Aims. The aim of this study was to analyze how proximal radial neck resorption (PRNR) starts and progresses radiologically in two types of press-fit radial head arthroplasties (RHAs), and to investigate its clinical relevance. Methods. A total of 97 patients with RHA were analyzed: 56 received a bipolar RHA (Group 1) while 41 received an anatomical implant (Group 2). Radiographs were performed postoperatively and after three, six, nine, and 12 weeks, six, nine, 12, 18, and 24 months, and annually thereafter. PRNR was measured in all radiographs in the four radial neck quadrants. The Mayo Elbow Performance Score (MEPS), the abbreviated version of the Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), and the patient-assessed American Shoulder and Elbow Surgeons score - Elbow (pASES-E) were used for the clinical assessment. Radiological signs of implant loosening were investigated. Results. The mean follow-up was six years (2 to 14). PRNR started after a mean of 7.5 weeks (SD 2.1) and progressed significantly during the first two years, by the end of which the bone resorption stabilized. PRNR was detected in 81% (n = 45) of patients in Group 1 and 88% (n = 36) in Group 2. The final mean PRNR was 3.0 mm (SD 2.3) in Group 1 and 3.7 mm (SD 2.5) in Group 2. The mean MEPS, QuickDASH, and pASES-E were 95.9 (SD 11.5), 4.4 (SD 9.2), and 94.8 (SD 10.9) in Group 1 and 92.2 (SD 16.2), 9.9 (SD 21.5), and 90.8 (SD 15) in Group 2, respectively. No significant differences were observed between groups in the clinical and radiological outcomes. No correlations were found between PRNR and the clinical results. Conclusion. PRNR after press-fit RHA is a common radiological finding that develops in the first 24 months before stabilizing definitively. PRNR does not affect the clinical results or implant survival in the mid term. Cite this article: Bone Joint J 2023;105-B(8):905–911

Aims. A recent study used the RAND Corporation at University of California, Los Angeles (RAND/UCLA) method to develop anatomical total shoulder arthroplasty (aTSA) appropriateness criteria. The purpose of our study was to determine how patient-reported outcome measures (PROMs) vary based on appropriateness. Methods. Clinical data from a multicentre database identified patients who underwent primary aTSA from November 2004 to January 2023. A total of 390 patients (mean follow-up 48.1 months (SD 42.0)) were included: 97 (24.9%) were classified as appropriate, 218 (55.9%) inconclusive, and 75 (19.2%) inappropriate. Patients were classified as “appropriate”, “inconclusive”, or “inappropriate”, using a modified version of an appropriateness algorithm, which accounted for age, rotator cuff status, mobility, symptomatology, and Walch classification. Multiple pre- and postoperative scores were analyzed using Pearson’s chi-squared test and one-way analysis of variance (ANOVA). Postoperative complications were also analyzed. Results. All groups achieved significant improvement in mean PROM scores postoperatively. “Appropriate” patients experienced significantly greater improvement in visual analogue scale (VAS) and American Shoulder and Elbow Surgeons (ASES) score compared to “inconclusive” and “inappropriate”. The appropriate group had a significantly greater proportion of patients who achieved minimal clinically important difference (MCID) (95.8%; n = 93) and substantial clinical benefit (SCB) (92.6%; n = 89). Overall, 13 patients had postoperative complications. No significant differences in postoperative complications among classifications were found. Conclusion. Our data clinically validate the RAND/UCLA aTSA appropriateness criteria algorithm, allowing for more rapid and reliable determination of aTSA candidacy. “Appropriate” patients were more likely to achieve MCID and SCB for ASES scores compared to “inappropriate” patients. Among “appropriate” patients who did not achieve SCB, 50% (n = 4) had a postoperative complication. There was a significantly higher proportion of postoperative complications among those who did not achieve SCB across all three groups. Only 7.1% (n = 1) of patients who did not achieve SCB in the inappropriate group had a postoperative complication. Thus, it can be inferred that the failure to reach SCB in the appropriate group was likely to be due to a postoperative complication, whereas for patients deemed “inappropriate”, failure to reach SCB may be secondary to factors accounted for within our algorithm. Cite this article: Bone Joint J 2024;106-B(12):1451–1460

