Total shoulder arthroplasty in patients aged 80 years and older: a systematic review.

BACKGROUND: Elderly patients and their surgeons may eschew shoulder arthroplasty due to concerns over patient safety and longevity. The purpose of this study was to review the current literature evaluating the clinical and radiographic outcomes of shoulder arthroplasty performed in patients 80 years and older. METHODS: A literature search of the Embase, PubMed, Medline, and Cochrane databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies evaluating the outcomes of primary and revision anatomic (aTSA) and reverse (RSA) total shoulder arthroplasty in patients 80 years and older were included for analysis. RESULTS: A total of 15 studies evaluating 1685 primary aTSAs, 1170 primary RSAs, 69 RSAs performed for fracture, and 45 revision RSAs were included for review. The postoperative active forward flexion and external rotation ranged from 138° to 150° and 45° to 48° after aTSA and from 83° to 139° and 16° to 47° after RSA, respectively. Postoperative visual analog scale pain scores ranged from 0 to 1.8 after aTSA and from 0 to 1.4 after RSA. Ninety-day mortality ranged from 0% to 3%, and perioperative complications ranged from 0% to 32%. Late complications ranged from 5.6% to 24% for aTSA patients and 3.5% to 29% for patients undergoing RSA for all indications. Common complications included glenoid loosening (0%-18%) and rotator cuff tear (5.6%-10%) after aTSA and scapular notching (0%-40%) and scapular fracture (4%-9.4%) after RSA. Reoperation rates ranged from 0% to 6% after aTSA and from 0% to 13% after RSA. CONCLUSIONS: aTSA and RSA in this population are safe and effective, demonstrating low rates of perioperative mortality and reoperation, durability that exceeds patient longevity, satisfactory postoperative range of motion, and excellent pain relief. Late complication rates appear to be similar for aTSA and RSA.

Editorial Commentary: Superior Capsular Reconstruction Employing Allograft Heals and Functions Well if the Graft Is Sufficiently Thick and Stiff.

Superior capsular reconstruction (SCR) has fallen into disrepute, and the numbers performed appear to be on the decline because it is technically demanding and time-consuming, requires a long postoperative recovery, and does not always heal or function as expected. In addition, two "new kids on the block," the subacromial balloon spacer and the lower trapezius tendon transfer, have emerged as viable alternatives for low-demand patients who cannot tolerate a lengthy recovery and for high-demand patients who lack external rotation strength, respectively. However, carefully selected patients continue to do well after SCR, when surgery is meticulously performed using a graft that is sufficiently thick and stiff. The clinical results and healing rates after SCR using allograft tensor fascia lata are comparable with those after SCR using tensor fascia lata autograft and without donor-site morbidity. Robust comparative clinical study is needed to sort out the optimal graft type and thickness for SCR and the precise indications for each of the surgical treatment options for the irreparable rotator cuff tear, but let's not "throw the baby out with the bathwater" and abandon SCR altogether.

Editorial Commentary: Avoiding Complications in Elbow Arthroscopy: Know the Indications, Learn the Anatomy, and Master a Safe Technique.

Elbow arthroscopy enables surgeons to treat a vast range of elbow injuries and pathologies in a minimally invasive manner. It has a lower morbidity rate and is often followed by a faster recovery than traditional open surgery unless it is followed by a serious complication. Although most complications are minor and transient, the incidence of both minor and major complications is considerably higher than that after arthroscopy of other joints, specifically the risk of neurovascular injury including permanent nerve injury because of the proximity of neurovascular structures. A recent review of 114 studies reported a median 3% incidence of complications and 2% incidence of reoperation, with transient nerve palsies accounting for about one third. Surgeon experience may influence complication rates; a survey suggested that surgeons need to experience more than 200 cases to be considered expert. In addition, patient-related factors such as obesity, female gender, age over 65 years, elevated blood sugar levels, hypercoagulable disorder, tobacco or alcohol use or both, as well as history of previous surgery and perioperative corticosteroid injections are identified as risk factors for complications after elbow arthroscopy. Keys to avoiding complications include precise surgical indications and understanding the 3-dimensional anatomy-especially the relationship of the various nerves to the portals and joint capsule.

Arthroscopic Repair of Retracted Large and Massive Rotator Cuff Tears with and without Augmentation with a Bio-Inductive Collagen Implant Reveals Substantial and Comparable Clinical Improvement.

