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Background: Revision rotator cuff repair is a surgical challenge, and the results have generally been inferior to those of primary repair. We examined the results of revision rotator cuff repair in a large series of patients and assessed which subgroups of patients had the greatest chance for a satisfactory functional outcome. Methods: A revision rotator cuff repair was performed in eighty patients after the failure of a previous operative repair. The average age of the patients at the time of the revision was fifty-nine years. Prior to revision, the average pain score was 7.4 points (with 0 points indicating no pain and 10 points, severe pain) and the active range of motion of the shoulder averaged 105° of elevation, 39° of external rotation, and internal rotation to the eleventh thoracic vertebra. All patients underwent repeat repair of the rotator cuff tendons to bone. Additional procedures included revision acromioplasty (fifty-three patients; 66%) and distal clavicular excision (twenty-six patients; 33%), among others. Results: After an average duration of follow-up of forty-nine months, the result was rated as satisfactory (excellent, good, or fair) in fifty-five patients (69%) and as unsatisfactory (poor) in twenty-five (31%). At the time of the latest follow-up, the average pain score had improved to 3.0 points and the active range of motion averaged 130° of elevation, 53° of external rotation, and internal rotation to the tenth thoracic vertebra. Improved results were associated with an intact deltoid origin, good-quality rotator cuff tissue, preoperative active elevation of the arm above the horizontal, and only one prior procedure. All seventeen patients who met all four of these criteria had a satisfactory result. Conclusions: The results of revision rotator cuff repair are inferior to those of primary repair. While pain relief can be reliably achieved in most patients, the functional results are improved principally in patients with an intact deltoid origin, good-quality rotator cuff tissue, preoperative elevation above the horizontal, and only one prior procedure.

The objective of this study was to quantitatively describe the supraspinatus musculotendinous architecture. After supraspinatus muscles were harvested from 25 embalmed shoulders, each muscle was divided into an anterior and posterior muscle belly on the basis of muscle fiber insertion. Pennation angles and musculotendinous dimensions were measured, and the physiologic cross-sectional area was calculated for each muscle belly. The physiologic cross-sectional areas of the anterior and posterior bellies were calculated to be 140 +/- 43 mm2 and 62 +/- 25 mm2, respectively, whereas their tendon cross-sectional areas were 26.4 +/- 11.3 mm2 and 31.2 +/- 10.1 mm2, respectively. The average anterior-to-posterior ratios for the muscle physiologic cross-sectional area and the tendon cross-sectional area were 2.45 +/- 0.82 and 0.87 +/- 0.30, respectively. Thus, a larger anterior muscle pulls through a smaller tendon area. These data suggest that physiologically, anterior tendon stress is significantly greater than posterior tendon stress and that rotator cuff tendon repairs should incorporate the anterior tendon whenever possible, inasmuch as it functions as the primary contractile unit.

The mechanical response of the inferior glenohumeral ligament to varying subfailure cyclic strains was studied in 33 fresh frozen human cadaver shoulders. The specimens were tested as bone-ligament-bone preparations representing the 3 regions of the inferior glenohumeral ligament (superior band and anterior and posterior axillary pouches) through use of uniaxial tensile cycles. After mechanical preconditioning, each specimen was subjected to 7 test segments, consisting of a baseline strain level L1 (400 cycles) alternating with either 1 (group A, 10 shoulders), 10 (group B, 13 shoulders), or 100 (group C, 10 shoulders) cycles at increasing levels (L2, L3, L4) of subfailure strain. Cycling to higher levels of subfailure strain (L2, L3, L4) produced dramatic declines in the peak load response of the inferior glenohumeral ligament for all specimens. The group of ligaments subjected to 100 cycles of higher subfailure strains demonstrated a significantly greater decrease in load response than the other 2 groups. Ligament elongation occurred with cyclic testing at subfailure strains for all 3 groups, averaging 4.6% +/- 2.0% for group A, 6.5% +/- 2.6% for group B, and 7.1% +/- 3.2% for group C. Recovery of length after an additional time of nearly 1 hour was minimal. The results from this study demonstrate that repetitive loading of the inferior glenohumeral ligament induces laxity in the ligament, as manifested in the peak load response and measured elongations. The mechanical response of the ligament is affected by both the magnitude of the cyclic strain and the frequency of loading at the higher strain levels. The residual length increase was observed in all of the specimens and appeared to be largely unrecoverable. This length increase may result from accumulated microdamage within the ligament substance, caused by the repetitively applied subfailure strains. The clinical relevance of the study is that this mechanism may contribute to the development of acquired glenohumeral instability, which is commonly seen in the shoulders of young athletes who participate in repetitive overhead sports activities.

