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To report clinical and radiologic outcomes of arthroscopic Eden-Hybinette using 2 cortical suture buttons in a series of patients with previous failed Latarjet and persistent glenoid bone loss.Between 2015 and 2019, patients with recurrent anterior instability after failed Latarjet underwent arthroscopic Eden-Hybinette procedure using 2 cortical buttons for graft fixation. Exclusion criteria were open and primary Eden-Hybinette and less than one year follow-up. Functional assessment was performed using Rowe and Walch-Duplay scores, subjective shoulder value, visual analog scale, and degree of satisfaction. Iliac crest bone graft placement and healing were assessed postoperatively with computed tomography imaging.A total of 17 patients with a mean age of 28 years (range, 21-43 years) at time of revision were included. The mean glenoid bone loss was 23% (range, 18%-42%). Medium or deep Hill-Sachs lesion (Calandra 2 and 3) was present in 65% of cases. At a mean follow-up of 3 ± 1.6 years, all but 1 patient (94%) considered their shoulder stable, and 15 patients (88%) were satisfied or very satisfied. The subjective shoulder value increased from 51% to 87% (P.05), the Walch-Duplay increased from 23 to 86 points (P.05), and Rowe scores improved from 30 to 92 points (P.05). Apprehension was still positive in 3 patients (17.6%), with this percentage being greater in the presence of Hill-Sachs Calandra 3 (P = .02). Postoperative computed tomography scans showed optimal bone autograft position in all patients (below the glenoid equator and flush to the glenoid rim). Iliac crest bone graft healed to the anterior glenoid neck in 16 shoulders (94%). The rate of recurrent instability was 11.7% but only 1 patient required revision surgery (5.8%).Arthroscopic Eden-Hybinette using 2 cortical buttons leads to satisfactory clinical outcomes and a low recurrence rate after failed Latarjet, allowing successful reconstruction of the anterior glenoid rim and simultaneous treatment of capsular deficiency and humeral bone loss.Therapeutic, level IV, retrospective case series.

BACKGROUND Gradual loss of overhead range of motion (ROM) has been observed after reverse shoulder arthroplasty (RSA). It remains unclear if this is caused by the effect of RSA design on muscle fiber lengthening or is part of the natural aging process of the shoulder musculature. Although studies have attempted to evaluate deltoid fatigue after RSA, there is a paucity of literature evaluating this effect after anatomic shoulder arthroplasty (aTSA), which would be expected to occur due to aging alone. The purpose of this study is to evaluate the effect of time on overhead ROM after aTSA and compare this with previous data on a similar cohort of RSAs. We hypothesized that overhead ROM would decrease gradually over time in both groups without differences between prosthesis types. METHODS A retrospective review of 384 aTSAs without complications was performed over a 10-year period. All shoulders were treated for primary osteoarthritis using a single implant system. Patients were evaluated longitudinally at multiple postoperative time points. At least 1 follow-up visit was between 1 and 2 years postoperatively and another at least 5 years after surgery. ROM and patient reported outcome measures (PROMs) were evaluated using linear-mixed models for repeated measures. These results were compared with a previously evaluated cohort of 165 well-functioning RSAs analyzed using the same methodology. RESULTS Primary aTSA shoulders were observed to lose 0.7° of abduction per year starting 1 year postoperatively (P = .001). Smaller losses were observed in external rotation (-0.3°/yr, P = .06) and internal rotation (-0.04/yr, P < .001). However, no significant losses were observed in forward elevation (P = .8). All PROMs diminished slowly over time, but these changes did not exceed the minimally clinically important difference when modeled over 10 years (Simple Shoulder Test -0.08/yr, P < .001; American Shoulder Elbow Surgeons -0.5/yr, P < .001; University of California Los Angeles Shoulder Score -0.2/yr, P < .001). When compared with a similarly analyzed cohort of RSAs, overhead ROM decreased at a slower rate in the aTSA cohort (abduction -0.7° vs. -0.8°/yr, P = .9; FE -0.06° vs. -0.8°/yr, P = .05). DISCUSSION In the well-functioning aTSA, gradual loss of ROM occurs in all planes of motion except forward elevation. However, these losses are small and have little meaningful impact relative to minimally clinically important difference thresholds on PROMs. Progressive loss of abduction seen in both aTSA and RSA is likely secondary to aging of the periscapular and rotator cuff musculature. When compared with RSA, loss of motion after aTSA was statistically similar, calling into question the belief that RSA-induced deltoid fatigue leads to loss of overhead motion over time.

The trapezius muscle produces upward scapular rotation that in turn allows complete lateral elevation (abduction) by maintaining the acromiohumeral distance and the deltoideus resting length. Loss of trapezius function leads to shoulder drooping, loss of scapular external rotation with secondary loss of abduction. When conservative treatment has failed and in cases where nerve surgery is not indicated, the most common procedure for treating this condition is the Eden-Lange (EL) procedure. This procedure entails transferring the levator scapulae (LS) to the lateral part of the scapular spine, and the rhomboid major (RM) and minor (Rm) to the infraspinatus fossa to restore the lost trapezius function. Recently, Elhassan et al. proposed a modification of the original EL procedure to recreate the line of pull of the different parts of the trapezius muscle. The modified transfer may yield successful outcomes in patients with trapezius paralysis who failed to improve after well-conducted conservative treatment. Longer follow-up is needed to confirm the stability of the good outcomes of this reconstruction.

INTRODUCTION It has been well established that the subscapularis is divided in two different parts with a tendinous insertion at its superior two-thirds and a muscular attachment on its inferior third. The objective of this cadaveric study was to follow the muscular insertion of the subscapularis medially in order to determine the origin of this inferior muscle insertion and whether a subscapularis minor can be individualized MATERIALS AND METHODS: Twenty-six shoulders from thirteen fresh-frozen cadaveric specimens (5 males and 8 females; mean age, 74.4 years) were dissected in our anatomy lab. The humeral insertion of the subscapularis was then analyzed, and the inferior muscular part of the insertion was identified. The muscle fibers were followed medially until their scapular origin which was recorded as line drawings and photographs. We measured the dimensions of both the humeral insertion and of the scapular origin of the fibers going to the muscular portion. RESULTS In all cases, the fibres going to the tendinous portion and those going to the muscular portion of the insertion had a different orientation. The fibres going to the muscular portion of the humeral insertion did not originate from the subscapularis fossa but on the glenoid neck and in a depression at the infero-lateral part of the scapular pillar. The mean length of the superior tendinous portion of the humeral insertion was 3.42 cm (± 0.43 cm); the mean length of the inferior muscular portion of the humeral insertion was 1.88 cm (± 0.80 cm). The mean length of the scapular origin in the depression at the infero-lateral part of the scapular pillar of the fibres going to the muscular portion of the humeral insertion was 3.7 cm (± 0.17 cm). CONCLUSION The fibres of the subscapularis do not all originate from the subscapularis fossa. An additional origin exists at the inferior part of the glenoid neck and in a depression at the infero-lateral part of the scapular pillar. The fibers which originate at this location all insert on the humerus at the muscular portion of the subscapularis humeral insertion. This portion however does not seem to correspond to the so-called subscapularis minor which has been previously described.

