Current Concept Review

Acta of Shoulder and Elbow Surgery | Volume 1 | Issue 1 | Oct-Dec 2016 | Page 62-80 | Jose Carlos Garcia Jr., Mário Henrique Lobão Gonçalves, Luiz Fernando do Souto Fink, Sérgio Rowinski, Álvaro Motta Cardoso Jr., Maurício de Paiva Raffaelli, Eduardo Ferreira Cordeiro, Márcio Eduardo Kozonara, Marcelo Boulos Dumans Mello, Hilton Lutfi, Rodrigo Vick F. Gomes, Maurício Salomão Fadel, Alfredo Mendes Steffen, Alciomar Veras Viana, Rafael Gadioli, Felipe do Amaral, Samir Husseim Salem, Cássio Nunes.

Authors: Jose Carlos Garcia Jr., Mário Henrique Lobão Gonçalves, Luiz Fernando do Souto Fink, Sérgio Rowinski, Álvaro Motta Cardoso Jr., Maurício de Paiva Raffaelli, Eduardo Ferreira Cordeiro, Márcio Eduardo Kozonara, Marcelo Boulos Dumans Mello, Hilton Lutfi, Rodrigo Vick F. Gomes, Maurício Salomão Fadel, Alfredo Mendes Steffen, Alciomar Veras Viana, Rafael Gadioli, Felipe do Amaral, Samir Husseim Salem, Cássio Nunes [1].

[1] NAEON-Santa Catarina Hospital.

Address of Correspondence
Dr. Jose Carlos Garcia Jr., MD, MSc, PhD
NÆON-Hospital Santa Catarina-SP-Brazil

Current Concepts

It is a section devoted to give the readers a general panorama over all the news of other scientific sources out of Acta of Shoulder and Elbow Surgery.

In this edition you will find a brief summary, smaller than the abstract, of papers from the last editions of Arthroscopy Journal and Journal of Shoulder and Elbow Surgery.

Our aim is that our reader can be in touch with all news from our and other sources.

In a near future our team will work hard in order to add summaries from more periodicals.


This section was created by a collaboration of many shoulder and elbow surgeons as listed above in the authors list

Arthroscopy Journal Reviews

Suture Anchor Biomechanics After Rotator Cuff Footprint Decortication

Hyatt AE, Lavery K, Mino C and Dhawan A Arthroscopy. 2016 Apr;32(4):544-550.

The objective was to identify the biomechanical consequences of violating the cortical shelf when preparing the greater tuberosity for suture anchor repair. Anchors were tested under cyclic loads followed by load-to-failure testing. Regression analysis showed positive correlations with female gender and decreased bone mineral density . Thereby, the decortication of the rotator cuff footprint significantly decreases the pullout strength of the suture anchor. Gender and bone mineral density also play a significant role in bone-anchor biomechanics and should be considered during repair. Therefore, caution should be exercised when preparing the rotator cuff footprint before suture anchor placement because of the significant risk of early repair failure at the bone-anchor interface.


Effect of Teres Minor Fatty Infiltration on Rotator Cuff Repair Outcomes

Kim JK, Yoo HJ, Jeong JH and Kim SH

Arthroscopy. 2016 Apr;32(4):552-558

The objective was to observe changes in fatty infiltration (FI) of the teres minor without tear of the teres minor in a postoperative magnetic resonance imaging and to evaluate the influence of FI of the teres minor in the clinical outcomes of rotator cuff repair. Methods: Of 816 patients who underwent rotator cuff repair, 51 (6.3%) had FI of the teres minor without tear involvement and 30 cases were available for postoperative magnetic resonance imaging. Thus, it was verified the degree of FI was not related to the amount of tendon involvement of a rotator cuff tear. All postoperative functional outcome scores significantly improved , and there were no significant differences compared with that of the control group. In most of the cases, FI of the teres minor was unchanged. With this, the conclusion was reached that FI of the teres minor without tear involvement can be observed in a rotator cuff tear as a possibly incidental finding of unknown clinical significance. Nevertheless, the functional outcomes of the repair were successful; therefore, rotator cuff repair can be performed without a great deal of concern in the presence of FI in the teres minor.


Which Is Better for Arthroscopic Tenodesis of the Long Head of the Biceps: Soft Tissue, or Bony Interference Fixation?

Hwang JT, Yang CJ, Noh KC, Yoo YS, Hyun YS, Lee YB and Liu X

Arthroscopy. 2016 Apr;32(4):560-567

To compare the outcome between arthroscopic soft tissue tenodesis (STT) at the rotator interval and bony interference fixation tenodesis (BIFT) at the distal bicipital groove for the long head of the biceps (LHB), were used American Shoulder and Elbow Surgeons scores, Constant score, and elbow flexion strength index (EFSI). Were checked preoperatively, postoperative 1 year and 2 years. Ultrasound imaging evaluation took place at 1 year and 2 years postoperatively as well. Thereby overall functional outcomes improved after surgery in both groups.  However, the Arthroscopic BIFT for the LHB showed better improvement in EFSI than arthroscopic STT. In addition, the STT group showed a higher failure rate than the BIFT group.


The Effects of Arthroscopic Lateral Acromioplasty on the Critical Shoulder Angle and the Anterolateral Deltoid Origin: An Anatomic Cadaveric Study

Os efeitos da acromioplastia lateral artroscópica no ângulo crítico do ombro e a origem anterolateral do deltoide: um estudo anatômico em cadáveres.

Katthagen JC, Marchetti DC, Tahal DS, Turnbull TL and Millett PJ

Arthroscopy. 2016 Apr;32(4):569-575.

The objective was To investigate if an anterolateral acromioplasty and a lateral acromion resection alter the critical shoulder angle (CSA) without affecting the deltoid origin. First, the native CSAs of 10 human cadaveric shoulders  were determined with the use of fluoroscopy. It was detected that: The mean native CSA was reduced significantly by acromioplasty and further reduced by lateral acromion resection. Anterolateral acromioplasty reduced the CSA by a mean of 1.4° , and in combination with lateral acromion resection, the CSA was reduced by a mean of 2.8° . In all specimens (5 of 5) with a presurgery CSA of 35°or greater, the CSA was reduced to the range of 30° to 35° by the combination of both techniques.  The acromial deltoid attachment was found to be well preserved in all specimens. With this, it is concluded that: Arthroscopic anterolateral acromioplasty and a 5-mm lateral acromion resection each reduced the CSA significantly and did not damage the deltoid origin. Clinical Relevance: The combination of both techniques could potentially be used in clinical practice to reduce a CSA greater than 35° to the desired range of 30° to 35°.


Arthroscopic Treatment of Lateral Epicondylitis: Tenotomy Versus Debridement

Solheim E, Hegna J, Øyen J and Inderhaug E

Arthroscopy. 2016 Apr;32(4):578-585.

The objective was to compare the outcome of 2 arthroscopic techniques for treating  lateral epicondylitis. Conducted during 2 different time periods: April 2005 to October 2007 (tenotomy) and May 2009 to June 2010 (debridement).   Thereby a total of 326 patients fulfilling the requirements for inclusion in the study, 283 patients  were followed up, 204  in the tenotomy group and 79  in the debridement group. Therefore both arthroscopic methods lead to a significant improvement of pain and function, and no statistically significant difference was found in any outcome parameters between the 2 techniques at this minimum 4-year evaluation. The results indicate that tenotomy of the extensor carpi radialis brevis may be an unnecessary step in the arthroscopic treatment of lateral epicondylitis. Debridement only is a potentially less costly procedure, and the current finding of a mean 2 weeks shorter sick leave in the debridement only group proposes a substantial cost saving in a societal perspective.


Current Practice for the Surgical Treatment of SLAP Lesions: A Systematic Review

Kibler WB and Sciascia A

Arthroscopy. 2016 Apr;32(4):669-683.

The aim of this study was to analyze current literature reporting surgical treatment of SLAP lesions to examine the consistency of reported surgical details (surgical indications, surgical technique, and postoperative rehabilitation) that are deemed important for best treatment outcomes and to try to establish a consensus regarding treatment. Then a systematic review of papers reporting surgical treatment of a SLAP lesion was performed. Each paper was analyzed for the description of (1) the arthroscopic indications for surgery; (2) surgical aspects including type, location, and number of anchors and sutures; (3) description of criteria for determination of completeness of the repair; and (4) postoperative rehabilitation details.Therefore twenty-six papers were included, with 12 focused on isolated SLAP repair and 14 focused on combined SLAP repair with other lesions. Thereby, current practice of treating SLAP lesions is controversial, some of which results from imprecision in the treatment. This study demonstrated a wide variability in the reported arthroscopic indications for repair and the specific technical details to accomplish the repair.


Factors Affecting Clinical Outcome in Patients With Structural Failure After Arthroscopic Rotator Cuff Repair

Nakamura H, Gotoh M, Mitsui Y, Honda H, Ohzono H, Shimokobe H et al. Arthroscopy. 2016 May;32(5):732-739.

Retrospective study to compare clinical outcomes between patients with lesions of the large or massive rotator cuff that had healing or structural failures of post-operative repair (re-rupture after complete or partial repair) and (2) to identify factors associated with the results clinical in patients with post-operative structural failure.

Based on intraoperative findings and MRI at the end of follow-up, patients were divided into three groups: cured group, re-rupture group (after complete repair) and group partial repair.

The extent of tendon rehabilitation at the top facet, middle and lower and lower tuberosity were examined in magnetic resonance imaging at the end of follow-up.

In re-break groups and partial repair, preservation of the tendon in the mean facet significantly affected the JOA score and UCLA.

The only clinical factor that affected patient outcomes was the healing of the tendon in the media facet. Thus the preservation of the tendon on the facet average was a predictor of good clinical outcomes in patients undergoing arthroscopic repair of the large or massive rotator cuff tears who had postoperative structural failure.

Clinical Results After Conservative Management for Grade III Acromioclavicular Joint Injuries: Does Eventual Surgery Affect Overall Outcomes? Petri M, Warth RJ, Greenspoon JA, Horan MP, Abrams RF, Kokmeyer D et al

Arthroscopy. 2016 May;32(5):740-746.

This study compares the clinical outcomes in patients with lesions of the acromioclavicular joint (AC) grade III in which conservative treatment was successful and those who have failed conservative treatment and progressed to surgical treatment.

The most important finding of this study was that patients who have failed conservative treatment and underwent further joint reconstruction AC had similar results when compared to those who successfully completed the conservative treatment after a median follow-up period of 3.3 years . However at the end time of follow-up, patients who underwent joint reconstruction possible AC were more likely to return to its level of sports participation pre-injury intensity.

Patients who presented clinical over 30 days after the initial injury were more likely to have failed conservative treatment and showed significant reduction in mean scores postoperative SANE and SF-12 PCS when compared with the rest of the group.


Clinical, Radiographic, and Surgical Presentation of Subscapularis Tendon Tears: A Retrospective Analysis of 139 Patients

Naimark M, Zhang AL, Leon I, Trivellas A, Feeley BT and Ma CB.

Arthroscopy. 2016 May;32(5):747-752.

Retrospective study of 139 patients to evaluate and correlate clinical, radiographic and arthroscopic findings of subscapularis (SE) tears, either isolated or combined with other rotator cuff tendon lesion. The size of lesions were arthroscopically classified as upper third, two-thirds or full tears.

All patients had a positive physical exam and MRI assessing associated injuries. Data were plotted according to the size of SE lesion.

Diagnosis of SE tears remains a challenge because of limited sensitivity of MRI and physical exam. MRI sensitivity is directly proportional to size of SE tear, while physical exam does not depend on it.

Additional factors that correlate to increased SE tear size identified in this study are history of trauma, supraspinatus and biceps tears.


Triple-Loaded Single-Row Versus Suture-Bridge Double-Row Rotator Cuff Tendon Repair With Platelet-Rich Plasma Fibrin Membrane: A Randomized Controlled Trial

Barber FA

Arthroscopy. 2016 May;32(5):753-761

Prospective randomized trial comparing healing and clinical outcomes of triple-loaded single-rows versus suture-bridging double-row repairs of full-thickness rotator cuff tears, both constructs received platelet-rich plasma fibrin membrane aumentation.

Evaluation was done by magnetic resonance imaging (MRI) at 12 months postoperatively and by secondary clinical outcomes.

3 out of 20 triple-loaded single-row repairs and 3 out of 20 suture-bridge double-row repairs (15%) had tear relapse at 12 month follow-up MRIs. On the first group all tears failed at the original attachment site (Cho type 1), while tears on the second group failed medially to medial row at muscle-tendon inferface (Cho type 2).

Clinical outcomes found no statistical difference between both groups postoperatively


The Impact of Fatigue on Baseball Pitching Mechanics in Adolescent Male Pitchers

Erickson BJ, Sgori T, Chalmers PN, Vignona P, Lesniak M, Bush-Joseph CA et al

Arthroscopy. 2016 May;32(5):762-71.

Study to determine shoulder and elbow kinematics, pitching velocity and accuracy and pain changes during a simulated baseball game in adolescent pitchers.

As pitchers progressed through a simulated game, their pitching throw velocity diminished, they got fatigued and pain increased. Core and leg muscles got fatigued earlier than upper-limb kinematics changed.

Basis of these results, core and leg strengthening may be valuable adjuncts to prevent upper-limb injury in adolecent pitchers.


Does the Use of Platelet-Rich Plasma at the Time of Surgery Improve Clinical Outcomes in Arthroscopic Rotator Cuff Repair When Compared With Control Cohorts? A Systematic Review of Meta-analyses

Saltzman BM, Jain A, Campbell KA, Mascarenhas R, Romeo AA, Verma NN et al.

Arthroscopy. 2016 May;32(5):906-918.

Systematic review of meta-analyzes evaluating use of platelet-rich plasma (PRP) at the time of arthroscopic rotator cuff repair and determine its effect on re-rupture rates and clinical outcomes. Seven meta-analyzes and a total of 3,193 patients with 12 to 31 months of mean follow-up. Overall, when compared to controls, the use of PRP at the moment of the rotator cuff repair had no significant results in lowering rates of re-rupture neither improving clinical scores.

However a subgroup of 3 meta-analyzes showed best results in the following scenarios: solid matrix PRP against liquid matrix; small or medium rotator cuff tears against large or massive ones; injection of PRP in tendon-to-bone interface against injection on tendon; and, double-row attachment against single-row.

Level of Evidence: Level III, systematic review level II and III studies.


Treating Subscapularis and Lesser Tuberosity Avulsion Injuries in Skeletally Immature Patients: A Systematic Review. Vavken P, Bae DS, Waters PM Flutie B and Kramer DE.

Arthroscopy. 2016 May;32(5):919-928.

Study to develop evidence-based recommendations for the diagnosis and treatment of subscapularis injury and injuries spare the small tuberosity in young patients

We identified 32 publications on 60 patients with a mean age of 13.5 / 1.7 years. The most common physical examination found at diagnosis was anterior shoulder pain, followed by weakness of the subscapularis muscle. The sensitivity of the X-ray image was 16% and 95% for MRI. The average time of diagnosis was two months.

60 patients, 10 (17%) underwent successful conservative treatment. Fifty patients (83%) underwent surgical correction, with no differences in clinical outcomes after open versus arthroscopic repair. Five cases (8%) when identified and treated late, were associated with sub- optimal results and shoulder pain continues.

Subscapularis avulsion injuries and less tuberosity in young patients are more commonly seen in males during early adolescence. It should be suspected in patients with anterior shoulder pain and weakness of the subscapularis muscle, especially after a fall on the outstretched arm or on eccentric external rotation. MRI should be considered early even if the radiographic findings are negative. open and arthroscopic repair are effective in restoring function, the setting respects the immature bone less tuberosity.


Surgical Versus Nonoperative Treatment in Patients Up to 18 Years Old With Traumatic Shoulder Instability: A Systematic Review and Quantitative Synthesis of the Literature

Longo UG, van der Linde JA, Loppini M, Coco V, Poolman RW and Denaro V.

Arthroscopy. 2016 May;32(5):944-952.

Study to compare the results of surgical treatment and conservative in patients 18 years or less with traumatic instability of the shoulder.

Fifteen articles, a total of 693 patients with 705 shoulders with 18 years or less. 411 shoulder, 293 (71.3%) treated with a conservative approach had redislocation compared with shoulders 55 of 314 (17.5%) who had been surgically treated. The results of the quantitative synthesis of recurrence rate was significantly lower in the surgical group compared to the conservative group.

The recurrence rate is lower in patients undergoing surgery. More studies are needed to clarify several points in the treatment of young patients with traumatic instability of the shoulder.


Comparison of Treatments for Superior Labrum-Biceps Complex Lesions with Concomitant Rotator Cuff Repair: A Prospective, Randomized, Comparative Analysis of Debridement, Biceps Tenotomy, and Biceps Tenodesis.

Oh JH, Lee YH, Kim SH, Park JS, Seo HJ, Kim W et al.. Arthroscopy. 2016 Jun;32(6):958-967.

Compared clinical outcomes in patients with concomitant superior labrum-biceps complex (SLBC) lesions and rotator cuff tears who underwent arthroscopic rotator cuff repair, according to 3 different treatment methods (simple debridement, biceps tenotomy, or biceps tenodesis) for the SLBC lesions

One hundred twenty patients who underwent arthroscopic rotator cuff repair with SLBC lesions (biceps partial tears <50%, partial pulley lesions, and type II SLAP lesions) were enrolled in this prospective comparative study and randomly assigned to 1 of 3 treatment groups. Patients with isolated subscapularis tears or osteoarthritis were excluded. Finally, 86 patients (Deb in 28, BTo in 27, and BTd in 31) were analyzed (mean follow-up, 22.1 ± 7.72 months; mean age, 58.98 ± 7.8 years). Pain; functional, clinical, and radiologic outcomes; and the strength index of elbow flexion and forearm supination were analyzed.

All 3 treatments improved pain and function. Simple debridement showed the lowest risk of the Popeye deformity and preserved forearm supination strength. Biceps tenotomy and tenodesis may be preferable for selected patients: biceps tenotomy for patients with definite bicipital groove tenderness and biceps tenodesis for patients, especially male patients, with bicipital groove tenderness who want to preserve supination strength.


Morphology of the Lesser Tuberosity and Intertubercular Groove in Patients with Arthroscopically Confirmed Subscapularis and Biceps Tendon Pathology.

Shah SH, Small KM, Sinz NJ and Higgins LD. Arthroscopy. 2016 Jun;32(6):968-975.

Evaluated association between the morphology of the lesser tuberosity and intertubercular groove and subscapularis tendon tears and biceps tendon pathology.

Sixty-six patients with arthroscopically confirmed subscapularis tendon tears were compared with 59 demographically matched control patients who underwent magnetic resonance imaging or computed tomography arthrography examination of the shoulder. Measurements of the lesser tuberosity and intertubercular groove included maximum depth of the intertubercular groove, intertubercular groove depth at the midpoint of the glenoid, lesser tuberosity length, length from the top of the humeral head to the point of maximum depth of the intertubercular groove, length from the top of the humeral head to the top of the lesser tuberosity, and medial wall angle and depth.

Patients with subscapularis tears showed a significantly decreased depth of the intertubercular groove at the mid glenoid (P = .01), shorter length of the lesser tuberosity (P = .002), and greater distance from the top of the humeral head to the top of the lesser tuberosity (P = .02). There was a trend toward a decreased medial wall angle (P = .07) and greater distance from the top of the humeral head to the point of maximum intertubercular groove depth (P = .06). Patients with biceps tendon pathology showed a significantly decreased depth of the intertubercular groove at the mid glenoid (P = .001), shorter length of the lesser tuberosity (P = .0003), greater distance from the top of the humeral head to the top of the lesser tuberosity (P = .01), and decreased medial wall angle (P = .01) and depth (P = .03).

There are several morphologic factors related to the lesser tuberosity and intertubercular groove that are associated with both subscapularis tendon tears and biceps tendon pathology.


SLAP Lesions: Trends in Treatment.

Erickson BJ, Jain A, Abrams GD, Nicholson GP, Cole BJ, Romeo AA et al. Arthroscopy. 2016 Jun;32(6):976-981.

To determine the trends in SLAP repairs over time, including patient age, and percentage of SLAP repairs versus other common shoulder arthroscopic procedures,

The records of 4 sports or shoulder/elbow fellowship trained orthopaedic surgeons were used to identify the total number of common shoulder arthroscopic cases performed between 2004 and 2014 using current procedural terminology codes (CPT): 29822, 29823, 29826, 29827, 29806, 29807, 29825, and 29828. The number of SLAP repairs (CPT code 29807) as a combined or isolated procedure were recorded, and the classification of SLAP type was undertaken using operative reports. Patient age was recorded. Linear regression was used to determine statistical significance.

There were 9,765 patients who underwent arthroscopic shoulder procedures using the defined CPT codes between 2004 and 2014 by our 4 orthopaedic surgeons. Of these, 619 underwent a SLAP repair (6.3%); average age 31.2 ± 11.9. The age of patients undergoing SLAP repair significantly decreased over time. Most SLAP repairs were performed on type II SLAP tears. The percentage of SLAP repairs compared with the total number of shoulder arthroscopic surgeries and total number of patients who underwent SLAP repair significantly decreased over time. Conversely, the number and percentage of biceps tenodeses are increasing over time

Over the past 10 years, the total number of biceps tenodeses has increased, whereas the number and relative percentage of SLAP repairs within our practice have decreased. The average age of patients undergoing SLAP repair is decreasing, and most SLAP repairs are performed for type II SLAP tears.


Effect of Coracoid Drilling for Acromioclavicular Joint Reconstruction Techniques on Coracoid Fracture Risk: A Biomechanical Study.

Martetschläger F, Saier T, Weigert A, Herbst E, Winkler M, Henschel J, et al.

Arthroscopy. 2016 Jun;32(6):982-987.

To biomechanically compare the stability of the coracoid process after an anatomic double-tunnel technique using two 4-mm drill holes or a single-tunnel technique using one 4-mm or one 2.4-mm drill hole

For biomechanical testing, 18 fresh-frozen cadaveric scapulae were used and randomly assigned to one of the following groups: two 4-mm drill holes (group 1), one 4-mm drill hole (group 2), or one 2.4-mm drill hole (group 3). After standardized coracoid drilling, load was applied to the conjoined tendons at a rate of 120 mm/min and ultimate failure load, along with the failure mode, was recorded.

There was no significant difference between groups regarding load to failure. Mean load to failure in group 1 was 392 N; group 2, 459 N; and group 3, 506 N. However, the failure mode for the group with one 4-mm drill hole and the group with two 4-mm drill holes was coracoid fracture, whereas the group with one 2.4-mm drill hole showed 5 tears of the conjoined tendons and only 1 coracoid fracture

Although there was no significant difference regarding load-to-failure testing between groups, the failure mechanism analysis showed that one 2.4-mm drill hole led to less destabilization of the coracoid than one or two 4-mm drill holes.


Qualitative Assessment and Quantitative Analysis of the Long Head of the Biceps Tendon in Relation to the Pectoralis Major Tendon Humeral Insertion: An Anatomic Study.

Nossov SB, Ross JR, Robbins CB and Carpenter JE.

Arthroscopy. 2016 Jun;32(6):990-998.

To qualitatively assess and to quantitatively analyze the long head of the biceps tendon (LHBT) in the region of the pectoralis major (PM).

From 11 fresh cadaveric donors, 20 cadaveric shoulders without operative scars were dissected-mean age, 76.9 years. The LHBT circumference was measured at the anterior edge of supraspinatus, suprapectorally, midpectorally, and subpectorally. The muscle was then removed from the LHBT and the circumference was again measured at the supra-, mid-, and subpectoral levels. These data were used to calculate the area of the tendon. All measurements were performed by 2 independent observers. Statistical analysis was performed to assess reliability of data and the difference between serial measurements.

The mean calculated percentage tendon decreased from 86.7% at the superior edge of the PM to 49.8% at the midpoint of the PM and to 17.5% at the inferior edge of the PM.Distal to the PM, the LHBT was composed of a small percentage of tendon to muscle, which may have implications for the mechanical strength of fixation of tenodesis. The anatomic location of the musculotendinous junction of the LHBT began proximal to the superior edge of the PM tendon, which implies that restoration of anatomic tensioning may require a more proximal docking site than previously described. Tenodesis performed between the midpoint of the PM insertion and more distal points involves a significant portion of muscle, which may not be optimal.


Major Peripheral Nerve Injuries After Elbow Arthroscopy.

Desai MJ, Mithani SK, Lodha SJ, Richard MJ, Leversedge FJ and Ruch DS.

Arthroscopy. 2016 Jun;32(6):999-1002.

To survey the American Society for Surgery of the Hand membership to determine the nature and distribution of nerve injuries treated after elbow arthroscopy. An online survey was sent to all members of the American Society for Surgery of the Hand under an institutional review board approved protocol. Collected data included the number of nerve injuries observed over a 5-year period, the nature of treatment required for the injuries, and the outcomes observed after any intervention. Responses were anonymous, and results were securely compiled. We obtained 372 responses. A total of 222 nerve injuries were reported. The most injured nerves reported were ulnar, radial, and posterior interosseous (38%, 22%, and 19%, respectively). Nearly half of all patients with injuries required operative intervention, including nerve graft, tendon transfer, nerve repair, or nerve transfer. Of the patients who sustained major injuries, those requiring intervention, 77% had partial or no motor recovery. All minor injuries resolved completely. Our results suggest that major nerve injuries after elbow arthroscopy are not rare occurrences and the risk of these injuries is likely under-reported in the literature. Furthermore, patients should be counseled on this risk because most nerve injuries show only partial or no functional recovery. With the more widespread practice of elbow arthroscopy, understanding the nature and sequelae of significant complications is critically important in ensuring patient safety and improving outcomes.


The Safety of Using Proximal Anteromedial Portals in Elbow Arthroscopy with Prior Ulnar Nerve Transposition.

Park SE, Bachman DR and O’Driscoll SW.

Arthroscopy. 2016 Jun;32(6):1003-1009.

To report the safety of using the proximal anteromedial portal, using a simplified ulnar nerve management strategy derived from an earlier study, in a series of patients with previously transposed ulnar nerves.

A retrospective review of all elbow arthroscopies performed by a single surgeon from 2009 to 2014 was performed. The following techniques were used if, by palpation, localization of the ulnar nerve was considered to be certain (group 1) or uncertain (group 2): In group 1 (certain) the proximal anteromedial portal was established in the normal antegrade fashion. In group 2 (uncertain) a 1 to 3cm incision was made at the planned proximal anteromedial portal site, and blunt dissection down to the capsule was performed without identification of the nerve. The nerve was not visualized but sometimes was palpated through the wound to confirm its location anteriorly or posteriorly. If there was a disparity between the prior operative records and the physical examination findings, the nerve was explored through a 3- to 4-cm incision.

We reviewed 394 elbow arthroscopy cases, 22 of which had a prior transposed ulnar nerve (21 subcutaneous and 1 submuscular) that required anterior-compartment arthroscopic surgery. Group 1 (certain location) consisted of 9 elbows (41%), whereas group 2 (uncertain location) consisted of 13 (59%). In 2 cases in group 2, the ulnar nerve was explored because of the disparity between the previous medical records and the physical examination findings. There were no operative ulnar nerve injuries related to the use of the proximal anteromedial portal.

The proximal anteromedial portal was able to be used safely in patients with prior transposition of the ulnar nerve. This was achieved by using an algorithm based on the degree of certainty with which the nerve can be localized in the region of the planned portal by clinical palpation. Level of Evidence: Level IV, therapeutic case series


Evaluation of factors affecting acute postoperative pain levels after Arthroscopic Rotator Cuff Repair.

Cuff DJ, O’brien KC, Pupello DR and Santoni BG. Arthroscopy. 2016 Jul;32(7):1231-6.

181 patients underwent arthroscopic RC surgery along with subacromial decompression.

Preoperative subjective pain tolerance, notably those patients rating themselves as having an extremely high pain tolerance, was the most significant predictor of high VAS pain scores on both postoperative day 1 (P = .0001)

Pre operative narcotic use was also significantly predictive ( p=.010) of high pain scores  on postoperative day 1 and day 7 (p=.019) along with nonsmokers (p=.008) and younger patients (p=.006) being predictive on day 7. There were no patients factor that were predictive of VAS Scores 3 months postoperatively (p=.567).

Preoperative subjective pain tolerance, notably those patients rating themselves as having an extremely high pain tolerance, was the strongest factor predicting high acute pain levels after arthroscopic rotator cuff surgery. Preoperative narcotic use, smokers, and younger patients were also predictive of higher pain levels during the first postoperative week.


The Cost-Effectiveness of using Platelet-Rich Plasma during Rotator Cuff Repair: A Markov Model Analysis.

Eric M. Samuelson, Susan M. Odum, James E. Fleischli . Arthroscopy. 2016 Jul;32(7):1237-1244.

The cost per quality-adjusted life-year ($/QALY) of RCR with and without PRP was $6,775/QALY and $6,612/QALY, respectively. In our base case, the use of PRP to augment RCR was not cost-effective because it had exactly the same “effectiveness” as RCR without augmentation while being associated with a higher cost ( additional $750). Sensitivity analysis showed that to achieve a willingness-to-pay threshold of $50,000/QALY, the addition of PRP would need to be associated with a 9.1% reduction in retear rates. If the cost of PRP were increased to $1,000, the retear rate would need to be reduced by 12.1% to reach this same threshold. This compared with a necessary reduction of only 6.1% if the additional cost of PRP was $500.

This cost-utility analysis shows that, currently, the use of PRP to augment RCR is not cost-effective.


Biomechanical Comparison of All-Suture Anchor Fixation and Interference Screw Technique for Subpectoral Biceps Tenodesis.. Florence L. Chiang, Chih-Kai Hong, Chih-Hsun Chang, Cheng-Li Lin, I-Ming Jou, Wein-Ren Su.

Arthroscopy, 32(7): 1247-1252.

To compare the biomechanichal characteristics of the subpectoral Y-knot all-suture anchor fixation with those of the interference screw technique.

The all-suture anchor fixation is an alternative technique for subpectoral biceps tenodesis even at greater displacement when compared with the interference screw fixation during cyclic and failure loading.


Outcomes of Bankart Repairs Using Modern Arthoscopic Technique in an Athletic Population.

Charles Milchteim, Scott A. Tucker, Darin D. Nye, Richard J. Lamour, Wei Liu, James R. Andrews, Roger V. Ostrander.

Arthroscopy, 32(7): 1263-1270.

A retrospective analysis of all patients with a history of trauma to their shoulder resulting in an anterior shoulder dislocation was performed. Both primary and revision arthroscopic Bankart repairs using bioabsorbable anchors with at least two-year follow-up were included. The recurrence rate was 6/94 (6.4%) at a mean follow-up of 4.3 years (range 2.3 – 8.3). The mean postoperative scores were as follows: ASES=91.5/100; Rowe=84.3/100; VAS=0.8/10; satisfaction=8.8/10. Return to sports at the previous level for at least one season was possible in 88% of patients. Statistical analyses revealed a significant increase in risk of recurrence amongst high school and recreational athletes. No recurrences were observed amongst professional or college level athletes. No significant difference in recurrence rates were observed in regards to age, time to surgery, type of athlete (collision vs limited contact), repair of SLAP lesion, number of anchors, overhead athlete or revision surgery.

