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Background: Glenoid and humeral head bone defects are common in chronic shoulder instability. The talus, and more specifically, the subtalar joint, has been proposed as a unique allograft from which bipolar bone loss can be addressed. However, there are few biomechanical data or joint reconstruction analyses of the glenoid using the posterior facet of a subtalar joint allograft (STA)., Purpose: To compare the contact mechanics of an STA versus a coracoid graft (Latarjet procedure) versus a distal tibial allograft (DTA) for anatomic glenoid reconstruction., Study Design: Controlled laboratory study., Methods: A total of 8 fresh-frozen, unpaired cadaveric specimens underwent repeated-measures biomechanical testing in 5 stages: native (intact) state, bone loss (30% glenoid bone defect), Latarjet procedure, glenoid reconstruction using a DTA, and glenoid reconstruction using an STA. A compressive load of 440 N was applied to the glenohumeral joint when the humerus was mounted to a dynamic tensile testing machine in 3 shoulder positions: 30° of abduction, 60° of abduction, and 60° of abduction with 90° of external rotation (ER). Average contact pressure, contact area, and peak contact pressure were determined from the sensors. Surface area and surface congruency were calculated using a custom script. Data were analyzed using analysis of variance., Results: There was a significantly higher surface area with glenoid reconstruction using the DTA (859 ± 78 mm 2 ; P = .005) than with glenoid reconstruction using the STA (806 ± 88 mm 2 ; P < .001) and the Latarjet procedure (692 ± 91 mm 2 ). Surface congruency was significantly better with reconstruction using the DTA (2.0 ± 0.3 mm; P = .003) or the STA (1.9 ± 0.3 mm; P = .004) than with the Latarjet procedure (2.6 ± 0.4 mm). In all shoulder positions, the average contact pressure in the bone loss state was significantly higher than that in the native state ( P < .05). All repair states restored average contact pressure to the native state at 60° of abduction and 60° of abduction with 90° of ER. There was less contact area after the Latarjet procedure than in the native state at 30° and 60° of abduction ( P = .009 and P = .040, respectively). There was no significant difference in contact area and peak contact pressure after reconstruction with the DTA or STA compared with the native state., Conclusion: Anatomic glenoid reconstruction using a DTA or STA restored average contact pressure, peak contact pressure, and contact area at 60° of abduction and 60° of abduction with 90° of ER in a cadaveric model. In addition, surface congruency and surface area improved over the traditional Latarjet procedure., Clinical Relevance: The STA showed comparable contact mechanics and surface geometry to the DTA. Further research is needed to determine the in vivo clinical outcomes of this new alternative graft., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: M.T.P. has received royalties from Arthrex, Arthrosurface, Responsive Arthroscopy, and Anika Therapeutics; consulting fees from Arthrex, the Joint Restoration Foundation, Zimmer Biomet, and Arthrosurface; grants from the United States Department of Defense, the National Institutes of Health, and DJO; and honoraria from Flexion Therapeutics. 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: There is growing evidence that medial meniscotibial ligament (MTL) deficiency and medial meniscus extrusion may precede the development of some medial meniscus posterior root (MMPR) tears. However, no study has investigated the biomechanical consequences of MTL deficiency on the MMPR., Hypothesis: (1) MTL deficiency leads to increased medial meniscus extrusion, (2) increased medial meniscus extrusion is correlated with increased compression and shear forces at the MMPR, and (3) MTL repair restores medial meniscus extrusion and MMPR forces to native levels., Study Design: Controlled laboratory study., Methods: Fifteen pairs of fresh-frozen cadaveric knees were tested. Specimens were organized into 3 groups according to a balanced incomplete block design: (1) native, (2) MTL deficiency, and (3) MTL repair. For the MTL deficiency group, a 3-cm deficiency in the MTL was developed under direct arthroscopic visualization. Specimens in the MTL repair group underwent a 2-anchor repair that compressed the joint capsule to the proximal tibia. All specimens were biomechanically tested in full extension with a tensile testing machine. The specimens underwent cyclic loading for 10,000 cycles at 1 Hz and compression of 20 to 500 N, with a 500-N compressive force applied for 30 seconds after the 0th, 100th, 1000th, and 10,000th cycles. Ultrasound was used to measure medial meniscus extrusion. Shear and compressive forces at the MMPR were measured with a 3-axis sensor installed inferior to the MMPR tibial attachment., Results: Medial meniscus extrusion was significantly increased in the MTL deficiency group compared with the native group (0th: 1.6 ± 0.1 mm vs 1.2 ± 0.1 mm, P < .05; 100th: 2.2 ± 0.2 mm vs 1.5 ± 0.2 mm, P < .05; 1000th: 2.8 ± 0.2 mm vs 1.8 ± 0.2 mm, P < .05; 10,000th: 3.5 ± 0.3 mm vs 2.1 ± 0.2 mm, P < .05). Compression root force was significantly increased in the MTL deficiency group compared with the native group at all cyclic loading points (0th: 21.7 ± 12.8 N vs 13.6 ± 2.4 N, P < .05; 100th: 18.9 ± 11.0 N vs 12.1 ± 7.5 N, P < .05; 1000th: 16.5 ± 9.9 N vs 11.2 ± 7.5 N, P < .05; 10,000th: 12.6 ± 8.6 N vs 9.0 ± 6.9 N, P < .05). Root shear force was significantly increased in the MTL deficiency group compared with the native group at the 0th (17.5 ± 2.5 N vs 13.6 ± 2.4 N, P < .001) and 100th (16.2 ± 2.6 N vs 12.1 ± 2.2 N, P < .001) cycles. Medial meniscus extrusion, root shear force, and compression root force of the MTL repair group were not significantly different from the native group for all cyclic loading points., Conclusion: Medial MTL deficiency led to increased medial meniscus extrusion as well as greater compression and shear forces at the MMPR compared with the intact and repaired MTL states, suggesting that MTL deficiency may predispose the MMPR to injury in a cadaveric model., Clinical Relevance: MTL deficiency predisposes one to medial meniscus extrusion and MMPR tears. Subsequently, MTL repair can potentially correct medial meniscus extrusion and normalize forces at the MMPR., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: A.F.V. has received consulting fees from Arthrex Inc and Stryker, honoraria from Vericel Corp, speaking fees from Smith & Nephew, hospitality payments from BodyCAD USA, and support for education from Gemini Mountain Medical. M.T.P. has received royalties from Arthrex Inc, Arthrosurface, Responsive Arthroscopy, and Anika Therapeutics Inc; consulting fees from Arthrex Inc, Joint Restoration Foundation (JRF), Zimmer Biomet Holdings, and Arthrosurface; grants from the Department of Defense (DoD), National Institutes of Health (NIH), and DJO; and honoria from Flexion Therapeutics. M.J.J.A. has received grants from Arthrex and DJO, support for education from Smith & Nephew, and hospitality payments from Medical Device Business Services. E.A.W. has received grants from DJO and support for education from Smith & Nephew. J.M.A. has received grants from Arthrex, hospitality payments from Arthrex, and support for education from Smith & Nephew and Stryker Corp. 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: The concept of on-track versus off-track bone lesions in glenohumeral instability continues to evolve. Although much has been ascertained from an original biomechanical model, bony pathological changes, especially on 3-dimensional (3D) imaging, have not been fully evaluated., Purpose: To compare the differences in on-track versus off-track lesions to characterize glenoid and humeral head bone defects using 3D modeling software., Study Design: Cross-sectional study; Level of evidence, 3., Methods: A consecutive cohort of 75 patients with recurrent anterior instability, with evidence of Hill-Sachs lesions (HSLs) and glenoid bone loss (GBL) and a mean age of 27.1 years (range, 18-48 years), were reviewed. 3D models of unilateral proximal humeri and glenoids were reconstructed. The volume, surface area, width, and depth of identified HSLs were quantified, along with their location (medial, superior) and orientation (Hill-Sachs angle). The percentage, width, and length of GBL as well as the glenoid track status were calculated. The on-track and off-track groups were compared using the Mann-Whitney U test., Results: The off-track group had greater HSL surface area (374.23 vs 272.64 mm 2 , respectively; P = .001), more HSL medialization (14.96 vs 17.62 mm, respectively; P = .028), greater HSL volume (603.08 vs 433.61 mm 3 , respectively; P = .007), and a greater mean HSL width (16.06 vs 11.53 mm, respectively; P = .001) than the on-track group. The off-track group also had greater GBL (22.55% vs 17.73%, respectively; P = .037), a greater GBL width (6.92 vs 3.58 mm, respectively; P < .001), and a greater GBL length (21.61 vs 16.1mm, respectively; P = .015) than the on-track group. Further analysis of large off-track lesions revealed a greater Hill-Sachs angle (33.16° vs 26.20°, respectively; P = .035) and a more superior extent of HSLs compared with borderline off-track and on-track lesions., Conclusion: Off-track lesions were found to have larger GBL, a larger HSL width, a more medialized HSL, and greater HSL surface area. This study outlines the specific characteristics of high-risk bipolar bone loss lesions to simplify the identification of patients in a clinical setting and aid in appropriate treatment planning., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.W.A. has received hospitality payments from Arthrex, Mid-Atlantic Surgical Systems, and Smith+Nephew; education payments from Mid-Atlantic Surgical Systems; and grants from Arthrex and DJO. C.B.R. has received grants from Arthrex and DJO and education payments from Smith+Nephew and MedInc of Texas. M.T.P. has received royalties from Anika Therapeutics, Arthrex, and Arthrosurface; consulting fees from Arthrex, Zimmer Biomet, and JRF Ortho; nonconsulting fees from Arthrex and Arthrosurface; education payments from Arthrex; and honoraria from Flexion Therapeutics and JRF Ortho. 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) 2024.)

