Decision making in treatment after a first-time anterior glenohumeral dislocation: A Delphi approach by the Neer Circle of the American Shoulder and Elbow Surgeons.

BACKGROUND: The treatment of patients who sustain a first-time anterior glenohumeral dislocation (FTAGD) is controversial. The purpose of this study was to find consensus among experts using a validated iterative process in the treatment of patients after an FTAGD. METHODS: The Neer Circle is an organization of shoulder experts recognized for their service to the American Shoulder and Elbow Surgeons. Consensus among 72 identified experts from this group was sought with a series of surveys using the Delphi process. The first survey used open-ended questions designed to identify patient-related features that influence treatment decisions after an FTAGD. The second survey used a Likert scale to rank each feature's impact on treatment decisions. The third survey used highly impactful features to construct 162 clinical scenarios. For each scenario, experts recommended surgery or not and reported how strongly they made their recommendation. These data were analyzed to find clinical scenarios that had >90% consensus for recommending treatment. These data were also used in univariate and multivariate mixed-effects models to identify odds ratios (ORs) for different features and to assess how combining these features influenced the probability of surgery for specific populations. RESULTS: Of the 162 scenarios, 8 (5%) achieved >90% consensus for recommending surgery. All of these scenarios treated athletes with meaningful bone loss at the end of their season. In particular, for contact athletes aged > 14 years who were at the end of the season and had apprehension and meaningful bone loss, there was >90% consensus for recommending surgery after an FTAGD, with surgeons feeling very strongly about this recommendation. Of the scenarios, 22 (14%) reached >90% consensus for recommending nonoperative treatment. All of these scenarios lacked meaningful bone loss. In particular, surgeons felt very strongly about recommending nonoperative treatment after an FTAGD for non-athletes lacking apprehension without meaningful bone loss. The presence of meaningful bone loss (OR, 6.85; 95% confidence interval, 6.24-7.52) and apprehension (OR, 5.60; 95% confidence interval, 5.03-6.25) were the strongest predictors of surgery. When these 2 features were combined, profound effects increasing the probability of surgery for different populations (active-duty military, non-athletes, noncontact athletes, and contact athletes) were noted, particularly non-athletes. CONCLUSION: Consensus for recommending treatment of the FTAGD patient was not easily achieved. Certain combinations of patient-specific factors, such as the presence of meaningful bone loss and apprehension, increased the probability of surgery after an FTAGD in all populations. Over 90% of shoulder instability experts recommend surgery after an FTAGD for contact athletes aged > 14 years at the end of the season with both apprehension and meaningful bone loss. Over 90% of experts would not perform surgery after a first dislocation in patients who are not athletes and who lack apprehension without meaningful bone loss.

Subscapularis tendon tears: Management and arthroscopic repair.

Tears of the subscapularis tendon have been under-recognised until recently. Therefore, a high index of suspicion is essential for diagnosis.A directed physical examination, including the lift-off, belly-press and increased passive external rotation can help identify tears of the subscapularis.All planes on MR imaging should be carefully evaluated to identify tears of the subscapularis, retraction, atrophy and biceps pathology.Due to the tendency of the tendon to retract medially, acute and traumatic full-thickness tears should be repaired. Chronic tears without significant degeneration should be considered for repair if no contraindication exists.Arthroscopic repair can be performed using a 30-degree arthroscope and a laterally-based single row repair; one anchor for full thickness tears ⩽ 50% of tendon length and two anchors for those ⩾ 50% of tendon length.Biceps pathology, which is invariably present, should be addressed by tenotomy or tenodesis.Timing of post-operative rehabilitation is dictated by the size of the repair and the security of the repair construct. The stages of rehabilitation typically involve a period of immobilisation followed by range of movement exercises, with a delay in active internal rotation (IR) and strengthening in IR. Cite this article: EFORT Open Rev 2017;2:484-495. DOI: 10.1302/2058-5241.2.170015.

Why repair the subscapularis? A logical rationale.

Tears of the subscapularis tendon are now more frequently recognized and are often associated with tears of the posterosuperior rotator cuff tendons. This has been facilitated by arthroscopic approaches, and repair techniques have been developed. In the setting of a rotator cuff repair, when a subscapularis tendon tear is found in continuity with a supraspinatus tendon tear, it is essential to recognize how the repair of both tendon tears can influence the overall security of the entire repair construct. When a repairable subscapularis tendon tear is left unrepaired, the function of the subscapularis muscle will be lost. In addition, the posterosuperior rotator cuff tear will be more difficult to repair, and it will be less securely repaired. When the subscapularis tendon is repaired initially, the posterosuperior rotator cuff repair can be more easily and more reliable achieved.

Management of the failed AC joint reconstruction: causation and treatment.

With recent studies showing improved biomechanical behavior of anatomic acromioclavicular joint reconstructions, these techniques are more frequently being performed. With both the more historic methods of fixation such as coracoacromial ligament transfer along with the newer anatomic reconstruction, potential for failure exists. However, there is a paucity of literature addressing these failures and possible treatment options. The purpose of this review is to report cases of failed reconstructions, describe failure mechanisms, and propose treatment options.

The inferior glenohumeral ligament: a correlative investigation.

