Athens, Greece | 21–22 June 2025

(Reported by Emmanouil Brilakis, ESA Vice-Chair)

Course overview

The “All about shoulder instability” hands-on cadaveric course took place on 21–22 June 2025 in Athens. Developed under the leadership of ESSKA Teachers Manos Antonogianakis and Manos Brilakis, co-ordinated by Angelos Trellopoulos, and endorsed by ESSKA, this course offered an immersive training environment that combined expert lectures with practical cadaver workshops.

Faculty highlights

The following Board members of ESSKA were hosted in this course and shared their experience:

• Michael Hantes
• Berte Bøe
• Baris Kocaoglu
• Frank Martetschläger

Many other European Shoulder experts also participated, forming an outstanding faculty, including:

• Ettore Taverna
• Enrico Gervasi
• Philippe Valenti
• Sokratis Kalogrianitis
• Georgios Arealis

The course’s Faculty has also included many of the local experts, including:

• Grigorios Avramidis
• Dimitrios Alexakis
• Ioannis Chiotis
• Anastasios Deligeorgis
• Emmanouil Fandridis

Their contributions, spanning lectures and cadaver lab guidance, ensured a rich, multifaceted educational experience.

Key themes & sessions

The course covered the entire spectrum of shoulder instability, including diagnostic protocols, arthroscopic repair methods, bone-block procedures, and decision-making in complex cases. Faculty-led debates and interactive sessions encouraged delegates to improve their clinical reasoning and practical skills. Ultimately, this course met delegates’ expectations of participating in a preparatory programme, equipping them to apply for the Instability Module of the ESSKA’s European Certification Programme.

Feedback from Faculty & participants

Participants were enthusiastic, particularly emphasising the generous time spent in the cadaver lab (nearly 8 hours during a 1.5-day course). The ESSKA Board Faculty posted in the SM:

“Dear Manos and Manos, congratulations on the organisation, hospitality, and scientific content. The course was high-level, and I thoroughly enjoyed it. Keep going!” – Michael Hantes

“Congrats! It was a fantastic course, and thank you for your great hospitality.” – Baris Kocaoglu

“Congratulations, Manos and Manos, on a perfectly organised course. Thank you and your team for the effort and enthusiasm you put into educating our next generation of shoulder colleagues, which is very important for ESA and ESSKA.” – Frank Martetschlager

“Thank you! And congratulations on this successful course!! Your contribution to education is exceptional, and I highly appreciate our friendship!” – Berte Boe

Industry & institutional support

Gratitude is extended to industry sponsors for the course: Arthrex, CPO Greece, MEDINOR Medical Supplies, MEDIPLAT LTD, Medisports, and Zimmer Biomet, as well as to the ESSKA staff, the Hellenic Association of Orthopaedic Surgery and Traumatology, and Hygeia Hospital, whose support was essential.

ESA Section Commentary

The ESSKA-ESA 360° sequence continues to embody our mission of delivering high-quality, practical educational events across Europe. These course series, combining expert faculty with hands-on cadaveric training, set a benchmark in shoulder instability education. This preparatory course is designed for surgeons aiming to apply for the ESSKA European Certification Program. We thank everyone involved — organisers, faculty, sponsors, and delegates — for their dedication and expertise.

What’s next?

Check out the upcoming ESA events at the ESSKA Congress in Prague 2026.

Enhance your shoulder instability practice with the ESA teaching modules on the ESSKA Academy.

]]> Mon, 28 Jul 2025 13:55:00 GMT https://www.esska.org/news/news.asp?id=702850 https://www.esska.org/news/news.asp?id=702850

The 7th Practical Course on Shoulder Surgery (PCCS), chaired by Dr. Antoon Van Raebroeckx, took place on 31 January–1 February 2025 at the Walburg Conference Center in Sint‑Niklaas, Belgium. This biennial event continues a tradition of excellence in shoulder surgery education, attracting both national and international experts.

A significant highlight was the esteemed ESA faculty, including Dr. Frank Martetschläger (current ESA President) and other prominent ESA members, whose contributions shaped the course content. Their involvement, alongside leading European experts, enhanced the scientific rigour of the event and fostered a collaborative environment for sharing cutting‑edge research and clinical techniques.

Course Highlights:

• Scapula fractures
• New techniques in rotator cuff lesion treatment
• Latest advancements in instability management

Each lecture was followed by a live technical demonstration, including five in‑theatre surgery cases. Dr Van Raebroeckx presented on cuff augmentation with an implant, joined by:

• Dr. Roman Brzoska – subscapularis repair
• Dr. Jean Kany – lower trap tendon transfer
• Dr. Frank Martetschläger – trans‑subscapularis instability repair
• Dr. Jérôme Garret – open Latarjet procedure

These sessions provided unparalleled practical insights and hands‑on learning opportunities.

Over two days, we welcomed 91 delegates. A Friday evening dinner facilitated valuable social interaction, and many faculty explored Antwerp by night afterwards—further reinforcing professional bonds and personal connections. Truly, the ESA network was strengthened in meaningful ways!

Esteemed Faculty

International Experts:

• Frank Martetschläger (Germany), President of ESA‑ESSKA
• Roman Brzoska (Poland), Past‑President of ESA
• Maristella Saccomanno (Italy), Scientific Chair ESSKA Milan 2024
• Felix Dyrna (Germany), Sportklinik Leipzig
• Lucca Lacheta (Germany), Universität München
• Ettore Taverna (Italy–Switzerland), Milano‑Mendrisio
• Jérôme Garret (France), Clinique du Parc Lyon
• Ana Catarina Angelo (Portugal), Lisbon
• Clara Azevedo (Portugal), Lisbon
• Jean Kany (France), Toulouse

National Experts:

• Philippe Debeer, UZ Leuven
• Alexander Van Tongel, UZ Gent
• Olivier Verborgt
• Tom Claes, AZ Herentals
• Tom Van Isacker, AZ St‑Lucas Brugge

ESA Chairmans Editorial
F. Martetschläger

Artificial intelligence and its application in shoulder surgery – Just a modern hype or a real chance for improvement?

Introduction

The rapid evolution of computing power and imaging technology over the last decades has not only influenced our daily lives but also tremendously changed all different professional fields across the globe. Of course, this also applies to the field of medicine and orthopaedics. These groundbreaking advancements in computing technology have already been increasingly implemented in the field of medicine thus leading to a revolutionary transformation of the healthcare system to improve patient care and outcomes. But has AI already arrived in the field of shoulder surgery and what can we expect for the future?

“Artificial intelligence has the potential to revolutionize health care by advancing medical product development, improving patient care, and augmenting the capabilities of health care practitioners”. With this sentence the FDA introduces their white paper titled, “Artificial Intelligence & Medical Products: How CBER, CDER, CDRH, and OCP are Working Together.”(1) According to this recent paper from March 2024, the rising interest regarding AI in medicine can be demonstrated by the number of AI (Artificial Intelligence) and ML (Machine Learning) submissions to the FDA over the last years: while the submission rate was slowing recently, there was a rise of 39% from 2019 to 2020 and the growth rate is still predicted to reach over 30% in the future.(2) Looking closer into the latest submissions, there was a large representation in radiology with 79% of the submissions in this area , which is not surprising given the close connection of imaging data to software tools. In contrast, the number of orthopaedic submissions was only 1 out of 692.
While the field of orthopaedics and especially shoulder surgery was not in the forefront of AI adopters in the beginning, there has been a tremendous increase of research interest in applying AI to shoulder surgery recently and several publications can help better understand the current use today and possible benefits of this technology in the future. The entire field of orthopaedic surgery, particularly shoulder surgery, is undergoing a transformative shift due to the integration of artificial intelligence (AI) and machine learning (ML). These advanced technologies are revolutionising how surgeons diagnose, plan, and execute surgical procedures, thereby enhancing patient outcomes and optimising healthcare delivery.

Diagnostic Precision and Predictive Analytics

One of the most significant contributions of AI and ML in shoulder surgery is in the realm of diagnostics. Traditional diagnostic methods often rely heavily on the subjective expertise of radiologists and surgeons. However, AI-powered systems can analyze medical images, such as X-rays, MRIs, and CT scans, with high accuracy, identifying subtle patterns and anomalies that may be missed by the human eye. These systems use deep learning algorithms, a subset of ML, to train on vast datasets of medical images. For instance, convolutional neural networks (CNNs) have been particularly effective in image recognition tasks, enabling the precise detection of conditions like rotator cuff tears, labral tears, and arthritis. For example, Taghizadeh et al.(3) and Ro et al.(4) developed AI models capable of automatically quantifying muscle atrophy and fatty infiltration on CT, respectively MRT in patients with rotator cuff tears which could help standardise diagnostics and better comparability for clinical research.
Beyond diagnostics, AI and ML also play a crucial role in predictive analytics. By analysing patient data, including demographic information, medical history, and imaging results, these technologies can predict the likelihood of certain shoulder conditions and the potential success of various treatment options. This predictive capability is invaluable for personalised medicine, allowing for tailored treatment plans that align with individual patient profiles.
It was already in 2019 when Gowd et al.(5) published their work on the impact of supervised machine learning models to predict postoperative complications following total shoulder arthroplasty. The authors concluded that ML algorithms could accurately predict postoperative complications based on routinely collected preoperative variables and outperformed models by comorbidity indices alone.
In a recent article by Potty et al. the authors could show that the same applies to prediction of postoperative outcomes. A specific machine learning algorithm has been used for calculation of postoperative outcomes following arthroscopic rotator cuff repair based on multiple preoperative factors. The authors concluded that this model can be used to accurately predict postoperative ASES scores which could further supplement preoperative counselling, planning and resource allocation.(6)

Surgical Planning, Simulation and Robotic-Assisted Surgery

Surgical planning is another area where AI and ML are making a substantial impact. Preoperative planning traditionally involves meticulous manual assessment of medical images and anatomical structures. AI-driven tools can now automate and enhance this process by creating detailed 3D models of the patient's shoulder anatomy. These models facilitate precise surgical planning, allowing surgeons to visualise the operative field, anticipate challenges, and determine the most effective surgical approach.
Furthermore, AI-based simulation platforms enable surgeons to practice and refine their techniques in a virtual environment before performing the actual surgery. These simulations use realistic anatomical models and real patient data to provide an immersive and interactive training experience. By practicing on virtual models, surgeons can improve their skills, reduce the learning curve, and enhance their confidence, ultimately leading to better surgical outcomes. Vedula et al.(7), namely a Consensus Panel defined important future AI applications and artificial intelligence-enabled metrics for surgical education and a timeframe when these important AI applications should be implemented (Table 1).
However, AI innovations do not end with planning the procedures or medical education. AI has already entered the operating theater, where preoperative planning can precisely be transferred into the operating field by use of navigation, patient specific instrumentation, augmented reality or even robotic assistance. (8)

The advent of robotic-assisted surgery represents one of the most advanced applications of AI and ML in shoulder surgery. Robotic systems, equipped with AI algorithms, can assist surgeons in performing complex procedures with unparalleled precision and control. These systems use real-time data and advanced imaging techniques to guide the surgeon's movements, ensuring accurate and minimally invasive interventions. For instance, robots can assist in the precise placement of implants during shoulder arthroplasty, minimizing the risk of complications and improving the longevity of the implants. (9)
However, in contrast to knee and hip surgery, the routine use of robotic assistance in shoulder surgery will need some time for development and must stand the test of time.

Postoperative Care and Rehabilitation

AI and ML also extend their influence to postoperative care and rehabilitation, which are critical phases in the recovery process. AI-powered monitoring systems can continuously track a patient's recovery progress, analyzing data from wearable devices, sensors, and mobile health applications. These systems can detect early signs of complications, such as infections or improper healing, and alert healthcare providers for timely intervention.
Moreover, ML algorithms can personalize rehabilitation programs based on the patient's progress and specific needs. By analyzing data from physical therapy sessions and patient feedback, these algorithms can adjust the intensity, frequency, and type of exercises to optimize recovery. This personalized approach not only enhances the effectiveness of rehabilitation but also increases patient adherence and satisfaction.

Challenges and Future Directions

Despite the promising advancements, the integration of AI and ML in shoulder surgery is not without challenges. Data privacy and security concerns, the need for large and diverse datasets, and the potential for algorithmic bias are significant issues that need to be addressed. Additionally, the adoption of these technologies requires substantial investment in infrastructure, training, and ongoing research.
Looking ahead, the future of AI and ML in shoulder surgery holds immense potential. Continued advancements in AI algorithms, improved data integration, and enhanced collaboration between technologists and clinicians will drive further innovation. The development of more sophisticated AI-powered diagnostic tools, real-time intraoperative guidance systems, and adaptive rehabilitation programs will continue to elevate the standard of care in shoulder surgery.

Conclusion

In conclusion, artificial intelligence and machine learning are transforming shoulder surgery by enhancing diagnostic accuracy, optimizing surgical planning, enabling robotic-assisted interventions, and personalizing postoperative care. While challenges remain, the ongoing integration of these technologies promises to revolutionize the field, hopefully improving patient outcomes and advancing the practice of shoulder surgery. Nowadays, a routine use of AI based applications in shoulder surgery still leaves much to be desired. According to Gupta et al. AI model performence is still modest and external validation remains to be demonstrated suggesting increased scientific rigor is warranted prior to deploying AI based applications to the clinical setting.(10)

Future applications of artificial intelligence methods and AI-enabled metrics for surgical education defined by a Delphi Consensus Panel.

Recognize anatomy in images from videos of the surgical field (2)
Provide performance feedback to surgeon immediately after the operation (2)
Identify parts of the operation on which the surgeon needs feedback (5)
Overlay images to display surrounding anatomy (5)
Guide surgeons on optimal use of instruments/devices (5)
Enable intraoperative navigability using video, kinematics, and other imaging data for multiple procedures (10)
Detect intraoperative error (10)
Provide guidance on the next best step to address an intraoperative error or complication (10)
Time frame (y)
Adapted from Vedula et al. (7)

Introduction

1. (https://www.fda.gov/media/177030/download?attachment)
2. (https://www.fda.gov/medical-devices/software-medical-device-samd/artificial-intelligence-and-machine-learning-aiml-enabled-medical-devices)
3. Taghizadeh E, Truffer O, Becce F, Eminian S, Gidoin S, Terrier A, et al. Deep learning for the rapid automatic quantification and characterization of rotator cuff muscle degeneration from shoulder CT datasets. Eur Radiol 2021;31:181- 90. https://doi.org/10.1007/s00330-020-07070-7.
4. Ro K, Kim JY, Park H, Cho BH, Kim IY, Shim SB, et al. Deep-learning framework and computer assisted fatty infiltration analysis for the supraspinatus muscle in MRI. Sci Rep 2021;11, 15065. https://doi.org/10.1038/s41598-021-93026-w.
5. Gowd AK, Agarwalla A, Amin NH, Romeo AA, Nicholson GP, Verma NN, Liu JN. Construct validation of machine learning in the prediction of short-term postoperative complications following total shoulder arthroplasty. J Shoulder Elbow Surg. 2019 Dec;28(12):e410-e421. doi: 10.1016/j.jse.2019.05.017. Epub 2019 Aug 3. PMID: 31383411.
6. Potty AG, Potty ASR, Maffulli N, Blumenschein LA, Ganta D, Mistovich RJ, Fuentes M, Denard PJ, Sethi PM, Shah AA, Gupta A. Approaching Artificial Intelligence in Orthopaedics: Predictive Analytics and Machine Learning to Prognosticate Arthroscopic Rotator Cuff Surgical Outcomes. J Clin Med. 2023 Mar 19;12(6):2369. doi: 10.3390/jcm12062369. PMID: 36983368; PMCID: PMC10056706.
7. Vedula SS, Ghazi A, Collins JW, Pugh C, Stefanidis D, Meireles O, et al. Artificial intelligence methods and artificial intelligence-enabled metrics for surgical education: a multidisciplinary consensus. J Am Coll Surg 2022;234:1181-92.
8. Lee KS, Jung SH, Kim DH, Chung SW, Yoon JP. Artificial intelligence- and computer-assisted navigation for shoulder surgery. J Orthop Surg (Hong Kong). 2024 Jan-Apr;32(1):10225536241243166. doi: 10.1177/10225536241243166. PMID: 38546214.
9. Twomey-Kozak J, Hurley E, Levin J, Anakwenze O, Klifto C. Technological innovations in shoulder replacement: current concepts and the future of robotics in total shoulder arthroplasty. J Shoulder Elbow Surg. 2023 Oct;32(10):2161-2171. doi: 10.1016/j.jse.2023.04.022. Epub 2023 May 30. PMID: 37263482.
10. Gupta P, Haeberle HS, Zimmer ZR, Levine WN, Williams RJ, Ramkumar PN. Artificial intelligence-based applications in shoulder surgery leaves much to be desired: a systematic review. JSES Rev Rep Tech. 2023 Jan 7;3(2):189-200. doi: 10.1016/j.xrrt.2022.12.006. PMID: 37588443; PMCID: PMC1

In recent years, technological advancements have significantly reshaped the landscape of orthopedic surgery. Innovations in 3D printing and 3D digital CT planning are ushering in a new era of precision, customization and enhanced decision-making capabilities, ultimately improving patient outcomes.

