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Background The purpose of this study was to evaluate the clinical and radiographic outcomes of a transosseous suture fixation technique for the treatment of unstable lateral clavicle fractures. The appropriate treatment for lateral clavicle fractures is controversial. Many authors have argued for nonsurgical treatment of these injuries; however, recent literature has shown a role for the surgical treatment of unstable fractures. The paucity of lateral clavicular bone and the unique anatomy of this area of the shoulder makes surgical treatment of these injuries challenging. This article reports a single-surgeon experience with a transosseous suture fixation technique for the treatment of unstable lateral clavicle fractures. Materials and Methods A retrospective review of all patients with unstable lateral clavicle fractures treated with a transosseous suture technique from 2015-2018 was performed. The indication for surgery was significant displacement between the main medial and lateral clavicle fragments. The surgical technique used was a modification of the technique as described by Levy. Patients were followed postoperatively with active and passive range of motion (ROM) measurements, strength testing, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, visual analog scale score, and standard radiographs. Patients were followed to radiographic union. Results Twelve patients underwent surgical fixation of unstable lateral clavicle fractures from 2015-2018. All patients had excellent function, full ROM, minimal pain, and improved functional scores at final follow-up. Eleven patients achieved complete union of the fracture. One patient healed with a fibrous union; however, the fracture had maintained alignment and the patient was asymptomatic and satisfied with the result. No patient required a second surgery. Conclusion We found that the transosseous suture technique for fixation is an effective treatment for unstable lateral clavicle fracture. This technique is reproducible, cost effective, and limits the need for revision surgery often encountered with other techniques.

Stemless humeral components for shoulder arthroplasty represent the fourth generation of modern prosthetic shoulder implants. Because of their metaphyseal fixation, the implantation technique is rather straightforward and preserves the humeral canal from violation. Substantial benefits have been highlighted with such a design, including less perioperative morbidity, independence from the proximal humeral anatomy, preservation of bone stock, ease of potential revision surgeries, and limited risk of complex periprosthetic fractures. Initially conceived to better re-create the center of rotation of the humeral head in anatomic arthroplasties, their use has been successfully extended to reverse total shoulder arthroplasty. Provided that contraindications are respected (eg, poor proximal humeral bone quality, proximal humerus fractures, patients who are elderly and/or overweight), short-term and midterm functional outcomes as well as postoperative complications appear to be similar to those of traditional stemmed implants, without increased risk of loosening of the humeral component.

Total shoulder arthroplasty implant design, instrumentation, and outcomes continue to evolve; however, accurate glenoid placement remains a challenge especially in cases of glenoid deformity. Knowledge that malpositioning of the glenoid can lead to inferior outcomes and glenoid component loosening has led to the development of patient specific instrumentation (PSI). The ideal PSI system should be consistent, reliable, cost-effective, reusable, and robust enough to withstand applied stress during difficult exposures. In addition, short-stemmed humeral components appear to offer several advantages over the traditional length stems.

Measurements made on routine A-P radiographs can predict strength/quality of the proximal humerus, as shown in terms of two easy-to-measure parameters: cortical index (CI) and mean-combined cortical thickness (MCCT). Because of high variability inherent when using established methods to measure these parameters, we describe a new orientation system. Using digitized radiographs of 33 adult proximal humeri, five observers measured anatomical reference locations in accordance with: (1) Tingart et al. (2003) method, (2) Mather et al. (2013) method, and (3) our new humeral head Circle-Fit method (CFM). The Tingart and Mather methods measure CI and MCCT with respect to upper and lower edges of 20 mm tall rectangles fit to a proximal diaphyseal location where endosteal (Tingart) or periosteal (Mather) cortical margins become parallel. But high intra- and inter-observer variability occurs when placing the rectangles because of uncertainty in identifying cortical parallelism. With the CFM an adjustable circle is fit to the humeral head articular surface, which reliably and easily establishes a proximal metaphyseal landmark (M1) at the surgical neck. Distal locations are then designated at successive 10 mm increments below M1, including a second metaphyseal landmark (M2) followed by diaphyseal (D) locations (D1, D2 …D6). D1 corresponds most closely to the proximal edges of the rectangles used in the other methods. Results showed minimal inter-observer variations (mean error, 1.5 ± 1.1mm) when the CFM is used to establish diaphyseal locations for making CI and MCCT measurements when compared to each of the other methods (mean error range, 10.7 ± 5.9 to 13.3 ± 6.7 mm) (p

