Acromioclavicular joint dislocation Rockwood type III and V show no difference in functional outcome and 91% recovered well without the need for surgery.

PURPOSE: Acromioclavicular (AC) joint dislocations are common injuries, but the indication for and timing of surgery is debated. The objective of the study was to evaluate the results after acute AC joint dislocations Rockwood type III and V treated nonsurgically with the option of delayed surgical intervention. METHODS: This is a prospective cohort study with clinical, radiological and patient-reported outcome assessment at baseline, 6 weeks, 3 months, 6 months and 1 year after acute AC joint dislocation. Patients aged 18-60 with acute AC joint dislocation and a baseline panorama (Zanca) radiograph with an increase in the coracoclavicular distance of >25% compared to the uninjured side were eligible for inclusion. All patients were treated nonsurgically with 3 months of home-based training and with the option of delayed surgical intervention. The primary outcome was the Western Ontario Shoulder Instability Index (WOSI). Secondary outcomes were surgery yes/no and the Shoulder Pain and Disability Index (SPADI). RESULTS: Ninety-five patients were included. Fifty-seven patients were Rockwood type III and 38 patients were type V. There were no statistically significant differences in WOSI and SPADI between patients with type III and V injuries at any time point. Nine patients (9.5%) were referred for surgery; seven type III and two type V (ns). CONCLUSION: Ninety-one percent of patients with acute AC joint dislocation Rockwood type III and V recovered without surgery and there were no differences in outcome scores between type III and V at any time point. LEVEL OF EVIDENCE: Level IV.

Decision-making in massive rotator cuff tear.

Treatment of massive rotator cuff tears has developed over many years ranging from conservative treatment to open and arthroscopic repair, muscle transfers and reversed arthroplasty. The evolution of more advanced techniques in arthroscopic repair has changed the treatment approach and improved the prognosis for functional outcome despite low healing rates. Due to this rapid development, our evidence-based knowledge today is mainly founded in Level 3 and Level 4 studies. Based on the literature, the current knowledge on treatment of symptomatic massive rotator cuff tears is proposed in an algorithm. Level of evidence V.

ISAKOS upper extremity committee consensus statement on the need for diversification of the Rockwood classification for acromioclavicular joint injuries.

Optimal treatment for the unstable acromioclavicular (AC) joint remains a highly debated topic in the field of orthopaedic medicine. In particular, no consensus exists regarding treatment of grade III injuries, which are classified according to the Rockwood classification by disruption of both the coracoclavicular and AC ligaments. The ISAKOS Upper Extremity Committee has provided a more specific classification of shoulder pathologies to enhance the knowledge on and clinical approach to these injuries. We suggest the addition of grade IIIA and grade IIIB injuries to a modified Rockwood classification. Grade IIIA injuries would be defined by a stable AC joint without overriding of the clavicle on the cross-body adduction view and without significant scapular dysfunction. The unstable grade IIIB injury would be further defined by therapy-resistant scapular dysfunction and an overriding clavicle on the cross-body adduction view.

Reconstruction of the chronic anterior unstable sternoclavicular joint using a tendon autograft: medium-term to long-term follow-up results.

BACKGROUND: Chronic symptomatic anterior sternoclavicular (SC) instability is a rare condition with sparse treatment options. Owing to the rarity of the condition and the potential risk of fatal complications, only a few reports on treatment of this condition have been published. We evaluated a prospective series of patients with chronic anterior SC instability who underwent minimally open reconstruction with an autologous tendon graft. METHODS: From 2002 to 2010, 32 consecutive patients underwent minimally open SC ligament reconstruction using a tendon autograft. A palmaris longus was used in 7 patients and a gracilis tendon autograft was used in 25. All patients with at least 2 years of follow-up were reviewed. Five were lost to follow-up. The remaining 27 patients (84.4%) were a median age of 35 years (range, 11-61 years) at surgery. Patients were evaluated with the Western Ontario Shoulder Instability (WOSI) score preoperatively and at follow-up at a median 54 months (range, 24-120 months) postoperatively. RESULTS: The total WOSI score improved from a median of 44% (range 6%-62%) preoperatively to 75% (range, 13%-93%) at follow-up (P = .0001). Two failures (7.4%) occurred; after revision, both patients remained stable. After the operation, 17 of 25 patients (68%) complained of donor site morbidity, and 10 (40%) still had some discomfort at follow-up. No infections or local vascular complications occurred. CONCLUSIONS: Miniopen SC joint reconstruction using a tendon autograft results in prolonged improvement in shoulder function in most patients with symptomatic anterior SC instability.

Clinical implications of scapular dyskinesis in shoulder injury: the 2013 consensus statement from the 'Scapular Summit'.

