Shoulder strength after open versus arthroscopic stabilization

[Translated article] Latarjet procedure for shoulder instability: Implications in the innervation of the subscapularis muscle

INTRODUCTION

Our aim was to describe whether Latarjet's technique affects subscapularis muscle innervation.

MATERIALS AND METHODS

We studied 12 embalmed shoulders. Subscapularis muscle innervation pattern was registered. Dimensions of the subscapularis at the glenohumeral joint line and the nerves entry point were measured. Horizontal distances from the nerves to the glenohumeral joint line as well as vertical ones to the split were measured before and after Latarjet procedure. A safe zone for the split was designed to avoid damage to subscapularis innervation.

RESULTS

Subscapularis muscle is innervated by three principal branches: upper, middle, and inferior subscapularis nerves. No statistical differences were found between innervation distances before and after Latarjet procedure. To perform subscapularis split along the muscle safe zone, two thirds' proportions throughout all the split must be maintained.

CONCLUSIONS

Subscapularis muscle has a triple innervation and was not altered after Latarjet procedure. Therefore, Latarjet technique seems to respect subscapularis muscle innervation if its split is placed through the subscapularis muscle safe zone.

Latarjet procedure for shoulder instability: Implications in the innervation of the subscapularis muscle

INTRODUCTION

Our aim was to describe whether Latarjet's technique affects subscapularis muscle innervation.

MATERIALS AND METHODS

We studied 12 embalmed shoulders. Subscapularis muscle innervation pattern was registered. Dimensions of the subscapularis at the glenohumeral joint line and the nerves entry point were measured. Horizontal distances from the nerves to the glenohumeral joint line as well as vertical ones to the split were measured before and after Latarjet procedure. A safe zone for the split was designed to avoid damage to subscapularis innervation.

RESULTS

Subscapularis muscle is innervated by three principal branches: upper, middle, and inferior subscapularis nerves. No statistical differences were found between innervation distances before and after Latarjet procedure. To perform subscapularis split along the muscle safe zone, two thirds' proportions throughout all the split must be maintained.

CONCLUSIONS

Subscapularis muscle has a triple innervation and was not altered after Latarjet procedure. Therefore, Latarjet technique seems to respect subscapularis muscle innervation if its split is placed through the subscapularis muscle safe zone.

Post-operative rehabilitation following traumatic anterior shoulder dislocation: A systematic scoping review

Background

This systematic scoping review aimed to describe the content of post-operative rehabilitation programmes, and outcome measures selection following stabilisation surgery for traumatic anterior shoulder dislocation (TASD).

Methods

An electronic search of Medline, EMBASE, CINAHL and AMED was conducted (2000-2021). Any cohort or clinical trial of patients receiving post-operative TASD rehabilitation were included. Study selection, data extraction and quality appraisal were undertaken by two independent reviewers.

Results

Twelve studies including fourteen treatment programmes were eligible. Period of post-operative immobilisation ranged from 1 day to 6 weeks, with exercise introduced between 1 and 7 weeks. Strengthening exercises were introduced between 1 and 12 weeks. Two studies described "accelerated" rehabilitation programmes, differing in immobilisation period and exercise milestones. No increased recurrence was reported in professional footballers. Two studies compared rehabilitation programmes, one not randomised, the other 18 years old. There was variability in selected outcomes measures, with only 4 studies using a common measure.

Discussion

There is minimal evidence to guide post-operative rehabilitation, variability in immobilisation periods and when exercise is introduced. There is no consensus on the definition of accelerated rehabilitation, or outcome measure selection. Clinical consensus of standardised terminology and stages of rehabilitation is required prior to efficacy studies.

Anterior Shoulder Instability and Open Procedures: History, Indications, and Clinical Outcomes

The shoulder, being the most mobile joint in the human body, is often susceptible to dislocations and subluxations more so than other joints. As such, shoulder instability constitutes a common complaint among patients worldwide, especially those who are young, participate in contact sports, and have increased innate flexibility in their joints. Management options in the setting of instability vary between conservative and surgical options that aim to mitigate symptoms and allow return of function. Surgical options can be arthroscopic and open, with a general shift among surgeons towards utilizing arthroscopic surgery in the past several decades. Nevertheless, open procedures still play a role in managing shoulder instability patients, especially those with significant bone loss, recurrent instability, coexisting shoulder pathologies, and high risk of failure with arthroscopic surgery. In these clinical settings, open procedures, like the Latarjet procedure, open Bankart repair, glenoid bone augmentation using iliac crest autograft or distal tibial allograft, and salvage options like glenohumeral arthrodesis and arthroplasty may show good clinical outcomes and low recurrence rates. Each of these open procedures possesses its own set of advantages and disadvantages and entails a specific set of indications based on published literature. It is important to cater treatment options to the individual patient in order to optimize outcomes and reduce the risk of complications. Future research on open shoulder stabilization procedures should focus on the long-term outcomes of recently utilized procedures, investigate different graft options for procedures involving bone augmentation, and conduct additional comparative analyses in order to establish concrete surgical management guidelines.

Serum Vitamin D Level Correlations With Tissue Vitamin D Level and Muscle Performance Before and After Rotator Cuff Repair

BACKGROUND

There is a lack of studies about serum and tissue vitamin D levels of the rotator cuff muscle on muscle power, fatty degeneration, and healing failure after rotator cuff repair (RCR). Furthermore, no studies have evaluated vitamin D receptor proteins in the rotator cuff that show a close association with serum vitamin D levels.

PURPOSE

To evaluate the correlations between serum vitamin D and tissue vitamin D as well as perioperative variables of arthroscopic RCR.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

From March 2017 to October 2017, a total of 36 patients who underwent RCR were prospectively enrolled, and supraspinatus muscle tissue was obtained during surgery to analyze tissue vitamin D levels. Serum vitamin D levels were checked preoperatively and at 6 months and 1 year postoperatively. Tissue vitamin D levels were assessed using liquid chromatography, and the vitamin D receptor was measured by western blotting. Isokinetic muscle performance test (IMPT; peak torque and torque deficiency compared with the opposite shoulder) results and fatty degeneration of the rotator cuff using the Goutallier classification were assessed preoperatively and at 1 year after surgery. The American Shoulder and Elbow Surgeons score and Constant score were collected at 2 years after surgery. Healing failure of the repaired rotator cuff was analyzed by magnetic resonance imaging at 1 year after surgery.

RESULTS

Overall, only three patients (8.3%) had serum vitamin D sufficiency (>20 ng/mL). Among 36 patients, 26 patients returned for their 1-year follow-up. Lower preoperative serum vitamin D levels resulted in lower serum vitamin D levels at 6 months and 1 year postoperatively (all P < .05). Lower preoperative and 1-year postoperative serum vitamin D levels resulted in more torque deficiency on the IMPT in abduction than higher preoperative and 1-year postoperative serum vitamin D levels (all P < .05). Tissue vitamin D levels had a strong correlation with preoperative serum vitamin D levels (P = .001). Lower tissue vitamin D levels were associated with lower peak torque on the IMPT in abduction (P = .043) and a tendency of lower peak torque on the IMPT in external rotation (P = .077) at 1 year postoperatively. There was no correlation between tissue and serum vitamin D levels and functional outcomes, fatty degeneration, and healing failure after surgery (all P > .05). The vitamin D receptor showed no correlation with any variables (all P > .05).

CONCLUSION

Lower preoperative serum vitamin D levels had a strong correlation with lower tissue vitamin D levels and lower serum vitamin D levels at 1 year after surgery. Furthermore, the patients with lower serum vitamin D levels showed more weakness of muscle power perioperatively. The results of this study emphasized the association between vitamin D levels and rotator cuff muscle power.

Functional Deficits After Open Latarjet Procedure and Dominance of the Operated Shoulder: An Analysis of 133 Patients

BACKGROUND

Return to sport after stabilization surgery using the open Latarjet procedure remains challenging. Additional knowledge is needed about postoperative shoulder functional deficits in order to better design return-to-sport programs.

