Instability after arthroplasty of the shoulder
is difficult to correct surgically. Soft-tissue procedures and revision surgery
using unconstrained
Despite the expansion of arthroscopic surgery
of the shoulder, the open deltopectoral approach to the shoulder
is still frequently used, for example in fracture fixation and shoulder
replacement. However, it is sometimes accompanied by unexpected
bleeding. The cephalic vein is the landmark for the deltopectoral
interval, yet its intimate relationship with the deltoid artery,
and the
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
We treated 31 intra-articular fractures of the distal radius by arthroscopically-assisted reduction and percutaneous fixation with Kirschner (K-) wires. Tears of the triangular fibrocartilage (58%), scapholunate (85%) and lunotriquetral (61%) instability and osteochondral lesions (19%) were also treated. A total of 26 patients was independently reviewed at an average of 19 months. The mean pain score was 1.3/10, the range of movement 79% and the grip strength 90% of the contralateral wrist. Using the New York Orthopaedic Hospital score, 88% were graded excellent to good. On follow-up radiographs, 65% had no step and 31% had a step of ≤1 mm. Pain was significantly related to the size of the step. There was a significant difference in the incidence of persistent scapholunate diastasis and the Leibovic and Geissler grade (p <
0.01): I (0%), II (0%), III (42%) and IV (100%). We recommend
Rotator cuff (RC) injuries are characterized by tendon rupture, muscle atrophy, retraction, and fatty infiltration, which increase injury severity and jeopardize adequate tendon repair. Epigenetic drugs, such as histone deacetylase inhibitors (HDACis), possess the capacity to redefine the molecular signature of cells, and they may have the potential to inhibit the transformation of the fibro-adipogenic progenitors (FAPs) within the skeletal muscle into adipocyte-like cells, concurrently enhancing the myogenic potential of the satellite cells. HDACis were added to FAPs and satellite cell cultures isolated from mice. The HDACi vorinostat was additionally administered into a RC injury animal model. Histological analysis was carried out on the isolated supra- and infraspinatus muscles to assess vorinostat anti-muscle degeneration potential.Aims
Methods
Objectives. Indocyanine green (ICG) fluorescence angiography is an emerging technique that can provide detailed
We reviewed the outcome of 28 patients who had been treated using the Aequalis fracture prosthesis for an acute fracture of the proximal humerus at a mean follow-up of 39.3 months (24 to 63). The mean age of the patients at the time of the fracture was 66.3 years (38 to 80). The mean Constant score was 68.2 (37 to 84) for the operated shoulder, which represented 89.5% of the mean score for the uninjured side (p <
0.001). The quality of the reconstruction as shown on the immediate post-operative radiographs was categorised into three types,
The outcome of an
The zona conoidea comprises the area of the lateral
trochlear ridge of the humerus. The purpose of this study is to reintroduce
this term ‘zona conoidea’ to the discussion of the human elbow and
to investigate its significance in the development of osteoarthritis
of the elbow. The upper extremities of 12 cadavers were prepared. With the
forearm in neutral, pronation and supination, the distance between
the bevel of the radial head and zona conoidea was inspected. A
total of 12 healthy volunteers had a CT scan. The distance between
the zona conoidea and the bevelled rim of the radial head was measured
in these positions. In the
Mason type III fractures of the radial head are treated by open reduction and internal fixation, resection or prosthetic joint replacement. When internal fixation is performed, fixation of the radial head to the shaft is difficult and implant-related complications are common. Furthermore, problems of devascularisation of the radial head can result from fixation of the plate to the radial neck. In a small retrospective study, the treatment of Mason type III fractures with fixation of the radial neck in 13 cases (group 2) was compared with 12 cases where no fixation was performed (group 1). The mean clinical and radiological follow-up was four years (1 to 9). The Broberg-Morrey index showed excellent results in both groups. Degenerative radiological changes were seen more frequently in group 2, and removal of the implant was necessary in seven of 13 cases. Post-operative evaluation of these two different techniques revealed similar ranges of movement and functional scores. We propose that
This study investigated the
We treated 32 displaced mallet finger fractures by a two extension block Kirschner-wire technique. The clinical and radiological outcomes were evaluated at a mean follow-up of 49 months (25 to 84). The mean joint surface involvement was 38.4% (33% to 50%) and 18 patients (56%) had accompanying joint subluxation. All 32 fractures united with a mean time to union of 6.2 weeks (5.1 to 8.2). Congruent joint surfaces and
Fractures of the proximal humerus can lead to malalignment of the humeral head, necrosis and post-traumatic osteoarthritis. In such cases surface replacement might be a promising option. A total of 28 shoulders with glenohumeral arthritis subsequent to a fracture underwent surface replacement arthroplasty of the humeral head in patients with a mean age of 60 years (35 to 83). On the basis of the inclination of the impacted head, post-traumatic arthritis was divided into three types: type 1, an impacted fracture of the head in an
We treated 34 consecutive articular fractures of the proximal humerus in 33 patients with good bone quality by open reduction and internal fixation.