PURPOSE: The study objective was to compare clinical and imaging results after repair of retracted large and massive full-thickness rotator cuff tears, including revision repairs, with and without augmentation with a bio-inductive collagen implant. METHODS: The study group comprised 24 patients (17 males) with retracted 2 or 3 tendon rotator cuff tears undergoing arthroscopic repair followed by onlay augmentation with a bio-inductive collagen implant. The control group comprised 24 patients (19 males) matched by tear size undergoing repair without augmentation. Mean patient age at repair in both groups was 61 years. Active range of motion (ROM) and patient-reported outcomes (PROs) were recorded before and after surgery. Noncontrast high-field magnetic resonance imaging (MRI) was obtained in 20/24 collagen implant patients and 17/24 control patients at minimum 6 months follow-up to assess tendon healing. RESULTS: American Shoulder and Elbow Surgeons and Simple Shoulder Test scores improved from 35 to 86 and 3.6 to 9.3, respectively, in the collagen implant group and from 39 to 87 and 3.9 to 9.7 in the control group. The visual analog score-pain improved from 6.0 to 0.9 and from 5.9 to 0.9 in the collagen implant and control groups, respectively (P < .001 for all). Overall improvements in ROM and PROs were similar in both groups. MRI revealed intact repairs in 11/20 (55%) patients in the patch group and 9/17 (53%) in the control group. Two patients in each group were revised to reverse shoulder arthroplasty. CONCLUSIONS: Arthroscopic repair of retracted large and massive rotator cuff tears, including revision repairs, with and without augmentation using a bio-inductive collagen implant results in substantial and comparable early clinical improvement, although predictable healing remains elusive. Further work is needed to optimize patient selection for massive rotator cuff repair and define more precisely the indications for augmentation of these repairs using the collagen implant. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Editorial Commentary: A Consensus of Experts Complements the Clinical Evidence on Diagnosis and Treatment of Anterior Glenohumeral Instability.

The current diagnostic and treatment strategies for anterior glenohumeral instability have been refined by high-quality clinical and basic science studies, but many controversies remain. These include the bone loss threshold for arthroscopic Bankart repair and the influence of other clinical factors on this decision, the optimal bracing position following anterior glenohumeral dislocation, and the optimal coracoid graft orientation during the Latarjet procedure. Randomized clinical trials often present conflicting results, and many of these are small-sample and fragile studies. Obtaining an expert consensus on the topic, by means of the Delphi method, is an attractive alternative to such clinical trials. Several studies employing variations of the Delphi method have addressed the diagnosis and treatment of anterior glenohumeral instability. These have stressed the importance of a meticulous technique during arthroscopic Bankart repair and of recognition of glenoid and humeral bone loss and treating this appropriately. These studies have also helped identify areas where consensus is modest or lacking to motivate additional clinical research study.

Reverse shoulder arthroplasty in patients 85 years and older is safe, effective, and durable.

BACKGROUND: Reverse shoulder arthroplasty (RSA) was originally indicated for older adults, but outcomes in the oldest patients have not been studied. The purpose of this study was to report on patients aged ≥85 years undergoing RSA. We hypothesized that RSA would be safe, effective, and durable. METHODS: Sixty-one RSAs were performed in 58 patients aged ≥85 years (16 patients aged ≥90 years); 40 RSAs were performed for arthritis with cuff deficiency, 14 were performed for proximal humeral fractures, and 7 were performed as revisions. Active range of motion and patient-reported outcomes, comprising the American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and visual analog scale pain score, were obtained preoperatively and at final follow-up. Hospital length of stay, discharge disposition, and complications were recorded. Kaplan-Meier survivorship was computed with revision surgery or death as an endpoint. RESULTS: The mean age at RSA was 88.0 years. Mean forward elevation improved from 50.5° to 105.3°; abduction, from 48.7° to 96.1°; and external rotation, from 10.2° to 26.9° (P < .001 for all). Similarly, at a mean follow-up of 2.4 years, the visual analog scale pain score improved from 6.1 to 0.6; Simple Shoulder Test score, from 2.2 to 7.0; and American Shoulder and Elbow Surgeons score, from 33.6 to 78.2 (P < .001 for all). The mean length of stay was 3.6 days, and 15 patients were discharged home. Seven patients received a blood transfusion, and only 2 patients underwent a reoperation, neither of whom required explantation. DISCUSSION AND CONCLUSION: Improvements in active range of motion and patient-reported outcomes in our patients were comparable to those observed in younger cohorts and exceeded published minimal clinically important differences for most patients undergoing RSA for cuff deficiency. Additionally, to date, the patients in our study who died had lived with their RSA for a mean of 3.4 years and living patients had lived with their RSA for a mean of 4.3 years. RSA in patients aged ≥85 years is safe, effective, and durable for their remaining life expectancy. This information may help counsel older patients who are considering RSA, electively or for fractures.

