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The surgical treatment of anterior shoulder instability includes various open and arthroscopic surgical techniques. Soft-tissue procedures can be successful treatment options for patients with predominant soft-tissue lesions. The results in terms of stability after the surgical procedure in these cases can be comparable to other surgical procedures such as stabilization using bone block or coracoid transfer. Identification of risk factors that can influence the outcome is of the utmost importance. Among these, the most important factor is the bony status of the glenoid and humeral head. In the absence of important bony injuries, including a bony Bankart lesion and a Hill–Sachs lesion, soft-tissue procedures are frequently successful. Additional important factors that should be taken into account in the surgeon’s decision-making process are shoulder laxity, underlying lesions, concomitant shoulder injuries, and the presence and quantity of instability events that predispose the quality of the soft tissue, especially the capsule and ligaments. To better describe and illustrate diagnostic process in the patients with anterior shoulder instability, some scenarios from clinical practice are used, showing the author’s preferred choice of treatment.

Posterior shoulder instability in athletes and the sports-active population can be an important factor for disability and lesser performance than expected. Two main groups of patients with different injury etiology and different pathomechanics should be differentiated. They also differ each from other in their participating sport. Contact athletes are exposed to traumatic events and repetitive microtrauma with overload to the posterior part of the glenohumeral joint. Traumatic posterior shoulder dislocation or subluxation can be result of the force applied in the posterior direction. On the other hand, repetitive microtrauma to the posterior shoulder complex, which is the most frequent cause of posterior shoulder instability, is the result of the continuous loading to the posterior glenohumeral restraints. The second group are overhead athletes, where the origin of posterior shoulder instability is mainly atraumatic, with gradually developed pain and a sensation of unstable shoulder. In these cases, concomitant injuries and pathological findings in addition to posterior shoulder instability are common. The connection between labral lesion, dynamic shoulder dysfunction, and capsular laxity can be described as a vicious circle. Microinstability events in a decompensated shoulder with excessive laxity leads to progression of labral lesions. Adaptive mechanisms in the glenohumeral joint specific for overhead athletes may challenge the diagnosis as the examiner must differentiate between adaptive capsular laxity and pathological instability. Prevention and conservative approach should be the first treatment option, especially in overhead athletes. Good indications for surgical treatment are structural pathological changes to the posterior capsulolabral complex in cases of traumatic posterior shoulder instability.

Symptomatic dysfunction of rotator cuff in anatomic shoulder arthroplasty may require conversion to reverse shoulder arthroplasty (RSA). The case presented in this chapter is a failed hemiarthroplasty (HA) implanted for the treatment of proximal humerus fracture. In this scenario, the relatively high prevalence of complications related to healing of the tuberosities in anatomical position is the main cause of dysfunction of rotator cuff.

Treatment of irreparable massive rotator cuff tears remains challenging and controversial. The decision-making process includes surgeon personal experience as well as scientific evidence. A thorough knowledge of existing treatment options and indications is crucial to achieve the best outcome. The chapter provides an overview of the different available treatments, including: scaffold augmentation, superior capsule reconstruction, subacromial biodegradable spacer, tendon transfers, up to reverse shoulder replacement.

The management of massive, irreparable rotator cuff tears (RCT) is challenging and associated with high failure rates. There are no current consensus or definitive guidelines concerning the optimal surgical treatment for this devastating condition. This study was designed to confirm the long-term safety and efficacy of the biodegradable inflatable InSpace™ system in patients with massive reparable or irreparable RCTs. In this open-label, single arm, prospective study, subjects with massive RCT underwent subacromial implantation with the biodegradable spacer. Follow-up visits were scheduled according to routine clinical practice. Shoulder function was evaluated using Total Constant Score (TCS). Twenty-four patients were treated and assessed. Four patients had partial tears, and in three of them RC repair was performed. These patients were not included in the efficacy analyses. Of the participating subjects who reached the 5-year follow-up, 84.6% of the patients showed a clinically significant improvement of at least 15 points in their score, while 61.54% showed at least 25 points of improvement. Only 10% of the treated patients showed no improvement or worsening in the shoulder score comparing to their baseline. An overall improvement in the total CS commencing at 3 months and sustained by 6 months through to 5 years of follow-up (P

