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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.

Objectives: While rotator cuff tears often require repair of the supraspinatus, patients can also have a concurrent tear of the subscapularis requiring repair. Previous smaller studies have shown good clinical outcomes following the repair of the subscapularis and rotator cuff during the same procedure.1 The purpose of this study was to compare clinical outcome measures between patients who had isolated supraspinatus repairs versus those who had a supraspinatus tear with a concurrent subscapularis repair. Methods: A retrospective review of 166 patients who underwent arthroscopic supraspinatus repair with or without a concurrent subscapularis repair between 2013-2018 with a minimum of one-year follow up was performed. Patients were separated into two groups based on their treatment: 100 had an isolated supraspinatus repair (SP) and 66 had both a supraspinatus and subscapularis repair (SB). The primary outcome was revision rotator cuff repair. Secondary outcomes were objective measures such as range of motion (ROM) and strength testing, including flexion (FF), external rotation (ER), and internal rotation (IR), as well as patient-reported outcome measures (PROs) including visual analog pain scale (VAS) and subjective shoulder value (SSV). Outcomes were compared using the Mann- Whitney Test and Fisher’s Exact Test with pResults: There was no significant difference in the rate of revision surgery required following isolated supraspinatus repair versus those with a subscapularis repair. Additionally, there were no significant differences between groups for all PROs, all ROM parameters, and all strength parameters (all p > 0.05) (Table 1). Conclusions: The data from this study demonstrated that patients who require a subscapularis repair at the time of their rotator cuff repair can expect similar short term outcomes to those patients who only required repair of their supraspinatus.

Objectives: Patients with irreparable rotator cuff tears (RCT) exhibit functional limitations including limited ability to perform functional tasks such as combing their hair. One viable treatment is superior capsular reconstruction (SCR). SCR has been shown to restore stability of the glenohumeral (GH) joint in cadavers1, but its effect on in vivo scapular and humeral motion is unknown. The aims of this study were to determine the effect of SCR on in vivo scapular and humeral kinematics during a functional hand to head motion and to identify associations between shoulder kinematics and patient-reported outcomes (PROs). We hypothesized that moving the hand to the back of the head would be accomplished by using more GH based movement including rotation and abduction, and less scapular motion after SCR, and there would be a positive correlation between kinematics changes and improved PROs. Methods: Ten patients (8M, 2F, age 63 ± 7 years) with irreparable RCT provided informed consent to participate in this prospective IRB-approved study. American Shoulder and Elbow Surgeon (ASES), Disability of the Arm Shoulder and Hand (DASH), and Western Ontario Rotator Cuff Index (WORC) surveys were completed before (PRE) and 1-year (1YR-POST) after SCR. Participants were seated and instructed to move their hand from their lap to the back of their head while synchronized biplane radiographs of the shoulder were collected PRE and 1YR-POST at 50 images/s for 3 separate trials. Six degree of freedom GH and scapular kinematics were determined with sub-millimeter accuracy by matching subject-specific CT-based bone models of the humerus and scapula to the synchronized radiographs using a validated volumetric tracking technique3. The contributions of humeral abduction, plane of elevation and internal/external (I/E) rotation relative to the scapula, as well as scapular upward rotation, protraction, and tilt, were calculated for each subject before and after SCR. Differences in rotational contributions from PRE to POST were evaluated using a paired t-test. Variability in rotational contributions was characterized by the inter-subject standard deviation in rotational component contributions to the movement. Correlations among changes in the contribution of each rotation component and between the contribution of each rotation component and PROs were evaluated with Pearson’s correlation coefficients. Significance was set at p < 0.05 for all tests. Results: No differences in contribution to motion were identified in any of the rotational components from PRE to POST (all p > 0.15, Figure 1). Inter-subject variability in rotational contributions to the movement decreased in 5 of the 6 rotational components from PRE to 1YR-POST (Table 1; Figure 1). The PRE to 1YR POST change in contribution from GH abduction was positively correlated to the change in contribution from GH I/E rotation (Figure 2, R = 0.8, p = 0.001) and negatively correlated to the change in contribution from scapular protraction (Figure 2, R = -0.94, p = 0.001). ASES scores were negatively correlated with abduction contribution PRE (R = -0.65, p = 0.043), and positively correlated with plane of elevation PRE (R = 0.685, p = 0.03). Changes in the plane of elevation contribution were also positively correlated with changes in ASES scores (R = 0.635, p = 0.048). Conclusions: This is the first study to report GH and scapular kinematics when performing the functional task of placing the hand to the back of the head. Changes in contributions to the motion were inconsistent across subjects, making it difficult to find differences from PRE to POST. However, inter-subject variation was reduced following surgery, suggesting the participants’ movement strategy converged toward a more similar and possibly more efficient movement pattern following SCR. Increased contributions of glenohumeral rotation and abduction were offset by decreased scapular protraction and indicates SCR affects the contributions from these three rotations, partially supporting our first hypothesis. In addition, increased GH plane of elevation contribution following surgery was associated with improved ASES scores supporting our second hypothesis. This may be consistent with improved glenohumeral kinematics and efficiency of movement during a functional task following SCR. Future work will investigate GH and scapular kinematics in healthy individuals performing the hand to head movement to determine if movement strategy is closer to healthy after SCR.

