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Background: The Chinese unique inlay Bristow (Cuistow) procedure is a modified Bristow surgery in which an inlay (mortise-and-tenon) structure is added to the contact surface between the coracoid tip and the glenoid. Patients who have undergone the Cuistow procedure have had satisfying clinical performance and excellent postoperative bone healing rates (96.1%). Purpose: To compare the clinical and radiographic outcomes after the arthroscopic Cuistow procedure and the arthroscopic Bristow procedure. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 91 patients who underwent either the Cuistow or Bristow procedure between January 2017 and March 2018 were selected, and 69 patients (70 shoulders; 35 in the Cuistow group and 35 in the Bristow group) were included. Clinical assessment at minimum 24 months postoperatively, including the visual analog scale for pain and instability, American Shoulder and Elbow Surgeons score, Rowe score, subjective shoulder value score, and active range of motion, was completed by independent observers and compared with values collected preoperatively. Assessment with 3-dimensional computed tomography scans was performed preoperatively; immediately after the operation; at 3, 6, and 12 months postoperatively; and at the final follow-up. Results: A total of 69 patients (70 shoulders) were included, with a mean follow-up duration of 34.41 ± 5.99 months (range, 24-50 months). Both groups saw significant improvement in visual analog scale for pain and instability, American Shoulder and Elbow Surgeons, Rowe, and subjective shoulder value scores at the final follow-up compared with the preoperative values (P <.001 for all), with no significant between-group differences on any clinical outcomes at the final follow-up. The 3-month postoperative graft union rate on computed tomography was significantly higher in the Cuistow group compared with the Bristow group (82.9% vs 51.4%, respectively, P =.003), although the graft union rate at the final follow-up was not significantly different (94.3% vs 85.7%, respectively; P =.449). Conclusion: Patients receiving the Cuistow procedure had equivalent clinical outcomes and a significantly higher bone union rate at 3 months postoperatively than those in the Bristow group. The inlay structure used in the Cuistow procedure was found to be associated with accelerated bone union. [ABSTRACT FROM AUTHOR]

Background: Knowledge of acromioclavicular (AC) joint kinematics and distance may provide insight into the biomechanical function and development of new treatment methods. However, accurate data on in vivo AC kinematics and distance between the clavicle and acromion remain unknown. Purpose/Hypothesis: The purpose of this study was to investigate 3-dimensional AC kinematics and distance during arm elevation in abduction, scaption, and forward flexion in a healthy population. It was hypothesized that AC kinematics and distance would vary with the elevation angle and plane of the arm. Study Design: Controlled laboratory study. Methods: A total of 19 shoulders of healthy participants were enrolled. AC kinematics and distance were investigated with a combined dual fluoroscopic imaging system and computed tomography. Rotation and translation of the AC joint were calculated. The AC distance was measured as the minimum distance between the medial border of the acromion and the articular surface of the distal clavicle (ASDC). The minimum distance point (MDP) ratio was defined as the length between the MDP and the posterior edge of the ASDC divided by the anterior-posterior length of the ASDC. AC kinematics and distance between different elevation planes and angles were compared. Results: Progressive internal rotation, upward rotation, and posterior tilt of the AC joint were observed in all elevation planes. The scapula rotated more upward relative to the clavicle in abduction than in scaption (P =.002) and flexion (P =.005). The arm elevation angle significantly affected translation of the AC joint. The acromion translated more laterally and more posteriorly in scaption than in abduction (P <.001). The AC distance decreased from the initial position to 75° in all planes and was significantly greater in flexion (P <.001). The MDP ratio significantly increased with the elevation angle (P <.001). Conclusion: Progressive rotation and significant translation of the AC joint were observed in different elevation planes. The AC distance decreased with the elevation angle from the initial position to 75°. The minimum distance between the ASDC and the medial border of the acromion moved anteriorly as the shoulder elevation angle increased. Clinical Relevance: These results could serve as benchmark data for future studies aiming to improve the surgical treatment of AC joint abnormalities to restore optimal function. [ABSTRACT FROM AUTHOR]

