Anterior Dislocation Research Articles

Comparative efficacy of sedation or analgesia methods for reduction of anterior shoulder dislocation: A systematic review and network meta-analysis.

We performed a network meta-analysis (NMA) to compare the efficacy and safety of intravenous sedation (IVS), intraarticular anesthetic injection (IAA), and peripheral nerve block (PNB) as sedation or analgesia methods for the reduction of anterior shoulder dislocation. We included randomized controlled trials (RCTs) comparing different sedation or analgesia methods for anterior shoulder dislocation reduction. The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, ICTRP, ClinicalTrials.gov, and Google Scholar databases were searched in October 2021. We conducted a random-effects NMA within a frequentist framework. We evaluated the confidence in each outcome using the CINeMA tool. Sixteen RCTs (957 patients) were included. Regarding the primary outcomes, the three methods might result in little to no difference in the immediate success rate of reduction and patient satisfaction. The IAA method had a shorter emergency department length of stay than that of the IVS method (mean difference [MD] -107.88 min, 95% confidence interval [CI] -202.58 to -13.18). In the secondary outcomes, the IAA method had a lower pain score than that of the PNB method (standardized MD -1.83, 95% CI -3.64 to -0.02). The IAA and PNB methods might require a longer time for reduction than that of the IVS method (MD 5.3 min, 95% CI 2.4 to 10.36; MD 15.25, 95% CI 5.49 to 25.01). The three methods might result in little to no difference in the number of reduction attempts and total success rate of reduction. However, the confidence ratings for all treatment comparisons were very low. IAA and PNB had no adverse respiratory events. The results of our NMA indicated that three sedation or analgesia methods (IVS, IAA, and PNB) might result in little to no difference in the success rate of reduction and patient satisfaction. IAA and PNB had no adverse respiratory events.

Penthrox enables quicker management of fractures, dislocations and more: learning lessons from expedited care of trauma patients during the COVID-19 pandemic.

Methoxyflurane is an historical anaesthetic agent that has undergone a renaissance with the introduction of a smaller dose in a handheld 'Penthrox' device. The benefits of Penthrox include its ease of use, with disposable individual packets, and the need for less monitoring and staff, when compared with deeper sedation. The literature acknowledges its use for analgesia and in the management of anterior shoulder dislocation but in no other procedural orthopaedic circumstance. Following institutional approval, we undertook a retrospective review of all incidences of Penthrox use to facilitate minor procedures within a 2-month period starting 24 March 2020. Time to procedure and success were recorded using the surrogate markers of patient attendance and x-Ray occurrence times. Some 101 Penthrox doses were given to 89 patients over 97 unique episodes between 24 March and 26 May 2020. No complications were recorded following the use of Penthrox during this period. Patient demographics were explored. Fracture manipulations and casting (n=54) had a 100% success rate in achieving adequate and safe reduction. Joint dislocations (n=34) were treated with varying success. Native elbow dislocations were reduced most successfully (4/4, 100%). Native shoulder dislocations were seen in 17 patients and successful relocation was seen in 11 cases, giving a success rate of 65%. This is the first study, outside anterior shoulder dislocations, to report on the efficacy of Penthrox within emergent orthopaedic scenarios. We have demonstrated Penthrox to be a safe tool for helping to manage trauma procedures in the emergency department.

Analysis of the effectiveness of coracoid osteotomy and concentric coaxial reconstruction of the glenoid cavity in the treatment of recurrent anterior dislocation of the shoulder joint

Objective: To investigate the clinical efficacy of the modified Latarjet procedure in the treatment of recurrent anterior subluxation of the shoulder by "coaxial co-arc" reconstruction of the glenoid cavity. Methods: The clinical data of 103 cases (106 shoulders) of recurrent anterior dislocation of the shoulder admitted to the First Affiliated Hospital of the Army Military Medical University from January 2005 to December 2020 were retrospectively studied. Out of these cases, 84 were males and 19 were females; 31 with left-sided injuries while 75 with right-sided injuries, with a mean age of (29.4±11.5) years (16-61 years). The preoperative anterior fear test was positive, and a modified Latarjet procedure was used to reconstruct the shoulder glenoid defect through a "coaxial co-arc". The Rowe score, simple shoulder test (SST) score, and Visual analogue scale (VAS) score of pain were used to assess the shoulder's function. Parameters such as the postoperative shoulder recurrent dislocation rate, shoulder body external rotation angle, and subscapularis muscle strength changes were recorded postoperatively. Moreover, radiographs and CT scans were used to check for the incidence of osteoarthritis (Samson-Prieto score). Results: After a mean follow-up of 9.0 years (1 to 16 years), bony healing occurred 3 to 6 months postoperatively. The Rowe score improved from 40.4±6.5 preoperatively to 93.2±2.5 (P<0.001), the SST score improved from 5.2±1.3 preoperatively to 10.1±1.5 (P<0.001), and the VAS pain score decreased from 3.5±1.9 preoperatively to 1.1±1.2 (P<0.001) at the final follow-up. The angle of lateral external rotation of the shoulder joint was 58.8°±15.6° preoperatively and 57.6°±14.5° postoperatively with no statistically significant difference (P>0.05). There was no statistically significant difference in the measurement of subscapularis muscle strength between the healthy side and the affected side (P>0.05). In 89.6% of patients after surgery, coaxial co-arc reconstruction of the shoulder glenoid was obtained, and the shoulder glenoid defect and postoperative inclusion angle were significantly improved compared with those before surgery (P<0.001). Postoperatively, new-onset osteoarthritis developed in 7 cases (7/98), arthritis progressed in 2 cases (2/8), incisional healing was poor in 2 cases (2/98), and revision surgery was performed in 2 cases (2/98) due to bone mass detachment. Conclusion: Coracoid osteotomy and concentric coaxial reconstruction of the glenoid cavity elicits adequate good clinical efficacy for cases of recurrent anterior shoulder dislocation, with low recurrence rates, low revision rates and low incidence of osteoarthritis.

