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Testa EJ, Kutschke MJ, He E, Owens BD. Biomechanics and Pathoanatomy of Posterior Shoulder Instability. Clin Sports Med 2024; 43:723-735. [PMID: 39232576 DOI: 10.1016/j.csm.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2024]
Abstract
Posterior glenohumeral instability represents a wide spectrum of pathoanatomic processes. A key consideration is the interplay between the posterior capsulolabral complex and the osseous anatomy of the glenoid and humeral head. Stability is dependent upon both the presence of soft tissue pathology (eg, tears to the posteroinferior labrum or posterior band of the inferior glenohumeral ligament, glenoid bone loss, reverse Hill Sachs lesions, and pathologic glenoid retroversion or dysplasia) and dynamic stabilizing forces. This review highlights unique pathoanatomic features of posterior shoulder instability and associated biomechanics that may exist in patients with posterior glenohumeral instability.
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Affiliation(s)
- Edward J Testa
- Department of Orthopedics, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Michael J Kutschke
- Department of Orthopedics, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Elaine He
- Department of Orthopedics, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Brett D Owens
- Department of Orthopedics, The Warren Alpert Medical School of Brown University, Providence, RI, USA.
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Nyffeler RW, Raass I, Haupt-Bertschy B. Posterior shoulder dislocation with acromion fracture: a case that illustrates a possible mechanism of posterior shoulder instability. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:536-539. [PMID: 39157215 PMCID: PMC11328993 DOI: 10.1016/j.xrrt.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Affiliation(s)
- Richard W. Nyffeler
- Orthopädie Sonnenhof, Bern, Switzerland
- Campus Stiftung Lindenhof Bern (Campus SLB), Bern, Switzerland
| | - Iina Raass
- Orthopädie Sonnenhof, Bern, Switzerland
- Campus Stiftung Lindenhof Bern (Campus SLB), Bern, Switzerland
| | - Bettina Haupt-Bertschy
- Institute of Physiotherapy, Insel Group, Inselspital, University Hospital, Bern, Switzerland
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Testa EJ, Morrissey P, Albright JA, Levins JG, Marcaccio SE, Badida R, Owens BD. A Posterior Acromial Bone Block Augmentation Is Biomechanically Effective at Restoring the Force Required To Translate the Humeral Head Posteriorly in a Cadaveric, Posterior Glenohumeral Instability Model. Arthroscopy 2024; 40:1975-1981. [PMID: 38278462 DOI: 10.1016/j.arthro.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 12/23/2023] [Accepted: 01/07/2024] [Indexed: 01/28/2024]
Abstract
PURPOSE To assess the biomechanical utility of a posterior acromial bone block (PABB) for the treatment of posterior glenohumeral instability. METHODS Ten fresh-frozen cadaveric specimens were obtained based upon an a priori power analysis. A 2.5-cm scapular spine autograft was harvested from all shoulders. A custom robot device was used to apply a 50-N compressive force to the glenohumeral joint. The humeral head was translated 10 mm posteroinferiorly at 30 degrees from the center of the glenoid at a rate of 1.0 mm/s in 6 consecutive conditions: (1) intact specimen, (2) intact with PABB, (3) posterior capsulolabral tear, (4) addition of the PABB, (5) removal of the PABB and repair of the capsulolabral tear (LR), and (6) addition of the PABB with LR. The maximum force required to obtain this translation was recorded. Paired t tests were performed to compare relevant testing conditions. RESULTS Ten cadavers with a mean ± SD age of 54.4 ± 13.1 years and mean ± SD glenoid retroversion of 6.5 ± 1.0 degrees were studied. The PABB provided greater resistance force to humeral head translation compared to the instability state (instability, 29.3 ± 15.3 N vs PABB, 47.6 ± 21.0 N; P = .001; 95% confidence interval [CI], -27.6 to -10.0). When comparing PABB to LR, the PABB produced higher resistance force than LR alone (PABB, 47.6 ± 21.0 N; LR, 34.2 ± 20.5 N; P = .012; 95% CI, -23.4 to -4.1). An instability lesion treated with the PABB, with LR (P = .056; 95% CI, -0.30 to 20.4) or without LR (P = .351; 95% CI, -6.8 to 15.7), produced resistance forces similar to the intact specimen. CONCLUSIONS A PABB is biomechanically effective at restoring the force required to translate the humeral head posteriorly in a cadaveric, posterior glenohumeral instability model. A posterior acromial bone block is a biomechanically feasible option to consider in patients with recurrent posterior instability. CLINICAL RELEVANCE Augmentation of the posterior acromion may be a biomechanically feasible option to treat posterior shoulder instability.
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Affiliation(s)
- Edward J Testa
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, U.S.A..
| | - Patrick Morrissey
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, U.S.A
| | - J Alex Albright
- Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, U.S.A
| | - James G Levins
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, U.S.A
| | - Stephen E Marcaccio
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, U.S.A
| | - Rohit Badida
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, U.S.A
| | - Brett D Owens
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, U.S.A
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Moroder P, Lacheta L, Minkus M, Gebauer H, Paksoy A, Thiele K, Akgün D. SECEC Didier Patte Prize 2023: the ABC classification of posterior shoulder instability. J Shoulder Elbow Surg 2024; 33:1435-1447. [PMID: 38218406 DOI: 10.1016/j.jse.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 11/16/2023] [Accepted: 11/19/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND The ABC classification has recently been proposed as a comprehensive classification system for posterior shoulder instability (PSI). The purpose of this study was to analyze the comprehensiveness as well as inter-rater and intrarater reliability of the ABC classification. METHODS All consecutive patients presenting with unidirectional PSI from June 2019 to June 2021 were included in a prospective study. No patients were excluded, leaving a consecutive series of 100 cases of PSI in 91 patients. All recorded clinical and imaging data were used to create anonymized clinical case vignettes, which were evaluated twice according to the ABC classification at the end of the recruitment period in random sequential order by 4 independent raters (2 experienced shoulder surgeons and 2 orthopedic residents) to analyze the comprehensiveness as well as inter-rater and intrarater reliability of the ABC classification for PSI and to describe differences in characteristics among subtypes. Group A was defined as a first-time singular PSI event <3 months in the past regardless of etiology and is further subdivided into type 1 and type 2 depending on the occurrence of a subluxation (A1) or dislocation (A2). Group B comprises recurrent dynamic PSI regardless of time since onset and is further subdivided by the cause of instability into functional (B1) and structural (B2) dynamic PSI. Group C includes chronic static PSI with posterior humeral decentering that can be either constitutional (C1) or acquired (C2). RESULTS None of the cases was deemed unsuitable to be classified based on the proposed system by the observers. After consensus agreement between the 2 expert raters, 16 cases were attributed to group A (8 type A1 and 8 type A2); 64, to group B (33 type B1 and 31 type B2); and 20, to group C (11 type C1 and 9 type C2). The expert raters agreed on the classification subtypes in 99% and 96% of the cases during the first rating and second rating, respectively (intraclass correlation coefficients [ICCs], 0.998 and 0.99, respectively). The intraobserver reliability was excellent for both raters. The beginners reached the same conclusion as the consensus agreement in 94% of the cases (ICC, 0.99) and 89% of the cases (ICC, 0.97) during the first round and 94% each (ICC, 0.97) during the second round. The intraobserver reliability was excellent for both beginners. Overall, discrepancies between raters were found between groups B1 and B2 (n = 14), groups B2 and C2 (n = 4), groups B1 and C1 (n = 1), and groups A1 and B2 (n = 1). In general, each subtype showed distinctive clinical and imaging characteristics that facilitated the diagnosis. CONCLUSION The presented ABC classification for PSI is a comprehensive classification with a high reliability and reproducibility. However, a gradual transition and potential progression between the subtypes of PSI must be considered. The reliable distinction between different subtypes of PSI based on etiology and pathomechanism provides a standardized basis for future investigations on treatment recommendations.
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Affiliation(s)
- Philipp Moroder
- Department for Shoulder and Elbow Surgery, Schulthess Klinik, Zurich, Switzerland
| | - Lucca Lacheta
- Department of Sports Orthopedics, Technical University of Munich, Munich, Germany
| | - Marvin Minkus
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Henry Gebauer
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Alp Paksoy
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Kathi Thiele
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Doruk Akgün
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.
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Werthel JD, Dufrenot M, Schoch BS, Walch A, Morvan Y, Urvoy M, Walch G, Gauci MO. Are glenoid retroversion, humeral subluxation, and Walch classification associated with a muscle imbalance? J Shoulder Elbow Surg 2024; 33:1493-1502. [PMID: 38242526 DOI: 10.1016/j.jse.2023.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/07/2023] [Accepted: 11/27/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND The etiology of humeral posterior subluxation remains unknown, and it has been hypothesized that horizontal muscle imbalance could cause this condition. The objective of this study was to compare the ratio of anterior-to-posterior rotator cuff and deltoid muscle volume as a function of humeral subluxation and glenoid morphology when analyzed as a continuous variable in arthritic shoulders. METHODS In total, 333 computed tomography scans of shoulders (273 arthritic shoulders and 60 healthy controls) were included in this study and were segmented automatically. For each muscle, the volume of muscle fibers without intramuscular fat was measured. The ratio between the volume of the subscapularis and the volume of the infraspinatus plus teres minor (AP ratio) and the ratio between the anterior and posterior deltoids (APdeltoid) were calculated. Statistical analyses were performed to determine whether a correlation could be found between these ratios and glenoid version, humeral subluxation, and/or glenoid type per the Walch classification. RESULTS Within the arthritic cohort, no statistically significant difference in the AP ratio was found between type A glenoids (1.09 ± 0.22) and type B glenoids (1.03 ± 0.16, P = .09), type D glenoids (1.12 ± 0.27, P = .77), or type C glenoids (1.10 ± 0.19, P > .999). No correlation was found between the AP ratio and glenoid version (ρ = -0.0360, P = .55) or humeral subluxation (ρ = 0.076, P = .21). The APdeltoid ratio of type A glenoids (0.48 ± 0.15) was significantly greater than that of type B glenoids (0.35 ± 0.16, P < .01) and type C glenoids (0.21 ± 0.10, P < .01) but was not significantly different from that of type D glenoids (0.64 ± 0.34, P > .999). When evaluating both healthy control and arthritic shoulders, moderate correlations were found between the APdeltoid ratio and both glenoid version (ρ = 0.55, P < .01) and humeral subluxation (ρ = -0.61, P < .01). CONCLUSION This in vitro study supports the use of software for fully automated 3-dimensional reconstruction of the 4 rotator cuff muscles and the deltoid. Compared with previous 2-dimensional computed tomography scan studies, our study did not find any correlation between the anteroposterior muscle volume ratio and glenoid parameters in arthritic shoulders. However, once deformity occurred, the observed APdeltoid ratio was lower with type B and C glenoids. These findings suggest that rotator cuff muscle imbalance may not be the precipitating etiology for the posterior humeral subluxation and secondary posterior glenoid erosion characteristic of Walch type B glenoids.
