Aims. The current evidence comparing the two most common approaches for reverse total shoulder arthroplasty (rTSA), the deltopectoral and anterosuperior approach, is limited. This study aims to compare the rate of loosening, instability, and implant survival between the two approaches for rTSA using data from the Dutch National Arthroplasty Registry with a minimum follow-up of five years. Methods. All patients in the registry who underwent a primary rTSA between January 2014 and December 2016 using an anterosuperior or deltopectoral approach were included, with a minimum follow-up of five years. Cox and logistic regression models were used to assess the association between the approach and the implant survival, instability, and glenoid loosening, independent of confounders. Results. In total, 3,902 rTSAs were included. A deltopectoral approach was used in 54% (2,099/3,902) and an anterosuperior approach in 46% (1,803/3,902). Overall, the mean age in the cohort was 75 years (50 to 96) and the most common indication for rTSA was cuff tear arthropathy (35%; n = 1,375), followed by osteoarthritis (29%; n = 1,126), acute fracture (13%; n = 517), post-traumatic sequelae (10%; n = 398), and an irreparable cuff rupture (5%; n = 199). The two high-volume centres performed the anterosuperior approach more often compared to the medium- and low-volume centres (p < 0.001). Of the 3,902 rTSAs, 187 were revised (5%), resulting in a five-year survival of 95.4% (95% confidence interval 94.7 to 96.0; 3,137 at risk). The most common reason for revision was a periprosthetic joint infection (35%; n = 65), followed by instability (25%; n = 46) and loosening (25%; n = 46). After correcting for relevant confounders, the revision rate for glenoid loosening, instability, and the overall implant survival did not differ significantly between the two approaches (p = 0.494, p = 0.826, and p = 0.101, respectively). Conclusion. The surgical approach used for rTSA did not influence the overall implant survival or the revision rate for instability or glenoid loosening. Cite this article: Bone Joint J 2023;105-B(9):1000–1006

The October 2023 Shoulder & Elbow Roundup. 360. looks at: Arthroscopic capsular shift surgery in patients with atraumatic shoulder joint instability: a randomized, placebo-controlled trial; Superior capsular reconstruction partially restores native glenohumeral loads in a dynamic model; Gene expression in glenoid articular cartilage varies in acute instability, chronic instability, and osteoarthritis; Intra-articular injection versus interscalene brachial plexus block for acute-phase postoperative pain management after arthroscopic shoulder surgery; Level of pain catastrophizing rehab in subacromial impingement: secondary analyses from a pragmatic randomized controlled trial (the SExSI Trial); Anterosuperior versus deltopectoral approach for primary reverse total shoulder arthroplasty: a study of 3,902 cases from the Dutch National Arthroplasty Registry with a minimum follow-up of five years; Assessment of progression and clinical relevance of stress-shielding around press-fit radial head arthroplasty: a comparative study of two implants; A number of modifiable and non-modifiable factors increase the risk for elbow medial ulnar collateral ligament injury in baseball players: a systematic review

Aims. Despite the expansion of arthroscopic surgery of the shoulder, the open deltopectoral approach is increasingly used for the fixation of fractures and arthroplasty of the shoulder. The anatomy of the terminal branches of the posterior circumflex humeral artery (PCHA) has not been described before. We undertook an investigation to correct this omission. Patients and Methods. The vascular anatomy encountered during 100 consecutive elective deltopectoral approaches was recorded, and the common variants of the terminal branches of the PCHA are described. Results. In total, 92 patients (92%) had a terminal branch that crossed the space between the deltoid and the proximal humerus and which was therefore vulnerable to tearing or avulsion during the insertion of the blade of a retractor during the deltopectoral approach to the shoulder. In 75 patients (75%) there was a single vessel, in 16 (16%) a double vessel and in one a triple vessel. Conclusion. The relationship of these vessels to the landmark of the tendon of the insertion of pectoralis major into the proximal humerus is described. Damage to these previously undocumented branches can cause persistent bleeding leading to prolonged surgery and post-operative haematoma and infection, as well as poor visualisation during the procedure. Cite this article: Bone Joint J 2016;98-B:1395–8

Treatment of proximal humerus fractures (PHF) is controversial in many respects, including the choice of surgical approach for fixation when using a locking plate. The classic deltopectoral (DP) approach is believed to increase the risk of avascular necrosis while making access to the greater tuberosity more difficult. The deltoid split (DS) approach was developed to respect minimally invasive surgery principles. The purpose of the present study (NCT-00612391) was to compare outcomes of PHF treated by DP and DS approaches in terms of function (Q-DASH, Constant score), quality of life (SF12), and complications in a prospective randomized multicenter study. From 2007 to 2016, all patients meeting the inclusion/exclusion criteria in two University Trauma Centers were invited to participate in the study. Inclusion criteria were: PHF Neer II/III, isolated injury, skeletal maturity, speaking French or English, available for follow-up (FU), and ability to fill questionnaires. Exclusion criteria: Pre-existing pathology to the limb, patient-refusing or too ill to undergo surgery, patient needing another type of treatment (nail, arthroplasty), axillary nerve impairment, open fracture. After consent, patients were randomized to one of the two treatments using the dark envelope method. Pre-injury status was documented by questionnaires (SF12, Q-DASH, Constant score). Range of motion was assessed. Patients were followed at two weeks, six weeks, 3-6-12-18-24 months. Power calculation was done with primary outcome: Q-DASH. A total of 92 patients were randomised in the study and 83 patients were followed for a minimum of 12 months. The mean age was 62 y.o. (+- 14 y.) and 77% were females. There was an equivalent number of Neer II and III, 53% and 47% respectively. Mean FU was of 26 months. Forty-four patients were randomized to the DS and 39 to the DP approach. Groups were equivalent in terms of age, gender, BMI, severity of fracture and pre-injury scores. All clinical outcome measures were in favor of the deltopectoral approach. Primary outcome measure, Q-DASH, was better statistically and clinically in the DP group (12 vs 26, p=0,003). Patients with DP had less pain and better quality of life scores than with DS (VAS 1/10 vs 2/10 p=0,019 and SF12M 56 vs 51, p=0,049, respectively). Constant-Murley score was higher in the DP group (73 vs 60, p=0,014). However, active external rotation was better with the DS approach (45° vs 35°). There were more complications in DS patients, with four screw cut-outs vs zero, four avascular necrosis vs one, and five reoperations vs two. Calcar screws were used for a majority of DP fixations (57%) vs a minority of DS (27%) (p=0,012). The primary hypothesis on the superiority of the deltoid split incision was rebutted. Functional outcome, quality of life, pain, and risk of complication favoured the classic deltopectoral approach. Active external rotation was the only outcome better with DS. We believe that the difficulty of adding calcar screws and intramuscular dissection in the DS approach were partly responsible for this difference. The DP approach should be used during Neer II and III PHF fixation

Despite the expansion of arthroscopic surgery of the shoulder, the open deltopectoral approach to the shoulder is still frequently used, for example in fracture fixation and shoulder replacement. However, it is sometimes accompanied by unexpected bleeding. The cephalic vein is the landmark for the deltopectoral interval, yet its intimate relationship with the deltoid artery, and the anatomical variations in that structure, have not previously been documented. In this study the vascular anatomy encountered during 100 consecutive elective deltopectoral approaches was recorded and the common variants described. Two common variants of the deltoid artery were encountered. In type I (71%) it crosses the interval and tunnels into the deltoid muscle without encountering the cephalic vein. However, in type II (21%) it crosses the interval, reaches the cephalic vein and then runs down, medial to and behind it, giving off several small arterial branches that return back across the interval to the pectoralis major. Several minor variations were also seen (8%). These variations in the deltoid artery have not previously been described and may lead to confusion and unexpected bleeding during this standard anterior surgical approach to the shoulder. Cite this article: Bone Joint J 2013;95-B:657–9

Aim. Clavicular osteotomy was described as an adjunct to deltopectoral approach for improved exposure of the glenohumeral joint. This study aims to present contemporary outcomes and complications associated with the routine use of clavicular osteotomy by a single surgeon in a regional setting within New Zealand. Methods. A retrospective case series of patients who have undergone any shoulder arthroplasty for any indication between March 2017 to August 2022. This time period includes all patients who had clavicular osteotomy(OS) and patients over an equal time period prior to the routine use of osteotomy as a reference group (N-OS). Oxford Shoulder Score (OSS) and a Simple Shoulder Test (STT) were used to assess functional outcomes and were compared with the reported literature. Operative times and Complications were reviewed. Results. 66 patients were included in the study. 33 patients in the OS group and 33 in the N-OS group. No difference in age, sex, indications for operative intervention and the surgery provided was identified. No significant difference in operative time between groups (N-OS 121 minutes; OS 128 minutes). No clinically significant difference was identified in the OSS (N-OS; mean 38 vs OS 39) or the STT (N-OS 8.3 vs OS 9). The outcomes scores of both groups are in keeping with published literature. Two post operative clavicle fractures, one prominent surgical knot occurred in the OS that required further surgical intervention. Two cases of localized pain over the clavicle and one case of the prominent lateral clavicle were reported in the OS group. Two cases of localized pain over clavicle reported in the N-OS group. Conclusion. Use of clavicular osteotomy is not associated with inferior patient reported. The osteotomy introduces specific risks, however, the study provides evidence that these complications are infrequent and avoidable. Surgeons should feel confident in using this adjunct when exposure to the shoulder is difficult

The deltopectoral approach is a common approach for Shoulder joint replacements where a normal subscapularis tendon is divided. Despite meticulous attention to the subscapular repair, suboptimal return of function was found on clinical examination in 92% of patients (Miller S L: Journal of Shoulder & Elbow Surgery. 12(1): 29–34, February 2003). Therefore the aim was to study the integrity of the Subscapularis tendon in patients with Shoulder joint Replacements both clinical and ultrasound examination. Methods: A cohort of 25 subjects who had undergone Copeland Shoulder replacements through deltopectoral approach were included. All patients had same technique of tendon-to-tendon repair and postoperative rehabilitation. After ethics committee approval subjects were evaluated prospectively with Lift off test, Belly press test and the Constant score. Average follow-up was 29.6 months. An experienced Radiologist performed the Ultrasound examination. Results: Ultrasound examination showed 8 % (2 of 25) had full thickness rupture of subscapularis with 44% (11 of 25) showed mild to moderate atrophy of subscapularis muscle and 12%(3 of 25) severe atrophy. 20%(5 of 25) had Lift off test and Belly press test positive. 40%(10 of 25) had either or both of these tests positive. 60%(15 of 25) had clinical or radiological evidence of reduced function (Fisher exact test, P < 0.01). Constant score are 37.5 with full thickness tears compared to 59.4 with intact subsapularis tendon. Conclusion: Subscapularis tendon function following shoulder replacement had received poor attention. It is deficient in over 60% of patients with joint replacement through Deltopectoral approach with tendon-to-tendon repair. We therefore conclude for this study that alternative techniques of subscapularis tendon repair or alternative approaches to the shoulder joint need to be considered to improve the functional outcome in these patients

