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Background: All-suture anchors (ASAs) are noted to cause various bone reactions when used in upper limb surgery but clinical implications are unknown. Methods: 88 shoulders and 151 elbows with a mean follow-up of 47.1 ± 17.7 months were invited for follow-up including clinical examination, questionnaires and radiographs. The anchor drill holes were radiographically assessed. Results: At final follow up, mean DASH was 12.9 ± 13.8 and mean VAS 2.2 ± 2.4 in the shoulder population. In the elbow group mean MEPS was 91.8 ± 12.7 and mean VAS 1.5 ± 1.9. Implant-specific complications were seen in 10 elbow cases but none in the shoulder group. The mean diameter of the 1.4 mm all-suture anchor drill hole was enlarged to 2.5 ± 1.4 mm in the shoulder group and to 2.9 ± 1.0 mm in the elbow group. 50% of the 1.4 mm anchor drill holes showed abnormal morphology but these morphologic changes did not correlate with clinical outcome, complications or reoperation rate. Discussion: Satisfying clinical outcomes are found in upper limb surgery using ASAs. Various bone changes are seen after implantation of an ASA, but these are not clinically relevant. Long-term consecutive follow-up data is required.

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PURPOSE: Despite good clinical results and low recurrence rates, post-operative complications of coracoid process transfer procedures are not well understood. This study aims to evaluate the underlying failure mechanism in cases requiring major open revision surgery after prior Bristow or Latarjet stabilization. METHODS: Between January 2006 and January 2017, 26 patients underwent major open revision after primary Bristow or Latarjet procedure. Clinical notes and radiographic images were retrospectively reviewed for all cases to determine underlying pathology. Choice of treatment and clinical and radiographic outcome were similarly reported for all cases. RESULTS: The underlying failure mechanism was associated with non-union in 42.3%, resorption in 23.1%, graft malpositioning in 15.4%, and trauma or graft fracture in 19.2% of cases. Although none of the patients reported any dislocations, mean subjective shoulder score was 60.2% and WOSI scores averaged 709.3 points at final follow-up. Radiographic signs of deteriorating degenerative arthritis were seen in 34.6%. CONCLUSION: Graft non-union resulting in recurrent instability was the main indication for open revision surgery after Bristow or Latarjet procedure, followed by resorption, malpositioning, and graft fracture in this retrospective case series. Revision surgery consisted of a structural iliac crest bone graft in the majority of cases. Clinical and radiographic outcomes are predictably variable in this population of multioperated patients.

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INTRODUCTION: Three-dimensional (3D) preoperative planning and patient-specific instrumentation (PSI) improve accuracy of glenoid component implantation in reverse shoulder arthroplasty. STEP 1 PREOPERATIVE VIRTUAL 3D PLANNING VIDEO 1: Use a 3D software tool for virtual preoperative planning of glenoid component implantation. STEP 2 PATIENT POSITIONING AND SURGICAL APPROACH VIDEO 2: Place the patient in a semi-beach-chair position and perform a standard deltopectoral approach. STEP 3 HUMERAL PREPARATION VIDEO 3: Prepare the humeral side for implantation of the humeral component using standard instrumentation. STEP 4 GLENOID EXPOSURE AND PREPARATION VIDEO 4: Expose the glenoid and prepare the glenoid surface for component implantation. STEP 5 GLENOID PREPARATION AND IMPLANTATION OF THE GLENOID BASEPLATE USING 4 PSI GUIDES VIDEO 5: Use the 4 PSI guides to prepare the glenoid for component implantation according to the preoperative plan. STEP 6 DEFINITIVE IMPLANTATION OF THE COMPONENTS AND REDUCTION VIDEO 6: Implant the glenosphere and humeral component and reduce the prosthesis. STEP 7 POSTOPERATIVE REHABILITATION PROTOCOL: Start passive and active-assisted exercises immediately, and begin muscle strengthening and active exercises at 6 weeks. RESULTS: A recent prospective, comparative study assessed the influence of 3D preoperative planning and PSI guidance of glenoid component positioning in total shoulder arthroplasty and reverse shoulder arthroplasty18.

