Conservative treatment of 3- and 4-part proximal humeral fractures: Can poor outcomes be predicted?

PURPOSE: 3- and 4-part proximal humeral fractures are frequently treated conservatively. This study aims to combine radiographic, and patient reported outcome data to identify factors leading to poor outcomes following conservative treatment. METHODS: A retrospective local database analysis identified 3- and 4-part fractures. Radiographic and functional outcomes including Oxford Shoulder Score (OSS), QuickDash (QD), Subjective Shoulder Score (SSV) and VAS pain scores were collected. RESULTS: 104 patients were included at mean follow-up of 55 months. Analysis highlighted significant OSS differences in 3- versus 4-part (p = 0.027), dominant arm injury (p = 0.046), age > 65 (p = 0.006), varus coronal neck-shaft angle < 115 versus 115-155 degrees (p = 0.008), posterior head tilt > 155 degrees (p = 0.005), greater tuberosity (GT) displacement > 5 mm (p = 0.001), GT comminution (p = 0.01), medial calcar hinge displacement > 2 mm (p = 0.032). According to QD scores; age > 65 (p = 0.012), varus neck-shaft angle (p = 0.01), GT displacement > 5 mm (p = 0.001), GT comminution (p = 0.01), medial calcar hinge displacement > 2 mm (p = 0.006). SSV varied significantly with 3- versus 4-part fractures (p = 0.005), age > 65 (p = 0.04), varus neck-shaft angle (p = 0.001), posterior head tilt (p = 0.005), GT displacement > 5 mm (p = 0.001), GT comminution (p = 0.003), and medial calcar hinge displacement > 2 mm (p = 0.001). CONCLUSION: We highlight risk factors for unfavourable outcomes following conservative management, aiding surgeons in shared decision-making and patient expectation management.

Operative versus non-operative treatment of extra-articular distal humeral shaft fractures: a retrospective comparative study evaluating clinical and radiological outcomes.

PURPOSE: There is limited evidence for comparing operative and non-operative management of closed, extra-articular distal humeral shaft fractures. This study aims to evaluate these outcomes. METHODS: A comparative retrospective study was performed for patients who underwent either operative fixation or conservative management with a humeral brace, with clinical and radiological outcomes at minimum 2-year follow-up. RESULTS: Forty-two patients with median 4.6 years follow-up were included; 24 had surgical fixation and 18 were managed with humeral brace. Assessment of clinical and radiological outcomes demonstrated few statistically significant functional differences between the two groups. Surgical patients achieved faster union for non-comminuted fractures. All patients maintained functional range of motion, with similar complication rates. CONCLUSION: This study suggests that similar outcomes can be achieved with both managements, though faster union times may be seen in the operative group. Further studies are recommended to evaluate the impact of fracture comminution causing delayed unions.

Outcomes of primary Latarjet vs. revision Latarjet after prior surgery for anterior shoulder instability: a systematic review and meta-analysis.

BACKGROUND: Latarjet has become an increasingly popular treatment option for recurrent anterior shoulder instability. With the reported complication rates for primary Latarjet surgery, there are concerns about the complications of Latarjet as a revision surgery. It remains unclear if poor results after previous surgical management can be improved with revision Latarjet as well as with primary Latarjet. The aim of this systematic review and meta-analysis is to compare the outcomes of primary Latarjet and revision Latarjet for the treatment of anterior shoulder instability. METHODS: A systematic search was performed on 3 databases for studies that compared primary Latarjet with revision Latarjet used after failed arthroscopic stabilization or failed free bone block procedures. From the included studies, demographic data, clinical outcome scores, range of motion measurements, and postoperative complications were obtained. RESULTS: A total of 11 studies were included for data analysis. Compared with the primary Latarjet cohort, revision Latarjet cohorts had a higher infection rate (1.2% vs. 2.6%; RR 0.46, P = .039). The primary Latarjet group showed a greater rate of return to sport (89.7% vs. 80.5%; RR 1.12, P = .41) and less subjective feeling of instability (12.6% vs. 20.9%; RR 0.60, P = .085) compared with the revision Latarjet group; however, this was not statistically significant. There were no significant differences in complication rates, reoperation, recurrence, and range of motion between primary Latarjet and revision Latarjet groups. Clinical outcome scores such as visual analog scale and Rowe scores were not significantly different between the cohorts. CONCLUSION: Based on the current evidence, primary Latarjet presents reduced infection rates but similar clinical outcome measures, overall complication, and range of motion measurements than revision Latarjet performed after failed prior operative treatment.

