Arthroscopic Bankart Repair With Remplissage in Comparison to Bone Block Augmentation for Anterior Shoulder Instability With Bipolar Bone Loss: A Systematic Review.

PURPOSE: The purpose of this systematic review is to examine the rates of postoperative recurrence of instability, functional outcomes, and complications after treatment with bone augmentation procedures or arthroscopic Bankart repair with remplissage for recurrent anterior shoulder instability in the setting of subcritical glenoid bone loss. METHODS: EMBASE, PubMed, and MEDLINE were searched from database inception until June 2019 for articles examining either bone block augmentation to the glenoid or Bankart repair with remplissage (BRR) in the setting of subcritical glenoid bone loss. Search and data extraction were performed by 2 reviewers independently and in duplicate. A separate analysis was done for comparative studies. RESULTS: Overall, 145 studies were identified, including 4 comparative studies. Across all studies, postoperative recurrence rates ranged from 0% to 42.8% for bone block augmentation and 0% to 15% for Bankart repair with remplissage. In comparative studies reporting subcritical glenoid bone loss, rates were 5.7% to 11.6% in the Latarjet group and 0% to 13.3% in the Bankart repair with remplissage group. However, in all studies reporting 10% to 15% mean glenoid bone loss, there was an increased rate of recurrent instability with arthroscopic soft tissue repair (6.1% to 13.2%) in comparison with bony augmentation (0% to 8.2%). Lastly, complication rates ranged from 0% to 66.7% for the bone block group and 0% to 2.3% for arthroscopic Bankart repair with remplissage. CONCLUSION: Both bone block augmentation and Bankart repair with remplissage are effective treatment options for recurrent anterior shoulder instability in patients with bipolar bone loss but subcritical glenoid bone loss. Both have comparable functional outcomes, albeit bone block procedures carry an increased risk of complications. Arthroscopic BRR may be associated with a higher failure rate for preoperative glenoid bone loss >10%. Therefore, it may represent a stabilization procedure best suited for cases of recurrent anterior instability with glenoid bone loss <10% and the presence of a significant, off-track Hill-Sachs lesion. LEVEL OF EVIDENCE: Level IV, systematic review of Level II-IV studies.

Primary arthroscopic repair of massive rotator cuff tears results in significant improvements with low rate of re-tear.

PURPOSE: To conduct a systematic review of outcomes following primary arthroscopic repair of chronic massive rotator cuff tears (RCTs) and to assess clinical outcomes and rates of repair failure. The authors' preferred treatment algorithm is also provided. METHODS: Medline, Embase and PubMed were searched identifying articles pertaining to primary arthroscopic repair of chronic massive RCTs without the use of augmentation. Primary outcomes were patient-reported outcomes and the secondary outcome was the rate of repair failure. Outcome data were pooled and presented as well as assessment of study methodological quality. Data from studies reporting similar outcome measures were pooled when possible, and mean differences alongside confidence intervals and p values were reported, where appropriate. RESULTS: Twenty-six studies (1405 participants) were included, with mean age of 62 years (range 52-69). The mean duration of symptoms pre-operatively was 31 months (range 6-40), and the mean follow-up time was 39 months (range 12-111). Complete repair was performed in 78% of patients and partial repair was performed in 22%. Both complete and partial repairs resulted in significant improvements with respect to pain, range of motion and functional outcome scores. The rate of repair failure for the total cohort was 36% at a mean follow-up of 31 months, and for the complete and partial repair subgroups the failure rate was 35% and 40%, respectively. CONCLUSIONS: Arthroscopic repairs of chronic, massive RCTs, whether complete or partial, are associated with significant improvements in pain, function and objective outcome scores. The rate of repair failure is lower than previously reported, however, still high at 36%. The present paper finds that arthroscopic repair is still a viable treatment option for massive RCTs. LEVEL OF EVIDENCE: IV.

The Role of Deltoid Ligament Repair in Ankle Fractures With Syndesmotic Instability: A Systematic Review.

