A modified Delphi study to identify which items should be evaluated in shoulder instability research: a first step in developing a core outcome set.

Background: The aim of this study was to identify items that healthcare providers and/or patients consider important to include in a questionnaire for clinical trials and cohort studies in shoulder instability research. This could serve as a basis to develop a core outcome set for shoulder instability research. Methods: Healthcare providers and patients were included in a panel for a modified Delphi consensus study. The study consisted of three rounds, comprising (1) identifying items, (2) rating the importance of the items, and (3) rating the importance again after seeing a summary of the results of round two. Importance was rated on a 9-point Likert scale. Consensus was defined as ≥ 80% of the panel giving a score of 7 or higher. Results: In total, 44 healthcare providers and 30 patients completed all three rounds. Round one identified 54 items. After round three, the panel reached a consensus on 11 items that should be included in a questionnaire, comprising re-dislocation (99%), instable feeling of the shoulder (96%), limitations during sport (93%), patient satisfaction with the shoulder (93%), fear/anxiety for re-dislocation (91%), range of motion (88%), return to old level of functioning (85%), performing daily activities (85%), return to sport (82%), return to work (82%), and trusting the shoulder (81%). Conclusion: Healthcare providers and patients reached a consensus on 11 items that should be included in a questionnaire for shoulder instability research. These items can facilitate design and development of future clinical trials and form the basis for the development of a core outcome set.

Surgical Intervention Following a First Traumatic Anterior Shoulder Dislocation Is Worthy of Consideration.

Up to 60% of patients experience recurrence after a first traumatic anterior shoulder dislocation (FTASD), which is often defined as having experienced either dislocation or subluxation. Thus surgical intervention after FTASD is worthy of consideration and is guided by the number of patients who need to receive surgical intervention to prevent 1 redislocation (i.e., number needed to treat), (subjective) health benefit, complication risk, and costs. Operative intervention through arthroscopic stabilization can be successful in reducing recurrence risk in FTASD, as has been shown in multiple randomized controlled trials. Nevertheless, there is a large "gray area" for the indication of arthroscopic stabilization, and it is therefore heavily debated which patients should receive operative treatment. Previous trials showed widely varying redislocation rates in both the intervention and control group, meta-analysis shows 2% to 19% after operative and 20% to 75% after nonoperative treatment, and redislocation rates may not correlate with patient-reported outcomes. The literature is quite heterogeneous, and a major confounder is time to follow-up. Furthermore, there is insufficient standardization of reporting of outcomes and no consensus on definition of risk factors. As a result, surgery is a reasonable intervention for FTASD patients, but in which patients it best prevents redislocation requires additional refinement.

Concurrent intraosseous cartilaginous lesions in patients with multiple osteochondromas identified on total-body MR imaging.

PURPOSE: To assess the prevalence of intraosseous cartilaginous lesions in patients with multiple osteochondromas based on total-body (TB) MRI examinations, used for screening purposes. SUBJECTS AND METHODS: Between 2013 and 2020, TB-MRI examinations were performed in 366 patients with proven multiple osteochondromas syndrome, to rule out malignant progression. For this study, presence, or absence of intraosseous central or eccentrical chondroid lesions, defined as lobulated lesions with low signal intensity on T1-weighted images, replacing bone marrow and high signal intensity equal to fluid on T2-weighted images in the bone marrow of the meta-diaphysis of (one of) the long bones, were recorded in the long bones as part of a TB-MRI protocol. RESULTS: In 62 patients out of the 366 MO patients (17%), one or more intraosseous chondroid lesions (either enchondroma or atypical cartilaginous tumor) were detected. The age of the patients at time of diagnosis ranged from 17 to 61 years (mean, 36). Size of the lesions varied from 4 to 69 mm (mean, 16.3 mm). The most common location was the proximal femur (n = 29), followed by the distal femur and proximal humerus (n = 18 and n = 10, respectively). In nine of the patients with an intraosseous chondroid lesion, a second and/or third TB-MRI were available during the period of evaluation (mean interval, 2.7 years between the exams). In none of these patients increase of these intraosseous lesions was noticed. CONCLUSION: Intraosseous chondroid lesions (enchondroma and ACT) appear to occur more frequently in MO patients than in the general population. TB-MRI allows to detect these, besides the identification of OC with suspicious features.

