Bone grafting augmentation choices in complex proximal humerus fractures: A systematic review.

Objective: To systematically identify and evaluate different bone graft augmentation techniques in the operative treatment of complex proximal humerus fractures. Methods: Four databases were searched from 1970 to February 2023 for Level I to IV English studies that investigated outcomes of different bone augments in the primary surgical fixation of proximal humerus fractures. The JBI critical appraisal checklist, methodological index for non-randomized studies and cochrane risk of bias tool were used to assess study quality. Descriptive statistics including weighted means are presented where applicable. Methods: Thirty-three articles including 964 patients met the inclusion. Seven bone augments were identified, including fibular strut allograft (693 patients across 21 studies), femoral head allograft (84 patients across 4 studies), iliac crest allograft (54 patients across 3 studies), iliac crest autograft (94 patients across 5 studies), humeral endosteal allograft (6 patients in 1 single study), unspecified cancellous allograft (28 patients in 1 single study) and distal clavicle autograft (3 patients in 1 single study). Mean patient age was 67.1 years, with female patients comprising 65.2 %. Fracture union rates were similar between groups, with an average of 99.6 %. The average Constant Murley Score (CMS) was not reported in the humeral endosteal allograft or the distal clavicle autograft group but was 81.8 (fibular strut allograft), 79.1 (femoral head allograft), 76.8 (iliac crest allograft), 77.7 (iliac crest autograft), and 81.5 (unspecified cancellous allograft) in the remaining groups. Revision surgery was required in 16.7 % of patients receiving humeral endosteal allograft, 7 % of patients with femoral head allograft, 2 % of iliac crest autografts and 1.9 % in the fibular allograft group. Reported complications included avascular necrosis, hardware complications and loss of reduction. Conclusion: Bone graft augmentation is an effective adjunct to open reduction internal fixation of complex proximal humerus fractures. Fibular strut allograft is the most common bone graft augment used. Majority of patients treated with bone graft augmentation achieved bony union (83%-100 %) and average CMS scores at final follow-up were similar between graft types (76-82). However, no conclusive data suggests superiority of one bone graft type over another. Future studies should aim to compare the outcomes amongst graft types.

Upper extremity neuromuscular function can distinguish between individuals with and without glenohumeral labral repair.

The purpose of this study was to determine whether common measures of neuromuscular function could distinguish injury status indicated by group membership (glenohumeral labral repair, uninjured controls). 16 individuals with glenohumeral labral repair (24.1 ± 5.0 years, 36.7 ± 33.3 months after surgery) and 14 uninjured controls (23.8 ± 2.7 years) volunteered. We measured mass-normalized shoulder abduction and wrist flexion maximal voluntary isometric contraction torque (Nm/kg), motoneuron pool excitability of the flexor carpi radialis (Hoffmann reflex), corticospinal excitability of the upper trapezius, middle deltoid, and flexor carpi radialis (active motor threshold [%]) bilaterally. Receiver operator characteristic curve analyses were performed to determine if each outcome could distinguish injury status along with their outcome thresholds. Binary logistic regression was used to determine the accuracy of classification for each outcome. Our results suggest shoulder abduction torque symmetry (≤95.5 %) and corticospinal excitability for the upper trapezius (≥41.0 %) demonstrated excellent diagnostic utility. Shoulder abduction torque (≤0.71 Nm/kg) and motoneuron pool excitability (≤0.23) demonstrated acceptable diagnostic utility. Shoulder abduction torque symmetry alone was the strongest indicator, and classified injury status with 90.0 % accuracy (p < 0.01). Overall, symmetric shoulder abduction strength most accurately distinguished individuals' injury status, suggesting the utility of bilateral assessment in this population.

Convertible glenoid replacement in the anatomical total shoulder arthroplasty: medium-term results.

