Background: The common surgical procedure in the treatment of bilateral shoulder osteoarthritis is surgical correction in two steps. There is little experience regarding the safety and the effectiveness of the simultaneous bilateral shoulder arthroplasty, as for other joints like knee and hip. In this study the results of the surgical procedure of both shoulders, in a single surgical stage, are presented and compared with an equal number of patients who underwent total shoulder arthroplasty in both their shoulders in two different stages.

Materials and Method: We studied a series of 7 patients treated with bilateral shoulder arthroplasty in a single stage procedure for severe degenerative glenohumeral joint disease. The average age at the time of surgery was 72 years. These were 4 patients with primary osteoarthritis (8 total anatomical prostheses) and 3 patients with rotator cuff arthropathy (6 reverse prostheses). The second series include 7 consecutive patients who underwent the same shoulder arthroplasties in two different stages for the same diseases. The average age was 69 years and the time between the two operations was 6 to 12 months.

The effectiveness of each one of the two procedures was evaluated on the basis of multiple objective characteristics like safety, total surgical duration, total blood loss, Constant Score, range of motion of the joints, post-surgical discomfort (pain, stiffness, motion, disability), post-surgical complications and ability of resumption of daily living activities.

Results: The average follow up was 18 months. Patients that underwent bilateral shoulder arthroplasty in one stage had significantly shorter total time of in-hospital stay (mean stay 5 days in the first and 9.3 days in the second group), recovery (9 weeks vs. 20 weeks) and proportionately lower rate of post-operative blood loss in comparison with the patients that were treated with two different surgical procedures. The average need for blood transfusion was 2 blood units in the first group and 3.5 blood units in the second. The overall rate of complication was the same in two groups. The Constant Score improvement and the joint function, range of motion and pain improved more, but not in a statistically significant degree in the single-stage group.

Conclusions: Bilateral shoulder arthroplasty in a single stage, in carefully chosen patients regarding their general condition, is a safe procedure, not associated with increase in complications, yielded better clinical results, reduced in-hospital stay and recovery period and decreased patient discomfort in comparison to the standard surgical procedure in two surgical stages and must be considered for selected cases.

AIM: The diagnosis of the posterior dislocation can be missed. Chronic missed locked posterior fracture dislocations of the shoulder raise a difficult problem for treatment especially in young patients. The options for the treatment depend on the size of the humeral defect, the age of the patients and the time from injury to diagnosis.

METHOD: Eleven patients with missed locked posterior fracture dislocation of the glenohumeral joint, 25 to 52 years of age were treated with open reduction and transfer of the subscapularis tendon to the defect (modified Mc Laughlin technique). The interval from the injury to diagnosis ranged from 6 weeks to 6 months. Significant pain, prominence of the acromion, posterior bulging and complete loss of external rotation of the shoulder led to the diagnosis that was confirmed by an axillary radiograph and C.T. scan. The humeral head defect was from 20 to 40 per cent of the articular surface. Four patients also had a minimally displaced fracture of the upper humerus.

RESULTS: The average length of follow up was 3,5 years. Stability was restored and maintained in all cases. Six patients reported little or no pain. They had almost full range of motion and no functional restriction in the ADL. The remaining five patients had mild pain and slight restriction of movements mainly in external rotation in abduction (elevation 150°, external rotation 25°, internal rotation to L5). These patients had mild functional dysfunction in the ADL. All patients had normal muscle strength and constant score from 60–82.

CONCLUSION: Once the diagnosis is established, open reduction and subscapularis tendon transfer reliably decreased patients pain level and significally improved the range of motion and the level of function, restoring stability of the joint. The alternative for older patients or patients with humeral head defect greater than 40% is the use of shoulder prosthesis.

Aim: The common cause for recurrent instability in older patients, is the massive tear of the rotator cuff tendons. This paper presents the results of the operative treatment for the above-mentioned rare and complex lesion. Method: Seven (7) patients, three (3) male and four (4) female with a mean age of 71 years developed recurrent shoulder instability as a result of trauma or preceding infection, which destroyed the rotator cuff. All cases presented with instability, pain and weakness, and in 2 cases the subluxation was obvious in every attempt to raise the arm. All of the patients had tears in at least two tendons of the rotator cuff. The cases were treated operatively with a combination of the Boytchev anterior stabilization procedure with an attempt to close the rotator cuff tear. A complete closure was achieved in 3 cases, and a partial closure in 2. In the remaining 2 cases the closure of the tear was impossible. All of the patients postoperatively underwent an early mobilization regime. Results: The mean follow-up was 30 months. Stabilization of the shoulder was achieved in 6 cases. Constant score varied from 50 to 85. One patient had a recurrent of the subluxation. All of the patients presented marked improvement in pain and in muscle strength. Two (2) of them developed almost full range of motion and satisfactory muscle strength. Four (4) patients presented decreased range of motion and muscle strength 50% of the unaffected arm, while one patient developed inability to raise his arm above 70 degrees. Conclusions: The combination of recurrent anterior instability with massive rotator cuff tears presents great difþculty in treatment especially in the cases where an infection had preceded. A complete closure of the rotator cuff tear is usually very difþcult to achieve.

