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Purpose: The purpose of this study was to quantify the improvement patients undergoing scope-assisted lower trapezius tendon transfer (SALTT) for irreparable rotator cuff tears (IRCT) have and whether intra-operative subscapularis management affected these outcomes., Methods: From 2015 to 2023, patients undergoing primary SALTT for IRCT without osteoarthritis or brachial plexopathy with serial follow-up at 6- and minimum 12-months post-operatively were identified. Subjective Shoulder Value (SSV) scores, active forward elevation (aFE), external rotation (ER) lag, and cuff strength was recorded. Continuous variables were analyzed with one-way or repeated measures analysis of variance, and a multivariate linear regression was performed evaluating demographic, radiographic, and intra-operative variable effects on SSV and ER lag., Results: Seventy-six (mean age: 56.5±8.1 years; BMI: 29.0±4.3; 73% male) patients operated on by 4 surgeons (A: 66%; B: 15%; C: 13%; D: 4%) demonstrated significant improvement in baseline SSV scores (mean: 23.9±SD:13.1) to 6-month (mean: 73.5±10.6, 91% MCID achievement P<0.001) and final (mean: 43.5±29.5 months) follow up scores (mean: 79.9±16.5, 92% MCID achievement P<0.001; n=45/122:37% 2-year inclusion rate). Regression analysis for final SSV demonstrated age (beta: 0.8, P=0.017) to have a positive effect and subscapularis fatty infiltration (beta: -10.6, P<0.001) to have a negative effect. Active FE improved from 6-month (139±SD:23.8°) to final (146±23.0°, P=0.013) follow-up while ER lag (17±SD:17°) improved as well (6-month mean: 3±7.8°, P<0.001; final: 3±5.6°, P<0.001). Regression analysis demonstrated subscapularis fatty infiltration (beta:-11.6, P=0.003) had a negative effect on final aFE while infraspinatus fatty infiltration (beta:-1.2, P=0.048) and concomitant subscapularis repair (beta:-5.0, P=0.023) had a negative effect in final ER lag. Presence of subscapularis tears alone (beta:4.5, P=0.030) had a positive effect on ER lag. Overall, five (7%) patients underwent re-operations., Conclusion: Patients with IRCT undergoing SALTT with or without subscapularis tears requiring repair achieve excellent short-term clinical outcomes while improving from an exam standpoint., (Copyright © 2025. Published by Elsevier Inc.)

Background: Birth brachial plexus palsy (BBPP) can severely impair shoulder function by restricting external rotation and abduction, often leading to posterior subluxation or dislocation. Progressive shoulder dysplasia, a secondary condition of BBPP, further exacerbates functional disability by limiting shoulder function. Several techniques have been developed to address these challenges, including microsurgery, muscle transfer, and bony procedures. Recent reports on lower trapezius muscle transfer to the infraspinatus footprint demonstrate promising results in restoring shoulder biomechanics in adults. In this study, we aimed to treat patients younger than 7 years with BBPP through lower trapezius muscle transfer without allograft support., Patients and Methods: Between 2014 and 2018, 15 patients with BBPP and impaired shoulder external rotation and/or abduction (mean age, 22 months; range: 10 to 41 months) underwent lower trapezius muscle transfer surgery at our institution. A glenoid osteotomy was performed in patients without concentric joints, followed by the transfer of the lower trapezius muscle to the footprint of the infraspinatus. Patients were followed for an average of 25 months (range: 14 to 46 months). Outcomes assessed included shoulder external rotation, shoulder abduction, hand-to-mouth, hand-to-back, hand-to-neck, and Mallet scores., Results: Significant improvements were observed in hand-to-mouth, hand-to-neck, global shoulder abduction, global shoulder external rotation, and total Mallet scores (P < 0.01). A nonsignificant decrease in hand-to-back was noted (P > 0.05). Both shoulder external rotation and abduction increased significantly (P < 0.01). No complications were reported after the muscle transfer procedure., Discussion: Lower trapezius muscle transfer to the infraspinatus footprint markedly improves shoulder external rotation and abduction in children younger than 7 years without adverse effects on daily activities. This procedure is an effective treatment option for patients who present outside the optimal window for nerve transfer., Level of Evidence: Level IV; Case Series; Treatment Study., (Copyright © 2025 by the American Academy of Orthopaedic Surgeons.)

Background: Painful degeneration of the sternoclavicular joint refractory to nonoperative treatment has historically been managed with resection of the degenerative segment of the medial clavicle. Although this has produced good results with improvement in symptoms, recurrent pain necessitating revision surgery is not an infrequently encountered outcome. To reduce the occurrence of recurrent postoperative pain, a novel technique to reconstruct the intra-articular disc at the time of medial clavicle resection was developed., Methods: 10 patients whom underwent medial clavicle excision and interposition arthroplasty with a lateral meniscus allograft were retrospectively reviewed. Functional results were based on VAS pain scores and subjective shoulder scores., Results: VAS pain score improved from 7.5 (5-10) preoperatively to 1.2 (0-2; p = .005, W-value = 0) postoperatively, with an average improvement of 6.3. The mean preoperative SSV score improved from 54.5 (25-70) preoperatively to 88.5% (80-95%; p = .005; W-value = 0) postoperatively, with a mean increase of 34 percentage points. No patients experienced a complication and or recurrence of pain at most recent follow-up., Conclusion: Minimal excision of the medial clavicle and interposition arthroplasty with lateral meniscal allograft successfully reduces pain and restores stability and function for the treatment of painful degeneration of the SC joint., (Copyright © 2025. Published by Elsevier Inc.)

Introduction: Shoulder and elbow surgery fellowships in the United States are recognized for their academic emphasis, yet the correlation between an applicant's research productivity and fellowship match results remains unclear. This study (1) analyzed temporal trends in research productivity among matched fellowship applicants, (2) evaluated the influence of quantity of publications and first authorships on match positions, and (3) investigated program variations in research productivity., Methods: This is a retrospective analysis of data from the San Francisco (SF) Match Database for shoulder and elbow surgery applicants matched between 2017 and 2024. Allopathic (MD), osteopathic (DO), and international medical graduates (IMGs) were included. PubMed was queried to quantify publications and first authorship before and during residency, analyzing their association with applicant and fellowship rank. Publication volumes per fellowship program were also calculated for institutions with at least five years of match data., Results: 290 matched applicants were evaluated across 34 fellowship programs, comprising 229 MDs, 29 DOs, and 32 IMGs. There was almost a five-fold increase in the average number of publications per applicant, from 2.72 ± 3.54 in 2017 to 12.80 ± 15.88 in 2024 (B 1.30; p = 0.001). Similarly, first authorship publication counts increased almost three-fold, from 1.31 ± 2.12 in 2017 to 3.66 ± 5.01 in 2024 (B = 0.29, p = 0.02). Fellowship program analysis revealed wide variation in mean publication counts of matched applicants (p = 0.008), with Rush University Medical Center (27.88 ± 33.86), Massachusetts General Hospital (13.65 ± 26.62), Mayo Clinic (13.06 ± 14.77), Thomas Jefferson University Hospital (12.19 ± 10.64) exhibiting the highest averages. Candidates with more publications (p = 0.04), first authorships(p = 0.02), and total first authorships (p = 0.04) during residency were ranked higher by fellowship programs. There was a significant correlation between greater publication count during residency and more favorable fellowship rank (-0.15, p = 0.02) and applicant match position (-0.12, p = 0.049). No significant associations were found between pre-residency publications (p = 0.38), total publications (p = 0.13), and pre-residency first authorships (p = 0.20) with fellowship rank positions., Conclusion: Research productivity has increased substantially among matched applicants. The more academically productive residents tend to be ranked more favorably by fellowship programs and match higher on their list. However, these associations were relatively weak, highlighting the complexity of the fellowship selection process and the notion that research productivity alone does not guarantee placement in preferred programs., (Copyright © 2025. Published by Elsevier Inc.)