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BACKGROUND: Only a few articles describe the reproducibility and clinical feasibility of glenoid inclination measurements on conventional radiographs, and none of them validated their method in shoulder arthroplasty cases. From a clinical point of view, the angle measured between the supraspinatus fossa and the glenoid fossa line (angle ß) appears to be the most interesting angle to assess glenoid inclination. This study aimed to validate the angle ß in shoulder arthroplasty patients to facilitate the assessment of glenoid component inclination. MATERIALS AND METHODS: Seventeen patients who underwent total or reverse shoulder arthroplasty were evaluated. The angle ß was measured by 2 independent observers on postoperative radiographs and 3-dimensional (3D) models. The interobserver variability and accuracy of angle ß were analyzed by calculating the intraclass correlation coefficient (ICC) and by generating Bland-Altman plots. RESULTS: The angle ß showed a good interobserver variability (ICC = 0.971 for radiographs, ICC = 0.980 for 3D models) and a good agreement between the radiographic and 3D measurements (ICC = 0.904 for observer 1 and ICC = 0.908 for observer 2). Bland-Altman plots demonstrated that in 95% of the measurements on radiographs, the error will be <10. In the investigated population, 85% showed an error <6. CONCLUSION: This study demonstrates that angle ß can be measured on radiographs to assess glenoid component inclination in total and reverse shoulder arthroplasty, but clinicians and researchers should keep in mind that measurement errors of 10° may occur in a minority of cases.

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BACKGROUND: The aim of this study was to assess the influence of 3-dimensional (3D) preoperative planning and patient-specific instrument (PSI) guidance of glenoid component positioning on its inclination in total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA). MATERIALS AND METHODS: Thirty-six shoulder arthroplasties (12 TSAs, 24 RSAs) were analyzed, of which 18 procedures (6 TSAs, 12 RSAs) were executed using preoperative 3D planning and patient-specific guides to position the central guide pin for glenoid component implantation. In 9 cases, the glenoid anatomy was severely distorted through wear or previous surgery. The inclination of the glenoid component was measured by 2 observers, using the angle between the glenoid baseplate and the floor of the supraspinatus fossa (angle ß) on postoperative radiographs. RESULTS: For TSA, the average angle ß was 74 ± 9 in the PSI group and 86 ± 12 in the non-PSI group; for RSA, the average angle ß was 83 ± 7 in the PSI group and 90 ± 17 in the non-PSI group. Extreme angles ß, which represent extreme values of glenoid component inclination, are more likely to occur in the non-PSI group than in the PSI group (P < .001 for TSA; P = .02 for RSA). CONCLUSIONS: The3D preoperative surgical planning and PSI guidance reduce variability in glenoid component inclination and avoid extreme inclination errors for TSA and RSA.

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The number of shoulder arthroplasty procedures performed in the United States is steadily increasing as a result of an expansion in implant options, clinical indications, and surgical experience. Available options include stemmed implants, short-stemmed or stemless prostheses, fracture-specific designs, resurfacing implants, partial surface replacement, metal-backed or polyethylene glenoid components designed for cementation or bone ingrowth, and reverse total shoulder arthroplasty. Efforts to re-create anatomy, improve outcomes, and avoid complications have resulted in many changes in prosthesis design. Despite these changes, failures still occur, and revision surgery is sometimes necessary. A thorough knowledge of current arthroplasty options, indications, and the principles of implantation is necessary to optimize outcomes after shoulder arthroplasty.

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Longevity of total anatomic and reversed shoulder arthroplasty largely depends on accurate correction of glenoid deformity and correct positioning and fixation of the glenoid component. However, the morphology of the scapula is inconsistent, varying degrees of osteoarthritis cause numerous anatomic changes, and standard 2-dimensional imaging and standard surgical instrumentation are imprecise for preoperative planning and execution of glenoid reconstruction. Recently, various authors have shown that preoperative 3-dimensional surgical planning and computer navigation technology may increase the accuracy and repeatability of the implantation of the glenoid component, especially for the position and orientation of the glenosphere and screws in reversed arthroplasty. These novel techniques may allow the surgeon to better define the preoperative deformity, select the optimal implant position, and then accurately execute the plan at the time of surgery. Future studies are needed to determine the long-term effect on functional outcome and cost-effectiveness of computer-assisted technology in shoulder arthroplasty.

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Posterior sternoclavicular (SC) dislocation is a rare diagnosis, which tends to be missed initially. Here we report two cases of a dislocated SC joint: one left and one right. The first case describes a 25-year-old male who sustained a direct injury caused by his seatbelt during a car accident. The diagnosis was made 3 months after the initial trauma following performance of a CT scan. His left SC joint was stabilized using a hamstring tendon allograft. The second patient, a 55-year-old female, sustained an indirect injury following a fall onto her right shoulder. The diagnosis was made 6 weeks after the trauma had occurred. Her SC joint was also stabilized using a tendon allograft reconstruction. The clinical outcome of both cases was very satisfactory. Better diagnostics - more attention for subtle symptoms during physical examination, the right choice of imaging (CT scan) and meticulous following of Advanced Trauma Life Support (ATLS) protocols - could diminish the number of delayed diagnoses in this rare but potentially dangerous injury.

