Periosteal Sleeve Research Articles

Glenohumeral capsular injury rate in patients with glenohumeral instability: a systematic review and meta-analysis

Glenohumeral instability is a complex clinical problem with underlying pathology in the bony, labral, and capsular tissues. The rate of specific capsular injuries varies widely in the literature and the clinical importance of these specific injury patterns remains unclear. Following Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, a systematic review was performed of multiple databases for all primary research articles between 2008 and 2023 which included advanced imaging and included rates of capsular injury in patients with glenohumeral instability. Twelve studies met inclusion criteria. The most prevalent capsular injury seen was in the inferior glenohumeral ligament (34.1%) across all studies, followed by anterior labroligamentous periosteal sleeve avulsions with 24.9% prevalence. Humeral avulsions of the glenohumeral ligaments lesions were the least common (6.2%) of subjects, followed closely by capsular tears (8.3%) of subjects. Capsular injury is commonly seen in magnetic resonance imaging of patients with anterior shoulder instability. Significant heterogeneity in language and imaging techniques was found in the existing literature. Further research is needed to explore these specific capsular lesions' clinical implications and rehabilitation strategies.

Anterior Labrum Periosteal Sleeve Avulsion Lesions of the Shoulder: A Scoping Review.

Anterior labrum periosteal sleeve avulsion (ALPSA) lesion of the shoulder is defined as a labral avulsion with an intact periosteum of the glenoid neck resulting in medial malattachment of the labrum, which is both nonanatomic and nonfunctional. It is relatively rare compared with Bankart lesions, and its results are usually reported in combination with other anterior labroligamentous lesions in the literature. To (1) assess the size and scope of the literature on ALPSA lesions, (2) highlight the importance of this lesion, and (3) distinguish between ALPSA and Bankart lesions in diagnostic and treatment strategies. Scoping review; Level of evidence, 4. The PubMed, Scopus, Embase, and Google Scholar databases were searched with the keywords "ALPSA,""anterior labrum periosteal sleeve avulsion,""anterior labral periosteal sleeve avulsion," and "anterior labroligamentous periosteal sleeve avulsion" lesion. Duplicate articles and those that did not meet the inclusion criteria were excluded, resulting in the identification of 42 relevant articles. Their references were analyzed for further data curation. This scoping review demonstrated that ALPSA lesions are difficult to clinically identify. Magnetic resonance angiography in the adduction internal rotation position is the most sensitive and specific imaging modality for identification. Optimal views are the anterosuperior portal for accurate identification and the anteroinferior portal for surgical repair during arthroscopy. Treatment begins with correctly identifying the labrum, in contradistinction to dense reactive fibrous tissue, and reattaching the labrum to the correct anatomic glenoid footprint. Chronic lesions with bone loss require either bone block or soft tissue augmentation procedures. There is paucity of exclusive literature on ALPSA lesions. It is important to distinguish this lesion from the Bankart lesion as it is associated with worse outcomes. The higher failure rates of ALPSA lesion repair indicate that the current repair techniques require further refinement to improve the outcomes to the standard of Bankart lesions.

What is the Utilization and Impact of Advanced Imaging for Tibial Tubercle Fractures? An Analysis of 598 Patients From the Tibial Tubercle Study (TITUS) Group.

Given the rare nature of tibial tubercle fractures, previous studies are mostly limited to small, single-center series. This results in practice variation. Previous research has shown poor surgeon agreement on utilization of advanced imaging, but improved evidence-based indications may help balance clinical utility with resource utilization. The purpose of this study is to quantify diagnostic practices for tibial tubercle fractures in a large, multicenter cohort, with attention to the usage and impact of advanced imaging. This is a retrospective series of pediatric tibial tubercle fractures from 7 centers between 2007 and 2022. Exclusion criteria were age above 18 years, missing demographic and pretreatment data, closed proximal tibial physis and tubercle apophysis, or a proximal tibia fracture not involving the tubercle. Demographic and injury data were collected. Fracture classifications were derived from radiographic evaluation. The utilization of advanced imaging was recorded as well as the presence of findings not identified on radiographs. Standard descriptive statistics were reported, and χ2 tests were performed (means reported±SD). A total of 598 patients satisfied the inclusion criteria, of which 88.6% (530/598) were male with a mean age of 13.8±1.9 years. Internal oblique x-rays were obtained in 267 patients (44.6%), computed tomography (CT) in 158 (26.4%), and magnetic resonance imaging (MRI) in 64 (10.7%). There were significant differences in the frequency at which CT (7.2% to 79.4%, P<0.001) and MRI were obtained (1.5% to 54.8%, P<0.001). CT was obtained most frequently for Ogden type IV fractures (50/99, 50.5%), and resulted in novel findings that were not visualized on radiographs in a total of 37/158 patients (23.4%). The most common finding on CT was intra-articular fracture extension (25/37). MRI was obtained most frequently for Ogden type V fractures (13/35, 37.1%), and resulted in novel findings in a total of 31/64 patients (48.4%). The most common finding was patellar tendon injury (11/64), but only 3 of these patients required tendon repair. Substantial variation exists in the diagnostic evaluation of tibial tubercle fractures. CT was most helpful in clarifying intra-articular involvement, while MRI can identify patellar tendon injury, periosteal sleeve avulsion, or a nondisplaced fracture. This study quantifies variation in diagnostic practices for tibial tubercle fractures, highlighting the need for evidence-based indications for advanced imaging. Level III.

