Introduction:. External rotation (ER) of the shoulder is a commonly used clinical measurement to assess the glenohumeral joint; however, the position in which these measurements are obtained varies between clinicians. The purpose of this study was to compare the following: ER in the upright & supine positions, motion capture & goniometric values of ER, active & passive ER, ER in the right & left shoulders, and ER in male & female subjects. Methods:. Eighteen subjects (mean age 25.4 yrs) with ‘normal’ shoulders (by screening questionnaire) were enrolled in the study and subject to triplicate measurements of active and passive ER of both shoulders with a goniometer and a 12 camera, high speed optical motion analysis system in both the upright and supine positions. ANOVA was used to compare variables and linear regression used to correlate the goniometer & optical motion capture measurements. Results:. On average, shoulder ER in the supine position was 10.0° greater than in the upright position (p < 0.001) using the motion capture data and 5.8° greater using the goniometer (p = 0.025). There was a strong correlation between the goniometer and optical motion capture measurements with an R. 2. value of 0.6573 (p = 2.39E-13); on average, the goniometer readings were 11.0° greater than the corresponding optical measurements. External rotation of the right shoulder was 7.2° greater than the left using the optical measurements (p = 0.02) and 4.4° greater with the goniometer (p = 0.039). In addition, females did have significantly greater external rotation than males using the optical measurements (p < 0.001), averaging 16.7° more external rotation; findings were similar for the goniometric measurements with 18.5° greater average external rotation seen in female subjects (p < 0.001). There was no significant difference between measured active and passive external rotation (p = 0.589). Conclusion:. Significant differences do exist between measured values of external rotation depending on the position of measurement (upright vs supine), hand dominance, and gender. It does not appear that there is a difference between active and passive external rotation. Our recommendations are for the musculoskeletal clinician to be meticulous when documenting the position of measured external rotation, as values vary depending on the position of measurement. One should also be cautious of comparing external rotation of one shoulder to the contralateral side, as well as comparing values between genders, as these measurements appear to be different as well

Introduction. While shoulder elevation can be reliably restored following reverse total shoulder arthroplasty (RTSA), patients may experience a loss of internal and external rotation. Several recent studies have investigated scapular notching and have made suggestions regarding glenosphere placement in order to minimize its occurrence. However, very few studies have looked at how changes in glenosphere placement in RTSA affect internal and external rotation. The purpose of this study was to determine the effect of glenosphere position on internal and external rotation range of motion at various degrees of scaption following RTSA. We hypothesized that alteration in glenosphere position will affect the amount of impingement-free internal and external rotation. Methods. CT scans of the scapula and humerus were obtained from seven cadaver specimens and 3-Dimensional (3D) reconstructions were created. A corresponding 3D RTSA model was created by laser scanning the baseplate, glenosphere, humeral stem and bearing. The RTSA models were then virtually implanted into each specimen. The glenosphere position was determined in relation to the neutral position in 6 different settings: Medialization (5 mm), lateralization (10 mm), superior translation (6mm), inferior translation (6 mm), superior tilt (20°), and inferior tilt (15° and 30°). The humerus in each virtual model was allowed to freely rotate at a fixed scaption angle until encountering bone-bone or bone-implant impingement (180 degrees of limitation). Each model was tested at 0, 20, 40, and 60 degrees of scaption and the impingement-free internal and external rotation range of motion for each scaption angle was recorded. Results. At 0Ëš scaption, only inferior translation, lateralization, and inferior tilt allowed any impingement-free motion in IR and ER. At mid ranges of scaption (20Ëš and 40Ëš) a predictable pattern was seen in which increased lateralization and inferior translation resulted in improved rotation. Supraphysiologic motion (>90Ëš rotation) was seen consistently at 60Ëš of scaption in internal rotation. Both superior and inferior tilt positions resulted in increased ROM in the mid-range of scaption. Acromial impingement was seen when the glenosphere was medialized, superiorly translated and with a superior tilt. Superior translation (6 mm) resulted in no rotation at 0 and 20 degrees of scaption (both IR and ER). Figure 1 and 2: Represents the amount of internal (fig. 1) and external rotation (fig. 2) range of motion measured to bony impingement. 180 degrees was set as the physiologic limit for all measurements. Conclusion. Glenosphere position significantly affected humeral internal and external rotation after Reverse Total Shoulder Arthroplasty in our computer model. Inferior translation (6 mm) or lateralization (10 mm) appears to have the most beneficial effects to internal and external rotation of the shoulder. Inferior tilt (15° and 30°) of the glenosphere also improved overall arc of motion in IR and ER when compared to superior tilt and neutral positions. Superior translation (6 mm) and medialization (5 mm) of the glenosphere caused marked limitations in internal and external rotation due to scapular notching and acromial impingement

