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Purpose To systematically review and compare the surgical indications, technique, peri-operative treatment, outcomes measures, and how recurrence of instability was reported and defined after coracoid transfer procedures. Methods A systematic review of the literature examining open coracoid transfer outcomes was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the Cochrane registry, MEDLINE, and EMBASE databases from 2010 to 2020. Inclusion criteria included open coracoid transfer techniques including the Bristow or Latarjet technique, full text available, human studies, and English language. Results A screen of 1096 coracoid transfer studies yielded 72 studies which met inclusion criteria with a total of 4,312 shoulders. One study was a randomized controlled trial, but the majority were retrospective. Of those, 65 studies reported on post-operative outcome scores, complication rates, revision rate, and recurrence rates. Forty-three reported on range of motion results. Thirty studies reported on primary coracoid transfer only, 7 on revision only, and 30 on both primary and revision with 5 not reporting. Average follow-up was 26.9 months (range, 1-316.8 months). Indications for coracoid transfer, technique, peri-operative care, complications, and how failure was reported varied greatly among studies. Conclusions Latarjet and coracoid transfer surgery varies greatly in its indications, technique, and post-operative care. Further, there is great variation in reporting of complications as well as recurrence and failure and how it is defined. Although coracoid transfer is a successful treatment with a long history, greater consistency regarding these factors is essential for appropriate patient education and surgeon knowledge.

Although coracoid fractures are rare fractures, their treatment is critical as they form the coracoacromial arch and superior shoulder suspensory complex (SSSC), which are important structures for shoulder biomechanics. In this case series, clinical, radiological, and demographic characteristics of three male patients who received treatment due to coracoid fracture presenting with traumatic injuries were discussed. The fractures were classified according to the Ogawa and Eyres classifications, and fracture fixation was achieved surgically with the cannulated screws. All patients had a right coracoid fracture. The Constant–Murley Score and the Disabilities of the Arm, Shoulder and Hand scores the patients in the final follow-up visit at 12 months were calculated. In conclusion, good clinical and functional outcomes can be achieved by anatomical reduction and fixation through surgery for displaced coracoid fractures presenting with multiple traumatic injuries located in multiple regions of the SSSC.

The functions of the subclavius muscle (SM) are described as stabilization of the sternoclavicular joint (SCJ) and resisting elevation of the lateral end of the clavicle. During systematic cadaveric dissections, we observed additional fibrous structures, previously described as variants of the anatomy, extending from the SM and inserting into the coracoid process (CP). Due to the high incidence of these structures in our dissections, we hypothesized that the attachment at the CP is more common than appreciated and that, as a corollary, the function of the SM was (or has been) more complex than simply depressing the clavicle and generating stability at the SCJ. For our investigation, fifty‐two upper extremities of 26 human cadavers were dissected. The SM was demonstrated from costal to clavicular attachment. We documented additional fibrous structures apparently derived from the SM inserting into the CP. Measurements of the length of the SM, the length of its attachment, and the length of the clavicle were taken in situ, with the specimens supine and the upper extremity in the anatomical position. Variations in the anatomy of the SM and its coracoidal attachment were recorded, and potential correlations were investigated. For documentation purposes photographs and video sequences of passive motion of the shoulder girdle of the specimens were taken. In 49 of the 52 specimens we found additional fibrous structures passing from the SM to the CP. We differentiated three types: (1) a strong cord‐like structure; (2) a small or thin cord‐like structure or structures; and (3) a planar twisted sheet‐like structure. The SM and its extension to the CP appears to contribute to a ‘functional scapular suspension system’ together with the other muscles enveloped by the clavipectoral fascia (pectoralis minor, coracobrachialis and the short head of the biceps brachii). This system assists in the control of the position of the scapula in relation to the thorax, particularly in elevated positions of the upper extremity. We speculate that the differentiation of the fibrous structure depends on the functional demands of the individual. Level of Evidence: Basic science study., Dissections of the upper extremity showed a fibrous structure, extending from the subclavius muscle (SM) and inserting into the coracoid process. Due to the high incidence, we hypothesized that this structure is more common than appreciated and that the function of the SM was (or has been) more complex.

PURPOSE The aim of this study was to describe the results of an arthroscopic Trillat procedure utilized to treat patients with symptomatic antero-inferior shoulder instability associated with hyperlaxity. METHODS A retrospective review was performed on 19 consecutive shoulders (17 patients, 2 bilateral) who underwent a Trillat procedure combined with anterio-inferior capsulolabral plasty from 2016 to 2019. Patients included in the study presented with shoulder instability combined with shoulder hyperlaxity and no glenoid or humeral bone loss. Clinical assessment included range of motion, apprehension, and instability tests. Outcome measures Constant-Murley score (CMS) scale, Walch-Duplay, ROWE, Subjective Shoulder Value (SSV), Visual Analogue Scale (VAS). Post-operatively, healing of the coracoid osteoclasy was evaluated by CT scan. RESULTS The mean follow-up was 24.8 months (range, 12-51). Post-operatively, none of the patients experienced a recurrent dislocation or subluxation and the anterior apprehension test was negative in all shoulders. Post-operative motion deficits of 22.1° ± 15.8 [p

Background: Coracoclavicular (CC) ligament reconstruction is a commonly performed procedure for high-grade acromioclavicular (AC) joint separations. Although distal clavicle and coracoid process fractures represent potential complications, they have been described in only case reports and small case series. Purpose: To identify the incidence and characteristics of clavicle and coracoid fractures after CC ligament reconstruction. Study Design: Case series; Level of evidence, 4. Methods: The US Military Health System Data Repository was queried for patients with a Current Procedural Terminology code for CC ligament repair or reconstruction between October 2013 and March 2020. The electronic health records, including patient characteristics, radiographs, operative reports, and clinical notes, were evaluated for intraoperative or postoperative clavicle or coracoid fractures. Initial operative technique, fracture management, and subsequent clinical outcomes were reviewed for these patients. Results: A total of 896 primary CC ligament repairs or reconstructions were performed during the study period. There were 21 postoperative fractures and 1 intraoperative fracture in 20 patients. Of these fractures, 12 involved the coracoid and 10 involved the clavicle. The overall incidence of fracture was 3.81 fractures per 1000 person-years. In 5 patients who sustained a fracture, bone tunnels were not drilled in the fractured bone during the index procedure. A total of 17 fractures were ultimately treated operatively, whereas 5 fractures had nonoperative management. Of the 16 active-duty servicemembers who sustained intraoperative or postoperative fractures, 11 were unable to return to full military duty after their fracture care. Conclusion: Fracture of the distal clavicle or coracoid process after CC ligament repair or reconstruction is a rare but serious complication that can occur independent of bone tunnels created during the index procedure. Fractures associated with CC ligament procedures occurred at a rate of 2.46 per 100 cases. Most patients were ultimately treated surgically with open reduction and internal fixation or revision CC ligament reconstruction. Although the majority of patients with intraoperative or postoperative fractures regained full range of motion, complications such as anterior shoulder pain, AC joint asymmetry, and activity-related weakness were common sequelae resulting in physical limitations and separation from military service.

The success of the modified Latarjet procedure depends on proper sizing of the coracoid graft. There is no information available regarding the morphometric relationship between the glenoid cavity and the coracoid process for the South African population. This study aims at measuring the relationship between the glenoid and coracoid morphometries and investigates their gender-related differences.Glenohumeral computerized tomography scans of 100 consecutive patients were considered for this study. Morphometric measurements were performed after aligning the coracoid and glenoid in their optimum orientation. These measurements were performed by 2 independent observers. The ratio between glenoid and coracoid measurements was calculated and statistically compared using the Mann-Whitney U test. Intraclass correlation coefficients were calculated to analyze interobserver reliability. All the statistical tests were performed in SPSS v.26, and power calculations in G∗Power v.3.1.An average intraclass correlation coefficient value of 0.79 suggested that the interobserver reliability was good. Except for coracoid length, statistically significant (P.05) gender differences were observed for all the other morphometries. The coracoid width (16.5 ± 1.4 mm vs. 14.7 ± 1.4 mm) and height (13.6 ± 1.6 mm vs. 10.5 ± 1.5 mm) differed between genders by 1.8 and 3.1 mm, respectively. The glenoid anteroposterior (AP) (25.3 ± 2.9 mm vs. 23.2 ± 2.4 mm) and superioinferior (36.9 ± 1.9 mm vs. 33.7 ± 2.6 mm) measurements differed by 2.1 and 3.3 mm, respectively, between the males and the females. The ratio between the AP width of the glenoid and the coracoid height was also found to be significantly different (P.05) between the gender groups. These morphometric ratios for the coracoid width (0.66 ± 0.09 mm vs. 0.64 ± 0.08 mm) and the coracoid height (0.55 ± 0.09 mm vs. 0.46 ± 0.07 mm) differed between genders by 0.02 and 0.09, respectively.Measurements taken from computerized tomography scans showed significant differences between genders in absolute measurements and in the ratio of the coracoid height to the glenoid AP distance. This could have implications on the ability of the Latarjet procedure to compensate for bone loss in female patients.

