Ehlers-Danlos Syndrome (EDS) is a family of connective tissue disorders resulting from a collagen formation defect. The prevalence of EDS is between 0.2/1,000 to 10/1000 people, with the hypermobile type accounting for up to 80-90% of EDS patients.48Tinkle B. Castori M. Berglund B. Cohen H. Grahame R. Kazkaz H. et al.Hypermobile Ehlers-Danlos syndrome (a.k.a. Ehlers-Danlos syndrome Type III and Ehlers-Danlos syndrome hypermobility type): Clinical description and natural history.Am J Med Genet C Semin Med Genet. 2017; 175: 48-69https://doi.org/10.1002/ajmg.c.31538Crossref PubMed Scopus (290) Google Scholar The most common manifestations of hypermobile EDS (hEDS) include generalized ligamentous hyperlaxity, recurrent symptomatic subluxations/dislocations, tendon ruptures, chronic musculoskeletal pain (including fibromyalgia), and functional impairment.48Tinkle B. Castori M. Berglund B. Cohen H. Grahame R. Kazkaz H. et al.Hypermobile Ehlers-Danlos syndrome (a.k.a. Ehlers-Danlos syndrome Type III and Ehlers-Danlos syndrome hypermobility type): Clinical description and natural history.Am J Med Genet C Semin Med Genet. 2017; 175: 48-69https://doi.org/10.1002/ajmg.c.31538Crossref PubMed Scopus (290) Google Scholar,49Tinkle B.T. Levy H.P. Symptomatic Joint Hypermobility: The Hypermobile Type of Ehlers-Danlos Syndrome and the Hypermobility Spectrum Disorders.Med Clin North Am. 2019; 103: 1021-1033https://doi.org/10.1016/j.mcna.2019.08.002Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar hEDS can be described by its three chronological phases: the "hypermobility" phase, "pain" phase that begins during adolescence, and "stiffness" phase, appearing in adulthood and characterized by progressive limitations in joint motion.16Castori M. Camerota F. Celletti C. Danese C. Santilli V. Saraceni V.M. et al.Natural history and manifestations of the hypermobility type Ehlers-Danlos syndrome: a pilot study on 21 patients.Am J Med Genet A. 2010; 152A: 556-564https://doi.org/10.1002/ajmg.a.33231Crossref PubMed Scopus (157) Google Scholar Joint hypermobility can be quantified using the Beighton score (Table 1).4Alter M. Science of Flexibility. 3 ed. Champaign, IL: Human Kinetics Publisher, Inc.; 2004. (ISBN No. 0-7360-4898-7)Google Scholar,9Beighton P. Solomon L. Soskolne C.L. Articular mobility in an African population.Ann Rheum Dis. 1973; 32: 413-418Crossref PubMed Google Scholar,21Colombi M. Dordoni C. Chiarelli N. Ritelli M. Differential diagnosis and diagnostic flow chart of joint hypermobility syndrome/ehlers-danlos syndrome hypermobility type compared to other heritable connective tissue disorders.Am J Med Genet C Semin Med Genet. 2015; 169C: 6-22https://doi.org/10.1002/ajmg.c.31429Crossref PubMed Scopus (80) Google Scholar The shoulder is among the most commonly affected joints,17Castori M. Camerota F. Celletti C. Grammatico P. Padua L. Ehlers-Danlos syndrome hypermobility type and the excess of affected females: possible mechanisms and perspectives.Am J Med Genet A. 2010; 152A: 2406-2408https://doi.org/10.1002/ajmg.a.33585Crossref PubMed Scopus (81) Google Scholar,43Schwartz D.G. Goebel S. Piper K. Kordasiewicz B. Boyle S. Lafosse L. Arthroscopic posterior bone block augmentation in posterior shoulder instability.J Shoulder Elbow Surg. 2013; 22: 1092-1101https://doi.org/10.1016/j.jse.2012.09.011Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar due to its reliance on static and dynamic soft tissue stabilizers and lack of inherent bony stability. This also makes management challenging, as stabilization of pathologic recurrent shoulder instability with lax soft tissues increases the risk of recurrence.Table 1Beighton Score for Joint HypermobilityBeighton ScaleLeftRightPassive dorsiflexion and hyperextension of 5th MCP Joint beyond 90º11Passive apposition of the thumb to flexor aspect of forearm11Passive hyperextension of elbow beyond 10º11Passive hyperextension of knee beyond 10º11Active forward flexion of trunk with knees fully extended so palms of hands rest flat1Total/9 Open table in a new tab Although posterior shoulder instability accounts for <10% of all cases of shoulder instability,6Antosh I.J. Tokish J.M. Owens B.D. Posterior Shoulder Instability.Sports Health. 