Glenoid baseplate orientation in reverse shoulder arthroplasty (RSA) influences clinical outcomes, complications, and failure rates. Novel technologies have been produced to decrease performance heterogeneity of low and high-volume surgeons. This study aimed to determine novice and experienced shoulder surgeon's ability to accurately characterise glenoid component orientation in an intra-operative scenario.

Glenoid baseplates were implanted in eight fresh frozen cadavers by novice surgical trainees. Glenoid baseplate version, inclination, augment rotation, and superior-inferior centre of rotation (COR) offset were then measured using in-person visual assessments by novice and experienced shoulder surgeons immediately after implantation. Glenoid orientation parameters were then measured using 3D CT scans with digitally reconstructed radiographs (DRRs) by two independent observers. Bland-Altman plots were produced to determine the accuracy of glenoid orientation using standard intraoperative assessment compared to postoperative 3D CT scan results.

Visual assessment of glenoid baseplate orientation showed “poor” to “fair” correlation to 3D CT DRR measurements for both novice and experienced surgeon groups for all measured parameters. There was a clinically relevant, large discrepancy between intra-operative visual assessments and 3D CT DRR measurements for all parameters. Errors in visual assessment of up to 19.2 degrees of inclination and 8mm supero-inferior COR offset occurred. Experienced surgeons had greater measurement error than novices for all measured parameters.

Intra-operative measurement errors in glenoid placement may reach unacceptable clinical limits. Kinesthetic input during implantation likely improves orientation understanding and has implications for hands-on learning.

This review compares the outcomes and complication rates of three surgical strategies used for the management of symptomatic os acromiale. The purpose of this study was to help guide best practice recommendations.

A systematic review of nine prospective studies, seven retrospective studies, and three case studies published across ten countries between 1993 and 2018 was performed. Adult patients (i.e., ≥ 18 years of age) with a symptomatic os acromiale that failed nonoperative management were included in this review. Surgical techniques utilized within the included studies include excision, acromioplasty, and open reduction and internal fixation (ORIF). The primary outcomes of interest included patient satisfaction and return to activity. Range of motion and several standardized outcome measurement tools were also included in the final analysis.

Patient satisfaction was highest in the excision and ORIF groups, with 92% and 82% of patients reporting good to excellent postoperative results, respectively, compared to 63% in the acromioplasty group. All three patient groups experienced improved postoperative objective scores (i.e., patient-reported outcome scores and active range of motion). The excision group experienced a complication rate of 1%, while the acromioplasty group experienced a complication rate of 11% and the ORIF group a rate of 67%.

This study reports on the largest sample of patients who have undergone surgical treatment for a symptomatic os acromiale. We have demonstrated that excision of the os with repair of the deltoid resulted in the best clinical outcomes with the least complications. In healthy adult patients with a large os fragment and a normal rotator cuff, surgical fixation may provide increased preservation of deltoid function while offering good patient satisfaction. Such patients should be aware that they are at increased risk of requiring a second procedure due to symptomatic hardware following ORIF.

A reverse total shoulder arthroplasty (RSA) is frequently performed in the revision setting. The purpose of this study was to report the clinical outcomes and complication rates following revision RSA (RRSA) stratified according to the primary shoulder procedure undergoing revision, including failed hemiarthroplasty (HA), anatomic total shoulder arthroplasty (TSA), RSA, soft tissue repair (i.e., rotator cuff repair), and open reduction internal fixation (ORIF).

A systematic review of the literature was performed using four databases (EMBASE, Medline, SportDISCUS, and Cochrane Controlled Trials Register) between January 1985 and September 2017. The primary outcomes of interest included active range-of-motion (ROM), pain, and functional outcome measures including the American Shoulder and Elbow Surgeons Score (ASES), Simple Shoulder Test (SST), and Constant-Murley (CS) Score. Secondary outcomes included complication rates, such as infection, dislocation, perioperative fracture, base plate failure, neurovascular injury, soft tissue injury, and radiological evidence of scapular notching. Clinical outcome data was assessed for differences between preoperative and postoperative results and complication results were reported as pooled complication rates.

