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The objective of this study was to evaluate the clinical and radiological outcomes of reverse shoulder arthroplasty (RSA) associated with two techniques: L'Episcopo procedure (combined teres major and latissimus dorsi transfer) and modified L'Episcopo procedure (isolated latissimus dorsi transfer).A retrospective review of 36 RSAs (mean age 69.8 years; SD 8.9) associated with either L'Episcopo procedure (Group 1, 21 cases) or modified L'Episcopo procedure (Group 2, 15 cases) was performed between 2007 and 2020. Clinical outcome measures consisted of range of motion (ROM), SSV, VAS, and Constant-Murley scores. These scores were compared between the two groups. Radiographs were assessed for transfer site bony lesions.With a mean follow-up of 40.8 months (6-98; SD 28.8), no significant differences were revealed in the clinical outcomes: Constant score, SSV, VAS, ROM. The entire study group demonstrated a significant improvement in post-operative functional outcome scores and ROM parameters compared to their pre-operative state, IR measures being the only exception (p = 0.26). Radiographs demonstrated transfer site bony lesions in 60% of the patients (18/30). Three complications (8.3%) were noted in the study.At the short-term follow-up, RSA combined with either latissimus dorsi (LD) transfer in isolation or in association with teres major proved to be equally effective in restoring external rotation in the settings of an irreparable postero-superior cuff tear treated with RSA. Although the LD transfer group displayed a tendency towards superior ROM, this was not supported statistically. Post-operative radiographs confirmed the presence of bony lesions at the transfer fixation sites in both groups of patients (52% vs. 72%).

To report clinical and radiologic outcomes of arthroscopic Eden-Hybinette using 2 cortical suture buttons in a series of patients with previous failed Latarjet and persistent glenoid bone loss.Between 2015 and 2019, patients with recurrent anterior instability after failed Latarjet underwent arthroscopic Eden-Hybinette procedure using 2 cortical buttons for graft fixation. Exclusion criteria were open and primary Eden-Hybinette and less than one year follow-up. Functional assessment was performed using Rowe and Walch-Duplay scores, subjective shoulder value, visual analog scale, and degree of satisfaction. Iliac crest bone graft placement and healing were assessed postoperatively with computed tomography imaging.A total of 17 patients with a mean age of 28 years (range, 21-43 years) at time of revision were included. The mean glenoid bone loss was 23% (range, 18%-42%). Medium or deep Hill-Sachs lesion (Calandra 2 and 3) was present in 65% of cases. At a mean follow-up of 3 ± 1.6 years, all but 1 patient (94%) considered their shoulder stable, and 15 patients (88%) were satisfied or very satisfied. The subjective shoulder value increased from 51% to 87% (P.05), the Walch-Duplay increased from 23 to 86 points (P.05), and Rowe scores improved from 30 to 92 points (P.05). Apprehension was still positive in 3 patients (17.6%), with this percentage being greater in the presence of Hill-Sachs Calandra 3 (P = .02). Postoperative computed tomography scans showed optimal bone autograft position in all patients (below the glenoid equator and flush to the glenoid rim). Iliac crest bone graft healed to the anterior glenoid neck in 16 shoulders (94%). The rate of recurrent instability was 11.7% but only 1 patient required revision surgery (5.8%).Arthroscopic Eden-Hybinette using 2 cortical buttons leads to satisfactory clinical outcomes and a low recurrence rate after failed Latarjet, allowing successful reconstruction of the anterior glenoid rim and simultaneous treatment of capsular deficiency and humeral bone loss.Therapeutic, level IV, retrospective case series.

