Statistical shape models that predict native glenoid width based on glenoid height are inaccurate in their current form: a cross-sectional study.

BACKGROUND: The extent of measurement errors of statistical shape models that predict native glenoid width based on glenoid height to subsequently determine the amount of anterior glenoid bone loss is unclear. Therefore, the aim of this study was to (1) create a statistical shape model based on glenoid height and width measured on 3-dimensional computed tomography (3D-CT) and determine the accuracy through measurement errors and (2) determine measurement errors of existing 3D-CT statistical shape models. MATERIALS AND METHODS: A retrospective cross-sectional study included all consecutive patients who underwent CT imaging before undergoing primary surgical treatment of traumatic anterior shoulder dislocation between 2007 and 2022 at the Tohoku University Hospital and affiliated hospitals. Patients were included when instability was unilateral and CT scans of both the injured and contralateral uninjured shoulder were available. 3D segmentations were created and glenoid height and width of the injured and contralateral uninjured side (gold standard) were measured. Accuracy was determined through measurement errors, which were defined as a percentage error deviation from native glenoid width (contralateral uninjured glenoid), calculated as follows: measurement error = [(estimated glenoid width with a statistical shape model - native glenoid width) / native glenoid width] × 100%. A linear regression analysis was performed to create a statistical shape model based on glenoid height according to the formula: native glenoid width = a × glenoid height + b. RESULTS: The diagnosis and procedure codes identified 105 patients, of which 69 (66%) were eligible for inclusion. Glenoid height demonstrated a very strong correlation (r = 0.80) with native glenoid width. The linear regression formula based on this cohort was as follows: native glenoid width = 0.75 × glenoid height - 0.61, and it demonstrated an absolute average measurement error of 5% ± 4%. The formulas by Giles et al, Chen et al and Rayes et al demonstrated absolute average measurement errors of 10% ± 7%, 6% ± 5%, and 9% ± 6%, respectively. CONCLUSION: Statistical shape models that estimate native glenoid width based on glenoid height demonstrate unacceptable measurement errors, despite a high correlation. Therefore, great caution is advised when using these models to determine glenoid bone loss percentage. To minimize errors caused by morphologic differences, preference goes to methods that use the contralateral side as reference.

Minimal but potentially clinically relevant anteroinferior position of the humeral head following traumatic anterior shoulder dislocations: A 3D-CT analysis.

In unstable shoulders, excessive anteroinferior position of the humeral head relative to the glenoid can lead to a dislocation. Measuring humeral head position could therefore be valuable in quantifying shoulder laxity. The aim of this study was to measure (1) position of the humeral head relative to the glenoid and (2) joint space thickness during passive motion in unstable shoulders caused by traumatic anterior dislocations and in contralateral uninjured shoulders. A prospective cross-sectional CT-study was performed in patients with unilateral anterior shoulder instability. Patients underwent CT scanning of both injured and uninjured side in supine position (0° abduction and 0° external rotation) and in 60°, 90°, and 120° of abduction with 90° of external rotation without an external load. Subsequently, 3D virtual models were created of the humerus and the scapula to create a glenoid coordinate system to identify poster-anterior, inferior-superior, and lateral-medial position of the humeral head relative to the glenoid. Joint space thickness was defined as the average distance between the subchondral bone surfaces of the humeral head and glenoid. Fifteen consecutive patients were included. In supine position, the humeral head was positioned more anteriorly (p = 0.004), inferiorly (p = 0.019), and laterally (p = 0.021) in the injured compared to the uninjured shoulder. No differences were observed in any of the other positions. A joint-space thickness map, showing the bone-to-bone distances, identified the Hill-Sachs lesion footprint on the glenoid surface in external rotation and abduction, but no differences on average joint space thickness were observed in any position.

Ten technical aspects of baseplate fixation in reverse total shoulder arthroplasty for patients without glenoid bone loss: a systematic review.

The aim of this systematic review was to collect evidence on the following 10 technical aspects of glenoid baseplate fixation in reverse total shoulder arthroplasty (rTSA): screw insertion angles; screw orientation; screw quantity; screw length; screw type; baseplate tilt; baseplate position; baseplate version and rotation; baseplate design; and anatomical safe zones. Five literature libraries were searched for eligible clinical, cadaver, biomechanical, virtual planning, and finite element analysis studies. Studies including patients >16 years old in which at least one of the ten abovementioned technical aspects was assessed were suitable for analysis. We excluded studies of patients with: glenoid bone loss; bony increased offset-reversed shoulder arthroplasty; rTSA with bone grafts; and augmented baseplates. Quality assessment was performed for each included study. Sixty-two studies were included, of which 41 were experimental studies (13 cadaver, 10 virtual planning, 11 biomechanical, and 7 finite element studies) and 21 were clinical studies (12 retrospective cohorts and 9 case-control studies). Overall, the quality of included studies was moderate or high. The majority of studies agreed upon the use of a divergent screw fixation pattern, fixation with four screws (to reduce micromotions), and inferior positioning in neutral or anteversion. A general consensus was not reached on the other technical aspects. Most surgical aspects of baseplate fixation can be decided without affecting fixation strength. There is not a single strategy that provides the best outcome. Therefore, guidelines should cover multiple surgical options that can achieve adequate baseplate fixation.

