Treatment of proximal humerus fractures (PHF) is controversial in many respects, including the choice of surgical approach for fixation when using a locking plate. The classic deltopectoral (DP) approach is believed to increase the risk of avascular necrosis while making access to the greater tuberosity more difficult. The deltoid split (DS) approach was developed to respect minimally invasive surgery principles. The purpose of the present study (NCT-00612391) was to compare outcomes of PHF treated by DP and DS approaches in terms of function (Q-DASH, Constant score), quality of life (SF12), and complications in a prospective randomized multicenter study. From 2007 to 2016, all patients meeting the inclusion/exclusion criteria in two University Trauma Centers were invited to participate in the study. Inclusion criteria were: PHF Neer II/III, isolated injury, skeletal maturity, speaking French or English, available for follow-up (FU), and ability to fill questionnaires. Exclusion criteria: Pre-existing pathology to the limb, patient-refusing or too ill to undergo surgery, patient needing another type of treatment (nail, arthroplasty), axillary nerve impairment, open fracture. After consent, patients were randomized to one of the two treatments using the dark envelope method. Pre-injury status was documented by questionnaires (SF12, Q-DASH, Constant score). Range of motion was assessed. Patients were followed at two weeks, six weeks, 3-6-12-18-24 months. Power calculation was done with primary outcome: Q-DASH. A total of 92 patients were randomised in the study and 83 patients were followed for a minimum of 12 months. The mean age was 62 y.o. (+- 14 y.) and 77% were females. There was an equivalent number of Neer II and III, 53% and 47% respectively. Mean FU was of 26 months. Forty-four patients were randomized to the DS and 39 to the DP approach. Groups were equivalent in terms of age, gender, BMI, severity of fracture and pre-injury scores. All clinical outcome measures were in favor of the deltopectoral approach. Primary outcome measure, Q-DASH, was better statistically and clinically in the DP group (12 vs 26, p=0,003). Patients with DP had less pain and better quality of life scores than with DS (VAS 1/10 vs 2/10 p=0,019 and SF12M 56 vs 51, p=0,049, respectively). Constant-Murley score was higher in the DP group (73 vs 60, p=0,014). However, active external rotation was better with the DS approach (45° vs 35°). There were more complications in DS patients, with four screw cut-outs vs zero, four avascular necrosis vs one, and five reoperations vs two. Calcar screws were used for a majority of DP fixations (57%) vs a minority of DS (27%) (p=0,012). The primary hypothesis on the superiority of the deltoid split incision was rebutted. Functional outcome, quality of life, pain, and risk of complication favoured the classic deltopectoral approach. Active external rotation was the only outcome better with DS. We believe that the difficulty of adding calcar screws and intramuscular dissection in the DS approach were partly responsible for this difference. The DP approach should be used during Neer II and III PHF fixation

Proximal humeral fractures are common fractures that may lead to severe functional disability. In open reduction and internal fixation of these fractures deltopectoral approach is pereferred by many surgeons being an internervous plane and because of familiarity. However when this aprroach is used extensive soft tissue dissection is inevitable and control of the commonly displaced tuberculum majus fragment which is displaced posterolateraly is difficult. In this prospective study we compared deltopectoral and lateral deltoid splitting approach by using the same fixation material. Between October 2005 and March 2007 42 patients were included in the study group. In Group A a lateral deltoid split approch and in Group B deltopectoral approach was used. Group A consisted of 22 cases; mean age 60.95 (26–90 years old); 12 female and 10 male, Group B 20 cases; mean age 56.9 (24–86 years old); 13 female, 7 male. Philos locking plate fixation (Synthes) was used in every case. When deltoid split approach was used axillary nerve was explored and protected, a C-arm was used in every case. Functional results and compications were compared at the follow up visits. When radiological results were compared the reduction of head and tubercular fragments were better in deltoid splitting approach. The Constant score was better in Group A at an earlier time period 68.9 vs 58.4 (p< 0.01). At the 6th month follow up the difference between Constant scores was not significant, 85.9 vs 85.2 (p> 0.05). Axillary nerve lesion due to lateral deltoid split exposure was not observed in any of the cases. Lateral deltoid split exposure with identification and protection of the axillary nerve facilitates 270 degrees control of the head and tubercular fragments in AO/ASIF type B and C fractures. Additional fixation of tubercular fragments by sutures passed through cuff tendons and fixed to the plate helps to maintain the reduction. Compared to double incision minimal invasive approach a shother plate is used without any inadvertant risk to the axillary nerve. Better Constant scores are achieved at an earlier time. We recommend this technique in AO/ASIF type B and C fractures