Background Although fibromyalgia is associated with poor outcomes following orthopedic surgeries, several studies show some benefit from surgical intervention and nevertheless recommend operative treatment when indicated. There is sparse evidence of the effect of fibromyalgia on the outcomes of shoulder surgery. The purpose of this study was to investigate the effect of fibromyalgia on patient-reported outcomes of arthroscopic rotator cuff repair (ARCR). Methods All patients with a confirmed diagnosis of fibromyalgia who underwent ARCR in one institution between 2010 and 2021 were included. Data retrieved from medical records included demographics, characteristics of the cuff tear and the surgical procedure, and preoperative and last follow-up (minimum 1 year) postoperative Disabilities of the Arm, Shoulder and Hand (DASH) score, Subjective Shoulder score (SSV), and Numeric Pain Rating Scale (NPRS). A matched controlled group of patients without fibromyalgia who had undergone ARCR was selected according to age, sex, and preoperative DASH, SSV, and NPRS scores. Results There were no significant differences in demographics, cuff tear and surgical procedure characteristics, and preoperative scores between the fibromyalgia and control groups. The fibromyalgia patients’ postoperative scores for all 3 measurements showed significant improvement: SSV by 32.1 (P = 0.004), DASH by 20.3 (P = 0.016), and NPRS by 2.33 (P = 0.017). There were no significant differences in the postoperative DASH, SSV, and NPRS between the fibromyalgia and control groups. Conclusion Fibromyalgia patients with rotator cuff tears who undergo ARCR do not have inferior patient-reported outcomes compared with non-fibromyalgia controls. Fibromyalgia should not be a considered a contraindication for ARCR. Level of evidence: III

To evaluate long-term results after arthroscopic Bankart repair and Hill-Sachs remplissage (BHSR) in bipolar bone defects with less than 20% of glenoid bone loss (GBL) and to analyse risk factors for recurrent dislocation.From 2009-2012, 43 patients with recurrent anterior shoulder instability were treated with BHSR. Inclusion criteria were GBL 20% and minimum of 4-yearfollow-up. There were 35 males and 8 females with a mean age of 29 years (range 16-53). The mean ISIS score was 3.6 (range 2-6). Patients were evaluated for recurrence, range of motion and functional outcomes (Walch-Duplay and Rowe score). Post-operative MRI was performed at least 6 months after surgery to evaluate infraspinatus capsulotenodesis healing. Glenoid track was assessed retrospectively from pre-operative computed tomography. Mean follow-up was 7.3 years (range 4-11).At the last follow-up, good to excellent outcomes were reported in 86% of patients. Average post-operative Walch-Duplay was 87.9 (range 75-100) and ROWE 93.7 (range 70-100). Infraspinatus capsulotenodesis healing was achieved in 86%. The rate of recurrence and revision surgery was 9.3% and 13.9%, respectively. Recurrence was associated with higher ISIS score (p = 0.0191) and lower age at surgery (p = 0.0227). Four (9.3%) Hill-Sachs lesions were considered off-track. The presence of off-track Hill-Sachs was associated with higher risk of recurrence (p 0.00001).Arthroscopic BHSR improves shoulder instability in the setting of bipolar bone defects with less than 20% of GBL. Patient-related factors and pre-operative glenoid track should be taken into consideration to reduce the risk of recurrence.

Background Little information exists to guide the choice of exercise for regaining shoulder range of motion (ROM). The purpose of this study was to compare the maximal ROM reached, pain and difficulty associated with 4 commonly prescribed exercises. Methods Forty (9 females) patients with various shoulder disorders and a limited flexion ROM performed 4 exercises for regaining shoulder flexion ROM in a randomized order. Exercises included the self-assisted flexion, forward bow, table slide and rope-and-pulley. Participants were videotaped while performing all exercises and the maximal flexion angle reached during each exercise was recorded using Kinovea motion analysis freeware (Kinovea 0.8.15). Pain intensity and the perceived level of difficulty associated with each exercise were also recorded. Results The forward bow and table slide generated significantly greater ROM compared with the self-assisted flexion and rope-and-pulley (P ≤ 0.005). The self-assisted flexion was associated with a greater pain intensity compared with the table slide and rope-and-pulley (P = 0.002) and a greater perceived level of difficulty compared with the table slide (P = 0.006). Conclusions Due to the greater ROM allowed, and similar or even lower level of pain or difficulty, clinicians may wish to initially recommend the forward bow and table slide for regaining shoulder flexion ROM.

