Criteria, Timing, and Factors Associated With Return to Competitive Sport After Rotator Cuff Surgery.

Rotator cuff pathology in competitive athletes is common and may produce chronic symptoms and joint disability, impairing sports participation and leading to premature retirement. Athletes are a high-functioning patient population with unique characteristics. Decision-making for return to sport is a complex and multifactorial process. Literature is sparse and does not provide precise guidelines to assist physicians to make the right decision. This review aimed to highlight factors affecting outcome, timing, and criteria for return to competitive sport after rotator cuff surgery to help physicians to clearly counsel athletes and make high-quality decisions for return to sport.

BLU-DAT: a new reliable and accurate arthrometer for measuring anterior knee laxity.

PURPOSE: Although many arthrometers have been developed to assess anterior knee laxity, reliability and diagnostic accuracy of these devices are still debated. The aim of the present study was to evaluate the validity of a new arthrometer in the outpatient setting, with the hypothesis that it had good validity in terms of reliability and diagnostic accuracy. METHODS: Seventy-eight subjects (39 with ACL injury and 39 with normal ACL) were tested. ATT was assessed by means of the Lachman test at 30° of flexion with a new testing device (BLU-DAT) under three different loading conditions: 7 kg (69 N), 9 kg (88 N) and maximum (MMT). The tests were performed on both knees to obtain SSD. In the ACL injury group, the tests were performed by two examiners and one of them repeated a second test series. Inter- and intra-observer reliability were assessed with the intraclass correlation coefficients (ICCs) for the average SSD measures. In the normal-ACL group, the analysis was performed with the same testing setup. Side-to-side difference measures of the two groups at every loading condition were compared by Student's t test. Data of test series were dichotomized based on the threshold value of 3-mm SSD as pathological ATT and 2 × 2 contingency tables were used to assess diagnostic accuracy. RESULTS: The ICCs for intra-observer reliability at 7-kg (69 N), 9-kg (88 N) and MMT measurements were 0.781, 0.855 and 0.913, respectively. The ICC for inter-observer reliability at 7-kg (69 N), 9-kg (88 N) and MMT measurements were 0.701, 0.845 and 0.834, respectively. Comparison between the two groups showed a significant mean difference ranging from 3.4 mm for 7-kg (69 N) load to 4.6 mm for MMT. Overall accuracy ranged from 84.6% for 7-kg load to 98.7% for MMT. CONCLUSION: The BLU-DAT has proven to be an instrument with good intra- and inter-observer reliability and very good accuracy in the diagnosis of ACL injuries in the outpatient setting. So, the BLU-DAT can be a new useful tool in everyday clinical practice to assist in the diagnosis of ACL injury. LEVEL OF EVIDENCE: II.

Combined Arthroscopic-Assisted Lower Trapezius Tendon Transfer and Superior Capsule Reconstruction for Massive Irreparable Posterior-Superior Rotator Cuff Tears: Surgical Technique.

Primary or revision irreparable rotator cuff tears remain a challenge. Clear algorithms do not exist. Several joint-preserving options are available, but no technique has been definitely proven to be better than another. Although superior capsule reconstruction has been shown to be effective in restoring motion, lower trapezius transfer can provide strong external rotation and abduction moment. The aim of the present article was to describe an easy and reliable technique to combine both options in 1 surgery, aiming to maximize the functional outcome by getting motion and strength back.

High degree of consensus on diagnosis and management of rotator cuff tears: a Delphi approach.

