The current standard of the shoulder trauma series in Ireland - A national audit.

OBJECTIVES/AIMS: The primary aim of this study was to assess the current standard of shoulder radiographs in Ireland. The secondary aim of this study was to determine whether orthopaedic surgeons in Ireland are of the opinion that a national protocol is required, and what this protocol should consist of. METHODS: A national audit of shoulder trauma series x-rays performed in emergency departments was conducted. The number and type of views performed was recorded. The anteroposterior (AP) and axillary or Velpeau views were assessed to determine if they met pre-defined audit criteria. Consultant orthopaedic surgeons working in public trauma hospitals were invited to participate in an online survey by email. RESULTS: The number of shoulder trauma series included in this audit was 789. The majority of patients had two views performed (75.92%, n â€‹= â€‹599) and 21.17% (n â€‹= â€‹167) had an axillary or Velpeau view. The AP view met the audit criteria in 23.09% (n â€‹= â€‹181) of cases. The survey response rate was 70.8% (n â€‹= â€‹17). 88.2% (n â€‹= â€‹15) of surgeons agreed that three views should be performed for a shoulder trauma series and 94.12% (n â€‹= â€‹16) agreed that an axillary or Velpeau view should be included. The majority of surgeons surveyed (94%, n â€‹= â€‹16) are in favour of establishing a national protocol. CONCLUSION: The current standard shoulder trauma series in Irish hospitals consists of two views, most frequently a thoracic AP and a scapular Y view. We propose the introduction of a national protocol consisting of three views: Grashey AP, Scapular Y, and an axillary or Velpeau view.

Arthroscopic approach does not yield better results than open surgery after subscapularis repair: a systematic review.

PURPOSE: This study aimed to compare the long-term outcomes of arthroscopic versus mini-open repair in patients with isolated subscapularis tendon tears. METHODS: Google Scholar, PubMed, and Embase databases were searched for studies evaluating isolated subscapularis tears subsequently treated by arthroscopic or mini-open repair. The inclusion criteria were clinical studies reporting isolated subscapularis lesions treated by arthroscopic or mini-open repair, a minimum follow-up of 12 months, and clinical and functional outcomes reported in the study results. Articles not reporting functional outcomes or studies that reported results for anterosuperior rotator cuff tears without a separate analysis of subscapularis tendon tears were excluded. Studies older than 20 years and studies with a minimum follow-up of less than 12 months were also excluded. RESULTS: A total of 12 studies met the inclusion criteria; 8 papers were included in the arthroscopic repair group, and 6 were included in the mini-open repair group (2 studies reported results for both techniques). The mean age reported was 49.3 years, and 85.1% of patients were male. The dominant limb was involved in 77.6% of the patients, and a traumatic onset of symptoms was verified in 76.3%. The mean time to surgery was 9.6 months. The Constant-Murley score showed positive results for the arthroscopic and mini-open groups, with mean postoperative values of 84.6 and 82.1, respectively. Promising results were also observed for pain, with a mean of 13.2 (out of 15) points for the arthroscopic group and 11.7 for the mini-open group. The long head of the biceps was involved in 78% of the patients, and LHB tenodesis or tenotomy were the most common concomitant procedures performed. CONCLUSIONS: There was no significant difference in clinical and functional outcomes between open and arthroscopic repair. Moreover, the same complication rates were reported in both treatments, but arthroscopic repair led to less postoperative pain. LEVEL OF EVIDENCE: IV.

Two-year clinical and radiographic outcomes following uncemented reverse shoulder replacements for proximal humerus fractures.

