Anatomic total shoulder arthroplasty with inlay glenoid component: A systematic review.

Background: A total shoulder arthroplasty (TSA) system utilizing an inlay glenoid component has been proposed as a means of reducing glenoid component loosening while still providing patients with desirable functional and clinical outcomes. The purpose of this study was to systematically review current outcomes literature on TSA using an inlay glenoid component. Methods: A literature search was conducted using PubMed/MEDLINE, Cochrane Database of Systematic Reviews, and Web of Science databases. Studies comparing pre- and postoperative functional and clinical outcomes were included. Results: Five studies with 148 shoulders (133 patients) were included. Patient-reported outcomes improved, including the American Shoulder and Elbow Surgeons score (mean change 34.1 to 80.6), Penn Shoulder Score (mean change 43.3 to 85.5), Single Assessment Numeric Evaluation score (mean change 34.1 to 80.6), and visual analog scale-pain (mean change 6.9 to 1.6). Range of motion improved for forward elevation (mean change 109.6 to 156.2) and external rotation (mean change 21.5 to 50.8). Glenoid component loosening occurred in one shoulder (0.68%). Two revision surgeries (1.35%) were performed. Discussion: The use of an inlay glenoid component is associated with improvements in postoperative pain, function, and satisfaction while minimizing rates of glenoid component loosening and the need for revision surgery over short-term follow-up. Level of evidence: systematic review, level IV.

Outcomes of the Latarjet procedure in female patients: A case series and matched-pair analysis.

Background: The objective of this study was to retrospectively report on the outcomes of female patients undergoing the Latarjet procedure. Methods: Female patients undergoing the Latarjet procedure with minimum 1 year follow-up were identified and contacted to obtain Numeric Pain Rating Scale (NPRS), Subjective Shoulder Value (SSV), and return to sport (RTS) data. Eligible females were then matched 1:1 with a male counterpart based on laterality and age (± 3 years), and outcomes compared. Results: A total of 20 female patients with a mean follow-up of 73.8 months reported postoperative NPRS and SSV scores of 2.2 ± 2.3 and 69.3 ± 22.0, respectively. Of the nine athletes, 3 (33%) reported a successful RTS at a mean of 9 months. Four patients (20.0%) required reoperation at a mean of 27.1 months. The matched analysis demonstrated similar NPRS scores between male and female patients and a trend towards lower SSV scores and rates of RTS. Conclusion: At mid-term follow-up female patients reported pain levels similar to female-specific literature reports, but overall low subjective shoulder function and RTS. Compared to propensity-matched males, females reported similar levels of pain, lower shoulder function, and lower rates of RTS, however, differences did not reach statistical significance. Level of Evidence: IV, retrospective case series.

Clinical and radiographic outcomes of the modified McLaughlin procedure for locked posterior dislocation of the shoulder: a systematic review.

Background: Multiple treatment options for locked posterior dislocation of the shoulder (LPDS) have been described, including the modified McLaughlin procedure. The purpose of this review, therefore, was to perform a systematic review of the literature to synthesize the available data reporting on the clinical and radiographic outcomes of patients undergoing the modified McLaughlin procedure for the treatment of LPDS. Methods: A systematic review of the PubMed Central, MEDLINE, Embase, Scopus, Web of Science, and Cochrane Library databases from inception through January 2023 was performed. Outcomes studies reporting on clinical and radiographic outcomes in patients undergoing the modified McLaughlin procedure for LPDS were included. Postoperative complications and episodes of recurrent instability were noted. Results: A total of 1322 studies were initially identified, of which 9 were deemed eligible for inclusion in our review. Among included studies, a total of 97 shoulders (96 patients) with a mean age of 37.7 years (range, 26-51) were identified. The most common mechanisms of injury included trauma, seizure, and electrocution. Reverse Hill-Sachs lesions ranged in size from 20% to 50% of the humeral head articular surface. At final follow-up, the weighted mean University of California at Los Angeles shoulder score, Constant-Murley Score, American Shoulder and Elbow Surgeons shoulder score, and visual analog scale for pain score were 29 (range, 27-31), 75 (range, 65-92), 92 (range, 83-98), and 1.9 (range, 1-2.4), respectively. Postoperative Constant-Murley Score and University of California at Los Angeles scores were highest in the one study reporting exclusively on treatment during the acute period. Weighted mean postoperative forward flexion, abduction, external rotation, and internal rotation were 154° (range, 102-176), 144° (range, 118-171), 64° (range, 44-84), and 47° (range, 42-56), respectively. Osteointegration of the lesser tuberosity was noted in all patients at the final follow-up. Postoperative complications occurred in one patient (1.0% of cohort); a screw migration successfully treated with operative removal. Recurrent instability was noted in two epileptic patients (2.1% of cohort). Conclusion: The literature surrounding the use of the modified McLaughlin procedure for LPDS remains sparse. This review demonstrates that this procedure is associated with favorable clinical and radiographic outcomes with overall low rates of complication and recurrent instability, especially when the time from injury to surgery is minimized. These findings illustrate that in patients presenting with LPDS and a reverse Hill-Sachs lesion between 20% and 50% of the humeral head articular surface, the modified McLaughlin procedure is a safe and effective treatment option.

