Open anatomical glenoid reconstruction with an iliac crest bone autograft effectively resolves off-track Hill-Sachs lesions to on-track lesions.

INTRODUCTION: The purpose of this study was to determine if "off-track" Hill-Sachs lesions in patients with dynamic anteroinferior instability were transformed into "on-track" lesions using iliac bone autografts with screw fixation. The secondary purpose was to observe if postoperative bony remodeling would occur over time, resulting in recurrent "off-track" Hill-Sachs lesions with corresponding instability. MATERIALS AND METHODS: We retrospectively reviewed clinical and CT records of 8 patients with an "off-track" Hill-Sachs lesion who underwent open anatomical glenoid reconstruction with an iliac crest bone autograft. Hill-Sachs lesions, glenoid track widths, and glenoid surface areas were measured on a preoperative and two postoperative (6 weeks, ≥ 2 years) 3D-CT models to determine graft resorption over time. All patients were available for postoperative clinical and CT final follow-up 3 years (2-4 years) postoperatively. RESULTS: In all patients, the Hill-Sachs lesions were "on-track" 6 weeks postoperatively and remained "on-track" at final-follow-up. Compared to preoperative values, the glenoid track width and glenoid surface area both were higher 6 weeks postoperatively (p < 0.001 and p = 0.023, respectively) and at final follow-up (p < 0.001 and p = 0.023, respectively). Whereas the glenoid track width between 6 weeks and final follow-up showed no decrease (p = 0.234), glenoid surface area tended to decrease (p = 0.055). The median SSV was 93 points (85-95 points), the Rowe score 90 points (80-100 points) and the WOSI 1980 points (1783-2067 points) at final follow-up. No recurrent dislocations or subluxations were observed. CONCLUSIONS: An open anatomical glenoid reconstruction with an iliac crest bone autograft technique using screw fixation effectively transformed "off-track" Hill-Sachs lesions to "on-track" lesions, resulting in good short-term clinical outcomes. Whereas glenoid surface area tended to be reduced by bony remodeling processes over time, the glenoid track width did not decrease at final follow-up and consequently no recurrence of "off-track" lesions occurred. LEVEL OF EVIDENCE: Case series; Level of evidence, IV.

Posterior shoulder instability: a systematic review.

INTRODUCTION: This review aims to provide information on outcomes of surgical procedures for soft tissue or bony glenoid and/or humeral abnormalities in case of posterior shoulder instability. SOURCE OF DATA: A systematic review of the literature according to the PRISMA guidelines was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, Ovid and Google Scholar databases using various combinations of the keywords 'shoulder', 'posterior instability', 'dislocation', 'reversed bony bankart', 'reversed Hill Sachs', and 'capsulolabral' was performed. AREAS OF AGREEMENT: A total of 847 shoulders in 810 patients were included. A redislocation event occurred in 33 (8.7%) of 411 shoulders with soft tissue abnormalities and in 12 (9.1%) of 132 shoulders with bony abnormalities of the glenoid, humeral head or both. AREAS OF CONTROVERSY: The optimal treatment modalities for posterior shoulder dislocation remain to be defined. GROWING POINTS: Operative stabilization for posterior shoulder instability should be lesion-specific and should correct all components of the posterior instability. AREAS TIMELY FOR DEVELOPING RESEARCH: Future prospective studies should aim to establish the optimal treatment modalities for posterior shoulder instability.

Epidemiology of Paediatric Shoulder Dislocation: A Nationwide Study in Italy from 2001 to 2014.

Limited knowledge is accessible concerning the tendencies of hospitalization for skeletally immature patients with episodes of shoulder dislocation. Our research aim was to evaluate annual hospitalizations for shoulder dislocation in paediatric patients in Italy from 2001 to 2014, on the basis of the official data source as hospitalization reports. The second purpose was to investigate geographical diversification in hospitalization for shoulder dislocation in regions of Italy. The last aim was to make statistical predictions of the number of shoulder dislocation hospitalization volumes and rates in skeletally immature patients based on data from 2001 to 2014. An examination of the National Hospital Discharge records (SDO) kept at the Italian Ministry of Health regarding the 14 years of our study (2001 through 2014) was conducted. These data are anonymous and include patient's age, gender, domicile, region and time of hospitalization, and the kind of reimbursement (public or private). In the 14-year study time, 344 hospitalizations for shoulder dislocation of patients aged 0-14 years took place in Italy. The male/female hospitalization ratio varied from a maximum of 3.0 (2001) to a minimum of 1.1 (2013), with a mean average ratio in the 2001-2014 timespan of 2.0. Almost half of the hospitalizations (49.1%) were performed in the South. The mean incidence of hospitalizations in Italy for shoulder dislocation in patients with less than 14 years was 0.3 for every 100,000 inhabitants in the same class of age. The most common treatment was a closed reduction (60.8%), followed by open stabilization (16.6%) and arthroscopic procedures (13.7%). The present registry study shows a low incidence of hospitalization for shoulder dislocation in young patients. The most common treatment for a shoulder dislocation in paediatric patients is a closed shoulder reduction. Regions from the south and the centre of Italy are marked by an inferior number of operations and a higher number of hospitalization for closed shoulder reduction.

