Posterior shoulder instability is increasingly recognized as a morphology-driven disorder in which abnormal glenoid and acromial anatomy reduces resistance to posterior translation of the humeral head. When the underlying scapular deformity is not corrected, isolated soft-tissue or glenoid-based procedures show limited and inconsistent success. Within the SCOPE (Scapular Corrections for Posterior Escape) concept, a short, high posterior acromion with reduced posterior coverage can be addressed by restoring posterior acromial height and sagittal coverage.This technical note describes a modification of the Scapinelli posterior acromial bone block (PABB) that uses patient-specific three-dimensional planning to correct an isolated posterior acromial deficiency. In carefully selected patients with increased posterior acromial height and decreased posterior sagittal coverage but normal lateral acromial extension and normal glenoid orientation, patient-specific restoration of posterior acromial morphology re-establishes the normal posterior osseous buttress.A computed tomography scan of the scapula is segmented and compared with a statistical mean shape model derived from a control cohort of 40 stable shoulders. Scapular parameters, including glenoid version, posterior acromial height, posterior sagittal coverage, sagittal tilt, lateral acromial extension, and the critical shoulder angle, are measured against these normative values. Because these parameters are continuous variables, deviations exceeding one standard deviation from the normal mean are used as pragmatic decision thresholds, always interpreted together with the overall morphology and the clinical context, rather than as absolute cut-offs. An explicit stepwise algorithm guides the choice between an isolated PABB, a corrective acromial osteotomy, a glenoid osteotomy, or their combination. The surgical technique, including graft harvest, patient-specific positioning and fixation, deltoid refixation, and a structured rehabilitation protocol, is described and supplemented by an operative video.To date, the technique has been performed in 15 patients, of whom 10 have a minimum follow-up of 12 months; clinical outcomes remain to be established. This patient-specific procedure addresses the underlying morphologic abnormality while preserving native glenoid anatomy. Its clinical superiority has not yet been demonstrated, and further studies are required to refine the indications and to evaluate mid- to long-term outcomes.
Background: Glenoid morphology plays a critical role in reverse total shoulder arthroplasty, influencing implant positioning and fixation. Although advanced Three dimensional pre-operative planning allows patient-specific optimization, a simple and reproducible framework for rapid assessment of glenoid size and bone stock remains lacking. The purpose of this study is to propose a computed tomography-based classification of glenoid size using a reproducible parameter and evaluate its potential as a complementary screening tool for pre-operative planning. Methods: A retrospective analysis of 200 non-pathological glenoids was performed. Measurements included maximum anteroposterior diameter (MAD, representing glenoid width), superoinferior diameter, surface area, and glenoid bone depth. A K-means clustering algorithm based on MAD defined 3 groups. Correlations with patient height were assessed. Baseplate compatibility and fixation potential were evaluated theoretically. Results: Three groups were identified: small (MAD <27 mm), medium (27-30 mm), and large (>30 mm). MAD strongly correlated with glenoid surface area (r = 0.82, P < .001). A 24-mm baseplate provided full bone contact in 90% of cases. Glenoid bone depth increased significantly with glenoid size (P < .001), supporting adaptation of screw length and positioning. Conclusion: This classification provides a simple and reproducible anatomical framework for glenoid size stratification. While not intended to replace patient-specific three dimensional planning, it may serve as a complementary screening tool to anticipate implant sizing and fixation strategies. Validation in pathologic glenoids is required.