BACKGROUND: Uncertainty remains regarding the role and long-term outcomes following uncemented reverse shoulder replacements (RSRs) in managing displaced proximal humeral fractures (PHFs). Although RSRs for trauma have traditionally undergone cemented fixation of the humeral component, there is increasing interest in uncemented RSRs. Our primary aim was to evaluate 2-year outcomes following uncemented RSR fixation for 3- and 4-part PHFs in the elderly. A secondary aim was to evaluate if timing of surgery affected outcomes. METHODS: This cohort series evaluated 2-year outcomes for 42 patients with Neer 3- and 4-part PHFs treated with uncemented RSRs between October 2016 and December 2019. Thirty-eight patients (90%) had clinical and radiologic follow-up at a minimum of 2 years. The primary outcomes compared postoperative range of movement, radiographic outcomes, and patient-reported outcome measures (PROMs). The PROMs collected included Oxford Shoulder Scores (OSSs), satisfaction scores, and the Friends and Family Test. The secondary outcome involved a subanalysis to see if outcomes were affected by treatment timing-within 2 weeks, 2-12 weeks, and >12 weeks. RESULTS: The mean age of patients was 74.1 years (range 58-89). There were 11 males and 31 females. No intraoperative fractures were sustained. There was 1 transient axillary neurapraxia, which fully resolved by 4 months. Three patients required postoperative transfusions. During the study follow-up period, no patients developed either deep infections requiring a washout or dislocation, and none underwent further surgery. At 2-year follow-up, radiologic follow-up demonstrated tuberosity union in 29 of 38 cases (76%). Eight of 38 patients (21%) demonstrated some glenoid notching (Sirveaux 1 or 2 only) on radiographic follow-up. There was no evidence of loosening. The mean OSS was 38 (range 15-48). Mean range of movement achieved at 2 years was as follows: forward flexion 122° (50°-180°), abduction 116° (46°-180°), and external rotation 25° (range 5°-60°). Eighteen patients (47%) described their result as excellent, 17 (45%) as good, and 3 (8%) as poor. When comparing the time from injury to treatment, there was no statistically significant difference in complications or radiographic outcomes between the groups. Patients had a reduced forward flexion when treated between 2 and 12 weeks compared with the other groups (P = .019). CONCLUSION: Uncemented RSR is a safe treatment option for the management of complex PHFs in the elderly. We report low complication rates, high patient satisfaction, and good outcomes at 2-year follow-up.

Three Years of COVID-19 on Orthopaedic Trauma; Are We Going Back to Normality?

Background and Objective: On March 2020, our country became a protected area due to the COVID-19 pandemic. The consequences of COVID-19 on trauma surgery were great. We aimed to evaluate the activity of the Trauma Centre of a highly populated suburban area over 30 days starting from the first day of restrictions, to compare it with the same period of 2019 and 2022 and to evaluate whether a progressive return to normality has taken place. Materials and Methods: All patients older than 18 years managed in our Trauma Unit between 8 March 2020 and 8 April 2020 (the first COVID-19 period) were compared to the same period of 2019 (a COVID-19 free period) and 2022 (the second COVID-19 period). Clinical records were examined. Five categories of diagnoses and six mechanisms of injury were distinguished. Results: There were 1351 patients [M:719-F:632; mean age (SD):49.9 (18.7)], 451 [M:228-F:223; mean age (SD):55.9 (18.4)] and 894 [M:423-F:471;mean age (SD):54.1 (16.7)] in the COVID-19 free and in the first and second COVID-19 periods, respectively (p < 0.05). In 2020, the most significant decrease was registered for sprains/subluxations (80%); contusions decrease by 77% while fractures decrease only by 37%. The lowest reduction was found for dislocations (26%). In 2022, dislocations decreased by only 16% and both fractures and sprains decreased by about 30% with respect to the pre-pandemic period. Patients with minor trauma (contusions) were half compared to 2019. Accidental falls remain the most frequent mechanism of injury. The incidence of proximal femur, proximal humerus and distal radius fractures remained almost unchanged during both pre-pandemic and pandemic periods. Conclusions: COVID-19 has markedly altered orthopaedic trauma. Injuries related to sports and high energy trauma/traffic accidents drastically reduced in 2020; however, we are slowly going back to normality: the same injuries increased in 2022 due to the progressive easing of restrictions. Elderly fractures related to accidental falls remained unchanged.

A prospective randomized controlled trial comparing plating augmented with coracoclavicular fixation and hook plate fixation of displaced distal-third clavicle fractures.

BACKGROUND: Two popular methods used to treat distal-third clavicle fractures are the traditional hook plate and the anatomically contoured locking plate. No consensus exists on whether one method is more effective than the other. Therefore, the aim of this study was to compare the efficacy of a traditional hook plate with that of an anatomically contoured locking plate augmented with coracoclavicular fixation in the treatment of distal-third clavicle fractures. METHODS: Enrolled patients were randomly assigned to either the hook plate group (n = 13) or the locking plate group (n = 17). Follow-up assessments (clinical and radiologic) were performed at 6 and 12 months postoperatively. RESULTS: In both groups, union was achieved in 91% of cases at 6 months and 100% at 12 months. No differences in Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley shoulder scores were noted between the hook plate and locking plate groups at 12 months. From 6 to 12 months, DASH scores improved in the hook plate group (P = .007) and Constant-Murley shoulder scores tended to improve (P = .075). Surgical time was longer in the locking plate group than in the hook plate group (P < .001). CONCLUSION: Similar functional outcomes and union rates were achieved in both groups at 12 months postoperatively. However, the improvement in DASH scores in the hook plate group from 6 to 12 months suggests that patients treated with an anatomically contoured locking plate make a quicker recovery than patients treated with a hook plate.