Aim. Clavicular osteotomy was described as an adjunct to deltopectoral approach for improved exposure of the glenohumeral joint. This study aims to present contemporary outcomes and complications associated with the routine use of clavicular osteotomy by a single surgeon in a regional setting within New Zealand. Methods. A retrospective case series of patients who have undergone any shoulder arthroplasty for any indication between March 2017 to August 2022. This time period includes all patients who had clavicular osteotomy(OS) and patients over an equal time period prior to the routine use of osteotomy as a reference group (N-OS). Oxford Shoulder Score (OSS) and a Simple Shoulder Test (STT) were used to assess functional outcomes and were compared with the reported literature. Operative times and Complications were reviewed. Results. 66 patients were included in the study. 33 patients in the OS group and 33 in the N-OS group. No difference in age, sex, indications for operative intervention and the surgery provided was identified. No significant difference in operative time between groups (N-OS 121 minutes; OS 128 minutes). No clinically significant difference was identified in the OSS (N-OS; mean 38 vs OS 39) or the STT (N-OS 8.3 vs OS 9). The outcomes scores of both groups are in keeping with published literature. Two post operative clavicle fractures, one prominent surgical knot occurred in the OS that required further surgical intervention. Two cases of localized pain over the clavicle and one case of the prominent lateral clavicle were reported in the OS group. Two cases of localized pain over clavicle reported in the N-OS group. Conclusion. Use of clavicular osteotomy is not associated with inferior patient reported. The osteotomy introduces specific risks, however, the study provides evidence that these complications are infrequent and avoidable. Surgeons should feel confident in using this adjunct when exposure to the shoulder is difficult

The standard approach is through the deltopectoral interval. Among patients with prior incisions, one makes every effort to either utilise the old incision or to incorporate it into a longer incision that will allow one to approach the deltopectoral interval and retract the deltoid laterally. The deltopectoral interval is most easily developed just distal to the clavicle, where there is a natural infraclavicular triangle of fat that separates the deltoid and pectoralis major muscles even in very scarred or stiff shoulders. Typically, the deltoid is retracted laterally leaving the cephalic vein on the medial aspect of the exposure. The anterior border of the deltoid is mobilised from the clavicle to its insertion on the humerus. The anterior portion of the deltoid insertion together with the more distal periosteum of the humerus may be elevated slightly. The next step is to identify the plane between the conjoined tendon group and the subscapularis muscle. Dissection in this area must be done very carefully due to the close proximity of the neurovascular group, the axillary nerve, and the musculocutaneous nerve. Scar is then released from around the base of the coracoid. The subacromial space is freed of scar and the shoulder is examined for range of motion. Particularly among patients with prior rotator cuff surgery, there may be severe scarring in the subacromial space. Internal rotation of the arm with dissection between the remaining rotator cuff and deltoid is critical to develop this plane. If external rotation is less than 30 degrees, one can consider incising the subscapularis off bone rather than through its tendinous substance. For every 1 cm that the subscapularis is advanced medially, one gains approximately 20 to 30 degrees of external rotation. The rotator interval between the subscapularis and supraspinatus is then incised. This release is then continued inferiorly to incise the inferior shoulder capsule from the neck of the humerus. This is performed by proceeding from anterior to posterior with progressive external rotation of the humerus staying directly on the bone with electrocautery and great care to protect the axillary nerve. The key for glenoid exposure as well as improvement in motion is deltoid mobilization, a large inferior capsular release, aggressive humeral head cut and osteophyte removal

