First-time shoulder dislocation: High prevalence of labral injury and age-related differences revealed by MR arthrography

Isolated Transitory Radial Nerve Palsy as a Complication After Luxatio Erecta Humeri: A Case Report

Shoulder dislocations are common, with luxatio erecta humeri (LEH) being a rare variant. This report discusses a case of isolated transitory radial nerve palsy following LEH, which occurred after a high-energy motorcycle accident. Neurological examination revealed radial nerve involvement. Following reduction of the dislocation and appropriate physiotherapy, the patient experienced full functional recovery. This case underscores the rarity of isolated radial nerve palsy in LEH and highlights the importance of thorough neurological assessment in such injuries.

Anterior Labrum Periosteal Sleeve Avulsion Lesions of the Shoulder: A Scoping Review

Background

Anterior labrum periosteal sleeve avulsion (ALPSA) lesion of the shoulder is defined as a labral avulsion with an intact periosteum of the glenoid neck resulting in medial malattachment of the labrum, which is both nonanatomic and nonfunctional. It is relatively rare compared with Bankart lesions, and its results are usually reported in combination with other anterior labroligamentous lesions in the literature.

Purpose

To (1) assess the size and scope of the literature on ALPSA lesions, (2) highlight the importance of this lesion, and (3) distinguish between ALPSA and Bankart lesions in diagnostic and treatment strategies.

Study Design

Scoping review; Level of evidence, 4.

Methods

The PubMed, Scopus, Embase, and Google Scholar databases were searched with the keywords "ALPSA,""anterior labrum periosteal sleeve avulsion,""anterior labral periosteal sleeve avulsion," and "anterior labroligamentous periosteal sleeve avulsion" lesion. Duplicate articles and those that did not meet the inclusion criteria were excluded, resulting in the identification of 42 relevant articles. Their references were analyzed for further data curation.

Results

This scoping review demonstrated that ALPSA lesions are difficult to clinically identify. Magnetic resonance angiography in the adduction internal rotation position is the most sensitive and specific imaging modality for identification. Optimal views are the anterosuperior portal for accurate identification and the anteroinferior portal for surgical repair during arthroscopy. Treatment begins with correctly identifying the labrum, in contradistinction to dense reactive fibrous tissue, and reattaching the labrum to the correct anatomic glenoid footprint. Chronic lesions with bone loss require either bone block or soft tissue augmentation procedures.

Conclusion

There is paucity of exclusive literature on ALPSA lesions. It is important to distinguish this lesion from the Bankart lesion as it is associated with worse outcomes. The higher failure rates of ALPSA lesion repair indicate that the current repair techniques require further refinement to improve the outcomes to the standard of Bankart lesions.

A new, effective method for diagnosing GLAD lesions: the chicken-wing muscle up test

PURPOSE

We aimed to develop and evaluate a new diagnostic method, the 'chicken-wing muscle up test', to improve the accuracy of diagnosis of glenolabral articular disruption (GLAD) lesions compared to currently used clinical tests for injuries to the labrum.

METHODS

Preoperative evaluations were conducted on 85 patients undergoing arthroscopic surgery at a single center between July 2021 to July 2022. The diagnostic performance of the preoperative clinical examinations (chicken-wing muscle up test, O'Brien test, crank test, and O'Driscoll test) were validated against the findings of arthroscopic examinations.

RESULTS

12 of the 85 patients in this study had arthroscopically confirmed GLAD lesions. The chicken-wing muscle up test demonstrated significantly higher sensitivity (83.33%) for GLAD lesions than the O'Brien test (33.33%), but not the crank test (50.00%) or O'Driscoll test (25.00%), and significantly higher specificity (95.89%) than the O'Brien test (75.34%), crank test (82.19%), and O'Driscoll test (71.23%). The chicken-wing muscle up test had the largest area under the receiver operating characteristic curve (AUC = 0.896, P < 0.001; O'Driscoll test AUC = 0.543, P > 0.05; crank test AUC = 0.661, P > 0.05; O'Brien test AUC = 0.481, P > 0.05), indicating significantly better diagnostic efficacy for GLAD lesions than the other three tests.

CONCLUSIONS

The chicken-wing muscle up test is a reliable diagnostic method that improves the accuracy of diagnosis of GLAD lesions.

Controversies in surgical management of anterior shoulder instability. State of the Art

Arthroscopic Bankart repair (ABR) has been accepted as a standard procedure for anterior shoulder instability with a minimum or no glenoid bone loss and an on-track Hill-Sachs lesion if present. However, several controversies exist in the surgical treatment of anterior shoulder instability. This article will discuss some of these controversies in, "simple," dislocations (without bone loss) as well as, "complex," (with critical bone loss). Determining which patients will benefit from an arthroscopic procedure depends on multiple factors including age, activity level, adequate determination of bone loss, performed with feasible and reliable imaging techniques. In the absence of concomitant significant bony and soft tissue pathology, ABR alone can provide satisfactory clinical results on a long-term basis. Controversies, including whether to remove cartilage from the edge of the glenoid, knotted versus knotless anchors, and routine rotator interval closure, still exist. In cases with significant bone loss, several bone restoring procedures have been described, such as, the Latarjet procedure, iliac crest bone graft, arthroscopic anatomic glenoid reconstruction with a frozen distal tibial allograft, and fresh distal tibial allograft reconstruction. This article will address these controversies and provide guidance based on available published data.

SLAP lesion type IX: case series and a review of literature

PURPOSE

A type IX SLAP (superior labrum anterior to posterior) lesion involves 360° of the glenohumeral labrum. Only rare reports have been published analyzing the risk factors of this lesion and the success of its arthroscopic management. The aim of our study is to evaluate predisposing factors that lead to SLAP IX and to assess the clinical outcome after arthroscopic treatment. Our treatment algorithm is also presented.

METHODS

We report on a series of six patients treated in our institution between January 2014 and January 2019 who underwent shoulder arthroscopy and were intraoperatively found to have a SLAP lesion type IX. Arthroscopic labral repair and biceps tenodesis were indicated in all patients. American Shoulder and Elbow Surgeons (ASES) Shoulder Score, Rowe Score and Constant Murley Shoulder Score (CS) were used for clinical evaluation. Patients were evaluated preoperatively and at 12 weeks, 1 year and 2 years postoperatively.

RESULTS

We analyzed six patients of which 83% were males (5/6 patients). The average age at the time of surgery was 37.16 (range 30-42 years). The dominant arm was affected in 50% of patients (3/6 patients). A significant postoperative improvement was seen in all six patients. 83% (5/6) of patients returned to their pre-injury activity level. Average values of all three measured scores show a significant increase comparing preoperative to postoperative period (P-value < 0.05). All patients were able to return to work.

CONCLUSIONS

The final diagnosis was established intraoperatively as 83% (5/6) of radiology reports differed from subsequent arthroscopic findings. The mechanism of injury in all our cases was high energy trauma with traction, arm in abduction or anteflexion. We observed great success with arthroscopic treatment as high percentage of our patients returned back to work and sports.

Glenohumeral Pathologies following Primary Anterior Traumatic Shoulder Dislocation-Comparison of Magnetic Resonance Arthrography and Arthroscopy

BACKGROUND

We assessed intraarticular injuries in patients after primary anterior traumatic shoulder dislocation by comparing magnetic resonance arthrography (MRA) results with concomitant arthroscopic findings.

METHODS

All patients with primary traumatic shoulder dislocation who underwent arthroscopic surgery between 2001 and 2020 with preoperative MRA were included in this study. MRA was retrospectively compared with arthroscopic findings. Postoperative shoulder function was prospectively assessed using the Disabilities of Arm, Shoulder and Hand score (quick DASH), the Oxford Shoulder Score (OSS), the Subjective Shoulder Value (SSV), as well as the rate of return to sports.