INTRODUCTION: The older generation of high thickness metal-backed glenoid prostheses had a high failure rate. The goal of our study was to analyze the medium-term clinical and radiological results of a technically modified generation of metal backed glenoids with 35% decrease in thickness. METHODS: Thirty-nine patients (43 shoulders) with a mean age of 66.5 years at surgery were examined from two to ten years (mean 71.2 months) using the Constant-Score, Subjective Shoulder Value and X-ray in a.p. and axial view. Indication for surgery included patients with glenoid types B1, B2, or B3 and/or posterior subluxation but intact rotator cuff, or patients who did not want a reverse prosthesis and had high functional demands. Inclusion criteria comprised participation in a clinical and radiological follow-up examination, along with a minimum follow-up duration of 24 months. Additionally, in all cases, the Constant Score and the Subjective Shoulder Value (PROM) had to be determined. Exclusion criteria were an incomplete dataset, implantation of a different prosthesis type, and failure to meet the minimum follow-up time. RESULTS: The absolute Constant Score (CS) improved significantly (p < 0.0001) from 43 ± 13 (range: 20-69) points before to 80 ± 13 (range: 46-98) points after surgery. The only preoperative negative influencing factor on the result was the glenoid protrusion according to Lévigne (p = 0.0150). No significant differences in functional outcomes were found between glenoid types A2, B1, B2 and B3. Radiolucent lines at the interface were observed in a total of four patients (13%). Radiological signs of glenoid osteolysis were seen in six patients (20%). Humeral upward migration was observed in four patients (13%) and posterior shoulder joint decentering occurred in one patient (3%). Implant-specific complications occurred in three cases (7%). Due to a massive rotator cuff tear, two cases (4.7%) had to be converted to a reversed implant, with the primary metal component remaining in place. If the implant-specific and rotator cuff-associated complications are summarized, the rate is 11.7%. All components that required conversion to an reverse implant have so far remained free of complications. CONCLUSION: Favorable clinical results can be achieved, especially in patients with an eccentric glenoid type. Severe preoperative glenoid erosion (Walch A2, B2, B3) does not appear to have any influence on postoperative functional results. The complication and revision rates are significantly better than in previous studies with conventional metal-backed glenoid components. Conversion of the anatomical glenoid component to a reverse system was always possible and good clinical results were achieved.

Cross-cultural adaptation and test-retest reliability assessment of a Swedish version of the exercise adherence rating scale in patients after shoulder surgery.

BACKGROUND: Adherence to prescribed home exercise is an important predictor for the long-term effectiveness of exercise therapy and therefore important to evaluate. The Exercise Adherence Rating Scale (EARS) is a valid and reliable tool to assess exercise adherence behavior, but it is not translated into Swedish. This study aimed to translate EARS into Swedish and to explore the psychometric properties in terms of test-retest reliability, internal consistency as well and possible floor-/ceiling effects. MATERIALS AND METHODS:   A translation and cultural adaptation process followed international guidelines and resulted in EARS-Sv. A total of 30 patients who had undergone shoulder surgery were included in the study and filled out EARS-Sv at two different time points. The test-retest reliability was evaluated through the weighted kappa coefficient and Intraclass Correlation Coefficient (ICC). Cronbach's alpha was used to assess internal consistency. Floor-/ceiling effects were calculated. RESULTS: The test-retest reliability of the questionnaire was good with ICC (0.79, CI 95%) and moderate with weighted kappa-coefficient (MD= 0.58). Cronbach's alpha was considered good (0.88). A ceiling effect was registered in all 6 items of EARS-Sv. CONCLUSION: EARS-Sv has moderate to good test-retest reliability and good internal consistency in patients who have undergone shoulder surgery.

The postoperative results in orthopaedic patients are often dependent on adherence to postoperative home rehabilitation programs.Exercise Adherence Rating Scale (EARS) is a questionnaire assessing adherence to prescribed home exercise and the Swedish version has an acceptable test-retest reliability and good internal consistency for patients who have undergone shoulder surgery.The Swedish version of EARS could be used as a tool to identify patients having difficulties adhering to the prescribed home exercises.

Intraoperative Spinal Accessory Nerve Monitoring During Neck Dissection Surgery as a Predictor for Shoulder Dysfunction.

Shoulder dysfunction is one of the most common complications seen in patients who have undergone neck dissection surgery. The prevalence of shoulder dysfunction increases depending on the type and extent of neck dissection surgery. We aim to study the relationship between changes in intraoperative neuromonitoring (IONM) threshold during SAN stimulation, ultrasonographic measurement of muscle size and shear wave elastography with shoulder dysfunction. This is a prospective study. All patients who have undergone neck dissection in our centre have been recruited. Analysis of demographic data, IONM threshold during exposure and pre-closure, shoulder function score, neck disability index score (NDII) and ultrasonographic parameters pre-op and during follow up was done. The cohort was divided into patients who suffered from shoulder dysfunction post op (Group A) and patients with normal shoulder function post op (Group B). Statistical significance were seen in IONM threshold during SAN stimulation and Constant shoulder score for 6 months follow up in Group A. IONM threshold difference during exposure and pre-closure could effectively prognosticate shoulder dysfunction post op. A return of shoulder function could be seen in patients who suffered from shoulder dysfunction if early physiotherapy could be commenced.

Locked Posterior Shoulder Dislocation with Accompanying Fracture: A Debilitating Rare Injury for Athletes?

