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 anatomical variations in that structure, have not previously been
documented. In this study the vascular anatomy encountered during 100 consecutive
elective deltopectoral approaches was recorded and the common variants
described. Two common variants of the deltoid artery were encountered.
In type I (71%) it crosses the interval and tunnels into the deltoid
muscle without encountering the cephalic vein. However, in type
II (21%) it crosses the interval, reaches the cephalic vein and
then runs down, medial to and behind it, giving off several small
arterial branches that return back across the interval to the pectoralis
major. Several minor variations were also seen (8%). These variations in the deltoid artery have not previously been
described and may lead to confusion and unexpected bleeding during
this standard anterior surgical approach to the shoulder. Cite this article:
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:
The outcome of an anatomical shoulder replacement
depends on an intact rotator cuff. In 1981 Grammont designed a novel
large-head reverse shoulder replacement for patients with cuff deficiency.
Such has been the success of this replacement that it has led to
a rapid expansion of the indications. We performed a systematic
review of the literature to evaluate the functional outcome of each
indication for the reverse shoulder replacement. Secondary outcome
measures of range of movement, pain scores and complication rates
are also presented.
In order to compare the outcome from surgical repair and physiotherapy, 103 patients with symptomatic small and medium-sized tears of the rotator cuff were randomly allocated to one of the two approaches. The primary outcome measure was the Constant score, and secondary outcome measures included the self-report section of the American Shoulder and Elbow Surgeons score, the Short Form 36 Health Survey and subscores for shoulder movement, pain, strength and patient satisfaction. Scores were taken at baseline and after six and 12 months by a blinded assessor. Nine patients (18%) with insufficient benefit from physiotherapy after at least 15 treatment sessions underwent secondary surgical treatment. Analysis of between-group differences showed better results for the surgery group on the Constant scale (difference 13.0 points, p − 0.002), on the American Shoulder and Elbow surgeons scale (difference 16.1 points, p <
0.0005), for pain-free abduction (difference 28.8°, p = 0.003) and for reduction in pain (difference on a visual analogue scale −1.7 cm, p <
0.0005).
We undertook clinical and ultrasonographic examination of the shoulders of 420 asymptomatic volunteers aged between 50 and 79 years. MRI was performed in selected cases. Full-thickness tears of the rotator cuff were detected in 32 subjects (7.6%). The prevalence increased with age as follows: 50 to 59 years, 2.1%; 60 to 69 years, 5.7%; and 70 to 79 years, 15%. The mean size of the tear was less than 3 cm and tear localisation was limited to the supraspinatus tendon in most cases (78%). The strength of flexion was reduced significantly in the group with tears (p = 0.01). Asymptomatic tears of the rotator cuff should be regarded as part of the normal ageing process in the elderly but may be less common than hitherto believed.
We have undertaken an All of the torn tendons had lower levels of cellular activity than the control group. This activity was lower still in the tissue nearest to the edge of the tear with the larger tears showing the lowest activity. This indicated reduced levels of tissue metabolism and infers a reduction in tendon viability. Our findings suggest that surgical repair of torn tendons of the rotator-cuff should include the more proximal, viable tissue, and may help to explain the high rate of re-rupture seen in larger tears.
This is a prospective study of 107 repairs of obstetric brachial plexus palsy carried out between January 1990 and December 1999. The results in 100 children are presented. In partial lesions operation was advised when paralysis of abduction of the shoulder and of flexion of the elbow persisted after the age of three months and neurophysiological investigations predicted a poor prognosis. Operation was carried out earlier at about two months in complete lesions showing no sign of clinical recovery and with unfavourable neurophysiological investigations. Twelve children presented at the age of 12 months or more; in three more repair was undertaken after earlier unsuccessful neurolysis. The median age at operation was four months, the mean seven months and a total of 237 spinal nerves were repaired. The mean duration of follow-up after operation was 85 months (30 to 152). Good results were obtained in 33% of repairs of C5, in 55% of C6, in 24% of C7 and in 57% of operations on C8 and T1. No statistical difference was seen between a repair of C5 by graft or nerve transfer. Posterior dislocation of the shoulder was observed in 30 cases. All were successfully relocated after the age of one year. In these children the results of repairs of C5 were reduced by a mean of 0.8 on the Gilbert score and 1.6 on the Mallett score. Pre-operative electrodiagnosis is a reliable indicator of the depth of the lesion and of the outcome after repair. Intra-operative somatosensory evoked potentials were helpful in the detection of occult intradural (pre-ganglionic) injury.
We carried out a prospective randomised study comparing medial epicondylectomy with anterior transposition for the treatment of ulnar neuropathy at the elbow. The mean follow-up period was 4.5 years and we assessed the patients neurologically and orthopaedically. Neither procedure appeared to have a significant effect on elbow function. Our study showed better results after medial epicondylectomy; in particular patient satisfaction was higher than after ulnar nerve transposition. There were no significant differences in motor power or nerve-conduction rates and sensory fibres appeared to be more vulnerable to devascularisation.