Shoulder & Elbow

We aimed to determine if recognised histological features seen in specimens taken during rotator cuff repair could predict which tendon repairs were at risk of re-rupture.

Forty rotator cuff tendon edge specimens from 40 patients were analysed histologically following routine mini-open rotator cuff repair. Thirty-two patients returned at a mean follow up of 35 months for an ultrasound examination to determine repair integrity.

Overall there were 8 small tears, 13 medium tears, 15 large tears and 4 massive tears. Of the 32 patients followed up with ultrasound scan (USS) the overall re-rupture rate was 46%. Small and medium tears had a re-rupture rate of 35% while 60% of the large and massive tears suffered a re-rupture. Comparison of histological features and repair integrity revealed that the rotator cuff repairs which remained intact demonstrated a greater reparative response, in terms of increased fibroblast cellularity, cell proliferation and a thickened synovial membrane, than those repairs that re-ruptured. The larger tears that did remain intact also showed a higher degree of vascularity and a significant inflammatory component than the larger tears that re-ruptured.

These results indicate the importance of good tissue quality at the time of surgery but that larger tears can heal if the tissue quality is favourable. Post-operative histological analysis of tendon tear edge can aid prognosis and has the potential to guide post-operative immobilization and subsequent physiotherapy.

The decision to repair the rotator cuff in patients with impingement is controversial. This study aimed to determine whether there was a difference in outcome in patients both with and without rotator cuff tears undergoing subacromial decompression (SAD).

Ninety-eight patients underwent an arthroscopic SAD for impingement. No rotator cuff tear was repaired. The patients were assessed pre-operatively, at 6 months and 3 years using the ASES, Constant, DASH and the physical SF-36 scores. The rotator cuff was categorized as ‘tear/no tear’ depending on whether a cuff tear was present.

Both the ‘tear’ and ‘no tear’ groups showed a significant improvement with all scores at 6 months and 3 years. There was no significant difference in these outcome measures between the ‘tear’ and ‘no tear’ groups at 6 months. At 3 years there was no significant difference between the groups using the ASES and DASH scores, but there was a significant improvement in the Constant and SF-36 scores in the ‘no tear’ group.

SAD significantly improves outcome even in patients whose cuff tear was left unrepaired. Comparison of the ‘tear’ and ‘non-tear’ patient groups suggest that cuff tears can be left unrepaired in selected patients.

Frozen shoulder is a chronic fibrosing condition affecting the capsule of the joint. The predominant cells involved are fibroblasts and myofibroblasts that lay down a dense matrix of type I and type III collagen within the capsule. This subsequently contracts leading to the typical features of pain and stiffness. The histology is very similar to Dupuytren's contracture [1]–[5]. Chromosomal abnormalities, particularly Trisomy 7 and 8, have been found in Dupuytren's disease.

The aim of this study was to see if there are chromosomal changes in frozen shoulder. The anterosuperior shoulder joint capsule was excised in 16 patients with resistant primary frozen shoulder according to the method of Ozaki et al. [4]. The tissue was examined for chromosomal abnormalities using standard cytogenetic methods.

Ten of the 16 showed chromosomal abnormalities, of which 7 had clonal chromosomal abnormalities; 4 had trisomy 7, 2 had trisomy 8, and 1 both trisomy 7 and 8.

This is approximately the same percentage and numerical type of change to the same chromosomes as previously reported in Dupuytren's disease.

There is continued interest in day surgery. Arthroscopic shoulder surgery may be performed on a daycase basis. Historically, daycase shoulder surgery has been limited by peri-operative pain and anaesthetic issues; and to date there are no reports of daycase shoulder arthoplasty in the literature.

A prospective study of 112 patients having shoulder therapeutic arthroscopy or arthroplasty managed according to the total daycare pathway, which includes balanced anaesthesia and simple analgesia.

One hundred and eight patients (96%) were discharged home by 17.00 hours without complications. However the remaining five cases required overnight admission for medical or anaesthetic reasons.

This study demonstrates that, with the correct infrastructure and a multidisciplinary approach: the full spectrum of shoulder surgery may be performed on a daycase basis using interscalene block and simple analgesia.

Surgical approaches have been developed to enhance exposure and facilitate operative procedures. Some approaches are not commonly used or preferred due to prolonged learning curves and higher risk of iatrogenic injuries, which can be distressing to both the patient and the surgeon. The antero-superior approach provides good exposure to the rotator cuff, the anterior and posterior aspects of the shoulder and the glenoid. This approach is gaining popularity as a preferred exposure for shoulder arthroplasty as well as trauma surgery. Knowledge of the axillary nerve anatomy, however, is vital in this approach; in order to avoid injury.

