Instability after arthroplasty of the shoulder is difficult to correct surgically. Soft-tissue procedures and revision surgery using unconstrained anatomical components are associated with a high rate of failure. The purpose of this study was to determine the results of revision of an unstable anatomical shoulder arthroplasty to a reverse design prosthesis. Between 2004 and 2007, 33 unstable anatomical shoulder arthroplasties were revised to a reverse design. The mean age of the patients was 71 years (53 to 86) and their mean follow-up was 42 months (25 to 71). The mean time to revision was 26 months (4 to 164). Pain scores improved significantly (pre-operative visual analogue scale (VAS) of 7.2 (. sd. 1.6); most recent VAS 2.2 (. sd. 1.9); p = 0.001). There was a statistically significant increase in mean active forward elevation from 40.2° (. sd. 27.3) to 97.0° (. sd. 36.2) (p = 0.001). There was no significant difference in internal (p = 0.93) or external rotation (p = 0.40). Radiological findings included notching in five shoulders (15%) and heterotopic ossification of the inferior capsular region in three (9%). At the last follow-up 31 shoulders (94%) were stable. The remaining two shoulders dislocated at 2.5 weeks and three months post-operatively, respectively. According to the Neer rating system, there were 13 excellent (40%), ten satisfactory (30%) and ten unsatisfactory results (30%). Revision of hemiarthroplasty or anatomical total shoulder replacement for instability using a reverse design prosthesis gives good short-term results. Cite this article: Bone Joint J 2013;95-B:668–72

We diagnosed 50 patients (58 shoulders) with a mean age at presentation of 17.3 years, as having involuntary positional instability of the shoulder. They were managed by a programme consisting of a careful explanation, analysis of abnormal muscle couples and then muscle retraining carried out by a specialist physiotherapist. The mean follow-up was two years. Six shoulders had a poor result, but 52 were graded as good to excellent. Nine patients (12 shoulders) relapsed and required further episodes of retraining. In our experience, involuntary positional instability of the shoulder causes symptoms which interfere with normal activities; these can be controlled by a treatment plan of retraining of the muscle pattern with functional benefit. Only 19 of the patients were referred with a diagnosis of positional instability. There should be more awareness of this rather uncommon condition. Surgery is not indicated in these patients

Objectives. To report the five-year results of a randomised controlled trial examining the effectiveness of arthroscopic acromioplasty in the treatment of stage II shoulder impingement syndrome. Methods. A total of 140 patients were randomly divided into two groups: 1) supervised exercise programme (n = 70, exercise group); and 2) arthroscopic acromioplasty followed by a similar exercise programme (n = 70, combined treatment group). Results. The main outcome measure was self-reported pain as measured on a visual analogue scale. At the five-year assessment a total of 109 patients were examined (52 in the exercise group and 57 in the combined treatment group). There was a significant decrease in mean self-reported pain on the VAS between baseline and the five-year follow-up in both the exercise group (from 6.5 (1 to 10) to 2.2 (0 to 8); p < 0.001) and the combined treatment group (from 6.4 (2 to 10) to 1.9 (0 to 8); p < 0.001). The same trend was seen in the secondary outcome measures (disability, working ability, pain at night, Shoulder Disability Questionnaire and reported painful days). An intention-to-treat analysis showed statistically significant improvements in both groups at five years compared with baseline. Further, improvement continued between the two- and five-year timepoints. No statistically significant differences were found in the patient-centred primary and secondary parameters between the two treatment groups. Conclusions. Differences in the patient-centred primary and secondary parameters between the two treatment groups were not statistically significant, suggesting that acromioplasty is not cost-effective. Structured exercise treatment seems to be the treatment of choice for shoulder impingement syndrome