High resorption rates following glenoid augmentation procedures do not seem to lead to higher recurrence rates or worse clinical outcomes: a systematic review and meta-analysis.

PURPOSE: Bone augmentation techniques show a relatively high complication rate, which might be due to graft non-union and resorption. It is unclear which augmentation techniques demonstrate the highest amount of non-union and resorption and whether this leads to worse clinical or functional outcomes. Therefore, the aim of this review was (i) to compare non-union and resorption rates between surgical approaches, procedures, graft types, donor sites and fixation methods regarding clinical and functional outcomes and (ii) determine whether high non-union or resorption rates lead to less favorable clinical or functional outcomes. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statements were followed. PubMed, EMBASE (Ovid) and Cochrane Library were searched on December 15th 2021 for studies examining bone graft non-union or resorption using radiograph or CT following glenoid augmentation to treat anterior shoulder dislocation. RESULTS: The search resulted in 103 inclusions, comprising 5,128 glenoid augmentations. When comparing pooled proportions of bony union, graft fracture rate, hardware failure rate, recurrence rate, return to sports and Rowe score, most results were similar between approaches, procedures, graft types, donor sites and fixation methods. High resorption rates were seen for allograft augmentation (74.3; 95% CI: 39.8-92.7) compared to autograft augmentation (15.5; 95% CI 10.1-23.2), but this was not associated with higher recurrence rates or worse clinical outcomes. Meta-analyses (8 studies; 494 patients) demonstrated no difference in incomplete and complete non-union rates between arthroscopic and open procedures; however, both analyses showed substantial heterogeneity. Higher partial resorption rates were observed on CT (48.0; 95% CI 43.3-52.7) compared to radiograph (14.1; 95% CI 10.9-18.1). Three studies comprising 267 shoulders demonstrated a higher rate of non-union and recurrence in smokers, whereas one study comprising 38 shoulders did not. CONCLUSION: Non-union and resorption rates were similar among procedures, grafts and fixation methods. Higher resorption rates were observed in allografts, but this was not associated with higher recurrence rates or worse clinical outcomes. Pooling data demonstrated substantial heterogeneity and definitions varied among studies, warranting more standardized measuring. LEVEL OF EVIDENCE: IV.

Greater tuberosity fractures are not a continuation of Hill-Sachs lesions, but do they have a similar etiology?

Background: It is unclear whether greater tuberosity fractures (GTF) in the setting of a shoulder dislocation are due to an avulsion of the rotator cuff or a result of an extensive Hill-Sachs lesion (HSL). To explore whether these lesions have similar etiology, the primary aim of this study is to compare the postinjury morphology of the proximal humerus after GTF and HSL. Methods: Computed tomography scans of 19 patients with HSL and 18 patients with GTF after first-time shoulder dislocations were analyzed. We assessed the location by measuring height in relation to the highest point of the humerus and angles for the origin (most medial point of lesion), center, and endpoint (most lateral point of lesion) between GTF and HSL and the bicipital groove. For both GTF and HSL, we assessed whether infraspinatus and supraspinatus insertions were involved and whether they were off-track or on-track. Results: Measured from the bicipital groove, HSLs and GTFs have different origins (153˚ vs. 110˚; P < .0001, respectively), centers (125˚ vs. 60˚; P < .0001, respectively), and endpoints (92˚ vs. 37˚; P < .0001, respectively). HSLs had a higher position (0.76 cm vs. 1.71 cm; P < .0001), involved the supraspinatus footprint less often (16% vs. 72%; P = .0008), and were less likely to be off-track (31% vs. 94%; P = .0002). Half of the GTF were on the lateral side of the glenoid track and thus extra-capsular, versus 0% of HSL. Conclusion: HSLs and GTFs have different anatomical characteristics and thus GTFs are likely to be distinct from extensive HSLs.

