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Hohmann E. Editorial Commentary: A Delphi Expert Consensus Provides Clarity on Diagnosis, Treatment, Rehabilitation, and Return-to-Sports for Posterior Shoulder Instability. Arthroscopy 2024:S0749-8063(24)00443-2. [PMID: 38897485 DOI: 10.1016/j.arthro.2024.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Revised: 06/02/2024] [Accepted: 06/02/2024] [Indexed: 06/21/2024]
Abstract
Posterior shoulder instability (PSI) is an uncommon condition, accounting for 2% to 12% of shoulder instability cases. However, PSI might be more common and possibly accounts for up to 24% of all young, active patients treated for shoulder instability. The etiology of PSI is complex and multifactorial, making accurate diagnosis, classification, and treatment challenging. The accurate diagnosis of PSI is problematic and varies with symptoms ranging from pain, decreased strength, or endurance to mechanical symptoms such as clicking or popping, and only a minority of patients present after a posterior shoulder dislocation. Appropriate imaging is necessary and should include radiographs and advanced imaging with magnetic resonance imaging, preferably magnetic resonance arthrography. The goal of treatment is to reduce pain, improve function, and prevent or reduce recurrence. Both surgical and conservative treatments are demanding, and both osseous and soft-tissue pathologies need to be addressed adequately. Typically, a conservative approach should be considered first for the first 6 months, with a focus on proprioceptive exercises, strengthening of the dynamic stabilizers, and improving scapulothoracic mechanics. The primary indication for surgery is recurrent symptoms. Controversies exist regarding the choice between open and arthroscopic stabilization of soft-tissue defects, the treatment of the McLaughlin lesion, and the management of osseous defects.
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Watts V GJ, Tai R, Joshi G, Garwood E, Saha D. Reinjury Following Return to Play. Semin Musculoskelet Radiol 2024; 28:154-164. [PMID: 38484768 DOI: 10.1055/s-0043-1778022] [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: 03/19/2024]
Abstract
Radiologists are frequently called on for guidance regarding return to play (RTP) for athletes and active individuals after sustaining a musculoskeletal injury. Avoidance of reinjury is of particular importance throughout the rehabilitative process and following resumption of competitive activity. Understanding reinjury risk estimation, imaging patterns, and correlation of clinical and surgical findings will help prepare the radiologist to identify reinjuries correctly on diagnostic imaging studies and optimize management for a safe RTP.
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Affiliation(s)
- George J Watts V
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, UMass Chan Medical School, Worcester, Massachusetts
| | - Ryan Tai
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, UMass Chan Medical School, Worcester, Massachusetts
| | - Ganesh Joshi
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, UMass Chan Medical School, Worcester, Massachusetts
| | - Elisabeth Garwood
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, UMass Chan Medical School, Worcester, Massachusetts
| | - Debajyoti Saha
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, UMass Chan Medical School, Worcester, Massachusetts
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Aier S, Reddy B, Pandey V. Does glenoid version affect the post-operative clinical outcome after repair of posterior labral tear: A retrospective study. J Orthop 2024; 49:134-139. [PMID: 38223426 PMCID: PMC10784136 DOI: 10.1016/j.jor.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 12/17/2023] [Indexed: 01/16/2024] Open
Abstract
Introduction Posterior shoulder instability and consequent labral tear have been predominantly associated with retroversion of the bony glenoid and chondrolabral version. However, literature concerning the degree of glenoid and chondrolabral version and clinical outcomes following labral repair is scarce. Methods A retrospective cohort study was undertaken among patients with posterior shoulder instability who had undergone arthroscopic isolated posterior labral repair. The MRI was used to assess the bony and labral variations of the glenoid using the Friedman method and further categorized as either anteverted or retroverted glenoid. American Shoulder and Elbow Surgeons (ASES), Oxford Shoulder Score (OSS), and Single Assessment Numeric Evaluation (SANE) scores were used to evaluate pre- and postoperative clinical outcomes at a minimum follow-up of one year. Results 33 shoulder MRIs performed at our institution were available for radiographic analysis. Among the 33 shoulders that underwent posterior shoulder capsulolabral repair, 23 were available for clinical follow-up for at least one year (range, 12-108 months). The mean (±SD) labral version and bony version were -3.98 (±5.68) and -2.83 (±5.20), respectively. The mean (±SD) postoperative ASES, Oxford score, and SANE scores for all participants were 84.04 (±14.14), 43.38 (±3.81), and 78.57 (±17.40), respectively. However, the difference in clinical outcomes in patients with anteverted or retroverted glenoid versions was not statistically significant. Conclusion Our study concludes a strong correlation between posterior glenohumeral instability and higher degree of glenoid retroversion. Nevertheless, variations in the glenoid version appear to have no significant impact on clinical outcomes. Level of study Level IV, retrospective cohort.
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Affiliation(s)
- Sashitemjen Aier
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Udupi, Karnataka, 576104, India
| | - Bishak Reddy
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Udupi, Karnataka, 576104, India
| | - Vivek Pandey
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Udupi, Karnataka, 576104, India
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Rhee SM, Youn SM, Lee JU, Kim CH, Kim SY, Ham HJ, Rhee YG. Posterior Compression Test: a Provocative Test for Detecting Posterior Labral Tears. Indian J Orthop 2024; 58:48-55. [PMID: 38161393 PMCID: PMC10754776 DOI: 10.1007/s43465-023-01028-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 10/15/2023] [Indexed: 01/03/2024]
Abstract
Purpose The purpose is to assess the diagnostic accuracy of a provocative test coined as the 'posterior compression test' (PCT) in those with the suspected posterior labral tear or lesion. Methods A total of 515 'arthroscopic labral repairs' were identified between April 2013 and September 2020. Excluding those with concomitant shoulder pathologies, and only including those with pre-operative documentation of the PCT and/or the Jerk test, 191 patients were included. For the purposes of the analyses, the patients were divided into 'non-posterior' labral tear group which included the anterior labral tears and/or the superior labral anterior-to-posterior (SLAP) tears, versus 'any posterior' labral tear group which included the isolated posterior labral tears, the SLAP tears with posterior extension and the pan-labral tears. Results When the PCT was performed for the isolated posterior labral tears, the sensitivity was 92.6% with the specificity of 86.5%. The positive predictive value and negative predictive value were 71.4-97%, respectively. The Jerk test's sensitivity was 77.8% but when the two tests were combined, the sensitivity increased up to 96.3%. The combined sensitivity with the Jerk test was still up to 94.6% with the AUC (area under curve) /ROC (receiver operator characteristic) at 0.855. Low 'false-positive' rate with the PCT was observed when the test was performed for the 'non-posterior' labral group, with the sensitivity of 13.5%. Conclusions The posterior compression test correlated well with the arthroscopic diagnoses in a subset of patients with suspected posterior labral pathology, possibly by means of direct stimulation. Level of Evidence III; Diagnostic Study.
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Affiliation(s)
- Sung Min Rhee
- Shoulder and Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Seung Min Youn
- The Department of Orthopaedic Surgery, Royal Brisbane and Women’s Hospital, Butterfield St, Herston, QLD Australia
| | - Jong Ung Lee
- Department of Orthopaedic Surgery, Myongji Hospital, 697-24 Hwajung-Dong, Deokyang-Gu, Goyang-Si, Gyeonggi-Do, 10475 Korea
| | - Cheol Hwan Kim
- Department of Orthopaedic Surgery, Myongji Hospital, 697-24 Hwajung-Dong, Deokyang-Gu, Goyang-Si, Gyeonggi-Do, 10475 Korea
| | - Se Yeon Kim
- Department of Orthopaedic Surgery, Myongji Hospital, 697-24 Hwajung-Dong, Deokyang-Gu, Goyang-Si, Gyeonggi-Do, 10475 Korea
| | - Hyun Joo Ham
- Department of Orthopaedic Surgery, Myongji Hospital, 697-24 Hwajung-Dong, Deokyang-Gu, Goyang-Si, Gyeonggi-Do, 10475 Korea
| | - Yong Girl Rhee
- Department of Orthopaedic Surgery, Myongji Hospital, 697-24 Hwajung-Dong, Deokyang-Gu, Goyang-Si, Gyeonggi-Do, 10475 Korea
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Luzzi A, Boddapati V, Rogalski BL, Knudsen ML, Levine WN, Jobin CM. Graft Resorption After Posterior Distal Tibial Allograft Augmentation for Posterior Shoulder Instability: A Case Report. JBJS Case Connect 2024; 14:01709767-202403000-00049. [PMID: 38517987 DOI: 10.2106/jbjs.cc.23.00511] [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: 03/24/2024]
Abstract
CASE A 19-year-old man underwent arthroscopic posterior glenoid reconstruction with a distal tibia allograft (DTA) after failing 2 posterior, soft-tissue instability surgeries. Although he experienced near-complete resolution of symptoms and return to sport, graft resorption was noted 7 months postoperatively. The patient underwent revision surgery for screw removal. CONCLUSION Graft resorption has not previously been reported in the setting of arthroscopic DTA use for posterior instability. It is believed that stress shielding contributed to resorption. In such situations, screw removal may be warranted. Consideration of alternative fixation techniques and additional investigation into the causes, clinical significance, and optimal management of posterior DTA resorption are warranted.
