Biceps tendon autograft augmentation for rotator cuff and instability procedures: a narrative review.

Rotator cuff tears (RCT) and instability are the most common surgically treated shoulder pathologies. The concept of augmentation using the long head of the biceps tendon (LHBT) autograft was created to improve the results of surgical treatment of these pathologies, especially in cases of chronic and massive injuries. The popularity of using the LHBT for augmentation is evidenced by the significant number of publications on this topic published in the last 3 years; however, only one systematic review has been published regarding only LHBT augmentation for massive RCTs. Several studies comparing partial repair with partial repair and additional LHBT augmentation for RCT showed superior clinical outcomes and lower re-tear rates when LHBT augmentation was performed. There is a rising popularity of using LHBT as an autograft to perform superior capsule reconstruction (SCR) in case of irreparable rotator cuff tears. In recent years, shoulder stabilization by arthroscopic Bankart repair with biceps augmentation has been promoted with very promising short-term results. The evidence provided by studies appears to be sufficient to recommend the use of LHBT for augmentation whenever necessary; however, larger studies with long-term follow-up are needed.

Remplissage May Decrease the Redislocation Rate After Arthroscopic Bankart Repair in Patients With an Engaging Hill-Sachs Defect: A Systematic Review and Meta-analysis of Studies With Minimal 2-Year Follow-up.

BACKGROUND: The redislocation rate after arthroscopic Bankart repair (BR) among patients with a Hill-Sachs lesion (HSL) may be reduced with the use of remplissage. PURPOSE: To investigate the outcomes of adding remplissage to an arthroscopic BR in patients with concomitant HSL. STUDY DESIGN: Meta-analysis; Level of evidence, 3. METHODS: PubMed and ScienceDirect databases were searched between February 2022 and April 2023 with the terms "remplissage" and "shoulder instability" according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The inclusion criteria were formed using the population, intervention, control, and outcome method; the investigation included studies that compared BR with and without remplissage and had ≥24 months of follow-up. RESULTS: From 802 articles found during the initial search, 7 studies with a total of 837 patients-558 receiving isolated BR (BR group) and 279 receiving BR with remplissage (BR+REMP)-were included. The probability of recurrence of instability among patients with an engaging HSL was significantly diminished in the BR+REMP group compared with the BR group (odds ratio, 0.11; 95% CI, 0.05 to 0.24; P < .001). Regarding shoulder range of motion, the BR+REMP group achieved increased forward flexion (mean difference [MD], 1.97°; 95% CI, 1.49° to 2.46°; P < .001) and decreased external rotation in adduction (MD, -1.43°; 95% CI, -2.40° to -0.46°; P = .004) compared with the BR group. Regarding patient-reported outcome measures, the BR+REMP group had Rowe (MD, 2.53; 95% CI, -1.48 to 6.54; P = .21) and Western Ontario Shoulder Instability Index (WOSI) (MD, -61.60; 95% CI, -148.03 to 24.82; P = .162) scores that were comparable with those of the BR group. CONCLUSION: Remplissage resulted in a 9-fold decrease in the recurrence of instability after arthroscopic BR in patients with HSL. Remplissage not only led to an increase in forward flexion but also only slightly limited patients' external rotation in adduction. WOSI and Rowe scores after remplissage at the final 24-month follow-up were comparable with those obtained after isolated Bankart repair.

Tethered vagina syndrome: massive urine loss caused by bladder neck scarring cured by skin graft.

The bladder neck area of the vagina is known as the "zone of critical elasticity" (ZCE). Adequate vaginal elasticity at ZCE is required for the oppositely-acting muscles to independently close the distal urethra and bladder neck. Scarring at ZCE "tethers" the more powerful posterior muscles to the anterior muscles and the bladder neck is forcibly pulled open, resulting in massive urine loss. This condition is known as "tethered vagina syndrome" (TVS). In developed countries, the main cause of TVS is iatrogenic. Vaginal repairs, vaginal mesh, may cause scarring at ZCE and this directly links the oppositely-acting muscle forces. Over-elevated Burch colposuspensions may stretch the ZCE to the point where its elasticity is lost so the muscles can no longer function independently. The treatment is to dissect the vagina clear of the scarring and to insert a skin graft to the bladder neck to restore ZCE elasticity. In developing countries, extensive trauma to the vagina and bladder from obstructed childbirth can cause obstetric fistulas. In up to 40-50% of these women, there is ongoing massive urine loss after the fistula has been successfully closed. Performing a prophylactical skin graft during fistula closure if there is vaginal tissue deficit is proving to be revolutionary. In women with Goh type 4 fistula (n=45), 46% were cured (full dryness) against an expected 19%. The same operation can produce equally dramatic cures in women who continue to leak urine after successful fistula repair.