[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.

Ultrasound of the neonatal hip as a screening tool for DDH: how to screen and differences in screening programs between European countries.

Developmental dysplasia of the hip comprises a broad spectrum of abnormalities in hip development, of variable severity. Besides physical examination, ultrasound is the preferred imaging modality for screening for developmental dysplasia of the hip in children aged younger than six months. The Graf method is the most widely used ultrasound technique for infant hips; a stepwise approach will be shown in this article. Furthermore, the process of dynamic ultrasound imaging will be explained as well as the use of transinguinal ultrasound in infants wearing a spica cast. There is no consensus on the best way to screen for developmental dysplasia of the hip, which is probably the reason why different screening programs exist throughout Europe, as will be discussed in this article. The use of universal versus selective ultrasound remains a controversy, as does the timing. Is it better to perform sonography in all newborn infants like in Germany and Austria? Or should we examine only the infants with clinical hip instability or risk factors (breech position, positive family history), like in the UK and the Netherlands? This article reviews the epidemiology, static and dynamic ultrasound techniques in screening for developmental dysplasia of the hip, and differences in screening programs throughout Europe. Set aside the uncertainties about whom and when to screen, it needs to be emphasized that ultrasound screening for developmental dysplasia of the hip is important, since the disease is initially occult and easier to treat when identified early. In this way, the radiologist can aid in preventing serious disability of the hip.

Identifying predictive factors for vertebral collapse fractures in multiple myeloma patients.

BACKGROUND CONTEXT: Vertebral compression fractures (VCFs) are a common complication for patients with multiple myeloma. These fractures are associated with significant morbidity and mortality due to severe back pain, spinal instability, increased risk of new fractures, neurologic dysfunction, and other physical symptoms. PURPOSE: To identify risk factors associated with the development of VCFs which may help to predict them in future patients. STUDY DESIGN: A retrospective multicenter cohort study. PATIENT SAMPLE: Patients with multiple myeloma diagnosed between 2012 and 2018 and appropriate baseline- and follow-up imaging studies (>6 months after diagnosis) were included. OUTCOME MEASURES: Individual odds ratios for each of the fifteen potential risk factors including patient factors and radiographical characteristics. METHODS: Relevant clinical baseline data were extracted from the patient charts. Computed tomography (CT) scans were used to score all radiographic variables. VCFs were graded following the Genant grading system. General Linear Mixed Models were used to analyze risk factors associated with vertebral fractures. RESULTS: A total of 143 patients with 1,605 eligible vertebrae were included in the study with a mean follow-up time of 25 months. Mean age at diagnosis was 65 years and 39% were female. Among 1,605 vertebrae, there were 192 (12%) VCFs (Genant grade 1 or higher) at the time of diagnosis and 111 (7%) occurred during follow-up. In a General Linear Mixed Model, significant predictors were gender (odds ratio [OR]=1.5), International Staging System stage 2 and 3 (OR=3.6 and OR=4.1 respectively), and back pain (OR=2.7). Furthermore, lower Hounsfield Unit score, lytic lesions and abnormal alignment were risk factors for (the development of) VCFs. CONCLUSIONS: This study investigated both patient characteristics and vertebra-specific risk factors for VFCs in multiple myeloma patients. The factors found in this study might be useful for identifying patients at higher risk of VFCs to help clinical management to prevent vertebral collapse and the development of spinal deformities.

Tennis elbow.

Tennis elbow is the most common cause of lateral-sided elbow pain with a major socioeconomic impact. The etiology of tennis elbow is not completely understood, but there are many different treatment options. This review gives an overview of the current concepts of diagnosis and treatment of tennis elbow and the impact on work participation.