After establishing
Intraspinal re-implantation after traumatic avulsion of the brachial plexus is a relatively new technique. Three different approaches to the spinal cord have been described to date, namely the posterior scapular, anterolateral interscalenic multilevel oblique corpectomy and the pure lateral. We describe an
The aim of this study was to define the microcirculation of the normal rotator cuff during arthroscopic surgery and investigate whether it is altered in diseased cuff tissue. Blood flow was measured intra-operatively by laser Doppler flowmetry. We investigated six different zones of each rotator cuff during the arthroscopic examination of 56 consecutive patients undergoing investigation for impingement, cuff tears or instability; there were 336 measurements overall. The mean laser Doppler flowmetry flux was significantly higher at the edges of the tear in torn cuffs (43.1, 95% confidence interval (CI) 37.8 to 48.4) compared with normal cuffs (32.8, 95% CI 27.4 to 38.1; p = 0.0089). It was significantly lower across all
The integrity of the spinal accessory nerve is fundamental to thoracoscapular function and essential for scapulohumeral rhythm. This nerve is vulnerable along its superficial course. This study assessed the delay in diagnosis and referral for management of damage to this nerve, clarified its
We reviewed 39 patients with displaced three- and four-part fractures of the humerus. In 21 patients (group A) we had used an
We have used Fourier transform infrared spectroscopy (FTIR) to characterise the chemical and structural composition of the tendons of the rotator cuff and to identify structural differences among
The combination of an irreparable tear of the rotator cuff and destructive arthritis of the shoulder joint may cause severe pain, disability and loss of independence in the aged. Standard
Our aim in this prospective study was to evaluate the outcome of total shoulder replacement in the treatment of young and middle-aged active patients with primary glenohumeral osteoarthritis. We reviewed 21 patients (21 shoulders) with a mean age of 55 years (37 to 60). The mean follow-up was seven years (5 to 9). The same
Plating displaced proximal humeral fractures is associated with a high rate of screw perforation. Dynamization of the proximal screws might prevent these complications. The aim of this study was to develop and evaluate a new gliding screw concept for plating proximal humeral fractures biomechanically. Eight pairs of three-part humeral fractures were randomly assigned for pairwise instrumentation using either a prototype gliding plate or a standard PHILOS plate, and four pairs were fixed using the gliding plate with bone cement augmentation of its proximal screws. The specimens were cyclically tested under progressively increasing loading until perforation of a screw. Telescoping of a screw, varus tilting and screw migration were recorded using optical motion tracking.Aims
Methods
We have examined 167 patients who had a hemiarthroplasty for three- and four-part fractures and fracture-dislocations of the head of the humerus in a multicentre study involving 12 Austrian hospitals. All patients were followed for more than a year.