In both anatomic and reverse total shoulder arthroplasty, getting the glenoid component position right is crucial for success. Despite this, there's a 4.6% cumulative revision rate at 5 years, and the top reasons for revisions are instability (38.5%) and loosening (18.0%) [1]. Attaining optimal alignment, inclination, and projection is crucial for maximizing the utilization of the available bone for secure fixation.

The prevalence of shoulder replacement revision, primarily due to glenoid positioning errors, is rising. This trend can be attributed to various factors such as the scapula's flat nature, the lack of a clear reference axis, surgical approaches that expose the glenoid with limited bone landmarks, challenges posed by the humerus and deltoid that impede glenoid access, and the considerable variability in scapula morphology [2].

3D Printing

3D printing, or additive manufacturing, is a revolutionary method for creating three-dimensional objects layer by layer, deviating from traditional subtractive manufacturing processes. This technique employs a diverse range of materials, including plastics, metals, ceramics and biomaterials. The process involves initiating a digital image through various methods such as computer-aided design (CAD), online libraries, 3D scanning or DICOM files derived from CT and MRI scans. The obtained image is then converted into an STL file within modelling software, followed by layer slicing and the generation of G-Code, a file containing instructions for the printer. This G-Code is inserted into the 3D printer, marking the commencement of the printing process [3,4].

The adaptability and transformative nature of 3D printing is not only reshaping manufacturing approaches, but also pushing the boundaries of personalized interventions, patient comfort and preoperative rehabilitation. Beyond personalized manufacturing, the development of 3D bioprinting, artificial intelligence and advanced biomaterials promises to revolutionize precision medicine, offering innovative solutions for tissue engineering, regenerative medicine, and personalized healthcare.

3D Planning

3D virtual planning based on CT scans represents a virtual reconstruction of a 3D anatomical model and it is often used for surgical planning and interventions. This fully manipulable technology helps in the preoperative period, aiding surgeons in choosing the optimal approach and determining the dimensions and type of implants or components, while the software provides both coloured and numeric feedback on the baseplate's position, the extent of bone removal and the prosthetic/bone contact [5].

3D Printed Anatomical Models

The incorporation of 3D-printed anatomical models into preoperative planning offers a multitude of advantages. Firstly, these models are educational tools for less experienced surgeons and serve to familiarize themselves with the patient`s specific anatomy and the surgical steps in a feel-and-see manner. Additionally, the utilization of 3D-printed models has the potential to transform preoperative planning for surgeons who may have limited experience in the field [6].

Secondly, the patient-specific nature of these models is especially beneficial for addressing anatomical variations or complex pathologies. Surgeons can strategize and optimize their approach, tailoring plans to the unique details of each case. This precision contributes to more effective interventions, potentially reducing complications and improving overall surgical outcomes. KC Wang et al. studied the usefulness of bony morphology and model evaluation of CT-Based 3D printed glenoid models before shoulder arthroplasty and proved that the 3D models helped the surgeons to appreciate more clearly the bony morphology as the complexity of the glenoid structure increased [7]. Utilizing the entire scapula as a reference enhances accuracy and reduces the occurrence of glenoid vault perforation. Achieving this level of visualization requires pre-operative 3D CT planning, 3D virtual models or 3D printed anatomical models and the accuracy can be further augmented by using Patient-Specific Instrumentation (PSI). Incorporating automatic software in the pre-operative planning and PSI ensures precise and reproducible positioning and orientation of the glenoid component [8,9,10].

3D Printed Patient-Specific Instrumentation (PSI)/ Patient-specific guides (PSGs)

The advantages of 3D-printed patient-specific instrumentation lie in the enhanced accuracy they provide during surgery. The utilization of 3D printing begins with the generation of patient-specific digital models derived from preoperative imaging data, such as CT scans or MRI scans. This meticulous mapping of the patient's anatomy allows for the creation of personalized instruments that precisely fit the contours of the individual's shoulder joint.

There are 2 types of PSI: moulded and stool guides. In theory, guides formed through moulding should enhance stability by establishing a larger contact area with the glenoid. However, stool guides are preferable due to bone visualization limitations [2].

Several authors proved that the use of 3D-printed PSI can have a superior outcome than standard instrumentation. Gauci et al, performed 17 TSA assessing the accuracy and effectiveness of a 3D-printed PSI in guiding the surgical placement of the glenoid component. The mean error in the accuracy of the entry point was -0.1 mm in the horizontal plane, 0.8 mm in the vertical plane, the mean error in the orientation of the glenoid component was 3.4° for version and 1.8° for inclination [9].

Walch et al, made a quantitative analysis of guide pin positioning on cadaveric scapulae (N=18), the mean error in the 3D orientation of the guide pin was 2.39°, the mean entry point position error was 1.05 mm, the mean inclination angle error was 1.42° and the average error in the version angle was 1.64° [11]. In a study conducted by CSY Yung et al, a multi-centre retrospective analysis of 73 patients who underwent RTSA between 2015 and 2020 revealed a significant advantage in favour of PSI, demonstrating that it leads to substantially longer superior and inferior mean screw lengths compared to conventional instrumentation and during the average 2-year follow-up duration there was no occurrence of glenoid component loosening observed in any of the patients [12].

Jacquot et al, concluded that PSI slightly enhanced the positioning of the central point, particularly for a severely retroverted glenoid, but there was no significant improvement in the orientation of the component compared to the freehand method. In 17 TSA patients, the mean error for the central point was 2.89 mm with the freehand method versus 2.1 mm with the use of a targeting guide, the mean errors for version and inclination were respectively 4.82° and 4.2° with the freehand method, compared to 4.87° and 4.39° with a targeting guide [13]. As MGJ Yam et al highlighted, there is a significant cost disparity between in-house 3D printing (that can go as low as $50) and commercially vendor-created guides, typically manufactured abroad (rising up to $1000-1500 per surgery) [14].

Despite the net improvement in surgical planning, PSI is beneficial in reducing intraoperative radiation, operative time and is also aiding younger or less experienced doctors to operate more difficult cases [2,15,16].

Conclusions

The advancements in 3D printing, 3D planning and patient-specific guides have individually revolutionized the landscape of shoulder arthroplasty. Each method brings its own set of benefits, from precision in surgical planning to real-time intraoperative insights.

With further studies and technological improvements, it will be important to understand how 3D printing and 3D planning could link with other innovative technologies like artificial intelligence, machine learning, and computer-assisted navigation for better patient outcomes. It is at the intersection of these technologies that the true potential for transformative change emerges. It's like upgrading from a regular map to a GPS system—more accurate, personalized, and ultimately leading to better results for everyone involved. This collaboration of technologies marks a new era in shoulder surgery, where innovation meets patient-focused excellence.

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References

1. Graves SE, Davidson D, Ingerson L, et al. The Australian Orthopaedic Association National Joint Replacement Registry. Med J Aust. 2004;180(5):31-34. doi:10.5694/j.1326-5377.2004.tb05911.x
2. Gauci MO. Patient-specific guides in orthopedic surgery. Orthop Traumatol Surg Res. 2022 Feb;108(1S):103154. doi: 10.1016/j.otsr.2021.103154. Epub 2021 Nov 24. PMID: 34838754.
3. Levesque JN, Shah A, Ekhtiari S, Yan JR, Thornley P, Williams DS. Three-dimensional printing in orthopaedic surgery: a scoping review. EFORT Open Rev. 2020 Aug 1;5(7):430-441. doi: 10.1302/2058-5241.5.190024. PMID: 32818070.
4. Wixted CM, Peterson JR, Kadakia RJ, Adams SB. Three-dimensional Printing in Orthopaedic Surgery: Current Applications and Future Developments. J Am Acad Orthop Surg Glob Res Rev. 2021 Apr 20;5(4):e20.00230-11. doi: 10.5435/JAAOSGlobal-D-20-00230. PMID: 33877073.
5. Moreschini F, Colasanti GB, Cataldi C, Mannelli L, Mondanelli N, Giannotti S. Pre-Operative CT-Based Planning Integrated With Intra-Operative Navigation in Reverse Shoulder Arthroplasty: Data Acquisition and Analysis Protocol, and Preliminary Results of Navigated Versus Conventional Surgery. Dose Response. 2020 Nov 28;18(4):1559325820970832. doi: 10.1177/1559325820970832. PMID: 35185413.
6. Kang HJ, Kim BS, Kim SM, Kim YM, Kim HN, Park JY, Cho JH, Choi Y. Can Preoperative 3D Printing Change Surgeon's Operative Plan for Distal Tibia Fracture? Biomed Res Int. 2019 Feb 11;2019:7059413. doi: 10.1155/2019/7059413. PMID: 30886862.
7. Wang KC, Jones A, Kambhampati S, Gilotra MN, Liacouras PC, Stuelke S, Shiu B, Leong N, Hasan SA, Siegel EL. CT-Based 3D Printing of the Glenoid Prior to Shoulder Arthroplasty: Bony Morphology and Model Evaluation. J Digit Imaging. 2019 Oct;32(5):816-826. doi: 10.1007/s10278-019-00177-4. PMID: 30820811.
8. Berhouet J, Gulotta LV, Dines DM, Craig E, Warren RF, Choi D, et al. Preoperative planning for accurate glenoid component positioning in reverse shoulder arthroplasty. Orthop Traumatol Surg Res 2017;103:407–13.
9. Gauci MO, Boileau P, Baba M, Chaoui J, Walch G. Patient-specific glenoid guides provide accuracy and reproducibility in total shoulder arthroplasty. Bone Joint J 2016;98-B:1080–5.
10. Moreschini F, Colasanti GB, Cataldi C, Mannelli L, Mondanelli N, Giannotti S. Pre-Operative CT-Based Planning Integrated With Intra-Operative Navigation in Reverse Shoulder Arthroplasty: Data Acquisition and Analysis Protocol, and Preliminary Results of Navigated Versus Conventional Surgery. Dose Response. 2020 Nov 28;18(4):1559325820970832. doi: 10.1177/1559325820970832. PMID: 35185413.
11. Walch G, Vezeridis PS, Boileau P, Deransart P, Chaoui J. Three-dimensional planning and use of patient-specific guides improve glenoid component position: an in vitro study. J Shoulder Elbow Surg. 2015 Feb;24(2):302-9. doi: 10.1016/j.jse.2014.05.029. Epub 2014 Aug 31. PMID: 25183662.
12. Yung CS, Fang C, Fang E, Siu YC, Yee DKH, Wong KK, Poon KC, Leung MMF, Wan J, Lau TW, Leung F. Surgeon-designed patient-specific instrumentation improves glenoid component screw placement for reverse total shoulder arthroplasty in a population with small glenoid dimensions. Int Orthop. 2023 May;47(5):1267-1275. doi: 10.1007/s00264-023-05706-z. Epub 2023 Feb 10. PMID: 36763126.
13. Jacquot A, Gauci MO, Chaoui J, Baba M, Deransart P, Boileau P, Mole D, Walch G. Proper benefit of a three dimensional pre-operative planning software for glenoid component positioning in total shoulder arthroplasty. Int Orthop. 2018 Dec;42(12):2897-2906. doi: 10.1007/s00264-018-4037-1. Epub 2018 Jul 2. PMID: 29968136.
14. Yam MGJ, Chao JYY, Leong C, Tan CH. 3D printed patient specific customised surgical jig for reverse shoulder arthroplasty, a cost effective and accurate solution. J Clin Orthop Trauma. 2021 Jul 17;21:101503. doi: 10.1016/j.jcot.2021.101503. PMID: 34414069.
15. Pérez-Mananes R, Burró JA, Manaute JR, Rodriguez FC, Martín JV. 3D surgical printing cutting guides for open-wedge high tibial osteotomy: do it yourself. J Knee Surg 2016;29:690–5.
16. Farshad M, Betz M, Farshad-Amacker NA, Moser M. Accuracy of patient-specific template-guided vs. free-hand fluoroscopically controlled pedicle screw place- ment in the thoracic and lumbar spine: a randomized cadaveric study. Eur Spine J 2017;26:738–49.

¹3^rd Orthopaedic Department, Hygeia Hospital | Greece
² ESSKA-ESA Board Member

Rotator cuff injuries are a common orthopaedic condition often caused by trauma, repetitive strain, or age-related degeneration. The healing process of tendons is slow and incomplete, resulting in reduced functionality and patient-reported outcomes. Traditional treatments, such as physical therapy and surgery, have limited success, especially for chronic tears or poor tendon quality. In recent years, the focus has shifted towards enhancing the biologics of rotator cuff repair, with the use of bio-inductive scaffolds. In our clinical practice, we utilize a bovine bio-inductive collagen implant called Regeneten, manufactured by Smith & Nephew, Memphis, TN, USA, as a supplementary technique for rotator cuff repairs. This article aims to provide an overview of its use and our experience in clinical practice.

The rationale behind using Regeneten is to promote tendon healing and regeneration by providing a scaffold for progenitor stem cells to migrate on. Derived from highly purified bovine Achilles tendon, it forms a matrix that guides cell growth, enables the formation of new tissue, and promotes integration with the repaired tendon. It should be noted that the collagen implant is not intended to provide immediate structural support after surgery and typically absorbs within 6 months.

Clinical Evidence

Several clinical studies have investigated the safety and efficacy of Regeneten in rotator cuff tears. One notable study by Schegel et al. demonstrated healing rates of 84% and 91% in high and intermediate grade partial-thickness tears, respectively. Patients reported significant improvement in ASES and Constant scores, with a high overall satisfaction rate. Another study by Thon et al. reported successful healing rates at 2 years (96%) when Regeneten was used to augment rotator cuff repairs in large and massive tears. They observed no adverse effects related to the implant. McIntyre et al. reported their results in a larger study involving 170 patients with either partial-thickness or full-thickness tears. Eight patients required reoperation, with two cases attributed to adhesive capsulitis.

Complications and adverse effects

Although Regeneten has shown positive results, there have been some reported complications and adverse effects. Case reports have mentioned stiffness, sometimes due to subacromial bursitis with rice-bodies, associated with the implantation. Yeazell et al. compared the results of augmenting repair with Regeneten to a control group treated only with rotator cuff repair and reported a significant reoperation rate due to stiffness in the implant-augmented group. Long-term follow-up studies are necessary to assess the safety, durability, and functionality of the regenerated tendon. Additionally, cost-effectiveness analyses are needed to determine the economic viability and accessibility of this technology.

