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BACKGROUND: Patellofemoral (PF) instability is a syndrome involving several factors and conditions. Trochlear dysplasia (TD) has been shown to be the feature most frequently diagnosed in patients with OPI (Objective Patellar Instability). Even the patella might have an altered shape. Articulating during growth with an abnormal trochlea might lead the patellar posterior surface to modify accordingly, becoming congruent with the trochlear shape. A mismatch between the two articulating surfaces has a role in patellofemoral dislocations. Rarely and in case of a highly dysplastic patella, reshaping only the trochlear groove might lead subsequently to an incongruence between the two bones. When isolated sulcus-deepening trochleoplasty does not restore a congruent patellofemoral tracking tested perioperatively, further surgical procedures might be required. METHODS: A medial closing wedge patellar osteotomy (MCWPO) added to sulcus deepening trochleoplasty should be performed to create a congruent patellofemoral joint. Indications for this procedure are Wiberg type III or IV patella with an intraoperative abnormal patellar tracking after the sulcus deepening trochleoplasty procedure has been concluded. RESULTS: From January 2012 to August 2020, 21 (6 right and 15 left knees) sulcus deepening trochleoplasties with a concomitant medial closing wedge patellar osteotomy have been performed. The mean follow up was 35,25 months (ranging from 10 to 60 months). The average Kujala, IKDC and Lysholm score were respectively 70,14 ± 15,51; 55,75 ± 7,12 and 77,12 ± 14,80. No further patellar dislocation has been assessed in those patients during follow up. CONCLUSION: This technique has shown good and promising clinical outcomes and should be considered when treating patients with a still unsatistactory patellofemoral tracking after the sulcus deepening trochleoplasty has been performed due to a patella-trochlea shape mismatch.

The scapulothoracic, acromioclavicular and sternoclavicular joints play a fundamental role in the shoulder function. Shoulder complex kinematics have been studied with different methods using: goniometers, 2 static radiographs, 3D motion analyzers (invasive or noninvasive) and digital inclinometers. Goniometers have been used traditionally to assess scapular rotation in relation to the thorax. The intrinsic limit of multiple static two-dimensional shoulder radiographs is the attempt of describing in two what is occurring in three dimensions. Technology innovations have led to the development of the 3D shoulder complex kinematics analysis ETS (Electromagnetic tracking systems) using sensors (invasive bone-pin markers or noninvasive skin surface marker) stitched to the scapula/clavicula, thorax, and humerus. Despite being uncomfortable, invasive 3D motion cortical pins analyzers still represent the current gold standard for tracking shoulder complex kinematics. Therefore, access to three-dimensional biomechanical instrumentations for collecting kinematic data represents an active problem for many physicians. A precise, easy to use and low-cost non-invasive method able to draw and analyze the kinematics of the shoulder complex has not been developed yet. Further researches are necessary to design a new non-invasive method able to draw and analyze the kinematics of the scapula and the whole shoulder complex, precisely.

When? Only patients with high-grade trochlear dysplasia types B and D, in which the prominence of the trochlea (supratrochlear spur) is over 5 mm, recurrent patellar dislocation, and maltracking. How? Sulcus deepening trochleoplasty: modifies the trochlear shape with a central groove and oblique medial and lateral facets; decreases the patellofemoral joint reaction force by reducing the trochlear prominence (spur); and reduces the tibial tubercle and the trochlear groove value by a proximal realignment. Pros: This procedure is highly effective in restoring patellofemoral stability and satisfying the patients. Cons: The patients must be aware of the risk of continuing residual pain and range-ofmotion limitation and that the development of patellofemoral osteoarthritis is not predictable.

