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PURPOSE OF THE STUDY Acromioclavicular (AC) joint dislocation and its surgical treatment still raises a number of questions that remain to be answered. In some types of dislocations, Rockwood type III in particular, the indication for surgical treatment as such is relative. There are numerous techniques and implants available for the reconstruction of AC joint. In our research we focused on the necessity of coracoclavicular (CC) joint reconstruction. MATERIAL AND METHODS In this paper, a cohort of 56 patients with Rockwood type III AC joint injury who underwent surgical treatment at our department in 2010-2016 period was retrospectively evaluated. The patients were treated with open reduction with AC joint stabilisation using hook plate or tension band. The patients were divided into 2 groups, namely group 1 with CC ligament reconstruction and group 2 without CC ligament reconstruction. The assessment was done at 6 months, 1 year and 2 years after surgery. The clinical outcomes were assessed based on the absolute Constant score (CS) and coracoclavicular distance (CCD) on the X-ray. Subsequently, the outcomes were statistically processed and compared using the Student s ttest. RESULTS The least invasive surgical intervention, as to the length of incision, was the reconstruction using the hook plate without CC ligament suture, whereas the longest incision was performed in tension band with CC ligament suture. In the CC ligament suture group, the mean operative time was 10 minutes longer. When evaluating the CS of the compared groups with and without CC ligament reconstruction, no statistically significant difference (p > 0.05) was found between the two groups. Similarly, the CCD values at 2-year follow-up did not show any statistically significant difference between the two groups (p > 0.05). CONCLUSIONS The available outcomes suggest that the surgical methods used by us are adequately safe and reliable. Good clinical outcomes can be achieved by open reduction and fixation of Rockwood type III AC joint dislocation even without CC ligament reconstruction. Key words: acromioclavicular dislocation, classification, reconstruction, coracoclavicular ligament.

PURPOSE OF THE STUDY This study aimed to evaluate the clinical outcomes and the rate of recurrence in patients who had undergone arthroscopic Bankart repair with remplissage for anterior instability of the glenohumeral joint. MATERIAL AND METHODS The study included 96 arthroscopic Bankart procedures with remplissage performed between 2013 and 2019 at our department in 93 patients (81 men and 12 women; with the mean age of 33 years). We gathered and analysed preoperative data, including a 3D-CT scan of the affected shoulder. Apart from stability, the functional results were assessed postoperatively using the WOSI, SSV, Rowe score, and by measuring the strength of shoulder girdle muscles. The non-parametric MannWhitney U-test was used to identify the predisposing factors for recurrence of glenohumeral instability. RESULTS The arthroscopic Bankart repair with remplissage was indicated in 74 shoulders for primary TUBS and in 22 shoulders as a revision procedure. The recurrent instability was observed in 13 of 96 operated shoulders (13.5%). Subjective instability (positive apprehension test in the extreme positions of the shoulder joint, in abduction and external rotation in particular) was reported by 10 patients (10/13; 77%), three patients experienced a redislocation of the glenohumeral joint in the postoperative follow-up (3/13 patients; 23%). The risk of recurrence of the glenohumeral instability was not correlated with either the number of previous stabilisation procedures, or any other preoperative or intraoperative parameters. Conversely, a new postoperative injury was a factor of key importance. The patients with recurrent instability (subjective instability or glenohumeral dislocation) achieved a significantly lower Rowe score, SSV, postoperative VAS, and worse overall satisfaction with the procedure compared to the group with no recurrent instability. The remplissage induced minor limitations of external rotation at 0° abduction and internal rotation at 90° abduction. After rehabilitation, the muscle strength of the operated shoulder in both groups was comparable to that of the untreated shoulder in all planes of the shoulder range of motion. DISCUSSION Our study confirms the clinical relevance of the addition of remplissage to the arthroscopic Bankart procedure for reducing the rate of recurrent glenohumeral instability in TUBS with a clinically significant Hill-Sachs lesion. Satisfaction with the surgical outcome is high; the functional outcomes are very good, including muscle strength. Surprisingly, though, the risk of recurrent instability does not correlate with the number of implants used in the stabilisation procedure. CONCLUSIONS Addition of remplissage to the arthroscopic Bankart stabilisation in patients with a clinically significant Hill-Sachs lesion shows a low risk of recurrence of glenohumeral instability after surgery compared to the conventional arthroscopic Bankart repair alone. The remplissage does cause minor restrictions in the glenohumeral joint external rotation, but it was not reflected in the satisfaction of patients or a lower clinical score of the shoulder joint. The preoperative assessment of the HillSachs lesion using the "glenoid track" on a 3D-CT scan helps improve the preoperative planning and prediction of outcomes of the stabilisation procedure. Key words: glenohumeral instability, Bankart defect, Hill-Sachs lesion, Bankart repair, remplissage, arthroscopy.

