Limitation Of External Rotation Research Articles

The Trillat procedure: the man and the technique revisited through the lens of arthroscopy.

The Trillat procedure, initially described by Albert Trillat, is historically one of the first techniques for addressing recurrent anterior shoulder instability, incorporating fascinating biomechanical mechanisms. After lowering, medializing, and fixing the coracoid process to the glenoid neck, the subcoracoid space is reduced, the subscapularis lowered, and its line of pull changed, accentuating the function of the subscapularis as a humeral head depressor centering the glenohumeral joint. Furthermore, the conjoint tendon creates a 'seatbelt' effect, preventing anteroinferior humeral head dislocation. Even though contemporary preferences lean towards arthroscopic Bankart repair with optional remplissage, bone augmentation, and the Latarjet procedure, enduring surgical indications remain valid for the Trillat procedure, which offers joint preservation and superior outcomes in two distinct scenarios: (i) older patients with massive irreparable cuff tears and anterior recurrent instability with an intact subscapularis tendon regardless of the extent of glenoid bone loss; (ii) younger patients with instability associated shoulder joint capsule hyperlaxity without concomitant injuries (glenoid bone loss, large Hill-Sachs lesion). Complications associated with the Trillat procedure include recurrent anterior instability, potential overtightening of the coracoid, leading to pain and a significant reduction in range of motion, risk of subcoracoid impingement, and restriction of external rotation by up to 10°, a limitation that is generally well-tolerated. The Trillat procedure may be an effective alternative technique for specific indications and should remain part of the surgical armamentarium for addressing anterior shoulder instability.

Addressing Extra-Articular Impingement in the Athlete

Extra-articular impingement (EAI) is an atypical, infrequent source of hip pain. Unlike femoroacetabular impingement (FAI) and acetabular dysplasia (AD), EAI results from abnormal contact of the proximal femur and trochanteric region, and the ischium or subspine areas. Hip pain and potential instability are reported. Causes of EAI include a narrowed ischiofemoral space, coxa valga, femoral torsion abnormalities, avulsion malunions, and more complex deformities resulting from pediatric hip diseases. Unique history and examination findings not commonly seen with standard FAI are noted, including pain with standing and hip extension and imbalanced hip motion with excessive internal rotation and limited external rotation (or vice versa). Surgical indications are yet to be definitively defined, but surgical treatment options include lesser trochanter resection, femoral osteotomy, and surgical hip dislocation. Proper workup and surgical planning have demonstrated good outcomes for treatment of EAI with these techniques, but information to optimally define which patients benefit most from which surgeries is pending.

Impact of Coracohumeral Ligament Release on Treatment Outcomes in Patients with Idiopathic Adhesive Capsulitis

Background. The coracohumeral ligament restricts external rotation of the shoulder joint and, along with the upper, middle, and lower glenohumeral ligaments, participates in stabilizing the shoulder joint. There is ongoing debate regarding the division of this anatomical structure in patients with limited external rotation. Objective: to compare the treatment outcomes of patients with idiopathic adhesive capsulitis who underwent coracohumeral ligament release along with selective capsulotomy to those who underwent only partial coracohumeral ligament release. Material and Methods. We treated 85 patients with idiopathic adhesive capsulitis, who were divided into two groups: group 1 underwent selective anterior capsulotomy of the shoulder joint with the division of the middle and lower glenohumeral ligaments, biceps long head tenotomy, subacromial decompression, and partial coracohumeral ligament release; group 2 underwent a similar surgical procedure with complete coracohumeral ligament excision. The average age of the patients was 47.9±19.1 years. The function of the shoulder joint was assessed using the Constant Shoulder Score and VAS scales before surgery and at 3 and 6 months postoperatively. Results. At 3 months postoperatively, group 2 showed a slightly better functional outcome according to the Constant Shoulder Score (12.2±6.9 points) compared to group 1 (18.1±6.4 points, p=0.038). At 6 months postoperatively, group 1 had a mean Constant Shoulder Score of 15.1±7 points, while group 2 had a score of 10.1±6.3 points (p=0.02). Conclusions. Excision of the coracohumeral ligament in patients with idiopathic adhesive capsulitis allows for better functional outcomes according to the Constant Shoulder Score and VAS at both 3 and 6 months postoperatively.

Shoulder Stabilization Technique Using the Medial Glenohumeral Ligament in Patients With the Buford Complex

The Buford complex is an anatomic variation defined as the association of a cordlike middle glenohumeral ligament (MGHL) and an absent anterosuperior labrum. It can be challenging to properly identify on preoperative imaging and remains mostly an arthroscopic finding. It may, however, lead to problematic situations when encountered during an arthroscopic soft-tissue stabilization procedure, as the treatment of choice in such cases is a bone block. Moreover, reattaching the MGHL to the anterior border of the glenoid rim has traditionally not been recommended because it theoretically leads to severe restriction in external rotation. This technical note describes arthroscopic stabilization for anterior traumatic glenohumeral instability associated with the Buford complex. The cordlike MGHL is used to reconstruct a neo-labrum, associated with an anteroinferior glenohumeral ligament plication. Glenohumeral stabilization using the cordlike MGHL of the Buford complex may be an efficient alternative to a bone block procedure.

