The aim of the study was to assess the rate of greater tuberosity non union in reverse shoulder arthroplasty performed for proximal humerus fractures and to assess if union is related to type of fracture or the intraoperative reduction of the greater tuberosity.

All cases of reverse shoulder arthroplasty for proximal humerus fractures at our institution over a three year period were retrospectively reviewed from casenotes and radiologically and the position of the greater tuberosity was documented at immediate post op, 6 months and 12 months. Any malunion or non union were noted.

A total of 27 cases of reverse shoulder arthroplasty for proximal humeral fractures were identified. 4 cases did not have complete follow up xrays and were excluded from analysis. The average age at operation of the cohort of the 23 remaining patients was 79 years (range 70–91). The greater tuberosity was anatomically well positioned intraoperatively in 17 of the 23 cases.

At the end of 12 months there were 4 cases of tuberosity non union (17%), all except one occurring in poorly intraoperatively positioned greater tuberosity. 50% (3 out of 6) of greater tuberosities displaced further and remained ununited if the intraoperative position was poor. Only 6% (1 out of 17) greater tuberosities did not unite if the greater tuberosities was reduced anatomically. Intra operatively position of the greater tuberosity was strongly associated with their union (Fischer's exact test p<0.05). Union of greater tuberosity was not statistically associated with fracture pattern (Fischer's exact test p=0.48).

Our case series show a low rate of tuberosity malunion after reverse shoulder arthroplasty for proximal humerus fracture. Good positioning and fixation of the greater tuberosity intra operatively is a strong predictor of their uneventful union to shaft.

Introduction

Massive rotator cuff repairs have up to 60% failure rate and repair of a chronic repair can have up to 40% failure rate. With this in mind, new methodologies are being to being developed to overcome this problem. The use of tendon augmentation grafts is one of them. Prior attempts have shown equivocal or poorer outcomes to control repairs. Aims and objectives: The specific aim of these expereiments was to test how well ovine tendon cells would take to a specific biological augmentation graft (Ligamimetic), and wheter tissue engineering techniques would enhance this.

Introduction

Rotator cuff tears remain a problem, with massive tears having a failure rate of repair reported of up to 60%, despite advances in surgical techniques. Tissue engineering techniques offers the possibility of regenerating damaged tendon tissue to a pre-injury state. We explore these techniques by implanting two novel tendon augmentation grafts with use of platelet rich plasma (PRP) in sheep.

Introduction

The Stanmore Percentage of Normal Shoulder Assessment (SPONSA) is a simple, fast and reproducible measure of the subjective state of a shoulder. It has been invaluable in our busy clinical practice. This study validates the SPONSA score against the Oxford Shoulder and Constant score and demonstrates a greater sensitivity to change.

This study identifies variations in presentation and demographics between structural and non-structural (muscle patterning) shoulder instability.

We analysed 1020 unstable shoulders (855 patients) from our institution database. Demographic details, direction and aetiology were obtained from medical records. Anterior dislocations comprised 67%, posterior 31% and inferior 2% of all directions of instability and 75 shoulders had multidirectional instability.

Structural causes were dominant in anterior instability (traumatic 39% and atraumatic 38%) and muscle patterning in posterior (81%) and inferior (90%) instability. Males accounted for 64% of all patients (73% of all structural patients and 53% of muscle patterning patients. Mean age at presentation was 25 years old (structural patients 28 years and muscle patterning patients 21 years old). There were 690 unilaterally unstable shoulders (57% right- and 43% left-sided); the dominant arm was affected in 58% overall, in 42% of all left-handers and only 33% of left-handers with muscle patterning. Bilateral shoulder instability occurred in 19% of all patients (12% of patients with structural instability and 28% of those with muscle patterning instability). For muscle patterning, the mean age at onset of symptoms was 14 years, and mean length of symptoms before presentation was 8 years. There was a trimodal distribution of age at onset of symptoms corresponding to peaks at 6, 14 and 20 years. In the group with onset of muscle patterning under 10 years old, there was a higher proportion of females (71% vs 47%), laxity (63% vs 29%) and bilaterality (54% vs 42%), and fewer presenting with pain (17% vs 50%).

