Splitting the subscapularis at the upper two-third and lower one-third junction or in the middle during the Latarjet-Walch procedure does not affect the external rotation range of motion.

BACKGROUND: Our purpose was to investigate (1) the difference in external rotation range of motion (ROM) limitation between the two recommended subscapularis-splitting techniques (mid-split vs. upper 2/3rd -lower 1/3rd split) and (2) the differences in elevation ROM, internal rotation (IR) ROM, the functional outcomes and the IR strength between the two techniques in the Latarjet-Walch procedure. MATERIAL AND METHODS: We conducted a prospective cohort study of patients with recurrent shoulder instability treated by the Latarjet-Walch procedure between January 2021 and January 2022. After a priori calculation of sample size, 32 patients were divided into two groups according to the type of intraoperative subscapularis split [upper 2/3rd -lower 1/3rd level split (LS group, n = 19) vs. mid-LS (MS group, n = 13)] performed in the Latarjet-Walch procedure. RESULTS: The final external rotation with the arm adducted deficit (as compared to opposite normal shoulder) was not significantly different between the LS (9° ± 8°) and the MS (10° ± 8°, P = .8) groups. The final ER with the elbow abducted @ 90° (ER2) deficit was not significantly different between that of the LS (14° ± 12°) and the MS groups (12° ± 9°, P = .5). Only in the MS group were the final ER with the arm adducted deficit (P = .03) and the final ER with the elbow abducted @ 90° deficits (P = .05) significantly better (smaller) than the corresponding baseline values. The Rowe scores (P = .2) and the Shoulder Subjective Value (P = .7) were not significantly different between the two groups. There were no postoperative subluxations in either group. However, 3 patients tested positive in apprehension testing in the LS group compared to none in the MS group, the difference being statistically insignificant. The IR strength was 95% of the normal, unaffected shoulder in the LS group and 93% of the normal in the MS group (P = .6). Computed tomography scan evaluation showed that the transverse diameter index of subscapularis (upper subscapularis diameter/lower subscapularis diameter) was not different in the MS (0.9 ± 0.1) and the LS (0.9 ± 0.1, P = .3) groups. CONCLUSION: We found no difference in final external rotation limitation between the upper 2/3rd - lower 1/3rd vs. mid-level subscapularis split techniques. The functional outcomes, the IR strength, subscapularis transverse diameter index, and fatty infiltration in the computed tomography scan were similar in both groups.

Coracoid graft resorption after the Latarjet procedure does not depend on the preoperative glenoid defect.

BACKGROUND: The primary purpose was to compare coracoid graft resorption after the Latarjet procedure in patients without preoperative glenoid bone loss vs. those with more than critical glenoid loss. The secondary purposes were to compare the functional outcomes and to investigate the association of graft position, angle of the screws, preoperative glenoid defect, age at surgery, and smoking status with graft resorption. METHODS: Sixty consecutive patients with recurrent anterior instability were treated by the Latarjet procedure as the index procedure, irrespective of the glenoid bone loss between 2018 and 2021. Fifty-five patients were evaluated via computed tomography scans after a minimum of 1 year after surgery (range: 1-4 years). Twenty-five patients had no prior glenoid defect (No-defect group), 24 patients had preoperative glenoid defects ≥15% (Critical defect group), and 6 patients had glenoid defects between 5% and 15%. The No-defect group (n = 25) was compared with the Critical defect group (n = 24). Multivariate logistical regression was performed to evaluate the association of independent factors with the grade of resorption for all 55 patients in the cohort. RESULTS: Major graft resorption at the level of the superior screw was observed in 72%-84% of patients in the No-defect group (n = 25) and in 75%-83% of patients in the Critical defect group (n = 24) (P = 1, P = 1; no significant difference). No to mild resorption at the level of the inferior screw was observed in 96% of patients in the No-defect group and 100% of patients in the Critical defect group (P = 1; no significant difference). Postoperative Rowe scores (100 [95-100] vs. 100 [95-100]; P = .8) and shoulder subjective value (87 [11] vs. 86 [9]; P = .9) were not significantly different between the 2 groups. None of the independent factors, including the corresponding screw angle, the mediolateral graft positioning, prior glenoid defect, age, and smoking status, were associated with graft resorption in multivariate logistical regression. CONCLUSIONS: Graft resorption after the Latarjet procedure does not depend on the preoperative glenoid defect. The coracoid graft may be mostly resorbed around the superior screw but mildly or none at the level of the inferior screw, but this graft resorption is not dependent on the smoking status, age, prior glenoid defect, mediolateral graft positioning, and the angle of the screws.