Background: Neer and Foster previously described the inferior capsular shift procedure for treating multidirectional instability of the shoulder and reported preliminary results that were quite satisfactory. The purpose of our study was to perform a longer-term follow-up evaluation of the efficacy of the inferior capsular shift procedure for treating multidirectional instability of the shoulder. Methods: An inferior capsular shift procedure was used to treat multidirectional instability of the shoulder in forty-nine patients (fifty-two shoulders). All patients had failed to respond to an exercise program. In this series, the operative approach (anterior or posterior) was based on the major direction of the instability, as determined by the preoperative history and physical examination and as verified by examination with the patient under anesthesia. In all of the patients, the inferior capsular shift was the primary attempt at operative stabilization. The repair consisted of a lateral-side (or humeral-side) shift of the capsule to reduce capsular redundancy and, when necessary, a reattachment of the avulsed labrum to the anteroinferior aspect of the glenoid. Results: A redundant capsular pouch was seen in all of the shoulders in this series. In addition, detachment of the anteroinferior aspect of the labrum was found in ten shoulders and an anterior fracture of the glenoid rim was seen in two shoulders. At an average of sixty-one months (range, twenty-four to 132 months), results were available for forty-nine shoulders (forty-six patients). Thirty shoulders (61 percent) had an excellent overall result, sixteen (33 percent) had a good result, one (2 percent) had a fair result, and two (4 percent) had a poor result. Forty-seven (96 percent) of the forty-nine shoulders remained stable at the time of follow-up. Two of the thirty-four shoulders that had been repaired through an anterior approach began to subluxate anteroinferiorly again. None of the fifteen shoulders that had been repaired through a posterior approach had recurrent instability. Full function, including the ability to perform strenuous manual tasks, was restored to forty-five shoulders (92 percent). A return to sports was possible after thirty-one (86 percent) of the thirty-six procedures done in athletes; however, a return to the premorbid level of participation was possible after only twenty-five (69 percent) of the thirty-six procedures. Conclusions: The results in this series demonstrate the efficacy and the durability of the results of the inferior capsular shift procedure for the treatment of shoulders with multidirectional instability. The procedure directly addresses the major pathological feature - a redundant joint capsule. Similar results were seen with either an anterior or a posterior approach, and we continue to approach shoulders with multidirectional instability on the side of greatest instability. A postoperative brace was reserved for patients in whom a posterior approach had been used or in whom an anterior approach had involved extensive posterior capsular dissection (ten of the thirty-four shoulders treated with the anterior approach).

One hundred consecutive stiff shoulders in 93 patients resistant to conservative therapy were treated with surgery and intermittent regional anesthesia via indwelling interscalene catheter. Each patient underwent manipulation and one of several operative treatments to release any additional contracture. The indwelling interscalene catheter remained in place and functioned well for an average of 3 days in 87 shoulders. At an average follow-up of 3.0 years, overall clinical results according to Neer's criteria were excellent in 39 shoulders (39%), satisfactory in 28 (28%), and unsatisfactory in 33 (33%). Patients reported no or mild pain in 83 (83%) of the shoulders in the study. At final follow-up, average gains in motion were 44° of elevation (115° to 159°), 31° of external rotation (22° to 53°), and 5 spine segments of internal rotation (L 4 to T 11 ) . At final follow-up, 95% of the elevation and 79% of the external rotation achieved intraoperatively were maintained. The best results were obtained in those shoulders with idiopathic stiffness (88% excellent or satisfactory results); the worst results were in the postsurgical shoulders (47% excellent or satisfactory results). There were no catheter-related complications. The use of an indwelling interscalene catheter for postoperative pain control is a safe technique that facilitates early physical therapy in a patient population with a high risk of developing recurrent stiffness. (J Shoulder Elbow Surg 2000;9:268-74.)

