Anatomical total shoulder arthroplasty revision to reverse shoulder arthroplasty using convertible glenoid: a systematic review of clinical and radiological outcomes.

PURPOSE: The aim of the present systematic review is to collect all the available evidence regarding the clinical and radiological results of revision to reverse shoulder arthroplasty (RSA) of modular anatomic shoulder prostheses (TSA) using a convertible metal-backed glenoid (MBG). METHODS: This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies investigating revision of TSA to RSA utilizing a convertible MBG and reporting clinical and radiological outcomes were identified. RESULTS: A total of five studies on the use of convertible modular glenoid component in the setting of TSA revision to RSA were finally included in the present systematic review. A total of 60 procedures were reported. Mean operative times was 65 min. Intraoperative complications included 3 cases of glenoid loosening. Only one case of dislocation was reported as postoperative complication. At mean follow-up of 32.3 months post-revision, no glenoid loosening was reported, VAS score decreased from 7.7 to 1.5, Constant Score increased from 24.8 to 57.6. CONCLUSIONS: Revision to RSA after failed TSA using a convertible modular glenoid component was associated with a low rate of intraoperative and postoperative complications, low surgical time and led to good results in term of pain relieve and functional outcomes. Given the complexity and risk associated with revision of anatomic shoulder prosthesis having a convertible glenoid may help to simplify the procedure and improve clinical results.

Editorial Commentary: Recurrence After Arthroscopic Bankart Repair: What the Instability Severity Index Score Will and Will Not Predict.

The recurrence of shoulder instability is a challenging complication after anterior open or arthroscopic stabilization in patients with glenohumeral instability. Use of the arthroscopic Bankart procedure has increased over the last decade, because of its less invasiveness and low complication rates compared with the Latarjet procedure. However, arthroscopic repair has the possibility of a greater recurrent instability rate. The Instability Shoulder Index Score (ISIS) has been developed to predict the success of isolated arthroscopic Bankart repair for the management of recurrent anterior shoulder instability. The risk factors associated with the recurrence of instability are age, level and type of sports participation, shoulder hyperlaxity, and humeral and glenoid bony lesions. The ISIS is a validated tool to predict the recurrence of dislocation after arthroscopic surgery in patients with shoulder instability. The arthroscopic Bankart procedure can be performed in patients with ISIS ≤3 with a low risk of recurrence of glenohumeral instability. The Latarjet procedure should be recommended in patients with ISIS >6. The management of patients with ISIS between 4 and 6 is still controversial and ranges from arthroscopic Bankart procedure with the addition of remplissage to the Latarjet procedure. Because advanced imaging techniques, such as computed tomography scans, allow us to assess appropriately the glenoid and humeral bone defect, their use is recommended in addition to ISIS.

US-guided percutaneous irrigation of calcific tendinopathy of the rotator cuff in patients with or without previous external shockwave therapy.

OBJECTIVES: To compare the outcome of US-guided percutaneous irrigation of calcific tendinopathy (US-PICT) of the rotator cuff in patients with or without previous external shockwave therapy (ESWT). METHODS: We analyzed all patients treated with US-PICT from March 1, 2016, to October 1, 2019, with shoulder pain refractory to conservative management for rotator cuff calcific tendinopathy, diagnosed with ultrasound. Each patient was examined using the Constant-Murley Score (CMS) questionnaire (score 0-100) before and after treatment. We tested CMS differences using the Mann-Whitney U (Wilcoxon rank-sum) test in the two groups. US-PICT was performed placing two or multiple 14G needles, according to the calcification size, inserted under US guidance to create a circuit of irrigation in the calcified tendon. NaCl solution at 38 °C was then injected from the entry needle in a variable amount to hydrate and fragment the calcification, finally allowing for its expulsion through the exit needle. All patients also received an intrabursal steroid injection. RESULTS: From 2016 to 2019, 72 US-PICT treatments were performed on 70 patients (females = 46; males = 26) with a mean age of 49.7 years (SD = 8.7. Thirty-three (47%) underwent previous ESWT, while thirty-seven (53%) had no previous treatments. No treatment-related complications were observed. Follow-up was averagely 14.4 months (median = 11.6, SD = 11.9, range 1-45); 37 patients had a follow-up shorter than 12 months (1-11.6); 35 patients were visited after more than 1 year (12.2-45.6, Table W). Before treatment, the mean CMS was 35 (SD = 21); after treatment, it reached 75.4, with an average CMS improvement of 40.3 points (SD = 23.7, p < 0.001). The comparison of improvement between the ESWT and non-ESWT group yielded no significant difference (p = 0.3). CONCLUSIONS: US-PICT of the rotator cuff is an effective procedure to reduce shoulder pain and increase mobility in patients with calcific tendinopathy, both in short- and long-term time intervals. Previous unsuccessful ESWT does not affect the outcome of US-PICT.

