Editorial Commentary: Both 3-Dimensional Magnetic Resonance Imaging and Computed Tomography Are Valuable for Determination of Glenoid and Humeral Bone Loss in Patients With On- and Off-Track Shoulder Instability.

Improving the modalities for advanced glenohumeral joint imaging has been an important area to address in the field of orthopaedic surgery. The current gold standard for imaging glenoid and humeral bone loss in patients with shoulder instability, 3-dimensional (3D) computed tomography (CT), provides high-quality 3D images of bones but comes with a cost of extra time, additional imaging because of the need for an additional magnetic resonance imaging (MRI) scan, and exposure to radiation. Three-dimensional MRI is a promising solution that can produce high-contrast images depicting both bony structures and soft tissues. Multiple 3D MRI sequences have been studied, with the FRACTURE (fast field echo resembling a CT using restricted echo-spacing) sequence showing high comparability of bony measurements to 3D CT scans, as well as the ability for widespread clinical use. Recent research has shown minimal differences in 3D CT and 3D MRI and has confirmed that 3D imaging does provide clinically relevant data for determination of on- and off-track instability. Finally, the gold standard for determination of bone loss is the measurement of deficiencies in the surface area of the glenoid using the best-fit circle with a diameter line measurement. This is most practical for day-to-day clinical use.

Editorial Commentary: Even With a High Retear Rate, Shoulder Capsular Reconstruction Outcomes are Promising, But Are We Seeing an Increase in Strength?

Superior capsular reconstruction was developed to restore patient biomechanics for patients with massive irreparable rotator cuff tears that preclude shoulder arthroplasty. Recent studies have shown excellent short-term clinical outcomes and improved pain and functional scores but high rates of complications including retear, loss of fixation, or incomplete healing. An alternative option, reverse total shoulder arthroplasty, is a reliable and safe method to ensure good muscle strength and return to play in this patient group.

The Impact of Neurological Disorders on Clinical and Functional Outcomes after Shoulder Arthroplasty: A Systematic Review.

BACKGROUND: Patients with pre-existing neurologic disorders present a unique set of challenges for shoulder arthroplasty (SA) surgeons due to the presence of concomitant contractures, muscle weakness, and spasticity, which may affect outcomes and complication rates after shoulder arthroplasty. The goal of this systematic review was to evaluate the clinical and functional outcomes after SA in patients pre-existing with neurologic disorders, focusing on complication and reoperation rates. METHODS: This systematic review was performed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines outlined by Cochrane Collaboration. A search of PubMed, the Medline Library, and EMBASE from inception until September 2023 was conducted to obtain studies reporting on outcomes after SA in patients with neurological disorders. Study demographics and information on outcomes including patient-reported outcomes and complication rates were collected. The methodological quality of included primary studies was appraised using the MINORS scoring system. RESULTS: Twenty articles published between 1997 and 2023 met inclusion criteria. In total, 13,126 patients with neurological conditions with 7 different neurological disorders (Parkinson's disease (PD), epilepsy and seizures, cerebral palsy (CP), poliomyelitis, Charcot neuropathy (CN), cerebrovascular disease (CVD) and multiple sclerosis (MS)) were included. The mean patient age was 64.3 years (range, 33.0 - 75.8 years), 51.4% of patients were male, and the mean postoperative follow-up time was 5.1 years (range, 1.4 - 9.9 years). PD was the most reported neurological disorder (9 studies, 8,033 patients), followed by epilepsy (4 studies, 3,783 patients), and MS (1 study, 1,077 patients). While these patients did experience improvements in outcomes following SA, high complication and revision rates were noted. CONCLUSIONS: Patients with neurologic disorders demonstrate improvements in pain and function after SA but have higher reported complication and revision rates when compared with patients without neurologic conditions. This systematic review offers valuable data for both the surgeon and patient regarding anticipated clinical results and possible complications from SA in patients with neurologic disorders that may aid in shared decision-making when considering SA.

Treatment of Shoulder Cartilage Defects in Athletes.

Articular cartilage defects in the glenohumeral joint may be found in laborers, the elderly, and young athletes, among others. Various factors can contribute to cartilage damage, including prior surgery, trauma, avascular necrosis, inflammatory arthritis, joint instability, and osteoarthritis. There is a wide variety of treatment options, from conservative treatment, injections, and surgical options, including arthroscopic debridement, microfracture, osteochondral autograft transfer, osteochondral graft transplantation, autologous chondrocyte implantation, and the newly emerging techniques such as biologic augmentation. There is a challenge to determine the optimal treatment options, especially for young athletes, due to limited outcomes in the literature. However, there are many options which are viable to address osteochondral defects of the glenohumeral joint.

