Rehabilitation of the painful shoulder.

Managing the painful shoulder in overhead athletes can be difficult because of a lack of time-loss injuries in overhead sports and focusing primarily on either pathoanatomic causes or movement impairments. Although managing the painful shoulder can be challenging, the combination of identifying pathoanatomic causes with movement impairments can provide a more focused rehabilitation approach directed at the causes of shoulder pain. Understanding the potential influence of scapular positioning as well as mobility and/or strength impairments on shoulder pain can help clinicians develop more directed rehabilitation programs. Furthermore, sports-specific methods such as long toss or the use of weighted balls for achieving physiological or performance-based gains have limited empirical evidence regarding their clinical and performance-based benefits, which may impede the rehabilitation process. Applying a comprehensive evaluation approach prior to and throughout the treatment process can assist clinicians with selecting the most appropriate treatment based on patient need. Reconsidering traditional treatments based on existing evidence may help refine the treatment process for overhead athletes with shoulder pain.

Preparing for and Executing the Ideal Posterior Labral Repair.

Posterior labral tears are a source of pain and instability of the shoulder. Despite being relatively uncommon (reported in approximately 10% of instability cases), the incidence of posterior labral tear is increasingly recognized as underestimated in highly active populations. Posterior labral tears can result from a traumatic posterior dislocation or repetitive microtrauma, leading to posterior chondral/labral attrition. Patients often present with vague, deep-seated shoulder discomfort rather than the sensation of instability. Unfavorable results with nonsurgical management will indicate which patients will most benefit from surgery. Arthroscopic stabilization has proven to be an effective and reliable treatment, and many techniques for posterior labral repair have been described. It is important to highlight the evaluation, preparation, and execution of arthroscopic stabilization of an isolated posterior labral repair using high-strength knotless all-suture anchors to allow for a stable, efficient, reproducible, and reliable repair while maintaining a low-profile construct that minimizes damage to the surrounding tissue.

Chronic shoulder injury related to vaccine administration following coronavirus disease 2019 vaccination: a case report.

BACKGROUND: Shoulder injury related to vaccine administration, defined as shoulder pain and limited range of motion occurring after administration in the upper arm, has been previously reported. The symptom resolved completely after treatment with oral nonsteroidal anti-inflammatory drugs or an intraarticular steroid injection, however there have been few reports of long-term symptoms following coronavirus disease 2019 vaccination. This case report describes a healthy, middle-aged, healthcare worker who developed post-vaccination subacromial-subdeltoid bursitis that lasted for more than 6 months after Pfizer-BioNTech coronavirus disease 2019 vaccination. CASE PRESENTATION: A 55-year-old Japanese woman with no significant medical history was vaccinated in the standard site, with the needle direction perpendicular to the skin. Within a few hours after the second vaccination, severe shoulder pain and limited range of motion appeared. Although shoulder range of motion improved, her shoulder pain did not improved for several months, and she consulted an orthopedic doctor 5 months later. Radiographs of her left shoulder did not provide helpful diagnostic information. High intensity in the subacromial-subdeltoid space was seen on short TI inversion recovery of magnetic resonance imaging, showing subacromial-subdeltoid bursitis. She was diagnosed with a shoulder injury related to vaccine administration. The patient was started on an oral anti-inflammatory drug, and the left subacromial space was injected with 2.5 mg of betamethasone with 3 ml of 1% lidocaine without epinephrine every 2 weeks. One month after starting this treatment, since her shoulder pain had not improved, the oral anti-inflammatory drug was switched to tramadol hydrochloride acetaminophen. However, 3 months after switching medication, the shoulder pain continued, and she worked so as to have minimal impact on her shoulder. CONCLUSION: A case of subacromial-subdeltoid bursitis following a second dose of the Pfizer-BioNTech coronavirus disease 2019 vaccine that lasted many months is reported. Injection technique is a modifiable risk factor, the adverse effects of which could potentially be mitigated with appropriate and relevant training of healthcare providers. To prevent this type of case, the appropriate landmark, needle length, and direction should be confirmed.

Dynamic Horizontal Instability of the Acromioclavicular Joint: A Case Report.