Patients using a neutral rotation brace post proximal humerus fracture fixation have improved functional outcome and external rotation of the shoulder compared to patients using a standard polysling. Patients who have proximal humerus fracture fixation with extramedullary plates and screws have a risk of reduced range of movement especially external rotation. Gerber et al showed that the average external rotation after fixation of proximal humeral fractures was 39 degrees in their patient cohort compared to a normal range of 80–100 degrees. This can lead to reduced function and poor patient related outcomes. Geiger et al showed that in a cohort of 28 patients, poor functional outcome was noted in 39.3% with an average Constant-Murley Score of 57.9. Current practice is to utilise a polysling holding the shoulder in internal rotation post-shoulder fixation. Patients usually wear the sling for up to 6 weeks. We believe that this increases the risk of adhesion formation with the shoulder in internal rotation in the shoulder joint. Therefore this can cause loss of external rotation in the shoulder joint. We believe that holding the shoulder in a neutral alignment, with a neutral rotation brace post-fixation, will enable an increased rate of external rotation post-operatively thus improving external rotation and functional outcome. There is currently no literature comparing the different slings used post-operatively and we believe that this study would be the first of its kind. It would have a substantial change in the way clinicians manage proximal humeral fractures and will potentially reduce the numbers of re-operations to divide adhesions or perform capsular releases. Secondary benefits include a potential earlier return to full function and work and improved patient satisfaction. Study proposal: Prospective Randomised Controlled Trial of the neutral rotation brace compared to the standard, currently used, polysling post proximal humerus fracture fixation. No blinding of either participants or clinicians. Three surgeons utilising similar fixation techniques via the deltopectoral approach and using Philos plate fixation (Synthes Ltd.). Standardised post-operative rehabilitation protocol for all patients. Follow up: clinical review and postal outcomes for 1 year. Primary outcomes: Post operative functional outcome scores (Oxford, DASH, EQL) obtained at 6 weeks, 9 weeks, 3 months and 1 year). These will be compared to scores taken pre-operatively. Secondary outcomes: Clinical review at 6 weeks, 3 months and 1 year with range of movement measurements. Radiographs also taken at 6 weeks and 3 months to assess union. Patient questionnaire at 1 year (with outcome scores) assessing patient return to work, complications and patient satisfaction. Inclusion criteria: Proximal humeral fractures requiring operative intervention with extramedullary plate fixation (i.e. fractures displaced by 1cm and/or angulated by 45 degrees or more). Age>18. Exclusion Criteria: Patients having intra-operative findings of complete Pectoralis major rupture or if operative exposure requires complete Pectoralis major tenotomy. (These patients need to be held in internal rotation with a standard polysling to allow healing of the Pectoralis major tendon)

Background. Scapular notching is a complication after reverse shoulder arthroplasty with a high incidence up to 100%. Its clinical relevance remains uncertain; however, some studies have reported that scapular notching is associated with an inferior clinical outcome. There have been no published articles that studied positional relationship between the scapular neck and polyethylene insert in vivo. The purpose of this study was to measure the distance between the scapular neck and polyethylene insert in shoulders with Grammont type reverse shoulder arthroplasty during active external rotation at the side. Methods. Eighteen shoulders with Grammont type prosthesis (Aequalis Reverse, Tornier) were enrolled in this study. There were 13 males and 5 female, and the mean age at surgery was 74 years (range, 63–91). All shoulders used a glenosphere with 36mm diameter, and retroversion of the humeral implant was 10°in 4 shoulders, 15°in 3 shoulders, and 20°in 11 shoulders. Fluoroscopic images were recorded during active external rotation at the side from maximum internal to external rotation at the mean of 14 months (range, 7–24) after surgery. The patients also underwent CT scans, and three-dimensional glenosphere models with screws and scapula neck models were created from CT images. CT-derived models of the glenosphere and computer-aided design humeral implant models were matched with the silhouette of the implants in the fluoroscopic images using model-image registration techniques (Figure 1). Based on the calculated kinematics of the implants, the closest distance between the scapular neck and polyethylene insert was computed using the scapular model and computer-aided design insert models (Figure 2). The distance was computed at each 5° increment of glenohumeral internal/external rotation, and the data from 20°internal rotation to 40°external rotation were used for analyses. One-way repeated-measures analysis of variance was used to examine the change of the distance during the activity, and the level of significance was set at P < 0.05. Results. The mean glenohumeral abduction during the activity was 17°-22°. The mean distance between the neck and insert was approximately 1mm throughout the activity (Figure 3). The distance tended to become smaller with the arm externally rotated, but the change was not significant. Discussion. The reported incidence of scapular notching after Grammont type reverse shoulder arthroplasty is generally higher than the newer design prosthesis with the lateralized center of rotation. This may be associated with the design of the prosthesis, and the results of this study that the distance between the neck and insert was approximately 1mm throughout active external rotation at the side will support the high incidence of notching. We may need to analyze the distance with the newer design reverse shoulder prosthesis to prove the architectural advantage of the newer systems. Conclusion. The distance between the scapular neck and polyethylene insert was approximately 1mm throughout active external rotation activity in shoulders with Grammont type prosthesis

Reverse total shoulder arthroplasty (RTSA) was designed to treat the cuff-deficient shoulder with arthritis and irreparable rotator cuff tears of the supraspinatus and infraspinatus tendons. The results of RTSA in this patient population have been very good and reliable in the majority of cases. However, it has also been reported that patients whose rotator cuff tear involves the supraspinatus, infraspinatus and teres minor and who demonstrate a ‘horn-blower's sign’ do very poorly if a muscle transfer is not performed to improve external rotation in these shoulders in abduction. The loss of the teres minor in these patients results in grave difficulty for the patient attempting to perform their activities of daily living even if they can obtain reasonable good forward flexion. The muscle transfer that is most commonly used for these select patients is a latissmus dorsi tendon transfer in conjunction with RTSA. The purpose of this talk is to review the pathology of this problem and review the technique for its surgical treatment

