Aim

To see if minor upper limb surgery procedures like CTR, Trigger release, Joint injections are safe for a remote telephonic review by specialist nurse. This arrangement was to help maintain our current agreed departmental New to Follow up ratio of 1:1.56 and also to improve access to specialist clinics.

We wished to assess the usefulness of Inspace balloon arthroplasty (IBA), in our Upper limb unit by regular patient reviews prospectively. This prospective study was started adhering to local approval process. Patients were identified in routine clinical practice by three upper limb consultants presenting with pain and disability and diagnosis of cuff tear was established clinically and on MRI. The patients were explained of ‘available’ treatment options and an information leaflet about balloon arthroplasty provided. Patients were seen in 4 weeks, in a dedicated clinic to find out their willingness to participate. Consultant shoulder surgeons carried out all Balloon arthroplasties and where the cuff was reparable or contraindications identified were excluded from study.

All the patients were reviewed by an independent clinician pre-operatively and post operatively using the assessment tools of Oxford Shoulder Scores (OSS), SF12 and VAS at 6 weeks, followed by 3, 6, 12 months and annually after.

We performed a total of 32 IBA procedures. At the latest follow-up we identified that 24 patients have completed 2 years post procedure. Of these patients 1 deceased after 6 months, 3 were lost to follow up one each at 6, 12 and 24 months. Three were revised to reverse TSA. The OSS reflects that the positive difference of 10 in the average scores (24 pre-operative versus 34 at 2 years) noted at one year follow up were maintained at 2 years. Similar observations made analysing at 12 months and 2 years scores for the VAS pain scores of 3 at 2 years compared to pre-operative score of 6 and so were improvements in both physical & mental components of SF12.

Our study observes that the IBA provides a sustainable pain relief and functional improvements over 2 years and may be a suitable alternative in physiologically compromised patients with irreparable RCT.

Introduction: The upper edge of pectoralis major tendon insertion (PMTI) on the humerus is touted as a reference to restore humeral height, to be used in hemi-arthroplasty for proximal humeral fracture. The aim of the study was to verify the reliability of reference and ease of its use in routine practice.

Materials and Methods: Tests were carried out in line with UK HTA regulations.

21 fresh frozen shoulders were stripped of all tissues except the rotator cuff and the PMTI. In each specimen the tuberosities were osteotomised, and the humeral head dislocated. The top margin of the PMTI was sought and marked. A flat object was held on the top of the humeral head perpendicular to the shaft and the vertical height from upper edge of PMTI to this object was measured.

Results: The 21 measurements (12 right +9 left) had a mean height of 5.98cm (95% CI: 5.64 – 6.31cm). The range of heights was 5 to 7.3 cm for all shoulders and also for right and left sides separately. Eighteen of these 21 shoulders were a pair i.e. right and left of 9 cadavers. The average height for 12 right shoulders was 5.91cm and for the left side average height was 6.05cm. The heights for a pair matched within 0.5 cm only in four pairs (8 shoulders) and exactly in only two pairs (4 shoulders) of specimens. The maximum difference in heights for one pair of shoulders from the same cadaver was as large as 1.4 cm. In comparison to previous studies our measurements were significantly greater than 5.6 cm (P = 0.029). Furthermore, there were 4 measurements of at least 7cm (19.0%, 95%CI: 5.4 – 41.9%).

Conclusion: Proximal humeral fracture treatment is a clinical challenge. In these fractures, usually all the ‘bony’ landmarks are lost. In these circumstances an anatomical landmark is needed to navigate from, and the upper edge of PMTI serves as a reference in restoring the height.

We found the average values for height to be larger than previously reported. Additionally the notion that the contra-lateral side can be used to calculate the height as a percentage of the length, accepting an error of +/− 0.5cm; was not corroborated. In 3 cases of the 9 pairs available a difference of 14, 7 and 6mm was seen. Lastly in certain cases a flimsy layer of fascia curved superiorly at the top margin, and we were in doubt as to whether to take this fascial extension as the top margin; in one case this flimsy layer also had muscular tissue attached. Though use of the fixed value had on our testing, a wider range than reported, we feel that PMTI is a useful landmark in these operations.