The second international consensus conference on the scapula was held in Lexington Kentucky. The purpose of the conference was to update, present and discuss the accumulated knowledge regarding scapular involvement in various shoulder injuries and highlight the clinical implications for the evaluation and treatment of shoulder injuries. The areas covered included the scapula and shoulder injury, the scapula and sports participation, clinical evaluation and interventions and known outcomes. Major conclusions were (1) scapular dyskinesis is present in a high percentage of most shoulder injuries; (2) the exact role of the dyskinesis in creating or exacerbating shoulder dysfunction is not clearly defined; (3) shoulder impingement symptoms are particularly affected by scapular dyskinesis; (4) scapular dyskinesis is most aptly viewed as a potential impairment to shoulder function; (5) treatment strategies for shoulder injury can be more effectively implemented by evaluation of the dyskinesis; (6) a reliable observational clinical evaluation method for dyskinesis is available and (7) rehabilitation programmes to restore scapular position and motion can be effective within a more comprehensive shoulder rehabilitation programme.

Management of disorders of the rotator cuff: proceedings of the ISAKOS upper extremity committee consensus meeting.

The goal of this article is to consolidate the International Society of Arthroscopy, Knee Surgery & Orthopaedic Sports Medicine (ISAKOS) Upper Extremity Committee's (UEC's) current knowledge on rotator cuff disease and management, as well as highlight key unresolved issues. The rotator cuff is an anatomically complex structure important for providing glenohumeral function and stability as part of a closed chain system. Current consensus suggests rotator cuff injuries are most accurately diagnosed, at levels similar to diagnosis by magnetic resonance imaging, with a combination of cuff- and impingement-specific clinical tests. Updates in the understanding of acromion morphology, the insertional anatomy of the rotator cuff, and the role of suprascapular nerve release may require changes to current classification systems and surgical strategies. Although initial management focuses on nonoperative protocols, discussion continues on whether surgery for isolated impingement is clinically more beneficial than rehabilitation. However, clear indications have yet to be established for the use of single- versus double-row repair because evidence confirms neither is clinically efficacious than the other. Biceps tenodesis, however, in non-isolated cuff tears has proven more successful in addressing the etiology of shoulder pain and yields improved outcomes over tenotomy. Data reviewing the benefits of tendon transfers, shoulder prostheses, and mechanical scaffolds, as well as new research on the potential benefit of platelet-rich plasma, pluripotential stem cells, and gene therapies, will also be presented.

Rockwood type III is the most common type of acromioclavicular joint dislocation: A prospective cohort study investigating the incidence and epidemiology of acute acromioclavicular joint dislocations in an urban population.

Introduction: Acromioclavicular (AC) joint dislocations are common, but basic epidemiological features and sub-classification are not well investigated. The aim of the study was to investigate the incidence and epidemiology of acute AC joint dislocations in the capital region of Denmark. Methods: All patients with acute AC joint dislocation admitted to the emergency departments at 3 University Hospitals serving a population of 549,225 residents were prospectively registered from January to December 2019. Patients with trauma to the shoulder, pain from the AC joint and increased coracoclavicular distance on radiographs were included and classified according to Rockwood's classification. Data on age, sex and mechanism of injury were registered. Results: A total of 106 patients, male:female ratio 8.6:1, were included. Rockwood type III was most common accounting for 59/106(55.7%) of the injuries. The incidence was 19.3 per 100,000 person-years at risk (PYRS). The age distribution was bimodal peaking at the ages of 20-24 and 55-59 years. The most common mechanism of injury was sports, 80/106, with cycling accounting for 51/106. Discussion/Conclusion: Rockwood type III was the most common type of AC joint dislocation constituting 55.7% of the injuries. The incidence was 19.3 per 100,000 PYRS. Young and middle-aged males were at highest risk and most injuries occurred during sports.

Training induces scapular dyskinesis in pain-free competitive swimmers: a reliability and observational study.