Analysis of early and late clinical and radiologic complications of proximal humeral fractures using open reduction, internal fixation, and intramedullary titanium cage augmentation.

BACKGROUND: An intramedullary augmentation technique using a titanium cage with different types of hardware can be considered a new option in the management of proximal humeral fractures. This study aimed to report the perioperative, early, and late complications of proximal humeral fractures using the intramedullary augmentation technique. METHODS: From 2005 to 2017, 142 displaced proximal humeral fractures were treated in the same unit by the aforementioned technique. Perioperative, early, and late complications were evaluated in all patients. Clinical evaluation was performed according to the Constant and Disabilities of the Arm, Shoulder and Hand scores. Only 115 patient records could be considered to have long-term follow-up (7-12 years). RESULTS: Extra-articular migrations of K-wires, plate cutout, and screw penetration were not observed. A transitory axillary nerve palsy with inferior humeral head subluxation was observed in 41 patients (29.8%). Of the 142 patients, 2 (1.4%) manifested early signs of infection, and 1 underwent a reoperation after 30 days. Complete bone healing was obtained at a mean of 3.5 months in 140 of 142 shoulders (98.6%). We achieved long-term follow-up on only 115 patients because 14 had died, 6 lived abroad, and 7 could not participate due to illness. The results were good or excellent in 99 patients (86%), fair in 12 (10.4%), and poor in 4 (3.4%). K-wires were removed in 15 of 79 patients (11.5%). Nonunion or malunion occurred in 1 patient (0.8%). Asymptomatic avascular necrosis developed in 8 patients (6.9%) after 5 years, and secondary glenohumeral osteoarthritis occurred in 6 (5.2%). CONCLUSIONS: Intraoperative and postoperative analyses with short-, medium-, and long-term outcomes show that the intramedullary augmentation technique improves fracture treatment with significantly good anatomic reconstruction in complex and unstable cases. The bone healing rate is significantly high, and the technique is associated with a significantly low percentage of complications.

The impact of COVID-19 on shoulder and elbow trauma: an Italian survey.

BACKGROUND: Because of the rapid spread of COVID-19, on March 8, 2020 Italy became a "protected area": people were told not to leave their homes unless it was essential. The aim of this study was to evaluate the activity of our trauma center, relative to shoulder and elbow, in the 30 days starting from March 8, 2020, the first day of restrictions in Italy, and to compare it with the same days of 2019 to weigh the impact of COVID-19 on shoulder and elbow trauma. MATERIALS AND METHODS: Patients managed in our trauma center between March 8, 2020, and April 8, 2020 (COVID period), for shoulder and elbow trauma were retrospectively included and compared to patients admitted in the same period of 2019 (no-COVID period). Clinical records of all participants were examined to obtain information regarding age, sex, mechanism of injury, and diagnosis. RESULTS: During the no-COVID period, 133 patients were admitted for a shoulder or elbow trauma; in the COVID period, there were 47 patients (65% less first aid). In the no-COVID and COVID period, patients with shoulder contusion totaled 60 (14.78% of all; male [M]: 34; female [F]: 26; mean age 51.8 years, range 18-88) and 11 (12.09% of all contusions; M: 7, F: 4; mean age 43 years, range 24-60), respectively. In the no-COVID period, 27 fractures (9.34% of all fractures) involved the shoulder, whereas 18 fractures (8.69%) were registered in the COVID period. In the no-COVID period, 14 elbow fractures were treated (4.8% of all fractures), compared with 4 in the COVID period. In the no-COVID and COVID periods, 6 patients (M: 5, F: 1; mean age 42 years, range 21-64) and 2 patients (M: 1, F: 1; mean age 29.5 years, range 24-35) reported having a feeling of momentary post-traumatic shoulder instability, and 0 and 1 patients (M: 1, F: 0; age 56 years), respectively, reported similar symptoms at the elbow. Finally, first or recurrent dislocations in the no-COVID period were 10, and in the COVID period, 7; elbow dislocations in the no-COVID period were 2, and in the COVID period, there were 3. CONCLUSIONS: During the COVID period, we provided a reduced number of health services, especially for patients with low-energy trauma and for those who underwent sports and traffic accidents. However, during the COVID period, elderly subjects remain exposed to shoulder and elbow trauma due to low-energy (domestic) falls. The subsequent hospitalization of these patients has contributed to making it more difficult to manage the hospital wards that are partly occupied by COVID-19 patients.

