Background:
The appropriate age at which to perform reverse shoulder arthroplasty (RSA) is controversial. The aim of this study was to compare the outcomes of RSA between younger and older patients.

Methods:
Patients undergoing primary RSA between January 2000 and December 2019 were identified from the New Zealand Joint Registry. Patients were stratified into two cohorts according to age at the time of surgery: <55-years and ≥55-years. These were then compared with regards to demographics, surgical indications, revision rates, and patient reported outcomes using the Oxford Shoulder Score (OSS) and American Shoulder and Elbow Score (ASES). .

Results:
A total of 5,518 primary RSA cases were identified, with 75 patients <55-years at the time of surgery (range, 34-54 years). The mean duration of follow-up was 2.36 years in the younger cohort and 3.10 years in the older patient cohort. Surgical indications differed significantly between the two groups, with younger patients having higher rates of inflammatory arthritis (p<0.001), post-traumatic arthritis (p<0.001), and avascular necrosis (p=0.049).

The younger cohort had an inferior 6-month postoperative OSS compared to the older cohort (mean, 28.5 [younger cohort] vs. 35.7 [older cohort]; p<0.001). There was no significant difference in revision rate between the younger and older patient cohorts during the study period (1.56 [<55-years] vs 0.74 [≥55-years] revisions per 100-component-years; p=0.332).

Conclusion:
Our early results suggest that younger patients undergoing RSA demonstrate high implant retention rates, comparable to older patients. Longer-term patient reported outcomes in younger patients are required to guide appropriate patient selection for RSA.

To this date, few studies have investigated modern implants of reverse shoulder arthroplasty (RSA) in the long term.

We included 108 patients receiving a Delta-Xtend RSA (Depuy) in 2008. Patients were divided into four indication groups: Cuff-tear-arthropathy (CTA) (60%), revision shoulder arthroplasty (15%), fracture sequelae (19%) and post-infectious implantation (6%). Mid-term (5.7 years) and long-term clinical and radiographic follow-up were performed.

Median follow-up of the 33 (31%) patients presenting for clinical examination was 12.5 years. CS at follow-up was 56.0 [41.0–64.0] points (pt) with a significant increase since implantation of 34.3 [23.3–44.0] pt (p<0.001). The CS decreased significantly between the mid-term and the latest follow-up (10.0 [1.6–13.7] pt, p=0.004).
Patients with revision arthroplasty had a significantly worse range of motion at long-term-follow-up than patients with CTA (p=0.013).
Patients who had previous surgery on this shoulder before the index arthroplasty had a significantly worse CS than patients without previous surgery (p=0.032).

Implant survival was 95.3%, patients with fracture sequelae showed a significantly higher risk for revision than patients with CTA (odds ratio 11.1, p=0.042).
Including implant failure, we observed 4 complications (6.3%) in the CTA group, 2 (12.5%) in the revision arthroplasty group, 4 (28.6%) in the fracture sequelae group and no complication in the post-infectious implantation group. This difference was not significant (p=0.3). The overall complication rate was 12.5%.

For a broader spectrum of indications, the results and survival of RSA are slightly inferior. Previous surgery of the shoulder before the index arthroplasty leads to a worse shoulder function.

Purpose: We aimed to compare the outcomes and complications of anatomical shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) for primary glenohumeral osteoarthritis with intact cuff tissue.
Materials and methods: The MEDLINE, Embase, and Cochrane Library databases were systematically searched for studies published before March 2, 2021 using the PRISMA guidelines. Studies were included if they directly compared aTSA and rTSA for treating primary glenohumeral arthritis. A meta-analysis was performed using six studies that compared radiologic outcomes, functional scores, and range of motion (ROM). All the data were pooled using a random-effects model. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated as dichotomous data, while continuous data were analyzed using mean differences with 95% CIs.
Results: Two independent researchers reviewed 1,061 studies. Six studies met the inclusion criteria. The range of motion, especially external rotation, was better for aTSA than for rTSA (MD = -10.28, 95% CI: -16.69–-3.88, P = 0.002). Functional scores showed no difference. Glenoid loosening (OR = 0.17, 95% CI: 0.06–0.50, P = 0.001) was more common with aTSA and scapula notching (OR = 10.63, 95% CI: 1.73–65.27, P = 0.01), with rTSA. In the mid-term follow-up, the overall revision rate showed no difference with a pooled OR of 0.33 (95% CI: 0.07–1.57, P = 0.16).
Conclusion: Increased ROM could be achieved after aTSA. There was no difference in the revision rate at mid-term follow-up between groups. Glenoid loosening was more common with aTSA and scapula notching, with rTSA.