Tension-free artisan tape: a low-cost option for cure of pelvic organ prolapse and stress incontinence.

The Lancet PROSPECT Trial has shown that vaginal repair has dismal cure rates of some 20% at 12 months. Meanwhile 10-year data from collagen creating ligament repair methods (implanted mini-sling tapes), with no vaginal excision, report very high, long-term cure rates. The reason for conserving the vagina, is that the vagina's main function is to transmit the muscle forces for external urethral closure or opening. Ligaments provide the main structural support for the organs, much like a suspension bridge. Collagen is the key structural component of the ligaments which structurally support the organs. However, collagen breaks down after the menopause and is excreted as hydroxyproline. If sufficient collagen breaks down, the ligaments weaken, and this explains the 80% failure rates for native ligament in the Lancet PROSPECT Trial. Whereas satisfactory results for pelvic organ prolapse (POP) and symptoms have been obtained with native ligament repair in premenopausal women, it has been shown that collagen-creating ligament repair method, for example, precisely inserted tapes, is required in older women. Tension-free" artisan tapes work in the same way as commercial tape kits which have been used to cure stress urinary incontinence (SUI) and POP. The "tension-free" artisan tape results for POP at three years were encouraging, but were applied only in a small number of cases. Very recently, long-term (5.7 years) tension-free artisan tape data has become available from artisan SUI surgery. Results from 93 women using an artisan transobturator tape (TOT) achieved a cure rate of 91.3% at a mean of 5.7 years postoperatively. The only significant complication was a 4.3% erosion rate. The implications are that tension-free artisan tape for POP is also likely to be long-lasting. Another implication is the cost, which, for each tape, is a few Euros. The low cost allows the artisan method to be applied even in the poorest nations.

A unifying modelling of multiple land degradation pathways in Europe.

Land degradation is a complex socio-environmental threat, which generally occurs as multiple concurrent pathways that remain largely unexplored in Europe. Here we present an unprecedented analysis of land multi-degradation in 40 continental countries, using twelve dataset-based processes that were modelled as land degradation convergence and combination pathways in Europe's agricultural (and arable) environments. Using a Land Multi-degradation Index, we find that up to 27%, 35% and 22% of continental agricultural (~2 million km2) and arable (~1.1 million km2) lands are currently threatened by one, two, and three drivers of degradation, while 10-11% of pan-European agricultural/arable landscapes are cumulatively affected by four and at least five concurrent processes. We also explore the complex pattern of spatially interacting processes, emphasizing the major combinations of land degradation pathways across continental and national boundaries. Our results will enable policymakers to develop knowledge-based strategies for land degradation mitigation and other critical European sustainable development goals.

Climbing anxiety scale (CAS-20): Preliminary development and validation.

Anxiety has been the primary focus of emotion research in sport psychology. Most of the existing anxiety measures focus on the competition related anxiety. Little is known about the way in which anxiety affects athletic outcomes in extreme sports. We contribute to the literature on anxiety in extreme sports by: (1) developing and providing a preliminary validation for a novel, theoretically anchored sport climbing inventory, Climbing Anxiety Scale (CAS-20), among an international sample of rock-climbers (N = 153); and (2) providing preliminary evidence on its factorial and criterion-related validity. Our investigation includes two phases. The first phase (6 clinical and sport psychology experts) included the development and expert review of a climbing specific anxiety scale. The second phase (N = 153) offers preliminary evidence pertaining to the measure's reliability, factorial, convergent and criterion related validity. Factorial validity was investigated by deploying a series of confirmatory factorial analyses. Convergent and discriminatory validity were examined by comparing the scale's associations with a general anxiety measure, a sport anxiety measure, as well as climbing self-efficacy. Criterion-related validity was estimated by examining its relationship with rock-climbing performance. We contribute to the general domain of sport and athletic research by developing a sport-specific anxiety measure, investigating whether and how anxiety comes into play in rock-climbing, a high-risk sport. This scale can be used for assessing anxiety in climbing and monitoring the impact of an interventions designed to reduce these symptoms.