Residual muscle weakness in obstetric brachial plexus palsy results in soft-tissue contractures which limit the functional range of movement and lead to progressive glenoid dysplasia and joint instability. We describe the results of surgical treatment in 98 patients (mean age 2.5 years, 0.5 to 9.0) for the correction of active abduction of the shoulder. The patients underwent transfer of the latissimus dorsi and teres major muscles, release of contractures of subscapularis pectoralis major and minor, and axillary nerve decompression and neurolysis (the modified Quad procedure). The transferred muscles were sutured to the teres minor muscle, not to a point of bony insertion. The mean pre-operative active abduction was 45° (20° to 90°). At a mean follow-up of 4.8 years (2.0 to 8.7), the mean active abduction was 162° (100° to 180°) while 77 (78.6%) of the patients had active abduction of 160° or more. No decline in abduction was noted among the 29 patients (29.6%) followed up for six years or more. This procedure involving release of the contracted internal rotators of the shoulder combined with decompression and neurolysis of the axillary nerve greatly improves active abduction in young patients with muscle imbalance secondary to obstetric brachial plexus palsy

We measured torsion of the humeral head in 38 patients (40 shoulders) with recurrent anterior dislocation of the shoulder (RADS) and in 40 normal subjects. We found a reduced mean retroversion in the patients with RADS at 4.3 +/- 10.56 degrees (17 degrees anteversion to 32 degrees retroversion) as compared with 16.1 +/- 11.07 degrees in the control group (0 degrees to 49 degrees) (p = 0.0001). There was anteversion in 11 of the 40 shoulders in the RADS group (27.5%) and in none of the control group. The first dislocation had occurred after minimal force in 18 of 25 patients with less than 10 degrees retroversion, but in only three of 15 with over 10 degrees retroversion. We conclude that decreased retroversion of the humeral head is often associated with RADS and with first dislocation of the shoulder caused by minimal force

The results of 63 operative repairs of chronic tears of the rotator cuff in 61 patients are reviewed retrospectively; the mean follow-up was 32.7 months. Fifty-four patients presented with symptoms of persistent pain and seven patients with gross loss of movement. All the patients had failed to respond to conservative treatment. Results were assessed in terms of relief of pain, restoration of movement, the patients' ability to return to work and whether they were satisfied with the results. Overall, a good result in terms of relief of pain was achieved in 40 shoulders. In 31 shoulders (30 with pain and one without pain) the operation included particular measures to decompress the subacromial space; 26 of the patients achieved relief of pain which was significantly better than in those patients whose operation did not include a decompression. The complications and failures are discussed. It is suggested that operative repair of the chronically torn rotator cuff of the shoulder is a worthwhile operation and that the operation should include an adequate decompression of the subacromial space

A reduced retroversion angle of the humeral head may predispose to recurrent anterior shoulder dislocation and may also be a factor in persistent instability after soft-tissue repair. We performed rotational osteotomy of the proximal humerus in 20 patients with recurrent anterior shoulder dislocations (10 traumatic, 10 non-traumatic) and a decreased retroversion angle of the humeral head. The mean preoperative retroversion angle was 12 degrees, which was increased after surgery to a mean value of 32 degrees. All patients regained a normal range of shoulder motion and normal function within three months after surgery. At the five-year review all shoulders were stable, pain-free and had no radiological signs of osteoarthritis

Reverse total shoulder replacement (RTSR) depends on adequate deltoid function for a successful outcome. However, the anterior deltoid and/or axillary nerve may be damaged due to prior procedures or injury. The purpose of this study was to determine the compensatory muscle forces required for scapular plane elevation following RTSR when the anterior deltoid is deficient. The soft tissues were removed from six cadaver shoulders, except for tendon attachments. After implantation of the RTSR, the shoulders were mounted on a custom-made shoulder simulator to determine the mean force in each muscle required to achieve 30° and 60° of scapular plane elevation. Two conditions were tested: 1) Control with an absent supraspinatus and infraspinatus; and 2) Control with anterior deltoid deficiency. Anterior deltoid deficiency resulted in a mean increase of 195% in subscapularis force at 30° when compared with the control (p = 0.02). At 60°, the subscapularis force increased a mean of 82% (p < 0.001) and the middle deltoid force increased a mean of 26% (p = 0.04). Scapular plane elevation may still be possible following an RTSR in the setting of anterior deltoid deficiency. When the anterior deltoid is deficient, there is a compensatory increase in the force required by the subscapularis and middle deltoid. Attempts to preserve the subscapularis, if present, might maximise post-operative function

