Short-Term Radiographic Outcomes of Bone Versus Metallic Augmented, Central Screw Type Baseplate in Reverse Total Shoulder Arthroplasty: Matched Case-Control Study.

Background: Although glenoid bone grafting and metallic augmented baseplates have demonstrated success in restoring the glenohumeral joint line in the recent literature, there remain no consensus guidelines defining the use of one versus the other. Methods: Between 2017 and 2020, 15 primary RTSA with screw-in metallically augmented glenoid baseplates were identified and 2:1 matched by age, sex, and body mass index with primary bony-augmented glenoid baseplate patients. Patients with previous glenoid implantation or fracture were excluded. Charts, routine radiographic series (Grashey, Scapula Y, Axillary lateral), and 3-dimensional computed tomography (3D CT) scans were retrospectively reviewed. Structural patient-specific metal or bony augmentation was indicated based on preoperative glenoid morphology as identified by 3D CT. Aseptic failure was identified as hardware breakage and/or shift in glenoid baseplate component position. Results: There were 45 eligible cases with mean age of 65.7 years (range 44-85 years) and 65.5 years (range 42-82 years) for the metallic-augmented and bone graft group, respectively. Correspondingly, mean follow up was 22.6 months (range 12-53 months), and 27.3 months (range 11-53 months). At latest follow up, there were no baseplate failures in the metallic augment group and 2 baseplate failures (7%) in the bone graft group at a mean of 42.5 months (range 32-53 months) postoperatively. Mean age of the bone failure group was 64.5 years (range 64-65 years). Conclusion: Contemporary reversed shoulder arthroplasty glenoid baseplate designs appear to have low incidence of failure. Further analysis is necessary to determine if a critical degree of glenoid retroversion or inclination is preferable with a specific form of augmentation. Level of Evidence: III; Retrospective Cohort Comparison.

Cementless reverse total shoulder arthroplasty implantation with humeral matchstick autograft augmentation: early radiographic outcomes.

BACKGROUND: Humeral-sided complications account for up to 21% of all revision reverse total shoulder arthroplasty (RTSA) surgeries. Stress shielding with large bulky stems can lead to proximal bone resorption per Wolff law, complicating further surgeries. Previously published studies suggest that lowering the metaphyseal implant fill ratio can lead to fewer adaptive radiographic changes and decreased bone resorption. Inspired by these studies, cementless primary RTSA implantation technique with humeral matchstick autografts was proposed to augment cementless humeral constructs, foster the use of a smaller size stem, and create primary stability of the humeral implant even in osteoporotic or in-between size medullary canals. In this study, retrospective review of this cementless RTSA technique with short-term radiographic evaluation was performed. METHODS: Forty-six nonconsecutive patients underwent primary RTSA with a short-stem cementless prosthesis (Stryker Ascend Flex) augmented by matchstick bone grafting from January to July 2020. Patient demographics were recorded, and follow-up radiographs were retrospectively reviewed to assess metaphyseal fill ratios and incidence of stress shielding at minimum 1-year follow-up. Discrepancies between templated and final stem sizes were recorded, along with all intraoperative and postoperative complications. RESULTS: Of the 46 patients originally identified, there were 5 men and 41 women with a mean age of 71 years (standard deviation [SD] 7, range 53-88). Mean templated stem size was 4 (SD 2, range 1-8), whereas the mean final implant size was 2 (SD 1, range 1-3). Mean fill ratios were 0.76 (SD 0.06, range 0.54-0.89) along the metaphysis and 0.67 (SD 0.09, range 0.49-0.83) along the diaphysis. There were no intraoperative humeral fractures from implantation. All patients were available for radiographic follow-up with a mean of 19 months (SD 8, range 12-40). There were 3 cases (7%) of proximal humeral stress shielding, with average fill ratios of 0.857 and 0.807 in the metaphysis and diaphysis, respectively. There were 3 patients (7%) who underwent revision surgeries for baseplate failure and periprosthetic humeral fracture. There were no cases of early humeral loosening. DISCUSSION: Matchstick autograft humeral augmentation is a simple, promising surgical technique with low intraoperative complication rates and good short-term radiographic outcomes. When the implant fill ratio is successfully reduced, there is a possible lower risk of humeral stress shielding. The authors believe this technique can help maximize implant stability in cementless shoulder arthroplasty and preserve humeral bone stock for future revision surgeries.

