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Background The purpose of this paper is to examine the intra-observer and inter-observer reliability of preoperative templating to help determine its usefulness for approximating proximal humeral stem and head size in shoulder arthroplasty. Methods Thirty-one nonconsecutive patients underwent uncemented total shoulder arthroplasty using 1 of 2 commonly used prostheses. Templating was performed by 4 independent observers (2 experienced shoulder surgeons and 2 PGY-3 residents). Two readings were performed with a minimum 2-week interval between templating sessions. Templating was performed in a blinded manner using appropriately magnified templates provided by the prosthesis manufacturer. Postoperative radiographs were analyzed in the same fashion and each observer graded qualitative stem and head size radiographically. Pre-operative templated sizes were compared to actual implant sizes obtained from dictated operative reports. Results There was substantial (kappa > 0.7) intraobserver reliability for stem and head size selection for both prostheses. Interobserver reliability was moderate for stem size (kappa = 0.53) and substantial (kappa = 0.66) for head size. Preoperative templating accurately predicted stem (84-95%) and head (44-66%) size within 1 size variation (stem width, head thickness, or diameter) for shoulder replacement surgery. There was no significant difference in accuracy between attendings and residents when templating for stem or head size. Conclusion Preoperative templating is a reliable and reasonably accurate step when planning shoulder replacement surgery. Templating for stem size is more accurate than for head size. Level of evidence Level IV, Case Series, Treatment Study.

Hypothesis We hypothesized that releasing the subscapularis with lesser tuberosity bone may improve strength of fixation of the subscapularis during total shoulder atthroplasty (TSA). Materials and methods In 15 cadaveric humeri, all musculature was removed except the subscapularis. A standard humeral head osteotomy was performed for TSA. The subscapularis was released with a fleck of lesser tuberosity bone in 10 specimens from five matched pairs, and a tenotomy was performed in five. Five osteotomies were repaired with single-row heavy non-absorbable sutures and five with an additional double-row. Repairs were subjected to cyclical loading at 180 newtons for 400 cycles, increasing by 180 newtons to failure. A retrospective review of 100 consecutive patients who underwent dual-row repair of the subscapularis fleck osteotomy following TSA was also performed with minimal follow-up of 24 months (24-48). Results Both single (430 N) and double-row (466 N) fixation of the fleck osteotomy were significantly stronger than tenotomy suture repair (252 N) ( p .04). There was no significant difference between single and double-row ultimate strengths. Qualitatively, double-row fixation fixed the fleck osteotomy more securely to the donor site with respect to gross rotational motion. At final clinical review, the lift-off test was rated as normal in 79%. The belly press was rated as normal in 86%. Eighty-two percent were able to tuck in their shirts. Conclusion Subscapularis release with fleck osteotomy provides superior biomechanical ultimate strength compared to standard tenotomy. There was no visible motion during biomechanical testing with dual-row osteotomy fixation compared to single-row fixation. Clinical results of this dual-row technique document showed good restoration of subscapularis integrity for activities of daily living. Level of evidence Basic science study and level 4; retrospective review, case series, no control group.

Purpose To compare distal radius volar fixed-angle plates for anatomic fit. Methods Twenty embalmed radii were stripped of soft tissues. The volar lip (watershed line) on the volar distal radius served as a reference line. Seven volar fixed-angle plates were tested (Acumed Acu-loc Standard, Hand Innovations DVRAW and DVRAN, Synthes Juxta-articular [JA], Synthes Extra-articular [EA], Trimed Volar Bearing, Zimmer Volar Lateral Column). Four parameters of anatomic fit were studied: (1) site of best fit; (2) percent plate contact; (3) pin–subchondral bone distance; and (4) extraosseous penetrations. The Wilcoxon signed rank test and Pearson's correlation coefficient were used to compare interobserver plate placement. A Kruskal-Wallis analysis of variance was used to compare percent plate contact and pin–subchondral bone distance across all plates. The Bonferroni correction for multiple comparisons was used to compare pin–subchondral bone distances for all possible plate combinations. Results There was no difference between observers for plate placement. Each plate had a specific site of best fit, and the 7 plates varied widely in best fit location. Percent contact (range, 3% to 6%) between plates was significantly different. Pin–subchondral bone distance across all plates was significantly different. Analysis of all possible plate combinations showed that the Synthes EA pin–subchondral bone distances were significantly different than those of all plates except Zimmer. Amongst the 140 plate insertions, the radiocarpal joint was penetrated in 17, the styloid in 7, (with 6 associated with the DVRAW plate), and the distal radioulnar joint in 9 (all associated with the DVRAW plate). Conclusions There was considerable variation in ideal plate location among the 7 plates tested. Total contact was minimal for all plates tested. The Synthes EA pin–subchondral bone distance was significantly greater than those of other plates tested. Joint penetration was relatively common, necessitating use of fluoroscopy and proper plate width.

Suprascapular nerve decompression is an important entity that is quite uncommon but may often be neglected. Physical examination, imaging techniques, and electromyographic studies are the keys to a successful diagnosis, treatment, and outcomes. With the help of contributions from the recent literature, current management and treatment techniques for suprascapular nerve compression are covered in this chapter.