The results of a cadaver dye-infusion experiment suggested that the hand has ten muscle compartments and that the volar interossei occupy a separate
Os acromiale is a rare
The objective of this study was to perform a meta-analysis of all randomised controlled trials (RCTs) comparing surgical and non-surgical management of fractures of the proximal humerus, and to determine whether further analyses based on complexity of fracture, or the type of surgical intervention, produced disparate findings on patient outcomes. A systematic review of the literature was performed identifying all RCTs that compared surgical and non-surgical management of fractures of the proximal humerus. Meta-analysis of clinical outcomes was performed where possible. Subgroup analysis based on the type of fracture, and a sensitivity analysis based on the type of surgical intervention, were also performed.Objectives
Methods
Necrotising soft-tissue infections (NSTIs) of
the upper limb are uncommon, but potentially life-threatening. We
used a national database to investigate the risk factors for amputation
of the limb and death. We extracted data from the Japanese Diagnosis Procedure Combination
database on 116 patients (79 men and 37 women) who had a NSTI of
the upper extremity between 2007 and 2010. The overall in-hospital mortality was 15.5%. Univariate analysis
of in-hospital mortality showed that the significant variables were
age (p = 0.015), liver dysfunction (p = 0.005), renal dysfunction
(P <
0.001), altered consciousness (p = 0.049), and sepsis (p
= 0.021). Logistic regression analysis showed that the factors associated with
death in hospital were age over 70 years (Odds Ratio (OR) 6.6; 95%
confidence interval (CI) 1.5 to 28.2; p = 0.011) and renal dysfunction
(OR 15.4; 95% CI 3.8 to 62.8; p <
0.001). Univariate analysis of limb amputation showed that the significant
variables were diabetes (p = 0.017) mellitus and sepsis (p = 0.001).
Multivariable logistic regression analysis showed that the factors
related to limb amputation were sepsis (OR 1.8; 95% CI 1.5 to 24.0;
p = 0.013) and diabetes mellitus (OR 1.6; 95% CI 1.1 to 21.1; p
= 0.038). For NSTIs of the upper extremity, advanced age and renal dysfunction
are both associated with a higher rate of in-hospital mortality.
Sepsis and diabetes mellitus are both associated with a higher rate
of amputation. Cite this article:
Latissimus dorsi tendon transfer (LDTT) is technically
challenging. In order to clarify the local structural anatomy, we undertook
a morphometric study using six complete cadavers (12 shoulders).
Measurements were made from the tendon to the nearby neurovascular
structures with the arm in two positions: flexed and internally
rotated, and adducted in neutral rotation. The tendon was then transferred
and measurements were taken from the edge of the tendon to a reference
point on the humeral head in order to assess the effect of a novel
two-stage release on the excursion of the tendon. With the shoulder flexed and internally rotated, the mean distances
between the superior tendon edge and the radial nerve, brachial
artery, axillary nerve and posterior circumflex artery were 30 mm
(26 to 34), 28 mm (17 to 39), 21 mm (12 to 28) and 15 mm (10 to
21), respectively. The mean distance between the inferior tendon
edge and the radial nerve, brachial artery and profunda brachii
artery was 18 mm (8 to 27), 22 mm (15 to 32) and 14 mm (7 to 21), respectively.
Moving the arm to a neutral position reduced these distances. A
mean of 15 mm (8 to 21) was gained from a standard soft-tissue release,
and 32 mm (20 to 45) from an extensile release. These figures help to define further the structural anatomy of
this region and the potential for transfer of the latissimus dorsi
tendon. Cite this article:
The sternoclavicular joint (SCJ) is a pivotal
articulation in the linked system of the upper limb girdle, providing
load-bearing in compression while resisting displacement in tension
or distraction at the manubrium sterni. The SCJ and acromioclavicular
joint (ACJ) both have a small surface area of contact protected
by an intra-articular fibrocartilaginous disc and are supported
by strong extrinsic and intrinsic capsular ligaments. The function
of load-sharing in the upper limb by bulky periscapular and thoracobrachial
muscles is extremely important to the longevity of both joints.
Ligamentous and capsular laxity changes with age, exposing both
joints to greater strain, which may explain the rising incidence
of arthritis in both with age. The incidence of arthritis in the
SCJ is less than that in the ACJ, suggesting that the extrinsic
ligaments of the SCJ provide greater stability than the coracoclavicular
ligaments of the ACJ. Instability of the SCJ is rare and can be difficult to distinguish
from medial clavicular physeal or metaphyseal fracture-separation:
cross-sectional imaging is often required. The distinction is important
because the treatment options and outcomes of treatment are dissimilar,
whereas the treatment and outcomes of ACJ separation and fracture
of the lateral clavicle can be similar. Proper recognition and treatment
of traumatic instability is vital as these injuries may be life-threatening.
Instability of the SCJ does not always require surgical intervention.
