Lower Trapezius Transfer Improves Clinical Outcomes With a Rate of Complications and Reoperations Comparable to Other Surgical Alternatives in Patients with Functionally Irreparable Rotator Cuff Tears: A Systematic Review.

PURPOSE: To analyze the clinical outcomes of lower trapezius transfer (LTT) for patients with functionally irreparable rotator cuff tears (FIRCT) and summarize the available literature regarding complications and reoperations. METHODS: After registration in the International prospective register of systematic reviews (PROSPERO [CRD42022359277]), a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. Inclusion criteria were English, full-length, peer-reviewed publications with a level of evidence IV or higher reporting on clinical outcomes of LTT for FIRCT. Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus via Elsevier databases were searched. Clinical data, complications and revisions were systematically recorded. RESULTS: Seven studies with 159 patients were identified. The mean age range was 52 to 63 years, 70.4% of the patients included were male, and the mean follow-up time ranged between 14 and 47 months. At final follow-up, LTT lead to improvements in range of motion, with reported forward elevation (FE) and external rotation (ER) mean gains of 10° to 66° and 11° to 63°, respectively. ER lag was present before surgery in 78 patients and was reversed after LTT in all shoulders. Patient-reported outcomes were improved at final follow-up, including the American Shoulder and Elbow Society score, Shoulder Subjective Value and Visual Analogue Scale. The overall complication rate was 17.6%, and the most reported complication was posterior harvest site seroma/hematoma (6.3%). The most common reoperation was conversion to reverse shoulder arthroplasty (5%) with an overall reoperation rate of 7.5%. CONCLUSIONS: Lower trapezius transfer improves clinical outcomes in patients with irreparable rotator cuff tears with a rate of complications and reoperations comparable to other surgical alternatives in this group of patients. Increases in forward flexion and ER are to be expected, as well as a reversal of ER lag sign when present before surgery. LEVEL OF EVIDENCE: Level IV, systematic review of Level III-IV studies.

Clavicular tunnel widening after coracoclavicular stabilization surgery: a systematic review and meta-analysis.

BACKGROUND: This systematic review and meta-analysis aimed to (1) estimate the prevalence of clavicular tunnel widening (TW) after coracoclavicular stabilization surgery and its risk factors and (2) assess whether TW is correlated with clavicle fracture or loss of reduction of the acromioclavicular joint (ACJ). METHODS: In January 2023, 3 electronic databases were searched to collect data on postoperative clavicular TW, its prevalence, magnitude, and correlation with fracture and ACJ loss of reduction. Studies were classified according to the time of surgical intervention, and the clavicular tunnels were categorized by their anatomic location. Mean differences were calculated using a DerSimonian-Laird random-effects model, while binomial outcomes were pooled using the Freeman-Tukey double arcsine transformation. Univariate and multivariate meta-regression analyses were performed to determine the effect of several variables on the proportion of cases with TW. RESULTS: Fifteen studies (418 shoulders) were included. At the final follow-up, evidence of clavicular TW was found in 70% (95% confidence interval [CI]: 70%-87%; I2 = 89%) of 221 shoulders. Surgeries in acute cases had a lower prevalence of TW (52%) compared to chronic cases (71%) (P < .001). Significant TW was found in the central tunnel (3.2 mm; 95% CI: 1.8-4.6 mm; P < .001; I2 = 72%) for acute injuries and in the medial (1.2 mm; 95% CI: 0.7-1.7 mm; P < .001; I2 = 77%) and lateral (1.5 mm; 95% CI: 0.7-2.3 mm; P < .001; I2 = 77%) tunnels for chronic cases. Single central-tunnel techniques were positively associated with the prevalence of TW (P = .046), while biotenodesis screw fixation was associated with a lower prevalence (P = .004) in chronic cases. Reconstruction of the ACJ ligament complex with tendon grafts or sutures was associated with a higher prevalence of TW (P < .001). Drill sizes between 2.5 and 5 mm were significantly associated with a lower prevalence of TW, regardless of injury chronicity (P = .012). No correlation was found between TW and the loss of ACJ reduction or clavicle fractures. CONCLUSIONS: This systematic review and meta-analysis explored TW occurrence following coracoclavicular stabilization surgery. TW was observed in 70% of patients at final follow-up, with a higher prevalence in chronic than in acute cases. Modifiable surgical variables, such as single-tunnel tendon graft constructs for acute or chronic injuries and knotted graft procedures for chronic injuries, were significantly associated with TW. Furthermore, the prevalence of TW increased with concomitant surgical treatment of the ACJ ligament complex, and decreased with drill sizes between 2.5 and 5 mm, regardless of lesion chronicity. These surgical variables should be considered when establishing transosseous tunnels for coracoclavicular stabilization. Clavicle fractures and TW mechanisms require further investigation.