Thirty-six consecutive patients who underwent revision decompression for refractory subacromial impingement were studied retrospectively. Average interval from the primary decompression procedure to revision was 29 months. Eighteen patients underwent arthroscopic and 18 underwent open revision. Six (33%) patients in the arthroscopic group and 12 (67%) patients in the open group were workers' compensation cases. At an average follow-up of 26 months, 17 (94%) patients in the arthroscopic group and 8 (44%) in the open group were satisfied with their procedure. Comparing workers' compensation patients, 5 of 6 in the arthroscopic group and 4 of 12 in the open group were satisfied. For nonworkers' compensation patients, all 12 patients in the arthroscopic group and 4 of 6 in the open group were satisfied. Average pain scores and postoperative range of motion was improved in both groups. Dense subacromial scarring with thick, fibrous adhesions was present in all patients. Residual, prominent bone, or an acromial spur was found in 20 (56%) patients. Overall, revision arthroscopic subacromial decompression was superior to open revision. However, there were more workers' compensation patients in the open group. Workers' compensation patients fared worse for both groups, but a significant proportion (83%) of the arthroscopic group was satisfied. Since subacromial scarring may be the most important pathology, arthroscopy is less invasive, allowing earlier, unrestricted postoperative rehabilitation and proving more effective.

One hundred ten consecutive cases (110 patients) of arthroscopically assisted rotator cuff repair through a limited, portal-extension approach were retrospectively reviewed. The average age of our patients was 58 years (range, 30 to 79). There were 35 women and 75 men. The dominant shoulder was affected in 67 patients (61%). All patients underwent a standard arthroscopic decompression. Acromioclavicular resections were performed in 15% of patients. The anterolateral portal was extended in the direction of Langer's lines to a total length of no more than 3 cm. The torn tendon was accessed through a small deltoid muscle split and repaired with nonabsorbable sutures. At an average follow-up of 35 months (range, 24 to 86), 106 patients (96%) had achieved excellent or satisfactory results. The average American Shoulder and Elbow Surgeons pain score improved from 7 preoperatively to 2 postoperatively. All but four patients were satisfied with the clinical result and reported significant improvement in active elevation and strength and a significant lessening of pain. Late acromioclavicular joint pain contributed to failure in three of the four patients with unsatisfactory results in this series. The results of this study suggest that, in selected patients with small to medium rotator cuff tears, arthroscopically assisted repair through an anterolateral portal-extension approach can produce excellent results.

Fifty patients (average age, 27 years) who underwent revision anterior stabilization surgery for failed anterior glenohumeral instability procedures were retrospectively reviewed. Failure of the original procedure occurred subsequent to significant trauma in only 17 of 50 shoulders. At revision, 49 shoulders underwent an anteroinferior capsular shift procedure and 23 underwent concurrent repair of a Bankart lesion. One shoulder was treated with a coracoid transfer to reconstruct the anteroinferior glenoid. At an average follow-up of 4.7 years (range, 2 to 10), there were 36 excellent and 3 good results (78%). Eleven shoulders were considered unsatisfactory (22%); 7 of these 11 patients had a diagnosis of voluntary dislocation. All 17 patients who had failed results after significant trauma had excellent results after revision surgery. However, only 22 of the 33 patients (67%) with atraumatic recurrent instability achieved excellent or good results after revision surgery. This difference was statistically significant. No patients had radiographic evidence of osteoarthritis at the most recent follow-up. Range of motion, return to function, and glenohumeral stability can be reliably restored in a high percentage of patients after revision anterior stabilization surgery for glenohumeral instability. However, the results are not as predictable as for primary surgery. Factors associated with poor results of revision repair included an atraumatic cause of failure, voluntary dislocations, and multiple prior stabilization attempts.

