The role of physical activity as conservative treatment for massive rotator cuff tears in elderly patients: a systematic review.

The aim of this systematic review is to determine the effectiveness on functional and pain outcomes of different exercise protocols as a conservative treatment for massive, irreparable rotator cuff tears in elderly patients. A literature search was carried out consulting Pubmed -Medline, Cochrane central and Scopus to select randomized clinical trials, prospective and retrospective cohort studies or case series, that evaluated functional and pain outcomes after physical therapy in patients aged 65 or over, affected by massive rotator cuff tears. The present systematic review followed the Cochrane methodology for systematic reviews and the reporting was implemented using through the PRISMA guidelines. The Cochrane risk of bias tool and MINOR score were used for methodologic assessment. Nine articles were included. Data concerning physical activity, functional outcomes and pain assessment were obtained from the included studies. The exercise protocols assessed within the included studies were extremely wide with equally different methods of evaluation of the outcomes. However, most of the studies demonstrated a trend of improvement after the treatment, in terms of functional scores, pain, ROM and quality of life. An intermediate methodological quality of the included papers was assessed through the risk of bias evaluation. Our results showed a positive trend in patients who underwent physical exercise therapy. Our conclusion is that further studies of a high level of evidence are needed to achieve consistent evidence to improve clinical practice in the future.

2017 Marathon of Rome: Anthropometry and Sport Profile in 350 Runners and Association With Achilles and Patellar Tendinopathy.

BACKGROUND: Achilles and patellar tendinopathy are common in runners. Despite the relevance of the problem, causative factors remain poorly understood. This cross-sectional study evaluated the association between Achilles and patellar tendinopathy and age, sex, weight, height, number of marathons, and impact profile in runners who participated in the 2017 Marathon of Rome. METHODS: At the 2017 Marathon of Rome, 350 athletes (256 men and 94 women; mean age: 44.8 years, range 12-80 years) filled in the VISA-A and VISA-P questionnaires. A fully trained orthopedic surgeon made a diagnosis of Achilles and patellar tendinopathy according to clinical criteria. RESULTS: Ninety-five participants were diagnosed with Achilles tendinopathy and 96 with patellar tendinopathy. There was evidence of a statistically significant positive association between age and Achilles and patellar tendinopathy, with no effect of sex, weight, and height on the presence of Achilles tendinopathy. There was no evidence of a statistically significant positive association between the number of marathons and impact profile and VISA-A score. There was a statistically significant association between VISA-P score and impact profile. Finally, there was evidence of a statistically significant positive association between VISA-A score and VISA-P score (P = 0.007). CONCLUSIONS: In marathon runners, there was no evidence of a statistically significant association between sex, weight, height, number of marathons, and Achilles and patellar tendinopathy. However, age was associated with Achilles and patellar tendinopathy, and impact profile was associated with patellar tendinopathy.

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.

Hip scores: A current concept review.

INTRODUCTION: During the past decades, several rating scales have been developed to assess the functional status of patients with hip pain. SOURCE OF DATA: A search in Medline, PubMed, Cochrane and CINAHL was performedusing combinations of the following'hip', 'scoring system', 'scale', 'scores', 'outcome assessment', 'arthroplasty', 'arthroscopy' and 'clinical evaluation'. AREAS OF AGREEMENT: A total 16 scoring systems are currently available for the evaluation of the hip. AREAS OF CONTROVERSY: Two types of questionnaires are available: physician-rated and patient-rated questionnaires. GROWING POINTS: Each hip score consists of different domains. Interpreting these domains becomes sometimes difficult, because, even though they can be common to more than one scoring system, each stresses them in a different way. AREAS TIMELY FOR DEVELOPING RESEARCH: Although many scoring systems have been used to evaluate hip function, we are still far from a single outcome evaluation system which is reliable, valid and sensitive.

The effectiveness of conservative and surgical treatment for shoulder stiffness: a systematic review of current literature.