High variability in what is considered important to report following instability surgery: a Delphi study among Dutch shoulder specialists.

Background: Standardized reporting leads to high-quality data and can reduce administration time. The aim of this study was to (1) get an insight into the variability of what is considered important to report in the surgical report following shoulder instability surgery and (2) determine which elements should be included in the surgical report following shoulder instability surgery according to Dutch surgeons using a Delphi method. Methods: Dutch orthopedic shoulder surgeons were included in a panel for a Delphi study consisting of 3 rounds. Importance of the elements was rated on a 9-point Likert scale. High variability was defined as an element that received at least 1 score between 1 and 3 and 1 score between 7 and 9 in round 3. Consensus was defined as ≥80% of the panel giving a score of 7 or more. Results: Seventeen shoulder specialists completed all 3 rounds and identified a total of 82 elements for the arthroscopic Bankart repair and 60 for the open Latarjet. High variability was observed in 57 (70%) and 52 (87%) of the elements, respectively. After round 3, the panel reached consensus on 27 and 11 elements that should be mentioned in the surgical report following arthroscopic Bankart repair and open Latarjet. Conclusion: There is high variability in what shoulder specialists regard essential to report. Consensus was reached on 27 and 11 elements to be reported following arthroscopic Bankart repair and open Latarjet, respectively. Future studies on an international scale can further improve data collection and communication between specialists.

Why do patients with anterior shoulder instability not return to sport after surgery? A systematic review of 63 studies comprising 3545 patients.

Purpose: To review athletes' reasons not to return to sport (RTS) after surgical treatment of anterior shoulder instability, comparing capsulolabral repair and bony reconstruction procedures. The hypothesis is that the most common reason for patients unable to RTS is not due to physical inability of the shoulder. Methods: A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. PubMed, Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, SPORTDiscus/Ebsco, and Web of Science/Clarivate Analytics were searched in collaboration with an information specialist up to August 11, 2022. Observational and interventional studies reporting reasons for no RTS following surgical treatment of anterior shoulder instability were included. Quality assessment of studies was conducted using the Methodological Index for Non-Randomized Studies (MINORS) criteria and Risk of Bias (RoB) assessment. Forest plots were generated to show an overview of the proportion shoulder function independent reasons for each study. Results: Sixty-three studies were included reporting on 3545 athletes, of which 2588 (73%) underwent capsulolabral repair versus 957 (27%) who underwent surgical treatment with bony reconstruction procedures. A total of 650 athletes (18%) were unable to RTS. The reason not to RTS was most frequently shoulder function independent (70%) compared to shoulder function dependent (30%) following both capsulolabral repair and bony reconstruction procedures. Most cited reasons for no RTS after capsulolabral repair were fear of reinjury (17%), personal reasons or change of priorities (11%) and retirement/discharge of military service or sports team (10%). Of these reasons, 106 (22%) were not specified other than being shoulder function dependent or shoulder function independent. Most cited reasons for no RTS after bony reconstruction procedures were fear of reinjury (12%), shoulder pain (10%), and retirement/discharge of military service or sports team (9%). Of these reasons, 74 (44%) were not specified other than being shoulder function dependent or shoulder function independent. Forest plots showed a variation from 0% to 100% shoulder independent reasons for both capsulolabral repair and bony reconstruction procedures. Conclusion: The majority of athletes who did not RTS following surgical treatment for anterior shoulder instability did so due to shoulder function independent reasons, such as fear of reinjury. However, there was a high variety between studies and many reasons were unspecified, warranting unified definitions for reasons of patients that do not RTS.

Prognostic factors associated with failure to return to sport following primary arthroscopic Bankart repair: a retrospective multicenter study.

