Tendinopathy of the conjoint tendon (CjT), comprising the short head of the biceps brachii and coracobrachialis, represents an uncommon etiology of anterior shoulder pain. To our knowledge, this is the first documented case in which leukocyte-rich platelet-rich plasma (LR-PRP) was employed for its treatment. A 54-year-old male weightlifter presented with right shoulder pain that was refractory to conventional conservative management. Although magnetic resonance imaging revealed mild rotator cuff tendinopathy and acromioclavicular osteoarthritis, point-of-care ultrasound (POCUS) identified a hypoechoic lesion within the CjT accompanied by enthesopathy. An ultrasound-guided injection of LR-PRP resulted in complete symptom resolution within 1 month, with sustained improvement observed at the 12-month follow-up. Adverse effects were limited to mild, transient deep injection-site soreness noted on the first post-procedure day. Furthermore, ultrasound evaluation at 6 months demonstrated notable improvement in tendon morphology. This case underscores the importance of considering CjT tendinopathy in the differential diagnosis of anterior shoulder pain and highlights the critical role of POCUS in enhancing diagnostic accuracy and guiding targeted therapeutic interventions. LR-PRP may serve as a regenerative alternative to corticosteroid therapy, promoting tendon healing while avoiding corticosteroids side-effects. As a single case report, generalizability is limited, and conclusions should be interpreted with caution.

Pectoralis Major Transfer Over versus Under the Conjoint Tendon for the Treatment of Irreparable Subscapularis Rupture. A Systematic Review Comparing Clinical Outcomes, Complications, and Failure Rates.

Shoulder deformities and impaired function in individuals with birth brachial plexus injury (BBPI) are often caused by internal rotator (IR) contractures and abductor weakness, which may progress to glenohumeral dysplasia. Although subscapularis-complex release and tendon transfer is a time-tested procedure, there are controversies regarding the appropriate management of shoulder contractures, especially in preschool children. Therefore, this study examines the efficiency of arthroscopically done progressive controlled release of IR contracture combined with tendon transfer. This study included 12 children who presented with shoulder soft tissue contractures and functional impairments, specifically, loss of shoulder abduction and external rotation, but with good deltoid function. They underwent a surgical intervention involving arthroscopy-assisted subscapularis-complex release and conjoint muscle transfer onto the infraspinatus footprint on the humeral head. The evaluation of shoulder function was conducted using the Mallet score system, and the range of motion was measured at preoperative and six month postoperative intervals. Statistical analyses were performed to determine the significance of the outcomes. The average age of participants was 4.83 ± 2.1 years. Preoperatively, the mean Mallet score was 14.08 ± 1.4, which improved to 23.83 ± 1.2 postoperatively. The average gain in shoulder abduction was 66.4 ± 5.6°, and external rotation improved by 85.4 ± 16.6° at 18 months final follow-up. All patients exhibited improvements in shoulder function, with a significant correlation (p value = 0.037) between Naraka grading, and clinical outcomes. The combined surgical approach of arthroscopic subscapularis-complex release with conjoint tendon transfer effectively enhances the shoulder function in the studied cohort. Further research and extended follow-up are needed to evaluate the long-term benefits. Level IV (Therapeutic case series).

Reverse Shoulder Arthroplasty Implant Design and Configuration has a Significant Effect on Conjoint Tendon Impingement

