Search

Background: Isokinetic torque in shoulder internal rotation (IR) and external rotation (ER) can be considered as potential indicators for dynamic stability of the glenohumeral joint., Purpose: To assess the efficacy of 4-month isokinetic testing in predicting the 6-month return-to-sports (RTS) status after Latarjet surgery, explore its correlations with testing parameters, and identify optimal thresholds to ensure a safe RTS., Study Design: Cohort study; Level of evidence, 2., Methods: The study assessed athletes who underwent the Latarjet stabilization procedure between January 2022 and June 2023. The primary outcome was RTS at 6 months after surgery. The primary examined predictors were isokinetic testing metrics at 4 months postoperatively. Secondary outcomes comprised the modified Closed Kinetic Chain Upper Extremity Stability Test (mCKCUEST) and several patient-reported outcome measures, including the Walch-Duplay score, the Western Ontario Shoulder Instability Index (WOSI), and the Shoulder Instability-Return to Sports after Injury scale. To assess the predictors, patients were divided into those who returned to any level of sports compared with those who did not return to sports. The correlation between isokinetic testing results and other outcome scores was also analyzed., Results: A total of 71 patients (mean age, 27.43 ± 9.09 years) were included in the study. Of these, 23.61% did not return to sports, 38.89% returned at a lower level, and 37.50% returned to the same level. Significant rotational strength disparities were noted. Patients who did not return to sports at 6 months demonstrated inferior strength in concentric ER at 60 deg/s, concentric ER at 240 deg/s, concentric IR at 240 deg/s, and eccentric IR at 30 deg/s ( P < .05). Similar trends appeared for all studied patient-reported outcome measures and the mCKCUEST ( P < .05). Receiver operating characteristic analysis emphasized the significance of isokinetic testing in concentric ER at 240 deg/s (area under the curve = 0.759; P = .001; cutoff = 0.32 N·m/kg; sensitivity = 100.0%; specificity = 49.1%) and eccentric ER at 30 deg/s (area under the curve = 0.760; P = .001; cutoff = 0.51 N·m/kg; sensitivity = 94.1%; specificity = 49.1%) for RTS prediction. Additionally, ER strength moderately correlated with the Walch-Duplay score across all examined velocities ( r = 0.26-0.34; P < .05). The modified WOSI score was weakly linked to ER strength at 240 deg/s and 30 deg/s ( r = 0.24-0.25; P < .05) as well as moderately linked to the limb symmetry index in ER at 60 deg/s and 30 deg/s ( r = 0.30-0.38; P < .05)., Conclusion: Isokinetic testing can act as an independent predictor of successful RTS after Latarjet surgery, with concentric ER at 240 deg/s, concentric IR at 240 deg/s, eccentric ER at 30 deg/s, and eccentric IR at 30 deg/s showing the most accuracy. Strength recovery in ER was associated with better Walch-Duplay and modified WOSI scores., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: N.L. has received consulting fees from Websurvey Society. J.-D.W. has received royalties from FH Orthopedics and consulting fees from Zimmer. A.H. has received consulting fees from Arthrex and DePuy. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: Reverse shoulder arthroplasty (RSA) with concurrent latissimus dorsi transfer (LDT) is a potential treatment option for restoration of external rotation (ER). Biomechanical studies have emphasized the importance of the insertion site location for achieving optimal outcomes. In this systematic review and meta-analysis, we aimed to describe what insertion sites for LDT are utilized during concomitant RSA and their associated clinical outcomes., Methods: A systematic review and meta-analysis were performed per PRISMA guidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles reporting on patients who received RSA with LDT to restore ER and specified the site of tendon transfer insertion on the humerus. We first describe reported insertion sites in the literature. Secondarily, we present preoperative and postoperative range of motion and Constant score for different insertion sites as well as reported complications., Results: Sixteen studies, analyzed as 19 separate cohorts (by insertion site and tendon-transfer), reporting on 264 RSAs with LDT (weighted mean age 66 years, follow-up 39 months, 61% female) were evaluated. Of these, 143 (54%) included a concomitant teres major transfer (LDT/TMT) and 121 (46%) were LDT-only. Fourteen cohorts (14/19, 74%) reported insertion at the posterolateral aspect of the greater tuberosity, four cohorts (4/19, 21%) reported insertion site at the lateral bicipital groove, and one cohort (1/19, 5%) reported separate LDT and TMT with insertion of the TMT to the posterolateral aspect of the greater tuberosity and LDT to the lateral bicipital groove. Meta-analysis revealed no differences in range of motion or Constant score based on humeral insertion site or whether the LDT was transferred alone or with TMT. Leading complications included dislocation, followed by infection and neuropraxia. No discernible correlation was observed between postoperative outcomes and the strategies employed for tendon transfer, prosthesis design, or subscapularis management., Conclusion: The posterolateral aspect of the greater tuberosity was the most-utilized insertion site for LDT performed with RSA. However, in the current clinical literature, LDT with or without concomitant TMT result in similar postoperative ROM and Constant score regardless of insertion site. Analysis of various proposed transfer sites reinforce the ability of LDT with RSA to restore both FE and ER in patients with preoperative active elevation and external rotation loss. Meta-analysis revealed significant improvements in range of motion and Constant score regardless of humeral insertion site or whether the LDT was transferred alone or with TMT, although future studies are needed to determine whether an ideal tendon transfer technique exists., Level of Evidence: IV., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Introduction: Similar to the management of periprosthetic joint infections of the lower limb, one-stage revision in total shoulder arthroplasty (TSA) infections is an option that has been highlighted in scientific publications since the early 2010s. However, there are only a few studies which validate this treatment and determine its scope of application in relation to two-stage treatment., Hypothesis: Single-stage revision for infected TSA is a reliable treatment allowing good infection control and satisfactory functional results., Methods: This single-center retrospective series of 34 consecutive patients operated on between 2014 and 2020 for a one-stage prosthetic revision was evaluated at a minimum of 2 years of follow-up. All of the patients included underwent revision shoulder arthroplasty during this period with the diagnosis of infection confirmed by microbiological analysis of surgical samples. Patients who did not benefit from a bipolar revision were excluded. All patients were followed at least 2 years after the intervention. Clinically suspected recurrence of infection was confirmed by a periprosthetic sample under radiographic guidance. Functional clinical outcomes as well as mechanical complications were also reported., Results: The average follow-up was 40.4 months (24-102±21.6). A septic recurrence was observed in three patients (8.8%). A mechanical complication was present in four patients (14.7%), and three (11.8%) required at least one surgical revision. The mean Constant-Murley score at the last follow-up was 49 (42-57±21.83)., Discussion: Single-stage revision for shoulder periprosthetic joint infection results in a success rate of 91.2% with satisfactory functional results after more than 2 years of follow-up., Level of Evidence: IV; retrospective study., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

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.)