Predicting the need for collateral ligament repair in transolecranon fractures of the elbow: a traffic light model.

BACKGROUND: Biomechanical studies have shown that translation of the proximal radius relative to the capitellum in the sagittal plane can predict integrity of the collateral ligaments in a transolecranon fracture model; no studies have examined this in clinical practice. METHODS AND MATERIALS: Nineteen consecutive transolecranon fracture dislocations were retrospectively reviewed. Data collection included patient demographics, fracture classifications, surgical management, and failure with instability. Distance between the center of the radial head and the center of the capitellum was measured on initial radiographs by 2 independent raters on 3 separate occasions. Statistical analysis was used to compare the median displacement between patients who required collateral ligament repair for stability and those who did not. RESULTS: Sixteen cases with a mean age of 57 years (range 32-85) were analyzed with an inter-rater Pearson coefficient of 0.89 for displacement measurement. Median displacement where collateral ligament repair was needed and performed was 17.13 mm (interquartile range [IQR] = 10.43-23.88) compared with 4.63 mm (IQR = 2.68-6.58) where collateral ligament repair was not performed and not required (P = .002). In 4 cases, ligament repair was not performed initially but deemed necessary based on clinical outcome and postoperative and intraoperative images. Of these, the median displacement was 15.59 mm (IQR = 10.09-21.20), and 2 of these required revision fixation. DISCUSSION: Where displacement on initial radiographs exceeded 10 mm, lateral ulnar collateral ligament (LUCL) repair was required in all cases (red group). If less than 5 mm, ligament repair was not required in any case (green group). Between 5 and 10 mm, following fracture fixation, the elbow must be screened carefully to assess for any instability and a low threshold set for LUCL repair to prevent posterolateral rotatory instability (amber group). Using these findings, we propose a traffic light model to predict the need for collateral ligament repair in transolecranon fractures and dislocation.

Outcomes of acute vs. delayed reverse shoulder arthroplasty for proximal humerus fractures in the elderly: a systematic review and meta-analysis.

HYPOTHESIS: Reverse shoulder arthroplasty (RSA) has become an increasingly popular treatment option for proximal humerus fractures in the elderly. There is however contradictory evidence on the impact of timing of RSA on patient outcomes. It remains unclear if poor results after initial nonsurgical or surgical management can be improved with delayed RSA. The aim of this systematic review and meta-analysis is to compare the outcomes of acute RSA and delayed RSA for the treatment of proximal humerus fractures in the elderly. MATERIALS AND METHODS: A systematic search was performed on 4 databases for studies that compared acute RSA with RSA used after prior nonoperative or operative treatment. Studies with a mean cohort age of <65 years were excluded. Demographical data, clinical outcome scores, range of motion measurements, and postoperative complications were collected from the included studies. RESULTS: Sixteen studies were included for data analysis. Compared with delayed RSA cohorts, acute RSA cohorts had higher forward flexion (124.3° vs. 114.9°; P = .019), external rotation (24.7° vs. 20.2°; P = .041), and abduction (113.2° vs. 99.8°; P = .03). Compared with RSA after conservative management, acute RSA had greater external rotation (29.9° vs. 21.4°; P = .043). The acute RSA cohort had significantly higher American Shoulder and Elbow Surgeons (76.4 vs. 68.2; P = .025) and Constant-Murley scores (65.6 vs. 57.3; P = .002) compared with the delayed RSA cohort. Subgroup analyses showed significantly greater Constant-Murley (64.9 vs. 56.9; P = .020) and Simple Shoulder Test scores (8.8 vs. 6.8; P = .031) with acute RSA compared with RSA after conservative treatment. The American Shoulder and Elbow Surgeons score was higher in the acute RSA cohort compared with RSA after open reduction internal fixation (77.9 vs. 63.5; P = .008). The overall complication rate per 100 patient-years was 11.7 for the acute RSA cohort and 18.5 for the delayed RSA cohort (risk ratio: 0.55; P = .015). CONCLUSION: Based on the current evidence, acute RSA presents better clinical outcome measures and range of motion measurements, with decreased complication rates than RSA performed after prior nonoperative or operative treatment.