Skeletal maturity of children with multiple osteochondromas: is diminished stature due to a systemic influence?

BACKGROUND: Multiple ostechondromas (MO) is an autosomal dominant inherited disease caused by mutated exostosin genes. It mostly affects the long bones and can lead to growth disturbances, especially disproportionate short stature. Both the local effect on growth plates and the systemic influence of the gene disorder on growth mechanisms might explain the diminished stature. PURPOSE: The hypothesis of this study is that the diminished stature in adults with MO is due to a systemic influence, leading to early skeletal maturation and early closure of the growth plate. Therefore, in these patients the skeletal age in adolescence is hypothesized to be higher than the calendar age. METHODS: Radiographs of the left hand were collected from 50 MO-affected children. The skeletal age was calculated using these radiographs according to the Greulich-Pyle bone scale and was compared to the calendar age at the time of radiography. RESULTS: Children aged 3-12 years had a significantly lower skeletal age compared to their calendar age (p = 0.030). Children aged 12-17 years had a significantly higher skeletal age (p = 0.019), especially boys. Skeletal maturation in children with MO therefore differs from their peers. CONCLUSION: In this study, the skeletal age in younger children with MO is lower than their calendar age. For adolescents, particularly boys, this is reversed, suggesting an earlier or faster closure of the growth plates. These findings support a systemic influence of the gene defect on growth rate.

Intraosseous atypical chondroid tumor or chondrosarcoma grade 1 in patients with multiple osteochondromas.

BACKGROUND: The autosomal dominant condition multiple osteochondromas, formerly called multiple hereditary exostoses, is associated with a risk of malignant progression of osteochondroma into secondary peripheral chondrosarcoma. Most patients with multiple osteochondromas have exostosin-1 or exostosin-2 gene mutations. To our knowledge, it has not been previously reported that patients may also harbor intraosseous (central) chondroid neoplasms, enchondromas, or atypical chondroid tumors or central chondrosarcomas. The combination of osteochondroma and enchondromas also exists in patients with metachondromatosis, a disorder associated with a protein tyrosine phosphatase non-receptor type 11 gene mutation. This study aims to establish any correlation between multiple osteochondromas and intraosseous cartilaginous neoplasms. METHODS: We retrospectively reviewed all histologically proven intraosseous atypical chondroid tumors or chondrosarcomas in our prospective nationwide Dutch tertiary referral multiple osteochondromas database. Demographic, clinical, radiographic, histological, and genetic data were recorded. The institutional medical ethics review board approved the study. RESULTS: From 195 adult patients, seven (3.6%) were identified with intraosseous atypical chondroid tumor or chondrosarcoma World Health Organization grade 1 and had a mean age of forty-two years; five of these patients were male. In all cases, radiographic and genetic findings were consistent with multiple osteochondromas, not metachondromatosis; three patients had an exostosin-1 mutation, four patients had an exostosin-2 mutation, and no patients had a protein tyrosine phosphatase, non-receptor type 11 mutation. Six patients underwent successful operative treatment without complications or recurrences after a mean follow-up duration of forty-eight months (range, twelve to 144 months). One patient was scheduled for surgery after biopsy and histologic confirmation. Of the seven patients, five (71%) also developed a peripheral chondrosarcoma in a known osteochondroma during the study period. CONCLUSIONS: Apart from osteochondromas or peripheral chondrosarcomas, multiple osteochondromas are also associated with intraosseous chondroid neoplasms, potentially resulting in central chondrosarcoma. Therefore, intraosseous lesions should not automatically be regarded as innocuous in this patient population.

The diagnostic value of the combination of patient characteristics, history, and clinical shoulder tests for the diagnosis of rotator cuff tear.