In conclusion, arthroscopic Bankart repairs can yield excellent results in highly active patients. Particular attention should be paid to the younger, underdeveloped athletes as they may be at higher risk for recurrence.


Treatment of Ulnar Collateral Ligament Injuries and Superior Labral Tears by Major League Baseball Team Physicians.

Erickson BJ, Harris JD, Fillingham YA, Cvetanovich GL, Bush-Joseph CA, Bach BR Jr., Romeo AA and Verma NN

Arthroscopy, 32(7): 1271-1276.

Seventy-four MLB team orthopedic surgeons were surveyed via an online survey system. A 14-question survey was used to assess surgeon experience, technique, and graft choice for UCL reconstruction (UCLR), treatment of type II SLAP tears, and other common pathologic conditions.

Thirty team orthopaedic surgeons (41%) responded (mean experience as team physicians: 9.37 ` 6.33 years). Seventeen (56.7%) surgeons use the docking technique for UCLR whereas 20% use the modified Jobe technique. Nineteen (63.3%) use palmaris longus autograft in UCLR. Overall, 28 (93.3%) do not routinely perform elbow arthroscopy or perform an obligatory transposition of the ulnar nerve in patients without preoperative ulnar nerve symptoms. Twenty-eight (93.3%) would repair a type II SLAP tear, whereas only 1 (3.3%) would debride the tear. No surgeon would perform a concomitant biceps tenodesis, either open or arthroscopic


Effect of Additional Sutures per Suture Anchor in Arthroscopic Bankart Repair: A Review of Single-loaded Versus Double-loaded Suture Anchors.

Chen JS, Novikov D, Kaplan DJ and Meislin RJ. Arthroscopy, 32(7): 1415-1420.

To directly compare single-loaded suture anchors (SSA) with double-loaded suture anchors (DSA) to help surgeons optimize the operative technique, time, and cost of Bankart repairs.

A total of two studies were included, both of which were cadaveric laboratory studies. A total of 28 shoulders were tested.

Conclusions: Based on limited cadaveric study, DSA are at least equivalent biomechanically to SSA, and may be superior. By using DSA, surgeons create repair constructs that are as strong as, or stronger than, those made with SSA, but with fewer anchors. This reduces the amount of holes drilled and implants placed in the glenoid, while also minimizing cost.


Journal of Shoulder and Elbow Surgery Review


Causes of poor postoperative improvement after reverse total shoulder arthroplasty.

Werner BC, Wong AC, Mahony GT, Craig EV, Dines DM, Warren RF, Gulotta LV.

J Shoulder Elbow Surg. 2016 Aug;25(8):e217-222.

The study evaluated reverse shoulder arthroplasty(RSA), presenting at least 2-year follow up, using ASES score and its relationship with patient risk factors.

150 shoulders were assessed.

Improvements in ASES score were poorer in patients presenting the following characteristics: Male sex, intact rotator cuff at the time of surgery(these maybe associated to higher baseline ASES), depression and higher number of comorbidities.

Factors such as patient age and indication for surgery were not found to correlate with poor improvement after RTSA.


A new posterior triceps approach for total elbow arthroplasty in patients with osteoarthritis secondary to fracture: preliminary clinical experience.

Celli A. J Shoulder Elbow Surg. 2016 Aug;25(8):e223-231

The present study presents an alternative posterior elbow approach for elbow arthroplasty(EA) minimizing damage risks to the extensor mechanism.

It uses the lateral anconeus-triceps lateral flap approach, which preserves the olecranon insertion of the medial portion of the triceps proper tendon.

The analysis was carried out by using 20 patients,2 years minimal follow up.

Mayo Elbow Performance Score rose from 41.3 to 94.3. The mean pain score on the visual analog scale fell from 7.1 to 1.1. There were no patients with insufficiency, secondary detachment of the triceps tendon

These preliminary data suggest that preservation of the insertion of the medial portion of the triceps proper tendon enables earlier active rehabilitation.


Irreducible anteromedial radial head dislocation caused by the brachialis tendon: a case report

Cates RA, Steinmann SP and Adams JE.

J Shoulder Elbow Surg. 2016 Aug;25(8):e232-235

This paper is a case report about a rare condition, the Anteromedial radial head dislocations.  These dislocations often occur in the setting of trauma and are associated with fractures and ligamentous injuries. The open reduction is required when Soft tissue interposition occur, leading to an irreducible radial head. Several structures have been reported to be interposed in the radiocapitellar joint in those cases, including the annular ligament, anterior capsule, biceps tendon, and brachialis tendon. This paper presents a case of an irreducible anterior radial head subluxation caused by the brachialis tendon, and demonstrates in a cadaver dissection, that both the biceps tendon and the superficial tendon of the brachialis can lead to an anteromedial radial head dislocation or subluxation


 Drug eruption secondary to vaconmicyn-laden spacer in the shoulder: a case report

Xu S, Ponce BA, Pavlidakey PG and Brabston EW III

J Shoulder Elbow Surg. 2016 Aug;25(8):e236-240.

The article describes the case of a 69-year-old, 78 Kg male patient with skin eruption caused by the parenteral use of vancomycin, associated with shoulder spacer using the same antibiotics. The case reports a post-operative shoulder arthroplasty infection by reverse prosthesis that evolved into an infection identified as p.acnes. The patient was treated with the withdrawal of the prosthesis, infusion of vancomycin and the use of a spacer.

The patient evolved with evident clinical signs of fever, pustule and eruptions. He underwent the withdrawal of the spacer and the substitution for vancomycin and gentamicin showing fast clinic improvement. The conclusion is that drug eruption can occur after both systemic and local diffusion from antibiotic-laden cement spacers.


Rotator cuff tear and sarcopenia: are these related?

J Shoulder Elbow Surg. 2016 Sep;25(9):e249-255.

Chung SW, Yoon JP, Oh KS, Kim HS, Kim YG, Lee HG et al

Sarcopenia is the loss of muscle mass and consequent loss of muscle function with aging. We evaluated (1) the difference in the prevalence of sarcopenia between patients with rotator cuff tear and controls and (2) the sarcopenia severity according to the size of the rotator cuff tear. Group 1 included 48 consecutive patients with chronic symptomatic full-thickness rotator cuff tears (mean age, 60.1 ± 6.5 years; range, 46-76 years), and group 2 included 48 age- and sex-matched patients. The sarcopenic index was evaluated by using the grip strength of the asymptomatic contralateral side and the skeletal muscle mass. The sarcopenic index was significantly inferior in the rotator cuff tear group than in the age- and sex-matched control groups. The results showed that sarcopenia was more severe in patients with a chronic symptomatic full-thickness rotator cuff tear than in the age- and sex-matched control population and was correlated with the size of the tear.


Short-term outcomes after arthroscopic capsular release for adhesive capsulitis

Barnes CP, Lam PH and Murrell GA.

J Shoulder Elbow Surg. 2016 Sep;25(9):e256-264.

Little is known about the short-term temporal outcomes of an arthroscopic capsular release for adhesive capsulitis. The study included 140 shoulders in 133 patients with idiopathic adhesive capsulitis who underwent a complete arthroscopic release of the shoulder capsule. Patient-reported pain and shoulder function were evaluated with the use of Likert scales, and an independent examiner assessed shoulder strength and range of motion preoperatively and at 1 week, 6 weeks, 12 weeks, and 24 weeks postoperatively. Arthroscopic capsular release resulted in immediate improvements in pain, functional outcomes, and range of motion. Passive range of shoulder motion improved at 1 week, deteriorated slightly at 6 weeks, and then continued to improve at 12 and 24 weeks. Before surgery, 38% of patients reported extreme pain. This proportion reduced to 30% at 1 week postoperatively and 2% at 24 weeks postoperatively. Patients who underwent an arthroscopic capsular release for idiopathic adhesive capsulitis experienced significant reductions in pain, improvements in range of motion, and improvements in overall shoulder function in the first postoperative week and continue to improve at 6, 12, and 24 weeks postoperatively.


Recovery of active external rotation and elevation in young active men with irreparable posterosuperior rotator cuff tear using arthroscopically assisted latissimus dorsi transfer

Petriccioli D, Bertone C and Marchi G.

J Shoulder Elbow Surg. 2016 Sep;25(9):e265-275.

Massive irreparable posterosuperior rotator cuff tears represent a serious functional disablement for young and active patients in their daily activities. Latissimus dorsi (LD) muscle-tendon transfer can restore elevation and external rotation where supraspinatus and infraspinatus function is lost. Between 2009 and 2013, 33 patients participate in this retrospective study. For 8 patients, we used a standard passage of the LD through the plane between the infraspinatus–teres minor and the deltoid muscles. For 25 patients, we transferred the LD tendon in front of the triceps muscle according to a personal described technique. The follow-up period was 35.7 months. Final follow-up included assessment by standard radiographs, bipolar surface electromyography, pain score by visual analog scale, Constant-Murley shoulder score, and Disabilities of the Arm, Shoulder, and Hand score. For quantitative strength evaluation measurements, a dynamometer was used. Arthroscopic LD tendon transfer for irreparable posterosuperior rotator cuff tears can achieve good clinical outcomes at a midterm follow-up, especially in active men 60 years of age or younger and in patients with low preoperative elevation (<80°) but an intact or reparable subscapularis tendon


Is radiographic measurement of acromiohumeral distance on anteroposterior view after reverse shoulder arthroplasty reliable?

Werner BS, Jacquot A, Molé D and Walch G

J Shoulder Elbow Surg. 2016 Sep;25(9):e276-280.

This study evaluated the reliability of the acromiohumeral distance in determining arm lengthening, resulting from a reverse shoulder arthroplaty. Forty four patients with a minimum 6 months follow up followed, a standardized protocol including preoperative and postoperative radiographs on anteroposterior view in neutral rotation, measured independently in random order by 2 orthopedic surgeons. The average lengthening was 2.5 cm, with significant differences in interobserver and intraobserver variability (P < .01). The mean intrapatient difference was 0.5 cm. The study concluded that the acromiohumeral distance is not a reliable measurement technique to determine arm lengthening after reverse shoulder arthroplasty.


Intra-aortic migration of a Kirschner pin: hybrid surgical repair 

Tesson P, Ammi M, Ghomri D, Daligault M, Péret M and Picquet J.

J Shoulder Elbow Surg. 2016 Sep;25(9):e281-283.

An 85-year-old-woman was treated for recurrent shoulder dislocation by a glenohumeral stabilization with 2 Kirschner pins. At day 30, an X-ray showed that one of the pins suffered intra-aortic migration, without any cardiorespiratory symptom.  For extraction of the pin, hybrid surgery was performed, with an uneventful postoperative course.   Shoulder movement associated to bone resorption can explain the intrathoracic migration of the pins.  Then, pulmonary movements and the pin’s weight made it progress to a mediastinal position. Dementia also facilitates such migration, leading to the difficulties of immobilization.  To avoid similar recurrent events, we propose a bending or a collar lock to secure the pin at the skin. However, there still remains a risk of breakage and migration of the medial segment. The learning point of this case is that these orthopedic devices should be used with consideration, particularly for patients who would not be able to respect the immobilization.


The yield of subsequent radiographs during nonoperative treatment of radial head and neck fractures

Burton KR, Mellema JJ, Menendez ME, Ring D and Chen NC1.

J Shoulder Elbow Surg. 2016 Aug;25(8):1216-1222.

This study, considering radial head or neck fractures selected to nonoperative treatment, evaluated formerly, the null hypothesis that there are no patient, surgeon or injury factors associated with alteration in patient management based on subsequent radiographs and then the null hypothesis that the use of subsequent radiographs is not associated with patient, surgeon, and fracture characteristics. During 2013 and 2014, 415 adult patients with nonoperative radial head or neck fractures (Broberg and Morrey modified Mason type 1 or 2) were analyzed through bivariate and multivariable logistic regression modeling. Displaced fractures, in multivariable analysis, were more often to have subsequent radiographs, but surgeon-to-surgeon variation was the more influential factor. After the diagnosis, subsequent radiographs did not alter treatment of these fractures.

This paper suggests the necessity for quality improvement initiatives among orthopedic surgeons.


The morphologic change of the ulnar collateral ligament of elbow in high school baseball pitchers, with and without symptoms, by sonography

Tajika T, Yamamoto A, Oya N, Ichinose T, Shimoyama D, Sasaki T et al

J Shoulder Elbow Surg. 2016 Aug;25(8):1223-1228.

In this study, ultrasonography (US) was used to assess the ulnohumeral joint space width, with and without valgus stress, to evaluate changes of the ulnar collateral ligament (UCL) in a group of high school pitcher’s elbows, with and without elbow symptoms. US of the medial aspect of both elbows were obtained, with and without a valgus stress, being the elbows at 30° of flexion. Still, a questionnaire related to the pitching performance and elbow joint pain during the prior 3 years was applied to  122 high school baseball pitchers. Pitchers with elbow symptoms showed difference between the UCL thickness on the throwing side, when compared with asymptomatic patients (P=.0013). This morphologic change might reflect an early pathological finding in pitching.


Factors associated with adverse events after distal biceps tendon repair or reconstruction.

Beks RB, Claessen FMAP, Oh LS, Ring D and Chen NC

J Shoulder Elbow Surg. 2016 Aug;25(8):1229-1234.

Between January 2002 and March 2015, 373 adult patients who underwent repair or reconstruction of a distal biceps tendon tear were analyzed about factors associated with adverse events after their surgery. In the end, 82 patients (22%) had an adverse event (the most common one was lateral antebrachial cutaneous nerve  neurapraxia); 5,3% were major adverse events; single-incision and obesity were associated to a higher rate of adverse events. 15 patients (18% of patients with an adverse event; 4% of all patients) had a second surgery after index distal biceps surgery. Based on this study, authors suggest that patients should be advised that 1 in 5 patients will have a minor adverse event and 1 in 20 patients will have a major complication after repair or reconstruction of a distal biceps tendon tear.


Press-fit bipolar radial head arthroplasty, midterm results

Kodde IF, Heijink A, Kaas L, Mulder PGH, Dijk N and Eygendaal D

J Shoulder Elbow Surg. 2016 Aug;25(8):1235-1242.

The advantages of a bipolar radial head prosthesis compared with a monopolar one  are: better radiocapitellar alignment accommodation, less capitellar abrasion and less occurrence of “stress shielding” over the bone-implant interfaces. Twenty seven out of 30 patients treated with a press-fit bipolar radial head arthroplasty were evaluated in this study. The mean follow-up was 48 months (28-73); a revision surgery had to be performed in 3 cases (2 capitellar abrasions and 1 prosthesis instability); in all such revisions, the stems appeared to be well fixed. The average flexion-extension final ROM was 136° (120°-145°); pronation-supination final ROM was 138° (70°-180°). According to the Mayo Elbow Performance Score, excellent and good results were obtained in 70% of the included patients. Authors end concluding that a press-fit bipolar radial head prosthesis shall be considered in the treatment of acute comminuted radial head fractures.


Application of the suture bridge method to olecranon fractures with a poor soft-tissue envelope around the elbow: Modification of the Cha-Bateman methods for elderly populations

Cha SM, Shin HDAE and Lee JW

J Shoulder Elbow Surg. 2016 Aug;25(8):1243-1250.

The Cha-Bateman transosseous modified technique can be used for Mayo’s types IIA or IIIA olecranon fractures in elder patients with osteoporotic bone and poor soft-tissue envelope. This technique is based on tension-band and suture-bridge methods using high-strength braded sutures and two anchors to  enhance healing process and mechanical strength without the need of future hardware removal. Series of 13 factures in patients with mean age of 69.7 years and at least one comorbidity showed union and excellent functional outcomes.


Selected anteromedial coronoid fractures can be treated nonoperatively

Chan K, Faber K, King G and Athwal G

J Shoulder Elbow Surg. 2016 Aug;25(8):1251-1257.

Nonoperative treatment of anteromedial coronoid fractures subtype 2 of O’Driscoll’s classification (rim and tip) may be considered for patients that meet all the following criteria: (1) fragment size ≤5mm, (2) minimally displaced (≤3mm), (3) concentrically reduced elbow joint seen on both plain radiographs and CT, (4) stable elbow range of movement to a minimum of 30º of extension, and (5) normal findings on hyperpronation and gravity varus stress testing. Series of 10 cases treated nonoperatively with mean follow-up of 50 months showed consolidation with excellent functional outcomes. However, treatment success depends on patient compliance with the splinting and supervised exercises protocol and be available for serial follow-up monitoring.


Long-term results after a free vascularized adipofascial graft for congenital proximal radioulnar synostosis with an average follow-up of 10 years: a series of four cases

Kanaya K, Iba K and Yamashita T

J Shoulder Elbow Surg. 2016 Aug;25(8):1258-1267.

A free vascularized adipofascial graft interposition with radial osteotomy (Kanaya surgery) for congenital proximal radioulnar synostosis is a unique procedure for children, providing long-lasting rotational motion of the forearm and satisfactory functional outcomes. A 10-year follow-up analysis of 6 forearms in 4 patients treated with this technique demonstrated no recurrence rate. Extension, flexion and pronation range of movement achieved postoperatively persisted throughout follow-up.  However, supination decresed by a mean of 16º from 1 year postoperatively to the final follow-up and it must be kept in mind when indicating this procedure together with other possible complications like radio head hypertrophy, epiphyseal arrest, flap congestion and transient radial nerve palsy.


Anatomic cadaveric study of the extensile extensor digitorum communis splitting approach for exposing the ulnar coronoid process

Sukegawa K, Suzuki T, Ogawa Y, Ueno K, Kiuchi H et al.

J Shoulder Elbow Surg. 2016 Aug;25(8):1268-1273.

The extensile extensor digitorum communis (EDC) splitting approach provides sufficient exposure to the coronoid process. It may be clinically applied to cases of complex elbow instability centering on the lateral components and coronoid process fractures. Dissection of 20 fresh frozen cadaveric upper limbs at 70º of elbow flexion showed an average distance of 10mm between the most distal site of the EDC splitting and the posterior interosseous nerve, indicating that the splitting must be carefully performed and not extended longer than 40mm distally to the lateral epicondyle.


Long-term results after a free vascularized adipofascial graft for congenital proximal radioulnar synostosis with an average follow-up of 10 years: a series of four cases

The effect of myofibroblasts and corticosteroid injections in adhesive capsulitis.

Hettrich CM, DiCarlo EF, Faryniarz D, Vadasdi KB, Williams R and Hannafin JA.

J Shoulder Elbow Surg. 2016 Aug;25(8):1274-1279.

Adhesive capsulitis is a condition that results in restricted glenohumeral motion. Fibroblasts has been implicated in the disease process; however, their role is not well understood.

In this paper, The autors hypothesized that myofibroblast prevalence in capsular biopsy specimens from patients with adhesive capsulitis would be increased compared with controls and that patients treated with an intra-articular injection of corticosteroid would have fewer myofibroblasts.

The study prospectively enrolled 20 consecutive patients with adhesive capsulitis scheduled for capsular release and matched controls. Tissue samples were collected from the posterior and anterior capsule for histomorphologic and immunohistologic analyses. Identical sectioning and preparation was per- formed in 14 additional adhesive capsulitis specimens from patients who had not received corticosteroid injections.

Results confirmed that Patients with adhesive capsulitis not treated with preoperative corticosteroid demonstrated more histologic evidence of fibromatosis, synovial hyperplasia, and an increase in positive staining for α-smooth muscle actin

The paper conclusões that Intra-articular steroid injection decreases the presence and amount of fibromatosis, vascular hyperplasia, fibrosis, and the presence of fibroblasts staining for α-smooth muscle actin. This supports the use of steroid injections to alter the disease process by decreasing the pathologic changes found in the capsular tissue.


Delayed administration of recombinant human parathyroid hormone improves early biomechanical strength in a rat rotator cuff repair model

Duchman KR, Goetz JE, Uribe BU, Amendola AM, Barber JA, Malandra AE et al

J Shoulder Elbow Surg. 2016 Aug;25(8):1280-1287

In this paper the authors hypothesized that administration of rhPTH beginning on postoperative day 7 would result in improved early load to failure after acute rotator cuff repair in an established rat model. Recombinant human parathyroid hormone (rhPTH) has been shown to improve healing at the tendon-to- bone interface in an established acute rat rotator cuff repair model,

They made 108 acute rotator cuff repairs in male Sprague-Dawley rats. Fifty-four rats received daily injections of rhPTH beginning on postoperative day 7 until euthanasia or a maximum of 12 weeks postoperatively. The remaining 54 rats received no injections and served as the control group. Animals were euthanized at 2 and 16 weeks postoperatively and evaluated by gross inspection, biomechanical testing, and histologic analysis.

At 2 weeks postoperatively, rats treated with rhPTH demonstrated significantly higher load to failure than controls. No difference in load to failure was found between the 2 groups at 16 weeks postoperatively, blood vessel density appeared equivalent between the 2 groups at both time points, but increased intracellular and extracellular vascular endothelial growth factor expression was noted in the rhPTH-treated group at 2 weeks.

Delayed daily administration of rhPTH resulted in increased early load to failure and equivalent blood vessel density in an acute rotator cuff repair model.

They believe that the early improvement in biomechanical properties of the repaired rotator cuff after administration of rhPTH has some promise considering the relatively high reported rate of mechanical failure of rotator cuff repairs in humans without biologic augmentation, and that the results of their study warrant further investigation of both the biomechanical and histologic effects of rhPTH on rotator cuff healing while considering the optimal dose and duration of rhPTH administration.


Fatigue failure of reverse shoulder humeral tray components of a single design

Lewicki KA, Martin AJ, Bell JE and Van Citters DW.

J Shoulder Elbow Surg. 2016 Aug;25(8):1288-1296.

This Study aimed to determine the impact on geometry and materials used for modular humeral trays from a single manufacturer. Modularity in shoulder arthroplasty provides surgical flexibility and facilitates less complex revision surgery. Modular designs must fit in the glenohumeral joint space, necessitating minimal thickness and careful material selection. The potential for fatigue fracture is higher, and fatigue fracture has been experienced by patients.

They retrieved 8 humeral trays of nearly identical designs: 4 Ti-6Al-4V (Ti) and 4 CoCrMo (CoCr). Optical microscopy and scanning electron microscopy were used, along with metallurgical techniques. Finite element and fatigue analyses of the stresses at the humeral tray taper informed observation interpretation.

Scanning electron microscopy showed cracking in 2 Ti trays and no evidence of cracking in the CoCr components. A geometric difference in the CoCr devices resulted in a 25% decreased stress under simulated activities of daily living. The fatigue failure envelope ranged from 1000 to 1 million cycles for Ti and from 30,000 to >10 million cycles for CoCr.

All Ti humeral trays retrievals fractured in vivo or were cracked at the taper fillet. No CoCr retrievals showed signs of cracking. Finite element and fatigue analyses predict a 10-fold lifetime increase for the CoCr devices compared with the Ti devices.

The results showed that failure of a clinical lifetime is within the realistic spectrum for titanium components and is less likely for cobalt chrome components. Furthermore, cracks in titanium are more likely to propagate to a critical length, especially in a thin component such as the humeral tray. This study shows that fatigue failure is a concern for some reverse shoulder components and should be carefully considered when designing and testing prostheses.


The osseous morphology of nondegenerated shoulders shows no side-related differences in elderly patients: an analysis of 102 computed tomography scans

Bockmann B, Soschynski S, Lechler P, Schwarting T, Debus F, Soca B et al

J Shoulder Elbow Surg. 2016 Aug;25(8):1297-1302.

The aim of this study was to identify side-dependent differences in the osseous anatomy of the shoulder joint. A precise understanding of glenohumeral anatomy is required to optimize preoperative planning in shoulder joint arthroplasty, which is difficult in the presence of degenerative disease. In unilateral disease, the contralateral shoulder can be used as a representation of normal anatomy; however, intrasubject differences in shoulder morphology have not been investigated.

A retrospective study of all patients aged >65 years who received whole body computed to- mography at their trauma center from 2010 through 2014 was conducted. Right and left shoulder computed tomography scans were examined, and the following anatomic parameters were measured: humeral head diameter in anteroposterior and axial views, glenoid diameter in anteroposterior and axial views, glenoid surface, scapula neck depth, neck-shaft angle, glenoid inclination, glenoid/head ratio, and glenoid version. Patients with inadequate scan quality, osseous lesions, pre-existing anatomic abnormality, or metallic implant at the shoulder region and significant osteoarthritis were excluded.

Statistical lanalysis of CT scans from 102 individuals failed to reveal any significant difference between left and right shoulder joint anatomy. Limitations of this study include the inclusion of only Caucasian subjects; it would be useful to extrapolate the study to those of differing ethnic backgrounds.

There are no significant side-dependent differences in the osseous anatomy of the glenohu- meral joint. In cases in which severe monolateral glenohumeral de- generation limits anatomic assessment, measurement of the contralateral shoulder will provide a reliable repre- sentation of the patient’s normal shoulder anatomy.


2013 Neer Award: predictors of failure of nonoperative treatment of chronic, symptomatic, full-thickness rotator cuff tears

Dunn WR, Kuhn JE, Sanders R, An Q, Baumgarten KM, Bishop JY et al

J Shoulder Elbow Surg. 2016 Aug;25(8):1303-1311.

Prospective, multi-center, cohort study for define the indication for rotator cuff repair from identifying the  predictors of failure of nonoperative treatment, examining  risk factors for failing the rehabilitation. Dependent variable was time of surgery; the independent variables were tear severity and baseline patient factors: age, activity level, body mass index, sex, clinical score, pain scale, education, handedness, comorbities, symptom duration, strength, employment, smoking and patient expectations. From 433 patients with full-thickness cuff tears in MRI, only 87 patients underwent surgery, with 93-88% follow-up in 1-2 years. Median age was 62 years, 49% were female. Stronger predictors for surgery were: expectations regarding physical therapy (p<0.0001), higher activity level (p=0.011), and not smoking (p=0.023). The Authors also concluded that patient symptoms and anatomic cuff features may not be the best features when deciding for surgery.


Does application of moderately concentrated platelet-rich plasma improve clinical and structural outcome after arthroscopic repair of medium-sized to large rotator cuff tear? A randomized controlled trial

Pandey V, Bandi A, Madi S, Agarwal L, Acharya KK, Maddukuri S et al

J Shoulder Elbow Surg. 2016 Aug;25(8):1312-1322.

This randomized study compares if Platelet-rich plasma (PRP) application after repair of degenerative postero superior medium/large cuff tears leads to superior structural and clinical outcome, especially after single-row repair. PRP group (52 patients) and control group (50 patients) were included for arthroscopic repair with a minimum follow-up of 2 years. Patients were evaluated with 4 different clinical scores and ultrasound to assess retear and vascularity pattern of the cuff. Clinical scores results were controversial, varying from lower, higher or equal for PRP, depending of the score in use. At 24 months, the re-tear difference was significantly lower in the PRP group, for large tears only. Doppler ultrasound examination showed significant vascularity in the PRP group repair site at 3 months postoperatively and in peribursal tissue until 12 months.



Gender differences in expectations and outcomes for total shoulder arthroplasty: a prospective cohort study.

Jawa A, Dasti U, Brown A, Grannatt K and Miller S.

J Shoulder Elbow Surg. 2016 Aug;25(8):1323-1327.

Andrew Jawa, Umer Dasti, Amy Brown, Kathryn Grannatt, Suzanne Miller

Gender may has an impact on the expectations and outcomes of orthopedic procedures, and limited data suggest that women may have worse outcomes in total shoulder arthroplasty (TSA). The objective of this study is compare the expectations and post operative outcomes between men and women. A group of 63 patients with a minimum of 3 years follow-up, 36 men, 27 women, answered a preoperative survey and were measured post operatively with 2 clinical scores. The main expectation in men were related to exercise and sports (lower age average), while in women were maintain the daily routine and chores. The second biggest expectations were related to sleep quality in both genders. In general, the expectations were high. The clinical scores revealed an increase in scores after surgery, without difference between genders.


Predominance of the critical shoulder angle in the pathogenesis of degenerative diseases of the shoulder

Blonna D, Giani A, Bellato E, Mattei L, Caló M, Rossi R et al.

J Shoulder Elbow Surg. 2016 Aug;25(8):1328-1336.

Davide Blonna, Andrea Giani, Enrico Bellato, Lorenzo Mattei, Michel Caló, Roberto Rossi, Filippo Castoldi

As the Critical Shoulder Angle (CSA) may be one of the responsible for rotator cuff tears RCT and concentric osteoarthritis. This cohort study aim to assess the association of CSA wit RCT, excluding potential confounding factors. Group has 200 patients, divided as 40 with osteoarthritis, 40 with isolates supraespinatus tear, 40 with at least supraespinatus and infraespinatus tears, and 80 with no shoulder problem (control). Larger CSAs are associated with increased risk of symptomatic cuff tears, larger cuff tears, and the severity of eccentric osteoarthritis. Smaller angles increased the risk and severity of concentric symptomatic osteoarthritis. These associations remained significant even after removal of some of the potentially confounding variables.


Outcomes in the treatment of periprosthetic joint infection after shoulder arthroplasty: a systematic review.

Nelson GN, Davis DE and Namdari S.

J Shoulder Elbow Surg. 2016 Aug;25(8):1337-1345.

This systematic review synthesizes the available literature on shoulder periprosthetic joint infection, to quantify and compare treatment effectiveness. In April 2014, from 663 initial articles, 30 high quality articles were used. Principal bacteria were Propionibacterium acnes (38,9%) followed by Staphylococcus sp. Principal risk factors were previous surgery, increased age, male gender, increased body mass index, and diabetes mellitus. Other data analyzed was: white blood cell cont, erythrocyte sedimentation, and C-reactive protein. No difference was found in the success rates of 1-stage or 2-stage nor resection arthroplasty revision,  all with a >90% success. As confounding variables may occur in retrospective patients, more direct comparisons of 1-stage and 2-stage treatment are needed, comparing cost, morbidity and functional outcomes.


Outcome of lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tear

Elhassan BT, Wagner ER and Werthel JD.

J Shoulder Elbow Surg. 2016 Aug;25(8):1346-1353.

The authors describe the lower trapezius transfer technique, associated with the use of an Achilles tendon allograft, for the treatment of irreparable rotator cuff tears. 33 patients were included in this study, all of them presenting with advanced fatty degeneration (Goutallier III / IV) and irreparable postero-superior rotator cuff tears, retracted at the level of the glenoid in their respective MRIs. 2/3 of these patients had been previously operated for a rotator cuff repair, without success. The average age of these patients was 53 years old. The authors report good clinical results using this technique, with a minimum 02 years follow-up, with significant improvement in shoulder pain; in terms of shoulder function, improvements were best in external rotation, although shoulder elevation and abduction have also significantly increased, especially in those patients who had 60° (or more) of shoulder elevation, preoperatively. This study has evidence level IV.


Total shoulder arthroplasty using an inlay mini-glenoid component for glenoid deficiency: a 2-year follow-up of 9 shoulders in 7 patients

Davis DE, Acevedo D, Williams A and Williams G.

J Shoulder Elbow Surg. 2016 Aug;25(8):1354-1361.

The authors describe retrospectively the results and complications of the use of a “mini-glenoid” component in TSA (Total Shoulder Arthroplasty), in patients with dysplastic glenoids and in glenoids with significant bone loss. For each of the 09 shoulders involved in this study, a specific mini-glenoid component was “customized”  from pre-operative tomographic 3D images. All surgeries were performed using a standard delto-pectoral approach, and the original glenoid retroversion was not changed during the operation. The authors report, in a 02 years follow-up, significant improvement in pain, and, clinically, in forward elevation and in external rotation. This technique, thus, can be an option in the management of a notoriously difficult situation – the use of glenoid components in dysplastic glenoids and in glenoids with significant bone loss.


