Shoulder surgery has experienced a dramatic development in recent decades, and the diseases treated by arthroscopy are now the majority; arthroscopic dedicated toolkits exist, developed by bio-medical industries, in combination with resorbable fixation screws and pins, both for instability and cuff problems; arthroscopic liberation of the suprascapular nerve is also an arthroscopi procedure, in which we are even able to explore the nerve trunks of the brachial plexus and the axillary vessels; we can also realize tendon transpositions arthroscopically assisted when indicated (chronic infraspinatus tendon deficiency).
In joint instability we distinguis traumatic dislocations, multidirectional instability and acquired micro and multidirectional instability, often secondary to a lesion of the rotator cuff. The number of episodes of traumatic dislocation or subluxation of the humeral head, capsular-labral lesions derived from them and the eventual presence of other cuff concomitant conditions influence surgical indication.
Cuff injuries, traumatic and degenerative, are an increasing patology routinely treated in aryhroscopy: the reinsertion of broken tendons is made simple by the use of dedicated instruments and realized with metal or absorbable screws and pins and non absorbable high resistence wires. Early diagnosis and early treatment of cuff tendons injuries allow to avoid fatty degeneration of retracted muscles, and reduce the risk of suprascapular nerve entrapment.
Generally, surgical indication for cuff injuries in patients older than 70 years in discussed, because the prognosis of these tendon lesions is better to below this scrimine of age, but one has to consider that biological age not always corresponds to chronological age. Evaluation and judgment on single clinical cases and their therapeutic indications is always to be done by a shoulder specialist and adapted to each patient, and not only taking account of medical statistics.
‘Gene therapy’ is now the new challenge of shoulder surgery, using platelet growth factor to promote the regeneration of new arterial and venous vessels and undifferentiated stem cells for tissue repair of the joint and the rotator cuff.
The pathology of the long head of the biceps is often a crossing point between lesions that can cause instability of the humeral head and cuff pathology: the rotator interval that this contributes to draw is a frequent site of morphodynamic alterations that are often misunderstood if not well investidated.
Acute acromion-clavicular dislocation (id est within 15 days from the trauma) and chronic ones are treated by the use of arthroscopic implantation of artificial fixation devices that allow a quick and safe recovery of function; moreover, today we also similarly treat in arthroscopy distal fractures of the clavicule, fractures of the humeral tuberosities and fractures of scapular glenoid.
In traumatic outcomes, in elderly patients affected by osteoarthritis of the shoulder, in shoulder osteoarthritis secondary to massive chronic lesions of the rotator cuff, we can respectively implant shoulder trauma prosthesis, total anatomical prosthesis with long or short stem or stemless, and reverse total shoulder prosthesis, to solve the problem of pain and restore function in a satisfactory manner; thanks also to the surface and coating prosthesis we also are able to treat young and very active patients with primary or post-traumatic arthritis of the shoulder, with tissue sparing technique and small surgical incision.
Concentric osteoarthritis can be idiopathic (primary) and secondary outcome of a trauma or inflammation; is staged radiologically according to Samilson-Prieto, studied with MRI and TC3D (respectively for tendons and capsuloligamentous structures, and for bone stock) and treated with the various overmentioned prosthetic implants: surface, short-stemmed and long-stemmed total prosthesis, cemented or non cemented.
Eccentric osteoarthritis (cuff tear arthropathy) is secondary to chronical cuff deficiency and, after a similar radiological detection, treated with total inverse shoulder prostheses.