Aims. This study aimed to assess the impact of using the metal-augmented glenoid baseplate (AGB) on improving clinical and radiological outcomes, as well as reducing complications, in patients with superior glenoid wear undergoing reverse shoulder arthroplasty (RSA). Methods. From January 2016 to June 2021, out of 235 patients who underwent primary RSA, 24 received a superior-AGB after off-axis reaming (Group A). Subsequently, we conducted propensity score matching in a 1:3 ratio, considering sex, age, follow-up duration, and glenoid wear (superior-inclination and retroversion), and selected 72 well-balanced matched patients who received a standard glenoid baseplate (STB) after eccentric reaming (Group B). Superior-inclination, retroversion, and lateral humeral offset (LHO) were measured to assess preoperative glenoid wear and postoperative correction, as well as to identify any complications. Clinical outcomes were measured at each outpatient visit before and after surgery. Results. There were no significant differences in demographic data and preoperative characteristics between the two groups. Both groups showed significant improvements in patient-reported outcome measures (visual analogue scale for pain, visual analogue scale for function, American Shoulder and Elbow Surgeons, Constant, and Simple Shoulder Test scores) from preoperative to final assessment (p < 0.001). However, AGB showed no additional benefit. Notably, within range of motion, Group B showed significant postoperative decrease in both external rotation and internal rotation, unlike Group A (p = 0.028 and 0.003, respectively). Both groups demonstrated a significant correction of superior-inclination after surgery, while patients in Group B exhibited a significant decrease in LHO postoperatively (p = 0.001). Regarding complications, Group A experienced more acromial stress fractures (3 cases; 12.5%), whereas Group B had a higher occurrence of scapular notching (24 cases; 33.3%) (p = 0.008). Conclusion. Both eccentric reaming with STB and off-axis reaming with AGB are effective methods for addressing superior glenoid wear in RSA, leading to improved clinical outcomes. However, it is important to be aware of the potential risks associated with eccentric reaming, which include excessive bone loss leading to reduced rotation and scapular notching. Cite this article: Bone Joint J 2024;106-B(3):268–276

Aims. The aim of this study was to longitudinally compare the clinical and radiological outcomes of anatomical total shoulder arthroplasty (aTSA) up to long-term follow-up, when using cemented keel, cemented peg, and hybrid cage peg glenoid components and the same humeral system. Methods. We retrospectively analyzed a multicentre, international clinical database of a single platform shoulder system to compare the short-, mid-, and long-term clinical outcomes associated with three designs of aTSA glenoid components: 294 cemented keel, 527 cemented peg, and 981 hybrid cage glenoids. Outcomes were evaluated at 4,746 postoperative timepoints for 1,802 primary aTSA, with a mean follow-up of 65 months (24 to 217). Results. Relative to their preoperative condition, each glenoid cohort had significant improvements in clinical outcomes from two years to ten years after surgery. Patients with cage glenoids had significantly better clinical outcomes, with higher patient-reported outcome scores and significantly increased active range of motion, compared with those with keel and peg glenoids. Those with cage glenoids also had significantly fewer complications (keel: 13.3%, peg: 13.1%, cage: 7.4%), revisions (keel: 7.1%, peg 9.7%, cage 3.5%), and aseptic glenoid loosening and failure (keel: 4.7%, peg: 5.8%, cage: 2.5%). Regarding radiological outcomes, 70 patients (11.2%) with cage glenoids had glenoid radiolucent lines (RLLs). The cage glenoid RLL rate was 3.3-times (p < 0.001) less than those with keel glenoids (37.3%) and 4.6-times (p < 0.001) less than those with peg glenoids (51.2%). Conclusion. These findings show that good long-term clinical and radiological outcomes can be achieved with each of the three aTSA designs of glenoid component analyzed in this study. However, there were some differences in clinical and radiological outcomes: generally, cage glenoids performed best, followed by cemented keel glenoids, and finally cemented peg glenoids. Cite this article: Bone Joint J 2023;105-B(6):668–678