Combined Medial Collateral Ligament Reconstruction and Polyethylene Exchange for Valgus Instability Following Total Knee Arthroplasty.

Valgus instability can occur after total knee arthroplasty (TKA) due to traumatic medial collateral ligament (MCL) injury, component malpositioning, or progressive ligamentous laxity. Although revision TKA with exchange of the polyethylene to a varus-valgus-constrained liner can reduce laxity due to MCL insufficiency, isolated liner exchange in the setting of collateral ligament insufficiency may lead to greater strain at the cement-bone or implant-cement interface and possibly a greater rate of aseptic loosening. Anatomic MCL reconstruction can be performed in conjunction with liner exchange to restore stability and reduce strain compared with liner exchange alone. The purpose of this Technical Note is to describe a technique for MCL reconstruction and liner exchange for treatment of valgus instability after TKA.

Effect of osteophyte removal on simulated range of motion using 3-dimensional preoperative planning software for reverse total shoulder arthroplasty.

Background: Glenohumeral osteophytes (OPs) can adversely influence postoperative range of motion (ROM) following shoulder arthroplasty due to mechanical impingement. Though commercial three-dimensional preoperative planning software (3D PPS) is available to simulate ROM before and after OP resection, little is known about the magnitude of effect OPs and their subsequent removal have on simulated glenohumeral ROM. Methods: Included patients were 1) indicated for reverse total shoulder arthroplasty (rTSA) using 3D PPS and 2) presented with glenoid and/or humeral head OPs on preoperative two-dimensional computed tomography (2D-CT) imaging. Thirty patients met the inclusion criteria (9 females, 21 males; mean age 70.45 ± 4.99 years, range 63-80 years). All subjects (n = 30) presented with humeral OPs (mean volume: 2905.16 mm3, range 109.1-11,246 mm3), while 11 subjects also presented with glenoid OPs (mean volume 108.06 mm3, range 37.59-791.4 mm3). Preoperative CTs were used to calculate OP volume (mm3) and OP circumferential extent (clockface). Mean clockface position for circumferential humeral OPs originated at 6:09 (range 4:30-7:15) and extended to 8:51 (range 8:15-10:15). Mean clockface position for glenoid OPs originated at 3:00 (range 2:00-5:00) and extended to 6:16 (range 3:00-7:30). 3D implants on PPS were standardized to achieve 0° of version, 0° of inclination and 4 mm of net lateralization. Thirty-nine and thirty-six mm glenospheres were used for males and females, respectively. 3D PPS was used to evaluate simulated ROM differences before and after OP removal in the planes of adduction (ADD), abduction, internal rotation (IR), external rotation (ER), extension, and flexion. Impact of OP volume and circumferential extent on pre and postop removal ROM were also analyzed. Results: Humeral OP removal significantly increased impingement-free ADD, IR, ER, extension, and flexion. Removal of larger (mm3) humeral OPs positively correlated with improvement in IR (R = 0.452, P = .011), ER (R = 0.394, P = .033), and flexion (R = 0.500, P < .01). Greater circumferential extent of humeral OPs correlated with worse preremoval ROM in the planes of ADD (R = 0.364, P = .02) and extension (R = 0.403, P = .04), and improvements in ER postop removal (R = 0.431, P = .03). Conclusion: Humeral OP removal significantly increases impingement-free ADD, IR, ER, extension, and flexion in simulated 3D PPS models following rTSA. Magnitude of simulated ROM improvement is influenced by initial humeral OP volume and circumferential clockface extent. Surgeons should consider these effects when using 3D PPS for rTSA planning to optimize postoperative ROM prognostics.

The impact of mental health conditions on clinical and functional outcomes after shoulder arthroplasty: a systematic review.

