Current concepts in chronic traumatic anterior shoulder instability.

Chronic traumatic anterior shoulder instability can be defined as recurrent trauma-associated shoulder instability requiring the assessment of three anatomic lesions: a capsuloligamentous and/or labral lesion; anterior glenoid bone loss and a Hill-Sachs lesion. Surgical treatment is generally indicated. It remains controversial how risk factors should be evaluated to decide between a soft-tissue, free bone-block or Latarjet-type procedure. Patient risk factors for recurrence are age; hyperlaxity; competitive, contact and overhead sports. Trauma-related factors are soft tissue lesions and most importantly bone loss with implications for treatment. Different treatment options are discussed and compared for complications, return to sports parameters, short- and long-term outcomes and osteoarthritis. Arthroscopic Bankart and open Latarjet procedures have a serious learning curve. Osteoarthritis is associated with the number of previous dislocations as well as surgical techniques. Latarjet-type procedures have the lowest rate of dislocation recurrence and if performed correctly, do not seem to increase the risk of osteoarthritis.

Short-term outcomes of arthroscopic partial repair vs. latissimus dorsi tendon transfer in patients with massive and partially repairable rotator cuff tears.

BACKGROUND: There is limited evidence on clinical outcomes of arthroscopic partial repair (APR) and latissimus dorsi tendon transfer (LDTT) for posterosuperior massive rotator cuff tears (mRCTs). We aimed to compare clinical outcomes of APR and LDTT for partially repairable posterosuperior mRCTs and to determine whether outcomes differ among tears that involve the teres minor. METHODS: We retrieved the records of 112 consecutive patients with mRCTs deemed partially repairable due to fatty infiltration (FI) stage ≥3 in one or more rotator cuff muscles. Of the tears, 12 involved the subscapularis, 32 were managed conservatively, 14 were treated by reverse shoulder arthroplasty, and 7 were treated by stand-alone biceps tenotomy. Of the remaining 47 shoulders, 26 underwent APR and 21 underwent LDTT. At a minimum of 12 months, we recorded complications, active forward elevation, external rotation, the Constant-Murley score, American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), and Simple Shoulder Test (SST) score. RESULTS: No significant differences between the APR and LDTT groups were found in terms of follow-up (23.4 ± 3.5 months vs. 22.1 ± 4.1 months, P = .242), Constant-Murley score (64.8 ± 13.7 vs. 58.9 ± 20.0, P = .622), ASES score (78.3 ± 19.3 vs. 74.4 ± 14.5, P = .128), active forward elevation (158.1° ± 19.4° vs. 142.8° ± 49.1°, P = .698), or external rotation (33.3° ± 17.4° vs. 32.2° ± 20.9°, P = .752). By contrast, the APR group had a higher SSV (73.3 ± 17.5 vs. 59.5 ± 20.0, P = .010), and SST score (8.3 ± 2.4 vs. 6.4 ± 3.0, P = .024). Univariable analysis revealed that advanced FI of the teres minor compromised Constant-Murley scores (ß = -25.8, P = .001) and tended to compromise ASES scores (ß = -15.2, P = .062). Multivariable analysis corroborated that advanced FI of the teres minor compromised Constant-Murley scores (ß = -26.9, P = .001) and tended to compromise ASES scores (ß = -16.5, P = .058). CONCLUSION: Both APR and LDTT granted similar early clinical outcomes for partially repairable posterosuperior mRCTs, regardless whether the teres minor was intact or torn. Advanced FI of the teres minor was the only independent factor associated with outcomes, as it significantly compromised Constant-Murley scores and tended to compromise ASES scores.

Ten-year clinical and magnetic resonance imaging evaluation after repair of isolated subscapularis tears.

HYPOTHESIS: The purpose was to evaluate long-term clinical outcomes and tendon structural integrity after repair of isolated subscapularis (SSC) tendon tears. METHODS: Sixty-one patients who underwent repair of isolated SSC tears were evaluated. The mean interval from symptom onset to surgery was 5.3 months. Shoulder function was investigated using the Constant score and Subjective Shoulder Value (SSV). Structural integrity of the repair and quality of the repaired tendon were assessed using magnetic resonance imaging. Independent preoperative factors affecting clinical outcomes, including patient sex, age, smoking habits, injections, dominant shoulder, profession, and tear onset (chronic vs. traumatic), were evaluated. RESULTS: A total of 35 patients (9 women and 26 men; mean age, 54 years) were included at the final 10-year follow-up because 21 patients were lost to follow-up and 5 underwent reoperations. The mean Constant score improved from 55.1 points preoperatively to 75.4 points postoperatively (P = .001). The postoperative SSV was 80.9, and the retear rate was 12.9%. Postoperative fatty infiltration increased in 26% of the patients with grades 3-4, but it was not related to lower clinical outcomes. Multivariable regression analysis revealed no correlation among the preoperative factors, including sex, age, smoking habits, injections, dominant shoulder, profession, and tear onset, and the postoperative Constant score, SSV, and tendon healing. CONCLUSION: At a mean of 10 years after repair of isolated SSC tears, clinical results were satisfactory and functional improvement was maintained in the long term. Severe fatty infiltration increased with time, but it was not related to clinical outcomes and the retear rate.