PURPOSE

To investigate the effects of the dominance status of the operated shoulder on the shoulder functional profile recovery at 4.5 months after open Latarjet procedure.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A retrospective analysis of prospectively collected data was performed. All patients who underwent the open Latarjet procedure between December 2017 and February 2021 were eligible for the study. Functional assessment at 4.5 months after the surgery was performed using the following tests: maximal voluntary isometric contractions in glenohumeral internal and external rotation, upper-quarter Y balance test, unilateral seated shot-put test, and modified closed kinetic chain upper extremity stability test, leading to 10 outcome measures. Patients whose dominant side had undergone surgery and those whose nondominant side had undergone surgery were compared with a group of 68 healthy control participants.

RESULTS

A total of 72 patients who underwent an open Latarjet procedure on the dominant side and 61 patients who underwent open Latarjet on the nondominant side were compared with 68 healthy control athletes. In patients whose dominant shoulder had undergone surgery, significant deficits for the dominant side (P < .001) and for the nondominant side (P < .001) were found in 9 of 10 functional outcome measures. Among patients whose operations were on the nondominant shoulder, significant deficits for the nondominant side (P < .001) and for the dominant side (P < .001) were found in 9 and 5 of the 10 functional outcome measures, respectively.

CONCLUSION

Regardless of dominance of the stabilized shoulder, persistent deficits in strength, stability, mobility, power, and stroke frequency were observed at 4.5 months postoperatively. Stabilization of the dominant shoulder resulted in residual surgery-related functional impairments on both sides. However, stabilization of the nondominant shoulder resulted in impairments primarily noted in the nondominant, operative shoulder.

REGISTRATION

NCT05150379 (ClinicalTrials.gov identifier).

Clinical outcomes following open anterior shoulder stabilization for glenohumeral instability in the young collision athlete

BACKGROUND

Anterior glenohumeral instability occurs most commonly in those aged 15-29, with 72% of individuals younger than 22 years suffering recurrent episodes; collision athletes are at particular risk. In the setting of subcritical glenoid bone loss, arthroscopic Bankart repair is widely used despite concerns of recurrent dislocations when compared with open techniques. Furthermore, indications for bone-block procedures are evolving with the Latarjet procedure being favored amongst recent authors as a primary stabilization method in elite and contact athletes.

OBJECTIVE

To determine the efficacy of open modified Bankart stabilization in treating anterior glenohumeral instability in young collision athletes.

METHODS

This was a retrospective review of outcomes of consecutive patients aged 15-20 years who underwent unilateral or bilateral open stabilization for recurrent anterior glenohumeral instability over a 7-year period (2007-2015). The cohort was selected as recent literature suggests that this is the group with the highest redislocation rate and poorest outcomes. Outcome assessments included redislocation rate, return to sport, pain score, patient-related satisfaction scores, and the Western Ontario Shoulder Instability Index.

RESULTS

A total of 60 patients (55 male: 5 female) of mean age 18 years (range: 15-20 years) were available for follow-up at 7 years. All but 3 were competitive athletes with 18 competing regionally and 9 internationally; rugby union and rugby league represent the most common sports. Fifty-five of 60 (92%) have returned to their desired level of sport with 62% of athletes returning to their previous level of competition sport and 1 retuning at a higher level. The mean postoperative pain score was 2.5/10. The mean time to return to play was 14 months (range: 5-48 months). Eight of 60 shoulders reported redislocation (13%), 7 of these being traumatic dislocations after return to high-impact sporting activities. At 7 years of follow-up, 4 of 60 shoulders (7%) had undergone revision surgery.

CONCLUSION

Young collision athletes represent a challenging cohort of instability patients. This study of open modified Bankart in young collision sport athletes revealed excellent outcomes with 92% return to sport and a low revision rate. The results from this cohort rival those of arthroscopic repair. The open procedure described here in this 7-year series represents a robust, reliable technique that could be considered as an alternative to arthroscopic Bankart due to concern for recurrence, while avoiding potential morbidity and complication of bone-block procedures. There is still a role for the open modified Bankart procedure in treating traumatic anterior instability.

Clinical Outcomes of Revision Arthroscopic Capsulolabral Repair for Recurrent Anterior Shoulder Instability With Moderate Glenoid Bone Defects: A Comparison With Primary Surgery

Background:

The optimal revision surgery for failed primary arthroscopic capsulolabral repair (ACR) has yet to be determined. Revision ACR has shown promising results.

Purpose:

To compare the functional, strength, and radiological outcomes of revision ACR and primary ACR for anterior shoulder instability.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Between March 2007 and April 2017, a total of 85 patients underwent ACR (revision: n = 23; primary: n = 62). Functional outcome scores and positive apprehension signs were evaluated preoperatively, at 1 year, and then annually. Isokinetic internal and external rotation strengths were evaluated preoperatively and at 1 year after surgery.

Results:

The mean follow-up was 36.5 ± 10.2 months (range, 24-105 months). There was no significant difference between the revision and primary groups in the glenoid bone defect size at the time of surgery (17.3% ± 4.8% vs 15.4% ± 5.1%, respectively; P = .197). At the final follow-up, no significant differences were found in the American Shoulder and Elbow Surgeons score (97.6 ± 3.1 vs 98.0 ± 6.2, respectively; P = .573), Western Ontario Shoulder Instability Index score (636.7 ± 278.1 vs 551.1 ± 305.4, respectively; P = .584), or patients with a positive apprehension sign (17.4% [4/23] vs 11.3% [7/62], respectively; P = .479) between the revision and primary groups. There was no significant difference between the revision and primary groups for returning to sports at the same preoperative level (65.2% vs 80.6%, respectively; P = .136) and anatomic healing failure at 1 year after surgery (13.0% vs 3.2%, respectively; P = .120). Both groups recovered external rotation strength at 1 year after surgery (vs before surgery), although the strength was weaker than in the uninvolved shoulder. In the revision group, a larger glenoid bone defect was significantly related to a positive apprehension sign (22.0% ± 3.8%) vs a negative apprehension sign (16.0% ± 3.2%; cutoff = 20.5%; P = .003).

Conclusion:

In patients with moderate glenoid bone defect sizes (10%-25%), clinical outcomes after revision ACR were comparable to those after primary ACR. However, significant glenoid bone loss was related to a positive remaining apprehension sign in the revision group. Surgeons should consider these findings when selecting their revision strategy for patients with failed anterior shoulder stabilization.

The Calculation, Thresholds and Reporting of Inter-Limb Strength Asymmetry: A Systematic Review

The prevalence of inter-limb strength differences is well documented in the literature however, there are inconsistencies related to measurement and reporting, and the normative values and effects associated with inter-limb asymmetry. Therefore, the aims of this systematic review were to: 1) assess the appropriateness of existing indices for the calculation of asymmetry, 2) interrogate the evidence basis for literature reported thresholds used to define asymmetry and 3) summarise normative levels of inter-limb strength asymmetry and their effects on injury and performance. To conduct this systematic review, scientific databases (PubMed, Scopus, SPORTDiscus and Web of Science) were searched and a total of 3,594 articles were retrieved and assessed for eligibility and article quality. The robustness of each identified asymmetry index was assessed, and the evidence-basis of the identified asymmetry thresholds was appraised retrospectively using the references provided. Fifty-three articles were included in this review. Only four of the twelve identified indices were unaffected by the limitations associated with selecting a reference limb. Eighteen articles applied a threshold to original research to identify "abnormal" asymmetry, fifteen of which utilised a threshold between 10-15%, yet this threshold was not always supported by appropriate evidence. Asymmetry scores ranged between and within populations from approximate symmetry to asymmetries larger than 15%. When reporting the effects of strength asymmetries, increased injury risk and detriments to performance were often associated with larger asymmetry, however the evidence was inconsistent. Limitations of asymmetry indices should be recognised, particularly those that require selection of a reference limb. Failure to reference the origin of the evidence for an asymmetry threshold reinforces doubt over the use of arbitrary thresholds, such as 10-15%. Therefore, an individual approach to defining asymmetry may be necessary to refine robust calculation methods and to establish appropriate thresholds across various samples and methodologies that enable appropriate conclusions to be drawn.

