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.

Quality of internet-based decision aids for shoulder arthritis: what are patients reading?

BACKGROUND: The objective of this study was to assess the source, quality, accuracy, and completeness of Internet-based information for shoulder arthritis. METHODS: A web search was performed using three common Internet search engines and the top 50 sites from each search were analyzed. Information sources were categorized into academic, commercial, non-profit, and physician sites. Information quality was measured using the Health On the Net (HON) Foundation principles, content accuracy by counting factual errors and completeness using a custom template. RESULTS: After removal of duplicates and sites that did not provide an overview of shoulder arthritis, 49 websites remained for analysis. The majority of sites were from commercial (n = 16, 33%) and physician (n = 16, 33%) sources. An additional 12 sites (24%) were from an academic institution and five sites (10%) were from a non-profit organization. Commercial sites had the highest number of errors, with a five-fold likelihood of containing an error compared to an academic site. Non-profit sites had the highest HON scores, with an average of 9.6 points on a 16-point scale. The completeness score was highest for academic sites, with an average score of 19.2 ± 6.7 (maximum score of 49 points); other information sources had lower scores (commercial, 15.2 ± 2.9; non-profit, 18.7 ± 6.8; physician, 16.6 ± 6.3). CONCLUSIONS: Patient information on the Internet regarding shoulder arthritis is of mixed accuracy, quality, and completeness. Surgeons should actively direct patients to higher-quality Internet sources.

Radiographic results of augmented all-polyethylene glenoids in the presence of posterior glenoid bone loss during total shoulder arthroplasty.

BACKGROUND: Chronic osteoarthritis can result in glenohumeral subluxation and loss of posterior glenoid bone. This can alter normal glenohumeral biomechanics and affect the stress placed on the glenoid implant after total shoulder arthroplasty. This study evaluated the clinical and radiographic results of an augmented all-polyethylene glenoid for the treatment of glenoid osteoarthritis in the presence of posterior glenoid bone loss and determined whether any failures or complications occurred with short-term follow-up. METHODS: During a 2-year period, 21 patients were treated with an augmented glenoid for an index diagnosis of osteoarthritis with a biconcave glenoid and average posterior glenoid bone loss of 4.7 mm. Clinical outcomes were recorded for the American Shoulder and Elbow Surgeons Shoulder Assessment, Simple Shoulder Test, and active motion. Radiographic analysis included glenoid version, humeral head subluxation, component seating, ingrowth, and loosening. RESULTS: Significant improvements were demonstrated for American Shoulder and Elbow Surgeons Shoulder Assessment (52.3), Simple Shoulder Test (8.1), forward flexion (50°), external rotation (32°), and pain. Radiographic improvements were found for glenoid version (12°), humeral scapular alignment (23%), and humeral glenoid alignment (8%). Central peg ingrowth was demonstrated in all patients, and complete component seating was achieved in 19 patients. No complications were encountered, and no clinical or radiographic failures were identified. CONCLUSION: Augmented polyethylene glenoid components demonstrated improved clinical outcome, without implant failure or complications, during short-term follow-up.

Distribution of High-Volume Shoulder Arthroplasty Surgeons in the United States: Data from the 2014 Medicare Provider Utilization and Payment Data Release.

