A Comparison of Proximal Patellar Realignment vs. Medial Patellofemoral Ligament Reconstruction: A Review of the Literature.

¼ Patellar instability is challenging to address, and although there are many surgical options, proximal patellar realignment (PPR) and medial patellofemoral ligament (MPFL) reconstruction are both used-recently, the MPFL reconstruction has become more popularized.¼ Both procedures have demonstrated similar recurrent dislocation rates and rates of arthritic progression.¼ PPR is a cost-efficient procedure using just suture alone as compared with MPFL reconstruction, which uses different grafts and methods of fixation.¼ PPR has demonstrated durable results, with a lower overall complication rate, much of which is caused by the MPFL reconstruction having unique complications due to fixation methods.¼ The PPR is a beneficial procedure and should still be considered when dealing with patellar instability.

Whether the potential degree of cervical instability and cervical muscle degeneration in patients with cervical spondylosis radicular affect the efficacy of cervical traction.

To explore whether the potential instability of the cervical spine and cervical muscle degeneration in patients with cervical spondylotic radiculopathy (CSR) affect the efficacy of cervical traction, and whether cervical traction can aggravate the potential instability of the cervical spine. We divided the 113 recruited CRS patients into three groups based on the differences in horizontal displacement and abnormal angle, and measured the degree of cervical muscle degeneration in the patients through MRI. Considering functional scores, VAS, NDI and PCS scores of the three groups post-treatment were significantly improved. Through the intergroup analysis, we found that the improvement in functional scores in the mild and moderate instability trend groups was better than that in the severe group. Through MRI measurements, we found that the degree of cervical muscle degeneration was significantly increased in the severe instability trend group. Regarding the changes in X-Ray imaging parameters pre- and post-treatment, no significant differences were observed pre- and post-treatment. For patients with CSR, the more serious their predisposition for cervical instability was, the more severe the degree of cervical muscle degeneration was, which means the worse the curative effect was, but cervical traction did not aggravate the potential degree of cervical instability.

The Effect of Strength and Balance Training on Kinesiophobia, Ankle Instability, Function, and Performance in Elite Adolescent Soccer Players with Functional Ankle Instability: A Prospective Cluster Randomized Controlled Trial.

We aimed to implement strength and balance training for elite adolescent male soccer players with functional ankle instability (FAI) to assess kinesiophobia, ankle instability, ankle function, and performance. This cluster randomized controlled trial comprised 51 elite adolescent male soccer players with FAI recruited from six different teams, divided into strength, balance, and control groups (SG, n = 17; BG, n = 17; and CG, n = 17, respectively). The SG and BG underwent strength and balance training sessions three times per week for 6 weeks. Primary outcomes were the Tampa scale for kinesiophobia-17 (TSK) and Cumberland ankle instability tool (CAIT) scores to assess kinesiophobia and FAI, respectively. Secondary outcomes were ankle strength (four directions), dynamic balance, static balance (ellipse, displacement, velocity), and performance (figure 8 and side-hop tests). A significant interaction effect was observed for both TSK and CAIT post-intervention (both, P < 0.01). In post hoc analyses, the BG had significantly better outcomes in reducing TSK. The SG and BG showed greater improvements in CAIT scores. Regression analysis indicated that CAIT severity correlated significantly with TSK (P = 0.039, R = 0.289). For secondary outcomes, the SG and BG were superior in terms of ankle dorsiflexion/inversion strength, static balance displacement, and figure-8 and side-hop tests (all, P < 0.05). The BG showed significantly better static balance ellipse results (P < 0.05). The 6-week intervention significantly enhanced kinesiophobia management, ankle stability, and performance. Balance training effectively mitigated kinesiophobia and improved balance, compared with strength training alone. Even small variations in CAIT severity can influence kinesiophobia, highlighting the potential benefits of balance training. Integrating balance training into training programs can address both physical and psychological aspects of ankle instability. Research is recommended to explore the longitudinal effects of these interventions and their potential to prevent injury recurrence.

Functional Anatomy and Biomechanics of Shoulder Instability.

The glenohumeral joint is the least congruent and least constrained joint with a complex relationship of static and dynamic stabilizers to balance its native mobility with functional stability. In the young athlete, anterior shoulder instability is multifactorial and can be a challenge to treat, requiring a patient-specific treatment approach. Surgical decision-making must consider patient-specific factors such as age, sport activity and level, underlying ligamentous laxity, and goals for return to activity, in addition to careful scrutiny of the underlying pathology to include humeral and glenoid bone loss and surrounding scapular bone morphology.

Evaluating the Athlete with Instability from on the Field to in the Clinic.

Shoulder glenohumeral joint dislocations and subluxations are a relatively common injury among athletic populations. Evaluating the patient both on the field initially and through early recovery helps to determine the best treatment strategies and predict the natural history of each unique injury.

Current Imaging of Anterior and Posterior Instability in the Athlete.

