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

Alternative Management of the Capsule in the Bristow-Latarjet Procedure

The Bristow-Latarjet procedure is considered the current gold standard for the management of anterior glenohumeral joint instability in which significant glenoid bone loss is present, and numerous techniques have been proposed for capsular management after the bony augmentation component of the procedure. These techniques for capsular management include excision of the capsule and labrum, 2-flap elevation, T-capsulotomy, or an L-shaped incision into the capsule. Capsular management during open shoulder procedures may vary among surgeons and may or may not include capsulolabral repair after the Bristow-Latarjet procedure. The purpose of this Technical Note was to illustrate an alternative approach to capsular management, focusing on the elevation of the capsulolabral complex as a sleeve along with augmentation using the coracoacromial ligament during the Bristow-Latarjet procedure in patients with anterior glenohumeral instability. The proposed technique provides the benefit of improvement in visualization to more reliably identify the ideal location for bone block placement and allows for the surgeon to perform a large inferior-to-superior capsular shift to prevent inferior subluxation or instability

Surgical Treatment of Medial Gastrocnemius Tear

Medial gastrocnemius tears typically occur with forced dorsiflexion while the knee is extended. Myotendinous injuries occur most commonly, which are almost always treated without surgery. If a tendinous injury or avulsion occurs, nonoperative treatment should first be attempted. However, in patients where forceful plantar flexion is required for their desired activities or occupation, surgical fixation is an important treatment option. Postoperative bracing should be used to protect the repair with a graduated therapy progression, including range of motion followed by strengthening and return to activities. This technical note describes the technique for a safe and reliable medial gastrocnemius tendinous repair using two suture anchors

Glenohumeral Resurfacing in Young, Active Patients With End-Stage Osteoarthritis of the Shoulder

Treatment of end-stage glenohumeral arthritis in young patients is a challenge; however, there is a lack of consensus on optimal treatment algorithms. A thorough history and physical examination are essential. Nonoperative treatments should first be attempted, whereas surgical options range from arthroscopic debridement to arthroplasty. One arthroplasty option is glenohumeral resurfacing with the objective of maintaining more native anatomy and bone stock. The described treatment includes a hemi-cap implant for the humerus and inlay polyethylene glenoid. While hemi-caps have been successfully used for decades, inlay glenoid implants are a more modern treatment, with the objective of less glenoid loosening, the typical complication and failure method in young patients. With the potential for greater longevity and preservation of anatomy, glenohumeral resurfacing for end-stage shoulder arthritis is an important treatment option to consider before total shoulder arthroplasty. This Technical Note describes resurfacing of the glenohumeral joint in a young, active patient presenting with extensive osteoarthritis on both the glenoid and humerus after a previous failed Trillat stabilization

Arthroscopic Labral Repair of the Hip Using a Self-Grasping Suture-Passing Device: Maintaining the Chondrolabral Junction

In the setting of femoroacetabular impingement, the acetabular labrum may be torn or pathologic, and it must be surgically repaired to restore the native suction seal and hip function. However, the current methods of arthroscopic suture passage commonly result in some degree of disruption of the chondrolabral junction, with penetration and shuttling of the repair sutures. Novel instrumentation and surgical techniques have aimed to repair the acetabular labrum with decreased violation of the intrasubstance fibers to provide anatomic eversion/inversion of the labrum to restore the suction seal. In this Technical Note, we describe a method of suture passage through the use of a self-grasping suture-passing device that allows for anatomic labral repair while maintaining the chondrolabral junction as well as minimizing iatrogenic damage the labrum intrasubstance fibers

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

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

Chronic Instability and Pain of the Sternoclavicular Joint: Treatment With Semitendinosus Allograft to Restore Joint Stability.

Chronic instability of the sternoclavicular (SC) joint is a challenging clinical problem, particularly in a patient population for which nonoperative forms of treatment prove ineffective. Patients present after experiencing recurrent subluxation events and subsequent pain, which commonly result in increasing functional limitation. Recurrent SC joint instability of this nature can lead to damage of the SC joint cartilage and bone, and in cases of posterior subluxation or dislocation, damage to mediastinal structures. While the precise treatment algorithm requires tailoring to individual patients and their respective pathologies, we have demonstrated successful outcomes in correcting chronic SC joint instability by means of SC joint reconstruction with semitendinosus allograft, SC joint capsular reconstruction, and, in cases of arthritic damage, resection of a small portion of the degenerative component of the medial clavicle. The purpose of this Technical Note is to describe a technique that uses a semitendinosus allograft to stabilize the SC joint combined with a capsular reconstruction in patients who have previously failed nonoperative treatment methods

Distal Clavicular Augmentation with Acromioclavicular and Coracoclavicular Ligament Reconstruction in the Setting of Iatrogenic Induced Acromioclavicular Instability

Although chronic pain and dysfunction of the acromioclavicular (AC) joint can reliably be treated with distal clavicle excision, disruption of the local stabilizing ligamentous structures may result in iatrogenic instability of the joint. Iatrogenic AC joint instability is a rare condition caused by over resection of the distal clavicle with unintended injury to the stabilizing ligaments in the treatment of AC joint pain. Addressing postresection instability can prove to be difficult because most reconstruction techniques are intended for patients with traumatic AC joint instability with the goal of creating an anatomically stable joint. However, in the setting of iatrogenic instability, the decreased bone stock of the distal clavicle results in instability of the AC joint, especially in the horizontal plane, and may cause these techniques to fail. Thus, operative management must aim to correct both the osseous and ligamentous deficits responsible for the genesis of this instability. In this Technical Note, we describe bony augmentation of the distal clavicle with an iliac crest bone autograft for chronic iatrogenic acromioclavicular joint instability with concomitant reconstruction of the AC and coracoclavicular ligaments

Following Anterior Cruciate Ligament Reconstruction With Bone–Patellar Tendon–Bone Autograft, the Incidence of Anterior Knee Pain Ranges From 5.4% to 48.4% and the Incidence of Kneeling Pain Ranges From 4.0% to 75.6%: A Systematic Review of Level I Studies

Purpose: To perform a systematic review of level I randomized controlled trials (RCTs) detailing the incidence of anterior knee pain and kneeling pain following anterior cruciate ligament reconstruction (ACLR) with bone–patellar tendon–bone (BPTB) autograft and to investigate the effect of bone grafting the patellar harvest site on anterior knee and kneeling pain. Methods: A systematic review of level I studies from 1980 to 2023 was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary outcome evaluated was the presence of donor site morbidity in the form of anterior knee pain or kneeling pain. A secondary subanalysis was performed to assess for differences in the incidence of postoperative pain between patient groups undergoing ACLR with BPTB receiving harvest site bone grafting and those in whom the defect was left untreated. Results: Following full-text review, 15 studies reporting on a total of 696 patients met final inclusion criteria. Patients were followed for an average of 4.78 years (range, 2.0-15.3), and the mean age ranged from 21.7 to 38 years old. The incidence of anterior knee pain, calculated from 354 patients across 10 studies, ranged from 5.4% to 48.4%. The incidence of postoperative pain with kneeling was determined to range from 4.0% to 75.6% in 490 patients from 9 studies. Patients treated with bone grafting of the BPTB harvest site had no significant difference in incidence of any knee pain compared with those who were not grafted, with incidences of 43.3% and 40.2%, respectively. Conclusions: Based on the current level I RCT data, the incidences of anterior knee pain and kneeling pain following ACLR with BPTB autograft range from 5.4% to 48.4% and 4.0% to 75.6%, respectively. Level of Evidence: Level I, systematic review of RCTs