Thirty patients (31 shoulders) were retrospectively reviewed after hemiarthroplasty for glenohumeral osteoarthritis. Ten shoulders had primary osteoarthritis, and 21 shoulders had secondary osteoarthritis. Glenoid surface wear was evaluated and classified as either type I, concentric, (15 shoulders) or type II, nonconcentric, (16 shoulders). Postoperative results were reviewed with the American Shoulder and Elbow Surgeons' evaluation form, Neer classification, and the Constant score. Overall, 23 (74%) shoulders achieved satisfactory results, and 8 (26%) shoulders had unsatisfactory results. Results were similar in the primary and secondary osteoarthritis groups. Outcome correlated most significantly with the status of posterior glenoid wear. Patients with concentric, type I glenoids achieved 86% satisfactory results, whereas patients with nonconcentric, type II glenoids had only 63% satisfactory results. Although pain relief was similar in both groups, the unsatisfactory results were attributed to loss of forward elevation and external rotation in patients with type II glenoids. On the basis of these results hemiarthroplasty can be an effective treatment for both primary and secondary arthritis but should be reserved for patients with a concentric glenoid, which affords a better fulcrum for glenohumeral motion. (J Shoulder Elbow Surg 1997;6:449-54.)

To add clinical perspective to the articles of this two-issue collection, eight prominent shoulder surgeons discuss their approach to the treatment of rotator cuff disease. There is broad agreement in many areas, however, significant controversies remain.

Arthroscopically assisted rotator cuff repair, through a mini-open, deltoid-splitting approach, is an effective treatment for small- to medium-sized full-thickness tears of the rotator cuff. Advantages over traditional open repair include relative deltoid preservation, the ability to assess and treat coexisting intra-articular pathology, shorter hospitalization, reduced early morbidity, easier and quicker rehabilitation, and a smaller scar. Standard open repair is preferred for larger tears with a greater degree of tendon retraction or when the subscapularis tendon is involved in the tear.

The shoulder is characterized foremost by its mobility and large range of motion. The glenohumeral joint is notable for its relative lack of bony constraint, relying heavily on the congruent articulating surfaces and surrounding soft tissue envelope for static and dynamic stability. Effective function in the articulation is achieved by a complex interaction between the various articular and soft tissue restraints. The rotator cuff muscles center the humeral head in the congruent glenoid fossa through the midrange of motion, when the capsuloligamentous structures are lax. However, incongruent joints, especially in positions of loading asymmetry (in external rotation), have larger translations that occur at the extremes of motion. Excessive translations are then effectively restricted by the mechanical properties of the inferior glenohumeral ligament. When the capsule is tightened anteriorly it results in an anterior tether and causes an associated posterior shift in contact on the glenoid. The posterior migration of the humeral head center and glenohumeral contact are again more pronounced in shoulders with reduced congruence. Additional studies of normal motion in different planes, the effects of rotator cuff pathology and dysfunction on the kinematics of the joint, proprioception of the capsule, and biomechanical tests of the inferior glenohumeral ligament and other components of the joint capsule at strain rates associated with injury, need to be conducted to understand the specifics of normal shoulder function and the pathophysiologic processes that occur during shoulder degeneration.

Twenty patients underwent surgical reconstruction for nonunion of fractures of the surgical neck of the humerus. Average time from injury to surgery was 10 months (range 4 to 14 months). The operation consisted of bone grafting combined with humeral head replacement in 10 cases and open reduction and internal fixation in 10 cases. Results, at an average follow-up of 51 months (range 24 to 124 months), were excellent in five (25%), satisfactory in six (30%), and unsatisfactory in nine (45%). Twelve nonunions resulted from fractures initially treated with close reduction; repair of these nonunions achieved by 67% excellent or satisfactory results. Eight nonunions resulted from fractures initially treated with internal fixation; repair of these nonunions achieved only 38% excellent or satisfactory results. Fifteen complications, 11 of which necessitated reoperation, occurred. Surgical reconstruction for nonunions of the surgical neck of the humerus usually results in significant improvement in pain but much more modest improvement in active motion and function. Surgery should be reserved for patients with significant symptoms and disability.

Surgical Principles The posterior-inferior capsular shift is performed to treat recurrent glenohumeral instability that has failed to respond to conservative therapy. Through a posterior approach, the excessively redundant posterior and inferior joint capsule is shifted superiorly to reduce excessive capsular volume. The extent of the lateral capsular dissection inferiorly, as well as the amount of tissue shifted, can be tailored to fit the degree and location of the laxity. When the posterior labrum is found to be detached, it is reattached to the glenoid rim before proceeding with the posterior capsulorrhahy. Bony augmentation of the repair is needed in only rare cases, i.e. in glenoid hypoplasia or in revision capsulorrhaphy procedures.