OBJECTIVE: Scapular dyskinesis is a major etiological factor in overhead athletes' shoulder problems. Our hypotheses were to evaluate if (1) visual observation of scapular dyskinesis during scaption has substantial interobserver reliability, and (2) scapular dyskinesis may be induced by swim training in pain-free swimmers. DESIGN: A reliability and observational study. SETTING: Bachelor project at a college institution and at a private sports orthopedic hospital. PARTICIPANTS: Seventy-eight competitive swimmers with no history of shoulder pain were included in the study. Fourteen swimmers were evaluated regarding reliability. Inclusion criteria were competitive swimmers with high training volume who previously had no shoulder pain. INTERVENTIONS: Observations of scapular dyskinesis (yes/no) during simple scaption. The interobserver reliability of scaption and wall push-up was evaluated in 14 swimmers using kappa analysis. MAIN OUTCOME MEASURES: Prevalence of scapular dyskinesis at 4 time intervals during a swim training session. RESULTS: The scaption test resulted in a weighted kappa value of 0.75. Scapular dyskinesis was seen in 29 shoulders (37%) after the first time interval, in another 24 (cumulated prevalence 68%) after one-half of the training session, and in an additional 4 swimmers (cumulated prevalence 73%) after three-quarters of the training session. During the last quarter of the training session, another 7 swimmers had dyskinesis, resulting in a cumulated prevalence of 82%. CONCLUSIONS: The prevalence of abnormal scapular kinesis during a normal training session is high in previously pain-free swimmers. The prevalence increases with more training and occurs early during the training session.

Consensus statement on shoulder instability.

The understanding and treatment of shoulder instability comprise a rapidly evolving area of interest in orthopaedics. Evaluation methods are becoming more specific in showing the exact pathologies causing the symptoms. Magnetic resonance arthrography and arthroscopy have contributed to this development. The patient with an unstable shoulder should be thoroughly evaluated through their history and specific clinical tests of the shoulder as well as the scapulothoracic joint. Often, shoulder instability can be classified after this primary evaluation. Magnetic resonance arthrography and arthroscopy are the gold standards in soft-tissue evaluation, whereas specialized radiographic examinations and computed tomography scans are used to assess bony defects. Patients are treated according to the pathology found on preoperative or pretreatment evaluation. Multiple factors need to be considered before the treatment program is instituted, including the patient's age, activity demands, associated pathology and dysfunction, soft-tissue pathology, degree of instability, direction, frequency, and etiology. Treatment can be nonoperative or arthroscopic or open repair. Soft-tissue pathology and bony defects should be addressed, and the surgeon's preferred method and skills are important in choosing the right treatment for the patient. The patient should be informed about possible complications, restrictions during the treatment period, and the prognosis for the particular type of instability. To improve progress in shoulder orthopaedics, one of the most important factors can be a universal agreement on an outcome measurement tool that is well designed and validated.

The value of clinical tests in acute full-thickness tears of the supraspinatus tendon: does a subacromial lidocaine injection help in the clinical diagnosis? A prospective study.

PURPOSE: Early repair of rotator cuff tears leads to superior results. To detect symptomatic full-thickness tears of the supraspinatus tendon at an early stage, we conducted a prospective study to evaluate the value of clinical examination with and without subacromial lidocaine within the first weeks after an acute injury to the shoulder. METHODS: Of 104 patients included in a prospective investigation, 52 patients were selected to evaluate the diagnostic accuracy of clinical tests in acute full-thickness tears of the supraspinatus tendon. Clinical tests and ultrasound examination were performed at a median of 13 days (range, 3 to 49 days) after the initial injury. The study group consisted of 29 patients (median age, 56 years [range, 39 to 75 years]) who all had an acute complete tear of the supraspinatus tendon verified by ultrasound and arthroscopy. The control group consisted of 23 patients who all had an intact tendon confirmed by ultrasound (median age, 38 years [range, 19 to 73 years]). RESULTS: The Hawkins sign (0.83) and the painful arc test (0.97) had high sensitivity but low specificity (0.23 and 0.05, respectively). The external rotation lag sign (ERLS) and the drop-arm test (DAT) had a sensitivity of 0.39 and 0.37, respectively, and specificity of 0.91 and 0.86, respectively, in diagnosing acute full-thickness tears of the rotator cuff. After a subacromial lidocaine injection, sensitivity of all lag sign tests was reduced, whereas specificity and likelihood ratios of the Jobe test, the ERLS, and the DAT improved. Active abduction was significantly reduced in the full-thickness tear group. CONCLUSIONS: A positive lag sign (ERLS or DAT) is indicative of a full-thickness supraspinatus tear, but a negative lag sign does not preclude a tear. After a subacromial injection of lidocaine, the specificity improves whereas the sensitivity is reduced. Overall, in patients with suspected acute rotator cuff tear, clinical tests cannot stand alone in the evaluation the first weeks after an acute injury. LEVEL OF EVIDENCE: Level I, diagnostic study-testing of previously developed criteria in a series of consecutive patients (by use of arthroscopy and ultrasound as the gold standard).

The practical management of swimmer's painful shoulder: etiology, diagnosis, and treatment.

