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Purpose: To compare the clinical outcomes and retear rates after rotator cuff repair (RCR) between delaminated and non-delaminated tears. Methods: This systematic review was conducted according to the preferred reporting items for systematic reviews and meta-analyses guidelines using the PubMed, Cochrane Library, the Web of Science and Embase databases. Only articles on arthroscopic RCR with clinical outcome scores and data on the number of rotator cuff retears and complete healing were included. This study's relevant data were extracted and statistically analyzed. The methodological index for nonrandomized studies was used to assess the risk of bias in the included studies. After conducting a heterogeneity test and sensitivity analysis to determine whether the samples were heterogeneous, the study also detected publication bias. A sub-group test was used to evaluate the influences of the imaging follow-up period on retear rates. Results: Ten eligible articles were identified with 2,061 patients (925 in the delaminated group and 1,136 in the non-delaminated group). The meta-analysis demonstrated that delamination was significantly associated with higher retear rates (P = 0.026; odds ratio = 1.873, 95% confidence interval 1.079–3.252; I2 = 51.6%) with an imaging follow-up period of > 1 year and lower rates of complete healing (P = 0.036; odds ratio = 0.659, 95% confidence interval 0.446–0.973; I2 = 9.0%) in patients after rotator cuff repair. However, no significant differences were observed between the two groups based on American Shoulder and Elbow Surgeons score, Constant score, visual analog scale score, external rotation, internal rotation, or forward elevation. Conclusions: This meta-analysis found that delamination was significantly associated with higher retear rates with imaging follow-up period of > 1 year, and lower rates of complete healing. In addition, the preoperative and postoperative clinical scores and shoulder joint range of motion were similar between patients with delaminated and non-delaminated tears. Level of evidence: Level IV. [ABSTRACT FROM AUTHOR]

Purpose: Arthroscopic superior capsule reconstruction (SCR) with the long head of the biceps (LHBT) was performed to restore structural stability, force couple balance, and shoulder joint function. This study aimed to evaluate the functional outcomes of SCR using the LHBT over at least 24 months of follow-up. Method: This retrospective study included 89 patients with massive rotator cuff tears who underwent SCR using the LHBT, met the inclusion criteria and underwent follow up for at least 24 months. The preoperative and postoperative shoulder range of motion (forward flexion, external rotation, and abduction), acromiohumeral interval (AHI), visual analog scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) score and Constant–Murley score were obtained, and the tear size, and Goutallier and Hamada grades were also investigated. Results: Compared with those measured preoperatively, the range of motion, AHI, and VAS, Constant–Murley, and ASES scores were significantly improved immediately postoperatively (P < 0.001) and at the 6-month, 12-month, and final follow-ups (P < 0.001). At the last follow-up, the postoperative ASES score and Constant-Murley score increased from 42.8 ± 7.6 to 87.4 ± 6.1, and 42.3 ± 8.9 to 84.9 ± 10.7, respectively; with improvements of 51 ± 21.7 in forward flexion, 21.0 ± 8.1 in external rotation, and 58.5 ± 22.5 in abduction. The AHI increased 2.1 ± 0.8 mm and the VAS score significantly changed from 6.0 (5.0, 7.0) to 1.0 (0.0, 1.0), at the final follow-up. Eleven of the 89 patients experienced retears, and one patient needed reoperation. Conclusion: In this study with at least 24-months of follow-up, SCR using the LHBT for massive rotator cuff tears could effectively relieve shoulder pain, restore shoulder function and increase shoulder mobility to some extent. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the results of arthroscopic autologous iliac bone graft suspension fixation combined with the Remplissage procedure in the treatment of recurrent shoulder dislocation with bony Bankart lesions and joint hyperlaxity. Methods: From 2018 to 2020, 22 patients with joint laxity underwent arthroscopic autologous iliac bone graft suspension fixation and Bankart repair combined with the Remplissage procedure due to recurrent shoulder dislocation. Clinical assessment included range of motion (forward flexion, abduction, 90° external rotation, conventional external rotation, adduction, and internal rotation), visual analog scale (VAS) score, Rowe score, University of California Los Angeles (UCLA) score, and Western Ontario Shoulder Instability Index (WOSI) score. Post-operatively, the healing of the bone graft was evaluated with computed tomography (CT) scanning. Results: All 22 patients were followed up for a mean of 19.3 ± 4.1 months. CT imaging showed that the healing time of the bone graft was 6–8 weeks. The patient satisfaction rate was 100%, there were no cases of redislocation, all patients returned to their preinjury training state, and the fear test was negative. At the final follow-up, the UCLA, VAS, Rowe, and WOSI scores were 29.8 ± 2.1, 2.2 ± 0.8, 89.4 ± 4.2, and 482.3 ± 46.2, respectively (p < 0.001). Conclusion: Arthroscopic autologous iliac bone graft suspension fixation and Bankart repair combined with the Remplissage procedure are effective in preventing recurrent instability with joint hyperlaxity. Furthermore, no patient had redislocation. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: The Stump classification is significantly correlated with a retear after arthroscopic rotator cuff repair. However, no study has evaluated whether or not the stump classification is correlated with retear in the suture-bridge or double-row repair techniques. The aim of this study was to evaluate the relationship between a retear and the stump classification in the suture-bridge and double-row repair techniques. Methods: Among 389 patients who underwent arthroscopic repairs of full-thickness rotator cuff tears using suture-bridge or double-row repair techniques, 326 patients (median age 67.0 years; range 25–85) were included. There were 51 small, 172 medium, 83 large, and 20 massive tears. Two hundred forty patients were treated with the suture-bridge technique, and 86 patients were treated with the double-row technique. The following variables were analyzed: age, sex, the Cofield classification, anteroposterior and mediolateral tear size on preoperative MRI, global fatty degeneration index, and the stump classification. Cuff integrity was evaluated on magnetic resonance imaging at 6 months after surgery. The patients were divided into the intact and retear groups and the relationship between the variables and retear was evaluated by multivariate logistic regression analysis. Results: The overall retear rate was 10.1%. In the multivariate logistic regression analysis, the independent predictors of a retear were the stump classification type 3 (Odds ratio: 4.71, p = 0.0246), global fatty degeneration index (Odds ratio: 3.87, p = 0.0030), and anteroposterior tear size (Odds ratio: 1.07, p = 0.0077) in the suture bridge technique. In the double-row technique, the independent predictors of retear were stump classification type 3 (Odds ratio: 7.82, p = 0.0348), and age (Odds ratio: 1.22, p = 0.0163). Conclusion: The stump classification was significantly correlated with retear in the suture-bridge and double-row repair technique. Stump classification type 3 was indicated to be an important risk factor for predicting retear. Level of evidence: III [ABSTRACT FROM AUTHOR]