Long head of the biceps tendon versatility in reconstructive shoulder surgery: a narrative review of arthroscopic techniques and their biomechanical principles with video presentation.

The management of the long head of the biceps tendon (LHBT) during shoulder arthroscopy has been a subject of controversy for many years, with evolving discussions and trends. Despite long-standing debate, the nature of the surgical indication regarding how to treat concomitent LHBT injuries has undergone changes in recent years. It now extends beyond the timing of tenotomy to encompass considerations of alternative methods for preserving the LHBT, along with an ongoing exploration of how it can be effectively utilized in reconstructive shoulder surgery. Recent techniques describe approaches to using LHBT in a wide range of procedures, from shoulder instability to rotator cuff tears. Additionally, LHBT-based reconstructive techniques have surfaced for addressing what were formerly denoted as irreparable rotator cuff tears. While current literature provides detailed anatomical descriptions of the LHBT and many reports of novel, advanced techniques, there is still much debate regarding the decision-making process in each case. Because of the growing number of emerging techniques and the escalating debate in the subsequent paper, a decision has been made to present the current literature review concerning the potential utilization of LHBT in shoulder arthroscopy. In a dedicated video, we demonstrate the main arthroscopic techniques employed by the authors in their daily practice.

Dynamic Anterior Stabilization with Hill-Sachs Remplissage Can be Employed in Skeletally Immature Patients-Operative Technique.

BACKGROUND: Numerous studies indicate that glenoid bony augmentation raises the risk of complications during and after surgery. On the other hand, repairing the labrum alone in cases with subcritical glenoid bone loss results in recurrent instability and persistent apprehension. As a result, recent advancements in shoulder instability surgery prioritize fully restoring the anterior shoulder restraint. OPERATIVE TECHNIQUE: A novel method for treating recurrent anterior shoulder instability with subcritical glenoid bone loss and off-track Hill-Sachs lesion in skeletally immature patients is suggested: the use of dynamic anterior stabilization technique incorporating the long head of the biceps tendon onto the anterior glenoid rim via trans-subscapular transfer, in conjunction with Hill-Sachs remplissage. A practical, step-by-step surgical technique for a complete reconstruction of the anterior capsule-labral-ligamentous complex is provided. This involves utilizing a soft-tissue dynamic anterior sling, achieved through the trans-subscapularis transfer of the long head of the biceps tendon at the glenoid level. The procedure concludes with a Hill-Sachs remplissage to further prevent off-track events and alleviate apprehension. CONCLUSION: Dynamic anterior stabilization is a suitable approach for addressing recurring anterior shoulder instability in skeletally immature patients who have subcritical glenoid bone loss and bipolar bone lesions.

Evaluation of Total Hip Arthroplasty Performed from a Lateral Approach as Optimal Treatment for Femoral Neck Fractures in Elderly, Active Patients.

BACKGROUND: The aim of the study was to evaluate total hip arthroplasty in terms of clinical and functional outcomes, rate of complications and hospitalization, as a treatment of choice for displaced femoral neck fractures. MATERIALS AND METHODS: We retrospectively reviewed the data of 526 patients with THA operated on in our department between January 2017 and December 2021. Clinical examinations, functional outcome assessment and radiographic evaluation were performed during follow-up. Patients were evaluated at the following time points: postoperatively at 3 days, 6 weeks, 12 weeks and 1 year, and we recorded surgery related data, complications, Visual Analogue Scale pain score, Harris Hip Score, the Western Ontario McMaster Osteoarthritis Index, and range of motion. RESULTS: Low intraoperative blood loss, short surgical time, short hospitalization, early mobilization of the patient and a good range of motion testify that the modified direct lateral approach is a valuable procedure for the patients with THA. A VAS score evaluated at 3 days and 6 weeks indicated a very good overall postoperative experience. The HHS and Womac scores were evaluated at 6 weeks, 12 weeks and 1 year and showed excellent results. CONCLUSION: THA for active patients with a displaced fracture of the femoral neck is an excellent treatment option which provides lasting pain relief, a high level of function and very low rates of reoperation.

Primary affective systems and personality: Disentangling the within-person reciprocal relationships.