An accurate diagnosis is required before surgery can be considered,
and we recommend the use of the Stanmore instability triangle. Most
poor outcomes result from a failure to recognise the underlying
pathology. There is a natural reluctance for orthopaedic surgeons to operate
in this area owing to unfamiliarity with, and the close proximity
of, the related vascular structures, but the interposed sternohyoid
and sternothyroid muscles are rarely injured and provide a clear
boundary to the medial retroclavicular space, as well as an anatomical
barrier to unsafe intervention. This review presents current concepts of instability of the SCJ,
describes the relevant surgical anatomy, provides a framework for
diagnosis and management, including physiotherapy, and discusses
the technical challenges of operative intervention. Cite this article:
We present a review of claims made to the NHS
Litigation Authority (NHSLA) by patients with conditions affecting the
shoulder and elbow, and identify areas of dissatisfaction and potential
improvement. Between 1995 and 2012, the NHSLA recorded 811 claims
related to the shoulder and elbow, 581 of which were settled. This
comprised 364 shoulder (64%), and 217 elbow (36%) claims. A total
of £18.2 million was paid out in settled claims. Overall diagnosis,
mismanagement and intra-operative nerve injury were the most common
reasons for litigation. The highest cost paid out resulted from
claims dealing with incorrect, missed or delayed diagnosis, with
just under £6 million paid out overall. Fractures and dislocations
around the shoulder and elbow were common injuries in this category.
All 11 claims following wrong-site surgery that were settled led
to successful payouts. This study highlights the diagnoses and procedures that need
to be treated with particular vigilance. Having an awareness of
the areas that lead to litigation in shoulder and elbow surgery
will help to reduce inadvertent risks to patients and prevent dissatisfaction
and possible litigation. Cite this article:
A suspected fracture of the scaphoid remains difficult to manage despite advances in knowledge and imaging methods. Immobilisation and restriction of activities in a young and active patient must be balanced against the risks of nonunion associated with an undiagnosed and undertreated fracture of the scaphoid. The assessment of diagnostic tests for a suspected fracture of the scaphoid must take into account two important factors. First, the prevalence of true fractures among suspected fractures is low, which greatly reduces the probability that a positive test will correspond with a true fracture, as false positives are nearly as common as true positives. This situation is accounted for by Bayesian statistics. Secondly, there is no agreed reference standard for a true fracture, which necessitates the need for an alternative method of calculating diagnostic performance characteristics, based upon a statistical method which identifies clinical factors tending to associate (latent classes) in patients with a high probability of fracture. The most successful diagnostic test to date is MRI, but in low-prevalence situations the positive predictive value of MRI is only 88%, and new data have documented the potential for false positive scans. The best strategy for improving the diagnosis of true fractures among suspected fractures of the scaphoid may well be to develop a clinical prediction rule incorporating a set of demographic and clinical factors which together increase the pre-test probability of a fracture of the scaphoid, in addition to developing increasingly sophisticated radiological tests.
We systematically reviewed all the evidence published
in the English language on proximal interphalangeal joint (PIPJ)
replacement, to determine its effectiveness on the function of the
hand and the associated post-operative complications. Original studies were selected if they reported clinical outcome
with a minimum of one year’s follow-up. Quality was assessed using
the Cowley systematic review criteria modified for finger-joint
replacements. Of 319 articles identified, only five were adequately
reported according to our quality criteria; there were no randomised
controlled trials. PIPJ replacements had a substantial effect size
on hand pain of -23.2 (95% confidence interval (CI) -27.3 to -19.1)
and grip strength 1.2 (95% CI -10.7 to 13.1), and a small effect
on range of movement 0.2 (95% CI -0.4 to 0.8). A dorsal approach
was most successful. Post-operative loosening occurred in 10% (95%
CI 3 to 30) of ceramic and 12.5% (95% CI 7 to 21) of pyrocarbon
replacements. Post-operative complications occurred in 27.8% (95%
CI 20 to 37). We conclude that the effectiveness of PIPJ replacement has not
been established. Small observational case studies and short-term
follow-up, together with insufficient reporting of patient data,
functional outcomes and complications, limit the value of current
evidence. We recommend that a defined core set of patients, surgical and
outcome data for this intervention be routinely and systematically
collected within the framework of a joint registry.
