Labral Lesions Research Articles

Can capsular plication compensate the lack of one suture anchor in an arthroscopic three suture anchor Bankart repair? A comparative study

ObjectiveThe aim of this study was to compare the complication rates and clinical results of labral repair with two suture anchors and capsular plication, and labral repair with three suture anchor fixation in artroscopic Bankart surgery. MethodsSixty-nine patients (60 males, 9 females; mean age: 28.2 ± 7.8 years (range: 16–50)) who had undergone arthroscopic repair of a labral Bankart lesion were evaluated. Group A underwent an arthroscopic Bankart repair with three knotless suture anchors, while group B underwent a modified arthroscopic Bankart repair with two knotless suture anchors and an additional capsular plication procedure. The mean follow-up was 52.5 months. Constant Shoulder Score (CSS), Rowe Score (RS), modified UCLA Shoulder Score (mUSS) and range of motion (ROM) were used as outcome measures. ResultsIn both groups, a significant improvement was detected in functional outcomes at postoperative last follow-up compared to the preoperative period. No statistically significant difference was found (p > 0.05) in clinical scores (CSS; Group A: 89.7, Group B: 80.2) (RS; Group A: 88.2, Group B: 80.2) (mUSS; Group A: 26.3, Group B: 25.7) external rotation loss (At neutral; Group A: 4.5°, Group B: 5.2°. At abduction; Group A: 4.3°, Group B: 5.7°) and recurrence rates (Group A: 13.3%, Group B: 20.8%). Although the difference was not statistically significant, the recurrence rate was higher in group B (20.8%), compared to group A (13.3%), despite the shorter average follow-up time of group B (p = 0.417). ConclusionsArthroscopic repair of labral Bankart lesions with both techniques showed good functional outcomes and stability at the latest follow-up. Higher recurrence rate despite the shorter average follow-up of group B suggests that two anchor usage might not be sufficient for Bankart repair in terms of better stability and less recurrence risk. Level of evidenceLevel III, Therapeutic Study.

Anteromedial Labral Tears: Surgical Prevalence and Relationship with Chondral Damage of the Hip

AbstractStructural abnormalities of the hip joint have been identified as a common cause of labral and chondral lesions of the hip joint. However, labral and chondral damage can occur in the absence of structural abnormalities. The authors examined the incidence of anteromedial (AM) labral lesions, occurring in a nonimpinging region of the hip joint, and determined if the prevalence and location of concomitant chondral lesions differ between patients with AM lesions and those without. Between 2001 and 2013, they assessed 2,080 hips (1,818 patients) undergoing hip arthroscopy for the presence of AM labral lesions (between 4 and 6 o'clock position) and documented incidence of these lesions. The articular cartilage of the posterior, superior, and anterior regions of the acetabulum and femoral head was assessed. The degree of damage was classified as absent, mild (grades I/II), or severe (grades III/IV). The prevalence and severity of lesions in each region were compared between patients with AM lesions and those without. The authors identified 1,140 hips (1,028 patients) (55%) with labral tears in the AM region of the acetabulum. The cohort consisted of 689 females and 328 males, with an average age of 37.9 ± 12 years. Chondral lesions were present in all regions of the femoral head and acetabulum in both patients with AM lesions and those without. There is a relationship between the presence of AM lesion and prevalence of chondral lesions in the posterior and anterior femoral head and acetabulum, with a higher prevalence of lesions observed in patients without AM tears. Their findings show that lesions in the AM region of the acetabular labrum can occur with high prevalence in patients. These lesions are often associated with concomitant injuries to the anterior chondral surfaces, which may differ from lesions in the impingement zone. A thorough evaluation of all regions of the hip joint is warranted during arthroscopy to identify and treat all potential lesions.

Higher Prevalence of Concomitant Shoulder Labral Tears in Patients With Femoroacetabular Impingement

