Examination

The most striking clinical feature was the severe limitation of all glenohumeral movements.Abduction was 90 degrees(normal=180),external rotation was 20 degrees(normal=45).Tests for rotator cuff pathology were negative.

Special Investigations

Recent X-rays did not reveal any evidence of arthritis or calcific tendonitis and an ultrasound done in the rooms did not show any tears of the rotator cuff tendons.

Diagnosis

Given the fact that Mr L.L. was a diabetic and that his shoulder movements were severely restricted,the diagnosis in his case was very easily made – frozen shoulder.

Treatment Options

It was explained to Mr L.L.that there were 3 main treatment options:1)Nil – 100% of frozen shoulders resolve irrespective of the treatment.2)Intra-articular injection of steroid – particularly useful in the early(inflammatory) stages of the disease.3)Arthroscopic capsulotomy – very useful in the later(stiff)stages. Given that Mr L.L.had already had frozen shoulder for the last 2 years and that 2 previous injections had not helped him,he was very keen on having the operation.

Operations Details

Under general anaesthetic and in the “beach-chair”position,an examination under anaesthesia was performed.This confirmed the diagnosis of frozen shoulder,as external rotation was limited to 20 degrees and external rotation with the arm in 90 deg abduction was only 20 deg(normal=90deg).At the same time,the anaesthetist placed an indwelling catheter along the brachial plexus,for intra- and postop pain relief. Arthroscopic assessment of the glenohumeral joint was then done,which revealed all the classical signs of frozen shoulder viz.severe inflammation and a very thickened capsule. With the camera placed posteriorly,a special capsulotomy forceps was used to divide the anterior capsule,taking care not to damage the tendon of subscapularis.The camera was then placed anteriorly and the forceps used to release the posterior capsule without damaging the axillary nerve.

Postoperative Course

Mr L.L. stayed in hospital for one night and received physiotherapy 3 hrs after the procedure,as well as the following morning.He was discharged with his indwelling catheter,which continued to give him continuous pain relief while at home.He also continued to receive twice daily physio until the catheter was removed two days later. 12 days after the procedure,Mr L.L.reported that his level of pain had dropped from a preop level of 8/10 to 1/10.His range of movement had also increased by an average of 50%.He was quite happy to return to work at that stage.

Examination

Active elevation of the shoulder away from the body was severely restricted to less than 20 degrees!Specific testing of the supraspinatus tendon revealed marked pain and weakness.There were also very clear signs of a secondary frozen shoulder being present.

Special Investigations

X-rays were normal and an ultrasound done in the rooms confirmed a tear of the supraspinatus tendon with 2cm retraction. An MRI scan was done which identified a large tear of the supraspinatus tendon.More importantly no other pathology was identified,especially fractures of the glenoid.

Treatment Options

Due to the presence of a frozen shoulder, an intra-articular injection of cortisone was given to relief the symptoms. This did help significantly but it was quite clear that the tendon would need to be repaired operatively. Father McB was very happy to go ahead with this.

Operations

Under general anaesthetic Father McB was placed in the “beach-chair position” and an arthroscopy performed. The presence of the tear was confirmed and a plan made to repair it. A standard arthroscopic subacromial decompression was performed. The greater tuberosity was prepared for the attachment of the torn tendon, which was fixed down onto the bone with 3 bone anchors. A secure fixation was achieved.

Postoperative Course

Father McB noticed an immediate reduction in pain and was discharged the day after the operation. He wore a sling for 6 weeks after the operation and has been receiving physiotherapy twice weekly since the operation.

Examination

As expected,a full range of movement was demonstrated and tests for rotator cuff pathology were negative. However, all tests for anterior instability were strongly positive, suggesting a possible Bankart lesion.

Special Investigations

An ultrasound done in the rooms did not demonstrate any tears of the rotator cuff tendons or Hill-Sachs lesion. An MRI/CT scan was organised to assess for the presence of a possible glenoid bony lesion anteriorly and this was,in fact,found!No other abnormalities of the cuff or labrum were found.

Treatment Options

These were discussed at length and although a condition such as this could be managed nonoperatively, given that Mr F.P.was only 16 and wanted to continue with rugby,an operation was advised. Operations for recurrent dislocations are divided into 2 broad categories:

1. Arthroscopic soft tissue procedures were reserved for soft tissue problems
2. Open bony procedures were reserved for “bony” problems – as seen in Mr F.P.

Opertaions Details

Under a general anaesthetic.Mr F.P. was placed in the supine position.Via a deltopectoral approach, the glenoid was exposed after reflecting the tendon of sugscapularis off the capsule of the glenohumeral joint. The coracoid was then transected at its base, and along with its muscle attachments it was transported to the anterior neck of the glenoid,where it served to reconstitute the missing part of the glenoid.The joint capsule is then reattached to the glenoid,by means of bone anchors.

Postoperative Course

Mr F.P. was discharged the following day and a sling worn for 3 weeks.Physiotherapy was arranged twice a week for 6 weeks.A full range of movement was achieved at 6 months, at which time rugby was slowly recommenced.