The Latarjet procedure is an effective procedure for the treatment of anterior glenohumeral joint instability; however, the complications are concerning. The purpose of this study was to review a single institution's experience with the Latarjet procedure for recurrent anterior glenohumeral instability specifically focusing on early complications.This was a retrospective review of all Latarjet procedures performed at a single institution from August 2008 to July 2018. The 90-day complication rate and associated risk factors for all complications and graft failure were recorded. Postoperative radiographs were reviewed for coracoid graft position and screw divergence.During the study period, 190 Latarjet procedures were performed with 90-day follow-up. The average age was 28.7 ± 11.3 years, male patients comprised 84.2% of the population, and 62.6% of patients had undergone a prior stabilization procedure. We observed 15 complications, for a 90-day complication rate of 9.0%; of the patients, 8 (4.2%) underwent reoperations. Graft or hardware failure occurred in 9 patients (4.7%) with loosened or broken screws, and 6 required reoperations (revision Latarjet procedure in 4, distal tibia allograft in 1, and iliac crest autograft in 1). Fixation with only 1 screw (P.001) and an increased screw divergence angle (37° ± 8° vs. 24° ± 11°, P = .0257) were statistically associated with graft failure, whereas the use of cannulated screws (P = .487) was not. There were 6 nerve injuries (3.2%), including 2 combined axillary and suprascapular nerve injuries, 1 musculocutaneous nerve injury, 1 brachial plexopathy, 1 peripheral sensory nerve deficit (likely axillary), and 1 sensory plexopathy. Suprascapular nerve injury at the spinoglenoid notch was associated with a longer superior screw (41.0 ± 1.4 mm vs. 33.5 ± 3.5 mm, P = .035) and increased screw divergence angle (40° ± 6° vs. 24° ± 11°, P = .0197). The coracoid graft was correctly positioned in the axial plane in 71% of cases and in the coronal plane in 73% of cases.The Latarjet procedure is a procedure that can reliably restore shoulder stability; however, graft- and nerve-related complications are relatively common. Two-thirds of the graft failures required reoperations, and half of the nerve injuries in this study led to residual symptoms. Fixation with only 1 screw and an increased screw divergence angle were significant predictors of graft failure. Suprascapular nerve injury at the spinoglenoid notch was associated with an increased screw divergence angle and longer superior screw.

The coracobrachialis muscle (CBM) originates from the apex of the coracoid process, in common with the short head of the biceps brachii muscle, and from the intermuscular septum. The CBM demonstrates variability in both the proximal and distal attachment, with some extremely rare varieties, such as the coracobrachialis superior, coracobrachialis longus and coracocapsularis muscle. This case report describes an extremely rare variant of the coracobrachialis superior muscle, or a very rare variant of the CBM. Our findings highlight the importance of muscle variants in the shoulder region, especially the coracoid region, and are significant for radiologists, anatomists, physiotherapists and surgeons specializing in the shoulder joint.

To describe the bilateral coracohumeral morphological discrepancy in rotator cuff rupture patients with and without subscapularis (SSC) involvement and to investigate its association with SSC tears. Two hundred and thirteen consecutive patients who were scheduled to have arthroscopic rotator cuff repair were prospectively enrolled in the current study. Patients with acute traumatic rotator cuff rupture, glenohumeral osteoarthritis, bilateral rotator cuff rupture, recurrent shoulder instability, systemic inflammatory disease, and previous shoulder surgery history were excluded. Coracohumeral distance (CHD), coracoid overlap (CO), lesser tuberosity index (LTI) and acromiohumeral interval (AHI) were measured bilaterally using CT scans. Based on arthroscopic findings, patients were included in either the SSC tear group (n = 72) or the control group (n = 141). In the SSC tear group, the affected shoulder possessed a significantly smaller CHD [95% confidence interval (CI) 6.1–7.2 vs. 7.2–8.0 mm, p

Study design This is a retrospective study. Objective This study aims to determine (1) when shoulder rebalancing occurs after adolescent idiopathic scoliosis (AIS) correction surgery and (2) whether shoulder asymmetry was influenced by the use of pedicle screws or hooks. Summary of background data Postoperative shoulder imbalance is an important outcome of AIS correction surgery as it may influence a patient's appearance and satisfaction. Materials and methods Seventy AIS patients undergoing AIS correction surgery at a single institution were retrospectively reviewed. Radiographic parameters were measured from anteroposterior x-rays at preoperative, immediate postoperative, 6 months postsurgery, and 12 months postsurgery. Shoulder parameters measured were: radiographic shoulder height (RSH), clavicle angle, coracoid height difference (CHD), and T1 tilt. The Cobb angle of the proximal thoracic curve, major thoracic curve, and thoracolumbar/lumbar curve. The percentage of correction was also calculated. Results Lateral shoulder asymmetry (RSH and CHD) changed significantly from preoperative to up to 6 months postsurgery. T1 tilt, a measure of medial shoulder asymmetry, did not change significantly. Postoperatively, the hook group attained significantly better shoulder balance than the screw group in terms of RSH and CHD up to 12 months postsurgery. However, the percentage correction of the major thoracic curve was significantly greater in the screw group than the hook group (hook: 62.2+/-18.4% vs. screw: 76.0+/-16.0%, P=0.007). Conclusions Lateral shoulder rebalancing occurs up to 6 months after surgery. While thoracic pedicle screws offer greater correction of major AIS curves, hook constructs offer better postoperative shoulder symmetry. Level of evidence III.

To (1) determine the rate of surgical complications and venous thromboembolism (VTE) in patients undergoing arthroscopic Bankart repair, open Bankart repair, or Latarjet-Bristow; and (2) assess potential risk factors for surgical complications and VTE in patients undergoing shoulder stabilization procedures.The NSQIP database was used to identify patients undergoing isolated surgery for shoulder instability from 2005 to 2017. Demographic data were collected and compared. Logistic regression was used to assess the risk factors for developing a postoperative complication, and regression analyses were used to evaluate the odds of postoperative complications between types of surgery.We identified 7,233 patients for inclusion. Patients undergoing Latarjet-Bristow were more likely to be male and Black and to report current tobacco use. Overall, there was a low rate of surgical complications (0.4%) and VTE (0.2%). However, patients undergoing Latarjet-Bristow had nearly a 10-fold increase in the risk of surgical complications compared with an arthroscopic or open Bankart repair (1.9% versus 0.2%, P.001), including deep surgical site infections, return to operating room within 30 days, and symptomatic VTE (deep venous thrombosis rate: arthroscopic Bankart repair, 0.1%; Latarjet-Bristow, 0.8%; P.001). There were no differences in the odds of developing a surgical complication or VTE between patients undergoing arthroscopic or open Bankart repair.This study used a nationally representative, widely validated, peer-reviewed database to demonstrate that patients undergoing a Latarjet-Bristow procedure are at significantly higher risk for short-term postoperative complications, including deep surgical site infections, return to the operating room, and symptomatic VTE, than those undergoing Bankart repair. These findings should not discourage surgeons from proceeding with a coracoid transfer procedure when indicated for glenoid deficiencies, but should inform preoperative counseling and help guide perioperative care to optimize patient outcomes.III, retrospective comparative trial.

Background Restoration of native glenohumeral joint line is important for a successful outcome after reverse shoulder arthroplasty (RSA). The aims of this study were to quantify the restoration of glenoid joint line after structural bone grafting and RSA, and to evaluate graft incorporation, correction of glenoid version, and rate of notching. Methods This is a retrospective review of 21 patients who underwent RSA (20 primary, 1 revision) with glenoid bone grafting (15 autografts, 6 allografts). Grammont design implants and baseplate with long peg were used in all patients. Preoperative and postoperative 3D models were created using MIMICS 21.0. Preoperative defects were classified, and postoperative joint line restoration was assessed based on the lateral aspect of the base of the coracoid. Postoperative computed tomographic (CT) scans were evaluated for graft incorporation, version correction, and presence of notching. Results Preoperative glenoid defects were classified as massive (5%), large (29%), moderate (52%), and small (14%). The average preoperative version was 8° of retroversion. The average postoperative version was 5° of retroversion. The average preoperative medialization was noted to be 8.4 mm medial to native joint line or 0.6 mm (range −16.8 to 13.2) lateral to the coracoid base. The postoperative CT scans demonstrated a mean joint line at 12.1 mm (range 1.3-22.4) lateral to the coracoid base. At the 3-month follow-up, all patients demonstrated graft incorporation on CT scans. Graft osteolysis was observed on CT scan in 4.8% of patients at a mean follow-up of 19.5 months. Discussion Structural bone grafting of glenoid defect effectively re-creates the glenoid anatomy, restores glenoid bone stock, re-creates the true glenohumeral joint line, and corrects glenoid deformity. The use of bone grafting also allows lateralization of the baseplate and glenosphere, reducing the risk of severe scapular notching. Conclusion Restoration of the glenoid joint line was achieved in all patients. Glenoid bone grafting is a viable option for restoring glenoid joint line in cases of significant glenoid defects encountered during RSA.

