arthrodesis of the shoulder is a surgical procedure that is indicated in cases of infection , obstetrical brachial plexus palsy , post - traumatic brachial plexus palsy , massive unrepairable rotator cuff tears , combined paralysis and insufficiency of the rotator cuff and deltoid muscle , omarthrosis without indication for arthroplasty , salvage surgery after failed glenohumeral arthroplasty ( with bone loss and muscular insufficiency of the rotator cuff and deltoid ) , recurrent shoulder dislocations , or stabilization after resection of a neoplastic lesion . arthroscopic arthrodesis of the shoulder is a procedure that is only carried out in exceptional circumstances.[57 ] our aim is to present the results in a patient who was operated on using this method with arthroscopic techniques , after 14-year follow - up . we present a case report of a 17-year - old male who suffered an accident in 1996 , which caused cranioencephalic trauma , thoracic trauma with fracture of the left fourth rib , comminuted fracture of the left scapula ( ideberg type v , [ figures 13 ] ) , fracture of the left clavicle ( middle third , craig type i ) , left acromioclavicular dislocation ( rockwood grade i ) , and fracture of the left distal cubitus , as well as multiple contusions . an emergency operation was performed with open reduction and osteosynthesis using a plate and screws in order to stabilize the clavicle of this floating shoulder . an electromyography ( emg ) was performed 2 months later , and motor affection of the axillary nerve was detected , with lengthened latency and reduced amplitude . in deltoid muscle , partial moderate - to - severe denervation was observed , whereas in supraspinatus muscle , there was no denervation . after 7 months of follow - up , axillary nerve still presented a low motor potential . there was an intermediate recruitment without denervation in supraspinatus muscle in repose , and there was a moderate denervation in deltoid muscle at rest , with simple recruitment . these aspects indicated that axonotmesis of the axillary nerve had persisted and it was becoming established . craig type i fracture of clavicle ( middle third ) , fracture of scapula ( probably ideberg type v ) , floating shoulder ct image . observe the high degree of comminution in the area of the scapula three - dimensional ct reconstruction . comminuted fracture of scapula , probably ideberg type v we considered the situation of the paralyzed shoulder , with omarthrosis , instability , and floating shoulder . due to these findings , we decided that arthrodesis should be performed percutaneously with arthroscopic support , using three cannulated screws , under scopic control [ figure 4 ] . clavicle osteosynthesis is also noteworthy ; this had been performed 7 months previously , using an osteosynthesis plate ( 1996 ) under general anesthesia , patient was placed in beach chair position , with circumferential accessibility to the left shoulder , and the operative arm was draped free . the arthroscope was placed through a standard posterior arthroscopic portal and an arthroscopic cannula anteriorly . the shoulder was held in a position of 30 of flexion , 30 of abduction , and 30 of internal rotation , while a radius bur was used to denude the articular surfaces of both the humeral head and glenoid to bleeding subchondral bone . an anterior cruciate ligament guide was used to direct percutaneous placement of two guidewires through the proximal humerus from lateral to medial and into the joint under direct arthroscopic visualization . both guidewires were driven through the center of the glenoid , where they were then measured and reamed for placement of 6.5-mm cannulated cancellous screws . with the arm held in the appropriate position , sequential tightening of the screws achieved adequate compression of the glenohumeral surfaces . the positions of the two glenohumeral screws were verified with biplanar fluoroscopy before a third 6.5-mm cannulated cancellous screw was placed from the lateral edge of the acromion into the humeral head inferiorly toward the shaft - glenoid . finally , we did not need bone graft , because we achieved total compression into the glenohumeral joint before incisions were closed . an abduction pillow was placed under the operative arm , holding it in the appropriate position , and kept in place for 3 months . rehabilitation consisted of passive assisted exercises and progressed to active assisted exercises after 4 weeks [ figures 57 ] . glenohumeral joint viewed from standard arthroscopic portal after we denuded articular surfaces of both humeral head and glenoid to bleeding subchondral bone , we used two guidewires through the proximal humerus from lateral to medial and into the joint under direct arthroscopic visualization . both guidewires were driven through the center of the glenoid see initial placement of one 6.5-mm cannulated cancellous screw arthroscopic shoulder orientation , a good level of experience in glenolabral arthroscopic surgery , and management of anterior cruciate ligament guides are very important points in this procedure . one typical pitfall is tightening of screws without previous correct arthroscopic control or loosening of guide position before tightening cannulated cancellous screws . another interesting point is that threads of the screws must engage across the joint into the glenoid to ensure solid bone compression . we consider that this arthroscopic technique is better than the open one , because it is a less - invasive procedure . with two arthroscopic portals and percutaneous cancellous screws , we can achieve similar results , without problems like intolerance of the material , due to protrusion at the side of the acromion with posterior removal , risk of infection , and risk of fractures of the humerus after surgery with plates . clinical evolution developed favorably , since surgery pain disappeared , and the arm became functional for everyday activities . at