Aims. The aims of this study were to validate the minimal clinically important difference (MCID) and patient-acceptable symptom state (PASS) thresholds for Western Ontario Shoulder Instability Index (WOSI), Rowe score, American Shoulder and Elbow Surgeons (ASES), and visual analogue scale (VAS) scores following arthroscopic Bankart repair, and to identify preoperative threshold values of these scores that could predict the achievement of MCID and PASS. Methods. A retrospective review was conducted on 131 consecutive patients with anterior shoulder instability who underwent arthroscopic Bankart repair between January 2020 and January 2023. Inclusion criteria required at least one episode of shoulder instability and a minimum follow-up period of 12 months. Preoperative and one-year postoperative scores were assessed. MCID and PASS were estimated using distribution-based and anchor-based methods, respectively. Receiver operating characteristic curve analysis determined preoperative patient-reported outcome measure thresholds predictive of achieving MCID and PASS. Results. MCID thresholds were determined as 169.6, 6.8, 7.2, and 1.1 for WOSI, Rowe, ASES, and VAS, respectively. PASS thresholds were calculated as ≤ 480, ≥ 80, ≥ 87, and ≤ 1 for WOSI, Rowe, ASES, and VAS, respectively. Preoperative thresholds of ≥ 760 (WOSI) and ≤ 50 (Rowe) predicted achieving MCID for WOSI score (p < 0.001). Preoperative thresholds of ≤ 60 (ASES) and ≥ 2 (VAS) predicted achieving MCID for VAS score (p < 0.001). A preoperative threshold of ≥ 40 (Rowe) predicted achieving PASS for Rowe score (p = 0.005). Preoperative thresholds of ≥ 50 (ASES; p = 0.002) and ≤ 2 (VAS; p < 0.001) predicted achieving PASS for the ASES score. Preoperative thresholds of ≥ 43 (ASES; p = 0.046) and ≤ 4 (VAS; p = 0.024) predicted achieving PASS for the VAS. Conclusion. This study defined MCID and PASS values for WOSI, Rowe, ASES, and VAS scores in patients undergoing arthroscopic Bankart repair. Higher preoperative functional scores may reduce the likelihood of achieving MCID but increase the likelihood of achieving the PASS. These findings provide valuable guidance for surgeons to counsel patients realistically regarding their expectations. Cite this article: Bone Joint J 2024;106-B(10):1118–1124

Aims. This study aimed to determine the minimal detectable change (MDC), minimal clinically important difference (MCID), and substantial clinical benefit (SCB) under distribution- and anchor-based methods for the Mayo Elbow Performance Index (MEPI) and range of movement (ROM) after open elbow arthrolysis (OEA). We also assessed the proportion of patients who achieved MCID and SCB; and identified the factors associated with achieving MCID. Methods. A cohort of 265 patients treated by OEA were included. The MEPI and ROM were evaluated at baseline and at two-year follow-up. Distribution-based MDC was calculated with confidence intervals (CIs) reflecting 80% (MDC 80), 90% (MDC 90), and 95% (MDC 95) certainty, and MCID with changes from baseline to follow-up. Anchor-based MCID (anchored to somewhat satisfied) and SCB (very satisfied) were calculated using a five-level Likert satisfaction scale. Multivariate logistic regression of factors affecting MCID achievement was performed. Results. The MDC increased substantially based on selected CIs (MDC 80, MDC 90, and MDC 95), ranging from 5.0 to 7.6 points for the MEPI, and from 8.2° to 12.5° for ROM. The MCID of the MEPI were 8.3 points under distribution-based and 12.2 points under anchor-based methods; distribution- and anchor-based MCID of ROM were 14.1° and 25.0°. The SCB of the MEPI and ROM were 17.3 points and 43.4°, respectively. The proportion of the patients who attained anchor-based MCID for the MEPI and ROM were 74.0% and 94.7%, respectively; furthermore, 64.2% and 86.8% attained SCB. Non-dominant arm (p = 0.022), higher preoperative MEPI rating (p < 0.001), and postoperative visual analogue scale pain score (p < 0.001) were independent predictors of not achieving MCID for the MEPI, while atraumatic causes (p = 0.040) and higher preoperative ROM (p = 0.005) were independent risk factors for ROM. Conclusion. In patients undergoing OEA, the MCID for the increased MEPI is 12.2 points and 25° increased ROM. The SCB is 17.3 points and 43.3°, respectively. Future studies using the MEPI and ROM to assess OEA outcomes should report not only statistical significance but also clinical importance. Cite this article: Bone Joint J 2021;103-B(2):366–372

Aims. Depression can significantly affect quality of life and is associated with higher rates of medical comorbidities and increased mortality following surgery. Although depression has been linked to poorer outcomes following orthopaedic trauma, total joint arthroplasty and spinal surgery, we wished to examine the impact of depression in elective total shoulder arthroplasty (TSA) as this has not been previously explored. . Patients and Methods. The United States Nationwide Inpatient Sample (NIS) was used to identify patients undergoing elective TSA over a ten-year period. Between 2002 and 2012, 224 060 patients underwent elective TSA. Results. Among the identified patients who had undergone TSA, 12.4% had a diagnosis of a history of depression. A diagnosis of depression was twice as common in women compared with men (16.0% vs 8.0%, p < 0.001), and more frequent in those with low income and Medicaid insurance (p < 0.001). A diagnosis of depression was an independent risk factor for post-operative delirium (odds ratio (OR) 2.29, p < 0.001), anaemia (OR 1.65, p < 0.001), infection (2.09, p = 0.045) and hospital discharge to a placement other than home (OR 1.52, p < 0.001) . Conclusion. A history of clinical depression is present in 12.4% of patients undergoing elective TSA and the disease burden is projected to increase further in the future. Depression is often underdiagnosed and pre-operative screening and appropriate peri-operative management of patients is encouraged. Take home message: The awareness that clinical depression is associated with increased complications following total shoulder arthroplasty provides physicians an opportunity for early intervention in this at-risk population. Cite this article: Bone Joint J 2016;98-B:818–24