Forty-five studies met the inclusion criteria for analysis, which included 1,016 shoulder arthroplasties with a mean follow-up of 45.2 months (range, 31.1 to 57.2 months) (Fig. 1). The mean patient age at revision was 60.2 years (range, 36 to 65.2 years). Overall, RSA as a revision procedure for failed HA revealed favorable outcomes with respect to forward elevation (FE), CS pain, ASES, SST, and CS outcome assessment scores, with mean improvements of 52.5° ± 21.8° (P = < 0 .001), 6.41 ± 4.01 SD (P = 0.031), 20.1 ± 21.5 (P = 0.02), 5.2 ± 8.7 (P = 0.008), and 30.7 ± 9.4 (P = < 0 .001), respectively. RSA performed as a revision procedure for failed TSA demonstrated an improvement in the CS outcome score (33.8 ± 12.4, P = 0.016). RSA performed as a revision procedure for failed soft tissue repair demonstrated significant improvements in FE (60.2° ± 21.2°, P = 0.031) and external rotation (20.8° ± 18°, P = 0.016), respectively. Lastly, RSA performed as a revision procedure for failed ORIF revealed favorable outcomes in FE (61° ± 20.2°, P = 0.031). There were no significant differences noted in RSA performed as a revision procedure for failed RSA, or when performed for a failed TSA, soft tissue repair, and ORIF in any other outcome of interest. Pooled complication rates were found to be highest in failed RSA (10.9%), followed by soft tissue repair (7.1%), HA (6.8%), TSA (5.4%) and ORIF (4.7%).

When compared to other revision indications, RRSA for failed HA demonstrated the most favorable outcomes, with significant improvements in ROM, pain, and in several outcome assessments. Complication rates were determined and stratified as per the index procedure undergoing RRSA, patients undergoing revision of a failed RSA were found to have the highest complication rates. With this additional information, orthopaedic surgeons will be better equipped to provide preoperative education regarding the risks, benefits and complication rates to those patients undergoing a RRSA.

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Rotator cuff disease encompasses a spectrum from partial to full thickness tears. Despite being 2–3 times more common than full–thickness tears, effective non-operative treatment for partial thickness tears has remained elusive. Platelet enriched plasma (PRP) has been proposed to enhance rotator cuff healing by enhancing the natural healing cascade. However, its utility in rotator cuff disease remains controversial. The purpose of this study was to compare the patient reported outcomes between PRP and corticosteroid injection in patients with symptomatic partial thickness tears.

This double blind randomized controlled trial enrolled patients with symptomatic, partial thickness rotator cuff tears or rotator cuff tendinopathy proven on ultrasound or MRI. Patients were randomized to either corticosteroid or PRP ultrasound-guided injection of the affected shoulder. Patients completed patient reported outcomes at 6 weeks and 12 weeks. The primary outcome was Visual Analog Scale (VAS) pain scores. Secondary outcomes included the Western Ontario Rotator Cuff (WORC) index, American Shoulder and Elbow Surgeons (ASES) score, and failure of non-operative management as determined by consent for surgery or progression to operative intervention.

Ninety-nine patients were enrolled in the study with equal demographics between the two groups. Taking into account pre-injection scores, patients with PRP injections demonstrated a statistically significant improvement in VAS scores compared to patients receiving corticosteroid injections at 12 weeks (p=0.045) but not at 6 weeks (p=0.704). There was no difference in other outcome measures or progression of the two groups to surgical intervention.

The use of PRP in the management of partial thickness rotator cuff tears demonstrates significant improvement of pain scores at 12 week follow up compared to corticosteroid injections. However, this did not affect the rate of progression to surgical intervention. Continued study is required to determine the utility of PRP in this patient population.

Total Elbow Arthroplasty (TEA) is a procedure to treat a number of conditions including rheumatoid arthritis (RA), post-traumatic arthritis, and osteoarthritis. To date, there has been minimal literature published on the Latitude since its release in 2001. There is one study reporting outcomes from the Latitude, a German study published in 2010. The purpose of this study was to analyse outcomes from primary Latitude TEAs.

We performed a retrospective case series of 23 TEAs performed on 20 patients. 6 patients required revision surgery and were not included in the analysis. One patient was lost to follow up, resulting in 17 patients included for ROM analysis. All patients received Latitude TEA through a posterior approach and underwent a standard rehab protocol. 11 Patients were recalled at least two years post-op and were administered DASH and MAYO questionnaires. Complications such as triceps insufficiency, ulnar nerve dysfunction, infection, and aseptic loosening were recorded. Outcomes were compared using the Wilcoxon Signed-Rank test in STATA. Immediate post-op radiographs and patients most recent radiographs were analysed by a blinded upper-extremity surgeon not involved in the initial operation and analysed for loosening and implant malpostioning.