Resume Introduction Depuis la proposition en 2012 de Mihata de reconstruire sous arthroscopie la capsule superieure des patients ayant une rupture massive irreparable de la coiffe, de nombreux articles ont rapporte les resultats cliniques de cette technique en utilisant differents types de greffons (autogreffe de fascia lata, allogreffe de derme, xenogreffe porcine de derme ou autogreffe du long biceps). Objectif L’objectif de cette meta-analyse etait de rapporter les resultats cliniques et radiologiques de ces reconstructions capsulaires superieures. Methodes Les recommandations PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) ont ete utilisees pour mener cette revue systematique. Une recherche bibliographique a ete effectuee dans les bases de donnees electroniques MEDLINE, Scopus, Embase et la Cochrane Library. La qualite des etudes a ete evaluee selon le critere MINORS (Methodological Index for Nonrandomized Studies). Les criteres d’inclusion etaient les etudes en anglais evaluant la reconstruction capsulaire superieure. Resultats Aucune etude de niveau I ou II ne repondait aux criteres d’inclusion. Dix-huit etudes ont ete selectionnees parmi les 97 identifiees, incluant 637 epaules (64 % d’hommes) avec un âge moyen de 62 ans [IC95 % : 60,3–63,5]. Au recul moyen de 24,3 mois (12–60), les amplitudes articulaires etaient significativement augmentees de 82,6° [60,0–105,2] a 141,9° [109,9–173,8] en abduction, de 113,1° [98,3–127,9] a 153,3° [147,4–159,2] en elevation, de 35,5° [30,9–40,2] 43,4° [35,4–51,3] en rotation externe et de 7,2 [5,4–9] a 9,9 [8,9–10,9] en rotation interne. Les scores fonctionnels etaient significativement ameliores de 5,4 [4,8–5,9] a 1,3 [0,9–1,7] points pour le VAS, de 42,5 [15,7–69,3] a 59,3 [30,1–88,6] points pour le Constant, de 39,0 % [38,1–39,8] a 79,8 % [76,4–83,3] pour le SSV, et de 48,2 [45,2–51,1] a 81,2 [77,2–85,1] points pour l’ASES. Le taux de cicatrisation est de 76,1 % [64,4–84,9]. Le taux de complication etait de 5,6 % [1,8–16,3] et le taux de reprise par prothese inversee representait 7,1 % [3,8–12,8]. Conclusion Les reconstructions capsulaires superieures permettent d’obtenir des resultats cliniques et radiologiques satisfaisants a 2 ans de recul. La faible quantite d’etudes comparatives de haut niveau de preuve ne permet pas de conclure sur la place a reserver a cette technique chirurgicale dans l’arsenal therapeutique. Cependant, il semble que la meilleure indication pour cette technique soit la rupture irreparable isolee du supraspinatus en echec de traitement medical. Niveau de preuve III Meta-analyse d’etudes heterogenes.

Background Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatologic disease that occurs in the pediatric population. Often, JIA continues throughout life leading to progressive polyarticular arthritis and significant joint destruction and disability, oftentimes requiring replacement surgery. This study aimed to determine the outcomes of primary shoulder arthroplasty (SA) in patients with JIA. Methods Over a 42-year time period (1977 - 2019), 67 primary SA (20 hemiarthroplasty (HA), 38 anatomic total shoulder arthroplasty (TSA), and 9 reverse shoulder arthroplasty (RSA)) with a prior diagnosis of JIA formally established in a multi-disciplinary rheumatologic clinic met inclusion criteria. Further assessment was performed with inclusion of the visual analog scale (VAS) pain score, active shoulder range of motion (ROM), imaging studies, complications, and implant survivorship free from reoperation and revision. Results SA led to substantial improvements in pain and ROM across the entire cohort at an average follow-up period of 12.2 years (range, 2- 34 years). TSA was associated with the lowest pain scores (0.8; p = 0.02) and the highest ASES scores (77.4; p = 0.04) at most recent follow-up when compared to HA and RSA. There were 14 (21%) complications across the cohort with rotator cuff failure (n=4; 5.9%) as the most common complication followed by infection (n=3; 4.5%). Revision surgery was performed in 5 shoulders (7.5%), with five-year implant survival rates of 95.1% at five years, 93% at ten years, 89.4% at twenty years, and 79.5% at thirty years. At 30 years, TSA was associated with better survival (90.1%) when compared with HA (71.8%). Conclusions Primary shoulder arthroplasty in the form of HA, TSA, and RSA offers a reliable surgical option for JIA patients with respect to pain reduction and ROM improvements. Unique challenges still exist in this cohort, in particular younger patients with an elevated propensity for glenoid bone erosion and a complication rate of 20.9%. As such, HA may not be ideal in this patient population. However, despite rotator cuff and glenoid concerns, TSA seems to be associated with better pain relief and patient reported outcomes with the most durability in the long term when compared to HA. Level of evidence Level III; Retrospective Cohort Comparison; Treatment Study.

INTRODUCTION Rotator cuff repair (RCR) is commonly performed before reverse shoulder arthroplasty (RSA) with conflicting evidence on the effect on arthroplasty outcomes. The purpose of this investigation was to evaluate the effect of a prior RCR on the outcomes and complications of primary RSA. METHODS Between 2007 and 2017, 438 RSAs performed in patients with a prior RCR and 876 case-matched controls were identified from a multicenter database. Patients were grouped based on a preoperative diagnosis of glenohumeral osteoarthritis (GHOA) and rotator cuff tear arthropathy (CTA). Data collected included range of motion, strength, complications, and revisions. Additional clinical metrics included American Shoulder and Elbow Society score, Constant score, Shoulder Pain and Disability Index, Simple Shoulder Test, and the University of California Los Angeles shoulder score. RESULTS Compared with controls, both GHOA and CTA study groups demonstrated lower postoperative forward elevation (FE) (133° versus 147°, P < 0.001; 133° versus 139°, P = 0.048) and FE trength (6.5 versus 8.2, P = 0.004; 6.1 versus 7.3, P = 0.014). In addition, inferior improvements were observed in the GHOA and CTA study groups with respect to abduction (38° versus 52°, P = 0.001; 36° versus 49°, P = 0.001), FE (41° versus 60°, P < 0.001; 38° versus 52°, P = 0.001), ER (16° versus 25°, P < 0.001; 10° versus 17°, P = 0.001), and Constant score (28.4 versus 37.1, P < 0.001; 26.2 versus 30.9, P = 0.016). Compared with controls, no differences were observed in the GHOA and CTA study groups with respect to notching (11.2% versus 5.6%, P = 0.115; 5.8% versus 7.9%, P = 0.967), complications (4.3% versus 1.6%, P = 0.073; 2.5% versus 2.7%, P = 0.878), and revision surgery (3.1% versus 0.9%, P = 0.089; 1.1% versus 1.3%, P = 0.822). CONCLUSION RSA after a prior RCR improves both pain and function, without increasing scapular notching, complications, or revision surgery. However, compared with patients without a prior RCR, postoperative shoulder function may be slightly decreased. LEVEL OF EVIDENCE III; Retrospective Cohort Study.

Patients with Ehlers-Danlos syndrome (EDS) have high rates of shoulder instability, which place them at increased risk for instability-related arthropathy. Many studies have assessed outcomes for both primary and revision shoulder instability procedures in this patient population, but there is a paucity of data regarding the outcome of shoulder arthroplasty in EDS patients. The purpose of this study is to evaluate the results and complications of shoulder arthroplasty (SA) performed in a cohort of patients with EDS and compare them to a matched cohort of patients with no EDS.Over an 11-year period, 10 patients with EDS were identified at a single institution who underwent primary SA (6 anatomic total shoulder arthroplasties [aTSAs], 4 reverse shoulder arthroplasties [RTSAs]). Shoulders were evaluated at a mean follow-up of 60 months (range 25-97 months). This cohort was matched 1:2 based on age, sex, and year of surgery, with patients who underwent SA for either primary osteoarthritis (OA) for aTSA or cuff tear arthropathy for RTSA. EDS patients had a mean age of 55 years, mean body mass index of 26.1, and were all female. The primary outcome measures were postoperative pain, range of motion, complications, and reoperations.SA produced similar postoperative pain, range of motion, complications, and reoperations in patients with EDS vs. controls. EDS patients improved pre- to postoperative visual analog scale (VAS) pain score (6.5 to 1.7, P.001), elevation (96° to 138°, P = .04), and external rotation (36° to 57°, P = .16). Three EDS patients sustained postoperative complications (2 instability and 1 acromial fracture); however, no shoulder was reoperated.EDS patients undergoing SA can expect outcomes comparable to patients with primary OA or cuff tear arthropathy, with clinically meaningful improvements in pain and range of motion. Although EDS patients had no statistically significant increase in complications when compared to controls, their absolute rate of overall complications (3/10 patients; 30%) and postoperative instability (2/10 patients; 20%) in this small case series was relatively high and should be considered when performing SA.