The effectiveness of conservative and surgical treatment for shoulder stiffness: a systematic review of current literature.

Introduction: Currently, no therapeutic intervention is universally accepted, and the most effective management for restoring motion and diminishing pain in patients with shoulder stiffness has yet to be defined. This systematic review analyses outcomes of conservative and surgical interventions to treat shoulder stiffness. Source of data: A systematic review of literature according to the PRISMA guidelines was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, Ovid and Google Scholar databases using various combinations of the keywords 'shoulder', 'shoulder stiffness', 'stiff shoulder', 'conservative', since inception of databases to June 2018 was performed. Areas of agreement: Shoulder stiffness could be treated with conservative means including nonsteroidal anti-inflammatory medications, corticosteroid injections, or transcutaneous electrical nerve stimulation, manipulation under anaesthesia, and arthroscopic capsular release. Areas of controversy: No therapeutic intervention is universally accepted, and the most effective management to restore motion and diminish pain in patients with shoulder stiffness has yet to be defined. Growing points: The rate of failure after treatment for stiff shoulder is higher in the surgical group than in the conservative group. Areas timely for developing research: There is insufficient evidence to establish whether surgical or conservative management is the best choice to manage shoulder stiffness. Prospective, randomized studies are needed to establish whether surgical or conservative management produce a clinically relevant difference in functional outcome.

Outcomes of Posterior-Stabilized Compared with Cruciate-Retaining Total Knee Arthroplasty.

The aim of this systematic review is to compare clinical outcome scores, rate of complications, and range of motion (ROM) of posterior-stabilized (PS) and cruciate-retaining (CR) total knee arthroplasties (TKAs) both pre- and postoperatively to establish which of the two kinds of implants have the best efficiency. A comprehensive search was performed of studies comparing CR and PS TKAs on PubMed, OVID/Medline, Cochrane, CINAHL, Google scholar, and Embase databases. Finally, 37 studies were selected with a total of 5,407 knees in 4,445 patients. For the PS knees, the Knee Society Functional Score (KSFS) improved from 44.6 to 77.6 (p = 0.04), extension decreased from 6.6 to 1.8 degrees (p-value), and flexion increased from 115.2 to 119.4 degrees (p < 0.00001), compared with the CR knees. No significant difference in the Knee Society objective score (KSOS) (p = 0.82) or complication rates (p = 0.29) was found. The overall complication rate was 3.9%, 213 in 5,407 knees. Surgeons must be careful in interpreting these results, as an improved ROM for the PS group may not correlate to better patient outcomes. This meta-analysis has demonstrated that PS TKA has a statistically significant greater postoperative improvement of KSFS (p = 0.04), flexion (p < 0.00001), and extension (p = 0.02), compared with the CR group. These findings seem to lead the surgeons to prefer the PS design for TKAs especially to achieve a higher postoperative ROM in patients with high functional demands. On the contrary, the CR and PS TKAs have similar results in terms of complications and most of clinical outcomes analyzed in the included studies. Therefore, the long-term follow-up of high-quality randomized controlled trials is needed to clarify which of the two types of prosthesis provide the better clinical outcome and the lower rate of complications for osteoarthritis patients in particular cohorts. This is a systematic review (level II).

Outcome of ankle arthrodesis and ankle prosthesis: a review of the current status.

