BIO-RSA vs. metal-augmented baseplate in shoulder osteoarthritis with multiplanar glenoid deformity: a comparative study of radiographic findings and patient outcomes.

BACKGROUND: Reverse shoulder arthroplasty (RSA) requiring extensive reaming to address severe glenoid bone loss increases the risk of glenoid medialization and baseplate failure. We hypothesized that (1) metal-augmented baseplate prevents the medialization of the joint line and preserves glenoid bone stock similarly to bony increased-offset (BIO)-RSA and (2) bone graft viability and healing in BIO-RSA patients become compromised over time. MATERIALS AND METHODS: Eighty-one patients (83 shoulders) underwent glenoid lateralization with bone (BIO-RSA group, 44) or metal-augmented baseplate (metallic increased-offset [MIO]-RSA group, 39) and a minimum follow-up of 24 months were included. The orientation and direction of glenoid erosion was identified and recorded using computerized 3D planning. Active range of motion, and the Western Ontario Osteoarthritis of the Shoulder (WOOS) index were assessed before arthroplasty and at the last follow-up visits. Radiographic changes around the glenoid and humeral components were assessed. Healing and thickness of bone graft were evaluated by predefined criteria. Postoperative global glenoid inclination (ß angle) and retroversion were also measured. RESULTS: Delta scores of active anterior elevation were higher in the MIO-RSA group (P = .027). The differences in the other planes of shoulder motion and in WOOS index scores between the groups were not significant. Preoperative glenoid retroversion was higher in BIO-RSA patients, and glenoid inclination was similar in both groups. Type B2 and B3 glenoids had a posterior-central (91%) and posterior-superior (90%) erosion with a mean posterior humeral head subluxation of 76% and 78%, respectively. The direction of erosion in type E2 and E3 glenoids was posterior-superior, with a mean posterior humeral head subluxation of 74%. The rate of high position of the glenosphere was higher in the BIO-RSA group (P = .022), whereas the values of ß angle and postoperative retroversion were similar in the 2 groups. BIO-RSA group showed radiolucent lines <2 mm around the bone graft in 16 patients (36.4%) and decreased thickness in 15 (34.1%). Incomplete baseplate seating was found in 4 MIO-RSA patients (10%). We found higher rates of humerus condensation lines in MIO-RSA patients (P = .01) and higher rates of cortical thinning and tuberosity resorption in the BIO-RSA group (P = .027 and P = .004, respectively). CONCLUSION: Metal-augmented glenoid is a suitable alternative to BIO-RSA to preserve bone and prevent the medialization of the joint line in arthritic glenoid with multiplanar glenoid deformity. Bone and metal augmentation provided satisfactory clinical outcomes. Bone graft resorption in BIO-RSA patients raise concern about the risk of baseplate loosening and requires further long-term studies.

What to expect after revision shoulder arthroplasty? A comprehensive review of the literature.

The number of shoulder arthroplasties has increased tremendously over the last twenty years, creating a proportional increase in complications rates and revision. Shoulder arthroplasty surgeon should have a clear understanding of the reasons for failure based on the specific index procedure that was performed. The main challenge includes the need for component removal and managing glenoid and humeral bone defects. This manuscript aims to outline the most common indications for revision surgery and treatment options based on a careful and detailed review of the available literature.  This paper should help the surgeon in patient evaluation and selection of the optimal procedure for an individual patient.

Shoulder Rehabilitation Exercises With Kinematic Biofeedback After Arthroscopic Rotator Cuff Repair: Protocol for a New Integrated Rehabilitation Program.

