Characteristics and functional outcomes of varus displaced proximal humerus fractures.

BACKGROUND: The purpose of this study was to compare fracture characteristics and functional outcomes between patients with proximal humerus fractures with and without initial varus displacement. METHODS: A retrospective review of 325 patients with proximal humerus fractures was performed. Patients with initial varus displacement were placed in Varus cohort and were age- and sex-matched 1:1 with a second cohort presenting proximal humerus fractures without varus displacement, referred to as Fracture cohort. Varus fracture displacement was defined when the most proximal aspect of humeral head was below the most proximal aspect of greater tuberosity on initial radiographs, and the head shaft angle was <130°. RESULTS: There were 60 patients in V cohort and 60 patients in F cohort. Statistical analysis revealed that there were significant differences in initial horizontal offset (38.8 vs. 45.9 mm), initial anterior angulation angle (36.5° vs. 16.4°), postoperative head shaft angle (132.2° vs. 141.3°), last head shaft angle (122.2° vs. 138.5°), difference for head shaft angles (10.0° vs. 2.7°), postoperative horizontal offset (43.4 vs. 45.3 mm), last horizontal offset (38.4 vs. 42.8 mm), difference for offsets (4.9 vs. 2.5 mm), complications (15 vs. 7 cases), and revision surgery (7 vs. 1 case) between two cohorts. Overall satisfactory results were achieved in most patients regardless of varus displacement, pain-VAS and Constant scores in V cohort were inferior to the scores in F cohort. The cut-off value of postoperative head shaft angle for good/excellent outcomes was 135.5° using receiver operating characteristic curve analyses. CONCLUSION: Varus displaced proximal humerus fractures were accompanied by decreased horizontal offset and increased anterior angulation angle, and had a course of more varization and horizontal shortening compared with those without initial varus displacement. Patients with varus displaced fractures were associated with worse functional outcomes, and these factors might affect functional outcomes. LEVEL OF EVIDENCE: Prognostic, cohort study, Level III.

Wide Resection Preserving Conjoined Tendons of the Rotator Cuff Muscles for Undifferentiated Pleomorphic Sarcoma at the Suprascapular Fossa - A Case Report.

Surgical principles in sarcoma are a wide resection, including surrounding tissues and maximisation of the function of the affected limb. Rotator cuff muscles are biomechanically important structures acting as a force couple in movement of the shoulder joint. Thus, conjoined tendons are essential for motion capability in absence of the supraspinatus muscle. This article reports a case of a large undifferentiated pleomorphic sarcoma (UPS) at the suprascapular fossa in a 78-year-old man. After diagnosis of sarcoma, he underwent wide, en-bloc excision preserving conjoined tendons of rotator cuff muscles and low-dose radiation therapy for surveillance of local recurrence. All dissection was performed to avoid contaminating the tumour and involved the whole supraspinatus except the conjoined tendons. We report a case of UPS at the suprascapular fossa, which showed a good result after a wide resection preserving conjoined tendons of rotator cuff muscles. Level of Evidence: Level V (Therapeutic).

Humeral head coverage in arthroscopic partial repair of massive rotator cuff tears improves functional outcomes: an analysis of influential factors.