Introduction Implantation of a reverse shoulder arthroplasty (RSA) impacts deltoid length, shape and tension. Quantification of changes in deltoid muscle tension with implantation of RSA has remained elusive. The purpose of this study was to use shear wave elastography (SWE) to quantify deltoid muscle stiffness preoperatively, intraoperatively and postoperatively in patients undergoing RSA. Methods Twenty patients scheduled to undergo RSA (ReUnion, Stryker) were prospectively enrolled in this study. A single observer trained in SWE quantified deltoid stiffness preoperatively, intraoperatively, and postoperatively. Clinical evaluation included pain, motion, quickDASH, ASES, Oxford, and subjective shoulder value scores. Preoperative and postoperative radiographs were measured by an independent observer to determine the lateralization and distalization shoulder angles (LSA and DSA). A statistical analysis was then performed to determine whether changes in deltoid muscle stiffness correlated with any of these parameters. Results Implantation of a RSA lead to an increase SWE deltoid stiffness value from 22.4 ± 4.2 kPa preoperatively to 29.9 ± 5.23 kPa (P˂ .0001) immediately after surgery, and 26.6 ± 6.6kPa (P= .03) at most recent follow-up. Preoperative SWE deltoid stiffness values did not differ when measured in the office or under anesthesia. Reverse arthroplasty did not significantly change the LSA (P= .051), but did increase the DSA (P Conclusion After implantation of one RSA design incorporating glenoid and humeral lateralization, deltoid stiffness as measured with SWE increased significantly. Deltoid stiffness seems to correlate with joint distalization, elevation and external rotation. SWE seems to be reliable to quantify deltoid stiffness after reverse shoulder arthroplasty. Level of Evidence Level IV; Diagnostic Study

Component selection and placement in reverse total shoulder arthroplasty (RTSA) is still being debated. Recently, scapulothoracic orientation and posture have emerged as relevant factors when planning an RTSA. However, the degree to which those parameters may influence ROM and whether modifiable elements of implant configuration may be helpful in improving ROM among patients with different postures have not been thoroughly studied, and modeling them may be instructive.Using a dedicated expansion of a conventional preoperative planning software, we asked: (1) How is patient posture likely to influence simulated ROM after virtual RTSA implantation? (2) Do changes in implant configuration, such as humeral component inclination and retrotorsion, or glenoid component size and centricity improve the simulated ROM after virtual RTSA implantation in patients with different posture types?In a computer laboratory study, available whole-torso CT scans of 30 patients (20 males and 10 females with a mean age of 65 ± 17 years) were analyzed to determine the posture type (Type A, upright posture, retracted scapulae; Type B, intermediate; Type C, kyphotic posture with protracted scapulae) based on the measured scapula internal rotation as previously described. The measurement of scapular internal rotation, which defines these posture types, was found to have a high intraclass correlation coefficient (0.87) in a previous study, suggesting reliability of the employed classification. Three shoulder surgeons each independently virtually implanted a short, curved, metaphyseal impaction stem RTSA in each patient using three-dimensional (3D) preoperative surgical planning software. Modifications based on the original component positioning were automatically generated, including different humeral component retrotorsion (0°, 20°, and 40° of anatomic and scapular internal rotation) and neck-shaft angle (135°, 145°, and 155°) as well as glenoid component configuration (36-mm concentric, 36-mm eccentric, and 42-mm concentric), resulting in 3720 different RTSA configurations. For each configuration, the maximum potential ROM in different planes was determined by the software, and the effect of different posture types was analyzed by comparing subgroups.Irrespective of the RTSA implant configuration, the posture types had a strong effect on the calculated ROM in all planes of motion, except for flexion. In particular, simulated ROM in patients with Type C compared with Type A posture demonstrated inferior adduction (median 5° [interquartile range -7° to 20°] versus 15° [IQR 7° to 22°]; p0.01), abduction (63° [IQR 48° to 78°] versus 72° [IQR 63° to 82°]; p0.01), extension (4° [IQR -8° to 12°] versus 19° [IQR 8° to 27°]; p0.01), and external rotation (7° [IQR -5° to 22°] versus 28° [IQR 13° to 39°]; p0.01). Lower retrotorsion and a higher neck-shaft angle of the humeral component as well as a small concentric glenosphere resulted in worse overall ROM in patients with Type C posture, with severe restriction of motion in adduction, extension, and external rotation to below 0°.Different posture types affect the ROM after simulated RTSA implantation, regardless of implant configuration. An individualized choice of component configuration based on scapulothoracic orientation seems to attenuate the negative effects of posture Type B and C. Future studies on ROM after RTSA should consider patient posture and scapulothoracic orientation.In patients with Type C posture, higher retrotorsion, a lower neck-shaft angle, and a larger or inferior eccentric glenosphere seem to be advantageous.

PURPOSE The aim of this study was to describe the results of an arthroscopic Trillat procedure utilized to treat patients with symptomatic antero-inferior shoulder instability associated with hyperlaxity. METHODS A retrospective review was performed on 19 consecutive shoulders (17 patients, 2 bilateral) who underwent a Trillat procedure combined with anterio-inferior capsulolabral plasty from 2016 to 2019. Patients included in the study presented with shoulder instability combined with shoulder hyperlaxity and no glenoid or humeral bone loss. Clinical assessment included range of motion, apprehension, and instability tests. Outcome measures Constant-Murley score (CMS) scale, Walch-Duplay, ROWE, Subjective Shoulder Value (SSV), Visual Analogue Scale (VAS). Post-operatively, healing of the coracoid osteoclasy was evaluated by CT scan. RESULTS The mean follow-up was 24.8 months (range, 12-51). Post-operatively, none of the patients experienced a recurrent dislocation or subluxation and the anterior apprehension test was negative in all shoulders. Post-operative motion deficits of 22.1° ± 15.8 [p

The primary objective of this study was to obtain a reliable method of automatic segmentation of shoulder muscles. The secondary objective of this study was to define a new computed tomography (CT)-based quantitative 3-dimensional (3D) measure of muscle loss (3DML) based on the rationale of the 2-dimensional (2D) qualitative Goutallier score. 102 CT scans were manually segmented and an algorithm of automated segmentation of the muscles was created. The volume of muscle fibers without intramuscular fat was then calculated for each rotator cuff muscle and normalized to the patient's scapular volume to account for the effect of body size (NVfibers). 3D muscle mass (3DMM) was calculated by dividing the NVfibers value of a given muscle by the mean expected volume in healthy shoulders. 3D muscle loss (3DML) was defined as 1 - (3DMM). Automated segmentation of the muscles was possible with a mean Dice of 0.904 ± 0.01 for the deltoid, 0.887 ± 0.014 for the infraspinatus (ISP), 0.892 ± 0.008 for the subscapularis (SSC), 0.885 for the supraspinatus (SSP) and 0.796 ± 0.006 for the teres minor (TM). The mean values of 3DFI and 3DML were 0.9% and 5.3% for Goutallier 0, 2.9% and 25.6% for Goutallier 1, 11.4% and 49.5% for Goutallier 2, 20.7% and 59.7% for Goutallier 3, and 29.3% and 70.2% for Goutallier 4, respectively. 3DML measurements obtained automatically incorporate both atrophy and fatty infiltration, thus they could become a very reliable index for assessing shoulder muscle function which could help in the decision process in shoulder surgery

