Research progress of the diagnosis and treatment of anterior shoulder instability / 中国修复重建外科杂志

The shoulder joint is the most prone to dislocation in the whole body, and more than 95% of them are anterior dislocation. Improper treatment after the initial dislocation is easy to lead to recurrent anterior dislocation or anterior shoulder instability, and the outcomes following conservative treatment is poor. Anterior shoulder instability can damage the soft tissue structure and bone structure that maintain the stability of shoulder joint, among which bone structure is the most important factor affecting the stability of shoulder joint. Diagnosis should be combined with medical history, physical examination, and auxiliary examination. Currently, three-dimensional CT is the most commonly used auxiliary examination means. However, various bone defect measurement and preoperative evaluation methods based on three-dimensional CT and the glenoid track theory have their own advantages and disadvantages, and there is still a lack of gold standard. Currently, the mainstream treatment methods mainly include Bankart procedure, coracoid process transposition, glenoid reconstruction with free bone graft, Bankart combined with Remplissage procedure, and subscapular tendon binding tamponade, etc. Each of these procedures has its own advantages and disadvantages. For the diagnosis and treatment of anterior shoulder instability, there are still too many unknown, further research and exploration need to be studied.

The Painful Anterior Apprehension Test – an Indication of Occult Shoulder Instability

@#Introduction: To evaluate the clinical relevance of the painful anterior apprehension test in shoulder instability. Materials and methods: We performed a retrospective study of 155 patients that underwent arthroscopic anterior Bankart repair between 2014–2016. Exclusion criteria were previous ipsilateral shoulder surgery, bony Bankart lesions, glenohumeral osteoarthritis and concomitant surgery involving rotator cuff tears, biceps tendon pathology and superior labrum from anterior to posterior (SLAP) lesions. The study cohort was divided into three groups: apprehension test with apprehension only, apprehension test with pain only, and apprehension test with both apprehension and pain. Patient demographics, clinical characteristics, radiological imaging, arthroscopy findings and surgical outcomes (Constant, American Shoulder and Elbow Surgeons (ASES), SF-36 scores) were evaluated. Results: A total of 115 (74.2%) had apprehension only, 26 (16.8%) had pain only and 14 (9.0%) had pain and apprehension with the apprehension test. Univariate analysis showed significant differences between the groups in patients with traumatic shoulder dislocation (p=0.028), patients presenting with pain (p=0.014) and patients presenting with recurrent dislocations (p=0.046). Patients with a purely painful apprehension test were more likely to have a traumatic shoulder dislocation, more likely to present only with pain, and less likely to present with recurrent shoulder dislocations. Multivariate analysis showed that none of these factors alone were significant as single predictors for shoulder instability. All three groups were otherwise similar in patient profile, MRI and arthroscopic assessments, and clinical outcomes of surgery. Excellent clinical outcomes were achieved in all groups with no difference in pre-operative and post-operative scores across all groups at all time points. Conclusion: The painful apprehension test may suggest underlying shoulder instability.

Evaluation of the Glenoid Track Tomographic Method in Magnetic Resonance Imaging/Arthro-MRI / A avaliação do método tomográfico glenoid track na ressonância magnética/artro RM

Abstract Objective To evaluate and compare the glenoid track method in 3D-reconstructed computed tomography (3D-CT) scans with magnetic resonance imaging (MRI) and/or arthro-MRI. Methods Forty-four shoulders with clinical and radiographic diagnosis of traumatic anterior instability were assessed using 3D-CT, MRI, and/or arthro-MRI scans. Glenoid track (GT), Hill-Sachs interval (HSI), and glenoid bone loss (GBL) were determined by a radiologist using 3D-CT images, and classified as on-track/off-track. Three surgeons, blinded to the radiologist's evaluation, performed the same determinations using MRI/arthro-MRI. Descriptive analysis, variance analysis, results disagreement analysis, and receiver operating characteristic (ROC) curves were performed. Results Results from the 4 examiners were fully consistent in 61.4% of the cases. Magnetic resonance imaging/arthro-MRI diagnosed off-track injuries with 35 to 65% sensitivity and on-track injuries, with 91.67 to 95.83% specificity. Accuracy ranged from 68.1 to 79.5%. The greatest data divergence occurred for off-track injuries diagnosed by MRI/arthro-MRI. The greatest data variability referred to HSI calculation. Higher HSI and GBL values were associated with greater disagreement among examiners. Hill-Sachs interval values were lower at MRI/arthro-MRI when compared to 3D-CT. Agreement between CT and MRI/arthro-MRI for the GT method was only moderate (kappa value, 0.325-0.579). Conclusion Magnetic resonance imaging/arthro-MRI showed low accuracy and moderate agreement for the GT method; as such, it should be used with caution by surgeons.

Resumo Objetivo Comparar a avaliação do método glenoid-track (GT) em exames de tomografia computadorizada com reconstrução 3-D (TC-3D) com a avaliação realizada em exames de ressonância magnética (RM) e/ou artro-ressonância magnética (ARM). Métodos Quarenta e quatro ombros com diagnóstico clínico e radiográfico de instabilidade anterior traumática foram avaliados por meio de exames de TC-3D, RM e/ou ARM. As variáveis GT, intervalo de Hill-Sachs (IHS) e a perda óssea da glenoide (POG) foram realizadas por um médico radiologista, utilizando imagens de TC-3D, e classificadas em on-track/off-track. Três cirurgiões cegos à avaliação do radiologista realizaram o mesmo método utilizando RM/ARM. O estudo realizou análise descritiva, de variância, de associação da discordância de resultados, de concordância e curva característica de operação do receptor. Resultados Os resultados dos 4 examinadores foram totalmente concordantes em 61,4%. A RM/ARM diagnosticou lesões off-track com a sensibilidade variando de 35 a 65%, e lesões on-track com a especificidade variando de 91,67 a 95,83%. A acurácia variou de 68,1 a 79,5%. A maior divergência de dados ocorreu para o diagnóstico por RM/ARM de lesões off-track. A maior variabilidade dos dados ocorreu para o cálculo do IHS. Valores maiores de IHS e de POG foram associados a maior discordância entre os examinadores. A RM/ARM apresentou menor medida de valores de IHS quando comparado com a TC-3D. Ocorreu apenas moderada concordância no método GT entre a TC e a RM/ARM (Kappa 0,325-0,579). Conclusão A RM/ARM apresentou baixa acurácia e moderada concordância para o método GT, devendo ser utilizada com cautela por cirurgiões.

