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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.)

The "postage stamp fracture" is an anterior glenoid rim fracture following arthroscopic repair of a Bankart lesion. Often occurring at the time of an acute trauma, a fracture line propagates though the previous Bankart repair anchor sites, resulting in recurrent anterior instability of the glenohumeral joint. The resultant glenoid rim fracture edge gives a similar appearance as the edge of a stamp, with the osseous edge having the classic "perforation" pattern. When patients present with a postage stamp fracture, even in the setting of subcritical glenoid bone loss, we believe that additional soft-tissue stabilization procedures and/or fracture fixation pose a significant risk of failure. In our opinion, a Latarjet procedure is recommended in a majority of patients with a postage stamp fracture for restoration of glenohumeral stability. The procedure offers a reliable, reproducible surgical intervention that controls for many of the factors that can make arthroscopic revision unreliable, such as poor bone quality, adhesions, labral degeneration, and bone loss. Here, we outline our preferred surgical technique to restore glenohumeral stability using the Latarjet procedure for a patient with a postage stamp fracture., (© 2022 The Authors.)

Background: Anterior shoulder instability (ASI) is a frequently encountered pathology. Patients with a history of ASI have an increased rate of developing glenohumeral osteoarthritis and becoming candidates for shoulder arthroplasty. This systematic review aims to synthesize outcomes for patients undergoing shoulder arthroplasty with a history of ASI., Methods: A comprehensive literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) using PubMed, Embase, OVID Medline, Scopus, CINAHL, Web of Science, and Cochrane databases for studies evaluating the impact of prior ASI on total shoulder arthroplasty (TSA), reverse TSA, and/or hemiarthroplasty outcomes, with a minimum follow-up of 12 months. Studies were graded by level of evidence and data concerning patient demographics and outcomes were extracted., Results: Sixteen articles met the inclusion criteria, including 596 patients (413 male, 181 female). The average age of the control and prior ASI groups were 57.5 and 57.0 years, respectively. Overall, 251 patients were treated operatively, 132 nonoperatively, and 213 were controls without a history of prior ASI. Shoulder arthroplasty techniques included TSA (436 shoulders), reverse TSA (130 shoulders), and hemiarthroplasty (14 shoulders). Prior anterior stabilization management included soft tissue repair, bony augmentation, and nonoperative treatment. Almost all studies reported no significant difference in subjective and functional arthroplasty outcomes between control and prior ASI groups, or between patients with prior ASI treated nonoperatively vs. surgically., Conclusion: Shoulder arthroplasty in the setting of prior ASI results in improved subjective and functional outcome scores that are comparable to patients without a history of instability., (© 2022 The Authors.)

Fresh distal tibia allograft (DTA) has been gaining popularity among surgeons as an anatomic reconstruction option for the treatment of significant glenoid bone loss. Fresh DTA results in a clinically stable joint with excellent clinical outcomes and minimal graft resorption, and it has similar outcomes as the Latarjet procedure. Proper graft preparation and fixation are critical to ensuring optimal outcomes. The purpose of this Technical Note is, therefore, to describe our updated technique for DTA preparation that highlights precise cutting anatomy, sizing options, and use of orthobiologics to optimize distal tibia graft union to the native glenoid surface.

Recurrent shoulder instability with glenoid bone deficiency remains an increasing risk for failed shoulder stabilization surgery. Numerous free bone block procedures for primary treatment of anterior shoulder stability have been introduced as an alternative for the Latarjet procedure, including both autografts and allografts. Among such options is the fresh distal tibial allograft (DTA), a dense weightbearing bone without donor site morbidity and excellent conformity to the native glenoid. The aim of this Technical Note is therefore to describe our surgical technique for use of fresh DTA as a free bone block choice in the setting of primary anterior glenoid reconstruction in a patient with recurrent shoulder instability.