BACKGROUND: The recovery of scapular and humeral physiological kinematic parameters, as well as the sensorimotor control of movement, plays a primary role in the rehabilitation process after arthroscopic rotator cuff repair. A highly customized rehabilitation approach is required to achieve this aim. Biofeedback can be a useful tool, but there is poor evidence of its application in the rehabilitation after arthroscopic rotator cuff tear repair. OBJECTIVE: The aim of this paper is to outline an innovative exercise-based rehabilitation program exploiting visual biofeedback for the recovery of patients arthroscopically treated for rotator cuff repair. METHODS: For establishment of the innovative program, a multidisciplinary team involving experts in shoulder surgery, rehabilitation medicine, physical therapy, and biomedical and clinical engineering was formed. Starting from a conventional rehabilitation program, the team selected a set of exercises to be integrated with a biofeedback tool, named the INAIL (National Institute for Insurance against Accidents at Work) Shoulder and Elbow Outpatient program (ISEO program). ISEO is a motion analysis system based on inertial wearable sensors positioned over the thorax, scapula, humerus, and forearm. ISEO can return a visual biofeedback of humerus and scapula angles over time or of the scapula-humeral coordination, with possible overlap of patient-specific or asymptomatic reference values. A set of 12 progressive exercises was defined, divided into four groups based on humerus and scapula movements. Each group comprises 2-4 of the 12 exercises with an increasing level of complexity. Exercises can require the use of a ball, stick, rubber band, and/or towel. For each exercise, we present the starting position of the patient, the modality of execution, and the target position, together with notes about the critical factors to observe. The type of visual biofeedback to adopt is specified, such as the coordination between angles or the variation of a single angle over time. To guide the therapist in customizing the patient's rehabilitation program, a list of operative guidelines is provided. RESULTS: We describe various applications of the ISEO exercise program in terms of frequency and intensity. CONCLUSIONS: An innovative rehabilitation program to restore scapular and humeral kinematics after rotator cuff repair based on kinematic biofeedback is presented. Biofeedback is expected to increase patient awareness and self-correction under therapist supervision. Randomized controlled trials are needed to investigate the potential effect of the exercise-based biofeedback in comparison with conventional rehabilitation programs. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/35757.

Pediatric elbow arthroscopy: clinical outcomes and complications after long-term follow-up.

BACKGROUND: Elbow arthroscopy is becoming increasingly important for the treatment of a wide range of acute and chronic elbow pathologies. Even if elbow arthroscopy is technically demanding, in the pediatric population this minimally invasive technique is preferred by many surgeons for the treatment of pathologies such as osteochondritis dissecans (OCD), posttraumatic stiffness (PTS), or elbow posterior impingement (PI). The aim of this study is to evaluate outcomes and safety of elbow arthroscopy in the pediatric and adolescent population after long-term follow-up. MATERIALS AND METHODS: In this retrospective study, 26 patients younger than 18 years old undergoing elbow arthroscopy were evaluated. All surgeries were performed by a single senior surgeon. Patients were divided into three subgroups based on preoperative diagnosis: OCD, PTS, and PI. After at least 60 months follow-up, several outcome measures, including range of motion (ROM), Mayo Elbow Performance Score (MEPS), and visual analog scale (VAS) were evaluated in relation to preoperative values. The level of patient satisfaction on a five-level Likert scale, any limitation or change in sport activity, and the onset of any possible complications were also evaluated. RESULTS: In the study population, we found an improvement in ROM (flexion of 14.4 ± 13.6°, extension of 19.5 ± 13.9°, pronation of 5.8 ± 5.7°, and supination of 8.5 ± 11.6°) and in validated outcome measures (MEPS of 21.0 ± 13.5 points and VAS of 3.8 ± 2.2 points). The satisfaction rate was 4.5, with no dissatisfaction. Eighty-seven percent of patients fully recovered their performance levels, 9% changed sport, and 4% were unable to return to sport. We identified one major and one minor complication, with an overall complication rate of 7.7%. No neurovascular injuries were detected. CONCLUSIONS: Elbow arthroscopy in a pediatric population can be considered an effective and safe procedure for selected pathologies when performed by an experienced surgeon. At long-term follow-up, we reported excellent clinical outcomes (both objective and subjective), with a relatively low complication rate without permanent injuries. LEVEL OF EVIDENCE: Level IV-case series.