Yoke procedure as a salvage treatment option for failed reverse total shoulder arthroplasty with irreconstructible glenoid.

BACKGROUND: Glenoid bone loss is a known challenge in primary and revision reverse total shoulder arthroplasty. In severe deficiency, even placing the baseplate in alternative centerline or using an augmented baseplate may be insufficient. This study reports on the use of a soft tissue resurfacing technique using Achilles tendon allograft, coined Yoke procedure, for salvage treatment of glenoid deficient shoulder requiring reconstruction. MATERIALS AND METHODS: All patients who underwent the Yoke procedure between 2014 and 2020 by a single surgeon at a single academic center were identified and had their charts retrospectively reviewed. Demographics and surgical information were recorded. Preoperative X-rays and 3D-computed tomography scans were reviewed to classify patient glenoid types, evaluate glenoid medialization, and measure shoulder angles. Preoperative and postoperative range of motions and patient-reported outcome scores were evaluated, including anterior elevation, external rotation, internal rotation, visual analog scale, subjective shoulder value score, Simple Shoulder Test, and American Shoulder and Elbow Surgeons (ASES) scores. Postoperative radiographs and follow-up notes were reviewed to evaluate postoperative complication profiles at 1 year. RESULTS: Seven patients with a median age of 69 years (range, 54-77 years) underwent Yoke procedure and had a median 12-month follow-up (range, 9-56 months). All patients were female and had a median of 2 prior shoulder surgeries (range, 0-13). Of all the patients, the most common comorbidity was osteoporosis (6) followed by rheumatoid arthritis (3). Of the 5 patients who had previous arthroplasty, the most common indications were baseplate failure (4), followed by instability (3) and infection (3). The median visual analog scale score improved from 8 (range, 3-9) to 2 (range, 1-4). The median Simple Shoulder Test improved from 8% (range, 0%-42%) to 33% (range, 17%-83%). The median ASES score improved from 15 (range, 5-38) to 52 (range, 40-78). The median anterior elevation and external rotation improved from 20° (range, 0°-75°) to 100° (range, 40°-145°) and 10° (range, 0°-20°) to 20° (range, 0°-55°), respectively. There was no change in median internal rotation. As of the last follow-up, one patient reported postoperative complications of anterior-superior implant escape, heterotopic ossification, and scapular notching. CONCLUSION: The Yoke procedure is a promising salvage treatment that can offer patients consistent pain reduction and moderate functional improvements at short-term follow-up. In the setting of poor bone quality and severe glenoid deficiency, glenoid baseplate implantation may not be absolutely necessary for a pain-relieving, functionally acceptable outcome.

Arthroplasty as Primary Treatment for Metadiaphyseal Proximal Humerus Fractures: A Viable Alternative to Osteosynthesis for the Elderly.

Introduction: in the elderly patient population, where fracture comminution, osteoporotic fractures, and associated arthritis or rotator cuff pathologies dominate, metadiaphyseal proximal humeral fracture is a challenging subset of fractures to treat. This study reports on cementless long-stem reverse total shoulder arthroplasty (RTSA) as primary treatment of metadiaphyseal proximal humeral fractures in elderly patients. Materials & Methods: Between January 2018 and October 2021, 22 consecutive patients sustained proximal humerus fractures with metadiaphyseal extension and underwent surgery with cementless long-stem RTSA. Patients older than 60 years with minimum 1 year of clinical and radiographic follow-up were included. Patient demographics, range of motion, and patient reported outcomes [Visual Analog Scale (VAS) pain scale, Simple Shoulder Test (SST), Subjective Shoulder Value (SSV), and American Shoulder Elbow Surgeon (ASES) scores] were retrospectively collected. Postoperative X-rays were evaluated for fracture and tuberosity union. Results: There were 14 eligible patients with a median age of 71 years (range 61-91 years) and a median 13 months follow-up. At final follow-up, the median active elevation was 120° (range 80°-150°), external rotation was 40° (range 0°-50°), and internal rotation was 40° (range 0°-80°). Median VAS was 2 (range 0-8), SST was 71% (range 33%-92%), SSV was 78% (range 20-90%), and ASES was 73 (range 17-90). All patients exhibited radiographic union. There were five minor complications in three patients: postoperative neuropathy, tuberosity nonunion, scapula notching, and proximal humeral stress shielding. Conclusion: Cementless long-stem RTSA is a viable alternative to primary fracture fixation in the elderly patient population with metadiaphyseal proximal humerus fractures.