Background: The etiology of humeral posterior subluxation remains unknown, and it has been hypothesized that horizontal muscle imbalance could cause this condition. The objective of this study was to compare the ratio of anterior-to-posterior rotator cuff and deltoid muscle volume as a function of humeral subluxation and glenoid morphology when analyzed as a continuous variable in arthritic shoulders., Methods: In total, 333 computed tomography scans of shoulders (273 arthritic shoulders and 60 healthy controls) were included in this study and were segmented automatically. For each muscle, the volume of muscle fibers without intramuscular fat was measured. The ratio between the volume of the subscapularis and the volume of the infraspinatus plus teres minor (AP ratio) and the ratio between the anterior and posterior deltoids (AP deltoid ) were calculated. Statistical analyses were performed to determine whether a correlation could be found between these ratios and glenoid version, humeral subluxation, and/or glenoid type per the Walch classification., Results: Within the arthritic cohort, no statistically significant difference in the AP ratio was found between type A glenoids (1.09 ± 0.22) and type B glenoids (1.03 ± 0.16, P = .09), type D glenoids (1.12 ± 0.27, P = .77), or type C glenoids (1.10 ± 0.19, P > .999). No correlation was found between the AP ratio and glenoid version (ρ = -0.0360, P = .55) or humeral subluxation (ρ = 0.076, P = .21). The AP deltoid ratio of type A glenoids (0.48 ± 0.15) was significantly greater than that of type B glenoids (0.35 ± 0.16, P < .01) and type C glenoids (0.21 ± 0.10, P < .01) but was not significantly different from that of type D glenoids (0.64 ± 0.34, P > .999). When evaluating both healthy control and arthritic shoulders, moderate correlations were found between the AP deltoid ratio and both glenoid version (ρ = 0.55, P < .01) and humeral subluxation (ρ = -0.61, P < .01)., Conclusion: This in vitro study supports the use of software for fully automated 3-dimensional reconstruction of the 4 rotator cuff muscles and the deltoid. Compared with previous 2-dimensional computed tomography scan studies, our study did not find any correlation between the anteroposterior muscle volume ratio and glenoid parameters in arthritic shoulders. However, once deformity occurred, the observed AP deltoid ratio was lower with type B and C glenoids. These findings suggest that rotator cuff muscle imbalance may not be the precipitating etiology for the posterior humeral subluxation and secondary posterior glenoid erosion characteristic of Walch type B glenoids., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The role of tendon transfer and ideal insertion sites to improve axial rotation in reverse total shoulder arthroplasty (RTSA) is debated. We systematically reviewed the available biomechanical evidence to elucidate the ideal tendon transfer and insertion sites for restoration of external and internal rotation in the setting of RTSA and the influence of implant lateralization., Patients and Methods: We queried the PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify biomechanical studies examining the application of tendon transfer to augment shoulder external or internal rotation range of motion in the setting of concomitant RTSA. A descriptive synthesis of six included articles was conducted to elucidate trends in the literature., Results: Biomechanics literature demonstrates that increasing humeral-sided lateralization optimized tendon transfers performed for both ER and IR. The optimal latissimus dorsi (LD) transfer site for ER is posterior to the greater tuberosity (adjacent to the teres minor insertion); however, LD transfer to this site results in greater tendon excursion compared to posterodistal insertion site. In a small series with nearly 7-year mean follow-up, the LD transfer demonstrated longevity with all 10 shoulders having>50% ER strength compared to the contralateral native shoulder and a negative Hornblower's at latest follow-up; however, reduced electromyography activity of the transferred LD compared to the native contralateral side was noted. One study found that transfer of the pectoralis major has the greatest potential to restore IR in the setting of lateralized humerus RTSA., Conclusion: To restore ER, LD transfer posterior on the greater tuberosity provides optimal biomechanics with functional longevity. The pectoralis major has the greatest potential to restore IR. Future clinical investigation applying the biomechanical principles summarized herein is needed to substantiate the role of tendon transfer in the modern era of lateralized RTSA., Level of Evidence: IV; systematic review., (Copyright © 2024. Published by Elsevier Masson SAS.)

Background: Knowledge of premorbid glenoid parameters at the time of shoulder arthroplasty, such as inclination, version, joint line position, height, and width, can assist with implant selection, implant positioning, metal augment sizing, and/or bone graft dimensions. The objective of this study was to validate a scapular statistical shape model (SSM) in predicting patient-specific glenoid morphology in scapulae with clinically relevant glenoid erosion patterns., Methods: Computed tomography scans of 30 healthy scapulae were obtained and used as the control group. Each scapula was then virtually eroded to create 7 erosion patterns (Walch A1, A2, B2, B3, D, Favard E2, and E3). This resulted in 210 uniquely eroded glenoid models, forming the eroded glenoid group. A scapular SSM, created from a different database of 85 healthy scapulae, was then applied to each eroded scapula to predict the premorbid glenoid morphology. The premorbid glenoid inclination, version, height, width, radius of best-fit sphere, and glenoid joint line position were automatically calculated for each of the 210 eroded glenoids. The mean values for all outcome variables were compared across all erosion types between the healthy, eroded, and SSM-predicted groups using a 2-way repeated measures analysis of variance., Results: The SSM was able to predict the mean premorbid glenoid parameters of the eroded glenoids with a mean absolute difference of 3° ± 2° for inclination, 3° ± 2° for version, 2 ± 1 mm for glenoid height, 2 ± 1 mm for glenoid width, 5 ± 4 mm for radius of best-fit sphere, and 1 ± 1 mm for glenoid joint line. The mean SSM-predicted values for inclination, version, height, width, and radius were not significantly different than the control group (P > .05)., Discussion: An SSM has been developed that can reliably predict premorbid glenoid morphology and glenoid indices in patients with common glenoid erosion patterns. This technology can serve as a useful template to visually represent the premorbid healthy glenoid in patients with severe glenoid bony erosions. Knowledge of the premorbid glenoid preoperatively can assist with implant selection, positioning, and sizing., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: Several descriptions of the anatomy of the pectoralis major (PM) have been published. However, the precise description of its distal humeral insertion, which is involved in traumatic tears, remains controversial. The distal tendon is classically described as being made of two layers, one anterior (ALPM) and one posterior (PLPM), which regroup at their distal edge. The clavicular head (CH) participates in the ALPM according to most authors. However, others describe a more superficial termination in a close relationship with the deltoid humeral insertion. The objective of this anatomical work is to precisely describe the anatomy of the CH and its relationship with the rest of the distal PM tendon and the distal deltoid tendon., Materials: Twenty-three fresh cadaveric specimens were dissected (41 shoulders). The entire PM as well as the deltoid were exposed. Several measurements were collected to establish the relationships between the distal tendon of the CH and the PM, the deltoid and the bony landmarks., Results: In all cases, the CH muscular portion sits on the ALPM but does not participate in the connective structure of the PM distal tendon. The inferolateral part of its distal end gives a thin tendinous portion that inserts lower on the humerus in conjunction with the distal tendon of the deltoid. In 24.4%, this tendon was more difficult to isolate but was always observed., Conclusions: The distal tendon of the PM only comes from the muscle fibres of its sternal head. The CH fibres do not contribute to this tendon but appear to terminate in a separate tendon fusing with the humeral insertion of the deltoid: the deltopectoral tendon. This could explain the different patterns of tears observed in clinical practice., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