Our Clinical Series

In our clinical series, we have used Regeneten in rotator cuff tears either as a standalone implant or as an augmentation to repair. Our series involved 20 patients, 13 males and 7 females, with a mean follow-up of 9.9 months (±5.3 months). Nine patients had medium-sized tears, 4 had large tears, and 7 had massive tears. Different techniques were used for repair, including transosseous, double-row, single-row, and patch implantation. Complete repair was achieved in all patients. (figure 1)

We modified the standard technique by using spinal needles for intraoperative scaffold stabilization after unfolding it. We achieved strong fixation of the scaffold with specific tendon anchors and bone anchors using specific inserters. (figure 2, figure 3)

The patients showed improvement in VAS scores (rest/move/night) improved at the 6- and 12-month follow-up (by 2.7/3.95, 2.7/3.95 and 4.4/5.15, respectively). The mean Constant score, ASES and Oxford score improved at the 6- and 12-month follow-up by 14.2/28.1, 26.7/49.2 and 10.8/16.6, respectively. Eight of the patients had a follow up for more than 6 months but less than 12 months so they did not complete 12 months follow up.

Eleven patients underwent MRI at 6 months postoperatively: 8 showed complete healing (Sugaya I-III), 2 partial healing (Sugaya IV) and 1 no healing (Sugaya V). Four of them had massive tears, 2 large, 5 medium (for the massive tears SII:1, SIII: 2, SV:1, for the large tears SII: 1, SIV: 1 and for the medium tears SI: 1, SII: 2. SIII:1, SIV:1). Needle-arthroscopy was performed on 8 patients for postoperative evaluation at 6 months; Three of them had massive tears, 3 large, 2 medium and only one patient with massive tear had incomplete healing. Adverse effects were reported in one patient. He was reoperated for stiffness and inflammation; no pathogen was detected, and his postoperative course remains uneventful.

Our experience using the bioinductive collagen implant alongside arthroscopic rotator cuff repair has resulted in improved patient-reported outcome measures (PROMs) and reduced VAS pain scores. Additionally, 72.7% of patients who underwent MRI at 6 months postoperatively showed complete healing of the tear, while 12.5% showed incomplete healing.

Benefits

1. Enhanced Healing: it provides a conducive environment for cell proliferation and tissue regeneration, promoting faster and more effective healing of tendon injuries.^8,10 This often translates into quicker recovery times and improved patient outcomes.
2. Potentially Reduced Re-rupture Rates: By supporting the formation of new tissue and integration with the surrounding healthy tendon, it reduces the risk of re-rupture, a common complication in tendon injuries.⁸
3. Minimally Invasive Procedure: Its implantation can be performed using minimally invasive techniques, reducing surgical trauma, resulting in smaller incision and faster recovery times compared to traditional open surgical procedures.
4. Versatile Application: it has shown promising early results in various tendon injuries, including rotator cuff tears^11–14 and patellar tendon injuries.¹⁵ This makes it a potential treatment option where conventional treatments have historically yielded suboptimal outcomes.

Future Implications

Looking forward, the introduction of bio-inductive collagen scaffolds could be a significant advancement in regenerative medicine and tendon repair. Early results are promising in promoting tendon healing and improving patient outcomes and this method can open new possibilities for treating various, previously challenging to manage, tendon injuries. Continued research and clinical trials will provide valuable insights into its long-term safety, efficacy, optimal use, and cost-effectiveness.

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Figure 1: Medium size RCT: (A) Preoperative MRI (B) Intraoperative Image (C) Postoperative MRI at 6 months

Figure 2: Modified Technique for the Stabilization of the Implant with Spinal Needles (Red Arrows). Shoulder Arthroscopy, Posterolateral Viewing Portal, Manufacturer’s Unfolding Device (Yellow Arrows). The Scaffold is painted Blue circumferentially.

Figure 3: Intraoperative Image after Implantation with Staples (Red Arrows). Shoulder Arthroscopy, Posterolateral Viewing Portal. The Scaffold is painted Blue circumferentially.

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References
1. Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am. 2004 Feb;86(2):219–24.
2. Eckers F, Loske S, Ek ET, Müller AM. Current Understanding and New Advances in the Surgical Management of Reparable Rotator Cuff Tears: A Scoping Review. J Clin Med. 2023 Feb;12(5).
3. Neri BR, Chan KW, Kwon YW. Management of massive and irreparable rotator cuff tears. J shoulder Elb Surg. 2009;18(5):808–18.
4. Avanzi P, Giudici LD, Capone A, Cardoni G, Lunardi G, Foti G, et al. Prospective randomized controlled trial for patch augmentation in rotator cuff repair: 24-month outcomes. J shoulder Elb Surg. 2019 Oct;28(10):1918–27.
5. Chalmers PN, Tashjian RZ. Patch Augmentation in Rotator Cuff Repair. Curr Rev Musculoskelet Med. 2020 Oct;13(5):561–71.
6. Denard PJ, Burkhart SS. Techniques for managing poor quality tissue and bone during arthroscopic rotator cuff repair. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc North Am Int Arthrosc Assoc. 2011 Oct;27(10):1409–21.
7. McCormack RA, Shreve M, Strauss EJ. Biologic augmentation in rotator cuff repair--should we do it, who should get it, and has it worked? Bull Hosp Jt Dis. 2014;72(1):89–96.
8. Bokor DJ, Sonnabend D, Deady L, Cass B, Young A, Van Kampen C, et al. Evidence of healing of partial-thickness rotator cuff tears following arthroscopic augmentation with a collagen implant: a 2-year MRI follow-up. Muscles Ligaments Tendons J. 2016;6(1):16–25.
9. Schlegel TF, Abrams JS, Angelo RL, Getelman MH, Ho CP, Bushnell BD. Isolated bioinductive repair of partial-thickness rotator cuff tears using a resorbable bovine collagen implant: two-year radiologic and clinical outcomes from a prospective multicenter study. J shoulder Elb Surg. 2021 Aug;30(8):1938–48.
10. Schlegel TF, Abrams JS, Bushnell BD, Brock JL, Ho CP. Radiologic and clinical evaluation of a bioabsorbable collagen implant to treat partial-thickness tears: a prospective multicenter study. J shoulder Elb Surg. 2018 Feb;27(2):242–51.
11. Berthold DP, Garvin P, Mancini MR, Uyeki CL, LeVasseur MR, Mazzocca AD, et al. Arthroscopic rotator cuff repair with biologically enhanced patch augmentation. Oper Orthop Traumatol. 2022 Feb;34(1):4–12.
12. Thon SG, O’Malley L 2nd, O’Brien MJ, Savoie FH 3rd. Evaluation of Healing Rates and Safety With a Bioinductive Collagen Patch for Large and Massive Rotator Cuff Tears: 2-Year Safety and Clinical Outcomes. Am J Sports Med. 2019 Jul;47(8):1901–8.
13. McIntyre LF, Bishai SK, Brown PB 3rd, Bushnell BD, Trenhaile SW. Patient-Reported Outcomes After Use of a Bioabsorbable Collagen Implant to Treat Partial and Full-Thickness Rotator Cuff Tears. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc North Am Int Arthrosc Assoc. 2019 Aug;35(8):2262–71.
14. Bushnell BD, Connor PM, Harris HW, Ho CP, Trenhaile SW, Abrams JS. Retear rates and clinical outcomes at 1 year after repair of full-thickness rotator cuff tears augmented with a bioinductive collagen implant: a prospective multicenter study. JSES Int. 2021 Mar;5(2):228–37.
15. Looney AM, Fortier LM, Leider JD, Bryant BJ. Bioinductive Collagen Implant Augmentation for the Repair of Chronic Lower Extremity Tendinopathies: A Report of Two Cases. Vol. 13, Cureus. United States; 2021. p. e15567.
16. Yeazell S, Lutz A, Bohon H, Shanley E, Thigpen CA, Kissenberth MJ, et al. Increased stiffness and reoperation rate in partial rotator cuff repairs treated with a bovine patch: a propensity-matched trial. J shoulder Elb Surg. 2022 Jun;31(6S):S131–5.
17. Barad SJ. Severe subacromial-subdeltoid inflammation with rice bodies associated with implantation of a bio-inductive collagen scaffold after rotator cuff repair. J shoulder Elb Surg. 2019 Jun;28(6):e190–2.
18. Root KT, Wright JO, Mandato N, Stewart BD, Moser MW. Subacromial-Subdeltoid Bursitis With Rice Bodies After Rotator Cuff Repair With a Collagen Scaffold Implant: A Case Report. JBJS case Connect. 2023 Jan;13(1).

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¹3rd Orthopaedic Department, Hygeia Hospital | Greece
² ESSKA-ESA Board Member

Comparison between Bone Marrow Aspirate and Concentrate Samples Harvested from Three Different Anatomic Sites as Augmentation to Arthroscopic Treatment of Rotator Cuff Tears.

Mesenchymal stem cells (MSCs) are bone marrow stromal cells which are present in all types of tissues and are currently considered as the “gold standard” for biologic augmentation of arthroscopic treatment of rotator cuff tears.¹ These cells have been shown to demonstrate high differentiation potential in regenerative medicine as they play an important role in the healing process of injured bones, ligaments, tendons and cartilage.^2-6 The number of MSCs in bone marrow ranges from 1 in 104 to 1 in 106 mononuclear cells. This heterogeneous population of units was described in 1968 by Friedenstein as Colony Forming Units (CFUs) as they can differentiate into various mesenchymal tissues.^4-5 The total number of immature blood cells and non-blood or stromal cells in bone marrow are characterized as Total Nucleated Cells (TNC). Therefore, the efficiency of bone marrow aspirates depends on the aspiration technique and the culture process as it may be negatively affected by other cell populations because of blood dilution.

Aspiration technique plays an important role in the quality of the bone marrow samples in relation to the concentration of the osteogenic cells and the differentiation potential. The yield of osteoprogenitor cells is further increased by a greater concentration of the aspirate sample which is then characterized as bone marrow aspirate concentrate.

The aim of this study was to evaluate the levels of Total Nucleated Cells (TNC), Platelets (PLTs) and Colony Forming Units (CFU- Fs) in bone marrow aspirate samples compared to bone marrow concentrates as well as compare the quantitative and qualitative characteristics of bone marrow samples obtained from three different anatomic sites, the anterior and posterior superior iliac spine and the proximal tibia using the same aspiration technique. No clinical outcomes were reported.

A retrospective comparative study was conducted. Bone marrow samples were obtained from three different anatomic sites with the same aspiration technique and were processed with the same centrifugation system for augmentation of arthroscopic treatment of rotator cuff tears. Total Nucleated Cells, Platelets and Colony Forming Units levels were evaluated in bone marrow aspirate and concentrate samples obtained from all three anatomic sites. No further clinical evaluation was conducted.

One hundred and thirteen patients were included in the study. Of 113 patients, 51 patients - 31 females and 20 males - were included in Group A (anterior superior iliac spine), 26 patients - 16 females and 10 males - in Group B (proximal tibia) and 26 patients - 18 females and 8 males - in group C (posterior superior iliac spine). The mean age of patients was 58.13 ± 13.35 years in Group A, 55 ± 13.25 years in Group B and 46 ± 16.12 in group C. Age between group A and C was significantly different (p=0.002).

In the operating room, patients received general anaesthesia and harvest sites were prepared. Samples were collected from the anterior iliac crest (51) (Figure 1), the proximal tibia (26) (Figure 2) and the posterior iliac crest (26) (Figure 3). As per manufacturer instructions, at each individual site, 5 mL were aspirated, and the Jamshidi- style trocar needle was then rotated 90 degrees. After the next 5 mL were aspirated, the needle was advanced 1–2 cm, and the process was repeated. After harvesting, the skin entry incision was properly attended and dressed. BMA was collected into a sterile conical tube and transported to the laboratory for analysis. This sample was taken just prior to centrifugation step and was thus considered representative of the unconcentrated bone marrow aspirate (BMA) produced by the system. The remaining BMA was placed in the system centrifuge for concentration in accordance with manufacturer’s directions.

When comparing the levels of TNC, PLTs and CFU-fs in bone marrow aspirates, we found that total nucleated cell count of bone marrow aspirate from the posterior superior iliac spine was 31.23% higher than from anterior superior iliac spine while platelet count from the tibia was 4 times higher than from the posterior superior iliac spine. Total Colony-Forming Unit formations were significantly higher (28.84%) in the posterior compared to the anterior superior iliac spine. The quality of bone marrow concentrate was significantly higher with no significant difference between the different cites of extraction.

The expanding use of bone marrow aspirate in the field of regenerative medicine resulted in the increasing use of BMA and BMAC as a biological scaffold augmenting various orthopedic procedures, including shoulder arthroscopy. In 2013 Marx et al demonstrated the results of bone marrow aspirates of sixty patients in total. Twenty samples were obtained from the anterior ilium, 20 samples from the posterior ilium and 20 samples from the tibial plateau. The authors concluded that the ilium is preferable for harvesting multipotent stem cells compared to the tibia.⁷ In the same year, Hyer et al compared the quality of bone marrow samples obtained by three different harvest sites, anterior iliac crest, tibia and calcaneus. The number of total nucleated cells was significantly higher in the samples obtained from the ilac crest compared to the samples obtained from the distal tibia and the calcaneus.³ Pierini et al compared the quality of bone marrow samples obtained from the anterior and posterior iliac crest in 22 patients with a mean age of 37 years. The study demonstrated significantly higher levels of Colony Forming Units in the samples obtained from the posterior iliac crest compared to the anterior iliac crest.⁸ These results were consistent with our study.

The number of Colony Forming Units (CFUs) is increasing with increasing number of aspiration sites while age, BMI and medical comorbidities seem to affect CFUs yield.^9-10 Aspiration of small volumes is another way of avoiding blood dilution. However multiple- site aspiration requires more time to obtain the desired volume of bone marrow. Strong aspiration seems to increase the negative pressure needed for the higher concentration of MSCs whereas filling the syringe decreases the desired pressure for obtaining a high- quality aspiration sample.¹¹ In another study, higher quality samples were obtained by rapid aspiration compared to the slow- aspiration patient group.¹²

Several authors reported that a small volume of aspirated bone marrow is associated with a lower risk of blood dilution.¹³ Aspiration volume lower than 10ml is generally associated with an increasing number of MSCs and it may be obtained by single-site aspiration in multiple depths achieved by rotation of the syringe in use.¹⁴ As aspiration volume also depends on the volume of the aspiration site, it is essential to avoid vessels at the time of aspiration and in this way avoid dilution of the sample by the peripheral blood and decrease the number of MSCs.

Our study demonstrated an aspiration technique which allows the aspiration of small volumes from different depths of the same site after sequential rotation to avoid dilution and increase the quality of the obtained bone marrow samples. The purpose was to evaluate the levels of Total Nucleated Cells (TNC), Platelets (PLTs) and Colony Forming Units (CFU- Fs) in BMA compared to BMAC as well as compare the quantitative and qualitative characteristics of bone marrow samples obtained from three different anatomic sites, the anterior and posterior superior iliac spine and the proximal tibia using the same aspiration technique.

There are some studies that support that the proximal humerus is also suitable as a potential donor site for harvesting bone marrow.¹⁵ In our practice during shoulder arthroscopy, it was very difficult to obtain a clear sample of bone marrow because of the existence of a large volume of fluid and the absence of watertightness of the aspiration trocar during the procedure.

In conclusion, proximal tibia and the anterior and posterior superior iliac spine can be considered as reliable sources of bone marrow aspirate for use in biologic augmentation during arthroscopic treatment of rotator cuff tears. However, bone marrow aspirates from the posterior superior iliac spine yielded significantly higher colony-forming units and higher TNC levels than the anterior superior iliac spine and the tibia. Bone marrow concentrates yielded significantly higher TNC, and CFU-f levels compared to bone marrow aspirate samples obtained from all three anatomic sites.

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Figure 1: Bone marrow aspiration from the anterior superior iliac spine.

