Aspirin is a safe and effective thromboembolic prophylaxis after total knee arthroplasty: a systematic review and meta-analysis.

PURPOSE: Patients undergoing total knee arthroplasty (TKA) are at high risk for thromboembolic events compared to non-surgical patients. Both anticoagulants and antiplatelet agents are used as antithrombotic prophylaxis in TKA. The aim of this review is to understand the role of aspirin in the prevention of thromboembolic events and to compare its efficacy and safety with the main anticoagulants used in antithromboembolic prophylaxis in TKA. METHODS: A systematic review and meta-analysis was performed according to the PRISMA guidelines. An electronic systematic search was conducted using PubMed, Scopus, and the Cochrane Central Registry to evaluate studies that compared aspirin with other anticoagulants, in terms of deep venous thrombosis and pulmonary embolism after TKA. The meta-analysis compared the rate of complications between aspirin and other anticoagulants. RESULTS: Thirteen studies were included in the systematic review for a total of 163,983 patients, and 10 studies were included in the meta-analysis. The meta-analysis demonstrated no statistically significant differences between aspirin and other anticoagulants in terms of the rate of deep venous thrombosis (OR 0.93, 95% CI 0.81-1.08, p = 0.35) and pulmonary embolism (OR 0.89, 95% CI 0.56-1.41, p = 0.61). CONCLUSION: Aspirin is safe, effective, and not inferior to other main anticoagulants in preventing thromboembolic events following TKA.

Genetic factors in rotator cuff pathology: potential influence of col 5A1 polymorphism in outcomes of rotator cuff repair.

BACKGROUND: Investigations in genetics have provided valuable information about the correlation between gene variants and tendinopathy. Single Nucleotide Polymorphisms of COL5A1 gene are reported to be involved in Achilles tendinopathy, chronic degenerative tendon changes at the elbow, and other tendinopathies. The influence of Single Nucleotide Polymorphisms of COL5A1 was previously analyzed in rotator cuff disease with confounding results. Moreover, the rs12722 polymorphism in COL5A1 gene has been implicated in the aetiology of musculoskeletal soft tissue injuries in several association studies. This study aims to analyse the possible influence of rs12722 polymorphism in COL5A1 in the outcomes of rotator cuff repair. METHODS: Seventy-nine patients were included in the study. DNA was extracted from 1.2 ml of venous blood and genotyped for COL5A1 SNPs rs12722. Rotator cuff muscle strength and range of motion (ROM) in anterior elevation, external and internal rotation of the shoulder were evaluated. RESULTS: Patients presenting COL5A1 SNP rs12722 CC showed a ROM of passive external rotation statistically significantly higher compared to patients with CT genotype and TT genotype. CONCLUSIONS: COL5A1 SNP rs12722 may influence the functional outcomes of RCRs, even though further studies are required to confirm these preliminary results.

Arthroscopic rotator cuff repair with and without subacromial decompression is safe and effective: a clinical study.

BACKGROUND: Subacromial decompression, that consists of the release of the coracoid-acromial ligament, subacromial bursectomy and anterior-inferior acromioplasty, has traditionally been performed in the management of this pathology. However, the purpose of subacromial decompression procedure is not clearly explained. Our reaserch aimed to analyse the differences among the outcomes of arthroscopic rotator cuff repair (RCR) made with suture anchors, with or without the subacromial decompression procedure. METHODS: 116 shoulders of 107 patients affected by rotator cuff (RC) tear were treated with Arthroscopic RCR. In 54 subjectes, the arthroscopic RCR and the subacromial decompression procedure (group A) were executed, whereas 53 took only arthroscopic RCR (group B). Clinical outcomes were evaluated through the use of the modified UCLA shoulder rating system, Wolfgang criteria shoulder score and Oxford shoulder score (OSS). Functional outcomes were assessed utilizing active and passive range of motion (ROM) of the shoulder, and muscle strength. The duration of the follow up and the configuration of the acromion were used to realize the comparison between the two groups. RESULTS: In patients with 2 to 5 year follow up, UCLA score resulted greater in group A patients. In subjectes with longer than five years of follow up, group B patients showed considerably greater UCLA score and OSS if related with group A patients. In subjectes that had the type II acromion, group B patients presented a significant greater strength in external rotation. CONCLUSION: The long term clinical outcomes resulted significantly higher in patients treated only with RCR respect the ones in patients underwent to RCR with subacromial decompression.