Capsular repair is not an important part of the Latarjet-Walch procedure.

BACKGROUND: Patte et al noted that the Latarjet procedure works by the triple blocking effect of (1) the conjoint tendon sling effect, (2) the bone block effect, and (3) the capsular repair. However, no clinical study has specifically investigated the role of capsular repair in the Latarjet procedure. AIMS: The primary aim was to compare (1) the external rotation range of motion (ROM) achieved after the Latarjet procedure with and without the capsule to coracoacromial (CA-CAL) repair. The secondary aims were to compare the functional outcomes, forward elevation ROM, and internal rotation ROM after the Latarjet procedure with and without the CA-CAL repair. METHODS: A prospective cohort of 30 patients who underwent the Latarjet-Walch procedure with a CA-CAL repair between October 2018 and February 2020 was compared with the preceding group of 31 patients who underwent the Latarjet-Walch procedure without any capsular repair between October 2016 and September 2018, at a minimum of 1-year of follow-up. RESULTS: External rotation with the elbow abducted at 90° (ER2) deficit (compared to the normal opposite side) was significantly larger after the CA-CAL repair augmentation of the Latarjet procedure (mean difference = 6°, P = .03) than that after no repair. External rotation with the elbow adducted (ER1) deficit after the CA-CAL repair augmentation was not significantly different from that after no repair. ER2 deficit of more than 15° (minimum clinically important difference) was observed in 11 patients (38%) in the CA-CAL repair group and 3 patients (10%, P = .015) in the no repair group. Walch-Duplay score, Rowe score, and Subjective Shoulder Value were not significantly different between the CA-CAL repair group and the no repair group. Covariates of hand dominance, overhead sports, and glenoid defect size did not significantly affect the ER2 deficit and ER1 deficit outcomes. CONCLUSIONS: This study disproved the long-held belief that capsular repair is an essential step of the Latarjet-Walch procedure. Capsular repair to the coracoacromial ligament in the Latarjet procedure leads to a clinically insignificant restriction of external rotation (with the arm abducted), no restriction of external rotation (with the arm adducted), but functional outcomes similar to those after Latarjet without a capsular repair in a nonoverhead athlete.

Validation of an on-screen application-based measurement of shoulder range of motion over telehealth medium.

BACKGROUND: Shoulder range-of-motion (ROM) assessment is vital for the follow-up evaluation of operated patients and for the outcome-based research studies. The aim of this study was to investigate the accuracy and reliability of a remote on-screen application (app)-based method of shoulder ROM measurement through a telehealth medium. MATERIALS AND METHODS: A consultant shoulder surgeon, a board-certified orthopedic resident, and a graduate medical doctor served as the examiners. The cohort consisted of 24 healthy volunteers and 16 symptomatic patients with expected shoulder ROM deficits. Shoulder ROM was first examined physically using a goniometer in the clinic and then over Zoom remote conferencing using the protractor extension app of the Chrome browser. RESULTS: Instrument validity was examined by comparing the goniometer method with the protractor app-based method of the expert shoulder consultant using Bland-Altman analysis. It showed only minor mean differences between the healthy volunteers and the patients in elevation (2.0° and 5.0°, respectively), abduction (2.0° and 3.0°, respectively), external rotation with the elbow adducted (1.9° and 0.2°, respectively), external rotation with the elbow abducted at 90° (0.4° and 4°, respectively), and internal rotation with elbow abducted at 90° (2.3° and 1.2°, respectively), with limits of agreement that were below the well-established minimal clinically important difference values. The intraclass correlation coefficient (ICC) values varied between 0.83 and 0.96 for the volunteers and between 0.90 and 0.98 for the patients, indicating excellent correlation between the 2 methods. The interobserver reliability between 2 examiners for the protractor app-based method as evaluated by ICC scores was excellent; it ranged between 0.86 and 0.98 for the volunteers and between 0.88 and 0.99 for the patients. Comparison of the protractor app-based method with the gold-standard goniometer method for the resident and the graduate doctor showed excellent ICC values. CONCLUSION: A protractor app-based method of measuring shoulder ROM over a telehealth medium is accurate and reliable compared with a clinical goniometer method. This validated method can be used during remote telehealth consultation with significant benefits of saving patients travel and time during the COVID-19 (coronavirus disease 2019) pandemic and even later.

