The aim of the study was to assess the medium term outcome for complex proximal humeral fractures treated with the long proximal humeral internal locking system (PHILOS) plate fixation.

All patients who had long PHILOS plate fixation of proximal humerus fractures with metaphyseal or diaphyseal extension over a three year period at our institution were included in the study. Patients had their case notes and radiographs reviewed. Patients were also contacted to assess functional outcome using the Visual Analogue Scale (VAS) for pain, DASH, Oxford shoulder score (OSS) and Stanmore Percentage of Normal Shoulder Assessment (SPONSA).

Out of an initial cohort of 34 patients, 1 died, 2 patients had unrelated illnesses resulting in them being unable to complete the assessment and 6 were lost to follow-up, leaving 25 patients (74%) for review. All patients had proximal humeral fractures with metaphyseal or diaphyseal extension requiring long plate osteosynthesis. One patient had the procedure for non union following initial treatment with an intra medullary nail and the rest were acute injuries. The patients were followed up after a mean of 27 months (range 11–60). The length of plate used varied from 5 to 12 holes for the shaft region.

There was 1 wound infection. 3 patients had non unions which required bone grafting and revision internal fixation. At final follow-up, mean pain was 3.6 (95% Confidence Interval 2.5–4.8) with only 4 patients having residual pain greater than 5 on the VAS scale. Mean DASH score was 41.2 (95% CI 32.0–50.4), mean OSS was 29.1 (95% CI 24.3–33.9) and mean SPONSA was 63.9% (95% CI 50.8–77.2)

The long PHILOS plate appears to represent a good treatment option for complex proximal humerus fractures with favourable medium term results and few complications.

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.

The aim of this study was to evaluate prospectively the outcome following arthroscopic Bankart repair using two types of suture anchors, absorbable and non-absorbable. Patients with a diagnosis of recurrent traumatic anterior instability of the shoulder, seen between April 2000 and June 2003 in a single unit, were considered for inclusion in the study. Patients were assessed pre-operatively and post-operatively using a subjective patient related outcome measurement tool (Oxford instability score), a visual analogue scale for pain and instability (VAS Pain and VAS instability) and a quality of life questionnaire (SF-12). The incidence of recurrent instability and the level of sporting ability were recorded. Patients were randomised to undergo surgical repair with either non-absorbable or absorbable anchors.

130 patients were included in the study. 6 patients were lost to follow-up and 124 patients (95%) completed the study. Both types of anchors were highly effective. There were no differences in the rate of recurrence or any of the scores between the two. Four patients in the non-absorbable group and 3 in the absorbable group experienced further episodes of dislocation after a traumatic event. The rate of redislocation in the whole series was therefore, 5.6%. In addition, 4 patients, all of them in the absorbable group (4%) described ongoing symptoms of instability but no true dislocations. 85% of the patients have returned to their previous level of sporting activity.

There are no differences in the outcome of Arthroscopic Bankart repair using either absorbable or non-absorbable anchors. Both are highly effective, showing a redislocation rate of 5.6%.

This study investigated the anatomical relationship between the clavicle and its adjacent vascular structures, in order to define safe zones, in terms of distance and direction, for drilling of the clavicle during osteosynthesis using a plate and screws following a fracture. We used reconstructed three-dimensional CT arteriograms of the head, neck and shoulder region. The results have enabled us to divide the clavicle into three zones based on the proximity and relationship of the vascular structures adjacent to it. The results show that at the medial end of the clavicle the subclavian vessels are situated behind it, with the vein intimately related to it. In some scans the vein was opposed to the posterior cortex of the clavicle. At the middle one-third of the clavicle the artery and vein are a mean of 17.02 mm (5.4 to 26.8) and 12.45 mm (5 to 26.1) from the clavicle, respectively, and at a mean angle of 50° (12 to 80) and 70° (38 to 100), respectively, to the horizontal. At the lateral end of the clavicle the artery and vein are at mean distances of 63.4 mm (46.8 to 96.5) and 75.67 mm (50 to 109), respectively.