BACKGROUND: Although partial rotator cuff repair has shown good outcomes, differences in clinical outcomes remain concerns. This study was performed to determine whether patients with humeral head coverage would show better functional outcomes than patients without humeral head coverage and to identify the factors for humeral head coverage after arthroscopic partial repair of massive tears. METHODS: We performed a retrospective study of 63 patients with massive rotator cuff tears who underwent arthroscopic partial repair between 2012 and 2018. Two to four margin convergences were first performed; then, the Mason-Allen technique was performed. The patients were divided into 2 groups: those with humeral head coverage (38 cases) and those without humeral head coverage (25 cases). The following factors were evaluated: age; sex; hypertension; diabetes; osteoporosis; preoperative and postoperative pseudoparalysis, visual analog scale (VAS) pain score, Constant score, acromiohumeral distance, and subacromial bony spur; and subscapularis tear and repair. Muscle atrophy and fatty degeneration were evaluated by magnetic resonance imaging preoperatively, and the integrity of the repaired cuff was evaluated by ultrasonography at a minimum of 2 years after surgery. RESULTS: Compared with preoperative values, significant improvements in VAS pain scores (from 6.27 to 2.32 in patients with humeral head coverage and from 7.00 to 2.81 in those without humeral head coverage) and Constant scores (from 51.35 to 75.95 and from 44.62 to 69.81, respectively) were observed in both groups (P < .001). Statistical analysis revealed that postoperative VAS pain scores (2.32 vs. 2.81) and Constant scores (75.95 vs. 69.81) in patients with humeral head coverage were superior to those in patients without humeral head coverage (P = .044 and P = .003, respectively). The integrity of the repaired cuff was evaluated by ultrasonography, and partial tears were found in 4 of 37 patients with humeral head coverage and 2 of 26 patients without humeral head coverage (P = .816). Univariable logistic regression analysis revealed that age (P < .001), comorbidity (P = .005), symptom duration (P = .023), preoperative shoulder mobility (P < .001), maintained acromiohumeral distance (P = .006), subscapularis tear (P = .026), and less preoperative supraspinatus and infraspinatus muscle atrophy (P = .001 and P = .010, respectively) had significant correlations with humeral head coverage. CONCLUSIONS: Overall satisfactory results were achieved in most patients regardless of high retear rates, but patients with partial repair covering the humeral head were associated with better outcomes than patients without humeral head coverage. Multivariable regression analysis revealed that age (<70 years, P = .003), capability of shoulder mobility (P = .005), maintenance of the acromiohumeral space (>7 mm, P = .016), and less atrophy of the rotator cuff muscles (P = .021) were favorable factors to achieve humeral head coverage during surgical partial repair of massive rotator cuff tears.

Diagnostic value of the axial view of magnetic resonance imaging to identify two-dimensional shapes of full-thickness rotator cuff tears.

BACKGROUND: Coronal and sagittal views of magnetic resonance imaging (MRI) were used to determine rotator cuff tear size and fatty infiltration, but these images were not enough to identify the tear shape. PURPOSE: To correlate the preoperative axial MRI views and arthroscopic surgical findings to identify the two-dimensional shapes in rotator cuff tears. MATERIAL AND METHODS: This study included 166 patients who underwent arthroscopic repair between 2015 and 2018. Preoperative coronal, sagittal, and axial MRI views were evaluated for tear size and geographic configuration in axial sections, and the length and the width were measured and were matched with arthroscopic surgical views by lateral portals. RESULTS: The agreement of axial MRI views with the arthroscopic view was 88.0% in crescent, 97.2% in longitudinal, 78.6% in massive, and 100% in rotator cuff tear arthropathy. The mean agreement rate of axial MRI views with arthroscopic view was 81.9%. Mean mediolateral and anteroposterior tear sizes on axial MRI were 16.68 mm and 19.33 mm, respectively. Mean mediolateral and anteroposterior tear sizes by arthroscopic view were 21.49 mm and 21.04 mm, respectively. Tear sizes by MRI axial images were 71.3% of arthroscopic view. SST/IST degenerative changes were noted in most patients with massive tears and rotator cuff arthropathy (P = 0.001). CONCLUSION: Rotator cuff tear shape on preoperative axial MRI view had close agreement (81.9%) with arthroscopic findings by lateral portal, and tear size by preoperative axial MRI views was 71.3% of that of arthroscopic view. Axial MRI views helped to predict the geometric tear shape of rotator cuff tears.

Risk Factors That Influence Subsequent Recurrent Instability in Terrible Triad Injury of the Elbow.

