Aims

Both anatomical and reverse total shoulder arthroplasty (aTSA and rTSA) provide functional improvements. A reported benefit of aTSA is better range of motion (ROM). However, it is not clear which procedure provides better outcomes in patients with limited foward elevation (FE). The aim of this study was to compare the outcome of aTSA and rTSA in patients with glenohumeral osteoarthritis (OA), an intact rotator cuff, and limited FE.

The April 2023 Shoulder & Elbow Roundup³⁶⁰ looks at: Arthroscopic Bankart repair in athletes: in it for the long run?; Functional outcomes and the Wrightington classification of elbow fracture-dislocations; Hemiarthroplasty or ORIF intra-articular distal humerus fractures in older patients; Return to sport after total shoulder arthroplasty and hemiarthroplasty; Readmissions after shoulder arthroplasty; Arthroscopic Bankart repair in the longer term; Bankart repair with(out) remplissage or the Latarjet procedure? A systematic review and meta-analysis; Regaining motion among patients with shoulder pathology: are all exercises equal?

Aims

Open reduction and plate fixation (ORPF) for displaced proximal humerus fractures can achieve reliably good long-term outcomes. However, a minority of patients have persistent pain and stiffness after surgery and may benefit from open arthrolysis, subacromial decompression, and removal of metalwork (ADROM). The long-term results of ADROM remain unknown; we aimed to assess outcomes of patients undergoing this procedure for stiffness following ORPF, and assess predictors of poor outcome.

Subacromial bursa fibrosis are linked to rotator cuff lesion with shoulder stiffness; however, the mechanism underlying this shoulder disorder remain elusive. MicroRNA-29s (miR-29s) are emerging fibrosis inhibitor targeting fibrogenic matrices during tissue fibrosis. This study is aimed to investigate clinical relevance and function of miR-29 signalling to subacromial bursa homeostasis in shoulder stiffness. Subacromial bursa in patients with rotator cuff lesion with or without shoulder stiffness who required open acromioplasty were harvested for assessing fibrosis histopathology using Manson's trichrome staining. Expressions of proinflammatory cytokines, fibrotic matrices, and miR-29s were quantified using RT-PCR and in situ hybridization. Range of motion and pain scores of the stiffness group were higher than those of non-stiffness group. Upregulated proinflammatory cytokines (IL-1β, IL-6, and TNF-α) and fibrotic matrices (collagen 1α1, 3α1, and 4α1) but decreased miR-29a and b expression existed in the stiffness group. Affected tissues exhibited severe fibrotic matrix accumulation, synovial hyperangiogenesis, hyperplasia, and strong miR-29a transcripts. In vitro, IL-1β rather than IL-6 and TNF-α decreased miR-29a expression of subacromial bursa fibroblasts. miR-29a knockdown escalated fibrotic matrix expression, whereas forced miR-29a expression alleviated the IL-1β-induced fibrotic matrix expression. Of interest, miR-29a transgenic mice displayed moderate responses to supraspinatus and infraspinatus tenotomy-induce fibrosis and gait irregularity of affected shoulders. Weak miR-29 signalling causes excessive fibrosis and remodelling in subacromial bursa and ultimately increases the prevalence of shoulder stiffness. This study reveals a new mechanistic underlying shoulder stiffness and highlights that sustained miR-29a potentially ameliorates the severity and function of stiff shoulder

The standard approach is through the deltopectoral interval. Among patients with prior incisions, one makes every effort to either utilise the old incision or to incorporate it into a longer incision that will allow one to approach the deltopectoral interval and retract the deltoid laterally. The deltopectoral interval is most easily developed just distal to the clavicle, where there is a natural infraclavicular triangle of fat that separates the deltoid and pectoralis major muscles even in very scarred or stiff shoulders. Typically, the deltoid is retracted laterally leaving the cephalic vein on the medial aspect of the exposure. The anterior border of the deltoid is mobilised from the clavicle to its insertion on the humerus. The anterior portion of the deltoid insertion together with the more distal periosteum of the humerus may be elevated slightly. The next step is to identify the plane between the conjoined tendon group and the subscapularis muscle. Dissection in this area must be done very carefully due to the close proximity of the neurovascular group, the axillary nerve, and the musculocutaneous nerve. Scar is then released from around the base of the coracoid. The subacromial space is freed of scar and the shoulder is examined for range of motion. Particularly among patients with prior rotator cuff surgery, there may be severe scarring in the subacromial space. Internal rotation of the arm with dissection between the remaining rotator cuff and deltoid is critical to develop this plane. If external rotation is less than 30 degrees, one can consider incising the subscapularis off bone rather than through its tendinous substance. For every 1 cm that the subscapularis is advanced medially, one gains approximately 20 to 30 degrees of external rotation. The rotator interval between the subscapularis and supraspinatus is then incised. This release is then continued inferiorly to incise the inferior shoulder capsule from the neck of the humerus. This is performed by proceeding from anterior to posterior with progressive external rotation of the humerus staying directly on the bone with electrocautery and great care to protect the axillary nerve. The key for glenoid exposure as well as improvement in motion is deltoid mobilization, a large inferior capsular release, aggressive humeral head cut and osteophyte removal

