The Global Track Concept for Assessment of Engaging Hill-Sachs Defects in Anterior Shoulder Instability.

BACKGROUND: The glenoid track concept is used to determine preoperatively whether a Hill-Sachs defect is engaging or not. Currently, the glenoid track concept relies on measurements of bony structures as well as on the confines and elasticity of the rotator cuff as a reference point, which varies extensively among individuals and therefore limits the reliability and accuracy of this concept. PURPOSE: To evaluate the reliability of the global track concept, which determines the angular distance of the Hill-Sachs defect from the center of the articular surface of the humeral head as a new reference point with the help of an automated image analysis software and 3-dimensional analysis of the humeral head. STUDY DESIGN: Controlled laboratory study. METHODS: Computed tomography scans of 100 patients treated for anterior shoulder instability with different sizes of Hill-Sachs defects were evaluated manually by 2 orthopaedic surgeons independently using the software OsiriX as well as automatically by using a dedicated prototype software (ImFusion). Obtained manual and automated measurements included the Hill-Sachs length, Hill-Sachs width, and Hill-Sachs depth of the defect; the Hill-Sachs interval (HSI); and the glenoid width for the glenoid track concept, as well as the angular distance of the Hill-Sachs defect from the center of the articular surface of the humeral head (global track concept). The reliability of the different measurement techniques was compared by calculating intraclass correlation coefficients (ICCs). RESULTS: There was a significant difference for all obtained parameters comparing manual and automatic measurements. For manually obtained parameters, measurements referring to bony boundaries (glenoid width, Hill-Sachs length, and Hill-Sachs width) showed good to excellent agreement (ICC, 0.86, 0.82, and 0.62, respectively), while measurements referring to soft tissue boundaries (HSI and glenoid track; ICC, 0.56 and 0.53, respectively) or not directly identifiable reference points (center of articular surface and global track) only showed fair reliability (ICC middle excursion, 0.42). When the same parameters were measured with the help of an automated software, good reliability for the glenoid track concept and excellent reliability for the global track concept in the middle excursion were achieved. CONCLUSION: The present study showed that the more complex global track measurements of humeral defects are more reliable than the current standard HSI and glenoid track measurements. However, this is only true when automated software is used to perform the measurements. CLINICAL RELEVANCE: Future studies using the new proposed method in combination with an automated software need to be conducted to determine critical threshold values for defects prone to engagement.

Exploring temporal trends and burden of traumatic shoulder dislocation: a global perspective.

Objective: To explore the geographical and temporal trends of traumatic shoulder dislocation, describe the association between the social and demographic factors and the health burden due to traumatic shoulder dislocation, and further investigate its causes. Methods: Data on traumatic shoulder dislocation was collected from the Global Burden of Disease 2019, spanning the years 1990 to 2019. The epidemiology and disease burden were examined at global, regional, and national levels. Additionally, the age and gender patterns were analyzed, followed by an investigation into the primary causes. Lastly, the study studied the correlation between age-standardized rates and the socio-demographic index (SDI). Results: Over a span of 30 years, both the crude and age-standardized rates of incidence and years lived with disability (YLDs) rates for all genders displayed a slight fluctuating downward trend. The incidence and YLDs rates in males were consistently higher than those in females. The study analyzed both incidence and YLDs rates of the global, regional, and national of traumatic shoulder dislocations from 1990 to 2019, as well as the temporal trends. Among males, the highest incidence rate was observed in young adulthood, while females exhibited the highest incidence rate in old age. This pattern was mirrored in the YLDs rate. Falls were identified as the main cause contributing to the disease burden related to traumatic shoulder dislocations. Moreover, a positive correlation was found between the age-standardized rates and SDI. Conclusion: The disease burden of traumatic shoulder dislocation has not significantly decreased from 1990 to 2019. The incidence and YLD rates are associated with age, gender, and SDI. A thorough examination of the disease burden contributes to the efficient allocation and utilization of resources, as well as the development of targeted and effective intervention strategies.

Acute rehabilitation following traumatic anterior shoulder dislocation (ARTISAN): pragmatic, multicentre, randomised controlled trial.

