Editorial Commentary: At Present, ChatGPT Cannot Be Relied Upon to Answer Patient Questions and Requires Physician Expertise to Interpret Answers for Patients.

ChatGPT is designed to provide accurate and reliable information to the best of its abilities based on the data input and knowledge available. Thus, ChatGPT is being studied as a patient information tool. This artificial intelligence (AI) tool has been shown to frequently provide technically correct information but with limitations. ChatGPT provides different answers to similar questions based on the prompts, and patients may not have expertise in prompting ChatGPT to elicit a best answer. (Prompting large language models has been shown to be a skill that can improve.) Of greater concern, ChatGPT fails to provide sources or references for its answers. At present, ChatGPT cannot be relied upon to address patient questions; in the future, ChatGPT will improve. Today, AI requires physician expertise to interpret AI answers for patients.

Establishing the Minimal Clinically Important Difference and Patient Acceptable Symptom State Thresholds Following Arthroscopic Capsular Release for the Treatment of Idiopathic Shoulder Adhesive Capsulitis.

PURPOSE: To determine the minimal clinically important difference (MCID) and the patient acceptable symptom state (PASS) threshold for the visual analog scale (VAS), Constant, Single Assessment Numeric Evaluation (SANE), and American Shoulder and Elbow Surgeons (ASES) scores following arthroscopic capsular release for the treatment of idiopathic shoulder adhesive capsulitis. METHODS: A retrospective review of prospective collected data was performed in patients undergoing arthroscopic capsular release for the treatment of idiopathic adhesive capsulitis at a single institution from January 2018 through January 2019. Patient-reported outcome measures were collected preoperatively and 6 months' postoperatively. Delta was defined as the change between preoperative and 6 months' postoperative scores. Distribution-based and anchored-based (response to a satisfaction question at 1 year) approaches were used to estimate MCIDs and PASS, respectively. The optimal cut-off point where sensitivity and specificity were maximized (Youden index) and the percentage of patients achieving those thresholds were also calculated. RESULTS: Overall, a total of 100 patients without diabetes who underwent arthroscopic capsular release and completed baseline and 6-month patient-reported outcome measures were included. The distribution-based MCID for VAS, Constant, SANE, and ASES were calculated to be 1.1, 10.1, 9.3, and 8.2, respectively. The rate of patients who achieved MCID thresholds was 98% for VAS, 96% for Constant, 98% for SANE, and 99% for ASES. The PASS threshold values for VAS, Constant, and ASES were ≤2, ≥70, ≥80, and ≥80, respectively. The rate of patients who achieved PASS thresholds was 84% for VAS, 84% for Constant, 89% for SANE, and 78% for ASES. CONCLUSIONS: In patients without diabetes and idiopathic adhesive capsulitis, high rates of MCID and PASS thresholds can be achieved with arthroscopic anteroinferior capsular release LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Shoulder Instability-Return to Sports After Injury Scale Shows That Lack of Psychological Readiness Predicts Outcomes and Recurrence Following Surgical Stabilization.

PURPOSE: This study aimed to evaluate the predictive ability of psychological readiness to return to sports on clinical outcomes and recurrences in athletes who return to sports following shoulder instability surgery. METHODS: A retrospective analysis was performed of patients who underwent shoulder instability surgery between September 2020 and October 2021 (arthroscopic Bankart repair or Latarjet procedure) with a minimum follow-up of 2 years. Patients were grouped according to the achievement of psychological readiness to return to play using the Shoulder Instability-Return to Sports After Injury (SIRSI) scale (≥55 points) measured at 6 months following surgery. Recurrences were measured and functional outcomes were evaluated by the visual analog scale (VAS), Rowe, and Athletic Shoulder Outcome Scoring System. The minimal clinically important difference (MCID) for the VAS and Rowe scores was calculated using the distribution-based method of a half standard deviation of the delta (difference between postoperative and preoperative scores). The patient acceptable symptomatic state (PASS) for the VAS scale was set at 2.5 based on previous literature. To evaluate the predictive ability of SIRSI, a regression model analysis and a receiver operating characteristic curve were used. RESULTS: A total of 108 who achieved psychological readiness (PSR) and 41 who did not achieve PSR met the study criteria. PSR achieved significantly higher percentages of MCID and PASS thresholds for VAS than non-PSR (MCID: 68.5% vs 48.7%, P = .026; PASS: 92.5% vs 58.5%, P < .001). However, there were no differences in the percentage of patients achieving MCID for the Rowe score between groups (98.1% vs 100%, P = .999). The only strongest independent predictor of postoperative outcomes was being psychologically ready to return to sports. The SIRSI scale had an excellent predictive ability for recurrences (area under curve, 0.745; 95% confidence interval, 0.5-0.8). Of those who sustained a recurrence, 20% were not psychologically ready compared to 4.3% who were (P = .002). A power analysis was not conducted for this study. CONCLUSIONS: The SIRSI scale is associated with postoperative clinical outcomes and recurrences in patients who returned to sports following shoulder instability surgery. Patients who were not psychologically ready following shoulder instability surgery had worse clinical outcomes with fewer patients achieving clinically significant outcomes (PASS and MCID) for pain and a higher risk of recurrence. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Editorial Commentary: Latarjet for Anterior Shoulder Instability Literature Shows Limited Reporting of Outcomes in Female Patients: Female Patients Show Similar Outcomes but Greater Rate of Emergency Department Visits and Possible Greater of Complications.