Unlinked, linked and convertible total elbow arthroplasties (TEAs) are currently available. This study is the first to report the clinical results of the convertible Latitude TEA. This was a retrospective study of a consecutive cohort of 63 patients (69 primary TEAs) with a mean age of 60 years (23 to 87). Between 2006 and 2008 a total of 19 men and 50 women underwent surgery. The mean follow-up was 43 months (8 to 84). The range of movement, function and pain all improved six months post-operatively and either continued to improve slightly or reached a plateau thereafter. The complication rate is similar to that reported for other TEA systems. No loosening was seen. Remarkable is the disengagement of the radial head component in 13 TEAs (31%) with a radial head component implanted. Implantation of both the linked and the unlinked versions of the Latitude TEA results in improvement of function and decreased pain, and shows high patient satisfaction at mid-term follow-up. Cite this article: Bone Joint J 2015; 97-B:681–8

Aims. Revision total elbow arthroplasty (TEA) is often challenging. The aim of this study was to report on the clinical and radiological results of revision arthroplasty of the elbow with the Latitude TEA. Patients and Methods. Between 2006 and 2010 we used the Latitude TEA for revision in 18 consecutive elbows (17 patients); mean age 53 years (28 to 80); 14 women. A Kudo TEA was revised in 15 elbows and a Souter-Strathclyde TEA in three. Stability, range of movement (ROM), visual analogue score (VAS) for pain and functional scores, Elbow Functional Assessment Scale (EFAS), the Functional Rating Index of Broberg and Morrey (FRIBM) and the Modified Andrews’ Elbow Scoring System (MAESS) were assessed pre-operatively and at each post-operative follow-up visit (six, 12 months and biennially thereafter). Radiographs were analysed for loosening, fractures and dislocation. The mean follow-up was 59 months (26 to 89). Results. The ROM of the elbow did not improve significantly. The mean EFAS and MAESS scores improved significantly six months post-operatively (18.6 points, standard deviation (. sd. ) 7.7; p = 0.03 and 28.8 points, . sd . 8.6; p = 0.006, respectively) and continued to improve slightly or reached a plateau. The mean pain scores at rest (Z = -3.2, p = 0.001) and during activity (Z = -3.2, p = 0.001), and stability (Z = -3.0, p = 0.003) improved significantly six months post-operatively. Thereafter scores continued to improve slightly or a plateau was reached. There were no signs of loosening. Conclusion. Revision surgery using the Latitude TEA results in improvement of functionality, reduced pain and better stability of the elbow. Improvement of ROM of the elbow should not be expected. Cite this article: Bone Joint J 2016;98-B:1086–92

Medium-term results of the Discovery elbow replacement are presented. We reviewed 51 consecutive primary Discovery total elbow replacements (TERs) implanted in 48 patients. The mean age of the patients was 69.2 years (49 to 92), there were 19 males and 32 females (37%:63%) The mean follow-up was 40.6 months (24 to 69). A total of six patients were lost to follow-up. Statistically significant improvements in range movement and Oxford Elbow Score were found (p < 0.001). Radiolucent lines were much more common in, and aseptic loosening was exclusive to, the humeral component. Kaplan–Meier survivorship at five years was 92.2% (95% CI 74.5% to 96.4%) for aseptic loosening. In four TERs, periprosthetic infection occurred resulting in failure. A statistically significant association between infection and increased BMI was found (p = 0.0268). Triceps failure was more frequent after the Mayo surgical approach and TER performed after previous trauma surgery. No failures of the implant were noted. . Our comparison shows that the Discovery has early clinical results that are similar to other semi-constrained TERs. We found continued radiological surveillance with particular focus on humeral lucency is warranted and has not previously been reported. Despite advances in the design of total elbow replacement prostheses, rates of complication remain high. Cite this article: Bone Joint J 2014;96-B:1359–65