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Affiliation(s)
| | | | | | | | | | | | - Gilles Walch
- Ramsay Générale de Santé, Centre Orthopédique Santy, Jean Mermoz Private Hospital, Lyon, France
| | - Marc-Olivier Gauci
- Institut Universitaire Locomoteur et du Sport - Centre Hospitalier Universitaire (IULS-CHU) de Nice, Nice, France
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Cui DD, Long Y, Yan Y, Li C, Yang YT, Zhong JL, Yang R. Three-Dimensional Magnetic Resonance Imaging Fast Field Echo Resembling a Computed Tomography Using Restricted Echo-Spacing Sequence Is Equivalent to 3-Dimensional Computed Tomography in Quantifying Bone Loss and Measuring Shoulder Morphology in Patients With Shoulder Dislocation. Arthroscopy 2024; 40:1777-1788. [PMID: 38154531 DOI: 10.1016/j.arthro.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 12/30/2023]
Abstract
PURPOSE To evaluate the equivalence of 3-dimensional (3D) magnetic resonance imaging (MRI) (FRACTURE [Fast field echo Resembling A CT Using Restricted Echo-spacing]) and 3D computed tomography (CT) in quantifying bone loss in patients with shoulder dislocation and measuring morphologic parameters of the shoulder. METHODS From July 2022 to June 2023, patients with anterior shoulder dislocation who were aged 18 years or older and underwent both MRI and CT within 1 week were included in the study. The MRI protocol included an additional FRACTURE sequence. Three-dimensional reconstructions of MRI (FRACTURE) and CT were completed by 2 independent observers using Mimics software (version 21.0) through simple threshold-based segmentation. For bone defect cases, 2 independent observers evaluated glenoid defect, percentage of glenoid defect, glenoid track, Hill-Sachs interval, and on-track/off-track. For all cases, glenoid width, glenoid height, humeral head-fitting sphere radius, critical shoulder angle, glenoid version, vault depth, and post-processing time were assessed. The paired t test was used to assess the differences between 3D CT and 3D MRI (FRACTURE). Bland-Altman plots were constructed to evaluate the consistency between 3D CT and 3D MRI (FRACTURE). Interobserver and intraobserver agreement was evaluated with the interclass correlation coefficient. The paired χ2 test and Cohen κ statistic were used for binary variables (on-track/off-track). RESULTS A total of 56 patients (16 with bipolar bone defect, 5 with only Hill-Sachs lesion, and 35 without bone defect) were ultimately enrolled in the study. The measurements of 21 bone defect cases showed no statistically significant differences between 3D CT and 3D MRI: glenoid defect, 4.05 ± 1.44 mm with 3D CT versus 4.16 ± 1.39 mm with 3D MRI (P = .208); percentage of glenoid defect, 16.21% ± 5.95% versus 16.61% ± 5.66% (P = .199); glenoid track, 18.02 ± 2.97 mm versus 18.08 ± 2.98 mm (P = .659); and Hill-Sachs interval, 14.29 ± 1.93 mm versus 14.35 ± 2.07 mm (P = .668). No significant difference was found between 3D CT and 3D MRI in the diagnosis of on-track/off-track (P > .999), and diagnostic agreement was perfect (κ = 1.00, P < .001). There were no statistically significant differences between the 2 examination methods in the measurements of all 56 cases, except that the post-processing time of 3D MRI was significantly longer than that of 3D CT: glenoid height, 34.56 ± 1.98 mm with 3D CT versus 34.67 ± 2.01 mm with 3D MRI (P = .139); glenoid width, 25.32 ± 1.48 mm versus 25.45 ± 1.47 mm (P = .113); humeral head-fitting sphere radius, 22.91 ± 1.70 mm versus 23.00 ± 1.76 mm (P = .211); critical shoulder angle, 33.49° ± 2.55° versus 33.57° ± 2.51° (P = .328); glenoid version, -3.25° ± 2.57° versus -3.18° ± 2.57° (P = .322); vault depth, 37.43 ± 1.68 mm versus 37.58 ± 1.75 mm (P = .164); and post-processing time, 89.66 ± 10.20 seconds versus 360.93 ± 26.76 seconds (P < .001). For all assessments, the Bland-Altman plots showed excellent consistency between the 2 examination methods, and the interclass correlation coefficients revealed excellent interobserver and intraobserver agreement. CONCLUSIONS Three-dimensional MRI (FRACTURE) is equivalent to 3D CT in quantifying bone loss in patients with shoulder dislocation and measuring shoulder morphologic parameters. LEVEL OF EVIDENCE Level II, development of diagnostic criteria (consecutive patients with consistently applied reference standard and blinding).
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Affiliation(s)
- De-Dong Cui
- Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yi Long
- Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yan Yan
- Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Cheng Li
- Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yi-Tao Yang
- Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jing-Lian Zhong
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Rui Yang
- Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.
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Akgün D, Gebauer H, Paksoy A, Schafer F, Herbst E, Karczewski D, Pastor MF, Moroder P. Differences in Osseous Shoulder Morphology, Scapulothoracic Orientation, and Muscle Volume in Patients With Constitutional Static Posterior Shoulder Instability (Type C1) Compared With Healthy Controls. Am J Sports Med 2024; 52:1299-1307. [PMID: 38488401 PMCID: PMC10986147 DOI: 10.1177/03635465241233706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND Constitutional static posterior humeral decentering (type C1 according to ABC Classification) has been recognized as a pre-osteoarthritic deformity that may lead to early-onset posterior decentering osteoarthritis at a young age. Therefore, it is important to identify possible associations of this pathologic shoulder condition to find more effective treatment options. PURPOSE To perform a comprehensive analysis of all parameters reported to be associated with a C1 shoulder-including the osseous shoulder morphology, scapulothoracic orientation, and the muscle volume of the shoulder girdle in a single patient cohort. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS A retrospective, comparative study was conducted analyzing 17 C1 shoulders in 10 patients who underwent magnetic resonance imaging (MRI) with the complete depiction of the trunk from the base of the skull to the iliac crest, including both humeri. The mean age of the patients was 33.5 years, and all patients were men. To measure and compare the osseous shoulder morphology (glenoid version, glenoid offset, humeral torsion, anterior acromial coverage, posterior acromial coverage, posterior acromial height, and posterior acromial tilt) and scapulothoracic orientation (scapular protraction, scapular internal rotation, scapular upward rotation, scapular translation, scapular tilt, and thoracic kyphosis), these patients were matched 1 to 4 according their age, sex, and affected side with shoulder-healthy patients who had received positron emission tomography (PET)-computed tomography. To measure and compare the muscle volume of the shoulder girdle (subscapularis, infraspinatus/teres minor, supraspinatus, trapezius, deltoid, latissimus dorsi/teres major, pectoralis major, and pectoralis minor), patients were matched 1 to 2 with patients who had received PET-MRI. Patients with visible pathologies of the upper extremities were excluded. RESULTS The C1 group had a significantly higher glenoid retroversion, increased anterior glenoid offset, reduced humeral retrotorsion, increased anterior acromial coverage, reduced posterior acromial coverage, increased posterior acromial height, and increased posterior acromial tilt compared with controls (P < .05). Decreased humeral retrotorsion showed significant correlation with higher glenoid retroversion (r = -0.742; P < .001) and higher anterior glenoid offset (r = -0.757; P < .001). Significant differences were found regarding less scapular upward rotation, less scapular tilt, and less thoracic kyphosis in the C1 group (P < .05). The muscle volume of the trapezius and deltoid was significantly higher in the C1 group (P < .05). CONCLUSION Patients with C1 shoulders differ from healthy controls regarding osseous scapular and humeral morphology, scapulothoracic orientation, and shoulder girdle muscle distribution. These differences may be crucial in understanding the delicate balance of glenohumeral centering.
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Affiliation(s)
- Doruk Akgün
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Henry Gebauer
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Alp Paksoy
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Frederik Schafer
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Daniel Karczewski
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Testa EJ, van der List JP, Waterman BR, Caldwell PE, Parada SA, Owens BD. Management of Bone Loss in Posterior Glenohumeral Shoulder Instability: Current Concepts. JBJS Rev 2024; 12:01874474-202404000-00005. [PMID: 38619382 DOI: 10.2106/jbjs.rvw.23.00243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
» Posterior glenohumeral instability is relatively uncommon compared with anterior instability, but is becoming an increasingly recognized and surgically managed shoulder pathology.» Soft-tissue stabilization alone may not be sufficient in patients who present with substantial bone loss to the posterior glenoid and/or the anterior humeral head.» For posterior glenoid defects, posterior glenoid osteoarticular augmentation can be used, and posterior glenoid opening wedge osteotomy can be considered in cases of posterior instability with pathologic retroversion.» For humeral head lesions, several surgical treatment options are available including subscapularis transposition into the humeral head defect, autograft or allograft reconstruction, humeral rotation osteotomy, and shoulder arthroplasty.
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Affiliation(s)
- Edward J Testa
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island
| | - Jelle P van der List
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Brian R Waterman
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Paul E Caldwell
- Orthopaedic Research of Virginia, Richmond, Virginia
- Tuckahoe Orthopaedic Associates, Richmond, Virginia
| | - Stephen A Parada
- Medical College of Georgia at Augusta University, Augusta, Georgia
| | - Brett D Owens
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island
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Rawal A, Eckers F, Lee OSH, Hochreiter B, Wang KK, Ek ET. Current Evidence Regarding Shoulder Instability in the Paediatric and Adolescent Population. J Clin Med 2024; 13:724. [PMID: 38337418 PMCID: PMC10856087 DOI: 10.3390/jcm13030724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 01/18/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
Paediatric and adolescent shoulder instability is caused by a unique combination of traumatic factors, ligamentous laxity, and pattern of muscle contractility. The multifactorial nature of its aetiology makes interpretation of the literature difficult as nomenclature is also highly variable. The purpose of this review is to summarize the existing literature and shed light on the nuances of paediatric and adolescent shoulder instability. The epidemiology, clinical features, imaging, and management of all forms of paediatric shoulder instability are presented. The main findings of this review are that structural abnormalities following a dislocation are uncommon in pre-pubertal paediatric patients. Young post-pubertal adolescents are at the highest risk of failure of non-operative management in the setting of traumatic instability with structural abnormality, and early stabilisation should be considered for these patients. Remplissage and the Latarjet procedure are safe treatment options for adolescents at high risk of recurrence, but the side-effect profile should be carefully considered. Patients who suffer from instability due to generalized ligamentous laxity benefit from a structured, long-term physiotherapy regimen, with surgery in the form of arthroscopic plication as a viable last resort. Those who suffer from a predominantly muscle patterning pathology do not benefit from surgery and require focus on regaining neuromuscular control.
