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Optimal glenosphere positioning in a lateralized reverse shoulder arthroplasty (RSA) to maximize functional outcomes has yet to be clearly defined. Center of rotation (COR) measurements have largely relied on anteroposterior radiographs, which allow assessment of lateralization and inferior position, but ignore scapular Y radiographs, which may provide an assessment of the posterior and inferior position relative to the acromion. The purpose of this study was to evaluate the COR in the sagittal plane and assess the effect of glenosphere positioning with functional outcomes using a 135° inlay stem with a lateralized glenoid. A retrospective review was performed on a prospectively maintained multicenter database on patients who underwent primary RSA from 2015 to 2021 with a 135° inlay stem. The COR was measured on minimum 2-year postoperative sagittal plain radiographs using a best-fit circle fit method. A best-fit circle was made on the glenosphere and the center was marked. From there, 4 measurements were made: (1) center to the inner cortex of the coracoid, (2) center to the inner cortex of the anterior acromion, (3) center to the inner cortex of the middle acromion, and (4) center to the inner cortex of the posterior acromion. Regression analysis was performed to evaluate any association between the position of the COR relative to bony landmarks with functional outcomes. A total of 136 RSAs met the study criteria. There was no relation with any of the distances with outcome scores (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, visual analog scale). In regard to range of motion (ROM), each distance had an effect on at least 1 parameter. The COR to coracoid distance had the broadest association with ROM, with improvements in forward flexion (FF), external rotation (ER0), and internal rotation with the arm at 90° (IR90) (P <.001, P =.031, and P <.001, respectively). The COR to coracoid distance was also the only distance to affect the final FF and IR90. For every 1-mm increase in this distance, there was a 1.8° increase in FF and 1.5° increase in IR90 (β = 1.78, 95% confidence interval [CI] 0.85-2.72, P <.001, and β = 1.53, 95% CI 0.65-2.41, P <.001; respectively). Evaluation of the COR following RSA in the sagittal plane suggests that a posteroinferior glenosphere position may improve ROM when using a 135° inlay humeral component and a lateralized glenoid. [ABSTRACT FROM AUTHOR]

Computer simulation has indicated a significant effect of scapulothoracic orientation and posture on range of motion (ROM) after reverse total shoulder arthroplasty (RTSA). We analyzed this putative effect on the clinical and radiologic outcome post-RTSA. We retrospectively assessed 2-year follow-up data of RTSA patients treated at our clinic between 2008 and 2019. Patients were categorized into posture types A, B, and C based on an established method using scapular internal rotation on preoperative cross-sectional imaging. We compared differences in clinical ROM, pain, Subjective Shoulder Value, Constant Score, Shoulder Pain and Disability Index (SPADI), quality of life (EuroQol–5 Dimensions–5 Level utility index), and radiologic outcomes between posture types using linear regression analyses. Of 681 included patients, 225 had type A posture, 326 type B, and 130 type C. Baseline group characteristics were comparable, although the type C group had a higher proportion of females (60% [A], 64% [B], 80% [C]) with lower abduction strength (0.7 kg [A], 0.6 kg [B], 0.3 kg [C]) and a slightly higher proportion with a Grammont design RTSA (41% [A], 48% [B], 54% [C]). There were significant adjusted differences in mean (±standard deviation) active flexion (A: 137° ± 21°; B: 136° ± 20°; C: 131° ± 19°) and passive flexion (A: 140° ± 19°; B: 138° ± 19°; C: 134° ± 18°), active (A: 127° ± 26°; B: 125° ± 26°; C: 117° ± 27°) and passive abduction (A: 129° ± 24°; B: 128° ± 25°; C: 121° ± 25°), SPADI (A: 81 ± 18; B: 79 ± 20; C: 73 ± 23), and pain (A: 1.2 ± 1.7; B: 1.6 ± 2.2; C: 1.8 ± 2.4) between posture types at 2 years (P ≤.035). A higher distalization shoulder angle was associated with better abduction in type C patients (P =.016). Type C patients showed a trend toward a higher complication rate (3.9% vs. 1.1% [A], 3.2% [B]) (P =.067). Type C posture influences the 2-year clinical outcome of RTSA patients in terms of worse flexion, abduction, SPADI, and pain. Scapulothoracic orientation and posture should be considered during the patient selection process, preoperative planning, and implantation of an RTSA. [ABSTRACT FROM AUTHOR]

Posterior shoulder dislocation frequently results in a centrally located impression fracture of the anterior humeral head, known as reverse Hill-Sachs lesion (RHSL). Depending on its size and location, the RHSL can lead to engagement with the posterior glenoid rim and subsequently redislocation of the shoulder joint. The objective of this study was to present the clinical and radiologic outcomes of anatomic reconstruction of the humeral articular surface using arthroscopically assisted disimpaction in patients with acute posterior shoulder dislocation and an engaging RHSL. As part of a retrospective analysis, 9 shoulders in 9 patients (1 female, 8 males) with engaging RHSL following acute posterior shoulder dislocation (type A2 according to the ABC classification) who underwent arthroscopically assisted disimpaction of the RHSL between 2016 and 2023 were identified. Eight patients were included, because 1 patient refused to participate. In all patients, a radiologic analysis of the RHSL was accomplished on preoperative and postoperative cross-sectional imaging including the alpha, beta, and gamma angle as well as depth measurements. The clinical examination included an assessment of the active range of motion, instability tests, and patient-reported outcome measures, such as the Western Ontario Shoulder Instability (WOSI) Index, the Constant Score, and the Subjective Shoulder Value (SSV). The mean follow-up period for all 8 patients was 34.4 ± 38 months (range: 6-102 months). The mechanisms of injury included falls (n = 6), traffic accident (n = 1), and convulsive episode (n = 1). The average time from injury to surgery was 6.8 ± 4.7 days (range: 2-16). Patient-reported outcomes at the final follow-up indicated an average WOSI Index of 77.8% ± 17%, a mean Constant Score of 88.3 ± 11 points, and a mean SSV of 87% ± 16%. None of the patients experienced recurrent dislocations during the follow-up period. Post-traumatically, the mean absolute defect depth was 8.4 ± 2.2 mm and the mean gamma angle was 115.8° ± 13°. In the radiologic follow-up, the RHSL depth measurements showed a significant reduction in the mean defect depth from 8.4 ± 2 mm to 1.2 ± 1 mm resulting in an average reduction of the RHSL by 7.1 mm (P <.001). In 3 of the 8 patients (37.5%), the RHSL was not identifiable any more at follow-up and in 5 patients barely identifiable. Arthroscopically assisted disimpaction of acute RHSLs leads to close to anatomic reduction of RHSL, achieving a stable shoulder and good clinical outcomes. [ABSTRACT FROM AUTHOR]