Background: Shoulder arthroplasty (SA) has been shown to improve quality of life, though outcomes may vary between individuals. Multiple factors may affect outcomes, including preoperative mental health conditions (MHCs). The goal of this systematic review was to evaluate the clinical and functional outcomes after SA in patients with MHC compared to patients without MHC. Methods: This systematic review was performed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines outlined by Cochrane Collaboration. A search of PubMed, the Medline Library, and EMBASE was conducted from inception until September 2023 to obtain studies reporting outcomes after total shoulder arthroplasty and reverse total shoulder arthroplasty in patients with and without MHC. Study characteristics and information on clinical and functional outcomes were collected. All included studies were case-control studies. The methodological quality of the included primary studies was appraised using the methodological index for nonrandomized studies scoring. Results: Eleven articles published between 2016 and 2023 met inclusion criteria. In total, 49,187 patients, 49,289 shoulders, and five different MHC were included. 8134 patients in the cohort had a diagnosed MHC. The mean patient age was 67.8 years (range, 63.5-71.6 years), and 52.6% of the patients were female. The mean follow-up time was 35.5 months (range, 16.2-58.3 months). Reverse total shoulder arthroplasty was the most common type of procedure (25,543 shoulders, 51.8%). Depression and anxiety were the most reported psychiatric diagnoses (7990 patients, 98.2%). Patients with versus without MHC reported mean improvements of 38 and 42 in American Shoulder and Elbow Surgeons shoulder score and mean Visual Analog Scale pain improvements of 4.7 and 4.9, respectively. Mean complication rates of 31.4% and 14.2% were observed in patients with versus without MHC, respectively. The most prevalent surgical complication in patients with MHC was infection (1.8%), followed by prosthetic complication (1.7%), and adhesive capsulitis (1.6%). Conclusions: Patients with MHC may have lower preoperative range of motion, worse postoperative shoulder function, and higher postoperative pain levels than patients without MHC. Patients with MHC demonstrated improvements in range of motion and functional outcomes after SA but had higher reported complication and revision rates when compared to patients without MHC. Depression and anxiety were the leading conditions correlated with lower outcomes in patients with MHC after SA. Preoperative physical therapy, mental health counseling, and expectation setting may help these patients reach the maximal achievable benefit from SA.

Biomechanical Evaluation of the 2 Different Levels of Coracoid Graft Positions in the Latarjet Procedure for Anterior Shoulder Instability.

Background: In the Latarjet procedure, the ideal placement of the coracoid graft in the medial-lateral position is flush with the anterior glenoid rim. However, the ideal position of the graft in the superior-inferior position (sagittal plane) for restoring glenohumeral joint stability is still controversial. Purpose: To compare coracoid graft clockface positions between the traditional 3 to 5 o'clock and a more inferior (for the right shoulder) 4 to 6 o'clock with regard to glenohumeral joint stability in the Latarjet procedure. Study Design: Controlled laboratory study. Methods: A total of 10 fresh-frozen cadaveric shoulders were tested in a dynamic, custom-built robotic shoulder model. Each shoulder was loaded with a 50-N compressive load while an 80-N force was applied in the anteroinferior axes at 90° of abduction and 60° of shoulder external rotation. Four conditions were tested: (1) intact, (2) 6-mm glenoid bone loss (GBL), (3) Latarjet procedure fixed at 3- to 5-o'clock position, and (4) Latarjet procedure fixed at 4- to 6-o'clock position. The stability ratio (SR) and degree of lateral humeral displacement (LHD) were recorded. A 1-factor random-intercepts linear mixed-effects model and Tukey method were used for statistical analysis. Results: Compared with the intact state (1.77 ± 0.11), the SR was significantly lower after creating a 6-mm GBL (1.14 ± 0.61, P = .009), with no significant difference in SR after Latarjet 3 to 5 o'clock (1.51 ± 0.70, P = .51) or 4 to 6 o'clock (1.55 ± 0.68, P = .52). Compared with the intact state (6.48 ± 2.24 mm), LHD decreased significantly after GBL (3.16 ± 1.56 mm, P < .001) and Latarjet 4 to 6 o'clock (5.48 ± 3.39 mm, P < .001). Displacement decreased significantly after Latarjet 3 to 5 o'clock (4.78 ± 2.50 mm, P = .04) compared with the intact state but not after Latarjet 4 to 6 o'clock (P = .71). Conclusion: The Latarjet procedure in both coracoid graft positions (3-5 and 4-6 o'clock) restored the SR to the values measured in the intact state. A more inferior graft position (fixed at 4-6 o'clock) may improve shoulder biomechanics, but additional work is needed to establish clinical relevance. Clinical Relevance: An inferior coracoid graft fixation, the 4- to 6-o'clock position, may benefit in restoring normal shoulder biomechanics after the Latarjet procedure.