Failed Latarjet procedure: a systematic review of surgery revision options.

BACKGROUND: Revision surgery after the Latarjet procedure is a rare and challenging surgical problem, and various bony or capsular procedures have been proposed. This systematic review examines clinical and radiographic outcomes of different procedures for treating persistent pain or recurrent instability after a Latarjet procedure. METHODS: A systematic review of the literature was performed using the Medline, Cochrane, EMBASE, Google Scholar and Ovid databases with the combined keywords "failed", "failure", "revision", "Latarjet", "shoulder stabilization" and "shoulder instability" to identify articles published in English that deal with failed Latarjet procedures. RESULTS: A total of 11 studies (five retrospective and six case series investigations), all published between 2008 and 2020, fulfilled our inclusion criteria. For the study, 253 patients (254 shoulders, 79.8% male) with a mean age of 29.6 years (range: 16-54 years) were reviewed at an average follow-up of 51.5 months (range: 24-208 months). CONCLUSIONS: Eden-Hybinette and arthroscopic capsuloplasty are the most popular and safe procedures to treat recurrent instability after a failed Latarjet procedure, and yield reasonable clinical outcomes. A bone graft procedure and capsuloplasty were proposed but there was no clear consensus on their efficacy and indication. Level of evidence Level IV Trial registration PROSPERO 2020 CRD42020185090- www.crd.york.ac.uk/prospero/.

Shoulder arthroplasty to address the sequelae of anterior instability arthropathy and stabilization procedures: systematic review and meta-analysis.

PURPOSE: Chronic anterior glenohumeral joint instability is a common situation and can lead to progressive cartilage deterioration and ultimately instability arthopathy. Progressive cartilage deterioration can occur despite conservative or surgical treatment and the sequelae of these conditions are often addressed with total shoulder arthroplasty. Aims of the present study were to analyze the available literature to describe the technical aspects of this particular operation and to report outcomes and complication rates. The hypothesis was that shoulder arthropalsty in the sequelae of instability had lower outcomes and higher complication rates than arthroplasties for primary arthritis. METHODS: A systematic review of the literature was performed, in accordance with the PRISMA guidelines. PubMed, Ovid, Cochrane Reviews, and Google Scholar were comprehensively searched using a combination of the following keywords: shoulder arthroplasty, reverse shoulder arthroplasty, dislocation arthropathy, capsulorrhaphy arthropathy and stabilization procedures. RESULTS: Thirteen studies with 365 patients met inclusion criteria. Since 13 patients were lost to follow-up, 352 were reviewed at an average follow-up of 53.4 months. The average Constant-Murley (CM) and American Shoulder and Elbow Society (ASES) scores improved from 35.6 and 35.7 to 72.7 and 77, respectively. The overall complication rate was 25.7% and the reoperation rate was 18.5%. Radiographs at follow-up revealed radiolucent lines on the humerus in 12.4% of cases and radiolucent lines or notching on the glenoid side in 22.7% of cases. The average Methodological Index for Non-randomized Studies Score (MINORS) was 12.9 for non-comparative studies and 21.3 for comparative studies. CONCLUSION: Shoulder arthroplasty to address the sequelae of instability arthropathy and stabilization procedures can be a challenging procedure as a consequence of the distorted anatomy and severe glenohumeral joint pathology. Complication and reoperation rates are higher compared to shoulder arthroplasty for primary glenohumeral joint arthritis; however, the difference is not statistically significant. When reverse shoulder arthroplasties (RSA) were considered as a subgroup and compared to anatomic shoulder replacements (total shoulders and hemiarthroplasties), they showed a lower revision rate.

Isolated displaced type II partial articular radial head fracture: correlation of preoperative imaging with intraoperative findings of lateral ulnar collateral ligament tear.