PURPOSE OF THE STUDY The purpose of this study is to remind of the specific features of diagnosis and therapy of dorsal dislocations of the glenohumeral joint to prevent frequent neglect or misdiagnosis during primary treatment. Also, we strived to present our experience and outcomes of posterior dislocation treatment by McLaughlin procedure and its modified version. MATERIAL AND METHODS We retrospectively evaluated 7 patients who had been treated at our department in the period 2015-2019 by McLaughlin procedure or its modification. The group consisted of 5 men and 2 women aged 33-79 years. In five patients, the dislocation occurred during an epileptic seizure, in two patients during an accident. The patients were treated by McLaughlin procedure or the Neer modification of McLaughlin procedure. The deltoideopectoral surgical approach was always used. Based on the preoperative planning, we decided, or intraoperatively changed our decision, as to whether mere transposition of the subscapularis is satisfactory or whether transposition of the lesser tuberosity to the defect, a bone graft and arthroplasty are necessary. Postoperatively, the operated limb was fixed for 6 weeks in neutral position, which was followed by rehabilitation. RESULTS We evaluated subjective and objective outcomes of the surgery, the radiological finding and in 2 patients also a control CT scan. The function of the shoulder was assessed using the Constant shoulder score and the OSIS scoring system. The resulting score: the mean OSIS was 55.7 points (92.8%) and the mean Constant score was 86.2 points (86.2%), which we regard as a very good result. All patients consider the surgery successful and are satisfied with the outcome. No patient reported recurrent dislocation. DISCUSSION When treating the posterior dislocation of the shoulder, vital is the shoulder reducibility and also the presence or the size of reverse Hill-Sachs defect. The transfer of the subscapularis tendon can be performed as an open procedure or arthroscopically. Inveterate irreducible posterior dislocation of the shoulder is quite a rare diagnosis, which is why even at our department the McLauglin procedure is performed in the order of units per year only. CONCLUSIONS The surgical solution of inveterate posterior dislocation of the shoulder is hardly ever uncomplicated. The reduction alone is often insufficient and some other way of shoulder stabilisation is necessary, often times addressing the humeral head defect. In our to date experience, the McLaughlin procedure or the Neer s modification is an elegant and safe method to treat posterior dislocation with a humeral head defect. The functional outcomes are very good and enable the patients to reengage in everyday activities. Thanks to this procedure shoulder joint arthroplasty can be avoided in younger patients. Nonetheless, in defects that are greater than 50% of the head the replacement is necessary. Due to frequently associated rotator cuff injuries, the most often procedure indicated by us is the reverse total shoulder replacement. Key words: posterior dislocation of the shoulder, reverse Hill-Sachs defect, McLaughlin procedure, Neer s modification.

A rare case of a fracture of the anatomical neck of the humerus associated with a posterior dislocation of the shoulder in a 43-year-old man is presented. It was managed by immediate surgery using locking plate osteosynthesis. The shoulder was immobilised for 5 weeks in a Gilchrist brace. The outcome was very good with a full range of motion and a stable shoulder at 1 year after injury, with no signs of avascular necrosis of the humeral head. The aetiology of this injury and possibilities of its treatment are discussed. Key words: shoulder dislocation, humeral fractures.

The aim of this study was to present the results of surgical treatment in two male patients with chronic locked posterior dislocation of the shoulder, who underwent total shoulder arthroplasty due to destruction of more than 45% of the humeral head articular surface and glenoid impairment. The deltopectoral approach was used in both cases. Total shoulder arthroplasty (Epoca-Synthes) was carried out in the standard manner. Case one: A 29-year-old, extremely obese patient suffered injury to his shoulder during an epileptic seizure. At 11 months after injury, surgery was performed using an interscalene plexus block because general anaesthesia presented a high risk for the patient. The total follow-up period was 4 years. Between the 2nd and the 3rd follow-up year, the patient lost about 46% of his body weight. At the first year, when the patient maintained his initial overweight, shoulder elevation was 170° and range of motion was not restricted. The overall Constant Score (CS) was 96. Due to a massive weight loss, muscle strength was reduced and the CS decreased to 82. Case two: A 41- year-old man injured his shoulder in a fall and, due to a late diagnosis, underwent surgery under general anaesthesia at 11 months after injury. At 3-year follow-up the overall result was excellent, with only slightly limited internal rotation of the shoulder.

A rare case of a middle-third clavicle fracture concurrent with ipsilateral acromioclavicular dislocation in a 46-year-old women who had fallen off her bicycle is presented. The clavicular fracture was managed by locking plate osteosynthesis. The acromioclavicular joint was stabilised by traction osteorrhaphy that was removed at 7 weeks after the procedure. Both the radiographic and clinical outcomes were very good. The epidemiology, aetiology, diagnosis and therapy of this injury are discussed.