PURPOSE: To develop a consensus on diagnosis and treatment of rotator cuff tears. The study focused on selected areas: imaging, prognostic factors, treatment options, surgical techniques. METHODS: Panel was composed of all members of the shoulder committee of the Italian Society of Arthroscopy, Knee, Upper arm, Sport, Cartilage and Orthopedic techniques (SIAGASCOT). Four rounds were performed. The first round consisted of gathering questions which were then divided into seven blocks referring to: imaging, patient-related prognostic factors, treatment options, surgical steps, reparative techniques, surgical predictive factors, advanced techniques. Subsequent rounds consisted of condensation by means of online questionnaire and debates. Consensus was defined as two-thirds agreement on one answer. Descriptive statistic was used to summarize the data. RESULTS: Forty-one shoulder experts were involved. Fifty-six statements were finally formulated. A consensus could be achieved on 51. Experts agreed that preoperative magnetic resonance imaging is strongly recommended because it allows a careful evaluation of tear characteristics, while the role of US remains debatable. Controversial patient-related factors such as age, comorbidities, smoking and stiffness do not contraindicate the repair. From a surgical standpoint, the experts highlighted that pseudo-paralysis is not a contraindication to rotator cuff repair. Consensus on specific surgical steps was also achieved: capsular release should be performed only in stiff shoulders; footprint preparation is mandatory, while debridement of tendon edges is not essential. If necessary, a rotator interval release could be performed without interrupting the continuity between subscapularis and supraspinatus tendon; posterior delamination should be always included in the repair. Advanced techniques such as tendon transfers should be selected based on the main clinical deficit, while the superior capsule reconstruction plays a role only in combination with a functional repair. CONCLUSION: A consensus was achieved almost on every topic of controversy explored. Particularly, MRI was deemed necessary to determine tear characteristics, while radiographs remain important for differential diagnosis; age should not be considered a contraindication to surgery; pseudo-paralysis does not represent a contraindication to arthroscopic rotator cuff repair, but superior capsule reconstruction plays a role only in combination with a functional repair. Latissimus dorsi transfer plays a role when the main functional deficit is in elevation, while the lower trapezius transfer plays a role when the main functional deficit is the external-rotation. LEVEL OF EVIDENCE: V.

A new knee arthrometer demonstrated to be reliable and accurate to assess anterior tibial translation in comparison with stress radiographs.

INTRODUCTION: For several years, many arthrometers have been developed to assess anterior knee laxity. The aim of our study was to evaluate the validity of a new practical and handy testing device with the hypothesis that the new arthrometer had good validity in terms of reliability and accuracy. METHODS: Lachman test was performed on five fresh frozen cadaveric knees by five examiners. Anterior tibial translation (ATT) was measured with a new arthrometer (BLU-DAT) and on lateral stress radiographs. Data on ATT were obtained under 7 kg (69 N), 9 kg (88 N), and maximum manual traction (MMT). Tests were performed on the same specimens before and after arthroscopic ACL excision. Inter-rater reliability of the BLU-DAT measures was assessed with the intraclass correlation coefficient (ICC) for single and average measurements. The Bland-Altman method was used to estimate agreement between the BLU-DAT and stress radiographs. RESULTS: ICC values for single measurements were 0.62, 0.54 and 0.58 for 7-kg, 9-kg and MMT assessment, respectively. Overall reliability was good (ICC = 0.63). ICC values for average measurements were 0.89, 0.85 and 0.88 for 7-kg, 9-kg and MMT assessment, respectively. Overall reliability was very good (ICC = 0.90) SEM ranged from 1.4 mm to 1.6 mm for single measurements and was below 1 mm at each testing condition for average measurements. Analysis of agreement between BLU-DAT and radiographic measurements showed a mean difference equal to 0.83 mm ± 2.1 mm (95% CI: 0.55-1.11). Upper LOA was equal to 4.9 mm (95% CI: 5.39-4.41). Lower LOA was equal to - 3.2 mm (95% CI: - 2.71 to - 3.69). CONCLUSION: Measurement of anterior knee laxity with the BLU-DAT testing device has a good to very good inter-rater reliability and good agreement with a gold standard such as stress radiographs. Cadaveric Diagnostic Study, Level of Evidence IV.

Sulcus Angle, Trochlear Depth, and Dejour's Classification Can Be Reliably Applied To Evaluate Trochlear Dysplasia: A Systematic Review of Radiological Measurements.

PURPOSE: To summarize data on the reliability of available imaging criteria for the assessment of trochlear dysplasia and to assess the methodological quality of the included studies. METHODS: This systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline. Search was performed using major electronic databases from their inception to September 2021. All studies enrolling patients of any age who underwent a radiological exam to rule out features related to trochlear dysplasia were included. After the identification of available imaging criteria, reliability studies were analyzed. Descriptive statistics were used to summarize findings. Methodological quality was assessed using the Quality Appraisal of Reliability studies checklist. RESULTS: A total of 2391 articles were identified, and 33 articles comprising 3036 patients with a mean age of 28.6 years were included. Thirty different measurements were extracted. Magnetic resonance imaging (MRI) was the most used imaging modalities (21 studies), followed by computed tomography (10 studies), conventional radiology (8 studies) and ultrasonography (US) (1 study). Sulcus angle, trochlear depth, and Dejour's classification were the most explored measurements. Overall, sulcus angle can be reliably assessed on radiography, CT and MRI, whereas trochlear depth can be reliably measured only with CT and MRI. Reliability of Dejour's classification ranged from poor or fair to very good for all imaging modalities. Methodological quality of included studies varied from 2 to 9 positive items out of 11 possible. Twenty-four studies (72.7%) were considered at high risk of bias. CONCLUSION: Trochlear dysplasia can be reliably evaluated at least with 3 measurements: sulcus angle, trochlear depth and Dejour's classification. Methodological quality assessment showed high risk of bias in most included studies. LEVEL OF EVIDENCE: Level III, systematic review of Level II-III studies.

