The primary goals of successful rTSA (Reverse Total Shoulder Arthroplasty) are pain relief, improved shoulder motion and function with the restoration of patient independence. These goals can be achieved by optimal prosthesis design and surgical technique.

Historically there have been two predominant reverse shoulder design philosophies: the traditional valgus 155-degree neck-shaft angle with a medialised center of rotation introduced by Dr. Grammont, and the more recent varus 135-degree neck-shaft angle with a lateralised center of rotation, developed by Dr. Frankle. The latter design has reported lower incidences of scapular notching, coupled with improved adduction and external rotation. Over time, an understanding of the factors which resulted in clinical complications and those that contributed to the clinical success of both these design philosophies has been analyzed and widely publicised. With the currently available reverse prostheses the surgeon is required to be committed to one design philosophy or the other. This commitment to one singular design may hinder surgeons from the ability to individualise each case regardless of patient anatomy, rotator cuff condition, arthritic state and post-operative expectation.

Recently, a system has been launched which offers both design philosophies in one system, providing unsurpassed intra-operative flexibility. This allows the surgeon to adapt to each individual case and choose either design philosophy based on patient condition and anatomy, thus optimizing patient outcome.

The treatment of proximal humeral fractures has historically included Hemi Arthroplasty (HA) or Total Shoulder Arthroplasty (TSA). However, rTSA has recently become the surgery of choice for many fracture treatments based on more reproducible results. Certain implant characteristics are gaining favor in the treatment of proximal humerus fractures namely:

Press fit humeral stems - which avoid the risks of cement in-between the tuberosities which has been reported to compromise healing.

Introduction

Injectable collagenase clostridium histolyticum (CCH) is a minimally invasive non-surgical therapy with efficacy in correcting Dupuytren's contracture (DC). In the concurrently run JOINT I and JOINT II studies, designed to follow clinical practice, we evaluated the efficacy of ?5 CCH injections in patients with DC.

Aims: The purpose of the study was to analyse the early experience of the technique of transitory percutaneous pinning to manage three and four part proximal humeral fractures. Methods: An independent review of 66 consecutive patients with proximal humeral fractures treated in our unit over a three-year period was carried out. The patients underwent closed reduction under image intensiþer guidance with percutaneous pinning using an average of 3.5 wires (range 3–4). A standard three dose prophylactic antibiotic regime was used. A protective collar and cuff was the used for 4 weeks, and a physiotherapy program of pendular movements going on to assisted active exercises started after this. The wires were typically removed in an outpatient setting at 4 to 6 weeks. Results: The postoperative radiographs were deemed satisfactory with good overall alignment by two external observers in all cases. Our þndings were however remarkable for a very high early complication rate. This included pin migration (50%), stiffness (41%), pain (33%), infection (25%), nonunion (8%) and radial nerve palsy (8%). The complication rate increased dramatically in those over the age of 50 or those with osteopenia. Conclusions: The technique of transitory percutaneous humeral pinning is technically demanding. Our early experience would suggest high rates of early complications and readmissions. This technique should be applied with caution in older patients with osteopenia.