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Case: A patient presented with complete coracoclavicular ligament ossification after an unnoticed acromioclavicular joint Rockwood Type IV dislocation. He had full passive range of motion in the glenohumeral joint but was disabled by a loss of both active (80°) and passive (90°) abduction due to insufficient passive scapulo-thoracic motion. He was treated with an arthroscopic osteotomy of the coracoclavicular ligament ossification., Conclusion: One year after the surgery, active abduction was improved by 45° (80°-125°) with no recurrence of the ossification on the radiographs. Arthroscopic osteotomy of complete coracoclavicular ligament ossification seems effective in restoring abduction in these patients., Level of Evidence: IV., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C398)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Case: A 19-year-old female patient with a history of shoulder trauma 6 years ago presented with dynamic horizontal instability of the acromioclavicular joint (ACJ). She was treated with open ACJ reconstruction using gracilis allograft and showed a satisfactory clinical result at 1-year follow-up., Conclusion: Dynamic pure horizontal instability of the ACJ is a rare entity with only 6 cases reported in the literature. Till now, all reported patients who necessitated surgical treatment failed because of residual instability and/or pain. We present the seventh case of this type with a successful clinical outcome., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C162)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Latissimus dorsi transfer (LDT) has been purported to restore motion in patients undergoing reverse shoulder arthroplasty (RSA) who have preoperative combined loss of forward elevation (FE) and external rotation (ER). This systematic review summarizes the available evidence for the functional outcomes and complications after RSA with LDT. Furthermore, the effect of implant design and whether a concomitant teres major transfer (TMT) was performed were studied., Methods: A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles reporting on LDT with RSA to restore ER. Our primary outcomes were ER, FE, Constant score, and complication incidence. Secondarily, we reported postoperative internal rotation (IR) and compared ER, FE, and Constant score based on lateralized versus medialized global implant design and whether concomitant TMT was performed., Results: Nineteen studies were evaluated; functional outcomes were assessed in 16 articles reporting on 258 RSAs (123 LDT, 135 LDT-TMT). Surgical indication was most commonly cuff tear arthropathy and massive irreparable cuff tear. Mean ER was -12° preoperatively and 25° postoperatively, FE was 72° preoperatively and 141° postoperatively. Mean postoperative Constant score was 65. Of 138 patients (8 studies) describing IR, only 25% reported a mean postoperative IR ≥L3. Subanalysis comparing lateralized versus medialized implants and whether TMT was concomitantly performed demonstrated no significant difference in postoperative ER, FE, and Constant score, nor preoperative to postoperative improvement in ER and FE. The complication rate was 14.1% (of 291 shoulders from 16 studies), including tear in the tendon transfer (n = 3), revision tendon repair (n = 1), nerve-related complication (n = 9), and dislocation (n = 9)., Conclusions: RSA with LDT is a reliable option to restore motion, with a comparable complication rate with standard RSA. The use of medialized versus lateralized implants and whether the TM was concomitantly transferred may not influence clinical outcomes., Level of Evidence: Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/A974)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: 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., Questions/purposes: 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?, Methods: 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., Results: 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°]; p < 0.01), abduction (63° [IQR 48° to 78°] versus 72° [IQR 63° to 82°]; p < 0.01), extension (4° [IQR -8° to 12°] versus 19° [IQR 8° to 27°]; p < 0.01), and external rotation (7° [IQR -5° to 22°] versus 28° [IQR 13° to 39°]; p < 0.01). 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°., Conclusion: 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., Clinical Relevance: In patients with Type C posture, higher retrotorsion, a lower neck-shaft angle, and a larger or inferior eccentric glenosphere seem to be advantageous., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Association of Bone and Joint Surgeons.)

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., (Copyright © 2021 by the American Academy of Orthopaedic Surgeons.)

Introduction: 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., Methods: 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°, and >45°) and also analyzed as a continuous variable. The groups were compared using analysis of variance and chi-square tests as indicated., Results: 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 (P < 0.05). After surgery, forward elevation and abduction were similar among all groups (<25: 133°, 25 to 45: 132°, >45: 127°; P = 0.199 and <25: 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)., Discussion: 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., Level of Evidence: III., (Copyright © 2021 by the American Academy of Orthopaedic Surgeons.)

Background: Hemiarthroplasty (HA) of the elbow represents an alternative to total elbow arthroplasty (TEA) without the associated activity restrictions. This study reviews our experience with distal humerus HA with minimum 2-year follow-up., Methods: Between 2002 and 2012, 16 elbows underwent HA for posttraumatic arthritis of the elbow. Patients were followed for a minimum of 2 years or until revision surgery. Outcome measures included pre- and postoperative Mayo Elbow Performance Scores (MEPSs), complications, and revisions., Results: Mean age at arthroplasty was 45 years, and follow-up averaged 51 months. All patients had previously undergone one or more surgical procedures at the elbow (average of 1.5 procedures). At follow-up, five had undergone additional surgery; two were revised to TEA. In surviving implants, the range of motion at follow-up was markedly improved from preoperative motion. The MEPS for the remaining HA included five excellent results, three good results, five fair results, and one poor result., Discussion: Elbow HA is an option for young or active patients with end-stage elbow posttraumatic arthritis who are unwilling to accept activity limitations. However, high rates of revision surgery and revision to TEA occur after HA for posttraumatic osteoarthritis of the elbow. Only 57% of patients with surviving implants had a good to excellent MEPS, although improvement in the range of motion was predictable.

Introduction: The purpose of this study was to evaluate the biomechanical effectiveness regarding scapulothoracic (ST) upward rotation of two different tendon transfer procedures involving the levator scapulae, rhomboid major, and rhomboid minor to restore the function of the paralyzed trapezius., Methods: Six fresh frozen hemithoraces were mounted on a custom-built apparatus. A three-dimensional electromagnetic tracking system was used to record ST upward/downward rotation of the (1) normal trapezius, levator scapulae, rhomboid minor, and rhomboid major; (2) Eden-Lange (EL) transferl and (3) a modified EL transfer (triple transfer)., Results: The normal trapezius was found to be an upward rotator of the scapula and led to a mean ST rotation angle of 26.98°. Similarly, the modified triple transfer led to an upward rotation of the scapula, with a mean ST rotation angle of 22.23°, whereas the EL led to an initial downward rotation of the scapula to -6.69°, with a mean scapulothoracic displacement angle of 1.13°., Discussion: The upward rotation of the scapula from the modified transfer mimicked the function of the normal trapezius better than did the traditional EL transfer., Level of Evidence: Level V, biomechanical study.

Purpose: The purposes of this study were to evaluate the radiographic anatomy of the elbow and try to determine its possible relation to elbow flexion contracture in patients with obstetric brachial plexus injury (OBPI)., Methods: All patients with a history of OBPI with elbow flexion contracture who were evaluated clinically and radiographically were included in the study. A review was performed to include serial elbow examinations and previous treatment. Radiographs of the elbow were examined for the presence of bony abnormalities as a potential cause of elbow flexion contracture or the presence of progressive arthritic changes over time., Results: Fifty-nine patients with a history of OBPI with elbow flexion contracture were included in the study. Of them, 53 had normal bony architecture, 2 had mild radial head subluxation, and 4 had chronic anterior radial head dislocations. At a mean age at final clinical follow-up of 21 years (range, 7 to 83 years), only 7% of patients had pain localized to their elbow. There were only three patients with elbow arthritis, including two of the four with radial head dislocations., Conclusions: In the absence of a radial head dislocation, most elbow joints do not seem to undergo abnormal anatomic bony changes in patients with OBPI and flexion contractures., Level of Evidence: Level IV (retrospective case series).