Introduction: Currently, no therapeutic intervention is universally accepted, and the most effective management for restoring motion and diminishing pain in patients with shoulder stiffness has yet to be defined. This systematic review analyses outcomes of conservative and surgical interventions to treat shoulder stiffness. Source of data: A systematic review of 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', 'shoulder stiffness', 'stiff shoulder', 'conservative', since inception of databases to June 2018 was performed. Areas of agreement: Shoulder stiffness could be treated with conservative means including nonsteroidal anti-inflammatory medications, corticosteroid injections, or transcutaneous electrical nerve stimulation, manipulation under anaesthesia, and arthroscopic capsular release. Areas of controversy: No therapeutic intervention is universally accepted, and the most effective management to restore motion and diminish pain in patients with shoulder stiffness has yet to be defined. Growing points: The rate of failure after treatment for stiff shoulder is higher in the surgical group than in the conservative group. Areas timely for developing research: There is insufficient evidence to establish whether surgical or conservative management is the best choice to manage shoulder stiffness. Prospective, randomized studies are needed to establish whether surgical or conservative management produce a clinically relevant difference in functional outcome.

Sudden cardiac death in young athletes with long QT syndrome: the role of genetic testing and cardiovascular screening.

Introduction: Sudden cardiac death (SCD) of young athletes during competition or training is a tragic event. The long QT syndrome (LQTS) is an arrythmogenic disorder characterized by prolonged ventricular repolarization leading to torsade de pointes evident at electrocardiogram (ECG). Implantable cardioverter defibrillator is an option to revert ventricular fibrillation to sinus rhythm, although the implantation may result in denial of sports participations to the athlete. The authors reviewed the current literature on LQTS in young athletes, to clarify the role of different screening technologies to prevent SCD. Sources of data: A systematic review of the literature was performed applying the PRISMA guidelines according to the PRISMA checklist and algorithm. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase and Google Scholar databases using various combinations of the keywords: 'QT', 'syndrome', 'screening', 'young', 'athletes', 'genetic', 'electrocardiogram', 'echocardiography' and 'prevention' were used. Areas of agreement: Young athletes with LQTS are at greater risk of SCD. Areas of controversy: Different detection screening technologies, including ECG monitoring and genetic testing, are recommended, even though their role is not fully understood. Growing points: ECG and genetic testing screening programmes could reduce the incidence of SCD, and they may positively impact on the health and safety of young athletes during sport. Areas timely for developing research: Further studies should analyze other modalities of screening to allow early detection of cardiovascular conditions to prevent SCD in young athletes.

Biomechanical effects of metastasis in the osteoporotic lumbar spine: A Finite Element Analysis.

BACKGROUND: Cancer patients are likely to undergo osteoporosis as consequence of hormone manipulation and/or chemotherapy. Little is known about possible increased risk of fracture in this population. The aim of this study was to describe the biomechanical effect of a metastatic lesion in an osteoporotic lumbar spine model. METHODS: A finite element model of two spinal motion segments (L3-L5) was extracted from a previously developed L3-Sacrum model and used to analyze the effect of metastasis size and bone mineral density (BMD) on Vertebral bulge (VB) and Vertebral height (VH). VB and VH represent respectively radial and axial displacement and they have been correlated to burst fracture. A total of 6 scenarios were evaluated combining three metastasis sizes (no metastasis, 15% and 30% of the vertebral body) and two BMD conditions (normal BMD and osteoporosis). RESULTS: 15% metastasis increased VB and VH by 178% and 248%, respectively in normal BMD model; while VB and VH increased by 134% and 174% in osteoporotic model. 30% metastasis increased VB and VH by 88% and 109%, respectively, when compared to 15% metastasis in normal BMD model; while VB and VH increased by 59% and 74% in osteoporotic model. CONCLUSION: A metastasis in the osteoporotic lumbar spine always leads to a higher risk of vertebral fracture. This risk increases with the size of the metastasis. Unexpectedly, an increment in metastasis size in the normal BMD spine produces a greater impact on vertebral stability compared to the osteoporotic spine.

Trochleoplasty techniques provide good clinical results in patients with trochlear dysplasia.

PURPOSE: The aim of this systematic review is to compare the clinical outcomes of patients treated with different trochleoplasty procedures, the rate of complications and recurrence of patellar dislocation. METHODS: A systematic review of the literature was performed, in accord with the PRISMA guidelines. PubMed, MEDLINE, CINAHL, Cochrane, EMBASE and Google Scholar databases were comprehensively searched using the keyword combinations, "Dejour trochleoplasty", "Bereiter Trochleoplasty", "Albee Trochleoplasty", "Recession Trochleoplasty", "Trochlear Dysplasia", "Instability", "Adult", "Clinical Outcome" and "Surgery". RESULTS: Three-hundred and ninety-two knees in 371 patients were included. Bereiter U-shaped deepening trochleoplasty was the most commonly used technique for the treatment of trochlear dysplasia in the included studies with the lowest rate of recurrence and post-operative ROM deficiency. On the other hand, Dejour V-shaped deepening trochleoplasty showed the highest mean post-operative value of Kujala score with 79.3 (SD 8.4) points. Statistical differences were found in terms of redislocation rate between Goutallier procedure and Bereiter trochleoplasty (p < 0.05) and in terms of post-operative osteoarthritis between Bereiter and Dejour procedures (p < 0.05). CONCLUSION: Bereiter trochleoplasty seems to be the most efficiency procedure in terms of post-operative patellar redislocation, post-operative osteoarthritis and ROM, but the highest mean post-operative Kujala score is obtained by Dejour procedure. Therefore, none of the surgical techniques analysed highlighted a real superiority. Randomised clinical trials are needed to establish whether of available surgical technique is the best to treat patient with trochlear dysplasia. The clinical relevance of this paper is that the three most popular trochleoplasty techniques are associated with significantly improved stability and function, showing a relatively low rate of osteoarthritis and pain, and a moderate rate of complications. LEVEL OF EVIDENCE: Systematic review, Level IV.

Patellar Resurfacing in Total Knee Arthroplasty: Systematic Review and Meta-Analysis.

BACKGROUND: Patellar resurfacing in total knee arthroplasty remains controversial. The aim of this study is to evaluate this technique through an analysis of comparative studies in the current literature. METHODS: We performed a comprehensive search of PubMed, MEDLINE, Cochrane, CINAHL, and EMBASE databases using various combinations of the keywords "Knee," "Replacement," "Prosthesis," "Patella," "Resurfacing," and "Arthroplasty." All articles relevant to the subject were retrieved, and their bibliographies were hand searched for further references relevant to primary patellar resurfacing in total knee arthroplasty. Only articles published in peer-reviewed journals were included in this systematic review. RESULTS: The percentage for a reoperation was 1% for the patellar resurfacing group (17/1636) and 6.9% for the non-resurfacing group (118/1699) (odds ratio [OR] 0.18, 95% confidence interval [CI] 0.11-0.29, P < .00001). The patellar resurfacing group showed a significantly higher postop Knee Society Score (KSS) pain (OR 1.52, 95% CI 0.68-2.35, P = .004) and postop Hospital for Special Surgery score (OR 4.35, 95% CI 3.21-5.49, P < .00001), over the non-resurfacing group. CONCLUSION: Based on the outcome scores of KSS (pain), KSS (function), and Hospital for Special Surgery postop, patellar resurfacing TKAs have performed better than non-resurfaced TKAs. The lower secondary operation and revision rates for patellar resurfaced TKAs also demonstrate that this technique is the more effective option. However, the full impact of patellar resurfacing still needs to be critically evaluated by larger randomized controlled trials with long-term follow-up.

Surgical versus conservative management of Type III acromioclavicular dislocation: a systematic review.

Introduction: The management of Type III acromioclavicular (AC) dislocations is still controversial. We wished to compare the rate of recurrence and outcome scores of operative versus non-operative treatment of patients with Type III AC dislocations. Source of data: A systematic review of the literature was performed by applying the PRISMA guidelines according to the PRISMA checklist and algorithm. A search in Medline, PubMed, Cochrane and CINAHL was performed using combinations of the following keywords: 'dislocation', 'Rockwood', 'type three', 'treatment', 'acromioclavicular' and 'joint'. Areas of agreement: Fourteen studies were included, evaluating 646 shoulders. The rate of recurrence in the surgical group was 14%. No statistical significant differences were found between conservative and surgical approaches in terms of postoperative osteoarthritis and persistence of pain, although persistence of pain seemed to occur less frequently in patients undergoing a surgical treatment. Areas of controversy: Persistence of pain seemed to occur less frequently in patients undergoing surgery. Growing points: Persistence of pain seems to occur less frequently in patients treated surgically for a Type III AC dislocation. Areas timely for developing research: There is insufficient evidence to establish the effects of surgical versus conservative treatment on functional outcome of patients with AC dislocation. High-quality randomized controlled clinical trials are needed to establish whether there is a difference in functional outcome.

Treatment of Primary Acute Patellar Dislocation: Systematic Review and Quantitative Synthesis of the Literature.

PURPOSE: The aim of this study was to evaluate clinical outcomes, rate of redislocation, and complications after conservative or surgical procedures used to treat primary acute patellar dislocation. METHODS: A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases using various combinations of the keywords "patella," "dislocation," "treatment," "acute," "primary" was performed. The following data were extracted: demographics, chondral defects and soft tissue lesions, outcome measurements, type of management, recurrence of instability, and complications. RESULTS: A total of 2134 knees in 2086 patients were included, with an average age at dislocation of 20.3 years. The average Kujula score was 75.6 for patients treated conservatively and 88.7 for patients undergoing surgical treatment in the short-medium follow-up (less than 5 years); the average Kujula score was 87.5 for patients treated conservatively and 86.6 for patients undergoing surgical treatment in the long-term follow-up (more than 5 years). The rate of recurrence was significantly lower in the surgical group (25%) than in the conservative group (36.4%). The overall complication rate was 6.5% (29 of 441 knees) in the surgical management group. No complications were reported for patients treated conservatively. CONCLUSIONS: Surgical treatment of primary acute patellar dislocation leads to significantly lower rate of redislocation and provides better short-medium clinical outcomes, whereas in the long-term follow-up, results of patients treated conservatively were as good as those of surgical patients. Further randomized controlled trials, describing anatomical abnormalities and soft-tissue integrity that may influence the choice of treatment, are needed. LEVEL OF EVIDENCE: Systematic review, level IV.

All-polyethylene versus metal-backed tibial component in total knee arthroplasty.

PURPOSE: The aim of this systematic review was to evaluate the clinical outcomes, rate of revisions and complications of all-polyethylene tibial and metal-backed tibial components in patients treated with knee arthroplasty for primary or secondary osteoarthritis. METHODS: A systematic review of the literature according to the PRISMA guidelines was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases using various combinations of the keywords such as "knee", "arthroplasty", "metal-backed", and "all-polyethylene", since inception of databases to 2016, was performed. RESULTS: Thirty-two articles, describing patients with all-polyethylene tibial or metal-backed tibial components in the setting of osteoarthritis, were included. A total of 68,202 knees in 58,942 patients were included, with an average age at surgery of 69.3 years, ranging from a mean age of 57.9-82 years. The mean KSS was 82.4 and 81.3 (n.s.), the mean KSS(F) was 73.6 and 74.9 (p = 0.04), the mean ROM was 104.5 and 104.6 (n.s.), and the mean HSS was 87 and 86, each, respectively, for the metal-backed tibial components group and all-polyethylene tibial components group. The overall rate of revisions was 1.90 %. The rate of revision in the metal-backed tibial components group was 1.85 %, whilst the rate of revision in the all-polyethylene tibial components group was 2.02 % (p < 0.00001). CONCLUSION: Metal-backed tibial and all-polyethylene tibial components did not show any significant difference in most of the included outcome scores, but statistical differences were found in terms of complications and revision rate. These items have a negative impact on the cost-effectiveness of all-polyethylene tibial components. Even if all-polyethylene tibial components show similar clinical outcome score, equivalent range of knee motion, and long-term survival compared to metal-backed tibial components, complications and revision rate seem to lead the surgeon to prefer the last ones. The clinical relevance of this study is that metal-backed tibial components should be preferred in TKA surgery because complications are higher using all-polyethylene tibial components. On the other hand, the quality of evidence, according to GRADE system, is low underling the necessity of more randomised study to clarify these items. LEVEL OF EVIDENCE: III.

The burden of rotator cuff surgery in Italy: a nationwide registry study.

PURPOSE: This study aimed to estimate the yearly number of RC surgeries in Italy, a country with universal access to healthcare for its population, from 2001 to 2014, based on official information source as hospitalization records. A secondary aim was to explore geographical variation in equity in access to RC surgery between three macroregions of Italy (North, Center and South). A tertiary aim was to perform statistical projections of the number of RC procedure volumes and rates on the basis of data from 2001 to 2014. Finally, we aimed to perform a prediction of charges by 2025 to examine the economic impact of RC surgery. METHODS: The analysis of the National Hospital Discharge records (SDO) maintained at the Italian Ministry of Health, concerning the 14 years of our survey (2001 through 2014) was performed. These data are anonymous and include the patient's age (in aggregate for class of age), sex, domicile, region of hospitalization, length of the hospitalization, and type of reimbursement (public or private). RESULTS: During the 14-year study period, 390,001 RC repairs were performed in Italy, which represented an incidence of 62.1 RC procedures for every 100,000 Italian inhabitants over 25 years old. Approximately 65% of RC repair were performed annually in patients ages <65 years, thus affecting the working population. 246,810 patients (63.3%) from the North underwent RC repairs from 2001 through 2014, 78,540 patients (20.2%) from the Center, and 64,407 patients (16.5%) from the South. The projection model predicted substantial increases in the numbers of RC repairs. CONCLUSIONS: This study confirms that the socioeconomic burden of RC surgery is growing and heavily affecting the working population. According to the prediction model, hospital costs sustained by the national health care system for RC procedures are expected to be over 1 billion euros by 2025. LEVEL OF EVIDENCE: II.

Apophyseal injuries in children's and youth sports.

INTRODUCTION: The authors reviewed the current English literature regarding apophyseal injuries affecting young athletes, to highlight the frequency and characteristics of these injuries, to clarify risk factors and specific prevention measures, and to identify future research objectives. SOURCES OF DATA: The authors performed a comprehensive search of the medical literature, using the Medline database, including all English articles. Various combinations of the Keywords 'injury', 'sports', 'athletic injuries', 'avulsion fractures', 'physeal', 'physis', 'apophysis', 'apophysitis', 'growth plate' were used. AREAS OF AGREEMENT: Growth benefits from a moderate physical activity. AREAS OF CONTROVERSY: Growth deficit may occur in young athletes involved in intensive practice of sport following apophysitis. GROWING POINTS: Apophyseal injuries occurring during sport are less common than overall rate of injuries affecting the adolescent population. Growth disturbance occurs only rarely after an apophyseal injury. AREAS TIMELY FOR DEVELOPING RESEARCH: Further studies should consider analytical as well as descriptive components of apophyseal injuries, to allow the identification of new possible risk factors and preventive measures and to help early detection and proper treatment as well.

Medial Patellofemoral Ligament Reconstruction Combined With Bony Procedures for Patellar Instability: Current Indications, Outcomes, and Complications.

PURPOSE: The aim of this literature review is to analyze current indications, outcomes, and complication rates of medial patellofemoral ligament (MPFL) reconstruction associated with bony procedures in order to clarify efficacy and adoptability in selected patients with patellar instability. METHODS: A systematic review of the literature was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search on PubMed, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases was performed, using various combinations of the keywords patellar instability, MPFL reconstruction, tibial tubercle osteotomy, and trochleoplasty. RESULTS: Fourteen of 501 articles were included. Indications for surgery included dysplasia and malalignment. All studies reported significant improvements in overall clinical outcomes. The most frequently used score was the Kujala score, with a mean value of 83.26. Functional failures ranged from 0% to 8.8%. Major complications were not described. Minor complications ranged from 0% to 40%. Reoperations ranged from 4.5% to 17.7%. CONCLUSIONS: A combined approach seems indicated in patients with patellar instability, especially among those with high tibial tuberosity-trochlear groove or severe trochlea dysplasia. Indications for combined MPFL and bony procedure are influenced by anatomy, including dysplasia and malalignment. We are unable to identify an absolute indication. Bony procedures are associated with increased morbidity. LEVEL OF EVIDENCE: Level IV, systematic review of Level I to IV studies.

Elmslie-Trillat, Maquet, Fulkerson, Roux Goldthwait, and Other Distal Realignment Procedures for the Management of Patellar Dislocation: Systematic Review and Quantitative Synthesis of the Literature.

PURPOSE: To evaluate clinical outcomes, rate of recurrence, and complications following distal realignment procedures (Elmslie-Trillat, Maquet, Fulkerson, Roux Goldthwait, and other distal realignment procedures) performed alone or in combination with proximal procedures for the management of patellar dislocation. METHODS: A systematic literature review was performed following the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). A search in PubMed, Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, Embase, and Google Scholar databases using various combinations of the keywords "patellar," "dislocation," "tibial transfer," "Elmslie-Trillat," "Roux Goldthwait," "tibial tubercle osteotomy," "Fulkerson," "Maquet," "procedure," "clinical," and "outcome." RESULTS: Thirty-eight articles were included in the systematic review. A total of 1,182 knees belonging to 1,023 patients were grouped according to the duration of the follow-up period. The overall rate of recurrence was 7% (83 of 1,182 knees). Approximately 5.3% (28 of 520 knees) of the redislocation occurred in the short-medium term, and 8.3% (55 of 662 knees) occurred in the long-term. CONCLUSIONS: Distal realignment procedures performed alone or in combination with proximal procedures for the management of patellar dislocation have shown good clinical outcomes and a low rate of recurrence highlighting the efficacy of these procedures. To date no randomized controlled clinical trials are available on the topic. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Humeral Avulsion of the Glenohumeral Ligaments: A Systematic Review.

PURPOSE: To analyze clinical outcomes, range of motion, rate of recurrence, and complications after procedures to manage shoulder instability in patients with humeral avulsion of the glenohumeral ligament (HAGL) lesions. METHODS: A systematic review of the literature according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines with a PRISMA checklist and algorithm was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases using various combinations of the Keywords "shoulder," "HAGL," "treatment," "lesion," "dislocation," "instability," "clinical," "outcome," "Bankart" since inception of databases to 2015 was performed. All the investigators independently extracted the following data: demographics, types of lesions and associated injuries, treatment, outcome measurements, range of motion, recurrent instability, and complications. RESULTS: Eleven articles were included in which 42 shoulders with HAGL lesions were evaluated. Patients were assessed at a median follow-up period of 25.5 months, ranging from 12 to 54 months. The overall rate of recurrence was 0% (0 of 25) in case of surgery and 90% (9 of 10) in case of nonoperative treatment. The surgical approach was associated with lower rate of recurrence when compared with nonoperative treatment (odds ratio 0.05, 95% confidence interval 0.01 to 0.42, and P = .006). Only 2 papers reported loss of external rotation after surgery. No complications were reported after surgery. Complications after nonoperative treatment were not discussed. CONCLUSIONS: Recognizing HAGL lesions is important to manage patients with glenohumeral instability. Patients' complaints are often nonspecific. A high index of suspicion is required in patients with prior failed shoulder surgery. HAGL lesions are often associated with other shoulder lesions. Arthroscopic or open repairs of HAGL lesions are associated with good clinical outcomes and a lower rate of recurrence compared with nonoperative treatment. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Conservative and surgical management of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines.