Purpose of the Study: Shoulder instability adversely affects the quality of life and restricts the functional capacity of the upper extremity involved. Today stabilisation surgery is almost always performed arthroscopically. The aim of this study was to present our experience with arthroscopic stabilisation of the shoulder and to identify risk factors responsible for its failure., Material and Methods: The group of 110 patients with recurrent anterior dislocation of the shoulder, who were treated between January 2007 and December 2010, consisted of 19 women and 91 men with an average age of 27 years (range, 14 to 56) at the time of surgery. Patients who had a concomitant tear of the rotator cuff or of the long head tendon of the biceps were excluded from the study. The minimum follow-up period was 2 years. The patients were evaluated for signs of clinical instability. Function was evaluated using WOSI, Constant-Murley and Rowe-Zarins. Statistical methods were used to assess factors leading to failed arthroscopic stabilisation., Results: At final follow-up, 17 patients (17 shoulders, 15.3%) had re-dislocation or subluxation of the joint treated. Age over 20 years reduced the probability of re-dislocation (odds ratio, OR=0.87; p=0.021) while the finding of an engaging Hill-Sachs lesion increased the risk of re-dislocation (OR=5.53; p=0.0028). The presence of a bony Bankart lesion had only a marginal effect on the probability of re-dislocation (p=0.0512). In stable shoulders the average pre-operative values improved to the final follow-up values as follows: WOSI index, 53.65 ± 5.6 to 94.8 ± 5.2 (p<0.0001); Constant-Murley score, 78.9 ± 6.1 to 95.6 ± 4.4 (p<0.0001); and Rowe-Zarins score, 53.3 ± 6.7 to 92.9 ± 7.8 (p<0.0001). No peri-operative complication was recorded., Discussion: Our study confirmed the role of 3D CT examination before arthroscopic stabilisation of the shoulder joint. The exact identification of bone injury and its extent is of prognostic importance. At the same time special attention should be paid to surgical and post-operative tactics in patients operated on before their 20 years of age. On the other hand, no risks were found to be associated with gender, sports activities, the number of previous dislocations, types of anchors, suture material or knot tying., Conclusions: Arthroscopic stabilisation of the shoulder significantly relieves pain and improves shoulder function in 85% of the patients with anterior shoulder dislocation. The risk that this stabilisation surgery will fail increases with lower age of the patient and the presence of an engaging Hill-Sachs lesion.

Purpose of the Study: To present the TightRope (Arthrex, Naples, FL) technique and its results in the arthroscopic stabilisation of acute acromioclavicular joint (ACJ) dislocation carried out at our department., Material and Methods: From July 2009 till December 2010, arthroscopic stabilisation of acute ACJ dislocation was performed in 22 patients. The group consisted of 18 men and four women with an average age of 37.4 years. The Rockwood type III to type V ACJ dislocations (III, 16; IV, 1; V, 5) were indicated for surgery. The average interval between injury and surgery was 5.4 days. In all cases, a second-generation TightRope implant was inserted by the EndoButton technique joining the distal end of the clavicle and the coracoid process. The results were evaluated using the UCLA Shoulder Scale at 6 months after surgery., Results: All 22 patients returned to their pre-operative activities without any restriction of shoulder motion within 5 months of surgery. The average post-operative UCLA score was 31.2 points (range, 28 to 35). Radiographic evidence of the loss of full reduction, with no effect on the clinical outcome, was recorded in four patients (18%) during post-operative rehabilitation. Of these, one had Rockwood type III, two had type IV and one had type V dislocations. One patient suffered post-operative pull-out of the implant from the coracoid; three patients showed skin wound healing by second intention above the lateral clavicle, with one requiring surgical repair under local anaesthesia. There was no neurovascular complication, intra- or postoperative fracture of the coracoid process or lateral clavicle, or deep wound infection., Discussion: Arthroscopic stabilisation of acute ACJ dislocation is a minimally invasive procedure providing the coracoclavicular ligament complex with dynamic stability. In comparison with open procedures, it is less painful post-operatively, allows the patients to return early to daily activities and has a better cosmetic effect. It eliminates the necessity of removing the osteosynthetic material, as is the case in commonly used techniques such as Bosworth's method, K-wiring, osteorrhaphy or hook plate insertion. The loss of full reduction in four patients, as observed on radiographs during their rehabilitation, was not accompanied by any clinical problems and is in agreement with the findings of other authors. In our group, it occurred in Rockwood grade IV and grade V dislocations. For these, there is a possibility of using two implants in order to increase stability and prevent the loss of full reduction but this involves a higher risk of coracoid fracture, extension of operative time and higher costs. However, a loss of reduction in some patients has also been reported by the authors who have used two implants. Therefore we prefer using a single TightRope implant, particularly in acute grade III ACJ dislocations requiring surgical treatment in patients engaged in repetitive overhead activities related to sports or occupation., Conclusions: Arthroscopic stabilisation of acute ACJ dislocations using a single TightRope implant is an elegant minimally invasive method with good results in indicated cases. It proves efficient particularly in Rockwood type III injuries in patients who have to do repetitive overhead activities. Acute type IV and type V ACJ dislocations treated by this technique show a loss of full reduction on radiographs more frequently, although no effect on the clinical outcome is evident.