Mid- to long-term outcomes of latissimus dorsi tendon transfer for massive irreparable posterosuperior rotator cuff tears: a systematic review and meta-analysis.

BACKGROUND: This study aims to analyze the mid-to long-term results of the latissimus dorsi tendon for the treatment of massive posterosuperior irreparable rotator cuff tears as reported in high-quality publications and to determine its efficacy and safety. METHODS: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Scopus, and EMBASE databases were searched until December 2022 to identify studies with a minimum 4 year follow-up. Clinical and radiographic outcomes, complications, and revision surgery data were collected. The publications included were analyzed quantitatively using the DerSimonian Laird random-effects model to estimate the change in outcomes from the preoperative to the postoperative condition. The proportion of complications and revisions were pooled using the Freeman-Tukey double arcsine transformation. RESULTS: Of the 618 publications identified through database search, 11 articles were considered eligible. A total of 421 patients (432 shoulders) were included in this analysis. Their mean age was 59.5 ± 4 years. Of these, 277 patients had mid-term follow-up (4-9 years), and 144 had long-term follow-up (more than 9 years). Postoperative improvements were considered significant for the following outcome parameters: Constant-Murley Score (0-100 scale), with a mean difference (MD) = 28 points (95% confidence interval [CI] 21, 36; I2 = 89%; P < .001); visual analog scale, with a standardized MD = 2.5 (95% CI 1.7, 3.3; P < .001; I2 = 89%; P < .001); forward flexion, with a MD = 43° (95% CI 21°, 65°; I2 = 95% P < .001); abduction, with a MD = 38° (95% CI 20°, 56°; I2 = 85%; P < .01), and external rotation, with a MD = 8° (95% CI 1°, 16°; I2 = 87%; P = .005). The overall reported mean complication rate was 13% (95% CI 9%, 19%; I2 = 0%), while the reported mean revision rate was 6% (95% CI: 3%, 9%; I2 = 0%). CONCLUSIONS: Our pooled estimated results seem to indicate that latissimus dorsi tendon transfer significantly improves patient-reported outcomes, pain relief, range of motion, and strength, with modest rates of complications and revision surgery at mid-to long-term follow-up. In well-selected patients, latissimus dorsi tendon transfer may provide favorable outcomes for irreparable posterosuperior cuff tears.

Complications of antibiotic cement spacers used for elbow infections.

BACKGROUND: Antibiotic cement spacers have been widely used in the treatment of joint infections. There are no commercially available antibiotic spacers for the elbow. Instead, they are typically fashioned by the surgeon at the time of surgery using cement alone or a combination of cement with sutures, Steinmann pins, external fixator components, or elbow arthroplasty components. There is no consensus regarding the ideal elbow antibiotic spacer and no previous studies have examined the complications associated with these handmade implants in relation to their unique structural design. METHODS: We retrospectively reviewed 55 patients who had 78 static antibiotic cement spacers implanted between January 1998 and February 2021 as part of a 2-stage treatment plan for infection of an elbow arthroplasty, other elbow surgery, or primary elbow infection. Several antibiotic spacer structures were used during the study period. For analysis purposes, the spacers were classified into linked and unlinked spacers based on whether there was a linking mechanism between the humerus and the ulna. Complications related to these spacers that occurred either during the implantation, between implantation and removal, or during removal were recorded and analyzed from chart review and follow-up x rays. Reoperations due to spacer-related complications were also recorded. RESULTS: Among the 55 patients (78 spacers), there were 23 complications, including 17 minor and 6 major complications. The most common complication of unlinked spacers (intramedullary [IM] dowels, beads and cap spacer) was spacer displacement. Other complications included IM dowel fracture and difficulty locating beads during spacer removal. The major complications of linked cement spacers included two periprosthetic humerus fractures after internal external fixator cement spacers and re-operation due to breakage and displacement of one bushing cement spacer. The major complications of unlinked cement spacers included two reoperations due to IM dowel displacement and one reoperation due to displacement of beads. Among patients who had removal of all components and those with native joints, there was no statistically significant difference between internal external fixator cement spacers and unlinked cement spacers in minor complication rates (30% vs. 16%, P = .16), major complication rates (7% vs. 8%, P = .85) and reoperation rates (0% vs. 8%, P = .12). CONCLUSIONS: Static handmade antibiotic elbow spacers have unique complications related to their structural designs. The most common complication of linked and nonlinked cement spacers were failure of the linking mechanism and displacement, respectively. Surgeons should keep in mind the possible complications of different structures of cement spacers when choosing 1 antibiotic spacer structure over another.