1. Coracoid transplantation for recurring dislocation of the shoulder is described. 2. In my experience of over thirty cases only once has true dislocation recurred after this operation. Recurrence was due to avulsion of the bone block. 3. Failure to repair the original detachment of the glenoid labrum is a frequent cause of recurrence of dislocation of the shoulder. An explanation is offered for this failure; namely that the injured labrum adheres to the deep surface of the subscapularis muscle instead of reattaching itself to bone. This reinforces Watson-Jones's advice that the original dislocation should be treated by complete immobilisation in full medial rotation for three weeks

A man of 52 years of age had a grand mal seizure. He presented to our unit three months later with irreducible bilateral posterior dislocation of the shoulder. CT scans revealed large compression defects on the anteromedial aspect of the heads of both humeri. The defect on the right side was of more than 50% of the articular surface, and on the left side of 40%. He was treated by a one-stage operation with a hemiarthroplasty on one side and reconstruction of the head by an osteochondral autograft on the other. Three years later the clinical and radiological results were excellent

Double-contrast shoulder arthrograms were performed in 20 patients at an average of 30 months after operative repair of a torn rotator cuff. In 18 out of 20 shoulders the contrast medium leaked into the subacromial bursa indicating a defect in the rotator cuff. Despite this, 17 patients had complete relief of pain and 15 had a full range of shoulder elevation. The results suggest that a completely watertight closure is not essential for a good functional result, and that arthrography may not be helpful in the investigation of failure of repair

1. Degenerative lesions of the shoulder joint can often be demonstrated radiographically before there is actual rupture of the musculo-tendinous cuff. 2. The characteristic pathological, clinical and radiographic features of degenerative lesionsare described. 3. All injuries of the shoulder joint, however trivial, occurring in patients over middle age, should be studied carefully by radiographic examination. 4. In injuries of the shoulder joint the presence of a degenerative lesion prolongs the duration of symptoms, and the prognosis is less satisfactory than when there is no radiographic evidence of abnormality

1. Complete rupture of the axillary artery caused by dislocation of the shoulder in a man aged seventy-four is reported. There was severe arteriosclerosis and the simple operation of ligation of the artery was performed with success. There was excellent function of the shoulder and hand on review thirteen years later. 2. Previously recorded cases are reviewed

The rotator cuff is often severely damaged in arthritis of the shoulder and there is no satisfactory technique for its repair. patients with a ruptured cuff and an eroded glenohumeral joint may have intractable pain, and standard methods of joint replacement are then inappropriate. A ball and socket prosthesis has been designed to replace the function of both the rotator cuff and the glenohumeral joint. Mechanical testing has shown that the scapular cup can be securely fixed. The outcome in 71 shoulders operated upon since 1973 is reported

Between 1976 and 2004, 38 revision arthroplasties (35 patients) were performed for aseptic loosening of the humeral component. The mean interval from primary arthroplasty to revision was 7.1 years (0.4 to 16.6). A total of 35 shoulders (32 patients) were available for review at a mean follow-up of seven years (2 to 19.3). Pre-operatively, 34 patients (97%) had moderate or severe pain; at final follow-up, 29 (83%) had no or only mild pain (p < 0.0001). The mean active abduction improved from 88° to 107° (p < 0.01); and the mean external rotation from 37° to 46° (p = 0.27). Excellent or satisfactory results were achieved in 25 patients (71%) according to the modified Neer rating system. Humeral components were cemented in 29, with ingrowth implants used in nine cases. There were 19 of standard length and 17 were longer (two were custom replacements and are not included). Bone grafting was required for defects in 11 humeri. Only two glenoid components were left unrevised. Intra-operative complications included cement extrusion in eight cases, fracture of the shaft of the humerus is two and of the tuberosity in four. There were four re-operations, one for recurrent humeral loosening, with 89% survival free of re-operations at ten years. Revision surgery for aseptic loosening of the humeral component provides reliable pain relief and modest improvement of movement, although there is a substantial risk of intra-operative complications. Revision to a total shoulder replacement gives better results than to a hemiarthroplasty