We reviewed a series of 30 shoulders in 25 patients who had glenohumeral arthritis and rotator cuff deficiency and who underwent prosthetic replacement. Nineteen shoulders underwent humeral head replacement, and 11 shoulders had total shoulder arthroplasty. Meticulous mobilization and reconstruction of the deficiencies in the thin atrophic rotator cuff tissues were attempted in all shoulders. Emphasis was placed on anteroposterior stability, and this was achieved in all shoulders; superior coverage was fully achieved in 15 shoulders and was partially achieved in 11. All shoulders had less pain after surgery, and 93% achieved satisfactory pain relief. Total shoulder arthroplasty and humeral hemiarthroplasty were found to provide similar results with respect to pain relief, functional improvement, and patient satisfaction. Shoulders with hemiarthroplasty gained significantly more active elevation (+52° vs + 2°) after surgery. Cuff repair was easier when a humeral head prosthesis alone was used because less lateralization of the humerus occurred. Also, operative time, anesthesia time, and blood loss were decreased with hemiarthroplasty. Because the lack of glenoid resurfacing did not adversely affect pain relief or function and avoided the potential problem of glenoid loosening, we favor humeral hemiarthroplasty as a treatment for glenohumeral arthritis in the rotator cuff-deficient shoulder.

Operative treatment of two-part, displaced surgical neck fractures of the proximal humerus is used when satisfactory closed reduction cannot be achieved or maintained. Percutaneous pin stabilization is a reasonable option for unstable but reducible surgical neck fractures. When required, internal fixation is most reliably achieved with minimal hardware fixation, using heavy, nonabsorbable sutures or wire that incorporate the rotator cuff tendons, which are often stronger than the soft, osteoporotic bone. In cases with significant surgical neck comminution, humeral Enders nails may be incorporated into a tension-band construct for added longitudinal stability.

The tensile properties of the inferior glenohumeral ligament have been determined in 16 freshly frozen cadaver shoulders. The inferior glenohumeral ligament was divided into three anatomical regions: a superior band, an anterior axillary pouch, and a posterior axillary pouch. This yielded 48 bone-ligament-bone specimens, which were tested to failure in uniaxial tension. The superior band was consistently the thickest region, averaging 2.79 mm. The thickness of the inferior glenohumeral ligament decreased from antero-superiorly to postero-inferiorly. The resting length of all three anatomical regions was not statistically different. Total specimen strain to failure for all bone-ligament-bone specimens averaged 27%. Variations occurred between the three regions, with the anterior pouch specimens failing at a higher strain (34%) than those from the superior band (24%) or the posterior pouch (23%). Strain to failure for the ligament midsubstance (11%) was found to be significantly less than that for the entire specimen (27%). Thus, larger strain must occur near the insertion sites of the inferior glenohumeral ligament. Stress at failure was found to be nearly identical for the three regions of the ligament, averaging 5.5 MPa. These values are lower than those reported for other soft tissues, such as the anterior cruciate ligament and patellar tendon. The anterior pouch was found to be less stiff than the other two regions, perhaps suggesting that it is composed of more highly crimped collagen fibers. Three failure sites were seen for the inferior glenohumeral ligament: the glenoid insertion (40%), the ligament substance (35%), and the humeral insertion (25%). In addition, significant capsular stretching occurred before failure, regardless of the failure mode.

Purpose: The purpose of this study was to evaluate the outcome of arthroscopic distal clavicle resection by the direct superior approach for treatment of isolated osteolysis of the distal clavicle. Type of Study: Case series. Materials and Methods: Forty-one shoulders in 37 patients underwent arthroscopic resection of the distal clavicle. Thirty-three patients were male and 4 female, with an average age of 39 years. All patients complained of pain localized to the acromioclavicular joint region. Symptoms began after a traumatic event in 18 shoulders and were associated with repetitive stressful activity in 23 shoulders. Results: At an average follow-up of 6.2 years, 22 shoulders had excellent results, 16 had good results, and 3 were failures. All 3 failures occurred in patients with a traumatic etiology. Conclusions: Arthroscopic resection for osteolysis of the distal clavicle has results comparable to open excision with low morbidity. Patients with a traumatic etiology had slightly worse results compared with patients with a microtraumatic etiology. Arthroscopy: The Journal of Arthroscopic and Related surgery, Vol 16, No 6 (September), 2000: pp 600–605