Metallic versus biodegradable suture anchors for rotator cuff repair: a case control study.

BACKGROUNDS: Repair of full-thickness rotator cuff (RC) tears is routinely performed using suture anchors, which produce secure and effective soft tissue fixation to bone. The aim of this prospective study is to compare the long-term outcomes of single row arthroscopic rotator cuff repair (RCR) performed using metal or biodegradable suture anchors. The null hypothesis is that there is no difference in shoulder function using metal or biodegradable suture anchors as evaluated by UCLA shoulder score, Wolfgang criteria, and Oxford shoulder score. METHODS: Arthroscopic RCR was performed in 110 patients included in this case control study. They were divided into 2 groups of 51 and 59 patients respectively. Metal suture anchors were used in group 1, and biodegradable suture anchors in group 2. Results were obtained at a mean follow up of 4.05 + 2 years. Clinical outcomes and functional outcomes were evaluated. RESULTS: The mean modified UCLA shoulder score was 26.9 + 7.1 in group 1, and 27.7 + 6.5 in group 2 (P = 0.5); the mean Wolfgang score was 13.3 + 3.3 in group 1, and 14 + 2.6 in group 2 (P = 0.3); the mean OSS was 23.7 + 11.4 in group 1, and 20.7 + 9.2 points in group 2 (P = 0.1). The mean active anterior elevation was 163.5° + 28.2° in group 1 and 163.6° + 26.9 in group 2 (P = 0.9); the mean active external rotation was 46° + 19.7° in group 1 and 44.6° + 16.3° in group 2 (P = 0.7). The mean strength in anterior elevation was 4.8.02 + 23.52 N in group 1, and 43.12 + 17.64 N in group 2 (P = 0.2); the mean strength in external rotation was 48.02 + 22.54 N in group 1 and 46.06 + 17.64 N in group 2 (P = 0.6); the mean strength in internal rotation was 67.62 + 29.4 N in group 1, and 68.6 + 25.48 N in group 2 (P = 0.9). CONCLUSIONS: There are no statistically significant differences at a mean follow-up of 4.05 + 2 years in clinical and functional outcomes of single row arthroscopic RCR using metallic or biodegradable suture anchors for RC < 5 cm.

Conservative Rehabilitation Provides Superior Clinical Results Compared to Early Aggressive Rehabilitation for Rotator Cuff Repair: A Retrospective Comparative Study.

Background and objectives: To compare the long term clinical outcomes, range of motion (ROM) and strength of two different postoperative rehabilitation protocols after arthroscopic rotator cuff repair (RCR) for full-thickness rotator cuff (RC) tears. Materials and Methods: Patients undergoing RCR were divided into two groups. In 51 patients (56 shoulders), rehabilitation was performed without passive external rotation, anterior elevation ROM, and active pendulum exercises in the first 2 weeks after surgery (Group A). In 49 patients (50 shoulders) aggressive rehabilitation was implemented, with early free passive external rotation, anterior elevation ROM, and active pendulum exercises were allowed from the day after surgery (Group A). Results: No statistically significant differences were found in clinical scores, muscle strength, passive forward flexion, passive and active internal/external rotation between the two groups. However, the mean active forward flexion was 167.3° ± 26° (range 90-180°) in group A and 156.5° ± 30.5° (range 90-180°) in group B (p = 0.04). Conclusions: A statistically significant difference between the 2 groups was found in active forward flexion ROM, which was better in patients of group A.

Genetics of rotator cuff tears: no association of col5a1 gene in a case-control study.

