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Background: To compare clinical outcomes following lateralized reverse shoulder arthroplasty (RSA) versus RSA with latissimus dorsi transfer (LDT) in patients with poor preoperative active external rotation (ER)., Methods: We performed a systematic review per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We queried PubMed/Medline, Embase, Web of Science, and Cochrane databases to identify articles reporting clinical outcomes of RSA with LDT or lateralized RSA alone performed in patients with preoperative ER ≤0°. Our primary outcomes were active ER, active forward elevation (FE), Constant score, and the incidence of complications., Results: We included 12 RSA with LDT studies with 188 shoulders and 4 lateralized RSA without transfer studies with 250 shoulders. Mean preoperative ER in RSA with LDT was -14°, while mean preoperative ER in lateralized RSA alone was -11°. Lateralized RSA alone was associated with superior postoperative ER (28° vs. 22°, P=0.010) and Constant score (69 vs. 65, P=0.014), but similar postoperative FE (P=0.590). Pre- to postoperative improvement in ER and FE was similar between cohorts. RSA with LDT had a higher incidence of nerve-related complications (2.1% vs. 0%) and dislocation (2.8% vs. 0.8%) compared to lateralized RSA alone., Conclusions: Both RSA with LDT and lateralized RSA are reliable options to restore ER in patients with significantly limited preoperative ER. Our analysis suggests that lateralized RSA alone is superior to RSA with LDT in patients with either a medialized or lateralized implant design and confers a lower risk of complications, particularly nerve injury and dislocation. However, the addition of an LDT may still be indicated in certain patient populations with very severe ER loss. Level of evidence: IV.

Congenital pseudarthrosis of the clavicle remains remarkably rare, and the pathogenesis is unclear, but orthopaedic surgeons should be prepared to make this diagnosis and confident in the outcomes of open reduction and internal fixation with grafting. A 15-year-old female softball player presented with anterior shoulder pain during softball activities, with no precipitating trauma. She was diagnosed with congenital pseudarthrosis of the clavicle and initially treated conservatively. Following no improvement with physical therapy, home therapy, rest, and anti-inflammatory drugs, she was treated with open reduction and internal fixation of the clavicle with iliac crest autograft and demineralized bone matrix allograft., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background: This study sought to determine if preoperative forward elevation (FE) weakness affects outcomes of anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA) for patients with rotator cuff-intact glenohumeral osteoarthritis (RCI-GHOA)., Methods: A retrospective review of a single institution's prospectively collected shoulder arthroplasty database was performed between 2007 and 2020, including 333 aTSAs and 155 rTSAs for primary RCI-GHOA with a minimum 2-year follow-up. Defining preoperative weakness as FE strength ≤4.9 lb (2.2 kg), three cohorts were matched 1:1:1 by age, sex, and follow-up: weak (n=82) to normal aTSAs, weak (n=44) to normal rTSAs, and weak aTSAs (n=61) to weak rTSAs. Compared outcomes included range of motion, outcome scores, and complication and revision rates at latest follow-up., Results: Weak aTSAs and weak rTSAs achieved similar postoperative outcome measures to normal aTSAs and normal rTSAs, respectively (P>0.05). Compared to weak rTSAs, weak aTSAs achieved superior postoperative passive (P=0.006) and active external rotation (ER) (P=0.014) but less favorable postoperative Shoulder Pain and Disability Index (P=0.032), American Shoulder and Elbow Surgeons (P=0.024), and University of California, Los Angeles scores (P=0.008). Weak aTSAs achieved the minimal clinically important difference and substantial clinical benefit at a lower rate for abduction (P=0.045 and P=0.003) and FE (P=0.011 and P=0.001). Weak aTSAs had a higher revision rate (P=0.025) but a similar complication rate (P=0.291) compared to weak rTSAs., Conclusions: Patients with RCI-GHOA and preoperative FE weakness obtain postoperative outcomes similar to patients with normal preoperative strength after either aTSA or rTSA. Preoperatively, weak aTSAs achieved greater ER but lower rates of clinically relevant improvement in overhead motion compared to weak rTSAs. Level of evidence: III.

