Timothy D. Bunker

The detection of full thickness rotator cuff tears using ultrasound

We have examined the accuracy of 143 consecutive ultrasound scans of patients who subsequently underwent shoulder arthroscopy for rotator-cuff disease. All the scans and subsequent surgery were performed by an orthopaedic surgeon using a portable ultrasound scanner in a one-stop clinic. There were 78 full thickness tears which we confirmed by surgery or MRI. Three moderate-size tears were assessed as partial-thickness at ultrasound scan (false negative) giving a sensitivity of 96.2%. One partially torn and two intact cuffs were over-diagnosed as small full-thickness tears by ultrasound scan (false positive) giving a specificity of 95.4%. This gave a positive predictive value of 96.2% and a negative predictive value of 95.4%. Estimation of tear size was more accurate for large and massive tears at 96.5% than for moderate (88.8%) and small tears (91.6%). These results are equivalent to those obtained by several studies undertaken by experienced radiologists. We conclude that ultrasound imaging of the shoulder performed by a sufficiently-trained orthopaedic surgeon is a reliable time-saving practice to identify rotator-cuff integrity.

Clinical and radiological follow-up of the Aequalis third-generation cemented total shoulder replacement A MINIMUM TEN-YEAR STUDY

There are no long-term published results on the survival of a third-generation cemented total shoulder replacement. We describe a clinical and radiological study of the Aequalis total shoulder replacement for a minimum of ten years. Between September 1996 and May 1998, 39 consecutive patients underwent a primary cemented total shoulder replacement using this prosthesis. Data were collected prospectively on all patients each year, for a minimum of ten years, or until death or failure of the prosthesis. At a follow-up of at least ten years, 12 patients had died with the prosthesis intact and two had emigrated, leaving 25 available for clinical review. Of these, 13 had rheumatoid arthritis and 12 osteoarthritis. One refused radiological review leaving 24 with fresh radiographs. Survivorship at ten years was 100% for the humeral component and 92% for the glenoid component. The incidence of lucent lines was low. No humeral component was thought to be at risk and only two glenoid components. The osteoarthritic group gained a mean 65 degrees in forward flexion and their Constant score improved by a mean 41.4 points (13 to 55). The rheumatoid group gained a mean of 24 degrees in flexion and their Constant score improved by 29.4 points. This difference may have been due to failure of the rotator cuff in 75% of the patients with rheumatoid arthritis. Thus a third-generation total shoulder replacement gives an excellent result in patients with osteoarthritis and an intact rotator cuff. Patients with rheumatoid arthritis have a 75% risk of failure of the rotator cuff at ten years.

Primary glenoid dysplasia: A REVIEW OF 12 PATIENTS

We reviewed 12 patients with primary glenoid dysplasia. Ten were assessed clinically and two from case notes and radiographs. We identified two groups according to the age at onset of symptoms. The first (seven patients) consisted of boys and younger men, all of whom developed symptoms before the age of 40 years. All four children were free from pain, whereas the three adults in this group had varying degrees of this. Four patients had symptoms of instability. The second group consisted of older men (five patients) all of whom had noted the onset of symptoms, in the form of pain and stiffness, after the age of 40 years. All five had radiological evidence of osteoarthritis. Although the four children in our study had minimal symptoms, all eight adults had ongoing shoulder pain and dysfunction, despite a specific rehabilitation programme. Four patients required surgery; one had posterior stabilisation for instability and three arthroplasties of the shoulder for osteoarthritis.

Indications for reverse shoulder replacement: A systematic review

The outcome of an anatomical shoulder replacement depends on an intact rotator cuff. In 1981 Grammont designed a novel large-head reverse shoulder replacement for patients with cuff deficiency. Such has been the success of this replacement that it has led to a rapid expansion of the indications. We performed a systematic review of the literature to evaluate the functional outcome of each indication for the reverse shoulder replacement. Secondary outcome measures of range of movement, pain scores and complication rates are also presented.

The Delta III reverse shoulder replacement for cuff tear arthropathy: a single-centre study of 50 consecutive procedures.

The combination of an irreparable tear of the rotator cuff and destructive arthritis of the shoulder joint may cause severe pain, disability and loss of independence in the aged. Standard anatomical shoulder replacements depend on a functioning rotator cuff, and hence may fail in the presence of tears in the cuff. Many designs of non-anatomical constrained or semi-constrained prostheses have been developed for cuff tear arthropathy, but have proved unsatisfactory and were abandoned. The DePuy Delta III reverse prosthesis, designed by Grammont, medialises and stabilises the centre of rotation of the shoulder joint and has shown early promise. This study evaluated the mid-term clinical and radiological results of this arthroplasty in a consecutive series of 50 shoulders in 43 patients with a painful pseudoparalysis due to an irreparable cuff tear and destructive arthritis, performed over a period of seven years by a single surgeon. A follow-up of 98% was achieved, with a mean duration of 39 months (8 to 81). The mean age of the patients at the time of surgery was 81 years (59 to 95). The female to male ratio was 5:1. During the seven years, six patients died of natural causes. The clinical outcome was assessed using the American Shoulder and Elbow score, the Oxford Shoulder Score and the Short-form 36 score. A radiological review was performed using the Sirveaux score for scapular notching. The mean American Shoulder and Elbow score was 19 (95% confidence interval (CI) 14 to 23) pre-operatively, and 65 (95% CI 48 to 82) (paired t-test, p < 0.001) at final follow-up. The mean Oxford score was 44 (95% CI 40 to 51) pre-operatively and 23 (95% CI 18 to 28) (paired t-test, p < 0.001) at final follow-up. The mean maximum elevation improved from 55° pre-operatively to 105° at final follow-up. There were seven complications during the whole series, although only four patients required further surgery.

