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Rotator cuff retear is a major concern after arthroscopic rotator cuff repair (ARCR); however, the effects of retear remain unclear. Therefore, the purpose of this study was to assess the clinical outcomes of postoperative retear and intact tendons after ARCR.We searched PubMed, Cochrane Library, Scopus, and PEDro databases for studies performed from January 2000 to June 2020. Clinical outcomes included the Constant score, American Shoulder and Elbow Surgeons (ASES) score, University of California Los Angeles shoulder (UCLA) score, pain score, range of motion, and muscle strength. Meta-analysis using random-effects models was performed on the pooled results to determine significance.The initial database search yielded 3141 records. After removal of duplicates, 26 of which met the inclusion criteria. Patients in the retear group had significantly lower Constant score [- 8.51 points (95% CI, - 10.29 to - 6.73); P 0.001], ASES score [- 12.53 points (95% CI, - 16.27 to - 8.79); P 0.001], UCLA score [- 3.77 points (95% CI, - 4.72 to - 2.82); P 0.001], and significantly higher pain score [0.56 cm (95% CI, 0.10 to 1.01); P = 0.02] than the intact group. In addition, the retear group had significantly lower flexion [- 10.46° (95% CI, - 19.86 to - 1.07); P = 0.03], abduction [- 14.84° (95% CI, - 28.55 to - 1.14); P = 0.03], and external rotation [- 7.22° (95% CI, - 13.71 to - 0.74); P = 0.03] range of motion, and flexion [- 1.65 kg·f (95% CI, - 2.29 to - 1.01); P 0.001], abduction [- 1.87 kg·f (95% CI, - 3.02 to - 0.72); P = 0.001], and external rotation [- 1.66 kg·f (95% CI, - 3.25 to - 0.07); P = 0.04] muscle strength.Our results suggest that retear after ARCR leads to poor clinical outcomes after surgery.

Introduction We use machine learning to create predictive models from preoperative data to predict the Shoulder Arthroplasty Smart (SAS) score, the American Shoulder and Elbow Surgeons (ASES) score, and the Constant score at multiple postoperative timepoints and compare the accuracy of each algorithm for anatomic (aTSA) and reverse (rTSA) total shoulder arthroplasty. Methods Clinical data from 2,270 aTSA and 4,198 rTSA patients were analyzed using 3 supervised machine learning techniques to create predictive models for the SAS, ASES, and Constant score at 6 different postoperative timepoints using a full input feature set and the 2 different minimal feature sets. Mean absolute errors (MAE) quantified the difference between actual and predicted outcome scores for each model at each postoperative timepoint. The performance of each model was also quantified by its ability to predict improvement greater than the minimal clinically important difference (MCID) and the substantial clinical benefit (SCB) patient satisfaction thresholds for each outcome measure at 2-3 years after surgery. Results All 3 machine learning techniques were more accurate at predicting aTSA and rTSA outcomes using the SAS score (aTSA: ±7.41 MAE; rTSA: ±7.79 MAE), followed by the Constant score (aTSA: ±8.32 MAE; rTSA: ±8.30 MAE), and finally the ASES score (aTSA: ±10.86 MAE; rTSA: ±10.60 MAE). These prediction accuracy trends were maintained across the 3 different model input categories for each of the SAS, ASES, and Constant models at each postoperative timepoint. For aTSA patients, the XGBoost predictive models achieved 94-97% accuracy in MCID with an AUROC between 0.90-0.97 and 89-94% accuracy in SCB with an AUROC between 0.89-0.92 for the 3 clinical scores using the full feature set of inputs. For rTSA patients, the XGBoost predictive models achieved 95-99% accuracy in MCID with an AUROC between 0.88-0.96 and 88-92% accuracy in SCB with an AUROC between 0.81-0.89 for the 3 clinical scores using the full feature set of inputs. Discussion Our study demonstrated that the SAS score predictions are more accurate than the ASES and Constant predictions for multiple supervised machine learning techniques, despite requiring less input data for the SAS model. Additionally, we predicted which patients will, and will not achieve clinical improvement that exceeds the MCID and SCB thresholds for each score; this highly accurate predictive capability effectively risk-stratifies patients for a variety of outcome measures using only preoperative data.

Introduction: The aim of this study was to create a novel complication classification for osteosynthesis-related complications following angular stable plating of the proximal humerus subsuming the influence of these complications on clinical outcome in relation to fracture morphology and consequent revision strategies. A total of 1047 proximal humerus fractures with overall 193 osteosynthesis-associated complications (24.5%) were included. The following complication types could be clarified: complication Type 1 is defined by mild varus (20°) of the humeral head with screw cutout at the humeral head cortex. Complication Type 3 describes a displacement of the angular stable plate in the humeral shaft region with associated shaft-sided screw cutout, while the position of the humeral head remains static. Complication Type 4 is characterized by the occurrence of AVN with or without glenoidal affection (4a/b). Clinical outcome according to the constant score was mainly affected by type 2–4, leading to a deteriorated result. Depending on the type of complication, specific revision strategies can be considered. Additionally, more complex fracture patterns fostered the incidence of complications.

The purpose was to report the short-term outcomes and survival of hemiarthroplasty with a pyrocarbon head (HA-PYC) for the treatment of shoulder osteoarthritis in patients aged ≤ 60 years. We hypothesized that HA-PYC could be an alternative to hemi-metal (avoiding the risk of rapid glenoid erosion) and total shoulder arthroplasty (TSA) (avoiding the risk of rapid glenoid loosening) in an active patient population.Sixty-four consecutive patients (mean age, 53 years) who underwent HA-PYC for glenohumeral osteoarthritis were included. The primary outcome was revision to TSA or reverse shoulder arthroplasty. Secondary outcome measures included functional outcome scores; return to work and sports; and radiographic evaluation of humeral reconstruction quality using the "circle method" of Mears, as well as glenoid erosion severity and progression using the Sperling classification. Patients were reviewed and underwent radiography at an average follow-up of 33 months (range, 24-60 months).At last follow-up, the rate of survival of the HA-PYC prosthesis was 92%. Revision was performed in 5 patients, with a mean delay of 24 months (range, 15-37 months): 1 conversion to TSA and 4 conversions to reverse shoulder arthroplasty. The Constant score and Subjective Shoulder Value increased from 36 points (range, 26-50 points) to 75 points (range, 69-81 points) and from 35% (range, 20%-50%) to 80% (range, 75%-90%), respectively (P.001). Postoperatively, 91% of the patients (42 of 46) returned to work and 88% (15 of 17) returned to sport. The severity of preoperative and postoperative glenoid wear (Sperling grade 3 or 4) had no influence on the functional results. Patients who underwent associated concentric glenoid reaming (n = 23) had similar Constant scores and Subjective Shoulder Values (P = .95) to other patients and did not show more progression of glenoid wear. Nonanatomic reconstruction of the proximal humerus (center of rotation of the prosthesis3 mm from the anatomic center) occurred in 29% (18 of 62 patients) and was associated with significantly lower functional and subjective results, more complications (subscapularis insufficiency and/or symptomatic glenoid erosion), and a higher risk of revision. The additional 1.5-mm thickness of the metal disc under the pyrocarbon head was found to be the main reason for oversizing of the prosthetic head.HA-PYC is a reliable procedure to treat shoulder osteoarthritis and allows return to work and sports in a young (≤60 years) and active patient population. The severity of glenoid bone erosion or the association with glenoid reaming does not affect functional outcomes and failure risk. By contrast, nonanatomic reconstruction of the proximal humerus after HA-PYC (because of humeral head oversizing) occurred in one-third of the cases and is associated with lower functional outcomes, as well as higher risks of complications and revision.

Background Reverse shoulder arthroplasty (RSA) is a valuable solution for patients with shoulder pain or injury primarily due to a rotator cuff tear or secondary to traumatic events. Nevertheless, several complications are known to appear, with the most frequent being scapular notching (SN) on the inferior and posterior scapular neck. Controversial data exist about the clinical relevance of SN. Since further consequences are still not clearly understood, we aimed to provide more clarity on which factors, especially external rotation (ER), contribute to the appearance and progress of notching. Methods Constant Score (CS), Subjective Shoulder Value (SSV), flexion, abduction, and ER were evaluated retrospectively in 153 shoulders of 147 patients (mean age 79±7.7 years; 62% women) who underwent RSA between 2005 and 2010. Anteroposterior radiographs were evaluated before and 1, 2, 3, and 5 years after RSA for SN according to the Sirveaux classification. The evaluation was performed by two independent surgeons. Spearman’s coefficient and t-test were used. Results CS, SSV, flexion, and abduction increased significantly 1 year after RSA compared to before (all p