Ankle fractures are the fourth most common fracture requiring surgical management. The deltoid ligament is a primary ankle stabilizer against valgus forces. It is frequently ruptured in ankle fractures; however, there is currently no consensus regarding repair. A systematic database search was conducted with Medline, PubMed, and Embase for relevant studies discussing patients with ankle fractures involving deltoid ligament rupture and repair. Screening, quality assessment, and data extraction were performed independently and in duplicate. Data extracted included pain, range of motion (ROM), function, medial clear space (MCS), syndesmotic malreduction, and complications. After screening, 9 eligible studies from 1990 to 2018 were included (N = 508). Compared to nonrepair groups, deltoid ligament repair patients had lower syndesmotic malreduction rates (0%-9% vs 20%-35%, p ≤ .05), fewer implant removals (5.8% vs 41% p ≤ .05), and longer operating time by 16-20 minutes (p ≤ .05). There was no significant difference for pain, function, ROM, MCS, and complication rate (p ≤ .05). In conclusion, deltoid ligament repair offers lower syndesmotic malreduction rates and reduced re-operation rates for hardware removal in comparison to trans-syndesmotic screws. Repair groups demonstrated equivalent or better outcomes for pain, function, ROM, MCS, and complication rates. Other newer syndesmotic fixation methods such as suture-button fixation require further evaluation when compared to the outcomes of deltoid ligament repair. A randomized control trial is required to further examine the outcomes of ankle fracture patients who undergo deltoid ligament repair versus trans-syndesmotic screw fixation.

Stemless anatomic total shoulder arthroplasty: a systematic review and meta-analysis.

BACKGROUND: Stemless anatomic total shoulder arthroplasty (TSA) is used in the treatment of osteoarthritis of the shoulder joint and other degenerative shoulder diseases. It has several proposed advantages over stemmed TSA including increased bone preservation, decreased operative time, and easier removal at revision. METHODS: A systematic search was conducted using MEDLINE, Embase, PubMed, and CENTRAL (Cochrane Central Register of Controlled Trials) to retrieve all relevant studies. RESULTS: The literature search yielded 1417 studies, of which 22 were included in this review, with 962 patients undergoing stemless TSA. Stemless TSA led to significant improvements in range of motion and functional scores in all included studies. Meta-analysis of comparative studies between stemless and stemmed TSA identified no significant differences in postoperative Constant scores (mean difference [MD], 1.26; 95% confidence interval [CI], -3.29 to 5.81 points; P = .59) or complication rates (odds ratio, 1.79; 95% CI, 0.71-4.54; P = .22). Stemless TSA resulted in a significantly shorter operative time compared with stemmed TSA (MD, -15.03 minutes; 95% CI, -23.79 to -6.26 minutes; P = .0008). Stemless TSA also resulted in significantly decreased intraoperative blood loss compared with stemmed TSA (MD, -96.95 mL; 95% CI, -148.53 to -45.36 mL; P = .0002). CONCLUSION: Stemless anatomic TSA resulted in similar functional outcomes and complication rates to stemmed TSA with decreased operative time and lower blood loss. Further research is required to investigate the long-term durability of the stemless implant.

Reverse total shoulder arthroplasty in the younger patient (≤65 years): a systematic review.

The purpose of this study was to evaluate outcomes of reverse total shoulder arthroplasty (RTSA) in patients aged ≤65 years. MEDLINE, Embase, and PubMed were searched for relevant studies from database inception to September 18, 2018. All studies that evaluated RTSA in patients aged ≤65 years were included. Two independent reviewers screened all studies and performed a quality assessment. In the total of 6 studies reviewed, 245 participants underwent RTSA, with the most common indications being failed rotator cuff repair and rotator cuff tear arthropathy. Postoperative functional outcomes indicated a significant level of improvement across all reported outcomes at a mean follow-up of 49 months (range, 19-140 months) (P < .05). The pooled mean complication rate was 18% (n = 44/245), and this higher rate may be due to 36% of patients undergoing an RTSA for a failed arthroplasty procedure and the inclusion of older studies that lacked modern implants and techniques. Although there is a significant improvement in functional outcomes at midterm follow-up for RTSA in the patients aged ≤65 years, the pooled complication rates are high. However, the results of this systematic review are limited because of the heterogenous patient population undergoing surgery for various indications, including revision arthroplasty. Long-term studies and registry data are required using current modern techniques and implants to provide an accurate assessment of outcomes following RTSA in a young patient population.