Latarjet procedure for failed Bankart repair provides better stability and return to sports, but worse postoperative pain and external rotation limitations with more complications, compared to revision Bankart repair: a systematic review and meta-analysis.

This study aimed to compare the clinical results of revision Bankart repair versus the Latarjet procedure for failed Bankart repair. A literature search was performed in databases, such as Pubmed, Embase, and Scopus Library. The studies were appraised using the Methodological Index for Non-randomized Studies tool. Studies for failed Bankart repair with revision Bankart repair or Latarjet procedure were included. The pain VAS, ROWE score, rate of return to sports and preinjury level of sports, recurrent instability, range of motion, and complications were compared. Additionally, the pain VAS, ROWE score, forward flexion, and external rotation at side were subjected to a meta-analysis. Twenty-four articles were included in the systematic review. The functional outcomes in terms of the ROWE score, recurrent instability, return to sports, and the preinjury level of sports was better in the Latarjet procedure group than those in the revision Bankart repair group (ROWE score, 91 vs. 86.7; recurrent instability rate, 3.5% vs. 14.4%; return to sports rate, 100% vs. 87.9%; return to preinjury level of sports rate, 89.9% vs. 74.9%; all P < 0.001). However, the results of postoperative pain and the postoperative limitation of external rotation at side were worse in the Latarjet procedure group than those in the revision Bankart repair group (pain VAS, 1.4 vs. 0.8; postoperative external rotation at side, 38° vs. 60°; all P < 0.001). In addition, the majority of the complications occurred in the Latarjet procedure group. In the meta-analysis, the postoperative ROWE score was significantly higher in the Latarjet procedure group than that in the revision Bankart group (revision Bankart repair: 95% CI 88.9-80.9, I2 = 65.70; Latarjet procedure: 95% CI 95.8-88.1, I2 = 93.37; P = 0.014). However, the pain VAS, forward flexion, and external rotation at side did not reach the significant level in the meta-analysis. Compared with revision Bankart repair, the Latarjet procedure for failed Bankart repair showed better ROWE scores, stability, and return to sports or preinjury level of sports; however, the postoperative pain and the limitation of external rotation at side were worse with more complications. KUMC 2022-01-024. Level IV.

Latarjet procedure without capsular repair produces favorable clinical results and avoids limitation in external rotation.

This study aimed at analyzing the range of motion (ROM) and other clinical outcomes in patients with > 20% glenoid bone loss who underwent the Latarjet procedure with or without anterior capsule repair. This retrospective study included 47 patients with > 20% glenoid bone loss who underwent the classic Latarjet procedure from 2016 to 2021. Of these, 25 did not undergo capsular repair (no-capsular-repair group; group I) whereas 22 patients did (capsular-repair group; group II). The Rowe score, American Shoulder and Elbow Surgeons score, Visual Analogue Scale, ROM, recurrence, and complications were evaluated before and 3, 6, and 12months after the surgery. A goniometer was used to measure the forward flexion and external rotation (arm adducted, 90° abducted) of both shoulders. The ROM deficit was measured as the difference from the contralateral healthy shoulder. The external rotation in arm adduction at 3 and 6months after surgery showedsignificantly better results in group I than group II(p = 0.002 at 3months; p = 0.005 at 6months). The deficit in external rotation with arm adduction was also significantly lower in group I at 3months (p = 0.001) and 6months (p = 0.001) after surgery. However, external rotation with arm adduction at 12months after surgery did not significantly differ between the groups. Moreover, the ROM in external rotation with 90° arm abduction was significantly better in group I than that in group II at 3, 6, and 12months postoperatively (p = 0.002, p = 0.001, and p = 0.005, respectively). The deficit in external rotation with 90° arm abduction gradually decreased with time after surgery and differed significantly between the groups. However, the difference in deficit between the two groups at 12months after surgery did not exceed the measurement error. All clinical scores significantly improved after surgery compared to before surgery; however, the improvement did not significantly differ between the two groups. The Latarjet procedure without capsular repair showed good laxity restoration and clinical results with less early postoperative external rotation limitation than that achieved by the same procedure with capsular repair. However, external rotation deficit at 1year after surgery did not show a clinically relevant difference difference between the two groups. Level III.

