Ideberg-Goss type VI/AO F2(4) glenoid fossa fractures are a rare and complex injury. Although some advocate non-operative management, grossly displaced glenoid fossa fractures in the young patient may warrant fixation. Current approaches still describe difficulty with access of the entirety of the glenoid, particularly the postero-superior quadrant. We present 2 cases of Ideberg-Goss type VI/AO F2(4) glenoid fossa fractures treated with fixation through a novel “Deltoid Takedown” approach, which allows safe access to the whole glenoid with satisfactory clinical results at 5 and 7 years respectively

Reverse shoulder arthroplasty is becoming a frequent treatment of choice for patients with shoulder disorders. Complication rates after reverse shoulder arthroplasty may be three-fold that of conventional total shoulder arthroplasty especially in high risk patient populations and diagnoses like revision arthroplasty, fracture sequelae, and severe glenoid bone loss. Complications include component malposition, stiffness, neurological injury, infection, dislocation or instability, acromial or scapular spine fractures, scapular notching, and loosening of implants. Recognition of preoperative risk factors and appropriate 3D planning are essential in optimizing patient outcome and intraoperative success. Failure of reverse shoulder arthroplasty is a significant challenge requiring appropriate diagnosis of the failure mode. The most common neurological injuries involve the brachial plexus and the axillary nerve due to traction, manipulation of the arm, aberrant retractor placement, or relative lengthening of the arm. Intraoperative fractures are relatively uncommon but include the greater tuberosity, acromion, and glenoid. Tuberosity fracture can be repaired intraoperatively with suture techniques, glenoid fractures may be insignificant rim fractures or jeopardise baseplate fixation and require abandoning RSA until glenoid fracture ORIF heals and then a second stage RSA. Periprosthetic infection after RSA ranges from 1 to 10% and may be higher in revision cases and frequently is Propionibacterium acnes and Staphylococcus epidermidis. Dislocation was one of the most common complications after RSA approximately 5% but with increased surgeon experience and prosthetic design, dislocation rates are approaching 1–2%. An anterosuperior deltoid splitting approach has been associated with increased stability as well as subscapularis repair after RSA. Scapular notching is the most common complication after RSA. Notching may be caused by direct mechanical impingement of the humerosocket polyethylene on the scapular neck and from osteolysis from polyethylene wear. Sirveaux classified scapular notching based on the defect size as it erodes behind the baseplate towards the central post. Acromial fractures are infrequent but more common is severely eroded acromions from CTA, with osteoporosis, with excessive lengthening, and with superior baseplate screws that penetrate the scapular spine and create a stress riser. Nonoperative care is the mainstay of acromial and scapular spine fractures. Recognizing preoperative risk factors and understanding component positioning and design is essential to maximizing successful outcomes

Intra-operative complications vary from extremely benign such as glenoid vault penetration to life and limb threatening for example brachial artery injury. Most intra-operative complications can be avoided with careful pre-operative planning, anticipation, and execution. However, even the best planning and execution including fluoroscopic guided reaming cannot prevent all complications. The following intra-operative complications will be discussed in detail in regards to both prevention and management: Glenoid vault penetration, Glenoid component malposition - reverse and primary, Glenoid fracture - reverse and primary, Humeral component malposition - reverse and primary, and Humeral fracture - reverse and primary

Scapula fractures mostly occur following high energy trauma, however, the demographics are unknown in deployed soldiers. We analysed the incidence, aetiology, associated injuries, treatment and complications of these fractures in military personnel from Afghanistan and Iraq (2004–2014). Forty-four scapula fractures from 572 upper limb fractures (7.7%) were sustained. 85% were caused by blast or gunshot wounds and 54% were open blast fractures. Multiple injuries were noted including lung, head, vascular and nerve injuries. Injury Severity Scores were almost double compared to the average upper limb injury without a scapula fracture (21 vs. 11). Brachial plexus injuries (17%) have a favourable outcome following GSW compared to blast injuries. Glenoid fractures or floating shoulders were internally fixed (10%) and resulted from high velocity gunshot wounds or mounted blast ejections. There were no cases of deep soft tissue infection or osteomyelitis and all scapula fractures united. Scapula fractures have a 20 times higher incidence in military personnel compared to the civilian population. These fractures are often associated with multiple injuries, including brachial plexus injuries, where those sustained from blast have less favourable outcome. High rates of union following fixation and low rates of infection are expected despite significant contamination and soft tissue loss