Aims The outcomes with metal head hemiarthroplasties (HA) are contrasted, especially in young, active patients. An innovative Pyrocarbon interface was introduced in 2014 in order to decrease potential glenoid wear. The aim of this study is to evaluate survival and short-term results of HA with a pyrocarbon head. Methods We conducted a retrospective single-centre study: 30 consecutive patients underwent HA with pyrocarbon humeral head and were assessed with a minimum follow-up of 2 years. The mean age at surgery was 54 ± 13 years; 38% of patients (n = 13) had undergone surgery at least once on the affected shoulder. Depending on the aetiology, 4 groups were analyzed: group 1 (osteonecrosis, n = 12), group 2 (primary gleno humeral osteoarthritis, n = 10), group 3 (fracture sequelae, n = 4) and group 4 (revision, n = 4). Results A significant improvement in clinical results was documented at mean follow-up of 38 months: mean Constant score (preop 35 ± 15 vs. postop 67 ± 19 points; Conclusion HemiPYC provided satisfactory clinical outcomes without glenoid wear at short-term follow-up. Disappointing results were recorded in the case of severe fracture sequelae. Mid and long-term studies should be carried out to confirm these results. Level of evidence Level IV; Retrospective Study

Background: Few studies on the outcomes of anatomic total shoulder arthroplasty (aTSA) in Asian populations have been reported. In addition, approximately one-third of primary aTSA were performed for patients 80 years or older in Japan, but the indication of aTSA for the primary shoulder osteoarthritis in the elderly population remained unclear. The purposes of this study were (1) to investigate clinical outcomes of aTSA in Japanese patients with primary glenohumeral osteoarthritis and (2) to compare clinical outcomes between patients 80 years or older and 70 years or younger. We hypothesized that aTSA would yield favorable outcomes in Japanese patients and that the outcomes of aTSA in patients 80 years or older would be comparable to those 70 years or younger. Methods: Patient records were retrospectively reviewed to collect patients who underwent aTSA for glenohumeral osteoarthritis between August 2011 and September 2017. The inclusion criterion of this study was aTSA performed for glenohumeral osteoarthritis. Exclusion criteria were as follows: (1) secondary osteoarthritis, (2) revision surgery, and (3) < 24-month follow-up. Range of motion (ROM) and Constant score were evaluated, and complications were investigated. Rotator cuff integrity was assessed by ultrasonography. We compared the outcomes between patients 80 years or older and 70 years or younger. Results: Seventy-seven shoulders (72 patients) met the study criteria. There were 14 men and 58 women with a mean age of 75 years (range, 57-93 years) at the time of surgery. The mean follow-up was 40 months (range, 24-84 months). The Constant score significantly improved from preoperative 54 (range, 35-78) to postoperative 89 (range 69-100, P = .03). Range of motion also showed significant improvement after surgery: flexion, 90° (range, 60°-130°) to 140° (range, 90°-170°); external rotation at the side, from 7° (range, -10 to 60°) to 40° (range, 5°-70°); internal rotation, from buttock (range, buttock-L3) to L2 level (range, buttock-T8) (P

Background There is still a disagreement on the postoperative rehabilitation concerning position of immobilization of the shoulder after arthroscopic anterior shoulder stabilization and its influence on the clinical outcome. The aim of this study was to evaluate the clinical results and the recurrence rate after arthroscopic anteroinferior shoulder stabilization and postoperative immobilization in internal rotation vs. external rotation. Methods Twenty-five patients (22 male and 3 female, mean age 28.5 years) were included in this prospective nonrandomized cohort study. In group I (11 male, 2 female, mean age 28 years), the postoperative functional immobilization was carried out in internal rotation of 60°, and in group II (11 male, 1 female, mean age 30 years), 15° of external rotation of the arm for 4 weeks in both groups. The clinical follow-up was performed at 2, 4, and 6 weeks as well as at 3, 6, and 12 months postoperatively including assessment of range of motion and functional shoulder scores (Subjective Shoulder Value, Constant score, Rowe score, Walch Duplay score, Melbourne Instability Shoulder Score). Furthermore, shoulder instability was evaluated using the apprehension, relocation, and surprise tests. Mid-term follow-up data were additionally assessed after a minimum of 4 years. Results Twenty patients (19 male and 1 female) with an average age of 28 years were followed up for 62 (53-72) months after arthroscopic stabilization. The comparison of both groups showed almost equal results regarding the range of motion without any significant differences (P > .05). The evaluation of the shoulder function scores also showed no significant differences with an average Subjective Shoulder Value of 95% vs. 91%, Constant score of 89 vs. 88 points, Rowe score of 96 vs. 94 points, Walch Duplay score of 86 vs. 89 points, Melbourne Instability Shoulder Score of 96 points, and Western Ontario Shoulder Instability Index of 88% vs. 84% (P > .05). There was no recurrent dislocation in both groups. Conclusion The type of immobilization after arthroscopic shoulder stabilization does not influence the clinical results after a mid- to long-term follow-up.

To compare outcomes, complications, revisions, and rates of implant removal of superior compared to anteroinferior plating in displaced midshaft clavicle fractures at mid-term follow-up. We retrospectively reviewed 79 patients who underwent operative treatment for displaced midshaft clavicle fractures (Group A: 28 patients with superior plating; Group B: 51 patients with anteroinferior plating) that were at least 2 years postoperatively. Adjusted Constant Score (aCS), Visual Analog Scale (VAS), and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score were compared. Bone union, implant removal, complications and revision surgeries were assessed. Group A had a significantly higher aCS compared to group B (90, IQR: 85.0–91.0 vs. 91, IQR: 90.0–93.0; P = 0.037). No significant differences between groups were seen in VAS (P = 0.283) and QuickDASH (P = 0.384). Bone union was achieved in 76 patients (96.2%) with no significant differences between groups (Group A: 96.4% vs. Group B: 96.1%; P > 0.999). There were no significant differences in implant removal rates (Group A: 60.7% vs. Group B: 66.7%; P = 0.630), complications (Group A: 46.4% vs. Group B: 31.4%; P = 0.226) and revisions (Group A: 25% vs. Group B: 9.8%; P = 0.102). Superior and anteroinferior plating result in high bone union rates and good clinical outcomes with similar rates of plate removal.

BACKGROUND It is unknown whether locking or nonlocking superior plate fixation is better for managing displaced midshaft clavicle fractures. Therefore, we aimed to compare the clinical and radiographic outcomes of locking and nonlocking superior plate fixation of displaced midshaft clavicle fractures. METHODS A total of 102 consecutive patients with displaced midshaft clavicle fractures (2B1 and 2B2 in Robinson classification) participated in this randomized controlled trial; 12 patients were excluded. Surgeries were performed using a 3.5-mm Locking Compression Plate (LCP) between 2007 and 2015. Patients were treated either with a locking plate (group L, n = 45) or a nonlocking plate (group N, n = 45). In both groups, the plates were fixed to the proximal and distal clavicle with two and/or three screws, respectively. The main outcome measures were complication rates, time to bone union, and Constant score. RESULTS Forty-two patients in group L (mean age, 45.9 years) and 41 in group N (mean age, 43.6 years) were followed. The overall complication rates in groups L and N were 7.2% (three peri-implant fractures) and 7.3% (non-union, deformed plate, and peri-implant fracture), respectively (p = .98). The average time to union significantly differed between groups (L vs. N: 13.0 ± 4.1 vs. 17.5 ± 6.3 weeks; p

Purpose To perform a systematic review comparing clinical outcomes, radiographic outcomes, and complication rates after acute (surgery ≤6 weeks from injury) versus chronic (surgery >6 weeks from injury) acromioclavicular joint reconstructions for grade III injuries using modern suspensory fixation techniques. Methods We performed a systematic review of the literature examining acute versus chronic surgical treatment of Rockwood grade III acromioclavicular joint separations using the Cochrane registry, MEDLINE database, and Embase database over the past 10 years according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The inclusion criteria included techniques using suspensory fixation, a minimum study size of 3 patients, a minimum follow-up period of 6 months, human studies, and English-language studies. The methodology of each study was evaluated using the Methodological Index for Non-randomized Studies (MINORS) tool for nonrandomized studies and the revised Cochrane risk-of-bias (RoB 2) tool for randomized controlled trials. Results The systematic review search yielded 20 studies with a total of 253 patients. There were 2 prospective randomized controlled trials, but most of the included studies were retrospective. On comparison of acute surgery (≤6 weeks) and chronic surgery (>6 weeks), individual studies reported a range of Constant scores of 84.4 to 98.2 and 80.8 to 94.1, respectively. The ranges of radiographic coracoclavicular distances reported at final follow-up also favored acute reconstructions, which showed improved reduction (9.2-15.7 mm and 11.7-18.6 mm, respectively). The reported complication rates ranged from 7% to 67% for acute reconstructions and from 0% to 30% for chronic reconstructions. Conclusions The ranges in the Constant score may favor acute reconstructions, but because of the heterogeneity in the surgical techniques in the literature, no definitive recommendations can be made regarding optimal timing. Level of Evidence Level IV, systematic review of Level I through IV studies.