Fractures and nonunions of the proximal humerus are increasingly treated by open reduction and internal fixation. The extended deltopectoral approach remains the most widely used for this purpose. However, it provides only limited exposure of the lateral and posterior aspects of the proximal humerus. We have previously described the alternative extended deltoid-splitting approach. In this paper we outline variations and extensions of this technique that we have developed in the management of further patients with these fractures

Proximal humeral fractures are common fractures that may lead to severe functional disability. In open reduction and internal fixation of these fractures deltopectoral approach is pereferred by many surgeons being an internervous plane and because of familiarity. However when this aprroach is used extensive soft tissue dissection is inevitable and control of the commonly displaced tuberculum majus fragment which is displaced posterolateraly is difficult. In this prospective study we compared deltopectoral and lateral deltoid splitting approach by using the same fixation material. Between October 2005 and March 2007 42 patients were included in the study group. In Group A a lateral deltoid split approch and in Group B deltopectoral approach was used. Group A consisted of 22 cases; mean age 60.95 (26–90 years old); 12 female and 10 male, Group B 20 cases; mean age 56.9 (24–86 years old); 13 female, 7 male. Philos locking plate fixation (Synthes) was used in every case. When deltoid split approach was used axillary nerve was explored and protected, a C-arm was used in every case. Functional results and compications were compared at the follow up visits. When radiological results were compared the reduction of head and tubercular fragments were better in deltoid splitting approach. The Constant score was better in Group A at an earlier time period 68.9 vs 58.4 (p< 0.01). At the 6th month follow up the difference between Constant scores was not significant, 85.9 vs 85.2 (p> 0.05). Axillary nerve lesion due to lateral deltoid split exposure was not observed in any of the cases. Lateral deltoid split exposure with identification and protection of the axillary nerve facilitates 270 degrees control of the head and tubercular fragments in AO/ASIF type B and C fractures. Additional fixation of tubercular fragments by sutures passed through cuff tendons and fixed to the plate helps to maintain the reduction. Compared to double incision minimal invasive approach a shother plate is used without any inadvertant risk to the axillary nerve. Better Constant scores are achieved at an earlier time. We recommend this technique in AO/ASIF type B and C fractures

Purpose: The purpose of this multicentric study was to report results obtained with the Aequalis system using the simple humeral or total prosthesis, at at least two years follow-up in patients with shoulder joint degeneration and non-repairable rotator cuff tears. Material and methods: Sixty-eight Aequalis arthroplasties were performed between 1992 and 1998. Outcome was assessed on the basis of the Constant score and radiological findings. Female gender predominated (78%) in this series with a mean age of 72 years. There were 62 simple humeral implantations and six total shoulder arthroplasties. The deltopectoral approach was used in 63 cases and the superior approach in five. All stems and sockets were cemented. There were no neurological or infectious complications. Results: Two humeral stem implants were failures and required revision with a Grammont prosthesis. There was also one reoperation for arthrolysis with preservation of the implant; the outcome was fair. Functional outcome: Sixty-six patients were reviewed with a mean follow-up of 45 months. All implantations except one were performed to achieve pain relief. The absolute Constant score improved by 20 points (from 25 to 46) with a 7-point gain for pain (3 to 10), a 20° gain for active elevation, an 18° gain for external rotation, and a 0.4 point gain for force. Pain relief was greater with total prostheses. Only five patients stated they were dissatis-fied with the outcome despite the fact that 18 reported significant persistent pain. The Constant score was analysed as a function of follow-up, size of the humeral head, and preoperative morphology of the glenoid surface. Radiological outcome: Certain loosening was recognised for one glenoid and one humeral stem. Among 52 shoulders with strictly identical radiological results, 33 exhibited deterioration either for the vault or the glenoid or both, with no effect on the Constant score. Discussion: In this indication the Adqualis prosthesis is implanted to achieve a “limited” objective: pain relief. The deltopectoral approach is preferable in order to preserve elements inhibiting superior migration of the humerus (in a parallel study, the absence of these elements explains the poor outcome observed in 3 out of 9 patients). Unlike other series, the present series exhibited a significant effect of a type E2 biconcave glenoid surface. The pain score was better with total shoulder prostheses than with humeral stems alone and four of the six glenoid sockets remained perfectly fixed. The long-term outcome of these glenoid surfaces remains unknown so it would be inappropriate to advise systematic use. Clinical outcome did not show any deterioration over time despite deterioration of the vault, the glenoid, or both. Indications for non-constrained pros-theses should however be retained with caution due to open questions concerning long-term outcome, particularly for shoulders which have already been operated on or with type E2 glenoids. Considering these reservations, the Aequalis prosthesis has reached, at nearly five years follow-up, the assigned objectives: significant pain relief, satisfactory overall shoulder function

Anatomic and accurate placement of components is a primary goal in all arthroplasty procedures. Unique to total shoulder arthroplasty, challenging glenoid exposure and osteoarthritic glenoid deformity offer significant challenges and impediments to this goal. Despite thorough pre-operative planning strategies and contemporary cannulated pin-based shoulder systems, it is often times still difficult to accurately aim the guide pin to the medial border of the scapula when the deformity is substantial or exposure is difficult. Even small errors in guide pin position can result in problems with final component version, inclination and glenoid vault perforation. In addition, a malpositioned glenoid component has been shown to have a negative impact on implant longevity and clinical performance. Image-based patient specific instrumentation has been available in the lower extremity for nearly a decade with reliable results. The application of similar technology in the shoulder has demonstrated reliable positioning of the guide pin to a pre-operative plan with subsequent accurate placement of the glenoid component. This surgical demonstration will feature one of the currently available CT-based patient specific glenoid guides using a standard deltopectoral approach

Hemi shoulder arthroplasty is a rather successful procedure although revision surgery due to secondary glenoid erosion is reported in more than 25%. The downside of common shoulder arthroplasty is that in a deltopectoral approach the subscapularis tendon needs to be detached for exposure of the humeral head. Refixation of subscapularis tendon is associated with a retear rate of 4%, furthermore with progressing fatty muscle infiltration and loss of function. In case of revision surgery a second subscapularis tendon detachment is even more associated with worse function. Thus, arthroscopic humeral head resurfacing is an expedient alternative for minimal invasive humeral head arthroplasty without compromising subscapularis function. The purpose of this study was to report first clinical and subjective results after arthroscopic-assisted resurfacing of the humeral head. For this prospective case series, 24 patients (7 females, 17 males; mean age 59 years, range 42–73 years) undergoing arthroscopic-assisted partial shoulder resurfacing with the partial eclipse prosthesis were included in the study. Clinical conditions and subjective assessments were evaluated before surgery and annually thereafter using the Constant score (CS), active range of motion (ROM), visual analog scale (VAS) for pain, and the American Shoulder and Elbow Surgeons scale (ASES). Radiological outcomes and major complications were monitored. The mean CS for all patients improved significantly from 51 points preoperatively to 83 points 12 months after surgery (p=0.005). Trends towards increasing ROMs were detected. Subjective scores significantly improved from baseline to the 1-year follow-up (VAS: from 6.4 to 2.5, p=0.010; ASES: from 47 to 76, p=0.026). The majority of patients (88%) stated that they would undergo the procedure again. Revisions were indicated in 17% due to progression of osteoarthritis. Arthroscopic-assisted partial humeral head resurfacing as a minimal invasive procedure with the advantages of bone stock preservation and intact subscapularis tendon allowed immediate postoperative active mobilization and provided significant improvements in subjective outcome. In case of revision surgery a primary situation was encountered with postoperative results comparable to primary arthroplasty

Aim. Recent studies have indicated that the presence of P. acnes in the skin of the shoulder and around the acromion is higher than other body regions like the knee or the hip. The aim of this study was to estimate the presence of P. acnes in a real set of primary shoulder arthroplasty, after skin preparation with chlorhexidine and administration of empirical antibiotic therapy. Method. A prospective observational study involving 63 patients undergoing primary shoulder arthroplasty was designed. In all patients two skin biopsies with a 3 mm dermal punch and one subcutaneous tissue sample after surgical incision were obtained. Skin biopsies were obtained at the most anterior part of the surgical wound in case of superior approach and at the upper part in the deltopectoral approach. All patients underwent preoperative antibiotic prophylaxis with cefazolin 2g ev and skin preparation with 2% chlorhexidine alcoholic tinted before the start of surgery twice. The aerobic cultures were incubated at 37ºC for 7 days whereas the anaerobic ones incubated for 14 days. Results. A total of 63 consecutive patients who underwent shoulder arthroplasty (58 reverse shoulder arthroplasty and 5 anatomical) were analysed. 54 women and 9 men, mean age of 73.94 (SD 6.19). The indication for arthroplasty was a secondary arthropathy cuff injury in 42 cases, primary osteoarthritis in 3, acute fracture in 9 and fracture sequelae in 9. We obtained 189 tissue cultures (126 skin cultures and 63 subcutaneous) and 4 cultures were positive (2.02%) for P. acnes in 3 different patients. A first patient (female) had both positive skin cultures, the second patient (male) only had positive the subcutaneous tissue cultures and the third patient had positive also the subcutaneous tissue culture. The first patient underwent anatomical shoulder arthroplasty whereas the second and third patients underwent reverse shoulder arthroplasty. The time to grow was 15 days in first patient and 14 days in the second and third patient (mean 14.5 days). Conclusions. In a real setting of patients undergoing shoulder arthroplasty using antibiotic prophylaxis and standard preoperative skin preparation with chlorhexidine we found a low rate of positive cultures for P. acnes (2.02 %). The higher rate of P. acnes positive cultures in skin reported in previous studies may be caused by a different population study group (healthy and younger volunteers without antibiotic prophylaxis) or suboptimal culture technique (use of swaps)