Editorial Commentary: Biology and Biomechanics Must Be Carefully Balanced for a Durable Rotator Cuff Repair.

Arthroscopic rotator cuff repair strategies have evolved over 3 decades, but suture anchor design, anchor configuration, and stitches have been largely driven by repair biomechanics. In recent years there has been a shift toward repair strategies that enhance the biology of tendon repair. Double-row and transosseous equivalent suture anchor repair constructs demonstrate excellent time zero mechanical properties, but the resulting increased repair tension and tendon compression may compromise tendon healing. Modern single-row repairs employing medialized triple-loaded suture anchors, simple stitches, and lateral marrow venting avoid some of the problems associated with double-row repairs and demonstrate excellent short-term healing and clinical results. The most robust repair fails if the tendon does not heal. Biology and biomechanics must be carefully balanced.

Editorial Commentary: Superior Capsular Reconstruction Works Biomechanically but Should Be Used Selectively for Genuinely Irreparable Tears.

Superior capsular reconstruction (SCR) has undergone extensive biomechanical and clinical study. Systematic review of biomechanical studies has shown that SCR functions to depress the humeral head and improve the glenohumeral register, which provides proof of concept. Clinical studies have shown the short-term effectiveness of SCR, but this is influenced by graft type and thickness, as well as surgical technique. These studies are mostly flawed because follow-up is brief, postoperative imaging is often lacking, and the results may not be generalizable. Multiple systematic reviews pooling the results of these various clinical studies have mostly produced diluted conclusions that are not clinically helpful. To date, there is a dearth of comparative studies to help guide the selection of SCR over other treatment options such as subacromial balloon spacer, partial repair with or without augmentation, tendon transfer, reverse shoulder arthroplasty, or even continued nonoperative care. Additionally, SCR is a salvage operation rather than an expedient alternative to careful mobilization of a rotator cuff tear for primary repair. Ultimately, large-scale, long-term imaging-based comparative clinical studies, rather than additional systematic clinical or biomechanical reviews, must provide the evidence needed to determine the precise indications and optimal technique for SCR.

Editorial Commentary: Monitoring Tendon and Muscle Recovery After Rotator Cuff Repair Using Diagnostic Ultrasound Demonstrates that Early Repair is Beneficial for Many Patients With Reparable Tears.

Rotator cuff repair is performed to effect healing of the enthesis; to restore shoulder comfort, strength, and function; to prevent tear propagation; and to prevent progression of atrophic muscle changes (fatty degeneration, fatty infiltration, and fatty atrophy) that eventually occur. Non-retracted and moderately retracted rotator cuff tears usually heal after repair, and muscle atrophy may recover over time. It follows that early rotator cuff repair is beneficial for many patients with chronic but reparable rotator cuff tears. Diagnostic ultrasound can provide quantitative information about the recovery of both muscle and tendon and represents a viable alternative to magnetic resonance imaging for evaluating healing after rotator cuff repair.

Editorial Commentary: Classic and Congruent-Arc Latarjet Techniques Are Equally Safe and Effective Procedures, so Choose Whichever Technique Works Best in Your Hands for Your Patients.

The classic and congruent-arc Latarjet techniques are equally safe and effective in restoring glenohumeral stability, even when performed as a revision of a failed stabilization. The classic technique provides a broader contact area for healing and facilitates and improves screw fixation. The congruent-arc technique theoretically optimizes glenohumeral contact forces because of the matched radius of curvature, provides better restoration of glenoid depth, and restores larger glenoid defects. However, rotating the coracoid graft for the congruent-arc technique eliminates the possibility of imbricating the coracoacromial ligament stump to the capsule. Surgeons have little reason to change from one technique to the other; both techniques result in successful outcomes.