Background: Biocomposite anchors have been a popular choice for use in coracoid transfer procedures for shoulder instability and are hypothesized to allow bone ingrowth. Purpose: To quantitatively evaluate the osteointegration of 85% PLLA/15% β-TCP biocomposite anchors used in the coracoid transfer procedure for shoulder instability. Study Design: Case series; Level of evidence, 4. Methods: We performed a retrospective case series of abstracted data from the records of 74 patients who underwent coracoid transfer procedures with biocomposite anchors. Computed tomography was performed at 24 months postoperatively. A total of 4 researchers independently reviewed the computed tomography images. The density (in Hounsfield unit [HU] values) of the anchor tunnels, glenoid, and subscapularis was assessed, and osteointegration of the anchor tunnels was evaluated with HU values, the quantitative ossification quality score (QOQS), and tunnel widening. Results: Included were 74 patients (58 male, 16 female), involving 76 shoulders and 124 biocomposite anchors. At ≥24-month follow-up, 72 of 124 (58.06%) anchor tunnels were classified as QOQS type 1, including 12 completely ossified tunnels and 60 almost completely ossified tunnels. Some degree of ossification (QOQS types 1-3) was observed in 118 (95.16%) anchor tunnels. Overall, 3 anchor tunnels were enlarged (QOQS type 5). The mean HU value of the anchor tunnels was 339.75, which was significantly higher than the preoperative HU value of the glenoid vault (262.19). Among the 124 anchor tunnels, 79 had HU values higher than their glenoid HU values, and 45 had lower HU values than their glenoid HU values. In the comparison of tunnel HU values at 12 versus ≥24 months, the HU value at ≥24 months was significantly higher. A total of 20 anchor tunnels widened. Conclusion: Among 124 anchor tunnels, 95.16% showed ossification, 58.06% were completely or nearly completely ossified, and 3 were enlarged. The HU value of the anchor tunnel increased over time. [ABSTRACT FROM AUTHOR]

Background: Avulsion fracture of the lesser tuberosity (AFLT) of the humerus has traditionally been treated with open reduction internal fixation using screw fixation. The clinical outcomes of arthroscopic repair with suture anchors remains unknown. Hypothesis: It was hypothesized that arthroscopic fixation with suture anchors would result in good clinical outcomes for the treatment of AFLT. Study Design: Case series; Level of evidence, 4. Methods: This study included 15 patients who underwent arthroscopic repair of AFLT of the humerus between January 2014 and October 2017. All patients had 3-dimensional computed tomography scans and magnetic resonance imaging to evaluate the avulsed fracture and concomitant injuries before surgery. The arthroscopic double-row and suture-bridge techniques were used based on the morphology of the avulsion fractures. Functional outcomes were assessed with range of motion, the visual analog scale (VAS) for pain, the Subjective Shoulder Value (SSV), the American Shoulder and Elbow Surgeons (ASES) score, and the University of California, Los Angeles (UCLA) shoulder score. The bear-hug test, liftoff test, and internal rotation resistance test at 90° abduction and external rotation (IRRT 90°) were used to evaluate subscapularis tendon integrity. Results: The mean follow-up time was 3.5 years (range, 3-5 years). Comminuted fractures with 1 large part and ≥1 small pieces were seen in 12 cases, partial tear of the supraspinatus in 2 cases, Bankart lesion in 2 cases, and superior labrum anterior to posterior injury in 2 cases. There was a statistically significant improvement from the baseline to the final follow-up in the VAS (from 6.9 ± 1.5 to 1.1 ± 1), SSV (from 30.7 ± 5.1 to 90.5 ± 11.6), ASES (from 28.5 ± 7.7 to 92.3 ± 4.5), and UCLA (from 29.5 ± 6.3 to 94.2 ± 8.3) scores (P <.001 for all). All patients showed full range of shoulder motion and bilateral symmetric strength on physical examination with the bear-hug test, liftoff test, and IRRT 90° test. Conclusion: The arthroscopic repair of AFLT resulted in excellent reduction and healing of the displaced fragment. At the final follow-up, clinical and functional results were good. Associated injuries occurred in 40% of patients but did not affect outcomes. [ABSTRACT FROM AUTHOR]