One of the most frequent concerns of the increasing number of patients undergoing shoulder arthroplasty is the possibility to resume sport after surgery. This systematic review determined the rate of return to sport after total shoulder arthroplasty (TSA) and hemiarthroplasty (HA).The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed to perform this systematic review. A systematic electronic search was performed using the PubMed (MEDLINE), EMBASE, and Cochrane Library databases. All the studies analyzing the rates of reverse shoulder arthroplasties were pooled; data were extracted and statistically analyzed. Only studies with at least 10 adult patients recruited were considered. All studies had to relate return to sport after TSA or HA.A total of 76 studies were included for a total of 694 patients. The mean age and average follow-up were, respectively, 64.5 years (range: 24 to 92 y) and 4.5 years (range: 0.5 to 12 y). The mean rate of return to sport ranged from 49.3% to 96.4%. The mean time to resume sports was 8.1 months. The overall rate of return to sport after the procedures, according to a random effect model, was 83%. The mean level of sports at the time of the survey was worsened in 9.4% (±2.82%), improved or reported from good to excellent in 55.6% (±13.6%), and did not change in 40% (±1.4) of patients.On the basis of current available data, return to sports after TSA and HA is possible and is highly frequent. The subjective level of practice does not change or improve in most patients. More studies and better designed trials are needed to enrich the evidence on specific sport recovery after the procedure.

When? Only patients with high-grade trochlear dysplasia types B and D, in which the prominence of the trochlea (supratrochlear spur) is over 5 mm, recurrent patellar dislocation, and maltracking. How? Sulcus deepening trochleoplasty: modifies the trochlear shape with a central groove and oblique medial and lateral facets; decreases the patellofemoral joint reaction force by reducing the trochlear prominence (spur); and reduces the tibial tubercle and the trochlear groove value by a proximal realignment. Pros: This procedure is highly effective in restoring patellofemoral stability and satisfying the patients. Cons: The patients must be aware of the risk of continuing residual pain and range-ofmotion limitation and that the development of patellofemoral osteoarthritis is not predictable.

Purpose Although proximal and diaphyseal humerus fractures are frequent, the optimal management remains controversial. Antegrade nailing prevents further damage to the soft tissues and to the vascularization, but it has been associated with postoperative shoulder pain and dysfunction. During the latest years a straight nail design was developed to minimize these problems. Methods A total of 243 patients who had undergone surgery for antegrade intramedullary humeral nailing between January 2013 and July 2018 in A. Gemelli Trauma Center were divided into two groups according to the nail design used: straight nail group (S-group) and curvilinear nail group (C-group). Clinical data were collected using assessment forms (SF12-v2, Quick-DASH, ASES and Constant-Murley). Radiographic bone healing was assessed with RUST score at 30, 90 and 180 days after surgery. Results The S-group was made up of 128 patients with a mean age of 59 ± 19 (range 18–97) and a mean follow-up of 46 ± 9 months. The C-group was made up of 115 patients with a mean age of 53 ± 16 (range 18–88) and a mean follow-up of 51 ± 8 months. The S-group had a mental component summary (MCS) score of 54.3 ± 7.7 and a physical component summary (PCS) score of 46 ± 10.2, the C-group had a MCS score of 50.9 ± 8.4 and a PCS score of 44.1 ± 7.4. Quick-DASH and ASES were respectively 18.8 ± 4.3 and 78.6 ± 8.2 in the S-group, 28.3 ± 11.6 and 72.1 ± 13.5 in the C-group with statistical significance. Constant-Murley score was 73.9 ± 9.1 in the S-group (76% of the contralateral healthy side) and 69.4 ± 10.4 in the C-group (73% of the contralateral healthy side). The radiographic union score in the S-group was 4.1 ± 0.3 at 30 days after surgery, 7 ± 0.8 at 90 days and 10 ± 1.2 at 180 days, while in the C-group it was 4.2 ± 0.4 at 30 days, 6.4 ± 0.7 at 90 days and 9 ± 0.9 at 180 days. Conclusion Newer generation straight nails allow a faster bone healing and better functional outcome at mid-term follow up. Level of evidence III.

