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Background: Rotator cuff tears involving the subscapularis are less common than those involving the superior aspect of the rotator cuff. The purpose of the present study was to report the results of repair of isolated tears of the subscapularis.Methods: The records on eighty-four shoulders that had undergone open repair of the subscapularis tendon were reviewed. The mean age of the patients at the time of surgery was 53.2 years. The mean interval from the onset of symptoms to the time of surgery was 12.5 months. Fifty-seven tears were traumatic, and twenty-seven were degenerative. Twenty-three tears involved the superior one-third of the subscapularis tendon, forty-one tears involved the superior two-thirds, and twenty tears were complete. Fifty-four shoulders had a dislocation or subluxation of the long head of the biceps tendon, and ten shoulders had a rupture of the long head of the biceps tendon. Forty-eight shoulders underwent concomitant biceps tenodesis, thirteen shoulders underwent concomitant biceps tenotomy, and four shoulders underwent concomitant recentering of the biceps. Patients were evaluated clinically and radiographically at a mean of forty-five months (range, twenty-four to 132 months) postoperatively.Results: The mean Constant score increased from 55.0 points preoperatively to 79.5 points postoperatively. Seventy-five patients were satisfied or very satisfied with the result. Preoperatively, four shoulders had mild glenohumeral arthritis. Postoperatively, twenty-five shoulders had mild glenohumeral arthritis and two shoulders had moderate glenohumeral arthritis. Tenodesis or tenotomy of the biceps tendon at the time of subscapularis repair was associated with improved subjective and objective results, independent of the preoperative condition of the biceps tendon.Conclusions: Repair of isolated subscapularis tears yields acceptable improvement in shoulder function in selected patients. Additionally, the results of the present study support routine tenodesis or tenotomy of the long head of the biceps tendon at the time of subscapularis repair. [ABSTRACT FROM AUTHOR]

Background: There is no evidence on which functional levels have to be recovered to return to the preinjury sport at preinjury level, i.e. successful RTS, after open Latarjet procedure. Therefore, this study aimed to identify whether RTS criteria assessed at 4.5 months postoperatively predict successful RTS at 1 year after open Latarjet procedure., Methods: All patients who underwent an open Latarjet procedure between August 2018 and July 2021 were eligible. At 4.5 months postoperatively, patients completed the Shoulder Instability-Return to Sport after Injury questionnaire, and performed unilaterally with each side maximal isometric strength in glenohumeral internal and external rotation, upper-quarter Y balance test, unilateral seated shot-put test, and modified closed kinetic chain upper extremity stability test. They answered RTS inquiry at 12 months postoperatively. Logistic regressions were applied to assess the ability of ratios based on operated-nonoperated ratios, or on dominant-nondominant ratios, to predict successful RTS., Results: Among 126 eligible patients, 110 answered the RTS inquiry; 21 were excluded, 49 patients were included in the successful RTS group, and 40 in the unsuccessful RTS. No ratios based on operated-nonoperated ratios were prognostic factors for successful RTS. Despite a low precision of the model (area under the ROC curve = 0.64), dominant-nondominant ratios in internal rotation strength (Odd-Ratio = 0.98; p=0.02), balance between external and internal rotator strength at the operated shoulder (OR = 1.03; p=0.02) and muscular endurance ability (OR = 1.03; p=0.04) were found prognostic factors for successful RTS., Conclusion: The findings challenge the ability of criteria expressing operated shoulder functions with reference to those of the contralateral one in predicting a successful return to sport. They suggest that, when assessed 4.5 months postoperatively, the balance of function between dominant and nondominant shoulders in reference to those of healthy athletes would be better predictors of returning to preinjury sport at the preinjury level. This study highlights that clinicians and sport supervisors may place particular care on recovery in dominant-nondominant balance in maximal internal rotation strength and in upper extremities strength endurance to enhance the likelihood to return to sport successfully for their athletes who underwent anterior shoulder stabilization surgery by open Latarjet procedure., (Copyright © 2025. Published by Elsevier Inc.)

Background: The debate surrounding the influence of the open Latarjet procedure on postoperative scapular motions persists, and there is no evidence regarding its effects on periscapular muscle activation. This study aimed to assess the short-term influence of the open Latarjet procedure on scapular kinematics and periscapular muscle activity during arm raising and lowering based on comparisons between patients and healthy athletes., Methods: 22 healthy male athletes and 22 male athletes scheduled for glenohumeral stabilization surgery by the open Latarjet procedure were included. Scapular kinematics, periscapular muscle activities, and shoulder-related quality of life were recorded before surgery and 3 months postoperatively for the Latarjet group. For the healthy group, same assessments were performed 3 months apart. Bilateral differences in both scapular kinematics and periscapular muscle activation ratios and the Western Ontario Shoulder Instability (WOSI) index were defined as dependent variables., Results: Scapular kinematics of the operated shoulder, namely scapular upward/downward rotation, internal/external rotation, and anterior/posterior tilt recorded between 20° and 120° of humerothoracic elevation, showed no alterations 3 months after surgery (P > .05) and did not differ from those observed in healthy athletes (P > .05). Similarly, all periscapular muscle activations were not different within time and between groups (P > .05). The WOSI index of the operated shoulder was significantly improved postoperatively (871.9 ± 443.7 vs. 1346.3 ± 552.3) but remained higher than the WOSI indices of the nonoperated shoulder or those of the healthy group (52.7 ± 75.6)., Conclusions: This study emphasizes the short-term effects of the open Latarjet procedure, demonstrating an improvement in the shoulder-related quality of life 3 months after surgery. Notably, during this period, both kinematics and periscapular muscle activity remained consistent and similar to the patterns observed for healthy athletes., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to observe the effects of changing humeral tray thickness on the resultant of intraoperative glenohumeral joint loads using a load-sensing system (LSS)., Methods: An rTSA was performed on fresh frozen full-body cadaver shoulders by using an internal proprietary LSS on the humeral side. The glenohumeral loads (Newtons) and the direction of the resultant force applied on the implant were recorded during four standard positions (External rotation, Extension, Abduction, Flexion) and three "complex" positions of Activity Daily Life ("behind back", "overhead reach" and "across chest"). For each position, the thickness was increased from 0 to 6 mm in a continuous fashion using the adjustment feature of the humeral system. Each manoeuvre was repeated three times., Results: All shoulder positions showed a high repeatability of the glenohumeral load magnitude measured with an intra-class correlation coefficient of over 0.9. For each position, we observed a strong but no linear correlation between humeral tray thickness and joint loads. It was a cubical correlation (r s = 0,91) with a short ascending phase, then a plateau phase, and finally a phase with an exponential growth of the loads on the humeral implant. In addition, an increase in trail-poly thickness led to a recentering of force application at the interface of the two glenohumeral implants., Conclusion: This study provides further insight into the effects of humeral implant thickness on rTSA glenohumeral joint loads during different positions of the arm. Data obtained using this type of device could guide surgeons in finding the proper implant balance during rTSA., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

Background: Hypoinflammatory and hyperinflammatory phenotypes have been identified in both Acute Respiratory Distress Syndrome (ARDS) and sepsis. Attributable mortality of ARDS in each phenotype of sepsis is yet to be determined. We aimed to estimate the population attributable fraction of death from ARDS (PAF ARDS ) in hypoinflammatory and hyperinflammatory sepsis, and to determine the primary cause of death within each phenotype., Methods: We studied 1737 patients with sepsis from two prospective cohorts. Patients were previously assigned to the hyperinflammatory or hypoinflammatory phenotype using latent class analysis. The PAF ARDS in patients with sepsis was estimated separately in the hypo and hyperinflammatory phenotypes. Organ dysfunction, severe comorbidities, and withdrawal of life support were abstracted from the medical record in a subset of patients from the EARLI cohort who died (n = 130/179). Primary cause of death was defined as the organ system that most directly contributed to death or withdrawal of life support., Results: The PAF ARDS was 19% (95%CI 10,28%) in hypoinflammatory sepsis and, 14% (95%CI 6,20%) in hyperinflammatory sepsis. Cause of death differed between the two phenotypes (p < 0.001). Respiratory failure was the most common cause of death in hypoinflammatory sepsis, whereas circulatory shock was the most common cause in hyperinflammatory sepsis. Death with severe underlying comorbidities was more frequent in hypoinflammatory sepsis (81% vs. 67%, p = 0.004)., Conclusions: The PAF ARDS is modest in both phenotypes whereas primary cause of death among patients with sepsis differed substantially by phenotype. This study identifies challenges in powering future clinical trials to detect changes in mortality outcomes among patients with sepsis and ARDS., (© 2024. The Author(s).)

