Aims of the study: To assess the results of one-stage revision of infected reverse total shoulder arthroplasty as a new treatment for this major surgical complication.

Materials: 11 consecutive patients with infected reverse shoulder prosthesis (DePuy International Ltd, Leeds, UK) were treated with a direct-exchange reverse total shoulder arthroplasty between March 2005 and June 2007. These patients were retrospectively followed.

Methods: Via a superior extended deltoideopectoral, clavicular osteotomy approach, according to Redfern-Wallace, a removal of the prosthesis is performed. Multiple operative specimens (4 to 8) are taken and cultured. A thorough synovectomy is performed before implanting a new reverse total shoulder arthroplasty (7 Delta^® 3.2 tsp and 4 DeltaXtend^® tsp). A gentamycine (Duracol^®) impregnated membrane is interpositioned between baseplate and glenosphere. Immediate postoperative passive and active mobilisation is permitted if no pain is present.

Results: Clinical symptoms are seldom severe pain (3) or severe limitation of function (3). A fistula is mainly present (8) without alterating the function. No prosthetic loosening was present at the humeral and glenoid site confirming the absence of radiological infectious signs. All but one patient are considered free of infection at mean follow up of 24 months (12m – 36m) and without antibiotic treatment for minimum 6 months. In only 1 patient the infection persisted necessitating a two-stage revision, unfortunately without definitive cure. Only three early complications are seen (< 2 months: posterior dislocation, postoperative haematoma and clavicle fracture). The mean postoperative Constant-Murley score was 52 (14–81) at latest follow up.

Peroperative samples identified Propionbacterium species (5), Coagulase-negative staphylococci (4), MRSA (1) and with E.Coli (1) infection. Monobacterial infection was seen in 6 shoulders, multibacterial in 2 shoulders and in 2 shoulders cultures were negative.

Discussion: This cohort of patients has a different syndrome than the known infected anatomical prosthesis. This pathology seems to be rarely associated with severe pain (3) or limitation of function (3). Draining fistulas without alterating the function of the shoulder [CS: mean 43 (3–63)] are more frequently present making a preoperative diagnosis easier and more certain.

Recurrence rate of infection is comparable to the classical two-stage revision. Preoperative stiff and painful shoulders seems to have a bad prognosis despite definite cure of the infection. Supple shoulders (mainly associated with a fistula) can be treated with a good functional result.

Conclusion: One-stage revision arthroplasty is an attractive alternative treatment for infected reverse total shoulder arthroplasty.

Study design: Retrospective study of 34 patients with a massive rotator cuff tear, who were treated with an arthroscopic tuberoplasty, debridement of the degenerate cuff and biceps tenotomy.

Objectives: To evaluate the clinical outcome of a reversed decompression at the medium term follow up.

Summary of background data: Rotator cuff repair can become impossible for massive tears in the elderly. If conservative management fails, a reverse total shoulder arthroplasty (RSA) is commonly used. However, Fenlin described in 2002 a tuberoplasty for this pathology and reported good to excellent results. This procedure appears to be well tolerated as it is arthroscopic, not time consuming and not depending on intensive physiotherapy. In case of failure, a primary RSA is still possible.

Methods: 36 patients treated with a tuberoplasty between February 2002 and September 2006 were identified.

One patient deceased, one patient developed Alzheimer dementia, leaving 34 patients available for follow-up. They completed the SF-36 questionnaire and the Simple shoulder test. They were clinically reviewed and scored with the Constant-Murley score. All 34 had complete radiographic work-up (x-ray; ultrasound) preoperatively and at final follow up.

Results: Median age at operation was 71 years (range: 52,5 – 82,16). Mean follow-up was 3,1 years (SD: +/− 0,75).

Mean operating time was 35 minutes (SD: +/− 12.33). There were no surgical complications. Postoperatively, there was an uneventful recovery in all patients.

At final follow-up, two patients were revised to a RSA. One patient was revised after 9 months because of continuous pain and loss of function. The second patient developed a complete osteonecrosis and was revised after one year.

The 32 remaining patients had a preoperative Constant-Murley score adjusted for age and gender of 34,8. This improved to an average of 84 at final follow up.

The simple shoulder test improved from an average of 1,8 to 8,4.

The average decrease of subacromial space was 2,34 mm and the loss of glenohumeral joint space was 0,57. Finally, the preoperative grade of arthrosis was 0,46 compared to a postoperative average of 1,1.

At final follow-up, 85% (27/32) were either satisfied or very satisfied with the result. 12,5% (4/32) appreciated the result as only fair. 2,5% (1/32) was dissatisfied, but didn’t consider revision surgery.

Conclusion: We conclude that a tuberoplasty with rotator cuff debridement and biceps tenotomy is a reliable treatment for massive rotator cuff tears in the elderly at medium follow up. In case of failure, revision to RSA is still a valuable option.