Management of irreparable massive rotator cuff tears: a systematic review and meta-analysis of patient-reported outcomes, reoperation rates, and treatment response.

BACKGROUND: There is no consensus on the treatment of irreparable massive rotator cuff tears. The goal of this systematic review and meta-analysis was to (1) compare patient-reported outcome scores, (2) define failure and reoperation rates, and (3) quantify the magnitude of patient response across treatment strategies. METHODS: The MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and Scopus databases were searched for studies including physical therapy and operative treatment of massive rotator cuff tears. The criteria of the Methodological Index for Non-randomized Studies were used to assess study quality. Primary outcome measures were patient-reported outcome scores as well as failure, complication, and reoperation rates. To quantify patient response to treatment, we compared changes in the Constant-Murley score and American Shoulder and Elbow Surgeons (ASES) score with previously reported minimal clinically important difference (MCID) thresholds. RESULTS: No level I or II studies that met the inclusion and exclusion criteria were found. Physical therapy was associated with a 30% failure rate among the included patients, and another 30% went on to undergo surgery. Partial repair was associated with a 45% retear rate and 10% reoperation rate. Only graft interposition was associated with a weighted average change that exceeded the MCID for both the Constant-Murley score and ASES score. Latissimus tendon transfer techniques using humeral bone tunnel fixation were associated with a 77% failure rate. Superior capsular reconstruction with fascia lata autograft was associated with a weighted average change that exceeded the MCID for the ASES score. Reverse arthroplasty was associated with a 10% prosthesis failure rate and 8% reoperation rate. CONCLUSION: There is a lack of high-quality comparative studies to guide treatment recommendations. Compared with surgery, physical therapy is associated with less improvement in perceived functional outcomes and a higher clinical failure rate.

Glenohumeral chondrolysis: part I--clinical presentation and predictors of disease progression.

PURPOSE: The objective of this 2-part study is to report on the etiology, clinical findings, and predictors of disease progression (part I) and the results of treatment (part II) in a group of patients with glenohumeral chondrolysis. METHODS: Forty patients presented with glenohumeral chondrolysis after treatment elsewhere. Twenty patients have been followed up since their initial presentation before arthroplasty (group 1), and 20 patients were referred either for management of complications arising after prosthetic arthroplasty or for evaluation only (group 2). RESULTS: Thirty-seven patients received an intra-articular pain pump (IAPP) delivering bupivacaine, and 3 patients had prominent suture anchors or tacks. Symptoms related to chondrolysis developed in patients at a mean of 9.8 months (range, 1 to 34 months) after the index procedure. Radiographs showed joint space obliteration in 30 of 40 patients at most recent follow-up or before arthroplasty. Of the patients receiving an IAPP delivering bupivacaine, the majority received 0.5% with epinephrine. Higher bupivacaine dose (P < .05) and female gender (P < .05) were associated with a longer interval to onset of symptoms. In addition, a shorter interval to onset of symptoms predicted the need for subsequent surgery (P < .05) and a shorter interval to second-look arthroscopy (P < .001). CONCLUSIONS: Post-arthroscopic glenohumeral chondrolysis is a devastating and rapidly evolving condition that most often strikes young patients. The use of IAPPs delivering local anesthetics should be abandoned because nearly all cases of glenohumeral chondrolysis in this series were associated with their use. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Glenohumeral chondrolysis: part II--results of treatment.