Purpose: Systematic reviews report return to play (RTP) within 5.8 months (range, 3–8) following the Latarjet procedure, but the factors that influence RTP remain unknown. The present study aimed to report the rate and time of return to play (RTP) during the first 8 months following the Latarjet procedure, and to determine the influence of sport type or patient characteristics. Methods: The authors retrospectively collected the records of patients that underwent Latarjet procedures for anterior shoulder instability between 2015 and 2017. Patients were excluded if they had any concomitant rotator cuff tendon lesions, or previous ipsilateral shoulder surgery. The authors retrieved patient demographics, time from injury to surgery, type of sport practiced (overhead/non-overhead, contact/non-contact), as well as pre- and postoperative Western Ontario Shoulder Instability index (WOSI), Shoulder Instability-Return to Sport After Injury index (SIRSI), and Rowe score. Results: A total of 217 patients (217 shoulders) were eligible for inclusion, comprising 184 males and 33 females, aged 26.8 ± 7.3 years at index surgery. The main sport practiced prior to surgery involved overhead (n = 173, 80%) and/or contact (n = 152, 70%) activities. By 8 month follow-up, 158 patients (73%) resumed their main sport, at a mean of 5.1 ± 1.5 months. Multivariable analysis revealed that RTP was more likely in patients with higher preoperative Rowe score (OR, 1.02; p = 0.024) and SIRSI score (OR, 1.02; p = 0.008). Conclusions: By 8 months following the Latarjet procedure, 73% of patients had resumed their main sport. The likelihood of RTP was significantly associated with preoperative Rowe and SIRSI scores, but not with sport type. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: Since poor repeatability of the load and shift test using a grading scale has been reported, an objective and quantitative method to assess anterior translation should be established to assess glenohumeral joint function. The purpose of this study was to assess the accuracy and repeatability of the ultrasonographic techniques to quantify anterior translation of the glenohumeral joint. Methods: Eight fresh-frozen cadaveric shoulders were used. For the standard technique, the ultrasound transducer was positioned on the anterolateral aspect of the shoulder viewing the coracoid process, glenoid, and humeral head. For the revised technique, the transducer was positioned on the anterior aspect of the shoulder, perpendicular to the scapular plane, viewing the conjoint tendon, glenoid, and humeral head. During the load and shift test, the distance between anterior edges of the glenoid and the humeral head was measured. The difference between distances before and after applying an anterior load was calculated as an anterior translation and compared with the anterior translation assessed using a motion tracking system. The repeatability and accuracy of both techniques were analyzed statistically. Results: Intra- and inter-observer repeatability was good–excellent for both ultrasonographic techniques (ICC, 0.889–0.998). The revised technique achieved a stronger correlation to the anterior translations obtained using the motion tracking system (R = 0.810–0.913, p < 0.001) than the standard technique (R = 0.619–0.806, p < 0.001). Conclusion: Better accuracy and repeatability was found in the revised technique than the standard technique. The revised technique will be useful to determine the individual laxity and modify the treatment plan and return-to-sports protocol. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate with computed tomography (CT) the incidence of anchor-related osteolysis after implantation of two types of all-suture anchors for the management of labral lesions in shoulder instability.Methods: Single-cohort, observational study with 12-month follow-up. Thirty-three participants (27 males/6 females; age 38.3 years [SD 11.3]) with anterior labral lesions in which 143 all-suture anchors (71 Iconix 1.4 mm and 72 Suturefix 1.7 mm) were implanted were evaluated with a CT performed a mean of 15.4 [3.85] months after surgery. The volume of the bone defects was measured in the CT. Every anchor was classified into one of four groups: (1) no bone defect. (2) Partial bone defect (defects smaller than the drill used for anchor placement). (3) Tunnel enlargement (defects larger than the drill volume but smaller than twice that volume). (4) Cystic lesion (defects larger than twice the drill volume).Results: No bone defect was identified in 16 anchors (11.2%, [95% CI 6.5-17.5%]). A partial bone defect was found in 84 anchors (58.7% [50.2-66.9%]). Tunnel enlargement was found in 43 anchors (30.11% [22.6-37.6%]). No anchor caused cystic lesions (0% [0-2.5%]). The defect volume was a mean of 27.8 mm3 (SD 18.4 mm3, minimum 0 mm3, maximum 94 mm3). Neither the position in the glenoid nor the type of implant used had a significant effect in the type or size of the defects.Conclusion: When using all-suture anchors in the glenoid during instability surgery, relevant bone osteolytic defects are rare at 1-year follow-up. Most anchor insertion tunnels will fill completely (11%) or partially (59%) with bone. Tunnel enlargement will develop in 30% of anchors. No cystic defects larger than 0.125 cm3 were observed. There is a low risk that all-suture anchors cause significant osteolytic bone defects in the glenoid. These implants can be used safely. Level of evidence IV. [ABSTRACT FROM AUTHOR]

Purpose: The acromiohumeral distance is in practice often evaluated on MRI by radiologists and a reduction diagnosed as subacromial impingement. However, the acromiohumeral distance as indicator for a decentered glenohumeral joint is defined on a true AP radiograph with the patient standing or sitting. The present study therefore evaluated the influence of the patient position by comparing the acromiohumeral distance in both modalities in shoulders with an intact rotator cuff.Methods: On MRI images and true AP radiographs of patients > 20 and < 80 years with an intact rotator cuff the acromiohumeral distance was measured. The maximum cranio-caudal size of the glenoid was measured as a reference to allow a direct comparison of both modalities.Results: Two-hundred and thirty-four shoulders (mean patients age 45.8 ± 14.3 years) were included. The mean acromiohumeral distance/glenoid size ratio of all shoulders was significantly larger (P < 0.0001) on the MRI with 4.6 ± 1.0 in comparison to 4.1 ± 0.9 in the radiographs indicating a smaller acromiohumeral distance on the MRI. In absolute values, a mean acromiohumeral distance of 9.2 mm ± 1.8 on MRI in comparison to 10.4 mm ± 2.4 on the radiographs was calculated. Herewith, the acromiohumeral distance in the MRI was in the average 1.2 mm ± 2.1 (13%) smaller than the in corresponding radiographs (P < 0.0001).Conclusion: The acromiohumeral distance is significantly smaller in the MRI in comparison to AP radiographs in shoulders with an intact rotator cuff and should not be used as a decision criterion on MRI to assess glenohumeral centering or subacromial space width.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: Previous studies show no difference in clinical outcomes between patients with healed and structurally failed rotator cuff repairs. The objective of this study was to assess ceiling effects when reporting surgical outcomes of arthroscopic rotator cuff repair using four of the currently most popular clinical shoulder outcome scoring systems.Methods: Ninety-two patients who underwent arthroscopic rotator cuff repair were examined. The simple shoulder test (SST), American Shoulder and Elbow Surgeons (ASES) score, University of California at Los Angeles (UCLA) shoulder rating scale, and Constant-Murley shoulder score were completed 2 years postoperatively. Demographic data of the subjects were analysed using descriptive statistics. The ceiling effects in the outcome data assessed for each scale were estimated based on two previously reported definitions.Results: The number of patients with the maximum possible score was 31 (33.7%) with the SST, 26 (28.3%) with the ASES score, 28 (30.4%) with the UCLA scale, and 18 (19.6%) with the Constant-Murley score. The standardised distance of the outcome data assessed by the SST, ASES score, UCLA scale, and Constant-Murley scores were 0.92, 0.97, 0.96, and 1.18, respectively.Conclusion: The SST, ASES score, and UCLA scale evaluated at 2 years postoperatively have substantial ceiling effects showing that the proportion of patients with the maximum possible score is > 20%, and the standardised distance is < 1.0. Researchers should be aware of possible biases due to ceiling effects when interpreting the results of studies investigating the surgical outcomes of arthroscopic rotator cuff repair. It could increase the likelihood of a type II error.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: To synthesise the evidence on the prevalence of associated intraarticular lesions in subjects with acute acromioclavicular joint (ACJ) dislocations.Methods: A search in two electronic databases (PUMBMED and EMBASE) was performed from 1985 to 2019. Two independent reviewers selected studies that complied with the following inclusion criteria: (1) the study included data on surgically treated ACJ dislocation grade III-V in the Rockwood classification, (2) the ACJ injuries were acute (the surgery was performed less than 6 weeks after injury), (3) an arthroscopic evaluation of the glenohumeral joint was performed during surgery. The quality of the studies included was assessed using the tool of the Joanna Briggs Institute.Results: A total of 47 studies with acute ACJ injuries met the initial inclusion criteria. Of these, 21 studies (9 retrospective case series, 9 prospective case series and 3 retrospective cohort studies) presented data on associated intraarticular lesions amenable for use in the meta-analysis. The meta-analysed studies included a total of 860 subjects with acute ACJ dislocations with a male/female ratio of 6.5 and a mean age of 32 years. The meta-analysis showed a prevalence of associated intraarticular lesions in subjects with acute ACJ of 19.9% (95% confidence interval [CI] 14.0-26.4%; 21 studies, 860 analysed participants; P = 0.000; I2: 74.5% random-effects model; low risk of bias).Conclusion: One in five subjects with surgically treated acute ACJ dislocations will have an associated intraarticular lesion that requires further intervention. The case for a customary arthroscopic evaluation of the joint, even when an open procedure is performed to deal with the ACJ dislocation, is strong. Level of evidence IV Trial registry Systematic review registration number: PROSPERO CRD42018090609. [ABSTRACT FROM AUTHOR]

