The treatment of Grade III acromioclavicular joint (ACJ) dislocations has been a subject of much controversy, even as early as Hippocrates. We hypothesized that this surgical technique would improve patient functional outcome.

Most common current surgical treatment options for cuff tear arthropathy (CTA) are hemiarthroplasty and reverse total shoulder replacement. At our unit we have been using Reverse Total shoulder replacement (TSR) for CTA patients since 2001. We present our results of Reverse TSR in 64 patients (single surgeon) with a mean follow up of 2 years (Range 1 to 8 years). There were 45 males and 19 females in the study with a mean age of 70 years. Preoperative and postoperative Constant scores were collected by a team of specialist shoulder physiotherapists. Preoperatively plain radiographs were used to evaluate the severity of arthritis and bone stock availability.

90% patients showed an improvement in the Constant score post operatively. The mean improvement in Constant score was 25 points. The mean Pain Score (max 15) improved from 6.3 to 11.8; the mean ADL Score (max 20) improved from 6.8 to 12.3; the mean Range of Motion score (max 40) improved from 10.8 to 20.2; but the mean Power Score (max 25) only improved from 0.9 to 4.9. The differences in improvement were statistically significant in each category. A total 6 patients (10%) required 10 revision surgeries for various reasons. Two patients dislocated anteriorly who were treated by open reduction. Two patients required revision of the glenoid component due to loosening after a mean of 2 years. One patient required revision of the humeral component with strut grafting secondary to severe osteolysis. Only one patient required revision of both humeral and glenoid components secondary to malpositioning. Three patients died for reasons unconnected with their shoulder problems and surgery. Radiographic analysis at the latest follow up (mean 24 months) showed inferior glenoid notching in 40% cases. Heterotrophic ossification was not seen in our series.

We conclude that reverse TSR is a viable option for treatment of cuff tear arthropathy however glenoid loosening and scapular notching remains an issue.

Introduction: Injury to the distal third of the axillary artery is well recognised as a complication of proximal humeral fractures. However the risk of iatrogenic injury at shoulder surgery has not, to date, been fully appreciated.

Patients: Four female patients aged 59 and over who suffered iatrogenic injury to the axillary artery at the time of shoulder surgery are reported. Two occurred during surgery for planned elective shoulder arthroplasty, while two occurred while treating elderly patients who had previously sustained a 3 part proximal humeral fracture. In all 4 cases the injury probably started as an avulsion of the anterior or posterior humeral circumflex vessels.

Results: Vascular surgeons were called in urgently to help with the management of all 4 cases. In two cases the axillary artery was found to have extensive atheroma, was frail and, after initial attempts at end-to-end repair, it became clear that a reversed vein graft was required. Three patients had a satisfactory outcome after reconstruction, while one patient who had previously had local radiotherapy for malignancy, but was now disease free, developed a completely ischaemic upper limb and required a forequarter amputation to save her life.

Message: The axillary artery can be very frail in the elderly, is often diseased with atheroma, and is vulnerable to iatrogenic injury at surgery. If injury occurs at surgery, small bulldog clamps should be applied to the cut ends and a vascular surgeon should be called immediately. A temporary arterial shunt should be considered urgently to provide an early return of vascularisation to the limb and to prevent serious complications. The axillary artery is very difficult to repair, and, in our experience may require a vein graft. In addition, distal clearance of the main brachial artery with a Fogarty catheter which is an essential part of the management.

Purpose of the study: To present our experience in managing Sterno-Clavicular Joint (SCJ) problems. SCJ pain is caused by a number of pathological conditions that include primary, post-infection, and post-traumatic OsteoArthritis (OA), Sterno-Costo-Clavicular Hyperotosis (SCCH) and posttraumatic instability.

Methods: All cases of painful SCJ problems treated surgically by the senior author over the past 20 years have been reviewed.

Results: All operations have been carried out using a “necklace” thyroid type incision. OA in which the pain becomes chronic and disabling, has been treated surgically. Medial clavicle reshaping (2), or hemiarthroplasty with a radial head prosthesis (3), sometimes combined with an interpositional arthroplasty using a GraftJacket is a new technique, developed to obliterate dead space, improve wound cosmesis, and prevent regeneration of the medial clavicle. SCCH is strongly associated with seronegative spondyloarthropathy, and can from part of the SAPHO syndrome (Synovitis, Acne, Pustulosis, Hyperostosis, and Osteitis), Patients with severe excruciating pain and those with restricted motion resulting from complete fusion of the clavicle and sternum may be candidates for surgical treatment. Excision of the medial end of the clavicle (1), the whole clavicle (1) and replacement hemiarthroplasty using a radial head as well as a pectoralis major flap interposition between the first rib and the clavicle (1), is a technique that has not been described previously.

