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Purpose: Unrecognized posterior shoulder dislocation with a concomitant humeral head fracture affects joint function and no consensus exists regarding treatment. The present study analyses clinical and radiographic outcomes of a novel arthroscopic technique for reducing chronic locked posterior shoulder dislocation associated with subscapularis remplissage., Methods: The study comprises a retrospective analysis of consecutive chronic posterior locked shoulders (CPLS) with minimum 2-years follow-up of patients who had undergone McLaughlin technique arthroscopic modification for the treatment of CPLS with a reverse Hill-Sachs lesion. Active range of motion (ROM), Western Ontario (WOSI) and Constant Score (CS), were evaluated pre- and postoperatively. Plain radiographs and magnetic resonance imaging (MRI) scans were collected pre- and post-operatively, recording bone defect, osteoarthritis, cuff integrity/fatty infiltration, and the grade of filling of the reverse Hill-Sachs., Results: Twelve male patients with a mean follow-up of 37.3 months ± 10.5 (range, 24-58) were included. Mean WOSI and CS scores improved from 41 to 92 and 28 to 94 points, respectively. ROM measurements all had significantly increased at final follow-up, with no significant differences in arm rotation. No defects were left unfilled at final MRI examination., Conclusion: The results of this uncontrolled study with a limited number of patients confirm that arthroscopic reduction and subscapularis remplissage is a highly effective and satisfactory treatment method resulting in no shoulder rotation deficits., Level of Evidence: Level IV.

Background: The main aim of this study was to evaluate the performance of magnetic resonance imaging (MRI) and interobserver agreement in the identification of the comma sign. The second objective was to look for a correlation between the comma sign and the detachment of the superficial fascia of the subscapularis., Materials and Methods: Two radiologists, blinded to the arthroscopic findings, retrospectively assessed the magnetic resonance images of 110 shoulders and were asked to assess the presence of the comma sign and the intact subscapularis fascia. The inter-reader agreement and the MRI performance values for detection of the comma sign were calculated. In addition, the association between the intact superficial subscapularis fascia and the comma sign was evaluated., Results: The agreement between the 2 radiologists was perfect. The following values were obtained: sensitivity, 90.9%; specificity, 98.8%; positive predictive value, 95.2%; negative predictive value, 97.7%; and accuracy, 97.2%. No association between the comma sign and subscapularis fascia lesions was found., Conclusion: MRI appears to be a reliable method for preoperative assessment of the comma sign. The comma sign appears not to be formed by the detached subscapularis fascia., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Periprosthetic joint infections of the shoulder (PJIS) are the major cause for revision within the first two post-operative years, and are challenging both to diagnose and treat. Success depends on early identification of microorganisms, appropriate surgical procedures and efficient antibiotic administration. The peculiar microbiology of the shoulder may render the criteria for hip/knee PJI management inappropriate. In addition, later cases with clinically subtle signs often present diagnostic challenges. In recent years, specific issues of PJIS have been managed through the use of new instruments, such as MicroDTTect in pathogen detection and Bioactive Glass and tantalum cones in humeral bone loss. In the literature to date, no reports have been found that discuss the application in shoulder revisions and infections. The early identification of the microorganisms that cause infection may help improve both treatment strategies and the efficacy of therapy. MicroDTTect proved to be more efficient than swab collection for bacterial identification in orthopedic surgery, thus reducing analysis costs. The increasing number of shoulder arthroplasties is associated with an increase in the number of revisions. In cases of massive metaphyseal humeral bone loss, several techniques have been described; no reports have been reported regarding tantalum in humeral bone loss management. In some cases the tantalum cones required adaptation for femoral diaphysis in the augmentation of the humerus metaphysis and bone loss management improvement. Obtaining stable osseointegration of prosthetic implants is one of the greatest issues in orthopedic surgery, and even more crucial in revisions. Bioactive glasses demonstrated good regenerative and osseointegration properties, and an excellent candidate as a bone graft, scaffold and antibiotics deliverer. The Bioactive glasses were used to increase prosthesis-bone interface stability and fill bone defects in PJIS revision surgeries, contributing to the prevention of re-infection. Longer-term follow-up will be necessary to determine if construction durability is improved in the long term.