2016; 8: 520-526https://doi.org/10.1177/1941738116672446Crossref PubMed Scopus (62) Google Scholar,11Bradley J.P. McClincy M.P. Arner J.W. Tejwani S.G. Arthroscopic capsulolabral reconstruction for posterior instability of the shoulder: a prospective study of 200 shoulders.Am J Sports Med. 2013; 41: 2005-2014https://doi.org/10.1177/0363546513493599Crossref PubMed Scopus (136) Google Scholar,23DiMaria S. Bokshan S.L. Nacca C. Owens B. History of surgical stabilization for posterior shoulder instability.JSES Open Access. 2019; 3: 350-356https://doi.org/10.1016/j.jses.2019.08.008Abstract Full Text Full Text PDF Scopus (21) Google Scholar patients with hEDS are predisposed to both posterior and multidirectional shoulder instability.33Homere A. Bolia I.K. Juhan T. Weber A.E. Hatch G.F. Surgical Management of Shoulder and Knee Instability in Patients with Ehlers-Danlos Syndrome: Joint Hypermobility Syndrome.Clin Orthop Surg. 2020; 12: 279-285https://doi.org/10.4055/cios20103Crossref PubMed Scopus (7) Google Scholar,37Johnson S.M. Robinson C.M. Shoulder instability in patients with joint hyperlaxity.J Bone Joint Surg Am. 2010; 92: 1545-1557https://doi.org/10.2106/JBJS.H.00078Crossref PubMed Scopus (96) Google Scholar,43Schwartz D.G. Goebel S. Piper K. Kordasiewicz B. Boyle S. Lafosse L. Arthroscopic posterior bone block augmentation in posterior shoulder instability.J Shoulder Elbow Surg. 2013; 22: 1092-1101https://doi.org/10.1016/j.jse.2012.09.011Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar While the failure rate of arthroscopic capsulorrhaphy and posterior labral repairs is less than 10% in patients without hEDS,11Bradley J.P. McClincy M.P. Arner J.W. Tejwani S.G. Arthroscopic capsulolabral reconstruction for posterior instability of the shoulder: a prospective study of 200 shoulders.Am J Sports Med. 2013; 41: 2005-2014https://doi.org/10.1177/0363546513493599Crossref PubMed Scopus (136) Google Scholar these procedures are not as effective in EDS where the tissue structural integrity is poor.33Homere A. Bolia I.K. Juhan T. Weber A.E. Hatch G.F. Surgical Management of Shoulder and Knee Instability in Patients with Ehlers-Danlos Syndrome: Joint Hypermobility Syndrome.Clin Orthop Surg. 2020; 12: 279-285https://doi.org/10.4055/cios20103Crossref PubMed Scopus (7) Google Scholar When these procedures fail, the patient is left with limited options.51Wagner E.R. Gottschalk M.B. Editorial Commentary: Open Posterior Shoulder Stabilization-When Is It Needed? Glenoid Bone Loss Patterns Are Not Created Equal.Arthroscopy. 2019; 35: 2785-2787https://doi.org/10.1016/j.arthro.2019.06.007Abstract Full Text Full Text PDF Scopus (3) Google Scholar The joint preservation options include arthroscopic or open posterior bone blocks,15Camenzind R.S. Martin Becerra J. Gossing L. Serane-Fresnel J. Wagner E.R. Lafosse L. Acceptable Long-Term Outcomes of Arthroscopic Bone Grafting for Recurrent Posterior Shoulder Instability: Minimum Follow-Up of 5 Years.Arthroscopy. 2021; 37: 816-823https://doi.org/10.1016/j.arthro.2020.10.052Abstract Full Text Full Text PDF Scopus (12) Google Scholar,20Cognetti D.J. Hughes J.D. Kay J. Chasteen J. Fox M.A. Hartzler R.U. et al.Bone Block Augmentation of the Posterior Glenoid for Recurrent Posterior Shoulder Instability Is Associated With High Rates of Clinical Failure: A Systematic Review.Arthroscopy. 