Shoulder dislocation is undoubtedly one of the most common injuries in traumatology. Posterior dislocation of the shoulder is regarded as comparatively rare compared to anterior dislocation, whilst it is strikingly extraordinary for this type of injury to be accompanied by a concomitant fracture. Accurate diagnosis and appropriate treatment can be considerably demanding, while being vitally important in this exceedingly rare condition. These injuries are broadly considered to be under-reported in the existing literature, especially among high-demand athletes. We present a rare case of a high-demand athlete sustaining a traumatic locked posterior shoulder dislocation with an accompanying fracture treated in our Institution. A detailed clinical examination and plain radiography revealed the peculiar condition, and a CT scan was subsequently performed for more thorough evaluation of the injury. The patient underwent surgery on the day following admission for repair of the extensive shoulder damage, and a deltopectoral approach was utilized. Reduction of the metaphyseal fracture and the dislocation was accomplished with gentle manipulations, and stabilization was obtained with an anatomic plate. A modified McLaughlin procedure was carried out to address the reverse Hill-Sachs lesion. The postoperative period was uneventful, followed by a painstaking physical rehabilitation program, and the patient returned successfully to his sporting activities 6 months postoperatively. By presenting this thought-provoking case, we stress the challenging nature of these immensely infrequent injuries while also highlighting the requirement for more sensitive factor-specific studies regarding their optimal treatment.

Inferior Glenoid HyperOSTosis (GHOST) Lesion Development Following Reverse Total Shoulder Arthroplasty.

BACKGROUND: Patients undergoing reverse shoulder arthroplasty (RTSA) have been noted on postoperative radiographs to have a curved bony overgrowth on the inferior glenoid neck. This study aims to investigate potential risk factors for and postoperative effects of these ossifications, here called glenoid hyperostosis (GHOST) lesions due to their location. METHODS: A retrospective review of patients undergoing reverse total shoulder arthroplasty between 2007 and 2020 at a single institution was performed. Predictors including gender, age, implant sizing, and preoperative diagnosis were examined using logistic regression analysis. Outcomes including readmission rate, revision rate, preoperative and postoperative range of motion, visual analog scale (VAS) pain scores, and American Shoulder and Elbow Surgeons (ASES) functional outcome scores were also analyzed using two-sample t-tests. RESULTS: Preoperative and postoperative radiographs of 170 primary reverse shoulder arthroplasty patients were assessed. 25.9% of RTSAs were identified to have a GHOST lesion. When adjusting for race, age, BMI, preoperative diagnosis, male patients were still associated with 2.28 odds of developing a GHOST lesion compared to female patients (95% CI: 1.08 - 4.86). Other elements such as age, race, BMI, laterality, preoperative diagnosis, implant manufacturer, and implant sizing demonstrated no statistically significant association to GHOST lesion presence. Postoperatively, GHOST lesion development was not associated with range of motion or ASES score. However, presence of GHOST lesions on radiographs was associated with increased pain scores for patients at 2 months (p = 0.034) and 12 months (p = 0.029) postoperatively. DISCUSSION: Inferior glenoid hyperostosis (GHOST) lesions is a common and potentially benign finding following reverse shoulder arthroplasty, with unclear etiology. Risk factors for GHOST lesions included male gender, while patient demographics, implant type or size, shoulder lateralization and distalization were not associated with lesion formation. Clinically, greater short-term VAS scores were seen in patients with GHOST lesions. However, there were no differences observed between the two groups in ASES scores or postoperative range of motion at later time points. Further research is needed to identify risk factors and assess the clinical implications of GHOST lesions.

Prevalence and associated factors of non-traumatic shoulder pain during spike and serve movements in male high school volleyball players: a cross-sectional study.

BACKGROUND: Nontraumatic shoulder pain is a prevalent issue among male high school volleyball players, but its comprehensive assessment has been lacking in prior research, which often isolated specific aspects of shoulder function. This study aimed to identify contributing factors to shoulder pain in this population. HYPOTHESIS: The hypothesis posited that limited shoulder internal rotation (IR) range of motion (ROM), imbalance in rotator cuff muscle strength, intrinsic sensory disturbance, and joint stability are associated with shoulder pain in male high school volleyball players. Additionally, there was an anticipation that a substantial proportion of players would experience shoulder pain but refrain from reporting it to coaches. METHODS: Forty-nine male volleyball players aged 15-17 years were evaluated between February and June 2023. Questionnaires assessed the prevalence of shoulder pain during spiking and/or serving, as well as the frequency of reporting this pain to coaches. Various factors, including acromio-humeral distance, shoulder ROM, isometric strength, proprioception, joint stability (Upper Quarter Y-Balance Test), joint position sense, and upper extremity power (Seated Medicine Ball Throw Test; SMBT), were quantified. Logistic regression analyses was conducted to explore potential connections between these variables and shoulder pain. RESULTS: Shoulder pain was reported by 39% of participants, but it was rarely communicated to coaches (95%). Jump serves (odds ratio 1.84, p=0.02) and reduced shoulder IR ROM (odds ratio 0.94, p=0.03) were associated with shoulder pain. CONCLUSION: This study provides crucial insights into the prevalence, severity, and associated factors of shoulder pain among male high school volleyball players. The findings underscore the importance of improving athlete-coach communication to facilitate early intervention and preventive measures. Significant associations were observed between the use of jump serves, reduced shoulder internal rotation range of motion, and shoulder pain, highlighting the relevance of specific volleyball techniques in injury prevention. These findings offer valuable guidance to coaches and trainers in developing interventions aimed at mitigating the risk of shoulder pain and enhancing player performance.

