Repeat Dislocation Research Articles

Paper 37: Outcomes of Medial Patellofemoral Ligament Reconstruction Patients Over 30 Years of Age

Objectives: Medial patellofemoral ligament reconstruction (MPFLR) is a common procedure to treat recurrent patellofemoral instability, typically in a younger, active patient population. While many patients treated with MPFLR fall into this age group, patellar instability is encountered in older patients as well. Outcomes in older patient populations have been less frequently reported in the literature. We hypothesize that patients over 30 at the time of surgery will have poorer postoperative patient reported outcome measures (PROMs) following MPFLR than patients under age 30. Methods: Retrospective review was undertaken to identify patients who underwent isolated MPFLR between 2008 and 2020. Chart review was utilized to obtain patient demographic, anatomical, and surgical factors. Patients were contacted via mail and/or phone and patient-reported outcomes were recorded. PROMs included the knee injury and osteoarthritis injury outcome score (KOOS), Norwich patellar instability score, and Marx activity score. Differences between groups were evaluated by Mann-Whitney and Fisher-exact tests. KOOS and Norwich scores were also evaluated using a multivariable linear regression adjusting for the following variables selected a priori: sex, body mass index, Caton-Deschamps index, TT-TG distance, sulcus angle, and the presence or absence of ≥ Grade 2 cartilage damage. Results: A total of 228 patients underwent isolated MPFL reconstruction in the study period. 177 patients (78%) had data on repeat patellar dislocations at least 1 year postoperatively, with a median follow-up interval of 40.8 months (3.4 years) postoperative. Of these 177, 140 were under age 30 at time of surgery, 7 (5%) of whom had a repeat dislocation; of 37 patients at or over age 30 at time of surgery, 2 (6.6%) had a repeat dislocation. 147 patients further completed KOOS, Norwich, and Marx activity score surveys with a median follow-up of 45.3 months (3.8 years) post-operative. Patients ≥ 30 years old at surgery (n=31) had lower KOOS pain (82.1 vs 91.7; p=0.03), KOOS activities of daily living (94.1 vs 97.1; p=0.04), and Marx activity scores (1 vs 7; p<0.001) compared to the patients under age 30 (n=116) (Table 1). After adjusting for covariates, multivariable regression models for KOOS and Norwich scores showed only KOOS pain subscores were lower for patients ≥ 30 years (β= -4.2; 95% CI -8.3, -0.2; p=0.04). Conclusions: Patients over age 30 at the time of MPFLR demonstrated similar recurrence risk but lower KOOS pain and Marx activity scores at 3.8 years postoperative than patients under age 30 at the time of MPFLR. [Figure: see text]

Medial Patellofemoral Ligament Reconstruction With a Single-Limb Allograft: A Reproducible and Effective Technique

Background: Medial patellofemoral ligament (MPFL) injury occurs in up 96% of lateral patellar dislocations, commonly affecting those less than 20 years old. The MPFL can be reconstructed using either a double-limb or single-limb technique. While both techniques achieve similar patient outcomes, a single-limb technique may require less operative time. Indications: The MPFL reconstruction is indicated in patients with recurrent patellar subluxations, dislocations, or unresolved apprehension. Care should be exercised in identifying whether patients require additional procedures in addition to MPFL reconstruction such as tibial tubercle osteotomy or trochleoplasty. These considerations include TT-TG >17 to 20 mm and Dejour B/D trochlear dysplasia. Technique Description: Following diagnostic arthroscopy, a medial peripatellar incision is made. Layers 1 and 2 are sharply dissected over the patellar periosteum, and tissue planes are subsequently developed using Metzenbaum scissors. A plane between layers 2 and 3 extending from the medial patella to the medial femoral epicondyle is developed. Using fluoroscopy, Schöttle point is identified, and a femoral tunnel is drilled. Two PEEK anchors are placed at the junction of the proximal one-third and distal two-thirds of the patella. In parallel, a tibialis anterior graft is sized, whipstitched, and tensioned on the back table. One end of the prepared graft is secured in the femoral tunnel with a PEEK tenodesis screw. The graft is then shuttled between layers 2 and 3, followed by fixation on the patellar side using the previously placed suture anchors. Isometry of the graft is confirmed under direct and arthroscopic visualization. Results: In multiple systematic reviews of single-limb versus double-limb MPFL reconstruction, no differences were observed in terms of patient-reported outcome scores, repeat dislocation, and reoperation. Furthermore, a recent meta-analysis suggests a trend toward less postoperative stiffness (1.2% vs 3.5%, P = .09) for single-bundle techniques. Discussion/Conclusion: Single-limb MPFL reconstruction is reproducible and effective, with clinically satisfactory outcomes and low failure rates. Single-limb MPFL reconstruction demonstrates similar outcomes as double-limb reconstruction, with a potential decrease in surgical time and postoperative stiffness. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

A Systematic Review of Acute Irreducible Shoulder Dislocations in the 21st Century.

