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Background: Patient-specific instrumentation (PSI) may potentially improve humeral osteotomy in shoulder arthroplasty. The purpose of this study was to compare the deviation between planned and postosteotomy humeral inclination, retrotorsion, and height in shoulder arthroplasty, using PSI vs. standard cutting guides (SCG)., Methods: Twenty fresh-frozen cadaveric specimens were allocated to undergo humeral osteotomy using either PSI or SCG, such that the 2 groups have similar age, gender, and side. Preosteotomy computed tomography (CT) scan was performed and used for the 3-dimensional (3D) planning. The osteotomy procedure was performed using a PSI designed for each specimen or an SCG depending on the group. A postosteotomy CT scan was performed. The preosteotomy and postosteotomy 3D CT scan reconstructions were superimposed to calculate the deviation between planned and postosteotomy inclination, retrotorsion, and height. Outliers were defined as cases with 1 or more of the following deviations: >5° inclination, >10° retrotorsion, and >3 mm height. The deviation and outliers in inclination, retrotorsion, and height were compared between the 2 groups., Results: The deviations between planned and postosteotomy parameters were similar among the PSI and SCG groups for inclination (P = .260), whereas they were significantly greater in the SCG group for retrotorsion (P < .001) and height (P = .003). There were 8 outliers in the SCG group, compared with only 1 outlier in the PSI group (P = .005). Most outliers in the SCG group were due to deviation >10° in retrotorsion., Conclusion: After 3D planning, PSI had less deviation between planned and postosteotomy humeral retrotorsion and height, relative to SCG., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Because of detachment of the pectoralis minor and variation of the vector of the conjoint tendons, we hypothesized that the Latarjet procedure may alter scapular position and motion. The purpose of this study was to evaluate scapular position and motion in patients who underwent a Latarjet or a modified iliac crest bone graft transfer (ICBGT) procedure (J-bone graft)., Methods: Forty-six consecutive patients treated for recurrent anterior shoulder dislocation between 2010 and 2012 were retrospectively enrolled. Twenty-three were treated with a Latarjet and 23 with an ICBGT procedure. Twenty Latarjet and 20 ICBGT patients were available at a mean follow-up of 20 months (min, 12; max, 60). We recorded the Western Ontario Instability Index, the Rowe Score, and the Subjective Shoulder Value. Scapulothoracic position was studied according to the dyskinesis yes/no method. Intraobserver and interobserver reliability of the dyskinesis assessment was assessed., Results: Intraobserver and interobserver reliability of scapula dyskinesis assessment was high (Latarjet: intratester, κ = 0.84; intertester, κ = 0.75; ICBGT: intratester, κ = 0.78; intertester, κ = 0.71). Scapular dyskinesis was observed after 5 of 20 Latarjet and after 0 of 20 ICBGT procedures (P = .047). Patients with dyskinesis had lower scores (Western Ontario Instability Index, P = .043; Rowe, P = .047; Subjective Shoulder Value, P = .046), but no statistically significant difference was found between the Latarjet and ICBGT groups. Two of the 5 scapular dyskinesis patients reached the SICK (Scapular malposition, Inferior medial scapular winging, Coracoid tenderness, and scapular dysKinesis) scapula syndrome definition., Conclusions: Scapular dyskinesis was found in 5 of 20 patients who underwent a Latarjet procedure. Dyskinesis may be related to the detachment of the pectoralis minor, and variation of the vector and the working length of the coracobrachialis and the short head of the biceps., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to evaluate the long-term results of instability patients treated with iliac crest graft glenoid augmentation., Materials and Methods: Retrospective study including 48 consecutive patients (40 male; mean age 25; range, 17-35). There were 20 primary and 28 revision cases. Three patients declined follow-up examination, and 5 lost to >5 years follow-up. Mean follow-up was 9.2 years (range, 5-19). Reconstruction comprised: iliac crest graft, interposition of the labrum on the burred surface of the graft and capsular re-tensioning. We measured the Oxford Shoulder Instability Score (OSIS) and assessed arthrotic changes and atrophy and fatty infiltration of the subscapularis., Results: 8/43 had residual pain, 3/43 had a subjective sensation of instability, 1/43 had a re-dislocation and required re-intervention. The mean OSIS was 18.1 points (12-50) (n = 40). 1/40 developed postoperative subscapularis insufficiency. The mean subscapularis atrophy was 7.4% (37% atrophy to 27% hypertrophy). 