Aims The aim of this study was to describe a quantitative 3D CT method to measure rotator cuff muscle volume, atrophy, and balance in healthy controls and in three pathological shoulder cohorts. Methods In all, 102 CT scans were included in the analysis: 46 healthy, 21 cuff tear arthropathy (CTA), 18 irreparable rotator cuff tear (IRCT), and 17 primary osteoarthritis (OA). The four rotator cuff muscles were manually segmented and their volume, including intramuscular fat, was calculated. The normalized volume (NV) of each muscle was calculated by dividing muscle volume to the patient’s scapular bone volume. Muscle volume and percentage of muscle atrophy were compared between muscles and between cohorts. Results Rotator cuff muscle volume was significantly decreased in patients with OA, CTA, and IRCT compared to healthy patients (p < 0.0001). Atrophy was comparable for all muscles between CTA, IRCT, and OA patients, except for the supraspinatus, which was significantly more atrophied in CTA and IRCT (p = 0.002). In healthy shoulders, the anterior cuff represented 45% of the entire cuff, while the posterior cuff represented 40%. A similar partition between anterior and posterior cuff was also found in both CTA and IRCT patients. However, in OA patients, the relative volume of the anterior (42%) and posterior cuff (45%) were similar. Conclusion This study shows that rotator cuff muscle volume is significantly decreased in patients with OA, CTA, or IRCT compared to healthy patients, but that only minimal differences can be observed between the different pathological groups. This suggests that the influence of rotator cuff muscle volume and atrophy (including intramuscular fat) as an independent factor of outcome may be overestimated. Cite this article: Bone Jt Open 2021;2(7):552–561.

Tissue banking programs fail to meet the demand for human organs and tissues for transplantation into patients with congenital defects, injuries, chronic diseases, and end-stage organ failure. Tendons and ligaments are among the most frequently ruptured and/or worn-out body tissues owing to their frequent use, especially in athletes and the elderly population. Surgical repair has remained the mainstay management approach, regardless of scarring and adhesion formation during healing, which then compromises the gliding motion of the joint and reduces the quality of life for patients. Tissue engineering and regenerative medicine approaches, such as tendon augmentation, are promising as they may provide superior outcomes by inducing host-tissue ingrowth and tendon regeneration during degradation, thereby decreasing failure rates and morbidity. However, to date, tendon tissue engineering and regeneration research has been limited and lacks the much-needed human clinical evidence to translate most laboratory augmentation approaches to therapeutics. This narrative review summarizes the current treatment options for various tendon pathologies, future of tendon augmentation, cell therapy, gene therapy, 3D/4D bioprinting, scaffolding, and cell signals.

While most patients undergoing reverse total shoulder arthroplasty (rTSA) have substantial improvement in pain and function at early follow-up, improvements in pain and range of motion (ROM) progress more slowly during postoperative rehabilitation in a subset of patients. The purpose of this study was to define a patient's risk of persistent shoulder dysfunction beyond the early postoperative period and identify risk factors for persistent poor performance.We retrospectively reviewed 292 primary rTSAs with early poor performance and a preoperative diagnosis of osteoarthritis, cuff-tear arthropathy, or rotator cuff tear from a multicenter database. Early poor performance was defined as a postoperative ASES score below the 20At 2-year follow-up, 61% (178) of patients with poor performance at either 3- or 6-month follow-up had persistent poor performance. This increased to 85% if poor performance occurred at both 3- and 6-month follow-up. The minimal clinically important difference (MCID) and substantial clinical benefit (SCB) for ROM and outcome scores was exceeded by early poor performers at rates of 83-92% and 60-77% at 2-year follow-up, respectively. On multivariate logistic regression, independent predictors of persistent poor performance after rTSA were lack of hypertension (0.27 [0.13-0.57], P0.001), heart disease (2.89 [1.24-6.77], P=0.011), uncemented humeral fixation (0.11 [0.01-1.18], P =0.037), previous shoulder surgery (2.14 [1.06-4.30], P=0.031), a lower preoperative ASES score (0.92 [0.87-0.97], P=0.002), and lower preoperative subjective pain at worst (0.73 [0.54-0.99], P=0.038).Despite the fact that 85% of rTSA patients with an ASES score below the 20

Background Studies evaluating the mid-term performance of reverse shoulder arthroplasty (RSA) have identified a drop in the Constant-Murley score between 6 and 8 years after surgery, which is most affected by a loss of forward elevation and strength. Alterations of the deltoid length and moment arm after RSA lead to nonphysiological stress on the deltoid muscle. Concern has arisen that the long-term implications of increased deltoid work may be causing “deltoid fatigue.” The purpose of this study was to evaluate the long-term effects of RSA on overhead range of motion (ROM) and validate the hypothesis of deltoid fatigue. Methods We performed a retrospective review of 165 RSAs over a 5-year period. Diagnoses were limited to cuff tear arthropathy, osteoarthritis with rotator cuff deficiency, and irreparable rotator cuff tear. All procedures were performed using a single implant system. Patients were evaluated longitudinally at multiple time points. They were required to undergo a minimum of 3 follow-up visits, with at least 1 visit at >5 years. ROM and patient-reported outcome measures were evaluated using linear mixed models for repeated measures to evaluate changes in outcome measures over time. A secondary analysis was performed to assess the influence of patient demographic factors on observed changes in ROM and patient-reported outcome measures. Results Primary RSA shoulders were observed to lose 0.8° of forward elevation and abduction per year starting at 1 year postoperatively (P = .006), without a significant drop at mid-term follow-up. No significant change in external or internal rotation was observed. Male patients and patients with a diagnosis of osteoarthritis with rotator cuff deficiency showed greater baseline overhead ROM at 1 year postoperatively, but the subsequent rates of functional decline were similar regardless of age, sex, or indication. Discussion This study challenges the previous theory of deltoid fatigue resulting in a significant loss of overhead ROM beginning 6-8 years after index arthroplasty. However, a slower progressive decline in overhead ROM in well-functioning RSA shoulders was observed, averaging 0.8° of overhead ROM per year. This progressive deterioration occurs at a slightly greater rate than that observed in the natural shoulder. The observed rate of functional decline was found to be independent of age, sex, and preoperative diagnosis.

Patient dissatisfaction after primary reverse total shoulder arthroplasty (rTSA) has been reported as high as 9%. In patients with excessive thoracic kyphosis, the scapula protracts and tilts anteriorly, which may lead to early impingement with the acromion and loss of forward elevation. The primary purpose of this study was to evaluate the effect of thoracic kyphosis on overhead ROM after rTSA.A prospectively collected shoulder registry was retrospectively reviewed for all patients undergoing primary rTSA with a minimum of 2-year follow-up. Preoperative and latest follow-up ROM (forward elevation, abduction, internal rotation, and external rotation), patient-reported outcome measures (SPADI, SST-12, ASES, UCLA, SF-12, and the visual analog scale), and the Constant score were collected. Postoperative radiographs were evaluated for implant loosening and notching. Patients were separated into three groups according to the thoracic kyphosis angle (25°, 25 to 45°, and45°) and also analyzed as a continuous variable. The groups were compared using analysis of variance and chi-square tests as indicated.Three hundred five shoulders in 279 patients were reviewed at a mean follow-up of 3.9 years (range 2 to 10 years). Female patients and patients with a history of heart disease were statistically more likely to have increased thoracic kyphosis (P0.05). After surgery, forward elevation and abduction were similar among all groups (25: 133°, 25 to 45: 132°,45: 127°; P = 0.199 and25: 123°, 25 to 45: 122°,45: 117°; P = 0.330). All other postoperative ROM measurements and all patient-reported outcome measures were also similar, regardless of measured kyphosis. In addition, no association was observed between the degree of thoracic kyphosis and scapular notching (P = 0.291).Despite thoracic kyphosis being a known risk factor for loss of overhead motion in the native shoulder, shoulders with excessive thoracic kyphosis demonstrated similar overhead ROM at early follow-up after primary rTSA.III.