Background: Total shoulder arthroplasty (TSA) aims to reconstruct the premorbid anatomy of a pathologic shoulder. A healthy contralateral shoulder could be useful as a template in planning TSA. The symmetry between the left and right shoulders in healthy patients remains to be proved. The purpose of this study was to compare the 3-dimensional anatomy of the glenoid between sides in a healthy population., Methods: A multinational computed tomography scan database was retrospectively reviewed for all healthy bilateral shoulders in patients aged between 18 and 50 years. One hundred thirty pairs of healthy shoulder computed tomography scans were analyzed, and glenoid version, inclination, width, and height, as well as glenoid lateral offset and scapula lateral offset, were measured. All anatomic measures were computed with Blueprint, validated 3-dimensional planning software. The intraclass correlation coefficient was determined for each measure between left and right shoulders. The minimal detectable change (MDC) was calculated using the following formula: MDC=2×1.96×Standarderrorofmeasurement., Results: The comparison between 130 pairs of healthy scapulae showed statistically significant differences in absolute values between right and left glenoid version (-5.3° vs. -4.6°, P < .01), inclination (8.4° vs. 9.3°, P < .01), and width (25.6 mm vs. 25.4 mm, P < .01), as well as scapula offset (105.8 mm vs. 106.2 mm, P < .01). Glenoid height was comparable between right and left shoulders (33.3 mm vs. 33.3 mm, P = .9). The differences between the means were always inferior to the MDC regarding glenoid version, inclination, height, and width, as well as scapula offset. Very strong intraclass correlation coefficients between the left and right shoulders were found for all evaluated paired measures., Conclusion: Healthy contralateral scapulae are highly reliable to predict inclination, height, width, and scapula offset and are reliable to predict version of a given scapula. Paired right and left scapulae were not statistically symmetrical regarding mean glenoid version, inclination, and width, as well as scapula offset. Nevertheless, the reported differences were not higher than the MDC for this cohort, confirming that healthy contralateral shoulders can be a useful template in TSA preoperative planning., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare clinical outcomes and complication rates of full arthroscopic latissimus dorsi tendon transfer (LDTT) vs. arthroscopically assisted LDTT, for the treatment of irreparable posterosuperior massive rotator cuff tears (mRCTs) in shoulders that had failed rotator cuff repair (RCR)., Methods: We evaluated a continuous series of 191 patients who underwent LDTT over 4 consecutive years. A total of 107 patients did not have previous shoulder surgery, leaving 84 patients who had prior surgical procedures. All procedures performed over the first 2 years were arthroscopically assisted (n = 48), whereas all procedures performed over the last 2 years were full arthroscopic (n = 36). We noted all complications, as well as clinical scores and range of motion at ≥24 months. To enable direct comparison between the 2 techniques, propensity score matching was used to obtain 2 groups with equivalent age, sex, and follow-up., Results: Compared with the 48 patients who underwent arthroscopically assisted LDTT, the 36 patients who underwent full arthroscopic LDTT had comparable complications (13% vs. 11%) and conversions to RSA (8.3% vs. 5.6%). Propensity score matching resulted in 2 groups, each comprising 31 patients, which had similar outcomes in terms of clinical scores (except mobility component of Constant score, which was better following fully arthroscopic LDTT; P = .037) and range of motion at a minimum follow-up of 2 years., Conclusion: At a minimum follow-up of 24 months, for the treatment of irreparable posterosuperior mRCTs in shoulders that had surgical antecedents, full arthroscopic LDTT had significantly better mobility component of the Constant score than arthroscopically assisted LDTT, although there were no significant differences in the other clinical or functional outcomes. Arthroscopically assisted LDTT and full arthroscopic LDTT had comparable rates of complications (8.3% vs. 13%) and conversion to RSA (5.6% vs. 8.3%)., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Restoration of external (ER) and internal rotation (IR) after Grammont-style reverse shoulder arthroplasty (RSA) is often unreliable. The purpose of this systematic review was to evaluate the influence of RSA medio-lateral offset and subscapularis repair on axial rotation after RSA., Methods: We conducted a systematic review of studies evaluating axial rotation (ER, IR, or both) after RSA with a defined implant design. Medio-lateral implant classification was adopted from Werthel et al. Meta-analysis was conducted using a random-effects model., Results: Thirty-two studies reporting 2,233 RSAs were included (mean patient age, 72.5 years; follow-up, 43 months; 64% female). The subscapularis was repaired in 91% (n=2,032) of shoulders and did not differ based on global implant lateralization (91% for both, P=0.602). On meta-analysis, globally lateralized implants achieved greater postoperative ER (40° [36°-44°] vs. 27° [22°-32°], P<0.001) and postoperative improvement in ER (20° [15°-26°] vs. 10° [5°-15°], P<0.001). Lateralized implants with subscapularis repair or medialized implants without subscapularis repair had significantly greater postoperative ER and postoperative improvement in ER compared to globally medialized implants with subscapularis repair (P<0.001 for both). Mean postoperative IR was reported in 56% (n=18) of studies and achieved the minimum necessary IR in 51% of lateralized (n=325, 5 cohorts) versus 36% (n=177, 5 cohorts) of medialized implants., Conclusions: Lateralized RSA produces superior axial rotation compared to medialized RSA. Lateralized RSA with subscapularis repair and medialized RSA without subscapularis repair provide greater axial rotation compared to medialized RSA with subscapularis repair. Level of evidence: 2A.