Success of staged revision reverse total shoulder arthroplasty in eradication of periprosthetic joint infection.

INTRODUCTION: Management of periprosthetic joint infection (PJI) in shoulder arthroplasty remains a challenge, with no established gold standard treatment. This study presents the unique experience of a high-volume single-surgeon, single-institution approach on staged revision reverse total shoulder arthroplasty (RTSA) for infection. The authors theorize that staged revision RTSA is an effective treatment for PJI. MATERIALS AND METHODS: Between 2013 and 2018, 38 patients underwent a staged RTSA for treatment of PJI. Patient histories were collected and classified using Cierny-Mader classification. Infection workup for all patients included radiographs, laboratory indices, and computed tomographic aspiration arthrogram. PJI was identified based on high clinical and radiographic suspicion, elevated serologic markers, and/or aspirate culture results per 2018 International Consensus Meeting Shoulder guidelines on Orthopedic Infections. All patients underwent first stage with implant removal, irrigation and débridement, and antibiotic spacer placement. Next, intravenous antibiotics were administered by infectious disease consultants for a minimum of 6 weeks. Infection workup was then repeated and, if normalized, final-stage revision commenced with antibiotic spacer removal and revision to RTSA. If indices were persistently abnormal, an additional stage of débridement and spacer placement procedure was performed. Treatment failure was defined as recurrent periprosthetic infection after final prosthesis implantation or persistently elevated indices despite adequate débridement and spacer placement. RESULTS: Mean age of the cohort was 68 (standard deviation [SD] 8.9) years and mean follow-up was 33 (SD 14) months with 34 Cierny-Mader C hosts and 4 B hosts. Patients underwent a mean of 2 (SD 1.1) previous surgeries. The staged revision protocol was successful in 34 (89.5%) patients for management of PJI. Four patients (10.5%) were considered failures with recurrent infections at a mean of 13 months (range 2-26 months) after the final RTSA implantation and underwent repeat staged revisions. Of the 34 patients who had successful infection eradication, 31 had 2-stage treatment and 3 had to undergo 3 stages. There were no treatment-associated mortalities and 10 major complications (26%), including permanent neuropathy, instability, and periprosthetic fractures. The most common cultured microorganism was Cutibacterium acnes (18%), with no polymicrobial infections detected. DISCUSSION: Although there are multiple treatment options for PJI management, staged revision remains an effective means of treatment. Although there were several patients who required an additional stage of treatment, and a significant complication rate, staged revision RTSA proved successful in the ultimate eradication of the PJI.

Prior shoulder surgery and rheumatoid arthritis increase early risk of infection after primary reverse total shoulder arthroplasty.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) has become an increasingly popular surgery for patients with rotator cuff arthropathy, unreconstructible proximal humeral fracture, and end-stage glenohumeral arthritis. The increased annual volume of RTSAs has resulted in more postoperative complications and revision rates between 3.3% and 10.1%. Postoperative infection is one of the most common complications requiring revision surgery after primary RTSA. This study assesses patient-specific risk factors for development of early infection after primary RTSA in a single high-volume shoulder arthroplasty institution. METHODS: From 2014 to 2019, 902 consecutive primary RTSAs were performed for surgical treatment of rotator cuff arthropathy, glenohumeral arthritis, inflammatory arthropathy, and/or dislocation. Excluding proximal humeral or scapula fractures, 756 cases met the inclusion criteria and had a minimum of 3-month follow-up. All surgeries were performed using the same surgical technique and received similar antibiotic prophylaxis. Age, patient demographics, medical history, smoking history, and prior ipsilateral shoulder treatment and/or surgery were recorded. Multivariable logistic regression analysis was used to determine risk factors associated with development of postoperative shoulder infection. RESULTS: Thirty-five patients did not meet minimum follow-up criteria and were lost to follow-up. Overall, of 721, 22 patients (3%) developed a postoperative ipsilateral shoulder infection. Previous nonarthroplasty surgery and history of rheumatoid arthritis were significantly associated with the development of postoperative shoulder infection. Amongst 196 patients who had previous nonarthroplasty shoulder surgery, there were 12 postoperative shoulder infections (6%) compared with those without previous shoulder surgery (10 of 525, 2%) (P = .003). Among 58 patients with rheumatoid arthritis, there were 5 postoperative shoulder infections (9%) compared with patients without rheumatoid arthritis (17 of 663, 3%) (P = .010). Patient age, gender, smoking status, history of diabetes mellitus, history of cancer/immunosuppression, and prior cortisone injection did not demonstrate significant associations with the development of postoperative infection. CONCLUSION: Prior nonarthroplasty shoulder surgery and/or rheumatoid arthritis are independently associated with the development of postoperative infection after primary RTSA. Patients who demonstrate these risk factors should be appropriately evaluated and preoperatively counseled before undergoing primary RTSA. Strong consideration should be given to avoid minimally invasive nonarthroplasty surgery as a temporizing measure to delay definitive RTSA.