Arthroscopic Bristow: Assessments of Safety and Effectiveness, 12 Years of Experience / Bristow artroscópico: Avaliação da segurança e da eficácia, 12 anos de experiência

Abstract Objective The open Bristow procedure is a long established and effective method for treating anterior shoulder instability. Following the trends of minimally-invasive surgeries, these procedures were performed arthroscopically, and their outcomes were evaluated. Methods A total of 43 shoulders of patients submitted to Bristow procedures by arthroscopy, using a graft positioned horizontally and a screw, with at least two years of postoperative follow-up, were evaluated regarding quality of life, de novo dislocation index, and loss of lateral rotation. Results The mean follow-up time was of 76 months (range: 129 to 24 months). The University of California at Los Angeles (UCLA) score varied from 25.56 ± 0.50 (standard deviation [SD] = 3.25) to 33.23 ± 0.44 (SD = 2.91) (p < 0.0001). Two or more years after surgery, the mean Rowe score was of 94.25 ± 1.52 (SD = 1.34), whereas the good results standard is 75 (p < 0.0001). The mean value for the simple shoulder test was of 11.35 ± 0.21 (SD = 1.34), while the mean value of the lateral rotation loss was of 10.37º ± 1.36º (SD = 8.58º). There were no de novo dislocations. In total, there were 12 complications, 8 of which had no clinical repercussions. The clinically-significant complications included an infection six months after surgery with a potential hematogenous origin, a coracoid fracture that required an intraoperatively procedure change, and two patients with previous impingement who required synthesis material removal more than six months after surgery. Conclusion Although the arthroscopic Bristow procedure was effective in treating anterior shoulder instability, it is not a complication-free surgery.

Resumo Objetivo O procedimento de Bristow aberto é um método há muito estabelecido e eficaz no tratamento da instabilidade anterior do ombro. Seguindo as tendências das cirurgias minimamente invasivas, essa cirurgia foi realizada por artroscopia, e seus resultados foram avaliados. Métodos Foram avaliados 43 ombros de pacientes submetidos ao procedimento de Bristow por artroscopia, com o enxerto em posição horizontal e uso de um parafuso, com pelo menos dois anos de seguimento pós-cirúrgico, por meio de escores qualidade de vida, índice de reluxação e perda de rotação lateral. Resultados A média de seguimento foi de 76 meses (variando de 129 a 24 meses), e o escore da University of California at Los Angeles (UCLA) variou de 25,56 ± 0,50 (desvio padrão [DP] = 3,25) para 33,23 ± 0,44 (DP = 2,91) (p < 0,0001). A média para o escore de Rowe com 2 anos ou mais de cirurgia foi de 94,25 ± 1,52(DP = 1,34), sendo que o padrão de bons resultados é de 75 pontos (p < 0,0001). A média do teste simples de ombro foi de 11,35 ± 0,21 (DP = 1,34), e, para perda de rotação lateral, foi de 10,37º ± 1,36º (DP = 8,58º). Não houve reluxações. Entre os 43 pacientes operados, ocorreram um total de 12 complicações, das quais 8 não apresentaram qualquer repercussão clínica. As complicações com repercussão clínica foram uma infecção de possível origem hematogênica seis meses após a cirurgia, uma fratura do coracoide que fez com que o paciente precisasse mudar o procedimento no intraoperatório, e dois pacientes com impacto anterior, que necessitaram de retirada de material de síntese mais de seis meses após a cirurgia. Conclusão O procedimento de Bristow artroscópico mostrou eficácia no tratamento da instabilidade anterior do ombro, embora não seja livre de complicações.

Técnica de Eden Hybinette en inestabilidad anterior de hombro con pérdida de stock óseo en paciente con epilepsia: reporte de caso / Eden Hybinette technique in anterior instability of the shoulder with bone loss in a patient with epilepsy: case report

La inestabilidad de hombro es una lesión de incidencia relevante en trauma, ocasionalmente asociada con pérdida ósea glenoidea en pacientes con epilepsia. Ha habido pocos artículos que describan tratamientos quirúrgicos específicos para este tipo de lesión y en este grupo de pacientes. Este reporte de caso muestra un enfoque quirúrgico exitoso utilizado en un paciente epiléptico con múltiples luxaciones de hombro derecho que ocurrieron principalmente durante convulsiones, a través de la técnica Eden Hybinette, en donde se utilizó un autoinjerto de cresta ilíaca. El paciente ha sido seguido en un año de postoperatorio, sin nuevos episodios de luxación de hombro derecho, sin quejas de dolor, con buen rango de movimiento del hombro sin limitaciones para actividades cotidianas o laborales. Se han publicado diferentes métodos quirúrgicos para estos pacientes, incluidas las operaciones de reparación de tejidos blandos, así como las reconstrucciones esqueléticas con terapias de injerto óseo, siendo Eden Hybinette una de estas. Esta cirugía es una opción válida, ya que permite una posición adecuada del injerto en el defecto glenoideo, disminuyendo potencialmente el riesgo de lesiones neurovasculares y miotendinosas; aunque, de manera más importante, reduce las recurrencias de luxación de hombro en pacientes con epilepsia no controlada y les da la oportunidad de una buena calidad de vida.

