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Abane C, Macheix PS, Labattut L, Delgrandre D, Antoni M, Dordain F, Billaud A, Nourissat G, Villatte G. Glenohumeral bone lesions occurring during the first episode of shoulder dislocation do not influence function at an average of 2 years. J Shoulder Elbow Surg 2024:S1058-2746(24)00860-7. [PMID: 39631558 DOI: 10.1016/j.jse.2024.09.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 09/01/2024] [Accepted: 09/23/2024] [Indexed: 12/07/2024]
Abstract
BACKGROUND After a first shoulder dislocation, the rate of recurrence varies according to age and type of activity. The rule of bony lesions is logical but not demonstrated. We conducted a study to analyze bony lesions observed after a first episode of anterior shoulder dislocation in patients younger than 50 years of age. We assessed the functional outcomes and rate of recurrence among dislocations depending on bony lesions. METHODS We conducted a prospective, multicenter study for an average of 2 years that included patients aged 18-50 years who had experienced a first episode of anterior shoulder dislocation and who agreed to undergo computed tomography imaging within 3 weeks of trauma. A minimum follow-up duration of 1 year was required for clinical analysis. RESULTS Ninety-two patients, with a mean follow-up duration of 2 years, participated in the study. Ultimately, 13 patients were excluded: 2 were lost to follow-up, 6 underwent stabilization surgery, and 5 had a follow-up duration of less than 1 year. The mean age at inclusion was 27 years and 94% were men. Glenoid lesions were observed in 39% of patients; humeral lesions were present in 95%. Recurrence occurred in 24% of cases. There was no significant difference in functional scores between patients with and without bony lesion. There was a lower rate of residual apprehension in nonrecurrent patients compared with those who had experienced recurrence (P = .02) and a greater return to sport in the "no recurrence" subgroup (P = .02). The risk of recurrence was equivalent, regardless of the status of glenoid, humerus, or bipolar lesions. The sole predictor of recurrence after a first episode of dislocation was age younger than 20 years (P = .002). CONCLUSION Our study results provide insight into the functional outcomes and likelihood of dislocation recurrence with bony lesions after initial glenohumeral dislocation. If the first episode occurred before the age of 50 years, bony lesions were common. The overall recurrence rate was 24% with an average time of recurrence of 16 months (1-24). In our study, the presence of glenoid and/or humeral bony lesions does not seem to be a risk factor for luxation recurrence.
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Affiliation(s)
- Cynthia Abane
- Department of Orthopedics-Traumatology, CHU Dupuytren. 2, Limoges Cedex, France
| | | | - Ludovic Labattut
- Orthopedics Department, CHU F.Mitterrand Dijon-Bourgogne, Dijon, France
| | - Damien Delgrandre
- Institut de chirurgie orthopédique de Provence - Clinique Axium, Aix-en-Provence, France
| | - Maxime Antoni
- Service de chirurgie du membre supérieur, hôpital de Hautepierre 2, CHU de Strasbourg, Strasbourg, France
| | | | | | | | - Guillaume Villatte
- Service de chirurgie orthopédique et traumatologique, CHU de Clermont-Ferrand, Clermont-Ferrand, France
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Khan M, Bedi A, Degen R, Warner J, Bhandari M. Multicentre randomised controlled trial comparing Bankart repair with remplissage and Latarjet procedure in shoulder instability with subcritical bone loss (STABLE): study protocol. BMJ Open 2024; 14:e089831. [PMID: 39542469 PMCID: PMC11575273 DOI: 10.1136/bmjopen-2024-089831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2024] Open
Abstract
INTRODUCTION Recurrent shoulder dislocations often cause attrition of the labrum and progressive loss of the anterior bony contour of the glenoid. Treatment options for this pathology involve either soft tissue repair or bony augmentation procedure. The optimal management for patients with shoulder instability with subcritical bone loss remains unknown and current clinical practice is highly varied. METHODS AND ANALYSIS The Shoulder instability Trial comparing Arthroscopic stabilisation Benefits compared with Latarjet procedure Evaluation (STABLE) is an ongoing multicentre, randomised controlled trial of 114 patients diagnosed with recurrent anterior shoulder instability and subcritical glenoid bone loss (10%-20%, measured on 3D CT using circle of best fit technique). Patients are randomised either arthroscopic capsuloligamentous repair (Bankart repair+remplissage) or open or arthroscopic coracoid transfer (Latarjet procedure). The primary outcome of this trial will be the between-group difference in the change from baseline to 24 months postintervention in Western Ontario Shoulder Instability Index scores. Secondary outcomes include: (1) rates of recurrent shoulder dislocations and symptoms of instability up to 24 months' postsurgery; (2) clinical outcomes measured by American Shoulder and Elbow Society score, Shoulder Activity Scale, EQ-5D and Patient Satisfaction Scale; (3) physical examination (range of motion, stability); (4) return to previous level of activity/sport; (5) rate of shoulder-related complications and serious adverse events. ETHICS AND DISSEMINATION This protocol has been reviewed and approved by the Hamilton Integrated Research Ethics Board (HiREB; project number 15998) prior to commencement of the trial. Results from the study will be submitted for publication in a peer-reviewed journal regardless of whether there are statistically significant findings. TRIAL REGISTRATION NUMBER NCT05705479; this study was prospectively registered on clinicaltrials.gov.
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Affiliation(s)
- Moin Khan
- Surgery, McMaster University, Hamilton, Ontario, Canada
| | | | - Ryan Degen
- University of Western Ontario, London, Ontario, Canada
| | - Jon Warner
- Harvard University, Cambridge, Massachusetts, USA
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
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Johnson CM, DeFoor MT, Griswold BG, Bozzone AE, Galvin JW, Parada SA. Functional Anatomy and Biomechanics of Shoulder Instability. Clin Sports Med 2024; 43:547-565. [PMID: 39232565 DOI: 10.1016/j.csm.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2024]
Abstract
The glenohumeral joint is the least congruent and least constrained joint with a complex relationship of static and dynamic stabilizers to balance its native mobility with functional stability. In the young athlete, anterior shoulder instability is multifactorial and can be a challenge to treat, requiring a patient-specific treatment approach. Surgical decision-making must consider patient-specific factors such as age, sport activity and level, underlying ligamentous laxity, and goals for return to activity, in addition to careful scrutiny of the underlying pathology to include humeral and glenoid bone loss and surrounding scapular bone morphology.
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Affiliation(s)
- Craig M Johnson
- Madigan Army Medical Center, 9040 Jackson Avenue, Tacoma, WA 98431, USA
| | - Mikalyn T DeFoor
- San Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA
| | - Branum Gage Griswold
- Denver Shoulder/Western Orthopaedics, 1830 Franklin Street, Denver, CO 80218, USA
| | - Anna E Bozzone
- Medical College of Georgia at Augusta University, 1120 15th Street, Augusta, GA 30912, USA
| | - Joseph W Galvin
- Orthopaedic Surgery, Madigan Army Medical Center, 9040 Jackson Avenue, Tacoma, WA 98431, USA
| | - Stephen A Parada
- Orthopaedic Research, Medical College of Georgia at Augusta University, 1120 15th Street, Augusta, GA 30912, USA.
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Kim JH, Kwon YU, Lee CR, Kim DY, Jung SH, Hwang JW. Longer peripheral-track lesions are associated with instability after arthroscopic Bankart repair. J Shoulder Elbow Surg 2024; 33:1724-1732. [PMID: 38367925 DOI: 10.1016/j.jse.2023.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/05/2023] [Accepted: 12/25/2023] [Indexed: 02/19/2024]
Abstract
BACKGROUND The glenoid track concept has enabled the categorization of Hill-Sachs lesions (HSLs) into on-track lesions and off-track lesions. Furthermore, among the on-track lesions, further categorization has been established based on the distance from the medial edge of the Hill-Sachs lesion to the medial edge of the glenoid track, into peripheral-track lesions and central-track lesions. Recent studies on peripheral-track lesions and central-track lesions within the glenoid track have shown inconsistencies in failure rates, which deserves further investigation. METHODS A retrospective cohort comparison of patients who underwent arthroscopic Bankart repair between 2015 and 2020 was performed. 102 patients with peripheral-track HSLs were included. The patients were divided into 2 groups based on the results of the postoperative apprehension test: the apprehension positive group (n = 30), and the apprehension negative group (n = 72). Using preoperative computed tomography (CT) and an image reconstruction program, 3-dimensional (3D) images were segmented to calculate the length, width, depth, and distance of the HSLs. A multivariate logistic regression was used to determine the risk factors of recurrence, for which odds ratio (OR) and 95% confidence interval (CI) were provided. RESULTS A multivariate logistic regression analysis revealed that the length of the peripheral-track HSLs was a significant independent predictor of failure in this study. (OR 1.380; 95% CI 1.170-1.627; P < .001). The receiver operating characteristics curve (ROC) demonstrated a predictive power (area under the curve = 0.841) and a threshold value of 14.2 mm. CONCLUSION Length was the only risk factor for the recurrent instability of peripheral-track HSLs after ABR. In the context of surgical decision-making, utilizing the glenoid track concept, medical practitioners may need to evaluate instability by considering the length as a continuous factor, while differentiating between peripheral-track and central-track classifications.
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Affiliation(s)
- Jung-Han Kim
- Department of Orthopedic Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Yong-Uk Kwon
- Department of Orthopedic Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Chang-Rack Lee
- Department of Orthopedic Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Dae-Yoo Kim
- Department of Orthopedic Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Soo-Hwan Jung
- Department of Orthopedic Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Joo-Won Hwang
- Department of Orthopedic Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea.
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Gordins V, Sansone M, Thorolfsson B, Möller M, Carling M, Olsson N. Incidence of bony Bankart lesions in Sweden: a study of 790 cases from the Swedish fracture register. J Orthop Surg Res 2023; 18:680. [PMID: 37705094 PMCID: PMC10498552 DOI: 10.1186/s13018-023-04173-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/08/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND A bony Bankart lesion directly affects the stability of the shoulder by reducing the glenoid joint-contact area. The aim of this study was to report on the epidemiological data relating to bony Bankart lesions in Sweden using the Swedish fracture register. The purpose is to evaluate age and sex distribution in the population with bony Bankart lesions, its impact on treatment strategy and further to analyse patient-reported outcomes. METHODS This was an epidemiological descriptive study. The inclusion criteria were all patients with a unilateral bony Bankart lesion registered between April 2012 and April 2019. The patients' specific data (age, sex, type and time of injury, treatment option and patient-reported outcomes) were extracted from the Swedish fracture register database. RESULTS A total of 790 unilateral bony Bankart fractures were identified. The majority of the patients were male (58.7%). The median age for all patients at the time of injury was 57 years. Females had a higher median age of 66 years, compared with males, 51 years. Most of the bony Bankart lesions, 662 (91.8%), were registered as a low-energy trauma. More than two-thirds of all treatment registered cases, 509/734 patients (69.3%), were treated non-surgically, 225 (30.7%) were treated surgically, while, in 17 patients (7.5% of all surgically treated patients), the treatment was changed from non-surgical to surgical due to recurrent instability. Surgical treatment was chosen for 149 (35%) of the males and for 76 (25%) of the females. Patient quality of life decreased slightly in both surgically and non-surgically treated groups 1 year after bony Bankart injury. CONCLUSION This national register-based study provides detailed information on the epidemiology, choice of treatment and patient-reported outcomes in a large cohort of bony Bankart lesions. Most bony Bankart lesions affected males between 40 and 75 years after low-energy falls and non-surgical treatment dominated.