Outcomes of subacromial balloon spacer implantation for irreparable rotator cuff tears: a systematic review and meta-analysis.

BACKGROUND: The management of irreparable rotator cuff tears remains a topic of considerable debate among orthopedic surgeons. Currently, there is little consensus regarding the gold-standard treatment; however, an emerging option involves the use of a biodegradable subacromial spacer. The purpose of this study, therefore, was to systematically review and synthesize the current literature reporting on the clinical outcomes following implantation of a subacromial balloon spacer (SABS) for the treatment of patients with irreparable rotator cuff tears. METHODS: A systematic review of the PubMed Central, MEDLINE, Embase, Scopus, and Cochrane Library databases from inception through December 2022 was performed. Clinical outcome studies reporting on functional and clinical outcomes, as well as postoperative complications, were included. RESULTS: A total of 127 studies were initially identified, of which 28 were deemed eligible for inclusion in our review. Of these studies, 17 reported adequate preoperative and postoperative data (mean and a measure of variance) and thus were included in the meta-analysis. Among the included studies, a total of 894 shoulders (886 patients) were included; the mean age was 67.4 years (range, 61.7-76.2 years). The average follow-up period was 30.4 months (range, 12-56 months). All postoperative patient-reported outcomes improved significantly from baseline, including the Constant score (mean difference, 33.53; P < .001), American Shoulder and Elbow Surgeons score (mean difference, 40.38; P < .001), Oxford Shoulder Score (mean difference, 12.05; P = .004), and visual analog scale pain score or Numeric Pain Rating Scale score (mean difference, -3.79; P < .001). Forward elevation (mean difference, 24°; P < .001), abduction (mean difference, 52°; P = .02), and external rotation (mean difference, 15°; P < .001) improved. Device-related complications occurred at a rate of 3.6%, the most common of which were balloon migration (1.0%) and synovitis (0.6%). Ultimately, 5% of patients required salvage reverse shoulder arthroplasty. CONCLUSION: Short-term outcomes suggest that SABS implantation can be a safe and effective treatment and appears to be associated with early improvements in postoperative pain and function. Clinical heterogeneity, use of concomitant procedures, and variations in patient selection limit our ability to conclusively interpret the available evidence. We do not yet know the potential therapeutic value of SABS implantation relative to other currently accepted treatment strategies, the length of symptomatic improvement that can be expected, or the long-term implications of SABS use on the outcomes of further salvage procedures.

Onlay versus inlay humeral components in reverse shoulder arthroplasty: A systematic review and meta-analysis.