Background: The utilization of lateral extra-articular tenodesis (LET) augmentation for anterior cruciate ligament reconstruction has increased. Various fixation points have been recommended based on tactile and anatomic landmarks; however, there is limited reporting of the accuracy or precision of these techniques in clinical practice., Purpose/hypothesis: The purpose of this study was to evaluate whether LET fixation points identified using anatomic landmarks and tactile techniques would fall within a predefined radiographic zone. It was hypothesized that the majority of LET fixation points would be inside the radiographic zone., Study Design: Cross-sectional study; Level of evidence, 4., Methods: Postoperative lateral knee radiographs of patients who underwent anterior cruciate ligament reconstruction with LET using a landmark-based technique without fluoroscopy between January 2018 and September 2023 were reviewed. Fixation points were measured by 2 raters based on their distance from an extension of the posterior femoral cortex line (PFCL) distally and a line perpendicular to the PFCL at the posterior condylar flare (PCF). Patients were excluded if the tunnel position could not be identified or if postoperative radiographs were malrotated. The mean LET position and percentage of points within the radiographic isometric zone, defined as 4 ± 4 mm posterior and 4 ± 3 mm anterior to the PFCL and 6 ± 4 mm distal and 20 ± 5 mm proximal to the PCF were calculated., Results: Complete data sets were obtained for 47 cases. The mean LET position was 6.4 ± 7.1 mm (range, -9 to 27.3 mm) anterior to the PFCL and 1.8 ± 7.6 mm (range, -16.7 to 12.6 mm) proximal to the PCF. Overall, 53% of LET fixation points were within the predefined radiographic zone. Of the malpositioned tunnels (n = 22), their locations relative to the radiographic zone were anterior (n = 18), posterior (n = 2), proximal (n = 1), and anterior and distal (n = 1)., Conclusion: This study found large variation in the location of LET fixation points, and almost half of fixation points were outside the predefined radiographic zone. Accurate and precise tunnel placement is one of multiple factors that may be important to minimize the risk of lateral compartment overconstraint, anterior cruciate ligament graft failure, and anisometry leading to LET graft loosening., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: Steadman Philippon Research Institute has received grant funding or in-kind donations from Arthrex, DJO, MLB, Ossur, Siemens, Smith & Nephew, and XTRE. T.R.H. has received consulting fees and research support from Arthrex Inc and owns stocks or stock options in NICE. J.A.G. has received consulting fees from Bioventus, Smith & Nephew, DePuy Synthes Products, and Mitek; owns stock or stock options in Nice Recovery Systems; has received support for education from Gemini Mountain Medical and Arthrex; and has received hospitality payments from Medical Device Business Services. A.F.V. has received research support and consulting fees from Arthrex Inc; IP royalties and consulting fees from Stryker; speaking fees from Vericel and Smith & Nephew; hospitality payments from Bodycad USA; and support for education from Gemini Mountain Medical. A.C.K. has received support for education from Suvon Surgical. M.E.C. has received support for education from Evolution Surgical and hospitality payments from Stryker. 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.

Utilizing fresh distal tibia allograft in anterior glenoid reconstruction has emerged as a highly advantageous approach in addressing instances of failed anterior shoulder stabilization with glenoid bone loss. This procedure offers several benefits, including the absence of donor-site morbidity, restoration of significant glenoid defects, reestablishment of joint congruity with the humeral head, restoration of glenoid biomechanics, and the addition of cartilage to the glenoid. Furthermore, it provides a robust and reliable alternative for managing failed stabilization procedures, leading to improved clinical outcomes and a high graft healing rate, while maintaining a low occurrence of recurrent instability., Competing Interests: Disclosure The authors declare that there are no relevant or material financial interests that directly relate to this work. Outside of this work, Matthew T. Provencher declares royalties from Arthrex, Inc. Arthrosurface, Responsive Arthroscopy (2020), and Anika Therapeutics, Inc.; Consulting fees from Arthrex, Inc., Joint Restoration Foundation (JRF), Zimmer Biomet Holdings, and Arthrosurface; received grants from the Department of Defense, United States (DoD), the National Institutes of Health, United States, (NIH), and the DJO (2020); Honoria from Flexion Therapeutics; is an editorial board or governing board member for SLACK, Inc.; Board or committee member for Arthoscopy Association of North America (AANA), American Academy of Orthopaedic Surgeons (AAOS), American Orthopaedic Society for Sports Medicine (AOSSM), ASES, San Diego Shoulder Institute (SDSI), and Society of Military Orthopaedic Surgeons (SOMOs); serves on the medical board of trustees for the Musculoskeletal Transplant Foundation (through 2018)., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Subscapularis tendon (SSc) dysfunction after total shoulder arthroplasty (TSA) results in poor functional outcomes. There have been numerous SSc repair constructs tested biomechanically and clinically; however, none has been demonstrated as superior. Newer techniques and implants have emerged but have not been fully tested., Hypothesis: We hypothesized that the unicortical button (UB) fixation would provide significantly improved restoration of the anatomic footprint and biomechanical properties compared with transosseous (TO) repair of the SSc., Methods: A digital footprint of SSc humeral insertion was obtained in 6 pairs of fresh-frozen cadaveric shoulders using a 3-dimensional digitizer. A complete SSc tear was created, and each pair of shoulders was randomized to either SSc repair with UB or TO repair. Each specimen underwent a cyclic loading protocol, followed by pull to failure. The failure load, elongation at failure, gapping failure, number of cycles until failure, the load at key gapping points (1 mm, 3 mm, 5 mm, and 10 mm), and the failure mode were recorded using high-resolution video recording. Three-dimensional surfaces of the insertion footprint and repair site were obtained, and surface areas were calculated using a custom MATLAB script and laser scanner. Paired t tests were conducted to compare differences between the 2 repair groups., Results: Failure load was significantly higher in the UB group (382.4 N ± 56.5 N) than in the TO group (253.6 N ± 103.4 N, P = .005). TO repair provided higher gapping at failure (28.8 mm ± 8.2 mm) than UB repair (10.4 mm ± 6.8 mm, P = .0017). UB repair had significantly higher load at the 1-mm, 5-mm, and 10-mm gapping than TO repair, with P = .042, P = .033, and P = .0076, respectively. There were no significant differences in elongation failure, the difference in footprint area from native to repair states, or the percentage of the restored footprint area between the groups (P = .26, P = .18, and P = .21, respectively)., Conclusions: The UB fixation showed a significantly lower gap at failure, higher failure load and number of cycles until failure, and higher gap loads than the traditional TO repair for SSc. Although more clinical research is necessary, the UB fixation that uses cortical bone presents promising results., (Copyright © 2024. Published by Elsevier Inc.)

Chronic Osgood-Schlatter disease can cause significant knee pain and can result in severe functional deficits. For large, painful Osgood-Schlatter disease ossicles refractory to conservative management, surgical ossicle excision can provide resolution of symptoms. After diagnostic arthroscopy and intra-articular debridement, our preferred excision technique uses an open incision for direct visualization and removal of intratendinous ossicles, followed by distal patellar tendon repair and subsequent fixation with FiberTape sutures and knotless anchors to the tibial tubercle., (© 2024 The Authors.)