2022; 38: 551-563 e5https://doi.org/10.1016/j.arthro.2021.07.018Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar capsular reconstructions with allograft,30Gallagher F. Wong I.H. Anterior Capsule Augmentation and Posterior Glenohumeral Capsular Reconstruction With Human Dermal Allograft for Multidirectional Shoulder Instability.Arthrosc Tech. 2020; 9: e657-e662https://doi.org/10.1016/j.eats.2020.01.020Abstract Full Text Full Text PDF Scopus (4) Google Scholar glenoid osteotomy if there is concomitant severe glenoid retroversion,57Waltenspul M. Haller T. Ernstbrunner L. Wyss S. Wieser K. Gerber C. Long-term results after posterior open glenoid wedge osteotomy for posterior shoulder instability associated with excessive glenoid retroversion.J Shoulder Elbow Surg. 2022; 31: 81-89https://doi.org/10.1016/j.jse.2021.05.028Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar with salvage reconstruction options such as arthrodesis or arthroplasty as a last resort.6Antosh I.J. Tokish J.M. Owens B.D. Posterior Shoulder Instability.Sports Health. 2016; 8: 520-526https://doi.org/10.1177/1941738116672446Crossref PubMed Scopus (62) Google Scholar,51Wagner E.R. Gottschalk M.B. Editorial Commentary: Open Posterior Shoulder Stabilization-When Is It Needed? Glenoid Bone Loss Patterns Are Not Created Equal.Arthroscopy. 2019; 35: 2785-2787https://doi.org/10.1016/j.arthro.2019.06.007Abstract Full Text Full Text PDF Scopus (3) Google Scholar Rebalancing the dynamic soft tissue stabilizers and deforming forces in patients with hEDS may represent an alternative approach. The latissimus dorsi (LD) originates on the posterior aspect of the hemithorax and inserts anteriorly in the floor of the bicipital groove. This functions not only as a humerothoracic internal rotator and adductor but it also pulls the humeral head posteriorly and inferiorly, making it a significant contributor to posterior instability when overactive.41Saha A.K. Bhadra N. Dutta S.K. Latissimus dorsi transfer for recurrent dislocation of the shoulder.Acta Orthop Scand. 1986; 57: 539-541Crossref Scopus (6) Google Scholar Although LD tendon transfer has been described extensively for irreparable rotator cuff tears,5Anastasopoulos P.P. Alexiadis G. Spyridonos S. Fandridis E. Latissimus Dorsi Transfer in Posterior Irreparable Rotator Cuff Tears.Open Orthop J. 2017; 11: 77-94https://doi.org/10.2174/1874325001711010077Crossref PubMed Google Scholar,14Broida S.E. Sweeney A.P. Gottschalk M.B. Woodmass J.M. Wagner E.R. Clinical outcomes of latissimus dorsi tendon transfer and superior capsular reconstruction for irreparable rotator cuff tears: a systematic review.Eur J Orthop Surg Traumatol. 2022; 32: 1023-1043https://doi.org/10.1007/s00590-021-03046-5Crossref PubMed Scopus (8) Google Scholar,26Elhassan B.T. Wagner E.R. Kany J. Latissimus dorsi transfer for irreparable subscapularis tear.J Shoulder Elbow Surg. 2020; 29: 2128-2134https://doi.org/10.1016/j.jse.2020.02.019Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar,39Leivadiotou D. Ahrens P. Arthroscopic treatment of posterior shoulder instability: a systematic review.Arthroscopy. 2015; 31: 555-560https://doi.org/10.1016/j.arthro.2014.11.009Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar,44Shi L.L. Cahill K.E. Ek E.T. Tompson J.D. Higgins L.D. Warner J.J. Latissimus Dorsi and Teres Major Transfer With Reverse Shoulder Arthroplasty Restores Active Motion and Reduces Pain for Posterosuperior Cuff Dysfunction.Clin Orthop Relat Res. 2015; 473: 3212-3217https://doi.org/10.1007/s11999-015-4433-4Crossref PubMed Scopus (46) Google Scholar,56Wagner E.R. Woodmass J.M. Welp K.M. Chang M.J. Elhassan B.T. Higgins L.D. et al.Novel Arthroscopic Tendon Transfers for Posterosuperior Rotator Cuff Tears: Latissimus Dorsi and Lower Trapezius Transfers.JBJS Essent Surg. Tech 2018; 8e12https://doi.org/10.2106/JBJS.ST.17.00062Crossref Scopus (27) Google Scholar,60Woodmass J.M. Wagner E.R. Chang M.J. Welp K.M. Elhassan B.T. Higgins L.D. et al.Arthroscopic Treatment of Massive Posterosuperior Rotator Cuff Tears: A Critical Analysis Review.JBJS reviews. 2018; 6e3https://doi.org/10.2106/JBJS.RVW.17.00199Crossref Scopus (8) Google Scholar its use to treat posterior shoulder instability has not been reported. Furthermore, many patients with hEDS have scapular dyskinesia due to pectoralis minor (PM) overactivity, leading to an increased risk of instability, particularly in the posterior direction.13Broida S. Sweeney A. Gottschalk M. E W. Management of shoulder instability in hypermobility-type Ehlers-Danlos syndrome.JSES Rev Rep Tech. 2021; 1: 155-164https://doi.org/10.1016/j.xrrt.2021.03.002Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar,54Wagner E.R. Hussain Z.B. Karzon A.L. Warner J.J.P. Elhassan B.T. Sanchez-Sotelo J. The Scapula: The Greater Masquerader of Shoulder Pathologies.Instructional course lectures. 