After a rigorous peer review process, twelve papers were accepted and published. These papers cover a wide range of topics including shoulder arthroscopy, arthroplasty and related neuropathies. This Special Issue focuses on “New trends in shoulder surgery from Biomechanics to the operating room”, and aims to cover recent advancements as well as future trends in the field of shoulder surgical treatments. Lee et al. [1] evaluated the functional and radiologic outcomes of biocompatible non-absorbable PEEK and biocomposite anchors used during rotator cuff repair, focusing on the rate of perianchor cyst formation during the first six months postoperatively. This paper demonstrated that the biocomposite anchor has a statistically significant tendency to form higher grades of fluid collection at 3 months after surgery, though this is usually reduced by the sixth postoperative month. Three papers published by the group of Romano et al. [2,3,4] are focused on both shoulder arthroscopy and arthroplasty. The first one [4] proves that the Infinity-lock button system is effective for the treatment of chronic grade III AC joint dislocation, resulting in elevated satisfaction ratings and predictable outcomes. The second paper [3] analyzes midterm results of onlay lateralized cementless stem reverse total shoulder arthroplasty in patients with valgus/varus malunion proximal humerus fracture sequelae without metaphyseal osteotomy, showing improved clinical outcomes and decreased complications. Our interest in this new prosthesis design has increased over the last decade too, showing better clinical outcomes while using an onlay curved lateralized cementless stem [5,6]. The third paper [2] emphasizes the use of MicroDTTect, bioactive glasses and tantalum cones in periprosthetic joint infections and revision surgery of the shoulder. The application of those instruments would allow for earlier bacterial identification and higher prosthesis–bone interface stability, respectively. Therefore, we are also proud to present the results of our study on the efficacy of the lateral acromioplasty [7]. This technique seems to be safe and reproducible, preventing the recurrence of rotator cuff tears in patients with small and medium lesions and a CSA greater than 35*. A mathematical formula has been proposed to resect the correct amount of acromial bone and decrease the CSA within a favorable range (30°–35°). Ladermann et al. [8] compared scapulothoracic alignment in pathologic type B shoulders with contralateral healthy shoulders. The non-statistically significant results of this study found that Walch type B shoulders had some limitations in maximal glenohumeral motion but exhibited significantly greater anterior scapular tilt with internal rotation, which might be adaptive. Therefore, Ladermann et al. [9] have published an observational study with the aim of determining the incidence of OBPP (obstretical brachial plexus palsy) risk factors in type B patients. They concluded that perinatal factors related to OBPP did not occur in a higher frequency in patients with Walch type B OA compared to the general population, although some of them were in the high normal range. The study presented by Riedl et al. [10] showed the first clinical and structural results of the recently introduced loop LHB tenodesis procedure. This technique provided good-to-excellent overall clinical results after a short-term follow-up of six months, with an inferior incidence of cosmetic deformities compared to conventional therapy options, such as tenotomy and anchor tenodesis. The proper treatment for the long head of the biceps is a topic still debated. Treatments available range from tenotomy to tenodesis, which has been described using different systems and in different positions along the humerus. Our group has recently published a paper comparing high and subpectoral tenodesis during rotator cuff repair [11]. Pascarella et al. [12] tested and demonstrated the effectiveness of triple monitoring (a combination of ultrasound, nerve stimulation and opening injection pressure) while performing an interscalene brachial plexus block (IBPB) for arthroscopic shoulder surgery. Three review papers complete this Special Issue. Bozzi et al. [13], with their “Suprascapular Neuropathy around the Shoulder: A Current Concept Review”, present an overview of the state-of-the-art diagnosis and treatment of suprascapular neuropathy. Nerve entrapment is an uncommon but increasingly recognized cause of shoulder pain. It is more frequently diagnosed in over-head athletes or patients with massive rotator cuff tears. Prompt diagnosis is crucial to treat it successfully through a conservative or an arthroscopic procedure, which is then considered the gold standard. Yon CJ et al. demonstrate that arthroscopic revision Bankart repair might lead to an improvement in clinical outcomes and reasonable satisfaction with proper patient selection [14]. Giovannetti de Sanctis et al. [15] compare corticosteroid injections to other drugs in the treatment of partial rotator cuff tears, focusing on the effectiveness of this therapeutic modality in terms of pain and shoulder functionality. PRP injections seem to lead to significantly better outcomes in terms of pain and shoulder function in long-term follow-up. Given these different contributions, it is evident that shoulder surgery still has fundamental questions that remain unanswered. We would like to thank the Editor in Chief for his support throughout the preparation of this Special Issue. We are grateful to all the anonymous reviewers who devoted their precious time reviewing the papers submitted to this Special Issue. Their reviews helped us select the best papers to be included in this Special Issue. We would like also to thank all authors who contributed to this Special Issue. Hopefully you will enjoy reading this selection of articles, as we did, and you will find them informative and helpful in keeping yourself up to date in the field of shoulder surgery.