Purpose: Capsular volume reduction in the context of anterior arthroscopic shoulder stabilization represents an important but uncontrolled parameter. The aim of this study was to analyse capsular volume reduction by arthroscopic Bankart repair with an individualized capsular shift in patients with and without ligamentous hyperlaxity compared to a control group. Methods: In the context of a prospective controlled study, intraoperative capsular volume measurements were performed in 32 patients with anterior shoulder instability before and after arthroscopic Bankart repair with an individualized capsular shift. The results were compared to those of a control group of 50 patients without instability. Physiological shoulder joint volumes were calculated and correlated with biometric parameters (sex, age, height, weight and BMI). Results: Patients with anterior shoulder instability showed a mean preinterventional capsular volume of 35.6 ± 10.6 mL, which was found to be significantly reduced to 19.3 ± 5.4 mL following arthroscopic Bankart repair with an individualized capsular shift (relative capsular volume reduction: 45.9 ± 21.9%; P < 0.01). Pre-interventional volumes were significantly greater in hyperlax than in non-hyperlax patients, while post-interventional volumes did not differ significantly. The average shoulder joint volume of the control group was 21.1 ± 7.0 mL, which was significantly correlated with sex, height and weight (P < 0.01). Postinterventional capsular volumes did not significantly differ from those of the controls (n.s.). Conclusion: Arthroscopic Bankart repair with an individualized capsular shift enabled the restoration of physiological capsular volume conditions in hyperlax and non-hyperlax patients with anterior shoulder instability. Current findings allow for individual adjustment and intraoperative control of capsular volume reduction to avoid over- or under correction of the shoulder joint volume. Future clinical studies should evaluate, whether individualized approaches to arthroscopic shoulder stabilization are associated with superior clinical outcome. [ABSTRACT FROM AUTHOR]

Purpose: The hypothesis of this study is that Dynamic Contact Area Ratio of the humerus and glenoid, measured with CT scans, is significantly reduced in patients with anterior shoulder instability compared to the Dynamic Contact Area Ratio in a control group of people without shoulder instability.Methods: Preoperative CT scans of patients who underwent surgery for anterior shoulder instability were collected. Additionally, the radiologic database was searched for control subjects. Using a validated software tool (Articulis) the CT scans were converted into 3-dimensional models and the amount the joint contact surface during simulated motion was calculated.Results: CT scans of 18 patients and 21 controls were available. The mean Dynamic Contact Area Ratio of patients was 25.2 ± 6.7 compared to 30.1 ± 5.1 in healthy subjects (p = 0.014).Conclusion: Dynamic Contact Area Ratio was significantly lower in patients with anterior shoulder instability compared to controls, confirming the hypothesis of the study. The findings of this study indicate that calculating the Dynamic Contact Area Ratio based on CT scan images may help surgeons in diagnosing anterior shoulder instability.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Purpose: Overuse shoulder injuries are common in youth handball, but research is limited. The purpose of this study was to identify pre-season risk factors associated with overuse shoulder injuries in this population.Methods: One-hundred and thirty-eight (70 boys and 68 girls) youth elite players (age 14.1 ± 0.8 years, height 175.2 ± 8.2 cm, weight 64.0 ± 9.6 kg) completed a pre-season screening protocol. Passive glenohumeral range of motion and maximum external (ER) and internal rotation (IR) strength were measured with a manual goniometer and a hand-held dynamometer. Scapular dyskinesia and maximum throwing velocity were also assessed. Players completed standardised questionnaires over the 2017-2018 season and reported any overuse shoulder symptoms.Results: Decreased isometric and eccentric ER strength was identified as a risk factor for overuse shoulder injury, both for absolute (OR 10.70, 95% CI 1.2-95.6, p = 0.034) and normalised ER strength (OR 1.2, 95% CI 1.0-1.4, p = 0.015) and the ER:IR strength ratio (OR 1.2, 95% CI 1.1-1.5, p = 0.012). ER gain of more than 7.5° (p = 0.025) and GIRD of more than 7.5° (p = 0.014) were identified as risk factors for overuse shoulder injury in girls. Scapular dyskinesia (OR 1.1, n.s.) and maximum throwing velocity did not seem to contribute to injury risk. The average response rate was 63%.Conclusion: In elite youth handball, deficits in ER strength is a risk factor for overuse shoulder injury for both sexes; ER gain and GIRD are only risk factors for girls. Focused pre-season assessments may aid the identification of risk factors for shoulder overuse injuries and the application of specific programmes to reduce risk.Level Of Evidence: II. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate short-term clinical outcomes of shoulders treated for anterior instability by open Latarjet procedures (OLP) followed by immediate self-rehabilitation. The hypothesis was that patients would recover preoperative function at 3 months with no adverse events related to self-rehabilitation.Methods: The authors retrieved clinical and radiographic records of 307 consecutive shoulders treated by the same surgeon for anterior instability by OLP with immediate self-rehabilitation. Four shoulders did not meet eligibility criteria and 38 were lost to follow-up, leaving a study cohort of 265 shoulders. Patients performed self-rehabilitation exercises at home from the first postoperative day. Follow-ups at 1 and 3 months evaluated recurrence of instability, postoperative complications, pain, active forward elevation (AFE), passive forward elevation (PFE), external rotation (ER) and internal rotation (IR).Results: The difference between mobility before surgery and at 3 months was 0° for AFE, 0° for PFE, 10° for ER, and 0 spine segments for IR. Thirteen shoulders (5%) which had not followed the self-rehabilitation protocol during the first month had significantly more pain and less improvements in mobility (p < 0.05). Multivariable analyses revealed that patients who adhered to self-rehabilitation in the first month had greater improvements of AFE, PFE, and IR (p < 0.05).Conclusions: Immediate self-rehabilitation after open Latarjet procedures enabled recovery of preoperative shoulder mobility at 3 months. Patients who did not adhere to immediate self-rehabilitation had more pain and less improvement in mobility. Furthermore, immediate self-rehabilitation was found to be independently associated with better recovery and did not cause any adverse events.Level Of Evidence: Level IV. [ABSTRACT FROM AUTHOR]

An introduction to the journal is presented in which the authors discuss various reports about the management of acromioclavicular (AC) joint injuries, the most common sports-related disorders, published within the issue.