BACKGROUND: It is unknown which combination of patient information and clinical tests might be optimal for the diagnosis of rotator cuff tears. This study aimed to determine the diagnostic value of nine individual clinical tests for evaluating rotator cuff tear and to develop a prediction model for diagnosing rotator cuff tear. METHODS: This prospective cohort study included 169 patients with shoulder complaints. Patients who reported a previous shoulder dislocation were excluded from the analysis (N = 69). One experienced clinician conducted 25 clinical tests of which 9 are specifically designed to diagnose rotator cuff pathology (empty can, Neer, Hawkins-Kenney, drop arm, lift-off test, painful arc, external rotation lag sign, drop sign, infraspinatus muscle strength test). The final diagnosis, based on magnetic resonance arthrography (MRA), was determined by consensus between the clinician and a radiologist, who were blinded to patient information. A prediction model was developed by logistic regression analysis. RESULTS AND DISCUSSION: In this cohort, 38 patients were diagnosed with rotator cuff tears. The individual overall accuracy of the rotator cuff clinical tests was 61%-75%. After backward selection, the model determined that the most important predictors of rotator cuff tears were higher age and a positive Neer test. This internally validated prediction model had good discriminative ability (area under the receiver operating characteristic curve (AUC) = 0.73). CONCLUSION: Our results showed that individual clinical shoulder tests had moderate diagnostic value for diagnosing rotator cuff tear. Our prediction model showed improved diagnostic value. However, the prediction value is still relatively low, supporting a low threshold for additional diagnostic tests for the diagnosis of rotator cuff tears. LEVEL OF EVIDENCE: Study of diagnostic test: level I.

Complications After Facial Injections With Permanent Fillers: Important Limitations and Considerations of MRI Evaluation.

BACKGROUND: Soft-tissue fillers have become more prevalent for facial augmentation in the last 2 decades, even though complications of permanent fillers can be challenging to treat. An investigative imaging tool could aid in assessing the nature and extent of these complications when clinical findings are ambiguous. OBJECTIVES: The authors analyzed the value of magnetic resonance imaging (MRI) in the assessment of delayed-onset complications after injection of patients with permanent fillers. METHODS: Thirty-two patients with complications related to facial fillers were evaluated in this prospective cohort study. Their medical history was documented, and MRI was conducted before treatment of the complications. Radiologists were informed of the injection sites but were blinded to the results of other clinical evaluations. Levels of agreement between clinical and radiologic findings were calculated with the Jaccard similarity coefficient. RESULTS: A total of 107 site-specific clinicoradiologic evaluations were analyzed. The level of agreement was assessed as strong for deposits without complications and noninflammatory nodules (combined 85%), moderate for abscesses (60%), fair for low-grade inflammations (32%), and slight for migrations (9%). Results from the MRI examinations aided in subsequent treatment decisions in 11% of cases. CONCLUSIONS: Study results show that MRI may be useful for diagnosing complications associated with fillers that have migratory potential, for depiction of the extent of deposits before treatment, and for follow-up of low-grade inflammation and abscesses after surgery. LEVEL OF EVIDENCE: 3.

Guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopaedic Association.

Treatment of "subacromial impingement syndrome" of the shoulder has changed drastically in the past decade. The anatomical explanation as "impingement" of the rotator cuff is not sufficient to cover the pathology. "Subacromial pain syndrome", SAPS, describes the condition better. A working group formed from a number of Dutch specialist societies, joined by the Dutch Orthopedic Association, has produced a guideline based on the available scientific evidence. This resulted in a new outlook for the treatment of subacromial pain syndrome. The important conclusions and advice from this work are as follows: (1) The diagnosis SAPS can only be made using a combination of clinical tests. (2) SAPS should preferably be treated non-operatively. (3) Acute pain should be treated with analgetics if necessary. (4) Subacromial injection with corticosteroids is indicated for persistent or recurrent symptoms. (5) Diagnostic imaging is useful after 6 weeks of symptoms. Ultrasound examination is the recommended imaging, to exclude a rotator cuff rupture. (6) Occupational interventions are useful when complaints persist for longer than 6 weeks. (7) Exercise therapy should be specific and should be of low intensity and high frequency, combining eccentric training, attention to relaxation and posture, and treatment of myofascial trigger points (including stretching of the muscles) may be considered. (8) Strict immobilization and mobilization techniques are not recommended. (9) Tendinosis calcarea can be treated by shockwave (ESWT) or needling under ultrasound guidance (barbotage). (10) Rehabilitation in a specialized unit can be considered in chronic, treatment resistant SAPS, with pain perpetuating behavior. (11) There is no convincing evidence that surgical treatment for SAPS is more effective than conservature management. (12) There is no indication for the surgical treatment of asymptomatic rotator cuff tears.