To examine the prevalence of concomitant symptomatic glenoid labral tears in patients with femoroacetabular impingement (FAI) in comparison to a control group of patients undergoing anterior cruciate ligament (ACL) reconstruction. We retrospectively identified 1,644 patients who underwent femoroacetabular osteoplasty (FAO) and labrum repair from January 2007 to September 2016 and 1,055 patients who underwent arthroscopic ACL reconstruction from January 2012 to December 2014, which acted as our control group. An electronic questionnaire, including 8 questions regarding history of shoulder pathology, was sent to all patients in both groups. Symptomatic shoulder labral tears were identified on the basis of a positive magnetic resonance imaging scan or history of labral repair by reviewing patients' medical records and the filled questionnaire. Continuous variables were compared by use of a Mann-Whitney U test, and categorical variables were compared using Fisher's exact test. The Holm-Bonferroni sequential correction method was used to adjust P values for multiple comparisons of the presence of shoulder pathology. A total of 443 patients (405 cam lesion) in the FAO group and 307 patients in the ACL reconstruction group completed the prepared questionnaire and were included in the study. Patients in the FAO group were slightly older (36.3years [range, 15.4-61.7] vs 32.3years [range, 16.3-75.7]) and more commonly female in the FAO group (58.0%, n= 257) compared with those in the ACL group (48.9%, n= 150). The prevalence of shoulder labral tear was 12.0% (95% confidence interval [CI], 9.3%-15.3%) for the FAO group compared with only 3.3% (95% CI, 1.8%-5.9%) for the ACL group. This represents a 3.7-fold (95% CI, 1.9-7.1) increase in the risk of shoulder labral tear for patients in the FAO group. Furthermore, shoulder labral tears were reported to be traumatic in only 43.4% of patients in the FAO group compared with 80.0% of patients in the ACL group. A similar proportion of patients in both groups (66.0% for FAO vs 60.0% for ACL) underwent a shoulder labral repair procedure. There appears to be an association between acetabular labral tear caused by FAI and shoulder labral lesions. Patients in the FAI group had a 3.7-fold increase in the risk of shoulder labral tear compared with the ACL group. Future studies are needed to examine a possible cause behind the current findings. Level III, comparative trial study.

Assessments of activities of daily living after arthroscopic SLAP repair with knot-tying versus knotless suture anchors.

The clinical influence of knot-tying or knotless anchor systems for the arthroscopic repair of SLAP lesions (superior labrum lesion from anterior to posterior) remain unclear. In a retrospective cohort analysis, 61 of 78 (78.2%) patients with isolated symptomatic SLAP II lesions were examined with a minimum of 24months after arthroscopic SLAP repair compared to a control group: 28 patients with knot-tying anchors (group I, G1; 28.95 ± 9.48 years, 23 male/5 female), 33 with knotless anchors (group II, G2; 31 ± 10.09 years, 26 male/7 female) and 140 healthy volunteers (group III, G3; 30.9 ± 8.9 years, 109 male/31 female). The clinical assessment included an examination and estimated parameters of ADL (activities of daily living), the CS (Constant score), ASES (American Shoulder and Elbow score), DASH (disability of arm-shoulder hand) and the RS (Rowe score). The ROM analysis recorded no significant differences for the external rotation in 0° abduction (G1 63.75° ± 15.55° versus = vs G2 65.30° ± 18.15°; pERG1 vs G2 = 0.72). The clinical outcomes revealed significantly decreased pain status in G1 for the O'brien test and in G2 for the Palm-up test, whereas Yergason test showed similar pain levels (pO'brien = 0.03; ppalm up = 0.02; pyergason > 0.5). The pulley associated rotator cuff tests revealed a significantly inferior force status in G2 compared to G1 (plift-off = 0.005, pJobe = 0.02) whereas the further rotator cuff assessments were equal. In general, the intervention group showed increased pain level and functional deficits compared to the G3. The score analysis detected no significant differences with PCSG1 vs G2, PASESG1 vs G2, PDASHG1 vs G2 and PRSG1 vs G2 all > 0.05 and significant impairments compared to G3 in all scores pG1/G2 vs G3 < 0.05 (CSG1 = 88.28 ± 14.42, CSG2=92.73 ± 9.24, CSG3 = 96.2 ± 4.96; ASESG1 = 81.10 ± 21.69, ASESG2 = 85.35 ± 17.12, ASESG3 = 94.95 ± 10.39,; DASHG1= 35.75 ± 13.44, DASHG2 = 36.03 ± 17.55, DASHG3 = 27.13 ± 6.52; RSG1 = 90.71 ± 9.88, RSG2 = 88.33 ± 11.22, RSG3= 92.96 ± 11.27). The clinical assessment revealed for both anchor systems similar outcomes but showed general underestimated impairments after the SLAP repair surgery compared to the healthy control. The clinical status only marginally differed between both techniques, wherefore the present assessment of ADL allowed no recommendation of one of these two specific surgery technique for SLAP repair.