CASE: A 19-year-old female patient with a history of shoulder trauma 6 years ago presented with dynamic horizontal instability of the acromioclavicular joint (ACJ). She was treated with open ACJ reconstruction using gracilis allograft and showed a satisfactory clinical result at 1-year follow-up. CONCLUSION: Dynamic pure horizontal instability of the ACJ is a rare entity with only 6 cases reported in the literature. Till now, all reported patients who necessitated surgical treatment failed because of residual instability and/or pain. We present the seventh case of this type with a successful clinical outcome.

Functional and Sport-Specific Outcome Following Traumatic First-Time Shoulder Dislocation and Arthroscopic Surgical Repair in Rock Climbers.

INTRODUCTION: Traumatic shoulder dislocations rank among the most common shoulder injuries in climbers, with rising numbers over the last years. The objective of this study was to analyze the outcome following traumatic first-time shoulder dislocation and subsequent surgical treatment in this population. METHODS: In a retrospective study, climbers who experienced a traumatic shoulder dislocation were treated with an arthroscopic repair of the labrum-ligament complex (LLC). The functional outcome was assessed with a standardized questionnaire and clinical examination, including the Constant Murley and Single Assessment Numeric Evaluation scores. The sport-specific outcome was analyzed using the Union Internationale des Associations d'Alpinisme (UIAA) scale of difficulty and a sport-specific outcome score. RESULTS: The functional and sport-specific outcome for 27 climbers (20 men; 7 women; 3 with bilateral injuries; age, 34±11 [17-61] y; data presented as mean±SD [range]) was assessed 53±29 (12-103) mo after surgery. The postoperative Constant Murley score was 95±8 (67-100) points. At follow-up, 93% (n=25) of patients had started climbing again. Twenty-one climbers (78%) reached a climbing level within the range of ±0.33 UIAA grades of their initial capability or even exceeded their preinjury grade. Only 7% (n=2) of the patients had a recurrent shoulder dislocation, leading to a secondary surgery, and, therefore, required ongoing postoperative treatment at the time of follow-up. CONCLUSIONS: Arthroscopic repair of the LLC following first-time traumatic shoulder dislocation in climbers shows a good outcome and a low recurrence rate. After surgery, most patients are able to regain a high level of rock-climbing ability.

Magnetic resonance arthrographic demonstration of extension of labral defects in paraglenoid labral cysts.

OBJECTIVE: This study aimed to investigate the extension of labral tears associated with paraglenoid labral cysts by magnetic resonance arthrography. METHODS: The magnetic resonance and magnetic resonance arthrography images of patients with paraglenoid labral cysts who presented to our clinic between 2016 and 2018 were examined. In patients with paraglenoid labral cysts, the location of the cysts, the relation between the cyst and the labrum, the location and extent of glenoid labrum damage, and whether there was contrast medium passage into the cysts were investigated. The accuracy of magnetic resonance arthrographic information was evaluated in patients undergoing arthroscopy. RESULTS: In this prospective study, a paraglenoid labral cyst was detected in 20 patients. In 16 patients, there was a defect in the labrum adjacent to the cyst. Seven of these cysts were adjacent to the posterior superior labrum. In 13 patients, there were contrast solution leak into the cyst. For the remaining seven patients, no contrast-medium passage was observed in the cyst. Three patients had sublabral recess anomalies. Two patients had rotator cuff muscle denervation atrophy accompanying the cysts. The cysts of these patients were larger compared to those of the other patients. CONCLUSION: Paraglenoid labral cysts are frequently associated with the rupture of the adjacent labrum. In these patients, symptoms are generally accompanied by secondary labral pathologies. Magnetic resonance arthrography can be successfully used not only to demonstrate the association of the cyst with the joint capsule and labrum, but also to reliably demonstrate the presence and extension of labral defects.

Managing Scapular Dyskinesis.

Scapular dyskinesis, the impairment of optimal scapular position and motion, is common in association with shoulder injury. A comprehensive evaluation process can show the causative factors and lead to effective treatment protocols. The complexity of scapular motion and the integrated relationship between the scapula, humerus, trunk, and legs suggest a need to develop rehabilitation programs that involve all segments working as a unit rather than isolated components. This is best accomplished with an integrated rehabilitation approach that includes rectifying deficits in mobility, strength, and motor control but not overtly focusing on any one area.

