News Category: Shoulder

Athletes who dislocate their shoulder can develop chronic dislocation. When rehab fails to stabilize the shoulder, then surgery is the treatment of choice. But now there are two ways to do the surgery. There’s the traditional open-incision method and the less invasive arthroscopic approach. Which is better?

At first arthroscopic repair of shoulder instability had high rates of failure. Compared to open procedures, arthroscopic surgery was not better. But this may have changed with improved instruments and arthroscopic techniques.

To compare these two surgical methods, two groups of military soldiers with shoulder instability were followed. Half of the patients received an open stabilization. The other half had arthroscopic stabilization. The same surgeon did all operations. The patients in both groups were athletes (military) of equal ages, educational level, and socioeconomic background.

Results were measured by number of failed surgeries, function, motion, and patient satisfaction. The authors report comparable results between the two groups. Differences were seen in blood loss, narcotic use, and hospital stay. All were less for the arthroscopic group. Likewise, the arthroscopic group lost less time from work or training. Patients in the arthroscopic group also had fewer problems after surgery compared to the open group.

The authors advise using the arthroscopic approach for young athletes. Both open and arthroscopic repairs are safe and reliable. Both have equal (low) failure rates. But the arthroscopic method is best for those who want to return to preinjury levels as quickly as possible.

Backpack palsy is an increasing problem among military soldiers. The average load they carry is over 100 pounds. Backpacks can get as heavy as 175 pounds. The weight compresses or stretches the nerves to the arm. Soldiers report numbness, weakness, and paralysis. Pain is not a problem at first but can develop later.

In this retrospective study of 152,095 Finnish soldiers, researchers looked for risk factors for brachial plexopathy. Retrospective means they looked back over the medical records of the soldiers after the problem was diagnosed. Brachial plexopathy is another way to say nerve palsy involving the brachial plexus. The brachial plexus is the main group of nerves in the neck and arm.

Each soldier’s height, weight, and physical fitness was evaluated as a possible risk factor for backpack palsy. Results of electromyography (EMG) muscle test and nerve conduction tests were reviewed. Training and background for each recruit were also studied.

The results showed that backpack palsy affects about 54 soldiers out of every 100,000 soldiers. Different nerves in the brachial plexus were affected in the group. Brachial plexopathy occurred in soldiers carrying a backpack with and without a frame. Heavier loads carried for longer periods of time were more likely to cause a problem.

Height, weight, and fitness level were not linked with nerve palsy. A few soldiers had a hereditary condition. Overall, the incidence of nerve palsy from carrying heavy backpacks is low among Finnish soldiers.

Many people believe a backpack with a frame and waist belt prevents these types of nerve injuries. This study does not support that idea. This style of backpack pulls the shoulders back enough to compress the long thoracic nerve.

The authors offer some suggestions for ways to improve backpack design. Adjustable shoulder straps may help each soldier find the right amount of pull for his or her body build and posture. Horizontal sternum straps across the upper chest might help reduce the back and downward pull on the shoulders.
More studies are needed to find a better design for heavy backpacks carried by military personnel. Soldiers who are strong and in good condition should not be asked to carry heavier loads on long marches.

One of the four muscle-tendon units of the rotator cuff in the shoulder is the subscapularis muscle. There are four clinical tests doctors can use to find out if the subscapularis is torn and how large the tear is. In this study each test is measured for accuracy.

A new test called the Bear-Hug test is included. In this test the patient places the hand of the painful shoulder on his or her opposite shoulder. The elbow is bent and the fingers are straight. The patient tries to keep the hand in that position while the examiner tries to pull the hand away. An external (outward) rotation force is applied. A positive test occurs when the patient can’t hold the hand in place.

Researchers tested 68 patients with possible rotator cuff tears (RCTs) using three standard tests: the lift-off test, the belly-press test, the Napoleon test, and the new Bear-hug test. Results were compared with final findings on arthroscopic exam.

Here’s what they found:

In this article, orthopedic surgeons from Harvard Medical School provide a review of surgical and nonsurgical treatment of rotator cuff tears (RCTs). The authors review shoulder anatomy and biomechanics and the stages of tendon healing to help the reader understand the decision-making needed in choosing the right treatment for each patient.

Nonsurgical conservative care is usually advised first. In the acute phase, physical therapists may use modalities such as electrical stimulation, ultrasound, and/or ice to manage early painful symptoms. A special kind of soft-tissue work called transverse friction massage is used to help realign the fibers of the healing tendon.