Background: Lesions of the rotator cuff (RC) are a common occurrence affecting millions of people across all parts of the globe. RC tears are also rampantly prevalent with an age-dependent increase in numbers. Other associated factors include a history of trauma, limb dominance, contralateral shoulder, smoking-status, hypercholesterolemia, posture and occupational dispositions. The challenge lies in early diagnosis since a high proportion of patients are asymptomatic. Pain and decreasing shoulder power and function should alert the heedful practitioner in recognizing promptly the onset or aggravation of existing RC tears.Aim of the work: The present study aims to conduct a systematic review and meta-analysis about arthroscopic repair outcomes in patients with full thickness rotator cuff tear, using double row suture anchor techniques.Patients and Methods: Systematic review and Meta-analysis study. The literature search identified 50 studies for consideration; however, 7 studies were excluded following abstract screening. For the remaining studies, examination of the full-text manuscripts was conducted, and only 9 of the 33 articles met all eligibility criteria and were included in the analysis.Results: The study yielded the following results: the average pain score improved from 7.4 points preoperatively to 0.7 point postoperatively. The subjective outcome was excellent or good in 220 (90.9%) of the 242 shoulders. the average increase in the Constant score after the operation was 25.4.Conclusion: Nine studies were selected which met all eligibility criteria because of lack of studies containing these criteria. Also meta-analysis was used to get this conclusion. Nevertheless, this study does not include uniform studies as currently there is no consensus on same data of selected studies; however it includes repair by double row technique only.

Background The effect of humeral component retroversion on clinical outcomes after reverse total shoulder arthroplasty (RTSA) is unclear. Intended retroversion intraoperatively may not produce the same retroversion of the humeral component postoperatively. Methods This retrospective study was conducted on consecutive patients who received RTSA using a single product with humeral lateralization at a targeted 25° of humeral retroversion from 2014 to 2019 with minimum 1-year clinical follow-up and postoperative computed tomography (CT). Forty-five patients were enrolled, and humeral component retroversion was measured three-dimensionally. Correlation and regression analyses were conducted between humeral retroversion and postoperative isometric strength and range of motion in forward flexion (FF), external rotation (ER), and internal rotation (IR). Group comparison between a ≤25° group and a >25° group was conducted as sub-analysis to verify possible confounders. Results The actual humeral retroversion was 21.7 ± 11.9°, and it was significantly correlated with postoperative FF [Pearson's correlation coefficient (PCC) = 0.464, P= .003], ER (PCC = 0.481, P = .002), and IR (PCC = 0.471, P = .002) strengths. Multivariable regression analysis showed that humeral retroversion was significantly associated with postoperative FF (Exp(B) = 0.492, P = .003), ER (Exp(B) = 0.336, P = .002), and IR (Exp(B) = 0.578, P = .002) strengths. Two groups in sub-analysis showed no significant difference in pre- or intraoperative variables other than humeral component retroversion. Some functional outcome scores including the Constant score, American Shoulder and Elbow Surgeons score, and activity scales were significantly higher in the >25° group. Conclusion Discrepancies between intraoperatively targeted humeral retroversion angle and actual postoperative angle after RTSA should be considered by operators and researchers. Increased humeral component retroversion than recommendation can yield acceptable outcomes and might be associated with higher postoperative strength, and possibly with better functional outcome after RTSA with humeral lateralization. Level of evidence Level III; Retrospective Comparative Study

Background To evaluate the feasibility and safety of a new minimally-invasive surgical approach–anteromedial minimally-invasive plate osteosynthesis (MIPO)–in the treatment of middle and distal humeral shaft fractures. Methods Fourteen patients with humeral shaft fracture treated with anteromedial MIPO from November 2016 to March 2020 (MIPO Group) were selected as the study subjects. Open reduction and internal fixation (ORIF) were used to treat 14 patients with humeral shaft fractures as the control group (ORIF group). The two groups were fixed with a locking compression plate (LCP) or LCP + multi-directional locking screw system (MDLS). The incision length, intraoperative blood loss, intraoperative fluoroscopy time, operation time, length of hospital stay, fracture healing time, QuickDASH score and Constant score were observed and compared between the two groups. Results Fourteen patients were enrolled in each group. The incision length (7.79 ± 2.39 cm), intraoperative blood loss (96.07 ± 14.96 mL), operative time (110.57 ± 21.90 min), hospital stay (6.29 ± 1.49 days) and fracture healing time (14.94 ± 0.99 weeks) in the MIPO group were all lower than those in the ORIF group, and the difference was statistically significant for each parameter (P P P = 0.078), QuickDASH score (P = 0.074) or Constant score (P = 0.293) between the two groups and no postoperative complications occurred in any of the patients. Conclusion The anteromedial approach MIPO technique has the advantages of less trauma, less bleeding, low risk of nerve injury and high rate of fracture healing. It is one of the most effective methods for the treatment of middle and middle–distal humeral shaft fractures.

Fragestellung: Die Schulterkraftmessung ist ein essenzielles diagnostisches Mittel zur Evaluation der prä- und postoperativen Schulterfunktion. Verschiedene Arten der Kraftmessung wurden beschrieben und eingesetzt. Die isometrische Kraftmessung des Constant Score (CS) wurde initial mit einem Kabel-Tensiometer [zum vollständigen Text gelangen Sie über die oben angegebene URL]

In this article we report a 74 year old patient with Ideberg-type III fracture who was treated with indirect reduction and fixation. The patient was a sportive biker who suffered from a high energy trauma (road accident). X-ray revealed a scapula fracture, and only after a CT-Scan we could confirm the fracture type (Ideberg-type III glenoid fracture). The patient was operated and re-evaluated at follow-up. During the surgery we prefered not to access intra-articular due to the low joint involvement. He was able to resume his daily activities at two months postoperatively. At three months ASES Score was 91.5; Constant Score was 71 (vs 96 of unaffected arm). The patient revealed to be satisfied with the treatment, moreover the clinical results are encouraging in view of further improvements in the following months.

Publisher Copyright: © 2021 Arthroscopy Association of North America Purpose: The purpose of this noninterventional, register-based study was to report the outcomes and wound healing of surgically treated chronic acromioclavicular (AC) dislocations using a tendon graft and knot-hiding titanium implants. Methods: Thirty-two cases with chronic AC separation underwent an arthroscopic coracoclavicular (CC) ligament reconstruction and an open AC ligament reconstruction using knot-hiding titanium implants. The wound healing was assessed 2 months after the operation. The Nottingham Clavicle score, Constant score, and Simple Shoulder Test were obtained postoperatively and at a minimum of one-year postsurgery. The radiographic change in distance between the clavicular and coracoid cortices and clavicular tunnel diameter was measured. General patient satisfaction with the outcome (poor, fair, good, or excellent) was also assessed 1 year postoperatively. Results: The mean Nottingham Clavicle score increased from a preoperative mean of 41.66 ± 9.86 to 96.831 ± 5.86 (P ≤.05). The Constant score increased from a preoperative mean of 44.66 ± 12.54 to 93.59 ± 7.01 (P ≤.05). The Simple Shoulder Test score increased from a preoperative mean of 7.00 ± 2.14 to 11.84 ±.63 (P ≤.05). The coracoclavicular distance increased from 11.32 ± 3.71 to 13.48 ± 3.79 mm (P ≤.05). The clavicular drill hole diameter increased from 6 mm to a mean of 6 to a mean of 8.13 ± 1.12 mm. Twenty-three (71.9%) patients reported an excellent outcome, and nine (28.1%) reported a good outcome. One clavicular fracture occurred but no coracoid fractures. There was one reconstruction failure leading to a reoperation. Conclusions: In this series, combining the arthroscopic CC ligament reconstruction to an open reconstruction of the AC joint with a tendon graft proved to be a stable solution. The knot-hiding titanium implant effectively eliminated the problems related to the clavicular wound healing. Level of Evidence: Level IV, therapeutic case series.

Background An important psychometric parameter of validity that is rarely assessed is predictive value. In this study we utilize machine learning to analyze the predictive value of 3 commonly used clinical measures to assess 2-year outcomes after total shoulder arthroplasty (TSA). Methods XGBoost was used to analyze data from 2790 TSA patients and create predictive algorithms for the American Shoulder and Elbow Surgeons (ASES), Constant, and the University of California Los Angeles (UCLA) scores and also quantify the most meaningful predictive features utilized by these measures and for all questions comprising each measure to rank and compare their value to predict 2-year outcomes after TSA. Results Our results demonstrate that the ASES, Constant, and UCLA measures rarely considered the most-predictive features relevant to 2-year TSA outcomes and that each outcome measure was composed of questions with different distributions of predictive value. Specifically, the questions composing the UCLA score were of greater predictive value than the Constant questions, and the questions composing the Constant score were of greater predictive value than the ASES questions. We also found the preoperative Shoulder Pain and Disability Index (SPADI) score to be of greater predictive value than the preoperative ASES, Constant, and UCLA scores. Finally, we identified the types of preoperative input questions that were most-predictive (subjective self-assessments of pain and objective measurements of active range of motion and strength) and also those that were least-predictive of 2-year TSA outcomes (subjective task-specific activities of daily living questions). Discussion Machine learning can quantify the predictive value of the ASES, Constant, and UCLA scores after TSA. Future work should utilize this and related techniques to construct a more efficient and effective clinical outcome measure that incorporates subjective and objective input questions to better account for the preoperative factors that influence postoperative outcomes after TSA. Level of Evidence Level III; Retrospective Comparative Study

Introduction Little information is available on the clinical and radiographic outcome of intraoperative, non- to minimally displaced humeral fractures that occur during implantation of a stemmed, reverse shoulder prosthesis but are only recognized on routine postoperative radiographs. The goal of this study is to report the clinical and radiographic outcome for this rarely reported fracture type. Materials and methods 39 conservatively treated non- to minimally displaced intraoperative periprosthetic humeral fractures after stemmed RTSA were detected from our radiographic database between 1.1.2006 and 31.1.2018. Exclusion criteria were lack of patient consent, preoperative humeral fracture, and revision arthroplasties. Clinical (absolute and relative Constant score, the Subjective Shoulder Value) and radiographic (conventional radiographs) assessment was performed preoperatively, at 6 weeks (only radiographically) and at latest follow-up with a minimum follow-up of 2 years. Results 35 patient’s with a mean age of 72 years (range 32–88, SD ± 11 years) and a mean follow-up of 53 months (range 24–124, SD ± 31) were included in the study. At latest follow-up, all clinical outcome parameters except external rotation improved significantly. A complication rate of 17% (n:6) was recorded. At 6 weeks after the index surgery, none of the radiographs showed a fracture displacement or a sintering of the stem. At latest follow-up, all fractures were healed and no stem loosening was observed in any of the shoulders. Conclusions Non- to minimally displaced intraoperative periprosthetic humeral fractures in RTSA have an incidence of about 5% in this series of mainly uncemented press-fit stems. They generally heal without any further treatment and are not associated with stem loosening or compromise the clinical outcome after primary RTSA. Except slight restriction in the postoperative rehabilitation protocol, no further attention or action is needed.