Limited External Rotation and Hip Extension Due to Posterior Extra-articular Ischiofemoral Hip Impingement in Female Patients With Increased Femoral Anteversion: Implications for Sports, Sexual, and Daily Activities

Background: Posterior femoroacetabular impingement (FAI) is poorly understood. Patients with increased femoral anteversion (FV) exhibit posterior hip pain. Purpose: To correlate hip impingement area with FV and with combined version and to investigate frequency of limited external rotation (ER) and hip extension (<40°, <20°, and <0°) due to posterior extra-articular ischiofemoral impingement. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Osseous patient-specific three-dimensional (3D) models based on 3D computed tomography scans were generated of 37 female patients (50 hips) with positive posterior impingement test (100%) and increased FV >35° (Murphy method). Surgery was performed in 50% of patients (mean age, 30 years; 100% female). FV and acetabular version (AV) were added to calculate combined version. Subgroups of patients (24 hips) with increased combined version >70° and patients (9 valgus hips) with increased combined version >50° were analyzed. The control group (20 hips) had normal FV, normal AV, and no valgus. Bone segmentation was performed to generate 3D models of every patient. Validated 3D collision detection software was used for simulation of impingement-free hip motion (equidistant method). Impingement area was evaluated in combined 20° of ER and 20° of extension. Results: Posterior extra-articular ischiofemoral impingement occurred between the ischium and the lesser trochanter in 92% of patients with FV >35° in combined 20° of ER and 20° of extension. Impingement area in combined 20° of ER and 20° of extension was larger with increasing FV and with higher combined version; correlation was significant (P < .001, r = 0.57, and r = 0.65). Impingement area was significantly (P = .001) larger (681 vs 296 mm2) for patients with combined version >70° (vs <70°, respectively) in combined 20° of ER and 20° of extension. All symptomatic patients with increased FV >35° (100%) had limited ER <40°, and most (88%) had limited extension <40°. The frequency of posterior intra- and extra-articular hip impingement of symptomatic patients (100% and 88%, respectively) was significantly (P < .001) higher compared with the control group (10% and 10%, respectively). The frequency of patients with increased FV >35° with limited extension <20° (70%) and patients with limited ER <20° (54%) was significantly (P < .001) higher compared with the control group (0% and 0%, respectively). The frequency of completely limited extension <0° (no extension) and ER <0° (no ER in extension) was significantly (P < .001) higher for valgus hips (44%) with combined version >50° compared with patients with FV >35° (0%). Conclusion: All patients with increased FV >35° had limited ER <40°, and most of them had limited extension <20° due to posterior intra- or extra-articular hip impingement. This is important for patient counselling, for physical therapy, and for planning of hip-preservation surgery (eg, hip arthroscopy). This finding has implications and could limit daily activities (long-stride walking), sexual activity, ballet dancing, and sports (eg, yoga or skiing), although not studied directly. Good correlation between impingement area and combined version supports evaluation of combined version in female patients with positive posterior impingement test or posterior hip pain.

Comparing the Results of Latissimus Dorsi Versus Teres Major Transfer in Children With Obstetric Brachial Plexus Injury and Residual Shoulder Sequelae.

Obstetric brachial plexus injury (OBPI) remains a fairly common problem in newborns despite the improved obstetric care. Children who do not show complete recovery often present with residual shoulder deformity of limited external rotation and abduction. Secondary interventions in the form of tendon transfer and soft tissue release are aimed at correcting the implicated muscular imbalance to restore shoulder function. The aim of this work was to compare the results of latissimus dorsi versus teres major tendon transfer in patients with OBPI with limited shoulder external rotation. This study included 40 patients admitted to El Hadara University Hospital with OBPI and limited shoulder abduction and external rotation aged between 1.5 and 4 years. Half of the patients had a latissimus dorsi transfer, and the other half, a teres major one. Children with limited preoperative passive external rotation in both groups required a subscapularis slide. Patients were evaluated preoperatively, at 6 months, and 12 months postoperatively using the Gilbert scale. Teres major tendon transfer showed better results in restoring limited shoulder abduction and external rotation than latissimus dorsi transfer. Limited shoulder internal rotation was the main complication occurring postoperatively. Loss of the last degree of internal rotation occurred in most patients who had subscapularis slide. Most patients regained functional midline abilities with physiotherapy and required no further interventions. Isolated teres major transfer has shown better results in improving the range of external rotation and abduction compared with isolated latissimus dorsi tendon transfer. Age of the patients did not affect the overall final improvement in shoulder range of motion. Limited internal rotation is the main complication postoperatively, which was prevalent in patients who required a subscapularis slide but was not statistically significant.

Two cases of bilateral reverse shoulder arthroplasty performed in patients with rheumatoid arthritis.