2024; 73: 587-607Google Scholar,55Wagner E.R. Karzon A.L. Hussain Z.B. Warner J.J.P. Elhassan B.T. Sanchez-Sotelo J. Scapular Dyskinesia: How to Differentiate Between Etiologies.Instructional course lectures. 2024; 73: 609-624Google Scholar We present a novel approach to surgical management of recurrent posterior shoulder instability in hEDS using an arthroscopically-assisted LD transfer with an arthroscopic PM release, and confirm reduction radiographically with dynamic digital radiography. A 14-year-old female with hEDS presented with a 5-year history of recurrent atraumatic left shoulder dislocations and subluxations. Her past medical history was significant for patellar and hip instability and contralateral right shoulder posterior instability treated twice with arthroscopic capsulorrhaphies. On the left, initially, an arthroscopic posterior 3-anchor capsulorrhaphy procedure with non-absorbable sutures had been performed 3 years prior and failed with multiple subsequent posterior instability events. She subsequently underwent a revision arthroscopic anterior and posterior capsular plication and rotator interval closure. This then failed on advancing motion out of the immobilizer, with a recurrent posterior dislocation event. She underwent multiple, unsuccessful courses of physical therapy focused on strengthening and retraining her rotator cuff and periscapular musculature. She reported over 100 dislocations or severe subluxations, had received over 8 corticosteroid injections into her glenohumeral joint, and was on chronic oral opioids for the preceding 3 years. Upon her initial consultation, she reported pain with most motions of her shoulder, with limitations in active range of motion in flexion (90o), abduction (70o), external rotation (40o), and internal rotation (side) secondary to pain. Her VAS pain was rated at 8/10, shoulder SANE score was 5%, and American Shoulder and Elbow Surgeons (ASES) score was 10. On examination, she had multidirectional instability with a subtle sulcus sign. Her Beighton Score was 9. She had positive posterior provocative maneuvers, including the Kim56Wagner E.R. Woodmass J.M. Welp K.M. Chang M.J. Elhassan B.T. Higgins L.D. et al.Novel Arthroscopic Tendon Transfers for Posterosuperior Rotator Cuff Tears: Latissimus Dorsi and Lower Trapezius Transfers.JBJS Essent Surg. Tech 2018; 8e12https://doi.org/10.2106/JBJS.ST.17.00062Crossref Scopus (27) Google Scholar and Jerk58Warner J.J. Parsons IMt Latissimus dorsi tendon transfer: a comparative analysis of primary and salvage reconstruction of massive, irreparable rotator cuff tears.J Shoulder Elbow Surg. 2001; 10: 514-521Abstract Full Text Full Text PDF PubMed Scopus (228) Google Scholar tests, with grade 3 posterior subluxation of her humeral head relative to the glenoid. She had a negative anterior relocation test and only grade 1 anterior subluxation. Furthermore, she had significant LD spasms at rest and with attempted elevation or abduction. She was also tender to palpation at the PM insertion on to the coracoid, with a positive Tinel's sign under it, and had marked scapular dyskinesia associated with a resting protracted posture of her scapula. Her PM length was 12 cm on the involved side compared to 14 cm on the contralateral side. Radiographs demonstrated severe posterior humeral head subluxation on the axillary view (Figure 1), while magnetic resonance imaging (MRI) showed a severely retroverted and dysplastic glenoid with posterior capsulolabral complex redundancy and detachment, and a reverse Hill-Sachs lesion (Figure 2). Furthermore, computed tomography (CT) demonstrated glenoid retroversion of 28.3° using Friedman method,29Friedman R.J. Hawthorne K.B. Genez B.M. The