This article presents a unified clinical theory that links established facts about the physiology of bone and homeostasis, with those involved in the healing of fractures and the development of nonunion. The key to this theory is the concept that the tissue that forms in and around a fracture should be considered a specific functional entity. This ‘bone-healing unit’ produces a physiological response to its biological and mechanical environment, which leads to the normal healing of bone. This tissue responds to mechanical forces and functions according to Wolff’s law, Perren’s strain theory and Frost’s concept of the “mechanostat”. In response to the local mechanical environment, the bone-healing unit normally changes with time, producing different tissues that can tolerate various levels of strain. The normal result is the formation of bone that bridges the fracture – healing by callus. Nonunion occurs when the bone-healing unit fails either due to mechanical or biological problems or a combination of both. In clinical practice, the majority of nonunions are due to mechanical problems with instability, resulting in too much strain at the fracture site. In most nonunions, there is an intact bone-healing unit. We suggest that this maintains its biological potential to heal, but fails to function due to the mechanical conditions. The theory predicts the healing pattern of multifragmentary fractures and the observed morphological characteristics of different nonunions. It suggests that the majority of nonunions will heal if the correct mechanical environment is produced by surgery, without the need for biological adjuncts such as autologous bone graft.

Cite this article: Bone Joint J 2016;98-B:884–91.

Peri-prosthetic fractures around implants in the proximal humerus can present substantial challenges. Most individuals who undergo upper limb arthroplasty tend to be osteopenic to begin with, and the anatomy of the proximal humerus does not provide an excess of bone to work with. Therefore, peri-prosthetic fractures pose difficulties to rotator cuff function and implant stability. There are multiple classification systems, but series are small and the classification does not always lead to treatment algorithms. Risk factors for humeral fractures after shoulder arthroplasty include endosteal notching, cortical perforation, varus malalignment, stem perforation, ipsilateral shoulder and elbow arthroplasties, and loose stems. Many of these risk factors are directly related to technical errors at the time of surgery. Poor exposure can lead to aberrant starting point and errors in reaming. Oversized prostheses can lead to cortical perforation or even stem perforation. Proper positioning of the patient on the table and surgical releases help avoid these technical errors. Peri-prosthetic fractures should be carefully evaluated radiographically for stability. Two important considerations: 1. Is the implant stable? 2. Is the fracture stable? Generally, if the implant is unstable, the implant must be revised. In the setting of a stable implant, many humeral fractures can be treated nonoperatively. Many fractures at or below the level of the tip of the implant can be treated as typical humeral fractures. Options for fixation include plates with cables or long stem prostheses which bypass the fracture. Displaced tuberosity fractures are treated with suture or wire fixation. Risk factors for a poor outcome include increased time to union, skin breakdown, and stiff shoulder

The December 2013 Shoulder & Elbow Roundup³⁶⁰ looks at: Platelet-rich plasma; Arthroscopic treatment of sternoclavicular joint osteoarthritis; Synchronous arthrolysis and cuff repair; Arthroscopic arthrolysis; Regional blockade in the beach chair; Recurrent instability; Avoiding iatrogenic nerve injury in elbow arthroscopy; and Complex reconstruction of total elbow revisions