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Affiliation(s)
- Vladislavs Gordins
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden.
- Department of Orthopaedics, Sahlgrenska University Hospital, Göteborgsvägen 31, 431 80, Mölndal, Sweden.
| | - Mikael Sansone
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Göteborgsvägen 31, 431 80, Mölndal, Sweden
| | - Baldur Thorolfsson
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Göteborgsvägen 31, 431 80, Mölndal, Sweden
| | - Michael Möller
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Göteborgsvägen 31, 431 80, Mölndal, Sweden
| | - Malin Carling
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Göteborgsvägen 31, 431 80, Mölndal, Sweden
| | - Nicklas Olsson
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Göteborgsvägen 31, 431 80, Mölndal, Sweden
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Menendez ME, Sudah SY, Denard PJ, Feeley BT, Frank RM, Galvin JW, Garber AC, Crall TS, Crow S, Gramstad GD, Cheung E, Fine L, Costouros JG, Dobbs R, Garg R, Getelman MH, Buerba R, Harmsen S, Mirzayan R, Pifer M, McElvany M, Ma CB, McGoldrick E, Lynch JR, Jurek S, Humphrey CS, Weinstein D, Orvets ND, Solomon DJ, Zhou L, Saleh JR, Hsu J, Shah A, Wei A, Choung E, Shukla D, Ryu RK, Brown DS, Hatzidakis AM, Min KS, Fan R, Guttmann D, Rao AG, Ding D, Andres BM, Cheah J, Mierisch CM, Hoellrich RG, Lee B, Tweet M, Provencher MT, Butler JB, Kraetzer B, Klug RA, Burns EM, Schrumpf MA, Savin D, Sheu C, Magovern B, Williams R, Sears BW, Stone MA, Nugent M, Gomez GV, Amini MH. Surgeon variation in glenoid bone reconstruction procedures for shoulder instability. J Shoulder Elbow Surg 2023; 32:133-140. [PMID: 36208672 DOI: 10.1016/j.jse.2022.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 08/22/2022] [Accepted: 09/04/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND Advances in the understanding and management of glenoid bone loss in shoulder instability have led to the development of alternative bony reconstruction techniques to the Latarjet using free bone grafts, but little is known about surgeon adoption of these procedures. This study sought to characterize surgeon variation in the use of glenoid bone reconstruction procedures for shoulder instability and ascertain reasons underlying procedure choice. METHODS A 9-question survey was created and distributed to 160 shoulder surgeons members of the PacWest Shoulder and Elbow Society, of whom 65 (41%) responded. The survey asked questions regarding fellowship training, years in practice, surgical volume, preferred methods of glenoid bone reconstruction, and reasons underlying treatment choice. RESULTS All surgeons completed a fellowship, with an equal number of sports medicine fellowship-trained (46%) and shoulder and elbow fellowship-trained (46%) physicians. The majority had been in practice for at least 6 years (6-10 years: 25%; >10 years: 59%). Most (78%) performed ≤10 glenoid bony reconstructions per year, and 66% indicated that bony procedures represented <10% of their total annual shoulder instability case volume. The open Latarjet was the preferred primary reconstruction method (69%), followed by open free bone block (FBB) (22%), arthroscopic FBB (8%), and arthroscopic Latarjet (1%). Distal tibia allograft (DTA) was the preferred graft (74%) when performing an FBB procedure, followed by iliac crest autograft (18%), and distal clavicle autograft (6%). The top 5 reasons for preferring Latarjet over FBB were the sling effect (57%), the autologous nature of the graft (37%), its robust clinical evidence (22%), low cost (17%), and availability (11%). The top 5 reasons for choosing an FBB procedure were less anatomic disruption (58%), lower complication rate (21%), restoration of articular cartilage interface (16%), graft versatility (11%), and technical ease (11%). Only 20% of surgeons indicated always performing a bony glenoid reconstruction procedure in the noncontact athlete with less than 20% glenoid bone loss. However, that percentage rose to 62% when considering a contact athlete with the same amount of bone loss. CONCLUSIONS Although open Latarjet continues to be the most popular glenoid bony primary reconstruction procedure in shoulder instability, nearly 30% of shoulder surgeons in the western United States have adopted FBB techniques as their preferred treatment modality--with DTA being the most frequently used graft. High-quality comparative clinical effectiveness research is needed to reduce decisional conflict and refine current evidence-based treatment algorithms.
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Affiliation(s)
- Mariano E Menendez
- Oregon Shoulder Institute at Southern Oregon Orthopedics, Medford, OR, USA
| | - Suleiman Y Sudah
- Department of Orthopedics, Monmouth Medical Center, Long Branch, NJ, USA
| | - Patrick J Denard
- Oregon Shoulder Institute at Southern Oregon Orthopedics, Medford, OR, USA.
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Woodmass JM, Wagner ER, Smith J, Welp KM, Chang MJ, Morissette MP, Higgins LD, Warner JJP. Postoperative recovery comparisons of arthroscopic Bankart to open Latarjet for the treatment of anterior glenohumeral instability. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:1357-1364. [PMID: 35665856 DOI: 10.1007/s00590-022-03265-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/15/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Recurrent anterior glenohumeral instability is a disabling pathology that can be successfully treated by arthroscopic Bankart repair or open Latarjet. However, there is a paucity of studies comparing the postoperative recovery. The purpose of this study is to evaluate the postoperative pain and functional recovery following arthroscopic Bankart versus open Latarjet. METHODS This is a retrospective analysis of a multicenter prospective outcomes registry database. Postoperative recovery outcomes of either a primary or revision arthroscopic Bankart and open Latarjet procedures were compared. A minimum of 1-year follow-up was required. Outcomes measures included pain visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) function score, ASES index score, and single assessment numeric evaluation (SANE) score. Overall, 787 patients underwent primary arthroscopic Bankart, 36 underwent revision arthroscopic Bankart and 75 underwent an open Latarjet procedure. RESULTS When compared to primary arthroscopic Bankart, open Latarjet demonstrated significantly lower VAS scores at 6 weeks (p = 0.03), 3 months (p = 0.01), and 2 years (p < 0.05). Medium-term outcomes for ASES scores and SANE score, at 1 and 2 years showed no difference. Latarjet demonstrated significantly lower (p < 0.05) preoperative early postoperative VAS pain scores with no difference at 1 year or 2 years when compared to primary Bankart. There was no difference in ASES function or index between Bankart and Latarjet. Revision Bankart provided inferior outcomes for VAS, ASES function, and ASES index when compared to primary Bankart and Latarjet at 1 year and 2 years. CONCLUSIONS Primary arthroscopic Bankart repair and open Latarjet provided nearly equivalent improvements in pain (VAS) and functional outcomes (ASES, SANE, VR-12) during the early recovery phase (2 years). This study supports the use of either procedure in the primary treatment of anterior glenohumeral instability. Revision arthroscopic Bankart repair demonstrated deteriorating outcomes at 1 and 2 years postoperatively.
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Affiliation(s)
- Jarret M Woodmass
- Boston Shoulder Institute, Boston, MA, USA.,Pan Am Clinic, University of Manitoba, Winnipeg, MB, Canada
| | - Eric R Wagner
- Boston Shoulder Institute, Boston, MA, USA.,Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | | | - Kathryn M Welp
- Boston Shoulder Institute, Boston, MA, USA.,Tufts University School of Medicine, Boston, MA, USA
| | - Michelle J Chang
- Boston Shoulder Institute, Boston, MA, USA.,Kansas City University of Medicine and Biosciences, Kansas City, MO, USA
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Scanaliato JP, Dunn JC, Fitzpatrick KV, Czajkowski H, Parnes N. Double-Pulley Remplissage in Active-Duty Military Population With Off-Track Anterior Shoulder Instability Results in Improved Outcomes and Low Recurrence at Minimum 4-Year Follow-Up. Arthroscopy 2022; 38:743-749. [PMID: 34530108 DOI: 10.1016/j.arthro.2021.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 07/03/2021] [Accepted: 09/07/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To report mid-term outcomes of active-duty patients with anterior shoulder instability following our technique for double-pulley remplissage (DPR) with concomitant anterior labral repair. METHODS All consecutive patients from 1/2010 through 12/2016 that underwent DPR by the senior surgeon with complete outcome scores were identified. All patients had experienced a shoulder dislocation following a traumatic event, and had subsequent instability recalcitrant to conservative management. Patients were excluded if they were lost to follow-up (3) of if they underwent stabilization procedures other than DPR (148). Outcome measures were completed by patients within 1 week prior to surgery and at latest follow-up. Twenty-four patients met the inclusion criteria for the study, and all were active-duty military at the time of surgery. RESULTS 20/24 (83.3%) patients met the patient acceptable symptomatic state (PASS), while 21/24 (87.5%) achieved substantial clinical benefit (SCB) and 22/24 (91.7%) exceeded the minimal clinically important difference (MCID) for their operative shoulder, as determined by the American Shoulder and Elbow Surgeons (ASES) Score. 21/24 (87.5%) patients met the PASS, while 19/24 (79.2%) achieved SCB and 20/24 (83.3%) exceeded the MCID for their operative shoulder, as determined by the single assessment numeric evaluation (SANE). In addition, 23/24 (95.8%) patients exceeded the MCID for their operative shoulder, as determined by the Rowe Instability score. Preoperative and postoperative range of motion did not vary significantly. All patients had decreased pain postoperatively (P < .0001); 22/24 (91.67%) of patients remained on active-duty status. Failure rate, defined as recurrent subluxation or dislocation, was 4.2%. CONCLUSIONS Mid-term outcomes in this population of active-duty patients undergoing DPR for shoulder instability without glenoid bone loss demonstrate a statistically and clinically significant improvement in patient-reported outcomes, a significant decrease of pain and an overall return to active-duty rate of 91.67%. LEVEL OF EVIDENCE IV, therapeutic case series.
