Copeland surface replacement of the shoulder. Results of an hydroxyapatite-coated cementless implant in patients over 80 years of age.

We describe the results of Copeland surface replacement shoulder arthroplasty using the mark III prosthesis in patients over 80 years of age. End-stage arthritis of the shoulder is a source of significant pain and debilitating functional loss in the elderly. An arthroplasty offers good relief of pain and may allow the patient to maintain independence. The risk-benefit ratio of shoulder replacement may be felt to be too high in an elderly age group, but there is no published evidence to support this theory. We have assessed whether the procedure was as reliable and safe as previously seen in a younger cohort of patients. Between 1993 and 2003, 213 Copeland surface replacement arthroplasty procedures were performed in our unit, of which 29 (13.6%) were undertaken in patients over the age of 80. This group of patients was followed up for a mean of 4.5 years (2.1 to 9.3). Their mean age was 84.3 years (81 to 93), the mean operating time was 40 minutes (30 to 45) and the mean in-patient stay was five days (2 to 21). There were no peri-operative deaths or significant complications. The mean Constant score adjusted for age and gender, improved from 15.1% to 77%. Copeland surface replacement shoulder arthroplasty may be performed with minimal morbidity and rapid rehabilitation in the elderly.

Scapular fixation in muscular dystrophy.

BACKGROUND: Winging of the scapula is caused by weakness of the thoracoscapular muscles, which allows the scapula to lift off the chest wall during shoulder movements. In facioscapulohumeral muscular dystrophy (and occasionally in other muscular dystrophies) there is selective weakness of the thoracoscapular muscles which may spare other shoulder muscles such as the deltoid muscle. This imbalance results in significant winging and loss of shoulder function. Historically, a number of different surgical and non-surgical interventions have been used to achieve scapular stability. This review examines the evidence available for the use of all scapular fixation techniques in muscular dystrophy, especially facioscapulohumeral muscular dystrophy. OBJECTIVES: To examine the evidence for the relative efficacy of scapular fixation techniques in muscular dystrophy (especially fascioscapulohumeral muscular dystrophy) in improving upper limb function. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group trials register (search updated March 2003) for randomised trials and other reports, and made enquiries from authors of trials and other experts in the field. SELECTION CRITERIA: All reports of scapular fixation for muscular dystrophy, including quasi-randomised or randomised controlled trials, comparing any form of scapular fixation (surgical and non-surgical) in people (of all ages and of all severity) with scapular winging due to muscular dystrophy. Our primary outcome measure was objective improvement in shoulder abduction. Our secondary outcome measures were: patient-perceived improvement in performance of activities of daily living, cosmetic results, subjective improvement in pain and proportion of patients with significant postoperative complications. DATA COLLECTION AND ANALYSIS: We collated and summarised studies on the treatment of scapular winging in muscular dystrophy. MAIN RESULTS: No randomised trials were identified. We therefore present a review of the non-randomised literature available. REVIEWER'S CONCLUSIONS: Operative interventions appear to produce significant benefits, though these have to be balanced against postoperative immobilisation, need for physiotherapy and potential complications. We conclude that a randomised trial would be difficult, but a register of cases and the use of a standardised assessment protocol would allow more accurate comparison of the disparate techniques.

Subacromial decompression. Treatment for small- and medium-sized tears of the rotator cuff.

We report the results of arthroscopic subacromial decompression and debridement of the rotator cuff for chronic small- and medium-sized tears in 114 patients (118 shoulders) between two and five years after surgery. The mean Constant score was improved to 69.8, and 88 shoulders (74.6%) had a satisfactory outcome. Of patients under the age of 60 years the outcome was satisfactory in 59.3%, and in those over 60 years, in 87.5% (p < 0.001). An unsatisfactory outcome was related to manual work (p < 0.001) and a duration of symptoms of more than 12 months (p < 0.05). The outcome was not related to the size of the tear, the muscles involved or biceps pathology. Further surgery was required in 25 patients after a mean of 13.7 months (3 to 35); ten tears had progressed in size, but none became irreparable. There was no relationship between the increase in the size of the tear and its initial size, the muscles involved or the presence of biceps pathology. No tear became smaller with time.