Reverse shoulder arthroplasty with a cementless short metaphyseal humeral implant without a stem: clinical and radiologic outcomes in prospective 2- to 7-year follow-up study.

Levy O, Narvani A, Hous N, Abraham R, Relwani J, Pradhan R et al

J Shoulder Elbow Surg. 2016 Aug;25(8):1362-1370.

The authors describe their clinical and radiological results using a reverse prosthesis with a new kind of humeral component, without the presence of a stem. 98 shoulders were operated, with an average age of 74 years, and the humeral (stemless) component was always used without cement – authors fixed it in “press-fit” fashion into the proximal humerus, making the fixation, thus, more biological. The authors insist that the presence of osteoporosis is not a contraindication to the technique. Good clinical and radiological results were reported in a follow-up from 2 to 7 years. Still, the preservation of the proximal humerus bone stock in fact shall favor a possible surgical revision, in future.


Loose glenoid components in revision shoulder arthroplasty: is there an association with positive cultures?

Lucas RM, Hsu JE, Whitney IJ, Wasserburger J and Matsen FA 3rd.

J Shoulder Elbow Surg. 2016 Aug;25(8):1371-1375

In this study, the authors analyzed a series of 221 total shoulder arthroplasties that underwent surgical revision, to assess whether there would be a relationship between glenoid component loosening and positive intraoperative cultures. 2/3 of the patients had loosening of the glenoid component, while in 1/3 the glenoid component was still well fixed, and stable. None of these patients had clinical signs of infection. Intraoperative cultures revealed that, in patients with loosening of the glenoid component, 54% had positive cultures, while in patients with the glenoid component still well fixed, 51% had positive cultures. The authors end concluding that there must be a high suspicion of infection anytime a shoulder surgeon is facing a total shoulder arthroplasty revision.


Effect of surgeon-sonographer interaction on ultrasound diagnosis of rotator cuff tears: a five year cohort study in 775 shoulders.

Kurz AZ, Kelly MJ, Hackett L and Murrell GA.

J Shoulder Elbow Surg. 2016 Sep;25(9):1385-1394.

The study aims to determine whether the surgeon-sonographer interaction improves the accuracy at predicting rotator cuff injuries. It is a cohort study that assessed 775 shoulders.

The authors used three interactions between surgeon and ultrasonographer per patient – (1) within the surgeon’s clinic, (2) at surgical center, (3) preoperatively and postoperative.

Variables assessed by presence of cuff injury and size of the cuff injury.

The authors divided the patients also into 5 groups, each one by assessment year.

Sensitivity and specificity increased when compared to the group 5 with group 1, with variation from 93% to 99% in sensitivity, and 68% to 93% in specificity. There was an improvement in the correlation of the ability to estimate the size of rotator cuff tears from ultrasonography to surgery in both full- and partial-thickness tears.

Surgeon-ultrasonographer interaction can improve the diagnosis of rotator cuff injury particularly with respect to the overall accuracy.


Effects of two stretching methods on shoulder range of motion and muscle stiffness in baseball players with posterior shoulder tightness: a randomized controlled trial

Yamauchi T, Hasegawa S, Nakamura M, Nishishita S, Yanase K, Fujita K et al

J Shoulder Elbow Surg. 2016 Sep;25(9):1395-1403.

This study aims to evaluate the effects of 2 stretching methods, the modified cross-body stretch (MCS) and the modified sleeper stretch (MSS), on shoulder ROM and muscle stiffness in young baseball players with posterior shoulder tightness. These stretching methods were modified by Wilk from cross-body stretch and sleeper stretch.

The authors evaluated twenty-four college baseball players with ROM limitations in shoulder internal rotation. The baseball players were randomly assigned to the MCS or MSS group. They were asked to perform 3 repetitions of the stretching exercises

every day, for 30 seconds, with their dominant shoulder.

The authors measured shoulder internal rotation and horizontal adduction ROM and assessed posterior shoulder muscle stiffness with ultrasonic shear wave elastography before and after a 4-week intervention.

Shoulder internal rotation and horizontal adduction ROM were significantly increased in both groups, but the stiffness of the teres minor decreased in the MCS group and the stiffness of the infraspinatus decreased in the MSS group.

These stretching techniques can be performed by players without the help of

a therapist, which enables them to treat or to prevent posterior shoulder tightness.

This study demonstrated that the MCS and MSS are effective for increasing shoulder internal rotation and horizontal adduction ROM and decreasing muscle stiffness of the infraspinatus or teres minor, but to assess long-term results this study should continue.

The ultrasonographic evaluation with anatomical parameters and top rated member position may also represent a method of evaluation to be improved because of variables that can occur, but clinical improvement should always be considered.


Length of stay after shoulder arthroplasty – the effect of an orthopedic specialty hospital

Padegimas EM, Zmistowski BM, Clyde CT, Restrepo C, Abboud JA, Lazarus MD et al.

J Shoulder Elbow Surg. 2016 Sep;25(9):1404-1411.

This study assesses hospital length of stay(LOS) in patients that underwent to primary arthroplasty shoulder in 2 different hospital types: an orthopedic specialty hospitals (OSH) versus a tertiary referral center (TRC).

The authors evaluated the data of 136 patients of OSH and 1138 of TRC from January 1, 2013 to July 1, 2015. LOS and readmissions were assessed. The surgical procedures were performed by the same team of experts in shoulder surgery in both hospitals.

The patients evaluated in these hospitals presented balance in the baseline, making comparisons between hospitals very reliable.

The LOS of OSH was on average 1.31 days, while in TRC was 1.85 days on average, and the rehospitalization rate was similar among hospitals.

The authors demonstrate that LOS difference is relevant and that this is due to rapid rehabilitation and orthopedic protocols performed in OSH, believing that this decrease demand lower rates of infection and improved patient satisfaction with the procedure.


Surgical management of midshaft clavicle nonunions is associated with a higher rate of short-term complications compared with acute fractures.

McKnight B, Heckmann N, Hill JR, Pannell WC, Mostofi A, Omid R et al

J Shoulder Elbow Surg. 2016 Sep;25(9):1412-1417.

This study reports the perioperative complication rates after surgical management of nonunions versus acute fractures. The patient for this study were enrolled by using the American College of Surgeons National Surgical Quality Improvement Program database using Current Procedural Terminology to identify patients between 2007 and 2013.

The authors evaluated a total of 1215 patients, 1006 with midshaft clavicle fractures and 209 with midshaft nonunions. On multivariate analysis, Patients undergoing surgical fixation for nonunion had a higher rate of total complications compared with the acute fracture group with 5.26% vs. 2.28% in analysis for the first 30-day of postoperative clavicule´s ORIF.

This study concludes that the nonunion group presented increased risk of short-term complications comparing with acute fractures.

The authors believe that study provides additional information to consider in making management decisions for these common injuries.

Monitoring for longer periods and evaluation of the causes of midshaft clavicle nonunion can contribute to understand the complications found in this study and improve additional information for surgical decisions.


Younger patients report similar activity levels to older patients after reverse total shoulder arthroplasty

Walters JD, Barkoh K, Smith RA, Azar FM and Throckmorton TW

J Shoulder Elbow Surg. 2016 Sep;25(9):1418-1424.

The purpose of this study was to evaluate patient-reported activities after RTSA in two cohorts, patients younger than 65 years and patients older than 65 years at the time of surgery. 46 patients answered a visual analog score (VAS) for pain, patient reported range of motion, patient-reported strength on a scale from 1 to 10, narcotic use, and additional demographic data.

The postoperative activity levels, pain, range of motion, strength, and number of activities were similar in patients of different age groups. Such findings are encouraging because RTSA has been shown to have better outcomes than hemiarthroplasty, the typical alternative in younger patients, despite its relatively high complication rate. Although it is logical to suggest that younger patients will place increased stress on RTSA implants, leading to premature implant failure, our data indicate that patients younger than 65 years did not perform more high-demand activities than their older counterparts. Thus, the same wear rate could be expected in the 2 groups; however, even if wear rates are similar, the longer life expectancy of the younger cohort would still be expected to result in more overall prosthetic wear complications in the long term, and these data are not meant to be predictive of implant survival or revision rates.


Reverse total shoulder arthroplasty with structural bone grafting of large glenoid defects

Jones RB, Wright TW and Zuckerman JD

J Shoulder Elbow Surg. 2016 Sep;25(9):1425-1432.

Large structural grafts from the humeral head or iliac crest have been used to reconstruct posterior, superior, and anterior defects. More recently, extended pegged baseplates have been used to assist fixation to the native scapula.

This study quantified the clinical outcomes and compared results using a structural allograft or autograft placed behind the glenoid baseplate to address large structural defects of the glenoid during RTSA.

Preoperative and postoperative data were analyzed from 44 patients (20 men and 24 women), with an average age of 69.1 ± 7.4 years, who received primary RTSA or revision RTSA requiring a structural bone graft behind the baseplate for a severe glenoid defect. The average follow-up was 40.6 ± 16 months. These patients were evaluated and scored preoperatively and at the latest follow-up using the ASES, Constant, simple shoulder test (SST), and shoulder pain and disability index (SPADI) scoring metrics. Daily pain, active abduction, forward flexion, and external rotation were also measured.

RTSA presents a more favorable environment for graft incorporation compared with anatomic TSA. This is due to the ability to achieve graft compression and fixation with screws placed through the baseplate in conjunction with a long peg or cage into the native glenoid. Although the RTSA with bone graft does show significant improvements, these patients still do not reach the same level of improvement as those who do not require bone grafts. An autograft humeral head/iliac crest or allograft femoral head may be used during RTSA to reconstruct large glenoid defects with no clinical difference between than in this report. Excellent clinical outcomes can be expected, as evidenced by improvements in postoperative function and clinical outcome measures 2 years postoperatively.


Quantitative diffusion-weighted magnetic resonance imaging for the diagnosis of partial-thickness rotator cuff tears

Lo HC, Hung ST, Kuo DP, Chen YL and Lee HM. J Shoulder Elbow Surg. 2016 Sep;25(9):1433-1441.

This study investigated diffusion-weighted (DWI) magnetic resonance imaging (MRI) as an alternative to fat-suppressed T2-weighted imaging (FS-T2WI) for assessment of partial-thickness rotator cuff tears (RCTs). Patients with arthroscopy proven partial-thickness RCTs who also received MRI (FS-T2WI and DWI) before surgery were prospectively included. Included were 146 patients, with a mean age of 48.3 years (range, 19-86 years), of whom 43 had full-thickness RCTs, 67 had partial-thickness RCTs, and 36 had no tears.

Two observers (H.C.L. and Y.L.C., with 20 and 5 years of musculoskeletal MRI experience, respectively) retrospectively and independently reviewed conventional FS-T2WI and combined DWI images. The observers were blind to the arthroscopy results and clinical diagnosis; the surgeons, however, had reviewed the MRI results before surgery. FST2WI and DWI images were interpreted at the same session because DWI was felt to provide better sensitivity and additional information regarding detection of partial-thickness RCTs when FS-T2WI and DWI images were interpreted at the same time. Images were analyzed in 2 sessions, 4 to 6 weeks apart.

They concluded that DWI is more accurate and sensitive than FS-T2WI for diagnosing partial-thickness RCTs and can distinguish them from full-thickness tears. Thus, DWI can be used as an alternative means of diagnosing partial-thickness tears when they are not easily differentiated using FS-T2WI.


Core decompression and arthroplasty outcomes for atraumatic osteonecrosis of the humeral head

Kennon JC, Smith JP and Crosby LA

J Shoulder Elbow Surg. 2016 Sep;25(9):1442-1448.

The objective of the study was to analyze the effectiveness of the treatment strategy used at the institution for patients with AVN. They attempted to stimulate angiogenesis and prevent humeral head collapse by combining standard core decompression with ultrasound bone stimulation in the treatment of stage I and II patients. This study used resurfacing as a treatment for stage III patients and arthroplasty for stage IV/V patients in an attempt to analyze the outcome and determine efficacy with these treatment modalities..

The study population represents etiology primarily due to CSI osteonecrosis or SCD. They documented radiographic progression and functional outcomes after procedures for HAAVN and determine efficacy of core decompression and arthroplasty treatments.

Between 2009 and 2014, 25 shoulders (20 patients) were treated surgically for HAAVN at a single institution by a single surgeon and principal investigator (L.A.C.).

The results suggest core decompression for early AVN in SCD patients does not alter the progression of osteonecrosis and progression to humeral head collapse, necessitating further surgical treatment. Patients who develop humeral head osteonecrosis secondary to SCD are at increased risk of progression when treated with core decompression during the early stages of the disease.

Based on their patient series, they would consider bypassing core decompression in favor of resurfacing and arthroplasty options, which may prove more beneficial. Resurfacing, hemiarthroplasty, TSA, and RTSA displayed favorable results across all risk factors. Using resurfacing or hemiarthroplasty for stage III and performing TSA or RTSA for stage IV/V disease is a viable treatment algorithm for improving clinical outcomes with stage III, IV, or V disease. The addition of ultrasound bone stimulation does not appear to add any beneficial aspects to the treatment of HAAVN.


Comparison of implant cost and surgical time in arthroscopic transosseous and transosseous equivalent rotator cuff repair

Black EM, Austin LS, Narzikul A, Seidl AJ, Martens K and Lazarus MD

J Shoulder Elbow Surg. 2016 Sep;25(9):1449-1456.

This study analyzed differences in implant costs and surgical time between 2 cohorts of patients—one undergoing arthroscopic transosseous equivalent (TOE) rotator cuff repair and other undergoing arthroscopic transosseous rotator cuff repair.

Operative time did not significantly differ between TOE and transosseous groups However, there was a substantial increase within the TOE group in surgical time by upwards of 35 minutes between small and massive rotator cuff repairs (with a semilinear increase in the medium and large categories). In the transosseous group, this case time increase was less (9-16 minutes longer for massive tears compared with small and medium tears, respectively).

The overall cost of implants was significantly less in the arthroscopic transosseous repair by an average of $336.05 (P < .0001). This cost difference was magnified with larger tear sizes—transosseous repair was $153.25 less with small- sized tears, $275.28 less with medium-sized tears, $409.01 less with large-sized tears, and $791.29 less for massive- sized tears.

We determined that implant costs are significantly lower in transosseous repair than in TOE repair, by an average of $336.05 per case. In large and massive tears, this number was even higher ($409.01savings per case for large tears and $791.29 for massive tears).

Arthroscopic transosseous rotator cuff repair can afford substantial cost savings compared with TOE repairs. This cost savings is magnified with increasing tear sizes.


Is the arthroscopic modified tension band suture technique suitable for all full-thickness rotator cuff tears?

Bae KH, Kim JW, Kim TK, Kweon SH, Kang HJ, Kim JY et al

J Shoulder Elbow Surg. 2016 Sep;25(9):1457-1463.

The purpose of this study was therefore to explore whether the modified tension band suture technique, is appropriate for arthroscopic repair of full-thickness rotator cuff tears of all sizes.

47 patients were enrolled in this study.

For tendon-to-bone repair, we used a modified tension band suture technique (a modified version of the tension band suture technique) and a knotless suture anchor.

Overall, the mean VAS score improved.

At the final follow-up, the clinical results showed significant improvements compared with those at the preoperative evaluations.

We found that clinical improvements were unsatisfactory and the retear rates were excessively high in the group with large to massive tears (69%) compared with those in the group with small to medium tears (6%).

We suggest that the modified tension band suture technique, as described here, has more advantages than does a traditional tension band suture technique. By using a knotless suture anchor, the operating time was shortened.


Isokinetic shoulder strength correlates with level of sports participation and functional activity after reverse total shoulder arthroplasty

Wang A, Doyle T, Cunningham G, Brutty M, Campbell P, Bharat C et al

J Shoulder Elbow Surg. 2016 Sep;25(9):1464-1469.

The aims of this study were to measure isokinetic strength after RTSA and to evaluate the correlation of various strength parameters on participation in sports and recreation and patient- reported outcome scores.

A retrospective study was performed of all patients having undergone RTSA during the period 2008 to 2013. RTSA was performed using the uncemented SMR Modular Shoulder System (Lima Corporate, Udine, Italy) in all cases.

The suyvey included 51 patients at a mean of 29.5 months (range, 12-60 months) after surgery. Mean age was 74.1 years. Patient-reported sporting activity was classified as low, medium, or high demand.

Reported sporting activity was high demand in 35% and moderate demand in 43%. There was a large variation in shoulder isokinetic strength parameters especially for internal and external rotation.

In this study, 78% of subjects had returned to moderate- or high-grade recreational or sporting activity in the short term after RTSA. This is a rate of participation similar to that reported in previously published patient surveys after RTSA as well as after anatomic TSA and hemiarthroplasty.  In addition, our study reports a high level of patient satisfaction and clinical function with RTSA.

Increased isokinetic shoulder strength correlates with greater participation in sports and recreational activity after RTSA.

The importance of internal rotation strength after RTSA has been highlighted by this study.


Shoulder arthroplasty for chondrolysis

Schoch B, Werthel JD, Cofield R, Sanchez-Sotelo J and Sperling JW

J Shoulder Elbow Surg. 2016 Sep;25(9):1470-1476.

Between January 2000 and January of 2013, 23 consecutive shoulders with chondrolysis were treated.

Shoulder arthroplasty significantly reduced pain.

Overall, 15 patients were satisfied, rating their shoulder as much better or somewhat better. Four patients rated their shoulder the same, and 4 reported being worse than before arthroplasty.

This is the largest series of shoulder arthroplasty for chondrolysis. The results of our study indicate that shoulder arthroplasty can be expected to provide pain relief and improved motion for patients with chondrolysis. However, outcome scores and subjective satisfaction are variable, with 35% of patients reporting that their shoulder is the same or worse than before surgery.

The high early rates of reoperation after shoulder arthroplasty for chondrolysis are significantly higher than those reported for TSA for the treatment of osteoarthritis in patients younger than 55 years.

The shoulder arthroplasty is a good option to give the pain relief. But the high revision rates (22%) and  no satisfaction rates (35%) are concerns.


Prevalence of posterior elbow problems in Japanese high school baseball players

Kida Y, Morihara T, Furukawa R, Sukenari T, Kotoura Y, Yoshioka N et al

J Shoulder Elbow Surg. 2016 Sep;25(9):1477-1484.

Posterior elbow problems with pain are related to baseball player and the study aimed to determinate the prevalence and diagnoses associated and the post-treatment recovery time for returning to the sport. 576 Japanese high school baseball players were enrolled in the study. The elbow of each player’s throwing arm was assessed by use of a questionnaire and physical examination. When problem detected, players visited the hospital and were initially treated conservatively and underwent surgery if necessary. Retrospectively, players with positive physical examination results associated with posterior elbow pain, defined as olecranon tenderness and/or a positive elbow extension impingement test, were selected. Those problems were found in 76 players (13.2%). Of these, 33 agreed to visit the hospital for further diagnostic imaging and 25 players (75.8%) were diagnosed with posteromedial elbow impingement. By the next spring, 87.9% of players returned to sport, and 100% of players returned to sport before the next summer. The average recovery period was 77 ± 47 days.


Articular shear injuries of the capitellum in adolescents

Frank JM, Saltzman BM, Garbis N and Cohen MS

J Shoulder Elbow Surg. 2016 Sep;25(9):1485-1490.

Fractures of the capitellum are rare and classified into 4 types in adolescents, being studied 3 type II cases, that involves a shear injury with a mostly articular cartilage component and little subchondral bone, so the diagnoses can be difficult in the immature skeleton. Those cases were treated conservativelt by misdiagnosing  and rapidly developed radiocapitellar arthrosis. They were then operated with a postoperative follow up of 49 months with good results, but one of then needed 2 subsequent operations, despite the fact that all of them demonstrated advanced degenerative changes on imaging. Results demonstrates that by the unknown long term prognosis, better imaging and a high index of suspicion is necessary and maybe a early intervention might have altered the outcome for these patients.


Interosseous membrane reconstruction with a suture-button construct for treatment of chronic forearm instability

Gaspar MP, Kane PM, Pflug EM, Jacoby SM,  Osterman AL and Randall Culp RW

J Shoulder Elbow Surg. 2016 Sep;25(9):1491-1500.

This study reports outcomes of interosseous membrane (IOM) ) reconstruction with a suture-button construct for treatment of chronic longitudinal forearm instability, by a retrospective review with prospective follow-up of patients who underwent ulnar shortening osteotomy and IOM reconstruction. Preoperative and postoperative were compared with QuickDASH score, range of motion, grip strength and ulnar variance. Ten patients were included, 8 post-traumatic sequelae of Essex-Lopresti–type injuries, 1 forearm instability secondary to previous elbow surgery, and 1 instability secondary to trauma and multiple elbow surgeries. Surgeries were performed an average of 28.6 months from injury wuith a mean follow-up of 34.6 months. Significant improvement in elbow and wrist flexion-extension arc, Quick DASH score and ulnar variance was observed. Three patients underwent for an additional surgery, but it concluded that IOM reconstruction using a suture-button construct is an effective treatment option for chronic forearm instability.


Inhibition of p38 mitogen-activated protein kinase signaling reduces fibrosis and lipid accumulation after rotator cuff repair

Wilde JM

J Shoulder Elbow Surg. 2016 Sep;25(9):1501-1508.

Because there are no known pharmacologic treatments available to effectively prevent degeneration or cause regeneration of torn rotator cuff muscles after repair, using a preclinical rat model of rotator cuff injuries, we sought to determine the ability of a small molecule inhibitor of p38 MAPK, SB203580, to reduce muscle tissue damage from inflammation, fatty degeneration, and muscle atrophy after rotator cuff repair.

Adult rats underwent a bilateral supraspinatus tenotomy that was repaired 30 days later. Rats were treated with SB203580 or vehicle every 2 days, with injections beginning 3 days before surgery and continuing until 7 days after surgery. Two weeks after surgical repair, muscles were analyzed using histology, lipid profiling, gene expression, and permeabilized muscle fiber contractility.

In this study, inhibition of p38 MAPK at the time of rotator cuff repair resulted in a clinically favorable decrease in lipid accumulation, which is a hallmark in the rotator cuff degenerative cascade and predictive of clinical outcomes.

Inhibition of p38 MAPK was also effective at reducing collagen content and inflammatory biomarkers. In addition, we found that it is possible to markedly reduce fat accumulation and fibrosis without affecting muscle fiber force production.



Fracture Mapping of Displaced Partial articular Fratures of the Radial Head.

Mellena JJ and Eygendaal D

J Shoulder Elbow Surg. 2016 Sep;25(9):1509-1516.

We tested the null hypothesis that there is no difference in fracture line distribution and location of displaced partial articular radial head fractures between specific patterns of traumatic elbow instability.

Fracture line distribution and location of 66 acute displaced partial articular radial head fractures were identified using quantitative 3D computed tomography reconstructions that allowed reduction of fracture fragments and a standardized method to divide the radial head into quadrants with forearm in neutral position. Based on qualitative and quantitative assessment of fracture maps, the association between fracture characteristics of displaced partial articular radial head fractures and specific elbow fracture patterns was determined.

Most fracture lines entered the posterolateral quadrant and exited the radial head through the anterior quadrants (77% and 98%, respectively) and parts of the posteromedial quadrant were involved in a minority of the fractures (15%). The highest fracture line intensity was located in the anterolateral quadrant near the center of the radial head, indicating that most fracture lines pass through the radial head through the anterolateral quadrant slightly anterolateral to the center of the radial head. This suggests a common mechanism of radial head fractures. Furthermore, we demonstrated that the radial head fracture location did not differ between the fracture patterns of the elbow.

Thus our fracture maps demonstrated no association between fracture line distribution and location of displaced partial articular fractures of the radial head and specific patterns of traumatic elbow instability, suggesting one common fracture mechanism that involves the anterolateral part of the radial head in most patients.


Joint capsule attachment to the coronoid process of the ulna: an anatomic study with implications regarding the type 1 fractures of the coronoid process of the O’Driscoll classification.

Shimura H, Nimura A, Nasu H, Fujishiro H, Imatani J, Okawa A et al

J Shoulder Elbow Surg. 2016 Sep;25(9):1517-1522.

This is an anatomic study using embalmed cadavers. We used 17 arms (8 right and 9 left) from embalmed cadavers. The relationship between the joint capsule attachment and the coronoid process was examined macroscopically and microscopically.

The length of the capsule attachment at the radial side of the coronoid (11.9mm) was greater than that at the ulnar side (6.1 mm). The bone thickness on the coronoid tip from the proximal edge of the joint capsule attachment was 1.9 mm; together, the cartilage and bone thickness was 4.7 mm. At the radial side of the coronoid, the thickness of the joint capsule at the proximal aspect of the attachment of 2 samples was 0.6 mm and 0.3 mm, and that at the tip of the coronoid was 2.6 mm and 1.7 mm, respectively. Based on this result, the classification between subtypes 1 and 2 of coronoid tip fractures with the O’Driscoll classification could be proved to be anatomically meaningful because it distinguishes the inclusion of the capsule attachment implying on a much larger fragment including joint cartilage and the attachment of the anterior capsule.


Comparison of shoulder internal rotation passive range of motion in various positions in nonathletic persons and the establishment of normative values for the side lying position                                    Cieminski CJ, Kelly SM, Nawrocki TJ, Indrelie AJ, Klaers H and Stelzmiller MR.

J Shoulder Elbow Surg. 2016 Sep;25(9):1523-1531.

To determine shoulder internal rotation (IR) range of motion (ROM) in three different positions (sidelying, semi-side lying and supine) and establish normative values for IR ROM in this positions, 204 nonathetic persons were evaluated. The sidelying IR showed the highest level of intra-rater and inter-rater reliability among positions analysed. Sidelying IR ROM was 47.1º for dominant side and 53.9º for nondominant shoulder, which were significantly smaller than values on semi-sidelying (56.9º / 62.1º) and supine (57.4º / 63.3º).

It was suggested that sidelying position limits the anterior tilt of scapula reducing IR. Men showed less IR ROM when compared to women for all 3 positions. IR ROM decreases with aging on both dominant and nondominant shoulders.


An anthropometric analysis to derive formulae for calculating the dimensions of anatomically shaped humeral heads

Humphrey CS, Sears BW and Curtin MJ.

J Shoulder Elbow Surg. 2016 Sep;25(9):1532-1541.

For the 79 humeral heads used, the average difference between D(diameter)F(frontal plane) and DS(sagital plane) measurements at the base of the head was 4.3 mm but the average difference clearly increased in value as humeral head size increased.  The elongation of the elliptical shape of the head base that occurs with increasing head size may be demonstrated by the evidence that DS lengthens at a slower rate than DF as head size increases and also because results show that if the difference between DF   and DS is plotted relative to the length of DF results show that the value of (DF − DS) increases as the head size increases.  To substantiate these linear regression analysis results, they compared (DF –DS) values between small, medium, and large head sizes. They conclude that on average, small humeral heads are closer to being spherically shaped, whereas with larger humeral heads, the elliptical shape at the base of the head is typically more elongated.

It was observed that females have smaller humeral heads in general than males, but the dimensional changes that occur with increasing head size appear to happen predictably and proportionally for both males and females.

This is the first study to report that on average the elliptical shape of the base of the humeral head elongates with increasing humeral head size; the biomechanical and clinical implications of this phenomenon are not yet well understood. The methods and findings of this study may have implications for future prosthetic shoulder design in which the goal is to replicate normal anatomy.


Distal tibia allograft for glenohumeral instability: does radius of curvature match?                                                  Decker MM, Strohmeyer GC, Wood JP, Hatch GM, Qualls CR, Treme GP et al

J Shoulder Elbow Surg. 2016 Sep;25(9):1542-1548.

This study evaluated radius of curvature (ROC) as the glenoid mismatch as measured on CT scans between the glenoid, distal tibia, and humeral head. Bilateral CT images were formatted giving 20 specimens per anatomic location. The mean ± standard deviation ROC was 2.9 ± 0.25 cm for the glenoid, 2.3 ± 0.21 cm for the distal tibia, and 2.5 ± 0.12 cm for the humeral head. The most significant finding in our study was that when a distal tibia was randomly assigned to a given glenoid, the mean difference between the distal tibia and the glenoid ROC was 0.55 ± 0.31 cm.  Only 22% of randomly paired distal tibias and glenoids had a difference in ROC of 0.3 cm or less. CT measurement of the ROC of the glenoid, distal tibia, and humeral head is reliable and reproducible. The probability of obtaining a random distal tibia allograft with a similar ROC to the glenoid is low. Obtaining ROC measurements of the injured glenoid and the distal tibia allograft specimen before use for glenoid reconstruction may be useful.


Redislocation risk after an arthroscopic Bankart procedure in collision athletes: a systematic review

Alkaduhimi H, van der Linde JA, Willigenburg NW, Paulino Pereira NR, van Deurzen DF and van den Bekerom MP.

J Shoulder Elbow Surg. 2016 Sep;25(9):1549-1558.

The purpose of this review was to determine the redislocation risk for collision athletes after an arthroscopic Bankart repair and to compare the redislocation rate between collision athletes and noncollision athletes after an arthroscopic Bankart repair. Screening all relevant literature of arthroscopic Bankart procedures mentioning redislocation rates in collision athletes. Therewere 1012 studies screened and finally 20 studies were included. Fourteen studies reported increased redislocation rates for collision athletes in comparison to noncollision athletes (absolute risk difference varying from 0.4% to 28.6%), whereas 2 studies reported decreased rates (absolute risk differences of −6% and −2.4%). A combined analysis revealed that collision athletes have an increased absolute risk from 3.61 to 12.57% for development of postoperative instability in comparison to noncollision athletes (P = .001). Collision athletes have an increased risk for redislocation in comparison to noncollision athletes after an arthroscopic Bankart repair, although there were no differences in return for sport.



How to Cite this article: JC Garcia Jr, Gonçalves MHL, Fink LFS, Rowinski S, AM Cardoso Jr, Raffaelli MP,
Cordeiro EF, Kozonara ME, Mello MBD, Lutfi H, Gomes RVF, Fadel MS, Steffen AM, Viana AV, Amaral RGF, Salem SM, Nunes C. Current Concepts Oct – Dec 2016. Acta of Shoulder and Elbow Surgery Oct – Dec 2016;1(1): 62-80

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Why a new Shoulder and Elbow Journal?

Acta of Shoulder and Elbow Surgery | Volume 1 | Issue 1 | Oct-Dec 2016 | Page 2-3 | José Carlos Garcia Jr.

Author: José Carlos Garcia Jr. [1].

[1] NAEON-Santa Catarina Hospital

Address of Correspondence
Dr. Jose Carlos Garcia Jr., MD, MSc, PhD
NÆON-Hospital Santa Catarina-SP-Brazil

Most Shoulder and Elbow Surgery journals are written in a far beyond context than most developing countries are up to. Distinguished features related to developed countries impact on the way people make surgeries, use materials and even make researches.