PURPOSE The aim of this study was to describe the results of an arthroscopic Trillat procedure utilized to treat patients with symptomatic antero-inferior shoulder instability associated with hyperlaxity. METHODS A retrospective review was performed on 19 consecutive shoulders (17 patients, 2 bilateral) who underwent a Trillat procedure combined with anterio-inferior capsulolabral plasty from 2016 to 2019. Patients included in the study presented with shoulder instability combined with shoulder hyperlaxity and no glenoid or humeral bone loss. Clinical assessment included range of motion, apprehension, and instability tests. Outcome measures Constant-Murley score (CMS) scale, Walch-Duplay, ROWE, Subjective Shoulder Value (SSV), Visual Analogue Scale (VAS). Post-operatively, healing of the coracoid osteoclasy was evaluated by CT scan. RESULTS The mean follow-up was 24.8 months (range, 12-51). Post-operatively, none of the patients experienced a recurrent dislocation or subluxation and the anterior apprehension test was negative in all shoulders. Post-operative motion deficits of 22.1° ± 15.8 [p

Aims Rotator cuff (RC) tears are common musculoskeletal injuries which often require surgical intervention. Noninvasive pulsed electromagnetic field (PEMF) devices have been approved for treatment of long-bone fracture nonunions and as an adjunct to lumbar and cervical spine fusion surgery. This study aimed to assess the effect of continuous PEMF on postoperative RC healing in a rat RC repair model. Methods A total of 30 Wistar rats underwent acute bilateral supraspinatus tear and repair. A miniaturized electromagnetic device (MED) was implanted at the right shoulder and generated focused PEMF therapy. The animals’ left shoulders served as controls. Biomechanical, histological, and bone properties were assessed at three and six weeks. Results Extension of the tendon from preload to the maximum load to failure was significantly better in the PEMF-treated shoulders at three weeks compared to controls (p = 0.038). The percentage strain was significantly higher in the PEMF group at both timepoints (p = 0.037). Collagen organization was significantly better (p = 0.034) as was tissue mineral density in the PEMF-treated group at three weeks (p = 0.028). Tendon immunohistochemistry revealed a prominent increase in type I collagen at the repair site at three weeks following continuous PEMF treatment compared with controls. None of the other tested parameters differed between the groups. Conclusion MED-generated PEMF may enhance early postoperative tendon-to-bone healing in an acute rat supraspinatus detachment and repair model. Superior biomechanical elasticity parameters together with better collagen organization suggest improved RC healing. Cite this article: Bone Joint Res 2021;10(5):298–306.

Therapeutic management of recurrent anterior shoulder instability with an anterior glenoid defect and a Hill-Sachs lesion requires a bone graft to restore the width of the glenoid. The Latarjet procedure is the most popular technique but an iliac crest bone graft is preferred when the coracoid process is dysplastic or too short or after failure of Latarjet or Bristow-Latarjet. The purpose of this manuscript is to describe a full arthroscopic Eden-Hybinette-guided technique with 2 cortical suture buttons for bone graft fixation. This procedure allows reconstruction of severe glenoid bone defects and treatment of concomitant capsulolabral lesions and humeral bone loss, while preserving the subscapularis muscle. In addition, the use of 2 cortical buttons for bone graft fixation simplify graft transport and positioning, provides good control of the rotation, improving healing of the iliac crest bone graft to the anterior glenoid rim.

The objective of this study was to describe the outcome of reverse shoulder arthroplasty (RSA) combined with modified L’Episcopo procedure at long-term follow-up (5 to 12 years). A retrospective review of 17 RSAs (mean age 67.2 years) with the modified L’Episcopo procedure conducted between 2006 and 2016 was performed. All patients had a combined loss of active elevation and external rotation with an irreparable posterosuperior rotator cuff tear. Clinical assessment was performed with a minimum follow-up of five years (mean 97.3 months). Outcome measures included range of motion, subjective shoulder value (SSV), visual analogue scale (VAS), and Constant-Murley scores. All patients (16) demonstrated a significant improvement in all clinical and functional parameters. VAS pain scores improved from 6 ± 2.6 to 1 ± 1; SSV improved from 35 ± 14 to 72 ± 10; active forward elevation increased from 66° ± 34 to 125° ± 29; and active external rotation arm at the body increased from −11° ± 22 to 21° ±11 and in 90° of abduction from −10° ± 17 to 37° ± 24. The mean Constant score improved from 25 ± 11 to 59 ± 8. Active internal rotation did not significantly change (p = 0.332). At long-term follow-up, RSA combined with modified L’Episcopo procedure resulted in significant improvements in pain, range of motion, and functional scores for patients with shoulder pseudoparalysis and a lack of active external rotation caused by a massive posterosuperior cuff tear with a teres minor deficiency.