Factors association with reparability of rotator cuff tears: A systematic review and meta-analysis.

PURPOSE: To identify and quantify the factors associated with the reparability of rotator cuff tears (RCTs). METHODS: PubMed, Scopus, and Web of Science databases were searched for clinical studies published in English focusing on RCT reparability by using the keywords "rotator cuff tear" and "reparability". A meta-analysis was conducted if ≥3 studies examined the same factor and provided enough data to assess RCT reparability. Quality assessment was completed using the QUADAS-2 tool. RESULTS: Eighteen studies (2700 patients) were enrolled, and 26 factors were included in the meta-analysis. The dichotomous variables associated with irreparability were Patte stage 3 (Odds ratio (OR): 8.0, 95% CI: 4.3-14.9), massive tear versus large tear (OR: 3.1, 95% CI: 1.3-7.2), Goutallier stage for each tendon, and tangent sign (OR: 11.1, 95% CI: 4.3-28.4). The continuous variables associated with irreparability were age (Mean difference (MD): 3.25, 95% CI: 1.4-5.1), mediolateral tear size (MD: 12.3, 95% CI: 5.8-18.9), anteroposterior tear size (MD: 10.4, 95% CI: 5.2-15.6), acromiohumeral distance on X-ray (MD: -2.3, 95% CI: -3.0 to -1.6) and magnetic resonance imaging (MD: -1.8, 95% CI: -2.8 to -0.9), and inferior glenohumeral distance on MRI (MD: 2.2, 95% CI: 1.4-3.0). CONCLUSION: This study revealed that older age, larger tear size, severe fatty infiltration, muscle atrophy, and advanced superior migration of the humeral head were strongly associated with irreparable RCTs. Conversely, clinical symptoms provided limited information for predicting reparability. Additionally, the tangent sign emerged as a powerful and simple tool for individual prediction, and several quantitative scoring systems also proved useful.

Trans-ulnar fracture dislocations of the elbow: a systematic review and clarification of classification systems.

BACKGROUND: Complex elbow dislocations in which the dorsal cortex of the ulna is fractured can be difficult to classify and therefore treat. These have variably been described as either Monteggia variant injuries or trans-olecranon fracture dislocations. Additionally, O'Driscoll et al classified coronoid fractures that exit the dorsal cortex of the ulna as "basal coronoid, subtype 2" fractures. The Mayo classification of trans-ulnar fracture dislocations categorizes these injuries in 3 types according to what the coronoid remains attached to: trans-olecranon fracture dislocations, Monteggia variant fracture dislocations, and trans-ulnar basal coronoid fracture dislocations. The purpose of this study was to evaluate the outcomes of these injury patterns as reported in the literature. Our hypothesis was that trans-ulnar basal coronoid fracture dislocations would have a worse prognosis. MATERIALS AND METHODS: We conducted a systematic review to identify studies with trans-ulnar fracture dislocations that had documentation of associated coronoid injuries. A literature search identified 16 qualifying studies with 296 fractures. Elbows presenting with basal subtype 2 or Regan/Morrey III coronoid fractures and Jupiter IIA and IID injuries were classified as trans-ulnar basal coronoid fractures. Patients with trans-olecranon or Monteggia fractures were classified as such if the coronoid was not fractured or an associated coronoid fracture had been classified as O'Driscoll tip, anteromedial facet, basal subtype I, or Regan Morrey I/II. RESULTS: The 296 fractures reviewed were classified as trans-olecranon in 44 elbows, Monteggia variant in 82 elbows, and trans-ulnar basal coronoid fracture dislocations in 170 elbows. Higher rates of complications and reoperations were reported for trans-ulnar basal coronoid injuries (40%, 25%) compared to trans-olecranon (11%, 18%) and Monteggia variant injuries (25%, 13%). The mean flexion-extension arc for basal coronoid fractures was 106° compared to 117° for Monteggia (P < .01) and 121° for trans-olecranon injuries (P = .02). The mean Mayo Elbow Performance Score was 84 points for trans-ulnar basal coronoid, 91 for Monteggia (P < .01), and 93 for trans-olecranon fracture dislocations (P < .05). Disabilities of the Arm, Shoulder and Hand and American Shoulder and Elbow Surgeons scores were 22 and 80 for trans-ulnar basal coronoid, respectively, compared to 23 and 89 for trans-olecranon fractures. American Shoulder and Elbow Surgeons was not available for any Monteggia injuries, but the mean Disabilities of the Arm, Shoulder and Hand was 13. DISCUSSION: Trans-ulnar basal coronoid fracture dislocations are associated with inferior patient reported outcome measures, decreased range of motion, and increased complication rates compared to trans-olecranon or Monteggia variant fracture dislocations. Further research is needed to determine the most appropriate treatment for this difficult injury pattern.