2/40 had a relevant fatty infiltration of the SSC muscle stage III to stage IV. 19/40 had mild and 1/40 had a moderate arthrosis. Arthrosis progressed by 1 stage in 7 of 35 shoulders. The mean residual glenoid defect area was 4.0% (0-13.5) and the mean defect width was 8.3% (range, 0-19.2) (n = 40)., Conclusion: Glenoid rim reconstruction with iliac crest graft was equally effective for patients with primary repair and for failed previous stabilization. It offered the advantage of an anatomic reconstruction with a comparatively good long-term preservation of the joint line., (Copyright © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Background: Path analysis methods were used to test the prognostic value of 10 patient-related and treatment-related factors on the 1-year functional outcome of 463 proximal humeral fractures measured using the Constant score. Complex inter-relationships between these factors were also evaluated., Materials and Methods: Data were collected from a prospective cohort study that included 3 operative groups repaired using nail or plate fixation and 1 nonoperative group. From the available information, various factors potentially having a direct influence on the functional Constant score were identified. The process of creating a hypothetical causal path diagram was undertaken to order the factors in a sequence of associations or cause-and-effect relationships., Results: Our final multivariable regression model for the 1-year Constant score included the 6 factors of age, sex, treatment, occurrence of intraoperative and local post-treatment complications, and anatomic restoration. Being a woman aged older than 40 years, treated with a locking proximal humeral plate (LPHP), having experienced intraoperative and local post-treatment complications, and varus deformity of more than 30° were negative predictors of the Constant score (ie, poor shoulder function 1 year after treatment initiation). Three factors, the dominant side fractured and the Neer and AO fracture type, showed only significant association on intermediate factors. The presence of concomitant disease did not show any significant direct or indirect effect. A final pathway outlines these associations and inter-relationships., Conclusion: Prevention of local complications, in particular those leading to severe varus deviation, appears essential to improve shoulder function after a proximal humeral fracture., (Copyright © 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Hypothesis: This study evaluated several classification systems and expert surgeons' anatomic understanding of these complex injuries based on a consecutive series of patients. We hypothesized that current proximal humeral fracture classification systems, regardless of imaging methods, are not sufficiently reliable to aid clinical management of these injuries., Materials and Methods: Complex fractures in 96 consecutive patients were investigated by generation of rapid sequence prototyping models from computed tomography Digital Imaging and Communications in Medicine (DICOM) imaging data. Four independent senior observers were asked to classify each model using 4 classification systems: Neer, AO, Codman-Hertel, and a prototype classification system by Resch. Interobserver and intraobserver κ coefficient values were calculated for the overall classification system and for selected classification items., Results: The κ coefficient values for the interobserver reliability were 0.33 for Neer, 0.11 for AO, 0.44 for Codman-Hertel, and 0.15 for Resch. Interobserver reliability κ coefficient values were 0.32 for the number of fragments and 0.30 for the anatomic segment involved using the Neer system, 0.30 for the AO type (A, B, C), and 0.53, 0.48, and 0.08 for the Resch impaction/distraction, varus/valgus and flexion/extension subgroups, respectively. Three-part fractures showed low reliability for the Neer and AO systems., Discussion: Currently available evidence suggests fracture classifications in use have poor intra- and inter-observer reliability despite the modality of imaging used thus making treating these injuries difficult as weak as affecting scientific research as well. This study was undertaken to evaluate the reliability of several systems using rapid sequence prototype models., Conclusion: Overall interobserver κ values represented slight to moderate agreement. The most reliable interobserver scores were found with the Codman-Hertel classification, followed by elements of Resch's trial system. The AO system had the lowest values. The higher interobserver reliability values for the Codman-Hertel system showed that is the only comprehensive fracture description studied, whereas the novel classification by Resch showed clear definition in respect to varus/valgus and impaction/distraction angulation., (Copyright © 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.)