RESULTS

A total of 74 patients were included in this study. A Hill-Sachs lesion was consistently found in the corresponding shoulders on MRA and arthroscopy in 35 cases (p = 0.007), a Bankart lesion in 37 shoulders (p = 0.004), and a superior labrum from anterior to posterior (SLAP) lesion in 55 cases (p = 0.581). Of all cases, 32 patients were available for a clinical and functional follow-up evaluation. A positive correlation was found between the level of sport practiced and the Oxford Shoulder Score (redislocation subset) (p = 0.032) and between the age at the time of surgery and the follow-up SSV (p = 0.036). Conversely, a negative correlation was observed between the age at the time of surgery and the Oxford Instability Score (redislocation subset) (p = 0.038).

CONCLUSIONS

The results of this study show a good correlation between MRA and arthroscopy. Therefore, MRA is a valid tool for the detection of soft tissue pathologies after primary anterior traumatic shoulder dislocation and can aid in presurgical planning.

Lesion prevalence and patient outcome comparison between primary and recurrent anterior shoulder instability

BACKGROUND

The purpose of this study was to compare lesion prevalence and treatment outcomes in patients with primary and recurrent anterior shoulder instability.

METHODS

Patients who were admitted to the institution with a diagnosis of anterior shoulder instability and who underwent arthroscopic surgery between July 2006 and February 2020 were retrospectively evaluated. Minimum follow-up duration of the patients was 24 months. The recorded data and magnetic resonance imaging (MRI) of the patients were examined. Patients aged ≥40 years, with a history of shoulder region fracture, inflammatory arthritis, a history of epilepsy, multidirectional instability, nontraumatic dislocation, and off-track lesions were excluded from the study. Shoulder lesions were documented and patient outcome evaluation was made with the Oxford Shoulder Score (OSS) and visual analog scale (VAS).

RESULTS

A total of 340 patients were included in the study. The mean age of patients was 25.6 years (±6.49). The recurrent instability group had a significantly higher rate of anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions compared to the primary instability group (40.6% vs. 24.6% respectively) (P = .033). Twenty-five patients (43.9%) had superior labrum anterior and posterior (SLAP) lesions in the primary instability group and 81 patients (28.6%) had SLAP lesions in the recurrent instability group (P = .035). OSS increased for both primary (from 35 [16-44] to 46 [36-48]) (P = .001) and recurrent instability groups (from 33 [6-45] to 47 [19-48]) (P = .001). There was no significant difference between the groups regarding postoperative VAS and OSS scores (P > .05).

CONCLUSIONS

Successful results were obtained in patients younger than 40 years with both primary and recurrent anterior shoulder instability after arthroscopic treatment. ALPSA lesion prevalence was higher whereas SLAP lesion prevalence was lower in patients with recurrent instability. Although the postoperative OSS was comparable between the patient groups, the failure rate was higher in the recurrent instability patients.

Type IX Superior Labrum Anterior and Posterior Lesion in a Professional Football Player: A Rare Pattern of Shoulder Instability in a Non-throwing Athlete

Anterior shoulder instability is the most frequent type of glenohumeral instability, especially among young athletes. Superior labral anterior-posterior (SLAP) injuries involve the superior glenoid labrum where the long head of the biceps tendon (LHBT) inserts. There is still some debate regarding the pathogenesis, clinical presentation, and treatment of these lesions. We report a clinical case of an 18-year-old male professional football player with a rare type IX SLAP lesion. Given the recurrence of instability after prior nonoperative management, surgical treatment was seen as the best option, and a pan-labral arthroscopic repair suture anchor fixation was performed. Three months after undergoing a personalized postoperative rehabilitation program, he was able to return to full sport with the same competitive level, and no recurrent instability or other symptoms were reported throughout the 18-month follow-up period.

Arthroscopic Management Strategies for Glenohumeral Articular Cartilage Lesions and Defects

Glenoid articular cartilage lesions are a source of shoulder pain and can occur in the setting of glenohumeral instability and degenerative shoulder disease. Glenolabral articular disruption lesions have been reported to be associated with worse outcomes after arthroscopic repair of labral tears. There are relatively few published studies evaluating outcomes after surgical treatment of glenoid articular lesions; however, it is generally accepted that management should consist of restoring the glenoid articular surface, minimizing exposed articular defect, and re-establishing capsulolabral integrity to achieve stability. We present arthroscopic strategies to manage these glenoid articular defects through debridement, abrasion, microfracture, capsulolabral advancement and labral interposition.

[Research progress on the relationship between shoulder instability and superior labrum anterior posterior lesion]

OBJECTIVE

To summarize the relationship between shoulder instability and superior labrum anterior posterior (SLAP) lesion.

METHODS

The characteristics of shoulder instability and SLAP lesion were analyzed, and the relationship between them in pathogenesis, clinical symptoms, and biomechanics was discussed by referring to relevant domestic and foreign literature.

RESULTS

Shoulder instability and SLAP lesion can occur both spontaneously and respectively. SLAP lesion destroys the superior labrum integrity and the long head of biceps tendon (LHBT) insertion, causing excessive humeral head displacement against glenoid, and leading to shoulder instability. While chronic repetitive or acute high-energy traumatic shoulder instability can in turn aggravate SLAP lesion, resulting in expansion and increased degree of the original lesion.

CONCLUSION

SLAP lesion destroys mechanisms of shoulder stability, while shoulder instability causes tears of the upper labrum and the LHBT, showing a connection between shoulder instability and SLAP lesion. However, the existing evidence can only demonstrate that shoulder instability and SLAP lesion induce and promote the development of each other, instead of a necessary and sufficient condition. Therefore, the specific causal relationship between the two remains unknown and needs to be further studied.

Associated Pathologies following Luxatio Erecta Humeri: A Retrospective Analysis of 38 Cases

Inferior shoulder dislocation in fixed abduction, also known as luxatio erecta humeri (LEH), is a rare injury with little data available. Therefore, the primary aim of this study was to evaluate and present our case series of this type of injury with special emphasis on associated pathologies; the secondary aim was to present diagnostic recommendations to detect for potential associated pathologies typically seen with this injury. A total of 38 patients (13 females, average age 72.8 years and 25 males, average age 41.4 years), who have been treated for inferior shoulder dislocation between 1992 and 2020, were included in this study. Associated pathologies after LEH were found in 81% of the cases. Twenty-one of these patients presented with secondary bony pathologies. Six patients revealed rotator cuff injuries diagnosed by magnetic resonance imaging (MRI). Seven patients exhibited pathological findings at the capsule-ligament complex. Eight patients presented with neurological findings. All neurologic symptoms except one axillary nerve palsy and a radialis paresis dissolved during the follow-up period. Five patients received surgical treatment of the affected shoulder. Inferior shoulder dislocation is a rare condition presenting with a high number of associated injuries. According to the findings of the present study, we want to raised awareness of the high rate of potential secondary shoulder pathologies associated with LEH. Beside a thorough clinical examination and immediate standard radiographs in two planes, we recommend to perform computed tomography scanning and an MRI of the shoulder as soon as possible. In the case of neurologic deficiencies, a determination of nerve conduction should be performed.

How to Report: Shoulder MRI

Magnetic resonance imaging of the shoulder is a commonly performed investigation. This article discusses the common shoulder pathologies encountered, emphasizes the key features to report, and provides examples of terminology used to describe these pathologies.