this moment , 14 years later , this patient is still working with the same paralysis , in a workplace that has been adapted to his pathology . he presents movement arc of 0 - 90 for anterior flexion , maximum abduction of 20 , and atrophy of the deltoid , supraspinatus , and infraspinatus . we have measured 47 points on constant 's test and 17 points on the ucla scale . we tried to achieve radiographic arthrodesis , but finally , we could see a gap between the bone of the glenoid and the humeral head , with no secondary displacement , infectious complications , or intolerance of material , and patient is satisfied with results of this surgery [ figures 8 and 9 ] . we consider that it is very important fact that the threads of the screws cross the joint , in order to achieve solid compression of the bone . we only had these screws several years ago , with a long area of threads . we think we have to warn the readers to ensure that the threads of the screws engage across the joint into the glenoid to ensure solid bone compression . with this warning , fourteen years later , we think that structure stability is present , although with gap between the bone of the glenoid and the humeral head , glenohumeral fibrous union , and no secondary displacement at present , movement arc is 0 - 90anterior flexion , maximum abduction of 20 , with atrophy of the deltoid , supraspinatus , and infraspinatus muscles . 47 points on the constant scale and 17 points on the ucla scale recently , in the last revision , after 14 years and 8 months of follow - up , patient suffered a trauma on the affected shoulder , with minimal pain . however , movement arc did not change : 0 - 90 for anterior flexion , maximum abduction of 40 , and atrophy of the deltoid , with the same result in constant 's and ucla scales . we only have seen one broken screw , and fibrous union is reached on the x - ray study . however , fibrous union with no secondary displacement can be seen x - ray . another actual projection . under general anesthesia , patient was placed in beach chair position , with circumferential accessibility to the left shoulder , and the operative arm was draped free . the arthroscope was placed through a standard posterior arthroscopic portal and an arthroscopic cannula anteriorly . the shoulder was held in a position of 30 of flexion , 30 of abduction , and 30 of internal rotation , while a radius bur was used to denude the articular surfaces of both the humeral head and glenoid to bleeding subchondral bone . an anterior cruciate ligament guide was used to direct percutaneous placement of two guidewires through the proximal humerus from lateral to medial and into the joint under direct arthroscopic visualization . both guidewires were driven through the center of the glenoid , where they were then measured and reamed for placement of 6.5-mm cannulated cancellous screws . with the arm held in the appropriate position , sequential tightening of the screws achieved adequate compression of the glenohumeral surfaces . the positions of the two glenohumeral screws were verified with biplanar fluoroscopy before a third 6.5-mm cannulated cancellous screw was placed from the lateral edge of the acromion into the humeral head inferiorly toward the shaft - glenoid . finally , we did not need bone graft , because we achieved total compression into the glenohumeral joint before incisions were closed . an abduction pillow was placed under the operative arm , holding it in the appropriate position , and kept in place for 3 months . rehabilitation consisted of passive assisted exercises and progressed to active assisted exercises after 4 weeks [ figures 57 ] . glenohumeral joint viewed from standard arthroscopic portal after we denuded articular surfaces of both humeral head and glenoid to bleeding subchondral bone , we used two guidewires through the proximal humerus from lateral to medial and into the joint under direct arthroscopic visualization . both guidewires were driven through the center of the glenoid see initial placement of one 6.5-mm cannulated cancellous screw arthroscopic shoulder orientation , a good level of experience in glenolabral arthroscopic surgery , and management of anterior cruciate ligament guides are very important points in this procedure . one typical pitfall is tightening of screws without previous correct arthroscopic control or loosening of guide position before tightening cannulated cancellous screws . another interesting point is that threads of the screws must engage across the joint into the glenoid to ensure solid bone compression . we consider that this arthroscopic technique is better than the open one , because it is a less - invasive procedure . with two arthroscopic portals and percutaneous cancellous screws , we can achieve similar results , without problems like intolerance of the material , due to protrusion at the side of the acromion with posterior removal , risk of infection , and risk of fractures of the humerus after surgery with plates . clinical evolution developed favorably , since surgery pain disappeared , and the arm became functional for everyday activities . at this moment , 14 years later , this patient is still working with the same paralysis , in a workplace that has been adapted to his pathology . he presents movement arc of 0 - 90 for anterior flexion , maximum abduction of 20 , and atrophy of the deltoid , supraspinatus , and infraspinatus . we have measured 47 points on constant 's test and 17 points on the ucla scale . we tried to achieve radiographic arthrodesis , but finally , we could see a gap between the bone of the glenoid and the humeral head , with no secondary displacement , infectious complications , or intolerance of material , and patient is satisfied with results of this surgery [ figures 8 and 9 ] . we consider that it is very important fact that the threads of the screws cross the joint , in order to achieve solid compression of the bone . we only had these screws several years ago , with a long area of threads . we think we have to warn the readers to ensure that the threads of the screws engage across the joint into the glenoid to ensure solid bone compression . with this warning , fourteen years later , we think that structure stability is present , although with gap between the bone of the glenoid and the humeral head , glenohumeral fibrous union , and no secondary displacement at present , movement arc is 0 - 90anterior flexion , maximum abduction of 20 , with atrophy of the deltoid , supraspinatus , and infraspinatus muscles . 