BACKGROUND. Reverse total shoulder arthroplasty (RTSA) provides an alternative to standard total shoulder arthroplasty in the treatment of selected complex shoulder problems including failed shoulder replacements. The purpose of this report is to present outcome of RTSA using Comprehensive Reverse System (CRS) as either primary or revision treatment choice. PATIENTS AND MATERIALS. Between September 2010 and April 2012, 54 patients (36 females, 18 males) with the mean age of 68.4 (±10) underwent RTSA-CRS. In 27 patients RTSA-CRS was performed as a revision due to failed previous arthroplasty. Primary underlying conditions included AVN (2), massive irreparable rotator cuff tear (2), primary osteoarthritis (7), post-traumatic osteoarthritis (2), rheumatoid arthritis (6), and rotator cuff arthropathy (8). It was not possible to complete the operation in 6 patients (4 revisions group 2 AVN cases) due to substantial glenoid erosion. Preoperative CT scan was performed in 50% of patients to assess the bony stock of the glenoid. In some patients ultrasound and MRI were performed to acquire additional information. A total of 46 patients were followed-up by means of antroposterior and axial plain X-rays, pain and satisfaction level (VAS/0–10), stiffness, Constant Score, Oxford Shoulder Score, SF-12 (Physical and mental Subscales), and range of movement for a mean duration of 6.5 months (±4.2). RESULTS. The table presents the pre- and postoperative outcome variables for both primary and revision RTSA-CRS groups. The majority of outcome measures indicated a considerable improvement in both groups during the short term follow-up. Significant correlations were noted in-between some key outcome variables. However; due to the short period of follow-up and continuity of collecting data, we intend to produce a more realistic picture of the results s and outcome of the RTSA-CRS in coming years. COMPLICATIONS. There was no vascular complication. Disassociation of glenosphere from the base-plate happened in one patient 8 weeks post-op due to technical mistake, this was repaired later with a satisfactory outcome. One case had enormous hematoma formation 72 hours post-op due to anticoagulants administration leading to second stage evacuation and increased stiffness of shoulder. One patient sustained deltoid partial rupture due to recurrent falls and managed by conservatively. Another patient sustained a type C periprosthetic fracture and was later revised to custom-made stem prosthesis. CONCLUSION. The results of this short-term report indicate a satisfactory and acceptable outcome for RTSA-CRS as reflected in the assessment tools in both primary and revision cases, however with superior results in the primary group. Long-term follow-up is essential to have a more rational assessment of the clinical outcome as well as associated complications

Purpose. Electrothermal arthroscopic capsulorrhaphy (ETAC) was a technology introduced for orthopaedic surgery without good scientific clinical evidence supporting its use. This multicentre randomized clinical trial provides the scientific clinical evidence comparing ETAC to Open Inferior Capsular Shift (ICS), by measuring disease-specific quality of life at 2-years post-operatively, in patients with shoulder instability due to capsular redundancy. Method. Fifty-four subjects (37 females and 17 males; mean age 23.3 years (SD = 6.9; 15–44 years) with multidirectional instability (MDI) or multidirectional laxity with antero-inferior instability (MDL-AII) were randomized intra-operatively to ETAC (n = 28) or Open ICS (n = 26) using concealed envelopes, computer-generated, variable block randomization with stratification by surgeon and type of instability. Outcomes were measured at baseline, 3 and 6 months, 1 and 2 years. The Western Ontario Shoulder Instability (WOSI) Index is a quality of life outcome measure that is scored on a visual analog scale from 0 to 100, where a higher score represents better quality of life. Two functional assessments included the American Shoulder and Elbow Society (ASES) Score and the Constant Score. Post-operative recurrent instability and surgical time were also measured. Analyses included ANOVA of repeated measures with Bonferroni adjustments for multiple comparisons, Chi-square and independent t-tests (p < 0.05). Results. At 2-years post-operatively, mean WOSI scores were not statistically different between the groups (p=0.61): ETAC = 74 (SD = 24; 95% CI = 64 84); Open ICS = 77 (SD = 20; 95% CI = 68 86). There was no difference between groups for mean ASES scores (p=0.34): ETAC = 81 (SD = 20; 95% CI = 73 90); Open ICS = 87 (SD = 18; 95% CI = 79 95), mean Constant scores (p = 0.35): ETAC = 83 (SD = 7; 95% CI = 80 86); Open ICS = 85 (SD = 11; 95% CI = 80 − 90), and recurrent instability (p = 0.41): ETAC = 2; Open ICS = 4. Mean surgical time was 23 minutes for ETAC and 59 minutes for Open ICS (p = 0.00). Three subjects (1 ETAC, 2 Open ICS) had stiff shoulders; however, no major complications were observed. Conclusion. Patient outcomes improved from baseline to all follow-up periods. There was no difference between the ETAC and Open ICS groups in quality of life, functional outcomes, and recurrent instability at 2 years post-operatively

The outcome of an anatomical shoulder replacement depends on an intact rotator cuff. In 1981 Grammont designed a novel large-head reverse shoulder replacement for patients with cuff deficiency. Such has been the success of this replacement that it has led to a rapid expansion of the indications. We performed a systematic review of the literature to evaluate the functional outcome of each indication for the reverse shoulder replacement. Secondary outcome measures of range of movement, pain scores and complication rates are also presented.