Background: Tranexamic acid (TXA) has been shown to reduce blood loss in shoulder arthroplasty. Oral TXA is significantly cheaper than intravenous TXA. The purpose of this study was to compare the efficacy and safety of oral versus intravenous TXA in shoulder arthroplasty. Methods: Patients undergoing shoulder arthroplasties were randomized into one of two groups. In the oral group, 2g of TXA was administered two hours prior to induction of anesthesia and in the intravenous group, 1.5g of TXA was administered following induction of anesthesia. The primary outcome was reduction in hemoglobin. The secondary outcomes included drain output, number of blood units transfused, length of hospital stay and complications. Results: 80 consecutive patients were randomized. There was no difference in the primary outcome measure or any of the secondary outcome measures. Furthermore, there was no difference in the number of blood units transfused, length of hospital stay and complications. Discussion: This is the first study in the literature comparing oral and intravenous tranexamic in shoulder arthroplasty, and we found no difference in the efficacy of the two routes of administration. Surgeons should be encouraged to use the less expensive oral form of the medication as a means to minimize overall health care expenditure.
(This study has been published in the Seminars in Arthroplasty - Journal of Shoulder and Elbow Surgery 2022)

ABSTRACT: Recurrent shoulder dislocation leading to shoulder instability is a cumbersome clinical problem for patients and orthopaedicians. Due to a lack of knowledge in young patients of developing countries, there is a delay in presentation from the first time of dislocation. The aim of this retrospective study was to evaluate functional and radiographic outcomes of patients with shoulder instability after the Congruent Arc Latarjet procedure. 20 patients with history of recurrent shoulder dislocation having glenohumeral instability were treated surgically in our institute. Open Congruent Arc Latarjet procedure was performed in 20 patients. Twenty shoulders of 20 patients were evaluated for a mean period of 30 months postoperatively. At the time of the latest consultation, the range of motion and the shoulder functional evaluations based on ROWE score which was 89.64 ± 5.71 ( RANGE 80-95) ,improved to 20.36 ± 8.87 (RANGE 10-30),[p = 0.001]. The mean preoperative ASES score was 22.60 ± 1.09 (RANGE 20.6-25) which improved to 72.50 ± 7.33 (RANGE 52.8-77.2), [p = 0.001] . The overall re-dislocation rate was 0% (0 of 20). In our study, 60% had excellent outcome, 30% had good outcome and 10% had fair outcome. The Congruent Arc Latarjet procedure for the treatment of recurrent shoulder dislocation in young patients of developing countries with glenoid bone loss of >20 % is a successful and efficient method with better outcome in daily work profile and no further episode of redislocation.

