The Impact of Superior Labral Anterior to Posterior Lesions on Functional Status in Shoulder Instability: A Multicenter Cohort Study

BACKGROUND: Type IV superior labral anterior to posterior (SLAP) lesions, which are superior labral detachments associated with Bankart tears, are reported to occur in up to 25% of recurrent shoulder instability patients. However, the clinical implications of this finding are debatable. PURPOSE: To determine whether there are any functional differences between anterior instability patients with and without type IV SLAP lesions at the time of presentation and at short-term follow-up after surgical intervention. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A prospective, multicenter database was established to follow the clinical evolution of patients with shoulder instability. Patients were diagnosed as having a type IV SLAP lesion at the time of arthroscopic Bankart surgery (SLAP+). These patients were compared with a group of patients who simply had a Bankart lesion (SLAP-). The 2 groups had their functional outcomes (Western Ontario Shoulder Instability Index [WOSI]; Disability of the Arm, Shoulder, and Hand [QuickDASH]; and Walch-Duplay) compared prior to surgery and 1 year postoperatively. RESULTS: A total of 103 subjects were included in the study; of these, 56 (43 men, 13 women) completed 1-year follow-up. Twenty-three subjects had a type IV SLAP tear, and most had this repaired along with their Bankart lesion. At baseline, SLAP+ subjects had inferior QuickDASH scores compared with SLAP- subjects (37.8 vs 29.0) as well as poorer pain subscores on both the WOSI and QuickDASH. At 1-year follow-up, however, there were no significant differences in any of the outcome measures. CONCLUSION: A type IV SLAP lesion can be expected in 22% of patients with recurrent shoulder instability. This finding implies that at baseline, the patient will have slightly worse functional scores related to pain. However, following surgical management of the labral pathology, these patients will have equivalent functional outcomes at short-term follow-up. CLINICAL RELEVANCE: With surgical management of the superior and anteroinferior labrum, patients with type IV SLAP lesions will do as well as those with only Bankart tears. Thus, the presence of SLAP lesions should not alter the decision to provide surgical management and should not change the prognosis for a specific patient

Gln-tRNAGln synthesis in a dynamic transamidosome from Helicobacter pylori, where GluRS2 hydrolyzes excess Glu-tRNAGln

In many bacteria and archaea, an ancestral pathway is used where asparagine and glutamine are formed from their acidic precursors while covalently linked to tRNAAsn and tRNAGln, respectively. Stable complexes formed by the enzymes of these indirect tRNA aminoacylation pathways are found in several thermophilic organisms, and are called transamidosomes. We describe here a transamidosome forming Gln-tRNAGln in Helicobacter pylori, an ε-proteobacterium pathogenic for humans; this transamidosome displays novel properties that may be characteristic of mesophilic organisms. This ternary complex containing the non-canonical GluRS2 specific for Glu-tRNAGln formation, the tRNA-dependent amidotransferase GatCAB and tRNAGln was characterized by dynamic light scattering. Moreover, we observed by interferometry a weak interaction between GluRS2 and GatCAB (KD = 40 ± 5 µM). The kinetics of Glu-tRNAGln and Gln-tRNAGln formation indicate that conformational shifts inside the transamidosome allow the tRNAGln acceptor stem to interact alternately with GluRS2 and GatCAB despite their common identity elements. The integrity of this dynamic transamidosome depends on a critical concentration of tRNAGln, above which it dissociates into separate GatCAB/tRNAGln and GluRS2/tRNAGln complexes. Ester bond protection assays show that both enzymes display a good affinity for tRNAGln regardless of its aminoacylation state, and support a mechanism where GluRS2 can hydrolyze excess Glu-tRNAGln, ensuring faithful decoding of Gln codons

Treatment of glenohumeral instability in rugby players

Rugby is a high-impact collision sport, with impact forces. Shoulder injuries are common and result in the longest time off sport for any joint injury in rugby. The most common injuries are to the glenohumeral joint with varying degrees of instability. The degree of instability can guide management. The three main types of instability presentations are: (1) frank dislocation, (2) subluxations and (3) subclinical instability with pain and clicking. Understanding the exact mechanism of injury can guide diagnosis with classical patterns of structural injuries. The standard clinical examination in a large, muscular athlete may be normal, so specific tests and techniques are needed to unearth signs of pathology. Taking these factors into consideration, along with the imaging, allows a treatment strategy. However, patient and sport factors need to be also considered, particularly the time of the season and stage of sporting career. Surgery to repair the structural damage should include all lesions found. In chronic, recurrent dislocations with major structural lesions, reconstruction procedures such as the Latarjet procedure yields better outcomes. Rehabilitation should be safe, goal-driven and athlete- specific. Return to sport is dependent on a number of factors, driven by the healing process, sport requirements and extrinsic pressures

Validation of the instability shoulder index score in a multicenter reliability study in 114 consecutive cases.