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Soccer players frequently experience acute and chronic groin pain. Sportsman's hernia is a common injury in professional soccer players, that causes inguinal pain. The authors discuss their experience with the management of sportsman's hernia in professional soccer players competing in national and international competition in a retrospective review of prospectively collected data. Between March 2004 and December 2009, seventy-one professional soccer players were surgically treated for sportsman's hernia. Average age at surgery was 24 years, and average duration of symptoms from onset to surgical repair was 11 months. Conservative treatment improved symptoms temporarily or to some extent in 18 athletes. All athletes underwent a bilateral open hernia repair with concurrent adductor tendon release. Average follow-up was 4 years, and average time to return to competitive sport was 4 months. At final follow-up, 95% of soccer players were still active, 48 at the same level and 19 at a lower level. Four athletes had stopped their careers because of another injury (n=2) or recurrence (n=2). Sportsman's hernia is a potentially career-ending injury in professional soccer players. Conservative management is often unsuccessful. An open surgical hernia repair combined with an adductor longus tenotomy relieves the symptoms caused by a sportsman's hernia and restores activity in 95% of athletes. This study offers insight into the management of sportsman's hernia and offers a successful treatment to salvage the careers of professional soccer players.

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UNLABELLED: This study aimed to evaluate the long-term results of arthroscopic thermal shrinkage of the anterior capsule in athletes with internal shoulder impingement. In recent years, opinion with regards to the aetiology of internal shoulder impingement has changed significantly. The traditional treatment of internal impingement consisted of debridement of labral and/or undersurface cuff lesions. The use of concomitant thermal capsulorrhaphy, based on the concept of anteroinferior laxity, has also been advocated with excellent short-term results. In this study we investigated the long-term effects of this technique. Twelve overhead athletes with internal impingement underwent traditional arthroscopic treatment plus thermal capsulorrhaphy for internal impingement. All patients were evaluated 1, 2 and 7 years postoperatively using a questionnaire regarding their sports activity, and the modified Rowe score. At 1, 2 and 7 years postoperatively there was a significant improvement in the modified Rowe score when compared to the preoperative scores. However, follow-up at 7 years showed a significant deterioration of the initial 1 and 2 year results (p < 0.001), with only 25% of the athletes able to perform sports at their preoperative level. CONCLUSION: Excellent short-term results with thermal capsulorrhaphy, in addition to traditional arthroscopic treatment, in patients with internal shoulder impingement were not sustained over time. After 7 years, only 25% of the athletes were able to perform sports at their preoperative level.

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Chronic groin pain in athletes is a difficult diagnostic and therapeutic condition. Between March 2004 and December 2009, 241 male athletes (mean age: 25.8 years, range: 16-41) in whom chronic sportsman's hernia was diagnosed, were surgically treated using a standardised technique. In this retrospective study, charts were analyzed for preoperative duration of symptoms and prior treatment. Perioperative complications were noted. Patients were contacted and were asked to answer a telephone questionnaire: 162 patients agreed to be questioned as part of the current study. A surgical intervention with reinforcement of the posterior inguinal wall and tenotomy of the adductors has lead to satisfactory results in over 90% of athletes with chronic groin pain who failed to improve with conservative treatment.

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Humeral implant design in shoulder arthroplasty has evolved over the years. The third generation shoulder prostheses have an anatomic humeral stem that replicates the 3-dimensional parameters of the proximal humerus. The overall complication rate has decreased as a result of these changes in implant design. In contrast, the rate of periprosthetic humeral fractures has increased. To avoid stem-related complications while retaining the advantages of the third generation of shoulder implants, the stemless total evolutive shoulder system has been developed. The indications, the surgical technique, and the complications of this humeral implant in shoulder arthroplasty will be described.