Strengthening exercises combined with joint mobilization have been shown to work better than exercise alone. The therapist also helps reduce stiffness and scarring in the shoulder. If conservative care fails and the patient needs surgery, the treatment isn’t wasted because postoperative recovery is better in a supple shoulder.

When surgery is needed, the tear is repaired and the shoulder is immobilized. Instead of a plain sling, studies have shown an abduction immobilizer is best. A sling with a firm support under the arm abducts the shoulder (moves the arm away from the body). This position allows for better blood flow to the rotator cuff and decreases tension on the repair.

The authors present four phases of postoperative rehabilitation. An indepth discussion of each phase is included. The length of each phase, the goals and precautions, and activities to be done are presented. Phase 1 starts with passive exercises. Phase 2 progresses through active exercises. Phase 3 includes strengthening exercises. Phase 4 is advanced training.

Total shoulder replacements (TSRs) aren’t as common as total hip or total knee replacements. But their number is increasing every year. Along with this increase are more postoperative problems. In this report, surgeons from the University of Texas review the most common of these complications.

Reports of TSR complications range from zero to 62 per cent. The average number of complications reported is around 14 per cent. Many surgeons only perform one or two TSRs each year. Studies show fewer problems occur when done by high-volume surgeons. Problems such as loosening, infection, nerve damage, and rotator cuff tears can occur.

Postoperative failure of the TSR is usually multifactorial. In other words, there is more than one reason why a TSR fails. Instability often leading to dislocation results from any of the causes listed. Long-term studies (10 years or more) of TSR outcomes are still scarce. The authors report only finding three of 39 studies in the long-term group.

Recent advances in the design and methods of inserting TSRs have shown good short-term results. For example, improved cement techniques and a pegged instead of a keeled insertion have improved results. The pegged implant has two or three pegs that fit into holes to hold the implant in place. The keel design looks more like a fin on a shark or as named, like the keel on the bottom of a boat. It slips into a matching slit-shaped hole.

The reverse shoulder prosthesis (RSP) has also improved results for patients with massive rotator cuff tears. The RSP is also being used as the revision implant when the first TSR fails.

Every year orthopedic surgeons gather at the annual meeting of the American Academy of Orthopaedic Surgeons (AAOS). Instructional lectures are presented on a wide variety of topics. The information in this review article on irreparable rotator cuff tears (RCTs) was presented at the Academy’s 2006 Annual Meeting.

The problem of pain and disability that comes with massive, irreparable RCTs is presented. Who is affected most often, symptoms presented, types of tears, and treatment are included.

Patients with irreparable RCTs are usually in one of two patient groups. The first group includes women 70 years old and older. Minor trauma brings on mild to severe symptoms. The second group is younger and more active. An acute injury or previous history of rotator cuff problems is common in this second group.

The tears are severe with muscle wasting called atrophy. Often the area fills in with fat cells. Severe arthritis of the shoulder joint adds to the complex picture. The patient presents with variable amounts of pain, loss of motion, weakness, and loss of function.

Treatment depends on the patient’s symptoms, age, and activity level. Other problems such as diabetes, heart disease, or lung problems must be considered. Surgery to repair the RCT isn’t possible. Studies show that fatty infiltration makes the chances of retear very likely.

Nonoperative care with antiinflammatories, steroid injections, and physical therapy may be helpful. Once the symptoms are under control then strengthening exercises can begin. Surgery can include debridement (to clean out the area), tendon transfers, or reverse shoulder replacement.

The authors conclude there isn’t one best treatment for all patients with irreparable RCTs. The surgeon decides what to do based on each patient’s specific needs. A description of the decision tree and details about each operation are also provided for the surgeon.

In this review article, surgeons from the Florida Orthopaedic Institute in Tampa, Florida give a step-by-step description of the surgery to implant a Reverse Shoulder Prosthesis (RSP). This mew implant is used with patients who have a torn rotator cuff that can’t be repaired. They also have severe shoulder arthritis.

During the operation, the top of the humeral head (upper arm bone) is cut off. A half-cup spherical shape is inserted into the bone. The cup side is against the bone. This forms a socket where the round head used to be.

On the scapular side, the normal socket is reamed out and a flat, base plate is inserted. A smooth, three-quarter spherical-shaped implant is attached to the base plate. This forms a round implant called a glenosphere where the shoulder socket used to be.