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Affiliation(s)
- John P Scanaliato
- William Beaumont Army Medical Center, Department of Orthopaedic Surgery, El Paso, Texas, U.S.A..
| | - John C Dunn
- William Beaumont Army Medical Center, Department of Orthopaedic Surgery, El Paso, Texas, U.S.A
| | - Kelly V Fitzpatrick
- William Beaumont Army Medical Center, Department of Orthopaedic Surgery, El Paso, Texas, U.S.A
| | | | - Nata Parnes
- Carthage Area Hospital, Carthage, New York, U.S.A.; Claxton-Hepburn Medical Center, Ogdensburg, New York
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Khan M, Bedi A, Degen R, Warner J, Bhandari M, Khan M, Degen R, Bhandari M, Bedi A, Warner J. A pilot multicenter randomized controlled trial comparing Bankart repair and remplissage with the Latarjet procedure in patients with subcritical bone loss (STABLE): study protocol. Pilot Feasibility Stud 2022; 8:20. [PMID: 35101120 PMCID: PMC8802453 DOI: 10.1186/s40814-022-00987-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 01/20/2022] [Indexed: 12/28/2022] Open
Abstract
Abstract
Introduction
Anterior dislocations, the most common type of shoulder dislocation, are often complicated by subsequent instability. With recurrent dislocations there often is attrition of the labrum and progressive loss of the anterior bony contour of the glenoid. Treatment options for this pathology involve either soft tissue repair or bony augmentation procedure. The optimal management remains unknown and current clinical practice is highly varied.
Methods and analysis
The Shoulder instability Trial comparing Arthroscopic stabilization Benefits compared with Latarjet procedure Evaluation (STABLE) is an ongoing multi-centre, pilot randomized controlled trial of 82 patients who have been diagnosed with recurrent anterior shoulder instability and subcritical glenoid bone loss. Patients are randomized to either soft tissue repair (Bankart + Remplissage) or bony augmentation (Latarjet procedure). The primary outcome for this pilot is to assess trial feasibility and secondary outcomes include recurrent instability as well as functional outcomes up to two years post-operatively.
Conclusions
This trial will help to identify the optimal treatment for patients with recurrent shoulder instability with a focus on determining which treatment option results in reduced risk of recurrent dislocation and improved patient outcomes. Findings from this trial will guide clinical practice and improve care for patients with shoulder instability.
Trial registration
This study has been registered on http://www.ClinicalTrials.gov with the following identifier: ClinicalTrials.gov Identifier: NCT03585491, registered 13 July 2018, https://www.clinicaltrials.gov/ct2/show/NCT03585491?term=NCT03585491&draw=2&rank=1.
Ethics and dissemination
This study has ethics approval from the McMaster University/Hamilton Health Sciences Research Ethics Board (REB) (approval #4942). Successful completion will significantly impact the global management of patients with recurrent instability. This trial will develop a network of collaboration for future high-quality trials in shoulder instability.
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Tat J, Crawford J, Chong J, Powell T, Fevens TG, Popa T, Martineau PA. Three-Dimensional (3D) Animation and Calculation for the Assessment of Engaging Hill-Sachs Lesions With Computed Tomography 3D Reconstruction. Arthrosc Sports Med Rehabil 2021; 3:e89-e96. [PMID: 33615252 PMCID: PMC7879177 DOI: 10.1016/j.asmr.2020.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/06/2020] [Indexed: 11/16/2022] Open
Abstract
Purpose To dynamically assess for Hill-Sachs engagement with animated 3-dimensional (3D) shoulder models. Methods We created 3D shoulder models from reconstructed computed tomography (CT) images from a consecutive series of patients with recurrent anterior dislocation. They were divided into 2 groups based on the perceived Hill-Sachs severity. For our cohort of 14 patients with recurrent anterior dislocation, 4 patients had undergone osteoarticular allografting of Hill-Sachs lesions and 10 control patients had undergone CT scanning to quantify bone loss but no treatment for bony pathology. A biomechanical analysis was performed to rotate each 3D model using local coordinate systems to the classical vulnerable position of the shoulder (abduction = 90°, external rotation = 0-135°) and through a functional range. A Hill-Sachs lesion was considered "dynamically" engaging if the angle between the lesion's long axis and anterior glenoid was parallel. Results: In the vulnerable position of the shoulder, none of the Hill-Sachs lesions aligned with the anterior glenoid in any of our patients. However, in our simulated physiological shoulder range, all allograft patients and 70% of controls had positions producing alignment. Conclusions The technique offers a visual representation of an engaging Hill-Sachs using 3D-animated reconstructions with open-source software and CT images. In our series of patients, we found multiple shoulder positions that align the Hill-Sachs and glenoid axes that do not necessarily meet the traditional definition of engagement. Identifying all shoulder positions at risk of "engaging," in a broader physiological range, may have critical implications toward selecting the appropriate surgical management of bony defects. Level of Evidence level III, case-control study.
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Affiliation(s)
- Jimmy Tat
- Division of Orthopedic Surgery, University of Toronto, Toronto, Ontario
- Address correspondence to Jimmy Tat, M.D., M.Sc., University of Toronto, 149 College St., Toronto, ON M5T 1P5.
| | - Jordan Crawford
- Department of Radiology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jaron Chong
- Department of Computer Science and Software Engineering, Concordia University, Montreal, Quebec, Canada
| | - Tom Powell
- Department of Radiology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Thomas G. Fevens
- Department of Computer Science and Software Engineering, Concordia University, Montreal, Quebec, Canada
| | - Tiberiu Popa
- Department of Computer Science and Software Engineering, Concordia University, Montreal, Quebec, Canada
| | - Paul A. Martineau
- Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
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11
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Wolfe JA, Elsenbeck M, Nappo K, Christensen D, Waltz R, LeClere L, Dickens JF. Effect of Posterior Glenoid Bone Loss and Retroversion on Arthroscopic Posterior Glenohumeral Stabilization. Am J Sports Med 2020; 48:2621-2627. [PMID: 32813547 DOI: 10.1177/0363546520946101] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Posterior glenohumeral instability is an increasingly recognized cause of shoulder instability, but little is known about the incidence or effect of posterior glenoid bone loss. PURPOSE To determine the incidence, characteristics, and failure rate of posterior glenoid deficiency in shoulders undergoing isolated arthroscopic posterior shoulder stabilization. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS All patients undergoing isolated posterior labral repair and glenoid-based capsulorrhaphy with suture anchors between 2008 and 2016 at a single institution were identified. Posterior bone deficiency was calculated per the best-fit circle method along the inferior two-thirds of the glenoid by 2 independent observers. Patients were divided into 2 groups: minimal (0%-13.5%) and moderate (>13.5%) posterior bone loss. The primary outcome was reoperation for any reason. The secondary outcomes were military separation and placement on permanent restricted duty attributed to the operative shoulder. RESULTS A total of 66 shoulders met the inclusion criteria, with 10 going on to reoperation after a median follow-up of 16 months (range, 14-144 months). Of the total shoulders, 86% (57/66) had ≤13.5% bone loss and 14% (9/66) had >13.5%. Patients with moderate posterior glenoid bone loss had significantly greater retroversion (-11.5° vs -4.3°; P = .01). Clinical failure requiring reoperation was seen in 10.5% of patients in the minimal bone deficiency group and 44.4% in the moderate group (P = .024). There was no difference between groups in rate of military separation or restricted duty. Patients with moderate posterior glenoid bone deficiency were more likely to be experiencing instability instead of pain on initial presentation (P < .001), were more likely to have a positive Jerk test result (P = .05), and had increased glenoid retroversion (P = .01). CONCLUSION In shoulders with moderate glenoid bone deficiency (>13.5%) and increased glenoid retroversion, posterior capsulolabral repair alone may result in higher reoperation rates than in shoulders without bone deficiency.
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Affiliation(s)
- Jared A Wolfe
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.,Uniformed University of the Health Sciences, Bethesda, Maryland, USA
| | - Michael Elsenbeck
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.,Uniformed University of the Health Sciences, Bethesda, Maryland, USA
| | - Kyle Nappo
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.,Uniformed University of the Health Sciences, Bethesda, Maryland, USA
| | - Daniel Christensen
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.,Uniformed University of the Health Sciences, Bethesda, Maryland, USA
| | - Robert Waltz
- Naval Health Clinic Annapolis, United States Naval Academy, Annapolis, Maryland, USA
| | - Lance LeClere
- Naval Health Clinic Annapolis, United States Naval Academy, Annapolis, Maryland, USA
| | - Jonathan F Dickens
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.,John A. Feagin Jr Sports Medicine Fellowship, West Point, New York, USA
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12
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Bois AJ, Mayer MJ, Fening SD, Jones MH, Miniaci A. Management of bone loss in recurrent traumatic anterior shoulder instability: a survey of North American surgeons. JSES Int 2020; 4:574-583. [PMID: 32939489 PMCID: PMC7479034 DOI: 10.1016/j.jseint.2020.04.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Management of bone loss in recurrent traumatic anterior shoulder instability remains a topic of debate and controversy in the orthopedic community. The purpose of this study was to survey members of 4 North American orthopedic surgeon associations to assess management trends for bone loss in recurrent anterior shoulder instability. Methods An online survey was distributed to all members of the American Shoulder and Elbow Surgeons, American Orthopaedic Society for Sports Medicine, and Canadian Orthopaedic Association and to fellow members of the Arthroscopy Association of North America. The survey comprised 3 sections assessing the demographic characteristics of survey respondents, the influence of prognostic factors on surgical decision making, and the operative management of 12 clinical case scenarios of varying bone loss that may be encountered in clinical practice. Results A total of 150 survey responses were returned. The age of the patient and quantity of bone loss were consistently considered important prognostic criteria. However, little consensus was reached for critical thresholds of bone loss and how this affected the timing (ie, primary or revision surgery) and type of bony augmentation procedure to be performed once a critical threshold was reached, especially in the context of critical humeral and bipolar bone loss. Conclusions Consistent trends were found for the management of recurrent anterior shoulder instability in cases in which no bone loss existed and when isolated critical glenoid bone loss was present. However, inconsistencies were observed when isolated critical humeral bone loss and bipolar bone loss were present.