Knotless PEEK and double-loaded biodegradable suture anchors ensure comparable clinical outcomes in the arthroscopic treatment of traumatic anterior shoulder instability: a prospective randomized study.

PURPOSE: To compare the clinical outcome of arthroscopic capsulolabral repair for traumatic anterior shoulder instability with PEEK knotless and knotted biodegradable suture anchors. METHODS: Arthroscopic stabilization was performed in 78 patients with recurrent traumatic anterior shoulder instability. They were divided into 2 groups of 39 patients each, according to suture anchors used: knotless PEEK anchors in group 1, and biodegradable anchors in group 2. Exclusion criteria were: instability without dislocation, posterior or multidirectional instability, glenoid bone loss > 20%, off-track lesions, concomitant rotator cuff tears and previous surgery. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) self-administered questionnaire. Secondary outcomes were: Work-DASH, Sport-DASH, Rowe score, recurrent instability and subsequent surgery. The following independent variables were considered: age, gender, dominance, generalized ligamentous hyperlaxity, duration of symptoms, age at first dislocation, number of dislocations, type of work, type of sport, sports activity level, capsule-labral injury pattern, SLAP lesion and number of anchors. Differences between groups for numerical variables were analyzed by use of the Student's t-test or Mann-Whitney U-test. Fisher's exact test was used for analysis of categorical variables. Significance was set at p < 0.05. RESULTS: Seven patients (9%) were lost at follow-up, 5 from group 1 and 2 from group 2. Follow-up ranged from 36 to 60 months (median: 44; IQR: 13). Comparison between groups did not show significant differences for each independent variable considered. No differences could be found either for DASH (n.s.) or Rowe (p = n.s.) scores between the two groups. Overall recurrence rate was 7%. Three re-dislocations were reported in group 1 and two in group 2 (n.s.). Only one patient in each group underwent re-operation. CONCLUSIONS: The study showed no significant differences in clinical outcomes after arthroscopic treatment of traumatic anterior shoulder instability using PEEK knotless or biodegradable knotted anchors at mid-term follow-up. LEVEL OF EVIDENCE: I.

Editorial Commentary: Acromioplasty Does Not Improve Clinical Outcome of Arthroscopic Rotator Cuff Repair: The Game Is Over!

Acromioplasty is a well-known, simple, and reproducible surgical technique that is used in isolation or in combination with other arthroscopic procedures. The clinical value of acromioplasty combined with arthroscopic rotator cuff repair has been largely investigated. Main theoretical benefits lie in the opportunity to improve the visualization, decrease abrasive wear with prominent acromial morphology, and release natural growth factors. On the other hand, acromioplasty and release of the coracoacromial ligament may weaken the insertion of the deltoid muscle, induce scar formation in the subacromial space, theoretically limiting shoulder mobility, and increase risk of anterior-superior humeral escape, especially in patients with large to massive rotator cuff tears. Clinical studies report conflicting results. My results show no differences in clinical outcomes in rotator cuff repairs with or without subacromial decompression, regardless of the acromial morphology. At the same time, I do believe that confirmatory studies are always necessary, especially if the aim is to disprove the usefulness of a common practice.

No differences between conservative and surgical management of acromioclavicular joint osteoarthritis: a scoping review.