It has been reported that use of the Latarjet procedure for anterior shoulder instability increased 250% from 2008 to 2019. With this increase in use, it is imperative to minimize complications. At present, most literature focuses on male patients, with scant evidence regarding female patients. Outcomes are similar when female with male patients are compared, but female patients have greater postoperative visits to the emergency department than male patients, which requires specific attention during the postoperative period. In addition, the literature reporting complications in female versus male patients after Latarjet is conflicting; some studies show similar rates of complications, whereas other studies show greater rates of adverse events in female patients. Previous consensus statements recommended (1) careful dissection; (2) identification of the musculocutaneous and axillary nerves; (3) prevention of overlateralization of the graft; (4) the use of tranexamic acid to reduce blood loss; (5) accurate screw placement; and (6) careful preparation of the glenoid neck and coracoid to reduce rates of nonunion or delayed union.

Young Collision Athletes Have High Rate of Return to Play and Good Clinical Outcomes Following Open Latarjet Procedure.

PURPOSE: To evaluate return to play (RTP), clinical outcomes, and recurrence rates in collision athletes 20 years of age and younger who underwent open Latarjet for anterior shoulder instability. METHODS: A retrospective review of collision athletes 20 years of age and younger, who underwent an open Latarjet procedure by a single surgeon between the years of 2010-2020 was carried out. Inclusion criteria were 1) collision athlete, 2) underwent open Latarjet procedure, 3) 16-20 years old, and 4) minimum 24-month follow-up. Exclusion criteria were 1) other pathology of the ipsilateral shoulder and 2) noncollision athlete. Rate of RTP, time to RTP, rate of return to preinjury level, the Shoulder Instability Return to Sport after Injury score (SIRSI) score, Subjective Shoulder Value (SSV), visual analogue scale (VAS) scores, and recurrence events were recorded. Quantitative statistical analysis was carried out. RESULTS: The study included 105 male collision athletes with a mean age of 18.6 ± 1.0 years (range: 17-20). The mean follow-up for patients was 36 ± 26.2 months. A total of 93 (88.6%) RTP at a mean time of 6.3 ± 2.2 months, with 73 (69.5%) returning to their preinjury level of participation. The mean SIRSI score was 69.2 ± 21.8, the mean VAS score was 2.3 ± 2.1, and the mean SSV score was 84.1 ± 16.8. Five patients (4.8%) redislocated their shoulder, with 4 of these requiring a further surgery (3.8%). Two patients (1.9%) reported incidents of subluxation. CONCLUSIONS: The open Latarjet procedure in young collision athletes results in high rates of RTP, excellent functional outcomes and low recurrence rates at mid-term follow-up. Additionally, complication rates are low in this cohort. LEVEL OF EVIDENCE: Level IV, case series.

Acellular Collagen Matrix Patch Augmentation of Arthroscopic Rotator Cuff Repair Reduces Re-Tear Rates: A Meta-analysis of Randomized Control Trials.