47 points on the constant scale and 17 points on the ucla scale recently , in the last revision , after 14 years and 8 months of follow - up , patient suffered a trauma on the affected shoulder , with minimal pain . however , movement arc did not change : 0 - 90 for anterior flexion , maximum abduction of 40 , and atrophy of the deltoid , with the same result in constant 's and ucla scales . we only have seen one broken screw , and fibrous union is reached on the x - ray study . however , fibrous union with no secondary displacement can be seen x - ray . another actual projection . among the procedures that have been described for arthrodesis of the shoulder , various alternatives have been suggested . osteosynthesis using 1 or 2 plates is a priori the most solid system , although it has the drawback that material has to be withdrawn , which involves risk of infection and skin necrosis . pelvic reconstruction plates and locking compression plates ( lcp ) have been proposed . they are easier to adapt to this type of surgical procedure , as described by richards et al . this place avoids the problem of intolerance of the material , because it decreases protrusion at the side of the acromion when screws are inserted . there is also a high degree of compression , and physiotherapy can be started at an early stage . on the other hand , arthrodesis with cancellous bone screws offers the most effective system , with a subjective improvement reported by patients in 82% of cases , when three screws are used : two glenohumeral screws and one acromiohumeral screw . rhmann et al . compared systems based on plates and screws , and observed that although the degree of pseudoarthrosis appeared to be less severe when plates were used , there was a greater risk of infection , there were more fractures of the humerus after surgery , and material needed to be removed more often than when screws were used . arthrodesis performed with screws offered more benefits , because it required less - invasive surgery , even though the patient had to be immobilized for longer time than when plates were used . however , it has certain complications , such as loosening of the pins , infection of their route , or fracture at the insertion points . arthroscopic arthrodesis with screws has only been described in a few cases,[57 ] although it is a procedure that allows complete visualization of joint surface so that accurate acromiohumeral and glenohumeral decortication can be performed , with a minimum degree of surgical aggressiveness . we think we have to warn the readers to ensure that the threads of the screws engage across the joint into the glenoid to ensure solid bone compression , in order to achieve a better technical and radiological result . to obtain an optimum functional result in arthrodesis , trapezius , levator scapulae , serratus anterior , and rhomboid muscles must be able to function properly . moreover , according to safran and iannotti , the use of a vascularized autologous graft from the iliac crest or fibula improves the rates of consolidation in such procedures . shoulder is placed at 15 - 30 flexion , 35 - 45 abduction , and 30 - 40 internal rotation . safran and iannotti recommend another position of 20 of anterior flexion , 20 of abduction , and 40 of internal rotation . the most frequent complications of shoulder arthrodesis are pseudoarthrosis ( 4 - 12% or 5 - 20% ) , humerus fractures ( 10 - 15% , 50% of which are in patients with brachial plexus palsy ) , pain ( 25% or 30% ) , infection ( 3 - 5% ) , skin necrosis , and acromioclavicular arthrosis . we consider that arthroscopic shoulder arthrodesis should be the procedure of choice in post - traumatic omarthrosis where there is injury of brachial plexus , because clinical results are favorable and there are few complications . threads of the screws must engage across the joint into the glenoid to ensure solid bone compression , in order to achieve solid bone compression and no fibrous union .
shoulder arthrodesis is indicated in infections , brachial paralysis , irreparable rotator cuff tears , osteoarthritis without indication of prosthesis , rescue after arthroplasty , or after surgery for cancer . 
 arthroscopic arthrodesis is exceptional . 
 our aim is presenting our result after 14 years of follow - up of one patient . 
 we present a case report of a 17-year - old male patient . 
 he suffered fracture of left scapula ( type v , ideberg ) , fracture of left clavicle ( type i , craig ) , and fracture of left distal ulna . 
 we realized osteosynthesis of clavicle ( plate and screws ) with the aim of treating this floating shoulder . 
 electromyography showed partial axonotmesis of axilar nerve . 
 after 7 months of follow - up , axonotmesis was still present . 
 we realized arthroscopic shoulder arthrodesis ( three cannulated screws ) . 
 fourteen years later , shoulder movement was as follows : flexion , 0 - 90 ; maximum abduction , 40 with shoulder atrophy ; constant , 47 points ; and ucla , 17 points , without pain . arthrodesis with screws reaches a subjective benefit in 82% of patients . 
 percentage of pseudarthrosis is less than in patients treated with plates , although the risks of infections , fractures , and material removal are greater than in patients treated with plates . 
 shoulder arthroscopic arthrodesis is exceptional , but it allows minimal surgical aggression .