Aims

The aim of this study is to provide a detailed description of cases combining bridging patch repair with artificial ligament “internal brace” reinforcement to treat irreparable massive rotator cuff tears, and report the preliminary results.

1 . The concept of the capsular mechanism of the shoulder joint with regard to recurrent anterior dislocation of the shoulder has been defined and a survey of the literature presented. 2. An anatomical, including an embryological, investigation of shoulder joints with special reference to the structure and function of the glenoid labrum and to the variations in the arrangement of the gleno-humeral ligaments and the synovial recesses of the anterior capsular mechanism is reported. The labrum, which is generally believed to be a consistent, fibrocartilaginous structure, is shown to be a redundant portion of capsular tissue and a continuation of the capsule as it attaches to the osseous glenoid rim. The fibrocartilaginous element is confined to a small transition zone at the capsular attachment in the great majority of cases. The great variability in the arrangement of the gleno-humeral ligaments and synovial recesses is stressed, and it is shown that an anterior pouch of variable size is present when the middle gleno-humeral ligament is attached to the scapular neck and not to the labrum. 3. The basic lesions of the anterior capsular mechanism found at operation for recurrent anterior dislocation of the shoulder in twenty-five consecutive cases using a modified Bankart procedure with a standard anterior approach to the joint are reported, and the findings are correlated with the results of the anatomical investigation. In most cases the lesions were found to be of the Bankart type with or without avulsion of the periosteum of the scapular neck. In four cases, however, the soft-tissue attachment to the anterior glenoid rim was intact; in those cases a large synovial pouch was present and the middle gleno-humeral ligament was either not discernible or it arose from the scapular neck. In all cases a postero-lateral notch on the humeral head was palpable and laxity of the subscapularis could be demonstrated. When measured, the joint capacity was always greatly augmented. 4. The present work shows, from a basic standpoint, that Bankart's original idea that the recurrent state was due to the failure of healing of the fractured fibrocartilaginous glenoid labrum is no longer tenable. 5. Finally, the anomalous attachment or the insufficient development of the middle gleno-humeral ligament in certain cases of recurrent anterior shoulder dislocation is shown to provide the anatomical basis for the recurrent state in these cases; this is the weak area in the antero-inferior part of the capsule which has been described in the literature for the past hundred years. Thus we have returned to the original view of Hippocrates

Metallosis after shoulder replacement has not previously been described in the literature. We report a patient who developed extensive metallosis after implantation of an uncemented Nottingham shoulder replacement. He underwent a revision procedure. Examination of the retrieved prosthesis showed that the titanium porous coating was separating from the humeral stem and becoming embedded in the ultra-high-molecular-weight polyethylene glenoid component, resulting in abrasive wear of the humeral component. There was metallosis despite exchange of the modular humeral head. Both components had to be exchanged to resolve the problem

We have previously described the short-term outcome of the use of reverse shoulder arthroplasty in the treatment of acute complex proximal humeral fractures in the elderly. We now report the clinical and radiological outcome of 36 fractures at a mean of 6.6 years (1 to 16). Previously, at a mean follow-up of 6 years (1 to 12) the mean Constant score was 58.5; this was reduced to 53 points with the further follow-up. A total of 23 patients (63%) had radiological evidence of loosening of the glenoid component. Nevertheless, only one patient had aseptic loosening of the baseplate at 12 years’ follow-up. The reduction in the mean Constant score with longer follow-up and the further development of scapular notching is worrying. New developments in design, bearing surfaces and surgical technique, and further follow-up, will determine whether reverse shoulder arthroplasty has a place in the management of complex proximal humeral fractures in the elderly

Aims

It is important to understand the rate of complications associated with the increasing burden of revision shoulder arthroplasty. Currently, this has not been well quantified. This review aims to address that deficiency with a focus on complication and reoperation rates, shoulder outcome scores, and comparison of anatomical and reverse prostheses when used in revision surgery.