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Affiliation(s)
- Aziz Rawal
- Melbourne Orthopaedic Group, Windsor, Melbourne, VIC 3181, Australia; (A.R.); (F.E.)
| | - Franziska Eckers
- Melbourne Orthopaedic Group, Windsor, Melbourne, VIC 3181, Australia; (A.R.); (F.E.)
- Orthopädie und Traumatologie, Universitätsspital Basel, 4031 Basel, Switzerland
| | - Olivia S. H. Lee
- Victorian Paediatric Rehabilitation Service, The Royal Children’s Hospital, Melbourne, VIC 3052, Australia;
| | - Bettina Hochreiter
- Melbourne Orthopaedic Group, Windsor, Melbourne, VIC 3181, Australia; (A.R.); (F.E.)
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, 8006 Zürich, Switzerland
| | - Kemble K. Wang
- Department of Orthopaedic Surgery, The Royal Children’s Hospital, Melbourne, VIC 3052, Australia;
| | - Eugene T. Ek
- Melbourne Orthopaedic Group, Windsor, Melbourne, VIC 3181, Australia; (A.R.); (F.E.)
- Department of Surgery, Monash University, Melbourne, VIC 3800, Australia
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Testa EJ, Katz L, Zhang H, Chang K, Kutschke MJ, Dworkin M, Owens BD. Rotator Cuff Tears to Shoulder Instability: The Relationship Between Acromial Morphology and Shoulder Pathology. JBJS Rev 2024; 12:01874474-202401000-00004. [PMID: 38181125 DOI: 10.2106/jbjs.rvw.23.00188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Abstract
» The acromion is a well-studied region of the scapula that has demonstrated substantial relationships to various shoulder pathologies.» Abnormal acromial morphology is associated with rotator cuff pathology, and our understanding of this risk factor inspired acromioplasty as an adjunctive treatment for rotator cuff tears.» The acromion is linked closely to shoulder kinematics and biomechanics, as it serves as the origin for the deltoid muscle.» In degenerative shoulder disease, eccentric glenohumeral osteoarthritis has been associated with a higher, flatter acromial roof.» Increasing literature is emerging connecting morphology of the acromion with shoulder instability.
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Affiliation(s)
- Edward J Testa
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island
| | - Luca Katz
- Brown University, Warren Alpert School of Medicine, Providence, Rhode Island
| | - Helen Zhang
- Brown University, Warren Alpert School of Medicine, Providence, Rhode Island
| | - Kenny Chang
- Brown University, Warren Alpert School of Medicine, Providence, Rhode Island
| | - Michael J Kutschke
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island
| | - Myles Dworkin
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island
| | - Brett D Owens
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island
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11
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Niu Z, Shen X, Li M, Fan M, Zuo J, Liu T. Comparison of Glenohumeral Bone Morphology Between Patients With Versus Without Anterior Shoulder Instability. Orthop J Sports Med 2023; 11:23259671231217971. [PMID: 38145224 PMCID: PMC10748947 DOI: 10.1177/23259671231217971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/13/2023] [Indexed: 12/26/2023] Open
Abstract
Background The stability of the glenohumeral joint is associated with anatomic characteristics including bony structures and soft tissues. Purpose To compare the differences in specific bony glenohumeral geometries between shoulders with anterior shoulder instability (ASI), unaffected contralateral shoulders, and healthy control shoulders. Study Design Cross-sectional study; Level of evidence, 3. Methods Shoulder computed tomography (CT) scans of 36 patients with ASI and 36 matched healthy controls were retrieved and 3-dimensionally reconstructed. We measured the glenoid radius of curvature (GROC) in the anterior-posterior (AP) and superior-inferior directions, humeral head radius of curvature (HROC) in the AP direction, conformity index, glenoid height, glenoid width, glenoid index, stability angle, glenoid version, and glenoid depth. The differences between the groups were statistically calculated. CT scans of the unaffected contralateral shoulders from 21 of the ASI patients were also collected to identify the consistency of the bony structures in bilateral shoulders. Results Patients with ASI had greater GROC in the AP direction (P < .001), HROC in the AP direction (P = .002), glenoid height (P = .005), and glenoid index (P < .001) and smaller conformity index (P < .001), glenoid width (P = .002), stability angle (P < .001), and glenoid depth (P < .001). In addition, the glenoid of the ASI patients was more anteverted compared with that of controls (P = .001). There was no statistical difference in half the measurements between the bilateral shoulder joints in patients with ASI. Conclusion In this study, glenohumeral geometric differences were found between ASI patients and healthy control participants. Glenoid curvature and conformity index, based on bilateral comparisons of affected and contralateral shoulders, appear inherent and may predict ASI risk.
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Affiliation(s)
- Zhixin Niu
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, Jilin Province, China
- Department of Orthopedics, Jiaozuo People's Hospital, Jiaozuo, Henan Province, China
| | - Xianyue Shen
- Department of Orthopedics, The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology of China, Hefei, Anhui Province, China
| | - Menglong Li
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, Jilin Province, China
| | - Mingrui Fan
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, Jilin Province, China
| | - Jianlin Zuo
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, Jilin Province, China
| | - Tong Liu
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, Jilin Province, China
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12
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Arner JW, Nolte PC, Ruzbarsky JJ, Woolson T, Provencher MT, Bradley JP, Millett PJ. Correlation of Acromial Morphology With Risk and Direction of Shoulder Instability: An MRI Study. Am J Sports Med 2023; 51:3211-3216. [PMID: 37732534 DOI: 10.1177/03635465231197661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
BACKGROUND The influence of bony morphology on the development of posterior shoulder instability is not well known. PURPOSE To determine if acromial morphology, as measured on magnetic resonance imaging (MRI), is associated with posterior or anterior shoulder instability. DESIGN Cross-sectional study; Level of evidence, 3. METHODS MRI measurements of posterior acromial coverage (PAC), posterior acromial height (PAH), posterior acromial tilt (PAT), and anterior acromial coverage (AAC) were completed for 3 separate matched groups who underwent surgical intervention: posterior instability, anterior instability, and a comparison group of patients who underwent arthroscopic surgery for snapping scapula. Inclusion criteria were patients with recurrent instability <40 years of age without multidirectional instability, glenoid bone loss >13.5%, or glenoid retroversion >10%. RESULTS Overall, 37 patients were included in each group. PAC was significantly less in the posterior instability group than in the anterior instability and comparison groups (68.3° vs 88.7° vs 81.7°; P < .001). PAH was significantly greater in the posterior group than in the anterior instability group (11.0 mm vs -0.1 mm; P < .001) and comparison group (0.7 mm; P < .001). There was no difference between the posterior and anterior groups in terms of PAT or AAC (P = .45 and P = .05, respectively). PAT was significantly smaller in the posterior instability group than the comparison group (55.2° vs 62.2°; P = .026). The anterior and comparison groups were not significantly different in PAH or PAT (P = .874 and P = .067, respectively) but were significantly different in AAC (P = .026). CONCLUSION A higher and flatter posterior acromion, as measured on preoperative MRI, appears to be associated with patients who require arthroscopic capsulolabral repair due to posterior shoulder instability. This information may help clinicians to both diagnose and predict the need for operative intervention for patients with posterior labral tears.
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Affiliation(s)
- Justin W Arner
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Joseph J Ruzbarsky
- The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Thomas Woolson
- The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Matthew T Provencher
- The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado, USA
| | - James P Bradley
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Peter J Millett
- The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado, USA
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13
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Livesey MG, Bedrin MD, Baird MD, Tran A, Weir TB, Hasan SA, Gilotra MN, Kilcoyne KG, Dickens JF. Acromion morphology is associated with glenoid bone loss in posterior glenohumeral instability. J Shoulder Elbow Surg 2023; 32:1850-1856. [PMID: 37003427 DOI: 10.1016/j.jse.2023.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 02/22/2023] [Accepted: 03/01/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND The acromion morphology in a shoulder with posterior instability differs from that of a shoulder without glenohumeral instability. Specifically, the acromion with a flatter sagittal tilt, greater posterior acromial height, and less posterior coverage is associated with posterior instability. However, the association between acromion morphology and glenoid bone loss (GBL) in the setting of posterior glenohumeral instability has not previously been investigated. The purpose of this study was to determine whether acromial morphology influences the extent or pattern of posterior GBL in a cohort of patients with posterior glenohumeral instability. METHODS This multicenter retrospective study identified 89 shoulders with unidirectional posterior glenohumeral instability. Total area GBL was measured using the best-fit circle method on magnetic resonance imaging (MRI). Shoulders were divided into 3 groups: (1) no GBL (n = 30), (2) GBL 0%-13.5% (n = 45), or (3) GBL ≥13.5% (n = 14). Acromion measurements were performed on MRI and included acromial tilt, posterior acromial height, anterior acromial coverage, and posterior acromial coverage. RESULTS Patients without GBL had a steeper acromial tilt (58.5° ± 1.4°) compared with those with 0%-13.5% GBL (64.3° ± 1.5°) or GBL ≥13.5% (67.7° ± 1.8°) (P = .004). Patients without GBL also had greater posterior coverage (65.4° ± 1.7°) compared with those with GBL (60.3° ± 1.4°) (P = .015). Posterior acromion height was not significantly different among groups. CONCLUSION The results demonstrate that an acromion with a flatter sagittal tilt and less posterior coverage is associated with GBL in the setting of posterior glenohumeral instability. This is important to consider as posterior GBL has been identified as a risk factor for failure of posterior soft tissue-stabilizing procedures.
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Affiliation(s)
| | - Michael D Bedrin
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center Uniformed Services University of Health Sciences, Bethesda, MD, USA
| | - Michael D Baird
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center Uniformed Services University of Health Sciences, Bethesda, MD, USA
| | - Andrew Tran
- University of Maryland Medical Center, Baltimore, MD, USA
| | - Tristan B Weir
- University of Maryland Medical Center, Baltimore, MD, USA
| | - S Ashfaq Hasan
- University of Maryland Medical Center, Baltimore, MD, USA
| | | | - Kelly G Kilcoyne
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center Uniformed Services University of Health Sciences, Bethesda, MD, USA
| | - Jonathan F Dickens
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center Uniformed Services University of Health Sciences, Bethesda, MD, USA; Department of Orthopaedics, Duke University, Durham, NC, USA; Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.