Introduction: Aim: to investigate the effectiveness of hydrodilatation in patients with primary adhesive capsulitis (PAC) and their evolution with minimum 5 years follow-up. Methods: Between 2012 -2016 a retrospective study:85 hydrodilatations in PAC patients with 59 patients available at follow-up. The evaluation was performed before treatment, immediately after, 1, 3, 6, 12 months and at minimum 5 years after the hydrodilatation. Range of motion (ROM) and function was assessed with Constant-Murley Score (CMS), a visual analogue scale (VAS) for pain and Subjective Shoulder Value (SSV) during study. Results: 25 patients were women (42.4%) and 34 men (57.6%). The mean age: 54.6 ± 8.2 years. The affected shoulder: the right in 28 cases (47.4%). The mean follow-up:7 years (5-9). After hydrodilatation and already at 1 month, all patients improved significantly in shoulder ROM (P < 0.001), and VAS for pain significantly decreased. The results at 5 years improved significantly comparing with those before treatment (P < 0.001): External rotation, 55.7 ± 8.8 vs.14.5± 14.5º; Forward flexion, 168.9 ± 13.8 vs. 93.9 ± 29.7; Abduction, 168.1 ±13.6 vs. 74.7 ± 35.0; Internal rotation, 8.4 ± 1.4 vs. 1.9 ± 0.8; VAS, 0.2 ± 0.7 vs. 6.4 ± 1.5; CMS, 94.7 ± 6.3 vs. 45.3 ± 9.9. Patients recovered 94% compared to contralateral shoulder (SSV). Satisfaction survey after >5 years: 82% very satisfied and 18% satisfied. Conclusion: With a minimum follow-up of 5 years hydrodilatation provides restoration of shoulder ROM, without pain with an excellent improvement of function and high level of satisfaction.

OBJECTIVE: To analyze the efficacy and safety of cellular therapy utilizing Mesenchymal Stromal Cells(MSCs) in the management of rotator cuff(RC) tears from clinical studies available in the literature. MATERIALS AND METHODS: We conducted independent and duplicate electronic database searches including PubMed, Embase, Web of Science, and Cochrane Library on August 2021 for studies analyzing the efficacy and safety of cellular therapy(CT) utilizing MSCs in the management of RC tears. VAS for pain, ASES Score, DASH Score, Constant Score, radiological assessment of healing and complications and adverse events were the outcomes analyzed. Analysis was performed in R-platform using OpenMeta [Analyst] software. RESULTS: 6 studies involving 238 patients were included for analysis. We noted a significant reduction in VAS score for pain at 3 months (WMD=-2.234,p<0.001) and 6 months (WMD=-3.078,p<0.001) with the use of CT. Concerning functional outcomes, utilization of CT produced a significant short-term improvement in the ASES score (WMD=17.090,p<0.001) and significant benefit in functional scores such as Constant score (WMD=0.833,p=0.760) at long-term. Moreover, we also observed a significantly improved radiological tendon healing during the long-term follow-up (OR=3.252,p=0.059). We also noted a significant reduction in the retear rate upon utilization of CT in RC tears both at short- (OR=0.079,p=0.032) and long-term (OR=0.434,p=0.027). We did not observe any significant increase in the adverse events as compared with the control group (OR=0.876,p=0.869). CONCLUSION: Utilization of CT in RC tear is safe and it significantly reduced pain severity, improved functional outcome, enhanced radiological tendon healing, and mitigated retear rates at short- and long-term follow-up.

Background:Rotator cuff pathology common condition affecting shoulder.Mini-open repair has been regarded as the gold standard for rotator cuff tear repair giving good outcomes.The purpose of our study was to analyse functional outcome,ultrasound finding of healing &bone tendon healing on MRI in post-operative supraspinatus tear patients operated using mini open repair.Materials and methods:It is a prospective observational study conducted between 2019-2021,of 50 patients with full thickness supraspinatus tear treated surgically with mini-open repair.All patients followed standardized postoperative rehabilitation protocol and were followed-up for atleast 12 months after which patient were assessed for functional assessment using SPADI score.Post-operative USG & MRI was done at 12 months to see for retears & if present thickness of tear(partial/full),size of tear(maximum dimension)& retraction of proximal fibres in full thickness tears.Results:Mean age was 49 years with 64%males & 36%females.Right side was involved in 56% while 44% patients had left sided tear.Mean preoperative SPADI score was 87 while mean Postoperative SPADI was 65.On USG,88% had no tears while 12% had retears(8%-partial thickness,4%-full thickness tear)& 6% patients had retraction of proximal tendon.On MRI 80% had no tears with 20% had retears(14%-partial thickness,6%-full thickness tear)& 6% patients had retraction of proximal tendon.Sensitivity and specificity of USG in relation to MRI for retear was 62.5% &100% respectively.Mean SPADI in patients with Retear on MRI was 78 while patients without Retear was 61.Conclusion:Mini-open repair gives good functional outcomes with less chance of retear.Failure of rotator cuff structural integrity after mini-open repair is problematic.USG &MRI has significant usefulness in detection of retears.