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Affiliation(s)
- Aaron J Bois
- Section of Orthopaedic Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - Michelle J Mayer
- Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - Stephen D Fening
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - Morgan H Jones
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Anthony Miniaci
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
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13
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Provencher MT, Peebles LA, Dekker TJ, Aman ZS, Kennedy MI. Assessment of Bone Loss in the Shoulder. OPER TECHN SPORT MED 2019. [DOI: 10.1053/j.otsm.2019.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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14
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Meraner D, Smolen D, Sternberg C, Thallinger C, Hahne J, Leuzinger J. 10 Years of Arthroscopic Latarjet Procedure: Outcome and Complications. Indian J Orthop 2019; 53:102-110. [PMID: 30905989 PMCID: PMC6394195 DOI: 10.4103/ortho.ijortho_273_17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The treatment of anterior glenohumeral instability with a Bankart repair combined with a capsular plication is a frequently used arthroscopic technique. Latarjet created an open bone block procedure in 1954 for the treatment of anteroinferior glenohumeral instability. This procedure has been further developed by Lafosse in 2003 for arthroscopic surgery. The aim of this study is to evaluate the clinical outcome and complications of the latter procedure, most notably infection rate and nerve damage. MATERIALS AND METHODS 132 shoulders (106 males/19 females, 68 right/64 left) were included in this retrospective study. Patients were included if treatment was performed for anterior instability and if the patient's instability severity index score was at least 4, or if a revision procedure was performed after a prior unsuccessful arthroscopic or open capsule and labral repair. Treatment included the arthroscopic transfer of the coracoid process for the anterior stabilization of the shoulder joint. The disabilities of the arm, shoulder, and hand score were evaluated postoperatively in 76 patients and compared with the results found in the literature. Mean followup was 20.1 [±14.09] months. RESULTS The rate of recurrent glenohumeral instability which needed revision surgery after the arthroscopic Latarjet procedure was 6.1% (n = 8). There were no severe neurovascular complications seen in our cohort. In 32 cases, re-operation was performed due to subjective discomfort because of screw impingement or postoperative shoulder stiffness. CONCLUSION The all-arthroscopic Latarjet procedure developed by Lafosse is a valid and reliable method for the treatment of shoulder instability. Our favorable results indicating that this procedure can prevent chronic shoulder luxation are repeatable, and the rate of postoperative recurrence is low.
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Affiliation(s)
- Dominik Meraner
- Orthopaedic Department, Shoulder Team, Orthopaedic Hospital Speising – Vienna, Austria,Address for correspondence: Dr. Dominik Meraner, Speisinger Strasse 109, 1130 Vienna, Austria. E-mail:
| | - Daniel Smolen
- Department of ShoulderTeam, Etzelclinic, Center for Minimally Invasive Surgery, 8808 Pfäffikon, Switzerland
| | - Christoph Sternberg
- Department of ShoulderTeam, Etzelclinic, Center for Minimally Invasive Surgery, 8808 Pfäffikon, Switzerland
| | - Christoph Thallinger
- Orthopaedic Department, Shoulder Team, Orthopaedic Hospital Speising – Vienna, Austria
| | - Julia Hahne
- Center of Orthopaedic Excellence, Orthopaedic Hospital Speising-Vienna, 1130 Vienna, Austria
| | - Jan Leuzinger
- Department of ShoulderTeam, Etzelclinic, Center for Minimally Invasive Surgery, 8808 Pfäffikon, Switzerland
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15
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Long Head of Biceps Tendon Transfer for Anterior Shoulder Instability. TECHNIQUES IN SHOULDER AND ELBOW SURGERY 2018. [DOI: 10.1097/bte.0000000000000153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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16
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Knapik DM, Cumsky J, Tanenbaum JE, Voos JE, Gillespie RJ. Differences in Coracoid and Glenoid Dimensions Based on Sex, Race, and Age: Implications for Use of the Latarjet Technique in Glenoid Reconstruction. HSS J 2018; 14:238-244. [PMID: 30258327 PMCID: PMC6148576 DOI: 10.1007/s11420-018-9618-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/30/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The Latarjet procedure restores shoulder stability through reconstruction of the glenoid arc. Prior investigations of glenoid and coracoid dimensions have been underpowered to detect differences based on sex and race. QUESTIONS/PURPOSES We sought to establish normative values for glenoid width and coracoid dimensions based on sex, race, and age. In addition, we assessed the restoration of glenoid dimensions using the classic and modified Latarjet techniques (classic technique: placing lateral surface of the coracoid to the glenoid; modified technique: placing inferior surface of the coracoid to the glenoid). METHODS A total of 993 cadaveric specimens (n = 1986 scapulae) from people over 18 years of age at the time of death were analyzed. Measurements of maximal glenoid width, coracoid width, thickness, and length were recorded. Statistical analysis was performed to detect differences based on sex and race, while univariable linear regression was used to determine the association of increasing age on measured dimensions. RESULTS All dimensions of specimens were significantly larger in males than in females. Caucasians possessed larger mean glenoid width, coracoid width, and coracoid length, while coracoid thickness was significantly larger in African Americans. Linear regression analysis found that increasing age was associated with increased glenoid width and coracoid dimensions. Coracoid positioning restored glenoid width in defects measuring 20% of glenoid width using both classic and modified Latarjet techniques, while defects measuring up to 25% were more accurately reproduced using the modified technique. CONCLUSION Dimensions were significantly larger in males and in Caucasians, aside from coracoid thickness. Mean dimensions increased with advancing age. Coracoid positioning using classic or modified Latarjet techniques restored glenoid width defects measuring 20% of the glenoid width, while the modified technique allowed for restoration of larger defects.
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Affiliation(s)
- Derrick M. Knapik
- University Hospitals Sports Medicine Institute, 11100 Euclid Ave., Hanna House 5043, Cleveland, OH 44106 USA ,School of Medicine, Case Western Reserve University, Cleveland, OH USA
| | - Jameson Cumsky
- University Hospitals Sports Medicine Institute, 11100 Euclid Ave., Hanna House 5043, Cleveland, OH 44106 USA ,School of Medicine, Case Western Reserve University, Cleveland, OH USA
| | - Joseph E. Tanenbaum
- University Hospitals Sports Medicine Institute, 11100 Euclid Ave., Hanna House 5043, Cleveland, OH 44106 USA ,School of Medicine, Case Western Reserve University, Cleveland, OH USA
| | - James E. Voos
- University Hospitals Sports Medicine Institute, 11100 Euclid Ave., Hanna House 5043, Cleveland, OH 44106 USA ,School of Medicine, Case Western Reserve University, Cleveland, OH USA
| | - Robert J. Gillespie
- University Hospitals Sports Medicine Institute, 11100 Euclid Ave., Hanna House 5043, Cleveland, OH 44106 USA ,School of Medicine, Case Western Reserve University, Cleveland, OH USA
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17
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Harmsen K, Huijsmans PE. Management of Glenoid Defects in Anterior Shoulder Instability: A Review of Current Concepts. Open Orthop J 2018; 11:934-945. [PMID: 29403566 PMCID: PMC5780676 DOI: 10.2174/1874325001711010934] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 10/22/2016] [Accepted: 10/28/2016] [Indexed: 11/24/2022] Open
Abstract
Background: Bone defects of the glenoid are often found in patients with traumatic
anterior glenohumeral instability. There is no consensus regarding which
glenoid defects need to be treated surgically. The aim of this review is to
describe the management of glenoid defects in anterior shoulder instability
in patients with traumatic anterior glenohumeral instability. Methods: We conducted a review of the literature through a Pubmed search. Results: The management of glenoid defects in anterior shoulder instability consists
of conservative or operative treatment. There is a wide variety in the
treatment options. Also, the diagnostics of the presence and size of a
glenoid bone defect is still debated on in literature. Conclusion: Based on the current available literature, we advise to begin management of
traumatic anterior shoulder instability combined with glenoid defects with
conservative treatment. Operative treatment can be used when the bone
fragment consists of a large glenoid surface and the patient is active, or
in the case of a chronic defect or recurrent instability.
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Affiliation(s)
- Kennard Harmsen
- Department of Orthopaedics, Haga Hospital, Sportlaan 600, 2566 MJ, The Hague, The Netherlands
| | - Polydoor E Huijsmans
- Department of Orthopaedics, Haga Hospital, Sportlaan 600, 2566 MJ, The Hague, The Netherlands
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18
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Abstract
PURPOSE OF REVIEW Injuries to the labrum, joint capsule (in particular the inferior glenohumeral ligament), cartilage, and glenoid periosteum are associated with anterior shoulder instability. The goal of this review is to provide common radiographic images and findings in patients with anterior shoulder instability. Furthermore, we will demonstrate the best methods for measuring anterior glenoid bone loss. RECENT FINDINGS Magnetic resonance (MR) imaging is highly relied upon for evaluating anterior shoulder instability and can diagnose soft tissue injuries with high sensitivity. While 3D computed tomography (CT) scan has been considered the optimal tool for evaluating osseous defects, certain MR imaging sequences have been shown to have similar diagnostic accuracy. Repair of Bankart lesions is critical to stabilizing the shoulder, and in the recent years, there has been an increasing focus on imaging to accurately characterize and measure glenoid bone loss to properly indicate patients for either arthroscopic repair or anterior bony reconstruction. Furthermore, Hill-Sachs lesions are commonly seen with shoulder instability, and importance must be placed on measuring the size and depth of these lesions along with possible engagement, as these factors will dictate management. The labral-ligamentous complex and rotator cuff are primary stabilizers of the shoulder. With anterior shoulder instability, the labrum is frequently injured. MRI with an arthrogram or provocative maneuvers is the gold standard for diagnosis. Various imaging modalities and methods can be performed to identify and measure Bankart and Hill-Sachs lesions, which can then be used for surgical planning and treating shoulder instability.
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19
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Baudi P, Rebuzzi M, Matino G, Catani F. Imaging of the Unstable Shoulder. Open Orthop J 2017; 11:882-896. [PMID: 29114335 PMCID: PMC5646151 DOI: 10.2174/1874325001711010882] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 10/22/2016] [Accepted: 10/28/2016] [Indexed: 12/23/2022] Open
Abstract
Background: Unstable shoulder can occur in different clinical scenarios with a broad spectrum of symptoms and presentations: first-time (or recurrent) traumatic acute shoulder anterior dislocation or chronic anterior instability after repeated dislocations. Imaging in unstable shoulder is fundamental for choosing the right treatment preventing recurrence. The goal of imaging depends on clinical scenario and patient characteristics. Method: Careful selection and evaluation of the imaging procedures is therefore essential to identify, characterize and quantify the lesions. Proper imaging in unstable shoulder cases is critical to the choice of treatment to prevent recurrence, and to plan surgical intervention. Results: In acute setting, radiographs have to roughly detect and characterize the bone defects present. At about 7 days, it is recommended to perform a MR to demonstrate lesions to labrum and/or ligaments and bone defects: in acute setting, the MRA is not necessary, because of effusion and hemarthrosis that behave as the contrast medium. In recurrence, it is fundamental not only to detect lesions but characterize them for planning the treatment. The first study to do is the MRI (with a magnetic field of at least 1.5 Tesla), and if possible MRA, above all in younger patients. Then, on the basis of the pathologic findings as bipolar lesion or severity of bone defects, CT can be performed. PICO method on 2D or 3D CT is helpful if you need to study a glenoid bone loss, with the “en face view” of glenoid, while a 3D CT reconstruction with the humeral head “en face view” is the gold standard to assess an Hill-Sachs lesion. Conclusion: The clinical diagnoses of anterior shoulder instability can be different and acknowledgement of imaging findings is essential to guide the treatment choice. Imaging features are quite different in chronic than in acute scenario. This requires appropriate indications of many different imaging techniques.