Clinical outcome and return to sports activity after surgical treatment for recurrent shoulder instability with a modified Latarjet procedure

INTRODUCTION

The Latarjet procedure is an attractive surgical option for the management of chronic anterior shoulder instability. The original surgical approach involves the vertical tenotomy of the subscapularis tendon. Alternatively, the subscapularis muscle is split longitudinally and the tendon left attached at the lesser tuberosity.

HYPOTHESIS

The hypothesis is that the longitudinal split is of functional advantage and may lead to better functional results and earlier return to sports activities compared to the vertical tenotomy.

MATERIAL AND METHODS

Thirty-two patients were included in this retrospective cohort study. In 14 patients, the subscapularis tendon was vertically incised (group A), whereas in 18 patients, the subscapularis muscle was split longitudinally (group B). Patients were evaluated at 1 year (FU1) and 2 years (FU2) after the Latarjet procedure. Results at follow-up were correlated with patient-specific data and compared with the preoperative status. Primary outcomes were the functional assessment based on Western Ontario Shoulder Instability (WOSI) index and Constant Score (CS) and the assessment of the return to sports activity. Patients' demographics, duration of surgery, and the rate of recurrent dislocations were recorded as secondary variables.

RESULTS

All patients started their sports activities with a mean±SD of 12.41±1.24 weeks. Interestingly, the time from surgery to full recovery of sports activities was significantly longer for group A (mean±SD of 30.17±10.36 weeks) compared to group B (mean±SD of 20.71±3.67 weeks). There is a statistically significant decrease of the WOSI score from the preoperative level compared to FU1 and FU2, indicating a decrease in instability related symptoms during the entire follow up period with no statistically significant difference between group A and B. There is an increase in shoulder function during the entire follow up period based on the CS. Most interestingly, there is a statistically significant difference between group A and B at FU1, indicating a significantly better shoulder function for group B at the early follow up timepoint (FU1). At the later follow up timepoint (FU2), no difference exists in the individual items. However, a significantly better total CS remains in group B, indicating an overall improved function compared to group A.

DISCUSSION/CONCLUSION

The longitudinal split of subscapularis muscle is a safe approach which leads to quicker functional recovery and return to sports activity compared to the vertical tenotomy, which is a benefit especially for active individuals. It is therefore recommended as the standard surgical approach.

LEVEL OF EVIDENCE

III; Retrospective cohort study.

Assessment of postoperative acromial and subacromial morphology after arthroscopic acromioplasty using magnetic resonance imaging

OBJECTIVE

To identify the morphological characteristics of the acromion and subacromial bursal space after arthroscopic acromioplasty using magnetic resonance imaging (MRI).

MATERIALS AND METHODS

One hundred patients who received arthroscopic rotator cuff repair and acromioplasty each received at least three MRI examinations (preoperative, first immediate postoperative, and second follow-up imaging between 8 months and 1 year postoperatively). Changes over time in the thickness and morphology of the postoperative acromion as well as the subacromial bursal space were assessed. Clinical and radiological parameters were also analyzed to identify any association with changes in acromial morphology.

RESULTS

Despite minimal acromial thinning observed at the first immediate postoperative state, the acromions showed significant thinning at the second postoperative MRI, with a mean reduction of 32%. Along with acromial thinning, an exaggerated concave contour of the acromial undersurface was observed in some patients. In the subacromial space, a loculated fluid collection developed in 91% of the patients at the second postoperative follow-up. No statistically significant association was noted between postoperative acromial thickness change and clinical or radiological factors (P value > 0.05).

CONCLUSION

A significant delayed reduction in acromial thickness within approximately 1 year of arthroscopic acromioplasty is thought to be a normal postoperative feature. The simultaneous collection of a loculated, cyst-like fluid in the subacromial bursal space may be an important associated factor of postoperative acromial thinning.

Changes in Shoulder Rotator Strength After Arthroscopic Capsulolabral Reconstruction in Patients With Anterior Shoulder Instability

Background:

The correlation between isokinetic internal and external rotation (IR and ER) strength and functional outcomes in patients with anterior shoulder instability treated by arthroscopic capsulolabral reconstruction (ACR) has not been studied.

Purpose:

To analyze isokinetic IR and ER strength and their correlation with clinical outcomes in patients with anterior shoulder instability treated by ACR.

Study Design:

Case series; Level of evidence, 4.

Methods:

Between January 2004 and June 2015, a total of 104 patients who underwent ACR for anterior shoulder instability were analyzed. The mean peak torque (PT) in IR (IR_PT) and ER (ER_PT), PT deficit (PTD; %) relative to the opposite healthy shoulder, and PT ratio (PTR; ER_PT/IR_PT) were calculated before and 1 year after surgery. Functional scores were evaluated before surgery and at every follow-up visit. Recurrence and postoperative apprehension during ER at 90° of arm abduction were evaluated at 1 year and the final follow-up (76.6 ± 64.4 months).

Results:

IR and ER strength were measured for 68 of 104 patients at 1 year after surgery. ER_PT and IR_PT were less on the involved side than on the uninvolved side before surgery (0.29 ± 0.10 vs 0.33 ± 0.10 N·m/kg, respectively, for ER_PT [P = .002]; 0.36 ± 0.14 vs 0.41 ± 0.16 N·m/kg, respectively; for IR_PT [P = .01]). At 1 year after surgery, IR_PT on the involved side recovered (0.40 ± 0.20 N·m/kg), whereas ER_PT remained weak (0.30 ± 0.13 N·m/kg) relative to the baseline value. PTD in IR (PTD_IR) improved to 2.2% ± 24.4% (P = .012), whereas PTD in ER (PTD_ER) showed no improvement (13.5% ± 13.8%; P = .569). PTR on the involved side improved from 1.07 ± 1.71 to 0.86 ± 0.23 at 1 year (P < .001). All functional scores improved significantly at the final follow-up. At 1 year, 9 of 68 (13.2%) patients showed positive apprehension. PTD_IR and PTD_ER on the involved side were worse in patients with positive apprehension than in those with negative apprehension (P = .039 and .014, respectively). PTD_ER was worse than PTD_IR in patients with positive apprehension at 1 year (P = .022).

Conclusion:

For those with anterior shoulder instability, preoperative IR and ER strength of the involved shoulder were lower than those of the uninvolved shoulder. IR_PT recovered, whereas ER_PT remained weak after ACR. To prevent positive apprehension after surgery, IR and ER strengthening exercises are important, with more emphasis on exercises for ER.

The Evaluation and Management of the Failed Primary Arthroscopic Bankart Repair

Primary arthroscopic Bankart repair is a common procedure that is increasing in popularity; however, failure rates can approach up to 6% to 30%. Factors commonly attributed to failure include repeat trauma, poor or incomplete surgical technique, humeral and/or glenoid bone loss, hyperlaxity, or a failure to identify and address rare pathology such as a humeral avulsion of the glenohumeral ligament lesion. A thorough clinical and radiographic assessment may provide insight into the etiology, which can assist the clinician in making treatment recommendations. Surgical management of a failed primary arthroscopic Bankart repair without bone loss can include revision arthroscopic repair or open repair; however, in the setting of bone loss, the anterior-inferior glenoid can be reconstructed using a coracoid transfer, tricortical iliac crest, or structural allograft, whereas posterolateral humeral head bone loss (the Hill-Sachs defect) can be addressed with remplissage, structural allograft, or partial humeral head implant. In addition to the technical demands of revision stabilization surgery, patient and procedure selection to optimize outcomes can be challenging. This review will focus on the etiology, evaluation, and management of patients after a failed primary arthroscopic Bankart repair, including an evidence-based treatment algorithm.

Subscapularis structural integrity and function after arthroscopic Latarjet procedure at a minimum 2-year follow-up

BACKGROUND

Subscapularis function after arthroscopic Bankart repair has been widely studied. However, data regarding subscapularis performance after arthroscopic Latarjet procedures are lacking. This study aimed to evaluate subscapularis clinical and radiologic performance after arthroscopic Latarjet procedures.