PURPOSE: The objective of this 2-part study is to report on the etiology and disease progression (part I) and results of treatment (part II) of glenohumeral chondrolysis. METHODS: Forty patients presented with glenohumeral chondrolysis after treatment elsewhere. Twenty patients have been followed since their initial presentation and before prosthetic shoulder arthroplasty (group 1), and 20 patients were referred either for management of complications arising after shoulder arthroplasty or for evaluation only (group 2). All patients underwent standardized clinical and radiographic examination and completed shoulder-specific self-assessment questionnaires at initial presentation and after prosthetic shoulder arthroplasty for patients in group 1. RESULTS: Thirty of 40 patients underwent subsequent arthroscopy for debridement, chondroplasty, capsular release, or a combination of these procedures. Of these, 23 patients (77%) required additional surgery, comprising 18 prosthetic shoulder arthroplasties performed at a mean 13 months of follow-up (range, 3 to 33 months), as well as 5 repeated arthroscopies. At most recent follow-up, 15 of 20 patients in group 1 had undergone shoulder arthroplasty, with improvements in active forward elevation from 92.6° to 140.0° (P < .0001), active abduction from 81.6° to 131.3° (P < .0001), active external rotation from 22.1° to 49.3° (P < .0001), and active internal rotation from the gluteal region to the T12 spinous process (P < .001). Pain scores improved from 6.4 to 3.4 (P < .01), and self-assessed outcome also improved significantly. Twelve patients in group 2 underwent shoulder arthroplasty, so overall 27 of 40 patients (68%) underwent prosthetic shoulder arthroplasty for chondrolysis at a mean of 32 months (range, 9 to 66 months) after the index procedure. CONCLUSIONS: Postarthroscopic glenohumeral chondrolysis is a devastating condition that strikes young patients, responds poorly to arthroscopic interventions, and often requires shoulder arthroplasty within a few years. Patients can expect improved range of motion and outcome after shoulder arthroplasty, but pain relief is often incomplete. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Addressing Arthroscopic-Assisted Acromioclavicular Joint Reconstruction in the Beach Chair Position With Concomitant Labral Pathology in the Lateral Decubitus Position.

High-grade Acromioclavicular (AC) injuries are complete dislocations, involving ruptures of the AC and coracoclavicular ligaments. They occur following trauma after a fall, direct-blow to an adducted arm, or indirectly by falling onto an abducted, outstretched extremity. Given this traumatic etiology, additional intra-articular pathologies can arise and may go unnoticed because of the painful and prominent AC joint (ACJ). Previous studies have evaluated patients with high-grade ACJ injuries with diagnostic arthroscopy at the time of an ACJ reconstruction. They found associated injuries to the labrum/biceps, rotator cuff, and articular cartilage. The arthroscopic-assisted ACJ reconstruction (AA-ACJR) technique has made it possible to identify the associated injuries and treat them concurrently. The previous studies have performed this reconstruction in the beach chair position (BCP) and have addressed the concomitant pathology in the same position. As opposed to the BCP, the lateral decubitus position (LDP) allows for easier application of traction to the arm and, thus, improves visualization of the glenoid, especially the inferior and posteroinferior portions. It is imperative to gain appropriate access to the inferior glenoid for anchor placement to address this component of traumatic instability. We present the technique for addressing high-grade ACJ injuries with AA-ACJR in the BCP preceded by labral repair in the LDP.

Prosthetic shoulder arthroplasty in patients 40 years or younger: outcomes stratified by diagnosis and surgery.

BACKGROUND: The outcomes of patients 50-55 years old or younger undergoing prosthetic shoulder arthroplasty (PSA) may not generalize to younger patients. We report outcomes following PSA in a consecutive series of patients 40 years or younger. We hypothesize that total shoulder arthroplasty (TSA) provides better outcome and durability than resurfacing hemiarthroplasty (RHA). METHODS: Patients were stratified by diagnosis and surgical procedure performed, RHA or TSA. Active range of motion and self-assessed outcome were evaluated preoperatively and at final follow-up. RESULTS: Twenty-nine consecutive PSAs were identified in 26 patients, comprising 9 TSAs and 20 RHAs, with a minimum of 2-year follow-up. Twelve PSAs were performed for chondrolysis. Mean active forward elevation, abduction, external rotation, and internal rotation improved significantly (p<0.001 for all). Mean pain score improved from 6.3 to 2.1, Simple Shoulder Test from 4.0 to 9.0, and American Shoulder and Elbow Surgeons score from 38 to 75 (p<0.001 for all). Patients undergoing RHA and TSA had similar outcomes; but three RHAs required revision, two of these within 4 years of implantation. Four of five patients undergoing revision during the study period had an original diagnosis of chondrolysis. CONCLUSIONS: PSA in young patients provides substantial improvement in active range of motion and patient reported outcomes irrespective of diagnosis and glenoid management. However, patients undergoing RHA, especially for chondrolysis, frequently require subsequent revision surgery, so that RHA should be considered with caution in young patients and only after shared decision-making and counsel on the risk of early revision to TSA.

Shoulder Hemiarthroplasty with Nonprosthetic Glenoid Arthroplasty: The Ream-and-Run Procedure.

