The presented study investigated the difference of positioning sense of the shoulder before and after surgery (capsular shift or Arthroscopic Bankart repair) for shoulder instability.

For this purpose a sample of patients with recurrent dislocations of the shoulder that underwent surgery and patients with instability before surgery volunteered to participate in a set of experiments. Their results were compared to the results obtained from a matching sample of healthy subjects.

All subjects completed all movement’s conditions that included the performance of hand movements towards memorized visual target in A-horizontal plane condition and B-Three dimensional movement condition.

The mixed design (3 groups x 3 2D levels x 3 3D levels) with repeated measures allowed the comparison among the groups in terms of final accuracy measures (Absolute and Variable Errors) and variability around mean tangential velocities and end-point paths.

The results showed that operative shoulder stabilization improves the ability to accurately position the arm on a target at the end of the movement and in addition the kinematic profile, which is disturbed before stabilization, improves as well.

These measures may be used as an objective tool to asses the success of conservative as well as operative treatment for shoulder instability.

Introduction: Fracture of the proximal humerus are challenging for diagnosis and treatment. The vast majority of these fracture associated with osteoporosis in elderly. Decision making for the treatment must include all arguments of fracture type, physical demands and rehabilitation cooperation of patients. This is particularly crucial in proximal humerus fracture. Results of surgery including hemiarthroplasty are difficult to predict and many times type of surgical treatment can be determined intra-operative or at least after closed manipulation attempt.

Material and methods: Between September 1998 to September 2000, 68 patients underwent surgery for proximal humerus fracture. Patients who underwent hemiarthroplasty were not included in this study. Diagnosis of the fracture was based on Neer classification system and was aided by CT scan. Type of surgery was made finally after closed manipulation attempt under anesthesia. Patients were consented for closed manipulation, open reduction and internal fixation or hemiarthroplasty. Data was collected retrospectively from outpatients notes. 32 males and 36 females, age 40–88 (mean: 62), underwent closed manipulation and pinning (30), ORIF included pinning and PDS suture (32) and ORIF included PDS suture only (6). Fracture type distributed as follows: 2 parts surgical neck – 9, 2 parts GT – 6, 3 parts – 29, fracture dislocations – 6, 4 parts – 12, impacted valgus fracture 6.

Four threaded pins were inserted retrograde and trimmed under the skin. Two antegrade pins were left out of the skin and banded to prevent migration to the axilla. Patients were immobilized in shoulder immobilizer for 6 weeks when pins were removed in outpatient clinic. Control X-ray was taken at 2, 4, 6, 12 weeks. If fracture was noted to be unstable, X-ray was taken every week up to 4 weeks. In case of any deterioration after 12 weeks X-ray was taken to detect signs of AVN.

Rehabilitation program commenced after clinical union with passive and assisted active for 4 weeks followed by active mobilization. Follow-up ranged from 10–34 months (mean: 22) and range of motion with X-ray description were documented.

Results: All fractures but one were united, fracture position was noted in 31 patients as normal in 46 (68%), head-shaft in extension in 8 (11.7%), varus head – 7 (10%), valgus head – 1 (1.4%), prominent GT – 4 (6%), prominent LT – 3 (4.4%), complete displacement – 2 (2.8%), dislocated – 1 (1.4%).

Mean range of motion for all groups was: Elevation – 144 (60–180), External Rotation – 54.6 (−10–80), Internal Rotation – L1 (Throchanter – T8). Statistical analysis for fracture groups showed best results for impacted valgus and greater tuberosity fracture after open reduction and worst results were noted for 4 parts fractures and fracture dislocation. Although the study was not randomized there was no significant difference between the group of closed pinning and open surgery.

Complications: Six patients had revision surgery during the early follow up due to fixation failure. In one case repinning was performed, in 2 cases closed pinning transformed to open surgery and suture of GT, in one case osteotomy and re-insertion of LT was needed, one case complete lost of fixation ended in hemiarthroplasty and one case of fracture dislocation failed to closed and open surgery and need bone block (Laterget) to prevent re-dislocation. AVN was noted in 5 cases – 2 partial and 3 complete (3% and 4.4%, respectively). Pin tract infection occurred in the 6 of prominent antegrade pins and resolved after early removal of these pins without the retrograde pins. G-H arthrosis was noted in one case after 2 years.

Conclusions: Surgical treatment of proximal humerus fracture and attempt to preserve the humeral head is alternative to conservative treatment or hemiarthroplasty from the other hand. High surgical are demanded and fixation cannot be guaranteed due to minimal bone stock for fixation. Partial loss of fixation still leave better position and reasonable functional results. Further attention is needed to the lesser tuberosity which could be seen better under fluoroscopy under anesthesia.

Introduction: Thermal shrinkage represents a major innovation in the evolving field of surgery for shoulder instability. The basic science of collagen fiber change has been studied in detailed and set the physical basis for mechanical properties change of the capsule. Animal models and clinical studies has been published for the last decade with short and mid-term results. A clinical application has proceeded basic knowledge in many respects and there is concern about the safety and efficacy of the procedure.

Materials and Methods: Between February 1999 and January 2001, 25 patients, mean age 21.5 (range 16–28) were operated (single shoulder) for radiofrequency capsular shrinkage with VAPR device. In this group 2 high performance sportsmen (basketball and judo), 4 leisure sports activities (mainly basketball), 6 combat soldiers and 13 non related to sporting activities. In 5 of these patients arthroscopic Bankart repair was performed. In one case the procedure was performed after failure of capsular shift in an extreme hyperlax multidirectional instability and this patients was excluded from the study.

Indication for surgery were: 1. Multidirectional instability with less than 3 frank dislocation. 2. Symptomatic subluxators with positive apprehension test after failed non-operative rehabilitation program. 3. High demands first dislocators sportsman with failure of non operative rehabilitation program.

The arthroscopy was performed in sitting position with posterior and anterior portals as a day surgery or overnight hospitalization. Anterior portal was used for VAPR probe first and portals were switched if needed.

All patients were immobilized in shoulder immobilizer for 6 weeks. Rehabilitation program was planed on individual basis and patients were instructed not to return to full contact sport or activities at least 6 months post operatively. Patients were checked at 2 and 6 weeks before commence rehabilitation and than at 3, 6, 24 months. Mean follow up was 17.6 months (range 6–27 m.).

Results: Operation and postoperative course was uneventful and no complications were detected. All patients had normal axillary nerve sensation and normal deltoid function. 21 of 24 (87.5%) regain pre dislocation activity between 6 to 12 months and had no dislocation or instability symptoms. Range of motion after 6 months was fully functional and comparable with the opposite side in 22 of these 23 patients. One patient had postoperative stiffness up to 12 months from operation and recover completely then. All but two followed rehabilitation instructions One of these two regains basketball activities 4 weeks postoperatively and dislocated his shoulder immediately. These patients underwent inferior capsular shift operation later on.

The second patient, a 16 years female elite judoka, commenced judo matches after 3 months and was asymptomatic with 24 months follow-up time.

Conclusion: In selective indications with multidirectional instability, individual rehabilitation program and good cooperation success rate of 91% could be achieved among mixed activities group. We think that this procedure is a good alternative in selected cases. Longer follow-up for selected groups is still needed.