Shoulder instability is occasionally associated with glenoid bone loss in patients with epilepsy. There have been few articles that describe specific surgical treatments for this type of injury. This case report shows a successful surgical approach used in an epileptic patient with multiple right shoulder dislocations that occurred mainly during seizures, through the Eden Hybinette technique, performed using an iliac crest autograft. The patient has been followed up for one year postoperatively, without new episodes of right shoulder dislocation, without complaints of pain, with good range of movement of the shoulder without limitations for daily or work activities. Different surgical methods have been published for these patients, including soft tissue repair operations, as well as skeletal reconstructions with bone graft, Eden Hybinette being one of these. This surgery is a valid option, since it allows an adequate position of the graft in the glenoid defect, potentially reducing the risk of neurovascular and myotendinous lesions; although, more importantly, it reduces the recurrences of shoulder dislocation in patients with uncontrolled epilepsy and gives them the opportunity for a good quality of life.

Latarjet procedure on anterior shoulder instability in professional soccer players / Cirurgia de latarjet na instabilidade anterior do ombro em jogadores profissionais de futebol

ABSTRACT Anterior glenohumeral instability is a frequent cause of professional soccer players' removal, reduced performance, and prolonged recovery. Players are subjected to intense physical contact and high performance, thus demanding lower rates of recurrence after surgical correction so they can return to sport quickly. Objective: To assess professional soccer players treated by the Lartajet technique considering the rate and time of return to sports activities, complications or failures. Methods: Analysis held between 2010 and 2018 of professional soccer players diagnosed with anterior shoulder instability operated by the open procedure of Lartajet in our service. Results: The mean return to professional sports was 93.5 days. The mean time of surgery in relation to the first dislocation was 12.4 months. Each athlete had 4.3 shoulder dislocations until the procedure was performed. The rate of recurrence was zero and subluxation was not observed. Conclusion: The Latarjet procedure allowed all professional athletes to return to competitive activities quickly, without dislocations and subluxation, negative seizure and without complications during follow-up. Level of evidence IV, Case series.

RESUMO A instabilidade glenoumeral anterior é uma frequente causa de afastamento dos jogadores de futebol profissional, redução do desempenho e recuperação prolongada. Os jogadores são submetidos ao contato físico intenso e ao alto desempenho, sendo assim necessário atingir menores taxas de recidiva após a correção cirúrgica e retorno ao esporte de forma mais rápida. Objetivo: Avaliar jogadores de futebol profissionais tratados pela técnica de Lartajet com análise da taxa e tempo de retorno às atividades esportivas, complicações ou falhas. Métodos: Análise entre 2010 a 2018 de dez jogadores de futebol que estão atuando em clubes profissionais, diagnosticados por instabilidade anterior do ombro operados pelo procedimento aberto de Lartajet em nosso serviço. Resultados: A média de retorno ao esporte profissional foi de 93,5 dias. A média de tempo da cirurgia em relação ao primeiro episódio de luxação foi de 12,4 meses. Cada atleta teve 4,3 luxações de ombro até o procedimento ser realizado. A taxa de recidivas foi zero e não foi observada subluxação. Conclusão: O procedimento Latarjet propiciou que todos os atletas profissionais de futebol retornassem às atividades competitivas de maneira rápida, sem recidivas das luxações e subluxações e sem complicações durante o acompanhamento realizado. Nível de evidência IV, Séries de casos.

Arthroscopic Latarjet: Technique Description and Preliminary Results. Study of the First 30 Cases / Latarjet artroscópico: Descrição de técnica cirúrgica e resultados preliminares. Estudo de 30 primeiros casos

Abstract Objective Arthroscopic Latarjet has been performed with the aim to be an accurate technique with a low incidence of complications. The aim of the present study was to briefly describe the technique and to evaluate the shot-term complications following arthroscopic Latarjet procedure to correct anterior shoulder dislocation with glenoid bone loss. Methods Retrospective study with 30 subjects with anterior shoulder instability, submitted to arthroscopic Latarjet. Intraoperative and short-term postoperative complications were recorded, as well as the rate of revision surgery. Results Five cases had complication (16.7%), and in the last 10 cases no complication occurred. In 1 case (3.3%), it was required to reverse for open surgery due to a fracture of the coracoid process during fixation in the glenoid. No other intraoperative complication occurred. No infection was observed. Two cases (6.7%) evolved with temporary neuropraxia of the musculocutaneous nerve, totally reversed with physiotherapy. With a follow-up from 6 to 26 months, 2 patients (6.7%) required a new intervention for graft/screws removal and release of the joint due to excessive limitation in external rotation. There was no case of recurrence. Conclusion Even in an initial learning curve, arthroscopic Latarjet demonstrated a low rate of short-tem complications and was a safe procedure for treating anterior dislocation of the shoulder with glenoid bone loss.

Resumo Objetivo A realização da cirurgia de Latarjet por via artroscópica tem sido possível pelo desenvolvimento de instrumentais adequados e um protocolo para cirurgia estabelecido e reprodutível, que promete uma técnica mais precisa e com menor incidência de complicações. O objetivo do presente estudo foi fazer uma breve descrição de técnica cirúrgica e avaliar as complicações de curto prazo após a cirurgia de Latarjet por via artroscópica para correção de luxação anterior do ombro com perda óssea glenoidal. Método Estudo retrospectivo com 30 pacientes com instabilidade anterior do ombro, operados com a técnica de Latarjet por via artroscópica. Foram feitas avaliação das complicações intraoperatórias e pós-operatório de curto prazo e documentação de necessidade de reintervenções. Resultados Cinco casos tiveram complicação (16,7%), sendo que nos últimos 10 casos nenhuma complicação foi observada. Em 1 caso (3,3%) foi necessária conversão para cirurgia aberta por fratura do processo coracoide no momento de fixação na glenoide. Nenhum outro caso apresentou complicação intraoperatória. Não houve infecção nos casos operados. Dois casos (6,7%) evoluíram com neuropraxia temporária do musculocutâneo, revertida com fisioterapia. Em tempo de seguimento de 6 a 26 meses, 2 pacientes (6,7%) necessitaram de nova intervenção para retirada do material de síntese e liberação articular por excessiva limitação da rotação externa. Não houve caso de recidiva. Conclusão O procedimento de Latarjet artroscópico se mostrou seguro e com baixa incidência de complicações de curto prazo para correção da luxação anterior no ombro com perda óssea na glenoide mesmo em curva inicial de aprendizagem.

