Introduction: Pre-existing glenoid bone loss poses significant challenges for reverse shoulder arthroplasty (RSA). Excess reaming can lead to further bone loss and medialisation of the joint line. Metallic augments have been described as a technique to address this issue. However, no studies to date have evaluated the effect of metallic augments on anatomic outcomes.

Objectives: To evaluate post-operative bone loss and joint line anatomy in patients with pre-existing glenoid bone loss who undergo primary RSA with metallic augments.

Methods: A prospective cohort study. 16 shoulders (single implant) with glenoid bone loss (Walch A1-D; Favard E0-E3) underwent primary RSA with metallic augments. Pre- and post-operative CT scans were performed. The scapula and humerus were reconstructed into high definition 3D models in each scan using Mimics (v24.0). Pre- and post-operative models were superimposed, and anatomic comparisons performed using Geomagic Wrap (v2015.3.1). The primary outcome was post-operative bone volumetric analysis. Secondary outcomes include post-operative joint line metrics (medial/lateralisation, inclination, and version) and shoulder centre of rotation.

Results: The mean follow up time was 13.1 months between scans. Mean bone volume removed during surgery was 1292 mm3 (range 525 – 2256; standard deviation 527; for reference a standard teaspoon equals 5000mm3). Metallic augments lateralised the joint line by a mean of 10.2 mm (range 6.9 – 14.3; standard deviation 2.0). Inclination and version were restored to acceptable limits in all cases.

Conclusions: RSA with metallic augments reliably preserves bone and prevents medialisation of the joint line in patients with pre-operative glenoid bone loss.

Introduction: Shoulder arthroplasty in the management of proximal humerus complex fractures (Neer III or IV PHF) is becoming more and more indicated. However, the exact place of this surgery next to osteosynthesis is not yet clear and continues to be debated. Our study aims to report the functional and radiological outcomes of PHF treated with shoulder arthroplasty and to compare our results with those of the literature. methods: We carried out a retrospective observational study over 13 years between January 2007 and June 2019 including patients with surgically treated Neer III or IV PHF with anatomical hemiarthroplasty (HA) or reverse total shoulder arthroplasty (RTSA). The range of motion, the Constant score, and postoperative X-rays were evaluated.
Results: Twenty patients (14 women and 6 men) were enrolled with a mean age of 65 years. The dominant limb was concerned in 45%. Neer IV-type fractures were more common (12 cases). was utilized in 6 patients and HA in 14 patients.
At the final follow-up (8 years), we have noted three tuberosities nonunion in the HA group. The mean active external rotation and ante Pulsion were 15 and 95 degrees respectively. The mean Constant score was 57.7 ( range 32-74). Conclusion: We suggest the use of RTSA in the treatment of complex proximal humerus fracture in the elderly (> 65 years) with low functional demand. The HA would be recommended for younger patients with the imperative of anatomical reintegration of tuberosities.

Shoulder intramuscular abscess with concurrent osteomyelitis of the proximal humerus is a rare occurrence and is often diagnosed late or misdiagnosed due to its vague clinical presentation that is often masked by symptoms that are more suggestive of rotator cuff arthropathy or tendinitis. Plain radiographs usually appear unremarkable while most shoulder intramuscular collections remain undetectable on ultrasound. Collection and bony destruction are only identified upon proceeding with magnetic resonance imaging (MRI) or computerized tomography scan (CT). Here we report two very similar cases of shoulder intramuscular abscess with osteomyelitis of proximal humerus presented to our hospital. Both patients are females at the age of 50-80 years with underlying multiple comorbids. Their main complaints were unilateral shoulder pain and swelling with joint line tenderness and reduced range of motion on shoulder examination. Ultrasound done for both patients were negative but intramuscular abscess and osteomyelitis were then detected on MRI and CT scan. For the first case we did incision and drainage of the shoulder with humerus intramedullary reaming to evacuate pus from the canal. Patient was discharged well and had a painless shoulder during routine follow-up. A similar approach was planned for the second patient however surgery was withheld as she was unstable in ward. Our recent encounter emphasizes the importance of high index of suspicion and the significant role of MRI or CT in detecting collections that are usually not found on ultrasound in cases where clinical picture and blood investigation are suggestive of infection but source is unknown.

Introduction

The pectoralis major muscle (PM) rupture is rare in literature and most commonly reported in weight lifting and athletes. Early repair has better outcome as compared to delayed or non operative treatment

Case report

We encountered a case of a 22 year old male, professional bodybuilder who lifted a heavy weight during exercises, which caused a rupture in the musculotendinous junction of the left pectoralis major muscle.

Discussion

Musculotendinous junction rupture is rare entity, we inserted 3 anchors into

the humeral at pectoralis major footprint, and sutured at musculotendinous

junction levels in multiple directions.

Conclusion

The aim of this case repot is to study the techniques and complications of suture anchor and the functional outcomes of PM rupture repair with suture anchors.

Septic pyogenic arthritis of the acromioclavicular
joint is a rare entity, presenting mainly in immunocompromized patients.
We report a case of septic AC joint in the absence of trauma or intravenous drug use.