Background Locked dislocations of the glenohumeral joint are disabling and often painful conditions and the treatment is challenging. This study evaluates the functional outcome and the different prosthetic treatment options for chronic locked dislocations of the glenohumeral joint and a subclassification is proposed. Methods In this single-center retrospective case series, all patients with a chronic locked dislocation treated surgically during a four-year period were analyzed. Constant score (CS), Quick Disabilities of Shoulder and Hand Score (DASH), patient satisfaction (subjective shoulder value (SSV)), revision rate and glenoid notching were analyzed. Results 26 patients presented a chronic locked dislocation of the glenohumeral joint. 16 patients (62%) with a mean age of 75 [61–83] years were available for follow-up at 24 ± 18 months. CS improved significantly from 10 ± 6 points to 58 ± 21 points (p Conclusion With good preoperative planning and by using the adequate surgical technique, good clinical short-term results with a low revision rate can be achieved. The authors suggest extending the Boileau classification for fracture sequelae type 2 and recommend using a modified classification to facilitate the choice of treatment as the suggested classification system includes locked posterior and anterior dislocations with and without glenoid bone loss. Level of evidence: IV.

Background: Complex regional pain syndrome (CRPS)-related hand lesions are one of the complications following arthroscopic rotator cuff repair (ARCR). This study aimed to investigate the clinical outcomes of patients with CRPS-related hand lesions following ARCR.Methods: Altogether, 103 patients with ARCR were included in this study (mean age, 63.6±8.2 years; 66 males and 37 females; follow-up period, preoperative to 12 months postoperative). Clinical assessment included the Japanese Orthopaedic Association (JOA) score, University of California, Los Angeles (UCLA) score, Constant score, 36-item short form health survey (SF-36) score, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score from preoperative to 12 months postoperatively. The patients were either assigned to the CRPS group or non-CRPS group depending on CRPS diagnosis until the final follow-up, and clinical outcomes were then compared between the groups.Results: Of 103 patients, 20 (19.4%) had CRPS-related hand lesions that developed entirely within 2 months postoperatively. Both groups showed significant improvement in JOA, UCLA, and Constant scores preoperatively to 12 months postoperatively (P

Introduction Various surgical techniques and implants are available for surgical treatment of significantly displaced proximal humerus fractures. We describe a minimally invasive technique using 3 curved wires, inserted in a retrograde fashion into the humeral head. These are aimed to diverge within the humeral head to provide three separate 3-point fixations to achieve good stability. We present the results of proximal humerus fractures managed with the modified palm tree technique. Methods A retrospective analysis of data collected prospectively including demographics, radiographs, clinical outcomes, complications and revision surgery for patients treated with the palm tree technique was performed. Results Between 1998 and 2017, 132 patients underwent fixation with this technique. Average age was 61.8 years. Fifty-Eight fractures were 2 part, 46 were three part and 28 were four part. Average follow up was 26 months. In three to four part fractures, a bone graft substitute block was used behind the humeral head fragment for structural support. There were 11 early revisions (8.3%). In 7 cases the fixation failed early and was revised to other implants like angular & locking plates (4), hemiarthroplasties (2) and reverse arthroplasty (1). In 4 cases the construct was revised to achieve better positioning of the wires. From the 125 remaining patients, 120 achieved union(96.8%). There were 3 painless fibrous non-unions and 2 painful non-unions requiring revision. The mean final Constant score was 75.5 and subjective shoulder value was 7.8/10. Nine patients (6.8%) developed avascular necrosis of the humeral head of which three patients were revised later to an arthroplasty. Conclusion This technique is a simple, minimally invasive technique which can be used for two, three and four part fractures with good functional outcomes and high union rates. No metalwork remains in the proximal humerus should another procedure like arthroplasty be required in case of avascular necrosis of the humeral head or fracture sequela.

Background The use of plate fixation to treat displaced midshaft clavicular fractures in adults reduces complications and residual shoulder disability. New features of the precontoured locking plates have been shown to reduce the need for hardware removal in adults. There is a lack of studies evaluating surgical fixation of displaced clavicular fractures with precontoured plates in adolescents. We evaluate outcomes and complications of adolescents with displaced midshaft clavicular fractures treated with precontoured locking plates. Materials and Methods 40 adolescents with displaced midshaft clavicular fractures were surgically treated from January 2010 to May 2017. Outcomes were evaluated using the Constant score, the 11- item version of the Disabilities of Arm, Shoulder and Hand (QuickDASH) questionnaires, and radiographs, and a visual analog scale. Return-to-sport rate, level achieved and complications were recorded. Results Mean follow-up was 50 months (18–108 months). Constant, Quick-DASH, and visual analog scale scores were 95.6, 2.8 and 0.5 points, respectively. 100 % of adolescents returned to sports at the same level they had before injury. Mean time to return was 69 days and 95 % of patients were able to return before 12 weeks. Complication rate was 12.5 %, 3 patients (7.5 %) required hardware removal. Conclusions Adolescents with displaced midshaft clavicular fractures treated with precontoured locking plates exhibited satisfactory outcomes and low complication rate. Compared to other reports, this study had lower rates, anatomic plates might reduce hardware-related complications.

Background A machine learning analysis was conducted on 5774 shoulder arthroplasty patients to create predictive models for multiple clinical outcome measures after anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA). The goal of this study was to compare the accuracy associated with a full–feature set predictive model (ie, full model, comprising 291 parameters) and a minimal–feature set model (ie, abbreviated model, comprising 19 input parameters) to predict clinical outcomes to assess the efficacy of using a minimal feature set of inputs as a shoulder arthroplasty clinical decision-support tool. Methods Clinical data from 2153 primary aTSA patients and 3621 primary rTSA patients were analyzed using the XGBoost machine learning technique to create and test predictive models for multiple outcome measures at different postoperative time points via the full and abbreviated models. Mean absolute errors (MAEs) quantified the difference between actual and predicted outcomes, and each model also predicted whether a patient would experience clinical improvement greater than the patient satisfaction anchor-based thresholds of the minimal clinically important difference and substantial clinical benefit for each outcome measure at 2-3 years after surgery. Results Across all postoperative time points analyzed, the full and abbreviated models had similar MAEs for the American Shoulder and Elbow Surgeons score (±11.7 with full model vs. ±12.0 with abbreviated model), Constant score (±8.9 vs. ±9.8), Global Shoulder Function score (±1.4 vs. ±1.5), visual analog scale pain score (±1.3 vs. ±1.4), active abduction (±20.4° vs. ±21.8°), forward elevation (±17.6° vs. ±19.2°), and external rotation (±12.2° vs. ±12.6°). Marginal improvements in MAEs were observed for each outcome measure prediction when the abbreviated model was supplemented with data on implant size and/or type and measurements of native glenoid anatomy. The full and abbreviated models each effectively risk stratified patients using only preoperative data by accurately identifying patients with improvement greater than the minimal clinically important difference and substantial clinical benefit thresholds. Discussion Our study showed that the full and abbreviated machine learning models achieved similar accuracy in predicting clinical outcomes after aTSA and rTSA at multiple postoperative time points. These promising results demonstrate an efficient utilization of machine learning algorithms to predict clinical outcomes. Our findings using a minimal feature set of only 19 preoperative inputs suggest that this tool may be easily used during a surgical consultation to improve decision making related to shoulder arthroplasty.