Posterior shoulder instability has been shown more recently to be more common than previously thought [1, 2]. It can be challenging to diagnose and even more challenging to treat. Patients typically present with a variety of symptoms. The signs of instability are often nonspecific, and complete dislocation does not always occur. Classification and terminology are difficult as we have to distinct between unidirectional and multidirectional instability, instability and laxity, subluxation, or luxation caused by involuntary and voluntary muscle control. Recently, pathomechanics of shoulder instability is much better understood. Many structural abnormalities are recognized and can be properly addressed with surgical treatment. When conservative treatment fails, surgical treatment is valuable option if proper mechanical factors are modified with surgical procedure.

The purposes of this prospective non-randomized study were to confirm the feasibility of the biodegradable sub-acromial spacer (InSpace™) implantation in patients with massive irreparable rotator cuff tear and to determine the safety profile and functional results 3 years post-implantation. Twenty patients were implanted with the InSpace™ device and assessed up to 3 years of post-implantation. Improvement in shoulder function was assessed using Constant score, while ease of use of the system was recorded by surgeons as were device-related adverse events. Twenty patients were available for assessment. Implantation was performed arthroscopically in all patients, and a range of deployment time was 2–20 min. The mean total Constant score increased from 33.4 to 65.4 points at 3 years. There was an improvement of 6.4 points in subjective pain score which commenced at 1 week post-operatively and was sustained until 3 years of follow-up. Also activities of daily living and motions commenced improvement by 9.4 and 7.7 points, respectively. Improvement in power was only evident at 18 months of follow-up but was sustained at 3 years. Arthroscopic deployment of a co-polymer biodegradable spacer (balloon) into the sub-acromial space for an irreparable rotator cuff tear was found to be low-risk and simple procedure associated with improvement in shoulder function and low rate of complications. IV; therapeutic case series

Multiple etiologies have been implicated in the pathogenesis of rotator cuff tear mainly of two types: extrinsic, such as subacromial and internal impingement, tensile overload, repetitive stress; intrinsic, such as poor vascularity, alterations in material properties, matrix composition, and aging. The work of Yamamoto [1] statistically identified that the risk factors associated with rotator cuff tears in the general population were a history of trauma, the dominant arm, and age. In subjects who were under 49 years of age, rotator cuff tears were more strongly associated with the dominant arm and a history of trauma. These results indicated that extrinsic factors were more closely associated in the tears of the younger patients. The same study found 6.7 % of patients in their 40s with rotator cuff ruptures, 12.8 % in their 50s, 25.6 % in their 60s, 45.8 % in their 70s, and 50.0 % in their 80s, with the prevalence increasing with age. Despite these results, 16.9 % of the subjects without symptoms have also a rotator cuff rupture.

The suprascapular nerve has three distinctive anatomical locations where it is most vulnerable to injury: at the suprascapular and spinoglenoid notch and along the supraspinatus fossa, where it is relatively fixed to the periosteum. The supraspinatus muscle has closest relation to all three and is also the most studied muscle of rotator cuff in conjunction with the mechanism of nerve neuropathy. Several anatomical studies try to mimic rotator cuff rupture and surgical reconstruction and thus describe effect on nerve when medial retraction or lateral advancement of the supraspinatus is present. Clinical series do not correlate with anatomical studies concerning safe amount of lateral traction of supraspinatus tendon. It is recommended to do a neurological evaluation of the suprascapular nerve in patients who are being considered for surgical repair of the rotator cuff tears and have a significant degree of muscle atrophy, as the accompanying neuropathy may prolong post-surgical recovery or result in a poor outcome. Recently new arthroscopic techniques have been described to release the suprascapular nerve at the suprascapular notch, and it is believed that this will have a beneficial effect on nerve recovery and resolution of pain in case of nerve entrapment.