Objectives This investigation sought to advance the work published in our prior biomechanical study (Journal of Orthopaedic Research, 2016). We specifically sought to determine whether there are additional easy-to-measure parameters on plain radiographs of the proximal humerus that correlate more strongly with ultimate fracture load, and whether a parameter resembling the Dorr strength/quality characterisation of proximal femurs can be applied to humeri. Materials and Methods A total of 33 adult humeri were used from a previous study where we quantified bone mineral density of the proximal humerus using radiographs and dual-energy x-ray absorptiometry (DEXA), and regional mean cortical thickness and cortical index using radiographs. The bones were fractured in a simulated backwards fall with the humeral head loaded at 2 mm/second via a frustum angled at 30° from the long axis of the bone. Correlations were assessed with ultimate fracture load and these new parameters: cortical index expressed in areas (“areal cortical index”) of larger regions of the diaphysis; the canal-to-calcar ratio used analogous to its application in proximal femurs; and the recently described medial cortical ratio. Results The three new parameters showed the following correlations with ultimate fracture load: areal cortical index (r = 0.56, p < 0.001); canal-to-calcar ratio (r = 0.38, p = 0.03); and medial cortical ratio (r = 0.49, p < 0.005). These correlations were weaker when compared with those that we previously reported: mean cortical thickness of the proximal diaphysis versus ultimate fracture load (r = 0.71; p < 0.001); and mean density in the central humeral head versus ultimate fracture load (r = 0.70; p < 0.001). Conclusion Simple-to-measure radiographic parameters of the proximal humerus reported previously are more useful in predicting ultimate fracture load than are areal cortical index, canal-to-calcar ratio, and medial cortical ratio. Cite this article: J. G. Skedros, C. S. Mears, W. Z. Burkhead. Ultimate fracture load of cadaver proximal humeri correlates more strongly with mean combined cortical thickness than with areal cortical index, DEXA density, or canal-to-calcar ratio. Bone Joint Res 2017;6:1–7. DOI: 10.1302/2046-3758.61.BJR-2016-0145.R1

Methods are needed for identifying poorer quality cadaver proximal humeri to ensure that they are not disproportionately segregated into experimental groups for fracture studies. We hypothesized that measurements made from radiographs of cadaveric proximal humeri are stronger predictors of fracture strength than chronological age or bone density values derived from dual-energy x-ray absorptiometry (DXA) scans. Thirty-three proximal humeri (range: 39–78 years) were analyzed for: (1) bone mineral density (BMD, g/cm2) using DXA, (2) bulk density (g/cm3) using DXA and volume displacement, (3) regional bone density in millimeters of aluminum (mmAl) using radiographs, and (4) regional mean (medial+lateral) cortical thickness and cortical index (CI) using radiographs. The bones were then fractured simulating a fall. Strongest correlations with ultimate fracture load (UFL) were: mean cortical thickness at two diaphyseal locations (r = 0.71; p 0.80, but none included DXA-derived density, CI, or age. Radiographic morphometric and densitometric measurements from radiographs are therefore stronger predictors of UFL than age, CI, or DXA-derived density measurements. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res

Glenohumeral instability is the second most common complication of shoulder arthroplasty, occurring in 4.9% of cases. Instability following arthroplasty is best classified based on its direction. The unconstrained shoulder arthroplasty can be unstable superiorly, anteriorly, inferiorly, and posteriorly. The causes and incidences of each direction are unique and individualized. The goal of this paper is to identify the cause of different types of total shoulder arthroplasty instability and discuss techniques to avoid such complications.

Take down of the subscapularis tendon is a necessary step in performing total shoulder arthroplasty through the deltopectoral approach. Anatomic repair and healing of the subscapularis is vital to achieving reliable functional outcomes postoperatively. Detachment of the subscapularis is typically achieved by either tenotomy, subscapularis peel, or lesser tuberosity osteotomy. Previous reports have suggested that subscapularis dysfunction after either tenotomy or peel is remarkably high. It is our opinion that lesser tuberosity osteotomy is the preferred method of subscapularis take down during shoulder arthroplasty. Herein we review the literature comparing the various techniques of subscapularis management and discuss our preferred method for lesser tuberosity osteotomy during total shoulder arthroplasty via the standard deltopectoral approach.