Purpose of the study: A stiff shoulder in internal rotation is a classical complication of obstetrical injury to the brachial plexus. The condition generally associates glenohumeral dysplasia. In 2003, Pearl proposed arthroscopic release of the shoulder, with or without latissimus dorsi transfer as an alternative to an open procedure. We report a series of 13 patients who underwent this procedure. Material and method: From 2004 to 2007, 13 children aged 1 to 11 years (range 3.5) underwent surgery. The procedure was an arthroscopic tenotomy of the intra-articular portion of the subscapularis associated with release of the anterior capsuloligament structures without tendon transfer. A thoracobrachial resin cast maintained the shoulder in maximal external rotation for six weeks. The functional outcome was assessed on the basis of the passive and active range of motion and the Mallet score. Pre and postoperative MRI was used to assess glenohumeral dysplasia and check its correction. Results: Mean follow-up was 23 months (range 5–40). There were no complications. Mean immediate postoperative gain was 53 (range 30–70) for external rotation (RE1). On average, passive RE1 improved from −5.4 to +57.7. Eight patients (61%) recovered active external rotation (57.5 on average). Mean active abduction improved from 45.8 to 56.5. Active internal rotation declined in 38% of the shoulders. The Mallet score improved in 69% of the shoulders. The best results were observed for children aged less than 4 years. There was one failure, related to major dyplasia which could not be reduced with an open procedure. Correction of the glenohumeral dysplasia was noted on 7 of the 9 MRI performed and the retroversion angle of the glenoid improved from −28.2 to −25.6, on average. Discussion: Open techniques are aggressive and only variably effective. A majority of our patients (8/13) achieved improved passive and active RE1 solely with the arthroscopic procedure. Correction of the glenohumeral dysplasia with growth appears to correspond to the clinical improvement but further follow-up is needed. Conclusion: Our results are comparable with those reported by Pearl. This is a minimally invasive easy-to-perform technique. For children aged less than 4 years, systematic tendon transfer does not appear to be necessary

There are many types of treatment used to manage the frozen shoulder, but there is no consensus on how best to manage patients with this painful and debilitating condition. We conducted a review of the evidence of the effectiveness of interventions used to manage primary frozen shoulder using the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Physiotherapy Evidence Database, MEDLINE and EMBASE without language or date restrictions up to April 2009. Two authors independently applied selection criteria and assessed the quality of systematic reviews using the Assessment of Multiple Systematic Reviews (AMSTAR) tool. Data were synthesised narratively, with emphasis placed on assessing the quality of evidence.

In total, 758 titles and abstracts were identified and screened, which resulted in the inclusion of 11 systematic reviews. Although these met most of the AMSTAR quality criteria, there was insufficient evidence to draw firm conclusions about the effectiveness of treatments commonly used to manage a frozen shoulder. This was mostly due to poor methodological quality and small sample size in primary studies included in the reviews. We found no reviews evaluating surgical interventions.

More rigorous randomised trials are needed to evaluate the treatments used for frozen shoulder.

We retrospectively reviewed 11 consecutive patients with an infected reverse shoulder prosthesis. Patients were assessed clinically and radiologically, and standard laboratory tests were carried out. Peroperative samples showed Propionbacterium acnes in seven, coagulase-negative Staphylococcus in five, methicillin-resistant staphylococcus aureus in one and Escherichia coli in one. Two multibacterial and nine monobacterial infections were seen. Post-operatively, patients were treated with intravenous cefazolin for at least three days and in all antibiotic therapy was given for at least three months. Severe pain (3 of 11) or severe limitation of function (3 of 11) are not necessarily seen. A fistula was present in eight, but function was not affected. All but one patient were considered free of infection after one-stage revision at a median follow-up of 24 months, and without antibiotic treatment for a minimum of six months. One patient had a persistent infection despite a second staged revision, but is now free of infection with a spacer. Complications included posterior dislocation in one, haematoma in one and a clavicular fracture in one. At the most recent follow-up the median post-operative Constant-Murley score was 55, 6% adjusted for age, gender and dominance.

A one-stage revision arthroplasty reduces the cost and duration of treatment. It is reliable in eradicating infection and good functional outcomes can be achieved.