In the evaluation of shoulder instability, recognition of relevant pathology on imaging is critical to planning a surgical treatment that minimizes the risk for recurrent instability. The purpose of this review is to (1) discuss the use of radiography, computed tomography, and MRI in evaluating shoulder instability and (2) demonstrate how various imaging modalities are useful in identifying critical pathologies in the shoulder that are relevant for treatment.

Open Bone Augmentation Solutions for the Failed Shoulder Stabilization.

Utilizing fresh distal tibia allograft in anterior glenoid reconstruction has emerged as a highly advantageous approach in addressing instances of failed anterior shoulder stabilization with glenoid bone loss. This procedure offers several benefits, including the absence of donor-site morbidity, restoration of significant glenoid defects, reestablishment of joint congruity with the humeral head, restoration of glenoid biomechanics, and the addition of cartilage to the glenoid. Furthermore, it provides a robust and reliable alternative for managing failed stabilization procedures, leading to improved clinical outcomes and a high graft healing rate, while maintaining a low occurrence of recurrent instability.

Decision Making of the In-season Athlete with Anterior Shoulder Instability.

In-season management of anterior shoulder instability in athletes is a complex problem. Athletes often wish to play through their current season, though recurrent instability rates are high, particularly in contact sports. Athletes are generally considered safe to return to play when they are relatively pain-free, and their strength and range of motion match the uninjured extremity. If an athlete is unable to progress toward recovering strength and range of motion, surgical management is an option, though this is often a season-ending decision.

Management of Shoulder Instability in the Overhead Athletes.

Overhead athletes with anterior, posterior, and multidirectional shoulder instability present with a wide range of symptoms, especially considering the injury mechanism and affected supportive structures. As such, the management of shoulder instability is widely variable and relies on rehabilitation, operative management, and sport-specific considerations, such as positional and seasonal demands on the athlete. Biomechanical analysis may further aid in the recovery process or serve as a predictive tool to identify an increased risk for injury.

Arthroscopic Management of the Contact Athlete with Anterior Instability.

Anterior glenohumeral instability is one of the most common injuries suffered from sport. Despite padding and conditioning, the shoulder joint remains particularly vulnerable to injury, especially in the setting of contact. The overall rate of anterior instability is reported to be 0.12 injuries per 1000 athlete exposures, although this is increased up to 0.40 to 0.51 in the contact athlete. Successful treatment requires consideration of restoring stability while minimizing loss of glenohumeral motion. Common treatment strategies involve addressing the pathology that results from anterior shoulder dislocation including labral detachment as well as bony defects to the humeral head and glenoid.

Open Bankart Repair: Technique and Outcomes for the High-Level Athlete.

Historically considered the gold standard technique for glenohumeral instability, the open Bankart repair is being performed at decreased rates because of the current trends favoring arthroscopic Bankart repair and the lack of consistent training of the open technique. However, open Bankart repairs may be more appropriate for certain high-risk populations (ie, high-level collision athletes) because of their reduced recurrent instability rates. Further investigations are needed to identify the indications for arthroscopic versus open Bankart repair and compare their outcomes in high-level athletes. This review highlights the indications, surgical technique, and clinical outcomes following open Bankart repairs in athletes.

The Latarjet Procedure for Recurrent Anterior Shoulder Instability in the Contact Athlete.

In young athletes, anterior shoulder instability is a prevalent condition. Because of high-energy traumas, contact athletes often suffer recurrent instability, bone loss and postoperative recurrences. Patients younger than 20 years, symptomatic for more than 6 months, with ≥ 2 dislocations, with off-track Hill-Sachs lesion, glenoid bone loss, ALPSA lesion, Instability Severity Index Score > 3, and Glenoid Track Instability Management Score > 3 are at higher risk of failure. In cases of multiple dislocations with critical or subcritical glenoid bone loss, notably in collision and contact athletes, the Latarjet procedure is widely recognized as the treatment of choice.

Current Evidence and Techniques for Arthroscopic Bone Augmentation.

The indications for bone block augmentation of the glenoid following recurrent anterior shoulder instability are expanding. Arthroscopic anatomic glenoid reconstruction (AAGR) is an evolving technique with similar clinical results to the Latarjet procedure and other open bone block procedures. Multiple types of bone grafts and fixation techniques have been described, with varying results on bony integration, resorption, articular congruity, and recurrence rates. This review focuses on biomechanics, patient workup, indications, current evidence, and the authors' preferred surgical technique for AAGR.

Arthroscopic Management of Posterior Shoulder Instability.

Posterior shoulder instability is a distinct subcategory of shoulder instability with an incidence higher than previously reported. Pain is typically the primary complaint, with pathology due to repetitive microtrauma being more common that a specific traumatic event. If nonoperative treatment fails, arthroscopic posterior capsulolabral repair has been shown to result in excellent outcomes and return to sport, with American football players having the best outcomes and throwers being slightly less predictable. Risk factors for surgical failure include decreased glenoid bone width, rotator cuff injury, female gender, and the use of less than 3 anchors.