Hypothesis: Rotator cuff repair remains associated with high retear rates, which range from 13% to 79%. The objective of this study was to evaluate the long-term clinical and structural results after revision rotator cuff repair at a minimum 10-year follow-up., Methods: We retrospectively studied the records of all patients who underwent revision rotator cuff repair in 3 different institutions between July 2001 and December 2007 with a minimum 10-year follow-up. A total of 54 patients (61% males, mean age 52 ± 6 years old) met the inclusion criteria. Outcome measures included pain (visual analog scale [VAS]), range of motion (ROM), Subjective Shoulder Value (SSV), and the Constant score. Superior migration, osteoarthritis, and acromiohumeral interval (AHI) were assessed on standard radiographs. Fatty infiltration and structural integrity of the repaired tendon were evaluated on magnetic resonance imaging or computed tomographic arthrogram., Results: At a mean 14.1 years (10.4-20.5), range of motion did not progress significantly in elevation and internal rotation between pre- and postoperation (158° [range, 100°-180°] to 164° [range, 60°-180°], P = .33, and L3 [range, sacrum-T12] to T12 [range, buttocks-T7], P = .34, respectively) and decreased in active external rotation from 45° (range, 10°-80°) to 39° (range, 10°-80°) (P = .02). However, VAS, SSV, and Constant score were all significantly improved at last follow-up (P < .001). AHI decreased significantly (P = .002) from 10 mm (7-14 mm) to 8 mm (0-12 mm). Two percent of the supraspinatus/infraspinatus tendons were Sugaya 1, 24% were Sugaya 2, 35% were Sugaya 3, 12% were Sugaya 4, and 27% were Sugaya 5. Goutallier score progressed for all muscles, but this did not reach significance and mean Goutallier remained <2 for all 4 muscles at last follow-up. Hamada score progressed from 0% >grade 2 preoperatively to 6% >grade 2 at last follow-up., Conclusion: Revision rotator cuff repair provides significant pain relief and improvement in functional scores at long-term follow-up. The mild progression of fatty infiltration, AHI, and Hamada score suggests that despite high retear rates (39% of stage 4 and 5 in the Sugaya classification), revision repair could possibly have a protective role on the evolution toward cuff tear arthropathy., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Sugaya et al described a classification system to assess postoperative rotator cuff tendon healing. Although Sugaya I and II tendons can be considered as healed and Sugaya type IV and V can be considered as retorn, the exact status of Sugaya III tendons remains unclear. The objective of this study was to evaluate the impact of Sugaya III tendons on postoperative functional scores in a population of patients undergoing revision rotator cuff repair., Methods: We retrospectively studied the records of all patients who underwent revision rotator cuff repair in one of 12 different institutions between July 2001 and December 2020. A total of 203 shoulders were included (59% males, mean age: 51 ± 8 years old, mean follow-up 11.5 years [range: 2-28.8 yr]). Fifty-four patients (61% males, mean age 52 ± 6 years old, mean follow-up 14.1 years [range: 10.4-28.8 yr]) had a follow-up ≥10 years (mean 14.1 years [range: 10.4-28.8 yr]) and were included in a long-term follow-up subgroup analysis. Structural integrity of the repaired tendon was evaluated on magnetic resonance imaging at last follow-up. Functional scores, acromiohumeral index (AHI), and progression of fatty infiltration and of osteoarthritis were compared according to Sugaya type., Results: Mean Constant score and mean strength were significantly higher in Sugaya I and II tendons than in Sugaya III (P = .021 and .003) and Sugaya IV and V tendons (P = .07 and .038), but did not differ between Sugaya III and Sugaya IV and V tendons. Mean Subjective Shoulder Value, pain, AHI were significantly higher and fatty infiltration and progression in the Hamada classification were significantly lower in Sugaya I and II tendons and in Sugaya III than in Sugaya IV and V tendons (P < .05), but did not differ between Sugaya I and II and Sugaya III tendons. Similar characteristics could also be observed in the long-term follow-up subgroup., Conclusion: Sugaya III tendons after revision rotator cuff repair do not allow restoration of strength thereby impacting the Constant score. However, there seems to be a protective effect of Sugaya III tendons with regard to pain, progression of proximal migration of the humeral head, osteoarthritis, and fatty infiltration, which seems to last at long-term follow-up., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: Periprosthetic fractures around a stemless implant often involve lesser and greater tuberosities with a well-fixed implant in the metaphysis. This exposes the surgeon to unique questions and challenges as no surgical option (open reduction and internal fixation or revision to a stem) appears satisfactory to address them. Purpose of this study was to evaluate the clinical outcomes after non-operative management of periprosthetic fractures after stemless shoulder arthroplasty., Methods: A retrospective multicenter study was conducted to identify all patients who had sustained non-operative management of a periprosthetic fracture after a stemless shoulder. Exclusion criteria were as follows: (1) intraoperative fractures and (2) implant loosening. Primary outcomes included mean Constant score and mean active range of motion. Secondary outcomes were VAS, radiological analysis, and complications., Results: Nine patients were included. One was excluded due to the loss of follow-up at three months. Mean age was 79 years. At the last follow-up, no significant difference was observed between the Constant score, VAS, or the range of motion before fracture and at the last follow-up. Fracture healing did not result in any change in angulation in the frontal plane in seven cases and was responsible for a varus malunion in two cases of anatomic arthroplasty. No change in lateralization or distalization was reported. No cases of implant loosening after fracture have been observed., Conclusions: Conservative management seems to be appropriate in cases of minimally displaced fractures without implant loosening., (© 2023. The Author(s) under exclusive licence to SICOT aisbl.)