BACKGROUND: Access to total shoulder arthroplasty (TSA) may become a concern in the United States because of an aging and active population resulting in increased demand. As high-volume TSA surgeons have demonstrated superior outcomes, access to these surgeons is a matter of patient and public health policy interest. The release of the 2012 Medicare Provider Utilization and Payment Data Public Use File (MPUPD-PUF) in 2014 provided volume and reimbursement data for procedures performed by individual physicians participating in Medicare. This study analyzed surgeon prevalence, surgeon distribution, and factors associated with higher or lower surgeon prevalence in metropolitan areas. METHODS: The MPUPD-PUF was reviewed for the 2012 calendar year, and data were extracted for all physicians who performed a minimum of 11 TSA procedures for Medicare beneficiaries. Physicians in each major metropolitan area (population of >1 million) were grouped together. Average reimbursement, number of high-volume TSA surgeons, and number of total procedures were calculated per major metropolitan area. The presence of an American Shoulder and Elbow Surgeons (ASES) fellowship program and mean geographic reimbursement were analyzed for association with the number of high-volume TSA surgeons. RESULTS: The MPUPD-PUF included 774 surgeons across the United States who performed an annual minimum of 11 TSA procedures covered by Medicare, with a combined total of 19,505 TSA procedures. Of these surgeons, 45% practiced within major metropolitan areas with a population of >1 million. Surgeons who had completed an ASES fellowship had a higher volume of procedural claims (median, 26; range, 11 to 120) compared with other surgeons (median, 17; range, 11 to 163; p < 0.001). The distribution among major metropolitan areas was highly unequal, and more surgeons were present in cities with an ASES fellowship program. CONCLUSIONS: Access to high-volume shoulder arthroplasty surgeons by the Medicare population is lacking in multiple major metropolitan areas in the United States because of the uneven distribution of these surgeons. The method of analysis in this study allows for opportunities to target training programs as well as placement of physicians to ensure access to high-volume shoulder arthroplasty surgeons.

What Factors are Associated With Clinically Important Improvement After Shoulder Hemiarthroplasty for Cuff Tear Arthropathy?

BACKGROUND: In selected patients with a desire to maintain activity levels greater than those recommended after reverse total shoulder arthroplasty, hemiarthroplasty remains an option for treatment of cuff tear arthropathy (CTA). However, given the relatively small case series that have been reported to date, little is known regarding which patients will show functional improvement after this surgery. QUESTIONS/PURPOSES: We asked: What factors are associated with achieving the minimum clinically important difference in the simple shoulder test (SST) after hemiarthroplasty for cuff tear arthropathy? PATIENTS AND METHODS: Between 1991 and 2007, two surgeons at one academic center performed 48 shoulder hemiarthroplasties for CTA. No patients were known to have died before data collection, and of those not known to have died, 42 (88%) were available for followup at a mean of 48 months (range, 24-132 months). During that time, the general indications for this approach were glenohumeral arthritis with superior decentering of the humeral head. The majority of the patients with CTA were treated nonoperatively with patient-directed physical therapy and other modalities. A total of 42 patients (42 shoulders; 24 males and 18 females) with CTA were treated with hemiarthroplasty and followed for a mean of 48 months (range, 24-132 months). This is a retrospective study that made use of a longitudinally maintained database, which included physical examination of ROM, the SST, VAS, and standardized radiographs. At latest followup, 33 of 42 patients achieved a clinically important percentage of maximum possible improvement (%MPI) in SST score, defined as an improvement of 30% of the total possible improvement on the 12-point scale (with higher scores representing better results). RESULTS: Intraoperative findings of a rotator cuff tear limited to the supraspinatus and infraspinatus (odds ratio [OR], ∞; 95% CI, 2.01 to ∞; p = 0.020) and limited preoperative external rotation (15° [range, -40° to 45°] vs 35° [range, 20°-45°], OR, 0.71; 95% CI, 0.38-0.90; p < 0.001) were associated with achieving the defined minimum functional improvement (30% of MPI) on multivariate analysis. Preoperative active elevation (p = 0.679) and use of a CTA-specific implant (p = 0.707) were not significantly associated with achievement of 30% of MPI. CONCLUSION: Patients with intact teres minor and subscapularis tendons and patients with lower preoperative external rotation had a better prognosis for achieving a clinically important percentage of MPI at short-term followup. Although some patients were followed for more than 10 years, the majority were followed for fewer than 5 years; future studies will need to determine whether these early functional results are maintained for longer periods. LEVEL OF EVIDENCE: Level III, therapeutic study.

Humeral Head Arthroplasty and Meniscal Allograft Resurfacing of the Glenoid: A Concise Follow-up of a Previous Report and Survivorship Analysis.

