Differences in Outcomes Between Anterior and Posterior Shoulder Instability After Arthroscopic Bankart Repair: A Systematic Review and Meta-analysis

A grant from the One-University Open Access Fund at the University of Kansas was used to defray the author's publication fees in this Open Access journal. The Open Access Fund, administered by librarians from the KU, KU Law, and KUMC libraries, is made possible by contributions from the offices of KU Provost, KU Vice Chancellor for Research & Graduate Studies, and KUMC Vice Chancellor for Research. For more information about the Open Access Fund, please see http://library.kumc.edu/authors-fund.xml.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

Imaging Modalities for the Glenoid Track in Recurrent Shoulder Instability: A Systematic Review

A grant from the One-University Open Access Fund at the University of Kansas was used to defray the author's publication fees in this Open Access journal. The Open Access Fund, administered by librarians from the KU, KU Law, and KUMC libraries, is made possible by contributions from the offices of KU Provost, KU Vice Chancellor for Research & Graduate Studies, and KUMC Vice Chancellor for Research. For more information about the Open Access Fund, please see http://library.kumc.edu/authors-fund.xml.Background: The glenoid track (GT) concept illustrates how the degree of glenoid bone loss and humeral bone loss in the glenohumeral joint can guide further treatment in a patient with anterior instability. The importance of determining which lesions are at risk for recurrent instability involves imaging of the glenohumeral joint, but no studies have determined which type of imaging is the most appropriate. Purpose/Hypothesis: The purpose of this study was to determine the validity and accuracy of different imaging modalities for measuring the GT in shoulders with recurrent anterior instability. We hypothesized that 3-dimensional computed tomography (3D-CT) would be the most accurate imaging technique. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using PubMed, Scopus, Medline, and Cochrane libraries between database inception and July 2019. We included all clinical trials or cadaveric studies that evaluated imaging modalities for assessing the GT. Results: A total of 13 studies were included in this review: 1 study using 2-dimensional CT, 6 studies using 3D-CT, 4 studies using magnetic resonance imaging (MRI), 1 study using magnetic resonance arthrography (MRA)/MRI, and 1 study combining CT and MRI. The mean sensitivity, specificity, and accuracy for 2D-CT was 92%, 100%, and 96%, respectively. For MRI, the means were 72.2%, 87.9%, and 84.2%, respectively. No papers included 3D-CT metrics. The mean intraclass correlation coefficients (ICCs) for intraobserver reliability were 0.9046 for 3D-CT and 0.867 for MRI. ICCs for interobserver reliability were 0.8164, 0.8845, and 0.43 for 3D-CT, MRI, and MRA/MRI, respectively. Conclusion: There is evidence to support the use of both CT and MRI imaging modalities in assessing the GT. In addition, few studies have compared radiographic measurements with a gold standard, and even fewer have looked at the GT concept as a predictor of outcomes. Thus, future studies are needed to further evaluate which imaging modality is the most accurate to assess the GT

Rehabilitation Following Posterior Shoulder Stabilization

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

Latarjet Procedure for the Treatment of Anterior Glenohumeral Instability in the Athlete – Key Considerations for Rehabilitation

The Latarjet procedure with transfer of the coracoid process and its attached conjoint tendon is a well-established surgical technique for the treatment of anterior glenohumeral instability in patients with anteroinferior bone loss and/or high risk for recurrence. Biomechanical and clinical studies have shown excellent results and high rates of return to sports. However, there is an absence of standardized, objective criteria to accurately assess an athlete’s ability to progress through each phase of rehabilitation. Return to sports rehabilitation, progressed by quantitatively measured functional goals, may improve the athlete’s integration back to sports participation. Therefore, the purpose of this clinical commentary is to provide a rehabilitation protocol for the Latarjet procedure, progressing through clearly defined phases, with guidance for safe and effective return to sport. Recommended criteria are highlighted which allows the clinician to progress the patient through each phase appropriately rather than purely following timeframes from surgery. This progression ensures the patient has completed a thorough rehabilitation program that addresses ROM, strength, power, neuromuscular control and a graded return to play. Level of Evidence:

Revision Acromioclavicular-Coracoclavicular Reconstruction: Use of Precontoured Button and 2 Allografts

Injuries to the acromioclavicular (AC) joint are common, particularly in the young and active population. Approximately 9% of all shoulder girdle injuries involve the AC joint, and AC joint dislocations represent approximately 8% of all joint dislocations throughout the body. AC joint injuries are graded as type I through type VI according to the Rockwood classification. Type I and II injuries are typically treated nonoperatively, whereas type IV, V, and VI injuries are most often treated surgically. A variety of surgical techniques have been described, including anatomic and nonanatomic reconstruction. However, up to 80% of patients go on to lose radiographic reduction, and between 20% and 30% have complications leading to reoperation. Therefore, the objective of this Technical Note is to describe our preferred technique for the treatment of AC joint instability in the revision setting. This technique uses a Dog Bone Button (Arthrex, Naples, FL) and 2 allografts