BACKGROUND: The aim of this study was to determine the lateral ulnar collateral ligament (LUCL) injury associated with isolated radial head fracture (RHF) and the relationship of the ligament injury with the displacement of the fragment-loss of contact-in unstable displaced partial articular RHF in individuals without any history of ulnohumeral dislocation. METHODS: We retrospectively identified 131 consecutive patients who underwent open reduction and internal fixation of isolated closed Mason type II RHF performed at our institution. We identified 3 subsets by the pattern of RHF and the position of the unstable fragment (anterior or posterior) relative to the capitulum humeri: displaced stable (group I), displaced anterior unstable (group II), and displaced posterior unstable (group III). Standard radiographs were obtained preoperatively and postoperatively. The pattern of lateral collateral ligament avulsion and its distribution were inferred from intraoperative records. RESULTS: Preoperative radiographs of the 131 patients showed 101 nonseparated fractures (77%, group I) and 30 unstable fractures (23%). Anterior displacement of the fragment was found in 18 elbows (14%, group II) and posterior displacement in 12 (9%, group III). LUCL avulsion was found in 18 of 30 unstable RHFs (60%) and in 1 of 60 stable RHFs (1.6%). CONCLUSION: RHF is a complex fracture often associated with soft tissue lesions. It is important to determine which structures need to be repaired to avoid complications that could lead to elbow instability. The RHF pattern and classification as stable or unstable can help the surgeon in the identification and treatment of LUCL lesions.

One and two-year clinical outcomes for a polyethylene glenoid with a fluted peg: one thousand two hundred seventy individual patients from eleven centers.

PURPOSE: Clinical shoulder science lacks a benchmark against which the early clinical value of new glenoid components can be compared; such a benchmark may be derived from a multicenter study of patients receiving an established, internationally used design of glenoid component. METHODS: We obtained data from 11 centers on 1270 patients having total shoulder arthroplasty using an all-polyethylene component with a fluted central peg. We analyzed individual patient outcomes at 1 and 2 years after surgery. We compared the improvement for each patient to the minimal clinically important difference (MCID) and calculated each patient's improvement as a percent of maximal possible improvement (MPI). RESULTS: The preoperative scores improved from SST 3 ± 2, ASES 37 ± 15, Constant score 36 ± 16, and Penn score 30 ± 19 to SST 10 ± 2, ASES 90 ± 12, Constant 76 ± 13, and Penn 80 ± 24 (p < 0.001 for each). A high percentage of patients improved by more than the MCID (SST 96%, ASES 98%, Constant 94%, Penn 93%) and obtained improvement of at least 30% of the MPI (SST 95%, ASES 98%, Constant 91%, Penn 87%). The clinical outcomes realized with this glenoid design were not worse for the 41% of shoulders with preoperative type B glenoids or for the 30% of shoulders with more than 15 degrees of glenoid retroversion. CONCLUSIONS: Individual patients from 11 international practices having total shoulder arthroplasty using a basic glenoid component design obtained highly significant clinical outcomes, providing a benchmark against which the early outcomes of new designs can be compared to determine whether they provide increased clinical value.

Comparison of shoulder replacement to treat osteoarthritis secondary to instability surgery and primary osteoarthritis: a retrospective controlled study of patient outcomes.