Background: The popularity of team handball is increasing, with >10 million children playing this overhead throwing and collision sport with highest demands on the shoulder joint. Because of the risk of recurrent instability, the Latarjet-Patte (LP) procedure has been recommended to treat young competitive players. This is the first LP outcome study in professional handball players., Methods: We retrospectively included 20 shoulders (18 players [17 male patients]; mean age, 22.9 years [range, 17-35 years]; minimum follow-up period, 2 years; mean follow-up period, 6.6 years) operated on by 3 expert surgeons (2011-2020) with the Walch LP technique. We documented preoperative hyperlaxity (25%, n = 5), affected throwing arm (55%, n = 11), position (backcourt, winger, and goalkeeper, 22% each; full back and pivot, 17% each), >2 dislocations prior (20%, n = 4), >10 dislocations prior (5%, n = 1), previous failed Bankart or humeral avulsion of glenohumeral ligament (HAGL) repair (10%, n = 2), and large Hill-Sachs lesions (HSLs) (20%, n = 4). Clinical and radiographic outcomes, visual analog scale score, Subjective Shoulder Value, Walch-Duplay score, Rowe score, and return-to-sport (RTS) rate were recorded., Results: The RTS rate was 85% (17 of 20 shoulders); rate of RTS at the same level, 80% (16 of 20); and rate of RTS with no throwing pain, 73% (8 of 11). The time to training with a ball was 3.2 months, and the time to competition was 4.9 months. The mean Rowe score, Walch-Duplay score, and Subjective Shoulder Value were 90 points, 88 points, and 89%, respectively. Shoulder symptoms led players to give up handball in 2 cases (10%), whereas 1 player (5%) stopped playing handball for other reasons. We recorded 1 recurrent dislocation (5%) (non-throwing arm, winger, no recurrence after rehabilitation). Persistent apprehension occurred in 1 goalkeeper (5%). Residual pain was seen in 4 shoulders (20%); this was relieved by screw removal in 1. Resistant pain (throwing shoulder) was seen in 2 backcourt players (10%, 1 of whom had a large HSL) and 1 goalkeeper (5%; large HSL with >10 dislocations prior), all 3 of whom were aged > 30 years. Bone block positioning was correct (no lateral overhang) in all shoulders. At final follow-up, 1 shoulder (5%) showed mild arthritic changes (>10 dislocations, large HSL)., Conclusion: The open LP procedure is consistent in providing shoulder stability combined with return-to-throwing performance in professional handball players with a short time to RTS and high same-level RTS rate without increasing the risk of arthritic changes. Throwing shoulders of backcourt players, large HSLs, or age > 30 years may have an increased risk of persistent symptoms., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Advancements in rotator cuff tear repair have led to innovative techniques for complex cases. In this article, we introduce the "shoe shop" lacing technique, a knotless, side-to-side, and tendon-to-bone suture method augmented with the long head of the biceps tendon (LHBT) for anterior margin-deficient massive rotator cuff tears. This approach offers simplicity, durability, and potential advantages in biomechanics. The LHBT integration and knotless sutures make it a promising solution for challenging tear patterns. This technique provides an attractive option for arthroscopic repair, improving outcomes in cases where anterior cable reinforcement is essential., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Y.L. reports a relationship with Move up that includes royalties or licenses or consulting and a relationship with Arthrex that includes consulting. L.N. reports a relationship with Arthrex (consulting) Stryker (consulting and royalties), SpartaBiopharma (equity or stocks) and Statera (equity or stocks). All other authors (R.B., A.F.S., A.L.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Rationale: Two molecular phenotypes have been identified in acute respiratory distress syndrome (ARDS). In the ROSE (Reevaluation of Systemic Early Neuromuscular Blockade) trial of cisatracurium in moderate to severe ARDS, we addressed three unanswered questions: 1 ) Do the same phenotypes emerge in a more severe ARDS cohort with earlier recruitment; 2 ) Do phenotypes respond differently to neuromuscular blockade? and 3 ) What biological pathways most differentiate inflammatory phenotypes? Methods: We performed latent class analysis in ROSE using preenrollment clinical and protein biomarkers. In a subset of patients ( n  = 134), we sequenced whole-blood RNA using enrollment and Day 2 samples and performed differential gene expression and pathway analyses. Informed by the differential gene expression analysis, we measured additional plasma proteins and evaluated their abundance relative to gene expression amounts. Measurements and Main Results: In ROSE, we identified the hypoinflammatory (60.4%) and hyperinflammatory (39.6%) phenotypes with similar biological and clinical characteristics as prior studies, including higher mortality at Day 90 for the hyperinflammatory phenotype (30.3% vs. 61.6%; P  < 0.0001). We observed no treatment interaction between the phenotypes and randomized groups for mortality. The hyperinflammatory phenotype was enriched for genes associated with innate immune response, tissue remodeling, and zinc metabolism at Day 0 and collagen synthesis and neutrophil degranulation at Day 2. Longitudinal changes in gene expression patterns differed dependent on survivorship. For most highly expressed genes, we observed correlations with their corresponding plasma proteins' abundance. However, for the class-defining plasma proteins in the latent class analysis, no correlation was observed with their corresponding genes' expression. Conclusions: The hyperinflammatory and hypoinflammatory phenotypes have different clinical, protein, and dynamic transcriptional characteristics. These findings support the clinical and biological potential of molecular phenotypes to advance precision care in ARDS.

Purpose: Reverse shoulder arthroplasty (RSA) has shown improvement in clinical outcomes for various conditions, although some authors expressed concern about the restoration of active internal rotation (AIR). The current study assesses preoperative and intraoperative predictive factors of AIR in patients having a Grammont-style RSA with a minimum five year follow-up., Methods: We conducted a retrospective multicentric study, including patients operated on with a 155° Grammont-style RSA for cuff-related pathology or primary osteoarthritis with posterior subluxation or an associated cuff tear. Patients were clinically evaluated at a minimum of five year follow-up. Patients with previous surgery or those who had a tendon transfer with the RSA were excluded. Demographic parameters, BMI, preoperative notes, and operative reports were obtained from medical records. AIR was graded according to the constant score system from 0 to 10., Results: A total of 280 shoulders in 269 patients (mean age at surgery, 74.9 ± 5.9 years) met the inclusion criteria and were analyzed. The average follow-up was 8.1 years (range, 5-16 years). Overall, AIR increased from 4.2 (SD 2.5, range 0 to 10) preoperatively to 5.9 (SD 2.6, range 0 to 10) at final follow-up. At the last follow-up, AIR increased in 56% of cases, was unchanged in 26% and decreased in 18%. In 188 shoulders (67%), internal rotation was functional and allowed patients to reach the level of L3 or higher. Multivariable linear regression found the following preoperative clinical factors predictive of worse AIR after RSA: male gender (ß = -1.25 [-2.10; -0.40]; p = 0.0042) and higher values of BMI (ß = -0.085 [-0.17; -0.0065]; p = 0.048). Two surgical factors were associated with better AIR after RSA: glenoid lateralization with BIO-RSA technique (ß = 0.80 [0.043; 1.56]; p = 0.039) and subscapularis repair (ß = 1.16 [0.29; 2.02]; p = 0.0092)., Conclusions: With a mean of eight year follow-up (5 to 16 years), internal rotation was functional (≥ L3 level) in 67% of operated shoulders after Grammont-style RSA; however, two patients out of ten had decreased AIR after surgery. Male patients and those with higher BMIs had worse AIR, with glenoid lateralization (using the BIO-RSA technique) and subscapularis repair, as they are predictive of increased AIR after RSA., Level of Evidence: Case series, Level IV., (© 2023. The Author(s) under exclusive licence to SICOT aisbl.)