Objectives: Post-operative rehabilitation following arthroscopic rotator cuff repair (ARCR) is crucial for optimal outcomes. Early post-operative passive range of motion (PROM) is encouraged by some surgeons to minimize the development of adhesions and subsequent decreased range of motion. Existing literature comparing early and delayed PROM for small and medium size tears has demonstrated equivalent functional outcomes, with early PROM resulting in improved long-term active range of motion (AROM). The specific modality used for early PROM varies and may include manual home exercises, machine-assisted home exercises, or formal physical therapy (PT). In this study, we investigated Shoulder Strengthening and Stabilization Systems (SSS) (Advanced Integrated Motion; Elizur), a home-based machine monitored through telemedicine which allows for passive, active-assisted, and active motion in the early post-operative rehabilitation process. The benefit of SSS predominantly derives from the convenience of performing early PROM at home instead of attending in-person formal physical therapy. The objective of this study was to compare patient reported outcomes (PROs) and perioperative AROM after ARCR between patients who utilized SSS and those who underwent formal PT. We hypothesized that those who use SSS would have equivalent ROM and PROs compared to those who did not use SSS. Methods: A retrospective study comprised of patients undergoing RCR between 2018-2020 was conducted. Cohorts were defined by confirmation of SSS utilization via data provided by Elizur. SSS was started within several days following surgery in lieu of formal PT which started at 6 weeks. This was matched with a control group undergoing ARCR over the same time range, who initiated a formal PT protocol without the SSS machine when it was not available at our institution. The post-operative rehabilitation protocol consisted of PROM/pendulums beginning at 10 days, AROM at 6 weeks, and strengthening at 12 weeks. Data were collected from electronic medical records (EMR), entered into an institutional redcap database (UL1-TR-001857), and institutional review board approval was acquired. Patients undergoing concomitant labral repairs, capsular reconstruction procedures, revision ARCR, or with less than 3 months follow up were excluded. Primary outcome measure was subjective shoulder value (SSV) score. Secondary outcomes included American Shoulder and Elbow Surgeons Shoulder Score (ASES), visual analog scale (VAS), and AROM (forward flexion and external rotation). Baseline characteristics were analyzed with two sample t-tests and chi-square or Fisher’s exact test for continuous and categorical variables, respectively. A linear mixed model with fixed effects for cohort, time, and the cohort-time interaction was used to analyze PROs and AROM at various timepoints. Statistical significance was set at p < 0.05. Results: A total of 417 patients (243 SSS; 174 no SSS) with an average follow up of 5.5 months met inclusion criteria. SSS was used for an average of 36.2 days. Baseline characteristics including gender, BMI, nature of injury, time from injury to surgery, and preoperative PROs (SSV, ASES, and VAS) did not differ significantly between cohorts. The cohort without SSS was older at the time of surgery (61.3 years vs. 59.3 years, p=0.03). Linear mixed model analysis revealed no significant differences in AROM at any timepoint (table 1). There was no significant difference between cohorts with respect to SSV, ASES, and VAS at any timepoint (Table 2). Both cohorts had significant increases in each PRO over time, exceeding minimal clinically important difference (MCID) at 6 months post-operatively. Conclusions: The use of SSS demonstrated excellent ROM and patient reported outcomes equivalent to those who initiated formal PT in the early postoperative period. The convenience of a home-based therapy program monitored via telemedicine in lieu of formal PT during the first 6 post-operative weeks may be an attractive option for patients following ARCR. Future studies will elucidate whether there are potential cost saving implications. [Table: see text][Table: see text]

