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Objectives: Treatment options for recurrent shoulder instability, in the setting of significant glenoid bone loss, consists of several iterations of bone stabilization procedures. However, advanced arthritic changes with the Laterjet procedure and rapid resorption changes with the iliac crest bone graft reconstruction has led into the search for more optimal surgical reconstruction options. The purpose of this study is to evaluate the clinical and functional outcomes of patients with recurrent shoulder instability, with significant glenoid bone loss, treated with fresh distal tibial allograft reconstruction with regards to recurrence, revision surgery, and complications. Methods: At a single institution, all consecutive patients with recurrent shoulder instability and at least 15% anterior glenoid bone loss, undergoing distal tibial allograft reconstruction, between 2011 to 2016, were identified by diagnostic and procedural codes. All clinical notes, diagnostic imaging, and operative reports were reviewed in detail. From these sources, demographics, operative techniques, and radiographic parameters were collected and measured. Functional outcome scores were prospectively collected from patients. The primary outcome of the study was the Disability of Arm, Shoulder, Hand (DASH) score. The secondary outcomes of the study were the Visual Analog Scale (VAS) pain score, Single Assessment Numeric Evaluation (SANE) score, recurrent instability, revision surgery, and complications. Results: At 6 years, there were a total of 36 distal tibial allograft reconstructions performed in patients with recurrent shoulder instability in the setting of significant glenoid bone loss. Amongst this cohort, average age was 35 years old with 72% of patients being male. The dominant extremity was involved in 20 (56%) of patients and 24 (67%) of patients had previous surgery to address episodes of shoulder instability. Follow-up, for the entire cohort was on average 15.5 months. In comparison to preoperative range of motion, after surgery there was significantly less abduction (P=0.01). At final follow-up, patients undergoing distial tibial allograft reconstruction showed trend towards significant improvement in the DASH score (preoperative DASH=50.7, postoperative DASH=37.1, P=0.09). In like manner, there was significant improvement in both the VAS score (P=0.001) and the SANE score (P=0.002). There was no significant difference in functional outcome scores between those patients who had failed a previous surgery for instability. Recurrent instability, after distal tibial allograft reconstruction, occurred in 4 (11%) of patients and 8 (22%) of patients underwent an additional surgical procedure. Complications occurred in 31% of patients, with the most common complication being rupture of the subscapularis. Conclusion: This study provides functional outcomes in one of the largest consecutive cohort of patients undergoing distal tibial allograft reconstruction for recurrent shoulder instability due to significant glenoid bone loss. The study suggests that distal tibial allograft reconstruction may provide improved functional outcomes in patients with recurrent shoulder instability. After this procedure, 89% of patients did not experience any additional episodes of shoulder instability. Despite these encouraging results, complications are common after this procedure, with 31% of patients experiencing a complication. Table 2. Range of Motion & Physical Examination in patients with Tibial Plafond Allograft Reconstruction Tibial Plafond Allograft (n = 36) Preoperative Postoperative P-Value Range of Motion (Active) Abduction 102.2 ± 26.8 82.6 ± 14.8 0.01 Forward Flexion 125.8 ± 31.3 137.9 ± 32.9 0.25 External Rotation 46.1 ± 9.8 43.2 ± 10.1 0.52 Internal Rotation 47.8 ± 9.3 52.3 ± 12.5 0.46 Continuous data are reported as mean ± standard deviation. Categorical data reported as number (%). Table 3. Functional Outcomes at Final Follow-Up of Tibial Platfond Allograft Reconstruction Tibial Plafond Allograft (n = 36) Preoperative Postoperative P-Value Primary Outcome DASH 50.7 ± 27.8 37.1 ± 27.4 0.09 Secondary Outcome Vas 5.62 ± 2.7 43.2 ± 10.1 0.001 SANE 32.5 ± 18.9 75.8 ± 21.9 0.002 Continuous data are reported as mean ± standard deviation.