Background:Rarely, closed reduction cannot be achieved in patients with acute shoulder dislocation, necessitating open management. A paucity of literature exists regarding these cases.Purpose:To perform a systematic review on the mechanism, management, and outcome data of acute irreducible shoulder dislocations.Study Design:Systematic review; Level of evidence, 4.Methods:A systematic review of the literature was performed using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, and MEDLINE between 2000 and 2020. Inclusion criteria were as follows: human participants, acute irreducible shoulder dislocation requiring open management, English language, and publication within the past 20 years. We excluded basic science articles, technique articles, reviews, editorials, and studies of chronic shoulder dislocations or dislocations with ipsilateral humeral shaft fractures.Results:Twelve articles fit the inclusion criteria and were considered for review. All studies were single case reports (level 4 evidence). Ten of the 12 studies were of male patients. The direction of dislocation included 7 anterior/anteroinferior, 2 posterior, 1 inferior, 1 bilateral inferior, and 1 superolateral. Most dislocations were irreducible owing to a mechanical block to reduction. The most common type of block was an incarcerated long head of the biceps tendon, followed by interposition of 1 of the rotator cuff tendons. The axillary and musculocutaneous nerves, displaced fracture fragments, and Hill-Sachs and bony Bankart lesions were other causes of blocks to reduction. Eleven patients were treated with open surgery, while 1 patient was treated arthroscopically. Procedures performed were dependent on concurrent pathology. Final follow-up ranged from 6 weeks to 2 years, with no repeat dislocation episodes reported. Complications after open reduction included 1 case of brachial plexopathy (posterior cord) and 1 case of musculocutaneous nerve palsy.Conclusion:There is a paucity of literature on the management of irreducible acute shoulder dislocations. The most common irreducible dislocation found in this systematic review was anterior with a mechanical block attributed to interposition of the long head of the biceps tendon. When patients were treated with an open or arthroscopic procedure, recurrence was low, with none reporting recurrent dislocation in limited follow-up.

Clinical outcomes of medial patellofemoral ligament reconstruction using FiberTape and knotless SwiveLock anchors

BackgroundWe aimed to prospectively investigate the clinical outcomes of medial patellofemoral ligament (MPFL) reconstruction using polyester high-strength suture tape with knotless anchors. MethodForty-three patients (65 knees) were followed for at least 1 year postoperatively, with 27 patients (43 knees) followed for 2 years postoperatively. All patients underwent MPFL reconstruction using polyester high-strength suture tape (FiberTape®; Arthrex) with knotless anchors (SwiveLock®; Arthrex). Repeated dislocation and residual patellar apprehension signs were recorded, and congruence and tilting angles were measured. Changes in Knee Injury and Osteoarthritis Outcome Scale (KOOS) scores and their associations with the preoperative tibial tubercle–trochlear groove (TT-TG) distance were analyzed. ResultsNo repeat dislocations (0%) were observed. One (2.4%) residual positive patellar apprehension sign was noted. The mean tilting angle decreased from 24.8° to 10.7° (P < 0.001), and the mean congruence angle decreased from 24.9° to 4.3° (P < 0.001). At 2 years follow up, all KOOS subscales had improved: pain (92.0 ± 12.9), symptoms (90.2 ± 11.9), activities of daily living (95.7 ± 7.3), sports activity (85.7 ± 16.9), quality of life (87.7 ± 12.9), and patellofemoral (89.0 ± 9.6) outcomes. KOOS subscale scores improved regardless of the preoperative TT-TG distance (21.1 ± 3.5 mm; range, 13.8–29.9 mm). ConclusionsMPFL reconstruction using FiberTape and knotless SwiveLock anchors was performed without sacrificing autologous tissue. No recurrent patellar dislocation was observed during the 2-year follow up period. All KOOS subscale scores improved using FiberTape and SwiveLock anchors in MPFL reconstruction.

Clinical Comparison of Medial Patellofemoral Ligament Reconstruction With or Without Tibial Tuberosity Transfer for Recurrent Patellar Instability