 

Figure 2: Bone marrow aspiration from the proximal tibia.

 

Figure 3: Bone marrow aspiration from the posterior superior iliac spine.

 

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References
1. Hernigou P, Flouzat Lachaniette CH, Delambre J, Zilber S, Duffiet P, Chevallier N, et al. Biologic augmentation of rotator cuff repair with mesenchymal stem cells during arthroscopy improves healing and prevents further tears: a case-controlled study. Int Orthop. 2014 Sep;38(9):1811-8.
2. Friedlis MF, Centeno CJ. Performing a Better Bone Marrow Aspiration. Phys Med Rehabil Clin N Am. 2016 Nov;27(4):919-939. doi: 10.1016/j.pmr.2016.06.009. PMID: 27788908.
3. Hyer CF, Berlet GC, Bussewitz BW, Hankins T, Ziegler HL, Philbin TM. Quantitative assessment of the yield of osteoblastic connective tissue progenitors in bone marrow aspirate from the iliac crest, tibia, and calcaneus. J Bone Joint Surg Am. 2013 Jul 17;95(14):1312-6. doi: 10.2106/JBJS.L.01529. PMID: 23864180.
4. Kuroda Y, Kitada M, Wakao S, Dezawa M. Bone marrow mesenchymal cells: how do they contribute to tissue repair and are they really stem cells? Arch Immunol Ther Exp (Warsz). 2011 Oct;59(5):369-78. doi: 10.1007/s00005-011-0139-9. Epub 2011 Jul 26. PMID: 21789625.
5. Otto A, Muench LN, Kia C, Baldino JB, Mehl J, Dyrna F, Voss A, McCarthy MB, Nazal MR, Martin SD, Mazzocca AD. Proximal Humerus and Ilium Are Reliable Sources of Bone Marrow Aspirates for Biologic Augmentation During Arthroscopic Surgery. Arthroscopy. 2020 Sep;36(9):2403-2411. doi: 10.1016/j.arthro.2020.06.009. Epub 2020 Jun 15. PMID: 32554079.
6. Roukis TS, Hyer CF, Philbin TM, Berlet GC, Lee TH. Complications associated with autogenous bone marrow aspirate harvest from the lower extremity: an observational cohort study. J Foot Ankle Surg. 2009 Nov-Dec;48(6):668-71. doi: 10.1053/j.jfas.2009.07.016. Epub 2009 Aug 26. PMID: 19857823.
7. Marx RE, Tursun R. A qualitative and quantitative analysis of autologous human multipotent adult stem cells derived from three anatomic areas by marrow aspiration: tibia, anterior ilium, and posterior ilium. Int J Oral Maxillofac Implants. 2013 Sep-Oct;28(5):e290-4. doi: 10.11607/jomi.te10. PMID: 24066346.
8. Pierini M, Di Bella C, Dozza B, Frisoni T, Martella E, Bellotti C, Remondini D, Lucarelli E, Giannini S, Donati D. The posterior iliac crest outperforms the anterior iliac crest when obtaining mesenchymal stem cells from bone marrow. J Bone Joint Surg Am. 2013 Jun 19;95(12):1101-7. doi: 10.2106/JBJS.L.00429. PMID: 23783207.
9. LaPrade RF, Murray IR. Editorial Commentary: Bone Marrow Aspirate Concentrate: Time to Harvest Locally? Arthroscopy. 2020 Sep;36(9):2412-2414. doi: 10.1016/j.arthro.2020.07.015. PMID: 32891243.
10. Li H, Ghazanfari R, Zacharaki D, Lim HC, Scheding S. Isolation and characterization of primary bone marrow mesenchymal stromal cells. Ann N Y Acad Sci. 2016;1370(1):109-18. doi: 10.1111/nyas.13102. PMID: 27270495.
11. Hernigou P, Homma Y, Flouzat Lachaniette CH, Poignard A, Allain J, Chevallier N, Rouard H. Benefits of small volume and small syringe for bone marrow aspirations of mesenchymal stem cells. Int Orthop. 2013 Nov;37(11):2279-87. doi: 10.1007/s00264-013-2017-z. Epub 2013 Jul 24. PMID: 23881064; PMCID: PMC3824897.
12. Grønkjær M, Hasselgren CF, Østergaard AS, Johansen P, Korup J, Bøgsted M, Bilgrau AE, Jensen P. Bone Marrow Aspiration: A Randomized Controlled Trial Assessing the Quality of Bone Marrow Specimens Using Slow and Rapid Aspiration Techniques and Evaluating Pain Intensity. Acta Haematol. 2016;135(2):81-7. doi: 10.1159/000438480. Epub 2015 Oct 28. PMID: 26505268.
13. Fennema EM, Renard AJ, Leusink A, van Blitterswijk CA, de Boer J. The effect of bone marrow aspiration strategy on the yield and quality of human mesenchymal stem cells. Acta Orthop. 2009 Oct;80(5):618-21. doi: 10.3109/17453670903278241. PMID: 19916699; PMCID: PMC2823327.
14. Oliver K, Awan T, Bayes M. Single- Versus Multiple-Site Harvesting Techniques for Bone Marrow Concentrate: Evaluation of Aspirate Quality and Pain. Orthop J Sports Med. 2017 Aug 29;5(8):2325967117724398. doi: 10.1177/2325967117724398. PMID: 28890905; PMCID: PMC5580846.
15. Muench LN, Kia C, Otto A, Mehl J, Baldino JB, Cote MP, McCarthy MB, Beitzel K, Mazzocca AD. The effect of a single consecutive volume aspiration on concentrated bone marrow from the proximal humerus for clinical application. BMC Musculoskelet Disord. 2019 Nov 14;20(1):543. doi: 10.1186/s12891-019-2924-2. PMID: 31727036; PMCID: PMC6857344.

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¹ Associate Professor; Department of Orthopaedics, PGIMER, Chandigarh, India
² Sporthopaedicum Regensburg/Straubing, Germany
³ Department of Trauma Surgery, University Hospital Regensburg, Germany

Shoulder arthroplasty has emerged as a gold standard for various indications including advanced osteoarthritis and rotator cuff arthropathy of the shoulder joint. Although the results have been generally good, yet there is always a scope for improvement. Proper glenoid positioning is considered an essential element for achieving long-term success in shoulder arthroplasty. Conventional methods of using plain radiographs or two-dimensional CT scan frequently result in misinterpretation of inclination and glenoid version as compared to three-dimensional CT scans¹. Although the intention of a surgeon is never to land up in a complication, stakes are higher when "quality of life enhancing" surgery is performed as compared to a "life-saving" procedure, and shoulder arthroplasty if done in non-traumatic conditions generally belongs to the former category. Nothing can be left to chance, not least with improper glenoid placement, especially in cases with pre-existing glenoid deformity or bone loss.

We are currently in the age of advanced technology and the influence of "augmented reality" can be seen in every aspect of our life and the field of shoulder arthroplasty is no exception to it. One recent trend in the last few years to improve glenoid placement is the use of preoperative planning software (PPS). This commentary is an attempt to introduce the readers to the recent trend of the use of PPS, its advantages and disadvantages, and some commercially available PPS.

Multiple commercial and non-commercial groups have reported the use of computer planning software to simulate glenoid implantation^2-4. These preoperative planning softwares have demonstrated improvement in both bone models and actual surgical procedures ^2,3. Iannotti et al³ reported in a randomized controlled trial of 46 patients that they could place the glenoid component within 5 degrees of desired inclination and 10 degrees of desired version with three-dimensional templating and computer planning when compared to standard techniques. Venne et al⁵ in a cadaveric lab study also reported that computer planning and navigation improved the accuracy and precision of screw placement and higher precision of baseplate placement. Although these studies hint towards increased accuracy, until now there are no published reports of improvement in patient-reported outcomes or long-term survivorship of implants as these softwares are in the stage of "recent advancements".

It needs to be emphasized, especially for the new shoulder arthroplasty surgeons, that these softwares do not replace the need to have an "in-depth" understanding of the shoulder anatomy and its variations. The surgeon must be fully aware of the traditional preoperative planning which involves the standard AP view (Grashey view), scapular Y view and axillary view along with the assessment of two-dimensional and three-dimensional CT cuts especially when there is altered glenoid anatomy. It is equally relevant to understand how conventional two-dimensional measurements, three-dimensional measurements, and software measurements are correlated to each other.

For glenoid inclination in reverse shoulder arthroplasty, the typical guidelines recommend neutral tilt. However, this estimate is based on the implant positioning in AP radiograph which accounts for both scapulothoracic and glenohumeral positioning. In software planning, the scapulothoracic joint position is difficult to be accounted and further research is awaited to determine the method of including scapulothoracic positioning in inclination of glenoid baseplate. (Fig. 1) So, the surgeon should have an orientation of glenoid inclination in a normal radiograph before he jumps to the software-directed positioning so that he can improvise intraoperatively in case the predetermined positioning appears to be incorrect.

Higher retroversion also leads to early failure in shoulder arthroplasty. However, there is always a lack of complete agreement between the two-dimensional, three-dimensional, and software generated measurement in glenoid version. Budge et al⁶ did a comparison of two-dimensional and three-dimensional methods and reported that in 50% of cases, there was a difference of 5-15 degrees in version. Erickson et al⁷ also demonstrated significant difference in both version and inclination in the preoperative planning between CT scan and software-based methods. The difference may arise because there is no fixed and standardized CT scan protocol for measurement of anteroposterior location for inclination measurement or superior-inferior location for version measurement⁸.

And to make matters complicated, there are also disagreements within the various software-based methods. Currently, we are spoiled for choices as several companies are available for preoperative planning for shoulder arthroplasty. Each system is slightly different based on the reference of the position of the guide. The commonly used software systems include Virtual Implant positioning VIP (Arthrex, Naples, FL, USA), Blueprint (Wright Medical, Memphis, TN, USA), GPS (Exactech, Gainesville, FL, USA) and Materialise (DJO, Vista, CA, USA). VIP, Materialise, and GPS use anatomical landmarks to determine the plane of the scapula to determine the position of maximum coverage (Fig. 2) while Blueprint uses an average plane of the scapula and the best-fit sphere method. It is yet unknown, which method is better to approximate the true anatomy and provides better practise of glenoid placement.

Erickson et al⁷ analyzed 81 preoperative CT scans by using these four software systems and five fellowship-trained shoulder surgeons and compared the preoperative planning for version and inclination. The authors reported that software methods produced more inclination and more retroversion. Also, there were variations within the software groups. VIP and Blueprint overestimated inclination by 2 degrees and GPS underestimated inclination by 2 degrees. Denard et al¹ also evaluated the differences in inclination and version between two commonly used PPS systems (VIP and Blueprint). The authors reported a difference of 5 or more degrees in inclination and version in 46% and 30% of cases. Intra-group variations between the software planning methods may arise as some systems are "semiautomated" and rely on manual input of the standard anatomic landmarks while other systems could be fully automated volume-based systems¹.

The number of shoulder arthroplasties is expected to increase in the future. We endeavour to maximize patient satisfaction and clinical outcome and minimize complications. 3D CT scan is currently the gold standard for the assessment patient’s glenoid anatomy and planning for glenoid placement in shoulder arthroplasty. The use of preoperative planning software is on the rise amongst shoulder surgeons to improve the understanding of the complexity of the anatomy and glenoid placement. But surely, it goes without saying that these softwares are best used for augmentation and not a replacement for surgeon's thoughts and understanding. Grady Booch once famously said "A fool with a tool is still a fool". We don't contradict the statement but "A wise man with a gadget will find himself in the higher bracket" also makes sense. In essence, a sound surgeon can benefit from such advancements yet in adversity, should trust his judgment while the average one can still make mistakes.

Cost-benefit effectiveness has always been a roadblock for recent advances and we leave it to the future to see how titration between the "additional costs" and "improved longevity" affects to acceptance of PPS, but one thing is sure, and we are threading into the right direction.

Figure 1: A representative figure taken from VIP (Virtual implant positioning) software determining the native (3⁰) and implant (0) inclination and native (-1⁰) and implant version (0).

Figure 2A

Figure 2B

Figure 2: A representative figure demonstrating 100% coverage of the glenoid implant over the native glenoid as well as the provisional screw trajectory (2B)

Affiliation: St. Luke's Hospital Bielsko-Biała, ul. Bystrzańska 94B, 43-309 Bielsko-Biała, Poland

The shoulder arthritis among young (<50 years old) and active patients presents a challenging entity, that possesses unique and gradually more often encountered dilemma for orthopedic surgeons. The reason for this is questionable total arthroplasty implant longevity that remains a concern in more active patients and is a potential threat of reoperation and lifestyle impairment [1].

Omarthrosis as described by Samilson & Prieto is classified into 3 stages depending on humeral head and glenoid osteophyte size as well as joint space narrowing seen on plain radiographs. The well-known classification however does not necessarily correlate with patient’s symptoms such as pain or range of motion limitation which should be surgeons main focus and according to which the treatment option should be chosen [2]. Furthermore, it is also known that among the young the pathogenesis standing behind arthritic changes is much more complex and encompasses such conditions as avascular osteonecrosis, post-traumatic changes or rheumatoid spectrum diseases and this fact may also play role in decision algorithm. Classic degenerative omarthrosis is seen occasionally specifically among heavy weight lifters or manual laborers.

There are multiple non-operative treatment options, that should be gradually applied based on severity of symptoms as to prolong time to more invasive steps. First, physiotherapy as well as kinesiotherapy optimally tailored to patient should find its place. Progressive self-exercise as well as manual therapy with shoulder girdle muscle strengthening and stretching have shown to improve function in a variety of shoulder disorders. Simultaneous oral drugs application, such as Acetaminophen 1g every 3-4 times a day or if non tolerated NSAIDs (Non Steroidal AntiInflammatory Drugs) decrease pain and ease rehabilitation protocol allowing for greater joint mobility in comparison to placebo [2].

If the treatment fails to bring sufficient effect and the patient becomes eventually symptomatic, intraarticular US (UltraSound) guided or blind injections are suggested with comparable results [3]. Despite what has just been said, there is certain controversy about such injections and up to date there are no clear indications on what exactly to inject and which dose to choose. Among available medications, steroids placed into subacromial bursa are best studied, giving improvement in pain management and overall joint function in 12 weeks follow up with risk however to induce partial rotator cuff tears progression into full thickness tears [2].

High molecular weight viscosupplementation is a viable modality as suggested by the AAOS (American Academy of Orthopedic Surgeons) guidelines proving to be successful in pain relief even up to 6 months post injection. They are best known for being safe, generally well-tolerated and most effective in isolated omarthrosis but it is unknown if presence of concomitant intraarticular comorbidities impair the pain-reduction effect [3]. Little evidence is available concerning usage of PRP (Platelet Rich Plasma) or mesenchymal stem cells as non the ideal concentration nor most suitable laboratory kit is known. The authors agree however that PRP application is generally safe and brings scarcely any adverse effects.

Along with joint stiffness and general arthritic progression (Fig. 1) operative treatment comes into play. As originally described by Millett et al. CAM procedure (Comprehensive Arthroscopic Management) is considered [4]. It comprises several procedures that aim to address pain generators in the joint and serves as a bridging treatment before TSA (Total Shoulder Arthroplasty). During the operation a biceps tenodesis, axillary nerve decompression, osteophyte resection (Fig. 2,3) with capsulotomy (Fig. 4,5) and chondral debridement are the key steps. According to the authors careful patient selection with joint space narrowing more than 2 mm, flattening of the humeral head and abnormal posterior glenoid anatomy being failure predictors, the procedure brings favorable clinical outcomes in 92% individuals after 1 year follow up and 63% at 10 year follow up respectively. In addition, CAM procedure does not impact subsequent TSA results if such is undertaken [5].