How Effective is Fibula Pro Tibia Plating in Treatment of Distal Tibial Fractures: A Pilot Study.

Despite recent advances, management of distal tibial fractures is challenging, with high rate of complications. Fibula pro tibia plating technique fixes fibula and tibia together, via laterally placed fibular plate without disturbing the tibial soft tissue sleeve. We contemplated this pilot study to assess effectiveness of fibula pro tibia plating in management of distal tibia fibula fractures. A total of 30 patients with distal tibia fibula fractures with fracture line extending within 5cm from tibial plafond were managed with fibula pro tibia plating, with or without minimal articular fixation. Outcome evaluation was done by union, union time, alignment and functional outcome as assessed by AOFAS score. Mean age in the series was 39.4 years with male to female ratio of 3:2. Mean duration of surgery, blood loss and C arm exposure were 79 minutes (range 52 to 98min), 80ml (range 62 to 102ml) and 48 shoots (range 36 to 81 shoots), respectively. All fractures united in mean union time of 10.2 weeks (range 9 to 14 weeks) with acceptable alignment in all the patients except one. Mean AOFAS score was 86.3 (range 70 to 93) with 29 patients having good to excellent outcome. One patient had varus malunion and in one case infection was seen. Fibula pro tibia plating can be successfully used to manage complex distal tibia fractures which leaves the soft tissue and periosteal sleeve undisturbed, thus avoiding wound related problems and leading to early union.

Thumb Metacarpal Periosteal Sleeve Avulsion: A Case Report.

Periosteal sleeve fractures, or avulsions of cartilage and/or periosteum with or without an osseous fragment in skeletally immature individuals, are notoriously easy to miss and a high index of suspicion is necessary for accurate diagnosis and treatment. While periosteal sleeve avulsion fractures are classically reported in the patella, they have also been reported in the shoulder, clavicle, and elsewhere in the knee. However, no published reports exist for a periosteal sleeve avulsion fracture in the hand. This case details the first reported instance of such an injury involving a thumb metacarpal in a 3-year-old boy, treated with open reduction and percutaneous pinning of the thumb metacarpal.

A Novel Method in Restoring Form and Function Following Malunited Isolated Zygomatic Arch Fractures- A Technical Note

Isolated zygomatic arch fractures of the facial skeleton are rare. Blunt force to the cheek can result in an isolated zygomatic arch fracture, with resulting aesthetic issues such as indendations and functional impairments such as trismus. Symptomatic or visible isolated zygomatic arch fractures are commonly treated using either the Keen (intraoral) or Gillies (temporal) approaches to reduce the fracture while avoiding visible scars. Typically, the reduced fractures are not rigidly fixated but rather held in place by the native periosteal sleeve. However, cold fractures of the zygomatic arch are difficult to treat as they require a wide area of exposure for re-osteotomy and fixation. In the present technical note, we describe a novel technique to overcome this. Through a minimally invasive approach, two osteotomies were made proximally and distally to the fracture segment, and the segment was rolled 180 degrees along the sagittal axis. The medially depressed zygomatic arch is now projected laterally and was found to give adequate prominence and relieve restrictions in mouth opening. This is a novel method for reestablishing the prominence of the zygomatic arch and aiding in mandibular function following malunion of the fractured, isolated zygomatic arch.

Wedgeless V-Shaped Osteotomy of the Distal Medial Femur with Locking Plate Fixation for Correction of Genu Valgum in Adolescents and Young Adults.