The deltopectoral approach is a common approach for Shoulder joint replacements where a normal subscapularis tendon is divided. Despite meticulous attention to the subscapular repair, suboptimal return of function was found on clinical examination in 92% of patients (Miller S L: Journal of Shoulder & Elbow Surgery. 12(1): 29–34, February 2003). Therefore the aim was to study the integrity of the Subscapularis tendon in patients with Shoulder joint Replacements both clinical and ultrasound examination. Methods: A cohort of 25 subjects who had undergone Copeland Shoulder replacements through deltopectoral approach were included. All patients had same technique of tendon-to-tendon repair and postoperative rehabilitation. After ethics committee approval subjects were evaluated prospectively with Lift off test, Belly press test and the Constant score. Average follow-up was 29.6 months. An experienced Radiologist performed the Ultrasound examination. Results: Ultrasound examination showed 8 % (2 of 25) had full thickness rupture of subscapularis with 44% (11 of 25) showed mild to moderate atrophy of subscapularis muscle and 12%(3 of 25) severe atrophy. 20%(5 of 25) had Lift off test and Belly press test positive. 40%(10 of 25) had either or both of these tests positive. 60%(15 of 25) had clinical or radiological evidence of reduced function (Fisher exact test, P < 0.01). Constant score are 37.5 with full thickness tears compared to 59.4 with intact subsapularis tendon. Conclusion: Subscapularis tendon function following shoulder replacement had received poor attention. It is deficient in over 60% of patients with joint replacement through Deltopectoral approach with tendon-to-tendon repair. We therefore conclude for this study that alternative techniques of subscapularis tendon repair or alternative approaches to the shoulder joint need to be considered to improve the functional outcome in these patients

Revision of the humeral component in shoulder arthroplasty is frequently necessary during revision surgery. Newer devices have been developed that allow for easy extraction or conversion at the time of revision preserving bone stock and simplifying the procedure. However, early generation anatomic and reverse humeral stems were frequently cemented into place. Monoblock or fixed collar stems make accessing the canal from above challenging. The cortex of the Humerus is far thinner than the femur and stress shielding has commonly led to osteopenia. Many stem designs have fins that project into the tuberosities putting them at risk for fracture on extraction. Extraction starts with an extended deltopectoral incision from the clavicle to the deltoid insertion. The proximal humerus needs to be freed from adhesions of the deltoid and conjoined tendon. The deltopectoral interval is fully developed. Complete subscapularis and anterior capsular release to the level of the latissimus tendon permits full exposure of the humeral head. After head removal the stem can be assessed for loosening and signs of periprosthetic joint infection. The proximal bone around the fin of the implant should be removed from the canal. If possible, the manufacturer's extractor should be utilised. If not, then a blunt impactor can be placed from below against the collar of the stem to assist in extraction. With luck the stem can be extracted from the cement mantle. If there is no concern for infection, the cement-in-cement technique can be used for revision. Otherwise, attempts should be made to extract all the cement and cement restrictor, if present. The small cement removal tools from the hip set can be used and specialised shoulder tools are available. An ultrasound cement removal device can be very helpful. The surgeon must be particularly careful to avoid perforation of the humeral cortex. This is especially important when near the radial nerve as injury can occur. When a well-fixed stem is encountered, an osteotomy of the proximal humerus is necessary. The surgeon can utilise a linear cut with an oscillating saw along the bicipital groove for the length of the implant. An osteotome is used to crack the cement mantle allowing stem extraction. Alternatively, a window can be created to offer additional access to the cement mantle. In the event the surgeon has required an osteotomy or window, cerclage wires, cables or suture will be needed and when the bone is potentially compromised, allograft bone graft struts (tibial shaft) are used for additional support. Care is needed when passing cerclage wires to avoid injury to the radial nerve which is adjacent to the deltoid insertion. If infection is suspected or confirmed an ALBC spacer is placed. When single stage revision is planned both cemented and uncemented stem options are available. Cement placed around the humeral stem has been suggested to decrease infection incidence. Revision of cemented humeral stems is a continued challenge in revision shoulder surgery. Newer systems and reverse total shoulder options have improved the surgeon's ability to achieve good outcomes when revising prior shoulder arthroplasty

