Dynamic contact area ratio in shoulder instability: an innovative diagnostic technique measuring interplay of bony lesions

Purpose: The hypothesis of this study is that Dynamic Contact Area Ratio of the humerus and glenoid, measured with CT scans, is significantly reduced in patients with anterior shoulder instability compared to the Dynamic Contact Area Ratio in a control group of people without shoulder instability. Methods: Preoperative CT scans of patients who underwent surgery for anterior shoulder instability were collected. Additionally, the radiologic database was searched for control subjects. Using a validated software tool (Articulis) the CT scans were converted into 3-dimensional models and the amount the joint contact surface during simulated motion was calculated. Results: CT scans of 18 patients and 21 controls were available. The mean Dynamic Contact Area Ratio of patients was 25.2 \ub1 6.7 compared to 30.1 \ub1 5.1 in healthy subjects (p = 0.014). Conclusion: Dynamic Contact Area Ratio was significantly lower in patients with anterior shoulder instability compared to controls, confirming the hypothesis of the study. The findings of this study indicate that calculating the Dynamic Contact Area Ratio based on CT scan images may help surgeons in diagnosing anterior shoulder instability. Level of evidence: III

International survey and surgeon’s preferences in diagnostic work-up towards treatment of anterior shoulder instability

Purpose: Recurrent anterior shoulder instability after surgical treatment can be caused by bony defects. Several diagnostic tools have been designed to measure the extent of these bony lesions. Currently, there is no consensus which measurement tool to use and decide which type of surgery is most appropriate. We therefore performed an evaluation of agreement in surgeons\u2019 preference of diagnostic work-up and surgical treatment of anterior shoulder instability. Methods: An international survey was conducted amongst orthopaedic shoulder surgeons. The survey contained questions about surgeons\u2019 experience, clinical and radiological examination and the subsequent treatment for anterior shoulder instability. Descriptive statistics were used to present the data, and percentages of responding surgeons were calculated. Results: The questionnaire was completed by 197 delegates from 46 countries. 55\ua0% of the respondents think evidence in current literature is sufficient on diagnostic work-up for anterior shoulder instability. Anamnestic, number of dislocations was most frequently asked (by 95\ua0% of respondents), the most frequently used test is the apprehension test (91\ua0%). For imaging, conventional X-ray in various directions was most performed, followed by MR arthrography and plane CT scan respectively. The responding surgeons perform surgery (labrum repair or Latarjet) in 51\ua0% of the patients. A median of 25\ua0% glenoid bone loss was given by the respondents, as cut-off from when to perform a bony repair. Conclusion: Many different diagnostic examinations for assessing shoulder instability are used and a high variety is seen in the use of diagnostic tools. Also no consensus is seen in the use of different surgical options (arthroscopic and open procedures). This implies the need for more research on diagnostic imaging and the correlation with specific subsequent surgical treatment. Level of evidence: Survey, level of evidence IV

In patients eligible for meniscal surgery who first receive physical therapy, multivariable prognostic models cannot predict who will eventually undergo surgery

Purpose Although physical therapy is the recommended treatment in patients over 45 years old with a degenerative meniscal tear, 24% still opt for meniscal surgery. The aim was to identify those patients with a degenerative meniscal tear who will undergo surgery following physical therapy. Methods The data for this study were generated in the physical therapy arm of the ESCAPE trial, a randomized clinical trial investigating the effectiveness of surgery versus physical therapy in patients of 45-70 years old, with a degenerative meniscal tear. At 6 and 24 months patients were divided into two groups: those who did not undergo surgery, and those who did undergo surgery. Two multivariable prognostic models were developed using candidate predictors that were selected from the list of the patients' baseline variables. A multivariable logistic regression analysis was performed with backward Wald selection and a cut-off of p < 0.157. For both models the performance was assessed and corrected for the models' optimism through an internal validation using bootstrapping technique with 500 repetitions. Results At 6 months, 32/153 patients (20.9%) underwent meniscal surgery following physical therapy. Based on the multivariable regression analysis, patients were more likely to opt for meniscal surgery within 6 months when they had worse knee function, lower education level and a better general physical health status at baseline. At 24 months, 43/153 patients (28.1%) underwent meniscal surgery following physical therapy. Patients were more likely to opt for meniscal surgery within 24 months when they had worse knee function and a lower level of education at baseline at baseline. Both models had a low explained variance (16 and 11%, respectively) and an insufficient predictive accuracy. Conclusion Not all patients with degenerative meniscal tears experience beneficial results following physical therapy. The non-responders to physical therapy could not accurately be predicted by our prognostic models.Orthopaedics, Trauma Surgery and Rehabilitatio