Morphological characteristics and management of greater tuberosity fractures associated with anterior glenohumeral joint dislocation: A single centre 10-year retrospective review

IntroductionGreater tuberosity (GT) fractures associated with anterior gleno-humeral (GH) dislocations are unstable, with inadequate treatment leading to displacement, malunion, stiffness and functional disability. We explored its morphological characteristics to ultimately optimize their management. MethodsWe retrospectively reviewed all shoulder radiographs with GT fractures associated with anterior GH dislocations in a university hospital between December 1, 2009 and December 31, 2019. Special considerations were given to fracture morphology, presence and site of comminution, degree of displacement and need for surgical intervention. Results133 patients were identified. Most of the fracture-dislocations were multi-fragmentary (86.5%) and located antero- or postero-superiorly (68.7%). Superiorly comminuted GT fractures were twice as likely to displace compared to other sites of comminution (43% vs. 21%, p = 0.03), and require surgery (p = 0.03). Undisplaced comminuted GT fragments, particularly superior patterns, could undergo secondary migration if conservatively treated (p = 0.01). GT fractures fixed with interfragmentary screw suffered more secondary migration but those treated with double-row suture anchors (DRSA) did not on follow-up x-rays at two months. ConclusionGT fractures with anterior GH dislocations are frequently comminuted. Those with superiorly situated comminution should have a low threshold for surgical fixation, particularly with DRSA which can prevent secondary fragment migration.

A Case Series on Whether Arthroscopic Bankart Repair Following Primary Traumatic Anterior Shoulder Dislocation or Recurrent Dislocation in Soldiers Has an Effect on the Postoperative Recurrence Rate.

BackgroundAnterior traumatic shoulder dislocation is very common among soldiers or any young population following injury, which is invariably treated by closed reduction. The dislocation when treated nonsurgically has a 71% high rate of recurrence. There is not much data available on the rate of recurrence when primary dislocation (first time) was treated by arthroscopic Bankart repair and in those who have recurrent (multiple) dislocations before surgery.AimThis study aims to report the postoperative recurrence rate in soldiers with first-time dislocation versus those with recurrent dislocations before surgery.Study designThe present study is a level IV case series treatment study.MethodsIn this prospective study, 143 soldiers were included, of which 82 patients had first-time dislocation (F group) and 61 patients had recurrent dislocation before surgery (R group). The patients were evaluated and followed up for over three years. Nonabsorbable PEEK suture anchors (Chetan Meditech, India) were used for arthroscopic Bankart repair. The recurrence rates, Rowe scores, visual analog scale (VAS) scores, subjective shoulder values (SSVs), and satisfaction were compared. We also used the Simple Shoulder Test (SST) score for evaluation. The scores were recorded preoperatively and at three-year follow-up. The range of motion, postoperative function, recurrence rates, and return to pre-injury state was evaluated.ResultsA total of 143 patients were included, providing 97.3% follow-up at an average of 36 months. The postoperative recurrence rate was 19.7% in the F group and 58.3% in the R group (P < 0.001). The odds of postoperative recurrence were five times higher in the recurrent dislocation group (odds ratio (OR): 5.23).ConclusionPatients who underwent repair after first-time dislocation show a lower postoperative recurrence rate as compared with those who had multiple dislocations before surgery. It is prudent to advise early repair even after the first dislocation especially in young active soldiers to reduce the risk of postoperative recurrence.

Short- and long-term outcomes in Bankart repair vs. conservative treatment for first-time anterior shoulder dislocation: a systematic review and meta-analysis of randomized controlled trials.