Risk of Prolonged Opioid Use Among Opioid-Naïve Patients After Common Shoulder Arthroscopy Procedures

Background: Opioid-related morbidity and mortality are major public health concerns, and the risk of long-term opioid use after shoulder arthroscopy is not well defined. Hypothesis: Substance abuse disorders, pain disorders, and psychiatric conditions increase the risk for prolonged opioid use. Study Design: Case-control study, Level of evidence, 3. Methods: Insurance claims data from the Truven Health MarketScan Research Databases was used to identify patients who underwent shoulder arthroscopy between January 1, 2010, and March 31, 2015. Opioid-naïve patients were included. New prolonged opioid use was defined as continued opioid use between 91 and 180 days after the index procedure. The authors used a multivariable logistic regression model to identify patient factors associated with the risk of new prolonged opioid use. Results: In this cohort of 104,154 opioid-naïve adult patients, 8686 (8.3%) developed new prolonged opioid use as defined in this study. A total of 31,768 (30.5%) filled an opioid prescription in the 30 days before surgery. Patients who had limited debridement had the highest prolonged use rate (9.0%), followed by rotator cuff repair (8.5%), anterior labrum lesion repair (8.5%), and extensive debridement (8.2%). Patient characteristics associated with the highest odds ratios (ORs) of prolonged opioid use included those who had a total opioid dose during the perioperative period that was ≥743 oral morphine equivalents (ie, at least 149 tablets of 5-mg hydrocodone) (OR, 2.0; 95% CI, 1.9-2.1), followed by patients with a suicide and self-harm disorder (OR, 2.0; 95% CI, 1.1-3.4), a history of alcohol dependence or abuse (OR, 1.6; 95% CI, 1.3-1.9), a mood disorder (OR, 1.3; 95% CI, 1.2-1.4), an opioid prescription filled in the 30 days before surgery (OR, 1.3; 95% CI, 1.2-1.4), female sex (OR, 1.3; 95% CI, 1.2-1.3), an anxiety disorder (OR, 1.2; 95% CI, 1.1-1.3), and a history of a pain diagnosis (OR, 1.2; 95% CI, 1.1-1.2). Conclusion: The risk of prolonged opioid use after arthroscopic shoulder procedures is 8.3%, and it is higher among women and among those with greater opioid use in the early postoperative period, mental health conditions, substance dependence and abuse, and preexisting pain disorders. Patients at high risk warrant close surveillance after surgery for early recognition and management.

Femoroacetabular impingement - Update 2019

Since the first description of the femoroacetabular impingement (FAI) concept diagnostic imaging of FAI has continuously been developed. The biomechanical concept is explained and an update on diagnostic imaging of FAI is presented. Based on a literature search this review article presents the current state of knowledge about FAI mechanisms and gives an overview on state of the art radiological diagnostics. A perspective on new imaging methods is also given. The FAI is adynamic phenomenon with amechanical conflict between the femoral head and/or neck and the acetabulum. It is usually suspected clinically; however, imaging plays an essential role in establishing the diagnosis by detecting and defining the underlying deformities of the proximal femur (cam deformity) and the acetabulum (pincer deformity) and by evaluating associated lesions of the articular cartilage and labrum. Basic imaging diagnostics consist of anteroposterior and lateral radiographs. Magnetic resonance imaging (MRI) and MR arthrography are the preferred imaging modalities for detailed analysis of deformities, for the detection and graduation of lesions of articular cartilage (sensitivity 58-91%) and labral lesions (sensitivity 50-92%). Simultaneously, these methods can exclude other hip diseases. Current standards and new developments in FAI imaging are presented. For the diagnosis of FAI typical clinical and imaging findings are required. Radiological diagnostics are an indispensable component in establishing the diagnosis of FAI, in the differentiation of the underlying deformities and in the assessment of treatment-relevant joint damage.

Arthroscopic Findings and Clinical Outcomes in Patients 40 Years of Age and Older With Recurrent Shoulder Dislocation

The present study investigates the intra-articular findings and clinical outcomes after arthroscopic surgery in patients after age 40 with chronic anterior shoulder instability. Fifty patients older than 40years who underwent arthroscopic stabilization for recurrent anterior shoulder dislocation were analyzed. The mean age at the time of surgery was 44.8years (range, 40-72years), and the mean duration of follow-up was 45months (range, 28-150months). The mean visual analog scale score for pain with motion significantly improved from 4.1 preoperatively to 1.7 at the last follow-up (P < .001). The range of motion in the affected shoulder revealed limitations of 9.4° in forward flexion and 17.8° in external rotation compared with the unaffected shoulder. Both the Constant and Rowe scores significantly improved (P < .001 and P < .001, respectively). Recurrence, which includes dislocation and subluxation, occurred in 14% postoperatively. Anteroinferior labral lesion was seen in 92% of patients. Associated lesions included superior labrum anterior to posterior lesion (22%), midsubstance capsular tear (10%), and Hill-Sachs lesion (92%). Rotator cuff tears were found in 18%-partial-thickness tear in 10% and full-thickness tear, which was repaired with suture anchor, in 8%. Among the intra-articular lesions, there was no significant relation with recurrent instability or functional outcome as a single factor. In patients with chronic anterior shoulder instability who were older than 40years, the clinical results after arthroscopic surgery showed statistically significant improvement with good muscle strength recovery. The quality of labral lesion, size of the Hill-Sachs lesion, and glenoid defect showed positive correlation with the number of preoperative dislocation. The intra-articular pathologies were varied, however no single articular lesion had significant impact on the recurrence rate. Level IV, case series.