Introduction. The effect of each step of medial soft tissue releases on the external rotation angle of the femoral component was assessed during posterior stabilized total knee arthroplasty (PS-TKA) with modified gap control technique. Methods. Consecutive 840 knees were assessed. During PS-TKA, medial soft tissue release was done to obtain rectangular gap in extension using tensors/balancers. The deep fiber of medial collateral ligament (MCL) was released in all cases. No more release was done in 464 knees. Only anterior fiber of superficial MCL was released in 49 knees, and only posterior fiber of superficial MCL was released in 129 knees. Both fibers were released in 169 knees. Additional pes anserinus was released in 29 knees. Rotation angle of the femoral component was decided based on the flexion gap angle. The angle was compared among the five groups. Results. The average external rotation angle of the femoral component was 4.8°, 5.3°, 4.6°, 4.3°, 4.1°, respectively. The external rotation angle in knees after release of superficial MCL fibers and more was statistically significantly smaller compared to that in knees without release (P<0.001). Conclusion. Releases of MCL superficial fibers and more in order to obtain soft tissue balancing in extension significantly widened the medial joint gap in flexion and reduced external rotation angle of the femoral component

Introduction. Patellofemoral (PF) complications are among the most frequently observed adverse events after total knee arthroplasty (TKA). It has been reported that PF complications after TKA include decreasing knee range of motion, anterior knee pain, quadriceps and patellar-tendon rupture, patellar subluxation, and partial abrasion and loosening of the patellar component. Although recent improvements in surgical technique and prosthetic design have decreased these complications, the percentage of patients who have a revision TKA for PF complications still ranged up to 6.6% to 12%. For the present study, we hypothesized that the alignment of the femoral component is correlated with PF contact stress. The purpose of this study was to investigate the relationship between femoral component alignment and PF contact stress in vivo, using a pressure sensor in patients who had favorable extension-flexion gap balance during TKA. Methods. Thirty knees with medial compartment osteoarthritis that underwent posterior stabilized mobile-bearing TKA using identical prostheses (PFC Sigma RPF; Depuy, Warsaw, IN, USA) by a single surgeon (TM) with modified gap technique under a computed tomography (CT)-based navigation system (Vector Vision 1.61; Brain Lab, Heimstetten, Germany) were evaluated. PF contact stress was measured intraoperatively and compared with the alignment of the femoral component including intraoperative navigation data concerning medial shift of the patella and lateral tilt of the patella, postoperative coronal femoral component angle (alpha angle), postoperative sagittal femoral component angle (gamma angle), postoperative condylar twist angle (CTA), postoperative lateral condylar lift-off angle, and postoperative mechanical femoral component angle (mFCA). In addition, postoperative Insall-Salvati ratio (I-S ratio) was measured by dividing the length of patellar tendon by the greatest diagonal length of the patella. Results. Maximum PF stress was 2.4 ± 1.9 MPa, medial shift of the patella was 2.6 ± 1.5 mm, and lateral tilt of the patella was 8.5 ± 4.2 degrees. The PF contact stress was not correlated sagittal and coronal alignment of the femoral component and patella tracking, whereas rotational alignment of the femoral component was negatively correlated with the PF contact stress (r = −0.718, p < 0.01). Discussion and conclusion. Multiple regression analysis shows that PF contact stress correlates with CTA, I-S ratio positively correlates with PF contact stress in Spearman correlation analysis. The results of the present study showed a negative correlation between maximum stress in the PF joint and CTA. It has been reported that excessive external rotation increases the medial flexion gap, leading to symptomatic flexion instability of the femoral component. In addition, external rotation of the femoral component can cause relative medialization of the trochlear groove during flexion, resulting in anterior knee pain. Therefore, we should carefully decide the proper rotational alignment of the femoral component. It has been reported that PF contact stress in a normal knee was from 2.1 to 2.9 MPa in a cadaveric study. In the present study, patients with rotational alignment of the femoral component after TKA between 1.2° and 2.2° internally rotated from CEA had PF contact stress in this normal range

INTRODUCTION. Use of a novel ligament gap balancing instrumentation system in total knee arthroplasty resulted in femoral component external rotation values which were higher on average, compared to measured resection systems. In one hundred twenty knees in 110 patients the external rotation averaged 6.9 degrees (+/− 2.8) and ranged from 0.6 to 12.8 degrees. The external rotation values in this study were 4° and 2° larger, respectively, than the typical 3° and 5° discrete values that are common to measured resection systems. The purpose of the present study was to determine the effect of these greater external rotation values for the femoral component on patellar tracking and flexion instability. METHODS. One hundred twenty knees in 110 patients were consecutively enrolled by a single surgeon using the same implant across subjects. All patients underwent arthroplasty with tibial resection first and that set external rotation of the femoral component based upon use of a ligament gap balancing system. Following ligament tensioning/balancing, the femur was prepared. The accuracy of the ligament balancing system was assessed by reapplying equal tension to the ligaments using a tensioning bolt and torque wrench in flexion and extension after the bone resections had been made. The resulting flexion and extension gaps were then measured to determine rectangular shape and equality of the gaps. Postoperative Merchant views were obtained on all of the patients and patellar tracking was assessed and compared to 120 consecutive total knee arthroplasties previously performed by the same surgeon with the same implant using a measured resection system. RESULTS. Rectangular flexion and extension gaps were obtained within +/− 0.5mm in all cases. Equality of the flexion and extension gaps was also obtained within +/− 0.5mm in all cases. Merchant views of the total knee arthroplasties showed central patellar tracking with no tilt or subluxation in 90% of the ligament gap balanced knees and 74% of the measured resection knees. DISCUSSION AND CONCLUSION. External rotation values are higher on average, when ligament tensioning/balancing is employed with this novel system compared to measured resection systems. In this study this resulted in consistent matching of the flexion gap to the extension gap and better patellar tracking. These findings suggest that limiting the surgeon to discrete rotation values may be at odds with where the femur “desires” to be, given soft tissue considerations for each patient