BACKGROUND: Even though many studies have been published regarding return-to-sport (RTS) rates following arthroscopic Bankart repair (ABR), evidence regarding prognostic factors for which patients do not RTS is limited. The aim of this study was to identify prognostic factors that are associated with failure to RTS and failure to return to preinjury level of sport (RTPS) following primary ABR. The hypothesis was that prognostic factors for failure to RTS and failure to RTPS would be similar to those predisposing recurrence. METHODS: A multicenter, retrospective case-control study including 6 Dutch hospitals was performed. Consecutive patients who underwent primary ABR between 2014 and 2019 were invited to participate and received a questionnaire. Sports participation was assessed before symptom onset, at 6 months postoperatively, and at final follow-up. Failure to RTS was defined as no return to any sport, and failure to RTPS was defined as no return to the same level (or a higher level) of sport. Prognostic factors for failure to RTS or failure to RTPS were identified using logistic regression. Covariates for the regression analysis were selected based on univariate analyses. RESULTS: This study included 318 patients with a mean follow-up period of 4.2 years (standard deviation, 1.8 years). Of these 318 patients, 26 (8.2%) did not RTS and 100 (31%) did not RTPS. Logistic regression analysis demonstrated that glenoid bone loss (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.04-1.15; P = .001) and overhead use of the shoulder during work (OR, 3.77; 95% CI, 1.45-9.85; P = .007) were prognostic factors for failure to RTS. In addition, it showed that preoperative professional sports level (OR, 2.94; 95% CI, 1.07-8.05; P = .04) and preoperative body mass index (OR, 1.11; 95% CI, 1.01-1.21; P = .04) were prognostic factors for failure to RTPS. Repair of a bony Bankart lesion (OR, 0.35; 95% CI, 0.15-0.81; P = .02) and the presence of an anterior labral periosteal sleeve avulsion (ALPSA) (OR, 0.44; 95% CI, 0.20-0.97; P = .04) were identified as factors that facilitated RTPS. CONCLUSION: This study identified glenoid bone loss and overhead use of the shoulder during work to be associated with failure to RTS. Moreover, preoperative sports level and preoperative body mass index were found to be associated with failure to RTPS. In contrast, a bony Bankart lesion and an anterior labral periosteal sleeve avulsion (ALPSA) lesion facilitated RTPS. Future prospective studies are needed to confirm these factors and determine which part of the effect can be attributed to (failure of) surgical treatment or changes in behavior.

Management of Acromioclavicular Injuries - Current Concepts.

Introduction: Treatment of a patient with acromioclavicular joint (ACJ) injury remains challenging for orthopedic surgeons. To date, there is debate over the optimal management of ACJ injuries. This review provides an overview of assessment, treatment, and future perspectives for the treatment of and research into ACJ. Material and Methods: A scoping literature review was performed. The search was built including the following terms: acromioclavicular joint injuries or dislocation, and pathophysiology, etiology, anatomy, treatment, and trauma mechanism. The papers with evidence levels 1-3 were included in the current narrative review. Results: A total of 2242 potential relevant studies were identified in the searches. After removal of duplicates, 432 studies were screened on their titles and abstracts, resulting in 35 studies being included in the review, based on the eligibility criteria. Conclusion: The management of acute and chronic ACJ injuries is not clarified in the current literature. However, there is currently insufficient high-level evidence for the overall treatment options for ACJ injuries. If surgical intervention is decided upon in consultation with the patient, the complications may not outweigh the benefits. The multitude of existing techniques is indicative of the uncertainty surrounding this issue, and no gold standard has yet been established for treatment methods. An ideal classification would include not only vertical and horizontal instability, but also the severity of kinematic alterations of the shoulder complex. This indicates the need for a new and improved diagnostic tool for the classification of ACJ injuries.

Outcomes, Union Rate, and Complications After Operative and Nonoperative Treatments of Neer Type II Distal Clavicle Fractures: A Systematic Review and Meta-analysis of 2284 Patients.