Capsulolabral Reconstruction During the Open Latarjet Procedure

Surgical treatment of anterior glenohumeral joint instability can be challenging and carries the inherent risk of recurrent instability, dislocation arthropathy, and postoperative loss of external rotation. In the current manuscript, a technique for combined reconstruction of anterior labrum and capsule, with concomitant reduction of the humeral head during anterior capsule reconstruction in open Latarjet procedure, is presented. Analogous to other techniques, the coracoid graft is fixed on the anteroinferior part of the glenoid between 3 and 5 o'clock. However, for this technique, reattachment of the labrum is performed between the native glenoid and the bone graft. Additionally, during the reconstruction of the anterior capsule on the coracoacromial ligament, while the operated arm is held in external rotation to avoid the postoperative rotational deficit, the humeral head is reduced posteriorly in the center of the glenoid during adduction, slight anterior forward flexion, and a posterior lever push. By doing so, the inherent theoretical risks of persistent instability and dislocation arthropathy are believed to be decreased. Further studies are needed to clarify the long-term consequences of this surgical technique in the clinical setting.

Glenoid labrum articular disruption in a six-year-old child: A case report

Introduction

Traumatic anterior shoulder instability is a rare occurrence in the childhood. While glenoid labrum articular disruption itself is an uncommon condition that accompanies shoulder instability in the contact athletes, the occurrence of such lesion in a child is of extreme rarity. To the best of our knowledge, this case is the first to be reported at such a young age.

Case presentation

A six-year-old female child is presented to the clinic with a painful left shoulder and limited range of motion after a fall which was abruptly prevented by the father; hence, the child was grabbed by the arm, leaving the body to pivot around the shoulder at full force in an abduction external rotation position. Radiological studies revealed anteroinferior osteochondral fragment and a matching glenoid defect. Open surgery was performed, and the osteochondral fragment with the attached labrum was fixed using smooth K-wires.

Conclusions

Although rare, shear fractures of the anterior glenoid associated with chondral damage are possible in early childhood. However, it demands a forceful burst of abduction external rotation force which could have been avoided if the child was left to fall. The use of two K-wires via an open deltopectoral approach achieved excellent results with minimum cartilage damage.

Common animal models lack a distinct glenoid labrum: a comparative anatomy study

Purpose

Development and validation of an animal model of labral healing would facilitate translation of novel surgical and biological strategies to improve glenolabral healing. The purpose of this study was to characterize the anatomic and histological properties of the shoulder labrum in rat, rabbit, dog, pig, goat, and humans. Given the demonstrated similarities in size and structural morphology in other joints, it was hypothesized that the goat glenoid with surrounding capsulolabral complex would most closely resemble that of humans in terms of dimensions and structure, as observed grossly and histologically.

Methods

Cadaveric glenohumeral joints from rats (n = 8), New Zealand white rabbits (n = 13), Mongrel dogs (n = 9), Spanish goats (n = 10), Yorkshire pigs (n = 10), and humans (n = 9) were freshly harvested. Photographs were taken of the glenoid with its surrounding capsulolabral complex. Linear dimensions of the glenoid articular surface were measured. It was determined where the capsulolabral complex was continuous with, or recessed from, the articular glenoid surface. The glenoid was divided into 6 equal segments radiating out toward 12, 2, 4, 6, 8, and 10 o’clock positions. Samples were sectioned and stained with Safranin O/Fast green and Mallory Trichrome. Insertion of the capsulolabral tissue onto the glenoid was qualitatively assessed and compared with gross morphology.

Results

Dimensions of the goat glenoid most closely paralleled dimensions of the human glenoid. A capsulolabral complex was continuous with the glenoid surface from ~ 9 to 12 o’clock in the rats, 7 to 12 o’clock in rabbits, 5 to 12 o’clock in the dogs, and 9 to 12 o’clock in goats, 6 to 12 o’clock in pigs, and 2 to 8 o’clock in humans. In contrast to humans, no other species demonstrated an organized fibrocartilaginous labrum either macroscopically or histologically.

Conclusion

The animals in the present study did not possess a discrete fibrocartilaginous labrum by gross or histological evaluation, as directly compared to humans. While models using these animals may be acceptable for examining other shoulder pathologies, they are not adequate to evaluate labral pathology.

Level of evidence

Basic Science Study; Anatomy and Histology; Cadaveric Animal Model.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40634-021-00383-6.

Arthroscopic management of anterior labrum periosteal sleeve avulsion (ALPSA) lesions: A case series with improved clinical outcomes using a modified technique

Introduction

Obejctive

Method

Results and conclusion

The GLAD Lesion: are the definition, diagnosis and treatment up to date? A Systematic Review

INTRODUCTION

Although GLAD lesions are quite common, only sporadic case reports describe surgical techniques and clinical outcomes. Even if cartilage defects can result from various pathogenic mechanisms, the resulting defect has some similarities with GLAD, and its management can be a starting point to treat both types of lesion. Aim of the present study is to find a commonly accepted definition for GLAD lesions in order to understand its pathogenesis, diagnosis and possible treatments.

METHODS

A search of PubMed (MEDLINE) database has been performed in June 2020 to identify relevant articles including a combination of the following search terms: "GlenoLabral Articular Disruption" OR "GLAD" AND "shoulder" AND "cartilage, articular".

RESULTS

Abstract evaluation included 31 articles in the full-text review. Various studies showed that the performance of MR arthrography in the detection of glenohumeral cartilage lesions, including GLAD lesions, was moderate. Different therapeutic solutions have been described. Arthroscopic debridement of the lesion and reattachment of the labrum have been often used. In case of large articular defects, the labrum could be advanced in the cartilage defect to cover it. In case of cartilage flap with reparable margins, this could be reattached with different suture constructs. Neglected GLAD lesions following a chronic trauma or shoulder instability have not been described in literature.

CONCLUSIONS

The definition of GLAD injury has changed over the time. Many authors associate this lesion with shoulder instability, with trauma in abduction and extra rotation, while Neviaser's original definition described stable shoulders following a trauma in adduction.

First-time Glenohumeral Dislocations: Current Evidence and Considerations in Clinical Decision Making

The decision to manage first-time shoulder dislocations conservatively or operatively has become increasingly complex because of conflicting literature. Although shoulder dislocations have traditionally been managed with reduction and immobilization, recent evidence has suggested high rates of subsequent recurrence. Surgical intervention is thought to better restore stability and decrease recurrence rates; however, it also has the potential for additional morbidity and financial cost. As such, recent literature has sought to better define patient risk profiles to identify optimal candidates for both conservative and operative management. The purpose of the current review is to provide a comprehensive and evidence-based assessment of the most recent literature to better delineate an appropriate treatment algorithm for this challenging clinical scenario.

Arthroscopic Management of Glenoid and Greater Tuberosity Bipolar Fractures

OBJECTIVE

To report the clinical and radiological outcomes of arthroscopically assisted surgery for combination of glenoid and greater tuberosity fractures after traumatic shoulder dislocation.

METHODS

From December 2013 to December 2018, patients with concomitant fracture of the greater tuberosity and glenoid who underwent arthroscopically assisted surgery were retrospectively reviewed. Fifteen patients were included. Preoperative computed tomography (CT) scans with 3D reconstruction were performed to evaluate the fracture configuration and associated fractures. All patients underwent arthroscopically assisted surgery under general anesthesia with brachial plexus anesthesia in the lateral position. Under the arthroscopic approach, a comprehensive inspection of the joints was firstly conducted to examine the injury of bones and other tissues. With arthroscopy support, closed reduction and internal fixation of both fractures were performed with suture anchors, with or without additional cannulated screws. At the same time, other injuries were also repaired under the arthroscope. Patients were followed up (6 weeks，8 weeks，3 months，6 months，1 year after surgery) regularly for at least 1 year. At the follow-up, clinical outcomes (Constant score, ASES score, range of motion, and VAS score) and radiological outcomes were analyzed.