The traditional treatment for a primary anterior shoulder dislocation has been immobilisation in a sling with the arm in adduction and internal rotation. The recurrence rates after the initial traumatic event range from 20% to 94%. However, recent results have suggested that recurrent instability after primary shoulder dislocation may be reduced with immobilisation in external rotation. Since then, controversy exists regarding the position of immobilisation following these injuries. The objective of the present study was to compare immobilisation in internal and external rotation after a primary anterior shoulder dislocation. Fifty patients presenting to our fracture clinic with a primary traumatic anterior dislocation of the shoulder were randomly assigned to treatment with immobilisation in either internal rotation (IR; 25 patients) or external rotation (ER; 25 patients) for three weeks. In addition of a two-years clinical follow-up, patients underwent a magnetic resonance imaging (MRI) of the shoulder with intra-articular contrast within four days following the traumatic event, and then at three months of follow-up. The primary outcome was a recurrent dislocation within 24 months of follow-up. The secondary outcome was the healing rate of the labral lesion seen on MRI (if present) within each immobilisation group. The follow-up rate after two years was 92% (23 of 25) in the IR group and 96% (24 of 25) in the ER group. The recurrence rate in the IR group (11 of 23; 47.8%) was higher than that in the ER group (7 of 24; 29.2%) but the difference did not reach statistical significance (p=0.188). However, in the subgroup of patients aged 20–40 years, the recurrence rate was significantly lower in the ER group (3 of 17; 6.4%) than that in the IR group (9 of 18; 50%, p<0,01). In the subgroup of patients with a labral lesion present on the initial MRI, the healing rate of the lesion was 46.2% (6 of 13) in the IR group and 60% (6 of 10) in the ER group (p=0.680). Overall, the recurrence rate among those who showed healing of the labrum (regardless of the immobilisation group) was 8.3% (1 of 12), but patients who did not healed their labrum had a recurrence rate of 45.5% (5 of 11; p=0.069). This study suggests that immobilisation in ER reduces the risk of recurrence after a primary anterior shoulder dislocation in patients aged between 20 and 40 years. At two years follow-up, the recurrence rate is lower in patients who demonstrated a healed labrum at three months, regardless of the position of immobilisation. Future studies are required in order to identify factors that can improve healing of the damaged labrum following a traumatic dislocation of the shoulder

INTRODUCTION. Use of a novel ligament gap balancing instrumentation system in total knee arthroplasty (TKA) resulted in femoral component external rotation values which were higher on average, compared to measured bone resection systems. In one hundred twenty knees in 110 patients the external rotation averaged 6.9 degrees (± 2.8) and ranged from 0.6 to 12.8 degrees. The external rotation values in this study were 4° and 2° larger, respectively, than the typical 3° and 5° discrete values that are common to measured resection systems. The purpose of the present study was to determine the effect of these greater external rotation values for the femoral component on patellar tracking, flexion stability and function of two different TKA implant designs. METHODS. In the first arm of the study, 120 knees in 110 patients were consecutively enrolled by a single surgeon using the same implant design (single radius femur with a medial constraint tibial liner) across subjects. All patients underwent arthroplasty with tibial resection first and that set external rotation of the femoral component based upon use of a ligament gap balancing system. Following ligament tensioning / balancing, the femur was prepared. The accuracy of the ligament balancing system was assessed by reapplying equal tension to the ligaments using a tensioning bolt and torque wrench in flexion and extension after the bone resections had been made. The resulting flexion and extension gaps were then measured to determine rectangular shape and equality of the gaps. Postoperative Merchant views were obtained on all of the patients and patellar tracking was assessed and compared to 120 consecutive total knee arthroplasties previously performed by the same surgeon with the same implant using a measured resection system. In the second arm of the study, 100 unilateral knees in 100 patients were consecutively enrolled. The same instrumentation and technique by the same surgeon was used, but with a different implant design (single radius femur without a medial constraint tibial liner). RESULTS. Rectangular flexion and extension gaps were obtained within ± 0.5mm in all cases. Equality of the flexion and extension gaps was also obtained within ± 0.5mm in all cases. Merchant views of the total knee arthroplasties showed central patellar tracking with no tilt or subluxation in 90% of the ligament gap balanced knees and 74% of the measured resection knees. Arthrofibrosis resulting in a closed manipulation under anesthesia was required in 6% of the knees with single radius femurs and medial constaint tibial liners, but only in 1% of the single radius femur knees without medial constraint liners. DISCUSSION AND CONCLUSION. External rotation values are higher on average, when ligament tensioning / balancing is employed with this novel system compared to measured resection systems. In this study this resulted in consistent matching of the flexion gap to the extension gap and better patellar tracking. These findings suggest that limiting the surgeon to discrete rotation values may be at odds with where the femur “desires” to be, given soft tissue considerations for each patient. Also, even with ideal soft tissue balancing, TKA implant design can have a significant affect on the outcome measure of development of arthrofibrosis