Almost 70 scapular fractures in children and adolescents, up to the age of 17 years, have been described in detail in the literature since 1839. The diagnosis of these injuries was based on autopsy, radiographs, CT and MRI examinations. The most frequent findings were fractures/epiphyseolyses of the coracoid, followed by fractures of the infraspinous part of the body and avulsion of the inferior angle of the scapular body. Less common were fractures of the acromion. Intra-articular fractures of the glenoid, or separation of an intact glenoid along the line of the anatomical or surgical necks, were reported only sporadically. Scapulothoracic dissociation was also recorded in several cases. The majority of fractures were treated non-operatively; operative treatment was used in glenoid fractures, certain fractures of the coracoid and fractures of the scapular body with intrathoracic penetration. Except for scapulothoracic dissociation, outcomes of treatment of these injuries were very good.

Summary Objective The aim of our study was to describe the anatomy of the anterior shoulder, specifically structures potentially involved in subscapularis tears pathophysiology and also to identify structures at risk during surgical approaches of this area. Materials and methods We designed an observational, experimental study based on cadaveric models. Dissection was performed and several structures of the anterior shoulder were characterized including the subscapularis, coracoid morphology, the coracoacromial ligament, coraco-humeral distance, and the axillary and musculocutaneous nerves. Results Our sample included 16 shoulders. The coracoacromial ligament presented two bands in 37.5%, and these variants were significantly wider and thinner, and were associated with inferior coraco-humeral distance in internal rotation. The subscapularis footprint was longer and the coracoid process was bigger in male specimens, and the median coracoid angle was 122°, corresponding to a Leite-Torres type I. The Subscapularis showed a median thickness of 0.7 cm, while the coraco-humeral distance in our sample ranged from 0.30 cm in internal rotation to 0.85 cm in external rotation. Neurologic relevant structures were at least more than 2.55 cm from the coracoid tip. Conclusions This is the first paper to explore the eventual relationship between the presence of a double band coracoacromial ligament variant and subcoracoid impingement. Also, to our knowledge, this is the first cadaveric model study to postulate a possible anatomic base for subcoracoid impingement, as the SS myotendinous junction thickness was found to be greater than the coraco-humeral distance in neutral position and in IR.

OBJECTIVES To assess surgical and functional outcomes in a cohort of patients having operatively reconstructed scapula process malunions and/or nonunions. DESIGN Retrospective case series. SETTING Level I trauma center. PATIENTS/PARTICIPANTS Between 2003 and 2018, we identified 16 patients who presented to our institution with symptoms associated with a nonunion or malunion of closed, displaced fractures of the scapula processes after acute injury mechanisms. INTERVENTION Surgical osteotomy of the malunion or debridement of the nonunion and subsequent reconstruction. MAIN OUTCOME MEASUREMENTS The primary outcome measured included range of motion, strength, and DASH. Return to work was a secondary outcome. RESULTS Among 13 of the 16 (81%) patients with ≥12 months follow-up, the mean follow-up was 34 months (range, 12-112 months). Three patients were lost to follow-up. The mean DASH score improved from 56.4 ± 22.4 preoperatively to 23.4 ± 22.2 postoperatively (P < 0.001). Among the patients with ≥1-year follow-up, range of motion improved from preoperative to final follow-up in abduction (P = 0.020). Among the 15 of 16 patients for whom occupation data are available, 73% either returned to their original occupation (n = 7) or did not due to reasons other than their reconstructive surgery (n = 4). Two postoperative complications occurred including failure of acromion nonunion fixation at 4 months and went on to heal after revision surgery. All reconstructions united without malunion. CONCLUSIONS Reconstruction of the scapula process malunion and nonunion is possible, providing restoration of function and symptom relief, with a low complication rate. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Arthur Sidney Blundell Bankart was a London-based orthopedic surgeon who discovered the essential lesion in recurrent anterior shoulder instability in 1923. He pioneered a technique, the Bankart repair, to re-establish stability to the glenohumeral joint, without sacrificing native joint motion. In this article, the original Bankart repair is compared to the modern arthroscopic Bankart repair, accompanied by a surgical video of Blundell Bankart performing the Bankart repair in 1951, shortly before his death. Bankart's original description included an open repair with a coracoid osteotomy and subscapularis tenotomy and repair. The history of the technique, its utility in present day, and the future of the Bankart repair are discussed.

Objective To evaluate the early clinical and radiographic results of arthroscopic Latarjet procedure using screw or suture‐button fixation in patients with recurrent anterior shoulder dislocation. Methods Twelve patients who underwent arthroscopic Latarjet procedure between January 2015 and December 2018 at our institution were retrospectively studied. Data of the patients' history, including age, gender, side of affected arm, body mass index (BMI), and the number of dislocations since fist dislocation were collected. Preoperative and postoperative clinical follow‐up data were evaluated using Walch–Duplay score, American Shoulder and Elbow Society (ASES) score, and modified Rowe score. Active external rotation and active internal rotation at 90° of abduction as well as active elevation were evaluated preoperatively and postoperatively. The position and healing condition of the transferred coracoid bony graft were also assessed using computed tomography (CT) and Mimics 19.0 software. Results Mean follow‐up was 24.9 months (range, 13 to 53 months) of all patients. At final follow‐up, the average ASES score (preoperative vs postoperative values) had improved from 68.9 ± 7.9 to 91.1 ± 6.1 in screw fixation group and 68.9 ± 8.9 to 87.5 ± 6.7 in suture‐button fixation group; the average Rowe score (preoperative vs postoperative values) had improved from 25.0 ± 8.4 to 92.5 ± 4.2 in screw fixation group and 21.7 ± 13.7 to 93.3 ± 4.1 in suture‐button fixation group; the average of Walch–Duplay score (preoperative vs postoperative values) had improved from 12.5 ± 15.1 to 91.7 ± 4.1 in screw fixation group and 18.3 ± 20.7 to 88.3 ± 7.5 in button fixation group. The forward flexion was 175.0° ± 8.4° preoperatively and 178.3° ± 4.1° postoperatively in screw fixation group while 174.8° ± 10.2° preoperatively and 175.0° ± 5.5° postoperatively in suture‐button fixation group. The active external rotation was 77.5° ± 5.2° preoperatively and 71.7° ± 4.1° postoperatively in screw fixation group while 72.5° ± 6.9° preoperatively and 68.3° ± 7.5° postoperatively in suture‐button fixation group. The average of active internal rotation was 66.7° ± 6.1° preoperatively and 67.5° ± 6.1° postoperatively in screw fixation group while 68.3° ± 11.3° preoperatively and 66.7° ± 7.5° postoperatively in suture‐button fixation group. In postoperative CT scan, 91.7% grafts midline center were located at or under the equator in the en face view; 75% of the bone blocks were flush to the glenoid face in the axial view, with only two grafts exhibiting slight medial placement in screw fixation group (33.3%) and one graft exhibiting slight lateral placement in suture‐button fixation group (16.7%). All grafts achieved bone union. Graft absorption mostly occurred outside of the “best‐fit” circle. The average bony absorption rates of the coracoid grafts were 25.2% and 10.18% in screw fixation group and suture‐button fixation group, respectively, at 6 months postoperative follow‐up. Conclusion Both suture‐button fixation and screw fixation techniques in arthroscopic Latarjet procedure revealed excellent clinical outcomes with low complication rates in the early follow‐up. The suture‐button fixation exhibited a flexible fixation pattern that allowed for self‐correction to some extent, even slight lateralization could finally remodel over time., The Latarjet prodedure is becoming increasingly popular when considering treating severe anterior shoulder instability. Whether operating openly or arthroscopily, the coracoid fixation method varies among surgeons and arouse unsolved disputes in recent years. Arthroscopic Latarjet procedure is a challenging yet viable technique, achieving equal results to the open technique with advantages of the arthroscopic setting.