Purpose of the Study: Post-traumatic ventral shoulder instability is a frequent disorder resulting from ventral and caudal dislocation of the humeral head. The aim of this retrospective study is to evaluate the long-term results of arthroscopy-assisted reinsertion of the ventral labrum using absorbable bioknotless suture anchors., Material and Methods: A group of 129 patients with unidirectional ventral instability of the shoulder was evaluated for the results of treatment involving labrum reinsertion with use of absorbable bioknotless anchors. This arthroscopy-assisted method is performed from two minimal incisions, with the patient in a beach-chair position. The shoulder rating scale of Rowe and Zarins was used to compare the pre-operative status with the treatment outcomes during follow-up ranging from 12 months to 5 years., Results: Return to the pre-injury level of activities was recorded in 93.8 % of the patients. The methods failed and dislocation recurred in 4.6 % of the patients. These underwent repeat surgery with the same technique and implants., Discussion: Arthroscopy-assisted stabilisation of the shoulder is a minimally invasive technique allowing for anatomically exact and complete treatment of traumatic injury to the intra-articular structures. It results in faster convalescence and provides better results than open methods. It requires short hospital stay and is performed as one-day surgery in our department; consequently, the costs of care for one patient are reduced. The use of absorbable suture anchors permits reimplantation of other anchors, either when suture material at primary stabilisation fails or at a potential repeat operation. The cosmetic effect of only two minimal incisions also plays a role. CONCLUSIONS Arthroscopic labrum repair with absorbable knotless anchors is, after a perfect mastering of the surgical technique, an effective treatment and, based on the results achieved, also the method of choice used at our department for managing labral lesions caused by traumatic unidirectional instability of the glenohumeral joint.

Purpose of the Study: The aim of the study is to remind the medical community of the occurrence of rare dorsal glenohumeral dislocations and of the need to pay increased attention to radiographic and clinical examination in the patients in whom signs of this injury are also supported by medical history. When this dislocation becomes a chronic disorder, it can frequently be managed only by surgical intervention. The treatment algorithm used at the authors' institutions is described., Material: In the period from 2000 to 2008, a total of l7 patients (9 women and 8 men) with an average age of 65.5 years (51 to 89 years) had surgery for inveterated dorsal glenohumeral dislocation. The average injury-surgery interval was 5.6 weeks (1 to 18 weeks). The average follow-up was 38 months (101 to 13 months)., Methods: Surgery was performed via an anterior deltoideopectoral approach. Under pathological conditions, the subscapular muscle was identified. When a large reverse Hill-Sachs defect was present, the lesser tuberosity with the subscapular tendon was osteomited (10 patients). After scar and granulation tissue had been removed, the humeral head was reduced. Using Neer's modification of the McLaughlin procedure, the excised lesser tuberosity fragment was transferred into the antero-medial defect in the humeral head and fastened with a screw. In the case of an unstable humeral head, this was held in the reduced position by two Kirschner wires either passed through the acromion or fixed to the glenoid (11 patients). The arm was immobilized in a brace for four weeks. Then the wires were removed and rehabilitation was started with avoidance of internal rotation., Results: None of the patients had recurrent dislocation. All were satisfied with the outcome and capable of resuming their daily activities sufficiently. Six patients complained of occasional pain. The average value of active elevation was 113° (40° to 160°). Reduced muscle strength in abduction, as compared with the contralateral arm, was observed in two patients. Injury to the axillary vein was recorded in one patient. Two patients had a large haematoma of the arm with swelling of the whole extremity. Two of the 11 patients treated with Kirschner wires developed infection around the wires that healed after their removal at four weeks after surgery. DISCUSSION The open reduction and stabilization of a posterior inveterated glenohumeral dislocation can be regarded as a rare procedure performed only occasionally even in specialized institutions. The international literature also provides information on only a few tens of such cases over a number of years. Causal procedures, performed through both an anterior and posterior approach, as well as extrafocal (rotational) osteotomy have been recommended. Currently, surgery from an anterior approach is preferred, because a reverse Hill-Sachs defect, if present, can be managed either by transfer of the lesser tuberosity with the subscapular tendon or by massive allograft. CONCLUSIONS The authors' experience suggests that Neer's modification of the McLaughlin procedure is the optimal treatment for posterior inveterated glenohumeral dislocation with an anteromedial defect of the humeral head. The excision of the lesser tuberosity with the subscapular tendon provides good access to the shoulder joint and thus allows for its reliable reduction. The fastening of a tuberosity fragment into the compression defect resolves one of the major risks for recurrent dislocation, without necessity to use allogenic material. Transfixation of the humeral head with Kirschner wires for four weeks is a reliable method of holding the head in the glenoid without risk of significantly restricting shoulder motion in the future.

