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

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

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

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