Background: Operative repair of partial proximal hamstring avulsions has been shown to improve pain and function at short- and midterm follow-up. Long-term outcomes have not yet been reported. Furthermore, it is unknown whether greater tendon involvement (ie, tendon number) in partial tears affects clinical outcomes. Hypothesis: Hamstring function and patient satisfaction would remain stable over time at minimum 5-year and mean 10-year follow-up, with no differences in outcomes when comparing isolated and combined tendon involvement. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent surgical repair of partial proximal hamstring avulsions refractory to nonoperative measures were included. Patient-reported outcome measures were completed and included the Lower Extremity Functional Score (LEFS), Marx Activity Rating Scale, custom LEFS, custom Marx, and total proximal hamstring score. Patient satisfaction, return to play, current sport participation, subjective strength, and postoperative complications were also recorded. Long-term outcomes were compared with midterm outcomes. Outcomes of isolated (semimembranosus or conjoint tendon) versus combined (semimembranosus and conjoint tendon) tendon injuries were also compared. Results: A total of 53 patients (57 hamstrings) met the inclusion criteria at a mean follow-up of 10.1 years (range, 5.1-16.2 years). The mean Marx score was 8.0 (range, 0-16), the custom Marx score was 95% (range, 15%-100%), the LEFS and custom LEFS were 90% (range, 22%-100%) and 83% (range, 19%-100%), respectively, and total proximal hamstring score was 89% (range, 19%-100%). In total, 91% of patients were satisfied with surgery and 95% of patients returned to sport at a mean of 11 months after surgery. Current participation in sport was endorsed by 86% of patients. Hamstring strength >75% compared with the contralateral leg was reported in 88% of patients, with 58% of patients reporting equal strength (100%). No differences were found in comparing long-term (mean 10.7 years) to midterm (mean 6.2 years) follow-up with the exception of decreases in the Marx score from 12.0 to 8.5 and custom Marx score from 100% to 95%. One case (1.7%) required revision due to acute reinjury at 4 months postoperatively, with other complications including sitting pain, occasional posterior thigh cramping, and posterior thigh or foot paresthesia. Conclusion: Surgical repair of partial proximal hamstring avulsions refractory to nonoperative measures led to successful outcomes and high rates of return to activities with low complications at mean 10.1-year follow-up, with no differences in outcomes comparing isolated versus combined tendon involvement.

Background: Latarjet is the gold standard procedure for treating anterior shoulder instability associated with significant bone loss. However, concerns arise regarding associated anatomic and mechanical changes, including release of the pectoralis minor tendon and alteration of the conjoint tendon vector. Recent studies have investigated alterations in scapular position and motion after Latarjet, with conflicting findings. Purpose: To evaluate the clinical outcomes and scapular position and motion in patients treated with the pectoralis minor–repairing Latarjet (PMRL) compared with traditional Latarjet (TL) after midterm follow-up. Study Design: Case-control study; Level of evidence, 3. Methods: A case-control study included 41 consecutive patients (27 men and 14 women; mean age, 37.4 years; mean body mass index, 26.4) with anterior recurrent shoulder instability. Patients underwent TL (21 patients) or PMRL (20 patients). Clinical evaluation, including Western Ontario Shoulder Instability Index (WOSI), Rowe score, and Subjective Shoulder Value (SSV), was performed preoperatively and at various postoperative intervals. Scapular position and motion were assessed using established protocols. Statistical analyses were conducted. Results: The mean follow-up was 34 months. No significant differences were observed in surgical time, clinical scores, or patient satisfaction between groups. Recurrence of dislocation occurred in 1 TL patient and persistent apprehension in 1 PMRL patient. Postoperative hematoma occurred in 1 TL patient. The rate of return to preoperative sport activity for the TL and PMRL groups was 93% and 95%, respectively (P > .05). Scapular dyskinesis occurred in 5 TL patients (25%) and 0 PMRL patients; in all cases, a type III dyskinesis was present. Four of 5 cases resolved with 6 months of a specific rehabilitation protocol. A significance difference was found between patients with and without dyskinesis, according to the WOSI, Rowe score, and SSV (P < .05). Scapular malposition was observed in 2 TL patients with dyskinesis. Conclusion: The study confirmed that postoperative scapular dyskinesis occurred frequently (25%) after the Latarjet procedure. A simple modification of the original technique, which consists of repairing the pectoralis minor to the coracoid stump, prevented the risk of postoperative dyskinesis, maintaining the stabilizing benefits of the TL procedure.