First-time anterior shoulder dislocations are associated with a high rate of residual instability. Therefore, many surgeons support initial Bankart repair surgery over conservative management to address this issue. However, the optimal treatment remains controversial because of uncertainty regarding long-term surgical outcomes. The primary objective of this systematic review and meta-analysis was to compare the short- and long-term rates of residual instability following Bankart repair or conservative management after a first-time anterior shoulder dislocation. PubMed/MEDLINE, Embase, The Cochrane Library, Web of Science, CINAHL, and ScienceDirect databases were accessed for randomized controlled trials (RCTs) comparing Bankart repair to conservative management. RoB (Risk of Bias) 2 was used to check study quality. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) guidelines were followed in assessing primary outcomes. The inverse-variance method for continuous variables and the Mantel-Haenszel method for dichotomous variables was used. A total of 348 patients from 6 RCTs published across 8 articles, with a mean age of 23.7 years, were included. Bias was graded low in 3 studies, some concerns in 3 studies, and high in 2 studies. In the short term (2-3 years), surgery lowered recurrent instability (risk ratio [RR] 0.15, 95% confidence interval [CI] 0.08, 0.27; I2=0%; P<.0001). Similar findings were seen in the long term (5-12 years) (RR 0.23, 95% CI 0.14, 0.39; I2=0%; P<.0001). No difference was observed in return to sport (RR 1.18, 95% CI 0.91, 1.52; I2=78%; P=.21). Initial surgery lowered subsequent stabilization surgery in the short (RR 0.19, 95% CI 0.09, 0.43; I2=0%; P<.0001) and long term (RR 0.17, 95% CI 0.07, 0.39; I2=25%; P<.0001). Western Ontario Shoulder Instability Index (WOSI) scores did not differ in the short term (MD, 2.54, 95% CI -0.51, 5.59; I2=48%; P=.1) but were higher in the surgical group at long-term follow-up. Patient satisfaction was also higher with surgery (RR 1.75, 95% CI 1.4, 2.2; I2=88%; P<.0001). Certainty of evidence was low for only 1 long-term outcome measure. Bankart repair surgery for first-time anterior shoulder dislocation results in a large reduction in the risk of recurrent shoulder instability and subsequent stabilization surgery in both short- (2-3 years) and long-term (5-12 years) follow-up intervals. Additionally, slight improvements in overall patient satisfaction and WOSI score can be seen at long-term follow-up. However, surgical intervention failed to significantly improve the rate of return to sport when compared with conservative management.

Large aortic pseudoaneurysm after fusion surgery for hyperextension-type lumbar fracture in diffuse idiopathic skeletal hyperostosis: illustrative case.

This study aimed to report an aortic pseudoaneurysm, a rare but lethal complication, after a spinal fracture in ankylosing spine. An 83-year-old obese woman presented with dementia and was nonambulatory after a fall. She was transported to the hospital, and imaging showed a hyperextension-type L1 fracture with diffuse idiopathic skeletal hyperostosis (DISH). After posterior fusion surgery using percutaneous pedicle screws, screw loosening was detected 10 days postoperatively. Fracture dislocation was reduced by changing to transdiscal screws and rodding while in the lateral position. However, the anterior opening persisted. Enhanced computed tomography performed at 6 weeks postoperatively showed a large aortic pseudoaneurysm extending into the vertebral fracture site without screw loosening. Neither endovascular aortic repair nor open surgery was applicable. The patient was transferred to a sanatorium and died of pneumonia 5 months postoperatively without aortic aneurysm rupture. An aortic pseudoaneurysm can occur in hyperextension-type spinal fractures in DISH, even after fusion surgery, when the edge of the fracture is in contact with the aortic wall. The anterior opening dislocation should be reduced as much as possible.

The Use of a Suprascapular Nerve Block to Facilitate the Reduction of an Anterior Shoulder Dislocation: An Alternative for Elderly and Patients With Cardiopulmonary Comorbidities?

BackgroundAnterior shoulder dislocation is a common presentation to the emergency department (ED). Dislocations are spontaneous or traumatic. Generally, a reduction is performed under procedural sedation and analgesia (PSA). Other approaches include the use of intra-articular lidocaine or, in rare instances, nerve blocks. Here we discuss the case of a 66-year-old female patient who presented with left shoulder pain and limited range of motion after a fall. After discussing potential treatment options to reduce the dislocation, the patient agreed to a nerve block. DiscussionThe dislocation was reduced successfully with a suprascapular nerve block (SSNB) without complications. The duration of the patient's ED stay was shorter than those who had received PSA. ConclusionsSSNB could be an alternative method for shoulder dislocation reduction, particularly for patients who are obese, older, or have cardiopulmonary comorbidities.