BACKGROUND: Anterior shoulder stabilization surgery with the arthroscopic Bankart procedure can have a high recurrence rate in certain patients. Identifying these patients to modify outcomes has become a focal point of research. PURPOSE: The Instability Shoulder Index Score (ISIS) was developed to predict the success of arthroscopic Bankart repair. Scores range from 0 to 10, with higher scores predicting a higher risk of recurrence after stabilization. The interobserver reliability of the score is not known. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: This is a prospective multicenter (North America and Europe) study of patients suffering from shoulder instability and waiting for stabilization surgery. Five pairs of independent evaluators were asked to score patient instability severity with the ISIS. Patients also completed functional scores (Western Ontario Shoulder Instability Index [WOSI], Disabilities of the Arm, Shoulder and Hand-short version [QuickDASH], and Walch-Duplay test). Data on age, sex, number of dislocations, and type of surgery were collected. The test-retest method and intraclass correlation coefficient (ICC: >0.75 = good, >0.85 = very good, and >0.9 = excellent) were used for analysis. RESULTS: A total of 114 patients with anterior shoulder instability were included, of whom 89 (78%) were men. The mean age was 28 years. The ISIS was very reliable, with an ICC of 0.933. The mean number of dislocations per patient was higher in patients who had an ISIS of ≥6 (25 vs 14; P = .05). Patients who underwent more complex arthroscopic procedures such as Hill-Sachs remplissage or open Latarjet had higher preoperative ISIS outcomes, with a mean score of 4.8 versus 3.4, respectively (P = .002). There was no correlation between the ISIS and the quality-of-life questionnaires, with Pearson correlations all >0.05 (WOSI = 0.39; QuickDASH = 0.97; Walch-Duplay = 0.08). CONCLUSION: Our results show that the ISIS is reliable when used in a multicenter study with anterior traumatic instability populations. There was no correlation between the ISIS and the quality-of-life questionnaires, but surgical decisions reflected its increased use

The POSI study: Gender differences in 94 cases Postoperative Shoulder Surgery Infection: Results of a 7-year retrospective multicenter study.

Contrary to lower limb infection, POstoperative Shoulder Infection (POSI) often involves Cutibacterium acnes (C. acnes). Our aim was to describe patient characteristics and pathogens retrieved in POSI to guide initial empiric antibiotic selection with suspected infection during revision. We also compared microorganisms in infection following trauma, arthroplasty (AP) and arthroscopy (AS). A multicenter retrospective study from 2010 to 2016 reviewed laboratory databases and medical records to identify patients with a previous shoulder surgery and a confirmed shoulder infection. The following procedures were included: AP, AS, fracture fixation (FF) or another open surgery (OS). A confirmed shoulder infection was defined as two positive cultures or more of the same microorganism, or clear clinical infection with one positive culture or more. Among the five hospitals and 28 surgeons involved, 94 POSI cases were identified. Mean age was 59 years at index surgery (Range: 22 - 91) with a majority of men (n = 70, 74 %). Among POSI cases, AP was the most common index surgery (n=41), followed by FF (n=27), AS (n=16) and OS (n=10). The median time between index surgery and the first positive sample was five months and the mean was 23 months, (min 6 days - max 27 years), illustrating a positively skewed distribution. Cutibacterium spp. were identified in 64 patients (68%), including 59 C. acnes patients (63%), which was the most frequent germ in all four surgical groups. In 86 % of cases, C. acnes was identified at the first revision. The other two most common germs were: Staphylococcus epidermidis and Staphylococcus aureus, with 29 % and 17 %, respectively. Polymicrobial infection was present in 30% of patients. Gender analysis revealed that C. acnes was twice as frequent in males (male = 52/70; female = 7/24, p<0.001). S. epidermidis was more prevalent in women (n=11, 46 %) compared to men (n= 16, 21%) (p=0.032). C. acnes infection was most frequent in arthroscopic surgery (n=14, 70%, p=0.049). S epidermidis was three times more prevalent in chronic than in acute cases. Empiric antimicrobial therapy following POSI, while waiting for culture results, should cover C. acnes, S. epidermidis and S. aureus. There is a significant gender difference regarding POSI culture results. C. acnes is more frequent in men, but should still be covered in women as it was found in 29% of cases

Validity, reliability and responsiveness of the French language translation of the Western Ontario Shoulder Instability Index (WOSI).