BACKGROUND: The incidence of RC tears increases with aging, affecting approximately 30 to 50% of individuals older than 50 years, and more than 50% of individuals older than 80 years. Intrinsic factors (age or gender), extrinsic factors (sports activity or occupation), and biological factors were identified in the onset and progression of RC tears. The attention in the study of aetiology of RC tendinopathy has shifted to the identification of gene variants. Genes encoding for proteins regulating the concentration of pyrophosphate in the extracellular matrix and genes encoding for fibroblastic growth factors, defensin beta 1 and estrogen-related receptor-beta were analyzed. However, only in one study the role of variants of collagen type V alpha 1 (col5a1) gene in RC tears was assessed. The objective of this study was to determine whether a col5a1 DNA sequence variant, rs12722 (C/T) was associated with rotator cuff (RC) tears in a case-control study. METHODS: The study included 93 Caucasian patients undergoing surgery for RC tears and 206 patients with no history and sign of RC disease as evaluated by MRI. Patients were divided into two groups. Group 1 included patients with RC tear diagnosed on clinical and imaging grounds and confirmed at the time of surgery. Group 2 (control group) included patients without history or clinical symptoms of RC disorders and with a MRI negative for RC disease. DNA was obtained from approximately 1.2 ml of venous blood using the MagCore extractor system H16 with a MagCore Genomic DNA Large Volume Whole Blood Kit (RBC Bioscience Corp., Taiwan). All study participants were genotyped for SNPs rs12722. RESULTS: We first estimated that our study had 92% power at p < 0.05 to detect a genetic effect size of 2.05 in the RT tears (93 individuals) and healthy population (206 individuals) cohorts, assuming a minor allele frequency for col5a1 variant rs12722 of 0.5707 in the Italian population (gnomAD frequency). No significant difference in allele and genotype frequencies was observed between RT tears patients and healthy controls. Similarly, no significant association was seen between the RT tears and healthy controls participants in the combined genotype distributions. CONCLUSION: In conclusion, no correlations between the SNP rs12722 of col5a1 gene and RC tears susceptibility was found.

Surgical versus conservative management of Type III acromioclavicular dislocation: a systematic review.

Introduction: The management of Type III acromioclavicular (AC) dislocations is still controversial. We wished to compare the rate of recurrence and outcome scores of operative versus non-operative treatment of patients with Type III AC dislocations. Source of data: A systematic review of the literature was performed by applying the PRISMA guidelines according to the PRISMA checklist and algorithm. A search in Medline, PubMed, Cochrane and CINAHL was performed using combinations of the following keywords: 'dislocation', 'Rockwood', 'type three', 'treatment', 'acromioclavicular' and 'joint'. Areas of agreement: Fourteen studies were included, evaluating 646 shoulders. The rate of recurrence in the surgical group was 14%. No statistical significant differences were found between conservative and surgical approaches in terms of postoperative osteoarthritis and persistence of pain, although persistence of pain seemed to occur less frequently in patients undergoing a surgical treatment. Areas of controversy: Persistence of pain seemed to occur less frequently in patients undergoing surgery. Growing points: Persistence of pain seems to occur less frequently in patients treated surgically for a Type III AC dislocation. Areas timely for developing research: There is insufficient evidence to establish the effects of surgical versus conservative treatment on functional outcome of patients with AC dislocation. High-quality randomized controlled clinical trials are needed to establish whether there is a difference in functional outcome.

The burden of rotator cuff surgery in Italy: a nationwide registry study.

PURPOSE: This study aimed to estimate the yearly number of RC surgeries in Italy, a country with universal access to healthcare for its population, from 2001 to 2014, based on official information source as hospitalization records. A secondary aim was to explore geographical variation in equity in access to RC surgery between three macroregions of Italy (North, Center and South). A tertiary aim was to perform statistical projections of the number of RC procedure volumes and rates on the basis of data from 2001 to 2014. Finally, we aimed to perform a prediction of charges by 2025 to examine the economic impact of RC surgery. METHODS: The analysis of the National Hospital Discharge records (SDO) maintained at the Italian Ministry of Health, concerning the 14 years of our survey (2001 through 2014) was performed. These data are anonymous and include the patient's age (in aggregate for class of age), sex, domicile, region of hospitalization, length of the hospitalization, and type of reimbursement (public or private). RESULTS: During the 14-year study period, 390,001 RC repairs were performed in Italy, which represented an incidence of 62.1 RC procedures for every 100,000 Italian inhabitants over 25 years old. Approximately 65% of RC repair were performed annually in patients ages <65 years, thus affecting the working population. 246,810 patients (63.3%) from the North underwent RC repairs from 2001 through 2014, 78,540 patients (20.2%) from the Center, and 64,407 patients (16.5%) from the South. The projection model predicted substantial increases in the numbers of RC repairs. CONCLUSIONS: This study confirms that the socioeconomic burden of RC surgery is growing and heavily affecting the working population. According to the prediction model, hospital costs sustained by the national health care system for RC procedures are expected to be over 1 billion euros by 2025. LEVEL OF EVIDENCE: II.

