Shoulder & Elbow

There are limited data available on the outcome of patients following isolated fractures of the greater tuberosity of the humerus. In this retrospective study, we looked at how differences with respect to the injury and subsequent management affected patient outcomes.

Forty-eight (28 men and 20 women) patients (mean age 45 years) who were treated at our institution between 1999 and 2009 matched our inclusion criteria. Thirty-five patients were treated surgically and 13 were managed conservatively. Functional outcome was assessed after a mean follow-up of 5.5 years using the Oxford Shoulder Score (OSS), the University of California and Los Angeles (UCLA) rating scale and the shoulder index of the American Shoulder and Elbow Surgeons (ASES).

Post-fixation displacement of the greater tuberosity fragment of < 5 mm led to a significantly better outcome than displacement > 5 mm (OSS = 43 versus 37; ASES = 25.6 versus 17.7; UCLA 28.2 versus 21.3). Patients who had surgery > 2 weeks after the initial injury had a significantly worse outcome than those who had surgery in < 2 weeks (OSS = 37.4 versus 44.7; ASES = 18.9 versus 27.2). Patients with shoulder dislocation had worse outcome than those with no dislocation (OSS = 40.6 versus 44; ASES 22.9 versus 26) and rotator cuff tears were also associated with worse outcome scores than those without (OSS 42.8 versus 36.8; ASES 24.5 versus 20.5), although neither of these variables proved statistically significant.

Isolated fractures of the greater tuberosity have a worse outcome if there is a delay in surgical fixation of > 2 weeks and post-fixation displacement of > 5 mm.

Chronic shoulder pain is an increasing problem in the ageing population. For patients with inoperable problems, management of persistent pain is often inadequate with current non-operative measures. Suprascapular nerve (SSN) block and pulsed radiofrequency (RF) treatment of the SSN gives relief for up to 12 weeks. It is considered that continuous thermal radiofrequency treatment (CTRF) of the SSN may give longer pain relief.

Sixty-two patients with chronic shoulder pain were assessed for CTRF treatment of the SSN using a standard technique with a Neurotherm RF lesion generator under image intensification as a day case.

The mean age of the patients was 74 years. The majority of patients had a significant rotator cuff lesion. Mean visual analogue scores scores fell significantly from 9.1 to 4.5 at 6 months following treatment (p = 0.0001) and 85% patients reported > 50% pain relief at 6 months. Half the patients reported an improvement in sleep and mobility. No serious adverse effects were reported.

CTRF to the SSN significantly reduced shoulder pain for up to 6 months without adverse effects and gave longer relief than pulsed RF or SSN block. It may be repeated with a similar effect being achieved. The limitations of the present study is the use of a medium-sized series with 6-month follow-up.

The blood loss associated with arthroscopic surgery has generally been considered to be minimal and not clinically relevant. However, there are currently no data available in the published literature to support this assumption.

The present prospective study used spectrophotometry of collected irrigation fluid to measure the blood loss associated with a variety of arthroscopic shoulder procedures conducted in 20 patients.

Measured blood loss ranged from 1.22 mL to 36.45 mL. This confirmed that, even in lengthy arthroscopic procedures without a tourniquet, blood loss is minimal.

The results obtained in the present study confirm the presumed advantage of arthroscopic surgery in terms of blood loss, and also confirm that the full range of arthroscopic shoulder surgery can be safely performed, from a haemodynamic perspective, as day case procedures.

Chronic posterolateral rotatory instability occurs as a result of disruption of the lateral ulnar collateral ligament of the elbow. It is usually treated by ligament reconstruction using an autogenous graft. We present our experience of reconstruction with the use of a synthetic polyester (LARS®; Ligament Advanced Reinforcement System; Surgical Implants and Devices, Arc-sur-Tille, France) ligament and discuss the advantages of this technique.