Hypothesis: This study reassessed the sensitivity and the specificity of the external rotator lag sign (ERLS) for diagnosis of supraspinatus tears in a large cohort of patients., Materials and Methods: The ERLS was used to assess 401 consecutive patients with 406 painful shoulder conditions. The clinical diagnosis was controlled either arthroscopically or by open surgery., Results: For isolated full-thickness supraspinatus tears, the ERLS had a sensitivity of 56% and a specificity of 98%. When the lesion involved the infraspinatus and the teres minor the sensitivity improved substantially. There was a strong correlation between the extension of the tear and the amount of the lag. The lag increased from 7 degrees for an isolated rupture of the supraspinatus tendon to 26 degrees in case of extension to the teres minor., Conclusion: The ERLS is highly specific and acceptably sensitive for diagnosis of full-thickness tears, even in case of an isolated lesion of the supraspinatus tendon., Level of Evidence: Level 2; Prospective cohort treatment study.

Hypothesis: This study addresses the outcome after osteosynthesis or hemiarthroplasty, using a cohort of patients that was enrolled in a previous prospective study on humeral head perfusion and was consequently treated using a common conceptual approach., Materials and Methods: Between 1998 and 2001, 98 patients with 100 fractures of the proximal humerus were treated surgically by a single surgeon with open reduction and internal fixation (ORIF) (51/100, group A, median age 54 years; range, 21-88) or with hemiarthroplasty (49/100, group B, median age 66 years; range, 38-87). Seventy-six of 98 patients were available for re-evaluation at a mean follow-up of five years (3.3-7.3) using the Constant-Murley score (CMS), the Subjective Shoulder Value (SSV), and conventional radiographs., Results: The median total CMS was 77 (range, 37-98) for group A and 70 (range, 39-84) for group B. The median SSV was 92 (range, 40-100) for group A and 90 (range, 40-100) for group B. Avascular necrosis occured in 6/40 fractures treated with ORIF., Conclusion: Osteosynthesis and hemiarthroplasty yield similar functional results and comparable patient satisfaction following the applied decision making process in this selected patient cohort. Osteosynthesis with preservation of the humeral head is worth considering when adequate reduction and stable conditions for revascularization can be obtained. In patients with osteopenic bone and/or comminuted fractures, hemiarthroplasty is a viable alternative., Level of Evidence: Level 2; Prospective non-randomized comparison study.

This study evaluated the reliability of the Constant-Murley Score. Two testers assessed 63 patients twice on the same day using the original publication by Constant and Murley. The intratester reliability of the total score was high and the differences between the tests were small; 2 of 14 items were unreliable. The intertester reliability was high, but there were significant median differences of the total score; 12 of 14 items were unreliable. We believe that the differences between the testers were due to the brief explanations of test components in the original publication. The reliability of the Constant-Murley Score could possibly be improved by a better standardization of the assessment procedure.

We evaluated the functional outcome and the occurrence of avascular necrosis in 51 consecutive patients (26 women) with intracapsular fractures of the proximal humerus treated with open reduction and internal fixation between February 1998 and December 2001. Mean age was 44 years (range, 21-60 years). Forty-one heads were initially perfused (group A), and 10 were ischemic (group B). Seven patients were lost to follow-up. Forty-four were evaluated using the Constant-Murley score and the Subjective Shoulder Value; 40 patients consented to a radiographic evaluation. The mean follow-up was 5 years (range, 3.3-7.3 years). In group A, 20 of 30 heads had no sign of structural alterations, 6 had signs of structural alterations of the cancellous bone, and 4 showed collapse of the subchondral bone plate of varying degrees. In group B, 8 of 10 heads were structurally altered, and 2 had collapsed. The median uncorrected Constant-Murley score was 80 (range, 37-98) for patients without structural alterations, 81 (range, 53-93) for patients with structural alterations, and 68 (range, 48-74) for patients with collapsed heads. The median Subjective Shoulder Value was 95 (range, 50-100), 90 (range, 50-100), and 55 (range, 40-80), respectively. Eight of 10 initially ischemic heads did not develop avascular necrosis, indicating that revascularization may indeed occur. The reason for late necrosis in some of the initially perfused heads remains unclear. Collapse was associated with a significantly worse clinical outcome. We conclude that osteosynthesis with preservation of the humeral head is worth considering when adequate reduction and stable conditions for revascularization can be obtained.