The purpose of this study was to compare the
outcome and complications of endoscopic We conclude that endoscopic release for de Quervain’s tenosynovitis
seems to provide earlier improvement after surgery, with fewer superficial
radial nerve complications and greater scar satisfaction, when compared
with open release. Cite this article:
Dislocation of the shoulder may occur during
seizures in epileptics and other patients who have convulsions. Following
the initial injury, recurrent instability is common owing to a tendency
to develop large bony abnormalities of the humeral head and glenoid
and a susceptibility to further seizures. Assessment is difficult
and diagnosis may be missed, resulting in chronic locked dislocations
with protracted morbidity. Many patients have medical comorbidities,
and successful treatment requires a multidisciplinary approach addressing
the underlying seizure disorder in addition to the shoulder pathology.
The use of bony augmentation procedures may have improved the outcomes
after surgical intervention, but currently there is no evidence-based
consensus to guide treatment. This review outlines the epidemiology
and pathoanatomy of seizure-related instability, summarising the
currently-favoured options for treatment, and their results.
We assessed the short- to mid-term survival of
metallic press-fit radial head prostheses in patients with radial
head fractures and acute traumatic instability of the elbow. The medical records of 42 patients (16 males, 26 females) with
a mean age of 56 years (23 to 85) with acute unstable elbow injuries,
including a fracture of the radial head requiring metallic replacement
of the radial head, were reviewed retrospectively. Survival of the
prosthesis was assessed from the radiographs of 37 patients after
a mean follow-up of 50 months (12 to 107). The functional results
of 31 patients were assessed using range-of-movement, Mayo elbow
performance score (MEPS), Disabilities of the Arm, Shoulder and
Hand (DASH) score and the RAND 36-item health survey. At the most recent follow-up 25 prostheses were still well fixed,
nine had been removed because of loosening, and three remained implanted
but were loose. The mean time from implantation to loosening was
11 months (2 to 24). Radiolucent lines that developed around the
prosthesis before removal were mild in three patients, moderate
in one and severe in five. Range of movement parameters and mass
grip strength were significantly lower in the affected elbow than
in the unaffected side. The mean MEPS score was 86 (40 to 100) and
the mean DASH score was 23 (0 to 81). According to RAND-36 scores,
patients had more pain and lower physical function scores than normal population
values. Loosening of press-fit radial head prostheses is common, occurs
early, often leads to severe osteolysis of the proximal radius,
and commonly requires removal of the prosthesis.
We evaluated the biomechanical properties of two different methods of fixation for unstable fractures of the proximal humerus. Biomechanical testing of the two groups, locking plate alone (LP), and locking plate with a fibular strut graft (LPSG), was performed using seven pairs of human cadaveric humeri. Cyclical loads between 10 N and 80 N at 5 Hz were applied for 1 000 000 cycles. Immediately after cycling, an increasing axial load was applied at a rate of displacement of 5 mm/min. The displacement of the construct, maximum failure load, stiffness and mode of failure were compared. The displacement was significantly less in the LPSG group than in the LP group (p = 0.031). All maximum failure loads and measures of stiffness in the LPSG group were significantly higher than those in the LP group (p = 0.024 and p = 0.035, respectively). In the LP group, varus collapse and plate bending were seen. In the LPSG group, the humeral head cut out and the fibular strut grafts fractured. No broken plates or screws were seen in either group. We conclude that strut graft augmentation significantly increases both the maximum failure load and the initial stiffness of this construct compared with a locking plate alone.
Radiological changes and differences between cemented and uncemented components of Grammont reverse shoulder arthroplasties (DePuy) were analysed at a mean follow-up of 9.6 years (8 to 12). Of 122 reverse shoulder arthroplasties implanted in five shoulder centres between 1993 and 2000, a total of 68 (65 patients) were available for study. The indications for reversed shoulder arthroplasty were cuff tear arthropathy in 48 shoulders, revision of shoulder prostheses of various types in 11 and massive cuff tear in nine. The development of scapular notching, bony scapular spur formation, heterotopic ossification, glenoid and humeral radiolucencies, stem subsidence, radiological signs of stress shielding and resorption of the tuberosities were assessed on standardised true anteroposterior and axillary radiographs. A scapular notch was observed in 60 shoulders (88%) and was associated with the superolateral approach (p = 0.009). Glenoid radiolucency was present in 11 (16%), bony scapular spur and/or ossifications in 51 (75%), and subsidence of the stem and humeral radiolucency in more than three zones were present in three (8.8%) and in four (11.8%) of 34 cemented components, respectively, and in one (2.9%) and two (5.9%) of 34 uncemented components, respectively. Radiological signs of stress shielding were significantly more frequent with uncemented components (p <
0.001), as was resorption of the greater (p <
0.001) and lesser tuberosities (p = 0.009).