Little is known about the incidence of rotator cuff pathology or its demographic associations in the general population. We undertook a large epidemiological study of rotator cuff pathology in the United Kingdom using The Health Improvement Network (THIN) database. The incidence of rotator cuff pathology was 87 per 100 000 person-years. It was more common in women than in men (90 cases per 100 000 person-years in women and 83 per 100 000 person-years in men; p < 0.001). The highest incidence of 198 per 100 000 person-years was found in those aged between 55 and 59 years. The regional distribution of incidence demonstrated an even spread across 13 UK health authorities except Wales, where the incidence was significantly higher (122 per 100 000 person-years; p < 0.001). The lowest socioeconomic group had the highest incidence (98 per 100 000 person-years). The incidence has risen fourfold since 1987 and as of 2006 shows no signs of plateauing. This study represents the largest general population study of rotator cuff pathology reported to date. The results obtained provide an enhanced appreciation of the epidemiology of rotator cuff pathology and may help to direct future upper limb orthopaedic services. Cite this article: Bone Joint J 2014;96-B:350–3

Aims. Favourable short-term outcomes have been reported following latissimus dorsi tendon transfer for patients with an irreparable subscapularis (SSC) tendon tear. The aim of this study was to investigate the long-term outcomes of this transfer in these patients. Methods. This was a retrospective study involving 30 patients with an irreparable SSC tear and those with a SSC tear combined with a reparable supraspinatus tear, who underwent a latissimus dorsi tendon transfer. Clinical scores and active range of motion (aROM), SSC-specific physical examination and the rate of return to work were assessed. Radiological assessment included recording the acromiohumeral distance (AHD), the Hamada grade of cuff tear arthropathy and the integrity of the transferred tendon. Statistical analysis compared preoperative, short-term (two years), and final follow-up at a mean of 8.7 years (7 to 10). Results. There were significant improvements in clinical scores, in the range and strength of internal rotation and aROM compared with the preoperative values in the 26 patients (87%) who were available for long-term follow-up. These improvements were maintained between short- and long-term follow-ups. Although there was a decreased mean AHD of 7.3 mm (SD 1.5) and an increased mean Hamada grade of 1.7 (SD 0.5) at final follow-up, the rate of progression of cuff tear arthropathy remained low-grade. Comparison between the isolated SSC and combined SSC and reparable supraspinatus tear groups showed no significant differences. At final follow-up, one patient (3.8%) had undergone revision surgery to a reverse shoulder arthroplasty (RSA). No neurological complications were associated with the procedure. Conclusion. Latissimus dorsi transfer for an irreparable SSC tendon tear resulted in a significant clinical improvement, particularly in pain, range and strength of internal rotation and aROM, which were maintained over a mean of 8.7 years following surgery. Given that this was a long-term outcome study, there was a low-grade progression in the rate of cuff tear arthropathy. Thus, the long-term clinical efficacy of latissimus dorsi tendon transfer in patients with irreparable SSC was confirmed as a joint-preserving procedure for these patients, suggesting it as an effective alternative to RSA in young, active patients without degenerative changes of the glenohumeral joint. Cite this article: Bone Joint J 2024;106-B(9):957–963

Aims. Vascular compromise due to arterial injury is a rare but serious complication of a proximal humeral fracture. The aims of this study were to report its incidence in a large urban population, and to identify clinical and radiological factors which are associated with this complication. We also evaluated the results of the use of our protocol for the management of these injuries. Methods. A total of 3,497 adult patients with a proximal humeral fracture were managed between January 2015 and December 2022 in a single tertiary trauma centre. Their mean age was 66.7 years (18 to 103) and 2,510 (72%) were female. We compared the demographic data, clinical features, and configuration of those whose fracture was complicated by vascular compromise with those of the remaining patients. The incidence of vascular compromise was calculated from national population data, and predictive factors for its occurrence were investigated using univariate analysis. Results. A total of 18 patients (0.5%) had a proximal humeral fracture and clinical evidence of vascular compromise, giving an annual incidence of 0.29 per 100,000 of the population. Their mean age was 68.7 years (45 to 92) and ten (56%) were female. Evidence of a mixed pattern neurological deficit (brachial plexus palsy) (odds ratio (OR) 380.6 (95% CI 85.9 to 1,685.8); p < 0.001), complete separation of the proximal shaft from the humeral head with medial displacement (OR 39.5 (95% CI 14.0 to 111.8); p < 0.001), and a fracture-dislocation (OR 5.0 (95% CI 1.6 to 15.3); p = 0.015) were all associated with an increased risk of associated vascular compromise. A policy of reduction and fixation of the fracture prior to vascular surgical intervention had favourable outcomes without vascular sequelae. Conclusion. The classic signs of distal ischaemia are often absent in patients with proximal injuries to major vessels. We were able to identify specific clinical and radiological ‘red flags’ which, particularly when present in combination, should increase the suspicion of a fracture with an associated vascular injury, and facilitate early diagnosis and appropriate combined orthopaedic and vascular intervention. Cite this article: Bone Joint J 2024;106-B(8):842–848