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Affiliation(s)
- Andrew Luzzi
- Department of Orthopaedic Surgery; New York-Presbyterian/Columbia University Irving Medical Center, New York, New York
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6
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Yu VJ, Taliaferro JP, Bonner KF. Portal Closure After Segmental Posterior Labral Repair for Posterior Shoulder Instability. Arthrosc Tech 2023; 12:e511-e515. [PMID: 37138695 PMCID: PMC10149978 DOI: 10.1016/j.eats.2022.12.002] [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: 09/25/2022] [Accepted: 12/08/2022] [Indexed: 05/05/2023] Open
Abstract
Posterior instability, although an uncommon shoulder pathology, is reported most frequently in the athletic population. Arthroscopic repair has emerged as the main surgical treatment modality for posterior instability. However, when compared with arthroscopic repair for anterior instability, the results of this procedure remain suboptimal. The creation of iatrogenic defects in the capsule, due to cannula placement, is a possible culprit. Because these defects typically do not heal satisfactorily, they become stress risers within the capsule itself, which may lead to recurrent instability or an otherwise compromised repair construct. Therefore, we find that routine intraoperative repair of these defects after repair can reduce the risk of injury and possibly improve long-term outcomes. In this article, we illustrate the repair of a posterior segmental tear using all-suture knotless implants with closure of the posterior and posterior-inferior portals after stabilization.
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Affiliation(s)
- Victor J. Yu
- Eastern Virginia Medical School, Norfolk, Virginia, U.S.A
- Address correspondence to Victor J. Yu, M.S., Eastern Virginia Medical School, PO Box 1980, Norfolk, VA 23501-1980, U.S.A.
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Livesey MG, Bedrin MD, Kolevar MP, Lundy AE, Weir TB, Kaveeshwar S, Kilcoyne KG, Dickens JF, Hasan SA, Gilotra MN. Glenoid Bone Loss Pattern in Patients With Posterior Instability Versus Anterior Instability: A Matched Cohort Study. Orthop J Sports Med 2023; 11:23259671221146559. [PMID: 36874054 PMCID: PMC9974616 DOI: 10.1177/23259671221146559] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 10/11/2022] [Indexed: 03/03/2023] Open
Abstract
Background The pattern of glenoid bone loss (GBL) in anterior glenohumeral instability is well described. It was recognized recently that posterior GBL after instability has a posteroinferior pattern. Purpose/Hypothesis The purpose of this study was to compare GBL patterns in a matched cohort of patients with anterior versus posterior glenohumeral instability. The hypothesis was that the GBL pattern in posterior instability would be more inferior than the GBL pattern in anterior instability. Study Design Cohort study; Level of evidence, 3. Methods In this multicenter retrospective study, 28 patients with posterior instability were matched with 28 patients with anterior instability by age, sex and number of instability events. GBL location was defined using a clockface model. Obliquity was defined as the angle between the long axis of the glenoid and a line tangent to the GBL. Superior and inferior GBL were measured as areas and defined relative to the equator. The primary outcome was the 2-dimensional characterization of posterior versus anterior GBL. The secondary outcome was a comparison of the posterior GBL patterns in traumatic and atraumatic instability mechanisms in an expanded cohort of 42 patients. Results The mean age of the matched cohorts (n = 56) was 25.2 ± 9.87 years. The median obliquity of GBL was 27.53° (interquartile range [IQR], 18.83°-47.38°) in the posterior cohort and 9.28° (IQR, 6.68°-15.75°) in the anterior cohort (P < .001). The mean superior-to-inferior bone loss ratio was 0.48 ± 0.51 in the posterior cohort and 0.80 ± 0.55 (P = .032) in the anterior cohort. In the expanded posterior instability cohort (n = 42), patients with traumatic injury mechanism (n = 22), had a similar GBL obliquity compared to patients with an atraumatic injury mechanism (n = 20) (mean, 27.73° [95% CI, 20.26°-35.20°] vs 32.20° [95% CI, 21.27°-43.14°], respectively) (P = .49). Conclusion Posterior GBL occurred more inferiorly and at an increased obliquity compared with anterior GBL. This pattern is consistent for traumatic and atraumatic posterior GBL. Bone loss along the equator may not be the most reliable predictor of posterior instability, and critical bone loss may be reached more rapidly than a model of loss along the equator may predict.
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Affiliation(s)
| | - Michael D Bedrin
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | | | - Alexander E Lundy
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Tristan B Weir
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Samir Kaveeshwar
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kelly G Kilcoyne
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | | | - S Ashfaq Hasan
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Mohit N Gilotra
- University of Maryland School of Medicine, Baltimore, Maryland, USA
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Stokes DJ, McCarthy TP, Frank RM. Physical Therapy for the Treatment of Shoulder Instability. Phys Med Rehabil Clin N Am 2023; 34:393-408. [PMID: 37003660 DOI: 10.1016/j.pmr.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
Shoulder instability is the separation of the humeral head from the glenoid. Injury to the static and dynamic stabilizers can result in instability. Anterior shoulder instability is the predominant form of instability. It is usually a result of trauma. Posterior shoulder instability often presents with an insidious onset of pain. Multidirectional instability of the shoulder is symptomatic laxity in more than one plane of motion. The primary goal of rehabilitation is to restore pain-free mobility, strength, and functioning. Rehabilitation implements range of motion and strengthening exercises to restore proprioceptive control and scapular kinematics.
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Feinstein SD, Gregory JM. Arthroscopic Stabilization of Posterior Shoulder Instability Without Glenoid Bone Loss. VIDEO JOURNAL OF SPORTS MEDICINE 2022. [DOI: 10.1177/26350254221123339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background: Contact athletes who experience posterior shoulder instability have a high likelihood of recurrence necessitating surgery. Indications: Patients with posterior shoulder instability without glenoid or humeral head bone loss who have failed activity modification, bracing, and physical therapy may benefit from arthroscopic stabilization surgery. Technique Description: We describe a technique for arthroscopic labral repair with capsular plication through 4 portals in the lateral decubitus position. Results: Arthroscopic capsulolabral reconstruction is an effective and reliable treatment for posterior shoulder instability with good patient-reported outcomes, low recurrence rates, and high rate of return-to-play. Discussion/Conclusion: Arthroscopic capsulolabral reconstruction in the lateral decubitus position with appropriately placed portals allows for safe and effective repair of the labrum and capsular plication to address posterior shoulder instability. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
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Affiliation(s)
- Shawn D. Feinstein
- The Department of Orthopaedic Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - James M. Gregory
- The Department of Orthopaedic Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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10
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Ernat JJ, Jildeh TR, Peebles AM, Hanson JA, Mologne MS, Golijanin P, Provencher MT. How to Fashion the Bone Block for Reconstruction of the Glenoid in Anterior and Posterior Instability. Am J Sports Med 2022; 50:3333-3340. [PMID: 36122346 DOI: 10.1177/03635465221121583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Glenoid restoration techniques to address glenohumeral instability-induced anterior and posterior glenoid bone loss (AGBL and PGBL) often require reconstruction, but best-fit bone block (BFBB) modeling has not been developed. PURPOSE To provide glenoid bony reconstruction models for anterior and posterior instability of the shoulder using a bone loss instability cohort with high-fidelity 3-dimensional (3D) imaging. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS We reviewed consecutive patients indicated for operative stabilization who had posterior glenohumeral instability and suspected GBL who underwent 2-dimensional (2D) computed tomography (CT). Patients were matched by sex, laterality, and age to patients who underwent operative stabilization of anterior glenohumeral instability. Mimics software was used to convert all 2D CT scans into 3D models of the scapula. A BFBB model was designed to digitally reconstruct GBL and was used to predict the amount, anatomic configuration, and fixation configuration of bony reconstruction required in AGBL and PGBL. RESULTS The study included 30 patients with posterior instability and 30 patients with anterior instability; the participants' mean ± SD age was 28.8 ± 8.15 years (range, 16.0-51.0 years). Mean surface area of AGBL was 24.9% ± 7.7% (range, 14.7%-39.1%). Mean BFBB dimensions to reconstruct the anterior glenoid were determined to be a superior-inferior length of 23.9 ± 4.2 mm, anterior-posterior width of 6.4 ± 2.4 mm, and height of 1 cm. Mean angle of AGBL bone block interface relative to glenoid to reconstruct the native concavity was 79.4°± 5.9°. For PGBL, the mean surface area was 9.2% ± 5.6% (range, 3.0%-26.3%). Mean BFBB dimensions to reconstruct the posterior glenoid were a superior-inferior length of 21.9 ± 3.4 mm, width of 4.5 ± 2.3 mm, and height of 1 cm. The mean angle of PGBL bone block interface relative to the glenoid to reconstruct the native concavity was 38.6°± 14.3°. Orientation relative to the vertical glenoid axis was 77.2°± 13.8° in anterior reconstructions versus 105.9°± 10.9° in posterior reconstructions. CONCLUSION Patients with anterior instability required a more rectangular BFBB with a bone block-glenoid interface angle of 79°, whereas patients with posterior instability required a more trapezoidal, obtusely oriented BFBB with a bone block-glenoid interface angle of 39°. BFBBs for either AGBL or PGBL can be effectively designed, and their size and/or shape can be predicted based on approximate percentage of GBL.