Background: Our study aims to validate a commercially available inertial measurement unit system against a standard laboratory-based optical motion capture system for shoulder measurements in a clinical context.
Methods: The validation analyses were conducted on 19 healthy male volunteers. 12 reflective markers were placed on each participant’s trunk, scapula and across the arm and one inertial measurement unit was attached via a self-adhesive strap on the forearm. A single tester simultaneously collected shoulder kinematic data for four shoulder movements: flexion, extension, external rotation, and abduction. Agreement between optical motion capture system and inertial measurement unit measurements was assessed with Bland-Altman analyses. Secondary analysis included mean biases, root mean square error analysis and Welch’s t-test.
Results: Bland-Altman limits of agreement exceeded the acceptable range of mean difference for 95% of the population (−22.27°, 11.31°). The mean bias showed high levels of agreement within 8° for all four movements. More than 60% of participants demonstrated mean bias less than 10° between methods. Statistically significant differences were found between measurements for abduction (p < .001) and flexion (p = 0.027) but not for extension and external rotation (p > .05).
Conclusions: Our study shows preliminary evidence for acceptable accuracy of a commercially available inertial measurement unit against an optical motion capture system for assessment of shoulder movements by a single tester. The inertial measurement unit also exhibits similar whole degree of error compared to a standard goniometer with potential for application in remote rehabilitation.

Tennis elbow or Lateral epicondylitis (LE) is a very common disease among females. Various modalities of modalities have been described in literature to address LE. Two such modalities, Corticosteroid (CS) injections and Dry needling (DN) are the most widely used treatment options. It was hypothesized that the use of DN to treat LE would be comparable to using CS injections. We compared the pain relief recorded and improvements in functional disability after DN and CS injection. A total of 91 patients with refractory LE whose pain was not relieved by 3 weeks of first-line treatment were included in a randomised manner, using an online application into DN (45) or CS (46) groups with periodic follow-up at 6 weeks, 3 months and 6 months. We recorded pain using Visual analog scale (VAS) and Patient-Rated Tennis Elbow Evaluation (PRTEE) scores before treatment and at every visit after treatment. Before treatment, the groups were similar in terms of age, symptom duration, VAS score and PRTEE score, but after treatment, DN-treated patients showed better improvement in patient evaluation scores than CS-treated patients (P < .01). From assessments at 6 weeks and 6 months post-treatment, VAS and PRTEE scores decreased over time. Two DN-treated patient (2.1%) could not tolerate the pain of the intervention and withdrew from treatment. Although both DN and CS injection group patients recorded major improvements during the 6 months of follow-up. However, compared with CS injection, DN was more effective and is strongly recommended.