Background: Advances have been made to the traditional inlay Grammont Reverse Shoulder Arthroplasty (RSA) design such as the onlay humeral component prosthesis. Currently, there is no agreement in the literature regarding the best option for the humeral component when comparing inlay and onlay designs. This review compares the outcomes and complications between onlay versus inlay humeral components for RSA. Methods: A literature search was conducted using PubMed and Embase. Only studies reporting outcomes comparing onlay versus inlay RSA humeral components were included. Results: Four studies with 298 patients (306 shoulders) were included. Onlay humeral components were associated with better external rotation (ER) (p < 0.0001). No significant difference in forward flexion (FF) or abduction was found. Constant scores (CS) and VAS scores did not differ. Increased scapular notching was found in the inlay group (23.18%) versus the onlay group (7.74%) (p = 0.02). Postoperative scapular fractures and acromial fractures did not differ. Conclusion: Onlay and inlay RSA designs are associated with improved postoperative range of motion (ROM). Onlay humeral designs may be associated with greater ER and lower rate of scapular notching; however, no difference was found in Constant and VAS scores, so further studies are required to assess the clinical significance of these differences.

Outcomes After Arthroscopic Revision Bankart Repair: An Updated Systematic Review of Recent Literature.

PURPOSE: To provide an update of recent literature with a specialized focus on clinical outcomes following arthroscopic revision Bankart repair (ARBR) by performing a systematic review of all available literature published between 2013 and 2020. METHODS: A literature search reporting clinical outcomes after ARBR was performed. Criteria for inclusion consisted of original studies; Level of Evidence of I-IV; studies focusing on clinical outcomes after ARBR published between January 1, 2013, and January 4, 2021; studies reporting recurrent dislocation or instability rate after ARBR; reoperation/revision following ARBR, return to sport rates following ARBR; and patient-reported outcomes. The primary outcomes of interest were failure defined as recurrent instability or dislocation, return to sport rates, and patient-reported outcomes at follow-up. RESULTS: A large proportion of patients undergoing arthroscopic revision Bankart repair were male, ranging between 67.7% and 93.8%. Failure rate and return to sports rate ranged between 6.1% and 46.8% and 25.9% and 88.3%, respectively, when patients with significant or greater than 20% glenoid bone loss was excluded. Patient-reported outcome scores, which included American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale, saw significant improvement over mean follow-up of ranging 21.64 to 60 months. CONCLUSIONS: Both the failure rate and RTS rates after ARBR had a wide range, given the heterogeneity of the studies included, which varied in patient selection criteria pertaining to patients with greater than 20% glenoid bone. Although there have been advancements in arthroscopic techniques and a trend favoring arthroscopic stabilization procedures, there is a lack of consensus in recent literature for careful patient selection criteria that would minimize failure rates and maximize RTS rates after ARBR. LEVEL OF EVIDENCE: Level IV, a systematic review of Level III-IV studies.

Outcomes after arthroscopic repair of rotator cuff tears in the setting of mild to moderate glenohumeral osteoarthritis.

BACKGROUND: Rotator cuff pathology is a very common source of shoulder pain. Similarly, osteoarthritis of the glenohumeral joint can cause shoulder pain and produce similar symptoms. Surgical management can be indicated for both pathologies, however, outcomes data is limited when examining rotator cuff repair (RCR) in the setting of glenohumeral arthritis (GHOA). Thus, this study sought to determine outcomes for patients who undergo RCR in the setting of GHOA. AIM: To evaluate if a relationship exists between outcomes of RCR in the setting of GHOA. METHODS: This was a retrospective analysis of patients who underwent arthroscopic rotator cuff repair with concurrent glenohumeral osteoarthritis between 2010-2017. Patients were stratified based on rotator cuff tear size and glenohumeral osteoarthritis severity. Cohorts were paired 1:1 with patients without glenohumeral osteoarthritis. Patients included had a minimum two year follow-up. Rate of conversion to total shoulder arthroplasty, complication rates following initial surgery, and patient-reported outcome measures were collected. RESULTS: A total of 142 patients were included. The number of patients that required total shoulder arthroplasty within two years after index surgery was low. 2/71 (2.8%) patients with GHOA, and 1/71 (1.4%) without GHOA. Following rotator cuff repair, both groups showed favorable patient-reported outcomes. CONCLUSION: Patients with glenohumeral osteoarthritis who underwent arthroscopic rotator cuff repair showed comparable outcomes to patients without glenohumeral osteoarthritis.

Clinical outcomes of a unique ulnar collateral ligament reconstruction hybrid technique with ulnar-sided suspensory fixation.

