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Background: The use of isolated soft tissue repair versus bone block stabilization for the treatment of recurrent anterior shoulder instability in adolescents has no scientific evidence. Purpose: To compare the clinical outcomes of adolescent patients who underwent isolated arthroscopic Bankart (iB) repair with those who underwent the arthroscopic Bristow-Latarjet procedure in addition to Bankart (BLB) repair. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 60 shoulders in adolescents (aged 13-18 years) were reviewed with a minimum 2 years' follow-up: iB repair (n = 36) and arthroscopic Bankart repair with an additional Bristow-Latarjet procedure (BLB; n = 24). The characteristics of the patients in each group in terms of age at the first instability episode, age at surgery, hyperlaxity, participation in at-risk sports, and Instability Severity Index Score were comparable. The mean follow-up was longer in the iB group (7.7 vs 4.1 years, respectively), whereas the rates of patients engaged in competition and those with glenoid lesions were higher in the BLB group. The primary outcome measures were failure, defined as the recurrence of instability (clinical dislocation or subluxation), and return to sports. The mean follow-up was 6.2 years (range, 2-16 years). Results: At the last follow-up, the rate of recurrence was significantly higher in the iB group, with 22% (8/36) failures, than in the BLB group, with 8% (2/24) instability recurrences (P <.05). The rate of return to sports at the same level was significantly higher after the BLB repair than after iB repair (79% vs 47%, respectively; P <.001). No statistical difference was found in patient-reported outcome scores between treatment groups (P >.05). Although failures occurred early after the BLB repair, 88% of failures after iB repair occurred after 2 years. On multivariate analysis, adolescents in the iB group with >3 episodes of preoperative dislocation and shoulder hyperlaxity (external rotation >90°) had a 60% recurrence rate (P <.005). Conclusion: Adolescent patients undergoing the BLB repair had a lower rate of recurrent instability and higher rates of return to sports and competition than those undergoing iB repair. Patients with shoulder hyperlaxity (external rotation >90°) and >3 dislocations had an unacceptable failure rate of 60% after iB repair. [ABSTRACT FROM AUTHOR]

Objective Functional posterior shoulder instability (FPSI) (type B1) is a severe type of instability, mainly in teenagers and young adults, that leads to loss of function, pain, and stigmatization among peers. An experimental nonsurgical treatment protocol based on neuromuscular electrical stimulation (NMES) showed very promising early results in the treatment of FPSI. The hypothesis of this study was that NMES-enhanced physical therapy leads to better outcomes than physical therapy alone as the current gold standard of treatment in patients with FPSI. Methods In this multicenter randomized controlled trial, patients with FPSI were randomly allocated in a 1:1 ratio to either 6 weeks of physical therapy or 6 weeks of physical therapy with simultaneous motion-triggered NMES. Baseline scores as well as outcome scores at 6 weeks, 3 months, 6 months, and 12 months after the intervention were obtained. The predefined primary outcome of this trial was the Western Ontario Shoulder Instability Index (WOSI) at the 3-month time point. Results Forty-nine patients were randomized and eligible for the trial. The group that received physical therapy with simultaneous motion-triggered NMES showed a significantly better main outcome measurement in terms of the 3-month WOSI score (64% [SD = 16%] vs 51% [SD = 24%]). Two-thirds of the patients from the physical therapist group crossed over to the group that received physical therapy with simultaneous motion-triggered NMES due to dissatisfaction after the 3-month follow-up and showed a significant increase in their WOSI score from 49% [SD = 8%] to 67% [SD = 24%]. The frequency of instability episodes showed a significant improvement in the group that received physical therapy with simultaneous motion-triggered NMES at the 3-month follow-up and beyond, while in the physical therapist group, no significant difference was observed. Conclusion The current study shows that NMES-enhanced physical therapy led to statistically significant and clinically relevant improvement in outcomes in the treatment of FPSI compared to conventional physical therapy alone—from which even patients with prior unsatisfactory results after conventional physical therapy can benefit. Impact Based on the results of this study, NMES-enhanced physical therapy is an effective new treatment option for FPSI, a severe type of shoulder instability. NMES-enhanced physical therapy should be preferred over conventional physical therapy for the treatment of patients with FPSI. [ABSTRACT FROM AUTHOR]