The authors report good results in terms of reduced pain and improved function. Increased shoulder motion and improved patient satisfaction were also positive outcomes of the RSP. The downside of this procedure was the complications afterwards.

Shoulder instability was common with mechanical failure of the implant. Since the early studies using the RSP, changes have been made in the size, shape, and design of the RSP. The goal is to improve fixation of the implant. Matching the right implant for each patient is important. Designs based on soft tissue tension and rotator cuff deficiency may also decrease problems.

More studies are needed to follow patients long-term and see what kind of results are possible 10 or more years later. How long will the implant last? How much improvement in function is possible? These and many more questions will be addressed.

Sometimes a “shoulder” problem isn’t exactly in the shoulder. It may be in the position and movement of the shoulder blade or wing bone called the scapula. Scapular dyskinesia is a term used to describe abnormal scapular position and motion.

Patients with this problem often have a loss of shoulder internal rotation. They may have signs of shoulder impingement. This means some structure in the shoulder complex is getting pinched during motion.

For example, if the scapula is resting too far forward (away from the spine), the head of the humerus can’t slide down inside the socket during upward motion of the arm. As the patient raises his or her arm, the humeral head bumps up against the acromion. The acromion is a ridge of bone across the back of the scapula. It forms a small, protective shelf over the top of the shoulder.

The authors of this article instruct physicians in how to screen the shoulder complex for scapular dyskinesia and core weakness that might cause it. The first step is to visually inspect the scapula for position and balance. If it “wings” out away from the trunk, it’s a sign of abnormal function. This may be caused by muscular inflexibility, weakness, or fatigue or nerve injury.

Three specific tests for core strength and stability are shown. Patient photos of each test along with instructions to carry out the test are included. The scapular assistance test is also pictured and described. These tests help the examiner assess for dyskinesia and its cause.

Using the information gained from the testing procedures, a special exercise program can be prescribed. Muscle weakness and inflexibility can be addressed in the rehab program. The goal is to improve stability and function of the arm.

Infection of the shoulder joint called septic arthritis is a fairly rare condition. The staphylococcus bacteria is the most common cause. Often the patient has some other medical condition such as diabetes, heart disease, tumor, or rotator cuff tear. They may have a previous history of steroid injections or acupuncture with needle placement into the shoulder.

Little is known about the best treatment for septic arthritis of the shoulder. In this report, surgeons describe an arthroscopic procedure called debridement to treat the infection. Debridement is a way to clean and irrigate or wash an area. The goal is to remove debris and inflamed or dead tissue.

Taking out as much of the infectious material gives the joint a better chance to heal. Systemic antibiotics given intravenously are an important part of the treatment program, too.

In this study 14 of the 17 patients were cured after a single arthroscopic debridement. A second operation was needed by a smaller number of patients. The presence of pain that didn’t go away, local warmth, and loss of motion were red flags. These symptoms suggest that the infection had not been resolved. Most of the patients who needed a reoperation had much more damage. Major bone or cartilage erosion can prevent healing from occurring.

The authors conclude that arthroscopic debridement of septic shoulder arthritis is a safe and effective way to treat joint infection. Early treatment has the best results. Diagnosis delayed by more than two weeks is more likely to result in a second operation.

In this review article, surgeons from the Cleveland Clinic Foundation report the overall results of thermal capsulorrhaphy (TC). TC is a heat treatment delivered by laser or radiofrequency energy. It has been used for the last 12 years in the treatment of shoulder instability.

This type of heat treatment causes the capsule around the shoulder joint to shrink and tighten up. It was hoped that overhead-throwing athletes with unstable shoulder joints could benefit from this procedure.

The results of TC have been hard to determine because it’s not usually done alone. Most of the time TC is done along with surgery to repair tears in the labrum, a rim of cartilage around part of the shoulder socket.

From studying other reports, the authors give the following summary:

Physical therapists (PTs) treating patients with shoulder pain and loss of motion need reliable tests to measure the outcome of treatment. In this study two PTs from Taiwan measure the reliability of three tests of shoulder function. Forty-six (46) patients with shoulder problems and 46 healthy subjects (control group) with no shoulder problems were included.

The three tests were 1) hand-to-neck, 2) hand-to-scapula, and 3) hand-to-opposite scapula. For the hand-to-neck test, the patient or subject reached up and puts both hands on the back of the neck. The therapist gave a score from zero to four based on where the fingers touched the neck.