Instability for persistent subluxation or dislocation of the SCJ has been treated with interposition with Graft-Jacket +/− medial clavicle resection (2) or a sterno-mastoid tendon stabilisation (2).

Conclusions: Previous surgical treatment of SCJ problems has been disappointing. Rockwood’s success rate with excision of the medial end of the clavicle alone has been poor (40% good only) – these newer techniques show greater promise.

Introduction and Aims: To determine differences in rotator cuff tissue with duration of symptoms and tear size

Method: Rotator cuff tissue was obtained at debridement from 44 patients undergoing surgical repair. Pathological assessment was performed on H& E sections. Features evaluated included inflammation, micro-calcification, tendolipomatosis and fibroblast hypocellularity. Matrix quality and endothelial cell proliferation were examined. Patient details – age, tear size and duration of symptoms were extracted from notes.

Results: Matrix quality was significantly worse in small tears (p=0.028), particularly the extent of mucoid degeneration in the debrided tissue (p=0.017). Presence of a healthy cut margin was more likely in a large tear (10/14). Poor matrix was significantly associated with symptom duration > 15months (p=0.006) especially microcalicification (p=0.019) and mucoid degeneration (p=0.047). Endothelial cell proliferation was significantly more apparent in patients with longer duration of symptoms: previous vascular tufting (p=0.001) and ongoing vascular proliferation (p=0.019). Of 27 patients > 15months symptoms, vascular proliferation was strongly correlated with split collagen fibres (p< 0.018) and mucoid degeneration (p< 0.018) but not microcalcification. Tendolipomatosis was strongly correlated with ongoing vascular proliferation (p< 0.0006).

Conclusion: Successful surgical repair is only achieved in 30% patients with rotator cuff tears. Improvements in this success rate will be essential in order to maintain the independent lifestyle of an elderly population. Although the tissue examined here is debrided, and hence worst case tissue, several time-dependent processes are ongoing, degeneration, repair and remodelling. Matrix quality is deteriorating, however, this maybe supportive of the angiogenic component of repair. Remodelling may be seen in the increased probability of a healthy cut margin from patients with longer symptom duration.

Introduction and Aims: To determine whether non-steroidal anti-inflammatory drugs (NSAID) administration influences ongoing endothelial cell proliferation in tom rotator cuff?

Method: Rotator cuff tissue, obtained at debridement from 53 patients undergoing surgical repair, was fixed and embedded. Pathological assessment was performed on H& E sections. Ongoing vascular proliferation was identified by plump endothelial cells and budding of vessels. Patient cuff details and pre-operative drug prescription data was obtained from patients’ notes and by telephone from general practitioners. The drugs used were NSAIDs (including Aspirin, Ibuprofen and Diclofenac), COX 2 inhibitors and Opiates. The data was analysed using the SPSS program and the Pearson Chi-square test.

Results: Of the 35 patients taking analgesics, vascular proliferation was absent or reduced in 22 (63%). Twenty of these patients were taking NSAIDs. Four patients were taking only COX-2 inhibitor drugs; all these patients had increased vascularity. Twenty-three patients were taking codeine-based analgesics. Of 10 patients using codeine without NSAIDs, eight demonstrated active ongoing vascular proliferation (p=0.027).

Conclusion: Patients taking NSAIDs showed a significant reduction in ongoing vascular proliferation. If endothelial cell proliferation is an important component of repair in either the onset or post-operative stages of rotator cuff pathology, then attempts at repair could be compromised by inadequate local function of the vascular system. We have previously identified strong p27 positivity in rotator cuff endothelial 0 cells. NSAIDs can impair healing by inhibiting angiogenesis; the mechanism includes upregulation of p27 in endothelial cells. More work should be done to clarify this matter in the rotator cuff.