The ABC classification has recently been proposed as a comprehensive classification system for posterior shoulder instability (PSI). The purpose of this study was to analyze the comprehensiveness as well as inter-rater and intrarater reliability of the ABC classification. All consecutive patients presenting with unidirectional PSI from June 2019 to June 2021 were included in a prospective study. No patients were excluded, leaving a consecutive series of 100 cases of PSI in 91 patients. All recorded clinical and imaging data were used to create anonymized clinical case vignettes, which were evaluated twice according to the ABC classification at the end of the recruitment period in random sequential order by 4 independent raters (2 experienced shoulder surgeons and 2 orthopedic residents) to analyze the comprehensiveness as well as inter-rater and intrarater reliability of the ABC classification for PSI and to describe differences in characteristics among subtypes. Group A was defined as a first-time singular PSI event <3 months in the past regardless of etiology and is further subdivided into type 1 and type 2 depending on the occurrence of a subluxation (A1) or dislocation (A2). Group B comprises recurrent dynamic PSI regardless of time since onset and is further subdivided by the cause of instability into functional (B1) and structural (B2) dynamic PSI. Group C includes chronic static PSI with posterior humeral decentering that can be either constitutional (C1) or acquired (C2). None of the cases was deemed unsuitable to be classified based on the proposed system by the observers. After consensus agreement between the 2 expert raters, 16 cases were attributed to group A (8 type A1 and 8 type A2); 64, to group B (33 type B1 and 31 type B2); and 20, to group C (11 type C1 and 9 type C2). The expert raters agreed on the classification subtypes in 99% and 96% of the cases during the first rating and second rating, respectively (intraclass correlation coefficients [ICCs], 0.998 and 0.99, respectively). The intraobserver reliability was excellent for both raters. The beginners reached the same conclusion as the consensus agreement in 94% of the cases (ICC, 0.99) and 89% of the cases (ICC, 0.97) during the first round and 94% each (ICC, 0.97) during the second round. The intraobserver reliability was excellent for both beginners. Overall, discrepancies between raters were found between groups B1 and B2 (n = 14), groups B2 and C2 (n = 4), groups B1 and C1 (n = 1), and groups A1 and B2 (n = 1). In general, each subtype showed distinctive clinical and imaging characteristics that facilitated the diagnosis. The presented ABC classification for PSI is a comprehensive classification with a high reliability and reproducibility. However, a gradual transition and potential progression between the subtypes of PSI must be considered. The reliable distinction between different subtypes of PSI based on etiology and pathomechanism provides a standardized basis for future investigations on treatment recommendations. [ABSTRACT FROM AUTHOR]

To compare the 2-year clinical and radiological outcomes of an arthroscopic-assisted bidirectional stabilization procedure using a single low-profile (LPSB) or double-suture button (DSB) technique with additional percutaneous acromioclavicular (AC) cerclage fixation for patients with acute high-grade AC joint dislocation. This retrospective cohort study compared male patients aged between 18 and 56 years with acute high-grade AC joint dislocation fixed with either a LPSB or DSB technique. Patients were examined at least 24 months after surgery. Subjective Shoulder Value (SSV), Taft (TF), and Acromioclavicular Joint Instability (ACJI) scores were evaluated. Coracoclavicular difference, ossification, AC joint osteoarthritis, and dynamic posterior translation (DPT) were assessed on bilateral anteroposterior stress radiographs and modified Alexander views. The revision rate due to implant conflict and duration of surgery were reported. Group outcome differences were analyzed using standardized hypothesis tests. 28 patients aged 39.2 (LPSB) and 36.4 years (DSB) (P =.319; CI: −2.77–8.34) were eligible per cohort. The follow-up was 30.5 (LPSB) and 37.4 months (DSB) (P =.02; CI: −12.73−1.08). LPSB patients rated a significantly higher SSV (93.2% vs 81.9% [DSB]; P =.004). TF and ACJI scores were similar between the groups. Coracoclavicular difference markedly decreased from 12 mm to 3 mm for both cohorts (P <.001). Ossification was identified in over 85% in both cohorts (P =.160; CI −0.77–0.13) and osteoarthritis in 21.4% (LPSB) and 39.3% (DSB) (P =.150). Persistent DPT was found in around 30% for both cohorts (P =.561; CI −0.26–0.48). The revision rates were 0% (LPSB) and 7% (DSB) (P =.491). LPSB surgery was shorter (59.7 vs 71.5 mins [DSB]) (P =.011). The results of the LPSB and DSB techniques with additional percutaneous AC cerclage fixation showed comparable outcomes with excellent clinical and satisfactory radiological results. The assessment of the subjective patient satisfaction was in favor of the LPSB technique and no postoperative revision event was observed following this procedure. Level III, retrospective comparative therapeutic trial. [ABSTRACT FROM AUTHOR]

Rotator cuff lesions are a common shoulder pathology mainly affecting patients aged >50 years. This condition is accompanied by not only pain and loss of function but also impaired quality of life and psychological stress. A frequently employed treatment option is arthroscopic repair. But expectations regarding the outcome after surgery might differ between patients and surgeons and therefore lead to dissatisfaction on both sides. The aim of this study was to document patient expectations of a planned arthroscopic rotator cuff repair and compare the results with the assessment of shoulder surgeons. A total of 303 patients and 25 surgeons were involved in this study. Patients with partial- or full-thickness tear of the rotator cuff scheduled for arthroscopic repair were included in this study. Preoperatively, they were asked to fill out questionnaires inquiring sociodemographic data, scores of the underlying pathology, as well as expectations regarding the operation with regard to pain relief, gain of range of motion and strength, as well as the effect on activities of daily life, work, and sports. Furthermore, 25 surgeons were surveyed on what they think their patients expected using the same standardized questions. Among the patients, 43.9% considered gain of range of motion to be the most important goal after rotator cuff repair, followed by pain relief (30.6%) and gain of force (13.7%). Among the surgeons, 72% believed pain relief to be the most important for their patient followed by movement (20%) and strength (8%). When asked which parameter was the most important to achieve after operation, for patients, movement was on first place, pain second, and strength third. For shoulder specialists, the ranking was pain, movement, and strength. Surgeons significantly overrated pain relief when ranking against movement compared with their patients. The expectations of patients regarding their operation differ from the surgeon's assessment. Whereas gaining range of motion was more important for patients, surgeons clearly voted for pain relief. Different expectations should therefore be discussed within the pretreatment interview and taken into account when planning the right therapy. This might lead to better satisfaction on both sides. [ABSTRACT FROM AUTHOR]

In the treatment of anterior shoulder instability with glenoid bone loss, free bone graft transfers have proven to be a viable anatomic alternative to the commonly performed, nonanatomic Latarjet procedure. Implant-free fixation of the free bone grafts, in particular, has rendered excellent short- and long-term results. However, a drawback remains the source of the graft. We describe an arthroscopic bone block cerclage technique using a tricortical scapular spine autograft, which provides an anatomic arthroscopic glenoid reconstruction with the combined benefit of sparing the subscapularis, metal-free fixation, and intraregional donor site for autograft harvesting. [Display omitted] [ABSTRACT FROM AUTHOR]

