Failed surgery for recurrent anterior dislocation of the shoulder. Causes and management.

We have reviewed 36 patients who had recurrent anterior dislocation of the shoulder after a previous anterior repair and analysed the various causes of failure. It was found that failure could have been avoided in virtually all of the patients by correct pre-operative diagnosis, selection of the appropriate operation and its proper execution. The further management of these patients is described and suggestions are made as to means of reducing the incidence of failure after primary operation.

Progression in idiopathic scoliosis: A preliminary report of a possible mechanism.

Recent surveys have shown that idiopathic structural scoliosis of mild degree is generally not progressive. We will propose a mechanism which may be responsible for deterioration in the few. It has been observed that the spinal cord, although displaced towards the concavity, does not rotate in company with the vertebrae, thus exposing the emerging nerve roots to the effects of traction and possibly of entrapment. We suggest that progression occurs when the neuraxis is unable to adjust to the change in the anatomy of vertebral column. Our proposition is based upon our findings in a complete spinal column obtained from a baby with structural scoliosis. Support is provided by intercostal angiography, and by observations upon normal anatomy, the pathological anatomy of mature scoliotic spines and the anatomy of contrived scoliosis in normal spines. Although our histological and electrophysiological investigations are incomplete we can demonstrate a significant increase in degenerate cells in the dorsal root ganglia at the apex on the convex side. Lack of suitable necropsy material prevents us from confirming our observations so that our report is inevitably preliminary. We enter a plea that careful examination of the neuraxis be undertaken whenever a specimen of a scoliotic spine becomes available.

Glenohumeral arthrodesis for the treatment of recurrent shoulder instability in epileptic patients.

We report our experience with glenohumeral arthrodesis as a salvage procedure for epilepsy-related recurrent shoulder instability. A total of six patients with epilepsy underwent shoulder fusion for recurrent instability and were followed up for a mean of 39 months (12 to 79). The mean age at the time of surgery was 31 years (22 to 38). Arthrodesis was performed after a mean of four previous stabilisation attempts (0 to 11) in all but one patient in whom the procedure was used as a primary treatment. All patients achieved bony union, with a mean time to fusion of 2.8 months (2 to 7). There were no cases of re-dislocation. One revision was undertaken for loosening of the metalwork, and then healed satisfactorily. An increase was noted in the mean subjective shoulder value, which improved from 37 (5 to 50) pre-operatively to 42 (20 to 70) post-operatively although it decreased in two patients. The mean Oxford shoulder instability score improved from 13 pre-operatively (7 to 21) to 24 post-operatively (13 to 36). In our series, glenohumeral arthrodesis eliminated recurrent instability and improved functional outcome. Fusion surgery should therefore be considered in this patient population. However, since the majority of patients are young and active, they should be comprehensively counselled pre-operatively given the functional deficit that results from the procedure.

A reverse shoulder arthroplasty with increased offset for the treatment of cuff-deficient shoulders with glenohumeral arthritis.

Inherent disadvantages of reverse shoulder arthroplasty designs based on the Grammont concept have raised a renewed interest in less-medialised designs and techniques. The aim of this study was to evaluate the outcome of reverse shoulder arthroplasty (RSA) with the fully-constrained, less-medialised, Bayley-Walker prosthesis performed for the treatment of rotator-cuff-deficient shoulders with glenohumeral arthritis. A total of 97 arthroplasties in 92 patients (53 women and 44 men, mean age 67 years (standard deviation (sd) 10, (49 to 85)) were retrospectively reviewed at a mean follow-up of 50 months ((sd 25) (24 to 96)). The mean Oxford shoulder score and subjective shoulder value improved from 47 (sd 9) and 24 points (sd 18) respectively before surgery to 28 (sd 11) and 61 (sd 24) points after surgery (p < 0.001). The mean pain at rest decreased from 5.3 (sd 2.8) to 1.5 (sd 2.3) (p < 0.001). The mean active forward elevation and external rotation increased from 42(°)(sd 30) and 9(°) (sd 15) respectively pre-operatively to 78(°) (sd 39) and 24(°) (sd 17) post-operatively (p < 0.001). A total of 20 patients required further surgery for complications; 13 required revision of components. No patient developed scapular notching. The Bayley-Walker prosthesis provides reliable pain relief and reasonable functional improvement for patients with symptomatic cuff-deficient shoulders. Compared with other designs of RSA, it offers a modest improvement in forward elevation, but restores external rotation to some extent and prevents scapular notching. A longer follow-up is required to assess the survival of the prosthesis and the clinical performance over time.

Management of peri-prosthetic fracture of the humerus with severe bone loss and loosening of the humeral component after total shoulder replacement.