Joint replacement surgery as a treatment for glenohumeral arthritis with glenoid bone loss is challenging. The aim of this study is to offer an anatomical orientation for glenoid reconstruction. In this study, we measured size, inclination and version of the glenoid surface, as well as the distance between the articular line of the glenoid, base of the coracoid process, and acromion using computer tomographic (CT) imaging of 131 study participants aged 19–88 years in the period of 2010–2013. We measured a mean distance of 6.5 ± 0.2 mm from the glenoid articular line to the base of the coracoid process in the transverse CT plane. Body height has shown no significant impact on the glenoid morphology. We observed significant differences between males and females: The glenoid appeared to be located 5.2 ± 0.9 mm higher and the humeral head was 4.5 ± 0.7 mm larger in male subjects compared with females (r = .699; p

Background Multiple disruptions of the superior shoulder suspensory complex (SSSC) involving more than two components are extremely rare. In some extreme situations, three components of the SSSC structure can be involved. The ideal treatment for this type of injury is debatable. Case presentation A 21‐year‐old woman was referred to our emergency center following a traffic accident. A three‐dimensional CT scan showed triple disruption of the SSSC involving concomitant ipsilateral fractures of the coracoid, the acromion, and the distal clavicle. The connection between the upper limber and the axial skeleton was destroyed. There was no evidence of associated injury and the neurovascular examination of the injured upper limb was normal. The patient underwent an open reduction and internal fixation to restore the anatomic integrity of the SSSC. The arm was supported in a broad arm sling for 2 weeks after surgery. Gentle passive range of motion activity under analgesic was encouraged from the second day postoperatively. One year and half after the operation, the patient had regained pain free and unrestricted shoulder stability and mobility. Conclusion The manifestations of multiple disruptions of the SSSC may be variable. This case illustrated the challenges of treating the multiple disruption of the SSSC structure. It also showed that surgical intervention for this rare combination injury yields an excellent functional result. The good outcome achieved in this patient demonstrates that surgical intervention might be an optional resolution for multiple disruptions of the SSSC., The SSSC is a ring of bone and soft tissue, which is composed of the coracoclavicular ligament, the distal clavicle, the AC joint, the coracoacromial ligament and the acromion, the coracoid process, and the glenoid. We presented a case of a triple bone break of this ring.

Isolated coracoid fractures (ICFs) are rare and the management is controversial. In this article, we report a displaced ICF, treated con- servatively with success. A 12-year-old male patient presented with mild pain in his right shoulder after simple fall. Physical examina- tion was normal except mild tenderness on the coracoid process and mildly limited active shoulder motion. Plain radiographs did not demonstrate any apparent finding of pathology. Computed tomography (CT) images revealed isolated coracoid mid-process fracture with displacement. Significant symptomatic relief as well as sufficient callus formation, confirmed by follow-up CT exami- nation, was achieved after Velpeau sling use for four weeks. After a follow-up duration of 14 months, excellent clinical and radiologic outcomes were accomplished. The result of this case supports the efficiency of conservative treatment for ICFs in adolescents, even in the presence of considerable fracture displacement. Computed tomography imaging is a valuable diagnostic tool for the assess- ment of ICF.

Congruent arc Latarjet procedure involves rotating the coracoid process so that its inferior surface is flush with the glenoid face, owing to their matching radius of curvature (ROC). However, there has been no cadaveric study to actually measure and compare the ROC of coracoid with glenoid, especially in Indian population. 44 shoulders were dissected in 24 cadavers to measure usable length of coracoid process, width, height, ROC of coracoid and glenoid as well as ulnar length (as proxy of cadaver height). Critical coracoid height and length were estimated based on screw sizes of 2.7 mm, 3.5 mm, 4 mm and 4.5 mm, and pair concordance between height and length calculated. ROC of coracoid and glenoid were compared to measure extent of congruency. The mean usable length of coracoid process, width and height at mid-point were 21.8 mm, 13.7 mm and 8.6 mm, respectively. Out of the different screw sizes, 2.7 mm screws were found safe in 82% shoulders. 24 coracoid–glenoid pairs fulfilled the operational definition (≤ 5 mm) of congruency while rest 20 were seemingly incongruent chiefly due to coracoid variations, with mean ROC difference 4.13 mm (95% CI 1.51–6.74 mm). The ulnar length was significantly smaller in the incongruent ROC group (p = 0.0002). The available length as well as height of the transferred coracoid must be considered when deciding optimum diameter fixation screws in Latarjet procedure. Owing to smaller anatomic dimensions of coracoid in Indian population, 2.7-mm screws provide the safest fixation option. Also, the ROC of coracoid and glenoid does not match in substantial proportion of the cadavers. Pre-operative planning should include a CT-based assessment of glenoid and coracoid dimensions to decide the technique of Latarjet procedure and the optimum diameter fixation screws required.

Objective To investigate the clinical efficacy and outcomes of the coracoid osteotomy with or without Bristow–Latarjet procedures in the treatment of chronic anterior shoulder dislocation (CASD). Methods Between January 2013 and January 2019, 20 shoulders of 18 patients who were diagnosed with chronic anterior dislocation and underwent open reduction in our trauma center were retrospectively studied. Open coracoid osteotomy with Bristow–Latarjet procedures were performed on 16 shoulders and open coracoid osteotomy without Bristow–Latarjet procedures were performed on four shoulders. Open coracoid osteotomy with or without Bristow–Latarjet procedures were chosen on the basis of the stability of the shoulder after reduction. Outcomes were assessed preoperatively and postoperatively with the visual analog scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) score, the University of California Los Angeles (UCLA) shoulder rating scale, and the range of motion (ROM) for shoulder activity. Results There were three males and 15 females with an average age of 60.94 ± 2.69 years. The time between dislocation and treatment ranged from 21 to 240 days with an average of 73.3 ± 14.4 days. All patients were available for a mean follow‐up of 15.2 ± 4.3 months. No procedure‐related death or incision‐related superficial or deep tissue infection was identified in all cases. No iatrogenic neurovascular injuries or fractures were found in this study. At the time of 12 months follow‐up, the range of motion and the shoulder functional evaluation (VAS [P, Treatment of chronic anterior shoulder dislocation with open coracoid osteotomy and latarjet procedure.

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.

Objective To reconstruct the acromioclavicular (AC) joint using an adjusted closed‐loop double Endobutton technique via a guiding locator that was applied using three‐dimensional (3D) printing technology. At the same time, the reliability and safety of the novel double Endobutton (NDE) were tested by comparing the biomechanics of this technique with the TightRope (TR) approach. Methods This retrospective study was conducted between January 2017 and January 2019. The Department of Anatomy at Southern Medical University obtained 18 fresh‐frozen specimens (8 left and 10 right; 12 men and 6 women). First, the guiding locators were applied using 3D printing technology. After preparation of materials, specimens were divided into an NDE group, a TR group, and a normal group. In the NDE and TR groups, the navigation module was used to locate and establish the bone tunnels; after that, the NDE or TR was implanted. However, the Endobuttons were fixed while pressing the distal clavicle downwards and the length of the loop could be adjusted by changing the upper Endobutton in the NDE group while the suture button construct was tensioned and knotted after pressing down the distal clavicle in the TR. Finally, load testing in anterior–posterior (AP), superior–inferior (SI), and medial–lateral (ML) directions as well as load‐to‐failure testing in the SI direction were undertaken to verify whether the NDE or TR had better biomechanics. Results In the load testing, the displacements of the NDE and TR groups in the AP, SI, and ML direction were significantly shorter than those of the normal group (P 0.05). In the NDE group, four of six failures were a result of tunnel fractures of the coracoid, while two of six were due to suture breakage. In the TR, three failures were due to coracoid tunnel fractures, one was a result of a clavicle tunnel fracture, and the rest were due to suture breakage. In the normal group, half of the failures were a result of avulsion fractures of the conical ligament at the point of the coracoid process, and the other three were due to rupture of the conical ligament, fracture of the distal clavicle, and fracture of the scapular body. Conclusion As for the TR technique, the stability and strength of the AC joint were better in patients who underwent reconstruction using the NDE technique than in the intact state., This study created a novel double Endobutton technique combined with 3D printing and verified that its biomechanics were not statistically different from those of TR but were better than for normal ligaments.

Glenoid augmentation using free bone blocks for anterior shoulder instability has been proposed as an alternative to or bail-out for the Latarjet procedure. The purpose of this investigation was to systematically review and compare outcomes of patients undergoing glenoid augmentation using free bone block autografts versus allografts. A systematic review using PubMed, MEDLINE, Embase, and the Cochrane Library databases was performed in line with the PRISMA statement. Studies reporting outcomes of patients treated with free bone block procedures for anterior shoulder instability with minimum 2-year follow-up were included. Random effects modelling was used to compare patient-reported outcomes, return to sports, recurrent instability, non-instability related complications, and development of arthritis between free bone block autografts and allografts. Eighteen studies comprising of 623 patients met the inclusion criteria for this investigation. There were six studies reporting on the use of allografts (of these, two used distal tibial, three iliac crest, and one femoral head allograft) in 173 patients and twelve studies utilizing autografts (of these, ten used iliac crest and two used free coracoid autograft) in 450 patients. Mean age was 28.7 ± 4.1 years for the allograft group and 27.8 ± 3.8 years for the autograft group (n.s). Mean follow-up was 98 months in autograft studies and 50.8 months for allograft studies (range 24–444 months, n.s). Overall mean increase in Rowe score was 56.2 with comparable increases between autografts and allografts (n.s). Pooled recurrent instability rates were 3% (95% CI, 1–7%; I2 = 77%) and did not differ between the groups (n.s). Arthritic progression was evident in 11% of autografts (95% CI, 2–27%; I2 = 90%) and 1% (95% CI, 0–8%; I2 = 63%) of allografts (n.s). The overall incidence of non-instability related complications was 5% (95% CI, 2–10%; I2 = 81%) and was similar between the groups (n.s). Pooled return to sports rate was 88% (95% CI, 76–96%; I2 = 76%). Glenoid augmentation using free bone block autograft or allograft in the setting of recurrent anterior shoulder instability with glenoid bone loss is effective and safe. Outcomes and complication incidence using autografts and allografts were comparable. Due to the high degree of heterogeneity in the data and outcomes reported in available studies, which consist primarily of retrospective case series, future prospective trials investigating long-term outcomes using free bone block autograft versus allograft for anterior shoulder instability with glenoid bone loss are warranted. IV.