Background The delivery of orthopaedic care via telemedicine services has the potential to promote accessibility and decrease medical care expenses, while facilitating the control of infectious disease spreading. The purpose of this study was to assess agreement regarding diagnosis, recommended course of management and the perceived need for additional diagnostic testing between a video examination (VE) and a face to face (FTF) assessment of patients with shoulder disorders. Methods Forty-seven (18 females) patients presenting to a shoulder surgery clinic were assessed consecutively by VE and a FTF examination. All assessments were conducted by a shoulder specialist. Agreement regarding the established diagnosis, the recommended course of management and the need for additional diagnostic tests was assessed using percent agreement and kappa (95% CI) coefficient. Differences in the content, duration and satisfaction between the two examination modes were also assessed. Results Percent agreement and kappa (95% CI) coefficient for agreement regarding diagnosis were 85.1% and 0.82 (0.69–0.94), respectively. Percent agreement and kappa (95% CI) coefficient regarding the recommended course of management and the need for additional diagnostic testing were 61.7% and 0.43 (0.22–0.63), and 74.5% and 0.49 (0.25–0.74), respectively. The VE resulted in collection of less physical examination information, took longer to complete and was associated with less satisfaction by both patient and examiner. Conclusions Video examination of patients with shoulder disorders may present a valid alternative to FTF examination. Nevertheless, the content of the video-based physical examination may need to be modified to facilitate a clearer detection of indications for specific interventions or diagnostic tests.

To prospectively compare the effectiveness of three methods for self-assisted shoulder reduction demonstrated using a smartphone video link. Anterior shoulder dislocation is very common among young adults. Patients often seek medical assistance in the emergency department to reduce their shoulder. Many techniques for shoulder reduction had been described, some of which do not require professional assistance and can be performed by patients themselves. Patients admitted with anterior shoulder dislocation were randomized to either the Stimson, Milch or the Boss–Holtzach–Matter technique. Each patient was given a link to watch a short instructional video on his smartphone and instructed to attempt self-reduction. Success of the reduction, pain level, patient satisfaction and complications were recorded. The study cohort consisted of 58 patients (mean age was 31.6 (18–66, median = 27), 82% males, 88% right hand dominant). Success rate using Boss–Holtzach–Matter (10 of 19, 53%) and self-assisted Milch (11 of 20, 55%) were significantly higher than with the self-assisted Stimson method (3 of 19, 16%), p

Introduction: Literature addressing postoperative pain management after hip arthroscopy is relatively scarce. This study aimed to assess if there was added analgesic benefit associated with postoperative intra-articular bupivacaine blockade for patients who received preoperative peri-acetabular blockade for hip arthroscopy procedures. Methods: 52 patients were included in this comparative cohort study. Group 1 consisted of 20 patients who received preoperative peri-acetabular blockade and postoperative intra-articular blockade. The control group (Group 2), consisted of 32 patients who received only preoperative peri-acetabular blockade. Postoperative pain was recorded via visual analogue scale (VAS) pain scores, analgesic consumption, and pain diaries for 2 weeks postoperatively. Results: Postoperative VAS pain scores were significantly lower in the experimental group at the 30-minute recovery room assessment (VAS scores Group 1: 1.1; Group 2: 3.00, p = 0.034). Other than the 30-minute recovery room assessment, VAS pain scores, narcotic medication consumption, and non-narcotic analgesic consumption did not differ between the 2 groups at any time point in the study period. Conclusions: This study did not demonstrate significant clinical benefit for patients who receive postoperative intra-articular blockade in addition to preoperative peri-acetabular blockade with bupivacaine 0.5%. We recommend the use of preoperative peri-acetabular bupivacaine blockade without intra-articular blockade postoperatively for pain control in the setting of hip arthroscopy surgery.