Therapeutic management of recurrent anterior shoulder instability with an anterior glenoid defect and a Hill-Sachs lesion requires a bone graft to restore the width of the glenoid. The Latarjet procedure is the most popular technique but an iliac crest bone graft is preferred when the coracoid process is dysplastic or too short or after failure of Latarjet or Bristow-Latarjet. The purpose of this manuscript is to describe a full arthroscopic Eden-Hybinette-guided technique with 2 cortical suture buttons for bone graft fixation. This procedure allows reconstruction of severe glenoid bone defects and treatment of concomitant capsulolabral lesions and humeral bone loss, while preserving the subscapularis muscle. In addition, the use of 2 cortical buttons for bone graft fixation simplify graft transport and positioning, provides good control of the rotation, improving healing of the iliac crest bone graft to the anterior glenoid rim.

Background: Latissimus dorsi tendon transfer (LDTT) is increasingly performed with arthroscopic assistance, requiring an open axillary incision, which could increase risks of infection, hematoma, and lymphoedema. Technological advancements now enable LDTT to be fully arthroscopic, but its benefits and safety have not yet been confirmed. Purpose: To compare the clinical outcomes and complication rates of arthroscopic-assisted versus full-arthroscopic LDTT for irreparable posterosuperior massive rotator cuff tears in shoulders with no surgical antecedents. Study Design: Cohort study; Level of evidence, 3. Methods: The study included 90 patients who had undergone LDTT over 4 consecutive years by the same surgeon and did not have prior surgery. During the first 2 study years, all procedures were arthroscopically assisted (n = 52), while during the last 2 years, all procedures were fully arthroscopic (n = 38). Procedure duration and all complications were recorded, as well as clinical scores and range of motion at minimum 24-month follow-up. To enable direct comparison between the techniques, propensity score matching was used to obtain 2 groups with equivalent age, sex, and follow-up. Results: From the initial cohort of 52 patients who underwent arthroscopic-assisted LDTT, 8 had complications (15.4%), of which 3 (5.7%) required conversion to reverse shoulder arthroplasty and 2 (3.8%) required drainage or lavage. From the initial cohort of 38 patients who had full-arthroscopic LDTT, 5 had complications (13.2%), of which 2 (5.2%) required conversion to reverse shoulder arthroplasty but no patients (0%) required other procedures. Propensity score matching resulted in 2 groups, each comprising 31 patients, with similar outcomes in terms of clinical scores and range of motion. The procedure time was about 18 minutes shorter for full-arthroscopic LDTT, which had different complications (2 axillary nerve pareses) as compared with arthroscopic-assisted LDTT (1 hematoma and 2 infections). Conclusion: Equivalent outcomes at minimum 24-month follow-up were found for arthroscopic-assisted and full-arthroscopic LDTT in terms of complications rates (15.4% and 13.2%, respectively), conversion to reverse shoulder arthroplasty (5.7% and 5.2%), clinical scores, and range of motion.

Management of irreparable posterosuperior rotator cuff tears (RCTs) presents a significant challenge to shoulder surgeons. Previous studies on latissimus dorsi transfer (LDT) have demonstrated good to excellent outcomes in younger patients, but this indication is debatable in the elderly. The main objective of this study was to compare the results of LDT in a group of patients aged ≤55 years vs. one of patients aged ≥75 years. We hypothesized that LDT could give equally good results in the elderly as in the younger population.Between 2014 and 2017, a total of 153 patients who underwent LDT either for irreparable posterosuperior RCT or for failed prior repair were enrolled. All LDTs were performed by a single surgeon, were arthroscopically assisted, and fixed onto the humeral head with 2 anchors. A retrospective comparative clinical study was conducted. Patients with a minimum of 24 months of follow-up were divided into 2 groups: group A (≤55 years old at surgery) and group B (≥75 years old at surgery). The age-adjusted Constant-Murley score (aCMS), Subjective Score Value (SSV), Simple Shoulder Test (SST), Activities of Daily Living requiring active External Rotation (ADLER) score, visual analog scale for pain (VAS), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, patient's satisfaction, and rate of LD tendon rupture at last follow-up were compared.A total of 66 patients met inclusion criteria. Four in 66 patients (6%) were lost to follow-up. There were 31 patients in group A and 31 patients in group B. The mean age was 52 and 77 years for the respective groups. Preoperatively, the 2 groups were comparable with respect to other characteristics like the mean number of ruptured tendons, mean preoperative Hamada stage, mean SST, and mean aCMS. The mean follow-up was 33 and 31 months, respectively. At last follow-up, there was no significant difference in the scores evaluated between groups A and B with SSV (61 vs. 66.7 points), ADLER (23 vs. 26.4 points), VAS (2.8 vs. 2.2 points), and ASES (64.4 vs. 72.4 points), respectively, except for the aCMS (75 vs. 96.3; ±001) and the SST (6.2 vs. 8.3; P.001). Patient's satisfaction was not significantly different in both groups (81% of either satisfied or very satisfied patients in both groups). The rate of LD tendon rupture was higher in group A: 10 (33%) vs. 8 (26%).Posterior transfer of latissimus dorsi tendon could be an effective surgical option for the treatment of massive irreparable posterosuperior cuff tears in patients ≥75 years of age.

Resume Introduction L’omarthrose avant l’âge de 50 ans est rare et sa prise en charge delicate. Si le traitement choisi est une prothese d’epaule, les risques evolutifs a long terme, plutot frequents avec un fort taux de revision, rendent l’indication discutable chez un patient jeune et actif. Le but de cette etude etait de connaitre les caracteristiques epidemiologiques des arthroses du patient de moins de 50 ans et d’evaluer les resultats cliniques des alternatives therapeutiques proposees. Hypothese L’hypothese principale etait qu’un traitement non chirurgical bien conduit pouvait retarder la mise en place d’une prothese. L’hypothese secondaire etait qu’une prothese totale anatomique restait le traitement a privilegier en cas d’echec des autres traitements. Materiels et methodes Il s’agit d’une etude multicentrique retrospective incluant les arthroses primitives (AP) ou post-instabilite (API) chez les patients âges de 50 ans ou moins au debut des symptomes. Ont ete exclues les arthroses post-traumatiques, les polyarthrites rhumatoides et les necroses. Ont ete inclus 266 patients (273 epaules) issus de 13 centres specialises dans la chirurgie de l’epaule. Deux traitements non chirurgicaux (28 PRP et 88 viscosupplementations), 73 arthroscopies et 150 protheses dont 62 hemiarthroplasties humerales (10 « hemi-metal », 24 « hemi-pyrocarbones », 28 hemi-resurfacages), 77 protheses totales anatomiques et 11 protheses inversees ont ete analyses. Le recul minimum etait de 12 mois pour le traitement non chirurgical, et de 24 mois pour les patients ayant beneficie d’une arthroplastie, certains ayant eu deux types de traitements. Les criteres d’evaluation suivants etaient analyses : score de Constant, Subjective Shoulder Value (SSV) et le nombre de complications/revisions. Resultats L’âge moyen au moment de la prise en charge etait de 43 ans (23–65), avec une predominance masculine (75 %). Le debut des symptomes etait plus precoce pour les API que pour les AP : 36 vs. 39 ans (20–50). PRP et viscosupplementation permettaient de retarder de 3,5 ans la pose d’un implant dans 86 % des cas et l’arthroscopie dans 56 %. La limitation de la RE1 etait le facteur le plus pejoratif. Au recul moyen de 74 mois pour les hemiarthroplasties et de 95 mois pour les protheses totales anatomiques, le score de Constant moyen etait significativement inferieur pour les hemiprotheses (56 vs. 67 ; p = 0,004), avec un taux plus eleve de complications (31 % vs. 11 % respectivement) et de changements de protheses (13 % vs. 9 % respectivement). Discussion/Conclusion PRP, viscosupplementation et arthroscopie peuvent retarder la mise en place d’une prothese avant que l’epaule ne devienne raide et douloureuse. En cas d’echec, la prothese totale anatomique reste la solution la plus efficace a moyen terme. Niveau d’evidence IV a, Therapeutic Studies - Investigating the Results of Treatment.