Effects of sex and age on work-related upper extremity musculoskeletal disorders in Ontario, Canada.

BACKGROUND: Effective targeting of workplace upper extremity musculoskeletal disorder (MSD) prevention strategies requires the identification of demographic groups most at risk. Workers' compensation data provides an effective means of surveillance of MSDs at the population level. OBJECTIVE: The primary purpose of this study was to identify the effects of age and sex on rates of tendon injuries of the wrist and hand, carpal tunnel syndrome (CTS), epicondylitis, and soft tissue shoulder injuries in Ontario, Canada between 2000-2019 using workers' compensation data from the Association of Workers Compensation Boards of Canada (AWCBC). METHODS: Age and sex specific rates of lost-time injury claims from the four identified injury categories as well as "non-specific" upper extremity MSDs which did not fit into the four categories were calculated by standardizing injury claim totals with "at-risk" population estimates from the Canada Labour Force Survey. A multiple regression analysis was used to analyze the effects of age and sex on rates of specific injury claims. RESULTS: Statistically significant age and sex effects were identified for rates of claims from tendon injuries of the wrist and hand, CTS, and shoulder injuries, while only age effects were significant for epicondylitis. Between 2000-2019, rates of claims from the four injury categories studied and the magnitude of the age and sex effects declined substantially over time. CONCLUSION: Detailed surveillance of workplace ergonomic hazards in Ontario workplaces is needed to determine what is causing rates of upper extremity claims to decline.

Childhood and Adolescent Sports-Related Overuse Injuries.

Childhood and adolescent sports participation is encouraged because of health and wellness benefits. However, the increasing number of young athletes means there is the potential for more sports-related overuse injuries. Most youth sports injuries occur at the bone's relatively weaker growth centers: the epiphyses and apophyses. Little league shoulder and elbow are common overuse injuries in baseball and other single-arm dominant sports. Little league shoulder is a Salter-Harris fracture of the proximal humerus, and little league elbow is an apophysitis of the medial epicondyle. In both injuries, the athlete often reports decreased throwing velocity or accuracy. The physician should emphasize the Major League Baseball Pitch Smart guidelines when counseling on rehabilitation and prevention. Gymnast's wrist is a distal radial epiphysis injury in which the patient reports chronic wrist pain. Gymnast's wrist should be managed conservatively with immobilization. Spondylolysis is an important cause of overuse back pain in young athletes and can progress to spondylolisthesis. Patellofemoral pain syndrome presents with anterior knee pain, often made worse with running or descending stairs and improved with physical therapy. Osgood-Schlatter disease and Sinding-Larsen-Johansson disease are forms of knee apophysitis. Calcaneal apophysitis is a common cause of heel pain in young athletes and can be diagnosed clinically with the calcaneal squeeze test. Calcaneal apophysitis is treated conservatively, with good evidence for the use of heel cups and physical therapy.

Shoulder Pain and Injury after COVID-19 Vaccination.

Shoulder injury related to vaccine administration (SIRVA) is a term given to describe shoulder pain and dysfunction arising within 48 hours after vaccine administration and lasting for more than one week. While SIRVA is most commonly seen after influenza and tetanus vaccines, there have been a few recent case reports describing SIRVA-like symptoms after COVID-19 vaccine administration. Two patients presented to the shoulder surgeon's practice center with complaints of shoulder stiffness and pain following the COVID-19 vaccine. The first patient was a 33-year-old man; he presented within 2 days of onset of the pain and 14 days from the vaccine date. He had a complete restriction of shoulder motion (0° flexion, and no external or internal rotation) at presentation. This patient was treated with non-steroidal anti-inflammatory drugs (NSAID) and rested in a sling for a week. The second patient was a 53-year-old woman; she presented with a 6-week duration of mild restriction of active shoulder motion and shoulder pain. Her magnetic resonance imaging (MRI) revealed the presence of subacromial-subdeltoid bursitis. She was treated with subacromial steroid injection and range of motion shoulder exercises. Both patients recovered a near-normal range of motion recovery within a month, and their pain improved significantly. The main lessons from this case report were: (1) patients presenting with a recent increase in pain and acute loss of shoulder movements after vaccination may be managed conservatively with rest and NSAID medications and (2) in case of a subacromial-subdeltoid bursitis in the MRI, subacromial injection of steroid may provide good pain relief.

