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To determine the in vivo effects of superior capsule reconstruction (SCR) on glenohumeral kinematics during abduction and to compare those kinematics results with patient-reported outcomes, range of motion, and strength.Dynamic biplane radiography was used to image 10 patients with irreparable rotator cuff tears while performing scapular plane abduction pre- and 1-year post-surgery. Shoulder kinematics were determined by matching subject-specific computed tomography-based bone models to the radiographs using a validated tracking technique.No change was detected in static acromiohumeral distance (-0.7 ± 2.1 mm; P = .35); however, average dynamic acromiohumeral distance decreased (2.7 ± 1.2 mm to 2.3 ± 1.0 mm; P = .035) from pre- to 1-year post-surgery, respectively. The humeral head position was 0.5 ± 0.5 mm more superior 1-year post-surgery compared with pre-surgery (P = .01). Glenohumeral abduction increased from pre-surgery (150 ± 20°) to 1-year post-surgery (165 ± 10°) (P = .04) and all patient-reported outcomes improved from pre-surgery to 1-year post-surgery (all P.002). A more posterior shift in humeral head position was associated with improved American Shoulder and Elbow Surgeons Shoulder Score from pre-surgery to 1-year post-surgery (r = 0.71, P = .02).These data suggest that SCR may not depress the humeral head during functional abduction, as previously postulated, and postoperative improvements in subjective and clinical outcomes may be affected by mechanisms other than changes in shoulder kinematics.In vivo kinematics changes after SCR are small and do not correspond to previously postulated changes.

Background A viable treatment option for young patients with massive, irreparable rotator cuff tears is arthroscopic superior capsule reconstruction (SCR). SCR theoretically improves shoulder stability and function and decreases pain. However, no prospective studies to date have correlated magnetic resonance imaging (MRI) healing with in vivo kinematic data. The purpose of this study was to evaluate the association between graft healing and in vivo kinematics, range of motion (ROM), strength, and patient-reported outcomes (PROs). Methods Ten patients (8 men and 2 women; mean age, 63 ± 7 years) with irreparable rotator cuff tears underwent arthroscopic SCR with dermal allograft. Strength was measured with isometric internal rotation and external rotation (ER) at 0° of abduction, ER at 90° of abduction, and scapular-plane abduction, whereas ROM was measured during shoulder flexion, abduction, and ER and internal rotation at 90° of abduction both before and 1 year after SCR. PROs included American Shoulder and Elbow Surgeons, Western Ontario Rotator Cuff Index, and Disabilities of the Arm, Shoulder and Hand surveys that were collected before and 1 year after SCR. Synchronized biplane radiographs were collected at 50 images/s before and 1 year after SCR while patients performed 3 trials of scapular-plane abduction. A validated volumetric tracking technique with submillimeter accuracy determined 6-df glenohumeral and scapular kinematics. The acromiohumeral distance (AHD), humeral head translation, and scapulohumeral rhythm (SHR) were calculated from the in vivo kinematics. Healing at 5 locations was evaluated on 1-year postoperative MRI scans: anterior and posterior glenoid, anterior and posterior humerus, and posteriorly along the infraspinatus. Each subject was given a score from 0 to 5 based on number of sites healed. Results Of the 10 patients, 9 (90%) had complete (n = 4) or partial (n = 5) healing of the graft whereas 1 (10%) had complete failure at the glenoid. No correlation existed between MRI healing and the AHD, SHR, strength, ROM, or PROs. American Shoulder and Elbow Surgeons, Western Ontario Rotator Cuff Index, and Disabilities of the Arm, Shoulder and Hand scores all significantly improved from before to 1 year after SCR regardless of graft healing. Conclusions The rate of complete or partial graft healing on MRI mimics findings of prior reports in the literature. MRI healing was correlated with humeral head anterior-posterior translation but not with the static and dynamic AHDs, SHR, humeral head superior-inferior translation, ROM, strength, or PROs 1 year after SCR. All PROs improved significantly from before to 1 year after SCR regardless of graft status on MRI. In vivo kinematic changes were small after SCR and not clinically significant, and the data suggest that improvements in clinical and functional outcomes may occur in the absence of full graft healing.