The objective of this study was to describe the outcome of reverse shoulder arthroplasty (RSA) combined with modified L’Episcopo procedure at long-term follow-up (5 to 12 years). A retrospective review of 17 RSAs (mean age 67.2 years) with the modified L’Episcopo procedure conducted between 2006 and 2016 was performed. All patients had a combined loss of active elevation and external rotation with an irreparable posterosuperior rotator cuff tear. Clinical assessment was performed with a minimum follow-up of five years (mean 97.3 months). Outcome measures included range of motion, subjective shoulder value (SSV), visual analogue scale (VAS), and Constant-Murley scores. All patients (16) demonstrated a significant improvement in all clinical and functional parameters. VAS pain scores improved from 6 ± 2.6 to 1 ± 1; SSV improved from 35 ± 14 to 72 ± 10; active forward elevation increased from 66° ± 34 to 125° ± 29; and active external rotation arm at the body increased from −11° ± 22 to 21° ±11 and in 90° of abduction from −10° ± 17 to 37° ± 24. The mean Constant score improved from 25 ± 11 to 59 ± 8. Active internal rotation did not significantly change (p = 0.332). At long-term follow-up, RSA combined with modified L’Episcopo procedure resulted in significant improvements in pain, range of motion, and functional scores for patients with shoulder pseudoparalysis and a lack of active external rotation caused by a massive posterosuperior cuff tear with a teres minor deficiency.

Cerebrovascular accidents (CVA), or strokes, are the second most common cause of mortality and third most common cause of disability worldwide. Though advances in the treatment of strokes have improved survivorship following these events, there remains a limited understanding of the effect of a prior stroke and sequalae on patients undergoing shoulder arthroplasty (SA). This study aimed to determine the outcomes of patients with a history of stroke with sequela undergoing primary shoulder arthroplasty.Over a 30-year time period (1990 to 2020), 205 primary SA (32 hemiarthroplasties [HA], 56 anatomic total shoulder arthroplasties [aTSA], and 117 reverse shoulder arthroplasties [RSA]) were performed in patients who sustained a previous stroke with sequela and were followed for a minimum of 2 years. This cohort was matched (1:2) according to age, sex, body mass index, implant, and year of surgery with patients who had undergone HA or aTSA for osteoarthritis or RSA for cuff tear arthropathy. Mortality after primary SA was individually calculated through a cumulative incidence analysis. Implant survivorship was analyzed with a competing risk model selecting death as the competing risk.The stroke cohort sustained 38 (18.5%) surgical and 42 (20.5%) medical perioperative complications. Compared to the control group, the stroke cohort demonstrated higher rates of any surgical complication (18.5% vs. 10.7%; P = .007), instability (6.3 % vs. 1.7%; P = .002), venous thromboembolism (3.4% vs. 0.5%; P = .004), pulmonary embolus (2.0% vs. 0%; P = .005), postoperative stroke (2.4% vs. 0%; P = .004), respiratory failure (1.0% vs. 0%; P = .045), any medical complication (20.5% vs. 7.3%; P.001), and 90-day readmission (16.6% vs. 4.9%; P.001). Additionally, RSA in the stroke cohort was associated with higher reoperation (8.5% vs. 2.6%; P = .011) and revision rates (6.8% vs. 1.7%; P = .013) compared to the matched cohort. Subsequent cumulative incidences of death at 1, 2, 5, 10, 15, and 20 years were 4.4% vs. 3.4%, 10.7% vs. 5.1%, 25.6% vs. 14.7%, 51.6% vs. 39.3%, 74.3% vs. 58.6%, and 92.6% vs. 58.6% between the stroke and matched cohorts, respectively (P.001) CONCLUSIONS: A preoperative diagnosis of a stroke in patients undergoing primary SA is associated with higher rates of perioperative complications and mortality when compared to a matched cohort. This information should be considered to counsel patients and surgeons to optimize care and help mitigate risks associated with perioperative period.

Purpose Patient-reported outcome measures (PROMS) are increasingly used for patient evaluation, as well as for scientific research. Few are used for practical purposes in the clinical setting, and few are reliable enough to allow proper feedback to physicians. Two of the most commonly used assessment tools in shoulder instability are the Walch–Duplay and the Rowe scores. The aim of this study was to evaluate the validity of self-administered versions of the Walch–Duplay and Rowe scores following shoulder stabilization procedure. Methods Between the months of May and December 2021, all patients who were followed in one of six institutions for shoulder instability were included. Patients were required to anonymously fill a self-administered version of Walch–Duplay and Rowe score. The classic scores were measured by the surgeon. Correlations between self-assessment and physician-assessment were then recorded. Results A total of 106 patients were evaluated during the study period. Using the Spearman coefficient for correlation, a strong correlation (r > 0.5) was found between the results of the self-administered questionnaire and the surgeon-measured score. The difference between surgeon- and patient-administered questionnaires was non-significant. Conclusion The self-administered version of the Walch–Duplay and Rowe questionnaires can reliably be used in the clinical setting for post-operative follow-up of patients undergoing shoulder stabilization procedures. Level of evidence Level II.

There have been incredible innovations in knowledge, techniques, and implants for total shoulder arthroplasty over the last few decades. On the humeral side, modularity has improved the ability to recreate native anatomy, while shorter humeral stems have improved our ability to preserve bone stock. On the glenoid side, the anatomic restoration and baseplate fixation have improved and augments have allowed surgeons to overcome bone loss. Future innovations in implant design, surgical technique and planning will continue to improve this operation. These will likely include robotic assisted surgery, augmented reality, patient specific guides, and others. In this review, the recent literature highlighting important recent innovations in the field of shoulder arthroplasty are critically reviewed and compiled. Recent innovations and projected future trends are discussed.

Introduction As surgeons' confidence in reverse shoulder arthroplasty (RSA) increases, they may tend to offer RSA earlier in the course of glenohumeral joint disease. This study evaluates the changes in the “tipping point” for primary RSA over a 10-year period to evaluate changes in practice. Methods A total of 3975 primary RSAs performed over a 10-year period were retrospectively reviewed from a multi-institutional database. Of these, 3536 primary RSAs with preoperative diagnoses of osteoarthritis with rotator cuff deficiency (1626), irreparable rotator cuff tear (396), and rotator cuff tear arthropathy (1514) were included in the analysis. Preoperative range of motion (ROM) and patient-reported outcome measures (PROMs) were used to calculate tipping points for each subgroup on a yearly basis over a 10-year period, and assessed for changes over time. Results PROMs (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Simple Shoulder Test) and the Constant score remained similar over the 10-year study period, with all demonstrating slightly higher tipping points later in the study. ROM measures (forward elevation, abduction, and external rotation) all showed small increases over time, demonstrating better ROM before electing to undergo RSA in later years. Conclusions With the increasing use of RSA over the last decade, the ROM tipping point for patients electing to undergo surgery has increased, whereas the PROM tipping point has remained stable. This indicates that patients undergoing RSA in the present have greater ROM preoperatively compared with 10 years ago; however, their perceived disability remains similar. Surgeons and patients continue to pursue RSA at a similar preoperative morbidity over the last 10 years.

