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Medial clavicle excision is a rarely indicated procedure and may be performed in different pathologies affecting the medial clavicle. Excessive medial clavicle resection with an injury to the costoclavicular ligament often leads to poor postoperative results. The exact surgical treatment used in this kind of pathology when conservative treatment is unsuccessful remains unclear. The aim of this Technical Note is to describe our preferred surgical technique to treat this condition., Technique Video Video 1 Surgical technique demonstration of reconstruction of the SCJ after excessive medial clavicle resection. An iliac crest autograft is first harvested. The size of the graft is determined by the size of the clavicle defect. A 1/3 tubular plate can be applied after graft harvest onto the iliac crest to prevent cosmetic deformity. An incision is made over the medial clavicle and sternum, and the medial clavicle is exposed. It is revitalized with an oscillating saw and rongeur. The sternal portion of the SCJ is exposed, preserving the capsule. The first rib is exposed and two strands of Ethibond 5 are passed through it. Two tunnels are drilled from the anterior sternal edge to the sternal articular surface. The iliac crest bone graft is shaped to the defect size, with a horizontal tunnel drilled through it to pass the gracilis allograft. The iliac crest bone graft is fixed to the native clavicle with a 3.5mm limited-contact dynamic compression plate. The sutures from the first rib are passed around the clavicle. The gracilis allograft ends are introduced into the sternal tunnel in a figure-of-eight configuration. The joint is reduced, and the graft is sutured onto itself. The sutures from the first rib are tied around the clavicle for the final costoclavicular stabilization. Pooled saline solution is used to check for pneumothorax. The capsule and platysma are approximated and closed.

There are different techniques to address severe glenoid erosion during reverse shoulder arthroplasty (RSA). This study assessed the clinical and radiological outcomes of RSA with combined bony and metallic augment (BMA) glenoid reconstruction compared to bony augmentation (BA) alone. A review of patients who underwent RSA with severe glenoid bone loss requiring reconstruction from January 2017 to January 2019 was performed. Patients were divided into two groups: BMA versus BA alone. Clinical outcome measurements included two years postoperative ROM, Constant score, subjective shoulder value (SSV), and the American Shoulder and Elbow Surgeons Shoulder (ASES) score. Radiological outcomes included radiographic evidence of scapular complications and graft incorporation. The BMA group had significantly different glenoid morphology (p &lt, 0.001) and greater bone loss thickness than the BA group (16.3 ± 3.8 mm vs. 12.0 ± 0.0 mm, p = 0.020). Both groups had significantly improved ROM (anterior forward flexion and external rotation) and clinical scores (Constant, SSV and ASES scores) at 2 years. Greater improvement was observed in the BMA group in terms of anterior forward flexion (86.3° ± 27.9° vs. 43.8° ± 25.6°, p = 0.013) and Constant score (56.6 ± 10.1 vs. 38.3 ± 16.7, p = 0.021). The BA group demonstrated greater functional and clinical improvements with higher postoperative active external rotation and ASES results (active external rotation, 49.4° ± 17.0° vs. 29.4° ± 14.7°, p = 0.017, ASES, 89.1 ± 11.3 vs. 76.8 ± 11.0, p = 0.045). The combination use of bone graft and metallic augments in severe glenoid bone loss during RSA is safe and effective and can be considered in cases of severe glenoid bone loss where bone graft alone may be insufficient.

Objective To present our technique and early results using the Masquelet technique. Design Retrospective cohort study. Patients/participants Thirteen patients with 14 open fractures of the femur and tibia were included between November 2013 and December 2014. Intervention A Masquelet technique was used to manage the open fractures. Main outcome measure Infection and union rate. Results The mean follow-up was 17 months. The mean bone defect was 56.6 mm. Eight fractures (57.1%) progressed to union at an average of 42.1 weeks. Infection developed in 3 fractures (21.4%). Overall, the induced membrane technique was abandoned in 5 (35.7%) cases. Conclusions The induced membrane technique showed a substantial rate of failure in the acute trauma setting in the lower limb. In the absence of sound published evidence, the authors now use the technique in selected cases only. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

(1) Background: Postoperative recovery of external rotation after reverse shoulder arthroplasty (RSA) has been reported despite nonfunctional external rotator muscles. Thus, this study aimed to clinically determine the ideal prosthetic design allowing external rotation recovery in such a cohort. (2) Methods: A monocentric comparative study was retrospectively performed on patients who had primary RSA between June 2013 and February 2018 with a significant preoperative fatty infiltration of the infraspinatus and teres minor. Two groups were formed with patients with a lateral humerus/lateral glenoid 145° onlay RSA—the onlay group (OG), and a medial humerus/lateral glenoid 155° inlay RSA—the inlay group (IG). Patients were matched 1:1 by age, gender, indication, preoperative range of motion (ROM), and Constant score. The ROM and Constant scores were assessed preoperatively and at a minimum follow-up of two years. (3) Results: Forty-seven patients have been included (23 in OG and 24 in IG). Postoperative external rotation increased significantly in the OG only (p = 0.049), and its postoperative value was significantly greater than that of the IG by 11.1° (p = 0.028). (4) Conclusion: The use of a lateralized humeral stem with a low neck-shaft angle resulted in significantly improved external rotation compared to a medialized humeral 155° stem, even in cases of severe fatty infiltration of the infraspinatus and teres minor. Humeral lateralization and a low neck-shaft angle should be favored when planning an RSA in a patient without a functional posterior rotator cuff.