For the hand-to-scapula test the patient or subject reached the hand behind the back and up as close to the scapula (shoulder blade) as possible. A similar scoring test was used with points given for distance reached. The final test (hand-to-opposite scapula) required each person to reach across the front of the body to touch the top of the opposite shoulder as far back toward the scapula as possible.

Each patient and each control group subject were tested by two different PTs. There was at least 20 minutes between each testing. The therapists did not know the results of the other PT. This is a measure of interrater reliability. In other words, how accurate are the results when the test is used by different people?

The second test of intrarater reliability was performed by having the therapists retest each person three to five days later. Intrarater reliability shows how well the test works when given over time by the same person. A useful test has both intrarater and interrater reliability.

The results showed that all three tests have high intra- and interrater reliability. This was true for different types of shoulder problems. Each test measured a different shoulder motion and function. The authors comment that although the tests are easy to use and reliable, other means of assessing movement and endurance are still needed.

Arthroscopy has made it possible to see how well clinical tests used to diagnose shoulder problems measure up. Researchers can identify which tests are best to diagnose shoulder instability by comparing the final results of arthroscopy against the results of clinical tests.

In this study, three shoulder tests were done on 363 shoulder pain patients. Then shoulder arthroscopy was done to identify the exact problem. If the clinical test was positive during the test and the problem was seen with arthroscopy, the test was sensitive. If the test was negative and the arthroscope also showed nothing wrong, then the test was also specific.

Sensitivity and specificity was measured for anterior apprehension, relocation, and the anterior drawer test. The anterior apprehension test is positive when the patient has pain and is afraid the shoulder will dislocate. This occurs when the arm is placed in a position of shoulder abduction (away from the body) and external rotation (hand placed behind the head).

The relocation test is done with the patient lying down on his or her back (supine position). If the position causes pain or makes the patient anxious, then pressure is placed against the front of the shoulder. A positive relocation test occurs when the downward force against the shoulder relieves the sense that the shoulder is going to dislocate.

The final test (anterior drawer) is done in the same position as the relocation test (lying supine on a table with the shoulder just over the edge). The patient’s arm is next to his or her body with the elbow bent 90 degrees.

Shoulder joint replacement is becoming more common all the time. As more people have a total shoulder arthroplasty (TSA) the number of revision surgeries is also increasing. TSA failure is usually because of infection, implant wear, or bone or soft tissue problems. In this study, 78 patients who had TSA revision surgery were reviewed and reported.

Patients ranged in age from 26 to 82 years old. Arthritis from trauma or instability was the main cause of shoulder problems requiring a TSA. In some cases cancer, fracture that didn’t heal, or rotator cuff tear was the underlying problem.

Results were measured in terms of patient satisfaction, pain, motion, and function. Revision operation either repaired the problem or removed the implant. The authors provide details of types of surgeries done for each problem requiring revision. Factors such as patient age, condition of the bone, and general health were considered when planning the revision operation.

The authors report better results were obtained in patients who had a loose implant or bone deficiency. There were more problems with the glenoid component (socket side of the replacement). Problems with the humeral side were less common. The humeral component consists of a stem fitting down into the shaft of the humerus (upper arm bone). There’s a round ball or new head of the humerus at the top of the stem.

Patients who needed soft tissue reconstructions had only fair results. Most of the reconstruction surgeries were done to stabilize the shoulder or repair rotator cuff problems. Patients who had a new glenoid component were most satisfied with the results.

The authors conclude shoulder revision surgery can be difficult and complex. Results are often based on the reason the surgery was needed in the first place. Better ways to treat TSA patients who have infection or soft-tissue problems are needed and should be the focus of future research efforts.

When a shoulder dislocates more than once, the joint becomes unstable. Usually shoulder dislocation is in the forward or anterior direction. In a small number of patients the dislocation is backward or posterior. In this article, recurrent posterior shoulder dislocation and instability are reviewed.

Trauma, especially during high-risk sports activities is the most common cause of posterior shoulder instability. Pain or tenderness along the joint line may be the only symptom. Strength and motion are usually normal.

The doctor must perform specific tests for shoulder posterior instability to make the diagnosis. Often the diagnosis is incorrect, delayed, or missed altogether. The authors describe (including patient photos) four tests that can be done. These include the posterior stress test, the jerk test, the load and shift test, and the modified load and shift test.