Recurrence Of Anterior Shoulder Dislocation with Or Without Physiotherapy

Shoulder withdrawals are horrendous and can hinder everyday activities as well as help in sports. The greater part of shoulder separations (&gt;95%) happen in the front course and are from time to time achieved by injury. Discontinuous separations can be avoided and social costs can be diminished with proper treatment. Objective: To evaluate the recurrence of anterior should dislocation with or without physiotherapy. Methods: This cross-sectional study was conducted over 180 participants of recurrence of anterior shoulder dislocation according to inclusion exclusion criteria. Non probability purposive sampling was used to assemble data from Lahore. Data was collected by questionnaire Functional shoulder Instability. Data were collected from the Patients of the University of Lahore Teaching Hospital, Mansoora Hospital, Jinnah Hospital and Mayo Hospital. Results: Out of total 180 participant’s, 140 were males and 40 were females. Mean age was 25.9 with a St. Deviation of 5.3 having maximum age of 35.00 and minimum age of 15.00. Injury mechanism among participants was seizure in 20 (11.1%), falls present in 46 (25.6%), sporting injury in 54 (30.0%), motor vehicle accident in 54 (30.0%) and in other is 6 (3.3%). 98 (54.4%) participants have previous instability of other shoulder and 82 (45.6%) don’t have previous instability of other shoulder. 74 (41.1%) participants have left dislocation side and 106 (58.9%) participants have right dislocation side. 28 (15.6%) participant’s undergoes physiotherapist treatment and 152 (84.4%) participant’s undergoes general physician treatment. Conclusions: Hence it was concluded that, recurrence of shoulder was occurred mostly in that participants’ which were undergoes general physician treatment.

Patient-Preference Diagnostics: Adapting Stated-Preference Methods to Inform Effective Shared Decision Making.

While clinical practice guidelines underscore the need to incorporate patient preferences in clinical decision making, incorporating meaningful assessment of patient preferences in clinical encounters is challenging. Structured approaches that combine quantitative patient preferences and clinical evidence could facilitate effective patient-provider communication and more patient-centric health care decisions. Adaptive conjoint or stated-preference approaches can identify individual preference parameters, but they can require a relatively large number of choice questions or simplifying assumptions about the error with which preferences are elicited. We propose an approach to efficiently diagnose preferences of patients for outcomes of treatment alternatives by leveraging prior information on patient preferences to generate adaptive choice questions to identify a patient's proximity to known preference phenotypes. This information can be used for measuring sensitivity and specificity, much like any other diagnostic procedure. We simulated responses with varying levels of choice errors for hypothetical patients with specific preference profiles to measure sensitivity and specificity of a 2-question preference diagnostic. We identified 4 classes representing distinct preference profiles for patients who participated in a previous first-time anterior shoulder dislocation (FTASD) survey. Posterior probabilities of class membership at the end of a 2-question sequence ranged from 87% to 89%. We found that specificity and sensitivity of the 2-question sequences were robust to respondent errors. The questions appeared to have better specificity than sensitivity. Our results suggest that this approach could help diagnose patient preferences for treatments for a condition such as FTASD with acceptable precision using as few as 2 choice questions. Such preference-diagnostic tools could be used to improve and document alignment of treatment choices and patient preferences. Approaches that combine patient preferences and clinical evidence can facilitate effective patient-provider communication and more patient-centric healthcare decisions. However, diagnosing individual-level preferences is challenging, and no formal diagnostic tools exist.We propose a structured approach to efficiently diagnose patient preferences based on prior information on the distribution of patient preferences in a population.We generated a 2-question test of preferences for the outcomes associated with the treatment of first-time anterior shoulder dislocation.The diagnosis of preferences can help physicians discuss relevant aspects of the treatment options and proactively address patient concerns during the clinical encounter.

Han's technique: a new reduction technique for acute anterior shoulder dislocation.

Acute anterior shoulder dislocation (AASD) is the most common joint dislocation. Here, we introduced a new reduction technique for AASD, named "Han's technique" (or "Touch overhead technique"). Patients diagnosed with AASD were treated with "Han's technique" in the orthopaedic department of our hospital from October 2018 to November 2020. An orthopedic surgeon performed the reduction maneuver without any anesthesia or sedation throughout the reduction process. The fundamental information and related data were recorded, including patients' age, sex, dislocation side, previous dislocations history, reduction time, number of attempts at reduction, success rate of the reduction, intensity of pain during reduction using the 10-point visual analogue scale score (VAS), any complications, with or without the fracture and neurovascular examination results. Forty-one patients with AASD were involved in our study. Thirty-nine cases (95%) were primary dislocation. Eleven patients (27%) were complicated with large tubercle fracture and one patient (2%) complicated with inferior glenoid fractures. All patients were successfully reduced by Han's technique with mean reduction time was 138s. The pain score during the reduction operation is only1.83 ± 0.83 points. No neurovascular injury or iatrogenic fracture was found after reduction in all patients. Han's technique (or Touch overhead technique) is a simple, safe, effective, mild and easy to master which can be operated by one surgeon without anesthesia or sedation for AASD.