Background: In sepsis and acute respiratory distress syndrome (ARDS), heterogeneity has contributed to difficulty identifying effective pharmacotherapies. In ARDS, two molecular phenotypes (hypoinflammatory and hyperinflammatory) have consistently been identified, with divergent outcomes and treatment responses. In this study, we sought to derive molecular phenotypes in critically ill adults with sepsis, determine their overlap with previous ARDS phenotypes, and evaluate whether they respond differently to treatment in completed sepsis trials., Methods: We used clinical data and plasma biomarkers from two prospective sepsis cohorts, the Validating Acute Lung Injury biomarkers for Diagnosis (VALID) study (N=1140) and the Early Assessment of Renal and Lung Injury (EARLI) study (N=818), in latent class analysis (LCA) to identify the optimal number of classes in each cohort independently. We used validated models trained to classify ARDS phenotypes to evaluate concordance of sepsis and ARDS phenotypes. We applied these models retrospectively to the previously published Prospective Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis and Septic Shock (PROWESS-SHOCK) trial and Vasopressin and Septic Shock Trial (VASST) to assign phenotypes and evaluate heterogeneity of treatment effect., Findings: A two-class model best fit both VALID and EARLI (p<0·0001). In VALID, 804 (70·5%) of the 1140 patients were classified as hypoinflammatory and 336 (29·5%) as hyperinflammatory; in EARLI, 530 (64·8%) of 818 were hypoinflammatory and 288 (35·2%) hyperinflammatory. We observed higher plasma pro-inflammatory cytokines, more vasopressor use, more bacteraemia, lower protein C, and higher mortality in the hyperinflammatory than in the hypoinflammatory phenotype (p<0·0001 for all). Classifier models indicated strong concordance between sepsis phenotypes and previously identified ARDS phenotypes (area under the curve 0·87-0·96, depending on the model). Findings were similar excluding participants with both sepsis and ARDS. In PROWESS-SHOCK, 1142 (68·0%) of 1680 patients had the hypoinflammatory phenotype and 538 (32·0%) had the hyperinflammatory phenotype, and response to activated protein C differed by phenotype (p=0·0043). In VASST, phenotype proportions were similar to other cohorts; however, no treatment interaction with the type of vasopressor was observed (p=0·72)., Interpretation: Molecular phenotypes previously identified in ARDS are also identifiable in multiple sepsis cohorts and respond differently to activated protein C. Molecular phenotypes could represent a treatable trait in critical illness beyond the patient's syndromic diagnosis., Funding: US National Institutes of Health., Competing Interests: Declaration of interests PS reports funding from the US National Institutes of Health (NIH) and National Institute of General Medical Sciences; and consulting fees from AstraZeneca. LBW reports funding from NIH, Department of Defense (DoD), Genentech, Boehringer Ingelheim, and CSL Behring; consulting fees from Akebia Therapeutics, Santhera, Global Blood Therapeutics, and Boehringer Ingelheim; and stock options in Virtuoso Surgical. CSC reports funding from NIH; research grants from Roche Genentech and Quantum Leap Healthcare Collaborative; consulting fees from Vasomune Therapeutics, GEn1E Lifesciences, NGM Bio, Cellenkos, and Janssen; and a patent on metagenomic sequencing for sepsis diagnosis (co-recipient). MAM reports funding from Roche Genentech, Quantum Therapeutics, NIH/National Heart, Lung, and Blood Institute/National Institute of Allergy and Infectious Diseases, DoD, and California Institute for Regenerative Medicine; and consulting fees from Johnson & Johnson, Gilead Sciences, and Novartis. MMC reports funding from NIH and DoD; and intellectual property royalties from an issued patent (#11 410 777). JAR reports an investigator-initiated grant from Grifols provided to and administered by the University of British Columbia, Canadian Institutes of Health Research; three grants from the St Paul's Foundation; patents owned by the University of British Columbia related to the use of PCSK9 inhibitor(s) in sepsis and the use of vasopressin in septic shock, and by Ferring Pharmaceuticals for use of selepressin in septic shock; formerly being a founder, Director, and shareholder in Cyon Therapeutics (now closed); being a shareholder in Molecular You; receiving consulting fees in the last 3 years from SIB, Ferring Pharmaceuticals, and Par Pharmaceutical; and having been a funded member of the Data and Safety Monitoring Board of an NIH-sponsored trial of plasma in COVID-19 (PASS-IT-ON). KDL reports grants from NIH: National Institute of Diabetes and Digestive and Kidney Diseases; consulting fees from bioMérieux, UpToDate, SeaStar Medical, AM-Pharma, and Baxter; and stock or stock options in Amgen. All other authors declare no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: The most common complication with reverse shoulder arthroplasty Grammont based design with a 155° neck shaft angle (NSA) is scapular notching. Scapular notching has been associated with reduced clinical outcomes. Reducing the humeral NSA from 155° has been shown to reduce the incidence of scapular notching however it is unknown whether there is a difference in scapular notching between a 145° and 135° NSA. The purpose of this study was to evaluate the effect of decreasing the NSA on scapular notching rate and postoperative range of motion comparing 145° and 135° NSA stems at minimum 2 yr of follow-up., Methods: Consecutive patients undergoing primary reverse shoulder arthroplasty with a NSA of either 145° or 135° between January 2014 and February 2019 were retrospectively reviewed. Patients were included if they were over the age of 18, had minimum clinical follow-up of 24 mo with true postoperative anteroposterior radiographic view., Results: One hundred and three patients were included for the final analysis: 73 with a 145° NSA and 30 with a 135° NSA stem. The mean age and mean follow-up were respectively 70.9 yr (range, 52.0-89.0) and 32.1 mo. The overall incidence of scapular notching was 46.6 %. There was a statistically significant difference in scapular notching between the 145° (53.4%) and 135° (30%) NSA groups (P = .028). There was no difference in terms of postoperative Constant-Murley Score (mean, 66.1 vs. 68.2; P = .395), Subjective Shoulder Value (mean, 76.5 vs. 83.1%, P = .167), forward flexion (mean, 140° vs. 142°, P = .704), abduction (mean, 123.2° vs. 121.5°, P = .771), external rotation with the arm at the side (mean, 34.1° vs. 37.3°, P = .341) and internal rotation (mean, 5.3 vs. 5.4 pts P = .336) between the 2 groups., Conclusion: This is the first study to compare the effect of a 145° vs. 135° NSA on scapular notching rates. The key finding of this study is that scapular notching rate was significantly reduced from 53% to 30% in 135° NSA compared to 145° NSA, after at least 24 mo of follow-up. Our data also show that glenoid lateralization and inferiorization has an influence on scapular notching. We are unable to state that the reduced scapular notching rate was due to a reduction in NSA alone. Despite a lower rate of scapular notching, the 135° NSA group has not shown any significant better clinical and functional outcomes., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Chronic traumatic anterior shoulder instability can be defined as recurrent trauma-associated shoulder instability requiring the assessment of three anatomic lesions: a capsuloligamentous and/or labral lesion; anterior glenoid bone loss and a Hill-Sachs lesion. Surgical treatment is generally indicated. It remains controversial how risk factors should be evaluated to decide between a soft-tissue, free bone-block or Latarjet-type procedure. Patient risk factors for recurrence are age; hyperlaxity; competitive, contact and overhead sports. Trauma-related factors are soft tissue lesions and most importantly bone loss with implications for treatment. Different treatment options are discussed and compared for complications, return to sports parameters, short- and long-term outcomes and osteoarthritis. Arthroscopic Bankart and open Latarjet procedures have a serious learning curve. Osteoarthritis is associated with the number of previous dislocations as well as surgical techniques. Latarjet-type procedures have the lowest rate of dislocation recurrence and if performed correctly, do not seem to increase the risk of osteoarthritis.

The Trillat procedure has been described for the management of shoulder instability in younger patients but also for shoulder instability in older patients with irreparable rotator cuff tears. We describe an all-arthroscopic technique using screw fixation. This technique allows for safe dissection, clearance and osteotomy of the coracoid, and direct visualization during screw tensioning and fixation to minimize the risk of subscapularis impingement. We outline our stepwise approach to medialize and distalize the coracoid process using arthroscopic screw fixation and present pearls to avoid fracture through the superior bone bridge., (© 2023 The Authors.)

Background: Return to sport after stabilization surgery using the open Latarjet procedure remains challenging. Additional knowledge is needed about postoperative shoulder functional deficits in order to better design return-to-sport programs., Purpose: To investigate the effects of the dominance status of the operated shoulder on the shoulder functional profile recovery at 4.5 months after open Latarjet procedure., Study Design: Cross-sectional study; Level of evidence, 3., Methods: A retrospective analysis of prospectively collected data was performed. All patients who underwent the open Latarjet procedure between December 2017 and February 2021 were eligible for the study. Functional assessment at 4.5 months after the surgery was performed using the following tests: maximal voluntary isometric contractions in glenohumeral internal and external rotation, upper-quarter Y balance test, unilateral seated shot-put test, and modified closed kinetic chain upper extremity stability test, leading to 10 outcome measures. Patients whose dominant side had undergone surgery and those whose nondominant side had undergone surgery were compared with a group of 68 healthy control participants., Results: A total of 72 patients who underwent an open Latarjet procedure on the dominant side and 61 patients who underwent open Latarjet on the nondominant side were compared with 68 healthy control athletes. In patients whose dominant shoulder had undergone surgery, significant deficits for the dominant side ( P < .001) and for the nondominant side ( P < .001) were found in 9 of 10 functional outcome measures. Among patients whose operations were on the nondominant shoulder, significant deficits for the nondominant side ( P < .001) and for the dominant side ( P < .001) were found in 9 and 5 of the 10 functional outcome measures, respectively., Conclusion: Regardless of dominance of the stabilized shoulder, persistent deficits in strength, stability, mobility, power, and stroke frequency were observed at 4.5 months postoperatively. Stabilization of the dominant shoulder resulted in residual surgery-related functional impairments on both sides. However, stabilization of the nondominant shoulder resulted in impairments primarily noted in the nondominant, operative shoulder., Registration: NCT05150379 (ClinicalTrials.gov identifier).