Glenoid inclination must be assessed precisely during preoperative planning for reverse shoulder arthroplasty (RSA) to position the glenoid baseplate correctly. We hypothesized that a more dynamic measurement method would better match the diversity of glenoid heights in the population and the variety of commercialized glenoid baseplates. Our purpose was to describe a new method to measure the RSA angle accounting for the baseplate size.Computed tomography scans of 50 shoulders that underwent RSA for primary osteoarthritis or cuff tear arthropathy between June 2019 and February 2020 were included (mean age, 76 years). Three variants of the RSA angle were measured: the RSA angle as originally described by Boileau et al, the relative RSA 25 angle (which simulates the implantation of a 25-mm baseplate), and the relative RSA 29 angle (which simulates the implantation of a 29-mm baseplate). Measurements in the 2-dimensional true reformatted scapular plane were made by 3 independent operators.The mean R-S distance (ie, distance between point R [intersection of supraspinatus fossa line with glenoid surface] and point S [inferior border of glenoid]) was 24.2 ± 4.0 mm. The mean RSA angle was 20.3° ± 8.4°, whereas the mean relative RSA 25 angle was 19.3° ± 7.8° and the mean relative RSA 29 angle was 15.6° ± 7.6°. The mean difference between the RSA angle and the relative RSA 25 angle was 1.0° ± 4.1° (P = .16). The mean difference between the RSA angle and the relative RSA 29 angle was 4.7° ± 3.8° (P .0001). In half of the shoulders in our series, the difference between the RSA angle and the RSA 29 angle exceeded 5°.The RSA angle is a reproducible measure of the inclination of the inferior part of the glenoid that is reliable in most cases for glenoid baseplates of 24-25 mm in height. However, surgeons should be aware that the RSA angle may overestimate the superior orientation of the inferior glenoid for baseplates of different sizes or for small- or large-stature patients. In these cases, the relative RSA angle adapted to the size of the baseplate more accurately evaluates the inclination of the inferior glenoid.

A commonly used method of fixation of the transferred coracoid in the traditional Latarjet–Bristow procedure (open or arthroscopic) is by two bicortical screws. Although mechanically effective, screw fixation is also a major source of hardware and neurologic complications. This study aimed to compare the biomechanical performances of traditional metal screws and endobuttons as fixators of the Latarjet–Bristow procedure. Nine fresh-frozen cadaveric human scapulae with the conjoined tendon attached to the coracoid process were used for the Latarjet–Bristow procedure. The specimens were randomly assigned one of two groups: fixation using two 4.5-mm cannulated partially threaded Latarjet–Bristow experience screws or fixation using a suture-button construct. Specimens were secured in a material testing machine and cyclically preconditioned from 2 to 10 N at 0.1 Hz for ten cycles. They were then pulled to failure at a normalized displacement rate of 400% of the measured gauge length per minute. The maximal load-to-failure, stiffness and stress were calculated using a custom script. The failure mechanism and site were recorded for each specimen. There were no significant differences in the maximal load-to-failure or other biomechanical properties of the two fixation techniques, but the failure mechanisms were unique to each one. Four specimens fixated with screws underwent graft failures (fracture) through the proximal or distal drill hole. Five specimens fixated with endobuttons underwent failure due to glenoid bone fractures. A single endobutton fixation appears to be biomechanically comparable to screw fixation in the Latarjet–Bristow procedure and provides a lower risk for graft fracture. Further studies with more numerous specimens are warranted to conclusively validate these findings.

The footprint medialization allows a tension free repair in severely retracted rotator cuff tears (RCT), thereby de-creasing the rate of retear. The purpose of the study was to evaluate the clinical and radiological results in a cohort of chronic RCT treated with medialized repair. Secondary purpose was to analyze the impact of medialization length on shoulder function and tendon healing.It was hypothesized that the medialization length would have an impact on clinical and radiological outcome.A consecutive series of thirty patients that underwent arthroscopic repair of a massive posterosuperior RCT at a single institution were retrospectively studied at mean follow-up 18.4months (SD 15.3; range 9-58). The medialization of the medial footprint was measured intraoperatively. Preoperative and postoperative examination included active range of motion, abduction strength, pain assessment, and functional scores. The postoperative rotator cuff integrity was evaluated according to the Sugaya's classification. Types IV-V were categorized as absence of healing.At final follow-up the clinical outcomes were significantly improved in all patients (p≤0.001) with the exception of external rotation that displayed no significant improvement (p=0.05). In group 1 (n=8) medialization length was≤10mm (mean 8, SD 1.9) and in group 2 (n=14)10mm (mean 12.6, SD 1.7). There were no significant differences regarding preoperative and postoperative clinical outcomes (p0.05) between two groups. Group 2 demonstrated moderate correlation between length of medialization and Sugaya stage of tendon healing (r=0.53, p=0.049). Absence of healing was noted in 4/22 patients, 1/8 in group 1 and 3/14 in group 2.Medialized repair is an effective technique for treating chronic, massive and retracted posterosuperior RCT. A medialization of the footprint less than or equal to 10mm is recommended, as it was associated with good clinical and radiological results. The rate of tendon healing decreases when medialization exceeds 10mm.III.