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

Agreement on the definition of human trafficking was reached in 2000 with the adoption of the Protocol to Prevent, Suppress and Punish Trafficking in Persons Especially Women and Children, supplementing the United Nations Convention against Transnational Organized Crime.1 The Convention defines trafficking in persons as the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation.2The definition includes three elements that must be fulfilled for conduct to amount to human trafficking, namely, an act, a means, and a purpose.3 Despite the apparent consensus, discussion has continued as to the definition’s precise scope,4 and the relationship between the concept of trafficking and related concepts, such as slavery, servitude, and forced labor.5 On the relationship between trafficking and forced labor, the International Labor Organization’s (ilo) position is that “trafficking in persons for the purpose of exploitation is encompassed by the definition of forced or compulsory labor.”6 Moreover, the 2014 Protocol to Convention No. 29 on Forced Labor explicitly requires efforts to combat trafficking for the purpose of forced labor.7 Notably, Stoyanova regards the ILO’s position as an “erroneous” one.8 These differing positions demonstrate that consensus on the conceptual boundaries of each of the elements of trafficking has yet to be reached. In S.M. v. Croatia, the European Court of Human Rights’ (ECtHR) Grand Chamber engaged anew with the discussion on trafficking and its conceptual proximity to or overlap with the terms in Article 4 of the European Convention on Human Rights (ECHR), namely, slavery, servitude, and forced labor. The issue centred upon whether Croatia had fulfilled its procedural obligations under Article 4, and the holding of the Court on this matter should not be overlooked.9 The focus in this article, however, is the Court’s analysis of the material scope of Article 4, especially the place of trafficking within such material scope; the connection between trafficking and forced labor; and the relationship between exploitation of prostitution, forced labor, and trafficking.10 With previous case-law on trafficking and Article 4 having attracted criticism,11 the task faced by the Grand Chamber was to take a step in the direction of clarity. Although it has succeeded in doing this to an extent, the question is whether the clarity that has been achieved is being built on an unstable foundation.

To identify the rate and risk factors of posterior labral involvement in operatively managed Bankart lesions and assess the effectiveness of MRI arthrogram for preoperative identification of such injury patterns.A consecutive cohort of patients undergoing arthroscopic Bankart repair were retrospectively reviewed. All subjects underwent a prearthroscopy MRI arthrogram. Operative findings were used as the gold standard for posterior labral tear extension. Patient demographic and surgical data were then analyzed to identify independent factors associated with the presence of concomitant posterior labral injury.Of 124 patients undergoing arthroscopic Bankart stabilization, 23 (19%) were noted to demonstrate posterior labral injury on arthroscopic evaluation. Factors associated with injury to the posterior labrum included those sustaining two or fewer dislocations events (Posterior propagation of Bankart lesions is relatively common following shoulder dislocations, with a rate of 18.5%. Risk factors for posterior labral extension include two or fewer dislocations, early presentation from the time of injury, and contact sports. On the basis of these findings, careful assessment of the posterior labrum on MRI arthrogram may reveal the majority, but not all, of these lesions.Level III, retrospective case-controlled study.