Aim: Chronic rotator cuff tears raise a difþcult problem for treatment. The purpose of the study is to evaluate the results of surgical treatment of 96 full thickness rotator cuff tears. Method: There were 59 males and 37 females with average age of 56 years (35–78). The dominant shoulder was involved in 70% of the cases. Most of the patients had weakness and all of them had pain during the night. The duration of symptoms was more than 4months. 22 tears were small, 38 medium, 28 large and 8 massive. All of the patients had positive arthrogram or MRI. Surgical management consisted of deltoid splitting approach, anterior Neerñs acromioplasty modiþed by Rockwood and repair of the tear. In 6 cases dislocation long head of the biceps was found and repaired. In two cases the long head of biceps was incorporated in the repair. In 5 cases full coverage of the head could not be achieved. Results: F.U. averaged six years. The results were granted according to Wolfgang scale. There were 46 excellent, 39 good, 7 fair and 4 poor. Signiþcant improvement in pain achieved in 90% of the cases and strength improved in 78%. Postoperatively three patients had drop arm sign and one had developed ectopic ossiþcation. Negative prognostic factor was the dislocation of long head of biceps in combination with irreparable tears. The quality of the repair correlated with þnal outcome. Conclusions: The results of this study conþrm the view that operative management of rotator cuff tears offers reliable results and indicated in relatively young patients. Release of coracohumeral ligament and mobilization of supraspinatus decreased the need for tendon transfer.

Purpose: The accurate preoperative evaluation of impingement syndrome and rotator cuff lesions, as well as the confirmation of the clinical and operative findings.

Material-Method: 281 patients with clinical findings of impingement syndrome and/or lesions of the rotator cuff were evaluated with MRI.

Results: The following MRI diagnoses were made: tendons’ lesions 306 (degeneration 138, complete rupture 116, partial rupture 52), impingement 196. The following RC lesions were in association with impingement syndrome: degenerative changes 106, complete rupture 101, incomplete rupture 48. The above mentioned tendon lesions were in many patients in all forms of degeneration (mixed). The dimention of all complete ruptures were measured on the MRI (116). In 93 patients of them operation followed. The MRI findings were confirmed in all patients except three (the operative findings showed 8,10,15 mms larger tears in comparison with the MRI measurements, 2, 4.5 and 5 months post-MRI examination respectively). Comparing the clinical and MRI findings we found agreement in 83.54%, unclear clinical diagnosis in 5.06%, partial agreement in 8.86% and disagreement in 2.53%.

Conclusions: MRI is an excellent method in evaluating the rotator cuff lesions and those of the impingement syndrome as well as the extend and degree of muscle atrophy. More important though is the accurate evaluation of the extend and quality of RC lesions, which are closely related to the result of surgical intervention.

Purpose: The confirmation of clinical findings as well as the accurate preoperative evaluation of patients with shoulder instability and rupture of the glenoid labrum. Material-Method: 180 patients with shoulder instability or suspected labral lesions were examined with MR arthrography.

Results: The MR arthrography findings were the following: lesions of the labrum, SLAP lesions, redundant articular capsule, lesions of the capsule, lesions of the glenohumeral ligaments. In particular, we present: a) The spectrum of labral ruptures: Bankart lesions, SLAP, HAGL, ALPSA, GLAD lesions), b) various lesions of the labrum: degenerative changes, discoid labrum. In a few cases with MDI the MR arthrography was negative. Fifty (50) patients of these were operated upon. We report the results and compare the MR arthrography findings with those of the operation. SLAP type II lesions are difficult to be distinguished from normal conditions.

Conclusions: MR arthrography is a reliable method in the study of shoulder instability and offers significantly in the treatment of this group of patients.

Airn: Treatment of acromioclavicular joint dislocations depends on the type of the dislocation and the patients symptoms. We present the results of surgical treatment with transfer of the acromical end of coracoacromial ligament in the distal end of the clavicle. (The Weaver Dunn procedure). Material – Method: 32 patients with acromioclavicular dislocation type III, IV and V according Rockwood, 20 acute and 12 chronic, were treated with open reduction and stabilization of the distal end of clavicle and transfer of the coracoacromial ligament. They were 26 men and 6 women, the average age was 28 years. The indications for the operation were: deformity, pain and numbness. On 28 patients resection of the distal end of the clavicle was performed but on 4 acute dislocations the stabilization was made without osteotomy.

Surgery was performed with the patients in the beach chair position and with a horizontal skin incision above the acromioclavicular joint. The length of the coracoacromial ligament was determinant to achieved reduction. The soft tissues were double breasted above the acromioclavicular joint. After surgery the limb was placed in a sling for 15 days and then complete mobilization exercises was began. Draft weight was avoided for 3 months.

Results: The average length of follow up was 4 years. All patients had almost no pain and full range of motion. Constant score was above 80 in all cases. Full range of motion was obtained until 2 months after operation. In 3 cases the primary reduction was not fully achieved. In 3 other cases loss of the primary reduction was observed due to suture rupture. In these cases the displacement was significantly minor than pre operatively. 15 patients had developed ectopic ossification bellow the acromioclavicular joint without consequence in the shoulder motion. The resection of the distal end of the clavicle did not alter the results.