Long-term Outcomes After the Open Latarjet Procedure for the Surgical Management of Humeral Avulsion of the Glenohumeral Ligament Lesions.

BACKGROUND: Recurrent anterior glenohumeral instability caused by a humeral avulsion of the glenohumeral ligament (HAGL) lesion has been studied, but very limited long-term evidence is available. PURPOSE: To retrospectively review patients with a HAGL lesion who underwent an open Latarjet procedure for recurrent anterior shoulder instability. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 16 patients with complete clinical and radiological data were available for a review. Clinical outcomes were assessed by range of motion, apprehension testing, the visual analog scale for pain, the Walch-Duplay score, the Rowe score, the Constant-Murley score, the Subjective Shoulder Value, and return to sports. Radiographs were reviewed for osteoarthritis and complications. RESULTS: The median age of patients at the time of surgery was 28 years (range, 18-42 years). All patients were male with no hyperlaxity. The median follow-up time was 10 years (range, 2.8-15 years). Postoperative range of motion showed recovered forward elevation (median, 175°), external rotation (median, 62°), and internal rotation (median, 9 points). Overall, 87% returned to sports, with 68% to the same level and 93% satisfied or very satisfied. Median clinical outcomes were the following: visual analog scale score, 1 (range, 0-2); Walch-Duplay score, 86 (range, 75-100); Rowe score, 95 (range, 90-100); Constant-Murley score, 77 (range, 74-79); and Subjective Shoulder Value, 88% (range, 80%-95%). There were no recurrent dislocations or subluxations. One patient described mild long-term pain, and 1 patient had persistent stiffness. Other complications included 12% with subjective apprehension, 1 patient with a wound infection, and another patient with delayed bone graft union. Additionally, 56% of cases had mild postoperative arthritis at the final follow-up. There were no reoperations. CONCLUSION: The open Latarjet procedure provided good outcomes with acceptable complication rates in the long term for patients with HAGL lesions. It is an effective treatment option and a safe alternative to arthroscopic or open HAGL repair.

Survivorship of Reverse Shoulder Arthroplasty According to Indication, Age and Gender.

Background. The indications for reverse shoulder arthroplasty (RSA) have been widely expanded, but only a few studies report the long-term survival of these implants. Our objective was to report the long-term survivorship of a large series of RSAs implanted for different etiologies. Methods. A retrospective multicenter study including all the RSAs was performed in six shoulder-specialized centers with at least 2 years of follow up. We reviewed 1611 RSAs, operated between 1993 and 2010, including 497 cuff-tear arthropathies (CTA), 239 revision RSAs, 188 massive cuff tears (MCT), 185 fracture sequelae (FS), 183 failed previous cuff repairs (FCR), and 142 primary osteoarthritis (POA). The mean follow-up was 5.6 ± 3.9 years (range 2−20). Results. Overall, 266 RSAs (16.5%) had at least one complication leading to 64 reoperations (4.0%) and 110 revision surgeries (6.8%). The most frequent complications were infection (3.8%), instability (2.8%), and humerus-related complications (2.8%). At 10 years, the survival without revision surgery was 91.0% in primary RSAs and 80.9% in revision RSAs for failed arthroplasty (p < 0.001). In the primary RSA group, MCT and FCR led to 10-year survivals for over 95% but fracture sequelae and tumors had the lowest 10-year survivals (83.9% and 53.1%). Younger patients had a lower 10-year survival. In revision RSAs, male patients had a significantly lower survival than females (72.3% vs. 84.5% at 10 years, p = 0.020). Discussion. Primary RSA for cuff-deficient shoulders or POA leads to a high 10-year survival, but revision RSA or primary RSA for FS and tumors are at high-risk for revision. Surgeons should be aware of high rates of complications and lower survival rates of RSA in younger patients, in males, and in RSAs for revision surgery.

