The purpose of this paper is to discuss sternal instability a problem occasionally associated with midline sternotomy, including the etiology, predisposing conditions, diagnosis and management. Among the methods of repair, sternal weaving and pectoralis muscle advancement are thought to be especially effective.

We have studied the long-term results of core decompression as the sole treatment for Ficat stages I, II and III ischaemic necrosis of 128 femoral heads in 90 patients. The 5-, 10-and 15-year survival rates for the three stages were respectively: stage I 100%, 96% and 90%; stage II 85%, 74% and 66%; and stage III 58%, 35% and 23%. At a mean follow-up of 11 years (4.5 to 19), 55 hips had failed (43%). No further surgery had been needed for 88% of stage-I, 72% of stage-I! and 26% of stage-Ill hips; but despite the generally satisfactory clinical results, 56% of the hips had progressed radiographically by at least one Ficat stage. Complications of the core procedure included four fractures, all from postoperative falls, and one head perforation due to technical error. We conclude that core decompression delays the need for total hip replacement in young patients with ischaemic necrosis.

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The purpose of this study was to analyse the intermediate-term results of an arthroscopic procedure to debride and resurface the arthritic glenoid, in a middle-aged population, using an acellular human dermal scaffold. Between 2003 and 2005, thirty-two consecutive patients underwent an arthroscopic debridement and biological glenoid resurfacing for glenohumeral arthritis. The diagnoses included primary osteoarthrosis (28 patients), arthritis after arthroscopic reconstruction for anterior instability (1 patient) and inflammatory arthritis (3 patients). All shoulders were assessed clinically using the Constant and Murley score, and results graded according to Neer's criteria. Statistical analysis was performed to determine significant parameters and associations. A significant improvement (P < 0.0001) in each parameter of the subjective evaluation component (severity of pain, limitation in daily living and recreational activities) of the Constant score was observed. The Constant and Murley score increased significantly (P < 0.0001) from a median of 40 points (range 26-63) pre-operatively to 64.5 (range 19-84) at the final assessment. Overall, the procedure was considered as "successful outcome" in 23 patients (72%) and as a "failure" in 9 patients (28%). According to Neer's criteria, the result was categorized as excellent in 9 (28%), satisfactory in 14 (44%) and unsatisfactory in 9 (28%). Within the unsatisfactory group, there were five conversions to prosthetic arthroplasty. A standard magnetic resonance imaging was performed on 22 patients in the successful outcome group; glenoid cartilage was identified in 12 (thick in 5, intermediate in 1, thin in 6) and could not be identified in 10 patients (complete/incomplete loss in 5, technical difficulties in 5). Overall, five complications included transient axillary nerve paresis, foreign-body reaction to biological material, inter-layer dissociation, mild chronic non-specific synovitis and post-traumatic contusion. Dominance of affected extremity and generalized disease (diabetes, rheumatoid arthritis, generalized osteoarthritis) was associated with an unsatisfactory outcome (P < 0.05). Arthroscopic debridement and biological resurfacing of the glenoid is a minimally invasive therapeutic option for pain relief, functional improvement and patient satisfaction, in glenohumeral osteoarthritis, in the intermediate-term.

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The coracoid process forms an important part of scapular-glenoid construct and is involved in many surgical procedures on the glenohumeral joint. The unique three-dimensional orientation of each coracoid pillar makes radiographic imaging difficult. Congenital variations and minimal traumatic/iatrogenic changes in this orientation can predispose to subcoracoid impingement. We performed a quantitative and statistical analysis of the osseous anatomy of the coracoid process in 101 scapulae; the purpose was to determine the anatomical variations and gender-specific differences in the length, breadth, thickness, vertical and horizontal projections, and triplane angulations of each individual coracoid pillar. All parameters were measured in reference to the glenoid plane to ensure surgical and radiological applicability. The mean dimensions of the inferior coracoid pillar were 31.1 x 16.6 x 9.9 mm and that of the superior coracoid pillar were 41.7 x 14.2 x 8.4 mm (medial)/6.6 mm (lateral). The mean maximal harvestable coracoid length measured 19.0 mm. The mean angular orientation of the inferior coracoid pillar, with reference to the glenoid, measured 51.2 degrees (axial), 126.1 degrees (sagittal), and 134.6 degrees (coronal), and that of the superior coracoid pillar measured 146.1 degrees (axial) with an interpillar angulation of 84.9 degrees (axial). A statistically significant gender difference (P < 0.05) was found in the lengths, breadths, and projections of each coracoid pillar. We used data from this study to devise two new radiographic views (for imaging individual coracoid pillars), to calculate dimensions and orientation of internal fixation/prosthetic hardware during surgery, and conceptualize a geometric model to explain the role of measured parameters in coracoid impingement syndrome.

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Postoperative DBT impingement in the RUS may be prevented by avoiding techniques that increase the thickness of the tendon and by using a reattachment site at the proximal aspect of the tuberosity.