BACKGROUND: As nonoperative treatment of Neer type II distal clavicle fractures is associated with nonunion rates up to 33%, operative treatment is frequently advocated. However, evidence is lacking regarding which operative treatment to perform and whether this is superior to nonoperative treatment in terms of functional outcome and complication rate. PURPOSE: (1) To evaluate which surgical technique in the treatment of Neer type II distal clavicle fractures is optimal with regard to patient-reported outcomes and union and complication rates. (2) To review nonoperatively treated patients. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review of the literature and meta-analysis were performed on January 27, 2021, in PubMed, Embase, CENTRAL, CINAHL/EBSCO, Web of Science/Clarivate Analytics, and SPORTDiscus/EBSCO. The search included all studies regarding nonoperative and operative treatment of Neer type II distal clavicle fractures with a minimum of 20 patients and follow-up of 12 months. The primary and secondary outcomes were patient-reported outcome measures at 12 months and union, complication, and revision rates. RESULTS: A total of 59 articles were included involving 2284 patients. Coracoclavicular fixation, hook plate, transacromial pins, alternative plate, tension band wire/K-wire, a combination of surgical techniques, and a nonoperative group were described. Hook plates showed lower Constant-Murley scores as compared with coracoclavicular fixation (standard mean difference, -0.77; 95% CI, -1.26 to -0.28; P = .002). However, no significant difference was seen when the hook plate was compared with the locking plate and tension band wire/K-wire groups, and no significant difference in union rate was seen among all operative treatment groups. Operatively treated patients had significantly higher union rates than patients treated nonoperatively (standard mean difference: 0.05; 95% CI, 0.01 to 0.37; P = .004). CONCLUSION: Patients treated with hook plates showed significantly lower Constant-Murley scores and higher complication and revision rates as compared with those treated with coracoclavicular fixation, without differences in union rate. Higher Constant-Murley scores were seen in those patients with supplemental coracoclavicular fixation when using locking. Nonoperatively treated patients showed good functional outcome despite the 31% nonunion rate, although future studies are necessary to substantiate this conclusion. When using a locking plate, additional craniocaudal fixation showed significant better functional outcome.

"Nearly off-track lesions" or a short distance from the medial edge of the Hill-Sachs lesion to the medial edge of the glenoid track does not seem to be accurate in predicting recurrence after an arthroscopic Bankart repair in a military population: a case-control study.

BACKGROUND: On-track lesions with a short distance from the medial edge of the Hill-Sachs lesion to the medial edge of the glenoid track (nearly off-track) may predispose recurrence after arthroscopic Bankart repair (ABR) in the general population. The aim of this study was to determine if a shorter distance between the medial edge of the Hill-Sachs lesion and the medial edge of the glenoid track could accurately predict recurrence after an ABR in a high-demand military population. It was hypothesized that a shorter distance would not accurately predict recurrence. MATERIALS AND METHODS: A retrospective monocenter case-control study was performed at the Dutch Central Military Hospital. Patients with an on-track Hill-Sachs lesion who underwent a primary ABR between 2014 and 2019 with a minimal follow-up of 2 years and a preoperative magnetic resonance imaging (MRI) assessment received a questionnaire. The primary outcome was recurrence, defined as a complete dislocation or subluxation. Glenoid bone loss was assessed using a linear-based method on MRI. The distance from the medial edge of the Hill-Sachs lesion to the medial edge of the glenoid track was defined as the distance to dislocation (DTD). A receiver operating characteristic curve was created to determine the predictive value of the DTD for recurrence. Logistic regression was used to determine preoperative risk factors that predispose recurrence. Covariates were selected based on univariable analysis and included gender, body mass index, age at surgery and first dislocation, laterality, smoking habits, overhead shoulder activity during work, preoperative dislocations, sports type and level, bony or labral lesions on MRI, and DTD. RESULTS: In total, 80 patients with an average follow-up of 4.8 ± 1.9 years completed the questionnaire and were included in the analyses. Seventeen patients (21%) experienced recurrence at the final follow-up. No difference in DTD was observed among patients who experienced recurrence (9 ± 4 mm) compared with patients who did not (9 ± 5 mm; P = .81). The receiver operating characteristic curve demonstrated no predictive power of DTD for recurrence (area under the curve = 0.49). Smoking at the time of surgery (odds ratio: 3.9; confidence interval: 1.2-12.7; P = .02) and overhead shoulder movement during work (odds ratio: 9.3; confidence interval: 1.1-78.0; P = .04) were associated with recurrence according to the logistic regression analysis. CONCLUSION: A shorter DTD demonstrated no accuracy in predicting recurrence in a military population. Smoking at the time of surgery and overhead shoulder activity during work were associated with recurrence; however, these analyses were underpowered to draw valid conclusions.

Shoulder muscle activity after latissimus dorsi transfer in an active elevation.