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: Patients with irreparable rotator cuff tears (RCT) exhibit functional limitations believed to be caused by superior migration of the humerus1,2. One viable treatment is superior capsule reconstruction (SCR). SCR has been shown to restore stability of the glenohumeral (GH) joint in cadavers1, but its effectiveness at controlling in vivo humeral motion is unknown. Outcomes are typically evaluated through standard clinical radiographs to assess acromial-humeral distance (AHD), and patient-reported outcomes (PROs) such as ASES and Visual Analog Scale3. Reported changes in AHD are inconsistent, with some studies reporting an increase in AHD of 2.6 to 3.2 mm4,7, while other studies reported no significant change5,6 in AHD after SCR. Scapulohumeral rhythm (SHR), a measure of shoulder motion fluidity, has been reported at 2:1 (glenohumeral to scapulothoracic motion) in healthy individuals9, but the effects of SCR on SHR are unknown. The aim of this study was to determine the effect of SCR on static and dynamic AHD, shoulder function, and patient-reported outcomes. We hypothesized that after SCR, static and dynamic AHD would increase, SHR would approximate that of a healthy shoulder, maximum GH abduction would increase, and PROs would improve. Methods: Ten patients with irreparable RCT provided informed consent prior to receiving human dermal allograft SCR. To date, seven (6M, 1F, age 60 ± 8 years) have returned for 1 year post-operative testing. ASES, DASH, and WORC surveys were completed before (PRE), 6 months (6MO-POST), and 1-year after SCR (1YR-POST). Synchronized biplane radiographs of the shoulder were collected PRE and 1YR-POST at 50 images/s while patients performed 3 trials of scapular plane arm abduction. Six degree of freedom GH and scapular kinematics were determined with sub-millimeter accuracy by matching subject-specific CT-based bone models of the humerus and scapula to radiographs using a validated volumetric tracking technique8. AHD was calculated as the minimum distance between the acromion and the humerus at 5° increments of GH abduction. Scapulohumeral rhythm (SHR) was calculated by finding the average change in glenohumeral abduction per degree of scapular upward rotation during scapular abduction.Differences between PRE and 1YR-POST SHR and static AHD distance were evaluated using a paired t-test with significance set at p < 0.05. Changes in PROs were compared to the minimum clinically important difference (MCID). Results: There was a trend toward decreasing static AHD from PRE to 1YR-POST (average decrease: 1.5±1.6mm (p=0.06), however, dynamic AHD did not change from PRE to 1 YR-POST between 45° and 95° of glenohumeral abduction (all p > 0.11) (Figure 1). There was a trend toward increased SHR from 1.1 ± 0.5 PRE to 1.5 ± 0.3 1YR-POST (p = 0.08) (Figure 2), while the increase in maximum GH abduction during scapular abduction from PRE (76.7°±24.5°) to 1YR-POST (91.8°±14.9°) was not statistically significant (p = 0.14) (Figure 2). ASES, WORC, and DASH scores improved beyond the minimum clinically important difference from PRE to 1YR-POST (Table 1) for all patients. Conclusion: In general, SHR tended to more closely resemble that of a healthy shoulder following SCR. Althoughaverage maximum GH abduction was higher postoperatively than preoperatively, that increase was not statistically significant and may reflect that most patients in our cohort had reasonable preoperative abduction. In contrast to those quantitative measures of shoulder function, patient-reported qualitative outcomes all improved significantly. Conflicting results between static and dynamic AHD during higher glenohumeral abduction angles suggest SCR does not appear to affect AHD in higher abduction angles, though the static AHD suggests there may be a difference at lower abduction angles. Dynamic measurements of AHD at lower abduction angles will be necessary to fully characterize the dynamic changes of AHD following SCR. Figure 1. Patient-reported outcomes. Bolded scores represent changes greater than the minimum clinically important different (MCID) compared to PRE and average contact center locations ± 1 standard deviation throughout scapular plane abdjuction. Black + indicates the glenoid center with anterior (A) and posterior (P) directions indicated on the glenoid.