Recognition of central nervous system sensitization and its risk factors in patients with unilateral musculoskeletal shoulder pain

BACKGROUND: Overall, inferences from the majority of the literatures reviewed provide increasing evidence on the presence of central nervous system sensitization in unilateral shoulder pain. The possibility of presence of central sensitization (CS) among patients with unilateral musculoskeletal shoulder pain has not been adequately explored till date. The term “unilateral shoulder pain” in this study will be used to refer to nonneuropathic shoulder pain of different etiologies including rotator cuff pathology, adhesive capsulitis, or labral lesion. OBJECTIVES: The purpose of this study was to determine the presence of a subgroup of patients among patients with unilateral musculoskeletal shoulder pain and to further explore what extent the central nervous system sensitization correlates with other clinical measures. METHODS: Ninety-one patients with unilateral musculoskeletal shoulder pain participated in this cross-sectional study. Standardized outcome measures such as Central Sensitization Inventory-Gujarati (CSI-G) for the presence of CS, pressure pain threshold by pressure algometry, and Shoulder Pain and Disability Index for disability were administered as per standardized protocol. RESULTS: The results of the present study showed that 17 (18.7%) patients had CS. The CSI score had mild correlation with the demographic and clinical outcome measures and comorbidities such as gender (r = 0.208), duration of the condition (r = 0.208), hypertension (r = −0.238), sleep disturbance (r = −0.327), numbness (r = −0.238), and fatigue perception (r = −0.314) by the pain and disability score also had mild correlation with CSI score (P, 0.05). The risk ratio for sensitization was 2.40 for female gender, 3.07 for hypertension, 3.19 for sleep disturbance, 2.06 for numbness, and 3.87 for perceived fatigue in patients with unilateral musculoskeletal shoulder pain. CONCLUSION: The present study showed that the central nervous system becomes hypersensitive in a subgroup of patients and weakly related to factors such as female gender, chronicity of shoulder pain, hypertension, pain and disability, sleep disturbance, and perceived fatigue in patients with unilateral musculoskeletal shoulder pain.

Femoroacetabular impingement after the femoral neck fracture healed in a nonanatomical position

Introduction. Femoroacetabular impingement is the result of the pathological conditions in the osseous acetabulum and/or the proximal femur. One of its causes is a non-anatomically healed femoral neck fracture. Case report. A male, aged 51, with a subcapital left femoral neck fracture was treated conservatively. The fracture healed 9 months later and although the patient was walking on crutches he suffered from pain in the left groin. The X-ray images showed the valgus and the retroposition of the left femoral head. The patient was operated on and intraoperatively the thickness and a bone prominence in the anterosuperior femoral neck area in the line of the previous fracture were found, which was pressing and spreading beneath the acetabular labrum, thus squeezing the acetabular cartilage. The labrum lesion which was found was the result of the mechanical pressure of the existing femoral neck deformity during the hip movements. Irretrievably damaged part of the labrum was resected and the anterosuperior femoral headneck osteochondroplasty was done. One year after the surgery, the patient had no pain, he walked without limping, the impingement test was negative, the radiological parameters were adjusted and there were no signs of the avascular necrosis of the femoral head. Conclusion. The femoral neck fracture should be treated adequately with the full anatomical position and the proper internal fixation. If the deformity occurs as the result of a treatment, it should be removed as soon as possible to prevent the osteoarthritis of the hip.