Genu valgum is a common disorder affecting adolescents and young adults. Treatment of this disorder requires restoration of normal mechanical axis alignment and joint orientation, for which it is important to assess whether the deformity arises from the distal femur, knee joint, or proximal tibia. Most commonly, the deformity originates from the distal femur, and various osteotomies of the distal femur have been described1-6. The presently described wedgeless V-shaped osteotomy7,8 is a good option among the various alternative procedures listed below. The anesthetized patient is placed in the supine position on a radiolucent operating table. A bolster is placed beneath the knee to relax the posterior structures. A medial longitudinal skin incision is made that extends from the level of the medial joint line to 5 cm proximal to the adductor tubercle. The vastus medialis is identified and elevated anteriorly by detaching it from its distal and posterior aspects. The leash of vessels underneath the vastus medialis is identified, and the apex of the V-shaped osteotomy is kept just proximal to it. The anterior arm of the V is kept longer than the posterior one, both of them are kept perpendicular to each other, and the apex of the V is made to point distally. The osteotomy is performed on the medial cortex with use of an oscillating saw or multiple drill holes that are then connected using a thin osteotome. Care is taken not to utilize a saw or drill on the lateral cortex. A gentle valgus thrust is applied to break the lateral cortex without periosteal disruption. The apex of the V osteotomy on the proximal fragment is trimmed, and the deformity is corrected with varus force. The osteotomy site is stabilized with use of an anatomically contoured distal medial femoral locking plate or a medial proximal tibial L-shaped buttress plate (of the contralateral side). The implant position is verified under a C-arm image intensifier. The wound is closed in layers over a suction drain in a standard manner. Various types of corrective osteotomies of the distal femur have been described in the literature, including the lateral opening wedge, medial closing wedge, dome, and spike osteotomies1-6. All of these procedures have certain limitations and shortcomings. The wedgeless V-shaped osteotomy is another described procedure that is inherently stable7,8. It is a safe procedure and yields good clinical outcomes8,9. The posterior arm of the V-shaped osteotomy is kept smaller than the anterior arm. The proximal cortical bone is allowed to dig into the cancellous bone of the wider distal metaphysis during deformity correction. Trimming the apex of proximal bone end after making the osteotomy facilitates the process. In a study of 46 patients with a mean age of 16.9 years (range, 15 years to 23 years), Gupta et al.8 reported that the mean radiographic tibiofemoral angle improved from 22.2° (range, 16° to 29°) preoperatively to 5.1° (range, 0° to 10°) postoperatively (p < 0.001). Similarly, the mean lateral distal femoral angle improved from 79.2° preoperatively to 89.1° postoperatively (p < 0.001) and the mean mechanical axis deviation improved from 19.6 mm preoperatively to 3.7 mm postoperatively (p < 0.001). A total of 44 of 46 cases had an excellent functional outcome, with the other 2 having good outcomes. None of the patients in the study had an unsatisfactory outcome. It is important to keep the whole lower limb accessible to the image intensifier intraoperatively.Identification of the leash of vessels underneath the vastus medialis is important to decide the level of the osteotomy.It is important to preserve the periosteal sleeve on the lateral aspect of the femur. CORA = center of rotation of angulationECG = electrocardiogramLDFA = lateral distal femoral angleMAD = mechanical axis deviationMPTA = medial proximal tibial angle.

Revision Clavicle Fracture ORIF with Bone Graft from the Distal Clavicle Utilizing BioBrace

Introduction Clavicle fractures are among the most common fractures. Nonunion fracture of the clavicle has traditionally been treated with autograft from the iliac crest, although it has been proposed that distal clavicle autograft would have less morbidities associated. Case Report Patient presented with a left midshaft clavicle fracture with broken hardware from previous open reduction internal fixation (ORIF). This was treated with removal of broken hardware, revision ORIF, and autograft bone from distal clavicle. Healing was augmented with bone marrow aspirate from the ipsilateral proximal humerus as well as with BioBrace (CONMED Corporation, Largo, FL) collagen strips to reestablish periosteal sleeve and retain bone graft material. Conclusion Distal clavicle autograft augmented with BioBrace is presented as a novel method to treat nonunion clavicle fracture and may be associated with less morbidities.

Lesion prevalence and patient outcome comparison between primary and recurrent anterior shoulder instability

To compare lesion prevalence and treatment outcomes in patients with primary and recurrent anterior shoulder instability. Patients who were admitted to the institution with a diagnosis of anterior shoulder instability and who underwent arthroscopic surgery between July 2006 and February 2020 were retrospectively evaluated. Minimum follow-up duration of the patients was 24 months. The recorded data and Magnetic Resonance Imaging (MRI) of the patients were examined. Patients over 40 years of age, with a history of shoulder region fracture, inflammatory arthritis, a history of epilepsy, multi-directional instability, non-traumatic dislocation, and off-track lesions were excluded from the study. Shoulder lesions were documented and patient outcome evaluation was made with the Oxford Shoulder Score (OSS) and Visual Analog Scale (VAS). A total of 340 patients were included in the study. The mean age of patients was 25.6 (±6.49). Recurrent instability group had significantly higher rate of Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) lesions compared to primary instability group (40.6% vs 24.6% respectively) (p=0.033). 25 patients (43.9%) had Superior Labrum Anterior and Posterior (SLAP) lesions in primary instability group and 81 patients (28.6%) had SLAP lesions in recurrent instability group (p=0.035). OSS increased for both primary (from 35 (16-44) to 46 (36-48)) (p=0.001) and recurrent instability groups (from 33 (6-45) to 47 (19-48)) (p=0.001). There was no significant difference between the groups regarding postoperative VAS and Oxford scores (p>0.05). Successful results were obtained in patients younger than 40 years old with both primary and recurrent anterior shoulder instability after arthroscopic treatment. ALPSA lesion prevalence was higher while SLAP lesion prevalence was lower regarding the patients with recurrent instability. Postoperative OSS was comparable between the patient groups however failure rate was higher in the recurrent instability patients.