Introduction: Infected total elbow arthroplasty (TEA) is challenging to treat and often results in significant patient morbidity. We report the clinical and radiologic outcomes for infected TEA with staged revision. Methods: We retrospectively reviewed 10 patients who underwent two-stage revision for infected TEA from 2010 to 2017. Mean patient age was 69.1 years, average time from index arthroplasty to infection was 70.3 months, and nine patients had positive cultures. The most common causative organism was methicillin-resistant Staphylococcus aureus. The clinical outcomes were assessed using visual analogue scale (VAS), range of motion (ROM) arc, and Mayo Elbow Performance Score (MEPS). Radiographic outcomes, time to revision, pathogenic bacteria, preoperative complications, and disease period were evaluated.
Results: After a mean follow-up of 62 months (range, 25–108 months), mean preoperative VAS score of 6.1 had improved to 3.3. Mean preoperative ROM was 68° (flexion–extension), which improved to 86.7°. Mean preoperative MEPS was 46 (range, 0–70), which improved to 75.5 (range, 35–85). Mean disease duration was 8.4 months (range, 5–20 months). Reinfection rate was 40%. The second revision rate was 80% at final follow-up. Radiographic outcome at final follow-up showed that 3 of 10 patients exhibited radiolucency evidence around the components. Radiolucency around the implant interfaces was nonprogressive, and there was no indication of infection at the most recent follow-up. Conclusion: In patients with chronic, deep infection after TEA, two-stage revision eradicated the infection, relieved pain, and restored joint function. However, high second revision rate owing to bone and soft-tissue deficits remains a critical issue.

Background: Scapular notching in reverse shoulder arthroplasty may be due to impingement between the humeral polyethylene cup and scapular neck in adduction and external rotation. Various glenoid component strategies have been described, but their relative effectiveness may be prosthesis specific.
Questions/Purpose: What glenoid component position maximizes impingement-free range of motion (ROM) following implantation of an onlay humeral component with a neck-shaft angle of 147 degrees?
Methods: A computer model simulated external rotation and adduction of three dimension scapula and humerus models. Four glenosphere parameters were assessed – diameter, lateralization, inferior tilt, and inferior overhang. For each simulation, the humeral neck-shaft angle was 147 degrees and retroversion was 30 degrees. Eighty-four combinations were tested. Combinations achieving at least 70 degrees of external rotation and neutral adduction were noted.
Results: Increasing inferior eccentric positioning increased external rotation and adduction by 15.0 degrees and 18.8 degrees respectively. Glenosphere lateralization increased external rotation by 13. 6 degrees and adduction by 4.3 degrees. Larger glenosphere diameter increased external rotation and adduction by 9.4 degrees and 10.1 degrees respectively. Glenosphere tilt had a negligible effect on impingement-free ROM. Twenty-one combinations achieved at least 70 degrees external rotation and neutral adduction.
Conclusion: Maximizing inferior glenosphere overhang, glenosphere lateralization, and glenosphere diameter improves impingement-free ROM following implantation of an onlay humeral component with a 147 degree neck-shaft angle.

OBJECTIVE:
To compare the efficacy of intra-articular Methylprednisolone versus Ketorolac in shoulder pathologies in terms of improvement in range of motion (ROM).
METHODS:
This randomized controlled trial was carried out between 10th April 2019 to 10th April 2020 at the Department of Orthopaedics. The research involved patients aged 20 to 65 years of both sexes who were diagnosed with a specific shoulder pathology and had shoulder pain for at least three months. Patients were randomly distributed into two groups: A and B. Group A patients were infiltrated with Methylprednisolone Acetate injection while those in group B were injected Ketorolac. The ROM of the involved joint was determined using goniometry before and four weeks after injection The collected data were then statistically analyzed using SPSS.
RESULTS:
A total of 60 patients finally selected, 38 (63.3%) were male and 22 (36.7%) were female. The mean age was 44.6±8.3 years in group A while it was 45.2±7.5 years in group B. Thirty three (55 %) patients had adhesive capsulitis, 20 (33.3 %) had rotator cuff syndrome and 7 (11.7 %) had impingement syndrome. Flexion, extension, abduction, internal, and exterior rotation all showed substantial increases in ROM following therapy (p<0.001). The mean increase in flexion, extension, abduction, internal or external rotation between the two groups did not differ considerably (p>0.05).

CONCLUSION:
Both Methylprednisolone and Ketorolac show comparable efficacy when administered intra-articularly in shoulder problems, as measured by shoulder ROM improvement.

KEYWORDS:
Adhesive capsulitis, Impingement syndrome, Ketorolac, Methylprednisolone, Rotator cuff syndrome.