Protocolo de fisioterapia y educación para la salud en dolor crónico de hombro de origen musculoesquelético. Experiencia en atención primaria / Physiotherapy and health education protocol in chronic musculoskeletal shoulder pain. Experience in Primary Care

Objetivo: Evaluar la experiencia de un programa de educación para la salud en atención primaria en pacientes con dolor de hombro crónico de origen musculoesquelético, sobre el dolor y la discapacidad e instaurar el protocolo en atención primaria. Diseño: Estudio observacional descriptivo longitudinal quasi-experimental. Emplazamiento: Centro de Salud Arroyo de la Vega. Alcobendas, Madrid. Participantes: Pacientes remitidos por su médico de atención primaria a la unidad de fisioterapia de atención primaria por dolor de hombro de origen musculoesquelético. Intervención: Siete sesiones grupales de educación para la salud y ejercicio terapéutico. Mediciones principales: Se valoró la intensidad del dolor a través de la escala visual analógica, la discapacidad del miembro superior con el cuestionario Disabilities of the Arm, Shoulder and Hand y el nivel de discapacidad y dolor de hombro con el questionario Shoulder Pain and Disability Index. Resultados: Se encontraron diferencias estadísticamente significativas en la reducción del dolor y la discapacidad (p<0,01), además se redujo el consumo de fármacos y las recidivas. Conclusiones: El protocolo de fisioterapia de hombro con educación para la salud fue eficaz para reducir el dolor y la discapacidad en pacientes con dolor de hombro crónico, de origen musculoesquelético, en atención primaria.(AU)

Objective: To evaluate the experiencie with a health education program in Primary Care in patients with chronic shoulder pain of musculoskeletal origin, on pain and disability and establish the protocol in primary care. Design: Quasi-experimental longitudinal descriptive observational study. Location: Arroyo de la Vega Health Center, Alcobendas, Madrid. Participants: Patients referred by their Primary Care Physician to the Primary Care Physiotherapy Unit for shoulder pain of musculoskeletal origin. Intervention: 7 group sessions of health education and therapeutic exercise. Main measurements: Pain intensity was assessed through the Visual Analogue Scale (VAS), the disability of the upper limb with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and the level of disability and shoulder pain with the Shoulder Pain and Disability Index (SPADI) questionnaire. Results: Statistically significant differences were found in the reduction of pain and disability (P<.01), in addition, drug use and recurrences were reduced. Conclusions: The shoulder physiotherapy protocol with health education was effective in reducing pain and disability in patients with chronic shoulder pain of musculoskeletal origin in Primary Care.(AU)

High Incidence of Combined and Posterior Labral Tears in Military Patients With Operative Shoulder Instability.

BACKGROUND: Anterior shoulder instability is the pattern most commonly reported in the civilian population, but military servicemembers may represent a unique population. At 1.7 per 1000 person-years, servicemembers not only have a higher incidence of instability events compared with civilians (reported rate of 0.2-0.8), but the distribution of labral tears in the military may differ significantly as well. HYPOTHESIS: The incidence of combined and posterior labral tears in the military population will be greater than numbers previously reported. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: The Wounded, Ill, and Injured Registry, a Department of Defense patient reported outcomes data collection platform that includes all military branches, was queried retrospectively for all patients who had undergone a primary arthroscopic or open shoulder stabilization procedure (Current Procedural Terminology codes 29806, 23455, 23462) between October 2016 and January 2019. Demographic information was obtained through intake forms completed by patients at the time of enrollment into the Military Orthopaedics Tracking Injuries and Outcomes Network. Tear location was determined arthroscopically and labeled as anterior, inferior, posterior, superior, or any combination thereof. Chi-square analysis was used to compare the percentage of patients with isolated anterior, isolated posterior, isolated inferior, or combined labral tears in the current study cohort with those in a previously reported cohort of patients with operative shoulder instability at a single military treatment facility. RESULTS: A total of 311 patients were included who had undergone primary shoulder stabilization during the study period. Of these patients, 94 (30.2%) had isolated anterior tears, 76 (24.4%) had isolated posterior tears, and 136 (43.7%) had combined tears. We observed a higher percentage of combined tears in our data set than in a data set from a single military treatment facility (χ2(2) = 48.2; P < .00001). Chi-square analysis demonstrated that significantly more female patients had an isolated anterior labral tear (51.2%) compared with male patients (27.1%; χ2(2) = 9.4; P = .009). CONCLUSION: The incidence of combined and posterior labral tears in the military population is greater than numbers previously reported in both military and civilian populations.