Is the Instability Severity Index Score a Valid Tool for Predicting Failure After Primary Arthroscopic Stabilization for Anterior Glenohumeral Instability?

PURPOSE: To assess the validity of the Instability Severity Index Score in predicting the rate of recurrence of dislocation in patients undergoing arthroscopic Bankart repair. METHODS: The inclusion criteria were recurrent anterior traumatic glenohumeral instability and a minimum follow-up of 5 years. According to the preoperative Instability Severity Index Score, patients were divided into the following groups: ≤3 points (A), 4 to 6 points (B), and >6 points (C). The recurrence rate was determined by telephone interviews. The estimated overall rate of success at 5 years was defined as the estimated overall percentage of patients free of recurrence at 5 years. RESULTS: Six hundred seventy patients (572 men and 98 women) were included. The average age was 27 years (range, 18 to 39 years) at the time of surgery. One hundred fourteen of 670 patients had a recurrence of instability, with an overall recurrence rate of 17% (95% confidence interval [CI] 14.2%-19.9%). The Instability Severity Index Score had a significant association with recurrence. Compared with patients in group A, those in group B had double the risk of recurrence (hazard ratio [HR] = 2.43, 95% CI 1.38-4.28, P = .002), and patients in group C a 9 times greater risk of recurrence (HR = 9.42, 95% CI 5.20-17.7, P < .001). The estimated overall rate of success at 5 years was 84.8% (95% CI 81.8-87.3). The rate of success with an Instability Severity Index Score ≤3 points was 93.7% (95% CI 89.6-96.2), but it dropped to 85.7% (95% CI 81.7-88.9) in those with an Instability Severity Index Score of 4 to 6 points and became 54.6% (95% CI 42.8-64.9) in those with an Instability Severity Index Score >6 points. On multivariable analysis, the Instability Severity Index Score was found to significantly affect the risk of recurrence, corrected by type of sport and glenoid bone loss. CONCLUSIONS: The Instability Severity Index Score is a validated tool with which to assess the recurrence rate of dislocation after arthroscopic surgery in patients with shoulder instability. Arthroscopic stabilization in patients with an Instability Severity Index Score ≤3 is associated with a significantly lower risk of recurrence of glenohumeral instability compared with that in patients with an Instability Severity Index Score >3 points. LEVEL OF EVIDENCE: III, case-control study.

Aetiopathogenesis of cuff-tear arthropathy: Could juvenile joint laxity be considered a predisposing factor?

PURPOSE: Although many hypotheses have been formulated, aetiopathogenesis of cuff-tear arthropathy (CTA) is still motive for discussion. Since prevalence of CTA is notoriously higher in women, as is joint hypermobility, we hypothesised a possible correlation between the two conditions. METHODS: One hundred thirty-three (n = 133) consecutive patients with glenohumeral osteoarthritis [48 men, 85 women; mean age (SD) 72.32 (7.05)] were divided into two groups: Groups 1 (CTA) and 2 (concentric shoulder arthropathy) comprised 71 (22 men, 49 women) and 62 (26 men, 36 women), respectively. The presence of current or previous joint hypermobility was assessed using two standardised methodologies: the Beighton criteria score, and a five-item self-report questionnaire. Data were submitted to statistical analysis. RESULTS: A moderate association between Beighton criteria and the five-item self-report (φ = 0.481, p < 0.001) was detected. Beighton criteria led to a diagnosis of joint hypermobility in 16 patients (22.5%) in Group 1 and 15 (24.2%) in Group 2. According to five-item self-report questionnaire, juvenile joint laxity was diagnosed in 11 (15.5%) and 12 (19.4%) patients in Groups 1 and 2, respectively. No significant association between groups and the Beighton criteria [χ2(1) = 0.051, p = 0.82] and five-item self-report questionnaire [χ2(1) = 0.67, p = 0.41] was found. CONCLUSION: Juvenile joint hyperlaxity is not a predisposing factor for cuff arthropathy. Further studies will be needed to explain CTA aetiopathogenesis. LEVELS OF EVIDENCE: III.

Deep partial rotator cuff tear: transtendon repair or tear completion and repair? A randomized clinical trial.