Hypothesis and Background: There is no differences in abduction, internal rotation, or external rotation strength after reverse total shoulder arthroplasty (rTSA) with or without subscapularis repair. Repair of the subscapularis can be effective in the setting of rTSA. However, consensus has yet to be reached on whether postoperative strength after rTSA differs based on subscapularis management. The purpose of this review is to evaluate shoulder strength outcomes after rTSA with and without subscapularis tendon repair., Methods: A comprehensive literature review was conducted using the key terms "subscapularis" AND "reverse total shoulder arthroplasty" AND "muscle strength" in PubMed, Embase, Web of Science, Cochrane Reviews and Trials, and Scopus. Original, English-language studies evaluating shoulder strength outcomes after rTSA published from January 1, 2000, to present were evaluated. Strength outcomes reported included abduction strength (kg) and internal rotation strength (kg) using an electric spring balance and external rotation strength (lb) using a handheld dynamometer. Heterogeneity of data in the included studies did not allow for meta-analysis., Resuts: The search yielded 4253 unique results, which were screened for inclusion according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Two articles met eligibility criteria and were included in the final full-text review. A total of 267 shoulders were represented, 111 with subscapularis repair and 156 without subscapularis repair. No significant differences in abduction ( P  = .39), internal rotation ( P  = .09), and external rotation ( P  = .463) strength were observed between subscapularis repair and nonrepair groups., Conclusion: There were no differences in abduction, internal rotation, or external rotation strength after rTSA with or without subscapularis repair. The literature on postoperative strength outcomes after rTSA is limited, and further study in this area is warranted.

Background: Coracoid transfer procedures have been increasingly utilized for anterior shoulder instability with associated glenoid bone loss 1 . Unfortunately, in a young, high-risk patient population, these procedures can fail secondary to traumatic causes but also because of bone graft resorption or malposition or hardware prominence, among other reasons 2 . In active patients, revision glenoid reconstruction may be indicated. Distal tibial osteoarticular allografts have been utilized to treat recurrent anterior shoulder instability for several years 3 . Recently, this technique has been applied to cases of failed Latarjet procedures in order to reconstitute the absent glenoid bone stock 4 , demonstrating excellent clinical outcomes at a minimum follow-up of 3 years 2 ., Description: The procedure is performed in the beach-chair position. First, a diagnostic shoulder arthroscopy is performed to assess the cartilaginous surfaces, to examine the Hill-Sachs lesion and its engagement, and to remove any loose bodies. Next, the prior deltopectoral incision is developed, and the deltopectoral interval is utilized to visualize the subscapularis. The subscapularis is split at the junction of its upper two-thirds and lower one-third. Careful dissection is used to develop the subscapularis split from lateral to medial because the prior coracoid transfer affects the native neurovascular anatomy medially. If substantial coracoid bone remains from the previous transfer, a conjoined tendon tenotomy can be performed to further aid in visualization 5 . Next, any associated hardware is removed, and the coracoid bone remnant is removed. The glenoid defect is sized, and the osseous glenoid bed is prepared. A fresh-frozen distal tibial allograft is then fashioned, washed of marrow elements, and enhanced with platelet-rich plasma before being fixed to the glenoid with use of 2 cortical screws in a lagged fashion. The capsule and subscapularis split are then closed to complete the repair., Alternatives: Alternatives to revision glenoid reconstruction with distal tibial allograft include reconstruction with an iliac crest autograft, distal clavicular autograft, revision coracoid transfer, or nonoperative treatment through rehabilitation and activity modification., Rationale: In cases of failed coracoid transfer for anterior shoulder instability with associated glenoid bone loss, distal tibial allograft is the superior revision treatment option for several reasons: it allows for an osteoarticular graft, offers flexibility in terms of graft size, and requires no donor-site morbidity. Distal tibial allograft allows active, high-risk patients to have restored and maintained stability with low complication and graft-resorption rates 2 ., Expected Outcomes: Glenoid reconstruction with a distal tibial allograft is associated with improved patient-reported outcomes from preoperatively, as well as recurrence rates of <10% and graft-union rates of >90% 2 ., Important Tips: Initiating the procedure with an arthroscopic evaluation allows for a complete diagnostic examination, including the Hill-Sachs lesion, articular cartilage, and rotator cuff, as well as removal of any loose bodies, which are frequently present and sometimes difficult to visualize and access during the open procedure.A subscapularis split allows for maintenance of the subscapularis insertion on the lesser tuberosity as well as minimal disruption of the muscle fibers.A conjoined tendon tenotomy can provide improved access for hardware removal if the coracoid bone graft from the prior transferred coracoid is present.A 5.5-mm arthroscopic burr is utilized to decorticate the anterior aspect of the glenoid, which facilitates graft union because the burr allows built-in suction capability during constant irrigation, minimizing the possibility of heat necrosis.The distal tibial allograft is thoroughly lavaged to remove residual marrow elements prior to insertion in order to diminish potential immunogenicity.Two solid, fully threaded 3.5-mm cortical screws are placed in a lagged fashion to fix the distal tibial allograft to the glenoid., Competing Interests: Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work and “yes” to indicate that the author had other relationships or activities that could be perceived to influence, or have the potential to influence, what was written in this work (http://links.lww.com/JBJSEST/A317)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)