An appreciation of the information gathered from this study will help minimise the risk of inadvertent iatrogenic vascular injury during plating of the clavicle.

Aim: The aim of this study was to evaluate prospectively the mid-term outcome following arthroscopic Bankart repair using two types of suture anchor, the G II (Mitek) non-absorbable and the Panalok (Mitek) absorbable anchor.

Method: Patients with a diagnosis of recurrent traumatic anterior instability of the shoulder seen between April 2000 and June 2003 in a single unit were considered for inclusion in the study. Patients were assessed preoperatively and postoperatively using a subjective patient related outcome measurement tool (Oxford instability score), visual analogue scales for pain and instability and a quality of life questionnaire (SF-12). Patients were randomised to undergo surgical repair with either non-absorbable or absorbable anchors. Length of follow-up was 3.3–6.5 (mean 5.0) years. The incidence of recurrent instability and the level of sporting ability were recorded.

Results: 130 patients were included in the study. 25 patients were lost to follow-up, 105 patients (81%) completed the study. 5 patients in absorbable group and 4 patients in non-absorbable group experienced further dislocation (8.5%). Both types of anchor were highly effective. There were no differences in the rate of recurrence or any of the scores between the two.

Conclusions: There are no differences in the outcome of arthroscopic Bankart repair using either absorbable or non-absorbable anchors. Both are highly effective, showing a redislocation rate of 8.5%.

Aim: To compare 2 rehabilitation regimes after arthroscopic interval release: immediate mobilization versus immediate mobilization and external rotation night splint for ten days.

Methods: 30 patients aged 40–67 years with primary frozen shoulder were included in the study. The surgical procedure consisted of release of the coracohumeral ligament, rotator interval and the posterior capsule with electrocautery, followed by gentle manipulation. Patients were randomised into 2 rehabilitation groups: immediate mobilization (IM) or immediate mobilization with external rotation night splint (ERS) used for 10 days post-operatively. Patients were assessed pre & post operatively and using the visual analogue score for pain, Constant and Oxford scoring systems.

Results: There were 15 patients in the IM group and 15 in ERS group. In the IM group the Constant score improved from 35±10 (mean±SD) pre-operatively to 63±14 at 1 month and 75±11 at 6 months, and in the ERS group the Constant score improved from 33±9 pre-operatively to 59±14 at 1 month and 75±7 at 6 months. The Oxford score in the IM group improved from 35±9 pre-operatively to 25±8 at 1 month and 18±9 at 6 months, and in the ERS group from 38±9 pre-operatively to 27±8 at 1 month and 18±8 at 6 months (all changes P< 0.001 cf pre-operative, but NS from 1 to 6 months). Improvements in VAS were significant in both groups (P< 0.02) at 6 months but not at 1 month. There was no significant difference between the two groups in terms of Oxford or Constant scores or VAS at 1 and 6 months.

Conclusion: Arthroscopic interval release is successful in restoring range of motion in patients with idiopathic frozen shoulder. Both groups showed significant improvement during the study period with most improvement in terms of range of movement occurring in the first month. There was no significant difference in outcome between the two groups studied.

Purpose: The aim of this study was to evaluate prospectively the outcome following arthroscopic Bankart repair using two types of suture anchors, absorbable and non-absorbable.

Method: Patients with a diagnosis of recurrent traumatic anterior instability of the shoulder, seen between April 2000 and June 2003, in a single unit were considered for inclusion in the study. Patients were assessed preoperatively and postoperatively using a subjective patient related outcome measurement tool (Oxford instability score), a visual analogue scale for pain and instability (VAS Pain and VAS instability) and a quality of life questionnaire (SF-12). Length of follow up was 1.5 to 5 years, mean 2.6 years. The incidence of recurrent instability and the level of sporting ability were recorded. Patients were randomised to undergo surgical repair with either non-absorbable or absorbable anchors.