Regeneration of the coracoacromial ligament after acromioplasty and arthroscopic subacromial decompression.

The clinical observation of apparent and complete regeneration of the coracoacromial ligament after known partial excision of the ligament and acromioplasty has been investigated. Ten patients who had open revision surgery following failure of symptomatic relief after arthroscopic subacromial decompression were studied. All of them had acromioplasty with documented partial resection of the coracoacromial ligament at the first operation. There were 5 men and 5 women with an average age of 54.5 years (range, 44-65 years). In all patients surgery revealed a ligamentous structure resembling the coracoacromial ligament that was attached to the anterior acromion. Histology in all patients revealed appearances indistinguishable from normal ligament, which was in continuity with the reformed periosteum of the acromion.

Cementless surface replacement arthroplasty of the shoulder. 5- to 10-year results with the Copeland mark-2 prosthesis.

Cementless surface replacement arthroplasty of the shoulder is designed to replace the damaged joint surfaces and restore normal anatomy with minimal resection of bone. We have used the Copeland shoulder arthroplasty for 14 years. Between 1986 and 2000, 285 surface replacement arthroplasties were implanted in our unit. The prosthesis has evolved during this time, but the principle of minimal bone resection has remained the same. Between 1990 and 1994, 103 Mark-2 prostheses were inserted into 94 patients (9 bilateral). The operations were carried out for the treatment of osteoarthritis, rheumatoid arthritis, avascular necrosis, instability arthropathy, post-traumatic arthropathy and cuff arthropathy. The mean follow-up was for 6.8 years (5 to 10). The best results were achieved in primary osteoarthritis, with Constant scores of 93.7% for total shoulder replacement and 73.5% for hemiarthroplasty. The poorest results were seen in patients with cuff arthropathy and post-traumatic arthropathy with adjusted Constant scores of 61.3% and 62.7%, respectively. Most patients (93.9%) considered their shoulder to be much better or better than before the operation. Of the 88 humeral implants available for radiological review, 61 (69.3%) showed no evidence of radiolucency, nor did 21 (35.6%) of the 59 glenoid prostheses. Three were definitely loose, and eight shoulders required revision (7.7%), two (1.9%) for primary loosening. The results of this series are comparable with those for stemmed prostheses with a similar follow-up and case mix. The cementless surface replacement arthroplasty diminishes the risk of complications involving the humeral shaft and periprosthetic fractures. Revision or arthrodesis can be undertaken easily since the bone stock has been maintained with no loss of length.

Manipulation under anesthesia for primary frozen shoulder: effect on early recovery and return to activity.

Frozen shoulder is still an enigma of shoulder surgery. It is reported that at 2 years from onset, most patients will have recovered whether treated or not. However, the duration of morbidity has major implications for patient function and satisfaction. In view of this fact, we have focused on the early effect of manipulation under anesthesia on shoulder function. We prospectively assessed 39 shoulders in 37 patients who were given the diagnosis of primary frozen shoulder between June 1997 and June 1998 and were treated with manipulation under anesthesia of the affected shoulder. The median preoperative Constant score rose from 24 of 100 to 63 of 100 at 3 to 6 weeks and to 69 of 100 at 3 months. Improvement was maintained at a mean follow-up of 11 months after surgery (range 6 to 18 months). Overall, 94% of patients were satisfied with the procedure. At 3 months 59% (23 shoulders) were rated as having no or mild disability only, 28.2% (11 shoulders) as having a moderate degree of disability, and 12.8% (5 shoulders) as having a severe degree of disability. Of the 5 cases scoring less than 50 of 100 (mean 40) at 3-month follow-up, 1 had unmasked symptoms of a subacromial impingement syndrome that has required further treatment. There was no relationship between the initial Constant score or the initial range of movement after manipulation and the eventual result. We recommend the use of manipulation under anesthetic in primary frozen shoulder to restore early range of movement and to improve early function in this often protracted and frustrating condition.

The shoulder in patients with muscular dystrophy.