RESULTS

Of the 15 patients, there are seven cases of men, eight cases of women; aged 22-66 years, with an average age of 48 years; left shoulder for five cases, 10 cases of the right shoulder. The injury mechanisms were: a simple fall (n = 9), an epileptic seizure (n = 1), a high fall injury (n = 2), and a traffic accident (n = 3). Of the 15 cases of glenoid fracture, 11 cases were type Ia and four cases were type II according to the Ideberg Classification System. The mean size of the glenoid fracture fragment was 28.4% (range, 8.7%-47.2%). According to the Mutch classification system, the fractures of the greater tuberosity were divided into: five cases of avulsion, one case of compression, and nine cases of split. Average time of follow-up was 38.2 months (range, 12-70 months), and one case was lost to follow-up. With fractures healing well, almost all patients had a good joint function. At the final follow-up, mean anterior flexion was 157°; mean external rotation was 40°; mean internal rotation was T₁₁ level; the mean Constant-Murley score was 94.6 points (range, 70-100 points); the mean ASES score was 94.6 points (range, 79-100 points); and the mean VAS score was 0.4 points (range, 0-2 points). No recurrent instability or re-dislocation occurred. No patient had revision surgery.

CONCLUSION

Arthroscopic management of glenoid and greater tuberosity bipolar fractures was useful and effective with minimal injury, and it achieved satisfactory clinical and radiological outcomes at a mean follow-up time of more than 3 years.

Editorial Commentary: Evidence to Support Surgical Intervention for First-Time Shoulder Instability: Stabilize Them Early!

Historically, a primary anterior instability event has been treated nonoperatively. In the literature, a multitude of outcome scores and definitions for recurrence of instability complicates the interpretation and synthesis of evidence-based recommendations. However, there is an emerging body of high-quality evidence that early surgical stabilization yields better overall outcomes. A wait-and-see approach would be acceptable if it was without detrimental effects, but there is a cost to recurrence of instability events, such as more extensive soft-tissue, cartilage, and bony lesions. Young age, male sex, and contact sport participation have been identified as risk factors for recurrence of anterior shoulder instability, and today, these patients are routinely recommended surgical treatment. It is also paramount to identify concomitant injury following the primary anterior instability event. The sensitivity, specificity, and reliability of radiographs is suboptimal, and the threshold to obtain advanced imaging such as computed tomography or magnetic resonance imaging with 3-dimensional reconstructions should be low. Taking into account the low non-recurrence complication rate following arthroscopic stabilization, early surgical intervention should be considered following the first instability event.

Anterior Shoulder Instability in the Aging Population: MRI Injury Pattern and Management

BACKGROUND. Literature on glenohumeral dislocations has focused on younger patient populations because of high recurrence rates. However, the spectrum of injuries sustained in younger versus older patient populations is reported to be quite different. OBJECTIVE. The purpose of this article is to describe MRI findings and management of anterior shoulder instability in the aging (≥ 60 years) population. METHODS. Shoulder MRI examinations of anterior glenohumeral dislocations in patients 40 years old and older were subdivided into groups younger than 60 years old or 60 years old and older and reviewed by two musculoskeletal radiologists for a Hill-Sachs lesion, other fracture, glenoid injury, capsulolabral injury, rotator cuff tear, muscle atrophy, and axillary nerve injury. Fischer exact test and logistic regression was evaluated for significant differences between cohorts, and interreader agreement was assessed. Surgical management was recorded, if available. RESULTS. A total of 104 shoulder MRI examinations (age range, 40-79 years; mean age, 58.3 years; 52 women, 52 men) were reviewed (54 examinations < 60 years; 50 examinations ≥ 60 years). Acute high-grade or full-thickness supraspinatus (64.0% vs 37.0%; p = .001), infraspinatus (28.0% vs 14.8%; p = .03), and subscapularis (22.0% vs 3.7%; p = .003) tears were more common in the group 60 years old and older. Hill-Sachs lesions were more common in the younger group (81.5% vs 62.0%; p = .046). Greater tuberosity fractures were seen in 15.4% of the overall cohort, coracoid fractures in 4.8%, and acute axillary nerve injuries in 9.6%. Interreader concordance was 88.5-89.4% for rotator cuff tears and 89.4-97.1% for osseous injury. In the group younger than 60 years old, 11 of 37 subjects (29.7%) had rotator cuff repair and 11 of 37 (29.7%) had labral repair, whereas 17 of 36 (47.2%) of the older group underwent rotator cuff repair, six of 36 (16.7%) underwent reverse shoulder arthroplasty, and six of 36 (16.7%) underwent labral repair. CONCLUSION. Radiologists should have a high index of suspicion for acute rotator cuff tears in anterior shoulder instability, especially in aging populations. Greater tuberosity or coracoid fractures and axillary nerve injury occur across all ages, whereas Hill-Sachs injuries are more common in younger patients. CLINICAL IMPACT. Acute high-grade or full-thickness rotator cuff tears are seen with higher frequency in older populations after anterior glenohumeral dislocation. Osseous and nerve injuries are important causes of patient morbidity that if not carefully sought out may be overlooked by the interpreting radiologist on routine imaging.

Management of bone loss in recurrent traumatic anterior shoulder instability: a survey of North American surgeons

Background

Management of bone loss in recurrent traumatic anterior shoulder instability remains a topic of debate and controversy in the orthopedic community. The purpose of this study was to survey members of 4 North American orthopedic surgeon associations to assess management trends for bone loss in recurrent anterior shoulder instability.

Methods

An online survey was distributed to all members of the American Shoulder and Elbow Surgeons, American Orthopaedic Society for Sports Medicine, and Canadian Orthopaedic Association and to fellow members of the Arthroscopy Association of North America. The survey comprised 3 sections assessing the demographic characteristics of survey respondents, the influence of prognostic factors on surgical decision making, and the operative management of 12 clinical case scenarios of varying bone loss that may be encountered in clinical practice.

Results

A total of 150 survey responses were returned. The age of the patient and quantity of bone loss were consistently considered important prognostic criteria. However, little consensus was reached for critical thresholds of bone loss and how this affected the timing (ie, primary or revision surgery) and type of bony augmentation procedure to be performed once a critical threshold was reached, especially in the context of critical humeral and bipolar bone loss.

Conclusions

Consistent trends were found for the management of recurrent anterior shoulder instability in cases in which no bone loss existed and when isolated critical glenoid bone loss was present. However, inconsistencies were observed when isolated critical humeral bone loss and bipolar bone loss were present.

Anterior Instability: What to Look for

Most first-time anterior glenohumeral dislocations occur as the result of trauma. Many patients suffer recurrent episodes of anterior shoulder instability (ASI). The anatomy and biomechanics of ASI is addressed, as is the pathophysiology of capsulolabral injury. The roles of imaging modalities are described, including computed tomography (CT) and MR imaging with the additional value of arthrography and specialized imaging positions. Advances in 3D CT and MR imaging particularly with respect to the quantification of humeral and glenoid bone loss is discussed. The concepts of engaging and nonengaging lesions as well as on-track and off-track lesions are examined.

Concomitant Coracoid Process Fracture with Bony Bankart Lesion Treated with the Latarjet Procedure

Bony lesions of the glenoid and Hill-Sachs lesions are the most common injuries after a first-time traumatic shoulder dislocation. However, fracture of the coracoid process after traumatic shoulder dislocation is rare. A single, open surgical procedure could be performed by a Latarjet procedure using a fractured fragment of the coracoid process. If a fracture of the coracoid process is associated with a traumatic anterior shoulder dislocation, the Latarjet procedure may be the most appropriate surgical option.