Introduction: The etiology of humeral posterior subluxation remains unknown, and it has been hypothesized that horizontal muscle imbalance could cause this condition. The objective of this study was to compare the ratio of anterior to posterior rotator cuff muscle and deltoid volumes as a function of humeral subluxation and glenoid morphology when analyzed as continuous variable in arthritic shoulders., Methods: Three hundred and thirty-three (273 arthritic and 60 healthy controls) CT scans of shoulders were included in this study and were segmented automatically. For each muscle, the volume of muscle fibers without intra-muscular fat was then measured. The ratio between the volume of the subscapularis and the volume of the infraspinatus + teres minor (AP ratio) and the ratio between the anterior and posterior deltoid (AP deltoid ) were calculated. Statistical analyses were performed to determine whether a correlation could be found between these ratios and glenoid version/ humeral subluxation/glenoid type in the Walch classification., Results: Within the arthritic cohort, no statistically significant difference was found between the AP ratio between A and type B glenoids (1.09 ± 0.22 versus 1.03 ± 0.16 p=0.09), between A and D type glenoids (1.09 ± 0.22 versus 1.12 ± 0.27, p=0.77) nor between the A and C type glenoids (1.09 ± 0.22 versus 1.10 ± 0.19, p=1). No correlation was found between AP ratio and glenoid version/humeral subluxation (rho =-0.0360, p=0.55; rho = 0.076; p=0.21). The AP deltoid ratio of type A glenoids was significantly greater than that of type B glenoids (0.48 ± 0.15 versus 0.35 ± 0.16, p< 0.01), and type C glenoids (0.48 ± 0.15 versus 0.21±0.10, p < 0.01) but not significantly different from the AP deltoid ratio of type D glenoids (0.48 ± 0.15 versus 0.64 ± 0.34, p=1). When evaluating both healthy control and arthritic shoulders, moderate correlations were found between AP deltoid ratio and glenoid version/humeral subluxation (rho=0.55, p<0.01; rho=-0.61, p<0.01)., Conclusion: As opposed to previous two-dimensional CT scan studies, we did not find any correlation between AP muscle volume ratio and glenoid parameters in arthritic shoulders. Therefore, rotator cuff muscle imbalance does not seem to be associated with posterior humeral subluxation leading to posterior glenoid erosion and subsequent retroversion characteristic of Walch B glenoids. However, our results could suggest that a larger posterior deltoid pulls the humerus posteriorly into posterior subluxation, but this requires further evaluation as the deltoid follows the humerus possibly leading to secondary asymmetry between the anterior and the posterior deltoid., (Copyright © 2023. Published by Elsevier Inc.)

Purpose: To investigate the gliding resistance dynamics between the supraspinatus (SSP) tendon and the coracoacromial arch, both before and after subacromial decompression (anterolateral acromioplasty) and acromion resection (acromionectomy)., Methods: Using 4 fresh-frozen cadaveric shoulders, acromion shapes were classified (2 type I and 2 type III according to Bigliani). Subacromial bursa and coracoacromial ligament maintenance replicated physiologic sliding conditions. Gliding resistance was measured during glenohumeral abduction (0° to 60°) in internal rotation (IR) and external rotation (ER). Peak gliding resistance between the SSP tendon and the coracoacromial arch was determined and compared between intact, anterolateral acromioplasty, and acromionectomy., Results: Peak SSP gliding resistance during abduction in an intact shoulder was significantly higher in IR than in ER (4.1 vs 2.1 N, P < .001). The mean peak SSP gliding resistance during 0° to 60° glenohumeral abduction in IR in the intact condition was significantly higher compared with the subacromial decompression condition (4.1 vs 2.8 N, P  = .021) and with the acromionectomy condition (4.1 vs 0.9 N, P < .001). During 0° to 60° glenohumeral abduction in ER, mean peak SSP gliding resistance in the intact condition was not significantly different compared with the subacromial decompression condition (2.1 vs 2.0 N, P  = .999). The 2 specimens with a hooked (i.e. type III) acromion showed significantly higher mean peak SSP gliding resistance during glenohumeral abduction in IR and ER when compared with the 2 specimens with a flat (i.e. type I) acromion (IR: 5.8 vs 3.0 N, P  = .006; ER: 2.8 vs 1.4 N, P  = .001)., Conclusions: In this cadaveric study, peak gliding resistance between the SSP tendon and the coracoacromial arch during combined abduction and IR was significantly reduced after anterolateral acromioplasty and was significantly higher in specimens with a hooked acromion., Clinical Relevance: The clinical benefit of subacromial decompression remains unclear. This study suggests that anterolateral acromioplasty might reduce supraspinatus gliding resistance in those with a hooked acromion and in the typical "impingement" position., Competing Interests: The authors report no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material., (© 2023 The Authors.)