Measurements made on routine A-P radiographs can predict strength/quality of the proximal humerus, as shown in terms of two easy-to-measure parameters: Cortical index (CI) and mean-combined cortical thickness (MCCT). Because of high variability inherent when using established methods to measure these parameters, we describe a new orientation system. Using digitized radiographs of 33 adult proximal humeri, five observers measured anatomical reference locations in accordance with: (i) Tingart et al. (2003) method, (ii) Mather et al. (2013) method, and (iii) our new humeral head Circle-Fit method (CFM). The Tingart and Mather methods measure CI and MCCT with respect to upper and lower edges of 20 mm tall rectangles fit to a proximal diaphyseal location where endosteal (Tingart) or periosteal (Mather) cortical margins become parallel. But high intra- and inter-observer variability occurs when placing the rectangles because of uncertainty in identifying cortical parallelism. With the CFM an adjustable circle is fit to the humeral head articular surface, which reliably and easily establishes a proximal metaphyseal landmark (M1) at the surgical neck. Distal locations are then designated at successive 10 mm increments below M1, including a second metaphyseal landmark (M2) followed by diaphyseal (D) locations (D1, D2 ⋯D6). D1 corresponds most closely to the proximal edges of the rectangles used in the other methods. Results showed minimal inter-observer variations (mean error, 1.5 ± 1.1 mm) when the CFM is used to establish diaphyseal locations for making CI and MCCT measurements when compared to each of the other methods (mean error range, 10.7 ± 5.9 to 13.3 ± 6.7 mm) (p 0.001). © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2313-2322, 2017.

Biological glenoid resurfacing provides an alternative to conventional prosthetic glenoid components in young patients with end-stage arthritic shoulders. Although results have remained controversial in the peer-reviewed literature, successful clinical outcomes have been reported by several authors. Adherence to several critical technical steps can lead to the best possible clinical results.

There are certain scenarios in shoulder arthroplasty in which cementless fixation has a widely accepted role, including glenosphere fixation in reverse total shoulder arthroplasty and humeral head surface replacement arthroplasty. However, there has been some debate regarding fixation of humeral components, especially in total shoulder arthroplasty, because early prosthetic designs and surgical techniques showed inferior results when cementless humeral component fixation was used. Recent advances in implant design and surgical techniques have led to improved clinical results with uncemented humeral components. Thus, there is an established role of cementless fixation of humeral components in total shoulder arthroplasty and hemiarthroplasty.

Chondrolysis is a process of unknown etiology characterized by rapid progressive cartilage destruction with resultant pain and loss of motion. Chondrolysis after arthroscopic surgery of the shoulder is multifactorial. Recent reports suggest that the heat from radiofrequency ablation devices, certain bioabsorbable implants, and the local anesthetics delivered in excessive doses via pain pumps could play a role in its development. We review the current understanding of this condition and our institution's experience with glenohumeral chondrolysis. Our discussion will serve almost exclusively as a caveat to surgeons of a potentially catastrophic complication in the young patient.

Difficult clinical cases will be presented for discussion of possible treatment options. The pros and cons of each treatment will be discussed by experts in the field. The cases will include both primary and revision topics in shoulder reconstruction. Different surgical options and new emerging technology will be discussed in these challenging cases.

Hypothesis We hypothesized that releasing the subscapularis with lesser tuberosity bone may improve strength of fixation of the subscapularis during total shoulder atthroplasty (TSA). Materials and methods In 15 cadaveric humeri, all musculature was removed except the subscapularis. A standard humeral head osteotomy was performed for TSA. The subscapularis was released with a fleck of lesser tuberosity bone in 10 specimens from five matched pairs, and a tenotomy was performed in five. Five osteotomies were repaired with single-row heavy non-absorbable sutures and five with an additional double-row. Repairs were subjected to cyclical loading at 180 newtons for 400 cycles, increasing by 180 newtons to failure. A retrospective review of 100 consecutive patients who underwent dual-row repair of the subscapularis fleck osteotomy following TSA was also performed with minimal follow-up of 24 months (24-48). Results Both single (430 N) and double-row (466 N) fixation of the fleck osteotomy were significantly stronger than tenotomy suture repair (252 N) ( p .04). There was no significant difference between single and double-row ultimate strengths. Qualitatively, double-row fixation fixed the fleck osteotomy more securely to the donor site with respect to gross rotational motion. At final clinical review, the lift-off test was rated as normal in 79%. The belly press was rated as normal in 86%. Eighty-two percent were able to tuck in their shirts. Conclusion Subscapularis release with fleck osteotomy provides superior biomechanical ultimate strength compared to standard tenotomy. There was no visible motion during biomechanical testing with dual-row osteotomy fixation compared to single-row fixation. Clinical results of this dual-row technique document showed good restoration of subscapularis integrity for activities of daily living. Level of evidence Basic science study and level 4; retrospective review, case series, no control group.

