Introduction: Latarjete operation for anterior shoulder instability, first described by Latarjete in 1954 consists of transfer of the coracoid process through the sub-scapularis tendon to the neck of the scapula. Many modifications were described in the English literature as described by Mc Murray in 1958, by Bonin in 1969 or May in 1970. In 1985, Braly and Tullos emphasized that the Bankart lesion, when present, should be corrected.

Rockwood transplants the entire coracoid process onto the neck by “laying it flat” onto the neck of the scapula using two screws instead of one, which gives a larger base for the coracoid transplant.

The disadvantages of this procedure, as described in the English literature, are relative shortening of the sub-scapularis tendon, thereby decreasing internal rotation power, limited external rotation and the possibility to damage the musculocutaneous nerve.

Purpose of the Study: To demonstrate that transplantation of the coracoid process with its tendon attachments through a split in the subscapularis muscle and tendon without shifting the capsula gives better results then transplant of the coracoid process with capsule-labral repair. The goal of this report is to review the result of our series.

Patients and Methods: Between January 2000 and June 2005, 26 Latarjete operations (Rockwood modification) were performed by the senior author. The indication for surgery was failed artroscopic Bankart repair or anterior shoulder instability associated with anterior inferior glenoid deficiencies (“inverted pear” deformity). Five cases were excluded having less than 6 months follow-up. In the first 5 cases in addition to the coracoid process transfer, labral repair with capsular shift was performed whereas in the next 21 cases only coracoid process transplant with excision of the damaged labrum/scar tissue and no capsular shift was performed. The postoperative rehabilitation program was the same for both groups. The patients age and sex was very close in both groups.

The parameters for comparison between the two groups were: range of motion, stability after 6 months, return to work and sport activity, satisfaction, and complication rate.

Results: 6 months after surgery all patients of both groups returned to full work and sport activity including contact sports. No recurrent dislocation was encountered during this short period of follow up. All patients who underwent this procedure, with or without capsule-labral repair, were satisfied with the procedure.

In the small group that included capsulo-labral repair an average of 10 degrees decrease of external rotation was encountered compared to the opposite shoulder. In the second group no decrease in range of motion was found.

Conclusion: Transfer of the coracoid process through the subscapularis tendon alone has better results then Latarjete operation complemented with capsulo-labral repair in regard of range of motion. The procedure is simple and of short duration giving the best solution for failed artroscopic procedures or for cases of shoulder instability having anterior inferior glenoid deficiencies.

The authors are aware that longer follow up is mandatory.

Introduction: In many cases of massive rotator cuff tears, especially in cases of revision repairs the shoulder surgeon is facing a technical and biological challenge. The loss of collagenous material in the tendon, coupled with poor quality of the remaining rotator cuff, makes obtaining a mechanically strong repair difficult. Primary closure of such defects may result in excessive tissue tension, which may further increase the chance of failure.

Purpose: The objective of this study is to determine the feasibility of using xenogeneic small intestine submucosa (SIS) as a biomaterial to reinforce repair of massive rotator cuff tears.

Clinical Material and Methods: Nine patients ranging in age from 52 to 74 with massive rotator cuff tears were selected for the study. Selection of these patients was based upon the quality of remaining rotator cuff tendon tissue at the time of the repair. Seven cases after failed repair of massive rotator cuff tear and two cases of long standing neglected rotator cuff tears in patients with weight bearing shoulders (bilateral below the knees amputation and incomplete paraplegia after anterior poliomyelitis) were selected for this study.

In all patients first the tear was repaired by well-known techniques: tendon to tendon, tendon to bone through bone tunnels or using suture anchors. After the repair was accomplished, the poor quality tissue obtained was reinforced by a patch of Restore Orthobiologic Soft Tissue Implant (DePuy, Johnson & Johnson). The Restore Implant is a xenograft obtained of ten layers of porcine small intestine submucosa, it is biocompatible, infection resistant, possess predictable mechanical properties, and, perhaps most significantly, induce a host connective and epithelial tissue response that results in regeneration of specialized connective tissues.

Results: Follow-up ranging between 6 to 22 month excellent and good results were observed in eight cases (88%), whereas in the patient aged 74, the cuff repair failed again (after two previous failures). In the eight successful cases an almost normal painfree active range of movements was observed three month after surgery.