The two to five-year results of humeral head arthroplasty and lateral meniscal allograft resurfacing of the glenoid in patients fifty-five years of age or younger were previously reported by the senior author (M.A.W.). The purpose of the present study was to report the survival rate, clinical findings, and radiographic results of the original thirty shoulders (thirty patients) followed for a mean duration of 8.3 years (range, five to twelve years). The scores on the visual analog scale for pain, American Shoulder and Elbow Surgeons scoring system, and Simple Shoulder Test were significantly improved at the latest follow-up evaluation compared with the preoperative findings (p < 0.001). Radiographic indices of posterior subluxation did not significantly increase from the immediate postoperative imaging to the latest radiographs, while the glenohumeral joint space demonstrated a gradual decrease. Nine (30%) of thirty shoulders were known to have undergone a reoperation. The present study demonstrated that biological glenoid resurfacing combined with hemiarthroplasty can provide significant improvement in shoulder function and pain relief in young patients with glenohumeral arthritis; however, mid-term follow-up at a mean of over eight years demonstrated a high reoperation rate.

The effect of proximal humeral bone loss on revision reverse total shoulder arthroplasty.

BACKGROUND: Revision shoulder arthroplasty can be complicated by osseous and soft tissue deficiencies. Proximal humeral bone loss can result in diminished implant stability and reduced functional outcomes, and some studies have advocated the use of humeral allograft in this setting. This study compares the outcomes of revision reverse total shoulder arthroplasty (RTSA) in patients both with and without proximal humeral bone loss. METHODS: During a 6-year period, 32 patients were revised to RTSA for failed shoulder hemiarthroplasty. Proximal humeral bone loss was found in 16 patients, with an average loss of 36.3 mm (range, 17.2-66 mm). Patients were followed up an average of 51.2 months with the American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, visual analog scale score for pain, subjective outcome ratings, and radiographs. RESULTS: Significant improvement was found for average American Shoulder and Elbow Surgeons score (30.7 to 66.8), Simple Shoulder Test score (1.6 to 5.3), visual analog scale score (6.0 to 2.6), and forward flexion (51° to 100°) but not for external rotation (15° to 19.1°). No difference was demonstrated for functional or subjective outcomes compared with patients with intact humeral bone, except for active motion. On radiographic examination, 3 patients demonstrated humeral-sided loosening. Five complications were noted in patients with humeral bone loss. CONCLUSION: Revision RTSA can provide successful outcomes in the presence of proximal humeral bone loss without the use of allograft. Implant stability may be improved by the use of a cemented long-stem monoblock humeral prosthesis in revision settings.

Shoulder arthroplasty in the presence of posterior glenoid bone loss.

➤ Chronic osteoarthritis of the glenohumeral joint, traumatic injury, post-reconstruction arthropathy, and developmental conditions such as glenoid dysplasia can result in posterior glenoid bone loss and excessive retroversion of the glenoid. Shoulder replacement in this setting is technically challenging and characterized by higher rates of complications and revisions.➤ Current options that should be considered for managing glenoid bone loss that results in >15° of retroversion include bone-grafting, augmented glenoid components, and reverse total shoulder replacement.➤ Asymmetric reaming is commonly used to improve version but should be limited to correction of 10° to 15° of retroversion in order to preserve subchondral bone.➤ Bone-grafting of glenoid defects has had mixed results and has been associated with graft-related complications, periprosthetic radiolucencies, and glenoid component failure; however, it provides a biologic option for patients with severe bone loss.➤ Implantation of an augmented polyethylene glenoid component offers the potential to improve version while preserving subchondral bone, but the procedure is technically demanding and without clinical follow-up data at this point.➤ Reverse total shoulder arthroplasty offers improved fixation and stability compared with an anatomic prosthesis for elderly patients with severe glenoid bone loss but is associated with a high complication rate.➤ Glenoid dysplasia is defined as a deformity that results in >25° of glenoid retroversion. Advanced imaging needs to be obtained in order to ensure enough glenoid bone stock is present to allow anatomic glenoid component placement.

Self-assessed and radiographic outcomes of humeral head replacement with nonprosthetic glenoid arthroplasty.