A comparative study of 6-week and 12-week Radiographic Union Scores for HUmeral fractures (RUSHU) as a predictor of humeral shaft non-union.

Background: Non-union in non-operatively managed humeral shaft fractures are associated with significant morbidity. Hence, developing a robust system that could help with early diagnosis is important. We aimed to evaluate the validity of the Radiographic Union Score for HUmeral fractures (RUSHU) at 6 weeks (RUSHU-6) and test whether a RUSHU at 12 weeks (RUSHU-12) would be a better predictor of non-union. Methods: We retrospectively reviewed all non-operatively managed humeral diaphyseal fractures from 2012 to 2018. Statistical analysis was used to determine the cut-off RUSHU-12 and evaluate the effect of RUSHU-6 and RUSHU-12 on non-union prediction. Results: In sum, 32 patients had radiographs at 6 weeks post-injury, 27 of which also had radiographs at 12 weeks. A RUSHU cut-off of 9 was the best predictor of non-union at 12 weeks. Only RUSHU-12 had a statistically significant influence predicting non-union (P = 0.011) and there was a significant correlation (P = 0.003) between score progression from RUSHU-6 to RUSHU-12 and the development of non-union. Discussion: A RUSHU-12 of <9 and a low score progression between 6 and 12 weeks suggest superior predictive value in determining the likelihood of non-union. Further validation in the form of a large multicentred study is however required.

Impact of the National Lockdown Due to the COVID-19 Pandemic On Upper Limb Trauma Workload in Central London: A Multi-Centre Longitudinal Observational Study During Implementation and Ease of National Lockdown.

Background: This study assessed the impact of the COVID-19 pandemic on acute upper limb referrals and operative case-mix at the beginning and ease of British lockdown. Methods: A longitudinal multicentre observational cohort study was conducted for both upper limb trauma referrals and operative case-mix over a 12-week period (6 weeks from the beginning and 6 weeks from the ease of the national lockdown). Statistical analysis included median (± median absolute deviation), risk and odds ratios, and Fisher's exact test to calculate the statistical significance, set at p ≤ 0.05. Results: There was a 158% (n = 456 vs. 177) increase in upper limb referrals and 133% (n = 91 vs. 39) increase in the operative trauma caseload at the ease of lockdown compared with its commencement. An increase in sporting injuries was demonstrated (p=0.02), specifically cycling (p=0.004, OR=2.58). A significant increase in COVID-19 testing was demonstrated during the ease of lockdown (p=0.0001) with more patients having their management changed during the beginning of the pandemic (9.6% vs. 0.7%, p=0.0001). Of these patients, 47% went on to have delayed surgery within 6 months. No patients who underwent surgery tested positive for COVID-19 infection within 14 days post-operatively and no mortalities were recorded at 30 days. Conclusion: The ease of lockdown has seen upper limb referrals and operations more than double compared to early lockdown. With no patients testing positive for COVID-19 within 14 days of the procedure, this demonstrates that having upper limb surgery during the current pandemic is safe.

A unique case of bilateral triceps avulsion fracture in a patient with pseudohypoparathyroidism.

Triceps tendon ruptures and avulsions are rare injuries and are often associated with systemic diseases. This paper illustrates the unique case of a 20-year-old female patient with pseudohypoparathyroidism, who sustained bilateral triceps avulsion fractures after a fall. She underwent suture anchor fixation, augmented with tension band suture as double row repair with excellent post-operative results. We describe the pathophysiology of this injury and the unique method of fixation, which can be an alternative effective method to repair these injuries.

Risk factors for instability after reverse shoulder arthroplasty.