Rotator cuff fatty infiltration (FI) is one of the most important parameters to predict the outcome of certain shoulder conditions. The primary objective of this study was to define a new computed tomography (CT)–based quantitative 3-dimensional (3D) measure of muscle loss (3DML) based on the rationale of the 2-dimensional (2D) qualitative Goutallier score. The secondary objective of this study was to compare this new measurement method to traditional 2D qualitative assessment of FI according to Goutallier et al and to a 3D quantitative measurement of fatty infiltration (3DFI). 102 CT scans from healthy shoulders (46) and shoulders with cuff tear arthropathy (21), irreparable rotator cuff tears (18), and primary osteoarthritis (17) were analyzed by 3 experienced shoulder surgeons for subjective grading of fatty infiltration according to Goutallier, and their rotator cuff muscles were manually segmented. Quantitative 3D measurements of fatty infiltration (3DFI) were completed. The volume of muscle fibers without intramuscular fat was then calculated for each rotator cuff muscle and normalized to the patient's scapular volume to account for the effect of body size (NV fibers). 3D muscle mass (3DMM) was calculated by dividing the NV fibers value of a given muscle by the mean expected volume in healthy shoulders. 3D muscle loss (3DML) was defined as 1 – (3DMM). The correlation between Goutallier grading, 3DFI, and 3DML was compared using a Spearman rank correlation. Interobserver reliability for the traditional 2D Goutallier grading was moderate for the infraspinatus (ISP, 0.42) and fair for the supraspinatus (SSP, 0.38), subscapularis (SSC, 0.27) and teres minor (TM, 0.27). 2D Goutallier grading was found to be significantly and highly correlated with 3DFI (SSP, 0.79; ISP, 0.83; SSC, 0.69; TM, 0.45) and 3DML (SSP, 0.87; ISP, 0.85; SSC, 0.69; TM, 0.46) for all 4 rotator cuff muscles (P <.0001). This correlation was significantly higher for 3DML than for the 3DFI for SSP only (P =.01). The mean values of 3DFI and 3DML were 0.9% and 5.3% for Goutallier 0, 2.9% and 25.6% for Goutallier 1, 11.4% and 49.5% for Goutallier 2, 20.7% and 59.7% for Goutallier 3, and 29.3% and 70.2% for Goutallier 4, respectively. The Goutallier score has been helping surgeons by using 2D CT scan slices. However, this grading is associated with suboptimal interobserver agreement. The new measures we propose provide a more consistent assessment that correlates well with Goutallier's principles. As 3DML measurements incorporate atrophy and fatty infiltration, they could become a very reliable index for assessing shoulder muscle function. Future algorithms capable of automatically calculating the 3DML of the cuff could help in the decision process for cuff repair and the choice of anatomic or reverse shoulder arthroplasty. [ABSTRACT FROM AUTHOR]

Rotator cuff tears (RCTs) remain a significant source of pain and disability in the shoulder. Although much work has been done in the study of the effects of rotator cuff tears on glenohumeral joint motion, much less has been done in understanding the effect of rotator cuff tearing on scapular motion or activation. It remains unknown whether scapular dyskinesis is causative or adaptive. The purpose of this study was to systematically review the literature to determine the relationship between rotator cuff tear presence and size on scapular motion, and if rotator cuff repair restored normal motion. A systematic review using PRISMA guidelines was accomplished to include all studies with biomechanical or clinical outcomes of scapular motion in the presence of RCTs. Studies were excluded if they involved shoulder arthroplasty, rotator cuff tendinopathy, or shoulder impingement without an RCT. From 530 initial references, 42 manuscripts were selected for full review and cross referenced. All studies were evaluated for inclusion and exclusion criteria. Sixteen studies including 335 rotator cuff tears were included in the final review. There were several findings of interest in the literature. First, although all studies demonstrated scapular dyskinesis, they did not report a consistent pattern of motion in the presence of an RCT. In general, scapular posterior tilt was decreased, and scapular upward rotation was increased, especially in large tears, but the literature was unclear as to whether this was a result of the RCT or an adaptive attempt to maintain elevation. Larger RCTs resulted in more pronounced scapular dysfunction, but there was significant variability within studies. Further, dyskinesis was confounded by pain with more abnormal movement in symptomatic vs. asymptomatic RCTs, the latter of which were not different from normal healthy controls. Four studies addressed the effect of RCT on scapular mechanics and found that repair consistently improved it compared to the normal side, but the time to normalization varied between 5 months and 2 years. Scapular motion is abnormal in the presence of an RCT, but the literature is inconsistent regarding a universally affected variable or consistent degree of scapular dysfunction in this setting. Furthermore, it remains unknown which changes are adaptive vs. pathologic. Understanding the relationship between rotator cuff tearing and scapular dyskinesis will require better biomechanical models that consider scapular dyskinesis in their design. [ABSTRACT FROM AUTHOR]

Posterior bone grafting represents an emerging therapeutic approach for addressing recurrent instability in the posterior shoulder, particularly when coupled with substantial glenoid bone loss. Although not as prevalent as anterior instability, recent years have witnessed the development of numerous open and arthroscopic bony reconstruction methods. A technical gold standard for posterior bone grafting remains undefined, leading to ongoing advancements in bone grafting techniques. In response to past challenges associated with screw fixation, metal-free arthroscopic fixation procedures have been introduced to the realm of bone grafting. These metal-free methods often entail intricate transglenoid drilling, which poses potential surgical complexities and risks to both posterior and anterior soft tissues, as well as neurovascular structures. Therefore, we introduce an arthroscopic approach to posterior bone grafting using PEEK (polyether ether ketone) anchors with interconnected sutures and a scapular spine autograft. This method overcomes previous hurdles by facilitating the restoration of the posterior glenoid bone stock with precise positioning and secure fixation of the tricortical scapular spine bone autograft. [Display omitted] [ABSTRACT FROM AUTHOR]

Due to the very limited information available during building design phase, lighting automation systems tend to follow pre-defined control curves and use normative default values. However, these are unlikely to reflect the wide variation in daily working hours and individual lighting preferences. Inadequate user modelling can result in missed energy and comfort targets, as well as insufficient light doses. Given that the building sector accounts for around one third of the world's energy demand, and lighting is one of the main consumers, a higher level of user representation in lighting control systems is essential to meet climate and environmental targets. The general practical applicability of user-centred concepts usually fails due to implementation, inadequate mapping of objectives to required parameters, availability of information and mapping in control systems. This comprehensive literature review of 160 articles evaluates the potential of individual control concepts in relation to the target criteria of lighting systems and identifies the necessary technical system components for greater applicability. The focus of the review is on daylight and artificial lighting and their application in office environments. From the results obtained, key elements for better implementation of user-centred concepts in lighting control were derived. These include zoned lighting, human-in-the-loop approaches, and sensor fusion. Post-occupancy evaluation, supported by social science methods, can help to capture relevant physiological and psychological parameters. The review concludes that post-occupancy optimisation of user-centred lighting applications offers great potential for overcoming previous design limitations and subsequently reducing performance gaps. • A bibliometric and manual evaluation of 123 research articles. • Technologies for detecting relevant user variables on KPIs are highlighted. • Tabular comparison of user-centred lighting concepts in the context of KPIs. • Zoning, post-occupancy evaluation and reinforcement learning are key technologies. [ABSTRACT FROM AUTHOR]