Background: After latissimus dorsi transfer (LDT), an increase in scapulothoracic (ST) contribution in thoracohumeral (TH) elevation is observed when compared to the asymptomatic shoulder. It is not known which shoulder muscles contribute to this change in shoulder kinematics, and whether the timing of muscle recruitment has altered after LDT. The aim of the study was to identify which shoulder muscles and what timing of muscle recruitment are responsible for the increased ST contribution and shoulder elevation after LDT for a massive irreparable posterosuperior rotator cuff tear (MIRT). Methods: Thirteen patients with a preoperative pseudoparalysis and MIRT were recruited after LDT with a minimum follow-up of 1 year. Three-dimensional electromagnetic tracking was used to assess maximum active elevation of the shoulder (MAES) in both the LDT and the asymptomatic contralateral shoulder (ACS). Surface electromyography (EMG) tracked activation (% EMG max) and activation timing of the latissimus dorsi (LD), deltoid, teres major, trapezius (upper, middle and lower) and serratus anterior muscles were collected. MAES was studied in forward flexion, scapular abduction and abduction in the coronal plane. Results: In MAES, no difference in thoracohumeral motion was observed between the LDT and ACS, P = .300. However, the glenohumeral motion for MAES was significantly lower in LDT shoulders F(1,12) = 11.230, P = .006. The LD % EMG max did not differ between the LDT and ACS in MAES. A higher % EMG max was found for the deltoid F(1,12) = 17.241, P = .001, and upper trapezius F(1,10) = 13.612, P = .004 in the LDT shoulder during MAES. The middle trapezius only showed a higher significant difference in % EMG max for scapular abduction, P = .020 (LDT, 52.3 ± 19.4; ACS, 38.1 ± 19.7).The % EMG max of the lower trapezius, serratus anterior and teres major did not show any difference in all movement types between the LDT and ACS and no difference in timing of recruitment of all the shoulder muscles was observed. Conclusions: After LDT in patients with a MIRT and preoperative pseudoparalysis, the LD muscle did not alter its % EMG max during MAES when compared to the ACS. The cranial transfer of the LD tendon with its native %EMG max, together with the increased %EMG max of the deltoid, middle and upper trapezius muscles could be responsible for the increased ST contribution. The increased glenohumeral joint reaction force could in turn increase active elevation after LDT in a previous pseudoparalytic shoulder.

Distal Biceps Tendon Ruptures: Diagnostic Strategy Through Physical Examination.

BACKGROUND: Distinguishing a complete from a partial distal biceps tendon rupture is essential, as a complete rupture may require repair on short notice to restore function, whereas partial ruptures can be treated nonsurgically in most cases. Reliability of physical examination is crucial to determine the right workup and treatment in patients with a distal biceps tendon rupture. PURPOSES: The primary aim of this study was to find a (combination of) test(s) that serves best to diagnose a complete rupture with certainty in the acute phase (≤1 month) without missing any complete ruptures. The secondary aims were to determine the best (combination of) test(s) to identify a chronic (>1 month) rupture of the distal biceps tendon and indicate additional imaging in case partial ruptures or tendinitis are suspected. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 2. METHODS: A total of 86 patients with anterior elbow complaints or suspected distal biceps injury underwent standardized physical examination, including the Hook test, passive forearm pronation test, biceps crease interval (BCI), and biceps crease ratio. Diagnosis was confirmed intraoperatively (68 cases), by magnetic resonance imaging (13 cases), or by ultrasound (5 cases). RESULTS: A combination of the Hook test and BCI (ie, both tests are positive) was most accurate for both acute and chronic ruptures but with a different purpose. For acute complete ruptures, sensitivity was 94% and specificity was 100%. In chronic cases, specificity was also 100%. Weakness on active supination and palpation of the tendon footprint provided excellent sensitivity of 100% for chronic complete ruptures and partial ruptures, respectively. CONCLUSION: The combination of a positive Hook test and BCI serves best to accurately diagnose acute complete ruptures of the distal biceps tendon. Weakness on active supination and pain on palpation of the tendon footprint provide excellent sensitivity for chronic complete ruptures and partial ruptures. Using these tests in all suspected distal biceps ruptures allows a physician to refrain from imaging for a diagnostic purpose in certain cases, to limit treatment delay and thereby provide better treatment outcome, and to avoid hospital and social costs.

Bony reconstruction after failed labral repair is associated with higher recurrence rates compared to primary bony reconstruction: a systematic review and meta-analysis of 1319 shoulders in studies with a minimum of 2-year follow-up.

BACKGROUND: There is uncertainty with regard to the optimal revision procedure after failed labral repair for anterior shoulder instability. An overview of outcomes of these procedures with quantitative analysis is not available in literature. The aim of this review is (1) to compare recurrence rates after revision labral repair (RLR) and revision bony reconstruction (RBR), both following failed labral repair. In addition, (2) recurrence rates after RBR following failed labral repair and primary bony reconstruction (PBR) are compared to determine if a previous failed labral repair influences the outcomes of the bony reconstruction. METHODS: Randomized controlled trials and cohort studies with a minimum follow-up of 2 years and reporting recurrence rates of (1) RBR following failed labral repair and PBR and/or (2) RLR following failed labral repair and RBR following failed labral repair were identified by searching PubMed, Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, and Web of Science/Clarivate Analytics. RESULTS: Thirteen studies met the inclusion criteria and comprised 1319 shoulders. Meta-analyses showed that RBR has a significantly higher recurrence rate than PBR (risk ratio [RR] 0.51, P < .008) but found no significant difference in the recurrence rates for RLR and RBR (RR 1.40, P < .49). Also, no significant differences were found between PBR and RBR in return to sport (RR 1.07, P < .41), revision surgery (RR 0.8, P < .44), and complications (RR 0.84, P < .53). Lastly, no significant differences between RLR and RBR for revision surgery (RR 3.33, P < .19) were found. CONCLUSION: The findings of this meta-analyses show that (1) RBR does not demonstrate a significant difference in recurrence rates compared with RLR and that (2) RBR has a significantly higher recurrence rate than PBR.