Humeral Avulsion of the Glenohumeral Ligaments: A Systematic Review.

PURPOSE: To analyze clinical outcomes, range of motion, rate of recurrence, and complications after procedures to manage shoulder instability in patients with humeral avulsion of the glenohumeral ligament (HAGL) lesions. METHODS: A systematic review of the literature according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines with a PRISMA checklist and algorithm was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases using various combinations of the Keywords "shoulder," "HAGL," "treatment," "lesion," "dislocation," "instability," "clinical," "outcome," "Bankart" since inception of databases to 2015 was performed. All the investigators independently extracted the following data: demographics, types of lesions and associated injuries, treatment, outcome measurements, range of motion, recurrent instability, and complications. RESULTS: Eleven articles were included in which 42 shoulders with HAGL lesions were evaluated. Patients were assessed at a median follow-up period of 25.5 months, ranging from 12 to 54 months. The overall rate of recurrence was 0% (0 of 25) in case of surgery and 90% (9 of 10) in case of nonoperative treatment. The surgical approach was associated with lower rate of recurrence when compared with nonoperative treatment (odds ratio 0.05, 95% confidence interval 0.01 to 0.42, and P = .006). Only 2 papers reported loss of external rotation after surgery. No complications were reported after surgery. Complications after nonoperative treatment were not discussed. CONCLUSIONS: Recognizing HAGL lesions is important to manage patients with glenohumeral instability. Patients' complaints are often nonspecific. A high index of suspicion is required in patients with prior failed shoulder surgery. HAGL lesions are often associated with other shoulder lesions. Arthroscopic or open repairs of HAGL lesions are associated with good clinical outcomes and a lower rate of recurrence compared with nonoperative treatment. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Elmslie-Trillat, Maquet, Fulkerson, Roux Goldthwait, and Other Distal Realignment Procedures for the Management of Patellar Dislocation: Systematic Review and Quantitative Synthesis of the Literature.

PURPOSE: To evaluate clinical outcomes, rate of recurrence, and complications following distal realignment procedures (Elmslie-Trillat, Maquet, Fulkerson, Roux Goldthwait, and other distal realignment procedures) performed alone or in combination with proximal procedures for the management of patellar dislocation. METHODS: A systematic literature review was performed following the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). A search in PubMed, Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, Embase, and Google Scholar databases using various combinations of the keywords "patellar," "dislocation," "tibial transfer," "Elmslie-Trillat," "Roux Goldthwait," "tibial tubercle osteotomy," "Fulkerson," "Maquet," "procedure," "clinical," and "outcome." RESULTS: Thirty-eight articles were included in the systematic review. A total of 1,182 knees belonging to 1,023 patients were grouped according to the duration of the follow-up period. The overall rate of recurrence was 7% (83 of 1,182 knees). Approximately 5.3% (28 of 520 knees) of the redislocation occurred in the short-medium term, and 8.3% (55 of 662 knees) occurred in the long-term. CONCLUSIONS: Distal realignment procedures performed alone or in combination with proximal procedures for the management of patellar dislocation have shown good clinical outcomes and a low rate of recurrence highlighting the efficacy of these procedures. To date no randomized controlled clinical trials are available on the topic. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Bone loss in patients with posterior gleno-humeral instability: a systematic review.