Purpose of the Study: The aim of this presentation is to inform the medical community about causal therapy (transhumeral head plasty or massive osteochondral allograft transplantation) for large Hill-Sachs lesions which frequently cause failure of anterior stabilisation following ventral shoulder dislocations., Material: Seven men with an average age of 26 years (19 to 33 years) undergoing surgery in 2006 and 2007 were evaluated. The minimum follow-up was 18 months (41 to 18 months). Impressions on more than 30 % of the articular surface, or those whose critical size was larger than one-eighth of the humeral diameter (on CT scan) were taken as indications for surgery. Four patients had had previous surgery for anterior instability and three had a primary procedure. Four men underwent acute surgery and three had elective operations.Trans- humeral head plasty was used in five and massive osteochondral allograft in two patients., Methods: In the patients with large lesions in the anterior aspect of the shoulder joint, transhumeral head plasty involving repair of the ventral structures from the anterior approach was indicatedúúú in those with an isolated posterior bony defect, a massive osteochondral allograft was transplanted through the posterior approach. The Constant-Murley score was used to assess clinical status before (not in acute conditions) and after surgery., Results: All patients reported improved clinical status. The average Constant-Murley score at final follow-up was 95.9 points (83-100 points). In the patients not having an acute procedure in whom pre-operative Constant-Murley scores were obtained, the average improvement was by 22.7 points (8 - 37 points). No general surgical complications were recorded. All patients reported subjective satisfaction and willingness to undergo surgery under the same conditions again., Discussion: A Hill-Sachs lesion is a frequent injury to the humeral head resulting from anterior shoulder dislocation. To distinguish between major and minor defects in terms of clinical significance is essential for the choice of appropriate shoulder treatment. Up to now large lesions have mostly been managed by non-causal techniques affecting shoulder biomechanics. Transhumeral head plasty or transplantation of a massive osteochondral allograft, on the other hand, offers a causal treatment. However, these two methods have rarely been mentioned in the international literature, and usually only as case reports., Conclusions: Transhumeral head plasty and transplantation of a massive osteochondral allograft offer a causal therapy for the management of Hill-Sachs lesions that does not alter shoulder biomechanics. They are not associated with a higher percentage of post-operative complications. Neither technique is more demanding than non-causal procedures. Operations carried out as primary and not as "salvage" procedures restored the function of the shoulder joint to normal. After secondary surgery, occasional shoulder pain may persist as well as its restricted range of motion.

Purpose of the Study: Transfer of the tip of the coracoid process to the anterior margin of the glenoid is a procedure indicated in shoulder instability due to bone lesion. However, it is also used in inveterated shoulder dislocations refractory to conservative treatment that require open reduction of the joint. The bone block thus created allows for more effective and safer rehabilitation than does a temporary rigid Ki-wire fixation of the humeral head. The aim of this retrospective study was to evaluate the group of patients treated for irreducible inveterated shoulder dislocations by the Latarjet procedure., Material: Between 2005 and 2009, 16 patients with inveterated anterior shoulder dislocations were operated on. The group comprised 11 men and five women with an average age of 58 years. In all patients the duration of shoulder dislocation was longer than 3 days and reduction that would keep the humeral head in the glenoid socket was not possible even under general anaesthesia. The reasons for the late treatment included a delayed visit to the doctor's because the injury was not considered serious, the dislocation being missed in the presence of other more serious conditions, and even an overlooking by the attending physician. The longest time between the dislocation and its treatment was 23 days. Alcohol abuse was evident in some of the patients., Methods: In the patients with irreducible inveterated shoulder dislocations who were referred to us, closed reduction was attempted in the first place.When this failed or when spontaneous dislocation subsequently occurred, open revision surgery was carried out. After coagula and synovia were removed from the glenoid socket, the head still had a tendency to dislocate spontaneously. Subsequently, the Latarjet procedure ;was performed this involved osteotomy of the coracoid process, retaining the attachment of the short head of the biceps brachii, and its transposition, through a split in the subscapularis ten- don, to the anterior lower margin of the glenoid. The process was fixed with two traction screws to create a firm bone barrier preventing dislocation., Results: The functional outcome was assessed at 6 months after surgery, ;using the Constant score its average value was 60 points (35 to 85). From the evaluation of individual cases it appeared that the longer the time of shoulder dislocation, the worse the functional outcome of treatment. In comparison with the patients treated by open reduction with a temporary rigid Ki-wire fixation, the Latarjet procedure was clearly beneficial., Discussion: Before the Latarjet procedure has been adopted, inveterated dislocations were treated by open reduction and a temporary fixation of the head in the socket by means of Ki-wires for three weeks. The functional outcomes following inveterated dislocation and rigid fixation were pitiable. Although the shoulder was articulated, its motion was restricted and painful. The procedure described here allows the patient to start early rehabilitation while maintaining shoulder stability., Conclusions: Inveterated irreducible shoulder dislocation is a rare diagnosis which is usually associated with the patient's personality disorder or is missed in patients with a disorder of consciousness. The treatment is difficult, but with the use of the procedure described here it is possible, with some limitation, to restore the shoulder function and its range of motion.

