Abstract:The techniques of shoulder arthroscopy and shoulder surgery for shoulder disorders and injuries has been developing rapid- ly in recent years. As some clinicians pay more attention to surgical technique itself, while ignore to accurate clinical diagnosis; expand the surgical indication without comprehensive master of required skill, the missed diagnosis, misdiagnosis and mistreatment happened frequent- ly in some extent. Therefore, it is necessary to discuss the pitfalls in shoulder arthroscopy and shoulder surgery deeply. In this issue of Or- thopedic Journal of China, the complications and adverse events in the diagnosis and treatment of shoulder disease and injury were ana- lyzed, involving shoulder instability, shoulder fracture dislocation complicated with injuries to blood vessels and nerve, shoulder dislocation complicated with rotator cuff tear, labral tear, infection, instability secondary to syringomyelia. Furthermore, relevant factors are searched re- garding to the occurrence of recurrent shoulder instability, re-torn rotator cuff, unstable anchor fixation, failure of Latarjet procedure, and complications of internal fixation of shoulder fractures. Moreover, the nursing and rehabilitation, as well as relative basic researches are dis- cussed regarding abovementioned dilemmas, in order to remind the large number of clinicians to caution the mistakes and pitfalls in clini- cal practice of shoulder arthroscopy and surgery to prevent adverse consequences. In addition, this article also proposed some suggestions, including strengthening the clinical training to reduce misdiagnosis and missed diagnosis, executing the operation indications to avoid com- plications, paying attention to innovation and new technology development to avoid surgical technique "show"; enhancing continuing educa- tion to improve the level of diagnosis and treatment, and follow the concept of function first.

Abstract:[Objective] To investigate factors related to failure of arthroscopic rotator cuff repair with anchor suture and the outcomes of corresponding revision arthroscopies. [Methods] From June 2012 to June 2020, a total of 18 patients, including 8 males and 10 females aged 45~73 years with a mean of (58.2±4.5) years, received corresponding revision arthroscopies for anchor failure in primary arthroscopic rotator cuff repair for its tear. [Results] All the 18 patients were proved subacromial synovial hyperplasia and partial rotator cuff re-tear un- der arthroscopic examination. Among them, 5 cases were proved of anchor pull out, accounting for 27.8%; 9 cases were proved of anchor loosening, accounting for 50.0%; and 4 cases of suture tied loosening, accounting for 22.2%; which was statistically significant (P＜0.05) . All the 18 patients underwent revision surgery with operation time of 45~110 min, with an average of (63.7±11.3) min, whereas without seri- ous complications such as vascular and nerve injuries. After more than 12 months of follow- up, the VAS, Neer and Constant- Murley scores, as well as forward flexion-lifting, abduction-lifting and lateral external rotation range of motions (ROMs) of the affected side were significantly improved compared with those before revision surgery (P＜0.05) . The affected side was significantly inferior to the healthy side in terms of abovementioned parameters preoperatively (P＜0.05) , whereas which became not statistically significant between the two sides at the latest follow-up (P＞0.05) . Radiographically, all the patients had anchors remained in good position after operation without loosening or displacement until the latest follow-up. Compared with those preoperatively, the MRI rotator cuff grade on the affected side improved (P＜ 0.05) , the acromiohumeral interval (AHI) remained unchanged at the latest follow up (P＞0.05) . The affected side proved significantly infe- rior to the healthy side in MRI rotator cuff grade preoperatively (P＜0.05) , but there was no significant difference in AHI between the two sides (P＞0.05) . At last follow-up, there was no significant difference in MRI rotator cuff grade and AHI between the two sides (P＞0.05) . [Conclusion] Anchor failure may occur in the arthroscopic repair of rotator cuff injury, anchor loosening is the most common one among them. According to the specific situation, removing or retaining the loosed anchor and replacing the new anchors to repair the rotator cuff can still obtain satisfactory clinical results.