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Affiliation(s)
- Justin J Ernat
- The Steadman Clinic, Vail, Colorado, USA.,University of Utah Health, Salt Lake City, Utah, USA
| | | | | | - Jared A Hanson
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | | | - Matthew T Provencher
- The Steadman Clinic, Vail, Colorado, USA.,Steadman Philippon Research Institute, Vail, Colorado, USA
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Bedrin MD, Owens BD, Slaven SE, LeClere LE, Donohue MA, Tennent DJ, Goodlett RP, Cameron KL, Posner MA, Dickens JF. Prospective Evaluation of Posterior Glenoid Bone Loss After First-time and Recurrent Posterior Glenohumeral Instability Events. Am J Sports Med 2022; 50:3028-3035. [PMID: 35983958 DOI: 10.1177/03635465221115828] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although posterior glenohumeral instability is becoming an increasingly recognized cause of shoulder pain, the role of posterior glenoid bone loss on outcomes remains incompletely understood. PURPOSES To prospectively determine the amount of bone loss associated with posterior instability events and to determine predisposing factors based on preinstability imaging. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS A total of 1428 shoulders were evaluated prospectively for ≥4 years. At baseline, a subjective history of shoulder instability was ascertained for each patient, and bilateral noncontrast magnetic resonance imaging (MRI) scans of the shoulders were obtained regardless of any reported history of shoulder instability. The cohort was prospectively followed during the study period, and those who were diagnosed with posterior glenohumeral instability were identified. Postinjury MRI scans were obtained and compared with the screening MRI scans. Glenoid version, perfect-circle-based bone loss was measured for each patient's pre- and postinjury MRI scans using previously described methods. RESULTS Of the 1428 shoulders that were prospectively followed, 10 shoulders sustained a first-time posterior instability event and 3 shoulders sustained a recurrent posterior instability event. At baseline, 11 of 13 shoulders had some amount of glenoid dysplasia and/or bone loss. The change in glenoid bone loss was 5.4% along the axis of greatest loss (95% CI, 3.8%-7.0%; P = .009), 4.4% at the glenoid equator (95% CI, 2.7%-6.2%; P = .016), and 4.2% of total glenoid area (95% CI, 2.9%-5.3%; P = .002). Recurrent glenoid instability was associated with a greater amount of absolute bone loss along the axis of greatest loss compared with first-time instability (recurrent: 16.8% ± 1.1%; 95% CI, 14.6%-18.9%; first-time: 10.0% ± 1.5%; 95% CI, 7.0%-13.0%; P = .005). Baseline glenoid retroversion ≥10° was associated with a significantly greater percentage of bone loss along the axis of greatest loss (≥10° of retroversion: 13.5% ± 2.0%; 95% CI, 9.6%-17.4%; <10° of retroversion: 8.5% ± 0.8%; 95% CI, 7.0%-10.0%; P = .045). CONCLUSIONS Posterior glenohumeral instability events were associated with glenoid bone loss of 5%. The amount of glenoid bone loss after a recurrent posterior glenohumeral instability event was greater than that after first-time instability. Glenoid retroversion ≥10° was associated with a greater amount of posterior glenoid bone loss after a posterior instability event.
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Affiliation(s)
- Michael D Bedrin
- Walter Reed National Military Medical Center, Department of Orthopaedic Surgery, Bethesda, Maryland, USA.,Uniformed Services University of the Health Sciences, Department of Surgery, Bethesda, Maryland, USA
| | - Brett D Owens
- John A. Feagin Jr. Sports Medicine Fellowship, Keller Army Community Hospital, United States Military Academy, West Point, New York, USA.,Brown University Alpert Medical School, Providence, Rhode Island, USA
| | - Sean E Slaven
- Walter Reed National Military Medical Center, Department of Orthopaedic Surgery, Bethesda, Maryland, USA.,Uniformed Services University of the Health Sciences, Department of Surgery, Bethesda, Maryland, USA
| | - Lance E LeClere
- United States Naval Academy, Department of Orthopaedic Surgery, Annapolis, Maryland, USA.,Vanderbilt Orthopaedics, Nashville, Tennessee, USA
| | - Michael A Donohue
- John A. Feagin Jr. Sports Medicine Fellowship, Keller Army Community Hospital, United States Military Academy, West Point, New York, USA.,Department of Orthopedic Surgery, Keller Army Community Hospital, West Point, New York, USA
| | - David J Tennent
- John A. Feagin Jr. Sports Medicine Fellowship, Keller Army Community Hospital, United States Military Academy, West Point, New York, USA.,Department of Orthopaedic Surgery, Evans Army Community Hospital, Fort Carson, Colorado, USA
| | - Ronald P Goodlett
- John A. Feagin Jr. Sports Medicine Fellowship, Keller Army Community Hospital, United States Military Academy, West Point, New York, USA.,Womack Army Medical Center, Fort Bragg, North Carolina, USA
| | - Kenneth L Cameron
- John A. Feagin Jr. Sports Medicine Fellowship, Keller Army Community Hospital, United States Military Academy, West Point, New York, USA.,Department of Orthopedic Surgery, Keller Army Community Hospital, West Point, New York, USA
| | - Matthew A Posner
- John A. Feagin Jr. Sports Medicine Fellowship, Keller Army Community Hospital, United States Military Academy, West Point, New York, USA.,Department of Orthopedic Surgery, Keller Army Community Hospital, West Point, New York, USA
| | - Jonathan F Dickens
- Uniformed Services University of the Health Sciences, Department of Surgery, Bethesda, Maryland, USA.,Duke University, Department of Orthopaedic Surgery, Durham, North Carolina, USA.,Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
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Hachem AI, Molina-Creixell A, Rius X, Rodriguez-Bascones K, Cabo Cabo FJ, Agulló JL, Ruiz-Iban MA. Comprehensive management of posterior shoulder instability: diagnosis, indications, and technique for arthroscopic bone block augmentation. EFORT Open Rev 2022; 7:576-586. [PMID: 35924637 PMCID: PMC9458942 DOI: 10.1530/eor-22-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Recurrent posterior glenohumeral instability is an entity that demands a high clinical suspicion and a detailed study for a correct approach and treatment. Its classification must consider its biomechanics, whether it is due to functional muscular imbalance or to structural changes, volition, and intentionality. Due to its varied clinical presentations and different structural alterations, ranging from capsule-labral lesions and bone defects to glenoid dysplasia and retroversion, the different treatment alternatives available have historically had a high incidence of failure. A detailed radiographic assessment, with both CT and MRI, with a precise assessment of glenoid and humeral bone defects and of glenoid morphology, is mandatory. Physiotherapy focused on periscapular muscle reeducation and external rotator strengthening is always the first line of treatment. When conservative treatment fails, surgical treatment must be guided by the structural lesions present, ranging from soft tissue repair to posterior bone block techniques to restore or increase the articular surface. Bone block procedures are indicated in cases of recurrent posterior instability after the failure of conservative treatment or soft tissue techniques, as well as symptomatic demonstrable nonintentional instability, presence of a posterior glenoid defect >10%, increased glenoid retroversion between 10 and 25°, and posterior rim dysplasia. Bone block fixation techniques that avoid screws and metal allow for satisfactory initial clinical results in a safe and reproducible way. An algorithm for the approach and treatment of recurrent posterior glenohumeral instability is presented, as well as the author’s preferred surgical technique for arthroscopic posterior bone block.
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Affiliation(s)
- Abdul-Ilah Hachem
- Department of Orthopedic Surgery, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Xavier Rius
- Department of Orthopedic Surgery, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Francisco Javier Cabo Cabo
- Department of Orthopedic Surgery, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Jose Luis Agulló
- Department of Orthopedic Surgery, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
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Evaluation and Management of the Contact Athlete's Shoulder. J Am Acad Orthop Surg 2022; 30:e584-e594. [PMID: 35171860 DOI: 10.5435/jaaos-d-20-01374] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 12/10/2021] [Indexed: 02/01/2023] Open
Abstract
Shoulder injuries are common in contact athletes and vary in severity because of the required complex interplay of shoulder stability and range of motion for proper function. Pathology varies based on sport but most commonly includes shoulder instability, acromioclavicular injuries, traumatic rotator cuff tears, and brachial plexus injuries. Acute management ranges from reduction of shoulder dislocations to physical examination to determine the severity of injury. Appropriate radiographs should be obtained to evaluate for alignment and fracture, with magnetic resonance imaging commonly being necessary for accurate diagnosis and management. Treatments range from surgical stabilization in shoulder instability to repeat examinations and physical therapy. Return-to-play decision making can be complex with avoidance of reinjury and player safety being of utmost concern. Appropriate evaluation and treatment are vital because repeat injury can lead to long-term effects due to the relatively high effectsometimes seen in contact sports.