Background The re-tear rate after supraspinatus tendon (SSP) repair is high despite optimization of surgical techniques. The critical shoulder angle (CSA) > 35° has been identified as a risk for re-tear. Surgical reduction of the CSA performing additional lateral acromioplasty (ALAP) is intended to reduce the risk. Objective We aimed to evaluate the effect of ALAP on the re-tear rate in patients with a CSA > 35° after SSP repair. Patients and methods The study included 49 shoulders fulfilling predefined inclusion criteria. The patients were assigned to two groups; group I (25 SSP) was additionally treated with an ALAP. In group II (24 SSP) standard acromioplasty was performed during reconstruction. Magnetic resonance imaging and a clinical examination (Constant Score; CS) were performed 12 months after surgery. Results After 15 months group I showed a re-tear rate of 20%, a decreased CSA (mean 38.0° preoperatively vs. 34.5° postoperatively) and an increase in CS (mean 53.9 vs. 84.6). After 16 months group II showed a re-tear rate of 16.7%, no difference between pre- and postoperative CSA (37.8° vs. 37.6°), and an increase in CS (48.9 vs. 84.5). There was no difference between the groups in terms of re-tears and postoperative CS (p = 0.4557), but there was a significant difference in postoperative CSA (p 35° did not have a worse clinical outcome and no increased rate of re-tears compared with patients with a mechanically reduced CSA. Conclusion Additive lateral acromioplasty does not decrease the re-tear rate after arthroscopic SSP repair. However, ALAP significantly decreases the CSA to normal values.

The goal of this study was to assess the clinical outcomes associated with anatomic healing of the greater tuberosity in patients treated for proximal humerus fractures with reverse shoulder arthroplasty. Our hypothesis was that anatomic healing of the greater tuberosity leads to less complications and better functional outcomes.RESULTS: Patients from the GT+ group presented better functional outcomes than the GT- group in all evaluated outcomes. Mean constant score was 61 ± 14 versus 56 ± 15, and the subjective shoulder value (SSV) was 77 ± 14 versus 64 ± 21 (p 0.001). Forward elevation was 128° ± 28° versus 107° ± 30° and external rotation was 23° ± 17° versus 14° ± 17° (p 0.001). Twenty patients presented with at least one prosthetic dislocation (7 GT+ vs 13 GT-) while nine patients were revised for humeral loosening (1 GT+ vs 8 GT-). The use of a fracture specific humeral stem was associated with a higher rate of greater tuberosity healing.Non-anatomic healing of the greater tuberosity was associated with a higher dislocation and humeral loosening rate. Anatomic healing of the greater tuberosity lead to better functional outcomes, less humeral-sided complications, and fewer re-operations.

Introduction Displaced fractures of middle third of clavicle are traditionally managed non-operatively. Recently, the trend is towards surgical management considering functional deficits in some of the non-operatively managed patients. The purpose of the study was to examine the functional outcome of non-operative treatment in these injuries, while identifying the factors responsible for less than ideal outcome and determine the guidelines for patient counselling. Patients and Methods One hundred patients with displaced fractures of middle third of clavicle were prospectively evaluated clinico-radiologically for one year from injury. Risk factors for non-union were determined using Fisher's exact test. Logistic regression was used to identify factors contributing to functional outcome. Threshold values for the radiological displacements were estimated with the smooth threshold regression using the logistic transition function. Results Ninety-four out of 100 fractures united. The factors associated with non-union were: smoking, diabetes and poor soft tissue condition over the fracture. Ninety-two out of 94 patients who had their fractures united achieved “good” (Constant Score above 70) or “very good” (Constant Score above 85) functional outcome at one year, out of which only 49 belonged to “very good” category. The most important factors influencing functional outcome were fracture angulation and clavicular shortening. From the model, it was estimated that with one unit increase in degree of angulation or 1 mm increase in shortening, the odds of scoring above 85 reduces by around 14%. Based on this, an equation and a probability calculator were developed from which the probability of achieving a Constant Score above 85 can be calculated. Threshold analysis yielded 22.8° for angulation and 16.8 mm for shortening at which the probability of achieving “very good” function is only 0.23. Conclusion Displaced midshaft clavicular fractures with the intent of achieving “good” outcome must be managed non-operatively. If the patient expectation is not to accept even minor functional deficits, the treatment objective must be raised to achieve a minimum Constant score of 86. Substituting the radiological displacements in the equation, the probability of the patient achieving this objective can be calculated. Non-operative management is offered if this probability figure is acceptable to the patient, otherwise counselled for surgery. Non-operatively managed patients with coexisting diabetes, smoking or poor soft tissue condition must be watched for the possibility of going for non-union.

The aim of this study was to evaluate functional outcomes in patients with varus malposition following open reduction and internal fixation of displaced proximal humeral fractures.Data of 685 patients with a mean age of 67±15.8 years (67% female), that were treated by open reduction and internal fixation for a displaced proximal humeral fracture at a level 1 trauma center, were analyzed. On standardized x-ray imaging, the degree of varus displacement was measured over a minimum of two years follow-up and patients were divided into three groups. Group A: anatomic or10° of varus or valgus malposition, group B: 10-20° of varus malposition and group C:20° varus malposition, while anatomic head-shaft-angle was defined 135° The groups were compared with regards to functional outcomes by means of the Constant Score (CS).In 565 patients with anatomic to minor10° varus or valgus malposition (Group A), the mean CS was 72.5 ± 18.8 points. The %CS to the uninjured side was 87.2 ± 24.1 and the age and gender normalized nCS was 84.7 ± 21.7. In comparison, in group B (10-20° varus) the mean CS was 64.7 ± 16.9, the mean %CS was 84.5 ± 18.3 and the mean nCS was 76.2 ± 20.6. In group C (20° varus) the mean CS was 54.1 ± 19.5, the mean was %CS: 72.3 ± 26.4 and the mean nCS was 64.8 ± 23.8 (p = 0.02, p = 0.03, p = 0.01). Overall, the CS, %CS and nCS correlated significantly with the degree of varus position (Pearson correlation, r = 0.23, r = 0.21, r = 0.25).Varus malposition is related to inferior functional outcomes compared to anatomic healing in patients treated by open reduction and internal fixation for proximal humeral fractures. The data supports suggestions to prevent varus malposition in open reduction and internal fixation. In severe20° of varus malposition, revision surgery should be considered.

Background: Subacromial impingement syndrome is a common disorder associated with functional impairment and disability of the shoulder. Internal/external glenohumeral rotation is important for shoulder function. However, because it is difficult to measure the glenohumeral joint rotation angle physically, the relationship between this angle and the clinical symptoms of subacromial impingement syndrome is still largely unknown. Using advanced cine-magnetic resonance imaging techniques, we designed a study to improve our understanding of the nature of this relationship. Methods: We evaluated 100 shoulders with subacromial impingement syndrome. Patients underwent cine-magnetic resonance imaging during axial rotation with the arm adducted. During imaging, patients rotated their shoulder from maximum internal rotation to maximum external rotation over 10 seconds and then to maximum internal rotation over 10 seconds. The rotation angles were then evaluated using a series of axial images. The Constant–Murley (Constant) and UCLA scores for each patient were determined, and the correlation between the scores and rotational angles was assessed. Patients were divided into 3 groups according to the Constant pain score, and the rotational angles of each group were compared. Rotational angles were also compared between shoulders with and without night pain. Results: The external rotation angle showed a significant but low correlation with the Constant and UCLA scores (ρ = 0.24 and 0.24, respectively), whereas the internal rotation angle did not. In comparing the pain groups of Constant score and UCLA score, the external rotation angle significantly decreased as pain increased (P

In order to minimize the risk of damaging the radial nerve while using a long PHILOS plate for proximal humerus fractures, recent studies have proposed twisting the plate in a helical form. This implies a modified surgical approach being yet unclear whether it leads to different middle to long-term shoulder function. This study compares the one-year shoulder functional outcomes of both techniques (helical vs. control). In this retrospective comparative study, we analyzed 30 patients that fit the inclusion criteria, being 14 treated with a helical plate and 16 with a conventional straight long PHILOS plate. The primary endpoint was the normalized constant score after a minimum follow up of one year. Both groups had a good one-year shoulder function, and no significant difference between the normalized constant scores was seen. There was no significant difference in the surgical complications as well. Opting for a helical long PHILOS plate in order to avoid radial nerve damage provided a safe treatment with similarly good one-year shoulder function compared to straight PHILOS plates. Level 3, Retrospective Cohort Study.

Purpose The purpose of this study was to evaluate the intermediate-term clinical and radiological outcomes for acute, unstable acromioclavicular joint (ACJ) injuries treated with the arthroscopically assisted BiPOD stabilisation technique. Methods Twenty-three patients who sustained acute, unstable ACJ injuries were included in this prospective study. We recorded demographics, injury classification, time to surgery, clinical scores, radiological outcomes and complications; each patient completed a minimum of 2 years post-operative observation. Results Mean follow-up was 26 months (range, 24—34). Clinical outcomes scores demonstrated good 2-year results: relative Constant score, 97.9/100; ACJ Index, 89.4/100; Subjective Shoulder Value, 92.4/100 and Taft = 11.1/12. Final C–C distance showed a mean of 0.7 mm (SD ± 1.8 mm) at 2 years. Complication rate was 9%. Conclusion The BiPOD technique shows excellent, reliable intermediate-term results with a favourable complication rate compared to existing techniques; it provides a comprehensive surgical option for the stabilisation of acute ACJ injuries restoring both vertical and horizontal stability.