Modified notching classification in inverted-bearing and conventional-bearing reverse total shoulder arthroplasty.

BACKGROUND: Scapular notching is a common complication of reverse total shoulder arthroplasty (RTSA). Although the notching rate has reduced significantly thanks to modifications to the surgical technique and humeral and glenoid components, uncontrollable polyethylene (PE)-induced osteolysis can still occur. In contrast to conventional-bearing (CB-RTSA), inverted-bearing RTSA (IB-RTSA) systems, with PE glenospheres and metal or ceramic humeral liners, avoid PE abrasion through scapulohumeral contact. If present, the resulting notch has a different size and configuration than with CB-RTSA. Thus, a modified notching classification seems reasonable. Even in CB-RTSA, the early stages of notching show a different configuration than implied by the established Nerot-Sirveaux classification; therefore, a modification of the classification system is recommended. METHODS: In a prospective multicentre study, 250 cases underwent IB-RTSA. Of these, 39 died, and 28 were lost to follow-up for other reasons, leaving 183 shoulders for the final follow-up examination at a mean of 120.7 months (range 84.1-172.4 months). In the CB-RTSA group, we retrospectively evaluated radiographs of 59 consecutive patients with a follow-up ranging from 2 to 7 years. We analysed the appearance, evolution over time, and location of bone loss on the scapular neck according to the modified Nerot-Sirveaux classification. RESULTS: In IB-RTSA, notching resulted in a new morphological configuration: In contrast to the Nerot-Sirveaux classification, notching began far from the baseplate as an impression or abrasion of the humeral component in the inferior scapular rim. Due to simultaneous mechanical ablation, the defect gradually enlarged, but usually did not contact the baseplate or extend beyond the inferior peg. No signs of PE-induced osteolysis were found. The notching rate reached 19% after 2 years and approached 36% after 10 years. Most shoulders had grade 0 notching (64%), followed by grade 1 (29%); extensive erosion (grade 4) was not observed. In the CB-RTSA group, a small bony impression or erosion without signs of PE-induced osteolysis was observed medial to the scapular neck, without contact with the metaglene in the early phase, which was similar to the impression of the humeral component in IB-RTSA. The notching rate was 86% for CB-RTSA. CONCLUSIONS: A new classification was developed for IB-RTSA, which corresponds to the pathophysiological processes and is compatible with the existing Nerot-Sirveaux classification. Bone erosion in CB-RTSA is not adequately represented by the established classification in the early stages. For this reason, a supplement to the existing classification is presented. LEVEL OF EVIDENCE: Level 4, Case Series, Treatment Study.

5 months old neglected anterior shoulder dislocation treated with open reduction and laterjet procedure: A case report.

INTRODUCTION: Shoulder dislocation is very common. However, neglected or chronic shoulder dislocations are extremely rare. The position of the humeral head determines the classification of shoulder dislocation. Anterior shoulder dislocation accounts for most cases, while inferior dislocation is rare. Negligence from the patient and misdiagnosis are the leading causes of chronic shoulder dislocation. Treatment of the condition poses a significant challenge for surgeons since there is no widely accepted treatment protocol. CASE PRESENTATION: A 56-year-old woman presented with a neglected anterior subglenoid dislocation of the shoulder joint. The dislocation occurred due to a cow kick, and initial treatment from a traditional healer and an unqualified health practitioner failed. Clinical examination and X-ray confirmed the dislocation without associated fractures. An initial attempt at closed reduction under sedation was unsuccessful. Subsequently, open reduction and a Latarjet procedure were performed successfully, resulting in a satisfactory outcome. DISCUSSION: Chronic anterior dislocation primarily affects the elderly population. Open reduction and fixation procedures have shown satisfactory outcomes. The choice of treatment depends on several factors, including bone deficiencies, soft tissue damage, and the presence of Hill-Sachs or Bankart lesions. Open reduction and laterjet procedure is a validated treatment. However, early physical therapy contributes to favorable outcomes. CONCLUSION: The condition's rarity makes it difficult to establish a well-accepted treatment protocol. Early and strict rehabilitation protocols will lead to a favorable outcome.

Factors associated with resorption of calcific deposits in the shoulder with extracorporeal shock wave therapy.