PURPOSE: The purpose of this study is to compare the clinical and subjective difference between transtendon repair or complete/repair in two homogeneous groups of patients affected by deep partial articular supraspinatus tear. METHODS: Seventy-four patients were randomized in two groups of 37 patients each. The first group (A) was treated with arthroscopic transtendon repair while the second group (B) was treated with an arthroscopic completion of the tear and formal repair. All the patients were revaluated at a minimum 2 years of follow-up with Constant score and Visual Analogic Scale (VAS). RESULTS: Constant score improved by a mean value of 25 (95 % CI 21-28) (p < 0.0001) and of 29 (95 % CI 26-31) (p < 0.0001), respectively; VAS score decreased by a mean value of 3.4 (95 % CI 2.9-3.9) (p < 0.0001) and of 3.6 (95 % CI 3.3-4.0) (p < 0.0001), respectively. The improvement was higher in both groups for the ADL, and in Group B, the improvement in strength was higher than in Group A. There were no statistical differences between the two different techniques. CONCLUSION: Both repairing techniques of deep partial supraspinatus tear provide good results in terms of function and pain. There were no statistically significant differences between the two techniques. LEVEL OF EVIDENCE: Prospective comparative study, Level II.

The use of an eccentric glenosphere compared with a concentric glenosphere in reverse total shoulder arthroplasty: two-year minimum follow-up results.

PURPOSE: The current models of reverse shoulder arthroplasty (RSA) expose the procedure to the risk of scapular notching, possibly leading to loosening of the glenoid. We compared the clinical and radiographic results obtained with a concentric or eccentric glenosphere to assess whether the eccentric design might give better clinical results and avoid or decrease the risk of scapular notching METHODS: Of our patients, 31 underwent RSA using a concentric glenosphere (group A), while 29 had an eccentric glenosphere (group B). Postoperatively, patients were followed-up at one to 12 months and annually thereafter, with the mean being 33 months in group A and 27.5 in group B. In both groups the minimum follow up (F-U) was 24 months. Preoperatively and at each F-U starting from six months, patients were assessed using the Constant score. On radiographs, prosthesis scapular neck angle (PSNA), distance between scapular neck and glenosphere (DBSNG) and peg-glenoid rim distance (PGRD) were calculated. The severity of notching was classified in four grades. RESULTS: In group A the mean Constant score increased by 30 points compared to the preoperative score and the active ROM increased considerably. At latest F-U, the mean PSNA, DBSNG and PGRD were, respectively, 87°, 3.4 mm and 19.8 mm. Glenoid notching was present in 42% of cases. In group A, the mean Constant score increased by 34 points and the mean ROM was better than in group A. The average PSNA, PGRD and DBSNG were, respectively, 92°, 21.2 mm and 4.3 mm. Radiographs showed no inferior scapular notching. CONCLUSIONS: The eccentric glenosphere yielded better clinical results than the concentric glenosphere and was associated with no scapular notching.

Conversion of shoulder arthroplasty to reverse implants: clinical and radiological results using a modular system.

PURPOSE: Revision of a shoulder arthroplasty to a reverse arthroplasty is a highly demanding procedure. The aim of this study is to report the clinical results of hemi and total shoulder prosthesis revisions to reverse implants without removal of the humeral stem, using a modular shoulder replacement system (SMR Lima LTD). We retrospectively reviewed 26 patients who underwent an operation from 2004 to 2009. METHODS: The patients were divided into two groups: in Group I, 18 patients underwent a revision of hemiarthroplasty implanted for fracture; in Group II, eight patients underwent a revision of anatomical total prosthesis. All patients were evaluated at a mean follow-up of 32.3 (±12.7) months using the Constant score rating scale and by range of motion evaluation, EQ-VAS, X-ray and CT scan. RESULTS: The Constant score of each patient was 47.88 (±5.88) after the revision. The EQ-VAS improved from 40 (±20) to 70 (±10). All patients improved in terms of range of motion. The radiographs and CT scans obtained after revision showed good integration and no signs of loosening of the implant. The mean time of surgery was recorded as 62' (±8'), with a maximum blood loss of less than 300 ml in all cases. CONCLUSIONS: Our study demonstrates that using a full modular system at the time of the first implant allows avoidance of the step to remove the humeral stem and metal back in cases of shoulder prosthesis revision to a reverse prosthesis, resulting in a short operative time, few intraoperative complications and a satisfactory clinical outcome at medium-term follow-up.

Arthroscopic stabilization of the shoulder in adolescent athletes participating in overhead or contact sports.