OBJECTIVE: To assess the effects of an additional programme of physiotherapy in adults with a first-time traumatic shoulder dislocation compared with single session of advice, supporting materials, and option to self-refer to physiotherapy. DESIGN: Pragmatic, multicentre, randomised controlled trial (ARTISAN). SETTING AND PARTICIPANTS: Trauma research teams at 41 UK NHS Trust sites screened adults with a first time traumatic anterior shoulder dislocation confirmed radiologically, being managed non-operatively. People were excluded if they presented with both shoulders dislocated, had a neurovascular complication, or were considered for surgical management. INTERVENTIONS: One session of advice, supporting materials, and option to self-refer to physiotherapy (n=240) was assessed against the same advice and supporting materials and an additional programme of physiotherapy (n=242). Analyses were on an intention-to-treat basis with secondary per protocol analyses. MAIN OUTCOME MEASURES: The primary outcome was the Oxford shoulder instability score (a single composite measure of shoulder function), measured six months after treatment allocation. Secondary outcomes included the QuickDASH, EQ-5D-5L, and complications. RESULTS: 482 participants were recruited from 40 sites in the UK. 354 (73%) participants completed the primary outcome score (n=180 allocated to advice only, n=174 allocated to advice and physiotherapy). Participants were mostly male (66%), with a mean age of 45 years. No significant difference was noted between advice compared with advice and a programme of physiotherapy at six months for the primary intention-to-treat adjusted analysis (between group difference favouring physiotherapy 1.5 (95% confidence interval -0.3 to 3.5)) or at earlier three month and six week timepoints. Complication profiles were similar across the two groups (P>0.05). CONCLUSIONS: An additional programme of current physiotherapy is not superior to advice, supporting materials, and the option to self-refer to physiotherapy. TRIAL REGISTRATION: Current Controlled Trials ISRCTN63184243.

Long-term Effectiveness and Outcome-Determining Factors of Arthroscopic Bankart Repair for Recreational Sports Population: An Assessment of 100 Patients With a Mean Follow-up of 12.7 Years.

BACKGROUND: A limited number of studies have reported the long-term effectiveness of and associated factors for recurrence of anterior shoulder instability after arthroscopic Bankart repair (ABR). PURPOSE: To report the long-term clinical outcomes after ABR in a recreational sports population and identify the associated factors that influence the final instability status. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective study was performed in patients treated with ABR between 2007 and 2013 by a single surgeon. Patient data, magnetic resonance imaging measurements of bone loss and glenoid track, and intra- and perioperative factors were analyzed. After a minimum follow-up of 10 years, patient-reported outcomes including the Western Ontario Shoulder Instability Index score, the Rowe score, the visual analog scale for pain and function, the American Shoulder and Elbow Surgeons score, and sports activity were assessed. The current instability status was classified into 3 groups: stable, apprehensive, and redislocated. These groups were statistically compared with respect to outcomes and associated factors. RESULTS: A total of 100 patients with a mean age of 22.4 ± 5.5 years and a mean follow-up of 12.7 ± 2.1 years were included. At the final follow-up, 38 patients (38%) showed recurrent symptoms: 19 patients (19%) with subjective apprehension and 19 patients (19%) with redislocation, including 10 patients (10%) with revision surgery. At the final follow-up, the redislocated group showed the lowest patient-reported outcomes and return to sports (both P < .001). The apprehensive group also showed a lower Western Ontario Shoulder Instability Index score (P = .011), Rowe score (P = .003), American Shoulder and Elbow Surgeons score (P = .027), and return to sports (P = .005) than the stable group. Participation in contact sports (P = .026), glenoid bone loss (P = .005), size of Hill-Sachs lesion (P = .009), and off-track lesions (P = .016) were all associated with recurrent symptoms, whereas age <20 years (P = .012), participation in contact sports (P = .003), and off-track lesions (P = .042) were associated with redislocation. CONCLUSION: After long-term follow-up in a recreational sports population, ABR demonstrated a 19% rate of subjective apprehension and 19% rate of redislocation, with a gradual decline in clinical outcomes and sports activity over time. Therefore, candidates for ABR should be selected based on consideration of risk factors such as off-track lesions, age <20 years, and participation in contact sports.

The V angle compliments radiographic assessment of acute acromioclavicular joint dislocations by differentiating between Rockwood types III versus V and by considering dynamic horizontal translation in coronal radiographs.