Artificial intelligence-based three-dimensional templating for total joint arthroplasty planning: a scoping review.

PURPOSE: The purpose of this review is to evaluate the current status of research on the application of artificial intelligence (AI)-based three-dimensional (3D) templating in preoperative planning of total joint arthroplasty. METHODS: This scoping review followed the PRISMA, PRISMA-ScR guidelines, and five stage methodological framework for scoping reviews. Studies of patients undergoing primary or revision joint arthroplasty surgery that utilised AI-based 3D templating for surgical planning were included. Outcome measures included dataset and model development characteristics, AI performance metrics, and time performance. After AI-based 3D planning, the accuracy of component size and placement estimation and postoperative outcome data were collected. RESULTS: Nine studies satisfied inclusion criteria including a focus on computed tomography (CT) or magnetic resonance imaging (MRI)-based AI templating for use in hip or knee arthroplasty. AI-based 3D templating systems reduced surgical planning time and improved implant size/position and imaging feature estimation compared to conventional radiographic templating. Several components of data processing and model development and testing were insufficiently covered in the studies included in this scoping review. CONCLUSIONS: AI-based 3D templating systems have the potential to improve preoperative planning for joint arthroplasty surgery. This technology offers more accurate and personalized preoperative planning, which has potential to improve functional outcomes for patients. However, deficiencies in several key areas, including data handling, model development, and testing, can potentially hinder the reproducibility and reliability of the methods proposed. As such, further research is needed to definitively evaluate the efficacy and feasibility of these systems.

Substantial influence of psychological factors on return to sports after anterior shoulder instability surgery: a systematic review and meta-analysis.

PURPOSE: This systematic review and meta-analysis aimed to (1) determine the proportion of patients who underwent anterior shoulder instability surgery and did not return to sports for psychological reasons and (2) estimate differences in psychological readiness scores between patients who did and did not return to sports. METHODS: The EBSCOhost/SPORTDiscus, PubMed/Medline, Scopus, EMBASE and Cochrane Library databases were searched for relevant studies. The data synthesis included the proportion of patients who did not return to sports for psychological reasons and the mean differences in the psychological readiness of athletes who returned and those who did not return to sports. Non-binomial data were analysed using the inverse-variance approach and expressed as the mean difference with 95% confidence intervals. RESULTS: The search yielded 700 records, of which 13 (1093 patients) were included. Fourteen psychological factors were identified as potential causes for not returning to sports. The rates of return to sports at any level or to the preinjury level were 79.3% and 61.9%, respectively. A total of 55.9% of the patients cited psychological factors as the primary reason for not returning to sports. The pooled estimate showed that patients who returned to sports had a significantly higher Shoulder Instability-Return to Sport After Injury score (P < 0.00001) than those who did not, with a mean difference of 30.24 (95% CI 24.95-35.53; I2 = 0%; n.s.). CONCLUSIONS: Psychological factors have a substantial impact on the rate of return to sports after anterior shoulder instability surgery. Patients who returned to sports had significantly higher psychological readiness than those who did not return to sports. Based on these results, healthcare professionals should include psychological and functional measurements when assessing athletes' readiness to return to sports. LEVEL OF EVIDENCE: Level IV.

Advancements in the diagnosis and management of rotator cuff tears. The role of artificial intelligence.

