Aim: The common cause for recurrent instability in older patients, is the massive tear of the rotator cuff tendons. This paper presents the results of the operative treatment for the above-mentioned rare and complex lesion. 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. All cases presented with instability, pain and weakness, and in 2 cases the subluxation was obvious in every attempt to raise the arm. 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 with an attempt to close the rotator cuff tear. A complete closure was achieved in 3 cases, 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. Conclusions: The combination of recurrent anterior instability with massive rotator cuff tears presents great difþculty in treatment especially in the cases where an infection had preceded. A complete closure of the rotator cuff tear is usually very difþcult to achieve.

Aim: Chronic rotator cuff tears raise a difþcult problem for treatment. The purpose of the study is to evaluate the results of surgical treatment of 96 full thickness rotator cuff tears. Method: There were 59 males and 37 females with average age of 56 years (35–78). The dominant shoulder was involved in 70% of the cases. Most of the patients had weakness and all of them had pain during the night. The duration of symptoms was more than 4months. 22 tears were small, 38 medium, 28 large and 8 massive. All of the patients had positive arthrogram or MRI. Surgical management consisted of deltoid splitting approach, anterior Neerñs acromioplasty modiþed by Rockwood and repair of the tear. In 6 cases dislocation long head of the biceps was found and repaired. In two cases the long head of biceps was incorporated in the repair. In 5 cases full coverage of the head could not be achieved. Results: F.U. averaged six years. The results were granted according to Wolfgang scale. There were 46 excellent, 39 good, 7 fair and 4 poor. Signiþcant improvement in pain achieved in 90% of the cases and strength improved in 78%. Postoperatively three patients had drop arm sign and one had developed ectopic ossiþcation. Negative prognostic factor was the dislocation of long head of biceps in combination with irreparable tears. The quality of the repair correlated with þnal outcome. Conclusions: The results of this study conþrm the view that operative management of rotator cuff tears offers reliable results and indicated in relatively young patients. Release of coracohumeral ligament and mobilization of supraspinatus decreased the need for tendon transfer.

Aim: The detachment of superior glenoid labrum extending anterior and posterior (SLAP) is a traumatic condition which is just recently recognized as an important source of shoulder pain and dysfunction. This lesion can occur isolated or in association with other pathologic entities such as: impingement syndrome, rotator cuff ruptures and instability. The diagnosis with clinical examination, simple x-rays and MRI is difficult and it can be established only arthroscopicaly. The aim of this study is to present the technique and the results of the arthroscopic labral reattachment and also to point out the necessity of treatment especially in the coexistence with other pathologies.

Method: 7 patients with SLAP type II were arthroscopicaly operated. There were 6 males and 1 female aged from 31 to 52 years. 4 patients had an associated rotator cuff partial rupture and 2, had a Bankart lesion with anterior instability. Arthroscopy was performed under general anesthesia with the patients in the beach chair position. We used the standard posterior and anterior portals and also a third superior-anterior. We used VAPR and shaver for preparation and slight decortication of superior glenoid. With a special curved needle we passed a suture PDS NoI from the superior anterior labrum then through a Mitek GII anchor which we place after predriling at the superior glenoid. The Ethibon suture of the anchor was passed through the posterior superior labrum. We used arthroscopic knots to tie down the sutures. Finally the superior labrum is stabilized with 2 sutures in V configuration through a singular Mitek GII anchor anterior and posterior the anchor of biceps. Postoperative care depended on coexisting lesions. Most of the patients had their shoulder immobilized for 3 weeks in a sling.

Results: The average follow up was 18 months (12–22). All patients had complete resolution of the preoperative pain. 5 patients had full range of movements and no functional restriction. The remaining 2 patients had a slight restriction of movements mainly in internal rotation. All patients had normal muscle strength and all had constant score above 80.

Conclusion: Stabilization of the superior labrum with the described technique is successful and effective for type II SLAP lesion treatment. We believe that arthroscopic examination of the shoulder should be done even before an open shoulder surgery for other pathologies. Arthroscopy is the only way to detect a coexisting SLAP lesion and repair it, otherwise it may negatively influence the success of the operation.

Airn: Treatment of acromioclavicular joint dislocations depends on the type of the dislocation and the patients symptoms. We present the results of surgical treatment with transfer of the acromical end of coracoacromial ligament in the distal end of the clavicle. (The Weaver Dunn procedure). Material – Method: 32 patients with acromioclavicular dislocation type III, IV and V according Rockwood, 20 acute and 12 chronic, were treated with open reduction and stabilization of the distal end of clavicle and transfer of the coracoacromial ligament. They were 26 men and 6 women, the average age was 28 years. The indications for the operation were: deformity, pain and numbness. On 28 patients resection of the distal end of the clavicle was performed but on 4 acute dislocations the stabilization was made without osteotomy.

Surgery was performed with the patients in the beach chair position and with a horizontal skin incision above the acromioclavicular joint. The length of the coracoacromial ligament was determinant to achieved reduction. The soft tissues were double breasted above the acromioclavicular joint. After surgery the limb was placed in a sling for 15 days and then complete mobilization exercises was began. Draft weight was avoided for 3 months.

Results: The average length of follow up was 4 years. All patients had almost no pain and full range of motion. Constant score was above 80 in all cases. Full range of motion was obtained until 2 months after operation. In 3 cases the primary reduction was not fully achieved. In 3 other cases loss of the primary reduction was observed due to suture rupture. In these cases the displacement was significantly minor than pre operatively. 15 patients had developed ectopic ossification bellow the acromioclavicular joint without consequence in the shoulder motion. The resection of the distal end of the clavicle did not alter the results.

Conclusion: The operation offers low percentage of complications and quick rehabilitation. It is recommended in acute as well in chronic injuries with very good results. The good results were not varied with time during follow up. Advantage of this operation represents the no use of metals. The pull angle of the ligament might create an anterior sublaxation during reduction of the dislocation, but this does not influence the results.

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.