Shoulder weakness and instability are not usually a major part of the clinical picture of muscular dystrophies. Problems usually do not arise until the patient is wheelchair bound, at which time assistive appliances may be required. The majority of orthopaedic intervention is confined to the rare facioscapulohumeral dystrophy. Facioscapulohumeral dystrophy causes muscular weakness of the face, shoulder girdle, and upper arm with selective sparing of the deltoid muscle. This leads to scapular winging and a marked decrease in flexion and abduction of the shoulder. As the muscles stabilizing the scapula become involved, the scapula starts to wing. The deltoid is spared, but its action is wasted because of the unstable scapula. The deltoid contracts and the arm attempts to move in a normal fashion, but because the scapula is no longer stable, it wings and rotates under the forces of the long lever arm of the upper limb and scapula complex. Mechanical fixation of the scapula to the thoracic wall provides a stable fulcrum on which the deltoid can exert its powerful action on the humerus and abduct the arm without rotation of the scapula. Twenty thoracoscapular fusions were performed on 13 patients. Ten patients (14 shoulders) were available for long term followup. The long term results showed that this operation is successful in achieving stability of the scapula, while greatly improving function and cosmesis. Although the course of this type of muscular dystrophy is variable, the benefits of surgery have not deteriorated with progression of the disease during a maximum followup of 44 years.

Aquaflo pump vs FMS 4 pump for shoulder arthroscopic surgery.

A prospective controlled trial was carried out to compare two different fluid delivery systems used for shoulder arthroscopy. One an advanced pump system that controls both pressure and flow of fluid delivered, the other an air-driven diaphragm pump that only controls fluid pressure. Blood loss, presence of bleeding vessels and visual clarity were parameters used to assess the pump systems. There was no difference between the pumps in straightforward shoulder procedures. However, complicated and prolonged procedures benefited from the use of the advanced pump system.

Arthroscopic and endoscopic skills: a method of assessment.

An aptitude test has been designed to assess the psychomotor ability of surgeons under the special conditions and difficulties of endoscopic surgery. Results show increased errors and inferior tracking skill when images are rotated or reflected under test conditions simulating endoscopy. This indicates that more than simple hand-eye co-ordination is required to perform good endoscopic surgery. Interestingly, a proportion of trainee surgeons found adaptation to these altered conditions difficult to master. This aptitude test might usefully identify junior surgeons who would benefit from extra tuition at instructional endoscopic courses. The implications for the selection and training of surgeons are discussed.

Rupture of the Achilles tendon: a new clinical test.

A new diagnostic test using a sphygmomanometer cuff to detect a spontaneous rupture of the Achilles tendon is described. It has also been found to be useful in monitoring progress following treatment.

Avascular necrosis following chevron distal metatarsal osteotomy: a significant risk?

The authors have shown the chevron osteotomy to be an effective operation for hallux valgus where degenerative changes have not occurred in the metatarsophalangeal joint. Chevron osteotomy is normally restricted to younger patients, yet in this study there has been no upper limit for age and the authors have shown a high rate of patient satisfaction with good mobility and cosmesis. Results are not significantly operator-dependent, and the procedure is simple and reliable. The authors have been unable to verify previous reports in smaller studies of the serious complication of avascular necrosis of the metatarsal head on clinical or radiological grounds.

Pseudarthrosis of the radius treated by free vascularised bone graft.

We report a case of pseudarthrosis of the radius successfully treated by free vascularised bone grafting. After a comprehensive review of the literature, we recommend this as the treatment of choice in this condition. We also report the use of callus distraction of an incorporated vascularised bone graft to achieve bone lengthening.

Valproic acid and immune thrombocytopenia.

During the course of a prospective serial study over a period of one year, findings compatible with immune-mediated thrombocytolysis accompanied the administration of valproic acid in about half of 45 children with epilepsy. Thrombocytopenia occurred in 15 and neutropenia in 12 patients, but was transient and self-limiting in each. The association is probably one of cause and effect, and it may reflect the structural similarity between valproic acid and constituents of cell membranes.