BACKGROUND: Focused extracorporeal shock wave therapy (FSWT) is effective for treating calcific tendinitis of the shoulder. However, only a few reports exist on the factors related to calcium resorption after FSWT. Thus, this study aimed to investigate the factors associated with calcium resorption. METHODS: In 117 shoulders with chronic calcific rotator cuff tendinitis, FSWT was administered nine times once every 2 weeks (a total of 16 weeks). After nine sessions of FSWT, the shoulders were radiographed and categorized into complete resorption (CR) and incomplete resorption (ICR) groups. Evaluated parameters included age, duration of disease, Gärtner classification, size of calcium deposits, presence of blood flow around calcium deposits using the Doppler function of the ultrasound imaging system, Japanese Orthopaedic Association (JOA) score, University of California at Los Angeles score, disability of the arm, shoulder, and hand (UCLA) score, and tenderness. RESULTS: The CR group included 93 shoulders (79.4%) and the ICR group included 24 shoulders (20.6%). In the two-arm comparison, CR showed significantly longer disease duration (P=.012) and high tenderness (P=.0013). Blood flow around calcium deposits was observed in 79.5% of shoulders in the CR group (P<.0001) and 29.1% in the ICR group. Type 1 Gärtner classification (P=.0009) was observed in 28 shoulders (30.1%) in the CR group and 17 shoulders (70.8%) in the ICR group. The two groups had no significant differences in age, size of calcium deposits, JOA score, or UCLA score. Multiple logistic regression analysis was performed using the following items that showed significant differences: absence of blood flow (odds ratio [OR], 8.51, 95% confidence interval [CI]: 2.24-22.8), Gärtner classification (OR, 5.60, 95%CI: 1.73-13.3), and duration of disease (OR, 1.06, 95%CI: 0.97-1.26). Longer disease duration, Gärtner type 1, and absence of blood flow around calcium deposits resulted in difficulty in calcium resorption. CONCLUSION: Patients with Gärtner type 1 with prolonged disease duration and absence of blood flow around calcium deposits may have difficulty in achieving complete resorption.

Differences in Primary Total Shoulder Arthroplasty Volume, Reimbursement, Practice Styles, and Patient Populations Based on Surgeon Gender: A Temporal Analysis.

BACKGROUND: Orthopedic surgery has previously been shown to have a shortage of female physicians and a gender pay gap. However, this has not been thoroughly evaluated in the setting of shoulder surgery. The primary purpose of this study was to evaluate differences in total shoulder arthroplasty (TSA) volume, reimbursement, surgeon billing practices, and patient populations between male and female surgeons from 2013 to 2021. METHODS: The Medicare Physician and Other Practitioners database, a publicly available dataset that includes 100% of services billed to Medicare Part B was utilized. The database was queried for all billing episodes of Current Procedural Terminology (CPT) code 23472, which encompasses both anatomic and reverse primary TSA. Procedural volume, average inflation-adjusted reimbursement per TSA, physician billing information, and the patient demographics of each surgeon who performed TSAs were collected. Welch's t-test and Kruskal-Wallis were utilized to compare male and female surgeons each year between 2013 and 2021. RESULTS: Between 2013 and 2021, the proportion of TSAs performed by female surgeons nationally increased from 1.8% to 2.9% (+1.1%). This increase was greatest in the Northeast (2.0% to 6.1%), while a decrease was seen in the Midwest (1.9% to 1.6%). In 2021, there was no significant difference between male and female surgeons in the average inflation-adjusted reimbursement per TSA ($1,144.00 vs $1,143.00, p=0.792) and the average number of TSAs performed per surgeon (26.6 vs 23.1, p=0.105). Female TSA surgeons, on average, had less Medicare beneficiaries (348 vs 462, p<0.001), performed fewer annual services (1,817 vs 3,630, p<0.001), and performed fewer unique services (60 vs 76, p<0.001) compared to male surgeons. A higher proportion of female surgeon's patient populations were non-White (24% vs 22%, p=0.028), female (61% vs 59%, p=0.001), and dual enrolled Medicare-Medicaid patients (13% vs 10%, p<0.001). However, there was no difference in the average patient complexity between male and female TSA surgeons based on hierarchical condition category (HCC) score (1.0783 vs 1.0732, p=0.228). CONCLUSION: Female representation within TSA surgery is increasing nationally, with the greatest representation in the Northeast and West and the lowest representation in the South and Midwest. Although female TSA surgeons perform a similar number of TSAs, receive comparable reimbursement per TSA, and have a similarly complex patient population as their male counterparts, they perform significantly fewer total and unique billable services annually. Additionally, female TSA surgeons tend to see more non-White, women, and dual Medicare-Medicaid enrolled patients.

Isolated humeral distalization in reverse total shoulder arthroplasty: a biorobotic shoulder simulator study.