Bilateral shoulder joint disorders caused by rheumatoid arthritis significantly impair daily functioning owing to a lack of contralateral compensation. In Japan, reverse shoulder joint prostheses were approved in 2014. This was expected to improve the surgical outcomes of rheumatoid shoulder arthroplasty. We report two patients with rheumatoid arthritis who underwent bilateral reverse shoulder arthroplasty. This study aims to evaluate their postoperative clinical outcomes and activities of daily living. The patients were women in their 70s with stage III class 2 rheumatoid arthritis. Their treatment and postoperative activities of daily living were retrospectively reviewed. The first patient underwent the inlay type and experienced a residual limitation of external rotation postoperatively; therefore, she was restricted to dress with front-open clothes. However, she was able to undress after the lining of the garment was changed to a slippery material. The second patient underwent the onlay type and showed almost no limitations in postoperative activities of daily living. She was able to undress with an external rotation of 40-50°. Bilateral reverse shoulder arthroplasty improved range of motion, the Japanese Orthopaedic Association shoulder score, and functional outcomes. Only a few difficulties were encountered in the activities of daily living.

Role of middle glenohumeral ligament in external shoulder rotation

The middle glenohumeral ligament (MGHL) is one of the three ligaments that stabilize the anterior capsule of the shoulder. Recent work suggests that it inserts distally into the deep layer of the subscapularis tendon. The role of the MGHL remains debated. The hypothesis of this study was that the MGHL plays a significant functional role in limiting external rotation of the shoulder while allowing a wide range of motion through its distal insertion into the subscapularis rather than directly onto the humerus. In a cadaveric study performed on 20 shoulders (10 subjects), the MGHL and the other anterior structures of the shoulder were successively cut according to a standardized protocol. At each stage, the external rotation range of the shoulder was measured with the arm at the side (ER 1) and in 90° abduction (ER 2) using a goniometer. After dissection, the structure of the MGHL and its distal insertion were analyzed. Cutting the MGHL led to significant increases in ER 1 but not in ER 2. Shoulder range of motion in ER 1 increased on average by 15±5° (P<.001) after cutting the MGHL and by 21±11° (P<.001) after subscapularis peel. The range of motion in ER 2 increased by 3±4° (P=.048) after cutting the MGHL, by 4±6° (P=.02) after subscapularis peel and by 25±8° (P<.001) after cutting the inferior glenohumeral ligament. The MGHL was present in all dissected shoulders. It was leaf-like in 12 cases, cord-like in 6 cases and had a vestigial appearance in 2 cases. The distal insertion was in all cases in the deep layer of the subscapularis in a thickening of the anterior capsule in the superior part of the muscle, except for two cases in which the tendinous part of the subscapularis was also involved. The MGHL limited shoulder external rotation by a similar amount as the subscapularis muscle. Further studies are required to understand the clinical relevance of these findings, notably for the treatment of shoulder stiffness.

Remplissage in Addition to Arthroscopic Bankart Repair for Shoulder Instability With On-Track Hill–Sachs Lesions Reduces Residual Apprehension Without External Rotation Limitation

<h3>Purpose</h3> To evaluate the role of remplissage as an adjunct to Bankart repair in patients with recurrent anterior shoulder dislocation combined with on-track Hill–Sachs lesion. <h3>Methods</h3> Arthroscopic Bankart repair with remplissage data (December 2018-2020) were collected (BR group). Inclusion criteria were (1) recurrent anterior shoulder dislocation, (2) on-track Hill–Sachs lesion, (3) minimal/subcritical glenoid bone loss (<17%), and (4) postoperative follow-up >1 year. Exclusion criteria were (1) revision surgery, (2) first dislocation with acute glenoid rim fracture, and (3) combined with other surgery. The control group was identified in Bankart repair–only cohort (B group). All patients were evaluated preoperatively, and at 3 weeks, 6 weeks, 3 months, 6 months, and then annually postoperatively. Visual analogue scale for pain, Self-Assessment Numerical Evaluation, American Shoulder and Elbow Surgeons Shoulder score, ROWE, and Western Ontario Shoulder Instability were evaluated at preoperative and final follow-up. Residual apprehension experience and external rotation deficit were evaluated. Patients, who were followed-up for more than 1 year, were asked how often they experienced any subjective apprehension in 4 grades (1: always, 2: frequently, 3: occasionally, 4: never). Patients who had a history of recurrent dislocation or revision surgery were investigated. <h3>Results</h3> In total, 53 patients (B, 28; BR, 25) were included. At final follow-up, both groups showed improvement in 5 clinical scores postsurgery (<i>P</i> < .001). The BR group showed greater ROWE scores than the B group (B: 75.2 ± 13.6, BR: 84.4 ± 10.8; <i>P</i> = .009). Residual apprehension patient ratio (B: 71.4% [20/28], BR: 32% [8/25]; <i>P</i> = .004) and the mean subjective apprehension grade (B: 3.1 ± 0.6, BR: 3.6 ± 0.6; <i>P</i> = .005) showed statistically significant difference, whereas no patients in either group experienced external rotation deficit (B: 14.8 ± 12.9°, BR: 18.0 ± 15.2°, <i>P</i> = .420). Only 1 patient in the B group had not responded to surgery, with dislocation recurrence (<i>P</i> = .340). <b>Conclusions</b>: Remplissage with arthroscopic Bankart repair in on-track Hill–Sachs lesion has a role in reducing residual apprehension without external rotation limitation. <h3>Level of Evidence</h3> Level III, retrospective comparative therapeutic trial.