Background: No clear guidelines or widespread consensus has defined a threshold value of tibial tuberosity–trochlear groove (TT-TG) distance for choosing the appropriate surgical procedures when additional tibial tuberosity osteotomy (TTO) should be added to augment medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability. Purpose: To compare the clinical outcomes between MPFL reconstruction and MPFL reconstruction with TTO for patients who have patellar instability with a TT-TG distance of 15 to 25 mm. Study Design: Cohort study; Level of evidence, 3. Methods: We retrospectively analyzed 81 patients who underwent surgical treatment using either MPFL reconstruction or MPFL reconstruction with TTO for recurrent patellar instability with a TT-TG distance of 15 to 25 mm; the mean follow-up was 25.2 months (range, 12.0-53.0 months). The patients were divided into 2 groups: isolated MPFL reconstruction (iMPFL group; n = 36) performed by 2 surgeons and MPFL reconstruction with TTO (TTO group; n = 45) performed by another 2 surgeons. Clinical outcomes were assessed using the Kujala score, Knee injury and Osteoarthritis Outcome Score, and Tegner activity score. Radiological parameters, including patellar height, TT-TG distance, patellar tilt, and congruence angle were compared between the 2 groups. Functional failure based on clinical apprehension sign, repeat subluxation or dislocation, and subjective instability and complications was assessed at the final follow-up. We also compared clinical outcomes based on subgroups of preoperative TT-TG distance (15 mm ≤ TT-TG ≤ 20 mm vs 20 mm < TT-TG ≤ 25 mm). Results: All of the clinical outcome parameters significantly improved in both groups at the final follow-up (P < .001), with no significant differences between groups. The radiological parameters also showed no significant differences between the 2 groups. The incidence of functional failure was similar between the 2 groups (3 failures in the TTO group and 2 failures in the iMPFL group; P = .42). In the TTO group, 1 patient experienced a repeat dislocation postoperatively and 2 patients had subjective instability; in the iMPFL group, 2 patients had subjective instability. The prevalence of complications did not differ between the 2 groups (P = .410). In the subgroup analysis based on TT-TG distance, we did not note any differences in clinical outcomes between iMPFL and TTO groups in subgroups of 15 mm ≤ TT-TG ≤ 20 mm and 20 mm < TT-TG ≤ 25 mm. Conclusion: MPFL reconstruction with and without TTO provided similar, satisfactory clinical outcomes and low redislocation rates for patients who had patellar instability with a TT-TG distance of 15 to 25 mm, without statistical difference. Thus, our findings suggest that iMPFL reconstruction is a safe and reliable treatment for patients with recurrent patellar dislocation with a TT-TG distance of 15 to 25 mm, without the disadvantages derived from TTO.

Glenoid track measurement using magnetic resonance imaging arthrography is predictive of recurrent instability following arthroscopic shoulder stabilisation.

The primary aim of this study was to investigate medium-term survivorship following arthroscopic Bankart repair (ABR) for anterior glenohumeral instability. The secondary aim was to determine whether the pre-operative magnetic resonance (MR) arthrography glenoid track measurement predicted recurrent instability following ABR. Over a 9-year period (2008-2017), 215 patients underwent ABR. Median age was 26years (IQR 22-32.5; range 14-77). There were 173 males (81%). 175 patients (81%) had available pre-operative MR arthrography, which was used to determine the presence of "off-track" bone loss. Retrospective analysis was undertaken to determine recurrence of instability at a median follow-up of 76months (range 21-125months). Survivorship analysis was undertaken using Kaplan-Meier methodology: the endpoints examined were repeat dislocation, revision stabilisation, and symptomatic instability. 56 patients (26%) presented with further instability, including 29 patients with recurrent dislocation and 15 patients required revision stabilisation. Cumulative incidence of instability was 10% at 1year, 27% at 5years and 28% at 7years. No significant difference in instability was seen between men and women 7years after stabilisation (19% vs 17%; p = 0.87). Age at time of surgery did not predict recurrence. "Off-track" lesions were identified in 29 patients (16.1%). The incidence of redislocation was significantly higher in these patients (24% vs 3%; p = 0.01; relative risk 7.2; 95% CI 2.45-20.5; p = 0.001). Recurrent instability without frank redislocation was also significantly higher in this group (60% vs 18%; RR 3.33, 95% CI 2.02-5.20; p < 0.0001). This study has reported a significant rate of recurrent instability in longer-term follow-up after ABR. It has also identified pre-operative MR arthrography as an important predictor of recurrent instability, which may be used to risk stratify patients with anterior instability in a typical UK population. III (cohort study).

Athletes With Anterior Shoulder Instability: A Prospective Study on Player Perceptions of Injury and Treatment.