BACKGROUND: This study aims to identify risk factors related to postoperative instability after reverse shoulder arthroplasty and evaluate the modalities and results of treatments in a large series of patients, with medium to long-term follow-up. METHODS: Retrospective multicenter series of 1035 consecutive Grammont type reverse shoulder arthroplasties implanted between 1992 and 2010. 19.9% had a reverse shoulder arthroplasty with bony lateralization on the glenoid side. Patients were reviewed and radiographed with minimum five years' follow-up. RESULTS: At a mean follow-up of eight years, the overall rate of postoperative instability was 3.0%. Instability was more frequent in case of reverse shoulder arthroplasty for revision surgery, in younger patients, in case of scapular notching, and tuberosity resorption. Lateralized reverse shoulder arthroplasties were associated with a lower instability rate. A reoperation to restore stability was needed in 70% of cases. The improvement in Constant Score was lower in patients with unstable reverse shoulder arthroplasties when compared to stable reverse shoulder arthroplasties. CONCLUSIONS: Younger patients are at higher risk for instability after Grammont type reverse shoulder arthroplasty implantation. Conversely, lateralized reverse shoulder arthroplasties resulted protective. When conservative treatment had failed, shoulder stability can be obtained with reoperation or prosthetic revision (needed in 70% of the cases), but to the price of lower functional results.

Clinical and radiologic outcomes of eccentric glenosphere versus concentric glenosphere in reverse shoulder arthroplasty.

BACKGROUND: The use of an eccentric glenosphere (EG) has been proposed as a way to prevent scapular notching in reverse shoulder arthroplasty (RSA). The purpose of this study was to investigate whether the use of an EG decreases scapular notching compared with matched standard concentric glenosphere (CG) controls. METHODS: A retrospective analysis was performed. This study included 49 RSAs with an EG and 49 paired RSAs with a CG with a minimum 60 months of both clinical and radiographic follow-up. Clinical and radiologic outcomes of the EG and CG groups were compared at inclusion and at the last follow-up using the paired Student t test for quantitative data and the χ2 test for qualitative data. Scapular notching was graded according to the Sirveaux classification. Statistical significance was set at P < .05. RESULTS: Notching was observed 2.7 times (95% confidence interval, 1.0-6.8 times) more often in the CG group (P = .037). The difference in notching severity between the groups was not statistically relevant; however, there was a trend toward more severe notching in the CG group (P = .059). Compared with a CG, an EG did not increase the percentage of radiolucent lines around the screws (3% vs. 1.5%, P = .62), around the post (3% vs. 1.5%, P = .62), or below the baseplate (15% vs. 7.5%, P = .18). CONCLUSION: EGs are associated with less notching than CGs. This finding confirms that RSA with an EG is an effective procedure without specific complications at a minimum follow-up of 5 years.

Outcomes following revision of the revision total elbow arthroplasty.

BACKGROUND: There is very little information in the literature on the outcomes of revision of revision total elbow arthroplasty (RRTEA). Our aim was to report the outcomes of this rarely performed procedure. METHODS: We retrospectively identified all patients who had undergone RRTEA between 2007 and 2016. Outcomes were assessed clinically using a number of validated systems, and radiographs were reviewed for prosthesis alignment, cementation by Morrey grading, and heterotopic ossification. RESULTS: We identified 22 patients who underwent RRTEA. Of these patients, 14 were available for assessment (2 died of unrelated causes, 2 could not be contacted, 2 declined to participate because of travel difficulties, and 2 had incomplete data). At the final review, the median age was 73 years (range, 57-83 years), with a median follow-up period of 4.5 years (range, 2-7 years) since the last surgical procedure. The median number of previous revision arthroplasty procedures per patient was 3 (range, 2-6). The indications for RRTEA were aseptic loosening (60%), bushing wear (16%), fracture (14%), and infection (10%). Of the patients, 30% required extra-long or custom-made implants and 50% needed allograft augmentation. At final clinical assessment, 56% of patients had triceps insufficiency, the median flexion-extension arc was 90°, and the median prono-supination arc was 95°. The functional elbow scores revealed good outcomes in the majority of patients (median visual analog scale score, 5; median Oxford Elbow Score, 22; median Mayo Elbow Performance Index score, 55; and median QuickDASH [short version of Disabilities of the Arm, Shoulder and Hand questionnaire] score, 63). Eighty-one percent of patients were satisfied with their RRTEAs. Complications included infection in 2 patients (1 superficial and 1 deep), symptomatic aseptic humeral component loosening in 1, sensory ulnar nerve symptoms in 2, and radial nerve injury in 1. One patient required ulnar nerve release. Radiologic review revealed asymptomatic loosening in 1 patient (humeral component), and overall prosthesis alignment with cementation was adequate in 81%. Heterotopic ossification was present in 38% of cases. CONCLUSIONS: RRTEA is a satisfactory treatment option in these complex cases, with good short- to mid-term survival rates but a relatively high complication rate.