Muscle patterning instability is associated with a demographic and presentation profile which may help distinguish it from structural forms of instability. As age at presentation increased, pain increased and joint laxity decreased. Bilaterality did not appear to be associated with gender, the presence of laxity or pain.

We report our results and technique of scapulothoracic fusion. 14 fusions were performed in 10 patients between 2001 and 2005. The underlying diagnosis was fascioscapulohumeral dystrophy in 7 patients (11 cases). The diagnosis in the remaining three patients was failure of scapular suspension due to C4/5 tetraplegia, stroke and cerebral palsy. There were five women and five men with an average age of 35.4 years (range 15–75) In each case the medial scapular border was wired to the ribs with the support of a one-third semi-tubular plate and autologous bone graft. We compared pre and post-operative active forward flexion and abduction. Satisfaction with the procedure was also rated. There was no need for single-lung ventilation or a chest drain and there were no significant post-operative complications. There were two cases of non-union. One patient, a heavy smoker, travelled abroad and has been lost to follow-up, the other aged 76 is awaiting revision surgery. The mean range of preoperative active forward flexion and abduction were 71° (range 30–90°) and 58° (range 40–90°) respectively. The mean post-operative values were 96° (90–120°) and 94° (80–120°) respectively. The remaining 8 patients were enthusiastic or satisfied with the result of the operation. This technique was very successful in 12 out of our 14 cases (85.7%) and is to be recommended. However, union may be unpredictable in older patients

We report 5 cases of linked shoulder and elbow replacement (LSER) following failure of single-joint arthroplasty. Whilst total humeral replacement has been reported for treatment following resection for tumour we know of no reports of linked shoulder and elbow prostheses for arthropathy alone. Between May and December 2005, 2 patients with total elbow arthroplasty and 3 patients with total shoulder arthroplasty were revised to LSER for loosening of the long humeral stems or periprosthetic fracture. Custom-made prostheses were produced using computer-aided design and manufacture technology. There were no early complications including infection. All 5 patients reported early improvement of symptoms, with the ability to bear weight axially through the limb, restored. This technique avoids the problem of a stress riser between the stems of separate shoulder and elbow replacements and solves the problem of salvage of long-stemmed implants where no further humeral fixation is possible.

We present the use of dynamic electromyographic analysis (DEMG) in the diagnosis of muscle patterning instability. DEMG’s were requested in 168 of 562 muscle patterning shoulders with suspected subclinical or clinically complex muscle patterning instability. An experienced neurophysiologist (blinded to the clinical findings and direction of instability) inserted dual-wire tungsten electrodes into pectoralis major, latissimus dorsi, infraspinatus and anterior deltoid. Muscle activity was recorded during rest, flexion, abduction, extension, and cross-body adduction. 5 investigations were abandoned. The timing and magnitude of muscle activity was noted and compared to the clinical diagnosis and direction of instability. DEMG identified a total of 204 abnormal muscle patterns in 163 shoulders. The examination was normal in 13 patients (8%). A single muscle was abnormal in 63 shoulders, 2 muscles in 55, 3 muscles in 9, and all 4 muscles in one shoulder. Over-activation of pectoralis major was identified in 58%, and latissimus dorsi in 70%, of shoulders with anterior instability. In posterior instability, latissimus dorsi was overactive in 76%, anterior deltoid in 14% and infraspinatus was under-active in 24%. Pectoralis major and Latissimus dorsi were both overactive in 38% of anterior, 29% of posterior and 38% of multidirectional instability. Abnormal muscle patterns were identified in 52 shoulders with subclinical muscle patterning. A further 98 shoulders had 134 clinically abnormal muscle patterns. These were confirmed by DEMG in 57 cases (sensitivity 43%), and DEMG’s were normal in 77 (specificity 43%). DEMG also identified 65 additional muscles as abnormal in the 98 clinically abnormal shoulders. DEMG performed by an experienced neurophysiologist provides additional information regarding abnormal muscle activation in selected complex or subtle cases of muscle patterning instability in which clinical examination has a low sensitivity and specificity.

Purpose: The relationship of pattern of injury to this region of the knee to the intraoperative finding of abnormal common peroneal nerve position and associated nerve palsy was studied.

Methods: 54 consecutive patients with posterolateral corner disruption requiring surgery were assessed prospectively by MRI, arthroscopic examination, and by operative display. The pattern of disruption, the status of the biceps tendon and any displacement of the common peroneal nerve were recorded.