Background:Many in-season athletes choose to delay or avoid surgery in order to continue playing and avoid downtime such as missed games or seasons.Purpose:To learn about the attitudes toward the injury and treatment of in-season shoulder instability in competitive athletes who have suffered a shoulder dislocation.Study Design:Cross-sectional study; Level of evidence, 3.Methods:A study-specific questionnaire about athletes’ perceptions of injury and treatment was administered to injured players. Secondary outcomes included the American Shoulder and Elbow Surgeons (ASES) score and the Western Ontario Shoulder Instability Index (WOSI). Mean scores and standard deviations were calculated, and between-group analyses with t tests were performed to compare the ASES and WOSI scores. The Mann-Whitney U test was used for analyses performed on the following groups: early operative versus nonoperative management; age <18 versus ≥18 years; first-time dislocators versus recurrent dislocators; self-reducing subluxations versus dislocations requiring assistance; and dominant arm affected versus nondominant arm.Results:There were 45 patients included in this study (33 male, 12 female) with a mean age of 18 ± 2.8 years. Several sports were represented, with the most common being football, baseball, soccer, and rugby. In this study of in-season athletes with shoulder instability, 13 (28.9%) chose early surgery, 4 (8.9%) chose surgery at season’s end, while 28 (62.2%) chose physical therapy followed by a wait-and-see approach, with 13 (46.4%) of these patients ultimately requiring surgery. Athletes who chose nonoperative treatment were statistically more likely to believe that their shoulder would heal on its own (P < .001) or with physical therapy (P < .025); they were also more likely to agree that they would rather stop sports than undergo surgery (P < .04). Athletes with worse ASES and WOSI scores at injury were more likely to choose surgery (P < .03 and P < .05, respectively). Athletes with >1 dislocation were less likely to believe that the shoulder would heal without surgery (P < .025). Most athletes agreed that seasonal timing and recruitment prospects were an important factor in their decision in favor of surgery (P < .038), and most agreed that their doctor influenced their ultimate treatment decision (P < .006). Most athletes also agreed that a repeat dislocation would cause further injury to the shoulder.Conclusion:Treatment decisions were most strongly related to the athletes’ perceptions of injury severity and the influence of the treating surgeon.

Surgeon Applications of Patient Preferences in Treatment Decision Making for First-Time Anterior Shoulder Dislocation.

Background:Treatment of a first-time anterior shoulder dislocation (FTASD) is sensitive to patient preferences. The operative or nonoperative management debate provides an excellent opportunity to learn how surgeons apply patient preferences in treatment decisions.Purpose:To determine how patient preferences (repeat dislocation risk, recovery difficulties, fear of surgery, treatment costs) and surgeon factors influence a surgeon’s treatment plan for FTASD.Study Design:Cross-sectional study.Methods:Eight clinical vignettes of hypothetical patients with FTASD (including age, sex, and activity level) were presented to members of the Magellan Society. A second set of matched vignettes with patient preferences and clinical variables were also presented. The vignettes represented scenarios in which evidence does not favor one treatment over another. Respondents were asked how they would manage each hypothetical case. Respondents also estimated the risk of redislocation for the nonoperative cases for comparison with the published rates. Finally, respondents completed a Likert-scale questionnaire to determine their perceptions on factors influencing their decisions.Results:A total of 103 orthopaedic surgeons completed the survey; 48% practiced in an academic hospital; 79% were in practice for 10 years or longer; and 75% had completed a sports medicine fellowship. Patient preferences were the single most important factor influencing treatment recommendation, with activity type and age also important. Just 62% of the surgeon estimates of the risk of redislocation were consistent with the published rates. The inclusion of patient preferences to clinical variables changed treatment recommendations in 62.5% of our hypothetical cases. Respondents rated patient treatment preference as the leading factor in their treatment decision making.Conclusion:Patient preferences were important when deciding the appropriate treatment for FTASD. Respondents were inconsistent when applying evidence in their decision making and estimates of recurrent instability. Decision support tools that deliver patient preferences and personalized evidence-based outcome estimates improve the quality of decision making at the point of care.

Pediatric and Adolescent Shoulder Instability: Does Insurance Status Predict Delays in Care, Outcomes, and Complication Rate?

Background:Recurrent shoulder instability results from overuse injuries that are often associated with athletic activity. Timely diagnosis and treatment are necessary to prevent further dislocations and secondary joint damage. In pediatric and adolescent patients, insurance status is a potential barrier to accessing timely care that has not yet been explored.Purpose:To examine the effect of insurance status on access to clinical consultation, surgical intervention, and surgical outcome of pediatric and adolescent patients with recurrent shoulder instability.Study Design:Cohort study; Level of evidence, 3.Methods:We conducted a retrospective review of pediatric and adolescent patients who were treated at a single tertiary children’s hospital for recurrent shoulder instability between 2011 and 2017. Patients were sorted into private and public insurance cohorts. Dates of injury, consultation, and surgery were recorded. Number of previous dislocations, magnetic resonance imaging (MRI) results, surgical findings, and postoperative complications were also noted. Delays in care were compared between the cohorts. The presence of isolated anterior versus complex labral pathology as well as bony involvement at the time of surgery was recorded. The incidences of labral pathology and secondary bony injury were then compared between the 2 cohorts. Postoperative notes were reviewed to compare rates of repeat dislocation and repeat surgery.Results:A total of 37 patients had public insurance, while 18 patients had private insurance. Privately insured patients were evaluated nearly 5 times faster than were publicly insured patients (P < .001), and they obtained MRI scans over 4 times faster than did publicly insured patients (P < .001). Publicly insured patients were twice as likely to have secondary bony injuries (P = .016). Postoperatively, a significantly greater number (24.3%) of publicly insured patients experienced redislocation versus the complete absence of redislocation in the privately insured patients (P = .022).Conclusion:Public insurance status affected access to care and was correlated with the development of secondary bony injury and a higher rate of postoperative dislocations. Clinicians should practice with increased awareness of how public insurance status can significantly affect patient outcomes by delaying access to care—particularly if delays lead to increased patient morbidity and health care costs.