Indications and outcomes of simultaneous high tibial osteotomy and ACL reconstruction.

PURPOSE: The purpose of this study was to systematically review the existing literature reporting surgical outcomes of simultaneous high tibial osteotomy (HTO) and anterior cruciate ligament reconstruction (ACLR) in anterior cruciate ligament deficient (ACLD) knees. METHODS: This study was conducted per the methods of the Cochrane Handbook for Systematic Reviews of Intervention, with findings reported per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The electronic databases MEDLINE, EMBASE, and PubMed were searched for relevant studies and pertinent data was extracted. Studies reporting post-operative outcomes following simultaneous HTO and ACLR in ACLD knees were included. RESULTS: The search identified 515 studies, of which 18 (n = 516) were included. The mean MINORS scores for non-comparative and comparative studies were 11.6 ± 1.34 and 17.3 ± 1.9, respectively. Simultaneous HTO and ACLR resulted in improved functional subjective patient outcomes across a variety of scales. Simultaneous HTO and ACLR was effective in correcting varus angulation, with the post-operative mechanical angle ranging from 0.3° valgus to 7.7° valgus. The reported complication rate ranged from 0 to 23.5%. Across six studies, a total of 13 (6.5%) patients required revision HTO; while across four studies, 20 (17.5%) patients had failure of the ACL graft, with one receiving revision ACLR. CONCLUSIONS: Combined HTO and ACLR may be indicated in patients with ACLD knees with varus angulation. This systematic review found that the combined surgery resulted in significant improvement in post-operative functional subjective outcomes. However, it remains unclear if HTO with ACLR is superior to ALCR or HTO alone due to the lack of comparative studies. Overall, HTO with ACLR was found to have low rates of complications, re-ruptures, and need for revision surgery. This review found that patients continued to have progression of OA despite combined HTO with ACLR. Future research is required to better understand the effects of combined HTO and ACLR compared to ACLR or HTO alone and to evaluate the long-term post-operative progression of medial compartment OA following combined HTO and ACLR. LEVEL OF EVIDENCE: IV.

Outcomes of hyaluronic acid injections for glenohumeral osteoarthritis: a systematic review and meta-analysis.

BACKGROUND: Hyaluronic acid (HA) is an analgesic and chondroprotective agent often used for the nonoperative treatment of osteoarthritis (OA). The effects of HA injections are well studied in the treatment of knee OA, but the effects in glenohumeral OA remain unclear. This study evaluated the efficacy of HA to reduce pain in patients with glenohumeral OA. METHODS: PubMed, MEDLINE, CENTRAL, and Embase were searched from the database inception date through January 16, 2018. Two reviewers independently screened articles for eligibility and extracted data for analysis. A methodological quality assessment was completed for all included studies, including assessment of risk of bias. The primary outcome was change in visual analog scale for pain. The secondary outcomes were functional outcome and adverse events. RESULTS: In the HA arm, the reduction of visual analog scale pain score at 3 months was 26.2 mm (95% confidence interval, 22.0-30.3 mm; I2 = 31%) and at 6 months was 29.5 mm (95% confidence interval, 25.5-33.4 mm; I2 = 19%). All studies reported an improvement in functional outcome. Similar clinical improvements were reported in the intervention and control groups, suggesting that these improvements may not be directly related to HA. Commonly reported adverse events were rare and included swelling and mild pain at the injection site, local effusion, lethargy, and face rash. CONCLUSION: Intra-articular HA injection is safe and improves pain for patients with glenohumeral OA. Pain improvements also reported in the control group suggest that a significant placebo effect may be present with respect to intra-articular shoulder injection. Further randomized controlled trials are necessary to evaluate the efficacy of HA and identify optimal dosing and route of administration.