Background: This review examined the role of artificial intelligence (AI) in the diagnosis and management of rotator cuff tears (RCTs). Methods: A literature search was conducted in October 2023 using PubMed (MEDLINE), SCOPUS, and EMBASE databases, included only peer-reviewed studies. Relevant articles on AI technology in RCTs. A critical analysis of the relevant literature was conducted. Results: AI is transforming RCTs management through faster and more precise identification and assessment using algorithms that facilitate segmentation, quantification, and classification of the RCTs across various imaging modalities. Precise algorithms focusing on preoperative factors to assess RCTs reparability have been developed for personalized treatment planning and outcome prediction. AI also aids in exercise classification and promotes patient adherence during at-home physiotherapy. Despite promising advancements, challenges in data quality and symptom integration persist. Future research should include refining AI algorithms, expanding their integration into various imaging techniques, and exploring their roles in postoperative care and surgical decision-making. Conclusions: AI-driven solutions improve diagnostic accuracy and have the potential to influence treatment planning and postoperative outcomes through the automated RCTs analysis of medical imaging. Integration of high-quality datasets and clinical symptoms into AI models can enhance their reliability. Current AI algorithms can also be refined, integrated into other imaging techniques, and explored further in surgical decision-making and postoperative care.

Interposition Arthroplasty for Chronic Proximal Humerus Osteomyelitis: A Case Report.

CASE: Two years after a right shoulder arthroscopic procedure, a 49-year-old woman presented with significant dysfunction and pain to our orthopaedic department. Laboratory and imaging evaluation demonstrated chronic glenohumeral osteomyelitis with irreparable damage to the humeral articular surface. A 2-stage soft-tissue shoulder interposition arthroplasty was performed to rebalance the joint. Long-term follow-up revealed functional results with pain control and no reinfection. CONCLUSION: For patients at high risk of reinfection or unable to undergo prosthetic joint implantation, this approach may be considered a functional alternative to salvage procedures.

Does computer-assisted navigation improve baseplate screw configuration in reverse shoulder arthroplasty? A systematic review and meta-analysis of comparative studies.

Introduction: Navigation technologies have improved accuracy and precision in positioning glenoid components during shoulder arthroplasty. The influence of navigation on baseplate screw placement has not been independently investigated. This study aimed to evaluate and synthesize the best scientific evidence on the influence of intraoperative navigation on the length and number of screws for primary baseplate fixation in reverse total shoulder arthroplasty procedures. Methods: In August 2022, PubMed, Scopus, and Embase databases were accessed. We analyzed the screw purchase length, the number of screws required for the fixation of the baseplate, and the proportion of cases fixed with two screws in all clinical trials, comparing navigation to standard instrumentation for reverse shoulder arthroplasty. Following an evaluation of the heterogeneity of the studies, DerSimonian-Laird random-effects models were utilized to merge data from separate studies. Results: The systematic search revealed a total of 2034 articles. After excluding duplicates and irrelevant studies, 633 shoulder arthroplasties from 6 trials were included in the analysis. The pooled mean difference in screw purchase length was 5.839 mm (95 %CI 4.496 to 7. 182) in favor of navigation (P < .001). In addition, significant differences were also found in the number of screws per case (- 0.547, 95 %CI -0.890 to -0.203, P = .002) and in the proportion of cases fixed with two screws (Odds Ratio 3.182 95 %CI 1.057 to 9.579, P = .040) in favor of the navigation group. Conclusions: Intraoperative navigation improves the baseplate screw placement, allowing for a greater screw purchase length and fewer screws to achieve primary fixation of the glenoid component during reverse shoulder arthroplasty. It is unclear whether these improvements will increase the longevity of the prosthesis or the clinical outcomes of the patients.

The stress and strain pattern in the ligaments of the acromioclavicular joint using a quasi-static model.