PEDIATRIC AND ADOLESCENT SHOULDER INSTABILITY: DOES INSURANCE STATUS PREDICT THE DEVELOPMENT OF BONY BANKART AND ENGAGING HILL-SACHS LESIONS?

Background:Pediatric and adolescent patients who undergo shoulder stabilization surgery have higher rates of failure than their adult counterparts. The impact of insurance status on intra-operative findings and outcomes is largely unknown.Hypothesis/Purpose:We hypothesized that patients with public insurance who undergo shoulder stabilization surgery would have greater degrees of bony pathology; leading to poor outcomes after stabilization.Methods:This was a retrospective cohort study of pediatric and adolescent patients with public and private insurance who were treated for recurrent shoulder instability from 2011-2017. Patients were treated at a tertiary care children’s hospital by a single orthopaedic surgeon. Patients 10 to 18 years of age were included in the study if they presented with recurrent shoulder instability and underwent surgical intervention for their injury. Time from injury to clinical consultation, imaging, and surgical intervention; incidences of labral pathology and secondary bony injury; and rates of repeat dislocation and repeat surgery were compared between the public and private insurance cohortsResults:Thirty-seven patients had public insurance while 18 patients had private insurance. Privately insured patients were evaluated by clinicians nearly five times faster than were publicly insured patients (p < 0.001), and they obtained MRIs over four times faster than did public insurance patients (p < 0.001). Publicly insured patients were twice as likely to have secondary bony injuries (p=0.043). Postoperatively, a significantly greater number (24.3%) of publicly insured patients experienced re-dislocation versus the complete absence of re-dislocation in the privately insured patients (p=0.022).Conclusion:Public insurance status impacts access to care and correlates with both the development of secondary bony injury and an increased rate of clinical failure manifested as repeat post-operative dislocations.Table 1.Data SummaryAll (n=55)Public Insurance (n=37)Private Insurance (n=18)Days from Injury to Clinic298.71402.3885.61Days from Injury to MRI323.04431.9799.11Days from Injury to Surgery451.76561.38226.44*Days from Clinic to MRI24.3329.5913.50*Days from MRI to Surgery128.73129.41127.33Number of prior dislocationsNone = 3Single = 2Multiple = 32None = 6Single = 0Multiple = 12Incidence of anterior only vs. complex labral pathologyAnterior only = 81.8% (45/55)Complex = 18.2% (10/55)Anterior only = 83.8% (31/37)Complex = 16.2% (6/37)Anterior only = 77.8% (14/18)Complex = 22.2% (4/18)Incidence of bony involvement (Y/N)56.4% (31/55)67.6% (25/37)33% (6/18)Incidence of repeat dislocations16.4% (9/55)24.3% (9/37)0.00% (0/18)*Incidence of repeat surgery5.5% (3/55)8% (3/37)0.00% (0/18) Table 1 shows the summary of results for public and private insurance cohorts for days from injury to clinic, injury to MRI, injury to surgery, clinic to MRI, MRI to surgery as well as number of prior dislocations, incidence of anterior only vs. complex labral pathology, incidence of bony involvement, incidence of repeat dislocations, and incidence of repeat surgery. * denotes that the difference between the two insurance cohorts was not statistically significant.

OUTCOMES OF ARTHROSCOPIC BANKART REPAIR IN THE PEDIATRIC AND ADOLESCENT POPULATION: HIGH RATES OF FAILURE

BACKGROUND Shoulder instability is an increasingly common problem in the pediatric and adolescent population. As with anterior cruciate ligament reconstruction, surgical intervention in this population is becomingly increasingly common. Yet, although failure rates are much higher in this active population there has been limited examination of this population in the literature. The purpose this study was to review treatment of adolescent shoulder instability and to discuss factors influencing its management; particularly recurrent instability. METHODS A retrospective cohort study was performed at a single center. Inclusion criteria consisted of all adolescent aged patients identified who (1) had complaints of shoulder instability, (2) had radiographic findings consistent with anterior-inferior capsulolabral injury, (3) had documented evidence of a dislocation event, and (4) underwent arthroscopic shoulder stabilization. Patient demographics, pre-operative history and physical, imaging, surgical details, and post-operative complications were analyzed. RESULTS Thirty-six patients were identified with a mean follow-up 3.07 ± 1.2 years. The average patient age at the time the index procedure was 16.03 ± 1.67 years. All patients underwent arthroscopic shoulder stabilization consisting of arthroscopic Bankart repair. Five patients also underwent a remplissage. Nine patients (25.0%) developed a repeat dislocation following surgery. This occurred on average 20.67 months postoperatively (range 5-51 months). No single sport was associated with a statistically significant increased risk of re-dislocation. American football was the most common sport in both the stable and re-dislocated groups. Patients who re-dislocated had a higher frequency of a Hill-Sachs lesion on MRI (89%) compared to those who did not re-dislocate (52%) (p=0.048). Off-track lesions were not associated with repeat instability. CONCLUSIONS / SIGNIFICANCE The current study demonstrates that adolescent patients treated with arthroscopic shoulder stabilization have a high rate of recurrence of shoulder dislocations, particularly in the setting of a concomitant Hills-Sachs lesion. Patients may benefit from more aggressive stabilization strategies and techniques. Further prospective multi-center studies are necessary to determine the reasons for the high rate of re-dislocation in this population and develop strategies for prevention.