Arthroscopic transosseous rotator cuff repair: a cautionary tale

Background High re-tear rates and the cost of anchor repair have led some arthroscopic surgeons to consider going ‘back to the future’ and using Neer type transosseous sutures arthroscopically. Methods We examined the strength of suture repair in the laboratory using a Monsanto tensiometer (Monsanto, Swindon, UK) using a single pull to failure loading programme. Results This shows that, in transosseous repair, the bone tunnels can fail at between 16 N and 115 N compared to anchors that fail at 168 N to 712 N. Discussion This cautionary tale means that going back to ‘the good old days’ might not be such a good idea.

Anatomical variations of the deltoid artery: Relevance to the deltopectoral approach to the shoulder

Despite the expansion of arthroscopic surgery of the shoulder, the open deltopectoral approach to the shoulder is still frequently used, for example in fracture fixation and shoulder replacement. However, it is sometimes accompanied by unexpected bleeding. The cephalic vein is the landmark for the deltopectoral interval, yet its intimate relationship with the deltoid artery, and the anatomical variations in that structure, have not previously been documented. In this study the vascular anatomy encountered during 100 consecutive elective deltopectoral approaches was recorded and the common variants described. Two common variants of the deltoid artery were encountered. In type I (71%) it crosses the interval and tunnels into the deltoid muscle without encountering the cephalic vein. However, in type II (21%) it crosses the interval, reaches the cephalic vein and then runs down, medial to and behind it, giving off several small arterial branches that return back across the interval to the pectoralis major. Several minor variations were also seen (8%). These variations in the deltoid artery have not previously been described and may lead to confusion and unexpected bleeding during this standard anterior surgical approach to the shoulder.

Interference fit: a novel method for strong knotless arthroscopic fixation of sutures to bone

Background The present study examined the strength of fixation of a knotless anchor system that relies on trapping the suture between an interference fit screw and its bone tunnel, a method familiar to orthopaedic surgeons during anterior cruciate ligament reconstruction. Type of study In vitro biomechanical single-pull load to failure study of fixation achieved by interference fit screws in porcine bone. A standard suture anchor with eyelet was used as a control. Methods A single-pull to failure test was carried out on a Hounsfield H20K digital tensiometer (Tinius Olsen, Hersham, PA, USA). Two suture materials were compared [braided polyester (Ethibond; Ethicon Ltd, Edinburgh, UK) and a new suture (Fibrewire; Arthrex Inc., Naples, FL, USA) that has a high molecular weight polyethylene core]. Two interference fit screws were compared: one metal and the other plastic (PEEK; Parkus Medical, Sturgeon Bay, WI, USA). Results The average values were between 262 N and 584 N. The average failure value for a standard anchor was 206 N. Clinical Relevance Interference fit fixation provides an elegant strong knotless method for securing multiple sutures to a single point.

Anatomy of the terminal branch of the posterior circumflex humeral artery: relevance to the deltopectoral approach to the shoulder

AIMS Despite the expansion of arthroscopic surgery of the shoulder, the open deltopectoral approach is increasingly used for the fixation of fractures and arthroplasty of the shoulder. The anatomy of the terminal branches of the posterior circumflex humeral artery (PCHA) has not been described before. We undertook an investigation to correct this omission. PATIENTS AND METHODS The vascular anatomy encountered during 100 consecutive elective deltopectoral approaches was recorded, and the common variants of the terminal branches of the PCHA are described. RESULTS In total, 92 patients (92%) had a terminal branch that crossed the space between the deltoid and the proximal humerus and which was therefore vulnerable to tearing or avulsion during the insertion of the blade of a retractor during the deltopectoral approach to the shoulder. In 75 patients (75%) there was a single vessel, in 16 (16%) a double vessel and in one a triple vessel. CONCLUSION The relationship of these vessels to the landmark of the tendon of the insertion of pectoralis major into the proximal humerus is described. Damage to these previously undocumented branches can cause persistent bleeding leading to prolonged surgery and post-operative haematoma and infection, as well as poor visualisation during the procedure. Cite this article: Bone Joint J 2016;98-B:1395-8.

A pioneering legacy: the Devas elbow replacement 31 years on

We present a case report of a total elbow replacement that survived 31 years in a young female patient with, early onset rheumatoid arthritis. Professor Michael Devas inserted this self-designed, unlinked elbow prosthesis in 1973. The ulnar component loosened after 17 years and was revised using impaction grafting to restore bone stock. The original prosthesis demonstrated minimal wear and it was therefore reinserted. It functioned for a further 14 years, allowing the patient to continue working virtually pain free as a secretary, mother and housewife. To our knowledge, this is the longest surviving unlinked elbow replacement reported in the literature.