Can We Innovatively Modify the Surgical Helmets to Protect Against the Droplets and Aerosols of COVID-19?

We tested the filtration efficiency of Stryker T5 surgical helmets with and without the addition of a filter medium. Two particle counters were used to count the particles of sizes .5 µm, 1 µm, and 5 µm, both inside and outside the Stryker T5 helmet, concurrently. The total inward leakage (TIL) for the helmet with and without the filter was zero for 5 µm particles at all time points. The TIL (3.4) for the .5 µm particles decreased significantly after application of the filter (1.7; P = .007). We recommend that an N95 should be used inside the helmet system.

Shoulder Pain and Injury after COVID-19 Vaccination.

Shoulder injury related to vaccine administration (SIRVA) is a term given to describe shoulder pain and dysfunction arising within 48 hours after vaccine administration and lasting for more than one week. While SIRVA is most commonly seen after influenza and tetanus vaccines, there have been a few recent case reports describing SIRVA-like symptoms after COVID-19 vaccine administration. Two patients presented to the shoulder surgeon's practice center with complaints of shoulder stiffness and pain following the COVID-19 vaccine. The first patient was a 33-year-old man; he presented within 2 days of onset of the pain and 14 days from the vaccine date. He had a complete restriction of shoulder motion (0° flexion, and no external or internal rotation) at presentation. This patient was treated with non-steroidal anti-inflammatory drugs (NSAID) and rested in a sling for a week. The second patient was a 53-year-old woman; she presented with a 6-week duration of mild restriction of active shoulder motion and shoulder pain. Her magnetic resonance imaging (MRI) revealed the presence of subacromial-subdeltoid bursitis. She was treated with subacromial steroid injection and range of motion shoulder exercises. Both patients recovered a near-normal range of motion recovery within a month, and their pain improved significantly. The main lessons from this case report were: (1) patients presenting with a recent increase in pain and acute loss of shoulder movements after vaccination may be managed conservatively with rest and NSAID medications and (2) in case of a subacromial-subdeltoid bursitis in the MRI, subacromial injection of steroid may provide good pain relief.

Results and complications of head-preserving techniques in chronic neglected shoulder dislocation: a systematic review.

BACKGROUND: Humeral head-preserving procedures may be needed for chronic neglected shoulder dislocation because the presenting age of the patient is often reported to be less than 45 years. The aim of this systematic review was to evaluate the results of the various head-preserving procedures for chronic anterior dislocation (CAD) and chronic posterior dislocation (CPD). This review also aimed to evaluate the results of conservative neglect for CAD. METHODS: PubMed, Embase, and Cochrane library databases were queried for studies that reported on results of head-preserving procedures for CAD or CPD and for studies that reported on the results of conservative neglect for CAD. Case reports, review articles, acute dislocations, and fracture-dislocations were excluded. The results of the different techniques were pooled for further evaluation. RESULTS: Seventeen studies were selected for qualitative analysis. These were further subdivided into 9 studies for the CAD group and 11 studies for the CPD group. In the CAD intervention group, 53 shoulders in 7 studies were managed by 5 different head-preserving techniques. The choice of procedure to stabilize the shoulder after open reduction varied between coracoid transfer, capsulolabral repair, remplissage, and Putti-Platt procedure and acromiohumeral K-wire fixation. High resubluxation rates and early arthrosis were reported after open reduction techniques for CAD. In the CAD conservative group, 8 shoulders in 2 studies were managed by conservative methods. In the CPD group, the 2 most common techniques, McLaughlin or modified McLaughlin and bone grafting, were used to treat 74 shoulders in 7 studies and showed good functional outcomes. CONCLUSION: The choice of open reduction and stabilization technique for CAD was highly variable between the different studies and led to a wide variation in the reported outcomes with a high number of complications such as resubluxation and early arthrosis. The conservative treatment of CAD led to poor functional results. The choice of treatment for CPD was mostly between 2 techniques-McLaughlin and modified McLaughlin reconstruction or the bone graft reconstruction-and they consistently led to good functional outcomes with less complications.

Intraoperative and anatomic dimensions of the coracoid graft as they pertain to the Latarjet-Walch procedure.