Partial Resurfacing for Humeral Head Defects Associated With Recurrent Shoulder Instability.

Recurrent traumatic shoulder instability is a complex clinical entity that commonly affects young, active patients. Humeral head defects are frequently associated with this condition, but specific treatment to stabilize the shoulder is rarely needed. Management options for defects of the humeral head that do necessitate treatment carry various risks and disadvantages, including the need for bone or soft tissue healing, complications related to hardware, and loss of motion. Partial prosthetic resurfacing has been reported as a treatment option. The current study retrospectively reviewed a cohort of patients with recurrent or locked anterior and posterior instability who underwent partial prosthetic humeral head resurfacing for significant Hill-Sachs and reverse Hill-Sachs lesions. At an average of 36.4 months after the index procedure, 16 patients were contacted by mail and telephone. Of the study group, 13 patients underwent partial resurfacing for anterior instability and 3 patients underwent partial re-surfacing for posterior instability. No patient had a repeat dislocation. In addition, 77% of patients in the anterior instability cohort and all of the patients in the posterior instability cohort returned to their full preinjury activity level. For the anterior instability cohort, significant improvements from preoperatively to final follow-up occurred for mean Musculoskeletal Review of System score (4.54, P<.0001) and Short Form-12 physical component score (9.52, P=.002). For the combined cohort, the Penn Shoulder Score improved by 36.4 points (P=.059). This study showed the effectiveness of partial humeral head resurfacing for preventing redislocation for patients with significant Hill-Sachs and reverse Hill-Sachs lesions. [Orthopedics. 2017; 40(6):e996-e1003.].

Allograft Versus Autograft for Medial Patellofemoral Ligament Reconstruction

The use of either allograft or autograft tissue for MPFL reconstruction results in a very low (<3%) risk of repeat dislocation. Patellofemoral instability with recurrent patellar dislocations is a debilitating condition that frequently affects a young, active patient population. Isolated medial patellofemoral ligament (MPFL) reconstruction has emerged as an effective treatment of recurrent patellar dislocations that occur in the absence significant patellofemoral malalignment or osseous abnormalities. Both allografts and autografts have been successful used for MPFL reconstruction. We hypothesize that MPFL reconstruction with allograft or autograft tissue yields similar low rates of recurrent dislocation and subjective patellar instability. Chart review identified 117 MPFL reconstructions (80 allograft and 37 autograft) without concurrent bony procedures (such as tibial tubercle osteotomy) performed between 2008 and 2014 by four sports medicine fellowship trained orthopedic surgeons at our center. Patient demographics (age and sex) and surgical data (graft type) were identified by chart review. Chart review and patient interviews were undertaken to identify recurrent patellar dislocations as well as recurrent subjective patellofemoral instability. Recurrent dislocation and subjective instability risk were compared between the allograft and autograft groups. 53 patients (45%) with complete baseline data and minimum 1 year follow-up were contacted at a mean of 4.5 years following isolated MPFL reconstruction, including 37 patient with allograft reconstructions and 16 with autograft reconstructions. No significant differences in patient sex, age at reconstruction, body mass index, or time to follow-up were noted between groups. Recurrent dislocation occurred in 1 patient in the allograft group (2.7%) and 0 patients in the autograft group (0%), (p = 0.51). Recurrent subjective instability occurred in 9 patients in the allograft group (24.3%) and 5 patients in the autograft group (31.2%), (p = 0.74). The use of either allograft or autograft tissue for MPFL reconstruction results in a very low (<3%) risk of repeat dislocation. Recurrent subjective instability occurs more frequently (1/4 to 1/3 of patients) at a similar rate for both graft types.