Purpose: To investigate whether subscapularis integrity and compensatory teres, minor hypertrophy is associated with maintaining relatively good function and tolerable pain levels during non-operative treatment.Methods: This study included 108 patients with irreparable, massive rotator cuff tears involving at least two tendons and stage III or IV muscle hypotrophy and fatty infiltration on oblique sagittal magnetic resonance imaging, in which even a partial repair does not seem feasible. All supraspinatus and infraspinatus muscles were grade IV; if the subscapularis was involved, only stage III or IV was included. Patients were divided into two groups: group A consisted of 67 patients with both an intact subscapularis and teres minor hypertrophy; group B consisted of 41 patients lacking either one or both. The Visual Analogue Scale pain score, the American Shoulder and Elbow Surgeons score, the University of California at Los Angeles shoulder score, and active range of motion (ROM) were assessed.Results: During the follow-up period, failure of non-operative treatment was found in 29 (43%) patients in group A and 28 (68%) in group B (p = 0.012). Conversion to surgery was noted in 26 (39%) patients in group A and 27 (66%) in group B (p = 0.006). Among the remaining nonsurgical patients, there were no significant differences in clinical outcomes between the groups except ROM in internal rotation at final follow-up.Conclusions: Although conservative treatment was not always successful in patients with irreparable, massive cuff tears, patients with both an intact subscapularis tendon, and teres minor hypertrophy experienced significantly lower incidences of failure and conversion to surgery, since force couple is maintained in the setting of minimal arthritis.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Purpose: The goal of this study was to evaluate clinical and radiological outcomes after arthroscopic Latarjet stabilisation in anterior shoulder instability.Methods: Ninety-three patients after primary arthroscopic Latarjet stabilisation were reviewed. Satisfaction, subjective shoulder value (SSV), Walch-Duplay and Rowe scores, and range of motion and stability were evaluated on clinical examination. Computed tomography (CT) was used to analyse graft position and fusion.Results: Ninety patients (96.8%) were available for clinical and 85 for CT evaluation. The mean follow-up was 23.7 months (13-50, SD 7.1) and age at surgery was 26.2 years (16-44, SD 5.6). Intraoperative complications were reported in eight patients (8.9%) and recurrence in three (3.3%). Significantly, two out of three patients with recurrence had intraoperative graft complications (p = 0.0107). Forty-one patients (45.6%) reported the feeling of "subjective return to sport anxiety". External rotation with arm at the side was 59° (10-90°, SD 20) with 15° (0-70°, SD 17) of loss of rotation. These two factors correlated with results the most. Patient satisfaction was evaluated as 92% (40-100, SD 14) and SSV 90% (30-100, SD12). Revision rate after primary surgery was 10%. CT showed graft healing in 81 (95.3%) patients. A graft position between 2 and 5 o'clock was found in 70 (83.4%) patients and flush to the anterior glenoid rim in 34 (40.5%). Osteolysis of the superior part of the graft was found in 55 (64.7%) patients. CT evaluation showed no correlation with clinical results.Conclusion: Arthroscopic Latarjet stabilisation demonstrates satisfactory results in short-term follow-up; however, intraoperative graft-related complications are a risk factor for recurrence. "Subjective return to sport anxiety" and loss of external rotation with the arm at the side are factors worsening the results. Graft position imperfections and osteolysis of the superior part of the graft reported in CT evaluation do not influence the clinical results. [ABSTRACT FROM AUTHOR]

Purpose: Glenoid bone integrity is crucial for shoulder stability. The purpose of this study was to investigate a non-invasive method for quantifying bone loss regarding reliability and accuracy to detect glenoid bone deficiency in standard two-dimensional (2D) and three-dimensional (3D) computed tomography (CT) measurements at different time points. It was hypothesized that the diameter of the circle used would significantly differ between raters, rendering this method inaccurate and not allowing for an exact estimation of glenoid defect size.Methods: Fifty-two shoulder CTs from 26 patients (26 2D-CTs; 26 3D-CTs) with anterior glenoid bone defects were evaluated by 6 raters at time 0 (T0) and at least 3 weeks after (T1) to assess the glenoid bone defect using the ratio method ("best fit circle"). Inter- and intra-rater differences concerning circle dimensions (circle diameter), measured width of bone loss and calculated percentage of bone loss (length-width-ratio) were compared in 2D- versus 3D-CT scans. The intraclass coefficient (ICC) was used to determine the inter- and intra-rater agreement.Results: The mean circle diameter difference in 2D-CT was 2.0 ± 1.9 mm versus 1.8 ± 1.5 mm in 3D-CT, respectively (p < 0.01). Mean width of bone loss in 2D-CT was 1.9 ± 1.7 mm compared to 1.7 ± 1.5 mm in 3D-CT, respectively (p < 0.01). The mean difference of bone loss percentage was 5.1 ± 4.8% in 2D-CT and 4.8 ± 4.5% in 3D-CT (p < 0.01). No significant differences concerning circle diameter, bone loss width and bone loss percentage were detected comparing T0 and T1. Circle diameter, bone loss width and bone loss percentage measurements in 3D-CT were significantly smaller compared to 2D-CT at T0 and T1 (p < 0.01). Agreement (ICC) was fair to good for all indicators of circle diameter (range 0.76-0.83), bone loss width (range 0.76-0.86) and percentage of bone loss (range 0.85-0.91). Overall, 3D-CT showed superior agreement compared to 2D-CT.Conclusion: The ratio method varies in all glenoid parameters and is not valid for consistently quantifying glenoid bone defects even in 3D computed tomography. This must be taken into consideration when determining proper surgical treatment. The degree of glenoid bone loss alone should not be used to decide for or against a bony procedure. Rather, it is more important to define a defect size as "critical" and to also take other patient-specific factors into consideration so that the best treatment option can be undertaken. Application of the "best fitting circle" is a source of error when using the ratio method; therefore, care should be taken when measuring the circle diameter.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Purpose: A group of patients affected by bone loss in the context of recurrent anterior shoulder instability were treated arthroscopically with a modified Eden-Hybinette technique since 2005. The last modification was made in 2013, consisting of fixation using a pair of specifically designed double round Endobuttons, which secure the bone graft to the glenoid rim placed through a guide. This report describes patients operated on after this last modification. No reports have described the results of this technique, and the purpose of this study was to assess early clinical and radiological results of an arthroscopic bone block procedure with double round Endobutton fixation. We hypothesized that this technique would restore shoulder stability in patients with anteroinferior glenohumeral instability with glenoid bone deficit, with excellent clinical and radiological results.Methods: The clinical and radiological efficacy of this procedure was retrospectively evaluated in 26 patients with an average follow-up of 29.6 months (range 24-33 months).Results: At minimum 2-year follow-up, we had no recurrent anterior dislocations, excellent clinical results [average Walch-Duplay score 93.2, (SD 7.8); average Rowe score, 96.4 (SD 6.5); average SSV, 87.4 (SD 12.1); satisfaction rate, 88.5%; average loss of external rotation, 4.4° (SD 8.7°)] optimal graft positioning, and a healing rate of 92.3% on computed tomography scan.Conclusions: Arthroscopic bone block grafting combined with a standard Bankart repair restored shoulder stability in patients with anteroinferior glenohumeral instability with glenoid bone deficit, with excellent clinical and radiological results. This procedure did not substantially limit external rotation, allowing a high rate of return to sports even among competitive, overhead, and "at risk" athletes. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the location, magnitude, and change over time of osteolysis of coracoid grafts after Latarjet procedure.Methods: This is a retrospective study of 54 patients (55 shoulders) who underwent the Latarjet procedure. Three-dimensional computed tomography (CT) scans were performed preoperatively, immediately postoperatively, and at follow-up (mean 7.7 and 31.7 months postoperative). "En face" views of the glenoid, size of glenoid defect and changes in the glenoid surface area postoperatively were measured relative to the area of an assumed outer-fitting circle. On the oblique sagittal planes, location and subsequent severity of osteolysis of the graft at follow-up were documented.Results: The mean glenoid surface area increased significantly from 79.7 ± 4.8% of the original circle preoperatively to 111.3 ± 8.0% immediately postoperatively. At 7.7 and 31.7 months of follow-up, glenoid surface area decreased to 102.2 ± 6.0% and 100.3 ± 5.3%, respectively. Osteolysis occurred on the outer side of the graft in all cases, but did not occur on the inner side. Maximum osteolysis was observed in the superior third of the graft (78.5 ± 17.1%), followed by the middle third (15.8 ± 10.4%), and the inferior third (8.0 ± 5.1%). No significant difference in magnitude of osteolysis was observed between 7.7 and 31.7 months of follow-up.Conclusion: Osteolysis of the grafted coracoid mainly occurred on the outer side of the superior portion, resulting in reshaping of the rectangular shape of graft coracoids after Latarjet procedure. Coracoid graft remodelling was almost completed approximately 8 months postoperatively to reach the original glenoid dish with no further changes thereafter. These results may help surgeons to understand changes of grafts after the surgery.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: The Latarjet procedure has shown its efficiency for the treatment of anterior shoulder dislocation. The success of this technique depends on the correct positioning and fusion of the bone block. The length of the screws that fix the bone block can be a problem. They can increase the risk of non-union if too short or be the cause of nerve lesion or soft tissue discomfort if too long. Suprascapular nerve injuries have been reported during shoulder stabilisation surgery up to 6 % of the case. Bone block non-union depending on the series is found around 20 % of the cases. The purpose of this study was to evaluate the efficiency of this CT preoperative planning to predict optimal screws length. The clinical importance of this study lies in the observation that it is the first study to evaluate the efficiency of CT planning to predict screw length.Methods: Inclusion criteria were patients with chronic anterior instability of the shoulder with an ISIS superior to 4. Exclusion criteria were patients with multidirectional instability or any previous surgery on this shoulder. Thirty patients were included prospectively, 11 of them went threw a CT planning, before their arthroscopic Latarjet. Optimal length of both screws was calculated, adding the size of the coracoid at 5 and 15 mm from the tip to the glenoid. Thirty-two-mm screws were used for patients without planning. On a post-operative CT scan with 3D reconstruction, the distance between the screw tip and the posterior cortex was measured. A one-sample Wilcoxon test was used to compare the distance from the tip of the screw to an acceptable positioning of ±2 mm from the posterior cortex.Results: In the group without planning, screw 1 tended to differ from the acceptable positioning: mean 3.44 mm ± 3.13, med 2.9 mm, q1; q3 [0.6; 4.75] p = 0.1118, and screw 2 differed significantly from the acceptable position: mean 4.83 mm ± 4.11, med 3.7 mm, q1; q3 [1.7; 5.45] p = 0.0045. In the group with planning, position of screw 1 or 2 showed no significant difference from the acceptable position: mean 2.45 mm ± 2.07 med 1.8 mm, q1; q3 [1; 3.3] p = 1; mean 2.75 mm ± 2.32 med 2.3 mm, q1; q3 [1.25; 3.8] p = 0.5631.Conclusion: Unplanned Latarjet can lead to inaccurate screw length especially in the lower screw and can increase the risk of non-union and nerve damage. The clinical relevance of this article is that CT planning of screw length before surgery showed good results on post-operative CT. [ABSTRACT FROM AUTHOR]