BACKGROUND: The WOSI (Western Ontario Shoulder Instability Index) is a self-administered quality of life questionnaire designed to be used as a primary outcome measure in clinical trials on shoulder instability, as well as to measure the effect of an intervention on any particular patient. It is validated and is reliable and sensitive. As it is designed to measure subjective outcome, it is important that translation should be methodologically rigorous, as it is subject to both linguistic and cultural interpretation. OBJECTIVE: To produce a French language version of the WOSI that is culturally adapted to both European and North American French-speaking populations. MATERIALS AND METHODS: A validated protocol was used to create a French language WOSI questionnaire (WOSI-Fr) that would be culturally acceptable for both European and North American French-speaking populations. Reliability and responsiveness analyses were carried out, and the WOSI-Fr was compared to the F-QuickDASH-D/S (Disability of the Arm, Shoulder and Hand-French translation), and Walch-Duplay scores. RESULTS: A French language version of the WOSI (WOSI-Fr) was accepted by a multinational committee. The WOSI-Fr was then validated using a total of 144 native French-speaking subjects from Canada and Switzerland. Comparison of results on two WOSI-Fr questionnaires completed at a mean interval of 16 days showed that the WOSI-Fr had strong reliability, with a Pearson and interclass correlation of r=0.85 (P=0.01) and ICC=0.84 [95% CI=0.78-0.88]. Responsiveness, at a mean 378.9 days after surgical intervention, showed strong correlation with that of the F-QuickDASH-D/S, with r=0.67 (P<0.01). Moreover, a standardized response means analysis to calculate effect size for both the WOSI-Fr and the F-QuickDASH-D/S showed that the WOSI-Fr had a significantly greater ability to detect change (SRM 1.55 versus 0.87 for the WOSI-Fr and F-QuickDASH-D/S respectively, P<0.01). The WOSI-Fr showed fair correlation with the Walch-Duplay. DISCUSSION: A French-language translation of the WOSI questionnaire was created and validated for use in both Canadian and Swiss French-speaking populations. This questionnaire will facilitate outcome assessment in French-speaking settings, collaboration in multinational studies and comparison between studies performed in different countries. TYPE OF STUDY: Multicenter cohort study. LEVEL OF EVIDENCE: II

Impact of olecranon fracture malunion: Study on the importance of PUDA (Proximal Ulna Dorsal Angulation).

The Proximal Ulna Dorsal Angulation (PUDA) is part of the proximal ulna's normal anatomy. The importance of restoring ulnar anatomy characteristics precisely after olecranon fracture is not known, however, failure to recreate the PUDA after surgery may result in poorer functional outcomes. The purpose of this study is to evaluate the impact of minimal proximal ulna malunion on elbow ROM and function at least one year after olecranon ORIF. A retrospective comparative cohort study took place in three level-1 trauma centers. Forty-nine adult volunteers who underwent ORIF for olecranon fracture were included. Patients were separated into two groups according to PUDA malreduction-defined as more than 5° of difference between the fractured and the contralateral elbow. Radiographic ROM measurement, demographic data and quality of life questionnaires were recorded (PREE, MEPS, Q-DASH, SF12, VAS). The mean follow up was 3 years and 9 months (1-7 years). There was no difference in terms of outcome, quality of reduction or range of motion between patients treated with plate or tension band. The mean PUDA on the fracture side was different from the normal side (2.20 vs 4.90, p<0.001). Fourteen patients (29%) had PUDA malunion. Those patients had decreased elbow flexion (-7°, p=0.011), extension (-11.2°, p=0.013) and total ROM (-18.6°, p=0.006) as opposed to the control group. Both groups had comparable quality of life questionnaire scores. Alcohol consumption was the only risk factor associated with worse scores. Incidence of olecranon malunion-as defined by PUDA measurement - was 29% and it was associated with decreased elbow range of motion. Alcohol consumption was correlated with a worse prognosis in our series of patients. Tension band and plate fixation can maintain a good reduction in terms of PUDA and the choice of fixation method does not influence outcome. III Therapeutic study