Surgical treatment of anterior glenohumeral joint instability can be challenging and carries the inherent risk of recurrent instability, dislocation arthropathy, and postoperative loss of external rotation. In the current manuscript, a technique for combined reconstruction of anterior labrum and capsule, with concomitant reduction of the humeral head during anterior capsule reconstruction in open Latarjet procedure, is presented. Analogous to other techniques, the coracoid graft is fixed on the anteroinferior part of the glenoid between 3 and 5 o'clock. However, for this technique, reattachment of the labrum is performed between the native glenoid and the bone graft. Additionally, during the reconstruction of the anterior capsule on the coracoacromial ligament, while the operated arm is held in external rotation to avoid the postoperative rotational deficit, the humeral head is reduced posteriorly in the center of the glenoid during adduction, slight anterior forward flexion, and a posterior lever push. By doing so, the inherent theoretical risks of persistent instability and dislocation arthropathy are believed to be decreased. Further studies are needed to clarify the long-term consequences of this surgical technique in the clinical setting., Technique Video Video 1 After a 4- to 5-cm incision distal to the tip of the coracoid process, Richardson retractors are used to bluntly open the deltopectoral interval until the tip of the coracoid is exposed. A Hohmann retractor is placed on the base of the coracoid to gain its full exposure. The arm is put in abduction and full external rotation to improve visualization of the coracoacromial (CA) ligament, which is then released approximately 1.5 cm lateral from its attachment. Then, the pectoralis minor is released while the arm is internally rotated and adducted. A 90° angled saw blade is used to perform a coracoid process osteotomy just anterior to the attachment of coracoclavicular ligaments, and a chisel is meticulously used to complete the osteotomy. The coracoid process is rotated for 180° being held with a grasper and is attentively released until the muscle belly is uncovered. Its undersurface is first cleaned with electrocautery and is then flattened and slightly decorticated with a saw blade to create a healthy bleeding surface that will precisely conform to the later prepared anterior glenoid. The length of the coracoid is measured. Two central holes are drilled equally distant from the base and the tip, 1 cm apart and 8 to 9 mm laterally from the coracoacromial ligament insertion. Electrocautery is used to mark the entry holes. The coracoid is placed safely under the pectoralis major. The arm is put in abduction and external rotation. The subscapularis split between the upper two thirds and lower one third of the subscapularis is performed by sharply introducing the scissors toward the anterior glenoid neck. A Hohman retractor is placed between the blades on the medial side of the anterior glenoid neck. The subscapularis split is slightly increased laterally to improve visualization. A Gelpi retractor is placed deep below the subscapularis. The exact location of the glenohumeral joint is exposed by reducing the anteriorly dislocated humeral head, and a vertical incision is performed. A Trillat retractor is used next. The arm is put in adduction and internal rotation, and the Trillat retractor is introduced into the joint to get a better view of the anterior labrum. After the labrum is horizontally incised at 3 o’clock and released inferiorly, 2 sutures are passed through the released labrum. The Hohmann retractor is positioned on the inferior part of the glenoid neck, and a wide glenoid retractor is exchanged with the Hohmann retractor on the medial side of the anterior glenoid to improve the visualization. A curved osteotome is used to slightly decorticate the anteroinferior part of the glenoid. The position of the inferior hole is marked with a K-wire that is put 8 to 9 mm posteriorly to the glenoid face. The inferior screw is passed through the predrilled coracoid and glenoid hole to position the coracoid process on the anterior glenoid neck. The same is done for the superior screw. The screws are not fully tightened. A distinction between the CA ligament and the labrum, which is positioned posteriorly to the CA ligament, is made before the labrum is fixed on the coracoid process. Here, the Bankart repair was already performed. This is the CA ligament, and this is the anterior labrum that is fixed on the coracoid process. Then the sutures are passed through the CA ligament and through the anterior capsule. The operated arm is held in external rotation to avoid the postoperative rotational deficit. The humeral head is reduced posteriorly during adduction, slight anterior forward flexion, and a posterior lever push. At that time the knots of the anterior capsular reconstruction are tightened. Only then, an adequate capsular tension is expected. The lateral tendinous part of the subscapularis is repaired. The length of the incision ranges between 4 and 5 cm. A postoperative radiograph in the anteroposterior, Neer, and Bernageau views shows well-positioned graft and the 2 screws.