BACKGROUND: Our objective was to study the anatomic and intraoperative coracoid measurements with an aim to closely replicate the Latarjet-Walch technique and find the similarities and dissimilarities in our population. METHODS: In the cadaveric study, 20 shoulders in 10 fresh cadavers were dissected, and the coracoid length, width, and thickness were measured. In the intraoperative study, 10 patients underwent the classic Latarjet procedure according to the Walch technique. The harvested coracoid graft was analyzed for the length of the coracoid, the distance of the inferior hole from the lateral margin of the coracoid graft, and the width of the coracoid graft at the inferior and superior hole. RESULT: The average distance from the tip of the coracoid to the trapezoid insertion was 25.4 mm (standard deviation [SD], 1.7 mm). The mean width of the undersurface of the coracoid was 14.2 mm. The average length of the graft after harvesting was 25.1 mm (SD, 1 mm). The average distance between the lateral border and the inferior hole was 5.5 mm (SD, 1.1 mm). We used 25-mm malleolar screws in 3 shoulders and 30-mm malleolar screws in 7 shoulders. CONCLUSION: The"7-mm" rule of Walch could be followed in our population. The medial surface width of the coracoid in our Indian morphology was an average of 7 mm; hence, malleolar screws of 30 and 25 mm were used to fix the graft on the glenoid.

The effect of a radial neck notch on press-fit stem stability: a biomechanical study on 7 cadavers.

BACKGROUND: Minimal micromotion is necessary for osteointegration of cementless radial head prostheses. When radial head fractures extend longitudinally, where the neck cut for prosthetic replacement should be made is uncertain. We hypothesized that complete resection of the notched portion of a radial neck confers no advantage in initial stability compared with not resecting the defect and inserting the implant into a notched radial neck. MATERIALS AND METHODS: The radii of 7 cadavers underwent radial head resection and implantation with a 25-mm-long press-fit radial head stem. Before implantation, a 5-mm-long notch that was less than 1-mm wide was made in the radial neck. After the stem-bone micromotion was recorded, the proximal 5 mm of radial neck, incorporating the entire notch, was cut away, the stem was inserted 5 mm further, and the resulting micromotion was recorded. RESULTS: The mean micromotion measured in the presence of a cortical notch was 51 ± 6 µm. After the neck was circumferentially cut and the stem was advanced, the micromotion (46 ± 9 µm) was not statistically significantly different. DISCUSSION: Initial stability of an adequately sized cementless stem in the presence of a 5-mm-long cortical notch was well within the threshold needed for bone ingrowth (<100 µm). In addition, there was no reduction of micromotion after the notch-containing portion of the radial neck was resected and the stem was advanced. Making a neck cut distal to a 5-mm-long, 1-mm-wide cortical notch does not confer added stability. Thus, surgeons can preserve bone stock and avoid an aggressive neck cut.

Radiocapitellar contact characteristics during prosthetic radial head subluxation.

BACKGROUND: Metallic radial head prostheses are often used in the management of comminuted radial head fractures and elbow instability. We hypothesized that during radiocapitellar subluxation, the contact pressure characteristics of an anatomic radial head prosthesis will more closely mimic those of the native radial head compared with a monopolar circular or a bipolar circular radial head design. MATERIALS AND METHODS: With use of 6 fresh frozen cadaver elbows, mean radiocapitellar contact pressures, contact areas, and peak pressures of the native radial head were assessed at 0, 2, 4, and 6 mm of posterior subluxation. These assessments were repeated after the native radial head was replaced with anatomic, monopolar circular and bipolar circular prostheses. RESULTS: The joint contact pressures increased with the native and the prosthetic radial head subluxation. The mean contact pressures for the native radial head and anatomic prosthesis increased progressively and significantly from 0 to 6 mm of subluxation (native, 0.6 ± 0.0 MPa to 1.9 ± 0.2 MPa; anatomic, 0.7 ± 0.0 MPa to 2.1 ± 0.3 MPa; P < .0001). The contact pressures with the monopolar and bipolar prostheses were significantly higher at baseline and did not change significantly further with subluxation (monopolar, 2.0 ± 0.1 MPa to 2.2 ± 0.2 MPa [P = .31]; bipolar, 1.7 ± 0.1 MPa to 1.9 ± 0.1 MPa [P = .12]). The pattern of increase in contact pressures with the anatomic prosthesis mimicked that of the native radial head. Conversely, the circular prostheses started out with higher contact pressures that stayed elevated. CONCLUSION: The articular surface design of a radial head prosthesis is an important determinant of joint contact pressures.