INTRODUCTION: In advanced stages of ankle osteoarthritis (OA), ankle arthrodesis (AA) or total ankle arthroplasty (TAR) may be necessary. Our purpose is to compare AA and total ankle replacement for the surgical management of end stage ankle OA. SOURCES OF DATA: We conducted a literature search of PubMed, Medline, CINAHL, Cochrane, Embase and Google Scholar databases using the terms 'ankle' in combination with 'OA', 'arthrodesis', 'arthroplasty', 'joint fusion', 'joint replacement'. Studies where treatment was exclusively total ankle replacement or AA were excluded. Treatment characteristics and outcome parameters (overall postoperative outcome and complication rate) were reviewed. AREAS OF AGREEMENT: When counseling patients who are considering their options with regard to ankle arthritis treatment, surgeons should determine on an individual basis which procedure is more suitable. AREAS OF CONTROVERSY: TAR has become an accepted treatment for end-stage OA, but revision rates for TAR are significant higher than for AA (odds ratio 2.28 95% confidence interval [CI], 1.63-3.19; P < 0.0001). GROWING POINTS: The results of TAA are gradually improving, but the procedure cannot yet be recommended for the routine management of ankle OA. AREAS TIMELY FOR DEVELOPING RESEARCH: Although there is some evidence to support TAR to conserve ankle motion and offer improved function and decreased pain with high satisfaction rates, revision rates for TAR are significantly higher than revision rates for AA. Proper patient selection should be better addressed in future studies for successful treatment of end-stage ankle OA. LEVEL OF EVIDENCE: Systematic review, level III.

Treatment of Primary Acute Patellar Dislocation: Systematic Review and Quantitative Synthesis of the Literature.

PURPOSE: The aim of this study was to evaluate clinical outcomes, rate of redislocation, and complications after conservative or surgical procedures used to treat primary acute patellar dislocation. METHODS: A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases using various combinations of the keywords "patella," "dislocation," "treatment," "acute," "primary" was performed. The following data were extracted: demographics, chondral defects and soft tissue lesions, outcome measurements, type of management, recurrence of instability, and complications. RESULTS: A total of 2134 knees in 2086 patients were included, with an average age at dislocation of 20.3 years. The average Kujula score was 75.6 for patients treated conservatively and 88.7 for patients undergoing surgical treatment in the short-medium follow-up (less than 5 years); the average Kujula score was 87.5 for patients treated conservatively and 86.6 for patients undergoing surgical treatment in the long-term follow-up (more than 5 years). The rate of recurrence was significantly lower in the surgical group (25%) than in the conservative group (36.4%). The overall complication rate was 6.5% (29 of 441 knees) in the surgical management group. No complications were reported for patients treated conservatively. CONCLUSIONS: Surgical treatment of primary acute patellar dislocation leads to significantly lower rate of redislocation and provides better short-medium clinical outcomes, whereas in the long-term follow-up, results of patients treated conservatively were as good as those of surgical patients. Further randomized controlled trials, describing anatomical abnormalities and soft-tissue integrity that may influence the choice of treatment, are needed. LEVEL OF EVIDENCE: Systematic review, level IV.

All-polyethylene versus metal-backed tibial component in total knee arthroplasty.

PURPOSE: The aim of this systematic review was to evaluate the clinical outcomes, rate of revisions and complications of all-polyethylene tibial and metal-backed tibial components in patients treated with knee arthroplasty for primary or secondary osteoarthritis. METHODS: A systematic review of the literature according to the PRISMA guidelines was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases using various combinations of the keywords such as "knee", "arthroplasty", "metal-backed", and "all-polyethylene", since inception of databases to 2016, was performed. RESULTS: Thirty-two articles, describing patients with all-polyethylene tibial or metal-backed tibial components in the setting of osteoarthritis, were included. A total of 68,202 knees in 58,942 patients were included, with an average age at surgery of 69.3 years, ranging from a mean age of 57.9-82 years. The mean KSS was 82.4 and 81.3 (n.s.), the mean KSS(F) was 73.6 and 74.9 (p = 0.04), the mean ROM was 104.5 and 104.6 (n.s.), and the mean HSS was 87 and 86, each, respectively, for the metal-backed tibial components group and all-polyethylene tibial components group. The overall rate of revisions was 1.90 %. The rate of revision in the metal-backed tibial components group was 1.85 %, whilst the rate of revision in the all-polyethylene tibial components group was 2.02 % (p < 0.00001). CONCLUSION: Metal-backed tibial and all-polyethylene tibial components did not show any significant difference in most of the included outcome scores, but statistical differences were found in terms of complications and revision rate. These items have a negative impact on the cost-effectiveness of all-polyethylene tibial components. Even if all-polyethylene tibial components show similar clinical outcome score, equivalent range of knee motion, and long-term survival compared to metal-backed tibial components, complications and revision rate seem to lead the surgeon to prefer the last ones. The clinical relevance of this study is that metal-backed tibial components should be preferred in TKA surgery because complications are higher using all-polyethylene tibial components. On the other hand, the quality of evidence, according to GRADE system, is low underling the necessity of more randomised study to clarify these items. LEVEL OF EVIDENCE: III.