Purpose: The purpose of this multicentric study was to report results obtained with the Aequalis system using the simple humeral or total prosthesis, at at least two years follow-up in patients with shoulder joint degeneration and non-repairable rotator cuff tears. Material and methods: Sixty-eight Aequalis arthroplasties were performed between 1992 and 1998. Outcome was assessed on the basis of the Constant score and radiological findings. Female gender predominated (78%) in this series with a mean age of 72 years. There were 62 simple humeral implantations and six total shoulder arthroplasties. The deltopectoral approach was used in 63 cases and the superior approach in five. All stems and sockets were cemented. There were no neurological or infectious complications. Results: Two humeral stem implants were failures and required revision with a Grammont prosthesis. There was also one reoperation for arthrolysis with preservation of the implant; the outcome was fair. Functional outcome: Sixty-six patients were reviewed with a mean follow-up of 45 months. All implantations except one were performed to achieve pain relief. The absolute Constant score improved by 20 points (from 25 to 46) with a 7-point gain for pain (3 to 10), a 20° gain for active elevation, an 18° gain for external rotation, and a 0.4 point gain for force. Pain relief was greater with total prostheses. Only five patients stated they were dissatis-fied with the outcome despite the fact that 18 reported significant persistent pain. The Constant score was analysed as a function of follow-up, size of the humeral head, and preoperative morphology of the glenoid surface. Radiological outcome: Certain loosening was recognised for one glenoid and one humeral stem. Among 52 shoulders with strictly identical radiological results, 33 exhibited deterioration either for the vault or the glenoid or both, with no effect on the Constant score. Discussion: In this indication the Adqualis prosthesis is implanted to achieve a “limited” objective: pain relief. The deltopectoral approach is preferable in order to preserve elements inhibiting superior migration of the humerus (in a parallel study, the absence of these elements explains the poor outcome observed in 3 out of 9 patients). Unlike other series, the present series exhibited a significant effect of a type E2 biconcave glenoid surface. The pain score was better with total shoulder prostheses than with humeral stems alone and four of the six glenoid sockets remained perfectly fixed. The long-term outcome of these glenoid surfaces remains unknown so it would be inappropriate to advise systematic use. Clinical outcome did not show any deterioration over time despite deterioration of the vault, the glenoid, or both. Indications for non-constrained pros-theses should however be retained with caution due to open questions concerning long-term outcome, particularly for shoulders which have already been operated on or with type E2 glenoids. Considering these reservations, the Aequalis prosthesis has reached, at nearly five years follow-up, the assigned objectives: significant pain relief, satisfactory overall shoulder function

Aims

The aim of this study is to evaluate the change in incidence rate of shoulder arthroplasty, indications, and surgeon volume trends associated with these procedures between January 2003 and April 2021 in the province of Nova Scotia, Canada.

Anatomic and accurate placement of components is a primary goal in all arthroplasty procedures. Unique to total shoulder arthroplasty, challenging glenoid exposure and osteoarthritic glenoid deformity offer significant challenges and impediments to this goal. Despite thorough pre-operative planning strategies and contemporary cannulated pin-based shoulder systems, it is often times still difficult to accurately aim the guide pin to the medial border of the scapula when the deformity is substantial or exposure is difficult. Even small errors in guide pin position can result in problems with final component version, inclination and glenoid vault perforation. In addition, a malpositioned glenoid component has been shown to have a negative impact on implant longevity and clinical performance. Image-based patient specific instrumentation has been available in the lower extremity for nearly a decade with reliable results. The application of similar technology in the shoulder has demonstrated reliable positioning of the guide pin to a pre-operative plan with subsequent accurate placement of the glenoid component. This surgical demonstration will feature one of the currently available CT-based patient specific glenoid guides using a standard deltopectoral approach

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.

Cite this article: Bone Joint J 2024;106-B(10):1100–1110.

Aims

The aim of this study was to report long-term clinical outcomes of a modern convertible metal-backed glenoid (MBG) in total shoulder arthroplasty (TSA).