Some success in delaying the need of TSA has been reported with the use of allograft arthroplasty, which originally intends to separate glenoid from the humeral head adopting anterior capsule, fascia lata, Achilles tendon, lateral meniscus or dermal graft acting as interposition tissues. The durability of such constructs is however questionable. [3]

Apart from palliative approach, there is a group of procedures that aim to repair or restore chondral surfaces inside the joint. To such belong micro fracture technique along with chondral abrasion and drilling on one hand, and ACI (Autologous Chondrocyte Implantation) and OAT (Osteochondral Autograft Transfer) on the other. Reparative methods have shown to be most suitable for small chondral humeral head lesions with fibrin clot based scar tissue formation whereas restorative strategy intends to induce hyaline-like cartilage formation. Best known from good results in the knee joint treatment, the efficacy of such concepts in shoulder joint remains to be further studied. Failure in restoring the joint does not preclude TSA.

If all fails, taking into consideration that TSA in younger patients brings poorer satisfaction score [6], the first line of treatment should be anatomic shoulder arthroplasty which shows higher return to sports and prior activity level rate than hemiarthroplasty or RSA (Reverse Shoulder Arthroplasty).

What future will show remains a mystery but the studies designed through next years should focus around TSA technique and implants improvement to achieve maximal longevity and minimal risk of reoperation, which among the young presents as the ultimate challenge.

Figure 1: Osteoarthrosis of the glenohumeral joint
HH - humeral head
G - glenoid

Figure 2: Inferior osteophyte of the humeral head
IC - inferior capsule
IO - inferior osteophyte of the humeral head

Figure 3: Resection of the inferior osteophyte of the humeral head with the burr
IC - inferior capsule
IO - inferior osteophyte of the humeral head

Figure 4: Anterior capsulotomy of the glenohumeral joint
AL - anterior labrum
SSC - supscapularis muscle
HH - humeral head

Figure 5: Posterior capsulotomy of the glenohumeral joint
PL - posterior labrum
PC - posterior capsule
HH - humeral head

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References
[1] Brockmeier SF, Werner BC. Shoulder Arthritis in the Young and Active Patient. Clin Sports Med. 2018 Oct;37(4):xiii-xiv. doi: 10.1016/j.csm.2018.07.001. PMID: 30201176.
[2] Takamura KM, Chen JB, Petrigliano FA. Nonarthroplasty Options for the Athlete or Active Individual with Shoulder Osteoarthritis. Clin Sports Med. 2018 Oct;37(4):517-526. doi: 10.1016/j.csm.2018.05.003. PMID: 30201166.
[3] Jong BY, Goel DP. Biologic Options for Glenohumeral Arthritis. Clin Sports Med. 2018 Oct;37(4):537-548. doi: 10.1016/j.csm.2018.06.001. Epub 2018 Aug 3. PMID: 30201168.
[4] Arner JW, Ruzbarsky JJ, Millett PJ. Comprehensive Arthroscopic Management of Shoulder Arthritis. Arthroscopy. 2022 Apr;38(4):1035-1036. doi: 10.1016/j.arthro.2022.01.033. PMID: 35369910.
[5] Schiffman CJ, Whitson AJ, Chawla SS, Matsen FA 3rd, Hsu JE. Arthroscopic management of glenohumeral arthritis in the young patient does not negatively impact the outcome of subsequent anatomic shoulder arthroplasty. Int Orthop. 2021 Aug;45(8):2071-2079. doi: 10.1007/s00264-021-05133-y. Epub 2021 Jul 13. PMID: 34255098.
[6] Christensen J, Brockmeier S. Total Shoulder Arthroplasty in the Athlete and Active Individual. Clin Sports Med. 2018 Oct;37(4):549-558. doi: 10.1016/j.csm.2018.05.005. PMID: 30201169.

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¹ 401 Military Hospital of Athens, Athens, Greece
² Bioclinic of Athens, Athens, Greece
³ D Group Educational Center, Athens, Greece

Virtual Reality is a technology developed mainly by the video games industry. With the aid of special equipment, the user can isolate himself from the real environment and get into a "virtual" world, living an unprecedented experience.

Gradually the medical community, realizing the advantages of this new technology, started to develop applications for the training of young doctors. Orthopedics is one of the medical specialties that virtual reality tools can contribute substantially to the training of surgeons.

However, there are still questions to be answered:

• What is the level of this technology nowadays, and how can we use it?
• What is the effectiveness of these simulators in orthopedic training?

Traditional training methods in Orthopedic specialty

1. The primary training method of a resident is in the operating room during live surgery. Of course, it is the most realistic way of training, where the resident can operate under the supervision of an experienced surgeon with all the difficulties and tips and tricks that might come up. Nevertheless, this way of training creates much stress for both the trainer and the trainee and raises many ethical and safety issues for the patient.

2. Training in sawbones is another typical method. However, their availability is a law, their cost is high, and they do not offer actual operative room conditions.

3. Wet labs and training on cadavers are one more popular training methods in Orthopedics. Young surgeons compete to participate in numerous courses around the world. However, still, the availability of corpses remains low. Too often, they are characterized by poor quality, and trainees can practice only once while there are two or more over a specimen. To all the above, we must also add the high cost, the ethical issues, and the possibility of disease transmission.

Virtual Reality as a training method

Using virtual reality technology can avoid many of the above disadvantages, and the patient's safety is secured. The surgeon can perform an operation with or without guidance, without time or place limitations, quantify his results, and see his improvement. He can also repeat a procedure as often as he wants, choose between different scenarios with varying degrees of difficulty and teach himself without cost to the patient. Even experienced surgeons may prepare themselves before a high-demand, rare operation. Finally, the software offers the opportunity to cooperate with multiple surgeons worldwide.

Virtual Reality orthopedic training in literature

Many studies have been published on virtual reality methods for specific orthopedic surgical training.

In total hip arthroplasty, virtual Reality did not affect medical knowledge but significantly improved surgical skills, according to J. Hooper, E. Tsiridis, et al.³

In cervical pedicle screw placement during virtual reality training, the screws were in a good position in 100% of cases, and penetration of the pedicle wall was 10%. In cadavers, the percentages were 62,5% and 50%, respectively⁴. Likewise, Gasco et al.² demonstrated that even one virtual reality system could reduce the mistakes by 53% in lumbar pedicle screw placement.

In addition, the basic arthroscopic skills and autonomy of the residents seem to get improved after the training in 3D virtual environment⁶. However, most of the published studies are referred to arthroscopy training.

Finally, Clarke et al.¹, in a review of 2021, included 16 studies with a total of 431 trainees with virtual reality systems and measured 47 outcomes. They conclude that virtual Reality presents an immersive new simulation technology improving the users' technical skills exponentially. However, more studies are needed to prove the positive effects of this new tool in orthopedic surgery training.

Virtual Reality orthopedic training in Shoulder Surgery

D. Goel and G. Athwal from Canada reported up to a 570% decrease in the glenoid approach learning time when the trainee had used the software 3 to 5 times. In addition, the technical and nontechnical skills of participants were improved by 387% ⁵ (Figure 1)

Figure 1: Glenoid approach using virtual reality software

In Greece, our team carried out our first virtual reality course where the participants had the opportunity to train in reverse shoulder arthroplasty. Five young surgeons with no more than 3 years experience and eight residents (2^nd to 6 ^th year) trained for 4-5 hours each (Figure 2, 3). Furthermore, 54% of them were somewhat familiar with the shoulder surgical approaches, 55% were not or not very familiar with RSA and 75% of them has never been a primary surgeon. Regarding the VR experience, 76,9% never used a headset generally and none for surgery training.

Figure 2: Training of a young resident in the anatomy of the shoulder

Figure 3: Training of a young surgeon in placement of the reverse shoulder arthroplasty

The mean adaptation time of the participants in the virtual environment was 2-3 minutes. They all characterized their experience as immersive, and it was easy for them to understand the anatomy and the procedure. Finally, after assessing the metrics, 100% placed the first glenoid guide in a proper position after a mean of 4.1 attempts (Figure 4).

Figure 4: Baseplate placement assessment

After the training program approximately 70% of the participants felt certain for several technical steps to perform correctly an RSA and 80% to convince a consultant shoulder surgeon that they were competent if viewed. However, none of them felt extremely confident to completely perform an RSA as primary surgeon.

In conclusion, virtual reality systems may not develop alone a complete surgeon. Moreover, drawbacks like high cost, low availability and the lack of haptic feedback to recreate the sense of touch or motion restrict VR systems from broad use. However, it can be an immersive, safe, and reliable adjunct to a comprehensive education program focused on improving patient care.

The CEO of the VR software that we used (Precision OS) states:

"Surgical education is ready for disruptive technology to enhance skill acquisition while connecting surgeons to each other with no patient harm. As we continue to use virtual Reality in education, expertise will increase, and patient care will improve worldwide." (Figure 5)

Figure 5: Simultaneous training of multiple surgeons in a virtual environment

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Biography
1. Clarke E. Virtual reality simulation-the future of orthopaedic training? A systematic review and narrative analysis. Adv Simul (Lond). 2021 Jan 13;6(1):2. doi:10.1186/s41077-020-00153-x
2. Gasco J, Patel A, Ortega-Barnett J, Branch D, Desai S, Kuo YF, et al. Virtual reality spine surgery simulation: an empirical study of its usefulness. Neurol Res. 2014 Nov;36(11):968–973. doi:10.1179/1743132814Y.0000000388
3. Hooper J, Tsiridis E, Feng JE, Schwarzkopf R, Waren D, Long WJ, et al. Virtual Reality Simulation Facilitates Resident Training in Total Hip Arthroplasty: A Randomized Controlled Trial. J Arthroplasty. 2019 Oct;34(10):2278–2283. doi:10.1016/j.arth.2019.04.002
4. Hou Y, Shi J, Lin Y, Chen H, Yuan W. Virtual surgery simulation versus traditional approaches in the training of residents in cervical pedicle screw placement. Arch Orthop Trauma Surg. 2018 Jun;138(6):777–782. doi:10.1007/s00402-018-2906-0
5. Lohre R, Bois AJ, Athwal GS, Goel DP, Canadian Shoulder and Elbow Society (CSES). Improved Complex Skill Acquisition by Immersive Virtual Reality Training: A Randomized Controlled Trial. J Bone Joint Surg Am. 2020 Mar 18;102(6):e26. doi:10.2106/JBJS.19.00982
6. Walbron P, Common H, Thomazeau H, Hosseini K, Peduzzi L, Bulaid Y, Sirveaux F. Virtual Reality simulator improves the acquisition of basic arthroscopy skills in first-year orthopedic surgery residents. Orthop Traumatol Surg Res. 2020 Jun;106(4):717-724. doi:10.1016/j.otsr.2020.03.009.

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*Orthopaedic Surgeon, 3rd Orthopaedic Department, Hygeia General Hospital, Athens - Greece

Correspondence to: 2 Str. Alkionis, 175 61 Palaio Faliro, Athens, Greece
Mobile: +30 6973717069 - E-mail: Emmanuel.Brilakis@gmail.com

Introduction

Every surgeon should provide state-of-the-art care to his/her patients by using his/her medical and surgical skills. Nowadays, technology has brought vast and explosive development, critically affecting the field of surgery. New technologies are an essential weapon to the armamentarium of every modern surgeon who can use them to enhance his/her surgical skill and improve the offered care.

Shoulder arthroscopy has evolved at a very high speed in the last decades. It was just the era of the 1980s and 1990s when Dr Charles Rockwood was calling the arthroscope “the instrument of the devil”. However, nowadays, arthroscopic surgery is mainstream in shoulder surgery. During that period, many new technologies emerged, aiming to facilitate the surgeon’s life and the patients’ care, with the hidden lust of the industry to establish a new paradigm and shift the existing standards and raise the profits.

One of these inventions in the last few years is the mini arthroscope. Several commercial companies have evolved such devices, and their aim is the transfer of arthroscopy from the operation room into the orthopaedic surgeon’s office. Even if this ambitious change looks pretty feasible and logical, it has not to be applied as a routine in-office procedure. It may be one of the next steps in the evolution of this innovation. But first, we must consider the principles concerning using these mini devices.

Differences with conventional arthroscopic systems

A mini arthroscope has a diameter smaller than 2mm, which is half the size when compared to the standard arthroscope diameter (4mm). The sheath used to introduce this device through a portal is also smaller compared to the conventional sheath (2.2 vs 5.9, respectively). The mini arthroscope is a 0 degrees arthroscope, while the conventional arthroscope is a 30 degrees arthroscope. Appropriate instrumentation (shaver, cautery devices, surgical instruments) and small cannulas have also been developed to support the concept of mini arthroscopy. However, the fluid management is also different, apart from the smaller size of the mini scope and the rest of the instrumentation (Picture 1). The saline is inserted in the shoulder joint or the subacromial space through a syringe and the amount of the fluid inserted is significantly less than the conventional arthroscopy. All these differences indicate that the use of this new system should also be different.

Picture 1: Trocar insertion. A 3way catheter is adjusted to control the fluid needed for the proper visualisation. The image’s resolution is low quality, but it reflects the actual resolution that you usually obtain with these devices.

In conventional arthroscopy, the portals used have been standardised. However, the mini scope system is more flexible. Using a spinal needle, the viewing portal can be changed as many times as needed to visualise the region of interest in the most convenient way (Picture 2). This is a new and revolutionary way to observe and treat shoulder lesions, but familiarity with the mini scope is needed. A new routine is required for one more reason, the cost. The thinner device is more vulnerable to breaking if the surgeon bends it excessively. Thus, many different portals are needed to retain this single-use device’s gentle use.

Picture 2: Defining the more convenient anterosuperior portal placement under direct visualisation through the posterior portal using a spinal needle. The image’s resolution is low quality, but it reflects the actual resolution that you usually obtain with these devices.

Anaesthesia and setting needed

Two matters should be defined to broaden the use of these devices. Anaesthesia is the first. A diagnostic arthroscopy is feasible to be performed under local anaesthesia. However, general anaesthesia may be needed if therapeutic manoeuvres are performed. The time required is the main parameter that will define the need and the type of anaesthesia (general or local). The second is the setting where the arthroscopy should be performed. Currently, the OR is the environment that ensures the proper conditions for the surgeon and the optimal safety for the patient. The transition from the OR to the office should be done after providing the aseptic environment needed and the number of the staff (surgeon, assistant, nurses) that should be available for such a procedure.

Considering the minimality of this intervention, the little complexity of the device and the continuous medical and technological improvement, all those mentioned above seem to be not a big issue. The proposed solutions are beyond the scope of this article, which just aims to highlight the value of this new technology.

Indications

The minimally invasive experience and the atraumatic access to the shoulder joint and the subacromial space offer an alternative tool for diagnostic and therapeutic procedures. The indications of this innovative device are evolving continuously. The current indications of the mini arthroscopy system can be separated into (a) the use of a mini arthroscope for office use, which is a diagnostic tool, and (b) the use of mini arthroscope for second-look arthroscopy and mini procedures, and are the followings:

• This device is an alternative to Magnetic Resonance (MR) Imaging, and practically its morbidity is equivalent to MR Arthrogram (Picture 3). It can be used alternatively in patients suffering from claustrophobia and patients with a pacemaker.
• This is a precise and reliable option for a minimal invasive second-look arthroscopy, providing images and details more familiar to arthroscopic surgeons. The image’s resolution is currently low quality but adequate to help the surgeon recognise the intraarticular and the subacromial structures.
• It can be used in combination with standard arthroscope providing simultaneous viewing of the intraarticular and subacromial space, augmenting the traditional arthroscopy instrumentation offering alternative visualisation
• It can offer a precise and direct way to the shoulder injections because of the image-guided visualisation of the injection site
• Minor procedures such as biceps tenotomy can be performed under the visualisation of this device (Picture 4). The experience curve of the surgeon may increase what is considered minor as far as the time, and the morbidity is concerned.
• It can replace the standard arthroscopy when the small joints of the shoulder girdle (AC joint and SC joint) are considered.