use of computerized tomography in the measurement of glenoid version.J Bone Joint Surg Am. 1992; 74: 1032-1037Crossref PubMed Google Scholar with associated posterior subluxation of the humeral head relative to the glenoid (Figure 3 and 4). Three-dimensional reconstruction of the shoulder joint revealed posterior glenoid bone loss (Figure 5). Given the LD spasms on examination, a dynamic electromyogram (EMG) was performed that demonstrated abnormal LD firing at rest and humerothoracic abduction (Figure 6). Given these findings, she was referred for botulinum toxin injection to the LD muscle, significantly improving her shoulder pain and subluxations for around 6 weeks.Figure 2Proton density fat-saturated magnetic resonance imaging of left shoulder in axial (A), coronal (B), and sagittal (C) planes. (A) Axial view demonstrates severe glenoid dysplasia and retroversion with posterior capsulolabral complex detachment and soft tissue interposition in the anterior joint (star). Chondral defect at humeral head (*). (B) Coronal view demonstrates articular defects in location of previous anchor tracks. (C) Sagittal view demonstrates postsurgical anchor tracks in the glenoid from previous capsulolabral fixation (ˆ), and a deficient glenoid.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Computed tomography (CT) of left shoulder in axial (A), coronal (B), and sagittal (C) planes. Axial view demonstrates posterior subluxation of shoulder. Sagittal view demonstrates multiple glenoid cortical defects representing postsurgical anchor tracks from previous capsulolabral fixation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Axial CT image of left glenohumeral joint displaying Walch type B3 dysplastic glenoid with 28.3o of retroversion, and significant posterior humeral head subluxation in the setting of capsulolabral hyperlaxity.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Three-dimensional reconstruction of left scapula and glenoid en face (A) and proximal humerus (B). Posterior glenoid bone loss is seen when best-circle method applied. Coracoid (C), acromion (A), lesser tuberosity (LT), greater tuberosity (GT).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6A dynamic electromyogram (EMG) was performed, as latissimus dorsi spasming was encountered on clinical examination. On the side of interest, abnormal rapid firing patterns were recorded (A), compared to the contralateral latissimus dorsi (B).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Given the reemergence of her scapular dyskinesia and posterior shoulder instability events after botulinum injection wore off, a decision was made to proceed with surgical intervention. The patient underwent an arthroscopic-assisted LD tendon transfer from its insertion anteriorly in the floor of the bicipital groove, to cover the shoulder posteriorly and insert at the lateral aspect of the greater tuberosity (GT) (Figure 7, Figure 8, Figure 9). This was intended to dynamically correct the posterior shoulder instability and direct the force vector from posterior to anterior, enabling external rotation and blocking posterior translation. Furthermore, an arthroscopic pectoralis minor release was performed to correct the scapular dyskinesia and help rebalance the shoulder instability.Figure 8Mobilization and preparation of the latissimus dorsi (LD) tendon. (A) Adhesions are released from the LD tendon and muscle belly proximally. (B) The tendon is prepared for transfer with krackow sutures and a running baseball stitch (C) Proximal superficial and deep adhesions are released to mobilize the LD tendon further. (D) Adequate tendon excursion without allograft augmentation is confirmed.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 9Arthroscopic portion of the transfer. (A) An interval for transfer is developed over the infraspinatus and teres minor muscles with the assistance of a dilated foley catheter which is slid back and forth. (B) The tendon sutures are advanced toward the lateral aspect of the greater tuberosity. (C) Two suture anchors placed lateral to the bicipital groove and tuberosity secure the transfer.