Conclusions: The results confirm the usefulness of the SIS graft material in the patients having questionable quality cuff tissue remaining after repair. Use of the Restore soft tissue implant could possibly be utilized to strengthen the repair, as well as the inside ingrowth of the tendon, leading to a successful repair of the rotator cuff.

The Purpose: To compare clinical results of proximal humerus fractures following internal fixation with proximal humeral locked plate versus conservative treatment.

Materials and Methods: 25 patients sustained 3-part fractures of the proximal humerus. 8 were internally fixed and 17 were treated conservatively in two different centers.

Mean age: 65.4±12.7 Gender: 22 females, 3 males. Age and gender were similar in both groups. Follow up was longer in the conservative group (23.8 m ±7.5) compared to the operated one (11.1 m ±8.3).

All the patients were evaluated clinically using Constant’s score.

Statistical analysis was performed using Fisher’s exact test (examination rates differences), Mann-Whitney test (examination means difference) and Spearman’s test (evaluation of the correlation coefficient between two continuous variables).

Results: Constant’s score in the operated group was 57.1±19.3 and 58±21.5 in the conservative group. Union was noticed in all the operated patients, and there was one case of nonunion in the conservative group. There were no cases of AVN in any group.

Statistical Analysis: No significant difference between the two groups was found for total Constant’s score. ROM was similar in both groups except for the rotations, which tended to be better in the operated group: IR 7.6±2.6 versus 5.4±3.3 (p=0.103) respectively, ER 7.7±3.1 versus 6±2.6 (p=0.169) respectively.

Conclusions: Clinical results are similar for operative and conservative treatments in 3 part fractures of the proximal humerus. There are better results for rotations in the operated group. Strength in abduction is superior in the conservative group.

The difference could be influenced by the shorter follow–up period in the operated group.

Introduction: Three and four part fractures and fracture dislocations of the proximal humerus (Neer classification) presents a technical challenge for the shoulder surgeon. The high rate of excellent and good results of shoulder hemiarthroplasty reported by Charles Neer in the past was never again achieved by other surgeons in Israel and aboard. Up to day no satiafactory method of surgical treatment was for this group of fractures.

Purpose: The intention of this study is to demonstrate that the nonsurgical conservative management of complex proximal humeral fractures gives as good results as the surgical methods if not better.

Clinical Material and Methods: Between January 1, 2003 and December 31, 2003 fifty patients with three and four part fractures and fracture dislocations of the proximal humerus was treated in our outpatient facility. 25 patients were randomly selected for nonsurgical and 25 patients for surgical treatment. Three distinct groups were separated. The first group, selected for nonsurgical management, consisted of 19 female and 6 male patients with an average age of 66 years. The second group consisted of 9 females and 3 male patients treated by closed reduction and external fixation (CREF) or by open reduction and external fixation (OREF) with an average age of 67 years. The third group consisted of 10 females and 3 males treated by shoulder hemiarthroplasty with an average age of 70 years. Constant functional assessment score with “the limited goals” correction was used to evaluate the results.

Results: No significant differences were seen among the first and second group. Slightly better results were observed at the patients treated by external fixation means, but not statistically significant. The results of the hemiartroplasty group were found worse than the two previous groups, with statistically significant differences. It is interesting to mention that in the last group a better external rotation was seen in association with significantly worse abduction and forward elevation than in the first two groups.

Conclusion: Three and four part fractures and fracture dislocations of the proximal humerus are better managed by preserving the original head of the bone, even with gross deformity, than treated by hemiarthroplasty. Conducted by the results of this study we recommend to manage complex fractures of the proximal humerus by conservative methods or as needed by minimal invasive techniques (CREF or OREF).

Introduction: The increasing use of Arthroscopic surgery for recurrent anterior shoulder dislocations (RASD) has questioned the indications and contraindications for this procedure. The ideal candidate for this kind of surgery is an overhead athlete, who participates in a noncontact sport, with traumatic unidirectional anterior instability with a well-defined Bankart lesion.