Type V superior labral anterior-posterior (SLAP) lesion in recurrent anterior glenohumeral instability

BACKGROUND

The literature has reported debatable diagnostic accuracy of clinical provocative tests for a type II superior labral anteroposterior (SLAP) lesion, especially in the context of a type V SLAP (concurrent Bankart and type II SLAP) lesion. This study was conducted to determine whether the investigated provocative tests offer reliable predictive values in the diagnosis of type II SLAP lesions in patients with recurrent anterior glenohumeral (GH) instability.

METHODS

This prospective case-control study carried out between September 2014 and September 2018 included 51 patients with post-traumatic recurrent anterior GH instability. Patients were prospectively evaluated for type II SLAP lesions by 9 provocative tests: Jobe relocation test, abduction-external rotation test, anterior slide test, biceps load test I, biceps load test II, pain provocation test, labral tension test, crank test, and the O'Driscoll dynamic labral shear test. The results of these tests were compared with findings of diagnostic arthroscopic GH examinations (control).

RESULTS

Statistical analysis revealed the mean age of the studied group to be 26.1 ± 7.56 years, with male predominance (50 patients; 98.04%). Arthroscopic examination revealed a Bankart lesion in isolation and in association with a type II SLAP lesion (ie, a type V SLAP lesion) in 15 (29.4%) and 36 (70.6%) patients, respectively. The anterior slide test yielded the highest positive and lowest negative likelihood ratios (2.91 and 0.52, respectively).

CONCLUSION

Except for the anterior slide test, which can be validated for the clinical diagnosis of type II SLAP lesions in patients with traumatic recurrent anterior GH instability, the investigated tests offer poor predictive values and should be cautiously used in clinical practice.

ACR Appropriateness Criteria® Shoulder Pain-Traumatic

Traumatic shoulder pain is pain directly attributed to a traumatic event, either acute or chronic. This pain may be the result of either fracture (the clavicle, scapula, or proximal humerus) or soft-tissue injury (most commonly of the rotator cuff, acromioclavicular ligaments, or labroligamentous complex). Imaging assessment of traumatic shoulder pain begins with conventional radiography and, depending on physical examination findings, will require MRI or MR arthrography for assessment of soft-tissue injuries and CT for delineation of fracture planes. Ultrasound excels in assessment of rotator cuff injuries but has limited usefulness for assessment of the deep soft-tissues. CT angiography and conventional arteriography are helpful for assessment of vascular injury, and bone scintigraphy can be used in assessment of complex regional pain syndrome after traumatic shoulder injury. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Concurrent Primary Repair of a Glenoid Labrum Articular Disruption and a Bankart Lesion in an Adolescent: A Case Report of a Novel Technique

Glenoid labrum articular disruption (GLAD) lesions are an uncommon concomitant injury associated with labral tears, occurring in 1.5-2.9% of cases. In previous reported cases, the articular lesion is debrided during repair of the labral injury, which may predispose patients to osteoarthritis, a longitudinal complication seen in articular debridement of the hip. We report the case of a 15-year-old healthy adolescent male swimmer who sustained a labral injury with a concomitant GLAD lesion. During operative management, three Polyetheretherketone (PEEK) SutureTaks were placed on the glenoid. #2 FiberWire was used to imbricate capsular tissue, passed beneath the labrum, and was then subsequently advanced through the fibrous rim of the displaced cartilage flap/GLAD lesion at the site of each suture anchor. This construct restored tension to the anterior band of the inferior glenohumeral ligament, recreated the anteroinferior labral bumper, and effectively reduced the cartilage flap/GLAD lesion to the anterior inferior glenoid. By six months postoperatively, the patient demonstrated near-normal function with full range of motion and evidence of a stable construct on MRI. Unlike previously described cases, this is the first report of a hybrid technique that simultaneously performed a primary repair of both labral and articular injuries without the use of additional implants for the articular lesion. Primary repair of the labral and articular lesions should provide longitudinal benefit to the patient by reducing the risk of developing glenohumeral osteoarthritis.

A comparison of glenohumeral joint translation between young and older asymptomatic adults using ultrasonography: a secondary analysis

Background: The rotator cuff muscles are subject to age-related changes, but the effect of aging on glenohumeral joint stability is poorly understood. Objectives: This study aimed to compare glenohumeral joint translation in asymptomatic young and older people. Methods: Twenty young (23.6 ± 5.3 years) and twenty older (66.5 ± 7.8 years) participants with no symptomatic shoulder pathology were recruited. Anterior and posterior glenohumeral joint translations were measured using real-time ultrasound in two positions: (1) shoulder neutral; and (2) shoulder at 90 degrees' abduction and four testing conditions: (1) rest; (2) passive accessory motion testing (PAMT) force alone; (3) PAMT with isometric internal rotation contraction; and (4) PAMT with external rotation contraction. Results: In both groups, there were significant differences between the amount of translation limited by anterior and posterior rotator cuff muscles in response to anterior and posterior PAMT force (p < 0.03), indicating rotator cuff activity-limited translation in a direction-specific manner. Young participants demonstrated increased passive posterior glenohumeral joint translation in the neutral shoulder position (p < 0.001) and their rotator cuff muscle contraction led to greater reductions in glenohumeral joint translation in the neutral shoulder position (p < 0.001), as compared with older participants. Conclusions: Rotator cuff contraction limits glenohumeral joint translation in a direction-specific manner in both young and older participants. However, younger age is associated with increased passive translation but greater ability to reduce glenohumeral joint translation with rotator cuff muscle contraction. Age-related changes should be considered when assessing and treating glenohumeral joint stability.

Arthroscopic Remplissage for Anterior Shoulder Instability: A Systematic Review of Clinical and Biomechanical Studies

PURPOSE

To examine the clinical outcomes and biomechanical data supporting the use of the remplissage procedure.

METHODS

A query of the Embase, PubMed, Scopus, and Web of Science databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines from 2000 to 2017. Data were extracted from included studies for a qualitative review of both clinical and biomechanical outcomes.

RESULTS

After review, 18 clinical and 10 biomechanical studies were available for analysis; 10 of 18 clinical studies (55.6%) were Level IV evidence. Within the clinical studies, there were 567 patients (570 shoulders) evaluated with follow-up ranging from 6 to 180 months. Overall, 5.8% of shoulders (33 of 570) displayed recurrent instability after arthroscopic remplissage. Of the shoulders with recurrent instability, 42.4% of shoulders (14 of 33) underwent further surgical management. In all studies evaluating pre- and postoperative patient-reported outcomes, the arthroscopic remplissage procedure improved patient-reported outcomes a statistically significant amount postoperatively. Within individual clinical studies, external rotation with the arm in neutral was the most consistently limited range of motion (ROM) parameter, with deficits compared with the contralateral shoulder ranging from 9° to 14°. Biomechanical analysis appeared to corroborate the clinical results, although significant conclusions were limited by heterogeneity of reporting.

CONCLUSIONS

Arthroscopic remplissage performed in conjunction with arthroscopic Bankart repair is a safe and effective procedure for patients with engaging Hill-Sachs lesions and subcritical glenoid bone loss. Although both the included clinical and biomechanical studies would suggest minimal changes in glenohumeral ROM following the remplissage procedure, strong conclusions are limited by the heterogeneity in reporting ROM data and lack of comparative studies.

LEVEL OF EVIDENCE

IV, systematic review.

