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Background: The treatment of displaced midshaft clavicle fractures remains controversial.Methods: We undertook a multicenter randomized controlled trial to compare effectiveness and safety between nonoperative management and ORIF (open reduction and internal fixation) for displaced midshaft clavicle fractures in adults. Three hundred and one eligible adult patients were randomized to 1 of the 2 treatment groups and followed at 6 weeks, 3 months, and 9 months after recruitment. The primary outcome was the rate of radiographically evident nonunion at 3 months following treatment. Secondary outcomes were the rate of radiographically evident nonunion at 9 months, limb function measured using the Constant-Murley Score and DASH (Disabilities of the Arm, Shoulder and Hand) score, and patient satisfaction.Results: There was no difference in the proportion of patients with radiographic evidence of nonunion at 3 months between the operative (28%) and nonoperative (27%) groups, whereas at 9 months the proportion with nonunion was significantly lower (p < 0.001) in the operative group (0.8%) than in the nonoperative group (11%). The DASH and Constant-Murley scores and patient satisfaction were all significantly better in the operative group than in the nonoperative group at 6 weeks and 3 months.Conclusions: Although at 3 months there was no evidence that surgery had reduced the rate of nonunion of displaced midshaft clavicle fractures, at 9 months nonoperative treatment had led to a significantly higher nonunion rate (11% compared with <1%). The rate of secondary surgical intervention during the trial period was 12 (11%) of the 147 patients in the nonoperative group. ORIF is a safe and reliable intervention with superior early functional outcomes and should be considered for patients who sustain this common injury.Level Of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Lesions of the long head of the biceps tendon are often associated with massive rotator cuff tears and may be responsible for shoulder pain and dysfunction. The purpose of this study was to evaluate the clinical and radiographic outcomes of isolated arthroscopic biceps tenotomy or tenodesis as treatment for persistent shoulder pain and dysfunction due to an irreparable rotator cuff tear associated with a biceps lesion.Methods: We conducted a retrospective study of sixty-eight consecutive patients (mean age [and standard deviation], 68 +/- 6 years) in whom a total of seventy-two irreparable rotator cuff tears had been treated arthroscopically with biceps tenotomy or tenodesis. A simple tenotomy was performed in thirty-nine cases, and a tenodesis was performed in thirty-three. No associated acromioplasty was performed. All patients were evaluated clinically and radiographically by an independent observer at a mean of thirty-five months postoperatively.Results: Fifty-three patients (78%) were satisfied with the result. The mean Constant score improved from 46.3 +/- 11.9 points preoperatively to 66.5 +/- 16.3 points postoperatively (p < 0.001). A healthy-appearing teres minor on preoperative imaging was associated with significantly increased postoperative external rotation (40.4 degrees +/- 19.8 degrees compared with 18.1 degrees +/- 18.4 degrees ) and a significantly higher Constant score (p < 0.05 for both) compared with the values for the patients with an absent or atrophic teres minor preoperatively. Three patients with pseudoparalysis of the shoulder did not benefit from the procedure and did not regain active elevation above the horizontal level. In contrast, the fifteen patients with painful loss of active elevation recovered active elevation. The acromiohumeral distance decreased 1.1 +/- 1.9 mm on the average, and glenohumeral osteoarthritis developed in only one patient. The results did not differ between the tenotomy and tenodesis groups (mean Constant score, 61.2 +/- 18 points and 72.8 +/- 12 points, respectively). The "Popeye" sign was clinically apparent in twenty-four (62%) of the shoulders that had been treated with a tenotomy; of the sixteen patients who noticed it, none were bothered by it.Conclusions: Both arthroscopic biceps tenotomy and arthroscopic biceps tenodesis can effectively treat severe pain or dysfunction caused by an irreparable rotator cuff tear associated with a biceps lesion. Shoulder function is significantly inferior if the teres minor is atrophic or absent. Pseudoparalysis of the shoulder and severe rotator cuff arthropathy are contraindications to this procedure.Level Of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: The higher failure rates reported with arthroscopic stabilization of traumatic, recurrent anterior shoulder instability compared with open stabilization remain a concern. The purpose of this study was to evaluate the outcomes of arthroscopic Bankart repairs with the use of suture anchors and to identify risk factors related to postoperative recurrence of shoulder instability.Methods: Ninety-one consecutive patients underwent arthroscopic stabilization for recurrent anterior traumatic shoulder instability. The mean age (and standard deviation) at the time of surgery was 26.4 +/- 5.4 years. Seventy-one patients were male. Seventy-nine patients were involved in sports (forty, in high-risk sports). Capsulolabral reattachment and capsule retensioning was performed with use of absorbable suture anchors (mean, 4.3 anchors; range, two to seven anchors). All patients were prospectively followed, and, at the time of the last review, the patients were examined and assessed functionally by independent observers.Results: At a mean follow-up of thirty-six months, fourteen patients (15.3%) experienced recurrent instability: six sustained a frank dislocation and eight reported a subluxation. The mean delay to recurrence was 17.6 months. The risk of postoperative recurrence was significantly related to the presence of a bone defect, either on the glenoid side (a glenoid compression-fracture; p = 0.01) or on the humeral side (a large Hill-Sachs lesion; p = 0.05). By contrast, a glenoid separation-fracture was not associated with postoperative recurrent dislocation or subluxation. Recurrence of instability was significantly higher in patients with inferior shoulder hyperlaxity (p = 0.03) and/or anterior shoulder hyperlaxity (p = 0.01). On multivariate analysis, the presence of glenoid bone loss and inferior hyperlaxity led to a 75% recurrence rate (p < 0.001). Lastly, the number of suture-anchors was critical: patients who had three anchors or fewer were at higher risk for recurrent instability (p = 0.03).Conclusions: In the treatment of traumatic recurrent anterior shoulder instability, patients with bone loss or with shoulder hyperlaxity are at risk for recurrent instability after arthroscopic Bankart repair. At least four anchor points should be used to obtain secure shoulder stabilization. [ABSTRACT FROM AUTHOR]