Purpose: To determine how different combinations of humeral stem and glenosphere designs for reverse shoulder arthroplasty (RSA) influence range of motion (ROM) and muscle elongation.Methods: A computed tomography scan of a non-pathologic shoulder was used to simulate all shoulder motions, and thereby compare the ROM and rotator cuff muscle lengths of the native shoulder versus 30 combinations of humeral components (1 inlay straight stem with 155° inclination and five onlay curved stems with 135°, 145° or 155° inclinations, using concentric, medialized or lateralized trays) and glenospheres (standard, large, lateralized, inferior eccentric and bony increased-offset (BIO-RSA)).Results: Only five of the 30 combinations restored ≥ 50% of the native ROM in all directions: the 145° onlay stem (concentric tray) combined with lateralized or inferior eccentric glenospheres and the 145° stem (lateralized tray) combined with either a large, lateralized or inferior eccentric glenosphere. Lengthening of the supraspinatus and infraspinatus, observed for all configurations, was greatest using onlay stems (7-30%) and BIO-RSA glenospheres (13-31%). Subscapularis lengthening was observed for onlay stems combined with BIO-RSA glenospheres (5-9%), while excessive subscapularis shortening was observed for the inlay stem combined with all glenospheres except the BIO-RSA design (> 15%).Conclusions: The authors suggest implanting 145° onlay stems, with concentric or lateralized trays, together with lateralized or inferior eccentric glenospheres. [ABSTRACT FROM AUTHOR]

Background: Preoperative computed tomography (CT) measurements of glenoid version and inclination are recommended for planning glenoid implantation in shoulder arthroplasty. However, current manual or semi-automated 2-dimensional (2D) and 3-dimensional (3D) methods are user-dependent and time-consuming. We assessed whether the use of a 3D automated method is accurate and reliable to measure glenoid version and inclination in osteoarthritic shoulders.Methods: CT scans of osteoarthritic shoulders of 60 patients scheduled for shoulder arthroplasty were obtained. Automated, surgeon-operated, image analysis software (Glenosys; Imascap) was developed to measure glenoid version and inclination. The anatomic scapular reference planes were defined as the mean of the peripheral points of the scapular body as well as the plane perpendicular to it, passing along the supraspinatus fossa line. Measurements were compared with those obtained using previously described manual or semi-automated methods, including the Friedman version angle on 2D CTs, Friedman method on 3D multiplanar reconstructions (corrected Friedman method), Ganapathi-Iannotti and Lewis-Armstrong methods on 3D volumetric reconstructions (for glenoid version), and Maurer method (for glenoid inclination).The mean differences (and standard deviation) and the concordance correlation coefficients (CCCs) were calculated. Two orthopaedic surgeons independently examined the images for the interobserver analysis, with one of them measuring them twice more for the intraobserver analysis; interobserver and intraobserver reliability was calculated using the intraclass correlation coefficients (ICCs).Results: The mean difference in the Glenosys glenoid version measurement was 2.0° ± 4.5° (CCC = 0.93) compared with the Friedman method, 2.5° ± 3.2° (CCC = 0.95) compared with the corrected Friedman method, 1.5° ± 4.5° (CCC = 0.94) compared with the Ganapathi-Iannotti method, and 1.8° ± 3.8° (CCC = 0.95) compared with the Lewis-Armstrong method. There was a mean difference of 0.2° ± 4.7° (CCC = 0.78) between the inclination measurements made with the Glenosys and Maurer methods. The difference between the overall average 2D and 3D measurements was not significant (p = 0.45).Conclusions: Use of fully automated software for 3D measurement of glenoid version and inclination in arthritic shoulders is reliable and accurate, showing excellent correlation with previously described manual or semi-automated methods.Clinical Relevance: The use of automated surgeon-operated image analysis software to evaluate 3D glenoid anatomy eliminates interobserver and intraobserver discrepancies, improves the accuracy of preoperative planning for shoulder replacement, and offers a potential gain of time for the surgeon. [ABSTRACT FROM AUTHOR]