PURPOSE: To investigate the outcome of arthroscopic capsular repair for shoulder instability in an active adolescent population participating in overhead or contact sports. METHODS: We identified 67 patients (aged 13 to 18 years) with post-traumatic recurrent shoulder instability for inclusion in the study from our computer database. Of these patients, 65 (96%) were available for clinical review. There were 44 male and 21 female patients, with a mean age of 16 years at the time of surgery. All patients participated in overhead or contact sports at a competitive level. Arthroscopic capsulolabral repair was performed after at least 6 months of failed nonoperative treatment. The mean follow-up was 63 months. Shoulder range of motion and functional outcomes were measured preoperatively and postoperatively with Single Assessment Numeric Evaluation (SANE), Rowe, and American Shoulder and Elbow Surgeons (ASES) scores. Furthermore, type of sport, time until surgery, and number of dislocations were analyzed from our database to find any correlation with the recurrence rate. RESULTS: At final follow-up, the mean SANE score was 87.23% (range, 30% to 100%) (preoperative mean, 46.15% [range, 20% to 50%]); the mean Rowe score was 85 (range, 30 to 100) (preoperative mean, 35.9 [range, 30 to 50]); and the mean ASES score was 84.12 (range, 30 to 100) (preoperative mean, 36.92 [range, 30 to 48]). The mean forward flexion and external rotation with the arm at 90° abduction did not change from preoperative values; 81% of the patients returned to their preinjury level of sport, and the rate of failure was 21%. The recurrence rate was not related to the postoperative scores (P = .556 for SANE score, P = .753 for Rowe score, and P = .478 for ASES score), the number of preoperative episodes of instability (P = .59), or the time from the first instability episode to the time of surgery (P = .43). There was a statistically significant relation (P = .0021) between recurrence and the type of sport practiced. Recurrence rate was related to the type of sport practiced. CONCLUSIONS: Arthroscopic stabilization is a reasonable surgical option even in an adolescent population performing sports activities. However, it must be emphasized to the patients and their relatives that the recurrence rate that could be expected after an arthroscopic procedure is higher than in the adult population. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Arthroscopic transosseous (anchorless) rotator cuff repair.

UNLABELLED: The traditional open transosseous rotator cuff repair gives excellent results for the fixation of tendon to bone and has represented the gold standard for rotator cuff surgery with excellent long-term results. In the last few years, different arthroscopic techniques using suture anchors have been developed to increase the tendon-bone contact area in an attempt to reconstitute a more anatomic configuration of the rotator cuff footprint while providing a better environment for tendon healing. However, the anchor-based techniques have still not replicated the traditional open transosseous repair. A surgical technique that allows surgeons to perform a standardized arthroscopic transosseous (anchor free) repair of rotator cuff tears using a new disposable device is described. With this system, it is possible to perform a transosseous technique in a reproducible fashion. This novel technique combines the clinical advantages of minimally invasive arthroscopic surgery and the biomechanical advantages of open transosseous procedures. LEVEL OF EVIDENCE: V.

Total shoulder arthroplasty for the treatment of failed hemiarthroplasty in patients with fracture of the proximal humerus.

BACKGROUND: Little information is available for the outcomes of conversion to total shoulder arthroplasty (TSA) of failed hemiarthroplasty (HA) implanted for fractures or fracture-dislocations of the proximal humerus. MATERIALS AND METHODS: We evaluated the clinical and radiographic results in 16 patients who underwent conversion of HA to TSA due to pain and shoulder disfunction. Patients were a mean age of 63 years at revision, which was occurred a mean of 3.3 years after the HA. The main prerequisites for conversion were forward flexion to at least 60°, no massive cuff tear, or severe resorption or nonunion of the tuberosities. In all cases, a modular prosthesis was used in the HA, uncemented in 14 and cemented in 2. The latest follow-up was a mean of 4.6 years after revision. RESULTS: The mean Constant score was 50.6 (range, 33-69), with an average increase of 11.9 points compared with the preoperative score (P = .001). In 75% of patients, the mean score was 54.6 (average increase, 15.1 points). The lowest scores occurred in patients with a cemented prosthesis that needed to be removed, and in 1 patient who had loosening of the implanted glenoid that was revised. CONCLUSIONS: Conversion of HA to TSA can improve the preoperative condition in most patients aged in their 50s or 60s in the absence of rotator cuff deficiency and severe bone loss of the proximal humerus.

Inverted-Bearing Reverse Shoulder Arthroplasty: Consequences on Scapular Notching and Clinical Results at Mid-Term Follow-Up.