Background: This systematic review and meta-analysis sought to compare the clinical outcomes after proximal humerus reconstruction with a reverse allograft-prosthetic composite (APC) versus reverse endoprosthesis., Methods: Per PRISMA guidelines, we queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles reporting clinical outcomes of reverse APC or reverse endoprosthesis reconstruction of the proximal humerus for massive bone loss secondary to tumor, fracture, or failed arthroplasty. We compared postoperative range of motion, outcome scores, and the incidence of complications and revision surgery., Results: Of 259 unique articles, 18 articles were included (267 APC, 260 endoprosthesis). There were no significant differences between the APC and endoprosthesis cohort for postoperative forward elevation ( P  = .231), external rotation ( P  = .634), ASES score ( P  = .420), Constant score ( P  = .414), MSTS ( P  = .815), SST ( P  = .367), or VAS ( P  = .714). Rate of complications was 15% (31/213) in the APC cohort and 19% (27/144) in the endoprosthesis cohort. The rate of revision surgery was 12% after APC cohort and 7% after endoprosthesis. APC-specific complications included a 10% APC nonunion/malunion/resorption rate and 6% APC fracture/fragmentation rate., Discussion: Reverse APC and endoprosthesis are reasonable options for proximal humerus reconstruction. APC carries additional risks for complications, warranting evaluation of patients' healing capacity and surgeon experience., Level of Evidence: Level IV; Systematic Review., Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-024-01248-7., Competing Interests: Conflict of interestMr. Hao is a paid consultant for LinkBio Corp. Dr. Schoch receives royalties from Exactech, Innomed, and Responsive Arthroscopy. Dr. King is a paid consultant for Exactech, Inc. and LinkBio Corp. Dr. T. Wright is a paid consultant and receives royalties from Exactech, Inc. Dr. Fedorka is a paid consultant for Stryker Corporation. Dr. Srinivasan is a paid consultant for Acumed Exsomed LLC, Turner Imaging Systems and Hinge Health. The other authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article., (© Indian Orthopaedics Association 2024. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Background: Infusion catheters facilitate a controlled infusion of local anesthetic (LA) for pain control after surgery. However, their potential effects on healing fibroblasts are unspecified., Methods: Rat synovial fibroblasts were cultured in 12-well plates. Dilutions were prepared in a solution containing reduced-serum media and 0.9% sodium chloride in 1:1 concentration. Each well was treated with 500 μl of the appropriate LA dilution or normal saline for 15- or 30-min. LA dilutions included: 0.5% ropivacaine HCl, 0.2% ropivacaine HCl, 1% lidocaine HCl and epinephrine 1:100,000, 1% lidocaine HCl, 0.5% bupivacaine HCl and epinephrine 1:200,000, and 0.5% bupivacaine HCl. This was replicated three times. Dilution of each LA whereby 50% of the cells were unviable (Lethal dose 50 [LD50]) was analyzed., Results: LD50 was reached for lidocaine and bupivacaine, but not ropivacaine. Lidocaine 1% with epinephrine is toxic at 30-min at 1/4 and 1/2 sample dilutions. Bupivacaine 0.5% was found to be toxic at 30-min at 1/2 sample dilution. Bupivacaine 0.5% with epinephrine was found to be toxic at 15- and 30-min at 1/4 sample dilution. Lidocaine 1% was found to be toxic at 15- and 30-min at 1/2 sample dilution. Ropivacaine 0.2% and 0.5% remained below LD50 at all time-points and concentrations, with 0.2% demonstrating the least cell death., Conclusions: Though pain pumps are generally efficacious, LAs may inhibit fibroblasts, including perineural fibroblast and endoneurial fibroblast-like cells, which may contribute to persistent nerve deficits, delayed neurogenic pain, and negatively impact healing. Should a continuous infusion be used, our data supports ropivacaine 0.2%., Level of Evidence: Basic Science Study; Animal model., Competing Interests: Conflict of interest One author has a consultancy agreement with LinkBio Corp. not related to this study. One author receives royalties and is a consultant for Exactech, Inc. not related to this study. The remaining authors, their immediate families, and any affiliated research foundations with which they are affiliated, did not receive any financial payments or other benefits from any commercial entity related to the subject of this article., (Copyright © 2024 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Background: Literature on radiation exposure with use of the mini C-arm and value of having built-in laser guidance is limited. The purpose of this study was to determine whether laser guidance use on a mini C-arm fluoroscopy unit can reduce radiation exposure., Methods: Surgeons (N = 25) performed the same simulated surgical task, which involved obtaining "perfect circle" views of 2 cannulated screws placed into a cadaveric wrist, done with and without C-arm laser guidance. The testing order was randomized. Main outcomes were time to complete the task, number of shots required to complete the task, number of blank shots taken, radiation exposure, total dose area product (DAP), and total exposure time., Results: Laser guidance significantly reduced the percentage of surgeons who took blank shots, from 88% of the group without the laser to 12% of the group with the laser, and decreased the total average blank shots in the group from 3.5 to 0.1. While we found laser guidance led to shorter time to complete the task, decreased shots taken, and decreased exposure time and DAP, these findings only approached significance., Conclusion: While debate continues regarding whether mini or standard C-arm is safest, it is clear that decreasing the overall number of exposures limits potential adverse effects. Our study demonstrated that when using a mini C-arm, laser guidance decreases the number of exposures required to capture an image. These findings warrant a larger study to define the specific exposure savings and indicate potential benefit of mini C-arm use with laser guidance., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: TW receives royalties and is a consultant for Exactech, Inc. not related to this study. The remaining authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