PURPOSE: To perform a meta-analysis of randomized controlled trials (RCTs) to compare the outcomes of arthroscopic rotator cuff repair (ARCR) with and without acellular collagen matrix patch (ACMP) augmentation. METHODS: A literature search of 3 databases was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RCTs comparing ACMP augmentation and a control for ARCR were included. Clinical outcomes were compared using Revman, and a P value < .05 was considered to be statistically significant. RESULTS: Five RCTs with 307 patients were included. Overall, 11% of patients treated with ACMP augmentation and 34% of patients in the control group had a re-tear (P = .0006). The mean Constant score was 90.1 with ACMP augmentation, and 87.3 in controls (P = .02). Additionally, there was a significant higher American Shoulder and Elbow Surgeons score with ACMP augmentation (87.7 vs 82.1, P = .01). CONCLUSIONS: The RCTs in the literature support the use of ACMP augment as a modality to reduce re-tear rates and improve outcomes after ARCR. LEVEL OF EVIDENCE: Level II, Meta-Analysis of Level II Studies meta-analysis of Level II studies.

Studies on Bankart Repair for Anterior Shoulder Instability Show Poor Reporting of Data and Reflect Low Level of Evidence: A Systematic Review.

PURPOSE: To assess the quality and level of evidence of studies reporting on Bankart repair for anterior shoulder instability. METHODS: A search was performed using the PubMed/Medline database for all studies that reported clinical outcomes on Bankart repair for anterior shoulder instability. The search term "Bankart repair" with all results were analyzed via strict inclusion and exclusion criteria. Two independent investigators scored each included study based on the 10 criteria of the Modified Coleman Methodology Score (CMS) out of 100 and gave each study a score out of 25 based on the Anterior Shoulder Instability (ASI) Methodology criteria. RESULTS: Two hundred sixty-six studies were included in the analysis and encompassed a total of 19,156 patients and 19,317 surgical procedures for Bankart repair for shoulder instability. Overall, 81.6% of studies were Level III or IV evidence. The mean CMS score for the studies was 55.3 out of 100, and the mean ASI Methodology score for the studies was 12.1 out of 25. Weaknesses in the studies were identified in sample size, description of preoperative investigations and diagnoses, reporting of mean glenoid bone loss, nonsubjective clinical outcome reporting, and description of associated pathologies. CONCLUSIONS: A large proportion of studies reporting the clinical outcomes of Bankart repair for anterior shoulder instability are of low methodological quality and have a low level of evidence. CLINICAL RELEVANCE: This study emphasizes need for greater reporting of many variables such as body mass index, mean glenoid bone loss, and patient-reported outcomes and provides a framework for future studies reporting.

High Variability in Standardized Outcome Thresholds of Clinically Important Changes in Shoulder Instability Surgery: A Systematic Review.

PURPOSE: To examine reported minimal clinically important difference (MCID) and patient-acceptable satisfactory state (PASS) values for patient-reported outcome measures (PROMs) after shoulder instability surgery and assess variability in published values depending on the surgery performed. Our secondary aims were to describe the methods used to derive MCID and PASS values in the published literature, including anchor-based, distribution-based, or other approaches, and to assess the frequency of MCID and PASS use in studies on shoulder instability surgery. METHODS: A systematic review of MCID and PASS values after Bankart, Latarjet, and Remplissage procedures was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The Embase, PubMed, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were queried from 1985 to 2023. Inclusion criteria included studies written in English and studies reporting use of MCID or PASS for patient-reported outcome measures (PROMS) after Latarjet, Bankart, and Remplissage approaches for shoulder instability surgery. Extracted data included study population characteristics, intervention characteristics, and outcomes of interest. Continuous data were described using medians and ranges. Categorical variables, including PROMs and MCID/PASS methods, were described using percentages. Because MCID is a patient-level rather than a group-level metric, the authors confirmed that all included studies reported proportions (%) of subjects who met or exceeded the MCID. RESULTS: A total of 174 records were screened, and 8 studies were included in this review. MCID was the most widely used outcome threshold and was reported in all 8 studies, with only 2 studies reporting both the MCID and the PASS. The most widely studied PROMs were the American Shoulder and Elbow Surgeons (range 5.65-9.6 for distribution MCID, 8.5 anchor MCID, 86 anchor PASS); Single Assessment Numeric Evaluation (range 11.4-12.4 distribution MCID, 82.5-87.5 anchor PASS); visual analog scale (VAS) (range 1.1-1.7 distribution MCID, 1.5-2.5 PASS); Western Ontario Shoulder Instability Index (range 60.7-254.9 distribution MCID, 126.43 anchor MCID, 571-619.5 anchor PASS); and Rowe scores (range 5.6-8.4 distribution MCID, 9.7 anchor MCID). Notably, no studies reported on substantial clinical benefit or maximal outcome improvement. CONCLUSIONS: Despite the wide array of available PROMs for assessing shoulder instability surgery outcomes, the availability of clinically significant outcome thresholds such as MCID and PASS remains relatively limited. Although MCID has been the most frequently reported metric, there is considerable interstudy variability observed in their values. CLINICAL RELEVANCE: Knowing the outcome thresholds such as MCID and PASS of the PROMs frequently used to evaluate the results of glenohumeral stabilization surgery is fundamental because they allow us to know what is a clinically significant improvement for the patient.