Introduction. The use of reverse total shoulder arthroplasty (RSA) is becoming increasingly common in the treatment of rotator cuff arthropathy. In recent years indications for use have expanded to include elderly patients in whom either internal fixation is not possible due to fracture configuration, poor bone quality, or presence of a rotator cuff deficiency. There is however relatively little evidence to support its use in these circumstances. Objective. This study aims to assess the viability of RSA as a salvage procedure in the treatment of complex proximal humeral fractures or irreducible dislocations, quantified in terms of functional outcome, complication rates and patient reported satisfaction. Methods. All patients presenting between January 2011 and December 2013 with a complex 3- or 4-part humeral fracture or a delayed presentation with an irreducible non-acute dislocation, treated with salvage RSA were eligible for inclusion. All operations were performed in a single centre by one of two specialist upper limb surgeons. Standard deltopectoral approach was performed. Tournier reverse fracture stem with two choices of inserts and graft hole in the stem with proximal hydroxyapatite coating was the implant of choice. All patients and underwent a standardised rehabilitation programme. Clinical outcome was measured at final follow up using (1) patient reported satisfaction, (2) clinician measured range of movement (3) complication rate. Results. A total of 16 patients were eligible for inclusion in this study. Mean age at time of operation was 72.8 years (41–91 years) with a mean follow-up of 7 months (2–13 months). At time of last follow-up 100 per cent of patients were satisfied with the results of their operation and functionally independent with activities of daily living. Mean oxford score was 39 (36–48). Range of movement post-operatively had a mean active forward extension 97° (70–150°) and abduction 101° (80–170°). 43% of patients were pain-free, whilst the remainder only required the use of occasional analgesia. One patient developed heterotrophic ossification post operatively and underwent surgical excision. One patient sustained a peri-prosthetic avulsion fracture at 18months treated non-operatively. Patients who underwent RSA for dislocation fared better than for those with proximal humeral fractures. The mean active forward extension was 107.5° (90–150°) and abduction 112.5° (90–170°) in the dislocation group (N=5) compared with those who had a fracture (N= 11) in which the forward extension was 91.4° (70–120°) and abduction 95° (80–120°). Conclusion. Reverse TSA should be considered in patients with complex proximal humeral fractures or delayed presentation with irreducible dislocation. Early results demonstrate good outcomes in terms of patient satisfaction, pain relief and preservation of function. These early result are encouraging however a further study with longer follow-up is required to confirm sustained benefit

This study reviews the use of intramedullary fibular allograft in treating nonunion of the humeral neck in 11 patients. Nine women and two men with a mean age of 76 years (63 to 89) were followed up for a mean of 61 months (14 to 72). The nonunion was exposed through a deltopectoral approach and fibular allograft was inserted across the fracture site. As the fibula is a very dense cortical bone, a T-plate could then be applied to the humerus with the screws directed into the intra-medullary fibular peg. Supplementary corticocancellous bone from the iliac crest was used. Bony union was achieved in every case. The preoperative mean Constant score was 26 and the postoperative mean Constant score was 75. The most notable improvement was in patients’ ability to elevate the arm actively. Decreases in pain levels were observed but were less dramatic than the increases in function

Purpose. While reverse shoulder arthroplasty (RSA) corrects vertical muscle imbalance, it cannot restore the horizontal imbalance seen in cuff-deficient shoulders with combined loss of active elevation and external rotation (CLEER). We report the medium-term results of the modified latissimus dorsi/teres major tendon transfer (L'Episcopo procedure) associated with RSA, performed via a single deltopectoral approach. Method. Sixteen CLEER patients underwent the procedure and were followed up at a mean of 49 months (range, 36–70). All patients had lost spatial control of their arm, were unable to maintain neutral rotation, and had abnormal infraspinatus and teres minor muscles on imaging. Outcome measures included Constant score (CS), Subjective Shoulder Value (SSV), and ADLER score (activities of daily living requiring external rotation). Results. Fifteen patients were satisfied or very satisfied. There were significant improvements (p<0.05) in active elevation (72 degrees to 139 degrees), active external rotation (−24 degrees to 4 degrees), CS (27 to 64), ADLER score (5.0 to 23.8) and SSV (23% to 77%). Active internal rotation decreased from 6 to 3 points. Scapular notching was observed in 3 patients and spurs in 3 patients. One deep infection required two-stage revision of the prosthesis and the patient was disappointed with the result. One patient required reoperation (arthrolysis and acromioclavicular joint excision). Conclusion. Reverse shoulder arthroplasty combined with the modified L'Episcopo procedure improves shoulder function in patients with CLEER. Patients regain spatial control of their arm. The observed internal rotation loss has led us to modify the surgical technique by fixing the transferred tendons more posteriorly on the humerus

Introduction: Surgical treatment of most displaced proximal humerus fractures is challenging due to osteoporosis, which makes stable fixation difficult. Locking plates are intended to provide superior mechanical stability. The NCB. ®. -PH (Non-Contact-Bridging for the Proximal Humerus) plate is a locking plate of the latest generation that allows both open and minimally invasive (MI) application. Methods: In a prospective multicenter study 131 patients were treated (n = 78 open, n = 53 MI). The open procedure was performed using a standard deltopectoral approach; the MI technique involved percutaneous reduction and an anterolateral deltoid split approach. Clinical and radiological follow-up was obtained 6 weeks, 3, 6 and 12 months after surgery. An iADL (instrumental activities of daily living) score was used for functional assessment, the subjective outcome was measured using VAS (Visual Analogue Scale) for pain and mobility. Results: Improvement in function (ROM) was statistically significant in both groups (open and MI) postoperatively. Fracture type had the most significant impact on the complication rate. The most frequent complication was intraarticular screw perforation. The open treated group showed a higher complication rate. However, more C-type fractures (AO) were treated with this technique. Conclusion: The NCB-PH is suitable as a routine method of treatment for proximal humerus fractures. Complication rate and functional outcome are comparable to the literature. The MI technique, which is limited by percutaneous fracture reduction, provides a less invasive option for patients requiring fast recovery. Complex fractures should preferably be treated with the open technique

Background. Total Shoulder Arthroplasty (TSA) has been shown to improve the function and pain of patients with severe degeneration. Recently, TSA has been of interest for younger patients with higher post-operative expectations; however, they are treated using traditional surgical approaches and techniques, which, although amenable to the elderly population, may not achieve acceptable results with this new demographic. Specifically, to achieve sufficient visualization, traditional TSA uses the highly invasive deltopectoral approach that detaches the subscapularis, which can significantly limit post-operative healing and function. To address these concerns, we have developed a novel surgical approach, and guidance and instrumentation system (for short-stemmed/stemless TSA) that minimize muscle disruption and aim to optimize implantation accuracy. Development. Surgical Approach: A muscle splitting approach with a reduced incision size (∼6–8cm) was developed that markedly reduces muscle disruption, thus potentially improving healing and function. The split was placed between the infraspinatus and teres-minor (Fig.1) as this further reduces damage, provides an obvious dissection plane, and improves access to the retroverted articular surfaces. This approach, however, precludes the use of standard bone preparation methods/instruments that require clear visualization and en-face articular access. Therefore, a novel guidance technique and instrumentation paradigm was developed. Minimally Invasive Surgical Guidance: 3D printed Patient Specific Guides (PSGs) have been developed for TSA; however, these are designed for traditional, highly invasive approaches providing unobstructed access to each articular surface separately. As the proposed approach does not offer this access, a novel PSG with two opposing contoured surfaces has been developed that can be inserted between the humeral and scapular articular surfaces and use the rotator cuff's passive tension to self-locate (Fig.2). During computer-aided pre-operative planning/PSG design, the two bones are placed into an optimized relative pose and the PSG is constructed between and around them. This ensures that when the physical PSG is inserted intra-operatively, the bones are locked into the preoperatively planned pose. New Instrumentation Paradigm: With the constraints of this minimally invasive approach, a new paradigm for bone preparation/instrumentation was required which did not rely on en-face access. This new paradigm involves the ability to simultaneously create glenoid and humeral guide axes – the latter of which can guide humeral bone preparation and be a working channel for tools – by driving a short k-wire into the glenoid by passing through the humerus starting laterally (Fig.3). By preoperatively defining the pose produced by the inserted PSG as one that collinearly aligns the bones’ guide axes, the PSG and an attached c-arm drill guide facilitate this new lateral drilling technique. Subsequently, bone preparation is conducted using novel instruments (e.g. reamers and drills for creating holes radial to driver axis) powered using a trans-humeral driver and guided by the glenoid k-wire or humeral tunnel. Conclusion. To meet the expectations of increasingly younger TSA patients, advancements in procedural invasiveness and implantation accuracy are needed. This need was addressed by developing a novel, fully integrated surgical approach, PSG system, and instrumentation paradigm, the initial in-vitro results of which have demonstrated acceptable accuracy while significantly reducing invasiveness

Aims: The purpose of this study was to evaluate the efficacy of the inverted Delta 3 prosthesis in nonreconstructable massive rotator cuff tear. Methods: 31 inverted Delta 3 prostheses were performed between October 1999 and February 2002. The average age was 72.8 years old (65–84) and the average follow-up was 17.8 months (3–36). A deltopectoral approach was performed in all cases. Rotator cuffs were found to be nonreconstructable in all 31 cases. Results: Functional results were assessed using the Constant score. Constant score was improved from 32.1 preoperatively to 59 postoperatively. Forward flexion increased from 52 degrees to 135 mean degrees. 85% of the patients were satisfied. Two complications occurred: a stupor of the radial nerve and a ditching of the cementless humeral component. Conclusions: Inverted Delta 3 prosthesis represents a successful choice for cases of irreparable rotator cuff and gleno-humeral lesions in old patients with an excellent deltoid and a good glenoid bone stock. It reduces pain and improved function in all patients. The loosening of glenoid component is not frequent with a short-term follow-up

The purpose of this study was to look at the results of using the Copeland surface replacement in the treatment of arthritis of the shoulder. We report the results of 61 Type 3 Copeland surface replacements in 57 patients. Operations were performed in 33 cases of Rheumatoid Arthritis, 27 cases of Osteoarthritis and 1 case of posttraumatic arthritis. Hemiar-throplasty was performed via a Deltopectoral approach by the senior author in all cases. There were 38 females and 19 males with a minimum follow up of 1 year and a mean follow up of 26 months (range 12–65). Patients were scored pre and post operatively using the Constant score. Average pre-op score was 15.6 and post-operatively was 52.5. There was one case of loosening ( ? secondary to infection) requiring revision to a stemmed implant. Two patients required Sub-Acromial decompression for postoperative impingement. All patients considered their shoulder improved following this procedure. There was no evidence of radiolucency in any postoperative radiograph. Cementless surface replacement arthroplasty in our series show similar results to previously reported series of stemmed implants and to the published results available for this implant

In 42 elderly patients, 33 women and nine men with a mean age of 72 years, we treated displaced fractures of the proximal humerus (34 three-part, 8 four-part) using a blade plate and a standard deltopectoral approach. Functional treatment was started immediately after surgery. We reviewed 41 patients at one year and 38 at final follow-up at 3.4 years (2.4 to 4.5). At the final review, all the fractures had healed. The clinical results were graded as excellent in 13 patients, good in 17, fair in seven, and poor in one. The median Constant score was 73 ± 18. Avascular necrosis of the humeral head occurred in two patients (5%). We conclude that rigid fixation of displaced fractures of the proximal humerus with a blade plate in the elderly patient provides sufficient primary stability to allow early functional treatment. The incidence of avascular necrosis and nonunion was low. Restoration of the anatomy and biomechanics may contribute to a good functional outcome when compared with alternative methods of fixation or conservative treatment. Regardless of the age of the patients, we advocate primary open reduction and rigid internal fixation of three- and four-part fractures of the proximal humerus