PURPOSE: Acromioclavicular joint (ACJ) dislocations are usually graded radiographically according to Rockwood, but differentiation between Rockwood types III and V may be ambiguous. The potentially clinically relevant horizontal instability is barely addressed in coronal radiographs. It was hypothesized that a new radiologic parameter (V angle) would complement ACJ diagnostics on anteroposterior radiographs by differentiating between cases of Rockwood III and V while also considering the aspect of dynamic horizontal translation (DHT). METHODS: Ninety-five patients with acute ACJ dislocations (Rockwood types III and V) were included retrospectively between 2017 and 2020. On anteroposterior views (weightbearing: n = 62, non-weight-bearing: n = 33), the coracoclavicular (CC) distance and the newly introduced V angle for assessing scapular orientation were measured bilaterally. This angle is referenced between the spinal column and a line crossing the superior scapular angle and the crossing point between the supraspinatus fossa and the medial base of the coracoid process, reported as the side-comparative difference (non-injured side *minus* injured side). DHT on Alexander views was divided into stable, partially unstable or completely unstable. RESULTS: The V angle on the injured side alone (mean 50.0°; 95% confidence interval (CI), 48.6°-51.3°) showed no correlation with the side-comparative CC distance [%] (r = - 0.040; n.s.). Thus, the V angle on the non-injured side was considered, displaying a normal distribution (n.s.) with a mean of 58.0° (95% CI, 56.6°-59.4°). The side-comparative V angle showed a correlation with the side-comparative CC distance (r = 0.83; p < 0.001) and was able to differentiate between Rockwood types III (4.7°; 95% CI, 3.9°-5.5°; n = 39) and V (10.3°; 95% CI, 9.7°-11.0°; n = 56) (p < 0.001). A cut-off value of 7° had a 94.6% sensitivity and an 82.1% specificity (area under curve, AUC: 0.954; 95% CI, 0.915-0.994). The side-comparative V angle was greater for cases with complete DHT (8.7°; 95% CI, 7.9°-9.5°; n = 78) than for cases with partial DHT (4.8°; 95% CI, 3.3°-6.3°; n = 16) (p < 0.001). A cut-off value of 5° showed a sensitivity of 84.6% and a specificity of 66.7% (AUC 0.824; 95% CI, 0.725-0.924). CONCLUSION: The scapular-based V angle on anteroposterior radiographs distinguishes between Rockwood types III and V as well as cases with partial or complete DHT. STUDY DESIGN: Diagnostic study. LEVEL OF EVIDENCE: Level II.

Glenoid Track Assessment at Imaging in Anterior Shoulder Instability: Rationale and Step-by-Step Guide.

Anterior shoulder dislocation is the most common form of joint instability in humans, usually resulting in soft-tissue injury to the glenohumeral capsuloligamentous and labral structures. Bipolar bone lesions in the form of fractures of the anterior glenoid rim and posterolateral humeral head are often associated with anterior shoulder dislocation and can be a cause or result of recurrent dislocations. Glenoid track assessment is an evolving concept that incorporates the pathomechanics of anterior shoulder instability into its management. Currently widely endorsed by orthopedic surgeons, this concept has ramifications for prognostication, treatment planning, and outcome assessment of anterior shoulder dislocation. The glenoid track is the contact zone between the humeral head and glenoid during shoulder motion from the neutral position to abduction and external rotation. Two key determinants of on-track or off-track status of a Hill-Sachs lesion (HSL) are the glenoid track width (GTW) and Hill-Sachs interval (HSI). If the GTW is less than the HSI, an HSL is off track. If the GTW is greater than the HSI, an HSL is on track. The authors focus on the rationale behind the glenoid track concept and explain stepwise assessment of the glenoid track at CT or MRI. Off-track to on-track conversion is a primary goal in stabilizing the shoulder with anterior instability. The key role that imaging plays in glenoid track assessment warrants radiologists' recognition of this concept along with its challenges and pitfalls and the production of relevant and actionable radiology reports for orthopedic surgeons-to the ultimate benefit of patients. ©RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

Clavicular hook plate versus dog-bone technique for acute high-grade acromioclavicular joint dislocation: a retrospective cohort study comparing clinical outcome scores, complications, and costs.

INTRODUCTION: Arthroscopically assisted coracoclavicular (CC) ligament fixation techniques have been promoted as providing superior outcomes for the treatment of acute high-grade acromioclavicular joint (ACJ) dislocations. Nevertheless, there is a lack of high-level evidence for clinically relevant benefits. At our institute, orthopaedic surgeons use an arthroscopically assisted coracoclavicular ligament fixation technique (DB), while general trauma surgeons use a clavicular hook plate (cHP) technique. The aim of the study was to compare clinical outcomes, complication rates, and costs between the two groups. MATERIALS AND METHODS: The hospital database was searched for patients treated for acute traumatic high-grade (Rockwood Typ ≥ III) ACJ dislocation using either a cHP or arthroscopically assisted DB technique between 2010 and 2019. Seventy-nine patients could be included (56 patients in the cHP group and 23 in the DB group). QuickDASH scores, subjective shoulder value (SSV) scores, pain scores (numerical pain rating scale 10), and complication rates were retrospectively collected through phone interviews and by screening patient charts as well as surgical reports. Costs per patient were obtained from the hospital's accounting system. RESULTS: Mean follow-up was 54 ± 33.7 and 45 ± 21.7 months in the cHP and DB group, respectively. QuickDASH and SSV scores did not differ, but patients in the cHP group reported significantly lower pain scores (p = 0.033). More patients reported hypertrophic or disturbing scars (p = 0.49) and sensibility disturbances (p = 0.007) in the cHP group. Three patients suffered from a frozen shoulder in the DB group (p = 0.023). CONCLUSION: Patient-reported outcomes are excellent after long-term follow-up for both techniques. There are no clinically relevant differences in clinical outcome scores based on our results and a review of the literature. Both techniques certainly have their benefits regarding secondary outcome measures. LEVEL OF CLINICAL EVIDENCE: Level 3, retrospective cohort study.