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Marcaccio SE, O’Donnel RM, Schilkowsky R, Owens MBD, Bokshan SL. Posterior Glenoid Osteotomy With Capsulolabral Repair Improves Resistance Forces in a Critical Glenoid Bone Loss Model. Orthop J Sports Med 2022; 10:23259671221083579. [PMID: 35309235 PMCID: PMC8928394 DOI: 10.1177/23259671221083579] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 12/08/2021] [Indexed: 11/30/2022] Open
Abstract
Background: There is no widespread consensus on the surgical treatment of posterior shoulder instability with critical posterior glenoid bone loss. Hypothesis: That opening posterior glenoid wedge osteotomy with soft tissue repair would improve the resistance forces of instability when compared with soft tissue repair alone in the setting of 20% critical bone lose. Study Design: Controlled laboratory study. Methods: Native glenoid retroversion was measured on 9 shoulders using computed tomography (CT) scans. The humerus was potted in 90° of forward flexion and 30° of internal rotation relative to the scapula, and a posterior dislocation was performed to create a posterior capsulolabral injury model. The specimens were each taken through a fixed sequence of testing: (1) posteroinferior capsulolabral tear, (2) no glenoid bone loss with posteroinferior capsulolabral repair, (3) 20% posterior glenoid bone loss with posteroinferior capsulolabral repair, and (4) 20% glenoid bone loss with posterior glenoid opening wedge osteotomy and posteroinferior capsulolabral repair. Bone loss was created using a sagittal saw. The resultant peak forces with 1 cm of posterior translation were measured. A 1-way repeated-measures analysis of variance was used to compare mean force values. Results: After the initial dislocation event, all shoulders had a resultant posterior capsulolabral injury. The resulting labral injury was extended from 6- to 9-o’clock in all specimens to homogenize the extent of injury. Repairing the capsulolabral complex in the 20% posterior glenoid bone loss group did not result in a statistically significant increase in resistance force compared with the labral deficient group (34.1 vs 22.2 N; P = .068). When 20% posterior bone loss was created, the posterior glenoid osteotomy with capsulolabral repair was significantly stronger (43.8 N) than the posterior repair alone both with (34.1 N) and without (31.8 N) bone loss (P = .008 and .045, respectively). Conclusion: In the setting of critical posterior glenoid bone loss, an opening wedge posterior glenoid osteotomy with capsulolabral repair improved resistance to posterior humeral translation significantly compared with capsulolabral repair alone. Clinical Relevance: The results of this biomechanical cadaveric study may aid in surgical planning for this complex patient population.
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Affiliation(s)
- Stephen E. Marcaccio
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, USA
| | - Ryan M. O’Donnel
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, USA
| | - Rachel Schilkowsky
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, USA
| | - Meng Brett D. Owens
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, USA
| | - Steven L. Bokshan
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, USA
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15
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Xu AL, Beck JJ, Sweeney EA, Severson MN, Page AS, Lee RJ. Understanding the Cheerleader as an Orthopaedic Patient: An Evidence-Based Review of the Literature. Orthop J Sports Med 2022; 10:23259671211067222. [PMID: 35083360 PMCID: PMC8785319 DOI: 10.1177/23259671211067222] [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: 09/01/2021] [Accepted: 09/27/2021] [Indexed: 11/24/2022] Open
Abstract
Cheerleading is a highly popular youth sport in the United States and has been increasingly recognized in recent years for its athleticism and competitive nature. The sport has changed dramatically since its inception. When the sport of cheerleading was first developed, its primary purpose was to entertain crowds and support other athletes. Today, cheerleaders are competitive athletes themselves. Cheerleaders, most of whom are in the pediatric age group, and their parents commonly approach orthopaedic surgeons and sports medicine physicians with questions regarding the risks associated with participation in the sport. Appropriate clinical guidance is especially important for athletes returning to the sport after an injury. However, unlike other popular sports (eg, football, basketball, and volleyball), the intricacies of cheerleading are not well-known to those outside the sport, including many health care providers. Previous studies have reported on the epidemiological patterns of injuries associated with cheerleading and how such aesthetic sports affect the body, finding that fractures and concussions are prevalent and that catastrophic injuries are more common than in most other sports. Here, we provide an evidence-based discussion of 10 pertinent topics regarding cheerleading and its risks to the musculoskeletal system. The purpose of this review is to provide a comprehensive resource for orthopaedic surgeons and sports medicine physicians who care for these athletes.
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Affiliation(s)
- Amy L. Xu
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Jennifer J. Beck
- Orthopaedic Institute for Children/UCLA, Santa Monica, California, USA
| | - Emily A. Sweeney
- Sports Medicine Center, Children’s Hospital Colorado, Aurora, Colorado, USA
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Megan N. Severson
- Carilion Clinic Orthopaedic Surgery, Roanoke, Virginia, USA
- Department of Orthopaedic Surgery, Virginia Tech-Carilion School of Medicine, Roanoke, Virginia, USA
| | - A. Stacie Page
- Department of Physical Medicine and Rehabilitation, The Johns Hopkins Hospital, White Marsh, Maryland, USA
| | - R. Jay Lee
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
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Conservative treatment of acute traumatic posterior shoulder dislocations (Type A) is a viable option especially in patients with centred joint, low gamma angle, and middle or old age. Knee Surg Sports Traumatol Arthrosc 2022; 30:2500-2509. [PMID: 35092444 PMCID: PMC9206607 DOI: 10.1007/s00167-022-06883-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 01/12/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE Purpose of this study was to evaluate the mid- to long-term outcome after conservatively treated first-time posterior shoulder dislocations and to determine structural defects associated with failure. METHODS In this multi-centric retrospective study, 29 shoulders in 28 patients with first-time acute posterior shoulder dislocation (Type A1 or A2 according to the ABC classification) and available cross-sectional imaging were included. Outcome scores as well as radiological and magnetic resonance imaging were obtained at a mean follow-up of 8.3 ± 2.7 years (minimum: 5 years). The association of structural defects with redislocation, need for secondary surgery, and inferior clinical outcomes were analysed. RESULTS Redislocation occurred in six (21%) shoulders and nine shoulders (31%) underwent secondary surgery due to persistent symptoms. The posttraumatic posterior glenohumeral subluxation was higher in the redislocation group compared to the no redislocation group; however, statistical significance was not reached (61.9 ± 12.5% vs. 50.6 ± 6.4%). Furthermore, a higher adapted gamma angle was observed in the failed conservative treatment group versus the conservative treatment group, similarly without statistically significant difference (97.8° ± 7.2°, vs. 93.3° ± 9.7°). The adapted gamma angle was higher than 90° in all patients of failed conservative therapy and the redislocation group. An older age at the time of dislocation showed a significant correlation with better clinical outcomes (SSV: r = 0.543, p = 0.02; ROWE: r = 0.418, p = 0.035 and WOSI: r = 0.478, p = 0.045). Posterior glenohumeral subluxation after trauma correlated with a worse WOSI (r = - 0.59, p = 0.02) and follow-up posterior glenohumeral decentring (r = 0.68, p = 0.007). The gamma angle (r = 0.396, p = 0.039) and depth of the reverse Hill-Sachs lesion (r = 0.437, p = 0.023) correlated significantly with the grade of osteoarthritis at follow-up. CONCLUSION Conservative treatment is a viable option in patients with an acute traumatic posterior shoulder dislocation with good outcome after mid- and long-term follow-up especially in patients with centred joint, low gamma angle, and middle or old age. LEVEL OF EVIDENCE IV.