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Using standard portals and beach chair positioning, a subacromial decompression was performed. Using techniques previously described,1Ahmed A.S. Graf A.R. Karzon A.L. Graulich B.L. Egger A.C. Taub S.M. et al.Pectoralis minor syndrome - review of pathoanatomy, diagnosis, and management of the primary cause of neurogenic thoracic outlet syndrome.JSES Rev Rep Tech. 2022; 2: 469-488https://doi.org/10.1016/j.xrrt.2022.05.008Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar,3Ahmed A.S. Lafosse T. Graf A.R. Karzon A.L. Gottschalk M.B. Wagner E.R. Modern Treatment of Neurogenic Thoracic Outlet Syndrome: Pathoanatomy, Diagnosis, and Arthroscopic Surgical Technique.J Hand Surg Glob Online. 2023; 5: 561-576https://doi.org/10.1016/j.jhsg.2022.07.004Abstract Full Text Full Text PDF Scopus (1) Google Scholar,47Stern E. Karzon A.L. Hussain Z.B. Khawaja S.R. Cooke H.L. Pirkle S. et al.Arthroscopic Pectoralis Minor Release After Reverse Shoulder Arthroplasty: A Novel Consideration for Postarthroplasty Pain.JBJS Case Connect. 2023; 13 (e22.0080410.2106/JBJS.CC.22.00804)Crossref Scopus (0) Google Scholar,53Wagner E.R. Gottschalk M.B. Ahmed A.S. Graf A.R. Karzon A.L. Novel Diagnostic and Treatment Techniques for Neurogenic Thoracic Outlet Syndrome.Tech Hand Up Extrem Surg. 2023; 27: 100-114https://doi.org/10.1097/BTH.0000000000000419Crossref Scopus (0) Google Scholar the pectoralis minor (PM) was exposed and completely released from the coracoid, showing immediate retraction, signifying its overactivity and contribution to the scapular dyskinesia. Using an anterolateral viewing portal and anteromedial working portal, the insertion of the latissimus dorsi was exposed. The tendon was sharply released and mobilized from the teres major. Next, an open incision was performed using a longitudinal incision in the posterior axillary fold along the anterior aspect of the LD musculotendinous unit (Figure 7A). The LD tendon was dissected away from the teres major muscle (Figure 7B, 7C, and 7D). The muscle was released to the level of the scapular inferior border, enabling it to be mobilized up to the superior aspect of the acromion. A Krakow stitch followed by a running baseball stitch was performed to create two sutures on each end of the tendon (Figure 8B). Arthroscopically, a motorized shaver was used to prepare an area on the GT for the latissimus transfer. The plane was developed arthroscopically between the residual infraspinatus and teres minor (Figure 9A). A long hip arthroscopy grasper was passed from the anterolateral portal through the back incision. The sutures at the end of the tendon were retrieved and the tendon was pulled onto the lateral part of the GT (Figure 9B). The tendon was fixed with two anchors on the lateral GT just lateral and superior to the teres major insertion (Figure 9C). Postoperative rehabilitation protocol included 6 weeks in a sling, followed by physical therapy focusing on scapulohumeral re-training and strengthening beginning at 12 weeks. The patient recovered very well postoperatively, with VAS pain score of 3/10 at 6 weeks and 0/10 at 3, 7, 11, and 24 months postoperatively. Her shoulder SANE score improved to 50% at 6 weeks, 80% at months, and 90% at 7, 11, and 24 months postoperatively. At 7, 11, and 24 months, her ASES scores were 75, 82, and 85, respectively. At 2 months, she had full abduction (150°), forward flexion (170°), external rotation (70°), and internal rotation (>T10). She has had no subsequent dislocation or subluxation events on that shoulder. At her most recent follow-up at 2.9 years, she reported no issues with this shoulder and has regained complete motion without pain, with a SANE score of 90% and ASES of 88. A point of care ultrasound at 6 months, 1 year, and 2.9 years postoperatively performed in the clinic showed a completely healed latissimus dorsi following transfer. On static radiographs (Figure 10) of