Long-term Surgical Outcomes in Patients of Centurion Syndrome: A Mystic Etiology of Epiphora in Young

ABSTRACT Aim To describe the clinical features and long-term outcomes of the medial canthal tendon (MCT) release procedure in patients with Centurion Syndrome (CS). Methods We performed a retrospective analysis of the diagnosed patients with CS from July 2013 to December 2019. CS was diagnosed clinically based on the anterior displacement of MCT, anterior dislocation of lacrimal punctum out of tear lake, prominent nasal bridge, beak sign, and synophyrs. All symptomatic patients were advised the anterior limb of MCT release with modified closure of the skin incision. The outcome measures were based on Munk’s score (subjective) and the fluorescein dye disappearance test (objective). A minimum postoperative follow-up of 12 months was an inclusion criterion. Results We studied 22 patients (44 eyes) having a median age of 14.5 years. Anteriorly displaced MCT and lacrimal punctum were noted in 44 eyes (100%), prominent nasal bridge in 20 patients (90.9%), beak sign in 36 eyes (81.8%), and synophyrs in 17 (77.3%) patients. All 44 eyes underwent MCT release with adjunctive punctoplasty (n = 6 eyes) or lower eyelid retractor plication (n = 4 eyes). At a mean follow-up of 12.6 months, 26 eyes (59.1%) showed complete response, i.e., negative FDDT and grade 0 Munk score. Partial response was noted in 14 (31.8%) eyes, i.e., delayed FDDT and reduction of ≥2 grades on Munk score. Conclusion Along with the classic features of CS, beak sign and synophyrs are important diagnostic ophthalmic-facial features of CS. The transverse closure of surgical wounds may provide effective long-term benefits in the medial canthal tendon release procedure.

Man With Right Shoulder Pain

A 61-year-old man fell from his scooter resulting in right shoulder pain. The patient required first aid in a local hospital where plain film radiography showed no apparent abnormalities. He then presented to our emergency department due to persistent pain and an inability to move his right shoulder, with his right arm in a supportive sling. Radiography revealed rounding of the humeral head (Figure 1), which was confirmed by point-of-care ultrasound (Figure 2A ).Figure 2Point-of-care ultrasound, using a curvilinear probe in the transverse orientation behind the scapular spine. A, Before the procedure, the humeral head was protruding from the glenoid toward the posterior aspect of the shoulder, indicating a posterior dislocation. B, After the procedure, the humeral head was immediately adjacent to the glenoid, confirming a successful reduction. Ant, anterior side; Post, posterior side; Med, medial side; Lat, lateral side; D, deltoid muscle; G, glenoid; H, humeral head; I, infraspinatus muscle; S, scapula spine.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Posterior dislocation of the right shoulder. Point-of-care ultrasound showed that the humeral head protruded from the glenoid toward the posterior side. A closed reduction of the right shoulder was performed, and point-of-care ultrasound confirmed a successful reduction (Figure 2B). The patient was discharged and was followed up in an outpatient clinic. Posterior shoulder dislocations are rare. Missed diagnoses are frequent because the humeral head appears aligned within the glenoid fossa on plain film radiograph.1Hatzis N. Kaar T.K. Wirth M.A. et al.The often overlooked posterior dislocation of the shoulder.Tex Med. 2001; 97: 62-67PubMed Google Scholar,2Magnussen A.P. Watura C. Torr N. et al.Missed posterior shoulder fracture dislocations: a new protocol from a London major trauma centre.BMJ Open Quality. 2020; 9e000550Crossref Scopus (1) Google Scholar Additionally, patients with shoulder trauma usually have the shoulder immobilized with a sling at the time of imaging, causing the anteroposterior radiographs obtained to be imprecise with the expected rounding of the humeral head. This makes the characteristic “light bulb” sign on a radiograph unreliable.2Magnussen A.P. Watura C. Torr N. et al.Missed posterior shoulder fracture dislocations: a new protocol from a London major trauma centre.BMJ Open Quality. 2020; 9e000550Crossref Scopus (1) Google Scholar Ultrasonography is highly sensitive and specific for the identification of shoulder dislocation.3Gottlieb M. Holladay D. Peksa G.D. Point-of-care ultrasound for the diagnosis of shoulder dislocation: A systematic review and meta-analysis.Am J Emerg Med. 2019; 37: 757-761Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Normally, the humeral head appears as a hyperechoic, semicircular line with an acoustic shadow immediately lateral to the glenoid. The humeral head will not be congruent to the glenoid in shoulder dislocations, appearing deeper with an anterior dislocation and more superficial with a posterior dislocation.