Background: Splitting the subscapularis in the Latarjet procedure is known to influence subscapularis muscle mechanics postoperatively; however, the influence of split level on postoperative muscle and joint function remains poorly understood. Purpose: To assess the effects of midlevel, lower-third, and upper-third subscapularis split levels in the Latarjet procedure on subscapularis lines of action and moment arms in the shoulder abduction, abduction and external rotation (ABER), and apprehension positions. Study Design: Controlled laboratory study. Methods: The Latarjet procedure was performed on 8 fresh-frozen human cadaveric upper extremities with a simulated 20% anteroinferior glenoid bone defect. A midwidth subscapularis muscle belly split was first performed on all specimens in which the conjoint tendon was routed. Lines of action and moment arms of 4 subregions of the subscapularis muscle (superior, mid-superior, mid-inferior, and inferior) were quantified radiographically with the conjoint tendon unloaded and loaded and the glenohumeral joint positioned in (1) 0° of abduction, (2) 90° of abduction, (3) 90° of abduction and full external rotation (ABER), and (4) the apprehension position, defined as ABER with 30° of horizontal extension. Testing was then repeated in random order after rerouting the conjoint tendon through both an upper- and then lower-third subscapularis split. Utmost care was taken to ensure that the subscapularis muscle integrity was not disrupted during the rerouting process. Results: Subscapularis splitting in Latarjet surgery deformed the muscle fibers below the split level, significantly increasing the inferior inclination of subscapularis muscle lines of action, but only for the midlevel and lower-third subscapularis split levels ( P &lt; .001). This increased inferior inclination was significantly greater in the ABER and apprehension positions compared with those at 0° and 90° of abduction ( P &lt; .05). In the ABER and apprehension positions, the adduction moment arms of the mid-superior subscapularis muscle subregion were also significantly larger for the midlevel split compared with the lower-third and upper-third split ( P &lt; .05), indicating greater depressor capacity. Conclusion: Latarjet surgery deforms subscapularis muscle fibers below the level of the split, changing subscapularis leverage and line of force. The midlevel subscapularis muscle split in the Latarjet procedure confers greater mechanical advantage in terms of shoulder depressor function and stabilizing potential than that associated with an upper-third or lower-third split, particularly in the ABER and apprehension positions. Clinical Relevance: Subscapularis muscle leverage and force potential are significantly influenced by split location in Latarjet surgery. A midlevel subscapularis split is likely to provide the greatest mechanical stability, particularly in positions of shoulder instability.

Conjoint tendon release results in improved internal rotation and pain following reverse shoulder arthroplasty: a combined randomized clinical trial and biomechanical study.

No biomechanical study has established the effect of different graft positions or bone block options on anterior glenohumeral joint stability. The purpose of this study was to compare graft choice (distal clavicular vs coracoid autograft for Latarjet) and position on stability of the bone block for anterior glenohumeral instability. It was hypothesized that both grafts would be comparable if flush with the glenoid but that the sling effect of the Latarjet procedure would lead to greater stability in case of graft medialization. Controlled laboratory study. Eight cadaveric shoulders were included. Defects stabilized using a distal clavicular graft and a coracoid graft were consecutively positioned at 0, 4, and 8 mm medially. The starting position was determined by the humeral head's being seated at its most medial position on the glenoid surface. Each experiment comprised maximal external rotation and glenohumeral abduction at 60° while applying a constant 50-N medial compressive force to the humerus under all conditions. The conjoint tendon was routed through a split in the subscapularis and loaded with a 5-N weight using a pulley system for all Latarjet trials to simulate the sling effect. Regarding the clavicular graft, the stability ratio significantly decreased versus the intact condition at all medial offsets (P = .007 for 0 mm, P < .001 for 4 mm, and P < .001 for 8 mm), and it was significantly lower in the 4-mm versus 0-mm position (P = .008), significantly higher in the 4-mm versus 8-mm position (P < .001), and significantly lower in the 8-mm versus 0-mm position (P < .001). Regarding the coracoid graft, the stability ratio was comparable with intact for the 0-mm position (P = .12), while it was significantly lower in the 4-mm and 8-mm positions (P < .001 for both). The distal clavicular graft at 0-mm offset was comparable with the coracoid graft at 0-mm offset. In shoulders with anterior glenoid bone loss, the coracoid and distal clavicular autografts were biomechanically comparable when placed flush with the glenoid. The distal clavicle at 0-mm offset did not restore stability compared with the intact specimen, but the Latarjet at 0-mm offset was not significantly different from the intact condition. The Latarjet procedure provides higher stability compared with distal clavicular autograft when medialized.