Cost-effectiveness analysis of arthroscopic Bankart repair versus open Latarjet reconstruction in anterior shoulder instability.

PURPOSE: The ideal surgical treatment for anterior shoulder instability is still under debate. In the healthcare setting, both clinical and economic factors must be considered for optimal resource allocation. From the clinical perspective, the Instability Severity Index Score (ISIS) is a helpful and validated tool for surgeons, although a gray area between 4 and 6 exists. In fact, patients with an ISIS < 4 and > 6 can be treated effectively with arthroscopic Bankart repair and open Latarjet, respectively. The purpose of this study was to conduct a cost-effectiveness analysis of arthroscopic Bankart repair versus open Latarjet in patients with an ISIS between 4 and 6. METHODS: A decision-tree model was constructed to simulate the clinical scenario of an anterior shoulder dislocation patient with an ISIS between 4 and 6. Based on previously published literature, outcome probabilities and utility values in the form of Western Ontario Instability Score (WOSI) were assigned to each branch of the tree, alongside institutional cost. The primary outcome assessed was an Incremental cost-effectiveness ratio (ICER) of the two procedures. Eden-Hybbinette was also considered in the model as a salvage procedure for failed Latarjet. A two-way sensitivity analysis was performed to identify the most impactful parameters on the ICER upon their variation within a pre-determined interval. RESULTS: Base case cost was 1245.57 € (1220.48-1270.65 €) for arthroscopic Bankart repair, 1623.10 € (1580.82-1665.39 €) for open Latarjet and 2.373.95 € (1940.81-2807.10 €) for Eden-Hybbinette. Base-case ICER was 9570.23 €/WOSI. Sensitivity analysis showed that the most impactful parameters were the utility of arthroscopic Bankart repair, the probability of success of open Latarjet, the probability of undergoing surgery after post-operative recurrence of instability and the utility of Latarjet. Of these, utility of arthroscopic Bankart repair and Latarjet had the most significant impact on the ICER. CONCLUSION: From a hospital perspective, open Latarjet was more cost-effective than arthroscopic Bankart repair in preventing further shoulder instability in patients with an ISIS between 4 and 6. Despite its several limitations, this is the first study to analyze this subgroup of patients from a European hospital setting from both an economic and clinical perspective. This study can help surgeons and administrations in the decision-making process. Further clinical studies are needed to prospectively analyze both aspects to further delineate the best strategy.

A 2-Year Follow-up May Not be Enough to Accurately Evaluate Recurrences After Arthroscopic Bankart Repair: A Long-term Assessment of 272 Patients With a Mean Follow-up of 10.5 Years.

BACKGROUND: There is a great discrepancy between the rates of recurrent instability reported after arthroscopic Bankart repair in relation to the follow-up time. PURPOSE: To analyze the rate of recurrences after arthroscopic Bankart repair in the long term, emphasizing whether a minimum follow-up of 2 years is adequate to assess this outcome. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between January 2008 and April 2013, a total of 356 athletes underwent arthroscopic Bankart repair for anterior glenohumeral instability at our institution. Return to sports, the Rowe score, the Subjective Shoulder Value (SSV), and the Athletic Shoulder Outcome Scoring System (ASOSS) were used to assess functional outcomes. We analyzed the proportion of recurrences before and after 4 years of follow-up. Additionally, we performed a Kaplan-Meier analysis to evaluate recurrence-free time in patients with a recurrence. RESULTS: The mean follow-up was 10.5 ± 1.6 years, and the mean age was 20.8 ± 3.9 years. In total, 90% of patients were able to return to sports; of these, 91% returned to their preinjury level of play. The Rowe, SSV, and ASOSS scores showed a statistical improvement after surgery (P < .01). The proportion of patients with a recurrence during the follow-up period was 25% (95% CI, 20%-31%; n = 70), and the mean time until a recurrence was 3.8 ± 2.6 years. Only 39% of the recurrences (95% CI, 30%-48%) occurred in the first 2 years after surgery, while 61% (95% CI, 50%-73%) occurred in the first 4 years after surgery. CONCLUSION: In our study, the effectiveness of Bankart repair to stabilize the shoulder decreased significantly over time. Indeed, less than half of the recurrences occurred after 2 years of follow-up. Therefore, we propose that the recommended minimum follow-up should be 4 years; otherwise, it is very likely that the actual rate of recurrences will be significantly underestimated.

