Background Accurate assessment of the critical shoulder angle (CSA) is important in clinical evaluation of degenerative rotator cuff tears. This study analyzed the influence of radiographic viewing perspective on the CSA, developed a classification system to identify malpositioned radiographs, and assessed the relationship between the CSA and demographic factors. Methods Glenoid height, width and retroversion were measured on 3D CT reconstructions of 68 cadaver scapulae. A digitally reconstructed radiograph was aligned perpendicular to the scapular plane, and retroversion was corrected to obtain a true antero-posterior (AP) view. In 10 scapulae, incremental anteversion/retroversion and flexion/extension views were generated. The CSA was measured and a clinically applicable classification system was developed to detect views with >2° change in CSA versus true AP. Results The average CSA was 33±4°. Intra- and inter-observer reliability was high (ICC≥0.81) but decreased with increasing viewing angle. Views beyond 5° anteversion, 8° retroversion, 15° flexion and 26° extension resulted in >2° deviation of the CSA compared to true AP. The classification system was capable of detecting aberrant viewing perspectives with sensitivity of 95% and specificity of 53%. Correlations between glenoid size and CSA were small (R≤0.3), and CSA did not vary by gender (p=0.426) or side (p=0.821). Conclusions The CSA was most susceptible to malposition in ante/retroversion. Deviations as little as 5° in anteversion resulted in a CSA >2° from true AP. A new classification system refines the ability to collect true AP radiographs of the scapula. The CSA was unaffected by demographic factors.

This study confirms previous observations that open shoulder stabilization using a subscapularis tenotomy may lead to atrophy and fatty infiltration of the subscapularis muscle, resulting in postoperative subscapularis dysfunction. As expected, arthroscopic procedures do not significantly compromise clinical subscapularis function and structural integrity. However, no significant differences were observed in the overall outcome.

Open reconstruction of anteroinferior chronic glenoid defects via a complete SSC tenotomy using an iliac crest bone grafting technique allows an anatomic reconstruction of the anteroinferior glenoid with good and excellent clinical results. The anterior approach may lead to atrophy and fatty infiltration of the SSC muscle despite an intact tendon. However, this did not affect the results in terms of stability.

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