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Axillary nerve compression is a rare cause of posterolateral shoulder pain. Once the diagnosis is confirmed and after failure of conservative measures, open procedures have been the mainstay of treatment for several decades. More recently, arthroscopic techniques have been proposed, which offer several advantages, including improved access to difficult locations, better visualization, and less surgical morbidity. The objective of this Technical Note is to describe an arthroscopic neurolysis of the axillary nerve from the inferior humeral pouch, through the quadrilateral space and into the subdeltoid recess.

Subacromial decompression is one of the most frequently performed procedures in the setting of arthroscopic shoulder surgery and typically includes acromioplasty. However, the indication for acromioplasty remains a subject of debate. Possible complications involve deltoid muscle insufficiency due to an excessive removal of the anterior acromion. This case report is intended to draw attention to this particular complication and its management.

Arthroscopic Bankart repair techniques have evolved from solid anchors, with potential disadvantages such as glenoid rim fractures, anchor migration, and glenohumeral cartilage damage, to bone stock-preserving “soft” all-suture anchors. The aim of this study was to report on clinical short-term outcomes after arthroscopic knotless all-suture Bankart repair in patients with anterior shoulder instability. It is hypothesized that this technique provides good functional outcomes with low rates of re-dislocation and revision. A total of 39 patients with an average age of 28.8 (SD ± 10.5) years were included. The clinical outcome was evaluated at a minimum follow-up of 12 months in 28 of 39 (72%) patients. The American Shoulder and Elbow Surgeons Score (ASES), Single Assessment Numeric Evaluation Score (SANE), Quick Disabilities of the Arm, Shoulder and Hand Score (QuickDASH), the Short Form 12 physical component summary (SF-12 PCS) as well as general patient satisfaction were assessed. Re-dislocation and revision rates were recorded. Postoperatively, one patient (3.6%) re-dislocated his shoulder during a baseball game and required revision surgery with a Latarjet procedure. One patient (3.6%) reported a sensation of instability and 37 of 39 (95%) patients remained stable. At the final follow-up, the mean ASES (p

Treatment of severe acromioclavicular joint injuries remains controversial and has evolved over the past 4-plus decades. Although several variations on reconstruction exist, an ideal technique will likely use a combination of coracoclavicular ligament reconstruction with suture backup stabilization, minimal drill holes to reduce the risk of fracture, arthroscopic-assisted guidance for anatomic graft and suture placement in and around the coracoid, and fluoroscopic-aided reduction to ensure an anatomic acromioclavicular joint. The objective of this Technical Note is to describe an arthroscopic-assisted coracoclavicular ligament reconstruction with allograft using fluoroscopically guided and cerclage-controlled anatomic reduction of the acromioclavicular joint.

Background: Long-term clinical and radiographic outcome data after standard cemented long-stem reverse shoulder arthroplasty (RSA) remain underreported. The aim of this study is to report on medium- to long-term data of patients over 60 years of age. Methods: The same type of RSA (Aequalis Reverse II, Memphis, TN, USA) was implanted in 27 patients with a mean age of 73 years (range 61–84). Indications for RSA were cuff tear arthropathy (CTA) in 25 cases and osteoarthritis (OA) in two cases. Pre- and postoperative Constant Score was assessed and component loosening, polyethylene wear, scapular notching and revision rates were recorded at a mean clinical follow-up (FU) of 127.6 months (SD ± 33.7; range 83–185). Results: The mean-adjusted CS (aCS) improved from 30.0 (range 10–59) to 95.0 (range 33–141) points (p < 0.001). Glenoid loosening was found in two (9.1%) and stem loosening was found in three (13.6%) cases. Polyethylene wear was observed in four (18.2%) cases. Scapular notching appeared in 15 (68.2%) cases but was not associated with poor aCS (p = 0.423), high levels of pain (p = 0.798) or external rotation (p = 0.229). Revision surgery was necessary in three (11.1%) cases. Conclusions: RSA with a cemented standard long stem leads to improvement in forward elevation, abduction and pain after a mean FU of 10 years. However, external rotation does not improve with this prosthetic design. Moreover, scapular notching is observed in the majority of cases, and revision rates (11.1%) as well as humeral loosening rates (13.6%) remain a concern. Level of evidence: Level 4, retrospective cohort study.