BACKGROUND: Active and young patients who place frequent demands on their shoulder present a treatment dilemma when glenohumeral arthritis progresses to a point at which surgical intervention is considered. Humeral head replacement with nonprosthetic glenoid arthroplasty ("ream-and-run") has been proposed to address the limitations of total shoulder arthroplasty and hemiarthroplasty in this population. Several reports from a single institution have shown substantial improvement in self-assessed comfort and function after this procedure. However, to the best of our knowledge, no clinical results pertaining to this technique have been reported from other institutions. METHODS: Hemiarthroplasty with nonprosthetic glenoid arthroplasty was performed in 17 patients with a minimum 2-year follow-up. Patients were clinically evaluated preoperatively and postoperatively with physical examination, Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons score, visual analog scale, and standardized radiographs. Preoperative radiographs and patient demographics were assessed for correlation with outcome measures. RESULTS: Improvement of >30% of preoperative SST score was noted in 14 of 17 patients at a mean follow-up of 3.9 years (range, 2.0-6.8 years). SST score improved from mean 3.2 ± 3.1 preoperatively to 10.0 ± 2.6 at latest follow-up (P < .0001). American Shoulder and Elbow Surgeons score improved from mean 42 ± 23 to 90 ± 13 (P < .0001). Male patients had higher SST scores (P = .03) and greater external rotation (P = .03) at latest follow-up. CONCLUSIONS: Nonprosthetic glenoid arthroplasty demonstrated results that correlate with prior data published by the center at which the procedure was initially described. Patients with concentric glenoid morphology preoperatively did not demonstrate results superior to those of patients with eccentric glenoids.

Revision open capsular shift for atraumatic and multidirectional instability of the shoulder.

Shoulder stability is critical for proper functioning of the upper extremity and is dependent on the interplay between static and dynamic stabilizers of the glenohumeral joint. Surgical management of patients with atraumatic and multidirectional instability is effective if the capsular redundancy is properly reconstructed to restore glenohumeral joint biomechanics. Residual capsular laxity is a common cause of recurrent glenohumeral joint dislocation in patients who had previous stabilization procedures; surgical results become less predictable in patients who had multiple revision procedures. It is important to detect capsular laxity at the time of the index surgery and use reliable surgical techniques to obtain optimal results.

Short, locked humeral nailing via Neviaser portal: an anatomic study.

OBJECTIVE: Supraspinatus tendon trauma may contribute to residual shoulder pain after nail fixation for proximal humeral fractures. Some have proposed a more medial starting point for humeral nail insertion to avoid cuff tendon footprint damage. We hypothesized that percutaneous nail insertion via Neviaser portal would not only be possible, but would avoid tendon trauma, while sacrificing articular cartilage. MATERIALS AND METHODS: Under c-arm guidance and in percutaneous fashion, we nailed 16 consecutive complete (head and neck, etc, intact) specimen right proximal humeri with locked short humeral nails (Aequalis) via Neviaser portal. Each shoulder was dissected to study the damage to the rotator cuff and long head of the biceps tendons as well as to the articular surfaces. We measured the humeral-thoracic abduction arc before the damaged articular surface contacted the superior glenoid. There were 5 male specimens and 11 female specimens with a mean age of 83 years at the time of death. RESULTS: We successfully inserted 15 of 16 humeral nails through this percutaneous approach. No supraspinatus tendon or long head of the biceps tendon was damaged. All nails passed entirely through supraspinatus muscle belly. Thirteen of 15 starting points were entirely on articular surface. Mean arc of abduction before superior glenoid contact was 76 degrees (range, 50 degrees-130 degrees). Mean distance from the edge of the articular surface to the most lateral part of the nail insertion was 11 mm (0-25 mm). CONCLUSIONS: Short, locked humeral nail insertion is possible in percutaneous fashion via Neviaser portal without tendon injury. However, successful insertion comes at the cost of articular cartilage damage.

Total shoulder arthroplasty with an all-polyethylene pegged bone-ingrowth glenoid component: a clinical and radiographic outcome study.