Magnetic Resonance Arthrographic Demonstration of Association of Superior Labrum Anterior and Posterior Lesions With Extended Anterior Labral Tears

The objective of this study was to evaluate retrospectively the full extent of anterior labral tear and associated other labral tears on magnetic resonance arthrographic images in patients with anterior shoulder instability. One hundred ten magnetic resonance arthrography images with anterior labral tear were retrieved from the database of the Radiology Department. Two skeletal radiologists, one with 15 years of experience and the other with 5 years of experience analyzed the images in random order. Approval for the study was granted by the Ethics Committee. Statistical analyses were performed using SPSS software. The most common localization of the labral lesions was at the anterior-inferior part of the glenoid labrum (22.7%). The anterior labral tears were commonly associate with superior labrum anterior and posterior (SLAP) lesions (45%). The most common type of SLAP lesion was type V (23.6%). Superior Labrum Anterior and Posterior type V lesion was more often detected in patients with Bankart lesion (27.7%, P = 0.043). Isolated anterior labral tears are less than expected. In majority of the cases, a distinct tear at a different site of the labrum accompanies the anterior labral tear. Massive anterior labral tears are mostly seen together with SLAP lesions.

Is hip arthroscopy useful for the treatment of borderline dysplasia? A case-controlled study

Introduction:The idyllic treatment of hip dysplasia is periacetabular osteotomy (PAO). Since the indication of arthroscopy as a unique action is controversial in the treatment of dysplasia, our objective was to analyze its clinical and radiological results in a cohort of patients with borderline dysplasia and compare them with controls with femoroacetabular impingement (FAI).Material and methods:We retrospectively analyzed a group of 29 patients with a labral lesion secondary to borderline hip dysplasia (group 1) and another group of 197 patients with FAI (group 2) treated with hip arthroscopy, evaluating reoperations and joint survival as the main outcomes. Only patients with both diagnoses treated with hip arthroscopy and with a minimum follow-up of 2 years were included. We excluded patients with coxa profunda, patients who only underwent labral debridement, revisions, cases with dysplasia initially treated with PAO and those with previous ipsilateral hip pathology such as local neoplasia, avascular necrosis, Perthes disease or epiphysiolysis. The diagnosis of borderline dysplasia was made radiologically, with a lateral center-edge angle greater than 18° but less than 25°. Among patients of group 1, the arthroscopic capsulotomy was minimal (punctate) and the iliofemoral ligament was always respected; thus, capsular plicature was not performed in any case. The average follow-up was 43 months, being 41 months for group 1 and 43 months for group 2 (p=0.33). Although there was a greater proportion Tönnis 2 of degenerative changes among patients with FAI (10%) than in the group with borderline dysplasia (0.5%), this difference was not significant (p=0.14). Both groups presented with a high prevalence of CAM type lesion (88% of the series). However, the mean radiological alpha angle value was higher in group 1 (61°) than in group 2 (57°) (p=0.002). The Tönnis angle was categorized as normal (0-10°) in all patients with borderline dysplasia and in 71% of the FAI group, but in the rest of the latter group it was less than 0° (p<0.001). The average Wiberg angle was 22° in group 1 and 34° in those with FAI (p<0.001); while the average anterior center-edge angle was 23° in the first group and 30° in the second (p <0.001). We performed a multivariate regression analysis to associate the need of reoperation with different demographic, radiological and intraoperative variables.Results:There were 7 complications among patients of group 2: a superficial wound infection medically treated; 3 cases of paresthesias in pudendal territory that resolved spontaneously in all cases at 3 months postoperatively; 1 deep vein thrombosis and 2 cases of heterotopic calcifications in patients who remained asymptomatic. No complications were recorded in the borderline dysplasia group. Thirty-eight percent of the series presented with osteochondral lesions detected during the arthroscopy (p=0.69). Of these, 42% were treated with microfractures (p=0.21) because they were classified as Outerbridge grade 4. Five patients in group 2 required a new surgical procedure. In 2 of them, the reoperation consisted of a controlled dislocation due to the progression of the size of their osteochondral lesions at 21 and 48 months of the initial procedure. Both cases presented an Outerbridge 4 osteochondral lesion greater than 0.5 cm2 in the initial arthroscopy. The remaining 3 cases were treated with a revision arthroscopy due to the persistence of their symptoms at a mean of 22 months postoperatively, due to an insufficient osteochondroplasty done at the first procedure. However, the rate of joint preservation was 100% since at the end of follow-up none of the patients had to be converted to total hip replacement. Although there were no reoperations in the borderline dysplasia group, this difference with group 1 was not statistically significant (p=0.38). The multivariate regression model adjusted for reoperation showed a very strong statistical association between the finding of osteochondral lesions and therapeutic failure, with a coefficient of 0.12 (p<0.001, CI95% = 0.06 - 0.17). In the same way, although the association was weak (p=0.04, CI95% = -0.4 - -0.01), the fact of resecting the CAM lesion behaved as protector for the model with a coefficient of -0.2.Conclusion:Hip arthroscopy was useful in the treatment of borderline dysplasia, without showing survival differences with the FAI group. We suggest indicating it carefully in the dysplasia, whenever the symptoms of FAI prevail over those of instability.

