Treatment of OA of the shoulder in young and active patients remains a problem. Present treatment options are debridement, microfracturing, arthrodesis or shoulder replacement. We report the preliminary results of soft-tissue interposition arthroplasty with an acellular allograft skin-derived collagen matrix (Graft Jacket®, Wright Medical).

Between July and December 2003 five men and one woman with severe glenohumeral OA had a soft-tissue interposition arthroplasty of the shoulder. The mean age of the patients was 47 years (34 to 58). In four patients the procedure was done arthroscopically. The Graft Jacket® was sutured to the labrum with a minimum of five sutures. The mean postoperative follow-up was 6.2 months.

Four patients experienced notable pain relief after the operation. Preoperatively the mean visual analogue pain score was 7.2 and postoperatively it was 2.6. One patient had no improvement and elected to wait before having further treatment. One patient needed a hemi-arthroplasty. The range of motion improved in only one patient. The mean Constant score improved 14 points, from 45 to 59. There were no complications peroperatively or postoperatively.

While the long-term results are still unknown, soft-tissue interposition arthroplasty with the Graft Jacket® shows promising results.

The shape of the glenoid can vary between pear and oval, depending on the presence of a glenoid notch. We measured the glenoid notch angle (the angle between the superior and inferior part of the anterior glenoid rim) in 53 embalmed cadavers and investigated its relationship with the labral attachment to the glenoid at that point.

The attachment of the anterosuperior labrum at the site of the glenoid notch was classified as tight or loose or, in some cases, there was a sublabral foramen. The anterior labrum was then removed and digital images perpendicular to the glenoid notch were taken. Using a digital image analysis program, the angle of the glenoid notch was measured.

In 37 shoulders (70%) the attachment of the labrum at the site of the glenoid notch was assessed as tight and in eight (15%) as loose. In eight shoulders (15%) a sublabral foramen was found. The mean glenoid notch angle was 153° in the loosely attached group, 159° in the sublabral foramen group and 168° in the group with a tight attachment. The presence of a glenoid notch was noted only when the glenoid notch angle was less than 170°.

The glenoid notch angle is related to the attachment of the labrum. In the presence of a glenoid notch, there is more likely to be a loosely attached labrum or sublabral foramen. The loose attachment of the anterosuperior labrum may be a predisposing factor in traumatic anterior instability.

The management of bony lesions associated with glenohumeral instability is the subject of debate. Invariably some time elapses between injury and surgery, during which atrophy may reduce both size and quality of the bone.

The main purpose of our study was to assess the viability of the bone. Histomorphometric bone analyses were prospectively performed on glenoid fragments harvested from 21 male patients during modified Latarjet operations. Their median age was 21 years (16 to 50). Rugby was the main sport of 64% and water sports (surfing, water polo, water skiing) of 21%.

The mean glenoid bone loss on CT scan was 17% (10% to 50%). In 33% of patients, bone loss exceeded 20%. Gross morphology of glenolabral fragments identified a single large fragment in 11 patients, a dominant large fragment with smaller fragments in seven, and multiple fragments in the remaining patients. The mean volume of bony fragments was 2.18 ml (1 to 3) and the mean mass was 1.64 gm (0.43 to 2.8). Histological examination revealed that there was no bone in three of the 21 specimens. Bony necrosis was present in eight of the 18 specimens that contained bone (44%).

Given the histopathological findings, attempts to reattach these devitalised bone fragments by screws or anchors may fail and lead to recurrent instability.

Calcific tendinitis of the shoulder is a common cause of shoulder pain and is usually treated conservatively initially. We evaluated the ultrasound-guided needling procedure for calcium deposits in the rotator cuff.

Between 2002 and 2003 eight men and 18 women (mean age 49 years) with calcific tendinitis of the shoulder were treated this way. The mean duration of symptoms was 29 months. Before the procedure, the skin and subacromial bursa were infiltrated with local anaesthetic. The calcium deposit was perforated and aspirated when possible. With saline, a lavage was done to wash out the calcium.

Eleven patients (42.3%) had marked improvement in pain and needed no further treatment. Four patients required a reneedling procedure, and four patients needed repeated subacromial injections during the absorption phase of the calcium. In six patients arthroscopic calcium removal was needed. The mean visual analogue pain score during the procedure was 2.63. There were no complications.

The ultrasound-guided needling procedure is an effective and well-tolerated method of treatment of calcific tendinitis of the shoulder and in 77% of our cases there was no need for surgical removal. Where there is incomplete dissolution, the procedure can be repeated.

The research question was: can ex-vivo chondrocyte cultures be established in shoulder cartilage biopsies?

Arthroscopic or open biopsies were obtained, with informed consent and institution-approved review protocol, from patients undergoing total shoulder replacement or orthopaedic interventions for end-stage rotator cuff deficiency or arthropathy. Chondrocytes were isolated from eight biopsies and cells cultured over 4-weeks.

In the first week post-digestion, validation studies showed cell counts varying from 30 000 to 400 000 (mean 126 666) and viability ranging from 30% to 100% (mean 75.2%). No primary culture failures were observed. One of the eight had an unexplained lower cell count and viability. Viability exceeded 80% in six of the eight cultures (75%). Alcian Blue stains and flow cytometry (Facscan) confirmed stable cultures with matrix formation. Aggrecan studies are in progress.

The fact that ex-vivo chondrocyte cultures can be established in biopsied shoulder cartilage may prove encouraging for autologous chondrocyte transplant in selected patients meeting stringent inclusion criteria.

With widely reported co-existence of impingement syndrome and acromioclavicular joint (ACJ) disease, some surgeons recommend that ACJ resection be combined with subacromial decompression.

From 1998 to 2003, 201 patients with symptomatic ACJs were taken to theatre. Bursoscopy was performed on 129 males and 54 females, those patients who had previously undergone ipsilateral shoulder surgery or had sonographically-proven rotator cuff tears being excluded. The mean age was 41 years (16 to 72). The preoperative diagnosis was isolated ACJ disease in 136 patients and combined ACJ disease and impingement in 47. Bursoscopy revealed no abnormalities in 124 of the 136 patients in whom isolated ACJ disease was diagnosed. In two patients, minimal bursal fraying was noted but no decompression was performed. Significant ‘impingement lesions’ were seen in 10 patients, all of whom were over age 35 years.

Symptomatic ACJ disease coexisted with impingement (lesion or signs) in only 57 of 183 patients (31%) patients. With careful preoperative evaluation, unnecessary surgery is avoidable.