Introduction Reverse total shoulder arthroplasty (rTSA) has expanded rapidly, but its early postoperative outcomes relative to anatomic TSA (aTSA) remain unclear. This systematic review and meta-analysis evaluate serious adverse events (SAEs) and 30- and 90-day readmission rates following primary aTSA and rTSA. Method A systematic search of PubMed, Embase, Medline, Scopus, and Web of Science were performed through July 2025. Studies reporting SAEs or early readmissions after primary TSA were included. Risk of bias was assessed using ROBINS-I and RoB 2. Random-effects meta-analyses were conducted to estimate pooled event rates and comparative odds ratios (ORs) between rTSA and aTSA, and single-arm meta-analyses to determine pooled event rates for each procedure. Results Forty-six studies encompassing 1,445,486 patients (rTSA: 885,825; aTSA: 559,661) were included. Comparative analyses demonstrated that rTSA was associated with higher odds of SAEs (OR 1.38; 95% CI 1.10-1.74), 30-day readmission (OR 1.71; 95% CI 1.47-1.98), and 90-day readmission (OR 1.53; 95% CI 1.34-1.75) compared with aTSA. Single-arm pooled rates confirmed higher absolute event rates for rTSA (SAE 8.78% vs 5.28%; 30-day readmission 3.16% vs 1.24%; 90-day readmission 4.09% vs 3.05%). Both procedures exhibited low overall mortality, but rTSA had increased dislocation, infection, and revision rates, whereas aTSA showed higher mechanical loosening and rotator cuff failure. Conclusion rTSA carries higher perioperative morbidity and early readmission compared with aTSA, although absolute rates remain low. These findings underscore the importance of procedure-specific patient selection, comorbidity optimization, and tailored perioperative care to mitigate early complications and enhance value-based shoulder arthroplasty outcomes.
Background Steroid-induced avascular necrosis of the humeral head is an uncommon but clinically important complication of corticosteroid exposure. Although steroid-associated osteonecrosis has been extensively studied in the femoral head, considerably less attention has been directed toward the shoulder, particularly regarding whether a dose-response relationship or clinically meaningful corticosteroid threshold exists. This scoping review aimed to map the available literature on steroid-induced humeral head avascular necrosis and evaluate how corticosteroid dose, duration, route of administration, and timing have been reported. Methods A structured literature search was conducted across PubMed/MEDLINE, Embase, the Cochrane Library, and Google Scholar in accordance with scoping review methodology. Eligible studies included adult patients with humeral head avascular necrosis associated with corticosteroid exposure. Data were charted regarding study design, patient population, corticosteroid exposure, diagnostic approach, disease stage, management, and reported outcomes. Results Fifty-two sources of evidence were included; the literature was limited and heterogeneous, consisting largely of case reports, case series, and retrospective studies. Corticosteroid exposure was frequently identified as a risk factor, but dose reporting was inconsistent. Few studies provided sufficient detail regarding cumulative dose, peak dose, daily dose, route, duration, or timing of therapy. No consistent corticosteroid dose threshold for humeral head avascular necrosis could be identified. Conclusions Current evidence suggests an association between corticosteroid exposure and humeral head avascular necrosis, but the literature remains insufficient to define a reliable dose-response relationship or clinically useful dose threshold. Future studies should standardize reporting of corticosteroid exposure, including cumulative dose, peak dose, route, duration, and timing relative to symptom onset or diagnosis.
Background Postoperative reduction loss remains a major concern after arthroscopic coracoclavicular ligament (CCL) reconstruction. Although bone tunnel position has been suggested as a contributing factor, most previous studies have relied on plain radiographs, which are limited in evaluating three-dimensional positioning. The purpose of this study was to evaluate clavicular and coracoid bone tunnel positions using computed tomography (CT) and to investigate their association with postoperative reduction loss. Methods This retrospective, single-center study included 22 patients who underwent arthroscopic CCL reconstruction for acute acromioclavicular joint dislocation or distal clavicle fracture with CCL rupture. Postoperative CT with multiplanar reconstruction was used to assess the anteroposterior (AP) and mediolateral (ML) positions of the clavicular and coracoid tunnels. Reduction loss was defined as the percentage increase in coracoclavicular distance at final follow-up relative to the immediate postoperative value. Correlation analyses were performed between tunnel positions and reduction loss. Redisplacement was defined as ≥25% compared