The aim of this study was to compare a third-generation
cementing procedure for glenoid components with a new technique
for cement pressurisation. In 20 pairs of scapulae, 20 keeled and
20 pegged glenoid components were implanted using either a third-generation
cementing technique (group 1) or a new pressuriser (group 2). Cement penetration
was measured by three-dimensional (3D) analysis of micro-CT scans.
The mean 3D depth of penetration of the cement was significantly
greater in group 2 (p <
0.001). The mean thickness of the cement
mantle for keeled glenoids was 2.50 mm (2.0 to 3.3) in group 1 and
5.18 mm (4.4 to 6.1) in group 2, and for pegged glenoids it was 1.72 mm
(0.9 to 2.3) in group 1 and 5.63 mm (3.6 to 6.4) in group 2. A cement
mantle <
2 mm was detected less frequently in group 2 (p <
0.001). Using the cement pressuriser the proportion of cement mantles
<
2 mm was significantly reduced compared with the third-generation
cementing technique.
There have been only a few small studies of patients
with an infected shoulder replacement treated with a single-stage
exchange procedure. We retrospectively reviewed 35 patients (19 men
and 16 women) with a peri-prosthetic infection of the shoulder who
were treated in this way. A total of 26 were available for clinical
examination; three had died, two were lost to follow-up and four
patients had undergone revision surgery. The mean follow-up time was
4.7 years (1.1 to 13.25), with an infection-free survival of 94%. The organisms most commonly isolated intra-operatively were Single-stage exchange is a successful and practical treatment
for patients with peri-prosthetic infection of the shoulder. Cite this article:
Surgical repair of posterosuperior rotator cuff
tears has a poorer outcome and a higher rate of failure compared
with repairs of supraspinatus tears. In this prospective cohort
study 28 consecutive patients with an irreparable posterosuperior
rotator cuff tear after failed conservative or surgical treatment
underwent teres major tendon transfer. Their mean age was 60 years
(48 to 71) and the mean follow-up was 25 months (12 to 80). The
mean active abduction improved from 79° (0° to 150°) pre-operatively
to 105° (20° to 180°) post-operatively (p = 0.011). The mean active
external rotation in 90° abduction improved from 25° (0° to 70°)
pre-operatively to 55° (0° to 90°) post-operatively (p <
0.001).
The mean Constant score improved from 43 (18 to 78) pre-operatively
to 65 (30 to 86) post-operatively (p <
0.001). The median post-operative
VAS (0 to 100) for pain decreased from 63 (0 to 96) pre-operatively to
5 (0 to 56) post-operatively (p <
0.001). In conclusion, teres major transfer effectively restores function
and relieves pain in patients with irreparable posterosuperior rotator
cuff tears and leads to an overall clinical improvement in a relatively
young and active patient group with limited treatment options. Cite this article:
We retrospectively reviewed 11 consecutive patients with an infected reverse shoulder prosthesis. Patients were assessed clinically and radiologically, and standard laboratory tests were carried out. Peroperative samples showed Propionbacterium acnes in seven, coagulase-negative Staphylococcus in five, methicillin-resistant A one-stage revision arthroplasty reduces the cost and duration of treatment. It is reliable in eradicating infection and good functional outcomes can be achieved.
This study provides recommendations on the position
of the implant in reverse shoulder replacement in order to minimise
scapular notching and osteophyte formation. Radiographs from 151
patients who underwent primary reverse shoulder replacement with
a single prosthesis were analysed at a mean follow-up of 28.3 months
(24 to 44) for notching, osteophytes, the position of the glenoid
baseplate, the overhang of the glenosphere, and the prosthesis scapular
neck angle (PSNA). A total of 20 patients (13.2%) had a notch (16 Grade 1 and four
Grade 2) and 47 (31.1%) had an osteophyte. In patients without either
notching or an osteophyte the baseplate was found to be positioned
lower on the glenoid, with greater overhang of the glenosphere and
a lower PSNA than those with notching and an osteophyte. Female patients
had a higher rate of notching than males (13.3% Based on these findings we make recommendations on the placement
of the implant in both male and female patients to avoid notching
and osteophyte formation. Cite this article:
We undertook this study to determine the minimum
amount of coronoid necessary to stabilise an otherwise intact elbow
joint. Regan–Morrey types II and III, plus medial and lateral oblique
coronoid fractures, collectively termed type IV fractures, were
simulated in nine fresh cadavers. An electromagnetic tracking system
defined the three-dimensional stability of the ulna relative to
the humerus. The coronoid surface area accounts for 59% of the anterior articulation.