Introduction. The use of reverse total shoulder arthroplasty (RSA) is becoming increasingly common in the treatment of rotator cuff arthropathy. Standard RSA technique involves medialising the centre of rotation (COR) maximising the deltoid lever arm and compensating for rotator cuff deficiency. However reported complications include scapular notching, prosthetic loosening and loss of shoulder contour. As a result the use of Bony Increased Offset Reverse Shoulder Arthroplasty (BIO-RSA) has been gaining in popularity. The BIO-RSA is reported to avoid these complications by lateralising the COR using a modified base plate, longer central post and augmentation with cancellous bone graft harvested from the patients humeral head. Objectives. This study aims to compare the outcome in terms of analgesic effect, function and satisfaction, in patients treated with standard RSA and BIO-RSA. Methods. All cases were performed in a single centre by one of two upper limb consultant orthopaedic surgeons over a consecutive 2-year period. At time of listing for operation, the decision as to whether to undertake a bony-increased offset reverse total shoulder was made. Standard deltopectoral approach was performed. Standard and Bony increased offset Tournier reverse was the implant of choice (BIO-RSA). All patients underwent a standardised rehabilitation programme. Standard follow up was clinical review with radiographs at 2 weeks, 6weeks and 3months. Retrospective data was collected using case notes on patient reported stausfaction and oxford shoulder score, analgesia requirement at final follow up, and final range of movement. Results. A total of 60 patients (65 shoulders) were treated with reverse total shoulder replacements (RSA) within a 2-year period in a single centre for chronic complex shoulder conditions. Mean age at time of intervention was 74.1years (49.3 – 88.7). Mean follow up was 7.1 months (3.4 – 24). Average time to discharge 16.1 months (3.4 – 37.4). 43 patients currently under review. Of the 65 shoulders, 40 underwent BIO-RSA procedures. Indications for surgery were predominantly rotator cuff arthropathy (N=36). Other indications included severe osteoarthritis (N=1) and complex proximal humeral fracture (N=3). The remaining 25 patients treated with standard RSA were similar in terms of indication and basic demographics. In terms of range of movement, outcomes between the two groups were broadly similar. Patients receiving BIO-RSA demonstrated mean active forward flexion of 92.2° (70–120°) and abduction 93.3° (80–120°). The RSA group had mean forward flexion 90.5° (50–130°) and mean abduction 88.6° (40–160°). Both groups had excellent analgesic effect with 92% in each either being completely pain free or requiring only occasional analgesia. The majority of patients were either very satisfied or satisfied with the outcome of the surgery. Mean Oxford shoulder score for the BIO-RSA group was 4.9 (0–13) preoperatively and 43.7 (36–48) postoperatively. The mean RSA pre-operative score was 7.9 (0–19) and postoperatively 40.2(32–48). In total three patients experienced complications; 1 haematoma (BIO-RSA), 1 brachial plexus contusion (BIO-RSA) and 1 deep infection (RSA). Conclusion. If grafting is necessary, the use of BIO-RSA within this centre seems to have comparable results to those undergoing standard RSA. Early results also suggest the Bio-RSA allows earlier improvement and conserves a larger bone stock. These early result are encouraging however a further study with longer follow-up is required

The axillary nerve injuries most commonly are observed after trauma such as contusion-stretch, gunshot wound, laceration and iatrogenic injuries. Two of the most commons causes seem to be the glenohumeral dislocation and the proximal humerus fractures. The axillary nerve may sustain a simple contusion, or its terminal elements may be avulsed from the deltoid muscle. Compressive neuropathy in the quadrilateral space also has been reported (quadrilateral space syndrome, Calhill and Palmer, 1983). The axillary nerve injuries incidence represents less than 1% of all nerve injuries. Aim: The purpose of this study was to analyze outcome in patients, who presented with injuries to the axillary nerve. Material and methods: We report a series of 15 cases of axillary nerve lesions, which were operated between 1995 and 2002. These injuries resulted from shoulder injury either with or without fracture and or dislocation. Patients were operated between 3 to 6 months after trauma and an anterior deltopectoral approach was usually followed during surgery. The follow up period ranged from 1 to 8 years. Results: The results were considered as satisfactory in 11 out of 15 axillary nerve lesions. According to clinical examination, of the function of the shoulder and the muscle strength the results were classified as excellent in 5 cases, good in 6 cases and poor in 4 cases. Conclusions: If indicated, nerve repair can lead to useful function in carefully selected patients

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

Our aim was to analyse radiological outcome of proximal humerus fractures treated with Philos plate and to assess its usefulness in treatment of malunion and non-union. Seventy-seven patients were treated with Philos plate (24 men and 53 women). Mean age was 61 years (15–88). There were 66 acute fractures, 6 nonunion, 4 mal-union and one periprosthetic fracture. Acute fractures included 29 two part, 30 three part and five 4 part fractures. Seven had associated dislocation. There were two head splitting fractures. Deltopectoral approach was used in all. No acute fractures were bonegrafted however all nonunions had bonegraft. Postoperative radiographs were available for review for 59. Average union time was 12 weeks (8–24). Satisfactory union occurred in 51 (86.4%). Twenty-three (39 %) fractures had inadequate reduction. Malplacement of plate was observed in 25 (42%) leading to significant malunion in 11.8%. Satisfactory union was occurred in all of last 30 patients. Nonunion occurred in 2 with infection in one. Other complications included screw penetration into glenohumeral joint, avascular necrosis, screw backing out and tuberosity detachment. Philos plate fixation was used for treatment of 6 nonunions, 4 malunions and one periprosthetic fracture with satisfactory outcome in all. Relatively high rate of complications was observed in early cases in this series. This could be attributed to the steep learning curve with this technique. Emphasis should be put on careful and adequate reduction of fracture and optimal placement of plate (about 8 mm from the tip of tuberosity) to avoid impingement and to achieve correct screw placement in the humeral head. In conclusion, Philos plate has been of benefit in management of complex fractures as well as management of non-union of proximal humerus. Quality of reduction and optimal placement of plate appear to be the two most important parameters for a successful outcome

Purpose of the study: The purpose of this study was to determine the feasibility and reproducibility of a new arthroscopic procedure combining a Bristow-Latarjet lock with Bankart reinsertion of the lambrum. Material and methods: Forty-seven consecutive patients with significant bone defects in the glenoid and a deficient capsule were treated arthroscopically: arthroscopic Bankart had failed in six. The procedure was performed exclusively arthroscopically using a special instrumentation: after its osteotomy and identification of the axiallary nerve, the coracoids was passed through the subcapular muscle with its tendon; the block was fixed on the scapular neck after 90° lateral rotation so as to prolong the natural concavity of the glenoid. Anchors and sutures were then used to refix the capsule and the labrum onto the glenoid border, leaving the block in an extra-articular position. Follow-up included a physical examination and standard x-rays at 45, 90 and 180 days; 31 patients had a postoperative scan. Three independent operators read the images. Results: The procedure was completed arthroscopically in 41 of 47 patients (8%); conversion to a deltopectoral approach was required for six patients (12%). The axillary nerve was successfully identified in all shoulders. The block had a subequatorial position in 98% (46/47 shoulders) and equatorial in one. The block was tangent to the surface of the glenoid in 92% (43/47), lateral in one (2%) and too medial (> 5mm) in three (6%). One patient presented an early fracture of the block and five patients exhibited block migration; there was a partial lysis of the block in two patients. The final rate of nonunion of the block was 13% (6/47). Fractures, migrations and non-unions were related to technical errors: screws too short (unicortical) and/or poorly centred in the block. Conclusion: Our results show that arthroscopic transfer of the coracoids to the scapular neck is a safe and successful operation. The rate of correctly positioned healed blocks was equivalent or superior to conventional techniques. The complications observed show that the arthroscopic block technique is difficult with a long learning curve

Scapular notching is of concern in reverse shoulder arthroplasty and has been suggested as a cause of glenoid loosening. Our purpose was to analyze in a large series the characteristics and the consequences of the notch and then to enlighten the causes in order to seek some solutions to avoid it. 430 consecutive patients (457 shoulders) were treated by a reverse prosthesis for various etiologies between 1991 and 2003 and analyzed for this retrospective multicenter study. Adequate evaluation of the notch was available in 337 shoulders with a follow-up of 47 months (range, 24–120 months). The notch has been diagnosed in 62% cases at the last follow-up. Intermediate reviews show that the notch is already visible within the first postoperative year in 82% of these cases. Frequency and grade extension of the notch increase significantly with follow-up (p< 0.0001) but notch, when present, is not always evolutive. At this point of follow-up, scapular notch is not correlated with clinical outcome. There is a correlation with humeral radiolucent lines, particularly in metaphyseal zones (p=0.005) and with glenoid radiolucent lines around the fixation screws (p=0.006). Significant preoperative factors are: cuff tear arthropathy (p=0.0004), muscular fatty infiltration of infraspinatus (p=0.01), narrowing of acromio-humeral distance (p< 0.0001) and superior erosion of the glenoid (p=0.006). It was more frequent with superolateral approach than with deltopectoral approach (p< 0.0001) and with standard cup than with lateralized cup (p=0.02). We conclude that scapular notching is frequent, early and sometimes evolutive but not unavoidable. Preoperative superior glenoid erosion is significantly associated with a scapular notch, possibly due to the surgical tendency to position the baseplate with superior tilt and/or in high position which has been demonstrated to be an impingement factor. Preoperative radiographic planning and adapted glenoid preparation are of concern

Introduction: Various surgical techniques existed for the treatment of three and four part proximal humeral fractures with variable outcomes. The aim of this study is to present a technique using small materials, to preserve all the biologic principles of fracture fixation, in the treatment of these challenging injuries. Material: We perform a study taking as inclusion criteria: 3 and 4 parts proximal, closed, humeral fractures, treated surgically by open reduction and a modular biological internal fixation. Surgical technique: Through a standard deltopectoral approach the fragments reduced, taking care to preserve the periosteum and manipulate meticulously the soft tissues. All the fractures were fixed with a combined system of Kirschner wires inserted to the proximal fragments, connected by “bone clips” forming a modular construction and fixed to the main distal fragment by AO screws. Results: 24 patients complied with the inclusion criteria and were followed up a mean of 18 months. All patients achieved a satisfactory result except a fracture-dislocation that developed AVN and was revised into a shoulder arthroplasty and two demented elderly patients with metalware failure that were also revised. Conclusion: In this first series of non-selected cases the outcome of fracture consolidation is promising. Although this technique is in its embryonary phase of development and the functional results are currently been assessed, the radiological outcomes suggest that the technique described is a valid alternative to the treatment of these fractures if we indicate an osteosynthesis method that combines biology and stability

