Superior functional outcome following reverse shoulder arthroplasty compared to hemiarthroplasty for displaced three and four-part fractures in patients 65 and older: Results from a prospective multicentre randomised controlled trial - The Shoulder Hemiarthroplasty or Reverse Polarity Arthoplasty (SHeRPA) trial.

BACKGROUND: Acute unreconstructible 3- or 4-part proximal humerus fractures can be treated with hemiarthroplasty or reverse polarity shoulder arthroplasty. Randomized trials using implants from multiple different companies or uncemented implants have found superior results with reverse polarity arthroplasty. AIMS: This study aims to determine whether cemented reverse polarity arthroplasty produces a superior outcome compared to cemented hemiarthroplasty using one implant system in patients aged 65 years and over at 12 months follow-up as measured with the Constant score. METHODS: A prospective patient and assessor blinded multicenter randomized controlled trial was conducted of shoulder hemiarthroplasty or reverse polarity arthroplasty in patients aged 65 years and older with acute 3- and 4-part proximal humerus fracture not amenable to osteosynthesis. The primary outcome was the Constant score at 12 months with total follow-up to 24 months. Block randomization by site was undertaken using random number generation and sealed envelopes. Power analysis indicated that 17 patients were required in each arm to achieve 80% power with an alpha-value of 5%. Secondary outcome measures were the difference in the mean Constant Score, Quick Disabilities of the Arm Shoulder and Hand Questionnaire (QuickDASH), Oxford Shoulder Score (OSS), American Shoulder and Elbow Surgeons (ASES) Score and EQ5D-5L up to two years; differences in complication rate at one and two years; differences in revision and implant failure at one and two years. RESULTS: 18 patients were randomized to hemiarthroplasty and 18 to reverse polarity arthroplasty across 4 sites. The primary outcome as measured by the Constant score at 12 months was better in the reverse polarity shoulder arthroplasty (RSA) group (Mean 51.1, s.d. 14.9) compared to the hemiarthroplasty (HA) group (mean 35.0, s.d. 13.5) (p=0.004). No significant difference was reported at 24 months but this may be due to high rates of attrition (22%). The mean EQ-5D-5L patient rated health status score was significantly higher in the RSA group compared to the HA group at 12 months. One hemiarthroplasty was revised due to implant uncoupling and one reverse polarity shoulder replacement was revised due to instability. No other complications were recorded. DISCUSSION: Treatment of unreconstructible 3- or 4-part proximal humerus fractures with reverse polarity shoulder arthroplasty results in a superior outcome compared to shoulder hemiarthroplasty at 12 months measured with the Constant score with no increased risk of failure up to 24 months in patients age 65 years and over. High attrition rates are observed in this older population due to cognitive decline and death from other causes.

Biomechanical testing of trans-humeral all-suture anchors for rotator cuff repair.

BACKGROUND: Rotator cuff tears are one of the most common causes of shoulder pain. All-suture anchors are increasingly being used in the arthroscopic repair of rotator cuff tears. The purpose of this experimental study is to evaluate the biomechanical properties of all-suture anchors at different insertion sites in the proximal humerus relevant to rotator cuff repairs and the remplissage procedure. METHODS: Sixteen cadaveric shoulders were used for the study. Four all-suture anchors were inserted in each proximal humerus at common anchor insertion sites on the rotator cuff footprint and a simulated Hill-Sachs defect. Cyclic loading and load-to-failure tests were undertaken. The number of cycles, load to failure and nature of failure were recorded. RESULTS: The all-suture anchors placed in the cuff footprint using a transosseous technique displayed superior biomechanical properties. Sutures sited in this way demonstrated a maximum tensile load to failure of 542 N as well as a highest mean load to failure and the maximum number of cycles before anchor failure. In descending order, all-suture anchors placed in the lateral footprint were significantly superior to those located in the medial row and in a simulated Hill-Sachs defect. DISCUSSION: Anchors placed in the rotator cuff footprint exceeded the physiological isometric abduction forces for the supraspinatus and infraspinatus. Data obtained from our study suggest that all-suture anchors are strong enough to be used for the repair of rotator cuff tears.

All-Suture Transosseous Repair for Rotator Cuff Tear Fixation Using Medial Calcar Fixation.

We describe an all-suture transosseous repair technique used in the management of rotator cuff tears by means of an all-suture anchor secured on the intra-articular side of the humeral calcar. The technique uses an anterior cruciate ligament guide to ensure accurate positioning of the tunnels, avoiding the articular cartilage and minimizing risk to the neurovascular structures. The distal end of the guide is inserted through a rotator interval portal and passed down to the axillary pouch. The proximal end of the guide is approximated to the greater tuberosity at the cuff footprint, and a complete transosseous tunnel is created with a 2.4-mm drill. An all-suture implant is inserted through this tunnel down to the calcar, and its deployment is visualized under arthroscopy. Gentle traction is applied to the anchor, resulting in a 4-mm concertina of the suture anchor that rests opposed to the medial cortex. The major advantage of this technique is the fixation strength gained from the biomechanically superior cortical bone of the calcar. Furthermore, this method permits greater preservation of bone surface area at the level of the footprint for a larger tendon-to-bone healing surface. This technique also provides an excellent alternative in revision situations.

Arthroscopic posterior bone block augmentation in posterior shoulder instability.