with the contralateral side, and clinical outcomes (ASES, Constant score, and SSV) were compared between groups. Results The ML position of the clavicular tunnel showed a moderate correlation with reduction loss, whereas the AP position of the clavicular tunnel and both ML and AP positions of the coracoid tunnel showed weak or no significant correlation. The overcorrection rate demonstrated a strong correlation with reduction loss, whereas the preoperative displacement rate showed no significant association. Redisplacement occurred in 7 of 22 patients (31.8%) but was not associated with clinical outcomes. Conclusion The ML position of clavicular tunnel plays an important role in postoperative stability following arthroscopic CCL reconstruction. In contrast, AP tunnel position and coracoid tunnel position appear to have less influence on reduction loss. Although redisplacement was not associated with clinical outcomes, its relatively high incidence (31.8%) remains a concern. Accordingly, preventing redisplacement remains important, and particular attention should be paid to the ML position of the clavicular tunnel during arthroscopic CCL reconstruction. Level of Evidence Level IV, Case Series, Prognosis Study
Objectives The purpose of this study was to compare the day-of-surgery (DOS) costs between intramedullary nails and locking plates implants and identify independent predictors of total DOS cost using time-driven activity-based costing (TDABC). Methods A retrospective review of patients who underwent open reduction and internal fixation (ORIF) for proximal humerus fractures between 2022 and 2025 across two large metropolitan healthcare systems. Patients treated with intramedullary nail fixation were matched 1:1 to patients treated with locking plate fixation based on Neer classifications to ensure comparable fracture morphology. The primary outcome was total DOS cost and secondary outcomes included implant cost, operative duration, and postoperative outcomes. Results A total of 92 patients (46 matched pairs) were included in final analysis. On paired univariate analysis, plate fixation demonstrated significantly higher implant, direct DOS, indirect DOS, and total DOS costs compared to nail fixation (all p ≤ 0.013). In multivariate mixed effect model (R2 = 0.362; p < 0.001), intraoperative duration emerged as the strongest independent predictor of total DOS costs (β = 23.23 per minute; p < 0.001). Institutional site was also independently associated with cost (p = 0.013). Fixation type and patient characteristics were not independently associated with total DOS cost after adjustment. Conclusion Although plate fixation demonstrated higher unadjusted DOS costs compared to nail fixation, fixation construct was not independently associated with total DOS cost after adjusting for operative time, institutional site, and patient factors. Operative time emerged as the primary driver of cost variation, suggesting that operative efficiency rather than implant selection alone determines intraoperative economic value in proximal humerus fracture fixation.
Background Rotator cuff tears are a challenging problem for orthopedic surgeons, especially those with at risk features. Because of this it is imperative to establish reliable methods to maximize patient outcomes and mitigate the risk of retears. Biologic augmentation with acellular dermal allograft (DAA) has been proposed to improve tendon healing and structural integrity. This study describes a novel arthroscopic technique utilizing DAA augmentation with a box-configuration transosseous-equivalent canopy construct and reports early clinical outcomes. Methods A retrospective review was performed on patients who underwent arthroscopic RCR with DAA augmentation using a box-configuration construct between January 2021 and October 2025 by two surgeons at a single institution. Preoperative MRI was evaluated to classify tear size, tissue quality and tendon retraction. Clinical outcomes assessed included postoperative pain, range of motion, retear rate, and complications. Results Eleven patients underwent RCR with DAA augmentation. Mean age was 59.5 years (range, 51–72) with a mean BMI of 27.6. Seven repairs (63.6%) were revision procedures. Ten tears (90.9%) were full thickness, with a median of two tendons involved and a median Patte retraction grade of 2. Mean follow-up was 7.2 months. Postoperatively, ROM remained excellent in 5 patients (45.5%) and improved in 6 patients (54.5%). Pain improved completely in 9 patients (81.8%) and partially in 2 (18.2%). No postoperative infections were observed or reoperations. Conclusion Arthroscopic RCR with DAA augmentation using a box-configuration canopy construct demonstrated favorable early clinical outcomes and a low complication rate in a cohort with a high proportion of revision repairs. Larger prospective studies with longer follow-up are needed to further evaluate the durability and clinical benefits of this technique.