Evaluation High-Quality of Information from ChatGPT (Artificial Intelligence-Large Language Model) Artificial Intelligence on Shoulder Stabilization Surgery.

PURPOSE: To analyze the quality and readability of information regarding shoulder stabilization surgery available using an online AI software (ChatGPT), using standardized scoring systems, as well as to report on the given answers by the AI. METHODS: An open AI model (ChatGPT) was used to answer 23 commonly asked questions from patients on shoulder stabilization surgery. These answers were evaluated for medical accuracy, quality, and readability using The JAMA Benchmark criteria, DISCERN score, Flesch-Kincaid Reading Ease Score (FRES) & Grade Level (FKGL). RESULTS: The JAMA Benchmark criteria score was 0, which is the lowest score, indicating no reliable resources cited. The DISCERN score was 60, which is considered a good score. The areas that open AI model did not achieve full marks were also related to the lack of available source material used to compile the answers, and finally some shortcomings with information not fully supported by the literature. The FRES was 26.2, and the FKGL was considered to be that of a college graduate. CONCLUSIONS: There was generally high quality in the answers given on questions relating to shoulder stabilization surgery, but there was a high reading level required to comprehend the information presented. However, it is unclear where the answers came from with no source material cited. It is important to note that the ChatGPT software repeatedly references the need to discuss these questions with an orthopaedic surgeon and the importance of shared discussion making, as well as compliance with surgeon treatment recommendations. CLINICAL RELEVANCE: As shoulder instability is an injury that predominantly affects younger individuals who may use the Internet for information, this study shows what information patients may be getting online.

Experts Achieve Consensus on a Majority of Statements Regarding Platelet-Rich Plasma Treatments for Treatment of Musculoskeletal Pathology.

PURPOSE: To establish consensus statements on platelet-rich plasma (PRP) for the treatment of musculoskeletal pathologies. METHODS: A consensus process on the treatment of PRP using a modified Delphi technique was conducted. Thirty-five orthopaedic surgeons and sports medicine physicians participated in these consensus statements on PRP. The participants were composed of representatives of the Biologic Association, representing 9 international orthopaedic and musculoskeletal professional societies invited due to their active interest in the study of orthobiologics. Consensus was defined as achieving 80% to 89% agreement, strong consensus was defined as 90% to 99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. RESULTS: There was consensus on 62% of statements about PRP. CONCLUSIONS: (1) PRP should be classified based on platelet count, leukocyte count, red blood count, activation method, and pure-plasma versus fibrin matrix; (2) PRP characteristics for reporting in research studies are platelet count, leukocyte count, neutrophil count, red blood cell count, total volume, the volume of injection, delivery method, and the number of injections; (3) the prognostic factors for those undergoing PRP injections are age, body mass index, severity/grade of pathology, chronicity of pathology, prior injections and response, primary diagnosis (primary vs postsurgery vs post-trauma vs psoriatic), comorbidities, and smoking; (4) regarding age and body mass index, there is no minimum or maximum, but clinical judgment should be used at extremes of either; (5) the ideal dose of PRP is undetermined; and (6) the minimal volume required is unclear and may depend on the pathology. LEVEL OF EVIDENCE: Level V, expert opinion.

Majority of Studies Show Similar Rates of Return to Play After Arthroscopic Bankart Repair or Latarjet Procedure: A Systematic Review.