Results: Of the 54 cases, there were 9 with CPN palsy, 18 were seen to have distal injuries (13 suffering a fibular head avulsion fracture and 5 biceps tendon avulsion with no fracture). There was a strong relationship (p< 0.001) between such distal posterolateral corner injury and abnormal position of the common peroneal nerve, as 16 of the 18 (90%) patients were seen to have abnormal nerve position. No proximal injury resulted in abnormal nerve position and only 1 was associated with CPN palsy. 7 of the 13 cases of fibular head fracture had CPN palsy, and 1 of the 5 distal soft tissue avulsions.

Conclusion: There is a strong association of distal soft tissue avulsion and fibular head fracture and CPN palsy in these injuries. Whenever such a distal injury is suspected, the surgeon operating in this region should expect an abnormal position of the common peroneal nerve and appreciate the increased risk of iatrogenic damage. Presumably since the CPN is intimately bound to the biceps tendon by deep fascia, proximal retraction of the biceps tendon results in displacement of the CPN to an abnormal position and accounts for the high incidence of nerve palsy.

We reviewed the relationship between the pattern of damage to the posterolateral corner of the knee and the position of the common peroneal nerve in 54 consecutive patients with posterolateral corner disruption requiring surgery. We found that 16 of the 18 patients with biceps avulsions or avulsion-fracture of the fibular head had a displaced common peroneal nerve. The nerve was pulled anteriorly with the biceps tendon. None of the 34 proximal injuries resulted in an abnormal nerve position.

Whenever bone or soft-tissue avulsion from the fibular head is suspected, the surgeon should expect an abnormal position of the common peroneal nerve and appreciate the increased risk of iatrogenic damage.

MRI is a well-tolerated, short procedure that would provide an early, accurate and cost effective diagnosis in elderly patients with negative plain films and persistent post-traumatic hip pain, thereby facilitating their correct management.

It is 100% sensitive and specific to occult hip fractures and does not involve ionising radiation.

Fractured necks of femur in the elderly population are common. This group of patients are responsible for a significant proportion of health care costs and efforts today. The diagnosis of hip fractures is not always clear-cut and plain radiographs may not show an undisplaced fracture. The management of this patient group is dependant upon the correct diagnosis via imaging and treatment decisions are based on these findings. If these fractures are missed, there is a significant chance of displacement and avascular necrosis presenting at a later date. This would complicate matters and result in more complex surgery. This also increases health care costs due to an extra admission, more expensive and difficult surgery with longer rehabilitation and after care. In our study, the management of the patients reviewed was significantly altered due to the imaging process used.

We performed MRI scans on thirty-six patients who had post-traumatic hip pain and negative plain radiographs (reported as normal or equivocal). Twenty-three (64%) of the patients sustained a fracture, of which sixteen (44%) involved the neck of the femur, all of whom were above the age of 71 years. 100% of the elderly age group scanned were positive for a femoral neck fracture and eleven (31%) received operative intervention. The five patients who did not undergo operative management were deemed too unwell for surgery. Only three patients’ scans were negative.

These results confirm that MRI (in the 71 years and above age group), is indicated in order to diagnose an undisplaced fractured neck of femur not recognised on plain radiographs, which requires operative intervention in the form of dynamic hip screw or cannulated hip screws to prevent further deterioration or displacement.

Fourteen patients with neurofibromatosis presented with symptoms or radiological evidence of cervical spine involvement over a period of 27 years. The symptoms included neurological deficit in five, neck mass in two, deformity in eight, decrease in neck movement in two and two with neck pain. Patients’ age ranged from five to forty-two years. Twelve patients have had surgical procedures. Two patients have been followed up and treated non-operatively despite osteolysis of vertebral bodies with kyphosis of more than 100°.

Current literature presents few cases of neurofibromatosis of the cervical spine. The largest World Series is of eight cases (Craig and Govender et al 1992). At present there is no coherent strategy of management for these conditions. The authors of this series recommend that correcting spinal deformity or to stabilise an unstable spine requires combined anterior and posterior fusion. Posterior fusion alone has a higher failure rate. Surgery for severe kyphotic deformity is questionable especially with no neurological deficit.