Prognostic factors associated with failure to return to sport following primary arthroscopic Bankart repair: a retrospective multicenter study.

Even though many studies have been published regarding return-to-sport (RTS) rates following arthroscopic Bankart repair (ABR), evidence regarding prognostic factors for which patients do not RTS is limited. The aim of this study was to identify prognostic factors that are associated with failure to RTS and failure to return to preinjury level of sport (RTPS) following primary ABR. The hypothesis was that prognostic factors for failure to RTS and failure to RTPS would be similar to those predisposing recurrence. A multicenter, retrospective case-control study including 6 Dutch hospitals was performed. Consecutive patients who underwent primary ABR between 2014 and 2019 were invited to participate and received a questionnaire. Sports participation was assessed before symptom onset, at 6 months postoperatively, and at final follow-up. Failure to RTS was defined as no return to any sport, and failure to RTPS was defined as no return to the same level (or a higher level) of sport. Prognostic factors for failure to RTS or failure to RTPS were identified using logistic regression. Covariates for the regression analysis were selected based on univariate analyses. This study included 318 patients with a mean follow-up period of 4.2 years (standard deviation, 1.8 years). Of these 318 patients, 26 (8.2%) did not RTS and 100 (31%) did not RTPS. Logistic regression analysis demonstrated that glenoid bone loss (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.04-1.15; P=.001) and overhead use of the shoulder during work (OR, 3.77; 95% CI, 1.45-9.85; P=.007) were prognostic factors for failure to RTS. In addition, it showed that preoperative professional sports level (OR, 2.94; 95% CI, 1.07-8.05; P=.04) and preoperative body mass index (OR, 1.11; 95% CI, 1.01-1.21; P=.04) were prognostic factors for failure to RTPS. Repair of a bony Bankart lesion (OR, 0.35; 95% CI, 0.15-0.81; P=.02) and the presence of an anterior labral periosteal sleeve avulsion (ALPSA) (OR, 0.44; 95% CI, 0.20-0.97; P=.04) were identified as factors that facilitated RTPS. This study identified glenoid bone loss and overhead use of the shoulder during work to be associated with failure to RTS. Moreover, preoperative sports level and preoperative body mass index were found to be associated with failure to RTPS. In contrast, a bony Bankart lesion and an anterior labral periosteal sleeve avulsion (ALPSA) lesion facilitated RTPS. Future prospective studies are needed to confirm these factors and determine which part of the effect can be attributed to (failure of) surgical treatment or changes in behavior.

Poster 175: ALPSA Lesions Associated with High Rate of Early Repair Failure

Objectives: Anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions occur in patients with recurrent shoulder instability and are associated with higher rates of failure after capsulolabral repair surgery compared to typical Bankart lesions. Despite recognition that these lesions can portend poor outcomes, there is relatively limited data to understand the associated injuries and postoperative course in a young, active population. The purpose of this study is to evaluate ALPSA lesions for associated pathology and outcomes. Methods: Methods: We reviewed the records of 312 patients who underwent arthroscopic shoulder stabilization by one of two fellowship trained sports surgeons at a single facility between 1 January 2010 and 31 December 2015. Inclusion criteria were a minimum follow-up of five years after index surgical repair and presence of an ALPSA lesion as identified on arthroscopic exam, leaving 46 patients available for review. Our primary outcome measures were failure and operative revision surgery. We considered failure as any recurrent shoulder instability events including subjective subluxation and dislocation, recurrence of pain consistent with instability, or functionally limiting apprehension. We performed survival analysis and a multivariate logistic regression analysis to identify factors associated with failure. Results: Results: In total, 46 patients with average age 21.2 years met inclusion and underwent surgery a median of 7.1 months after initial recalled injury event. 11/46 had concomitant posterior pathology in addition to anterior labral lesion. Six patients were found to have SLAP lesions. All patients experienced subjective instability, and 44/46 endorsed pain prior to surgery. 38/46 reported having experienced complete dislocation. The median number of dislocations before surgery was 3. Repairs were performed with average 3.7 anchors. Eight patients failed surgery at median 15.1 months post-index procedure, with 75% of failures occurring before two years with the remaining 25% occurring later in follow-up. Three of these failed revision repair. Conclusions: Conclusions: ALPSA lesions frequently occur in the presence of other intra-articular shoulder lesions and portend a high rate of recurrent shoulder instability despite repair. Notably, while failure occurs at a high rate, most repair failure for these lesions tends to occur early.