Availability of materials and devices, costs, local regulatory agencies and many other points need to be considered when talking about developing countries.Sometimes solutions adapted for these countries will not make sense for people of developed countries, with a different reality.
Then researches using some of the developing countries’ solutions will don’t make sense for reviewers from developed countries.
In the opposite side, discussing these solutions may be very important to develop shoulder and elbow surgery in developing countries. It is not about making second class researches, it is about looking researches within a different way of view. The first answer therefore is: We made this journal because we need to discuss issues adapted to our reality. We need to demonstrate results that can improve techniques possible to be reproduced all over the world. Consequently we will need to makeresearches that can be more suitable to our day by day. It does not mean bad research or bad results, it means a different way to make good things.
The second answer is: Because low cost innovations will make the world better and more equal. This journal has begun with an editorial board capable of diffusing the most recent concepts at no cost, making data easy to spread and replicate.
The third answer is: Considering that, in general, developing countries need some degree of refinement in shoulder and elbow surgery yet, transformations will be required. A rational step towards this new paradigm is an intersection of the two worlds, developed and developing countries.
This journal aims to promote this intersection by using new surgical techniques, researches and symposiums. As one wants to go further, one must have a general panorama of what is going on around to better know where to go. That is the purpose of the Current Concepts section of this journal whose content is a summary of the main journals of Shoulder and Elbow Surgery. It is not intend to explore the deepness of all research published but just a general panorama. Our concept is by accessing just this journal one can know what is going on around the world of Shoulder and Elbow Surgery and also have access to researches, symposiums and many other academical papers.
Combining all these characteristics in a single journal is essential to make surgeons updated and open minded to innovations.
This journal also begins by bringing a new concept to understand researches within the surgical field, it uses new ideas from IDEAL-Collaboration, Oxford, aiming to improve research methodology on surgical field.
We hope Acta of Shoulder and Elbow Surgery can be the new channel for all orthopedic surgeons interested in the area.
You are invited to be our reader, contributor and friend.

Warm Regards

José Carlos Garcia Jr.

How to Cite this article:.JC Garcia Jr. Why a new Shoulder and Elbow Journal?. Acta of Shoulder and Elbow Surgery Oct – Dec 2016;1(1):1

José Carlos Garcia Jr., MD

José Carlos Garcia Jr., MD

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A Comprehensive Review of Triple Disruptions of the Superior Shoulder Suspensory Complex and Case Report

Acta of Shoulder and Elbow Surgery | Volume 1 | Issue 1 | Oct-Dec 2016 | Page 56-61  | Mário Henrique Lobão Gonçalves, Jose Carlos Garcia Jr

Authors: Mário Henrique Lobão Gonçalves [1], Jose Carlos Garcia Jr [1]

[1] NAEON-Santa Catarina Hospital

Address of Correspondence
Dr. Jose Carlos Garcia Jr., MD, MSc, PhD
NÆON-Hospital Santa Catarina-SP-Brazil


Introduction: The Superior Shoulder Suspensory Complex (SSSC) is a ring-shaped structure that plays important role in stability, biomechanics and overall function of the shoulder (3). Triple disruptions (TD) of SSSC during a single trauma are extremely rare events. This paper presents a rare case of TD and a comprehensive review of the literature.
Case report: A 30-year-old man presented a combination of fracture of the base of coracoid process, AC joint dislocation and fracture of the spine of scapula with reduction of subacromial space. He was treated surgically by a dual approach, reducing and fixing all three lesions with an excellent outcome at 3 months after surgery.
Discussion: After literature search we found only 41 multiple SSSC injuries. The most prevalent structure injured was the coracoid (70.73%). When considering possible bias for diagnosing TD, like fractures of mid-shaft clavicle, the number of “true” TD decreased to 23. This significant number of misdiagnosis calls attention to confusion between the concepts of floating shoulder and SSSC, which reflects in low reliability of diagnosing (41.46%).
Conclusion: Although triple disruptions of the SSSC are very rare, they may be becoming more frequent due to an increasing high-energy accidents caused by motor vehicles. As proposed by Goss, the treatment of these lesions must fix no less than the total number of SSSC structures injured minus one.
Key words: Superior Shoulder Suspensory Complex, Double disruptions, Acromion, Coracoid, Acromioclavicular, Floating Shoulder.


The Superior Shoulder Suspensory Complex (SSSC) is a ring-shaped structure that plays important role in stability, biomechanics and overall function of the shoulder (3). It comprises the distal end of clavicle, acromioclavicular (AC) joint, acromion, glenoid and coracoid processes, and coracoclavicular ligaments. Disruptions of the SSSC in a single spot due to an AC joint dislocation are very common injuries often treated conservatively as stability of SSSC structure remains intact. Double disruptions, like AC joint dislocation together with coracoclavicular ligaments tear, destabilize SSSC ring and are susceptible to delayed union, malunion and nonunion, as well as adverse long-term functional limitations to the shoulder (5). Therefore, double brakes usually require operative treatment to regain stability of the system (3,5). Triple Disruptions (TD) of SSSC during a single trauma are extremely rare events. In fact, only 41 cases have been reported so far (8,9,10,13,15,16,17,20,21,24,25). Although some authors published injuries claiming to be TD, many of them are not true TD, but in fact double disruptions (DD) (13,17,20,21). This paper presents a case of a patient presenting combined fractures of coracoid and scapular spine together with an acromioclavicular separation after a severe motorcycle accident. This injury pattern was only reported once before (20). It is also the first report of a triple disruption of the SSSC in South America.

Case Report

A 30-year-old man without previous shoulder injury experienced direct trauma to his shoulder during a motorcycle crash. He was taken to the emergency care center with a chief complaint of intense pain to his left shoulder. Although he had suffered a head trauma and did not remember details about the accident, initial evaluation and CT scans excluded major head, spine or vital organs injuries. Physical exam revealed tenderness, swelling and a bruise at the top of his left shoulder, pain to palpation of AC joint and crepitation over the anterior aspect of shoulder. Although no definite neurovascular abnormalities on the left upper extremity were found, there were important range of movement limitations due to pain, as follow: active shoulder forward flexion/abdution of 90º/80º, reaching 110º/90º passively; 30º external rotation; and internal rotation up to the sacrum.


Initial left shoulder radiographs showed a fracture of the base of coracoid process (Ogawa classification type I) (19), a 15mm AC joint dislocation and a fracture of the spine of scapula with reduction of subacromial space (Kuhn classification type III (11))  [Figure 1]. A left shoulder computed tomography scan with three-dimentional bone reconstruction was done to better understand fracture pattern and to plan surgical treatment. It showed a 27º inferior tilt of distal scapular spine and acromion significantly reducing the subacromial space, and a 38º rotational displacement of the coracoid fragment. Scapular spine fracture line clearly did not reach the spinoglenoid notch, classified as type I of Ogawa&Naniwa classification (18), which means less risk of suprascapular nerve being damaged. [Figure 1]. Surgery for SSSC complex repair was undertaken on the 7th day post-injury. Under general anesthesia, with patient in beach-chair position, a longitudinal approach over the spine of scapula extending to lateral acromion was adopted. Suprascapular nerve was identified and the scapular spine was fixed using a reconstructive 3.5mm plate and six cortical screws. Intra-operative fluoroscopy just after this first stage continued to show displacement of AC joint and coracoid fracture. So a second ‘saber-cut’ approach had to be done in the anterior aspect of the left shoulder in order to access both coracoid and AC joint. Lacerated meniscus was removed allowing AC joint reduction and provisional fixation using a 2.5mm Steinmann pin oriented from distal clavicle to the spine of scapula just medial to fracture site. Both coracoclavicular ligaments were intact when inspected. Finally, the coracoid fracture was reduced and fixed using a 3.5mm cannulated screw under fluoroscopy. After meniculous reattachment of deltoid, the wound was closed in layers. A CT scan was repeated on the first day post-operatively to evaluate correct position of the coracoid screw [Figure 2]. Postoperatively, the patient received a continuous sling. Active hand, wrist and elbow motion were encouraged since immediately after surgery but shoulder was restrained until 6 weeks after surgery, when the Steinmann pin was removed and shoulder rehabilitation started. Both factures healed and a full painless range of shoulder motion was obtained in a 3-month period. The patient was followed for 2 years and had excellent functional outcome at the last follow-up, returning to sports activities unhindered [Figure 2].



Fractures of the scapula result of high-energy traumatic events, like motor vehicles accidents and falls from heights (1). They affect mainly 30 to 45 year-old male adults (1). These relatively rare injuries account for 3-5% of all fractures involving the shoulder girdle and 1% of all fractures. Direct trauma to the lateral aspect of shoulder is the most common mechanism of injury causing scapular fractures (1). Coracoid fractures account for 2-5% of all scapular fractures. Ogawa et al. (20) reported 35 coracoid fractures and found among them 67% of double disruptions (DD) of the SSSC and 28% of triple disruptions (TD) in a 34 year-time period (1974-2008). It shows how rare TD lesions are. Our study analysed 41 TD and coracoid was found to be the most SSSC structure fractured in these injuries (70.73%) [Table]. Acromion fractures account for near 8% of all scapular fractures. In our review we found acromion fractures in 56.10% of TD. It was the second most prevalent SSSC structure injuried among TDs, tied with AC dislocations [Table]. As up to 90% of all scapula fractures are non-displaced or minimally displaced and so they can be treated conservatively using slings or braces (1,4,5,23), it took long time until surgical treatment of scapula fractures has come to spotlight, which only occurred in the nineties. There has been a growing body of scientific literature around double disruptions of the SSSC and floating shoulder injuries lately, which indicates that these injuries may not be as rare as originally proposed (17). The Superior Shoulder Suspensory Complex (SSSC) was described by Goss in 1993 as an osteoligamentous ring located around distal clavicle and scapular junction, which have ultimate importance in shoulder biomechanics (3). It comprises the distal end of clavicle, acromioclavicular (AC) joint, acromion, superior glenoid and coracoid processes, and coracoclavicular ligaments (3). Isolated disruptions to the SSSC with minimal or moderate displacement, like AC dislocations grades I and II of Rockwood classification (23), do not affect stability of the SSSC ring allowing them to be successfully treated conservatively. On the other hand, double disruptions of the SSSC injuries make the SSSC ring unstable affecting shoulder biomechanics. They involve several combinations of injuries to SSSC structures deeply related to each other, whose treatment is still challenging.  In the past, assessment of double disruptions of the SSSC was made in an isolated manner, which frequently took to inadequate treatment since biomechanical correlation between SSSC structures was unknown. Then, Goss made these injuries easier to comprehend as he compared SSSC to a ring(3,4,5), where every structure of the ring correlates to each other to grant stability to the system. So, surgical treatment must restore at least one of the SSSC lesions in order to restore ring stability and, by doing that, it indirectly reduces and stabilizes the second break (3). Without proper surgical repair these injuries commonly evolve to delayed-union, nonunion or mal-union, leading to a long-term dysfunctional shoulder (3). However, there is still missing trials that approach long-term shoulder dysfunction after conservative and surgical treatment for double disruptions of the SSSC. Ganz and Noesberger (6) described in 1975 a combined ipsilateral fracture of mid shaft clavicle and scapula neck, known as “Floating Shoulder”. Although described much earlier than the SSSC, this concept poses confusion to the diagnosis of SSSC lesions. When one tries to mix Floating Shoulder to the SSSC concept, it is common to see misdiagnosis. Mistakes usually happen when one consider mid-shaft clavicles as a part of the SSSC.


It is not rare to see misdiagnosed DD by including scapula body and glenoid intrarticular fractures as well. Most articular glenoid fractures do not disrupt the SSSC. In fact, the only ones that do affect the SSSC are Goss-Ideberg types III and variants(4). Triple disruptions (TD) of the SSSC are indeed very rare injuries. Generally they are much more unstable than a double disruption. So they require surgical stabilization of at least two structures in order to restore stability of the ring. Although there is none evidence-based guidelines for much complex injuries, most surgeons follow the same principles proposed by Goss for treatment of DD of the SSSC. Almost all published studies addressing TD injuries are case reports of surgical treatment and they have demonstrated good outcomes so far. Only one case report treated conservatively a 74-year-old men who, despite oriented about the severity of his lesions (AC dislocation, acromion, coracoid and posterior glenoid border fractures), decided not to operate and presented reasonable functional outcomes after one year(25). Although our case report did not presented any associated lesion, several reports mention associated injuries to SSSC disruptions, like rib fractures, proximal humerus fractures, spinal trauma, braquial plexus and peripheral nerves injuries, and hemothorax. As some of these are life-threatening injuries, they might contribute to the low prevalence of TD of the SSSC. After a comprehensive literature search we found eleven studies about multiple (more than two) SSSC injuries(8,9,10,13,15,16,17,20,21,24,25). Most papers describe the author’s experience of treating SSSC lesions through various techniques (8,10,15,16,24). From the 11 studies analysed in this study, 8 of them (72.72%) are case reports (8,9,10,13,15,16,24,25) and all but one describe surgical treatment (25). The largest series found include 15 patients with greater than two disruptions of the SSSC (12 triple and 3 quadruple ruptures). It is the only level IV therapeutic study available until now(17). All injuries presented on that paper affected mostly men with a mean age of 35 years. They resulted from motorcycle and snowmobile accidents, motor vehicle collisions and falls from heights. Considering the high-energy of trauma involved on TD of the SSSC, some authors believe these injuries could not be caused by a single impact to the shoulder, but rather they must result from multiple impacts during one severe high-energy trauma event. It also explains the significant number of concomitant associated injuries found on that study (87%), which delayed surgical treatment of the SSSC in mean 23 days. Such complex traumas demanded operative treatment for all 15 patients and 67% of them required more than 1 surgical approach to adequately restore alignment and stability of the SSSC. Post-operative functional scores (DASH and SF-26) and shoulder range of motion were good at mean follow-up of 30.7 months, with very low rate of complications, except for a mean overall decrease of 64.33% in shoulder strength for forward flexion, abduction and external rotation compared to the non-injured side. After plotting information from all 11 studies analysed, a total of 41 multiple disruptions of the SSSC were found. 35 (85.36%) were initially considered triple disruptions (TD) and 6 (14.64%) quadruple disruptions (QD). The most prevalent SSSC structure injured on these complexes traumas was the coracoid process (70.73%), followed by acromion (56.10%), clavicle (56.10%) and AC joint (56.10%). TD involving fractures of scapula spine, like the one presented on this case report, were the most rare, with only 2 cases reported (4.88%). Before this, only one similar case report had been published. When taking into consideration possible bias for diagnosing TD and QD of the SSSC, like fractures of mid-shaft clavicle, scapula body and glenoid cavity fractures, the number of “true” TD and QD decreased to 23 and 1 respectively. The main cause of misdiagnosis occurs when mid-shaft clavicle fractures are considered as an SSSC rupture (62.50%). In fact, according to Goss, mid-shaft clavicle fractures are not considered disruptions of the SSSC, neither scapula body (23.53%) nor glenoid edge fractures (13.97%). The significant number of misdiagnosed TD (52.17%) and QD (83.33%) calls attention to the very confusing interaction between the concepts of floating shoulder and the SSSC, which reflects in low reliability of diagnosing multiple simultaneous SSSC structures disruptions (41.46%). Le Coq et al (13) published in 2001 the first case report of a triple disruption of the SSSC. It was a combination of fractures of acromion and coracoid processes and a non-displaced mid-shaft clavicle fracture, which by definition is not a SSSC structure. So, in fact, it was a double disruption (DD) instead of a “true” triple disruption as proposed. The fact that he only had to fix the coracoid to obtain stability of the shoulder joint confirms the SSSC ring was only disrupted in two sites. Other authors also committed similar errors(9,20,21). Recently, Kim et al (9) reported a combination of AC dislocation, coracoid and mid-shaf clavicle fractures as a triple disruption, but that was in fact a DD. Toft et al (25) published the first QD of the SSSC treated non-operatively, but among the ruptures described there was an articular glenoid edge fracture that, despite needed fixation, is not a true SSSC disruption. From the 6 cases of QD ever published(17,21,25), only one is a “true” QD (17) and it is still one of a kind. It calls attention to the extreme rarity of QD lesions. Perhaps the reason for that is the supreme energy necessary to disrupt the SSSC ring in four concomitant sites.

Due to the rarity of triple disruptions, like in the others case reports, this case exhibits a possible surgical treatment based on techniques previously described for double ruptures of the SSSC. None technique presented can be considered as ‘gold standard’, neither superior to any other treatment option. Despite this case showed excellent outcomes in a 2-year follow-up after surgery, there is no long-term guarantee that this patient will preserve a functional and pain-free shoulder. At last, the low reliability in making a correct diagnosis of multiple concomitant SSSC disruptions presented in this comprehensive revision of the literature overclouds even more the understanding of such complex injuries and slow the settlement of treatment guides.


Although triple disruptions of the SSSC are very rare, they may be becoming more frequent due to an increasing high-energy accidents caused by motor vehicles. CT scans are important tools to better understand injuries patterns and to plan surgical treatment. Goss’ SSSC principles should be followed straightly in order to avoid misdiagnosis of triple and quadruple disruptions of the SSSC. Treatment of these lesions must also follow Goss’ principles, taking into consideration the scarce treatment trials available. The number of structures to be fixed may vary in each case, but it must not be less than the total number of SSSC structures injured minus one.


1. Ada JR, Miller ME. Scapular fractures. Analysis of 113 cases. Clin Orthop Relat Res. 1991; 269:174–80.
2. Egol KA, Connor PM, Karunakar MA, et al. The floating shoulder: clinical and functional results. J Bone Joint Surg Am. 2001; 8:1188-1194.
3. Goss TP. Double disruptions of the superior shoulder complex. J Orthop Trauma. 1993; 7:99-106.
4. Goss TP, Owens BD. Fractures of the Scapula. In: Rockwood CA Jr, Matsen FA, editors. The Shoulder. 4th ed. Vol. 1. Philadelphia, PA: Saunders/Elsevier. 2009; pp333–80.
5. Goss TP. Scapular fractures and dislocations: Diagnosis and treatment. J Am Acad Orthop Surg. 1995; 3:22–33.
6. Ganz R, Noesberger B. Treatment of scapular fractures. Heffe Unfalheikd. 1975; 126:59-62
7. Hak DJ, Johnson EE: Avulsion fracture of the coracoid associated with acromio-clavicular dislocation. J Orthop Trauma. 1993; 7:381-383.
8. Jung CY, Eun IS, Kim JW, Ko YC, Kim YJ, Kim CK. Treatment of triple fracture of the superior shoulder suspensory complex. J Korean Orthop Assoc. 2011; 46:68–72.
9. Kim BK, Dan J. A triple disruption of the superior shoulder suspensory complex mstaken for a Double disruption: a case report. Arthrosc Orthop Sports Med. 2016; 3:45-48.
10. Kim SH, Chung SW, Kim SH, Shin SH, Lee YH. Triple disruption of the superior shoulder suspensory complex. Int J Shoulder Surg. 2012; 6:67-70.
11. Kuhn JE, Blasier RB, Carpenter JE: Fractures of the acromion process: A proposed classification system. J Orthop Trauma. 1994; 8:6-13.
12. Kurdy NM, Shah SV: Fracture of the acromion associated with acromioclavicular dislocation. Injury . 1995; 26:636-637.
13. Lecoq C, Marck G, Curvale G, Groulier P. Triple fracture of the superior shoulder suspensory complex. Acta Orthop Belg. 2001; 67:68–72.
14. Lim KE, Wang CR, Chin KC, Chen CJ, Tsai CC, Bullard MJ. Concomitant fracture of the coracoid and acromion after direct shoulder trauma. J Orthop Trauma. 1996; 10:437–439.
15. Liu AJ, Chen PJ, Shen PW. Triple injury to the superior shoulder suspensory complex. Form J Musc Dis. 2013; 4:81-83.
16. Mariño IT, Martin Rodríguez I, Mora Villadeamigo J. Triple fracture of the shoulder suspensory complex. Rev Esp Cir Orthop Traumatol. 2013:57:371-4.
17.Mulawka B, Jacobson AR, Schoroder LK, Cole PA. Triple and quadruple disruption of the superior shoulder suspensory complex. J Orthop Trauma. 2015; 29:264-70.
18. Ogawa K, Naniwa T: Fractures of the acromion and the lateral scapular spine. J Shoulder Elbow Surg. 1997; 6:544-548.
19. Ogawa K, Yoshida A, Takahashi M, Ui M. Fractures of the coracoid process. J Bone Joint Surg Br. 1997; 79:17–9.
20. Ogawa K, Matsumura N, Ikegami H. Coracoid fractures: therapeutic strategy and surgical outcomes. J Trauma Acute Care Surg. 2012; 72:E20-E26.
21. Oshima M, Nakagawa Y, Mondori T. Complex injury patterns of the shoulder girdle three or four site injury. Shoulder Joint. 2003; 27:555-559.
22. Oh W, Jeon IH, Kyung S, Park C, Kim T, Ihn C. The treatment of double disruption of the superior shoulder suspensory complex. Int Orthop. 2002;26:145–9.
23. Rockwood CA: Injuries to the acromio-clavicular joint, pp. 680-910. Rockwood & Green 1stEd: In Fractures in Adults. JB Lippincott, Philadelphia, 1984.
24. Sung CM, Park HB. Triple disruption of the superior shoulder suspensory complex: case report at 5-year-follow up. Clin Should Elbow. 2012; 15:143-147.
25. Toft F, Moro F. Quadruple disruption of the superior shoulder suspensory complex and outcome after one yearof conservative treatment: a case report. J Clin Exp Orthop. 2016; 2:20.
26. van Noot A, te Slaa RL, Marti RK et al. The floating shoulder. A multicentre study. J Bone Joint Surg Br. 2001; 83:795-798.

How to Cite this article: Gonçalves MHL, JC Garcia Jr.,  A Comprehensive Review of Triple Disruptions of the Superior Shoulder Suspensory Complex and Case Report. Acta of Shoulder and Elbow Surgery Oct – Dec 2016;1(1):56-61.


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Cochrane’s Shoulder-and-Elbow Systematic Reviews Issues: Mistrustful Impact of Evidence

Acta of Shoulder and Elbow Surgery | Volume 1 | Issue 1 | Oct-Dec 2016 | Page 47-55 | Jose Carlos Garcia Jr, Mario H L Gonçalves, Eduardo F. Cordeiro, Luiz F S Fink, Alvaro M Cardoso Jr, Mauricio P Raffaelli, Maurício S Fade.

Authors: Jose Carlos Garcia [1], Mario H L Gonçalves [1], Eduardo F Cordeiro [1], Luiz F S Fink [1], Alvaro M Cardoso [1], Mauricio P Raffaelli [1], Maurício S. Fade [1]

[1] NAEON-Santa Catarina Hospital.

Address of Correspondence
Dr. Jose Carlos Garcia Jr., MD, MSc, PhD
NÆON-Hospital Santa Catarina-SP-Brazil


Introduction: Evidence-based guidelines are important for Medicine. However they have repeatedly failed in presenting conclusive evidence in surgical field. The reason is limited availability of well-designed scientific studies. In order to investigate limitations and their impact on Shoulder and Elbow Surgery field, we assessed data of Systematic Reviews (SRs) from the Cochrane Library database for risk of bias. Analysis of the 35 SRs assessed presented the following risk of bias: Comparable outcomes within SRs studies – 42.86%; Blinding – 40.80%; Sample size calculation – 7.43%; Missing valus handling – 16.14%; Adequate statistical analysis – 11.74%; Monitoring – 0.37%; and Meta-analysis data heterogeneity – 40.54%, showing that these papers have low methodological quality. This study may call attention of Shoulder and Elbow surgeons to aim in quality improvement, data comparability and reliability of primary trials and SRs. Future conjoint effort in defining and diffusing feasible standards for surgical trials must be made by local and international societies of surgical specialties.
Key Words: Shoulder, Elbow, Systematic Review, Methodological Quality.


Evidence-based medicine is the source for the highest level of evidence and reliability, driving to better decision-making in medical practice25. Despite all advantages of this method, one must be aware of the difficulty in accessing nonpublished Clinical Trials or Clinical Trials published in languages other than English, which are common limitations related to all Systematic Reviews (SRs) [29]. Clinical Trials whose statistical significance is not reached are frequently considered ‘second-class’ papers, being disregarded by clinical researchers and not accepted for publication by reviewers12. The absence of inclusion of these data into the SRs and meta-analysis leads to biased interpretations and conclusions40. The way SRs are conduted and how results are extracted from primary studies vary among different areas of medicine. Each different area has its particularities and limitations for research. It is very clear when we compare clinical and surgical trials. Following are the main particularities that preclude surgical field research to be conducted in similar way to clinical ones: (1) Impossibility of double blinding – some trials compare techniques that do not allow true blinding. For example, scars inherent to open surgery technique cannot be hidden when comparing it to an endoscopic procedure. (2) Learning curve – unlike of ministering manufactured pills, surgical performance will depend on surgeon’s experience and it surely affect outcomes33,10. (3) Technological evolution of implants and devices – over time history showed us improvement in outcomes of endoscopic procedures over open ones due to progress of devices [27]. Also it is not adequate to compare procedures done with different generation of implants (4) Technique evolution – modification of some steps within the same technique can also impact learning curve and results. These and other characteristics make surgical research much more complex than those within clinical trials outside the surgical field. Recentely Orthopaedic Surgery evidence-based medicine has promptly grown in importance after publication of some pivot Randomised Controlled Clinical Trials (RCTs) [24]. However, most SRs failed to present enough evidence to establish a reliable Evidence-Based Practice Guideline because strict selective criteria for inclusion in SRs limited the number of RCTs in the meta-analysis.  Methodological limitations, such as improper randomization40, absence of Intention-to-Treat analysis23, poor selection criteria [22] and lack of standardization of outcomes are pointed out as main causes of failure of Orthopedics’ and its subspecialties’ SRs [30,41]. Better and deeper understanding of these limitations may be key to improve both primary research and consequently SRs in orthopaedic surgery. Thus, better decisions based on the best evidence will be able to be made.


Study Design
This Systematic Review assesses Cochrane’s Systematic Reviews of Shoulder and Elbow. The authors are orthopaedic surgeons familiar with this field of knowledge. So Shoulder-and-Elbow subspecialty will represent orthopaedic surgery addressed in this study, following Descartes’ principle that “all complex matters need to be divided into many simpler parts in order to better focus on specific problems, thus creating greater possibilities of understanding and solving them”. As Cochrane Library is known as one of the most complete, important and reliable sources of SRs [13], a review of all Cochrane SRs related to shoulder-and-elbow subspecialty was conducted to better understand limitations and characteristics of RCTs and SRs related to orthopedics.

Search Strategy
Two strategies were used: (1) Cochrane website’s Search Tool – Medical Subject Headings (MeSH) terms searched: shoulder, elbow, scapula, humerus, cuff, ulna, epicondylitis and dislocation. The SRs that addressed the subspecialty of Shoulder-and-Elbow Surgery were chosen by assessing titles. (2) Direct search in Cochrane Bone, Joint and Muscle Trauma Group. Thereafter three senior specialized in should-and-elbow orthopaedic surgeons reviewed all abstracts identified and consensually withdrew duplicated papers, the ones that are not related to shoulder-and-elbow, studies that were just protocols, studies that were split into others and outdated ones. As inclusion phase is from utmost importance, five senior surgeons analysed all papers and consensually withdrew studies not related to at least one of the following topics: physical exam, clinical or surgical therapeutics of shoulder-and-elbow subspecialty.

Data Extraction
All data were extracted as consensus by three authors that assessed methodology of the selected SRs based on Cochrane’s Methodological Quality Assessment Tool [8,14,5,20,19] and Complementary Assessment of RCTs [40,41,43,15,39,11].

Measurement Tools
The Cochrane Musculosketal Group grades SRs’ evidence as: Platinum, Gold, Silver or Bronze levels, according to Cochane’s Methodological Quality Assessment. This has two different bias assessment tools: Surgical and Clinical, each specific for the nature of the SRs analysed. They comprise a judgement and support for each entry in a ‘Risk of bias’ table, where each entry addresses a specific feature of the study as low risk, high risk or unclear risk. For trials of clinical treatments, an eleven-item risk of bias assessment was used: randomization, allocation concealment, balance in baseline, blinding provider, co-interventions avoided, adherence acceptable, patient blinded, acceptable withdrawn, outcome assessor blind, timing of assessment comparable and Intention-to-Treat analysis [8,14,5,20,19].  For surgical treatment trials, a seven-item risk of bias was used assessing: randomization, allocation concealment, functional blinding, incomplete outcome (losses >20%), selective reporting, base-line balance and performance bias [8]. The Complementary Assessment of RCTs assesses other important points not considered by Cochrane’s tools. It was developed using important issues from CONSORT [11], COMET [32] and Cochrane Handbook [44] related to quality standards8. For each issue assessed there were five possible answer categories: yes, no, unclear, not-applicable (NA) and not-reported (NR). There are three sections: (1) Issues related to SRs – Less than 40% heterogeneity between primary trials within the review, which means low to moderate heterogeneity8; (2) Choice of Outcomes – if study present at least one outcome as ‘standard’ comparable at more than 50% of primary papers included in the review; (3) Issues related to primary studies in SRs – Choice of Target Population, Blinding, Sample Size (reduce type 2 error), Adequate Statistical Analysis (assessment of curves characteristicsto understand if data is parametric or non-paramentric, presence of standard deviations and standard errors, etc), Missing Values Handling (Intention-to-Treat or Per-Protocol), Data Entry Cautions (reading aloud, single data entry with cross-checks or double data entry) and Data Monitoring. Since clinical and surgical treatments present different patterns of assessment, the authors chose to stratify analysis through these two types of treatment to better understand differences between them. SRs that do not present any RCT were not removed. Instead they were assessed separately to better understand causes of withdrawal of primary papers.

Data Analysis/ Procedures
Variance with standard error, standard deviation and confidence intervals were not logical analysis for this review, once the entire population of Cochrane’s Shoulder-and-Elbow SRs was addressed. Statistical methods provide estimations with respect to a certain degree of uncertainty and results reflect all of the population of the SRs. Thus, this SR shows the ultimate results based on the whole data. Data for Cochrane Musculoskeletal Group’s primary trials were presented only descriptively.
Results for Cochrane’s Methodological Quality Assessment and Complementary Assessment of RCTs were presented in frequency through proportions and percentagens of risk of bias for each item stratified into subgroups. Papers withdrew from SRs, including SRs without meta-analysis, were analysed for most common reasons for withdrawal and data presented in frequency by absolute numbers. Results were stratified into the following groups: all SRs, Clinical SRs, Surgical SRs and SRs without meta-analysis.

As this study comprises a secondary data analysis, University of Liverpool Ethics Committee, Santa Catarina Hospital and the Brazilian Government granted approval based on the fact that there was no risk to human subjects.


Thrirty-eight SRs were included, 17 of them are surgical and 21 clinical. Of all surgical SRs, 2 did not present RCTs or quasi-randomised trials and therefore did not present meta-analysis. On the clinical group, one SR did not present meta-anaylisis.

Table 1: Results of Cochrane's Methodological Quality Assessment tools for clinical SRs

Table 1: Results of Cochrane’s Methodological Quality Assessment tools for clinical SRs

SRs were assessed in 3 groups: whole 38 SRs, Clinical (20 SRs) and Surgical (15 Srs). According to Cochrane Musculoskeletal Group grade for primary trial, including SRs without meta-analysis, of all 38 SRs selected only one paper reached platinum level of evidence. Three SRs reached silver level, one with high risk of bias due to heterogeneous intervention and two low risk of bias. Three other SRs presented very limited evidence. Due to lack of any proper evidence others SRs could not be graded by Cochrane Musculoskeletal. Results of Cochrane’s Methodological Quality Assessment tools for clinical and surgical SRs are respectively shown on TABLES 1 and 2.