Static posterior subluxation of the humeral head is a pre-osteoarthritic deformity preceding posterior erosion in young patients. Its etiology remains unknown. The aim of this study was to analyze the differences in scapular morphology between young patients with pre-osteoarthritic static posterior subluxation of the humeral head and healthy controls with a centered humeral head. We performed a retrospective analysis of all patients with pre-osteoarthritic static posterior subluxation of the humeral head who were treated in our institution between January 2018 and November 2019. Fourteen shoulders in 12 patients were included in this study and then matched according their age, sex, and affected side with controls. Computed tomography images of both groups were compared in the standardized axial imaging plane for differences in scapular morphology. The following parameters were measured: glenoid version relative to the Friedman line and scapular blade axis, scapulohumeral and glenohumeral subluxation index, and neck angle, as well as glenoid and humeral offset. The patients in the subluxation group showed significantly higher scapulohumeral and glenohumeral subluxation indexes than controls (0.76 vs. 0.55 P <.0001] and 0.58 vs. 0.51 P =.016], respectively). The mean measurements of glenoid version according to the Friedman line and relative to the scapular blade axis were significantly higher in the subluxation group than in controls (19° vs. 4° P <.0001]and 14° vs. 2° P =.0002], respectively). The glenoid vault was significantly more anteriorly positioned with respect to the scapular blade axis in the subluxation group than in controls (neck angle, 166° vs. 173° P =.0003]; glenoid offset, 9.2 mm vs. 4.6 mm P =.0005]). The midpoint of the humeral head showed a posterior offset with respect to the scapular blade axis in the subluxation group, whereas controls had an anteriorly placed midpoint of the humeral head (–2 mm vs. 3.1 mm, P =.01). A higher scapulohumeral subluxation index showed significant correlations with an increased anterior offset of the glenoid vault (increased glenoid offset: r = 0.493, P =.008 and decreased neck angle: r = –0.554, P =.002), a posterior humeral offset (r = –0.775, P <.0001), and excessive glenoid retroversion measured by both methods (Friedman line: r = 0.852, P <.0001; scapular blade axis: r = 0.803, P <.0001). A higher glenohumeral subluxation index also correlated significantly with an increased anterior offset of the glenoid vault (increased glenoid offset: r = 0.403, P =.034; decreased neck angle: r = –0.406, P =.032) and posterior humeral offset (r = –0.502, P =.006). Young patients with pre-osteoarthritic static posterior subluxation of the humeral head have significant constitutional differences in scapular morphology in terms of an increased anterior glenoid offset, excessive glenoid retroversion, and increased posterior humeral offset in relation to the scapular blade compared with healthy matched controls. [ABSTRACT FROM AUTHOR]

Irreparable supraspinatus tendon tears are challenging to treat, especially in a young and high-demanding patient population. Whereas interposition tendon grafting and partial repair are limited by the quality of the remaining rotator cuff tendons and muscles, superior capsular reconstruction and subacromial spacers do not provide the active biomechanical principle of a contracting supraspinatus. The purpose of this technical note is to introduce an arthroscopic middle trapezius transfer below the acromion to replace the former supraspinatus unit. This technique might combine the benefits of both the static concepts seen with subacromial spacers or superior capsular reconstruction and dynamic concepts such as interposition grafting and partial repairs. Video 1 Step-by-step video illustration of an arthroscopic partial repair and middle trapezius transfer in a patient with an irreparable superior rotator cuff tear in the left shoulder. [ABSTRACT FROM AUTHOR]

The literature suggests implantation of the humeral component in reverse total shoulder arthroplasty (RTSA) in 0°-40° of retrotorsion without further specification. We hypothesized that optimal humeral component retrotorsion to avoid notching and gain balanced rotational capacity would depend on scapular position and posture. We investigated 200 shoulders in 100 patients with available whole-body computed tomography scans and created 3-dimensional models. Implantation of a humeral component in 20° of retrotorsion was simulated, and a correction angle (CA) to yield perfect opposition to the glenosphere was calculated. Patient-specific variables such as age, sex, posture, and scapular orientation parameters were correlated with this CA. Scapular orientation showed large interindividual differences. A highly significant correlation was seen between the CA and scapular internal rotation (R = 0.71, P <.001) and protraction (R = 0.39, P <.001). When the CA was adjusted for glenoid retroversion, the correlation coefficient of scapular internal rotation increased even further (R = 0.91, P <.001). Scapular internal rotation itself showed a correlation with thoracic kyphosis (R = 0.27, P <.001), protraction (R = 0.57, P <.001), tilt (R = 0.29, P <.001), and scapular translation (R = −0.23, P <.001). Scapular orientation and posture should be integrated into the determination process of humeral component retrotorsion in RTSA. In theory, implantation of the humeral component with increased retrotorsion leads to improved neutral opposition of the RTSA components in patients with extensive internal rotation of the scapula. On the basis of varying scapular internal rotation, we propose the distinction of 3 different posture types (A-C) for enhanced appraisal of scapulothoracic orientation. [ABSTRACT FROM AUTHOR]

The effect of patient age on functional improvement after arthroscopic rotator cuff repair (ARCR) is still a matter of debate. The purpose of this study was to evaluate the clinical midterm results after ARCR in patients who were 75 years or older at the time of surgery. A total of 31 shoulders in 30 patients older than 75 years at the time of surgery underwent ARCR for a degenerative full-thickness rotator cuff tear (RCT) between 2010 and 2016. Among those, 23 shoulders in 22 patients (74%) with a mean age at time of surgery of 77 ± 2 years (range, 75-82 years) were followed up after a mean of 7 ± 2 years (range, 3-9 years). Clinical assessment included the Western Ontario Rotator Cuff (WORC) index as well as patient satisfaction, the Subjective Shoulder Value (SSV), Simple Shoulder Test (SST), and the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score. Overall, patient satisfaction was excellent, as everybody stated to be very satisfied with the surgery. Neither any complication nor revision surgery occurred during the study period. At final follow-up, the mean WORC index was 88% ± 15%. The mean SSV was comparable between the affected shoulder (90% ± 15%) and the contralateral side (87% ± 15%) (P =.235). The mean SST score was 10 ± 2 points and the mean ASES score was 89 ± 17 points. ARCR for symptomatic RCTs without advanced muscle degeneration in patients older than 75 years at the time of surgery provided good clinical results and high patient satisfaction at midterm follow-up. [ABSTRACT FROM AUTHOR]

The aim of this study was to investigate the validity of implant sonication fluid cultures in the diagnosis of shoulder periprosthetic joint infection (PJI) compared with tissue culture. This was a retrospective case-control study analyzing all patients who underwent a revision surgery for any kind of suspected septic or aseptic event due to failed shoulder arthroplasty at our institution between July 2014 and December 2018. The diagnostic validity of implant sonication was analyzed on the basis of the last proposed definition criteria of the International Consensus Meeting and compared with standard tissue cultures. Of the 72 patients, a total of 28 (38.9%) were classified as infected. Of the 28 infected patients, 20 (71.4%) had an identified organism by tissue cultures, and Cutibacterium acnes was the most commonly isolated pathogen. The sensitivities of sonicate fluid (≥50 CFU/mL) and periprosthetic tissue culture for the diagnosis of periprosthetic shoulder infection were 36% and 61% (P =.016), and the specificities were 97.7% and 100% (P >.99), respectively. If no cutoff value was used in sonication culture, the sensitivity increased to 75% whereas the specificity dropped to 82%. Although there was no significant difference in sensitivity between tissue culture and the no-cutoff sonication fluid culture (61% vs. 75%, P =.125), the specificity of tissue culture was significantly higher (100% vs. 82%, P =.01). Tissue culture showed a higher sensitivity and specificity than implant sonication in the diagnosis of shoulder PJI and should remain the gold standard for microbiological diagnosis of shoulder PJI. [ABSTRACT FROM AUTHOR]