We treated 47 patients with a mean age of 57 years (22 to 88) who had a proximal humeral fracture in which there was a severe varus deformity, using a standard operative protocol of anatomical reduction, fixation with a locking plate and supplementation by structural allografts in unstable fractures. The functional and radiological outcomes were reviewed. At two years after operation the median Constant score was 86 points and the median Disabilities of the Arm, Shoulder and Hand score 17 points. Seven of the patients underwent further surgery, two for failure of fixation, three for dysfunction of the rotator cuff, and two for shoulder stiffness. The two cases of failure of fixation were attributable to violation of the operative protocol. In the 46 patients who retained their humeral head, all the fractures healed within the first year, with no sign of collapse or narrowing of the joint space. Longer follow-up will be required to confirm whether these initially satisfactory results are maintained

This study examined the role of vitamin D as a factor accounting for fatty degeneration and muscle function in the rotator cuff. There were 366 patients with disorders of the shoulder. A total of 228 patients had a full-thickness tear (group 1) and 138 patients had no tear (group 2). All underwent magnetic resonance arthrography and an isokinetic muscle performance test. The serum concentrations of vitamin D (25(OH)D₃) were measured.

In general, a lower serum level of vitamin D was related to higher fatty degeneration in the muscles of the cuff. Spearman’s correlation coefficients were 0.173 (p = 0.001), −0.181 (p = 0.001), and −0.117 (p = 0.026) for supraspinatus, infraspinatus and subscapularis, respectively. In group 1, multivariate linear regression analysis revealed that the serum level of vitamin D was an independent variable for fatty degeneration of the supraspinatus and infraspinatus.

The serum vitamin D level has a significant negative correlation with the fatty degeneration of the cuff muscle and a positive correlation with isokinetic muscle torque.

Introduction: We have described nine clinical features to aid the clinical diagnosis of frozen shoulder. These include symptoms of pain and pins and needles radiating down the arm to the hand, feeling of lameness in the arm, tenderness over medial border of scapula, tenderness over the rotator interval, tenderness over the brachial plexus in the supraclavicular fossa, reduction of pain with passive abduction and forward flexion of the shoulder, asymmetry of the arm position at rest with an increase in elbow to waist distance and apparent winging of the scapula. Methods: We prospectively evaluate the sensitivity, specificity, predictive values and diagnostic accuracy of each clinical test in a consecutive series of 110 patients with idiopathic frozen shoulder. An equal number of patients with shoulder pathology other than frozen shoulder were used as controls matched to the study group for sex and age. We also discuss the probable causes and clinical relevance of these features. Results The most sensitive test was pain over the brachial p:lexus in the supraclavicular fossa (0.98) and the most specific test was apparent winging of the scapula (0.84). The single most accurate diagnostic test was relief of symptoms with abduction and flexion (85%). The incidence of positive accessory features was positively correlated with the visual analogue pain score (p< 0.0001, Spearman rank correlation coefficient) and negatively correlated with the length of duration of symptoms (p< 0.0001, Spearman rank correlation coefficient). Conclusion: These accessory tests are intended to supplement the original description made by Codman. They are most useful in the acute painful stage of the disease when symptoms have been present for less than 6 months. In the diagnosis of a patient with a painful stiff shoulder, if six of the tests with the highest correlation are positive, the diagnosis of frozen shoulder is likely

Aim: Distal clavicle excision (DCE) is the treatment of choice for A–C joint arthritis.The overall complication rate for open, isolated DCE is higher than previously reported. Distal clavicle excision (DCE) is the treatment of choice for A–C joint arthritis. Isolated DCE., as an open procedure has been considered to be a safe procedure, and it is the gold standard for comparison for arthroscopic distal clavicle excision. This study attempts to define the incidence of complications after isolated, open DCE. Materials & Methods: This prospective, non-randomized study included 702 patients who underwent arthroscopic surgery of the shoulder. 580 patients were included in the control group. All patients underwent a thorough preoperative evaluation and final diagnosis was given after arthroscopic evaluation. There were 42 patients with isolated A–C joint arthritis, which underwent an open D.C.E. Mean follow up was 16.7 months. There were 30 men and 12 women with a mean age of 42,6 (± 12,5) years. The dominant arm was involved in 30 patients. 16 patients participated in sports while 9 of them were competitive athletes. 38 (90%) patients had symptomatic arthritis, 2(5%) cases were of osteolysis and separation arthritis each. Results: 22 (52%) of the 42 patients developed complications. There were 2 deep infections and 2 stitches abscesses. 4 (9.5%) patients developed a stiff shoulder and 1(2.4%) patient developed heterotopic ossification. 16 (38%) patients had tenderness in A–C joint for a period over 3 months while 6 (14%) patients had local tenderness at the last follow up. Painful scar was present in 2 (5%) patients over 3 months. Conclusions: The overall complication rate for open, isolated DCE is higher than previously reported. Patients should be advised of these possibilities and this study serves as a baseline for comparison for future study