Apophyseal injuries in children's and youth sports.

INTRODUCTION: The authors reviewed the current English literature regarding apophyseal injuries affecting young athletes, to highlight the frequency and characteristics of these injuries, to clarify risk factors and specific prevention measures, and to identify future research objectives. SOURCES OF DATA: The authors performed a comprehensive search of the medical literature, using the Medline database, including all English articles. Various combinations of the Keywords 'injury', 'sports', 'athletic injuries', 'avulsion fractures', 'physeal', 'physis', 'apophysis', 'apophysitis', 'growth plate' were used. AREAS OF AGREEMENT: Growth benefits from a moderate physical activity. AREAS OF CONTROVERSY: Growth deficit may occur in young athletes involved in intensive practice of sport following apophysitis. GROWING POINTS: Apophyseal injuries occurring during sport are less common than overall rate of injuries affecting the adolescent population. Growth disturbance occurs only rarely after an apophyseal injury. AREAS TIMELY FOR DEVELOPING RESEARCH: Further studies should consider analytical as well as descriptive components of apophyseal injuries, to allow the identification of new possible risk factors and preventive measures and to help early detection and proper treatment as well.

Hill-Sachs Off-track Lesions as Risk Factor for Recurrence of Instability After Arthroscopic Bankart Repair.

PURPOSE: To evaluate the effect of "off-track" Hill-Sachs lesions, according to the glenoid track concept, as a risk factor for recurrent instability and need for revision surgery after arthroscopic Bankart repair. METHODS: We retrospectively reviewed 254 patients with anteroinferior glenohumeral instability who were managed with an arthroscopic stabilization procedure between 2006 and 2013. Preoperative magnetic resonance imaging and/or computed tomography scans were available for 100 of these patients to calculate the glenoid track and the presence of "on-track" or off-track Hill-Sachs lesions. Recurrence of instability was evaluated at a mean follow-up of 22.4 months. RESULTS: Of 100 patients whose magnetic resonance imaging and/or computed tomography scans were available, 88 had an on-track Hill-Sachs lesion and 12 had an off-track Hill-Sachs lesion. Revision surgery for recurrent instability was performed in 5 patients (6%) with an on-track Hill-Sachs lesion and in 4 patients (33%) with an off-track Hill-Sachs lesion (odds ratio, 8.3; 95% confidence interval, 1.85-37.26; P = .006). CONCLUSIONS: An off-track Hill-Sachs lesion is a significant and important risk factor for recurrence of instability and need for revision surgery after arthroscopic Bankart repair when compared with an on-track Hill-Sachs lesion. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Humeral Avulsion of the Glenohumeral Ligaments: A Systematic Review.

PURPOSE: To analyze clinical outcomes, range of motion, rate of recurrence, and complications after procedures to manage shoulder instability in patients with humeral avulsion of the glenohumeral ligament (HAGL) lesions. METHODS: A systematic review of the literature according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines with a PRISMA checklist and algorithm was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases using various combinations of the Keywords "shoulder," "HAGL," "treatment," "lesion," "dislocation," "instability," "clinical," "outcome," "Bankart" since inception of databases to 2015 was performed. All the investigators independently extracted the following data: demographics, types of lesions and associated injuries, treatment, outcome measurements, range of motion, recurrent instability, and complications. RESULTS: Eleven articles were included in which 42 shoulders with HAGL lesions were evaluated. Patients were assessed at a median follow-up period of 25.5 months, ranging from 12 to 54 months. The overall rate of recurrence was 0% (0 of 25) in case of surgery and 90% (9 of 10) in case of nonoperative treatment. The surgical approach was associated with lower rate of recurrence when compared with nonoperative treatment (odds ratio 0.05, 95% confidence interval 0.01 to 0.42, and P = .006). Only 2 papers reported loss of external rotation after surgery. No complications were reported after surgery. Complications after nonoperative treatment were not discussed. CONCLUSIONS: Recognizing HAGL lesions is important to manage patients with glenohumeral instability. Patients' complaints are often nonspecific. A high index of suspicion is required in patients with prior failed shoulder surgery. HAGL lesions are often associated with other shoulder lesions. Arthroscopic or open repairs of HAGL lesions are associated with good clinical outcomes and a lower rate of recurrence compared with nonoperative treatment. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Bone loss in patients with posterior gleno-humeral instability: a systematic review.