The European contribution to the development and improvement of anatomic and then reverse shoulder arthroplasty has been huge and fundamental. The development of the Grammont prosthesis (Delta III; DePuy, Warsaw, Indiana) in Europe leads to an increasing interest in rTSA. The biomechanics of the shoulder may be altered by this rTSA design due to a medial and distomedial shift, respectively, of the CoR and the humerus. Scapular notching and loss of extra rotation have been underlined as complication at long-term follow-up due to the Grammont design. Both glenoid and humeral component lateralization in reverse shoulder prosthesis has been indicated as possible solutions to deal with those complications.

Several studies have reported an overall increase incidence of proximal humeral fractures in the elderly with considerable patient disability and increased public spending...

Background: A Critical Shoulder Angle (CSA), evaluated on plain radiographs, greater than 35&deg, is considered predictive of rotator cuff tears. The present prospective comparative study aimed, firstly, to develop a formula to calculate the amount of acromion that should be resected performing a lateral acromioplasty and, secondly, verify whether lateral acromioplasty to reduce the CSA associated with arthroscopic cuff repair decreased the rate of recurrence of the tears, and impacted favorably on clinical postoperative outcomes. Methods: Patients undergoing arthroscopic rotator cuff repair (RCR) for rotator cuff tears with a CSA greater than 35&deg, were included in this study and divided into two groups, based on whether the CSA had been reduced by arthroscopic resection of the lateral portion of the acromion. A new mathematical formula was developed in order to quantify the amount of bone to be resected while performing the lateral acromioplasty. Patients with traumatic tears, previous surgery, osteoarthritis or plain radiographs, not classified as A1 according to Suter-Henninger, were excluded. Clinical and radiographic outcomes were assessed at a minimum of 2 years of follow-up considering the tear size. Results: 289 patients were included in this study. Thirty-seven were lost to follow-up. Group A (Lateral acromioplasty) patients included: 38 small tears, 30 medium tears, 28 large tears and 22 massive tears, Group B (control group) was composed of 40 small tears, 30 medium tears, 30 large tears and 23 massive tears. The Constants Score value and retear Rate were, respectively, significant higher (p = 0.007 and p = 0.004) and lower (p = 0.029 and p = 0.028) in Group A, both in the Small-and Medium-size subgroups. No complications were outlined. The mediolateral width of the acromion was reduced, according to the preoperatively calculated measure. Conclusion: Arthroscopic lateral acromioplasty decreased the CSA within the favorable range (30&deg, &ndash, 35&deg, ) in all patients treated, resecting the amount of bone predicted by the mathematical formula. Lateral acromioplasty is a safe and reproducible technique which may prevent recurrence of rotator cuff tears in patients with small and medium lesions. Level of evidence: II.

(1) Background: Even though rotator cuff tears are the most frequent tendon injuries in adults, the effectiveness of conservatively treated partial-thickness tears still remains a matter of debate. The purpose of this review is to compare corticosteroid injections to other drugs in the treatment of partial rotator cuff tears, focusing on the effectiveness of this therapeutic modality in terms of pain and shoulder functionality. (2) Methods: A systematic electronic search was performed using the PubMed (MEDLINE), EMBASE and Cochrane Library databases. All studies comparing the use of corticosteroids and other infiltrative techniques in the treatment of partial lesions (excluding studies that considered subacromial impingement as inclusion criteria) were pooled, data were extracted and statistically analyzed. (3) Results: Nine studies were included in this systematic review. Those studies, composed by a total of 494 shoulders treated, have been published from 1985 to 2019. All compared techniques have shown a significant improvement over baseline condition. PRP (Platelet Rich Plasma) injections have been shown to be significantly more effective in both functional and pain control only in the long term. (4) Conclusions: None of the techniques prevail indisputably on the others. Anyway, the treatment of partial rotator cuff tears with PRP injections seems to lead to significantly better outcomes in terms of pain and shoulder function in long term follow up. Whereas in short and medium term follow up, PRP injections was superior only in terms of shoulder function. The small number of studies on prolotherapy did not enable us to provide an opinion on the outcomes of this technique.