Prevalence Of Multidirectional Shoulder Instability In Shot Put Throwers

Objective: The objective of this study was to find out whether there was any shoulder instability prevailing in the shot put throwers due to the rotational activities achieved in the respective sport. Methods: A total of 76 shot put throwers were recruited for the study. The multidirectional instability of the shoulder joint was tested by performing special tests. Results: The study revealed that out of 76 shot put throwers, 49 individuals were found to be having shoulder instability, and 27 individuals were not having shoulder instability. This was confirmed by using a special test like the Sulcus sign and Rowe test followed by statistical analysis. The individuals diagnosed with multidirectional instability showed Sulcus sign and Rowe test positive, of which 30 individuals showed both the test positive and 19 individuals showed only Rowe test positive. Conclusion: About 64.47% of individuals were diagnosed with multidirectional instability in the shot put throwers while the rest 35.52% of individuals showed no signs of instability.

Tratamiento de la inestabilidad anterior de hombro con remplissage para lesiones de Hill-Sachs y lesión de Bankart comparado con lesiones de Bankart pura / Treatment of anterior shoulder instability with remplissage for Hill-Sachs injuries and Bankart injury compared to pure Bankart injuries

Resumen: Introducción: Las luxaciones anteriores de hombro ocurren en > 90% de las inestabilidades de hombro, la principal causa es traumática, describiéndose dos principales lesiones en esta patología: la lesión de Bankart y la de Hill-Sachs, existiendo una tasa de recurrencia similar en la reparación quirúrgica abierta y con ventaja de la cirugía artroscópica de realizar incisiones pequeñas, menor pérdida del rango de movimiento, menor riesgo de daño del músculo subescapular, retorno más rápido a las actividades diarias y mayor satisfacción de los pacientes. Objetivo: Valorar la funcionabilidad, movilidad y estabilidad postquirúrgica del hombro de los pacientes sometidos a tratamiento con dos técnicas artroscópicas: reparación de lesión de Bankart pura versus reparación Bankart + remplissage. Material y métodos: Se revisaron expedientes clínicos, se valoraron pacientes con inestabilidad de hombro y con lesiones de Hill-Sachs y Bankart; con un total de 21 pacientes postquirúrgicos se realizaron exploraciones físicas para valoración de los arcos de movimiento y aplicación de escalas funcionales de Rowe y Western Ontario Shoulder Instability Index, con el fin de medir la estabilidad postquirúrgica. Resultados: No hubo recurrencia de luxación con ninguna de las dos técnicas, se observó mayor satisfacción en el grupo de remplissage; sin embargo, la limitación del arco de movimiento es mayor. Conclusión: Ambas técnicas artroscópicas fueron capaces de restaurar la función, disminuir el dolor y satisfacer en su mayoría a los pacientes de nuestra serie de casos en el seguimiento a corto y mediano plazo.

Abstract: Background: Anterior shoulder dislocation occurs in more than 90% of the time, the main cause is traumatic, describing two main lesions in this pathology: Bankart's and Hill-Sachs's injury, the recurrence rate is not similar in open repair and with a possible advantage of arthroscopic surgery with less loss of movement range, lower risk of subscapular muscle damage, faster return to daily activities and increased patient satisfaction. Objective: Assessing functionality, mobility and stability of the shoulder in patients treated: arthroscopic Bankart repair versus arthroscopic Bankart repair + remplissage. Methods: Clinical records of patients with shoulder instability were reviewed Hill-Sachs and Bankart lesions were doumented; 21 post-surgical patients and were physically examined to evaluate the range of motion, Rowe functional scales and Western Ontario Shoulder Instability Index were used. 13 months of follow up as an average. Results: There was no recurrence of dislocation with either technique, greater satisfaction was observed in the remplissage group; however, the limitation of the motion arc is greater. Conclusion: Both groups reduce instability, control pain and mostly satisfy patients in the 13-month follow-up.

Evaluation of Inferior Capsular Laxity in Patients with Atraumatic Multidirectional Shoulder Instability with Magnetic Resonance Arthrography

OBJECTIVE: To compare inferior capsular redundancy by using magnetic resonance arthrography (MRA) images in patients with multidirectional instability (MDI) of the shoulder and control subjects without instability and thereby develop a screening method to identify the presence of shoulder MDI. MATERIALS AND METHODS: The MRA images of patients with MDI of the shoulder (n = 65, 57 men, 8 women; mean age, 24.5 years; age range, 18–42 years) treated over an eight-year period were retrospectively reviewed; a control group (n = 65, 57 men, 8 women; mean age, 27.4 years; age range, 18–45 years) without instability was also selected. The inferior capsular redundancy was measured using a new method we named the glenocapsular (GC) ratio method. MRA images of both groups were randomly mixed together, and two orthopedic surgeon reviewers measured the cross-sectional areas (CSAs) and sagittal capsule-head ratios on oblique sagittal images, as well as the axial capsule-head ratios on axial images and GC ratios on oblique coronal images. RESULTS: The CSAs and GC ratios were significantly higher in patients than in controls (both, p 1.42 was found to be most suggestive of MDI of the shoulder, owing to its high sensitivity (92.3%) and specificity (89.2%). CONCLUSION: GC ratio can be easily measured and used to accurately screen for MDI of the shoulder.