BACKGROUND: The precise role of the acromioclavicular and coracoclavicular ligaments during shoulder motion is unclear. We evaluate changes in the stress-strain distribution of the acromioclavicular joint's ligaments during different shoulder passive motion positions. METHODS: A 3D acromioclavicular joint model was reconstructed. A constitutive hyperelastic model was used for the ligaments. The kinematics of the shoulder girdle was taken to simulate shoulder abduction (Motion 1) and horizontal adduction (Motion 2). A computer-generated quasi-static and non-linear finite element model was used to predict the 3D stress-strain distribution pattern of the acromioclavicular ligament and the coracoclavicular ligament complex. FINDINGS: In motion 1, from 20 to 90° the peak von Mises stress was found in the conoid (4.14 MPa) and the anteroinferior bundle (2.46 MPa), while from 90 to 120° it was found in the conoid and the trapezoid. However, there were no significant differences between the mean stress values between anteroinferior bundle and trapezoid throughout the motion (p = 0.98). In Motion 2, from 20 to 80° the maximum equivalent elastic strain was found in the anteroinferior bundle (0.68 mm/mm) and the conoid (0.57 mm/mm), while from 80 to 100° it was higher in the conoid (0.88 mm/mm) than in the anteroinferior bundle (0.77 mm/mm). INTERPRETATION: The coracoclavicular ligament complex demonstrated a high stress-strain concentration during simulated passive shoulder abduction. Additionally, it was shown that the acromioclavicular ligament plays an important role in joint restraint during passive horizontal adduction, changing the primary role with the trapezoid and conoid at different motion intervals.

Arthroscopic Parachute Technique for Split-type Greater Tuberosity Fractures.

Over the past years, several arthroscopic fixation procedures have been adopted for fractures of the greater tuberosity. Although they offer advantages over open approaches, especially for avulsion-type fixation, split-type fractures are usually treated with open reduction and internal fixation. However, suture constructs can result in a more reliable fixation system for multifragment or osteoporotic split-type fractures. Currently, the use of arthroscopic techniques in these more complex fractures is questionable due to inherent limitations of anatomic reduction and stability concerns. The authors report a technically simple and reproducible arthroscopic procedure based on anatomic, morphologic, and biomechanical concepts, which offers advantages over traditional open approaches or double-row arthroscopic techniques in the treatment of most split-type greater tuberosity fractures.

The Reliability of Acromioclavicular Joint Dislocation Classification Systems: A Comparison Between the Rockwood and Kraus Classifications.

Background: The Rockwood system for the classification of acute acromioclavicular (AC) joint dislocations has been associated with a lack of reliability. A novel system has been proposed (Kraus classification) that is based on dynamic posterior translation of these injuries. Purpose: To assess the interobserver and intraobserver reliability of the Rockwood and Kraus classification systems and also to examine the impact of surgeon experience on the assessments. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Included were 45 patients with acute AC joint injuries who underwent a radiographic examination using standard bilateral AP and modified Alexander views. For interobserver reliability, 6 shoulder surgeons (expert group) and 6 orthopaedic residents (novice group) reviewed the radiographs to classify injuries according to the Rockwood and Kraus classifications; for each categorization, the participants chose between nonoperative management and surgical treatment. The evaluation was repeated 6 weeks later to determine intraobserver reliability. Kappa (κ) coefficients and their 95% CIs were used to compare interobserver and intraobserver reliability for each classification system according to assessor experience. Statistical differences were considered significant when the upper and lower boundaries of the 95% CI did not overlap. Results: The overall interobserver agreement for diagnosis (both novice and expert groups) was moderate (κ = 0.52 [95% CI, 0.51-0.54]) for the Rockwood classification and substantial (κ = 0.62 [95% CI, 0.53-0.65]) for the Kraus classification; however, no significant differences were observed between the κ values. The overall interobserver agreement for treatment selection was substantial when using both the Rockwood (κ = 0.78 [95% CI, 0.72-0.81]) and Kraus (κ = 0.77 [95% CI, 0.66-0.87]) classifications. The overall intraobserver agreement for diagnosis was substantial using both the Rockwood (κ = 0.65 [95% CI, 0.61-0.67]) and Kraus (κ = 0.73 [95% CI, 0.69-0.75]) classifications. There were no significant differences between the novice and expert groups on any of the evaluations. Conclusion: The Kraus system was slightly more reliable than the Rockwood system for classifying AC joint injuries both between assessor groups and overall. The level of surgeon experience had no impact on the evaluations.