There are a multitude of studies internationally that have considered the rates of redislocation of shoulders, where, after first time anterior dislocation, initial management has consisted of an internal rotation sling immobiliser or no immobility. The majority of these have indicated poor results. This is in comparison with recurrence rates of dislocation, post shoulder stabilisation (arthroscopic or open), after first time anterior dislocation, which have demonstrated excellent results. The question remains, is there a non-operative alternative that will give similarly good results for these patients. A selection criteria was set up for use of the external rotation brace for first time anterior dislocators. Thirty-five patients were used that fit the criteria and were able to be followed over time. A physiotherapy program was initiated at the two-week stage in combination with clinic reviews. We encouraged use of the brace for six weeks in total, with removal only for hygiene purposes. At two years, post first time anterior dislocation, patients were reviewed clinically and a quick DASH score performed. Any recurrence of dislocation was recorded and an MRI was also undertaken to show residual injury. The compliance with the brace and physiotherapy program were excellent, with only one reported redislocation, during this period, in the 31 patients that were followed up. The majority of patients were functioning at predislocation levels at review and no one had required surgical intervention for instability. Quick-Dash results were also very good, with a vast majority scoring less than 2/100 level of disability. Conclusion. The external rotation brace with a Physiotherapy program is an excellent alternative to early shoulder stabilisation for first time anterior dislocators

Purpose. While reverse shoulder arthroplasty (RSA) corrects vertical muscle imbalance, it cannot restore the horizontal imbalance seen in cuff-deficient shoulders with combined loss of active elevation and external rotation (CLEER). We report the medium-term results of the modified latissimus dorsi/teres major tendon transfer (L'Episcopo procedure) associated with RSA, performed via a single deltopectoral approach. Method. Sixteen CLEER patients underwent the procedure and were followed up at a mean of 49 months (range, 36–70). All patients had lost spatial control of their arm, were unable to maintain neutral rotation, and had abnormal infraspinatus and teres minor muscles on imaging. Outcome measures included Constant score (CS), Subjective Shoulder Value (SSV), and ADLER score (activities of daily living requiring external rotation). Results. Fifteen patients were satisfied or very satisfied. There were significant improvements (p<0.05) in active elevation (72 degrees to 139 degrees), active external rotation (−24 degrees to 4 degrees), CS (27 to 64), ADLER score (5.0 to 23.8) and SSV (23% to 77%). Active internal rotation decreased from 6 to 3 points. Scapular notching was observed in 3 patients and spurs in 3 patients. One deep infection required two-stage revision of the prosthesis and the patient was disappointed with the result. One patient required reoperation (arthrolysis and acromioclavicular joint excision). Conclusion. Reverse shoulder arthroplasty combined with the modified L'Episcopo procedure improves shoulder function in patients with CLEER. Patients regain spatial control of their arm. The observed internal rotation loss has led us to modify the surgical technique by fixing the transferred tendons more posteriorly on the humerus

Introduction:. Reverse total shoulder arthroplasty (RTSA) has become an accepted surgical treatment for patients with severe deficiency of the rotator cuff. Despite the utility of RTSA in managing difficult shoulder problems, humeral rotation does not reliably improve and may even worsen following RTSA. Several approaches to increase active external rotation (aER) postoperatively have been proposed including the use of concomitant latissimus dorsi tendon transfer (LDTT) or the use of an increased lateral-offset glenosphere (LG). We hypothesized that clinical outcome and range of motion after RTSA with a +4 mm or +6 mm LG would be comparable to RTSA with LDTT in patients with a lack of aER preoperatively. Methods:. An IRB-approved, prospective, single surgeon RTSA registry was reviewed for patients treated with LDTT or LG for preoperative aER deficiency with minimum 1-year follow-up. Patients qualified for aER deficiency if they had a positive ER lag sign or less than or equal to 10 degrees of aER preoperatively. Matched control groups with patients that did not have preoperative lack of aER and were not treated with LDTT or LG were included for comparison. Outcomes measures included Constant-Murley score (CMS), American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), ASES Activities of Daily Living (ADL) score, Visual Analogue pain Scale (VAS), active forward elevation (aFE), active internal rotation (aIR), and aER. An independent, institutional biostatistician performed statistical analyses. Results:. The LDTT group had 21 patients (10 male, 11 female) and the LG group had 16 patients (5 male, 11 female). CMS, ASES, SSV, ADL, VAS, and aFE were significantly improved in case and control groups following RTSA (P < .05). There was no significant difference in the degree of improvement of CMS, ASES, SSV, ADL, VAS or aFE between the LDTT group and its control group or the LG group and its control group (P > .05). aER was significantly improved in the LDTT and LG groups (P < .001), but did not improve significantly in either control group (P > .05) (Figure 1). The LDTT group had a significantly lower postoperative aER than its control group (P = .001), whereas the LG group had similar postoperative aER to its control group (P = .376) (Figure 1). The LG group had significantly greater aER preoperatively and postoperatively than the LDTT group (P < .001 and P = .013). There was no significant difference in degree of improvement of aER between the LDTT and LG groups (P = .212). The LDTT group had a significantly lower postoperative aIR than its control group (P=.025), whereas the LG group had similar postoperative aIR to its control group (P = .234). The LG group had significantly greater improvement in aIR than the LDTT group (P=.009). Conclusion:. To our knowledge, this is the first series to compare outcomes of two common techniques used to improve aER following RTSA. In this series, we found overall similar improvements in outcomes between the groups. These results suggest that use of a LG may be preferable to LDTT given the relatively simplified surgical technique, similar improvement in aER, comparable clinical outcome scores, and the added benefit of improved aIR