Background A Hill-Sachs lesion (HSL) is a significant risk factor for recurrent shoulder instability and an indication for surgery. Currently, several available methods exist to measure these lesions on imaging, combined into a multitude of classification and grading systems. There is no consensus on a universal classification system for HSLs leading to extensive heterogeneity in how surgeons classify lesions and identify surgical necessity. The purpose of this review is to provide a comprehensive overview of established HSL classification measures that may guide future HSL classification systems. Methods A comprehensive search of PubMed, Embase, CINAHL, and Scopus was conducted up to June 20, 2025, following PRISMA guidelines. Inclusion criteria consisted of peer-reviewed human studies using imaging to evaluate HSL. Exclusion criteria were reverse HSLs, reviews, case reports, cadaveric, and biomechanical studies. Risk of bias was assessed via the MINORS criteria. Results This study identified 39 studies pertaining to HSL classification or grading. Depth (21 studies), width (20), glenoid track/Hill-Sachs interval (18), volume (9), and location/medialization (9) were the five most commonly used measurements in classification. Wide variability exists in how each of these measurements should be made, and differing levels of agreement on their usefulness in different contexts. Of included measurements, the pooled conclusions on lesion depth, width, and location on severity were most consistent. Conclusions This study highlights the most common methods and measurements used to classify HSLs in the current literature. Width, depth, and glenoid track calculations were by far the most prevalent measurements, often being incorporated into larger classification criteria. By breaking down the published classification systems into individual measurements, this review aims to help guide future standardized HSL classification criteria. Level of Evidence Basic Science Study, Classification Systems, Systematic Review
Background Operative intervention is now frequently recommended for displaced midshaft clavicle fractures with shortening exceeding 15-20 mm. Accurate measurement of clavicular shortening is therefore critical for therapeutic decision-making. The diagnostic validity and reliability of the commonly used clinical and radiographic measurement methods remain subjects of debate. The purpose of this study was to evaluate the validity and interobserver reliability of clinical and radiographic measurements of acute clavicular fracture shortening using CT as the criterion standard and to evaluate their diagnostic performance to detect the shortening cut-off value of 15 mm. Methods Fifty-one corresponding measurements (clinical, radiography, and CT) for fractured clavicles with similar measurements for their normal contralateral side were evaluated by two experienced examiners. Shortening is then computed as the difference in length from the normal clavicle length. In addition, a combined clinical-radiographic measurement method was calculated for each patient. All patients had midshaft clavicle fracture without initial cortical contact and underwent the three clavicle measurements within the first 3 days after admission. Results All three index methods demonstrated poor agreement with CT measurements. Intraclass correlation coefficients were very low, and Bland–Altman analysis confirmed significant bias and wide limit of agreement for each method. Clinical and radiographic measurements were more specific than sensitive but with overall low accuracy. Combining clinical and radiography assessment improved specificity. The radiographic method was more reliable than clinical assessment. Conclusion Due to the detected wide measurement error, clinical examination and radiography are insufficient for determining operative indication.
Background The interplay between cervical degenerative disease (CDD) and shoulder surgery remains poorly understood. In particular, the influence of CDD on the outcomes of instability procedures has not been investigated. This study aimed to evaluate the impact of CDD on postoperative complications, opioid use, and reoperation risk following shoulder instability surgery. Methods The TriNetX US Collaborative Network was queried for patients undergoing instability procedures without rotator cuff tear from 2015 to 2025. Patients were stratified based on a prior diagnosis of CDD to create two cohorts: CDD versus no-CDD. Propensity score matching (1:1) was performed for demographics and comorbidities. Outcomes including arthroscopic and open reoperations, surgical complications (persistent pain, dislocation, stiffness), arthroplasty, rotator cuff tear, and opioid use were compared at 2- and 5-year follow-up. Results After matching, 778 patients were included in both the CDD and no-CDD cohorts. The risk of arthroscopic reoperation (OR 1.682; 95% CI, 1.119-2.527), rotator cuff tear (OR 2.033; 95% CI, 1.335-3.096), and persistent pain (OR 1.266; 95% CI, 1.036-1.548) were significantly higher in the CDD cohort. These associations remained significant at 5 years. The CDD group had a greater number of opioid prescriptions at both timepoints (P < 0.001). Conclusion Patients with CDD were at an increased risk of postoperative pain, opioid utilization, rotator cuff tear, and arthroscopic reoperation following shoulder instability surgery. These findings suggest CDD may be a clinically relevant factor associated with suboptimal outcomes following shoulder instability surgery, warranting further investigation to guide targeted optimization strategies. Level of Evidence Level III, Retrospective Cohort Comparison using Large Database, Prognosis Study
