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

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

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

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

1. A case is reported of traumatic dislocation of the shoulder joint complicated by rupture of the axillary artery and vein and complete brachial plexus palsy. Whether the rupture occurred at the time of injury or during reduction is not known. 2. Despite a delay of five weeks before operative treatment was undertaken the usefulness of the arm was preserved. 3. After rupture of the axillary artery at this level an adequate collateral circulation is rapidly established in a healthy young adult. 4. The case illustrates the importance of careful examination of the peripheral nervous and vascular systems before and after reduction of a dislocated shoulder

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. In a series of one hundred personal cases of "painful shoulder" rupture of the musculotendinous cuff was proved by operation in eighteen cases and was presumed in eight further cases, namely, in about one quarter of the series. 2. Of the eighteen cases treated by operation through the transacromial approach, perfect results were obtained only in four. The other results were unsatisfactory. In five, movement was good but there was pain or weakness of the limb. In nine the condition was unaltered or made worse. 3. Conservative treatment of traumatic lesions of the supraspinatus tendon is therefore advocated. The advisability of rest of the shoulder joint in an abduction splint for five or six weeks is stressed. Operative exposure, through a transacromial approach, is recommended only when conservative measures have failed. 4. When there is rupture of the cuff there is evidence that simple longitudinal suture of the gap after freshening of the margins is likely to give better results than attempts to suture the medial end of the rupture to the greater tuberosity. Most ruptures have a longitudinal extension of the initial transverse tear, and direct suture of the medial edge of the gap to the greater tuberosity may lead to shortening of the tendon and interference with its function. 5. Ruptures of the supraspinatus tendon may cause no symptoms, lead to complete loss of function, or cause a painful arc of movement during mid-elevation. The clinical state depends upon whether or not the condition of the ruptured tendon is causing pain, and whether the other short rotator muscles of the shoulder can compensate in tensor and fixator actions for the loss of action of the supraspinatus. 6. Capsulitis is a convenient term by which to describe inflammatory lesions of the capsule and bursae around the shoulder joint. The initial stage of irritative capsulitis may develop to the later stage of adhesive capsulitis. Differentiation is important because treatment in the first stage is by rest, and in the second by manipulation and exercise. 7. The subdeltoid bursa is the "peritoneum" of the spinatus tendons; like the peritoneum it shares the pathology of the organs it protects and is itself seldom the site of primary pathological processes. 8. The management of the "frozen shoulder," whether loss of movement is protective or adhesive, calls for time and patience but the ultimate outlook is good

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

We performed a double-blind, randomised controlled trial to assess the effectiveness of a continuous-infusion brachial plexus block with levobupivacaine compared with that of a standard single injection for the management of post-operative pain after surgery on the shoulder. Eight patients were randomised to receive a pre-operative brachial plexus block using 30 ml of levobupivacaine 0.5% with adrenaline 1:200 000 followed by insertion of a 20-gauge polyamide catheter. This was connected to a disposable elastometric pump, set immediately after surgery to administer a continuous flow of levobupivacaine 0.25% at a rate of 5 ml per hour. The other eight patients were randomised to receive only the initial injection of 30 ml. The study was double-blinded with the aid of sham catheters and clamped pumps. All patients were given regular paracetamol and were prescribed morphine through a patient-controlled analgesia pump. Motor and sensory block assessments, visual analogue scale pain scores and consumption of morphine were recorded after the operation and then at 6, 12 and 24 hours after administration of the block. Satisfactory motor and sensory block was achieved in all patients. The mean visual analogue scale pain score at 12 hours and consumption of morphine at 24 hours after injection were significantly lower (p < 0.05) in the continuous-infusion group. This group also took longer to request their first additional analgesia and reported a significantly higher overall level of satisfaction. Our study has shown that continuous interscalene infusion of levobupivacaine is an effective method of post-operative analgesia after major surgery of the shoulder

The case is reported of a fracture-dislocation of the shoulder, treated by an operation based upon a principle advanced by Moore in 1948. An excellent radiological and functional result was observed five and a half years after the injury

The stabilising effects on the glenohumeral joint of each of the rotator-cuff muscles and of the biceps were studied with the arm in abduction and external rotation in 13 cadaver shoulders. The muscles were loaded one at a time with forces proportional to their cross-sectional areas. We recorded the positions of the humeral head before and after the application to the humerus of an anterior force of 1.5 kg. When the capsule was intact, the anterior displacement with the subscapularis loaded was significantly larger than with the other muscles loaded (p = 0.0009). With the capsule vented, the displacement with the biceps loaded was significantly smaller than that with the subscapularis loaded (p = 0.0052). After creating an imitation Bankart lesion, the displacement with the biceps loaded was significantly less than with any of the rotator-cuff muscles loaded (p = 0.0132). We conclude that in the intact shoulder, the subscapularis is the least important anterior stabiliser, and that the biceps becomes more important than the rotator-cuff muscles as stability from the capsuloligamentous structure decreases. Strengthening of the biceps as well as the rotator-cuff muscles should be part of the rehabilitation programme for anterior shoulder instability

We performed a prospective study using MRI in 16 consecutive infants with a mean age of 5.2 months (2.7 to 8.7) who had shown inadequate recovery from an obstetric lesion of the brachial plexus in the first three months of life, in order to identify early secondary deformities of the shoulder. Shoulders were analysed according to a standardised MRI protocol. Measurements were made of the appearance of the glenoid, glenoid version and the position of the humeral head. The appearance of the glenoid on the affected side was normal in only seven shoulders. In the remainder it was convex in seven and bioconcave in three. The degree of subluxation of the humeral head was significantly greater (p = 0.01) in the affected shoulders than in normal shoulders (157° v 170°). The presence of an abnormal appearance of the glenoid, retroversion of the glenoid and subluxation of the humeral head increased with age. There was a statistical difference (p = 0.05) between infants younger than five months and those who were older

Reversed shoulder prostheses are increasingly being used for the treatment of glenohumeral arthropathy associated with a deficient rotator cuff. These non-anatomical implants attempt to balance the joint forces by means of a semi-constrained articular surface and a medialised centre of rotation. A finite element model was used to compare a reversed prosthesis with an anatomical implant. Active abduction was simulated from 0° to 150° of elevation. With the anatomical prosthesis, the joint force almost reached the equivalence of body weight. The joint force was half this for the reversed prosthesis. The direction of force was much more vertically aligned for the reverse prosthesis, in the first 90° of abduction. With the reversed prosthesis, abduction was possible without rotator cuff muscles and required 20% less deltoid force to achieve it. This force analysis confirms the potential mechanical advantage of reversed prostheses when rotator cuff muscles are deficient