[Simultaneous fracture of the acromion and coracoid process : Rare variant of double disruption of the superior shoulder suspensory complex]. / Gleichzeitige Frakturen von Acromion und Korakoid : Seltene Variante der doppelten Unterbrechung des "superior shoulder suspensory complex".

INTRODUCTION: Simultaneous fracture of the acromion and coracoid process represents a double disruption of the superior shoulder suspensory complex (SSSC). To date, the two largest reported series have comprised five and eight cases. The aim of this study was to investigate the functional outcome in patients who sustained this rare injury and to provide a review of the relevant literature. MATERIAL AND METHODS: In this retrospective study, patients who were surgically treated between 2009 and 2014 were identified from medical records and the patients were asked to attend a follow-up examination. Functional results, measured as the Constant score and Disabilities of the Arm, Shoulder and Hand (DASH) score, were the main outcomes of the study. RESULTS: A total of six patients underwent surgery for this type of double disruption of the SSSC. All but one patient suffered a high-impact trauma with other associated injuries. The coracoid fracture was classified as type I according to Ogawa in all cases, and the acromion fracture was type III according to Kuhn in 5 out of 6 cases. At least one of the fracture sites was stabilized. Of the patients one showed a concurrent lateral clavicle fracture, representing a third disruption of the SSSC, and another had a fracture of the medial third of the clavicle, representing a strut fracture. In these cases, two fracture sites were operated on. At an average follow-up period of 47 months all but one fracture had healed. In one patient, asymptomatic non-union of the acromion was found. The average DASH score was 22 points and the average Constant score was 74 points. CONCLUSION: This rare injury pattern is usually caused by high-impact trauma, and concomitant injuries frequently occur. Nevertheless, surgical stabilization of at least one of the fracture sites showed satisfactory functional results.

Differences in acromial morphology of shoulders in patients with degenerative and traumatic supraspinatus tendon tears.

PURPOSE: Distinct characteristics of acromial morphology seem to be one factor for the development of degenerative supraspinatus tendon tears. Thus, it is questionable whether patients with traumatic tendon tears also present these parameters. The hypothesis of the present study was that the acromial morphology of patients with degenerative supraspinatus tendon tears differs from patients with traumatic tears. METHODS: One hundred and thirty-six patients that were treated by arthroscopic rotator cuff repair from 2010 to 2013 were included in this study. Seventy-two patients had degenerative (group 1), and 64 had traumatic (group 2) supraspinatus tendon tears. On preoperative radiographs the Bigliani type, acromial slope, acromiohumeral (AH) distance, lateral acromial angle (LAA), acromion index (AI), and critical shoulder angle (CSA) were measured. Medians of these parameters as well as of age of both groups were compared using the t test. RESULTS: The percentaged distribution of the Bigliani type differed (group 1 vs. 2: type 1: 18/38, type 2: 56/55, type 3: 26/8). All parameters showed significant differences between degenerative and traumatic tears. Slope: 21.2° (SD 7.6°) versus 19.2° (SD 7.9°, p = 0.026), AH distance: 8.4 mm (SD 2.3 mm) versus 9.9 mm (SD 1.9 mm, p = 0.0006), LAA: 77.0° (SD 4.0°) versus 82.5° (SD 4.7°, p < 0.0001), AI: 0.77 (SD 0.07) versus 0.73 (0.06, p = 0.0239), and CSA: 36.8° (SD 3.6°) versus 35.3° (SD 2.9°, p = 0.007). An LAA <70° or an AH distance of <5 mm only occurred in degenerative tears. Patients with degenerative tears were significantly older (60 vs. 54 years). CONCLUSIONS: The hypothesis that the acromial morphology of patients with degenerative supraspinatus tendon tears differs from patients with traumatic tears was confirmed. Shoulders with degenerative tears show a narrower subacromial space and a larger lateral extension as well as a steeper angulation of the acromion than with traumatic tears. Thus, the results of this study support the theory of external impingement as a cause for degenerative rotator cuff tears. LEVEL OF EVIDENCE: IV.