Background. In elderly patients with complex proximal humerus fractures and osteoporotic bone reconstruction is not always possible. Although hemiarthroplasty is an alternative, non-union or tuberosity migration can lead to inferior functional results. Implantation of a Reverse Total Shoulder Arthroplasty (RTSA) seems to be an interesting alternative. In the present study we retrospectively analyzed the short-term results of RTSA for complex proximal humerus fractures in the elderly. Methods. From 31.10.2005 to 20.07.2010 RTSA was performed in 29 patients (average age 80 years [67;90], 25 women, 4 man) with subcapital, three- or four-part fracture of the proximal humerus as a primary treatment. All procedures were performed using the Anatomical Inverse Shoulder (Zimmer) with fracture stem. A deltopectoral approach was used in every case with reattachment of the tuberosities. Pain, range of motion, subjected shoulder value (SSV) as well as the Constant score (CS) were used to evaluate shoulder function. Implant positioning and signs of loosening were analyzed on standard x-rays. Results. Included were 23 patients with a minimal follow-up of 12 month. The average follow-up was 17 month (12 month to 5 years). The mean SSV was 81% [40;100]. The absolute CS averaged 67 points [34;84] and the relative CS 97% [52;139]. The mean pain score (VAS) was 13.7 of 15, the mean activity score 18.4 of 20, the mean mobility score 28.6 of 40 and the mean strength score 5.1 of 25. The mean active anterior elevation was 130° [80;160], the mean active abduction 128° [80;170] and the mean active external rotation in 0° abduction 21° [-30;70]. All patients reached the same activity level as before surgery and could return to independent living. The results after 12 month were already comparable to those after 24 month (10 patients). Radiographically no signs of loosening were detected. There was a total of 3 complications and reoperations, two due to a hematoma and one because of a periprosthetic fracture. Conclusions. In elderly patients with complex proximal humerus fractures and osteoporotic bone RTSA seems to be a very satisfactory procedure. The short-term clinical results are excellent and predictable with a rapid postoperative recovery of daily comfort. The complication rate is low and acceptable

The Copeland Shoulder Arthroplasty is a cementless, pegged humeral head surface replacement. The design is based on the principle of minimal bone resection and has been in clinical use since 1986. The only published series to date, that of Levy and Copeland, reported results for 103 patients which were comparable to those obtained with stemmed implants. We report the outcome at our institution using the same prosthesis with a hydroxyapatite coating. 81 shoulders (74 patients) underwent resurfacing hemiarthroplasty through an anterior deltopectoral approach. Preoperative diagnoses were: osteoarthritis (39), rheumatoid arthritis (29), rotator cuff arthropathy (1), post-traumatic arthrosis (2). They were followed for an average 28 months. 10 were lost to follow-up (8 deaths). Constant scores improved from a mean preoperative figure of 15.7 to 54.0 (p< 0.01) at last follow-up. For rheumatoid arthritis and osteoarthritis the scores improved from 15.2 to 50.4 (p< 0.01) and 16.0 to 55.4 (p,< 0.01) respectively. There was a 13% complication rate with one case requiring revision for loosening to a stemmed implant. Most were cases requiring subsequent acromioplasty. In one case the glenoid rim was fractured during head dislocation. There was a low rate of perioprosthetic radiolucency (4.2%) which may relate to the hydroxyappatite coating within the shell of the prosthesis. Ipsilateral stemmed elbow replacement was performed in some cases without a double stress riser effect. Periprosthetic humeral neck fracture as managed non-operatively with uneventful union. Conclusion: The good outcome reported in Copeland’s own series has been replicated in the early to medium term at our institution. The surface replacement system is simpler, accurate and preserves bone stock

Background: Avascular necrosis is a well recognised complication of displaced proximal humeral fractures irrespective of conservative and operative treatment. The reported rate of AVN with open reduction and internal fixation varies from 22 to 40%. The aim of our study was to look at the functional outcome and the incidence of AVN with operative treatment using locking plate with a minimum 3 year follow up. Materials and methods: We retrospectively reviewed a consecutive series of 50 patients with displaced proximal humerus fractures treated with ORIF from 2002 to 2004. All patients were operated by the two senior authors employing anterior deltopectoral approach, indirect reduction, secure suture repair of the tuberosities and fixation with locking plate. The minimum follow up was 3 years. There were 9 two-part, 19 three-part and 22 four-part fractures. Their average age was 63 years. All patients were assessed objectively with Constant score and subjectively with Oxford questionnaire by an independent observer. Fracture healing and complications were recorded. Results: 47 patients were available for follow-up. All fractures united. The average Constant score was 84. Their mean Oxford score was 16. There was no infection or metal work failure. One patient fractured below the plate after a fall but went onto uneventful union. 4 of 47 patients (8.5%) developed avascular necrosis. Three were four-part fracture and one was two-part fracture. Three patients underwent hemiarthroplasty of shoulder with good functional recovery. One patient declined further operative intervention due to low level of symptoms. Conclusion: Indirect reduction and secure fixation of the tuberosities onto the humeral head with a locking plate is a reliable technique of treating displaced proximal humeral fractures. Our experience of avascular necrosis in only 8.5% of these fractures is much lower than any reported series after open surgery

The benefit of open stabilization for recurrent shoulder instability is well known, however there have been recent reports of postoperative dysfunction of the subscapularis tendon following open shoulder surgery (Habermeyer et al, Scheibel et al). We present our findings in patients who have undergone an open anterior stabilization using a subscapularis split approach. We reviewed 48 patients (49 shoulders), who were treated by the senior author (SB) from 2003–2005. They all underwent an open anterior stabilization of shoulder through a deltopectoral approach, with a subscapularis split technique, without any lateral tendon detachment. The minimum follow-up was 2 years, with average 34 months. Thirty-eight shoulders underwent an isolated anterior stabilization (1 bilateral) and 11 patients had additional procedures (8 bone grafts, 1 SLAP repair, 1 cuff repair, 1 anterior and posterior repair). There were 41 male and 7 female patients, and the mean age was 23.9 years (range 15–47 years). All patients were involved in sports and 45 had presented with recurrent dislocations. Patients were followed up using the Oxford instability score and the Rowe score questionnaires. All had a clinical examination for range of movement, stability, subscapularis muscle function, or signs of dysfunction. All had a MRI to assess the quality of the subscapularis muscle and tendon. Mean postoperative Oxford instability score was 22.5 and the Rowe score was 69.38. Two patients had redislocated following re-injury. There was no evidence clinically of subscapularis dysfunction and the muscle and tendon were normal on all MRI scans. External rotation was reduced by a mean of 15.6 degrees. There was no significant loss of flexion or abduction. 81% of patients returned to their previous level of sport. With a subscapularis split technique for anterior shoulder stabilization there is no significant postoperative dysfunction or damage to the subscapularis muscle, and most patients return to their previous level of sport

We evaluated the results of Cementless Surface Replacement Arthroplasty (CSRA) of the shoulder in 67 patients with advanced glenohumeral destruction who have an intact rotator cuff. Between november 2002 and december 2008, 70 CSRA (32 Copeland/ Biomet and 38 SMRR/ Lima) were implanted in 67 patients. A deltopectoral approach was used in 34 cases and an anterosuperior approach in 36 cases. Patients were assessed using Constant score, a patient satisfaction score and a detailed radiographic analysis. The mean follow up was 3.4 years (range 1 to 7.5 years). The mean Constant score improved preoperatively from 17.6 points (range 2–55) to an average postoperative score of 66.1 (range 13–91). The pain score improved from 1.13 points (range 0–6) to 12.3 points (range 3–15). The forward flexion and external rotation improved from 71° (range 20 to 140) and 0° (range −40 to +45) to 143° (range 60 to180) and 34.4° (range −20 to +60) respectively. Complications included: 1 subscapularis detachment, 5 secondary rotator cuff tear, 1sepsis, 3 patients with shoulder stiffness. No shift in implant position was observed. 11 humeral components developed radiolucencies at the prosthesis-bone interface. The radiographic analysis involved a system of dividing the prosthesis/bone interface into 5 zones. The best clinical results were significantly achieved in patients with necrosis compared with osteoarthritis (Constant Score, ant. elevation, ext. Rotation). Using regression analysis we found that changes in the head-shaft angle position of the implant (valgus/varus placement of the CSRA) significantly predicted the age and sex adjusted Constant score. When the inclination angle of the humeral head decreases, the adjusted Constant score increases. In the same model, we also found that the lateral offset of the humerus significantly predicted the adjusted Constant score. When the lateral offset of the humerus decreases, the adjusted Constant score increases. The medialization of the glenoid significantly and negatively predicted the Constant score. Conclusion. CSRA of the shoulder outcomes have been comparable with those of stemmed arthroplasties. Radiolucent lines occur with follow up and most of the time located in the S1 area. Glenoid wear and humeral head lateralization negatively impact the clinical score. Cementless Shoulder resurfacing is a viable alternative to conventional shoulder arthroplasty

Aim: To evaluate the results of internal fixation of displaced proximal humeral fractures with a locking plate system. Material and Methods: Between 2002 and 2003, 126 patients presented to our shoulder unit with proximal humeral fractures. Of these, 22 healthy active patients with displaced two to four-part fractures underwent open reduction and internal fixation with a locking compression plate system (Philos, Stratec UK Ltd). Their average age was sixty-two years. They were evaluated clinically and radiologically at 4, 12, 26 weeks or until union. Objective assessment was measured by the Constant scoring system, subjective assessment by the Oxford shoulder questionnaire. Surgical Technique: Through an anterior deltopectoral approach, the fracture was reduced. A titanium plate designed to contour over the lateral aspect of the humeral head was applied with minimum of five locking screws in head fragment and three in the humeral shaft. Tuberosities approximation was reinforced with Ticron sutures through the rotator cuff and the holes in the plate. The shoulder was immobilised in a sling for two weeks followed by gradual mobilisation program with the physiotherapist. Results: All fractures united with a mean healing time of fourteen weeks. There were no malunion, non-union or failure of fixation. The mean constant score was 78. The average range of flexion was 1330, abduction of 1250 and external rotation of 430. One patient had a significant fall three months after surgery and sustained an undisplaced fracture of shaft of humerus below the plate. Treated non operatively, both fractures went on to uneventful union. Conclusions: Internal fixation with locking plate system in healthy active patients, disregarding their age, is a reliable method of treating displaced proximal humerus fractures. In our experience, the functional outcome of these patients was superior to those patients treated with hemiarthroplasty or intramedullary fixation