the surgical shoulder, the patient had a well-centered humeral head without any signs of posterior subluxation. Dynamic radiography (Video 1), which have been shown to have utility in diagnosing dynamic shoulder pathology,34Hussain Z.B. Khawaja S.R. Karzon A.L. Ahmed A.S. Gottschalk M.B. Wagner E.R. Digital dynamic radiography-a novel diagnostic technique for posterior shoulder instability: a case report.JSES Int. 2023; 7: 523-526https://doi.org/10.1016/j.jseint.2023.02.015Abstract Full Text Full Text PDF Scopus (1) Google Scholar,38Khawaja S.R. Kopriva J.M. Hussain Z.B. Cooke H.L. Gottschalk M.B. Wagner E.R. Serratus anterior palsy as a Masquerader: utilizing novel digital dynamic radiography for diagnosis and treatment response.JSES Int. 2024; 8: 540-545https://doi.org/10.1016/j.jseint.2023.12.001Abstract Full Text Full Text PDF Scopus (0) Google Scholar,47Stern E. Karzon A.L. Hussain Z.B. Khawaja S.R. Cooke H.L. Pirkle S. et al.Arthroscopic Pectoralis Minor Release After Reverse Shoulder Arthroplasty: A Novel Consideration for Postarthroplasty Pain.JBJS Case Connect. 2023; 13 (e22.0080410.2106/JBJS.CC.22.00804)Crossref Scopus (0) Google Scholar,61Xiao A.X. Karzon A.L. Hussain Z.B. Khawaja S.R. McGinley B.M. Ahmed A.S. et al.Variation in Scapulohumeral Rhythm on Dynamic Radiography in Pathologic Shoulders: A Novel Diagnostic Tool.J Shoulder Elbow Surg. 2023 Jun; 32: S123-S131https://doi.org/10.1016/j.jse.2022.12.023Abstract Full Text Full Text PDF Scopus (4) Google Scholar demonstrated humeral head concentric relocation and stability, facilitating glenohumeral motion.34Hussain Z.B. Khawaja S.R. Karzon A.L. Ahmed A.S. Gottschalk M.B. Wagner E.R. Digital dynamic radiography-a novel diagnostic technique for posterior shoulder instability: a case report.JSES Int. 2023; 7: 523-526https://doi.org/10.1016/j.jseint.2023.02.015Abstract Full Text Full Text PDF Scopus (1) Google Scholar She eventually started having symptoms on the contralateral shoulder static radiographs, dynamic images (Figure 11, Video 1), and CT scan demonstrated posterior subluxation associated with glenoid dysplasia and retroversion.Figure 11Grashey (A) and axial (B) radiographs of the contralateral right shoulder at 24 months follow-up. Both views demonstrate a concerning posterior subluxation of the shoulder with glenoid retroversion, similar to the initial presentation of the left side.View Large Image Figure ViewerDownload Hi-res image Download (PPT) hEDS is a common subtype of EDS, characterized by over 95% of patients experiencing frequent instability across all joints, often requiring surgical management.13Broida S. Sweeney A. Gottschalk M. E W. Management of shoulder instability in hypermobility-type Ehlers-Danlos syndrome.JSES Rev Rep Tech. 2021; 1: 155-164https://doi.org/10.1016/j.xrrt.2021.03.002Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar,48Tinkle B. Castori M. Berglund B. Cohen H. Grahame R. Kazkaz H. et al.Hypermobile Ehlers-Danlos syndrome (a.k.a. Ehlers-Danlos syndrome Type III and Ehlers-Danlos syndrome hypermobility type): Clinical description and natural history.Am J Med Genet C Semin Med Genet. 2017; 175: 48-69https://doi.org/10.1002/ajmg.c.31538Crossref PubMed Scopus (290) Google Scholar The reliance on dynamic and static soft tissue stabilizers without the bony stability within the glenohumeral joint leaves patients at risk of posterior dislocation and subluxation, especially in hEDS.13Broida S. Sweeney A. Gottschalk M. E W. Management of shoulder instability in hypermobility-type Ehlers-Danlos syndrome.JSES Rev Rep Tech. 2021; 1: 155-164https://doi.org/10.1016/j.xrrt.2021.03.002Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar When primary arthroscopic stabilization procedures fail to maintain shoulder stability, bone block procedures, arthroplasty, and arthrodesis are potential salvage procedures.6Antosh I.J. Tokish J.M. Owens B.D. Posterior Shoulder Instability.Sports Health. 2016; 8: 520-526https://doi.org/10.1177/1941738116
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