The purpose of this study was to evaluate predictors of fracture-induced humeral head ischemia. Between February 1998 and December 2001, 100 intracapsular fractures of the proximal humerus, treated by open surgery, were included in a prospective surgical evaluation protocol (mean age, 60 years; minimum, 21 years; maximum, 88 years; 45 men; 57 right shoulders). Fracture morphology was assessed following a structured questionnaire and based on radiographic and intraoperative findings. Perfusion was assessed intraoperatively by observation of backflow after a borehole was drilled into the central part of the head in all shoulders and by intraosseous laser Doppler flowmetry in 46. Good predictors of ischemia were the length of the metaphyseal head extension (accuracy, 0.84 for calcar segments <8 mm), the integrity of the medial hinge (accuracy, 0.79 for disrupted hinge), and the basic fracture pattern (accuracy, 0.7 for combined types 2, 9, 10, 11, and 12). Moderate and poor predictors of ischemia were fractures consisting of four fragments (accuracy, 0.67), angular displacement of the head (accuracy, 0.62 for angulations over 45 degrees ), the amount of displacement of the tuberosities (accuracy, 0.61 for displacement over 10 mm), glenohumeral dislocation (accuracy, 0.49), head-split components (accuracy, 0.49), and fractures consisting of three fragments (accuracy, 0.38). When the above criteria (anatomic neck, short calcar, disrupted hinge) were combined, positive predictive values of up to 97% could be obtained. The most relevant predictors of ischemia were the length of the dorsomedial metaphyseal extension, the integrity of the medial hinge, and the basic fracture type determined with the binary description system.

The purpose of this study was to add critical information to the data already available on anthropometry of the proximal humerus. Two hundred macerated humeri were examined. Measurements were taken either directly on the bones or on standardized radiographic projections. The methodology was validated and showed a mean interobserver correlation of 0.94 +/- 0.067. Results were expressed in mean values, first SD, and minimum and maximum values, as well as the 10th and 90th percentiles. The frontal radius of the head ranged between 21 and 26.5 mm (10th respectively 90th percentile). The frontal diameter of the base of the head ranged between 39.4 and 50 mm. The head height ranged between 14.4 and 18.8 mm. The frontal radius-head height ratio ranged between 0.64 and 0.77. The inclination of the head ranged between 132 degrees and 142 degrees. The medial offset ranged between 3.9 and 8.6 mm. The posterior offset ranged between -0.4 and 3.2 mm. The greater tuberosity offset (distance between the axis of the proximal humerus and the most medial insertion point of the supraspinatus tendon) ranged between 2.5 and 9.2 mm. Retrotorsion ranged between 7 degrees and 38.5 degrees. The distance from the bicipital groove to the head equator ranged between 6 and 10.5 mm. The anatomy of the proximal humerus showed a wide range for variables such as the medial offset and the greater tuberosity offset but was surprisingly constant for the inclination and relative dimensions of the head. The implications for prosthetic design are as follows: stem design and insertion should respect the insertion facet of the supraspinatus, a constant head inclination is an adequate approximation, only one head height per radius is required, and the capability for adjustment of medial offset is mandatory.

Malrotation has been suggested as a cause of failure of hemiarthroplasty of the proximal humerus. Placing a shoulder prosthesis in relationship to the bicipital groove might reproduce individual anatomy more reliably than using a standardized retrotorsion. The purpose of this study was to determine criteria for accurate adjustment of retrotorsion even when the proximal bicipital groove is destroyed, as is the case in fractures. The distance of the humeral head equatorial plane to the center of the bicipital groove was measured by high-resolution computed tomography at 4 levels (proximal and distal with 2 intermediate levels). The distal distance was considered to correspond to available references in fracture cases. The mean proximal distance was 8.0 mm (10th percentile, 6.2 mm; 90th percentile, 9.8 mm), and the mean distal distance was 8.5 mm (10th percentile, 7.1 mm; 90th percentile, 9.9 mm). As to the clinical relevance, there was no statistically significant difference between distances. For practical purposes in fracture indications, it is adequate to adjust the retrotorsion of the prosthetic component to the distal bicipital groove.