Mid-term outcomes of surgical management of complex, isolated radial head fractures: a multicentre collaboration.

OBJECTIVES: The available literature discussing optimal surgical management of Mason II and III radial head (RH) fractures without concomitant bone or ligamentous injuries is limited. We aim to help determine the appropriate management of these functionally significant injuries. DESIGN: We present our retrospective cohort study of outcomes of surgically managed isolated, displaced RH fractures SETTING: Study from three trauma centres. PATIENTS/PARTICIPANTS: Adults who underwent surgical treatment for isolated displaced RH fractures. INTERVENTION: RH open reduction internal fixation (ORIF), replacement or excision MAIN OUTCOME MEASUREMENTS: Elbow range of motion (ROM), pain and function using Oxford Elbow Score (OES), Mayo Elbow Performance Score (MEPS), Patient-Rated Elbow Evaluation (PREE) and QuickDASH (QD). RESULTS: Of 46 patients included (mean age 47 years and mean follow-up 48 months), 12 type II fractures were treated with ORIF and 34 type III injuries had ORIF (16), replacement (12) or resection (6). ROM was comparable in all groups, with mean arcs of flexion-extension of 131° and pronation-supination of 147°. Mean visual analogue score for pain was 1.3 in those treated with ORIF compared to 1.9 with arthroplasty and 2.5 with excision. Mean functional scores were 41, 92, 14 and 14 for OES, MEPS, PREE and QD, respectively. Complication rates were 39% for ORIF, 33% for arthroplasty and 33% for resection. Overall re-operation rate was 13%. CONCLUSIONS: Functional outcome is similar in all groups of surgically treated patients with isolated, displaced RH fractures. Complication rates are higher than that reported previously in the literature but with low re-operation rates. LEVEL OF EVIDENCE: IV.

Midterm clinical and radiologic results of reverse shoulder arthroplasty with an eccentric glenosphere.

BACKGROUND: An eccentric glenosphere (EG) has been proposed as a way of preventing scapular notching after reverse shoulder arthroplasty (RSA). Our aim was to report the midterm clinical and radiographic results of EG after RSA. A number of the patients described here were included in a previous study with short-term follow-up. The current retrospective study gave us the opportunity to follow many of these patients for a longer period of time. METHODS: A retrospective analysis of prospectively collected data was conducted. Statistical significance was set at P < .001. Forty-nine RSAs with an EG and at least 60 months of follow-up were included. Range of motion (ROM), Constant scores (CSs), and Subjective Shoulder Value (SSV) were assessed. Scapular notching was graded according to the Sirveaux classification. RESULTS: At the last follow-up, the mean improvement in active elevation (ROM) was 46° and the mean CS increased by nearly 31 points (both groups P < .001). The final SSV was 70%. Twenty-one patients (43%) had scapular notching, but in two-thirds of patients it was low-grade. CONCLUSION: The use of an EG provided excellent clinical outcomes that persisted with midterm follow-up. The rate of notching was lower than in other studies with EGs, but further studies are required to confirm this. An EG was safe and there were no issues with baseplate loosening or failure.

Clinical and radiographic outcomes of the open Latarjet procedure in skeletally immature patients.

