In a cadaveric study, the anterior shoulder capsule indicated the presence of the middle (MGHL) and inferior (IGHL) glenohumeral ligament by displaying folds. These folds became more prominent in adduction (AD) and internal rotation (IR), whereas they were smoothed out upon abduction (AB) and external rotation (ER).

The present study was set up to determine whether this folding-unfolding mechanism (FUM) is influenced by the type of shoulder pathology.

300 consecutive shoulder arthroscopies were evaluated. 68 were done for instability, 21 for frozen shoulder and 221 for various pathologies in stable shoulders of which 100 for rotator cuff tears.

Stable shoulders: The anterior band (AB) of the IGHL was marked by a prominent fold in IR and 30°AD. In full ER and 45°AB the fold was completely smoothed out. The MGHL was smooth in full ER and 15°AB.

Frozen shoulders: The anterior capsule was smooth without visible folds in any degree of rotation, limited by the adhesive capsulitis. Releasing the capsule from the glenoid rim did not change this appearance.

Unstable shoulders: In 17 shoulders with anterosuperior instability (SLAP and RCI lesions), the FUM of the anterior capsule had the same appearance as in stable shoulders. In 51 shoulders with anteroinferior instability, the MGHL and ABIGHL still formed prominent folds in IR. Full ER, increased up to 90° in some patients, did not result in smoothing of the folds, not even with up to 90°AB. After repair of the labroligamentous lesion and associated capsular shift, the FUM reappeared at 45°AB and ER that was reduced to 45°.

These observations suggest that smoothing of the anteroinferior capsule at a maximum of 45°ER and 45°AB could be used as an indication of normal tension in the MGHL and IGHL. When the FUM does not occur within this range, these ligaments are probably insufficient, be it torn or stretched. During capsular shift, esp electrothermal, a reappearing FUM could be used to evaluate achievement of adequate capsular tension. When no folds at all are visible, even with full IR, this indicates a very tight capsule and likely a frozen shoulder, esp when rotation is decreased.

A series of 116 patients surgically treated, with exclusion of arthroplasty, between December 1996 and December 2002 for a fracture of the proximal humerus, was retrospectively reviewed. Only 44 patients (45 shoulders) were available for clinical and radiological follow-up, 21 were deceased, 36 refused to participate and 14 could not be traced.

The mean age was 60 y (15–93 y), the mean follow up was 44 months (15–78 m.); 28 were women, 16 men.

The fractures were classified according the Neer-classification but also according the different types of surgery they underwent: percutaneous or retrograde pinning without opening the fracture site, osteosynthesis with plate and screws, osteosynthesis with screws alone, bone-graft and osteosutures or a combination of two or more methods.

Two-part fractures (10 out of 13 fractures), but also 9 of the 15 three-part fractures, were treated by pinning, whereas the remaining 2 and 3-part, the isolated fractures of tuberculi and two 4-part fractures needed open surgery and fixation. A plate was used in only 3 cases, screws alone in 6 cases, a cortical bone-graft with osteosutures in 4 cases and a combination of open fixation in 8 cases. Whenever possible a minimal invasive technique was thus preferred.

16 patients (35,7%) had complications: 6 were minor (pin migration, slight secondary displacement or impingement as a consequence of protruding hardware), but one non-union, 4 CRPS and 5 avascular necrosis occurred. Only one of the latter underwent shoulder-arthroplasty at time of review. Major complications occurred mainly in the more complex fracture types (3 or 4 part fractures)

Mean values of Constant score, ASES-score, Neerscore, UCLA score and Simple Shoulder test were not statistically different, neither between fracture types nor between surgical techniques. Using a correlation analyses we found a negative correlation between age and scoring systems: the older the patient, the lower the score. Patient satisfaction was higher in the percutaneous or retrograde pinning group than the other types of open surgery.

We can conclude that although no statistical differences could be observed in our series, minimal invasive surgical techniques, less prone to complications, are preferable in the treatment of two and three part fractures of the proximal humerus and 4-part fractures of the younger population.

Introduction Osteoarthritis of the knee is a very common disease.In 80 to 90% of the cases it starts in the medial compartment and tends to remain there.Therefore, the Oxford Unicondylar Knee Prosthesis (OUKP) is a attractive device as it only replaces the diseased parts of the knee.For the past 15 years, the results of the OUKP, especially those achieved by the designer’s group, have mostly been very good. However, reports about long-term follow-up are scarce. For the designer group, Murray reported a 98% ten year survival. The only independent research bij Svard an Price and by Lewold of the Swedish Arthroplasty Study showed a good survival of 95% at 10 years and a poor survival of 87% at 8 years respectively.Our independent study reviews a ten year follow up of 149 OUKP’s.