Hemi shoulder arthroplasty is a rather successful procedure although revision surgery due to secondary glenoid erosion is reported in more than 25%. The downside of common shoulder arthroplasty is that in a deltopectoral approach the subscapularis tendon needs to be detached for exposure of the humeral head. Refixation of subscapularis tendon is associated with a retear rate of 4%, furthermore with progressing fatty muscle infiltration and loss of function. In case of revision surgery a second subscapularis tendon detachment is even more associated with worse function. Thus, arthroscopic humeral head resurfacing is an expedient alternative for minimal invasive humeral head arthroplasty without compromising subscapularis function. The purpose of this study was to report first clinical and subjective results after arthroscopic-assisted resurfacing of the humeral head. For this prospective case series, 24 patients (7 females, 17 males; mean age 59 years, range 42–73 years) undergoing arthroscopic-assisted partial shoulder resurfacing with the partial eclipse prosthesis were included in the study. Clinical conditions and subjective assessments were evaluated before surgery and annually thereafter using the Constant score (CS), active range of motion (ROM), visual analog scale (VAS) for pain, and the American Shoulder and Elbow Surgeons scale (ASES). Radiological outcomes and major complications were monitored. The mean CS for all patients improved significantly from 51 points preoperatively to 83 points 12 months after surgery (p=0.005). Trends towards increasing ROMs were detected. Subjective scores significantly improved from baseline to the 1-year follow-up (VAS: from 6.4 to 2.5, p=0.010; ASES: from 47 to 76, p=0.026). The majority of patients (88%) stated that they would undergo the procedure again. Revisions were indicated in 17% due to progression of osteoarthritis. Arthroscopic-assisted partial humeral head resurfacing as a minimal invasive procedure with the advantages of bone stock preservation and intact subscapularis tendon allowed immediate postoperative active mobilization and provided significant improvements in subjective outcome. In case of revision surgery a primary situation was encountered with postoperative results comparable to primary arthroplasty

Aim. Recent studies have indicated that the presence of P. acnes in the skin of the shoulder and around the acromion is higher than other body regions like the knee or the hip. The aim of this study was to estimate the presence of P. acnes in a real set of primary shoulder arthroplasty, after skin preparation with chlorhexidine and administration of empirical antibiotic therapy. Method. A prospective observational study involving 63 patients undergoing primary shoulder arthroplasty was designed. In all patients two skin biopsies with a 3 mm dermal punch and one subcutaneous tissue sample after surgical incision were obtained. Skin biopsies were obtained at the most anterior part of the surgical wound in case of superior approach and at the upper part in the deltopectoral approach. All patients underwent preoperative antibiotic prophylaxis with cefazolin 2g ev and skin preparation with 2% chlorhexidine alcoholic tinted before the start of surgery twice. The aerobic cultures were incubated at 37ºC for 7 days whereas the anaerobic ones incubated for 14 days. Results. A total of 63 consecutive patients who underwent shoulder arthroplasty (58 reverse shoulder arthroplasty and 5 anatomical) were analysed. 54 women and 9 men, mean age of 73.94 (SD 6.19). The indication for arthroplasty was a secondary arthropathy cuff injury in 42 cases, primary osteoarthritis in 3, acute fracture in 9 and fracture sequelae in 9. We obtained 189 tissue cultures (126 skin cultures and 63 subcutaneous) and 4 cultures were positive (2.02%) for P. acnes in 3 different patients. A first patient (female) had both positive skin cultures, the second patient (male) only had positive the subcutaneous tissue cultures and the third patient had positive also the subcutaneous tissue culture. The first patient underwent anatomical shoulder arthroplasty whereas the second and third patients underwent reverse shoulder arthroplasty. The time to grow was 15 days in first patient and 14 days in the second and third patient (mean 14.5 days). Conclusions. In a real setting of patients undergoing shoulder arthroplasty using antibiotic prophylaxis and standard preoperative skin preparation with chlorhexidine we found a low rate of positive cultures for P. acnes (2.02 %). The higher rate of P. acnes positive cultures in skin reported in previous studies may be caused by a different population study group (healthy and younger volunteers without antibiotic prophylaxis) or suboptimal culture technique (use of swaps)