Current concepts of diagnostic techniques and measurement methods for bone defect in patient with anterior shoulder instability / 中国修复重建外科杂志

Objective: To summarize the diagnosis and measurement methods of bone defect in anterior shoulder instability (glenoid bone defect and Hill-Sachs lesion). Methods: The related literature on the diagnosis and measurement of the bone defect in anterior shoulder instability was reviewed and summarized. Results: The commonly used techniques for the diagnosis of anterior glenoid bone defect and Hill-Sachs lesion of humeral head include X-ray, CT, MRI, arthroscopy, arthrography. The methods for measuring the degree of anterior glenoid bone defect include Griffith method, glenoid index method, Pico method, and best-fit circle method. The indexes for measuring the Hill-Sachs lesion include the length, width, depth, and volume. X-ray is mainly used for primary screening. Best-fit circle method on three-dimensional (3D) CT reconstruction is commonly used to measure the glenoid bone defect currently. Glenoid track theory on 3D CT reconstruction is popular in recent years. Reliability of measuring the glenoid bone defect and Hill-Sachs lesion with MRI and arthroscopy is still debatable. Arthrography is more and more used in the diagnosis of shoulder joint instability of bone defect and concomitant soft tissue injury. Conclusion: How to improve the accuracy of evaluating glenoid bone defect and Hill-Sachs lesion before surgery still need further study.

Can we use the contralateral glenoid cavity as a reference for the measurement of glenoid cavity bone loss in anterior shoulder instability?: a comparative analysis of 3D CT measurements in healthy subjects / ¿Podemos utilizar la cavidad glenoidea contralateral como referencia para la medición de la pérdida ósea de la cavidad glenoidea en la inestabilidad del hombro anterior?: un análisis comparativo de mediciones 3D TC en sujetos sanos

The purpose of this study was to compare the glenoid cavity measurements in healthy subjects. 100 adult subjects without shoulder pathology who had pulmonary computed tomography for any reason, were included in the study. Lung CT images were three-dimensionally rendered and glenoid cavity enface images were obtained. On these images, the glenoid cavity superior-inferior long axis and anterior-posterior equator, as well as the equatorial anterior and posterior radii, were measured. Dominant and nondominant glenoid cavity measurements were compared using the t-test in dependent groups. The long axis of the dominant glenoid cavity was 38.15 ± 3.5 mm, whereas it was 37.87 ± 3.3 mm on the non-dominant side (p = 0.068). The mean width of the glenoid cavity was 28.60 ± 3.3 mm in dominant glenoids cavities and 28.00 ± 2.9 mm in the non-dominant side (p = 0.0001). The equatorial anterior and posterior radii were significantly different between the two sides (p = 0.010, p = 0.001, respectively). The ratio of length to equator was different between the two sides (p = 0.012). The difference in equatorial lengths was 0.98 ± 0.8 mm (range, 0-4.2 mm). The mean difference between the long axis of the glenoid cavity was 1.2 ± 0.9 mm (range 0-4.6 mm). The equator on 69 individuals was larger on the dominant side. Glenoid cavity long axis was larger on the dominant side of 61 individuals. Glenoids cavities are not equal and not symmetrical to each other or influenced by hand dominancy. Measurements based on the assumption that both glenoids cavities are equal may be misleading.

El propósito de este estudio fue comparar las mediciones de las cavidades glenoideas en sujetos sanos. Se incluyeron en el estudio 100 sujetos adultos sin patología de hombro que tenían tomografía computarizada pulmonar. Las imágenes de CT de pulmón se representaron tridimensionalmente y se obtuvieron imágenes de la faceta de la cavidad glenoidea. En estas imágenes, se midieron el eje largo glenoideo superior e inferior y el ecuador anteroposterior, así como los radios ecuatoriales anterior y posterior. Las mediciones de las cavidades glenoideas dominantes y no dominantes se compararon usando la prueba t en grupos dependientes. El eje largo de la cavidad glenoidea dominante fue 38,15 ± 3,5 mm, mientras que fue 37,87 ± 3,3 mm en el lado no dominante (p = 0,068). El ancho medio de la cavidad glenoidea fue de 28,60 ± 3,3 mm en las glenoides dominantes y de 28,00 ± 2,9 mm en el lado no dominante (p=0,0001). Los radios ecuatoriales anterior y posterior fueron significativamente diferentes entre los dos lados (p=0,010; p=0,001, respectivamente). La relación de longitud al ecuador fue diferente entre los dos lados (p=0,012). La diferencia en las longitudes ecuatoriales fue de 0,98 ± 0,8 mm (rango, 0-4,2 mm). La diferencia media entre el eje largo de la cavidad glenoidea fue de 1,2 ± 0,9 mm (rango 0-4,6 mm). El ecuador en 69 individuos era más grande en el lado dominante. En 61 individuos el eje largo de cavidad glenoidea fue más grande en el lado dominante. Las cavidad glenoideas no son iguales ni simétricas entre sí ni están influenciadas por la dominancia de la mano. Las mediciones basadas en la suposición de que ambas cavidades glenoideas son iguales pueden ser engañosas.