Background: The prevalence of nonunion after the Latarjet procedure remains high. The purpose of the present study was to investigate healing and clinical outcomes after a novel arthroscopic coracoid process transfer procedure.Methods: Sixty-three patients who underwent the arthroscopic inlay Bristow procedure combined with Bankart repair were identified, and 51 patients who met the inclusion criteria were enrolled in this study. The key feature of this technique was that the coracoid process was trimmed and fixed into a trough (5 to 10 mm deep) in the glenoid neck with a metal screw. Bone graft union and positioning accuracy were assessed with use of postoperative computed tomography (CT) imaging. Clinical examinations, return to sport, and functional scores (American Shoulder and Elbow Surgeons [ASES] and Rowe scores) were recorded.Results: The mean duration of follow-up (and standard deviation) was 41.5 ± 7.7 months (range, 36 to 48 months). Postoperative CT scans showed that the position of coracoid graft was at 4:10 (from 3:50 to 5:00) (referencing the right shoulder) in the sagittal view. The α angle was 16.4° ± 9.5°, with 4 (7.8%) of 51 screws being over-angulated (α > 25°). On the axial view, the graft position was considered to be flush in 33 patients (64.7%), medial in 11 (21.6%), congruent in 7 (13.7%), and lateral or too medial in none. At 1 year, the coracoid graft had healed in 49 patients (96.1%) and had failed to unite in 2 patients. CT scanning, performed for 47 patients, showed grade-0 osteolysis in 9 patients, grade-1 osteolysis in 21 patients, and grade-2 osteolysis in 17 patients. At the time of the latest follow-up, there was a significant increase in the Rowe score (from 35.5 ± 8.3 to 95.7 ± 7.2) and the ASES score (from 71.2 ± 9.7 to 91.5 ± 4.4), and 87.0% of patients were able to return to sport. No arthropathy was observed in any patient.Conclusions: After a minimum 3-year follow-up, the arthroscopic inlay Bristow procedure resulted in a high rate of graft healing, excellent clinical outcomes, and a high rate of return to sports.Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Coracoid graft positioning, fixation, and bone union are key factors affecting the clinical outcomes of Bristow and Latarjet procedures. We developed an arthroscopic "inlay" Bristow procedure based on the "mortise-tenon" joint structure concept using suture button fixation to achieve more stable fixation and better bone union of the graft. Purpose: To evaluate the positioning of the coracoid graft, bone union rate, and clinical outcomes of this arthroscopic inlay Bristow procedure with suture button fixation. Study Design: Case series; Level of evidence, 4. Methods: A total of 62 patients who received the arthroscopic inlay Bristow procedure with suture button fixation between June 2015 to June 2016 were eligible for inclusion, and 56 patients who met the inclusion criteria were enrolled in this study. Radiological assessment on 3-dimensional computed tomography scan was performed preoperatively, immediately after the operation, and postoperatively at 3 months, 6 months, 1 year, and the final follow-up. Pre- and postoperative clinical results were also assessed. Results: A total of 56 patients were included in this study. The mean ± SD follow-up time was 36.1 ± 3.7 months. Coracoid grafts (middle point) were positioned at 4 o'clock (range, 123.8°± 12.3°) in the sagittal view. In the axial view, 94.6% (53/56) of the graft positioning was measured as flush and 5.4% (3/56) as medial. Neither lateral nor too medial positioning was noted. The bone union rate was 96.4% at final follow-up. The mean visual analog scale score for pain during motion, American Shoulder and Elbow Surgeons score, and Rowe score all improved significantly after surgery—from 4.8 ± 2.6 to 1.1 ± 1.0, 69.2 ± 12.5 to 92.5 ± 7.0, and 33.5 ± 12.1 to 96.0 ± 4.9 at last follow-up, respectively. Almost all patients (98%; 55/56) returned to sports within 1 year after surgery at the same or higher level as compared with their preinjury performance. The mean subjective value for sports participation was 90.3% ± 7.1% (range, 70%-100%) as compared with the normal shoulder. The overall complication rate was 3.6%. No degenerative changes were noted in any patients. Conclusion: This study reported the first series of an inlay Bristow procedure with suture button fixation for recurrent shoulder dislocation, providing a satisfactory union rate and excellent graft positioning with a low complication rate. The mortise-tenon joint structure can provide excellent graft fixation and healing, while using suture button fixation instead of screw fixation could reduce osteolysis and complications related to hardware implantation. [ABSTRACT FROM AUTHOR]