Introduction. The use of reverse total shoulder arthroplasty (RSA) is becoming increasingly common in the treatment of rotator cuff arthropathy. In recent years indications for use have expanded to include elderly patients in whom either internal fixation is not possible due to fracture configuration, poor bone quality, or presence of a rotator cuff deficiency. There is however relatively little evidence to support its use in these circumstances. Objective. This study aims to assess the viability of RSA as a salvage procedure in the treatment of complex proximal humeral fractures or irreducible dislocations, quantified in terms of functional outcome, complication rates and patient reported satisfaction. Methods. All patients presenting between January 2011 and December 2013 with a complex 3- or 4-part humeral fracture or a delayed presentation with an irreducible non-acute dislocation, treated with salvage RSA were eligible for inclusion. All operations were performed in a single centre by one of two specialist upper limb surgeons. Standard deltopectoral approach was performed. Tournier reverse fracture stem with two choices of inserts and graft hole in the stem with proximal hydroxyapatite coating was the implant of choice. All patients and underwent a standardised rehabilitation programme. Clinical outcome was measured at final follow up using (1) patient reported satisfaction, (2) clinician measured range of movement (3) complication rate. Results. A total of 16 patients were eligible for inclusion in this study. Mean age at time of operation was 72.8 years (41–91 years) with a mean follow-up of 7 months (2–13 months). At time of last follow-up 100 per cent of patients were satisfied with the results of their operation and functionally independent with activities of daily living. Mean oxford score was 39 (36–48). Range of movement post-operatively had a mean active forward extension 97° (70–150°) and abduction 101° (80–170°). 43% of patients were pain-free, whilst the remainder only required the use of occasional analgesia. One patient developed heterotrophic ossification post operatively and underwent surgical excision. One patient sustained a peri-prosthetic avulsion fracture at 18months treated non-operatively. Patients who underwent RSA for dislocation fared better than for those with proximal humeral fractures. The mean active forward extension was 107.5° (90–150°) and abduction 112.5° (90–170°) in the dislocation group (N=5) compared with those who had a fracture (N= 11) in which the forward extension was 91.4° (70–120°) and abduction 95° (80–120°). Conclusion. Reverse TSA should be considered in patients with complex proximal humeral fractures or delayed presentation with irreducible dislocation. Early results demonstrate good outcomes in terms of patient satisfaction, pain relief and preservation of function. These early result are encouraging however a further study with longer follow-up is required to confirm sustained benefit

Background. Total Shoulder Arthroplasty (TSA) has been shown to improve the function and pain of patients with severe degeneration. Recently, TSA has been of interest for younger patients with higher post-operative expectations; however, they are treated using traditional surgical approaches and techniques, which, although amenable to the elderly population, may not achieve acceptable results with this new demographic. Specifically, to achieve sufficient visualization, traditional TSA uses the highly invasive deltopectoral approach that detaches the subscapularis, which can significantly limit post-operative healing and function. To address these concerns, we have developed a novel surgical approach, and guidance and instrumentation system (for short-stemmed/stemless TSA) that minimize muscle disruption and aim to optimize implantation accuracy. Development. Surgical Approach: A muscle splitting approach with a reduced incision size (∼6–8cm) was developed that markedly reduces muscle disruption, thus potentially improving healing and function. The split was placed between the infraspinatus and teres-minor (Fig.1) as this further reduces damage, provides an obvious dissection plane, and improves access to the retroverted articular surfaces. This approach, however, precludes the use of standard bone preparation methods/instruments that require clear visualization and en-face articular access. Therefore, a novel guidance technique and instrumentation paradigm was developed. Minimally Invasive Surgical Guidance: 3D printed Patient Specific Guides (PSGs) have been developed for TSA; however, these are designed for traditional, highly invasive approaches providing unobstructed access to each articular surface separately. As the proposed approach does not offer this access, a novel PSG with two opposing contoured surfaces has been developed that can be inserted between the humeral and scapular articular surfaces and use the rotator cuff's passive tension to self-locate (Fig.2). During computer-aided pre-operative planning/PSG design, the two bones are placed into an optimized relative pose and the PSG is constructed between and around them. This ensures that when the physical PSG is inserted intra-operatively, the bones are locked into the preoperatively planned pose. New Instrumentation Paradigm: With the constraints of this minimally invasive approach, a new paradigm for bone preparation/instrumentation was required which did not rely on en-face access. This new paradigm involves the ability to simultaneously create glenoid and humeral guide axes – the latter of which can guide humeral bone preparation and be a working channel for tools – by driving a short k-wire into the glenoid by passing through the humerus starting laterally (Fig.3). By preoperatively defining the pose produced by the inserted PSG as one that collinearly aligns the bones’ guide axes, the PSG and an attached c-arm drill guide facilitate this new lateral drilling technique. Subsequently, bone preparation is conducted using novel instruments (e.g. reamers and drills for creating holes radial to driver axis) powered using a trans-humeral driver and guided by the glenoid k-wire or humeral tunnel. Conclusion. To meet the expectations of increasingly younger TSA patients, advancements in procedural invasiveness and implantation accuracy are needed. This need was addressed by developing a novel, fully integrated surgical approach, PSG system, and instrumentation paradigm, the initial in-vitro results of which have demonstrated acceptable accuracy while significantly reducing invasiveness