Picture 3: Viewing the long head of the biceps through an anterosuperior cuff tear. The image’s resolution is low quality, but it reflects the actual resolution that you usually obtain with these devices.

Picture 4: Tenotomy of the long head of the biceps with the scalpel under direct visualisation. The image’s resolution is low quality, but it reflects the actual resolution that you usually obtain with these devices.

Outcomes

Searching the literature, these devices can offer a safe and effective real-time, minimally invasive alternative diagnostic tool for arthroscopy with efficacy, sensitivity, and specificity to evaluate intra-articular pathology. They can minimise the need for surgical, diagnostic arthroscopy or high-cost imaging [1]. The risk of major or minor complications is minimal [2]. These devices offer a very accurate diagnosis and more detailed and accurate diagnostic assessment of intra-articular pathology than MRI [3]. However, even if all the authors state the above, they underline that the mini arthroscopes cannot be used as a routine in-office procedure.

Second look arthroscopy

Second look arthroscopy has been used many times in literature to evaluate the surgical outcome or the tissue healing (Pictures 5 and 6). Many exciting and impressive images have been published in the literature to support the research and prove the studies’ hypotheses. This device offers an easy and reliable way to check the anatomy restoration, tissue healing, concomitant pathology, and a possible recurrence. This is a safe way to directly examine the surgical outcome with very high reliability and can revolutionise the patient’s rehabilitation by using the data about the healing provided. Based on these data that we did not have available in the past, the guidance of the physiotherapist can be more objective and individualised at the maximum level.

Picture 5: Evaluating the healing of the anteroinferior labrum repair. The bumper restoration and the sutures used are depicted. The healing of subscapularis tenodesis on the anterior labrum is also depicted. The image’s resolution is low quality, but it reflects the actual resolution that you usually obtain with these devices.

Picture 6: Evaluating the healing of subscapularis tenodesis on the anterior labrum. The image’s resolution is low quality, but it reflects the actual resolution that you usually obtain with these devices.

Advantages

The pros of the mini arthroscope devices are constantly evolving. The limited-time of general anaesthesia or the use of local anaesthesia and the no need for scalpel and narcotic medication are the main advantages. This can be used in patients with medical conditions lowering the need to undergo an operation under general anaesthesia. In addition, this minimally invasive device results in less scar tissue formation and less fluid diffusion. The reduced OR time, the need for fewer bags and special attire and the fast turnover between operations can also be considered advantages of those devices. Eventually, the patient’s satisfaction is high.

Disadvantages

This procedure’s cost is a significant disadvantage because this is a disposable device. Insurance coverage is problematic, like every innovative device, until it finds its place in the patient’s care. Eventually, the learning curve is new and different from the respective that conventional arthroscopic procedures need, and shoulder surgeons should be aware of it.

Epilogue

Mini arthroscopes and instrumentation are new technologies that seem to open new shoulder arthroscopy aspects that were never appreciated. However, before moving to the in-office use of these devices, we should be familiar with its principles. Smaller camera size and weight allow for an even more minimally invasive approach than the respective of the standard arthroscopy. The decreased use of arthroscopic fluid is also notable. Differences in the technology, such as a 0° optic and less rigid instrumentation, necessitate the surgeon to modify his/her technique for a diagnostic arthroscopy and therapeutic manoeuvres. The selection of patients is critical, and these devices should not be used on anxious patients. Surgeons should take into consideration that these instruments require previous experience in conventional arthroscopy, but the principles of use are different.

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References
1. Gill TJ, Safran M, Mandelbaum B, Huber B, Gambardella R, Xerogeanes J. A Prospective, Blinded, Multicenter Clinical Trial to Compare the Efficacy, Accuracy, and Safety of In-Office Diagnostic Arthroscopy with Magnetic Resonance Imaging and Surgical Diagnostic Arthroscopy. Arthroscopy. 2018;34(8):2429-2435. doi:10.1016/j.arthro.2018.03.010
2. McMillan S, Chhabra A, Hassebrock JD, Ford E, Amin NH. Risks and Complications Associated with Intra-articular Arthroscopy of the Knee and Shoulder in an Office Setting. Orthop J Sports Med. 2019;7(9):2325967119869846. Published 2019 Sep 27. doi:10.1177/2325967119869846
3. Deirmengian CA, Dines JS, Vernace JV, Schwartz MS, Creighton RA, Gladstone JN. Use of a Small-Bore Needle Arthroscope to Diagnose Intra-Articular Knee Pathology: Comparison with Magnetic Resonance Imaging. Am J Orthop (Belle Mead NJ). 2018;47(2):10.12788/ajo.2018.0007. doi:10.12788/ajo.2018.0007

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ORTHOS clinic, Sarajevo Bosnia and Herzegovina

Introduction

A smart person learns from his mistakes, but a truly wise person learns from the mistakes of others. From time to time, it is very useful to take a deep breath and dive into and explore literature. As surgeons we have to ask ourselves: “On what evidence do we base our knowledge, how do we make our decision and what is used to support our decisions?”

Randomized controlled trials (RCTs) are the foundation of our decision making, or at least they should be. But, is that really the truth, because only 3%-9% of all publication in peer reviewed journals are RCTs 1 This would imply, that case studies, case controlled studies, and observational studies are still dominant in our literature.

Going further, what about qualities of published RCTs? There is a significant amount of evidence to support the statement that RCTs are not executed and reported optimally in peer reviewed literature¹. Therefore, tools that help authors in conducting and importantly reporting RCTs were developed over time. In the 1990s, and international group of scientists developed a CONSORT statement (CONsolidated Standards of Reporting Trials)². The recommendation was updated in 2010 and represent the set of recommendation formulated in the form of a Check list for authors³. A different group of authors⁸ developed CLEAR recommendation for non-pharmacological trials (NPT) that also ask authors to supply essential information. Jadad score⁹ is also used with the aim to assess the quality of the report. It was criticized by some for oversimplification of the process but still it was included as analytic tool of systematic reviews.

Our aim was to look for systemic reviews and to identify:

• what type of outcome measures are used in publication in shoulder surgery?
• what is the quality of reporting in shoulder instability surgery
• what is the quality of reporting in shoulder cuff surgery

Outcome measures:

In clinical practice, we routinely use tests on pain, range of motion and strength. The same tests are used to report in trials, but more importantly, additional objective outcome measures, Patient Related Outcome Measures (PROMs), are developed. Usage of various types of outcome measures makes comparison among surgeons about level of care very difficult¹⁵. Some authors like Hawkins R el al. recommend a different set of outcome measures used in daily clinical practice and more robust PROMs for research purposes.

According to Ashton ML et al., more than 25 different scoring systems are used in various types of shoulder surgery research. In their systematic review, the focus was to identify mostly used outcome measures and to identify demographic variables related to use of identified scores. Literature from 180 studies was included in the research. A cut off value of at least 10% was established for PROM to be included in analysis. They found 5 scores that used most frequently in publications up to October 2019. It is important to note that authors did not limit research to randomised trials.

Here are five PROMs mostly used according to their findings:

There is a relation between geographical region where first author of the study is based and the type of PROM. CMS is strongly related to European authors. That has historical background and the fact that most of European journals endorse usage of CMS. On the other hand, almost 75% of American authors use ASES because it is recommended by the committee of the American Shoulder and Elbow Surgeons.

Vrotsou et al. suggest another way to look into this. They look for psychometric properties of PROMs. CMS is advisable to use in subacromial pathology. For other conditions data is inconclusive but authors suggest that score has the capacity to detect changes. On the other hand, ASES, according to the American Shoulder and Elbow Surgeons Value Committee, is “the best available joint specific outcome measurement to be used for shoulder assessment.”¹⁴ The ASES is the most valid and reliable outcome measurement for discriminating among patients’ or groups’ evaluations at one point in time as Schmidt S. et al. suggested. However, to this point, ASES did not become the golden standard in reporting on shoulder pathology.

Further research on applicability of the CMS for generalized shoulder pathology versus only acromioclavicular or subacromial pathology is warranted, given its widespread usage in evaluating the shoulder. It is worth mentioning that CMS is not considered as truly PROM because it includes clinical input to measure strength.

SSV was the second most widely used outcome measurement with 48.3%¹⁵. This is due to ease of use of this tool. This PROM is designed to reflect the view of the patient with a shoulder problem⁶.

Simple Shoulder Test (SST) is PROM that is mostly used in RCTs (> 50% of RCTs use SST). It is a practical, standardized easy to execute tool that is understandable to patients and to researchers. It is recommended in trials where reproducibility is priorty⁵. The drawback of this score is the tendency to have larger confidence intervals compared to other scores such as ASES.

Relation of PROM to type of surgery: ASES and DASH associated to surgery relates to degenerative changes including cuff pathology. On the other hand, instability groups use Rowe and WOSI (Western Ontario Shoulder Index).

SSV, ASES and DASH are significantly related to shoulder trauma surgery.

Angst et al. recommended usage of following scores based on their research:

Minimally Important Difference (MIDs) of PROMs

Another aspect of this issue is interpretation of scores. Minimally Important Difference is defined as the smallest change in score, positive or negative, that the patient perceives as important⁷. MIDs significance is de facto to estimate treatment effect whether if it trivial, small, moderate or large. Often times statistical significance is not clinically relevant. Statistical significance itself does not provide insight into this issue (Hao Q et al.).

Authors of this review conclude high credibility of MIDs estimates for: Constant score, Simple Shoulder Test (SST), Pain Visual Analogue Scale (VAS), DASH, OSS and Short Form Health Survey 12 (SF-12). On the other hand, the study provided low credibility MIDs estimates for the Pain Numeric Rating Scale, Quick DASH, Neer score and EuroQol 5 dimensions 3 levels (EQ-5D-3L).

An important strength of this review is identification of anchor-based MIDs for instruments commonly used in RCTs of shoulder conditions. Execution is without restrictions of study design or language of publication. Most studies provided highly credible estimates.

MIDs help both patient and their surgeons but also important, the scientist to interpret the magnitude of effects of interventions on PROMs. An additional benefit of MIDs is the use in power calculations in the future trials.

Quality of Randomized Control Trials:

CONSORT statement stands for CONsolidated Standards of Reporting Trials. It is a tool developed to help researchers to design, create and importantly, to report trials. From its inceptions in 1996, CONSORT statement underwent several improvements. The actual version originates from 2010. There are several different sections in the check list: Title and abstract, Introduction, Methods, Results, Discussion and Other information. The check list composes of 25 items of which 12 are subdivided into additional subgroups. All in all, the statement has 37 points in the check list and for research purposes adherence to the statement is scored with 1 point to each item (37 point maximum) (supplement 1).

Another way to check quality of reporting of RCTs in the surgical field is Use of CLEAR NPT and Jadad score. In the Checklist to Evaluate a Report of a Non-Pharmacologic Trial (CLEAR-NPT), points are assigned based on 18 items regarding patient characteristics, randomization, care provider characteristics, surgical details and blinding, with a total score ranging from 0 to 18 points.

Jadad scoring, or the “Oxford quality scoring system”, is another way to assess the methodological quality of a clinical trial. The score focuses mainly on Randomization, Blinding and Dropouts. It was described in 1996 and was later modified. Originally the score ranges were between zero (very poor) and five (rigorous).

All 3 methods are in use.

Instability surgery RCTs

Alkaduhimi H et al. conducted a systematic review of clinical trials that reported on surgical treatment of shoulder instability.

Using PRISMA guidelines, they screened The Cochrane Library, PubMed, EMBASE and Trip Database for RCTs that met inclusion criteria (surgical intervention, RCTs, English language) and 22 trials were included in the analysis. They found that the mean score of all 22 studies was 9.5 (of 18 CLEAR NPT). Interestingly, they did not find improvements in the score over time (time frames were 1990-2000, 2001-2005, 2006-2010 and 2011-2016). However, they found differences related to scores over specific journals, but the results are not related to the impact factor of the journal. The author personally contacted authors of all 22 research papers, and 11 of them provided information about data missing in the reports. The highest discrepancy between reported and additionally provided information occurs in items regarding: experience of the surgeon, blinding of the participants, level of activity of the patients, details about the comorbidity and blinding of care provider. When they included new information provided by researchers’, the average score in those 11 studies was 16.9 compared to 11.2 (p <0.001). Also, the authors found that studies reported by authors that corresponded to them directly, adhered better to initial recommendation of reporting (11.2 vs 7.9 p<0.012).

Authors of this systematic review concluded that RCTs in shoulder instability surgery are conducted very well but unfortunately, they are badly reported in the journals. This trend tends to remain over the years. The main points that were underreported are: “experience or skill of the care provider”, “blinding of participants”, “blinding of outcome assessors”, “blinding of care providers” and “analysing the results according to intention to the intention-to-treat principles”. Poor response rate (50%) of authors should be considered as a weakness of this review as this could lead to overestimation of the quality of the studies.

Notwithstanding these limitations, the results of the present study are highly important. They address the poor quality of reporting of the current RCTs regarding shoulder stability surgery which could lead to misinterpretation of the results as a result of missing information. Further research could include the validation of quality reporting measurement scales specifically designed for surgical trials, the authors concluded.

Rotator cuff surgery RCTs:

McCormick F, et al. made an effort to conduct a systematic review about quality of reporting in the area of rotator cuff surgery. Motivation for their review comes from earlier conclusions that cuff pathology as high prevalence problem still has a serious gap in knowledge. The lack of quality of RCTs in this field is identified as an important contributing fact of this gap. They chose to use CONSORT statement check list and Jadad score in order to quantify how studies are conducted and reported. The second aim was to identify factors associated with high-quality studies and common deficiencies.

Using standardized PRISMA protocol for systematic reviews and meta-analysis, they identified 54 studies that are published in six best ranked orthopaedic peer review journals according to impact factor.

The mean Jadad score in identified studies was 3.0. Sixty-six percent (35/53) of the studies were classified as high-quality based on a Jadad score of 3 or more. A linear regression demonstrated a moderate association of the Jadad Score with adherence the CONSORT.

The mean CONSORT Criteria Score was 70% (range,30-98%, SD 16). Around 20% of studies comply in 75% or more of the criteria. Deficiencies commonly identified in the majority of papers include: lack of description randomization type; lack of study funding source disclosure; trial registration; and full protocol general access.

Importantly, a power analysis was reported in only 35 out of 54 studies (64.8%), and sufficient blinding was absent in 40% (21/54).

Areas for future improvement based on the CONSORT Criteria include detailed description of trial design, detailed description of rigorous randomization methodology, and power analysis.

Authors identified common methodological flaws in subgroup of studies. They failed to report some of the fundamentals of RCT design such as power analysis, blinding, and randomization.

One third of the studies did not report power analysis. In eyes of reader this could mean that researcher does not understand population of interest. That puts reader in doubt whether the study was carefully planned. We have no clue about sample size, or if it is adequate to find important difference in clinical outcome.

Further, blinding is missed to report in almost 40% of trials which is an important drawback as blinding of the outcome assessment should be implemented to eliminate researchers bias and possibly overestimate effects.

Randomization, another essential process is failed to report in 37% of studies and additionally 48% of studies did not report on restriction or type of randomization.

Authors noted that many of the highest quality studies were non-Surgical trials (63% of high rated trials).

Interestingly, adherence to CONSORT statement in the rotator cuff literature appears to be stronger in comparison to similar surgical and other orthopaedic subspecialties. A recent systematic review¹² evaluating surgical RCTs published in high quality surgical journals found only 33% (20/61 studies) adherence. It appears that in the field of surgical treatments in general, further advancements are obligatory.

Very similar results and conclusions were drawn by Candela V et al. in their review with differences as they used much bigger time spans and did not limit the review to the six best rated journals.