Scapular notching is a common problem following reverse shoulder arthroplasty (RSA). This is due to impingement between the humeral polyethylene cup and scapular neck in adduction and external rotation. Various glenoid component strategies have been described to combat scapular notching and enhance impingement-free range of motion (ROM). There is limited data available detailing optimal glenosphere position in RSA with an onlay configuration. The purpose of this study was to determine which glenosphere configurations would maximise impingement free ROM using an onlay RSA prosthesis. A three-dimensional (3D) computed tomography (CT) scan of a shoulder with Walch A1, Favard E0 glenoid morphology was segmented using validated software. An onlay RSA prosthesis was implanted and a computer model simulated external rotation and adduction motion of the virtual RSA prosthesis. Four glenosphere parameters were tested; diameter (36mm, 41mm), lateralization (0mm, 3mm, 6mm), inferior tilt (neutral, 5 degrees, 10 degrees), and inferior eccentric positioning (0.5mm, 1.5mm. 2.5mm, 3.5mm, 4.5mm). Eighty-four combinations were simulated. For each simulation, the humeral neck-shaft angle was 147 degrees and retroversion was 30 degrees. The largest increase in impingement-free range of motion resulted from increasing inferior eccentric positioning, gaining 15.0 degrees for external rotation and 18.8 degrees for adduction. Glenosphere lateralization increased external rotation motion by 13. 6 degrees and adduction by 4.3 degrees. Implanting larger diameter glenospheres increased external rotation and adduction by 9.4 and 10.1 degrees respectively. Glenosphere tilt had a negligible effect on impingement-free ROM. Maximizing inferior glenosphere eccentricity, lateralizing the glenosphere, and implanting larger glenosphere diameters improves impingement-free range of motion, in particular external rotation, of an onlay RSA prosthesis. Surgeons’ awareness of these trends can help optimize glenoid component position to maximise impingement-free ROM for RSA. Further studies are required to validate these findings in the context of scapulothoracic motion and soft tissue constraints

Currently, the consensus regarding subscapularis tendon repair during a reverse total shoulder arthroplasty (rTSA) is to do so if it is possible. Repair is thought to decrease the risk of dislocation and improve internal rotation but may also increase stiffness and improvement in internal rotation may be of subclinical benefit. Aim is to retrospectively evaluate the outcomes of rTSA, with or without a subscapularis tendon repair. We completed a retrospective review of 51 participants (25 without and 26 with subscapularis repair) who received rTSR by a single-surgeon using a single-implant. Three patient reported outcome measures (PROM) were assessed pre-operatively and post-operative at twelve months, as well as range of movement (ROM) and plain radiographs. Statistical analysis utilized unpaired t tests for parametric variables and Mann-Whitney U test for nonparametric variables. External Rotation ROM pre-operatively was the only variable with a significance difference (p=0.02) with the subscapularis tendon repaired group having a greater range. Pre- and post-operative abduction (p=0.72 & 0.58), forward flexion (p=0.67 & 0.34), ASES (p=0.0.06 & 0.78), Oxford (p=0.0.27 & 0.73) and post-operative external rotation (p=0.17). Greater external rotation ROM pre-operatively may be indicative of the ability to repair the subscapularis tendon intra-operatively. However, repair does not seem to improve clinical outcome at 12 months. There was no difference of the PROMs and AROMs between the subscapularis repaired and not repaired groups for any of the variables at the pre-operative or 12 month post operative with the exception of the external rotation ROM pre-operatively. We can conclude that from PROM or AROM perspective there is no difference if the tendon is repaired or not in a rTSR and indeed the patients without the repair may have improved outcomes at 12 months