Heterotopic ossification after total elbow arthroplasty: a systematic review.

BACKGROUND: Heterotopic ossification (HO) is a known complication that can arise after total elbow arthroplasty (TEA). In most cases, it is asymptomatic; however, in some patients, it can limit range of motion and lead to poor outcomes. The objective of this review was to assess and report the incidence, risk factors, prophylaxis, and management of HO after TEA. METHODS: A systematic search was conducted using MEDLINE, Embase, and PubMed to retrieve all relevant studies evaluating the occurrence of HO after TEA. The search was performed in duplicate, and a quality assessment of all included studies was performed. RESULTS: A total of 1907 studies were retrieved, of which 45 were included involving 2256 TEA patients. HO was radiographically present in 10% of patients and was symptomatic in 3%. Fewer than 1% of patients went on to undergo surgical excision of HO, with outcomes after surgery reported as good or excellent as assessed by range of motion and the Mayo Elbow Performance Score. HO appears more likely to develop in patients undergoing TEA because of ankylosis, primary osteoarthritis, and distal humeral fractures. Surgical intervention is more likely to be required in patients in whom HO develops after TEA performed for ankylosis and post-traumatic osteoarthritis. CONCLUSION: HO is an uncommon complication after TEA, with most patients in whom HO develops being asymptomatic and requiring no surgical management. Routine HO prophylaxis for TEA is not supported by the literature. The effectiveness of prophylaxis in high-risk patients is uncertain, and future studies are required to clarify its usefulness.

Return to Sport and Clinical Outcomes After Surgical Management of Acromioclavicular Joint Dislocation: A Systematic Review.

PURPOSE: To evaluate the rate at which athletes return to sport after surgical management of acute and chronic acromioclavicular (AC) joint dislocations. METHODS: Three databases-PubMed, MEDLINE, and EMBASE-were searched from database inception until October 28, 2017, by 2 reviewers independently and in duplicate. The inclusion criteria were English language studies that reported return to sport outcomes in patients undergoing surgical management of AC joint dislocations. RESULTS: Overall, 12 studies with a combined total of 315 patients met the inclusion criteria, with a mean age of 33.8 years (range, 18-65 years) and a mean follow-up of 34.9 months (range, 6-126 months). Of the 12 included studies, 1 was a prospective comparative study (Level II), 1 was a retrospective comparative study (Level III), 1 was a prospective case series (Level IV), and 9 were retrospective case series (Level IV). The rates of return to any level of sport ranged from 94% to 100% (I2 = 0%), whereas the rates of return to the preinjury level of sport ranged from 62% to 100% (I2 = 61%). The pooled rate of return to preinjury level of sport in type V AC joint separations was 86.2% (95% confidence interval = 68.1%-98.0%), whereas that after type III or IV AC joint injuries was 89.6% (95% confidence interval = 79.9%-96.9%). CONCLUSIONS: An almost perfect rate of return to sport participation after surgical management of AC joint dislocations have been reported, with most returning to their preinjury level of sport. The rates of return to sport were comparable across the different types of injuries and surgical procedures. LEVEL OF EVIDENCE: Level IV, systematic review of Level II, III, and IV investigations.

Humeral Retroversion and Capsule Thickening in the Overhead Throwing Athlete: A Systematic Review.