Results: 130 patients were included in the study. 6 patients were lost to follow up; therefore 124 patients (95%) completed the study. Both types of anchors were highly effective. There were no differences in the rate of recurrence or any of the scores between the two groups. 4 patients in the non-absorbable group and 3 in the absorbable group experienced further episodes of dislocation after a traumatic event: the rate of redislocation in the whole series was therefore 6%. In addition 4 patients, all of them in the absorbable group (4%,) described ongoing symptoms of instability but no true dislocations. 85% of the patients have returned to their previous level of sporting activity.

Conclusions: There are no differences in the outcome of Arthroscopic Bankart repair using either absorbable or non-absorbable anchors. Both are highly effective, showing a redislocation rate of 5.6%.

A prospective study was carried out over a period of 4 years. 31 patients with a mean age of 49 years were treated using the clavicular hook plate. The mean follow up was 28.34 months. 23 patients were operated primarily and 8 patients were operated for symptomatic non-union.

All the patients achieved clinical and radiological union in a mean 12.71 weeks. According to Constant scoring the mean was 94. According to HSS (Hospital for Special Surgery) scoring 9 patients had excellent, 21 had good.

The clinical results of the clavicular hook plate were good leading to good shoulder girdle function.

Recently concerns have been raised as to the effect of intra-articular radio-frequency energy on axillary nerve function. In our unit 120 shrinkage procedures have been performed with 5 intra-operative contractions of deltoid and no axillary nerve palsy. In this study we aimed to identify and quantify any changes in axillary nerve function following capsular shrinkage. Needle electrodes were inserted into the deltoid muscle of 10 patients undergoing radio-frequency capsular shrinkage and 3 patients having diagnostic arthroscopy. Recordings of Compound Muscle Action Potentials (CMAPs) were made following pre-operative magnetic coil stimulation of the axillary nerve. The nerve was then monitored during operation. At the end of the procedure, a further recording of CMAP following axillary nerve stimulation was made to allow comparison with initial readings.

We have shown:

Low amplitude stimulations of the axillary nerve in 6 of the 10 patients undergoing shrinkage.

We have concluded:-

Stimulation of the axillary nerve occurs frequently during capsular shrinkage.

We would like to acknowledge the Magstim Company for their assistance with this project.

The aim of this study was to investigate if the rotational axis of normal human shoulders moves during flexion in the sagittal plane.

Twenty four shoulders were measured in twelve normal volunteers, aged 25-42, height range 1.65-1.88 m and weight range 63–120 Kg. Each subject had surface markers placed on their iliac crests, mastoid processes and upper arms. Joint movement was video recorded as shoulders were actively flexed and extended in the sagittal plane. For each joint, a typical flexion sweep was selected and replayed into a computerised imaging system, where still frames were captured at 20 degree intervals from 20 to 120 degrees. These images were analysed to extract the co-ordinates of each marker. The coordinates were then processed to determine the Instant Centres of Rotation (ICR) for each angle of flexion. These ICR’s were then plotted to derive the Rotational Axis Pathway (RAP) for each shoulder joint.

The results indicate that throughout the flexion arc, the rotational axis is located in the region of the humeral head. At the start of the arc the rotational axis is in the anterio-superior part of the shoulder joint. As the shoulder flexes forward the rotational axis moves posteriorly following a curved pathway. In 18 cases the RAPs moved posterio-inferiorly and in six cases the RAPs moved posterio-superiorly. The pathways can be quantified in terms of their curved pathway lengths and the displacements of their end points from their start points. In the case of the 18 posterio-inferior pathways, the mean pathway length was 98.3 mm (SD=31.5) and the mean posterior/inferior displacements were 59.6 mm (SD=34.7) and 43.2 mm (SD=24.6) respectively. In the case of the 6 posterior-superior pathways, the mean pathway length was 109.4 mm (SD=40.2) and the mean posterior/ superior displacements were 94.7 mm (SD=43.9) & 20.9 mm (SD=11.1) respectively. The variation in inferior-superior displacement of the axis may be due to normal variations in scapula movement during forward flexion.

This investigation indicates that in normal subjects, the rotational axis moves posteriorly during flexion.