Background To compare latissimus dorsi tendon rupture rates after arthroscopic transfer for posterior superior rotator cuff tear using 3 different humeral head fixation techniques. Methods One-hundred fifty consecutive latissimus dorsi transfers were included. Inclusion criteria were massive irreparable posterosuperior rotator cuff tear with advanced fatty infiltration associated with persistent pain and limited range of motion after failed conservative treatments or surgery. All transfers were arthroscopically assisted and fixed in a transosseous tunnel with a cortical button (group 1, n = 59), “over the top” onto the footprint of the supraspinatus (group 2, n = 47), or posteriorly onto the footprint of the infraspinatus (group 3, n = 44) with 2 suture anchors. The tendons were marked with 3 metallic clips placed intraoperatively at a fixed distance of 2, 4, and 6 cm from the tip. Immediate postoperative standard anteroposterior radiographs were performed to confirm the position of the clips and to determine whether the clips displaced on subsequent radiographs during follow-up, indicating tendon rupture. Results Repeat radiographs at 3-month follow-up showed higher risk of latissimus dorsi transfer rupture rate in 27/59 patients in group 1 (46%), 11/47 in group 2 (24%), and 7/44 in group 3 (15%). Conclusion Posterior anchor fixation of the latissimus dorsi tendon onto the infraspinatus footprint had the lowest rupture rate.

Background Glenosphere size remains 1 surgeon-controlled variable that can affect patient outcomes following reverse shoulder arthroplasty (RSA). There remains no objective criterion to guide surgeons in choosing glenosphere size. This study's purpose was to evaluate range of motion (ROM) as a function of patient height and glenosphere size to determine the optimal glenosphere size based on patient height. Methods We retrospectively reviewed 589 primary RSAs from a multicenter shoulder arthroplasty database of a single RSA system with multiple glenosphere sizes. Shoulders were separated into groups based on glenosphere size (38 or 42 mm). Predictive accuracy was calculated in relation to height and sex for predicting glenosphere size. Improvements in active ROM and patient-reported outcome measures (PROMs) were compared based on glenosphere size as a function of height. Results Logistic regression analysis demonstrated a strong association of height and sex with surgeon selection of glenosphere size, with shorter heights preferentially treated with 38-mm glenospheres and taller heights with 42-mm glenospheres. There were no statistically significant interaction effects of glenosphere size and height on improvements in ROM or PROMs. These results indicate that for a given glenosphere size, there is not an optimal height range to maximize improvements in postoperative outcome measures. Discussion Height and sex are highly correlated with a surgeon's choice of glenosphere size. However, on the basis of improvements in ROM and PROMs, no recommendation can be made for surgeons to select a particular glenosphere size based on a patient's height. Surgeons should consider other variables when selecting a glenosphere size.

Glenoid inclination must be assessed precisely during preoperative planning for reverse shoulder arthroplasty (RSA) to position the glenoid baseplate correctly. We hypothesized that a more dynamic measurement method would better match the diversity of glenoid heights in the population and the variety of commercialized glenoid baseplates. Our purpose was to describe a new method to measure the RSA angle accounting for the baseplate size.Computed tomography scans of 50 shoulders that underwent RSA for primary osteoarthritis or cuff tear arthropathy between June 2019 and February 2020 were included (mean age, 76 years). Three variants of the RSA angle were measured: the RSA angle as originally described by Boileau et al, the relative RSA 25 angle (which simulates the implantation of a 25-mm baseplate), and the relative RSA 29 angle (which simulates the implantation of a 29-mm baseplate). Measurements in the 2-dimensional true reformatted scapular plane were made by 3 independent operators.The mean R-S distance (ie, distance between point R [intersection of supraspinatus fossa line with glenoid surface] and point S [inferior border of glenoid]) was 24.2 ± 4.0 mm. The mean RSA angle was 20.3° ± 8.4°, whereas the mean relative RSA 25 angle was 19.3° ± 7.8° and the mean relative RSA 29 angle was 15.6° ± 7.6°. The mean difference between the RSA angle and the relative RSA 25 angle was 1.0° ± 4.1° (P = .16). The mean difference between the RSA angle and the relative RSA 29 angle was 4.7° ± 3.8° (P .0001). In half of the shoulders in our series, the difference between the RSA angle and the RSA 29 angle exceeded 5°.The RSA angle is a reproducible measure of the inclination of the inferior part of the glenoid that is reliable in most cases for glenoid baseplates of 24-25 mm in height. However, surgeons should be aware that the RSA angle may overestimate the superior orientation of the inferior glenoid for baseplates of different sizes or for small- or large-stature patients. In these cases, the relative RSA angle adapted to the size of the baseplate more accurately evaluates the inclination of the inferior glenoid.

A detailed overview of the basic science and clinical literature reporting on the challenges for the optimization of reverse shoulder arthroplasty (RSA) is presented in two review articles. Part I looks at (I) external rotation and extension, (II) internal rotation and the analysis and discussion of the interplay of different factors influencing these challenges. In part II, we focus on (III) the conservation of sufficient subacromial and coracohumeral space, (IV) scapular posture and (V) moment arms and muscle tensioning. There is a need to define the criteria and algorithms for planning and execution of optimized, balanced RSA to improve the range of motion, function and longevity whilst minimizing complications. For an optimized RSA with the highest function, it is important not to overlook any of these challenges. This summary may be used as an aide memoire for RSA planning.

In part II of this comprehensive review on the optimization of reverse shoulder arthroplasty (RSA), we focus on three other challenges: 1. “Conservation of sufficient subacromial and coracohumeral space”; 2. “Scapular posture”; and 3. “Moment arms and muscle tensioning”. This paper follows a detailed review of the basic science and clinical literature of the challenges in part I: 1. “External rotation and extension” and 2. “Internal rotation”. “Conservation of sufficient subacromial and coracohumeral space” and “Scapular posture” may have a significant impact on the passive and active function of RSA. Understanding the implications of “Moment arms and muscle tensioning” is essential to optimize active force generation and RSA performance. An awareness and understanding of the challenges of the optimization of RSA help surgeons prevent complications and improve RSA function and raise further research questions for ongoing study.

There is a common belief among some shoulder surgeons that the increased utilization of reverse shoulder arthroplasty (RSA) is driven by the operation being performed in younger patients. The primary purpose of this study was to evaluate the change in patient age at the time of primary RSA in the USA.All patients undergoing primary RSA (January 2011-June 2018) were identified in the Mariner database. The mean age at the time of primary RSA was evaluated for each patient and assessed in 6-month intervals. A longitudinal comparison over time was performed for all patients.A total of 56,141 primary RSA were evaluated, with the mean age increasing from 69 in the 2011 to 71 in 2018 (p 0.001). The largest increase in RSA utilization occurred in patients 70 (1092 in 2011 to 3499 in 2018), with patients 50 years demonstrating the slowest growth (13 in 2011 to 65 in 2018). However, when evaluated by percentage increase from 2011 to 2018, RSA volumes for patients 60 have increased 390% compared to 220% for those 70 years (p 0.001).RSA continues to be performed at a similar mean age despite expanded indications and surgeon comfort. However, patients 60 years have had a greater increase in utilization compared to patients 70 years. The volumetric growth of RSA has largely been driven by the older population, but younger patients have shown a higher percentage of growth, which may explain the generalized observation that RSA is performed in younger patients.Level III; Retrospective comparative study; Treatment study.

To evaluate the effect of prior anterior shoulder instability surgery (SIS) on the outcomes and complications of primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA).Between 2007 and 2018, 38 primary total shoulder arthroplasties (TSA) (22 aTSA and 16 rTSA) with a prior SIS and a minimum of 2 years of follow-up were identified. This cohort was matched 1:3 based on age, sex, body mass index, year of surgery, and dominant shoulder. aTSA and rTSA were matched to patients with primary osteoarthritis (OA) and rotator cuff tear arthropathy (CTA), respectively.TSA produced similar postoperative pain, ROM, patient-reported outcome measures, complications, and revisions in those with prior SIS vs. controls. aTSA with prior SIS demonstrated worse final postoperative abduction (116° vs. 133°; P = 0.046) and abduction improvement (24° vs. 47°; P = 0.034) compared to OA controls. Both aTSA and rTSA with prior SIS demonstrated significant improvements from baseline across all metrics, with no significant differences between the groups. aTSA and rTSA with prior SIS demonstrated no differences to controls in complications (4.6% vs. 6.1%; P = .786 and 0% vs. 6.3%. P = .183) or revisions (4.6% vs. 4.6%; P = .999 and 0% vs. 4.2%; P = .279).TSA after prior SIS surgery can improve both pain and function without adversely increasing the rates of complications or revision surgery. When compared to patients without prior SIS, aTSA demonstrated worse abduction; however, all other functional differences remained statistically similar.III; Retrospective Cohort Comparison; Treatment Study.