Arthroscopic Trillat technique for chronic post-traumatic anterior shoulder instability: outcomes at 2 years of follow-up.

The purpose of this study was to assess the outcomes of a new arthroscopic Trillat technique at a 2-year follow-up. Our current hypothesis was that this technique could be used for the effective treatment of chronic post-traumatic unidirectional anterior shoulder instability, and that the recurrence and complication rates, external rotation, and functional outcomes would be as good as those of the reference technique. Between April 2012 and August 2016, all patients older than 16 years who underwent the arthroscopic Trillat technique for unidirectional chronic post-traumatic anterior shoulder instability at the Dijon University Hospital (France), after the failure of well-conducted medical and rehabilitation treatment with at least 24 months of follow-up, were included. Criteria for noninclusion were association with posterior and/or inferior instabilities, voluntary instabilities, and glenoid bone loss greater than 20%. Patients attended follow-up with their surgeon before the intervention, in the immediate postoperative period, at 6 weeks, 3 and 6 months, and then by an independent observer for the last evaluation. Patients were then examined clinically with scores such as Constant, Rowe and Walch-Duplay scores, and subjective shoulder value, for shoulder range of motion, and radiographically (anteroposterior and Lamy's lateral x-rays of the operated shoulder). Forty-nine patients and 52 shoulders were included, with a mean follow-up of 40 months (range, 24-71 months). The recurrence rate of instability was 3.8% (2 of 52). No conversion to arthrotomy was necessary. No intraoperative complications, postoperative neurological lesions, or sepsis were observed. The mean Constant score was 92.1 (77.5-100) points, Walch-Duplay 82.9 (40-100), Rowe 81.73 (5-100), and subjective shoulder value 86.1 (50-100) at the last follow-up. The arm at side external rotation limitation averaged 8.4° (-25° to 40°) and the external rotation with 90° arm abduction limitation 0.34° (-5° to 15°). Forty-one patients (79%) resumed their sports activity at the same level. Fifty patients (96%) were satisfied to very satisfied. One patient developed nonunion of the coracoid process and subsequently underwent a Latarjet procedure with a good outcome. The arthroscopic Trillat procedure offers good outcomes as a first-line treatment for chronic anterior post-traumatic glenohumeral instability. It should be excluded in cases of glenoid loss greater than 20%.

Long-term results of arthroscopic Bankart repair with remplissage

Objectives:Arthroscopic Bankart repair with Hill-Sachs remplissage (BHSR) is suggested to treat anterior shoulder instability when there is an engaging humeral lesion. The objective of this study was to report the long-term clinical and radiological results of this procedure.Methods:This is a retrospective monocentric study including patients who underwent surgery for anterior shoulder instability by BHSR, seen again within a minimum of 5 years. 70% of the 51 patients (mean age 26 years; 16 - 49; ± 8.453 years) practiced sports. The mean ISIS score was 3.306 (0 - 7; ± 1.798). At the last follow-up, active range of motion, Subjective Shoulder Value (SSV), and Walch-Duplay and Rowe scores were measured. A radiographic assessment enabled the evaluation of arthrosis according to Samilson’s classification.Results:At a mean clinical follow-up of 86.8 months (60.0 - 123.9 ± 17.0 months), 83% of the patients had resumed sports activities. The mean Rowe, Walch-Duplay and SSV scores were 88.8 points (51-100; ± 12.4), 82.6 points (50 - 100; ± 16.4) and 87.9% (50 - 100, ± 8.5), respectively. 8 patients (15.6%) had a recurrence of dislocation or incomplete dislocation. In univariate analysis, patients who were stable at the last follow-up had a significant mean decrease in external rotation in adduction of 7° (p = 0.02) and in abduction of 6° RE2 (p = 0.006), a shallower Hill-Sachs (18% vs 25% of the humeral head diameter; p = 0.04), and were older (27 vs 19 years, p = 0.04). Radiographically, 84% of the patients had no osteoarthritis progression, while 13% had grade I osteoarthritis progression.Conclusion:BHSR allows resumption of sports activity in the majority of cases, with minor limitation of external rotation. However, the high failure rate in more than 5 years suggests that this procedure should be proposed with caution in case of a deep Hill-Sachs in young subjects.