Paediatric First-Time Patella Dislocators: An Approach to Conservative Management: 兒科首次髕骨脫位 : 保守治療進路

BackgroundFirst-time lateral patella dislocations are generally treated nonoperatively. However, the ideal form of conservative management and immobilization remains unknown. We compare the clinical outcomes after different immobilization methods. MethodsPaediatric-age patients that met our inclusion criteria, and presenting with a first episode of lateral patella dislocation to our hospital from 2006 to 2013, were enrolled. Different immobilization methods included brace, backslab, or cylinder cast. A retrospective review was performed to compare bracing against other immobilization methods, using a primary outcome measure of redislocation rate, and secondary outcome measures like progression to surgery, range-of-motion, pain, and weight-bearing status. ResultsA total of 142 patients (with 147 affected knees) with minimum 1-year follow-up were included in the study. Bracing was found to be superior to other immobilization methods in preventing repeat dislocations, and need for subsequent surgery. At 6 weeks, patients treated with the backslab had the highest incidence of pain. There were no differences with regards to range-of-motion or weight-bearing status. ConclusionWe recommend the use of a brace, with a progressive rehabilitation protocol in the management of first-time lateral patella dislocators. This study is also unique, in that it specifically addresses nonoperative management of first time patella dislocators in a paediatric-age population group.

Management of First-Time Shoulder Dislocation in the Contact Athlete

First-time anterior shoulder dislocation in the contact and collision athlete represents a treatment challenge for the orthopaedic surgeon, especially if the athlete is in season. Treatment starts with immediate on-field management and transitions to a thorough history and physical examination off the field. Plain film and advanced imaging then help to guide the orthopaedic surgeon in the shared decision-making process. The decision to return an athlete to play in the same season carries a high risk of repeat dislocation or instability, and the surgeon must not only counsel the athlete on this but also protect the athlete from returning before safe to do so. The optimal surgical treatment—arthroscopic vs open vs bone block—remains controversial as well. Historically, open Bankart repair and stabilization has shown a decreased risk of recurrence compared with arthroscopic, but the current literature has support for either options. Additionally, some authors now advocate open osseous augmentation procedures as having the lowest recurrence rates. This article explores the decision-making process from first clinic contact through clinical management.

Surgical versus conservative management of acute patellar dislocation in children and adolescents: a systematic review.

The goal of this study was to perform a comparative review to determine whether there is a significant difference in the rate of repeat dislocation and clinical outcome between surgical and conservative management of acute patellar dislocation in children and adolescents. A systematic review of the MEDLINE database was performed. English-language clinical outcome studies with a primary outcome/treatment specific to acute patella dislocation in a paediatric population were included. Eleven studies met inclusion criteria; Chi-square analysis, independent t tests and weighted mean pooled cohort statistics were performed where appropriate. A total of 470 conservatively managed and 157 operatively treated knees were included. Conservatively managed patients were on average 17.0 years and had a mean follow-up of 3.9 years; surgically managed patients were on average 16.1 years and had a mean follow-up of 4.7 years. Conservatively managed knees had a 31% rate of recurrent dislocation rate compared to 22% in surgical knees (p = 0.04). Trochlear dysplasia and skeletal immaturity confer greater risk for recurrent instability. Surgical treatment may provide clinically important quality of life and sporting benefit. Surgical treatment of first time patella dislocation in children and adolescents is associated with a lower risk of recurrent dislocation and higher health-related quality of life and sporting function. There is a paucity of evidence on MPFL reconstruction for first time traumatic patella dislocation in this population. IV.

Complete dissociation of a dual mobility acetabular liner secondary to repeat dislocation

Kunapuli, Sarat DOa; Newton, Michael D. BSb; Kurdziel, Michael D. MSb,c; Baker, Kevin C. PhDb,c; Verner, James J. MDa,c Author Information

T1ρ Magnetic Resonance Imaging to Assess Cartilage Damage After Primary Shoulder Dislocation