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14
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Galvin JW, Rooney P, Slevin J, Yu HH, Tokish JM, Grassbaugh JA, Arrington ED. The influence of posterior acromial morphology on outcomes and return to pushups in young patients undergoing arthroscopic posterior capsulolabral repair. JSES Int 2023; 7:737-742. [PMID: 37719809 PMCID: PMC10499847 DOI: 10.1016/j.jseint.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Background Prior evidence has identified specific posterior acromial morphology as significantly associated with unidirectional posterior shoulder instability. The purpose of this study is to determine the influence of posterior acromial morphology on the outcomes of arthroscopic posterior capsulolabral repair (APCLR) for unidirectional posterior shoulder instability. Additionally, we sought to determine the influence of posterior acromial morphology on the rate and time to return to pushups following APCLR. Methods We performed a retrospective review of prospectively collected data. The study included consecutive patients undergoing APCLR. Data collected included demographics, radiographic measurements including posterior acromial height (PAH) and posterior acromial tilt on preoperative scapular-Y radiographs, and patient-reported outcome measures at the preoperative and postoperative visits. In addition, starting at 6 months postoperative, patients were asked if they could perform pushups defined as at least 10 repetitions. At the final follow-up, we collected the number of pushups patients were able to perform. Results Thirty-two consecutive patients underwent APCLR with a mean follow-up of 26 months (range, 12-41). Significant improvement from preoperative to 2 years postoperative was demonstrated in Subjective Shoulder Value (50-85), VAS (6-2.5), American Shoulder and Elbow Surgeons (48 to 83), and Western Ontario Shoulder Instability (WOSI) (1437-777), P = .001. The recurrent instability rate was 3/32 (9%). Patients with PAH > 23 (N = 17) had a recurrent instability rate of 18% (3/17) versus PAH ≤ 23 (N = 15) 0% (0/15), worse WOSI scores (P = .41), and a lower number of pushups (P = .48). The percentage of patients reporting the ability to perform pushups was (6 months/1 year/2 years) (50%/78%/95%). The mean number of pushups reported at the final follow-up was 33 (range, 1-60). Discussion Following APCLR, approximately 50% of patients resume pushups at 6 months postoperatively, and 80% return at 1 year. Patients reported performing a mean of 33 pushups following APCLR at the final follow-up. Patients with a PAH greater than 23 on preoperative scapular-Y radiographs had a higher rate of recurrent posterior instability, worse WOSI scores, and lower return to pushups; however, the results did not meet statistical significance. Therefore, future larger studies are needed to determine if posterior acromial morphology is independently associated with worse outcomes and increased recurrent instability rates following APCLR.
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Affiliation(s)
- Joseph W. Galvin
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Tacoma, WA, USA
| | - Patrick Rooney
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Tacoma, WA, USA
| | - John Slevin
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Tacoma, WA, USA
| | - Henry H. Yu
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Tacoma, WA, USA
| | - John M. Tokish
- Department of Orthopaedic Surgery, Mayo Clinic-Arizona, Scottsdale, AZ, USA
| | - Jason A. Grassbaugh
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Tacoma, WA, USA
| | - Edward D. Arrington
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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15
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Ye Z, Qiao Y, Wu C, Chen C, Su W, Xu C, Dong S, Xu J, Zhao J. Effect of Anterior Acromial Coverage on Functional and Radiological Outcomes After Arthroscopic Repair of Anteroposterior Massive Rotator Cuff Tears. Am J Sports Med 2023; 51:2831-2841. [PMID: 37593843 DOI: 10.1177/03635465231187900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
BACKGROUND Rotator cuff tear size, fatty infiltration, and scapular morphology are correlated with tendon healing and functional outcomes after arthroscopic repair; however, the association between anteroposterior acromial coverage and the clinical outcomes of anteroposterior massive rotator cuff tears (AP-MRCTs; involving all 3 tendons) remains unclear. PURPOSE To identify the association between AP acromial coverage and functional and radiological outcomes after arthroscopic repair of AP-MRCTs. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A total of 98 patients who underwent arthroscopic repair of AP-MRCTs between January 2015 and December 2020 were included in the study and classified according to whether anterior acromial coverage (AAC) was anterior (46 patients; positive AAC group) or posterior (52 patients; negative AAC group) to the scapular line on true lateral shoulder radiographs. Demographic characteristics, surgical details, and functional outcomes were prospectively collected. Acromial morphological features, global tear extension (GTE), the global fatty infiltration index (GFII), tendon integrity after repair, proximal humeral migration, and glenohumeral abduction were measured and calculated on radiographs or magnetic resonance imaging scans preoperatively and at 2 years postoperatively. Multivariate logistic regression was performed to identify the independent risk factors of a rotator cuff retear. RESULTS The positive AAC group showed larger AAC, posterior acromial tilt, and anterior acromial slope as well as smaller posterior acromial coverage compared with the negative AAC group. Postoperatively, the American Shoulder and Elbow Surgeons score (82.5 ± 8.3 vs 77.2 ± 11.5, respectively; P = .013), active abduction (157.8°± 27.1° vs 142.7°± 39.6°, respectively; P = .048), and glenohumeral abduction (45.6°± 10.4° vs 39.7°± 14.9°, respectively; P = .041) in the positive AAC group were significantly higher than those in the negative AAC group, while the retear rate (23.9% vs 44.2%, respectively; P = .035) and proximal humeral migration (1.7 ± 1.0 vs 2.3 ± 1.2 mm, respectively; P = .006) were significantly lower in the positive AAC group than in the negative AAC group. Smaller AAC (odds ratio [OR], 0.93 [95% CI, 0.87-1.00]; P = .040), larger GTE (OR, 1.03 [95% CI, 1.01-1.06]; P = .017), and a higher GFII (OR, 3.49 [95% CI, 1.09-11.19]; P = .036) were associated with an increased risk of a rotator cuff retear. CONCLUSION Increased AAC was associated with a lower retear rate and better functional outcomes after arthroscopic repair of AP-MRCTs. A preliminary risk evaluation integrating GTE, the GFII, and AAC is recommended to consider the necessity of additional procedures for patients in need of arthroscopic rotator cuff repair.
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Affiliation(s)
- Zipeng Ye
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi Qiao
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chenliang Wu
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chang'an Chen
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Su
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Caiqi Xu
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shikui Dong
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Junjie Xu
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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16
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Waltz RA, Brown J, Brady AW, Bartolomei C, Dornan GJ, Miles JW, Arner JW, Millett PJ, Provencher MT. Biomechanical Evaluation of Posterior Shoulder Instability With a Clinically Relevant Posterior Glenoid Bone Loss Model. Am J Sports Med 2023; 51:2443-2453. [PMID: 37350387 DOI: 10.1177/03635465231177957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
BACKGROUND Existing biomechanical studies of posterior glenoid bone loss and labral pathology are limited by their use of anterior instability models, which differ in both orientation and morphology and have been performed in only a single, neutral arm position. PURPOSE To evaluate the biomechanical effectiveness of a posterior labral repair in the setting of a clinically relevant posterior bone loss model in various at-risk arm positions. STUDY DESIGN Controlled laboratory study. METHODS Ten fresh-frozen cadaveric shoulders were tested in 7 consecutive states using a 6 degrees of freedom robotic arm: (1) native, (2) posterior labral tear (6-9 o'clock), (3) posterior labral repair, (4) mean posterior glenoid bone loss (7%) with labral tear, (5) mean posterior glenoid bone loss with labral repair, (6) large posterior glenoid bone loss (28%) with labral tear, and (7) large posterior glenoid bone loss with labral repair. Bone loss was created using 3-dimensional printed computed tomography model templates. Biomechanical testing consisted of 75 N of posterior-inferior force and 75 N of compression at 60° and 90° of flexion and scaption. Posterior-inferior translation, lateral translation, and peak dislocation force were measured for each condition. RESULTS Labral repair significantly increased dislocation force independent of bone loss state between 10.1 and 14.8 N depending on arm position. Dislocation force significantly decreased between no bone loss and small bone loss (11.9-13.5 N), small bone loss and large bone loss (9.4-14.3 N), and no bone loss and large bone loss (21.2-26.5 N). Labral repair significantly decreased posterior-inferior translation compared with labral tear states by a range of 1.0 to 2.3 mm. In the native state, the shoulder was most unstable in 60° of scaption, with 29.9 ± 6.1-mm posterior-inferior translation. CONCLUSION Posterior labral repair improved stability of the glenohumeral joint, and even in smaller to medium amounts of posterior glenoid bone loss the glenohumeral stability was maintained with labral repair in this cadaveric model. However, a labral repair with large bone loss could not improve stability to the native state. CLINICAL RELEVANCE This study shows that larger amounts of posterior glenoid bone loss (>25%) may require bony augmentation for adequate stability.
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Affiliation(s)
- Robert A Waltz
- Naval Health Clinic Annapolis, United States Naval Academy, Annapolis, MD, USA
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Justin Brown
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Alex W Brady
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Grant J Dornan
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Jon W Miles
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Justin W Arner
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Peter J Millett
- Steadman Philippon Research Institute, Vail, Colorado, USA
- The Steadman Clinic, Vail, Colorado, USA
| | - Matthew T Provencher
- Steadman Philippon Research Institute, Vail, Colorado, USA
- The Steadman Clinic, Vail, Colorado, USA
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17
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Hochreiter B, Beeler S, Hofstede S, Sigrist B, Snedeker JG, Gerber C. Posterior stability of the shoulder depends on acromial anatomy: a biomechanical study of 3D surface models. J Exp Orthop 2023; 10:59. [PMID: 37261546 PMCID: PMC10235013 DOI: 10.1186/s40634-023-00623-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/24/2023] [Indexed: 06/02/2023] Open
Abstract
PURPOSE Primary glenohumeral osteoarthritis is commonly associated with static posterior subluxation of the humeral head. Scapulae with static/dynamic posterior instability feature a superiorly and horizontally oriented acromion. We investigated whether the acromion acts as a restraint to posterior humeral translation. METHODS Five three-dimensional (3D) printed scapula models were biomechanically tested. A statistical shape mean model (SSMM) of the normal scapula of 40 asymptomatic shoulders was fabricated. Next, a SSMM of scapular anatomy associated with posterior subluxation was generated using data of 20 scapulae ("B1"). This model was then used to generate three models of surgical correction: glenoid version, acromial orientation, and acromial and glenoid orientation. With the joint axially loaded (100N) and the humerus stabilized, an anterior translation force was applied to the scapula in 35°, 60° and 75° of glenohumeral flexion. Translation (mm) was measured. RESULTS In the normal scapula, the humerus translates significantly less to contact with the acromion compared to all other configurations (p < .000 for all comparisons; i.e. 35°: "normal" 8,1 mm (± 0,0) versus "B1" 11,9 mm (± 0,0) versus "B1 Acromion Correction" 12,2 mm (± 0,2) versus "B1 Glenoid Correction" 13,3 mm (± 0,1)). Restoration of normal translation was only achieved with correction of glenoid and acromial anatomy (i.e. 75°: "normal" 11 mm (± 0,8) versus "B1 Acromion Correction" 17,5 mm (± 0,1) versus "B1 Glenoid Correction" 19,7 mm (± 1,3) versus "B1 Glenoid + Acromion Correction" 11,5 mm (± 1,1)). CONCLUSIONS Persistence or recurrence of static/dynamic posterior instability after correction of glenoid version alone may be related to incomplete restoration of the intrinsic stability that is conferred by a normal acromial anatomy. LEVEL OF EVIDENCE V biomechanical study.