Moderate value of non-contrast magnetic resonance imaging after non-dislocating shoulder trauma.

PURPOSE: The purpose of the present study was to determine the value of shoulder magnetic resonance imaging (MRI) obtained in the community setting interpreted by musculoskeletal radiologists in patients with shoulder pain initiated by a single non-dislocating shoulder trauma. METHODS: In 56 of 61 consecutive patients who underwent shoulder arthroscopy due to pain after a single non-dislocating shoulder trauma, the data sets of non-contrast MRI were complete. These were retrospectively interpreted by three radiologists specialized on musculoskeletal MRI who were blinded for patients' history and who did not have access to the reports of arthroscopy. Standard evaluation forms were used to assess the MRIs for superior labrum anterior and posterior (SLAP) lesions, anterior or posterior labrum lesions, lesions of the long head of biceps tendon (LHB) and for partial tears of the supraspinatus tendon and the upper quarter of the subscapularis tendon. Quality of the MRI was assessed by each radiologist on a four-point scale. RESULTS: The pooled sensitivity for the three radiologists for the detection of SLAP lesions was 45.0 %, for anterior or posterior labrum tears 77.8 and 66.7 %, for lesions of the LHB 63.2 % and for partial tears of the supraspinatus or subscapularis tendon tears 84.8 and 33.3 %. Corresponding inter-rater reliabilities were poor (SLAP lesions) to substantial (anterior labrum tears). Quality of MRI only influenced the accuracy for the detection of posterior labrum tears. CONCLUSION: A non-contrast shoulder MRI obtained in the community setting after non-dislocating shoulder trauma has a moderate sensitivity for most intraarticular pathologies when interpreted by musculoskeletal radiologists. Accuracy is dependent on the observer and not on the assessed quality. LEVEL OF EVIDENCE: Case series, Level IV.

Intramedullary nailing of the proximal humerus: evolution, technique, and results.

Proximal humerus fractures are the third most common fracture in the elderly. Although most fractures can be treated conservatively with acceptable outcomes, certain fracture patterns are at high risk for progression to humeral malunions, nonunions, stiffness, and post-traumatic arthrosis. The goal of antegrade humeral nailing of proximal humerus fractures is to provide stability to a reduced fracture that allows early motion to optimize patient outcomes. Certain technical pearls are pivotal in managing these difficult fractures with nails; these include rotator cuff management, respect of the soft tissues, anatomic tuberosity position, blood supply maintenance, knowledge of the deforming forces on the proximal humerus, fracture reduction, and rehabilitation strategies. Modern proximal humeral nail designs and techniques assist the surgeon in adhering to these principles and have demonstrated promising outcomes. Humeral nail designs have undergone significant innovation during the past 40 years and now can provide stable fixation in the humeral shaft distally as well as improved stability in the head and tuberosity fragments, which were the common site of fixation failure with earlier generation implants. Compared with other fixation strategies, such as locking plate fixation, no compelling evidence exists to suggest one technique over another. The purpose of this review is to describe the history, results, new designs, and techniques that make modern intramedullary nailing of proximal humerus fractures a viable treatment option.

Reverse total shoulder arthroplasty for the treatment of proximal humeral fractures: patterns of use among newly trained orthopedic surgeons.