Objectives: Glenoid and humeral sided bone loss are both independent risk factors for failure after arthroscopic Bankart repair. The purpose of this study was to determine the combined effect of subcritical levels of humeral and glenoid sided bone loss on failure after arthroscopic Bankart repair. Methods: 171 individuals with minimum 2 years follow up who underwent primary arthroscopic Bankart repair between 2007-2015 were included in this study. Glenoid and humeral sided bone loss were measured using the glenoid track model. Cases were defined as individuals who sustained a subluxation or dislocation event after the index procedure, while controls were defined as individuals who did not. Subjects were stratified by age (20+ versus < 20 years). Receiver operating curves (ROC) were generated to determine the threshold of glenoid and humeral sided bone loss that could best predict failure. Results: There were 53 cases and 118 controls. Increased glenoid (p < .001) and humeral-sided (p = .013) bone loss independently predicted failure. ROC analysis demonstrated that threshold values of 12% glenoid (AUC = 0.62) and 13 mm humeral (AUC = 0.60) bone loss were predictive of failure. Combined subcritical thresholds of 10% glenoid and 10 mm humeral sided bone loss successfully predicted outcomes of 49/56 (87.5%) individuals over age 20 and 79/117 (67.5%) individuals under age 20. Humeral and glenoid sided bone loss had an additive effect on risk of failure in older individuals while glenoid sided bone loss was primarily responsible for failure in younger individuals. Conclusion: Both glenoid and humeral sided bone loss are predictive of failure after arthroscopic Bankart repair. Combined subcritical thresholds of glenoid and humeral sided bone loss accurately predict failure, particularly in individuals over the age of 20. These results suggest that individuals with subcritical bipolar lesions may be at higher risk of failure after arthroscopic Bankart repair than previously thought. Table 1. % Failure P value ≥Age 20 years Glenoid bone loss > 10%,Hill-Sachs > 10 mm 87.5% (7/8) P < .001 Glenoid bone loss > 10%,Hill-Sachs < 10 mm 33.3% (2.6) P = .53 Glenoid bone loss < 10%,Hill-Sachs > 10 mm 30% (3/10) P = .58 Glenoid bone loss < 10%,Hill-Sachs < 10 mm 3.1% (1/32) P < .001 Age < 20 years Glenoid bone loss > 10%,Hill-Sachs > 10 mm 62.5% (5/8) P = .080 Glenoid bone loss > 10%,Hill-Sachs < 10 mm 70.6% (12/17) P = .001 Glenoid bone loss < 10%,Hill-Sachs > 10 mm 23.6% (4/17) P = .32 Glenoid bone loss < 10%,Hill-Sachs < 10 mm 25.3% (19/75) P = .007

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.

Objectives: Patients with irreparable rotator cuff tears (RCT) exhibit functional limitations believed to be caused by superior migration of the humerus1,2. One viable treatment is superior capsule reconstruction (SCR). SCR has been shown to restore stability of the glenohumeral (GH) joint in cadavers1, but its effectiveness at controlling in vivo humeral motion is unknown. Outcomes are typically evaluated through standard clinical radiographs to assess acromial-humeral distance (AHD), and patient-reported outcomes (PROs) such as ASES and Visual Analog Scale3. Reported changes in AHD are inconsistent, with some studies reporting an increase in AHD of 2.6 to 3.2 mm4,5, while other studies reported no significant change in AHD after SCR6,7. Additionally, AHD does not account for anterior-posterior translations of the humeral head and clinical radiographs cannot assess dynamic translation of the humerus during arm abduction. The aim of this study was to determine the in vivo effect of SCR on in vivo glenohumeral arthrokinematics during scapular abduction, and to compare these results to PROs. We hypothesized that static and dynamic AHD would increase, humeral head location on the glenoid would be more inferior at corresponding abduction angles after SCR, and changes in humeral head translation or AHD would correlate with increased GH abduction range of motion and improved PROs. Methods: Ten patients (8M, 2F, age 63 ± 7 years) with irreparable RCT provided informed consent to participate in this prospective IRB-approved study. ASES, DASH, and WORC surveys were completed before (PRE) and 1-year (1YR-POST) after SCR. Synchronized biplane radiographs of the shoulder were collected PRE and 1YR-POST at 50 images/s while patients performed 3 trials of scapular plane arm abduction. Biplane radiographs were also collected during a static neutral trial where the participants placed their hand on their lap. Six degree of freedom GH and scapular kinematics were determined with sub-millimeter accuracy by matching subject-specific CT-based bone models of the humerus and scapula to radiographs using a validated volumetric tracking technique8. AHD was calculated as the minimum distance between the acromion and the humerus at 10° increments of GH abduction and averaged throughout the motion. Humeral head translation, defined as the relative translation of the center of the humeral head compared to the center of the glenoid, was calculated at 10° increments of GH abduction and expressed as averages in the superior/inferior (SI) and anterior/posterior (AP) directions. Differences between PRE and 1YR-POST static AHD, average dynamic humeral head location, PROs, and maximum GH abduction were evaluated using a paired t-test. A Pearson correlation was used to determine associations between static AHD and average humeral head location, and both PROs and maximum GH abduction. Significance was set at p < 0.05 for all tests. Results: There was no difference in static AHD from PRE (5.3±1.6mm) to 1YR-POST (4.6±1.6mm) while the average dynamic AHD during GH abduction decreased from 2.7±1.2mm PRE to 2.3±1.0mm 1YR-POST (Figure 1). Static AHD was larger than the average dynamic AHD both PRE and 1YR-POST (Figure 1). The average position of the humeral head during abduction moved 1.5% of the glenoid height superior from PRE to 1YR-POST and 1.7% of the glenoid width anterior from PRE to 1YR-POST (Figure 2). ASES, WORC, and DASH scores significantly improved from PRE to 1YR-POST and maximum GH abduction significantly increased from PRE (78.1±23.1°) to 1YR-POST (93.9±12.3°) (Table 1). Interestingly, there was a positive correlation between the AP humeral head location and DASH score PRE such that a higher DASH score was associated with the humeral head being more anterior (R = 0.767). No other associations were found between either average humeral head locations or AHD and either PROs or maximum GH abduction at both time points as well as the changes in those measures between time points (all R < 0.67). Conclusions: Static AHD, as measured clinically, may not be a good representation of dynamic AHD during scapular abduction given the differences between the static and dynamic AHD measurements at similar abduction angles. Additionally, our in vivo kinematics findings are not consistent with prior results of a cadaver-based biomechanical study of SCR as we found were minute changes in the SI humeral head position, with a 0.4mm more superior humeral head position following SCR. Regardless, patient-reported qualitative outcomes and maximum GH abduction all improved significantly. This suggests clinical outcomes after SCR may be influenced by mechanisms other than restoration of humeral head translation. Future in vivo studies are needed to evaluate the kinematic mechanisms behind improved PROs after SCR. [Table: see text]