Table 3: Complementary Assessment analysed 9 topics looking for potential bias not considered on Cochrane's Methodological Quality Assessment

Table 3: Complementary Assessment analysed 9 topics looking for potential bias not considered on Cochrane’s Methodological Quality Assessment

Complementary Assessment developed by the authors analysed 9 topics looking for potencial bias not considered on Cochrane’s Methodological Quality Assessment. Results are shown on TABLE 3.  Target Population topic assesses if patients were suitable for the proposed intervention and almost all SRs presented adequate target population. But 3 primary papers were conducted among militaries and were considered as potential bias. Heterogenity <40% and Comparable Outcomes were found in round 40% of the Srs. Blinding, as expected, showed a great difference between clinical (54,30%) and surgical (19,35%) papers. Sample Size Calculation, Statistical Analysis and Missing Values were presented in less than 20% of all SRs, what made us very concerned about reliability of results. Data Entry seems to be well difunded among SRs authors. All SRs analysed had reported it. However, none Primary Paper had it. Monitoring was the worst aspect taken into consideration by researchers. Only one SR (0,37%) had adequate monitoring and it was a clinical SR. Papers and SRs without meta-analysis were withdrawn and results are shown on TABLE 4, stratified by reason for exclusion.

Table 4: Papers and SRs without meta-analysis were withdrawn and stratified by reason for exclusion

Table 4: Papers and SRs without meta-analysis were withdrawn and stratified by reason for exclusion


Cochrane’s Systematic Reviews are known by high standard and reliability. Many physicians have been using them as guide for the best evidence possible in certain fields of medicine. Despite they have proven to be effective to summarise results of trials in the Clinical field, they lack effectiveness in many Surgery trials. A commom complaint among surgeons is that SRs have not been able to provide reliable guidelines. Conclusions are repetitively similar in most of SRs: “There is limited evidence available from RCTs on the relative effectiveness of [a certain surgical treatment]”. Considering SRs analysed in this article were conduted in conformance with the high standards of Cochrane Collaboration, the absence of adequate evidence must be due to failure within primary papers and withdrawn ones. Of all reviewed SRs, we found a low rate of conclusiveness. Only one article reached the Platinum level of evidence according to Cochrane, showing that Shoulder-and-Elbow SRs have often failed to present enough evidence to establish reliable evidence-based practice guidelines41. Some authors stated that “absence of evidence is not evidence of absence”1. Therefore, the main cause of this lack of evidence may just be absence of data for establishing reliable results. The number of individuals necessary to suitably answer a research question may be more than those enrolled in the SR, making results not truly reliable. So, larger samples will lead trials to achieve narrower confidence intervals and high statistical power31. SRs may be guides to determine whether more studies are necessary or not to suitably answer a research question, as well as to determine what direction researchers need to follow in future trials, like sample sizing and research harms9. Deep analysis of the only Platinum-level SR found in this study showed: inclusion of a Silver-level primary study, only 50% of included papers had Intention-to-Treat, only 40% performed Sample Size Calculation and less than half of outcomes were comparable. So, despite having 90% of blinded primary papers and 70% of adequate statistical analysis, there is a lack of methodological quality that precludes adequate use of this data for meta-analysis. Less than 50% of SRs presenting at least one comparable outcome indicate an immediate necessity of discussion and standardization of outcomes among Shoulder and Elbow researchers. The Rowe scale37 was the most ‘popular’ (50%) specific outcome for shoulder instability within Cochrane’s SRs probably because it is simple, fast and reproductible. For rotator cuff interventions we found 3 major outcome assessment scores: UCLA21 (5 /14) – the oldest and most used; Constant35 (3/14) – mostly used in Europe; and ASES28 (1/14) – mostly used in North America. Perhaps if all future primary papers could standardize the use of all three outcome-scores in a definite timeframe, papers would certainly be more comparable all around the world. There is over emphasis in effectiveness within the SRs in expence of many times omitting safety information16. Indeed, medical decision follows a Paraconsistent logic pattern where positive and negative aspects are weighted to reach the best decision for each individual3. Thus, insufficient disclosure of safety aspects within a SR can overestimate effectiveness, driving to biased decisions regarding treatment. Simple methodological issues like Blinding presented remarkable antagonism within clinical and surgical fields of the same subspecialty. Realiable blinding was found in only 19.35% surgical RCTs in contrast to 61.14% clinical RCTs. Surgical approach, post-surgical exams and ethics seems to be the main reasons why blinding is more feasible for Clinical Trials than Surgical ones. As Double-Blinding is extremely difficult to achieve in Surgical Trials, it is almost impossible for them to reach Cochrane’s Platinum level of evidence. In this way, Cochrane Musculoskeletal Group proper grading for primary trials does not seem suitable for surgical trials.  Sample Size Calculation is key factor to avoid Type II error but it is present in only 5.22% of primary papers analysed. This is an important reason why SRs lack statistical power and reliability36 and it must be highlighted in congresses and discussions in order to avoid biased conclusions of primary papers. Another important point to be considered in trials is data loss. There is tendency towards a higher drop out rate amongst patients who failed to respond to treatment2 resulting in bias towards positive results6. Intentio-to-Treat (ITT) is a good tool to avoid this type of bias. However in this study, the major part of the entire assessed primary papers that used ITT did not even mention the type of ITT technique used. Using Per-Protocol can estimate effectiveness to be overly optimistic, driving researchers to biased conclusions2. A reliable statistical analysis is also very important for achieving reliability. Different statistical approaches may be necessary in different conditions, depending on sample size, distribution of data and many other factors4. Many primary papers present results without mentioning data distribution verification and insufficient detail about statistical methods used. Only 18.69% of all SRs and 30.70% of primary papers presented analyses of statistical methodology. This must alerts investigators about potentially biased results and misleading conclusions38. Current high standards for Clinical Trials require data entry to be scrutinized for reliability. Strategies include reading aloud18, single data entry with cross check42 and double data entry7. All SRs assessed showed strategies used, but no primary paper reported data entry strategies. In fact, the whole set of primary papers never mentioned it. Good Clinical practices have standardised all legal and ethical steps to be followed in order to conduct a Clinical Trial. However, monitoring is main concern within this standardization17. Monitoring improves reliability by checking all steps within study. Only two primary clinical papers cared about this aspect in our study. A possible solution for improving monitoring could be subspecialty societies or international collaborations to assume this role.
Heterogenity is key factor within a meta-analysis. It shows how different results are among trials. So, the more heterogeneous results are, the more incompatible they will be, reflecting difficulty in assessing outcomes. In this review, 40.54% of SRs presented moderate to low rate of heterogeneity, suggesting better standardization of procedures, interventions, and/or assessments like the ones proposed by the IDEAL-Collaboration34. Randomization is ‘sine qua non’ for Primary Papers to provide data to meta-analysis within a Cochrane SR. But if not well done they can be under risk of bias. Quasi-randomization can be considered as high risk of bias. From all Shoulder-and-Elbow SRs analysed, randomization seemed not to be a concern at first look, as 63.43% of RCTs were considered low risk, but when stratified only 36.07% of surgical trials had adequate randomization against 75.85% on clinical ones. It clearly shows another fragility of Surgical Papers. Allocation Concealment is important to avoid selection bias and protect randomization. Only 29.14% of clinical RCTs and 29.03% of surgical trials presented low risk of bias allocation concealment. These rates are very low and require significant improvement. Balance at Baseline ensures homogeneity of individuals among groups researched. If imbalance is found, all results might be compromised. The baseline of surgical trials was balanced (low risk of bias) in only 24.73%, while for clinical trials more than double (51.43%).  Only 58.28% of RCTs were free of co-interventions in Clinical Trials. This measure was not performed for Surgical Trials. This data exposes an alarming situation wherein confounding factors can be present in 41.72% of the papers. Better inclusion/exclusion criteria are necessary in order to foresee and avoid any possible co-interventions. Adherence to treatment is crucial to adequate treatment and it is considered an important source of bias as noncompliant patients are removed from studies. Withdrawal is considered acceptable when inferior to 20% of all enrolled individuals. We found 62.28% of RCTs to present acceptable withdrawn, which suggest biased conclusions once most dropouts are poor results43,6. Intention-to-Treat analysis with a growning curve, baseline data and admitting failure of treatment are helpful strategies to mitigate this issue. Timing of assessment was just measured at the Clinical SRs group. Surgical trials did not present this data. In 73.71% of the assessments there was a low risk of bias, which seems acceptable. Selective Reporting was just measured at the Surgical SRs group. Low risk was found in just 15.05% of RCTs, which can drive investigators to biased results. The main causes of withdrawal found are: deficiency in randomization (183 papers), retrospective studies (154), not specified results (63), incorrect or insufficient enrolment (62) and incorrect intervention (61). Once again, this data point out deficit of high standard prospective papers in the Shoulded-and-Elbow field. In summary, it is clear that Clinical and Surgical Primary Trials within the Shoulder-and-Elbow subspecialty need to improve their methodological quality in order to reach a suitable pattern of quality. Surgical trials tend to present less quality and more inconclusive results than clinical ones41, because of following reasons: (1) learning curve of surgeons33 – minimally invasive techniques and new procedures tend to be technically more demanding, thus having worse initial results; (2) surgical dexterity33,26 – natural variability among surgeons must be addressed at SRs as a potential cause of bias; (3) evolution of devices – rapid evolution of devices may add additional bias when compared to older models; (4) lower budgets for surgical trials; and (5) variability of lesions – surgical trials have to group variable similar lesions in packages in order to harmonize the baseline. Local and international societies of specialties and subspecialties will have to work hard together to get into an agreement about methodologies in their research. The IDEAL-Collaboration34 has been a pioneer on this field, establishing and improving research methodology for future Surgical Trials, but it still lacks recognition and acceptance by societies.

This study is based only on SRs presented by Cochrane, which demands very high standards of methodology. Therefore, data presented here may underestimate methodological problem of primary papers.
As data assessed in this paper were extracted from Cochrane’s SRs, not directly from the primary trials, they might be suscectible to errors, misses or faults.


As most Systematic Reviews in Shoulder and Elbow Surgery contain primary trials and RCTs with a high risk of bias, their conclusions must be interpretated with caution. Data from this study may be helpful for future generations of shoulder-and-elbow researchers helping them to focus on methodological quality improvements and thereby enhance worldwide discussion about surgical research methodology, standardized outcomes, timing of assessment and adequate monitoring. Also, it may help to establish new standards for primary surgical trials within shoulder and elbow surgery, like the IDEAL-Collaboration has done in many other surgical fields.


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How to Cite this article: JC Garcia Jr, Gonçalves MHL, Cordeiro EF, Fink LFS, AM Cardoso Jr, Raffaelli MP,  Fade MS. Cochrane’s Shoulder-and-Elbow Systematic Reviews Issues: Mistrustful Impact of Evidence. Acta of Shoulder and Elbow Surgery Oct – Dec 2016;1(1):47-55


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Proximal Humerus Non Union

Acta of Shoulder and Elbow Surgery | Volume 1 | Issue 1 | Oct-Dec 2016 | Page 8-13| Ashish Babhulkar.

Authors: Ashish Babhulkar [1]

[1] Shoulder & Sports Injury Specialist, Deenanath Mangeshkar Hospital, Pune

Address of Correspondence
Dr. Ashish Babhulkar
Shoulder & Sports Injury Specialist, Deenanath Mangeshkar Hospital, Pune.


Introduction: Non-union proximal Humerus Fractures are complex and the aim of the surgeon should be pain free restoration of function – Functional range of movement & good rotator cuff strength. Pre operative planning in the form of appropriate clinical evaluation, CT scan or other imaging techniques and keeping all options open during surgery is useful. Patients must be counseled about the likely complications since a revision procedure is always fraught with hurdles and obstacles. Careful initial immobilisaiton followed by a supervised structured rehab programme will help the patient achieve a good result. Patients with cartilage damage and OA and in the elderly group may be offered a hemiarthroplasty provided there is no infection and the rotator cuff integrity is maintained. When rotator cuff function is compromised and Surgeon is dealing with a frail elderly patient, a Reverse Shoulder Arthroplasty is probably the surgery of choice , provided Deltoid is unaffected.
Keywords: Proximal humerus fracture, nonunion, fixation.


Proximal humerus fractures (PHF) are rather common and in the past have led to significant disabilities. The locked plate concept revolutionized early mobilization of PHF reducing incidence of post fracture stiffness. The provision of angle stable plates even within osteoporotic bones curtailed the use of shoulder replacements for complex PHF. With the success of locked plate fixations, conventional plating became redundant but along with it came high incidence of complications [1,2]. Hemiarthroplasty for PHF was also a revolution for the complex fracture dislocations and non-unions. After about 15 yrs of shoulder hemiarthroplasty we are now understanding its limitations in restoring full function [3]. Non-union after ORIF has been reported between 0% – 25% [3,4,5,6].  The challenges of non union PHF range from soft tissue fibrosis involving the rotator cuff, deltoid and short and long head of biceps, stiffness and capsular contractures, osteopenic bone, shortening and varus and perhaps most important – tuberosity displacements. Naturally, prudence lies in offering joint preservation in younger patients with ORIF and bone grafting if necessary. In the presence of split head fractures, late presentation of PHF, even in younger patients, and in the presence of AVN, it may not be possible to offer a joint preservation option. In the same vein elderly patients with non-union PHF are likely to be treated with shoulder hemiarthroplasty but this need not be the norm. The author classifies the elderly into three groups – (A) Less than 60yrs with adequate bone stock and vascularity in proximal humerus – may be offered a revision fixation with a locked plate and bone grafting. (B) The older than 60 yrs with good shoulder function and a healthy rotator cuff – should be offered a shoulder hemiarthroplasty which eliminates the doubt about union rates in elderly and may reduce the time to rehabilitation. A robust tuberosity fixation technique is however critical. The other group of elderly patients (C) above 70 years, frail, poor or absent rotator cuff function [7], with severe osteopenia have a high rate of complication [8]. The introduction of reverse shoulder arthroplasty (RSA) has changed the outlook for these very elderly patients and provided consistent restoration of function though with its added problems and issues. Absence of signs of union six months after fixation should qualify for a non-union. Lack of bridging or callous across the fracture site at two months could be a sign heralding non-union. Each case is diverse in nature and could fall between the three major groups and should be treated with its individual merit. Absence of infection and neuro-vascular deficit is vital before embarking on any of the above treatment plans.


Proximal humerus has a rich anastomosis of blood supply and hence union is usually brisk and predictable. Four-part fracture dislocations are a reflection of the velocity of trauma and the extent of disruption of the surrounding soft tissue. Thus AVN and non-union rates are often high in four–part fracture dislocations. The ascending branch of circumflex humeral artery is vulnerable near the long head of biceps groove – which is often the water shed line of fracture line between the lesser and greater tuberosity. In order to preserve the vascularity of the fractured head of humerus, the Surgeon should dissect carefully near the biceps groove. Even in the presence of four-part PHF a thick vascular posterior capsule is invariably intact and can serve as a source for restoring vascularity.

Patient factors

Several factors leading to osteoporosis and poor bone quality can be liable for non-union. Tobacco abuse and extreme alcoholics (extent of osteopenia) are common examples. Amongst the medical causes Hypothyroidism and similar metabolic bone disease, drug abuse and nutritional apathy are contributing factors too. Rheumatoid patients on steroids, Cushing’s disease and medication with steroids, anti epileptic medication are known to lead to osetomalacia and osteoporosis. Not all of these factors can be corrected but identification of these factors is important for prognostication. As an example a hypothyroid elderly lady on anti-epileptic medicine may warrant shoulder hemiarthroplasty rather than a plate fixation. Improper varus fixation with gaps between fracture fragments, or non-anatomical fixation will inevitably lead to non-union. Locked plate is a rigid fixation and if applied non-anatomically is a recipe for failure [2]. The intertubercular groove is fault line and fracture line often passes through it. The long head of biceps can easily be trapped between the fragments preventing effective union. Tuberosities are often best fixed with transosseous sutures rather than screws. In such a situation, post op mobilization (especially rotations) should be deferred as tuberosity migration can be a catastrophic failure, especially in Hemiarthroplasty for PHF [8]. PHF in presence of osteoarthritis can lead to troublesome non-union, especially if conserved, as most of the movement will inevitably occur at fracture site. After a conservative immobilization, a premature rehabilitation can disrupt the stability and lead to non-union.

Clinical Evaluation

The clinical picture of non-union PHF is uncharacteristic. Many non-union PHF patients are already mobilized and have commenced their ADLS. Pain is seldom a feature of Non union. Also stiffness and inability to reach extreme ranges is a usual feature even after healed Proximal Humerus Fractures.  A meticulous examination is desirable prior to planning any intervention. Often patients with non-union present with wasting of muscles especially Deltoid, Supraspinatus & Infraspinatus. If a previous surgery has been performed by a Delto-Pectoral approach, often the anterior deltoid is disproportionately wasted. This could be a result of injury to the branch of axillary nerve to the anterior deltoid. This wasting is permanent and unlikely to reverse. The anterior deltoid powers forward flexion and is an effective padding for the anterior shoulder. Non-union PHF combined with shoulder stiffness is a formidable challenge to overcome.  Deltoid wasting as a result of axillary nerve injury should be picked up clinically as it is futile to offer fixation or hemiarthroplasty. It is not infrequent to have normal axillary nerve sensory function in the presence of a Deltoid motor paralysis. The only surgical option in the presence of axillary neuropathy is a shoulder arthrodesis. A EMG will be useful to disprove a neuropathy. The RSA remains as a reliable salvage surgery after complex failures with damage to rotator cuff. It relies primarily on deltoid integrity for its stability. If the deltoid is dysfunctional a RSA is contra indicated. Non-unions are not unusual (31%) [7] in elderly population and the prevalence of rotator cuff tears in asymptomatic individuals above 70. Hence patients above 70yr with non union should be treated with caution. If there were a co-existing rotator cuff tear a revision plating or hemiarthroplasty would be a counter intuitive. Thus the logic of performing a RSA in most patients above 70yrs age. RSA is preferred in the senior citizen as they may be unable to cope with post op immobilization and the specialist rehab required later. Co-morbid factors such as Parkinson’s, Alzheimer’s, diabetes and imbalance can further compromise results of surgery. Although a RSA is meant for rotator cuff deficient shoulders, when performing a RSA for proximal humerus fractures or non-union, it is mandatory to repair the tuberosities with the same technique described for hemiarthroplasty. The reason for this is dual – a) to enhance soft tissue stability around prosthesis, b) healing of tuberosities will restore rotations and improve over all function of the shoulder [9].

Surgical Planning & Technique

The aim of surgery is to restore anatomy and enhance biology of healing. Careful dissection, minimal disruption of vascularity by minimizing use of cautery and need for bone grafting as a stand by. Since most non-union PHF are complex and revision surgeries, we prefer a pre op CT scan to assess the fracture anatomy, displacements reduction strategies can be simplified to some extent. A 3D reconstruction of CT image is far more preferable and informative than axial CT scans. CT provides limited information about the soft tissue cover, though fatty infiltration of supraspinatus and infraspinatus may be assessed on axial & sagittal sections. A more scientific assessment of rotator cuff integrity and quality can be obtained by MRI or USG. If there are implants in situ a good Musculoskeletal (MSK) sonologist can provide the surgeon better information on rotator cuff status provided there is reasonable passive movement of gleno-humeral joint.


Patient should be operated in the beach chair position with the Image intensifier mounted behind the patient and the monitor screen in clear view of the surgeon. Aligning the image intensifier to provide “True AP” and Axial images is a prerequisite before taking the incision.


Once the screws in proximal fragment have been inserted a good 360 degree rotation of the arm should allow visualization of the joint surface a “proud” screws can be revised there an then. Only a AP view is never adequate to confirm the anatomical reduction and tip apex distance.  As a rule, in revision surgery, almost always use the delto-pectoral approach. This is extensile and familiar to all surgeons. The deltoid split approach10 is favoured by surgeons for primary fixation and may not be a wise choice for revision or PHF non-unions. Scarring from delay and non-union may alter landmarks and perhaps render the neuro-vascular structures vulnerable.


Cephalic vein, first structure under the incision may often be absent or scarred or tethered in the scar tissue. In such a scenario, in order to identify the delto-pectoral interval, the surgeon may use individual direction of fibers of deltoid and pectoralis major to identify the interval. The subscapularis is often adherent to conjoined tendon and Deltoid and during the release it is possible that the axillary nerve is in the neighborhood due to the internal rotation contracture of the subscapularis. Subscapularis release not only enhances the exposure but also facilitates later restoration of external rotation.


The Long head of biceps (LHB) is sometimes scarred down between the fracture fragments and I would not hesitate to perform a tenotomy followed by a tenodesis at the end of surgery. A scarred, immobile biceps can be a pain generator post operatively. The identification of the long head of biceps also helps delineate the exact boundary of lesser tuberosity (LT) and greater tuberosity (GT).  Intra operative swabs for culture sensitivity is a norm and the authors preference is t take at least three swabs form different areas of the wound. Swab for microbiology are more relevant when performing a Hemiarthroplasty or a RSA. In our experience the incidence of infections or positive swabs is higher when revising per cutaneous K-wire failures of PHF. The shoulder joint is peculiar for being infected with propionibacterium acnes (and also coagulase-negative staphylococcus). It is recommended that at least 5 swabs from different areas of the wound be incubated for at least 14 days [11]. Presence of infection during a revision may entail a two-stage revision (Fig 5,6,7,8). However, if the infection is not overt and the swab reports turn up positive post operatively, then inadvertently a single stage revision has been performed. The functional results of single stage revision are far superior than two stage revision. There is a trend toward higher infection rates in revision surgery compared with primary arthroplasty groups. As previously mentioned, the large subacromial dead space, the compromised general health of some patients, and the large surgical dissection, especially in revision cases, may predispose to later infection. However, If prior knowledge of infection of operated case of PHF is available then a two stage revision should be planned with a antibiotic loaded cement spacer to maintain soft tissue balance. (Fig. 5,6,7,8). Irrespective of the nature of fracture or operative plan, the surgeon must keep iliac crest prepared for bone grafting (or have access to synthetic bone graft substitutes) and also keep a prosthesis on the back table, just to avoid any embarrassing last minute intra-operative surprises. If there is any free tuberosity fragment, then at this stage each must be held with a mattress Ethibond #2 or a stronger super suture. It may be ideal to use different coloured sutures for ease of suturing later on. Our choice is a locked plate and its standard procedure of fixation including the first screw as non-locking cortical screw and the calcar screw as the most important element of the locked plate.  A fibular cortical strut graft may be of help when the bone is osteoporotic, calcar is missing and the surgeon needs a biological augment to prevent head collapse. Sometimes the radiographs reveal a two-part fracture that can be fixed with a plate. Intra-operatively it may reveal an egg shell humeral head that is severely osteoporotic from within. In such cases a preparation for a fibular graft can be helpful (Fig 3 & 4). A vertical strut graft (can be split in two) is to be passed within the canal and screws should capture the fibular graft as they enter the far cortex.

Tuberosity Fixation

Tuberosity repair, retention and eventual healing is most challenging task. Over the years several techniques have emerged to ensure a robust repair and secure healing of tuberosities. Even then factors such as osteoporotic bone, tiny comminuted fragments and bone loss at tuberosity remain beyond the control of the surgeon. Both tuberosities are subject to shear stresses and are often osteoporotic or wafer thin fragments. Our recommendation for ideal stabilisation of tuberosities is to use a super suture or at least ethibond #5. The sequence of suturing is – 1- GT to humerus, 2- LT to humerus, and 3- GT to LT to close the rotator interval. In addition, the critical suture is the cerclage suture described by Frankel [12] for Hemiarthroplasty after proximal humerus fractures.


The cerclage suture adds another axial plane to consolidate the repair and hold it stable. It is necessary that both the tuberosities heal anatomically to restore good function and rotational control. We use the same principle for RSA for complex PHFs in the elderly. We do not recommend steel wires for tuberosity repair. In addition to the above technique, we also recommend the Nice Knot[13] which is a dynamic self-locking knot and has been proven stronger than the conventional surgical knot in another study which is submitted for publication.  Due to diverse configuration of various PHF, it is not possible to ensure bone to bone contact after tuberosity repair always. Often, even if some bone contact is achieved, this is marginal and may not be enough for creeping substitution to occur across the fracture line. On the other hand, some humeral prostheses have a smooth metal stem which is most unlikely to allow tuberosities to heal against the smooth stem. Tuberosity union to Hydroxyapatite to trabecular metal stems has been documented. Our recommendation is to use a fracture specific trauma stem (Fig. 11) that has features to encourage tuberosity adherence, integration leading to eventual union. Salient features of a trauma stem are dense hydroxyapatite coating, honeycomb proximal friction fit and smooth niche at medial calcar to allow smooth passage of cerclage sutures.  Stem height in the humeral canal cannot be determined as fracture configurations are diverse. Every effort should be made to replicate the stem insertion height (Often may have to be left proud due to bone loss or distal level of PHF). If the stem has identical markings (Fig.11) as the rasp, then the surgeon can precisely identify the exact depth of insertion of the definitive stem. Hemiarthroplasty in fractures is a distinctly different surgery as compared to hemiarthroplasty for non-traumatic conditions. It is more complex than a conventional hemiarthroplasty and the results are less gratifying [14]. Firstly the typical landmarks such as LHB or GT & LT are often missing or displaced and comminuted. Secondly the neck cut has been taken by nature and hence the depth of insertion is variable depending on site of the fracture line. Thirdly the quality of rotator cuff cannot be established pre operatively due to the existing trauma.


Fourthly anatomical version for a given case is impossible to be assessed precisely due to the exploded proximal humerus. As per our cadaveric study of 67 humerii, submitted for publication, maximum variation occurred in humeral version which varied from 20º to 50º (mean 36.85 ±7.72). In addition, often a axillary nerve injury, which is difficult to detect in fresh trauma, may compromise the outcome in few patients. Although most of us prefer an uncemented stem, when the fracture line extends into the metaphysis, it may be necessary to cement the lower half of the stem to provide additional stability.



By far stiffness and incompetent rotator cuff are the commonest complications after surgery for non-union PHF. Due to complexity of failed treatment of PHF, revision nature of surgery and lengthy surgical exposure, complications after surgery for non-union PHF are likely to be more common than primary treatment of PHF. However the most frequent issue with internal fixation, especially Locked plates, remains proud screws and these may seriously wear out the cartilage of the glenoid leading to a major issue (Fig 13). Due to tedious nature of surgery, scarring of soft tissues and likely bleeding, Injury to axillary and suprascapular nerve could be sinister and lead to a rather poor residual function of the shoulder. Infection though uncommon may be seen due to difficult dissection, post op haematoma and prolonged surgical exposure. AVN of the humeral head is relatively frequent with the overall rate approaching 35% (reported range: 6–75%). The most important predisposing factors are – length of the metaphyseal beak, integrity of the medial hinge, Anatomic neck fracture. When all three features are present then there is a 97% positive predictive value for AVN. Most patients with AVN are likely to improve to a good to excellent result without interference15,16. Hence, it may be prudent to give a significant rehab trial before an arthroplasty is contemplated.


Non-union proximal Humerus Fractures are complex and the aim of the surgeon should be pain free restoration of function – Functional range of movement & good rotator cuff strength. Pre operative planning in the form of appropriate clinical evaluation, CT scan or other imaging techniques and keeping all options open during surgery is useful. Patients must be counseled about the likely complications since a revision procedure is always fraught with hurdles and obstacles. Careful initial immobilisaiton followed by a supervised structured rehab programme will help the patient achieve a good result. Patients with cartilage damage and OA and in the elderly group may be offered a hemiarthroplasty provided there is no infection and the rotator cuff integrity is maintained. When rotator cuff function is compromised and Surgeon is dealing with a frail elderly patient, a Reverse Shoulder Arthroplasty is probably the surgery of choice , provided Deltoid is unaffected.


1 Agudelo J, Schurmann M, Stahel P et al. Analysis of efficacy and failure in proximal Humerus fractures treated with locking plates. J Orthop Trauma 2007;21(10):676-681.
2 Owsley KC, Goryca JT. Fracture Displacement and screw cutout after open reduction and locked plate fixation of proximal Humerus Fractures. J Bone Joint Surg Am 2008;90(2):233-240.
3 Bosch U, Skutek M, Fremerey RW, et al (1998) Outcome after primary and secondary hemiarthroplasty in elderly patients with fractures of the proximal humerus. J Shoulder Elbow Surg; 7(5):479–484.
4 Rose PS, Adams CR, Torchia ME, Jacofsky DJ, Hostad E. Displaced proximal Humerus Fractures: results of conservative treatment. Injury 1992;23(1): 41-43.
5 Schulte LM, Matteini LE, Neviaser RJ. Proximal periarticular locking plates in proximal Humerus Fractures: functional outcomes. J Shoulder Elbow Surg 2011:20(8):1234-40.
6 Sudkamp N, Bayer J, Hepp P et al/ Open Reduction & internal reduction of proximal Humerus Fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, onservational study. J Bone Joint Surg Am 2009;91(6): 1320-1328.
7 Tempelhof S , Rupp S, Seil R. Age related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg. 1999 Jul-Aug;8(4):296-9.
8 Boileu P, Trojani C, Walch G, Krishnan S, Romeo A, Sinnerton R. Shoulder arthroplasty for the treatment of sequelae of fractures of the proximal Humerus . J Shoulder Elbow Surg 2001;10:299-308.
9 Florian Grubhofer, Karl Wieser, Dominik C. Meyer, Sabrina Catanzaro, Silvan Beeler, Ulf Riede, Christian Gerber. Reverse total shoulder arthroplasty for acute head-splitting, 3- and 4-part fractures of the proximal humerus in the elderly J Shoulder Elbow Surg , 2016 Mar-Apr.
10 Lill H, Hepp P, Rose T, et al (2004) [The angle stable locking proximal- humerus-plate (LPHP) for proximal humeral fractures using a small anterior-lateral-deltoid-splitting-approach – technique and first results.] Zentralbl Chir.; 129(1):43–48.
11. Athwal GS, Sperling JW, Rispoli DM, Cofield RH.Acute deep infection after surgical fixation of proximal humeral fractures. J Shoulder Elbow Surg. 2007 Jul-Aug;16(4):408-412.
12. Frankle MA1, Ondrovic LE, Markee BA, Harris ML, Lee WE 3rd. Stability of tuberosity reattachment in proximal humeral hemiarthroplasty. J Shoulder Elbow Surg. 2002 Sep-Oct;11(5):413-20.
13. Hill SW, Chapman CR, Adeeb S, Duke K, Bouiane MJ. Biomechanical evaluation of the Nice Knot. Int J Shoulder Surg. 2016:10;15-20.
14. P. Boileau, S.G. Krishnan, L. Tinsi, G. Walch, J.S. Coste, D. Molé. Tuberosity malposition and migration: Reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus.Sep-Oct 2002, Vol 11, Issue 5, 401-412.
15. Hertel R, Hempfig A, Stiehler M, Leung M. Predictors of humeral head ischaemia after intracapsular fractures of the proximal humerus. J Shoulder Elbow Surg. 2004; 13: 427-433.
16. Nho SJ, Brophy RH, Barker JU, Cornell CN, MacGillivray JD. Management of proximal humeral fractures based on current literature. J Bone Joint Surg Am. 2007; 89(Suppl 3): 44-58).