Purpose: Estimation of anterior glenoid bone loss is important for surgical decision-making. The purpose of this study was to describe a method for estimating anterior glenoid bone loss.Methods: Thirty-nine cadaveric glenoids were digitized to obtain glenoid geometry. Glenoid bare spot centre, arthroscopic centre, and centre of the inferior glenoid circle relative to the geometric centre were measured. To simulate anterior glenoid bone loss, imaginary sequential osteotomies were created 0°, 22.5°, and 45° to the superior-inferior line in a 3D digitizing programme. Per cent of anterior glenoid bone loss area was calculated as the percentage of defect area relative to the entire area of the glenoid. The relationship between area loss and ratio of bone defect length to the distance from posterior glenoid to various centres was determined.Results: As the ratio of bone defect length to the distance from posterior glenoid to all three centres increased, the per cent area of bone loss increased exponentially. The ratio using the inferior circle centre and arthroscopic centre was highly correlated to the actual glenoid bone loss in all osteotomies (R 2 > 0.90). The ratio using the centre of bare area had the lowest correlation. The ratio of defect length to distance from posterior glenoid to arthroscopic centre greater than 2.4 for 0° and 2.0 for 45° osteotomies results in bone loss area greater than 25 %. The bare area centre had the largest variation. Average bone loss was overestimated when the centre of bare spot was used compared to other centre locations.Conclusion: Per cent of anterior glenoid bone loss can be estimated using the ratio of bone defect length to the distance from posterior glenoid rim to the centre of inferior glenoid circle or arthroscopic centre either preoperatively using 3D CT or arthroscopically which can be useful for determining surgical treatment. [ABSTRACT FROM AUTHOR]

Purpose: The arthroscopic Latarjet procedure has provided reliable results in the treatment of anterior shoulder instability. However, this procedure remains technically challenging and is related to several complications. The morphology of the coracoid and the glenoid are inconsistent. Inadequate coracoid and glenoid preparing may lead to mismatching between their surfaces. Inadequate screws lengthening and orientation are a major concern. Too long screws can lead to suprascapular nerve injuries or hardware irritation, whereas too short screws can lead to nonunions, fibrous unions or migration of the bone block. The purpose of the study was to investigate the application of virtual surgical planning and digital technology in preoperative assessment and planning of the Latarjet procedure.Methods: Twelve patients planned for an arthroscopic Latarjet had a CT scan evaluation with multi-two-dimensional reconstruction performed before surgery. Interobserver and intraobserver reliability were evaluated. The shape of the anterior rim of the glenoid and the undersurface of the coracoid were classified. Coracoid height was measured, respectively, at 5 mm (C1) and 10 mm (C2) from the tip of the coracoid process, corresponding to the drilling zone. Measurements of the glenoid width were then taken in the axial view at 25 % (G1) and 50 % (G2) of the glenoid height with various α angles (5°, 10°, 15°, 20°, 25°, 30°) 7 mm from the anterior glenoid rim. Shapes of the undersurface of the coracoid and the anterior rim of the glenoid were noted during the surgical procedure. Post-operative measurements included the α angle.Results: Concerning coracoid height measurements, there was an almost perfect to substantial intra- and inter-reliability, with values ranging from ICC = 0.75-0.97. For the shape of the coracoid, concordances were, respectively, perfect (ICC = 1) and almost perfect (0.87 [0.33; 1]) for the intra- and interobserver reliabilities. Concerning the glenoid, concordance was always almost perfect for 50 % height. Concordance was almost perfect for 25 % height 15° and 30° for inter- and intraobserver, for intraobserver at 0° and 25°. All the other values were still showing moderate concordance. Shape of the coracoid analysis reproducibility was perfect for both intra- and interobserver ICC = 1. There was a total agreement (ICC = 1) between the preoperative evaluation of the shape of the glenoid and the coracoid and the intraoperative assessment.Conclusion: The ideal and accurate preoperative planning of screwing of the coracoid graft in the arthroscopic Latarjet can be achieved in the real surgery assisted by the virtual planning. The clinical importance of this study lies in the observation that this new preoperative planning could offer a simple, effective and reproducible tool for surgeons helping them to prepare in the best possible way a technically challenging procedure usually associated with a high rate of complications. [ABSTRACT FROM AUTHOR]