The inferior glenohumeral ligament (IGHL) was investigated by correlating the biomechanical properties, biochemical composition, and histologic morphology of its 3 anatomic regions (superior band, anterior axillary pouch, and posterior axillary pouch) in 8 human cadaveric shoulders. The overall biochemical composition of the IGHL appeared similar to other ligaments, with average water content of 80.9 +/- 2.5%, collagen content of 80.0 +/- 9.2%, and crosslinks of 0.715 +/- 0.13 mol/mol collagen. The proteoglycan content was highest in the superior band (2.73 +/- 0.7 mg/g dry weight) and may, in part, explain its viscoelastic behavior. Histologic analysis demonstrated longitudinally organized fiber bundles that were more uniform in the mid-substance but more interwoven and less uniformly oriented near the insertion sites. The superior band had the most pronounced fiber bundle interweaving, while crimping was more evident in the anterior axillary pouch. Elastin was identified in each of the regions. Tensile testing demonstrated a trend toward higher ultimate tensile stress (16.9 +/- 7.9 MPa) and tensile modulus (130.3 +/- 47.9 MPa) in the superior band compared to the axillary pouch. The mean ultimate tensile strain of the IGHL was 16.8 +/- 4.6%. These complex IGHL properties may help to explain its unique functions in stabilizing the shoulder in different arm positions and at different rates of loading, including the failure patterns seen clinically, as in Bankart lesions (insertion site) versus capsular stretching (ligament substance).

The effect of arthroscopic suture passing instruments on rotator cuff damage and repair strength.

There are a variety of arthroscopic devices used to pass sutures through the rotator cuff for its repair. Because they vary in size and shape, it is possible that they could damage the cuff and affect the integrity of the repair. We chose four devices for assessment--SutureLasso (Arthrex, Naples, FL), straight BirdBeak (Arthrex, Naples, FL), Viper (Arthrex, Naples, FL), and a #7 tapered Mayo needle--and performed cuff reattachments in four paired shoulders using suture anchors. These repairs were cycled and tested to failure. The SutureLasso and Mayo needle repairs failed at approximately 285 N whereas the BirdBeak and Viper failed during cycling at 150 N. It appears that the devices, which made the bigger holes in the cuff, can compromise the integrity of the repair.

Variations in glenoid rim anatomy: implications regarding anchor insertion.

PURPOSE: The purpose of this study was to investigate normal bony anatomy of the glenoid rim and to define the angles for successful anchor placement for anterior and posterior labral repairs. TYPE OF STUDY: An anatomic study using cadaveric shoulder specimens. METHODS: Soft tissue was dissected from 20 cadaveric shoulders, and the glenoids were isolated. The glenoid specimens were scanned to obtain cross-sectional images using peripheral quantitative computed tomography (pQCT) in 4 different planes. Glenoid rim angles were measured from the cross-sectional pQCT images of the glenoids at 5 positions: the 3-o'clock, 4:30-, 6-, 7:30-, and 9-o'clock positions. Glenoid morphology was noted for each position. RESULTS: The glenoid rim angles from the 3-o'clock to the 9-o'clock positions were 53 degrees +/- 5 degrees, 45 degrees +/- 7 degrees, 80 degrees +/- 10 degrees, 61 degrees +/- 10 degrees, 49 degrees +/- 4 degrees, respectively. Asymmetric morphology of the glenoid was noted with an almost straight line extending medially from the rim at the 3-o'clock position, whereas a concave morphology was noted at the 9-o'clock position. Similarly at the 4:30-o'clock position, the scapular bony surface did not curve toward the base as markedly as it did at the corresponding posterior 7:30-o'clock position. CONCLUSIONS: The available bone mass for the anchor insertion was found to vary depending on the position of the glenoid rim. Both rim angle and glenoid morphology for each position must be considered when selecting the ideal anchor insertion angle for labral repair.

Anatomy of the superior glenoid rim. Repair of superior labral anterior to posterior tears.

BACKGROUND: Successful placement of a fixation device on the superior glenoid rim during superior labrum repairs requires accurate knowledge of the glenoid rim anatomy. PURPOSE: To investigate the normal bony anatomy of the superior glenoid rim. STUDY DESIGN: Descriptive anatomic study. METHODS: Twenty cadaveric glenoid specimens were scanned to obtain cross-sectional images with peripheral quantitative computed tomography in three different positions, each perpendicular to the articular surface. Two straight lines were drawn along the interior bony margins of the articular surface and cortex, and image analysis software was used to calculate the angle between these lines. Three bony angles were measured. RESULTS: The bony angles from the 10:30-, 12-, and 1:30-o'clock cross-sections were 55 degrees +/- 5 degrees, 64 degrees +/- 5 degrees, and 62 degrees +/- 8 degrees, respectively. The posterosuperior angle (at the 10:30-o'clock position) was statistically significantly lower than the superior and anterosuperior angles. Intraobserver variation was less than 3%. CONCLUSIONS: The most superior point of the glenoid rim (12-o'clock position) seems to provide the most bone stock for anchor insertion. The available bone support was found to decrease posteriorly on the glenoid rim. CLINICAL RELEVANCE: During superior labral repairs, the anchor or fixation device should be inserted at approximately a 30 degrees angle in relation to the articular surface for maximal bone support.