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Affiliation(s)
- Paolo Baudi
- Department of Othopaedics and Traumatology Modena and Reggio Emilia University - Modena Hospital - Italy Via del Pozzo, 71 - 41124 Modena (Italy)
| | - Manuela Rebuzzi
- Department of Othopaedics and Traumatology Piacenza Hospital - Italy Via Taverna, 49 - 29121 Piacenza (Italy)
| | - Giovanni Matino
- Department of Othopaedics and Traumatology Modena and Reggio Emilia University - Modena Hospital - Italy Via del Pozzo, 71 - 41124 Modena (Italy)
| | - Fabio Catani
- Department of Othopaedics and Traumatology Modena and Reggio Emilia University - Modena Hospital - Italy Via del Pozzo, 71 - 41124 Modena (Italy)
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20
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Zhu Y, Jiang C, Song G. Arthroscopic Versus Open Latarjet in the Treatment of Recurrent Anterior Shoulder Dislocation With Marked Glenoid Bone Loss: A Prospective Comparative Study. Am J Sports Med 2017; 45:1645-1653. [PMID: 28351205 DOI: 10.1177/0363546517693845] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Very few studies have compared open Latarjet versus arthroscopic Latarjet procedures. PURPOSE To compare the clinical and computed tomographic outcomes between open and arthroscopic Latarjet procedures. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A prospective, comparative study was performed. The open Latarjet group included 44 patients, and the arthroscopic Latarjet group included 46 patients. All patients had more than 2 years of clinical follow-up (range of motion, American Shoulder and Elbow Surgeons [ASES] score, Constant-Murley score, and Rowe score). The position of the transferred coracoid, the screw orientation, and graft resorption were evaluated on computed tomography (CT) scan. RESULTS The surgery time for the open group was significantly shorter than that for the arthroscopic group ( P = .003). No recurrent dislocation occurred in either group. The apprehension test was negative in all patients in both groups. At the final follow-up, no significant difference was detected between the open group and the arthroscopic group regarding any of the clinical outcome measurements. The transferred coracoid graft was level with the glenoid in all patients in both groups. The open group had better position in the superior-inferior direction compared with the arthroscopic group ( P < .001). No significant difference was found in screw orientation between the 2 groups ( P = .102). At 1 year after surgery, patients in the arthroscopic group had significantly less resorption compared with patients in the open group ( P = .044). CONCLUSION Both procedures are effective for the treatment of recurrent anterior shoulder dislocation with marked glenoid bone loss. The open group had better position in the superior-inferior direction compared with the arthroscopic group. At 1 year after surgery, patients in the arthroscopic Latarjet group showed notably less graft resorption compared with patients in the open Latarjet group.
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Affiliation(s)
- Yiming Zhu
- Shoulder Service, Beijing Ji Shui Tan Hospital, School of Medicine, Peking University, Beijing, China
| | - Chunyan Jiang
- Shoulder Service, Beijing Ji Shui Tan Hospital, School of Medicine, Peking University, Beijing, China
| | - Guanyang Song
- Shoulder Service, Beijing Ji Shui Tan Hospital, School of Medicine, Peking University, Beijing, China
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21
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Patel RM, Miniaci A. Editorial Commentary: Distal Tibia Allograft as an Option for Glenoid Reconstruction in Recurrent Shoulder Instability-It's All About the Bone? Arthroscopy 2017; 33:898-901. [PMID: 28476368 DOI: 10.1016/j.arthro.2017.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 01/07/2017] [Accepted: 01/25/2017] [Indexed: 02/02/2023]
Abstract
Bony defects in recurrent shoulder instability can lead to the failure of soft tissue reconstruction. Many techniques have been developed to address glenoid defects in an attempt to prevent recurrent instability. However, the high complication rates with the Latarjet procedure have led surgeons to identify other sources of bone graft, including the distal tibia allograft (DTA). The DTA appears to be a suitable option for anterior glenoid reconstruction, highlighting the importance of reconstructing all bony defects and the versatility and efficacy of allograft bone blocks.
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22
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Jacquot F, Zbili D, Feron JM, Sautet A, Doursounian L, Masquelet AC. Balloon humeroplasty reconstruction for acute Hill-Sachs injury: A technical note. HAND SURGERY & REHABILITATION 2016; 35:250-254. [PMID: 27781987 DOI: 10.1016/j.hansur.2016.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Revised: 07/01/2016] [Accepted: 07/04/2016] [Indexed: 10/21/2022]
Abstract
Posterior Hill-Sachs humeral defects are present in 80% to 100% of cases of anterior shoulder dislocation and are a factor in recurrent instability. Several techniques have been described to fill the defect and avoid recurrence. We developed a percutaneous technique to fill the newly created defect in which a percutaneous balloon, analogous to the one used in vertebral kyphoplasty, is used to reduce the defect, which is then filled with calcium phosphate cement. One patient with an acute anterior dislocation of the shoulder with no previous history was treated using this method. Early imaging results showed adequate reduction of the defect and no cement resorption. The patient was followed for 12 months; he had normal function of the shoulder and no recurrent dislocation. Shoulder computed tomography (CT) arthrography with contrast after 3 months showed an intact capsule and no recurrence of the defect. While this technique is certainly in its infancy, we have demonstrated that emergency reduction of the defect in acute first occurrence anterior shoulder dislocation is feasible, helps to restore normal anatomy of the humeral head and leads to good clinical results. Whether it can improve clinical results and prevent recurrent shoulder dislocation remains to be evaluated.
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Affiliation(s)
- F Jacquot
- Hôpital Saint-Antoine, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France.
| | - D Zbili
- Hôpital Saint-Antoine, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - J-M Feron
- Hôpital Saint-Antoine, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - A Sautet
- Hôpital Saint-Antoine, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - L Doursounian
- Hôpital Saint-Antoine, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - A-C Masquelet
- Hôpital Saint-Antoine, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
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23
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Mohammed H, Skalski MR, Patel DB, Tomasian A, Schein AJ, White EA, Hatch GFR, Matcuk GR. Coracoid Process: The Lighthouse of the Shoulder. Radiographics 2016; 36:2084-2101. [PMID: 27471875 DOI: 10.1148/rg.2016160039] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The coracoid process is a hook-shaped bone structure projecting anterolaterally from the superior aspect of the scapular neck. Surgeons often refer to the coracoid process as the "lighthouse of the shoulder" given its proximity to major neurovascular structures such as the brachial plexus and the axillary artery and vein, its role in guiding surgical approaches, and its utility as a landmark for other important structures in the shoulder. The coracoid also serves as a critical anchor for many tendinous and ligamentous attachments. These include the tendons of the pectoralis minor, coracobrachialis, and short head of the biceps brachii muscles, and the coracoclavicular, coracohumeral, coracoacromial, and transverse scapular ligaments. Consequently, the coracoid and its associated structures are linked to numerous shoulder pathologic conditions. This article will detail the anatomy of the coracoid and its associated structures and review the clinical and radiologic findings of corresponding pathologic conditions in this region with original illustrations and multimodality imaging examples. Highlighted in this article are the coracoclavicular joint, the classification and management of coracoid fractures, subcoracoid impingement, the coracoacromial arch and subacromial impingement, the coracohumeral ligament and the biceps pulley, the coracoclavicular ligament and its surgical reconstruction, adhesive capsulitis, the suprascapular notch and suprascapular notch impingement, subcoracoid bursitis, coracoid transfer procedures, and coracoid tumors. A brief summary of the pathophysiology, potential causes, and management options for each of the pathologic entities will also be discussed. ©RSNA, 2016.
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Affiliation(s)
- Hussan Mohammed
- From the Departments of Radiology (H.M., D.B.P., A.T., A.J.S., E.A.W., G.R.M.) and Orthopaedic Surgery (G.F.R.H.), Keck School of Medicine, University of Southern California, 1500 San Pablo St, 2nd Floor Imaging, Los Angeles, CA 90033-5313; and Department of Radiology, Southern California University of Health Sciences, Whittier, Calif (M.R.S.)
| | - Matthew R Skalski
- From the Departments of Radiology (H.M., D.B.P., A.T., A.J.S., E.A.W., G.R.M.) and Orthopaedic Surgery (G.F.R.H.), Keck School of Medicine, University of Southern California, 1500 San Pablo St, 2nd Floor Imaging, Los Angeles, CA 90033-5313; and Department of Radiology, Southern California University of Health Sciences, Whittier, Calif (M.R.S.)
| | - Dakshesh B Patel
- From the Departments of Radiology (H.M., D.B.P., A.T., A.J.S., E.A.W., G.R.M.) and Orthopaedic Surgery (G.F.R.H.), Keck School of Medicine, University of Southern California, 1500 San Pablo St, 2nd Floor Imaging, Los Angeles, CA 90033-5313; and Department of Radiology, Southern California University of Health Sciences, Whittier, Calif (M.R.S.)
| | - Anderanik Tomasian
- From the Departments of Radiology (H.M., D.B.P., A.T., A.J.S., E.A.W., G.R.M.) and Orthopaedic Surgery (G.F.R.H.), Keck School of Medicine, University of Southern California, 1500 San Pablo St, 2nd Floor Imaging, Los Angeles, CA 90033-5313; and Department of Radiology, Southern California University of Health Sciences, Whittier, Calif (M.R.S.)
| | - Aaron J Schein
- From the Departments of Radiology (H.M., D.B.P., A.T., A.J.S., E.A.W., G.R.M.) and Orthopaedic Surgery (G.F.R.H.), Keck School of Medicine, University of Southern California, 1500 San Pablo St, 2nd Floor Imaging, Los Angeles, CA 90033-5313; and Department of Radiology, Southern California University of Health Sciences, Whittier, Calif (M.R.S.)
| | - Eric A White
- From the Departments of Radiology (H.M., D.B.P., A.T., A.J.S., E.A.W., G.R.M.) and Orthopaedic Surgery (G.F.R.H.), Keck School of Medicine, University of Southern California, 1500 San Pablo St, 2nd Floor Imaging, Los Angeles, CA 90033-5313; and Department of Radiology, Southern California University of Health Sciences, Whittier, Calif (M.R.S.)
| | - George F Rick Hatch
- From the Departments of Radiology (H.M., D.B.P., A.T., A.J.S., E.A.W., G.R.M.) and Orthopaedic Surgery (G.F.R.H.), Keck School of Medicine, University of Southern California, 1500 San Pablo St, 2nd Floor Imaging, Los Angeles, CA 90033-5313; and Department of Radiology, Southern California University of Health Sciences, Whittier, Calif (M.R.S.)
| | - George R Matcuk
- From the Departments of Radiology (H.M., D.B.P., A.T., A.J.S., E.A.W., G.R.M.) and Orthopaedic Surgery (G.F.R.H.), Keck School of Medicine, University of Southern California, 1500 San Pablo St, 2nd Floor Imaging, Los Angeles, CA 90033-5313; and Department of Radiology, Southern California University of Health Sciences, Whittier, Calif (M.R.S.)