How to Cite this article: Babhulkar A. Proximal Humerus Non Union. Acta of Shoulder and Elbow Surgery Oct – Dec 2016;1(1):8-13


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Arthroscopic Fixation of Os Acromiale with Cannulated Screws

Acta of Shoulder and Elbow Surgery | Volume 1 | Issue 1 | Oct-Dec 2016 | Page 44-46 | Jose Carlos Garcia Jr, Mário Henrique Lobão Gonçalves, Márcio Eduardo Kozonara, Luciano Pascarelli, Roberto Bongiovanni.

Authors: Jose Carlos Garcia [1], Mário Henrique Lobão Gonçalves [1], Márcio Eduardo Kozonara [1], Luciano Pascarelli [2], Roberto Bongiovanni [2], Rafael Gadioli [1]

[1] NAEON-Santa Catarina Hospital.
[2] IFOR Hospital.

Address of Correspondence
Dr. Jose Carlos Garcia Jr., MD, MSc, PhD
NÆON-Hospital Santa Catarina-SP-Brazil


Introduction: Os acromiale is a developmental fusion failure of an acromion accessory ossification nucleus. It is associated to higher rates of Impingement Syndrome and rotator cuff tears due to narrowing of subacromial space. Surgical treatment of symptomatic os acromiale is classically done by open incision osteosynthesis or removal of the loose bone fragment. This study presents a modern minimally invasive arthroscopic technique and its preliminary result.
Methods: 13 arthroscopic surgeries were performed on patients with symptomatic os acromiale between 2007 and 2013. Outcomes were evaluated by UCLA scores before and 2 years post-operatively.
Results: Average follow up was 65.23 months (32-105). Pre-operative UCLA averaged 21.46±0.87 rising to 28.92±1.57 at 2 years post-operatively (p=0.001).
Adverse results occured in two patients: one patient had osteolysis of the anterior acromion fragment requiring a switch to open osteosynthesis; and another patient had fragmentation of the acromion during procedure and had to be excised.
Conclusion: Arthroscopic os acromiale osteosynthesis is still a difficult and challenging surgery. Evolution of technique and devices has been encouraging surgeons to make it doable and reproducible. Although there is not significant evidence of long-term benefits of arthroscopic over open technique, it is a minimally invasive procedure with better cosmetic results, reduced postoperative pain and magnified optic access to several shoulder structures.
Key words: Os Acromiale, Shoulder arthroscopy, rotator cuff.


Os acromiale is an uncommon shoulder disorder derived from nonunion of acromion accessory ossification centers. It is estimated to occur in 2.7% of shoulders (8). Acromium ossification nuclei rise between 15 to 18 year-old and usually get completely fused by 25 year-old (9). Failure of fusion might ensue at any ossification centers: preacromion, mesoacromion, metacromion or basiacromion. The most common type of os acromiale is the mesoacromiale, followed by preacromiale and metacromiale (12,14). Basiacromiale type is extremely rare. Excessive movement at fusion sites is thought as a possible reason for os acromiale formation (6) since impingement occurs over the anterior part of acromion. Most os acromiales are silent, only being diagnosed after imaging in patients suspected of Impingement Syndrome. Main symptoms are chronic sore shoulder, pain on elevation, night pain and movement restraint. There may be tenderness to palpation over the site of the nonunion. High rates of Impingement Syndrome are associated to os acromiale (11), whose prevalence in patients with massive rotator cuff tears rises up to 12% and it can be as high as 32% among those presenting cuff arthropathy (1). When bilateral involvement is present, prevalence reaches its utmost 62%(7,12,14).  Treatment of os acromiale has not been well established yet. Some suggest removal of the acromion loose fragment in symptomatic patients (9), whereas others prefer stable fixation if fragment is big enough (4,16). Osteosynthesis of mesoacromiale and metacromiale seems to have better results than excision by preserving anterior deltoid muscle attachment intact (16). Open osteosynthesis and bone grafts (2) have also been described to fix os acromiale. The development of shoulder arthroscopy allowed surgeons to access many different structures of shoulder, including the acromion. Recently a cadaveric study presented an arthroscopic technique to fix the os acromiale using 2 cannulated screews (5). This study presents results of an all-arthroscopic technique for treating symptomatic os acromiale.

Material and Methods

From 2007 to 2013, 13 patients underwent arthroscopic osteosynthesis for os acromiale. All patients were assessed prospectively according to the IDEAL-Collaboration (10) surgical research methodology.
Inclusion criteria are: over 18 years-old; shoulder pain resilient to conservative treatment for longer than 6 months; diagnosis of mesoacromiale or metacromiale, Liberson classification type 1 (8) on MRI or CT scan; and having more than 2 years of follow-up. Patients without pre-operative assessment and previous shoulder surgeries were excluded. Assessment of patients with UCLA score (13) was done before surgery (baseline) by the senior author and 2 years post-operativelly by others than the senior author who performed the surgical procedures. Roentgenograms of acromion were obtained at 2 and 5 weeks and 2 years after surgery to confirm union of the acromion. Statistical analyses were performed using Prism6® for Mac (GraphPad Software Inc.). All data were tested for normality using statistical tests of D’Agostino and Person, Shapiro-Wilk and Kolmogorov–Smirnov (KS). The Intention-To-Treat (ITT)(15) principle was used whenever possible. Interim sample size was calculated to determine whether this study achieve significance and statistical power as an adaptive design.


A two-tailed test of significance was used for all possible assessments considering p<0.05 statistically significant. Adverse events, complications and causes of withdrawal were reported for all the patients enrolled in the study. Surgical procedures were all performed by the senior author following the standardized technique that follows(Video 1): patient under general anesthesia in ‘beach-chair’ position, a standard posterior portal was settled to glenohumeral joint and subacromial space inspection using a 30º angled arthroscope and 60mmHg pump pressure; through lateral and anterior portals, bursectomy, coracoacromial ligament release, os acromiale site exposure and fibrotic tissues excision were performed using a 4mm shaver and electrocautery until exposure of cancellous bone of both acromion fragments. An osseous shaver is used to expose the marrow bone(Figs 1 and 2) in order to achieve the best osteosynthesis. The scope is inserted in the lateral portal just under the region of the os acromiale is. A spinal needle was inserted in antero-posterior direction just under acromion as reference for screw insert; two 1mm Kirshner wires are inserted through both acromion fragments(Fig3); finally, two 2.7mm cannulated screws are introduced fixing both parts of the acromion under fluoroscopy. A final Roentgenogram is done in order to confirm the osteosynthesis(Fig. 4)



Thirteen arthroscopic osteosynthesis of os acromiale were performed: 11 right shoulders and 2 lefts, 8 men and 5 women. Average follow-up was 65.23 months (32-105). Baseline UCLA scores average of 21.46 ± 0.87 (SD = 3.15; CI 19.56 to 23.37) rised to 28.92 ± 1.57 (SD = 5.65; CI 25.51 to 32.34) post-operatively confirming statistical difference on nonparametric Wilcoxon matched-pairs test (p=0.001). There was none withdrawal on this study since intention-to-treat (ITT) statistical model was used and sample size necessary to achieve the minimal of 4 points difference between baseline and 2-year follow-up UCLA mean scores was achieved on phase one of this trial. One patient that had a pre-operative 50% partial rotator cuff tear evolved to a complete tear and underwent surgical repair with satisfactory functional outcome at a 2-year period after surgery.
Adverse results occurred in two patients (15.38%). One patient had osteolysis of the anterior acromion fragment, evolving with poor UCLA post-operative score (15 points) and requiring an open procedure to remove screws. Another patient had a fracture of the anterior part of acromion during screw fixation and the fragment had to be excised. Despite this patient had a good result, he was graded the same for baseline and post-operative UCLA scores in order to use ITT analysis.


A gold standard for surgical treatment of os acromiale has not been established yet. Several osteosynthesis techniques were described with good and satisfactory outcomes. Until now, there are no trials comparing arthroscopic acromion osteosynthesis in human beings. Our review of scientific literature found only one cadaveric study demonstrating feasibility of performing an arthroscopic acromion fixation(5). Acromion fixation using cannulated screws has shown greater healing rates when compared to K-wires and the rate of radiographic healing has been positively correlated to better clinical outcomes(4). In this study we had 92.31% of union (healing) of os acromiale using 2.7mm screws, which confirms the superiority of cannulated screws.
The diameter of screws seems to be very important since some case reports had shown anterior acromion fragment fractures due to screw sizes over 2.7mm. This is of most importance in women whose acromion tends to be smaller and thinner.
Concerning the significant prevalence of right (84.61%) os acromiales over left-sided ones (15.39%) founded on our study, we identified that from the 2 left-sided cases, one patient was left handed, suggesting that the ‘dynamic subacromial space narrowing caused by os acromiale’ theory might be right. Arthroscopic approach to os acromiale allows better fibrotic tissues excision, which seems to favor the biological aspect of bone healing. It also makes possible accessing and repairing the rotator cuff and other shoulder structures through a minimal wound. While, an open technique would require a much larger incision or more than one wound, to access these same structures althogether. Some authors have presented good results when preacromiale is treated with excision of the bone fragment, but this technique seems not to have acceptable outcomes for mesacromiales(16). All patients enrolled in this trial had mesoacromiale or metacromiale, classified by Liberson as type1(8), confirming the trend of good outcomes with meso-metacromiale osteosynthesis.

Due to rarity of os acromiale it was difficulty to find symptomatic patients to enroll in this study. It took us 4 years to get 13 patients that needed surgical treatment for os acromiale. Multicentric trials would be a solution to improve statistical power of similar studies. This is an IDEAL type 2A trial, phase 1, which means it just enable us to conclude about effective of the surgical procedure, not allowing us to assume its superiority over other techniques. A long-term trial comparing arthroscopic versus open fixation of os acromiale with cannulated screws will be necessary to establish a definite conclusion.


Arthroscopic os acromiale osteosynthesis with cannulated screws is still a difficult and challenging technique. Outcomes of this study prove this technique is effective and reproducible for treatment of os acromiale, with benefits of being minimally invasive and allowing concomitant access to rotator cuff and other shoulder structures. Surgical devices advances may be necessary to facilitate this procedure in order to rise its acceptance among shoulder surgeons. Until now there is not significant evidence of long-term difference between open versus arthroscopic os acromiale fixation with cannulated screws. Further data and randomized controlled trials will be necessary to this purpose.


1. McCulloch P, Altman DG, Campbel WB, Flum DR, Glasziou P Marshall JC et al. No surgical innovation without evaluation: ID EAL recommendations. Lancet, 2009; 374:1105-1112.
2. Mudge MK, Wood VE and Frykman GK. Rotator cuff tears associated wit os acromiale. J Bone Joint Surg Am, 1984; 66(3):427-429
3. Nicholson G, Goodman DA, Flatow EL, Bigliani LU. The acromion: Morphologic condition and age-related changes. A study of 420 scapulas. J Shoulder Elbow Surg. 1996;5:1–11.
4. Romeo AA, Bach BR, O’Halloran KM. Scoring systems for shoulder conditions. Am J Sports Med 1996;24:472-476.
5. Sammarco VJ. Os acromiale: Frequency, anatomy, and clinical implications. J Bone Joint Surg Am. 2000;82:394–400.
6. Streiner D, Geddes J. Intention to treat analysis in clinical trials when there are missing data. Evid Based Ment Hea lth 2001;4:70-71.
7. Warner JJ, Beim GM, Higgins L. The treatment of symptomatic os acromiale. J Bone Joint Surg Am. 1998;80:1320–6.
8. Atoun E, Narvani A, Sforza G, Young L, Rath E and Levi O. The Prevalence of os Acromiale in patients with massive rotator cuff tears. Int Jof Orth, 2016; 3(2):525-527.
9. Garcia JC et al. Arthroscopic Bristow-Latarjet Procedure. Arthroscopy, 2012; 28(6): e3-e4.
10. Gerber C, Snedeker JG, Baumgartner D and Viehofer AF. Supraspinatus tendon load during abduction is dependent on the size of the critical shoulder angle: A biomechanical a nalysis.
11. Harris JD, Griesser MJ and Jones GL. Systematic review of the surgical treatment of os acromiale. Intl J Shoulder Surg. 2011; 5 (1): 9-16.
12. Kummer FJ, van Gelderen J and Meislin RJ. Two-screw, arthroscopic fixation of os acromiale compared to a similar, open procedure incorporati ng a tension ba nd: a laborato ry study. Shoulder and Elbow, 2011; 3:85-87.
13. Kurtz CA, Humble BJ, Rodosky MW, Sekiya JK. Symptomatic os acromiale. J Am Acad Orthop Surg. 2006;14:12–19.
14. Liberson F. The value and limitation of the oblique view as compared with the ordinary anteroposterior exposure of the shoulder: A report of the use of the oblique view in 1,800 cases. Am J Roentgenol. 1937;37:498–509.
15. Liberson F. Os acromiale a contested anomaly. J. Bone Joint Surg Am, 1937; 19(3): 683-689.

Video of the Surgical Technique

How to Cite this article: JC Garcia Jr.,  Gonçalves MHL, Kozonara ME, Luciano Pascarelli L, Bongiovanni R. Arthroscopic Fixation of Os Acromiale with Cannulated Screws. Acta of Shoulder and Elbow Surgery Oct – Dec 2016;1(1):44-46


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How to improve Surgical Research: the IDEAL approach

Acta of Shoulder and Elbow Surgery | Volume 1 | Issue 1 | Oct-Dec 2016 | Page 4-6  | Jose Carlos Garcia Jr, Allison Hirst, Joshua Feinberg.

Authors: Jose Carlos Garcia Jr [1], Allison Hirst [2], Joshua Feinberg [3].

[1] NÆON-Santa Catarina Hospital-São Paulo-Brazil.
[2] Oxford University-Oxford-UK.
[3] Maiomenides Medical Center-New York-USA.

Address of Correspondence
Dr. Jose Carlos Garcia Jr., MD, MSc, PhD
NÆON-Hospital Santa Catarina-SP-Brazil


Introduction: Here we introduce the IDEAL Framework and Recommendations for evaluating surgical innovation from an idea of a new technique towards a pivotal trial and beyond. We explain the core concepts here and future editions of this periodical will continue the IDEAL theme. IDEAL offers a rational way to explore the effectiveness and safety of new surgical procedures and medical devices in a more robust, transparent and ethical manner than current practice.
This symposium aims to present to the readers a new rational way to design,conduct and report surgical research based on the principles of the IDEAL-Collaboration and others within shoulder and elbow surgery. We examine how to improve research methods across all stages of evaluating innovation.
Keywords: IDEAL Framework and Recommendations, Research, Surgical Innovations.


The evaluation process for developing new medicines is a well-established and regulated pathway conducted by clinical researchers globally. Several steps are involved to minimize harms whilst rigorously testing efficacy of the drug as below:
1) Pre-Clinical Studies: Here, a new medication is studied outside the laboratory and in vivo using an animal model.
2) Phase 0 Studies: Also known as microdosage studies, these provide data on any potential harms of a new medication when administered in humans as opposed to animals. In addition to ensuring that a drug is safe, these studies help determine its basic pharmacodynamics and pharmacokinetics (6).
3) Phase 1 Studies: These are devoted to analyze efficacy, pharmacodynamics and pharmacokinetics in non-comparative trials.
4) Phase 2 Studies: Small case controlled trials comparing a drug against a placebo or another medicine with known and standardized outcomes.
5) Phase 3 Studies: Large randomized trials, generally multicentre, comparing a new drug against a placebo or another medicine with known and standardized outcomes (16).
6) Phase 4 Studies: Post marketing retrospective trials. More devoted to long term safety and effectiveness (11).

Historically the same rigorous standardized process has not developed in surgical research due to both a lack of regulatory requirements for surgical techniques but also due to several other specific challenges inherent in the nature of surgery as a complex intervention. These challenges include difficulties in defining a standard surgical intervention due to iterative changes being made by surgeons, the involvement of learning curves, attributes of individual surgeons’ effects on outcomes and a lack of agreed standard outcome measures in surgery. In addition there is often a lack of equipoise with both surgeons and patients expressing preferences in treatment. However it is possible to construct high-quality RCTs in surgery to test new techniques. The IDEAL Collaboration ( (Figure 1), an international group of surgeons and research methodologists have developed a rational way to move towards developing pivotal surgical RCTs via a systematic system using robust study designs. The word IDEAL present the initials of the stages of surgical development as following:
Idea, Development, Exploration, Assessment and Longterm study (7). Stages are broadly similar to those implemented in the pharmaceutical industry. Idea is analogous to phase 0, Development – phase 1, Exploration – phase 2, Assessment – phase 3 and Long-term-study phase 4. The only phase with no parallel in the original IDEAL is the preclinical phase, however it is comparable with surgical cadaveric studies performed to test the surgical idea before the technique reaches the live patients. The IDEAL Collaboration is currently updating the Framework and will provide further guidance on this pre-clinical stage. This has been in response to publications by researchers using IDEAL 0(10) and it being an important stage for developing medical devices – IDEAL has now developed a separate IDEAL-D (14, 16).Indeed creating a pathway for evaluation designed to address the unique characteristics of surgical procedures rather than simply applying drug clinical trials to the surgical field offers many advantages. Further research and development of IDEAL by using the Framework in practice will lead to more robust and comparable data thus providing reliable answers to the central questions within the field of surgery. Therefore the IDEAL-Collaboration developed stages for surgical development in a similar way to phases of clinical trials but respecting the characteristics that surgical trials need.


How to use IDEAL in your research

The IDEAL Collaboration has endorsed a number of suggestions for specific study designs and reporting standards which are recommended at different stages in the Framework. These suggestions are underpinned by a series of general principles for design and reporting, which are based on the different questions to be addressed and the challenges faced at each stage in the process (5).
Study design and reporting ideas for improving evidence on surgical and interventional therapy innovation are as follows:

The IDEAL Framework, Recommendations and Proposals:
Summary of key features

The IDEAL Collaboration grew out of an earlier initiative known as the Balliol Group who held a series of conferences at Balliol College, Oxford in 2007-2009 with a commitment to improve the quality of research in surgery. Their discussions led to the development of the IDEAL framework for describing the stages of development of surgical and interventional innovations, and a series of recommendations about how methodology and reporting of research at each of these stages could be improved. The group also made a series of proposals about how specific groups (publishers, funders, regulators, and professional organizations) can help to change the environment for this kind of research in a positive manner. The three tables below summarise the key issues described in the Lancet publications reporting the IDEAL Framework, Recommendations and Proposals in 2009 (1,4,8) and subsequently further detailed in 3 articles published in the BMJ in 2013 (2,3,9).


This initial effort of the IDEAL- Collaboration needs to be expanded to many other important points in order to achieve the best surgical designs for surgical trials. It is known that the current status of surgical trials remain something like a babel tower with regard to initiation of a new procedure, performing it in patients and assessing its safety and efficacy.  A wide discussion involving the main surgical societies about the organization of these points must be discussed.  Within the field of bone and soft tissue lesions for instance, the variability of lesions is an area that requires better standardization of terms. In order to group these conditions accordingly and provide data that can be applied clinically, it may be useful for surgical trials to be designed in such a way that data is collected on those lesions that share the same clinical characteristics.


This would be made possible by studying the most common lesions within one package allowing for variations to be minimized and comparisons to be made more easily.  Within shoulder and elbow surgery we can use the example of lesions of the supraspinatus tendon.  Lesions of the supraspinatus tendon with retraction Patte(12) type one and two, not compromising the biceps and with 50% or less degeneration (thus three types of degeneration) would most likely result in (2×3=6) the six most common types of lesions. Within the shoulder and elbow surgery community, to agree to group these lesions together, it is necessary to enter into an international agreement to be entitled, for example, the International Standards for Surgical Trials.


Local and international societies of all specialties and subspecialties would need to work together to arrive at this consensus.. While the author’s preferences to certain outcomes and timing to assess must be respected, a minimum of methodological harmonization is a current necessity.  To begin this step towards better standardization it is important for this discussion to take place within all the main surgical organizations. Primary trials need to be improved within a rational harmonization and follow the stages that can make surgical trials more reliable and generalizable.  Acta for Shoulder and Elbow Surgery is a journal committed to the new patterns from the IDEAL-Collaboration, CONSORT, COMET initiative and others in order to improve the research quality within the orthopedic subspecialty of shoulder and elbow surgery. The practical guides for investigators evaluating new surgical interventions will be better explored in the following volumes of this journal, beginning by the stages 1, 2a and 2b of the IDEAL Framework (13).

Comet-Initiative is Available from:
The CONSORT statement is Available from:
Ideal-Collaboration is Available from:


1-Barkun JS, Aronson JK, Feldman LS, Maddern GJ, Strasberg SM, for the Balliol Collaboration. Evaluation and stages of surgical innovations. Lancet 2009; 374: 1089–96.
2-Cook JA, McCulloch P, Blazeby JM, Beard DJ, Marinac-Dabic D, Sedrakyan A; IDEAL group. IDEAL framework for surgical innovation 3: randomised controlled trials in the assessment stage and evaluations in the long term study stage. BMJ. 2013 Jun 18;346:f2820.
3-Ergina PL, Barkun JS, McCulloch P, Cook JA, Altman DG; IDEAL group. IDEAL framework for surgical innovation 2: observational studies in the exploration and assessment stages. BMJ. 2013 Jun 18;346:f3011.
4-Ergina PL, Cook JA, Blazeby JM, Boutron I, Clavien PA, Reeves BC, Seiler CM, for the Balliol Collaboration, Challenges in evaluating surgical innovation. Lancet 2009; 374: 1097-104.
5-Hirst A, Agha RA, Rosin D, McCulloch P. How can we improve surgical research and innovation?: the IDEAL framework for action. Int J Surg. 2013;11(10):1038-42.
6-Kummar S, Rubinstein L, Kinders R, Parchment RE, Gutierrez ME, Murgo AJ et al. Phase 0 clinical trials: conceptions and misconceptions. Cancer Journal 2008, 14(3), May-Jun: 133-137.
7-McCulloch, P., Altman, D.G., Campbel, W.B. et al (2009) ‘No surgical innovation without evaluation: IDEAL recommendations.’ Lancet, 374, pp. 1105-1112.
8-McCulloch P, Altman DG, Campbell WB, et al, for the Balliol Collaboration. No surgical innovation without evaluation: the IDEAL recommendations. Lancet 2009; 374: 1105–12.
9-McCulloch P, Cook JA, Altman DG, Heneghan C, Diener MK; IDEAL group. IDEAL framework for surgical innovation 1: the idea and development stages. BMJ. 2013 Jun 18;346:f3012.
10-Menon M, Abaza R, Sood A, Ahlawat R, Ghani KR, Jeong W, Kher V, Kumar RK, Bhandari M. Robotic Kidney Transplantation with Regional Hypothermia: Evolution of a Novel Procedure Utilizing the IDEAL Guidelines (IDEAL Phase 0 and 1). Eur Urol. 2013 Nov 20. pii: S0302-2838(13)01208-6.
11-National Cancer Institute. Phase IV Trial. Available from: [Accessed 10 August 2016]
12-Patte D. Classification of rotator cuff lesions. Clin Orthop Relat Res. 1990 254:81-86.
13-Pennell CP, Hirst AD, Campbell WB, Sood A, Agha RA, Barkun,JS et al. Practical guide to Idea, Development and Exploration Stages of IDEAL Framework and Recommendations. Br J Surg. 2016 Apr;103(5):607-615.
14-Pennell CP, Hirst A, Sedrakyan A, McCulloch PG. Adapting the IDEAL Framework and Recommendations for medical device evaluation: A modified Delphi survey. Int J Surg. 2016 Apr;28:141-8.
15-Sedrakyan A, Campbell B, Merino JG, Kuntz R, Hirst A, McCulloch P. IDEAL-D: a rational framework for evaluating and regulating the use of medical devices. BMJ. 2016 Jun 9;353:i2372.
16-Temple, R. (2000) Current definitions of phases of investigation and the role of the FDA in the conduct of clinical trials. American Heart Journal, 2000 apr;139(4):133-S135.

How to Cite this article: JC Garcia Jr., Hirst A, Feinberg J. How to improve surgical research: the IDEAL approach. Acta of Shoulder and Elbow Surgery Oct – Dec 2016;1(1):4-7


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MIPO for Humeral Shaft Fractures: Correlation between Radiographic, DASH, and SF-12 results

Acta of Shoulder and Elbow Surgery | Volume 1 | Issue 1 | Oct-Dec 2016 | Page 35-43 | Adriano F Mendes Júnior, José da Mota Neto , Leandro F De Simoni, Carlos Alberto Menezes Mariosa, Bruno G. S. e Souza , Valdeci de Oliveira, Elmano de A Loures.

Authors: Adriano F Mendes Júnior [1,2], José da Mota Neto [1,2,3], Leandro F De Simoni [1,3], Carlos Alberto Menezes Mariosa [3], Bruno G. S. e Souza [2,3], Valdeci de Oliveira [2,3], Elmano de A Loures [2].

[1] Shoulder and Elbow Surgery Group of Juiz de Fora.
[2] University Hospital, Federal University of Juiz de Fora.
[3] Therezinha de Jesus Maternity Hospital.

Address of Correspondence
Dr. Adriano Fernando Mendes Junior
Rua Sampaio, 468, apto. 1402. Centro – CEP: 36010360 – Juiz de Fora, Minas Gerais – Brazil


Introduction: To present the correlation between the clinical and radiographic results of patients with a humeral shaft fracture treated with the MIPO technique. Method: A comparative retrospective study involving 31 patients with diaphyseal fractures of the humerus, from January 2014 to January 2016, with a minimum follow-up of six-months, surgically treated using the MIPO technique through an anterior approach. Outcomes were evaluated prospectively via clinical and radiographic exam, DASH, and SF-12.
Results: mean follow-up of 19-months, with the majority of fractures classified as complex (n = 16; 51.6%) and a healing rate of 90.32%. Mean shoulder range of motion was 167°/57°/T6. In the elbow, mean flexion/extension was 125°/-5°. Non-consolidation occurred in three patients (9.7%), with two pseudoarthroses and one loss of reduction after osteosynthesis. Five patients presented primary radial apraxia, two without recovery from the injury. Secondary radial apraxia occurred in two patients, with full recovery. Patients who did not consolidate the fracture presented greater radiographic coronal deviation (d = 2.2), with the differences being statistically significant. Eight patients (25.8%) had an unsatisfactory DASH, with a longer elapsed time until surgery, less elevation of the shoulder, lower scores on the physical component of the SF-12, and higher pain scores, with statistically significant differences. Conclusion: MIPO demonstrated a 90.32% healing rate in the first six months post-operatively, with good clinical and functional results according to the DASH and SF-12 scores. Injuries by firearm combined with impairment of the radial nerve are related to a worse functional outcome in the sample evaluated.
Evidence Level: III – comparative retrospective study.
Keywords: Diaphyseal fracture of the humerus, osteosynthesis, MIPO, radial nerve paralysis.


Diaphyseal fractures of the humerus represent 3 to 5% of the occurrence of all types of fractures,[11,30] with a bimodal age distribution: from 21 to 30 years – mainly due to high-energy trauma, and between 60 and 80 years, in cases of low-energy trauma [5,30]. Conservative treatment is indicated for the vast majority of these fractures,[4] provided they are within the guidelines including: angular deviations less than 20 degrees, rotational less than 30 degrees, and less than 3 cm of shortening, in selected patients [26]. However this can lead to unsatisfactory results associated with malunion of the fracture, pseudoarthrosis, and to weakening of the shoulder girdle [11,31,41]. Surgical treatment is indicated in patients with fractures with unacceptable deviations, polytrauma, with vascular and nerve injury, in obese patients, or in those with an orthostatic placement limitation,[20] with the objective of surgical treatment thus being to avoid these complications and promote early rehabilitation [3]. ORIF with plates and screws is still considered the gold standard of the surgical treatment options,[26] despite the advent of biological techniques such as intramedullary nailing or “bridge plates”. Livani and Belangero presented the clinical results of the bridge plate method for surgical treatment of diaphyseal fractures of the humerus,[20] and Apivatthakakul et al [2], detailed the anatomical landmarks of the technique and described the term MIPO (Minimally Invasive Plate Osteosynthesis).  With the MIPO technique, patients experience early and active mobilization of the shoulder and elbow, due to good stability achieved and the minimal surgical aggression of the technique,[20] in addition to the aesthetic benefit of two small incisions. Minimally invasive surgery has the potential to preserve the fracture hematoma, enhancing consolidation, [1,27] with the MIPO method for treatment of diaphyseal fractures of the humerus being considered reproducible, safe, and effective [14,18,20,22,37,38]. There are several characteristics fundamental for MIPO success, such as proper selection of the implant size, and the quantity and distribution of the screws [39]. The use of long plates is recommended for this technique because the longer the plate, the more stable and effective it will be, provided that the system complies with the minimum number of screws on each fracture side. However, according to Tanaka[39], this orientation is empirical. The aim of this study is to evaluate, in a series of patients with humeral shaft fractures surgically treated using the MIPO technique, the clinical and radiographic results of treatment, as well as its impact on the upper limb function and quality of life of the patients. At the same time, we seek to identify the characteristics of fixation systems and their relationship to the consolidation outcome six months after surgery, and possible factors related to treatment failure using this technique.


This is a retrospective study of patients with diaphyseal humeral fracture treated surgically using the MIPO technique in tertiary hospitals of our city, by three surgeons participating in the study, from January 2014 to January 2016. All patients operated on in this period were selected and invited to participate. The inclusion criteria were: over 18 years of age, surgery more than six months prior, and surgical treatment of humeral shaft fracture using the MIPO technique through an anterior approach. The exclusion criteria were: prior surgery on the same bone and inability to answer the functional assessment questionnaires or to appear for re-evaluation. This study was approved by the Research Ethics Committee of the institution, under opinion number CAAE 53181116.2.0000.5103. Patients who agreed to participate in the study signed a free and informed consent agreement.

A total of 35 surgeries were performed that met the inclusion criteria during the period from January 2014 to January 2016. Four patients were excluded, three due to death and the other for refusing to participate in the study, totaling a sample of 31 patients, of whom 24 were male (77.4%) and seven female. The mean patient age was 35.3 ± 14.3 years, ranging from 20 to 78 years. We prospectively evaluated the clinical-functional results with a minimum follow-up of six-months, with clinical and radiographic exam data, with EVA[32], DASH[24] functional assessment score, and the SF-12[7] quality of life questionnaire. The DASH results were divided into two groups: satisfactory and unsatisfactory, following the criteria of Chaitanya and Naveen[9]. Medical records data were collected about neurological function before the surgery and after the procedure, the presence of signs of infection of the surgical site, status of the fracture consolidation at six months postoperative, and other associated clinical events. Fractures were classified according to the AO[15] criteria and subsequently divided into simple (type A) and complex (type B and C), with postoperative radiographs being evaluated according to the following parameters: quality of reduction (angular deformity and distance between the main fragments), plate size used, number of screws on each side of the fixation, and working length area of the plate (distance between the screws closest to the fracture site) (Figure 1). Additionally, current radiographs of the humerus in coronal and sagittal views were obtained and were also evaluated regarding the status of consolidation, presence of loosening or failure of the implant, and residual deformity.


