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In recent years the advent of arthroscopy has given a great contribution to a better understanding of the pathological findings of shoulder instability. Today we know that between the classical TUBS and AMBRI there is a new group of instabilities defined as minor or occult instabilities (AIOS and AMSI). This group of instabilities is more difficult to diagnose and sometimes they are wrongly identified with a subacromial pathology in the preoperative phase. On the other hand, we have also understood that the capsular avulsion from the humeral head named HAGL and PHAGL lesion can be responsible of shoulder instability. These kind of lesions can be diagnosed arthroscopically and some of them can be also treated at the same time with satisfactory outcomes. However, not all of these minor capsulo-ligamentous lesions can be successfully treated by means of arthroscopy, particularly some HAGL lesions, and in selected cases we prefer to switch to open surgery.

Massive and irreparable rotator cuff tear in often associated with severe arthritis of the glenohumeral joint. In such conditions shoulder arthroplasty is considered the treatment of choice. Results are conditioned by patient selection, in terms of age, clinical condition, functional demands and level of activity. In this study the Authors analyze literature reports of different shoulder implants: total or hemiarthroplasty, bipolar arthroplasty and resufarcing arthroplasty. The best results reported in recent literature are those obtained with the use of reverse shoulder arthroplasty; they are very likely related to the peculiar biomechanics and semiconstrained structure of this implant. The Authors also underline that the surgeon should include the high rate of complications of this procedure as a factor in patient selection.

Chronic posterior dislocation of the shoulder is the result of a missed posterior acute dislocation. It is characterized by a damage to the humeral head: the McLaughlin anterolateral humeral defect. In type 1 the humeral defect involves 20% to 50% of the humeral articular surface and it may be treated by closed reduction (in recent lesions) or transposition of the subscapularis tendon or by means of bone allograft. In type 2 the humeral defect is more than 50% of the surface. A bone allograft or prosthetic surgery may be indicated. Type 3 is a posterior fracture-dislocation of the humeral head, with preserved humeral surface. The ORIF is the preferred treatment. Type 4 is a multi-fragmented fracture-dislocation of the head; here a shoulder arthroplasty is the treatment of choice. The results of these techniques are generally satisfactory, if the treatment choices are correctly adapted to the anatomical and clinical patient’s condition.

Total shoulder replacement is a successful procedure for degenerative or some inflammatory diseases of the shoulder. However, fixation of the glenoid seems to be the main weakness with a high rate of loosening. The results using all-polyethylene components have been better than those using metal-backed components. We describe our experience with 35 consecutive total shoulder replacements using a new metal-backed glenoid component with a mean follow-up of 75.4 months (48 to 154). Our implant differs from others because of its mechanism of fixation. It has a convex metal-backed bone interface and the main stabilising factor is a large hollow central peg. The patients were evaulated with standard radiographs and with the Constant Score, the Simple Shoulder Test and a visual analogue scale. All the scores improved and there was no loosening, no polyethylene-glenoid disassembly and no other implant-related complications. We conclude that a metal-backed glenoid component is a good option in total shoulder replacement with no worse results than of those using a cemented all-polyethylene prosthesis.

Today advances in techniques and materials for rotator cuff surgery allow the repair of a large variety of types or extensions of cuff lesions in patients from a wide range of age groups who have different kinds of jobs and participate in different kinds of sports, and who have widely different expectations in terms of recovery of functions and pain relief. A large number of factors must be taken into account before implementing a rehabilitation protocol after rotator cuff surgery. These mainly include the technique (materials and procedure) used by the surgeon. Moreover, tissue quality, retraction, fatty infiltration and time from rupture are important biological factors while the patient’s work or sport or daily activities after surgery and expectations of recovery must also be assessed. A rehabilitation protocol should also take into account the timing of biological healing of bone to tendon or tendon to tendon interface, depending on the type of rupture and repair. This timing should direct the therapist’s choice of correct passive or assisted exercise and mobilisation manoeuvres and the teaching of correct active mobilisation movements the patient has to do. Following accepted knowledge about the time of biological tissue healing, surgical technique and focused rehabilitation exercise, a conceptual protocol in four phases could be applied, tailoring the protocol for each patient. It starts with sling rest with passive small self-assisted arm motion in phase one, to prevent post-op stiffness. In phase two passive mobilisation by the patient dry or in water, integrated with scapular mobilisation and stabiliser reinforcement, are done. Phase three consists of progressive active arm mobilisation dry or in water integrated with proprioceptive exercise and “core” stabilisation. In phase four full strength recovery integrated with the recovery of work or sports movements will complete the protocol. Because of the multi-factorial aspects of the problem, the best results can be obtained through a full transfer of information from the surgeon to the therapist to optimise timing and sizing of the individual rehabilitation protocol for each patient.