PURPOSE: Correct management of syndesmotic injuries is mandatory to avoid scar tissue impingement, chronic instability, heterotopic ossification, or deformity of the ankle. The aim of the present study was to perform a systematic review of the current treatments of these injuries to identify the best non-surgical and surgical management for patients with acute isolated syndesmotic injuries. METHODS: A review of the literature was performed according to the PRISMA guidelines. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases was performed using the following keywords: "ankle injury", "syndesmotic injury", "chronic", "acute", "treatment", "conservative", "non-operative" "operative", "fixation", "osteosynthesis", "screw", "synostosis", "ligamentoplasties" over the years 1962-2015. RESULTS: The literature search and cross-referencing resulted in a total of 345 references, of which 283 were rejected due to off-topic abstract and/or failure to fulfil the inclusion criteria. After reading the remaining full-text articles, we included four studies, describing non-surgical management, and only two studies investigating surgical management of acute isolated injuries. CONCLUSIONS: The ESSKA-AFAS consensus panel provided recommendations to improve the management of patients with isolated acute syndesmotic injury in clinical practice. Non-surgical management is recommended for stable ankle lesions and includes: 3-week non-weight bearing, a below-the-knee cast, rest and ice, followed by proprioceptive exercises. Surgery is recommended for unstable lesions. Syndesmotic screw is recommended to achieve a temporary fixation of the mortise. Suture-button device can be considered a viable alternative to a positioning screw. Partial weight bearing is allowed 6 weeks after surgery. LEVEL OF EVIDENCE: IV.

Classification and diagnosis of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines.

PURPOSE: The aim of the present study was to perform a systematic review of the current classification systems, and the clinical and radiological tests for the acute isolated syndesmotic injuries to identify the best method of classification and diagnosis allowing the surgeon to choose the appropriate management. METHODS: A systematic review of the literature according to the PRISMA guidelines has been performed. A comprehensive search using various combinations of the keywords "classification", "grading system", "ankle injury", "ligament", "syndesmotic injury", "internal fixation", "acute", "synostosis", "ligamentoplasties", "clinical", "radiological" over the years 1962-2015 was performed. The following databases were searched: MEDLINE, Google Scholar, EMBASE and Ovid. RESULTS: The literature search resulted in 345 references for classification systems and 308 references for diagnosis methods, of which 283 and 295 were rejected due to off-topic abstract and/or failure to fulfil the inclusion criteria. After reading the remaining full-text articles, we included 27 articles describing classification systems and 13 articles describing diagnostic tests for acute isolated syndesmotic injuries. CONCLUSIONS: The ESSKA-AFAS consensus panel recommends distinguishing acute isolated syndesmotic injury as stable or unstable. Stable injuries should be treated non-operatively with a short-leg cast or brace, while unstable injuries should be managed operatively. The recommended clinical tests include: tenderness on palpation over the anterior tibiofibular ligament, the fibular translation test and the Cotton test. Radiographic imaging must include an AP view and a mortise view of the syndesmosis to check the tibiofibular clear space, medial clear space overlap, tibial width and fibular width. LEVEL OF EVIDENCE: IV.