Purpose: Traditionally and since Neer, the humeral side of shoulder arthroplasty consisted of a stemmed component but the real need for stem fixation in total shoulder arthroplasty (TSA) has barely been investigated. The current study evaluated the clinical and radiological outcomes with a stemless TSA.Methods: Forty-seven patients, 20 female and 27 male patients with an average age of 63, were selected in four orthopaedic centres during a four year period, and implanted with a humeral head prosthesis with a three-fin design and titanium coating. Aetiologies were: primary osteoarthritis (29), fracture sequelae (12) and avascular osteonecrosis (6). Minimum follow-up was two years (range 24-51 months). The patients were evaluated with the Constant score (CS) and radiological exams.Results: Two patients had revision of the implants, one for persistent pain and one for secondary massive rotator cuff tear. At the final follow-up, the mean CS was 69, with an average gain of 36. All parameters improved with a foremost in pain relief. Mean satisfaction rate was 87%. Average anterior active elevation was 131° with a gain of 48. Radiologic evaluations showed stable implants in all cases. However, 17 cases demonstrated radiolucent areas, particularly superior and lateral to the implant, which neither decreased nor increased with time. No revisions were related to humeral component loosening.Conclusions: Stemless TSA provides the same results as compared to TSA with a humeral stem. We are still unsure as to the nature of the lucent zones and we are continuing our investigation to better understand this radiological phenomenon. [ABSTRACT FROM AUTHOR]

Background: The treatment of fracture sequelae of the proximal part of the humerus in combination with posttraumatic arthritis is challenging. The reported results of treatment with anatomic shoulder arthroplasty are disappointing. The aim of this multicenter study was to analyze the clinical and radiographic results of reverse shoulder arthroplasty for treatment of posttraumatic sequelae of the proximal part of the humerus with malunion of the tuberosities.Methods: This was a retrospective, multicenter study of 42 patients (42 shoulders) with the diagnosis of posttraumatic sequelae of the proximal part of the humerus with malunions of the tuberosities who were treated with reverse shoulder arthroplasty between 2000 and 2010. The mean age at the time of arthroplasty was 68 years (range, 27 to 83 years; median, 70 years). The dominant side was treated in 24 cases. The mean clinical and radiographic follow-up was 4 years (range, 2 to 13 years; median, 3.5 years). The Constant score including subgroups, shoulder flexion, rotation motion, and radiographs of the affected shoulders were analyzed before the surgical procedure and at the time of the latest follow-up. Patients categorized their postoperative results as very good, good, satisfactory, or unsatisfactory.Results: The mean Constant score increased from 19.7 points (range, 0 to 52 points) preoperatively to 54.9 points (range, 21 to 83 points) postoperatively (p < 0.0001). All of the subgroups of the Constant score also increased, as did active shoulder flexion and external rotation (all p < 0.0001). In one case, loosening of the humeral and glenoid components occurred. Scapular notching was present in 22 shoulders (52%) and was grade 1 in 12 cases, grade 2 in 4 cases, grade 3 in 2 cases, and grade 4 in 4 cases. Complications occurred in 4 patients (9.5%). Eighteen patients (43%) rated their result as very good, 19 (45%) rated their result as good, 4 (10%) rated their result as satisfactory, and one (2%) rated the result as unsatisfactory.Conclusions: Reverse shoulder arthroplasty is a viable treatment option for type-4 proximal humeral fracture sequelae that cannot otherwise be treated with anatomic shoulder replacement.Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Purpose: The impacts of humeral offset and stem design after reverse shoulder arthroplasty (RSA) have not been well-studied, particularly with regard to newer stems which have a lower humeral inclination. The purpose of this study was to analyze the effect of different humeral stem designs on range of motion and humeral position following RSA.Methods: Using a three-dimensional computer model of RSA, a traditional inlay Grammont stem was compared to a short curved onlay stem with different inclinations (155°, 145°, 135°) and offset (lateralised vs medialised). Humeral offset, the acromiohumeral distance (AHD), and range of motion were evaluated for each configuration.Results: Altering stem design led to a nearly 7-mm change in humeral offset and 4 mm in the AHD. Different inclinations of the onlay stems had little influence on humeral offset and larger influence on decreasing the AHD. There was a 10° decrease in abduction and a 5° increase in adduction between an inlay Grammont design and an onlay design with the same inclination. Compared to the 155° model, the 135° model improved adduction by 28°, extension by 24° and external rotation of the elbow at the side by 15°, but led to a decrease in abduction of 9°. When the tray was placed medially, on the 145° model, a 9° loss of abduction was observed.Conclusions: With varus inclination prostheses (135° and 145°), elevation remains unchanged, abduction slightly decreases, but a dramatic improvement in adduction, extension and external rotation with the elbow at the side are observed. [ABSTRACT FROM AUTHOR]