Shoulder internal rotation contracture is one of the most common problems observed in patients with residual brachial plexus birth injury1,2. Minimally invasive subscapularis release is a simple extra-articular procedure that involves the release of the subscapularis origin from the undersurface of the scapula. This procedure addresses the contracture and has been shown to result in remodeling of the glenohumeral joint when concomitant conjoined tendon transfer is performed3. The procedure is performed with the patient in the lateral decubitus position. The procedure is initiated by elevating the medial border of the scapula by performing internal rotation and forward flexion of the arm. A 1-cm incision is made at the junction of the upper one-third and lower two-thirds of the medial border of the scapula, and space for insertion of a periosteal elevator is made with a hemostat. Sequentially, 5-mm and 10-mm periosteal elevators are inserted and are slid in a clockwise direction to release the muscle fibers from their origin on the undersurface of the scapula. After circumferential release, the internal rotators and the anterior shoulder joint capsule are stretched with gentle and progressive external rotation of the shoulder joint. A postoperative shoulder spica is applied with the shoulder in the corrected position. Operative alternatives to this technique include anterior open reduction of the glenohumeral joint with release of the pectoralis and subscapularis at their humeral insertions4,5. Arthroscopic subscapularis and anterior capsular release has also been described. Other extra-articular techniques, such as an open subscapularis slide from the lateral scapular border, have been described6,7. Losing strength of internal rotation at the shoulder is the main concern when releasing the subscapularis from its insertion. Internal rotation strength is maintained following this technique because the muscle-tendon unit ratio is unchanged. Benefits of performing this technique from the medial border include easier access to the tight superomedial septae of the subscapularis and reduced likelihood of iatrogenic injury to circumflex scapular neurovascular pedicle. Significant improvement in shoulder abduction and external rotation range (both passive and active) can be expected postoperatively. In a published series of 45 patients, the mean improvements in passive and active external rotation were 80° and 43°, respectively. Mean shoulder abduction improved from 101° preoperatively to 142° postoperatively. The aggregate 5-point Mallet Score improved from 12.8 points preoperatively to 18.5 points postoperatively. Glenohumeral remodeling can be expected in young children with Waters type-IV glenohumeral joint changes. Older pediatric patients may still have persistent internal rotation posture of the arm despite glenohumeral remodeling as a result of changes in the humeral torsion profile. Avoid going beyond the subscapularis ridge to prevent penetration into important neurovascular structures at the 1-o'clock and 3-o'clock positions for the right side.In patients with evidence of C7 involvement, such as weak wrist or elbow extension, postoperative immobilization should be in 40° of external rotation. These patients are at risk for developing postoperative external rotation contracture. MISR = minimally invasive subscapularis releaseBPBI = brachial plexus birth injuryCT = computed tomographyMRI = magnetic resonance imaging.

ObjectivesProximal hamstring tendon avulsion injuries are severe and potentially career-threatening for elite athletes. Until now, no data have been published on the non-operative treatment of this injury in elite athletes....

Background: Distal tibial allograft (DTA) reconstruction for glenoid bone loss (GBL) has gained popularity. While recent studies have demonstrated that glenoid concavity is an important factor in native glenohumeral stability, there remains a paucity of data regarding concavity restoration during reconstructive procedures for GBL and its biomechanical effect. Purpose: To compare the restoration of anterior glenohumeral stability and glenoid concavity after DTA and classic Latarjet procedures. Study Design: Controlled laboratory study. Methods: Nine human cadaveric specimens (mean age, 62.2 years; range, 52-69 years) underwent pretesting computed tomography (CT) to assess native glenoid concavity as determined by the glenoid depth and bony shoulder stability ratio (BSSR). GBL was created so the DTA and Latarjet graft could restore 100% of the native glenoid width. The rotator cuff tendons were loaded, and anterior stability testing was performed using a KUKA robot to apply a controlled anterior force with the shoulder in 90° of abduction and neutral external rotation. A motion capture system recorded humeral head translation. The following conditions were tested: intact, soft tissue Bankart lesion; bone loss model with DTA reconstruction; classic Latarjet procedure without conjoint tendon loaded; and classic Latarjet procedure with conjoint tendon loaded (sling effect). All specimens underwent posttesting CT to measure the BSSR of the DTA and Latarjet reconstructions. A repeated-measures analysis of variance was performed to compare the BSSR and anterior translations between the DTA and Latarjet reconstructions. Results: DTA produced greater concavity than the Latarjet procedure (BSSR: 0.45 vs 0.35; P < .001). There was no difference in anterior translation between the DTA and Latarjet procedures with the sling effect (5.1 mm vs 4.7 mm; P > .999). However, maximum anterior translation was decreased after the DTA procedure when compared with the Latarjet technique without the sling effect (5.1 mm vs 10.3 mm; P = .045). Conclusion: DTA produces a more concave reconstruction and decreased anterior translation compared with the flatter reconstruction produced by the classic Latarjet procedure without the sling effect. DTA and the classic Latarjet procedure with conjoint tendon loading, however, yielded equivalent reductions in anterior translation. Clinical Relevance: Distal tibial allograft reconstruction is a biomechanically equivalent alternative to the classic Latarjet due to the restoration of glenoid concavity in addition to glenoid width. Surgeons should consider the role of concavity when addressing glenohumeral instability with bone loss.