Background: Biomechanical research demonstrates increased subscapularis abduction range of motion (ROM) when the tendon's upper two-thirds is repaired over-the-top of the center of rotation during reverse shoulder arthroplasty (RSA). This study compares the clinical outcomes of patients undergoing RSA with over-the-top subscapularis repair (OTTR) to patients without repair., Methods: We retrospectively reviewed 97 consecutive RSAs with either OTTR of the subscapularis (N = 75) or no repair (N = 22). Repair was attempted in all patients but not performed if the subscapularis could not be brought to the over-the-top position in 20° of external rotation (ER) and 30° of abduction. Improvements in ROM were compared to the minimal clinically important difference for RSA., Results: The mean follow-up was 3.8 ± 1.6 years. Demographics were similar between groups. Preoperatively, patients undergoing repair had greater ER when compared to those without repair (15 ± 16° vs. 5 ± 12°, P  = .003). Postoperatively, patients undergoing repair had greater forward elevation (132 ± 21° vs. 126 ± 22°, P  = .268) and abduction (114 ± 26° vs. 106 ± 23°, P  = .193) with both exceeding the minimal clinically important difference (-2.9° and -1.9°, respectively); however, not statistically significant. Patients with repair were more frequently able to reach the small of their back postoperatively (65% vs. 21%, P  = .006) but had less improvement in ER (13 ± 20° vs. 24 ± 20°, P  = .028). Postoperative outcome scores, complications, and reoperations were similar between groups., Discussion: OTTR of the subscapularis in RSA had similar ROM and outcome scores compared to no repair, but a significantly larger proportion of patients with repair achieved functional internal rotation to the small of the back. ER limitations seen after conventional repair may also apply to this novel technique, but without a corresponding detrimental effect on forward elevation or abduction., (© 2024 The Author(s).)

Introduction: While lateralization of the glenohumeral center of rotation during reverse shoulder arthroplasty (RSA) has benefits of maintaining tension on the remaining rotator cuff and decreasing implant impingement on the glenoid, few clinical studies have evaluated the isolated effect of glenoid lateralization in RSA. The purpose of this study was to evaluate if clinical outcomes are affected by isolated glenosphere lateralization using a single implant design., Methods: A retrospective review from a multicenter shoulder arthroplasty research database was performed between 2011 and 2018 using a single implant system to perform this case-controlled study. Inclusion criteria included primary RSAs with adequate preoperative and postoperative active and passive range of motion (ROM) measurements, outcome scores, and a minimum two-year follow-up. Revision shoulder arthroplasties and RSA for fractures were excluded from analysis. 102 RSAs (61 females, 41 males) using a +4mm lateralized glenosphere were compared to 102 sex, age, and glenosphere diameter matched control shoulders with standard glenospheres (whose center of rotation (CoR) is 2mm lateral to the glenoid fossa). The mean age at surgery was 70.4 years. Mean follow up was 43.6+18.9 months. All RSAs were performed with the same implant system (Equinoxe, Exactech, Gainesville, FL). Clinical outcome measures included ROM, ASES, Constant, UCLA, SST, SPADI scores, and VAS pain scores. We used the chi-squared test and Fisher exact test for bivariate analysis and the student t-test for continuous variables., Results: Both groups were of similar average age and follow-up. They also had comparable rates of prior surgery and comorbidities. The lateralized glenosphere group had a slightly higher BMI (31.2 vs. 29.2, p=0.04). Both groups demonstrated significant improvements in all outcome scores that exceeded the MCID and the SCB. The groups demonstrated similar preoperative, postoperative and improvements in ROM as well as outcome scores. The overall complication rate was similar between groups (4% in lateralized and 5% in controls, p=0.73). Scapular or acromial fractures differences were not statistically significant between groups (1% in lateralized group vs. 3% in standard group, p=0.31). Scapular notching was more frequent in the standard group compared to the lateralized group (9% vs. 2%, p=0.03)., Conclusion: In a medialized glenosphere/lateralized humerus design, a +4mm lateralized glenosphere provided no significant advantage in postoperative pain, ROM, or outcome scores. However, lateralized glenospheres did demonstrate significantly lower scapular notching rates., Level of Evidence: III; retrospective cohort comparison; treatment study., (Published by Elsevier Masson SAS.)