Sentinel sign: a sign of biceps tendon which indicates the presence of subscapularis tendon rupture.

PURPOSE: Subscapularis tendon ruptures, which are small in size, can be missed on CT or MRI imaging and are also difficult to diagnose by arthroscopy. Here we discuss a new sign of biceps tendon, which may point towards rupture of the subscapularis tendon. The biceps tendon may have scuffing, abrasion or partial tear of its anterior portion. We have named this as sentinel sign as it signals the presence of a coexisting subscapularis rupture. MATERIALS AND METHODS: This study was a retrospective analysis of available arthroscopic rotator cuff repair surgery videos of 2009-2010. The videos were studied, and data recorded for number of cases showing the presence of sentinel sign and coexisting subscapularis rupture. Sensitivity, positive predictive value of the sign, was calculated. RESULTS: Out of 330 available videos, 79 showed the presence of subscapularis rupture. Ten patients had a positive sentinel sign, but an intact biceps pulley that obscured the visualisation of the subscapularis tendon tear. This tear became apparent after removal of anterior part of biceps sling. CONCLUSION: The presence of sentinel sign of the biceps tendon indicates the presence of a coexistent subscapularis rupture. If the rupture is not apparent, obscuring parts of the biceps sling should be removed to see the upper fibres of subscapularis tendon. LEVEL OF EVIDENCE: Study of diagnostic test, Level III.

Influence of radial head prosthetic design on radiocapitellar joint contact mechanics.

HYPOTHESIS: Our aim was to test whether anatomically designed metallic radial head implants could better reproduce native radiocapitellar contact pressure and areas than nonanatomic implants. METHODS: The distal humerus and proximal radius from 6 cadaveric upper extremities were serially tested in supination with 100 N of compression force at 4 angles of flexion (0°, 30°, 60°, and 90°). By use of a thin flexible pressure transducer, contact pressures and areas were measured for the native radial head, an anatomic implant, a nonanatomic circular monopolar implant, and a bipolar nonanatomic implant. The data (mean contact pressure and mean contact area) were modeled using a 2-factor repeated-measures analysis of variance with P ≤ .05 considered to be significant. RESULTS: The mean contact areas for the prosthetic radial heads were significantly less than those seen with the intact radial heads at every angle tested (P < .01). The mean contact pressures increased significantly with all prosthetic radial head types as compared with the native head. The mean contact pressures increased by 29% with the anatomic prosthesis, 230% with the monopolar prosthesis, and 220% with the bipolar prosthesis. Peak pressures of more than 5 MPa were more commonly observed with both the monopolar and bipolar prostheses than with the anatomic or native radial heads. CONCLUSIONS: The geometry of radial head implants strongly influences their contact characteristics. In a direct radius-to-capitellum axial loading experiment, an anatomically designed radial head prosthesis had lower and more evenly distributed contact pressures than the nonanatomic implants that were tested.

Neglected and locked anterior shoulder dislocation: functional outcomes and complications after open reduction and preservation of humeral head.

Background: Neglected and locked anterior shoulder dislocation is a rare problem that presents several treatment challenges. Our study aimed to evaluate the functional outcomes and postoperative complications after open reduction and head preservation surgery in patients with neglected and locked anterior shoulder dislocation. Methods: Ten patients (age 51 ± 22 years) with a follow-up of 27 months ± 7 months (range 24-40 months) were included in the study. The anteriorly dislocated humeral heads were open and reduced after an average neglect of 10 ± 15 months. The neglected dislocation was classified into two types by the severity of the injury. (1) Type 1: There were no associated severe injuries, and the humeral head was reduced in the glenoid cavity without take-down of the subscapularis (type 1a) (n = 5) or via take-down of the upper half of the subscapularis (type 1b) (n = 2). (2) Type 2: There were associated factors such as a greater tuberosity fracture (n = 2) or a grade 3/4 fatty infiltrated supraspinatus and infraspinatus muscles (n = 1). Complete removal of the subscapularis was necessary to reduce the humeral head. Results: The pain scores improved from a baseline value of 8 ± 1 to a final value of 1 ± 1 (P < .001), the absolute Constant score improved from a baseline value of 13 ± 8 to a final value of 69 ± 21 (P < .001), elevation range of motion (ROM) improved from a baseline value of 44° ± 43° to a final value of 123° ± 30° (P < .001), external rotation ROM improved from 0° ± 13° to 49° ± 12° (P < .001), and internal rotation ROM improved from sacroiliac joint ± 2 vertebra level to thoracic T11 ± 3 vertebrae level (P < .0001). The final shoulder subjective value was 77 ± 20 and was excellent in 3 patients, good in 5 patients, fair in 1, and poor in 1 patient. Major complications were observed in 30% (n = 3) of patients: persistent humeral head anterior subluxation in 20% (n = 2) of patients and superior migration of the humeral head in 10% (n = 1) of patients. Conclusion: Open reduction and head preservation in patients with neglected anterior dislocation led to good functional outcomes in 70% (as per Constant score) to 80% (as per shoulder subjective value) of the patients. However, we observed major complications such as persistent anterior subluxation (n = 2) and superior head migration (n = 1), leading to suboptimal functional outcomes in cases with associated factors such as a greater tuberosity fracture or severe fatty infiltrated cuff muscles.