PURPOSE: To investigate the humeral and soft-tissue adaptations, including humeral retroversion, range of motion, and posterior capsule changes, in overhead throwing athletes. METHODS: We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. PubMed, MEDLINE, CENTRAL (Cochrane Central Register of Controlled Trials), and Embase were searched from January 1, 2011, through April 23, 2017, by 2 reviewers independently and in duplicate. The methodologic quality of all included articles was assessed using the Methodological Index for Non-randomized Studies criteria. Interobserver agreement for assessments of eligibility was calculated with the Cohen κ statistic. Descriptive statistics and raw counts were used to summarize data. RESULTS: We identified 14 studies (6 Level IV and 8 Level III) including 1,152 overhead throwing athletes. The mean age of the included athletes was 18.37 years (standard deviation, 1.52 years), with 59% of the athletes being pitchers and 41% being position players. Significantly greater humeral retroversion was found across all studies evaluating bony morphology in the dominant arm of overhead throwing athletes (range of mean differences, 9.6°-25.8°). Each of these studies also found decreased internal rotation in the dominant arm (range of mean internal rotation differences, -28° to -7.8°). Five studies found a significant negative correlation between the difference in humeral retroversion between the 2 arms and the difference in internal rotation (range of Pearson correlation coefficients, -0.56 to -0.35). Soft-tissue adaptations were assessed in 5 studies, with 4 identifying significantly thicker posterior capsules and 2 identifying significantly stiffer posterior capsules (P < .05). CONCLUSIONS: Overhead throwing athletes consistently show several distinct changes in their dominant shoulder. These include increased humeral retroversion and the presence of a thickened and stiff posterior capsule. Concomitantly, there is often reduced internal rotation and increased external rotation of the dominant arm. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

The development of vaccination perspectives among chiropractic, naturopathic and medical students: a case study of professional enculturation.

An important influence on parents' decisions about pediatric vaccination (children under 6 years of age) is the attitude of their health care providers, including complementary and alternative medicine (CAM) providers. Very limited qualitative research exists, however, on how attitudes towards vaccination develop among healthcare professionals in-training. We explored perspective development among three groups of students: medical, chiropractic, and naturopathic. We conducted focus group sessions with participants from each year of study at three different healthcare training programs in Ontario, Canada. Semi-structured and open-ended questions were used to elicit dynamic interaction among participants and explore how they constructed their attitudes toward vaccination at the beginning and part way through their professional training. Analyses of verbatim transcripts of audiotaped interviews were conducted both inductively and deductively using questions structured by existing literature on learning, professional socialization and interprofessional relations. We found five major themes and each theme was illustrated with representative quotes. Numerous unexpected insights emerged within these themes, including students' general open-mindedness towards pediatric vaccination at the beginning of their training; the powerful influence of both formal education and informal socialization; uncritical acceptance of the vaccination views of senior or respected professionals; students' preference for multiple perspectives rather than one-sided, didactic instruction; the absence of explicit socio-cultural tensions among professions; and how divergences among professional students' perspectives result from differing emphases with respect to lifestyle, individual choice, public health and epidemiological factors-rather than disagreement concerning the biomedical evidence. This last finding implies that their different perspectives on pediatric vaccination may be complementary rather than irreconcilable. Our findings should be considered by developers of professional and interprofessional educational curricula and public health officials formulating policy on pediatric vaccination.

Forearm compartment syndrome as a result of eosinophilic fasciitis: case report.

Eosinophilic fasciitis is an uncommon scleroderma-like connective tissue disease, usually characterized by symmetrical and painful swelling and induration of the skin and thickened fascia infiltrated with lymphocytes and eosinophils. A middle-aged woman with follicular lymphoma being treated with chemotherapy presented with acute onset atraumatic forearm swelling and severe pain. The history, physical examination, and pressure measurements were consistent with compartment syndrome. Intraoperative biopsy of the forearm fascia confirmed eosinophilic fasciitis.

Radiographic assessment of prosthetic humeral head size after anatomic shoulder arthroplasty.