Background: Microvessels have been identified in the functionally avascular critical zone of the rotator cuff. Inadequate local sprouting of these capillaries might impair attempts at repair. We have identified widespread VEGF positivity in endothelial cells. However, this was accompanied by strong positivity for the cell cycle inhibitor p27 and little proliferation (Ki-67 positivity). Non-steroidal anti-inflammatory drugs (NSAID) can impair healing by inhibiting angiogenesis. The mechanisms include upregulation of p27 in endothelial cells. Objective: Does NSAIDs influence endothelial cell proliferation in torn rotator cuff? Methods: Pathological assessment of Rotator cuff tissue, obtained from 35 patients undergoing surgical repair, was performed on H& E sections. Ongoing vascular proliferation was identified by plump endothelial cells and budding of vessels. Preoperative drug prescription data was obtained from patient’s General practitioners. The drugs used were NSAIDs (including Ibuprofen and Diclofenac), COX2 inhibitors & Opiates. Results: Ongoing vascular proliferation was not identified in 20/35 patients. 25 patients were taking analgesics; vascular proliferation was absent in 15. 20 patients were taking NSAIDs of these 15 demonstrated no ongoing vascular proliferation, (p≤0.014). No significant effect of opiates or COX2inhibitors was found. Discussion: Patients taking NSAIDs showed a significant reduction in vascular proliferation. If endothelial cell proliferation is an important component of repair in rotator cuff tears, more work should be done to clarify this matter.

Introduction: Distal humeral fractures represent a constant challenge to the most experienced surgeon. This is the first report of the use of an unlinked prosthesis for the treatment of distal humeral fractures in elderly persons.

Materials and Methods: From July 2000 to June 2001, 9 iBP elbow arthroplasties were performed in patients with acute fractures of the distal humerus. The average age of the group was 71 years. The mean interval between injury and TER was 11 days. The follow-up period averaged 12 months (range 5 to 16).

Results: Functional outcome was evaluated with patient-completed questionnaires. All patients had a flexion contracture of the elbow ranging from 15 to 30 degrees. All patients were able to perform daily activities, pain relief was satisfactory and patient satisfaction was high. All elbows met the criteria for functional motion and were stable at the latest follow-up examination. There were no major complications such as dislocation, ulnar nerve dysfunction or deep infection.

Conclusion: Unlinked non-congruous elbow arthroplasty when combined with a surgical exposure that allows proper soft tissue balance and instrumentation that enables correct positioning of the components can be a successful alternative in the management of acute distal humeral fractures in selected patients when conventional fixation is not a viable option.

The overall incidence of cuff tears increases with age, individuals over 80years having a 51% incidence of a tear. Currently, the aetiology of rotator cuff tears remains unclear and successful repair is achieved in only 30% patients. Matrix metalloproteinases (MMPs) have roles in a wide range of physiological processes including placentation and embryogenesis, tissue remodelling and wound healing. However, the ability of MMPs to dissolve extracellular matrix has been linked to a variety of pathological processes including rheumatoid arthritis, osteoarthritis, periodontitis and multiple sclerosis, which involve excessive matrix destruction. Production of gelatinase MMPs by torn rotator cuff has been demonstrated. The objectives of this study were to examine the expression of MMPs and their association with histological changes in full thickness tears of the rotator cuff.

Rotator cuff tissue was obtained from ten patients (age 40–80years) undergoing surgical repair. The size of tear was 1–4.5cm; time from presentation to surgery was 1 month (acute) to between 0.5–4years (chronic). Immunohistochemical staining with commercial monoclonal antibodies to a range of MMPs, endothelial, macrophage and fibroblast markers was performed. Production of gelatinase MMPs was measured by gelatin zymography on tissue culture supernatant. Visualisation used a standard DAB chromagen technique.

In the acute specimens there was an infiltrate of macrophages with little collagen degeneration; the fibro-blasts were MMP1 positive and endothelial cells MMP2 positive. At 12 months post-tear mature collagen, plump fibroblasts and proliferating endothelial cells were identified adjacent to the resection edge. Towards the torn edge areas of lower cellularity, sparse vascularity and collagen degeneration were observed. Vimentin positive, CD68 negative cells within this matrix were rounded with foamy cytoplasm, and intensely positive for MMP1 and MMP2, and positive for MMP-3, -10, -11, -13 and -14. Tissue culture supernatant demonstrated active and latent MMP2 production in all cases.

The prolonged interval between trauma and surgical repair, with potential pharmacological intervention, remedial physiotherapy and disuse immobility, make assessment of the factors contributing to tendon degeneration difficult to determine. Fatty infiltration, dystrophic calcification and patchy collagen degeneration were common. However, clear evidence of cellular activities typical of wound repair were also identified, including fibroblast and endothelial cell proliferation. The most striking finding was the association between areas of poor collagen structure with fibroblasts staining intensely for both MMP1 and MMP2 and positive for other matrix metalloproteinases. The production of MMP1 and MMP2 may contribute to active remodelling of the tendon matrix. Success of repair could be influenced by both the quality of the matrix and the cell types and activities in the tissue at the resection edge.