PURPOSE: To systematically review the current evidence in the literature to compare return to play following arthroscopic Bankart repair versus open Latarjet procedure for the treatment of anterior shoulder instability. METHODS: A literature search was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Comparative studies reporting return to play following arthroscopic Bankart repair versus open Latarjet procedure were included. Return to play was compared, with all statistical analysis performed using Review Manager, Version 5.3. RESULTS: Nine studies with 1,242 patients (mean age: 15-30 years) were included. The rate of return to play was 61% to 94.1% among those undergoing arthroscopic Bankart repair and 72% to 96.8% in those undergoing an open Latarjet procedure. Two studies (Bessiere et al. and Zimmerman et al.) found a significant difference in favor of the Latarjet procedure (P < .05 for both, I2 = 37%). The rate of return to play at preinjury level was 9% to 83.8% among those undergoing arthroscopic Bankart repair and 19.4% to 80.6% in those undergoing an open Latarjet procedure, with no study finding a significant difference (P > .05 for all, I2 = 0%). The mean time of return to play was 5.4 to 7.3 months among those undergoing arthroscopic Bankart repair and 5.5 to 6.2 months in those undergoing an open Latarjet procedure, with no study finding a significant difference (P > .05 for all, I2 = 39%). CONCLUSIONS: Overall, the majority of studies showed no significant difference in rates of return to play or timing following arthroscopic Bankart repair or open Latarjet procedure. Furthermore, no study has found a significant difference in rate of return to play at pre-injury level, or rate of return to play among collision athletes. LEVEL OF EVIDENCE: Level III, systematic review of Level I-III studies.

Bioinductive Collagen Implant Has Potential to Improve Rotator Cuff Healing: A Systematic Review.

PURPOSE: To systematically review the literature to evaluate the clinical studies on bioinductive collagen implant (BCI) for the treatment of rotator cuff tears. METHODS: A literature search of MEDLINE, Embase, and the Cochrane Library was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Clinical studies reporting BCI for rotator cuff tears were included. Quantitive and qualitative data were evaluated. RESULTS: A total of 21 studies were included. In patients with full-thickness tears, 7 of the 8 studies with pre- to postoperative American Shoulder and Elbow Surgeons (ASES) scores demonstrated statistically significant improvements in mean pre- to postoperative ASES scores, with 75% to 100% of patients meeting the minimal clinically important difference. In those with partial-thickness tears, 7 of the 8 studies with pre- to postoperative ASES scores demonstrated statistically significant improvements in mean pre- to postoperative ASES scores, with 54.4% to 100% of patients meeting the minimal clinically important difference. For studies that quantified percent increases in tendon thickness, the reported increases ranged from 13% to 44% in full-thickness tears and 14% to 60% in partial-thickness tears. Six studies evaluated rotator cuff retears after BCI treatment in the full-thickness cohort, with rates reported ranging from 0% to 9%. Five studies evaluated rotator cuff retears after BCI treatment in the partial-thickness cohort, with rates reported ranging from 0% to 18%. Two of the included studies found that BCI was cost-effective due to the increased tendon healing, with cost savings of $5,338 to $13,061 per healed rotator cuff tendon. CONCLUSIONS: The literature on rotator cuff tear augmentation with BCI has shown consistently reported good results. Additionally, there was evidence of low retear rates and consistently improved tendon thickness with BCI, with 2 randomized controlled trials showing improved tendon healing with BCI. However, there appears to be a higher rate of adhesive capsulitis reported. LEVEL OF EVIDENCE: Level IV, systematic review of Level I, III, and IV studies.

Posterior Shoulder Instability, Part I-Diagnosis, Nonoperative Management, and Labral Repair for Posterior Shoulder Instability-An International Expert Delphi Consensus Statement.

PURPOSE: To establish consensus statements on the diagnosis, nonoperative management, and labral repair for posterior shoulder instability. METHODS: A consensus process on the treatment of posterior shoulder instability was conducted, with 71 shoulder/sports surgeons from 12 countries participating on the basis of their level of expertise in the field. Experts were assigned to 1 of 6 working groups defined by specific subtopics within posterior shoulder instability. Consensus was defined as achieving 80% to 89% agreement, whereas strong consensus was defined as 90% to 99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. RESULTS: Unanimous agreement was reached on the indications for nonoperative management and labral repair, which include whether patients had primary or recurrent instability, with symptoms/functional limitations, and whether there was other underlying pathology, or patient's preference to avoid or delay surgery. In addition, there was unanimous agreement that recurrence rates can be diminished by attention to detail, appropriate indication and assessment of risk factors, recognition of abnormalities in glenohumeral morphology, careful capsulolabral debridement and reattachment, small anchors with inferior placement and multiple fixation points that create a bumper with the labrum, treatment of concomitant pathologies, and a well-defined rehabilitation protocol with strict postoperative immobilization. CONCLUSIONS: The study group achieved strong or unanimous consensus on 63% of statements related to the diagnosis, nonoperative treatment, and labrum repair for posterior shoulder instability. The statements that achieved unanimous consensus were the relative indications for nonoperative management, and the relative indications for labral repair, as well as the steps to minimize complications for labral repair. There was no consensus on whether an arthrogram is needed when performing advanced imaging, the role of corticosteroids/orthobiologics in nonoperative management, whether a posteroinferior portal is required. LEVEL OF EVIDENCE: Level V, expert opinion.