BACKGROUND: Biologic glenoid resurfacing was developed in 1988 as an alternative to total shoulder arthroplasty in selected (usually younger) patients with primary, posttraumatic, or postreconstructive glenohumeral arthritis. A variety of biologic surfaces, including anterior capsule, autogenous fascia lata, and Achilles tendon allograft, have been combined with a humeral hemiarthroplasty. METHODS: From November 1988 to November 2003, thirty-four patients (thirty-six shoulders) who were managed with biologic glenoid resurfacing and humeral head replacement either with cement (ten shoulders) or without cement (twenty-six shoulders) were followed prospectively. The study group included thirty men and four women with an average age of fifty-one years. The diagnoses included primary glenohumeral osteoarthritis (eighteen shoulders), postreconstructive arthritis (twelve), posttraumatic arthritis (five), and osteonecrosis (one). Anterior capsule was used for seven shoulders, autogenous fascia lata for eleven, and Achilles tendon allograft for eighteen. All shoulders were assessed clinically and with serial radiographs. RESULTS: The mean American Shoulder and Elbow Surgeons score was 39 points preoperatively and 91 points at the time of the most recent follow-up. According to Neer's criteria, the result was excellent for eighteen shoulders, satisfactory for thirteen, and unsatisfactory for five. Glenoid erosion averaged 7.2 mm and appeared to stabilize at five years. There were no revisions for humeral component loosening. Complications included infection (two patients), instability (three patients), brachial plexitis (one patient), and deep-vein thrombosis (one patient). Factors that appeared to be associated with unsatisfactory results were the use of capsular tissue as the resurfacing material and infection. CONCLUSIONS: Biologic resurfacing of the glenoid can provide pain relief similar to total shoulder arthroplasty. It allows selected younger patients to maintain an active lifestyle, including weight-lifting and manual work, without the risk of polyethylene wear. On the basis of this and previous reviews, we currently recommend Achilles tendon allograft as the preferred resurfacing material when this option is chosen. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. ORIGINAL ABSTRACT CITATION: “Humeral Hemiarthroplasty with Biologic Resurfacing of the Glenoid for Glenohumeral Arthritis. Two to Fifteen-Year Outcomes” (2007;89:727-34).

Degenerative glenohumeral arthritis in the athlete can be a devastating condition that often impedes performance and may derail a career. Treatment options for this difficult patient population are limited. Conservative therapies and patient education are the mainstays of treatment. However, failing this, there are surgical options ranging from arthroscopic debridement to total joint arthroplasty. In this article, we describe the historical background and a current technique for humeral hemiarthroplasty with biologic resurfacing of the glenoid, including short- and mid-term results. In our experience, this procedure reliably improves pain and function without the concerns of polyethylene wear and glenoid failure associated with traditional arthroplasty in the young, active population.

Four-part proximal humerus fractures represent a difficult entity in the management of upper extremity trauma. Most of these fractures are not amenable to operative fixation; thus, surgical address is necessarily one of fracture arthroplasty. Timely reestablishment of the Gothic arch using a fracture-specific prosthesis leads reliably to anatomic tuberosity osteosynthesis. Hence, shoulder arthroplasty for fracture should be considered an augmented osteosynthesis, with precise prosthetic implantation supplementing anatomic tuberosity reconstruction. Further investigations are ongoing regarding the use of specific fracture implants and biologic substrates in an attempt to improve further the rate of tuberosity healing in the older patient population after this operation.

In recent years there has been a resurgence of interest in the use of biologic resurfacing of the glenoid for the treatment of glenohumeral arthritis in younger patients. We review the history as well as the current applications of this procedure.

Double-row rotator cuff repairs are becoming popular because of their ability to improve initial ultimate failure load for full-thickness rotator cuff tears, especially in middle-aged to elderly patients. We hypothesized a quasi-double-row repair using a combination of transosseous sutures, anchors, and double knots (TOAK technique) would exceed the clinically relevant 250-N load threshold and the initial mean ultimate failure loads of anchor-only and transosseous suture-only fixation. In simulated full-thickness supraspinatus tears in cadavers (mean age, 62 years; range, 50-77 years), failure loads of two repair techniques were compared with a TOAK repair using sutures and bioabsorbable anchors. Radiographic densitometry was conducted on all humeral heads. Testing was performed at 6 mm per minute in 18 bones in the following three groups (n = 6 per group): (1) transosseous suture-only with weave-type stitch and single-knot fixation; (2) anchor-only with horizontal mattress stitch and single-knot fixation; and (3) TOAK. The mean ultimate failure load was 238 N for the transosseous suture-only group and 215 N for the anchor-only group. Although the bones had lower density, TOAK specimens failed at 55% to 67% higher loads (mean, 404 N) than the other groups. These data support further evaluation of the TOAK technique for full-thickness supraspinatus tears in middle-aged to elderly patients.