Articular cartilage defects in the glenohumeral joint may be found in laborers, the elderly, and young athletes, among others. Various factors can contribute to cartilage damage, including prior surgery, trauma, avascular necrosis, inflammatory arthritis, joint instability, and osteoarthritis. There is a wide variety of treatment options, from conservative treatment, injections, and surgical options, including arthroscopic debridement, microfracture, osteochondral autograft transfer, osteochondral graft transplantation, autologous chondrocyte implantation, and the newly emerging techniques such as biologic augmentation. There is a challenge to determine the optimal treatment options, especially for young athletes, due to limited outcomes in the literature. However, there are many options which are viable to address osteochondral defects of the glenohumeral joint., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To analyze radiographic outcomes by conventional radiography, computed tomography (CT), or both and complication rates of open coracoid transfer at a minimum of 12-months follow-up., Methods: A literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using PubMed, Medline (Ovid), and EMBASE library databases. Inclusion criteria were clinical studies reporting on open Latarjet as the primary surgical procedure(revision coracoid transfer after failed prior stabilization excluded) with postoperative radiographic outcomes at a minimum mean 1-year follow-up. Patient demographics, type of postoperative imaging modality, and radiographic outcomes and complications including graft union, osteoarthritis, and osteolysis were systematically reviewed. Data were summarized as ranges of reported values for each outcome metric. Each radiographic outcome was graphically represented in a Forest plot with point estimates of the incidence of radiographic outcomes with corresponding 95% confidence intervals and I 2 ., Results: Thirty-three studies met inclusion criteria, with a total of 1,456 shoulders. The most common postoperative imaging modality was plain radiography only (n = 848 [58.2%]), both CT and radiography (n = 287 [19.7%]), and CT only (n = 321 [22.1%]). Overall, the reported graft union rate ranged from 75% to 100%, of which 79.8% (n = 395) were detected on plain radiography. The most common reported postoperative radiographic complications after the open coracoid transfer were osteoarthritis (range, 0%-100%, pooled mean 28%), graft osteolysis (range, 0%-100%, pooled mean 30%), nonunion (range, 0%-32%, pooled mean 5.1%), malpositioned graft (range, 0%-75%, pooled mean 14.75%), hardware issues (range, 0%-9.1%, pooled mean 5%), and bone block fracture (range, 0%-8%, pooled mean 2.1%). Graft healing was achieved in a majority of cases (range, 75%-100%)., Conclusion: Postoperative radiographic outcomes after open coracoid transfer vary greatly in definition, classification, and imaging modality of choice. Greater consistency in postoperative radiographic outcomes is essential to evaluate graft healing, osteolysis, and nonunion., Level of Evidence: Level IV, systematic review of Level III-IV studies., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Valgus instability can occur after total knee arthroplasty (TKA) due to traumatic medial collateral ligament (MCL) injury, component malpositioning, or progressive ligamentous laxity. Although revision TKA with exchange of the polyethylene to a varus-valgus-constrained liner can reduce laxity due to MCL insufficiency, isolated liner exchange in the setting of collateral ligament insufficiency may lead to greater strain at the cement-bone or implant-cement interface and possibly a greater rate of aseptic loosening. Anatomic MCL reconstruction can be performed in conjunction with liner exchange to restore stability and reduce strain compared with liner exchange alone. The purpose of this Technical Note is to describe a technique for MCL reconstruction and liner exchange for treatment of valgus instability after TKA., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: A.C.K. reports Editorial Board member for Arthroscopy. A.F.V. reports a relationship with American Academy of Orthopaedic Surgeons that includes: board membership; a relationship with American Orthopaedic Society for Sports Medicine that includes: board membership; a relationship with Arthrex that includes: funding grants; and a relationship with 10.13039/100008894Stryker that includes: consulting or advisory. J.C.R. reports a relationship with American Academy of Orthopaedic Surgeons that includes: board membership; a relationship with Aerobiotix that includes: consulting or advisory; a relationship with DePuy Orthopaedics that includes: consulting or advisory; and a relationship with Zimmer that includes: consulting or advisory. M.T.P. reports a relationship with 10.13039/100009885American Academy of Orthopaedic Surgeons that includes: board membership; a relationship with 10.13039/100011549American Orthopaedic Society for Sports Medicine that includes: board membership; a relationship with 10.13039/100013615American Shoulder and Elbow Surgeons that includes: board membership; a relationship with 10.13039/100007307Arthrex that includes: consulting or advisory and funding grants; a relationship with 10.13039/100008542Arthroscopy Association of North America that includes: board membership; a relationship with Elsevier that includes: consulting or advisory and funding grants; a relationship with International Society of Arthroscopy Knee Surgery and Orthopaedic Sports Medicine that includes: board membership; a relationship with JRF Ortho that includes: consulting or advisory; a relationship with Knee that includes: board membership; a relationship with Orthopedics that includes: board membership; a relationship with San Diego Shoulder Institute that includes: board membership; a relationship with Slack Incorporated that includes: board membership, consulting or advisory, and funding grants; and a relationship with The Society of Military Orthopaedic Surgeons that includes: board membership. R.H.K. reports a relationship with DJO Global that includes: consulting or advisory; a relationship with Innomed that includes: consulting or advisory; and a relationship with International Orthopedic Education Network that includes: board membership. T.R.H. reports a relationship with Arthrex that includes: consulting or advisory and funding grants; and a relationship with NICE Recovery Solutions that includes: equity or stocks. All other authors (C.C.L., R.J.W.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

The management of glenoid bone loss in shoulder instability can be challenging. Although shoulder instability can often be managed with arthroscopic soft-tissue procedures alone, the extent of glenoid bone loss and bipolar bone defects may require bone augmentation procedures for restoration of stability. In this setting, patient evaluation, examination, treatment options, and surgical pearls are vital. Furthermore, a treatment algorithm is established to guide both indications and the technical application of procedures including Bankart repair with remplissage, Latarjet procedure, and glenoid bone graft options. The limitations, complications, and current research pertinent to each treatment assist in guiding treatment.