METHODS

We included 40 patients who underwent arthroscopic Latarjet procedure with a minimum 2-year follow-up. Clinical evaluation included Western Ontario Shoulder Instability Index and Rowe scores, specific subscapularis isokinetic study, and lift-off tests. Contralateral measurements were used for comparison. Computed tomographic evaluation included graft consolidation, muscle dimensions, and degree of fatty atrophy, calculated as the mean muscle attenuation (MMA).

RESULTS

There was a decrease of 8.3% of maximum internal rotation peak torque in the operated arm (P = .02). However, there was no significant difference in the agonist-antagonist ratio: 76.9% in the operated arm and 76% in the contralateral (P = .82). Lift-off strength test demonstrated a decrease in the first year but not at final follow-up (P = .38). There was a significant decrease in lift-off distance of 23% compared to the contralateral side (P < .001). Subscapularis MMA was diminished when compared to the infraspinatus/teres minor (P < .001) at the expense of its upper part (P = .03). Hyperlaxity and number of dislocation episodes were correlated to a lower MMA (P = .046 and P = .005).

CONCLUSION

Arthroscopic Latarjet procedures provide satisfactory clinical results. There seems to be a diminished subscapularis MMA depending on its superior half. Hyperlaxity and number of previous dislocations were correlated to a lower MMA. Although there was a decrease in the maximum internal rotation peak torque, we did not find any difference in the agonist-antagonist ratio or in the final lift-off strength between sides.

The infraspinatus test may not be used to screen for shoulder external rotator strength deficits among patients with shoulder pathology

BACKGROUND

The infraspinatus test is often used to determine the presence of shoulder external rotator strength deficits. As the accuracy of this test has not been established adequately, the purpose of this study was to determine the accuracy of the infraspinatus test in detecting shoulder external rotator strength deficits.

METHODS

Sixty-two patients with a unilateral shoulder disorder underwent the infraspinatus test followed by instrumented assessment of shoulder external rotator muscle strength. The infraspinatus test was rated positive or negative based on the presence or absence of a strength deficit on the involved compared with the uninvolved shoulder. The instrumented strength assessment was rated positive or negative based on 4 cutoff thresholds for the presence of a strength deficit on the involved side: ≥10%, ≥15%, ≥20%, or ≥30%. The Sensitivity, specificity, positive and negative likelihood ratio of the infraspinatus test was determined based on each cutoff threshold.

RESULTS

Sensitivity ranged from 52.5 to 61.1%, specificity ranged from 72.7 to 90.9%, the positive likelihood ratio ranged from 2.24 to 5.77, while the negative likelihood ratio ranged from 0.52 to 0.59.

CONCLUSIONS

As considerable external rotator strength deficits may frequently exist among patients with a negative infraspinatus test, this test may not serve a good screening test for external rotator strength deficits. Contrarily, clinicians can be reasonably certain of the presence of an external rotator strength deficit given a positive infraspinatus test.

Arthroscopic soft tissue reconstruction in anterior shoulder instability

Anterior glenohumeral instability remains a difficult problem in the athletic and working patient populations. Treatment strategies are variable and range from nonoperative approaches incorporating immobilization and rehabilitation to surgical management. Surgical decision-making can be challenging, especially with a high-level patient who wishes to return to high-demand activities. Operative options range from open soft tissue stabilization to arthroscopic soft tissue stabilization, with both open and arthroscopic options for bony reconstruction in the setting of clinically significant anterior glenoid bone loss. In all cases, understanding appropriate indications and utilizing sound surgical techniques are critical for achieving a successful result. For the majority of patients with anterior shoulder instability, arthroscopic soft tissue reconstruction with suture anchors is a successful, minimally invasive approach that results in a stable shoulder with excellent outcomes and low complication rates.

Anterior Shoulder Instability: A Systematic Review of the Quality and Quantity of the Current Literature for Surgical Treatment

Background

Anterior shoulder instability is the most common sequela of shoulder dislocation and can result in repeated dislocations or subluxation of the glenohumeral joint. Anterior shoulder instability can be treated conservatively or surgically with several procedures.

Purpose

To date, arthroscopic Bankart is the most common surgical procedure for the treatment of anterior shoulder instability. No previous studies have compared all anterior shoulder surgical procedures. In this study, the authors performed a systematic review of journal articles describing all surgical procedures for anterior shoulder instability to determine the scientific evidence and level of recommendation.

Study Design

Systematic review; Level of evidence, 4.

Method

A comprehensive literature search was conducted (July 19, 2016) with 4 reputed databases: PubMed, EMBASE, the Cochrane databases, and Web of Science. The articles found in the literature search were screened by 2 reviewers on the basis of their titles, abstracts, and full text. Data were extracted from relevant studies, and potentially relevant records were selected for full-text review. Included articles were classified according to their scientific quality (level of evidence, 1-5). The studies were then combined for each surgical procedure, and a grade of recommendation was assigned for each procedure: grade A, treatment recommendation based on level 1 evidence studies; B, based on level 2 or 3 evidence studies; C, based on level 4 or 5 evidence and could represent conflicting results; or I, insufficient evidence to recommend a treatment. As such, the grade of recommendation provides a summary score for the quality and quantity of available literature to support the surgical procedures reviewed here.

Results

The systematic literature review generated 11,281 articles. After screening, 655 articles were included. Results revealed 31 surgical procedures for shoulder instability following dislocation: 10 surgical procedures were given an A or B recommendation; 11, a C recommendation; and 10, an I recommendation.

Conclusion

This review identified many surgical procedures to treat anterior shoulder instability. Ten of these surgical procedures had an abundant amount of published articles to describe their safety and efficacy. Arthroscopic Bankart and open Bankart were the most commonly reported procedures that cite satisfactory postoperative outcomes and limited complications. Publications on the other surgical procedures were less common. Surgeons should be careful when recommending surgery, and they should choose the appropriate surgical procedure based on evidence-based literature.

An assessment of quality of randomized controlled trials in shoulder instability surgery using a modification of the clear CLEAR-NPT score

BACKGROUND

The present study aimed to evaluate the methodological quality and determine the quality of reporting of randomized controlled trials (RCTs) that assess surgical treatment for shoulder instability.

METHODS

A Cochrane, Pubmed, EMBASE and Trip database search was performed, including the relevant literature, regarding RCTs that report on shoulder instability published between January 1994 and January 2017. Methodological quality was assessed with a modification of the Checklist to Evaluate A Report of a Nonpharmacologic Trial (CLEAR-NPT). Points were assigned based on 18 items regarding patient characteristics, randomization, care provider characteristics, surgical details and blinding, with a total score ranging from 0 points to 18 points. Missing items were verified with the corresponding authors of the studies. Quality of reporting corresponds to the total scores including the items that were additionally provided by the authors.

RESULTS

We included 22 studies. Of these, nine corresponding authors provided additional information. The average methodological quality was 16.9 points (11 studies) and the average quality of reporting was 9.5 points (22 studies). Items scoring worst included information regarding the surgeon's experience, the patients' level of activity, comorbidities, analyzing according to 'intention-to-treat' principles, and blinding of care providers, participants and assessors.

CONCLUSIONS

RCTs reporting on shoulder instability surgery are well performed but poorly reported.

Return to sport following arthroscopic Bankart repair: a systematic review

HYPOTHESIS AND BACKGROUND

The purpose of this systematic review was to determine the return-to-sport rate following arthroscopic Bankart repair, and it was hypothesized that patients would experience a high rate of return to sport.

METHODS

The MEDLINE, Embase, and PubMed databases were searched by 2 reviewers, and the titles, abstracts, and full texts were screened independently. The inclusion criteria were English-language studies investigating arthroscopic Bankart repair in patients of all ages participating in sports at all levels with reported return-to-sport outcomes. A meta-analysis of proportions was used to combine the rate of return to sport using a random-effects model.

RESULTS

Overall, 34 studies met the inclusion criteria, with a mean follow-up time of 46 months (range, 3-138 months). The pooled rate of return to participation in any sport was 81% (95% confidence interval [CI], 74%-87%). In addition, the pooled rate of return to the preinjury level was 66% (95% CI, 57%-74%) (n = 1441). Moreover, the pooled rate of return to a competitive level of sport was 82% (95% CI, 79%-88%) (n = 273), while the pooled rate of return to the preinjury level of competitive sports was 88% (95% CI, 66%-99%).