Pectoralis major tendon transfer for recurrent anterior shoulder dislocation after primary surgery in an elderly patient: A case report

RATIONALE

Adequate stability of traumatic anterior shoulder dislocation without any obvious damage to the anterior capsulolabral structure in elderly patients can be achieved by treating the associated rotator cuff injuries. However, in case of recurrent shoulder dislocation despite rotator cuff repair, the repaired rotator cuff may be weakened or reruptured and is often impossible to repair again. Therefore, the role of the rotator cuff as a shoulder stabilizer cannot be expected. Even if the anterior joint capsule is left, it is too weak to imbrication either. An additional anterior structural reconstruction that can replace the rotator cuff and capsule is needed to prevent recurrence.

PATIENT CONCERNS

A 59-year-old man visited our clinic because of traumatic anterior dislocation of the right shoulder combined with anterior-superior rotator cuff tear. Because there was no obvious anterior capsulolabral injury, he underwent arthroscopic rotator cuff repair only. Postoperative rehabilitation was maintained; however, anterior shoulder dislocation recurred 10 months postoperatively.

DIAGNOSIS

Physical examination revealed anterior instability in abduction and external rotation of the shoulder joint. Magnetic resonance imaging suggested retear of the repaired anterior-superior rotator cuff and Hill-Sachs lesion of the humeral head.

INTERVENTIONS

Diagnostic arthroscopy was performed. The reruptured rotator cuff seemed impossible to repair; thus, arthroscopic remplissage procedure was performed for engaging the Hill-Sachs lesion. In addition, open pectoralis major tendon transfer for anterior stabilization was performed via the deltopectoral approach.

OUTCOMES

At the 12-month follow-up, the patient showed good clinical outcomes, including internal rotation of the shoulder joint without recurrent instability.

LESSON

Recurrent anterior shoulder dislocation after primary surgery in the elderly may be a challenging situation for surgeons. In patients with irreparable anterior rotator cuff tear and for whom reconstruction of the anterior glenoid is not indicated, pectoralis major tendon transfer is a good treatment option for satisfactory clinical outcomes without recurrence.

Shoulder apprehension: A multifactorial approach

Shoulder apprehension is related to changes in functional cerebral networks induced by dislocations, peripheral neuromuscular lesions and persistent mechanical glenohumeral instability consisting of micro-motion.All the damage to the osseous and soft-tissue stabilizers of the shoulder, as well as neurologic impairment persisting even after stabilization, must be properly identified in order to offer the best possible treatment to the patient.There is growing evidence supporting the use of a global multimodal approach, involving, on the one hand, shoulder 'reafferentation', including proprioception, mirror therapy and even cognitive behavioural approaches, and, on the other hand, surgical stabilization techniques and traditional physical therapy in order to minimize persistent micro-motion, which may help brain healing. This combined management could improve return to sport and avoid dislocation arthropathy in the long term. Cite this article: EFORT Open Rev 2018;3:550-557. DOI: 10.1302/2058-5241.3.180007.

Imaging the Glenoid Labrum and Labral Tears

The shoulder joint is the most unstable articulation in the entire human body. While this certainly introduces vulnerability to injury, it also confers the advantage of broad range of motion. There are many elements that work in combination to offset the inherent instability of the glenohumeral joint, but the glenoid labrum is perhaps related most often. Broadly, clinical unidirectional instability can be subdivided into anterior and posterior instability, which usually raise concern for anteroinferior and posteroinferior labral lesions, respectively. In the special case of superior labral damage, potential dislocation is blocked by structures that include the acromion; hence, while damage elsewhere commonly manifests as clinical instability, damage to the superior labrum is often described by the term microinstability. In this particular case, one of the radiologist's main concerns should be classic superior labral anteroposterior lesions. The glenoid labrum is also subject to a wide range of normal variants that can mimic labral tears. Knowledge of these variants is central to interpreting an imaging study of the labrum because misdiagnosis of labral variants as tears can lead to superfluous surgical procedures and decreased shoulder mobility. This article reviews labral anatomy and normal labral variants, describes their imaging features, and discusses how to discriminate normal variants from labral tears. Specific labral pathologic lesions are described per labral quadrant (anteroinferior, posteroinferior, and superior), and imaging features are described in detail. Online supplemental material is available for this article. ^©RSNA, 2016.

The "triple dislocation fracture": anterior shoulder dislocation with concomitant fracture of the glenoid rim, greater tuberosity and coracoid process-a series of six cases

BACKGROUND

A combined fracture of the glenoid rim, greater tuberosity, and coracoid process after anterior shoulder dislocation is a rare event. Only 1 patient has been reported in the literature.

METHODS

All patients with a first-time traumatic anterior shoulder dislocation in a level A trauma center were retrospectively reviewed. Among the 2068 patients treated between 1998 and 2013, we identified 6 patients (0.3%; 1 female, 5 male) with "triple dislocation fracture" (anterior shoulder dislocation with concomitant fracture of the glenoid rim, greater tuberosity, and coracoid process). All patients underwent surgery and had computed tomography scans before surgery and the first postoperative day. Mean follow-up time was 59 months. Clinical and radiographic evaluation, Constant-Murley Score, Simple Shoulder Test, and Subjective Shoulder Value were performed at the final follow-up.

RESULTS

Surgery was determined individually according to the radiologic findings, patient's age, and personal demands. Glenoid reconstruction was performed in all 6 patients, greater tuberosity refixation in 4 patients, and coracoid process refixation in 3. Two patients needed revision surgery due to loss of reduction. At the final follow-up, mean abduction was 133°, mean anterior flexion was 138°; the mean Constant-Murley Score was 72 points; the mean Simple Shoulder Test was 9 points; and the mean Subjective Shoulder Value was 72%. No recurrent instability occurred.

CONCLUSIONS

A "triple dislocation fracture," especially coracoid process fractures, can easily be overlooked in radiographs. Computed tomography scans are strongly recommended in patients with a first-time traumatic shoulder dislocation. Because recurrent joint instability and secondary arthropathy are serious complications after anterior shoulder dislocation, surgery should be considered and provides satisfying to excellent results.

The Glenoid Labrum

The glenoid labrum is a critical structure within the gleno-humeral joint and commonly requires treatment by the shoulder surgeon. This review presents a concise summary of the embryology, anatomy, microscopy, biomechanical properties and clinical lesions involving the glenoid labrum. This knowledge will aid the clinician in understanding its function and pathology.

MR arthrography evaluation in patients with traumatic anterior shoulder instability

INTRODUCTION

To evaluate retrospectively the diagnostic accuracy of MR arthrography, compared with arthroscopy, in research of the glenoid labrum tear in patients with a first episode of traumatic anterior shoulder instability (TUBS).

MATERIAL AND METHODS

We retrospectively reviewed the MR arthrography shoulder images of 118 patients with a first episode of TUBS, between June 2014 and May 2016.

RESULTS

The overall accuracy of MR arthrography compared with arthroscopy of the glenoid labrum lesions was 94%, sensitivity 93%, and specificity 96%. The sensitivity of MR arthrography for Perthes lesion was 71.4%, and for ALPSA lesion, it was 91%. Slap lesion occurred in 11 out of 77 cases (9.3% of 118 cases). The Hill-Sachs lesion occurred in 48 out of 118 cases (40.7%), while the Hill-Sachs reverse lesion in 4 cases (3.4%).

CONCLUSIONS

The MR arthrography is accurate in detecting labral injuries. However, other studies are needed to assess the less frequent tear, as Perthes lesion. The presence of the Hill-Sachs lesion could provide useful information about the level of the shoulder instability.

Anterior Shoulder Instability with Concomitant Superior Labrum from Anterior to Posterior (SLAP) Lesion Compared to Anterior Instability without SLAP Lesion

BACKGROUND

The aims of this study were to investigate the clinical characteristics of patients with combined anterior instability and superior labrum from anterior to posterior (SLAP) lesions, and to analyze the effect of concomitant SLAP repair on surgical outcomes.