Social and Demographic Factors Impact Shoulder Stabilization Surgery in Anterior Glenohumeral Instability

PurposeTo assess independent predictors of surgery after an emergency department visit for shoulder instability, including patient-related and socioeconomic factors.MethodsPatients presenting to the emergency department were identified in the New York Statewide Planning and Research Cooperative System database from 2015 to 2018 by International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes for anterior shoulder dislocation or subluxation. All shoulder stabilization procedures in the outpatient setting were identified using Current Procedural Terminology codes (23455, 23460, 23462, 23466, and 29806). A multivariable logistic regression was performed to assess the impact of patient factors on the likelihood of receiving surgery. The variables included in the analysis were age, sex, race, social deprivation, Charlson Comorbidity Index, recurrent dislocation, and primary insurance type.ResultsIn total, 16,721 patients with a shoulder instability diagnosis were included in the analysis and 1,028 (6.1%) went on to have surgery. Patients <18 years old (odds ratio [OR] 8.607, P < .0001), those with recurrent dislocations (OR 2.606, P < .0001), or worker’s compensation relative to private insurance (OR 1.318, P = .0492) had increased odds of receiving surgery. Hispanic (OR 0.711, P = .003) and African American (OR 0.63, P < .0001) patients had decreased odds of surgery compared with White patients. Patients with Medicaid (OR 0.582, P < .0001) or self-pay (OR 0.352, P < .0001) insurance had decreased odds of undergoing surgery relative to privately insured patients. Patients with greater levels of social deprivation (OR 0.993, P < .0001) also were associated with decreased odds of surgery.ConclusionsAnterior glenohumeral instability and subsequent stabilization surgery is associated with disparities among patient race, primary insurance, and social deprivation.Clinical RelevanceConsidering the relationship between differential care and health disparities, it is critical to define and increase physician awareness of these disparities to help ensure equitable care.

Chronic Irreducible Knee Dislocations: Outcomes following Open Reduction and Reconstructive Surgery.

The management of unreduced knee dislocations who present late is challenging. The aim of this study was to determine the clinical, radiological, and functional outcomes following open reduction and reconstructive surgery for chronic irreducible knee dislocations. This retrospective study analyzed prospectively collected data of patients with an unreduced fixed anterior or posterior knee dislocation of 1 to 6 months' duration, treated with open reduction, hinged external fixator application, and ligament reconstruction who had a minimum 2-year follow-up. Patients were classified based on presence of prior periarticular surgery and direction of dislocation. Data on pre- and posttreatment clinical, radiological, and functional scores were analyzed. A total of 21 patients (age range: 19-43 years) fulfilled all inclusion criteria. These included 13 missed dislocations and 8 neglected postoperative dislocations. There were 18 posterior and 3 anterior dislocations. The mean follow-up was 6.9 years (range: 2.7-16.2 years). On final follow-up, all 21 patients were independently ambulatory with mean knee range of motion 127 degrees. No patient had symptomatic knee instability at final follow-up, despite four having isolated grade-III posterior cruciate ligament (PCL) laxity. Anatomical reduction was achieved in 19 patients, whereas 2 patients had incomplete joint reduction with a persistent grade-II fixed posterior subluxation. Scanograms revealed coronal alignment within 5 degrees of the opposite unaffected limb in 17 patients. Mean functional scores improved from preoperative 9.4 ± 4.7 (range: 2-19) to postoperative 75.9 ± 8.0 (range: 64-95) for Lysholm's and preoperative 10.7 ± 1.8 (range: 8.3-13.7) to postoperative 73.5 ± 6.7 (range: 66.7-88.7) for knee injury and osteoarthritis outcome score (KOOS) scores. Prior periarticular surgery was associated with significantly inferior Lysholm's scores (p < 0.04). Although 23.8% knees developed posttraumatic knee arthritis, no patient had undergone conversion to knee arthroplasty or arthrodesis. The study concludes that open reduction and reconstructive surgery is an effective surgical treatment for chronic irreducible knee dislocations of up to 6 months duration. An individualized, often staged approach that prioritizes joint reduction, early knee mobilization, and knee stability, ensures satisfactory clinical, radiological, and functional outcomes in the medium term. This is a clinical case series and reflects level of evidence IV.

Poster 152: Arthroscopic Bankart Repair Following a Second Dislocation Results in Increased Failure Rates Compared to Immediate Repair After Following a Traumatic First Time Dislocation