Frozen shoulder after COVID-19 vaccination versus idiopathic frozen shoulder: similar clinical features and functional improvement at 1-year follow-up.

Background: Frozen shoulder after COVID-19 vaccination is sparsely discussed in the medical literature. We aimed to evaluate: (1) the differences in the baseline clinical features and functional outcomes of conservatively treated frozen shoulder following COVID-19 vaccination compared to idiopathic frozen shoulder (2) the improvements in pain scores, functional outcomes, and range of motion (ROM) at 6-10 months and at 1 year of follow-up in patients with frozen shoulder after COVID-19 vaccination treated by conservative therapy. Methods: Between June 2021 and December 2021, 12 patients (13 shoulders) that were diagnosed with frozen shoulder after COVID-19 vaccination (vaccine related frozen shoulder [VRF] group) (final follow-up of 12.4 months ± 0.8 months) were compared with 20 patients that were diagnosed as idiopathic frozen shoulder unrelated to vaccination (unvaccinated frozen shoulder [UFS] group) (average follow-up of 13.4 ± 3.1 months). All patients were treated with home-based stretching exercises. Four (33%) patients in the VRF group and 15 (75%) patients in the UFS group underwent steroid injection in the suprascapular notch by an experienced radiologist. Results: The left side was affected more frequently in the VRF group [n = 10 (83.3%)] than in the UFS group [n = 8 (40%), P = .03]. The VRF and the UFS groups were similar in the rest of the baseline clinical features, such as the age distribution, men/women ratio, baseline Oxford Shoulder Scores (OSS), ROM deficit, and pain visual analogue scale (VAS) scores. The OSS, VAS pain scores, and the ROM deficit significantly improved in the VRF group at the 6-10-month follow-up and then at the final (12.4 ± 0.8 months) follow-up compared to the baseline values. At the final follow-up, there were no significant differences in the average external rotation, external rotation deficit, elevation, elevation deficit, internal rotation, pain VAS scores, and OSS between the VRF and the UFS group. Conclusion: To conclude, frozen shoulder following COVID-19 vaccination may present with clinical features similar to those of the idiopathic frozen shoulder. Furthermore, the patients with frozen shoulder following COVID-19 vaccination may continue to improve over one year with conservative treatment; the final improvements in function and ROM are similar to those with idiopathic frozen shoulder.

Management of type III acromioclavicular joint dislocation: A Delphi consensus survey by Shoulder & Elbow Society, India (SESI).

PURPOSE: The study aimed to report the results of the Delphi survey conducted by the Shoulder, Elbow Society India (SESI), to achieve consensus on ambiguous topics in managing type III acromioclavicular joint (ACJ) dislocations. METHODS: This study was based on responses from the Shoulder Elbow Society India (SESI) panel of peer-selected twenty senior surgeons practicing shoulder orthopedics. They participated in two rounds of the survey to obtain consensus on several topics pertaining to the management of type III ACJ dislocations. Consensus was achieved when at least 70 % of the panel members selected at least a 4-point on a 5-point Likert scale. RESULTS: Our Delphi survey reached a consensus on seven topics of ambiguity. An anteroposterior and axillary view of the shoulder without any traction or weight in hand is sufficient in the setting of a suspected type III ACJ dislocation. Magnetic resonance imaging (MRI) is not routinely indicated in type III ACJ dislocation. Either cross-arm adduction X-rays or clinical examination may be used to distinguish between ISAKOS (International Society of Arthroscopy, Knee surgery and Orthopaedics Sports medicine) IIIA and B classification of ACJ to identify stable and unstable injuries. Conservative treatment can be offered to patients who have stable injuries and who are not high-demand individuals in acute type III ACJ dislocations. In conservative management of type III ACJ dislocation, a two-week sling suffices. Jones strapping has no clear advantage over a shoulder sling. Coracoclavicular reconstruction with an autograft is an acceptable way to treat symptomatic, chronic grade III ACJ dislocation. CONCLUSION: The survey helped achieve consensus on several controversial issues related to type III ACJ dislocations. However, there remains ambiguity on the definition of chronicity of such dislocations, the necessity of bilateral Zanca views, and the duration of conservative trial before switching to a surgical line of management.