Personality traits and affective functioning have been closely linked. Empirical evidence suggests that the Five-Factor Model traits have been linked with Panskepp's six primary affective systems, as measured by the Affective Neuroscience Personality Scales: SEEKING, PLAY, CARE (positive emotions) and FEAR, SADNESS, ANGER (negative emotions). OBJECTIVE: The present work investigated the dynamic relations between primary affective systems and FFM personality. METHOD: Drawing from a sample of 220 participants completing surveys on four consecutive days, we used the random intercept cross-lagged panel model (RI-CLPM) to investigate the associations between primary affective systems and personality traits. RESULTS: The following associations were identified: bidirectional associations between negative emotions and neuroticism, unidirectional associations from SEEKING to openness and from agreeableness to three primary affective systems. No significant associations were observed between extraversion and primary affective systems. CONCLUSIONS: Our findings highlight the importance of disentangling the within-person effects when examining the relationship between primary affective systems and personality.

Partial Articular Supraspinatus Tendon Avulsion Repair and Patch: A Technical Note for Augmenting the Supraspinatus Reinsertion with the Long Head of the Biceps Tendon.

BACKGROUND: There is no clear consensus on the treatment of partial articular-sided supraspinatus tendon avulsions. Debridement alone might not be sufficient to prevent further tendon degradation or alleviate patient complaints. Direct repair using a suture anchor without treating the concomitant conditions of the long head of the biceps tendon might come with residual anterior shoulder pain or even further loss of function in cases of failed repair. The purpose of the present study is to describe an arthroscopic technique by which the long head of the biceps tendon can be included in the partial articular-sided supraspinatus tendon avulsion repair. TECHNIQUE PRESENTATION WITH VIDEO: In this technical note we describe the arthroscopic repair and augmentation with tenotomized biceps of partial supraspinatus tendon tears to address three main concepts for successful rotator cuff repairs, namely rotator cuff biologic augmentation, tendon to bone healing and postoperative pain prevention. CONCLUSION: The biceps tendon is a mechanically robust, locally available autograft that can be used in borderline partial articular-sided supraspinatus tendon avulsions in order to biologically augment healing at the tendon-bone interface without any immunogenic reactions or morbidity following harvesting.

Childhood maltreatment and emotion regulation in everyday life: an experience sampling study.

Childhood maltreatment is a major risk factor for psychopathology, and increasing evidence suggests that emotion regulation is one of the underlying mechanisms. However, most of this evidence comes from single assessments of habitual emotion regulation, which may not overlap with spontaneous emotion regulation in daily life and which fail to account for within-individual variability in emotion regulation across multiple contexts. In the present study, we investigated the relation between history of childhood maltreatment, positive and negative affect, and multiple dimensions of spontaneous emotion regulation (strategy use, emotion regulation goals, emotion regulation success and effort) in everyday life, using experience sampling method (3 assessments/day, for 10 consecutive days), in a sample of healthy volunteers (N = 118). Multilevel modeling results indicated that childhood maltreatment was associated with lower positive affect and higher negative affect. Childhood maltreatment was also related to lower use of reappraisal and savoring (but not suppression, rumination and distraction), reduced emotion regulation success (but not effort), as well as lower levels of and higher within-individual variability of hedonic (but not instrumental) emotion regulation goals. These results provide ecological evidence for multiple differences in emotion regulation in individuals with a history of childhood maltreatment.

Events-Affect-Personality: A Daily Diary Investigation of the Mediating Effects of Affect on the Events-Personality Relationship.

Our 10-day diary investigation anchored in dynamic personality theories, such as Whole Trait Theory examined (a) whether within-person variability in two broad personality traits Extraversion and Neuroticism is consistently predicted by daily events, (b) whether positive and negative affect, respectively partly mediate this relationship and (c) the lagged relationships between events, and next day variations in affect and personality. Results revealed that personality exhibited significant within-person variability, that positive and negative affect partly mediate the relationship between events and personality, affect accounting for up to 60% of the effects of events on personality. Additionally, we identified that event-affect congruency was accountable for larger effects compared to event-affect non-congruency.

Combined Reconstruction of the Medial Patellofemoral Ligament and Medial Quadriceps Tendon Femoral Ligament in Skeletally Immature Patients.