Effectiveness of Mobilization with Exercise V/S Mulligan Internal Rotation MWM with Stretching in Patient with Glenohumeral Internal Rotation Deficit

Background: The glenohumeral joint consists of dynamic and static stabilizer, which works, in concert to allow for stability and mobility through a large arc of motion, in recent years there has been significant focus on shoulder motion, particularly in overhead throwing athletes. Glenohumeral internal rotation deficits (GIRD) are common physical impairments in evaluated both adolescent and overhead sports such as baseball, cricket, and tennis. Therefore the aim of the study firstly was to determine the effectiveness of mobilization with exercise in patients with glenohumeral internal rotation deficit and secondly to determine whether mulligan internal rotation MWM with stretching in patients with glenohumeral internal rotation deficit. Materials and methods: 60 patients were included in the study which was divided into two groups; Group A and Group B, 30 patients in each group. All the subjects were randomly selected and assigned to each group. A pretest measurement with the help of two measures - Oxford Shoulder Instability Score (OSI) for disability, and inclinometer for an internal range of motion shoulder was Sreenivasu Kotagiri, Anup Kumar Songa, Mayuri Vijay Gad, Jaideep Lad. Effectiveness of Mobilization with Exercise V/S Mulligan Internal Rotation MWM with Stretching in Patient with Glenohumeral Internal Rotation Deficit. IAIM, 2018; 5(5): 138-145. Page 139 done in each group. Subjects in Group-A were given mobilizations with stabilization exercise for capsule for a total of 12 minutes a minimum of 4 times per week over a 4-week period and Group-B were given mulligan mobilization with Posterior Capsule Stretching As follows, 1st day 3 glides, 2 nd day 3 sets of six glides, 3rd day 3 sets of 10 glides were given and 4th day again 3 sets of 10 was given. A patient who failed to come for 4 days with stretching performed 3–5 repetitions each repetition was held for 30 seconds, four days a week for four weeks total 16 sessions. Results: On comparing Group A and Group B for post-treatment OSI score, results showed a significant difference (p=0.001) in improvement in terms of OSI. On comparing Group A and Group B for post-treatment inclinometer score, results showed a significant difference in improvement in terms of the inclinometer. This study showed that Mulligan MWM along with stretching exercises was more effective to that patient as compared to mobilization with strengthening exercises given to a patient with glenohumeral internal rotation deficit. Conclusion: The study showed a significant difference between both the groups when the values obtained were analysed. It indicated that Group B in Range mulligan mobilization with Posterior Capsule Stretching of Motion in internal rotation and external rotation. Their scores in Index Oxford Shoulder Instability Score (OSI) have reduced which indicates the decreased level of disability and better functional ability.

Clinical Outcome after Surgical Treatment of Recurrent Shoulder Dislocation with Small Bony Bankart

BACKGROUND: The consensus is that a bony Bankart lesion shorter than 25% of the length of glenoid does not affect the clinical result; hence, such lesions were often neglected. However, small bony Bankart lesions are associated with various types of capsulolabral lesions. METHODS: A total of 82 patients who had undergone arthroscopic capsulolabral lesion repair surgery for anterior shoulder dislocation were reviewed. The prevalence rates of early and late type of capsulolabral lesions were compared between a group of patients with and a group without small bony Bankart lesions. In addition, the types of accompanying capsulolabral lesion were analyzed according to the type of bony Bankart lesion. Finally, the clinical outcomes were evaluated (active range of motion, American Shoulder and Elbow Surgeons score and Rowe's score). RESULTS: Among the 13 patients who had small bony Bankart lesions, the prevalence rate of early and late type of capsulolabral lesions was 38.5% and 61.5%, respectively. Among the 69 patients without bony Bankart lesion, the prevalence rates of early and late type of capsulolabral lesions were 74% and 26%, respectively. Significantly worse clinical outcome was observed for the group of patients with both small bony Bankart lesions and late type of capsulolabral lesion. CONCLUSIONS: More severe type of small bony Bankart lesion appears to be associated with late type of capsulolabral lesion. The significantly worse clinical outcome for patients with both small bony Bankart lesion and late type of capsulolabral lesion indicates that small bony Bankart lesions cannot always be neglected.

Clinical Outcome after Surgical Treatment of Recurrent Shoulder Dislocation with Small Bony Bankart

BACKGROUND: The consensus is that a bony Bankart lesion shorter than 25% of the length of glenoid does not affect the clinical result; hence, such lesions were often neglected. However, small bony Bankart lesions are associated with various types of capsulolabral lesions. METHODS: A total of 82 patients who had undergone arthroscopic capsulolabral lesion repair surgery for anterior shoulder dislocation were reviewed. The prevalence rates of early and late type of capsulolabral lesions were compared between a group of patients with and a group without small bony Bankart lesions. In addition, the types of accompanying capsulolabral lesion were analyzed according to the type of bony Bankart lesion. Finally, the clinical outcomes were evaluated (active range of motion, American Shoulder and Elbow Surgeons score and Rowe's score). RESULTS: Among the 13 patients who had small bony Bankart lesions, the prevalence rate of early and late type of capsulolabral lesions was 38.5% and 61.5%, respectively. Among the 69 patients without bony Bankart lesion, the prevalence rates of early and late type of capsulolabral lesions were 74% and 26%, respectively. Significantly worse clinical outcome was observed for the group of patients with both small bony Bankart lesions and late type of capsulolabral lesion. CONCLUSIONS: More severe type of small bony Bankart lesion appears to be associated with late type of capsulolabral lesion. The significantly worse clinical outcome for patients with both small bony Bankart lesion and late type of capsulolabral lesion indicates that small bony Bankart lesions cannot always be neglected.