Using latent class analysis (LCA) of clinical and protein biomarkers, researchers have identified two phenotypes of the acute respiratory distress syndrome (ARDS) with divergent clinical trajectories and treatment responses. We investigated whether plasma metabolites differed among patients with LCA-derived hyperinflammatory and hypoinflammatory ARDS, and we tested the prognostic utility of adding metabolic clusters to LCA phenotypes. We analyzed data from 93 patients with ARDS and sepsis enrolled in a multicenter prospective cohort of critically ill patients, comparing 970 metabolites between the two LCA-derived phenotypes. In all, 188 metabolites were differentially abundant between the two LCA-derived phenotypes. After adjusting for age, sex, confounding medications, and comorbid liver and kidney disease, 82 metabolites remained significantly different. Patients with hyperinflammatory ARDS had reduced circulating lipids but high levels of pyruvate, lactate, and malate. Metabolic cluster and LCA-derived phenotypes were each significantly and independently associated with survival. Patients with hyperinflammatory ARDS may be experiencing a glycolytic shift leading to dysregulated lipid metabolism. Metabolic profiling offers prognostic information beyond what is captured by LCA phenotypes alone. Deeper biological profiling may identify key differences in pathogenesis among patients with ARDS and may lead to novel targeted therapies.

We carried out integrated host and pathogen metagenomic RNA and DNA next generation sequencing (mNGS) of whole blood (n = 221) and plasma (n = 138) from critically ill patients following hospital admission. We assigned patients into sepsis groups on the basis of clinical and microbiological criteria. From whole-blood gene expression data, we distinguished patients with sepsis from patients with non-infectious systemic inflammatory conditions using a trained bagged support vector machine (bSVM) classifier (area under the receiver operating characteristic curve (AUC) = 0.81 in the training set; AUC = 0.82 in a held-out validation set). Plasma RNA also yielded a transcriptional signature of sepsis with several genes previously reported as sepsis biomarkers, and a bSVM sepsis diagnostic classifier (AUC = 0.97 training set; AUC = 0.77 validation set). Pathogen detection performance of plasma mNGS varied on the basis of pathogen and site of infection. To improve detection of virus, we developed a secondary transcriptomic classifier (AUC = 0.94 training set; AUC = 0.96 validation set). We combined host and microbial features to develop an integrated sepsis diagnostic model that identified 99% of microbiologically confirmed sepsis cases, and predicted sepsis in 74% of suspected and 89% of indeterminate sepsis cases. In summary, we suggest that integrating host transcriptional profiling and broad-range metagenomic pathogen detection from nucleic acid is a promising tool for sepsis diagnosis., (© 2022. The Author(s).)

Background: Rapid consolidation of the bone block is paramount for the success of the Latarjet procedure. Noncannulated screws have shown satisfactory long-term bone block fusion, while cannulated screws are challenged with inferior mechanical properties and fusion rates., Purpose: To report outcomes of the Latarjet procedure using cannulated screws, notably bone block fusion and complication rates at 3 months, as well as clinical scores and return to sports at minimum 2 years postoperatively., Study Design: Case series; Level of evidence, 4., Methods: We reviewed the records of 124 consecutive patients (124 shoulders) who underwent primary Latarjet procedures using cannulated screws between 2015 and 2018. All patients underwent clinical examination at 3 months postoperatively, including range of motion and radiographs to assess graft fusion. The Walch-Duplay score, Rowe score, Subjective Shoulder Value, and visual analog scale for pain were collected at a minimum follow-up of 2 years., Results: Overall, 9 patients (7%) required reoperation: 7 (6%) had screw removal for unexplained residual pain, 1 (0.8%) had lavage for deep infection, and 1 (0.8%) had evacuation to treat a hematoma. Furthermore, 3 patients (2.4%) had recurrent instability, none of whom underwent reoperation. At 3-month follow-up, all 124 shoulders showed complete radiographic graft fusion, and at 40 ± 11 months (mean ± SD; range, 24-64 months), 88% of patients had returned to sport (109/124), the Walch-Duplay score was 86 ± 14, Rowe was 84 ± 15, Subjective Shoulder Value was 88 ± 11, and visual analog scale for pain was 1 ± 1., Conclusion: The clinical relevance of these findings is that 4.5-mm cannulated screws are safe and effective for primary Latarjet procedures and grant adequate graft healing, with low recurrence of instability and a high rate of return to sports., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: The statistical analysis and manuscript preparation for this study were funded by GCS Ramsay Santé pour l’Enseignement et la Recherche. L.N. has received consulting fees from Arthrex and Wright, royalties from Wright, and stock options from Sparta Biopharma. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Background: Glenoid bone loss in anatomic total shoulder arthroplasty (aTSA) remains a controversial and challenging clinical problem. Previous studies have shown high rates of glenoid loosening for aTSA in shoulders with retroversion, posterior bone loss, and posterior humeral head subluxation. This study is the first to present minimum 2-year follow-up data of an all-polyethylene, biconvex augmented anatomic glenoid component for correction of glenoid retroversion and posterior humeral head subluxation., Methods: This study is a multicenter, retrospective review of prospectively collected data on consecutive patients from 7 global clinical sites. All patients underwent aTSA using the biconvex posterior augmented glenoid (PAG). Inclusion criteria were preoperative computed tomographic (CT) scan, minimum 2 years since surgery, preoperative and minimum 2-year postoperative range of motion examination, and patient-reported outcome measures (PROMs). Glenoid classification, glenoid retroversion, and posterior humeral head subluxation were measured from preoperative CT and radiography and postoperative radiography. Statistical comparisons between pre- and postoperative values were performed with a paired t test., Results: Eighty-six of 110 consecutive patients during the study period (78% follow-up) met the inclusion criteria and were included in our analysis. Mean follow-up was 35 ± 10 months, with a mean age of 68 ± 8 years (range 48-85). Range of motion statistically improved in all planes from pre- to postoperation. Mean visual analog scale score improved from 5.2 preoperation to 0.7 postoperation, Single Assessment Numeric Evaluation score from 43.2 to 89.5, Constant score from 41.8 to 76.9, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score from 49.8 to 86.7 (all P < .0001). Mean glenoid retroversion improved from 19.3° to 7.4° (P < .0001). Posterior subluxation improved from 69.1% to 53.5% and posterior decentering improved from 5.8% to -3.0% (P < .0001). There was 1 patient with both a prosthetic joint infection and radiographic glenoid loosening that required revision. Seventy-nine of 86 patients had a Lazarus score of 0 (no radiolucency seen about peg or keel) at final follow-up., Conclusions: This study shows that at minimum 2-year follow-up, a posterior-augmented all-polyethylene glenoid can correct glenoid retroversion and posterior humeral head subluxation. Clinically, there was significant improvement in both range of motion and PROMs., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The time elapsed since surgery is the primary criterion for allowing athletes to return to sport after shoulder stabilization surgery using the Latarjet procedure. The objective assessment of shoulder functional status through the return-to-sport continuum demands a scoring instrument that includes psychological and physical dimensions. This study aimed to statistically validate the Shoulder-SanTy Athletic Return To Sport (S-STARTS) score in patients who have undergone primary shoulder stabilization surgery., Hypothesis: The S-STARTS score fulfils the criteria for statistical validation for assessing return-to-sport readiness after shoulder stabilization surgery., Study Design: Diagnostic study., Level of Evidence: Level 4., Methods: Fifty patients and 50 controls completed the Shoulder Instability-Return to Sport after Injury questionnaire and performed 4 physical performance tests, from which 8 outcome measures were extracted to provide a composite score, named S-STARTS, according to a scoring procedure. The statistical validation of the S-STARTS score was based on construct validity, discriminant validity, sensitivity to change, internal consistency, reliability, agreement, and feasibility., Results: The 8 components of the S-STARTS score provided additional information (0.01 ≤ | r | ≤ 0.59). The S-STARTS score exhibited good reliability (intraclass coefficient of correlation [3,k] = 0.74), no ceiling or floor effects, and high discrimination and sensitivity to change. The S-STARTS score was significantly lower in patients than in controls (13.5 ± 3.8 points vs 16.1 ± 2.7 points, respectively; P < 0.001). A significant increase was reported between 4.5 and 6.5 months postoperatively (12.8 ± 2.3 points vs 17.2 ± 2.4 points, respectively; P < 0.001)., Conclusions: The S-STARTS score meets statistical validation criteria for the assessment of shoulder functional status after shoulder stabilization surgery using the Latarjet procedure., Clinical Relevance: Using an S-STARTS score-based assessment to monitor an athlete's progression through the return-to-sport continuum may help clinicians and strength and conditioning coaches in return-to-sport decision-making.