Background: Adult traumatic brachial plexus injuries (BPIs) present a significant medical challenge, potentially leading to life-altering consequences for patients' upper extremity pain and function. However, the psychological impact on patients has not been extensively studied., Methods: Adult patients with traumatic BPIs treated at 2 tertiary referral centers in the United States from 2015 to 2019 were retrospectively identified. This cohort of 84 patients was targeted for prospective interviews, and 44 patients (52%) responded. Validated measures including the posttrumatic stress disorder (PTSD) Checklist for Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition (PCL-5), Decision Regret Scale, Patient-Reported Outcome Measurement Information System (PROMIS) Pain Intensity, PROMIS Pain Interference, PROMIS Upper Extremity, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) were obtained through telephone-based interviews. Additional data were collected through electronic medical record review., Results: On average, patients experience low post-traumatic stress (median score 6, interquartile range [IQR] 3-20) and decision regret (median score 5, IQR 0-22.5). However, a notable fraction (18%) of patients met the clinical threshold for PTSD. Significant correlations were observed between PCL-5 scores and worse PROMIS Pain Intensity, PROMIS Pain Interference, PROMIS Upper Extremity, and QuickDASH. Decision regret scores correlated with worse PROMIS Upper Extremity and QuickDASH., Conclusions: While the overall incidence of PTSD and treatment decision regret after adult traumatic BPI is low, clinical PTSD was found in a significant percentage of patients associated with pain and functional impairment. This study highlights the importance of understanding and addressing the psychological burden of traumatic BPI., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The utilization of total shoulder arthroplasty (TSA) in an aging population continues to rise, but the perioperative risk profile of TSA in the very elderly is not well-described. The objective of this study was to quantify the risk profile of 30-day perioperative adverse events after TSA in octogenarians and nonagenarians using a large national database over a recent 10-year period., Methods: The National Surgical Quality Improvement Program database was queried for TSA from 2011 to 2020. Patients were stratified into three age groups: (1) age < 80 years, (2) 80 years ≤ age < 90 years ("octogenarians" in this study), and (3) age ≥ 90 years ("nonagenarians" in this study). The primary outcome was 30-day complication, and secondary outcome variables included 30-day readmission, revision surgery, and mortality. Multivariable logistic regression analyses adjusted for relevant comorbidities were done., Results: The cohort included 33,089 patients who underwent TSA, including 28,543 patients younger than 80 years, 4,334 octogenarians, and 212 nonagenarians. Complication rates were 4% in patients younger than 80 years, 8% in octogenarians, and 16% in nonagenarians. Readmission rates were 3% in patients younger than 80 years, 4% in octogenarians, and 7% in nonagenarians. Mortality rates were 0.1% in patients younger than 80 years, 0.4% in octogenarians, and 2% in nonagenarians. Revision surgery was not markedly different among age groups. In the adjusted multivariable logistic regression analysis, compared with patients younger than 80 years, octogenarians had 1.9-times higher odds of complications and 1.5-times higher odds of readmission, and nonagenarians had 7.1-times higher odds of complications and 2.2-times higher odds of readmission., Discussion: Our findings are germane to preoperative counseling in very elderly patients considering TSA, to balance potential improvements in quality of remaining life years against the risk of adverse events., Level of Evidence: Level IV Prognostic., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Background: Shoulder fusion after nerve injury can improve overall arm function; however, high revision and low patient satisfaction rates have been described. The purpose of this study is to describe a 2-stage shoulder fusion, first pinning in a position of function and then converting to a shoulder fusion. Our hypothesis is that temporary pinning improves overall satisfaction after shoulder fusion in comparison to satisfaction reported in the literature., Methods: A retrospective review was performed for patients receiving 2-stage shoulder fusion between 2020 and 2023. Patient demographics and clinical outcomes were recorded. Univariate statistics were performed to compare pre- and postoperative values., Results: Eighteen patients with an average age of 47 ± 17.3 years and average follow-up of 23.7 ± 4.5 months were included. Preoperative diagnoses included brachial plexus injury (n = 13; 72%), late presentation obstetric brachial plexus injury (n = 2; 11%), traumatic brain injury (n = 1; 14.2%), cervical spinal cord injury (n = 1; 14.2%) and iatrogenic axillary nerve injury with advanced arthritis (n = 1; 14.2%). Twelve (67%) patients received unilateral shoulder fusion 2.7 ± 1.9 days after their initial pinning. Six patients (28.6%) did not receive a second stage fusion. Reasons for not continuing with fusion were attributed to perceived hand function and arm position. Three patients received 2 shoulder pinnings prior to their fusion to adjust the fusion position to accommodate more internal rotation. After fusion, both Subjective Shoulder Value (5.2 ± 5.5% vs. 71.6 ± 10.4%; P < .001) and pain (2.3 ± 4.0 vs. 0.5 ± 0.71; P = .56) improved. Forward elevation (5 ± 12 vs. 108 ± 35; P = .01), abduction (10 ± 15 vs. 78 ± 9; P < .001), and external rotation (5 ± 12 vs. 22 ± 17; P = .26) all improved postoperatively whereas internal rotation remained limited (1.3 ± 0.9 vs. 1.2 ± 0.5; P = .84). Time to union was 15.4 ± 15.4 weeks confirmed with computed tomography scan. There was 1 reoperation (5.5%) for nonunion, and patient satisfaction was 92% (n = 11/12)., Conclusion: Shoulder fusion after neurologic injury provides improved function and patient outcomes; however, some patients may be unsatisfied with their new arm position. Percutaneous pinning prior to fusion is tolerated and allows patients to trial potential fusion positions. This method may improve patient satisfaction and avoid excess morbidity in those that would not be satisfied with a shoulder fusion., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Despite the established importance of the United States Medical License Exam (USMLE) and Alpha Omega Alpha (AOA) status in orthopedic residency selection, their significance in the fellowship match remains unknown. This study evaluates the influence of USMLE scores and AOA status on interview invitation rates and match positions for shoulder and elbow surgery fellowship applicants., Methods: This is a retrospective analysis of data from the San Francisco Match database from 2018 to 2023. The study included matched applicants for shoulder and elbow surgery fellowship, excluding unmatched applicants, osteopathic, and international medical graduates. USMLE scores were categorized into 4 tiers, and interview invitation rates were examined based on USMLE tier and AOA status. Additionally, the association between USMLE scores and AOA status were analyzed by applicant and fellowship rank positions. Statistical analysis included descriptive statistics, linear regression, and analysis of variance., Results: Data from 218 matched applicants were included. On average, applicants submitted 23.3 ± 9.7 applications, with an average interview rate of 76%. The mean step 1 and 2 score was 247 ± 11 (n = 141) and 253 ± 12 (n = 171), respectively. USMLE scores showed a positive correlation with interview rates (step 1: P < .0001, B = 0.768; step 2: P < .0001, B = 0.727), indicating that higher scores were associated with increased interview opportunities. AOA members accounted for 38% of applicants (of 183 with available data), and they demonstrated a higher average percentage of interviews compared to non-AOA applicants (79% vs. 75%, P < .001). While no significant difference in the average step 1 (P = .17) or step 2 score (P = .79) was observed across applicant rank positions, AOA membership was more prevalent among applicants in higher rank tiers (P < .001). Additionally, AOA applicants (P < .001) and those with higher step 2 scores (P = .04) were more likely to be ranked higher by their matched fellowship program., Conclusion: USMLE scores and AOA status correlate with interview invitation rates and applicant ranking for shoulder and elbow surgery fellowships. Future work should examine the influence of residency reputation and research productivity on shoulder and elbow surgery fellowship match outcomes., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

