Arthroscopic Bankart repair associated with subscapularis augmentation (ASA) versus open Latarjet to treat recurrent anterior shoulder instability with moderate glenoid bone loss: clinical comparison of two series.

PURPOSE: The treatment of chronic anterior shoulder instability with glenoid bone loss is still debated. The purpose of this study is to compare short-term results of two techniques treating chronic shoulder instability with moderate glenoid bone loss: bone block according to open Latarjet-Patte procedure and arthroscopic Bankart repair in association with subscapularis augmentation. METHODS: Ninety-one patients with moderate anterior glenoid bone loss underwent from 2011 to 2015. From these patients, two groups of 20 individuals each have been selected. The groups were homogeneous in terms of age, gender, dominance and glenoid bone loss. In group A, an open Latarjet procedure has been performed, and in group B, an arthroscopic Bankart repair associated with subscapularis augmentation has been performed. The mean follow-up in group A was 21 months (20-39 months), while in group B was 20 months (15-36 months). QuickDash score, Constant and Rowe shoulder scores, were used for evaluations of results. RESULTS: The mean preoperative rate of QuickDash score was 3.6 for group A and 4.0 for group B; Rowe Score was 50.0 for group A and 50.0 for group B. Preoperative mean Constant score was 56.2 for Latarjet-Patte and 55.2 for Bankart plus ASA. Postoperative mean QuickDash score was in group A 1.8 and 1.7 in group B; Rowe Score was 89.8 and 91.6; Constant Score was 93.3 and 93.8. No complications related to surgery have been observed for both procedures. Not statistically significant difference was reported between the two groups (p > .05). Postoperatively, the mean deficit of external rotation in ER1 was -9° in group A and -8 in group B; In ER2, the mean deficit was -5° in both groups (p = .0942). CONCLUSIONS: Arthroscopic subscapularis augmentation of Bankart repair is an effective procedure for the treatment of recurrent anterior shoulder instability with glenoid bone loss without any significant difference in comparison with the well-known open Latarjet procedure.

Reverse shoulder prosthesis to treat complex proximal humeral fractures in the elderly patients: results after 10-year experience.

PURPOSE: The aim of this study is to report the clinical and radiological results of reverse total shoulder arthroplasty (rTSA) in elderly patients who have been treated for complex humeral fractures. MATERIALS AND METHODS: From January 2005 to December 2014, we have implanted rTSA for proximal humeral fractures in 95 patients (80 women, 15 men) about 75 years old on average (range 62-95 years). All rates and results on intraoperative and postoperative complications have been collected in a specific database. In all cases we have used a modular implant prosthesis (Lima Corporate, San Daniele del Friuli, Italy). The prosthesis was implanted cementless in 92 cases. Because of the presence of a high percentage of comorbidities in the elderly patients, we have retrospectively analyzed the necessity of a secondary hospitalization, from a week to a 6-month time after the discharge, due to general health problems and specific postoperative shoulder complications. The mean follow-up was 5 years (range 1-9 years) for 70 of 95 patients, 50 of whom had adequate radiographic controls. RESULTS: None of 95 patients has required a reoperation or a hospitalization for general health problems from 1 week to 6 months postoperative. No early or late infection of prosthesis has been observed. There were seven cases of perioperative complications, three humeral vertical bone fissuring, two glenoid fractures and two cases of deltoid muscle damage. We have had three cases of postoperative hematoma and one case of ulnar nerve neuropathy. The mean constant score was 85.4, and the mean simple shoulder test was 7.4. We have observed a grade 1 scapular notching in 15 cases (30 %). In the remaining 35 reviewed cases, there was no notching. Peri-articular heterotopic ossifications were found in 11 cases (22 %). CONCLUSION: Reverse shoulder prosthesis in complex humeral fractures in the elderly can be considered as a reliable surgical procedure, which leads to very good clinical and radiological results in case of cementless prosthesis, as well.

The role of dural sinus stenosis in idiopathic intracranial hypertension pathogenesis: the self-limiting venous collapse feedback-loop model.