Background: The acromioclavicular joint pathologies are one of the common causes of shoulder pain. The most common of these is the acromioclavicular joint arthritis. The management can be conservative or surgical. The conservative measures include activity modification, physiotherapy, Non-Steroidal Anti- Inflammatory Drugs (NSAIDs), and Intra-articular Steroid Injections (ISI). ISI has been used with variable success rates and the long-term effects are doubtful. Materials and Methods: Patients with clinical and radiological evidence of ACJ arthritis and not responding to exercise and NSAIDs for 2 months were enrolled for PRP injection. 1 mL of PRP prepared by the manual double spin method was injected into the ACJ and patients were followed for a minimum period of 6 months. Constant Score was used to measure the functional recovery at 1, 3, and 6 months post-injection therapy. Results: 13 patients including 16 shoulders were followed up for an average of 8 months (6 to 14 months).3 patients had bilateral ACJ involvement. 4 had left ACJ involvement and the rest had right side involvement. The mean pre-injection constant score was 45 (range 28-70). The mean score at the end of 1 month follow up was 69 (range 56-89). At the end of 3 months, the mean score was 81 range (63-93). Both were statistically significant improvements when compared to the pre-injection score (P=0.003,0.0021 respectively). At the end of 6 months, the score was 89 range (58–94). This sequential improvement was not however statistically significant. Conclusion: ACJ arthritis is one of the common causes of shoulder pain. In our pilot study, PRP has been a promising option to treat primary ACJ arthritis. Future RCTs are needed to establish it as a superior option in the management of ACJ arthritis. Keywords: Acromioclavicular joint (ACJ) NSAIDs.

Objectives This study aims to compare metal suture anchors and all-suture anchors clinically and radiologically in arthroscopic Bankart repair. Patients and methods In this retrospective study, 67 patients (61 males, 6 females; mean age 26.0±5.8; range, 18 to 43 years) who underwent arthroscopic Bankart repair between April 2009 and October 2016 were divided into two groups depending on the type of the suture anchor used in different periods. Group A comprised 32 patients with arthroscopic Bankart repair performed with metal suture anchors, and Group B comprised 35 patients with arthroscopic Bankart repair performed with all-suture anchors. The patients were clinically evaluated using Rowe scores, Constant scores, redislocation rates, and positive apprehension test rates. Radiographic evaluation was performed using the Samilson-Prieto classification to observe the development of glenohumeral osteoarthritis. Results The mean follow-up period was 41.1±10.4 (range, 30 to 60) months in Group A, and 39.6±9.4 (range, 28 to 60) months in Group B, with no significant difference between the two groups (p=0.559). No significant difference was observed between Group A and Group B in terms of mean Rowe score (89.2±13.8 [range, 40 to 100] vs. 88.7±16.9 [range, 25 to 100]; p=0.895) or Constant score (87.2±8.9 [range, 48 to 96] vs. 86.9±9.0 [range, 46 to 96]; p=0.878), which were the clinical outcomes at the final follow-up examination. Postoperative redislocation rates (3.1% vs. 2.9%, p=1.0) and positive apprehension test rates (6.3% vs. 8.6%, p=1.0) were found to be similar in both groups. According to the Samilson-Prieto classification, there was no evidence of glenohumeral osteoarthritis in any of the patients in either group. Conclusion Satisfactory outcomes were obtained with the use of all-suture anchors in arthroscopic Bankart repair for traumatic anterior shoulder instability. All-suture anchors and metal suture anchors, have similar outcomes in the mid-term and all-suture anchors are a reliable and effective option for arthroscopic Bankart repair.

Purpose To determine the clinical, biomechanical, and financial impact of the use of subacromial balloon spacers in the surgical management of massive, irreparable rotator cuff tears (RCTs). Methods All studies assessing the use of implantable subacromial balloon spacers for management of massive, irreparable RCTs were systematically searched. Risk of bias was assessed using Methodological Index for Non-Randomized Studies criteria. Data extraction and analysis was performed for pain and function scores, shoulder range of motion (ROM), glenohumeral contact pressure and vertical migration of humeral head, and cost. Subjective synthesis was performed with forest plots when outcomes were reported in 3 or more studies. Results In total, 19 studies met inclusion criteria for analysis; 337 patients (mean age 68 years) had 343 subacromial balloon spacer implantations. Throughout a mean follow-up of 33 months, there was significant improvement in the Total Constant Score (preoperative: 22.5-41.8; postoperative: 51.4-72.3), Oxford Shoulder Score (preoperative: 21.3-26; postoperative: 34.39-48.2), American Shoulder and Elbow Surgeons score (preoperative: 24.5-59.1; postoperative: 72.5-85.7), and shoulder ROM parameters. Subacromial balloon spacer placement resisted superior humeral head migration (range of preoperative to postoperative difference: 2.8-6.2 mm) and decreased peak subacromial pressure during shoulder ROM. Conclusions Existing literature of subacromial balloon spacers has a high risk of bias, lack of appropriate control, and low levels of evidence. A qualitative synthesis indicates that subacromial balloon spacer implantation in patients with massive irreparable RCTs is cost-effective and leads to improved function (Total Constant Score and Oxford Shoulder Score) and ROM. In cadaveric studies, subacromial balloon spacers resist superior humeral head migration and reduce subacromial pressure. The theoretical risk of biodegradation of the balloon spacer has not been substantiated in study of up to 5-years follow-up, and the risk of complications from this procedure appears to be minimal. Level of Evidence IV; Systematic review of level III-IV studies.

Background Patients with isolated loss of active external rotation (ILER) but preserved active forward elevation have recently been identified as a rare and distinct clinical entity. The modified L'Episcopo procedure attempts to restore horizontal muscle balance and restore active external rotation. Methods A retrospective study was performed for all patients with ILER and preserved forward elevation with Hamada stage ≤2 changes undergoing the modified L'Episcopo tendon transfer. Preoperative rotator cuff fatty infiltration and morphology was reported. Clinical, radiographic, and functional outcomes were recorded preoperatively and compared to postoperative outcomes at a minimum of 24 months' follow-up. Results Nine patients (8 male, 1 female) with a mean age of 58.4 years (range, 51-67 years) were evaluated at a mean follow-up of 64.3 months (range, 24-126 months). Significant improvement was demonstrated in active external rotation with the arm at the side (mean increase of 47°; range, 30°-60°, P = .004) and at 90° abduction (mean increase of 41°; range, 20°-70°, P = .004). The mean Constant score and pain score significantly improved at final follow-up (P = .004). All patients were either very satisfied or satisfied, with a mean subjective shoulder value of 74% (range, 60%-99%). Conclusion In appropriately selected patients with ILER and preserved active forward elevation, the modified L'Episcopo procedure can restore horizontal muscle balance and produce significant improvements in active external rotation, Constant score, and pain.

In case of failure of non-operative treatment of isolated supraspinatus tear, tendon surgery can improve shoulder function and alleviate pain. The present study hypothesis was that isolated supraspinatus repair shows good healing, with improved clinical results.A prospective multicentre study followed up 199 patients (mean age, 57 years) for one year. Inclusion criteria comprised: isolated full-thickness supraspinatus tear, retraction grade3, with the same double-row arthroscopic technique. Clinical assessment used Constant score at 6 weeks and 3, 6 and 12 months. Ultrasound control checked tendon repair quality on the Sugaya criteria, types I-II-III being considered as healed.At one year, mean Constant score had increased by 26 points (p0.001). Healing rate was 94% (n=187): Sugaya type I, 46% (n=92); type II, 41% (n=81); type III, 7% (n=14). Mean Constant score was significantly higher in case of healing: 81 vs. 70 points (p=0.002). Constant score progression was identical in both healing groups throughout follow-up. Univariate analysis showed no correlation between epidemiological or tear-related factors and tendon healing.Arthroscopic repair of isolated small supraspinatus tear provided 94% healing. Clinical results were better when healing was achieved.I, prospective cohort study.

IntroductionThe goal of this study was to provide an insight into the clinical results after modular short-stem shoulder arthroplasty for various indications.Materials and methodsA consecutive cohort study of 76 patients followed up for 23–55 (mean 31.4) months. 23 anatomical (TSA), 32 reverse (RSA) and 21 hemi-prostheses with a pyrocarbon head (PyC), using a modular short stem with proximal porous coating were implanted. Range of motion, pain and Constant score (CS) were recorded. Comparisons of pre- vs postoperative outcomes, between prosthesis types and indications, were made.ResultsAll prosthesis types brought about a significant improvement (p p = 0.002 and 0.003, respectively). TSA produced superior gains in all ROM compared with RSA (p p = 0.0001 and 0.008, respectively). TSA had greater pain relief than PyC (p = 0.02). TSA with Walch A glenoids seemed to improve more than type B in the CS. PyC patients with Walch B glenoids improved more than Walch A (p = 0.03). When implanted due to Osteoarthritis (OA), PyC had a comparable final outcome to TSA (p = 0.95), although the preoperatively worse TSA patients had a greater improvement in the CS (p = 0.026). The outcome of RSA did not differ between indications, but Walch A glenoids tended to improve more.ConclusionsUsing a second-generation short-stem shoulder prostheses, TSA achieves the best clinical improvements overall, especially for OA with a Walch A glenoid. Despite refixation of the subscapularis tendon in all cases, RSA has inferior internal rotation than TSA and PyC, suggesting a mechanical limitation. OA, a Walch B glenoid and arthritis caused by instability seem to be ideal indications when considering PyC.