OBJECTIVE: To identify risk factors associated with subsequent recurrent instability and to identify predictors of poor outcomes in terrible triad injury of the elbow. DESIGN: Retrospective cohort study. SETTING: University trauma center. PATIENTS/PARTICIPANTS: Seventy-six patients who were surgically treated for terrible triad injury of the elbow. INTERVENTION: Review of charts and standardized x-ray images before surgery and 2 years after surgery. Patients were categorized into 2 groups: recurrent instability (group A) or concentric stability (group B). MAIN OUTCOME MEASUREMENT: Primary outcome measures were injury mechanism, time between injury and operation, fracture type, ligament injury, radial head fixation, coronoid fixation, ligament repair, period of postoperative immobilization, joint space restoration, healing progress, secondary operation, functional outcomes, and complications. Secondary outcome measures were age, sex, height, body mass index, bone mineral density, and comorbidities (hypertension and diabetes). Outcomes were measured before surgery and 2 years after surgery and were compared between groups. RESULTS: Recurrent instability occurred in 19.7% of cases; revision surgeries were performed in 12 cases (80%). High-energy trauma (P = 0.012), time between injury and operation (P = 0.001), radial head comminution (P = 0.001), medial collateral injury (P = 0.041), and coronoid nonrepair (P = 0.030) were associated with recurrent instability. Posttraumatic arthritis developed more often in group A (P = 0.001). CONCLUSIONS: Recurrent instability was associated with high-energy trauma, time between injury and operation, Mason type III radial head fracture, medial collateral injury, and coronoid nonrepair. Patients with recurrent instability were more likely to require secondary surgery and develop posttraumatic arthritis than those with concentric stability. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

In vivo biomechanical measurement and haptic simulation of portal placement procedure in shoulder arthroscopic surgery.

A survey of 67 experienced orthopedic surgeons indicated that precise portal placement was the most important skill in arthroscopic surgery. However, none of the currently available virtual reality simulators include simulation / training in portal placement, including haptic feedback of the necessary puncture force. This study aimed to: (1) measure the in vivo force and stiffness during a portal placement procedure in an actual operating room and (2) implement active haptic simulation of a portal placement procedure using the measured in vivo data. We measured the force required for port placement and the stiffness of the joint capsule during portal placement procedures performed by an experienced arthroscopic surgeon. Based on the acquired mechanical property values, we developed a cable-driven active haptic simulator designed to train the portal placement skill and evaluated the validity of the simulated haptics. Ten patients diagnosed with rotator cuff tears were enrolled in this experiment. The maximum peak force and joint capsule stiffness during posterior portal placement procedures were 66.46 (±10.76N) and 2560.82(±252.92) N/m, respectively. We then designed an active haptic simulator using the acquired data. Our cable-driven mechanism structure had a friction force of 3.763 ± 0.341 N, less than 6% of the mean puncture force. Simulator performance was evaluated by comparing the target stiffness and force with the stiffness and force reproduced by the device. R-squared values were 0.998 for puncture force replication and 0.902 for stiffness replication, indicating that the in vivo data can be used to implement a realistic haptic simulator.

Septic arthritis associated with systemic sepsis.