PURPOSE: We hypothesized that osteoarthritis developing after instability surgery is radiographically similar to primary arthritis and that arthroplasty provides comparable outcomes in patients with these two types of osteoarthritis. METHODS: Patients with osteoarthritis due to instability surgery (group I) and with primary osteoarthritis (group II) were included. Mean follow-up was 52.6 and 41.6 months, respectively. Hemiarthroplasties (HA) were 32% in group I and 27% in group II; total shoulder arthroplasties (TSA) were 68 and 73% respectively. Outcome measures included active shoulder mobility (anterior elevation [AAE], lateral elevation [ALE], external rotation [ER], and internal rotation [IR]), pain, Constant-Murley score, and Simple Shoulder Test. Pre-operative and post-operative radiographs were taken. Glenoid arthritis was assessed by computed tomography. RESULTS: Participants were 19 in the group I (mean age 44.5 years, 12 males, 7 females) and 30 in the group II (mean age 48.2 years, 28 males, 12 females). Both patient groups had pre-operative concentric arthritis. Group II had higher rates of A2 and B1 glenoids (p = 0.003). A longer interval from stabilization to replacement was associated with lower post-operative IR (p = 0.017) and ALE (p = 0.035). Post-operative ER and IR were higher in group I (p < 0.001 and p = 0.001, respectively). In group I, AFE and ALE were higher in HA than TSA patients (both p = 0.009). The CS and SST score increased significantly in both groups (both p < 0.001). Group II showed significantly greater humeral radiolucency (p = 0.025) and a higher rate of TSA revision to reverse prostheses compared with group I. CONCLUSIONS: Shoulder replacement provides similar clinical and radiographic outcomes in arthritis secondary to instability surgery and in primary osteoarthritis. Posterior glenoid wear is more common in primary osteoarthritis.

Grammont humeral design versus onlay curved-stem reverse shoulder arthroplasty: comparison of clinical and radiographic outcomes with minimum 2-year follow-up.

BACKGROUND: There are few investigations comparing lateralized and medialized reverse total shoulder arthroplasty (RTSA) in patients with cuff tear arthropathy. This study assessed the outcomes of 2 RTSA designs. METHODS: Sixty-eight consecutive cuff tear arthropathy patients (74 shoulders) with a follow-up of at least 24 months received a Grammont or an onlay curved short-stem humeral component, with or without glenoid lateralization; a cementless humeral stem was implanted in >90%. Clinical outcome measures included active range of motion (anterior and lateral elevation, external and internal rotation), pain, and the Constant-Murley score. Radiologic outcomes included radiolucency, condensation lines, cortical thinning, spot weld, loosening and subsidence, and tuberosity resorption for the humeral component and radiolucency, scapular notching, formation of scapular bone spurs, ossifications, and loosening for the glenoid component. RESULTS: Both prostheses provided significant differences between preoperative and postoperative scores and showed a similar complication rate. Scapular fractures were found only in the patients who received the curved short-stem implant. Glenoid bone grafting did not significantly affect clinical scores. Both implants provided similar postoperative shoulder mobility, even though the lateralized curved stem was associated with higher delta scores for external rotation (P = .002) and lower rates of scapular notching (P = .0003), glenoid radiolucency (P = .016), and humeral bone remodeling (P = .004 and P = .030 for cortical thinning and spot weld, respectively). CONCLUSIONS: Medialized and short-stem lateralized RTSA implants provided similar midterm clinical outcomes and range of motion. The curved short stem was associated with higher delta scores for external rotation and a lower rate of radiographic risk factors.

Revision of failed shoulder hemiarthroplasty to reverse total arthroplasty: analysis of 157 revision implants.

BACKGROUND: There remains a paucity of studies examining the conversion of failed hemiarthroplasty (HA) to reverse total shoulder arthroplasty (RTSA). Therefore, the purpose of this study was to examine a large series of revision HA to RTSA. METHODS: A population of 157 patients who underwent conversion of a failed HA to a revision RTSA from 2006 through 2014 were included. The mean follow-up was 49 months (range, 24-121 months). The indications for revision surgery included instability with rotator cuff insufficiency (n = 127) and glenoid wear (n = 30); instability and glenoid wear were associated in 38 cases. Eight patients with infection underwent 2-stage reimplantation. RESULTS: Patients experienced significant improvements in their preoperative to postoperative pain and shoulder range of motion (P < .0001), with median American Shoulder and Elbow Surgeons and Simple Shoulder Test scores of 60 and 6 points, respectively. There were 11 (7%) repeated revision surgeries, secondary to glenoid component loosening (n = 3), instability (n = 3), humeral component disassembly (n = 2), humeral stem loosening (n = 1), and infection (n = 2). Implant survivorship was 95.5% at 2 years and 93.3% at 5 years. There were 4 reoperations including axillary nerve neurolysis (n = 2), heterotopic ossification removal (n = 1), and hardware removal for rupture of the metal cerclage for an acromial fracture (n = 1). At final follow-up, there were 5 "at-risk" glenoid components. CONCLUSION: Patients experience satisfactory pain relief and recovery of reasonable shoulder function after revision RTSA from a failed HA. There was a relatively low revision rate, with glenoid loosening and instability being the most common causes.