Introduction. Persistent problems and relatively high complication rates with reverse total shoulder arthroplasty (RTSA) are reported (1, 2). It is assumed that some of these complications are affected by improper intraoperative soft tissue tension. Achieving proper intraoperative soft tissue tension is an obvious surgical goal. However, intraoperative soft tissue tension measurements and methods for RTSA have not been reported. One way to quantify soft tissue tension is to measure intraoperative joint forces using an instrumented prosthesis. Hence, we have developed an instrumented RTSA to measure shoulder joint forces intraoperatively. The goal of this study was to measure intraoperative shoulder joint forces during RTSA. Materials and Methods. The instrumented shoulder prosthesis measures the contact force vector between the glenosphere and humeral tray. This force sensor is a custom instrumented trial implant that can be used with an existing RTSA system (EQUINOXE, Exactech Inc, Gainesville, FL) just as a standard trial implant is used. Four uniaxial foil strain gauges (QFLG-02-11-3LJB, Tokyo Sokki Kenkyujo Co., Ltd., JP) are instrumented inside the sensor. Using a calibration matrix, the three force components were calculated from four strain gauge outputs (3). Sixteen patients who underwent RTSA took part in this IRB approved study. All patients were greater than 50 years of age and willing to review and sign the study informed consent form. After obtaining informed consent for surgery, a standard deltopectoral approach to the shoulder was performed. The instrumented trial prostheses were assembled on the glenoid baseplate instead of a standard glenosphere. After the joint was reduced, joint forces were recorded during cyclic rotation, flexion, scapular plane movement (scaption), and adduction of the shoulder. Strain gauge outputs were recorded during these movements as well as the neutral position just before movements. Mean values of forces with each motion were compared by one-way analysis of variance (ANOVA). A multiple comparisons test was subsequently performed to examine differences between motions. Results. Three sensors failed due to intraoperative breakage of strain gauge wires, leaving 13 subjects with measured joint reaction forces. During abduction, for example, the force vector varied from superior to antero-medial, and the resultant joint force in abduction was 83 N in a representative subject (Figure 1). Average joint reaction forces decreased with shoulder motion from a neutral position to external rotation or scaption. Conversely, they increased with flexion or abduction (Figure 2). Mean force values were not the same for each movement (p = 0.018). Forces recorded during flexion and scaption movements differed significantly (p = 0.012). Discussion. The intraoperative forces acting in the RTSA have been measured for the first time, and these measurements are ongoing. We expect more measurements will permit surgeons objectively to place and align implant components to achieve predictable and durable RTSA results

Background: The Bankart repair remains a safe and effective method for repairing instability in shoulder injuries. We report the results of a large series of patients treated using this technique. Materials and Methods: We retrospectively reviewed 136 consecutively treated patients with either anterior, antero-inferior or multidirectional shoulder instability over a 7-year period from 1999–2006 with a minimum of 2-year follow-up. All patients underwent open bankart repair through a deltopectoral approach, performed by a single surgeon. A thorough chart review was performed and patients were evaluated according to the Oxford Instability Score (OIS), the level of sport returned to, the influence of pre-operative physiotherapy and the incidence of redislocation. Results: Of the 136 identified patients, 108 (79%) responded to the questionnaire. Of the responders, there were 95 males and 13 women. The average age was 24 years (range 14–72). Ninety-one patients had confirmed dislocations whereas 17 suffered from subluxations. The majority of patients had either anterior or antero-inferior instability, whereas four (3.7%) had multidirectional deficits. The average time to surgery from the index instability incident ranged from 3 months to 10 years. The average OIS was 23 which corresponded to a good result. There was no significance found in the OIS in relation to the age of the patient or pre-operative physiotherapy. Significant associations with a better outcome included: delay to surgery greater than 12 months; and the absence of multidirectional instability. Of those who actively participated in sport, 75% returned to the same level of non-contact sport where only 47% returned to a similar level in collision sports. Eight patients (7.4%) experienced re-dislocation post open repair and 3 (2.8%) reported feelings of subluxation. Conclusions: Open bankart repair +/− capsulorrhaphy remains the gold standard for treatment of patients with shoulder instability. While our rate of success, in terms of re-dislocation, is equivalent to international norms, we found that a delay to surgery may be associated with a better outcome. Furthermore, the use of the Oxford Instability Score enables accurate and easy determination of the success of the operation

Purpose of the study: The reversed total shoulder prosthesis is one of the treatments currently proposed for excentered glenoid osteoarthritic degeneration with massive rotator cuff tears. In light of the mediocre or at best highly variable results obtained with osteosynthesis or humeral arthroplasty for four-fragment fractures of the proximal humerus, indications for the reversed total shoulder prosthesis have been widened to include this category of traumatology patients. The purpose of this prospective study was to report outcome with the reversed prosthesis used for complex fracture of the proximal humerus in subjects aged over 70 years. Material and methods: Ten patients, mean age 76 years, underwent surgery performed by the same surgeon to insert a Delta (DePuy) reversed prosthesis for four-fragment complex displaced fracture of the proximal humerus. The deltopectoral approach was used for all patients. The rotator cuff status was assessed intraoperatively. Clinical (Constant score) and radiological assessment were noted at 24 months. Results: During the operation, only three of the ten shoulders presented a full thickness rotator cuff tear. One patients developed a complication requiring revision: early dislocation revised with a retaining polyethylene insert without recurrent dislocation. There were no cases of glenoid loosening at last follow-up. The weighted Constant score was 65/100. A pain-free shoulder was achieved in all ten patients. Anterior elevation was 130° on average, internal rotation reached hand to buttocks and active external rotation 20°. Discussion: In patients aged over 70 years presenting a complex four-fragment fracture of the proximal humerus, the reversed prosthesis enables improved function and restoration of satisfactory joint movement. Early postoperative recovery and the gain in pain relief are encouraging factors. There was however unsatisfactory restoration of active rotation. For the elderly subject, free of a massive rotator cuff tear, rapid recovery after insertion of an reversed prosthesis should be balanced against the possible preservation of active rotations with an anatomic prosthesis

Introduction and Aims: Isolated rupture of the subscapularis tendon is an uncommon condition that has generally been treated by early surgical repair. However, very little information is available regarding functional outcome following surgery. The purpose of this study was to evaluate patient reported outcome following surgical repair with a minimum follow-up of 12 months. Method: Thirteen consecutive patients underwent arthroscopy followed by open surgical repair of an isolated traumatic rupture of the subscapularis tendon. A deltopectoral approach was used in all cases with repair of the tendon using suture anchors. Tenodesis of the long head of the biceps tendon was carried out in all patients because of instability or rupture. Standardised pre- and post-operative examinations were performed which included goniometric measurements of range of motion and an assessment of subscapularis function and strength. The ASES Shoulder Assessment Form was completed both pre-operatively and at final review. Results: All patients reported significant pain and functional limitations pre-operatively, with an average pain score of 7/10 and ASES score of 41.2. Limitation of active arm elevation and clinical evidence of sub-scapularis rupture was present in all but one patient. At an average follow-up of 18 months all patients were satisfied and would undergo the procedure again. The average ASES score improved to 91.9, with all patients reporting minimal or no pain. All patients regained overhead elevation and external rotation to within 10 degrees of the other side. Internal rotation and subscapularis function improved in all patients. There were no complications. Conclusion: Early surgical repair of isolated tears of the subscapularis tendon provides excellent pain relief and reliable restoration of shoulder function and strength. Patient satisfaction is high and the average ASES score can be significantly improved. Associated abnormalities of the long head of biceps tendon are common and should be addressed at the time of surgery

Introduction: The reverse shoulder arthroplasty (RSA) is becoming increasingly common and the indications expanded. The objective of this study is to report the indications and results of RSA in a large multicenter study. Methodology: A retrospective, multicenter study was conducted including all RSA implanted between 1992 and 2002 in five centers in France. Of 457 patients involved in this study, 243 patients (53%) had cuff pathology: 149 had cuff tear arthropathy, 48 had massive cuff tears, and 45 had failed cuff surgery. Ninety-nine (22%) had revision of previous prostheses. Sixty (13%) had fracture-related problems. Twenty-six (6%) had osteoarthritis and two percent each had rheumatoid arthritis, tumors or other conditions. Three hundred and eighty-nine (85%) shoulders were available for review with greater than 2 years follow-up. The average age at review was 75.6 years (range, 22–92). The average follow-up was 43.5 months (range, 24–142). Results: Significant improvement was noted in Constant scores for pain (3.5 to 12.1), activity (5.8 to 15.1), mobility (12.1 to 24.5), and strength (1.3 to 6.1) (p< .0001). Active elevation improved, but active internal and external rotation did not. The results were dependent on the indication. Cuff tear arthropathy had the best results while revision procedures had the worst. Young age, preoperative stiffness, teres minor deficiency, tuberosity non-union and preoperative complaints of pain rather than loss of function tended to be associated with inferior results. The deltopectoral approach tended toward greater active elevation but greater risk of instability. Survivorship to the endpoints of revision and loosening was better for patients with rotator cuff problems than for patients with failed prior hemiarthroplasty. The functional results were noted to deteriorate progressively after six years in the cuff tear group, after five years in the revision hemiarthroplasty group, after three years in the osteoarthritis group, and after one year in the revision total shoulder arthroplasty group. Conclusions: The overall results of RSA are satisfactory and predictable. Functional results improved with improved active elevation, but no improvement in active internal and external rotation. However, results are dependent on the etiology

Humeral shaft fractures are among the most frequent fractures encountered in Orthopaedic Traumatology. Their treatment can be either conservative or operative depending on the location (proximal, middle or distal third), type (spiral, oblique, or transverse), radial nerve involvement, concomitant presence of thoracic injuries that preclude general anesthesia, as well as surgeon’s experience. Non union or delayed union complicates some of the conservatively and very few of the operatively treated fractures. We report of our experience with the management of humeral shaft non unions in 28 patients treated at our institution from 1990 to 2000. Six were male and twelve female aging from 21 to 68 years (mean 45 years).The interval between initial injury and operation varied from 6 months to 3 years (average 10 months).Regarding the location of non union,20 cases were located in the middle, 6 cases in the upper and 2 cases in the distal third. Operative technique: under general anesthesia using anterolateral approach for middle and distal third and deltopectoral approach for proximal third , the site of pseudarthrosis was exposed. In transverse and slightly oblique fractures a self compression plate was implanted without resection of pseudarthrosis or excessive soft tissue detachment .In spiral and true oblique fractures reduction performed initially, maintained with k-wires and fixated with self compression plate. Upon completion of osteosynthesis suction drain was put ,followed by wound closure and elastic bandage. Postoperatively a colar cuff was used for 2 weeks .Follow up examination with radiographic evaluation was done after 3 and 6 months. Signs of incomplete callus formation were obtained after 3 months whereas solid union was achieved after 6 months in all patients without any serious complication