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Affiliation(s)
- Bettina Hochreiter
- Department of Orthopaedics, University of Zurich, Balgrist University Hospital, Zurich, Switzerland.
| | - Silvan Beeler
- Department of Orthopaedics, University of Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Simon Hofstede
- Department of Orthopaedics, Biomechanical Research Laboratory, University of Zurich, Balgrist Campus, Zurich, Switzerland
| | - Bastian Sigrist
- Research in Orthopaedic Computer Science (ROCS), University of Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Jess G Snedeker
- Department of Orthopaedics, Biomechanical Research Laboratory, University of Zurich, Balgrist Campus, Zurich, Switzerland
| | - Christian Gerber
- Department of Orthopaedics, University of Zurich, Balgrist University Hospital, Zurich, Switzerland
- Balgrist Campus, Orthopaedic Research Center, Zurich, Switzerland
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18
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Gerber C, Sigrist B, Hochreiter B. Correction of Static Posterior Shoulder Subluxation by Restoring Normal Scapular Anatomy Using Acromion and Glenoid Osteotomies: A Case Report. JBJS Case Connect 2023; 13:01709767-202306000-00030. [PMID: 37172119 DOI: 10.2106/jbjs.cc.23.00060] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
CASE A 40-year-old man presented with progressive shoulder pain, associated with static posterior subluxation and mild eccentric glenohumeral osteoarthritis. Compared with a mean statistical shape model of a normal shoulder, the patient's acromion was abnormally high and horizontal, and the glenoid abnormally inclined inferiorly and minimally retroverted. Restoration of normal scapular anatomy using 3-dimensional planned acromial and glenoid osteotomies led to recentering of the joint and full shoulder function up to 24 months postoperatively. CONCLUSION The correction of associated acromial and glenoid malformation can revert early static posterior subluxation of the shoulder. Whether successful recentering prevents progression of osteoarthritis remains to be established.
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Affiliation(s)
- Christian Gerber
- Department of Orthopaedics University of Zürich, Balgrist University Hospital, Zürich, Switzerland
- Balgrist Campus, Orthopaedic Research Center, Zürich, Switzerland
| | - Bastian Sigrist
- Department of Orthopaedics, Laboratory for Research in Orthopaedic Computer Science (ROCS), University of Zurich, Balgrist Campus, Zurich, Switzerland
| | - Bettina Hochreiter
- Department of Orthopaedics University of Zürich, Balgrist University Hospital, Zürich, Switzerland
- Balgrist Campus, Orthopaedic Research Center, Zürich, Switzerland
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19
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Villefort C, Stern C, Gerber C, Wyss S, Ernstbrunner L, Wieser K. Mid-term to long-term results of open posterior bone block grafting in recurrent posterior shoulder instability: a clinical and CT-based analysis. JSES Int 2023; 7:211-217. [PMID: 36911764 PMCID: PMC9998725 DOI: 10.1016/j.jseint.2022.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background There is little consensus on the best treatment after failed conservative management of recurrent posterior shoulder instability. The purpose of this study was to analyze our clinical and radiological mid-term to long-term results of an open, posterior bone block procedure for the treatment of recurrent posterior shoulder instability. Methods From 1999 to 2015, 14 patients were included in the study and available for clinical and radiographic follow-up (FU). FU included a standardized physical examination, assessment of the Constant-Murley-Score, subjective shoulder value, American Shoulder and Elbow Surgeons score, and Western Ontario Shoulder Instability Index. Conventional radiographs and a computed tomography (CT)-scan were performed preoperatively and at latest FU. Glenohumeral arthropathy was classified as per Samilson and Prieto. The CT scans were used to evaluate the structure of the graft (resorption, union), graft positioning, glenoid version, centering of the humeral head, and glenoid erosion and morphology. Results The median age at the time of surgery was 26 years (range 16-41 years) and the median FU period was 9 years (range 4-20 years). The rate of reported dynamic postoperative subluxation and instability was 46% (n = 6) and the rate of dynamic posterior instability during clinical testing at FU was 31% (n = 4). The tested instability rate in the traumatic group was 14% (n = 1) compared to the atraumatic group with 50% (n = 3) during clinical FU. The mean Constant-Murley-Score increased from preoperatively (77 ± 11 points) to postoperatively (83 ± 14 points, P = .158). The last FU showed an American Shoulder and Elbow Surgeons score of 85 ± 12; the Western Ontario Shoulder Instability Index score was 715 ± 475 points. The mean subjective shoulder value increased from 58% ± 19 preoperatively to 73% ± 17 at final FU (P = .005). Degenerative changes increased by at least one grade in 67% of the patients. Mean preoperative glenoid retroversion (CT) was 7.5° ± 6°. The position of the graft was optimal in 86% (n = 12). In 62% of the cases, a major resorption of the graft (Zhu grade II) was observed. Conclusion The rate of tested recurrent instability at last FU was as high as 31% (n = 4, atraumatic [n = 3] vs. traumatic [n = 1]) after a median FU of 9 years. Given the moderate improvement of clinical outcome scores, shoulder stability and the increase of degenerative joint changes by at least one grade (Samilson/Prieto) in 67% of patients, a posterior bone block procedure is not a uniformly satisfying treatment option for recurrent posterior shoulder subluxation, especially in cases of atraumatic posterior instability.
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Affiliation(s)
- Christina Villefort
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Christoph Stern
- Department of Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Christian Gerber
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Sabine Wyss
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Lukas Ernstbrunner
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Karl Wieser
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Posterior Glenoid Bone Loss and Instability: An Evidence-based Approach to Diagnosis and Management. J Am Acad Orthop Surg 2023; 31:429-439. [PMID: 36848487 DOI: 10.5435/jaaos-d-22-00060] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 12/13/2022] [Indexed: 03/01/2023] Open
Abstract
Posterior glenohumeral instability is an underappreciated cause of disability that may necessitate surgical intervention to allow functional glenoid restoration. However, posterior glenoid bone abnormalities, when sufficiently severe, may contribute to persistent instability despite a well-performed capsulolabral repair. Recognition and understanding of these lesions is critical to both surgical decision making and execution of the surgical plan. Numerous procedures have been described to address posterior instability including recent developments in arthroscopic grafting techniques. The purpose of this article was to provide an evidence-based strategy for diagnosis and management of posterior shoulder instability and glenoid bone loss.
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21
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Mayntzhusen TW, Witten A, Gramkow J, Hansen SB, Chatterjee SA, Hølmich P, Barfod KW. Interrater and intrarater reliability of four different classification methods for evaluating acromial morphology on standardized radiographs. JSES Int 2023. [DOI: 10.1016/j.jseint.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
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22
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Rajeswaran G, Basu S, Funk L. Imaging Posterior Instability of the Shoulder. Semin Musculoskelet Radiol 2022; 26:558-565. [DOI: 10.1055/s-0042-1754365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AbstractPosterior instability of the shoulder is much less common than anterior instability with a clinical presentation that is often less obvious, making the diagnosis more challenging and more easily missed. We describe the imaging findings of posterior instability so the radiologist can make the diagnosis and provide a detailed description, enabling the surgeon to make more informed decisions regarding management and surgery.
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Affiliation(s)
- Gajan Rajeswaran
- Department of Imaging, OneWelbeck Imaging & Diagnostics, London, United Kingdom
| | - Subhasis Basu
- Department of Imaging, Wrightington Hospital, Wigan, Lancashire, United Kingdom
| | - Lennard Funk
- Department of Orthopaedics, Wrightington Hospital, Wigan, Lancashire, United Kingdom
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23
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Boileau P, Van Steyn PM, Czarnecki M, Teissier S, Gasbarro G, Galvin JW. The Thumb Test: A Simple Physical Examination Maneuver for the Diagnosis of Symptomatic Posterior Shoulder Instability. Arthrosc Tech 2022; 11:e1613-e1616. [PMID: 36185110 PMCID: PMC9520018 DOI: 10.1016/j.eats.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/18/2022] [Indexed: 02/03/2023] Open
Abstract
Posterior shoulder instability is becoming increasingly recognized in young active patient populations. Diagnosing posterior instability can be challenging because patients commonly present with a complaint of pain without a history of a dislocation or subluxation event. Additionally, a posterior labral tear is not always clearly visualized on advanced imaging studies. As such, physical examination is critical to the diagnosis. We report a simple physical examination maneuver for the diagnosis of symptomatic posterior shoulder instability. The thumb test attempts to replicate a posterior bone block procedure, helping to re-establish stability and relieve pain. The examiner places his or her thumb over the posterior glenohumeral joint line while the patient actively forward elevates the affected arm overhead. Improvement in pain and stability with this maneuver is diagnostic for symptomatic posterior shoulder instability. This test augments current physical examination maneuvers to assist with correctly diagnosing posterior shoulder instability.
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Affiliation(s)
- Pascal Boileau
- ICR–Institut de Chirurgie Réparatrice Locomoteur & Sports (Institute For Sports and Reconstructive Bone & Joint Surgery), Nice, France
- Address correspondence to Pascal Boileau, M.D., Ph.D., ICR–Institut de Chirurgie Réparatrice Locomoteur & Sports (Institute for Sports and Reconstructive Bone & Joint Surgery), 7, Avenue Durante, 06004 Nice, France.
| | - Peter M. Van Steyn
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, Washington, U.S.A
| | - Michael Czarnecki
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, Washington, U.S.A
| | - Sylvain Teissier
- ICR–Institut de Chirurgie Réparatrice Locomoteur & Sports (Institute For Sports and Reconstructive Bone & Joint Surgery), Nice, France
| | - Gregory Gasbarro
- The Shoulder, Elbow, Wrist, and Hand Center, Mercy Medical Center, Baltimore, Maryland, U.S.A
| | - Joseph W. Galvin
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, Washington, U.S.A
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24
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Dey Hazra ME, Dey Hazra RO, Hanson JA, Millett PJ. Arthroscopic Posterior Labral Repair and Capsular Closure via Single Working Portal for Posterior Shoulder Instability. Arthrosc Tech 2022; 11:e1557-e1561. [PMID: 36185126 PMCID: PMC9519942 DOI: 10.1016/j.eats.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 04/26/2022] [Indexed: 02/03/2023] Open
Abstract
Posterior shoulder instability (PSI) is a relatively less common form of instability that frequently affects young overhead or contact athletes. The etiology of PSI may be traumatic or atraumatic, with establishment of the diagnosis being more difficult in cases of atraumatic instability. Surgical management of PSI has evolved from open techniques to arthroscopic techniques. Posterior stabilization has commonly been performed with 2 posterior working portals with the patient in the lateral decubitus position. The objective of this Technical Note is to describe a technique for posterior labral repair using all-suture anchors with the patient in the beach-chair position via 1 working portal with capsular closure.
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Affiliation(s)
| | | | - Jared A. Hanson
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Peter J. Millett
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A,The Steadman Clinic, Vail, Colorado, U.S.A,Address correspondence to Peter J. Millett, M.D., M.Sc., The Steadman Clinic, 181 W Meadow Dr, Ste 400, Vail, CO 81657, U.S.A.