Abstract. Objective. Radial to axillary nerve and spinal accessory (XI) to suprascapular nerve (SSN) transfers are standard procedures to restore function after C5 brachial plexus dysfunction. The anterior approach to the SSN may miss concomitant pathology at the suprascapular notch and sacrifices lateral trapezius function, resulting in poor restoration of shoulder external rotation. A posterior approach allows decompression and visualisation of the SSN at the notch and distal coaptation of the medial XI branch. The medial triceps has a double fascicle structure that may be coapted to both the anterior and posterior division of the axillary nerve, whilst preserving the stabilising effect of the long head of triceps at the glenohumeral joint. Reinnervation of two shoulder abductors and two external rotators may confer advantages over previous approaches with improved external rotation range of motion and strength. Methods. Review of the clinical outcomes of 22 patients who underwent a double nerve transfer from XI and radial nerves. Motor strength was evaluated using the MRC scale and grade 4 was defined as the threshold for success. Results. 18/22 patients had adequate follow-up (Mean: 29.5 months). Of these, 72.2% achieved ≥grade 4 power of shoulder abduction and a mean range of motion of 103°. 64.7% achieved ≥grade 4 external rotation with a mean range of motion of 99.6°. Conclusions. The results suggest the use of the combined nerve transfer for restoration of shoulder function via a posterior approach, involving the medial head branch of triceps to the axillary nerve and the XI to SSN

As the field of hip arthroscopy continues to develop, functional measures and testing become increasingly important in patient selection, managing patient expectations prior to surgery, and physical readiness for return to athletic participation. The Hip Sport Test (HST) was developed to assess strength, coordination, agility, and range of motion prior to and following hip arthroscopy as a functional assessment. However, the relationship between HST and hip strength, range of motion, and hip-specific patient reported outcome (PRO) measures have not been investigated. The purpose of this study was to evaluate the correlation between the HST scores and measurements of hip strength and range of motion prior to undergoing hip arthroscopy. Between September 2009 and January 2017, patients aged 18-40 who underwent primary hip arthroscopy for the treatment of femoroacetabular impingement with available pre-operative HST, dynamometry, range of motion, and functional scores (mHHS, WOMAC, HOS-SSS) were identified. Patients were excluded if they were 40 years old, had a Tegner activity score < 7, or did not have HST and dynamometry evaluations within one week of each other. Muscle strength scores were compared between affected and unaffected side to establish a percent difference with a positive score indicating a weaker affected limb and a negative score indicating a stronger affected limb. Correlations were made between HST and strength testing, range of motion, and PROs. A total of 350 patients met inclusion criteria. The average age was 26.9 ± 6.5 years, with 34% females and 36% professional athletes. Total and component HST scores were significantly associated with measure of strength most strongly for flexion (rs = −0.20, p < 0 .001), extension (rs = −0.24, p<.001) and external rotation (rs = −0.20, p < 0 .001). Lateral and diagonal agility, components of HST, were also significantly associated with muscle strength imbalances between internal rotation versus external rotation (rs = −0.18, p=0.01) and flexion versus extension (rs = 0.12, p=0.03). In terms of range of motion, a significant correlation was detected between HST and internal rotation (rs = −0.19, p < 0 .001). Both the total and component HST scores were positively correlated with pre-operative mHHS, WOMAC, and HOS-SSS (p<.001 for all rs). The Hip Sport Test correlates with strength, range of motion, and PROs in the preoperative setting of hip arthroscopy. This test alone and in combination with other diagnostic examinations can provide valuable information about initial hip function and patient prognosis

Latissimus dorsi anterior to major transfers have been advocated in the setting of loss of external rotation and elevation in conjunction with reverse shoulder replacement. Reverse shoulder replacement is a prosthesis specifically designed for shoulders with poor rotator cuff function. In the vast majority of cases, some teres minor function at the minimum is maintained in shoulders destined for a reverse shoulder replacement. However, in certain circumstances there is complete loss of any external rotation, and a muscle transfer can be performed in order to restore some external rotation function. A reverse shoulder replacement in the absence of any rotator cuff function goes into obligate internal rotation with elevation. A minimum of external rotation strength is necessary in order to maintain the arm in normal rotation. The first tip is patient selection. Physical examination of active external rotation, external rotation strength and forward elevation should be just performed. A latissimus transfer is indicated in patients who cannot maintain their arm in neutral to at least a few degrees of external rotation. A lag sign is another physical examination finding which can indicate complete loss of rotator cuff function. The latissimus dorsi transfer is performed by first identifying and releasing the latissimus from its insertion on the anterior humerus. The arthroplasty is performed. The passage for the latissimus muscle is developed carefully and being mindful of the axillary nerve in particular. The latissimus is directed inferior to the nerve and around the medial and posterior aspect of the proximal humerus. Different ways of securing the transfer to the humerus have been described including bone tunnels and anchors. Often it is easier to place the anchors and/or the bone tunnels prior to inserting the humeral prosthesis. The latissimus is secured in the new position, enabling it to participate in external rotation. The value of this is difficult to clearly establish. Most studies are evidence level IV and there are no good comparative studies in a controlled patient population. This is a good option for shoulders with no active external rotation, but they may increase overall complication rate. Complications include dislocation, infection, and transient nerve palsy