Background: In the Latarjet procedure, the ideal placement of the coracoid graft in the medial-lateral position is flush with the anterior glenoid rim. However, the ideal position of the graft in the superior-inferior position (sagittal plane) for restoring glenohumeral joint stability is still controversial., Purpose: To compare coracoid graft clockface positions between the traditional 3 to 5 o'clock and a more inferior (for the right shoulder) 4 to 6 o'clock with regard to glenohumeral joint stability in the Latarjet procedure., Study Design: Controlled laboratory study., Methods: A total of 10 fresh-frozen cadaveric shoulders were tested in a dynamic, custom-built robotic shoulder model. Each shoulder was loaded with a 50-N compressive load while an 80-N force was applied in the anteroinferior axes at 90° of abduction and 60° of shoulder external rotation. Four conditions were tested: (1) intact, (2) 6-mm glenoid bone loss (GBL), (3) Latarjet procedure fixed at 3- to 5-o'clock position, and (4) Latarjet procedure fixed at 4- to 6-o'clock position. The stability ratio (SR) and degree of lateral humeral displacement (LHD) were recorded. A 1-factor random-intercepts linear mixed-effects model and Tukey method were used for statistical analysis., Results: Compared with the intact state (1.77 ± 0.11), the SR was significantly lower after creating a 6-mm GBL (1.14 ± 0.61, P  = .009), with no significant difference in SR after Latarjet 3 to 5 o'clock (1.51 ± 0.70, P  = .51) or 4 to 6 o'clock (1.55 ± 0.68, P  = .52). Compared with the intact state (6.48 ± 2.24 mm), LHD decreased significantly after GBL (3.16 ± 1.56 mm, P  < .001) and Latarjet 4 to 6 o'clock (5.48 ± 3.39 mm, P  < .001). Displacement decreased significantly after Latarjet 3 to 5 o'clock (4.78 ± 2.50 mm, P  = .04) compared with the intact state but not after Latarjet 4 to 6 o'clock ( P  = .71)., Conclusion: The Latarjet procedure in both coracoid graft positions (3-5 and 4-6 o'clock) restored the SR to the values measured in the intact state. A more inferior graft position (fixed at 4-6 o'clock) may improve shoulder biomechanics, but additional work is needed to establish clinical relevance., Clinical Relevance: An inferior coracoid graft fixation, the 4- to 6-o'clock position, may benefit in restoring normal shoulder biomechanics after the Latarjet procedure., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: this research was supported by the Steadman Philippon Research Institute. R.-O.D.H. and M.-C.R. have received grant support from AGA. P.J.M. has received consulting and nonconsulting fees from Arthrex; research support from Arthrex, Ossur, Siemens, and Smith & Nephew; royalties from Arthrex, Medbridge, and Springer; and stock or stock options from VuMed. M.T.P. has received royalties from Anika Therapeutics, Arthrex, and Arthrosurface; consulting fees from Arthrex, Zimmer Biomet Holdings, and JRF Ortho; nonconsulting fees from Arthrex and Arthrosurface; and honoraria from Flexion Therapeutics and JRF Ortho. 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: Posterior medial meniscus root (PMMR) tears are a challenge to assess and treat. However, the forces sustained at the PMMR are yet to be fully characterized. In addition, it has been shown that meniscotibial ligament (MTL) injuries happen before PMMR tears, suggesting that insufficiency of the MTL results in a change of forces acting on the PMMR., Purpose/hypothesis: The purpose of this study was to evaluate the 3-dimensional forces acting on the PMMR in the intact, MTL cut, and MTL tenodesis states. It was hypothesized that the MTL cut state would increase medial shear forces seen at the PMMR, whereas the medial shear force in the MTL tenodesis state would return PMMR forces to that of the intact state., Study Design: Controlled laboratory study., Methods: Ten fresh-frozen cadaveric knees were tested in 3 states (intact, MTL cut, and tenodesis). A 3-axis load cell was installed below the posterior tibial plateau and attached to the enthesis of the PMMR. The specimen was mounted to a load frame that applied an axial load, an internal torque, and an external torque. The amount of compression-tension, mediolateral shear force, and anteroposterior shear force acting on the PMMR was measured., Results: When the joint was loaded in compression, the MTL cut state significantly increased compression of the PMMR ( P = .0368). The tenodesis state did not significantly restore forces of the PMMR ( P = .008). When the joint was loaded in external torque, the MTL cut state significantly increased compression ( P < .0001) and significantly decreased anterior shear on the PMMR ( P = .0003). The tenodesis state did not significantly restore forces on the PMMR to the intact state ( P < .0001). Increased flexion angle significantly increased medial shear forces of the PMMR when the joint was loaded in compression ( P < .007 at every angle)., Conclusion: When evaluated biomechanically, MTL insufficiency resulted in increased compressive force at the PMMR. A single-anchor centralization procedure did not restore PMMR forces to that of the intact state. Increased knee flexion angle resulted in increased medial shear force on the PMMR., Clinical Relevance: The findings in this study provide clinicians information on PMMR forces when the MTL is disrupted. These data can aid in the decision-making for adding an MTL repair to augment PMMR repairs., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: H.M. has received support for education from Smith & Nephew. A.F.V. has received consulting fees from Arthrex and Stryker; honoraria from Vericel; and compensation for services other than consulting from Smith & Nephew. M.T.P. has received consulting fees and royalties from Arthrex and Anika Therapeutics; honoraria from Flexion Therapeutics Inc; and consulting fees from Zimmer Biomet Holdings. 