Biomechanics and Pathoanatomy of Posterior Shoulder Instability.

Posterior glenohumeral instability represents a wide spectrum of pathoanatomic processes. A key consideration is the interplay between the posterior capsulolabral complex and the osseous anatomy of the glenoid and humeral head. Stability is dependent upon both the presence of soft tissue pathology (eg, tears to the posteroinferior labrum or posterior band of the inferior glenohumeral ligament, glenoid bone loss, reverse Hill Sachs lesions, and pathologic glenoid retroversion or dysplasia) and dynamic stabilizing forces. This review highlights unique pathoanatomic features of posterior shoulder instability and associated biomechanics that may exist in patients with posterior glenohumeral instability.

Current Concepts in Assessment and Management of Failed Posterior Labral Repair.

Recurrent posterior shoulder instability after primary repair is uncommon, but presents a challenging clinical scenario. Most revisions in failed labral repair were associated with glenoid bone morphology related to critical bone loss, retroversion, or dysplasia. A variety of treatment options exist which include revision labral repair with or without capsular plication, glenoid osteotomy, humeral rotational osteotomy, or glenoid bone augmentation. No single technique has been shown to be superior and each technique has strengths and limitations. Therefore, thoughtful evaluation and planning is critical to address each patient's individual pathology to maximize success after revision surgery.

Rehabilitation and Return to Sport following Operative and Nonoperative Treatment of Anterior Shoulder Instability.

There has been growing interest in the rehabilitation process and timing of returning an athlete to sport following the management options for anterior shoulder instability. The purpose of this article is to review the current rehabilitation and return to sport (RTS) protocols for various nonoperative and operative management strategies following anterior shoulder instability events. When appropriate in the rehabilitation protocol, RTS testing should be criteria based, rather than time based, with a special focus given to psychological readiness in order to promote successful return to athletics and prevention of recurrent instability episodes in the future.

Mitigating the Risk of Instability After Reverse Shoulder Arthroplasty: A Critical Analysis Review of Patient and Surgical Factors.

¼ Instability and dislocation after reverse shoulder arthroplasty may occur in up to 31% of patients.¼ Clinical risk factors for instability include younger age, male sex, increased body mass index, preoperative diagnosis of proximal humerus fracture or rotator cuff pathology, history of instability of the native shoulder or after surgery, and a medical history of Parkinson's disease.¼ Patients with rheumatoid arthritis and decreased proximity to the coracoid may also be at greater risk.¼ In patients at a high risk of instability, surgeons should consider a more lateralized prosthesis (particularly in patients with an incompetent rotator cuff), repairing the subscapularis (particularly when using a medialized prosthesis), and upsizing the glenosphere (>40 mm in male and 38-40 mm in female patients).¼ While potentially useful, less evidence exists for the use of a constrained liner (particularly with a lateralized glenosphere and/or in low-demand patients) and rotating the polyethylene liner posteriorly to avoid impingement.

Can magnetic resonance imaging findings effectively diagnose the instability observed on radiographs in patients with degenerative lumbar spinal stenosis?

BACKGROUND: Degenerative lumbar spinal stenosis (LSS) is a common condition that involves the narrowing of the spinal canal. Diagnosing instability traditionally requires standing lateral radiographs to detect dynamic translation, but there is debate about relying solely on radiographs due to challenges like patient discomfort and radiation exposure. This study aimed to evaluate if Magnetic Resonance Imaging (MRI) findings could effectively diagnose instability observed on radiographs. METHODS: We reviewed 478 consecutive patients with degenerative LSS who had surgery at our institution. Instability was defined as a sagittal translation exceeding 3 mm on standing lateral radiographs in both extension and flexion. Patients were divided into stable (those with < 3 mm translation) and unstable groups (those with > 3 mm translation). The study assessed potential variables for instability, including MRI findings like facet joint effusion, facet joint angle, disk height index, intradiscal vacuum presence, endplate sclerosis, ligamentum flavum hypertrophy, and multifidus muscle fatty degeneration, comparing these factors between the two groups. RESULTS: A total of 478 consecutive patients diagnosed with degenerative Lumbar Spinal Stenosis (LSS) were included. The average age of the patients was 66.32 years, with 43.3% being male. Approximately 27.6% of the cases exhibited signs of instability on the standing lateral radiograph during extension and flexion. The multivariate analysis using binary logistic regression revealed that facet joint effusion (odds ratio [OR] 2.73; 95% confidence interval [CI] 1.27-3.94; P = 0.002), disk height index (OR 2.22; 95% CI 1.68-3.35; P = 0.009), and the presence of the Vacuum sign (OR 1.77; 95% CI 1.32-2.84; P = 0.021) were identified as factors associated with instability. CONCLUSIONS: Our findings showed thata higher facet joint effusion, the presence of Vacuum sign, and a greater Disk Height Index were associated with the presence of instability on the standing lateral radiograph in extension and flexion in patients with degenerative LSS.