A high level of scientific evidence is available to guide treatment of primary shoulder stiffness: The SIAGASCOT consensus.

PURPOSE: Shoulder stiffness (SS) is a condition characterised by active and passive restricted glenohumeral range of motion, which can occur spontaneously in an idiopathic manner or be associated with a known underlying aetiology. Several treatment options are available and currently no consensus has been obtained on which treatment algorithm represents the best choice for the patient. Herein we present the results of a national consensus on the treatment of primary SS. METHODS: The project followed the modified Delphi consensus process, involving a steering, a rating and a peer-review group. Sixteen questions were generated and subsequently answered by the steering group after a thorough literature search. A rating group composed by professionals specialised in the diagnosis and treatment of shoulder pathologies rated the question-answer sets according to the scientific evidence and their clinical experience. RESULTS: Recommendations were rated with an average of 8.4 points out of maximum 9 points. None of the 16 answers received a rating of less than 8 and all the answers were considered as appropriate. The majority of responses were assessed as Grade A, signifying a substantial availability of scientific evidence to guide treatment and support recommendations encompassing diagnostics, physiotherapy, electrophysical agents, oral and injective medical therapies, as well as surgical interventions for primary SS. CONCLUSIONS: A consensus regarding the conservative and surgical treatment of primary SS could be achieved at a national level. This consensus sets basis for evidence-based clinical practice in the management of primary SS and can serve as a model for similar initiatives and adaptable guidelines in other European countries and potentially on a global scale. LEVEL OF EVIDENCE: Level I.

Glenoid track revisited.

The risk of Hill-Sachs lesion (HSL) to cause instability depends not only on the HSL but also on the glenoid size. Clinically, the only method to assess the risk of instability considering the dynamic interaction of both, the HSL together with the glenoid bone loss, is the glenoid track concept. Since it was introduced in a cadaveric study, its clinical efficacy and validity have been reported in the literature. Sometimes, the medial margin of the footprint (lateral margin of the glenoid track) is difficult to identify when a HSL is overriding the footprint. In such cases, we propose a method to draw an imaginary line connecting 2 landmarks. Although 3-dimensional computed tomography is the most accurate and widely used method to assess on/off-track lesions, our interest gradually is shifting toward magnetic resonance imaging (MRI), which has no radiation concern. The current magnetic resonance method is still under way. There are various risk factors influencing the recurrent instability after surgery. The glenoid track concept deals with only 1 of these factors, that is, instability caused by bony lesions. Therefore, the following 2 issues are important: 1) how to assess the glenoid track precisely and 2) how to incorporate other risk factors into consideration. The former can be achieved by obtaining the custom-made glenoid track width using not the fixed value of 83%, but more individualized value obtained by measuring the active horizontal extension angle of the opposite shoulder in the sitting position. At the same time, the gray zone (peripheral-track lesion) needs to be clearly defined. The latter can be achieved by incorporating the risk factors other than the bony lesions. One example is the Glenoid Track Instability Management Score (GTIMS), a combination of the glenoid track concept and the instability severity index score. This new scoring system is expected to increase the predictive potential of the scoring system, and accordingly to enhance clinical decision-making.

Optimizing Muscle-Tendon Lengths in Reverse Total Shoulder Arthroplasty: Evaluation of Surgical and Implant-Design-Related Parameters.

BACKGROUND: Optimizing the function of muscles that cross the glenohumeral articulation in reverse total shoulder arthroplasty (RTSA) is controversial. The current study used a geometric model of the shoulder to systematically examine surgical placement and implant-design parameters to determine which RTSA configuration most closely reproduces native muscle-tendon lengths of the deltoid and rotator cuff. METHODS: A geometric model of the glenohumeral joint was developed and adjusted to represent small, medium, and large shoulders. Muscle-tendon lengths were assessed for the anterior deltoid, middle deltoid, posterior deltoid, and supraspinatus from 0 to 90° of scaption; for the subscapularis from 0° to 60° of internal rotation (IR) and 0° to 60° of scaption; for the infraspinatus from 0° to 60° of external rotation (ER) and 0° to 60° of scaption; and for the teres minor from 0° to 60° of ER at 90° of scaption. RTSA designs were virtually implanted using the following parameters: (1) surgical placement with a centered or inferior glenosphere position and a humeral offset of 0, 5, or 10 mm relative to the anatomic neck plane, (2) implant design involving a glenosphere size of 30, 36, or 42 mm, glenosphere lateralization of 0, 5, or 10 mm, and humeral neck-shaft angle of 135°, 145°, or 155°. Thus, 486 RTSA-shoulder size combinations were analyzed. Linear regression assessed the strength of association between parameters and the change in each muscle-tendon length from the native length. RESULTS: The configuration that most closely restored anatomic muscle-tendon lengths in a small shoulder was a 30-mm glenosphere with a centered position, 5 mm of glenoid lateralization, 0 mm of humeral offset, and a 135° neck-shaft angle. For a medium shoulder, the corresponding combination was 36 mm, centered, 5 mm, 0 mm, and 135°. For a large shoulder, it was 30 mm, centered, 10 mm, 0 mm, and 135°. The most important implant-design parameter associated with restoration of native muscle-tendon lengths was the neck-shaft angle, with a 135° neck-shaft angle being favored (ß = 0.568 to 0.657, p < 0.001). The most important surgical parameter associated with restoration of native muscle-tendon lengths was humeral offset, with a humeral socket placed at the anatomic neck plane being favored (ß = 0.441 to 0.535, p < 0.001). CONCLUSIONS: A combination of a smaller, lateralized glenosphere, a humeral socket placed at the anatomic neck plane, and an anatomic 135° neck-shaft angle best restored native deltoid and rotator cuff muscle-tendon lengths in RTSA. CLINICAL RELEVANCE: This study of surgical and implant factors in RTSA highlighted optimal configurations for restoration of native muscle-tendon lengths of the deltoid and rotator cuff, which has direct implications for surgical technique and implant selection. Additionally, it demonstrated the most influential surgical and implant factors with respect to muscle-tendon lengths, which can be used to aid intraoperative decision-making.

Cirurgia Assistida por Computador - Relato de caso clínico / Computer-Assisted Surgery - A clinical report

O sucesso das reabilitações orais suportadas por implantes requer um planejamento protético e cirúrgico cuidadoso. Recentemente sistemas computacionais associados à tecnologia de prototipagem rápida são utilizados como uma importante ferramenta otimizando os resultados e reduzindo o tempo cirúrgico. Neste processo primeiramente confecciona-se uma guia radiográfica com objetivo de transferir as informações protéticas e do contorno gengival para a tomografia computadorizada (TC). Os dados da TC são abertos em software de planejamento cirúrgico onde podemos visualizar tridimensionalmente as coroas nos espaços protéticos. Conciliando esta informação com a imagem do relevo ósseo instalam-se virtualmente os implantes. Baseado neste projeto confecciona-se a guia cirúrgica pela técnica de prototipagem rápida (PR) adequada a cirurgia sem retalho gengival. Este artefato direciona as fresas cirúrgicas durante as perfurações dos tecidos. Relataremos um caso clínico com a instalação de três implantes utilizando cirurgia sem retalho gengival, software de planejamento cirúrgico e guia cirúrgica em prototipagem rápida.