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Waltenspül M, Häller T, Ernstbrunner L, Wyss S, Wieser K, Gerber C. Long-term results after posterior open glenoid wedge osteotomy for posterior shoulder instability associated with excessive glenoid retroversion. J Shoulder Elbow Surg 2022; 31:81-89. [PMID: 34216782 DOI: 10.1016/j.jse.2021.05.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/26/2021] [Accepted: 05/30/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Treatment of posterior shoulder instability (PSI) associated with excessive glenoid retroversion is a rare, challenging problem in shoulder surgery. One proposed technique is posterior open wedge glenoid osteotomy to correct excessive glenoid retroversion as described by Scott. However, this operation is rarely performed, and limited long-term outcomes using this approach are available. The goal of this study was to analyze the long-term outcomes of posterior open wedge glenoid osteotomy for PSI associated with excessive glenoid retroversion. METHODS Six consecutive patients (7 shoulders) with a mean age of 24 years (range 19-34) were treated with posterior open wedge glenoid osteotomy for PSI associated with a glenoid retroversion greater than 15° and followed up clinically and radiographically at a mean age of 15 years (range 10-19). RESULTS Recurrent, symptomatic PSI was observed in 6 of 7 shoulders (86%). One necessitated revision with a posterior (iliac crest) bone block procedure and was rated as a failure and excluded from functional analysis. One patient rated his result as excellent, 3 as good, 1 as fair, and 1 as unsatisfactory. Mean relative Constant Score (CS%) was unchanged from preoperation to final follow-up (CS% = 72%) and pain did not significantly decrease (Constant Score = 7-10 points; P = .969). The mean Subjective Shoulder Value (SSV) improved postoperatively, but with 6 patients the improvement did not reach statistical significance (SSV = 42%-67%, P = .053) and the total Western Ontario Shoulder Instability Index averaged 30% at the final follow-up. Mean glenoid retroversion of all 7 shoulders was corrected from 20° (range 16°-26°) to 3° (range -3° to +8°) (P = .018). In the 5 shoulders with preoperative static posterior subluxation of the humeral head, the humeral head was not recentered. All 7 shoulders showed progression of glenoid arthritic changes. CONCLUSIONS Posterior open wedge glenoid osteotomy for PSI associated with excessive glenoid retroversion neither reliably restored shoulder stability nor recentered the joint or prevent progression of osteoarthritis. Alternative treatments for PSI associated with excessive glenoid retroversion have to be developed and evaluated.
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Affiliation(s)
- Manuel Waltenspül
- Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland.
| | - Thomas Häller
- Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Lukas Ernstbrunner
- Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Sabine Wyss
- Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Karl Wieser
- Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Christian Gerber
- Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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26
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Ferrando A, Aguilar J, Valencia M, Novo U, Calvo E. The Cartilage Wear Index: A new evaluation method to improve patient selection in surgical treatment of recurrent posterior glenohumeral instability. JSES Int 2022; 6:368-373. [PMID: 35572453 PMCID: PMC9091748 DOI: 10.1016/j.jseint.2021.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background The purpose of this study was to validate glenoid cartilage lesions as a negative prognostic factor and to define a new image-based preoperative evaluation method to identify surgical candidates for arthroscopic labral refixation with suture anchors in posterior shoulder instability. Methods Twenty-six patients who underwent arthroscopic posterior labral repair for shoulder instability were evaluated. Only patients with structural dynamic posterior instability were included. We evaluated on preoperative magnetic resonance arthrogram: glenoid version, humeral head subluxation, type of capsular insertion, and the cartilage lesions using the new Cartilage Wear Index (CWI). Two subgroups were analyzed with regard to the preoperative CWI and shoulder outcome scores: Single Assessment Numerical Evaluation (SANE) and Western Ontario Shoulder Instability Index (WOSI). Results The median age at operation was 28 (interquartile range = 21-33) years. Median overall postoperative outcome assessment demonstrated a SANE of 90 and a WOSI of 385. The median CWI was 1.02. Subgroup analysis revealed worse median WOSI and SANE scores in patients with a CWI >1.02 and a strong correlation between a high preoperative CWI and a higher postoperative WOSI score (R = 0.58; P = .038). Conclusion The CWI can be useful to identify patients who might obtain better outcomes when treated with arthroscopic labral repair in posterior shoulder instability.
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Affiliation(s)
- Albert Ferrando
- Shoulder Unit, Hospital Universitari Sant Joan de Reus, Reus, Spain
- Corresponding author: Albert Ferrando, MD, PhD, Avinguda del Doctor Josep Laporte, 2, 43204 Reus, Tarragona, Spain.
| | - Juan Aguilar
- Shoulder and Elbow Unit, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Maria Valencia
- Shoulder and Elbow Unit, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Ulrike Novo
- Musculoskeletal radiology Department, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Emilio Calvo
- Shoulder and Elbow Unit, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
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Paxton ES. CORR Insights®: Imbalance in Axial-plane Rotator Cuff Fatty Infiltration in Posteriorly Worn Glenoids in Primary Glenohumeral Osteoarthritis: An MRI-based Study. Clin Orthop Relat Res 2021; 479:2480-2482. [PMID: 34061809 PMCID: PMC8509961 DOI: 10.1097/corr.0000000000001853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 05/12/2021] [Indexed: 01/31/2023]
Affiliation(s)
- E Scott Paxton
- Assistant Professor, Department of Orthopedic Surgery, Brown University, Providence, RI, USA
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28
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Galvin JW, Yu H, Slevin J, Turner EK, Eichinger JK, Arrington ED, Grassbaugh JA. High Incidence of Anterior Shoulder Pain in Young Athletes Undergoing Arthroscopic Posterior Labral Repair for Posterior Shoulder Instability. Arthrosc Sports Med Rehabil 2021; 3:e1441-e1447. [PMID: 34712982 PMCID: PMC8527323 DOI: 10.1016/j.asmr.2021.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 06/25/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose The purposes of this study were to determine the incidence of anterior shoulder pain in young athletes undergoing arthroscopic posterior labral repair for symptomatic unidirectional posterior shoulder instability and in patients with preoperative anterior shoulder pain treated without biceps tenodesis at the time of arthroscopic posterior labral repair who underwent a revision biceps tenodesis procedure at short-term follow up. Methods A retrospective review was performed at a single institution over a 24-month period. The study included young patients who underwent an arthroscopic posterior labral repair for symptomatic unidirectional posterior shoulder instability. The electronic medical record, magnetic resonance arthrograms, and arthroscopic images were reviewed to exclude patients with posterior labral tears with anterior labral tear or SLAP (superior labrum anterior-to-posterior) tear extension on advanced imaging and arthroscopic examination. Data collected included the presence of preoperative tenderness to palpation of the biceps tendon in the groove, the results of a preoperative Speed test, postoperative Subjective Shoulder Value, the presence of postoperative anterior shoulder pain, and the need for a secondary biceps tenodesis. Results We identified 65 patients who underwent arthroscopic labral repair for posterior shoulder instability. From this cohort, 26 patients with symptomatic unidirectional posterior shoulder instability underwent an arthroscopic posterior labral repair. The incidence of preoperative anterior shoulder pain with Zone 2 biceps groove tenderness and a positive Speed test was identified in 20 of 26 patients (76.9%). Of 26 patients, 5 (19%) had concomitant biceps tenodesis. The median postoperative Subjective Shoulder Value was 80 (interquartile range, 60-90) at median follow-up of 2.1 years. Of the 20 patients with preoperative anterior shoulder pain, 8 of 20 (40%) reported persistent anterior pain. One patient (4.7%) underwent a secondary biceps tenodesis. Conclusions There is a high incidence of anterior shoulder pain and Zone 2 biceps groove tenderness in patients undergoing isolated arthroscopic posterior labral repair for unidirectional posterior shoulder instability. At short-term follow-up, few patients required a secondary biceps tenodesis procedure; however, 30% of patients had persistent anterior shoulder pain. Level of Evidence Level IV, retrospective diagnostic case series.