Comprehensive Modified Latarjet Technique: What the Masters Taught Us.

The Latarjet surgical technique is one of the most effective and well-known techniques in the treatment of anterior shoulder instability1. The modified Latarjet technique is a history book of surgical details demonstrated by renowned masters of shoulder surgery. The procedure includes soft-tissue repair and osseous reconstruction to stabilize the glenohumeral joint in recurrent anterior instability. The procedure has been shown to have reliable success in reducing recurrent instability and minimizing risk of dislocation arthropathy2-4. DESCRIPTION: The Latarjet technique can be performed via a cosmetic axillary-based approach. The subscapularis is split horizontally without detachment as described by Neer5. The capsule is released like in a medially based T-plasty as described by Altchek et al.6. The coracoid osteotomy is performed with a 90° oscillating saw and prepared for en-face implantation as described by Edwards and Walch7. The inferior surface of the coracoid is decorticated and prepared per Molé8. Coracoid fixation is performed with two 3.5-mm cortical screws. The soft-tissue reconstruction is selectively tensioned per Warner et al.9. The capsular shift is augmented with a pants-over-vest repair per Kim et al.10. ALTERNATIVES: Nonoperative treatment in young patients with glenohumeral instability and bone loss can lead to recurrence rates as high as 87%11. Arthroscopic management with anterior capsulolabral repair and a remplissage procedure can be beneficial for patients with instability. In the setting of bone loss, arthroscopic repair is associated with failure rates as high as 75%12. RATIONALE: In the setting of glenoid and/or humeral bone loss, there is a loss of native osseous anatomy, leading to a higher risk of instability. Gerber and Nyffeler reported a >30% loss of compressive force when the vertical edge of the glenoid defect is greater than one-half of the glenoid diameter13. The Latarjet procedure is a reliable procedure that reconstructs the anterior osseous anatomy as well as the capsular laxity, restoring glenohumeral stability. When compared with arthroscopic labral repair, the Latarjet procedure is superior with more consistent improvements in functional outcomes with low risk of recurrence, even in high-risk populations of young, active athletes in contact sports2,3. EXPECTED OUTCOMES: At our institution, a total of 34 patients underwent Latarjet reconstruction as described in the present article and videos from 2013 to 2018, with a minimum follow-up of 1 year. Among these patients, the mean Single Assessment Numeric Evaluation score was 90.7 (range, 70 to 100). There were 4 cases of recurrent instability with graft fracture or resorption (11.8%). Zimmermann et al. presented a series of Latarjet reconstructions with similar functional outcomes and a recurrence rate of 11%4. Meta-analysis of long-term Latarjet studies show high rates of return to sports and successful outcomes in 86% of cases, with an 8.5% recurrence rate2. IMPORTANT TIPS: The Latarjet procedure can be consistently performed with a subscapularis-sparing approach, which minimizes adverse comorbidities.Splitting the subscapularis at the inferior one-third junction will position the surgical window directly over the bottom half of the glenoid, which optimizes coracoid implantation.A medially based T-plasty will maximize the glenoid exposure for direct coracoid implantation. Subsequently, the capsule may be shifted for capsular imbrication.Low-profile, non-bulky retractors will help to improve visualization.Adjusting the arm is a key technique in performing this surgical procedure. This adjustment will help to shift the surgical window, expose key anatomic structures, and allow a capsular shift without overtensioning. This cannot be overstated.

Complex Shoulder Girdle Stabilization Using Allograft Capsular Reconstruction and Pectoralis Major Transfer: A Case Report.