Examination

As is always the case,the neck was examined first. This did not reveal any abnormalities.There was a full,painfree range of movement and all the tests for brachial plexus and thoracic outlet pathology were negative. The shoulder itself demonstrated a range of movement approximately 90% of the other side and all tests for rotator cuff pathology were negative.

Special Investigations

Ultrasound examination done in the rooms did not demonstrate any tears of the rotator cuff tendons. Recent x-rays revealed all the signs of severe glenohumeral joint(GHJ) arthritis,namely joint irregularity and narrowing with subchondral cysts and sclerosis. An axial CT scan was done to futher evaluate the glenoid. In particular, the glenoid needs to be 15mm “deep” to accommodate the keel of the glenoid prosthesis when a total shoulder replacement is done. The slope of the glenoid is also evaluated to allow the prosthesis to be placed in the correct version, thereby averting the possibility of dislocation in the postoperative period.

Diagnosis and further treatment

A diagnosis of grade 4 GHJ osteoarthritis was made and all treatment options discussed with Mrs S.R. and her husband.All in all,she elected to have the shoulder replaced i.e.a. Total Shoulder Replacement.This was scheduled 3 weeks later.

Operation Details

Under a general anaesthetic in the supine position, the shoulder was approached via a deltopectoral incision.The axillary nerve was then identified by means of a nerve stimulator.The joint was entered after dividing the tendon of subscapularis.After presenting the humeral head,all osteophytes were removed and the head was resected anatomically.The correct-fitting humeral prosthesis was then ascertained. After this the glenoid was prepared to accept the glenoid prosthesis. Both prostheses were cemented in. Standard closure with a drain was done.

Postoperative Course

Mrs S.R.recovered very quickly from the effects of the anaesthetic and was discharged after 2 nights in hospital.An x-ray was taken prior to discharge which showed the prosthesis to be satisfactorily situated in the joint. Physiotherapy was commenced the first day after surgery and continued twice weekly until the sling was removed at 4 weeks.At that stage she reported a pain level of 1/10 compared to a preoperative level of 8/10.For the first time in nearly one year she has been able to sleep on the shoulder.

Examination

Active elevation of the affected arm was both restricted and painful. Informal strength assessment revealed marked weakness of the all rotator cuff tendons.

Special Investigations

An ultrasound done in the rooms revealed complete disruption of all the rotator cuff tendons. An MRI scan was done to further assess the size of the tear as well as the quality of the muscles. An overall assessment regarding the “repairability” of the tendons was made.MRI findings revealed severe muscle wasting and large tears of all the rotator cuff tendons, suggesting the problem was longstanding and not primarily from the injury 3 days ago.

Treatment Options

Given the severity of her symptoms as well as the MRI findings, the chances of conservative treatment proving successful was exceedingly unlikely. All treatment modalities were discussed with the patient and it was finally agreed that an operation was necessary to provide effective pain relief.

Operations Details

Mrs V.M. was given a general anaesthetic and placed in the “beach-chair”position.An arthroscopy of the shoulder was done,which confirmed the preoperative diagnosis of irrepairable rotator cuff tears. The scope was withdrawn and a standard deltopectoral incision performed. The tendon of Pectoralis Major was dissected off its attachment to the humeral shaft and the muscle belly freed to allow adequate excursion of the tendon. The deep surface of the conjoint tendon was dissected free to allow the passage of Pectoralis Major. Care was taken not to damage the mucculocutaneous nerve. The lesser tuberosity was then prepared as a site where the tendon of Pec Major was attached, using 3 bone anchors.A secure fixation was achieved and routine closure performed.

Postoperative Course

Mrs V.M. was discharged 2 days later and although her arm was kept in a sling for 8 weeks, she had physiotherapy twice a week and did a number of exercises on her own at home. At 6 and 12 weeks a repeat ultrasound was done and on both occasions, the new tendon was shown to be healthy and growing onto the bone. Most importantly Mrs V.M. pain level had dropped precipitously from a preop level of 8 out of 10 to a postop level of 1-2 out of ten! Although true shoulder abduction is still limited to less than 90 degrees, she can at least wash her own hair and do her own toileting for the first time since the injury.

Examination

Revealed a full range of shoulder movements, but all rotator cuff tests were strongly positive.Specific strength testing of the supraspinatus tendon demonstrated weakness.An ultrasound was therefore done,which did not show any obvious tears of the rotator cuff.

Diagnosis

Given the history of having previously responded to 2 subacromial injectiuons, combined with positive rotator cuff signs,a diagnosis of a partial bursal sided rotator cuff tear was made.This was confirmed at operation.

Treatment

All treatment options were discussed and together it was decided that operative repair was the best method of achieving lasting relief.The operation was performed arthroscopically on Jan 27 2002.Here the tear was repaired with 2 arthroscopic anchors attached to sutures holding the tendon together.

Results

Significant pain relief was noticed immediately after the operation, and after referral to physiotherapy 3 days after surgery,a gradual return to full range of movement was made by 8 weeks postoperatively. A repeat ultrasound was done 6 weeks after surgery and this confirmed that the tendon had healed onto the greater tuberosity.