Purpose: The purposes of this study were to investigate a radiographic sign found on coronal magnetic resonance imaging (MRI) sequences in subscapularis (SSC) pathology, reporting interobserver reliability data and sensitivity and specificity; and to correlate the preoperative assessment of SSC pathology with intraoperative assessment of the SSc during shoulder arthroscopy., Methods: A consecutive series of patients undergoing arthroscopic rotator cuff repair from January 2020 to December 2020 were examined. The positive diagnosis of a subscapularis tendon tear was prospectively determined and confirmed by arthroscopy. The "digitation sign" was assessed by 3 independent shoulder-trained fellows when evaluating the SSC in the coronal plane on T2-weighted images., Results: Of the 132 patients included, 74 (56%) had SSC tendon tears confirmed during arthroscopy. Interobserver agreement for digitation sign was substantial (k= 0.640). Sensitivity for digitation sign only was 74.3%; for criteria of Adams et al. (Accuracy of preoperative magnetic resonance imaging in predicting a subscapularis tendon tear based on arthroscopy; Arthroscopy 2010;26:1427-1433) only, 83.8%; and for the combination of the 2 methods, 89.2%. Specificity was 84.5% for digitation sign only, 77.6% for Adams et al. criteria only, and 67.2% for the combination of the 2 methods. Sensitivity is statistically better when the digitation sign is added to the Adams et al. criteria for detection of SSC lesions. As expected, specificity is statistically lower. SSC tears are significantly associated with biceps lesions., Conclusion: Preoperative systematic MRI evaluation by shoulder surgeons can diagnose subscapularis lesions by using the digitation sign in the coronal plane along with Adams et al. criteria, leading to good sensitivity. This easy-to-apply sign can be helpful in the initial MRI evaluation in the coronal plane, with improved sensitivity when combined with a systematic approach., Level of Evidence: II, study of diagnostic test., (© 2022 The Authors.)

Background: The posterior subluxation and glenoid version in Walch B2 glenoids are routinely assessed by 2-dimensional (2D) computed tomography (CT). Different methods of calculation are used to analyze these parameters. Alternatively, the rising use of 3-dimensional (3D) planification tools in arthroplasty requires the clarification if the 3D measurements are equivalent to 2D. The aim of this study was to compare B2 glenoids characteristics between 2D CT assessment method and 3D automated software method., Methods: CT scans from patients who underwent a shoulder arthroplasty were identified. In the 2D method, measurement of glenoid version was determined. Measurement of the humeral head subluxation (HHS) (scapula axis method) was determined by the percentage of the humeral head posterior to the Friedman line (scapula axis). Three-dimensional analysis allowed an automated segmentation of the humerus and scapula, definition of scapular planes, and determination of glenoid version and HHS., Results: Fifty-one CT scans met inclusion criteria. The intraobserver and interobserver reliability of the 2D retroversion (RV) and 2D HHS intraclass correlation coefficient was excellent (intraclass correlation coefficient>0.9).The median RV was 16° [12-20] in 2D and 19° [16-23] in 3D ( P  < .0001). The median subluxation was 71% [66-75] in 2D and 81% [78-86] in 3D ( P  < .0001). Linear regression analysis demonstrated low positive correlation between RV and subluxation in 2D and 3D (R 2  = 0.31 and R 2  = 0.23, respectively)., Discussion/conclusion: The assessment of version and HHS in Walch B2 glenoids between 2D CT and a 3D planification were significantly different. Low correlation between RV and HHS was observed (2D and 3D assessment)., (© 2022 The Authors.)

Purpose: The purpose of this study was to establish consensus statements via a modified Delphi process on the Latarjet procedure, remplissage, and glenoid-bone grafting for anterior shoulder instability., Methods: A consensus process on the treatment utilizing a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability., Results: The technical approaches identified in the statements on the Latarjet procedure and glenoid bone-graft were that a subscapularis split approach should be utilized, and that it is unclear whether a capsular repair is routinely required. Furthermore, despite similar indications, glenoid bone-grafting may be preferred over the Latarjet in patients with bone-loss greater than can be treated with a coracoid graft, and in cases of surgeon preference, failed prior Latarjet or glenoid bone-grafting procedure, and epilepsy. In contrast, the primary indications for a remplissage procedure was either an off-track or engaging Hill-Sachs lesion without severe glenoid bone loss. Additionally, in contrast to the bone-block procedure, complications following remplissage are rare, and loss of shoulder external rotation can be minimized by performing the tenodesis via the safe-zone and not over medializing the fixation., Conclusion: Overall, 89% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the prognostic factors that are important to consider in those undergoing a glenoid bone-grafting procedure including age, activity level, Hill-Sachs Lesion, extent of glenoid bone-loss, hyperlaxity, prior surgeries, and arthritic changes. Furthermore, there was unanimous agreement that it is unclear whether a capsular repair is routinely required with a glenoid bone graft, but it may be beneficial in some cases. There was no unanimous agreement on any aspect related to the Latarjet procedure or Remplissage., Level of Evidence: Level V, expert opinion., (Copyright © 2021 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to establish consensus statements via a modified Delphi process on the diagnosis, nonoperative management, and Bankart repair for anterior shoulder instability., Methods: A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability., Results: The independent factors identified in the 2 statements that reached unanimous agreement in diagnosis and nonoperative management were age, gender, mechanism of injury, number of instability events, whether reduction was required, occupation, sport/position/level played, collision sport, glenoid or humeral bone-loss, and hyperlaxity. Of the 3 total statements reaching unanimous agreement in Bankart repair, additional factors included overhead sport participation, prior shoulder surgery, patient expectations, and ability to comply with postoperative rehabilitation. Additionally, there was unanimous agreement that complications are rare following Bankart repair and that recurrence rates can be diminished by a well-defined rehabilitation protocol, inferior anchor placement (5-8 mm apart), multiple small-anchor fixation points, treatment of concomitant pathologies, careful capsulolabral debridement/reattachment, and appropriate indications/assessment of risk factors., Conclusion: Overall, 77% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the aspects of patient history that should be evaluated in those with acute instability, the prognostic factors for nonoperative management, and Bankart repair. Furthermore, there was unanimous consensus on the steps to minimize complications for Bankart repair, and the placement of anchors 5-8 mm apart. Finally, there was no consensus on the optimal position for shoulder immobilization., Level of Evidence: Level V, expert opinion., (Copyright © 2021 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to establish consensus statements via a modified Delphi process on revision surgery, rehabilitation and return to play, and clinical follow-up for anterior shoulder instability., Methods: A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability., Results: The primary relative indications for revision surgery include symptomatic apprehension or recurrent instability, additional intra-articular pathologies, and symptomatic hardware failure. In revision cases, the differentiating factors that dictate treatment are the degree of glenohumeral bone loss and rotator cuff function/integrity. The minimum amount of time before allowing athletes to return to play is unknown, but other factors should be considered, including restoration of strength, range of motion and proprioception, and resolved pain and apprehension, as these are prognostic factors of reinjury. Additionally, psychological factors should be considered in the rehabilitation process. Patients should be clinically followed up for a minimum of 12 months or until a return to full, premorbid function/activities. Finally, the following factors should be included in anterior shoulder instability-specific, patient-reported outcome measures: function/limitations impact on activities of daily living, return to sport/activity, instability symptoms, confidence in shoulder, and satisfaction., Conclusion: Overall, 92% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were indications and factors affecting decisions for revision surgery, as well as how prior surgeries impact procedure choice. Furthermore, there was unanimous consensus on the role of psychological factors in the return to play, considerations for allowing return to play, as well as prognostic factors. Finally, there was a lack of unanimous consensus on recommended timing and methods for clinical follow-up., Level of Evidence: Level V, expert opinion., (Copyright © 2021 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