Concomitant glenohumeral injuries in patients with distal clavicle fractures undergoing arthroscopic-assisted surgery: a systematic review.

BACKGROUND: To determine the incidence of concomitant intra-articular glenohumeral injuries in patients undergoing surgical management from distal clavicle fractures (DCF) with shoulder arthroscopy and their impact on outcome. METHODS: This systematic review was conducted following the PRISMA guidelines. PubMed, EMBASE, and Virtual Health Library databases were accessed in October 2021. All the clinical studies evaluating the surgical management of DCF and using concomitant intra-operatory shoulder arthroscopy were included. Studies that did not specify the concomitant injury type were not eligible. Data from the incidence of intra-articular glenohumeral injuries, injury type, length of the follow-up, and clinical outcomes were retrieved. The quantitative content assessment was performed using the STROBE statement checklist. Evaluation of the publication bias of the included studies was performed using the risk of bias assessment tool for systematic reviews. RESULTS: Data from five retrospective and five prospective cohort studies were analyzed. Eight of the included studies were conducted on patient cohorts with Neer type II injuries. Data pooling revealed a mean of 17.70% of concomitant glenohumeral injuries, whereas 84.21% of them required additional surgical management (Table 1). Rotator cuff injuries, labral tears, and biceps pulley lesions were the most common concomitant injuries. CONCLUSION: Preoperative MRI or diagnostic arthroscopy to evaluate glenohumeral associated injuries to DCF should be recommended.

Treatment of a Combined Pectoralis Major Tear, Anterior Labral Tear, and Humeral Avulsion of the Glenohumeral Ligament (HAGL) in an Active Duty Soldier.

Anterior glenohumeral instability is an increasingly common injury among young military servicemen. First-time dislocations occurring in combination with anterior labral tears and humeral avulsion of glenohumeral ligament lesions, although rare, significantly contribute to further shoulder dysfunction with recurrent instability and pain. Tears of the pectoralis major are also a type of injury more common in the military population, with operative management resulting in decreased strength. We present a unique case of a young, active duty male that sustains an anterior shoulder dislocation with a concomitant pectoralis major tendon rupture while bench press weight lifting in preparation for the Army Special Forces selection. To the best of our knowledge, this is the first case presented in the literature describing management of a simultaneous anterior shoulder dislocation, humeral avulsion of glenohumeral ligament lesion, and pectoralis major tendon rupture treated with a single operation. After aggressive rehabilitation, the patient was able to successfully pass Special Forces selection and has near full function of the operative shoulder with remarkable satisfaction scores.

Patterns of Nerve Injury and Recovery Rates of Infraclavicular Brachial Plexus Lesions Following Anterior Shoulder Dislocation.

PURPOSE: We reviewed our cases of infraclavicular brachial plexus injuries associated with anterior shoulder dislocation to determine patterns of injury, recovery rates, and factors associated with a poor motor outcome. METHODS: This was a retrospective review of patients who had sustained a concomitant nerve injury following dislocation of the glenohumeral joint treated with closed manipulation. The data collected included patient demographics, injury factors, and patterns of neurological deficits. The Medical Research Council (MRC) grade for motor power was the primary outcome measure, where a grade of 4 or 5 was regarded as achieving good motor recovery. Univariate and multivariable analyses were used to identify factors associated with persistent motor weakness (MRC grades 0-3) at the final follow-up. RESULTS: Between 2015 and 2019, 61 patients were assessed. There were 36 males and 25 females, with a median age of 64 years (interquartile range [IQR], 53-73 years). Four patterns of injury were identified: (1) isolated axillary nerve lesions; (2) single cord lesions; (3) combined lesions involving the medial and posterior cords; and (4) diffuse lesions affecting all 3 cords. Of 28 patients with isolated axillary nerve injuries, 22 recovered. All lateral cord injuries (11/11) and 20 of 24 posterior cord injuries recovered spontaneously. Recovery of hand intrinsic function from medial cord injuries had the worst outcome, with 14 of 27 patients not recovering beyond MRC grades 0 to 3. The median duration of dislocation before reduction was 6 hours (IQR, 3-12 hours). A multivariate analysis showed an association between the duration of shoulder dislocation and the likelihood of persistent motor weakness. CONCLUSIONS: Shoulder dislocations with motor deficits should be regarded as orthopedic emergencies and reduced expediently. Persistent motor weakness may be associated with a prolonged duration of dislocation prior to glenohumeral relocation. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Circumferential shoulder laceration after posterior axilla sling traction: a case report of severe shoulder dystocia.