Purpose of the paper: To demonstrate that complementing the Arthroscopic Bankart Repair (ABR) with an Arthroscopic Rotator Interval Closure (ARIC) the indication for Arthroscopic management of Anterior shoulder instability can be broaden for patients who has a less defined Bankart lesion and has additional multidirectional hyperlaxity.

Patients and Methods: Between January 1, 1999 and December 31, 2002, 166 patients (175 shoulders) suffering from recurrent anterior dislocations were treated by ABR. In the first two years, only patients who had unidirectional instability with no Hyperlaxity or grade 1 Hyperlaxity were selected for this specific method of treatment. Encouraged by the results, beginning of October 2001, in addition to the first group of patients we started to operate patients suffering of recurrent dislocations having grade 2 or grade 3 Hyperlaxity. In this second group of patients we added to the ABR an ARIC procedure. In the first group 130 shoulders whereas in the second group 45 shoulders were operated on. We used Panalok-Panacryl Smith and Nephew 3.5mm x2 Ethibond sutures (OBL) suture anchors or Bioknotless (Mitek) anchors. 157 cases had one side operated whereas in 9 cases both sides were operated on. There were 150 male patients and 16 females in these two groups, 91 patients had the left shoulder, 66 patients had the right shoulder and nine patients had both shoulders operated on. The mean follow-up was 3 years ranging between 4.5 to 1.7 years.

Results: In spite of the relatively short follow-up for the second group of patients we encountered very good preliminary results. At revision of all the cases we found 9 recurrences for the ABR group (representing 6.9%) in comparation of the one reoccurrence in the ABR supplemented by ARIC procedure (2.2%).

Conclusions: The ARIC is a new technique that broadens the indications for Arthroscopic shoulder surgery as a solution for recurrent dislocations associated with joint Hyperlaxity.

Introduction: Fractures of the proximal humerus account for 4–5% of all fractures. The number one cause of this type of fracture is age related osteoporosis associated with minimal trauma. Approximately 80% of these fractures are non or minimally-displaced, and can be treated conservatively with good results. However, treatment of displaced complex fractures is still controversial. The disadvantage of open procedures is the risk of damaging the blood supply to the humeral head, leading to a higher incidence of avascular necrosis.

Closed Reduction and Percutaneous Fixation (CRPF) is a minimal invasive procedure with a lower risk of damaging the blood supply. The main complication of this technique is loosening of the guide wires and displacement of the fragments requiring a second operation.

Purpose: The guide wire loosening leads us to improve the technique by adding an external fixator to stabilize the guide wires and secure fragment positioning. We report our experience of treating displaced fractures of the proximal humerus with Closed Reduction and External Fixation (CREF).

Materials and methods: Between the years 1996–2001 we operated on 37 patients for 38 complex fractures and fracture dislocations of the proximal humerus. We had 16 two part fractures, 13 three part fractures, 3 four part fractures, 5 two part fracture dislocation and 1 four part fracture dislocation according to the Neer’s classification.

The mean age was 60 years old ranging from 16–90 with a male to female ratio of 1:1. The patients were placed in a beach chair position using an image intensifier for AP and axillary views. Because the closed reduction was unsatisfactory, six patients underwent open reduction and external fixation. The remaining 32 shoulders underwent CREF.

Passive motion exercises were initiated on the first postoperative day. The external fixator was removed after four to six weeks (mean time for external fixator – 5.3 weeks). After removing the external fixator the patients began with active assisted mobilization of the shoulder and isometric strengthening exercises.

Results: The average follow up was 31.6 months (range 6–60 months). No loosening was observed upon removal of the external fixator, however the following complications were encountered: 5 patients had superficial pin tract infections, 1 patients developed an avascular necrosis of the humeral head, 1 patient had a non union of the fracture. Of the remaining patients, 13 patients had an excellent result, 15 patients had a good result and 5 patients had a fair result.

Conclusions: CREF is a minimal invasive technique for complex fractures of the proximal humerus, greatly reducing the damage to the blood supply when compared to open surgical procedures. It offers a better stabilization than CRPF, thus reducing the complication rate. The percutaneous technique causes less scaring and therefore a shorter rehabilitation program. Consequently, this procedure is recommended for complex fractures of the proximal humerus.