Degenerative arthritis of the elbow in patients aged under 50 years can cause disabling pain, severely restricted range of motion (ROM), and functional limitations. Open ulnohumeral arthroplasty has been demonstrated to produce satisfactory pain relief and ROM gains. We report the results of an all-arthroscopic ulnohumeral arthroplasty for degenerative arthritis of the elbow in younger patients. Eleven consecutive patients aged under 50 years with radiographically documented degenerative elbow arthritis underwent an all-arthroscopic ulnohumeral arthroplasty as described by Savoie et al. Indications for surgery were pain and limited ROM refractory to 12 months of conservative treatment. The mean age at the time of surgery was 36 years (range, 23-47 years). The minimum postoperative follow-up was 24 months, with a mean of 26 months (range, 24-29 months). Preoperatively, mean flexion was 100 degrees (range, 70 degrees-140 degrees) and mean extension (short of neutral) was 40 degrees (range, 10 degrees-60 degrees). Postoperatively, mean flexion was 140 degrees (range, 130 degrees-150 degrees; P < .01) and mean extension was 7 degrees (range, 0 degrees-20 degrees; P < .01). The total arc of motion averaged 60 degrees preoperatively and 133 degrees postoperatively (improvement of 73 degrees, P < .01). The mean subjective pain level improved from 9.2 to 1.7 (where 10 indicates worst pain and 0 indicates no pain). Mean subjective patient satisfaction improved from 1.8 to 9.0 (where 0 indicates unsatisfied and 10 indicates completely satisfied). All-arthroscopic ulnohumeral arthroplasty provides significant short-term pain relief, as well as restoration of elbow ROM and function, in patients aged under 50 years with degenerative arthritis of the elbow. The long-term durability of this procedure with regard to preservation of ROM and radiographic progression of arthritis remains unknown.

Background: Total claviculectomy has been used for the treatment of tumor, infection, nonunion, and vascular compromise. Given its limited indications, few reports on the outcome after claviculectomy exist. The purpose of the present study was to evaluate the function of the shoulder, with use of a modern scoring system, after total claviculectomy. Methods: A retrospective review of the records of six patients who had undergone unilateral claviculectomy was performed after an average duration of follow-up of 5.7 years. The indication for surgery had been an infection at the site of a clavicular nonunion for three patients, nonunion with subclavian vein compression for two, and pain after a failed medial clavicular excision for one. The preoperative and postoperative evaluations included testing of the range of motion, strength, and stability as well as determination of the American Shoulder and Elbow Surgeons score on the basis of a functional questionnaire. Results: Range of motion was improved slightly or unchanged following claviculectomy. The mean American Shoulder and Elbow Surgeons score improved from 18 (range, 5 to 35) preoperatively to 88 (range, 75 to 95) postoperatively. The mean pain level (with 0 indicating no pain and 10 indicating the worst pain) decreased from 9.5 preoperatively to 1.5 postoperatively. Postoperatively, strength testing showed improvement from grade 4- (of 5) to 5 in all planes tested except extension (in which it remained at grade 4). Patient satisfaction was high, with a mean of 9.0 on a 10-point scale. There were five complications, including one subclavian vein laceration requiring vascular repair, two deep infections, and two superficial infections. Conclusions: Despite a high complication rate, the functional outcomes following claviculectomy were good in this group of six patients. Total claviculectomy may be a useful salvage procedure for clinical situations in which the restoration of normal clavicular osseous anatomy is impossible. Patients can expect acceptable pain relief and few or no deficits in activities of daily living. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Biologic glenoid resurfacing was developed in 1988 as an alternative to total shoulder arthroplasty in selected (usually younger) patients with primary, posttraumatic, or postreconstructive glenohumeral arthritis. A variety of biologic surfaces, including anterior capsule, autogenous fascia lata, and Achilles tendon allograft, have been combined with a humeral hemiarthroplasty.From November 1988 to November 2003, thirty-four patients (thirty-six shoulders) who were managed with biologic glenoid resurfacing and humeral head replacement either with cement (ten shoulders) or without cement (twenty-six shoulders) were followed prospectively. The study group included thirty men and four women with an average age of fifty-one years. The diagnoses included primary glenohumeral osteoarthritis (eighteen shoulders), postreconstructive arthritis (twelve), posttraumatic arthritis (five), and osteonecrosis (one). Anterior capsule was used for seven shoulders, autogenous fascia lata for eleven, and Achilles tendon allograft for eighteen. All shoulders were assessed clinically and with serial radiographs.The mean American Shoulder and Elbow Surgeons score was 39 points preoperatively and 91 points at the time of the most recent follow-up. According to Neer's criteria, the result was excellent for eighteen shoulders, satisfactory for thirteen, and unsatisfactory for five. Glenoid erosion averaged 7.2 mm and appeared to stabilize at five years. There were no revisions for humeral component loosening. Complications included infection (two patients), instability (three patients), brachial plexitis (one patient), and deep-vein thrombosis (one patient). Factors that appeared to be associated with unsatisfactory results were the use of capsular tissue as the resurfacing material and infection.Biologic resurfacing of the glenoid can provide pain relief similar to total shoulder arthroplasty. It allows selected younger patients to maintain an active lifestyle, including weight-lifting and manual work, without the risk of polyethylene wear. On the basis of this and previous reviews, we currently recommend Achilles tendon allograft as the preferred resurfacing material when this option is chosen.Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Tendon healing and improved strength in the face of massive rotator cuff tear repair remains a daunting challenge. Seventeen consecutive patients with massive rotator cuff tears were treated with a standardized open repair technique and the repair augmented with Graft Jacket (Wright Medical, Memphis, Tennessee). Mean follow-up was 1.2 years (438 days). Pain scores improved with 11 patients (64%) reporting no pain or occasional and slight pain. Functional status improved with 12 patients (70%) reporting normal function or slight restriction only. Active forward flexion improved with 10 patients (59%) having greater than 150°. UCLA scores improved significantly from a mean 9.06 preoperatively to 26.12 ( P value