The term "dyskinesia" has often been used interchangeably with "winging," leading to ambiguity in the literature. To address this, the broader term "scapulothoracic abnormal motion (STAM)" was introduced to describe any abnormal position or movement of the scapula on the chest, resulting in pain and dysfunction. Scapulothoracic abnormal motion has a wide range of causes, including musculoskeletal imbalances such as pectoralis minor hyperactivity, neurological impairments such as long thoracic nerve palsy, and genetic conditions like facioscapulohumeral muscular dystrophy (FSHD). This review aims to identify the different causes and classifications of STAM and to propose a detailed treatment algorithm specifically designed to manage these conditions effectively.

Rotator cuff pathology is the main cause of shoulder pain and dysfunction in older adults. When a rotator cuff tear involves the subscapularis tendon, the symptoms are usually more severe and the prognosis after surgery must be guarded. Isolated subscapularis tears represent 18% of all rotator cuff tears and arthroscopic repair is a good alternative primary treatment. However, when the tendon is deemed irreparable, tendon transfers are the only option for younger or high-functioning patients. The aim of this review is to describe the indications, biomechanical principles, and outcomes which have been reported for tendon transfers, which are available for the treatment of irreparable subscapularis tears. The best tendon to be transferred remains controversial. Pectoralis major transfer was described more than 30 years ago to treat patients with failed surgery for instability of the shoulder. It has subsequently been used extensively to manage irreparable subscapularis tendon tears in many clinical settings. Although pectoralis major reproduces the position and orientation of the subscapularis in the coronal plane, its position in the axial plane - anterior to the rib cage - is clearly different and does not allow it to function as an ideal transfer. Consistent relief of pain and moderate recovery of strength and function have been reported following the use of this transfer. In an attempt to improve on these results, latissimus dorsi tendon transfer was proposed as an alternative and the technique has evolved from an open to an arthroscopic procedure. Satisfactory relief of pain and improvements in functional shoulder scores have recently been reported following its use. Both pectoralis minor and upper trapezius transfers have also been used in these patients, but the outcomes that have been reported do not support their widespread use., Competing Interests: J. L. Ávila Lafuente reports consulting fees, support for attending meetings and/or travel, and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Smith & Nephew, unrelated to this article. B. Elhassan reports royalties or licenses, consulting fees, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events, and support for attending meetings and/or travel from DJO Global, unrelated to this article. A. Hachem reports consulting fees, and support for attending meetings and/or travel from Arthrex and Stryker, unrelated to this article. M. A. Ruiz Ibán reports institutional research grants, and individual speaker payments, from Smith & Nephew and Link, unrelated to this article., (© 2024 The British Editorial Society of Bone & Joint Surgery.)

Introduction  The costo-osteochondral autograft, vascularized medial femoral trochlear osteochondral autograft, and proximal hamate autograft have been used for the reconstruction of unsalvageable proximal pole scaphoid nonunions. Our hypothesis is that there is no difference in carpal kinematics after the proximal pole of the scaphoid is reconstructed with these three graft options. Methods  Wireless sensors were mounted to the carpus that was loaded through cyclical motion. Each specimen was tested under a series of the three reconstructed conditions and their kinematics compared. Results  No significant differences were found in scapholunate and lunocapitate joint motion during wrist flexion-extension and wrist radioulnar deviation between the three reconstructed conditions ( p  > 0.05). Discussion and Conclusion  There are minimal differences in carpal kinematics when comparing reconstruction of the proximal pole of the scaphoid with the costoosteochondral, medial femoral trochlear, and proximal hamate grafts., Competing Interests: Conflict of Interests Dr. Kakar is a consultant for Arthrex. The other author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (Thieme. All rights reserved.)

Objective: Mixed-Martial-Arts(MMA) is a worldwide growing sport that incorporates different fighting styles and disciplines and is often associated with the Ultimate Fighting Championship(UFC) . The aim of this study is to explore the patterns and trends of upper limb injuries in MMA., Methods: Ringside physician reports of the UFC fights between 2016 and 2019(inclusive) were extracted and screened from the Nevada State Athletic Commission(NSAC). The following variables were included: sex, weight division, injury mechanism, injury type, injury location, and type of finish. Injury rates were calculated and expressed per 100 athletic exposures (AE). An independent t-test, a one way analysis of variance(ANOVA), and a Joinpoint regression analysis were conducted to explore any significant differences or trends among variables. P-values<0.05 were considered significant(95% CI)., Results: A total of 81 upper limb injuries in 408 fights were recorded between 2016 and 2019. The injury rate was 9.9 injuries per 100 athletic-exposures(AE). Striking opponents was the most common mechanism of injury(p < 0.001). The hand was the most commonly injured location with an injury rate of 6.61 per 100AE(p < 0.001). Females had a higher upper limb injury rate than their male counterparts, but the difference failed to reach significance(p = 0.454). Similarly, no significant differences existed between rates of different types of injures. Matches ending with decision had the highest number of upper limb injuries with a rate of 12.6 per 100AE; however, no significant difference was determined between the rates of different ways of finish(p = 0.115). The strawweight(20.5 per 100AE), female flyweight(19.2 per 100AE), and male flyweight(13.8 per 100AE) divisions had the highest upper limb injury rates., Conclusion: The hand was the most commonly injured upper limb location in MMA, and 'striking opponent' was the most common injury mechanism. Increasing padding in gloves and implementing medical examinations during bouts can help reduce injury rates.