Ten consecutive cases of lateral ligament reconstruction using a LARS® ligament were reviewed. The mean age at the time of surgery was 30.2 years. The mean duration of instability symptoms preoperatively was 32.4 months. Three patients had generalized hyperlaxity. Three patients had previously undergone an unsuccessful autogenous graft reconstruction.

The mean postoperative follow-up was 27 months. At review, seven of the 10 patients had stable elbows with no feelings of recurrent instability. This included two of the patients with generalized hyperlaxity. The mean postoperative arc of flexion/extension was 13° to 137°. The mean Mayo Elbow Performance Score was 87.5.

The use of a synthetic ligament for reconstruction of posterolateral rotatory instability of the elbow provides satisfactory stability. It avoids the associated morbidity of using an autograft, appears to be well tolerated and is particularly valuable in the treatment of complex generalized hyperlaxity problems.

An understanding of the epidemiology of a problem is central to facilitating clinical understanding, resource allocation and future research priorities.

To systematically review and report incidence, prevalence, risk and prognostic factors for rotator cuff tendinopathy.

An electronic search of MEDLINE, CiNAHL, PsychINFO to December 2012 was complemented by hand and citation-searching. Studies were selected in relation to pre-defined criteria. A narrative synthesis was undertaken.

The incidence of rotator cuff tendinopathy ranges from 0.3% to 5.5% and annual prevalence from 0.5% to 7.4%. There is limited evidence suggesting that increasing age and other personal, work-related and psychosocial factors are associated with onset. There is strong evidence suggesting that high baseline pain and disability and previous episodes of shoulder pain are associated with an unfavourable outcome and strong evidence suggesting that biomedical diagnosis is not associated with outcome. Other factors were identified but were only supported by moderate or limited evidence.

Rotator cuff tendinopathy is a common problem but uncertainty remains regarding the true extent and risk factors associated with onset. High baseline pain and disability and previous episodes are associated with an unfavourable outcome but biomedical diagnosis is not associated with outcome.

Strength assessment is an integral part of many clinical tests and some outcome measures. However, shoulder strength may not only be influenced by pathology or treatment effect, but also by scapular position. The present study aimed to examine the influence of scapular positioning on shoulder strength.

Sixteen normal volunteers (seven males and nine females; mean age 35 years) conducted maximal isometric elevation strength tests in scapular positions of self-selected neutral (SN), maximal protraction (SP), maximal retraction (SR) and posterior tilt (ST), with all of these being assessed in the scapular plane. A prospective, repeated measure, balanced protocol was employed.

Resultant strengths were SN = 6.5 kg, SP = 5.0 kg, SR = 5.3 kg and ST = 5.0 kg. Analysis of variance was significant (p = 0.002) with post-hoc analysis revealing SN as being significantly stronger than SP (p = 0.002), SR (p = 0.004) and ST (p = 0.001). There were no significant differences between SP, SR and ST. Test – retest analysis yielded intraclass correlation coefficients exceeding 0.85.

Altering scapula position may affect shoulder strength in asymptomatic individuals. This has implications for the validity and reliability of shoulder tests and outcome measures that are reliant upon shoulder strength, at the same time as supporting the premise that the application of scapula correction exercises should be based upon individual assessment rather than general prescription.

Several different techniques have been described for repairing a lesser tuberosity osteotomy in shoulder arthroplasty, although all have potential drawbacks. We describe a novel repair technique and its radiological results.

All patients undergoing a total shoulder arthroplasty using a resurfacing humeral component from 2008 to date were identified retrospectively. Anteroposterior (AP) and axial radiographs at a minimum of 3 months postoperatively were used to assess union of the osteotomy fragment.

Seventy-six total shoulder replacements in 65 patients were eligible for review. Seven were excluded as a result of inadequate radiographs. Sixty-six of 69 had united (95.6%). There were two cases (2.9%) of a complete non-union that was undisplaced. In one patient (1.4%), the osteotomy fragment had displaced and this was apparent on the initial postoperative AP radiograph.

The modified union jack repair technique is simple, fast, economical and reliable.