Purpose: We sought to define the risk of persistent shoulder dysfunction after anatomic total shoulder arthroplasty (aTSA) beyond the early postoperative period and identify risk factors for persistent poor performance., Methods: We retrospectively identified 144 primary aTSAs performed for primary osteoarthritis with early poor performance and 2-year minimum follow-up. Early poor performance was defined as a postoperative ASES score below the 20th percentile at 3- or 6-months (62 and 72 points, respectively). Persistent poor performance at 2 years was defined as failing to achieve the patient acceptable symptomatic state (PASS) [ASES = 81.7 points]., Results: At 2-year follow-up, 51% (n = 74) of patients with early poor performance at either 3- or 6-month follow-up had persistent poor performance. There was no difference in the rate of persistent poor performance if patients were poor performers at the 3-, 6-month follow-up, or both (50% vs. 49% vs. 56%, P = .795). Of aTSAs achieving the PASS at 2-year follow-up, a greater proportion exceeded the minimal clinically important differences (MCID) [Forward elevation, external rotation, and all outcome scores] and substantial clinical benefit (SCB) [external rotation and all outcome scores] compared to persistent poor performers. However, over half of persistent poor performers still exceeded the MCID for all outcome measures (56-85%). Independent predictors of persistent poor performance were hypertension (2.61 [1.01-6.72], P = .044) and diabetes (5.14 [1.00-26.4], P = .039)., Conclusion: Over half of aTSAs with an ASES score < 20th percentile at early follow-up had continued poor shoulder function at 2-years postoperatively. Persistent poor performance was best projected by preoperative hypertension and diabetes., Level of Evidence: Level III; Retrospective Cohort Comparison using Large Database; Treatment Study., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: The purpose of this study was to evaluate the relationship between humeral lengthening and clinical outcomes after reverse shoulder arthroplasty (RSA) with stratification based on measurement method and implant design., Methods: This systematic review was performed using PRISMA-P guidelines. PubMed/Medline, Cochrane Trials, and Embase were queried for articles evaluating the relationship between humeral lengthening and clinical outcomes inclusive of range of motion (ROM), strength, outcome scores, and pertinent complications (acromial and scapular spine fractures, nerve injury) after RSA. The relationship between humeral lengthening and clinical outcomes was reported descriptively overall and stratified by measurement method and implant design (globally medialized vs. lateralized). A positive association was defined as increased humeral lengthening being associated with greater ROM, outcome scores, or a greater incidence of complications, whereas a negative association denoted that increased humeral lengthening was associated with poorer ROM, outcome scores, or a lower incidence of complications. Meta-analysis was performed to compare humeral lengthening between patients with and without fractures of the acromion or scapular spine., Results: Twenty-two studies were included. Humeral lengthening was assessed as the acromiohumeral distance (AHD), the distance from the acromion to the greater tuberosity (AGT), the acromion to the deltoid tuberosity (ADT), and the acromion to the distal humerus (ADH). Of 11 studies that assessed forward elevation, a positive association with humeral lengthening was found in 6, a negative association was found in 1, and 4 studies reported no association. Of studies assessing internal rotation (n = 9), external rotation (n = 7), and abduction (n = 4), all either identified a positive or lack of association with humeral lengthening. Studies assessing outcome scores (n = 11) found either a positive (n = 5) or no (n = 6) association with humeral lengthening. Of the studies that assessed fractures of the acromion and/or scapular spine (n = 6), 2 identified a positive association with humeral lengthening, 1 identified a negative association, and 3 identified no association. The single study that assessed the incidence of nerve injury identified a positive association with humeral lengthening. Meta-analysis was possible for AGT (n = 2) and AHD (n = 2); greater humeral lengthening was found in patients with fractures for studies using the AGT (mean difference 4.5 mm, 95% CI 0.7-8.3) but not the AHD. Limited study inclusion and heterogeneity prohibited identification of trends based on method of measuring humeral lengthening and implant design., Conclusion: The relationship between humeral lengthening and clinical outcomes after RSA remains unclear and requires future investigation using a standardized assessment method., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Abstract: Scapulothoracic arthrodesis has been proposed for the treatment of painful scapular winging in patients with facioscapulohumeral muscular dystrophy. It was introduced to improve shoulder function. Several methods of fixation have been proposed to obtain the union of the scapula to the ribs. These include plates, screws, cables, or wires with or without bone grafting. The purpose of this manuscript is to describe the surgical technique of scapulothoracic arthrodesis using plate and cerclage suture tapes., Level of Evidence: Level IV, treatment study (case series)., Competing Interests: Conflicts of Interest and Source of Funding: The authors report no conflicts of interest and no source of funding., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

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: Reverse total shoulder arthroplasty (rTSA) has begun to challenge the place of anatomic total shoulder arthroplasty (aTSA) as a primary procedure for certain indications. One purported benefit of aTSA is improved postoperative range of motion (ROM) compared to rTSA especially in internal rotation; however, it is unclear whether aTSA can provide patients with significant preoperative stiffness superior ROM compared to rTSA. Our purpose was to compare clinical outcomes of aTSA and rTSA performed in stiff vs. non-stiff shoulders for rotator cuff intact (RCI) glenohumeral osteoarthritis (GHOA)., Methods: A retrospective review of an international shoulder arthroplasty database identified 1608 aTSAs and 600 rTSAs performed for RCI GHOA with minimum 2-year follow-up. Defining preoperative stiffness as ≤ 0° of passive external rotation (ER), we matched: (1) stiff aTSAs (n = 257) 1:3 to non-stiff aTSAs, (2) stiff rTSAs (n = 87) 1:3 to non-stiff rTSAs, and (3) stiff rTSAs (n = 87) 1:1 to stiff aTSAs. We compared ROM, outcome scores, and the rate of complications and revision surgery at latest follow-up., Results: Despite stiff aTSAs having poorer preoperative ROM and functional outcome scores for all measures assessed (P < .001 for all), only poorer postoperative active abduction (113 ± 27° vs. 128 ± 35°; P < .001), active ER (39 ± 18° vs. 50 ± 20°; P < .001), and passive ER (45 ± 17° vs. 56 ± 18°; P < .001) persisted postoperatively compared to the non-stiff cohort. Similarly, stiff rTSAs had poorer preoperative ROM and functional outcome scores for all measures assessed compared to non-stiff rTSAs (P ≤ .044), but only poorer active abduction (108 ± 24° vs. 128 ± 29°, P < .001), active ER (28 ± 17° vs. 42 ± 17°, P < .001), and passive ER (36 ± 15° vs. 48 ± 17°, P < .001) persisted. When comparing stiff rTSAs to matched stiff aTSAs, no significant differences in preoperative ROM or functional outcome scores were found. However, stiff aTSAs had greater postoperative active internal rotation score (4.8 ± 1.5 vs. 4.2 ± 1.7, P = .022), active ER (40 ± 19° vs. 28 ± 17°, P < .001), and passive ER (46 ± 18° vs. 36 ± 15°, P = .001). Postoperative outcome scores were similar across all matched cohort comparisons despite motion differences. The rate of complications and need for revision surgery did not differ between any group comparisons., Conclusions: Patients with RCI GHOA who have preoperative rotational stiffness have poorer postoperative ROM compared with non-stiff patients following both aTSA and rTSA, but similar functional outcome scores. Notably, preoperative limitations in passive ER do not appear to be a limitation to utilizing aTSA. Indeed, patients with limited preoperative ER treated with aTSA had greater postoperative internal rotation and ER compared to those treated with rTSA., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

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., (© 2022. The Author(s).)