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Affiliation(s)
- Joseph W Galvin
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Henry Yu
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - John Slevin
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Eric K Turner
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Josef K Eichinger
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Edward D Arrington
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Jason A Grassbaugh
- Department of Orthopaedic Surgery, Madigan Army Medical Center, Tacoma, Washington
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Ernstbrunner L, Häller T, Waltenspül M, Wieser K, Gerber C. Posterior Open-wedge Osteotomy and Glenoid Concavity Reconstruction Using an Implant-free, J-shaped Iliac Crest Bone Graft in Atraumatic Posterior Instability with Pathologic Glenoid Retroversion and Dysplasia: A Preliminary Report. Clin Orthop Relat Res 2021; 479:1995-2005. [PMID: 33847693 PMCID: PMC8373563 DOI: 10.1097/corr.0000000000001757] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/09/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Atraumatic posterior shoulder instability in patients with pathologic glenoid retroversion and dysplasia is an unsolved problem in shoulder surgery. QUESTIONS/PURPOSES In a preliminary study of a small group of patients with atraumatic posterior shoulder instability associated with glenoid retroversion ≥ 15° and glenoid dysplasia who underwent posterior open-wedge osteotomy and glenoid concavity reconstruction using an implant-free, J-shaped iliac crest bone graft, we asked: (1) What proportion of the patients had persistent apprehension? (2) What were the improvements in patient-reported shoulder scores? (3) What were the radiographic findings at short-term follow-up? METHODS Between 2016 and 2018, we treated seven patients for atraumatic posterior shoulder instability. We performed this intervention when posterior shoulder instability symptoms were unresponsive to physiotherapy for at least 6 months and when it was associated with glenoid retroversion ≥ 15° and dysplasia of the posteroinferior glenoid. All seven patients had a follow-up examination at a minimum of 2 years. The median (range) age at surgery was 27 years (16 to 45) and the median follow-up was 2.3 years (2 to 3). Apprehension was assessed by a positive posterior apprehension and/or posterior jerk test. Patient-reported shoulder scores were obtained and included the subjective shoulder value, obtained by chart review (and scored with 100% representing a normal shoulder; minimum clinically important difference [MCID] 12%), and the Constant pain scale score (with 15 points representing no pain; MCID 1.5 points). Radiographic measurements included glenohumeral arthropathy and posterior humeral head subluxation, bone graft union, correction of glenoid retroversion and glenoid concavity depth, as well as augmentation of glenoid surface area. All endpoints were assessed by individuals not involved in patient care. RESULTS In four of seven patients, posterior apprehension was positive, but none reported resubluxation. The preoperative subjective shoulder value (median [range] 40% [30% to 80%]) and Constant pain scale score (median 7 points [3 to 13]) were improved at latest follow-up (median subjective shoulder value 90% [70% to 100%]; p = 0.02; median Constant pain scale score 15 points [10 to 15]; p = 0.03). Posterior glenoid cartilage erosion was present in four patients (all four had Walch Type B1 glenoids) preoperatively and showed no progression until the final follow-up examination. The median (range) humeral head subluxation index decreased from 69% (54% to 85%) preoperatively to 55% (46% to 67%) postoperatively (p = 0.02), and in two of four patients with preoperative humeral head subluxation (> 65% subluxation), it was reversed to a centered humeral head. CT images showed union in all implant-free, J-shaped iliac crest bone grafts. The median preoperative retroversion was corrected from 16° (15° to 25°) to 0° postoperatively (-5° to 6°; p = 0.02), the median glenoid concavity depth was reconstructed from 0.3 mm (-0.7 to 1.6) preoperatively to 1.2 mm (1.1 to 3.1) postoperatively (p = 0.02), and the median preoperative glenoid surface area was increased by 20% (p = 0.02). No intraoperative or postoperative complications were recorded, and no reoperation was performed or is planned. CONCLUSION In this small, retrospective series of patients treated by experienced shoulder surgeons, a posterior J-bone graft procedure was able to reconstruct posterior glenoid morphology, correct glenoid retroversion, and improve posterior shoulder instability associated with pathologic glenoid retroversion and dysplasia, although four of seven patients had persistent posterior apprehension. Although no patients in this small series experienced complications, the size and complexity of this procedure make it likely that as more patients have it, some will develop complications; future studies will need to characterize the frequency and severity of those complications, and we recommend that this procedure be done only by experienced shoulder surgeons. The early results in these seven patients justify further study of this procedure for the proposed indication, but longer term follow-up is necessary to continue to assess whether it is advantageous to combine the reconstruction of posterior glenoid concavity with correction of pathological glenoid retroversion and increasing glenoid surface compared with traditional surgical techniques such as the posterior opening wedge osteotomy or simple posterior bone block procedures. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Lukas Ernstbrunner
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Thomas Häller
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Manuel Waltenspül
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Karl Wieser
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Christian Gerber
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Passaplan C, Hasler A, Gerber C. The critical shoulder angle does not change over time: a radiographic study. J Shoulder Elbow Surg 2021; 30:1866-1872. [PMID: 33160027 DOI: 10.1016/j.jse.2020.09.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 09/24/2020] [Accepted: 09/29/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The anatomy of the scapula may predispose individuals to develop shoulder pathologies. The purpose of this study was to determine if the scapular anatomy, in particular the critical shoulder angle (CSA), changes over a long-term follow-up, or if it is a stable parameter. We hypothesized that increasing age would not influence the scapular morphology. METHODS We analyzed shoulder radiographs in our database from 2002 to 2019 to extract radiographs at an interval of at least 10 years. Radiographic analysis included measuring the CSA and assessing the acromion type according to Bigliani and Morrison, the posterior acromial height and the posterior acromial tilt. RESULTS A total of 41 patients (47 shoulders) with a mean age of 53 years (range, 15-76; standard deviation [SD], ±14) fulfilled the inclusion criteria. The mean interval between the 2 sets of radiographs was 12 years (range, 10-16; SD ±2).The mean CSA did not change significantly with 34° (range, 20-41; SD ±4) at the first and 34° (range, 19-44; SD ±5) (P = .597) at the second assessment. On the initial lateral radiographs ("Neer view"), there were 11 type 1 (24%), 32 type 2 (70%), and 3 type 3 (6%) acromia according to Bigliani and Morrison. At the second assessment, there were 16 type 1 (34%), 28 type 2 (60%), and 3 type 3 (7%). Between both sets of radiographs, 11 were different (23%), without a trend in the type of change being discernible. The posterior acromial height was stable with 19 mm (range, 2-36; SD ±8) at the first and 18 mm (range, 5-38; SD ±8) at the second assessment (P = .186). The posterior acromion tilt changed from 59° (range, 34-81; SD ±10) to 62° (range, 30-81; SD ±10) (P < .001). Among 6 cases with rotator cuff tears (RCTs) already at the first assessment, the CSA did not change significantly at 10 years' follow-up (P = .414). Among the 10 cases with new RCTs at the second assessment, the CSA did not change significantly at 10 years' follow-up from 34° (range, 25-41; SD ±5) to 35° (range, 24-44; SD ±6) (P = .510). In the group of 31 shoulders without RCT, the mean CSA at the first assessment of 34° (range, 28-41; SD ±3) stayed also stable with 34° (range, 28-40; SD ±3) (P = .796). CONCLUSION The CSA is an anatomical parameter of the scapula that does not change in size after closure of the physes.
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Affiliation(s)
- Caroline Passaplan
- Department of Orthopedics, University of Zürich, Balgrist University Hospital, Zürich, Switzerland.
| | - Anita Hasler
- Department of Orthopedics, University of Zürich, Balgrist University Hospital, Zürich, Switzerland
| | - Christian Gerber
- Department of Orthopedics, University of Zürich, Balgrist University Hospital, Zürich, Switzerland
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Mitterer M, Matis N, Steiner G, Vasvary I, Ortmaier R. Muscle volume imbalance may be associated with static posterior humeral head subluxation. BMC Musculoskelet Disord 2021; 22:279. [PMID: 33722224 PMCID: PMC7958704 DOI: 10.1186/s12891-021-04146-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 03/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The transverse force couple (TFC) of the rotator cuff (subscapularis vs. infraspinatus and teres minor muscle) is an important dynamic stabilizer of the shoulder joint in the anterior-posterior direction. In patients with posterior static subluxation of the humeral head (PSSH), decentration of the humeral head posteriorly occurs, which is associated with premature arthritis. We hypothesize that not only pathologic glenoid retroversion but also chronic muscle volume imbalance in the transverse force couple leads to PSSH. METHODS A retrospective analysis of the TFC muscle volumes of 9 patients with symptomatic, atraumatic PSSH, within 8 were treated with glenoid correction osteotomy, was conducted. The imaging data (CT) of 9 patients/10 shoulders of the full scapula and shoulder were analyzed, and the muscle volumes of the subscapularis (SSC), infraspinatus (ISP) and teres minor muscles (TMM) were measured by manually marking the muscle contours on transverse slices and calculating the volume from software. Furthermore, the glenoid retroversion and glenohumeral distance were measured. RESULTS The mean glenoid retroversion was - 16° (- 7° to - 31°). The observed mean glenohumeral distance was 4.0 mm (0 to 6.8 mm). Our study population showed a significant muscle volume imbalance between the subscapularis muscle and the infraspinatus and teres minor muscles (192 vs. 170 ml; p = 0.005). There was no significant correlation between the subscapularis muscle volume and the glenohumeral distance (r = 0.068), (p = 0.872). CONCLUSION The muscle volume of the SSC in patients with PSSH was significantly higher than the muscle volume of the posterior force couple (ISP and TMM). This novel finding, albeit in a small series of patients, may support the theory that transverse force couple imbalance is associated with PSSH. LEVEL OF EVIDENCE Level 4 - Case series with no comparison group.
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Affiliation(s)
- Marian Mitterer
- Department of Orthopaedics and Traumatology, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria
| | - Nicholas Matis
- Department of Orthopaedics and Traumatology, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria
| | - Gernot Steiner
- Department of Orthopaedics and Traumatology, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria
| | - Imre Vasvary
- Department for Radiology, Private Hospital Wehrle-Diakonissen, 5020 Salzburg, Austria
| | - Reinhold Ortmaier
- Department of Orthopedic Surgery, Ordensklinikum Barmherzige Schwestern Linz, Vinzenzgruppe, Center of Orthopedic Excellence, Teaching Hospital of the Paracelsus Medical University Salzburg, Seilerstätte 4, 4010, Linz, Austria. .,Institute for Sports Medicine, Alpine Medicine and Health Tourism (ISAG), Tirol Kliniken GmbH, Innsbruck and UMIT, 6060 Hall, Austria.
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Ernstbrunner L, El Nashar R, Favre P, Bouaicha S, Wieser K, Gerber C. Chronic Pseudoparalysis Needs to Be Distinguished From Pseudoparesis: A Structural and Biomechanical Analysis. Am J Sports Med 2021; 49:291-297. [PMID: 33253014 DOI: 10.1177/0363546520969858] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Chronic pseudoparalysis is generally defined as the inability to actively elevate the arm above 90° with free passive range of motion and no neurological deficits. It has been suggested that this arbitrary cutoff needs to be refined. PURPOSE To analyze whether there are structural and biomechanical differences in patients with chronic pseudoparalysis and those with chronic pseudoparesis. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS In this retrospective study, 50 patients with chronic massive rotator cuff tears (mRCTs; ≥2 tendons) and free passive and active scapular plane abduction <90° were divided into 2 groups: pseudoparalysis group (n = 24; active scapular plane abduction, <45°) and pseudoparesis group (n = 26; active scapular plane abduction, >45° and <90°). Radiographic measurements included the critical shoulder angle, acromiohumeral distance, posterior acromial tilt, anterior and posterior acromial coverages, and posterior acromial height on outlet views. Measurements on magnetic resonance imaging (MRI) included fatty infiltration of the rotator cuff muscles, anterior (subscapularis) and posterior (infraspinatus/teres minor) tear extensions, and global (anterior + posterior) tear extension in the parasagittal plane. A published musculoskeletal model was used to simulate the effect of different mRCTs on the muscle force required for scapular plane abduction. RESULTS Plain radiographs revealed no differences between patients with chronic pseudoparalysis and those with pseudoparesis. MRI assessment showed significant differences between patients with chronic pseudoparalysis and those with pseudoparesis with respect to fatty infiltration of the subscapularis (2.9 vs 1.6; P < .001) and infraspinatus (3.6 vs 3.0; P < .001) muscles, and anterior (-23° vs 4°; P < .001), posterior (-23° vs -14°; P = .034), and global rotator cuff (225° vs 190°; P < .001) tear extensions. The anterior tear extension in patients with chronic pseudoparalysis always involved more than 50% of the subscapularis, which was associated with an odds ratio of 5 for inability to actively abduct more than 45°. The biomechanical model was unable to find a combination of muscles that could balance the arm in space when the tear extended beyond the supraspinatus and the cranial subscapularis. CONCLUSION This study confirms that chronic pseudoparalysis and pseudoparesis are associated with different structural lesions. In the setting of a chronic mRCT, involvement of more than 50% of the subscapularis tendon with fatty infiltration of stage 3 is associated with pseudoparalysis of active scapular plane abduction <45°. The key function of the subscapularis was confirmed in the biomechanical model.