© 2020 Journal of Shoulder and Elbow Surgery Board of Trustees Background: The reconstructive options for instability-related anterior glenoid bone loss include iliac crest autograft, allograft, or coracoid transfer. The use of distal clavicle autograft (DCG) has also been described. The purpose of this imaging and cadaveric study was to examine the dimensions, morphology, and bone density of the DCG and compare it with the Latarjet procedure. Methods: We used 49 computed tomography scans from patients with anterior glenoid bone loss to measure the distal clavicle dimensions and bone density. Four glenoid reconstructions were simulated to compare techniques: DCG inferior surface toward glenoid (DCG inferior), DCG superior, classic Latarjet, and congruent-arc Latarjet. In addition, the morphology of the DCG was assessed on computed tomography and confirmed in 27 cadavers. Results: The mean width of the DCG (11 mm) was significantly greater (P

The superior surface of the anatomical neck is presented in the classification of scapular fractures as a 2-cm-long structure, which does not correspond to reality. This issue has not yet been adequately addressed in the literature. The aim of the study was to assess the variability of a notch between the upper rim of the glenoid and the coracoid base, the so-called coracoglenoid notch (CGN), and its clinical significance. The study was based on the examination of 204 dry bone specimens of adult scapulae (92 male and 112 female). We have determined quantitative criteria for the evaluation of the CGN type, measuring the offset of anatomical neck using a digital caliper. The findings were compared with 3D CT reconstructions of fractures of the scapular anatomical neck. Three basic types of CGN have been identified: type A—a well-developed notch in 31%, type B—a shallow notch in 53% and type C—an absent notch in 16%. No significant difference in CGN was found between the sexes, or between the right and left sides. When compared with our six cases of the anatomical neck fracture of the scapula, two patients displayed CGN type A and type B, respectively; but in four patients, it was impossible to distinguish between types A and B. The study has documented a high variability of CGN. Its presentation in the classification schemes does not correspond to anatomical reality. The presence of a deep, or shallow, notch may constitute an anatomical predisposition to a fracture of the anatomical neck.

The Latarjet procedure traditionally has been performed with 2 screws in an open manner. Recently, cortical suture button fixation for coracoid transfer has been used in hopes of mitigating complications seen with screw placement. The aim of this study was to evaluate a cortical suture button and technique currently available in the United States compared with screw fixation in the Latarjet procedure in a cadaveric model.We randomly assigned 9 matched pairs of fresh-frozen cadaveric shoulders (N = 18) to undergo the Latarjet procedure with either screw fixation or cortical suture button fixation. After fixation, all shoulders underwent biomechanical testing with direct loading on the graft vas a material testing system. Cyclic testing was performed for 100 cycles to determine axial displacement with time; each graft was then monotonically loaded to failure.The maximum cycle displacement was significantly less for screw fixation vs. cortical suture button fixation (3.1 ± 1.3 mm vs. 8.9 ± 2.1 mm, P.0001). The total load at failure was 481.1 ± 88.8 N for screws and 175.5 ± 95.8 N for cortical suture buttons (P.0001). Bony damage to the surrounding anatomy was more extensive at failure in the screw-fixation group.At time zero, the cortical button fixation and technique did not resist direct loads to the graft as much as traditional screw fixation, although bony damage to the surrounding anatomy was more extensive in screw fixation than button fixation. In the event of unanticipated loading, this could place a patient at higher risk of graft migration, which could lead to unintended early outcomes. These results support the need for implants and techniques specifically tailored to the Latarjet procedure and should bring into question the adoption of a cortical button and technique not specific to the procedure.

Background Accurate glenoid positioning in reverse total shoulder arthroplasty (RSA) is important to achieve satisfying functional outcome and prosthesis longevity. Optimal component placement can be challenging, especially in severe glenoid deformities. The use of patient-specific instruments (PSI) and 3D computer-assisted optical tracking navigation (NAV) are already established methods to improve surgical precision. Augmented reality technology (AR) promises similar results at low cost and ease of use. With AR, the planned component placement can be superimposed to the surgical situs and shown directly in the operating field using a head mounted display. We introduce a new navigation technique using AR via head mounted display for surgical navigation in this feasibility study, aiming to improve and enhance the surgical planning. Methods 3D surface models of ten human scapulae were printed from computed tomography (CT) data of cadaver scapulae. Guidewire positioning of the central back of the glenoid baseplate was planned with a dedicated computer software. A hologram of the planned guidewire with dynamic navigation was then projected onto the 3D-created models of the cadaver shoulders. The registration of the plan to the anatomy was realized by digitizing the glenoid surface and the base of the coracoid with optical tracking using a fiducial marker. After navigated placement of the central guidewires, another CT imaging was recorded, and the 3D model was superimposed with the preoperative planning to analyze the deviation from the planned and executed central guides trajectory and entry point. Results The mean deviation of the ten placed guidewires from the planned trajectory was 2.7° ± 1.3° (95% CI 1.9°; 3.6°). The mean deviation to the planned entry point of the ten placed guidewires measured 2.3 mm ± 1.1 mm (95% CI 1.5 mm; 3.1 mm). Conclusion AR may be a promising new technology for highly precise surgical execution of 3D preoperative planning in RSA.

Background: Since the description of the arthroscopic Latarjet technique, discussion about the superiority of the open or arthroscopic procedure has arisen. The appropriate placement of the coracoid graft (CG) on the anterior glenoid neck is reported to be the most important step of the Latarjet procedure. Purpose: To verify if there are differences in the parameters that may affect the final position and fixation of CG obtained from the open and arthroscopic Latarjet techniques. Study Design: Controlled laboratory study. Methods: Twenty fresh-frozen human paired cadaveric shoulder specimens were randomly distributed in 2 surgery groups (open group [OG] and arthroscopic group [AG]) with 10 specimens in each. Two surgeons, each with experience performing open and arthroscopic Latarjet techniques, executed these procedures: one surgeon performed all open techniques, and the other performed all arthroscopic techniques, respectively. After surgery, a computerized tomography scan was performed. The surgical time, the position of each CG, a series of variables that might affect the CG fixation, and the level of the subscapularis muscle split were evaluated. Results: The mean surgical time was significantly longer in the AG (mean, 26 minutes for OG and 57 minutes for AG). Three intraoperative complications (30%) were identified in the AG, consisting of graft fractures. The CG was determined to be in an optimal cranial-caudal position in 90% of specimens of the OG and 44% of the AG (Fisher, P = .057). In both groups, the CG was placed in an optimal medial-lateral position in all specimens. In the OG, the degree of parallelism between the major axes of the glenoid surface and CG was significantly greater than in the AG (mean, 3.8º for OG and 15.1º for AG). No significant differences were observed in superior and inferior screw orientation between the groups. In the longitudinal and transverse directions, significant differences were found in the centering of the superior screw, being closer to the ideal point in the OG than in the AG. The location where the longitudinal subscapularis muscle split was performed was significantly higher in the AG. Conclusion: The open Latarjet technique required less surgical time; presented a lower number of intraoperative complications; and allowed more adequate placement of the CG, better centering of the screws, and a subscapularis muscle split closer to the ideal position. Clinical Relevance: The reported benefits of the arthroscopic Latarjet technique seem less clear if we take into account the added surgery time and complications.

Background The observation of the roller-wringer effect fueled the idea that coracoid morphology is related to subscapularis pathology. We aimed to examine this relationship, specifically focusing on how the coracohumeral distance (CHD) and 2 new metrics of coracoid morphology relate to subscapularis tears. Methods In this retrospective study, we identified consecutive patients 45 years or older who underwent shoulder arthroscopy for any indication. We blindly reviewed preoperative magnetic resonance imaging studies of each patient, measuring the CHD, lateral extent (LE), and caudal extent (CE) of the coracoid process. Patients' subscapularis condition was assessed via operative reports; stratified according to Lafosse grade criteria; and compared for differences in the CHD, LE, and CE by 1-way analysis of variance and 2-tailed t tests. Results The study included 201 patients. Of these, 112 had no evidence of subscapularis injury, whereas Lafosse grade I injuries were identified in 52 patients; grade II, in 19; and grades III-V, in 18. The CHD, LE, and CE were not correlated with subscapularis injury (CHD, P = .36; LE, P = .36; and CE, P = .13). Conclusions We found no correlation between subscapularis injury and the CHD, LE, and CE. These findings support the idea that coracoid morphology may not be a cause of subscapularis pathology and suggest that coracoplasty may not be necessary prophylactically or as part of subscapularis repair.