PURPOSE: Septic arthritis presents with good joint function, but sometimes leads to poor outcomes. Concurrent systemic sepsis has been regarded as the poor outcome, and the exact cause remains unclear. This paper was performed to identify factors associated with concurrent systemic sepsis and to research results to predict poor outcomes in patients with septic arthritis. METHODS: Laboratory and medical data were reviewed for 137 adults with acute septic arthritis who underwent open or arthroscopic surgical debridement at our institution between January 2005 and December 2014. The patients were divided according to whether they had septic arthritis alone (Group A) or in combination with systemic sepsis (Group B). Systemic sepsis was defined as two more systemic inflammatory signs in response to an infectious process. Patient characteristics, laboratory findings, synovial fluid findings and cultures, and surgical results were compared between two groups. RESULTS: Of the 137 patients, 41 (29.9%) had initial systemic sepsis at the diagnosis of septic arthritis. Independent t test revealed that duration of prodromal symptom (p = 0.012), serum neutrophil percent (p = 0.008), C-reactive protein (p = 0.001), Charlson comorbidity index (p = 0.001), positive culture in synovial fluid (p = 0.001), and methicillin-sensitive Staphylococcus aureus (MSSA) isolate in synovial fluid (p = 0.001) had significant correlations with the group B. Repeated debridement was performed for those who had recurrence of infection, and this procedure was more often in group B (23 versus 21 joints, 23.9 versus 51.2%, p = 0.012). Progression of arthritis occurred more often in group B (16 versus 17 joints, 16.7 versus 41.5%, p = 0.001). CONCLUSION: Septic arthritis combined with systemic sepsis was related to duration of prodromal symptom, serum neutrophil percent, C-reactive protein, Charlson comorbidity index, positive culture in synovial fluid, and a MSSA isolate in synovial fluid. Concurrent systemic sepsis led to poor outcomes in patients with septic arthritis in terms of recurrence of infection and progression of arthritis. LEVEL OF EVIDENCE: III Case control study.

Arthroscopic modified Mason-Allen technique for large U- or L-shaped rotator cuff tears.

PURPOSE: While a conventional single- or double-row repair technique could be applied for repair of C-shaped tears, a different surgical strategy should be considered for repair of U- or L-shaped tears because they typically have complex patterns with anterior, posterior, or both mobile leaves. This study was performed to examine the outcomes of the modified Mason-Allen technique for footprint restoration in the treatment of large U- or L-shaped rotator cuff tears. METHODS: Thirty-two patients who underwent an arthroscopic modified Mason-Allen technique for large U- or L-shaped rotator cuff tears between January 2012 and December 2013 were included in this study. Margin convergence was first performed to reduce the tear gap and tension, and then, an arthroscopic Mason-Allen technique was performed to restore the rotator cuff footprint in a side-to-end repair fashion. All patients were evaluated preoperatively and for a minimum of 2 years of follow-up with a visual analog scale (VAS) for pain, Constant score, and ultrasonography. RESULTS: There was significant improvement in all VAS and Constant scores compared with the preoperative values (P < 0.001). Functional results by Constant scores included 9 cases that were classified as excellent, 11 cases as good, 8 cases as fair, and 2 cases as poor. Binary logistic regression analysis revealed that heavy work, pseudoparalysis, joint space narrowing, fatty degeneration of the SST and IST, and a positive tangent sign were found to significantly correlate with functional outcomes. Multivariable logistic regression analysis revealed that only fatty degeneration of the SST was a risk factor for fair/poor clinical outcomes. Complications occurred in 5 of the 32 patients (15.6 %), and the reoperation rate due to complications was 6.3 % (2 of 32 patients). CONCLUSIONS: An arthroscopic modified Mason-Allen technique was sufficient to restore the footprint of the rotator cuff in our data. Overall satisfactory results were achieved in most patients, with the exception of those with severe fatty degeneration. An arthroscopic modified Mason-Allen technique could be an effective and reliable alternative for patients with large U- or L-shaped rotator cuff tears. LEVEL OF EVIDENCE: Case Series, Therapeutic Level IV.

Triangular Fixation Technique for Bicolumn Restoration in Treatment of Distal Humerus Intercondylar Fracture.