Atypical Shoulder Instability Patterns in Adolescents Following Traumatic Anterior Shoulder Dislocation

Background: Traumatic anterior shoulder instability is common in the adolescent athlete, and when it is untreated, the recurrence rate is high. Atypical lesions—such as anterior glenoid periosteal sleeve, humeral glenohumeral ligament, and insertional tendon avulsions—may occur within this population, and accurate diagnosis and appropriate lesion management are key to treatment success. Purpose: To evaluate the age, skeletal immaturity, bone loss, and uncommon soft tissue lesions as correlates of posttraumatic anterior shoulder instability lesion patterns in an adolescent population. Study Design: Cross-sectional study, Level of evidence, 3. Methods: Consecutive patients ≤18 years of age (160 shoulders) treated within a single institution for traumatic anterior shoulder instability between June 2013 and June 2021 were reviewed. Demographics, injury mechanism, radiographic and magnetic resonance imaging of lesions, the presence of any bone loss, operative findings, and physeal status were recorded. An overall 131 shoulders met the inclusion criteria. Instability lesion type was analyzed categorically by age <15 or ≥15 years; individual age was assessed for correlation with any bone loss present. Atypical lesions—anterior labral periosteal sleeve avulsion, humeral avulsion of the glenohumeral ligament, subscapularis avulsion—were assessed for correlations with age, open physeal status, and the presence of any bone loss. Results: An overall 131 shoulders (mean, 15.3 years; range, 10.5-18.3) were identified for this study: 55 in patients <15 years old and 76 in patients ≥15 years old. Bony injuries such as Bankart and Hill-Sachs lesions were more common in the ≥15-year-old group (P = .044 and P = .024, respectively). Bony Bankart injuries were found at a rate of 18.2% in the <15-year-old group, as compared with 34.2% in the ≥15-year-old group (P < .05). Anterior labral periosteal sleeve avulsions were more common in the <15-year-old group (n = 13 [23.6%] vs n = 8 [10.5%]; P < .044), as were all atypical lesions combined (n = 23 [41.8%] vs n = 13 [17.1%]; P < .0018]. Conclusion: In this series of anterior shoulder instability in children and adolescents, instability lesions varied significantly by age. Bone loss was associated with older age at presentation, and atypical lesions were more common in patients <15 years of age. Treatment teams should be aware of less common soft tissue injuries in this young age group and ensure careful review of adequate imaging for proper diagnosis and treatment in these younger patients.

In-Season Management of Shoulder Instability: How to Evaluate, Treat, and Safely Return to Sport.

Anterior glenohumeral instability is a common injury in contact and collision athletes, and in-season management remains a controversial topic. Several recent studies have examined non-operative and operative management of in-season athletes after instability events. Non-operative treatment is associated with faster return to play and higher rates of recurrent instability. Dislocations and subluxations have similar rates of recurrent instability but non-operatively treated subluxations have a quicker return to play than dislocations. Operative treatment is often a season ending decision but is associated with high rates of return to sport and significantly lower rates of recurrent instability. Indications for in-season operative intervention may include critical glenoid bone loss (>15%), an off-track Hill-Sachs lesion, an acutely reparable bony Bankart lesion, high-risk soft tissue injures such as a humeral avulsion of the glenohumeral ligament or displaced anterior labral periosteal sleeve avulsion, recurrent instability, insufficient time remaining in season to rehabilitate from injury, and inability to successfully return to sport with rehabilitation. It is the role of the team physician to appropriately educate athletes on risks and benefits of operative and non-operative treatment strategies and guide athletes through the shared decision-making process that balances these risks against their long-term health and athletic career goals.

Surgical Outcomes and Associated Injuries of Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) Lesions: A Systematic Review.

Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) lesions can lead to chronic shoulder instability and repetitive dislocations in active populations. The purpose of this systematic review was to evaluate associated injuries and postoperative outcomes following ALPSA lesion repairs. Medline, Embase, Cochrane, and Web of Science were searched through May 2022 for studies that investigated management and surgical outcomes of ALPSA lesion repair. Data was extracted on the following topics: surgical management, surgical complications, associated injuries, follow-up duration, and outcome parameters, including recurrence rates, functional outcome scores, range-of-motion (ROM), and return to activity. A total of 6 studies covering 202 patients met the inclusion criteria. In the included studies, 79% of patient were male with a mean age of 25.1 years. A total of 192 associated injuries were reported amongst 176 patients with the most common being Hill Sachs lesions (84, 43.8%), synovitis (35, 18.2%), SLAP tears (32, 16.7%) and glenoid erosions or lesions (30, 15.6%). All 202 patients were treated arthroscopically with no reported complications. 26 patients (12.9%) experienced operative failure as evidenced by recurrence of shoulder instability over a mean follow-up of 4.3 years. Various clinical outcome scores showed postoperative functional improvement and one study reported a 100% return to activity rate in 26 patients. Our findings suggest a high 12.9 % risk of recurrence following ALPSA repair but satisfactory functional outcomes, both of which should be weighed by physicians when considering arthroscopic repair. Physicians should also be cognizant of co-pathologies when examining patients with suspected ALPSA lesions.

Poster 144: Minimum 2-year Outcomes after Knotless All-Suture Anchor Bankart Repair

Objectives:Knotless, all suture anchors have significant theoretical and technical advantages such as less bone removal, easier revision, lower profile so less risk for cartilage damage, but clinical results are lacking. The purpose of this study was to report on minimum 2-year outcomes after arthroscopic knotless all-suture Bankart repair in patients with anterior shoulder instabilityMethods:IRB approval was obtained prior to initiation of this study. Data was collected prospectively and retrospectively reviewed. Patients met inclusion criteria if they were a minimum 2 years out from a Bankart repair using all-suture, knotless anchors (FiberTak anchors) for the repairs by a single surgeon from September 2017 to June 2019. Patients were excluded if they had an anterior labroligamentous periosteal sleeve avulsion, humeral avulsion of the glenohumeral ligament, glenolabral articular disruption lesion, or a rotator cuff repair. Outcome data was collected preoperatively and evaluated at a minimum follow-up of 2 years postoperatively using the American Shoulder and Elbow Surgeons Score (ASES), Single Assessment Numeric Evaluation Score (SANE), Quick Disabilities of the Arm, Shoulder and Hand Score (QuickDASH), the Short Form 12 physical component summary (SF-12 PCS), and patient satisfaction to assess surgical outcomes at final follow-up. Also included are several questions regarding shoulder pain, function and sports participation. Patients with re-dislocations and revision surgery were noted along with any surgical complications. Surgical failure was defined as revision instability surgery, re-dislocation requiring reduction with an ASES score less than 70 or a satisfaction score of 6 or less.Results:A total of 32 patients, 8 females and 24 males, with an average age of 28.5 (SD10.7) years at the time of surgery were included. Postoperative shoulder re-dislocations were reported in 5 cases (15.6%) with 2 patients progressing to a Latarjet (6.0%) at 2 & 3 years post-operatively. There were no postage stamp fractures noted. Moreover, the anchors did not interfere with revision surgery in any way. At final follow-up, mean PRO’s significantly improved over preoperative levels. ASES score improved from 58 to 93 (p<0.001), SANE improved from 58-94 (p<0.001), QuickDASH improved from 32.0 to 6.0 (p<0.001) and SF-12 PCS improved from 45.6 to 55.7 (p<0.001). Median postoperative satisfaction was 10/10 (range4-10). Patients reported a significant improvement in shoulder pain during competition (p<.001), and ability to compete in sports (p< .001). There was also significant improvement in painless use of arm for overhead activities (p= .001) and ability to throw a softball 20 yards (p= .001)Conclusions:The arthroscopic treatment of Bankart lesions with knotless all-suture anchors leads to results similar to clinical outcomes to prior studies, with the advantage of ease of revision. Long-term follow-up studies with large patient cohorts will show if the other theoretical advantages of these anchors are born out.

Radiography Suggests a Fibrous Tubular Sleeve Distal to a Cartilaginous Anlage in a Limb with ‘Absent Fibula’ Represents a Traction