Purpose: Glenohumeral range of motion adaptations may affect throwing athletes and contribute to shoulder injury. The purpose of this study was to evaluate shoulder rotation deficits among elite professional handball players and its correlation to the presence of shoulder pain and morphological changes.Methods: Eighty-seven elite professional handball players and 41 healthy non-athlete volunteers participated in the study. Evaluations included measurement of range of internal and external rotation, total arch of motion, identification of shoulder pain and ultrasound scan for diagnosis of rotator cuff tears and internal impingement.Results: Glenohumeral rotational deficits (>20-25°) were found among 11 players group (13%). The throwing shoulders in the players group showed a decrease in internal rotation and an increase in external rotation with significantly larger ranges among players compared to the non-athlete group. Internal rotation deficit >20° was associated with higher incidence of shoulder pain among players. Both internal rotation deficits (>25°) and total arch of motion deficit (>20°) co-existed with higher incidence of internal impingement. Shoulder pain was common (36/97-41%) and was associated with decreased external rotation and total arch of motion. Internal impingement (found in 13/87-15%) correlated with decreased rotation ranges and a greater deficit in total arch of motion, whereas higher gain in external rotation correlated with a partial rotator cuff tear (found in 12/87-14%).Conclusions: Shoulder pathologies and problems commonly affected the group of handball players. Greater glenohumeral rotational deficits in throwing shoulders of handball players correlate with shoulder pain and internal impingement, while increased external rotation with partial rotator cuff tears. Such deficits affect 13% of the athlete population. Major clinical relevance of the study is to monitor handball players' shoulders both clinically and by proper imaging. Evaluation of range of rotation seems to identify shoulders at risk of the pathology.Level Of Evidence: Cross-Sectional study with control group, Level II. [ABSTRACT FROM AUTHOR]

Purpose: Latarjet, which is a coracoid bone block procedure, is an effective treatment for anterior shoulder instability with glenoid bone loss. During this reconstructive procedure the subscapularis may be tenotomized or be split to expose the glenoid neck. The aim of this study was to assess the effect of subscapularis management on functional outcomes and internal and external rotation durability and strength. Hypothesis is that the subscapularis split approach will result in better functional results and superior internal rotation strength and endurance.Methods: The study included 48 patients [median age 30 (range 16-69); 42 males, 6 females], who underwent a modified Latarjet procedure for anterior shoulder instability. There were 20 patients in the subscapularis tenotomy group and 28 patients in the subscapularis split group. The groups were compared isokinetically using a computerized dynamometer for internal and external rotation durability and strength. At the latest follow-up, the patients were evaluated with the American Shoulder and Elbow Surgeons (ASES) and ROWE scores for functional outcomes.Results: At a median follow-up period of 25 (range 12-73) months after the Latarjet procedure, the internal rotation durability was significantly higher in the split group (p = 0.045). However, a statistically significant difference could not be found for internal and external rotational strengths (n.s.). There was also no significant difference between the final ASES and ROWE scores (n.s.).Conclusion: Although both approaches offer promising results, the subscapularis split approach appears to provide better internal rotation durability compared to subscapularis tenotomy. Therefore, the subscapularis split approach may be more preferable for the management of the subscapularis muscle during Latarjet procedure.Level Of Evidence: Retrospective cohort study, Level III. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of the present study was to analyze biopsy samples from the subscapularis tendon and from the joint capsule from male patients with shoulder impingement syndrome (SAIS) and compare them with samples from male patients with post-traumatic recurrent shoulder instability. The hypothesis of the study was that patients with SAIS would have more histologic and ultrastructural degenerative changes in their subscapularis tendon and joint capsule than patients with post-traumatic recurrent shoulder instability.Methods: Male patients scheduled for surgery, with either subacromial decompression or Bankart reconstruction, were included. Four biopsies from each patient were obtained from the capsule and four from the subscapularis tendon during arthroscopic surgery. The histologic characteristics and the presence of glycosaminoglycans were assessed using the light microscope, and the ultrastructure was assessed using a transmission electron microscope.Results: Eight patients, median age 53 (45-74) years (p < 0.0001), were included in the impingement group, and 12 patients, median age 27 (22-48) years, were included in the instability group. The histologic assessment revealed significantly higher cellularity and total degeneration score in the capsule (p = 0.016 and p = 0.014 respectively) in patients with subacromial impingement compared with the instability patients. The corresponding finding was not made for the subscapularis tendon. The ultrastructural evaluation revealed that the instability patients had more fibrils with a large diameter (indicating less degeneration) in both the subscapularis tendon and the capsule compared with the impingement patients (p < 0.0001).Conclusion: Male patients with subacromial impingement have more histologic and ultrastructural degenerative changes in their shoulder compared with patients with post-traumatic recurrent shoulder instability.Clinical Relevance: It appears that in patients with subacromial impingement, the whole shoulder joint is affected and not only the subacromial space. It is the opinion of the authors that intra-articular therapeutic injections could be tried more often in these patients.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Purpose: A detailed structural anatomy of the posterosuperior shoulder capsule and "glenocapsular ligament" is still rather unknown. The purpose of this study was meticulously to investigate and describe the structure and blood supply of the glenocapsular ligament on the posterosuperior shoulder joint capsule.Method: Sixteen fixed and twelve fresh cadaveric shoulder specimens with a mean age of 73.4 (±6.4) years were analysed. Dissection without arterial injection was performed on the 16 fixed specimens-using an alcohol-formalin-glycerol solution. Before dissection, the 12 fresh specimens received of arterial injection a 10% aqueous dispersion of latex solution. After the injection, these shoulders were also fixed in an alcohol-formalin-glycerol solution.Results: The glenocapsular ligament was found in all 28 specimens. Single or double parallel-running bundles of connective tissue fibres were found to form a capsular-ligamentous structure on the posterosuperior part of the joint capsule. One part of the ligament was mediosuperior, another posterosuperior. The mediosuperior part varied in shape, and in 12 of 28 cases, it was absent. The glenocapsular ligament arose from the supraglenoid tubercle and posterior part of the collum scapulae and inserted into the semicircular humeral ligament. The posterior ascending branch of the circumflex scapular artery directly fed small branches laterally and medially to the joint capsule, supplying the glenocapsular ligament and the deep layer of the joint capsule.Conclusion: The glenocapsular ligament is a constant anatomical structure that consists of one or two different parts. The glenocapsular ligament and the posterosuperior part of the joint capsule appear well vascularized via the posterior ascending branch of the circumflex scapular artery.Clinical Relevance: It is the hope of the authors that this anatomical study can help surgeons who perform open or arthroscopic surgery to the posterior part of the shoulder. Knowledge of the vascular anatomy presented in this study may be especially important when incisions are made to the posterior part of the shoulder, and should minimize the risk of complications. [ABSTRACT FROM AUTHOR]