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Taverna E, Garavaglia G, Ufenast H, D'Ambrosi R. Arthroscopic treatment of glenoid bone loss. Knee Surg Sports Traumatol Arthrosc 2016; 24:546-556. [PMID: 26658567 DOI: 10.1007/s00167-015-3893-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 11/19/2015] [Indexed: 01/19/2023]
Abstract
Recurrent anterior instability of the glenohumeral joint has long been an arduous problem to solve surgically, owing to its difficulty to the need to restore both osseous and dynamic constraints in the unstable shoulder. Biomechanical studies have indicated that glenoid bone loss shortens the safe arc through which the glenoid can resist axial forces; in these cases, a soft tissue repair alone may be insufficient to maintain stability. Clinical studies have confirmed that major bone loss is associated with an unfavourable outcome. The benefits of using arthroscopic procedures for surgical stabilization of the shoulder include smaller incisions and less soft tissue dissection, better access for repair and, potentially, the maximum respect for the undamaged anatomical structures. The biggest disadvantage of arthroscopic procedures until recently was the inability to successfully treat a significant bone defect. Over the last 10 years, several new arthroscopic techniques have been developed, providing new surgical options for successfully treating soft tissues and bony lesions in anterior-inferior glenohumeral instability. Level of evidence V.
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Affiliation(s)
- Ettore Taverna
- U.O. Chirurgia della Spalla II, Istituto Ortopedico Galeazzi, Milan, Italy
| | - Guido Garavaglia
- Upper Limb Unit, Department of Surgery, OBV, Mendrisio, Switzerland
| | - Henri Ufenast
- Upper Limb Unit, Department of Surgery, OBV, Mendrisio, Switzerland
| | - Riccardo D'Ambrosi
- U.O. Chirurgia della Spalla II, Istituto Ortopedico Galeazzi, Milan, Italy.
- Universtià degli Studi di Milano, Milan, Italy.
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Arthroscopic "Remplissage" for shoulder instability: a systematic review. Knee Surg Sports Traumatol Arthrosc 2016; 24:578-84. [PMID: 24497056 DOI: 10.1007/s00167-014-2881-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 01/24/2014] [Indexed: 12/15/2022]
Abstract
PURPOSE Large Hill-Sachs lesions engaging the glenoid rim predispose to recurrent anterior instability and failure of isolated labrum repairs. In arthroscopic remplissage, the posterior capsule and infraspinatus are sutured into the humeral defect to limit such engagement. This systematic review assessed the outcomes and complications of arthroscopic remplissage for anterior shoulder instability. METHODS A search of the MEDLINE, EMBASE and evidence-based medicine Cochrane databases was conducted. Data were extracted by two reviewers in a standardised manner. Redislocation, instability and complication rates were calculated and expressed as percentages with 95 % confidence intervals. RESULTS Of 4,284 studies identified, eight articles with a total of 207 patients were analysed. Mean redislocation rate was 4.2 ± 3.9 % (range 0-15 %), and mean recurrent instability rate 3.2 ± 3.8 % (0-15 %). Posterosuperior shoulder pain and stiffness were the only complications described. Overall, there was a mean reduction in external rotation in adduction of 5.6° (-40 to +30), reduction in external rotation in abduction of 11.3° (-50 to +7) and reduction in internal rotation of 0.9 (-4 to 0) vertebral levels. CONCLUSIONS Arthroscopic remplissage alongside anterior labrum repair seems successful in treating recurrent shoulder instability in the presence of large or engaging Hill-Sachs lesion. However, the available literature consists mainly of heterogeneous case series. There is a need for a high-quality randomised trial to compare remplissage with other commonly used techniques for recurrent instability associated with substantial Hill-Sachs defects such as the Latarjet procedure. LEVEL OF EVIDENCE Systematic review, Level IV.
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McLaughlin RJ, Miniaci A, Jones MH. Bony Versus Soft Tissue Reconstruction for Anterior Shoulder Instability: An Expected Value Decision Analysis. Orthop J Sports Med 2016; 3:2325967115618161. [PMID: 26779552 PMCID: PMC4710124 DOI: 10.1177/2325967115618161] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background: One complication of anteroinferior glenohumeral shoulder dislocation is a critical bone defect that requires surgical repair to prevent recurrent instability. However, controversy exists regarding the surgical management because both open and arthroscopic surgeries have respective advantages and disadvantages. Moreover, it is difficult to determine the patient’s preferred treatment, as factors that influence treatment choice include recurrence rates, morbidity of the procedures, and patient preferences. Hypothesis: Patients who have a higher probability of recurrent instability after arthroscopic surgery will select open surgery whereas patients with a lower probability of recurrent instability after arthroscopic surgery will favor arthroscopy. Study Design: Economic and decision analysis; Level of evidence, 2. Methods: A decision tree was constructed to model each hypothetical outcome after open or arthroscopic surgery for glenohumeral instability in patients with bone defects. A literature review was performed to determine the probability of occurrence for each node while utility values for each outcome were obtained via patient-administered surveys given to 50 patients without prior history of shoulder injury or dislocation. Fold-back analysis was then performed to show the optimal treatment strategy. Finally, sensitivity analysis established the thresholds at which open treatment becomes the optimal treatment. Results: The ultimate expected value—the objective evaluation of all potential outcomes after choosing either open or arthroscopic surgery—was found to be greater for arthroscopic surgery than for open surgery (87.17 vs 81.64), indicating it to be the preferred treatment. Results of sensitivity analysis indicated that open surgery becomes the preferred treatment when probability of recurrence after arthroscopic treatment is ≥23.8%, although varying the utility, defined as an aggregate patient preference for a particular outcome, has no effect on the model. When the rate of no complication after open surgery is 97.6%, open surgery becomes the patient’s preferred treatment. Conclusion: Arthroscopic surgery is an acceptable treatment if recurrent instability occurs consistently at ≤23.8%. This has important implications given the technical difficulty of successfully performing arthroscopic fixation to resolve recurrent anteroinferior glenohumeral dislocations associated with critical osseous defects. However, due to a lack of clinical outcomes studies, more research is needed to better predict the optimal operative treatment.
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The lateral femoral notch sign following ACL injury: frequency, morphology and relation to meniscal injury and sports activity. Knee Surg Sports Traumatol Arthrosc 2015; 23:2250-2258. [PMID: 24797811 DOI: 10.1007/s00167-014-3022-5] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 04/19/2014] [Indexed: 12/22/2022]
Abstract
PURPOSE The purpose of this study was to determine the incidence of the "lateral femoral notch sign" in acute anterior cruciate ligament (ACL) tears and its correlation with lateral meniscal tears. METHODS Lateral plain radiographs and sagittal magnetic resonance images (each performed within 1 month following injury) of 500 patients with acute and arthroscopically confirmed ACL tears were retrospectively evaluated for depth, length and position of the "lateral femoral notch sign". The accompanying bone bruise was measured, as well. The correlation of the lateral femoral notch sign with high-risk and low-risk pivoting activities as well as with a lateral meniscus tear was evaluated. RESULTS A total of 26.4 % of the patients had a lateral femoral notch sign deeper than 2.0 mm with a mean depth of 2.8 ± 0.8 mm SD. All lateral femoral notches were situated near or slightly posterior to Blumensaat's line. ACL injuries sustained during high-risk pivoting sports were more prone to a lateral femoral notch sign than ACL injuries in low-risk pivoting sports (r = 0.107 vs r = -0.107). Of all patients with a lateral femoral notch sign, 40.2 % also had lateral meniscus tears. The correlation between the presence of the lateral femoral notch sign and lateral meniscus tears was statistically significant (p = 0.004). CONCLUSION In more than one-quarter of patients, plain radiographs may help to establish the diagnosis of an ACL tear. Further, a lateral femoral notch sign greater than 2.0 mm also correlates with lateral meniscus tears. Hence, the lateral femoral notch sign is a useful diagnostic tool in daily clinical practice. LEVEL OF EVIDENCE IV.
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Garcia GH, Liu JN, Dines DM, Dines JS. Effect of bone loss in anterior shoulder instability. World J Orthop 2015; 6:421-433. [PMID: 26085984 PMCID: PMC4458493 DOI: 10.5312/wjo.v6.i5.421] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 04/20/2015] [Accepted: 05/06/2015] [Indexed: 02/06/2023] Open
Abstract
Anterior shoulder instability with bone loss can be a difficult problem to treat. It usually involves a component of either glenoid deficiency or a Hill-Sachs lesion. Recent data shows that soft tissue procedures alone are typically not adequate to provide stability to the shoulder. As such, numerous surgical procedures have been described to directly address these bony deficits. For glenoid defects, coracoid transfer and iliac crest bone block procedures are popular and effective. For humeral head defects, both remplissage and osteochondral allografts have decreased the rates of recurrent instability. Our review provides an overview of current literature addressing these treatment options and others for addressing bone loss complicating anterior glenohumeral instability.