Conclusion: The operation offers low percentage of complications and quick rehabilitation. It is recommended in acute as well in chronic injuries with very good results. The good results were not varied with time during follow up. Advantage of this operation represents the no use of metals. The pull angle of the ligament might create an anterior sublaxation during reduction of the dislocation, but this does not influence the results.

Aim: The common anatomic pathology responsible for the recurrent dislocation of the shoulder is in younger patients a trauma causes the Bankart lesion. Contrary to that, the common cause for recurrent instability in older patients, which is far more rare, is the massive tear of the rotator cuff tendons. During that the shoulder loose the of the posterior-upper stabilizing element (posterior mechanism according to Neer), and present a secondary anterior-inferior recurrent instability. This paper presents the results of the operative treatment for the above-mentioned rare and complex lesion.

Material – Method: Seven (7) patients, three (3) male and four (4) female with a mean age of 71 years developed recurrent shoulder instability as a result of trauma or preceding infection, which destroyed the rotator cuff. The initial injury was associated with dislocation in 2 cases and without dislocation in 3. The other 2 had a prior infection of the glenohumeral joint, which was treated conservatively. The patients who suffered injury were initially treated with a sling for 2 to 4 weeks. All cases presented with instability, pain and weakness, and in 2 cases the subluxation was obvious in every attempt to raise the arm. The radiological findings consisted of subacromial space narrowing, sclerosis and spur formation of the inferior part of the acromion and diffuse osteoporosis. All of the patients had tears in at least two tendons of the rotator cuff. The cases were treated operatively with a combination of the Boytchev anterior stabilization procedure (osteotomy of the coracoid process, transfer of the conjoined tendon under the subscapularis tendon and repositioning of the coracoid process) with an attempt to close the rotator cuff tear. A complete closure was achieved in 3 cases (in one the long head of the biceps was used), and a partial closure in 2. In the remaining 2 cases the closure of the tear was impossible. All of the patients postoperatively underwent an early mobilization regime.

Results: The mean follow-up was 30 months. Stabilization of the shoulder was achieved in 6 cases. Constant score varied from 50 to 85. One patient had a recurrent of the subluxation. All of the patients presented marked improvement in pain and in muscle strength. Two (2) of them developed almost full range of motion and satisfactory muscle strength. Four (4) patients presented decreased range of motion and muscle strength 50% of the unaffected arm, while one patient developed inability to raise his arm above 70 degrees. Five cases out of seven showed a satisfactory response to daily life activities.

Conclusions: The combination of recurrent anterior instability with massive rotator cuff tears presents great difficulty in treatment especially in the cases where an infection had preceded. A complete closure of the rotator cuff tear is usually very difficult to achieve, while the treatment of the instability alone leads to dubious results as far as pain and range of motion is concerned. For the management of the above complex lesion the existing literature is rather poor, and the combination of the Boytchev procedure with an repair of the rotator cuff tear, yielded satisfactory results mainly in regard to pain control, and secondly in achieving a good postoperative range of motion.

Aim: Displaced intrarticular fractures and fracture-dislocations of the proximal humerus usually need operative treatment. The results of shoulder hemiartroplasty for the treatment of neglected fractures and fracture-dislocations are presented.

Material – Method: 9 shoulder hemiartroplasties with modular head was used for the treatment of 5 neglected comminuted fractures and 4 fracture-dislocations of the proximal humerus. They were 5 females and 4 males with a mean age of 58 years, which were followed-up for a mean period of 4 years. The time between the injury and the operation varied from 2 to 8 months. The main indications was pain, loss of shoulder movement in relatively young patients. The tuberosities were found and extensively mobilized. The prosthesis was inserted with cement and the tuberosities were reattached to the shaft.

Results: Main follow up was 4 years (2–8). The results were assessed according the modified UCLA score and were found excellent in 2, satisfactory in 4 and poor in z cases. Pain has improved in 7 cases and the mean postoperative elevation was 90? (20?–130?). External and internal rotation was significally improved. 5 patients presented satisfactory muscle strength and were able to perform satisfyingly the daily activities. Constant score rated from 50 to 80.

The presence of a dislocation did not affect the final outcome. On the contrary the displacement of the tuberosities was decisive, and it was combined with greater scaring of the soft tissues and greater loss of motion. One patient developed transient palsy of the axillary nerve and another aseptic loosening of the prosthesis 7 years postoperatively.

Conclusions: The success of the hemiartroplasty is based on the proper patient selection, the good operative technique and the meticulous postoperative rehabilitation. The retroversion, the height of the prosthesis and the correct balance of the soft tissues are of critical importance in the achievement of a good postoperative result. The tissue scaring, the tuberosities displacement and the rotator cuff lesions create such conditions that place these patients in the limited goal group, as introduced by Neer. The results of this group are considerably inferior to those treated soon after the injury. For this reason if indicated the prosthesis should be used at the first stage and not after the failure of the conservative treatment.