Shoulder Surgery – Relevant articles in 2016

Vol 1 | Issue 1 |  July – Dec 2016 | Page 41-42 | Dipit Sahu

Authors: Dipit Sahu [1].

[1] Sir H.N. Reliance hospital, Saifee Hospital, Dr R N Cooper Hospital and HBT Medical College, Mumbai, India.

Address of Correspondence
Dr Dipit Sahu, ,Consultant Shoulder Surgeon, Sir H.N. Reliance hospital, Saifee Hospital, Dr R N Cooper Hospital and HBT Medical College, Mumbai, India

1. Conservative treatment of atraumatic cuff tears
An important question about atraumatic rotator cuff tears is that which ones will need surgical repair and which of them could be successfully managed by physiotherapy. The MOON group [1] in their prospective study of 433 patients found that 20% of patients failed conservative therapy and the most important indicative factors were low expectations from physiotherapy, high activity level and non -smoking status. The factors, which were non-predictive of failure of physical therapy, were the size of the tear, VAS pain score status. The ones who eventually decided to opt for surgical treatment did so in the first 12 weeks of the therapy. Moreover it does reaffirm the belief that majority of the atraumatic cuff tears can be managed conservatively. However it is hard to put it in clinical practice perspective. The main result of the paper is that low patient expectation is the most important determinant of failure of conservative therapy in the management of atraumatic cuff tears.

2. Intra articular lesions in first time dislocators and recurrent dislocators
The researchers from Korea [2] tried to answer very pertinent questions regarding the differences in the observed intra articular lesion between first time dislocators and recurrent dislocators. They compared two groups of patients who underwent arthroscopic bankart repair, one who had only one dislocation episode and other group who had recurrent dislocation episodes. They found that there was a higher incidence of anterior glenoid erosion and ALPSA lesions in the group with recurrent dislocators. This also resulted in a higher failure rate with a higher incidence of recurrent subluxation and apprehension in the group with patients with recurrent dislocation as compared to the first time dislocation group.

3. Intramedullary nails in proximal humerus fractures have a higher complication rate
Intramedullary nails have recently gained popularity in the management of 2 and 3 part proximal humerus fracture because of the improved biomechanics and minimal exposure required to treat these fractures. However locked plates have been the gold standards in the management of such fractures. Can the intramedullary nails have better outcomes than locked plating? This prospective randomized study hypothesized that the outcomes will be no different in the two groups. And indeed they did find that final constant scores were not different at the end of one year [3]. However an important finding was that there was a higher complication rate (28 adverse events versus 10 in plating group) in the intra medullary nail group, with a higher incidence of re-operation and a higher incidence of rotator cuff tears.

4. North American experience with Arthroscopic Latarjet
Arthroscopic latarjet was first introduced in France by Laurent Lafosse and since then has become increasingly popular in North America and rest of the world. However the steep learning curve limits its use in the hands of highly experienced arthroscopy surgeons. Athwal et al [4] analyzed their results in a series of 83 patients who underwent Arthroscopic latarjet by 5 senior experienced arthroscopy surgeons. They found that there was a 25% incidence of complication rate. However the most significant of all was a graft fracture and inability to fix the graft with 2 screws in 6 patients. Nerve related complications were observed in 1 patient. Their complications rate is not much different from those in open latarjet, but the complications are unique to arthroscopic procedure like inability to fix the graft with two screws in 6 patients since an open procedure could have avoided this problem.

5. Association of rotator cuff tears with progression of shoulder arthritis
The association between rotator cuff tears and progression of arthritis in the shoulder has always been of great interest. However the exact relationship has not been deeply studied. The study from Washington University St Louis, attempts to investigate the relation between the presence of asymptomatic cuff tears and progression of osteoarthritis and cuff tear arthropathy [5]. In their study of 138 patients with median follow up of 8 years, they found minimal progression of arthropathy and arthritis as compared to the control group but no significant effect of the size of the tear, the enlargement of the tear size or the symptomatic status of the patient on the progression of arthropathy. However they evaluated their patients using ultrasound to assess the size and retraction of the tear, and the follow-up was also minimal (median 8 years)

6. Atraumatic shoulder instability has unsatisfactory outcome after labral repair
Posterior shoulder instability is rare but poses a challenge for the treating physician. A standard approach to treat posterior instability has not been yet defined. This retrospective study in 41 shoulders compared the clinical outcomes after arthroscopic capsulolabral repair in traumatic and atraumatic posterior shoulder instability and its relation with the glenoid retroversion [6]. They found less favorable clinical outcomes after repair following atraumatic instability as compared to traumatic one. They also found that atraumatic shoulder instability was associated with a higher glenoid retroversion angle as measured by the vault method. This suggests that the treatment of atraumatic posterior shoulder instability is challenging and needs to be investigated further.



1. Dunn WR, Kuhn JE, Sanders R, An Q, Baumgarten KM, Bishop JY, Brophy RH, Carey JL, Harrell F, Holloway BG, Jones GL, Ma CB, Marx RG, McCarty EC, Poddar SK, Smith MV, Spencer EE, Vidal AF, Wolf BR, Wright RW; MOON Shoulder Group.. 2013 Neer Award: predictors of failure of nonoperative treatment of chronic, symptomatic, full-thickness rotator cuff tears. J Shoulder Elbow Surg. 2016 Aug;25(8):1303-11.
2. Shin SJ, Ko YW, Lee J. Intra-articular lesions and their relation to arthroscopic stabilization failure in young patients with first-time and recurrent shoulder dislocations. J Shoulder Elbow Surg. 2016 Nov;25(11):1756-1763.
3. Gracitelli ME, Malavolta EA, Assunção JH, Kojima KE, dos Reis PR, Silva JS, Ferreira Neto AA, Hernandez AJ. Locking intramedullary nails compared with locking plates for two- and three-part proximal humeral surgical neck fractures: a randomized controlled trial. J Shoulder Elbow Surg. 2016 May;25(5):695-703.
4. Athwal GS, Meislin R, Getz C, Weinstein D, Favorito P. Short-term Complications of the Arthroscopic Latarjet Procedure: A North American Experience. Arthroscopy. 2016 Oct;32(10):1965-1970.
5. Chalmers PN, Salazar DH, Steger-May K, Chamberlain AM, Stobbs-Cucchi G, Yamaguchi K, Keener JD. Radiographic progression of arthritic changes in shoulders with degenerative rotator cuff tears. J Shoulder Elbow Surg. 2016 Nov;25(11):1749-1755.
6. Katthagen JC, Tahal DS, Montgomery SR, Horan MP, Millett PJ. Association of Traumatic and Atraumatic Posterior Shoulder Instability With Glenoid Retroversion and Outcomes After Arthroscopic Capsulolabral Repair. Arthroscopy. 2016 Oct 4.

How to Cite this article: Sahu D. Shoulder Surgery – Relevant articles in 2016. Journal of Clinical Orthopaedics July – Dec 2016; 1(1):41-42.

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