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17
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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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18
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Arner JW, Ruzbarsky JJ, Midtgaard K, Peebles L, Bradley JP, Provencher MT. Defining Critical Glenoid Bone Loss in Posterior Shoulder Capsulolabral Repair. Am J Sports Med 2021; 49:2013-2019. [PMID: 34081559 DOI: 10.1177/03635465211016804] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although critical bone loss for anterior instability is well defined, a clinically significant threshold of posterior bone loss has not been elucidated. HYPOTHESIS Patients with failed arthroscopic posterior shoulder capsulolabral repair will have increased posterior glenoid bone loss with a defined critical threshold. STUDY DESIGN Case control study; Level of evidence, 3. METHODS Athletes older than 18 years with unidirectional posterior instability treated with arthroscopic repair were evaluated at 2-year minimum follow-up. Failure was defined as revision surgery, American Shoulder and Elbow Surgeons (ASES) score of <60, or subjective stability score of >5. Magnetic resonance imaging (MRI) measurements from 19 patients with failed arthroscopic posterior shoulder capsulolabral repair were compared with 56 patients whose surgery was successful. MRI measures included glenoid version, labral version, glenoid width, labral width, percentage bone loss using the circle technique, labral height, percent subluxation, and recently described measures of defect slope, bone loss angle, and defect length. The P value threshold was set at .05, and a multivariable logistic regression analysis was performed for evaluation of risk of surgical failure. RESULTS Smaller glenoid width and greater percentage glenoid bone loss (25.5 ± 0.68 mm vs 28.8 ± 0.47 mm; P < .001; 6.8% ± 0.64% vs 4.6% ± 0.43%; P = .008) were seen in those patients with failed surgery. There was no difference in glenoid version or other measurements between the failures and nonfailures. A cutoff of 11% glenoid bone loss resulted in a 10.4 times statistically higher surgical failure rate, while a 15% bone loss resulted in a 24.4 times statistically higher failure rate. Six patients had >11% bone loss (range, 11.1 to 19.3) and 1 patient had >15% bone loss. CONCLUSION Risk factors for failure of arthroscopic posterior shoulder capsulolabral repair include smaller glenoid bone width and greater percentage of glenoid bone loss. A threshold of 11% posterior glenoid bone loss implicated a 10 times higher surgical failure rate, while a threshold of 15% led to a 25 times higher surgical failure rate. Surgical failure of posterior capsulolabral repair, however, is relatively rare as it is an overall successful intervention.
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Affiliation(s)
- Justin W Arner
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | | | - Liam Peebles
- The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado, USA
| | - James P Bradley
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Matthew T Provencher
- The Steadman Clinic, Vail, Colorado, USA.,The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado, USA
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19
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Goldenberg BT, Goldsten P, Lacheta L, Arner JW, Provencher MT, Millett PJ. Rehabilitation Following Posterior Shoulder Stabilization. Int J Sports Phys Ther 2021; 16:930-940. [PMID: 34123543 PMCID: PMC8168996 DOI: 10.26603/001c.22501] [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: 12/13/2019] [Accepted: 12/13/2020] [Indexed: 12/05/2022] Open
Abstract
Posterior shoulder instability has been noted in recent reports to occur at a higher prevalence than originally believed, with many cases occurring in active populations. In most cases, primary surgical treatment for posterior shoulder instability-a posterior labral repair-is indicated for those patients who have failed conservative management and demonstrate persistent functional limitations. In order to optimize surgical success and return to a prior level of function, a comprehensive and focused rehabilitation program is crucial. Currently, there is a limited amount of literature focusing on rehabilitation after surgery for posterior instability. Therefore, the purpose of this clinical commentary is to present a post-surgical rehabilitation program for patients following posterior shoulder labral repair, with recommendations based upon best medical evidence. LEVEL OF EVIDENCE 5.
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20
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Vopat ML, Coda RG, Giusti NE, Baker J, Tarakemeh A, Schroeppel JP, Mullen S, Randall J, Provencher MT, Vopat BG. Differences in Outcomes Between Anterior and Posterior Shoulder Instability After Arthroscopic Bankart Repair: A Systematic Review and Meta-analysis. Orthop J Sports Med 2021; 9:23259671211006437. [PMID: 34104660 PMCID: PMC8155769 DOI: 10.1177/23259671211006437] [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: 01/06/2021] [Accepted: 02/18/2021] [Indexed: 11/25/2022] Open
Abstract
Background: The glenohumeral joint is one of the most frequently dislocated joints in the
body, particularly in young, active adults. Purpose: To conduct a systematic review and meta-analysis to evaluate and compare
outcomes between anterior versus posterior shoulder instability. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was performed using the PubMed, Cochrane Library, and
MEDLINE databases (from inception to September 2019) according to PRISMA
(Preferred Reporting Items for Systematic Reviews and Meta-Analyses)
guidelines. Studies were included if they were published in the English
language, contained outcomes after anterior or posterior shoulder
instability, had at least 1 year of follow-up, and included arthroscopic
soft tissue labral repair of either anterior or posterior instability.
Outcomes including return-to-sport (RTS) rate, postoperative instability
rate, and pre- and postoperative American Shoulder and Elbow Surgeons (ASES)
scores were recorded and analyzed. Results: Overall, 39 studies were included (2077 patients; 1716 male patients and 361
female patients). Patients with anterior instability had a mean age of 23.45
± 5.40 years (range, 11-72 years), while patients with posterior instability
had a mean age of 23.08 ± 8.41 years (range, 13-61 years). The percentage of
male patients with anterior instability was significantly higher than that
of female patients (odds ratio [OR], 1.36; 95% CI, 1.04-1.77;
P = .021). Compared with patients with posterior
instability, those with anterior instability were significantly more likely
to RTS (OR, 2.31; 95% CI, 1.76-3.04; P < .001), and they
were significantly more likely to have postoperative instability (OR, 1.53;
95% CI, 1.07-2.23; P = .018). Patients with anterior
instability also had significantly higher ASES scores than those with
posterior instability (difference in means, 6.74; 95% CI, 4.71-8.77;
P < .001). There were no significant differences
found in postoperative complications between the anterior group (11
complications; 1.8%) and the posterior group (3 complications; 1.6%) (OR,
1.12; 95% CI, 0.29-6.30; P = .999). Conclusion: Patients with anterior shoulder instability had higher RTS rates but were
more likely to have postoperative instability compared with posterior
instability patients. Overall, male patients were significantly more likely
to have anterior shoulder instability, while female patients were
significantly more likely to have posterior shoulder instability.
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Affiliation(s)
- Matthew L Vopat
- University of Kansas School of Medicine-Wichita, Wichita, Kansas, USA
| | - Reed G Coda
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Nick E Giusti
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jordan Baker
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Armin Tarakemeh
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Scott Mullen
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jeffrey Randall
- University of Kansas School of Medicine-Wichita, Wichita, Kansas, USA
| | | | - Bryan G Vopat
- University of Kansas Medical Center, Kansas City, Kansas, USA
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21
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Posterior Shoulder Dislocation with Engaging Reverse Hill-Sachs Lesion: A Retrospective Study of Ten Patients Treated with Arthroscopy or Open Reduction and Stabilization. J Clin Med 2021; 10:jcm10071410. [PMID: 33915791 PMCID: PMC8037443 DOI: 10.3390/jcm10071410] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/09/2021] [Accepted: 03/24/2021] [Indexed: 11/25/2022] Open
Abstract
This study compares two surgical techniques used to treat patients with posterior shoulder dislocation with an engaging reverse Hill–Sachs lesion. We assessed ten patients who were treated at the Surgical Orthopedic and Traumatological Institute (ICOT) of Latina and the Clinic of Orthopedic and Traumatological Surgery of the ASST Sette Laghi of Varese between 2016 and 2019. The patients were divided into two groups: the first comprising six patients who underwent the open surgery McLaughlin procedure as modified by Neer, the second including four patients who underwent the arthroscopic McLaughlin procedure. All patients received postoperative rehabilitation to achieve the best possible functional recovery of the affected shoulder. We then assessed the shoulder range of motion, the pain level, and the impact on quality of life with four tests: the Constant Scale, the Simple Shoulder Test (SST), the OXFORD Scale, and The University of California—Los Angeles (UCLA) Shoulder Scale. The mean scores of the first group were: 81.3 ± 9.8 SD (Constant Scale), 10.8 ± 1.06 SD (SST), 42.5 ± 5.4 SD (Oxford Scale), 30.8 ± 3.02 SD (UCLA Shoulder Scale); we calculated the following mean scores in the second group: 80.25 ± 4.1 SD (Constant Scale), 11.5 ± 0.8 SD (SST), 42 ± 4.06 SD (Oxford Scale), 32 ± 2.9 SD (UCLA Shoulder Scale). We found no significant differences between the two groups.
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22
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Aman ZS, Peebles LA, Johnson DW, Hanson JA, Provencher MT. Multidirectional Shoulder Instability With Circumferential Labral Tear and Bony Reverse Hill Sachs: Treatment with 270° Labral Repair and Fresh Talus Osteochondral Allograft to the Humeral Head. Arthrosc Tech 2021; 10:e781-e787. [PMID: 33738215 PMCID: PMC7953230 DOI: 10.1016/j.eats.2020.10.068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 10/29/2020] [Indexed: 02/03/2023] Open
Abstract
Traumatic posterior dislocations of the shoulder can result in bony defects, labral tears, and cartilage injuries of the glenohumeral joint. Although traditional Hill-Sachs lesions from anterior dislocations are more commonly identified, reverse Hill-Sachs lesions caused by posterior dislocation often leads to recurrent engagement of the humeral head with the glenoid and significantly greater damage to the humeral chondral surface. In severe traumatic cases, concomitant damage of the capsulolabral soft tissues, such as circumferential labral lesions, can lead to chronic shoulder instability and residual glenoid bone loss. These lesions further add to the complexity of managing patients with posterior dislocations of the shoulder because of the challenges of achieving adequate anatomic reduction and tensioning of the capsulolabral junction, while also using a combination of arthroscopic and open-labral repair techniques. In the setting of reverse Hill-Sachs lesions treatment, it is important to address the bony and cartilage defect. The purpose of this Technical Note is to describe our preferred technique for arthroscopic repair of circumferential lesions of the glenoid labrum causing multidirectional instability with concomitant reverse Hill-Sachs Lesion treatment with fresh talus osteochondral allograft.