CONCLUSION

Arthroscopic Bankart repair yields a high rate of return to sport, in addition to significant alleviation of pain and improved functional outcomes in the majority of patients. However, approximately one-third of athletes do not return to their preinjury level of sports.

The effect of subscapularis tenotomy in athletes operated on for recurrent anterior shoulder dislocation

PURPOSE

Some authors consider preservation of the subscapularis tendon as one of the most important elements for a successful long-term outcome in patients operated on with open capsulorrhaphy for recurrent anterior shoulder dislocation. The purpose of this study was to evaluate whether vertical tenotomy of the subscapularis tendon might affect internal rotation strength recovery in patients operated on with open capsulorrhaphy for recurrent anterior shoulder dislocation.

METHODS

Ninety-six patients were retrospectively followed up at a mean of 72.5 months. They underwent clinical evaluation, Rowe and Walch-Duplay scoring scales, the Visual Analog Scale (VAS), and dynamometric measurements (side-to-side) of internal and external rotation, forward elevation, and abduction. All patients were athletes: 25% were practising risk-free sports, 44% contact sports, 14.5% sports with cocking of the arm, and 14.5% high-risk sports activities.

RESULTS

Five (5.2%) recurrences were registered, and all patients returned to pre-operative sports activity. The Rowe score was 98.12, the Walch-Duplay score 92.25, and the VAS score 0.1. Dynamometric assessment showed no significant differences (side-to-side) in internal rotation (p = 0.34), external rotation (p = 0.9), flexion (p = 0.7), and abduction (p = 0.7). Dominant arms showed better results than non-dominant arms (p < 0.01).

CONCLUSION

Complete tenotomy of the subscapularis tendon does not seem to negatively affect internal rotation strength recovery or external rotation movement in athletes.

Management of the first episode of traumatic shoulder dislocation

Shoulder joint dislocation is the most common joint dislocation seen in the emergency department.Traumatic dislocation may cause damage to the soft-tissues surrounding the shoulder joint and sometimes to the bone. The treatment, which aims at restoration of a fully functioning, pain-free and stable shoulder, includes either conservative or surgical management preceded by closed reduction of the acute dislocation.Conservative management usually requires a period of rest, generally involving immobilisation of the arm in a sling, even though it is still debated whether to immobilise the shoulder in internal or external rotation.Operative management, with no significant differences in term of re-dislocation rates between open and arthroscopic repair, incorporates soft-tissue reconstructions and/or bony procedures and is recommended in young male adults engaged in highly demanding physical activities.At our institution, non-operative management is favoured particularly for patients with multi-directional instability or soft-tissue laxity. Conservative measures are often preferred in older patients or younger patients that are not actively engaged in overhead activities. Immediate surgery on all first-time dislocations may subject many patients to surgery who would not have had any future subluxation.For these reasons, initially we will always try physical therapy and activity modification for the vast majority of our patients. Cite this article: EFORT Open Rev 2017;2:35-40.DOI: 10.1302/2058-5241.2.160018.

Precollegiate Knee Surgery Predicts Subsequent Injury Requiring Surgery in NCAA Athletes

BACKGROUND

The effect of precollegiate orthopaedic surgery on injury risk in the elite collegiate athlete is unknown.

PURPOSE

To (1) assess the relationship between precollegiate surgery and subsequent injury requiring surgery in National Collegiate Athletic Association (NCAA) Division I athletes at a single institution and (2) compare the risk of subsequent surgery in the ipsilateral versus contralateral extremity in those with a history of precollegiate surgery.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective chart review was performed of all athletes who began participation from 2003 to 2009 until completion of eligibility. Athletes who received orthopaedic surgery in college were identified through the Sports Injury Monitoring System and were cross-referenced with medical records. The risk of orthopaedic surgery was evaluated using multivariate Cox and Poisson regression models, with sex and sport as additional covariates. Risk of subsequent surgery in the ipsilateral versus contralateral extremity was compared using Kaplan-Meier survival estimates and Cox proportional hazards regression. Hazard ratios (HRs) and rate ratios (RRs) with corresponding 95% confidence intervals were used to compare groups.

RESULTS

In total, 1141 athletes were identified for analysis. Of these, 186 athletes (16.3%) had a history of precollegiate orthopaedic surgery. There were 261 documented intracollegiate orthopaedic surgeries in 181 athletes (15.9%). Precollegiate knee surgery was an independent predictor of orthopaedic surgery (HR, 1.85; 95% CI, 1.16-2.83) in college. When examining only surgeries resulting from acute or primary injuries, precollegiate knee surgery was an independent predictor of primary knee injury requiring surgery in college (HR, 4.45; 95% CI, 2.51-7.59). Athletes with a history of precollegiate surgery were more susceptible to subsequent surgery in their ipsilateral extremity compared with their other extremities (HR, 1.89; 95% CI, 1.03-3.53). In contrast, there was no additional risk of receiving subsequent surgery in the contralateral extremity (P = .54).

CONCLUSION

Precollegiate knee surgery in the Division I athlete is associated with subsequent injury requiring surgery in college. Athletes with a history of precollegiate surgery are at higher risk of subsequent surgery in their ipsilateral extremity compared with other extremities.

A new subscapular sling operation to stabilize the shoulder. A cadaver study

Introduction

A new arthroscopic shoulder stabilisation procedure is proposed, which for some patients could be an alternative to the arthroscopic Latarjet procedure.

Methods

The objective was to stabilize the shoulder by making a sling around the subscapularis tendon, using a hamstring graft and enhancing the anterior rim of the glenoid with the same graft. The anatomical feasibility of the surgical procedure was tested to establish the surgical method.

Results

Four surgeons performed the surgery on six cadavers. After the surgery the cadavers were dissected to visualize the result. The sling was placed according to the intention and the nerves in the area (axillary and musculocutaneus) were not at risk, nor had they altered position during the procedure.

Conclusion

The procedure is technically feasible and the risk of complications seems low. This procedure could be an alternative to the Latarjet procedure and to other operations used for anterior instability of the shoulder. A biomechanical study will be performed as the next stage of the development.

Clinical relevance

This procedure could be an alternative to the Latarjet procedure and to other operations used for anterior instability of the shoulder.

Trial registration

2012/1978/REK sør-øst

Structural and clinical integrity of the rotator cuff in athletes after arthroscopic Bankart repair using the three-portal technique

INTRODUCTION

Muscular recovery of structural integrity after arthroscopic Bankart repair using the para- and trans-musculotendinous three-portal technique has not been investigated.

MATERIALS AND METHODS

Twenty-seven athletes [mean age 26.9 years, (group 1; G1)] were prospectively and longitudinally monitored after arthroscopic Bankart repair using the three-portal technique by magnetic resonance imaging (MRI) and specific clinical muscular testing. The muscular integrity was assessed at the subscapularis (SSC) for the para-tendinous anteroinferior portal, the supraspinatus (SSP) for the trans-tendinous suprabicipital portal, and the infraspinatus (ISP) for the trans-tendinous posterior portal. Muscular atrophy was assessed by standardized ratios of transverse and vertical diameters for the SSC and ISP, as defined by cross-sectional area ratios for the SSP. Fatty infiltration was assessed by signal intensity analysis for the upper and lower SSC, SSP, and upper ISP as a ratio with the lower ISP. These parameters were analyzed for pre-operative (T0), 1-year (T1), and 2-year status (T2), and compared to 27 healthy volunteers [mean age 29.4 years, (group 2, G2)].

RESULTS

The structural integrity assessments were performed after 14.8 (T1) and 32.0 months (T2). The SSC analysis revealed no muscular impairments in the upper and lower portions between T0 and T2 or compared to G2. MRI analysis for SSP and ISP showed full muscular recovery without any changes between T0 and T2 or deficits compared to G2. The number of pre-operative dislocations had no influence on the muscular integrity. MR analysis detected signs of overuse syndrome in 15 % at T0, 41 % at T1, and 63 % at T2; 77, 22, and 26 % of patients at T0, T1, and T2, respectively, were symptomatic.