Purpose: This paper will present the types and rates of complications of an initial consecutive series of 100 reverse total shoulder arthroplasties (TSA). Method: Since 2004, the initial 100 consecutive reverse TSA were performed by a single US surgeon in 97 patients with an average age of 72 years. A deltopectoral approach was used in all cases. Diagnoses include 49 shoulders with cuff tear arthropathy, 24 with a failed prior shoulder arthroplasty, 23 with an irreparable rotator cuff tear, 2 with a malunion and post-traumatic arthritis, 1 with rheumatoid arthritis, and 1 with osteoarthritis. All patients had painful pseudoparalysis. Average follow-up was 8 months, with 77 patients having a minimum 2-month follow-up. Two patients have expired (unrelated to surgery), and 1 patient has been lost to follow-up. Results: Of the 100 shoulders, 9 had local perioperative complications (9%) including 2 dislocations requiring 1 open reduction and 1 closed reduction, 2 intraoperative glenoid fractures, 3 resolved mononeuropathies (radial, ulnar, and musculocutaneous), 1 resolving brachial plexopathy, 1 post-op hematoma, and 1 intraoperative broken screw head. Three of the 4 neuropathies occurred in revision arthroplasty shoulders. Six shoulders (6%) had systemic perioperative complications including subacute MI, DVT, PE, and C. difficile colitis. Two patients (2%) have had complications outside the perioperative period including 1 stable acromial fracture at 5 weeks post-op, and 1 patient with a subluxatable shoulder. No infections occurred. Other than the 2 dislocations and the acromial fracture, no radiographic complications, such as dissociation of the components or catastrophic failure of the glenosphere fixation, were observed. Seven shoulders (7%) had Grade 3 scapular notching and none (0%) had Grade 4 notching. The overall complication rate was 18% with rates of 17% vs. 21% in primary vs. revision arthroplasties, respectively (p=0.91). Transient nerve palsies were more frequent in revisions vs. primaries (12.5% vs. 1.3%, p=0.066). Conclusion: There is an acceptably low rate of complications related to reverse TSA, particularly severe ones requiring reoperation (2%). Overall complication rates are not significantly different between revisions and primaries, but revisions trended towards more transient nerve palsies

Purpose: The reverse shoulder arthroplasty (RSA) is becoming increasingly common and the indications expanded. The objective of this study is to report the indications and results of RSA in a large multicenter study. Method: A retrospective, multicenter study was conducted including all RSA implanted between 1992 and 2002 in five centers in France. Of 457 patients involved in this study, 243 patients (53%) had cuff pathology: 149 had cuff tear arthropathy, 48 had massive cuff tears, and 45 had failed cuff surgery. Ninety-nine (22%) had revision of a previous arthroplasty. Sixty (13%) had fracture-related problems. Twenty-six (6%) had osteoarthritis and two percent each had rheumatoid arthritis, tumors or other conditions. Three hundred and eighty-nine (85%) shoulders were available for review at a mean follow-up of 44 months (range, 24–142). The average age at review was 76 years (range, 22–92). Results: Overall, significant improvement was noted in Constant scores for pain (3.5 to 12.1), activity (5.8 to 15.1), mobility (12.1 to 24.5) and strength (1.3 to 6.1) (p< 0.0001). Active elevation improved (p< 0.0001), but active internal and external rotation did not. The results were dependent on the indication. Cuff tear arthropathy had the best results while revision procedures had the worst. Young age, preoperative stiffness, teres minor deficiency, tuberosity non-union and preoperative complaints of pain rather than loss of function tended to be associated with inferior results. The deltopectoral approach tended toward greater active elevation but greater risk of instability. Survivorship to the endpoints of revision and loosening was better for patients with cuff tear pathology than for patients with failed prior hemiarthroplasty. The functional results were noted to deteriorate progressively after six years in the cuff tear pathology group, after five years in the revision hemiarthroplasty group, after three years in the osteoarthritis group, and after one year in the revision total shoulder arthroplasty group. Conclusion: Overall results of RSA are satisfactory and predictable. Functional results improved with improved active elevation, but no improvement in active internal and external rotation. However, results are dependent on etiology

Purpose: Reverse shoulder arthroplasty (RSA) is becoming increasingly common for a variety of indications. The most common postoperative complication is instability. The objectives of this study are to describe causes of RSA instability and preventive and treatment recommendations. Method: All members of the American Shoulder and Elbow Society were asked for cases of RSA instability. We retrospectively reviewed 52 cases in 52 patients, performed by 13 surgeons. The mean age was 67.5 years (range, 36–83). The mean follow-up was 32.7 months (range, 3–43). Results: The etiology included: cuff tear arthropathy (14 patients); revision arthroplasty (13 patients); fracture sequelae (6 patients); and other (6 patients). Twenty-four patients had previous shoulder surgery. All patients had a deltopectoral approach. Anterior deltoid deficiency was noted in 3 cases. Subscapularis insufficiency was noted in 27 cases. Humeral component dissociation occurred in 2 patients. The instability was: anterior (27 patients); posterior (5 patients); or inferior (3 patients). Instability occurred: in the first 48 hours (10 cases); between 2 to 30 days (13 cases); or after one month (12 cases). Causes of instability included: inadequate soft-tissue tension (23 patients); a large antero-inferior release (22 patients); subscapularis insufficiency (7 patients); hematoma (2 patients); trauma (2 patients), deltoid insufficiency (2 patients); glenosphere malposition (2 patients); acromion fracture (2 patients); and other (4 patients). Initial treatment included: non-operative (6 patients); closed reduction (23 patients); open reduction (3 patients); and revision arthroplasty (11 patients). Final outcomes included: persistent instability (7 patients); humeral revision (19 patients); glenoid revision (one patient); hemiarthroplasty (3 patients); and resection arthroplasty (2 patients). Conclusion: Main causes of RSA instability include inadequate soft tissue tension, large anteroinferior release and subscapularis insufficiency. Preventive measures include careful patient selection, restoration of humeral length, minimizing anteroinferior releases, maximizing soft-tissue tension, maintaining or restoring subscapularis integrity, immobilization in the case of subscapularis insufficiency and use of a postoperative drain. Treatment recommendations include restoration of humeral length, soft-tissue retensioning and prolonged immobilization

Patients using a neutral rotation brace post proximal humerus fracture fixation have improved functional outcome and external rotation of the shoulder compared to patients using a standard polysling. Patients who have proximal humerus fracture fixation with extramedullary plates and screws have a risk of reduced range of movement especially external rotation. Gerber et al showed that the average external rotation after fixation of proximal humeral fractures was 39 degrees in their patient cohort compared to a normal range of 80–100 degrees. This can lead to reduced function and poor patient related outcomes. Geiger et al showed that in a cohort of 28 patients, poor functional outcome was noted in 39.3% with an average Constant-Murley Score of 57.9. Current practice is to utilise a polysling holding the shoulder in internal rotation post-shoulder fixation. Patients usually wear the sling for up to 6 weeks. We believe that this increases the risk of adhesion formation with the shoulder in internal rotation in the shoulder joint. Therefore this can cause loss of external rotation in the shoulder joint. We believe that holding the shoulder in a neutral alignment, with a neutral rotation brace post-fixation, will enable an increased rate of external rotation post-operatively thus improving external rotation and functional outcome. There is currently no literature comparing the different slings used post-operatively and we believe that this study would be the first of its kind. It would have a substantial change in the way clinicians manage proximal humeral fractures and will potentially reduce the numbers of re-operations to divide adhesions or perform capsular releases. Secondary benefits include a potential earlier return to full function and work and improved patient satisfaction. Study proposal: Prospective Randomised Controlled Trial of the neutral rotation brace compared to the standard, currently used, polysling post proximal humerus fracture fixation. No blinding of either participants or clinicians. Three surgeons utilising similar fixation techniques via the deltopectoral approach and using Philos plate fixation (Synthes Ltd.). Standardised post-operative rehabilitation protocol for all patients. Follow up: clinical review and postal outcomes for 1 year. Primary outcomes: Post operative functional outcome scores (Oxford, DASH, EQL) obtained at 6 weeks, 9 weeks, 3 months and 1 year). These will be compared to scores taken pre-operatively. Secondary outcomes: Clinical review at 6 weeks, 3 months and 1 year with range of movement measurements. Radiographs also taken at 6 weeks and 3 months to assess union. Patient questionnaire at 1 year (with outcome scores) assessing patient return to work, complications and patient satisfaction. Inclusion criteria: Proximal humeral fractures requiring operative intervention with extramedullary plate fixation (i.e. fractures displaced by 1cm and/or angulated by 45 degrees or more). Age>18. Exclusion Criteria: Patients having intra-operative findings of complete Pectoralis major rupture or if operative exposure requires complete Pectoralis major tenotomy. (These patients need to be held in internal rotation with a standard polysling to allow healing of the Pectoralis major tendon)

Introduction: The treatment of Complex Proximal Humeral Fractures and Fractures associated with Dislocation is not still resolved. Internal Fixation sometimes is not possible due to comminuted and osteoporotic bone which is commonly found in this kind of Fractures. The use of Hemiarthroplasty in this situation, not always achieves a good functional outcome, usually related to a Non Union or Malunion of the Tuberosities. We began using Reversed Shoulder Arthroplasty in this Fractures due to good results this implant had had in Glenohumeral Arthritis associated a Rotator Cuff Deficiency. Material and Methods: From January 2004 to December 2008 we have treated 50 patients with Complex Proximal Humeral Fractures with a Reversed Shoulder Arthroplasty,38 were women and 12 were men with a mean age of 76 (38–84). The mean follow-up time was 20 months (10–36). We have used a Lima Reversed Arthroplasty in all the cases. The dominant arm were involved in 65 % of the patients. The Deltopectoral approach were used in all the cases. Thirty-five patients (70 %) were treated in less than 30 days after the fracture and 15 (30 %) were treated 30 days or more since the fracture happened. The operations were performed by 6 surgeons, but only 3 of them have performed more than 10 operations. We used the Constant Score and the American Shoulder and Elbow Score to evaluate the outcome of the implant. The preoperative movement were estimated on the mobility score of the contralateral shoulder. Results: The mean Constant and the mean modified Constant Score were 55 (23 to 73) and 70 (34 to 95). The average range of motion was 105 (45–140) for anterior elevation and 100 (35–125) for abduction. The mean modified American Shoulder and Elbow Surgeon was 64 (44–82). The average operation time was 105 minutes with a range (60–170). The main clinical complications has been: Three intraoperative Fractures of Glenoid, 2 post operative Glenoid Fractures, 2 Brachial Plexus Paralysis, 2 cases of Cubital Neuroapraxia, 2 Dislocations of the Prosthesis,2 superficial infections and 1 deep infection. Radiography it has been found Scapular Notch in 17 patients (34%), Periprothesic Calcification in 42 (84 %) and migration of the Tuberosities in 22 (44%). Conclusions: We have had better results in acute situations than chronics ones. Most of the complications occurs in the group of patients treated in more than 30 days since the Fracture has happened. The Reverse Shoulder Arthroplasty is an alternative to the Hemiarthroplasty, and an important tool which an Orthopaedic Trauma Surgeon has to consider, to resolve this kind of Fractures specially in elderly patients