Background Reverse total shoulder arthroplasty (rTSA) offers good clinical outcomes, with varying complication rates. Despite the technological advances and increasing popularity of shoulder arthroplasty in the last two decades, a comprehensive understanding of the specific causes for failure after primary rTSA remains limited. Methods This PROSPERO-registered systematic review and meta-analysis was conducted following PRISMA guidelines. A literature search was performed on PubMed, Embase and Cochrane covering studies from 2014 to 2024 to identify studies reporting outcomes in primary rTSA.Data extraction focused on failure modality and subgroup analyses was performed. Proportional meta-analysis was performed using random-effects models and data was reported in estimated proportions with 95% confidence intervals (CI). It is important to emphasize that data consists of proportion of failures, not failure rates of rTSA. Results A total of 42 articles involving 69,222 rTSA procedures were identified, and 2,086 failures were included. Instability was the most common failure mode, which accounted for 21.4% of failures (95% CI [15.2 – 29.2%]. Aseptic loosening accounted for 19.4% [14.3 – 25.8%], followed by infection (18.6% [14.1 – 24.0%]) and periprosthetic fracture (10.6% [7.0 – 15.7%]). Of the total aseptic loosening failures, glenoid loosening accounted for 64.9% [43.9 – 81.4%], and humeral loosening accounted for 31.4% [16.6 – 51.4%] of the failures.Failures in studies with short-term follow-up (859 failures) were most commonly due to instability (24.9% [16.4 – 35.9%]), followed by infection (21.8% [16.8 – 27.8%]) and aseptic loosening (20.2% [11.7 – 32.7%]). Failures in studies with long-term follow-up (286 failures) were most commonly due to aseptic loosening (24.1% [19.5 – 29.4%], followed by infection (21.5% [11.2 – 37.1%]), and periprosthetic fracture (16.9% [7.5 – 34.0%]). Failures for onlay humeral stems (66 failures) were most commonly due to instability (36.7% [20.5 – 56.4%]), whereas failures for inlay stems (70 failures) were most commonly due to aseptic loosening (32.8% [13.6 – 60.3%]). Failures for cemented humeral stems (20 failures) were most commonly due to periprosthetic fracture (30.0% [14.1 – 52.7%]), whereas failures in cementless humeral stems (257 failures) were most commonly due to aseptic loosening (21.2% [8.6 – 43.7%]). Conclusions This study identified instability (21.4%) being the most common cause of failure after primary rTSA, followed by aseptic loosening (19.4%) and infection (18.6%), and that differences exist for duration of follow-up, time of publication implant design and use of cement, although some subgroup analyses were limited by number of failures. These findings emphasize the need for more research focused on mitigating these predominant causes of failure to improve long-term outcomes. Level of Evidence Level IV; Systematic Review Meta Analysis
Background Treatment options for painful elbow osteoarthritis are limited. When conservative therapy and debridement fail, total elbow arthroplasty remains the only salvage procedure. Yet it is costly, highly invasive, and unsuitable for younger, active patients due to strict activity restrictions and limited prosthesis longevity. While denervation is well established for hand and wrist osteoarthritis, its application in the elbow remains underexplored. This cadaveric study assesses the accessibility of elbow joint articular branches through a single posterior incision. Methods Ten fresh-frozen upper extremities were dissected via a standardized 20 cm posterior midline incision. Eight nerves were targeted: the medial antebrachial cutaneous nerve (MABCN), ulnar, ulnar collateral, median, posterior antebrachial cutaneous nerve (PABCN), radial, radial collateral, and musculocutaneous nerve. For each nerve, accessibility, number of articular branches (ABs), and distance from the corresponding epicondyle were recorded. Results All eight nerves and their ABs were successfully accessed in all ten specimens. Medial nerves: MABCN (mean 1.3 ABs; 4.8 cm from medial epicondyle), ulnar nerve (1.3 ABs; 1.6 cm), ulnar collateral nerve (7.4 cm), median nerve (1.2 ABs; 2.0 cm). Lateral nerves: PABCN (1.8 cm from lateral epicondyle), radial nerve (1.4 ABs; 6.4 cm), radial collateral nerve (7.0 cm), musculocutaneous nerve (1.0 AB; 1.2 cm). Conclusion A single-incision posterior approach provides consistent access to all key nerves innervating the elbow joint. These finding demonstrate the anatomical feasibility of elbow denervation, while preserving the option for future reconstructive surgery through the same incision.