BackgroundDissections of congenitally shortened limbs displaying congenital fibular deficiency have revealed pathologic cartilaginous bodies and fragments along the course of the “absent” fibula consistent with remnants of a fibular anlage (Wagstaffe, 1875; Freund, 1936; Harmon &amp; Fahey, 1937; Thompson et al., 1957). Bands distal to the anlagen have traditionally been reported as fibular calcaneal collateral ligaments.ObjectiveThis project reinterprets the composition of the posterolateral ankle band frequently found in patients with congenital shortened limb (CSL) with fibular deficiency based on advanced radiographic criteria.Patient and MethodBilateral thin slice computed tomography (TSCT) imaging was performed on the distal lower extremities of a 43‐year‐old female patient with unilateral congenital shortened limb with fibular “absence” for operative planning. The images were imported into virtual modeling system 3D Slicer and various tissues in the region were measured and compared for attenuation using the Hounsfield unit (HU) scale.ResultsThe radiological study of the posterolateral ankle band in the presence of a limb with a diminutive fibular anlage exhibiting a normal medullary density revealed a tubular structure sharing attenuation readings with nearby adipose tissue at its core and fibrous tissue at its periphery.ConclusionThe tubular structure of the posterolateral ankle band with an adipose core, surrounded by fibrous tissue in the presence of a retained primitive fibular anlage, supports the assertion that fibular absence in this congenitally shorted limb is a radiographic misnomer, since a dystrophic anlage persists in its place. Additionally, previously identified fibulocalcaneal structures (or bands) may actually represent a stretched periosteal sleeve caused by traction exerted on the anlage by the paired lower tibia.These findings support the hypothesis that this “ligament” structure is the distalmost tubular remnant of an otherwise normally formed cartilaginous scaffold of the fibular anlage. The anlage has failed to ossify to form a normal fibular long bone structure, due to embryonic arterial dysgenesis and failed vascular invasion during the sixth‐seventh weeks of embryonic development.

Outcomes of Arthroscopic Anterior Labroligamentous Periosteal Sleeve Avulsion Lesions: A Minimum 2-Year Follow-up

Background: Anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions can occur in recurrent anterior shoulder instability, which may lead to the labrum scarring medially to the glenoid. ALPSA lesions have also been associated with greater preoperative dislocations, larger Hill-Sachs lesions, and greater degrees of glenoid bone loss. Therefore, patients with these lesions have historically had a higher failure rate after repair, with nearly double the recurrent instability rate compared with those undergoing standard arthroscopic Bankart repair. Purpose: To compare minimum 2-year outcomes of arthroscopic mobilization and anatomic repair of ALPSA lesions with those after standard arthroscopic Bankart repair. Study Design: Cohort study; Level of evidence, 3. Methods: Consecutive patients who underwent arthroscopic repair of ALPSA lesions were matched in a 1-to-3 fashion to patients who underwent standard Bankart repair by age, sex, number of previous ipsilateral shoulder instability surgical procedures, and number of anchors used. Patient-reported outcome (PRO) scores were compared preoperatively and postoperatively (American Shoulder and Elbow Surgeons [ASES]; 12-Item Short Form Health Survey [SF-12] Physical Component Summary [PCS]; Single Assessment Numeric Evaluation [SANE]; shortened version of Disabilities of the Arm, Shoulder and Hand; and satisfaction). Recurrent instability, on- versus off-track Hill-Sachs lesion, and reoperation rates were analyzed. Results: A total of 100 shoulders (25 ALPSA and 75 Bankart) with an overall mean age of 25.7 years were evaluated. Patients in the ALPSA group demonstrated significant improvements in the ASES (preoperative, 74.8; postoperative, 89.7; P = .041) and SF-12 PCS (preoperative, 46.9; postoperative, 53.4; P = .021) scores but not the SANE score (preoperative, 65.2; postoperative, 75.3; P = .311). Patients in the Bankart group had significant improvements in all outcome scores at final follow-up: ASES (preoperative, 67.1; postoperative, 90.3), SANE (preoperative, 58.0; postoperative, 85.7), and SF-12 PCS (preoperative, 45.3; postoperative, 52.9) (all P < .001). There were no significant differences in PRO scores between the groups preoperatively or postoperatively (P > .05). The median satisfaction for the ALPSA group was 10 of 10 and for the Bankart group it was 9 of 10 (P = .094). There was a significantly higher rate of recurrent dislocation in the ALPSA group (8/25 [32.0%]) compared with the Bankart group (10/75 [13.3%]) (P = .040). Additionally, 5 patients (20.0%) in the ALPSA group underwent revision surgery at a mean of 5.6 years, and 8 patients (10.7%) in the Bankart group underwent revision surgery at a mean of 4.4 years (P = .311). Conclusion: Despite improvements in the recognition of and surgical techniques for ALPSA lesions, they still lead to significantly higher postoperative dislocation rates; however, no differences in PRO scores were found. These findings highlight the importance of early surgical interventions in anterior shoulder instability with the hope of lessening recurrent instability and the risk of developing an ALPSA lesion, as well as careful assessment of the quality of soft tissues and other risk factors for recurrence when considering what type of shoulder stabilization procedure to perform.

Athletes with primary glenohumeral instability demonstrate lower rates of bone loss than those with recurrent instability and failed prior stabilization.