Instead of conclusion:

For an orthopaedic surgeon, it is very difficult to run a slalom race, among the myriad of information provided in literature. Our feeling is that it is mandatory to develop a Core Outcome Set for shoulder surgery. It could be subdivided into Sets for different types of surgery (trauma, degenerative, instability). Reaching consensus in this matter would surely lead to better conduct of trials, as researchers would not mix apples and peaches. The general understanding and common language always generates advancement.

The implementation of CONSORT checklist items for randomized trials has been endorsed by many orthopaedic journals, and the reporting has shown steady improvement over the last decade. Criteria of adherence provides support for the widespread journal endorsement and use. The CONSORT checklist is in the supplement of this report.

Hand, Upper limb and Microsurgery Department, “KAT” Hospital, Athens, Greece

The role of partial repair with superior capsule reconstruction for posterosuperior tears

DEFINE THE PROBLEM

Chronic massive rotator cuff (RC) tears may result in severely dysfunctional shoulder and glenohumeral arthritis. Up to 40% of all RC tears (RCTs) are classified as massive RCTs (MRCTs). A generally accepted definition of MRCT includes rupture of 2 or more complete cuff tendons. MRCTs rarely result from an acute injury; usually they are chronic, and they are frequently related with irreversible factors and high failure rates after repair. Newer studies aim to introduce the tendon retraction to the definition of a MRCT¹. Chronic MRCT are frequently but not always characterized as irreparable because intraoperatively they cannot be repaired to reach the anatomic footprint even after adequate mobilization techniques. Preoperatively a MRCT is called irreparable due to certain clinical and radiological characteristics that deteriorate the probability of a successful repair.

Therefore, anatomical repair is usually not feasible, and several surgical options exist for treating symptomatic chronic MRCT that have failed conservative treatment. Partial repair with or without superior capsular reconstruction (SCR), tendon transfer, and reverse shoulder arthroplasty (RSA) with or without tendon transfer are some of the predominant reconstructive and reparative treatment options. Although no clear evidence-based guidelines exist, the ideal surgery is selected based on patient’s symptoms, functional demands and RCT characteristics (reparability) in a tailored and individualized approach. Presence or absence of dynamic instability, pseudoparalysis, age, occupational demand, intact or anatomically reparable subscapularis, and advanced fatty infiltration Goutallier grade 3 or 4 are the parameters that influence the most the decision for the ideal treatment option². Depending on the patient’s main complaint, functional demands, and expectations it is also important to define the gain for the patient after the proposed treatment.

A SYSTEMATIC APPROACH

Anatomically, the most common patterns of chronic MRCTs include the posterosuperior tears (supraspinatus and infraspinatus) that may extend or not to teres minor. Less frequent are the anterosuperior (supraspinatus and subscapularis), and global tears (posterosuperior with anterior extension to subscapularis). The patient with chronic massive posterosuperior RCT, that is the most common group, may present with pain, and/or loss of strength, and/or loss of motion. The planes that the loss of motion occur (isolated or combined), and the degree of defect (partial or complete) should be determined³. In non-balanced posterosuperior and global tears (non-functional shoulder) the loss of motion can occur for elevation at scapular level (will be called elevation), external rotation (ER) with arm in neutral position (ER1), and external rotation with arm in 90º abduction (ER2), while for anterosuperior tears elevation and internal rotation (IR) may be affected. Pseudoparalysis is defined as a chronic inability to actively elevate the arm beyond 45° at the scapular level with full passive motion, absence of neurological deficit and after excluding pain as the reason for impaired shoulder motion^4,5. Chronic pseudoparalysis (elevation <45º) is structurally and biomechanically different from the situation with elevation>45º and <90º ⁴. In the setting of chronic MRCT, patients with chronic pseudoparalysis for elevation show significantly more posterior, and especially more anterior, RCT extension, involvement of more than 50% of the subscapularis tendon, and fatty infiltration of grade ≥3⁴.

FACTORS RELATED WITH IRREPARABILITY

Several clinical and radiological preoperative factors have been clearly associated with irreparability and postoperative failure. Regarding the clinical determinants pseudoparalysis is related most of the times to irreparability. The presence of lag signs for external rotation (severe external rotation lag sign, drop sign, hornblower sign) is also associated with non-reparability. For anterosuperior tears (or anterior extension of a posterosuperior tear) static anterosuperior subluxation of the humeral head and dynamic anterosuperior escape are also suggestive of irreparability⁶.

In preoperative imaging evaluation, a decreased acromiohumeral distance ( <7 mm) in an anteroposterior radiograph increases the probability of finding an irreparable cuff tear. Acetabularization of the acromion (rotator cuff arthropathy Hamada stage 3) reflects significant chronic static superior instability and represents a contraindication for repair. More advanced stages of cuff arthropathy (Hamada stages 4 and 5) preclude the possibility for joint preserving options.

A valuable parameter in imaging is to look at the muscle bellies of the RC tendons. The intramuscular fat is quantified at the sagittal image of CT or MRI to determine the grade (stage) of fatty infiltration (FI) for each individual muscle belly. Advanced FI (Goutallier grade 3 or 4) is one of the most important predicting factors for structural failure of the repair and is irreversible even after repair. In the best scenario, after successful repair, FI can nearly be arrested but not reversed, while in the worst scenario it substantially increases within first 3 months after a failed repair. Reduced tendon length <15 mm is another important factor leading to failure of the repairs even in RCT with Goutallier grade 2. The presence of supraspinatus atrophy determined by the ‘tangent sign’ of Zanetti and tendon retraction beyond glenoid level are both associated with advanced FI and are predictors of irreparability⁷.

The pathoanatomic alterations after a chronic retracted RCT explain why MRCTs with advance stages of FI should not be repaired. In chronic MRCTs the muscle fibers are retracted and shortened. Individual muscle fiber’s length is divided at least by 2 and their pennation angle is increased. This decrease in muscle fiber resting length increases with advanced stages of FI. The stiffness of the muscle is increased 2-3 fold and FI is associated with overall contractile force of the muscle and poor recovery of strength. The torn tendon also shortens and retracts into the retracted muscle. Physiologically, the possible excursion of muscle fibers denotes that they can be lengthened by about 50% of their length without being destroyed. For chronic retracted RCTs that FI exceeds grade 2 Goutallier, the muscle fibers cannot be lengthened enough to repair the tear without being destroyed⁸.

GENERAL RECOMMENDATIONS OF TREATMENT ALGORITHMS

Although there is no evidence-based consensus, some basic treatment strategies have been suggested. For patients that one plane of motion is predominantly affected (isolated loss of elevation) the reparability of the involved muscle/tendons helps to decide between partial repair (and additional SCR) or tendon transfer. Partial repair with SCR is preferred in patients that posterior RCT can be partially repaired while for patients with advanced FI (stages ≥3) or previous repair, latissimus dorsi (LD) tendon transfer is the preferred treatment. Advanced atrophy and FI of teres minor deteriorate functional outcomes after both procedures⁹. Irreparable subscapularis tear, chronic pseudoparalysis of elevation and anterosuperior escape are contraindications for both partial repair and tendon transfer and RSA is the ideal treatment. For isolated loss of ER and irreparable tears lower trapezius (LT) transfer is indicated in absence of pseudoparalysis of elevation, stiffness, glenohumeral arthritis and irreparable subscapularis tear, and results in superior restoration of ER1 as compared with LD^10,11. In combined loss of motion that usually represents the “true pseudoparalytic” shoulder, and in anterosuperior escape RSA with tendon transfer is suggested as the ideal treatment.

PARTIAL REPAIR AND SUPERIOR CAPSULE RECONSTRUCTION (SCR)

The role of partial repair is to restore the transverse force couple by repairing the infraspinatus and the subscapularis tendon and the coronal force coupling of the deltoid and repaired RC to allow for centered humeral head motion and effective arm elevation. The original partial repair technique reestablishes shoulder function due to restoration of force couples even though the irreparable supraspinatus is left untreated¹². More recent knowledge highlighted the additional role of superior capsule as a static contributor to the humeral head centralization. The superior capsule is now a well described anatomical feature inserted on the greater tuberosity (GT) covering 30-60% of its surface with variations in thickness. It is overlaid by the supraspinatus and infraspinatus tendons and fused to the supraspinatus tendon at the RC insertion area, preventing independent reinsertion of the tendon¹³. Biomechanically, complete discontinuity of the supraspinatus tendon with superior capsule defect in cases of chronic, retracted MRTCs results in increased glenohumeral translation particularly in the superior direction¹⁴.

Superior capsule reconstruction (SCR) can either be performed with a fascia lata autograft^15,16, acellular dermal allograft¹⁷, or the long head of the biceps tendon (LHBT)^18,19. The graft is attached medially to the superior glenoid and laterally to the tendon footprint at the GT. Clinical studies showed that SCR combined with partial repair can reverse superior humeral head migration and restore the muscle balance of the force couples in a cuff-deficient shoulder, without requiring repair of the torn irreparable supraspinatus tendon¹⁷.

THE RATIONALE BEHIND THE “BOX” SCR TECHNIQUE

The LHBT is an alternative to fascia lata autografts or dermal allografts, because it is available locally, free of costs, potentially time-saving compared to the techniques that require preparation of the dermal allograft or graft harvest from lower limb, theoretically less technically demanding, and also minimizes donor site morbidity. The single bundle and V shaped techniques were the first techniques using LHBT autograft for SCR ^18,19. The need for a more effective coverage of the humeral head and a closer imitation of the wide humeral attachment of native superior capsule created the “box” technique that uses two bundles of LHBT instead of one in a rectangular “box” configuration²⁰ (Figure 1). The SCR “box” technique is always combined with partial repair in posterosuperior MRCTs since SCR alone cannot restore the abnormal superior humeral translation in normal levels ²².

The SCR “box” technique is indicated for young and active population with symptomatic posterosuperior MRCT²⁰. The best candidate has irreparable supraspinatus (tendon length <15mm, retraction Patte stage 3, FI grade ≥3). The infraspinatus tear should be reparable with FI grade <3. Contraindications are listed in Table 1. In lateral decubitus position the LHBT is tenotomized at musculotendinous junction and subpectoral tenodesis is performed. The proximal stump of LHBT is advanced subacromially and is fixed at posterior superior glenoid and at GT with knotless anchors substituting the superior capsule in a “box” configuration (double bundle). The subpectoral tenodesis provides a mean proximal tendon length 98.5mm that is sufficient for this double bundle technique. The LHBT autograft diameter ranges 5.1-6.6mm throughout its course that resembles the ideal graft thickness of 6-8mm for SCR but does not exceed too much the native capsule thickness that ranges between 1.3-4.5mm²⁰. In the “box” technique the broad insertion of native superior capsule on GT is imitated through the width and length of the BC part that increases the tendon-bone interface between LHBT graft and GT. Regarding the fixation of LHBT on glenoid side, different positioning of the posterior glenoid anchor (a wider box configuration with glenoid insertion at 9-10 o’clock position or a narrower one at 10-11 o’clock position) remain to be determined in relevant biomechanical study. The preservation of the vascularity of the LHBT graft while keeping its origin at superior labrum may allow for optimum graft incorporation and healing on the bony surface²¹.

The infraspinatus tendon is repaired with anchor at its footprint at GT and its superior border is sutured to the posterior bundle (CD) of the “box” construct (Figure 2). In MRCTs delamination of the superior capsule is frequent and it is important to address both layers, superficial and deep (cuff and capsule) by separate piercing in order to improve the healing rate of the repair construct²². Bursectomy and bursal side release usually help to adequately mobilize the torn tendon, while articular side release and interval slides are used with caution to avoid cuff devascularization. The concept and discussion for any clinical differences between incomplete and partial repair and the clinical significance of any remaining defect of uncovered humeral head should be reconsidered in cases of additional SCR to the classic isolated partial repair technique.

¹ Hospital Universitario de Bellvitge & Centro Médico Teknon (Barcelona)
² Tecnológico de Monterrey & Centro Médico AVE (Mexico)
³ Centro Quironsalud Aribau & Hospital el Pilar (Barcelona)

Introduction

Glenohumeral instability with anteroinferior glenoid bone loss has unacceptable failure rates after Bankart repair. Defects of more than 20% define significant anterior glenoid bone loss; subcritical bone loss, between 13 to 20%, has also been reported to have lower functional scores in some patients when using soft tissue repair only.^1–3 Anatomical and Non-anatomical bone graft reconstruction procedures have been described to treat these patients.³

The Latarjet technique is considered the gold standard; it transfers the coracoid and the conjoint tendon to the anterior glenoid through a split of the subscapularis tendon. The Latarjet has been described as open or arthroscopic using screws or buttons for fixation, with consistent satisfactory functional outcomes and low recurrence rate reported in the literature but is considered a non-anatomical procedure; it is also technically demanding and has a high rate of complications.^3,4

As alternatives to the Latarjet technique, more anatomic glenoid reconstruction procedures using different bone grafts have been developed; the best known is the Eden–Hybinette, which uses autologous iliac crest bone graft to compensate for these significant glenoid defects. The procedure was described as open, although all-arthroscopic methods are nowadays routinely performed.⁵ Free bone graft procedures have shown several advantages compared to Latarjet: subscapularis preservation, shorter learning curve, comparable clinical and radiographical outcomes, low recurrence, and low complication rate. Despite these advantages, metal implants for fixation remain an issue as bone graft reabsorption and remodeling are frequent, predisposing to metal-related problems.

The purpose of this article is to introduce a new anatomic, all-arthroscopic, and metal-free technique that uses tricortical autologous iliac crest graft and an ultra-high-strength suture tape cerclage system for fixation.⁵ A complete description, advantages, disadvantages, and possible complications are described below (Table 1). The early clinical and radiological results demonstrate a high-rate union; graft absorption mainly occurred on the edge and outside the “best-fit” circle.⁶

Surgical Technique

The patient is placed in a lateral decubitus position with 30^o of posterior inclination to ensure the glenoid surface is parallel to the floor and the arm in a 3-point traction system. Using the standard posterior, anterior and anterolateral (biceps) portals, and after identifying the glenoid defect, the anterior capsulolabral complex is released to expose the anterior glenoid surface. An arthroscopic measuring device is used to determine the defect’s size and adjust the graft accordingly. A specific drilling guide is introduced using a posterior accessory portal, fixing it in place in the center of the defect to create two parallel glenoid tunnels using cannulated 2.4mm drills. The exact exit points of the tunnels are measured to create two corresponding tunnels in the iliac crest graft. This allows for two preconfigured cerclage systems to be transported through the tunnels, first from posterior to anterior in the first glenoid tunnel and through the rotator interval, then through the tunnels in the graft and back through the second glenoid tunnel. This configuration allows for the graft to be pulled into the joint and set in the desired position as the tunnels in the graft will align with the glenoid tunnels (Fig. 1). The cerclage systems are then interconnected with the preconfigured racking-hitch knots, using manual traction and then a mechanic tensioner to ensure an adequate fixation and graft stability (Fig. 2). Finally, the capsulolabral complex is repaired to the native anterior glenoid rim, leaving the graft in an extra-articular position.

Figure 1: Surgical Technique. (A) Four ultra-high-strength suture tapes are shown going through the inferior and superior glenoid tunnels. (B) The cerclage tapes emerge from the rotator interval and pass through the graft. (C) The bone block is matched to the anterior glenoid wall. (D) The tapes between graft tunnels produce a high compression at the end of the cerclage construct, mimicking a plate.

Figure 2: Bone Block Cerclage (BBC) Technique. Drawing showing the final graft fixation with the metal-free cerclage system and the “best-fit” circle. Graft remodeling occurs in the areas outside this area.

Discussion

Reconstruction of glenoid bone defects with iliac crest bone graft has shown promising clinical results in different published series.^6,7 Multiple fixation methods have been described, ranging from screws to suture-based implants. The metal-free cerclage fixation used in the BBC technique achieves a solid and stable fixation, with graft-to-glenoid consolidation of 95.5%.⁶ Graft remodeling occurred predominantly in the graft’s peripheral zones, which lay outside the best-fit circle, and no significant complications have been reported.