Mean follow up was 4.8 years (range 2.6–7.5 years). Analysis of 17 TEAs in 16 patients revealed no difference in pre-operative ROM and post-operative ROM for flexion (121°±20 vs 129°±16, p=0.13) extension (40°±27 vs 27°±15, p=0.19), pronation (73°±13 vs 75°±24, p=0.55) or supination (64°±22 vs 68°±14, p=0.52). Patients who underwent TEA for RA had a significant improvement in flexion (121°±15 vs 135°±10, p<0.02). There was a statistically significant improvement in flexion-extension arc post-operatively (101°±28) compared to pre-operative scores (83±23 degrees, p<0.02). DASH and MAYO scores were calculated from 11elbows in 11 non-revision patients able to return for examination. The average MAYO score was 87.9 with nine patients in the “excellent” category, two patients in the “good” category, one patient in the “fair” category, and one in the “poor” category. The average DASH score was 32.9. Two patients underwent revision for periprosthetic fractures, two patients underwent revision for infection, one underwent revision for aseptic loosening and two for radial head dissociation (rate of 30%).

This is one of the first studies examining the outcomes of the Latitude TEA. This retrospective case series demonstrates that the Latitude TEA has promising outcomes with respect to improving patient pain and functioning as assessed by the MAYO. Treatment using the Latitude TEA results in favorable functional outcomes for a majority of patients and offers an improvement in flexion-extension arc. Furthermore, our results are comparable to the MAYO scores reported by other studies analysing different prosthesis designs. The complication rate in our series was comparable to published rates of 20–40%.

Clinical pathways are optimal patient care processes that have been developed to improve the quality of care for patients. Anecdotal evidence has suggested that patients presenting to the healthcare system with rotator cuff tears experience less than ideal quality care plagued by lengthy wait times, challenges in coordinating care, and inefficient use of healthcare resources. Therefore, diagnosis and treatment of patients with rotator cuff tears are in need of quality improvement through evidence-informed decision making. The purpose of this study is to develop a clinical pathway for patients presenting to the healthcare system with rotator cuff tears.

The following steps were taken in developing the clinical pathway: 1) a multidisciplinary expert panel was formed; 2) goals of the clinical pathway were identified by the panel; 3) the literature and current clinical practices for best practice were reviewed; 4) recommendations for treatment algorithms were developed using consensus methods.

The panel consisted of fourteen experts representing the two largest cities in Alberta, Canada (Edmonton and Calgary). The team consisted of at least one member from the clinical domains of sport medicine, orthopaedic surgery, athletic therapy, and physiotherapy. The first goal of the clinical pathway was to standardise screening, diagnosis, and physical examination of the patient. The second goal was to provide recommendations for appropriate investigations. The final goal was to map steps in the patients' care pathway including sequencing and timing recommendations for treatment and interventions. Best practices were reviewed by the panel and using a modified Delphi method, clinical pathways for three types of rotator cuff tears (acute, chronic, and acute-on-chronic) were developed.

A clinical pathway that reflected best practices was developed from the literature and experts. The clinical pathway for diagnosis and treatment of patients with rotator cuff pathology will help to standardised patient care, improve patient flow, reduce unnecessary interventions, reduce healthcare utilisation and costs, and improve the quality of patient care.

Spontaneous flexor tendon ruptures of the hand are uncommon and the current understanding of these ruptures is incomplete.

The purpose of this study is to report five cases of spontaneous flexor tendon rupture in the hand, and to contrast the findings to those in the literature.

A retrospective review of patients with flexor tendon injuries referred to our hand surgeons identified five patients who sustained a spontaneous rupture of the flexor digitorum profundus tendon. A literature search found a total of nineteen articles describing spontaneous tendon ruptures that met our criteria.

We report five cases of spontaneous rupture involving the flexor digitorum profundus tendon. One case involves an abnormal intertendinous connection between the ring and small finger profundus tendons and another involves a lumbrical muscle variant. To our knowledge, the latter has not been reported in association with spontaneous tendon rupture. In reviewing the literature for spontaneous flexor tendon ruptures, a total of fifty spontaneous ruptures in forty-three cases was found. The majority involve the profundus tendon of the small finger in the palm. The ruptures most often occur during periods of peak strain, but can also occur without identifiable trauma.

This study provides a detailed overview of spontaneous flexor tendon ruptures in the hand not found in the literature. The pathogenesis of spontaneous tendon ruptures is still unclear and is likely multifactorial. Although spontaneous flexor tendon ruptures of the hand are uncommon, these ruptures occur more often than one might recognise.