Background: Scapulothoracic (ST) fusion for facioscapulohumeral muscular dystrophy (FSHD) is an established treatment that corrects scapular instability, although it has high reported complication rates. The purpose of our study was to characterize the outcomes of ST fusion for FSHD in a large patient cohort and compare the outcomes based on bone graft type and fixation technique. Our hypothesis was that union rates would not differ by bone graft type during ST fusion., Methods: A retrospective chart review was undertaken to identify patients who underwent ST fusion at multiple institutions performed by a single surgeon between 2013 and 2019 with minimum 2-year follow-up. Patient demographic characteristics, surgical technique, time to union, complications, and clinical outcomes including patient-reported outcome measures were recorded. Univariate and multivariate statistical analyses including regression analyses were performed to compare preoperative and postoperative outcomes., Results: A total of 50 patients with 54 ST fusions (bilateral in 4 patients) and an average follow-up period of 5.8 years (standard deviation, 1.6 years) were included for analysis. Active forward elevation (77° vs. 124°, P < .00001) and abduction (60° vs. 90°, P < .00001) both improved significantly after fusion. Average internal rotation after fusion was at spinal level L3-L4. The visual analog scale pain score (2.6 vs. 1.2, P < .00001), Subjective Shoulder Value score (33 vs. 76, P < .00001), and American Shoulder and Elbow Surgeons (ASES) score (41.8 vs. 76.1, P < .00001) all improved significantly postoperatively. Of the shoulders, 50% (27 of 54) received treatment with cerclage wires and 50% (27 of 54) received treatment with Luque wires. Femoral head allograft was used in 53.7% of shoulders (29 of 54), whereas iliac crest autograft was used in 46.3% (25 of 54). Average radiographic time to healing was 11.1 weeks (standard deviation, 3.2 weeks), with no incidence of nonunion, and did not significantly differ by bone graft type (P = .26) or technique (P = .20). The complication rate was 24.1%, including seroma (n = 3), superficial infection (n = 2), transient neurologic injury (n = 2), hemothorax (n = 1), rib fracture (n = 1), pneumothorax (n = 1), and shortness of breath (n = 1), although none requiring reoperation. There was no significant difference in the rate of postoperative complications when compared by surgical technique (P = .81) and bone graft type (P = .93). There were no independently predictive factors influencing the rate of postoperative complications by multivariate regression. Regression analysis showed that the postoperative ASES score was independently associated with the preoperative ASES score (P < .0001), use of iliac crest autograft (P < .011), and presence of complications (P < .043)., Conclusion: Patients receiving ST fusion for FSHD demonstrate globally improved active motion and patient-reported outcome measures. Fusion construct or type of bone graft does not affect time to union or complication rates. Surgeons should be aware of a relatively high complication rate in the early postoperative period., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The objective of this study was to determine whether reconstruction of the proximal pole of the scaphoid with a proximal hamate graft restores native carpal kinematics., Methods: A cadaveric study was designed assessing wrist kinematic after proximal hamate graft for proximal pole of the scaphoid nonunion. Wireless sensors were mounted to the carpus using a custom pin and suture anchor system to 8 cadavers. A wrist simulator was used to move the wrist through a cyclical motion about the flexion/extension and radial/ulnar deviation axes. Each specimen was tested under a series of 3 conditions: (1) a native state, "Intact"; (2) fractured scaphoid proximal pole, "Fracture"; and (3) post-reconstruction of the proximal pole of the scaphoid using a proximal hamate graft, "Graft.", Results: The fracture condition resulted in a statistically significant change in scapholunate kinematics across the entire arc of motion relative to the intact condition. Reconstruction with proximal hamate grafts restored scapholunate kinematics close to the intact state in both flexion/extension and radial/ulnar deviation axes. The lunocapitate flexion during wrist flexion was significantly different after the hamate graft reconstruction., Conclusions: Proximal hamate to scaphoid transfer resulted in restoration of near normal carpal kinematics to the intact state.

There are several emerging treatments for patients with massive rotator cuff tears. Biologic tuberoplasty is still in its infancy but holds promise for improving pain and function by biologically covering a bare tuberosity with a dermal allograft to prevent bone-to-bone contact between the tuberosity and the undersurface of the acromion. Balloon arthroplasty is a technique of widespread interest, with the device recently gaining FDA approval. Anterior cable reconstruction uses the autologous long head of the biceps tendon to reconstruct the anterior cable of the rotator cuff. Tendon transfers, specifically lower trapezius tendon transfer, have now been established as a viable option especially in patients who want to regain active external rotation.

Background: The primary objective of this study was to identify patient-related and socioeconomic factors associated with the operative treatment of adult traumatic brachial plexus injuries (BPI) at two tertiary referral centres in a single metropolitan area in the United States. The secondary objective was to assess surgeon variability in operative treatment. Methods: Adult patients with traumatic BPI at two tertiary referral centres in a single metropolitan area from 2015 to 2019 were retrospectively identified. After applying exclusion criteria, 84 adult patients with traumatic BPI treated by 22 surgeons were included. Our response variable was operative treatment of the traumatic BPI. Bi-variate screen was performed, and multi-variable logistic regression analysis was used to identify factors associated with operative treatment. Surgeon variability was separately assessed using Fisher's exact test. Results: The mean age of the study cohort was 45 years, and 69% were male. The most common BPI pattern was a global injury (39%) followed by an upper trunk injury (23%). Thirty-eight patients (45%) underwent operative treatment for the traumatic BPI. Multivariable logistic regression analysis showed that younger age and out-of-state referral were associated with operative treatment. There was significant surgeon variation in the utilisation of operative treatment. Conclusions: Out-of-state patients had more than four times higher odds of operative treatment, suggesting a regional practise pattern in which BPI requiring surgery are referred from surrounding states to our tertiary centres. Supra-regional BPI centres may facilitate timely referrals for specialty care. High-quality outcomes research in BPI is needed to mitigate surgeon treatment variation. Level of Evidence: Level IV (Therapeutic).

Purpose: This study aimed to identify factors associated with complication, hospital readmission, and reoperation in a 30-day postoperative period after brachial plexus neurolysis., Methods: A retrospective case-control study was performed using the American College of Surgeons National Surgical Quality Improvement Program database by querying the Current Procedural Terminology code for brachial plexus neurolysis from 2011 to 2020. A cohort of 691 adult patients who underwent brachial plexus neurolysis was included. The outcome variables were 30-day postoperative complication, readmission, and reoperation. A bivariate screen was performed for explanatory variables associated with our outcome variables, and variables with a P value of <.05 in the bivariate screening were included in a multivariable logistic regression model., Results: Of the 691 patients in our cohort, 20 (2.9%) developed a postoperative complication, 31 (4.5%) were readmitted, and 22 (3.2%) underwent reoperation during the 30-day postoperative period. Bivariate analysis showed that longer operative times were associated with complication, and concurrent rib resection was associated with readmission; no other variables met the inclusion criteria in a multivariable logistic regression model for complication and readmission. Multivariable logistic regression analysis showed that a lower body mass index and longer operative time were independently associated with reoperation., Conclusions: Episode-of-care postoperative complication and reoperation after brachial plexus neurolysis are associated with operative time, which may be partially related to surgical complexity, additional procedures, and/or surgeon experience. Rib resection procedures are associated with a higher risk of readmission., Clinical Relevance: Our findings may be applied to preoperative risk stratification and patient counseling. Our research questions the role of bony rib resection in the routine treatment of neurogenic thoracic outlet syndrome when soft tissue release alone may be successful. Future research is necessary to define risk profiles for different surgical indications and concomitant procedures., Type of Study/level of Evidence: Prognostic III., (© 2022 The Authors.)