To determine whether glenoid retroversion is an independent risk factor for failure after arthroscopic Bankart repair.This was a retrospective review of patients with a minimum 2-year follow-up. In part 1 of the study, individuals with no glenoid bone loss on magnetic resonance imaging (MRI) and who failed arthroscopic Bankart repair (cases) were compared with individuals who did not fail Bankart repair (controls). In part 2 of the study, cases with subcritical (20%) glenoid bone loss as measured on sagittal T1 MRI sequences who failed arthroscopic Bankart repair were compared with controls who did not. For each part of the study, glenoid version was measured using axial T2 MRI sequences. Positive angular measurements were designated to represent glenoid anteversion, whereas negative measurements were designated to represent glenoid retroversion. Independent t tests were conducted to determine the association between glenoid version and failure after arthroscopic Bankart repair.There were 20 cases and 40 controls in part 1 of the study. In part 2, there were 19 cases and 21 controls. There was no difference in baseline characteristics between cases and controls. Among individuals with no glenoid bone loss, there was no difference in glenoid version between cases and controls (cases: 6.0° ± 8.1° vs controls: 5.1° ± 7.8°, P = .22). Among individuals with subcritical bone loss, cases (3.8° ± 4.4°) were associated with significantly less mean retroversion compared with controls (7.1° ± 2.8°, P = .0085). Decreased retroversion (odds ratio 1.34; 95% confidence interval 1.05-1.72, P = 20) was a significant independent predictor of failure using univariable logistic regression.While glenoid retroversion is not associated with failure after arthroscopic Bankart repair in individuals with no glenoid bone loss, decreased retroversion is associated with failure in individuals with subcritical bone loss.Level 3: Retrospective review.

Purpose Cryptoglandular anal fistula continues to be a subject of extensive surgical research due to the lack of effective and enduring treatments, some of which incur risks to continence and quality of life. However, the patient experience of disease has seldom been reported. The aims of this study are to understand the impact of living with a fistula and the treatment outcomes that are valued by patients. Methods Patients with cryptoglandular anal fistula were recruited using purposive sampling from two tertiary referral centres in the UK and the Netherlands. Patients underwent semi-structured interviews that were audio-recorded and transcribed verbatim. Dutch transcripts were translated into English and underwent independent, thematic analysis using open coding by two study team members to identify common themes and sub-themes. Results Twenty interviews were conducted before saturation was reached (11 male, median age 49, Interquartile range 39–55 years). Four broad themes emerged, covering the physical symptoms of fistula, the patient journey towards understanding the condition, life impact, and treatment. Several inter-related sub-themes were found, reflecting the extensive impact and adjustment that the disease entails. Conclusion The impact of cryptoglandular anal fistula extends beyond the physical symptoms of pain and discharge, requires significant readjustment, and often negatively impacts psycho-social wellbeing. These aspects of disease should receive greater attention in future assessment of treatment and quality of life.

BACKGROUND Off-track lesions are strongly associated with failure after arthroscopic Bankart repair. However, on-track lesions with a small distance-to-dislocation (DTD) value, or "near-track lesions," also may be at risk for failure. The purpose of the present study was to determine the association of DTD with failure after arthroscopic Bankart repair. METHODS We performed a retrospective analysis of 173 individuals who underwent primary arthroscopic Bankart repair between 2007 and 2015. Glenoid bone loss and Hill-Sachs lesion size were measured with use of previously reported methods. Patients with failure were defined as those who sustained a dislocation after the index procedure, whereas controls were defined as individuals who did not. DTD was defined as the distance from the medial edge of the Hill-Sachs lesion to the medial edge of the glenoid track. Receiver operating characteristic (ROC) curves were constructed for DTD to determine the critical threshold that would best predict failure. The study population was subdivided into individuals ≥20 years old and

The purpose of this study was to determine how implant characteristics affect in vivo shoulder kinematics after reverse shoulder arthroplasty (RSA). Kinematics of the affected upper limb were measured in 32 participants during five motions (scapular plane abduction, hand-to-head, hand-to-back, internal/external rotation at 90° abduction, and circumduction) using optical motion capture. Shoulder abduction, plane of elevation, and internal/external rotation range of motion (ROM), peak angles, and continuous kinematics waveforms were calculated for each motion. Multiple regression was used to identify associations between kinematics and implant characteristics of lateralization, humeral retroversion, glenosphere size, glenosphere tilt, glenoid eccentricity, and implant neck-shaft angle (135° or 145°). Less humeral retroversion was associated with greater shoulder rotation ROM (p = 0.036) and greater plane of elevation ROM (p = 0.024) during circumduction, while less eccentricity was associated with more posterior plane of elevation during hand-to-back (p = 0.021). The 145° implant was associated with greater internal/external shoulder rotation ROM (p 0.001), greater internal shoulder rotation (p = 0.002), and greater plane of elevation ROM (p = 001) during the hand-to-back. The 145° implant was also associated with more internal/external rotation ROM (p = 0.043) during shoulder rotation and more abduction ROM during circumduction (p = 0.043). During the hand-to-back motion, individuals having 135° neck-shaft angle implants were more abducted from 21 to 51% of the motion and were less internally rotated from 70 to 100% of the motion, while more lateralization was associated with less internal rotation from 90 to 100% of the motion. Retroversion and implant neck-shaft angle are the primary implant characteristics associated with in vivo shoulder kinematics during complex motions after RSA.