PURPOSE: The aim of this systematic review was to analyse outcomes of surgical procedures for glenoid and/or humeral bony defects, performed singularly or in combination, in patients with posterior gleno-humeral instability. A secondary aim was to establish in clinical settings which percentage of glenoid or humeral bone loss should be treated with a bony procedure to avoid recurrence of dislocation. METHODS: A systematic review of the literature according to the PRISMA guidelines was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, Ovid, and Google Scholar databases was performed using various combinations of the keywords "shoulder", "posterior instability", "dislocation", "bone loss", "reversed bony Bankart", "osseous glenoid defects", "glenoid bone grafting", "glenoid", "humeral head", "surgery", "gleno-humeral", "reversed Hill-Sachs", over the years 1966-2014. Data were independently extracted by all the investigators: demographics, previous surgery, imaging assessment, bone defect measurement, diagnosis, surgical management, return to sport, complications, and outcome measurements. The outcome parameters were recurrence of dislocation and clinical scores. RESULTS: Nineteen articles, describing patients with glenoid bony defects, humeral bony defects, or both in the setting of posterior gleno-humeral instability were included. A total of 328 shoulders in 321 patients were included, with a median age at surgery of 33.4 years, ranging from 14 to 79 years. Patients were assessed at a median follow-up period of 3.6 years (ranging from 8 months to 22 years). A redislocation event occurred in 32 (10 %) shoulders. The redislocation event occurred in 2 (10 %) of 20 shoulders with glenoid bony defect and in 12 (11 %) of 114 shoulders with humeral bony defect. CONCLUSION: Even though the general principle of treating recognized glenoid and humeral bone defects in patients with posterior gleno-humeral instability is widely accepted, to date few studies in the literature accurately establish which bone defects should be treated with bony procedures and the exact correlation between percentage of bone loss and higher risk of redislocation in clinical settings. A limitation to the present systematic review is the small number of included patients, due to the rare entity of posterior bone defects/reversed Hill-Sachs. The clinical relevance is that the results of this systematic review can be helpful to guide clinicians in the management of patients with posterior gleno-humeral instability and glenoid and/or humeral bony defects. This manuscript also highlights the need for accurate description of results in further investigations. The main drawback of the available articles in the topic is that they rarely clarify the percentage of bone loss in patients undergoing a redislocation event. LEVEL OF EVIDENCE: IV.

No difference between unicompartmental versus total knee arthroplasty for the management of medial osteoarthtritis of the knee in the same patient: a systematic review and pooling data analysis.

INTRODUCTION: One-third of patients with knee osteoarthritis (OA) has involvement of only one compartment, especially the medial one. SOURCES OF DATA: We performed a comprehensive search of studies comparing unicompartmental knee arthoplasty (UKA) and total knee arthroplasty (TKA) in the same patient on PubMed, OVID/Medline, Cochrane, CINAHL, Google scholar and Embase databases. AREAS OF AGREEMENT: UKA is indicated in knee with medial OA, no flexion deformity, no joint instability and no varus deformity. AREAS OF CONTROVERSY: Although high tibial osteotomy, UKA and TKA have been proposed to address medial OA of the knee, the best management is still controversial. GROWING POINTS: Studies investigating surgical management of medial OA of the knee are increasingly frequent. AREAS TIMELY FOR DEVELOPING RESEARCH: Large, multicentre, powered, randomized trials comparing UKA and TKA are needed to identify the best management for medial OA of the knee. Moreover, new score systems for satisfaction of the patient should be formulated.

Multidirectional Instability of the Shoulder: A Systematic Review.

PURPOSE: To analyze outcomes of surgical and conservative treatment options for multidirectional instability (MDI). METHODS: A systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. A comprehensive search of the PubMed, MEDLINE, CINAHL, Cochrane, EMBASE, and Google Scholar databases using various combinations of the keywords "shoulder," "multidirectional instability," "dislocation," "inferior instability," "capsulorrhaphy," "capsular plication," "capsular shift," "glenoid," "humeral head," "surgery," and "glenohumeral," over the years 1966 to 2014 was performed. RESULTS: Twenty-four articles describing patients with open capsular shift, arthroscopic treatment, and conservative or combined management in the setting of atraumatic MDI of the shoulder were included. A total of 861 shoulders in 790 patients was included. The median age was 24.3 years, ranging from 9 to 56 years. The dominant side was involved in 269 (58%) of 468 shoulders, whereas the nondominant side was involved in 199 (42%) shoulders. Patients were assessed at a median follow-up period of 4.2 years (ranging from 9 months to 16 years). Fifty-two of 253 (21%) patients undergoing physiotherapy required surgical intervention for MDI management, whereas the overall occurrence of redislocation was seen in 61 of 608 (10%) shoulders undergoing surgical procedures. The redislocation event occurred in 17 of 226 (7.5%) shoulders with open capsular shift management, in 21 of 268 (7.8%) shoulders with arthroscopic plication management, in 12 of 49 (24.5%) shoulders undergoing arthroscopic thermal shrinkage, and in 11 of 55 (22%) shoulders undergoing arthroscopic laser-assisted capsulorrhaphy. CONCLUSIONS: Arthroscopic capsular plication and open capsular shift are the best surgical procedures for treatment of MDI after failure of rehabilitative management. Arthroscopic capsular plication shows results comparable to open capsular shift. LEVEL OF EVIDENCE: Level IV, systematic review of Level I to IV studies.