Background Tenodesis of the long head of the biceps (LHB) is commonly undertaken during arthroscopic rotator cuff repair. We assessed the clinical and structural outcomes after high arthroscopic tenodesis (HAT) or mini-open subpectoral tenodesis (ST). We hypothesized that the clinical and structural results after HAT and ST are similar. Methods We included 40 patients with rotator cuff tear and LHB tendinopathy. Twenty patients (7 women and 13 men; mean age, 57.9 years; range, 56–63 years) were treated using HAT, and 20 patients (8 women and 12 men; mean age, 58.5 years; range, 55–64 years) were treated using an ST. Functional evaluation was performed preoperatively and at 6 weeks, 6 months, and 1 year after surgery, using the Constant Murley Score and Simple Shoulder Test scores; the LHB was evaluated using the LHB score. A Visual Analogue Scale was administered to all patients preoperatively and 2 days after surgery. Results The postoperative total and pain subscale's Constant score were significantly higher in the ST group. Moreover, 2 LHB score values were significantly different between the groups. The postoperative LHB total score in the ST and HAT groups averaged 86.9 ± 4.1 (mean ± SD) points and 73.3 ± 6.4 points, respectively. The Pain/Cramps subscale in the ST and HAT groups averaged 47.1 ± 5.9 and 33.2 ± 4.6 points, respectively. The 2 groups showed no difference in Visual Analogue Scale values (5.5 in the HAT group; 5.8 in the ST group) postoperatively. One patient in the HAT group reported a secondary onset of Popeye deformity. Conclusion Both high arthroscopic and mini-open ST of the LHB tendon produced reliably good functional results, but the ST group was associated with better postoperative clinical outcomes.

The reverse shoulder prost hesis (rTSA) is now implanted by the same percentage of anatomic shoulder prosthesis in the USA. Scapular notching and loss of extrarotation have been underlined as complication at long-term follow-up due to the Grammont design. The current trend to reduce those limits is to position both components lateralized. As the role of the subscapularis tendon in this new rTSA design is unclear, the purpose of this study is to quantify rTSA outcomes in patients with or without subscapularis tendon suture. The surgery was performed by the same orthopaedic surgeon (F.F.), using a Aequalis Ascend™ Flex prosthesis (Tornier, Montbonnot, France) with a bone autograft. Forty-four patients underwent surgery with the tendon sutured, whereas 40 patients underwent the same surgery without repairing it. Patients were evaluated pre-operatively and at the last follow-up using Constant score, VAS, and ROM. The minimum and mean follow-ups were six and 16.6 months, respectively. All patients showed statistically significant improvement in pain and joint function following surgery. This study highlighted significant higher values in intrarotation and abduction, respectively, with and without suturing the subscapularis tendon. However, no significant differences were underlined in Constant score, VAS, forward flexion, extrarotation at 0° and 90° of abduction, and rate of instability. As predicted, significant clinical improvements were observed in both groups with some differences. These clinical results showed that the use of rTSA with lateralized humerus and bony increase offset leads to realistic clinical improvements with a low risk of instability without the need for compression and stabilization of the tendon.

Background Two surgical techniques were compared : Standard BIO-RSA, performed with a glenoid eccentric reaming along with a cylindric bone graft augmentation vs. the Angled BIO-RSA, performed with a glenoid concentric reaming and a defect correction with an angled bone graft. Methods Patients undergoing RSA from January 2016 to April 2019, with one of the two techniques being performed, were retrospectively reviewed. Glenoids were classified according to Favard. Clinical (Constant-Murley, VAS and ROM) and radiographic (superior tilt correction) data were collected pre-operatively and at 12 months post-operatively. Results 141 shoulders were included. Angled BIO-RSA group showed statistically significant better outcomes in terms of forward flexion (149.9° Vs 139.3°) and abduction (136.4° Vs 126.7°). The use of an Angled BIO-RSA showed a statistically significant better superior tilt correction (1.252° Vs 4.09°). Angled BIO-RSA, leads to a better inclination correction and a mean postoperative tilt value inferior to 5° in E1 and E3 differently from standard BIO-RSA. Discussion Both techniques were able to correct glenoid superior inclination with excellent postoperative short-term results. However, angled BIO-RSA technique appears to be more effective in ensuring a correct inclination of the prosthetic glenoid component with better clinical outcomes.