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: Humeral head reconstruction with fresh osteochondral allografts (OCA) serves as a potential treatment option for anatomic reconstruction. More specifically, talus OCA is a promising graft source because of its high congruency with a dense cartilaginous surface., Purpose: To analyze the surface geometry of the talus OCA plug augmentation for the management of shoulder instability with varying sizes of Hill-Sachs lesions (HSLs)., Study Design: Controlled laboratory study., Methods: Seven fresh-frozen cadaveric shoulders were tested in this study. The humeral heads were analyzed using actual patients' computed tomography scans. Surface laser scan analysis was performed on 7 testing states: (1) native state; (2) small HSL; (3) talus OCA augmentation for small HSL; (4) medium HSL; (5) talus OCA augmentation for medium HSL; (6) large HSL; and (7) talus OCA augmentation for large HSL. OCA plugs were harvested from the talus allograft and placed in the most medial and superior aspect of each HSL lesion. Surface congruency was calculated as the mean absolute error and the root mean squared error in the distance. A 1-way repeated-measures analysis of variance was performed to evaluate the effects of the difference in the HSL size and associated talus OCA plugs on surface congruency and the HSL surface area., Results: The surface area analysis of the humeral head with the large (1469 ± 75 mm 2 ), medium (1391 ± 81 mm 2 ), and small (1230 ± 54 mm 2 ) HSLs exhibited significantly higher surface areas than the native state (1007 ± 88 mm 2 ; P < .001 for all sizes). The native state exhibited significantly lower surface areas as compared with after talus OCA augmentation for large HSLs (1235 ± 63 mm 2 ; P < .001) but not for small or medium HSLs. Talus OCA augmentation yielded improved surface areas and congruency after treatment in small, medium, and large HSLs ( P < .001)., Conclusion: Talus OCA plug augmentation restored surface area and congruency across all tested HSLs, and the surface area was best improved with the most common HSLs-small and medium., Clinical Relevance: Talus OCA plugs may provide a viable option for restoring congruity of the shoulder in patients with recurrent anterior glenohumeral instability and an HSL., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: M.T.P. has received research support from DJO; consulting fees from Arthrex, Arthrosurface, JRF Ortho, and Zimmer Biomet; royalties from Anika Therapeutics, Arthrex, Arthrosurface, and Responsive Arthroscopy; and honoraria from Flexion Therapeutics. 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: Posterior medial meniscus root (PMMR) tears have been associated with increased posterior tibial slope, but this has not been fully evaluated biomechanically. In addition, the effects of knee flexion and rotation on the PMMR are not well understood biomechanically because of technological testing limitations. A novel multiaxial force sensor has made it possible to elucidate answers to these questions., Purpose: (1) To determine if increased posterior tibial slope results in increased posterior shear force and compression on the PMMR, (2) to evaluate how knee flexion angle affects PMMR forces, and (3) to assess how internal and external rotation affects force at the PMMR., Study Design: Controlled laboratory study., Methods: Ten fresh-frozen cadaveric knees were tested in all combinations of 3 posterior tibial slopes and 4 flexion angles. A multiaxial force sensor was connected to the PMMR and installed below the posterior tibial plateau maintaining anatomic position. The specimen underwent a 500-N compression load followed by a 5-N·m internal torque and a 5-N·m external torque. The magnitude and direction of the forces acting on the PMMR were measured., Results: Under joint compression, an increased tibial slope significantly reduced the tension on the PMMR between 5° and 10° (from 13.5 N to 6.4 N), after which it transitioned to a significant increase in PMMR compression, reaching 7.6 N at 15°. Under internal torque, increased tibial slope resulted in 4.7 N of posterior shear at 5° significantly changed to 2.0 N of anterior shear at 10° and then 8.2 N of anterior shear at 15°. Under external torque, increased tibial slope significantly decreased PMMR compression (5°: 8.9 N; 10°: 4.3 N; 15°: 1.1 N). Under joint compression, increased flexion angle significantly increased medial shear forces of the PMMR (0°, 3.8 N; 30°, 6.2 N; 60°, 7.3 N; 90°, 8.4 N). Under internal torque, 90° of flexion significantly increased PMMR tension from 2.3 N to 7.5 N. Under external torque, 30° of flexion significantly increased PMMR compression from 4.7 N to 12.2 N., Conclusion: An increased posterior tibial slope affects compression and anterior shear forces at the PMMR. An increased flexion angle affects compression, tension, and medial shear forces at the PMMR., Clinical Relevance: The increase in compression and posterior shear force when the knee is loaded in compression may place the PMMR under increased stress and risk potential failure after repair. This study provides clinicians with information to create safer protocols and improve repair techniques to minimize the forces experienced at the PMMR., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: H.M. has received support for education from Smith & Nephew. M.T.P. has received royalties and consultant payments from Arthrex, Slack, and Joint Restoration Foundation; honoraria from Arthrosurface and Flexion Therapeutics; consulting fees from Zimmer Biomet Holdings; and royalties from Anika Therapeutics. 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.