Management of primary acute anterior shoulder dislocation: systematic review and quantitative synthesis of the literature.

PURPOSE: The aim of this study was to compare the clinical outcome of surgical versus conservative treatment of primary acute anterior dislocation of the shoulder. METHODS: A systematic review of published studies on the treatment of primary acute anterior dislocation of the shoulder was performed. Three investigators independently conducted the research. A comprehensive search of PubMed, MEDLINE, CINAHL, Cochrane Library, EMBASE, and Google Scholar databases using various combinations of the keywords "shoulder," "dislocation," "treatment," "acute," and "primary" over the years 1994 to 2013 was performed. The following data were extracted: demographics, soft tissue lesions and bone defects, outcome measurements, type of management, recurrence of instability, and complications. A quantitative synthesis of the literature was performed to compare surgery and conservative management and immobilization by internal and external in patients undergoing conservative treatment. RESULTS: Thirty-one studies were included in which 2,813 shoulders were evaluated. All patients sustained primary acute anterior shoulder dislocation. The mean Coleman Methodology Score (CMS) was 67 points (range, 19 to 84). Pooled results from comparative studies showed that the rate of recurrence was statistically significantly lower in the surgical group than in the conservative group (odds ratio, 12.71; 95% confidence interval [CI], 4.88 to 33.10; P < .00001). External rotation immobilization provided better results than internal rotation, being associated with a lower rate of recurrence (odds ratio, 2.28; 95% CI, 1.34 to 3.87; P = .002). CONCLUSIONS: Although limited, the available evidence from randomized controlled trials (RCTS) supports primary surgery in young adults engaged in highly demanding sports or job activities. There is lack of evidence to determine whether surgical or nonsurgical treatment is better for other categories of injury. LEVEL OF EVIDENCE: Level IV, systematic review of Level I to IV studies.

Remplissage, humeral osteochondral grafts, weber osteotomy, and shoulder arthroplasty for the management of humeral bone defects in shoulder instability: systematic review and quantitative synthesis of the literature.

PURPOSE: The aim of this study was to evaluate clinical outcomes, rate of recurrence, complications, and range of movement after remplissage, Weber osteotomy, humeral allograft reconstruction, shoulder arthroplasty, and hemiarthroplasty in patients with anterior or posterior shoulder instability associated with humeral bone loss. METHODS: A systematic review of published studies on the management of dislocation of the shoulder with humeral bony procedures was performed. A comprehensive search of the PubMed, Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane, Embase, and Google Scholar databases was performed using various combinations of the keywords "shoulder," "dislocation," "treatment," "remplissage," "hemiarthroplasty," "arthroplasty," "allograft," "osteotomy," "bone," "loss," "clinical," "outcome," and "Hill Sachs" since inception of the databases to 2014. The following data were extracted: demographic characteristics, bone defects and other lesions, type of surgery, outcome measurement, range of motion, recurrence of instability, and complications. RESULTS: Twenty-six studies were included, in which 769 shoulders were evaluated. The mean value of the Coleman Methodology Score was 69.2 points. Preoperatively, the most detected injuries were Hill-Sachs and Bankart lesions. Shoulder arthroplasty procedures had the highest rate of postoperative recurrence and the lowest scores for postoperative clinical outcomes. The combination of remplissage and Bankart procedures was associated with a lower rate of recurrence when compared with Bankart repair alone (odds ratio, 0.05; 95% confidence interval, 0.01 to 0.25; P = .0002). A high heterogeneity (I(2) = 85%) across the study results was found. CONCLUSIONS: Arthroscopic remplissage is the safest technique for the management of patients with shoulder instability with humeral bone loss. Remplissage-Bankart procedures are associated with a lower rate of recurrence when compared with Bankart repair alone. Weber osteotomy, humeral allograft reconstruction, shoulder arthroplasty, and hemiarthroplasty are characterized by a high rate of recurrence, complications, and poor outcome scores. LEVEL OF EVIDENCE: Level IV, systematic review of Level II, III, and IV studies.

