The current study describes several surgical techniques for the treatment of the reverse Hill - Sachs lesion after posterior shoulder dislocation; we also aimed to present long term results followed for a minimum of five years. This study is a prospective case series of 17 patients who were treated in our clinic between 2008 and 2011. Patients with a defect size smaller than 25% of the articular surface were treated conservatively. An endoprosthesis of the glenohumeral joint was implanted in patients with a defect size bigger than 40%. All remaining patients were treated by a variety of operative techniques, depending on the quality of the bone and size of the defect. Twelve of seventeen patients had a defect size of the humeral articular surface between 25% and 40% with a mean age of 39 years. Depending on the defect size these patients were treated with retrograde chondral elevation, antegrade cylindrical graft or a graft of the iliac bone crest with an open approach. All the procedures showed fair results, e.g. the open approach with a graft of the iliac bone crest (2010: Dash 3.89, Constant 90.33, Rowe 86.67; 2015: Dash 2.22, Constant 92.00, Rowe 93.33). The open approach is not a disadvantage for the functional outcome. The treatment algorithm should involve the superficial size of the defect as well as the depth of the defect and the time interval between the dislocation and the surgical treatment. 223/2012BO2 , 02 August 2010.

Background: Some unfavorable local events following shoulder arthroplasty occur without the patient experiencing symptoms and yet may be detected on diagnostic imaging, thereby serving as indicators of complications that may require revision. Our aim was to create a standardized protocol for an image-based monitoring process for assessing patients who are asymptomatic following shoulder arthroplasty. Methods: A Delphi exercise was implemented with the participation of an international panel of experienced shoulder surgeons. On the basis of expert opinion from a core steering group, an initial list of imaging parameters for shoulder arthroplasty monitoring of asymptomatic patients was developed and reviewed by panel members. The most appropriate imaging modality was identified. Between each survey, all feedback was considered in order to revise the proposed core set with its definitions and specifications. Consensus was reached upon a two-thirds agreement. Results: Three online surveys were administered, with 98 surgeons responding to the first and/or the second survey. The response rate for the final survey was 74%. Final parameter definitions were organized in 7 categories (implant migration, radiolucency around implant and implant loosening, signs of shoulder displacement, bone resorption and formation, wear of implant articular surfaces, fractures around the implant, and implant breakage and disassembly) and approved with 85% to 100% agreement. Seventy-eight percent of the panel members agreed on a minimum radiographic imaging schedule: standard anteroposterior and axial (alternatively, Y) views made within 6 weeks after implantation and between 3 and 6 months as well as at 12 months post-surgery. Conclusions: Our work presents a monitoring tool developed with international consensus for the assessment of asymptomatic patients after shoulder arthroplasty and including a structured core set of radiographic parameters. Clinical application and scientific evaluation of the monitoring process are needed. Clinical Relevance: This represents a major step toward the standardization of shoulder arthroplasty radiographic monitoring for routine quality controls and research investigations.

Interfragmental ischaemia is a prerequisite for the initiation of the inflammatory and immunological response to fracturing of bone. Intrafragmental ischaemia is inevitable: the extent of the initial ischaemic insult does not, however, directly relate to the outcome for healing of the fracture zones and avascular necrosis of the humeral head. The survival of distal regions of fragments with critical perfusion may be the result of a type of inosculation (blood vessel contact), which establishes reperfusion before either revascularization or neo-angiogenesis has occurred. Periosteum has a poorly defined role in fracture healing in the proximal humerus. The metaphyseal periosteal perfusion may have a profound effect, as yet undefined, on the healing of most metaphyseal fractures of the proximal humerus, and may be disturbed further by inadvertent surgical manipulation. The metaphysis can be considered as a ‘torus’ or ring of bone, its surface covered by periosteum antero- and posterolaterally, through which the tuberosity segments gain perfusion and capsular reflections antero- and posteromedially, through which the humeral head (articular) fragment gains perfusion. The torus is broken in relatively simple primary patterns: a fracture line at the upper surface of the torus is an anatomical ‘neck’ fracture; a fracture line at the lower surface of the torus is the surgical ‘neck’ fracture. Secondary fragmentation (through compression and/or distraction) of the torus itself creates complexity for analysis (classification), alters the capacity and outcome for healing (by variable interruption of the fragmental blood supply) and influences interfragmental stability. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.180005