Abstract:[Objective] To investigate the characteristics and management results of complications of open reduction and plate internal fixation for proximal humeral fractures. [Methods] From January 2018 to January 2021, a total of 114 patients received open reduction and plate internal fixation for proximal humeral fractures in our hospital. The occurrence, characteristics, management and outcome of complica- tions were assayed in this arthicle. [Results] Among 114 patients, 32/114 (28.1%) had late complications, including poor fracture reduction 8/114 (7.0%) , poor internal fixation position 7/114 (6.1%) , loose internal fixation 5/114 (4.4%) , malunion 4/114 (3.5%) , subacromial im- pact 4/114 (3.5%) , femoral head necrosis 2/114 (1.8%) , incision malunion 1/114 (0.9%), infection 1/114 (0.9%), which proved statistically significant in term of the incidence of various complications (P＜0.05) . In term of fracture classification, the total complication rate was of 4/ 16 (25.0%) in the two-part fracture, 17/82 (20.7%) in the three-part fracture, 7/8 (87.5%) in the four-part fracture and 4/8 (50.0%) in the fracture dislocation, with a significantly difference among them (P＜0.05) . After corresponding treatment, all patients had no serious adverse consequences. Of them, 12 patients had no pain at all, 15 patients had mild pain during activities, and 5 patients had obvious pain; 10 pa- tients had on shoulder motion affected, 18 cases got mildly limited, and 4 cases had significantly limited motion; 14 cases regained sports and labor capacity to the levels before injury, while 18 cases were under the levels at the latest follow-up. [Conclusion] The complications of open reduction plate internal fixation of proximal humerus fractures are as high as 13.2%, and the most common complications are loosen- ing of internal fixation, malunion and subacromial impingement, which should be paid more attention to.

Abstract:[Objective] To investigate the postoperative complications and their management strategies of hook plate fixation of acro- mioclavicular dislocation. [Methods] A retrospective study was performed on 105 patients who received clavicular hook plate fixation for acute acromioclavicular dislocation from January 2011 to January 2021. The clinical results and complications were evaluated. [Results] All 105 cases were successfully operated on without serious complications such as vascular and nerve injury. During the follow-up, 97 pa- tients of them had significant limitation of shoulder movement and pain during movement, and had the hook plate removed from 10 to 20 months with a mean of (12.3±5.3) months. In the hook plate removal, 12 cases underwent arthroscopic examination simutaneously, which re- vealed subacromial synovitis in 2 cases, subacromial impingement in 2 cases, and subacromial surface abrasion in 8 cases. Compared with 3 months after surgery, the VAS score, Constant-Murley score, forward flexion-lifting range of motion (ROM) , and abduction-lifting ROM on the affected side were significantly improved at the last follow-up (P＜0.05) . However, the involved side proved significantly inferior to the health side in terms of VAS and Constant-Murley scores, as well as ROMs at the corresponding time points (P＜0.05) . Radiographical- ly, of the 105 patients 98 patients had adverse imaging findings accounting for 84.8%. The incidence was ranked from high to low as fol- lows: acromioclavicular bone wear 86/105 (81.9% ) , acromioclavicular impingement 15/105 (14.3% ) , acromioclavicular arthritis 6/105 (5.7%) , acromioclavicular subluxation downward 6/105 (5.7%) , plate dislocation or anterior acromioclavicular subluxation 4/105 (3.8%) . There was no significant difference in the incidence of all types of adverse imaging findings (P=0.242) . [Conclusion] The hook plate inter- nal fixation for acromioclavicular dislocation has considerably high complication occurrence, should avoid being used for acromioclavicular dislocation caused by coracoclavicular ligament rupture as far as possible.