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Affiliation(s)
- Zachary S. Aman
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Liam A. Peebles
- Tulane University School of Medicine, New Orleans, Los Angeles, U.S.A
| | | | - Jared A. Hanson
- University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Matthew T. Provencher
- The Steadman Clinic, Vail, Colorado, U.S.A
- Address correspondence to CAPT Matthew T. Provencher, M.D., M.C., U.S.N.R., The Steadman Clinic, The Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 400, Vail, CO 81657.
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23
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Cusano A, Do A, Parisien RL, Li X. Arthroscopic Posterior Glenoid Reconstruction Using a Fresh Distal Tibia Allograft for Recurrent Posterior Instability. Arthrosc Tech 2021; 10:e341-e351. [PMID: 33680765 PMCID: PMC7917087 DOI: 10.1016/j.eats.2020.10.018] [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: 05/08/2020] [Accepted: 10/09/2020] [Indexed: 02/03/2023] Open
Abstract
Posterior glenohumeral instability is a relatively uncommon cause of shoulder instability. Recurrent posterior instability with static posterior humeral head subluxation is often associated with critical glenoid bone loss. Unlike anterior instability, the amount of bone loss for posterior instability that requires surgical reconstruction remains a topic of debate. Several techniques have been described to treat critical bony defects in patients with recurrent posterior shoulder instability with the use of both autografts and allografts depending on the amount of bone loss present. Open posterior glenoid bone block procedure is associated with increased risk of complications and morbidity to the patient. As such, all-arthroscopic techniques have emerged with the advantage of allowing for the diagnosis and treatment of concomitant glenohumeral pathology and minimizing soft-tissue dissection through the posterior deltoid and rotator cuff muscles. Reported short-term outcomes of arthroscopic posterior bone block stabilization are promising; however, it remains a technically challenging procedure due to intra-articular graft insertion and subsequent fixation congruent to the posterior glenoid articular margin. We describe an all-arthroscopic technique using a fresh distal tibia allograft fixation using 2 partially threaded screws in conjunction with an arthroscopic Latarjet fixation set for a patient with recurrent posterior shoulder instability and associated glenoid bone loss.
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Affiliation(s)
- Antonio Cusano
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut
| | - Andrew Do
- Department of Orthopaedic Surgery, Boston University Medical School and Medical Center, Boston, Massachusetts
| | - Robert L. Parisien
- Penn Sports Medicine Center, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Xinning Li
- Department of Orthopaedic Surgery, Boston University Medical School and Medical Center, Boston, Massachusetts
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24
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Schubert MF, Duralde XA. Posterior Shoulder Instability in the Throwing Athlete. OPER TECHN SPORT MED 2021. [DOI: 10.1016/j.otsm.2021.150802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Vaswani R, Arner J, Freiman H, Bradley JP. Risk Factors for Revision Posterior Shoulder Stabilization in Throwing Athletes. Orthop J Sports Med 2020; 8:2325967120967652. [PMID: 33330737 PMCID: PMC7720310 DOI: 10.1177/2325967120967652] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 07/18/2020] [Indexed: 01/15/2023] Open
Abstract
Background Revision posterior shoulder capsulolabral repair has inferior outcomes compared with primary surgery. Risk factors for revision in throwing athletes are unknown. Purpose/Hypothesis The purpose of this study was to characterize the revision rate and risk factors for revision surgery in throwing athletes. It was hypothesized that female athletes and those with smaller glenoid bone width would be at higher risk for revision surgery. Study Design Case-control study; Level of evidence, 3. Methods A total of 105 throwing athletes who underwent arthroscopic posterior capsulolabral repair of their throwing shoulder were reviewed at a minimum of 2-year follow-up, and patients who required a revision were compared with those who did not. Collected data compared between the revision and no-revision groups included age, sex, contact sport participation, and return to sport (RTS). American Shoulder and Elbow Surgeons (ASES) score, Kerlan-Jobe Orthopaedic Clinic (KJOC) score, stability, pain, strength, range of motion (ROM), and patient satisfaction. Radiographic parameters including glenoid bone version, cartilage version, labral version, bone width, labral width, glenoid labral version and width weight were also compared between both groups. Results Nine throwers required revision (8.6%) at an average of 2.8 years postoperatively. There were more female athletes in the revision than no-revision group (55.5% vs 23.4%; P = .03). There was no significant difference in age, proportion of contact athletes, rotator cuff tears, glenoid bone version, cartilage version, labral version, labral version weight, bone width, labral width, or labral width weight. Both groups had similar preoperative, postoperative, and change in ASES, KJOC, pain, strength, stability, and ROM scores. The proportion of patients with full strength and with full ROM, as well as patients who were satisfied with outcomes was similar between groups. Fewer patients in the revision group returned to sports compared with those in the no-revision group (14.3% vs 83.6%; P < .001), although return to sports at same level was not significantly different between groups (14.3% vs 37.2%; P = .41). Conclusion The revision rate of arthroscopic posterior shoulder stabilization in throwers was 8.6%. Female athletes were at higher risk for revision, and return to sports was lower in patients who underwent revision surgery.
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Affiliation(s)
- Ravi Vaswani
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Justin Arner
- Burke and Bradley Orthopaedics, Pittsburgh, Pennsylvania, USA
| | | | - James P Bradley
- Burke and Bradley Orthopaedics, Pittsburgh, Pennsylvania, USA
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Sheean AJ, Arner JW, Bradley JP. Posterior Glenohumeral Instability: Diagnosis and Management. Arthroscopy 2020; 36:2580-2582. [PMID: 32442706 DOI: 10.1016/j.arthro.2020.05.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 05/08/2020] [Indexed: 02/02/2023]
Abstract
Posterior glenohumeral instability can manifest as posterior shoulder pain and dysfunction, particularly among athletes. Repetitive, posteriorly-directed axial loads, as commonly encountered by contact athletes (American football linemen, rugby players), result in microtrauma that can induce posteroinferior labral tears. Alternatively, SLAP tears commonly seen in throwing athletes may propagate in a posteroinferior direction (i.e., a type VIII SLAP tear), owing to a complex pathologic cascade involving glenohumeral capsular contracture and imbalances among the dynamic stabilizing muscles of both the glenohumeral joint and shoulder girdle. The diagnosis of posterior glenohumeral instability is elucidated by a thorough history and physical examination. Posterior shoulder pain is oftentimes insidious in onset. The throwing athlete with posterior glenohumeral instability may complain of diminished control, accuracy, and generalized shoulder discomfort. A number of provocative physical examination maneuvers have been described (Kim test, Jerk test), which load the humeral head against the labral lesion and recreate patients' symptoms. Magnetic resonance imaging and magnetic resonance arthrography can be of value in demonstrating avulsions of the labrum from the posteroinferior glenoid, and computed tomography is useful for quantifying the location and amount of attritional glenoid bone loss, although in contradistinction to anterior glenohumeral instability, clearly defined thresholds that would otherwise guide treatment have not been established. In the absence of substantial bone loss, arthroscopic posterior capsulolabral repair remains the gold standard for the surgical management of symptoms refractory to nonoperative treatment, and excellent clinical outcomes have generally been reported. However, high rates of return to play at the previous level of participation, particularly among throwing athletes, have been less consistently observed. Risk factors for the need for revision stabilization include surgery on the dominant extremity, female sex, and capsulolabral repairs involving either anchorless techniques or the use of less than 4 anchors.
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Affiliation(s)
- Andrew J Sheean
- San Antonio Military Medical Center, San Antonio, Texas, U.S.A..
| | - Justin W Arner
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - James P Bradley
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
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Hachem AI, Rondanelli S R, Costa D'O G, Verdalet I, Rius X. Arthroscopic "Bone Block Cerclage" Technique for Posterior Shoulder Instability. Arthrosc Tech 2020; 9:e1171-e1180. [PMID: 32874898 PMCID: PMC7451436 DOI: 10.1016/j.eats.2020.04.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 04/25/2020] [Indexed: 02/03/2023] Open
Abstract
Many open and arthroscopic techniques have been described to treat posterior glenohumeral instability. Multifactorial features of posterior shoulder instability pathoanatomy and varied patient characteristics have challenged the understanding of this condition and have led to dissimilar results, without a strong consensus for the most adequate technique to treat it. We describe an arthroscopic anatomical metal-free posterior glenoid reconstruction technique, using a tricortical iliac crest allograft with 2 ultra-high strength sutures (FiberTape Cerclage System; Arthrex, Naples, FL) with concomitant posterior capsulolabral complex reconstruction procedure.