METHODS

We retrospectively reviewed patients who underwent arthroscopic stabilization for anterior shoulder instability between January 2004 and March 2013. A total of 120 patients were available for at least 1-year follow-up. Forty-four patients with reparable concomitant detached SLAP lesions (group I) underwent combined SLAP and anterior stabilization, and 76 patients without SLAP lesions (group II) underwent anterior stabilization alone. Patient characteristics, preoperative and postoperative pain scores, Rowe scores, and shoulder ranges of motion were compared between the 2 groups.

RESULTS

Patients in group I had higher incidences of high-energy trauma (p = 0.03), worse preoperative pain visual analogue scale (VAS) (p = 0.02), and Rowe scores (p = 0.04). The postoperative pain VAS and Rowe scores improved equally in both groups without significant differences. Limitation in postoperative range of motion was similar between the groups (all p-value > 0.05).

CONCLUSIONS

Anterior instability with SLAP lesion may not be related to frequent episodes of dislocation but rather to a high-energy trauma. SLAP fixation with anterior stabilization procedures did not lead to poor functional outcomes if appropriate surgical techniques were followed.

Effect of glenohumeral position on contact pressure between the capsulolabral complex and the glenoid in free ALPSA and Bankart lesions

PURPOSE

Anterior shoulder dislocation is a common injury, but the optimal management of dislocation remains controversial. We hypothesized that reducing the shoulder in externally rotated position would aid the reduction in capsulolabral lesions. Thus, in this study, contact pressure between the capsulolabral lesion and the glenoid in free ALPSA and Bankart lesions was measured using a cadaver model.

METHODS

In 10 specimens, the humerus was externally rotated by abduction on the coronal plane to measure the contact pressure between the capsulolabral complex and glenoid in free ALPSA and Bankart lesions using a Tekscan pressure system. Stability of the joint was confirmed using the Vicon motion analysis system.

RESULTS

In the normal shoulder joint, the peak pressure between the subscapularis muscle and the anterior capsule according to the location of the glenohumeral joint decreased to 83.4 ± 21.2 kPa in the 0° abduction and -30° external rotation positions and showed a 300.7 ± 42.9 kPa peak value in the 60° abduction and 60° external rotation positions. In both free ALPSA and Bankart lesions, the lowest pressure between the labral lesion and the glenoid was measured at 0° abduction and -30° external rotation, and the highest pressure was recorded at 60° external rotation and 60° abduction.

CONCLUSION

The contact pressure between the capsulolabral complex and the glenoid significantly increased when the abduction and external rotation angles were increased. Based on our results, the conservative management in free ALPSA lesions would respond better than Bankart lesions.

IRB OR ETHICAL COMMITTEE APPROVAL

YWMR-12-0-038.

Incapacity of work after arthroscopic Bankart repair

BACKGROUND AND INTRODUCTION

The incapacity with respect to work following anterior-inferior shoulder dislocation and subsequent Bankart repair has not been previously examined. The objective of this study was to examine a patient's incapacity according to the classification by the REFA Association. The recovery time was measured and the outcome of patients with heavy workload was compared to those with lower workloads.

MATERIALS AND METHODS

A total of 74 patients who underwent isolated arthroscopic Bankart repair fulfilled the inclusion criteria. The Constant-Murley Score, UCLA Shoulder Score and ROWE Score for Shoulder Instability were recorded for clinical assessment. The mean follow-up time was 43.1 months (SD ± 17.4; 24-110 months) with a mean age of 34.7 years (SD ± 12.6). Workload was classified as per the REFA Association classification system. Postoperative duration of a patient's incapacity with respect to work and other subjective ratings were provided by the patients themselves.

RESULTS

The mean incapacity of work was 2.73 months (95 % CI 1.19-5.36). The incapacity of work was 2.06 months (95 % CI 1.55-2.68) in the group with low physical strains at work (REFA 0-1) and 3.40 months (95 % CI 2.70-4.24) in the group with heavy workload (REFA 2-4/p = 0.005). Overall, the mean Constant-Murley Score was 87.7 (SD ± 13.5). The average UCLA Shoulder Score summed up to 31.9 (SD ± 3.87) and the mean ROWE Score was 87.6 (SD ± 21.7). 13 (17.5 %) patients had problems to compete in their jobs. Three patients had to change the job postoperatively.

CONCLUSION

In this study, a relationship between the time of incapacity of work and the workload was observed; patients with low physical strains returned significantly earlier to work after arthroscopic Bankart repair (p = 0.005). In general, the clinical results as measured in the Constant/UCLA/Rowe score were comparable to other studies.

A comparison of magnetic resonance arthrography and arthroscopic findings in the assessment of anterior shoulder dislocations

OBJECTIVE

The aim of this study is to establish the sensitivity and specificity of MRA in the investigation of patients with traumatic anterior shoulder dislocations.

MATERIALS AND METHODS

A retrospective analysis of consecutive patients undergoing both magnetic resonance arthrography and arthroscopic assessment after a traumatic anterior shoulder dislocation between January 2011 and 2014 was performed. Demographic data were collected from electronic records. Images were interpreted by 8 musculoskeletal radiologists and patients were treated by 8 consultant orthopaedic surgeons. Arthroscopic findings were obtained from surgical notes and these findings were used as a reference for MRA. The sensitivity, specificity, and positive predictive value were calculated for the different injuries.

RESULTS

Sixty-nine patients underwent both an MRA and shoulder arthroscopy during the study period; however, clinical notes were unavailable in 9 patients. Fifty-three patients (88 %) were male, the mean age was 28 years (range 18 to 50) and 16 subjects (27 %) had suffered a primary dislocation. The overall sensitivity and specificity of MRA to all associated injuries was 0.9 (CI 0.83-0.95) and 0.94 (CI 0.9-0.96) retrospectively. The lowest sensitivity was seen in osseous Bankart 0.8 (CI 0.44-0.96) and superior labral tear (SLAP) lesions 0.5 (CI 0.14-0.86). The overall positive predictive value was 0.88 (CI 0.76-0.91) with the lowest values found in rotator cuff 0.4 (CI 0.07-0.83) and glenohumeral ligament (GHL) lesions 0.29 (CI 0.05-0.7).

CONCLUSION

Magnetic resonance angiography has a high sensitivity when used to identify associated injuries in shoulder dislocation, although in 8 patients (13 %) arthroscopy identified an additional injury. The overall agreement between MRA and arthroscopic findings was good, but the identification of GHL and rotator cuff injuries was poor.

[Pathophysiology of traumatic bone marrow edema]

BACKGROUND

Morphologically, bone marrow edema (BME) is an accumulation of fluid in the bone marrow. The BME is per se non-specific but can be identified at an early stage with magnetic resonance imaging (MRI). The underlying pathomechanism remains unclear. The BME can occur as an individual entity and as an accompanying condition of many diseases. The BME can be divided into three groups, ischemic, reactive and mechanical BME. Mechanical BME occurs after trauma or repetitive strain. Typical histological changes are present and there is no clear boundary between edema and microfracture. Some forms of trauma show BME in typical localizations. Both the trauma and the possible accompanying injuries can be indirectly indicated in this way in cases with an unknown trauma mechanism.

CONCLUSION

The BME can be present as an isolated entity or as a comorbidity. For initiation of therapy, a comprehensive medical history and targeted diagnostics are indispensable. In some cases BME is indicative of the trauma mechanism and possible further accompanying injuries.