We have dissected the axillary nerve in six cadavers and measured its distance from inferior reflection of the subdeltoid bursa.

The axillary nerve was at least 1.5 cm distal to the bursa in all cases.

The deltoid muscle can safely be split to the level indicated by a finger placed into the inferior recess of the subdeltoid bursa. This method uses the patient's own anatomy, and does not rely on nonstandard data, or unreliable points of reference such as the acromion and offers a reliable guide for the use of this approach safely.

The use of suture anchors in glenoid labral reattachment is now routine in many shoulder procedures. However, debate still surrounds the biomechanical characteristics of suture anchors and the interplay with bone quality.

Eight embalmed cadaveric glenoids were investigated using a microCT and a tensile testing machine to study the correlation between the bone mineral density of four different regions on the glenoid rim and the pullout strength of the suture anchor. Six constructs failed by suture breakage whilst the remaining 25 positions suffered suture pullout. This study differed from previous investigations by using Orthocord, a much stronger suture material permitting better evaluation of bone properties.

The mean failure load at pullout and suture compromise was 125 ± 40 N and 189 ± 25 N, respectively. The largest value of bone mineral density (BMD) was found at the posterior suture site, whilst the lowest occurred at the inferior edge of the anterior margin. For those constructs that failed by anchor pullout a significant correlation was observed between failure load and local bone mineral density (r_Pearson = 0.56, p = 0.004).

This relationship between local bone quality and pullout strength maybe a clinical indicator of the relative risk of failure following the suture repairs and warrants further exploration.

Very few longer term follow-up of unlinked elbow replacements have been published and most series are small.

Since 1994 87 Kudo 5 total elbow replacements in 70 patients were undertaken by two specialist elbow surgeons (LN and MT) for adult rheumatoid arthritis. These were evaluated at a mean follow-up of 79 months (29 months to 137 months) using the Mayo Clinic performance index. Post-operative radiographs were also reviewed for loosening using standard antero-posterior and lateral films.

Eight patients were lost to follow-up and 16 patients had died leaving 62 total elbow replacements in 46 patients. Pre-operatively 6 had moderate pain and 56 had severe pain. Post-operatively the pain was rated as none by 58 and moderate by 4. The average Mayo elbow score improved from 37 pre-operatively to 86 post-operatively. The flexion extension arc improved from 60? to 99?, whilst pronation and supination improved by 18? and 20? respectively. The overall complication rate was 24% with ulnar neuropraxia being the commonest problem. Six cases were revised, four for aseptic loosening and two for sepsis. The ulnar component was the more commonly affected and appeared to be the cause of more problems. However with revision as the endpoint, the probability of survival of the Kudo 5 at 79 months using the Kaplan Meier method was 96% reducing to 86% at 100 months.

The results of the Kudo 5 total elbow replacement in patients with adult rheumatoid arthritis are acceptable and comparable with other reported series and to other unlinked implants with similar follow-up.

Tension band wiring of olecranon fractures has been shown to be associated with a high rate of metalwork removal. The purpose of this study was to investigate whether this remained true or whether there had been a reduction in metalwork removal following improvements in surgical technique.

The outcome of 44 olecranon fractures treated by tension band wire fixation were reviewed. Eighteen (41%) required a second operation to remove the metalwork. In order to determine what factors might pre-dispose to metalwork removal continuous (age) and categorical variables (sex, k-wire diameter, k-wire alignment, k-wire orientation, k-wire length distal to the fracture and the number of tightening loops on the cerclage wire) were evaluated.

No statistical significance was identified when each variable was analysed individually or cumulatively using a multiple backward stepwise logistic regression (P<0.05). Using Kaplan-Meier survivorship analysis removal of the tension band device was found to be most commonly performed within 6 months of the index procedure.

This study indicates that metalwork removal is more importantly related to anatomical site rather than the specific surgical technique.

This article compares an exercise regime with a control treatment for the physiotherapy management of patients with massive rotator cuff tears.

The study design was a randomized placebo controlled trial of 60 patients with radiologically confirmed massive rotator cuff tears evaluating the change from baseline to 3 months, 6 months and 12 months in shoulder function. The primary outcome measure was the Oxford shoulder score.

Both the control and the intervention groups had an improvement in their Oxford shoulder scores at 3 months, 6 months and 12 months. The mean improvement at 3 months was statistically significant in favour of the experimental group (p = 0.002). The mean improvement at 6 months was also statistically significant (p = 0.008) but by 12 months there was no statistically significant difference between the two groups (p = 0.16).

The rehabilitation programme for patients with massive rotator cuff tears significantly improved shoulder pain and function in the short term. These improvements in shoulder pain and function were sustained over time although the advantage of intervention against control were not.