The article presents the strategies and techniques in arthroscopic hill-sachs remplissage with bankart repair. Steps include anterior capsulolabral mobilization and glenoid preparation, preparation of the hill-sachs defect, and remplissage with the posterior aspect of the capsule and infraspinatus tendon. The anterior bankart repair and postoperative rehabilitation protocol are also discussed.

Introduction: Our purpose was to evaluate if, in case of aseptic glenoid loosening and failure in anatomical total shoulder arthroplasty (TSA), revision by a reverse shoulder arthroplasty (RSA) is a reliable therapeutic option. Methods: Retrospective multicenter cohort study of 37 consecutive anatomical TSA revised by RSA for aseptic glenoid loosening or failure. The decision to implant a RSA was related to the presence of associated complications: rotator cuff tears (n = 24), subscapularis insufficiency (n = 29), prosthetic instability (n = 13), and glenoid bone deficiency (n = 37). The patients were reviewed clinically and radiographically at a mean follow-up of 47 months (range, 24-104). Results: Eighty-six percent of the patients were satisfied or very satisfied. The average Constant score increased from 24 to 55 pts (P < .0001) and active anterior elevation from 68° to 121° (P < .0001). Twenty-two of the 29 (76%) associated bone grafts were incorporated in the glenoid. Eight patients (21%) needed a subsequent reoperation because of recurrent or new complications: glenoid loosening (n = 3), prosthetic anterior instability (n = 3), and humeral subsidence (n = 2); the reverse prosthesis had to be converted to a hemiarthroplasty in 1 patient and removed in another. Conclusion: Revision with a RSA is a reliable therapeutic option which provides the double benefit of glenoid bone stock reconstruction by fixing the bone graft with the help of the baseplate and screws and of solving the problem of soft tissue insufficiency and prosthetic instability. However, surgeons should be aware that the rate of postoperative complications and subsequent reoperations is high, and that the surgical technique is demanding. [ABSTRACT FROM AUTHOR]

Although ectopic insertion of the pectoralis minor has been previously described in the literature, the role of such anatomical variations in producing shoulder symptoms (i.e., pain and/or stiffness) remains controversial. We describe here a case of shoulder stiffness in which an ectopic insertion of the pectoralis minor over the supraspinatus tendon was found to be the main reason for severe contracture in external rotation and anterior thoracic pain. During arthroscopy, external rotation could not be restored despite anterior and inferior capsulotomy and release of the capsule of the rotator interval. Complete restoration of the passive external rotation was obtained only after complete release of the pectoralis minor from the supraspinatus. This observation underlines the importance of recognising such an anatomical variation when performing an arthroscopic arthrolysis in a stiff shoulder. [ABSTRACT FROM AUTHOR]