While the reverse prosthesis can provide dramatic, almost miraculous improvement in patients with debilitating shoulder dysfunction secondary to rotator cuff deficient arthritic shoulders, the reported complication rate is frightingly high. Some complications are by their very nature unavoidable. The purpose of this paper is to review the most common complications, give advice as to avoidance when possible and offer treatment alternatives should complications arise.

This is a broad statement and there is no doubt that in selected proximal humerus fractures percutaneous pinning is superior to plate fixation. However, unstable two- and three-part fractures in young patients may require plate fixation for reliable union. Comminuted higher energy injuries do well with dual-plate fixation. Older patients with four-part fractures are still best treated with hemiarthroplasty with tuberosity osteosynthesis. Percutaneous pinning, while being minimally invasive, is not without complications. Complications, including pin tract infections and subsequent septic arthritis from migration of septic pins, have been reported. In addition, pin migration has been associated with potentially life-threatening complications due to the close proximity to neurovascular structures and the thoracic cavity. Loss of position of fracture fragments in the first several weeks of treatment is not uncommon with pin fixation. Open reduction and internal fixation (ORIF) may be necessary to obtain anatomic reduction and secure fracture fixation. Recent changes in the approach to plate fixation with lateral based incisions and variable angle locking screw fixation have improved ORIF outcomes.

Background The treatment of young patients with glenohumeral arthritis has been challenging. Alternative treatment options include activity modification, arthroscopic debridement, and arthroplasty. Addressing the glenoid during arthroplasty in this population of patients continues to be a significant challenge. In this study, we evaluated the midterm outcomes of hemiarthroplasty with biologic resurfacing of the glenoid with human dermal matrix allograft. Methods Between 2004 and 2011, 55 patients underwent hemiarthroplasty and biologic resurfacing of the glenoid with human dermal matrix allograft. The average age was 50 ± 9 years. Subjective evaluation was performed with the Western Ontario Osteoarthritis of the Shoulder Index, American Shoulder and Elbow Surgeons score, visual analog scale, and Single Assessment Numeric Evaluation. Patients returned to the clinic for clinical examination and radiographic evaluation. The average follow-up was 60 months. Results The average postoperative American Shoulder and Elbow Surgeons score was 76 ± 22, and the Western Ontario Osteoarthritis of the Shoulder Index score was 76% ± 22%. The visual analog scale score was 2.4 ± 2.6. The average preoperative Single Assessment Numeric Evaluation score was 33% ± 22%, which significantly improved to 72% ± 22% postoperatively. Eighty-one percent of the patients were satisfied (10/47) or highly satisfied (28/47) with their result. With radiographic evaluation, the average joint space was 1 ± 1 mm preoperatively and 2 ± 1 mm postoperatively. A total of 5 cases (9.1%) were revised to anatomic total shoulder arthroplasty with implantation of a glenoid component. Discussion Hemiarthroplasty with biologic resurfacing of the glenoid using human dermal matrix allograft can lead to successful midterm outcomes with satisfactory complication and revision rates. Both patient satisfaction and clinical outcome remain high regardless of radiographic outcome.