It is generally recognised that any medical-surgical activity entails the risk of failure, placing the physician at risk of malpractice claims. In order to protect both the physician and the patient, it is important to identify the risk factors relating to the various pathological situations and assess both the incidence and significance of such risks. Hence, a "Potential Failure Rating" could be devised already during the preliminary stages for every type of medical process. Such a rating would be useful both in clinical and medicolegal settings. This article considers the most common and important risk factors involved in typical diseases of the shoulder, from which a relative failure rating is formulated.

Recently the posterior humeral avulsion of the glenohumeral capsule (Reverse HAGL or RHAGL) has been reported in the orthopaedic literature as another possible cause of posterior traumatic shoulder instability. In the present paper we describe three patients in whom a RHAGL was probably a consequence of a tight open anterior shoulder stabilisation. The main complaint of these patients was a stiff shoulder after an open anterior stabilisation. A progressive and worsening discomfort was reported by patients in spite of an accurate rehabilitation program. At persistence of symptoms arthroscopy was performed with evidence of RHAGL that was repaired in association with an anterior release. Clinical and functional improvement was observed but the final outcome seems to be related to range of motion recovery and not only to the posterior repair.

The aim of traumatological classification is to adopt criteria that are anatomopatho-logic, prognostic, and at the same time strategic for the choice of treatment.

Past radiologic and anthropometric studies report a high incidence of glenoid anteversion and increased humeral retrotorsion in patients with recurrent anterior dislocation (RAD) of the shoulder. However, recent radiologic studies do not demonstrate significant developmental variations between normal and unstable shoulders. To investigate these conditions, the authors used computed tomography (CT), which offered the advantage of permitting a transverse view at different levels of the glenohumeral joint. CT also avoided the typical distortion inherent in plain radiographs performed in the axial projection. No significant developmental differences in glenohumeral index, glenoid anteroposterior orientation, and humeral retrotorsion were found between 50 normal subjects and 40 patients with RAD. Only erosions and fractures of the glenoid may affect orientation and anteroposterior diameter of the glenoid. Mainly, traumatic lesions rather than developmental abnormalities seem to affect these parameters in RAD patients.

The authors discuss the value of computerised tomography combined with double contrast medium arthrography in the various pathological conditions associated with scapulohumeral instability. The results obtained in 18 patients with anterior instability and the findings reported in the literature indicate that arthro-C.T. is currently the simplest, most reliable and most comprehensive procedure for investigation of the lesions of the bones, joint capsule and glenoid labrum associated with instability of the shoulder. It is particularly indicated in the forms of instability in which there are no documented episodes of dislocation, while in cases of recurrent dislocation it provides a complete overview of the bone and capsule lesions that can be used as a basis for individually tailored surgical treatment.

Radiological investigation of the shoulder joint in articular instability syndromes often yields inadequate information. Computerised tomography, either with or without a contrast medium, can provide more precise information about the pathological anatomy of the bones and capsuloligamentous structures. The authors report their experience in 50 normal and 33 pathological shoulders.

The importance of instability in the determination of painful syndromes of the shoulder is examined, with particular reference to young people who engage in sport. The physiopathology and clinical features are described, and the importance of diagnostic tests is emphasized. These often disclose the underlying pathological anatomy. Surgical treatment, which is indicated whenever the lesion is well documented, follows the methods used in treating recurrent dislocation. The validity of the method of Latarjet and Bristow is emphasized.