Objectives:Many surgeons will consider nonoperative treatment following a 1st time dislocation and will consider operative management if a second instability event occurs particularly for the in season athlete. The objective of this study was to compare rates of recurrent dislocation and post-surgical outcomes in patients undergoing arthroscopic bankart repair for anterior shoulder instability immediately following a 1st time traumatic anterior dislocation versus patients who sustained a 2nd dislocation event following initial conservative management. We hypothesized that patients sustaining a 2nd anterior shoulder dislocation would be more at risk for recurrent dislocations after arthroscopic repair and secondarily, would have worse objective and subjective outcomes.Methods:This was a retrospective chart review identifying all patients undergoing primary arthroscopic surgical stabilization for anterior shoulder instability between 2013-2019 at a single academic institution. Demographics, clinical history, physical exam, imaging, operative details, and postoperative course was reviewed. Patients were eligible for inclusion if they underwent arthroscopic Bankart repair without remplissage sustained one or two dislocation events and were clinically followed for a minimum of 12 months postoperatively. Exclusion criteria included posterior instability, multidirectional instability, and previous stabilization surgery, Primary outcome was documentation of recurrent shoulder dislocation during the postoperative period. Secondary clinical outcome measures were assessed including need for revision surgery, need for manipulation under anesthesia (MUA), range of motion, strength, Subjective Shoulder Value (SSV), Visual Analog Scale (VAS), PROMIS mental and physical health, American Shoulder and Elbow Surgeons Shoulder Score (ASES), and Brophy shoulder activity scores.Results:A series of 89 patients (mean age 21.3 years ± 7.3 years) met criteria for inclusion. 72 shoulders underwent surgical stabilization after a single shoulder dislocation event and 17 underwent surgery after sustaining two documented shoulder dislocations. No significant difference in demographic and radiographic characteristics, including presence of bony Bankart and off-track Hill Sachs lesions, was present between the groups. The rate of recurrent dislocation was significantly higher in the multiple dislocation group compared to single dislocations (31% vs 12%, p=0.048). There was a trend toward increased rate of revision stabilization in the 2nd dislocation group which did not reach statistical significance (22% vs 58%, p=0.167). No significant difference was present in the need for revision surgery, need for MUA, conversion to Latarjet procedure, range of motion, supraspinatus strength, VAS, PROMIS, ASES, and Brophy scores between the groups.Conclusions:Immediate surgical stabilization following a 1st time dislocation significantly diminishes the risk of recurrent dislocation in comparison to those who undergo surgery following two dislocation events. These findings suggest that patients who return to activities after a primary anterior shoulder dislocation and undergo surgical stabilization following just one additional event are at increased risk of failure following surgery. Furthermore, patients who have sustained even one additional dislocation from the primary event may benefit from more aggressive approaches may be necessary including arthroscopic approaches with augmentation or open approaches. Despite differences in recurrence rates, both groups achieved excellent subjective functional outcomes at a minimum of 12 months after surgery.

Ultrasound-Guided Retroclavicular Approach to the Infraclavicular Region (RAPTIR) Brachial Plexus Block for Anterior Shoulder Reduction

BackgroundShoulder dislocations are a common presenting injury to the emergency department (ED), with anterior dislocations comprising the majority of these cases. Some patients may tolerate gentle manipulation and reduction, but many require analgesia of some type. Oral or parenteral pain medication is often used alone or in combination with procedural sedation if gentle manipulation fails to achieve reduction. Recently, this treatment algorithm has grown to include regional anesthesia as a mode of analgesia for reduction of shoulder dislocations in the form of brachial plexus blocks. It has been well described that the interscalene and supraclavicular approach to the brachial plexus can be used to assist in reduction of anterior shoulder dislocations; however, there has yet to be any published literature regarding the use of ultrasound-guided retroclavicular approach to the infraclavicular region (RAPTIR) brachial plexus blocks for shoulder reduction.Case Report: We describe three patients who presented to the ED with anterior shoulder dislocations. The RAPTIR block was performed, provided effective analgesia, and facilitated successful shoulder reduction in all three patients.Why Should an Emergency Physician Be Aware of This? The RAPTIR nerve block is a safe and effective option for analgesia in the patient with an anterior shoulder dislocation. It may have advantages over other brachial nerve blocks and avoids the risks and disadvantages of procedural sedation and opioids.

A case report of revision hip surgery in dislocation of primary operated THA

Total Hip Replacement is an increasingly common surgical intervention in the aging population these days and with that it brings with it increasingly frequent complications. Posterior dislocation is more common, anterior dislocation is still a concern and it’s management controversial. Study aims on understanding the pathology behind THR dislocation and ways to manage the same.

Paper 70: "Distance to Dislocation" as a Predictor of Surgical Failure Following Primary Arthroscopic Anterior Labral Repair: Rethinking the Glenoid Track Concept