Abstract:[Objective] To explore the effect of clavicular and coracoid bone tunnel enlargement and reduction loss on clinical out- comes after coracoclavicular ligament anatomical reconstruction. [Methods] A retrospective study was conducted on 30 patients who re- ceived coracoclavicular ligament anatomical reconstruction for Rockwood type III-V acromioclavicular dislocation in our department from November 2012 to December 2021. Clinical outcomes were evaluated by ASES, Constant-Murley and ULCA scores, whereas the coraco- clavicaular distance (CCD) , maximum diameter of coracoid bone tunnel and clavicular bone tunnel were measured radiographically. Pear- son or Spearman correlation analyses was used to search the correlation between clinical scores and changes of imaging measurement pa- rameters. [Results] All the 30 patients were successfully operated on, and followed up for (13.5±4.5) months on an average. At latest followup, the ASES, Constant-Murley and ULCA scores significantly increased compared with those preoperatively (P＜0.05) . However, the CCD and maximum diameter of coracoid and clavicular bone tunnel significantly increased at the latest follow-up compared with those within 3 days after operation (P＜0.05) . At latest follow-up, the ASES, Constant-Murley and ULCA scores proved not significantly correlated with the increments of CCD and the maximum diameter of coracoid and clavicular bone tunnels (P＞0.05) . Moreover, the increment of CCD was not correlated with those of the maximum diameter of coracoid and clavicle bone tunnels (P＞0.05) . The increment of maximum diameter of coracoid bone tunnel was positively correlated with that of the maximum diameter of clavicle bone tunnel (P＜0.05) . [Conclusion] The clavi- cle and coracoid bone tunnels does be enlarged in some extent after coracoclavicular ligament anatomical reconstruction for Rockwood type III-V acromioclavicular dislocation. However, the bone tunnel enlargement is not proved related to reduction loss, and has no effect on the clinical outcome.

Abstract:[Objective] To investigate the characteristics and management results of complications secondary to open reduction and in- ternal fixation (ORIF) of clavicle fractures. [Methods] A retrospective study was conducted on 228 patients who received ORIF of clavicle fractures in our hospital from January 2019 to December 2020. The occurrence, characteristics, management and outcome of complications were analyzed in this paper. [Results] Among 228 patients, 19 patients suffered from complications, accounting for 8.33%. In term of time of complication happened, the early complications were found in 6 cases, accounting for 31.57%, while late complications were seen in 13 cases, accounting for 68.4%, which was statistically significant (P=0.001) . In term of fracture site, the complication rate was 4/57(7.0%) in the lateral clavicle, 15/161 (9.3%) in the middle part of clavicle, 0/5 (0.0%) in the medial clavicle, whereas 0/5 (0.0%) in bipolar fracture with a statistically significant difference among the 4 parts (P=0.023) . In term of the internal fixation method, the complication rate proved 3/20 (15.0%) in the clavicle hook plate, 1/15 (9.3%) in the lateral end plate combined with the coracoclavicular suspension, 0/22 (0.0%) in the simple lateral end plate, 15/161 (9.3%) in mid-clavicle plate, while 0/5 (0.0%) in medial clavicle plate, which was statistically signifi- cant (P=0.036) . The incidence of specific complications ranked from high to low was of refracture after removal of internal fixation (7/19, 36.8%) , fracture of internal fixation (6/19, 31.6%) , incision infection (3/19, 15.8%) , irritation of internal fixation (1/19, 5.3%) and acromio- clavicular dislocation (1/19, 5.3%) with significant differences in the incidence of various complications (P=0.018) . Of the 19 patients, 4 cases were treated conservatively, whereas15 cases underwent revision surgery without serious adverse events. Of them, 15 patients had no pain at all, 3 patients had mild pain during activities, and 1 patients had obvious pain; 10 patients had no shoulder motion affected, 6 cases got mildly limited, and 3 case had significantly limited motion; 13 cases regained sports and labor capacity to the levels before injury, while 6 cases were under the levels at the latest follow-up. [Conclusion] Although ORIF of clavicle fractures is a routine operation, the complica- tion rate is still as high as 8.33%, including the most common complications of refracture after removal of internal fixation, fracture of inter- nal fixation and infection. Improving surgical technique is the key to reduce complications.