Reverse total shoulder arthroplasty (RSA) associated with modified L'Episcopo (isolated LD) or L'Episcopo (combined TM and LD) procedures had been confirmed to effectively overcome the expected external rotation deficit in patient with postero-superior massive cuff tear and teres minor deficiency. The objective of this study was to evaluate the radiological bony lesions of the lateral proximal humerus following RSA combined with tendon transfer, and to determine whether these bony lesions affect the clinical outcome.A retrospective review of 24 RSAs (mean age 68.71 years, range 52-83) associated with modified L'Episcopo procedure (9) and L'Episcopo procedure (15) was performed. X-rays were assessed for lateral cortex lesions and were categorized into either intact, irregular or complete lytic appearances. In addition, signs of stem loosening were assessed. Clinical outcome measures included range of motion, SSV, VAS, and Constant-Murley scores.With a mean follow-up of 44.71 months (12-97; SD 27.42), eight (33.3%) patients demonstrated intact lateral cortex, eight (33.3%) irregular and eight (33.3%) lytic lesions. 40% of cemented stems demonstrated a deformed cortex compared to 74% of cementless stems. Radiolucent lines were detected in one cemented stem (p=0.046). GT resorption (p=0.147), condensations lines (p=0.449) and spot weld (p=0.342), appeared exclusively in non-cemented stem. Postoperatively all patients (24) demonstrated significant improvements in all clinical and functional parameters. A comparison between patient with (Group 2, 16 patients) and without bony lesions (Group 1, 8 patients) revealed no significant differences in functional scores and range of motion: Constant (p=0,61), VAS (p=0,61), SSV (p=0,66) and external rotation (p=0,34).At short-term follow-up, RSA combined with L'Episcopo or modified l'Episcopo procedure resulted in high incidence (67%) of lateral proximal humerus lesions. Radiolucent lines were noted in cemented stems whereas, signs of stress shielding and GT resorption appeared in non-cemented stems. Yet, no case of humeral loosening was detected and these lesions did not seem to affect the clinical outcome. The use of cemented straight standard-length humeral stems should be positively considered in RSA associated with LD\TM tendon transfer.IV; retrospective study.

This study was designed to investigate the efficacy of the InSpace balloon spacer with a specific focus on clinical and patient-related parameters, functional scores InSpace durability, and satisfaction in patients with massive irreparable rotator cuff tears (IRCT) at minimum one year follow-up.Between 2010 and 2018, patients with symptomatic IRCTs were treated with InSpace balloon implantation. Demographic characteristics, concomitant procedures, and patient's reported outcomes (PROMs) were obtained as well as satisfaction rate and willingness to undergo the procedure again. Need for subsequent surgery and conversion to reverse total shoulder arthroplasty (RTSA) and time to conversion were also evaluated.Seventy-eight patients (mean age of 70 years, range 46-86) who underwent an InSpace (OrthoSpace, Inc., Caesarea, Israel) balloon implantation were included. Mean follow-up was 56 months (median = 49.6, range 16-129 months). Sixteen out of our 29 pseudoparalytic patients (55.2%) exceed 90° of forward flexion post-surgery with mean improvement of 73° (20-150). Patients older than 65 years of age displayed a statistically significant improved ASES score (60.6 to 46.4, P 0.05). Patients who underwent a subscapularis (SSC) repair demonstrated a superior ASES score (63.4 compared to 50.4, P = 0.06).Based on the current study, spacer implantation is a low-risk, clinically effective treatment for the patients with IRCTs. Patient-specific parameters such as age, BMI, and gender should be considered during patient selection process. SSC tendon tears should be repaired if needed. Improvement in function and symptoms from this procedure may negate or delay the need for RTSA even for some of the pseudoparalytic patients.

The therapeutic management of the paralytic shoulder after an obstetric brachial plexus injury is complex. When nerve repair or neurotization fail, or if the biological times for nerve reconstruction is over, tendon transfer to restore active external rotation of the shoulder becomes the main surgical alternative. The purpose of this manuscript is to describe the surgical technique of the lower trapezius muscle transfer to the infraspinatus muscle, to restore active shoulder external rotation in the child with paralytic shoulder, step by step with details and pearls.