Shoulder pain is the most common musculoskeletal complaint in competitive swimmers. Problems with the shoulders of swimmers resemble that of the disabled thrower's shoulder, but the clinical findings and associated dysfunctions are not quite the same. Therefore, swimmers with shoulder pain should be evaluated and treated as a separate clinical entity, aimed toward underlying pathology and dysfunction. Balanced strength training of the rotator cuff, improvement of core stability, and correction of scapular dysfunction is central in treatment and prevention. Technical and training mistakes are still a major cause of shoulder pain, and intervention studies that focus on this are desirable. Imaging modalities rarely help clarify the diagnosis, their main role being exclusion of other pathology. If nonoperative treatment fails, an arthroscopy with debridement, repair, or reduction of capsular hyperlaxity is indicated. The return rate and performance after surgery is low, except in cases where minor glenohumeral instability is predominant. Overall, the evidence for clinical presentation and management of swimmer's shoulder pain is sparse. Preliminary results of an intervention study show that scapular dyskinesis can be prevented in some swimmers. This may lead to a reduction of swimmer's shoulder problems in the future.

[Frozen shoulder].

Frozen shoulder, or adhesive capsulitis, is a painful inflammatory disorder with an unknown pathogenesis characterised by progressive fibrosis of the capsule. Frozen shoulder presents clinically with intense pain at rest and passive restricted motion. In general, treatment modalities seem to relieve pain and improve the range of movement, but no single treatment modality has been shown to affect the long-term outcome. Initially, a non-operative approach is traditionally recommended. Oral or intraarticular injection of cortisone relieves short-term pain. In refractory cases, arthroscopic capsular release is suggested.

Acute rotator cuff tear: do we miss the early diagnosis? A prospective study showing a high incidence of rotator cuff tears after shoulder trauma.

The aim of this study was to evaluate the epidemiologic data of patients with an acute soft-tissue injury to the shoulder, with an emphasis on improving the early diagnosis of acute rotator cuff tears. This study included 104 patients, with a median age of 49 years (range, 19-75 years). The patients were evaluated clinically and with ultrasonography at a median of 13 days (range, 3-49 days) after the injury. A total of 60 patients (58%) had some degree of cuff lesion on the ultrasonographic examination. Of these patients, 33 (32%) had a full-thickness rotator cuff tear, 14 (13%) had a partial-thickness cuff tear in the tendon substance, and 13 (13%) had a partial cuff tear at the insertion site on the major tubercle. The injury mechanism or activity at the moment of injury did not correlate with the presence of a rotator cuff lesion, but we found a strong age correlation, with a prevalence of any rotator cuff tear, above 50%, for patients aged above 50 years and with a prevalence of full-thickness tears of 50% in the groups aged 50 to 59 years and aged 60 to 69 years. In conclusion, this study found a high incidence of rotator cuff lesions by further evaluation of patients undergoing consultation at the emergency department, with an inability to perform active abduction above 90 degrees and normal radiographs, after an acute shoulder trauma.

Translation, adaptation and measurement properties of an electronic version of the Danish Western Ontario Shoulder Instability Index (WOSI).

OBJECTIVES: To translate and adapt the Western Ontario Shoulder Instability (WOSI) questionnaire into Danish and, to evaluate measurement properties of an electronic Danish WOSI version. METHODS: The Swedish WOSI version was used for translation and adaptation into Danish followed by examination of test-retest reproducibility (14-day interval) besides concurrent and construct validity. Concurrent validity was examined by comparing WOSI in paper version with an electronic version, whereas construct validity was examined by comparing WOSI with Numeric Pain Rating Scale (NPRS) and the Oxford Shoulder Score (OSS). Reproducibility was evaluated with Intraclass correlations (ICC), Standard Error of Measurement (SEM), minimal detectable change (MDC) and limits of agreement (LOA). Validity was evaluated with Pearson's (r) and Concordance Correlation Coefficients (CCC). RESULTS: 41 subjects (median age 34, range 18-57) were included in the analysis of reproducibility. An ICC of 0.97 (95% CI 0.95 to 0.99) for the total WOSI score was found. SEM was 100.1, resulting in an MDC of 277.5 and LOAs within the range of -246.4 and 308.6. 25 subjects (median age 34, range 18-72) were included in the analysis of concurrent validity obtaining a CCC of 0.96 (95% CI 0.91 to 0.98). Construct validity was investigated in 62 subjects (median age 31, range 18-72) obtaining correlations of 0.83 (95% CI 0.68 to 0.97) (NPRS) and 0.79 (95% CI 0.62 to 0.94) (OSS). CONCLUSIONS: An electronic Danish version of WOSI presented excellent test-retest reproducibility and acceptable measurement errors. Also, concurrent validity between paper and electronic version was highly satisfactory as was the construct validity. Surprisingly, though, the NPRS correlated more with WOSI than OSS.