This study aimed to analyze the impact of a criteria-based return-to-sport (CBRTS) testing protocol on recurrent instability following arthroscopic Bankart repair. We hypothesized that patients who underwent an objective CBRTS testing protocol to guide their clearance to return to sports would have less recurrent instability than those who did not undergo testing.Thirty-six consecutive patients who underwent arthroscopic Bankart repair from 2016 to 2018, had a minimum of 1 year of follow-up, and completed functional and strength testing to evaluate readiness to return to sports were included in this retrospective case-control study. Patients with critical glenoid bone loss13.5%, multidirectional instability, and off-track Hill-Sachs lesions necessitating a remplissage or bone augmentation procedure were excluded from the study. Recurrence was defined as dislocation or subluxation symptoms requiring revision surgery. Statistical analysis included analysis of variance and the independent t test.There was no difference between the study and control groups regarding age (P = .15), sex (P = .11), hand dominance (P = .56), or participation in contact sports (P = .78). Patients who underwent the CBRTS testing protocol had a reduced rate of recurrent shoulder instability (5% vs. 22%; odds ratio, 4.85; P.001). There was no difference in the time from surgery to recurrence between the groups (12 months vs. 13.6 months, P = .43).Athletes who underwent an objective CBRTS testing protocol to guide their clearance to return to sports had a lower rate of recurrent instability following arthroscopic Bankart repair than those cleared to return based on the time from surgery. Athletes who did not undergo CBRTS testing after arthroscopic shoulder stabilization had a 4.85 times increased likelihood of recurrent instability development after return to sports.

Objectives A good outcome after arthroscopic stabilization for recurrent shoulder instability is often characterized by a successful return to sport while minimizing complications. There is currently no consensus regarding timing or objective criteria for return to sport. The objective of this study is to evaluate the ability of postoperative patients to meet expected goals by using standardized objective evaluations of strength and physical function. Methods Forty-three (10 females, 76.7% male) subjects (mean age, 18.1 ± 3.7 years) who underwent arthroscopic shoulder stabilization surgery (anterior or posterior) from 2016 until 2018 were referred during their postoperative rehabilitation for functional testing at 6 months postoperatively to evaluate their readiness for return to sport. The Closed Kinetic Chain Upper Extremity Stability test and Unilateral Seated Shot Put test were used to assess shoulder function. Posterior rotator cuff activation was evaluated using a repetition to failure technique with 5% body weight at 0° and 90° of abduction with the goal of 90% of nonoperative extremity. Isokinetic strength testing of external rotation (ER) and internal rotation (IR) was evaluated using a Biodex isokinetic dynamometer at angular velocities of 60° and 180° per second, and a passing score was considered achieving 90% of nonoperative shoulder strength at both 60° and 180° per second. Results All subjects were competitive athletes (20 collegiate, 23 high school). The dominant extremity was the surgical extremity in 22 subjects. Only 5 subjects were able to successfully pass the battery of tests for strength and function. Strength testing revealed that 7 patients achieved 90% of the strength of the nonoperative extremity in both repetitions to failure (23 of 43) and comparative isokinetic testing (7 of 43). More subjects were able to meet IR strength (20 of 43) than ER strength (12 of 43) goals. Functional test goals were more frequently achieved, with 26 of 43 subjects meeting both functional test goals (33 Closed Kinetic Chain Upper Extremity Stability, 34 Unilateral Seated Shot Put). Only 2 subjects were able to achieve strength goals but did not pass functional tests, whereas 21 subjects passed functional tests without meeting strength goals. Conclusion A substantial number of athletes in our cohort do not meet the expected goals for their operative shoulder in achieving appropriate function and strength, compared with the contralateral shoulder. Functional goals were more often met than strength. IR strength goals were more frequently achieved than ER strength. Strength and functional testing could provide more reliable criteria than arbitrary passage of time for return to play after shoulder stabilization surgery.