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

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

Controversies in surgical management of anterior shoulder instability. State of the Art.

Arthroscopic Bankart repair (ABR) has been accepted as a standard procedure for anterior shoulder instability with a minimum or no glenoid bone loss and an on-track Hill-Sachs lesion if present. However, several controversies exist in the surgical treatment of anterior shoulder instability. This article will discuss some of these controversies in, "simple," dislocations (without bone loss) as well as, "complex," (with critical bone loss). Determining which patients will benefit from an arthroscopic procedure depends on multiple factors including age, activity level, adequate determination of bone loss, performed with feasible and reliable imaging techniques. In the absence of concomitant significant bony and soft tissue pathology, ABR alone can provide satisfactory clinical results on a long-term basis. Controversies, including whether to remove cartilage from the edge of the glenoid, knotted versus knotless anchors, and routine rotator interval closure, still exist. In cases with significant bone loss, several bone restoring procedures have been described, such as, the Latarjet procedure, iliac crest bone graft, arthroscopic anatomic glenoid reconstruction with a frozen distal tibial allograft, and fresh distal tibial allograft reconstruction. This article will address these controversies and provide guidance based on available published data.

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

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

Arthroscopic shoulder surgery for gouty long head of biceps tendinitis: a case report.

OBJECTIVE: The objective of the case report is to analyze the clinical manifestations and imaging features of gouty long head of biceps tendinitis, and to summarize the methods and effects of shoulder arthroscopic surgery. CLINICAL PRESENTATION AND INTERVENTION: The clinical data of a 39-year-old Han Chinese female with gouty long head of the biceps tendinitis was retrospectively analyzed, and the clinical manifestations, imaging features, and diagnosis and treatment were analyzed. The patient presented with pain and limited movement of right shoulder joint. Computed tomography showed irregular high-density shadows above the glenoid and adjacent to the coracoid process of the right shoulder. Magnetic resonance imaging revealed superior labrum anterior and posterior injury with edema in the upper recess and axillary sac. After arthroscopic surgery, the "tofu residue" tissue of the long head of the biceps was removed, and the postoperative pathological examination proved that it was gout stone. CONCLUSION: Gouty long head of the biceps tendinitis is a rare disease. Arthroscopic surgery can probe the structural lesions of shoulder cavity in all aspects, improve the surgical accuracy, and reduce the trauma.

Classification of Shoulder Implant Manufacturer Using Pre-Trained DenseNet201 Combined With Capsule Network.

BACKGROUND: This study aims to accelerate revision surgery and treatment using X-ray imaging and deep learning to identify shoulder implant manufacturers in advance. METHODS: A feature engineering approach based on principal component analysis and a k-means algorithm was used to cluster shoulder implant data. In addition, a pre-trained DenseNet201 combined with a capsule network (DenseNet201-Caps) shoulder implant classification model was proposed. RESULTS: DenseNet201-Caps was the most effective classification model on the clustered dataset with an accuracy of 94.25% and an F1 score of 96.30%. Notably, clustering the dataset in advance improved the accuracy and the Caps implementations successfully enhanced the performance of all convolutional neural network models. The analysed results indicate that DenseNet201-Caps struggled to distinguish between the Cofield and Depuy manufacturers. Hence, a multistage classification approach was developed with an improved accuracy of 96.55% achieved. CONCLUSIONS: The DenseNet201-Caps method enables the accurate identification of shoulder implant manufacturers.

Effect of low-volume ropivacaine in ultrasound-guided superior trunk block on diaphragmatic movement in patients undergoing shoulder arthroscopy: a randomized controlled trial.