Introduction. There is a high prevalence of obesity in the United States and the numbers are increasing. These patients comprise a significant portion of the shoulder arthroplasty patient population. There are several reports of outcomes in the literature on obese patients after total knee or hip replacement, however, this data is lacking in the shoulder arthroplasty patient population. The purpose of this study is to compare the functional outcomes and complications of obese patients undergoing shoulder arthroplasty with the non-obese population. Methods. Between 2009 to 2010, 76 patients that had a primary total shoulder replacement were grouped according to their Body Mass Index (BMI) and followed prospectively for 2 years. The groups were divided as normal (BMI <25, N=26), overweight (25 to 30 BMI, N=25), and obese (>30 BMI, N=25) according to the World Health Organization classifications. Preoperative demographics, age, comorbidities and postoperative complications were recorded. Perioperative operating room and hospital data were analyzed. Functional outcome measurements including ASES, SF-36 physical component (PC) scores, mental component (MC) scores and visual analog scale along with general health and fatigue were evaluated at the 0 and 2 year time period. Statistical analyses were performed. Results. Functional outcome: In the normal BMI group: Average ASES scores improved from 38.4 +/− 15.5 (pre-op) to 80.2 +/− 19.4 (2 yr), SF-36 Physical Component (PC) scores improved from 38.3 +/− 6.5 (pre-op) to 53.7 +/− 11.3 (2 yr), and VAS decreased from 62 to 12 (2 yr). There were no intraoperative complications and two patients required revision of components. In the overweight BMI group: Average ASES scores improved from 37.4 +/− 18.1 (pre-op) to 75.2 +/− 24.9 (2 yr), SF-36 Physical Component (PC) scores improved from 36.1 +/− 8.0 (pre-op) to 39.8 +/− 12.2 (2 yr), and VAS decreased from 68 to 18. One patient had deep infection that required surgical irrigation/debridement, one intraoperative glenoid fracture converted to hemiarthroplasty and two patients required revision of components. In the obese BMI group: Average ASES scores improved from 35.8 +/− 12.5 (pre-op) to 80.0 +/− 20.6 (2 yr), SF-36 Physical Component (PC) scores improved from 36.3 +/− 8.4 (pre-op) to 40.7 +/− 12.4 (2 yr), and VAS decreased from 66 to 11 (2 yr). There were no intraoperative complications and no patients required revision surgery. * Statistical analysis showed significant difference in the SF-36 PC scores between both the overweight and the obese group compared to the normal BMI group. No statistical difference was seen between the three groups with the perioperative OR/hospital data, SF-36 MC scores, general health and fatigue scales. Conclusion. Shoulder arthroplasty in all three groups were associated with significant improvements in ASES scores and decrease in overall pain. Obese and overweight patients after TSA had significantly less overall physical functional improvements compared to the normal BMI group. Both intraoperative and postoperative complications were minimal after TSA in all three BMI groups. OR time and intraoperative blood loss was higher in the obese group, but overall ASA scores and number of days of hospital stay were similar in all three groups

Hybrid fixation of total joint arthroplasty has been an accepted form of surgical approach in multiple joints. Principles of implant fixation should focus on durability providing secure long-term function. To date there is no conclusive evidence that pressed fit humeral stem fixation has an advantage over well-secured cemented humeral fixation. In fact, need for revision arthroplasty due to inadequate implant fixation has almost universally revolved around failure of cement fixation and loosening of the glenoid component. A case will be made based on 30 years of experience of one surgeon performing total shoulder arthroplasty using secure modern cement fixation techniques of humeral components. More recently, over the last 10 years, extremely high rate of durable secure glenoid implant fixation has been achieved using tantalum porous anchorage with polyethylene glenoid components. This has resulted in no cases of loosening of glenoid fixation and only 1 case of glenoid component fracture with greater than 95% survivorship over a 10 year period. A combination of well cemented humeral stem and trabecular metal anchorage of the glenoid has provided durable lasting function in primary total shoulder arthroplasty

Background. This is a continued assessment of the effectiveness of a locked intramedullary device in the treatment of acute clavicle shaft fractures. Results of patients treated thus far were assessed, including patients reported on previously. Description of methods. Patients admitted with midshaft clavicle fractures were assessed to determine whether operative fixation of the fracture was required. Indications for surgery were midshaft clavicle fractures with 100% displacement; more than 1.5 cm of shortening, presence of a displaced butterfly segment, bilateral clavicle fractures, ipsilateral displaced glenoid neck fractures, skin and neurovascular compromise. Patients that matched the criteria for surgery were treated operatively with an intramedullary locked device by the author. Post-operatively, patients were kept in a shoulder immobilizer for a period of 6 weeks. Patients were invited to attend a scheduled follow-up visit where the data was collected that comprised the review. All patients were assessed by the surgeon, a radiologist, a physiotherapist and an occupational therapist. Scar size and quality, Dash score, Constant Shoulder score, complications and the radiological picture were assessed. Summary of results. 50 patients (52 clavicle fractures – 2 patients sustained bilateral fractures), 28 males and 22 females with a mean age of 30 attended the schedule data collection visit and were included in the study. 48 clavicles achieved complete union with the remaining 4 fractures progressing normally to union at 10 and 12 weeks post surgery. No additional complications than those reported on previously were encountered. Conclusion. Locked intramedullary fixation of clavicle shaft fractures that match the criteria for operative fixation continues to give good results. No non-unions were found and a high level of patient satisfaction was achieved. The operative technique continues to be refined leading to less fixation related complications. MULTIPLE DISCLOSURES