[Assessment of Clinical Outcomes of Surgically Treated Rockwood Type III Acromioclavicular Dislocation with or without Coracoclavicular Ligament Suture]. / Zhodnocení klinických výsledku operacne resených akromioklavikulárních luxací typu Rockwood III se suturou ci bez sutury korakoklavikulárního vazu.

PURPOSE OF THE STUDY Acromioclavicular (AC) joint dislocation and its surgical treatment still raises a number of questions that remain to be answered. In some types of dislocations, Rockwood type III in particular, the indication for surgical treatment as such is relative. There are numerous techniques and implants available for the reconstruction of AC joint. In our research we focused on the necessity of coracoclavicular (CC) joint reconstruction. MATERIAL AND METHODS In this paper, a cohort of 56 patients with Rockwood type III AC joint injury who underwent surgical treatment at our department in 2010-2016 period was retrospectively evaluated. The patients were treated with open reduction with AC joint stabilisation using hook plate or tension band. The patients were divided into 2 groups, namely group 1 with CC ligament reconstruction and group 2 without CC ligament reconstruction. The assessment was done at 6 months, 1 year and 2 years after surgery. The clinical outcomes were assessed based on the absolute Constant score (CS) and coracoclavicular distance (CCD) on the X-ray. Subsequently, the outcomes were statistically processed and compared using the Student s ttest. RESULTS The least invasive surgical intervention, as to the length of incision, was the reconstruction using the hook plate without CC ligament suture, whereas the longest incision was performed in tension band with CC ligament suture. In the CC ligament suture group, the mean operative time was 10 minutes longer. When evaluating the CS of the compared groups with and without CC ligament reconstruction, no statistically significant difference (p > 0.05) was found between the two groups. Similarly, the CCD values at 2-year follow-up did not show any statistically significant difference between the two groups (p > 0.05). CONCLUSIONS The available outcomes suggest that the surgical methods used by us are adequately safe and reliable. Good clinical outcomes can be achieved by open reduction and fixation of Rockwood type III AC joint dislocation even without CC ligament reconstruction. Key words: acromioclavicular dislocation, classification, reconstruction, coracoclavicular ligament.

Development of a single-session physiotherapy and self-management intervention for the treatment of primary traumatic anterior shoulder dislocation for the 'Acute Rehabilitation following Traumatic anterior shoulder dISlocAtioN (ARTISAN)' multi centre RCT.

OBJECTIVE: Optimum physiotherapy management for people with a conservatively managed primary traumatic anterior shoulder dislocation is not known. The purpose of the ARTISAN trial is to compare the clinical and cost-effectiveness of a course of usual care physiotherapy with a single session of physiotherapy and self-management, the ARTISAN intervention. ARTISAN is a UK multi-centre, two-arm, parallel group, randomised controlled trial with 1:1 treatment allocation. DESIGN: The intervention was developed following the Medical Research Council framework for developing and evaluating complex interventions and will be reported in line with the template for intervention description and replication checklist (TIDieR) and the Consensus on Exercise Reporting Template (CERT). It was informed by published research, national clinical guidelines, current clinical practice and patient and public involvement. RESULTS: The ARTISAN intervention comprises education (Phase 1), progressive exercise (Phase 2 and Phase 3) and an optional return to sport component (Phase 4). Behaviour change strategies are embedded throughout intervention. The single session of physiotherapy is delivered by a chartered physiotherapist, within the first six weeks of injury, in an NHS outpatient setting. At the end of the initial session, paper-based booklets and/or a patient website with the same content are provided to participants to aid self-management and progression though the four phases of the trial intervention. CONCLUSION: The ARTISAN intervention was successfully implemented throughout the internal pilot and is suitable for testing in the subsequent definitive RCT ARTISAN trial. Trial Registration Number ISRCTN63184243.

Arthroscopic Versus Open Anterior Shoulder Stabilization: A Prospective Randomized Clinical Trial With 15-Year Follow-up With an Assessment of the Glenoid Being "On-Track" and "Off-Track" as a Predictor of Failure.