Shoulder arthroplasty is a reliable treatment for pain relief and restoration of function in patients with degenerative conditions of the glenohumeral joint. The designs of shoulder prostheses has evolved since Neer first introduced his original press-fit humeral hemiarthroplasty component back in 1951. This was followed by the development of a glenoid prosthesis for resurfacing of arthritic glenoid surfaces. Use of cement for fixation of both humeral and glenoid components became the gold standard for many years in the treatment of glenohumeral degenerative conditions, such as osteoarthritis and rheumatoid arthritis. The trend toward performing shoulder arthroplasty in younger, more active patients has led to a transition back to cementless fixation to preserve bone stock and make revision surgery easier. In addition, the concept of cementless surface replacement has also been described for treatment of arthritic conditions in younger patients. Results have been equivocal with uncemented versus cemented prostheses used on the humeral side. However, there have been problems with metal backed, press-fit glenoid fixation. At the current time, cemented all-polyethylene glenoid components remain the choice for most shoulder surgeons. As the technology improves, the use of press-fit, bone in-growth designs may become a more reliable alternative.

Although studies of glenohumeral arthroplasty have reported good to excellent results in >90% of shoulders, complications with shoulder replacement are inevitable, and have been reported to occur at a rate of 14%. Some of these complications are unavoidable, however, a significant number occur intraoperatively, and may be a result of errors in surgical technique or judgment. Depending on their severity, all of these complications can lead to poor outcomes. Effective management of intraoperative complications requires early recognition and prompt treatment. The aim of this review is to discuss the avoidance, early detection, and proper management of intraoperative complications related to total shoulder arthroplasty.

Biologic glenoid resurfacing was developed in 1988 as an alternative to total shoulder arthroplasty in selected younger patients with primary, posttraumatic, or postreconstruction glenohumeral arthritis as a method to improve the results of humeral head replacement. A variety of biologic surfaces have been combined with an uncemented hemiarthroplasty including anterior capsule, autogenous fascia lata, and tendoachilles allograft. This paper presents the senior author's 5 to 13 year results. From November 1988 to November 1997, 24 patients with 26 shoulders were followed prospectively. There were 22 males and 2 females, with an average age of 52 years (range, 30-75). Fourteen of 26 shoulders had undergone previous surgery. The diagnosis was primary glenohumeral osteoarthritis (9/26), posttraumatic arthritis (4/26), avascular necrosis (1/26), and postreconstructive arthritis (12/26). Anterior capsule was used for seven cases, autogenous fascia lata for 11 cases, and tendoachilles allograft for eight cases. A combination of sutures and anchors were utilized. All patients underwent a cementless humeral head replacement. Neer scores were performed on all patients and serial radiographs reviewed. Results were analyzed using Neer's criteria: 12/26 excellent (46%), 9/26 satisfactory (35%), and 5/26 unsatisfactory (19%). Glenoid erosion averaged 7.2 mm stabilizing at ∼5 years. Joint space averaged 1.3 mm. There were no revisions for humeral loosening. Complications included infection 2/26, instability 3/26, brachial plexitis 1/26, and DVT 1/26. Factors associated with unsatisfactory results: use of capsule, infection, and early re-injury. Three of five poor results have been revised to TSA, two with excellent results, and one with a poor result. This procedure provides pain relief similar to total shoulder arthroplasty for the diagnostic groups studied. It allows younger patients to maintain an active lifestyle including weight lifting and manual work without the risk of polyethylene wear. Based on this and previous reviews, the senior author recommends either autogenous fascia lata or tendoachilles allograft as the bearing surface.

Shoulder arthroplasty for fracture remains a technically challenging procedure, often with unpredictable clinical outcomes in the reported literature. Consequently, the appropriate management of certain 3- and 4-part fractures and fracture-dislocations of the proximal humerus remains controv

As arthroscopic techniques continue to evolve and become widespread, the repair of rotator cuff tears without an open incision will likely become both commonplace and the new “gold” standard. Similar to the evolution that occurred two decades ago with arthroscopic knee surgery, arthroscopic rotator cuff surgery will allow surgeons and patients to reduce the morbidity of this procedure while still attaining excellent final outcomes. Several peer-reviewed publications have documented excellent outcomes clinically, radiographically, and at second-look arthroscopy after arthroscopic cuff repair. With this background, we review here the arguments in favor of all-arthroscopic rotator cuff repair.

Methods are needed for identifying poorer quality cadaver proximal humeri to ensure that they are not disproportionately segregated into experimental groups for fracture studies. We hypothesized that measurements made from radiographs of cadaveric proximal humeri are stronger predictors of fracture strength than chronological age or bone density values derived from dual-energy x-ray absorptiometry (DXA) scans. Thirty-three proximal humeri (range: 39-78 years) were analyzed for: (1) bone mineral density (BMD, g/cm(2)) using DXA, (2) bulk density (g/cm(3)) using DXA and volume displacement, (3) regional bone density in millimeters of aluminum (mmAl) using radiographs, and (4) regional mean (medial+lateral) cortical thickness and cortical index (CI) using radiographs. The bones were then fractured simulating a fall. Strongest correlations with ultimate fracture load (UFL) were: mean cortical thickness at two diaphyseal locations (r = 0.71; p 0.001), and mean mmAl in the humeral head (r = 0.70; p 0.001). Weaker correlations were found between UFL and DXA-BMD (r = 0.60), bulk density (r = 0.43), CI (r = 0.61), and age (r = -0.65) (p values0.01). Analyses between UFL and the product of any two characteristics showed six combinations with r-values0.80, but none included DXA-derived density, CI, or age. Radiographic morphometric and densitometric measurements from radiographs are therefore stronger predictors of UFL than age, CI, or DXA-derived density measurements.