Abstract:Rotator cuff calcific tendinitis (RCCT) is a common cause of shoulder pain, usually occurs in women aged between 30 and 60 years. Although patients present severe pain during acute phase, the symptom could be released by effective treatments. Because of a self-healing disease, RCCT presents certain pitfalls in terms of pathogenesis, imaging diagnosis, choice and timing of treatments. This arti- cle reported a case of RCCT and reviewed the pitfalls and strategies focused on diagnosis and treatment.

Abstract:Rice body has been reported in multiple joints, and is usually thought that the disease is secondary to rheumatoid arthritis or other inflammatory arthropathy. Some scholars believe that the necrotic synovial membrane falls off into the synovial fluid after synovial infarction, and then is wrapped by fibrin to form the rice body. The main symptom of rice body is local swelling accompanied with pain. This paper reports a case of rheumatoid arthritis complicated with shoulder rice body, which were removed under shoulder arthroscopy with good results. In addition, the relevant literature was reviewed in this paper to provide reference for clinicians.

Abstract:Reverse humeral avulsion of the glenohumeral ligament (r-HAGL) is rare lesions, which might be exceedingly difficult to be diagnosed due to the lack of specific findings, and often be misdiagnosed. However, the r-HAGL leads to posterior glenohumeral instabili- ty. There have been only a few case reports published that described r-HAGL lesions. Combining a case report, this article reviews the path- ological mechanism, imaging, classification, diagnosis, method of treatment, postoperative rehabilitation and care, in order to increase levels of diagnosis and treatment of r-HAGL.

Abstract:Rotator cuff retear is a serious complication after arthroscopic rotator cuff repair, which impacts the quality of life of the pa- tients. There are many factors related to rotator cuff retear, such as age, hyperlipidemia, osteoporosis, etc., which have become hot and diffi- cult point of clinical practice in shoulder surgery at present. In order to find the related factors of rotator cuff retear, this paper reviewed the literature to find the most important single or multiple factors of rotator cuff retear, and to evaluate and improve the efficacy of rotator cuff re- pair.

Abstract:Recurrent anterior glenohumeral dislocation is a common shoulder injury, which gradually become to be treated by ar- throscopic Latarjet procedure if complicated with glenoid defect. However, the arthroscopic Latarjet procedure is difficult in operation tech- nique with a long learning curve. In this paper, we reported a 23-year-old patient who received arthroscopic Latarjet procedure combined with Bankart repair and Remplissage procedure for recurrent glenohumeral dislocation. At 72 months postoperatively, the 3D CT reconstruc- tion revealed that the bone graft was fixed and healed well to cover the 5 o'clocks position of the glenoid effectively, whereas insufficient at 3 to 4 o'clocks points of the glenoid, and the patients presented positive apprehension test from 90° to 120° abduction, regardless of nega- tive apprehension test in the remaining range of abduction. In addition, this article reviews the treatment mechanism, learning curve and ex- isting problems of arthroscopic Latarjet procedure to provide reference for clinicians.

Abstract:Shoulder dislocation accounts for half of all joint dislocation in human, among which recurrent anterior shoulder dislocation is the most common one with Bankart lesion in almost every case of anterior shoulder dislocation. Arthroscopic Bankart procedure is the main treatment for shoulder dislocation currently, however, postoperative recurrence remains a difficult problem. A large number of studies have shown that the recurrence after arthroscopic Bankart procedure is related to glenoid bone loss, patient's age, extent of motion, surgical methods, improper postoperative rehabilitation exercise and self-diseases. This paper reviews the factors related to recurrence after Bankart procedure, to provide reference for clinicians.