Irreparable rotator cuff tears are challenging to treat. Especially in younger patients without concomitant osteoarthritic changes, joint-preserving procedures are warranted. To date, no treatment guideline exists because none of the available techniques has shown superiority over the others, and long-term survivorship data are missing. The aim of the "Strings" is to provide an arthroscopic solution to anatomically reconstruct presumably irreparable rotator cuff tears by bridging the gap with multiple string-like tendon interposition autografts. [ABSTRACT FROM AUTHOR]

Pathologic activation pattern of muscles can cause shoulder instability. We propose to call this pathology functional shoulder instability (FSI). The purpose of this prospective study was to provide an in-detail description of the characteristics of FSI. In the year 2017, a total of 36 consecutive cases of FSI presenting to our outpatient clinic were prospectively collected. Diagnostic investigation included a pathology-specific questionnaire, standardized clinical scores, clinical examination, psychological evaluation, video and dynamic fluoroscopy documentation of the instability mechanism, as well as magnetic resonance imaging (MRI). In a final reviewing process, the material from all collected cases was evaluated and, according to the observed pattern, different subtypes of FSI were determined and compared. Based on the pathomechanism, positional FSI (78%) was distinguished from nonpositional FSI (22%). Controllable positional FSI was observed in 6% of all cases and noncontrollable positional FSI in 72%, whereas controllable and noncontrollable nonpositional FSI were each detected in 11% of the cases. The different subtypes of FSI showed significant differences in all clinical scores (Western Ontario Shoulder Instability Index: P =.002, Rowe Score: P =.001, Subjective Shoulder Value: P =.001) and regarding functional impairment (shoulder stability: P <.001, daily activities: P =.001, sports activities: P <.001). Seventy-eight percent had posterior, 17% anterior, and 6% multidirectional instability. Although several patients showed constitutional glenoid shape alterations or soft tissue hyperlaxity, only few patients with acquired minor structural defects were observed. FSI can be classified into 4 subtypes based on pathomechanism and volitional control. Depending on the subtype, patients show different degrees of functional impairment. The majority of patients suffer from unidirectional posterior FSI. [ABSTRACT FROM AUTHOR]

Purpose: To analyze the utility of arthroscopic biopsies for detection of periprosthetic infection in painful shoulder arthroplasty without objective signs of infection.Methods: A retrospective analysis of all patients who underwent a diagnostic arthroscopy for painful shoulder arthroplasty from June 2012 through July 2018 was performed. Patients with a subsequent revision shoulder arthroplasty after diagnostic arthroscopy were included. Arthroscopic tissue culture results were compared with the culture results of intraoperative tissue samples obtained at the time of open revision surgery. A minimum of 3 tissue samples from synovia and bone-prosthesis interface with signs of synovitis or abnormal appearance was routinely collected. Cases with 2 or more positive cultures for the same microorganism obtained at open revision surgery were considered as true presence of infection. The study protocol was reviewed and approved by the institutional ethics committee.Results: Twenty-three cases in 22 patients were included in this study. Five of these 23 cases were classified as true infection based on the samples obtained during open revision surgery, and 16 cases had a positive culture in diagnostic arthroscopy. Cutibacterium acnes was isolated in each case. Classifying any microbiologic growth in the arthroscopic biopsies as positive resulted in a sensitivity and negative predictive value of 100%, specificity of 39%, and positive predictive value of 31.3% for the detection of a periprosthetic shoulder infection (PPSI). If at least 2 positive samples with the same microbiologic growth in the arthroscopic biopsies were considered as positive, sensitivity and negative predictive value dropped to 80% and 94.4%, respectively, but the specificity and positive predictive value increased to 94.4% and 80%, respectively.Conclusions: Diagnostic arthroscopy is a useful diagnostic tool in patients with suspicion but no clear evidence of PPSI. Arthroscopically obtained tissue biopsies for culture offer a high sensitivity and specificity in the diagnosis of PPSI if at least 2 cultures positive for the same microorganism are considered as infection.Level Of Evidence: Level III. [ABSTRACT FROM AUTHOR]

The Latarjet and iliac crest bone graft transfer (ICBGT) procedures are competing treatment options for anterior shoulder instability with glenoid bone loss. In this bicentric prospective randomized study, 60 patients with anterior shoulder instability and glenoid bone loss were included and randomized to either an open Latarjet or open ICBGT (J-bone graft) procedure. Clinical evaluation was completed before surgery and 6, 12, and 24 months after surgery, including the Western Ontario Shoulder Instability index, Rowe score, Subjective Shoulder Value, pain level, satisfaction level, and work and sports impairment, as well as assessment of instability, range of motion, and strength. Adverse events were prospectively recorded. Radiographic evaluation included preoperative, postoperative, and follow-up computed tomography analysis. None of the clinical scores showed a significant difference between the 2 groups (P >.05). Strength and range of motion showed no significant differences except for diminished internal rotation capacity in the Latarjet group at every follow-up time point (P <.05). A single postoperative traumatic subluxation event occurred in 2 ICBGT patients and 1 Latarjet patient. The type and severity of other adverse events were heterogeneous. Donor-site sensory disturbances were observed in 27% of the ICBGT patients. Computed tomography scans revealed a larger glenoid augmentation effect of the ICBGTs; this, however, was attenuated at follow-up. The Latarjet and ICBGT procedures for the treatment of anterior shoulder instability with glenoid bone loss showed no difference in clinical and radiologic outcomes except for significantly worse internal rotation capacity in the Latarjet group and frequently noted donor-site sensory disturbances in the ICBGT group. [ABSTRACT FROM AUTHOR]

The purpose of this retrospective study was to evaluate the clinical and radiologic long-term results of medium-sized (Ellman grade 2) partial-thickness articular-sided supraspinatus tendon avulsion (PASTA) lesions treated arthroscopically. Of 22 patients, 18 (82%) were available for follow-up evaluation after a mean of 15 ± 2 years (range, 12-17 years). The mean age at time of surgery was 55 ± 9 years (range, 35-66 years). The Constant score was used as the primary outcome instrument to evaluate shoulder function. Furthermore, the University of California–Los Angeles shoulder score, the American Shoulder and Elbow Surgeons score, and the Subjective Shoulder Value were collected. The patients' satisfaction with the outcome was investigated. Tendon integrity of the affected shoulder at final follow-up was assessed with magnetic resonance imaging or ultrasound in 89% of the cohort. Overall, 94% of the patients were very satisfied or satisfied with the outcome. The average Constant score of the affected shoulder was 78 ± 21 points; the University of California–Los Angeles score, 31 ± 7 points; the American Shoulder and Elbow Surgeons score, 85 ± 24 points; and the Subjective Shoulder Value, 83% ± 21%. Radiologic evaluation showed progression to a full-thickness rotator cuff tear in 6% (1/16), and 60% of the patients (6/10) showed persistent signs of partial tearing evaluated by magnetic resonance imaging. At long-term follow-up, arthroscopic treatment of medium-sized PASTA lesions resulted in good clinical results together with a high satisfaction level of the patients. [ABSTRACT FROM AUTHOR]