Post-operative rotator cuff integrity, based on Sugaya's classification, can reflect abduction muscle strength of the shoulder.

PURPOSE: Magnetic resonance (MR) imaging is common in structural and qualitative assessment of the rotator cuff post-operatively. Rotator cuff integrity has been thought to be associated with clinical outcome. The purpose of this study was to evaluate the inter-observer reliability of cuff integrity (Sugaya's classification) and assess the correlation between Sugaya's classification and the clinical outcome. It was hypothesized that Sugaya's classification would show good reliability and good correlation with the clinical outcome. METHODS: Post-operative MR images were taken two years post-operatively, following arthroscopic rotator cuff repair. For assessment of inter-rater reliability, all radiographic evaluations for the supraspinatus muscle were done by two orthopaedic surgeons and one radiologist. Rotator cuff integrity was classified into five categories, according to Sugaya's classification. Fatty infiltration was graded into four categories, based on the Fuchs' classification grading system. Muscle hypotrophy was graded as four grades, according to the scale proposed by Warner. The clinical outcome was assessed according to the constant scoring system pre-operatively and 2 years post-operatively. RESULTS: Of the sixty-two consecutive patients with full-thickness rotator cuff tears, fifty-two patients were reviewed in this study. These subjects included twenty-three men and twenty-nine women, with an average age of fifty-seven years. In terms of the inter-rater reliability between orthopaedic surgeons, Sugaya's classification showed the highest agreement [ICC (2.1) = 0.82] for rotator cuff integrity. The grade of fatty infiltration and muscle atrophy demonstrated good agreement, respectively (0.722 and 0.758). With regard to the inter-rater reliability between orthopaedic surgeon and radiologist, Sugaya's classification showed good reliability [ICC (2.1) = 0.70]. On the other hand, fatty infiltration and muscle hypotrophy classifications demonstrated fair and moderate agreement [ICC (2.1) = 0.39 and 0.49]. Although no significant correlation was found between overall post-operative constant score and Sugaya's classification, Sugaya's classification indicated significant correlation with the muscle strength score. CONCLUSIONS: Sugaya's classification showed repeatability and good agreement between the orthopaedist and radiologist, who are involved in the patient care for the rotator cuff tear. Common classification of rotator cuff integrity with good reliability will give appropriate information for clinicians to improve the patient care of the rotator cuff tear. This classification also would be helpful to predict the strength of arm abduction in the scapular plane. LEVEL OF EVIDENCE: IV.

Diagnosis and treatment of obsessive compulsive behavior in a boy with Duchenne muscular dystrophy and autism spectrum disorder: A case report.

We describe a case study of comorbid obsessive-compulsive disorder (OCD) in a nine-year-old boy with Duchenne muscular dystrophy (DMD). Patient history included persistent deficits in social communication and restrictive and repetitive patterns of behavior: a diagnosis of autism spectrum was formalized. Due to serious disruption on social functioning and negative development of the obsessive behavior we decided to start pharmacotherapy. Fluoxetine 5 mg/day was started and gradually increased to 20 mg/day. A significant positive effect was observed by both parents and teacher in daily functioning. Although parents reported a positive change in mood, formal behavior rating by them did not reveal a significant effect, reflecting the insensitivity of general behavior rating scales. However, neuropsychological testing revealed a significant effect. This case report highlights the diagnostic and therapeutic challenges of complex neuropsychiatric comorbidities in DMD. It is the first scientific report on fluoxetine effectiveness in this patient group. Further research is needed.

Osteotomy and Re-fixation for treatment of Malunited Greater Tuberosity of Humerus.

INTRODUCTION: Most greater tuberosity humerus fractures can be treated successfully with either surgical or conservative methods and good results can be expected if fracture heals anatomically but a displaced fracture or an improperly reduced fracture can lead to a symptomatic mal-union. CASE PRESENTATION: 36years old man with mal-united greater tuberosity fracture presented to us 18 months following injury and percutaneous screw fixation and 9 months after screw removal. She complained of severe restriction of shoulder movements. A good result was achieved after corrective open reduction and fixation of the greater tuberosity and rotator cuff repair. CONCLUSION: Open reduction, re-fixation and soft tissue reconstruction can give excellent results in cases of malunited greater tuberosity fractures even as late as 20 months after trauma.