Abstract:Syphilitic arthritis is a very rare disease with diverse symptoms, therefore, prone to be of miss diagnosis or misdiagnosis. In this paper, we report a 61-year-old female patient with fever, right shoulder swelling and pain, and mobility limitation for 10 months. Ar- throscopy revealed synovial hyperplasia with some nodular and jelly-like changes, rotator cuff rupture, destruction of the humeral head and glenoid complicated with partial defects. The hyperplastic synovial tissue was debrided by shavers, and the broken cartilage and scar of the humeral head and glenoid were removed. Histopathological examination of the synovium revealed leptospira. Combined with this case, this paper also mentioned the clinical and imaging features, diagnosis, differential diagnosis, and treatment of syphilitic arthritis by a literature review to provide reference for clinicians.

Abstract:Shoulder instability is a common clinical disease. With the improvement of medical level, the treatment of shoulder instabili- ty is developing gradually, from open surgery to shoulder arthroscopy, from soft tissue repair surgery under arthroscopy to bone repair sur- gery. However, there is still a high recurrence secondary to surgical treatment of shoulder instability at present. This article aims to summa- rize recurrences related to personal factors and treatment factors after surgical treatment of shoulder instability to improve the understand- ing of shoulder instability and make a proper treatment.

Abstract:[Objective] To introduce the surgical technique and preliminary clinical results of the arthroscopic treatment of chronic locking anterior glenohumeral dislocation in the elderly. [Methods] From January 2016 to December 2020, 5 elderly patients received ar- throscopic treatment for chronic locking anterior glenohumeral dislocation. The scar tissue was removed arthroscopically and the normal gle- nohumeral alignment was recovered. Two anchors were placed in the middle of bone defect in the Hill-Sachs lesion. The bone defect area of the anteroinferior glenoid was exposed, and freshened with a curettage. A 2 cm×2 cm×1 cm bicortical bone block was harvest from the ili- um and trimmed according to the size and shape of the recipient area. After the anteroinferior approach was established, the bone block was placed on the anteroinferior edge of the glenoid, and fixed with two cannulated lag screws. Two to four anchors were inserted into the anteri- or margin of the glenoid at 1-7 o'clocks as needed, the anterior joint capsule and labrum were sutured. The sutures of the 2 posterior an- chors previously placed were tightened to fill the infraspinatus on the bone defect in the Hill-Sachs lesion, and if necessary, the torn rotator cuff was repaired in some cases. [Results] All 5 patients had arthroscopic procedures performed successfully without serious complications, and followed up for 9~18 months with a mean of (11.5±3.1) months. At last follow-up the range of motion of the shoulder, as well as ASES, Constant-Murley and Rowe scores were significantly improved compared with those preoperatively (P＜0.05) . Up to the latest follow-up, no recurrence of glenohumeral instability and no revision surgery happened in anyone of them. The CT examination confirmed that the bone graft had healed on the anteroinferior glenoid with proper glenohumeral alignment. [Conclusion] This arthroscopic procedure epitomizes the advantages of arthroscopic technique, which does effectively restore the normal glenohumeral alignment, reconstruct the glenoid, repair anterior capsule and the Hill-Sachs lesion, and is an effective method for the treatment of chronic locking anterior glenohumeral dislocation in the elderly.

Abstract:[Objective] To introduce the surgical technique and clinical efficacy of arthroscopic anchor placement at 6 o'clock position for anterior shoulder instability. [Methods] From January 1, 2018 to January 1, 2021, 51 adult patients underwent arthroscopic posterior Remplissage procedure and anterior Bankart repair for shoulder dislocation by using four- approach technique. The anterosuperior ap- proach should be as upward as possible, whereas the anteroinferior approach should be tested with hemostatic forceps to confirm if it can reach the 6 o 'clock position and the two approaches should not be too close. The anteriorly labial complex was released to 6 or even 7 o 'clock position, and 5mm cartilage was removed from the anteroinferior glenoid edge. As anchors placed, including the one at 6 o'clock posi- tion, the labrum complex was reduced and repaired in full thickness as possible. [Results] All patients were successfully operated on with- out serious intraoperative complications and were followed up for 12 to 24 months. No shoulder dislocation occurred again in any of the pa- tients. At last follow-up ASES score, Constant-Murley score and Rowe were significantly improved compared with those before operation (P＜0.05) . Postoperative routine three-dimensional CT showed that the anchor position was good. [Conclusion] Arthroscopic anchor place- ment at 6 o 'clock position for repair of labrum complex is effective treatment of glenohumeral instability, which depends on the precise pre- operative selection of indications and the proficiency of the operation technique under the arthroscope.