Posterior Shoulder Instability, Part II-Glenoid Bone Grafting, Glenoid Osteotomy, and Rehabilitation/Return to Play-An International Expert Delphi Consensus Statement.

PURPOSE: To establish consensus statements on glenoid bone grafting, glenoid osteotomy, rehabilitation, return to play, and follow-up for posterior shoulder instability. METHODS: A consensus process on the treatment of posterior shoulder instability was conducted, with 71 shoulder/sports surgeons from 12 countries participating on the basis of their level of expertise in the field. Experts were assigned to 1 of 6 working groups defined by specific subtopics within posterior shoulder instability. Consensus was defined as achieving 80% to 89% agreement, whereas strong consensus was defined as 90% to 99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. RESULTS: All of the statements relating to rehabilitation, return to play, and follow-up achieved consensus. There was unanimous consensus that the following criteria should be considered: restoration of strength, range of motion, proprioception, and sport-specific skills, with a lack of symptoms. There is no minimum time point required to return to play. Collision athletes and military athletes may take longer to return because of their greater risk for recurrent instability, and more caution should be exercised in clearing them to return to play, with elite athletes potentially having different considerations in returning to play. The relative indications for revision surgery are symptomatic apprehension, multiple recurrent instability episodes, further intra-articular pathologies, hardware failure, and pain. CONCLUSIONS: The study group achieved strong or unanimous consensus on 59% of statements. Unanimous consensus was reached regarding the criteria for return to play, collision/elite athletes having different considerations in return to play, indications for revision surgery, and imaging only required as routine for those with glenoid bone grafting/osteotomies at subsequent follow-ups. There was no consensus on optimal fixation method for a glenoid bone block, the relative indications for glenoid osteotomy, whether fluoroscopy is required or if the labrum should be concomitantly repaired. LEVEL OF EVIDENCE: Level V, expert opinion.

Glenohumeral morphological predictors of recurrent shoulder instability following arthroscopic Bankart repair.

PURPOSE: The purpose of this study was to evaluate glenohumeral morphological features on a magnetic resonance arthrogram (MRA) to determine risk factors for recurrence of anterior shoulder instability following arthroscopic Bankart repair (ABR). METHODS: A retrospective review of patients who underwent ABR between 2012 and 2017 was performed to identify patients who had recurrence of instability following stabilisation (Group 1). These were pair-matched in a 2:1 ratio for age, gender and sport with a control (Group 2) who underwent ABR without recurrence. Preoperative MRAs were evaluated for risk factors for recurrence, with glenoid bone loss and Hill-Sachs lesions also measured. Multilinear and multilogistic regression models were used to evaluate factors affecting recurrence. RESULTS: Overall, 72 patients were included in this study, including 48 patients without recurrence and 24 patients with recurrent instability. There was a significant difference between the two groups in mean glenoid bone loss (Group 1: 7.3% vs. Group 2: 5.7%, p < 0.0001) and the rate of off-track Hill-Sachs lesions (Group 1: 20.8% vs. Group 2: 0%, p = 0.0003). Of the variables analysed in logistic regression, increased glenoid anteversion (p = 0.02), acromioclavicular (AC) degeneration (p = 0.03) and increased Hill-Sachs width were associated with increased risk of failure. Increased chondral version (p = 0.01) and humeral head diameter in the anteriorposterior view were found to be protective and associated with a greater likelihood of success. CONCLUSION: Glenoid anteversion was a risk factor for recurrent instability, whereas increased chondral version and humeral head diameter were associated with higher rates of success following ABR. Glenoid bone loss, presence of an off-track Hill-Sachs lesion, increased Hill-Sachs width and AC degeneration were also associated with failure. These findings should be used by surgeons to stratify risk for recurrence following ABR. LEVEL OF EVIDENCE: Level III.

Defining pseudoparalysis and pseudoparesis: a consensus study.