Methods and Results One hundred forty-nine medial prostheses were implanted in 140 patients between 1988 and 1996. After a mean of 67 months 28 patients had died, without the need for revision. Seventeen prostheses were lost to follow-up. Revision surgery using a total knee prosthesis was performed in 16 cases. In 4 others, a lateral prosthesis was implanted subsequently to a medial one. One of these 4 was revised to a total knee prosthesis 6 years later. In another 4 cases, late complications of the meniscal bearing were treated with replacement of this bearing. In the group af patients older than 75 years, no revisions were recorded. The surviving prostheses were seen back after a mean of 126 months. The cumulative survival rate at 10 years was 82% for the whole population and 84% when knees with a previous high tibial osteotomy were excluded.

This difference is significant (p=0,0000).

Conclusion These results are in line with those of the Swedish arthroplasty register and compare poorly to the survival of total knee arthroplasty, therefore this prosthesis is not the first choice for most cases. Because it preserves a maximum of bone stock and is revised to a total prosthesis almost without difficulty, it is the first-choice implant for medial unicompartmental osteoarthritis in the relatively young patient.The survival rate in the group of patients older than 75 years is as good as or better than that for total knee arthroplasty.Since the OUKP can now be placed minimally invasive, it might have its place in this subgroup. It should not be used in osteotomized knees.

Aim: To study the contribution of humeral avulsion of the glenohumeral ligaments (HAGL) to shoulder instability. Methods: In fourteen fresh cadaver shoulders a selective cutting sequence was performed. After each section an abduction-external rotation manoeuvre with axial compression and translation was carried out to provoke dislocation. The resulting instability was graded on a scale of five, ranging from no translation to a locked dislocation. Results: Cutting of only the inferior glenohumeral ligament complex resulted at the most in increased translation, but not in subluxation. For subluxation to occur, at least the middle glenohumeral ligament needed to be cut. The entire humeral capsuloligamentous complex needed to be sectioned before subluxation or dislocation occurred. In half of the cases an additional lesion of the subscapularis or the latissimus dorsi is necessary to allow a locked antero-inferior dislocation. Conclusion: Extensive damage to the humeral side of the capsulo-ligamentous complex and, frequently, associated lesions of the subscapularis or latissimus dorsi muscles are necessary to allow dislocation. This might be the primary reason for the low incidence of HAGL observed in clinical series of shoulder instability

Aim: To study the morphology of the anterior cap-suloligamentous structures of the glenohumeral joint. Methods: Eighty non-embalmed cadaver shoulders were studied. Twenty shoulders were dissected through an anterior approach, twenty through a posterior approach. In another twenty shoulders the anteroinferior capsuloligamentous complex was examined arthroscopically through a posterior portal. In all of these sixty shoulders the functional anatomy was studied by moving the arm from its resting position along the body to maximal abduction and external rotation. Dissecting another twenty shoulders through an inferior approach completed the study of the humeral insertion of the inferior glenohumeral ligament. Results: The inferior, middle and superior glenohumeral ligament are usually only discernible by palpation, but not visually. When the capsule is ßattened out, these ligaments can no longer be discriminated macroscopically. The classic Z-like structure can be seen when examining the anterior capsule from its posterior side, but only when the shoulder is at rest, which is with the arm along the body. The functional study shows that this Z corresponds with a folding phenomenon of the capsuloligamentous ÒpouchÒ to accommodate the relative excess of length when the arm is at rest. A progressive unfolding occurs as the arm is progressively abducted and externally rotated. By creating a functional shortening, the folding mechanism provides pretensioning of the ligaments. Conclusion: At the anteroinferior part of the shoulder joint, there is a real, functional capsuloligamentous unit.

Aim: To determine whether isolated lesions of the glenoid labrum or capsulolabral lesios influence anterior and inferior shoulder stability in a cadaver model that leaves all other glenohumeral structures, including the capsule, intact. Methods: Sequential arthroscopic resection of the labrum was performed with a motorized shaver in seventeen fresh cadaver shoulders. A capsulolabral dehiscence was created arthroscopically in another eleven fresh cadaver shoulders. The capsulolabral complex was divided into five zones: from superior to posterior. Inferior and anterior stability were tested before and after each cutting step. Results: The hyper-abduction test showed progressive increase in abduction with each step, with a maximum of 120° reached after removal of the labrum in all four zones or after detachment of all zones. Resection of the superior to inferior labrum maximally resulted in subluxation, but not in dislocation of the shoulder. Capsulolabral dehiscence of all but the posterior zones resulted in a locked (6/11) or a metastable (4/11) dislocation. In the other specimens the posterior zone needed to be detached as well for a metastable dislocation. Conclusion: Purely labral lesions and limited capsulolabral detachments do not seem to be sufficient to allow the humeral head to dislocate. Labral tears can therefore be debrided without consequences for shoulder stability. In the present study, a capsulolabral detachment in the antero-inferior zone (the typical Bankart lesion) does not allow the humeral head to dislocate. This leads us to suggest that associated lesions must exist in chronic instability.