Profile of collagen gene expression in the glenohumeral capsule of patients with traumatic anterior instability of the shoulder / Perfil de expressão de genes do colágeno na cápsula glenoumeral de pacientes com instabilidade traumática anterior do ombro

Objective: To evaluate the expression of the genes COL1A1, COL1A2, COL3A1 and COL5A1 in the glenohumeral capsule of patients with traumatic anterior instability of the shoulder. Methods: Samples from the glenohumeral capsule of 18 patients with traumatic anterior instability of the shoulder were evaluated. Male patients with a positive grip test and a Bankart lesion seen on magnetic resonance imaging were included. All the patients had suffered more than one episode of shoulder dislocation. Samples were collected from the injured glenohumeral capsule (anteroinferior region) and from the macroscopically unaffected region (anterosuperior region) of each patient. The expression of collagen genes was evaluated using the polymerase chain reaction after reverse transcription with quantitative analysis (qRT-PCR). Results: The expression of COL1A1, COL1A2 and COL3A1 did not differ between the two regions of the shoulder capsule. However, it was observed that the expression of COL5A1 was significantly lower in the anteroinferior region than in the anterosuperior region (median ± interquartile range: 0.057 ±0.052 vs. 0.155 ±0.398; p = 0.028) of the glenohumeral capsule. Conclusion: The affected region of the glenohumeral capsule in patients with shoulder instability presented reduced expression of COL5A1...

Objetivo: Avaliar a expressão dos genes COL1A1, COL1A2, COL3A1 e COL5A1 na cápsula glenoumeral de pacientes com instabilidade anterior traumática do ombro. Métodos: Foram avaliadas amostras de cápsula glenoumeral de 18 pacientes com instabilidade anterior traumática do ombro. Foram incluídos pacientes masculinos, com teste de apreensão positivo e lesão de Bankart no exame de ressonância magnética. Todos os pacientes sofreram mais de um episódio de luxação do ombro. Foram coletadas amostras da cápsula glenoumeral lesionada (região anteroinferior) e da região macroscopicamente não afetada (região anterossuperior) de cada paciente. A expressão dos genes de colágeno foi avaliada por reação em cadeia da polimerase após transcrição reversa com análise quantitativa (qRT-PCR). Resultados: A expressão de COL1A1, COL1A2 e COL3A1 não diferiu entre as duas regiões da cápsula do ombro. No entanto, foi observado que a expressão de COL5A1 estava significantemente reduzida na região anteroinferior em relação à região anterossuperior (mediana ± intervalo interquartílico: 0,057 ± 0,052 vs 0,155 ± 0,398; p = 0,028) da cápsula glenoumeral. Conclusão: A região afetada da cápsula glenoumeral de pacientes com instabilidade do ombro apresentou uma expressão reduzida de COL5A1...

Clinical, MRI and arthroscopic correlation in anterior and posterior shoulder instability.

Background: The peculiar anatomy of shoulder puts the glenohumeral joint at a great risk of instability, which poses a challenge for management. Clinical examination is not always accurate. MRI and arthroscopy are hence used to aid the diagnosis. The study aimed to compare and correlate clinical and Magnetic Resonance Imaging (MRI) in cases of anterior and posterior shoulder instability against the arthroscopic confirmation of the diagnosis, which is considered gold standard. Methods: A prospective study of 30 patients of shoulder instability (either anterior or posterior) was carried out, including both sexes and all age groups. The patients were first examined clinically, followed by 1.5 tesla MRI scan and finally arthroscopically. The findings of diagnostic arthroscopy were correlated with clinical & MRI findings. A definitive procedure to treat the pathology was then performed as per requirements. Sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of clinical and MRI findings was calculated to correlate with arthroscopic findings. Results: Clinical diagnostic tests and MRI had a significant statistic correlation (P <0.05) with various lesions responsible for instability. Diagnostic accuracy of MRI was considerably higher in comparison to clinical examination for both anterior (90% vs. 86.67%) and posterior (96.67% vs. 93.33%) shoulder instability. Conclusion: By obtaining correlation between clinical examination, MRI scan and arthroscopy for anterior and posterior shoulder instability, we conclude that MRI can give a better diagnosis of the pathology in comparison to clinical examination.

Capsuloplastia derivativa en T para el tratamiento de la inestabilidad anteroinferior del hombro / Capsuloplastie dérivative en T pour le traitement de l'instabilité antéro-inférieure de l'épaule / Derivative T-capsuloplasty for the treatment of anterior-inferior shoulder instability

Introducción: el tratamiento abierto de la inestabilidad anteroinferior de hombro se ha llevado a cabo con diferentes técnicas, entre ellas, la capsuloplastia derivativa en T modificada. Objetivo: evaluar los resultados de la capsuloplastia citada en relación con la estabilidad, rango de movimiento y retorno a la actividad habitual de los pacientes. Métodos: estudio retrospectivo en una serie de 22 pacientes con diagnóstico de inestabilidad anterior y anteroinferior a quienes se les realizó capsuloplastia anterior derivativa modificada, desde enero de 2000-2012. Resultados: a los tres meses, la evaluación en 15 pacientes fue excelente y buena en siete; a los seis meses fue excelente en 20/22 pacientes, al año todas fueron excelente. Entre los dos y ocho meses posteriores a la operación, todos regresaron a su actividad previa, entre ellos, cuatro atletas, que se incorporaron al mismo nivel de competencia anterior. Hubo complicaciones en tres pacientes, solucionadas con tratamiento médico, entre ellas, una subluxación. La pérdida media de la rotación externa fue de 0 a 10º grados con una media de 5º a los tres meses, rangos que pueden estar en relación con el grado de tensión durante la capsuloplastia. Conclusiones: la capsuloplastia derivativa en T modificada, es una buena técnica para la inestabilidad anteroinferior de hombro sin lesión de Bankart, garantiza alto índice de estabilidad, conserva el rango de movimiento completo o casi completo con un bajo índice de complicaciones(AU)

Introduction: open treatment of anterior-inferior shoulder instability has been conducted with various techniques, including modified derivative T-capsuloplasty. Objective: evaluate the results of the aforementioned capsuloplasty in terms of stability, range of movement and patients' return to their routine activities. Methods: retrospective study of a series of 22 patients diagnosed with anterior and anterior-inferior instability undergoing modified derivative anterior capsuloplasty from January 2000 to 2012. Results: at three months, evaluation was excellent in 15 patients and good in 7. At six months it was excellent in 20 / 22 patients. At a year, all evaluations were excellent. All patients returned to their routine activities between two and eight months after surgery. Among them were four athletes, who reintegrated to their previous competition level. There were complications in three patients, which were solved with medical treatment. One of them was a subluxation. Average loss of external rotation ranged from 0º to 10º, with a mean 5º at three months. This could be associated with the degree of tension during the capsuloplasty. Conclusions: modified derivative T-capsuloplasty is a good technique for anterior-inferior shoulder instability without Bankart lesion. It ensures a high rate of stability, and preserves a full or almost full range of movement with a low rate of complications(AU)

