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Reverse shoulder arthroplasty (RSA) is based on the biomechanical advantages of lengthening the deltoid while medializing its center of rotation (COR). Little evidence exists describing the clinical benefits of these biomechanical advantages. The purpose of this study is to assess the relationship between deltoid lengthening and medialization of the COR with functional outcomes for RSA patients. We retrospectively reviewed patients treated with primary RSA. Radiographic measurements of deltoid length and COR, assessment of forward elevation (FE) and external rotation (ER), and functional outcome scores were obtained pre- and postoperatively. Linear regression analyses were performed to assess the relationship between these radiographic measurements and changes in shoulder functionality. On average, patients improved significantly in function and functional outcome scores. Postoperative COR correlated weakly with postoperative FE. There were weakly negative correlations between increase in acromion to greater tuberosity distance and postoperative FE, and between deltoid lengthening and FE improvement. Our results suggest that deltoid lengthening does not correlate with improvements in active FE or ER. These findings could indicate that change in deltoid length is less important than previously thought. Furthermore, the negative correlations seen could indicate that there is over-tensioning of the deltoid in specific cases. Further studies are needed to better assess the role of deltoid length and other factors that may impact RSA outcomes.

Reverse shoulder arthroplasty (RSA) is an effective surgery for a variety of patients with difficult shoulder pathology. Since postsurgical outcomes are often variable, there has been great effort made to optimize the design and use of these implants. Previous studies demonstrated an association between increased glenosphere size and improved range of motion. The purpose of this study is to assess the relationship between glenosphere size, range of motion, and functional outcome scores. This is a retrospective cohort study of 140 patients (148 shoulders) undergoing reverse shoulder arthroplasty. All patients were assessed pre- and postoperatively for range of motion, Constant score, ASES score, and Subjective Shoulder Value. Improvements in these variables were compared for patients treated with three different glenosphere sizes (36, 40, 42 mm). All groups had a mean improvement in range of motion and functional outcome scores, but there were no statistically significant differences between groups when controlling for preoperative differences. Our findings do not support a strong role for glenosphere size as a singular factor affecting range of motion or patient-reported outcome following RSA. These problems are most likely due to the multifactorial nature of shoulder dynamics. For this reason, assessing the effect a single surgical or biomechanical parameter on function has been challenging.

Some surgeons are reluctant to perform a reverse total shoulder arthroplasty (RTSA) on both shoulders because of concerns regarding difficulty with activities of daily living post-operatively as a result of limited rotation of the shoulders. Nevertheless, we hypothesised that outcomes and patient satisfaction following bilateral RTSA would be comparable to those following unilateral RTSA. A single-surgeon RTSA registry was reviewed for patients who underwent bilateral staged RTSA with a minimum follow-up of two years. A unilateral RTSA matched control was selected for each shoulder in those patients undergoing bilateral procedures. The Constant–Murley score (CMS), American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Values (SSV), visual analogue scale (VAS) for pain, range of movement and strength were measured pre- and post-operatively. The mean CMS, ASES, SSV, VAS scores, strength and active forward elevation were significantly improved (all p < 0.01) following each operation in those undergoing bilateral procedures. The mean active external rotation (p = 0.63 and p = 0.19) and internal rotation (p = 0.77 and p = 0.24) were not significantly improved. The improvement in the mean ASES score after the first RTSA was greater than the improvement in its control group (p = 0.0039). The improvement in the mean CMS, ASES scores and active forward elevation was significantly less after the second RTSA than in its control group (p = 0.0244, p = 0.0183, and p = 0.0280, respectively). Pain relief and function significantly improved after each RTSA in those undergoing a bilateral procedure.Bilateral RTSA is thus a reasonable form of treatment for patients with severe bilateral rotator cuff deficiency, although inferior results may be seen after the second procedure compared with the first.Cite this article: Bone Joint J 2013;95-B:1232–8.

The surgical management of posttraumatic arthritis is one of the most difficult problems encountered in shoulder surgery. Bone and soft tissue abnormalities resulting from the initial injury and from any subsequent surgery must be addressed to achieve the best outcome possible. A review of the literature reveals distinctly inferior results and a higher rate of complications following surgical treatment of posttraumatic sequelae compared with the surgical treatment of acute proximal humeral fractures. The authors present helpful hints for dealing with the complex problems encountered in the posttraumatic setting.

Injury to the spinal accessory nerve can lead to dysfunction of the trapezius. The trapezius is a major scapular stabilizer and is composed of three functional components. It contributes to scapulothoracic rhythm by elevating, rotating, and retracting the scapula. The superficial course of the spinal accessory nerve in the posterior cervical triangle makes it susceptible to injury. Iatrogenic injury to the nerve after a surgical procedure is one of the most common causes of trapezius palsy. Dysfunction of the trapezius can be a painful and disabling condition. The shoulder droops as the scapula is translated laterally and rotated downward. Patients present with an asymmetric neckline, a drooping shoulder, winging of the scapula, and weakness of forward elevation. Evaluation should include a complete electrodiagnostic examination. If diagnosed within 1 year of the injury, microsurgical reconstruction of the nerve should be considered. Conservative treatment of chronic trapezius paralysis is appropriate for older patients who are sendentary. Active and healthy patients in whom 1 year of conservative treatment has failed are candidates for surgical reconstruction. Studies have shown the Eden-Lange procedure, in which the insertions of the levator scapulae, rhomboideus minor, and rhomboideus major muscles are transferred, relieves pain, corrects deformity, and improves function in patients with irreparable injury to the spinal accessory nerve.

Injury to the long thoracic nerve causing paralysis or weakness of the serratus anterior muscle can be disabling. Patients with serratus palsy may present with pain, weakness, limitation of shoulder elevation, and scapular winging with medial translation of the scapula, rotation of the inferior angle toward the midline, and prominence of the vertebral border. Long thoracic nerve dysfunction may result from trauma or may occur without injury. Fortunately, most patients experience a return of serratus anterior function with conservative treatment, but recovery may take as many as 2 years. Bracing often is tolerated poorly. Patients with severe symptoms in whom 12 months of conservative treatment has failed may benefit from surgical reconstruction. Although many surgical procedures have been described, the current preferred treatment is transfer of the sternal head of the pectoralis major tendon to the inferior angle of the scapula reinforced with fascia or tendon autograft. Many series have shown good to excellent results, with consistent improvement in function, elimination of winging, and reduction of pain.

A male 17-year-old with multiple hereditary exostoses presented with a mass in the distal left thigh several days after lifting weights. An arteriogram showed a popliteal artery pseudoaneurysm adjacent to a femoral osteochondroma. The osteochondroma was excised and the artery was repaired with a saphenous vein interposition graft. A review of the literature identified 23 similar reports. The average age of the patients was 21.3 years. Seventy-eight percent were men and half of the patients had multiple hereditary exostoses. Ten patients were initially misdiagnosed. The clinician should consider the diagnosis of pseudoaneurysm in a young patient with an osteochondroma and a mass about the knee.