An Expert Consensus Statement on the Management of Large Chondral and Osteochondral Defects in the Patellofemoral Joint

© The Author(s) 2020. Background: Cartilage lesions of the patellofemoral joint constitute a frequent abnormality. Patellofemoral conditions are challenging to treat because of complex biomechanics and morphology. Purpose: To develop a consensus statement on the functional anatomy, indications, donor graft considerations, surgical treatment, and rehabilitation for the management of large chondral and osteochondral defects in the patellofemoral joint using a modified Delphi technique. Study Design: Consensus statement. Methods: A working group of 4 persons generated a list of statements related to the functional anatomy, indications, donor graft considerations, surgical treatment, and rehabilitation for the management of large chondral and osteochondral defects in the patellofemoral joint to form the basis of an initial survey for rating by a group of experts. The Metrics of Osteochondral Allografts (MOCA) expert group (composed of 28 high-volume cartilage experts) was surveyed on 3 occasions to establish a consensus on the statements. In addition to assessing agreement for each included statement, experts were invited to propose additional statements for inclusion or to suggest modifications of existing statements with each round. Predefined criteria were used to refine statement lists after each survey round. Statements reaching a consensus in round 3 were included within the final consensus document. Results: A total of 28 experts (100% response rate) completed 3 rounds of surveys. After 3 rounds, 36 statements achieved a consensus, with over 75% agreement and less than 20% disagreement. A consensus was reached in 100.00% of the statements relating to functional anatomy of the patellofemoral joint, 88.24% relating to surgical indications, 100.00% relating to surgical technical aspects, and 100.00% relating to rehabilitation, with an overall consensus of 95.5%. Conclusion: This study established a strong expert consensus document relating to the functional anatomy, surgical indications, donor graft considerations for osteochondral allografts, surgical technical aspects, and rehabilitation concepts for the management of large chondral and osteochondral defects in the patellofemoral joint. Further research is required to clinically validate the established consensus statements and better understand the precise indications for surgery as well as which techniques and graft processing/preparation methods should be used based on patient- and lesion-specific factors

Refined cut-off for TP53 immunohistochemistry improves prediction of TP53 mutation status in ovarian mucinous tumors: implications for outcome analyses.