Cross-cultural adaptation and validation of the Italian version of the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score.

BACKGROUND: The Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow score is a reliable and sensitive tool to measure the performance of overhead athletes. The purpose of this study was to carry out a cross-cultural adaptation and validation of the KJOC questionnaire in Italian and to assess its reliability, validity, and responsiveness. MATERIALS AND METHODS: Ninety professional athletes with a painful shoulder were included in this study and were assigned to the "injury group" (n = 32) or the "overuse group" (n = 58); 65 were managed conservatively and 25 were treated by arthroscopic surgery. To assess the reliability of the KJOC score, patients were asked to fill in the questionnaire at baseline and after 2 weeks. To test the construct validity, KJOC scores were compared to those obtained with the Italian version of the Disabilities of the Arm, Shoulder, and Hand (DASH) scale, and with the DASH sports/performing arts module. To test KJOC score responsiveness, the follow-up KJOC scores of the participants treated conservatively were compared to those of the patients treated by arthroscopic surgery. RESULTS: Statistical analysis demonstrated that the KJOC questionnaire is reliable in terms of the single items and the overall score (ICC 0.95-0.99); that it has high construct validity (r s = -0.697; p < 0.01); and that it is responsive to clinical differences in shoulder function (p < 0.0001). CONCLUSIONS: The Italian version of the KJOC Shoulder and Elbow score performed in a similar way to the English version and demonstrated good validity, reliability, and responsiveness after conservative and surgical treatment. LEVEL OF EVIDENCE: II.

Arthroscopic Debridement Versus Platelet-Rich Plasma Injection: A Prospective, Randomized, Comparative Study of Chronic Lateral Epicondylitis With a Nearly 2-Year Follow-Up.

PURPOSE: The purpose of this prospective, randomized study was to compare the efficacy of autologous platelet-rich plasma (PRP) injections and arthroscopic lateral release in treating chronic lateral epicondylitis (LE). METHODS: Patients who had a clinical diagnosis of LE confirmed by ultrasound (US) were included in this study. A total of 101 patients received arthroscopic release (n = 50) or US-guided PRP injections (n = 51). Outcomes were assessed using a visual analog scale for pain, the Patient-Rated Tennis Elbow Evaluation (PRTEE), and a calibrated hand dynamometer for grip strength. RESULTS: Both patient groups experienced significant improvement in all measures. Between-group comparisons showed a significantly higher value in the PRP group only for grip strength at week 8 (P = .0073); all other significant differences were in favor of arthroscopy: overall pain (P = .0021), night pain (P = .0013), and PRTEE score (P = .0013) at week 104 and grip strength at weeks 24, 52, and 104 (all P < .0001). Consumption of rescue pain medication was not significantly different between the groups. CONCLUSIONS: The present findings suggest that (1) PRP injections and arthroscopic extensor carpi radialis brevis release are both effective in the short and medium term; (2) PRP patients experienced a significant worsening of pain at 2 years; (3) arthroscopic release ensured better long-term outcomes in terms of pain relief and grip strength recovery; and (4) both procedures were safe and well accepted by patients. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Metallosis in shoulder arthroplasty: an integrative review of literature.