There is little information about the management of peri-prosthetic fracture of the humerus after total shoulder replacement (TSR). This is a retrospective review of 22 patients who underwent a revision of their original shoulder replacement for peri-prosthetic fracture of the humerus with bone loss and/or loose components. There were 20 women and two men with a mean age of 75 years (61 to 90) and a mean follow-up 42 months (12 to 91): 16 of these had undergone a previous revision TSR. Of the 22 patients, 12 were treated with a long-stemmed humeral component that bypassed the fracture. All their fractures united after a mean of 27 weeks (13 to 94). Eight patients underwent resection of the proximal humerus with endoprosthetic replacement to the level of the fracture. Two patients were managed with a clam-shell prosthesis that retained the original components. The mean Oxford shoulder score (OSS) of the original TSRs before peri-prosthetic fracture was 33 (14 to 48). The mean OSS after revision for fracture was 25 (9 to 31). Kaplan-Meier survival using re-intervention for any reason as the endpoint was 91% (95% confidence interval (CI) 68 to 98) and 60% (95% CI 30 to 80) at one and five years, respectively. There were two revisions for dislocation of the humeral head, one open reduction for modular humeral component dissociation, one internal fixation for nonunion, one trimming of a prominent screw and one re-cementation for aseptic loosening complicated by infection, ultimately requiring excision arthroplasty. Two patients sustained nerve palsies. Revision TSR after a peri-prosthetic humeral fracture associated with bone loss and/or loose components is a salvage procedure that can provide a stable platform for elbow and hand function. Good rates of union can be achieved using a stem that bypasses the fracture. There is a high rate of complications and function is not as good as with the original replacement.

The outcome of scapulothoracic fusion for painful winging of the scapula in dystrophic and non-dystrophic conditions.

Scapulothoracic fusion (STF) for painful winging of the scapula in neuromuscular disorders can provide effective pain relief and functional improvement, but there is little information comparing outcomes between patients with dystrophic and non-dystrophic conditions. We performed a retrospective review of 42 STFs in 34 patients with dystrophic and non-dystrophic conditions using a multifilament trans-scapular, subcostal cable technique supported by a dorsal one-third semi-tubular plate. There were 16 males and 18 females with a mean age of 30 years (15 to 75) and a mean follow-up of 5.0 years (2.0 to 10.6). The mean Oxford shoulder score improved from 20 (4 to 39) to 31 (4 to 48). Patients with non-dystrophic conditions had lower overall functional scores but achieved greater improvements following STF. The mean active forward elevation increased from 59° (20° to 90°) to 97° (30° to 150°), and abduction from 51° (10° to 90°) to 83° (30° to 130°) with a greater range of movement achieved in the dystrophic group. Revision fusion for nonunion was undertaken in five patients at a mean time of 17 months (7 to 31) and two required revision for fracture. There were three pneumothoraces, two rib fractures, three pleural effusions and six nonunions. The main risk factors for nonunion were smoking, age and previous shoulder girdle surgery. STF is a salvage procedure that can provide good patient satisfaction in 82% of patients with both dystrophic and non-dystrophic pathologies, but there was a relatively high failure rate (26%) when poor outcomes were analysed. Overall function was better in patients with dystrophic conditions which correlated with better range of movement; however, patients with non-dystrophic conditions achieved greater functional improvement.

Tenodesis of the long head of biceps brachii in the painful shoulder: improving results in the long term.

Fifteen shoulders of 14 patients with a keyhole tenodesis of the long head of the biceps were reviewed at an average follow-up of 7 years (3 years, 1 month to 13 years, 2 months). In 13 cases additional shoulder disease was noted during the operation. Eight patients had undergone rotator cuff decompression before the reference biceps tenodesis was performed. Eight (53%) cases achieved an excellent result; one was rated as good, four were rated as fair, and two had failures. Seven shoulders had an improved result from short to long term, and only two deteriorated. An upward migration of the humeral head on x-ray evaluation was noted but was without clinical significance. A local anesthetic test to the long head of the biceps before the operation seemed to be valuable in assessing chances of a good long-term result.

Reconstruction of the valgus-impacted humeral head fracture.

Between 1985 and 1991, 22 patients (average age 52 years, range 26 to 65 years) with severely impacted humeral head fractures were operated on with the aim of preserving the humeral head. All 22 cases showed no significant lateral displacement. Thus it was assumed that the periosteum leading medially to the humeral head was intact and that the vessels passing through the periosteum would ensure survival of the humeral head segment. All patients underwent treatment with open reduction. The impacted segment of the humeral head was raised, the tuberosities were relocated, and the void was filled with chips of cancellous bone. This procedure provided fixation with minimal osteosynthesis. At follow-up evaluation (minimum 18 months, average 36 months) one patient had sequestration of the head segment, and another patient had clinically asymptomatic partial necrosis. None of the remaining 20 patients showed signs of necrosis. Slight arthrosis was present in two patients, and moderate arthrosis was present in one. A correlation was found between the functional result and the quality of reduction. Where anatomic reconstruction had been successful, the long-term functional result was almost identical with the nontraumatized side.