The absence of metal reduces implant complications and allows for a better radiographic follow-up. Additionally, this technique preserves native anatomy and glenoid bone stock, preserving an intact subscapularis tendon and requiring only two 2.4 mm tunnels.

The cerclage fixation can be done not for ICBG only, also for Latarjet in an open, mini-assisted, or all arthroscopic manner and even for a posterior bone block.^8–10

Figure 3: Radiographic follow-up. CT scans of a patient treated with the BBC technique before surgery, one month after surgery, and at two years follow-up. Remodeling happened outside the “best-fit” circle.

Conclusion

Arthroscopic bone block techniques, such as the one described above, are effective, safe, and reproducible treatments for anterior glenohumeral instability with significant glenoid bone loss. The use of new, metal-free fixation methods contributes to reduced hardware complications and less demanding revisions when necessary.

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References
1. Shaha JS, Cook JB, Song DJ, Rowles DJ, Bottoni CR, Shaha SH, et al. Redefining “critical” bone loss in shoulder instability. American Journal of Sports Medicine. 2015 Jul 3;43(7):1719–25.
2. di Giacomo G, Piscitelli L, Pugliese M. The role of bone in glenohumeral stability. EFORT Open Reviews. 2018;3(12):632–40.
3. Provencher MT, Ferrari MB, Sanchez G, Anavian J, Akamefula R, Lebus GF. Current Treatment Options for Glenohumeral Instability and Bone Loss. JBJS Reviews. 2017 Jul 1;5(7).
4. Griesser MJ, Harris JD, McCoy BW, Hussain WM, Jones MH, Bishop JY, et al. Complications and re-operations after Bristow-Latarjet shoulder stabilization: A systematic review. Journal of Shoulder and Elbow Surgery. 2013;22(2):286–92
5. Hachem AI, del Carmen M, Verdalet I, Rius J. Arthroscopic Bone Block Cerclage: A Fixation Method for Glenoid Bone Loss Reconstruction Without Metal Implants. Arthroscopy Techniques. 2019 Dec 1;8(12):e1591–7.
6. Hachem A, del Carmen-Rodriguez M, Rondanelli R, Rius X, Molina-Creixell A, Cañete San Pastor P, et al. Arthroscopic bone block metal-free fixation for anterior shoulder instability. Short-term functional and radiological outcomes. Revista Espanola de Cirugia Ortopedica y Traumatologia. 2021;
7. Moroder P, Schulz E, Wierer G, Auffarth A, Habermeyer P, Resch H, et al. Neer Award 2019: Latarjet procedure vs. iliac crest bone graft transfer for treatment of anterior shoulder instability with glenoid bone loss: a prospective randomized trial. Journal of Shoulder and Elbow Surgery. 2019 Jul 1;28(7):1298–307.
8. Hachem A ilah, Rondanelli S R, Rius X, Barco R. Latarjet Cerclage: The All-Arthroscopic Metal-Free Fixation. Arthroscopy Techniques. 2021 Feb 1;10(2):e437–50.
9. Hachem A ilah, Costa D’O G, Rondanelli S R, Rius X, Barco R. Latarjet Cerclage: The Metal-Free Fixation. Arthroscopy Techniques. 2020 Sep 1;9(9):e1397–408.
10. Hachem A, Rondanelli SR, Costa D’O G, Verdalet I, Rius X. Arthroscopic “Bone Block Cerclage” Technique for Posterior Shoulder Instability. Arthroscopy Techniques. 2020 Aug 1;9(8):e1171–80.

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“Iuliu Hațieganu” Univ. of Medicine and Pharmacy Cluj-Napoca
Orthopedics and Traumatology Clinic, Cluj-Napoca, Romania
Correspondence: drbenea.ortho@yahoo.fr

Proximal humeral fractures are a common pathology in clinical practice, representing around 6% of all fractures and the third most common site for osteoporotic fractures. The treatment consists of nonoperative and operative methods. Although surgical treatment is becoming more and more common, nonoperative treatment is preferred in the majority of cases. In either situation, complications such as avascular necrosis, malunion, implant failure, non-union, rotator cuff injuries, infection, or posttraumatic arthritis can occur. These complications lead to pain, limited range of motion, functional impairment with an important impact on the quality of life.

The posttraumatic deformities of the proximal humerus represent a challenge in clinical practice due to the particular anatomy of the shoulder joint. In order to decide the optimal treatment, an in-depth understanding of the local and general factors is essential in order to determine the optimal treatment.

It is important to assess:

• The factors leading to the deformity – simple failure of conservative management, technical or implant-related issues, patient compliance, excessive motion or inadequate immobilization, neurovascular injuries, scapular dynamics
• Host-related factors – colonization with facultative pathogens: Propionibacterium acnes, Staphylococcus, or Streptococcus species
• Status of the humeral head, tuberosities, or rotator cuff tendons
• Neuro-vascular status – plexus/nerves injuries, medial displacement of fragments
• Associated conditions: alcoholism, diabetes, smoking, obesity, or osteoporosis.

A thorough preoperative evaluation must be performed, including x-rays, CT scan, MRI, electromyography (if the clinical examination shows any nerve deficit), joint fluid aspiration (if prior surgery), and lab tests (leukocytes and C-reactive protein).

In order to plan the management of the posttraumatic deformity, we must ask the following questions: Can we improve the current condition? Are there other associated lesions that can explain the pain (rotator cuff)? Can bone union be obtained? Is there a bone quality suitable for osteosynthesis?

For a better standardization of the treatment in posttraumatic deformities, the Boileau and Walch classification is used. A drawback of this classification is that it relies on radiographs instead of MRI or CT scans, which offer a far better understanding of the lesions. Nevertheless, the classification serves as a guideline, but the treatment must be individualized to each patient. The Boileau and Walch classification (Table 1) consists of 4 types, as follows: type 1 (AVN or cephalic collapse), type 2 (results from a chronic missed dislocation), type 3 (surgical neck non-union), and type 4 (severe tuberosity malunion or non-union, massive implant failure, or failure of a previous prosthesis)¹.

Table 1: Boileau and Walch classification of fractures sequelae of the proximal humerus¹

There are numerous surgical treatments of posttraumatic deformities, including arthroscopic capsular release, corrective oblique osteotomies (in young patients with stiffness and moderate arthritis), arthroplasty (hemiarthroplasty, anatomic shoulder arthroplasty, or reverse shoulder arthroplasty), bone graft augmentation, shoulder fusion, resection arthroplasty, and tendon transfer.

Shoulder arthroplasty can use different designs and principles, such as stem-less, short metaphyseal, standard implant anatomic arthroplasty, or reverse shoulder arthroplasty².

The stem-less shoulder arthroplasty indications are similar to those of any stemmed prosthesis when a good humeral head bone stock is present. Multiple studies point out similar results to the ones found in the standard anatomical prosthesis, with the advantage of preserving more bone³.

Short metaphyseal implants may be preferable to stem-less ones when significant avascular necrosis is found due to the limited quantity of cancellous bone. Moreover, the underlying necrotic bone could serve as a source of chronic pain if it is not adequately removed or decompressed. If the greater tuberosity is in a normal relationship with the acromion, then the prosthesis must be placed so that the humeral head is in an anatomic position. Short cemented stems can provide an extra degree of freedom, allowing the surgeon to adjust the implant in the desired position. The prosthesis must be inserted with minimal insult to the surrounding soft tissues because rotator cuff integrity influences the outcome.

Anatomic shoulder arthroplasty using standard implants is preferred whenever the bone stock is not enough for stem-less or short metaphyseal implants, and the rotator cuff muscles are well preserved. For a posterior dislocation, the stem should be placed in low to neutral retroversion, and the patient placed in a neutral or external rotation brace for at least six weeks to minimize the risk of recurrent posterior instability.

Reverse shoulder arthroplasty is usually indicated in the case of rotator cuff insufficiency, but the indications expand to the cases where a greater tuberosity osteotomy would be mandatory otherwise. If very large components are required to address a redundant soft tissue envelope, if the patient is elderly, or if there is glenoid bone loss, a reverse shoulder arthroplasty (RSA) potentially with glenoid bone grafting will lead to more reliable outcomes. Moreover, the constraint of RSA is the preferred option for chronic anterior dislocations⁴.

In cases of type 1 sequela (AVN or cephalic collapse), treatment options include arthroplasty with either "stem-less," modular, or short metaphyseal filling implants^5,6.

In type 2 sequela resulting from a chronic missed dislocation, options included are standard prosthesis, or if the patient is elderly, or there is glenoid bone loss, a reverse shoulder arthroplasty (RSA) potentially with glenoid bone grafting⁷.

Type 3 sequela, surgical neck non-union, most often resulting from an initial failure to treat the patient operatively, can benefit from prosthetic options, if there is cephalic necrosis, with a “low-profile” anatomic fracture prosthesis that allows bone grafting for a young patient, or with a reverse prosthesis for an elderly one.

Severe tuberosity malunion or non-union, massive hardware failure, or failure of a previous prosthesis for fracture are the hallmarks of a type 4 sequela. The x-rays may show that the tuberosities are healed to the posterior aspect of the head or are resorbed; hardware may be loose, eroding into the glenoid, or demonstrating implant failure. Very often, non-prosthetic management is unrealistic because of accompanying soft tissue contractures or loss of rotator cuff function due to tuberosity complications.

In these cases, anatomic reconstruction should be reserved for the very young and may require specialized implants or a staged approach. If possible, modular, adaptable implants that enable the surgeon to adapt to the patient’s anatomy may provide good results with minimal surgical trauma. Reverse shoulder arthroplasty may be the only option (Figure 1), and concomitant latissimus dorsi and teres major transfer may be necessary to restore external rotation⁸.

Figure 1: Type 4 proximal humeral deformity, solved with a reverse shoulder arthroplasty

For the patient with loss of both deltoid and rotator cuff function or severe brachial plexus damage, a shoulder fusion might be the only available option. Staged operations may be necessary to reduce complications related to occult infection.

Extreme caution must be taken with the conversion of a failed hemiarthroplasty to a reverse one due to high complication rates, especially instability. Because the contracted soft tissues (especially posteriorly and inferiorly) act as a fulcrum to dislocate the reverse when the arm is brought into extension, the approach requires extensive soft tissue mobilization and may require constrained implants.

In cases of isolated GT non-unions or malunions, posterior tuberosity displacement can block external rotation, and superior tuberosity displacement can limit abduction either mechanically or by limiting the mechanical advantage of the rotator cuff. Younger patients may benefit from osteotomy and repair of the fragment, but elderly patients, however, may require a reverse shoulder arthroplasty, with or without accompanying arthritis⁷.

Of course, contraindications exist for shoulder arthroplasty, such as active infection (absolute contraindication), inability to undergo a rehabilitation protocol (relative contraindication), and an overall poor health condition. One of the worst prognosis factors when performing a shoulder arthroplasty in posttraumatic deformities is the tuberosity osteotomy, which should be avoided whenever possible.

Despite offering a good treatment option in these complex scenarios, shoulder arthroplasty in posttraumatic deformities has a lower overall functional score and a higher rate of complications compared to the surgeries performed in the acute setting or for osteoarthritis.

In conclusion, an in-depth understanding of patho-anatomy is essential to select the optimal treatment. The classifications represent only a guideline; thus, all treatment must be individualized, and, in all cases, we have to take into consideration all therapeutic resources.

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References
1. Boileau P, Walch G, Trojani C, Veneau B, Sinnerton R. Sequelae of fractures of the proximal humerus: results of shoulder arthroplasty without greater tuberosity osteotomy. In: Walch G, Boileau P, editors. Shoulder arthroplasty. Berlin/Heidelberg/New York: Springer; 1999. p. 359–69.
2. Trail I, Funk L, Rangan A, Nixon M. Textbook of Shoulder Surgery. Springer International Publishing; 2019. p. 287-300.
3. Petriccioli D, Bertone C, Marchi G. Stemless shoulder arthroplasty: a literature review. Joints. 2015 Jan-Mar; 3(1):38–41.
4. Lee BK, Itamura JM. Reverse shoulder arthroplasty for proximal humerus fractures. Ann Joint 2021; 6:24.
5. Chuinard C, Boileau P, Walch G. Evaluation and prosthetic management of proximal humeral malunions. In: Iannotti JP, Williams GR, editors. Disorders of the shoulder: reconstruction. Philadelphia: Lippincott Williams and Wilkins; 2014.
6. Tauber M, Resch H. Prosthetic arthroplasty for delayed complications of proximal humerus fractures. In: Cofield R, Sperling J, editors. Revision and complex shoulder arthroplasty. Philadelphia: Lippincott, Williams, and Wilkins; 2010. p. 250–8.
7. Tashjian, R. Complex and Revision Shoulder Arthroplasty. Springer International Publishing; 2019. P. 75-103.
8. Boileau P, Baba M, McClelland WB Jr, Thélu CÉ, Trojani C, Bronsard N. Isolated loss of active external rotation: a distinct entity and results of L'Episcopo tendon transfer. J Shoulder Elbow Surg. 2018;27(3):499-509.

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¹ Shoulder and elbow unit, Orthopaedic and Traumatology department, Hospital dos SAMS de Lisboa, Portugal

 

The treatment of multidirectional shoulder instability (MDI) remains a huge elephant in the room. This unsolved problem begins with the definition of MDI and goes on throughout the various dogmas associated with this entity, such as hyperlaxity, voluntary dislocation, and poor surgical results.

MDI was classically defined in 1980 by Neer and Foster as shoulder instability in two or more planes of motion⁸. But what defines shoulder instability? Over-physiological range of motion (ROM)? Pain? Subjective instability (sensation) without an objective dislocation? One or more episodes of dislocation requiring reduction maneuvers?

This ill-definition of instability gives space to subjective interpretations that vary amongst authors, resulting in a high heterogeneity regarding definition, diagnosis, classification, and treatment of MDI^3,5,11.

Figure 1: Classification algorithm of MDI.

So how to define and diagnose MDI? Does your patient need to report at least one episode of objective dislocation in two or more directions? What if they dislocate anteriorly but report pain in the provocative maneuvers for posterior instability? Or the other way around? Well, these are all valid questions that are not clearly answered in the literature.

In our practice we use an algorithm to organize some concepts around MDI to minimize heterogeneity, and to properly treat our patients. This algorithm was presented in the last ESSKA-ESA closed meeting and the video of the presentation is available at ESA facebook page (Multidirectional Shoulder Instability: When to Operate).

We are excited to inform you that you can now register for the upcoming ESSKA-ESA Members' Meeting “Anterior shoulder instability – Diagnosis and Treatment”.

The meeting will be held Tuesday, 5 October 2021, 18:30-21:00, Zoom

The programme will consist of three scientific sessions:

• Scientific Session I: Re-Live surgical videos
• Scientific Session II: Case presentation
• Scientific Session III: Free papers
• Followed by ESA Members Meeting.

Please fill in the short registration form by clicking on this link.

The outline of the scientific programme can be viewed here.

Would you like to join this meeting but are not an ESA member yet? No problem, you can join ESA today and still have time to register for the meeting!

We are looking forward to seeing you there!

Following the rescheduling of the ESSKA Speciality Days 2021 to November 2023, we are delighted to announce a series of four online Section Meetings organised exclusively for Section members.

A chance to get back together, enjoy some top-quality specialised science and hear the latest news from the Section leadership.

Each Section Speciality Meeting will focus on a specific topic and will feature a 90-minute high level scientific programme followed by a Members' meeting.

Save the date and keep an eye out for more information!

Not yet an ESSKA member or a Section Member? No problem - you can still join today!

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The results of an ESSKA-ESA consensus project were recently published in the KSSTA journal: The High degree of consensus achieved regarding diagnosis and treatment of acromioclavicular joint instability among ESA-ESSKA members

Click on the below to hear Claudio Rosso give a brief summary of the results: