Dynamic Double-Sling Augmentation Prevents Anteroinferior Translation for Recurrent Anteroinferior Shoulder Dislocation With 20% Glenoid Bone Loss: A Cadaveric Biomechanical Study.

PURPOSE: To biomechanically compare the dynamic double-sling with single-sling augmentation using the conjoined tendon (CT) with 20% of an anteroinferior glenoid bone defect under the high loads in shoulders. METHODS: With the shoulder in 60° of glenohumeral abduction and 60° of external rotation, the 12 shoulders stability was tested sequentially in 5 conditions: intact, 20% glenoid bone loss, Bankart repair, single-sling augmentation with the CT, and double-sling augmentation with both the CT and long head of the biceps tendon (LHBT). The anteroinferior humeral head (HH) translation force of 20N, 30N, 40N, 50N, or 60N was applied to determine the shoulder stability in each condition. RESULTS: The total HH translation over 8.77 mm represented the anteroinferior shoulder instability (95% confidence interval of bone defect: 7.76-8.77 mm). A significant increase in anteroinferior HH translation was demonstrated after the creation of 20% glenoid bone defect under the 20N translational force (10.52 ± 0.71 mm). Structural failure after the Bankart repair and the single-sling augmentation under the 30N (9.84 ± 1.25 mm) and 40N (9.59 ± 0.66 mm) translational forces, respectively, were observed. The double-sling augmentation effectively prevented the anteroinferior HH translation under the translational force of less than 40N, and only half of the augmentation structure (8.25 ± 1.66 mm) had failed under the 50N translational forces. CONCLUSION: In the absence of any Hill-Sachs lesion and when tested at 60° abduction and external rotation in shoulders with 20% glenoid bone defects, at time-zero, the double-sling augmentation strategy could effectively prevent anteroinferior translation when compared with the Bankart repair or the single-sling augmentation technique under all magnitudes of the translational force in biomechanical simulation. Nevertheless, none of the constructs restored the HH translation to the normal intact state. CLINICAL RELEVANCE: Double-sling augmentation technique may represent a reliable option for preventing anteroinferior translation.

Posterior shoulder instability: a systematic review.

INTRODUCTION: This review aims to provide information on outcomes of surgical procedures for soft tissue or bony glenoid and/or humeral abnormalities in case of posterior shoulder instability. SOURCE OF DATA: A systematic review of the literature according to the PRISMA guidelines was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, Ovid and Google Scholar databases using various combinations of the keywords 'shoulder', 'posterior instability', 'dislocation', 'reversed bony bankart', 'reversed Hill Sachs', and 'capsulolabral' was performed. AREAS OF AGREEMENT: A total of 847 shoulders in 810 patients were included. A redislocation event occurred in 33 (8.7%) of 411 shoulders with soft tissue abnormalities and in 12 (9.1%) of 132 shoulders with bony abnormalities of the glenoid, humeral head or both. AREAS OF CONTROVERSY: The optimal treatment modalities for posterior shoulder dislocation remain to be defined. GROWING POINTS: Operative stabilization for posterior shoulder instability should be lesion-specific and should correct all components of the posterior instability. AREAS TIMELY FOR DEVELOPING RESEARCH: Future prospective studies should aim to establish the optimal treatment modalities for posterior shoulder instability.

Immobilization in external rotation after primary shoulder dislocation reduces the risk of recurrence in young patients. A randomized controlled trial.

INTRODUCTION: Patients that sustain anterior shoulder dislocation frequently experience recurrence. Immobilisation in external rotation has been proposed as a treatment that could lower this risk. HYPOTHESIS: There is a difference in recurrence rates between immobilization in internal or external rotation following a first-time anterior shoulder dislocation. PATIENTS AND METHODS: Single-center randomized controlled trial. Fifty patients with a first episode of traumatic anterior dislocation were randomly assigned to immobilization in internal rotation (IR; 25 patients) or external rotation (ER; 25 patients) for three weeks. Clinical follow-up: 24 months. Additionally, some patients underwent a magnetic resonance imaging with intra-articular contrast (MR arthrography) within seven days after trauma, and then at three months. PRIMARY OUTCOME: recurrence of dislocation. Secondary outcome: healing rate of labral lesions on MR arthrography. RESULTS: Follow-up rate in the IR and ER group was 92% and 96% respectively. Recurrence rate did not show a statistically significant difference overall (IR 47.8% vs. ER 29.2%; p=0.188), but showed a significant difference favouring ER in the 20-40 years subgroup (IR 50% vs. ER 6.4%; p=0.044). Labral lesions' healing rate was 46.2% vs. 60% (IR vs ER; p=0.680). The recurrence rate among those with healed vs. non-healed labrum (regardless of immobilization) was 11.1% vs. 77.7% (p=0.001). DISCUSSION: This study suggests that immobilization in ER compared to IR reduces the risk of recurrence after a first-time anterior shoulder dislocation in patients aged between 20 and 40 years. LEVEL OF EVIDENCE: II, low-powered prospective randomized trial.

Augmentation of plate osteosynthesis for proximal humeral fractures: a systematic review of current biomechanical and clinical studies.

INTRODUCTION: Secondary dislocation due to loss of fixation is the most common complication after plate fixation of proximal humeral fractures. A wide range of different techniques for augmentation has been described to improve the primary and secondary stability. Nevertheless, comparative analyses on the specific advantages and limitations are missing. Therefore, the aim of the present article was to systematically review and evaluate the current biomechanical and clinical studies. MATERIALS AND METHODS: The databases of PubMed and EMBASE were comprehensively searched for studies on augmentation techniques for proximal humeral fractures using defined search terms. Subsequently, all articles identified were screened for eligibility and subdivided in either clinical or biomechanical studies. Furthermore, the level of evidence and study quality were assessed according the Oxford Centre for Evidence-Based Medicine and the Coleman Methodology Score, respectively. RESULTS: Out of 2788, 15 biomechanical and 30 clinical studies were included. The most common techniques were structural allogenic or autologous bone grafting to enhance the medial support, metaphyseal void filling utilizing synthetic bone substitutes or bone grafts, and screw-tip augmentation with bone cement. Biomechanical data were available for structural bone grafting to enhance the medial support, void filling with synthetic bone substitutes, as well as for screw-tip augmentation. Clinical evidence ranged from level II-IV and study quality was 26-70/100 points. Only one clinical study was found investigating screw-tip augmentation. All studies included revealed that any kind of augmentation positively enhances mechanical stability, reduces the rate of secondary dislocation, and improves patients' clinical outcome. None of the studies showed relevant augmentation-associated complication rates. CONCLUSIONS: Augmentation of plate fixation for proximal humeral fractures seems to be a reliable and safe procedure. All common techniques mechanically increase the constructs' stability. Clinically evaluated procedures show reduced complication rates and improved patient outcomes. Augmentation techniques seem to have the highest significance in situations of reduced bone mineral density and in high-risk fractures, such as 4-part fractures. However, more high-quality and comparative clinical trials are needed to give evidence-based treatment recommendations.

Long-term outcome of arthroscopic remplissage in addition to the classic Bankart repair for the management of recurrent anterior shoulder instability with engaging Hill-Sachs lesions.

PURPOSE: The evaluation of the long-term outcome of the arthroscopic remplissage performed in addition to the classic Bankart repair for the primary management of recurrent anterior shoulder instability with engaging Hill-Sachs lesion without inverted pear appearance of the glenoid during arthroscopy. METHODS: During a 6-year period, from 2007 to 2012, 65 patients whose average age was 30.1 ± 7.6 years were operated on in our department and satisfied the inclusion criteria of this study. They all had a positive apprehension sign preoperatively. Among them, 51 patients (82%) were available for long-term evaluation. The mean follow-up period was 8.1 ± 1.8 years (range 5.6-10.6). RESULTS: Three patients (5.6%) had suffered a new dislocation. The remaining patients (94.4%) were satisfied with the surgical result and returned to their previous daily activities, whereas 71% continued to participate in sports without restrictions. The ASES score increased from 72.5 (range 18-100) preoperatively to 100 (range 85-100) postoperatively (p < 0.01). The modified Rowe score increased from 40 (range 15-70) to 100 (range 70-100) (p < 0.001), and the Oxford Instability score from 29 (range 9-47) to 48 (range 36-48) (p < 0.001). No significant restriction in the shoulder range of motion was documented. CONCLUSIONS: The combination of the arthroscopic remplissage with the classic Bankart repair was proven to be a safe and effective procedure for the treatment of "engaging" Hill-Sachs lesions without inverted pear appearance of the glenoid. This combination has long-term outcomes in terms of the recurrence rate and does not significantly influence the range of motion of the shoulder. LEVEL OF EVIDENCE: Therapeutic Study-Case series with no comparison group, Level IV.

Multidirectional Instability of the Shoulder: Treatment Options and Considerations.

Multidirectional instability (MDI) is a debilitating condition that involves chronic subluxation or dislocation of the shoulder in >1 direction. Numerous proposed mechanisms of MDI exist, which occurs in the setting of redundant capsular tissue. Symptoms can range from recurrent dislocations or subluxations to vague aching pain that disrupts activities of daily living. Magnetic resonance imaging is often performed during evaluation of this condition, although magnetic resonance arthrography may provide more detailed images of the patulous capsule. In the absence of a well-defined traumatic cause, such as a labral tear, initial treatment for MDI is a structured rehabilitation program with exercises aimed at strengthening the rotator cuff and periscapular muscles to improve scapular kinematics. Patients with recalcitrant symptoms may benefit from surgical stabilization, including open capsular shift or arthroscopic capsular plication, aimed at decreasing capsular volume and improving stability.

An Effective Treatment in the Austere Environment? A Critical Appraisal into the Use of Intra-Articular Local Anesthetic to Facilitate Reduction in Acute Shoulder Dislocation.

Acute shoulder dislocation is a common injury in the outdoor environment. The objective of this systematic review of the literature was to determine if intra-articular local anesthetic (IAL) is an effective treatment that could have prehospital application. A methodical search of MEDLINE, PubMed, and EMBASE databases targeted publications from January 1, 1990 until January 1, 2017. Eligible articles compared IAL with other analgesic techniques in patients 16 years or older experiencing acute glenohumeral dislocation. Reduction success, complications, and patient-reported outcome measures underwent comparison. All identified publications originated from the hospital setting. Procedural success rates ranged widely among randomized control trials comparing IAL with intravenous analgesia and sedation (IAL 48-100%, intravenous analgesia and sedation 44-100%). A pooled risk ratio [RR] favored intravenous analgesia and sedation (RR 0.91, 95% confidence interval [CI] 0.84-0.98), but there was significant inconsistency within the analysis (I2 = 75%). IAL provided lower complication rates (4/170, 2%) than intravenous analgesia and sedation (20/150, 13%) (RR 1.11, 95% CI 1.04-1.19, I2 = 63%). One trial found a clinically relevant reduction in visual analogue pain scores when comparing IAL against no additional analgesia in the first minute (IAL 21±13 mm; control 49±15 mm; P<0.001) and fifth minute (IAL 10±10 mm; control 40±14 mm, P<0.001) after reduction. The results suggest that IAL is an effective intervention for acute anterior shoulder dislocation that would have a place in the repertoire of the remote physician. Further research might be beneficial in determining the outcomes of performing IAL in the prehospital setting.

Glenohumeral and scapulohumeral kinematic analysis of patients with traumatic anterior instability wearing a shoulder brace: a prospective laboratory study.

PURPOSE: To assess the effectiveness of a novel glenohumeral joint immobilizer, the S2 Shoulder Stabilizer®, by evaluating shoulder kinematics with a stereophotogrammetry system. METHODS: Participants in this prospective laboratory study were recruited from patients with anterior traumatic instability awaiting arthroscopic glenohumeral stabilization. Glenohumeral and scapulohumeral kinematic data (arm abduction-adduction and internal-external rotation, and scapular pronation-retraction and mediolateral rotation) were collected twice, without and with the brace, using a VICON™ motion capture system, and processed with MATLAB® software. RESULTS: The tests showed a significantly lower joint angle during abduction-adduction (p = 0.0022) and external rotation (p = 0.0076) and a significantly lower (p = 0.0022) mediolateral scapular rotation angle in the limbs wearing the immobilizer. Humeral head translation during abduction-adduction and internal-external rotation was also lower in the patients wearing the brace. CONCLUSIONS: The immobilizer significantly limited joint excursion in all planes of movement except internal rotation. The narrower humeral head translation with respect to the trunk, measured in the tests with the brace, demonstrates that the immobilizer achieves the goal of preserving joint stability in the movements that are at risk of dislocation.

The development of the Patient Expectations of Shoulder Surgery survey.

BACKGROUND: Patient satisfaction after a surgical procedure is dependent on meeting preoperative expectations. There is currently no patient expectations survey available for patients undergoing shoulder surgery that is validated, reliable, and easy to use in daily practice. The aim of this study was to develop a Patient Expectations of Shoulder Surgery (PESS) survey. METHODS: In 315 patients, answers to an open-ended question about patient expectations were collected before shoulder surgery to develop the PESS survey. Patients' expectations of the PESS survey were associated with clinical outcome (change of Disabilities of the Arm, Shoulder, and Hand score). Content validity was assessed by a panel of 10 patients scheduled for shoulder surgery, and test-retest reliability was evaluated. RESULTS: Six items were included in the PESS survey: pain relief, improved range of motion, improved ability to perform daily activities, improved ability to perform work, improved ability to participate in recreational activities and sports, and stop shoulder from dislocating. Three of the 6 expectations were significantly associated with clinical outcome after shoulder surgery. Test-retest reliability was high with an intraclass correlation coefficient of 0.52-0.92. DISCUSSION: The PESS survey is a valid and reliable survey that can be used in future clinical research and in daily orthopedic practice. We believe that the preoperative evaluation of patient expectations should be a standard procedure before shoulder surgery.

The effect of glenoid component version and humeral polyethylene liner rotation on subluxation and impingement in reverse shoulder arthroplasty.

BACKGROUND: A previously validated finite element modeling approach was used to determine how changes in glenoid component version and polyethylene liner rotation within the humeral component affect the arm abduction angle at which impingement between the inferior glenoid and the polyethylene liner occurs as well as the amount of subluxation generated by that impingement. MATERIALS AND METHODS: Five glenoid component versions (5° anteversion; neutral; 5°, 10°, and 20° retroversion) and 7 polyethylene liner rotations (20° and 10° anterior; neutral; 10°, 20°, 30°, and 40° posterior) were considered, resulting in 35 different clinically representative models. The humerus was internally and externally rotated and extended and flexed, and the resulting impingement and subluxation were measured. To further analyze more global trends and to identify implantations least prone to subluxation, polyethylene liner rotation was additionally varied in coarser 30° increments across the entire 360° range. RESULTS: All subluxation caused by impingement occurred during external rotation and extension, and external rotation produced nearly 10-fold more subluxation than extension. Neutral glenoid component version was associated with the least amount of subluxation for all polyethylene liner rotations. Posteriorly rotated polyethylene liners, which place the thick inferior region of the component away from the scapula, produced the least amount of subluxation. The 90° and 120° posterior liner rotations produced no subluxation, whereas the 30° and 60° anterior liner rotations produced the greatest amount of subluxation. CONCLUSION: These results indicate that rotating modern radially asymmetric humeral polyethylene liners posteriorly can reduce the risk of subluxation leading to dislocation and increase external rotation range of motion.

A randomized controlled trial on the immediate and long-term effects of arm slings on shoulder subluxation in stroke patients.

BACKGROUND: Arm slings are often used in clinical practice to support the hemiplegic arm aiming to prevent or treat glenohumeral subluxation. Evidence supporting the corrective effect of slings on subluxation is scarce and long-term studies are lacking. AIM: The aim of this study was to determine both the immediate and long-term effect on acromiohumeral distance using the Actimove® sling and Shoulderlift and to determine the effect of slings on pain and passive range of motion of the shoulder in stroke patients with glenohumeral subluxation. DESIGN: Randomized control trial. SETTING: Hospital inpatients. POPULATION: Stroke patients. METHODS: Twenty-eight stroke patients, with severe upper limb impairments, were randomly allocated to 3 groups (Actimove, Shoulderlift, No sling). Patients wore their supportive device for 6 weeks and no sling in the control group. Immediate and postinterventional effect on acromiohumeral distance was measured using sonography. Pain (VAS), ROM (goniometry), spasticity (Modified Ashworth Scale), Fugl-Meyer Assessment and trunk stability (TIS) were also assessed before and after the intervention. RESULTS: The level of immediate correction of both slings was different at baseline and after 6 weeks (0 weeks: Shoulderlift 63%, Actimove 36%; 6 weeks: Shoulderlift 28%, Actimove 24%). Comparing the level of subluxation over time shows a distinct decrease in subluxation but only for the control group (-37.59% or 3.30 mm). Subluxation remained the same in the Actimove group (-2.77% or 0.27 mm) but increased in the Shoulderlift group (+12.44% or 1.03 mm). After 6 weeks, the Actimove group reported more pain at rest (P=0.036). ROM for abduction and external rotation decreased in 2 groups and remained un-altered in the Shoulderlift group. CONCLUSIONS: Results of immediate correction varied. Subluxation seemed to reduce in patients that did not wear a sling. CLINICAL REHABILITATION IMPACT: The (assumed) presence of subluxation may not benefit from wearing an arm sling which may itself inhibit active correction. If a sling is indicated the Shoulderlift may be preferable to the Actimove sling.

The prevalence of the complications and their associated factors in humeral lengthening for achondroplasia: retrospective study of 54 cases.

The aim of this study is to evaluate the complications of humeral lengthening and their associated factors. Fifty-four achondroplastic patients were treated by bilateral humeral lengthening. Our original shoulder sling was sufficient to prevent shoulder dislocation. Pre-existing radial head dislocation was observed in 18 patients. Lengthening was accomplished in all cases without a decrease in the elbow function. Seven humeri fractured after the fixator removal. The risk factors for postoperative fracture were a waiting period of less than 5 days, a healing index less than 25, and the concave shape of the callus. There was no radial nerve palsy.

Shoulder orthoses for the prevention and reduction of hemiplegic shoulder pain and subluxation: systematic review.

OBJECTIVES: To determine whether shoulder orthoses prevent or reduce gleno-humeral subluxation and hemiplegic shoulder pain. DATA SOURCES: OVID SP, MEDLINE, AMED, CINAHL, PEDro and the Cochrane Central Register of Controlled Trials. REVIEW METHODS: We included: randomised or quasi-randomised controlled trials, controlled before and after studies and observational studies. Two reviewers independently screened, critically appraised papers using the PEDro tool, and extracted data. A descriptive synthesis was performed as there were insufficient data for meta-analysis. RESULTS: Eight studies were included, totalling 186 participants: One randomised controlled trial with 41 participants, one quasi-randomised with 14 participants, one before and after controlled study with 40 participants and five observational studies with 91 participants met the inclusion criteria. Findings suggest that applying an orthosis to an already subluxed shoulder immediately reduced vertical subluxation on X-ray but improvements were not maintained when orthosis was removed. Orthoses with both proximal and distal attachments improved shoulder pain in the majority of stroke patients when worn for four weeks (starting several days or weeks post-stroke). There was no increase in adverse effects of contracture, spasticity or hand oedema when compared to no orthosis. Orthoses were generally well-tolerated and most patients rated the orthosis as comfortable to wear. CONCLUSION: Observational studies suggest that orthoses reduce vertical subluxation whilst in-situ. Available evidence from heterogeneous studies after stroke suggests that orthoses may reduce pain and are well-tolerated with prolonged use. No studies have tested whether subluxation and pain can be prevented by immediate post-stroke application of orthoses.

Lap-tray and triangular sling are no more effective than a hemi-sling in preventing shoulder subluxation in those at risk early after stroke: a randomized trial.

BACKGROUND: Shoulder subluxation is a common secondary impairment of the upper limb following stroke. A range of supportive devices are used in rehabilitation to prevent shoulder subluxation, including hemi-slings and firm supports, such as arm troughs, however, there is little evidence regarding their efficacy. AIM: To determine whether a modified lap-tray during sitting and a triangular sling during standing is more effective than a hemi-sling in preventing shoulder subluxation, pain, contracture and upper limb activity limitation after stroke. DESIGN: A prospective, randomized trial with concealed allocation, assessor blinding and intention-to-treat analysis. SETTING: Three inpatient rehabilitation units in Australia and Norway. POPULATION: Forty-six acute stroke survivors within 3 weeks of stroke who were at risk of subluxation. METHODS: The experimental group used a modified lap-tray while sitting and a triangular sling while standing to support the affected arm for four weeks. The control group used a hemi-sling while sitting and standing. The primary outcome was amount of shoulder subluxation on X-ray. Secondary outcomes were upper limb activity, pain and contracture. RESULTS: There was no significant difference between groups in terms of shoulder subluxation (MD -3 mm, 95% CI -8 to 3). There was a trend for the experimental group to develop less pain at rest (MD -0.7 out of 10, 95% CI -2.2 to 0.8) and during shoulder external rotation (MD -1.7 out of 10, 95% CI -3.7 to 0.3) and a trend towards having less contracture of shoulder external rotation (MD -10 deg, 95% CI -22 to 2). There was no significant difference between groups in terms of other contractures and activity of the upper limb. CONCLUSIONS: A lap-tray during sitting combined with a triangular sling during standing is no more effective than a hemi-sling in preventing subluxation, pain, contracture and activity limitation in acute stroke survivors at risk of shoulder subluxation. CLINICAL REHABILITATION IMPACT: The use of a lap-tray during sitting and triangular sling during standing is not indicated as an alternative to the hemi-sling to prevent shoulder subluxation in patients after stroke, so alternative strategies with proven efficacy, such as electrical stimulation, should be considered.

Cirugía artroscópica en la inestabilidad anterior traumatica de hombro (tubs). Nuestra experiencia en 30 pacientes / Arthroscopic sugery for anterior traumatic shoulder inestability. Our experience in 30 patients

Introducción: la inestabilidad glenohumeral habitualmente requiere cirugía cuando existe un antecedente traumático previo. Aunque en algunos casos se aboga por un tratamiento conservador, la mayoría de los pacientes precisan de estabilización quirúrgica. Objetivos: presentar nuestra experiencia en la reparación artroscópica en pacientes con luxación recidivante de hombro con componente traumático previo, con especial valoración de factores potencialmente implicados en los casos de reluxación tras la reparación. Métodos: se evaluaron de forma retrospectiva 30 pacientes intervenidos de inestabilidad glenohumeral en los últimos 5 años mediante técnica de Bankart artroscópica, con más de 12 meses de seguimiento posterior a la cirugía. Los pacientes fueron evaluados tras la cirugía mediante escala de ROWE. Se analizaron principalmente el ISIS preoperatorio, el tipo de lesión previa, el número de recidivas, la funcionabilidad y el grado de satisfacción del paciente. Resultados: de los 30 pacientes valorados, la gran mayoría presentaba inestabilidad predominantemente unidireccional, 7 pacientes con lesión de SLAP asociada. De nuestros pacientes, 2 de ellos requirieron nueva cirugía por dolor o inestabilidad. El número de reluxaciones fue dos. Conclusiones: la cirugía artroscópica resuelve gran parte de las inestabilidades unidireccionales y de sus lesiones asociadas con buenos resultados y baja tasa de reluxaciones y satisfacción alta de los pacientes tanto por el confort postoperatorio como por la función final. Es clave la selección adecuada de los pacientes y la reparación depurada de todas las lesiones

Introduction: The glenohumeral instability usually requires surgery when there is a previous history of trauma. Although in some cases it advocates a conservative treatment, most patients require surgical stabilization. Objectives: to present our experience in arthroscopic repair in patients with recurrent shoulder dislocation prior traumatic component, with special consideration of factors potentially involved in cases of redislocation after repair. Methods: We retrospectively evaluated 30 patients undergoing glenohumeral instability over the past 5 years through arthroscopic Bankart technique, with more than 12 months of follow-up after surgery. Patients were evaluated after sur gery by ROWE scale. ISIS preoperatively, type of previous injury, the number of recurrences, the functionality and degree of patient satisfaction was mainly analyzed. Results: Of the 30 patients evaluated, the vast majority had predominantly unidirectional instability, 7 patients with associated SLAP lesion. Of our patients, 2 of them required further surgery for pain and instability. There were 2 cases of redislocations. Conclusions: Arthroscopic surgery solves many of the unidirectional instability and injuries associated with good results and low rate of reluxaciones and high patient satisfaction post operation and final function. The key is proper selection of patients and purified repair of all injuries

Modified Boytchev procedure for recurrent anterior dislocation of shoulder.

PURPOSE. To evaluate results of the modified Boytchev procedure for recurrent anterior dislocation of the shoulder in 60 patients. METHODS. Medical records of 45 men and 15 women aged 20 to 44 years who underwent the modified Boytchev procedure for recurrent anterior dislocation of the right (n=44) and left (n=16) shoulders were reviewed. The mean number of dislocations was 14. Outcome was evaluated using the Burkhead and Rockwood criteria. RESULTS. The mean follow-up period was 56 months. Outcome was excellent in 32 patients, good in 21, and fair in 7. None had poor outcome. The mean external rotation deficit at 0º and 90º of abduction improved from 14º to 7º (p=0.04) and 18º to 7º (p=0.03), respectively. Two patients had fragmentation of the coracoid process, which was fixed with non-absorbable suture. Two patients had traction injury to the musculocutaneous nerve, which recovered after 6 months. One patient had recurrent dislocation that ruled out the chance of revision surgery. CONCLUSION. The modified Boytchev procedure is a viable and simple treatment for recurrent anterior shoulder dislocation.

Arthroscopic Bristow-Latarjet combined with bankart repair restores shoulder stability in patients with glenoid bone loss.

BACKGROUND: Arthroscopic Bankart repair alone cannot restore shoulder stability in patients with glenoid bone loss involving more than 20% of the glenoid surface. Coracoid transposition to prevent recurrent shoulder dislocation according to Bristow-Latarjet is an efficient but controversial procedure. QUESTIONS/PURPOSES: We determined whether an arthroscopic Bristow-Latarjet procedure with concomitant Bankart repair (1) restored shoulder stability in this selected subgroup of patients, (2) without decreasing mobility, and (3) allowed patients to return to sports at preinjury level. We also evaluated (4) bone block positioning, healing, and arthritis and (5) risk factors for nonunion and coracoid screw pullout. METHODS: Between July 2007 and August 2010, 79 patients with recurrent anterior instability and bone loss of more than 20% of the glenoid underwent arthroscopic Bristow-Latarjet-Bankart repair; nine patients (11%) were either lost before 2-year followup or had incomplete data, leaving 70 patients available at a mean of 35 months. Postoperative radiographs and CT scans were evaluated for bone block positioning, healing, and arthritis. Any postoperative dislocation or any subjective complaint of occasional to frequent subluxation was considered a failure. Physical examination included ROM in both shoulders to enable comparison and instability signs (apprehension and relocation tests). Rowe and Walch-Duplay scores were obtained at each review. Patients were asked whether they were able to return to sports at the same level and practice forced overhead sports. Potential risk factors for nonhealing were assessed. RESULTS: At latest followup, 69 of 70 (98%) patients had a stable shoulder, external rotation with arm at the side was 9° less than the nonoperated side, and 58 (83%) returned to sports at preinjury level. On latest radiographs, 64 (91%) had no osteoarthritis, and bone block positioning was accurate, with 63 (90%) being below the equator and 65 (93%) flush to the glenoid surface. The coracoid graft healed in 51 (73%), it failed to unite in 14 (20%), and graft osteolysis was seen in five (7%). Bone block nonunion/migration did not compromise shoulder stability but was associated with persistent apprehension and less return to sports. Use of screws that were too short or overangulated, smoking, and age higher than 35 years were risk factors for nonunion. CONCLUSIONS: The arthroscopic Bristow-Latarjet procedure combined with Bankart repair for anterior instability with severe glenoid bone loss restored shoulder stability, maintained ROM, allowed return to sports at preinjury level, and had a low likelihood of arthritis. Adequate healing of the transferred coracoid process to the glenoid neck is an important factor for avoiding persistent anterior apprehension. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Comparison between traction-countertraction and modified scapular manipulation for reduction of shoulder dislocation.

OBJECTIVE: One of the most common joint dislocations presented to the emergency department (ED) is anterior shoulder dislocation (ASD). Various techniques for the treatment of this abnormality have been suggested. In this study, we evaluated the efficacy and success rate of modified scapular manipulation (MSM) as a painless procedure compared to traction-countertraction (TCT) for reduction of ASD. METHODS: Patients with ASD who were presented to ED of Baqiyatallah Hospital, Tehran during 2011 were included. They were randomly divided into MSM group or TCT group and then pain at reduction, time of reduction, duration of hospitalization, and success rate were compared. In TCT group, reduction was performed using sedative and antipain medications. RESULTS: Ninety seven patients (81.6% male) with a mean age of 34.15 years±13.48 years were studied. The reduction time between both groups showed a significant difference (470.88 seconds±227.59 seconds for TCT group, 79.35 seconds±82.49 seconds for MSM group, P<0.001). The success rate in MSM group in the first and second effort were 89% and 97% whereas 73% and 100% in the TCT group respectively (P<0.001). CONCLUSION: It seems that the manipulation technique can be more successful than the TCT method at the first effort whilst the second effort has the opposite results. Also MSM can be safer, cheaper and more acceptable for patients than TCT as a standard traditional method.

Effect of electrical stimulation to long head of biceps in reducing gleno humeral subluxation after stroke.

BACKGROUND: Glenohumeral subluxation is the most frequent complication in post stroke hemiplegia and its reduction has been considered an important goal. Though it has been demonstrated that cyclical electrical stimulation of posterior deltoid and supraspinatus muscles can reduce subluxation, the role of biceps has not been given due consideration. OBJECTIVE: The purpose of this study was to determine whether electrical stimulation to the long head of biceps could more effectively reduce gleno humeral subluxation. METHODS: 24 patients were selected and consecutively assigned to group 1 (electrical stimulation to supraspinatus & posterior deltoid) and group II (electrical stimulation to supraspinatus, posterior deltoid & long head of the biceps) along with routine physiotherapy and occupational therapy for a period of 5 weeks. All patients were assessed for shoulder subluxation, pain and shoulder active abduction range of motion at the time of recruitment to study and after 5 weeks of therapy. RESULTS: Both the groups showed significant improvement in parameters measured. Tukey's post hoc analysis showed the results were more significant in Group II. CONCLUSIONS: Electrical stimulation to biceps along with the supraspinatus and posterior deltoid can more effectively reduce shoulder subluxation.