Introduction Proximal humerus nails (PHN) are commonly used for the treatment of simple proximal humerus fractures, and have a reported malunion rate of about 10%. The surgeons who used PHN in one medical institution have noticed a high rate of fracture re-displacement in the early post-operative period. This study's aim is to evaluate the rate of secondary displacement and malunion of patients treated for two part proximal humerus fractures with an angle-stable PHN (MultiLoc), and to assess possible risk factors for this secondary displacement. Methods A retrospective study comprised of 25 consecutive patients with 2 part surgical neck or metaphysis displaced proximal humerus fracture, treated with PHN between the years 2014–2017. Results assessed included radiographic measures (neck-shaft angle) and clinical data: range of motion (ROM) and functional scores (Constant, DASH, SSV). A univariate regression analysis was used to assess possible risk factors for secondary displacement. Results Mean age was 66.6 (range 17–93), and mean follow up was 20 months (range 6–40). Mean neck shaft angle (NSA) changed from 139.1° post operatively to 122.6° at last follow up, with 6 patients (24%) having a NSA change larger than 20°. Two patients (8%) ended up with NSA less than 90°, defined as malunion. The deltoid tuberosity index was found to correlate with the degree of displacement (−0.41, p = 0.04). Conclusions PHN for simple displaced proximal humerus fractures was associated with fair clinical results but an unacceptable rate secondary displacement. The deltoid tuberosity index was found to correlate with the degree of this secondary displacement.

Background: Humeral avulsion of the glenohumeral ligament (HAGL) is an uncommon condition but a major contributor to shoulder instability and functional decline. Purpose: To describe the pre- and postoperative HAGL lesion presentations of instability, pain, and functionality and the return-to-sports activities in patients managed arthroscopically for anterior and posterior HAGL lesions. Study Design: Case series; Level of evidence, 4. Methods: Data on patients with HAGL lesions treated with arthroscopic repair between 2009 and 2018 were retrospectively retrieved from medical charts, and the patients were interviewed to assess their level of postoperative functionality. The Rowe; Constant; University of California, Los Angeles; Oxford; and pain visual analog scale (VAS) scores were obtained for both pre- and postoperative status. Return-to-sports activities and level of activities after surgery were compared with the preinjury state, and complications, reoperations, and recurrent instability were recorded and evaluated. Results: There were 23 study patients (12 females and 11 males; mean age, 24 years). The mean follow-up duration was 24.4 months (range, 7-99 months; median, 17 months). In 7 (30.4%) of the patients, HAGL lesions were diagnosed only intraoperatively. A significant improvement was seen in all examined postoperative functional scores and VAS. At the last follow-up visit, 2 patients (8.7%) reported residual instability with no improvement in pain levels and declined any further treatment, and 3 others (13.0%) required revision surgeries for additional shoulder pathologies (reoperations were performed 18-36 months after the index procedure). The remaining 18 patients (78.3%) were free of pain and symptoms. There was a mean of 0.65 coexisting pathologies per patient, mostly superior labral anterior-posterior, Bankart, and rotator cuff lesions. Conclusion: HAGL lesions are often missed during routine workup in patients with symptoms of instability, and a high level of suspicion is essential during history acquisition, clinical examination, magnetic resonance imaging arthrogram interpretation, and arthroscopic evaluation. Arthroscopic repair yields good pain and stability results; however, some high-level athletes may not return to their preinjury level of activity.

Background The use of video examinations (VE) may improve patient care by offering them a low-cost and easy access to physicians, save traveling expenses and shorten waiting time. The aim of this study was to validate the use of Smartphones for distant assessment of shoulder function by comparing the Constant scores (CS) of patients obtained by both VE and conventional face-to-face (FTF) examination. Methods Fifty-one subjects (age 19–80 years; women:men 18:33) who presented to a shoulder clinic with a variety of complaints were prospectively recruited and underwent FTF and VE in alternating order. CS obtained by the two methods were compared. Four patients were unable to complete the VE due to technical problems or non-compliance. Results Forty-seven (92%) subjects successfully completed both examinations. The mean difference in CS was −0.53 points (95%CI: −2.6:1.6), with limits of agreement of −7.7:6 points. Agreement of correlation coefficient, accuracy and precision were 0.91 (95%CI: 0.86:0.96), 0.99 (95%CI: 0.92:1.00) and 0.91 (95%CI: 0.86:0.96), respectively. Conclusion VE can obtain a reliable estimate of shoulder function. The mean video CS was only −0.53 points from the mean frontal CS. Individual variations of CS did not exceed a 7-point distance from the “gold standard” estimate.