CONCLUSIONS

Arthroscopic Bankart repair using the three-portal technique prevents full muscular integrity for para-tendinous anteroinferior portals at the SSC, the trans-tendinous suprabicipital portal through the SSP, and the trans-tendinous portal through the ISP.

Survey on the management of acute first-time anterior shoulder dislocation amongst Dutch public hospitals

INTRODUCTION

The primary aim of this study was to record how orthopaedic surgeons are currently managing acute first-time anterior shoulder dislocation (AFASD) 8 years after introduction of the Dutch national guideline: "acute primary shoulder dislocation, diagnostics and treatment" in 2005. The second aim was to evaluate how these surgeons treat recurrent instability after AFASD.

MATERIALS AND METHODS

An online questionnaire regarding the management of AFASD and recurrent shoulder instability was held amongst orthopaedic surgeons of all 98 Dutch hospitals.

RESULTS

The overall response rate was 60%. Of the respondents, 75% had a local protocol for managing AFASD, of which 28% had made changes in their treatment protocol after the introduction of the national guideline. The current survey showed wide variety in the overall treatment policies for AFASD. Twenty-seven percent of the orthopaedic surgeons were currently unaware of the national guideline. The variability in treatment for AFASD was present throughout the whole treatment from which policy at the emergency department; when to operate for recurrent instability; type of surgical technique for stabilization and type of fixation of the labrum. As for the treatment of recurrent instability, the same variability was seen: 36% of the surgeons perform only arthroscopic procedures, 7% only open and 57% perform both open and arthroscopic procedures.

CONCLUSIONS

Despite the introduction of the national guideline for the initial management of AFASD in 2005, still great variety among orthopaedic surgeons in the Netherlands was present. As for the surgical stabilization technique, the vast majority of the respondents are performing an arthroscopic shoulder stabilization procedure at the expense of the more traditional open procedure as a first treatment option for post-traumatic shoulder instability.

Biomechanical evaluation of knotless anterior and posterior Bankart repairs

PURPOSE

The value of modern tape-like suture materials and the influence of the number of anchors inserted for arthroscopic Bankart repairs compared to the intact state have yet to be investigated. It was hypothesised: (1) suture-tape repairs will show higher biomechanical strength than common suture repairs, (2) four anchors will be stronger than three, and (3) the strength of the native capsulolabral complex will be greater than repairs.

METHODS

Six matched-paired cadaveric shoulders received Bankart lesions/reconstructions and three underwent intact state testing. Anteroinferior repairs compared suture and suture-tape repairs using three anchors, while posteroinferior repairs compared three and four suture anchors using common sutures. An established testing protocol was run for biomechanical testing.

RESULTS

There was no significant difference in the maximum loads, loads at 2 mm displacement, stiffness or energy between repair groups or between repairs and the intact state (n.s.). However, failure modes were different: 16/24 (66.7%) of the repair groups showed glenoid labrum detachment compared to 2/12 (16.7%) within the intact state group (P = 0.012).

CONCLUSIONS

While biomechanical parameters of repairs and intact states showed equivalence, failure-mode analysis reaffirms previous findings that capsulolabrum complex refixation is weaker than the native attachment. Therefore, in daily clinical practice, type of suture is secondary and insertion of a fourth anchor will be unlikely to add strength but may confer additional risk and cost.

A randomized clinical trial comparing open and arthroscopic stabilization for recurrent traumatic anterior shoulder instability: two-year follow-up with disease-specific quality-of-life outcomes

BACKGROUND

The literature comparing open and arthroscopic repair for glenohumeral instability is conflicting. We performed a prospective, expertise-based, randomized clinical trial to compare open shoulder stabilization with arthroscopic shoulder stabilization by measuring quality-of-life outcomes and recurrence rates at two years among patients treated for traumatic anterior shoulder instability.

METHODS

Computer-generated, variable-block-size, concealed randomization allocated 196 patients to either the open-repair group (n = 98) or the arthroscopic-repair group (n = 98). An expertise-based randomization design was employed to avoid a differential bias in terms of physician experience. Outcomes were measured at baseline, at three and six months postoperatively, and at one and two years postoperatively with use of the Western Ontario Shoulder Instability Index (WOSI) and the American Shoulder and Elbow Surgeons (ASES) functional outcome scale. Recurrent instability was also analyzed.

RESULTS

There were no significant differences in outcome scores at baseline. At two years, seventy-nine patients in the open group and eighty-three patients in the arthroscopic group were available for follow-up. There was no significant difference in mean WOSI scores between the groups; the mean WOSI score (and standard deviation) for the open group was 85.2 ± 20.4 (95% confidence interval [CI] = 80.5 to 89.8), and for the arthroscopic group, 81.9 ± 19.8 (95% CI = 77.4 to 86.4); p = 0.31. There was also no significant difference in mean ASES scores: 91.4 ± 12.7 (95% CI = 88.5 to 94.4) for the open group and 88.2 ± 15.9 (95% CI = 84.6 to 91.8) for the arthroscopic group; p = 0.17. Recurrence rates at two years were significantly different: 11% in the open group and 23% in the arthroscopic group (p = 0.05). Recurrent instability was more likely in patients with a preoperative Hill-Sachs lesion and in male patients who were twenty-five years old and younger. There was no significant difference in shoulder motion between the groups at two years.

CONCLUSIONS

There was no difference between open and arthroscopic repair in terms of patient quality of life. Open repair resulted in a significantly lower risk of recurrence. Secondary outcome data from this trial suggest that open surgical repair may be recommended to reduce the risk of recurrent instability in younger male patients with a Hill-Sachs lesion.

Are shoulders with a reverse shoulder prosthesis strong enough? A pilot study

BACKGROUND

It has been suggested that limited active ROM of reverse shoulder prostheses relates to lack of strength. However, the postoperative strength has not been quantified.

QUESTIONS/PURPOSES

We therefore measured joint torques in patients with reverse shoulder prostheses and correlated torques with functional scores.

METHODS

We recruited 33 patients (age, 72 ± 8 years) with a reverse prosthesis (37 shoulders, 21 primary and 16 revisions). We obtained Constant-Murley, DASH, and Simple Shoulder Test ([D]SST) scores, and performed two isokinetic protocols (abduction/adduction and external/internal rotation) at 60° per second. Minimum followup was 4 months (average, 23 months; range, 4-63 months).

RESULTS

Twenty-three patients (24 shoulders; 13 primaries, 11 revisions) were able to perform at least one of the defined tasks. Mean abduction and adduction torques were 15 Nm ± 7 Nm and 16 Nm ± 10 Nm (19%-78% of normal shoulders). External and internal rotation tasks could be performed by only 13 patients (14 shoulders; nine primary, five revisions) generating 9 Nm ± 4 Nm and 8 Nm ± 3 Nm, respectively (13%-71% of normal shoulders). We found moderate correlations between Constant-Murley, DASH and (D)SST (D = Dutch translation) scores and abduction and external rotation.

CONCLUSIONS

Patients with a reverse prosthesis had reduced strength when compared with normal values reported in the literature (only 65% of patients could perform the protocol). This effect was greatest for external rotation and might explain clinical outcomes with which a moderately strong relationship was observed. Our observations suggest limited strength is a major factor in reduced ROM.

Postoperative pain associated with orthopedic shoulder and elbow surgery: a prospective study

BACKGROUND

In the last 2 decades, extensive research in postoperative pain management has been undertaken to decrease morbidity. Orthopedic procedures tend to have increased pain compared with other procedures, but further research must be done to manage pain more efficiently. Postoperative pain morbidities and analgesic dependence continue to adversely affect health care.

MATERIALS AND METHODS

The study assessed the pain of 78 elbow and shoulder surgery patients preoperatively and postoperatively using the Short-Form McGill Pain Questionnaire (SF-MPQ). Preoperatively, each patient scored their preoperative pain (PP) and anticipated postoperative pain (APP). Postoperatively, they scored their 3-day (3dpp) and 6-week postoperative pain (6wpp). The pain intensities at these 4 intervals were then compared and analyzed using Pearson coefficients.