Shoulder arthroplasty has gained popularity as an efficient means of achieving pain relief and improved function in a variety of complex shoulder disorders. Despite promising reports, given the increasing number of shoulder arthroplasty procedures, various causes that may contribute to failure of a well-functioning arthroplasty are being increasingly recognized. One such disastrous condition is metallosis, a subject which has not been much talked off with reference to shoulder arthroplasty. This article besides reviewing the existing literature intends to discuss the possible causes that contribute to metallosis and devise a protocol for its timely diagnosis and management.

Latarjet procedure: is the coracoid enough to restore the glenoid surface?

PURPOSE: The aim of this study was to establish whether anterior glenoid bone loss in patients with large glenoid rim defects can be restored with a coracoid graft (Latarjet procedure). METHODS: A total of 143 consecutive patients with chronic anterior shoulder instability and glenoid bone deficiency were treated in 2013. A pre-operative computed tomography (CT) scan using the PICO method was obtained to estimate anterior glenoid rim erosion. The 23 patients with anterior glenoid deficiency exceeding 20 % were included in the study. A post-operative CT scan was obtained to establish whether coracoid transfer had fully restored the glenoid surface. RESULTS: Mean bone loss was 26 ± 3.9 % of the glenoid surface (range 20-34 %) compared with the contralateral glenoid. Mean coracoid dimensions were 26.3 ± 2.9 mm × 7.6 ± 0.65 mm. The graft successfully restored the glenoid surface in all patients (mean filling, 102.4 ± 0.8 %). DISCUSSION: The Latarjet procedure is a valuable approach to treat patients with chronic shoulder instability and glenoid deficiency. CONCLUSION: Coracoid transfer restored the glenoid surface even in patients with large defects. The Eden-Hybinette technique seems to be more appropriate for revision surgery and for patients with a failed Latarjet procedure.

Calcific tendinitis of the rotator cuff: state of the art in diagnosis and treatment.

Calcific tendinitis is a painful shoulder disorder characterised by either single or multiple deposits in the rotator cuff tendon. Although the disease subsides spontaneously in most cases, a subpopulation of patients continue to complain of pain and shoulder dysfunction and the deposits do not show any signs of resolution. Although several treatment options have been proposed, clinical results are controversial and often the indication for a given therapy remains a matter of clinician choice. Herein, we report on the current state of the art in the pathogenesis, diagnosis and treatment of calcific tendinitis of the rotator cuff.

The Constant score and the assessment of scapula dyskinesis: Proposal and assessment of an integrated outcome measure.

The Constant-Murley score (CMS) is a popular measure of shoulder function. However, its ability to monitor the evolution of patients during rehabilitation after rotator-cuff repair is controversial. Moreover, CMS does not account for possible alterations in the scapulo-humeral coordination (SHC, scapula dyskinesis), which are apparent in variety of shoulder pathologies. To address these issues, a new formulation of CMS was firstly proposed, which rates the "affected-to-controlateral side difference in SHC" of a patient with respect to reference values of asymptomatic controls (Scapula-Weighted CMS). Then, 32 patients (53±9year-old) were evaluated with CMS and SW-CMS at 45, 70, 90-day and >6-month after rotator-cuff repair, to test three hypotheses: (1) CMS and SW-CMS are largely responsive to change; (2) accounting (SW-CMS) or not (CMS) for scapula dyskinesis leads to statistically different scores and SW-CMS cannot be predicted from CMS without clinically relevant differences; (3) 90% of patients recover a side-to-side SHC similar to asymptomatic controls at 90days. Results supported hypotheses 1 and 2. On the contrary (hypothesis 3), only 10% of patients recovered for SHC alterations at 90days, and 50% at follow-up. These findings support the use of SW-CMS and the importance of treating scapula dyskinesis after rotator-cuff repair.