Background: Scapular notching following reverse shoulder arthroplasty (RSA) is caused by both biological and mechanical mechanisms. Some authors postulated that osteolysis that extends over the inferior screw is caused mainly by biological notching. Inverted-bearing RSA (IB-RSA) is characterized by a polyethylene glenosphere and a metallic humeral liner, decreasing the poly debris formation and potentially reducing high grades of notching. This study aims to report the results of IB-RSA on a consecutive series of patients at mid-term follow-up, focusing on the incidence of Sirveaux grade 3 and 4 scapular notching. Methods: A retrospective study on 78 consecutive patients who underwent primary IB-RSA between 2015−2017 was performed. At a 4 years minimum follow-up, 49 patients were evaluated clinically with Constant score (CS), Subjective shoulder value (SSV), American Shoulder and Elbow score (ASES), pain and range of motion, and with an X-ray assessing baseplate position (high, low), implant loosening, and scapular notching. Results: At a mean follow-up of 5.0 ± 0.9, all the clinical parameters improved (p < 0.05). One patient was revised for an infection and was excluded from the evaluation, two patients had an acromial fracture, and one had an axillary neuropraxia. Scapular notching was present in 13 (27%) patients (six grade 1, seven grade 2) and no cases of grade 3 and 4 were observed. Scapular nothing was significantly associated with high glenoid position (p < 0.001) and with lower CS (70 ± 15 vs. 58 ± 20; p = 0.046), SSV (81 ± 14 vs. 68 ± 20; p = 0.027), ASES (86 ± 14 vs. 70 ± 22; p = 0.031), and anterior elevation (148 ± 23 vs. 115 ± 37; p = 0.006). A 44 mm- compared to 40 mm-glenosphere was associate with better CS (63 ± 17 vs. 78 ± 11; p = 0.006), external (23 ± 17 vs. 36 ± 17; p = 0.036), and internal rotation (4.8 ± 2.7 vs. 7.8 ± 2.2; p = 0.011). Conclusions: IB-RSA is a safe and effective procedure for mid-term follow-up. Inverting biomaterials leads to a distinct kind of notching with mainly mechanical features. Scapular notching is associated with a high baseplate position and has a negative influence on range of motion and clinical outcome.

Posterior superior internal impingement: an evidence-based review [corrected].

Over the last decade, the concept of internal impingement has continued to evolve, and the frequency with which this condition is recognised continues to increase. This syndrome should be clearly differentiated from the classical (external) impingement that is thought to be caused by compression of the subacromial bursa, long head of the biceps tendon and rotator cuff (RC) by the coraco-acromial arch. Internal (posterosuperior) impingement syndrome is typified by a painful shoulder due to impingement of the soft tissue, including the RC, joint capsule and the posterosuperior part of the glenoid. The aetiology of this syndrome is unclear, but hypotheses include anterior shoulder instability or micro-instability, contracture of the posterior capsule, reduced humeral retroversion and scapular dyskinesis. Non-operative therapy represents the first line of treatment for this syndrome and includes the management of pain, stretching of the posterior capsule and a muscle strengthening programme. Surgical treatment should only be considered when conservative management fails. A number of different surgical procedures have been proposed, but the results are variable. The success rate is generally improved when the subtle instability, associated with internal impingement, is also addressed.

Effects of posterior-inferior capsular plications in range of motion in arthroscopic anterior Bankart repair: a prospective randomized clinical study.