Arthroscopic Cortical-Button Latarjet Procedure for Anterior Shoulder Instability With Glenoid Bone Loss

Background: The Latarjet procedure is a common treatment of anterior shoulder instability associated with glenoid bone loss. Advanced arthroscopic technique provided a safe cortical-button fixation of the coracoid process transferred onto the glenoid neck combined with a Bankart repair. Indications: This is an 18-year old woman, complaining of recurrent right shoulder dislocation and subluxation, which made her unable to play handball at competitive level. Physical examination confirmed anterior apprehension without hyperlaxity. Computed tomography (CT) scan identified a Hill-Sachs lesion and a glenoid bone loss of 11%. Instability Severity Index Score was calculated at 7 points. Technique Description: Patient was placed in a beach-chair position under general anesthesia combined with an interscalene nerve block. A 70° scope and specifically designed instruments were used. The technique required 5 steps: (1) coracoid preparation: pectoralis minor and coracoacromial ligament release, flattening of the undersurface, positioning of the peg button, and osteotomy of the coracoid; (2) glenoid preparation: flattening of the neck of the scapula, insertion of 2 anchors (3 and 6 o’clock), and glenoid drilling with a specific guide; (3) subscapularis split: use of an intra-articular and extra-articular spreader splitting the subscapularis muscle at the level of the glenoid wire (shoulder in neutral rotation) and opening of a “safe window”; (4) fixation step: transfer of the coracoid through the subscapularis split with shuttle suture and permanent fixation with a posterior cortical button (compression controlled at 100 Newtons with a dynamometer); and (5) Bankart repair. The shoulder was protected in a sling 4 weeks, and external rotation recovery was allowed at 6 weeks. Results: Favorable outcomes were reported at 6 months of follow-up without any complication. Full range of motion with limited external rotation deficit was obtained and a negative apprehension test. Radiologic assessment confirmed graft incorporation at 6 months, allowing return to overhead sports at a competitive level. Discussion/Conclusion: Arthroscopic cortical-button Latarjet procedure is a safe option to treat anterior shoulder instability associated with glenoid bone loss in patient with high demand sports. The procedure is safe and combine bone graft and Bankart repair. Using a cortical button fixation avoids screw related complications.

Latissimus dorsi transfer with amodified single-incision Herzberg technique and description of its arthroscopic advancement

Latissimus dorsi transfer aims to reduce pain and improve function for irreparable tears of the posterosuperior rotator cuff by restoring the transversal force couple to improve external rotation and delaying superior migration of the humeral head. Surgery is advocated in patients with unbearable shoulder pain and limited external rotation caused by an irreparable posterosuperior rotator cuff tear. Usually, alatissimus transfer is recommended in the presence of superior migration of the humeral head, higher grade fatty infiltration of the rotator cuff and arestriction of range of motion and strength for abduction and external rotation. Advantages of the arthroscopically assisted technique are the missing need of detaching the deltoid from its origin, smaller incisions and therapy of concomitant intraarticular lesions. Little pain and sufficient shoulder function in massive posterosuperior rotator cuff tears do not necessitate latissimus transfer. In the presence of subscapularis tears, osteoarthritis and deltoid dysfunction as well as shoulder stiffness tendon transfer are associated with inferior clinical outcomes. Surgery is performed in prone position. The incision is made about 5 cm caudal of the posterolateral corner of the acromion and extends over 6 cm at the inferior border of the deltoid muscle. After exploration and protection of the axillary and radial nerve the latissimus tendon is peeled off of the humerus. The medial part of the latissimus is then mobilized to gain length for the later transfer. Afterwards the footprint of the infraspinatus is visualized and debrided. Two or three suture anchors are placed into the posterosuperior aspect of the greater tuberosity. The sutures are stitched through the tendon in ahorizontal mattress stitch configuration and the tendon tied onto the bone. In arthroscopic advancement, the patient is placed in an upright beach-chair position with the arm attached to an arm holder. After debridement of the supraspinatus and infraspinatus footprint, arthroscopic preparation at the anterior border of the subscapularis tendon is performed. The latissimus tendon is visualized and detached with electrocautery. Afterwards the interval between posterior rotator cuff and deltoid muscle is prepared to allow the transfer of the latissimus tendon to the posterosuperior footprint. This marks the transition to the open approach, in which the arm is placed in aflexed and internally rotated position. Immobilization in ashoulder sling for 3weeks. Early passive range of motion (ROM: flexion30°, internal rotation60°, abduction0°, external rotation0°) was immediately allowed. After 3weeks, passive ROM was increased to90° of flexion, 60° of abduction, whereas external rotation was still restricted. After 7weeks, free passive ROM and after 8weeks active ROM (assisted) were allowed. In all, 67patients (mean age 63years) were examined 54months (± 28) after open transfer of the latissimus dorsi tendon. Constant score improved from 24 (± 6) points to 68 (± 17) points. Active flexion increased from 83° (± 47°) to 144° (± 35°), abduction from 69° (± 33°) to 134° (± 42°) and external rotation from 24° (± 18°) to 35° (± 21°). The VAS score decreased from 6.3 (± 1.1) to 1.8 (± 2). However, osteoarthritis worsened over time and the Hamada-Fukuda stage increased from1.4 to2.1 and the acromihumeral distance decreased from 7.9 (± 2.6) to 5.1 (± 2.2) at final follow-up.