Approach to the treatment of primary anterior shoulder dislocation: A review

Glenohumeral joint dislocation is common among younger, active patients. Anterior dislocation is the most common direction of instability following a traumatic event. Due to a high rate of recurrence following primary traumatic anterior shoulder dislocation, an evidence-based approach is necessary to determine the best treatment regime for a patient presenting with this problem. A history, physical examination, and radiographic imaging can help guide treatment recommendations by determining the extent of soft tissue damage following dislocation. Controversies in the treatment of the first-time dislocator include the length and position of immobilization following dislocation, and the role of initial surgical stabilization. This article outlines the treatment options for the first-time glenohumeral dislocator, with an emphasis on the available evidence in the literature. Where applicable, the criteria known as the Strength of Recommendation Taxonomy were used to summarize the strength of evidence available for recommendations.

Outcomes of arthroscopic Hill-Sachs remplissage and anterior Bankart repair: a retrospective controlled study including ultrasound evaluation of posterior capsulotenodesis and infraspinatus strength assessment

BACKGROUND

Hill-Sachs lesions are compression fractures that result from shoulder dislocation. They involve "engaging" the humeral head on the anterior glenoid rim when the arm is abducted and externally rotated. The defect grows as the number of dislocations increases.

HYPOTHESIS

Arthroscopic remplissage and anterior Bankart repair do not significantly affect infraspinatus strength while ensuring healing of the capsulotenodesis.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Sixty-one patients with traumatic anterior shoulder instability treated by arthroscopic Bankart repair and Hill-Sachs remplissage at least 24 months previously were compared with a control group of 40 healthy participants. Preoperative imaging included magnetic resonance imaging for Bankart lesion identification and computed tomography to quantify the humeral head defect. Active range of motion and clinical scores (Walch-Duplay, Constant-Murley, and Rowe) were assessed. External rotation (ER) and internal rotation (IR) were measured with arm at the side (ER1 and IR1) and abducted at 90° (ER2 and IR2). Infraspinatus strength was assessed with the scapula free (infraspinatus strength test [IST]) and retracted (infraspinatus scapula retraction test [ISRT]). Infraspinatus tenodesis and posterior capsulodesis healing were evaluated by ultrasound (US).

RESULTS

The follow-up median was 39.5 months (range, 24-56 months). One patient experienced a recurrence of instability at 34 months. In the remplissage patients, ER1 was significantly lower in the affected compared with the unaffected shoulder (P < .001). Mean IST and ISRT strength values did not show differences between sides. The mean Constant-Murley score rose from 62.9 ± 7.1 to 90 ± 5.2 (P < .0001). The Walch-Duplay and Rowe scores were excellent in 23 (78.6%), good in 6 (17.8%), and poor in 1 patient (both scores). The remplissage group had significantly lower ER1 (P < .001), ER2 (P < .001), and IR2 (P < .01) values compared with the control group. Differences in IST and ISRT between the groups were not significant. Capsulotenodesis healing and filling of the Hill-Sachs defect were confirmed by dynamic US in all subjects.

CONCLUSION

Arthroscopic remplissage is a reliable approach to Hill-Sachs lesions. The ER and IR restriction does not significantly affect quality of life. Infraspinatus strength recovery is satisfactory even compared with healthy subjects. Ultrasound examination allows accurate evaluation of capsulotenodesis healing.

First-time anterior shoulder dislocations: should they be arthroscopically stabilised?

The glenohumeral joint is inherently unstable because the large humeral head articulates with the small shadow glenoid fossa. Traumatic anterior dislocation of the shoulder is a relatively common athletic injury, and the high frequency of recurrent instability in young athletes after shoulder dislocation is discouraging to both the patient and the treating physician. Management of primary traumatic shoulder dislocation remains controversial. Traditionally, treatment involves initial immobilisation for 4-6 weeks, followed by functional rehabilitation. However, in view of the high recurrence rates associated with this traditional approach, there has been an escalating interest in determining whether immediate surgical intervention can lower the rate of recurrent shoulder dislocation, improving the patient's quality of life. This review article aims to provide an overview of the nature and pathogenesis of first-time primary anterior shoulder dislocations, the widely accepted management modalities, and the efficacy of primary surgical intervention in first-time primary anterior shoulder dislocations.

Assessment of coincidence and defect sizes in Bankart and Hill-Sachs lesions after anterior shoulder dislocation: a radiological study

OBJECTIVE

Bankart and Hill-Sachs lesions are often associated with anterior shoulder dislocation. The MRI technique is sensitive in diagnosing both injuries. The aim of this study was to investigate Bankart and Hill-Sachs lesions with MRI to determine the correlation in occurrence and defect sizes of these lesions.

METHODS

Between 2006 and 2013, 446 patients were diagnosed with an anterior shoulder dislocation and 105 of these patients were eligible for inclusion in the study. All patients were examined using MRI. Bankart lesions were classified as cartilaginous or bony lesions. Hill-Sachs lesions were graded I-III using a modified Calandra classification.

RESULTS

The co-occurrence of injuries was high [odds ratio (OR) = 11.47; 95% confidence interval (CI) = 3.60-36.52; p < 0.001]. Patients older than 29 years more often presented with a bilateral injury (OR = 16.29; 95% CI = 2.71-97.73; p = 0.002). A correlation between a Bankart lesion and the grade of a Hill-Sachs lesion was found (ρ = 0.34; 95% CI = 0.16-0.49; p < 0.001). Bankart lesions co-occurred more often with large Hill-Sachs lesions (O  = 1.24; 95% CI = 1.02-1.52; p = 0.033).

CONCLUSION

If either lesion is diagnosed, the patient is 11 times more likely to have suffered the associated injury. The size of a Hill-Sachs lesion determines the co-occurrence of cartilaginous or bony Bankart lesions. Age plays a role in determining the type of Bankart lesion as well as the co-occurrence of Bankart and Hill-Sachs lesions.

ADVANCES IN KNOWLEDGE

This study is the first to demonstrate the use of high-quality MRI in a reasonably large sample of patients, a positive correlation of Bankart and Hill-Sachs lesions in anterior shoulder dislocations and an association between the defect sizes.

Glenoid and humeral head bone loss in traumatic anterior glenohumeral instability: a systematic review

PURPOSE

The aim of this systematic review is to analyze outcomes of surgical procedures for glenoid and/or humeral bony defects, performed singularly or in combination, in patients with traumatic anterior glenohumeral instability. A secondary aim is to establish in clinical settings which percentage of glenoid or humeral bone loss needs to be treated with a bony procedure to avoid recurrence of dislocation.

METHODS

A systematic review of the literature according to the PRISMA guidelines was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase and Google Scholar databases using various combinations of the keywords "shoulder", "instability", "dislocation", "bone loss", "bony bankart", "osseous glenoid defects", "glenoid bone grafting", "Latarjet", "glenoid", "humeral head", "surgery", "glenohumeral", "Hill Sachs", "Remplissage", over the years 1966-2012 was performed.

RESULTS

Twenty-seven articles, describing patients with glenoid bony defect, humeral bony defect or both in the setting of traumatic anterior glenohumeral instability, were included. A total of 1,816 shoulders in 1,801 patients were included, with a median age at surgery of 27.1 years, ranging from 12 to 75 years. Patients were assessed at a median follow-up period of 2.8 years (ranging from 6 months to 28.2 years). The overall recurrence of redislocation occurred in 117 (6.5 %) shoulders. The redislocation event occurred in 40 of 553 (7.2 %) shoulders with glenoid bony defect, in 30 of 225 (13.3 %) shoulders with humeral bony defect and in 63 of 1,009 (6.3 %) shoulders with both glenoid and humeral involvement.

CONCLUSION

Even though the general principle of recognizing and treating glenoid and humeral bone defects in patients with traumatic anterior glenohumeral instability is widely accepted, few studies are available to date to accurately establish which bone defects should be treated with bone procedures and the exact percentage of bone loss leading to higher risk of redislocation in clinical settings.