Aberrant muscle activation patterns of periscapular and shoulder muscles can result in severe functional posterior shoulder instability (FPSI) without demonstrating underlying structural defects. Conventional physiotherapy as well as surgical interventions are often unsuccessful in the treatment of FPSI. We report a 13-year-old girl with rare, tic-like non-positional FPSI. 3 months of conventional conservative therapy failed and a rapid progression of the pathology resulted in an extremely limited shoulder function including repetitive posterior subluxations, chronic pain and stigmatization. The application of electric muscle stimulation ("EMS") immediately achieved a dislocation-free shoulder motion. After 6 weeks of treatment using an EMS therapy concept, the patient regained a stable shoulder motion for all retrained shoulder movements and a persistent effect of the treatment was observed at the 12 months' follow-up. However, rapid and uncoordinated shoulder movements still cause involuntary subluxations. Electric muscle stimulation ("EMS") is able to successfully re-establish glenohumeral stability even in patients with rare, tic-like non-positional FPSI. A sustained therapeutic effect that allows for a stable shoulder motion can be achieved after only a few therapeutic sessions. Die funktionelle hintere Schulterinstabilität (Polar-Typ III) wird durch eine Unterfunktion der Rotatorenmanschette und periskapulären Muskulatur verursacht. Chirurgische Eingriffe erzielen oftmals keine Besserung der Beschwerden und können zusätzliche Schmerzen und Funktionsverlust herbeiführen. Auch die konservative Therapie zeigt häufig keinen Erfolg. Anhand eines Fallbeispiels soll die Anwendung eines neuen Behandlungskonzepts mit elektrischer Muskelstimulation demonstriert werden. [ABSTRACT FROM AUTHOR]

Instability arthropathy (IA) is a major long-term concern in patients with anterior shoulder instability. This study investigated the association of glenoid morphology with the development of IA. The study included 118 patients with unilateral anterior shoulder instability and available bilateral computed tomography scans. Instability-specific information was obtained from all patients. The glenoid morphology of the affected shoulder was compared with the nonaffected contralateral side resembling the constitutional preinjury glenoid shape. Both shoulders were evaluated independently by 3 observers to assess the grade of IA according to a Comprehensive Arthropathy Rating (CAR) system. Associations between IA and the glenoid morphology parameters were investigated. The average glenoid retroversion (P <.001), glenoid depth (P <.001), glenoid diameter (P <.001), and the bony shoulder stability ratio (P <.001) of the affected shoulder were significantly reduced compared with the contralateral side due to bony defects in 79.6% of the patients. The CAR of the affected side was significantly higher (P <.001), with more osteophytes (P =.001) and more sclerosis and cysts (P <.001). Differences in CAR (Δ-CAR) correlated positively with the age at the time of the computed tomography scan (P <.001), age at the initial dislocation (P =.001), size of the glenoid defect (P =.005), and the contralateral glenoid depth (P =.011), glenoid diameter (P =.016), and bony shoulder stability (P =.029), and negatively with glenoid retroversion of the affected side (P =.027). Development of IA arthropathy is associated not only with the age of the patients but also with morphologic parameters of the glenoid, including glenoid defect size and the constitutional glenoid concavity shape. [ABSTRACT FROM AUTHOR]

Background The purpose of this study was to evaluate the long-term clinical and radiologic results after arthroscopic transosseous rotator cuff repair (TORCR). Methods A total of 69 patients with full-thickness supraspinatus tendon tears with or without infraspinatus tendon tears treated with arthroscopic TORCR by a single surgeon between 1998 and 2003 were included. Among them, 56 patients (81%) with a mean age of 58 ± 5 years (range, 42-70 years) were available for final follow-up examination after an average of 15 ± 2 years (range, 12-18 years). The Subjective Shoulder Value, Constant score (CS), University of California at Los Angeles score, and American Shoulder and Elbow Surgeons score were recorded. Magnetic resonance imaging (MRI) was performed to visualize tendon integrity in 66% of patients. Results At final follow-up, the mean CS was 84 ± 8 points; mean University of California at Los Angeles score, 33 ± 2 points; mean American Shoulder and Elbow Surgeons score, 92 ± 10 points; and mean Subjective Shoulder Value, 89% ± 17%. MRI revealed asymptomatic repair failure in 9 patients (27%). Moreover, 4 patients (7%) underwent revision surgery because of a symptomatic rerupture, resulting in an overall retear rate of 33%. Patients with intact repairs at final follow-up showed a significantly higher CS (P =.019) and abduction strength (P =.016) than patients with retears. Conclusion Arthroscopic TORCR for the treatment of full-thickness rotator cuff tears provided good clinical results 12 to 18 years after surgery. Cuff integrity on follow-up MRI scans had a positive effect on the clinical outcome. [ABSTRACT FROM AUTHOR]

Background The coracoid transfer procedure is commonly and successfully used to treat shoulder instability in young patients. However, there is concern that the outcome of this procedure might be inferior in older patients because of decreased bone graft quality and the potential concomitant presence of irreparable rotator cuff tears (RCTs). Methods All patients older than 40 years treated with a coracoid transfer procedure between 1998 and 2013 because of anterior shoulder instability were included. Surgical indication criteria were anterior glenoid bone defects and/or the presence of an irreparable yet functionally compensated RCT. Of 27 consecutive patients, 25 (93%) were followed up after an average of 9 years (2-15 years) clinically as well as by means of computed tomography scans. Mean age at surgery was 62 years (40-85 years). Results Nine patients (36%) were revised during the follow-up period. The average Western Ontario Shoulder Instability Index of the nonrevised patients was 556; Rowe score, 77; American Shoulder and Elbow Surgeons score, 75; Constant score, 65; and subjective shoulder value, 70%. The average preoperative instability arthropathy score of 0.7 increased to 2.0 ( P  < .001). An irreparable RCT showed no significant effect on the clinical outcome scores or revision rate but was associated with the development of cuff arthropathy ( R  = 0.89; P  = .01). An increased grade of preoperative cuff arthropathy was associated with a higher revision rate ( R  = 0.55; P  = .04). Conclusion The coracoid transfer procedure represents a joint-preserving treatment option for anterior shoulder instability in older patients with glenoid bone defects or concomitant irreparable yet functionally compensated RCTs. However, bone graft– and hardware-related complications as well as required revision operations are frequent. [ABSTRACT FROM AUTHOR]

Purpose: To analyze the effect of lack of standardization on the reliability of current measurement techniques for glenoid bone loss in clinical practice.Methods: Ten consecutive patients with anterior glenoid bone loss due to recurrent anterior shoulder instability and available computed tomographic (CT) scans of the affected shoulder were included in this study. One hundred seventy 3-dimensional en-face view images of the 10 glenoids with up to 20° degrees of tilt in the anterior, posterior, superior, and inferior direction were rendered. Three independent observers first identified the en-face view images and subsequently performed measurements of the defect surface and diameter as well as the glenoid surface and diameter on all 170 images. Measurements were completed based on the conventional best-fit circle technique using the edge of the visible glenoid bone as reference and additionally based on the so-called spoon technique, which places the best-fit circle on the edge of the visible glenoid concavity.Results: The overall agreement regarding en-face view image selection between the observers was 30% (K-alpha = 0.10, 95% confidence interval 0.02-0.22). Tilt of the en-face view in any direction resulted in significant alterations of all 4 measurement parameters as well as the relative defect area and diameter (P < .05). The conventional and the spoon techniques rendered significantly different results regarding all 4 measurement parameters as well as the relative defect area (P < .05).Conclusion: Impreciseness of scapula positioning for creation of an en-face view of the glenoid as well as varying best-fit circle placement significantly alter glenoid defect size measurement results.Clinical Relevance: Because the glenoid defect size plays an important role in the choice of treatment for anterior shoulder instability, measurement techniques need to be as precise as possible. [ABSTRACT FROM AUTHOR]