Aims. The aim of this study was to compare the clinical and radiological outcomes of reverse shoulder arthroplasty (RSA) using small and standard baseplates in Asian patients, and to investigate the impact of a mismatch in the sizes of the glenoid and the baseplate on the outcomes. Methods. This was retrospective analysis of 50 and 33 RSAs using a standard (33.8 mm, ST group) and a small (29.5 mm, SM group) baseplate of the Equinoxe reverse shoulder system, which were undertaken between January 2017 and March 2021. Radiological evaluations included the size of the glenoid, the β-angle, the inclination of the glenoid component, inferior overhang, scapular notching, the location of the central cage in the baseplate within the vault and the mismatch in size between the glenoid and baseplate. Clinical evaluations included the range of motion (ROM) and functional scores. In subgroup analysis, comparisons were performed between those in whom the vault of the glenoid was perforated (VP group) and those in whom it was not perforated (VNP group). Results. Perforation of the vault of the glenoid (p = 0.018) and size mismatch in height (p < 0.001) and width (p = 0.013) were significantly more frequent in the ST group than in the SM group. There was no significant difference in the clinical scores and ROM in the two groups, two years postoperatively (all p > 0.05). In subgroup analysis, the VP group had significantly less inferior overhang (p = 0.009), more scapular notching (p = 0.018), and more size mismatch in height (p < 0.001) and width (p = 0.025) than the VNP group. Conclusion. In Asian patients with a small glenoid, using a 29.5 mm small baseplate at the time of RSA was more effective in reducing size mismatch between the glenoid and the baseplate, decreasing the incidence of perforation of the glenoid vault, and achieving optimal positioning of the baseplate compared with the use of a 33.8 mm standard baseplate. However, longer follow-up is required to assess the impact of these findings on the clinical outcomes. Cite this article: Bone Joint J 2023;105-B(11):1189–1195

Rotator cuff pathology is the main cause of shoulder pain and dysfunction in older adults. When a rotator cuff tear involves the subscapularis tendon, the symptoms are usually more severe and the prognosis after surgery must be guarded. Isolated subscapularis tears represent 18% of all rotator cuff tears and arthroscopic repair is a good alternative primary treatment. However, when the tendon is deemed irreparable, tendon transfers are the only option for younger or high-functioning patients. The aim of this review is to describe the indications, biomechanical principles, and outcomes which have been reported for tendon transfers, which are available for the treatment of irreparable subscapularis tears. The best tendon to be transferred remains controversial. Pectoralis major transfer was described more than 30 years ago to treat patients with failed surgery for instability of the shoulder. It has subsequently been used extensively to manage irreparable subscapularis tendon tears in many clinical settings. Although pectoralis major reproduces the position and orientation of the subscapularis in the coronal plane, its position in the axial plane – anterior to the rib cage – is clearly different and does not allow it to function as an ideal transfer. Consistent relief of pain and moderate recovery of strength and function have been reported following the use of this transfer. In an attempt to improve on these results, latissimus dorsi tendon transfer was proposed as an alternative and the technique has evolved from an open to an arthroscopic procedure. Satisfactory relief of pain and improvements in functional shoulder scores have recently been reported following its use. Both pectoralis minor and upper trapezius transfers have also been used in these patients, but the outcomes that have been reported do not support their widespread use. Cite this article: Bone Joint J 2024;106-B(9):970–977