BACKGROUND: Ulnar collateral ligament reconstruction (UCLR) is the gold standard for treating ulnar collateral ligament injuries in throwing athletes who have failed conservative treatment. There are several described techniques that produce successful and reproducible outcomes. In addition, there is biomechanical evidence that supports hybrid fixation of the graft with a docking technique on the humeral side and suspensory fixation on the ulnar side. However, as of this writing there are no clinical studies that have reported results. This retrospective case series is the first of its kind to report on clinical outcomes following UCLR with hybrid suspensory fixation. METHODS: Fifty throwing athletes who underwent ULCR with hybrid suspensory fixation from 2010-2017 by one of 5 surgeons at a single institution were available at a median follow-up of 7 years. Return to sport, level of sport, and postoperative complications were recorded at final follow-up. RESULTS: A total of 50 patients were included in final analysis. Nearly all were able to return to sport at the same level or higher (48/50, 96%). One of these 50 athletes (2%) played professionally, 27 (54%) played collegiately, and 21 (42%) played at the high school level. Seven patients (14%) underwent reoperation following the index procedure. The median (interquartile range) Quick Disabilities of the Arm, Shoulder, and Hand questionnaire score was 0.098 (0-4.5) at final follow-up. CONCLUSION: Hybrid suspensory fixation is a safe and effective technique for UCLR in the throwing athlete. Throwers can expect to return to sport at a very high rate with low risks for postoperative complications.

Is postoperative glucose variability associated with adverse outcomes following shoulder arthroplasty?

BACKGROUND: Postoperative infection after shoulder arthroplasty is a devastating complication. Multiple patient risk factors have been associated with postoperative infection, including increased body mass index and diabetes. Although the association between preoperative glucose control and infection has been established, little is known about the effect of perioperative glycemic control on outcomes following shoulder arthroplasty. The purpose of this study was to investigate the association between postoperative glycemic variability and short-term complications after total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). METHODS: A retrospective study was performed at a large, single-specialty center from January 2015 to December 2018. Patients were included if they underwent primary TSA or RTSA with a minimum of 90 days' follow-up and had a minimum of 1 serum glucose value obtained per day of the hospital stay or had ≥3 measurements obtained during the hospital admission period. The primary outcome variable was postoperative infection per accepted definitions of surgical-site infection or periprosthetic joint infection. Secondary outcome variables included stiffness, periprosthetic fracture, periprosthetic dislocation, and reoperation. RESULTS: In total, 1074 TSAs or RTSAs (in 1032 patients) met the eligibility criteria. The mean patient age was 69.9 ± 8.4 years, and 40.3% of patients had a preoperative diagnosis of diabetes mellitus. Of the patients, 670 (62%) had a calculable coefficient of variation. A younger patient age (median, 65 years [interquartile range (IQR), 13.5 years] vs. 71 years [IQR, 11.0 years]; P = .02) and a preoperative diagnosis of diabetes mellitus (P = .01) showed statistically significant associations with postoperative infection. The first in-hospital glucose measurement beyond the reference tertile of 70-140 mg/dL showed a statistically significant association with postoperative infection, with a median of 128.0 mg/dL (IQR, 43 mg/dL) vs. 167.5 mg/dL (IQR, 37.0 mg/dL; P = .01), whereas the second and third glucose measurements showed no association with postoperative infection. We found no associations between the coefficient of variation and reoperations or complications including surgical-site infection, periprosthetic joint infection, death, postoperative infection, periprosthetic fracture, or stiffness. CONCLUSION: We found an association between a preoperative diagnosis of diabetes mellitus and postoperative infection following shoulder arthroplasty. We also found that an elevated first glucose measurement is associated with the development of postoperative infection. In-hospital glycemic control, as well as preoperative glycemic control and optimization, may be beneficial for reducing postoperative infections following shoulder arthroplasty.

Healing Rate and Clinical Outcomes of Lesser Tuberosity Osteotomy for Anatomic Shoulder Arthroplasty.