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: 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., Competing Interests: The authors have declared that there are no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

Background: Cerebrovascular accidents (CVAs), or strokes, are the second most common cause of mortality and third most common cause of disability worldwide. Although 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 sequelae on patients undergoing shoulder arthroplasty (SA). This study aimed to determine the outcomes of patients with a history of stroke with sequela undergoing primary SA., Methods: Over a 30-year time period (1990-2020), 205 primary SAs (32 hemiarthroplasties [HAs], 56 anatomic total shoulder arthroplasties [aTSAs], and 117 reverse shoulder arthroplasties [RSAs]) 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., Results: The stroke cohort sustained 38 (18.5%) surgical and 42 (20.5%) medical perioperative complications. Compared with 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 with 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 the perioperative period., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: 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., Methods: 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., Results: 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)., Conclusion: 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 of Evidence: Level III; Retrospective comparative study; Treatment study., (© 2022. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Although 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 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., Methods: 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 American Shoulder and Elbow Surgeons (ASES) score below the 20th percentile at 3 months (58 points) or 6 months (65 points) postoperatively. Persistent poor performance at 2 years was defined as failure to achieve the patient acceptable symptomatic state for rTSA (77.3 points for the ASES score). The primary outcome was the rate of persistent poor performance. Secondarily, we compared the clinical outcomes of persistent poor performers vs. shoulders that improved at 2-year follow-up and assessed risk factors for persistent poor performance., Results: At 2-year follow-up, 61% of patients (n = 178) with poor performance at either 3- or 6-month follow-up had persistent poor performance. The rate increased to 85% if poor performance occurred at both 3- and 6-month follow-up. The minimal clinically important difference and substantial clinical benefit for range of motion and outcome scores were exceeded by early poor performers at rates of 83%-92% and 60%-77%, respectively, at 2-year follow-up. On multivariate logistic regression analysis, independent predictors of persistent poor performance after rTSA were lack of hypertension (odds ratio [OR], 0.27; 95% confidence interval [CI], 0.13-0.57; P < .001), heart disease (OR, 2.89; 95% CI, 1.24-6.77; P = .011), uncemented humeral fixation (OR, 0.11; 95% CI, 0.01-1.18; P = .037), previous shoulder surgery (OR, 2.14; 95% CI, 1.06-4.30; P = .031), lower preoperative ASES score (OR, 0.92; 95% CI, 0.87-0.97; P = .002), and lower preoperative subjective rating of pain at its worst (OR, 0.73; 95% CI, 0.54-0.99; P = .038)., Discussion: Despite the fact that 85% of rTSA patients with an ASES score below the 20th percentile at early follow-up exceeded the minimal clinically important difference for improvement in the ASES score at 2-year clinical follow-up, 61% still had persistent poor performance, with failure to achieve the patient acceptable symptomatic state for the ASES score. Persistent poor performance after rTSA was best predicted by a history of shoulder surgery and a poorer preoperative ASES score. These findings can aid surgeons when counseling patients both preoperatively and postoperatively. In the setting of early poor performance, the risk of persistent poor performance must be balanced against the potential outcomes of revision surgery when considering early surgical intervention., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: 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)., Methods: 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., Results: 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)., Conclusions: 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., Level of Evidence: III; Retrospective Cohort Comparison; Treatment Study., (© 2022. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

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.

Background: 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., Methods: 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., Results: 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°., Conclusion: 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., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Management of combined persistent anterior glenoid bone deficiency with irreparable subscapularis tear can be very complicated and challenging especially if associated with arthritis. The objective of this study was to report the outcome of combined reconstruction of the anterior glenoid with bone autograft or allograft with additional anterior latissimus transfer to reconstruct irreparable subscapularis tear with or without humeral head replacement., Methods: Nineteen patients (average age 29 years old) who underwent open anterior glenoid bone reconstruction with iliac crest bone autograft or ostechondral bone allograft (distal tibia or glenoid allograft), with anterior latissimus transfer to reconstruct irreparable subscapularis tear with or without humeral head replacement were included in this study. Outcome measures included preoperative and postoperative pain score, visual analog scale, Subjective Shoulder Value, American Shoulder and Elbow Surgeons score, and Constant Score., Results: Out of the 19 patients, 5 patients underwent humeral resurfacing arthroplasty. Anterior glenoid bone reconstruction was performed with iliac crest bone autograft in 8 patients, glenoid osteochondral allograft in 7 patients, and tibial plafond in 4 patients. At mean 31-month follow-up of (13-63 months), 15 patients (79%) considered their shoulder stable and were able to return to their work and 14 (74%) patients returned to their sport activity. Redislocation had occurred in 1 of the 18 shoulders (5%), subluxation had occurred in 3 patients (16%) of the shoulders and apprehension was reported for 4 patients, 21% of the operated shoulders. All outcome measures showed significant improvement compared to before surgery. No intraoperative or immediate postoperative complications were observed. Four patients (21%) had to be revised to reverse shoulder arthroplasty., Conclusion: The combination of anterior latissimus transfer, anterior glenoid bone grafting with or without humeral head resurfacing is an effective salvage surgical reconstruction that can stabilize shoulders in the setting of recurrent anterior instability after a failed Latarjet with an irreparable subscapularis tear. This could be a potential alternative reconstruction option that might be offered to patients with this difficult problem. Long-term outcome is needed to better evaluate the validity of this technique., (© 2022 The Authors.)

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.

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 < 0.05] and 12.4° ± 10.1 [p < 0.05] loss were documented for ER1 and ER2, respectively. All functional scores exhibited significant improvements. Post-operative CT scan was available in 16 shoulders and revealed coracoid union in 15/16 shoulders and an asymptomatic fibrous non-union without coracoid or implant migration in one patient., Conclusion: The arthroscopic Trillat procedure combined with an antero-inferior capsulolabral plasty is effective in preventing recurrent instability and eliminating shoulder apprehension among patients suffering from anterior and or inferior hyperlaxity., Level of Evidence: Level IV., (© 2021. European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Background: 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)., Methods: 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 χ 2 test as indicated., Results: RTSAs 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., Conclusion: 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., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.)

Purpose: 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., Methods: 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., Results: 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%)., Conclusions: 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., Level of Evidence: Therapeutic, level IV, retrospective case series., (Copyright © 2021 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

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.)

Classical treatments of shoulder instability are associated with recurrence. To determine whether the modification of the capsule properties may be an alternative procedure, the effect of crosslinking treatment on the structure and mechanical properties of diseased human shoulder capsules was investigated. Joint capsules harvested from patients during shoulder surgery (n = 5) were treated or not with UV and/or riboflavin (0.1%, 1.0% and 2.5%). The structure and the mechanical properties of the capsules were determined by atomic force microscopy. The effect of treatments on cell death was investigated. Collagen fibrils were well-aligned and adjacent to each other with a D-periodicity of 66.9 ± 3.2 nm and a diameter of 71.8 ± 15.4 nm in control untreated capsules. No effect of treatments was observed on the organization of the collagen fibrils nor on their intrinsic characteristics, including D-periodicity or their mean diameter. The treatments also did not induce cell death. In contrast, UV + 2.5% riboflavin induced capsule stiffness, as revealed by the increased Young's modulus values ( p < 0.0001 for each patient). Our results showed that the crosslinking procedure changed the biomechanics of diseased capsules, while keeping their structural organisation unchanged at the single fibril level. The UV/riboflavin crosslinking procedure may be a promising way to preserve the functions of collagen-based tissues and tune their elasticity for clinically relevant treatments.