BACKGROUND: Restoring the premorbid proximal humeral anatomy during shoulder arthroplasty is critical yet can be difficult because of the deformity of the arthritic head. The purpose of this study was to measure the variation between surgeons and between types of prosthetics in reproducing the anatomic center of rotation (COR) of the humeral head after anatomic shoulder arthroplasty. METHODS: The anteroposterior radiographs of 125 stemmed and 43 resurfacing shoulder arthroplasties, performed by 5 experienced surgeons, were analyzed. All patients had primary replacement for treatment of end-stage glenohumeral arthritis. A best-fit circle to preserved nonarticular humeral landmarks was used to define the difference between the anatomic COR and the prosthetic COR. A difference in COR of >3.0 mm was considered clinically significant and analyzed for the cause of this deviation. RESULTS: The average deviation of the postoperative COR from the anatomic COR was 2.5 ± 1.6 mm for stemmed cases and 3.8 ± 2.1 mm for resurfacings. Thirty-nine stemmed cases (31.2%) and 28 resurfacings (65.1%) were beyond 3.0 mm of deviation and regarded as outliers. The majority of the stemmed outliers and all resurfacing outliers were overstuffed. An improper humeral head size selection and inadequate reaming were the main reasons for the deviation in stemmed and resurfacing outliers, respectively. CONCLUSION: A large percentage of shoulder replacements demonstrated significant deviations from an anatomic reconstruction. Resurfacing arthroplasty exhibited significantly greater deviations compared with stemmed arthroplasty (P < .001), indicating that surgeons have more difficulty in restoring the anatomy with resurfacings. Further studies are needed to assess the clinical impact of these deviations.

The effect of a coronoid prosthesis on restoring stability to the coronoid-deficient elbow: a biomechanical study.

PURPOSE: The coronoid process has been recognized as a critical component in maintaining elbow stability. In the case of comminuted coronoid fractures, where repair is not possible or has failed, a prosthesis may be beneficial in restoring the osseous integrity of the elbow joint. The hypothesis of this in vitro biomechanical study was that a coronoid prosthesis would restore stability to the coronoid-deficient elbow. METHODS: An anatomically shaped metallic coronoid prosthesis was designed and developed based on computed tomography-derived measurements and optimized to account for average cartilage thickness. Elbow kinematics and stability were determined for 8 cadaveric arms in active and passive elbow flexion in the varus, valgus, horizontal, and vertical positions using an elbow motion simulator. Varus-valgus angulation and internal-external rotation of the ulna relative to the humerus were quantified in the intact state, after collateral ligament sectioning and repair (control state), after a simulated 40% transverse coronoid fracture, and after implantation of the coronoid prosthesis. RESULTS: Internal rotation of the ulna increased with a 40% coronoid fracture in the horizontal and varus positions. Increases in varus angulation after coronoid fracture were also observed in the horizontal and varus positions, during active and passive flexion, respectively. Following implantation of the coronoid prosthesis, elbow kinematics were restored similar to control levels in all elbow positions. CONCLUSIONS: Our findings support our hypothesis that an anatomically shaped coronoid prosthesis would be effective in restoring stability to the coronoid-deficient elbow. CLINICAL RELEVANCE: This study provides evidence that the use of an anatomical implant restores stability to the coronoid-deficient elbow and rationale for further study and development of this method. For comminuted coronoid fractures, where repair is not possible or has failed, our research indicates that a prosthesis may be a feasible treatment option.

Selecting the diameter of a radial head implant: an assessment of local landmarks.

