5 Teslar) was used to facilitate shoulder positioning. Consent was obtained prior to scanning after information was given to subjects. They were placed under the scanner and images were obtained in axial, coronal and sagittal plane with shoulder in neutral, 45 degrees and 90 degrees of abduction. The images taken are T1, T2 axial spin-echo sequences with 2-mm cuts and coronal echo of a T1-3D gradient with 2 mm cuts, together with a T1 coronal spin-echo, with cuts 2 mm in width. Distance from coracoid process to the Brachial plexus bundle is measured in millimetre on the PACS system which has software to eliminate magnification.

Results The brachial plexus consistently moved away medially from the coracoid in all the subjects at 45 degrees abduction of the shoulder. It returned to the closer position to coracoid in 90Degree abduction. The statistical analysis showed that on an average the distance the brachial plexus moved away towards medial side by 4.37 mm with Standard deviation 3.57 (p= 0.014).

Conclusion The brachial plexus move medially away from coracoid process at 45 degrees shoulder abduction. This position reduces the risk of injury to the brachial plexus during surgery around the coracoid process.

In a prospective study, we have evaluated the impact of psychological disturbance on symptoms, self-reported disability and the surgical outcome in a series of 110 patients with carpal tunnel syndrome. Self-reported severity of symptoms and disability were assessed using the patient evaluation measure and the Boston carpal tunnel questionnaire. Psychological distress was assessed using the hospital anxiety and depression scale.

There was a significant association between psychological disturbance and the pre-operative symptoms and disability. However, there was no significant association between pre-operative psychological disturbance and the outcome of surgery at six months. We concluded that patients with carpal tunnel syndrome should not be denied surgery because of pre-operative psychological disturbance since it does not adversely affect the surgical outcome.