BACKGROUND: This study compared the use of reverse and hemishoulder arthroplasty for the treatment of proximal humeral fractures among orthopedic surgeons taking part II of the American Board of Orthopaedic Surgery board examination. We hypothesized that the use of reverse shoulder arthroplasty for fractures in the elderly is increasing amongst newly trained orthopedic surgeons. MATERIALS AND METHODS: We queried the American Board of Orthopaedic Surgery database for the cases of proximal humeral fractures treated with arthroplasty submitted between 2005 and 2012. We evaluated the prosthesis used, patient-specific factors, complications, and the difference in use by shoulder fellowship-trained surgeons. RESULTS: From 2005 to 2012, 5395 board-eligible orthopedic surgeons submitted cases to the database. Of these, 435 (mean, 54 per year) were proximal humeral fractures treated with arthroplasty. The overall incidence of reverse shoulder arthroplasty for fracture increased from 2% to 4% during 2005 to 2007 to 38% in 2012. Shoulder surgeons treated 5 times more proximal humeral fractures with shoulder arthroplasty and were also more than 20 times more likely to use a reverse implant (P < .0001). The difference in complication rates between reverse and hemishoulder arthroplasty was not significant (P = .49). Patients who received a hemiarthroplasty tended to be younger (mean age, 70.8 vs 75.7 years; P = .0015). CONCLUSIONS: Overall, the use of a hemiarthroplasty for fracture is still more common (62% in 2012), although the relative proportion of reverse implants is rising. Among shoulder surgeons, more than 50% of the arthroplasties performed for fractures during the past 3 years (2010-2012) have been reverse arthroplasties.

Neglected Superior Dislocation of the Shoulder Joint: A Case Report.

The anterior subtype of shoulder dislocations constitutes the vast majority that either reduces instantly or is reduced at the point of care with no serious complexities. The posterior ones are infrequent and inferior and superior dislocations are even more rare. Rupture of the deltoid is considered to be linked with superior dislocation; regardless, very few articles are available pertaining to the mechanism of onset and the management of a superior shoulder dislocation. In the line of traumatic shoulder dislocations, we present a one-year-old neglected case of a 23-year-old male who sustained an open injury over the right outstretched upper arm, abducted at an angle of approximately 45° due to a fall from a height of approximately 18 feet. This unique report outlines the various surgical modalities available, given the patient's late presentation due to neglect.

Comparison of clinical outcomes and complications in 2-part vs. 3- or 4-part proximal humerus fractures treated using an intramedullary nail designed to capture the tuberosities.

Background: Intramedullary nail fixation for proximal humerus fractures has been shown to provide satisfactory results. The quality of reduction correlates with clinical outcomes, the rate of complications, avascular necrosis, and postoperative loss of fixation. The purpose of this study was to evaluate the clinical outcomes and complications of 2-part proximal humerus fractures compared to 3- or 4-part proximal humerus fractures. Methods: A single-center retrospective review was carried out of patients who underwent an intramedullary nail for a proximal humerus fracture by one of three surgeons between the years of 2009 and 2022, and who had a minimum of 12-months follow-up. Fracture pattern, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, satisfaction, pain score, range of motion, and complications were recorded. The mechanism of injury (high energy vs. low energy), method of reduction (open vs. percutaneous), and evidence of radiographic healing were assessed. A P value of <.05 was considered to be statistically significant. Results: The study included 78 patients (62 female, 16 male). The number of patients in each group (2-part, N = 32 vs. 3- or 4-part, N = 46), mean age (2-part, 64 vs. 3- or 4-part,61), follow-up (2-part, 42.5 months vs. 3- or 4-part, 34.5 months), injury type (2-part, 88% low energy vs. 3- or 4-part, 78% low energy), and method of reduction (2-part, 81% percutaneous vs. 3- or 4-part 72% percutaneous) were similar among the two groups. There was fracture union in all patients. All patients demonstrated satisfactory patient-reported outcome measures. However, 2-part fractures did have a significantly lower pain score, higher Single Assessment Numeric Evaluation score, and higher percentage of patients being satisfied or very satisfied when compared to 3- or 4-part fractures. The rate of subsequent procedures was 13% (n = 4) in 2-part fractures compared to 19% (n = 9) in 3- or 4-part fractures but was not statistically significant (P = .414). The overall rate of conversion to arthroplasty was 3.2% in 2-part fractures and 10.4% in 3- or 4-part fractures. Conclusion: Multipart proximal humerus fractures remain difficult to treat. However, this study demonstrates an overall acceptable outcome with improvement in range of motion, patient-reported outcomes, and similar complication rates between 2-part and 3- or 4-part proximal humerus fractures treated with an intramedullary nail. However, the improvement in certain parameters is not as marked in 3- or 4-part fractures as 2-part fractures.

The Posterior Dislocation of the Shoulder With Reverse Hill-Sachs Lesion and Humerus Lesser and Greater Tuberosity Fracture.