Arthroscopic Management of Acute Traumatic Primary Anterior Shoulder Dislocation

AbstractBackground: Glenohumeral joint is the most mobile and most commonly dislocated joint in the human body. The patient's age at the time of injury is inversely related to the incidence of dislocation recurrence rate. Recurrence rate in athletes younger than 20, may be as high as 90%. Arthroscopic stabilization is usually successful in preventing the recurrence of shoulder dislocations leads to reduced recurrence, improved functional outcome.Aim of Study: The aim of this study is to asses the benefits of Bankart repair using suture anchors in treating patient with first time anterior traumatic shoulder instability.Patients and Methods: This prospective study was per-formed on 30 patients having anterior primary shoulder dislocation. All cases were managed by arthroscopic repair of the anterior labral lesion using suture knotted anchors.Results: Patients were assessed pre and post operatively by modified Rowe scale and ASES (American shoulder and Elbow disability system).Conclusion: Primary arthroscopic repair for first-time traumatic anterior shoulder dislocation provided satisfactory functional outcomes and improved quality of life. Primary arthroscopic stabilization can be considered best treatment option in patients younger than 30 years with first time shoulder dislocation.

Immobilization in external rotation after primary shoulder dislocation reduces the risk of recurrence in young patients. A randomized controlled trial

IntroductionPatients that sustain anterior shoulder dislocation frequently experience recurrence. Immobilisation in external rotation has been proposed as a treatment that could lower this risk. HypothesisThere is a difference in recurrence rates between immobilization in internal or external rotation following a first-time anterior shoulder dislocation. Patients and methodsSingle-center randomized controlled trial. Fifty patients with a first episode of traumatic anterior dislocation were randomly assigned to immobilization in internal rotation (IR; 25 patients) or external rotation (ER; 25 patients) for three weeks. Clinical follow-up: 24 months. Additionally, some patients underwent a magnetic resonance imaging with intra-articular contrast (MR arthrography) within seven days after trauma, and then at three months. Primary outcome: recurrence of dislocation. Secondary outcome: healing rate of labral lesions on MR arthrography. ResultsFollow-up rate in the IR and ER group was 92% and 96% respectively. Recurrence rate did not show a statistically significant difference overall (IR 47.8% vs. ER 29.2%; p=0.188), but showed a significant difference favouring ER in the 20–40 years subgroup (IR 50% vs. ER 6.4%; p=0.044). Labral lesions’ healing rate was 46.2% vs. 60% (IR vs ER; p=0.680). The recurrence rate among those with healed vs. non-healed labrum (regardless of immobilization) was 11.1% vs. 77.7% (p=0.001). DiscussionThis study suggests that immobilization in ER compared to IR reduces the risk of recurrence after a first-time anterior shoulder dislocation in patients aged between 20 and 40 years. Level of evidenceII, low-powered prospective randomized trial.

Shoulder ganglion cysts in MRI: accompanying tendon pathologies and labral lesions

Objective: The aim of this study was to investigate shoulder tendon pathologies and labral lesions that accompanied with ganglion cysts on the shoulder via magnetic resonance imaging (MRI). Material and Methods: The 893 shoulder MRIs registered in our computer automation system were reviewed retrospectively between January 2014 and December 2018. Thirty-two patients who ganglion cysts observed in three different localizations in MRI were included to our study. Three group were defined as spinoglenoid notch (1st group), paralabral (2nd group), supra acromioclavicular joint (3rd group). The cases age, gender, clinical findings, localization, size and accompanying pathologies were classified. Rotator cuff tendons, the long head of the biceps tendon pathologies and labral lesions were examined. Results: A total of 32 patients were 16 males (mean age 49±15 years) and 16 females (mean age 54.7±14 years). Groups were consisted 15 cases in 1st group, 12 cases in 2nd group and 5 cases in 3rd group. In all groups with ganglion cysts, rotator cuff pathologies were frequently accompanied. There was no a significant difference between the groups in terms of rotator cuff pathologies (p>0.05). Entrapment neuropathy in group 1, the long head of the biceps tendon and labral lesions in group 2 were frequently associated. This association was statistically significant among the groups. Large-sized cysts were observed in group 3. There was a positive correlation between cyst size and the number of accompanying pathologies in the 1st and 2nd groups (r:0.582, p:0.001). Conclusion: In symptomatic shoulder ganglion cysts, understanding ganglion cysts, knowing the pathologies accompanied with ganglion cysts may be useful for surgical plan of cases

Shoulder ganglion cysts in MRI: accompanying tendon pathologies and labral lesions

Shoulder ganglion cysts in MRI: accompanying tendon pathologies and labral lesions

The management of shoulder impingement and related disorders: A systematic review on diagnostic accuracy of physical tests and manual therapy efficacy

BackgroundDiagnostic accuracy of physical tests and effectiveness of musculoskeletal rehabilitation of shoulder disorders are still debated. ObjectivesTo investigate diagnostic accuracy of physical tests, efficacy of physiotherapy and coherence between target of assessment and intervention for shoulder impingement and related disorders like bursitis, rotator cuff and long head biceps tendinopathy and labral lesions. MethodsA systematic search of four databases was conducted, including RCTs and cross-sectional studies. Cochrane Risk of Bias and QUADAS-2 were adopted for critical appraisal and a narrative synthesis was undertaken. Results6 RCTs and 2 cross-sectional studies were appraised. Studies presented low to moderate risk of bias. There is a lack of evidence to support the mechanical construct guiding the choice of physical tests for diagnosis of impingement. Manual techniques appear to yield better results than placebo and ultrasounds, but not better than exercise therapy alone. Discrepancy between the goal of assessment strategies and the relative proposed treatments were present together with high heterogeneity in terms of selection of patients, type of endpoints and follow-ups. ConclusionsMusculoskeletal physiotherapy seems to be an effective treatment for patients with shoulder pain although it is still based on weak diagnostic clinical instruments. The adoption of more functional and prognostic assessment strategies is advisable to improve coherence between evaluation and treatment.

Acetabular Labral Reconstruction: Development of a Tool to Predict Outcomes

Background: Acetabular labral reconstruction has demonstrated good results for labral lesions not amenable to labral repair. Purpose: To determine the predictors of outcomes at a minimum 2 years after labral reconstruction. Study Design: Case series; Level of evidence, 4. Methods: Patients included in the study underwent labral reconstruction with a minimum 2-year follow-up. The primary outcome variable was the Hip Outcome Score–Activities of Daily Living (HOS-ADL). Secondary outcome measures included the 12-item Short Form Health Survey physical component summary (SF-12 PCS) and patient satisfaction with surgical outcomes. Preoperative and intraoperative variables assessed included demographics, prior surgery, chronicity of symptoms, radiographic measurements, preoperative outcome scores, and findings at arthroscopic surgery. Predictors were assessed using logistic regression with restricted cubic splines. Bivariate statistics assessed risk factors for reoperation including revision arthroscopic surgery and total hip arthroplasty (THA). Results: Three hundred seventeen of 368 labral reconstructions were available for follow-up (86.1%). Of these, 42 were converted to THA (13.2%) and 35 required revision arthroscopic surgery after labral reconstruction (11.0%). Factors associated with THA included older age, ≥2 previous surgeries, ≤2 mm of joint space, and lateral center edge angle (LCEA) <25°. Factors associated with revision included female sex, ≥2 previous surgeries, and LCEA <25°. Six patients refused to participate (1.9%), leaving 234 with a minimum follow-up of 2 years (mean, 3.7 years [range, 2.0-11.3 years]). These patients had significant improvement in HOS-ADL (71 to 90; P < .001), HOS-Sport (47 to 75; P < .001), Western Ontario and McMaster Universities Osteoarthritis Index (27 to 9; P < .001), modified Harris Hip Score (65 to 85; P < .001), and SF-12 PCS scores (41.6 to 53.1; P < .001). Median postoperative satisfaction was 9. Predictors of improvement for the HOS-ADL included higher preoperative HOS-ADL scores (P < .001), joint space >2 mm (P = .004), and no prior surgery (P = .039). Predictors of improvement for the SF-12 PCS included higher preoperative SF-12 PCS scores (P < .001), subacute chronicity (3 months to 1 year) of symptoms (P = .013), and joint space >2 mm (P = .046). Joint space >2 mm (P < .001) and higher preoperative SF-12 scores (PCS: P = .034; mental component summary: P = .039) predicted higher satisfaction. Conclusion: At a minimum 2 years’ follow-up, patients who did not undergo conversion to THA (13.2%) or require revision (11.0%), reported significant improvement in outcome scores and high satisfaction with outcomes. Predictors of revision or THA included ≥2 previous surgeries, low LCEA, female sex for revision, and narrowed joint space for THA. Higher preoperative outcome scores were the most significant predictors of improvement after labral reconstruction. Lower preoperative scores, joint space narrowing, and history of surgery were predictive of an inferior result and decreased postoperative satisfaction.

Shoulder Instability: Interobserver and Intraobserver Agreement in the Assessment of Labral Tears.