Background: Deltoid tensioning secondary to humeral lengthening after reverse shoulder arthroplasty (RSA) is commonly theorized to be crucial to improving range of motion (ROM) but may predispose patients to acromial/scapular spine fractures and neurologic injury. Clinical evidence linking patient outcomes to humeral lengthening is limited. This study assesses the relationship between humeral lengthening and clinical outcomes after RSA., Methods: A single institution review of 284 RSAs performed in 265 patients was performed. Humeral lengthening was defined as the difference in the subacromial height preoperatively to postoperatively as measured on Grashey radiographs. The subacromial height was measured as the vertical difference between the most inferolateral aspect of the acromion and the most superior aspect of the greater tuberosity. The relationship between humeral lengthening and clinical outcomes was assessed on a continuous basis. Secondarily, clinical outcomes were assessed using a dichotomous definition of humeral lengthening (≤25 vs. >25mm) based on prior clinical and biomechanical work purporting a correlation with clinical outcomes. Improvement exceeding the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) for ROM and outcome scores after RSA were also compared., Results: Humeral lengthening demonstrated a nonlinear relationship with postoperative ROM, clinical outcome scores, and shoulder strength and their improvement preoperatively to postoperatively. Furthermore, there were minimal differences in ROM measures, outcome scores, and shoulder strength when stratified using the dichotomous definition of humeral lengthening. No difference in the proportion of patients exceeding the MCID or SCB when stratified by humeral lengthening ≤25 vs. >25mm was found. There was no difference in humeral lengthening in patients with versus without complications., Conclusion: No clear relationship between humeral lengthening and clinical outcomes was identified. The previously purported 25mm threshold for humeral lengthening did not predict improved patient outcomes. Outcomes after RSA are multifactorial; the relationship between humeral lengthening and outcomes is likely confounded by other patient and surgical factors., Level of Evidence: IV; Case Series., (Copyright © 2022. Published by Elsevier Masson SAS.)

Epineural scarring following previous carpal or cubital tunnel release can lead to pain and permanent dysfunction. To prevent this cascade, nerve wraps are an option. The purpose of this study was to evaluate outcomes following use of VersaWrap nerve protector during surgical decompression and neurolysis in patients with recurrent compressive neuropathies in the upper extremity. Twenty patients comprised the patient cohort, with a mean postoperative follow-up time of 139 days (range: 42-356 days). There were 13 females and 7 males, with a mean age of 43.4 years. Fourteen surgeries were performed for revision cubital tunnel, 5 for revision carpal tunnel, and 1 for revision radial tunnel syndrome. Average duration of symptoms prior to revision surgery with VersaWrap was 2 years (range 9 months to 6 years). Postoperatively, the mean DASH score was 57.7 and VAS 3.1. Mean s2PD median distribution was 7.3, s2PD ulnar distribution 8.9, m2PD median distribution 6.9 and m2PD ulnar distribution 7.3. All patients had subjective improvement of symptoms and were satisfied with their result. No patients in our cohort required further revisional surgery. In conclusion, the use of VersaWrap as a nerve protector following revision surgery for recurrent compressive neuropathies in the upper extremity was safe and effective. Level of Evidence: IV; retrospective case series., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Hones, Nichols, Barker, Cox, Hones and Chim.)