BACKGROUND: Loosening of the glenoid component continues to be the foremost cause of medium and long-term failure of shoulder replacements. The purpose of this study was to evaluate the clinical and radiographic results of a minimally cemented all-polyethylene pegged glenoid component designed for biologic fixation. METHODS: Forty-four shoulders in forty-one patients with a mean age of sixty-six years underwent total shoulder arthroplasty with a pegged bone-ingrowth glenoid component. Outcome data included the American Shoulder and Elbow Surgeons questionnaire, the Simple Shoulder Test, and visual analog scales. A detailed radiographic analysis was performed by two board-certified musculoskeletal radiologists who were blinded to clinical and patient-reported outcomes. The radiographs were evaluated with regard to the presence of radiolucent lines at the bone-cement interface, implant seating, and the radiodensity between the flanges of the central peg. RESULTS: The mean duration of clinical follow-up was four years and the mean duration of radiographic follow-up was three years. Twenty shoulders had perfect seating and radiolucency grades, thirty had increased radiodensity between the flanges of the central peg, and three demonstrated osteolysis. Radiodensity about the uncemented central peg at the time of the latest follow-up was positively associated with perfect seating and radiolucency grades on the initial postoperative radiographs (p = 0.03, Fisher exact test). The Simple Shoulder Test score, the American Shoulder and Elbow Surgeons score, and all visual analog scale scores had improved significantly (p < 0.01) at the time of the latest follow-up. CONCLUSIONS: Total shoulder arthroplasty with a minimally cemented, all-polyethylene, pegged glenoid implant can yield stable and durable fixation at short to medium-term follow-up (mean, four years).

Shoulder arthroplasty for the young, active patient.

Patients younger than 55 years with degenerative conditions of the glenohumeral joint represent a unique population that can be treated with shoulder arthroplasty. Certain challenges related to this cohort may include greater patient expectations, higher functional demands, soft-tissue contracture from previous surgery, and glenoid bone loss. Surgical treatment options include unconstrained total shoulder arthroplasty; hemiarthroplasty; humeral head resurfacing alone; hemiarthroplasty with concentric reaming of the glenoid; and hemiarthroplasty with adjunctive biologic glenoid resurfacing with autogenous fascia lata, Achilles tendon allograft, or meniscal allograft.

Management of glenohumeral arthritis in the young adult.

The majority of cases of glenohumeral arthritis in older adults are primary osteoarthritis and treatment algorithms are well defined, with shoulder arthroplasty providing reliable pain relief and functional improvement of satisfactorily duration. In younger adults, however, diagnoses are more complex and arthroplasty outcomes are less durable. Arthroscopy may be useful both as a diagnostic tool for characterizing lesions and as a therapeutic tool for debridement. Arthroscopic debridement is most likely to benefit patients with mild glenohumeral arthritis, small lesions, and involvement of only one side of the glenohumeral joint. Reconstruction of the humeral joint surface may consist of cartilage repair or reconstruction, resurfacing arthroplasty, or arthroplasty with a stemmed component. Patients treated with hemiarthroplasty avoid glenoid implant loosening, but the procedure provides less predictable pain relief than does total shoulder arthroplasty and may lead to increased postoperative glenoid erosion.

Results of revision from hemiarthroplasty to total shoulder arthroplasty utilizing modular component systems.

BACKGROUND: Hemiarthroplasty continues to be a common surgical treatment for glenohumeral arthritis. Unfortunately, some patients will develop painful glenoid arthrosis necessitating revision to total shoulder arthroplasty. Previously reported results of revision have demonstrated variability in results and difficulty. The purpose of this study was to determine the difficulty and results of revision from hemiarthroplasty to total shoulder arthroplasty utilizing modular component systems. MATERIALS AND METHODS: Between 1995 and 2007, the authors identified 15 patients who underwent revision from hemiarthroplasty (HA) to total shoulder arthroplasty (TSA). Patients were assessed with the use of a UCLA score and a visual analogue scale at the time of the latest follow-up (mean, 40 months; range, 24-70 months). Radiographs were assessed for the presence of glenoid loosening, subluxation, and shift in component position. RESULTS: Revision HA to TSA was significantly associated with pain relief (P < .01) as well as improvement in forward elevation from a mean of 91° to 141°. According to the UCLA scoring, the result was excellent in 9 shoulders, good in 5, and fair in 1. No instances of humeral or glenoid loosening were identified at the most recent examination. Only 2 stem revisions were necessary in this series of modular shoulder arthroplasties. CONCLUSION: The data from this study suggest that revision of painful HA for glenoid arthrosis to TSA is a reliable procedure with good improvements in pain, range of motion, and function. With modular components, the complexity of the procedure is minimized. Poor results and the need for stem revision are infrequent occurrences.