BACKGROUND: Shoulder dystocia is an unpredictable and potentially catastrophic complication of vertex vaginal delivery. Posterior axilla sling traction (PAST) has recently been proposed as a method to resolve severe shoulder dystocia when commonly used techniques have failed. CASE PRESENTATION: A 33-year-old woman (gravida 5, para 0) at 35 weeks, 1 day gestation underwent induction of labor for poorly controlled type 2 diabetes mellitus. Delivery of the large-for-gestational-age infant (4,060 g) was complicated by intractable shoulder dystocia, relieved at 3 minutes with PAST, resulting in a deep, circumferential laceration of the fetal posterior shoulder and contralateral phrenic nerve palsy. CONCLUSIONS: PAST provides a potentially lifesaving option during intractable shoulder dystocia. Simulation or education about the technique facilitates its use when standard maneuvers fail. It is important to disseminate information about potential complications associated with these novel maneuvers.

Career Longevity and Performance After Shoulder Instability in National Football League Athletes.

PURPOSE: To investigate the career longevity, game utilization, and performance of National Football League (NFL) athletes after glenohumeral instability events treated operatively versus nonoperatively. METHODS: Using public resources, we identified NFL players who sustained a shoulder instability event from September 2000 to February 2019. Players with prior shoulder instability, without NFL experience before injury, or who did not return to play (RTP) after injury were excluded. Demographic information, utilization (games and seasons), and season approximate value (SAV) statistics were recorded 1 year prior to injury and 3 years after RTP. Statistical analysis compared utilization and the SAV after RTP for athletes managed operatively versus nonoperatively. RESULTS: We identified 97 NFL players who sustained their first instability event while playing in the NFL, 91 of whom returned to play (93.8%). Quarterbacks were significantly more likely to undergo immediate surgical management compared with players in other positions (P = .023). The final analysis included 58 players managed operatively and 33 managed nonoperatively by the end of the index season. Players treated operatively played in significantly more seasons after RTP during their remaining careers (4.1 ± 2.7 seasons vs 2.8 ± 2.5 seasons, P = .015). There were no differences in games played or started, offensive or defensive snap count percentage, or performance (SAV) before and after injury when compared between cohorts (P > .05). After surgical stabilization, time to RTP (36.62 ± 10.32 weeks vs 5.43 ± 12.33 weeks, P < .05) and time interval before recurrent instability (105.7 ± 100.1 weeks vs 24.7 ± 40.6 weeks, P < .001) were significantly longer than with nonoperative treatment. Additionally, the operative cohort experienced less recurrent instability (27% vs 50%, P = .035). CONCLUSIONS: Athletes who RTP in the NFL after a shoulder instability injury do so with a similar workload and performance irrespective of surgical or nonsurgical management. Whereas nonoperative treatment is associated with faster RTP, operative management is associated with fewer recurrent instability events, greater time between recurrent instability events, and greater career longevity. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

No differences between conservative and surgical management of acromioclavicular joint osteoarthritis: a scoping review.