Objective: Functional posterior shoulder instability (FPSI) (type B1) is a severe type of instability, mainly in teenagers and young adults, that leads to loss of function, pain, and stigmatization among peers. An experimental nonsurgical treatment protocol based on neuromuscular electrical stimulation (NMES) showed very promising early results in the treatment of FPSI. The hypothesis of this study was that NMES-enhanced physical therapy leads to better outcomes than physical therapy alone as the current gold standard of treatment in patients with FPSI. Methods: In this multicenter randomized controlled trial, patients with FPSI were randomly allocated in a 1:1 ratio to either 6 weeks of physical therapy or 6 weeks of physical therapy with simultaneous motion-triggered NMES. Baseline scores as well as outcome scores at 6 weeks, 3 months, 6 months, and 12 months after the intervention were obtained. The predefined primary outcome of this trial was the Western Ontario Shoulder Instability Index (WOSI) at the 3-month time point. Results: Forty-nine patients were randomized and eligible for the trial. The group that received physical therapy with simultaneous motion-triggered NMES showed a significantly better main outcome measurement in terms of the 3-month WOSI score (64% [SD = 16%] vs 51% [SD = 24%]). Two-thirds of the patients from the physical therapist group crossed over to the group that received physical therapy with simultaneous motion-triggered NMES due to dissatisfaction after the 3-month follow-up and showed a significant increase in their WOSI score from 49% [SD = 8%] to 67% [SD = 24%]. The frequency of instability episodes showed a significant improvement in the group that received physical therapy with simultaneous motion-triggered NMES at the 3-month follow-up and beyond, while in the physical therapist group, no significant difference was observed. Conclusion: The current study shows that NMES-enhanced physical therapy led to statistically significant and clinically relevant improvement in outcomes in the treatment of FPSI compared to conventional physical therapy alone—from which even patients with prior unsatisfactory results after conventional physical therapy can benefit. Impact: Based on the results of this study, NMES-enhanced physical therapy is an effective new treatment option for FPSI, a severe type of shoulder instability. NMES-enhanced physical therapy should be preferred over conventional physical therapy for the treatment of patients with FPSI.

The anatomy of the clavicle is specific and varied in reference to its topography and shape. These anatomic characteristics play an important role in the open treatment of clavicle fractures. The complex and variable topography creates challenges for implant placement, contouring, and position. Hardware prominence and irritation does influence the decision for secondary surgical intervention. Computerized tomographic scans of 350 adult clavicles with the corresponding patients' metadata were acquired and digitized. Morphologic parameters determining the shape of the clavicle were defined and computed for each digitized bone. The extracted morphologic parameters were correlated with patient metadata to analyze the relationship between morphologic variability and patient characteristics. The morphologic parameters defining the shape, that is, the radius of the medial and lateral curves, the apparent clavicle height and width, and the clavicle bow position, correlate with the clavicle length. The clavicle length correlates with the patients' height. Gender differences in shape and form were dependent and related to individual height distribution and clavicle length. Asian populations showed a similarly predictable, but shifted, correlation between shape and clavicle length. This anatomic analysis shows that the clavicle shape can be predicted through the clavicle length and patients' stature. Smaller patients have shorter and more curved clavicles, whereas taller patients have longer and less curved clavicles. This correlation will aid surgeons in fracture reduction, implant curvature selection, and in optimal adaptation of clavicle implants, and represents the basis for anatomically accurate solutions for clavicle osteosynthesis.

Background. Minimally invasive plate osteosynthesis (MIPO) is one of the generally accepted surgical techniques for the treatment of humeral shaft fractures. However, despite the high bone union rate, a variety of complications are still prevailing. Moreover, the current literature lacks data comparing the anterolateral MIPO approach using dynamic compression plates accommodating different numbers of screws. The aim of this study was to analyze the biomechanical performance of comminuted humeral shaft fractures fixed with dynamic compression plates using either two or three screws per fragment. Methods. Six pairs of fresh‐frozen human cadaveric humeri from donors aged 66.8 ± 5.2 years were randomized to two paired study groups for simulation of bridge‐plated comminuted shaft fracture type AO/OTA 12‐C1/2/3 without interfragmentary bony support, using a dynamic compression plate positioned on the anterolateral surface and fixed with two (group 1) or three (group 2) screws per fragment. All specimens underwent nondestructive quasistatic biomechanical testing under lateral bending, anterior bending, axial bending, and torsion in internal rotation, followed by progressively increasing cyclic torsional loading in internal rotation until failure. Results. Initial stiffness of the plated specimens in lateral bending, anterior bending, axial bending, and torsion was not significantly different between the groups (P ≥ 0.22). However, cycles to 10°, 15°, and 20° torsional deformation and cycles to construct failure were significantly higher in group 2 compared with group 1 (P ≤ 0.03). Conclusions. From a biomechanical perspective, no significant superiority is identified in terms of primary stability when using two or three screws per fragment for bridge compression plating of comminuted humeral shaft fractures. However, three‐screw configurations provide better secondary stability and maintain it with a higher resistance towards loss of reduction under dynamic loading. Therefore, the use of a third screw may be justified when such better secondary stability is required.