Objectives: A good outcome after arthroscopic stabilization for recurrent shoulder instability is often characterized by a successful return to sport while minimizing complications. While many physicians use a minimum of 5 months as a time to return, 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 of achieving appropriate strength and using standardized objective evaluations of strength and physical function. Methods: 33 consecutive patients who underwent arthroscopic shoulder stabilization surgery from 2012 until 2018 and completed their postoperative rehabilitation with the same institution were subjected to functional testing to evaluate their readiness for return to sport. Isometric unilateral external rotation to internal rotation (ER/IR) ratio was measured using a hand held dynamometer at 0 and 90 degrees of shoulder abduction. Posterior rotator cuff activation was evaluated using a repetition to failure technique with 5% body weight at 0 and 90 degrees of abduction. Prone trapezius activation was measured in repetitions to failure with a prone Y exercise. A subset of throwing athletes (N= 11) were evaluated for total arc of motion. Results: Isometric testing at revealed that 18% (6/33, mean ratio 71%) patients met the expected goal of 80% ER/IR strength at both 0 and 90 degrees of abduction, with mean ratios of 71% and 62%, respectively. 73% (24/33) and 42% (14/33) of patients met goal of 90% of the contralateral ER repetitions to failure in rotator cuff activation testing at 0 and 90 degress of abduction, respectively. 55% (18/33) of patients met goal of 90% of contralateral prone Y repetitions to failure on lower trapezius activation testing, with mean. Mean total arc of postoperative motion for the 11 throwers was 91.6% of the contralateral shoulder. Thirty-six percent (4/11) patients did not reach 90% of the total arc of motion of the uninvolved shoulder. Conclusion: A substantial number of athletes in our cohort do not meet the expected goals for their operative shoulder in achieving appropriate strength, particularly in ER, nor arc of motion compared to the contralateral shoulder.