[Diabetic muscle infarction]. / Het diabetische spierinfarct.

BACKGROUND: Diabetic muscle infarction is a rare complication of diabetes mellitus that typically presents in the thigh; microvascular abnormalities may play a role. CASE DESCRIPTION: A 32-year-old female presented at the outpatient clinic with a painful, swollen thigh. She had suffered from type 1 diabetes for 22 years. The patient was admitted to the nephrology ward for further evaluation. Deep-venous thrombosis and abscess were excluded with echography. After additional investigations - MRI and a biopsy of skin, muscle and fascia - the diagnosis diabetic muscle infarction was made. The patient was treated with bed rest and analgesics. With hindsight, the muscle biopsy was not actually required in reaching a diagnosis. CONCLUSION: The diagnosis 'diabetic muscle infarction' is made on the basis of clinical presentation in combination with MRI findings. The treatment consists of bed rest and analgesics.

Diagnostic value of patient characteristics, history, and six clinical tests for traumatic anterior shoulder instability.

BACKGROUND: It is unknown which combination of patient information and clinical tests might be optimal for the diagnosis of traumatic anterior shoulder instability. This study aimed to determine the diagnostic value of individual clinical tests and to develop a prediction model that combined patient characteristics, history, and clinical tests for diagnosis of traumatic anterior shoulder instability. MATERIALS AND METHODS: This prospective cohort study included 169 consecutive patients with shoulder complaints who were examined at an orthopaedic outpatient clinic. One experienced clinician conducted 25 clinical tests; of these, 6 were considered to be specific for testing of traumatic anterior shoulder instability (apprehension, relocation, release, anterior drawer, load and shift, and hyperabduction tests). Magnetic resonance arthrography was used to determine the final diagnosis. A prediction model was developed by logistic regression analysis. RESULTS: In this cohort, 60 patients (36%) were diagnosed with anterior shoulder instability on the basis of magnetic resonance arthrography. The overall accuracy of individual clinical tests was 80.5% to 86.4%. Age, previous shoulder dislocation, sudden onset of complaints, and the release test were important predictors for the diagnosis of traumatic anterior shoulder instability. The prediction model demonstrated high discriminative ability (AUC 0.95). CONCLUSION: Individual clinical shoulder tests provide good diagnostic accuracy. Young age, history of shoulder dislocation, sudden onset of complaints, and positive result of the release test were the most important predictors for traumatic anterior shoulder instability.

[Swelling of the finger as initial manifestation of sarcoidosis]. / Zwelling van de vinger als eerste teken van sarcoïdose.

BACKGROUND: An extensive differential diagnosis exists for swelling of the fingers. One of the rare causes of such a swelling is a multisystem disorder called sarcoidosis. CASE DESCRIPTION: We describe a 40-year-old female patient who was first seen at our outpatient clinic with a painless swelling of the middle phalanx of her right middle finger. The diagnosis initially made was enchondroma, which was treated conservatively. Thirteen years later, the patient returned with pain and progressive swelling of this same finger. Physical examination and imaging revealed a giant-cell tumour of the tendon sheath, which was excised. The diagnosis of sarcoidosis was made after histological analysis. CONCLUSION: The initial manifestation of sarcoidosis is rarely observed in bone and soft tissue. For this reason, symptoms arising from such tissues will not always lead to the consideration of this diagnosis. The typical radiological abnormalities of bone combined with swelling of soft tissue should, however, give rise to the consideration of this diagnosis.