BACKGROUND: Recent studies have demonstrated equivalent short-term results when comparing arthroscopic versus open anterior shoulder stabilization. However, none have evaluated the long-term clinical outcomes of patients after arthroscopic or open anterior shoulder stabilization, with inclusion of an assessment of preoperative glenoid tracking. PURPOSE: To compare long-term clinical outcomes of patients with recurrent anterior shoulder instability randomized to open and arthroscopic stabilization groups. Additionally, preoperative magnetic resonance imaging (MRI) studies were used to assess whether the shoulders were "on-track" or "off-track" to ascertain a prediction of increased failure risk. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A consecutive series of 64 patients with recurrent anterior shoulder instability were randomized to receive either arthroscopic or open stabilization by a single surgeon. Follow-up assessments were performed at minimum 15-year follow-up using established postoperative evaluations. Clinical failure was defined as any recurrent dislocation postoperatively or subjective instability. Preoperative MRI scans were obtained to calculate the glenoid track and designate shoulders as on-track or off-track. These results were then correlated with the patients' clinical results at their latest follow-up. RESULTS: Of 64 patients, 60 (28 arthroscopic and 32 open) were contacted or examined for follow-up (range, 15-17 years). The mean age at the time of surgery was 25 years (range, 19-42 years), while the mean age at the time of this assessment was 40 years (range, 34-57 years). The rates of arthroscopic and open long-term failure were 14.3% (4/28) and 12.5% (4/32), respectively. There were no differences in subjective shoulder outcome scores between the treatment groups. Of the 56 shoulders, with available MRI studies, 8 (14.3%) were determined to be off-track. Of these 8 shoulders, there were 2 surgical failures (25.0%; 1 treated arthroscopically, 1 treated open). In the on-track group, 6 of 48 had failed surgery (12.5%; 3 open, 3 arthroscopic [P = .280]). CONCLUSION: Long-term clinical outcomes were comparable at 15 years postoperatively between the arthroscopic and open stabilization groups. The presence of an off-track lesion may be associated with a higher rate of recurrent instability in both cohorts at long-term follow-up; however, this study was underpowered to verify this situation.

Anterior Glenohumeral Instability: Systematic Review of Outcomes Assessment Used in Brazil / Anterior Glenohumeral Instability: Systematic Review of Outcomes Assessment Used in Brazil

Abstract A review involving the six major international orthopedic journals has been published recently. It described the tools used for the evaluation of outcomes in the surgical treatment of recurrent anterior dislocation of the shoulder. There are no studies that exhibit the main outcome tools for this disease in Brazil. The authors evaluated the outcomes of clinical studies involving anterior glenohumeral instability that were published in the last decade in the two leading Brazilian orthopedic journals, Revista Brasileira de Ortopedia and Acta Ortopédica Brasileira. A review of the literature was performed, including all clinical papers published between 2007 and 2016 describing at least one outcome measure before and after surgical intervention. The outcomes were range of motion, muscle strength, physical examination testing, patient satisfaction, return to sports, imaging, complications, and functional outcomes scores. Twelve studies evaluating the clinical outcomes of surgical treatment for anterior shoulder instability were published. Ten studies (83%) were case series (level of evidence IV), 1 (8%) was a case-control study (III), and 1 was a retrospective cohort (III). On average, the number of outcomes assessed was 3.7 ± 1.7. The Rowe score was used in 9 studies (75%), and 7 (58%) papers used the University of California Los Angeles (UCLA) scale. Ten studies (83%) reported complications related to surgical treatment. The complication most frequently reported was recurrent instability, found in 9 studies (75%). The national studies have preferentially used scales considered to be of low reliability, responsiveness, and internal consistency.