Background: The proximal ulna dorsal angulation (PUDA) is an anatomical feature of the ulna pertinent to proximal ulna fracture reduction and implant design. This systematic review primarily aims to establish normative values for the PUDA through synthesis of the existing literature, with the secondary aim of evaluating methodological variability and identifying sources of heterogeneity across studies. Methods: Following Preferred Reporting Items of Systematic Reviews and Meta-Analyses guidelines, MEDLINE, Embase, and Cochrane Library were searched between January 2000 and November 2024. Eligible studies reported quantitative measurements of PUDA in adults without pathology. Imaging modality, measurement technique, and risk of bias (assessed using the Newcastle-Ottawa Scale) were extracted and analyzed. Weighted means were calculated and intergroup differences assessed using one-way analysis of variance with Tukey's honestly significant difference. Results: Twenty-one studies were included, comprising over 2000 ulnae across 3 imaging modalities: computed tomography (CT) (n = 6), lateral radiographs (n = 7), and cadaveric (n = 8). The weighted mean PUDA was 5.8° ± 1.4°. Cadaveric studies reported significantly higher mean (7.8° ± 2.87°), compared to CT (5.2° ± 1.07°) and radiographic (5.1° ± 0.43°) (P < .001). The weighted mean tip-to-apex distance was 53.7 mm ± 17.6 (25.8% ± 5.4% of ulna length). Cadaveric studies reported a significantly higher mean (79.5 mm ± 16.9), compared to CT (49.1 mm ± 6.1) and radiographs (51.8 mm ± 3.5) (P < .001). Substantial variation was observed such as ulna landmark reference points and line measurement technique across modalities. Conclusion: This review identified significant methodological heterogeneity across modalities, with radiological methods demonstrating greater reproducibility. These findings underscore the importance for standardization of measurement methodology, clinical practice, and implant design.
Introduction Interposition arthroplasty is a joint-preserving option for younger patients with elbow osteoarthritis (OA) who are poor candidates for total elbow arthroplasty. However, optimal graft choice and surgical technique remain unclear. This study evaluates clinical and radiographic outcomes following interposition elbow arthroplasty using acellular dermal allograft with a medial collateral ligament (MCL)–sparing approach. Methods A retrospective review was performed of consecutive patients undergoing interposition elbow arthroplasty at a single academic institution from 2014 to 2025. Patients with ≥6 months’ follow-up were included. Outcomes included Visual Analog Scale (VAS) pain, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, range of motion, radiographic joint space, complications, and reoperations. Subgroup analyses were performed by diagnosis and revision status. Radiographic outcomes were analyzed using repeated measures analysis of variance. Results Eighteen patients (mean age, 54 years) were included, with mean follow-up of 40 (6-87) months for patient-reported outcomes. Significant improvements were observed in VAS pain (–3.0, P = .013) and DASH scores (–15.9, P = .036), with mean final values of 4.0 and 36.0 respectively. Range of motion generally improved from preoperative to postoperative (flexion 112-128 degrees, P = 0.114; pronation 65-70 degrees, P = 0.498; supination 62-65 degrees, P = 0.507; extension was unchanged) but was not statistically significant. Complications and reoperation occurred in 0% of patients with primary surgery and in 50-60% of patients undergoing revision surgery. Radiocapitellar joint space increased postoperatively but decreased at final follow-up (P < .05), with no significant progression in OA severity. Conclusion Interposition elbow arthroplasty using acellular dermal allograft with an MCL-sparing approach yields improvements in pain and function that reach minimally clinically important difference. Patients undergoing revision or secondary surgery experienced very high rates of complication or reoperation, while those undergoing primary surgery did not. Despite partial loss of early radiographic gains, the procedure does not appear to accelerate degenerative changes, supporting its role as a joint-preserving option in younger patients.