Aims. To propose a new method for evaluating paediatric radial neck fractures and improve the accuracy of fracture angulation measurement, particularly in younger children, and thereby facilitate planning treatment in this population. Methods. Clinical data of 117 children with radial neck fractures in our hospital from August 2014 to March 2023 were collected. A total of 50 children (26 males, 24 females, mean age 7.6 years (2 to 13)) met the inclusion criteria and were analyzed. Cases were excluded for the following reasons: Judet grade I and Judet grade IVb (> 85° angulation) classification; poor radiograph image quality; incomplete clinical information; sagittal plane angulation; severe displacement of the ulna fracture; and Monteggia fractures. For each patient, standard elbow anteroposterior (AP) view radiographs and corresponding CT images were acquired. On radiographs, Angle P (complementary to the angle between the long axis of the radial head and the line perpendicular to the physis), Angle S (complementary to the angle between the long axis of the radial head and the midline through the proximal radial shaft), and Angle U (between the long axis of the radial head and the straight line from the distal tip of the capitellum to the coronoid process) were identified as candidates approximating the true coronal plane angulation of radial neck fractures. On the coronal plane of the CT scan, the angulation of radial neck fractures (CTa) was measured and served as the reference standard for measurement. Inter- and intraobserver reliabilities were assessed by Kappa statistics and intraclass correlation coefficient (ICC). Results. Angle U showed the strongest correlation with CTa (p < 0.001). In the analysis of inter- and intraobserver reliability, Kappa values were significantly higher for Angles S and U compared with Angle P. ICC values were excellent among the three groups. Conclusion. Angle U on AP view was the best substitute for CTa when evaluating radial neck fractures in children. Further studies are required to validate this method. Cite this article: Bone Joint J 2024;106-B(9):964–969

Aims. Acute and chronic injuries of the interosseus membrane can result in longitudinal instability of the forearm. Reconstruction of the central band of the interosseus membrane can help to restore biomechanical stability. Different methods have been used to reconstruct the central band, including tendon grafts, bone-ligament-bone grafts, and synthetic grafts. This Idea, Development, Exploration, Assessment, and Long-term (IDEAL) phase 1 study aims to review the clinical results of reconstruction using a synthetic braided cross-linked graft secured at either end with an Endobutton to restore the force balance between the bones of the forearm. Methods. An independent retrospective review was conducted of a consecutive series of 21 patients with longitudinal instability injuries treated with anatomical central band reconstruction between February 2011 and July 2019. Patients with less than 12 months’ follow-up or who were treated acutely were excluded, leaving 18 patients in total. Preoperative clinical and radiological assessments were compared with prospectively gathered data using range of motion and the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) functional outcome score. Results. Of the 18 patients (nine male, nine female) who met the inclusion criteria, the median follow-up was 8.5 years (interquartile range (IQR) 5.6 to 10). Their mean age was 49 years (SD 11). The mean extension improved significantly from 38° (SD 15°) to 24° (SD 9°) (p = 0.027), with a mean flexion-extension arc change from 81° (SD 27°) to 93° (SD 30°) (p = 0.172) but with no forearm rotational improvement (p = 0.233) at latest follow-up. The QuickDASH functional score improved significantly from 80 (SD 14) to 52 (SD 26) following reconstruction (p = 0.031), but generally the level of disability remains high. Radiological assessment showed no progression of proximal migration of the radius, with a stable interbutton distance and ulnar variance from immediate postoperative radiograph to the latest follow-up. Conclusion. Central band interosseus membrane reconstruction using a synthetic braided cross-linked graft can improve patient-rated arm function and range of motion, but significant functional deficits remain in patients with chronic injuries. Cite this article: Bone Joint J 2024;106-B(2):182–188

Aims. Both anatomical and reverse total shoulder arthroplasty (aTSA and rTSA) provide functional improvements. A reported benefit of aTSA is better range of motion (ROM). However, it is not clear which procedure provides better outcomes in patients with limited foward elevation (FE). The aim of this study was to compare the outcome of aTSA and rTSA in patients with glenohumeral osteoarthritis (OA), an intact rotator cuff, and limited FE. Methods. This was a retrospective review of a single institution’s prospectively collected shoulder arthroplasty database for TSAs undertaken between 2007 and 2020. A total of 344 aTSAs and 163 rTSAs, which were performed in patients with OA and an intact rotator cuff with a minimum follow-up of two years, were included. Using the definition of preoperative stiffness as passive FE ≤ 105°, three cohorts were matched 1:1 by age, sex, and follow-up: stiff aTSAs (85) to non-stiff aTSAs (85); stiff rTSAs (74) to non-stiff rTSAs (74); and stiff rTSAs (64) to stiff aTSAs (64). We the compared ROMs, outcome scores, and complication and revision rates. Results. Compared with non-stiff aTSAs, stiff aTSAs had poorer passive FE and active external rotation (ER), whereas there were no significant postoperative differences between stiff rTSAs and non-stiff rTSAs. There were no significant differences in preoperative function when comparing stiff aTSAs with stiff rTSAs. However, stiff rTSAs had significantly greater postoperative active and passive FE (p = 0.001 and 0.004, respectively), and active abduction (p = 0.001) compared with stiff aTSAs. The outcome scores were significantly more favourable in stiff rTSAs for the Shoulder Pain and Disability Index, Simple Shoulder Test, American Shoulder and Elbow Surgeons score, University of California, Los Angeles score, and the Constant score, compared with stiff aTSAs. When comparing the proportion of stiff aTSAs versus stiff rTSAs that exceeded the minimal clinically important difference and substantial clinical benefit, stiff rTSAs achieved both at greater rates for all measurements except active ER. The complication rate did not significantly differ between stiff aTSAs and stiff rTSAs, but there was a significantly higher rate of revision surgery in stiff aTSAs (p = 0.007). Conclusion. Postoperative overhead ROM, outcome scores, and rates of revision surgery favour the use of a rTSA rather than aTSA in patients with glenohumeral OA, an intact rotator cuff and limited FE, with similar rotational ROM in these two groups. Cite this article: Bone Joint J 2023;105-B(12):1303–1313