In recent years the efficacy of endovascular venous stenting in idiopathic IIH treatment has been consistently reported, strongly suggesting that sinus stenosis should be viewed as a causative factor rather than a secondary phenomenon. We propose that in subjects carrying one or more collapsible segments of large cerebral venous collectors and exposed to a number of different promoting factors, sinus venous compression and cerebrospinal fluid (CSF) hypertension may influence each other in a circular way, leading to a new relatively stable venous/CSF pressures balance state at higher values. The mechanism relay on self-limiting venous collapse (SVC) feedback-loop between the CSF pressure, that compresses the sinus, and the consequent venous pressure rise, that increases the CSF pressure. The result is the "coupled" increase of both pressure values, a phenomenon not expected in presence of sufficiently rigid central veins. Once the maximum stretch of venous wall is reached the loop stabilize at higher venous/CSF pressure values and become self-sustaining, therefore persisting even after the ceasing of the promoting factor. Notably, the SVC is reversible provided an adequate perturbation is carried to whichever side of the loop such as sinus venous stenting, on one hand, and CSF diversion or even a single CSF withdrawal by lumbar puncture (LP), on the other. The SVC model predicts that any condition leading to an increase of either, cerebral venous pressure or CSF pressure may trigger the feedback loop in predisposed individuals. Migraine with and without aura, a disease sharing with IIH a much higher prevalence among women of childbearing age, is associated with waves of significant brain hyperperfusion. These may lead to the congestion of large cerebral venous collectors and could represent a common SVC promoting condition in susceptible individuals. The SVC model give reason of the high specificity and sensitivity of sinus stenosis as IIH predictor and of the multiplicity of the factors that have been found associated with IIH. Moreover it might explain why, among the sinus stenosis carriers, young and overweight women are at higher risk of developing the disease. Finally, the SVC model fully explain the enigmatic longstanding remissions that can be commonly observed after a single LP with CSF subtraction in IIH with or without papilledema.

Surgical treatment of sequelae of fractures of the proximal third of the humerus. The role of osteotomies.

Between 1996 and 2003 a total of 19 humeral head osteotomies were performed to treat post-traumatic malunion of the proximal humerus. Mean age was 46 years, ranging from 17 to 71 years. The period of time between traumas and surgeries ranged from 6 to 22 months. Osteotomy procedure was as follows: one after two-part fracture of the greater tuberosity, three after two-part fracture of the surgical neck, five after three-part fracture of the greater tuberosity, eight after four-part fracture, two after complex head splitting fracture, one after two-part fracture with anterior dislocation. Three different types of osteotomies were performed: osteotomy of the humeral neck for varus deformity, isolated osteotomy of the greater tuberosity, and a new osteotomy technique (two-plane and three-plane osteotomy) for three- and four-fragment fracture sequelae. At the time of follow-up evaluation, all 19 patients were questioned regarding pain and function. Excellent results in 14 patients and satisfactory results in 5 were obtained. None of the patients required revision surgery. Findings were recorded using the Constant rating scale. All patients had had significant pain relief after shoulder osteotomy. Range of motion was increased in all patients treated by osteotomy. The success of osteotomy in these cases was based on: patient selection, extensive preoperative evaluation, surgical technique and postoperative rehabilitation.

Anterior-inferior shoulder instability: treatment based on the Thal method.

Purpose of this study is to analyze the results of a consecutive series of 139 patients affected with anterior-inferior shoulder instability and treated by arthroscopic capsuloplasty using the Thal method with absorbable and non-absorbable Mitek knotless anchors. Much attention was paid to the preoperative and intraoperative selection of patients, excluding from the arthroscopic procedure those with bony Bankart lesions measuring more than 25%, with an inverted-pear glenoid, with engaged Hill-Sachs lesions and patients with HAGL lesions. Pre- and postoperative clinical evaluation was carried out using the Rowe scale. Scores rose from 45-55 to 96 postoperatively. Intra-articular mobilization of the anchors did not occur and peri-metallic lysis was not manifested. Areas of bone resorption were observed in 7 cases (7/38, 18.4%) with the presence of peri-insertional geodes with biological anchors, but this had no effect on the clinical results.