Fourteen consecutive elbows have been treated for rheumatoid arthritis (9 elbows) and for post-traumatic osteoarthrosis (5 elbows) by total elbow replacement with the GSB III implant. The elbows were reviewed retrospectively after a mean follow-up of 6 years (2 to 9 years). Ten of 14 elbows had a functioning GSB III implant at follow-up; 7 of them were rated satisfactory and 3 unsatisfactory with the Mayo elbow performance score. In 5 of these 10 cases, the patients had significant pain relief with no or only mild pain at follow-up, whereas 5 had moderate to severe pain. With a functioning implant the range of motion averaged 140 degrees of flexion, 19 degrees of lack of extension, 65 degrees of pronation, and 84 degrees of supination. Six (43%) elbows had major complications requiring 1 to 8 additional operations. Aseptic loosening requiring revision occurred in 4 (29%) elbows. Two of them were treated by a resection arthroplasty, and 2 were revised with another hinged semiconstrained device. Three further elbows had radiolucent lines involving more than 50% of the cement-bone interface of either the humeral or the ulnar component. However, in 8 elbows the cementing technique was considered marginal or inadequate. Poor cementing (marginal or inadequate) was associated with loosening (P = .008). The GSB III total elbow prosthesis can restore function and reduce pain. The rate of aseptic loosening in this series was higher than previously reported. Based on this observation, we conclude that the GSB III implant seems to be sensitive to the insertion technique and does not tolerate suboptimal cementing.

Between 1968 and 1995, 37 patients with ununited fractures of the clavicle were treated by decortication and plate osteosynthesis. Thirty-two (86%) were failures of union of fractures of the middle third. Thirty-four (92%) patients had post-traumatic nonunion or delayed union. Sixteen (43%) patients had undergone primary operative treatment. Autogenous cancellous bone graft was used in 24 (65%) patients with atrophic nonunion. Nine tricortical, iliac crest, intercalary grafts were used for segmental bone loss equal to or greater than 15 mm. At the end of treatment, union had been achieved in 35 (95%) cases. At a mean follow-up of 8.6 years (range 13 months to 17 years), 32 (86%) patients had no symptoms and had a full range of motion of the shoulder. Decortication with plate osteosynthesis is a reliable, durable technique for the management of symptomatic, ununited fractures of the clavicle.

The purpose of this study was to identify possible causes for the low union rate for surgically stabilized os acromiale. Between February 1990 and November 1995, fusion of an os acromiale was attempted in 15 shoulders in 12 patients at our institution. All patients were men. The mean age was 54 years (range 37 to 63 years). All shoulders had an os mesoacromiale considered too large for simple resection. An associated lesion of the rotator cuff ranging from partial-to full-thickness tear was present in all patients. Eleven had an unfused acromial epiphysis in both shoulders. Two different surgical approaches were used. Seven shoulders were approached through an anterior deltoid-off approach, thus potentially devascularizing the os acromiale. Eight shoulders were approached transacromially, preserving the deltoid origin and hence the terminal branches of the thoracoacromial artery. The technique of internal fixation (tension band wiring) was the same for both groups. The mean follow-up was 44 months (range 13 to 72 months). Union, as demonstrated by axial radiographic views, occurred in 3 out of 7 cases with a devascularized os acromiale and in 7 out of 8 shoulders with a perfused os acromiale (P = .017), respectively. Patients with a united os acromiale had a significantly better functional outcome as measured by the Constant score (P = .0169). In conclusion, aiming at a stable fusion of a sizable and hypermobile os acromiale is probably desirable because it enhances the overall functional result. Obtaining consolidation was possible when the vascularity of the acromial epiphysis was respected.