CASE: A 21-year-old woman with a history of multiple failed surgical and conservative management for recurrent involuntary shoulder instability presented with 1-year history of shoulder pain. Physical examination demonstrated intractable static anterior glenohumeral instability, deficient capsular tissue, with reducible scapular winging secondary to long thoracic nerve palsy. Allograft capsular reconstruction and open split pectoralis major tendon transfer were performed to salvage shoulder motion and stabilize her shoulder girdle. CONCLUSION: This report presents a novel repair option for intractable shoulder instability and scapular winging. Surgeons should recognize potential causes of shoulder instability and familiarize themselves with multiple stabilization techniques as potential salvage options before glenohumeral fusion.

Custom Prosthetic Reconstruction for Severe Proximal Humeral Bone Loss Status Post Infected Arthroplasty: A Case Report.

CASE: A 68-year-old male, status post revision right reverse total shoulder arthroplasty (RTSA) for periprosthetic fracture, suffered a periprosthetic joint infection necessitating 2-stage revision. Imaging revealed 8.6 cm of ipsilateral proximal humeral bone loss (PHBL) including loss of the greater and lesser tuberosities. A 2-stage revision was performed using an antibiotic spacer, followed by a custom long-stem RTSA for definitive reconstruction. Two years postoperatively, the patient had significantly improved pain and functional range of motion. CONCLUSION: Custom long-stem RTSA could serve as a potentially viable reconstructive option in patients with severe PHBL.

Clinical and radiographic outcomes of cementless reverse total shoulder arthroplasty for proximal humeral fractures.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) has demonstrated successful outcomes in the treatment of both acute and chronic proximal humeral fractures (PHFs). The traditional RTSA surgical technique uses a methyl methacrylate cemented humeral component to restore and maintain both humeral height and retroversion. However, use of humeral bone cement has been associated intraoperatively with cardiopulmonary risk, increased operative cost, and postoperatively with difficulty if revision arthroplasty is required. We report the clinical and radiographic outcomes of a completely cementless RTSA technique for PHF surgery. METHODS: Between 2013 and 2018, 60 consecutive patients underwent surgical management of a PHF with cementless RTSA. All surgical procedures were performed by a single senior shoulder surgeon using a modified deltopectoral approach and a completely uncemented RTSA technique. Fractures were defined as either acute or chronic based on a 4-week injury-to-surgery benchmark. The mean age was 67 years (range, 47-85 years). There were 18 acute and 42 chronic fractures. The mean time from injury to surgery was 2 weeks (range, 0.4-4 weeks) for acute fractures and 60 months (range, 1-482 months) for chronic fractures. We excluded 17 cases from postoperative evaluation because of revision and/or loss to follow-up. The remaining 43 cases underwent clinical and radiographic evaluation by 2 independent fellowship-trained shoulder surgeons at a mean of 21 months (range, 10-46 months) postoperatively. Independent statistical analysis was performed using the paired t test and Wilcoxon signed rank test. RESULTS: At final review, mean active anterior elevation was 157° (range, 100°-170°); active external rotation, 52° (range, 6°-80°); and active internal rotation, 66° (range, 0°-80°). Improvements were seen in the visual analog scale pain score (from 6 to 0.2, P < .001), Simple Shoulder Test score (from 9 to 93, P < .001), American Shoulder and Elbow Surgeons score (from 19 to 91, P < .001), and Single Assessment Numeric Evaluation score (from 21% to 89%, P < .001). Overall, 39 of 43 greater tuberosities (91%) demonstrated osseous healing to the humeral shaft. No significant differences in clinical and radiographic outcomes were found in acute vs. chronic cases, as well as cases with minimum follow-up of 1 year vs. 2 years. Overall, there were 4 major complications necessitating surgical revision (6.7%) and no cases of aseptic humeral stem loosening. CONCLUSION: Cementless RTSA for acute and chronic PHFs demonstrates clinical and radiographic outcomes similar to those after traditional cemented RTSA. The successful greater tuberosity healing and absence of humeral stem loosening in this short-term cohort are encouraging for the continued long-term success of this technique. By avoiding cemented humeral implants, surgeons may minimize intraoperative complications, operative cost, and postoperative revision difficulty.

Latissimus Dorsi Myotendinous Repair with Allograft Hamstring Tendon Graft Augmentation: A Case Report.