BACKGROUND: Humeral distalization is inherent to reverse total shoulder arthroplasty (rTSA) and is often produced with concomitant humeral lateralization via the level of the humeral head cut, implant positioning, implant neck shaft angle, and polymer insert thickness. Biomechanical data on the isolated effects of humeral distalization remain limited but could be important to consider when optimizing postoperative rTSA shoulder function. This study investigated the effects of isolated humeral distalization on shoulder biomechanics using a biorobotic shoulder simulator. METHODS: Eight fresh-frozen cadaveric shoulders were tested using custom polymer inserts that translated the bearing surface 0, +5, +10, and +15 mm along the humeral stem axis, producing isolated distalization without lateralization. Specimens underwent passive elevation in the scapular plane with a static scapula to assess glenohumeral range of motion. Scapular plane abduction motion trajectories were then performed, driven by previously collected scapulothoracic and glenohumeral kinematics from rTSA patients. The effect of isolated distalization on passive elevation was tested using mixed-effects linear regression and the effect on muscle force, joint reaction force, and muscle excursion during active scapular-plane abduction was tested using statistical parametric mapping random effects analysis. RESULTS: Maximum passive scapular plane elevation increased with humeral distalization (4° per 5 mm distalization). During active elevation, deltoid and rotator cuff muscle forces, and joint reaction forces, increased up to 37% per 5 mm of distalization. Simulated deltoid muscle excursion was altered with increasing distalization but amounted to no more than 0.8 mm change from baseline per 5 mm of distalization. Rotator cuff muscles were consistently lengthened throughout abduction, up to 1.6 mm per 5 mm of distalization. These trends were observed across various patient motions. CONCLUSIONS: Isolated humeral distalization caused dramatic increases in the muscle forces required to perform scapular-plane abduction. Joint reaction forces increased correspondingly. These results suggest that implant and surgical strategies to generate deltoid muscle tension without humeral distalization may promote better active range of motion and more durable long-term outcomes over approaches that rely on distalization.

Changes in shoulder function and muscle strength following rehabilitation exercise program in male patients with forward shoulder posture undergoing rotator cuff repair.

BACKGROUND: Abnormal posture is known to affect the efficacy of exercise therapy for musculoskeletal diseases. However, no studies to date have examined the effect of exercise programs should take into account the posture of the upper body in patients with rotator cuff disease. This study aimed to assess how rotator cuff and corrective exercises impact shoulder function and muscle strength post-arthroscopic rotator cuff repair surgery, providing tailored rehabilitation programs for patients with forward posture. METHODS: Ninety male patients who underwent arthroscopic rotator cuff repair participated in this study. The patients were randomly divided into three groups corrective exercise group (CEG, n = 29), rotator cuff exercise group (REG, n = 27), and control group (CG, n = 28). Each group was instructed to apply different exercise programs to correct posture and enhance rotator cuff strength. All patients were checked by the American Shoulder and Elbow Surgeons (ASES) score, Constant score and muscle strength, and range of motion preoperatively and postoperatively at 6 months and 1 year. RESULTS: ASES shoulder function scores showed significant difference between the three groups (p = 0.002, F = 7.03), indicating that the corrective exercise program was more beneficial than rotator cuff exercises (p = 0.009, F = 3.78). A significant intergroup difference in mean Constant score was also noted (p = 0.025, F = 3.86), while a statistically significant interaction between time and group was observed (p = 0.032, F = 2.96). CONCLUSIONS: These results suggested that a corrective exercise program can improve shoulder muscle strength and function after rotator cuff repair in male patients with a forward shoulder posture.

Intraoperative Navigation in Reverse Shoulder Arthroplasty: Advantages and Future Prospects.

Intraoperative navigation is a novel technology that can provide real-time feedback to the surgeon during implantation and enhance the accuracy and precision of glenoid component positioning. Applications of intraoperative navigation systems have demonstrated increased precision in baseplate version and inclination, as well as improved baseplate screw placement, with fewer screws used and greater purchase length achieved when compared to standard instrumentation. Early clinical studies have shown favorable results, with significantly improved patient-reported and clinical outcomes and decreased complications. The implementation of intraoperative navigation is associated with a short learning curve and a minimal increase in operative time. Nevertheless, further research is necessary to substantiate the clinical benefit of navigation and evaluate its economic cost-effectiveness and impact on implant survival. Augmented reality and robotic-assisted surgery are additional emerging technologies that, while novel, hold the potential to further advance the field of shoulder arthroplasty.

Promising clinical effect of arthroscopic autologous iliac bone grafting with suture anchor binding fixation for recurrent anterior shoulder instability.