Several techniques are available for subscapularis management during total shoulder arthroplasty (TSA). Lesser tuberosity osteotomy (LTO) is advocated owing to improved biomechanical strength and high rates of healing. However, displacement or nonunion of the LTO could theoretically cause functional deficits for the affected shoulder. The purpose of this study is to examine the healing rate and clinical outcomes of LTO in patients undergoing anatomic TSA. Methods: A retrospective review of our institution's prospectively enrolled TSA registry was performed. Patients undergoing primary TSA who had an LTO performed and radiographs at a minimum of 3 months postoperatively were included. Two fellowship-trained shoulder and elbow surgeons reviewed all radiographs and categorized LTO healing into three groups: healed, nondisplaced nonunion, or displaced nonunion. Physical examination data and patient-reported outcome scores including American Shoulder and Elbow Score, Single Assessment Numeric Evaluation scores, and the Veteran Rand mental and physical component scores were obtained at a median of 1 year after surgery. Comparative statistical analysis was performed on the healed versus nondisplaced nonunion groups. Results: We included 142 shoulders in 130 patients who met the inclusion criteria with an average age of 65.2 years (SD: 10.3). Radiographic evaluation at a median of 1.0 years postoperatively (range: 6 months to 2.2 years) revealed 124 (87%) healed LTO, 12 (8%) nondisplaced nonunions, and six (5%) displaced nonunions. The median American Shoulder and Elbow Score total score was 89.2 (IQR: 72.2, 98.3) in the healed LTO group versus 96.7 (30, 98.3) in the LTO nondisplaced nonunion group (P = 0.9637). The median Veteran Rand mental component was 55.1 (IQR: 43.4, 61.0) in the healed LTO group versus 54.6 (38.8, 58.2) in the LTO nondisplaced nonunion group (P = 0.5679). The median Single Assessment Numeric Evaluation score was 85.0 (IQR: 70.0, 95.0) in the LTO-healed group versus 75.1 (35.0, 97.1) in the LTO nondisplaced nonunion group (P = 0.7699). There were no significant differences in revision surgery occurrence between the groups to address subscapularis instability: one patient in the LTO-healed group underwent revision surgery for subscapularis repair 3 months after primary surgery because of continued pain and weakness, and no patients in the other LTO groups underwent revision surgery. Conclusion: Although there is a risk of nonunion and displacement using the LTO technique in TSA, the overall clinical outcomes and radiographic union rates are high with a very low risk of revision surgery. In addition, radiographic evidence of nonunion does not significantly correlate with clinical outcomes.

Reverse shoulder arthroplasty with and without latissimus and teres major transfer for patients with combined loss of elevation and external rotation: a prospective, randomized investigation.

BACKGROUND: Latissimus dorsi (LD) and teres major (TM) tendon transfers have been performed concurrently with reverse shoulder arthroplasty (RSA) to address combined loss of elevation and external rotation (CLEER) at the shoulder. The purpose of this prospective, randomized study was to compare RSA with and without LD-TM tendon transfer in patients with rotator cuff tear arthropathy and CLEER. METHODS: Patients undergoing RSA for rotator cuff tear arthropathy who also had CLEER were randomized into the group undergoing RSA with tendon transfer or the group undergoing RSA without tendon transfer. The primary outcome measure was the Activities of Daily Living and External Rotation (ADLER) score 2 years after surgery. Secondary outcome measures included the Disabilities of the Arm, Shoulder and Hand (DASH) score, American Shoulder and Elbow Surgeons (ASES) score, and Simple Shoulder Test (SST) score. RESULTS: Both the treatment and control groups showed significant improvements in the ability to perform activities of daily living requiring active external rotation measured by the ADLER score postoperatively. No significant difference in the ADLER, DASH, ASES, or SST score was found between the 2 groups at final follow-up. Resolution of the Hornblower sign occurred postoperatively in 58.3% of patients in the control group and 73.3% of those in the treatment group. CONCLUSION: No differences in the ADLER, DASH, ASES, and SST results were found between patients treated with RSA alone and those treated with RSA with LD-TM transfer for rotator cuff tear arthropathy and CLEER. Both groups showed significant improvements in all clinical outcome assessments including functional tasks that require active external rotation.

Opioid-free shoulder arthroplasty: a prospective study of a novel clinical care pathway.