PURPOSE: To conduct a scoping review to clarify the management of acromioclavicular joint osteoarthritis, as well as to identify any existing gaps in the current knowledge. METHODS: Studies were identified by electronic databases (Ovid, Pubmed) from their inception up to April 2nd, 2020. All studies reporting functional outcomes after conservative or surgical treatment of acromioclavicular joint osteoarthritis, either primary or secondary to trauma or distal clavicle osteolysis, were included. Following data were extracted: authors, year of publication, study design (prospective or retrospective), LOE, number of shoulders treated conservatively or surgically, patients' age, OA classification, type of conservative treatment, surgical approach, surgical technique, functional outcomes, complications, revisions, and length of follow-up. Descriptive statistics was used. Quality appraisal was assessed through the Cochrane risk of bias tool for LOE I/II studies, while the MINORS checklist was used for LOE III/IV studies. RESULTS: Nineteen studies were included for a total of 861 shoulders. Mean age of participants was 48.5 ± 7.4 years. Mean follow-up was 43.8 ± 29.9 months. Four studies reported functional results after conservative treatment, whereas 15 studies were focused on surgical management. No studies directly compared conservative and surgical treatment. Seven studies reported a surgical approach after failure of previous conservative treatment. All studies reported functional improvement and pain relief. Complication rate was low. Overall methodological quality of included studies was very low. CONCLUSION: Conservative and surgical treatments are both effective in acromioclavicular joint osteoarthritis management. However, available data did not allow to establish the superiority of one technique over another. LEVEL OF EVIDENCE: Level IV.

High degree of consensus achieved regarding diagnosis and treatment of acromioclavicular joint instability among ESA-ESSKA members.

PURPOSE: To develop a consensus on diagnosis and treatment of acromioclavicular joint instability. METHODS: A consensus process following the modified Delphi technique was conducted. Panel members were selected among the European Shoulder Associates of ESSKA. Five rounds were performed between October 2018 and November 2019. The first round consisted of gathering questions which were then divided into blocks referring to imaging, classifications, surgical approach for acute and chronic cases, conservative treatment. Subsequent rounds consisted of condensation by means of an online questionnaire. Consensus was achieved when ≥ 66.7% of the participants agreed on one answer. Descriptive statistic was used to summarize the data. RESULTS: A consensus was reached on the following topics. Imaging: a true anteroposterior or a bilateral Zanca view are sufficient for diagnosis. 93% of the panel agreed on clinical override testing during body cross test to identify horizontal instability. The Rockwood classification, as modified by the ISAKOS statement, was deemed valid. The separation line between acute and chronic cases was set at 3 weeks. The panel agreed on arthroscopically assisted anatomic reconstruction using a suspensory device (86.2%), with no need of a biological augmentation (82.8%) in acute injuries, whereas biological reconstruction of coracoclavicular and acromioclavicular ligaments with tendon graft was suggested in chronic cases. Conservative approach and postoperative care were found similar CONCLUSION: A consensus was found on the main topics of controversy in the management of acromioclavicular joint dislocation. Each step of the diagnostic treatment algorithm was fully investigated and clarified. LEVEL OF EVIDENCE: Level V.

Anatomic reconstruction of the coracoclavicular and acromioclavicular ligaments with semitendinosus tendon graft for the treatment of chronic acromioclavicular joint dislocation provides good clinical and radiological results.

PURPOSE: To evaluate clinical and radiographic outcomes of anatomical reconstruction of the coracoclavicular and acromioclavicular ligaments with single-strand semitendinosus tendon graft for the treatment of chronic acromioclavicular joint dislocation. METHODS: Patients affected by chronic type III-V acromioclavicular joint dislocations were included. Exclusion criteria were: age under 18 years, concomitant rotator cuff tears, previous surgery to the same shoulder, degenerative changes of the glenohumeral joint, infections, neurologic diseases, patients with a previous history of ligament reconstruction procedures that had required harvesting of the semitendinosus tendon from the ipsilateral or contralateral knee. All patients underwent the same surgical technique and rehabilitation. Primary outcome was the normalized Constant score. Secondary outcomes were: DASH score, radiographic evaluation of loss of reduction and acromioclavicular joint osteoarthritis. RESULTS: Thirty patients with a mean age of 28.9 ± 8.3 years were included. Mean time to surgery was 12.8 ± 10 months. Mean follow-up was 28.1 ± 2.4 months (range: 24-32). Comparison between pre- and postoperative functional scores showed significant clinical improvement (p < 0.001). Time to surgery was independently associated with a poorer Constant score (p < 0.0001). On radiographs, 4 patients (13.3%) showed asymptomatic partial loss of reduction. CONCLUSION: Anatomic reconstruction of coracoclavicular and acromioclavicular ligaments using a semitendinosus tendon graft for the treatment of chronic acromioclavicular joint dislocation provided good clinical and radiological results at minimum 2-year follow-up. LEVEL OF EVIDENCE: Level III.