Drilling through bone is a complex action that requires precise motor skills of an orthopedic surgeon. In order to minimize plunging and soft tissue damage, the surgeon must halt drill progression precisely following penetration of the far cortex. The purpose of this study was to create a low-cost and easy-to-use drilling simulator to train orthopedic residents in reducing the drill plunging depth.This prospective observational study was performed in the division of orthopedic surgery of a single tertiary medical center. The participants included 13 residents and 7 orthopedic specialists. The simulator consisted of a synthetic femur bone model and ordinary modeling clay, and the training unit consisted of a disposable plastic tube (∼US$14), clamps (∼US$58), and a power drill + drill bit (standard hospital equipment). Plunging depths were measured by the simulator and compared between orthopedic specialists, the 6 "senior residents" (3+ years) and the 7 "junior residents" during a training session. Measurements were taken again 2 weeks following the training session.Initially, the plunging depths of the junior residents were significantly greater compared to those of the orthopedic specialists (7.00 mm vs. 5.28 mm, respectively, p0.038). There was no similarly significant difference between the senior residents and the orthopedic experts ([6.33 mm vs. 5.28 mm, respectively; p = 0.18). The senior residents achieved plunging depths of 5.17 mm at the end of the training session and 4.7 mm 2 weeks later compared to 7.14 mm at the end of the training session and 6 mm 2 weeks later for the junior residents.This study demonstrated the capability of a low-cost drilling simulator as a training model for reducing the plunging depth during the drilling of bone and soft tissue among junior and senior residents.

Background: This study compared the radiological outcomes of adult closed distal radius fractures (DRFs) reduction with and without fluoroscopy. We hypothesized that fluoroscopy-assisted reduction would not improve radiographic alignment or decrease the need for surgery. Methods: Hospital medical records and radiographic images of all patients who presented with DRFs between April to June 2009 and April to June 2013 were reviewed. All patients underwent closed reduction and immobilization with or without fluoroscopic assistance. Reduction attempts were noted and pre- and postreduction posteroanterior and lateral radiographs were reviewed for fracture stability. Results: Eighty-four patients underwent reduction without fluoroscopy (group 1), and 90 patients underwent reduction with the aid of fluoroscopy (group 2). According to accepted radiographic guidelines, nonsurgical treatment was indicated for 62% of patients in group 1 and 56% of patients in group 2 ( P = .44). In addition, no significant difference between the groups was observed in any postreduction radiographic parameters ( P > .53) or postreduction alignment of unstable fractures ( P = .47). Conclusions: Reduction without the use of fluoroscopy demonstrated noninferiority when compared with fluoroscopy-assisted reduction in the emergency department for closed adult DRFs.

To evaluate and compare the efficacy of intra-articular and periacetabular blocks for postoperative pain control after hip arthroscopy.Forty-two consecutive patients scheduled for hip arthroscopy were randomized into 2 postoperative pain control groups. One group received preemptive intra-articular 20 mL of bupivacaine 0.5% injection, and the second group received preemptive periacetabular 20 mL of bupivacaine 0.5% injection. Before closure all patients received an additional dose of 20 mL of bupivacaine 0.5% intra-articularly. Data were compared with respect to postoperative pain with visual analog scale (VAS) and analgesic consumption, documented in a pain diary for 2 weeks after surgery.Twenty-one patients were treated with intra-articular injection, and 21 patients with peri-acetabular injection. There were no significant differences with regards to patient demographics or surgical procedures. VAS scores recorded during the first 30 minutes postoperatively and 18 hours after surgery were significantly lower in the periacetabular group compared with in the intra-articular group (0.667 ± 1.49 vs 2.11 ± 2.29; P .045 and 2.62 ± 2.2 vs 4.79 ± 2.6; P.009). There were no differences between the groups with regard to analgesic consumption.Periacetabular injection of bupivacaine 0.5% was superior to intra-articular injection in pain reduction after hip arthroscopy at 30 minutes and 18 hours postoperatively. However, total analgesic consumption over the first 2 postoperative weeks and VAS pain measurements were not significantly affected.Level I, randomized controlled trial.