BACKGROUND Revision rates following radial head arthroplasty (RHA) for unreconstructible radial head fractures (RHFs) differ vastly in the literature, and little is known about the risk factors that are associated with revision surgery. The purposes of this study were to assess the revision rate following RHA and to determine the associated risk factors. METHODS A total of 122 patients (mean age, 50.7 years; range, 18 to 79 years) with 123 RHAs who underwent RHA for unreconstructible RHFs between 1994 and 2014 and were ≥3 years out from surgery were included. Demographic variables, injury and procedure-related characteristics, radiographic findings, complications, and revision procedures were assessed. Cox regression analysis was performed to identify the risk factors that were associated with revision surgery following RHA. RESULTS The median follow-up for the study cohort was 7.3 years (interquartile range [IQR], 5.1 to 10.1 years). All of the patients had unreconstructible RHFs: Mason-Johnston type-IV injuries were the most prevalent (80 [65%]). One or more associated osseous or ligamentous injuries were seen in 89 elbows (72.4%). The median time to surgery was 7 days (IQR, 3 to 11 days). Implanted prostheses were categorized as rigidly fixed (65 [52.8%]) or loosely fixed (58 [47.2%]). A total of 28 elbows (22.8%) underwent revision surgery at a median of 1.1 years (IQR, 0.3 to 3.8 years), with the majority of elbows (17 [60.7%]) undergoing revision surgery within the first 2 years. The most common reason for revision surgery was painful implant loosening (14 [29.2% of 48 complications]). Univariate Cox regression suggested that Workers' Compensation claims (hazard ratio [HR], 5.48; p < 0.001) and the use of an external fixator (HR, 4.67; p = 0.007) were significantly associated with revision surgery. CONCLUSIONS Revision rates following RHA for unreconstructible RHFs are high; the most common cause for revision surgery is painful implant loosening. Revision surgeries are predominantly performed within the first 2 years after implantation, and surgeons should be aware that Workers' Compensation claims and the use of an external fixator in management of the elbow injury are associated with revision surgery. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background Dual orthogonal plating of midshaft clavicle fractures is increasingly used for osteosynthesis. The risk of refracture after hardware removal remains unknown. The purpose of this study was to compare the torsional and 3-point bending loads to failure of the clavicle following removal of single-plane, superior 3.5-mm plate fixation vs. dual orthogonal plating 2.7-mm constructs. Methods This study used 12 pairs of clavicles (N = 24) harvested from cadaveric specimens with a mean age at death of 56.5 years (range, 46-65 years). One clavicle from each pair was randomly assigned to either superior plating (SP, n = 12) or double plating (DP, n = 12). For SP, a superior 3.5-mm plate was used as a template to drill 3 bicortical 2.8-mm holes medial and lateral to the center of the clavicle. For DP, two 2.7-mm plates were used as a template to drill 4 bicortical 2.0-mm holes medial and lateral to the center of the clavicle. Clavicle pairs were randomly and evenly distributed to undergo either 3-point bending (n = 12) or posterior torsional loading (n = 12). Cyclic loading was performed, followed by load-to-failure testing. Stiffness, displacement at failure, load to failure, and failure mode were assessed and compared between SP and DP constructs. Results No significant differences between the SP and DP groups were observed for stiffness (768.2 ± 281.3 N/mm vs. 785.5 ± 315.0 N/mm, P = .872), displacement at failure (8.1 ± 2.8 mm vs. 5.4 ± 1.2 mm, P = .150), and ultimate load at failure (1831.0 ± 229.6 N vs. 1842.0 ± 662.4 N, P = .964) under the condition of 3-point bending. Similarly, no significant differences between the SP and DP groups were observed for torsional stiffness (1.3 ± 0.8 N · m/° vs. 1.1 ± 0.4 N · m/°, P = .844), rotation at failure (17.3° ± 4.4° vs. 14.4° ± 1.2°, P = .205), and ultimate torque at failure (14.8 ± 6.5 N · m vs. 14.7 ± 6.9 N · m, P = .103) under the condition of posterior torsional loading. The most common mode of failure for 3-point bending testing was an oblique fracture (7 of 12 clavicles, 58.3%), with no significant difference between groups (3 of 6 in SP group [50%] vs. 4 of 6 in DP group [66.7%], P > .999). The most common mode of failure with posterior torsional loading was a spiral fracture (10 of 12 clavicles, 83.3%), with no significant difference between groups (4 of 6 in SP group [66.7%] vs. 6 of 6 in DP group [100%], P = .455). Conclusion Following clavicle plate removal of either DP or SP, there is no statistically significant difference in the amount of force, under the condition of 3-point bending or torsional loading, required to fracture the diaphyseal clavicle in vitro.