Posterior shoulder dislocations are the rarest of all shoulder dislocations. They are commonly associated with seizures, electric shocks, or trauma. This case report presents a 60-year-old male with a posterior shoulder dislocation complicated by fractures of the greater tuberosity (GT) and lesser tuberosity (LT) and a reverse Hill-Sachs lesion. The patient was treated surgically using a modified McLaughlin procedure. This case highlights the importance of the early recognition and appropriate surgical management of complex posterior shoulder dislocations to prevent recurrent instability and ensure optimal functional recovery.

Glenoid Fracture Fixation Using an Acu-Loc Distal Radius Plate.

Displaced fractures of the glenoid require surgical fixation. This poses multiple problems, including a difficult approach and achieving adequate reduction with current implants. We provide a surgical technical tip for fixing scapula neck and glenoid rim fractures with an Acu-Loc distal radius plate (Acumed, Weyhill, UK), illustrated with two recent case reports. Here, we present two cases of a 58-year-old female and a 51-year-old male presenting to a hospital following a fall, both sustaining an isolated right glenoid intra-articular fracture evident on plain radiographs. CT scans revealed a displaced and fragmented glenoid surface. A reverse Judet posterior approach facilitated exposure to enable the reduction of the glenoid, an uncommon approach. Current plate designs provide surgeons with limited options to fix complex fractures of the scapula and were not suitable here. The lateral scapula border and inferior glenoid have a similar anatomical shape to the distal radius. An Acu-Loc locking distal radius plate with a radial styloid plate was trialled and provided a good reduction to the fragmented glenoid. A distal radius plate can be a useful option to consider in complex scapula neck and glenoid rim fractures. A better understanding of glenoid shape will facilitate the further development of orthopaedic implants. Familiarity with various surgical approaches is needed to operate on these complex fractures.

Arthroscopic Repair of Acute Bony Bankart Lesion Following a Shoulder Dislocation Using Traction Sutures and Anchors: A Case Description.

Management of shoulder dislocation can be challenging especially when glenoid bone fracture is involved. Bony Bankart lesion can be managed either through an open surgery or, of late, using arthroscopic technique. Arthroscopic bony Bankart repair is technically difficult, requiring specialized instruments to penetrate the bone fragment within the detached labrum. This case report describes an alternative way of doing an arthroscopic reattachment of an acute bony Bankart lesion using traction sutures, an accessory anteromedial portal and utilization of knotless anchors. A 44-year-old male technician was climbing a ladder when he slipped and fell directly on his left shoulder. Imaging revealed bony Bankart fracture with presence of ipsilateral greater tuberosity (GT) fracture and a Hill-Sachs lesion. In a right lateral position, arthroscopic reduction of the bony fragment was performed utilizing a Fibrewire® (Arthrex, Inc., Naples, FL, USA) suture as traction apparatus while securing the upper and lower tissue enveloping the bony Bankart fragment. An accessory portal was made lower down anteriorly to de-rotate the fragment, holding it in place while securing two Pushlock® (Arthrex, Inc.) anchors to the native glenoid. We then performed GT fixation using two cannulated screws. Check radiographs revealed acceptable reduction of the Bankart fragment. With careful case selection, arthroscopic repair of acute bony Bankart lesions is possible using special arthroscopic reduction maneuver and fixation technique with subsequent good outcome.

MRI findings of traumatic and degenerative rotator cuff tears and introduction of the "cobra sign".

Background: A rotator cuff tear (RCT) is a common shoulder diagnosis and its etiology may be acute, traumatic, or chronic degenerative. Differentiation between the 2 etiologies may be important for multiple reasons, but remains difficult based on imaging. Further knowledge about radiographic and magnetic resonance findings to distinguish traumatic from degenerative RCT is needed. Methods: We analyzed magnetic resonance arthrograms (MRAs) of 96 patients with traumatic or degenerative superior RCT, which were matched according their age and the affected rotator cuff muscle into the 2 groups. Patients older than 66 years of age were excluded from the study to avoid including cases with pre-existing degeneration. In the case of traumatic RCT, the time between the trauma and MRA had to be less than 3 months. Various parameters of the supraspinatus (SSP) muscle-tendon unit were assessed (tendon thickness, presence of a remaining tendon stump at the greater tubercle, magnitude of retraction, layer appearance). The retraction of the 2 SSP layers were individually measured to determine the difference of retraction. Additionally, edema of the tendon and muscle, the tangent- and kinking-sign as well as the newly introduced Cobra-sign (bulging of the distal part of the ruptured tendon with slim configuration of the medial part of the tendon) were analyzed. Results: Edema within the SSP muscle (sensitivity 13%, specificity 100%, P = .011) or the tendon (sensitivity 86%, specificity 36%, P = .014) are more frequent in traumatic RCT. The same association was found for the kinking-sign (sensitivity 53%, specificity 71%, P = .018) and the Cobra sign (sensitivity 47%, specificity 84%, P = .001). Even though not statistically significant, tendencies were observed toward thicker tendon stumps in traumatic RCT, and greater difference in retraction between the 2 SSP layers in the degenerative group. The cohorts had no difference in the presence of a tendon stump at the greater tuberosity. Conclusion: Muscle and tendon edema, as well as tendon kinking appearance and the newly introduced cobra-sign are suitable MRA parameters to distinguish between traumatic and degenerative etiology of a superior RTC.