PURPOSE: To conduct a scoping review to clarify the management of acromioclavicular joint osteoarthritis, as well as to identify any existing gaps in the current knowledge. METHODS: Studies were identified by electronic databases (Ovid, Pubmed) from their inception up to April 2nd, 2020. All studies reporting functional outcomes after conservative or surgical treatment of acromioclavicular joint osteoarthritis, either primary or secondary to trauma or distal clavicle osteolysis, were included. Following data were extracted: authors, year of publication, study design (prospective or retrospective), LOE, number of shoulders treated conservatively or surgically, patients' age, OA classification, type of conservative treatment, surgical approach, surgical technique, functional outcomes, complications, revisions, and length of follow-up. Descriptive statistics was used. Quality appraisal was assessed through the Cochrane risk of bias tool for LOE I/II studies, while the MINORS checklist was used for LOE III/IV studies. RESULTS: Nineteen studies were included for a total of 861 shoulders. Mean age of participants was 48.5 ± 7.4 years. Mean follow-up was 43.8 ± 29.9 months. Four studies reported functional results after conservative treatment, whereas 15 studies were focused on surgical management. No studies directly compared conservative and surgical treatment. Seven studies reported a surgical approach after failure of previous conservative treatment. All studies reported functional improvement and pain relief. Complication rate was low. Overall methodological quality of included studies was very low. CONCLUSION: Conservative and surgical treatments are both effective in acromioclavicular joint osteoarthritis management. However, available data did not allow to establish the superiority of one technique over another. LEVEL OF EVIDENCE: Level IV.

Operative Treatment of Anterior Shoulder Instability A Network Meta-Analysis.

BACKGROUND: Traumatic anterior shoulder instability is a common clinical problem among athletic populations, with several surgical treatment options available. The optimal treatment remains undetermined. Currently the main current treatment options are the Latarjet procedure or open or arthroscopic Bankart repair. The purpose of this study was to network meta-analyze the recent evidence to ascertain if the open Latarjet procedure and open or arthroscopic Bankart repair result in lower recurrence rates and subsequent revision procedures. The results were ranked with the P-score. METHODS: A literature search was performed based on the PRISMA guidelines. Cohort studies comparing any of the open Latarjet procedure and open or arthrosopic Bankart repair for anterior shoulder instability were included. Clinical outcomes were compared using a frequentist approach to network meta-analysis, with statistical analysis performed using R. RESULTS: Twenty-nine studies with 2,474 patients were included. The open Latarjet procedure resulted in lower rates of recurrent instability and revisions due to recurrence compared to both open and arthroscopic Bankart repairs. The open Latarjet procedure resulted in the highest rate of return to play. However, the open Latarjet procedure also resulted in the highest complication rate. CONCLUSION: Our network meta-analysis found the open Latarjet procedure had the lowest recurrence rates, lowest revisions rates, and highest rates of return to play in the surgical treatment of anterior shoulder instability. However, the Latarjet procedure has been shown to result in a higher complication rate, which needs to be considered when deciding which stabilization procedure to perform.

Outcomes of Revision Surgery for a Failed Prior Latarjet Procedure A Systematic Review.

PURPOSE: This study systematically reviewed the literature for outcomes following revision surgery for a failed prior Latarjet procedure. METHODS: Two independent reviewers performed the literature search based on PRISMA guidelines using the EMBASE, MEDLINE, and The Cochrane Library databases. Studies in which the Latarjet procedure was performed as a revision procedure following failed prior shoulder instability surgery were included. Clinical outcomes analyzed were: 1. functional outcomes, 2. recurrent instability, 3. range of motion, and 4. COMPLICATIONS: Statistical analysis was performed using IBM SPSS. RESULTS: There were seven studies with 161 patients (162 shoulders) included. Four studies used a bone-block procedure, three used arthroscopic soft-tissue stabilization, and the mean follow-up was 49.8 months. The most commonly reported functional outcome measure was the Rowe score, with a weighted mean average of 79.7, with 82.9% of patients having good to excellent outcomes. Return to play was possible for 73.8% of patients, with 64.2% of those returning to at least the same level of competition. The overall recurrence rate was 9.5%, with 3.6% and 5.9% experiencing recurrent dislocations and subluxations, respectively. The overall revision rate was 4.2%, with all patients undergoing revisions due to recurrence. There were no reported neurovascular complications. Instability arthropathy was reported in 43.3% of patients. CONCLUSION: Surgical management following a failed Latarjet procedure results in moderate rates of recurrent instability and has a low intraoperative and postoperative complication rate. Additionally, the results across all techniques appear similar, with no procedure being identified as the gold-standard in the literature. However, there was a concerning rate of instability arthropathy, which may be related to the failure of a bony procedure.