Is limited external rotation after reverse shoulder arthroplasty associated with glenoidal notching?

AbstractBackgroundReverse shoulder arthroplasty (RSA) is a valuable solution for patients with shoulder pain or injury primarily due to a rotator cuff tear or secondary to traumatic events. Nevertheless, several complications are known to appear, with the most frequent being scapular notching (SN) on the inferior and posterior scapular neck. Controversial data exist about the clinical relevance of SN. Since further consequences are still not clearly understood, we aimed to provide more clarity on which factors, especially external rotation (ER), contribute to the appearance and progress of notching.MethodsConstant Score (CS), Subjective Shoulder Value (SSV), flexion, abduction, and ER were evaluated retrospectively in 153 shoulders of 147 patients (mean age 79±7.7 years; 62% women) who underwent RSA between 2005 and 2010. Anteroposterior radiographs were evaluated before and 1, 2, 3, and 5 years after RSA for SN according to the Sirveaux classification. The evaluation was performed by two independent surgeons. Spearman’s coefficient andt-test were used.ResultsCS, SSV, flexion, and abduction increased significantly 1 year after RSA compared to before (allp &lt; 0.0001). No improvement was shown for ER between the same timepoints. Between 2 and 5 years of follow-up, only flexion decreased by 5°(p = 0.02) while CS, SSV, abduction, and ER remained constant. After RSA, notching increases over time. There was no association between SN and CS, SSV, flexion, abduction or ER at any of the measured timepoints. Higher flexion correlated with higher abduction after RSA at every follow-up (1 yearr = 0.88, 2 yearsr = 0.89, 3 yearsr = 0.86, 5 yearsr = 0.86). The interrater correlation test showed a strong correlation (r = 0.7).ConclusionWe verified the functional benefits of RSA for patients. Additionally, our findings show that despite radiographic progression of notching and unchanged limited ER, the postoperative improvements in CS, SSV, flexion, and abduction are preserved over 5 years.

Gripforce reduction in children with an upper neonatal brachial plexus palsy.

ObjectiveTo assess gripforce in children with a C5 and C6 neonatal brachial plexus palsy, as it may affect hand use. Applying classic innervation patterns, gripforce should not be affected, as hand function is not innervated by C5 or C6. This study compares gripforce in children with a neonatal brachial plexus palsy with that in a healthy control group, and assesses correlations with hand sensibility, bimanual use and external rotation.MethodsA total of 50 children with neonatal brachial plexus palsy (mean age 9.8 years) and 25 controls (mean age 9.6 years) were investigated. Nerve surgery had been performed in 30 children, and 20 children had been treated conservatively. Gripforce of both hands was assessed using a Jamar dynamometer. Sensibility of the hands was assessed with 2-point discrimination and Semmes-Weinstein monofilaments. External rotation was assessed using the Mallet score. Bimanual use was measured by using 1 of 3 dexterity items of the Movement Assessment Battery for Children-2. The affected side of the neonatal brachial plexus palsy group was compared with the non-dominant hand of the control group using 1-way analysis of variance (ANOVA), χ2 and Mann–Whitney tests.ResultsThe mean gripforce of the affected non-dominant hand of children with neonatal brachial plexus palsy was reduced compared with healthy controls (95 N and 123 N, respectively, with p = 0.001). The mean gripforce of the non-dominant hand in the control group was 92% of that of the dominant hand, while it was only 76% in the neonatal brachial plexus palsy group (p = 0.04). There was no relationship between gripforce reduction and sensibility, bimanual use or shoulder external rotation.DiscussionThe gripforce in neonatal brachial plexus palsy infants with a C5 and C6 lesion is lower than that of healthy controls, although classic interpretation of upper limb innervation excludes this finding. The reduction in gripforce in upper neonatal brachial plexus palsy lesions is not widely appreciated as a factor inherently compromising hand use. The reduction in gripforce should be taken into consideration in planning the type of rehabilitation and future activities.LAY ABSTRACTChildren with a shoulder nerve lesion caused at birth, use the hand at that side in a limited way. This is odd, as hand function is not controlled by nerves of the shoulder plexus. To get more information about the hand use, we investigated the gripforce and compared this with healthy children. This objective comparison has not been carried out before. Fifty children with comparable shoulder nerve lesion and twenty five controls were investigated. Gripforce of the affected hand was 23 % lower than the gripforce of the hand of the controls. This finding contradict previous research. Also the often limited external rotation of the shoulder in the group with nerve lesion could not be correlated with the diminished gripforce. Diminished gripforce is not widely appreciated as a factor compromising hand use. This reduction should be taken into consideration in planning the type of rehabilitation and future activities.