Anatomic reconstruction of the acromioclavicular joint provides the best functional outcomes in the treatment of chronic instability.

PURPOSE: To systematically review the outcomes of surgical treatments of chronic acromioclavicular joint dislocation. METHODS: Studies were identified by electronic databases (Ovid, PubMed). All studies reporting functional and radiological outcomes of surgical treatments of chronic acromioclavicular joint dislocations were included. Following data were extracted: authors and year, study design, level of evidence, number of patients, age, classification of acromioclavicular joint dislocation, time to surgery, surgical technique, follow-up, clinical and imaging outcomes, complications and failures. Descriptive statistics was used, when a data pooling was not possible. Comparable outcomes were pooled to generate summary outcomes reported as frequency-weighted values. Quality appraisal was assessed through the MINORS checklist. RESULTS: Fourty-four studies were included for a total of 1020 shoulders. Mean age of participants was 38 years. Mean follow-up was 32.9 months. Arthroscopic techniques showed better results than open approach (p < 0.0001). Synthetic reconstructions demonstrated better functional outcomes compared to internal fixation and biologic techniques (p < 0.0001). Among biologic techniques, combined coracoclavicular and acromioclavicular ligaments reconstruction showed better Constant (p = 0.0270) and ASES (p = 0.0113) scores compared to isolated coracoclavicular ligaments reconstruction; anatomic biologic non-augmented graft reconstruction showed better Constant (p < 0.0001), VAS (p < 0.0001) and SSV (p = 0.0177) results compared to augmented techniques. No differences in functional outcomes could be found between anatomic biologic non-augmented graft versus synthetic reconstructions. Overall, methodological quality of the included studies was low. CONCLUSION: Anatomic reconstructions, both synthetic and biologic, showed the best functional results. LEVEL OF EVIDENCE: IV.

Biologic and synthetic ligament reconstructions achieve better functional scores compared to osteosynthesis in the treatment of acute acromioclavicular joint dislocation.

PURPOSE: To systematically review the outcomes of surgical treatments of acute acromioclavicular joint dislocation. METHODS: Studies were identified by electronic databases (Ovid, PubMed). All studies reporting functional and radiological outcomes of surgical treatments of acute acromioclavicular joint dislocations were included. Following data were extracted: authors and year, study design, level of evidence, number of patients, age, classification of acromioclavicular joint dislocation, time to surgery, surgical technique, follow-up, clinical and imaging outcomes, complications, and failures. Descriptive statistics was used, when a data pooling was not possible. Comparable outcomes were pooled to generate summary outcomes reported as frequency-weighted values. Quality appraisal was assessed through the MINORS checklist. RESULTS: One hundred and thirty-three studies were included for a total of 4473 shoulders. Mean age of participants was 36.9 years. Mean follow-up was 42.06 months. Arthroscopy showed better ASES (p < 0.0001) and lower VAS pain score (p = 0.0249) compared to an open approach. Biologic and synthetic reconstructions demonstrated better results over osteosynthesis techniques. Biologic techniques showed overall better Constant (p = 0.0001) and DASH (p = 0.0215) scores, while synthetic reconstruction showed better UCLA score (p = 0.0001). Among suture buttons, triple button showed overall better results in Constant (p = 0.0001) and VAS (p = 0.0001) scores, while better results in DASH score (p = 0.0003) were achieved by 2 double button techniques. Overall, the level of evidence was low. CONCLUSION: Biological and synthetic reconstructions achieved better functional scores compared to osteosynthesis. Among suture buttons, the triple button showed better functional performance. LEVEL OF EVIDENCE: IV.

Arthroscopic Superior Capsule Reconstruction With Doubled Autologous Semitendinosus Tendon Graft.

Massive and irreparable rotator cuff tears remain a difficult condition to treat. Fatty infiltration of the muscles and excessive retraction of the tendons predispose to high failure rates of arthroscopic repair techniques. In recent years, studies on the superior capsule have shown that it plays a key role in reducing superior humeral head translation and restoring balance to the force couples required for dynamic shoulder function. Superior capsule reconstruction has become common in clinical practice. Several techniques with different types of grafts have been described, such as fascia lata autograft, dermal allograft patch, and long head of the biceps tendon autograft. More recently, an open technique with semitendinosus tendon autograft has been proposed. Our aim is to describe an all-arthroscopic technique for superior capsule reconstruction using a doubled semitendinosus tendon autograft in a box-shaped configuration. We believe that the technique can combine the advantages of other techniques, such as graft availability, low harvest-site morbidity, limited cost, and mechanical strength.