The Value of Computer-Assisted Navigation for Glenoid Baseplate Implantation in Reverse Shoulder Arthroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: Glenoid baseplate malpositioning during reverse total shoulder arthroplasty can contribute to perimeter impingement, dislocation, and loosening. Despite advances in preoperative planning, conventional instrumentation may lead to considerable inaccuracy in implant positioning unless patient-specific guides are used. Optical navigation has the potential to improve accuracy and precision when implanting a reverse shoulder arthroplasty baseplate. This systematic review aimed to analyze the most recent evidence on the accuracy and precision of glenoid baseplate positioning using intraoperative navigation and its potential impact on component selection and surgical time. METHODS: We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. The PubMed, Scopus, and EMBASE databases were queried in July 2022 to identify all studies that compared navigation vs. conventional instrumentation for reverse shoulder arthroplasty. Data of deviation from the planned baseplate version and inclination, the use of standard or augmented glenoid components, and surgical time were extracted. Quantitative analysis from the included publications was performed using the inverse-variance approach and Mantel-Haenszel method. RESULTS: Of the 2,048 records identified in the initial query, only 10 articles met the inclusion and exclusion criteria, comprising 667 shoulders that underwent reverse total shoulder arthroplasty. The pooled mean difference (MD) of the deviation from the planned baseplate position for the clinical studies was -0.44 (95% confidence interval [CI], -3.26; p = 0.76; I2 = 36%) for version and -8.75 (95% CI, -16.83 to -0.68; p = 0.02; I2 = 83%) for inclination, both in favor of navigation. The odds ratio of selecting an augmented glenoid component after preoperative planning and navigation-assisted surgery was 8.09 (95% CI, 3.82-17.14; p < 0.00001; I2 = 60%). The average surgical time was 12 minutes longer in the navigation group (MD 12.46, 95% CI, 5.20-19.72; p = 0.0008; I2 = 71%). CONCLUSIONS: Preoperative planning integrated with computer-assisted navigation surgery seems to increase the accuracy and precision of glenoid baseplate inclination compared with the preoperatively planned placement during reverse total shoulder arthroplasty. The surgical time and proportion of augmented glenoid components significantly increase when using navigation. However, the clinical impact of these findings on improving prosthesis longevity, complications, and patient functional outcomes is still unknown. LEVEL OF EVIDENCE: Level III, systematic review and meta-analysis. See Instructions for Authors for a complete description of levels of evidence.

Role of platelet-rich plasma in the treatment of rotator cuff tendinopathy.

Shoulder pain is a common musculoskeletal complaint, and rotator cuff (RC) pathologies are one of the main causes. The RC undergoes various tendinopathic and avascular changes during the aging process. Other degenerative changes affecting its healing potential make it an appealing target for biological agents. Platelet-rich plasma (PRP) has demonstrated the potential to deliver a high concentration of several growth factors and anti-inflammatory mediators, and its clinical use is mainly supported by experiments that demonstrated its positive effect on muscle, ligaments, and tendinous cells. This review aimed to specify the role of PRP and its future applications in RC tendinopathies based on the current clinical evidence. Due to the different characteristics and conflicting outcomes, clinicians should use PRP with moderate expectations until more consistent evidence is available. However, it is reasonable to consider PRP in patients with contraindications to corticosteroid injections or those with risk factors for inadequate healing. Its autologous origin makes it a safe treatment, and its characteristics make it a promising option for treating RC tendinopathy, but the efficacy has yet to be established.

Modified McLaughlin Procedure Using a Double-Row Suture Anchor for Chronic Locked Posterior Shoulder Dislocation: A Case Report.

CASE: A 49-year-old highly active man had a direct fall on the left shoulder, causing a chronic locked posterior shoulder dislocation. Radiographic analysis revealed a reverse Hill-Sachs lesion (RHSL) that affected 31% of the articular surface. He was successfully treated with a modified McLaughlin procedure that included a double-row suture anchor as a novel fixation approach to secure the lesser tuberosity transfer and the subscapularis tenodesis. CONCLUSION: The reported approach for reconstructing the RHSL provides adequate stability, pain reduction, and functional outcomes. It may be considered as an option for joint preservation in extensive humeral head defects.

Reliability of the ISAKOS Modification to Subclassify Rockwood Type III Acromioclavicular Joint Injuries.