Until now, classifications of coracoid fractures have been based on plain radiographs, without use of 3D CT reconstructions. Therefore, the aim of the present study has been to describe the pathoanatomy of these fractures and their associated injuries to the shoulder girdle, on the basis of 3D CT reconstructions. The cohort comprised 39 patients, who each sustained a coracoid fracture investigated with 3D CT reconstructions. The patients were assessed in terms of age, gender, pathoanatomy of the coracoid fracture, fractures of other parts of the scapula, and associated injuries to the shoulder girdle. We identified 24 fractures of the base, one fracture of the beak body, eight fractures of the apex, and six comminuted fractures of the coracoid process. A total of 22 associated injuries were found (7 fractures of the acromion, 5 fractures of the anterior glenoid rim, 3 fractures of the superior glenoid, 1 fracture of the inferior glenoid, 4 fractures of the surgical neck, 2 fractures of the scapular body) and 18 other associated injuries to the shoulder girdle (8 AC dislocations, 5 proximal humeral fractures, and 5 clavicular fractures). On the basis of 3D CT reconstructions, four basic coracoid fracture patterns were identified. The authors´ findings and literature review have shown that a considerable number of coracoid fractures are combined with injuries to other parts of scapula and shoulder girdle. These associated injuries must be taken into account and targeted when taking the patient’s history, and during clinical and primarily radiological examinations.

Glenoid bony lesions play a role in approximately half of anterior shoulder instability cases. The purpose of this study is to see if the anatomy of the coracoid affects the location of glenoid rim defects. We hypothesized that a prominent coracoid (lower and lateral) would be more likely to cause an anterior–inferior glenoid lesion, and a less prominent coracoid more prone to cause an anterior lesion. The null hypothesis being the absence of correlation. Fifty-one shoulder CT-scans from a prospective database, with 3D reconstruction, were analyzed. The position of glenoid lesions was identified using the validated clock method, identifying the beginning and end time. The size of bony glenoid defects was calculated using the validated glenoid ratio method. The position of the coracoid tip was measured in three orthogonal planes. Analysis included 25 right shoulders and 26 left shoulders in seven females and 41 males. The vertical position of the coracoid tip relative to the top of the glenoid was highly correlated to the location of the glenoid defect on the profile view (r = −0.625; 95% CI 0.423–0.768; p = 0.001). Thus, higher coracoids were associated with anterior lesions, while lower coracoids were associated with anterior–inferior lesions. A more laterally prominent coracoid was also correlated with anterior–inferior lesions (r = 0.433; 95% CI 0.179–0.633; p = 0.002). This study shows that coracoid anatomy affects the location of bony Bankart defects in anterior shoulder instability. Lower and laterally prominent coracoids are associated with anterior–inferior lesions. This variation in anatomy should be considered during pre-op planning for surgeries involving bone graft. Level 4 basic science.

Purpose The purpose of this study was to compare the clinical, functional, and radiographic outcomes of open versus arthroscopic Latarjet procedures. Methods Between December 2009 to January 2015, all patients older than 18 years of age who were treated with a Latarjet procedure for chronic osseous anterior instability by a single surgeon were included in this retrospective cohort study. Range of motion, strength, Rowe, Western Ontario Shoulder Instability Index (WOSI) scores, and pain level according to the Visual Analog Scale (VAS) were evaluated. In addition, postoperative computed tomography scans were used to evaluate the position of the transferred coracoid, screw orientation, and degree of graft resorption. Results Forty-eight patients with a mean age of 29.5 years (range 19-59 years) who underwent open (n = 15; group OL) and arthroscopic (n = 33; group AL) Latarjet procedures were included in the study. The mean follow-up was 30.5 months (range 24-50 months). At final follow-up there were significant differences in the mean internal rotation loss (mean of 9° vs 14°, P = .044) favoring open surgery and WOSI (P = .017) scores favoring arthroscopic. No significant differences were detected in mean forward flexion loss (P = .918), external rotation loss (P = .883), Rowe (P = .429), and Visual Analog Scale (P = .208) scores. Mean superoinferior position of the coracoid bone graft was found between the 1:55 and 4:49 o’clock positions (2:05-4:55 for group OL; 1:51-4:47 for group AL) in en-face views. The grafts were placed laterally in 13% (group OL) and 9% (group AL) of patients. The mean α angles of the screws were 11° and 19.2°, respectively (P = .004). The mean graft resorption rates were 21% and 34% (P = .087), respectively. Conclusion Good functional results were obtained after both open and arthroscopic Latarjet procedures for the treatment of chronic osseous anterior shoulder instability. Comparative analysis showed small but statistically significant differences in internal rotation loss favoring open and in WOSI favoring arthroscopic techniques. All measured radiographic parameters were similar with the exception of a significant difference in alpha angle with improved screw position in open surgery. OL and AL techniques provide similar clinical and radiographic outcomes. Level of Evidence III; Retrospective cohort study with comparison group.

The glenoid track paradigm has played a pivotal role in the development of a contemporary approach to shoulder stabilization surgery. A number of studies have validated the importance of bipolar bone loss in the pathogenesis of recurrent anterior shoulder instability and defined the limitations of soft tissue–based, arthroscopic surgical approaches. The glenoid track paradigm has also helped to clarify the indications for coracoid transfer procedures, although some question persists as to the necessity of addressing an “off-track” Hill-Sachs lesion with remplissage concurrently with the Latarjet procedure for large glenoid bone defects. The best available evidence would suggest that the Latarjet procedure can be expected to yield favorable clinical outcomes even in the setting of an off-track Hill-Sachs lesion, thereby obviating the necessity of concomitant remplissage for cases involving advanced degrees of bipolar bone loss.

Surgical management of chronic acromioclavicular joint (ACJ) dislocations is a matter of controversy. In the acute setting of high-grade acromioclavicular separation, if a surgical repair of the ACJ capsule and ligaments and deltotrapezial fascia could allow biological healing of the ligaments themselves, this could be enough to restore the functional biomechanics of the joint; unfortunately, this is not true for chronic cases. In the latter situation, a surgical technique using biological augmentation such as autograft or allograft should be preferred. Time is very important for this injury, and a chronic lesion should be considered when treatment is being performed 3 weeks after trauma. The graft should be passed around the base of the coracoid or through a tunnel at the base of the coracoid itself and then at the level of the clavicle as anatomically possible to reproduce the function of the native ligaments. However, some studies have shown that passing the graft at the base of the coracoid and wrapping it around the clavicle could also achieve satisfactory outcomes. An arthroscopic technique, when used in combination, could be great to treat the associated lesions, which have a reported percentage between 30% and 49%. Finally, to restore the biomechanics of the ACJ, however, reconstruction of the acromioclavicular superior and posterior capsules together with the deltotrapezial fascia seems to be very important.

Aim Previous studies have suggested medial antebrachial cutaneous nerve of forearm (MACN) as a proper nerve graft to anastomosis of medial pectoral (MPN) and musculocutaneous (MCN) nerves.Evaluating the compatibility of MACN with MPN and MCN for the anastomosis from anatomical and histopathologic aspects. Material and methods Ten brachial plexus specimens from five cadavers were dissected. The distance of distal ends of MPN and MACN and proximal ends of MACN and MCN were measured from coracoid. Histopathologic slides from the four mentioned nerve ends provided. The Number of fascicles, cross-section diameter, and area of each nerve ends were measured. Results The distance of proximal and distal ends of MACN were adjacent to MPN and MCN. The mean number of fascicles (4.5 ± 1.2 vs. 2.9 ± 1.0), area (6.0 ± 2.5 vs. 2.8 ± 2.4) and diameter (2.7 ± 0.6 vs. 1.8 ± 0.7) of the distal end of MACN was significantly more than MCN. The mean number of fascicles (4.4 ± 1.4 vs. 2.6 ± 0.5), area (5.6 ± 2.4 vs. 2.0 ± 1.0) and diameter (2.6 ± 0.6 vs. 1.6 ± 0.4) of the proximal end of MACN was significantly more than MPN. The mentions parameters were similar between MCN and MPN. Conclusion Our study reveals that MACN is not a proper graft for MCN and MCN anastomosis due to the incompatibility of its diameter, area, and number of fascicles.

Background Anterior shoulder dislocation remains a clinical challenge. This study aimed to assess the graft position and clinical outcomes of the arthroscopic Latarjet procedure and capsular repair for the treatment of recurrent anterior shoulder dislocation with significant glenoid bone loss in 37 patients. Methods Between 2017 and 2017, 37 patients underwent arthroscopic Latarjet plus capsular repair procedure for recurrent anterior shoulder dislocation combined with significant glenoid bone loss. In follow-up examinations, Walch-Duplay scores, subjective shoulder value (SSV) scores, Rowe scores, and active range of motion (AROM) were assessed. Three-dimensional computed tomography (CT) was used to evaluate coracoid graft position and bone resorption. A new method of evaluating the position of the coracoid bone block after Latarjet (H-Z method) was developed. Results Thirty-seven patients were included in this study. Follow-up ranged from 6 to 36 months postoperatively (with an average of 13 months). No recurrent dislocation occurred at the final follow-up, and there was no significant effect on the AROM (all p > 0.05). Rowe (from 42.2 ± 5.6 to 91.1 ± 3.3), Walch-Duplay (from 31.5 ± 8.0 to 92.6 ± 3.7), and SSV (from 63.9 ± 6.1 to 79.3% ± 5.0%) scores were improved significantly after surgery (all p Conclusions In active patients with recurrent anterior shoulder dislocations and significant glenoid bone loss, the arthroscopic Latarjet procedure plus capsular repair could restore shoulder stability satisfactory.