This article critically examines long-standing groin pain (LSGP) in physically active adults related to sports overload by analyzing terminology, pathophysiology, and treatment. This review is based on data from over 10,000 patients managed through a multidisciplinary algorithm. (LSGP) has been variably labeled, using terms that have led to inconsistencies in understanding its origin and management. Terms such as "Pubic Inguinal Pain Syndrome," "Sportsman's Groin," and "Athletic Pubalgia" have been proposed to standardize terminology and unify the classification of (LSGP). Pathophysiologically, (LSGP) is often due to tendinopathies affecting major tendons in the groin region, such as the adductors, iliopsoas, conjoint tendon, and inguinal ligament, often associated with weakness in the posterior wall of the inguinal canal. This condition frequently arises in sports involving abrupt directional changes and high-energy loads in the groin. Tendinopathies progress through reactive, reparative, or degenerative stages of tendinosis. Literature supports a multidisciplinary approach involving surgeons, physiotherapists, sports medicine physicians, and orthopedists for accurate diagnosis and effective treatment. Our algorithm focuses on both anatomical and functional factors in managing (LSGP). Initial conservative therapies aim to support tendon regeneration and load correction, while surgical interventions, such as laparoscopic hernioplasty, are reserved for non-responsive cases. From 2004 to 2024, 12,144 patients completed this protocol, with only 14% requiring surgery. Long-term follow-up demonstrated a low recurrence rate of tendinopathy and an absence of severe complications. Standardizing terminology, understanding pathophysiology, and utilizing a multidisciplinary approach are essential for optimizing the diagnosis and management of sports-related (LSGP).

BackgroundLong term studies have shown the Latarjet procedure to be successful in preventing re-dislocation in primary and recurrent anterior inferior shoulder instability. It provides stability through the sling effect of the conjoint tendon and the bone block. It is unclear whether augmentation with capsular repair provides an added benefit or leads to restricted range of external rotation. The primary aim of this study is to evaluate the effect of capsular repair in the open Latarjet procedure on rotational range of active external rotation in 90 degrees abduction (RoM-ER90). The secondary aim is to evaluate the effect on clinical outcomes including post-operative apprehension, instability, proprioception and shoulder function scores.MethodsThis is a multi-national retrospective cohort study including patients with a minimum of 6-months follow-up post Latarjet procedure performed between 2016 and 2020 recruited from 3 units in Australia and France. Range of motion was measured using a Proteck goniometer. Clinical outcomes were assessed using the Western Ontario Shoulder Instability Index (WOSI), Oxford shoulder, Oxford instability, Walch-Duplay and Rowe scores. Shoulder proprioception was assessed by the active relocation test described by Glendon et al.ResultsForty-four patients were included, median age was 29.5 years and 91% male. Three groups were assessed, open latarjet with no capsular repair (OL n = 11), open latarjet with capsular repair (OLCR n = 20), and arthroscopic Latarjet without capsular repair (AL n = 13). There was no apparent effect of capsular repair on the ROM-ER 90 in the open groups with a median (interquartile range) of 78° (72°, 90°) for OL and 84° (75°, 90°; P = 0.87) for OLCR groups. Capsular repair and arthroscopic approach did not affect the proportion of patients reporting shoulder apprehension (P = 0.52 and 0.48 respectively). There was no difference in proprioception between operative and non-operative sides for the OL group (P = 0.43). Proprioception was poorer on the operative side for the OLCR group (P = 0.04) but better on the operative side for the AL group (P = 0.08). WOSI scores for the open surgical groups were similar (OL = 78, OLCR = 80, P = 0.91) and when combined (median WOSI = 79) demonstrated greater stability than the AL group (P = 0.009). There was no evidence of an effect of capsular repair or arthroscopic approach on the Walch-Duplay, Oxford Instability, or Rowe scores.ConclusionsThere is no significant difference in ROM-ER 90 or WOSI score in patients who undergo the Latarjet procedure with and without capsular repair. The arthroscopic Latarjet may preserve proprioception but did not improve shoulder stability compared to the open Latarjet.Level of evidenceIII, retrospective cohort study.