OBJECTIVES: The incidence of hemidiaphragmatic paresis (HDP) in superior trunk block (STB) usually depends on the dose of local anesthetic. This study aimed to further evaluate the impact of a lower volume (10 mL) of the same low concentration (0.25%) ropivacaine compared to a conventional volume (15 mL), on diaphragmatic function and analgesic efficacy under a multimodal analgesia regimen for shoulder arthroscopy. METHODS: Patients scheduled to undergo shoulder arthroscopy were randomized allocated to receive either 10 mL or 15 mL of 0.25% ropivacaine in the STB under ultrasound guidance prior to general anesthesia. The primary outcome was the percentage reduction in diaphragm excursion (ΔDE) between baseline and 30 min after block. Secondary outcomes included DE and diaphragm thickening fraction (DTF) before and after block, incidence of HDP, onset of sensory/motor block, duration of analgesia/motor block, dermatomal coverage area of the block, postoperative pain severity, pre- and post-block respiratory function and intraoperative hemodynamic parameters, the use of other anesthetic and analgesic drugs, post-block complications, and adverse events post-surgery. RESULTS: Compared with 15 mL volume, 10 mL ropivacaine significantly reduced the incidence of post-block HDP (as measured by ΔDE: 39.47% vs. 64.10%; and by post-block DTF: 13.16% vs. 33.33%). There was no significant difference in onset of sensory block, duration of analgesia/motor block, dermatomal coverage area of the block, postoperative pain severity between the two groups, except that the onset of motor block was significantly slower in the 10 mL group than in the 15 mL group. Pre- and post-block respiratory function and intraoperative hemodynamic parameters, the use of other anesthetic and analgesic drugs, post-block complications, or postoperative adverse events were not significantly different between the two groups. CONCLUSION: In shoulder arthroscopy, STB with 10 mL of ropivacaine can reduce the incidence of HDP with no significant difference in analgesic effects under a multimodal analgesia regimen compared with 15 mL. TRIAL REGISTRATION: We registered the study at chictr.org ( ChiCTR2200057543 , 14/03/2022. https://www.chictr.ogr.cn.

Management of bone loss in anterior shoulder instability.

Bone defects are frequently observed in anterior shoulder instability. Over the last decade, knowledge of the association of bone loss with increased failure rates of soft-tissue repair has shifted the surgical management of chronic shoulder instability. On the glenoid side, there is no controversy about the critical glenoid bone loss being 20%. However, poor outcomes have been described even with a subcritical glenoid bone defect as low as 13.5%. On the humeral side, the Hill-Sachs lesion should be evaluated concomitantly with the glenoid defect as the two sides of the same bipolar lesion which interact in the instability process, as described by the glenoid track concept. We advocate adding remplissage to every Bankart repair in patients with a Hill-Sachs lesion, regardless of the glenoid bone loss. When critical or subcritical glenoid bone loss occurs in active patients (> 15%) or bipolar off-track lesions, we should consider anterior glenoid bone reconstructions. The techniques have evolved significantly over the last two decades, moving from open procedures to arthroscopic, and from screw fixation to metal-free fixation. The new arthroscopic techniques of glenoid bone reconstruction procedures allow precise positioning of the graft, identification, and treatment of concomitant injuries with low morbidity and faster recovery. Given the problems associated with bone resorption and metal hardware protrusion, the new metal-free techniques for Latarjet or free bone block procedures seem a good solution to avoid these complications, although no long-term data are yet available.

Outcomes of arthroscopic stabilization for recurrent instability are equal to stabilization after a primary event.

Aims: Extensive literature exists relating to the management of shoulder instability, with a more recent focus on glenoid and humeral bone loss. However, the optimal timing for surgery following a dislocation remains unclear. There is concern that recurrent dislocations may worsen subsequent surgical outcomes, with some advocating stabilization after the first dislocation. The aim of this study was to determine if the recurrence of instability following arthroscopic stabilization in patients without significant glenoid bone loss was influenced by the number of dislocations prior to surgery. Methods: A systematic review and meta-analysis was performed using the PubMed, EMBASE, Orthosearch, and Cochrane databases with the following search terms: ((shoulder or glenohumeral) and (dislocation or subluxation) and arthroscopic and (Bankart or stabilisation or stabilization) and (redislocation or re-dislocation or recurrence or instability)). Methodology followed the PRISMA guidelines. Data and outcomes were synthesized by two independent reviewers, and papers were assessed for bias and quality. Results: Overall, 35 studies including 7,995 shoulders were eligible for analysis, with a mean follow-up of 32.7 months (12 to 159.5). The rate of post-stabilization instability was 9.8% in first-time dislocators, 9.1% in recurrent dislocators, and 8.5% in a mixed cohort. A descriptive analysis investigated the influence of recurrent instability or age in the risk of instability post-stabilization, with an association seen with increasing age and a reduced risk of recurrence post-stabilization. Conclusion: Using modern arthroscopic techniques, patients sustaining an anterior shoulder dislocation without glenoid bone loss can expect a low risk of recurrence postoperatively, and no significant difference was found between first-time and recurrent dislocators. Furthermore, high-risk cohorts can expect a low, albeit slightly higher, rate of redislocation. With the findings of this study, patients and clinicians can be more informed as to the likely outcomes of arthroscopic stabilization within this patient subset.