Purpose: To prospectively evaluate elbow flexion force, cosmetic and clinical outcome of all-arthroscopic suprapectoral biceps tenodesis for isolated biceps lesions.Methods: Tenodesis was performed using a 6.25-mm absorbable interference screw for intraosseous fixation. Seventeen out of 24 patients (70.8 %, median age 49.0 ± 10.1 years; 10 = male) could be included for 24 months follow-up. Elbow flexion strength in 10° and 90° elbow flexion, the upward-directed force of the upper arm in the O'Brien position, objective evaluation of a Popeye-sign deformity and validated clinical scores (CMS, SST, ASES) were assessed preoperatively, 3, 6, 12 and 24 months postoperatively.Results: Elbow flexion strength in 90° improved significantly from 12 months onwards (P = 0.001) without significant difference to the contralateral arm from 3 months postoperatively (n.s.). At 24 months, an average increase of 46.4 % (median 37.7 %) from preoperative could be seen. The dominant arm was affected in 70.6 %. All scores showed a significant improvement 3 months postoperatively: SST (P = 0.003), ASES (P = 0.006) and total CMS (P < 0.001). Three patients (17.6 %) developed a distalization of the maximum biceps circumference of more than 20 % compared to preoperative.Conclusions: All-arthroscopic proximal suprapectoral intraosseous single-limb biceps tenodesis for the treatment of isolated biceps lesions provides good-to-excellent clinical results with significant improvement of elbow flexion strength and clinical scores and no significant difference to the unaffected contralateral arm.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to evaluate whether glenohumeral arthroscopy is an appropriate gold standard for the diagnosis of long head of biceps (LHB) tendon pathology. The objectives were to evaluate whether the length of tendon that can be seen at arthroscopy allows visualisation of areas of predilection of pathology and also to determine the rates of missed diagnoses at arthroscopy when compared to an open approach.Methods: A systematic review of cadaveric and clinical studies was performed. The search strategy was applied to MEDLINE, PubMed and Google Scholar databases. All relevant articles were included. Critical appraisal of clinical studies was performed using a validated quality assessment scale.Results: Five articles were identified for inclusion in the review. This included both clinical and cadaveric studies. The overall population comprised 18 cadaveric specimens and 575 patients. Out of the five included studies, three reported the length of LHB tendon visualised during arthroscopy and four reported the rate of missed LHB diagnosis. Cadaveric studies showed that the use of a hook probe allowed arthroscopic visualisation of between 34 and 48 % of the overall length of the LHB. In the clinical series, the rate of missed diagnoses at arthroscopy when compared to open exploration ranged between 33 and 49 %.Conclusions: Arthroscopy allows visualisation of only a small part of the extra-articular LHB tendon. This leads to a high rate of missed pathology in the distal part of the tendon. Published figures for sensitivities and specificities of common physical examination and imaging tests for LHB pathology that are based on arthroscopy as the gold standard are therefore invalid. In clinical practice, it is important to note that a "negative" arthroscopic assessment does not exclude a lesion of the LHB tendon as this technique does not allow visualisation of common sites of distal pathology.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: In the present prospective study, the functional outcomes of non-operative treatment were evaluated in patients aged between 30 and 45 years presenting SLAP lesion in diagnostic provocative tests and magnetic resonance (MR) arthrography.Methods: Forty-six patients with a symptomatic SLAP lesion who participated in recreational level of sports were prospectively enroled. SLAP lesion was diagnosed using combinations of several clinical tests and MR arthrography findings. All patients were treated with intra-articular corticosteroid injections, followed by rotator cuff and periscapular muscle-strengthening exercises. Patients with persistent discomfort after second injection underwent arthroscopic SLAP repair. Functional outcomes were evaluated using ASES and Constant scores, and pain and satisfaction for visual analogue scale (VAS).Results: Pain had significantly improved from 5.2 ± 2.2 to 1.0 ± 1.1 (p < 0.001) in all patients after the first corticosteroid injection. SLAP symptoms relapsed in 12 patients at an average of 2.4 months after the first injection. Symptoms were relieved in 5 of 12 patients after the second injection and strengthening exercises. The remaining seven patients underwent arthroscopic SLAP repair. Thirty-nine patients (85 %) who were treated non-operatively showed improved VAS, Constant, and ASES scores at final follow-up (p < 0.001).Conclusions: Non-operative treatment with an appropriate regimen provided satisfactory clinical outcomes in middle-aged patients with symptomatic SLAP lesions and should be considered before recommending operative treatment.Clinical Relevance: Non-operative management using combined intra-articular corticosteroid injection with rotator cuff and periscapular strengthening exercises could be applied as primary treatment for patients with symptomatic SLAP lesion who participate in recreational level of sports.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: Postoperative stiffness can be a disabling condition after arthroscopic shoulder surgery. The purpose of this study was to analyse the potential contribution of subclinical forms of hypothyroidism and diabetes in the development of postoperative shoulder stiffness.Methods: A prospective study was conducted on 65 consecutive patients scheduled for arthroscopic subacromial decompression or rotator cuff tear repair. Patients with preoperative stiffness were excluded. Preoperative measurements of free thyroxine, free triiodothyronine, thyroid-stimulating hormone and fasting glycaemia were taken in all patients to detect subclinical forms of diabetes and hypothyroidism. A follow-up was planned at 30, 60, 90 and 180 days after surgery. According to range of motion measurements, postoperative stiffness was classified as severe or moderate at follow-up. Univariate and logistic regression analyses were performed for the assessment of risk factors for stiffness.Results: The overall incidence of postoperative stiffness was 29 % (19/65) in our cohort. Considering only the arthroscopic rotator cuff repairs, this incidence was 23 % (7/31). A new diagnosis of subclinical forms of diabetes or hypothyroidism was made in five cases. All five of these cases developed postoperative stiffness. The logistic regression analysis demonstrated that hypothyroidism was a risk factor for severe stiffness (RR = 25; p = 0.001) and that diabetes was a risk factor for moderate stiffness (RR = 5.7; p = 0.03).Conclusion: The postoperative stiffness in the majority of patients can be predicted by a careful analysis of past medical history and by detecting subclinical forms of hypothyroidism and diabetes.Level Of Evidence: Prognostic study, Level II. [ABSTRACT FROM AUTHOR]

Purpose: This study proposed new magnetic resonance imaging (MRI) of haemodialysis shoulders (HDS) focusing on the changes of the rotator cuff, and rotator interval and risk factors for the development of HDS were examined.Methods: Eighty-five shoulders in 72 patients with a chief complaint of shoulder pain during haemodialysis and at least 10 years of haemodialysis were included. They were classified into 5 groups based on the thickness of the rotator cuff and conditions of rotator interval. Clinical and radiological findings in each grade were examined, and risk factors for the development of HDS were evaluated. Arthroscopic surgeries were performed on 22 shoulders in 20 patients, and arthroscopic findings were also evaluated.Results: Positive correlations for the development of HDS were observed in duration of haemodialysis, positive hepatitis C virus (HCV) infection, and previous haemodialysis-related orthopaedic surgery (P < 0.001, respectively). Strong correlations were observed between positive HCV and the progression of HDS (odds ratio 24.8, 95 % confidence interval 5.7-107.6). Arthroscopically, progression of the surrounding soft tissue degeneration was observed, and operative times were lengthened depending on the progression of MRI grading.Conclusion: A new MRI classification of HDS which may be helpful when considering arthroscopic surgeries has been proposed. Positive HCV infection was strongly associated with the progression of HDS on MRI. Conditions of the rotator interval and the rotator cuff based on the MRI classification should be examined when treating HDS patients.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Purpose: Isolated lesions of the caudal portion of the subscapularis (SSC) tendon are rare and have not been subject of major attention in the literature yet. However, these lesions can lead to tremendous impairment of shoulder function. The purpose of the present study was to raise clinician's awareness for these "hidden lesions" and to present the crucial steps for diagnosis and management.Methods: Five patients (three men, two women; mean age 40) with traumatic isolated caudal SSC lesion were enrolled in the present study. After clinical and radiological examination, all patients underwent diagnostic arthroscopy and open inferior SSC repair. The results of the clinical and radiological examination were documented along with the intraoperative findings. Post-operative pain level and shoulder function were assessed.Results: In all patients the SSC lesion could be detected clinically. In two patients the caudal SSC tear was diagnosed delayed after initial conservative treatment. Preoperatively, all patients showed restricted active movement of the shoulder with positive clinical tests for the SSC. All SSC lesions could be detected on MR images and identified arthroscopically. After a mean follow-up of 12 months, all clinical SSC tests were negative, and the patients have almost regained preinjury shoulder function. The mean post-operative pain score (VAS) was 1 (range 0-1), and the mean ASES score was 93.3 (range 91.6-95).Conclusion: Arthroscopic visualization of the SSC tendon is incomplete rendering caudal SSC tears difficult to detect and easy to overlook. Clinicians' awareness of this pathology along with accurate clinical and radiological examination leads to the correct diagnosis. Open caudal SSC repair provides pain relief and reliable shoulder function after short-term follow-up.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to evaluate the kinematics of healthy shoulders during dynamic full axial rotation and scapular plane full abduction using three-dimensional (3D)-to-two-dimensional (2D) model-to-image registration techniques.Methods: Dynamic glenohumeral kinematics during axial rotation and scapular plane abduction were analysed in 10 healthy participants. Continuous radiographic images of axial rotation and scapular plane abduction were taken using a flat panel radiographic detector. The participants received a computed tomography scan to generate virtual digitally reconstructed radiographs. The density-based digitally reconstructed radiographs were then compared with the serial radiographic images acquired using image correlations. These 3D-to-2D model-to-image registration techniques determined the 3D positions and orientations of the humerus and scapula during dynamic full axial rotation and scapular plane full abduction.Results: The humeral head centre translated an average of 2.5 ± 3.1 mm posteriorly, and 1.4 ± 1.0 mm superiorly in the early phase, then an average of 2.0 ± 0.8 mm inferiorly in the late phase during external rotation motion. The glenohumeral external rotation angle had a significant effect on the anterior/posterior (A/P) and superior/inferior (S/I) translation of the humeral head centre (both p < 0.05). 33.6 ± 15.6° of glenohumeral external rotation occurred during scapular plane abduction. The humeral head centre translated an average of 0.6 ± 0.9 mm superiorly in the early phase, then 1.7 ± 2.6 mm inferiorly in the late phase, and translated an average of 0.4 ± 0.5 mm medially in the early phase, then 1.6 ± 1.0 mm laterally in the late phase during scapular plane abduction. The humeral abduction angle had a significant effect on the S/I and lateral/medial (L/M) translation of the humeral head centre (both p < 0.05).Conclusion: This study investigated 3D translations of the humerus relative to the scapula: during scapular plane full abduction, the humerus rotated 33.6° externally relative to the scapula, and during external rotation motion in the adducted position, the humeral head centre translated an average of 2.5 mm posteriorly. Kinematic data will provide important insights into evaluating the kinematics of pathological shoulders. For clinical relevance, quantitative assessment of dynamic healthy shoulder kinematics might be a physiological indicator for the assessment of pathological shoulders. [ABSTRACT FROM AUTHOR]