Resumo Uma revisão que envolveu as seis principais revistas ortopédicas internacionais foi publicada recentemente. A publicação descreveu as ferramentas usadas para a avaliação dos desfechos no tratamento cirúrgico da luxação anterior recidivante do ombro. Não existe um levantamento que mostre as principais formas de avaliação para essa doença no Brasil. Os autores avaliaram os desfechos usados nos estudos clínicos que envolveram a instabilidade glenoumeral anterior e que foram publicados na última década nos dois principais periódicos ortopédicos brasileiros, Revista Brasileira de Ortopedia e Acta Ortopédica Brasileira. Foi feita uma revisão da literatura na qual foram incluídos todos os artigos clínicos publicados entre 2007 e 2016 que descreveram ao menos uma medida de desfecho antes e após intervenção cirúrgica. Os desfechos avaliados foram amplitude de movimento, força muscular, testes de exame físico, satisfação, retorno ao esporte, exames de imagem, complicações e escalas clínicas. Foram publicados 12 estudos que avaliaram os resultados clínicos do tratamento cirúrgico da instabilidade anterior do ombro. Dez estudos (83%) eram séries de caso (nível de evidência IV), 1 (8%) caso-controle (III), e 1 coorte retrospectiva (III). A média de desfechos avaliados por estudo foi de 3,7 ± 1,7. A escala Rowe foi usada em 9 estudos (75%), e 7 publicações (58%) usaram a escala da University of California Los Angeles (UCLA). Dez estudos (83%) relataram as complicações relacionadas ao tratamento cirúrgico. A complicação mais frequentemente relatada foi a recidiva da luxação glenoumeral, encontrada em 9 estudos (75%). Os estudos nacionais usaram preferencialmente escalas consideradas de baixa conficabilidade, responsividade, e consistência interna.

Does Medicaid expansion improve access to care for the first-time shoulder dislocator?

BACKGROUND: The purpose of this study was to assess the effect of individual state Medicaid expansion status on access to care for shoulder instability. METHODS: Four pairs of Medicaid expanded (Louisiana, Kentucky, Iowa, and Nevada) and unexpanded (Alabama, Virginia, Wisconsin, and Utah) states in similar geographic locations were chosen for the study. Twelve practices from each state were randomly selected from the American Orthopedic Society for Sports Medicine directory, resulting in a sample size of 96 independent sports medicine offices. Each office was called twice to request an appointment for a fictitious 16-year-old first-time shoulder dislocator with either in-state Medicaid insurance or Blue Cross Blue Shield (BCBS) private insurance. RESULTS: A total of 91 physician offices in 8 states were contacted by telephone. An appointment was obtained at 36 (39.6%) offices when calling with Medicaid and at 74 (81.3%) offices when calling with BCBS (P < .001). Thirty-five (38.5%) offices were able to make appointments for both types of insurance, 39 (42.9%) for only BCBS, 1 (1.1%) for only Medicaid, and 16 (17.5%) for neither. For Medicaid patients, an appointment was booked in 13 (27.7%) clinics from Medicaid expanded states and in 23 (52.3%) clinics from unexpanded states (P = .016). CONCLUSION: For a first-time shoulder dislocator, access to care is more difficult with Medicaid insurance compared with private insurance. Within Medicaid insurance, access to care is more difficult in Medicaid expanded states compared with unexpanded states. Medicaid patients in unexpanded states are twice as likely as those in expanded states to obtain an appointment.

Treatment of first-time traumatic anterior shoulder dislocation: the UK TASH-D cohort study.