Injuries to the acromioclavicular (AC) joint are common shoulder injuries in contact/collision athletes. There are a number of different surgical options that can be used to treat these injuries. The majority of these injuries can be treated nonoperatively with an early return to play for type I and II injuries. Surgical intervention and AC/CC (coracoclavicular) ligament reconstruction have excellent postoperative outcomes if complications can be avoided. This review will focus on the pearls and pitfalls for anatomic AC and CC ligament reconstruction for high-grade AC joint injuries., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Engaging Hill-Sachs lesions (HSLs) pose a significant risk for failure of surgical repair of recurrent anterior shoulder instability. Reconstruction with fresh osteochondral allograft (OCA) has been proposed as a treatment for large HSLs., Purpose: To determine the optimal characteristics of talus OCA bone plugs in a computer-simulated HSL model., Study Design: Descriptive laboratory study; Level of evidence, 6., Methods: Included were 132 patients with recurrent anterior instability with visible HSLs; patients who had multidirectional instability or previous shoulder surgery were excluded. Three-dimensional computed tomography models were constructed, and a custom computer optimization algorithm was generated to maximize bone plug surface area at the most superior apex (superiorization) and minimize its position relative to the most medial margin of the HSL defect (medialization). The optimal number, diameter, medialization, and superiorization of the bone plug(s) were reported. Percentages of restored glenoid track width and conversion from off- to on-track HSLs after bone plug optimization were calculated., Results: A total of 86 patients were included in the final analysis. Off-track lesions made up 19.7% of HSLs and, of these, the mean bone plug size was 9.9 ± 1.4 mm, with 2.2 mm ± 1.7 mm of medialization and 3.3 mm ± 2.9 mm of superiorization. The optimization identified 21% of HSLs requiring 1 bone plug, 65% requiring 2 plugs, and 14% requiring 3 plugs, with a mean overall coverage of 60%. The mean width of the restored HSLs was 68%, and all off-track HSLs (n = 17) were restored to on-track. A Jenks natural-breaks analysis calculated 3 ideal bone plug diameters of 8 mm (small), 10.4 mm (medium), and 12 mm (large) in order to convert this group of HSLs to on-track., Conclusion: Using a custom computer algorithm, we have demonstrated the optimal talus OCA bone plug diameters for reconstructing HSLs to successfully restore the HSL track and, on average, 60% of the HSL surface area and 68% of the HSL width., Clinical Relevance: Reconstructing HSLs with talus OCA is a promising treatment option with excellent fit and restoration of HSLs. This study will help guide surgeons to optimize OCA bone plugs from the humeral head, femoral head, and talus for varying sizes of HSLs., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: M.T.P. has received grant support from DJO; consulting fees from Arthrex, Arthrosurface, JRF Ortho, and Zimmer Biomet; royalties from Anika Therapeutics, Arthrex, Arthrosurface, and Responsive Arthroscopy; honoraria from Flexion Therapeutics; is a governing board member for SLACK; and serves on the medical board of trustees for MTF Biologics. 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: Segmental medial meniscal allograft transplantation (MAT) has been shown to restore knee biomechanics; however, stable fixation of the transplantation is critical to avoid extrusion and maximize healing., Purpose: To evaluate the degree of meniscal extrusion and biomechanical function of segmental medial MAT performed with meniscocapsular sutures versus repair augmentation with knotless suture anchors., Study Design: Controlled laboratory study., Methods: Segmental midbody medial meniscectomy and subsequent segmental medial MAT were performed on 10 fresh-frozen cadaveric knees. The knees were then loaded in a dynamic tensile testing machine to 1000 N for 60 seconds at 0°, 30°, 60°, and 90° of flexion, and 4 conditions were tested: (1) intact, (2) segmental defect, (3) inside-out segmental repair, and (4) anchor plus inside-out segmental repair of the medial MAT. Meniscal extrusion was measured using high-fidelity ultrasound imaging. The mean contact area and the mean and peak contact pressures were assessed with submeniscal pressure-mapping sensors. Data from testing conditions were compared with 2-way repeated-measures analysis of variance, with pairwise comparison using the Bonferroni method., Results: At 90° of flexion, the segmental defect state showed a higher degree of meniscal extrusion compared with all other states ( P ≤ .012). There was no difference in the degree of meniscal extrusion between the intact state and the inside-out repair or anchor plus inside-out segmental repair states at all knee flexion angles ( P > .05). There was no significant difference in the mean and peak contact pressures among the 4 states at all flexion angles except that at 0° of knee flexion there was significantly lower peak contact pressure at the medial compartment after anchor plus inside-out segmental repair compared with the segmental defect state ( P = .048)., Conclusion: Meniscal extrusion was not significantly increased at any flexion angle after segmental resection. The addition of knotless anchors did not improve meniscal extrusion or contact pressures/area compared with capsular repair alone. The addition of knotless anchors did improve contact mechanics from the segmental defect state, but only at 0° of flexion., Clinical Relevance: The addition of knotless suture anchors to segmental meniscal transplantation increased stabilization of the meniscus at full extension compared with repair with sutures alone. This increased stabilization may lead to better long-term outcomes., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: M.J.F. has received education payments from Smith & Nephew. M.T.P. has received education payments from Arthrex; consulting fees from Arthrex, JRF Ortho, and Zimmer Biomet; nonconsulting fees from Arthrex and Arthrosurface; royalties from Anika Therapeutics, Arthrex, and Arthrosurface; and honoraria from Flexion Therapeutics and JRF Ortho. 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.)

Snapping scapula syndrome (SSS) is a source of pain and discomfort in patients. It is not uncommon for patients who present with SSS to have some degree of scapular dysfunction, especially with the tightness of the pectoralis minor (PM) muscle. In this Technical Note, we demonstrate our preferred technique for arthroscopic scapulothoracic bursectomy and partial scapulectomy with concomitant pectoralis minor release for the treatment of symptomatic SSS and PM tightness. In the treatment of these patients, PM release is beneficial because arthroscopic scapulothoracic bursectomy or partial scapulectomy alone may result in residual scapular dyskinesis., (© 2023 The Authors.)