Surgical technique
The patient was placed supine and given general anesthesia associated with interscalene brachial plexus block, and antibiotic therapy was carried out with one gram of intravenous cefazolin after anesthesia. The surgical technique used was similar to the technique described by Livani and Belangero[20]. Proximal access was gained, in an incision of approximately 3 to 5 cm, between the brachial tendon of the biceps muscle and the tendon of the deltoid muscle. Soon after, distal access was gained in an incision of about 3 to 5 cm between the biceps and the brachialis muscle. After visualization of the lateral cutaneous nerve of the forearm, the brachialis muscle was separated longitudinally. Narrow DCP plates were used, 4.5 mm (10 to 16 holes), which were inserted from proximal to distal, arm placed in the reduction position, one screw inserted distally and another proximally. At least two more screws, one proximal and another distal, were inserted for final fixation. After surgery, patients were encouraged to actively move the shoulder and the elbow, without load. Outpatient control was conducted at two and six weeks and at three and six months for functional and radiographic reevaluation looking for signs of consolidation.

The primary outcome was the presence or absence of fracture healing at the time of reevaluation (minimum 6 months). Secondary outcomes were the presence of complications, clinical-functional results via the DASH[24] scale, the visual analog score (VAS)[32] for pain, and the quality of life measured by the SF-12 questionnaire [7].

Statistical Analysis
Quantitative variables were described via mean and standard deviation, and qualitative variables via absolute frequency and percentages. Due to the sample size, we opted for the use of nonparametric tests. To test differences between groups in relation to the quantitative variables, we used the Mann-Whitney U test. The effect size was evaluated using Cohen’s d, using the weighted standard deviation, with the following classification for interpretation being adopted: 0.20 – 0:49: Small; 0.50 – 0.79: Medium; ≥ 0.80: Large.[10] To test differences between proportions, Fisher’s exact test was used. In this case, the effect size was evaluated using Cramer’s V, with the following classification for interpretation being adopted: 0.10 – 0.29: Small; 0:30 – 0.49: Medium; ≥ 0.50: Large [10]. All analyses were done with IBM SPSS V24 (IBM Corp., Armonk, NY) statistical software. The value of p <0.05 was adopted for statistical significance. For the variables where this study found a tendency of significance, using the G*Power 3.1 software, the sample size was calculated in order to find statistically significant relationships [13].


Of the 31 participating patients, the mean follow-up time was 19.3 ± 6.1 months. All were right-handed (n = 29; 93.5%), except two. The fracture occurred in the left humerus, in 17 patients (54.8%), and the right humerus, in 14 patients (45.2%). The mean elapsed time until surgery was 6.4 ± 7.0 days, ranging from 0 to 32 days, with a median of five days. The most common cause of the fractures was a car or motorcycle accident (n = 14; 45.2%) and the other causes were: gunshot (n = 7; 22.6%), simple fall (n = 6; 19.4%), and fall from a height or direct trauma (n = 4; 12.8%). The fractures were classified as A in 15, B in 12, and C in 4 cases, grouped into simple (n = 15; 48.4%) and complex (n = 16; 51.6%). Fifteen (15) patients (48.4%) had associated lesions, such as: radial nerve apraxia (n=5; 16.1%), other fractures of the same segment (n = 2), and other lesions (n = 8). The mean range of motion (ROM) of the shoulder was 167° of elevation (± 32.88°), 57° (± 32.88°) of lateral rotation, and internal rotation with mean vertebral level T6 (only four patients had no internal rotation to the thoracic level). In the elbow, the mean ROM was 125° (± 21.05°) in flexion and -5° (± 12.36°) in extension. We found, in our sample, a 90.32% healing rate (28 patients) (Figure 2), with mean values of DASH = 19.2 (± 29.6), SF-12 PCS = 47.1 (±8.7), SF-12 MCS = 52.1 (± 10.7), and VAS = 2.0 (± 2.4) (Table 1).

Table 1: Comparison of clinical evaluation, radiographic measures, and functional scores of patients with healed and non-healed fractures

Table 1: Comparison of clinical evaluation, radiographic measures, and functional scores of patients with healed and non-healed fractures

Non-consolidation of the fracture occurred in three patients (9.7%), with two pseudoarthroses and one loss of reduction after osteosynthesis, and all underwent ORIF with plates and screws. Eight patients (25.8%) had an unsatisfactory DASH, five patients (16.1%) had an unsatisfactory SF-12 PCS, and five patients (16.1%) had an unsatisfactory SF-12 MCS. Among the patients with primary radial nerve apraxia, two did not recover from the injury. Secondary radial nerve apraxia occurred in two patients, who achieved full recovery of function (mean 3.5 months). The comparison of plate characteristics, working length, and clinical-radiological and functional scores of the patients are presented in Tables 1 and 2.

Table 2: Association between possible explanatory factors and the outcome of a non-healed fracture of the humerus

Table 2: Association between possible explanatory factors and the outcome of a non-healed fracture of the humerus

The patients who did not consolidate the fracture presented greater coronal deviation (d = 2.2), less muscle strength (d = 2.2), and lower shoulder elevation (d = 1.8), with the differences being statistically significant, and the observed size of effect being of high magnitude. Considering the variables with a moderate threshold of significance and size of effect, the data suggest that patients who failed to heal the fracture have a greater deviation > 5°, less shoulder rotation, less flexion and extension of the elbow, a higher percentage of unsatisfactory DASH, and a lower SF-12 MCS. For the other variables, no statistically significant differences nor important effect sizes were observed. Comparing the patients with gunshot-induced etiology (GIE) vs. other causes, it was observed that patients with a gunshot wound had a higher percentage of complex fractures (X2 = 8.477; p = 0.007; V = 0.52), a higher percentage of associated lesion (X2 = 5.044; p = 0.04; V = 0.40), a higher percentage of radial apraxia (X2 = 4.775; p = 0.06; V = 0.39), a higher percentage of deviation > 5° (X2 = 6.178; p = 0.03; V = 0.45), and a lower mean age (27.4 ± 8.4 vs. 37.6 ± 15.0 years, p = 0.05). After stratification of the patients with GIE and with radial apraxia, a higher percentage of these patients with an unsatisfactory DASH were observed when compared to other patients with an unsatisfactory DASH (100.0% vs. 17.9%, respectively) (Table 3).

Table 3: Comparison of clinical evaluation, radiographic measures, and functional scores of patients with healed and non-healed fractures

Table 3: Comparison of clinical evaluation, radiographic measures, and functional scores of patients with healed and non-healed fractures

In addition, patients with GIE and radial apraxia presented less shoulder elevation (97.0 ± 76.0 vs. 175.0 ± 13.0; p = 0.02; d = 1.75) and greater pain (4.7 ± 2.3 vs. 1.7 ± 2.3; p = 0.04; d = 1.30) when compared with the other patients, respectively. From a practical point of view, the differences observed were of high magnitude. On the other hand, no association was observed between the SF-12 classification and the etiology of the lesion. Table 4 presents possible predictors of the disabilities assessed by the DASH in patients after surgery. It was observed that patients with an unsatisfactory DASH showed greater elapsed time until surgery, less elevation of the shoulder, lower scores on the physical component of the SF-12, and higher pain scores. The differences seen were statistically significant and the observed size of the effect was of high magnitude. Although they did not attain statistical significance, the presence of radial apraxia and the non-consolidation of the fracture presented a relation with the unsatisfactory DASH of moderate magnitude (Cramer’s V = 0.34 and 0.31, respectively).

Table 4: Variables associated with functionality in patients after humeral surgery

Table 4: Variables associated with functionality in patients after humeral surgery

Furthermore, the data suggest that patients with an unsatisfactory DASH have a lower number and density of screws, less elbow flexion, less muscle strength, and a lower mental component of the SF-12. Although statistical significance was not observed, the effect size was high magnitude for these variables. For the variables where this study found a tendency of significance, and considering the 10% prevalence of non-union, 80% power, significance level of 5%, and a moderate size of the effect (Cramer’s V = 0.31 to 0.34) between the risk factor and the non-consolidation of the lesion, a sample size between 68 and 82 patients is estimated for statistically significant associations to be found.


Humeral shaft fractures account for 5% of all fractures and the main treatment is still nonsurgical.[30] Nevertheless, this method can result in unsatisfactory clinical outcomes, non-union, and limited range of motion.[9,25] Surgical treatment with MIPO uses the principle of relative stability, enhancing healing,[38] and is a viable treatment option. We found involvement in 77.41% of men and a mean age of 35 years, with the fracture more common on the non-dominant side (54.83%), and that motor vehicle accidents (n = 10; 33.25%) and injuries by firearms (n = 7; 22.58%) were those mainly responsible for the fractures, similar to epidemiological data in the literature.[23,40,42] According to the AO classification, we found a higher incidence of type A (n = 15; 48.38%), followed by type B (n = 12; 37.50%), and C (n = 4; 12.90%), similar to the data in the literature [38, 40].  According to Tanaka [39], in the MIPO osteosynthesis, two factors are used to determine the length of the plate: the pattern of the fracture and the extent of the fracture line. The ratio of the plate length and the extent of the fracture line should be 2 or 3 in those with complex type and 8 to 10 in simple ones [39]. In this study we adopted a standardization of the working length in the X-rays, similar to the length of the initial fracture line. We evaluated the relationship between the implant size and the working length and found the mean value of 1.7, with no statistically significant differences observed between the healed and unconsolidated groups (p = 0.55). As to the screw density, we found a mean of 0.37, which is in accordance with the values below 0.5 that are recommended,[39] and observed no statistically significant differences between the healed and unconsolidated groups (p = 0.47). Large deviations of fragments can change the pattern of fracture healing, and the function. According to Perren[29], the elastic internal fixation is compatible with indirect fracture healing if there are no high levels of strain, which depends on the ratio between the length of the fracture zone and the displacement of the fragments. According to the same theory, strain values above 10% induce bone resorption from the fracture site, inhibiting consolidation. According to Shields[36], residual angular deformity of up to 18 degrees in the sagittal plane and up to 27 degrees in the coronal plane had no statistical correlation with DASH or patient satisfaction level. In patients where there was no consolidation, we observed major deviations in the anteroposterior radiograph (d = 2.2), with statistically significant differences, and the observed size of the effect was of high magnitude. The most common complication of diaphyseal fractures of the humerus is radial nerve palsy, occurring in 2 to 17% of the cases 24, and according to Samardizc et al [33] it can be divided into two types: primary, upon diagnosis of the fracture, and secondary, which arises after surgery. The management of primary apraxia associated with fractures with surgical indication is controversial. According to Liu et al [19], the recovery of the radial nerve function in an acute fracture of the humeral shaft does not depend upon the initial approach. Pailhé et al [28] state that the primary moment of fixation is ideal for exploring the radial nerve path in search of contusions or entrapments. Shao et al [34] does not advise early exploration due to the high rate of spontaneous recovery, indicating it only after 3 months and with signs of fracture healing. Pailhé et al [28] states that the open approach with reduction and fixation with plate and screws in fractures with primary apraxia provided recovery of function in 75% of the cases, in a period of three days. Livani and Belangero [21] used the MIPO technique combined with primary exploration of the nerve path and reported consolidation of all fractures in 3 months, with nerve paralysis recovery in all patients. We note that the five patients with primary apraxia underwent MIPO without primary exploration of the radial nerve, with bone healing in four cases and recovery of function in three. The choice of the MIPO technique without primary exploration of the nerve was also described by Kim et al [17], who reported 36 patients treated with the MIPO technique, with four presenting primary neurapraxia, and that recovery of function occurred in all of them. In open fractures with radial nerve paralysis, Pidhorz [30] states that the exploration should be performed if the fracture requires surgical correction. According to Carrol et al [8], there is an indication for exploration of the radial nerve in cases of fractures caused by firearm projectiles or penetrating wounds. However, Dougherty et al [12] states that surgical stabilization of the fracture depends on the surgical team, the degree of bone injury, and the resources available at the time of treatment. According to Bumbasirevi et al [6], 94% of his patients with fractures had recovery of their case, with low rates of pseudoarthrosis, leading the author to recommend no initial exploration. We found that patients with GIE and radial apraxia had a higher percentage of unsatisfactory DASH compared to other patients. Moreover, they had lower elevation of the shoulder and greater pain complaints. We set a standard, from these results, that in cases of displaced fractures of the humeral shaft from GIE and with clinical radial nerve injury, the fracture is to be stabilized using the MIPO technique, with exploration of the radial nerve. Overall evaluation of patients with functional and quality of life scores is important for measuring results of surgical treatment in trauma. Chaitanya 9 validated the use of the DASH in patients with humeral shaft fractures. Kiely et al [16] showed that the SF-12 can be used to assess quality of life in trauma victim patients, however, the mental component (MCS) proved to be minimally responsive to changes. Our results suggest that patients who do not consolidate present a higher percentage of unsatisfactory DASH, and a lower-SF-12 MCS. Shields et al [35] affirmed that among the independent variables predictive of DASH and SF-12, in patients with a humeral shaft fracture, increasing age influenced the result. This was not corroborated in our study, since we observed that patients with an unsatisfactory DASH presented lower scores on the physical component of the SF-12, and higher pain scores, with statistically significant differences. As limitations of the study we note the retrospective nature, loss of some data such as initial radiographs of some patients, preventing the assessment of the similarity between the ratio of plate size and length of the fracture. We had the loss of follow-up of some patients which, coupled with the small size of our sample, limited some conclusions.


The treatment of diaphyseal fractures of the humerus with an anterior MIPO demonstrated a 90.32% healing rate in the first six months post-operatively, with good clinical and functional results according to the DASH and SF-12 scores. Patients who did not heal the fracture presented greater radiographic coronal deviation. Patients with an unsatisfactory DASH had a longer elapsed time until surgery, less elevation of the shoulder, lower scores on the physical component of the SF-12, and higher pain scores, with statistically significant differences. Injuries by firearm combined with impairment of the radial nerve are related to a worse functional outcome in the sample evaluated.


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How to Cite this article: AF Mendes Jr, JM Neto, LFD Simoni, CAM Mariosa, BGS. e Souza, VD Oliveira, EA. Loures. MIPO for Humeral Shaft Fractures: Correlation between Radiographic, DASH, and SF-12 results. Acta of Shoulder and Elbow Surgery Oct – Dec 2016;1(1):35-43


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Arthroscopic Bristow – Latarjet Procedure: Results and Technique after nine-year experience.

Acta of Shoulder and Elbow Surgery | Volume 1 | Issue 1 | Oct-Dec 2016 | Page 27-34 | Jose Carlos Garcia Jr.

Authors: Jose Carlos Garcia Jr [1]

[1] NAEON-Santa Catarina Hospital.
[2] IFOR Hospital.

Address of Correspondence
Dr. Jose Carlos Garcia Jr., MD, MSc, PhD
NÆON-Hospital Santa Catarina-SP-Brazil


Introduction: The Bristow procedure is an established and effective method to treat anterior shoulder instability.
Following the current trend towards minimally invasive procedures, we performed the Bristow technique arthroscopically and assessed the results.
Materials and Methods: This study enrolled 33 patients with more than 2 years of follow-up. We assessed the UCLA score before and after surgery and completed post-surgical assessments of the Rowe score, Simple Shoulder Test (SST) score, and differences in external rotation (DER) at follow-up approximately 2 years or more post-surgery.
Results: At the 2-year follow-up, the average UCLA score increased from 25.48±0.64 (SD 3.67) pre-surgery to 33.03±0.57 (SD 3.26) (p<0.0001). In addition, the mean Rowe score was 93.33±2.00 (SD 10.93; compared with the cutoff score of 75, p<0.0001), the mean SST score was 11.20±0.28 (SD 1.52), and the mean DER was 11.50±1.65 (SD 9.02).
No recurrences of instability or musculocutaneous nerve lesions occurred in the patients.
Conclusion: Together, the UCLA score, SST score, DER, Rowe score and the recurrence rate suggest that the arthroscopic Bristow procedure was effective in treating anterior shoulder instability with short-term follow-up. However, although these results are encouraging, this procedure is not free of complications.
Additional data and prospective trials are important to better understand the possible advantages and disadvantages of this procedure.
Keywords: Latarjet, Bristow, shoulder instability, shoulder dislocation, arthroscopy, arthroscopic.


Anterior shoulder instability is one of the most common pathologies of the shoulder [8]. Among the many surgical techniques available to treat anterior shoulder instability, one of the most effective and well known techniques is the transfer of the coracoid and conjoined tendon to the anterior glenoid rim [2]. This procedure was suspected to be originally performed by Walter Rowley Bristow for the surgical treatment of recurrent anterior shoulder instability before 1929 [18]; however, no details on the surgical technique were reported until the Helfet report in 1958 over the technique he learnt in 1939 from Bristow [11]. In 1954, Michel Latarjet established the modern concept of this surgery using one screw to fix the coracoid and splitting the subscapularis in the horizontal direction [15]. Didier Patte et al. disseminated this technique throughout Europe in the 1980s and used two 4.5 mm screws to fix the graft [19].  This procedure involving the transfer of the coracoid and conjoined tendon to the anterior glenoid rim has been modified several times, but these modifications have always respected the principles established by Bristow and Latarjet [14]. Many of these modifications have resulted in successful results with some common complications. The most common complications include loss of external rotation, osteoarthritis, pain, Musculocutaneous nerve lesions and non-unions [10].  These complications have led many surgeons to avoid this procedure and prefer capsular plication with labral reconstruction.  Recently, minimally invasive arthroscopic techniques have been developed to perform Latarjet surgery [14 ].Through an intra-articular view, the surgeon is able to better position the graft and avoid some of the possible complications related to positioning, such as recurrence of dislocation and osteoarthritis. The intra-articular view of the insertion site also ensures the presence of bone marrow at the contact area, which allows for a more reliable osteosynthesis [1,14,17]. However, this new approach to the established procedure requires new instruments and increased surgical costs. In 2009, a surgical technique was created to allow the Bristow procedure to be performed with a minimally invasive procedure that uses regular arthroscopic devices and one screw [8]. In this study, we have modified this technique and present the results of 33 patients who underwent the arthroscopic Bristow procedure to treat anterior shoulder instability.
Hypothesis: This new modification of the arthroscopic Bristow procedure, which utilizes regular arthroscopic devices, is an effective procedure to treat patients with anterior shoulder instability.
Purpose: To assess the effectiveness and safety of the modified arthroscopic Bristow procedure.


This prospective case series study Stage 2a of the IDEAL-Collaboration. From September 2007 to September 2016, 47 patients underwent arthroscopic Bristow-Latarjet procedure. Of these 47 patients, the first three surgeries were not scored before the surgery and were therefore not allowed to take part of this trial. The records of two other patients were lost, one successfully returned to his high impact activities, and the records of the other present just the pictures of his recovered arch of motion. Nine patients present less than two years post surgery. The remaining 33 patients fulfilled the inclusion and exclusion criteria as described in Table 1.

The chosen outcomes included the following:
Modified UCLA score: The UCLA score was primarily created to assess shoulder arthroplasty patients. The modification of the UCLA score allows it to be used for various age groups and different conditions [22];
Simple Shoulder Test (SST);
Rowe score: The Rowe score is a post-surgical assessment that does not allow for a comparison with the condition before the surgery. In contrast, the results are compared with the cutoff point of 75. A score over 75 is considered good, whereas a score over 90 is considered excellent. An unstable shoulder will not result in a Rowe score over 50; therefore, comparing the results with a cutoff score of 75 offers a reasonable assessment of surgical success;
Loss of external rotation with the arm in adduction: The baseline measurements were used as a control and compared to the results at the 2-year post-surgical follow-up. Only differences before and after surgery were recorded. Because we used manual goniometry, external rotation was measured every 5º;
Elevation: The final range of motion was compared to the contralateral side if differences in elevation were greater than 10º; and Dislocation recurrence.
Assessments: Patients were assessed at baseline for external rotation in adduction of the affected shoulder and UCLA score.
Patients were assessed two years post-surgery for external rotation in adduction of the affected shoulder, shoulder elevation, Rowe score, SST score and UCLA score.
Post-surgical assessments also included roentgenograms at two weeks, five weeks and two years after surgery. Computed tomography (CT) scans were also performed when complications were suspected.
Statistical methods
Statistical analyses were performed using Prism6®for Mac (GraphPad Software Inc.).
All data were tested for normality using the D’Agostino and Person test, Shapiro-Wilk test and KS test. Thereafter, the data were assessed according to patient characteristics. The intention to treat (ITT) [24] principle was used whenever possible. Interim sample size was calculated to determine whether the study achieved significance and statistical power as an adaptive design. For all possible assessments, a two-tailed test of significance was used, and p<0.05 was considered statistically significant. Adverse events or complications are reported for all the 33 patients enrolled in the study. In addition, the causes for withdrawal from the study are also reported.

Surgical technique
Under general anesthesia, the patient was placed in the beach chair position with their arms free. A standard posterior portal was established, and the arthroscope was introduced. An arthroscopic pump with 40 mm Hg of pressure was used in the procedure. The patient’s blood pressure was not controlled during the procedure, except in cases of very high blood pressure that could potentially compromise the surgery. Diagnostic arthroscopy was performed, and a portal was placed under the anterior triangle, through the subscapularis. This anterior modified portal was inferior and medial to the traditional anterior portal. The location for the portal could be found using a needle, which was inserted where the surgeon planned to insert the screw. If the surgeon was troubled by the axillary nerve, nerve integrity could be confirmed through arthroscopic visualization using an arthroscope inserted into the lateral portal. The musculocutaneous nerve could also be visualized using this technique.
The arthroscope was returned to the posterior portal. After assessment of the joint and identification of the bony Perthes-Bankart lesion, the anterior glenoid rim was shaved. The rotator interval and coraco-clavicular ligaments were removed, and the lateral part of the coracoid was exposed using an electrocautery device. If necessary, a portion of the anterior capsule can be removed for better visualization. The subscapularis was opened in the same direction as its fibers with a Kelly device through the anterior modified portal. Caution should be taken when passing the device through the modified anterior portal, which is lateral to the conjoined tendon, to avoid nerve injuries. The electrocautery device can also be used at this point. The Kelly device was introduced through the anterior modified portal, and the subscapularis was opened from the bursal side to the articular side, which is similar to the open Bristow procedure. The tendon was opened wide in the middle of the tendon (Fig. 1).


Although the axillary nerve is in close proximity, lesions to this nerve are not common, as in the open Bristow procedure [7].
The anterior modified portal was used to introduce a 2.5 to 3.5 mm drill to the anterior glenoid defect at the location where the screw will be inserted and at the same axis as the glenoid through the subscapularis split. This procedure was performed under direct view using the arthroscope in lateral portal and the drill perpendicular to the shaved anterior glenoid rim. The hole needs to be at least 5-6 mm medial to the glenoid rim and inferior the humeral head equator to avoid redislocation [29] . A guide should be used for the drill to avoid nerve injuries. The Glenoid Bone Loss Instrument Set from Arthrex® (Naples-Fl-USA) (Fig. 2) contains a guide that can be used to make this step safer.


However, in the majority of the procedures performed in this study, we only protected the skin, deltoid and conjoined tendon because direct visualization showed that the drill was at a safe distance from the neurovascular structures. Sometimes the conjoined tendon can be medialized by the guide to enable an optimal position. The subscapularis is not affected during the drilling because of the saline solution used in arthroscopy. The 2.5 to 3.5 mm (depending on the coracoid diameter) drill was inserted until the posterior scapula cortical was felt. The distance from the hole to the glenoid rim was approximately 5 to 6 mm,29 which was measured using a probe and a surgical ruler. If the coracoid length is larger in the horizontal axis than the vertical axis, small corrections can be made by rotating the graft. Then, a second drill of equal size was placed beside the first one to compare and measure the difference in length between the two drills. This second drill is not inserted and no extra hole is made; the drill is only placed besides the other drill to measure the length. This measurement represents the glenoid length, and small differences in this measurement are expected.


The arthroscope was then reinserted into the lateral portal. To find the best portal for the osteotomy, an 18-gauge needle was used, which was inserted lateral to the coracoid and located near the clavicle. Direct visualization using the arthroscope is optimal to determine the most adequate point to insert the osteotome. This portal can also be used to access the superior tip of the coracoid (superior coracoid portal-SCP). The pectoralis minor and the facia were detached through this portal using electrocautery. A small nitrogen saw was inserted through this portal, and the coracoid was carefully cut. A regular osteotome can also be used for this purpose. The direction of the osteotomy is vertical to the coracoid. The risk of breaking the bone is avoided by using a nitrogen saw. The coracoid and the conjoined tendon were pulled out of the body using a Kocher device through the anterior portal (Fig. 3). Any irregularity of the coracoid graft was flattened to improve the contact surface. A hole was made in the coracoid using a 2.5 to 3.5 mm drill in the horizontal axis. The coracoid length was then measured.
However, if the surgeon’s preference is to use the vertical coracoid axis, he/she will also have to drill the inferior part of the coracoid to optimize bone healing and create an extra portal to insert the screw. The best location for this additional portal is just above the coracoid at the location where the screw will be inserted. This location can be better defined using a needle under direct arthroscopic visualization and is located near the clavicle. The use of the vertical position for the coracoid without exteriorization is recommended in heavy and extremely strong patients, where exteriorization is very difficult. We have performed this modification of the procedure when necessary (Fig. 4). However, exteriorization of the coracoid makes the procedure faster and easier, and the length of the anterior portal is not modified. The size of the anterior portal is the same size as the diameter of the coracoid (10-14 mm), as measured intraoperatively using a surgical ruler. This procedure of measuring clearly defines the length of the glenoid and coracoid, and the sum of the two is the exact length of the malleolar screw to be used. A 3.5 to 4.5mm mm malleolar screw was then inserted in the coracoid (Fig. 5). Most commonly, a 34 to 40 mm sized screw is used. For fixation, the arthroscope was reinserted in the posterior portal, and the coracoid plus the conjoined tendon were inserted through the split subscapularis tendon. A Kocher device and a probe are used to make this procedure easier. The screw was inserted into the anterior glenoid rim, and fixation was achieved with the graft in the horizontal position. Often the hole is not easy to locate; therefore, the arthroscope needs to be inserted in the SCP and the lateral portal to improve visualization. The screwdriver can be used as a joystick by using traction of the screw against the screwdriver with a synthetic multifilament number 5 polyester wire. A Kocher device can be inserted in the SCP to avoid the rotation of the coracoid while the screw is fixed(Fig. 6). If the graft is overhanging, sometimes a small rotation of the graft can be enough to correct this problem once the coracoid is more elliptical than circumferential. However, if the graft remains impinging on the humeral head, it can also be shaped using an osseous shaver. Finally, shoulder external rotation was checked using the arthroscope in the posterior portal (Fig. 7). A radiographic exam was also performed (Fig. 8). The portals were closed using nylon 4.0 or 3.0 sutures (Fig. 9) The capsule was never repaired in this arthroscopic procedure; however, it can be performed if desired by the surgeon.


Post-operative care
Post-operative care is similar to that with the open Bristow procedure protocol. The patient will use a shoulder immobilizer during the first five weeks. Minimal movements, such as free elbow flexion and extension and hand and wrist movements, are recommended, and the patient is instructed to avoid external rotation of the shoulder.The patient is encouraged to start pendular movements (external rotation from 0º to 10º) and assisted passive elevation (up to 60º) only after the second week following surgery.External rotation is avoided for five weeks. The progression of external rotation and elevation is in consideration of the patient’s pain level. Gain of range of motion begins only five weeks after the surgery. Aggressive gain of range of motion begins just six weeks after the surgery. Active rotator cuff exercises are also allowed five weeks post-surgery.
All sports can be performed after eight weeks; however, the patient may have poor external rotation at this time point, which may restrict the performance of some sports. Improvement in external rotation will occur approximately six months after surgery.


Overall results
Data loss: Of the 33 patients enrolled in this study, one died due to a car accident, one did not return for post-operative care, and another patient presented with a fracture to the coracoid, which required conjoined tendon tenodesis in the anterior glenoid rim. However, the data from these three patients were included in the study because UCLA baseline evaluations were obtained for these patients. Despite good results for pain, stability and function (UCLA=34), the patient who underwent the conjoined tendon tenodesis was graded postoperatively with the same baseline. Of the 33 patients included in the study, there were 32 males and 1 female with a mean age of 33.34 years (range: 18-60 years old). In total, 11 presented with anterior shoulder instability to the left side and 22 to the right side. The average follow-up time was 4.73 years (range 2-8 years).
The reasons for performing the procedure included bony Bankart lesions compromising 20% or more of the glenoid (20 patients), HAGHL lesions (1), failure of previous labrum reconstructions (7) and an instability severity index score higher than six(5).

Clinical results (effectiveness)
UCLA was assessed in ITT (33 patients), and the results are summarized in Table 2.


The Rowe score was assessed according to defined protocols (30 patients), and the results are summarized in Table 3.
Data showing p<0.0001 signaled for the trial to stop due to the effectiveness of the procedure.21
SST and DER were assessed according to defined protocols (30 patients), and the results are summarized in Table 4.
The frequencies of SST responses are summarized in Table 5.
There were no differences in elevation from the contralateral side of more than 10º, except in 2 cases. Internal rotation was not assessed; however, 9 of 30 patients presented with discomfort during this movement at the extremes of internal rotation, as assessed in question 11 of the SST.


Complications and revisions
i) Intraoperative complications in the 33 patients
a) Coracoid fractures
There were found two intraoperative coracoid fractures:
One was a complete fracture, and the surgeon successfully performed an anterior conjoined tendon tenodesis through the subscapularis split. The other fracture was a partial fracture, and the surgeon performed a coracoid cerclage and successfully completed the arthroscopic Bristow procedure.
b)Nerve lesions
No nerve lesions occurred.
c)Other complications
No other complications occurred.
ii) Post-surgical complications (30 patients): Of the 33 patients enrolled in this study, one died due to a car accident, one did not return for post-operative care, and another patient presented with a fracture to the coracoid, which required conjoined tendon tenodesis of the anterior glenoid rim.
I) Radiographic assessments
a) Coracoid fractures: One patient was found to have a partial coracoid fracture; however, the remaining part of the coracoid was sufficient to avoid redislocation.
b) Non-unions: There were no non-unions.
c) Screw torsion: There were no screw torsions.
d) Osteolysis: Osteolysis was assessed through an axillary roentgenogram and was present in three patients (10%), including two with no clinical repercussions, who refused screw removal, and one patient who underwent screw removal.
e) Osteoarthritis: Osteoarthritis was assessed using a roentgenogram and was present in 2 patients. Both patients presented with moderate arthrosis according to the Samilson & Prieto classification [23], although one patient presented with moderate osteoarthritis before the surgical procedure. Both received follow-up more than 2 years following the surgery (one at 7 years and the other at 5 years).
II) Clinical assessments
Infection: One patient contracted an infection more than 6 months post-surgery, which was the worst outcome observed.
Anterior impingement: Anterior impingement was present in two patients, including the patients with osteolysis. Both patients underwent hardware removal.
Subluxations: There were no subluxations reported.
Instability recurrences: There were no instability recurrences.
Sample size: An interim analysis13 was performed to confirm whether the sample size was suitable for analysis. We enrolled a total of 33 patients to provide data for the sample size calculation20 and determined that the number of individuals was sufficient to answer the research question with respect to an alpha and beta of <0.05.