INTRODUCTION: Recurrent anterior glenohumeral instability has been studied in the young population and limited evidence is available for adolescent patients. Our study is a retrospective review of patients aged <17 years who underwent open Latarjet procedure. METHODS: Forty-five patients were available for review. Clinical outcomes were assessed by range of movements, stability, Walch-Duplay score (WDS), Rowe score (RS), Constant-Murley score (CMS), Subjective Shoulder Value (SSV), and return to sport. Radiographs were reviewed for osteoarthritis and complications. RESULTS: The median age of patients was 15.7 years (13-17), and 56% had hyperlaxity. The median follow-up time was 6.6 years (3-26). The median postoperative movements showed recovered elevation (175°), external rotation (60°), and internal rotation (T9 level). Seventy-five percent of patients returned to the same level of sport, and 98% were satisfied. Clinical outcomes showed WDS, RS, and CMS scores of 85, 95, and 84 points, respectively, and an SSV of 95%. Twenty percent of patients described mild postoperative pain, and 1 had persistent stiffness. Other complications included 24% subjective apprehension, 4% redislocation, 4% wound problems, and 2% infection. Nine percent of cases had postoperative arthritis. The overall reoperation rate was 11%: 1 open washout for infection and 4 arthroscopic screw removal due to persistent pain. We found that hyperlaxity, female sex, and large or deep Hill-Sachs lesions were frequently associated with persistent apprehension at the last follow-up. CONCLUSIONS: The open Latarjet procedure provides a low rate of recurrent instability with acceptable complication rates in the long term for skeletally immature patients. It is an effective, safe treatment option without any significant glenoid growth disturbance.

Reverse shoulder arthroplasty in patients aged 65 years or younger: a systematic review of the literature.

BACKGROUND: Reverse shoulder arthroplasty (RSA) is offered to young patients with a failed previous arthroplasty or a cuff-deficient shoulder, but the overall results are still uncertain. We conducted a systematic review of the literature to report the midterm outcomes and complications of RSA in patients younger than 65 years. METHODS: A search of the MEDLINE and Cochrane electronic databases identified clinical studies reporting the results, at a minimum 2-year follow-up, of patients younger than 65 years treated with an RSA. The methodologic quality was assessed with the Methodological Index for Non-Randomized Studies score by 2 independent reviewers. Complications, reoperations, range of motion, functional scores, and radiologic outcomes were analyzed. RESULTS: Eight articles were included, with a total of 417 patients. The mean age at surgery was 56 years (range, 21-65 years). RSA was used as a primary arthroplasty in 79% of cases and revision of a failed arthroplasty in 21%. In primary cases, the indications were cuff tear arthropathy and/or massive irreparable cuff tear in 72% of cases. The overall complication rate was 17% (range, 7%-38%), with the most common complications being instability (5%) and infection (4%). The reintervention rate was 10% at 4 years, with implant revision in 7% of cases. The mean weighted American Shoulder and Elbow Surgeons score, active forward elevation, and external rotation were 64 points, 121°, and 29°, respectively. CONCLUSIONS: RSA provides reliable clinical improvements in patients younger than 65 years with a cuff-deficient shoulder or failed arthroplasty. The complication and revision rates are comparable to those in older patients.

Clinical and radiographic outcomes of open Latarjet procedure in patients aged 40 years or older.

BACKGROUND: The Latarjet procedure is often used to treat shoulder instability in younger patients. Little is reported on the outcomes of this procedure in older (≥40 years) populations. The purpose of this study was to evaluate the clinical and radiographic outcomes of patients aged 40 years or older with recurrent anterior shoulder instability who underwent open Latarjet stabilization. METHODS: A total of 168 patients aged 40 years or older were treated surgically for recurrent anterior shoulder instability with an open Latarjet procedure between 1988 and 2014. Bankart lesions or anteroinferior glenoid fractures were confirmed preoperatively with a computed tomography arthrogram. Outcomes were assessed with preoperative and postoperative physical examinations, clinical outcome scoring, and radiographic examinations. RESULTS: Ninety-nine patients with complete data were available with a mean follow-up period of 13 years (range, 3-23 years). At the time of final follow-up, 94% of patients did not have recurrence of instability. Of the patients, 90% were satisfied or very satisfied with their outcomes and 54% returned to their preinjury level of activity. The overall complication rate was 21% (the most common complications being subjective apprehension [9%] and recurrent instability [6%]), with 9% of patients requiring reoperation. A full-thickness rotator cuff requiring repair was identified in 22% of patients. CONCLUSIONS: The Latarjet procedure is an effective treatment option for older patients (aged ≥ 40 years) with recurrent anterior shoulder instability in the setting of an anteroinferior capsulolabral and/or bony injury.