BACKGROUND: Distal humerus intercondylar fractures are intra-articular and comminuted fractures involving soft tissue injury. As distal humerus is triangle-shaped, parallel plating coupled with articular fixation would be suitable for bicolumn restoration in treatment of distal humerus intercondylar fracture. METHODS: This study included 38 patients (15 males and 23 females) who underwent olecranon osteotomy, open reduction and internal fixation with the triangle-shaped cannulated screw and parallel locking plates (triangular fixation technique). Functional results were assessed with the visual analog scale (VAS) scores, Mayo elbow performance (MEP) scores and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaires. Anteroposterior and lateral elbow radiographs were assessed for reduction, alignment, fracture union, posttraumatic arthrosis, and heterotopic ossification, and computed tomography (CT) scans were used to obtain more accurate measurements of articular discrepancy. RESULTS: All fractures healed primarily with no loss of reduction. The mean VAS, MEP, and DASH scores of the affected elbow were not significantly different from those of the unaffected elbow (p = 0.140, p = 0.090, and p = 0.262, respectively). The mean degree of flexion was significantly lower in the affected elbow than in the unaffected elbow, but was still considered as functional (p = 0.001, > 100° in 33 of 38 patients). Two cases of articular step-offs (> 2 mm) were seen on follow-up CT scans, but not significantly higher in the affected elbow than in the unaffected elbow (p = 0.657). Binary logistic regression analysis revealed that only Association for Osteosynthesis (AO) type C3 fractures correlated with good/excellent functional outcome (p = 0.012). Complications occurred in 12 of the 38 patients, and the overall reoperation rate for complications was 10.5% (4 of 38 patients). CONCLUSIONS: Triangular fixation technique for bicolumn restoration was an effective and reliable method in treatment of distal humerus intercondylar fracture. This technique maintained articular congruency and restored both medial and lateral columns, resulting in good elbow function.

Factors that Influence Reduction Loss in Proximal Humerus Fracture Surgery.

OBJECTIVES: This study was performed to identify the risk factors for reduction loss after locking plate fixation of proximal humerus fractures. DESIGN: Retrospective study. SETTING: University trauma center. PATIENTS AND INTERVENTION: We retrospectively evaluated 252 patients who had been surgically treated for proximal humeral fractures with locking plates between January 2004 and December 2011. MAIN OUTCOME MEASUREMENTS: Charts and standardized x-rays (true anteroposterior and axillary lateral views) were used to evaluate the Neer and AO OTA fracture types, initial neck-shaft angle (NSA, varus displacement), medial comminution, postoperative NSA (reduction adequacy), medial support restoration, healing progress, reduction loss, and implant-related problems immediately after surgery and at 2 weeks, 1 month, 3 months, 6 months, 9 months, and at least 1 year after surgery. Reduction loss was defined as (1) ≥10 of angulation in any direction, (2) ≥5 mm of height loss of the humeral head from the plate, and (3) fixation failure. RESULTS: Reduction loss occurred in 6.7% (17 of 252) of cases; revision surgeries were performed in all cases. Univariable logistic regression analysis revealed that older age (P = 0.023), osteoporosis (P = 0.001), varus displacement (P = 0.001), medial comminution (P = 0.001), reduction adequacy (P = 0.036), and insufficient medial support (P = 0.001) had significant correlations with reduction loss. CONCLUSIONS: Multivariable regression analysis revealed that osteoporosis (less than -2.5 bone mineral density, P = 0.015), displaced varus fracture (less than 110° of NSA, P = 0.025), medial comminution (more than 1 fragment, P = 0.018), and insufficient medial support (no cortical or screw support, P = 0.001) were independent risk factors for reduction loss in the proximal humerus fractures surgery. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic all-intra-articular decompression and labral repair of paralabral cyst in the shoulder.