Safety-driven master's technique of the Latarjet-Walch procedure and its short-term complications: experience in a study of 150 consecutive patients.

Background: Although the classic open Latarjet has a low recurrence rate in unstable shoulders, this advantage may be offset by the higher number of complications. We aimed to report the safety-driven nuanced steps and the resulting short-term complications of the Latarjet-Walch technique. Methods: Between 2016 and 2022, 150 patients who underwent the Latarjet procedure following the key safety-driven technical steps were retrospectively evaluated for intraoperative and short-term (3 months) complications. The complications were divided into 3 types: Any adverse event that did not need a change in the treatment protocol was a type 1 complication. An event that resulted in a prolongation of rehabilitation protocol or an additional medical line of treatment was classified as type 2, and an event that resulted in readmission, a resurgery, or one that affected the outcome was classified as a type 3 complication. Results: There were 12 (8%) short-term complications in 9 patients. Neurological complications were noted in 3 (2%) patients (1 axillary nerve injury, 1 suprascapular nerve injury, and 1 musculocutaneous nerve injury). Type 1 complications were noted in 2 patients: 2 patients had hematoma that was detected as superficial swelling, but no surgical drainage was needed, and both resolved at their 1-month follow-up. Type 2 complications were noted in 4 patients. One patient had surgical site infection and a second patient had superficial wound dehiscence in the lower part of the wound. The third patient had suprascapular nerve paresis and the fourth had musculocutaneous nerve paresis and shoulder stiffness. Both nerve injuries recovered completely after 6 months of rehabilitation. Type 3 complications were noted in 3 patients. One patient had axillary nerve paresis and shoulder stiffness. The axillary nerve palsy had recovered partially by 8 months. One patient had an intraoperative graft fracture and postoperative shoulder stiffness, and the third patient had shoulder stiffness. Conclusion: Following the safety-driven nuanced steps in the Latarjet-Walch procedure, the short-term complication rate was 8%, and the neurological complication was 2% (n = 3). The musculocutaneous and suprascapular nerves completely recovered, and the axillary nerve had partially recovered.

Two-incision versus one-incision repair for distal biceps tendon rupture: a cadaveric study.

HYPOTHESIS: The purpose of this study was to accurately map the insertional footprint of the distal biceps tendon and to test our hypothesis that a superior anatomic repair can be achieved by a 2-incision technique when compared with a 1-incision technique. METHODS: We randomly assigned 20 cadaveric arms to 1 of 2 groups: 1 incision (group I) or 2 incision (group II). The bicipital tuberosity was exposed through either a single anterior incision (group I) or a posterolateral approach (group II). A guide pin was placed into the tuberosity to mark the axis for creating a virtual bone tunnel. Each radius was harvested with the biceps insertion intact. The length, width, and area of the insertion footprint for each tendon were determined with a 3-dimensional computerized digitizer. A 7.5 mm-diameter virtual bone tunnel was centered over the drill hole created by the guidewire. The percentage of the virtual tunnel within the original footprint was determined. RESULTS: The percentage of the virtual tunnel (repair site) within the original tendon footprint was 73.4% for the posterolateral approach and only 9.7% for the anterior approach. There was a statistically significant difference (P ≤ .001) in the median values of footprint covered when the 2 types of repair were compared. DISCUSSION AND CONCLUSION: The 2-incision technique results in a significantly improved anatomic repair of the biceps tendon to the original insertion site. Prospective clinical studies directly comparing the 2 techniques with regard to the strength of supination after repair may be helpful.