Background: Lesions that involve humeral avulsions of the glenohumeral ligament (HAGLs), although less common, are primary contributors to recurrent events of dislocation and subluxation of the glenohumeral joint., Purpose: To describe the clinical presentation, examination, and surgical outcomes of patients presenting with HAGL lesions who underwent repair using an arthroscopic or open technique., Study Design: Cohort study; Level of evidence, 3., Methods: A multicenter retrospective review of prospectively collected data was performed of skeletally mature patients without glenohumeral arthritis who presented with HAGL lesions and subsequently underwent arthroscopic or open repair between 2005 and 2017. Independent variables included patient characteristics, clinical presentation, physical examination findings, and arthroscopic findings. Dependent variables included pre- and postoperative Single Assessment Numeric Evaluation (SANE) score, Western Ontario Shoulder Instability Index (WOSI) score, and range of motion outcomes., Results: Eighteen patients diagnosed with a HAGL lesion who underwent primary arthroscopic repair (n = 7) or open repair (n = 11) were included. There were 17 male patients and 1 female patient with a mean age of 24.9 years (range, 16-38 years). Mean follow-up duration was 50.9 months (range, 24-160 months). Seventeen patients (94.4%) reported pain as the most common symptom, and 7 (38.9%) reported sensation of instability. Scores significantly improved from pre- to postoperative for the arthroscopic and open groups ( P < .001): SANE (mean ± SD; arthroscopic, 30.7 ± 15.7 to 92.1 ± 12.2; open, 45.5 ± 8.50 to 90.7 ± 5.24) and WOSI (arthroscopic, 51.4 ± 11.4 to 2.49 ± 3.70; open, 45.5 ± 7.37 to 11.5 ± 5.76). The magnitude of improvement in SANE scores was significantly higher for patients treated arthroscopically (Δ60.0; open, Δ46.5; P = .012). Postoperative WOSI scores were also significantly better in the arthroscopic cohort (2.49 ± 3.70; open, 11.5 ± 5.76; P = .00094)., Conclusion: Symptomatic HAGL tears present primarily with pain as opposed to instability, necessitating a high index of suspicion for injury. The tears may be treated successfully with an arthroscopic or open technique with significant improvements in patient-reported outcomes and stability.

Coaching, mentorship, and leadership are all paramount for the creation of a championship-winning football team. Looking back and studying the great coaches of professional football provides valuable insight into the qualities and the characteristics they possessed and how that impacted their leadership. Many of the great coaches from this game have instilled team standards and a culture that led to unprecedented success and sprouted into many other great coaches and leaders. Leadership at all levels of an organization is essential to consistently achieve a championship-caliber team., Competing Interests: Disclosure The authors have nothing to disclose about this work. Other disclosures: Dr M.T. Provencher receives royalties from Arthrex, Inc. and Elsevier, Inc., consulting fees from Arthrex, Inc., Joint Restoration Foundation, and SLACK, Inc., and is an honorarium for Arthrosurface. He is currently a Board or Committee member of the following: AAOS: Board or Committee member; AANA: Board or Committee member; AOSSM: Board or Committee member; ASES: Board or Committee member; Arthroscopy: Editorial or governing board; ISAKOS: Board or Committee member; Knee: Editorial or governing board; Orthopedics: Editorial or governing board; San Diego Shoulder Institute: Board or Committee member; SLACK Inc: Editorial or governing board; Society of Military Orthopaedic Surgeons: Board or Committee member., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Anatomic total shoulder arthroplasty (TSA) has become more common as surgical indications have expanded. However, the burden of revision shoulder arthroplasty has inevitably increased as well. Multiple studies have examined the use of reverse total shoulder arthroplasty (rTSA) as a revision option for failed anatomic TSA with a massive irreparable rotator cuff tear. Successful reconstruction of failed TSA with rTSA requires sufficient glenoid bone to place the glenoid segment, enough proximal humeral bone to allow for implantation of the humeral component, and sufficient tension in the soft-tissue envelope to ensure implant stability. In this article, we describe our preferred rTSA revision technique for the treatment of a failed TSA., (© 2022 The Authors.)

Better understanding of the causes and circumstances of maltreatment deaths of children is needed to prevent tragedy. The purpose of this article is to facilitate understanding of child maltreatment fatality review processes and their outcomes. A literature review was conducted through searches of the databases PubMed, PsycINFO, and EMBASE and through citations in publications. Over 165 publications were reviewed and 55 were selected for inclusion. Papers were from the United States, England, Ireland, Northern Ireland, Netherlands, France, Canada, Australia, South Africa, Switzerland, Saudi Arabia, Japan, and China. These were included if they described fatality review goals, authority, procedures, and outcomes. Although we searched databases on a continual basis during the preparation of this review, we could have missed publications, particularly those in newspapers and journals that are not included in large-scale databases or cited in other articles. Improvement of fatality review requires diligence by individuals and organizations that provide information to the reviewers. Among challenges to the review process are varying criteria for review, misclassifications of the manner of death, inadequate or incomplete forensic and medical investigations, lack of information about the perpetrator, diversity of the community, concealment of the cause of death by parents or other caregivers, and disagreement among reviewers about the results of their inquiries. Institutional challenges are also present, which include the need for funding, privacy issues on obtaining information, updating reviewer training, lack of follow-up by institutional authorities on the recommendations of the reviews, and research facilitating the review of maltreatment fatalities.