The effects of posterior plications associated with anterior shoulder instability surgery are still unclear both on shoulder range of motion (ROM) and on recurrence rate. The objective of this randomized study is to evaluate the influence of posterior-inferior plications, performed in association with repair of anterior Bankart lesion, on gleno-humeral (GH) range of motion. In a 24-month period, 40 patients were prospectively enrolled in this study. The criteria for inclusion were age between 17 and 40 years, traumatic unidirectional instability, no previous shoulder surgery, no more than three episodes of dislocation, no relevant glenoid bone deficiency, no clinical evidence of pathological anterior inferior laxity (measured with external rotation with the arm at the side inferior to 90 degrees and Gagey sign negative) and arthroscopic finding of isolated anterior Bankart lesion. A total of 20 patients (group A) were randomized to treat Bankart lesion using three bioadsorbable anchors loaded with a #2 braided polyester suture. In 20 randomized patients (group B) two posterior-inferior capsular plications performed with a #1 polidioxanone suture without any capsular shift were added to the same anterior capsulorraphy performed in group A. Postoperative rehabilitation protocol was the same for all 40 patients. Patients were examined preoperatively and at a 2-year follow-up by a single independent expert physician unaware of the surgical procedure. GH ROM, Constant, UCLA and ASES rating scores as well as recurrence of instability were recorded. At follow-up, forward flexion (FF) decreased by a mean value of 14.5 degrees (median -10 degrees ; range -5 degrees to -35 degrees ; P < 0.001) in group B and increased by a mean value of 3.5 degrees (median 0 degrees ; range -25 degrees to 40 degrees ; P < 0.312) in group A; external rotation with arm adducted (ER1) increased by a mean value of 1.8 degrees (median 0 degrees ; range -15 degrees to 30 degrees ; P < 0.924) in group B, and increased by a mean value of 2.6 degrees (median 2.5 degrees ; range -38 degrees to 40 degrees ; P < 0.610) in group A; external rotation with arm abducted at 90 degrees (ER2) decreased by a mean value of 2.9 degrees (median 0 degrees ; range: -20 degrees to 10 degrees ; P < 0.161) in group B and increased by a mean value of 0.7 degrees (median 0 degrees ; range -30 degrees to 25 degrees ; P < 0.837) in group A; the IR2 decreased by a mean value of 2.4 degrees (median -3.5 degrees ; range -15 degrees to 10 degrees ; P < 0.167) in group B and increased by a mean value of 2.2 degrees (median 0 degrees ; range -20 degrees to 30 degrees ; P < 0.456) in group A. The UCLA mean score gains by 43.1% (median 40; P < 0.001) relatively, and of 45.2% relatively (median 40; P < 0.001), respectively, in group B and A, ASES mean score relatively gains by 21.7% (median 21.2%; P < 0.001) in group B, and of 19.2% (median 18.9%; P < 0.001) in group A, and Constant mean score improves by 20.2% (median 16.5; P < 0.001) in group B, and 10.2% (median 8.4%; P < 0.001) in group A. Thus, the only statistical significant differences were the reduction of forward flexion in group B and the improvements of the scores in both groups. No recurrence of instability was found in the plicated group, while in the non-plicated group we had one traumatic recurrence. In conclusion, arthroscopic posterior-inferior plications associated with a Bankart lesion repair in a selected group of patients seem to reduce only FF, without any effect on rotation. A longer follow-up and a larger number of patients are needed to give definitive conclusions on the benefit to the recurrence rate.

Posterior shoulder pain and anterior instability: a preliminary clinical study.

Different clinical tests have been suggested in the literature as significant indicators of anterior shoulder instability. Sometimes patients with recurrent anterior shoulder instability may show some muscular guarding thus making the evaluation of specific clinical tests very difficult. These patients may also report a medical history with posterior shoulder pain that can be also elicited during some clinical manoeuvres. From September 2005 to September 2006 we prospectively studied patients who underwent an arthroscopic anterior capsuloplasty. Shoulder clinical examination was performed including anterior shoulder instability tests (drawer, apprehension and relocation tests). Furthermore the exam was focused on the presence of scapular dyskinesia and posterior shoulder pain. The patients were also evaluated with ASES, Rowe, SST (Simple Shoulder Test), Constant and UCLA (University of California at Los Angeles) scoring system preoperatively and at the latest follow-up time. In the period of this study we observed 16 patients treated for anterior gleno-humeral arthroscopic stabilisation, who preoperatively complained also of a posterior scapular pain. The pain was referred at the level of lower trapezium and upper rhomboids tendon insertion on the medial border of the scapula. It was also reproducible upon local palpation by the examiner. Four of these patients also referred pain in the region of the insertion of the infraspinatus and teres minor. After arthroscopic stabilisation the shoulder was immobilised in a sling with the arm in the neutral rotation for a period of 4 weeks. A single physician supervised shoulder rehabilitation. After a mean time of 6.8 months of follow-up, all the shoulder scores were significantly improved and, moreover, at the same time the patients referred the disappearance of the posterior pain. Posterior scapular shoulder pain seems to be another complaint and sign that can be found in patients affected by anterior shoulder instability. It can also be related to eccentric work of posterior stabilising muscles of scapula during the altered biomechanics observed in case of anterior shoulder instability. This pain responds positively to surgical intervention showing that re-centring the humeral head probably also re-establishes the periscapular muscle-firing pattern with a mechanism mediated by the proprioceptive system.

Arthroscopic rotator cuff repair using a triple-loaded suture anchor and a modified Mason-Allen technique (Alex stitch).