Background: To evaluate the clinical efficacy of arthroscopic autologous iliac bone grafting with suture anchor binding fixation combined with a Bankart repair for recurrent anterior shoulder dislocation with a significant anterior glenoid defect. Methods: Patients with recurrent anterior shoulder dislocation with an anterior glenoid defect area greater than 20% admitted to our department from March 2019 to March 2022 were prospectively enrolled. Arthroscopic autologous iliac bone grafting with suture anchor binding fixation combined with a Bankart repair was performed. Computed tomography (CT) images were captured preoperatively, immediately after surgery, and at 3, 6, and 12 months postoperatively to evaluate the glenoid defect area, graft area, and graft healing. Shoulder function was assessed using the Instability Severity Index, Oxford Shoulder Instability, and Rowe scores recorded preoperatively and at the final follow-up. The shoulder range of motion, shoulder stability test, surgery-related complications, subluxation/dislocation, and revision surgery were also evaluated. Results: A total of 32 patients were included in the study, with an average follow-up time of 18.3 ± 6.3 months, when the graft healing rate was shown to be 100%. The area ratio of the graft to the glenoid was 37.6% ± 10.5% (range, 23.5%-44.1%) determined by an enface-view three-dimensional CT performed immediately after surgery, and 29.2 ± 8.2% (range, 19.6%-38.7%) at 12 months postoperatively. At the final follow-up, the glenoid defect had improved from 28.7 ± 6.4% (range, 20.5%-40.6%) before surgery to -10.2 ± 4.7% (range, -13.8% to 6.1%). The preoperative Rowe and Oxford scores were 56.4 ± 8.5 and 34.7 ± 7.1 respectively, which improved to 94.3 ± 6.7 and 15.3 ± 3.2 at the final follow-up (p < .001). All patients had no limited shoulder joint activity, no re-dislocation or revision surgery, and no neurovascular injury. Conclusions: For recurrent anterior shoulder dislocation with an anterior glenoid defect area greater than 20%, arthroscopic autologous iliac bone grafting with suture anchor fixation combined with a Bankart repair produced a promising clinical effect. A significant shoulder function score was achieved, as was a 100% bone healing rate and ideal glenoid reconstruction without major complications. Thus, this technique may be considered an alternative to the classic Latarjet approach to treat recurrent anterior shoulder dislocation with an anterior glenoid defect area greater than 20%. Level of Evidence: IV.

Inlay total shoulder arthroplasty in the weight-bearing shoulder of wheelchair-bound patients with paraplegia. A case report.

INTRODUCTION AND IMPORTANCE: Paraplegic patients' activities of daily living (ADLs) involve the use of manual wheelchairs that increase the stress on the shoulder joint. Patients with advanced glenohumeral changes are often resistant to conservative measures and may require surgical interventions. The longevity of a Total Shoulder Arthroplasty is largely unknown in paraplegics due to a lack of studies investigating outcomes in these patients. CASE PRESENTATION: We examined the outcome of two paraplegic patients following inlay total shoulder arthroplasty (iTSA) with a non-spherical humeral head and glenoid inlay replacement. CLINICAL DISCUSSION: Two patients with paraplegia and advanced degenerative joint disease who underwent iTSA were seen at regular follow-up intervals to assess range of motion, strength, and patient-reported outcome measures. Radiographic imaging was utilized to monitor slipping, lateralization, and degradation of the joint space. CONCLUSION: Both patients have shown significant increases in strength, ROM, and PROMs. iTSA proved efficacious in paraplegic patients utilizing a manual wheelchair.

Complications after Reverse Total Shoulder Arthroplasty in the Korean Population: A Single Center Study of 299 Cases.

BACKGROUND: Knowledge regarding differences in the order of frequency of complications after reverse total shoulder arthroplasty (RTSA) between Asian and Western populations is limited. We therefore asked for (1) What is the order of frequency of complications after primary RTSA in the Korean population? (2) What are the rates of complication, reoperation, and revision, and clinical outcomes after index surgery? METHODS: We retrospectively reviewed the 299 consecutive cases who underwent primary RTSA with more than 1 year of follow-up over a period of 12 years. The mean age of the patients was 73.4 years (range, 58-88 years) and the mean follow-up period was 3.8 years (range, 1-11.5 years). Evaluation of the clinical outcomes, complications, and reinterventions was performed at the final follow-up. RESULTS: The mean VAS pain score, UCLA score, ASES score, and SSV improved from 6.7, 10.2, 30.7, and 27.7% before RTSA to 1.4, 26.4, 80.5, 77.2% after RTSA, respectively (P < .001). Overall, 45 complications (15.1%) were observed in 44 patients. The order of frequency of complications was as follows: 16 cases of scapular stress fracture (5.4%), 9 intraoperative or postoperative periprosthetic fracture (3.0%), 6 brachial plexus injury (2.0%), 4 instability (1.3%), 2 glenoid loosening (0.7%), 2 glenoid disassembly (0.7%), 2 periprosthetic joint infection (0.7%), 1 glenoid fixation failure (0.3%), 1 humeral stem fixation failure (0.3%), 1 hematoma (0.3%), and 1 complex regional pain syndrome (0.3%). Reintervention was performed in 15 cases (5.0%) including reoperation (8 cases; 2.7%) and revision surgery (7 cases; 2.3%). CONCLUSION: At a mean follow-up period of 3.8 years, primary RTSA showed satisfactory clinical outcomes with a complication rate of 15.1%, a reoperation rate of 2.7%, and a revision rate of 2.3%. Scapular stress fracture appears to be the most common complication after RTSA in the Korean population.