Hypothesis Persistent humeral shaft nonunions result in continued pain and disability of the affected arm and are difficult to treat even with several surgical procedures and locked plating. A fibular allograft provides bony purchase for fixation as well as rotational stability and bridging of nonunion defects. Methods We conducted a retrospective review of a single surgeon's clinical practice between July 1995 and January 2011. The inclusion criteria were patients aged ≥ 18 years who underwent revision surgery for a humeral shaft nonunion by open reduction and revision internal fixation with a supplementary fibular strut allograft. Results Thirteen patients who met the inclusion criteria were evaluated with physical examinations, validated functional outcome measures, and radiographs to assess union rates. The mean follow-up period was 7.5 years (range, 0.5-15.6 years); there were 11 women (85%) and 2 men (15%). Of the patients, 3 (23%) had proximal-third nonunions, 7 (54%) had middle-third nonunions, and 3 (23%) had distal-third nonunions. After revision surgery with fibular allograft, 10 of 13 patients went on to achieve healing, giving a union rate of 76.9%. The mean postoperative Disabilities of the Arm, Shoulder and Hand score was 38.1 points (standard deviation [SD], 27.6 points). The mean Constant score was 55.2 points (SD, 24.0 points), representing a 62% return of function compared with the contralateral side. The mean postoperative American Shoulder and Elbow Surgeons score was 65.4 points (SD, 28.5 points), and the average visual analog scale pain score (out of 10) was 2.1 (SD, 3.3) at final follow-up. Conclusion Fibular allograft is an effective and straightforward option for treating humeral midshaft and distal-shaft nonunions; however, treatment of proximal-third nonunions remains challenging.

Background Acromioclavicular (AC) separations are commonly seen shoulder injuries. Numerous surgical reconstruction techniques have been described. In this study, we present a series of patients who underwent an anatomic reconstruction using a synthetic ligament and allograft construct. Methods We performed a retrospective review of patients with type IV or V AC separations who underwent primary or revision AC reconstruction with a luggage-tag synthetic ligament and a semitendinosus allograft placed through the anatomic insertion sites of the coracoclavicular ligaments. Patient-reported outcomes, as well as complication rates, were recorded at a minimum 2-year follow-up. Results Ten patients with a mean age of 44.2 ± 14.9 years were included in the study. The mean Disabilities of the Arm, Shoulder and Hand score was 15.5 ± 15.4; mean Single Assessment Numeric Evaluation score, 81.8 ± 12.1; mean Simple Shoulder Test score, 11.4 ± 1.1; mean American Shoulder and Elbow Surgeons score, 84.6 ± 15.7; mean Constant score, 82.5 ± 11.6; and mean visual analog scale score, 2 ± 2.6. Conclusion The technique using a luggage-tag synthetic ligament along with an anatomic allograft coracoclavicular ligament reconstruction is a safe, effective alternative to other techniques described in the literature.

Background Proximal humeral fractures are one of the most common fractures in adults. Some patients treated operatively have restriction in range of motion (ROM) after surgery. This study aimed to evaluate arthroscopic pancapsular release in patients with severe stiffness after treatment with intramedullary nailing for proximal humeral fractures. Methods This study included 12 patients (7 women and 5 men) who underwent arthroscopic pancapsular release in the beach-chair position between May 2015 and February 2018. Intraoperative findings were recorded, and ordinary (with scapulothoracic motion) and true (without scapulothoracic motion) glenohumeral ROMs were measured with a goniometer. The American Shoulder and Elbow Surgeons shoulder score, Shoulder Rating Scale score of the University of California, Los Angeles scoring system, and Constant score were compared before and after the release. The Wilcoxon signed rank and Mann-Whitney U tests were used to analyze data. Results The average age of the patients was 65.1 years (standard deviation, 9.5 years), and the mean follow-up period after the release was 30.6 months (standard deviation, 11.7 months). All ROMs on the affected side after surgery were significantly greater than those before surgery in all directions. However, ROMs in forward flexion, lateral elevation, and external rotation with the arm at the side and at 90° of forward flexion on the affected side postoperatively were significantly lower than those on the unaffected side. All scores were significantly greater after surgery than before surgery. Conclusion Arthroscopic pancapsular release is effective for patients with proximal humeral fractures treated with intramedullary nailing.

Introduction The question of our study was to evaluate the incidence of coexisting outlet impingement among patients with calcifying tendinitis and a failure of the conservative treatment using intraoperative in addition to radiological criteria. This question is of clinical relevance as there is still a discussion about whether an additional arthroscopic subacromial decompression (ASD) should be performed when arthroscopic removal of the calcific deposits is needed. Materials and methods From February 2017 to 02/2018, we prospectively enrolled 50 patients who needed shoulder arthroscopy for calcifying tendinitis. We evaluated the x-rays for outlet impingement, measuring the lateral acromial angle (LAA), acromion slope, acromion index (AI) and Bigliani-type of the acromion. During shoulder arthroscopy, we evaluated the acromial undersurface for a bony impingement using a standardized view. If impingement was present, we performed an additional ASD. Before surgery, three months later and at final follow-up 20 months after surgery, we determined the relative Constant Score (rCS). Results 92.5% of the patients had an intraoperatively confirmed outlet impingement, whereas 82.5% of the patients had a radiological outlet impingement. The sensitivity of the radiographs was 83.8%, the specificity 33.3% when combining all parameters. The mean rCS improved significantly from 45% to 100% at final follow-up. Conclusion Our results show that coexisting outlet impingement is very common in patients with calcifying tendinitis and failure of the conservative treatment. As the radiological diagnosis is uncertain, an intraoperative assessment for impingement is rational and justifies an additional ASD.

Purpose To systematically review the comparative studies in the literature to compare joint stability, clinical outcomes, and complications of acromioclavicular joint fixation using a hook plate versus arthroscopic suture-button (SB) fixation. Methods A literature search was performed in accordance with the PRISMA guidelines to identify clinical studies comparing the hook plate and arthroscopic SB techniques for acromioclavicular joint injuries. Qualitative statistical analysis was performed using SPSS, and a P value of ≤.05 was considered to be statistically significant. Results Six clinical studies including 285 patients were included in the systematic review. In 3 of the studies, there was a significant difference in favor of SB for Constant score. Patients treated with the SB technique had a lower visual analog scale score at final follow-up in 2 of the 4 studies that measured this outcome. In addition, there were no significant difference in the rate of complications, revisions, or joint malreduction in any of the included studies. Conclusions The arthroscopic SB procedure resulted in lower postoperative pain scores, and improved postoperative functional outcomes, although this was not a clinically significant difference. In addition, there were no significant differences in the rate of complications, revisions, or joint malreduction. Level of Evidence Level III, systematic review of Level I, II, and III studies.

Proximal humerus fractures are common in the elderly population and are often treated with reverse shoulder arthroplasty (RSA). The purpose of this systematic review was to compare tuberosity healing and functional outcomes in patients undergoing RSA with humeral inclinations of 135°, 145°, and 155°.A systematic review was performed of RSA for proximal humerus fracture using Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guidelines. Radiographic and functional outcome data were extracted to evaluate tuberosity healing according to humeral inclination. Analysis was also performed of healed vs. nonhealed tuberosities.A total of 873 patients in 21 studies were included in the analysis. The mean age was 77.5 years (range of 58-97) and the mean follow-up was 26.2 months. Tuberosity healing was 83% in the 135° group compared with 69% in the 145° group and 66% in the 155° group (P = .030). Postoperative abduction was highest in the 155° group (P.001). No significant difference was found in forward flexion, external rotation, or postoperative Constant score between groups. Patients with tuberosity healing demonstrated 18° higher forward flexion (P = .008) and 16° greater external rotation (P.001) than those with unhealed tuberosities.RSA for fracture with 135° humeral inclination is associated with higher tuberosity healing rates compared with 145° or 155°. Postoperative abduction is highest with a 155° implant, but there is no difference in in postoperative forward flexion, external rotation, or Constant score according to humeral inclination. Patients with healed tuberosities have superior postoperative forward flexion and external rotation than those with unhealed tuberosities.

IntroductionThe purpose of this study was twofold. First, the efficacy of arthroscopic repair in patients with full thickness, isolated subscapularis tendon tears (I-STTs) or combined subscapularis tendon tears (C-STTs) involving the rotator cuff tendons was evaluated. Second, the outcomes between these two groups were compared. The influence of age and gender on the cohort clinical outcomes was also analysed. Our hypothesis was that satisfactory functional results could be obtained arthroscopically in both groups without any influence of age or gender.Material and methodsSeventy-nine patients were enrolled: 15 with I-STTs and 64 with C-STTs. The clinical outcomes were assessed using Constant and Disabilities of the Arm, Shoulder and Hand (DASH) scores, Numeric Rating Scale (NRS) for pain and Visual Analogue Scale (VAS) for satisfaction. The subscapularis strength was assessed using a comparative dynamometric bear-hug test. Group outcomes were compared, including statistical analysis.ResultsFor each group, there were no differences regarding the subscapularis strength of the operated and non-operated shoulders. A comparison of the post- with the pre-operative outcomes showed an increase in the Constant score and a decrease in the NRS. Comparing the two groups, we found no difference in strength of the operated and non-operated shoulders, but a significant difference in relation to pre-operative Constant score and pre-operative NRS. Age was negatively correlated with both pre-operative and post-operative Constant scores. No association was found between gender and the outcomes, although the DASH score was higher in women.ConclusionsArthroscopic repair of STTs provided functional restoration, pain relief and patient satisfaction in both groups. Age and gender did not affect the clinical outcomes achieved by arthroscopic STT repair.