Shoulder kinematics and muscle activity following latissimus dorsi transfer for massive irreparable posterosuperior rotator cuff tears in shoulders with pseudoparalysis.

BACKGROUND: The aim of this study was to evaluate the thoracohumeral (TH) and glenohumeral (GH) motion with muscle activity after latissimus dorsi transfer (LDT) in a shoulder with a massive irreparable posterosuperior rotator cuff tear (MIRT) and pseudoparalysis compared with the asymptomatic contralateral shoulder (ACS). METHODS: We recruited and evaluated 13 patients after LDT in a shoulder with preoperative clinical pseudoparalysis and an MIRT on magnetic resonance imaging, with a minimum follow-up period of 1 year, and with a Hamada stage of 3 or less. Three-dimensional electromagnetic tracking was used to assess shoulder active range of motion in both the LDT shoulder and the ACS. The maximal active elevation of the shoulder (MAES) was assessed and consisted of forward flexion, scapular abduction, and abduction in the coronal plane. Maximal active internal rotation and external rotation were assessed separately. Surface electromyography (EMG) was performed to track activation of the latissimus dorsi (LD) and deltoid muscles during shoulder motion. EMG was scaled to its maximal isometric voluntary contraction recorded in specified strength tests. RESULTS: In MAES, TH motion of the LDT shoulder was not significantly different from that of the ACS (F1,12 = 1.174, P = .300) but the GH contribution was significantly lower in the LDT shoulder for all motions (F1,12 = 11.230, P = .006). External rotation was significantly greater in the ACS (26° ± 10° in LDT shoulder vs. 42° ± 11° in ACS, P < .001). The LD percentage EMG maximum showed no significant difference between the LDT shoulder and ACS during MAES (F1,11 = 0.005, P = .946). During maximal active external rotation of the shoulder, the LDT shoulder showed a higher percentage EMG maximum than the ACS (3.0% ± 2.9% for LDT shoulder vs. 1.2% ± 2.0% for ACS, P = .006). CONCLUSIONS: TH motion improved after LDT in an MIRT with pseudoparalysis and was not different from the ACS except for external rotation. However, GH motion was significantly lower after LDT than in the ACS in active-elevation range of motion. The LD was active after LDT but not more than in the ACS except for active external rotation, which we did not consider relevant as the activity did not rise above 3% EMG maximum. The favorable clinical results of LDT do not seem to be related to a change in LD activation and might be explained by its effect in preventing proximal migration of the humeral head in active elevation.

Recurrence in traumatic anterior shoulder dislocations increases the prevalence of Hill-Sachs and Bankart lesions: a systematic review and meta-analysis.

PURPOSE: The extent of shoulder instability and the indication for surgery may be determined by the prevalence or size of associated lesions. However, a varying prevalence is reported and the actual values are therefore unclear. In addition, it is unclear whether these lesions are present after the first dislocation and whether or not these lesions increase in size after recurrence. The aim of this systematic review was (1) to determine the prevalence of lesions associated with traumatic anterior shoulder dislocations, (2) to determine if the prevalence is higher following recurrent dislocations compared to first-time dislocations and (3) to determine if the prevalence is higher following complete dislocations compared to subluxations. METHODS: PubMed, EMBASE, Cochrane and Web of Science were searched. Studies examining shoulders after traumatic anterior dislocations during arthroscopy or with MRI/MRA or CT published after 1999 were included. A total of 22 studies (1920 shoulders) were included. RESULTS: The proportion of Hill-Sachs and Bankart lesions was higher in recurrent dislocations (85%; 66%) compared to first-time dislocations (71%; 59%) and this was statistically significant (P < 0.01; P = 0.05). No significant difference between recurrent and first-time dislocations was observed for SLAP lesions, rotator-cuff tears, bony Bankart lesions, HAGL lesions and ALPSA lesions. The proportion of Hill-Sachs lesions was significantly higher in complete dislocations (82%) compared to subluxations (54%; P < 0.01). CONCLUSION: Higher proportions of Hill-Sachs and Bankart were observed in recurrent dislocations compared to first-time dislocations. No difference was observed for bony Bankart, HAGL, SLAP, rotator-cuff tear and ALPSA. Especially when a Hill-Sachs or Bankart is present after first-time dislocation, early surgical stabilization may need to be considered as other lesions may not be expected after recurrence and to limit lesion growth. However, results should be interpreted with caution due to substantial heterogeneity and large variance. LEVEL OF EVIDENCE: IV.