Characterization of articular lesions associated with glenohumeral instability using arthroscopy.

Aims: The prevalence of osteoarthritis (OA) associated with instability of the shoulder ranges between 4% and 60%. Articular cartilage is, however, routinely assessed in these patients using radiographs or scans (2D or 3D), with little opportunity to record early signs of cartilage damage. The aim of this study was to assess the prevalence and localization of chondral lesions and synovial damage in patients undergoing arthroscopic surgery for instablility of the shoulder, in order to classify them and to identify risk factors for the development of glenohumeral OA. Methods: A total of 140 shoulders in 140 patients with a mean age of 28.5 years (15 to 55), who underwent arthroscopic treatment for recurrent glenohumeral instability, were included. The prevalence and distribution of chondral lesions and synovial damage were analyzed and graded into stages according to the division of the humeral head and glenoid into quadrants. The following factors that might affect the prevalence and severity of chondral damage were recorded: sex, dominance, age, age at the time of the first dislocation, number of dislocations, time between the first dislocation and surgery, preoperative sporting activity, Beighton score, type of instability, and joint laxity. Results: A total of 133 patients (95%) had synovial or chondral lesions. At the time of surgery, shoulders were graded as having mild, moderate, and severe OA in 55 (39.2%), 72 (51.4%), and six (4.2%) patients, respectively. A Hill-Sachs lesion and fibrillation affecting the anteroinferior glenoid cartilage were the most common findings. There was a significant positive correlation between the the severity of the development of glenohumeral OA and the patient's age, their age at the time of the first dislocation, and the number of dislocations (p = 0.004, p = 0.011, and p = 0.031, respectively). Conclusion: Synovial inflammation and chondral damage associated with instability of the shoulder are more prevalent than previously reported. The classification using quadrants gives surgeons more information about the chondral damage, and could explain the pattern of development of glenohumeral OA after stabilization of the shoulder. As the number of dislocations showed a positive correlation with the development of OA, this might be an argument for early stabilization.

Staged Shoulder and Elbow Reconstruction in a Child with Obstetric Brachial Plexus Palsy: Six-year Follow-up.

ABSTRACT: The management of obstetric brachial plexus palsy (OBPP) can be challenging, particularly in neglected patients. We report the long-term results of the surgical management of a late-presenting adolescent girl with severe left shoulder and elbow flexor paralysis secondary to OBPP. She was subjected to staged shoulder and elbow reconstruction in the form of trapezius transfer and latissimus and teres major transfer to enhance shoulder abduction and lateral rotation, and flexor-pronator transfer to the anterior distal humerus to enhance elbow flexion. Flexor-pronator plasty was successful in restoring elbow flexion and function and maintaining joint stability in the long term in a patient with severe OBPP. This further consolidates its role as a feasible secondary reconstructive procedure in carefully selected patients with elbow flexor paralysis. Shoulder function improved less remarkably, yet it augmented the overall upper extremity function and correlated with pre-operative residual shoulder function. Fulfilling the candidacy for each surgical procedure is important to a successful outcome.

Mid- to long-term outcome of reverse total shoulder arthroplasty as revision procedure for failed hemiarthroplasty after proximal humerus fracture.