Introduction As surgeons' confidence in reverse shoulder arthroplasty (RSA) increases, they may tend to offer RSA earlier in the course of glenohumeral joint disease. This study evaluates the changes in the “tipping point” for primary RSA over a 10-year period to evaluate changes in practice. Methods A total of 3975 primary RSAs performed over a 10-year period were retrospectively reviewed from a multi-institutional database. Of these, 3536 primary RSAs with preoperative diagnoses of osteoarthritis with rotator cuff deficiency (1626), irreparable rotator cuff tear (396), and rotator cuff tear arthropathy (1514) were included in the analysis. Preoperative range of motion (ROM) and patient-reported outcome measures (PROMs) were used to calculate tipping points for each subgroup on a yearly basis over a 10-year period, and assessed for changes over time. Results PROMs (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Simple Shoulder Test) and the Constant score remained similar over the 10-year study period, with all demonstrating slightly higher tipping points later in the study. ROM measures (forward elevation, abduction, and external rotation) all showed small increases over time, demonstrating better ROM before electing to undergo RSA in later years. Conclusions With the increasing use of RSA over the last decade, the ROM tipping point for patients electing to undergo surgery has increased, whereas the PROM tipping point has remained stable. This indicates that patients undergoing RSA in the present have greater ROM preoperatively compared with 10 years ago; however, their perceived disability remains similar. Surgeons and patients continue to pursue RSA at a similar preoperative morbidity over the last 10 years.

Background The diagnosis and treatment of partial-thickness rotator cuff tears remain controversial, and only a few studies have carried out clinical evaluation and comparison based on different types of tears. The aim of this study was to compare the clinical outcomes of arthroscopic cuff repairs using the suture bridge technique in patients with articular partial-thickness rotator cuff tears (APRCTs) vs. those with bursal partial-thickness rotator cuff tears (BPRCTs). Methods We retrospectively evaluated 29 patients with APRCTs and 22 patients with BPRCTs who underwent arthroscopic cuff repair using the suture bridge technique with a minimum 2-year follow-up. Clinical outcomes were evaluated preoperatively and postoperatively using the visual analog scale score, Japanese Orthopaedic Association (JOA) score, Constant score (CS), active range of motion (ROM) of shoulder flexion and abduction, improvement rate for each score, and retear rate. Results The APRCT group had more women, fewer cases of subacromial decompression, and more patients whose condition changed intraoperatively and transitioned into a complete tear. Preoperatively, the JOA score, CS, ROM of shoulder flexion, ROM of shoulder abduction, and external shoulder rotation strength were lower in the APRCT group. Postoperatively, all scores improved significantly in both groups, and the JOA score, CS, and external shoulder rotation strength remained significantly lower in the APRCT group. Improvement and retear rates were not significantly different between the groups. Conclusions The suture bridge technique significantly improved the clinical outcomes of patients with APRCTs and BPRCTs. Preoperative and postoperative functional parameters were worse in APRCT patients.

Structural failures after rotator cuff repair are well known, and despite advances and improved techniques in rotator cuff repair (RCR), retear rates remain high. The aim of this study was to (1) evaluate the midterm clinical and radiological outcomes after revision RCR and to (2) analyze whether preoperative ultrasound can predict outcome of open revision rotator cuff repair. Twenty-five patients who underwent revision RCR in a single institution between 2010 and 2012 were retrospectively reviewed at a minimum follow-up of 2 years. The Constant Score (CS) and the Disabilities of the Arm, Shoulder and Hand score were collected. Ultrasound examination was used both before revision surgery and at follow-up to determine tendon integrity. At the final follow-up, 69.6% patients showed an intact rotator cuff and their CS had improved from 28.3 to 77. 30.4% patients had a persisting rotator cuff defect, and the CS had improved from 24 to 47.7. A preoperative tear size of more than 20 mm from an ultrasound examination could be identified as a factor that would risk structural failure of revision RCR. (1) Clinical outcomes after revision RCR improve in both patients with an intact RC and those with a retear at midterm follow-up. (2) Ultrasound seems to be a useful tool to predict whether reconstruction of recurrent rotator cuff tears is feasible. IV, Case series.

Chronic acromioclavicular (AC) joint instability may result after failed surgical or non-operative treatment of acute AC joint dislocation. Data on clinical outcomes of chronic AC joint instability are limited; thus, no gold standard surgical technique exists. This study aimed to evaluate clinical and radiological results after arthroscopically assisted or hook plate stabilization of chronic type III–V AC joint instability. We hypothesized that (1) operative treatment would improve outcomes in short-term follow-up (2) without a difference between the groups. Five level I trauma centers prospectively included patients in this non-randomized multicenter study. Patients had undergone reconstruction of the coracoclavicular (CC) and AC ligaments with an anatomic hamstring autograft. Graft healing was supported by arthroscopically assisted AC joint stabilization using a flip button or by a hook plate. Inclusion criteria were chronic high-grade (Rockwood III–V) AC joint instability and failed surgical or non-operative treatment after a trial of conservative management measures ≥12 weeks. Functional outcome measures (Subjective Shoulder Value, Constant Score, Taft Score, Acromioclavicular Joint Instability Score) were recorded preoperatively and at follow-up. Radiographs were performed pre- and postoperatively, and at follow-up. A total of 43 patients were included (mean age 44 ± 12 years, range 18–64; 17, 40%, Rockwood III and 26, 60%, Rockwood V; 32, 74%, arthroscopic and 11, 26%, hook plate; 35 available for follow-up; mean follow-up 12 ± 3 months, range 6–20). All clinical outcome measures improved significantly (p

Introduction: Acromioclavicular joint are common in physical active young adults, mostly involves in sports activities. Its male predominant and account 9% of all shoulder injuries. Tight rope and endobutton reduces the chances of clavicular fracture across the tunnels and avoids hardware related complications. Aims and Objectives: To study functional outcome of acromioclavicular joint dislocat ion by using tight rope and endobutton. Materials and methods: This is prospective study of 25 cases of AC joint dislocations type iii to vi admitted between oct 2017 to march 2019. Out of 25 only 16 patients was operated.In procedure, clavical tunnel made, tight rope passed around coronoid process and through clavicular tunnel and secure with endobutton. Observations and Results: In our study M:F of 17:8 and mean age of 44 years having right side predominance, average blood loss 150 ml functional outcome by CONSTANT score got 4 complications. 8 patients got excellent result, 6 good, 2 adequate results. Conclusions: AC joint dislocation type iii to type iv using tight rope with endobutton have excellent result give less complications and rigid fixation with extensive tensile strength allowing physiological motion between clavical and corocoid, endobutton avoid stress concentration over bone bridge between the two tunnels. Tight ropes prevents necessities of biological tendenous graft.

Purpose: To assess the change in quality of life (QOL) and costs for patients with rotator cuff tears after arthroscopic rotator cuff repair (aRCR) compared with continued nonoperativemanagement, using real-world evidence. Methods: Patients indicated for aRCR were included in a prospective study and followed up to 2 years after surgery (postop) for allmeasurements. QOL (EQ-5D-5L) and shoulder function (Constant Score, Oxford Shoulder Score, subjective shoulder value) were assessed. Sixteen major insurance companies provided all-diagnoses direct medical costs in Swiss francs (CHF; 1 CHF ¼ 1.03 USD). Baseline data at recruitment and costs sustained over 1 year before surgery (preop) served as a proxy for nonoperative management. Total direct medical costs to gain 1 extra quality-adjusted life year (QALY) were calculated as the incremental costeffectiveness ratio (ICER; mean of 2 years postop compared with 1 year preop) from a societal perspective. Subgroup analyses were separately performed for traumatic (trauma-OP) and degenerative (degen-OP) rotator cuff tear patients. Sensitivity analyses for aRCR patients includedmore intensive nonoperative treatment with corresponding QOL gain. The relationship between QOL and shoulder function was explored using regression analysis. Results: For 153 aRCR patients (mean age 57 years; 63% male), themean EQ-5D index improved from 0.71 (preop) to 0.94 (1 year postop) and 0.96 (2 years postop). Mean total costs increased from 5,499 CHF (preop) to 17,116 CHF (1 year postop), then decreased to 4,226CHF (2 years postop). The ICER for all aRCR patients was 24,924 CHF/QALY (95%confidence interval [CI] 16,742 to 33,106) and 17,357 CHF/QALY (95% CI 10,951 to 23,763) and 36,474 CHF/QALY (95% CI 16,301 to 56,648) for the trauma-OP and degen-OP groups, respectively. QOL and shoulder function were significantly associated (P < .001). Conclusions: For RC patients treated at a specialized Swiss orthopaedic clinic, aRCR is a cost-effective intervention associated with clinically relevant improvement in QOL up to 2 years after repair compared with prior nonoperative management. Level of Evidence: Economic Analyses e Developing an Economic Model, Level II