Arthroscopic Bankart repair with knotless suture anchors: A comparison of the permanent and absorbable types

Aim:The aim of this study was to compare the clinical outcomes of arthroscopic Bankart repair (ABR) using two types of knotless suture anchors (KSAs) in patients with post-traumatic recurrent anterior glenohumeral instability (AGHI).Methods:Thirty-two patients underwent an ABR using KSAs: a permanent KSA (PushLock) and an absorbable counterpart (BioKnotless). There were 16 patients in each group. Pre-and post-operative assessment for shoulder function using the American Shoulder and Elbow Surgeons and Constant–Murley scores, recurrence of instability, post-operative limitation of external rotation (ER) and ability to return to pre-injury level were recorded in both groups.Results:Both groups displayed significant improvements in functional scores ( p &lt; 0.0001) without a significant difference between the groups. Of the 32 patients, 9.4% had recurrence of instability (one re-dislocation in group 1 and two symptomatic subluxations in group 2). Return to pre-injury level occurred in 87.5% and 81.3% of group 1 and group 2, respectively. There was 2° to 3° loss of ER after ABR in both groups; the difference between the groups was not significant ( p = 0.45).Conclusion:ABR for recurrent AGHI using a permanent or absorbable KSA offers comparable successful outcomes; no significant statistical difference was found.

Updates on the treatment of adhesive capsulitis with hydraulic distension.

Adhesive capsulitis of the shoulder joint is a common disease characterized by pain at the insertional area of the deltoid muscle and decreased range of motion. The pathophysiological process involves fibrous inflammation of the capsule and intraarticular adhesion of synovial folds leading to capsular thickening and contracture. Regarding the multidirectional limitation of motion, a limitation in external rotation is especially prominent, which is related to not only global fibrosis but also to a localized tightness of the anterior capsule. Ultrasound and magnetic resonance imaging studies can be applied to rule out other structural lesions in the diagnosis of adhesive capsulitis. Hydraulic distension of the shoulder joint capsule provides pain relief and an immediate improvement in range of motion by directly expanding the capsule along with the infusion of steroids. However, the optimal technique for hydraulic distension is still a matter of controversy, with regards to the infusion volume and rupture of the capsule. By monitoring the real-time pressure-volume profile during hydraulic distension, the largest possible fluid volume can be infused without rupturing the capsule. The improvement in clinical outcomes is shown to be greater in capsule-preserved hydraulic distension than in capsule-ruptured distension. Moreover, repeated distension is possible, which provides additional clinical improvement. Capsule-preserved hydraulic distension with maximal volume is suggested to be an efficacious treatment option for persistent adhesive capsulitis.

Most of patients with femoral derotation osteotomy for posterior extraarticular hip impingement and high femoral version would do surgery again.

To assess (1) hip pain and function and ROM; (2) subsequent surgeries, complications; and (3) subjective satisfaction and PROMs in patients undergoing femoral derotation osteotomies. Femoral derotation subtrochanteric osteotomies to treat symptomatic posterior extraarticular ischiofemoral hip impingement were performed in 23 patients (25 hips) between 2013 and 2017. The mean age was 26 ± 8 years (96% female) with a minimum 2-year follow-up (mean follow-up of 4 ± 1 years). Surgical indication was a positive posterior impingement test and limited external rotation (mean 16° ± 8°) in extension in patients with abnormal high femoral version (mean 46° ± 9, measured on CT scans with the Murphy method) and high McKibbin instability index (mean 67°). Femoral osteotomies were combined with a surgical hip dislocation in 96% for cam resection and labrum or cartilage treatment. Preoperative MRI and 3D-CT with dynamic impingement simulation were evaluated. (1) The posterior impingement test decreased significantly from preoperatively 100% to 4% (p < 0.001). External rotation in extension increased significantly (p < 0.001) from preoperative 16° ± 8 to 44° ± 16°. The MdA score increased significantly from 14 ± 1 to 16 ± 2 (p < 0.001) points.(2) At follow-up, all 25 hips were preserved. No conversion to THA and no revision osteosynthesis was performed. 64% underwent complete hardware removal.(3) 80% of the patients reported at follow-up that they would undergo surgery again. Subjective satisfaction (SHV) increased significantly (p < 0.001) from preoperatively 24% to 84% postoperatively. Femoral derotation subtrochanteric osteotomies for the treatment of posterior extraarticular ischiofemoral hip impingement are safe and improve posterior hip pain and function and external rotation in mostly female patients with high femoral version and a high McKibbin instability index.