Purpose of the Study: The aim of this prospective study was to report on an open approach to a bony defect of the glenoid associated with anterior shoulder instability, using a modified Latarjet procedure, in elderly patients., Material: From 2003 to 2005, 11 patients older than 50 years underwent an open Latarjet procedure performed by two senior surgeons. The mean age of the patients was 65 years (range, 51 to 79 years). All of them were available for follow-up examination. There were seven women and four men. The study inclusion criteria were a bony defect of the anterior glenoid confirmed by a CT scan, age over 50 years, and three or more previous dislocations.The mean pre-operative forward elevation was 121.2 degrees+/-16.6 degrees (range, 40 degrees-180 degrees) and external rotation was 43.3 degrees+/-13.1 degrees (range, 5 degrees-80 degrees). The mean number of dis- locations before surgery was 4.8 (range, 3-8)., Methods: The Latarjet operation makes use of a large coracoid bone graft to extend the glenoid articular surface by means of a lengthened bone platform, and a sling effect of the conjoined tendon passing through the subscapularis muscle. The Constant-Murley score was used to evaluate the results., Results: Shoulder stability and function were restored in all 11 patients at a minimum follow-up of 4 years (range, 49-69 months). There was no recurrence of instability. The range of motion was minimally reduced; the mean loss of elevation was 18.8 degrees and the mean loss of external rotation was 4.0 degrees. The mean Constant-Murley score increased from 56.4+/-13.3 points preoperatively to 81.8+/-11.3 points post-operatively (p<0.05). No significant post-operative complications were observed., Discussion: It is necessary to differentiate between the Latarjet procedure and its modification popularised by Helfet as the Bristow or the Bristow-Latarjet operation. The Bristow procedure transfers only the tip of the coracoid, along with the attached con- joined tendon, to the anterior side of the neck. This procedure does not treat the bony defect and provides a mere soft-tis- sue constraint. Only a few reports of the original Latarjet procedure can be found in the international literature., Conclusions: The open Latarjet reconstruction can successfully restore shoulder stability in joints with a significant bony defect of the glenoid even in elderly patients. It is effective in situations in which soft-tissue reconstruction is not a reasonable option.

Purpose of the Study: The reconstructions of Bankart lesions, carried out according to the procedure recommended by the Mitek company, showed a high rate of recurrent dislocation. Therefore, based on operative experience, anatomical studies and reconstructive surgery on cadaver shoulders, we developed a new surgical technique that provided good shoulder stability and better operative outcomes. The results are reported here., Material: Between 1997 and 2005, arthroscopic Bankart repair with use of Mitek anchors was performed on 368 shoulders at the Department of Orthopedics, Faculty of Medicine, Palacky University in Olomouc. The average age of the patients was 22 years (range, 16 to 56 years). The patients were allocated to two groups according to the surgical technique used. Group 1, which comprised 100 shoulders, was treated by the Bankart repair procedure recommended by the Mitek Company. Group 2, which included 268 shoulders, underwent Bankart reconstruction by the technique developed at our department., Methods: In group 1, anchors were inserted in the anterior glenoid rim, as recommended by the Mitek company. In group 2, implants were inserted into the superior region, with surface reduced to spongious bone, of the anterior glenoid rim. This allowed for creation of a more robust capsulolabral complex preventing the humeral head from dislocation. The results were assessed by the UCLA (University of California at Los Angeles) shoulder score system and statistical evaluation was performed at the Department of Medical Biophysics, Faculty of Medicine, Palacky University in Olomouc., Results: In group 1 (Mitek procedure), the UCLA shoulder score evaluation was as follows: 22 (22 %) excellent, 28 (28 %) good, 22 (22 %) satisfactory, and 28 (28 %) poor outcomes. In group 2 (our technique), the results included 199 (74 %) excellent, 66 (24.6 %) good, two (0.8 %) satisfactory and one (0.6 %) poor outcomes. The difference between the groups was statistically significant (Chi-square, p 0.0001)., Discussion: The method of Bankart lesion repair has been a much discussed issue for a long time. At our department Mitek implants have been used. Although the operative procedures were faultlessly done, the results of the first 100 operations were not satisfactory. In some patients, the labrum reinserted by Mitek anchors failed to heal; it either remained loose or was attached to the scapular neck distally and thus did not provide sufficient stability that would prevent recurrent dislocation of the shoulder. In view of this, we conducted reconstructive operations on cadaver limbs, after a thorough topographic and anatomic study of the glenohumeral joint, and developed a modified method; after the labrum and capsule were freed, implants were inserted into the superior part of the anterior glenoid rim. This created a sufficient capsulolabral complex that prevented recurrent dislocation., Conclusion: Arthroscopic Bankart lesion repair, with the insertion of anchors by our method, markedly improved surgical outcomes and provided good shoulder stability. We believe that, in the future, this method will be more widely used in arthroscopic treatment of Bankart lesions.