Abstract:[Objective] To investigate the efficacy of arthroscopic reduction and Fiber Tape suture bridge fixation for humeral greater tuberosity fractures. [Methods] From March 2019 to January 2021, 10 patients with greater tuberosity fracture of the humerus were treated with arthroscopic reduction and Fiber Tape suture bridge fixation. [Results] All the 10 patients were successfully operated on without seri- ous complications such as vascular and nerve injury. Of them. 10 patients were followed up for 13 to 28 months, with an average of (18.5± 4.5) months. The patients resumed weight-bearing work or sports activity from 16 to 26 weeks with a mean of (20.1± 3.0) weeks after opera- tion. Compared with those at 1 month after surgery, the VAS, ASES and Constant-Murley scores, as well as ROMs in all directions signifi- cantly improved at latest follow-up (P＜0.05) . Radiographically, the fracture reduction quality was marked as excellent in 9 cases, good in 1 case, and poor in 0 case. By the time of latest follow up, all patients achieved fracture union without adverse imaging findings such as non- union and subacromial impingement. [Conclusion] This arthroscopic Fiber Tape suture bridge fixation is a reliable minimally invasive tech- nique for the treatment of humeral greater tuberosity fracture without cutting of rotator cuff tissue, and no need to remove the implant sec- ondarily, and does achieve satisfactory clinical outcomes.

Abstract:[Objective] To evaluate the clinical outcomes of standardized nursing and rehabilitation procedures for arthroscopic ana- tomical reconstruction of coracoclavicular ligament. [Methods] From November 2019 to December 2020, 15 patients received arthroscopic anatomical reconstruction of coracoclavicular ligament, standardized nursing and rehabilitation process for acromioclavicular dislocation. The clinical and imaging results were evaluated. [Results] All 15 patients had operation performed successfully without serious complica- tions, and followed up for 9.0~20.0 months, with an average of (12.0±4.1) months. At last follow-up, ASES and UCLA scores, SST scale, as well as lifting and external rotation range of motions (ROM) significantly improved compared with those preoperatively (P＜0.05) . At the last follow-up, 14 cases (93.3%) recovered to the pre-injury exercise level. Radiographically, the coracoclavicular distance (CCD) at the last fol- low-up was significantly reduced as compared with that preoperatively (P＜0.05) , whereas which increased significantly over time postoper- atively (P＜0.05) . [Conclusion] Standardized nursing and rehabilitation process plays an important role in the recovery of shoulder joint function after arthroscopic anatomical reconstruction of coracoclavicular ligament.

Abstract:[Objective] To evaluate the consequences of personalized perioperative nursing and rehabilitation for arthroscopic rotator cuff repair. [Methods] A retrospective study was performed on 103 patients who received arthroscopic repair of rotator cuff injury in our hospital from January 2018 to December 2019. All the patients were given personalized nursing and rehabilitation perioperatively. [Results] All patients were operated on successfully without serious complications during hospitalization. At discharge, the total score of pa- tient's satisfaction was (94.4±4.0) in five aspects including timely delivery of nursing services, ward rest experience, accurate and effective rehabilitation guidance, communication and standardization of management. The VAS and ASES scores, as well as upward flexion, upward abduction and posterior extension range of motions (ROMs) significantly improved in 103 patients over time (P＜0.05) . [Conclusion] The personalized perioperative nursing and rehabilitation for arthroscopic rotator cuff repair do reduce the pain, improve nursing and rehabilita- tion satisfaction, and contribute to the functional recovery of the shoulder.