BACKGROUND: The purpose of this study was to report the outcomes of all-intra-articular arthroscopic decompression and labral repair in patients with symptomatic paralabral cysts. METHODS: From 2005 to 2011, 20 consecutive cases of symptomatic paralabral cysts were included in this study. All surgical procedures were conducted with intra-articular arthroscopic decompression by use of a probe through the site of labral tear for cyst evacuation and suture anchor repair for the associated posterosuperior labrum. Clinical scores and magnetic resonance imaging (MRI) were obtained preoperatively and at follow-up. MRI was used to evaluate the size and segmentation of the cyst and the presence of the labral tear. RESULTS: MRI revealed paralabral cysts in association with labral tears in all cases. Cysts were extended in the spinoglenoid notch with a mean size of 2.5 × 2.6 × 2.2 cm on MRI. Cysts were nonsegmented in 5 cases (25%) and had multiple segments in 15 cases (75%). Mean follow-up was 42.8 ± 21.22 months. The mean visual analog scale score for pain, the American Shoulder and Elbow Surgeons score, and the Simple Shoulder Test score significantly improved at the last follow-up (P < .001, P < .001, and P = .001, respectively). The postoperative MRI study performed at a mean of 6 months for 18 of 20 cases (90%) revealed complete cyst removal. The satisfaction level with surgery was good to excellent in 18 patients, fair in 1 patient, and poor in 1 patient. No complication was related to the surgical procedure. CONCLUSION: Arthroscopic all-intra-articular decompression and labral repair of paralabral cyst can be a simple and effective treatment, regardless of segmentation or size. It also resulted in complete removal of the cyst at a mean of 6 months postoperatively as revealed by MRI. An additional subacromial procedure might not be necessary for complete decompression.

Knot impingement after rotator cuff repair: is it real?

PURPOSE: The purpose of this study was to compare morphologic features of the acromion after 2 different repair methods (single-row [SR] repair with a minimum of 4 knots and suture-bridge [SB] repair with minimal knots) in medium to large rotator cuff tears. METHODS: From May 2005 to July 2012, 1,693 rotator cuff repairs were performed, among them medium to large tears requiring more than 2 anchors for repair; those who had 6-month postoperative magnetic resonance imaging (MRI) scans were included (221 shoulders). They were divided into 2 groups; group A (SR repair) and group B (SB repair). Acromial morphologic characteristics were evaluated using MRI 6 months postoperatively. An acromial defect was defined as an irregular defect or erosion on the flat acromion. Clinical measurements were performed using the American Shoulder and Elbow Surgeons (ASES) score, Constant score, visual analogue scale (VAS) pain score, and range of motion (ROM). RESULTS: Erosion in the acromion was observed in 2 of 118 patients (1.7%) in group A and in 1 of 103 (1%) patients in group B. There was no statistically significant difference between the 2 groups (P = .796). A statistically significant improvement was observed in the clinical scores measured (P = .0043). ROM was not fully recovered to the preoperative level at 6 months postoperatively. Acromioplasty was performed in 2 of 3 patients with acromial erosion. There was acromial erosion in one patient in group A without performing subacromial decompression. CONCLUSIONS: Our study showed that there was no difference in acromial erosion in high-profile knots made by an SR compared with double-row (DR) SB low-profile repairs. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Standard versus over-tensioning in the transfer of extensor indicis proprius to extensor pollicis longus for chronic rupture of the thumb extensor.

PURPOSE: The purpose of this study was to evaluate the functional outcomes of the over-tensioning technique compared with those of the standard tensioning technique in the transfer of extensor indicis proprius (EIP) to extensor pollicis longus (EPL) for the chronic rupture of the thumb extensor. METHODS: Data were collected from patients who underwent tendon transfer using EIP between March 2003 and August 2011. 23 were treated with the standard tensioning technique and 25 patients (Group B) with the over-tensioning technique. While standard tension was maintained with the thumb in full extension and the wrist in 30° of flexion, over-tension was maintained with the thumb in full extension and the wrist in the neutral position. All patients were assessed for total range of motion, elevation and flexion deficit, the thumb grip and pinch strength, and the thumb and the index extension strength compared to the unaffected side, EIP-EPL evaluation as suggested by Lemmen et al. and Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH). RESULTS: Group A: total range of motion 115°, elevation deficit 2.0 cm, combined flexion deficit 1.0 cm, thumb extension strength 75%, thumb grip strength 91%, and pinch strength 87%. Functional outcomes were 13 excellent, 6 good, 3 fair, and 1 poor. Median DASH score was 21.3 points. Group B: total range of motion 125°, elevation deficit 1.0 cm, combined flexion deficit 1.5 cm, thumb extension strength 85%, thumb grip strength 88%, and pinch strength 83%. Functional outcomes were 16 excellent, 7 good, 2 fair, and 0 poor. Median DASH score was 19.8 points. There are significant differences in the range of motion, elevation deficit, and extension strength of thumb between the two groups (p=.001, p=.001, and p=.028, respectively). CONCLUSION: While the functional outcomes of both groups were favorably acceptable in a majority of the patients, there were significant differences in aspects of range of motion, elevation deficit, and strength of the thumb between both groups. LEVEL OF EVIDENCE: Case-control study, Level III.