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HYPOTHESIS: In total shoulder arthroplasty, the humeral component, particularly the stem, can be involved in some of the complications and technical difficulties increase in posttraumatic arthritis with proximal humeral malunion. To decrease the intraoperative complications related to the stem, the TESS (Biomet Inc, Warsaw, IN) humeral implant, was designed in 2004 hypothesis that we can obtain a good fixation with a stemless prosthesis. This investigation reports the preliminary results of this prosthesis with more than 3 years of follow-up. METHODS: Between March 2004 and June 2005, 70 patients underwent 72 shoulder replacements with the TESS humeral prosthesis. Sixty-three patients were reviewed with a follow-up of more than 36 months (average, 45.2 months; range, 36-51 months). The mean preoperative Constant score was 29.6. RESULTS: Gain in active mobility was 49 degrees for forward flexion and 20 degrees for external rotation. The postoperative Constant score was 75. Radiographic analysis showed no radiolucencies or implant migration. Functional results are comparable with previous reports on prosthetic glenohumeral replacement. DISCUSSION: Our clinical results are similar to this with classical prosthesis. The humeral head removal facilitates the glenoid exposure and implantation. After the initial cases any specific complication was seen. CONCLUSIONS: Owing to the automatic central positioning of the implant, an anatomic reconstruction was achieved. In malunions, no tuberosity osteotomy was required. At 3 years of follow-up, there is radiologic evidence of maintained implant stability. These encouraging preliminary results confirm our belief that a stemless prosthesis can be used to obtain an anatomic reconstruction of the proximal humerus. A longer-term follow-up study is needed to validate these results.

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HYPOTHESIS: The purpose of this study is to report the functional outcome of the repair of a distal biceps tendon rupture by the use of the endobutton technique. We hypothesized that the endobutton provides excellent strength and clinical results after repair of distal biceps tendon rupture. MATERIALS AND METHODS: Twenty-six patients underwent repair of biceps tendon ruptures by use of an endobutton for fixation of the biceps tendon stump to the radial tuberosity. There were 20 men and three women. The mean age was 52 years (39-75). The dominant side was involved in 11 patients. A partial rupture of the biceps tendon was found in four patients. The average delay in diagnosis was 16 days, with four patients presenting at six weeks or more after trauma. RESULTS: At an average follow-up of 16 months (6-48), 23 of 26 patients were available for follow-up and were examined clinically, radiologically, and by isokinetic testing. The average postoperative Mayo Elbow Performance Score (MEPS) was 94 points. The average Visual Analogue Scale (VAS) for pain was 1.5. Patients regained an almost full range of motion. Average flexion strength recovery was 80% and corresponding recovery of supination strength was 91%. Two patients developed asymptomatic heterotopic ossification seen on standard radiographs. In three patients, the endobutton had apparently disengaged without important difference in functional outcome. In one case, the endobutton had to be removed. There were no neurological complications. CONCLUSION: This study shows that a distal biceps tendon can be safely reattached to the radius by using the endobutton technique, yielding excellent and reproducible results. LEVEL OF EVIDENCE: Level 4; Retrospective case series, no control group.

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From 1995 to 2003, 39 semi-professional athletes (34 men and 5 women) aged 17-34 years (mountain bike racers, soccer players, swimmers and cyclists) with a displaced fracture of the middle-third of the clavicle were treated operatively using rigid plate fixation within one week after the initial trauma. In 90% of the athletes, radiographic union was achieved after 12 weeks. At 6 weeks post-operatively the mean Constant score was 88 points, the mean visual analogue pain score was 3 out of 10 and the average time for return to sports was 45 days. Seventy-five percent of the patients were very satisfied with the end-result and 95% would chose to have the same operation again. In 5% of the cases the end-result was unsatisfactory. The most frequent postoperative complication was wound infection (18% of the cases). Nevertheless, this did not affect the outcome. Other postoperative complications in our athletic population included refracture (5%), transient neurological complications (7%) and non-union (5%), which were equally low in the literature. These data suggest that rigid plate fixation of middle-third clavicle fractures gives good results in the semi-professional athlete and may result in early return to sports activity, at the expense of a significant risk for complications, which would not be considered acceptable in patients with lower functional demands.

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BACKGROUND: Altered muscle activity in the scapular muscles is commonly believed to be a factor contributing to shoulder impingement syndrome. However, one important measure of the muscular coordination in the scapular muscles, the timing of the temporal recruitment pattern, is undetermined. PURPOSE: To evaluate the timing of trapezius muscle activity in response to an unexpected arm movement in athletes with impingement and in normal control subjects. STUDY DESIGN: Prospective cohort study. METHODS: Muscle latency times were measured in all three parts of the trapezius muscle and in the middle deltoid muscle of 39 "overhand athletes" with shoulder impingement and compared with that of 30 overhand athletes with no impingement during a sudden downward falling movement of the arm. RESULTS: There were significant differences in the relative muscle latency times between the impingement and the control group subjects. Those with impingement showed a delay in muscle activation of the middle and lower trapezius muscle. CONCLUSION: The results of this study indicate that overhand athletes with impingement symptoms show abnormal muscle recruitment timing in the trapezius muscle. The findings support the theory that impingement of the shoulder may be related to delayed onset of contraction in the middle and lower parts of the trapezius muscle.

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