Anterior Glenoid Rim Fracture Following Use of Resorbable Devices for Glenohumeral Stabilization.

BACKGROUND: Resorbable anchors are widely used in arthroscopic stabilization of the shoulder as a means of soft tissue fixation to bone. Their function is to ensure repair stability until they are replaced by host tissue. Complications include inflammatory soft tissue reactions, cyst formation, screw fragmentation in the joint, osteolytic reactions, and enhanced glenoid rim susceptibility to fracture. PURPOSE: To evaluate resorption of biodegradable screws and determine whether they induce formation of areas with poor bone strength that may lead to glenoid rim fracture even with minor trauma. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This study evaluated 12 patients with anterior shoulder instability who had undergone arthroscopic stabilization with the Bankart technique and various resorbable anchors and subsequently experienced redislocation. The maximum interval between arthroscopic stabilization and the new dislocation was 52 months (mean, 22.16 months; range, 12-52 months). The mean patient age was 31.6 years (range, 17-61 years). The persistence or resorption of anchor holes; the number, area, and volume of osteolytic lesions; and glenoid erosion/fracture were assessed using computed tomography scans taken after redislocation occurred. RESULTS: Complete screw resorption was never documented. Osteolytic lesions were found at all sites (mean diameter, 5.64 mm; mean depth, 8.09 mm; mean area, 0.342 cm(2); mean volume, 0.345 cm(3)), and all exceeded anchor size. Anterior glenoid rim fracture was seen in 9 patients, even without high-energy traumas (75% of all recurrences). CONCLUSION: Arthroscopic stabilization with resorbable devices is a highly reliable procedure that is, however, not devoid of complications. In all 12 patients, none of the different implanted anchors had degraded completely, even in patients with longer follow-up, and all induced formation of osteolytic areas. Such reaction may lead to anterior glenoid rim fracture according to the literature and as found in 75% of the study patients with local osteolysis (9/12). Reducing anchor number and/or size may reduce the risk of osteolytic areas and anterior glenoid rim fracture.

Multidirectional instability of the shoulder: biomechanics, clinical presentation, and treatment strategies.

Multidirectional instability (MDI) of the shoulder is a condition where the dislocation occurs in more than one direction with minimal or no causative trauma. Its pathoanatomy is complex and characterized by a redundant capsule, resulting in increased glenohumeral joint volume. The fact that several further factors may contribute to symptom onset complicates the diagnosis and hampers the identification of a therapeutic approach suitable for all cases. There is general agreement that the initial treatment should be conservative and that surgery should be reserved for patients who have not responded to an ad hoc rehabilitation program. We review the biomechanics, clinical presentation, and treatment strategies of shoulder MDI.

Early anchor displacement after arthroscopic rotator cuff repair.

PURPOSE: Arthroscopic rotator cuff repair is a success and became the mainstream method of reconstruction in recent years. Due to the technical development in shoulder surgery, novel suture anchors and high-strength sutures are widely used providing convincing fixation, however anchor pullout still remains a problem. The aim of our study was to observe early anchor movement on a large patient cohort, and identify clinical, biological and technical variables that can lead to this complication. METHODS: A total of 5,327 patients who had arthroscopic rotator cuff reconstruction for full thickness tear were included in the study. Radiographs taken immediately after surgery were observed and occurrent anchor displacement was recorded. Patient-specific, tendon-specific, bone-specific and implant-specific variables were studied. Any possible relationship between these factors and anchor displacement was investigated. RESULTS: Early anchor movement occurred in six cases (0.1%). The involvement of two or more tendons, retraction of the tendon by more than 2 cm and the use of four anchors was associated with higher incidence of anchor displacement, however the difference was not significant. CONCLUSIONS: Based on our study, anchor pullout occurring immediately after surgery is a relatively rare complication. Instead of timing the radiologic examination directly after the procedure, assessment of the anchors' position four to six weeks after surgery should be considered.