Twenty-five patients underwent arthroscopic debridement to treat early glenohumeral osteoarthritis. The group consisted of 19 men and 6 women with an average age of 46 years (range, 27 to 72 years.) The operative procedure consisted of lavage of the glenohumeral joint, debridement of labral tears and chondral lesions, loose body removal, and partial synovectomy and subacromial bursectomy. Follow-up averaged 34 months, with a range of 12 to 63 months. Overall, results were rated as excellent in 2 patients (8%), good in 19 patients (72%), and unsatisfactory in 5 (20%). Two patients had complete relief of pain, 18 patients had only occasional mild pain, and 5 had moderate to severe pain postoperatively. Of the 12 patients with marked preoperative stiffness, 10 (83%) had improvement in range of motion postoperatively. Arthroscopic debridement is a reasonable approach for treating early glenohumeral osteoarthritis that has failed to respond to nonoperative treatment, in which the humeral head and glenoid remain concentric, and where there is still a visible joint space on an axillary radiograph. The procedure is not recommended when there is severe joint incongruity or large osteophytes.

Considerable attention has been directed towards elucidating factors responsible for mechanical failure of ligaments and tendons [2,10,11]. Still, very few studies to date have examined the effects of repetitive loads on either the transient response or failure properties of ligaments. Panjabi et al. [3] simulated a subfailure injury during cyclic testing using a single cycle of high subfailure strain and found no statistical difference between the deformation to failure in these ligaments as compared to the controls. However, this study incorporated a relatively small number of preconditioning cycles as opposed to a prolonged duration of repetitive strains.

When the diagnosis of suprascapular nerve entrapment syndrome is being considered, variations in anatomy are possible etiologic factors. Seventy-nine shoulders from 41 cadavers were examined for anatomic variations and for ganglion cyst formation in the suprascapular notch, superior transverse scapular ligament, and inferior transverse scapular ligament. The morphologic evaluation of the suprascapular notch revealed a "U" shape in 77% and a "V" shape in 23%, with 89% of cadavers having the same notch shape bilaterally. In 23% of shoulders a variation of the superior transverse scapular ligament was demonstrated such as partial and complete ossification and multiple bands including the first report of a trifid superior transverse scapular ligament. An inferior transverse scapular ligament was observed in only 14% of shoulders. One ganglion cyst was identified, for an incidence of 1%. The mass was located in the supraspinatus fossa adjacent to the superior transverse scapular ligament and appeared to compress and alter the course of the suprascapular nerve. When operative treatment is elected for suprascapular nerve entrapment syndrome and an open surgical approach is undertaken, the location and source of disease and morphologic and anatomic variants must be recognized to ensure adequate access and complete decompression of the suprascapular nerve. The classical description of the superior transverse scapular ligament as a completely nonossified single band should be expected, on average, in approximately three fourths of the cases. Partial or complete ossification and anomalous bands of the superior transverse scapular ligament or a ganglion cyst along the course of the suprascapular nerve may be encountered. Although a superior transverse scapular ligament should be anticipated in all shoulders, an inferior transverse scapular ligament will be a much less frequent finding. The role and significance of suprascapular notch morphologic characteristics warrant further investigation.