The all-arthroscopic Latarjet is gaining popularity among shoulder surgeons, although the procedure is technically demanding and potentially dangerous, placing the brachial plexus and axillary vessels at risk when using screws for fixation of the bone block from the front. Matsen once wrote that "lateral to the coracoid is the safe side, while medial to the coracoid is the suicide." However, creation of a portal medial to the coracoid during arthroscopic reconstruction of the glenoid is needed to permit accurate positioning of the screws (parallel to the glenoid surface) and coracoid bone block (flush to the glenoid surface). Our own clinical experience with the arthroscopic Latarjet over the last decade has shown us that the safety of the arthroscopic medial transpectoralis portal depends on 3 technical considerations: (1) the portal should always be established in an outside-in fashion from anterior to posterior; (2) passing through the pectoralis major muscle with a relatively superficial trajectory, using a switching stick oriented with a 45° orientation toward the tip of the coracoid; and (3) under visual control of the anterior extra-articular subdeltoid space to end up lateral to the coracoid process. If these conditions are respected, surgeons should not worry: medial to the coracoid can also be a safe side! An inside-out technique (introducing a switching stick from posterior to anterior) is forbidden, as this would end up piercing the neurovascular structures. Once the coracoid has been osteotomized and the conjoint tendon retracted distally, all instruments passing though the transpectoral portal are directly in contact with the neurovascular structures. This is why working through the medial transpectoralis portal should be done only with the help of a cannula or half-pipe. Ideally, the transpectoral portal should not be used as a "working portal" but as a "protecting portal" instead, placing a stick or spreader to protect the neurovascular structures. To avoid working through the anterior medial portal, we have proposed a much safer alternative that consists of drilling the glenoid from posterior to anterior (using a guide and remaining inside the glenohumeral joint) and using cortical-buttons (instead of screws) for coracoid fixation. In this modern technique, the transpectoral portal makes the arthroscopic safe as it allows the introduction of a spreader to retract the subscapularis muscle and protect the neurovascular structures during transfer and fixation of the coracoid bone block.

The Latarjet procedure to treat instability was first described by the eponymous surgeon in 1954. Long-term results from this procedure have been favorable. In 2007, Lafosse et al. first described an all-arthroscopic technique for the Latarjet procedure. In the United States, the Latarjet procedure is most predictably indicated by surgeons in cases of significant glenoid bone loss, revision instability, and patients engaging in high-risk sport. In some European centers, the Latarjet has broader indications and is often also used as a first-line surgical intervention when conservative treatment has failed, including for those without bone loss or with multidirectional instability. • Achieve exposure of the inferior pole of coracoid and anterior glenoid rim; • coracoid is prepared; axillary nerve and brachial plexus are exposed; • coracoid portal is created; • coracoid is drilled and osteotomy is made; • coracoid transferred to anterior glenoid rim through split in subscapularis; • the bone graft is fixed in place with screws. Arthroscopic Latarjet can have a difficult learning curve compared with the open procedure. Both arthroscopic and open Latarjet have similar complication rates. The most common complications include graft fracture, non-union, and infection and are less than 2%. Arthroscopic Latarjet is reported to be less painful initially, but this equalizes by 1 month. Studies have shown that arthroscopic Latarjet results in excellent graft position. Recurrent instability for arthroscopic Latarjet ranges from 0.3% to 4.8% and is comparable with open Latarjet procedures. In summary, the arthroscopic Latarjet procedure results in less pain early, excellent coracoid graft position, and has a similar complication rate to open Latarjet.

STUDY DESIGN Retrospective study. OBJECTIVE The primary objective of this study was to assess the conformity of the radiological neck and shoulder balance parameters throughout a follow-up period of more than 2 years. SUMMARY OF BACKGROUND DATA Postoperative shoulder and neck imbalance are undesirable features among Adolescent Idiopathic Scoliosis patients who underwent Posterior Spinal Fusion. There are many clinical and radiological parameters used to assess this clinical outcome. However, we do not know whether these radiological parameters conform throughout the entire follow-up period. METHODS This was a retrospective study done in a single academic institution. Inclusion criteria were patients with scoliosis who underwent posterior instrumented spinal fusion with pedicle screw fixation and attended all scheduled follow-ups for at least 24 months postoperatively. Radiological shoulder parameters were measured from both preoperative antero-posterior and postoperative antero-posterior radiographs. Lateral shoulder parameters were: Radiographic Shoulder Height, Clavicle Angle (Cla-A), Clavicle-Rib Intersection Difference, and Coracoid Height Difference. Medial shoulder and neck parameters were: T1 Tilt and Cervical Axis (CA). RESULTS The radiographs of 50 patients who had surgery done from November 2013 to November 2015 were analyzed. Mean age of this cohort was 16.3 ± 7.0 years. There were 38 (76%) female patients and 12 (24%) male patients. Mean final follow-up was 38.6 ± 5.8 months. When conformity assessment of the radiological parameter using the interclass coefficient correlation was done, we found that all parameters had significant correlation (P

Latarjet technique via open or arthroscopic approach is a very complex surgery that includes several steps. The coracoid placement that is performed at the end of this procedure represents the key point to avoid complications and attain the best clinical results. Mechanics and biology need to work as a whole to improve the integration of the graft on the glenoid neck.

To compare screw insertional torque and coracoid-glenoid compression from 4 fixation techniques with different screw design parameters and cortical augmentation for the Latarjet procedure.Simulated Latarjet procedures were performed with 4 fixation techniques using laminated polyurethane blocks with dimensions similar to the coracoid-glenoid construct. The groups included DePuy Synthes Mitek 3.5-mm partially threaded screws with top hats, Arthrex 3.75-mm fully threaded screws with a 2-hole plate, Arthrex 3.75-mm fully threaded screws, and SmithNephew 4.0-mm partially threaded screws. Screws were inserted using a digital torque-measuring screwdriver to determine maximum insertional torque. Pressure-sensitive film was used to measure the maximum contact pressure and the effective pressure distribution (EPD) between the coracoid and glenoid; the EPD represents the percentage of the film's surface area that experienced pressure greater than 10 MPa. One-way analysis of variance and post hoc tests were used for statistical analysis.Significant differences were found between the 4 fixation groups for each variable measured. The 2 cortically augmented systems produced significantly higher maximum insertional torque than the non-cortically augmented systems (P.001 for both). The 3.75-mm screws with a 2-hole plate yielded significantly higher contact pressures than the 4.0-mm screws (P = .028). This group also had a high EPD, with a mean value more than double the values of the non-cortically augmented systems (P = .037 and P.001).Cortically augmented fixation methods showed higher maximum insertional torque, maximum contact pressure, and EPD between the surfaces of the coracoid and glenoid in this Sawbones model.Various implants are available for the Latarjet procedure, but their biomechanical characteristics have not yet been fully elucidated. Graft fracture and nonunion represent 2 modes of failure that may be related to insertional torque and coracoid-glenoid compression. This study compared screw insertional torque and compression achieved using 4 fixation techniques with different screw design parameters and cortical augmentation in a Sawbones model.

Purpose The purpose of this descriptive study was to define patterns of ossification and fusion of growth centers around the pediatric and adolescent glenoid as a function of age using 3-dimensional, frequency-selective, fat-suppressed spoiled gradient recalled echo magnetic resonance (MR) imaging sequences, with a particular focus on the anterior glenoid rim because of its clinical relevance as a potential confounder of glenohumeral instability. Methods Picture Archiving and Communication System records at an urban academic tertiary care orthopaedic facility from October 2005 to December 2018 were queried for shoulder MRI in patients aged 9 to 17 years. Patients were excluded if they had any diagnoses that could alter glenoid development. All images were independently evaluated by a musculoskeletal fellowship-trained radiologist. Secondary ossification centers were characterized as cartilage anlage, ossified, or fused at 3 anatomic sites: the anterior glenoid rim, coracoid, and superior glenoid rim. Results A total of 250 MR examinations (143 males, 107 females) were assessed in this study. The glenoid develops in a predictably sequential manner with ossification at the anterior glenoid rim lagging behind the coracoid and superior glenoid rim. The earliest age of anterior glenoid rim ossification was 11 years for both males (range 11-17) and females (range 11-12). Anterior glenoid rim ossification peaked at age 16 among males (34.8%, 8/23) and age 11 among females (27.3%, 3/11). Conclusions Glenoid ossification and fusion progress in a predictable and chronological manner. This pattern should be used as a guideline when interpreting pediatric shoulder MRI examinations. In particular, an anterior glenoid ossification center should not be confused with an anterior glenoid injury (e.g., Bankart lesion), particularly in males 11 to 17 years old and females 11 to 12 years old. Level of Evidence IV (case series).