Management of traumatic sternoclavicular joint injuries.

Traumatic sternoclavicular joint injuries account for <3% of all traumatic joint injuries. Proper recognition and treatment are vital because these injuries may be life threatening. Injuries are classified according to patient age, severity, and, in the setting of dislocation, the direction of the medial clavicle. Anterior injuries are far more common than posterior injuries. Posterior dislocation may be associated with complications such as dyspnea, dysphagia, cyanosis, and swelling of the ipsilateral extremity as well as paresthesia associated with compression of the trachea, esophagus, or great vessels. These life-threatening complications may present at the time of injury but can develop later, as well. Radiography has been largely supplanted by CT for evaluation of this injury, although an oblique view developed by Wirth and Rockwood is useful in evaluating isolated sternoclavicular injury. MRI is useful in differentiating physeal injury from sternoclavicular dislocation in patients aged<23 years.

Treatment of traumatic posterior sternoclavicular dislocations.

BACKGROUND: Traumatic posterior sternoclavicular joint injuries are rare, but complications are common and include brachial plexus and vascular injury, esophageal rupture, and death. MATERIALS AND METHODS: The records of 21 patients treated at our institution for a posterior sternoclavicular injury were reviewed. All patients underwent a trial of closed reduction, which was effective in 8 patients (group I). The remaining 13 patients were treated with open reduction and sternoclavicular joint reconstruction (group II). RESULTS: Closed reduction was more likely to be successful (P < .05) in dislocations treated within 10 days of injury. Patients were evaluated by use of the University of California, Los Angeles rating scale. Overall, 18 of 21 patients were graded as good or excellent. Patients treated with either open or closed reduction as their definitive management compared favorably in terms of ratings for pain, strength, and motion. CONCLUSION: Our experience suggests that closed reduction compares favorably with open reduction. Of patients treated, 38% required only closed reduction as their definitive treatment. In this series early closed reduction was successful and obviated the risks of surgery. Patients who in whom closed reduction failed obtained good results with operative treatment aimed at reconstruction of the costoclavicular ligaments.

Results of treatment of luxatio erecta (inferior shoulder dislocation).

HYPOTHESIS: Traumatic inferior shoulder dislocation (luxatio erecta) injuries are rare, comprising less than 0.5% of all shoulder dislocations. Few cases have been reported, and the outcome of treatment has been ill defined. MATERIALS AND METHODS: Between 1968 and 2000, 18 patients (20 shoulders) with luxatio erecta were evaluated at our institution. Two patients (2 shoulders) were lost to follow-up, leaving 16 patients (18 shoulders) for long-term follow-up (average, 9 years). Associated injuries included peripheral nerve injury, humeral fracture, acromial fracture, and rotator cuff tear. All patients were initially managed with closed reduction, which was successful in 9 shoulders. The remaining 9 shoulders required operative treatment. RESULTS: Patients were evaluated with respected to pain, function, range of motion, strength, and patient satisfaction, according to the University of California at Los Angeles Rating Scale. Overall, 13 of the 16 patients were graded as good or excellent. Patients treated with closed reduction or operative treatment compared favorably in terms of improvements in ratings for pain, strength, motion, and the ability to perform work and sports. DISCUSSION: Our experience suggests that treatment of luxatio erecta is largely successful, with good or excellent results obtained in 83% of the shoulders. Half of the patients evaluated, required only closed reduction as their definitive treatment. Operative treatment is typically indicated for associated displaced humeral head fractures or patients with recurrent instability. Recurrent instability appears to be more likely in patients with a previous history of dislocation. Associated neurologic or vascular injury did not affect the final outcome.