¼: Glenoid component wear and loosening are the principal failure modes of anatomic total shoulder arthroplasty (aTSA). ¼: The ream-and-run (RnR) procedure is an alternative glenohumeral arthroplasty for patients who wish to avoid the risks and limitations of a prosthetic glenoid component. ¼: During the RnR procedure, the arthritic glenoid is conservatively reamed to a single concavity, while the prosthetic humeral component and soft tissues are balanced to provide both mobility and stability of the joint. ¼: The success of the RnR procedure depends on careful patient selection, preoperative education and engagement, optimal surgical technique, targeted rehabilitation, and close postoperative communication between the surgeon and the patient. ¼: While the RnR procedure allows high levels of shoulder function in most patients, the recovery can be longer and more arduous than with aTSA. ¼: Patients who have undergone an RnR procedure occasionally require a second closed or open procedure to address refractory shoulder stiffness, infection, or persistent glenoid-sided pain. These second procedures are more common after the RnR than with aTSA.

Arthroscopic Evaluation and Treatment of Complications That Arise Following Prosthetic Shoulder Arthroplasty.

Arthroscopy may be used to diagnose symptomatic glenoid loosening following anatomic total shoulder arthroplasty (aTSA), and arthroscopic glenoid component removal may suffice as treatment for some patients. Arthroscopy may be used to diagnose shoulder prosthetic joint infection (PJI) following aTSA and reverse shoulder arthroplasty (RSA). Tissues are biopsied from multiple sites within the joint and the subdeltoid or subacromial space, and they are cultured for a minimum of 14 days. Postoperative adhesions arising after prosthetic shoulder arthroplasty (PSA) may be released arthroscopically. However, other problems contributing to shoulder stiffness such as component malpositioning or shoulder PJI require additional intervention. Arthroscopy may be used to repair select rotator cuff tears that arise acutely following aTSA, but chronic attritional tears do not heal after repair; therefore, revision to RSA often is needed. Many complications following PSA, such as infection, fixed instability, humeral component loosening, and major humeral or glenoid bone loss, are not adequately treated using arthroscopic techniques. However, arthroscopy following PSA may help to diagnose and treat other complications, even as the precise indications following aTSA and RSA remain unclear.

Single-Shot Versus Continuous Interscalene Block for Postoperative Pain Control After Shoulder Arthroplasty: A Prospective Randomized Clinical Trial.

INTRODUCTION: Continuous catheter infusion of local anesthetics extends the efficacy of regional anesthesia after prosthetic shoulder surgery. Our purpose was to compare continuous interscalene block (CIB) with single-shot interscalene block, and the hypothesis was these would offer similar safety and efficacy in patients with prosthetic shoulder arthroplasty. METHODS: Seventy-six patients were randomized to ropivacaine single-shot interscalene block or CIB after prosthetic shoulder arthroplasty. Postoperative pain scores and opioid use, hospital length of stay (LOS), adverse events, and catheter tip withdrawal were recorded. RESULTS: Pain scores (P = 0.010) and opioid use (P = 0.003) on the first postoperative day were lower in the CIB group, but there was no difference in LOS. Adverse events were more common in the CIB group and 10% of catheters pulled out prematurely. CONCLUSION: Opioid use and pain levels during first postoperative day are clinically less after CIB, but this did not shorten LOS. The benefits of CIB may not justify the higher cost and complication rate.

Intraoperative Neuromonitoring for Brachial Plexus Neurolysis During Delayed Fixation of a Clavicular Fracture Presenting as Thoracic Outlet Syndrome: A Case Report.

CASE: Brachial plexopathy is a rare complication of nonoperatively treated clavicular fractures. We describe a 68-year-old man who presented with fracture-callus-induced acute brachial plexopathy and dynamic thoracic outlet syndrome after 9 weeks of nonoperative management for a clavicular fracture. He underwent fracture fixation with brachial plexus decompression via callus excision; intraoperative neuromonitoring was used to evaluate brachial plexus function. Postsurgery, his neurologic function recovered completely. CONCLUSION: Intraoperative neuromonitoring is a useful tool for minimizing the risk of additional brachial plexus injury and determining the adequacy of neural decompression during delayed open reduction and internal fixation of clavicular fractures with fracture-callus-induced brachial plexus compression.