CASE: A 30-year-old male weightlifter presented after suffering a myotendinous rupture of his latissimus dorsi from heavy weightlifting. Latissimus dorsi injuries are rare, with little to no documented technique in the literature on management, particularly of ruptures through the myotendinous junction of the anatomical muscle. This case report describes the surgical technique, approach, and postoperative management of an acutely avulsed latissimus dorsi using an allograft hamstring tendon to repair the myotendinous junction. CONCLUSION: Allograft hamstring tendon graft augmentation is a viable repair option for patients with latissimus dorsi myotendinous rupture.

Editorial Commentary: Don't Be Superficial in Life or When It Comes to Delaminated Rotator Cuff Tear Repair.

All rotator cuff tears are not created equal, and when it comes to delaminated tears, it is vital to identify, reduce, and anatomically repair the articular side. Regardless of technique, repair of the articular layer of the cuff is crucial to a tension-free construct anatomic reduction of the articular side of the cuff, and its associated superior capsule is the ultimate "biologic" superior capsular reconstruction.

Is there a difference in clinical outcomes and repair integrity between arthroscopic single-row versus transosseous (anchorless) fixation? A retrospective comparative study.

BACKGROUND: Few studies have investigated clinical and structural outcomes after transosseous (TO) repair. The purpose of this study was to compare structural and clinical outcomes of rotator cuff tear, repaired arthroscopically, with a single row (SR) or transossoeus (TO) anchorless technique. METHODS: 96 patients who underwent an arthroscopic repair for superior or posterosuperior rotator cuff tear using TO (n:54) or a SR (n:42) were retrospectively enrolled in this study after evaluation of clinical and surgical notes. Functional evaluation was performed with the adjusted Constant score, and American Shoulder and Elbow Surgeons (ASES) score. Postoperative cuff integrity was determined through MRI study. RESULTS: Patients were recalled after a minimum follow-up of two years. All the patients were available for the study. In the SR group the Constant rating system showed a significant improvement from a preoperative average rating of 44.8 to an average of 85.7. In the group of TO repair the Constant rating system showed a significant improvement from a preoperative average of 46.1 to an average of 87.6 postoperatively. According to ASES index scores, the average total score improved from 42.8 to 92.0 in the anchor group and from 40.4 to 94.6 in the TO group. There was no statistical difference between the two groups about clinical outcomes. Postoperative MRI revealed no differences in term of complete re-tears between the two techniques. In the SR group at MRI we observe significant more cases of rotator cuff with a Sugaya type III healing. CONCLUSIONS: Arthroscopic rotator cuff repair yielded successful clinical outcomes using SR and TO technique. However using the TO technique we saw less type 3 Sugaya readings on MRI suggesting a possible benefit with TO repair. LEVEL OF EVIDENCE II: Retrospective study.

Open capsular and ligament reconstruction with semitendinosus hamstring autograft successfully controls superior and posterior translation for type V acromioclavicular joint dislocation.

PURPOSE: Appropriate surgical management for type V complete acromioclavicular (AC) joint dislocation remains controversial. The purpose of this paper is to retrospectively report the clinical and radiographic outcomes of an open surgical technique consisting for AC joint ligamentous and capsular reconstruction using autologous hamstring tendon grafts and semi-permanent sutures. METHODS: Between January 2005 and December 2011, 32 consecutive patients with symptomatic type V complete AC joint dislocation underwent surgical treatment using the same technique. The median time from injury to surgery was 45 days (range 24-90). The average median postoperative clinical and radiographic follow-up time was 30 months (range 24-33). Clinical outcomes measures included the ASES score, the visual analog score (VAS), and subjective patient satisfaction score. Minimum follow-up was 2 years. RESULTS: ASES score increased from a median of 38.2 ± 6.2 preoperative to 92.1 ± 4.7 postoperatively (p ≤ 0.05). The median VAS score improved from 62 mm (range 45-100 mm) preoperatively to 8 mm (range 0-20 mm) at final follow-up (p ≤ 0.05). No patient experienced pain or discomfort with either direct palpation of the AC joint or with cross-body adduction. Final radiographs demonstrated symmetric AC joint contour in 25/32 (78%) patients. Seven patients (22%) radiographically demonstrated superior translation of the distal clavicle relative to the superior margin of the acromion but less than 50% of the clavicular width. 30/32 patients (93%) were able to return to their pre-injury level of work and sports activities. CONCLUSIONS: This novel surgical technique using a free graft and braided suture for simultaneous coracoclavicular ligament and AC joint capsular reconstruction successfully controls superior and posterior translations after type V AC joint dislocation and minimizes the incidence of persistent postoperative AC joint subluxation. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Massive irreparable rotator cuff tear and associated deltoid tear. Does the reverse shoulder arthroplasty and deltoid repair be a possible option of treatment?