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Affiliation(s)
- Lukas Ernstbrunner
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Rany El Nashar
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Philippe Favre
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Samy Bouaicha
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Karl Wieser
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Christian Gerber
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Abstract
Background There is evidence that specific variants of scapular morphology are associated with dynamic and static posterior shoulder instability. To this date, observations regarding glenoid and/or acromial variants were analyzed independently, with two-dimensional imaging or without comparison with a healthy control group. Therefore, the purpose of this study was to analyze and describe the three-dimensional (3D) shape of the scapula in healthy and in shoulders with static or dynamic posterior instability using 3D surface models and 3D measurement methods. Methods In this study, 30 patients with unidirectional posterior instability and 20 patients with static posterior humeral head subluxation (static posterior instability, Walch B1) were analyzed. Both cohorts were compared with a control group of 40 patients with stable, centered shoulders and without any clinical symptoms. 3D surface models were obtained through segmentation of computed tomography images and 3D measurements were performed for glenoid (version and inclination) and acromion (tilt, coverage, height). Results Overall, the scapulae of patients with dynamic and static instability differed only marginally among themselves. Compared with the control group, the glenoid was 2.5° (P = .032), respectively, 5.7° (P = .001) more retroverted and 2.9° (P = .025), respectively, 3.7° (P = .014) more downward tilted in dynamic, respectively, static instability. The acromial roof of dynamic instability was significantly higher and on average 6.2° (P = .007) less posterior covering with an increased posterior acromial height of +4.8mm (P = .001). The acromial roof of static instability was on average 4.8° (P = .041) more externally rotated (axial tilt), 7.3° (P = .004) flatter (sagittal tilt), 8.3° (P = .001) less posterior covered with an increased posterior acromial height of +5.8 mm (0.001). Conclusion The scapula of shoulders with dynamic and static posterior instability is characterized by an increased glenoid retroversion and an acromion that is shorter posterolaterally, higher, and more horizontal in the sagittal plane. All these deviations from the normal scapula values were more pronounced in static posterior instability.
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Lädermann A, Athwal GS, Bothorel H, Collin P, Mazzolari A, Raiss P, Charbonnier C. Scapulothoracic Alignment Alterations in Patients with Walch Type B Osteoarthritis: An In Vivo Dynamic Analysis and Prospective Comparative Study. J Clin Med 2020; 10:jcm10010066. [PMID: 33375443 PMCID: PMC7794942 DOI: 10.3390/jcm10010066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/11/2022] Open
Abstract
Background: Kinematic changes of the scapulothoracic joint may influence the relative position of the glenoid fossa and, consequently, the glenohumeral joint. As the alignment of the scapula relative to the thorax differs between individuals, such variability may be another factor in the development of posterior head subluxation. The purpose of this study was to compare scapulothoracic alignment in pathologic type B shoulders with contralateral healthy shoulders. Methods: Seven adult volunteers with unilateral type B glenohumeral osteoarthritis (OA) underwent bilateral computed tomography (CT) scans of the shoulders and arms. A patient-specific, three-dimensional measurement technique that coupled medical imaging (i.e., CT) and optical motion capture was used. Results: The scapulothoracic distance at the trigonum was 75 ± 15 mm for pathologic shoulders and 78 ± 11 mm for healthy shoulders (p = 0.583), while at the inferior angle, it was 102 ± 18 mm for pathologic shoulders and 108 ± 12 mm for healthy shoulders (p = 0.466). Conclusion: Scapula positioning at a resting position did not differ between pathologic and healthy shoulders. However, pathologic shoulders tended to be limited in maximal glenohumeral motion and exhibited greater anterior tilt of the scapula in internal rotation at 90 degrees, which may be adaptive to the restricted glenohumeral motion.
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Affiliation(s)
- Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, 1217 Meyrin, Switzerland;
- Faculty of Medicine, University of Geneva, 1206 Geneva, Switzerland;
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, 1205 Geneva, Switzerland
- Correspondence: ; Tel.: +41-22-719-75-55; Fax: +41-22-719-60-77
| | - George S. Athwal
- Department of Surgery, Roth MacFarlane Hand and Upper Limb Center, St. Joseph’s Health Care London, London, ON N6A 4V2, Canada;
| | - Hugo Bothorel
- Research Department, La Tour Hospital, 1217 Meyrin, Switzerland;
| | - Philippe Collin
- Centre Hospitalier Privé Saint-Grégoire (Vivalto Santé), 35760 Saint-Grégoire, France;
| | - Adrien Mazzolari
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, 1217 Meyrin, Switzerland;
| | - Patric Raiss
- Shoulder and Elbow Surgery, OCM (Orthopädische Chirurgie München), Steinerstrasse 6, 81369 Munich, Germany;
| | - Caecilia Charbonnier
- Faculty of Medicine, University of Geneva, 1206 Geneva, Switzerland;
- Medical Research Department, Artanim Foundation, 1217 Meyrin, Switzerland
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Goetti P, Denard PJ, Collin P, Ibrahim M, Hoffmeyer P, Lädermann A. Shoulder biomechanics in normal and selected pathological conditions. EFORT Open Rev 2020; 5:508-518. [PMID: 32953136 PMCID: PMC7484714 DOI: 10.1302/2058-5241.5.200006] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The stability of the glenohumeral joint depends on soft tissue stabilizers, bone morphology and dynamic stabilizers such as the rotator cuff and long head of the biceps tendon. Shoulder stabilization techniques include anatomic procedures such as repair of the labrum or restoration of bone loss, but also non-anatomic options such as remplissage or tendon transfers. Rotator cuff repair should restore the cuff anatomy, reattach the rotator cable and respect the coracoacromial arch whenever possible. Tendon transfer, superior capsular reconstruction or balloon implantation have been proposed for irreparable lesions. Shoulder rehabilitation should focus on restoring balanced glenohumeral and scapular force couples in order to avoid an upward migration of the humeral head and secondary cuff impingement. The primary goal of cuff repair is to be as anatomic as possible and to create a biomechanically favourable environment for tendon healing.
Cite this article: EFORT Open Rev 2020;5:508-518. DOI: 10.1302/2058-5241.5.200006
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Affiliation(s)
- Patrick Goetti
- Department of Orthopaedics and Traumatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Patrick J Denard
- Department of Orthopaedic & Rehabilitation, Oregon Health & Science University, Portland, Oregon, USA
| | - Philippe Collin
- Centre Hospitalier Privé Saint-Grégoire (Vivalto Santé), Saint- Grégoire, France
| | - Mohamed Ibrahim
- Department of Orthopaedics and Trauma Surgery, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | | | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
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Abstract
Background Glenohumeral instability is a common condition of the shoulder. Glenoid bone loss and humeral head bone loss are well recognized as risk factors for recurrent instability. There are few studies in the literature that examine the role of coracoacromial arch anatomy in the pathogenesis of glenohumeral instability. Previous reports found an association between posterior acromial coverage (PAC) and posterior instability. We hypothesize that coracoacromial arch anatomy is related to anterior shoulder instability. Methods In this retrospective cohort study, 50 patients with unidirectional anterior shoulder instability were matched to a control group of 50 glenohumeral arthritis patients without any history of shoulder instability. Radiographic measurements of the coracoacromial arch anatomy were made: shoulder arch angle, scapular Y angle, anterior coracoid tilt (ACT), posterior acromial tilt, anterior acromial coverage angle, PAC angle, coracoid height, posterior acromial height, and critical shoulder angle were determined using standard lateral scapular and anteroposterior radiographs. Results Logistic regression analyses found a significant association between the presence of anterior instability and flatter coracoacromial arch angles (mean, 124.1°) vs. the arthritis control group (mean, 120.6°) (odds ratios [OR] = 1.113; 95% confidence interval [CI] = 1.039-1.191; P = .002). There was a significant association between anterior instability and ACT (OR = 1.144; 95% CI = 1.053-1.243; P = .001), whereas a negative association was found between anterior instability and PAC (OR = 0.909; 95% CI = 0.853-0.969; P = .004) and posterior acromial tilt (OR = 0.878; 95% CI = 0.773-0.998; P = .046). Lower critical shoulder angle values were associated with the arthritis group (28.2° vs. 33.9°) (OR = 1.555; 95% CI = 1.202-2.012; P = .001). Conclusions Shoulder coracoacromial arch morphology may play a role in the stability of the shoulder joint and development of recurrent anterior instability. Shoulders with a decreased shoulder arch angle, a less contained and flatter coracoacromial arch and larger ACT, were associated with anterior instability. This study identifies the shoulder coracoacromial arch angle and anterior coracoid tile angles as risk factors for anterior shoulder instability. Our findings suggest that measuring these angles may help orthopedic surgeons understand the risk of anterior instability and analyze risk factors to improve clinical decision making.
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Ernstbrunner L, El Nashar R, Bouaicha S, Wieser K, Gerber C. Scapular Morphologic Characteristics and Rotator Cuff Tear Pattern Are Independently Associated With Chronic Pseudoparalyis: A Matched-Pair Analysis of Patients With Massive Rotator Cuff Tears. Am J Sports Med 2020; 48:2137-2143. [PMID: 32543907 DOI: 10.1177/0363546520929353] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND It is unclear which structural parameters determine the development or the absence of chronic pseudoparalysis (PP) in patients with massive rotator cuff tears (mRCTs). PURPOSE To determine whether scapular morphologic characteristics and extent of rotator cuff tearing are independent factors associated with chronic PP. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS In this retrospective case-control study, 50 patients with chronic mRCT (≥2 fully detached tendons) and active scapular plane abduction less than 90° (PP group) were age- and sex-matched with a cohort of 50 patients with chronic mRCT and an active scapular plane abduction greater than 90° (non-PP; NPP group). Analysis of standardized, plain radiographs included measurement of the critical shoulder angle (CSA) and the acromiohumeral distance (ACHD) on anteroposterior views and measurement of posterior acromial tilt, anterior and posterior acromial coverage, and posterior acromial height on standardized outlet views. Measurements on magnetic resonance imaging included fatty muscle infiltration, anterior (subscapularis) and posterior (infraspinatus/teres minor) tear extension, and global tear extension (anterior + posterior tear extension) in the parasagittal plane. RESULTS Overall, no significant difference was found in patients' demographic characteristics (P > .05). Univariate analyses confirmed significant differences between the PP and NPP groups in active scapular plane abduction (51°± 22° vs 135°± 29°; P < .001). Multivariate analyses revealed independent factors associated with PP compared with the NPP group: CSA (38.2°± 4.6° vs 35.2°± 3.7°; P = .001); ACHD (4.7 ± 2.2 vs 7.3 ± 2.6 mm; P < .001); posterior acromial height (22 ± 10 vs 17 ± 7 mm; P = .005); and anterior (-9°± 21° vs 25°± 12°; P < .001) and posterior (-18°± 14° vs 2°± 14°; P < .001) tear extension. The NPP group had significantly less involvement and fatty infiltration of the subscapularis (1.4 ± 0.6) compared with the PP group (2.2 ± 0.9) (P < .001). CONCLUSION This study confirms that global RCT extension and the quality of the inferior half of the subscapularis are significantly associated with chronic pseudoparalysis. The study further shows that acromial morphologic characteristics are relevant in the development of pseudoparalysis. Patients with pseudoparalysis have a larger CSA, less ACHD, and a higher positioned acromion in the sagittal plane.
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Affiliation(s)
- Lukas Ernstbrunner
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Rany El Nashar
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Samy Bouaicha
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Karl Wieser
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Christian Gerber
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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