There is no simple method available to identify patients who will develop recurrent instability after an arthroscopic Bankart procedure and who would be better served by an open operation. We carried out a prospective case-control study of 131 consecutive unselected patients with recurrent anterior shoulder instability who underwent this procedure using suture anchors. At follow-up after a mean of 31.2 months (24 to 52) 19 (14.5%) had recurrent instability. The following risk factors were identified: patient age under 20 years at the time of surgery; involvement in competitive or contact sports or those involving forced overhead activity; shoulder hyperlaxity; a Hill-Sachs lesion present on an anteroposterior radiograph of the shoulder in external rotation and/or loss of the sclerotic inferior glenoid contour. These factors were integrated in a 10-point pre-operative instability severity index score and tested retrospectively on the same population. Patients with a score over 6 points had an unacceptable recurrence risk of 70% (p < 0.001). On this basis we believe that an arthroscopic Bankart repair is contraindicated in these patients, to whom we now suggest a Bristow-Latarjet procedure instead

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 prospectively evaluated 61 patients treated arthroscopically for anterior instability of the shoulder at a mean follow-up of 44.5 months (24 to 100) using the Rowe scale. Those with post-operative dislocation or subluxation were considered to be failures. Logistic regression analysis was used to identify patients at increased risk of recurrence in order to develop a suitable selection system. The mean Rowe score improved from 45 pre-operatively to 86 at follow-up (p < 0.001). At least one episode of post-operative instability occurred in 11 patients (18%), although their stability improved (p = 0.018), and only three required revision. Subjectively, eight patients were dissatisfied. Age younger than 28 years, ligamentous laxity, the presence of a fracture of the glenoid rim involving more than 15% of the articular surface, and post-operative participation in contact or overhead sports were associated with a higher risk of recurrence, and scored 1, 1, 5 and 1 point, respectively. Those patients with a total score of two or more points had a relative risk of recurrence of 43% and should be treated by open surgery

We made a prospective study of 58 consecutive Neer II total shoulder replacements in 49 rheumatoid patients. Cemented glenoid and press-fit humeral components had been used. After a mean follow-up of 9.5 years (7 to 13), 11 patients (15 shoulders) had died, one shoulder had been arthrodesed and five patients (five shoulders) had been lost to follow-up. Of the remaining 37 shoulders 29 were painfree or had only slight discomfort, four had pain on unusual activity, and four had moderate or severe pain. There were satisfactory improvements in the mean range of active elevation (53° to 75°) and external rotation (5° to 38°); satisfactory performance of the activities of daily living had been maintained throughout follow-up. Radiographs showed loosening in ten shoulders of nine glenoid and nine humeral components but of these only three had significant symptoms. Three loose glenoid components and two loose humeral components required revision. We consider that the Neer total shoulder replacement provides a reasonable medium to long-term outcome in rheumatoid arthritis, but recommend that the humeral component should be routinely cemented

Aims

Open reduction and plate fixation (ORPF) for displaced proximal humerus fractures can achieve reliably good long-term outcomes. However, a minority of patients have persistent pain and stiffness after surgery and may benefit from open arthrolysis, subacromial decompression, and removal of metalwork (ADROM). The long-term results of ADROM remain unknown; we aimed to assess outcomes of patients undergoing this procedure for stiffness following ORPF, and assess predictors of poor outcome.

Whereas a general trend in the management of obstetric brachial plexus injuries has been nerve reconstruction in patients without spontaneous recovery of biceps function by three to six months of age, many recent studies suggest this may be unnecessary. In this study, the severity of glenohumeral dysplasia and shoulder function and strength in two groups of matched patients with a C5-6 lesion at a mean age of seven years (2.7 to 13.3) were investigated. One group (23 patients) underwent nerve reconstruction and secondary operations, and the other (52 patients) underwent only secondary operations for similar initial clinical presentations. In the patients with nerve reconstruction shoulder function did not improve and they developed more severe shoulder deformities (posterior subluxation, glenoid version and scapular elevation) and required a mean of 2.4 times as many operations as patients without nerve reconstruction. This study suggests that less invasive management, addressing the muscle and bone complications, is a more effective approach. Nerve reconstruction should be reserved for those less common cases where the C5 and C6 nerve roots will not recover

Aims

Stemless humeral implants have been developed to overcome stem-related complications in total shoulder arthroplasty (TSA). However, stemless implant designs may hypothetically result in less stable initial fixation, potentially affecting long-term survival. The aim of this study is to investigate early fixation and migration patterns of the stemless humeral component of the Simpliciti Shoulder System and to evaluate clinical outcomes.

