Aim: The common anatomic pathology responsible for the recurrent dislocation of the shoulder is in younger patients a trauma causes the Bankart lesion. Contrary to that, the common cause for recurrent instability in older patients, which is far more rare, is the massive tear of the rotator cuff tendons. During that the shoulder loose the of the posterior-upper stabilizing element (posterior mechanism according to Neer), and present a secondary anterior-inferior recurrent instability. This paper presents the results of the operative treatment for the above-mentioned rare and complex lesion.

Material – Method: Seven (7) patients, three (3) male and four (4) female with a mean age of 71 years developed recurrent shoulder instability as a result of trauma or preceding infection, which destroyed the rotator cuff. The initial injury was associated with dislocation in 2 cases and without dislocation in 3. The other 2 had a prior infection of the glenohumeral joint, which was treated conservatively. The patients who suffered injury were initially treated with a sling for 2 to 4 weeks. All cases presented with instability, pain and weakness, and in 2 cases the subluxation was obvious in every attempt to raise the arm. The radiological findings consisted of subacromial space narrowing, sclerosis and spur formation of the inferior part of the acromion and diffuse osteoporosis. All of the patients had tears in at least two tendons of the rotator cuff. The cases were treated operatively with a combination of the Boytchev anterior stabilization procedure (osteotomy of the coracoid process, transfer of the conjoined tendon under the subscapularis tendon and repositioning of the coracoid process) with an attempt to close the rotator cuff tear. A complete closure was achieved in 3 cases (in one the long head of the biceps was used), and a partial closure in 2. In the remaining 2 cases the closure of the tear was impossible. All of the patients postoperatively underwent an early mobilization regime.

Results: The mean follow-up was 30 months. Stabilization of the shoulder was achieved in 6 cases. Constant score varied from 50 to 85. One patient had a recurrent of the subluxation. All of the patients presented marked improvement in pain and in muscle strength. Two (2) of them developed almost full range of motion and satisfactory muscle strength. Four (4) patients presented decreased range of motion and muscle strength 50% of the unaffected arm, while one patient developed inability to raise his arm above 70 degrees. Five cases out of seven showed a satisfactory response to daily life activities.

Conclusions: The combination of recurrent anterior instability with massive rotator cuff tears presents great difficulty in treatment especially in the cases where an infection had preceded. A complete closure of the rotator cuff tear is usually very difficult to achieve, while the treatment of the instability alone leads to dubious results as far as pain and range of motion is concerned. For the management of the above complex lesion the existing literature is rather poor, and the combination of the Boytchev procedure with an repair of the rotator cuff tear, yielded satisfactory results mainly in regard to pain control, and secondly in achieving a good postoperative range of motion.

Aim: Displaced intrarticular fractures and fracture-dislocations of the proximal humerus usually need operative treatment. The results of shoulder hemiartroplasty for the treatment of neglected fractures and fracture-dislocations are presented.

Material – Method: 9 shoulder hemiartroplasties with modular head was used for the treatment of 5 neglected comminuted fractures and 4 fracture-dislocations of the proximal humerus. They were 5 females and 4 males with a mean age of 58 years, which were followed-up for a mean period of 4 years. The time between the injury and the operation varied from 2 to 8 months. The main indications was pain, loss of shoulder movement in relatively young patients. The tuberosities were found and extensively mobilized. The prosthesis was inserted with cement and the tuberosities were reattached to the shaft.

Results: Main follow up was 4 years (2–8). The results were assessed according the modified UCLA score and were found excellent in 2, satisfactory in 4 and poor in z cases. Pain has improved in 7 cases and the mean postoperative elevation was 90? (20?–130?). External and internal rotation was significally improved. 5 patients presented satisfactory muscle strength and were able to perform satisfyingly the daily activities. Constant score rated from 50 to 80.

The presence of a dislocation did not affect the final outcome. On the contrary the displacement of the tuberosities was decisive, and it was combined with greater scaring of the soft tissues and greater loss of motion. One patient developed transient palsy of the axillary nerve and another aseptic loosening of the prosthesis 7 years postoperatively.

Conclusions: The success of the hemiartroplasty is based on the proper patient selection, the good operative technique and the meticulous postoperative rehabilitation. The retroversion, the height of the prosthesis and the correct balance of the soft tissues are of critical importance in the achievement of a good postoperative result. The tissue scaring, the tuberosities displacement and the rotator cuff lesions create such conditions that place these patients in the limited goal group, as introduced by Neer. The results of this group are considerably inferior to those treated soon after the injury. For this reason if indicated the prosthesis should be used at the first stage and not after the failure of the conservative treatment.