Avascular necrosis (AVN) of the humeral head frequently results in humeral head collapse and end-stage arthritic changes of the glenohumeral joint. Despite the recent proliferation of reverse total shoulder arthroplasty (RTSA), reports on the use of RTSA for AVN remain limited. The purpose of this study was to document the outcomes of shoulders indicated for RTSA in the setting of humeral head AVN and compare these with AVN shoulders indicated for the gold standard, anatomic total shoulder arthroplasty (aTSA).A retrospective review of a multinational shoulder arthroplasty database was performed between August 2005 and August 2017. All shoulders with a preoperative diagnosis of AVN (aTSA in 52 and RTSA in 67) were reviewed. The shoulders in the RTSA cohort were matched (1:1) to shoulders with cuff tear arthropathy, whereas the shoulders in the aTSA cohort were matched (1:1) to shoulders with primary osteoarthritis. The mean follow-up period was 47 months (range, 24-130 months) for RTSA and 54 months (range, 24-124 months) for aTSA. Shoulders were evaluated for active range of motion (ROM) and patient-reported outcome measures (PROMs) prior to surgery and at latest follow-up. Patients treated with RTSA were compared with both the aTSA study cohort and the control group using the Student t test or χRTSAs performed for AVN demonstrated significant improvements in all ROMs and PROMs. Patients undergoing aTSA for AVN were significantly younger than those undergoing RTSA (59 years vs. 73 years, P .001). At similar follow-up points, the RTSA cohort demonstrated significantly greater improvement in abduction (+51° vs. +32°, P = .03) whereas the aTSA cohort demonstrated significantly greater improvement in internal rotation. Postoperative University of California, Los Angeles scores (30 vs. 27, P = .014) and visual analog scale scores (1.4 vs. 2.4, P = .025) were better after RTSA; however, these differences between prosthesis types did not exceed the minimal clinically important difference. When compared with the control patients, the patients undergoing RTSA for AVN showed similar improvements in all ROMs and PROMs. Similarly, aTSA performed for AVN resulted in comparable improvements in pain, ROMs, and PROMs compared with aTSA performed for primary osteoarthritis.RTSA results in similar PROMs to aTSA in the treatment of AVN. Therefore, surgeons should continue to consider other patient factors such as glenoid bone loss and rotator cuff status when selecting implant polarity in patients with AVN.

It has been well established that the subscapularis is divided in two different parts with a tendinous insertion at its superior two-thirds and a muscular attachment on its inferior third. The objective of this cadaveric study was to follow the muscular insertion of the subscapularis medially in order to determine the origin of this inferior muscle insertion and whether a subscapularis minor can be individualized MATERIALS AND METHODS: Twenty-six shoulders from thirteen fresh-frozen cadaveric specimens (5 males and 8 females; mean age, 74.4 years) were dissected in our anatomy lab. The humeral insertion of the subscapularis was then analyzed, and the inferior muscular part of the insertion was identified. The muscle fibers were followed medially until their scapular origin which was recorded as line drawings and photographs. We measured the dimensions of both the humeral insertion and of the scapular origin of the fibers going to the muscular portion.In all cases, the fibres going to the tendinous portion and those going to the muscular portion of the insertion had a different orientation. The fibres going to the muscular portion of the humeral insertion did not originate from the subscapularis fossa but on the glenoid neck and in a depression at the infero-lateral part of the scapular pillar. The mean length of the superior tendinous portion of the humeral insertion was 3.42 cm (± 0.43 cm); the mean length of the inferior muscular portion of the humeral insertion was 1.88 cm (± 0.80 cm). The mean length of the scapular origin in the depression at the infero-lateral part of the scapular pillar of the fibres going to the muscular portion of the humeral insertion was 3.7 cm (± 0.17 cm).The fibres of the subscapularis do not all originate from the subscapularis fossa. An additional origin exists at the inferior part of the glenoid neck and in a depression at the infero-lateral part of the scapular pillar. The fibers which originate at this location all insert on the humerus at the muscular portion of the subscapularis humeral insertion. This portion however does not seem to correspond to the so-called subscapularis minor which has been previously described.

Reverse shoulder arthroplasty (RSA) is rapidly becoming the preferred treatment for displaced proximal humerus fractures in older patients. However, few studies have analyzed the target population and the effect of RSA on survival, although the socioeconomic impact of this type of surgery is considerable.This was a retrospective epidemiological study of all patients with a displaced proximal humeral fracture treated by RSA in 14 public and private hospitals throughout France between 1995 and 2016. The French hospital discharge database (PMSI) was analyzed to isolate an 898-patient cohort who underwent RSA within 6 weeks of the fracture event. In 87% of cases, this was a 3- or 4-fragment fracture. We analyzed the epidemiological characteristics of the patients at the time of fracture, their survival (Kaplan-Meier estimate) and factors that may impact survival.The mean age at the time of fracture and surgery was 79 years (46-98 years). Eighty percent of the cohort was female (sex ratio: 0.18 [p=0.0042], with 21% obesity rate [BMI30]) and 60% of patients were ASA 1-2. The most common comorbidities were cardiovascular and neurological. The survival rate after RSA was 94% at 1 year and 73% at 5years. At the latest follow-up of 19 years, 42% of patients were still alive. In 18% of cases, the patient died within the first 15 days. The presence of comorbidities (ASA score3-4) (p0.004) and/or cognitive disorders (p0.0001) were risk factors for early mortality. The time to surgery, type of fracture, associated fractures and discharge destination (return home, transfer to nursing home) had no effect on postoperative mortality in our cohort.Despite being older (79 years) at the time of proximal humerus fracture, patients who underwent RSA treatment had a high survival rate (94% at 1 year, 73% at 5years), which is better than the survivorship reported after surgical treatment of femoral neck fractures (81-87% at 1 year, 38% at 5years). The presence of comorbidities (ASA3-4) and/or cognitive disorders are risk factors for early mortality and should be taken into account to prevent early death.IV, Retrospective study.

Background Although risk factors for poor outcomes and complications have been studied, there remain limited objective criteria to guide surgeons about the timing of arthroplasty. The purpose of this study was to further characterize the tipping-point scores for a group of patient-reported outcome measures (PROMs) in patients undergoing primary shoulder arthroplasty. Methods We retrospectively reviewed 5670 primary shoulder arthroplasties (1833 anatomic total shoulder arthroplasties and 3837 reverse shoulder arthroplasties [RSAs]) performed over a 10-year period. Preoperative range of motion, PROMs (American Shoulder and Elbow Surgeons, Simple Shoulder Test, and Shoulder Pain and Disability Index scores), and Constant scores were evaluated. The tipping point for each PROM was evaluated. Univariate and multivariate analyses were performed to assess risk factors for lower tipping points. Results Patients undergoing RSA demonstrated lower tipping points for all range-of-motion parameters as well as American Shoulder and Elbow Surgeons, Shoulder Pain and Disability Index, and Simple Shoulder Test scores. Female sex was predictive of a lower tipping point prior to shoulder arthroplasty, regardless of implant type. When the total shoulder arthroplasty subgroup was evaluated, both female sex and a higher body mass index were shown to be associated with a lower tipping point. Discussion The choice to undergo shoulder arthroplasty is a multifactorial decision that encompasses both physical and social factors. Female patients and patients undergoing RSA are more likely to accept slightly worse shoulder function prior to making the decision to undergo shoulder arthroplasty.