This study reviews the use of intramedullary fibular allograft in treating nonunion of the humeral neck in 11 patients. Nine women and two men with a mean age of 76 years (63 to 89) were followed up for a mean of 61 months (14 to 72). The nonunion was exposed through a deltopectoral approach and fibular allograft was inserted across the fracture site. As the fibula is a very dense cortical bone, a T-plate could then be applied to the humerus with the screws directed into the intra-medullary fibular peg. Supplementary corticocancellous bone from the iliac crest was used. Bony union was achieved in every case. The preoperative mean Constant score was 26 and the postoperative mean Constant score was 75. The most notable improvement was in patients’ ability to elevate the arm actively. Decreases in pain levels were observed but were less dramatic than the increases in function

Purpose. While reverse shoulder arthroplasty (RSA) corrects vertical muscle imbalance, it cannot restore the horizontal imbalance seen in cuff-deficient shoulders with combined loss of active elevation and external rotation (CLEER). We report the medium-term results of the modified latissimus dorsi/teres major tendon transfer (L'Episcopo procedure) associated with RSA, performed via a single deltopectoral approach. Method. Sixteen CLEER patients underwent the procedure and were followed up at a mean of 49 months (range, 36–70). All patients had lost spatial control of their arm, were unable to maintain neutral rotation, and had abnormal infraspinatus and teres minor muscles on imaging. Outcome measures included Constant score (CS), Subjective Shoulder Value (SSV), and ADLER score (activities of daily living requiring external rotation). Results. Fifteen patients were satisfied or very satisfied. There were significant improvements (p<0.05) in active elevation (72 degrees to 139 degrees), active external rotation (−24 degrees to 4 degrees), CS (27 to 64), ADLER score (5.0 to 23.8) and SSV (23% to 77%). Active internal rotation decreased from 6 to 3 points. Scapular notching was observed in 3 patients and spurs in 3 patients. One deep infection required two-stage revision of the prosthesis and the patient was disappointed with the result. One patient required reoperation (arthrolysis and acromioclavicular joint excision). Conclusion. Reverse shoulder arthroplasty combined with the modified L'Episcopo procedure improves shoulder function in patients with CLEER. Patients regain spatial control of their arm. The observed internal rotation loss has led us to modify the surgical technique by fixing the transferred tendons more posteriorly on the humerus

Purpose of the study: Proximal fractures of the humerus account for 10% of fractures in persons aged over 65 years. There is no optimal treatment. The goal of surgery is to restore joint congruency, preserve vascular supply, and allow functional recovery. We describe the results obtained with a surgical technique designed to meet these goals. Material and methods: Fifteen 3-fragment fractures of the proximal humerus were treated with transosseous suture. Mean age of patients was 58 years. Eighty-six percent of the patients were female. Follow-up was 18 months on average. The patients were placed in a lounge chair position for the deltopectoral or transdeltoid approach. For this type of fracture, the humeral head is displaced medially or laterally, so that care must be taken to ensure the realignment in the sagittal and coronal planes. The DASH and Constant scores were noted for the operated and non-operated shoulders. Signs of bone healing were noted on the plain x-rays. Results: The mean DASH was 12, mean Constant score for the operated shoulder was 80 versus 90 for the other shoulder. The mean neck-shaft angle was 139°. There was one case of lost reduction but with a good final result. There was one case converted to arthroplasty. Discussion: This technique is in line with the current trend for biological preservation minimising the aggression to the humeral head blood supply. There was no risk of migration with the fixation material used and no need to remove implants. Conclusion: Transosseous suture of proximal fractures of the humerus is a mini-invasive method which provides good functional results avoiding voluminous metal implants, known to be costly and source of complications. The incidence of avascular necrosis of the humeral head is low, in agreement with the international literature