RESULTS

APP and PP were strong predictors of postoperative pain. The average APP was higher than the average postoperative pain. The 6wpp was significantly lower than the 3dpp. Sex, chronicity, and type of surgery were not significant factors; however, the group aged 18 to 39 years had a significant correlation with postoperative pain.

CONCLUSION

PP and APP were both independent predictors of increased postoperative pain. PP was also predictive of APP. Although, overall postoperative pain was lower than APP or PP due to pain management techniques, postoperative pain was still significantly higher in patients with increased APP or PP than their counterparts. Therefore, surgeons should factor patient's APP and PP to better manage their patient's postoperative pain to decrease comorbidities.

Long-term subscapularis strength assessment after Bristow-Latarjet procedure: isometric study

BACKGROUND

The subscapularis is the strongest rotator cuff muscle. Bristow-Latarjet procedure may impair subscapularis function. The aim of the study is to describe the difference in isometric subscapularis (SSC) strength after L-shape tenotomy versus muscle split in patients who underwent to Bristow-Latarjet procedure.

MATERIALS AND METHODS

From 2000 to 2006, we enrolled 376 patients for Bristow-Latarjet procedures. We identified 2 groups according to the subscapularis approach. Group A included 264 subjects with subscapularis L shape tenotomy; group B included 112 subjects with subscapularis muscle split. The subscapularis function was assessed with lift-off and belly-press tests. Isometric strength of rotator cuff muscle was assessed at an average follow-up of 45 months in group A and 42 months in group B, recording the maximum isometric peak torque (PT) (N), maximum isometric couple (Nm), relative strength index (N/Kg), strength, couple and external/internal rotator ratio. Constant and Rowe were used as scores.

RESULTS

Subscapularis assessment in the overall population showed 33 cases (8.8%) with a positive Lift-off test and 30 cases (8%) with a positive belly-press test. Rowe and Constant scores increased in both groups (P < .01). The mean PT in group A was lower of 24,8 Nw than group B (P < .01); similarly, the max PT values of group A were lower of 26.1 Nw than group B (P < .01).

CONCLUSION

L-shaped tenotomy in Bristow-Latarjet procedure has a weakening effect on the subscapularis and for these reasons we strongly recommend the muscle split approach for an optimal subscapularis function recovery.

Rotator cuff strength in recurrent anterior shoulder instability

BACKGROUND

Although rotator-cuff muscle contraction plays an important role in stabilizing the glenohumeral joint, little is known about the role of these muscles in the pathophysiology of recurrent anterior instability. We intended to analyze the association between isokinetic internal rotator and external rotator muscle strength and glenohumeral joint instability in patients with recurrent anterior instability that was not previously treated surgically.

METHODS

We enrolled thirty-seven patients with unilateral recurrent anterior posttraumatic shoulder dislocation and eleven healthy nonathletic subjects in this controlled study. The association between internal rotator and external rotator strength and shoulder instability was analyzed by side-to-side comparisons and comparisons with a control group. Isokinetic internal rotator and external rotator strength was evaluated with a Con-Trex dynamometer, with the subject seated and the shoulder abducted 45° in the scapular plane. Tests were performed at 180°/s, 120°/s, and 60°/s in concentric mode for both sides. Peak torque normalized to body weight and external rotator to internal rotator ratio were calculated for each angular velocity. Clinical and isokinetic evaluation was done by the same rehabilitation physician.

RESULTS

The association between shoulder instability and internal rotator and external rotator strength was associated with side-to-side differences (p < 0.05). Compared with a control group, strength values were lower on the pathological shoulder side of the patients with shoulder instability than on the healthy contralateral shoulder of control subjects at 180°/s and 120°/s (p < 0.05). The side-to-side differences were increased when the nondominant upper-extremity side was involved and were decreased when the dominant side was involved. There was no association between glenohumeral joint instability and external rotator to internal rotator ratio.

CONCLUSIONS

Internal rotator and external rotator weakness was associated with recurrent anterior instability, and side-to-side differences depended on the side of hand dominance. Use of a control group may help in the analysis of the influence of constraints on shoulder strength. Further prospective studies are necessary to determine whether the weakness is a cause or an effect of the instability.

Surgery for Shoulder Osteoarthritis: A Cochrane Systematic Review

Objective.

To determine the benefits and harm of surgery for shoulder osteoarthritis (OA).

Methods.

We performed a Cochrane Systematic Review of clinical trials of adults with shoulder OA, comparing surgical techniques [total shoulder arthroplasty (TSA), hemiarthroplasty, implant types, and fixation] to placebo, sham surgery, nonsurgical modalities, and no treatment. We also reviewed trials that compared various surgical techniques, reporting patient-reported outcomes (pain, function, quality of life, etc.) or revision rates. We calculated the risk ratio for categorical outcomes and mean differences for continuous outcomes with 95% CI.

Results.

There were no controlled trials of surgery versus placebo or nonsurgical interventions. Seven studies with 238 patients were included. Two studies compared TSA to hemiarthroplasty (n = 88). Significantly worse scores on the 0–100 American Shoulder and Elbow Surgeons scale (mean difference, −10.05 at 24–34 mo; 95% CI −18.97 to −1.13; p = 0.03) and a nonsignificant trend toward higher revision rate in hemiarthroplasty compared to TSA (relative risk 6.18; 95% CI 0.77 to 49.52; p = 0.09) were noted. With 1 study providing data (n = 41), no differences were noted between groups for pain scores (mean difference 7.8; 95% CI −5.33 to 20.93), quality of life on Medical Outcomes Study Short-Form 36 physical component summary (mean difference 0.80; 95% CI −6.63 to −8.23), and adverse events (relative risk 1.2; 95% CI 0.4 to 3.8).

Conclusion.

TSA was associated with better shoulder function, with no other demonstrable clinical benefits compared to hemiarthroplasty. More studies are needed to compare clinical outcomes between them and comparing shoulder surgery to sham, placebo, and other nonsurgical treatment options.

Matrix metalloproteases MMP-2 and MMP-9: are they early biomarkers of bone remodelling and healing after arthroscopic acromioplasty?

Arthroscopic acromioplasty, one of the most frequent procedures in shoulder surgery, can promote tissue healing process by the release of growth/angiogenic factors from the acromion. Matrix metalloproteinases MMP-2 and MMP-9 are involved in such process. The purpose of this study was to measure MMP-2 and MMP-9 levels in the articular fluid and in the peripheral blood of patients undergoing arthroscopic acromioplasty in order to better understand the local involvement of such factors in the healing process after surgical procedures. Concentrations of MMP-2 and MMP-9 in the subacromial space and peripheral blood collected shortly after surgery were determined by ELISA. MMP-2 and MMP-9 concentrations were measured in the subacromial fluid of 23 patients. In subacromial fluid, the levels between MMP-2 and MMP-9 did not reach statistical significance (127.15±45.56 vs 149.41±53.61 pg/ml, respectively, p>0.05). Peripheral blood levels of MMP-2 (130.75±47.48 pg/ml) were comparable to the subacromial fluid ones (127.15±45.56 pg/ml) whereas MMP-9 level was higher in the subacromial space (149.41±53.61 pg/ml) than in the peripheral blood (67.61±12.62 pg/ml, p<0.001). This work suggests that the measurement of bone specific MMPs (MMP-2 and MMP-9) can be an useful tool to be monitored in parallel with growth factor levels and other bone turnover markers in order to evaluate the bone remodelling and tissue healing processes. This study suggests that the measurement of bone specific MMPs levels, in particular MMP-9, may evaluate the bone remodelling and healing after arthroscopic shoulder acromioplasty.

Surgery for shoulder osteoarthritis

BACKGROUND

Surgical treatment including shoulder arthroplasty is a treatment option for patients with advanced osteoarthritis of the shoulder who have failed conservative treatment.

OBJECTIVES

To determine the benefit and harm of surgery in patients with osteoarthritis of the shoulder confirmed on X-ray who do not respond to analgesics and NSAIDs.

SEARCH STRATEGY

We searched: The Cochrane Central Register of Controlled Trials (CENTRAL), via The Cochrane Library; OVID MEDLINE; CINAHL (via EBSCOHost); OVID SPORTdiscus; EMBASE; and Science Citation Index (Web of Science).