BACKGROUND: Insufficient tuberosity healing is the most common reason for poor outcome after treatment of proximal humerus fractures (PHFs) using hemiarthroplasty (HA). In these cases, revision to reverse total shoulder arthroplasty (RTSA) can improve function and reduce pain in the short term, however, long-term results remain scarce. Aim of this study was to evaluate the clinical and radiological mid- to long-term results in patients with a revision RTSA after failed HA for PHF. METHODS: In this retrospective study all patients that received a revision to RTSA after failed fracture HA between 2006 and 2018 were included. A total of 49 shoulders in 48 patients (38 female, 10 male; mean age 82 ± 9 years) were identified in our database. A total of 20 patients (17 female, 3 male; mean age was 79 ± 9 years) were available for follow-up examination after a mean time period of approximately eight years (3-14 years) after revision surgery. At final follow-up, patients were assessed using a subjective shoulder value (SSV), range of motion (ROM), visual analogue score (VAS), the Constant Score (CS) and the 12-Item Short Form Survey (SF-12). RESULTS: At final follow-up, mean CS was 55 ± 19 (19-91), VAS averaged 3 ± 3 (0-8) and mean SSV was 61 ± 18% (18-90%). Mean SF-12 was 44 (28-57) with a mean physical component summary (PCS) of 38 (21-56) and a mean mental component summary (MCS) of 51 (29-67). On average active forward flexion (FF) was 104° (10-170°), active abduction (ABD) was 101° (50-170°), active external rotation (ER) was 19° (10-30°) and active internal rotation (IR) of the lumbosacral transition was reached. Three patients presented with a periprosthetic humeral fracture after RTSA implantation and underwent a reoperation (15%) during follow-up period. CONCLUSIONS: Revision RTSA results in promising clinical results in patients after initial failed HA after PHF. A complication and reoperation rate of 15% is tolerable in consideration of satisfactory functional and psychological outcome. TRIAL REGISTRATION: Retrospectively registered.

The Arthroscopically Guided Bristow-Latarjet Procedure With Cortical Button Fixation: A Minimum 10-Year Follow-up.

BACKGROUND: Despite improved visualization, the use of arthroscopic surgery to perform the Latarjet procedure has not decreased the rates of complications and glenohumeral osteoarthritis (OA) in the long term. Many of the reported complications are related to the use of screws for bone block fixation with freehand drilling. PURPOSE: To evaluate the long-term (at a minimum 10-year follow-up) clinical and radiological outcomes of the arthroscopic Bristow-Latarjet procedure using a posterior guided drilling technique and suture button for coracoid bone graft fixation. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Consecutive patients who underwent the arthroscopic Bristow-Latarjet procedure with suture button fixation between 2011 and 2013 were reviewed by 2 independent evaluators. Complications and revision surgery were recorded, and we evaluated patient-reported outcomes including subjective scores, recurrence of shoulder instability (dislocation or subluxation), range of motion limitations, and return to sports. Patients had radiographs taken at least 10 years after surgery to assess glenohumeral OA according to the Samilson-Prieto classification system and computed tomography scans to assess bone block positioning and healing. RESULTS: A total of 65 consecutive patients (68 shoulders) with a mean follow-up of 135 months (range, 120-156 months) were included. The mean age at the time of surgery was 25 ± 8 years; 7 patients had previous failed Bankart repair. At follow-up, 94% (64/68) of the shoulders had no recurrence of instability. The 4 cases of instability recurrence were traumatic and occurred at 3 weeks (a fall), 4 months, 2 years, and 7 years after surgery. No hardware failures, coracoid fractures, or neurological complications were observed. Overall, 61 patients (94%) were still participating in sports, with 44 (68%) at the same or higher level. Range of motion showed nonsignificant restrictions in external rotation with the arm at the side (7° ± 9°) and with the arm at 90° of abduction (9° ± 10°) compared with the contralateral side. Additionally, 11 shoulders (16%) had some residual anterior apprehension on clinical examination. At last follow-up, 77% (47/61) of the shoulders had no OA development or progression. Previous failed Bankart repair was a risk factor for the development of OA. Patients with OA had significantly lower Subjective Shoulder Value scores (79% vs 91%, respectively; P = .01) and decreased external rotation with the arm at the side (40° vs 65°, respectively; P = .001) compared with patients with no or little OA. CONCLUSION: The arthroscopically guided Bristow-Latarjet procedure with suture button fixation is a safe and durable surgical treatment method for recurrent anterior shoulder instability, allowing a high rate of return to sports without significant motion restrictions and no or little OA in the long term.