BACKGROUND: The purpose of this study was to establish consensus statements via a modified Delphi process on the definition of shoulder pseudoparalysis and pseudoparesis. METHODS: A consensus process on the definition of a diagnosis of pseudoparalysis utilizing a modified Delphi technique was conducted, and 26 shoulder/sports surgeons from 11 countries, selected based on their level of expertise in the field, participated in these consensus statements. Consensus was defined as achieving 80%-89% agreement, whereas strong consensus was defined as 90%-99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. RESULTS: Three statements regarding the diagnosis of pseudoparalysis reached strong (>89%) consensus: passive range of motion should be unaffected, the passive range of abduction should not be considered, and diagnosis should be excluded if lidocaine injection produces a substantial improvement in range of motion. Additionally, consensus (>79%) was reached that the active range of external rotation should not be considered for diagnosis, pain as a cause of restricted motion must be excluded, and that distinctions between restricted active flexion and external rotation should be made by range of motion rather than tear characteristics. No consensus could be reached on statements regarding the size, number of tendons or chronicity of cuff tears. Nor was there agreement on the active range of flexion permitted or on the difference between pseudoparalysis and pseudoparesis. CONCLUSION: A modified Delphi process was utilized to establish consensus on the definition of shoulder pseudoparalysis and pseudoparesis. Unfortunately, almost half of the statements did not reach consensus, and agreement could not be reached across all domains for a unifying definition for the diagnosis of pseudoparalysis in the setting of rotator cuff tears. Furthermore, it was not agreed how or whether pseudoparalysis should be differentiated from pseudoparesis. Based on the lack of a consensus for these terms, studies should report explicitly how these terms are defined when they are used.

Radiographic comparison of eccentric stemmed vs. concentric stemless prosthetic humeral head positioning after anatomic total shoulder arthroplasty.

INTRODUCTION: Maintaining premorbid proximal humeral positioning is an essential consideration of anatomic total shoulder arthroplasty (aTSA), as malposition of the prosthetic humeral head can result in poor clinical outcomes. Stemless aTSA prosthetic heads are usually concentric, while stemmed aTSA prosthetic heads are typically eccentric in nature. Therefore, the purpose of this study was to compare the ability to restore native humeral head position between stemmed (eccentric) vs. stemless (concentric) aTSA. MATERIALS AND METHODS: Postoperative anteroposterior radiographs of 52 stemmed and 46 stemless aTSAs were analyzed. A best-fit circle was created using previously published and validated techniques to represent the premorbid humeral head position and axis of rotation. This circle was juxtaposed with another circle following the arc of the implant head. Next, the offset in center of rotation (COR), radius of curvature (RoC), and humeral head height above the greater tuberosity (HHH) were measured. Additionally, based on prior studies, an offset of >3 mm at any point between the implant head surface and premorbid best-fit circle was considered significant and further classified as overstuffed or understuffed. RESULTS: RoC deviation was significantly greater in the stemmed cohort than the stemless cohort (1.19 ± 1.37 mm vs. 0.65 ± 1.17 mm, P = .025). There was no statistically significant difference in deviation from premorbid humeral head between the stemmed and stemless cohorts for COR (3.20 ± 2.28 mm vs. 3.23 ± 2.09 mm, P = .800) or HHH (1.12 ± 3.27 mm vs. 0.92 ± 2.70 mm, P = .677). When comparing overstuffed implants to appropriately placed implants, there was a significant difference in overall COR deviation in stemmed implants (3.93 ± 2.51 mm vs. 1.92 ± 1.05 mm, P < .001). Superoinferior COR deviation (stemmed: 2.38 ± 3.01 mm vs. -0.61 ± 1.59 mm, P < .001; stemless: 2.70 ± 1.75 mm vs. -0.16 ± 1.87 mm, P < .001), mediolateral COR deviation (stemmed: 0.79 ± 2.65 mm vs. -0.62 ± 1.27 mm, P = .020; stemless: 0.40 ± 1.41 mm vs. -1.13 ± 1.96 mm, P = .020), and HHH (stemmed: 3.61 ± 2.73 mm vs. 0.50 ± 1.31 mm, P < .001; stemless: 3.98 ± 1.18 mm vs. 0.53 ± 1.41 mm, P < .001) were significantly different between overstuffed implants and appropriate implants in both the stemmed and stemless cohorts. DISCUSSION: Stemless and stemmed aTSA implants have similar rates of reproducing satisfactory postoperative humeral head COR with both producing COR deviation most commonly in the superomedial direction. Deviation in HHH contributes to overstuffing in both stemmed and stemless implants, COR deviation contributes to overstuffing in stemmed implants, while RoC (humeral head size) is not associated with overstuffing. Based on this study, it appears that neither eccentric nor concentric prosthetic heads are superior in recreating premorbid humeral head position.

Complications following arthroscopic Bankart repair: a systematic review.