The purpose of this study was to compare the preoperative magnetic resonance arthrography findings in patients who underwent glenohumeral stabilization with a history of primary instability, recurrent instability, or failed stabilization. All patients who presented with glenohumeral instability and underwent stabilization performed by a single surgeon in our institution between 2008 and 2020 were considered for inclusion in this study. The magnetic resonance arthrography findings of all patients were recorded. Imaging findings were compared between patients with primary instability, those with recurrent instability, and those with failed prior stabilization. P < .05 was considered statistically significant. Overall, 871 patients were included, of whom 814 (93.5%) were male patients; the mean age was 23.1 years (range, 13-57 years). There were 200 patients with primary instability, 571 with recurrent instability, and 100 who required revision stabilization surgery, with no significant differences in demographic characteristics between the groups. A significantly higher amount of glenoid bone loss was noted in patients with recurrent instability (43.4%) and failed prior stabilization (56%) than in those with primary instability (26.5%) (P < .0001). Additionally, a significantly higher number of Hill-Sachs lesions were observed in patients with recurrent instability (70.1%) and failed prior stabilization (89%) than in those with primary instability (67.5%) (P < .0001). We found no significant differences between the groups regarding articular cartilage damage, glenolabral articular disruption, anterior labral periosteal sleeve avulsion, humeral avulsion of the glenohumeral ligaments, or superior labral anterior-posterior tears (P > .05). Patients presenting for stabilization with recurrent instability or following a failed stabilization procedure have higher rates of glenohumeral bone loss than those with primary instability. Therefore, stabilization of primary instability, particularly in high-functioning athletes with a view to preventing recurrence, may reduce the overall progression of glenohumeral bone loss and potential subsequent inferior clinical outcomes.

Classification of vascularized fibular flap hypertrophy based on X-ray evaluation.

The aim of this study was to analyze and classify hypertrophy seen in vascularized fibula flaps used for reconstruction of tubular bone defects. Thirty-three patients who underwent a vascularized fibula flap for the reconstruction of massive bone defects of the upper or lower extremity long bones were retrospectively reviewed and included in this study. There were 24 lower extremities (21 tibial and 3 femoral) and 9 upper extremities (4 humeral, 2 radial and 3 ulnar) reconstructions in this series. The mean age was 32.7 (range= 10- 59) years. The mean length of bony defect following initial debridement was 10.3 (range= 4-25) cm. The fibula was inserted as a single strut in 29 patients, and as a double barrel construct in 4 patients. The degree of fibular hypertrophy was calculated based on anteroposterior (AP) and lateral X-ray measurements of fibular flaps at an average postoperative period of 52 months. The difference in thickness between the initial and final x- ray measurements were expressed as percentage of hypertrophy. The variances seen in this period were defined and classified. When bony consolidation of the 33 cases were examined in detail, 4 different modes of flap hypertrophy were defined: type 0- absence of hypertrophy, type 1- limited hypertrophy, type 2- marked hypertrophy triggered by stress fracture, and type 3- massive hypertrophy enhanced by peripheral bone production. Fibular hypertrophy follows different modes based on vascularity of the flap, amount of stress imparted on the flap, site of reconstruction, and whether the periosteal sleeve is retained at the reconstruction site. Determination of these factors at the initial period may help the surgeons to predict the final hypertrophy that will be seen at the end of flap maturation Level of Evidence: Level IV, Therapeutic Study.

Older age and varus alignment lead to early failure in treating patellofemoral osteoarthritis with Fulkerson osteotomy.

Background: It is unclear the risk factors for the failure of modified Fulkerson osteotomy. Methods: We retrospectively reviewed 40 patients who underwent the modified Fulkerson osteotomy from 1998 to 2015. There were 4 males and 36 females. The mean age of the study group was 50.2 ± 11.2 years. We used standard anteriorization measuring 10-15 mm and medialization measuring 10 mm while maintaining an intact periosteal sleeve. Results: Both the patellofemoral angle and the congruence angle improved significantly after 5.9 years. Preoperatively, the mean preoperative Lysholm score was 56.12, and the Knee Society score was 60.52. At the final follow-up, these scores improved significantly to 88.75 and 86.49, respectively. However, eight patients (20%) underwent total knee arthroplasty in the follow-up period, five of whom underwent the operation within 5 years. Comparing the survival and non-survival groups, there was a significant difference of an older age in the TKA conversion group (survival: 48.3 ± 11.1; non-survival: 57.8 ± 8.7, p = 0.03). For knee alignment, the non-survival group had a mean valgus femorotibial angle of 1.8° ± 4.9° preoperatively, and the survival group had a mean valgus angle of 6.4° ± 4.5° (p = 0.03). Conclusions: we found that patients with older age and those with varus alignment have an increased risk of deteriorated medial femorotibial cartilage.