Objectives: Recurrent shoulder instability after arthroscopic shoulder stabilization is a challenging complication that often manifests after return to sports. Many physicians use an arbitrary minimum of 5 months from surgery for clearance, although there is little data to support the use of temporal based criteria. Prior literature on ACL reconstruction has demonstrated overwhelming evidence for improved failure rates following return to sport after criteria based testing compared to time based clearance, but no such studies to date have evaluated the use of objective return to play testing protocols on recurrence rates following arthroscopic shoulder stabilization. We have prior presented on a return to sport criteria-based protocol that has demonstrated that a majority of athletes have residual strength and functional limitations which would preclude them from full clearance and return to play at 6 months postoperatively. The purpose of this study is to analyze the impact of a return to play criteria-based testing protocol on recurrent instability following arthroscopic shoulder stabilization. We hypothesized that patients who meet return to play criteria would have less recurrent instability compared to those who did not undergo the testing and were cleared to return based on time from surgery. Methods: Forty eight patients (group I) who underwent arthroscopic shoulder stabilization surgery from 2016 to 2018 with minimum 1 year follow up and were referred during postoperative rehabilitation for functional testing to evaluate readiness for return to sport were included in this retrospective case controlled study. These patients were compared to a control group of forty-eight historical consecutive cases (group II) who did not undergo return to sports testing and were cleared for sports after a minimum of 5 months following surgery. Patients with critical glenoid bone loss or off-track Hill-Sach’s lesions necessitating a remplissage or bone augmentation procedure were excluded from the study. ANOVA and independent t test were performed to analyze recurrence shoulder instability rates defined as dislocations or subluxation symptoms. Results: There was no difference between groups with regard to age ( p=0.64), sex (p=0.24), hand dominance (p=0.84), or participation in contact sports (p=0.66). Patients who underwent return to play criteria based testing protocol had a statistically significant difference in the rate of recurrent shoulder instability (10% vs. 31%, odds ratio=3.9, pConclusion: Athletes who undergo an objective return to play criteria based testing protocol have lower rates of recurrent instability following arthroscopic shoulder stabilization surgery than those cleared by time from surgery. Based on our findings, we strongly recommend the utilization of a criteria based testing protocol for return to play following arthroscopic shoulder stabilization, particularly for sports that have known higher risks of recurrence.

Latin America's transition to democracy in the 1970s and 1980s was accompanied by the increased political participation of women, who demanded not only equal rights, but also insisted that addressing women's specific interests was key to establishing a truly representative democracy. Many in the Latin American women's movement saw the right to safe, legal abortion as fundamental. To date, their demand for this has gone largely unfulfilled, except in Cuba. There is no panacea to rescinding punitive abortion laws. However, the region is currently witnessing shifts in government policies on abortion, both progressive and retrogressive, which suggest that there is potential for substantive reform. This article will use the recent experiences of Colombia, Mexico City, and Nicaragua to highlight shared challenges, establish linkages with other countries in the region, and demonstrate that the many different strategies which have been adopted present an opportunity to expand access to safe, legal abortion throug...

Based on research carried out on a mature estate in South Belfast, Northern Ireland, this paper investigates the obstacles to accessibility in order to produce an appraisal model for external accessibility. The study included a review of best practice, a preliminary access appraisal and resident and service provider consultation. Residents were surveyed on a number of issues including location, roads and pavements, transportation, level change, wayfinding, safety and security, and public areas. It was discovered that obstacles relating to wayfinding and traffic management created the greatest problems for residents. The resultant model will enable housing providers and managers to identify specific areas of inaccessibility and the feasibility of improving them as well as allowing comparisons between estates. It is intended to provide all agencies involved in housing with a basis for collaboration in the enhancement of accessibility.

Accessibility is now a major issue in the design and maintenance of housing estates. This paper considers the reasons why this issue has emerged and the main obstacles to accessibility encountered by housing estate residents. Focusing on a mature estate in South Belfast, Northern Ireland, investigates the obstacles to accessibility experienced by the residents in order to produce a hierarchy of impacts. Residents were surveyed on a number of issues including location, roads and pavements, transportation, level change, wayfinding, safety and security, and public areas. It was discovered that obstacles relating to wayfinding created the greatest problems for residents; however, attitudes towards accessibility varied according to the age of the respondent. The study concludes that accessibility should be introduced estate‐by‐estate dependent on a resident profile in order to maximise resources and advocates the adoption of a co‐ordinated interagency approach.