The medial patellofemoral ligament (MPFL) reconstruction is challenging in skeletally immature patients due to the anatomical particularities at this age. Recently, the medial quadriceps tendon femoral ligament (MQTFL) has received great interest for its ability to restrain the patella's instability along with MPFL. No gold-standard technique has been described so far to reconstruct both MPFL and MQTFL in skeletally immature patients. We present a technique to safely reconstruct the MPFL and the MQTFL in children and adolescents. The gracilis tendon autograft is harvested and passed through the medial collateral ligament as a pulley. The free ends of the graft are passed through the patella by an "L-shaped tunnel" and tied to itself. The other free end of the graft is pulled through the medial third of the quadriceps tendon and tied to itself to achieve tension. Our technique is reproducible, implant-free and avoids complications associated with femoral drilling and graft fixation. However no long-term follow-up results are available.

Machine learning-based prediction and assessment of recent dynamics of forest net primary productivity in Romania.

While the analysis of spatio-temporal changes in the net primary productivity (NPP) of forests can provide critical information on carbon cycle and climate change, these ecological trends have remained unclear in many countries worldwide, including Romania. By using complex (satellite, forest and climate) data, many sophisticated (machine learning) algorithms and some widely applied (the Mann-Kendall test and Sen's slope estimator) statistical procedures, this study investigates, for the first time, recent forest NPP trends (1987-2018) that occurred in Romania, in relation to climate change that affected the country over the past decades. Following the modelling, mapping and assessment of NPP dynamics, results showed almost exclusively positive trends for this ecological parameter, which accounts for ∼99% of all forest NPP changes that occurred throughout the country, after 1987. Interestingly, almost three quarters (∼73%) of all NPP increasing trends are statistically significant, which indicates that Romania's forests have recently experienced a large-scale improvement in carbon fluxes and stocks. Investigations of eco-climatic relationships suggest that climate change has partially contributed to these surprising NPP dynamics observed in recent decades. All these findings can provide valuable information for forest management and for many stakeholders and policymakers who operate in the forestry and climate fields in Romania.

Antegrade intramedullary locking nail in the management of proximal and middle thirds of humeral diaphyseal fractures.

PURPOSE: The aim of the study was to evaluate the antegrade intramedullary locking nail osteosynthesis for the treatment of the proximal and middle thirds of humeral shaft fractures. METHODS: A retrospective study was made on 218 patients diagnosed with humeral diaphysis fractures who undergo surgery with antegrade intramedullary locking nail between January 2017 and December 2021. The clinical follow-up started two days after surgery and continued at one month, three months, six months and one year. The functional recovery evaluation was performed using visual analogue scale (VAS) score, Rating Scale of American Shoulder and Elbow Surgeons Form (ASES), Mayo Elbow Performance Score System (MEPS) and rate of complications. RESULTS: Low intra-operative blood loss, short operation time, short hospitalisation, early mobilisation of the patient and high union rate imposed intramedullary nailing as a standard procedure for the treatment of proximal and middle thirds of humeral diaphyseal fractures in the past years, and the union rate was 99.5%. VAS score evaluated at one month, three months and six months indicated a very good overall post-operative experience. The ASES and MEPS score were evaluated at six months and one year and showed excellent results. All the patients (except 1 case) were able to return to their previous jobs within six months. CONCLUSION: Humeral nailing is associated with early return to function of the upper limb, with very good clinical and functional outcomes of the shoulder and elbow. This method could be considered the best surgical option for the management of proximal middle humeral fractures.

Modified Dynamic Anterior Stabilization (DAS) and Hill-Sachs Remplissage for the Treatment of Recurrent Anterior Shoulder Dislocation.

The optimal treatment for recurrent glenohumeral instability is a subject under debate. The recently described arthroscopic technique for dynamic anterior stabilization (DAS) fills the treatment indication gap between reconstructive bony procedures and soft tissue stabilization. However, indications for DAS are considered limited or not appropriate for patients with recurrent shoulder dislocations caused by severe bone defects. In this Technical Note, we present a modified all-arthroscopic DAS technique with added infraspinatus and posterior capsule remplissage to correct the extra-articular Hill-Sachs defect in a patient with recurrent dislocations and off-track bony lesions. The patient requested an alternative treatment option, other than the complication-prone Latarjet procedure.

Global changes in soil organic carbon and implications for land degradation neutrality and climate stability.