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Longo UG, Forriol F, Loppini M, Lanotte A, Salvatore G, Maffulli N, Denaro V. The safe zone for avoiding suprascapular nerve injury in bone block procedures for shoulder instability. A cadaveric study. Knee Surg Sports Traumatol Arthrosc 2015; 23:1506-1510. [PMID: 24531358 DOI: 10.1007/s00167-014-2900-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 02/05/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE The purpose of the study is to identify the safe zone in which the surgeon can place the screws for fixation of the coracoid graft during the Latarjet procedure to avoid injuries of the suprascapular nerve with the shoulder in internal and external rotation. METHODS The dissection on twelve fresh-frozen shoulders was performed according to a standard posterior approach to the gleno-humeral joint. The suprascapular nerve and its branches for the infraspinatus muscle were identified at the spinoglenoid notch region. Then, the distance between the glenoid and the suprascapular nerve at the spinoglenoid notch region was measured by using a ruler with the shoulder at 90° internal rotation and at 90° of external rotation. RESULTS The median distance between the glenoid and the suprascapular nerve was 12 mm (range 6-15 mm) with the shoulder at 90° of internal rotation and 19 mm (range 11-23 mm) with the shoulder at 90° of external rotation. The distance between the glenoid and the suprascapular nerve was statistically significantly greater with the shoulder at 90° of external rotation than 90° of internal rotation (P = 0.002). CONCLUSIONS The suprascapular nerve is furthest away from the glenoid with the shoulder at 90° of external rotation. Therefore, the placement of screws in external rotation of the humerus during glenoid bone block procedures likely reduces the risk of iatrogenic injuries of the suprascapular nerve.
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Affiliation(s)
- Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Rome, Italy.
| | - Francisco Forriol
- Orthopaedic Department, School of Medicine, University CEU Campus de Montepríncipe, 28886, Boadilla del Monte, Madrid, Spain
| | - Mattia Loppini
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Angela Lanotte
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Giuseppe Salvatore
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Nicola Maffulli
- Barts and The London School of Medicine and Dentistry, William Harvey Research Institute, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London, E1 4DG, UK
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Rome, Italy
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Amin NH, Patel RM, Sean Lynch T, Miniaci A. The Evaluation of Hill-Sachs Injuries and the Use of Humeral Head Allograft for Repair of Hill-Sachs and Reverse Hill-Sachs Injuries. OPER TECHN SPORT MED 2015. [DOI: 10.1053/j.otsm.2014.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Shoulder instability is common in military populations, and this demographic represents individuals at high risk for recurrence. Surgical management is often indicated, especially in high-demand young individuals, and provides a predictable return to military duties. Accurate recognition of glenoid bone loss and other associated anatomic lesions is of importance for appropriate selection between arthroscopic capsulolabral repair and bony reconstruction procedures. A thorough understanding of underlying pathology, diagnostic testing, and available treatment options provides for optimal care of the unstable shoulder.
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Affiliation(s)
- Guillaume D Dumont
- Department of Orthopaedic Surgery and Sports Medicine, University of South Carolina School of Medicine, 2 Medical Park, Suite 404, Columbia, SC 29203, USA.
| | - Petar Golijanin
- Sports Medicine Service, Massachusetts General Hospital, 175 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Matthew T Provencher
- Sports Medicine Service, Harvard Medical School, Massachusetts General Hospital, 175 Cambridge Street, Suite 400, Boston, MA 02114, USA
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Abstract
This review discusses the evaluation and management of bone loss in glenohumeral instability. The glenohumeral joint may experience a dislocation or subluxation associated with traumatic injury or through repetitive atraumatic events. Nearly 62% of cases with recurrent dislocation have both Hill-Sachs and bony Bankart defects. Treatment of unstable bone defects may require soft-tissue repair, bone grafting, or both, depending on the size and nature of the defects. The most common treatment is isolated soft-tissue repair, leaving the bone defects untreated, although emerging evidence supports directly addressing these bony defects.
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Boileau P, Thélu CÉ, Mercier N, Ohl X, Houghton-Clemmey R, Carles M, Trojani C. Arthroscopic Bristow-Latarjet combined with bankart repair restores shoulder stability in patients with glenoid bone loss. Clin Orthop Relat Res 2014; 472:2413-24. [PMID: 24942959 PMCID: PMC4079880 DOI: 10.1007/s11999-014-3691-x] [Citation(s) in RCA: 131] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Arthroscopic Bankart repair alone cannot restore shoulder stability in patients with glenoid bone loss involving more than 20% of the glenoid surface. Coracoid transposition to prevent recurrent shoulder dislocation according to Bristow-Latarjet is an efficient but controversial procedure. QUESTIONS/PURPOSES We determined whether an arthroscopic Bristow-Latarjet procedure with concomitant Bankart repair (1) restored shoulder stability in this selected subgroup of patients, (2) without decreasing mobility, and (3) allowed patients to return to sports at preinjury level. We also evaluated (4) bone block positioning, healing, and arthritis and (5) risk factors for nonunion and coracoid screw pullout. METHODS Between July 2007 and August 2010, 79 patients with recurrent anterior instability and bone loss of more than 20% of the glenoid underwent arthroscopic Bristow-Latarjet-Bankart repair; nine patients (11%) were either lost before 2-year followup or had incomplete data, leaving 70 patients available at a mean of 35 months. Postoperative radiographs and CT scans were evaluated for bone block positioning, healing, and arthritis. Any postoperative dislocation or any subjective complaint of occasional to frequent subluxation was considered a failure. Physical examination included ROM in both shoulders to enable comparison and instability signs (apprehension and relocation tests). Rowe and Walch-Duplay scores were obtained at each review. Patients were asked whether they were able to return to sports at the same level and practice forced overhead sports. Potential risk factors for nonhealing were assessed. RESULTS At latest followup, 69 of 70 (98%) patients had a stable shoulder, external rotation with arm at the side was 9° less than the nonoperated side, and 58 (83%) returned to sports at preinjury level. On latest radiographs, 64 (91%) had no osteoarthritis, and bone block positioning was accurate, with 63 (90%) being below the equator and 65 (93%) flush to the glenoid surface. The coracoid graft healed in 51 (73%), it failed to unite in 14 (20%), and graft osteolysis was seen in five (7%). Bone block nonunion/migration did not compromise shoulder stability but was associated with persistent apprehension and less return to sports. Use of screws that were too short or overangulated, smoking, and age higher than 35 years were risk factors for nonunion. CONCLUSIONS The arthroscopic Bristow-Latarjet procedure combined with Bankart repair for anterior instability with severe glenoid bone loss restored shoulder stability, maintained ROM, allowed return to sports at preinjury level, and had a low likelihood of arthritis. Adequate healing of the transferred coracoid process to the glenoid neck is an important factor for avoiding persistent anterior apprehension. LEVEL OF EVIDENCE Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Pascal Boileau
- Department of Orthopaedic Surgery and Sports Traumatology, Hôpital de L'Archet 2, University of Nice Sophia-Antipolis, 151 route de St Antoine de Ginestière, 06202, Nice, France,
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Longo UG, Loppini M, Rizzello G, Romeo G, Huijsmans PE, Denaro V. Glenoid and humeral head bone loss in traumatic anterior glenohumeral instability: a systematic review. Knee Surg Sports Traumatol Arthrosc 2014; 22:392-414. [PMID: 23358575 DOI: 10.1007/s00167-013-2403-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 01/14/2013] [Indexed: 01/23/2023]
Abstract
PURPOSE The aim of this systematic review is to analyze outcomes of surgical procedures for glenoid and/or humeral bony defects, performed singularly or in combination, in patients with traumatic anterior glenohumeral instability. A secondary aim is to establish in clinical settings which percentage of glenoid or humeral bone loss needs to be treated with a bony procedure to avoid recurrence of dislocation. METHODS A systematic review of the literature according to the PRISMA guidelines was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase and Google Scholar databases using various combinations of the keywords "shoulder", "instability", "dislocation", "bone loss", "bony bankart", "osseous glenoid defects", "glenoid bone grafting", "Latarjet", "glenoid", "humeral head", "surgery", "glenohumeral", "Hill Sachs", "Remplissage", over the years 1966-2012 was performed. RESULTS Twenty-seven articles, describing patients with glenoid bony defect, humeral bony defect or both in the setting of traumatic anterior glenohumeral instability, were included. A total of 1,816 shoulders in 1,801 patients were included, with a median age at surgery of 27.1 years, ranging from 12 to 75 years. Patients were assessed at a median follow-up period of 2.8 years (ranging from 6 months to 28.2 years). The overall recurrence of redislocation occurred in 117 (6.5 %) shoulders. The redislocation event occurred in 40 of 553 (7.2 %) shoulders with glenoid bony defect, in 30 of 225 (13.3 %) shoulders with humeral bony defect and in 63 of 1,009 (6.3 %) shoulders with both glenoid and humeral involvement. CONCLUSION Even though the general principle of recognizing and treating glenoid and humeral bone defects in patients with traumatic anterior glenohumeral instability is widely accepted, few studies are available to date to accurately establish which bone defects should be treated with bone procedures and the exact percentage of bone loss leading to higher risk of redislocation in clinical settings.
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Affiliation(s)
- Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy,
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Dubrow S, Noel C, Bell R. Anterior Shoulder Instability Repair and Reconstruction: An Algorithm for Patients with Bone Defects. OPER TECHN SPORT MED 2013. [DOI: 10.1053/j.otsm.2013.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Dumont GD, Brown TS, Russell RD, Robertson WJ. Beyond the peak of the anterior glenoid rim: A cadaveric study. INTERNATIONAL JOURNAL OF SHOULDER SURGERY 2013; 7:14-8. [PMID: 23858290 PMCID: PMC3707331 DOI: 10.4103/0973-6042.109880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
PURPOSE The purpose of this study was to quantify the width of bone beyond the peak of the anterior glenoid rim and to determine if this anatomic region of the glenoid significantly affects measurement of the anteroposterior glenoid diameter. MATERIALS AND METHODS 19 cadaveric scapulae were examined and the width of bone beyond the peak of the anterior glenoid rim was measured. The percent width of this region relative to the anteroposterior diameter of the glenoid was evaluated. Male and female specimens were compared. Measurements of the anteroposterior diameter of the glenoid, both including and excluding this region, were compared. RESULTS The mean width of bone beyond the peak of the anterior glenoid rim was 3.2 ± 0.7 mm, corresponding to 10.5% of the anteroposterior glenoid diameter. This anatomic region is of similar relative size in males and females (11% vs 10% of the glenoid diameter). Measurement of the anteroposterior diameter of the glenoid is significantly different depending on whether this region is included or not (P = 0.0064). CONCLUSIONS There exists a portion of the anterior glenoid that is beyond the peak of the anterior rim, and is not part of the concave articular surface. The width of this anatomic area comprises a significant percent of the anteroposterior glenoid diameter, and should be understood when quantifying and describing anterior glenoid bone loss in cases of glenohumeral instability. CLINICAL RELEVANCE Understanding of anterior glenoid anatomy is important in the evaluation of glenohumeral instability. The portion of glenoid bone beyond the anterior rim peak is likely important for its soft tissue attachments, but its contribution to bony stability may be misunderstood.