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Affiliation(s)
- Abdul-ilah Hachem
- Department of Orthopedic and Traumatology Surgery, Hospital Universitari de Bellvitge, Barcelona, Spain,Address correspondence to Abdul-ilah Hachem, M.D., C/ Feixa Llarga S/ N Hospital de Bellvitge Pl. 10 Traumatology and Orthopedic Secretary, Hospital Universitari de Bellvitge (L’Hospitalet de Llobregat), Barcelona, Spain, 08907.
| | - Rafael Rondanelli S
- University of Barcelona Shoulder Surgery Master Fellowship, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Gino Costa D'O
- University of Barcelona Shoulder Surgery Master Fellowship, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Iñigo Verdalet
- University of Barcelona Shoulder Surgery Master Fellowship, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Xavier Rius
- Department of Orthopedic and Traumatology Surgery, Hospital Universitari de Bellvitge, Barcelona, Spain
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Lansdown DA, Cvetanovich GL, Zhang AL, Feeley BT, Wolf BR, Hettrich CM, Baumgarten KM, Bishop JY, Bollier MJ, Bravman JT, Brophy RH, Cox CL, Frank RM, Grant JA, Jones GL, Kuhn JE, Marx RG, McCarty EC, Miller BS, Ortiz SF, Smith MV, Wright RW, Ma CB. Risk Factors for Intra-articular Bone and Cartilage Lesions in Patients Undergoing Surgical Treatment for Posterior Instability. Am J Sports Med 2020; 48:1207-1212. [PMID: 32150443 DOI: 10.1177/0363546520907916] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients with posterior shoulder instability may have bone and cartilage lesions (BCLs) in addition to capsulolabral injuries, although the risk factors for these intra-articular lesions are unclear. HYPOTHESIS We hypothesized that patients with posterior instability who had a greater number of instability events would have a higher rate of BCLs compared with patients who had fewer instability episodes. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group instability patient cohort were analyzed. Patients aged 12 to 99 years undergoing primary surgical treatment for shoulder instability were included. The glenohumeral joint was evaluated by the treating surgeon at the time of surgery, and patients were classified as having a BCL if they had any grade 3 or 4 glenoid or humeral cartilage lesion, reverse Hill-Sachs lesion, bony Bankart lesion, or glenoid bone loss. The effects of the number of instability events on the presence of BCLs was investigated by use of Fisher exact tests. Logistic regression modeling was performed to investigate the independent contributions of demographic variables and injury-specific variables to the likelihood of having a BCL. Significance was defined as P < .05. RESULTS We identified 271 patients (223 male) for analysis. Bone and cartilage lesions were identified in 54 patients (19.9%) at the time of surgical treatment. A glenoid cartilage injury was most common and was identified in 28 patients (10.3%). A significant difference was noted between the number of instability events and the presence of BCLs (P = .025), with the highest rate observed in patients with 2 to 5 instability events (32.3%). Multivariate logistic regression modeling indicated that increasing age (P = .019) and 2 to 5 reported instability events (P = .001) were significant independent predictors of the presence of BCLs. For bone lesions alone, the number of instability events was the only significant independent predictor; increased risk of bone lesion was present for patients with 1 instability event (OR, 6.1; P = .012), patients with 2 to 5 instability events (OR, 4.2; P = .033), and patients with more than 5 instability events (OR, 6.0; P = .011). CONCLUSION Bone and cartilage lesions are seen significantly more frequently with increasing patient age and in patients with 2 to 5 instability events. Early surgical stabilization for posterior instability may be considered to potentially limit the extent of associated intra-articular injury. The group of patients with more than 5 instability events may represent a different pathological condition, as this group showed a decrease in the likelihood of cartilage injury, although not bony injury.
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Affiliation(s)
- Drew A Lansdown
- Investigation performed at University of California, San Francisco, San Francisco, California, USA
| | - Gregory L Cvetanovich
- Investigation performed at University of California, San Francisco, San Francisco, California, USA
| | - Alan L Zhang
- Investigation performed at University of California, San Francisco, San Francisco, California, USA
| | - Brian T Feeley
- Investigation performed at University of California, San Francisco, San Francisco, California, USA
| | - Brian R Wolf
- Investigation performed at University of California, San Francisco, San Francisco, California, USA
| | - Carolyn M Hettrich
- Investigation performed at University of California, San Francisco, San Francisco, California, USA
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- Investigation performed at University of California, San Francisco, San Francisco, California, USA
| | - Keith M Baumgarten
- Investigation performed at University of California, San Francisco, San Francisco, California, USA
| | - Julie Y Bishop
- Investigation performed at University of California, San Francisco, San Francisco, California, USA
| | - Matthew J Bollier
- Investigation performed at University of California, San Francisco, San Francisco, California, USA
| | - Jonathan T Bravman
- Investigation performed at University of California, San Francisco, San Francisco, California, USA
| | - Robert H Brophy
- Investigation performed at University of California, San Francisco, San Francisco, California, USA
| | - Charles L Cox
- Investigation performed at University of California, San Francisco, San Francisco, California, USA
| | - Rachel M Frank
- Investigation performed at University of California, San Francisco, San Francisco, California, USA
| | - John A Grant
- Investigation performed at University of California, San Francisco, San Francisco, California, USA
| | - Grant L Jones
- Investigation performed at University of California, San Francisco, San Francisco, California, USA
| | - John E Kuhn
- Investigation performed at University of California, San Francisco, San Francisco, California, USA
| | - Robert G Marx
- Investigation performed at University of California, San Francisco, San Francisco, California, USA
| | - Eric C McCarty
- Investigation performed at University of California, San Francisco, San Francisco, California, USA
| | - Bruce S Miller
- Investigation performed at University of California, San Francisco, San Francisco, California, USA
| | - Shannon F Ortiz
- Investigation performed at University of California, San Francisco, San Francisco, California, USA
| | - Matthew V Smith
- Investigation performed at University of California, San Francisco, San Francisco, California, USA
| | - Rick W Wright
- Investigation performed at University of California, San Francisco, San Francisco, California, USA
| | - C Benjamin Ma
- Investigation performed at University of California, San Francisco, San Francisco, California, USA
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Revision Arthroscopic Posterior Shoulder Capsulolabral Repair in Contact Athletes: Risk Factors and Outcomes. Arthroscopy 2020; 36:660-665. [PMID: 31864814 DOI: 10.1016/j.arthro.2019.09.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 09/15/2019] [Accepted: 09/15/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine risk factors and outcomes of revision arthroscopic posterior capsulolabral repair in contact athletes. METHODS Contact athletes with unidirectional posterior instability who underwent arthroscopic posterior capsulolabral repair from 2000 to 2014 with minimum 4-year follow-up were reviewed. Revision rate was determined and those who required revision surgery were compared with those who did not. Age, gender, labral and/or capsular injury, level of sport, and return to sport were compared. Pre- and postoperative American Shoulder and Elbow Surgeons, pain, function, stability, range of motion, strength, and satisfaction were also compared. Magnetic resonance imaging measurements of glenoid bone width, glenoid version, labral width, labral version, and cartilage version were also compared. RESULTS A total of 149 contact athletes' shoulders met inclusion criteria. Eight shoulders required revision surgery (5.4%) at 13.0-year follow-up with 2.6 years between primary surgery and revision. Preoperative stability was significantly worse in those that required revision (0.008). Postoperative American Shoulder and Elbow Surgeons score was significantly worse in the revision group (75.1 vs 87.8, P = .03). The only significant risk factor for requiring revision surgery was decreased glenoid bone width (26.4 mm vs 29.1 mm, P = .005). Cartilage version, labral version, and bone version were not significantly different, nor was labral width. Sex, labral injury, capsule injury, both capsule and labrum injury, and level of sport were not risk factors. Both return to sport at the same level (revision = 16.7% vs nonrevision = 72.1%, P < .001) and overall return to sport (revision = 50.0% vs nonrevision=93.7%, P < .001) were significantly worse in the revision group. CONCLUSIONS Contact athletes underwent revision arthroscopic posterior capsulolabral repair at an incidence of 5.4% at minimum 4-year and average 13.0-year follow-up. The only significant risk factors for requiring revision surgery was smaller glenoid bone width and higher preoperative instability. Return to play after their subsequent surgery was significantly worse. LEVEL OF EVIDENCE Level III, comparative study.