Introduction Anterior latissimus dorsi and teres major (aLDTM) tendon transfer has been shown to restore transverse plane force coupling in patients with anterosuperior irreparable rotator cuff tears (ASIRCTs). However, when the preoperative acromiohumeral distance (AHD) is reduced, superior glenohumeral stability may remain compromised. Superior capsular reconstruction (SCR) was introduced to reestablish the superior stability by reconstructing the superior capsule. Therefore, this study evaluated the clinical and radiologic outcomes of patients with ASIRCTs and a narrow preoperative AHD who underwent aLDTM tendon transfer with SCR. Methods This retrospective case series included 13 patients diagnosed with ASIRCTs who underwent aLDTM tendon transfer with SCR between July 2018 and December 2019. Clinical evaluation encompassed pain assessment using the visual analog scale (VAS) and functional assessment with patient-reported outcome measures, including the Constant score, the American Shoulder and Elbow Surgeons (ASES) score, and the Activities of Daily Living and Internal Rotation (ADLIR) score. Active range of motion (aROM) and muscle strength during active motion were also recorded. Radiographic progression of degenerative changes was analyzed by measuring the acromiohumeral distance (AHD) and determining the Hamada classification grade. Postoperative tendon and graft integrity was assessed using magnetic resonance imaging. Results Compared with preoperative values, patients demonstrated significant reductions in pain (VAS, 6.1 ± 1.9 to 1.7 ± 1.1) and significant improvements in functional outcomes (Constant score, 46.0 ± 11.2 to 65.0 ± 10.6; ASES score, 47.2 ± 9.8 to 73.3 ± 6.8; ADLIR score, 44.4 ± 9.4 to 71.3 ± 5.6; all P < .001). Active forward elevation improved from 97.7° ± 24.6° to 144.6° ± 15.6° (P < .001), and internal rotation at the back improved from 1.9 ± 1.0 to 5.9 ± 1.3 vertebral levels (P = .008). Forward elevation strength increased from 17.2 ± 2.8 N to 24.0 ± 3.0 N, and internal rotation strength increased from 16.1 ± 2.1 N to 28.7 ± 3.8 N (both P < .001). No significant changes were observed in acromiohumeral distance or Hamada grade. Follow-up MRI demonstrated superior capsular graft retear in 8 of 13 patients (61.5%). Conclusions In patients with ASIRCTs, aLDTM tendon transfer with SCR resulted in significant clinical improvement. However, this combined procedure was associated with a high rate of SCR graft retear. Therefore, despite functional gains, the indication for aLDTM tendon transfer with SCR in this challenging population should be carefully considered given the high rate of structural failure. Level of evidence Case report
Background Isolated fractures of the Greater Tuberosity comprise nearly 20% of the fractures of the proximal humerus. The Mutch Classification categorizes these injuries by morphology into avulsion (Type I), split (Type 2), and depression (Type 3) patterns. While the efficacy of arthroscopic repair vs. open reduction internal fixation is well-studied, there is less-convincing data on the comparative effectiveness of different ORIF constructs in greater tuberosity fracture care. Methods A retrospective review analyzed patients with isolated greater tuberosity fractures of the humerus from February 2008 to June 2024 from Kaiser Permanente Southern California. Patients were treated with constructs consisting of 1) plate osteosynthesis alone; 2) suture anchors alone; 3) cannulated or solid lag screws alone; 4) combined plate osteosynthesis and screws; or 5) combined plate osteosynthesis and suture anchors. Primary outcomes were the rate of post-operative displacement and re-operation for each construct. A secondary outcome was reason for re-operation. Results The study population included 164 patients with a mean age of 52 years (Range 20-88). The distribution of injuries was 99 Mutch 1 Fractures (60.4%), 44 Mutch 2 Fractures (26.8%), and 21 Mutch 3 Fractures (12.8). There was no significant difference in Mutch 1 fractures between constructs in post-operative displacement (p = 0.538) or re-operation rates (p = 0.915). There was no significant difference in Mutch 2 fractures in post-operative displacement between constructs (p = 0.368); however, the difference in rate of re-operation was significant (p = 0.034) on univariate analysis. There was no significant difference in Mutch 3 fractures between constructs in post-operative displacement (p = 1) and none required re-operation. There were no significant differences in post-operative displacement or re-operation on multivariate analysis. Conclusions Overall, we did not find a statistically significant difference in rate of post-operative displacement or re-operation between fixation type for Mutch 1, 2, and 3 fractures on multivariate analysis. Surgeons should use the technique they are most comfortable with to achieve an appropriate reduction to restore proper rotator cuff biomechanics.