Long head biceps and rotator cuff surgery in the shoulder

Pooling data of studies that compared LHB tenotomy with tenodesis revealed no difference in clinical outcome parameters such as Constant score, elbow flexion strength and forearm supination strength. Popeye deformity and cramping pain were more prevalent following LHB tenotomy. Our randomized trial demonstrated that patients older than 50 year who were surgically treated for small to medium sized degenerative rotator cuff tears substantially improved in CMS after both LHB tenotomy and LHB tenodesis. At one year follow up none of the clinical outcome parameters, revealed a clinically relevant difference between groups. Surgical time for LHB tenotomy was significantly shorter compared to LHB tenodesis. As tenotomy is a more simple and quick procedure, these findings question the need for performing LHB tenodesis in this group of patients. In a reliability study we observed that the Popeye sign is more frequently identified by doctors than by patients older than 50 years after undergoing LHB surgery. Furthermore, doctors do not agree on the presence of Popeye sign. Maybe even more important, patients who reported a Popeye deformity were not dissatisfied. Several anatomical studies indicate that persisting pain following LHB surgery may originate from the bicipital groove. Tenodesis below the bicipital groove could therefore be preferred over a proximal tenodesis site. Release of the transverse ligament should be considered for all patients undergoing LHB surgery as it is involved in anterior shoulder pain. Pooling data of studies comparing subpectoral LHB tenodesis with suprapectoral LHB tenodesis revealed no clinical significant difference with regard to functional outcome scores, pain in the bicipital groove and avoiding a Popeye deformity. Literature reporting outcome of rotator cuff repair after one year shows significant improvements in the shoulder-specific indices after non-traumatic arthroscopic or mini-open rotator cuff repair. Functional and radiological assessment of patients 11 years after repair of small- to medium-size rotator cuff lesions revealed that functional outcome is good and structural integrity is high for the majority of patients

Gunshot uterine rupture: a case report

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A systematic and technical guide on how to reduce a shoulder dislocation

Objectives: Our objective is to provide a systematic and technical guide on how to reduce a shoulder dislocation, based on techniques that have been described in literature for patients with anterior and posterior shoulder instability. Materials and methods: A PubMed and EMBASE query was performed, screening all relevant literature on the closed reduction techniques. Studies regarding open reduction techniques and studies with fracture dislocations were excluded. Results: In this study we give an overview of 23 different techniques for closed reduction and 17 modifications of these techniques. Discussion: In this review article we present a complete overview of the techniques, that have been described in the literature for closed reduction for shoulder dislocations. This manuscript can be regarded as a clinical guide how to perform a closed reduction maneuver, including several technical tips and tricks to optimize the success rate and to avoid complications. Conclusion: There are 23 different reduction techniques with 17 modifications of these techniques. Knowledge of the different techniques is highly important for a good reduction. Keywords: Reposition, Techniques, Maneuver, Shoulder, Glenohumeral, Instabilit

Operative Versus Nonoperative Treatment Following First-Time Anterior Shoulder Dislocation: A Systematic Review and Meta-Analysis

Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.BACKGROUND: There is an ongoing debate about whether to perform operative or nonoperative treatment following a first-time anterior dislocation or wait for recurrence before operating. The aim of this systematic review is to compare recurrence rates following operative treatment following first-time anterior dislocation (OTFD) with recurrence rates following (1) nonoperative treatment (NTFD) or (2) operative treatment after recurrent anterior dislocation (OTRD). METHODS: A literature search was conducted by searching PubMed (Legacy), Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, and Web of Science/Clarivate Analytics from 1990 to April 15, 2020, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The revised tool to assess risk of bias in randomized trials (RoB 2) developed by Cochrane was used to determine bias in randomized controlled trials, and the methodological index for non-randomized studies (MINORS) was used to determine the methodological quality of non-randomized studies. The certainty of evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach using GRADEpro software. RESULTS: Of the 4,096 studies for which the titles were screened, 9 comparing OTFD and NTFD in a total of 533 patients and 6 comparing OTFD and OTRD in a total of 961 patients were included. There is high-quality evidence that OTFD is associated with a lower rate of recurrence (10%) at >10 years of follow-up compared with NTFD (55%) (p 10 years following OTFD compared with NTFD (or sham surgery) in young patients. There is evidence that OTFD is more effective than OTRD, but that evidence is of very low quality. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence

Comparative study of total shoulder arthroplasty versus total shoulder surface replacement for glenohumeral osteoarthritis with minimum 2-year follow-up

BACKGROUND: Compared with total shoulder arthroplasty (TSA), total shoulder surface replacement (TSSR) may offer the advantage of preservation of bone stock and shorter surgical time, possibly at the expense of glenoid component positioning and increasing lateral glenohumeral offset. We hypothesized that in patients treated for osteoarthritis with a sufficient rotator cuff, TSA and TSSR patients have comparable functional outcome, glenoid component version, and lateral glenohumeral offset. METHODS: We conducted a retrospective cohort study with a minimum of 2 years of follow-up. Patients in the TSA and TSSR groups received a cemented, curved, keeled, all-poly glenoid component. A cemented anatomical humeral stem was used in TSA. TSSR involved a humeral surface replacement (all components from Tornier Inc., St Ismier, France). Patients were assessed for functional outcome. Radiographs were assessed for radiolucent lines. Glenoid component position and lateral glenohumeral offset were assessed using computed tomography images. RESULTS: After 29 and 34 months of mean follow-up, respectively, TSA (n = 29) and TSSR (n = 20) groups showed similar median adjusted Constant Scores (84% vs. 88%), Oxford Shoulder Scores (44 vs. 44), Disabilities of the Arm, Shoulder and Hand scores (22 vs. 15), and Dutch Simple Shoulder Test scores (10 vs. 11). Glenoid components showed similar radiolucent line counts (median, 0 vs. 0), similar anteversion angles (mean, 0 degrees vs. 2 degrees ), and similar preoperative to postoperative increases in lateral glenohumeral offset (mean, 4 vs. 5 mm). One intraoperative glenoid fracture occurred in the TSSR group. CONCLUSION: Short-term functional and radiographic outcomes were comparable for TSA and TSSR