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Woodmass JM, Lee J, Johnson NR, Wu IT, Camp CL, Dahm DL, Krych AJ. Nonoperative Management of Posterior Shoulder Instability: An Assessment of Survival and Predictors for Conversion to Surgery at 1 to 10 Years After Diagnosis. Arthroscopy 2019; 35:1964-1970. [PMID: 31196692 DOI: 10.1016/j.arthro.2019.01.056] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 01/30/2019] [Accepted: 01/31/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To (1) define the rate of delayed surgery, between 1 and 10 years after injury, in a population-based study of patients with posterior shoulder instability (PSI), (2) evaluate predictive factors associated with delayed repair, and (3) identify differences between the nonoperative and operative groups at long-term follow-up. METHODS A population-based retrospectively reviewed study of all patients with PSI from January 1, 1994, to December 31, 2015, was performed. Inclusion required a clinical diagnosis of PSI combined with supporting imaging. Complete medical records were reviewed for 2,091 potential cases. Kaplan-Meier estimates were used to calculate survival. Landmark survival analysis was performed to identify predictors of conversion to surgery. RESULTS The study included 143 patients with PSI, 79 of whom were managed nonoperatively for at least 1 year after diagnosis. After the first year, survival free of surgery was 78.3% at 1 year, 63.1% at 5 years, and 51.5% at 10 years. There was a trend toward increased surgery in patients with a body mass index > 35 (P = .10; hazard ratio = 2.32; confidence interval, 0.8-6.8). Nonthrowing athletes (including contact/weight-lifting athletes) showed a trend toward an increased risk for surgery (P = .07). Patients who underwent surgery were significantly more likely to have progression in arthritis (P = .02; hazard ratio = 4.0; confidence interval, 1.2-13.2). CONCLUSIONS Nonoperative management was performed for at least 1 year in over half of patients diagnosed with PSI. Overall, long-term follow-up demonstrates that 46% of these patients converted to surgery between 1 and 10 years after initial diagnosis. Ultimately, 70% of patients diagnosed with PSI go on to surgical intervention. Patients who underwent surgery at any time point were at an increased risk of radiographic progression of arthritis at a minimum of 5 years of follow-up. LEVEL OF EVIDENCE Level III, cohort study.
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Affiliation(s)
- Jarret M Woodmass
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A.; Department of Orthopedic Surgery, Pan Am Clinic, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Julia Lee
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A.; Sierra Pacific Orthopedics, Fresno, California, U.S.A
| | - Nick R Johnson
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Isabella T Wu
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Christopher L Camp
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Diane L Dahm
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Aaron J Krych
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A..
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31
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Woodmass JM, Lee J, Wu IT, Desai VS, Camp CL, Dahm DL, Krych AJ. Incidence of posterior shoulder instability and trends in surgical reconstruction: a 22-year population-based study. J Shoulder Elbow Surg 2019; 28:611-616. [PMID: 30503178 DOI: 10.1016/j.jse.2018.08.046] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 08/22/2018] [Accepted: 08/29/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND The incidence of posterior shoulder instability (PSI) in the general population is not well defined. This study aimed to define the population-based incidence of PSI and describe trends in incidence and surgery rates. METHODS The study population included 143 patients (16 females, 127 males) diagnosed with new-onset PSI between January 1, 1994, and December 31, 2015. Medical records were reviewed to extract patient data. Age- and sex-specific incidence rates were calculated and adjusted to the 2010 United States population. Poisson regression was performed to examine trends by timeline, sex, and age. RESULTS Age- and sex- adjusted annual incidence of PSI was 4.64 per 100,000 person-years, and posterior dislocation was 1.30 per 100,000 person-years. Peak PSI incidence for males and females was at 14 to 19 years (31.82 and 5.23 per 100,000 person-years). PSI incidence was higher in males than females (8.86 vs. 1.07 per 100,000 person-years, P < .001). The 5-year cumulative risk of surgery for patients with PSI was 53.1% between 1996 and 2002, 59.9% between 2003 and 2008, and 87.5% between 2009 and 2015. Patients with PSI between 2009 and 2015 had a significantly increased rate of surgery (hazard ratio, 2.2; 95% confidence interval, 1.4-3.6; P = .001) compared with those between 1996 and 2002. CONCLUSION The age- and sex- adjusted incidence of PSI in the general population was 4.64 per 100,000 person-years. There is a significantly greater incidence of PSI in males than females, with both sexes peaking at 14 to 19 years and incidence rates remaining elevated throughout the third and fourth decades of life. The incidence of PSI remained stable over time; however, the rate of surgical intervention increased significantly, from 53.1% of patients between 1996 and 2002 to 87.5% of patients between 2009 and 2015.
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Affiliation(s)
- Jarret M Woodmass
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MN, USA
| | - Julia Lee
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MN, USA
| | - Isabella T Wu
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MN, USA
| | - Vishal S Desai
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MN, USA
| | - Christopher L Camp
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MN, USA
| | - Diane L Dahm
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MN, USA
| | - Aaron J Krych
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MN, USA.
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Frank RM. Editorial Commentary: Beach Chair Versus Lateral Decubitus for Arthroscopic Posterior Shoulder Stabilization-Here We Go Again. Arthroscopy 2019; 35:225-227. [PMID: 30611353 DOI: 10.1016/j.arthro.2018.09.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 09/27/2018] [Indexed: 02/02/2023]
Abstract
Recent literature has suggested that patient positioning matters when it comes to arthroscopic anterior shoulder stabilization. Although advocates of the lateral decubitus position argue that only in this position can the anteroinferior and posteroinferior aspects of the glenoid be adequately visualized and instrumented, outcomes following posterior shoulder stabilization appear independent of patient position.
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Byram GW, Field AC, Field LD. Arthroscopic Management of Locked Posterior Shoulder Dislocations. Arthrosc Tech 2018; 7:e945-e949. [PMID: 30258776 PMCID: PMC6153398 DOI: 10.1016/j.eats.2018.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 05/25/2018] [Indexed: 02/03/2023] Open
Abstract
Locked posterior shoulder dislocations occur relatively uncommonly but pose aunique array of challenges for the treating surgeon. Posterior labral detachments and capsular damage along with reverse Hill-Sachs lesions are commonly present in these patients and must often be addressed at the time of surgical intervention. Multiple open and arthroscopic procedures that address these pathologic lesions have been described. Arthroscopic shoulder stabilization for patients with locked posterior shoulder dislocations for whom significant posterior instability and subluxation persist following closed reduction is described. A specific patient who underwent both arthroscopic posterior stabilization and supplemental advancement of the subscapularis into the reverse Hill-Sachs defect serves as a case example of this technique.
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Affiliation(s)
| | | | - Larry D. Field
- Address correspondence to Dr. Larry D. Field, M.D., Mississippi Sports Medicine and Orthopaedic Center, 1325, Jackson, MS 39202, U.S.A.
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Nacca C, Gil JA, DeFroda SF, Badida R, Owens BD. Comparison of a Distal Tibial Allograft and Scapular Spinal Autograft for Posterior Shoulder Instability With Glenoid Bone Loss. Orthop J Sports Med 2018; 6:2325967118786697. [PMID: 30090835 PMCID: PMC6077901 DOI: 10.1177/2325967118786697] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Posterior glenoid bone deficiency can occur with recurrent glenohumeral instability. Glenoid reconstruction with a distal tibial allograft (DTA) has been reported to successfully restore contact pressures that occur during posterior glenohumeral translation. However, there are concerns regarding the risk of allograft resorption, availability, and costs. Extracapsular reconstruction using a scapular spinal autograft (SSA) has been reported as an alternative technique secondary to its anatomic location relative to the posterior shoulder and preferable autograft properties. There are no known prior biomechanical studies evaluating the scapular spine as an effective extracapsular graft choice. Purpose To compare the efficacy of a DTA and SSA in restoring the stability of a glenoid with a large posterior bone defect compared with the intact native glenoid. Study Design Controlled laboratory study. Methods Ten cadaveric shoulders were tested. With the use of a custom KUKA robot, a 50-N compressive force was applied to the glenohumeral joint. The peak force required to translate the humeral head beyond the glenoid lip posteriorly as well as the lateral displacement that occurred during posterior translation were measured. Testing was performed in 5 conditions: (1) intact glenoid and labrum, (2) simulated reverse Bankart lesion, (3) 12-mm posterior glenoid defect, (4) glenoid defect reconstructed with a fresh DTA, and (5) glenoid defect reconstructed with an SSA. Results The mean glenoid width was 30 mm. The mean peak force and lateral displacement decreased significantly with a glenoid defect (0.99 ± 2.3 N and 0.06 ± 0.09 mm, respectively; P < .0001) compared with the intact glenoid (23.00 ± 9.7 N and 1.83 ± 0.70 mm, respectively; P = .0001). There was no significant difference between the peak force after reconstruction of the defect with a DTA (23.00 ± 7.4 N) and SSA (23.00 ± 7.7 N) when compared with the intact glenoid (P = .9999). There were no significant differences in the peak force between the 2 grafts (P = .9999). Additionally, both the DTA (1.04 ± 1.09 mm) and the SSA (1.02 ± 1.17 mm) demonstrated no differences in lateral displacement when compared with the intact glenoid (P = .2336 and .2043, respectively). There was no difference in lateral displacement that occurred between the DTA and SSA (P = .9999). Conclusion Reconstruction of a large posterior glenoid defect with either a DTA or an SSA can effectively restore glenohumeral stability. Clinical Relevance This study supports the use of a DTA or SSA in posterior glenoid defect reconstruction. Clinical studies are needed to determine the long-term effects of utilizing such grafts.
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Affiliation(s)
- Christopher Nacca
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Joseph A Gil
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Steven F DeFroda
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Rohit Badida
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Brett D Owens
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
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