The deltoid extension lag sign has been developed to avoid the pitfalls confounding the diagnosis of an axillary nerve lesion. The physician elevates the arm into a position of near full extension. The patient is asked to attempt active maintenance of this position. If the deltoid is weak, the arm will drop. In five patients with traumatic axillary nerve palsy after anterior dislocation of the shoulder, the deltoid extension lag sign was used to evaluate the functional status of the deltoid muscle. The magnitude of the angular drop, or lag, of the arm was a precise indicator of the functional status and recovery of the deltoid. The sign proved to be objective and reproducible, allowing confident assessment of deltoid function and when repeated over time allowed precise follow-up of deltoid recovery.

Between December 1990 and September 1993, 26 consecutive patients (27 elbows) were treated for elbow contractures. We used a modified transhumeral approach supplemented by a limited lateral approach with or without a limited medial approach according to the correction gained after each step of the procedure. Eleven posttraumatic, 6 degenerative, and 10 miscellaneous contractures were evaluated. The mean follow-up was 30 months. Statistically significant improvement in the range of motion was obtained for all groups of patients; the mean flexion-extension arc of motion increased from 66 degrees to 100 degrees for the posttraumatic contractures, from 79 degrees to 102 degrees for the degenerative contractures, and from 85 degrees to 121 degrees for a miscellaneous group of contractures. Relief of pain was not an issue in the posttraumatic group; it was not significant for the degenerative group but was significant for the miscellaneous group. Flexion and extension force were maintained, and no joint was made unstable. Complications included three transient ulnar neuropathies and one tardy ulnar nerve palsy. The technique presented offers the advantage of virtually unlimited exposure of the joint in a stepwise manner, dictated by the intraoperative assessment of joint motion combined with preservation of the medial and lateral collateral ligament complexes and all relevant muscle insertions and origins. The concept is applicable to contractures of differing cause and can be adapted to the specific needs of the patient.

We assessed the relative value of lag signs for the evaluation of rotator cuff rupture in a prospective study of 100 consecutive painful shoulders with impingement syndrome, stages 1 to 3. Lag signs were compared with the Jobe and lift-off signs. Three tests were designed to assess the main components of the rotator cuff: the external rotation lag sign (ERLS) for the supraspinatus and the infraspinatus tendons, the drop sign for the infraspinatus, and the internal rotation lag sign (IRLS) for the subscapularis tendon. For assessment of the supraspinatus and infraspinatus the ERLS was less sensitive but more specific than the jobe sign. The drop sign was the least sensitive but was as specific as the ERLS. Partial ruptures of the supraspinatus remained concealed to the ERLS. For assessment of the subscapularis the IRLS was as specific but more sensitive than the lift-off sign. Partial ruptures of the subscapularis tendon could be missed by the lift-off sign but were detected by the IRLS. The magnitude of the lag correlated with the size of the rupture for both the ERLS and the IRLS. Clinical testing for lag signs was efficient, reproducible, and reliable. In patients with little or no restriction of motion it enhanced the accuracy of clinical diagnosis in rotator cuff lesions.

Forty-two shoulders in 40 patients operated on for anterior instability between 1986 and 1991 were reexamined. The mean follow-up was 47 months. The pathoanatomic findings at surgery were a Bankart lesion in 42 shoulders, a Hill-Sachs lesion in 31 shoulders, and a rounded or defective anterior glenoid rim in 29 shoulders. The surgical technique consisted of an open reinsertion of the anterior capsule-labral complex. Four shoulders had one or more recurrent anterior dislocations, and four shoulders had recurrent anterior subluxations. Three redislocations were caused by severe trauma. The presence and magnitude of a Hill-Sachs lesion did not influence the frequency of recurrence. An osseous defect of the glenoid rim > or = 3 mm was found in three patients, one of whom had redislocation after surgery. In patients with a large Bankart lesion the rate of recurrence was significantly higher.

We present a case of conversion of a glenohumeral fusion to an arthroplasty. Chronic pain in the scapulo-thoracic joint after shoulder arthrodesis, in the presence of a functional deltoid muscle, was judged to be the indication for conversion to a prosthesis. A deeply reamed glenoid fossa stabilized the prosthetic head. A glenoid component was not used. Pain relief was dramatic and permanent. Function was poor. Subjectively the patient was greatly improved. This solution is considered a salvage procedure for the rare instances of resistant, chronic pain originating in the scapulo-thoracic joint after glenohumeral fusion., (Copyright © 1994 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)