[Swelling at the sternoclavicular joint]. / Een zwelling ter plaatse van het sternoclaviculaire gewricht.

A visible mass around the sternoclavicular (SC) joint may be explained by a wide variety of diagnoses, each with its own diagnostic pathway and treatment options. Here we report three cases: a 56-year-old male with an anterior luxation of the right SC joint, a 59-year-old male with osteomyelitis of the left SC joint and a 78-year-old male with a painless swelling to the right medial clavicle, interpreted as sterno-costo-clavicular hyperostosis (SCCH) as part of his SAPHO syndrome. An atraumatic swelling of the SC joint is most often caused by osteoarthritis, characterized by a slowly progressing solid swelling. Acute swelling with concurrent redness and fever justifies an intra-articular- or bone aspiration, possibly CT guided, in combination with laboratory blood tests to differentiate between an infectious or rheumatologic cause. Since there are also multiple rare diseases that present specifically around the SC joint, a multidisciplinary review often proves helpful.

Age, participation in competitive sports, bony lesions, ALPSA lesions, > 1 preoperative dislocations, surgical delay and ISIS score > 3 are risk factors for recurrence following arthroscopic Bankart repair: a systematic review and meta-analysis of 4584 shoulders.

PURPOSE: Determining the risk of recurrent instability following an arthroscopic Bankart repair can be challenging, as numerous risk factors have been identified that might predispose recurrent instability. However, an overview with quantitative analysis of all available risk factors is lacking. Therefore, the aim of this systematic review is to identify risk factors that are associated with recurrence following an arthroscopic Bankart repair. METHODS: Relevant studies were identified by searching PubMed, Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, CINAHL/Ebsco, and Web of Science/Clarivate Analytics from inception up to November 12th 2020. Studies evaluating risk factors for recurrence following an arthroscopic Bankart repair with a minimal follow-up of 2 years were included. RESULTS: Twenty-nine studies met the inclusion criteria and comprised a total of 4582 shoulders (4578 patients). Meta-analyses were feasible for 22 risk factors and demonstrated that age ≤ 20 years (RR = 2.02; P < 0.00001), age ≤ 30 years (RR = 2.62; P = 0.005), participation in competitive sports (RR = 2.40; P = 0.02), Hill-Sachs lesion (RR = 1.77; P = 0.0005), off-track Hill-Sachs lesion (RR = 3.24; P = 0.002), glenoid bone loss (RR = 2.38; P = 0.0001), ALPSA lesion (RR = 1.90; P = 0.03), > 1 preoperative dislocations (RR = 2.02; P = 0.03), > 6 months surgical delay (RR = 2.86; P < 0.0001), ISIS > 3 (RR = 3.28; P = 0.0007) and ISIS > 6 (RR = 4.88; P < 0.00001) were risk factors for recurrence. Male gender, an affected dominant arm, hyperlaxity, participation in contact and/or overhead sports, glenoid fracture, SLAP lesion with/without repair, rotator cuff tear, > 5 preoperative dislocations and using ≤ 2 anchors could not be confirmed as risk factors. In addition, no difference was observed between the age groups ≤ 20 and 21-30 years. CONCLUSION: Meta-analyses demonstrated that age ≤ 20 years, age ≤ 30 years, participation in competitive sports, Hill-Sachs lesion, off-track Hill-Sachs lesion, glenoid bone loss, ALPSA lesion, > 1 preoperative dislocations, > 6 months surgical delay from first-time dislocation to surgery, ISIS > 3 and ISIS > 6 were risk factors for recurrence following an arthroscopic Bankart repair. These factors can assist clinicians in giving a proper advice regarding treatment. LEVEL OF EVIDENCE: Level IV.

High Variability of the Definition of Recurrent Glenohumeral Instability: An Analysis of the Current Literature by a Systematic Review.