Surgical repair of the rotator cuff must have good resistance and should restore the tendon footprint. To attain this goal, a stitch with a strong biomechanical profile that avoids tissue strangulation should be used. We describe an arthroscopic suture technique undertaken to repair rotator cuff tears with a single triple-loaded suture anchor. The technique consists of a combination of a horizontal mattress and 2 vertical simple sutures that are positioned medial to the mattress suture. The suture anchor used is the 5-mm self-tapping ThRevo (Linvatec). This anchor is loaded with 3 sutures: 2 No. 2 nonabsorbable braided polyester sutures of different colors and a central high-strength No. 2 polyethylene suture. The shape of the anchor eyelet permits all 3 sutures to glide freely. A modified Mason-Allen technique (Alex stitch) that combines a horizontal side-to-side suture and 2 simples sutures as vertical loops is used. With use of the Spectrum suture passing device and shuttle relay system (Linvatec), both limbs of the centrally located polyethylene suture are passed through the cuff from bottom to top, approximately 1 cm from the tendon edge. This suture is not immediately tied. Next, with use of the same system, the other 2 sutures are placed medially and over the previous horizontal suture. Simple sutures are placed at an approximately 30 degrees angle from the center of the anchor; 1 is placed anterior and the other posterior. The sutures are tied through the lateral portal. The mattress horizontal central stitch is always tied first, followed by the 2 vertical sutures. The horizontal mattress suture serves as a "rip stop stitch" and theoretically reduces the possibility of cutting out of the simple sutures.

Posterior humeral avulsion of the glenohumeral ligament: a clinical review of 9 cases.

PURPOSE: The purpose of this article is to report the characteristic conditions in which a posterior humeral avulsion of the glenohumeral ligament (PHAGL) lesion occurs, defining also the different possibility of association with other intra-articular shoulder pathologies. METHODS: We identified in our database 16 consecutive patients with a PHAGL lesion who underwent surgical treatment. Six of these patients had previous failed anterior shoulder stabilization, and 1 patient failed thermal shrinkage for a multidirectional instability and were not included in this study. The 9 remaining patients were enrolled in this study. All 9 patients developed a PHAGL lesion after a sports-related trauma. Clinical symptoms reported by the patients and clinical examination data were variable depending also on associated intra-articular shoulder pathology. The diagnosis of a PHAGL lesion was not made in any of the cases preoperatively. All 9 patients underwent arthroscopic repair of the PHAGL lesion. During the surgical procedure, any additional intra-articular shoulder lesion was treated. Patients were evaluated preoperatively and postoperatively for pain and range of motion using standardized shoulder scales including the Simple Shoulder Test (SST), University of California Los Angeles (UCLA) rating score, and Constant score. RESULTS: Arthroscopic evaluation revealed that PHAGL was seen as an isolated lesion in only 3 patients. At a mean follow-up of 34.2 months, all patients were pain free and reported a complete resumption of sports and daily living activities. Two patients had a limitation of internal rotation to the T11 level. The UCLA score improved from 16.3 to 34.7, the Constant score improved from 52.3 to 80.2, and the SST score improved from 7.9 to 4.2. CONCLUSIONS: The PHAGL lesion is challenging to diagnose clinically. It can be the cause of posterior instability or a component of the spectrum of shoulder instability and associated with anterior labral or capsular pathology. Because physical examination can be misleading, a gadolinium-magnetic resonance arthrogram and comprehensive arthroscopic evaluation visualizing from the anterior and posterior portals can confirm the diagnosis. We repaired the PHAGL lesions arthroscopically along with all associated shoulder abnormalities resulting in a good outcome. LEVEL OF EVIDENCE: Level IV, therapeutic cases series.

Influence of glenosphere design and material on clinical outcomes of reverse total shoulder arthroplasty.

BACKGROUND: The aim of this multicentre retrospective study was to compare reverse total shoulder arthroplasty clinical outcomes with glenospheres of different diameters, designs and materials. METHODS: Between 2003 and 2008, 133 patients were divided into three groups: 60 (45%) with 36-mm standard CoCrMo (group A), 21 (16%) with 36-mm eccentric cobalt-chromium-molybdenum (CoCrMo) (group B) and 52 (39%) with 44-mm cross-linked ultra-high molecular weight polyethylene (X-UHMWPE) (group C) glenospheres. Mean (SD) follow-up was 38.7 (17.4) months. Clinical evaluation included Constant score and range of motion. Radiographic analysis included radiolucent lines, instability, loosening and assessment of scapular notching. RESULTS: Mean Constant score significantly increased for all groups (Wilcoxon test, p < 0.001). Group C allowed a higher and stable increase in range of motion. After 12 months and 24 months, groups C and B showed less pain than group A (Mann-Whitney U-test, p < 0.05). Group C had significantly lower scapular notching than group B (Mann-Whitney U-test, p = 0.001) and A (Mann-Whitney U-test, p = 0.009) at 12 months, 24 months and 36 months. Groups A and C presented 5 (8.3%) and 4 (7.6%) early complications, respectively. CONCLUSIONS: The present study reported good results for all groups, although groups C and A presented better clinical outcomes, significantly lower notching and instability. A 44-mm X-UHMWPE glenosphere allowed a faster and more stable functional recovery, despite poorest pre-operative conditions. Additional long-term studies are needed to evaluate survivorship.