Over 40 months, 264 arthroscopic rotator cuff repairs were assessed prospectively. Preoperatively all patients were assessed using a modified Constant score and Visual Analogue Pain Scale (VAPS). The mean age at surgery was 59 years (19 to 83). In 151 cases (62%) the shoulders were on the dominant side. All patients underwent postoperative ultrasonography to assess cuff integrity at three weeks. Twenty-two patients were lost to follow-up. Of the rest, 210 were clinically reviewed and Constant scores produced. The remaining 32 were assessed using the VAPS and a subjective satisfaction questionnaire.

The Constant score improved by a mean of 29.6, with 166 patients (69%) reporting complete resolution of pain. The subjective outcome was rated excellent by 162 patients, good by 55, moderate by 20 and poor by five. There were 13 retears, 11 of which were identified on the three-week ultrasound. When four of these were revised, two required subscapularis repair. Importantly, five patients with retears had excellent subjective outcome. Complications were five superficial infections, 13 cases of transient neuritis following interscalene nerve blocks, four cases of bursitis, which required debridement and suture removal, and two anchor pull-outs. The overall reoperation rate was 4%.

Arthroscopic rotator cuff repair offers excellent objective and subjective outcomes, particularly pain relief. Ultrasonography at three weeks is a good indicator of whether or not a repair has taken.

The proximity of neural structures to the coracoclavicular ligaments limits the amount of coracoid process that can be harvested. The purpose of this study of 100 dry human scapulae was to define the anatomic limitations.

We found the mean measurement of the horizontal arm of the coracoid process anterior to the conoid tubercle was 21.5 mm (SD 0.9 mm). In 10% of the scapulae, it was larger than 30 mm. In 66%, the posterior aspect of the conoid fused with the vertical ramus and the lateral lip of the suprascapular notch.

This amount of coracoid appears to be large enough to expand the glenoid vault, and to hold two AO small fragment screws. It can be safely harvested if the conoid ligament is respected. Partial sacrifice of the trapezoid ligament is unavoidable, but does not compromise coracoclavicular stability. If the coracoid osteotomy is extended medial to the conoid tubercle it encroaches on the vertical ramus of the coracoid and can damage the suprascapular nerve. Posterior advancement of the osteotomy can extend onto the anterosuperior glenoid.

We evaluated the clinical outcome of arthroscopic labroplasty in 56 patients treated for shoulder instability owing to ligamentous laxity.

In our technique, the antero-inferior labral capsular complex is detached and mobilised from the glenoid. It is advanced superiorly and plicated to create a new labrum, retensioning the capsule and decreasing the articular volume. Usually, a rotator interval plication is also added. Postoperatively, patients wear an adduction sling for three weeks, but movement is permitted within pain limits.

The mean time to follow-up, when patients were clinically reviewed and assessed on the Walch-Du Play score, was 26 months (12 to 74). No intra-operative complications or nerve injuries were encountered. There was a single failure with frank redislocation. The mean Walch-Du Play score was 88/100 (10 to 100).

Redundant capsule and a hypoplastic labrum are common in unstable shoulders owing to ligamentous laxity. The labroplasty creates a ‘bumper’ and addresses the excess of capsule. In our short-term experience, this arthroscopic technique is superior to the open capsular shift.

Between 1996 and 2001 we used a modification of the Latarjet procedure to treat 70 patients with bony insufficiency of the glenoid. Our modification involves detaching a long piece of coracoid and rotating it to match its concave inferior surface with the surface of the glenoid. The coracoid graft is placed extra-articularly and the capsule repaired with bone anchors to the edge of the glenoid.

Postoperatively no sling is applied and rehabilitation is started early.

At a mean of 24 months (9 to 72) patients were clinically reviewed and assessed on the Walch-Du Play score. The results were excellent in 68%, moderate in 6% and poor in 1%. There were no redislocations.

The results were most satisfactory in this group of patients, most of whom participated in contact sports, where soft tissue procedures (e.g., open and arthroscopic Bankarts) carry unacceptable failure rates.

Purpose: To audit the improvement in function gained in patients with cuff tear arthropathy (CTA) using the reversed geometry delta 3 prosthesis and to balance this against operative and postoperative complications encountered.

Method: 20 consecutive patients with CTA were assessed using the ASES and Constant scores pre and postoperatively.

Results: All patients reported a marked improvement in post-operative pain relief. Average elevation increased from 49° to 102°. Function improved significantly. On the downside this is a technically difficult procedure in a group of patients whose average age was 81 (73–91) but whose biological age was higher. Technical difficulties arise from access to the glenoid, in particular to the inferior margin of the glenoid through a deltoid splitting approach. For this reason the surgical approach was changed to an extended deltopectoral approach with a large inferior capsular release after looping the axillary nerve. There was one death (not related to surgery), one acromial fracture, 2 glenoid fractures, 3 postoperative anaemias requiring transfusion, one postoperative hyponatraemia, one myocardial infarct and one pneumonia. These are severe complications for octogenarians to endure.

Conclusions: This is a technically demanding procedure with a heavy burden of complications for the surgeon and octogenarian patient to endure. However results in terms of postoperative pain relief and improvement in function have proved worthwhile to 19 of 20 patients.