BACKGROUND: Complications are rare after arthroscopic Bankart repair, and as a result, there is a lack of guidance over rates of complications that can be used to consent patients. The purpose of this study is to systematically review the literature to assess the complications after arthroscopic Bankart repair, other than recurrent instability. METHODS: A literature search of MEDLINE, Embase, and the Cochrane Library was performed based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Clinical studies reporting on the complications after arthroscopic Bankart repair were included. RESULTS: A total of 194 studies were included in the analysis, with 13,979 patients and 14,019 shoulders undergoing arthroscopic Bankart repair. The overall complication rate was 0.67%, with frozen shoulder being the most common complication occurring in 0.32%. Persistent pain occurred in 0.17%. The rates of nerve, hardware, and wound complications were 0.07%, 0.05%, and 0.03%, respectively. CONCLUSION: The arthroscopic Bankart repair has a very low rate of complications. Frozen shoulder and persistent pain are the most frequently encountered complications.

Complications Following Intramedullary Nailing of Proximal Humerus and Humeral Shaft Fractures - A Systematic Review.

HYPOTHESIS: The purpose of this study was to systematically review complications arising from intramedullary nailing (IMN) of proximal and humeral shaft fractures. This study hypothesized that there would be a low rate of complications and revision among patients treated with IMN for humerus fractures. METHODS: Two independent reviewers performed a literature search in the PubMed database based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if they reported on outcomes following the use of intramedullary nails for proximal humerus fractures or humeral shaft fractures. Variables that were collected included complications, Visual Analogue Scale (VAS) pain scores, and revision operations. RESULTS: Overall, 179 studies met the inclusion criteria, with 7984 shoulders. The average age of patients in this study was 55.2 years and 60.7% of patients were female. The mean follow-up was 16.6 months. The overall complication rate for all fractures treated with intramedullary nails was 18.9%, and the overall revision rate was 6.8%. Among the complications were fracture complications (7.5%), hardware complications (7.2%), soft tissue complications (1.8%), neurovascular complications (1.6%), and infection (0.8%). 4-part proximal humerus fractures (52.9%) and open fractures (36.7%) had the highest rates of complication. Among the reasons for revision were hardware removal or replacement (5.0%), conversion to arthroplasty (0.6%), and other (1.2%). The mean VAS pain score at last follow-up was 1.6. CONCLUSION: Overall, there was a moderate rate of complications but low rate of revision following IMN of humerus fractures. Open fractures and 4-part proximal humerus fractures had the highest complication rates.

Clinical outcomes in prospective versus retrospective studies on arthroscopic Bankart repair: a systematic review.

BACKGROUND: The majority of the current literature on arthroscopic Bankart repair is retrospective, and discrepancies exist regarding clinical outcomes including recurrent instability and return to play among studies of different levels of evidence. PURPOSE: The purpose of this study is to perform a systematic review of the literature to compare the outcomes of prospective and retrospective studies on arthroscopic Bankart repair. METHODS: A search was performed using the PubMed/Medline database for all studies that reported clinical outcomes on Bankart repair for anterior shoulder instability. The search term "Bankart repair" was used, with all results being analyzed via strict inclusion and exclusion criteria. Three independent investigators extracted data and scored each included study based on the 10 criteria of the Modified Coleman Methodology Score out of 100. A χ2 test was performed to assess if recurrent instability, revision, return to play, and complications are independent of prospective and retrospective studies. RESULTS: A total of 193 studies were included in the analysis, with 53 prospective studies and 140 retrospective in design. These studies encompassed a total of 13,979 patients and 14,019 surgical procedures for Bankart repair for shoulder instability. The rate of redislocation in the prospective studies was 8.0% vs. 5.9% in retrospective studies (P < .001). The rate of recurrent subluxation in the prospective studies was 3.4% vs. 2.4% in retrospective studies (P = .004). The rate of revision was higher in retrospective studies at 4.9% vs. 3.9% in prospective studies (P = .013). There was no significant difference in terms of overall rate to return to play between prospective and retrospective studies (90% and 91%, respectively; P = .548). The overall rate of non-instability complications in the prospective cohort was 0.27% vs. 0.78% in the retrospective studies (P = .002). CONCLUSIONS: The overall rates of recurrent dislocations-subluxations are higher in prospective studies than retrospective studies. However, rates of revision were reportedly higher in retrospective studies. Complications after arthroscopic Bankart repair are rare in both prospective and retrospective studies, and there was no difference in rates of return to play.