Objectives: Treatment options for massive irreparable rotator cuff tears, in middle aged adults, consists of tendon transfer or superior capsular reconstruction (SCR). The purpose of this study was to evaluate if transfer of the latissimus dorsi tendon transfer is enhanced with combination of superior capsular reconstruction for treatment of massive irreparable rotator cuff tears. Methods: At a single institution, all consecutive patients undergoing transfer of the latissimus dorsi tendon with or without superior capsular reconstruction, between 2013 and 2016, for treatment of irreparable rotator cuff tears were evaluated. SCR, was indicated, in addition to latissimus transfer, for patients with impaired preoperative active abduction. All clinical notes, diagnostic imaging, and operative reports were reviewed in detail. Demographics, operative techniques, and radiographic parameters were collected and measured. Functional outcome scores were prospectively collected from patients. The primary outcome of the study was the Disability of Arm, Shoulder, Hand (DASH) score. The secondary outcomes of the study were the Visual Analog Scale (VAS) pain score, Single Assessment Numeric Evaluation (SANE) score, and the American Shoulder and Elbow Society (ASES) score. Results: At 3 years, there were a total of 26 latissimus dorsi tendon transfers performed in patients with irreparable rotator cuff tears. Of these, 8 patients underwent only latissimus dorsi tendon transfer and 18 patients underwent latissimus dorsi tendon transfer combined with a superior capsular reconstruction. Average age was 53 years old with the majority of patients being male (88%). The dominant extremity was involved in 22 (85%) of latissimus transfers and 14 (53%) of patients had previous surgery to address a rotator cuff tear. Follow-up, for the entire cohort, was on average 29 months. At final follow-up, there was no significant difference in physical examination or radiographic measurements between patients with latissimus transfer alone and those with latissimus transfer with SCR. All patients, undergoing either technique, showed significant improvement in both the DASH score (preoperative DASH=59.6, postoperative DASH=39.9, P=0.049) and VAS score (preoperative VAS=6.6, postoperative VAS=3.3, P=0.0006). However, those patients undergoing revision surgery, regardless of technique, showed significantly less improvement in the DASH score (P=0.005), VAS score (P=0.002), SANE score (P=0.005), and the ASES score (P=0.001). Transfer of the Latissimus tendon with SCR, in comparison to only tendon transfer, did not show any significant difference in the final DASH score (p-value=0.72). At the same time, there was no significant difference between latissimus transfer, with or without SCR, in the secondary outcomes of the VAS score(P=0.97), the SANE score(P=0.63), or the ASES score (P=0.74). Conclusion: This is the first study to report the outcomes of latissimus dorsi tendon transfer with superior capsular reconstruction in comparison to only latissimus dorsi tendon transfer for treatment of irreparable rotator cuff tears. The study suggests that transfer of the latissimus dorsi tendon in combination with superior capsular reconstruction, at short term follow-up of 2 years, may not significantly influence functional outcome. Rather, patients undergoing revision surgery, regardless of technique, may demonstrate smaller improvements in functional outcomes. Table 2. Range of Motion & Physical Examination in Latissimus Dorsi Tendon Transfer with/without SCR Lat Only (n=8) Lat + SCR (n=18) Preoperative Postoperative P-Value Preoperative Postoperative P-Value Range of Motion (Active) Abduction 135 ± 21.2 76.4 ± 18 0.04 75.4 ± 26.0 71.5 ± 22 0.80 Forward Flexion 106.9 ± 36.7 135.7 ± 32.2 0.15 103.5 ± 32.2 110.6 ± 45.4 0.35 External Rotation 36 ± 11.4 42.9 ± 15 0.80 25.3 ± 18.6 38.5 ± 16.3 0.04 Internal Rotation 65 ± 22.9 59.3 ± 12.4 0.55 54.4 ± 13.3 63.1 ± 13.0 0.08 Hornblower Sign 2 (25%) 2 (25%) 0.98 14 (78%) 2 (11%) 0.07 External Rotation Lag 6 (75%) 2 (25%) 0.34 17 (94%) 3 (17%) 0.01 Continuous data are reported as mean ± standard deviation. Categorical data reported as number (%). Table 4. Functional Outcomes at Final Follow-Up of Latissimus Dorsi Tendon Transfer with/without SCR Lat Only (n=8) Lat + SCR (n=18) Mean (Std Dev) Mean (Std Dev) P-Value Primary Outcome DASH 47.0 ± 39.8 42.5 ± 27.5 0.72 Secondary Outcome Vas 3.14 ± 3.5 3.4 ± 3.5 0.97 SANE 54.7 ± 38.5 60.9 ± 22.1 0.63 ASES 65.8 ± 36.3 60.6 ± 30.9 0.74 Constance 63.8 ± 31.0 50.3 ± 23.3 0.34