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., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

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., (© 2021. The Author(s) under exclusive licence to SICOT aisbl.)

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., (Copyright © 2021. Published by Elsevier Masson SAS.)

Paralysis of the muscles around the shoulder is a debilitating condition that continues to be a very challenging problem. It leads to an inability to position one's hand in space. This greatly compromises the function of the upper limb and can lead to chronic shoulder pain due to inferior glenohumeral subluxation. Management of these complex problems has two main objectives: (i) stabilize the glenohumeral joint to decrease pain related to inferior glenohumeral subluxation; (ii) restore active range of motion in external rotation, abduction, and internal rotation. All the shoulder muscles contract in a coordinated and complex manner to allow the shoulder to move through a complete range of motion. Understanding how the different muscle groups coordinate their contractions and the basic biomechanical principles of tendon transfers is paramount before considering doing a tendon transfer around the shoulder. To function properly, a tendon transfer should have a similar line of pull (similar moment arm), similar tension and similar excursion to that of the muscle it replaces; one tendon transfer should replace only one function and the donor (transferred) muscle should have normal muscle strength (at least M4)., (Copyright © 2021. Published by Elsevier Masson SAS.)

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.)

Background: Rotator cuff fatty infiltration (FI) is one of the most important parameters to predict the outcome of certain shoulder conditions. The primary 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. The secondary objective of this study was to compare this new measurement method to traditional 2D qualitative assessment of FI according to Goutallier et al and to a 3D quantitative measurement of fatty infiltration (3DFI)., Materials and Methods: 102 CT scans from healthy shoulders (46) and shoulders with cuff tear arthropathy (21), irreparable rotator cuff tears (18), and primary osteoarthritis (17) were analyzed by 3 experienced shoulder surgeons for subjective grading of fatty infiltration according to Goutallier, and their rotator cuff muscles were manually segmented. Quantitative 3D measurements of fatty infiltration (3DFI) were completed. 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 (NV fibers ). 3D muscle mass (3DMM) was calculated by dividing the NV fibers value of a given muscle by the mean expected volume in healthy shoulders. 3D muscle loss (3DML) was defined as 1 - (3DMM). The correlation between Goutallier grading, 3DFI, and 3DML was compared using a Spearman rank correlation., Results: Interobserver reliability for the traditional 2D Goutallier grading was moderate for the infraspinatus (ISP, 0.42) and fair for the supraspinatus (SSP, 0.38), subscapularis (SSC, 0.27) and teres minor (TM, 0.27). 2D Goutallier grading was found to be significantly and highly correlated with 3DFI (SSP, 0.79; ISP, 0.83; SSC, 0.69; TM, 0.45) and 3DML (SSP, 0.87; ISP, 0.85; SSC, 0.69; TM, 0.46) for all 4 rotator cuff muscles (P < .0001). This correlation was significantly higher for 3DML than for the 3DFI for SSP only (P = .01). 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., Conclusion: The Goutallier score has been helping surgeons by using 2D CT scan slices. However, this grading is associated with suboptimal interobserver agreement. The new measures we propose provide a more consistent assessment that correlates well with Goutallier's principles. As 3DML measurements incorporate atrophy and fatty infiltration, they could become a very reliable index for assessing shoulder muscle function. Future algorithms capable of automatically calculating the 3DML of the cuff could help in the decision process for cuff repair and the choice of anatomic or reverse shoulder arthroplasty., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Since Mihata's 2012 proposal to arthroscopically reconstruct the superior capsule of patients with massive irreparable cuff tears, many studies have reported the clinical results of this technique using different types of grafts (fascia lata autograft, dermal allograft, porcine dermal xenograft or long head of biceps autograft)., Purpose: The objective of this meta-analysis was to report the clinical and radiological results of these superior capsule reconstructions., Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) recommendations were used to conduct this systematic review. A bibliographic search was performed of the electronic databases MEDLINE, Scopus, Embase and the Cochrane Library. The quality of the studies was assessed according to the MINORS criterion (Methodological Index for Nonrandomized Studies). The inclusion criteria were studies in English evaluating superior capsular reconstruction., Results: No level I or II studies met the inclusion criteria. Eighteen studies were selected from the 97 identified, including 637 shoulders (64% male) with a mean age of 62 years [95% CI: 60.3-63.5]. At the mean follow-up of 24.3 months (12-60), the range of motion was significantly increased from 82.6° [60.0-105.2] to 141.9° [109.9-173.8] in abduction, from 113.1° [98.3-127.9] to 153.3° [147.4-159.2] in elevation, from 35.5° [30.9-40.2] 43.4° [35.4-51.3] in external rotation and from 7.2 [5.4-9] to 9.9 [8.9-10.9] in internal rotation. Functional scores were significantly improved from 5.4 [4.8-5.9] to 1.3 [0.9-1.7] points for VAS, from 42.5 [15.7-69.3] to 59.3 [30.1-88.6] points for Constant, from 39.0% [38.1-39.8] to 79.8% [76.4-83.3] for the SSV, and from 48.2 [45.2-51.1] to 81.2 [77.2-85.1] points for the ASES. The healing rate was 76.1% [64.4-84.9]. The complication rate was 5.6% [1.8-16.3] and the reverse shoulder arthroplasty revision rate was 7.1% [3.8-12.8]., Conclusion: Superior capsule reconstructions allow satisfactory clinical and radiological results to be obtained at 2 years of follow-up. Due to the small number of high quality comparative studies available, its true place in the therapeutic arsenal cannot be fully confirmed. However, it seems that the best indication for this technique is isolated irreparable rupture of the supraspinatus, in cases of medical treatment failure., Level of Evidence: III; meta-analysis of heterogeneous studies., (Copyright © 2021. Published by Elsevier Masson SAS.)

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 multidisciplinary rheumatologic clinic met inclusion criteria. Further assessment was performed with inclusion of the visual analog scale 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 = .02) and the highest American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form scores (77.4; P = .04) at the 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 5-year implant survival rates of 95.1% at 5 years, 93% at 10 years, 89.4% at 20 years, and 79.5% at 30 years. At 30 years, TSA was associated with better survival (90.1%) than 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., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: 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., Methods: 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., Results: 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., Conclusions: 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., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)