Objective: With the remarkable advances in diagnostic ultrasound equipment, there is a growing need for ultrasound diagnosis of muscle and soft tissue injuries in sports injuries. Among these, hamstring strains are often difficult to treat and require early and accurate diagnosis. Injuries to the proximal part of the hamstring often take a long time to heal. For this reason, the diagnosis of proximal hamstring injuries is extremely important. The structure of the origin tendon is characteristic, and it is a complex in which the semitendinosus muscle (ST) of the medial hamstring and the long head of the biceps femoris muscle (BFLH) of the lateral hamstring share a conjoint tendon (CT). On the other hand, the semimembranosus muscle (SM) attaches to the ischial tuberosity independently. In this study, we created a classification of injury sites focusing on the origin tendon, and investigated the distribution of injury location, relationship to the player’s position, and the detection rate of ultrasound diagnosis. Material and Methods: We used ultrasound and MRI to diagnose 52 university men’s rugby players who had suffered a hamstring strain for the first time and investigated the distribution of the injured areas. We performed an ultrasound scan as the initial diagnosis and used MRI as a final diagnostic tool. A classification focusing on the origin of the muscle was created. First of all, it was divided into two types: the BFLH-ST complex type, which originates in the CT, and the SM type, which originates in the SMtendon. We also classified BFLH-ST complex damage, including CT damage, as Type I, a BFLH injury without CT injury as Type II, and a ST injury without CT injury as Type III. We then investigated the distribution of the injury location. The degree of ultrasound detection in each injury type was evaluated in three grades. The frequency of BFLH complex and SM injuries was investigated in players who played the forward (FW) and back (BK) positions. Results: The distribution was 40 limbs (77%) for BFLH-ST complex injury type and 12 limbs (23%) for SM injury type. In the BFLH complex type,19 limbs which met the Type I classification criteria for CT tear, 19 limbs met the Type II, and 2 limbs met the Type III. FWs had a higher incidence of SM injuries and BKs had a higher incidence of BFLH-ST complex injuries. With regard to the detection of muscle injuries via ultrasound, a high rate of detection was possible, except for a slight injury to the myofascial junction of the BFLH. Discussion: In terms of the distribution, the BFLH-ST complex, which shares the same origin tendon (i.e. CT), had a higher frequency of muscle tears than the SM. In addition, CT junction injuries occurred frequently in Type II as well as Type I (=CT injury). One possible cause is that the CT is subject to concentrated traction stress from both the medial and lateral hamstrings. With ultrasound, the detection rate of muscle damage around the BFLH-ST complex and SM originating tendon was high, suggesting that it is useful as an initial diagnosis. From this, it can be said that ultrasound is also useful for primary evaluation of “proximal hamstring injury”, which is prone to becoming severe. Conclusions: We created a classification system focusing on the originating tendons and clarified their incidence rates. In this study, ultrasound was found to be useful in the diagnosis of originating tendon injuries. We also identified the characteristic sonographic findings of each type.

Coracoid osteotomy approach for open free bone grafting of anterior glenoid defects