BACKGROUND: Opioid therapy has been a cornerstone of perioperative pain control for decades in the United States, despite our increased understanding of the morbidity and mortality linked to opioids. The purpose of this study is to explore the safety, efficacy, and feasibility of an entirely opioid-free perioperative pathway in patients undergoing elective shoulder arthroplasty. METHODS: Thirty-five patients undergoing elective total shoulder arthroplasty with a mean age of 71 (range, 50-87) years elected into a comprehensive opioid-free, multimodal pain management protocol. Opioid use was completely eliminated for all points in the perioperative period including during regional and general anesthesia. Data were collected regarding patient-reported pain, opioid consumption in the perioperative period, postoperative delirium, nausea, constipation, and falls. RESULTS: Pain level at the primary outcome point of 24 hours or discharge was rated at 2.5 on the numeric rating scale. Stable, low pain scores were demonstrated at all time points postoperatively. Low rates of nausea, falls, and constipation were reported. Only 1 patient required "rescue" opioid medications during the in-patient stay, and an additional patient was given a low-dose opioid prescription at the 2-week postoperative appointment. CONCLUSIONS: An opioid-free, multimodal pain management pathway is a safe and effective option in properly selected patients undergoing shoulder arthroplasty with a very low risk of requiring rescue opioids. This study is the first such study to present a surgical protocol entirely free of opioids at all portions of the patient care pathway.

Outpatient Shoulder Arthroplasty at an Ambulatory Surgery Center Using a Multimodal Pain Management Approach.

INTRODUCTION: Early reports of outpatient shoulder arthroplasty are promising, although a paucity of outcome data exists, particularly for the outpatient shoulder arthroplasty performed at a freestanding ambulatory surgery center (ASC). METHODS: A retrospective analysis of 61 shoulder arthroplasty procedures (21 consecutive outpatients and 40 inpatients) was performed. Outpatient shoulder arthroplasties were conducted at a freestanding ASC using a multimodal pain regimen without the use of regional anesthesia. The primary outcome was 90-day postoperative complication rate. Secondary outcomes included 90-day hospital admissions or readmissions, emergency department and urgent care visits, revision surgeries, mortality, postoperative pain, and functional scores. RESULTS: No major complications, readmissions, revision surgeries, or deaths occurred in the outpatient cohort. The rate of 90-day complications was 9.5% and 17.5% for the outpatient and inpatient cohorts, respectively. All patients who had their shoulder arthroplasty as an outpatient were discharged home the day of surgery. No complications related to the outpatient protocol were observed. However, 4.8% of those who had outpatient surgery visited an emergency department or urgent care within 90 days compared with 5.0% of those who had surgery as an inpatient. DISCUSSION: Outpatient shoulder arthroplasty can be performed safely and predictably in select patients at an ASC using a multimodal pain regimen without regional nerve block.

Arthroscopic repair of full-thickness tears of the rotator cuff in patients younger than 40 years.

PURPOSE: Recent reports document excellent outcomes with arthroscopic repair of rotator cuff tears (RCT). However, full-thickness RCT are uncommon in patients younger than 40 years, and few reports document results after repair in this population. The purpose of this study is to retrospectively report results of arthroscopic repair of full-thickness RCT in patients younger than 40 years. METHODS: Twenty-three consecutive patients younger than 40 years with full-thickness RCT underwent arthroscopic repair with suture anchors. Mean age was 37 years (range, 21 to 39). The mean size of RCT was 2.4 cm in the largest dimension (range, 1 to 4 cm). The mean number of anchors used was 2.5 (range, 1 to 4). Concomitant procedures included subacromial decompression (22), distal clavicle resection (13), SLAP repair (2), biceps tenodesis (2), anterior capsulorraphy (1), and capsular releases (1), and were performed at the discretion of the surgeon. Twenty-two patients (95%) recalled a single incipient trauma; two patients sustained a dislocation. Ten patients (43%) claimed Workers' Compensation (WC). Minimum follow-up was 24 months, and mean follow-up was 26 months (range, 24 to 29). RESULTS: Mean preoperative American Shoulder and Elbow Surgeon's (ASES) self-report score was 42 (range, 22 to 60); the mean postoperative score was 92 (range, 65 to 100; P < .01). Twenty-one patients (90%) returned to their previous level of activity and employment, including 9 (90%) with WC claims. All patients (100%) reported diminished pain, and 22 (95%) reported improvement with activities of daily living. Complications included superficial wound infection (1) and axillary nerve palsy after initial dislocation (1). Given the choice, 22 patients (95%) would have same procedure again. CONCLUSIONS: Excellent outcomes were observed following arthroscopic rotator cuff repair both with and without concomitant procedures in patients younger than 40 years. Full-thickness RCT in patients younger than 40 years appeared to be traumatic in etiology. Successful repair returns patients to their pre-injury level of function. These results support arthroscopic rotator cuff repair in young, active patients. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Functional outcomes after total claviculectomy as a salvage procedure. A series of six cases.