Background: Reverse shoulder arthroplasty (RSA) is increasingly being utilized for the treatment of primary osteoarthritis. However, limited data are available regarding the outcomes of RSA as compared with anatomic total shoulder arthroplasty (TSA) in the setting of osteoarthritis., Methods: We performed a retrospective matched-cohort study of patients who had undergone TSA and RSA for the treatment of primary osteoarthritis and who had a minimum of 2 years of follow-up. Patients were propensity score-matched by age, sex, body mass index (BMI), preoperative American Shoulder and Elbow Surgeons (ASES) score, preoperative active forward elevation, and Walch glenoid morphology. Baseline patient demographics and clinical outcomes, including active range of motion, ASES score, Single Assessment Numerical Evaluation (SANE), and visual analog scale (VAS) for pain, were collected. Clinical and radiographic complications were evaluated., Results: One hundred and thirty-four patients (67 patients per group) were included; the mean duration of follow-up (and standard deviation) was 30 ± 10.7 months. No significant differences were found between the TSA and RSA groups in terms of the baseline or final VAS pain score (p = 0.99 and p = 0.99, respectively), ASES scores (p = 0.99 and p = 0.49, respectively), or SANE scores (p = 0.22 and p = 0.73, respectively). TSA was associated with significantly better postoperative active forward elevation (149° ± 13° versus 142° ± 15°; p = 0.003), external rotation (63° ± 14° versus 57° ± 18°; p = 0.02), and internal rotation (≥L3) (68.7% versus 37.3%; p < 0.001); however, there were only significant baseline-to-postoperative improvements in internal rotation (gain of ≥4 levels in 53.7% versus 31.3%; p = 0.009). The overall complication rate was 4.5% (6 of 134), with no significant difference between TSA and RSA (p = 0.99). Radiolucent lines were observed in association with 14.9% of TSAs, with no gross glenoid loosening. One TSA (1.5%) was revised to RSA for the treatment of a rotator cuff tear. No loosening or revision was encountered in the RSA group., Conclusions: When performed for the treatment of osteoarthritis, TSA and RSA resulted in similar short-term patient-reported outcomes, with better postoperative range of motion after TSA. Longer follow-up is needed to determine the ultimate value of RSA in the setting of osteoarthritis., Level of Evidence: Therapeutic Level III . 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/JBJS/H24 )., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Wall push-up is the most common examination used for the diagnosis of scapular winging secondary to serratus anterior dysfunction. The wall push-up test (WPUT) however may not be able to differentiate causes of scapulothoracic abnormal motion (STAM) or winging. We introduce a novel physical examination maneuver, the shoulder flexion resistance test (SFRT), and we propose that this test is more specific and accurate in determining serratus anterior dysfunction as the cause of STAM., Methods: Fifty patients with STAM are included in this study. All patients underwent clinical scapular examination using both WPUT and SFRT. The SFRT is performed by resisting shoulder flexion while the elbow is fully extended at 30 ° , 60 ° , and 100 ° . All patients additionally received preoperative electromyography. All patients underwent exploration and intraoperative stimulation of the distal serratus anterior to characterize color, thickness, and contractility at the time of their arthroscopic pectoralis minor release and scapulopexy or tendon transfer if the serratus was paralyzed. The preoperative clinical examination findings were then correlated with intraoperative findings., Results: Abnormal distal serratus anterior was seen intraoperatively in 5/50 patients (10%) with marked alterations in color, thickness, and contractility. All (n = 50) patients had positive WPUT manifested by increased winging of the scapula off the chest wall (STAM) with 45 false positive tests. The WPUT was 100% (95% confidence interval [CI] 47.82%-100%) sensitive but 0% (95% CI 0%-7.87%) specific for lower serratus anterior deficiency. The SFRT was 100% sensitive (95% CI 47.82%-100%) and 100% specific (95% CI 92.13%-100%) for serratus anterior dysfunction as the cause of STAM. Using area under the curve (AUC) of receiver operating characteristic (ROC) curves for WPUT and SFRT tests, WPUT had clinically insignificant accuracy (AUC 0.5) compared to the excellent accuracy (AUC 1.0) of SFRT., Conclusion: SFRT is specific and accurate in determining serratus anterior dysfunction as a cause of STAM. Based on this study, the SFRT should replace the WPUT as the physical exam of choice to determine dysfunction of the serratus anterior muscle and guide operative management of STAM., (© 2022 The Authors.)

Background: Tendon transfers (TTs) can be successful for the management of selected posterosuperior functionally irreparable rotator cuff tears. However, when these procedures fail to provide adequate pain relief or functional improvement, reverse shoulder arthroplasty (RSA) is commonly considered the next treatment option. The effect of prior TT on RSA remains largely unknown. The purposes of this investigation were to evaluate the outcomes of RSA after previous TT performed for posterosuperior functionally irreparable rotator cuff tears and to determine the effect of various TT types on RSA., Methods: A retrospective review of 2 institutional databases identified 33 patients who underwent RSA implantation between 2006 and 2019 with a previous failed tendon transfer (FTT) of the shoulder and at least 2 years of clinical follow-up. FTTs included 21 latissimus dorsi transfers, 6 latissimus dorsi and teres major (LD-TM) transfers, and 6 lower trapezius transfers. RSAs were performed at an average of 5.5 years (range, 0.3-28 years) after FTT, with a mean follow-up period of 4.1 ± 2.0 years. Outcomes evaluated included the visual analog scale pain score, range of motion, absolute Constant-Murley score (CS) and relative CS, American Shoulder and Elbow Surgeons score, Subjective Shoulder Value, complications, and implant survivorship free of reoperation or revision., Results: RSA significantly improved pain and function, with improvements in the visual analog scale pain score (6.2 preoperatively vs. 2.2 at most recent follow-up, P < .001), active elevation (85° vs. 111°, P < .001), American Shoulder and Elbow Surgeons score (51 vs. 74, P = .001), absolute CS (34 vs. 48, P = .003), and relative CS (42% vs. 59%, P = .002), exceeding the minimal clinically important difference threshold. There were 7 complications (21%) across the entire cohort, with dislocation (n = 3, 9.1%) as the most common complication. Comparison across TT groups showed that LD-TM transfer had the highest complication rate (3 shoulders, 50%), followed by lower trapezius transfer (1 shoulder, 16.7%); latissimus dorsi transfer had the lowest rate (3 shoulders, 14.3%; P = .037). Survivorship free of revision or reoperation was estimated to be 90.1% at 1 year, 84.9% at 2 years, and 71.2% at 5 years, with no difference among TT groups (P = .654)., Conclusions: RSA can serve as a viable salvage option for FTT procedures. At mid-term follow-up, RSA led to significant improvements in pain, range of motion, and patient-reported outcomes. Patients with prior LD-TM transfers may have a higher complication rate, but no other differences were found between TT groups., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

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.)

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.)

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.)