The aim of this study was to assess the medium-term results of the Copeland cementless surface replacement of the shoulder for rheumatoid arthritis. Between 1986 and 1998, 75 patients with rheumatoid arthritis had a cementless surface replacement. They were 58 females and 17 males with a mean age 60 years (range: 24 to 88 years). The mean follow-up was 6 years (range: 2 to 14 years). The functional outcome was assessed using the Constant score and a patient satisfaction scale. The mean Constant score was 53.4 points for total shoulder replacements (76 age/ sex adjusted) and 47.9 points for hemiarthroplasty (71 age/ sex adjusted). Forward elevation improved from 50 degrees to 104 degrees for total shoulder replacements and from 47 degrees to 101 degrees for hemiarthroplasty. Seventytwo patients (96%) considered the shoulder to be better or much better. 3 patients (4%) felt the shoulder was the same. The deltopectoral approach was used in 38 while the antero-superior (Mackenzie) approach was used in 37 shoulders. The rotator cuff was intact in 24 shoulders, thin but intact in 21 shoulders, had a full thickness tear in 26 shoulders and a massive tear in four shoulders. Sixty-eight patients were available for radiological review. Fifty-six (82.4%) humeral components showed no lucent lines. Eleven (16.2%) showed localised lucent lines < 1mm and one was loose. Of the 39 glenoid components, 19 (48.7%) showed no lucent lines, 19 (48.7%) showed lucent lines < 1mm and one was loose. No lucencies were observed in the hydroxyapatite coated implants. Two patients in the total shoulder group with massive cuff tears required revision for component loosening. One patient in the hemiarthroplasty group was revised to a total due to pain, with complete pain relief. The results of CSRA are at least comparable to stemmed prosthesis in rheumatoid arthritis. However, CSRA preserves bone stock and allows easier revision in this relatively young group of patients. It also reduces the risk of humeral shaft fractures compared to a stemmed implant, especially when an elbow replacement is needed

Aims: The revision of hemi or total arthroplasty represents a difficult challenge for a shoulder surgeon. The purpose of this study was to report the results of a retrospective series of 30 reverse prosthesis. Materials and Methods: 17 patients were female, 13 were male; the mean age was 68 (45–84). 14 patients had at least 2 surgeries before the arthroplasty. Of the failed arthroplasties, 26 were hemiarthroplasties and 4 were total shoulder arthroplasties. The indication for the revision of hemiarthroplasty were: 10 migration of the tuberosities, 7 secondary rotator cuff tears, 5 were stiff, 2 glenoiditis,, one humeral loosening and one sepsis. The indication for the revision of total arthroplasty were 3 loosenning of the glenoïd component and 2 secondary rotator cuff tear with a superior ascension of the humeral head. The rotator cuff was always irreparable. We used mainly a deltopectoral approach. During the removing of the humeral component and the cement, 6 fractures of the diaphysis occurred treated by cerclage. A bone graft was used at the level of the glenoïd (3) and of the humerus (4). We implanted 19 Delta and 11 Arrow reverse prosthesis. The patients were reviewed clinically using the Constant score with a mean follow up 3 years (range 1–5 years). Results: The Constant score improved from 20 (6–39) pre operatively to 55 (44–87) post operatively. Shoulder flexion increased from 45 (20–100) pre operatively to 100 degrees (90–160) post operatively. Pain was improved from 3/15 to 13,66/15 post operatively. The worse results were obtained for the patients who were multioperated before the first arthroplasty. Four patients were reoperated: 2 for dislocations and two for material dysfunction(glenosphere). 6 patients were disappointed, 18 were satisfied and 6 patients were very satisfied subjectively with the procedure. No difference in term of clinical results between Delta and Arrow except no glenoid notch occurred with Arrow prosthesis. Discusssion and conclusion: After a failure of an hemi or total arthroplasty, if the cuff is no functional or no reparable, reverse prosthesis is currently the best salvage procedure. Bone glenoid stock and deltoid muscle are the limited factors. Surgical tips and tricks should be known before to do this difficult operation. Others procedures can be discussed: reconstruction of the coracoacromial arch, gleno-humeral arthrodesis, deltoïd flap or latissimus dorsi flap and others semi-contrained prosthesis. Patients who had pseudo-paralytic painfull shoulder, without stiffness after an arthroplasty with less than 2 previous operations represent our best results

Purpose: Nonunion of the surgical neck of the humerus can occur after orthopaedic or poorly-adapted surgery after displaced subtuberosity or cephalotuberosity fracture. The purpose of this study was to report functional and radiographic outcome after treatment with shoulder prosthesis. Material and methods: Twenty-two patients who had a non-constrained shoulder prosthesis were included in this retrospective multicentric study. Mean age was 70 years and mean follow-up was 45 months (range 2 – 9 years). The initial fracture had two fragments in six patients and was a three-fragment fracture involving the head and the tubercle in thirteen and a four-fragment fracture in three. Orthopaedic treatment was given in ten cases and surgical osteosynthesis was used in twelve. Time from fracture to implant insertion was 20 months. The deltopectoral approach was used for 21 humeral implants and one total shoulder arthroplasty (glenohumeral degeneration). The tuberosities were fixed to the cemented humeral stem and a crown of bone grafts were placed around the nonunion of the surgical neck. All patients were reviewed after a minimum of two years and assessed with the Constant score and x-rays. Results: The absolute Constant score improved from 23 reoperatively to 39 postoperatively with an anterior elevation of 53° to 63°. Pain score (from 3 to 9, p = 0.001) and external rotation (from 13° to 28°, p = 0.01) were significantly improved. Forty-five percent of the patients were satisfied and 55% were dissatisfied. The type of initial treatment, type of initial fracture, and time before implantation of the prosthesis did no affect final outcome. The complication rate was 36% (eight patients), and led to five revision procedures. The radiographic work-up disclosed six cases of persistent nonunion of the greater tuberosity, two proximal migrations of the prosthesis, and one humeral loosening. Conclusion: Outcome of shoulder prosthesis for sequela after fracture of the proximal humerus with nonunion of the surgical neck is poor. No improvement in anterior elevation, force, or motion was achieved. Shoulder prosthesis for sequelae of fracture of the proximal humerus with nonunion of the surgical neck should be considered as a “limited-objective” indication only providing beneficial pain relief

Purpose: We report the satisfactory results obtained in a retrospecive multicentric series of 80 shoulder prostheses implanted for aseptic osetonecrosis of the head of the humerus. Material and methods: Seventy-four patients (43 men, 31 women, men age 59 years) with aseptic osteonecrosis of the head of the humerus treated with a shoulder prosthesis were reviewed at least two years after surgery. The mean weighted score before surgery was 37%. Twenty-six total prostheses and 54 humeral prostheses were implanted via the deltopectoral approach. There had been few complications at review: seven stiff shoulders, one torn suture of the subscapularis with instability, two inflammatory glenoids, one migration. Physical exam and x-ray (ossifications, lucent lines) findings were recorded. Results: Mean follow-up was 47 months (24–104 months). The Constant score was improved significantly (p < 0.05). The total weighed score was 88% on the average and was not affected by gender, side, or dominant side. Ninety percent of the patients were satisfied or very satisfied. Gain in motion was significant in all movements with a mean 53° for active anterior elevation. For grade V shoulders, the improvement was significantly better with total shoulder arthroplasty while for grade II and III shoulders a humeral prosthesis was preferable. Full thickness tears of the rotator tendons did not influence overall outcome despite less recovery of motion (p < 0.05) and force (p = 0.09). Complications did not alter results. Discussion: A humeral prosthesis should be preferred for grade II–III shoulders and a total shoulder arthroplasty for major degeneration of the glenoid (grade V). For grade IV, either prosthesis may be used depending on the patient’s age, activity level, and status of the rotator cuff. For very young or very old patients, high levels of physical activity may argue against prosthesis implantation due to the risk of loosening or rotator cuff tears which are unfavourable factors. Conclusion: The results of this multicentric series corroborate data in the literature that shoulder arthroplasty provides good results for the treatment of aseptic necrosis of the head of the humerus. In generally, arthroplasty allows pain relief, good motion, particularly for external rotation, and good force recovery, explaining the better results obtained in active younger subjects

To devise an operative approach to the management of acute posterior fracture-dislocation of the shoulder which restores or retains normal proximal humeral anatomy and allows the early restoration of a complete, stable range of motion. Since 1996 we have treated four male patients (five shoulders) aged between 19 and 54 years at the time of first dislocation with autogenous iliac grafting of the anterior humeral head defect for acute and acuteon-chronic posterior dislocation of the shoulder. Two patients had epilepsy: one of these patients had bilateral dislocations. Two patients had motorbike RTAs. The deltopectoral approach with vertical division of the subscapularis tendon was used in all cases. The defects comprised 20– 25% of the volume of the humeral head at the equator after preparation for grafting. Grafts were fixed with compression screws. The subscapularis tendon was repaired anatomically. Active-assisted rehabilitation was started immediately, restricting external rotation to the neutral position for six weeks, thereafter allowing full rotation and elevation as comfort allowed. The patient with bilateral dislocations died of unrelated causes 18 months after surgery. He was reported to have had no further dislocations, complete pain free functional use of both shoulders and no complications of the procedure. The remaining three patients were reviewed at a minimum of 20 months after surgery (average 35 months). All grafts had incorporated. There was no graft collapse or boundary arthrosis. The absolute Constant scores were 85.1, 90.9, and 89.2; the subjective shoulder scores were 98%, 90%, and 99%; the Oxford rating scale for pain scores were 14 out of 60, 13 out of 60, and 14 out of 60; and the Oxford rating scale for instability scores were 14 out of 60, 15 out of 60 and 15 out of 60. There were no redislocations, or complications of the procedures. Posterior stability appears more dependant on surface arc of contact than on capsular integrity, in contrast to the anteriorly unstable shoulder. Restoration of the articular surface arc of contact by segmental autogenous grafting retains normal humeral anatomy, allows normal motion with excellent cuff function, and a return to normal daily activities. The procedure has been shown to be safe at a minimum of 20 months