Soil organic carbon (SOC) is a critical indicator for healthy and fertile lands across the world. It is also the planet's largest terrestrial carbon pool, so any changes of this pool may have profound implications for both land productivity and climate stability. However, SOC changes have so far remained largely unexplored, although their understanding is essential for many international environmental policies. Here we investigate for the first time recent global SOC changes, based on some SOC stock interannual data that were processed for the 2001-2015 period on a planetary scale. We analysed the global SOC dynamics using the Mann-Kendall test and Sen's slope estimator, which are widely acknowledged to be reliable geostatistical tools for detecting various environmental trends from global to local scale. We explored SOC changes via three metrics (averages, quantities, areas) of negative and positive trends, but also of the balance between soil carbon trends, a key statistic for monitoring land quality stability and soil-atmosphere carbon fluxes in the global environmental policies. Globally, we estimated a net average decrease of -58.6 t C km2 yr-1, a total loss of ~3.1 Pg C, and an area affected by net SOC losses of ~1.9 million km2. Using this triple statistic, we found that 79% of countries worldwide have been affected by net declines of SOC after 2001, which suggests that halting land degradation and mitigating climate change through the SOC pathway are still far from being achieved by international policies.

Arable lands under the pressure of multiple land degradation processes. A global perspective.

While agricultural systems are a major pillar in global food security, their productivity is currently threatened by many environmental issues triggered by anthropogenic climate change and human activities, such as land degradation. However, the planetary spatial footprint of land degradation processes on arable lands, which can be considered a major component of global agricultural systems, is still insufficiently well understood. This study analyzes the land degradation footprint on global arable lands, using complex geospatial data on certain major degradation processes, i.e. aridity, soil erosion, vegetation decline, soil salinization and soil organic carbon decline. By applying geostatistical techniques that are representative for identifying the incidence of the five land degradation processes in global arable lands, results showed that aridity is by far the largest singular pressure for these agricultural systems, affecting ~40% of the arable lands' area, which cover approximately 14 million km2 globally. It was found that soil erosion is another major degradation process, the unilateral impact of which affects ~20% of global arable systems. The results also showed that the two degradation processes simultaneously affect an additional ~7% of global arable lands, which makes this synergy the most common form of multiple pressure of land degradative conditions across the world's arable areas. The absolute statistical data showed that India, the United States, China, Brazil, Argentina, Russia and Australia are the most vulnerable countries in the world to the various pathways of arable land degradation. Also, in terms of percentages, statistical observations showed that African countries are the most heavily affected by arable system degradation. This study's findings can be useful for prioritizing agricultural management actions that can mitigate the negative effects of the two degradation processes or of others that currently affect many arable systems across the planet.

The V-shaped subscapularis tenotomy for anatomic total shoulder arthroplasty.

PURPOSE: Management of the subscapularis tendon during anatomic total shoulder arthroplasty (TSA) remains controversial. In our unit, subscapularis tenotomy is the preferred technique; however, the potential for tendon gapping and failure is recognised. The purpose of this study is to describe and provide early clinical results of a novel, laterally based V-shaped tenotomy (VT) technique hypothesised to provide greater initial repair strength and resistance to gapping than a transverse tenotomy (TT), with both clinically and radiologically satisfactory post-operative tendon healing and function. METHODS: A retrospective study of patients who underwent primary TSA with VT over a three year period was performed using shoulder and subscapularis-specific outcome scores, radiographs, and ultrasound. A separate cohort of patients who underwent TSA using a subscapularis sparing approach was also reviewed to provide comparative clinical outcomes of a group with TSA and an un-violated subscapularis. RESULTS: Eighteen patients were reviewed at mean 30.4 months (± 11.7). Constant (78.2 ± 12.3), UCLA (8.4 ± 1.5), pain VAS (2.3 ± 2.8), and strength in internal rotation were no different from the comparison group. Likewise, neither were the clinical outcomes of range-of-motion, belly-press, lift-off, and shirt-tuck tests. One patient (5.5%) was found to have a failed subscapularis repair on ultrasound. CONCLUSION: VT during TSA appears to provide healing rates at least equal to those reported for TT, and not dissimilar from those of lesser tuberosity osteotomy. Clinical outcomes are comparable to reported results in the literature for alternative techniques, and not different from those observed here in a comparison cohort with TSA performed without violating the subscapularis tendon. VT therefore potentially offers a more effective and secure tendon repair than a traditional TT, with at least comparable clinical outcomes.