Coracoid transfer to the anterior glenoid rim is one of the most reliable procedures to treat anterior shoulder instability due to the triple-block system, which includes:
1-Conjoined tendon;
2-Tension of the inferior part of the subscapularis with the shoulder during abduction and external rotation; and
3-Bone block [14]
Given that the current trend is to use minimally invasive surgical procedures to reduce surgical trauma and scars, it seems logical to modify established procedures to this new approach. Recently, modifications of the Bristow and Latarjet procedure have been developed to allow the procedure to be performed arthroscopically [1,14,17]. There are several advantages to the use of an arthroscopic coracoid transfer procedure, including better visualization of the insertion area in the anterior glenoid rim, the possibility to correct the graft to avoid overhanging, testing external rotation under direct visualization, treatment of concomitant intraarticular lesions, and a reduction of scars and possibly post-operative pain. In addition, there are several disadvantages, such as higher costs, a steeper learning curve for the surgeon, and a need for specific training. However, in the author’s opinion, the above-listed advantages make arthroscopic modifications of the coracoid transfer procedure a reliable possibility for treating anterior shoulder instability. In this study, fracture of the coracoid was the main complication of this procedure (3 cases). Edwards and Walsh have stated that fracture of the coracoid can be avoided by using the 2-finger technique, which improves torque control.7 Another consideration is the size of the screw; in this procedure, a 3.5 to 4.0 mm screw is more suitable for avoiding fractures compared with a 4.5 mm screw. It is also important to mention that to externalize the coracoid, the surgeon can insert the Kocher device in the soft tissue of the conjoined tendon beside the coracoid, instead of in the graft, to avoid graft fractures. In fact, when considering these 3 points, we felt more confident with the procedure and did not observe any further breakage. Regarding the treatment of the fractures, in 1 case the fracture was not complete and was successfully treated using a synthetic multifilament number 5 polyester cerclage around the coracoid. The partial fracture occurred in the shoulder of the only female in the study and was possibly because the screw was too large (4.5 mm) for her coracoid. In the other case, the fracture was complete and occurred during the fixation step; therefore, we performed a conjoined tendon tenodesis in the anterior glenoid rim using suture anchors similar to the way the procedure was performed in the past by Bristow [11]. The third patient did not require any further procedure. Studies have found no significant differences in cadaveric models when comparing coracoid transfer with conjoined tendon tenodesis only [25,28] .In addition, studies have shown that the coracoid transfer does not need to produce a bone-block effect [6]. In fact, neither the original Bristow nor the original Latarjet procedure presented enough bone to produce a bone-block effect. In the original Bristow procedure, the tip of the coracoid is sutured to the anterior glenoid rim,11 whereas in the original Latarjet procedure, the coracoid graft size is small, which allows for the complete preservation of the pectorals minor insertion in the remaining coracoid [15]. The bone-block effect of some modern variations of the Bristow and Latarjet procedures has added more stability to the original surgical procedures; however, this consideration may only be important for patients who present with Hill-Sachs lesions higher than the glenoid track [27]. Moreover, the data remain inconsistent regarding the best screw diameter for coracoid transfers. Walsh and Boileau successfully performed the procedure using 4.5 mm malleolar screws [26]; Burkhed et al.[3] and Di Giacomo et al.[5] used 3.75 mm screws; and Lafosse et al. used 3.5 mm screws [14]. The author’s personal experience is that screw size is dependent on the patient’s characteristics. For example, a 4.5 mm screw may be used for tall males; however, the most recommended size is 3.5 to 4.0 mm. Walsh and Boileau do not recommend using washers to avoid impingement [4]. However, the use of small washers is recommended when using 3.5 to 4.0 mm screws to better distribute the pressure on the graft without adding impingement. In the arthroscopic Bristow procedure used in this study, osteolysis was found in 3 cases. In the author’s opinion, osteolysis caalso be associated with the high forces that the screw impose on the graft [4]. However, assessments were performed only using X-rays, which is not the most sensitive method. One case of osteolysis was accompanied by impingement and required removal of the screw [9]. The patient with impingement underwent surgery for hardware removal; however, 9 of 30 patients answered no to question 11 of the SST. This result indicates that these patients had difficulty washing the back of the opposite shoulder with the affected extremity. Therefore, impingement may be underestimated by patients, although the author accepts the impingement rate of 9/30 in this study, even if only reported for extreme movements. Because impingement can be linked to the angle of the screw and the graft, it is important to note that higher angles within the arthroscopic procedures should never be more than perpendicular to the glenoid’s border. This is because direct visualization allows the surgeon to have direct control over the position, which avoids overhanging but occasionally causes impingement or discomfort in extremes of internal rotation. Moreover, the author suggests that the size and the obliquity of the graft can influence anterior impingement and the effective glenoid depth [16] In this study, the reoperation rate was 6.67%, which was only for hardware removal and is similar to the 7% reported in the literature for the open Bristow procedure [10]. Osteoarthritis was present in only 2 (6.67%) of the patient’s shoulders, and one of the two patients presented with osteoarthritis before the surgical procedure. This low rate may be associated to better graft positioning and less overhanging. However, the follow-up for assessing osteoarthritis was too small to emphasize these benefits. It is important to insert the coracoid graft in a flush position to avoid both an increase in edge loading and to shift contact pressure to the posterosuperior quadrant of the glenoid [17]. To date, no post-surgical recurrences of instability have occurred; however, the follow-up time may be insufficient to make conclusions regarding this outcome. Regarding the graft position, studies have suggested that a medial deviation of the coracoid of 5 mm or more is associated with a higher failure rate [12]. Therefore, graft positioning may be one advantage of the arthroscopic procedure.In this study, no non-unions were found. This result may be due to better exposure of the marrowbone of the anterior glenoid rim, better visualization during fixation to avoid interpositions and the author’s preference for the horizontal position of the graft. This position allows the biological union of the graft’s marrowbone with the glenoid rim’s marrowbone. However, follow-up assessments were performed only using X-ray, which is not the most sensitive method to detect non-unions. The author believes that one screw is sufficient to fix the coracoid. In Hovelius’ report on the Bristow procedure, he reported 16 redislocations within a sample of 319 shoulders, which included 5% that underwent the Bristow procedure using only 1 screw. Of those patients, 13% presented with a non-union; however, the fibrous union did not affect the recurrence rate, and only 3 patients underwent revision surgery because of the remaining instability [12]. According to Hovelius, the recurrence of instability is linked to medialization of the coracoid graft [12]. Our low rate of recurrence may be due to improved visualization during insertion of the graft; however, the small sample size of our study and the short follow-up period prevent us from confirming this notion. Similar redislocation rates (4%) to those reported by Hovelius were recently reported by Burkhart et al. in 102 patients [3], and Collin et al. in 74 patients [4], and both reports used 2 screws for fixation (Latarjet). The musculocutaneous nerve was the most common nerve injury and was reported in 0.6% of all surgical procedures [10]. The author did not find any nerve dysfunction or lesions; however, similar low rates of nerve compromise have been reported in the literature, and further studies are necessary to suggest any conclusions on nerve safety. The procedure presented in this study uses regular arthroscopic devices and screws, which provides significant cost advantages.

This study was not blinded.
The learning curve for this procedure requires specific and extensive training.
The high rates of coracoid fractures were overestimated because not all of the procedures used the 2-finger technique and smaller screw sizes.
The study was not a comparative study; therefore, comparing other techniques to the technique described in this study was not possible.
The follow-up for osteoarthritis assessment was short. Future assessments will make these data more suitable for analysis.


The UCLA score, SST score, DER, Rowe score and the recurrence rate reported herein suggest that the arthroscopic Bristow procedure is effective in treating anterior shoulder instability with short-term follow-up. However, although these results are encouraging, this procedure is not free of complications. Additional data and more prospective trials are important to better understand the possible advantages and disadvantages of this procedure. In particular, multicenter studies are needed to confirm the effectiveness and safety of this procedure, and new devices are needed to improve the accuracy and ease of using this procedure to treat anterior shoulder instability.


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Video of the Technique


How to Cite this article: JC Garcia Jr. Arthroscopic Bristow – Latarjet Procedure: Results and Technique after nine-year experience. Acta of Shoulder and Elbow Surgery Oct – Dec 2016;1(1):27-34.


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Current Trends in Shoulder Replacement: The Rational for Inlay Arthroplasty

Acta of Shoulder and Elbow Surgery | Volume 1 | Issue 1 | Oct-Dec 2016 | Page 14-19 | Gregory G Markarian, Aboul Deng Bab, John W Uribe.

Authors: Gregory G Markarian [1], Aboul Deng Bab [2], John W Uribe [3]

[1] OAN Sportsmedicine, Naperville, Il.
[2] Atlantic University, School of Medicine.
[3] Professor and Chairman, Department of Orthopaedic Surgery, Herbert Wertheim School of Medicine, Florida International University.

Address of Correspondence
Dr. Gregory G. Markarian, MD, FRCS
OAN Sportsmedicine 10 West Martin Ave Suite 50
Naperville, IL 60540


Introduction: Shoulder arthroplasty utilization worldwide has undergone significant changes in the past two decades. Early on, the procedure volume was relatively small and demonstrated a preference towards hemiarthroplasty. Starting with the new millennium, the overall arthroplasty volume not only drastically increased, but also showed a tendency towards younger patients. Recent reports revealed that more than three quarters of all shoulder arthroplasty procedures are performed as a stemmed total or reverse procedure. Younger patients result in a clear increase in the revision rate across all conventional implant classes as evidenced by arthroplasty registry results. Increased modularity and adaptability of modern stemmed arthroplasty improved the procedure, but remains largely non-anatomic with continued use of spherical humeral head and onlay glenoid components.  The purpose of this review is to highlight the technical and clinical advantages of inlay shoulder arthroplasty and to differentiate it from onlay resurfacing procedures and the current trends in shoulder arthroplasty. Resurfacing arthroplasty is an implant class consists of onlay hemi and total resurfacing, partial inlay and total resurfacing. The distinction is important as onlay procedures use spherical humeral head and onlay glenoid components whereas inlay arthroplasty is taking the geometrical humeral head mismatch into consideration and avoids glenoid related joint line changes. In keeping the glenohumeral joint volume near the native conditions, biomechanical and kinematic advantages can be appreciated. Registry results showed the lowest 5 year cumulative revision rate for partial inlay arthroplasty across the treatment spectrum and clinical results from stemless total resurfacing using non-spherical humeral head and inlay glenoid components display great promise for a new path in primary shoulder arthroplasty.


Shoulder arthroplasty as a specialty has undergone significant changes in the new millennium (11,19,24,39,44). This did not only cause a marked increase in procedure volume, but also a shift in the use of specific implant classes and age related trends towards younger patients (2,37,43). Combined, these factors have led to a substantial increase in revisions (44) and may have a significant impact on the long term management of shoulder patients. In the context of these developments, contemporary primary shoulder arthroplasty continues to show a disregard for joint preservation and anatomic surface reconstruction with preferential use of stemmed total and reverse procedures (11,35,43,44). Modularity and adaptability are important aspects of modern stemmed procedures (4,16,48); however, with continued use of spherical humeral head and onlay glenoid components, these procedures remain largely non-anatomic. The purpose of this review is to summarize trends in shoulder arthroplasty and present a rational for inlay arthroplasty as a less invasive alternative in primary shoulder replacement.

Morphology and Biomechanics of the Humeral Head
Since the introduction of modern shoulder arthroplasty by Neer (36), evidence on the non-spherical nature of the humeral head (HH) has steadily increased for more than 50 years with reports on biomechanical and morphological data that reference the native shape of the humeral head. In 1955, Neer (36) described the superior edge of the humeral head as somewhat flattened. In 1979, Clarke (8) showed that the best match to the plane of the cross sectioned humerus was in form of an elliptical shape. This was reconfirmed by multiple studies over the following three decades (1,3,6,18,20,21,31,42,49,50). Other studies comparing the major and minor planes of the HH reported a dimensional mismatch with a range from 1.6 to 6.5 mm (8,18,20,21,22,42,49). The principal goal for primary shoulder arthroplasty is to restore normal glenohumeral joint kinematics (23). Jun et al. (22) compared custom non-spherical and commercially available spherical implants to the native humeral head and showed that the non-spherical shape fit the native HH better. The study reported a significant reduction in rotational range of motion for spherical heads (mean 7.6 +/- 8.2 degrees) compared to the native humeral head; no statistical difference in rotational range of motion was found between the non-spherical and native conditions. The authors concluded that the use of non-spherical heads may improve functional results after shoulder arthroplasty by more closely approximating the rotational range of motion and kinematics of the native humeral head as compared to the current spherical prosthetic designs. The kinematical advantages of non-spherical implants were reconfirmed by the authors in their most recent publication: The non-spherical humeral head shape contributed to increased glenohumeral translation whereas the aspherical head shape did not show significant glenohumeral translation during humeral axial rotation, regardless of glenoid conformity (23).

Trends in Shoulder Arthroplasty
Procedure Volume
In 1993, the US shoulder arthroplasty volume included 13837 procedures with a slight preference for hemiarthroplasty (54%) over total shoulder arthroplasty (46%). In 1999, the total volume had increased to 19113 procedures and the preference for hemiarthroplasty remained (56%) (24). Since the start of the new millennium, shoulder arthroplasty experienced a drastic rise. The American Academy of Orthopaedic surgeons (AAOS) reported an absolute increase in primary procedures from 18,621 discharges in the year 2000 to 45,274 discharges in 2011 (2) with other estimates reporting a total of 66,485 for the same year (43). The Australian orthopaedic association’s annual shoulder arthroplasty registry report mirrored this trend. Since 2004, the registry recorded 32,406 shoulder replacement procedures (35). Starting in 2008, the number of shoulder replacement procedures has increased by 88.5%. Dillon et al. published their results on 6,336 primary shoulder arthroplasties recorded from 2005 – 2013 in the Kaiser Permanente shoulder arthroplasty registry (11). Procedures were classified as a total shoulder arthroplasty in 48%, followed by hemiarthroplasty procedures in 34%, reverse total shoulder arthroplasty in15%, and humeral head resurfacing in 3%. Shoulder arthroplasty utilization was based on the following diagnoses: Osteoarthritis (60%), fracture (17%), cuff tear arthropathy (15%), and avascular necrosis (2.6%). The all cause revision rate for elective shoulder arthroplasty was 4%. The most common reason for revision was glenoid wear following hemiarthroplasty or onlay humeral head resurfacing (27% of all revisions) followed by deep infection (20%), instability (18%), rotator cuff tear (17%), and glenoid component failure. Patients less than 60 years of age receiving a hemiarthroplasty had an almost 5 times higher revision risk than those patients who received a TSA.

Patient Age
From 2000 to 2011, the AAOS report (2) showed a 5% increase in total shoulder replacement in patients between 45 – 64 years old (29 –34%), whereas patients 65 – 84 years essentially remained unchanged with a 1% reduction over the same period. The proportion of partial shoulder replacements in middle-aged patients increased by 10% (25 – 35%) (2). US inpatient sample estimates showed that 53% of all patients treated with reverse total shoulder arthroplasty were less than 75 years old. The same applied for 50% of total shoulder arthroplasty (TSA) and 32% of hemiarthroplasty (43).

Procedure Type
Based on current Australian utilization, primary total shoulder replacement is the most common category (71.8%), followed by primary partial (17.9%) and revision procedures (10.3%). The proportion of total shoulder replacement has increased from 57.5% in 2008 to 82.1% in 2015. The majority of this increase has been led by a more than a fourfold increase in reverse total shoulder arthroplasty over this time frame. Between 2008 and 2015, partial shoulder replacement decreased from 32.6% to 7.2% (35). A similar trend towards total shoulder replacement has been reported in the US. Schwartz et al. showed a fivefold increase in primary total shoulder utilization based on a national hospital discharge survey with data from 2001 to 2010 (44). Based on 2011 estimates published by Schairer et al. (43), 32.6% of all procedures were reverse shoulder arthroplasties (RSA), 44.2% were total shoulder replacements, and 23.2% were hemi arthroplasty procedures.

Revision Rates by Age
Shoulder implant classes demonstrate an overall trend towards higher revision rates with younger patient age. The 5 year cumulative percent revision for primary hemi onlay resurfacing in patients under 55 years was 10.4, compared to 8.1 in the 65-74 year old patients and 6.6 in patients over 75 years. Similar 5 year trends were reported for primary stemmed hemiarthroplasty with a revision rate of 13.1 (<55 years) versus 7.0 (>75 years) and 11.0 (<55 years) versus 6.7 (>75 years) for primary stemmed TSA (35).

Hemi versus Total Shoulder Replacement

Several comparative studies support the preference towards TSA. A systematic review and meta- analysis conducted by Bryant et al. (5) compared TSA to hemiarthroplasty (HA) at a minimum of 2 years follow up. A total of 112 patients (62 TSA, 50 HA) were included in the review. The authors concluded that TSA showed better functional improvement than HA and contributed continuous degeneration of the glenoid to the result. In a 10-year update, Sandow et al. showed that 42 percent of the surviving TSA patients rated their shoulders as pain free while none of the HA patients were free of pain at 10 years (41). Radney et al. (40) conducted a systematic review comparing TSA to humeral head replacement (HHR) and concluded that TSA significantly improved pain relief, range of motion and patient satisfaction. TSA also had a significantly lower revision rate (6.5%) compared to patients undergoing HHR (10.2%). Garcia et al. (13) reported on patients with osteoarthritis (OA) who wished to return to sports following a total or hemi shoulder arthroplasty. He found that the rate of return to sports was significantly better after TSA compared with HA. In addition, the HA patients had significantly more pain, worse surgical satisfaction, and a decreased ability to return to high upper extremity use sports.

Inlay Arthroplasty

Shoulder resurfacing as a less invasive alternative to stemmed arthroplasty has been popularized by Copeland and Levy (27-29,34). Despite the inherent advantages from a joint preservation perspective, the use of spherical onlay implants has not been void of criticism. Five year revision rates for hemi onlay resurfacing (10.6%) have been higher than their stemmed counterparts (8.5%) (35). Despite previous reports of overstuffing or varus placement (32,45), underlying reasons are not yet fully understood. Inlay arthroplasty (IA) represents a departure from the use of spherical humeral head configurations. The concept was introduced more than decade ago and started with partial humeral head surface reconstruction, which was expanded in recent years to full head coverage. The system consists of various humeral head diameters ranging from 25 to 58mm. Each diameter has an array of shapes that allows for congruent surface reconstruction within the curvature of the humeral head. The two piece implant consists of a screw that is placed into the center of the defect for the purpose of fixation and surface measurement and an articular component that matches the superior-inferior (SI) and anterior-posterior (AP) curvatures of the surrounding surface. The contour is mapped intraoperative, corresponding surface reamers prepare an implant bed, and the screw and articular component are connected via morse taper. The surgical procedure has been described in detail previously (17,46,47). IA uses anatomic references to reconstruct the native geometry. Neither stemmed procedures, nor onlay resurfacing procedures take the non-spherical humeral head morphology into consideration; however, IA preserves anatomic landmarks for intraoperative measurements and reconstruction thereby keeping soft tissue tension and the moment arms of the shoulder muscles intact. Technical challenges associated with stemmed procedures are avoided by maintaining humeral head height, version, offset, and joint volume. This may not only have positive implications for postoperative recovery and rehabilitation, but also reduces the risk of implant related pressure on the rotator cuff and subscapularis repair following the customary deltopectoral approach. Hemi and total onlay resurfacing procedures using spherical implants reference the implant diameters off the larger superior-inferior humeral head plane to gain complete surface coverage. The non-physiological joint volume increase in the anterior-posterior plane can be avoided by using non-spherical implants that respect the SI – AP mismatch. Similar to onlay total shoulder resurfacing, IA allows for total resurfacing of the glenoid vault using dedicated 30 degree off axis reamers. Following preparation of the humeral head, the glenoid vault is accessed from the front using a circular paddle reamer. Single or double circle inlay glenoid components allow for surface reconstruction without lateralizing the joint line. Keeping glenohumeral volume contributions at their native levels may have positive implications for postoperative pain relief and functional improvements.

Biomechanical Comparison

The concept of inlay glenoid resurfacing has been previously described by Gunther et al. (15). Following cyclic loading to 100,000 cycles, no inlay glenoid components demonstrated signs of loosening. Finite element analysis results indicated that the inset technique achieved up to an 87% reduction in displacement compared with the onlay pegged implant and a 73% reduction compared with the onlay keel implant. Onlay implants exhibited high stress at the implant edges in form of a rocking-horse stress distribution, whereas the inset design did not show the rocking-horse stress distribution. The authors concluded that cyclic loading and finite element analysis support the concept of inset glenoid fixation in minimizing the risk of glenoid loosening. Recently, Gagliano et al. (12) presented their results comparing onlay versus inlay glenoid prosthetic design survivorship characteristics in total shoulder arthroplasty at the 2015 Orthopaedic Research Society Meeting (ORS). The study showed visible loosening in all onlay implants in less than 2000 cycles, whereas none of the inlay components showed signs of loosening following 4000 cycles. A biomechanical study by Hammond et al. (17) reported on the comparison of the intact glenohumeral joint to that following HH inlay arthroplasty and stemmed hemiarthroplasty. IA restored the center of rotation more closely than stemmed hemiarthroplasty and the glenoid had demonstrated less eccentric loading. The authors concluded that IA may provide better functional outcomes for patients as the biomechanics of the joint and the moment arms of the rotator cuff and deltoid more closely resembled the intact condition.

Clinical Results

The Australian Shoulder Arthroplasty Registry has been reporting on inlay arthroplasty since 2010. While the procedure volume has remained low, the revision rate (RR) has shown dramatic differences comparing partial inlay arthroplasty to other implant classes. In the 2016 report (35), the 5 year cumulative RR of partial inlay arthroplasty was 1.5%. No other implant class showed comparable registry results. As an implant class, hemi onlay resurfacing at 5 years had a cumulative revision rate of 10.6%, which was highest with Global CAP implants (12.8%, primary diagnosis OA), followed by Copeland (9.1%, primary diagnosis OA), and Aequalis (9.0%, primary diagnosis OA). These results highlight the importance of differentiating among inlay and onlay surface reconstruction methods. When addressing the glenoid as well, the 5 year cumulative revision rate of total onlay resurfacing was lowered to 7.3%. For comparison, the 5 year RR for stemmed hemiarthroplasty was 8.5%, for stemmed total shoulder arthroplasty 8.1%, and for total reverse arthroplasty 4.6%. It remains important to view registry and literature reports in the context of patient age and clinical exit opportunities. Procedures that are amenable for younger patients will be subject to higher demands and increased RR as reported earlier. End stage procedures such as stemmed total shoulder replacement and reverse arthroplasty face increasing technical demands when revision procedures become necessary. The management of patient expectation is generally more restrictive in these arthroplasty solutions when compared to less invasive alternatives and may impact the patients’ desire to undergo further surgery. Therefore, end stage procedures may show a false positive revision rate due to the lack of treatment alternatives. Advanced stages of osteonecrosis of the Humeral Head (ONHH) with separation of the subchondral bone or contour collapse are typically managed with arthroplasty. Uribe et al. reported on the use of partial inlay arthroplasty for advanced stage ONHH (47). The consecutive series of 12 shoulders (9 female, 2 male, one bilateral, mean age 56 years) was staged according to the Cruess classification and included five Stage III, 6 Stage IV, and one Stage V. All procedures were performed on an outpatient basis. The average procedure time was 41 minutes (range 23 to 62 min), blood loss was less than 100ml, no patient required transfusions peri-operatively and no complications were encountered. At an average follow up of 30 months, all patients reported significant pain relief. Visual analogue scales improved from 75 to 16 at the time of final evaluation. The mean Western Ontario Osteoarthritis of the Shoulder index score significantly improved from 1421 preoperatively to 471 postoperatively. The mean Shoulder Score Index score improved from 24 preoperatively to 75 postoperatively. The mean Constant score improved from 23 preoperatively to 62. Forward elevation improved from a mean of 94° to 142° (P < .001). External rotation improved from a mean of 28° to 46° (P < .001). All postoperative radiographs showed solid fixation of both implant components and no evidence of periprosthetic loosening, osteolysis, or device migration. In a retrospective case series of 19 patients (16 men, 3 women, 20 shoulders), Sweet et al. (46) reported their findings on inlay arthroplasty in young patients (average age of 48.9 years). Preoperative diagnoses included osteoarthritis in 16 shoulders and osteonecrosis in 4. At a mean follow-up of 33 months (range, 17-66 months), the mean American Shoulder and Elbow Surgeons score improved from 24.1 to 78.8, the mean Simple Shoulder Test score improved from 3.95 to 9.3, the mean visual analog scale score was reduced from 8.2 to 2.1, mean forward flexion improved from 100 degrees to 129, and the mean external rotation changed from 23 to 43 degrees (P<.001 for all). Radiographic examination showed no evidence of periprosthetic fracture, component loosening, osteolysis, or device failure. The overall patient shoulder self assessment was 90% poor prior to the procedure and improved to 75% good to excellent at final follow-up; 90% of patients were satisfied with the choice of the procedure. Three patients experienced postoperative complications unrelated to the prosthesis, that included a partial rotator cuff tear treated with physical therapy, a pre-existing glenoid wear which was effectively addressed with arthroscopic debridement and microfracture, and one infection that was complicated by a subscapularis rupture requiring several subsequent surgical interventions but with retention of the implant. The authors concluded that inlay arthroplasty is effective in providing pain relief, functional improvement, and patient satisfaction and called it a promising new direction in primary shoulder arthroplasty for younger and active patients with earlier stage disease. Since 2007, several authors advocated the use of IA in patients with Hill-Sachs lesions (7,10,14,25,26,33,38). Potential advantages were attributed to the anatomically contoured surface reconstruction, minimizing soft-tissue disruption, individual sizing, avoiding the limitations of autograft tissue, conservation of bone stock, short operative time, no associated graft resorption and subsequent hardware removal, and lack of disease transmission. Moros and Ahmad presented a case report with 2 years follow-up and reported full arm function with no pain, instability, clicking, catching, or dislocation. Range of motion was without limitations and the patient had returned to full work duties as a porter (33). In 2015, McKenna et al. (30) published their rational for outpatient treatment of compensated cuff arthropathy using inlay arthroplasty with subscapularis preservation. Using strict early disease stage selection criteria and addressing all primary and secondary pain generators, the authors concluded that the use of humeracromial IA in compensated cuff arthropathy has distinct advantages as the technique preserves the glenohumeral joint and avoids the bone loss and complications associated with stemmed arthroplasty. A deltoid splitting approach may reduce the risk of iatrogenic muscle imbalance leaving the subscapularis tendon intact. The outpatient procedure enabled patients to undergo an accelerated recovery and rehabilitation with emphasis on the deltoid driven functional compensation. Detailed results on their first 50 subjects treated since 2007 are pending to date. Most recently, Davis et al. (9) published their series of 9 patients treated with total shoulder arthroplasty combined with inlay glenoid components for glenoid deficiency. Four glenoids were classified as Walch type A2, 2 as type C, and 3 were unable to be classified. At a 34 month follow-up, seven patients (4 female and 3 male patients; 9 shoulders) with a mean age of 66 years showed a statistically significant increase in range of motion, decrease in pain scores (8 points to 1 point), and improvement in Single Assessment Numeric Evaluation scores (31.7% to 89.4%). The mean patient satisfaction score was 8.6 points on a 10-point scale. The authors concluded that management of the glenoid with severe retroversion or medial bone loss remains a challenging procedure at all levels of surgical expertise. Based on their 2-year follow-up, total shoulder arthroplasty with a mini glenoid component may be an option to address a glenoid deficiency and offer adequate pain relief and functional results.
Our own experience with stemless total shoulder arthroplasty using non-spherical humeral head resurfacing and inlay glenoid replacement has been very encouraging. In the ongoing prospective study, a total of 70 patients (74 shoulders) were treated for advanced glenohumeral arthritis. 38 reached their 2 year follow-up mark. Of those, 2 have been lost to follow-up and 2 did not consent to participate further. Thus 34 patients (36 shoulders, 20 male, 14 female) have reached a mean follow-up of 30 months (24-39 months). Their mean age was 65.9 years (range 45 – 81 years). All clinical outcomes scores showed statistically significant improvements (p<0.001): The mean ASES Score improved from 27.9 – 75.4, the Constant Score improved from 26.9 – 73.0, and the WOOS Index improved from 29.2 – 82.9. Range of motion improved in all dimensions particularly for forward flexion from 102° to 155° and internal rotation from the hip pocket to L3. The VAS Pain Score improved from 7.8 to a mean of 1.4. Patient satisfaction at last follow-up was excellent. All surgeries were performed on an outpatient or 23 hour admission basis. No patient required a transfusion. One patient suffered from a deep infection resulting in glenoid component loosening which was removed. Aside from this complication, radiographs showed no evidence of component loosening or migration. A subset of these patients demonstrated remarkable functional performance at a competitive level of bodybuilding or powerlifting. Five male athletes with an average age of 45.6 years (range 25-57) were prospectively followed. All had advanced glenohumeral arthritis and expressed a strong desire to continue their sport. All were treated utilizing stemless non-spherical resurfacing of the HH combined with an inlay glenoid. There were no blood transfusions and all cases were performed on an outpatient patient basis. The mean follow-up was 31 months (range, 16 – 51). The average ASES score improved from 26 to 93. The mean WOOS score improved from 18 to 87. The mean VAS pain score went from 9 to 1, mean forward flexion increased from 115° to 135°, mean external rotation from 30 ° to 60°; the preoperative internal rotation allowed patients to reach sacrum levels which improved to lumbar level 3 post-surgery. Four out of five patients assessed their shoulder as poor prior to surgery which improved to good to excellent in all subjects at follow-up. Radiographic assessment revealed no evidence of component loosening, glenoid migration, or evidence of device failure. All patients were satisfied with the choice of the procedure with 4 of the 5 reported to have returned to at least moderate weight lifting activities. One patient required an arthroscopic capsular release for arthrofibrosis which significantly improved function. In this difficult patient population, stemless non-spherical humeral head resurfacing along with an inlay glenoid has been a reliable and effective option for the management of symptomatic osteoarthritis and allowed athletes to return to their sport. The risk for future prosthetic problems or other complications appears less likely than with standard TSA although longer follow-up is necessary.


Current trends in shoulder arthroplasty have marginalized joint preservation despite a significant increase in volume and a tendency towards younger patients. The predominant use of non-spherical, non-anatomic solutions with stemmed total and reverse shoulder arthroplasty combined with a lack of distinction between inlay and onlay resurfacing procedures turned the specialty away from individual patient decisions and created a conventional treatment spectrum. Inlay arthroplasty shows great promise both from a biomechanical and clinical perspective to offer an individual alternative in primary arthroplasty. Patients may benefit from tissue preservation and a less invasive procedure that avoids the risks, and technical challenges associated with stemmed procedures. Respecting the humeral head geometry mismatch and avoiding glenohumeral joint volume alterations, inlay arthroplasty may become a new path for high demand and sedentary patients alike. However, larger procedure volumes have to be validated through registry and literature reports in order substantiate the presumed advantages.


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How to Cite this article: Markarian GG, Bab AD, Uribe JW. Current Trends in Shoulder Replacement: The Rational for Inlay Arthroplasty. Acta of Shoulder and Elbow Surgery Oct – Dec 2016;1(1):14-19


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