Mitigating the Risk of Instability After Reverse Shoulder Arthroplasty: A Critical Analysis Review of Patient and Surgical Factors.

¼ Instability and dislocation after reverse shoulder arthroplasty may occur in up to 31% of patients.¼ Clinical risk factors for instability include younger age, male sex, increased body mass index, preoperative diagnosis of proximal humerus fracture or rotator cuff pathology, history of instability of the native shoulder or after surgery, and a medical history of Parkinson's disease.¼ Patients with rheumatoid arthritis and decreased proximity to the coracoid may also be at greater risk.¼ In patients at a high risk of instability, surgeons should consider a more lateralized prosthesis (particularly in patients with an incompetent rotator cuff), repairing the subscapularis (particularly when using a medialized prosthesis), and upsizing the glenosphere (>40 mm in male and 38-40 mm in female patients).¼ While potentially useful, less evidence exists for the use of a constrained liner (particularly with a lateralized glenosphere and/or in low-demand patients) and rotating the polyethylene liner posteriorly to avoid impingement.

Current Imaging of Anterior and Posterior Instability in the Athlete.

In the evaluation of shoulder instability, recognition of relevant pathology on imaging is critical to planning a surgical treatment that minimizes the risk for recurrent instability. The purpose of this review is to (1) discuss the use of radiography, computed tomography, and MRI in evaluating shoulder instability and (2) demonstrate how various imaging modalities are useful in identifying critical pathologies in the shoulder that are relevant for treatment.

Open Bone Augmentation Solutions for the Failed Shoulder Stabilization.

Utilizing fresh distal tibia allograft in anterior glenoid reconstruction has emerged as a highly advantageous approach in addressing instances of failed anterior shoulder stabilization with glenoid bone loss. This procedure offers several benefits, including the absence of donor-site morbidity, restoration of significant glenoid defects, reestablishment of joint congruity with the humeral head, restoration of glenoid biomechanics, and the addition of cartilage to the glenoid. Furthermore, it provides a robust and reliable alternative for managing failed stabilization procedures, leading to improved clinical outcomes and a high graft healing rate, while maintaining a low occurrence of recurrent instability.

Decision Making of the In-season Athlete with Anterior Shoulder Instability.

In-season management of anterior shoulder instability in athletes is a complex problem. Athletes often wish to play through their current season, though recurrent instability rates are high, particularly in contact sports. Athletes are generally considered safe to return to play when they are relatively pain-free, and their strength and range of motion match the uninjured extremity. If an athlete is unable to progress toward recovering strength and range of motion, surgical management is an option, though this is often a season-ending decision.

Arthroscopic Management of the Contact Athlete with Anterior Instability.

Anterior glenohumeral instability is one of the most common injuries suffered from sport. Despite padding and conditioning, the shoulder joint remains particularly vulnerable to injury, especially in the setting of contact. The overall rate of anterior instability is reported to be 0.12 injuries per 1000 athlete exposures, although this is increased up to 0.40 to 0.51 in the contact athlete. Successful treatment requires consideration of restoring stability while minimizing loss of glenohumeral motion. Common treatment strategies involve addressing the pathology that results from anterior shoulder dislocation including labral detachment as well as bony defects to the humeral head and glenoid.

Open Bankart Repair: Technique and Outcomes for the High-Level Athlete.

Historically considered the gold standard technique for glenohumeral instability, the open Bankart repair is being performed at decreased rates because of the current trends favoring arthroscopic Bankart repair and the lack of consistent training of the open technique. However, open Bankart repairs may be more appropriate for certain high-risk populations (ie, high-level collision athletes) because of their reduced recurrent instability rates. Further investigations are needed to identify the indications for arthroscopic versus open Bankart repair and compare their outcomes in high-level athletes. This review highlights the indications, surgical technique, and clinical outcomes following open Bankart repairs in athletes.