Background: Loss of active shoulder internal rotation can be very disabling. Several tendon transfers have been described for the management of an irreparable subscapularis (SSC) tear. The purpose of this study was to determine and compare the internal rotation moment arm (IRMA) of the sternal head of the pectoralis major (PM), latissimus dorsi (LD), and teres major (TM) when transferred to different insertion sites to restore shoulder internal rotation with and without reverse shoulder arthroplasty (RSA)., Methods: Six fresh-frozen right hemithoraces were prepared and evaluated using a custom tendon transfer model to determine the IRMA of different tendon transfers using the tendon and joint displacement method. Five tendon-transfer pairs were modeled using a single suture and tested before and after implantation of an RSA (Comprehensive; Zimmer-Biomet, Warsaw, IN, USA): PM to the insertion site of the SSC, LD to the anterior insertion site of the supraspinatus (SSP) tendon on the greater tuberosity, LD to SSC, TM to SSP, and TM to SSC. The SSC was not repaired at the end of the RSA procedure to simulate an SSC deficiency. The PM transfer was passed under the conjoined tendon when tested on the intact shoulder and above the conjoined tendon when tested with an RSA., Results: Tendon transfers were shown to have a significant effect on IRMA. The effect of transferred tendons was significantly affected by the position of the humerus. With the humerus adducted, the IRMA of the TM-SSP (14.1 mm ± 3.1 mm) was significantly greater than the other transfers. With the humerus abducted to 90°, the IRMAs of the LD-SSP (30.0 mm ± 5.4 mm) and TM-SSP (28.4 mm ± 6.6 mm) were significantly greater than the IRMAs of other transfer options. The IRMA of the native shoulder differed significantly from that of the RSA state for all tendon transfers. With the humerus adducted to the side of the body, the IRMA of the RSA PM-SSC transfer was significantly greater than that without an RSA (19.0 mm ± 6.4 mm vs. 7.1 mm ± 0.9 mm), demonstrating increased efficiency for internal rotation in the RSA state., Conclusion: Tendon transfers to restore shoulder internal rotation differ in effectiveness and may be affected by arm position and by implantation of a lateralized humerus/lateralized glenoid RSA. The LD potentially results in superior restoration of shoulder internal rotation in a native shoulder (given the risk of nerve compression with the TM transfer) compared with PM and should be considered as a potential tendon transfer to restore internal rotation in selected patients. In combination with a lateralized humerus/lateralized glenoid RSA, the fulcrum provided by the biomechanics of the semiconstrained implant allows the PM transfer to become a more efficient tendon transfer to restore active internal rotation., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Several factors associated with B glenoid are also linked with obstetrical brachial plexus palsy (OBPP). The purpose of this observational study was to determine the incidence of OBPP risk factors in type B patients., Methods: A cohort of 154 patients (68% men, 187 shoulders) aged 63 ± 17 years with type B glenoids completed a questionnaire comprising history of perinatal characteristics related to OBPP. A literature review was performed following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) to estimate the incidence of OBPP risk factors in the general population., Results: Twenty-seven patients (18%) reported one or more perinatal OBPP risk factors, including shoulder dystocia ( n = 4, 2.6%), macrosomia >4 kg ( n = 5, 3.2%), breech delivery ( n = 6, 3.9%), fetal distress ( n = 8, 5.2%), maternal diabetes ( n = 2, 1.3%), clavicular fracture ( n = 2, 1.3%), and forceps delivery ( n = 4, 2.6%). The comparison with the recent literature suggested that most perinatal OBPP risk factors were within the normal range, although the incidence of shoulder dystocia, forceps and vaginal breech deliveries exceeded the average rates., Conclusion: Perinatal factors related to OBPP did not occur in a higher frequency in patients with Walch type B OA compared to the general population, although some of them were in the high normal range.

Irreparable posterosuperior rotator cuff tears are a challenging treatment problem. Several tendon transfers have been described for the treatment of irreparable tears. Recently the lower trapezius (LT) tendon transfer has grown in popularity. This procedure has shown promise in biomechanical studies, improving the external rotation moment arm at the side. This transfer may be done in several ways, including an open approach with an acromial osteotomy, mini-open, and arthroscopic-assisted. The purpose of this paper is to review the current evidence and rationale for the use of the LT transfer and to describe the available techniques., (© 2020 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Background: Allograft-prosthetic composite (APC) reconstruction of the proximal humerus is a technique for reconstruction of large bone deficits, provides improvement in pain and function, and is thought to restore bone if revision surgery is needed. The purpose of this study was to evaluate the ability of proximal humeral APCs to restore usable bone at the time of revision surgery., Methods: Two institutional electronic medical records were reviewed to evaluate proximal humeral APC procedures performed between 1970 and 2018. We identified 115 cases, of which 14 underwent revision for aseptic causes. The indications for revision included nonunion (n = 7), glenohumeral instability (n = 5), and allograft fracture (n = 2). Three categories were used to classify the amount of usable allograft retained at revision surgery: type A, complete allograft retention; type B, partial retention; and type C, no retention., Results: A total of 14 patients (6 male and 8 female patients) underwent revision of the APC reconstruction at a mean of 22.8 months. At revision, allograft retention was classified as type A in 6 shoulders, type B in 3, and type C in 5. Type A cases were associated with nonunion with a well-fixed stem, type B cases were associated with instability and were converted from a hemiarthroplasty to a reverse total shoulder arthroplasty, and type C cases were associated with an allograft fracture or nonunion with a loose humeral component., Conclusion: A substantial number of revisions of proximal humeral APC reconstructions maintain a portion of the allograft bone (64.3%). This study supports the ongoing use of the APC reconstruction technique for large bone deficits., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: To compare latissimus dorsi tendon rupture rates after arthroscopic transfer for posterior superior rotator cuff tear using 3 different humeral head fixation techniques., Methods: One-hundred fifty consecutive latissimus dorsi transfers were included. Inclusion criteria were massive irreparable posterosuperior rotator cuff tear with advanced fatty infiltration associated with persistent pain and limited range of motion after failed conservative treatments or surgery. All transfers were arthroscopically assisted and fixed in a transosseous tunnel with a cortical button (group 1, n = 59), "over the top" onto the footprint of the supraspinatus (group 2, n = 47), or posteriorly onto the footprint of the infraspinatus (group 3, n = 44) with 2 suture anchors. The tendons were marked with 3 metallic clips placed intraoperatively at a fixed distance of 2, 4, and 6 cm from the tip. Immediate postoperative standard anteroposterior radiographs were performed to confirm the position of the clips and to determine whether the clips displaced on subsequent radiographs during follow-up, indicating tendon rupture., Results: Repeat radiographs at 3-month follow-up showed higher risk of latissimus dorsi transfer rupture rate in 27/59 patients in group 1 (46%), 11/47 in group 2 (24%), and 7/44 in group 3 (15%)., Conclusion: Posterior anchor fixation of the latissimus dorsi tendon onto the infraspinatus footprint had the lowest rupture rate., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Distal radius fractures are common, and the trend in fixation has included the use of locked volar plating. The duration of splinting required after surgery and the effect splinting has upon outcome of the wrist are not clear. Our aim was to compare outcome of patients treated with early versus late motion protocol after volar plating. Methods: Thirty-three patients with distal radius fractures were prospectively and randomly enrolled into an early versus late motion study including volar plating of the distal radius fracture. Early motion included an active and passive wrist motion protocol by 14 days after surgery and delayed motion was initiated at 5 weeks. Fractures were defined as intra-articular and extra-articular, and those with, and without, ulnar styloid fracture. Motion and outcome scores (Disabilities of the Arm, Shoulder and Hand [DASH]/patient-rated wrist evaluation [PRWE]), and strength were measured through 1 year. Results: Wrist motion, DASH, and PRWE scores were only significantly different at 6 weeks with no significant differences at any later time points up to 1 year. One patient had complex regional pain syndrome (CRPS) and one had adhesive capsulitis in the late motion group. Conclusions: Following locked volar plating of distal radius fractures, early motion favored earlier return of motion along with lower DASH, PRWE, and pain scores within first 6 weeks. Although the late motion group had delayed recovery, there were no long-term significant differences in motion, strength, outcome, or pain scores. The 2 cases with complications (CRPS and adhesive capsulitis) did occur in the late motion group and may implicate late motion with these problems.