Femoroacetabular impingement (FAI) – enlarged, aspherical femoral head deformity (cam-type) or retroversion/overcoverage of the acetabulum (pincer-type) – is a leading cause for early hip osteoarthritis. Although anteverting/reverse periacetabular osteotomy (PAO) to address FAI aims to preserve the native hip and restore joint function, it is still unclear how it affects joint mobility and stability. This in vitro cadaveric study examined the effects of surgical anteverting PAO on range of motion and capsular mechanics in hips with acetabular retroversion. Twelve cadaveric hips (n = 12, m:f = 9:3; age = 41 ± 9 years; BMI = 23 ± 4 kg/m2) were included in this study. Each hip was CT imaged and indicated acetabular retroversion (i.e., crossover sign, posterior wall sign, ischial wall sign, retroversion index > 20%, axial plane acetabular version < 15°); and showed no other abnormalities on CT data. Each hip was denuded to the bone-and-capsule and mounted onto a 6-DOF robot tester (TX90, Stäubli), equipped with a universal force-torque sensor (Omega85, ATI). The robot positioned each hip in five sagittal angles: Extension, Neutral 0°, Flexion 30°, Flexion 60°, Flexion 90°; and performed hip internal-external rotations and abduction-adduction motions to 5 Nm in each position. After the intact stage was tested, each hip underwent an anteverting PAO, anteverting the acetabulum and securing the fragment with long bone screws. The capsular ligaments were preserved during the surgery and each hip was retested postoperatively in the robot. Postoperative CT imaging confirmed that the acetabular fragment was properly positioned with adequate version and head coverage. Paired sample t-tests compared the differences in range of motion before and after PAO (CI = 95%; SPSS v.24, IBM). Preoperatively, the intact hips with acetabular retroversion demonstrated constrained internal-external rotations and abduction-adduction motions. The PAO reoriented the acetabular fragment and medialized the hip joint centre, which tightened the iliofemoral ligament and slackenend the pubofemoral ligament. Postoperatively, internal rotation increased in the deep hip flexion positions of Flexion 60° (∆IR = +7°, p = 0.001) and Flexion 90° (∆IR = +8°, p = 0.001); while also demonstrating marginal decreases in external rotation in all positions. In addition, adduction increased in the deep flexion positions of Flexion 60° (∆ADD = +11°, p = 0.002) and Flexion 90° (∆ADD = +12°, p = 0.001); but also showed marginal increases in abduction in all positions. The anteverting PAO restored anterosuperior acetabular clearance and increased internal rotation (28–33%) and adduction motions (29–31%) in deep hip flexion. Restricted movements and positive impingement tests typically experienced in these positions with acetabular retroversion are associated with clinical symptoms of FAI (i.e., FADIR). However, PAO altered capsular tensions by further tightening the anterolateral hip capsule which resulted in a limited external rotation and a stiffer and tighter hip. Capsular tightness may still be secondary to acetabular retroversion, thus capsular management may be warranted for larger corrections or rotational osteotomies. In efforts to optimize surgical management and clinical outcomes, anteverting PAO is a viable option to address FAI due to acetabular retroversion or overcoverage

Introduction. Studies have shown that increased implant conformity in total knee arthroplasty (TKA) has been linked to increased constraint and thus rotational torque at the bone/implant interface. Anterior stabilized (AS) tibial inserts were designed to compensate for excessive AP motion in less-conforming cruciate-retaining (CR) tibial inserts. However, increased constraint may affect implant loading. Therefore, the purpose of this study is to model rotational prosthesis constraint based on implant-specific data and to compare rotational torque and 3D contact forces in implants with CR-lipped and AS tibial inserts during normal gait. Methods. A previously reported knee joint contact model was updated to include rotational torque due to prosthesis constraint (ASTM F1223(14)). Piecewise multiple linear regression with manually selected cutoff points was used to determine estimates of AP force, ML force, and rotation torque as functions of AP displacement, ML displacement, knee external rotation, respectively, and knee flexion angle from standard data. These functions were used to estimate total moment contribution of the prosthesis from measured knee displacement/rotation angles. Estimates were incorporated into the contact model equilibrium equations as needed by the model. As the model parametrically varies muscle activation coefficients to solve for the range of physiologically possible forces at each time point, the reported force/torque values are the mean across all solutions at each time point. Rotational torque and three dimensional contact forces were calculated for 14 informed-consented subjects, five with AS tibial inserts (1/4 m/f, 67±10 years, 29.2±4.4 BMI, 1/4 right/left) and nine with CR-lipped TKRs (2/7 m/f, 64±6 years, 30.6±5.8 BMI, 4/5 right/left). Rotational torque waveforms were compared using statistical nonparametric mapping; 3D contact forces were compared at mean timing of the flexion/extension moment peaks using independent samples t-tests. Results. Waveform analysis of rotational torque found no significant differences between implant types. CR- lipped inserts showed an initial peak internal rotation torque during weight acceptance and continued with a pattern of internal rotation throughout stance. Peak torque for AS inserts also occurred during weight acceptance, but it varied between internal/external rotation torque. Additionally, after weight acceptance, AS subjects showed a pattern of external rotation torque. Mean axial force, medial-lateral shear force, and anterior-posterior shear force waveforms were similarly shaped between implant groups. Flexion and extension moment peaks occurred at 23% and 74% stance on average. There were no significant differences in three-dimensional knee joint contact forces between groups at either time point. Discussion. There were different patterns of rotational torque between groups. Implants with lipped CR inserts tended to undergo internal rotation torques that peaked during weight acceptance. Torque seen in implants with AS inserts was also largest during weight acceptance, but greatly varied between internal and external rotation, before settling in a pattern of external rotation for the remainder of stance. This may be due to constraints added by AS insert geometry. In conclusion, a model of rotational torque due to implant constraints has been developed; increased implant constraint increased the external rotation torque experienced by the implant and may also affect shear forces at the implant surface. For any figures or tables, please contact authors directly