We retrospectively reviewed 117 consecutive patients who underwent arthroscopic acromioclavicular joint (ACJ) arthroplasties. Only patients who underwent ACJ arthroplasties from a bursal approach in conjunction with subacromial decompression were included. Patients with isolated ACJ arthrosis treated with resection of the distal clavicle from a superior approach, isolated impingement with only undersurface distal clavicle debridement, prior surgery, or other shoulder pathology were excluded. Twenty-four patients met these rigid criteria for inclusion in the study. After an arthroscopic subacromial decompression, the distal clavicle was visualized and resected through a standard bursal approach. In addition, an anterosuperior portal was used in 50% of the patients to confirm adequate clavicle resection. Postoperative follow-up averaged 32.5 months (range, 24 to 70 months). Preoperative and postoperative pain were rated subjectively on a 5-point scale (1, incapacitating pain; 5, no pain). Operative reports and postoperative radiographs were reviewed to determine technical factors that may have influenced outcome. Seventeen patients had excellent results (71%), 4 good (16.5%), and there were 3 failures (12.5%). Average preoperative pain rating was 1.8 and was improved to 4.3 postoperatively. The average amount of clavicle resection was only 5.4 mm. Given smooth, even, and complete bone removal, the amount of bone resected did not correlate with outcome. Arthroscopic distal clavicle resection performed in conjunction with subacromial decompression gave excellent results, comparable to isolated ACJ procedures. In this series, additional use of an anterosuperior portal for more direct shaver placement and complete ACJ viewing allowed consistent bone resection and excellent results in a high percentage of patients.

Proximale Humerusfrakturen sind insbesondere bei Alteren recht haufig (Lind et al. 1989). Bei jungeren Patienten kommen sie zwar ebenfalls vor, sind jedoch meist auf starke Gewalteinwirkung zuruckzufuhren. Ungefahr 80–85% aller proximalen Humerusfrakturen sind nicht disloziert und lassen sich mit gutem Ergebnis konservativ behandeln (Neer 1970a). Bei dislozierten Trummerfrakturen des proximalen Humerus sind konservative Masnahmen weniger erfolgversprechend (Neer 1970a), da es hier haufig zur Verheilung in Fehlstellung oder als Pseudarthrose mit Schmerzen und Bewegungseinschrankung kommt (Bloom und Obata 1967, Neer 1970a, Sturzenegger et al. 1982, Bigliani 1991). Wird eine Therapie der 3-Fragmentfraktur des proximalen Humerus erwogen, empfiehlt sich zur Wiederherstellung anatomiegerechter Verhaltnisse und Ermoglichung einer fruhzeitigen Rehabilitation ein operativer Eingriff.

The inferior glenohumeral ligament (IGHL) of the shoulder has been recognized as an important static restraint with the arm in a position of clinical instability [6,10]. Recent studies [1,7,9] have reported different nonlinear viscoelastic behavior among the three anatomical regions of the IGHL (superior band, anterior axillary pouch and posterior axillary pouch) [10] as well as its response to repetitive loading.

Cyclic tensile testing of soft collagenous tissues is a useful tool for studying their mechanical response in situ as well as for simulating repetitive joint motion [2,5]. It has been hypothesized that the cumulative effects of repetitive microtrauma may contribute to acquired instability in the glenohumeral joint [3]. Many investigations have focused on the inferior glenohumeral ligament (IGHL) which is the primary restraint of the joint in the most common position of shoulder dislocation [4,8]. Not until recently, however, has an experimental protocol addressed repetitive loading of the capsular ligaments at subfailure levels of strain [6,9], The objectives of this study are to examine the effects of increasing: 1) the number of repetitive loading cycles, and 2) strain magnitudes, on the tensile load response and induced laxity in the IGHL.

Thirty-five shoulders in thirty-four patients were treated with a superior shift of the posteroinferior aspect of the capsule because of recurrent posterior glenohumeral subluxation and dislocation. The physical examination revealed three types of posterior instability in these patients preoperatively: unidirectional (six shoulders), bidirectional (posterior and inferior) (seven shoulders), and multidirectional (posterior and inferior dislocation with anterior subluxation) (twenty-two shoulders). Eleven shoulders had had previous operative procedures. At the time of the index operation, the most common abnormal findings in these shoulders were capsular redundancy and excessive volume of the glenohumeral joint. Complete detachment of the posterior aspect of the labrum was found in only four shoulders. There was no excessive glenoid retroversion in these patients. All thirty-four patients were available for follow-up at an average of five years (range, two to twelve and a half years) postoperatively. Over-all, the result for seventeen of the thirty-five shoulders was rated as excellent; eleven, as good; one, as fair; and six, as poor. Four shoulders became unstable again. Six of the seven unsatisfactory results were in shoulders that had had previous attempts at stabilization. A successful result was achieved in twenty-three of the twenty-four shoulders in which the superior shift of the posteroinferior aspect of the capsule was the initial repair.