SELECTION CRITERIA

All randomized clinical trials (RCTs) or quasi-randomized trials including adults with osteoarthritis of the shoulder joint (PICO- patients) comparing surgical techniques (total shoulder arthroplasty, hemiarthroplasty, implant types and fixation- intervention) versus placebo or sham surgery, non-surgical modalities, no treatment, or comparison of one type of surgical technique to another (comparison) with patient-reported outcomes (pain, function, quality of life etc.) or revision rates (outcomes).

DATA COLLECTION AND ANALYSIS

We reviewed titles and abstracts for inclusion, extracted study and outcomes data and assessed the risk of bias of included studies. For categorical outcomes, we calculated the risk ratio (with 95% confidence interval (CI)) and for continuous outcomes, the mean difference (95% CI).

MAIN RESULTS

Seven studies (238 patients) were included for analyses. None of the studies compared shoulder surgery to sham surgery, non-surgical modalities or placebo. Two studies compared hemiarthroplasty to total shoulder arthroplasty; three compared keeled and pegged humeral components; and one each compared navigation surgery to conventional and all-polyethylene to metal-backed implant. Two studies (88 patients) compared hemiarthroplasty to total shoulder arthroplasty. Patients who underwent hemiarthroplasty had statistically significantly worse functional scores on American Shoulder and Elbow Surgeons Shoulder Scale (100 point scale; higher = better) at 24 to 34 month follow-up compared to those who underwent total shoulder arthroplasty (mean difference, -10.05; 95% CI, -18.97 to -1.13; 2 studies, 88 patients), but no statistically significant differences between hemiarthroplasty and TSA were noted for pain scores (mean difference, 7.8; 95% CI, -5.33 to 20.93; 1 study, 41 patients), quality of life on short-form 36 physical component summary (mean difference, 0.80; 95% CI, -6.63 to 8.23; 1 study, 41 patients) and adverse events (Risk ratio, 1.19; 95% CI, 0.37 to 3.81; 1 study, 41 patients), respectively. A non-statistically significant trend towards higher revision rate in hemiarthroplasty compared to total shoulder arthroplasty was noted (Risk ratio, 6.18; 95% CI, 0.77 to 49.52; 2 studies, 88 patients; P = 0.09).

AUTHORS' CONCLUSIONS

Total shoulder arthroplasty seems to offer an advantage in terms of shoulder function, with no other clinical benefits over hemiarthroplasty. More studies are needed to compare clinical outcomes of surgery using different components and techniques in patients with osteoarthritis of the shoulder. There is a need for studies comparing shoulder surgery to sham, placebo and other non-surgical treatment options.

A biomechanical analysis of anterior Bankart repair using suture anchors

BACKGROUND

Arthroscopic repair of anterior Bankart lesions is typically done with single-loaded suture anchors tied with simple stitch configuration.

HYPOTHESIS

The knotless suture anchor will have similar biomechanical properties compared with two types of conventional suture anchors.

STUDY DESIGN

Controlled laboratory study.

METHODS

Fresh-frozen shoulders were dissected and an anteroinferior Bankart lesion was created. For phase 1, specimens were randomized into either simple stitch (SSA) or knotless suture anchors (KSA) and loaded to failure. For phase 2, specimens were randomized into 1 of 4 repair techniques and cyclically loaded then loaded to failure: (1) SSA, (2) suture anchor with horizontal mattress configuration, (3) double-loaded suture anchor with simple stitch configuration, or (4) KSA. Data recorded included mode of failure, ultimate load to failure, load at 2 mm of displacement, as well as displacement during cyclical loading.

RESULTS

For phase 1, the load required to 2 mm displacement of the repair construct was significantly greater in SSA (66.5 +/- 21.7 N) than KSA (35.0 +/- 12.5 N, P = .02). For phase 2, there was a statistically significant difference in ultimate load to failure among the 4groups, with both the single-loaded suture anchor with simple stitch (184.0 +/- 64.5 N), horizontal mattress stitch (189.0 +/- 65.3N), and double-loaded suture anchor with simple stitch (216.7 +/- 61.7 N) groups having significantly (P < .05) higher loads than the knotless group (103.9 +/- 52.8 N). There was no statistically significant difference (P > .05) among the 4 groups in displacement after cyclical loading or load at 2 mm of displacement.

CONCLUSION

Both knotless and simple anchor configurations demonstrated similar single loads to failure (without cycling); however, the knotless device required less single load to displace 2 mm. All repair stitches, including simple, horizontal, and double-loaded performed similarly.

CLINICAL RELEVANCE

The findings may suggest that with cyclical loading up to 25 N there is no difference in gapping greater than 2mm, but a macrotraumatic event may demonstrate a difference in fixation during the initial postoperative period. Additional in vivo studies are needed to determine whether these differences affect the integrity of the repair construct and, ultimately, the clinical outcome.

A biomechanical analysis of shoulder stabilization: posteroinferior glenohumeral capsular plication

BACKGROUND

The use of posterior capsular plication to decrease capsular volume and address capsular laxity for treatment of posterior instability, multidirectional instability, or as an additional technique in the treatment of anterior instability is common. Multiple different suturing techniques have been described.

HYPOTHESIS

The simple stitch will have inferior biomechanical properties compared with either the horizontal mattress or figure-of-8 stitches for suture plication of the posteroinferior quadrant of the glenoid.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twenty-one fresh-frozen shoulders with a mean age of 57.7 +/- 12.3 years were randomized into capsulolabral plication of the posteroinferior quadrant using either simple stitch configuration, horizontal mattress configuration, or figure-of-8 configuration. Each shoulder was mounted onto a materials testing machine, preloaded to 5 N for 2 minutes, cycled from 5 to 25 N for 100 cycles (1 Hz), and then loaded to failure at 15 mm/min. Capsular displacement from the glenoid was determined using digital video analysis. Data recorded included mode of failure, ultimate load to failure, load at 2 mm of displacement, as well as displacement during cyclical loading (during the entire 100 cycles and during the final cycle only).

RESULTS

There was a statistically significant difference (P < .0001) in mechanism of failure among the 3 groups with the simple stitch group failing more often in the capsular tissue than in the mattress and figure-of-8 sutures, which more commonly failed at the capsulolabral junction. There was no statistically significant difference (P > .05) among the 3 groups in gapping (displacement) after cyclical loading, load at 2 mm of displacement, or in ultimate load to failure. Conclusion/

CLINICAL RELEVANCE

Based on these results, all 3 stitches can be used effectively for capsular plication, although the simple stitch may be preferred for the capsular plication because of technical ease and decreased trauma to the capsulolabral tissue.

Open capsular shift: there still is a role!

As our understanding of the pathoanatomy of glenohumeral instability has improved, surgical techniques for the treatment of anterior instability have progressed. Many stabilization procedures are now successfully performed arthroscopically; open capsular shift, however, continues to play an important role in the management of instability in certain patients, providing an accurate and selective means of capsular plication. When performed with proper surgical technique, shoulder range of motion can be preserved with low recurrence rates and high subjective satisfaction, making the open capsular shift a durable and effective option in the modern management of shoulder instability.

The American Society of Shoulder and Elbow Therapists' consensus rehabilitation guideline for arthroscopic anterior capsulolabral repair of the shoulder

This manuscript describes the consensus rehabilitation guideline developed by the American Society of Shoulder and Elbow Therapists. The purpose of this guideline is to facilitate clinical decision making during the rehabilitation of patients following arthroscopic anterior capsulolabral repair of the shoulder. This guideline is centered on the principle of the gradual application of stress to the healing capsulolabral repair through appropriate integration of range of motion, strengthening, and shoulder girdle stabilization exercises during rehabilitation and daily activities. Components of this guideline include a 0- to 4-week period of absolute immobilization, a staged recovery of full range of motion over a 3-month period, a strengthening progression beginning at postoperative week 6, and a functional progression for return to athletic or demanding work activities between postoperative months 4 and 6. This document represents the first consensus rehabilitation guideline developed by a multidisciplinary society of international rehabilitation professionals specifically for the postoperative care of patients following arthroscopic anterior capsulolabral repair of the shoulder.