Purpose: To assess the iliac crest bone graft (ICBG) position in the en-face view and axial plane comparing arthroscopic with open procedures.Methods: A total of 40 consecutive patients with recurrent anterior shoulder instability and glenoid bone loss over 10% treated by 2 independent orthopaedic departments were included. Two independent observers analyzed preoperative and immediate postoperative computed tomography scans of 20 open (group O) and 20 arthroscopic (group A) procedures. Defect and ICBG characteristics of the J-shaped graft in the en-face view and axial plane were manually assessed by multiplanar reconstructed computed tomography scans. Variances in terms of graft positioning were analyzed.Results: No significant variances in arthroscopic graft positioning were observed. The graft position in the en-face view was comparable in both groups, with the superior extent of the arthroscopic graft (40° ± 9° [inferior extent, 139° ± 16°]) lying significantly higher than the superior extent in group O (50° ± 13°, P = .005 [inferior extent, 147° ± 21°; P = .178]). The covered glenoid defect size was above 95% (98% ± 1% in group O vs 95% ± 2% in group A, P = .001). The arthroscopic graft in the axial plane showed a significantly steeper impaction angle (34.8° ± 7.8° vs 26.9° ± 9.9°, P = .010), with a significantly increased medial offset compared with group O (6.6 ± 1.7 mm vs 5.4 ± 1.3 mm, P = .024). The mediolateral step formation, however, was not significantly different (2.9 ± 1.1 mm in group A vs 3.2 ± 0.8 mm in group O, P = .289). The interobserver reliability was very good for all measurements (R = 0.969; 95% confidence interval, 0.965-0.972).Conclusions: Positioning of the arthroscopic ICBG in the en-face view and axial plane is comparable to that of the open technique. Good glenoid defect coverage and glenoid concavity reconstruction can be achieved with the arthroscopic technique. The main difference compared with the open procedure is the significantly steeper impaction angle.Level Of Evidence: Level III, case-control study. [ABSTRACT FROM AUTHOR]

Purpose To determine whether anterior shoulder instability is associated with an inherent deficiency of the bony glenoid concavity, which results in a reduced bony shoulder stability ratio (BSSR). Methods In this case-control study, we searched the institutional database for patients treated for unilateral recurrent anterior shoulder instability. We included 30 consecutive patients with atraumatic instability, 30 consecutive patients with traumatic instability, and 36 matched healthy controls, for a total of 96 shoulders. Computed tomography images of the unaffected shoulders of the instability patients were compared with images of the ipsilateral shoulders of age- and sex-matched healthy controls for differences in glenoid morphology. By use of a mathematical formula based on Pythagorean trigonometric identities, the mean BSSRs of the different groups were calculated and compared. Validation of the formula was accomplished by finite element analysis. Results The mean BSSR of atraumatic instability patients was 17.9% ± 8.5% and therefore significantly lower than the mean BSSR of 31.1% ± 7.5% of the control group (13.2%; 95% confidence interval [CI], 9.1% to 17.4%; P < .001). The mean BSSR of the traumatic instability group was higher, at 23.9% ± 8.5% ( P = .007), but still showed a deficit of 7.2% (95% CI, 2.8% to 11.7%; P = .002) compared with controls. The atraumatic instability group showed a mean reduction of 0.9 mm (95% CI, 0.6 to 1.1 mm; P < .001) in concavity depth and a decrease of 2.9° (95% CI, 0.4° to 5.3°; P = .021) in concavity retroversion, whereas the traumatic instability patients had a reduction of 0.4 mm (95% CI, 0.1 to 0.8 mm; P = .006) in concavity depth. Neither of the instability groups differed significantly from their respective controls in terms of glenoid concavity diameter, head radius, or glenoid vault morphology. Conclusions Anterior shoulder instability is associated with an inherent flattening of the bony glenoid concavity, which significantly decreases the BSSR. The deficiency appears to be more pronounced in patients with atraumatic instability than in patients with traumatic instability. Level of Evidence Level III, case-control study. [ABSTRACT FROM AUTHOR]

Background Treatment of young, active patients with symptomatic glenohumeral osteoarthritis, excessive glenoid retroversion, and static posterior humeral subluxation is challenging. Correction of glenoid retroversion may lead to centric loading and perhaps recenter the humeral head. We describe the functional and radiologic outcomes after corrective osteotomy of the glenoid in this population of patients. Materials and methods In this retrospective study, we included 10 shoulders (8 patients) that were observed for a mean of 33.4 months (range, 24-52 months) after corrective osteotomy of the glenoid. The mean age at surgery was 41.5 years (range, 24-51 years). On standardized axial images, glenoid retroversion and posterior static humeral subluxation were measured preoperatively and postoperatively and at the final follow-up. At final follow-up, anterior and posterior axial radiographs were performed to determine humeral head position in different arm positions. Clinical follow-up included Constant-Murley score, subjective shoulder value, and patient satisfaction. Results The mean Constant-Murley score improved significantly from 45.1 points (range, 24-71) to 64.1 points (range, 44-92; P  < .001). The average degree of anterior flexion improved significantly from 117° (range, 50°-160°) to 143° (range, 110°-180°; P  = .006). The mean glenoid retroversion changed from 16° (range, 11°-31°) preoperatively to 5° (range, 13° anteversion–16° retroversion; P  = .003) at the final follow-up. The mean posterior static subluxation of the humeral head changed from 5 mm (range, 0-10 mm) preoperatively to 6 mm (range, 0-14 mm; P  = .259) at the final follow-up. Conclusions This study shows that posterior open wedge osteotomy of the glenoid neck provides excellent correction of glenoid retroversion. [ABSTRACT FROM AUTHOR]

This article presents some results from a large monitoring campaign performed in 22 buildings around the world as part of International Energy Agency (IEA) Task 50 “Advanced lighting solutions for retrofitting buildings”. This article mainly addresses the work of Subtask D, which aims to demonstrate sound lighting retrofit solutions in a selection of representative, typical Case Studies. In order to evaluate the Case Studies, a monitoring protocol was developed to assess the overall lighting performance taking into consideration: 1) Energy use, 2) Retrofit costs, 3) Photometric assessment, and 4) User assessment. The monitoring was carried out from June 2014 to December 2015 in 22 non-residential buildings in ten countries. This article presents results from selected Case Studies, drawing conclusions regarding retrofit solutions as well as reflecting on methodological procedures for the measurements and data collection. Measured data as well as key conclusions from Subtask D will be summarized in an electronic web and portable sourcebook at the end of the IEA Task 50 (December 2015), which will be freely available through the Internet. [ABSTRACT FROM AUTHOR]