Background: To improve clinical management, the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) developed a specific subclassification of Rockwood type III acromioclavicular (AC) injuries: IIIA (no overriding distal clavicle) and IIIB (overriding distal clavicle). Purpose/Hypothesis: The study aimed to determine the inter- and intraobserver reliability of the radiographic classification proposed by ISAKOS for AC injuries. It was hypothesized that the strength of agreement for the ISAKOS modification will be substantial to almost perfect. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: We evaluated 40 radiographs of all types of AC joint injuries from patients at a single institution. The images were distributed to 6 shoulder and elbow fellowship-trained orthopaedic surgeons, along with standardized assessment questionnaires. The evaluators measured the bilateral coracoclavicular distance and the coracoclavicular ratio and classified the severity of the injuries according to the modified ISAKOS Rockwood classification. Four of the surgeons repeated the evaluation 6 weeks later to calculate intraobserver agreement. The kappa (κ) statistic was calculated for categorical inter- and intraobserver reliability. Intraclass correlation coefficient (ICC) estimates were calculated for the reliability of the coracoclavicular distance measurement. A 2-tailed test was performed to assess statistical significance. Results: Overall interobserver agreement was substantial (κ = 0.637; 95% CI, 0.595-0.680) among the 6 evaluators, and intraobserver agreement was also substantial among the 4 evaluators (κ = 0.616; 95% CI, 0.549-0.638). The interobserver agreement for evaluating types IIIA and IIIB was fair (κ = 0.215; 95% CI, 0.135-0.295) and moderate (κ = 0.473; 95% CI, 0.393-0.553), respectively. The agreement on the coracoclavicular distance measurements was excellent among the 6 evaluators on both the affected side (ICC, 0.982; 95% CI, 0.970-0.990) and the unaffected side (ICC, 0.930; 95% CI, 0.894-0.958). Conclusion: Substantial agreement was found when categorizing AC joint injuries using the ISAKOS modification of the Rockwood classification, with excellent reliability demonstrated for the quantitative assessment of vertical displacement of the clavicle. Visual examination was unreliable in differentiating type IIIA injuries from type IIIB injuries.

All-Arthroscopic Coracoacromial Ligament Transfer: The Modified Neviaser Procedure for Acromioclavicular Dislocations.

Over the course of the years, the topic of optimizing the management of acromioclavicular joint dislocations has gained popularity, remaining a subject of debate. It has been determined that posterior horizontal instability appears to be one of the factors influencing both clinical and radiographic outcomes, postsurgical reconstructions with coracoclavicular techniques. In contrast, the acromioclavicular ligament complex (ACLC) has been experimentally demonstrated to play a crucial role in horizontal translation and rotational stability of the clavicle. Although several strategies have been established, perfect surgical timing, and its potential impact during the healing process, remain poorly defined. Furthermore, appropriate surgical techniques to restore normal acromioclavicular joint kinematics while ensuring an adequate biological environment remain unclear. Due to the existence of multiple features present in acromioclavicular joint reconstruction techniques, an ideal approach involves ACLC and coracoclavicular combination reconstruction, minimal clavicular drilling, and biological enhancement to ensure anatomical reduction and an adequate process of ligament healing. The purpose of this Technical Note is to present a modified surgical technique of the Neviaser procedure. This modified surgical technique combines an all-arthroscopic single tunnel coracoclavicular fixation with the transfer of the coracoacromial ligament to reconstruct the ACLC.

The Trillat Procedure for Anterior Glenohumeral Instability.

¼: Anterior glenohumeral instability (AGI) is a challenging condition that requires close attention to osseous and soft-tissue abnormalities. The morphometric variance of the periarticular scapular anatomy may be involved in the pathogenesis of recurrent traumatic anterior instability. ¼: The Trillat procedure repositions the coracoid medially and downward by a partial wedge osteotomy, mimicking the sling effect of the Latarjet procedure by moving the conjoint tendon closer to the joint line in throwing position. The Trillat procedure decreases the coracohumeral distance without affecting the integrity of the subscapularis muscle and tendon. ¼: Joint preservation methods, such as the Trillat procedure, may be explored in older patients to treat AGI with simultaneous irreparable rotator cuff tears (RCTs) with a static centered head and a functional subscapularis. ¼: Shoulder hyperlaxity and instability can be challenging to treat with isolated soft-tissue procedures. In cases without glenoid bone loss, free bone block techniques are ineffective because of the subsequent potential graft resorption, apprehension, or recurrence. The Trillat surgery, in conjunction with an anteroinferior capsuloplasty, seems to be helpful in preventing recurrent instability and in reducing shoulder apprehension. ¼: Recently, several variations of the original technique have been described. In the future, anatomical, biomechanical, and clinical studies need to be conducted to further evaluate the morphometric characterization of the procedure, enhance the technical features, improve indications, and avoid coracoid impingement and other potential complications with the Trillat procedure.