Objectives:Anterior shoulder dislocation is a common injury with an estimated incidence of 23.1/100,000 person-years. In anterior dislocation, associated injuries typically involve the anteroinferior glenoid and posterosuperior humeral head. Patients who suffer a shoulder dislocation are at higher risk of developing glenohumeral arthropathy; the risk increases with recurrent dislocations. However, little is known about the initial cartilage damage after a primary shoulder dislocation. T1ρ is a magnetic resonance imaging (MRI) modality that allows quantification of cartilage proteoglycan content and can be used to detect physiologic changes in cartilage without intravenous contrast. Cartilage degeneration is characterized by decreased proteoglycan content, which results in an increased T1ρ relaxation constant. T1ρ MRI can detect differences in knee cartilage between Kellgren-Lawrence grades as well as acetabular cartilage changes in patients with femoroacetabular impingement. The objectives of this prospective study were to determine if T1ρ MRI can detect cartilage damage following primary shoulder dislocation and to assess for patterns in cartilage damage in anterior dislocations.Methods:This study received Institutional Review Board approval. Nine patients (mean age 31.3 years, range 20-59) who had sustained anterior shoulder dislocations underwent a 3T T1ρ MRI within ten days of their injury. Five control patients without prior dislocation or glenohumeral arthritis also underwent 3T T1ρ MRI. The T1ρ relaxation constant was determined for the entire glenoid and humeral head for dislocation and control patients. In addition, the glenoid was divided into nine zones, and T1ρ values were determined for each zone in dislocated and control patients to assess for differences between the two groups and to identify any patterns in cartilage damage in dislocated patients.Results:T1ρ mapping of glenohumeral cartilage in dislocated shoulders showed significant cartilage damage. Overall T1ρ values were increased in dislocated shoulders compared to control shoulders for glenoid and humeral head cartilage (53.46±0.99 vs. 36.60±3.6 and 46.50±1.1 vs. 36.19±1.7, respectively; mean±SEM, p = 0.0025, Fig. 1A). Furthermore, T1ρ values were significantly increased in all glenoid zones in dislocated shoulders compared to controls except for posterior/inferior (p = 0.064 for posterior/inferior, p < 0.02 for all other zones, Fig. 1B). However, there were no significant differences in T1ρ values between glenoid zones in dislocated shoulders across patients, reflecting widespread cartilage damage.Conclusion:T1ρ MRI is sensitive for detecting cartilage damage and proteoglycan loss after shoulder dislocation. T1ρ values were significantly higher (lower proteoglycan content) in nearly all glenoid zones in dislocated shoulders compared to controls and approached significant difference in the posterior/inferior zone. Although the anteroinferior glenoid and posterosuperior humeral head are characteristically affected in anterior dislocation, cartilage damage was surprisingly more widespread and affected the entire joint. The etiology of diffuse cartilage damage is unknown but may be due to hemarthrosis or additional trauma to the joint during humeral head relocation. Longer-term studies are needed to determine if the initial cartilage damage persists and if cartilage damage worsens with repeat dislocations.

Risk of arthropathy after the Bristow-Latarjet repair: a radiologic and clinical thirty-three to thirty-five years of follow-up of thirty-one shoulders

Transfer of the coracoid (Bristow-Latarjet [B-L]) is used to stabilize anterior shoulder instability. We report the long-term results of our first 31 operations with this method. Thirty-six patients (mean age, 26.7 years) had a B-L repair from 1977 to 1979. Five patients died, and during 2012 to 2013, the remaining 31 shoulders had a follow-up with questionnaire, physical examination, Western Ontario Shoulder Instability Index, Subjective Shoulder Value, Subjective Assessment of Shoulder Function, subjective assessment of loss of motion, and radiologic imaging. One patient required revision surgery because of recurrence and another because of repeat dislocation. Six patients reported subluxations. Eighteen patients (58%) were very satisfied, and 13 (42%) were satisfied. The mean Western Ontario Shoulder Instability Index score (100 possible) was 85, and the median score was 93. According to Samilson-Prieto classification of arthropathy of the shoulder, 39% were classified as normal, 27% as mild, 23% as moderate, and 11% as severe. The classification of arthropathy varied with observers and radiologic views. Age younger than 22 years at the primary dislocation meant less arthropathy at follow-up (P = .045). The degree of arthropathy 33 to 35 years after the B-L repair seems to follow the natural history of shoulder dislocation with respect to arthropathic joint degeneration. Postoperative restriction of external rotation does not increase later arthropathy.

Arthroscopic reduction and acetabuloplasty for the treatment of dislocated hips in children of walking age: a preliminary report.

This paper presents our initial findings on the use of arthroscopic hip reduction in conjunction with acetabuloplasty to treat patients of walking age who had congenital dislocation of the hip. Arthroscopic reduction with acetabuloplasty was performed on nine children of walking age with nine dislocated hips. The average age of the patients was 21.4months (14-41months). Arthroscopic reduction was performed using a two-portal method with a 2.7-mm mini cannulated arthroscopic instrument. We used a subadductor portal and a high anterolateral portal. The obstacles preventing reduction-hypertrophic teres ligament, pulvinar, capsular constriction, hypertrophic transverse ligament-were eliminated. We treated one grade 4 hip, four grade 3 hips and four grade 2 hips, as classified by Tönnis. We were able to perform arthroscopic reduction on all of the hips. The main obstacles preventing reduction were a capsular constriction and a hypertrophic teres ligament. During the investigation period, which averaged 15.4months (6-29months), no repeat dislocation occurred. According to the Tönnis classification system for avascular necrosis, there were two cases of a grade 2 necrosis of the femoral head. The average preoperative AC angle was 40° (34°-47°). The average AC angle at the follow-up examination was 18.7° (11°-27°). We can conclude that the standardized arthroscopic surgical technique presented here can also be used to safely perform arthroscopic reduction in toddlers. The new arthroscopic method is an alternative to open reduction for selective hip dislocations. We believe this approach can be used to treat dislocated hips that are classified as grades 2 and 3 dislocations according Tönnis. Early results are promising. Medium-term results are needed to make a definitive statement on the rates of necrosis of the femoral head.