Indirect reduction maneuver and minimally invasive approach for displaced proximal humerus fractures in elderly patients.

BACKGROUND: This study examined the clinical outcomes of indirect reduction maneuver and minimally invasive approach for treating displaced proximal humerus fractures in patients older than 60. METHODS: Thirty-two patients (11 male and 21 female) who had undergone treatment for displaced proximal humerus fracture were evaluated. The mean age of the patients was 72.4 years (range, 60 to 92 years). All cases were followed up for at least 12 months. All patients were interviewed and evaluated on the visual analog scale, with gender-specific constant score correction for age, standardized X-rays to check the neck-shaft angle (NSA) and the presence of medial support, and bone mineral density. Statistical analysis was performed with a multiple regression analysis. RESULTS: The average visual analog scale score was 2.4, and the average gender-specific constant score correction for age was 80.6 points. Final functional outcomes were 8 excellent, 15 good, 7 fair, and 2 poor. The average NSA was 122.8°; and the radiological results were 20 good, 11 fair, and 1 poor. There was significant difference of the gender-specific constant score for age between the group of NSA more than 110° and the group of NSA less than 110° (p = 0.00). There were 26 cases with and 6 cases without medial support, with significant difference between the gender-specific constant score correction for age of these groups (p = 0.01). Complications occurred in 4 patients (12.5%). CONCLUSIONS: The indirect reduction maneuver and minimally invasive approach were safe and reliable options for the treatment of displaced proximal humerus fractures in the elderly patients. An inadequate reduction (i.e., less than 110° NSA) or lack of medial support (e.g., no cortical or screw support) were significant factors contributing to poor functional outcomes.

An arthroscopic pleated capsular shift for recurrent anterior dislocation of the shoulder.

PURPOSE: This study examined the clinical results of an arthroscopic simple pleated capsular shift to treat severe recurrent anterior dislocation of the shoulder. METHODS: Twenty-four patients with anterior labroligamentous periosteal sleeve avulsion or advanced lesions who underwent an arthroscopic simple pleated capsular shift were included in this study. To create an arthroscopic simple pleated capsular shift, redundant capsules, including glenohumeral ligaments, were brought at least 1 cm lateral and 1 cm inferior and shifted to the prepared glenoid. Four sutures were made at the 5, 4, 3, and 1-2 o'clock positions with four anchors. Clinical results were evaluated using a visual analog scale (VAS), ROWE scores, active motion, and return to activity. Statistical analyses were carried out using paired t tests. RESULTS: Three out of 24 patients had complaints. Two patients with recurrent instability underwent a repeat surgery, while the other patient complained of a stiff shoulder. There was a significant improvement in the VAS and ROWE scores post-operatively versus pre-operatively (p < 0.001, p < 0.001, respectively), but no significant differences in active motion except for external rotation, which decreased post-operatively (p = 0.02). CONCLUSIONS: In patients with severe recurrent anterior dislocation, simple pleated capsular shift provided a reliable result. Four capsular shift sutures, 1 cm lateral and 1 cm inferior from the glenoid, were sufficient to reduce shoulder joint volume and restore stability. The arthroscopic capsular shift could be an alternative method in the case of no available labral lesion for repair. LEVEL OF EVIDENCE: Case series, Therapeutic, Level IV.