Latarjet, Bristow, and Eden-Hybinette procedures for anterior shoulder dislocation: systematic review and quantitative synthesis of the literature.

PURPOSE: The aim of this study was to evaluate clinical outcome, rate of recurrence, complications, and rate of postoperative osteoarthritis in patients with anterior shoulder instability managed with Latarjet, Bristow, or Eden-Hybinette procedures. METHODS: A systematic review of the literature on management of anterior dislocation of the shoulder with glenoid bony procedures was performed. A comprehensive search of PubMed, MEDLINE, CINAHL, Cochrane, EMBASE, and Google Scholar databases using various combinations of the keywords "shoulder," "dislocation," "treatment," "Latarjet," "Bristow," "bone loss," "Eden-Hybinette," "iliac," "bone," "block," "clinical," "outcome," and "Bankart." The following data were extracted: demographics, bone defects and other lesions, type of surgery, outcome measurement, range of motion (ROM), recurrence of instability, complications, and osteoarthritis. A quantitative synthesis of all comparative studies was performed to compare bone block procedures and Bankart repair in terms of postoperative recurrence of instability and osteoarthritis. RESULTS: Forty-six studies were included and 3,211 shoulders were evaluated. The mean value of the Coleman Methodology Score (CMS) was 65 points. Preoperatively, the injuries detected most were glenoid bone loss and Bankart lesions. The Eden-Hybinette procedure had the highest rate of postoperative osteoarthritis and recurrence. Pooled results from comparative studies showed that the bone block procedures were associated with a lower rate of recurrence when compared with Bankart repair (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.28 to 0.74; P = .002), whereas there was no significant difference between the 2 groups in terms of postoperative osteoarthritis (P = .79). CONCLUSIONS: The open Bristow-Latarjet procedure continues to be a valid surgical option to treat patients with anterior shoulder instability. Bone block procedures were associated with a lower rate of recurrence when compared with the Bankart repair. The Eden-Hybinette procedure has clinical outcomes very similar to the Bristow-Latarjet technique but has a higher rate of postoperative osteoarthritis and recurrence. An arthroscopic Bristow-Latarjet procedure seems to be better in terms of prevention of recurrence and rehabilitation, but randomized studies are needed to reach definitive conclusions. LEVEL OF EVIDENCE: Level IV, systematic review of Level II, III, and IV studies.

Glenoid and humeral head bone loss in traumatic anterior glenohumeral instability: a systematic review.

PURPOSE: The aim of this systematic review is to analyze outcomes of surgical procedures for glenoid and/or humeral bony defects, performed singularly or in combination, in patients with traumatic anterior glenohumeral instability. A secondary aim is to establish in clinical settings which percentage of glenoid or humeral bone loss needs to be treated with a bony procedure to avoid recurrence of dislocation. METHODS: A systematic review of the literature according to the PRISMA guidelines was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase and Google Scholar databases using various combinations of the keywords "shoulder", "instability", "dislocation", "bone loss", "bony bankart", "osseous glenoid defects", "glenoid bone grafting", "Latarjet", "glenoid", "humeral head", "surgery", "glenohumeral", "Hill Sachs", "Remplissage", over the years 1966-2012 was performed. RESULTS: Twenty-seven articles, describing patients with glenoid bony defect, humeral bony defect or both in the setting of traumatic anterior glenohumeral instability, were included. A total of 1,816 shoulders in 1,801 patients were included, with a median age at surgery of 27.1 years, ranging from 12 to 75 years. Patients were assessed at a median follow-up period of 2.8 years (ranging from 6 months to 28.2 years). The overall recurrence of redislocation occurred in 117 (6.5 %) shoulders. The redislocation event occurred in 40 of 553 (7.2 %) shoulders with glenoid bony defect, in 30 of 225 (13.3 %) shoulders with humeral bony defect and in 63 of 1,009 (6.3 %) shoulders with both glenoid and humeral involvement. CONCLUSION: Even though the general principle of recognizing and treating glenoid and humeral bone defects in patients with traumatic anterior glenohumeral instability is widely accepted, few studies are available to date to accurately establish which bone defects should be treated with bone procedures and the exact percentage of bone loss leading to higher risk of redislocation in clinical settings.