PURPOSE: To determine the definitions for recurrence used in the literature, assess the consensus in using these definitions, and determine the impact of these definitions on recurrence rates. METHODS: A literature search was performed in PubMed and EMBASE including studies from 2000 to 2020 reporting on recurrence rates after anterior arthroscopic shoulder instability surgery. Dislocation, apprehension, subluxation and recurrence rates were compared. RESULTS: Ninety-one studies were included. In 68% of the eligible studies, recurrence rates are not well defined. Thirty (33%) studies did not report on dislocations, 45 (49%) did not report on subluxations, and 58 (64%) did not report on apprehension. Seventeen different definitions for recurrence of instability, 4 definitions of dislocations, and 8 definitions of subluxation were used. CONCLUSION: Recurrence rates are poorly specified and likely underreported in the literature, hampering comparison with results of other studies. This highlights the need for a consensus on definition of recurrence across shoulder instability studies. We recommend not using the definition recurrence of instability anymore. We endorse defining dislocations as a radiographically confirmed dislocation or a dislocation that is manually reduced, subluxations as the feeling of a dislocation that can be (spontaneously) reduced without the need for a radiographically confirmed dislocation, and a positive apprehension sign as fear of imminent dislocation when placing the arm in abduction and external rotation during physical examination. Reporting on the events resulting in a dislocation or subluxation aids in making an estimation of the severity of instability. LEVEL OF EVIDENCE: Level IV, systematic review.

Review of Weaver and Dunn on treatment of acromioclavicular injuries, especially complete acromioclavicular separation.

This classic discusses the original publication "Treatment of acromioclavicular injuries, especially complete acromioclavicular separation" by Weaver and Dunn, which collaborated to develop a technique for acromioclavicular joint reconstruction in 1972. Their surgical technique described resection of 2 cm of the distal clavicle and transfer of the acromial end of the coracoacromial ligament into the medullary canal of the distal clavicle. (modified) Weaver-Dunn procedures have been regarded as one of the most effective techniques to treat complete acromioclavicular joint dislocation for a long time. However, anatomic reconstructions have taken over this position since recent biomechanical studies have demonstrated superior results. Although the Weaver-Dunn procedure has fallen out of favour, it remains of historical significance. For this reason, this review will comprise the historical overview of the Weaver-Dunn procedure, the men behind the eponym and the clinical implication then and now.

Long Head of Biceps Tenotomy Is Not Inferior to Suprapectoral Tenodesis in Arthroscopic Repair of Nontraumatic Rotator Cuff Tears: A Multicenter, Non-inferiority, Randomized, Controlled Clinical Trial.

PURPOSE: To determine if long head of the biceps (LHB) tenotomy is not inferior to suprapectoral LHB tenodesis when performed in conjunction with arthroscopic repair of small- to medium-sized nontraumatic rotator cuff tears. METHODS: This multicenter, randomized, non-inferiority trial recruited 100 participants older than 50 years who had a supraspinatus and/or infraspinatus tear sagittally smaller than 3 cm and arthroscopically confirmed LHB pathology. During arthroscopic rotator cuff repair, we randomized 48 patients to undergo suprapectoral LHB tenodesis and 52 patients to undergo LHB tenotomy. Data were collected preoperatively and at 6 weeks, 3 months, and 1 year postoperatively. The primary outcome was non-inferiority of the Constant-Murley score (CMS) at 1-year follow-up. Secondary outcomes included the Dutch Oxford Shoulder Score; Disabilities of the Arm, Shoulder and Hand questionnaire; Popeye deformity; elbow flexion strength index; arm cramping pain; and quality of life (EQ-5D score). The integrity of the rotator cuff repair was assessed with magnetic resonance imaging. Differences between intervention groups were analyzed by mixed modeling. RESULTS: The mean CMS in the LHB tenotomy group improved from 44 (95% confidence interval [CI], 39-48) to 73 (95% CI, 68-79). In patients with LHB tenodesis, the mean CMS improved from 42 (95% CI, 37-48) to 78 (95% CI, 74-82). The difference between groups at 1-year follow-up was 4.8 (97.5% CI, -∞ to 11.4), with a P value for non-inferiority of .06. The secondary outcomes also improved over time, with no remarkable differences between groups. A Popeye deformity occurred in 33% of tenodesis patients and 47% of tenotomy patients (P = .17). Tenotomy was performed with a shorter operative time (73 minutes vs 82 minutes, P = .03). Magnetic resonance imaging showed a recurrent rotator cuff tear in 20% of all cases. CONCLUSIONS: Although statistically "inconclusive" regarding non-inferiority of the CMS at 1-year follow-up, any observed differences between patients with LHB tenotomy and those with LHB tenodesis in all outcome scores were small. LEVEL OF EVIDENCE: Level I, randomized controlled trial and treatment study.