Aims

The aim of this study was to describe a quantitative 3D CT method to measure rotator cuff muscle volume, atrophy, and balance in healthy controls and in three pathological shoulder cohorts.

We have reviewed 12 fractures of the coracoid process. In two of these patients the fracture extended into the body of the scapula and resulted in displacement of the glenoid. In some cases, there were associated acromioclavicular and glenohumeral dislocations or fractures of the clavicle and the acromion. Two patients required internal fixation to restore congruence of the glenoid; the others were treated conservatively with success. We present a new classification of coracoid fractures which helps in their management

We reviewed 80 shoulders (77 patients) at a mean follow-up of 44 months after insertion of a Grammont inverted shoulder prosthesis. Three implants had failed and had been revised. The mean Constant score had increased from 22.6 points pre-operatively to 65.6 points at review. In 96% of these shoulders there was no or only minimal pain. The mean active forward elevation increased from 73° to 138°. The integrity of teres minor is essential for the recovery of external rotation and significantly influenced the Constant score. Five cases of aseptic loosening of the glenoid and seven of dissociation of the glenoid component were noted. This study confirms the promising early results obtained with the inverted prosthesis in the treatment of a cuff-tear arthropathy. It should be considered in the treatment of osteoarthritis with a massive tear of the cuff but should be reserved for elderly patients

Aims

The purpose of this study was to report bone adaptive changes after anatomical total shoulder arthroplasty (TSA) using a standard-length hydroxyapatite (HA)-coated humeral component, and to report on a computer-based analysis of radiographs to determine changes in peri-implant bone density objectively.

1. A series of experiments on the tensile strength of the anterior capsular mechanism have been performed. These show that in the young the weakest point is the glenoid labral attachment, whereas in the elderly calcification of tissues makes the capsule and subscapular tendon weaker. 2. It has been shown previously that glenoid labral detachment is the common injury in the young at the time of an acute dislocation, whereas capsular rupture and subscapularis tendon damage occur in the elderly. 3. These findings suggest that in an acute anterior dislocation of the shoulder the shoulder integuments give at their weakest point, and that it is the site of this weakest point and not the mechanism of injury which influences the liability to recurrence

1. A case of recurrent posterior subluxation of the shoulder is described. After failure of a soft-tissue repair, a posterior bone block operation was performed. 2. The distinction between traumatic dislocations with tearing of the capsule or of the glenoid labrum, and habitual luxations from laxity of the capsule, is emphasised. Although the anterior rim of the glenoid was detached in this case, it is considered to fall into the latter category. 3. A posterior bone block provides a simple and efficient form of repair in this type of case. It is free from the disadvantage of causing limitation of rotation at the shoulder joint; it employs a principle which might well merit more application than at present in the repair of anterior dislocations

The aim of this retrospective study was to review a series of patients with ipsilateral fractures of the neck of the scapula and of the clavicle. Between 1991 and 1996 a total of 79 general and orthopaedic surgeons treated 46 patients with a floating shoulder in The Netherlands. The records and radiographs of these patients were studied. Of the 35 patients available for follow-up, 31 had initially been treated conservatively and four by operation; three underwent secondary reconstructive surgery. The mean Constant score for the 28 patients treated conservatively was 76 and for the seven treated operatively it was 71 at a mean follow-up of 35 months. In six of the 28 patients treated conservatively the glenoid was dislocated caudally at the end of treatment; they had a score of 42. In the 22 patients without this dislocation the score was 85. We conclude that this rare injury is not inherently unstable and, in the absence of caudal dislocation of the glenoid, conservative treatment gives a good functional outcome