Background: The rate of nonunion observed among the variety of Bristow-Latarjet procedures reportedly ranges from 9.4% to 28%1. In Chinese timber buildings, the mortise-tenon joint is commonly utilized to connect beams to columns. Drawing inspirations from this concept, we created a bone trough in the glenoid neck to serve as a mortise and trimmed the coracoid graft to serve as a tenon, then fixed this mortise-tenon joint with a metal screw. Compared with a standard Bristow-Latarjet procedure, the key feature of this technique was that the coracoid process was placed into a trough (5 to 10 mm deep) in the glenoid neck, which substantially increased the bone contact area between the graft and glenoid neck. We called this surgical technique the Chinese unique inlay Bristow (Cuistow). Description: Specific instruments have been designed to improve the safety and accuracy of the arthroscopic inlay Bristow procedure (Weigao, Shangdong, China). The posterior portal (A), superolateral portal (B), and 3 anterior portals (i.e., proximal [C], inferolateral [D], and inferomedial [E]) were utilized. General anesthesia and an interscalene block were administered with the patient in the beach-chair position. The surgical technique can be divided into 6 steps: (1) evaluation of the shoulder joint; (2) coracoid preparation, drilling, and osteotomy; (3) subscapularis splitting and labrum detachment; (4) glenoid preparation and drilling; (5) coracoid retrieval, trimming, transfer, and fixation; and (6) Bankart repair. Alternatives: Soft-tissue capsulolabral repairs or bone reconstruction procedures are commonly performed for the treatment of anterior glenohumeral instability2. The arthroscopic Bristow-Latarjet procedure is increasingly popular for the treatment of anterior shoulder instability with a substantial osseous defect of the glenoid3. Defects that are too large to be restored with the coracoid process can be treated with use of the Eden-Hybbinette procedure or a distal tibial allograft4,5. Rationale: This procedure was inspired by the structure of mortise-tenon joints, resulting in a modified version of the Bristow-Latarjet technique in which the coracoid process is trimmed and placed into a trough (5 to 10 mm deep) in the glenoid neck. This procedure substantially increases the contact area between the fresh bone surface and the coracoid and glenoid neck. Another important advantage of this technique is that it can facilitate accurate positioning of the coracoid on the glenoid. This procedure resulted in a high rate of graft healing, excellent functional outcomes (Rowe and American Shoulder and Elbow Surgeons Shoulder scores), and a high rate of return to sport6. Currently, indications of this procedure are (1) participation in high-demand sports (i.e., collision and overhead) combined with the presence of a glenoid defect involving <25% of the glenoid, or (2) any glenoid defect involving 10% to 25% of the glenoid. Expected Outcomes: Increased bone-contact area and accurate positioning of the graft helped to facilitate osseous union, with a union rate of 96.1% at 12 months postoperatively. The clinical outcomes were excellent, with a high rate of return to sport (87%) at a minimum of 3 years of follow-up6. Important Tips: When the coracoid is retrieved through portal D (the inferolateral portal), there is a risk of stretching the musculocutaneous nerve. Trimming the coracoid graft could lead to stretching of the graft and the surrounding soft tissue, resulting in overstretching of the musculocutaneous nerve. To minimize the risk of musculocutaneous nerve injury, (1) the graft should be gently retrieved through portal D, (2) the graft should be trimmed with caution without overstretching it and surrounding soft tissue, and (3) a cannula should be utilized when driving the screw to fix the graft in order to avoid the surrounding soft tissue. Acronyms & Abbreviations: RHD = right-hand dominant MRA = magnetic resonance angiography 3D-CT = 3-dimensional computed tomography PDS = polydioxanone suture MCN = musculocutaneous nerve [ABSTRACT FROM AUTHOR]