TP53 mutations are implicated in the progression of mucinous borderline tumors (MBOT) to mucinous ovarian carcinomas (MOC). Optimized immunohistochemistry (IHC) for TP53 has been established as a proxy for the TP53 mutation status in other ovarian tumor types. We aimed to confirm the ability of TP53 IHC to predict TP53 mutation status in ovarian mucinous tumors and to evaluate the association of TP53 mutation status with survival among patients with MBOT and MOC. Tumor tissue from an initial cohort of 113 women with MBOT/MOC was stained with optimized IHC for TP53 using tissue microarrays (75.2%) or full sections (24.8%) and interpreted using established criteria as normal or abnormal (overexpression, complete absence, or cytoplasmic). Cases were considered concordant if abnormal IHC staining predicted deleterious TP53 mutations. Discordant tissue microarray cases were re-evaluated on full sections and interpretational criteria were refined. The initial cohort was expanded to a total of 165 MBOT and 424 MOC for the examination of the association of survival with TP53 mutation status, assessed either by TP53 IHC and/or sequencing. Initially, 82/113 (72.6%) cases were concordant using the established criteria. Refined criteria for overexpression to account for intratumoral heterogeneity and terminal differentiation improved concordance to 93.8% (106/113). In the expanded cohort, 19.4% (32/165) of MBOT showed evidence for TP53 mutation and this was associated with a higher risk of recurrence, disease-specific death, and all-cause mortality (overall survival: HR = 4.6, 95% CI 1.5-14.3, p = 0.0087). Within MOC, 61.1% (259/424) harbored a TP53 mutation, but this was not associated with survival (overall survival, p = 0.77). TP53 IHC is an accurate proxy for TP53 mutation status with refined interpretation criteria accounting for intratumoral heterogeneity and terminal differentiation in ovarian mucinous tumors. TP53 mutation status is an important biomarker to identify MBOT with a higher risk of mortality.KLG is supported by the Victorian Cancer Agency (MCRF15013) and the Australian National Health and Medical Research Council (APP1045783 and #628434). This study was supported by the Peter MacCallum Cancer Foundation. CS is supported by a University of Melbourne Postgraduate Scholarship. DDB is supported by National Health and Medical Research Council of Australia (NHMRC) grants APP1092856 and APP1117044 and by the US National Cancer Institute U54 programme (U54CA209978-04). ELG and SHK are supported through P50 CA136393-10. The following cohorts that contributed to the GAMuT study were supported as follows: CASCADE: Supported by the Peter MacCallum Cancer Foundation AOCS: The Australian Ovarian Cancer Study Group was supported by the U.S. Army Medical Research and Materiel Command under DAMD17-01-1-0729, The Cancer Council Victoria, Queensland Cancer Fund, The Cancer Council New South Wales, The Cancer Council South Australia, The Cancer Council Tasmania and The Cancer Foundation of Western Australia (Multi-State Applications 191, 211 and 182) and the National Health and Medical Research Council of Australia (NHMRC; ID400413 and ID400281). The Australian Ovarian Cancer Study gratefully acknowledges additional support from Ovarian Cancer Australia and the Peter MacCallum Foundation. The AOCS also acknowledges the cooperation of the participating institutions in Australia and acknowledges the contribution of the study nurses, research assistants and all clinical and scientific collaborators to the study. The complete AOCS Study Group can be found at www.aocstudy.org. We would like to thank all of the women who participated in these research programs. OVCARE receives core funding from The BC Cancer Foundation and the VGH and UBC Hospital Foundation. The Gynaecological Oncology Biobank at Westmead is a member of the Australasian Biospecimen Network-Oncology group, which was funded by the National Health and Medical Research Council Enabling Grants ID 310670 & ID 628903 and the Cancer Institute NSW Grants ID 12/RIG/1-17 & 15/RIG/1-16. COEUR: This study uses resources provided by the Canadian Ovarian Cancer Research Consortium’s - COEUR biobank funded by the Terry Fox Research Institute and managed and supervised by the Centre hospitalier de l’Université de Montréal (CRCHUM). The Consortium acknowledges contributions to its COEUR biobank from Institutions across Canada (for a full list see http://www.tfri.ca/en/research/translational-research/coeur/coeur_biobanks.aspx). The following cohorts that contributed to OTTA were supported as follows: AOV: Canadian Institutes of Health Research (MOP-86727), Cancer Research Society (19319). BAV: ELAN Funds of the University of Erlangen-Nuremberg; DOV: NCI/NIH R01CA168758. Huntsman Cancer Foundation and the National Cancer Institute of the National Institutes of Health under Award Number P30CA042014. HAW: U.S. National 19 Institutes of Health (R01-CA58598, N01-CN-55424 and N01-PC-67001); MAY: National Institutes of Health (R01-CA122443, P30-CA15083, P50-CA136393); Mayo Foundation; Minnesota Ovarian Cancer Alliance; Fred C. and Katherine B. Andersen Foundation; SEA: SEARCH team: Mitul Shah, Jennifer Alsopp, Mercedes Jiminez-Linan SEARCH funding: Cancer Research UK (C490/A16561), the Cancer Research UK Cambridge Cancer Centre and the National Institute for Health Research Cambridge Biomedical Research Centres. The University of Cambridge has received salary support for PDPP from the NHS in the East of England through the Clinical Academic Reserve. JBD: Cancer Research UK Institute Group Award UK A22905 and A15601; STA: NIH grants U01 CA71966 and U01 CA69417; SWE: Swedish Cancer foundation, WeCanCureCancer and årKampMotCancer foundation; TVA: Canadian Institutes of Health Research grant (MOP-86727) and NIH/NCI 1 R01CA160669- 01A1; VAN: M.S. Anglesio is funded through a Michael Smith Foundation for Health Research Scholar Award and the Janet D. Cottrelle Foundation Scholars program managed by the BC Cancer Foundation. The Vancouver study cohort (TVAN) is supported by BC’s Ovarian Cancer Research team (OVCARE), the BC Cancer Foundation and The VGH+UBC Hospital Foundation. WMH: National Health and Medical Research Council of Australia, Enabling Grants ID 310670 & ID 628903. Cancer Institute NSW Grants 12/RIG/1-17 & 15/RIG/1-16

Orthopaedic Rehabilitation of the Athlete: Getting Back in the Game

Prevent athletic injuries and promote optimal recovery with the evidence-based guidelines and protocols inside Orthopaedic Rehabilitation of the Athlete! Practical expert guidance; a templated user-friendly format make this rehab reference ideal for any practitioner working with athletes! Key Features Consult this title on your favorite e-reader, conduct rapid searches, and adjust font sizes for optimal readability. Apply targeted, evidence-based strategies for all internationally popular athletic activities, including those enjoyed by older adults. Ensure optimal care from injury prevention through follow up 2 years post injury. Make safe recommendations for non-chemical performance enhancement.https://digitalcommons.georgiasouthern.edu/rehabilitation-facbookshelf/1000/thumbnail.jp