X-rays are also used to make sure the joint is in place. The doctor uses X-rays to look for fractures, changes in anatomy, and any problems with the rim around the socket. CT scans and MRIs are needed to see any small changes in the shape of the shoulder socket. The same imaging studies help find changes in the normally round head of the humerus (upper arm bone). These imaging tests are critical when surgery is needed to treat the problem.

Physical therapy (PT) to strengthen the muscles that stabilize the joint is the first step in treating this problem. About 80 per cent of the patients with recurrent posterior instability have a good result with PT. Details of arthroscopic surgery for the remaining 20 per cent are described. Patient position, surgical technique, and postoperative rehab are presented.

Stiffness, tightness, and recurrence of dislocation are the major problems after surgery. Fracture and nerve injury occur but less often. The authors conclude by saying that with careful planning and understanding of the problem, treatment of recurrent posterior shoulder stability can be successful.

In this article, two orthopedic surgeons from Cleveland, Ohio review the anatomy, biomechanics, diagnosis, and treatment of the floating shoulder. If the bones are fractured but the ligaments are okay, then sometimes the injury can heal on its own.

But without the ligaments for stability, the weight of the arm along with gravity and muscle forces can pull the socket forward. When this happens, the rotator cuff muscles around the shoulder can no longer function normally. The shoulder may droop and pinch soft tissues or nerves causing pain and failure to heal.

Most floating shoulder injuries are caused by severe trauma from a fall or car accident. X-rays may help in making the diagnosis. Sometimes special views such as the Stryker notch. or special measures such as the glenopolar angle (GPA) are needed to see ligament damage. Three-dimensional (3-D) CT scan may be needed, too.

How to treat a floating shoulder remains a matter of debate among surgeons. Some favor nonsurgical treatment. It’s not invasive and there are no extra complications. Others advise surgery to give the patient pain relief and improve function. Surgery may be the only way to stabilize the shoulder. The authors review arguments for both treatment methods.

They advise nonsurgical care for patients with small fractures and no (or minimal) ligament damage. Surgery should be used for patients with fractures that are separated quite a bit. Each patient must be viewed on a case-by-case basis. Most of the time surgery isn’t needed. More studies are needed to compare which treatment works best, but this injury is rare so a definite answer about the best treatment may not be coming soon.

Rotator cuff repair surgery has slowly changed from a full open procedure to an all-arthroscopic (closed) operation. The middle step was a mini-open repair that combined arthroscopy with a small incision. In this study, results of the mini-open repair are compared to an all-arthroscopic method.

Patients ranging in age from 37 to 75 years old were included in this study. Sixty-nine (69) patients had the all-arthroscopic rotator cuff repair. Fifty-eight (58) patients had the mini-open repair. The results showed no difference between the two groups. Pain relief and improved function were the same for both groups. Rates of healing were very similar for patients in both groups.

The authors conclude the all-arthroscopic rotator cuff repair has become a very popular way to repair a torn rotator cuff tendon. In the hands of an experienced surgeon, the results were the same for both techniques. Repair failure rates were also equal between the two groups.

The choice of surgical method for rotator cuff repair is up to the surgeon. Experience and comfort level are the usual deciding factors. If the surgeon chooses to use the all-arthroscopic aproach, then the results can be just as good as with the mini-open method.

This report compares the results of open versus closed (arthroscopic) Bankart repairs for shoulder instability. This operation is used when the patient has a torn labrum. The labrum is a rim of cartilage around the shoulder socket. It helps keep the shoulder from dislocating. Instability is defined as a shoulder that dislocates more than once or dislocates over and over.

In the past, arthroscopic Bankart repairs weren’t as good as the open incision method. Newer methods of suture anchor have improved the results. Studies show that patients who have an arthroscopic Bankart repair have equal recurrent rates of instability compared to the open repair.

Instead of comparing instability rates, the authors of this study looked at differences in pain, function, and patient satisfaction to compare the two methods. They describe the surgical procedure used for both methods. One-third of the patients had the open Bankart and two-thirds had the arthroscopic approach. All patients in both groups had traumatic injuries as the cause of the instability.

Results were very similar for both groups. Each group had one patient dislocate more than a year later. Function, motion, and pain were the same between the two groups. Likewise, patient satisfaction was ranked equally between the arthroscopic and open repair groups.