Aims. This study compared patients who underwent arthroscopic repair of large to massive rotator cuff tears (LMRCTs) with isolated incomplete repair of the tear and patients with incomplete repair with biceps tendon augmentation. We aimed to evaluate the additional benefit on clinical outcomes and the capacity to lower the re-tear rate. Methods. We retrospectively reviewed 1,115 patients who underwent arthroscopic rotator cuff repair for full-thickness tears between October 2011 and May 2019. From this series, we identified 77 patients (28 male, 49 female) with a mean age of 64.1 years (50 to 80). Patients were classified into groups A (n = 47 incomplete) and B (n = 30 with biceps augmentation) according to the nature of their reconstruction. Clinical scores were checked preoperatively and at six months, one year, and two years postoperatively. In preoperative MRI, we measured the tear size, the degree of fatty infiltration, and muscle volume ratio of the supraspinatus. In postoperative MRI, the integrity of the repaired rotator cuff tendon was assessed using the Sugaya classification. Tendon thickness at the footprint was evaluated on T2-weighted oblique coronal view. Results. There were no significant differences in the initial preoperative demographic characteristics. In both groups, there were significant improvements in postoperative clinical scores (p < 0.001). However, most clinical outcomes, including range of motion measurements (forward elevation, external rotation, internal rotation, and abduction), showed no differences between the pre- and postoperative values. Comparing the postoperative outcomes of both groups, no further improvement from biceps augmentation was found. Group B, although not reaching statistical significance, had more re-tears than group A (30% vs 15%; p = 0.117). Conclusion. In LMRCTs, biceps augmentation provided no significant improvement of an incomplete repair. Therefore, biceps augmentation is not recommended in the treatment of LMRCTs. Cite this article: Bone Joint J 2022;104-B(11):1234–1241

Aims. Reverse total shoulder arthroplasty (rTSA) can be used in complex cases when the glenoid requires reconstruction. In this study, a baseplate with composite bone autograft and a central trabecular titanium peg was implanted, and its migration was assessed for two years postoperatively using radiostereometric analysis (RSA). Methods. A total of 14 patients who underwent a rTSA with an autograft consented to participate. Of these, 11 had a primary rTSA using humeral head autograft and three had a revision rTSA with autograft harvested from the iliac crest. The mean age of the patients was 66 years (39 to 81). Tantalum beads were implanted in the scapula around the glenoid. RSA imaging (stereographic radiographs) was undertaken immediately postoperatively and at three, six, 12, and 24 months. Analysis was completed using model-based RSA software. Outcomes were collected preoperatively and at two years postoperatively, including the Oxford Shoulder Score, the American Shoulder and Elbow Score, and a visual analogue score for pain. A Constant score was also obtained for the assessment of strength and range of motion. Results. RSA analysis showed a small increase in all translation and rotational values up to six months postoperatively, consistent with settling of the implant. The mean values plateaued by 12 months, with no evidence of further migration. In four patients, there was significant variation outside the mean, which corresponded to postoperative complications. There was a significant improvement in the clinical and patient-reported outcomes from the preoperative values to those at two years postoperatively (p < 0.001). Conclusion. These findings show, using RSA, that a glenoid baseplate composite of a trabecular titanium peg with autograft stabilizes within the glenoid about 12 months after surgery, and reinforce findings from a previous study of this implant/graft with CT scans at two years postoperatively, indicating that this type of structural composite results in sound early fixation. Cite this article: Bone Joint J 2023;105-B(8):912–919