Background The purposes of this study were (1) to report functional outcomes; (2) to assess complications, revisions, and survival rate; and (3) to assess differences in functional outcomes between removed and retained radial head arthroplasties (RHAs), early and delayed treatment, and type of RHA used at long-term follow-up after monopolar RHA for unreconstructible radial head fractures or their sequelae. Methods Seventy-eight patients (mean age, 59.2 years) who were at least 6 years postoperatively after monopolar RHA for unreconstructible RHFs or their sequelae were included. The Mayo Elbow Performance Score (MEPS); Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) score; visual analog scale; postoperative satisfaction (1-6, 6 = highly unsatisfied); range of motion; complications; and revisions were assessed. Radiographic findings were reported. Kaplan-Meier survival analysis was performed. Subgroups (RHA type, early vs. delayed surgery, RHA removed vs. retained) were compared. Results At a median clinical follow-up of 9.5 years (range: 6.0-28.4 years), median MEPS was 80.0 (interquartile range [IQR]: 60.0-97.5), median QuickDASH was 22.0 (IQR: 4.6-42.6), median visual analog scale was 1 (IQR: 0-4), median postoperative satisfaction was 2 (IQR: 1-3), and median arc of extension/flexion was 110° (IQR: 80°-130°). Radiographic follow-up was available for 48 patients at a median of 7.0 years (range: 2.0-15.0 years). Heterotopic ossifications were seen in 14 (29.2%), moderate-to-severe capitellar osteopenia/abrasion in 3 (6.1%), moderate-to-severe ulnohumeral degeneration in 3 (6.1%), and periprosthetic radiolucencies in 17 (35.4%) patients. Twenty-nine patients (37.2%) had complications and 20 patients (25.6%) underwent RHA exchange or removal. Kaplan-Meier analysis with failure defined as RHA exchange or removal demonstrated survival of 75.1% (95% confidence interval: 63.7-83.3) at 18 years. The highest annual failure rate was observed in the first year in which the RHAs of 7 patients (9%) were exchanged or removed. No significant differences were detected between type of RHA in MEPS (Mathys: 82.5 [75.0-100] vs. Evolve: 80.0 [60.0-95.0]; P = .341) and QuickDASH (Mathys: 12.5 [0-34.4] vs. Evolve: 26.7 [6.9-46.2]; P = .112). Early surgery (≤3 weeks) yielded significantly superior MEPS (80.0 [70.0-100.0] vs. 52.5 [30.0-83.8]; P = .014) and QuickDASH (18.6 [1.5-32.6] vs. 46.2 [31.5-75.6]; P = .002) compared with delayed surgery (>3 weeks). Patients with retained RHAs had significantly better MEPS (80.0 [67.5-100] vs. 70.0 [32.5-82.5]; P = .016) and QuickDASH (18.1 [1.7-31.9] vs. 49.1 [22.1-73.8]; P = .007) compared with patients with removed RHAs. Conclusions Long-term outcomes for RHA are satisfactory; however, there is a high complication and revision rate, resulting in implant survival of 75.1% at 18 years with the highest annual failure rate observed in the first postoperative year.