Purpose: The shoulder manual resistance test is one of the common clinical assessments for patients with muscle weakness. However, there have been no studies investigating the threshold for muscle weakness. The purpose of this study was to clarify the threshold for muscle weakness in the shoulder manual muscle resistance test.Methods: Fifty-three patients (37.9 ± 20.6 years old) with either rotator cuff tear (21 patients), superior labrum anterior-to-posterior (SLAP) lesion (7 patients), or Bankart lesion (25 patients) of one shoulder were administered three manual muscle resistance tests (abduction strength, external rotation, and belly press tests). Positive results in these tests were defined as a subjective weakness in the involved shoulder compared to the opposite shoulder. Based on this result, the patients were divided into positive and negative groups. Another observer measured isometric strength using a hand-held dynamometer and calculated the side-to-side ratio. Comparing instrument measurement with manual measurement, the cut-off point, at which we can recognise that there is a side-to-side difference, was calculated by receiver operating characteristic analysis.Results: The cases with less than 60% of the muscle strength in the contralateral shoulder were judged as positive in all examinations, whereas among the cases with 60-90% of muscle strength, there was a mixture of negative and positive determinations. The cut-off point was 78.9% in the abduction strength test, 73.8% in the external rotation test, and 84.0% in the belly press test.Conclusion: The side-to-side difference could be manually detected, when muscle strength was less than 75-85% of that on the contralateral side. This finding suggests that it is necessary to understand the limitation of these manual tests in the case of clinical examinations. Therefore, care must be taken for the shoulder manual muscle resistance test as muscle weakness cannot be fully detected by manual measurement.Level Of Evidence: Case-control study, Level IV. [ABSTRACT FROM AUTHOR]

Purpose: Vascularity of the subacromial bursa and rotator cuff tendons is key factors in the pathogenesis of subacromial bursitis and impingement syndrome, rotator cuff tendinitis, and rotator cuff tears. The purpose of this study was to investigate and describe blood supply to the cranial and caudal parts of the subacromial bursa and the vascularity of the rotator cuff tendons on the bursal side.Methods: Fourteen fresh cadaveric shoulders from six females and eight males with a mean age of 71.7 (±10.8) years were studied. Before dissection, an arterial injection of 10% aqueous dispersion of latex was administered. Post-injection, the shoulders were fixed in an alcohol-formalin-glycerol solution.Results: The cranial and caudal bursa of all specimens was mainly supplied by the thoracoacromial, suprascapular, and anterior and posterior circumflex humeral arteries. The cranial part of the bursa was supplied anteriorly by the thoracoacromial artery, and posteriorly and medially by the posterior circumflex humeral artery as far as the medial third. The caudal part received arterial blood anteriorly from the anterior circumflex humeral artery, and posteriorly and medially by the posterior circumflex humeral artery as far as the medial third of the caudal bursa. In addition, the suprascapular artery branched at the upper surface of the coracohumeral ligament, and the subcoracoid artery branched at the under surface of the same ligament.Conclusion: The subacromial bursa appears well vascularized. The results of the present investigation showed that blood supply to the subacromial bursa at the caudal part and rotator cuff tendons on the bursal side was linked to the same arteries. The subcoracoid artery supplied interval rotator structures close to the caudal bursa. It is the wish of the authors that this meticulous anatomical work will help surgeons in their day-to-day clinical work, e.g. to minimize the risk of complications such as perioperative bleeding. [ABSTRACT FROM AUTHOR]

Although the proximal humerus is a common site of osteochondroma, osteochondroma arising from the lesser tuberosity of the proximal humerus is rare. Because of the anatomy of the shoulder, mechanical impingement can occur via direct contact of the protruding lesser tuberosity against the glenoid rim or coracoid. In younger patients, this may cause isolated tearing of the subscapularis. In this study, is presented a rare case of osteochondroma on the lesser tuberosity that caused a subscapularis tear after shoulder impingement in a 34-year-old male. This case was managed using an arthroscopic approach. One year after the surgery, the patient had recovered a normal range of motion, with the resolution of impingement symptoms and the tearing of the subscapularis. Level of evidence IV. [ABSTRACT FROM AUTHOR]

Purpose: This study compared the clinical outcomes of arthroscopic remplissage with Bankart repair and Latarjet operation in patients with a large engaging Hill-Sachs lesion.Methods: Thirty-seven shoulders subjected to arthroscopic remplissage with a Bankart repair (group A) and 35 shoulders subjected to a Latarjet operation (group B), for a large engaging Hill-Sachs lesion without significant glenoid bone loss, were retrospectively evaluated. Each group was followed up for a mean more than 2-year period.Results: At the last follow-up, postoperative pain, shoulder mobility, muscle strength, Rowe score, and UCLA score revealed no significant difference between the two groups. The postoperative mean deficit in external rotation at the side (ERs) was 8° ± 23° in group A (P = 0.044). In group B, the mean deficits in ERs, external rotation at 90° of abduction, and internal rotation to the posterior were 10° ± 20°, 7° ± 16°, and 1.9° ± 4°, respectively (P = 0.004, 0.022, and 0.009, respectively). The recurrence rate was 5.4 % (two shoulders) in group A and 5.7 % (two shoulders) in group B (n.s.). The overall complication rate was significantly higher in group B (14.3 %) than in group A (0 %) (P = 0.017).Conclusions: For recurrent anterior shoulder instability with a large engaging Hill-Sachs lesion, both arthroscopic remplissage with Bankart repair and the Latarjet procedure were safe and reliable techniques with a low recurrence rate. However, the Latarjet group had a significantly higher postoperative complication rate than the remplissage group.Level Of Evidence: Case-control study, Level III. [ABSTRACT FROM AUTHOR]