The financial cost of using human tissues in biomedical testing and surgical reconstruction is predicted to increase at a rate that is disproportionately greater than other materials used in biomechanical testing. Our first hypothesis is that cadaveric proximal humeri that had undergone monotonic failure testing of simulated rotator cuff repairs would not differ in ultimate fracture loads or in energy absorbed to fracture when compared to controls (i.e., bones without cuff repairs). Our second hypothesis is that there can be substantial cost savings if these cadaveric proximal humeri, with simulated cuff repairs, can be re-used for fracture testing. Results of fracture tests (conducted in a backwards fall configuration) and cost analysis support both hypotheses. Hence, the bones that had undergone monotonic failure tests of various rotator cuff repair techniques can be re-used in fracture tests because their load-carrying capacity is not significantly reduced.

Over the past 20 to 30 years, arthroscopic shoulder techniques have become increasingly popular. Although these techniques have several advantages over open surgery, surgical complications are no less prevalent or devastating than those associated with open techniques. Some of the complications associated with arthroscopic shoulder surgery include recurrent instability, soft-tissue injury, and neurapraxia. These complications can be minimized with thoughtful consideration of the surgical indications, careful patient selection and positioning, and a thorough knowledge of the shoulder anatomy. Deep infection following arthroscopic shoulder surgery is rare; however, the shoulder is particularly susceptible to Propionibacterium acnes infection, which is mildly virulent and has a benign presentation. The surgeon must maintain a high index of suspicion for this infection. Thromboemoblic complications associated with arthroscopic shoulder techniques are also rare, and studies have shown that pharmacologic prophylaxis has minimal efficacy in preventing these complications. Because high-quality studies on the subject are lacking, minimal evidence is available to suggest strategies for prevention.

Subscapularis tendon ruptures, if left undiagnosed, can result in significant disability for individual patients. Thisarticle outlines the anatomy, techniques of diagnosis, and a method of repair that has been successful in the senior author's hands. Early recognition and aggressive operative repair are emphasized.

Rotator cuff disease strikes different patients at different points in their lives. To treat patients with rotator cuff tears successfully, either operatively or nonoperatively, each patient must be individualized, the disabilities from the current condition assessed, and the risks of living with the condition weighed carefully against the risks of surgical treatment. There are a number of patients who, for a variety of reasons, have rotator cuff tears that lend themselves to conservative treatment. Some patients, by virtue of age or activity level, to a certain extent have demand-type rotator cuff tears that require surgical treatment. Repetitive corticosteroid injections and prolonged strengthening exercises in these individuals make the inevitable surgical treatment more difficult, and sometimes impossible, compromising the patient's overall result. This article presents a historical review of the problem, discusses the mechanics of the shoulder, and presents a rationale for treatment based on the altered biomechanics seen in rotator cuff tears.

The treatment of massive rotator cuff tears can pose a difficult problem for the unprepared orthopaedic surgeon.There are many ways to treat massive rotator cuff tears, and one viable option is debridement with acromioplasty. For this form of treatment to be successful, the surgeon must choose his patient carefully. This report will focus on patient selection, biomechanics, and postoperative rehabilitation. A thorough understanding of rotator cuff tear biomechanics is needed when treating a massive tear; thorough physical and radiological examinations will help the orthopedist understand the biomechanic characteristic of the patient's tear. A tear that is balanced in both the transverse and coronal planes is stable and functional and will do well with debridement. Conversely, a tear that is unbalanced in either the transverse or coronal planes is unstable and nonfunctional and will not do well with simple debridement. Nonfunctional tears demand an attempt at rotator cuff tendon repair to restore balance to the cuff, making the tear functional. Debridement of a functional tear can be successfully performed with arthroscopic or open technique. Preservation or reconstruction of the coracoacromial (CA) arch is important because it adds anterosuperior stability to the shoulder with a massive rotator cuff tear. Postoperative rehabilitation is as important as the surgery itself and will also be emphasized. Many surgeons have had success with debridement of massive rotator cuff tears; however, as with any procedure, proper understanding of the pathology and proper patient selection is paramount to obtaining a successful result.