The bifurcate coracoacromial ligament: an arthroscopic variant.

A 28-year-old woman underwent shoulder arthroscopy. Bursoscopy revealed a bifurcate appearance of the coracoacromial ligament (CAL). We believe this case report is the first description of this appearance, which represents a normal variant. Several cadaveric studies have documented a bifurcate CAL to be seen frequently at dissection. Presumably, the bifurcate segment of the CAL usually lies out of view from inspection within the subacromial bursa, thereby accounting for the rarity of the appearance we describe.

The role of imaging in the diagnosis and management of thoracolumbar burst fractures: current concepts and a review of the literature.

The burst fracture of the spine was first described by Holdsworth in 1963 and redefined by Denis in 1983 as being a fracture of the anterior and middle columns of the spine with or without an associated posterior column fracture. This injury has received much attention in the literature as regards its radiological diagnosis and also its clinical management. The purpose of this article is to review the way that imaging has been used both to diagnose the injury and to guide management. Current concepts of the stability of this fracture are presented and our experience in the use of magnetic resonance imaging in deciding treatment options is discussed.

The effect of indomethacin upon experimental fractures in the rat.

The effect of Indomethacin upon the process of fracture repair and osteogenesis in bone isografts has been studied in the rat. It was found that the drug had no significant effect upon new bone formation in heterotopic bone grafts. It had no effect upon the osteogenesis in repairing drill holes in 2 month old rats. A significant impairment of osteogenesis was detected, however, in older (6--9 months) animals given continuous treatment with Indomethacin from the week before fracture. This effect was not apparent if treatment was terminated on the day after induction of the lesion. There is histological evidence of increased fibrogenesis and decreased osteogenesis and remodelling in fractures in old rats given high dosages of Indomethacin.

Human shoulder tendon biopsy samples in organ culture produce procollagenase and tissue inhibitor of metalloproteinases.

OBJECTIVE: To investigate the production of the matrix metalloproteinase (MMP), collagenase (MMP-1), and its natural inhibitor, the tissue inhibitor of metalloproteinases (TIMP) by diseased human tendon samples in organ culture. METHODS: Portions of tendons were excised from the shoulders of patients undergoing shoulder surgery, classified as either proximal to the lesion (abnormal) or distal to the lesion (normal) according to their macroscopic appearance at surgery, and placed in organ culture for periods of up to 28 days. The release of collagenase and TIMP activity in the conditioned culture medium was measured. RESULTS: Procollagenase and TIMP were both produced by all the tendon samples for an extended period of time. The levels of enzyme and inhibitor varied between patients, but in most of them TIMP levels were greater than collagenase levels. In one sample of calcified tendon, procollagenase levels were greater than those of TIMP. The mean level of collagenase produced by tendon proximal to the lesion and tendon distal to the lesion were not significantly different (95.2 (SD 106.8) U/g and 34.0 (45.3) U/g, respectively), while the corresponding figures for TIMP were 109.7 (62.3) U/g and 53.0 (27.9) U/g (p = < 0.05), although there was considerable variation in some samples. Western blotting and collagen fragment analysis confirmed that the collagenolytic activity detected was attributable to the metalloproteinase fibroblast collagenase (MMP-1). CONCLUSIONS: Tendon tissue can actively secrete procollagenase, an enzyme that, once activated, is capable of remodelling collagen, the major connective tissue component of tendon. Collagenase is produced even in unstimulated cultures, although the concentrations of TIMP are usually greater than that of collagenase in most samples. Some activation of collagenase appeared to have occurred. These results indicate that tendon tissue cells are capable of producing a remodelling response, even in end stage tendon disease.

A comparative study of postgraduate medical education in North East Thames Region.

As a prelude to more detailed formal contracting, North East Thames Region undertook a review to examine whether the content of postgraduate medical education (PGME) varies according to the type of hospital in which junior doctors are trained. The study covered a sample of 83 trainees at different grades in four types of hospital (postgraduate, university, district general hospital involved in off-site undergraduate medical education, and district general hospital with no formal involvement in undergraduate medical education) and was designed as a qualitative comparative study. The results of the study point to a perceived lack of structure in PGME and indicate that hospital type alone does not determine a trainees' PGME experience. Moreover, different training grades have different educational needs, which will need to be addressed under more formal contracting arrangements. The Region plans to take this work forward by convening one or more consensus conferences to examine how a more structured approach to PGME could be implemented.