A 65 year-old man with past medical history of peripheral artery disease, diabetes mellitus, pulomnary tuberculosis and chronic foot ulcers presented with severe left shoulder pain.
Physical examination revealed a swollen shoulder with diffuse tenderness at palpation and a limited range of motion. The patient was febrile at 38.4°C.
Ultrasound imaging detected a distended AC capsule and increased fluid in the subacromial-subdeltoid bursa.
Laboratory evaluation revealed elevated white blood count and C-Reactive Protein.
Operative management with open irrigation and debridement of the acromioclavicular joint was performed revealing a suppurated synovial fluid.
Cultures obtained intraoperatively were positive for Methicillin Sensitive Staphylococcus Aureus, which was also isolated in blood cultures. Adequate intravenous antibiotics were administred for 6 weeks, with full clinical and biological recovery.
The acromioclavicular joint is an exceptional location for septic arthritis. Less than 40 cases have been reported so far, in literature. It is a rare and misdiagnosed condition, presenting mainly in immunocompromized patients, resulting from a hematogenous spread, aside from any trauma or articular manipulation.
An entry wound is almost constantly found, responsible for the bacteremia and the most frequently isolated bacteria are Staphylococcus aureus and Streptococcus spp.
Magnetic resonance imaging and ultrasound are the most reliable imaging modalities for the diagnosis.
Adequate treatment consists of IV antibiotics with or without surgical drainage.

As surgeons, our quest for anatomical repair and restoration of function has been superseded by reconstruction, forged under the weight of historical research. With internal bracing principles and evolution of technology, we have been able to successfully return to ligament repair. We present a case, where used the principle of internal brace/ ligament augmentation, in the elbow for chronic Ulnar collateral ligament (UCL) rupture. A 30 year old male presented with persistent left elbow pain since the last 1 year. He was treated with rest, analgesics, activity modification & brace with no relief. He had MRI scan done which showed high grade rupture of the anterior band of his Ulnar collateral ligament in the left elbow. We used a medial incision and preserved both the ulnar and medial antebrachial cutaneous nerves. We found a near complete rupture of the anterior band of UCL. We used 2 SwiveLock anchors (one inserted in the medial epicondyle and other in the sublime tubercle) with a Fibertape acting as an internal brace/ ligament augmentation. We used Fiberwire to repair the remaining ligament. He was kept in a above elbow back slab for 2 weeks followed by ROM brace for further 4 weeks. He underwent physio rehabilitation subsequently. The patients mobilised well subsequently with no episodes of a further pain and instability. With this innovative approach, we can avoid the need of autograft and associated comorbidity.The internal brace has allowed a refocus on the restoration of normal anatomy & in turn function.

Introduction: AC joint dislocations account for about 8% of entire dislocation, which is thought to be very less as many are undiagnosed and untreated. The mechanism of injury is typically a direct impact at the acromion in the setting of an adducted shoulder. Material and method: 16 patients age 18-55yr were included in the study. Of them 14 were male and 2 female. All were less than3 weeks old. Results: Constant scoring system was used to measure functional outcome which checks pain, activity, rom and power. Out 0f 16 patients operated 12 – excellent results 2- good result 1- satisfactory result and 1 had poor result. The one with poor result had coracoid fracture which was revised using an open technique. Limitations :Very good method for acute Grade 3 - 5 AC disruption, but not excellent results with chronic cases which require use of biological augmentation like semitendinosus tendon graft and at times lateral end clavicle osteotomy.

Superior capsule reconstruction (SCR) was developed as an alternative treatment for irreparable rotator cuff tears. Fatty infiltration (FI) of the infraspinatus (IST) has been implicated as a predictor of outcome and repair integrity after rotator cuff repair but has not been fully investigated in SCR. Purpose of this study is to evaluate the impact of FI of the IST on clinical and radiological outcomes after SCR.
Fifty-five consecutive patients (2013-2020) with irreparable posterosuperior rotator cuff tears who underwent SCR were included retrospectively. Preoperative and postoperative clinical and radiological findings were reviewed. Divided into two groups: group 1 with mild FI of the IST and group 2 with severe FI of the IST. The ASES, Constant score, pVAS and ROM were evaluated. Postoperative graft integrity was evaluated by MRI. Univariate and multivariable logistic regression analyses were performed to evaluate clinical and radiological findings that might be associated with successful SCR.
Clinical and radiological outcomes significantly improved after SCR. Graft failure was noted in 15 (27.3%) patients and was more frequent in group 2 than group 1 (14.3% vs. 50%; P=0.004). Univariate analysis indicated a significant association with graft failure after SCR for group 2 (odds ratio [OR], 6.00; 95% confidence interval [CI], 1.65–21.80; P=0.006). Multivariable analysis indicated that FI of the IST was the only factor associated with graft failure (OR, 6.37; 95% CI, 1.62–24.90; P=0.008).
Severe FI of the IST is a factor indicating a poor prognosis for graft integrity after SCR.