There are different techniques to address severe glenoid erosion during reverse shoulder arthroplasty (RSA). This study assessed the clinical and radiological outcomes of RSA with combined bony and metallic augment (BMA) glenoid reconstruction compared to bony augmentation (BA) alone. A review of patients who underwent RSA with severe glenoid bone loss requiring reconstruction from January 2017 to January 2019 was performed. Patients were divided into two groups: BMA versus BA alone. Clinical outcome measurements included two years postoperative ROM, Constant score, subjective shoulder value (SSV), and the American Shoulder and Elbow Surgeons Shoulder (ASES) score. Radiological outcomes included radiographic evidence of scapular complications and graft incorporation. The BMA group had significantly different glenoid morphology ( p < 0.001) and greater bone loss thickness than the BA group (16.3 ± 3.8 mm vs. 12.0 ± 0.0 mm, p = 0.020). Both groups had significantly improved ROM (anterior forward flexion and external rotation) and clinical scores (Constant, SSV and ASES scores) at 2 years. Greater improvement was observed in the BMA group in terms of anterior forward flexion (86.3° ± 27.9° vs. 43.8° ± 25.6°, p = 0.013) and Constant score (56.6 ± 10.1 vs. 38.3 ± 16.7, p = 0.021). The BA group demonstrated greater functional and clinical improvements with higher postoperative active external rotation and ASES results (active external rotation, 49.4° ± 17.0° vs. 29.4° ± 14.7°, p = 0.017; ASES, 89.1 ± 11.3 vs. 76.8 ± 11.0, p = 0.045). The combination use of bone graft and metallic augments in severe glenoid bone loss during RSA is safe and effective and can be considered in cases of severe glenoid bone loss where bone graft alone may be insufficient.

The acute respiratory distress syndrome (ARDS) describes a heterogenous population of patients with acute severe respiratory failure. However, contemporary advances have begun to identify distinct sub-phenotypes that exist within its broader envelope. These sub-phenotypes have varied outcomes and respond differently to several previously studied interventions. A more precise understanding of their pathobiology and an ability to prospectively identify them, may allow for the development of precision therapies in ARDS. Historically, animal models have played a key role in translational research, although few studies have so far assessed either the ability of animal models to replicate these sub-phenotypes or investigated the presence of sub-phenotypes within animal models. Here, in three ovine models of ARDS, using combinations of oleic acid and intravenous, or intratracheal lipopolysaccharide, we investigated the presence of sub-phenotypes which qualitatively resemble those found in clinical cohorts. Principal Component Analysis and partitional clustering identified two clusters, differentiated by markers of shock, inflammation, and lung injury. This study provides a first exploration of ARDS phenotypes in preclinical models and suggests a methodology for investigating this phenomenon in future studies., (© 2021 The Authors. Physiological Reports published by Wiley Periodicals LLC on behalf of The Physiological Society and the American Physiological Society.)

Background: Despite the success of reverse shoulder arthroplasty (RSA), complication rates remain high (13% to 25%), due to instability, infection, and glenoid component loosening, which can lead to revision. The aim of the present study was to report the early clinical outcomes of RSA using a new hybrid baseplate design, in comparison with the literature on other common RSA baseplates., Methods: The authors retrospectively analyzed the records of 142 patients (142 shoulders) who underwent primary RSA using a hybrid baseplate design by the senior surgeons between May 2014 and December 2018. Preoperative and postoperative assessments included the Constant score (CS) and range of motion, including active forward elevation, external rotation, and internal rotation., Results: Of the initial cohort of 142 patients, 13 were lost to follow-up (8.6%), 2 died (1.3%), and 8 required reoperations with implant removal (5.3%). The remaining 119 patients comprised 71 women (60%) and 48 men (40%), aged 73.6 ± 7.3 years at index surgery, 43 of whom required bony increased offset (36%). At a minimum follow-up of 2 years, the CS improved by 37.3 ± 16.1, active forward elevation increased by 51.2° ± 38.1°, external rotation increased by 16.4° ± 25.0°, and internal rotation increased by 1.5 ± 3.2., Conclusion: At a minimum follow-up of 2 years after RSA using a new hybrid baseplate system, the CS and range of motion were satisfactory and comparable to those in recent systematic reviews. The findings of this study suggest that this hybrid baseplate system provides satisfactory outcomes in the short term, although longer follow-up studies are needed to validate its long-term efficacy., (© 2021 The Authors.)

Background: The Unilateral Seated Shot-Put Test (USSPT) consists of pushing an overweight ball as far as possible to assess upper extremity power unilaterally and bilateral symmetry. Literature however reports various body positions and upper limb pushing patterns to perform USSPT, demanding to provide additional guideline to achieve overweight ball push. This study therefore aimed at assessing the reliability and agreement of USSPT outcome measures when pushing an overweight ball in a horizontal direction., Methods: Twenty-seven healthy male athletes performed two sessions, one week apart, of three unilateral pushes per upper limb using a 3-kg medicine ball, for which the distances were measured. The intraclass correlation coefficient (ICC), standard error of measurement (SEM), minimum detectable change at a 95 % confidence level (MDC 95 % ) and coefficient of variation (CV) were assessed for the pushing distances based on one, two or three trials per side to produce two outcome measures: the pushing distance per limb and USSPT Limb Symmetry Index (LSI) when dividing pushing distance of the dominant side by that of the non-dominant side., Results: The most reliable pushing distance per limb was obtained when averaging three pushing distances, normalized by body mass with the exponent 0.35. The mean USSPT LSI was 1.09 ± 0.10 for the first session and 1.08 ± 0.10 for the second session, highlighting good reliability and agreement (ICC = 0.82; SEM = 0.045; MDC 95 % = 0.124; CV = 5.02 %)., Conclusions: When the overweight ball is pushed in a horizontal direction, averaging the distances of three trials for both the dominant and non-dominant limbs is advised to provide the most reliable USSPT distance per limb and USSPT LSI.

Background: Efforts during reverse total shoulder arthroplasty (RSA) have typically focused on maximizing ROM in elevation and external rotation and avoiding scapular notching. Improving internal rotation (IR) is often overlooked, despite its importance for functional outcomes in terms of patient self-care and hygiene. Although determinants of IR are multifactorial, it is unable to surpass limits of bony impingement of the implant. Identifying implant configurations that can reduce bony impingement in a computer model will help surgeons during preoperative planning and also direct implant design and clinical research going forward., Questions/purposes: In a CT-modeling study, we asked: What reverse total shoulder arthroplasty implant position improves the range of impingement free internal rotation without compromising other motions (external rotation and extension)?, Methods: CT images stored in a deidentified teaching database from 25 consecutive patients with Walch A1 glenoids underwent three-dimensional templating for RSA. Each template used the same implant and configuration, which consisted of an onlay humeral design and a 36-mm standard glenosphere. The resulting constructs were virtually taken through ROM until bony impingement was found. Variations were made in the RSA parameters of baseplate lateralization, glenosphere size, glenosphere overhang, humeral version, and humeral neck-shaft angle. Simulated ROM was repeated after each parameter was changed individually and then again after combining multiple changes into a single configuration. The impingement-free IR was calculated and compared between groups. We also evaluated the effect on other ROM including external rotation and extension to ensure that configurations with improvements in IR were not associated with losses in other areas., Results: Combining lateralization, inferiorization, varus neck-shaft angle, increased glenosphere size, and increased humeral anteversion resulted in a greater improvement in internal rotation than any single parameter change did (median baseline IR: 85° [interquartile range 73° to 90°]; combined changes: 119° [IQR 113° to 121°], median difference: 37° [IQR 32° to 43°]; p < 0.001)., Conclusion: Increased glenosphere overhang, varus neck-shaft angle, and humeral anteversion improved internal rotation in a computational model, while glenoid lateralization alone did not. Combining these techniques led to the greatest improvement in IR., Clinical Relevance: This computer model study showed that various implant changes including inferiorization, varus neck-shaft angle, increased glenosphere size, and increased humeral anteversion can be combined to increase impingement-free IR. Surgeons can employ these currently available implant configurations to improve IR when planning and performing RSA. These findings support the need for further clinical studies validating the effect of implant configuration on resultant IR., Competing Interests: Each author certifies that neither he, nor any member of his immediate family, has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2020 by the Association of Bone and Joint Surgeons.)