Forty-one patients (41 shoulders) with acromioclavicular joint disease refractory to conservative treatment underwent arthroscopic distal clavicle resection. Thirty-one men and 10 women with an average age of 32 years were studied. The dominant extremity was involved in 68% of the patients. At an average follow-up period of 31 months (range 24 to 49 months), 18 excellent, 16 good, and seven poor results were found. Twenty-seven (93%) of 29 shoulders with acromioclavicular arthritis or osteolysis of the distal clavicle went on to have satisfactory results compared with only seven (58%) of 12 shoulders with previous grade II acromioclavicular separations or acromioclavicular hypermobility. Total amount of bone removal did not correlate with success, if the resection was even. Five reoperations were done; one uneven resection was revised with arthroscopy, and four shoulders underwent acromioclavicular stabilization procedures. The high failure rate in patients with even subtle acromioclavicular instability (42%) suggests that in these cases formal stabilization with ligament reconstruction should be considered in addition to resection of the distal clavicle.

The results of split pectoralis major tendon transfer (sternal head) for symptomatic scapular winging because of palsy of the serratus anterior muscle were reviewed. Eleven consecutive patients, whose average age was 34 years, had a duration of preoperative symptoms ranging from 12 to 60 months. Ten patients had electromyograms documenting a long thoracic nerve injury. Using an inferior axillary incision, the tendon of the sternal head of the pectoralis major is mobilized and transferred to the inferior angle of the scapula. The tendon transfer is reinforced with autogenous fascia lata. After surgery, a scapulothoracic orthosis is worn for 6 weeks, and restriction of vigorous activities is recommended for 6 months. At an average followup of 41 months, 10 of 11 (91%) patients had satisfactory results with significant improvement in function and reduction of pain. Each of these 10 patients had improved scapular tracking with no scapular winging or mild, dynamic winging at latest followup. One patient had an unsatisfactory result with a full recurrence of scapular winging secondary to noncompliance with the postoperative physical therapy regimen. The split pectoralis major tendon transfer provides a reasonable substitute for a paralyzed serratus anterior muscle in scapular stabilization. Strict adherence to technical principles and postoperative rehabilitation reliably leads to satisfactory clinical results.

Arthroscopy serves as a useful adjunct to manipulation under anesthesia in the treatment of resistant frozen shoulder. In this technique the shoulder is manipulated under interscalene brachial plexus block anesthesia, followed by arthroscopic examination and debridement of the glenohumeral joint and the subacromial space. The addition of arthroscopy allows the identification and treatment of associated pathology, such as impingement lesions and secondary subacromial space inflammation, calcific deposits, and acromioclavicular arthritis. Range of motion can also be increased by arthroscopically guided sectioning of the coracohumeral ligament. This treatment regimen has yielded overall satisfactory results in 25 (83%) of 30 shoulders in this series. The subgroup with diabetes mellitus fared less well than the other groups, with only 64% satisfactory results. While most patients with frozen shoulder will respond to nonoperative treatment, the technique of manipulation under anesthesia followed by arthroscopy offers a safe and reliable treatment for the resistant frozen shoulder.

Recurrent posterior glenohumeral instability is regarded as a difficult problem to diagnose and treat. A careful history and physical examination are the most helpful tools in making this diagnosis. A positive posterior stress test, demonstrable posterior subluxation, and a sulcus sign are frequently present on examination. Special roentgenographic studies, such as the computerized arthrotomography (arthro-CT) scan, may be used in cases in which plain roentgenographs suggest bony glenoid abnormalities. When conservative therapy fails, there is no consensus on the operative treatment. Procedures that address the soft tissues, such as capsulorrhaphy and posterior labral repair, as well as those that alter the bony geometry of the joint, such as posterior bone blocks and glenoid or humeral osteotomies, have been described. Capsular laxity is the most common pathologic finding in the authors' experience, and they favor the use of a posterior-inferior capsular shift procedure to correct this problem. Augmentation of the repair with a posterior bone block is reserved for unusual cases, such as when glenoid hypoplasia is present or in certain revision situations.