BACKGROUND: Total claviculectomy has been used for the treatment of tumor, infection, nonunion, and vascular compromise. Given its limited indications, few reports on the outcome after claviculectomy exist. The purpose of the present study was to evaluate the function of the shoulder, with use of a modern scoring system, after total claviculectomy. METHODS: A retrospective review of the records of six patients who had undergone unilateral claviculectomy was performed after an average duration of follow-up of 5.7 years. The indication for surgery had been an infection at the site of a clavicular nonunion for three patients, nonunion with subclavian vein compression for two, and pain after a failed medial clavicular excision for one. The preoperative and postoperative evaluations included testing of the range of motion, strength, and stability as well as determination of the American Shoulder and Elbow Surgeons score on the basis of a functional questionnaire. RESULTS: Range of motion was improved slightly or unchanged following claviculectomy. The mean American Shoulder and Elbow Surgeons score improved from 18 (range, 5 to 35) preoperatively to 88 (range, 75 to 95) postoperatively. The mean pain level (with 0 indicating no pain and 10 indicating the worst pain) decreased from 9.5 preoperatively to 1.5 postoperatively. Postoperatively, strength testing showed improvement from grade 4- (of 5) to 5 in all planes tested except extension (in which it remained at grade 4). Patient satisfaction was high, with a mean of 9.0 on a 10-point scale. There were five complications, including one subclavian vein laceration requiring vascular repair, two deep infections, and two superficial infections. CONCLUSIONS: Despite a high complication rate, the functional outcomes following claviculectomy were good in this group of six patients. Total claviculectomy may be a useful salvage procedure for clinical situations in which the restoration of normal clavicular osseous anatomy is impossible. Patients can expect acceptable pain relief and few or no deficits in activities of daily living. LEVEL OF EVIDENCE: Therapeutic Level IV.

Anteroposterior centering of the humeral head on the glenoid in vivo.

BACKGROUND: The capsule and ligaments are generally viewed as the primary stabilizers of the glenohumeral joint, but many important activities are performed in midrange positions in which these structures are lax. HYPOTHESIS: In vivo, the humeral head can be centered in the glenoid, even when the shoulder is in positions in which the capsule is lax and even when the shoulder is passively positioned. STUDY DESIGN: Controlled laboratory study. METHODS: We documented the centering of the humeral head in the relaxed shoulders of six subjects using open-magnet magnetic resonance imaging scans. RESULTS: While these shoulders were passively placed in midrange positions (those not at the extremes of motion), the humeral head center was never more than 2.2 mm from the glenoid center (mean + 0.1 +/- 1.2 mm). CONCLUSIONS: The results suggest that mechanisms other than ligamentous restraint, such as the compressive effect of resting muscle tone into the conforming concavity of the glenoid, may be sufficient to maintain centering of the glenohumeral joint. Further exploration of these mechanisms may lead to methods other than ligament tightening or capsular shrinkage for restoration of stability to joints that are unstable in the midrange of motion. CLINICAL RELEVANCE: In that many patients with unstable shoulders demonstrate instability in midrange positions, it is hoped that further study of living shoulders will lead to a more effective understanding of the nonligament mechanisms of shoulder stability and the ways in which these stabilizing mechanisms can be restored.