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Affiliation(s)
- Guillaume D Dumont
- Department of Orthopaedic Surgery, University of Texas - Southwestern Medical Center, 1801 Inwood Road, Dallas, Tx 75390-8883, USA
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Ko SH, Shin SM, Jo BG. Outcomes of minimally 1 year follow-up for the arthroscopic Remplissage technique with Hill-Sachs lesion. J Orthop 2013; 10:41-5. [PMID: 24403747 DOI: 10.1016/j.jor.2013.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Accepted: 01/01/2013] [Indexed: 11/25/2022] Open
Abstract
PURPOSE We evaluated minimal 1 year follow-up results for the Remplissage technique to fill a Hill-Sachs lesion with anterior instability. METHODS The subjects were 12 patients, who could be followed-up for more than 12 months after the "Remplissage" procedures in our hospital from August 2008 to May 2010. Their mean age was 28.6 years old and the mean follow-up was 19 months. The evaluations included the ROM, the ASES score, the KSSI score, the ROWE score and postoperative MRI. RESULTS On the postoperative functional evaluation after an average 16 months, the ASES score improved 51.4 in preoperative to 86.6 in postoperatively, the KSSI score improved from 46.6 preoperatively to 84.9 postoperatively and the ROWE score improved from 43.6 preoperatively to 91.4 postoperatively. After an average 14 months for all the cases, the range of movement was nearly in the normal range which is 174.3 ± 5.04 (170-180) degrees in foreward flexion, and 56.4 ± 9.60 (50-60) degrees in external rotation. CONCLUSION For recurrent shoulder instability with a large Hill-Sachs lesion, the Remplissage technique has a good outcome after more than 1 year follow-up in terms of shoulder stability, and the clinical and functional results. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Sang-Hun Ko
- Department of Orthopedic Surgery, Ulsan University Hospital, University of Ulsan, College of Medicine, 290-3 Cheon-ha Dong, Dong Ku, Ulsan Metropolitan City 682-714, Republic of Korea
| | - Seung-Myeong Shin
- Department of Orthopedic Surgery, Ulsan University Hospital, University of Ulsan, College of Medicine, 290-3 Cheon-ha Dong, Dong Ku, Ulsan Metropolitan City 682-714, Republic of Korea
| | - Beom-Geon Jo
- Department of Orthopedic Surgery, Ulsan University Hospital, University of Ulsan, College of Medicine, 290-3 Cheon-ha Dong, Dong Ku, Ulsan Metropolitan City 682-714, Republic of Korea
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Elkinson I, Giles JW, Faber KJ, Boons HW, Ferreira LM, Johnson JA, Athwal GS. The effect of the remplissage procedure on shoulder stability and range of motion: an in vitro biomechanical assessment. J Bone Joint Surg Am 2012; 94:1003-12. [PMID: 22637206 DOI: 10.2106/jbjs.j.01956] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The remplissage procedure may be performed as an adjunct to Bankart repair to treat recurrent glenohumeral dislocation associated with an engaging Hill-Sachs humeral head defect. The purpose of this in vitro biomechanical study was to examine the effects of the remplissage procedure on glenohumeral joint motion and stability. METHODS Cadaveric shoulders (n = 8) were mounted on a biomechanical testing apparatus that applies simulated loads to the rotator cuff and the anterior, middle, and posterior heads of the deltoid muscle. Testing was performed with the shoulder intact, after creation of the Bankart lesion, and after repair of the Bankart lesion. In addition, testing was performed after Bankart repair with and without remplissage in shoulders with 15% and 30% Hill-Sachs defects. Shoulder motion and glenohumeral translation were recorded with an optical tracking system. Outcomes measured included stability (joint stiffness and defect engagement) and internal-external glenohumeral rotational motion in adduction and in 90° of composite shoulder abduction. RESULTS In specimens with a 15% Hill-Sachs defect, Bankart repair combined with remplissage resulted in a significant reduction in internal-external range of motion in adduction (15.1° ± 11.1°, p = 0.039), but not in abduction (7.7° ± 9.9, p = 0.38), compared with the intact condition. In specimens with a 30% Hill-Sachs defect, repair that included remplissage also significantly reduced internal-external range of motion in adduction (14.5° ± 11.3°, p = 0.049) but not in abduction (6.2° ± 9.3°, p = 0.60). In specimens with a 15% Hill-Sachs defect, addition of remplissage significantly increased joint stiffness compared with isolated Bankart repair (p = 0.038), with the stiffness trending toward surpassing the level in the intact condition (p = 0.060). In specimens with a 30% Hill-Sachs defect, addition of remplissage restored joint stiffness to approximately normal (p = 0.41 compared with the intact condition). All of the specimens with a 30% Hill-Sachs defect engaged and dislocated after Bankart repair alone. The addition of remplissage was effective in preventing engagement and dislocation in all specimens. None of the specimens with a 15% Hill-Sachs defect engaged or dislocated after Bankart repair. CONCLUSIONS In this experimental model, addition of remplissage provided little additional benefit to a Bankart repair in specimens with a 15% Hill-Sachs defect, and it also reduced specific shoulder motions. However, Bankart repair alone was ineffective in preventing engagement and recurrent dislocation in specimens with a 30% Hill-Sachs defect. The addition of remplissage to the Bankart repair in these specimens prevented engagement and enhanced stability, although at the expense of some reduction in shoulder motion.
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Affiliation(s)
- Ilia Elkinson
- H.U.L.C. Bioengineering Research Laboratory, University of Western Ontario, London, Ontario, Canada
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Ljungquist KL, Butler RB, Griesser MJ, Bishop JY. Prediction of coracoid thickness using a glenoid width-based model: implications for bone reconstruction procedures in chronic anterior shoulder instability. J Shoulder Elbow Surg 2012; 21:815-21. [PMID: 22217638 DOI: 10.1016/j.jse.2011.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Revised: 09/28/2011] [Accepted: 10/10/2011] [Indexed: 02/01/2023]
Abstract
BACKGROUND Chronic anterior shoulder instability with glenoid bone loss can be a very challenging clinical problem. Significant bone loss is commonly managed with the Latarjet procedure. However, in some cases with severe glenoid bone loss, iliac crest bone grafting is required to obtain a graft of adequate size. Iliac crest bone graft is associated with high rates of donor-site complications. Whereas glenoid dimensions can be determined by use of 3-dimensional computed tomography reconstructions, the thickness of the coracoid cannot be easily measured. This study aims to define a ratio between glenoid width and coracoid thickness that can be used in preoperative planning to determine whether coracoid transfer will yield adequate bone graft to restore glenoid contour or whether iliac crest bone graft must be taken. METHODS We studied 100 paired cadaveric scapulae (50 male and 50 female scapulae). The bony dimensions of the coracoid and glenoid were measured for each specimen. RESULTS Coracoid and glenoid dimensions are provided. The mean thickness of the male coracoid was 35.4% of the width of the glenoid. The mean female coracoid thickness was 34.4% of the glenoid width. DISCUSSION A new biomorphologic model is presented to predict coracoid thickness and the ability of the Latarjet procedure to restore stability to a given bone-deficient glenoid. This model may aid the shoulder surgeon in preoperative planning and help promote successful outcomes in glenoid reconstruction surgery by determining whether a Latarjet procedure or iliac crest bone graft is the most appropriate procedure given the predicted amount of coracoid bone graft available.
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Affiliation(s)
- Karin L Ljungquist
- Department of Orthopaedics, Division of Shoulder Surgery, The Ohio State University Medical Center, Columbus, OH, USA
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Abstract
The Hill-Sachs lesion is an osseous defect of the humeral head that is typically associated with anterior shoulder instability. The incidence of these lesions in the setting of glenohumeral instability is relatively high and approaches 100% in persons with recurrent anterior shoulder instability. Reverse Hill-Sachs lesion has been described in patients with posterior shoulder instability. Glenoid bone loss is typically associated with the Hill-Sachs lesion in patients with recurrent anterior shoulder instability. The lesion is a bipolar injury, and identification of concomitant glenoid bone loss is essential to optimize clinical outcome. Other pathology (eg, Bankart tear, labral or capsular injuries) must be identified, as well. Treatment is dictated by subjective and objective findings of shoulder instability and radiographic findings. Nonsurgical management, including focused rehabilitation, is acceptable in cases of small bony defects and nonengaging lesions in which the glenohumeral joint remains stable during desired activities. Surgical options include arthroscopic and open techniques.
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Dumont GD, Russell RD, Robertson WJ. Anterior shoulder instability: a review of pathoanatomy, diagnosis and treatment. Curr Rev Musculoskelet Med 2011; 4:200-7. [PMID: 21808996 DOI: 10.1007/s12178-011-9092-9] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The glenohumeral joint is inherently predisposed to instability by its bony architecture. The incidence of traumatic shoulder instability is 1.7% in the general population. Associated injuries to the capsulolabral structures of the glenohumeral joint have been described and may play a role in predicting recurrent instability. Advanced imaging, computed tomography or MRI may be necessary to adequately evaluate for associated glenohumeral pathology. Treatment algorithms have traditionally included a period of non-operative management in all patients, however young athletic patients may often benefit from early operative treatment. Various open and arthroscopic surgical options exist to address anterior glenohumeral instability. Bony injuries including bony Bankart lesions and Hills Sachs lesion have been implicated in failed surgical management using techniques that address only the soft tissues. An individualized treatment approach, based upon the patient's injury pattern and expectations, will likely lead to the most successful outcome.
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Affiliation(s)
- Guillaume D Dumont
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, Sports Medicine & Shoulder Service, 1801 Inwood Road, Dallas, TX, 75390-8883, USA,
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Ko SH, Jung KH, Shin SM, Park HC. Using the Arthroscopic Remplissage of Anterior Shoulder Instability with Hill-Sachs Lesion. ACTA ACUST UNITED AC 2011. [DOI: 10.5397/cise.2011.14.1.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Seo SS, Kim JH, Choi JS, Kim JG. A Retrospective Analysis of the Relationship Between Rotator Cuff Tear and Biceps Lesion. Clin Shoulder Elb 2011. [DOI: 10.5397/cise.2011.14.1.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Ko SH, Lee CC, Park HC. Review in Remplissage on Anterior Shoulder Instability with Huge Hill-Sachs Lesion. Clin Shoulder Elb 2011. [DOI: 10.5397/cise.2011.14.1.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Cho CH, Jung GH, Sin HK, Lee YK, Park JH. Coracoclavicular Ligament Augmentation Using Endobutton for Unstable Distal Clavicle Fractures - Preliminary Report -. Clin Shoulder Elb 2011. [DOI: 10.5397/cise.2011.14.1.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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