Background Latarjet is one of the most common surgical procedure performed on patients with shoulder instability with osseous defects, some complications include coracoid bone graft osteolysis, osteoarthritis, graft detachment, and malpositioning were previously reported. Several studies investigated potential causes of graft osteolysis but still, it remains a crucial area of investigation. We aim to use finite element analysis to examine the potential correlations between three modes of fixation methods used in the Latarjet procedure (screw, wedge plate, and endobutton), and the coracoid graft osteolysis. Hypothesis Finite element analysis tested the hypothesis that there is a linear relationship between the compression stress on graft which was generated by fixation methods used in the latarjet and the coracoid graft osteolysis. Material and methods Boundary conditions and inhomogeneous material properties were carefully assigned within the material of the scapula and coracoid interface. For the screw and wedge plate fixations, an applied torque in the range of 1–1.5 Nm was used to characterize the surgeon's insertion torque during the surgical operation, while a 100 N compressive force was selected for the endobutton fixation. Results Relatively lesser stress magnitudes were observed with endobutton fixation method rather than screw and the wedge plate fixation. Statistical analyses revealed significant differences between the groups (p Discussion Excessive compressive stresses within the coracoid graft regions may be responsible for osteolysis due to negative effects over biological factors such as blood flow. Our study emphasizes the importance of taking into account the fixation method while performing the Latarjet procedure. We concluded that the mode of fixation used within the Latarjet procedure has a correlation on the coracoid graft osteolysis. Level of evidence I.

The pathogenesis of degenerative subscapularis (SC) tear is not clear, several mechanisms are involved: intrinsic tendon degeneration or subcoracoid impingement. The aim of this study was to propose new radiographic markers, the coraco-lesser tuberosity angle (CLA), lesser tuberosity angle (LTA) and lesser tuberosity height (LTH). The hypothesis was that higher values of CLA, LTA, and LTH would be associated with a higher likelihood in detecting a SC tear.A total of 114 patients who classified as SC tears through arthroscopic evaluation were retrospectively enrolled in the study from 2016 to 2018. Fifty-seven patients with impingement syndrome were also enrolled as the control group for normal-population comparison. The CLA was measured on an anteroposterior shoulder x-ray image with the arm in neutral rotation, the LTA and LTH were measured on magnetic resonance imaging. Multivariable analyses were used to clarify the potential risks for SC tears. All measurements were calculated by two shoulder surgeons independently measured at 2 different times, 1 month apart.The intra- and inter-observer reliabilities for radiologic measurements and the interobserver reliability of SC tear classification were almost perfect. The mean CLA value of SC tear group (41.4±4.2°) was significantly larger than that of the control group (38.7±4.0°, p0.001). The mean LTA value of SC tear group (33.4±4.3°) was significantly larger than that of the control group (31.0±3.9°, p=0.001). Mean LTH value was 9.5±1.9mm in patients and 8.9±1.5mm for controls, there was no statistically significant difference (p=0.054). Multivariable analysis showed that larger CLAs significantly increased the risk of SC tears, with odds ratios of 1.17 per degree. Moreover, larger LTAs also significantly increased the risk of SC tears, with odds ratios of 1.14 per degree.Our findings confirmed associations between new predictors (CLA and LTA) and SC tears. CLA and LTA values were greater in patients with SC tears than in controls, suggesting that they may be independent risk factors for SC tear onset.IV, retrospective study.

Purpose: Iatrogenic coracoid and clavicle fracture is a known complication of drilling bone tunnels during anatomic coracoclavicular ligament reconstruction (ACCR). This study aims to measure the dimensions of coracoid process and clavicle in an Asian population to evaluate the suitability of drilling coracoid and clavicle tunnels for ACCR in Asians. Methods: Width measurements of 196 coracoids and 189 clavicles were obtained after reviewing all computed tomography (CT) scans of the shoulder performed over a 6 years period. Coracoid measurements were made on the CT slice which showed the maximum cross sectional width of the coracoid base. Medial to lateral measurements of the coracoid width were taken on an axial view, 4 mm above the identified junction of the coracoid base and glenoid base. Antero-posterior clavicle width was measured through a point directly above the midpoint of the coracoid and perpendicular to the long axis of the clavicle. Results: The overall mean coracoid width was 14.8 mm ± 2.54 mm (range 9.2-23.3 mm) and clavicle width was 17.1 mm ± 2.72 mm (range 11.1-25.3 mm). Conclusion: The Asian coracoid process is smaller than its Western equivalent. More research is required to validate this conclusion as no cadaveric studies with equivalent measurement techniques have been performed on Asians. Given the potentially narrower dimensions of the Asian coracoid process, extra precautions are required to minimize the risk of iatrogenic coracoid and clavicle fractures. Key words: Coracoclavicular ligament reconstruction; Coracoid process; Clavicle; Width

Background Data regarding the parameters of the coracoid process and glenoid width are insufficient, and information on gender, age, and ethnic differences in the parameters appear lacking in the Chinese population. This study aimed to investigate the morphometric parameters in the coracoid process and glenoid width. Methods Using our institution’s electronic database, we selected 84 patients (55 males and 29 females) who underwent a shoulder computed tomography (CT) scan from January 2017 to May 2018 in this study. Mimics19.0 software was used for three-dimensional (3D) reconstruction of CT and to measure the morphometric parameters of the coracoid process and glenoid width. Subgroup analyses stratified by gender and age were conducted and the parameters were compared with previously published reports. All data were statistically analysed by SPSS23.0 Statistical Package. Results A positive and significant relationship between the coracoid process and the glenoid width (R > 0.758, P < 0.01) was found. The midpoint width represents 52% (41–62%) of the glenoid width; the midpoint height, 40% (31–53%) of the glenoid width. Significant differences in all parameters between males and females were noted (P < 0.05). No significant differences among the age groups were observed (P > 0.05), whereas significant differences in almost all parameters between the ethnic groups were observed (P < 0.05). Conclusion Our results could supplement the information in the shoulder joint database with morphometric parameters and provide a reference for theoretical research on coracoid osteotomy, which may in turn help surgeons in the evaluation of coracoid process transfer.

Introduction There are many variations of scapula morphology. Evaluation of scapula morphology is necessary to elucidate shoulder joint movement. We aimed to analyze the bone morphology of various parts constituting the scapula to identify certain conserved features among them. Materials and methods Thirty-one healthy individuals were the subjects. We created a scapular three-dimensional (3D) model using computed tomography (CT). X and Y axes were set on a glenoid surface. We measured the approximate plane of the upper and lower scapular bodies and scapular spine and the central axis of the coracoid and acromion. The anatomical position of the scapular spine, upper and lower bodies, coracoid, and acromion was measured. The positional relationship between the upper and lower bodies and scapular spine and the coracoid and acromion was evaluated. The average angle of the upper and lower scapular bodies and the scapular spine with respect to the XZ plane was calculated. The average angle of the coracoid and acromion with the X-axis on the XY plane and Z-axis on the YZ plane was calculated. Results On the XY plane, approximate planes of the upper and lower part of the body and the scapular spine were significantly correlated to each inclination. On the XY plane, inclinations of the central axes of the coracoid and acromion were significantly correlated. Conclusions The findings revealed for the first time the correlation between the inclinations of the scapular body and scapular spine and the inclination angle between the coracoid and acromion.

A commonly used method of fixation of the transferred coracoid in the traditional Latarjet–Bristow procedure (open or arthroscopic) is by two bicortical screws. Although mechanically effective, screw fixation is also a major source of hardware and neurologic complications. This study aimed to compare the biomechanical performances of traditional metal screws and endobuttons as fixators of the Latarjet–Bristow procedure. Nine fresh-frozen cadaveric human scapulae with the conjoined tendon attached to the coracoid process were used for the Latarjet–Bristow procedure. The specimens were randomly assigned one of two groups: fixation using two 4.5-mm cannulated partially threaded Latarjet–Bristow experience screws or fixation using a suture-button construct. Specimens were secured in a material testing machine and cyclically preconditioned from 2 to 10 N at 0.1 Hz for ten cycles. They were then pulled to failure at a normalized displacement rate of 400% of the measured gauge length per minute. The maximal load-to-failure, stiffness and stress were calculated using a custom script. The failure mechanism and site were recorded for each specimen. There were no significant differences in the maximal load-to-failure or other biomechanical properties of the two fixation techniques, but the failure mechanisms were unique to each one. Four specimens fixated with screws underwent graft failures (fracture) through the proximal or distal drill hole. Five specimens fixated with endobuttons underwent failure due to glenoid bone fractures. A single endobutton fixation appears to be biomechanically comparable to screw fixation in the Latarjet–Bristow procedure and provides a lower risk for graft fracture. Further studies with more numerous specimens are warranted to conclusively validate these findings.