Comparison of Functional Outcomes After Arthroscopic Rotator Cuff Repair Between Patients With Traumatic and Atraumatic Tears.

Background: The role of tear etiology in outcomes after rotator cuff repair is not well understood. Purpose/Hypothesis: The purpose of this study was to determine the difference in outcomes after rotator cuff repair based on tear etiology. We hypothesized that traumatic rotator cuff tears will have greater improvements in functional outcome measures and range of motion (ROM) than atraumatic tears. Study Design: Cohort study; Level of evidence, 3. Methods: We conducted a chart review of 221 consecutive patients who underwent arthroscopic rotator cuff repair; prospectively collected preoperative and minimum 2-year postoperative data were evaluated. Shoulder ROM, strength, and standard shoulder physical examination findings were recorded pre- and postoperatively. Outcome measures included visual analog scale for pain, Subjective Shoulder Value (SSV), 10-item Patient-Reported Outcomes Measurement Information System (PROMIS-10; physical and mental components), and American Shoulder and Elbow Surgeons (ASES) form. Results: Of the 221 patients, 73 had traumatic tears and 148 had atraumatic/degenerative tears. There were no differences in age, body mass index, or Charlson Comorbidity Index between groups. Patients in the atraumatic cohort had significantly longer duration of symptoms before presentation (18 vs 7 months; P < .01). Preoperatively, the traumatic cohort had less motion to forward flexion (mean ± SD; 138° ± 43.7° vs 152° ± 29.8°; P = .02). Postoperatively, both groups experienced significant improvements in visual analog scale and SSV scores (P < .001 each). However, only the traumatic cohort demonstrated improvements in ASES and PROMIS-10 physical component scores. Patients with traumatic rotator cuff tears had lower preoperative SSV and less motion than those with atraumatic tears, but they had greater improvements in SSV (40.6% ± 39.0% vs 29.2% ± 39.7%; P = .005) and forward flexion (21.6° ± 48.6° vs 2.3° ± 48.2°; P < .001), as well as strength in forward flexion, external rotation, and internal rotation (P < .001, P = .003, and P = .002, respectively). Conclusion: Patients with traumatic rotator cuff tears have worse preoperative symptoms and more functional deficits but experience greater improvements in ROM, strength, and perceived shoulder function than those with degenerative/atraumatic tears.

A comparison of simple and complex single-row versus transosseous-equivalent double-row repair techniques for full-thickness rotator cuff tears: a systematic review and meta-analysis.

BACKGROUND: Rotator cuff injuries have traditionally been managed by either single-row or double-row arthroscopic repair techniques. Complex single-row techniques have recently been proposed as a biomechanically stronger alternative treatment option. However, no rigorous meta-analysis has evaluated the effectiveness of complex single-row against double-row repair. This meta-analysis aims to evaluate clinical outcomes in patients with full-thickness rotator cuff injuries treated with both simple and complex single-row, as well as transosseous-equivalent (TOE) double-row procedures. METHODS: An up-to-date literature search was performed using the predefined search strategy. All studies that met the inclusion criteria were assessed for methodological quality and included in the meta-analysis. Pain, functional scores, range of motion, and retear rate were all considered in the study. CONCLUSION: The results of our meta-analysis suggest that there is no significant difference between complex single-row and TOE double-row procedures in any of the observed outcomes. At this point in time, the available comparative data between simple single-row and TOE double-row repair techniques are limited. Further high-quality studies are required to assess the clinical outcomes and cost-effectiveness of these different techniques.