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

High-pressure injection injuries of the hand are rare, but potentially devastating injuries. The amount of tissue damage is dependent on the magnitude of the pressure generated by the device and the composition of the injected material. The standard of care is emergent surgical debridement of the injected material and devitalized tissue. Although, preoperative advanced imaging is not routinely pursued, MRI may be helpful in determining the anatomic distribution of the foreign material, and associated soft tissue or osseous injury. We present a case of a 28-year-old male with complications related to a high-pressure grease injection injury to his non-dominant hand. The MRI demonstrated peculiar imaging features of retained grease deposits and played an important role in surgical planning.

Background: Anatomic reconstruction techniques are increasingly used to address cases of acromioclavicular (AC) joint chronic instability. These usually involve an additional surgical site for autograft harvesting or an allograft., Purpose: To describe a triple-bundle (TB) anatomic reconstruction using on-site autografts, the semiconjoint tendon (SCT) and the coracoacromial ligament (CAL), and compare its primary stability to the native AC joint ligamentous complex and to a modified Weaver-Dunn (WD) reconstruction., Study Design: Controlled laboratory study., Methods: Intact AC joints of 12 paired cadaveric shoulders were tested for anterior, posterior, and superior translations under cyclic loading with a servo-hydraulic testing system. One shoulder from each pair was randomly assigned to the TB group, where 2 SCT strips were used to reconstruct the coracoclavicular ligaments while the distal end of the CAL was transferred to the distal extremity of the clavicle to reconstruct the AC ligaments; the other shoulder received a modified WD reconstruction. After reconstruction, the same translational testing was performed, with an additional load-to-failure test in the superior direction., Results: In both the TB and the WD groups, no significant differences were found before and after reconstruction in terms of joint displacements after cyclic loading, in all 3 directions. Compared with the WD reconstruction, the TB repair resulted in significantly lower displacements in both the anterior (ie, 2.59 ± 1.08 mm, P = .011) and posterior (ie, 10.17 ± 6.24 mm, P = .014) directions, but not in the superior direction. No significant differences were observed between the 2 reconstructions during the load-to-failure testing, except for the displacement to failure, which was significantly smaller (ie, 5.34 ± 2.97 mm) in the WD group ( P = .037)., Conclusion: Anterior, posterior, and superior displacements after an anatomic reconstruction of the AC joint complex using the SCT and CAL as graft material were similar to those of native AC joints and significantly smaller in the axial plane than those of AC joints after a WD repair., Clinical Relevance: An anatomic reconstruction is achievable using the CAL and the SCT as on-site graft materials, providing satisfactory initial stability and thereby allowing earlier mobilization.

Background: Subscapularis (SSC) tendon tears are a challenging problem because they can significantly alter shoulder mechanics and function. Tendon retraction and advanced fatty degeneration associated with a chronic tear may make it irreparable. Tendon transfers options for such tears are viable, but results in the setting of associated glenohumeral instability are inconsistent. With the potential to recreate the SSC line of pull, the teres major (TM) may be a viable option for transfer. This cadaveric study investigated the feasibility and outlined the steps of a bipolar, pedicled TM transfer for irreparable SSC tendon tears., Methods: Eight fresh frozen cadaver torsos from 4 women and 4 men (average age, 84 years; range, 68-96 years) were dissected. Anatomic details comparing TM to SSC were examined, including muscle width, length, thickness, and line of pull in the scapular plane. In addition, a surgical technique was described for implementing the pedicled TM transfer., Results: Measurements between the TM and SSC were comparable, with the exception of muscle belly width, which was significantly greater in the SSC. With transfer of the TM, there was no impingement or tension on the brachial plexus or the neurovascular pedicle of the TM. The line of pull of the TM relative to the SSC had a difference of 9°., Conclusions: This study demonstrates that a bipolar TM tendon transfer is an anatomically feasible option for reconstruction of an irreparable SSC tendon tear. Further clinical studies are necessary to understand its outcome in in vivo conditions., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Introduction: In cases of chronic acromioclavicular joint separation, the biomechanical properties of anatomical reconstructions are closer to the native configuration than the Weaver-Dunn procedure. Consequently, the radiological and clinical outcomes are better. However, an additional incision is needed to harvest the graft, which increases the procedure's morbidity., Hypothesis: Triple-bundle reconstruction can be performed with the coracoacromial ligament (CAL) and the semi conjoined tendon (SCT)., Material and Methods: Bilateral dissection was performed on the upper limb of six fresh-frozen cadavers. Measurements useful to the procedure were taken on one limb, specifically the minimum graft length needed and the available length. The surgical procedure was performed on the other limb. The proximally based SCT was passed through the base of the coracoid process, then divided into two strips tightened from the superior aspect of the coracoid process to the clavicular insertion points of the conoid and trapezoid ligaments. The CAL was detached from the coracoid process and then secured in the medullary canal of the clavicle, after its lateral one-quarter was resected (i.e., 10mm)., Results: The mean length of the SCT was 101.7±7.6mm (95.1-114.5) and the mean length of the CAL was 35.3±4.7mm (28.7-42.5). The SCT length needed for this reconstruction was 58±4.3mm (51.5-62) medially and 60.3±4.6mm (54.3-66.3) laterally. The procedure was feasible in all six cadavers with an average excess length of 39.9±5.7mm (32.2-47) for the conoid bundle, 37.6±5mm (31-45.1) for the trapezoid ligament and 6±2.7mm (3-9.5) for the CAL., Discussion: Triple-bundle anatomical reconstruction using the SCT and CAL is feasible. However, the strength of this construct must be evaluated biomechanically before it can be used clinically., Level of Evidence: Not applicable - cadaver study., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Introduction/hypothesis: The purpose of this study is to determine the mid/long term shoulder function in patients with complete deltoid paralysis and intact rotator cuff. 27 patients with at least 2-years FU were included., Materials and Methods: Outcome measures included pain, range of motion (including the swallowtail test STT), deltoid extension lag test DELT and Bertelli test), subjective fatigability using the injured shoulder and postoperative modified Neer ratings., Results: At an average 68 months FU, mean shoulder abduction was 131°, flexion 153°, external rotation with the arm at the side 58° and 58° with the arm abducted. All patients reported quick fatiguability with repetitive use of the injured arm which did not change over time. Average pain score was 2. Eighteen patients had positive STT and DELT tests and all patients had positive Bertelli test., Discussion: This study demonstrates that patients with deltoid paralysis and intact rotator cuff do maintain most of their shoulder function and this is sustained over time., Level of Evidence: Level IV; prognostic Study: case series., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

We report the outcomes of ulnar head replacement with concomitant resurfacing of the sigmoid notch with a lateral meniscal allograft that attempted to recreate the palmar and dorsal radioulnar ligaments in four patients. Patients' ranges of motion, grip strength, postoperative complications and radiographs were assessed. The mean follow-up was 20 (range 12-28) months. There was an increase in postoperative range of motion with an average increase in grip strength of 43% to the unaffected extremity. All patients experienced marked reduction in their postoperative pain. No patients reported symptoms of implant instability. Distal ulna implant arthroplasty with a lateral meniscal allograft gives favourable short-term outcomes., Level of Evidence: IV.