The long head of the biceps tendon (LHBT) has long been considered an intra-articular pain generator in the shoulder. While nonoperative treatment modalities can be acceptable for less severe presentations of LHBT pathology, surgical treatment options such as tenotomy and tenodesis remain controversial for recalcitrant cases. Open subpectoral biceps tenodesis allows for removal of all pathologic tissue from the bicipital groove, and all-suture anchor fixation utilizes a small caliber unicortical drill hole, which can potentially reduce the risk of a stress riser and iatrogenic fracture. In this study, we present a male patient with a history of left anterolateral shoulder pain worse overhead activities who has failed extensive physical therapy and other conservative measures. After extensive discussion regarding the treatment options, surgery in the form of shoulder arthroscopy, extensive debridement, rotator cuff repair, and open subpectoral biceps tenodesis was recommended and the patient had opted to proceed. For the purposes of this video, we focus on the open subpectoral biceps tenodesis portion of the procedure. Open subpectoral biceps tenodesis can reduce pain with low complication and high satisfaction rates. In this surgical technique study, we underline the importance position of the skin incision in axillary crease as well as skin tensioning when making the incision and retracting the conjoint tendon. We also highlight a locking lasso loop and double luggage tag fixation technique using a double-loaded all-suture anchor for the biceps tenodesis. We also provide technique commentary for appropriate restin tension of the LHBT. Finally, we review outcomes, postoperative management, rehabilitation protocol, and technique pearls and pitfalls. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

The Trillat procedure, initially described by Albert Trillat, is historically one of the first techniques for addressing recurrent anterior shoulder instability, incorporating fascinating biomechanical mechanisms. After lowering, medializing, and fixing the coracoid process to the glenoid neck, the subcoracoid space is reduced, the subscapularis lowered, and its line of pull changed, accentuating the function of the subscapularis as a humeral head depressor centering the glenohumeral joint. Furthermore, the conjoint tendon creates a 'seatbelt' effect, preventing anteroinferior humeral head dislocation. Even though contemporary preferences lean towards arthroscopic Bankart repair with optional remplissage, bone augmentation, and the Latarjet procedure, enduring surgical indications remain valid for the Trillat procedure, which offers joint preservation and superior outcomes in two distinct scenarios: (i) older patients with massive irreparable cuff tears and anterior recurrent instability with an intact subscapularis tendon regardless of the extent of glenoid bone loss; (ii) younger patients with instability associated shoulder joint capsule hyperlaxity without concomitant injuries (glenoid bone loss, large Hill-Sachs lesion). Complications associated with the Trillat procedure include recurrent anterior instability, potential overtightening of the coracoid, leading to pain and a significant reduction in range of motion, risk of subcoracoid impingement, and restriction of external rotation by up to 10°, a limitation that is generally well-tolerated. The Trillat procedure may be an effective alternative technique for specific indications and should remain part of the surgical armamentarium for addressing anterior shoulder instability.

Ultrasonographic measurements of gastro-soleus fascia thickness in midportion Achilles tendinopathy: A case-control study

To introduce a new magnetic resonance imaging (MRI) sign, termed the Cobra sign, and identify its diagnostic metrics. The secondary aim was to demonstrate that this sign can be a source of false evaluation of tendon retraction in patients with proximal hamstring avulsion injury. This retrospective cohort study targeted patients surgically treated for proximal hamstring avulsion injury from January 2019 to June 2023. The MRI Cobra sign was defined as a wavy curved T2-hypointense band with the free end folding distally over itself, resembling a cobra head. The primary outcome measure was the characterization of the Cobra sign in patients with proximal hamstring avulsion injury. The secondary outcome was the association of this sign with tendon retraction. The study included 81 proximal hamstring avulsion injury patients (mean age of 45.7, SD = 13.9), with 41 (50.6%) complete avulsions, 33 semimembranosus, and 7 conjoint tendons. The MRI Cobra sign was found in 25 patients (17 semimembranosus and 8 complete). It was confirmed surgically only in semimembranosus cases. It demonstrated 51.5% sensitivity and 83.3% specificity for isolated semimembranosus avulsions, with a significant positive likelihood ratio of 3.0. MRI retraction was 10.05 cm (±3.0), reducing to 7.9 cm (±2.5) on surgical measurement (mean difference = 2.0 cm, p < 0.001). The regression analysis confirmed MRI retraction's influence on the Cobra sign, with a 1.4 odds increase per unit (p < 0.001). In linear regression analysis, each unit increase in MRI retraction corresponded to a 79% increase in surgical retraction (coefficient 0.7, t = 11.1, p < 0.001). The Cobra sign demonstrated acceptable diagnostic accuracy for isolated semimembranosus avulsion, with a high specificity of 83.3%, a low sensitivity of 51.5%, and a positive likelihood ratio of 3.0. The presence of the Cobra sign indicates an overestimated MRI retraction by approximately 21%. Level III.