Anteromedial portal versus transtibial drilling techniques in anterior cruciate ligament reconstruction: any clinical relevance? A retrospective comparative study.

PURPOSE: This study aimed to undertake a retrospective analysis of prospectively collected data comparing, at a minimum follow-up of 5 years (78.1 ± 5.3 months v 75.6 ± 4.8 months), the clinical, functional, and radiographic outcomes of 2 homogeneous groups of athletes who had undergone arthroscopic single-bundle autologous hamstring reconstruction of the anterior cruciate ligament (ACL) using a transtibial (TT) or an anteromedial portal (AMP) approach to drill the femoral tunnel. METHODS: Ninety-four patients were operated on in 2005 and 2006, and 88 (93.6%) (73 men, 15 women) were evaluated subjectively and objectively, using the Lysholm and International Knee Documentation Committee (IKDC) scores, manual maximum displacement test with a KT-1000 arthrometer (MEDmetric, San Diego, CA) and the Lachman test, and rotational instability with the pivot shift test. Degenerative changes were assessed on radiographs according to the Fairbank classification. RESULTS: The median age at operation was 29 years (20 to 43 years; SD, 5.4) in the TT group 1 and 28 years (19 to 45 years; SD, 6.1) in the AMP group 2. At the last appointment, the 2 groups had similar results for the Lysholm and IKDC scores (primary outcome). Patients who underwent the AMP approach had less glide pivot shift (P = .42) and Lachman (P = .47) phenomena, with no statistically significant intergroup difference. Radiography showed fewer, but not significantly different, degenerative changes in the AMP ACL reconstruction group at final follow-up (P = .47). CONCLUSIONS: In our series, ACL reconstruction using a femoral tunnel drilled through an AMP provided better rotational stability and anterior translation than drilling the femoral tunnel using the TT technique. This difference likely is not relevant from a clinical and functional viewpoint. The 2 groups of patients were not significantly different in terms of development of degenerative changes seen radiographically at a minimum follow-up of 5 years. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Preoperative and Postoperative Kinesiophobia Influences Postoperative Outcome Measures Following Anterior Cruciate Ligament Reconstruction: A Prospective Study.

The anterior cruciate ligament (ACL) is the most injured ligament of the knee, and the treatment of choice is usually ACL reconstruction. Kinesiophobia refers to an irrational and paralyzing fear of movement caused by the feeling of being prone to injury or reinjury. The aim of the present study is to evaluate the relationship between preoperative and postoperative kinesiophobia with postoperative outcomes of ACL-R evaluated through SF-36, ACL-RSI, KOOS, and OKS scores. Included patients all underwent ACL reconstruction. The preoperative TSK-13 questionnaire and six-month postoperative TSK-13, ACL-RSI, SF-36, KOOS, and OKS questionnaires were assessed in included patients. Normal distribution was assessed using the Shapiro-Wilk test. The study included 50 patients who filled out the questionnaires at the 6-month postoperative follow-up. Correlations between preoperative TSK-13 and postoperative outcome measures revealed a low-moderate negative correlation between preoperative TSK-13 and SF-36 PCS at 6-month follow-up. Correlations between postoperative TSK-13 and postoperative outcome measures revealed a high negative correlation between preoperative TSK-13 and ACL-RSI, KOOS Symptoms, KOOS Pain, KOOS ADL, and OKS at 6-month follow-up. Preoperative and postoperative kinesiophobia were found to influence postoperative ACL-R outcomes negatively, more specifically an increase in kinesiophobia showed a statistically significant correlation with worse postoperative SF-36 PCS scores in patients.