Augmented Repair of Large to Massive Delaminated Rotator Cuff Tears With Autologous Long Head of the Biceps Tendon Graft: The Arthroscopic "Cuff-Plus" Technique.

An anatomic and tension-free repair is the goal of arthroscopic rotator cuff repair. However, this purpose is not always achievable in large and massive tears, and sometimes, even when intraoperative results seem acceptable, clinical and radiologic outcomes can be disappointing shortly afterward. Superior capsule reconstruction has been claimed as a valid and viable joint-preserving option for treating irreparable rotator cuff tears. However, the role of the superior capsule in repairable cuff tears has also been questioned. The aim of this article is to present the so-called arthroscopic cuff-plus technique. This technique consists of superior capsule reconstruction using the proximal part of the long head of the biceps tendon associated with a tension-free repair of the rotator cuff tendons in large to massive delaminated tears.

Satisfactory mid-term outcomes of condylar-constrained knee implants in primary total knee arthroplasty: clinical and radiological follow-up.

BACKGROUND: The purpose of this study was to evaluate (1) the reoperation rates and survivorship for septic and aseptic causes, (2) radiographic outcomes, and (3) clinical outcomes of condylar-constrained knee (CCK) implants used in primary total knee arthroplasty (TKA) with severe coronal deformity and/or intraoperative instability. MATERIALS AND METHODS: A consecutive series of CCK implants in primary TKA was retrospectively evaluated in patients with severe coronal deformities. Forty-nine patients (54 knees) were included with a mean follow-up of 9 years (range 6-12). All patients were treated with a single-design, second-generation CCK implant. The primary diagnosis was osteoarthritis in 36 knees, post-traumatic arthritis in 7 knees, and rheumatoid arthritis in 4 knees. Preoperatively, standing femorotibial alignment was varus in 22 knees and valgus in 20 knees. RESULTS: At a mean follow-up of 9 years, overall survivorship was 93.6%. Two knees (4.3%) required revision for periprosthetic joint infection. One knee (2.1%) required subsequent arthroscopy due to patellar clunk syndrome. At final follow-up, no evidence of loosening or migration of any implant was reported, and the mean Knee Society knee scores improved from 43 to 86 points (p < 0.001). The mean Knee Society function scores improved to 59 points (p < 0.001). The average flexion contracture improved from 7° preoperatively to 2° postoperatively and the average flexion from 98° to 110°. No knees reported varus-valgus instability in flexion or extension. CONCLUSION: CCK implants in primary TKA with major coronal deformities and/or intraoperative instability provide good midterm survivorship, comparable with less constrained implants. In specific cases, CCK implants can be considered a viable option with good clinical and radiographic outcomes. However, a higher degree of constraint should be used cautiously, leaving the first choice to less constrained implants. Level of evidence Therapeutic study, level IV.

Shoulder arthroplasty for proximal humerus fractures in the elderly: The path from Neer to Grammont.

Shoulder replacement is indicated for the surgical treatment of proximal humeral fractures in elderly patients, when severe comminution and osteoporosis jeopardize the chances of success of any fixation technique. Two different implants are available for this purpose: anatomical hemiarthroplasty (HA) and reverse total shoulder arthroplasty (RTSA). HA for fractures was popularized by Charles Neer in the '50s and for several decades remained the only reliable implant for these injuries. However, many authors reported inconsistent results with HA as a consequence of the high rate of tuberosity and rotator cuff failure. In 1987, Paul Grammont designed the first successful RTSA, which was the end result of a long thought process on functional surgery of the shoulder. This implant was initially used to treat cuff tear arthropathy and shoulder pseudoparalysis, but indications have gradually expanded with time. Since RTSA does not rely on a functional cuff for shoulder elevation, it was felt that results in fractures could be improved by this prosthesis. In this study, the salient features of these implants are described to understand the rationale behind both approaches and highlight their pros and cons. Several clinical studies comparing HA vs RTSA for proximal humeral fractures have been published during the last two decades. A literature review is carried out to analyze and compare outcomes of both implants, analyzing clinical results, radiographic findings and complications. The final goal is to provide an overview of the different factors to consider for making a choice between these two prostheses.