The authors say the results of this study are important because the patients in both groups were equally matched. They all had the same type of injury and were in the same age group. The similarities make it possible to compare results. The data from this study doesn’t favor one method of repair over another.

Doctors need an easy, inexpensive, and accurate way to tell if a patient has a rotator cuff tear (RCT). Efforts have been made to find a physical test, X-ray, or other means of identifying RCTs. In this study, a handheld dynamometer for shoulder strength testing is used.

A dynamometer is a small device used to test muscle strength. It can be used to measure rotator cuff strength in healthy adults with an intact rotator cuff. By measuring 100 patients with full-thickness RCTs and comparing the results with 100 subjects who had excellent rotator cuff function, researchers hoped to develop a functional index. The functional index would be used to predict which patients have a RCT.

Four tests to assess shoulder force were done on each person. Each test was described in detail. The four muscles of the rotator cuff were included: supraspinatus, infraspinatus, teres minor, and subscapularis. Adduction strength (moving the arm away from the body) was also tested.

The results showed that supraspinatus and adduction tests can be used to predict RCTs. These tests do not predict the size of the tear. The tests weren’t 100 percent though. Sensitivity was 83 percent and specificity was 79 percent. These results are considered “relatively high” by the authors.

Sensitivity reflects the test’s ability to show a true positive for RCT. This means that 83 percent of the time it was accurate and 17 percent of the time, it was wrong. Specificity reflects the test’s ability to tell a true negative test (no RCT tear). In this case, 79 percent of the time the test was negative and the patient didn’t have a RCT. But 21 percent of the time, the person did have a RCT and the test didn’t show it.

This study of shoulder dislocation in 75 patients confirms the safe and effective use of the Milch technique or maneuver. The Milch maneuver was named for Dr. Henry Milch in 1938. The examiner places the patient’s arm in 90 degrees of abduction (arm moved away from the body) and 90 degrees of external rotation. This position will “reduce” or put the dislocated shoulder back in place.

The authors report this method of reduction is simple and doesn’t require anesthesia or surgery. No force is needed because the position lines up the muscles, shoulder blade, and trunk to allow the humeral head to slide back into the shoulder socket. One person with training can do it. Medical residents, physician’s assistants, and emergency room staff should be trained to do the Milch technique.

Patients with recent (less than 24 hours) shoulder dislocation were included in this study. This was the first shoulder dislocation for 90 percent of the patients. X-rays were taken before and after the reduction. Bone fracture was present in 12 patients at the time of the dislocation.

All patients were reduced in the first try using the Milch method. Patients had pain relief right away. Results were the same for all patients no matter what the age or gender, or presence or absence of a fracture.

The Milch technique can be used to reduce a dislocated shoulder without medications or surgery. No pain is involved and one person can do it alone. In this study there were no complications such as nerve damage, displacement of bone fracture, new fracture, or injury to the blood vessels.

Over the top of the shoulder a bony projection from the shoulder blade (acromion) meets up with the collarbone (clavicle). This joint is called the acromioclavicular joint (ACJ). The ACJ can become very painful when there is arthritis or impingement. Impingement occurs when tendons from the rotator cuff get pinched as they pass through the space below this joint.

In this study, surgeons from Columbia University Medical Center in New York compare the results of two different ways to surgically repair the problem. The first, more common method is the bursal or indirect approach. The second is the direct approach. In both methods, the end of the clavicle is cut and taken out where it meets the acromion.

Sixty-six shoulders in 60 patients were divided into two groups based on the method used to resect the clavicle. Each procedure is described by the surgeon. All operations were done with minimal incisions or openings using an arthroscope. Results were measured by level of pain, shoulder instability, and function.

The authors report the direct approach gives the surgeon a better view of the entire joint and easier access to the ACJ compared to the bursa approach. However, the direct method may damage the capsular ligaments above the joint. The patient can be left with instability of the remaining clavicle.

In this study everyone was followed for at least two years. Measures of function reported after the operation were equal in both groups. Ten percent of the direct group needed a second operation for instability or return of painful symptoms.

The authors conclude both ways to treat problems at the ACJ work well. The direct approach may be a little more risky because of the potential for damage to the joint capsule and ligaments. They advise surgeons who use the direct approach to repair any damage done to these structures right away. The supporting and ligamentous tissues must be protected during surgery in order to maintain ACJ stability.