The role of arthroscopic capsulo-labral repair in unidirectional post-traumatic shoulder instability in adolescent athletes participating in overhead or contact sports.

PURPOSE: this study was performed to identify the role of arthroscopic capsulo-labral repair (ACR) in unidirectional post-traumatic shoulder instability in adolescent athletes participating in overhead or contact sports. METHODS: sixty-five adolescent patients (aged 13 to 18 years) with post-traumatic shoulder instability submitted to arthroscopic surgery were selected from our database. The mean follow-up duration was 63 months. Shoulder range of motion and functional outcomes were evaluated preoperatively and postoperatively using the Single Assessment Numeric Evaluation (SANE), Rowe, and American Shoulder and Elbow Surgeons (ASES) scores. In addition, details in the database on the type of sport practiced, time until surgery, and number of dislocations were analyzed to look for possible correlations with the recurrence rate. RESULTS: at the final follow-up, the mean SANE score was 87.23% (range: 30% to 100%) (preoperative mean score: 46.15% [range, 20% to 50%]); the mean Rowe score was 85 (range: 30 to 100) (preoperative mean score: 35.9 [range: 30 to 50]); and the mean ASES score was 84.12 (range: 30 to 100) (preoperative mean score: 36.92 [range: 30 to 48]). Mean forward flexion and external rotation with the arm at 90° abduction did not show changes compared with preoperative values; 81.5% of the patients returned to their pre-injury level of sports activities, and the failure rate was 21.5%. The recurrence rate was not related to the postoperative scores (p = 0.556 for SANE, p = 0.753 for Rowe, and p = 0.478 for ASES), number of preoperative episodes of instability (p = 0.59), or time that elapsed between the first instability episode and the surgery (p = 0.43). A statistically significant association (p = 0.0021) was found between recurrence and the type of sport practiced. CONCLUSIONS: ACR is a reasonable surgical option in an adolescent population participating in sports. It has a role in restoring shoulder stability with very low morbidity; however, the failure rate is higher than in the adult population and both the young patients and their relatives must be properly informed about the expected outcome of the procedure. LEVEL OF EVIDENCE: level IV, therapeutic case series.

Reverse total shoulder arthroplasty: radiological and clinical result using an eccentric glenosphere.

In reverse shoulder arthroplasty, an eccentric glenosphere has been developed with the aim of lowering the centre of rotation, in order to prevent inferior scapular notching as occurs with concentric designs. The objective of this retrospective study was to evaluate clinical and radiographic outcomes using the eccentric glenosphere and to determine whether this design might prevent inferior scapular notching. Between 2006 and 2010, 40 patients affected by cuff tear arthropathy underwent reverse shoulder arthroplasty with an eccentric 36-mm glenoid component. Patients with less than 2 years' follow-up were excluded. The results for 25 patients with a minimum of 24 months' follow-up are reported. Clinical and radiographic evaluation was performed preoperatively and at 1, 3, 6 months, 1 year and annually thereafter. All patients were evaluated with MRI or CT scan preoperatively and with X-ray examinations postoperatively to evaluate the presence of inferior scapular notching and to measure the prosthesis-scapular neck angle (PSNA), the peg-glenoid rim distance (PGRD) and the distance between the scapula neck and the glenosphere. At last follow-up (average 27.5 months, range 24-46), the Constant Score, the VAS score and range of motion had improved significantly. The average PSNA was 92° + 29°, the average PGRD was 21.2 mm + 9 mm and the average distance between the inferior bony glenoid rim and the inferior edge of the glenosphere was 4.3 mm + 0.8 mm. No inferior scapular notching and no implant-related complications were seen. The data suggest that use of an eccentric glenosphere lowers the centre of rotation, reducing the risk of inferior scapular notching. Level of evidence IV.