The successful treatment of proximal humeral fractures remains challenging for shoulder surgeons, and failure rates are high, regardless of initial treatment. This study aimed to analyze the clinical and radiographic midterm results of onlay lateralized cementless stem reverse shoulder arthroplasty (RSA) in patients with valgus/varus malunion proximal humerus fracture sequelae without metaphyseal osteotomy. We retrospectively studied 35 cases with the diagnosis of fracture sequelae of the proximal part of the humerus with valgus/varus malunion. The mean duration of follow-up was 4.6 years (range, 2 to 7 years), and the mean time between fracture and arthroplasty was 6 years (1 to 32 years). Seventeen patients (48.6%) had initially been treated nonoperatively. The Constant score (CS), active range of motion, and radiographs of the affected shoulders, as well as the acromion to greater tuberosity (AGT) distance and deltoid length (DL), were analyzed before surgery and at their latest follow-up. A total of thirty-three patients (94.3%) rated their outcome as very good or good. Mean CS, forward flexion, and external rotation improved significantly ( p < 0.0001), as did internal rotation and pain ( p < 0.05). AGT distance significantly increased postoperatively from 14.7 to 43.3 mm, as did DL from 143 to 170 mm ( p < 0.05). There was no correlation between the outcomes and valgus/varus deformity, previous surgeries, or AGT distance/DL. A total of four complications occurred (11.4%): two dislocations were detected (5.7%) and successfully revised with a longer cemented stem. Onlay lateralized uncemented stem RSA improves clinical outcomes and decreases complications when treating valgus/varus malunion fracture sequelae, avoiding intraoperative technical challenges, such as tuberosities osteotomy conscious of bone loss and proper deltoid tensioning.

Background: the choice of treatment of chronic grade III acromioclavicular (AC) joint dislocation is controversial. Several surgical techniques have been described in the literature, responding differently to nonoperative treatment. The aim of this study is to describe a modified technique of stabilizing an AC joint dislocation with the new Infinity-Lock Button System, in order to demonstrate that it is effective in optimizing outcomes and decreasing complications., Methods: this is a retrospective study of 15 patients who underwent surgical stabilization of the AC joint dislocation between 2018 and 2019, through modified surgical technique using the Infinity-Lock Button System. Active range of motion (ROM), Specific Acromio Clavicular Score (SACS) and Constant Score (CS) were evaluated preoperatively and postoperatively at last 18 months follow up. Patients rated their outcomes as very good, good, satisfactory, or unsatisfactory., Results: a total of twelve patients rated their outcome as very good and three as good; no patients were dissatisfied with surgery. The mean Constant Score increased from 38 points preoperatively to 95 postoperatively, the average SACS score decreased from 52 points preoperatively to 10 postoperatively, both significantly. No complications were detected., Conclusion: the described technique is effective for treatment of chronic grade III AC joint dislocation, resulting in elevated satisfaction ratings and predictable outcomes. Nevertheless, further longer term follow-up studies are required.

Background: Rehabilitation after Reverse Shoulder Arthroplasty (RSA) is still object of discussion with no based evidence guidelines. The aim of this study was to test a personalized rehabilitation protocol for three different patients groups according to clinical and intraoperative parameters that can affect final outcomes after RSA., Patients and Methods: We retrospectively evaluated a consecutive series of 112 patients who underwent to RSA between 2013 and 2015. The average follow-up was 29.2 months. A preoperative and postoperative clinical and radiographic assessment was performed. According to clinical, radiographic and intraoperative parameters, we selected three groups dedicating each one a specific level of post surgical care., Results: A statistically significant improvement was achieved from preoperative evaluation, regarding all analysed parameters. Notable improvements were reported in high care group: elevation improved of 63.9° despite of Group A 55.5° and Group B 54.5° and it resulted statistically significant ( p < 0.05). Costant Score increased of 35.9%, despite of Group A and Group B respectively 40.6% and 34.8% ( p > 0.05)., Conclusion: Our study shows that a personalized rehabilitation protocol can be effective improving clinical outcomes and decreasing complications rate, particularly in difficult management patients., Level of Evidence: Therapeutic Level IV., Competing Interests: Conflict of interest Alfonso Maria Romano, Angelo Di Giunta and Massimiliano Susanna receive fees for consulting from Exactech. The other Authors declare no conflicts of interest related to the subject of this article. This project does not infringe the Italian ethical rules and the privacy of the patients.

Shoulder arthroplasty is a technically demanding procedure to restore shoulder function in patients with severe osteoarthritis of the glenohumeral joint. The modern prosthetic system exploit the benefits of modularity and the availibility of additional sizes of the prosthetic components. In this paper we describe the biomechanics of shoulder arthroplasty and the technique for shoulder replacement including total shoulder arthroplasty (TSA) with all-polyethylene and metal-backed glenoid component, humeral head resurfacing and stemless humeral replacement.