BACKGROUND: Posterior instability is a relatively rare and challenging condition to treat. Soft-tissue procedures do not always provide satisfactory results. We present the results after arthroscopic posterior bone block augmentation with an iliac crest bone graft and a minimum of 12 months' follow-up. MATERIALS AND METHODS: Between 2008 and 2009, we performed 19 arthroscopic posterior bone blocks on 18 patients with posterior instability (bilaterally in 1 patient). The mean age was 29.85 years at the time of surgery. The mean follow-up was 20.5 months. All patients had a painful, unstable shoulder. Preoperative etiology included trauma, glenoid dysplasia, Ehlers-Danlos syndrome, and arthrosis with posterior glenoid erosion. RESULTS: The Rowe score improved from 18.4 points to 82.1 points, and the Walch-Duplay score improved from 37.4 points to 82.9 points, both statistically significant (P < .01). Radiologic bone healing was achieved in all cases. Nine cases had an excellent result with return to the previous level of sports, six were satisfied, and three had a persistently painful shoulder. Subsequent removal of screws improved symptoms in two of these patients, and in one patient, a cause for the pain and persistent instability was not found. CONCLUSION: Arthroscopic posterior bone block augmentation presents a reliable technique for the treatment of symptomatic posterior instability with varying origin. Although this is a technically demanding procedure, in our experience, the potential benefits and minimally invasive nature outweigh the risks and benefits of more invasive procedures.

Arthroscopic arthrolysis for recalcitrant frozen shoulder: a lateral approach.

PURPOSE: The purpose of this study was to evaluate a new all-arthroscopic technique in the management of recalcitrant globally stiff frozen shoulders. This adopts an initial extra-articular approach followed by intra-articular entry to perform a 360° capsular release. METHODS: Ten patients with global adhesive capsulitis were prospectively evaluated. All patients had not improved after undergoing a minimum of 6 months of physiotherapy, and 5 received intra-articular injections of steroids. The mean age was 47 years (range, 33 to 56 years). Patients were examined preoperatively and postoperatively for range of motion. A Constant score and visual analog scale score for pain were recorded. We described an all-arthroscopic technique by entering the subacromial space laterally and opening the rotator interval from the outside in, followed by a complete 360° capsular release and biceps tenotomy. RESULTS: The mean follow-up was 42 months (range, 18 to 90 months), and the mean Constant score improved from 21 to 72 (P < .01). Preoperative abduction improved from a mean of 40° to 165°, elevation improved from 55° to 175°, and external rotation improved from 6° to 58°. The visual analog scale pain score improved from 7 to 1.6, and all patients reported an excellent outcome after surgery. There were no complications particularly regarding axillary nerve injury, fracture, or infection. CONCLUSIONS: This study shows a combined extra-articular and intra-articular approach that is controlled and anatomic and achieves excellent results that were maintained at the midterm. The technique permits anatomic debridement of the rotator interval, enabling excellent intra-articular access, a circumferential capsular release, and biceps tenotomy. There were no complications, and no manipulations were required, which pose a risk of creating soft-tissue lesions, fractures, or dislocations. We recommend this 360° capsular release technique for releasing globally stiff shoulders where the surgeon is experienced in arthroscopy.

Arthroscopic latarjet procedure.

Although soft tissue stabilization procedures in the shoulder yield good results, arthroscopy and radiological investigations have identified more complex soft tissue and bony lesions that can be successfully treated using a Latarjet procedure. The authors have advanced this technique to make it possible arthroscopically, thereby conferring all the benefits that arthroscopic surgery offers. This article describes how and why the arthroscopic Latarjet procedure is a valuable tool in the treatment of complex shoulder instability and how the procedure can be introduced into practice. This technique has shown excellent results at short- to mid-term follow-up, with minimal complications. As such, this procedure is recommended to surgeons with good anatomic knowledge, advanced arthroscopic skills, and familiarity with the instrumentation.

Arthroscopic Latarjet procedure.

HYPOTHESIS: Arthroscopy reveals many previously unrecognized soft tissue and bony lesions underlying recurrent anterior shoulder instability. Certain stabilising procedures however fail to adequately address the underlying pathology. The open Latarjet procedure has shown to have excellent and reproducible results in recurrent instability. We believe that this success can be transferred using an all arthroscopic technique and gain the advantages of minimally invasive surgery. MATERIALS AND METHODS: Since December 2003, we performed over 180 arthroscopic Latarjet procedures. The technique and instruments have been refined and modified during this time. We prospectively collected the results for the first 100 shoulders. RESULTS: The average patient age was 27.5 with 88% actively involved in sports. Mean return to work was 2 months (7 days-4 months) and return to sport at 10 weeks (21 days-6 months). At 26 months, patient-reported outcomes revealed 91% excellent scores and 9% good. Range of motion showed an average loss of external rotation of 18 degrees . Perioperative complications included 2 hematomas, 1 graft fracture, and 1 transient musculocutaneous nerve palsy. Late complications included 4 cases of graft non-union and 3 of graft lysis. Graft position was flush with the glenoid in 80%, vertical positioning was excellent in 78% (3-5 o'clock). DISCUSSION: The all-arthroscopic Latarjet is a reliable but difficult technique, with a steep learning curve. Our technique has shown excellent results through midterm follow-up, with minimal complications and good graft positioning. CONCLUSIONS: We recommend this procedure to those surgeons with good anatomic knowledge, advanced arthroscopic skills, and familiarity with the instrumentation.

Arthroscopic removal of a plastic soft drink bottle cap in the knee: a case report.

We report a rare case of late knee locking after an open knee injury in a polytrauma patient with a pelvic fracture and a contralateral femoral artery injury. Once the life and limb threatening injuries were addressed, debridement and washout of the knee wound was performed. X-rays and subsequent CT revealed only an undisplaced patella fracture. The patient presented 6 months later to a knee surgeon with recurrent locking. An arthroscopy was performed and a 10 mm plastic soft drink bottle cap was retrieved leading to the immediate resolution of symptoms without complications.Open knee injuries require thorough debridement washout and joint assessment. Late locking should raise the suspicion of an intra-articular loose or foreign body. Arthroscopy is an excellent first line tool in the diagnosis and late management of this unusual problem.