Aims

Extensive literature exists relating to the management of shoulder instability, with a more recent focus on glenoid and humeral bone loss. However, the optimal timing for surgery following a dislocation remains unclear. There is concern that recurrent dislocations may worsen subsequent surgical outcomes, with some advocating stabilization after the first dislocation. The aim of this study was to determine if the recurrence of instability following arthroscopic stabilization in patients without significant glenoid bone loss was influenced by the number of dislocations prior to surgery.

Aims

Recurrent dislocation is both a cause and consequence of glenoid bone loss, and the extent of the bony defect is an indicator guiding operative intervention. Literature suggests that loss greater than 25% requires glenoid reconstruction. Measuring bone loss is controversial; studies use different methods to determine this, with no clear evidence of reproducibility. A systematic review was performed to identify existing CT-based methods of quantifying glenoid bone loss and establish their reliability and reproducibility

Our aim was to compare displayed pressure with actual intra-articular pressure using three fluid delivery systems. The pumps used were the Arthrex, FMS and Dyonics.

We investigated thirty patients undergoing shoulder arthroscopy. Patients with a previous disruption to the joint capsule were excluded.

A standard set-up was used with the patient in a lateral position and arm in traction. The arthroscope was introduced from the posterior portal. The rotator interval was identified and the needle introduced from this point. The needle was attached to a arterial pressure transducer. The pressure transducer was coupled to the anaesthetic machine. Pressures of 30, 50 and 80 mmHg were dialled on the fluid management systems. Once the pressures stabilised on the pumps the intra-articular pressure was measured independently using the pressure transducer.

Median pressures for the FMS and Arthrex pumps were approximately twice set pressures. Median pressures for the Dyonics pump were closer to set pressures but the range of values was wider.

The three pumps were inaccurate and behaved differently to each other. They are not interchangeable. Each pump performed inconsistently.

Considerable controversy remains in the literature as to whether hemiarthroplasty or total shoulder arthroplasty (TSA) is the better treatment option for patients with shoulder arthritis. Several cohort studies have compared the outcomes of stemmed hemiarthroplasty with those of stemmed TSA and had inconsistent conclusions as to which procedure is best. However, these studies suggest that stemmed TSA provided better functional outcome. 340 CSRA cases were performed between 1987–2003, 218 Hemiarthroplasty – Humeral Surface Arthroplasty (HSA) and 122 TSA. There was very little difference in the functional outcome and pain in patients with and without a glenoid implant early, as well as, later after surgery. Mean post-operative Constant score for TSA was 85.0% (59.8 points) and for HSA patients 86.8% (62.3 points) with no statistically significant differences (t-test, p=0.4821). A highly significant difference between the overall proportions of revised cases was observed, with (21/122) 17.2% and (6/218) 2.8% of TSA and HSA cases revised, respectively (p< 0.0001). Further, HSA prostheses survive significantly longer than TSA prostheses. The difference between the survival curves was highly significant, both in the earlier post-operative period (Wilcoxon’s test, p=0.0053) as well as the later on (Log-rank test, p=0.0028). Long-term survival of total joint replacement is related to polyethylene wear debris, and therefore its use should be avoided if possible. The difference between our series and those with stemmed prostheses may be due to the fact that with surface replacement the normal anatomy for each patient can be mimicked better than with the stemmed prostheses and there is substantially less place for error as in stem positioning, head sizing or wrong version that may lead to glenoid erosion and less favourable result. Our current practice is and we suggest performing Copeland humeral surface replacement without insertion of glenoid prosthesis.

We report the outcome of 58 knees with anteromedial osteoarthritis in which the Oxford unicompartmental arthroplasty was inserted. These were performed in a district general hospital by three surgeons.

All the knees had only anteromedial disease, an intact anterior cruciate ligament and correctable varus. The indication for replacement in all cases was pain. The mean follow up was 24.5 months (6–48). Outcome was assessed by patient satisfaction and the Oxford knee score. Complications, revisions, time to mobility and time to return to work were also noted.

The average age of the 26 women and 23 men at time of operation was 65 years. 31 of the patients were very happy with the outcome, 12 were happy, 5 were unhappy, and one was very unhappy. Mean pre-operative Oxford knee score was 43 (27–53) this improved post-operatively to 18 (12–45) a significant improvement (p< 0.005, paired t-test). Time taken to mobility was an average of 36 hours (24–72), 24 of the patients were in full or part time employment at the time of operation, all returned to their former posts at an average of 6 weeks (2–24).

Three patients have ongoing pain and are booked for revision to TKR. One patient had a dislocated femoral component and required this to be revised twice with a meniscus change at the same time; this patient is now happy. 2 further patients had revision of the meniscus to a larger size for meniscal dislocation. One patient had an infection treated with debridement and antibiotics; infection settled. Our results show that there is a learning curve; all of the insert revision occurred early in the series. Patient selection is important, those with disease in other compartments have continuing pain. Appropriate selection of patients and good surgical technique are the key to obtaining a good outcome.