INTRODUCTION: Little information exists on radial head implant diameter sizing methods. When the native head is absent due to extensive comminution or previous excision, the lesser sigmoid notch may be a useful landmark for sizing. We evaluated the reliability of native radial head measurements, and the lesser sigmoid notch, as landmarks for radial head implant diameter sizing. METHODS: We examined 27 fresh frozen ulnae and their corresponding radial heads. The maximum, minimum, and dish diameters of the radial heads were measured. A radial head implant diameter was selected based on the congruency of the trial implants with the radius of curvature of the lesser sigmoid notch. Intraobserver and interobserver reliability for all measurements and implant selection were assessed using intraclass correlation coefficients (ICC). Correlations between the native radial head measurements and the selected radial head implant diameter or the lesser sigmoid notch radius of curvature were assessed using the Pearson correlation coefficient (PCC). RESULTS: Radial head diameter measurements demonstrated strong to excellent intraobserver (ICC ≥ 0.75) and interobserver reliability (ICC ≥ 0.82). The lesser sigmoid notch sizing method showed poor interobserver reliability (ICC = 0.34). Only a moderate correlation was found between the native radial head and the lesser sigmoid notch (PCC ≤ 0.80) or the selected radial head implant size (PCC ≤ 0.59). CONCLUSION: Radial head diameter measurements showed excellent reliability, suggesting that the excised radial head, when available, should be used to select the implant diameter. The reliability of using the lesser sigmoid notch for sizing the diameter of radial head implants was only moderate, suggesting this is an unreliable landmark for implant diameter sizing.

Indications and outcomes of glenoid osteotomy for posterior shoulder instability: a systematic review.

Background: There is limited evidence examining glenoid osteotomy as a treatment for posterior shoulder instability. Methods: A search of Medline, Embase, PubMed and Cochrane Central Register of Controlled Trials was conducted from the date of origin to 28th November 2019. Nine out of 3,408 retrieved studies met the inclusion criteria and quality was assessed using the Methodological Index for Non-randomized Studies tool. Results: In 356 shoulders, the main indication for osteotomy was excessive glenoid retroversion (greater than or equal to approximately -10°). The mean preoperative glenoid version was -15° (range, -35° to -5°). Post-operatively, the mean glenoid version was -6° (range, -28° to 13°) and an average correction of 10° (range, -1° to 30°) was observed. Range of motion increased significantly in most studies and all standardized outcome scores (Rowe, Constant-Murley, Oxford instability, Japan Shoulder Society Shoulder Instability Scoring and mean shoulder value) improved significantly with high rates of patient satisfaction (85%). A high complication rate (34%, n = 120) was reported post-surgery, with frequent cases of persistent instability (20%, n = 68) and fractures (e.g., glenoid neck and acromion) (4%, n = 12). However, the revision rate was low (0.6%, n = 2). Conclusion: Glenoid osteotomy is an appropriate treatment for posterior shoulder instability secondary to excessive glenoid retroversion. However, the high rate of persistent instability should be considered when making treatment decisions.Level of Evidence: Systematic review; Level 4.

Reconstruction of the coronoid using an extended prosthesis: an in vitro biomechanical study.

BACKGROUND: When repair of comminuted coronoid fractures is not possible, prosthetic replacement may restore elbow stability. The purpose of this biomechanical study was to determine whether a coronoid implant with an extended tip would improve elbow stability compared with an anatomic prosthesis in the setting of collateral ligament insufficiency. MATERIALS AND METHODS: Passive elbow extension was performed in 7 cadaveric arms in the varus and valgus positions and active and passive extension in the horizontal position by use of an elbow motion simulator. Varus-valgus laxity of the ulna relative to the humerus was quantified with a tracking system with a native coronoid, a 40% coronoid deficiency, an anatomic prosthesis, and an extended prosthesis, with the collateral ligaments sectioned and repaired. RESULTS: Laxity significantly increased after a 40% coronoid deficiency with both repaired and sectioned collateral ligaments (P ≤ .01). With the ligaments repaired, there was no significant difference in laxity between the native coronoid, the anatomic implant, or the extended implant. Ligament sectioning alone produced severe instability, with a mean laxity of 42.75° ± 11.54° (P < .01). With insufficient ligaments, the anatomic prosthesis produced no change in laxity compared with the native coronoid, whereas the extended implant significantly reduced laxity by 21.56° ± 17.70° (P = .02). CONCLUSIONS: An anatomic coronoid implant with ligament repair restores stability to the coronoid-deficient elbow to intact levels. In the setting of ligament insufficiency, an extended implant improves stability relative to an anatomic implant, but the elbow remains significantly less stable than an intact elbow. Studies are needed to evaluate the feasibility of these designs.