The risk of poor post-operative outcome and the benefits of surgical resection as a curative therapy require careful assessment by the clinical care team for patients with primary and secondary liver cancer. Advances in surgical techniques have improved patient outcomes but identifying which individual patients are at greatest risk of poor post-operative liver performance remains a challenge. Here we report results from a multicentre observational clinical trial (ClinicalTrials.gov NCT03213314) which aimed to inform personalised pre-operative risk assessment in liver cancer surgery by evaluating liver health using quantitative multiparametric magnetic resonance imaging (MRI). We combined estimation of future liver remnant (FLR) volume with corrected T1 (cT1) of the liver parenchyma as a representation of liver health in 143 patients prior to treatment. Patients with an elevated preoperative liver cT1, indicative of fibroinflammation, had a longer post-operative hospital stay compared to those with a cT1 within the normal range (6.5 vs 5 days; p = 0.0053). A composite score combining FLR and cT1 predicted poor liver performance in the 5 days immediately following surgery (AUROC = 0.78). Furthermore, this composite score correlated with the regenerative performance of the liver in the 3 months following resection. This study highlights the utility of quantitative MRI for identifying patients at increased risk of poor post-operative liver performance and a longer stay in hospital. This approach has the potential to inform the assessment of individualised patient risk as part of the clinical decision-making process for liver cancer surgery., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: MK, GR, JJC, JMcG, RB, and JMB are employees and shareholders at Perspectum Ltd. This does not alter our adherence to PLOS ONE policies on sharing data and materials. There are no other actual or perceived conflicts of interest to declare.

Background: Patients with isolated loss of active external rotation (ILER) but preserved active forward elevation have recently been identified as a rare and distinct clinical entity. The modified L'Episcopo procedure attempts to restore horizontal muscle balance and restore active external rotation., Methods: A retrospective study was performed for all patients with ILER and preserved forward elevation with Hamada stage ≤2 changes undergoing the modified L'Episcopo tendon transfer. Preoperative rotator cuff fatty infiltration and morphology was reported. Clinical, radiographic, and functional outcomes were recorded preoperatively and compared to postoperative outcomes at a minimum of 24 months' follow-up., Results: Nine patients (8 male, 1 female) with a mean age of 58.4 years (range, 51-67 years) were evaluated at a mean follow-up of 64.3 months (range, 24-126 months). Significant improvement was demonstrated in active external rotation with the arm at the side (mean increase of 47°; range, 30°-60°, P = .004) and at 90° abduction (mean increase of 41°; range, 20°-70°, P = .004). The mean Constant score and pain score significantly improved at final follow-up (P = .004). All patients were either very satisfied or satisfied, with a mean subjective shoulder value of 74% (range, 60%-99%)., Conclusion: In appropriately selected patients with ILER and preserved active forward elevation, the modified L'Episcopo procedure can restore horizontal muscle balance and produce significant improvements in active external rotation, Constant score, and pain., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Objectives: To assess the effects of (1) rugby union practice, (2) history of injury managed nonoperatively, and (3) history of injury managed operatively on shoulder functional status in male rugby union players., Design: Cross sectional study., Setting: Clinical., Participants: 86 male athletes were assigned into four groups: multisport athletes, rugby union players without shoulder problems, with history of shoulder injury managed nonoperatively and with history of shoulder injury managed operatively., Main Outcome Measures: SI-RSI questionnaire, maximal isometric glenohumeral internal and external rotator strength, unilateral seated shot put test, upper quarter Y balance test., Results: Healthy players presented higher internal (p = 0.03) and external (p = 0.04) rotator strength than multisport athletes. History of shoulder injury managed nonoperatively did not impair physical abilities but limited player's psychological readiness (p < 0.001). After 4.5-months, shoulder stabilization surgery impaired maximal muscle strength and upper quarter body stability and mobility (p < 0.001 for all)., Conclusions: The shoulder functional status in rugby union player presented increased glenohumeral rotator strength when compared to non-collision sport athletes. In rugby union players, psychological concerns remained in the long-term after a shoulder injury managed nonoperatively, and psychological and physical readiness seemed not be reached at 4.5 months postoperatively to respond to rugby union practice demand., Competing Interests: Declaration of competing interest No conflict of interest. Acknowledgments The authors thank V. Bourquin, A. Benedetto and A. Bellegarde for their help in data collection., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Introduction: Recurrent anterior glenohumeral instability has been studied in the young population and limited evidence is available for adolescent patients. Our study is a retrospective review of patients aged <17 years who underwent open Latarjet procedure., Methods: Forty-five patients were available for review. Clinical outcomes were assessed by range of movements, stability, Walch-Duplay score (WDS), Rowe score (RS), Constant-Murley score (CMS), Subjective Shoulder Value (SSV), and return to sport. Radiographs were reviewed for osteoarthritis and complications., Results: The median age of patients was 15.7 years (13-17), and 56% had hyperlaxity. The median follow-up time was 6.6 years (3-26). The median postoperative movements showed recovered elevation (175°), external rotation (60°), and internal rotation (T9 level). Seventy-five percent of patients returned to the same level of sport, and 98% were satisfied. Clinical outcomes showed WDS, RS, and CMS scores of 85, 95, and 84 points, respectively, and an SSV of 95%. Twenty percent of patients described mild postoperative pain, and 1 had persistent stiffness. Other complications included 24% subjective apprehension, 4% redislocation, 4% wound problems, and 2% infection. Nine percent of cases had postoperative arthritis. The overall reoperation rate was 11%: 1 open washout for infection and 4 arthroscopic screw removal due to persistent pain. We found that hyperlaxity, female sex, and large or deep Hill-Sachs lesions were frequently associated with persistent apprehension at the last follow-up., Conclusions: The open Latarjet procedure provides a low rate of recurrent instability with acceptable complication rates in the long term for skeletally immature patients. It is an effective, safe treatment option without any significant glenoid growth disturbance., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Case: A 30-year-old woman with an irreparable subscapularis tear presented with persistent painful anterior instability despite several open and arthroscopic stabilization procedures. A pectoralis major tendon transfer (PMTT) was performed. The patient subsequently developed progressive glenohumeral arthritis over the next 10 years, ultimately necessitating shoulder arthroplasty., Conclusions: PMTT provides valuable anterior soft-tissue reconstruction stabilization for subscapularis insufficiency in a multioperated shoulder. Ten years later, the transfer was found to be intact and managed like a native subscapularis during anatomic shoulder replacement, thus avoiding a reverse arthroplasty in a young patient.

Background: Shoulder arthroplasty in young patients with primary glenohumeral osteoarthritis is an area of continued controversy., Methods: A retrospective multicenter study was performed for all patients aged 60 years or less undergoing either hemiarthroplasty (HA) or total shoulder arthroplasty (TSA) for primary glenohumeral osteoarthritis with a minimum of 24-month follow-up. Clinical and functional outcomes, complications, and need for revision surgery were analyzed. Survivorship analysis using revision arthroplasty as an endpoint was determined., Results: A total of 202 patients with a mean age of 55.3 years (range, 36-60 years) underwent TSA with a mean follow-up of 9 years (range, 2-24.7 years). Revision arthroplasty was performed in 33 (16.3%) shoulders, with glenoid failure associated with the revision in 29 shoulders (88%). TSA survivorship analysis demonstrated 95% free of revision at 5 years, 83% at 10 years, and 60% at 20-year follow-up. A total of 31 patients with a mean age of 52.5 years (range, 38-60 years) underwent HA with a mean follow-up of 8.7 years (range, 2-21.4 years). Revision arthroplasty was performed in 5 (16.1%) shoulders, with glenoid erosion as the cause for revision in 4 shoulders (80%). HA survivorship analysis demonstrated 84% free from revision at 5 years and 79% at the final follow-up. TSA resulted in a significantly better range of motion, pain, subjective shoulder value, and Constant score compared with HA., Conclusion: In young patients with primary glenohumeral osteoarthritis, TSA resulted in significantly better functional and subjective outcomes with no significant difference in longitudinal survivorship compared with patients treated with HA., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The Latarjet procedure is often used to treat shoulder instability in younger patients. Little is reported on the outcomes of this procedure in older (≥40 years) populations. The purpose of this study was to evaluate the clinical and radiographic outcomes of patients aged 40 years or older with recurrent anterior shoulder instability who underwent open Latarjet stabilization., Methods: A total of 168 patients aged 40 years or older were treated surgically for recurrent anterior shoulder instability with an open Latarjet procedure between 1988 and 2014. Bankart lesions or anteroinferior glenoid fractures were confirmed preoperatively with a computed tomography arthrogram. Outcomes were assessed with preoperative and postoperative physical examinations, clinical outcome scoring, and radiographic examinations., Results: Ninety-nine patients with complete data were available with a mean follow-up period of 13 years (range, 3-23 years). At the time of final follow-up, 94% of patients did not have recurrence of instability. Of the patients, 90% were satisfied or very satisfied with their outcomes and 54% returned to their preinjury level of activity. The overall complication rate was 21% (the most common complications being subjective apprehension [9%] and recurrent instability [6%]), with 9% of patients requiring reoperation. A full-thickness rotator cuff requiring repair was identified in 22% of patients., Conclusions: The Latarjet procedure is an effective treatment option for older patients (aged ≥ 40 years) with recurrent anterior shoulder instability in the setting of an anteroinferior capsulolabral and/or bony injury., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Objectives: To assess the reliability of a modified procedure for Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST)., Design: Intra- and intersession reliability and agreement; SETTING: Clinical., Participants: Twenty-seven asymptomatic athletes., Main Outcome Measures: The modifications (m-CKCUEST) in CKCUEST procedure consisted in hand spacing at one half arm-span, and to complete the three regular-series of 15 s exertion by performing a fourth 1-min series during which the number of touches was counted every 15 s. The intra- and intersession reliability and agreement were assessed for the numbers of touches in order to produce two outcome measures: m-CKCUEST score and muscular endurance index., Results: The most reliable m-CKCUEST score was obtained when averaging the numbers of touches of the second and third sets (Intraclass Coefficient of Correlation(3,k); ICC = 0.92). Good reliability was found for muscular endurance index computed when dividing the one-half number of touches counted during the last 30 s of 1-min set, by the m-CKCUEST score calculated above (ICC = 0.86)., Conclusions: The m-CKCUEST allowed the production of two reliable outcome measures, which assessed the upper limb stability and the muscular endurance. Such outcomes may be used in a follow-up to assess performance or rehabilitation level., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Contemporary arthroscopic double-row suture anchor rotator cuff repairs have superior biomechanics compared with prior iterations. Numerous techniques have been described, but consensus regarding value has yet to be established. We describe an effective and easily reproducible technique: the arthroscopic "Montgolfier double-row" repair technique. This knotless construct has an evenly distributed, load-sharing, radially oriented suture limb configuration much like the envelope cables of a Montgolfier hot-air balloon, its namesake. Other advantages include the ability to apply manual, progressive and calculated tension on each suture limb and easy intraoperative modification depending on tear size, shape, and delamination, as well as tissue tension and quality. Future studies are needed to validate the biomechanics and clinical outcomes of this technique.