PURPOSE: The aim of this systematic review was to analyse outcomes of surgical procedures for glenoid and/or humeral bony defects, performed singularly or in combination, in patients with posterior gleno-humeral instability. A secondary aim was to establish in clinical settings which percentage of glenoid or humeral bone loss should be treated with a bony procedure to avoid recurrence of dislocation. METHODS: A systematic review of the literature according to the PRISMA guidelines was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, Ovid, and Google Scholar databases was performed using various combinations of the keywords "shoulder", "posterior instability", "dislocation", "bone loss", "reversed bony Bankart", "osseous glenoid defects", "glenoid bone grafting", "glenoid", "humeral head", "surgery", "gleno-humeral", "reversed Hill-Sachs", over the years 1966-2014. Data were independently extracted by all the investigators: demographics, previous surgery, imaging assessment, bone defect measurement, diagnosis, surgical management, return to sport, complications, and outcome measurements. The outcome parameters were recurrence of dislocation and clinical scores. RESULTS: Nineteen articles, describing patients with glenoid bony defects, humeral bony defects, or both in the setting of posterior gleno-humeral instability were included. A total of 328 shoulders in 321 patients were included, with a median age at surgery of 33.4 years, ranging from 14 to 79 years. Patients were assessed at a median follow-up period of 3.6 years (ranging from 8 months to 22 years). A redislocation event occurred in 32 (10 %) shoulders. The redislocation event occurred in 2 (10 %) of 20 shoulders with glenoid bony defect and in 12 (11 %) of 114 shoulders with humeral bony defect. CONCLUSION: Even though the general principle of treating recognized glenoid and humeral bone defects in patients with posterior gleno-humeral instability is widely accepted, to date few studies in the literature accurately establish which bone defects should be treated with bony procedures and the exact correlation between percentage of bone loss and higher risk of redislocation in clinical settings. A limitation to the present systematic review is the small number of included patients, due to the rare entity of posterior bone defects/reversed Hill-Sachs. The clinical relevance is that the results of this systematic review can be helpful to guide clinicians in the management of patients with posterior gleno-humeral instability and glenoid and/or humeral bony defects. This manuscript also highlights the need for accurate description of results in further investigations. The main drawback of the available articles in the topic is that they rarely clarify the percentage of bone loss in patients undergoing a redislocation event. LEVEL OF EVIDENCE: IV.

Multidirectional Instability of the Shoulder: A Systematic Review.

PURPOSE: To analyze outcomes of surgical and conservative treatment options for multidirectional instability (MDI). METHODS: A systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. A comprehensive search of the PubMed, MEDLINE, CINAHL, Cochrane, EMBASE, and Google Scholar databases using various combinations of the keywords "shoulder," "multidirectional instability," "dislocation," "inferior instability," "capsulorrhaphy," "capsular plication," "capsular shift," "glenoid," "humeral head," "surgery," and "glenohumeral," over the years 1966 to 2014 was performed. RESULTS: Twenty-four articles describing patients with open capsular shift, arthroscopic treatment, and conservative or combined management in the setting of atraumatic MDI of the shoulder were included. A total of 861 shoulders in 790 patients was included. The median age was 24.3 years, ranging from 9 to 56 years. The dominant side was involved in 269 (58%) of 468 shoulders, whereas the nondominant side was involved in 199 (42%) shoulders. Patients were assessed at a median follow-up period of 4.2 years (ranging from 9 months to 16 years). Fifty-two of 253 (21%) patients undergoing physiotherapy required surgical intervention for MDI management, whereas the overall occurrence of redislocation was seen in 61 of 608 (10%) shoulders undergoing surgical procedures. The redislocation event occurred in 17 of 226 (7.5%) shoulders with open capsular shift management, in 21 of 268 (7.8%) shoulders with arthroscopic plication management, in 12 of 49 (24.5%) shoulders undergoing arthroscopic thermal shrinkage, and in 11 of 55 (22%) shoulders undergoing arthroscopic laser-assisted capsulorrhaphy. CONCLUSIONS: Arthroscopic capsular plication and open capsular shift are the best surgical procedures for treatment of MDI after failure of rehabilitative management. Arthroscopic capsular plication shows results comparable to open capsular shift. LEVEL OF EVIDENCE: Level IV, systematic review of Level I to IV studies.