Rehabilitation of the medial- and lateral collateral ligament-deficient elbow: an in vitro biomechanical study.

DESIGN: In vitro biomechanical research using an elbow motion simulator. INTRODUCTION: The optimal rehabilitation of elbow dislocations with medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries has not been defined. PURPOSE: To determine a safe rehabilitation protocol for elbow dislocations with MCL and LCL injuries. METHODS: Eight cadaveric elbows underwent simulated active and passive motions with the arm in multiple orientations. Varus-valgus angulation and internal-external rotation of the ulna relative to the humerus were quantified for the intact joint and with injured MCL and LCL. RESULTS: Active motion with injured MCL and LCL in the horizontal and vertical orientations resulted in kinematics similar to the intact elbow, whereas passive motion resulted in significant kinematic alterations. Marked elbow instability was noted in the varus and valgus orientations using both active and passive motion. CONCLUSIONS: Elbows with MCL and LCL injuries should be rehabilitated using active motion in the horizontal or vertical orientations. LEVEL OF EVIDENCE: Basic science research.

Hybrid Glenoid Designs in Anatomic Total Shoulder Arthroplasty: A Systematic Review.

Background: Hybrid glenoid components in total shoulder arthroplasty (TSA) utilize both polyethylene and metal components to provide short-term stability and long-term biologic fixation through bone ingrowth. Questions/Purpose: We sought to systematically review the literature for studies that assessed outcomes of TSA performed using hybrid glenoid components. Methods: PubMed, Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Embase were searched systematically for articles measuring clinical and patient-reported outcomes and rates of complication and revision following TSA using a hybrid glenoid component. Results: Seven studies with 593 shoulders were included in this review. The mean age of patients was 65 ± 1 years, and 46% of the population was male. Mean follow-up was 50 months (4.2 years). The overall complication rate was 7% and rate of revision was 2.5%; glenoid radiolucency was present in 33% of shoulders at mean follow-up of 50 months. Mean improvements in forward elevation, external rotation, internal rotation score, and abduction were 49°, 28°, 2 points, and 42°, respectively. Mean improvements in Constant, American Shoulder and Elbow Surgeons (ASES), and University of California, Los Angeles (UCLA) scores were 36 points, 52 points, and 17 points, respectively. Conclusion: Our review found that TSA using hybrid glenoid components results in low rates of complication and revision at early follow-up. Long-term studies are warranted to understand more fully the role of hybrid glenoid components in TSA.

Anatomic total shoulder arthroplasty in rheumatoid arthritis: A systematic review.

Purpose: Given the poor soft-tissue quality in rheumatoid arthritis patients, many believe that rheumatoid arthritis should be treated with reverse total shoulder arthroplasty (rTSA). The purpose of this paper is to systematically assess outcomes of anatomic total shoulder arthroplasty (aTSA) in rheumatoid arthritis to determine if aTSA remains a viable option. Methods: A comprehensive literature search was conducted identifying articles relevant to aTSA in the setting of rheumatoid arthritis with intact rotator cuff. Outcomes include clinical outcomes and rates of complication and revision. Results: Ten studies were included with a total of 279 shoulders with mean follow-up of 116 ± 69 months. The mean age was 68 ± 10 years. Survivorship was 97%, 97% and 89% at 5, 10 and 20 years, respectively. The overall complication rate was 9%. Radiolucency was present in 69% of patients, of which 34% were at risk of loosening at 79 months. The overall rate of revision was 8.4%. Studies generally reported clinically significant improvements in range of motion, Constant score and ASES score. Conclusion: aTSA in the rheumatoid patient results in improvements in range of motion and patient-reported outcomes. Rates of complications and survivorship are generally good in this population. However, it should be noted that there is significant heterogeneity in outcome reporting amongst the literature on this topic and that many studies fail to adequately report complication and revision rates. When compared to rTSA in patients with rheumatoid arthritis, evidence suggests that aTSA is still a viable treatment option despite the shift in utilization to rTSA.