Background:The glenohumeral joint combines large range of motion and insufficient bony stabilization, making it susceptible to instability and dislocations. Arthroscopic surgery is routinely used as a diagnostic tool and has been considered the gold standard for the diagnosis of shoulder lesions. However, several studies have demonstrated variability in intraobserver and interobserver agreement.Purpose:To evaluate interobserver and intraobserver agreement in the assessment of intra-articular lesions associated with shoulder instability among fellowship-trained shoulder surgeons.Study Design:Cohort study (diagnosis); Level of evidence, 3.Methods:A total of 24 arthroscopic videos from patients treated for recurrent shoulder instability were shown to a group of 10 fellowship-trained shoulder surgeons who are members of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group. They were presented to the surgeons on 2 different occasions at least 2 months apart. They were asked to classify labral tears by their position, type, extension, other intra-articular abnormality, and preferred treatment. No patient history or physical examination data were provided. The primary outcome was the median overall percentage of agreement for the surgeons performing a video review, measured for each variable evaluated. Intraclass correlation coefficients were used to evaluate continuous variables, and kappa values were used for categorical items.Results:Interobserver agreement was good for anterior labral lesions; good for Hill-Sachs lesions; and moderate for lesions of the superior labrum, posterior labrum, anterior sublabral foramen, and position and extension of the tear. Intraobserver agreement was either good or very good for all variables evaluated, except for being poor for inferior labral lesions and moderate for lesions of the meniscoid superior labrum.Conclusion:Interobserver and intraobserver reliability for the arthroscopic assessment of labral tears in patients with recurrent shoulder instability were good to moderate for the majority of anatomic structures assessed. There was relatively good agreement between shoulder instability surgeons on assessing and documenting shoulder instability–associated abnormalities. These findings are important when interpreting collaborative clinical cohort studies with numerous surgeons involved in the research.

Arthroscopic Decompression of Spinoglenoid Notch Cyst and SLAP Repair Through a Single Working Portal

A SLAP lesion can be found with a concomitant spinoglenoid notch cyst. The cyst can cause suprascapular nerve compression, resulting in shoulder pain and weakness of external rotation. Their management varies from conservative treatment to operative treatment. Cyst decompression through the labral tear is our preferred treatment. Previous studies demonstrated a good result after arthroscopic decompression of the cyst through the labral tear combined with SLAP repair. Many surgeons usually use 3 portals to perform this procedure. However, we prefer to use only 2 portals, 1 anterior viewing portal and 1 posterior working portal. This strategy is more time and cost efficient. The patient is positioned in lateral decubitus. The SLAP lesion is demonstrated by using a probe. Tissue elevator is inserted into the labral lesion to penetrate into the cyst wall. A soft anchor is placed. A birdbeak suture passer penetrates the posterior labrum. Then knot tying is done. The advantages of this single working portal technique are short operative time, a decreased risk of iatrogenic rotator cuff injury from accessory anterolateral portal or posterior labral injury from posterolateral portal, and avoiding unnecessary superior capsule incision for cyst exposure.

Clinical and radiological outcome at mean follow-up of 11 years after hip arthroscopy.

The use of hip arthroscopy (HA) has substantially increased over the last decade. However, while the benefits of HA after 1year in patients with femoroacetabular impingement (FAI) are well documented, long-term data on the progression of osteoarthritis (OA) or patient-reported outcomes (PROMs) are lacking. To evaluate long-term clinical and radiological outcomes after HA. Preoperative clinical records, operative notes, and radiographs from all patients who underwent HA at our hospital between 1998 and 2006 were reviewed. Exclusion criteria were previous hip surgery or diagnostic HA. Primary endpoints were subsequent total hip arthroplasty (THA) or other hip surgery. Secondary endpoints were OA progression and PROMs. HA was performed in 92 consecutive patients from 1998 to 2006. Indications for HA were FAI, labral lesions, early OA, and focal osteochondral defects. Mean follow-up was 11.2years (SD 2.5, range 7.9-16). Data from 43 patients were available for analysis; 38 patients were excluded, and 11 were lost to follow-up. 20 patients had subsequent hip surgery, of which 11 patients required THA. 33 patients (77%) stated that they would undergo HA again under the same circumstances. Longitudinal radiological analysis showed no significant OA progression in patients without THA. The Forgotten Joint Score-12 was the only PROM to significantly differ between patients who had no further surgery and patients who had undergone revision (p = 0.037). There was no significant OA progression on plain radiography at an average of 11years post-HA. Sound indication criteria is essential, as 45% of patients required subsequent surgery.