[Clinical problems in multiple osteochondroma]. / Klinische problemen bij multipele osteochondromen.

Multiple osteochondroma, also known as hereditary multiple exostoses, is a relatively rare genetic disorder characterized by the presence of multiple osteochondromas. The disease is frequently painful, with restriction of the activities of daily living, problems with carrying out an occupation and performance at school. In addition, characteristic skeletal deformities and postural abnormalities of the joints very frequently occur in patients with this disorder. Malignant transformation of osteochondroma to chondrosarcoma occurs in 1-5% of the patients with multiple osteochondroma. Treatment of patients with multiple osteochondromas must be tuned to the problems experienced by the patient. Symptomatic osteochondromas are often an indication for excision; knowledge of the natural progression of the abnormality is important in this. Periodical screening is essential: in children to prevent or correct deformity and postural abnormalities and in adults to detect and treat malignant transformation of osteochondroma at an early stage.

Infraglenoid tubercle avulsion and greater tuberosity fracture resulting from traumatic glenohumeral anterior dislocation: a case report.

Traumatic anterior shoulder dislocation can be associated with anteroinferior glenoid bone loss causing potential recurrent instability. We report on a 62-year-old man with a first-time traumatic anterior dislocation of the right shoulder, resulting in both an infraglenoid tubercle triceps avulsion fracture and a greater tuberosity fracture. After reduction, nonsurgical management was chosen. No inferior-oriented apprehension was noticed during follow-up, which might necessitate surgical treatment of the inferior glenoid rim. At latest follow-up, the patient had recovered his shoulder function. Avulsion fractures of the infraglenoid tubercle are uncommon lesions after an anterior shoulder dislocation and, without signs of instability, can be treated conservatively.

Is a single direct MR arthrography series in ABER position as accurate in detecting anteroinferior labroligamentous lesions as conventional MR arthography?

PURPOSE: The purpose of this study is to retrospectively compare accuracy of single magnetic resonance (MR) arthrography series in Abduction External Rotation (ABER) with conventional MR arthrography for detection and characterisation of anteroinferior labroligamentous lesions, with arthroscopy as reference standard. Inter-observer variability of both protocols was determined. METHODS AND MATERIALS: Institutional review board approval was obtained; informed consent was waived. MR arthrograms, including oblique axial fat suppressed T1-weighted images in ABER position and conventional imaging directions of 250 patients (170 men, 80 women; mean age, 36 years), were retrospectively and independently evaluated by three reviewers. Reviewers were blinded to clinical information and arthroscopic results. Labroligamentous lesions were registered in both ABER and MRa. The lesions were sub-classified (Bankart, Perthes, anterior labrum periosteal sleeve avulsion (ALPSA) or lesions not otherwise specified). Inter-observer agreement was assessed by Kappa statistics for all 250 patients. Ninety-two of 250 patients underwent arthroscopy. Sensitivity, specificity and accuracy of ABER versus conventional MR arthrography were calculated and compared using paired McNemar test. RESULTS: Kappa values of the ABER and conventional MR arthrography ranged from 0.44 to 0.56 and 0.44 to 0.62, respectively. According to arthroscopy, 45 of 92 patients had an intact anteroinferior labrum, and in 44 patients, a labroligamentous lesion (eight Bankart, seven Perthes, 29 ALPSA and three lesions not otherwise specified) was diagnosed. There were no statistically significant differences between ABER and conventional MR arthrography regarding sensitivity (85-89%, 89-96%), specificity (82-91%, 84-89%) and overall accuracy (50-62%, 53-63%). CONCLUSION: The results of a single MR arthrography series in ABER position are comparable with those of conventional MR arthrography for detecting anteroinferior labroligamentous lesions.