Aims: In the initial development of total shoulder arthroplasty (TSA), the humeral component was usually fixed with cement. Cementless components were subsequently introduced. The aim of this study was to compare the long-term outcome of cemented and cementless humeral components in arthroplasty of the shoulder., Patients and Methods: All patients who underwent primary arthroplasty of the shoulder at our institution between 1970 and 2012 were included in the study. There were 4636 patients with 1167 cemented humeral components and 3469 cementless components. Patients with the two types of fixation were matched for nine different covariates using a propensity score analysis. A total of 551 well-balanced pairs of patients with cemented and cementless components were available after matching for comparison of the outcomes. The clinical outcomes which were analysed included loosening of the humeral component determined at revision surgery, periprosthetic fractures, post-operative infection and operating time., Results: The overall five-, ten-, 15- and 20-year rates of survival were 98.9%, 97.2%, 95.5%, and 94.4%, respectively. Survival without loosening at 20 years was 98% for cemented components and 92.4% for cementless components. After propensity score matching including fixation as determined by the design of the component, humeral loosening was also found to be significantly higher in the cementless group. Survival without humeral loosening at 20 years was 98.7% for cemented components and 91.0% for cementless components. There was no significant difference in the risk of intra- or post-operative fracture. The rate of survival without deep infection and the mean operating time were significantly higher in the cemented group., Conclusion: Both types of fixation give rates of long-term survival of > 90%. Cemented components have better rates of survival without loosening but this should be weighed against increased operating time and the risk of bony destruction of the proximal humerus at the time of revision of a cemented humeral component. Cite this article: Bone Joint J 2017;99-B:666-73., (©2017 The British Editorial Society of Bone & Joint Surgery.)

Background: Fractures of the proximal pole of the scaphoid can be difficult to heal because of its limited vascular supply. Furthermore, nonunion with avascular necrosis and secondary fragmentation makes surgical reconstruction a challenging procedure. Method: We describe a technique and report the outcome of a proximal hamate autograft to treat a proximal pole scaphoid nonunion with avascular necrosis. Results: At 3.5 years post reconstruction, the patient remains asymptomatic with union of his scaphoid reconstruction without any evidence of scapholunate instability. Conclusion: Proximal hamate autograft is a useful technique for addressing proximal pole scaphoid nonunions with avascular necrosis., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Unlabelled: We conducted a review of 144 consecutive patients who underwent proximal row carpectomy from 1967 to 2010 for the diagnosis of wrist arthritis. At a mean follow-up of 13.4 years, patients experienced good pain relief with preservation (but not improvement) of wrist motion. A total of 17 patients (12%) required revision surgery at an average of 44.6 months. Improved pain, function, and survival outcomes were seen in those who underwent proximal row carpectomy after the age of 40, had a preoperative diagnosis of Kienbock's disease, who underwent a concomitant neurectomy procedure, patients who were non-labourers, and patients who underwent surgery after 1990. Although 45% of patients developed moderate to severe radiocapitate arthrosis postoperatively, these findings did not correlate with clinical outcomes or risk of revision surgery. Patients with type II lunate and type II and III capitate shapes had higher rates of postoperative radiocapitate arthrosis., Level of Evidence: III, Prognostic., (© The Author(s) 2015.)

Stenosing tenosynovitis or trigger finger is one of the most common disorders that affect the flexor tendon apparatus of the hand. Percutaneous release has been previously reported to be easier, quicker, less invasive and less costly than open surgery. The purpose of this study was to report the outcome of an alternative percutaneous trigger finger release technique. From March 2008 to January 2014, 92 patients (128 fingers) who underwent the alternative percutaneous trigger finger release, with a minimum of 6 months follow-up were included. Outcomes included size of skin incision, pain, residual symptoms, satisfaction and complications. Percutaneous release was achieved in all fingers, except 1 for which an opening of the skin was necessary to complete the release of the pulley. Eight fingers (6%) required revision open surgery because of persistence of their symptoms. At 1 week after the procedure, no finger swelling was reported, however 4 fingers (3%) were painful and 45 (35%) were stiff and required physiotherapy. Percutaneous release was successful in 120 fingers (94%). At the final follow-up, all the patients were satisfied by the procedure (95 rated their result as much better and 32 as better). This study shows that our alternative percutaneous trigger finger release is a reliable and safe procedure with high patient satisfaction., Level of Evidence: Level IV, clinical study, therapeutic study., (Copyright © 2016 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Scapulectomy can dramatically alter glenohumeral function and the ability of patients to conduct activities of daily living. In oncologic cases, treatment of the tumor can compromise local musculature, making successful reconstruction difficult to achieve. Depending on the resection level, local musculature may be inadequate to restore shoulder range of motion and/or glenohumeral stability. Surgeons have attempted to address these issues via soft-tissue repairs, allograft replacement, and prosthetic replacement, with variable success. Outcomes are better when a greater portion of the scapula is preserved, thus saving functional rotator cuff muscle bellies. However, preservation of significant rotator cuff musculature is not routinely possible. To our knowledge, no authors in the English-language orthopaedic literature have reported on local tendon transfers as a technique to augment and reconstruct the rotator cuff in a patient with previous scapulectomy.

Background: Several tendon transfers have been described to reconstruct irreparable subscapularis (SS) tears, but their outcomes are variable and unsatisfactory in the presence of anterior glenohumeral subluxation. We evaluated the anatomic feasibility of the latissimus dorsi (LD) or teres major (TM) muscle tendon transfer to reconstruct an irreparable SS tendon tear., Materials and Methods: The dimensions of the LD and TM tendons and the distance between their insertion and the SS tendon insertion were determined In 20 cadaveric shoulders. Feasibility of the isolated LD and TM tendon transfer to 3 locations on the SS tendon insertion, transfer of the LD to the proximal half, TM to the lower half of the SS tendon, and combined transfer of the LD/TM tendon to the central aspect of the SS tendon was assessed., Results: The LD and TM were an average length of 5.9 cm and 2.3 cm and an average width of 2.2 cm and 2.4 cm, respectively. The mean distances from the center of the LD and TM tendons insertion to the central aspect of the SS tendon insertion was 4.0 cm and 4.7 cm, respectively. All of the tendon transfers were feasible, and the risk of nerve compression was low, except for the combined tendon LD/TM transfer to the proximal third of the SS tendon., Conclusions: This study shows that transfer of the LD/TM to the lesser tuberosity to reconstruct an irreparable SS tear is feasible, with a low risk of nerve compression, with the exception of the combined LD/TM and more proximal TM tendon transfers., (Copyright © 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Restoration of shoulder external rotation in patients with paralytic shoulder is very challenging. When nerve repair and/or transfer fails, or if patients present late after injury such that nerve reconstruction is not possible, tendon transfer to restore shoulder external rotation becomes the main option. Good outcome has been reported with lower trapezius transfer to the infraspinatus to restore shoulder external rotation in patients with paralytic shoulder. The purpose of this manuscript is to describe the surgical technique of this transfer., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Pectoralis major transfer (partial or complete) is the most common transfer to the scapula for winging as a result of serratus anterior paralysis or injury. The most commonly described technique is to transfer the pectoralis major prolonged with tendon allograft or autograft to the scapula. We present a technique that entails direct transfer of the sternal head of the pectoralis major with its bony insertion to the lower scapula., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)