BACKGROUND: Shoulder dislocations are the most common joint dislocations seen in emergency departments. Most traumatic cases are anterior and cause recurrent dislocations. Management options include surgical and conservative treatments. There is a lack of evidence about which method is most effective after the first traumatic anterior shoulder dislocation (TASD). OBJECTIVES: To produce UK age- and sex-specific incidence rates for TASD. To assess whether or not surgery within 6 months of a first-time TASD decreases re-dislocation rates compared with no surgery. To identify clinical predictors of recurrent dislocation. DESIGN: A population-based cohort study of first-time TASD patients in the UK. An initial validation study and subsequent propensity-score-matched analysis to compare re-dislocation rates between surgery and no surgery after a first-time TASD. Prediction modelling was used to identify potential predictors of recurrent dislocation. SETTING: UK primary and secondary care data. PARTICIPANTS: Patients with a first-time TASD between 1997 and 2015. INTERVENTIONS: Stabilisation surgery within 6 months of a first-time TASD (compared with no surgery). Stabilisation surgery within 12 months of a first-time TASD was also carried out as a sensitivity analysis. MAIN OUTCOME MEASURE: Re-dislocation rate up to 2 years after the first TASD. METHODS: Eligible patients were identified from the Clinical Practice Research Datalink (CPRD) (1997-2015). Accuracy of shoulder dislocation coding was internally validated using the CPRD General Practitioner questionnaire service. UK age- and sex-specific incidence rates for TASD were externally validated against rates from the USA and Canada. A propensity-score-matched analysis using linked CPRD and Hospital Episode Statistics (HES) data compared re-dislocation rates for patients aged 16-35 years, comparing surgery with no surgery. Multivariable Cox regression models for predicting re-dislocation were developed for the surgical and non-surgical cohorts. RESULTS: Shoulder dislocation was coded correctly for 89% of cases in the CPRD [95% confidence interval (CI) 83% to 95%], with a 'primary' dislocation confirmed for 76% of cases (95% CI 67% to 85%). Far fewer patients than expected received stabilisation surgery within 6 months of a first TASD, leading to an underpowered study. Around 20% of re-dislocation rates were observed for both surgical and non-surgical patients. The sensitivity analysis at 12 months also showed little difference in re-dislocation rates. Missing data on risk factors limited the value of the prediction modelling; however, younger age, epilepsy and sex (male) were identified as statistically significant predictors of re-dislocation. LIMITATIONS: Far fewer than the expected number of patients had surgery after a first-time TASD, resulting in an underpowered study. This and residual confounding from missing risk factors mean that it is not possible to draw valid conclusions. CONCLUSIONS: This study provides, for the first time, UK data on the age- and sex-specific incidence rates for TASD. Most TASD occurs in men, but an unexpected increased incidence was observed in women aged > 50 years. Surgery after a first-time TASD is uncommon in the NHS. Re-dislocation rates for patients receiving surgery after their first TASD are higher than previously expected; however, important residual confounding risk factors were not recorded in NHS primary and secondary care databases, thus preventing useful recommendations. FUTURE WORK: The high incidence of TASD justifies investigation into preventative measures for young men participating in contact sports, as well as investigating the risk factors in women aged > 50 years. A randomised controlled trial would account for key confounders missing from CPRD and HES data. A national TASD registry would allow for a more relevant data capture for this patient group. STUDY REGISTRATION: Independent Scientific Advisory Committee (ISAC) for the Medicines and Healthcare Products Regulatory Agency (ISAC protocol 15_0260). FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Traumatic anterior shoulder dislocation (TASD) happens when the top of the arm bone is forced frontwards out of the shoulder socket. After a TASD, the shoulder joint can become 'unstable' and keep dislocating. The main treatments are surgery or physiotherapy; however, we do not know which treatment is best at stopping more dislocations. Two large NHS computer databases were studied to assess this problem. This has allowed us to produce information on the extent of this problem in the UK. We also looked for any differences in the number of people who suffered more shoulder dislocations when treated with either surgery or no surgery. The results showed that young men aged 16­20 years and women aged > 50 years suffer the most with this problem. In young people, the cause is thought to be due to sports injuries. These findings in women aged > 50 years are new and suggest that further research is needed to discover what puts them at a greater risk of TASD. When patients who had surgery and those who did not were compared, there appeared to be no difference in the number of people suffering a re-dislocation. Although, overall, this might suggest that surgery after only one dislocation does not have any extra benefit in preventing more dislocations, this research discovered that important information used to help decide on whether or not surgical treatment is needed is not reported in the databases. Some patients may be at a greater risk of more dislocations than other patients based on risk factors, such as sport and occupation, and this information is not recorded in the NHS databases. Therefore, the research question cannot be answered by studying these NHS databases and so other methods, such as a research trial or a custom database built especially for shoulder dislocation patients, would be needed.

Clinical outcomes and radiologic assessment of a modified suture button arthroscopic Latarjet procedure.

BACKGROUND: As several neurologic and hardware complications have been reported with screw fixation. Suture buttons are used to serve as an alternative to screw fixation to obtain better outcome and to reduce the complication. The purpose of this study was to observe the clinical outcomes and make the radiologic assessment of a modified suture button (MSB) arthroscopic Latarjet procedure. METHODS: A total of ninty-one patients with recurrent shoulder joint dislocation who underwent MSB arthroscopic Latarjet procedure was retrospectively reviewed. Fifty cases identified from the chart review met the inclusion criteria. The clinical outcomes and position of the grafts, glenohumeral degeneration, and graft healing condition were assessed postoperatively in a follow-up with at least one and half of a year. RESULTS: All the fifty patients were satisfied with their clinical outcome. The overall complication rate was 4% in this study. The mean visual analog scale score, the affected shoulder active mobility in Ers(external rotation at the side), Era(external rotation in abduction) decreased significantly; the ASES score, Rowe score, Walch-Duplay score improved significantly. CT scans in the sagittal view showed that grafts in 88% of cases were in good position, grafts in 12% of cases were fixed too superiorly and inferiorly. In the axial view grafts in forty cases were flush with the glenoid rim, ten were considered as too lateral. The ten grafts became remodeled and were more flush with the glenoid rim in the follow-up. CONCLUSIONS: The MSB arthroscopic Latarjet procedure provides excellent outcome with few complications, and no degenerative changes were observed in the follow-up. Moreover, the graft fixed too laterally presented a phenomenon of remodeling and became flush with the glenoid rim over time.