Purpose of the Study: The authors describe an arthroscopic procedure for multidirectional shoulder instability and its results in a group of their patients. They present a new argument to the widely accepted view that multidirectional instability of the shoulder is not an indication to surgical treatment., Material: A total of nine shoulders in seven patients were indicated to surgical intervention because of multidirectional shoulder instability. The average age of the patients was 19 years. Two patients underwent a bilateral procedure. Based on the preoperative clinical findings, two groups were distinguished: the patients with loose shoulders who, with overhead use of the arm, suffered from recurrent subluxations dorsally or caudally, and those who were able to voluntarily dislocate the glenohumeral joint as well as to reduce it spontaneously (habitual posterior dislocation). The patients were evaluated at one year follow-up using the Rowe and Zarins criteria. Patients with unidirectional instability of the shoulder were not included in the study., Methods: All patients diagnosed with multiple recurrent posterior dislocations of the shoulder were indicated for surgery. After clinical examination, arthroscopy was carried out in a lateral recumbent position and, according to the findings, first capsulorrhaphy of the posterior capsule of the joint and reattachment of the labrum were performed, and then a similar intervention was carried out on the anterior part of the joint. For the operation, only two incisions were made, one for insertion of the arthroscope, the other for the instruments, and they were used interchangeably. Both absorbable and non-absorbable anchors were used and the capsule was fixed with a sliding knot. Subsequently, the shoulder was immobilized in a Desault bandage for 6 weeks, then rehabilitation was carried out. Full activity including sports was allowed beginning with the third month after surgery., Results: Shoulder stability was achieved in all patients. After the procedure, no voluntary dislocation of the joint in the posterior direction or subluxations of the shoulder with overhead use of the arm were recorded. All patients, who had had serious problems pre-operatively, were satisfied with the results and would undergo the arthroscopic procedure again. Therefore, the therapy can be regarded as very effective., Discussion: Our results of operative treatment contradict the generally accepted view that multidirectional shoulder instability is not indicated for surgical treatment, and the only therapy recommended to the patients is shoulder muscle strengthening, with avoidance of excessive motion range. This approach has persisted since the time when open surgery permitted either an anterior or a posterior intervention, but not both at the same stage. Today, arthroscopic reconstruction of the whole capsule is possible, with only a minimal interference with the shoulder muscles. Therefore, its benefits for the patients are undisputable., Conclusions: Arthroscopic stabilization of the shoulder for the treatment of multidirectional instability is a demanding procedure; however, if performed technically well, it is very efficient and provides good outcomes for patients with this diagnosis.

Purpose of the Study: Minimally invasive technique have recently gained importance because of their apparent advantages. One of them is arthroscopic stabilization of the shoulder used for treatment of traumatic anterior glenohumeral dislocation with subsequent instability. In this study we describe the results of and experience with this technique., Material: Conventional treatment of glenohumeral dislocation, which includes reduction and subsequent immobilization for 4 weeks, has a high risk of recurrent dislocation particularly in young patients.Therefore surgical treatment lowering this risk is preferred. Arthroscopic stabilization is effective in patients with post-traumatic anterior instability of the glenohumeral joint. This technique involves fixation of the torn glenoid labrum and reduction of the anterior articular space. The evaluation of 77 patients treated by this method is presented here., Methods: The arthroscopic method of labrum fixation with Mitek anchors (Mitek, Norwood, Mass., USA) was used. Arthroscopic stabilization is carried out in a lateral recumbent position with an extension device, using two standard arthroscopic ports. After preparation of the glenoid rim, the torn labrum is sutured to GII anchors inserted in pre-drilled tunnels in the edge of the glenoid. Insertion of three anchors appears optimal, because the use of fewer anchors may result in failure and repeat dislocation. The anchors have to be inserted in a manner ensuring fixation of maximum of the torn labrum., Results: A total of 90 shoulder joints were treated by arthroscopic stabilization and 77 patients were followed up. Excellent results were achieved in 58 patients (75.4 %). Good results in 14 joints (18.2 %) and poor in 4 patients (5.2 %). Three repeat dislocations were recorded and one patient experienced restriction of motion in the treated shoulder., Discussion: The three repeat dislocations (3.9 %) correlate with the results reported in the recent relevant literature., Conclusions: Arthroscopic shoulder joint stabilization is a reliable method. It is a surgical procedure suitable for treatment of shoulder instability and is also indicated in patients with acute traumatic dislocation, because it significantly reduces the risk of recurrent dislocation that is high in conventional treatment. In the hands of an experienced surgeon this technique is fast and simple and, because of its minimal invasiveness, convenient for the patient. In comparison with open stabilization techniques, arthroscopy is associated with higher failure, but a classical open procedure can still be used for treatment of recurrent dislocations.