Background The purpose of this study was to analyze the pathomorphology of proximal humeral fractures to determine relevant and reliable parameters for fracture classification. Methods A total of 100 consecutive acute proximal humeral fractures in adult patients were analyzed by 2 non-independent observers from a single shoulder department using a standardized protocol based on biplane radiographs and 3-dimensional computed tomography scans. A fracture classification system based on the most reliable key features of the pathomorphologic analysis was created, and its reliability was tested by 6 independent shoulder experts analyzing another 100 consecutive proximal humeral fractures. Results The head position in relation to the shaft (varus, valgus, sagittal deformity) and the presence of tuberosity fractures showed a higher interobserver reliability (κ > 0.8) than measurements for medial hinge, shaft, and tuberosity displacement, metaphyseal extension, fracture impaction, as well as head-split component identification (κ < 0.7). These findings were used to classify nondisplaced proximal humeral fractures as type 1, fractures with normal coronal head position but sagittal deformity as type 2, valgus fractures as type 3, varus fractures as type 4, and fracture dislocations as type 5. The fracture type was further combined with the fractured main fragments (G for greater tuberosity, L for lesser). Interobserver and intraobserver reliability analysis for the fracture classification revealed a κ value (95% confidence interval) of 0.700 (0.631-0.767) and 0.917 (0.879-0.943), respectively. Conclusion The new classification system with emphasis on the qualitative aspects of proximal humeral fractures showed high reliability when based on a standardized imaging protocol including computed tomography scans. [ABSTRACT FROM AUTHOR]

Background Because of detachment of the pectoralis minor and variation of the vector of the conjoint tendons, we hypothesized that the Latarjet procedure may alter scapular position and motion. The purpose of this study was to evaluate scapular position and motion in patients who underwent a Latarjet or a modified iliac crest bone graft transfer (ICBGT) procedure (J-bone graft). Methods Forty-six consecutive patients treated for recurrent anterior shoulder dislocation between 2010 and 2012 were retrospectively enrolled. Twenty-three were treated with a Latarjet and 23 with an ICBGT procedure. Twenty Latarjet and 20 ICBGT patients were available at a mean follow-up of 20 months (min, 12; max, 60). We recorded the Western Ontario Instability Index, the Rowe Score, and the Subjective Shoulder Value. Scapulothoracic position was studied according to the dyskinesis yes/no method. Intraobserver and interobserver reliability of the dyskinesis assessment was assessed. Results Intraobserver and interobserver reliability of scapula dyskinesis assessment was high (Latarjet: intratester, κ = 0.84; intertester, κ = 0.75; ICBGT: intratester, κ = 0.78; intertester, κ = 0.71). Scapular dyskinesis was observed after 5 of 20 Latarjet and after 0 of 20 ICBGT procedures ( P = .047). Patients with dyskinesis had lower scores (Western Ontario Instability Index, P = .043; Rowe, P = .047; Subjective Shoulder Value, P = .046), but no statistically significant difference was found between the Latarjet and ICBGT groups. Two of the 5 scapular dyskinesis patients reached the SICK (Scapular malposition, Inferior medial scapular winging, Coracoid tenderness, and scapular dysKinesis) scapula syndrome definition. Conclusions Scapular dyskinesis was found in 5 of 20 patients who underwent a Latarjet procedure. Dyskinesis may be related to the detachment of the pectoralis minor, and variation of the vector and the working length of the coracobrachialis and the short head of the biceps. [ABSTRACT FROM AUTHOR]

In the field of lighting and daylighting, standard monitoring procedures to assess the overall performance of retrofit projects are scarce. Nevertheless the access to monitored data is crucial to assess whether daylighting or electric lighting systems deliver the expected performance in terms of cost-effectiveness and energy efficiency. In order to bridge this gap, a monitoring protocol is under development as part of the International Energy Agency – Solar Heating and Cooling Programme (IEA-SHC) Task 50 ‘Advanced Lighting Solutions for Retrofitting Buildings’. The protocol focuses on lighting and/or daylighting (façade or roof) retrofit in the non-residential building stock. It covers four key aspects: energy efficiency, costs, quality of the lighting environment and user satisfaction. The main features of this protocol are presented in this paper, along with some lessons learned from the ongoing application on selected case studies. [ABSTRACT FROM AUTHOR]

Background: The presence of a significant bony defect in anterior shoulder instability cases warrants glenoid reconstruction surgery typically by means of an autograft. Some surgeons use the same graft techniques even in the absence of a significant bony defect, thus augmenting the glenoid surface. The goal of this study is to investigate the clinical and computed tomography–radiologic outcome after glenoid augmentation surgery. Methods: Between 2006 and 2011, 11 patients with recurrent anterior shoulder instability and glenoid bone loss of 5% or less were treated with an iliac crest autograft. Of the patients, 9 were available for follow-up at a mean of 34.6 months (range, 12 to 80 months), including apprehension testing, Western Ontario Shoulder Instability Index, Rowe score, Simple Shoulder Value, and 3-dimensional computed tomography examination. Results: The mean Rowe score achieved was 85.0 points (range, 51 to 100 points); Simple Shoulder Value, 80.5 points (range, 30 to 100 points); and Western Ontario Shoulder Instability Index, 373.5 points (range, 61 to 878 points). Two patients reported a recurrence of instability, and one featured a positive apprehension test. The mean glenoid surface area was 96.5% (95% confidence interval [CI], 95.5% to 97.4%) preoperatively, increased after graft implantation to 119.5% (95% CI, 105.6% to 133.3%), and decreased to 102.8% (95% CI, 98.6% to 107.1%) at follow-up, concordant to an intact glenoid surface area. From preoperatively to follow-up, the mean increase in glenoid surface area was 6.4% (95% CI, 2.1% to 10.6%; P = .008); in concavity diameter, 2.0 mm (95% CI, ?0.9 to 4.9 mm; P = .168); in concavity depth, 0.9 mm (95% CI, 0.3 to 1.5 mm; P = .005); and in concavity retroversion, 2.4° (95% CI, ?1.2° to 6.1°; P = .178). Conclusion: Because of anatomic bony remodeling processes, glenoid augmentation surgery seems to be subject to extensive graft osteolysis and, consequently, unsatisfactory clinical outcome in terms of stability in some cases. [Copyright &y& Elsevier]

Background: Recurrence after first-time traumatic anterior shoulder dislocation is frequent. The prevalence of glenoid bone loss ranges from 41% after a first-time dislocation to 86% with recurrent dislocation. Postoperative recurrence can occur in up to 10% of cases. Thus, misdiagnosis of bony glenoid rim lesions has been assumed a major cause for failure. We evaluated the interobserver reliability of radiologic diagnoses after first-time traumatic shoulder dislocation based on radiographs and computed tomography (CT) images. Methods: Digital radiographs before and after reduction and CT images after reduction of 20 patients with a first-time shoulder dislocation were assessed by 6 observers. It was recorded whether they diagnosed a lesion at the greater tuberosity, a lesion at the glenoid rim, a Hill-Sachs lesion, or any other skeletal pathology. The average agreement among the investigators was evaluated, and radiographic diagnoses were compared with those based on CT images. Results: Of the 10 cases that presented with a glenoid rim fracture, each investigator had overlooked at least 1 fracture (range, 1-4) on the radiographs. No investigator had diagnosed all 8 Hill-Sachs lesions on the presented images. The average overall agreement among the investigators and corresponding sensitivity and specificity were calculated. Agreement of diagnoses based on radiographs with those based on CT images was lowest for glenoid rim fractures and Hill-Sachs lesions. Conclusion: Radiographs seem inferior to CT scans for assessing osseous lesions especially at the glenoid rim. We suggest performing a CT scan of the shoulder after primary dislocation to apply the correct treatment early and potentially avoid further dislocations. [Copyright &y& Elsevier]