Diagnostic Accuracy of Pre-operative Percutaneous Synovial Biopsy and Aspirate Compared with Open Biopsy for Prosthetic Shoulder Infections.

BACKGROUND: Shoulder arthroplasty revision is associated with a high prevalence of prosthetic infection, and diagnosis remains difficult. The primary aim of the study was to determine the diagnostic accuracy of percutaneous synovial biopsy (PSB) and joint aspiration compared with open culture results in detecting infection in revision shoulder arthroplasty. The second aim was to determine whether biopsy location within the shoulder was associated with culture status. METHODS: This was a multicenter prospective cohort study involving four sites and 69 patients undergoing revision shoulder arthroplasty. The cohort was 57% female with a mean age of 64 years. Preoperative fluoroscopic-guided PSB's and aspirates were carried out by a musculoskeletal radiologist prior to revision shoulder arthroplasty. The original prostheses consisted of hemiarthroplasties, total shoulder arthroplasties (TSA), resurfacing TSA, reverse shoulder arthroplasties (RSA), and antibiotic spacers. Six synovial tissue biopsies from separate regions in the shoulder were obtained both preoperatively and intra-operatively. The shoulder joint was aspirated, and synovial fluid collected, if available. Infection was considered positive in the setting of two or more matching positive cultures. The PSB cultures were considered "true positive" if the PSB cultures matched the open biopsy cultures. RESULTS: Nineteen percent had positive infection based on PSB and 23% had confirmed culture positive infections based on intra-operative biopsy. The diagnostic accuracy of PSB compared with open biopsy was as follows: sensitivity 0.37 (95% CI 0.13-0.61), specificity 0.81 (95% CI 0.7-0.91), positive predictive value 0.37 (95% CI 0.13 - 0.61), negative predictive value 0.81 (95% CI 0.70-0.91), positive likelihood ratio 1.98 and negative likelihood ratio 0.77. Of the 71 patients, aspiration yielded synovial fluid in 33 patients. Preoperative aspirates detected no infections confirmed positive by open biopsy and correctly identified 81% of absent infections. The diagnostic accuracy of aspirates compared with open biopsy was as follows: sensitivity 0%, specificity 0.81 (95% CI 0.66-0.96), positive predictive value 0%, negative predictive value 0.78 (95% CI 0.63-0.93). Biopsy location within the shoulder was not associated with infection status. DISCUSSION: Preoperative aspiration detected none of the infections proven positive via open biopsy. Although PSB was superior to synovial fluid aspirate, poor likelihood ratios suggests that PSB is not useful as an isolated test in the preoperative workup of the potentially infected patient. Biopsy location was not associated with culture status suggesting that the capsule is uniformly infected, and the location of tissue biopsies does not appear to matter.

Comparison of Mediolateral (V-shaped) versus Anteroposterior Dominant Rotator Cuff Tears: The Anteroposterior Tear Width Contributes More to Postoperative Retears than Mediolateral Length when the Tear Size Area is Similar.

BACKGROUND: Tear size is a significant prognostic factor following rotator cuff repair. However, no study has investigated which dimension of the tear, the mediolateral or anteroposterior, more significantly influences the outcome when the product of the two dimensions, the tear size area, is similar. METHODS: A retrospective cohort study was conducted with patients who underwent arthroscopic FTRCT repair. Two contrasting groups were derived from preoperative tear dimensions. The mediolateral dominant (MLD) group consisted of 45 FTRCTs with the mediolateral tear dimension at least 1.5 times larger than the anteroposterior, and retraction exceeding the humeral head apex. The anteroposterior dominant (APD) group included 35 FTRCTs with an inverse proportion of the dimensions and retraction short of the humeral head apex. Demographic data, pre- and postoperative magnetic resonance imaging (MRI), clinical scores, and strength were compared between the groups. RESULTS: The mean follow-up was 26.7 and 32.2 months in the MLD and APD groups, respectively. The tear size in area (MLD vs. APD, 521.0 vs. 523.4 mm2, P=.960) and the discrepancy between ML and AP dimensions (2.0 vs. 1.9, P=.597) were similar. However, the MLD group demonstrated significant female predominance (P=.003), dominant arm involvement (P=.007), a higher incidence of pathologic subacromial spurs (P=.016), narrower acromiohumeral distance (P<.001), shorter residual tendon (P<.001), and advanced supraspinatus muscle atrophy (P=.005). Other baseline parameters were comparable between the groups. At the one-year postoperative MRI, the MLD group demonstrated a significantly lower retear rate (4.4% vs. 31.4%, P=.001). Nevertheless, clinical scores and strength at the last follow-up did not significantly differ. CONCLUSION: In a similar tear size area, the greater AP width contributes more than the ML length in causing a retear. Female predominance, dominant arm involvement, subacromial spurs, shorter residual tendon, and supraspinatus muscle atrophy were more demonstrated in MLD tears. Surgeons should be aware that healing may be poor in APD tears despite less retraction.