Purpose of the Study: The authors present their experience with arthroscopic stabilization of a primary traumatic dislocation of the glenohumeral joint in young patients., Material: In up to 80% of patients younger than 25 years, traumatic dislocation of the glenohumeral joint is associated with its recurrence within one year of treatment even in well performed conservative therapy. Repeated dislocations gradually damage the joint and eventually result in the development of arthritis. The articular capsule becomes loose, glenoid surface is reduced and cartilage of the humeral head is affected. Repeated dislocation, reduction and immobilization are causes of patients' discomfort as well as morbidity. For these reasons, the stabilization of recurrent dislocations of the glenohumeral joint is performed by an open procedure or, most recently, arthroscopic method. Arthroscopic stabilization of a primary traumatic dislocation of the glenohumeral joint is an invasive yet gentle method that permits an exact reconstruction of the injured articular capsule and provides good conditions for complete healing of the affected tissues., Method: In order to prevent dislocations from recurring, we offered to perform minimal invasive arthroscopic stabilization in 30 patients who had undergone reduction of a primary dislocation of the glenohumeral joint in the 1999/2001 period. Of these, 18 (45%) accepted this offer. In 11 men and 7 women (average age, 22 years) 12 right and six left glenohumeral joints were treated arthroscopically with the use of absorbable or non-absorbable sutures. The procedure was performed at 2 to 7 days after injury and reduction. The joint was immobilized in an elastic Desault bandage for 6 weeks, but with exercising the elbow. From the 4th postoperative week, the glenohumeral joint was passively exercised in the sagittal plane, but abduction and external rotation were avoided. From the 7th week on, the joint was exercised to achieve its full range of motion., Results: The patients were followed up for 12 to 26 months. No repeated dislocation occurred. The range of motion comparable with the contralateral healthy joint was achieved in all patients by 12 weeks after surgery. One patient with a combined injury involving fracture of the first lumbar vertebra with signs of articular fibrosis underwent redress of the glenohumeral joint under general anesthesia at 6 weeks after arthroscopy. All patients returned to their previous everyday life, working and sports activities., Discussion: Arthroscopic stabilization of the glenohumeral joint is an invasive though gentle method which, when exactly performed and followed by adequate postoperative rehabilitation, can considerably or even completely reduce recurrence of joint dislocation. Its disadvantages include costs of surgery and hospital stay, and a risk of potential intra- or post-operative complications. The statistical evaluation of primary dislocations in young patients showed that, in 80% of them, recurrent dislocations would probably require surgical treatment. In addition, a joint suffering from repeated dislocation may develop lesions to such an extent that dislocation may continue to recur even after surgical treatment; this happens in about 10% of the cases. Our estimate was that only 20% of the patients with primary traumatic dislocation (ruptured articular capsule) would not be in need of further repair. However, it was impossible to determine who they would be. Our results, i. e., the absence of recurrent dislocations, suggest a way of reducing the recurrence of dislocations following a primary injury of the glenohumeral joint., Conclusions: Arthroscopic stabilization of a primary traumatic dislocation of the glenohumeral joint in young patients (under 25 or maximally 30 years of age) is the method that allows us, invasively but with a good outcome, to reduce a high number of post-traumatic dislocations and to return sporting and/or manually working subjects to their previous way of life.

In treatment of comminuted dislocation fractures of the proximal humerus the most serious therapeutic problem still remains the 6th group of Neer's classification, in particular fractures with four fragments and with a completely dislocated and devitalized head. The authors present in a retrospective study an overall comparison of results assembled in 30 patients (and 19 checked patients resp.) who were operated by the technique of anatomical reconstruction (13 and 8 patients resp.) or by the authors own technique of non-anatomical reconstruction (17 and 11 patients resp.), all operated on account of comminuted dislocation fractures of the proximal humerus at the orthopaedic clinics of the First and Third Medical Faculty, Charles University, Prague in 1976-1988. Analysis of the results of the checked patients made the authors draw the following conclusions: 1. Fractures of the proximal end of the humerus is a relative frequent injury, in particular in the elderly. About 20% of these injuries call for surgical treatment. 2. In all non-anatomical reconstructions the mobility is very restricted in particular exorotation, in anatomical reconstructions the restriction is much smaller. 3. In all patients operated by the technique of non-anatomical reconstruction within three years necrobiotic reconstruction of the fragment of the head occurred which is the greater, the larger the fragment of the head which was preserved. 4. The result of the reconstruction depends on the preservation of nurture of the fragment of the head and on selection of an adequate technique of osteosynthesis. 5. In anatomical reconstructions the most frequent complication was loosening of the osteosynthetic material, a varus position of the head and pseudoarthrosis.(ABSTRACT TRUNCATED AT 250 WORDS)