Objectives:Larger amounts of bipolar bone loss have a strong association with shoulder re-dislocation following arthroscopic labral repair. Development of the Glenoid Track (GT) concept has helped propose bone loss cut-offs for shoulders that should not be managed with arthroscopic labral repair alone. Recent literature has suggested the use of the glenoid track as a continuous variable rather than a binary “on-track/off-track” concept. The re-dislocation risk for “on-track” shoulders with smaller distances to dislocation (DTD), or “near-track” shoulders, has not been previously described. We hypothesized that decreasing DTD, or on-track lesions approaching an off-track lesion, would result in an increased risk of failure following arthroscopic Bankart repair alone.Methods:We performed a retrospective analysis of 197 patients who had undergone primary arthroscopic anterior labral repair between 2007 and 2019 with minimum 2-year follow-up. Glenoid bone loss using a perfect-circle method and Hills-Sachs (HS) interval, were measured from pre-operative MRIs. GT was calculated using previously described methods. Surgical failure was defined as a patient who re-dislocated their shoulder following surgery. DTD was calculated by subtracting the HS measurement from the GT calculation. Patients with “off-track” lesions (negative DTD), and those who had undergone a concomitant arthroscopic remplissage were excluded. We performed a logistical regression model to evaluate the relationship between surgical failure and DTD, glenoid bone loss, Hill-Sachs lesion size, number of anchors used, and patient age. We then created a risk estimator tool that calculates the risk of dislocation with DTD as a continuous variable.Results:Twenty-eight patients (14%) sustained recurrent shoulder dislocations following anterior shoulder labral repair. Average follow up was 7.8 years and there were no demographic differences between those with recurrence and those without (p>0.05). All patients had less than 25% glenoid bone loss (range 0-23%). Increased DTD (p < 0.0005) and glenoid bone loss (p < 0.0005) were independent predictors of surgical failure. After adjusting for glenoid bone loss and patient age, logistic regression modeling showed that for every 1mm decrease in DTD, there was an associated 13.6% increase in re-dislocation risk (p = 0.003). Patient age, Hill-Sachs length, participation in collision sports, and number of anchors used were not significantly associated with failure risk (p>0.05). A DTD <10mm had a 4.26 times greater odds of failure compared to those with DTD >10mm (OR 4.26; 95% CI 1.57-11.65; p = 0.005). The risk estimator tool developed using a logistic regression modeling demonstrated a 19% risk of failure for DTD 10mm, 26% risk for DTD 8mm, 36% risk for DTD 6mm, 49% risk for DTD 4mm, and 67% risk for DTD 2mm after adjusting for glenoid bone loss and patient age (Figure 1).Conclusions:The main finding of this study was that on-track lesions approaching off-track lesions, the so-called “near track” lesions, are associated with an exponentially increased risk of recurrent dislocation following primary arthroscopic anterior stabilization with labral repair alone. Furthermore, DTD values of <10mm were associated with the highest odds ratios for failure and were 4 times more likely to fail than for patients with DTD values >10mm. All of the patients included in this analysis had “on-track” shoulder lesions and <25% glenoid bone loss. Historically, these values have been identified as “cut-offs” used to identify patients who can be treated successfully with arthroscopic labral repair without a remplissage or other augmentation. DTD is a simple calculation for bipolar bone loss that can be used to predict risk of recurrent dislocation. Our results demonstrate potential pitfalls in making treatment decisions for bipolar bone loss using a binary “on-track, off-track” construct. Rather, the glenoid track concept applied as a continuum may be more useful for optimizing treatment.“On-track” shoulder lesions <10mm with diminishing DTD have a substantially higher risk of surgical failure with arthroscopic labral repair alone. As the DTD approaches 0mm (“off track lesion”), the risk of failure increases exponentially. When making treatment decisions for shoulder instability, bipolar bone loss should be viewed as a continuum rather than discreet “on-track, off-track” entities. For high-risk patients with a DTD approaching 0mm, additional augmentation with remplissage or open approaches should be considered.DTD can be used to estimate patient’s risk of recurrent dislocation following primary arthroscopic anterior labral repair for treatment of anterior shoulder instability. Application of this calculation would help surgeons decide the best surgical treatment for patients following anterior shoulder dislocation and can be particularly valuable for high risk patients. Understanding the association between lower DTD values and failure can also help inform the surgeon and patient regarding the risks and benefits of available treatment options.

Glenohumeral Joint Dislocation Classification: Literature Review and Suggestion for a New Subtype.

Glenohumeral joint (GHJ) dislocation is a relatively common injury. Anterior GHJ dislocations are divided into subcoracoid, subglenoid, subclavicular, and intrathoracic subtypes. The aim of this article is to review current GHJ dislocation classification and briefly discuss management of each type. Discrepancies and inaccuracies exist in regard to GHJ dislocation classification. We suggest adding a new subtype, "paraglenoid," to improve the current GHJ dislocation classification system. The paraglenoid subtype describes a portion of the subcoracoid anterior GHJ dislocation. GHJ dislocation is most often caused by force applied to the arm during a fall but also can be due to direct impact to the shoulder. Physical examination often reveals classic deformities, and thorough neurovascular examination is crucial. Radiographs should be used to confirm the diagnosis and assess for associated bony injuries. Numerous reduction techniques are described in the literature, with chosen method dependent on patient factors, provider experience, and GHJ dislocation type.