BACKGROUND AND PURPOSE: Rupture of the anterior and middle deltoid muscle associated with rotator cuff tear arthropathy (RCA) could result in a definitive loss of shoulder function. The purpose of this study was to evaluate clinical outcomes after a concomitant reverse shoulder arthroplasty (RSA) and deltoid repair under these circumstances. MATERIALS AND METHODS: Between 2006 and 2012, 18 consecutive patients with a mean age of 69.7 years, affected by massive irreparable rotator cuff tear and associated dehiscence or rupture of anterior and middle deltoid muscle underwent this operation through a modified anterosuperior approach. Four patients referred a previous shoulder surgery and deltoid tear was iatrogenic. The other 14 cases had an attritional deltoid tears. The average follow-up was 64 months (range 25-121 months). RESULTS: The mean active anterior elevation passed from a preoperative mean of 53 ± 9.1 (range 45-70) to 132.7 ± 11.6° (85-155°), active external rotation passed from a preoperative mean value of 22.4 ± 3.6° (range 18-26) to an average of 33.7 ± 4.7° (range 30-40°). Mean Constant score increased from 42 ± 6.1 (range 31-51) pre-operatively to 72.3 ± 8.2 (range 57-82) post-operatively. At final review, deltoid contour subjectively was satisfactory to all patients with no palpable defects. CONCLUSION: RSA associated with a repair of deltoid tear could be a viable surgical option in cases of tear involving the anterior and middle deltoid associated with a RCA. Patient with a preoperative chronic axillary nerve neuropathy associated with a deltoid muscle tear should be cautioned about the possibility of lower functional outcomes.

Midterm clinical outcomes following arthroscopic transosseous rotator cuff repair.

PURPOSE: Arthroscopic transosseous (TO) rotator cuff repair has recently emerged as a new option for surgical treatment of symptomatic rotator cuff tears. Limited data is available regarding outcomes using this technique. This study evaluated midterm clinical outcomes following a novel arthroscopic TO (anchorless) rotator cuff repair technique. MATERIALS AND METHODS: A consecutive series of 107 patients and 109 shoulders underwent arthroscopic TO (anchorless) rotator cuff repair for a symptomatic full-thickness tear. Pre and postoperative range of motion (ROM) was compared at an average of 11.8 months. Postoperative outcome scores were obtained at an average of 38.0 months. Statistical analysis was performed to compare pre and postoperative ROM data. Univariate analysis was performed using Student's t-test to compare the effect of other clinical characteristics on final outcome. RESULTS: Statistically significant improvements were noted in forward flexion, external rotation and internal rotation (P < 0.0001). Average postoperative subjective shoulder value was 93.7, simple shoulder test 11.6, and American Shoulder and Elbow Surgeons (ASES) score 94.6. According to ASES scores, results for the 109 shoulders available for final follow-up were excellent in 95 (87.1%), good in 8 (7.3%), fair in 3 (2.8%), and poor in 3 (2.8%). There was no difference in ROM or outcome scores in patients who underwent a concomitant biceps procedure (tenodesis or tenotomy) compared with those who did not. Furthermore, there was no significant difference in outcome between patients who underwent either biceps tenodesis or tenotomy. Age, history of injury preceding the onset of pain, tear size, number of TO tunnels required to perform the repair, and presence of fatty infiltration did not correlate with postoperative ROM or subjective outcome measures at final follow-up. Two complications and four failures were noted. CONCLUSIONS: Arthroscopic TO rotator cuff repair technique leads to statistically significant midterm improvement in ROM and satisfactory midterm subjective outcome scores with low complication/failure rates in patients with average medium-sized rotator cuff tears with minimal fatty infiltration. Further work is required to evaluate radiographic healing rates with this technique and to compare outcomes following suture anchor repair. LEVEL OF EVIDENCE: Level IV.

Long stem reverse shoulder arthroplasty and cerclage for treatment of complex long segment proximal humeral fractures with diaphyseal extension in patients more than 65 years old.