Arthroscopic treatment of an unusual distal clavicle ostheochondroma causing rotator cuff impingement: case report and literature review.

Chronic shoulder impingement is one of the most common causes of shoulder pain. Intrinsic, extrinsic and secondary factors play a role in this syndrome; however the etiology of the pathology is still under debate. In rare cases, it can be caused by tumors, such as an osteochondroma. In the present study, a 49-year-old patient presented with shoulder pain for 6 months. Initially he underwent conservative treatment, without relief of symptoms. Xrays and MRI were then performed and showed the presence of an exostotic formation on the undersurface of the lateral third of the clavicle. The formation was arthroscopically removed. Histologic examination confirmed the diagnosis of osteochondroma. After surgery, the patient resumed fully activities with no symptoms within 3 months. At 1 year follow up, there are still no clinical or radiological signs of recurrence. This is, to our knowledge, the first case where an arthroscopic approach was used to remove an ostochondroma of the distal third of the clavicle.

Allergy in total knee replacement surgery: Is it a real problem?

Total knee arthroplasty is a common procedure, with extremely good clinical results. Despite this success, it produces 20% unsatisfactory results. Among the causes of these failures is metal hypersensitivity. Metal sensitization is higher in patients with a knee arthroplasty than in the general population and is even higher in patients undergoing revision surgery. However, a clear correlation between metal sensitization and symptomatic knee after surgery has not been ascertained. Surely, patients with a clear history of metal allergy must be carefully examined through dermatological and laboratory testing before surgery. There is no globally accepted diagnostic algorithm or laboratory test to diagnose metal hypersensitivity or metal reactions. The patch test is the most common test to determine metal hypersensitivity, though presenting some limitations. Several laboratory assays have been developed, with a higher sensitivity compared to patch testing, yet their clinical availability is not widespread, due to high costs and technical complexity. Symptoms of a reaction to metal implants present across a wide spectrum, ranging from pain and cutaneous dermatitis to aseptic loosening of the arthroplasty. However, although cutaneous and systemic hypersensitivity reactions to metals have arisen, thereby increasing concern after joint arthroplasties, allergies against implant materials remain quite rare and not a well-known problem. The aim of the following paper is to provide an overview on diagnosis and management of metal hypersensitivity in patients who undergo a total knee arthroplasty in order clarify its real importance.

Treatment of Primary Shoulder Stiffness: Results of a Survey on Surgeon Practice Patterns in Italy.

Objectives Shoulder stiffness is a condition of restricted glenohumeral range of motion (ROM), which can arise spontaneously or as consequence of a known cause. Several treatment options are available and currently no consensus has been obtained on which treatment algorithm represents the best choice for the patient. The aim of this study was to investigate surgeon practice patterns in Italy regarding treatment of primary shoulder stiffness. Methods A literature review was performed to identify randomized controlled trials reporting results of shoulder stiffness treatment. The following controversial or critical points in the treatment of primary shoulder stiffness were identified: modalities of physical therapy; indication for oral corticosteroid; indication and frequency for injective corticosteroid; technique and site of injection; and indication, timing, and technique for surgery. A survey composed by 14 questions was created and administrated to the members of a national association specialized in orthopaedics and sports traumatology (SIGASCOT at the time of survey completion, recently renamed SIAGASCOT after the fusion of the societies SIGASCOT and SIA). Results A total of 204 completed questionnaires were collected. Physical therapy was recommended by 98% of the interviewed. The use of oral corticosteroids was considered by 51%, and injections of corticosteroids by 72%. The posterior injection approach was the one preferred and a number of three was considered the upper limit for repeated injections. Injective therapy with local anesthetics and hyaluronic acid was considered by more than 20% of the interviewed. Thirty percent of the interviewed did not treat shoulder stiffness surgically. Conclusion Several approaches to shoulder stiffness have been proposed and high-level evidence is available to analyze and discuss their results. Several controversial points emerged both from a literature review and from this national survey. Treatment of shoulder stiffness should be tailored to the patient's clinical situation and the stage of its pathology and should aim at pain reduction, ROM restoration, functional regain, and shortening of symptoms duration, with conservative therapy remaining the mainstay of treatment.