Introduction : le traitement ouvert de l'instabilité antéro-inférieure de l'épaule est réalisé par différentes techniques telles que la capsuloplastie dérivative en T modifiée. Objectif: le but de cette étude est d'évaluer les résultats de la capsuloplastie compte tenu de l'instabilité, le rang de mouvement, et la réintégration à la vie quotidienne des patients. Méthodes: une étude rétrospective d'une série de 22 patients diagnostiqués d'instabilité antérieure et antéro-inférieure de l'épaule, et traités par capsuloplastie antérieure dérivative modifiée, est effectuée entre janvier 2000 et janvier 2012. Résultats: au bout de trois mois, quinze patients ont eu des résultats excellents, tandis que sept ont eu des résultats bons ; les résultats ont eu excellents dans le plupart de patients (20/22) en six mois, et un an après les résultats ont été excellents dans la totalité des cas. Après 2-8 mois de l'opération, leur réintégration à la vie quotidienne est complète, y compris quatre athlètes, avec le même niveau compétitif d'auparavant. Il y a eu des complications (3 cas), telles qu'une sous-luxation, corrigées par traitement médical. La perte moyenne de la rotation externe a été 0° à 10°, avec une moyenne de 5° en trois mois, ce qui peut être associé au degré de tension au cours de la capsuloplastie. Conclusions: la capsuloplastie dérivative en T modifiée est une bonne technique pour la correction de l'instabilité antéro-inférieure de l'épaule sans lésion de Bankart, assurant un haut niveau de stabilité et conservant le rang de mouvement complet ou quasi complet avec un taux faible de complications(AU)

Enfrentamiento de la luxación de hombro en deportistas de contacto / Clinical approach to shoulder dislocation in contact sport athletes

La luxación de hombro es la más frecuente del organismo y su incidencia aumenta aún más en pacientes que practican deportes de contacto. Se denomina inestabilidad al hecho que la cabeza humeral pierda en forma recurrente la relación con la cavidad glenoidea y que genere disconfort en el pacientes. El diagnóstico de las lesiones asociadas (lesión de Balkart y de Hill-Sachs) y los factores de riesgo asociados a la inestabilidad (edad, hiperlaxitud, tipo de deporte y nivel de competencia) son importantes al momento de decidir el tratamiento a seguir. Éste es principalmente quirúrgico. Las técnicas quirúrgicas actuales permiten éxitos entre a un 85 y 93 por ciento. En los deportistas de contacto se tiende a elegir la técnica más segura y que aporte las menores tasas de fracaso. Tanto las técnicas artroscópicas como abiertas tienen validez para el manejo de este tipo de pacientes, pero la elección de una u otra dependerá de la experiencia, factores de riesgo y lesiones asociadas. El manejo post operatorio con rehabilitación intensiva es primordial para que este tipo de paciente y el objetivo es el retorno deportivo al mismo nivel que previo a la lesión y con una baja tasa de recidiva.

Shoulder dislocation is one of the most frequent orthopedics injury and the incidence is higher in patients who practice contact Sports. Shoulder Instability is when the humeral head lost more than once, the anatomical relation with the glenoid fossa and generates patients discomfort. The discard of another lesions (Balkart lesion, Hill-Sachs lesion) and the consideration of risk factors for instability, such as, age, hyperlaxity, type of sport and competition level, are very important elements to take into account when the physician has to choose the best treatment option. This is meanly surgical. The current surgical techniques are successful between the 85 to 93 percent of the cases. The open techniques and the arthroscopic ones , are reliable treatments for this condition in contact sport athletes, however the option has to be choose according to the surgeon skills, risk factors and associated lesions. The post operative treatment and rehabilitation are very important with an early and intensive physiotherapy in this kind of patient, to allow the same competitive sport level previous the lesion and with the lowest recurrence ratio.

Establishment of Anterior Instability of Gienohumeral Joint on Rabbits / 中国运动医学杂志

Objective To establish the animal model(rabbit) of shoulder instability for providing the experimental basis of related studies.Methods shoulder joints of 6 skeletally matured New Zealand white rabbits were measured with the anatomical characteristics and joint motion range in order to determine the operative approach,the similarities of skeletal structure,surrounding muscles,joint capsule and ligaments between rabbit and human were compared.Eighteen rabbits,weighing between 2.5 and 3kg were randomized into 2 groups(experimental group 12 and control 6).In experimental group,instability model was established by means of the operation procedure as follows:the glenohumeral joint of right shoulder was exposed by cutting the subscapularis tendon,then the anteroinferior labrum and surrounding capsular ligament were excised.For control group,sham operation was performed by only curing the skin and superficial tissue,the subscapularis tendon and glenoid structures was kept intact.The specimens of 6 rabbits were harvested 6 weeks after operation.The remaining rabbits of both experimental and control groups were killed 12 weeks post the operation for specimens processing.The motion range and instability were measured in all specimens.Results The gross anatomy of shoulder ioint in rabbit is similar to human.In experimental group,the stability is showed less than control,grade 2 anterior instability was found.The motion range was restricted in all directions,such as external and internal rotation,extension and abduction compared to control group.Conclusion Rabbit is suitable to establish animal model for shoulder instability and related iniuries,the animal model which was designed by this study could provide valuable information for the research of anterior shoulder instability.