Hypothesis/background Arthroscopic rotator cuff repair most commonly results in good clinical outcomes, however understanding of predictive factors influencing the final clinical outcome is limited. Aim The purpose of our study was to evaluate clinical outcomes of patients with healed supraspinatus tendon after arthroscopic rotator cuff repair and to identify its pre- and peri-operative predictive factors of good clinical results. Methods A multi-center prospective study followed up 188 patients, who had a healed tendon after an arthroscopic repair of isolated supraspinatus tear. Inclusion criteria were: age under 70 years old, isolated supraspinatus tear, stage 0 or I of fatty infiltration, healed supraspinatus tendon at one year postoperatively and the same arthroscopic double row rotator cuff repair used in all patients. Clinical assessment used Constant Murley Score (CMS) and Subjective Shoulder Value (SSV) preoperatively and at one year postoperatively. Ultrasound (US) control checked tendon repair quality based on Sugaya classification. Types I-II-III were considered as healed. Results The average age of our cohort was 57.57 (range; 41 to 70) years and the female to male ratio was 1.14 (range; 100 to 87). The average preoperative CMS was 53.75 ± 13.50 (mean ± SD; range; 16 to 83). At final follow up, the average postoperative CMS was 79.95 ± 12.05 (mean ± SD; range; 28 to 100). 12.22% (23/188) of patients, who had a CMS score below 70, had a clinically significant difference compared to the average CMS, due to the fact that the minimal clinically significant difference (MCID) in CMS is 10. A statistical analysis has shown that in patients with lower scores there was only a significant dominance of females (p-value = 0.001). No difference was found in regards to age, preoperative CMS, fatty degeneration and other factors. Conclusion Our study showed that despite all patients had a healed repair of supraspinatus, not all of them experienced a good final clinical outcome. The only factor negatively influencing the final clinical outcome was a female gender. No other structural factors seemed to influence the final clinical results. Futures studies should focus more on analyzing which personality traits and other psychosocial factors play an important role in determining the final outcome after arthroscopic rotator cuff repair. Level of evidence III; retrospective cohort study.

Patellar instability with recurrent dislocation prevents most patients from returning to regular physical and sports activities. For acute pattelar dislocation, conservative treatment is mainly the first choice of treatment. However, the redislocation rate is high. Anatomical and biomechanical studies show that the medial patellofemoral ligament (MPFL) is the primary restraint to lateral patellar translation between 0 and 30° of knee flexion. Patellar stabilization with MPFL reconstruction is a successful treatment option for patellar instability. It is a mini-invasive surgical procedure associated with low postoperative complications.

Posterolateral corner of the knee is an anatomically complex region with variable formation of tendons and ligaments which provide important posterolateral stability of the knee. Injury of this region is often a high-energy multi-ligament injury that rarely happens in isolation. The three posterolateral structures that are biomechanically and surgically most important are fibular collateral ligament, popliteus tendon muscle, and popliteofibular ligament. A thorough physical examination combined with stress radiographs and magnetic resonance imaging is critical to accurately define the injured structures. Diagnostic arthroscopy further enhances our surgical decision-making in choosing the proper reconstruction technique. The most appropriate posterolateral corner surgical reconstruction should be used based on the careful grading of each injury. The aim of different surgical reconstructions is to restore the normal knee biomechanics. Surgical techniques have progressed and range from the classical wide-open approach, to minimally invasive approach with two mini-open incisions and percutaneous posterolateral corner reconstruction to arthroscopic popliteus bypass reconstruction. Posterolateral reconstruction is usually involved in complex knee reconstruction and mostly combined with posterior or anterior cruciate ligament reconstruction. High tibial osteotomy is used in chronic cases of varus malalignment in knees with posterolateral injury. Posterolateral corner reconstructions are technically demanding procedures. Complications after such procedure can arise in large part due to the complex anatomy and injury pattern of this region combined with a surgeon’s lack of experience and thus require a highly skilled and experienced surgeon to perform them.

A combination of massive rotator cuff tear and recurrent shoulder instability is uncommon and represents a complex problem to treat. The significant range of shoulder motion is achieved due to the lack of bony constraints which sets the stage for pathologic instability. The balance between shoulder mobility and stability is related to a complex combination of dynamic and static stabilizers around the shoulder joint. One of the main dynamic stabilizers is represented by the rotator cuff, which centers the humeral head in the glenoid fossa through concavity compression mechanism. Disruption of the balance between dynamic and static stabilizers due to their loss of integrity may lead to instability. In patients who complain of pain and weakness for up to 3 weeks after an anterior dislocation a rotator cuff lesion should be suspected and further investigation should be taken. There are no clear guidelines as to whether either the rotator cuff tear or the anterior capsulolabral complex injury or both should be treated surgically if they occur simultaneously in a patient with recurrent anterior shoulder dislocation. A case example of a combined massive rotator cuff and recurrent shoulder instability in a 63-year-old female is presented.