Alteration in valgus, internal and external rotation occurred only
with a type III coronoid fracture, accounting for 68% of the coronoid
and 40% of the entire articular surface. A type II fracture removed
42% of the coronoid articulation and 25% of the entire articular
surface but was associated with valgus and external rotational changes
only when the radial head was removed, thereby removing 67% of the
articular surface. We conclude that all type III fractures, as defined here, are
unstable, even with intact ligaments and a radial head. However,
a type II deficiency is stable unless the radial head is removed.
Our study suggests that isolated medial-oblique or lateral-oblique
fractures, and even a type II fracture with intact ligaments and
a functional radial head, can be clinically stable, which is consistent
with clinical observation.
Like athletes, musicians are vulnerable to musculoskeletal
injuries that can be career ending or have a severe negative financial
impact. All ages are affected, with a peak incidence in the third
and fourth decades. Women are slightly more likely to be affected
than men. It is incumbent upon orthopaedic surgeons to be able to
complete a thorough physical assessment, be aware of the risk factors
associated with musculoskeletal symptoms in musicians, and have
a detailed knowledge of the specific syndromes they suffer and their
appropriate treatment. In this paper we review the common hand injuries that afflict
musicians and discuss their treatment. Cite this article:
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.
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.
We investigated the incidence of and risk factors
for venous thromboembolism (VTE) following surgery of the shoulder
and elbow and assessed the role of thromboprophylaxis in upper limb
surgery. All papers describing VTE after shoulder and elbow surgery
published in the English language literature before 31 March 2012
were reviewed. A total of 14 papers were available for analysis,
most of which were retrospective studies and case series. The incidence
of VTE was 0.038% from 92 440 shoulder arthroscopic procedures,
0.52% from 42 261 shoulder replacements, and 0.64% from 4833 procedures
for fractures of the proximal humerus (open reduction and internal fixation
or hemiarthroplasty). The incidence following replacement of the
elbow was 0.26% from 2701 procedures. Diabetes mellitus, rheumatoid
arthritis and ischaemic heart disease were identified as the major
risk factors. The evidence that exists on thromboprophylaxis is based on level
III and IV studies, and we therefore cannot make any recommendations
on prophylaxis based on the current evidence. It seems reasonable
to adopt a multimodal approach that involves all patients receiving
mechanical prophylaxis, with chemical prophylaxis reserved for those
who are at high risk for VTE. Cite this article:
In a prospective study between 2000 and 2005, 22 patients with primary osteoarthritis of the shoulder had a total shoulder arthroplasty with a standard five-pegged glenoid component, 12 with non-offset humeral head and ten with offset humeral head components. Over a period of 24 months the relative movement of the glenoid component with respect to the scapula was measured using radiostereometric analysis. Nine glenoids needed reaming for erosion. There was a significant increase in rotation about all three axes with time (p <
0.001), the largest occurring about the longitudinal axis (anteversion-retroversion), with mean values of 3.8° and 1.9° for the non-offset and offset humeral head eroded subgroups, respectively. There was also a significant difference in rotation about the anteversion-retroversion axis (p = 0.01) and the varus-valgus (p <
0.001) z-axis between the two groups. The offset humeral head group reached a plateau at early follow-up with rotation about the z-axis, whereas the mean of the non-offset humeral head group at 24 months was three times greater than that of the offset group accounting for the highly significant difference between them.
Bone loss involving articular surface is a challenging
problem faced by the orthopaedic surgeon. In the hand and wrist,
there are articular defects that are amenable to autograft reconstruction
when primary fixation is not possible. In this article, the surgical
techniques and clinical outcomes of articular reconstructions in
the hand and wrist using non-vascularised osteochondral autografts
are reviewed.