Background: The Walch classification describes glenoid morphology in primary arthritis. As knowledge grows, several modifications to the classification have been proposed. The type D, a recent modification, was defined as an anteverted glenoid with or without anterior subluxation. Literature on the anteverted glenoid in primary osteoarthritis is limited. The purpose of this study, therefore, was to analyze the anatomic characteristics of the type D glenoid on radiographs and computed tomography (CT)., Methods: The shoulder arthroplasty databases from 3 institutions were examined to identify patients with primary glenohumeral osteoarthritis and glenoid anteversion (≥5°), with or without anterior subluxation. The type D study cohort consisted of 18 patients (3% of the osteoarthritis cohort) and was a mean of 70 years old, with 11 women and 7 men. All radiographs were reviewed, and computed tomography Digital Imaging and Communications in Medicine (National Electrical Manufacturers Association, Rosslyn, VA, USA) data were analyzed on validated 3-dimensional imaging software. Rotator cuff fatty infiltration, glenoid measurements (anteversion and inclination), and humeral head subluxation according to the scapular plane were determined., Results: In the study cohort, the mean glenoid anteversion was 12° (range, 5°-24°), the mean inclination was 0°, and the mean anterior subluxation was 38% (range, 6%-56%). Eight patients (44%) had a biconcave glenoid with a posterosuperiorly positioned paleoglenoid and an anteroinferiorly positioned neoglenoid, and 10 patients had a monoconcave glenoid. Fatty infiltration of the rotator cuff muscles never exceeded Goutallier stage 2., Conclusion: The type D glenoid is an addition to the original Walch classification and is characterized by glenoid anteversion (≥5°), anteroinferior humeral head subluxation, and absence of severe subscapularis fatty infiltration., (Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.)

Background: Several short-stemmed press-fit humeral components have been developed in recent years for anatomic total shoulder arthroplasty (TSA) as well as reverse shoulder arthroplasty (RSA). Varying radiographic outcomes have been reported, with some studies reporting concerning rates of aseptic loosening. This study analyzed the radiographic findings of a press-fit convertible short-stemmed humeral component in both TSA and RSA., Methods: There were 150 anatomic TSAs (group 1) and 77 RSAs (group 2) analyzed radiographically at a minimum follow-up of 2 years postoperatively. Plain radiographs were reviewed for stem loosening, alignment, signs of stress shielding, and the filling ratio., Results: At final follow-up, 49% of group 1 and 65% of group 2 had no evidence for radiographic changes. In those with radiographic changes, low bone adaptions were found in 83% and high adaptions in 17% in both groups. Larger stem sizes with higher filling ratios were associated with high radiographic adaptions in both groups (P = .02). The overall filling ratios were higher in group 2 (P = .002). Cortical contact of the stem led to higher bone adaptions (P = .014)., Conclusions: The short humeral component analyzed in this study showed encouraging survival rates without aseptic loosening. Radiographic changes are associated with a higher filling ratio and cortical contact of the stem. Surgeons should aim to achieve fixation with the minimal required canal filling to minimize radiographic changes with the uncemented humeral component used in this study., (Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Disorders of the long head biceps tendon are among the most challenging of shoulder problems to diagnose and manage. In this Technical Note, we introduce an arthroscopic technique for proximal biceps tenodesis high in the groove at the articular margin of the humeral head using a single anchor and 2 self-cinching loops followed by 5 alternating half-hitches to secure the construct. This method is simple and enables stable fixation of the biceps tendon.

Background: Scapular fractures after reverse shoulder arthroplasty (RSA) are an increasingly reported complication. Information is missing regarding midterm to long-term follow-up consequences. The aim of this study was to determine the rate of scapular fracture (acromial base and spine) after Grammont-style RSA and to report functional and radiographic results of patients with a minimum 5-year follow-up., Materials and Methods: We retrospectively reviewed 1953 Grammont-style RSAs in 1745 patients in a multicenter study. Of these, 953 patients (1035 RSAs) had minimum 5-year follow-up for functional and radiographic assessment (anteroposterior and scapular Y views., Results: Twenty-six patients (1.3%) had sustained a scapular fracture; of these, 19 (10 acromial base and 9 spine fractures) had minimum 5-year follow-up and were reviewed at a mean follow-up of 97 months. Three patients (15.8%) were diagnosed at the last follow-up after an undiagnosed fracture. There were 3 traumatic cases (15.8%) and 13 (68.4%) without antecedent trauma. These 16 patients underwent nonoperative treatment. The fracture was healed in 8 (4 acromion and 4 spine). The average active forward elevation was 109° (range, 50°-170°), and the Constant score was 47.0 points (range, 8-81 points)., Conclusions: Scapular fractures after Grammont-style RSAs are rare (1.3%) but remain a concern. These fractures occur mainly in the early postoperative 6 months. Immobilization with an abduction splint frequently resulted in nonunion or malunion. Final functional outcomes are poor regardless of acromial or spine fracture compared with primary RSA without fracture., (Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Scapular stress fractures after reverse shoulder arthroplasty (RSA) are a potentially serious complication with modern lateralized and onlay implants. The aim of this study was to report the scapular spine stress fracture rate after RSA with an onlay, 145° humeral stem, analyzing potential fracture risk factors and clinical outcomes in a large cohort of patients., Methods: A consecutive series of 485 RSAs were implanted with the Aequalis Ascend Flex stem. Data collection included preoperative and postoperative clinical and radiographic assessment findings (rotator cuff Goutallier grade; Hamada, Walch, and Favard classifications; range of motion; Constant score) and perioperative data. Patients with a scapular spine fracture following RSA were matched with nonfracture control patients, and preoperative variables were tested to determine whether they were predictive of a scapular spine fracture., Results: A scapular spine fracture following RSA occurred in 21 patients (4.3%), with a mean time to diagnosis of 8.6 months (range, 1-34 months). No preoperative factor was found to be a significant predictor of scapular spine fracture. Both groups showed significant improvements in active mobility measurements and Constant scores from preoperatively to final follow-up (P < .001). The control group scored significantly better than the scapular spine fracture group regarding the Constant score and forward flexion., Conclusion: Scapular spine fractures have shown an increased prevalence after onlay-design RSA. This series was not able to link any clear risk factors. Functional results are limited, regardless of the fracture management., (Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)