Introduction. The use of reverse total shoulder arthroplasty (RSA) is becoming increasingly common in the treatment of rotator cuff arthropathy. Standard RSA technique involves medialising the centre of rotation (COR) maximising the deltoid lever arm and compensating for rotator cuff deficiency. However reported complications include scapular notching, prosthetic loosening and loss of shoulder contour. As a result the use of Bony Increased Offset Reverse Shoulder Arthroplasty (BIO-RSA) has been gaining in popularity. The BIO-RSA is reported to avoid these complications by lateralising the COR using a modified base plate, longer central post and augmentation with cancellous bone graft harvested from the patients humeral head. Objectives. This study aims to compare the outcome in terms of analgesic effect, function and satisfaction, in patients treated with standard RSA and BIO-RSA. Methods. All cases were performed in a single centre by one of two upper limb consultant orthopaedic surgeons over a consecutive 2-year period. At time of listing for operation, the decision as to whether to undertake a bony-increased offset reverse total shoulder was made. Standard deltopectoral approach was performed. Standard and Bony increased offset Tournier reverse was the implant of choice (BIO-RSA). All patients underwent a standardised rehabilitation programme. Standard follow up was clinical review with radiographs at 2 weeks, 6weeks and 3months. Retrospective data was collected using case notes on patient reported stausfaction and oxford shoulder score, analgesia requirement at final follow up, and final range of movement. Results. A total of 60 patients (65 shoulders) were treated with reverse total shoulder replacements (RSA) within a 2-year period in a single centre for chronic complex shoulder conditions. Mean age at time of intervention was 74.1years (49.3 – 88.7). Mean follow up was 7.1 months (3.4 – 24). Average time to discharge 16.1 months (3.4 – 37.4). 43 patients currently under review. Of the 65 shoulders, 40 underwent BIO-RSA procedures. Indications for surgery were predominantly rotator cuff arthropathy (N=36). Other indications included severe osteoarthritis (N=1) and complex proximal humeral fracture (N=3). The remaining 25 patients treated with standard RSA were similar in terms of indication and basic demographics. In terms of range of movement, outcomes between the two groups were broadly similar. Patients receiving BIO-RSA demonstrated mean active forward flexion of 92.2° (70–120°) and abduction 93.3° (80–120°). The RSA group had mean forward flexion 90.5° (50–130°) and mean abduction 88.6° (40–160°). Both groups had excellent analgesic effect with 92% in each either being completely pain free or requiring only occasional analgesia. The majority of patients were either very satisfied or satisfied with the outcome of the surgery. Mean Oxford shoulder score for the BIO-RSA group was 4.9 (0–13) preoperatively and 43.7 (36–48) postoperatively. The mean RSA pre-operative score was 7.9 (0–19) and postoperatively 40.2(32–48). In total three patients experienced complications; 1 haematoma (BIO-RSA), 1 brachial plexus contusion (BIO-RSA) and 1 deep infection (RSA). Conclusion. If grafting is necessary, the use of BIO-RSA within this centre seems to have comparable results to those undergoing standard RSA. Early results also suggest the Bio-RSA allows earlier improvement and conserves a larger bone stock. These early result are encouraging however a further study with longer follow-up is required

Introduction: Surgical treatment of most displaced proximal humerus fractures is challenging due to osteoporosis, which makes stable fixation difficult. Locking plates are intended to provide superior mechanical stability. The NCB. ®. -PH (Non-Contact-Bridging for the Proximal Humerus) plate is a locking plate of the latest generation that allows both open and minimally invasive (MI) application. Methods: In a prospective multicenter study 131 patients were treated (n = 78 open, n = 53 MI). The open procedure was performed using a standard deltopectoral approach; the MI technique involved percutaneous reduction and an anterolateral deltoid split approach. Clinical and radiological follow-up was obtained 6 weeks, 3, 6 and 12 months after surgery. An iADL (instrumental activities of daily living) score was used for functional assessment, the subjective outcome was measured using VAS (Visual Analogue Scale) for pain and mobility. Results: Improvement in function (ROM) was statistically significant in both groups (open and MI) postoperatively. Fracture type had the most significant impact on the complication rate. The most frequent complication was intraarticular screw perforation. The open treated group showed a higher complication rate. However, more C-type fractures (AO) were treated with this technique. Conclusion: The NCB-PH is suitable as a routine method of treatment for proximal humerus fractures. Complication rate and functional outcome are comparable to the literature. The MI technique, which is limited by percutaneous fracture reduction, provides a less invasive option for patients requiring fast recovery. Complex fractures should preferably be treated with the open technique