INTRODUCTION: Treatment of long segment proximal humeral fractures with extension below the surgical neck into the diaphysis remains a significant challenge for orthopaedic surgeons. The purpose of this paper was to evaluate the clinical and radiological outcomes following primary long-stem RSA with cerclage fixation for complex long segment proximal humeral fractures with diaphyseal extension in patients more than 65 years old. MATERIAL AND METHODS: Between February 2010 and March 2013, 22 patients who suffered a complex proximal humerus fracture with extended diaphyseal involvement underwent surgery with long-stem RSA and cerclages fixation. There were 17 female and 5 male patients, and the mean age was 77.2 years at time of surgery (range 65-84 years). All patients had a 3 or 4-part proximal humerus fracture or a two part fracture with a split of humeral head, with extension to the proximal diaphysis. Clinical and radiographic follow-up was performed on all 22 patients at 6 weeks, at 3, 6, and 12 months postoperatively, and then at 2 years. Clinical evaluation consisted of the shoulder rating Constant scale. X ray evaluation was done to evaluate fracture healing and eventually humeral and glenoid component loosening or other complications. RESULTS: No infections were reported, neither other serious complications. Two patients developed a seroma and one patient developed chronic pain at that was treated with referral to pain management. No patients were lost at follow-up. At final follow-up, average active elevation was 132.5° (range 100°-140°), external rotation 30° (range 55°-10°). Average abduction was 120° (range 90°-135°). The mean adjusted Constant score was 72/100 (range 64-82). All fractures were healed within 3 months after surgery. No loosening of the humeral or glenoid components and no episodes of dislocation/instability were observed in this series. We did not observe scapular notching in any patient on the x-ray at most recent follow-up. CONCLUSION: Long-stem RSA with cerclages wire fixation represents a viable treatment option for complex long-segment displaced proximal humerus fractures with diaphyseal extension in patients older than 65 years. Our results suggest clinical outcomes at two years of follow up are satisfactory with an acceptable complication rate.

Reverse shoulder arthroplasty for proximal humerus fracture using a dedicated stem: radiological outcomes at a minimum 2 years of follow-up-case series.

BACKGROUND: Complex proximal humeral fractures are very difficult to treat particularly in patients older than 65 years with an osteoporotic bone and tuberosities compromised. The goal of this paper is to evaluate radiological outcomes at mid-term follow-up of proximal humerus fractures treated with reverse shoulder arthroplasty using a dedicated fracture stem. MATERIALS AND METHODS: The study population included 98 patients who underwent reverse shoulder with a dedicated fracture stem for an acute proximal humerus fracture; 87/98 patients were available for analysis. There were 62 female and 25 male patients, and the mean age was 76.2 years at the time of surgery (range 61-90 years). Clinical and radiological outcomes were evaluated at a mean follow-up of 27 months after surgery. RESULTS: Average active elevation was 137.7°, external rotation 29.1°, and internal rotation 40.7°. Overall, the tuberosity healing rate was 75 %. There was a significant increase in active anterior elevation, external rotation, and internal rotation among patients who demonstrated radiographic evidence of tuberosity healing. All tuberosity nonunions (21 cases) occurred preferentially in females, but this number did not reach statistical significance. CONCLUSION: RSP using a dedicated stem is a very viable solution to treat complex humerus proximal fracture. Reliable restoration of elevation can be expected. However, in patients in whom tuberosity healing occurs, a better active elevation other than restoration of active rotational movement can be observed.

Complications of shoulder arthroscopy.

Over the past 20 to 30 years, arthroscopic shoulder techniques have become increasingly popular. Although these techniques have several advantages over open surgery, surgical complications are no less prevalent or devastating than those associated with open techniques. Some of the complications associated with arthroscopic shoulder surgery include recurrent instability, soft-tissue injury, and neurapraxia. These complications can be minimized with thoughtful consideration of the surgical indications, careful patient selection and positioning, and a thorough knowledge of the shoulder anatomy. Deep infection following arthroscopic shoulder surgery is rare; however, the shoulder is particularly susceptible to Propionibacterium acnes infection, which is mildly virulent and has a benign presentation. The surgeon must maintain a high index of suspicion for this infection. Thromboemoblic complications associated with arthroscopic shoulder techniques are also rare, and studies have shown that pharmacologic prophylaxis has minimal efficacy in preventing these complications. Because high-quality studies on the subject are lacking, minimal evidence is available to suggest strategies for prevention.