The effects of RF coils and SAR supervision strategies for clinically applicable nonselective parallel-transmit pulses at 7 T.

PURPOSE: To investigate the effects of using different parallel-transmit (pTx) head coils and specific absorption rate (SAR) supervision strategies on pTx pulse design for ultrahigh-field MRI using a 3D-MPRAGE sequence. METHODS: The PTx universal pulses (UPs) and fast online-customized (FOCUS) pulses were designed with pre-acquired data sets (B0 , B1 + maps, specific absorption rate [SAR] supervision data) from two different 8 transmit/32 receive head coils on two 7T whole-body MR systems. For one coil, the SAR supervision model consisted of per-channel RF power limits. In the other coil, SAR estimations were done with both per-channel RF power limits as well as virtual observation points (VOPs) derived from electromagnetic field (EMF) simulations using three virtual human body models at three different positions. All pulses were made for nonselective excitation and inversion and evaluated on 132 B0 , B1 + , and SAR supervision datasets obtained with one coil and 12 from the other. At both sites, 3 subjects were examined using MPRAGE sequences that used UP/FOCUS pulses generated for both coils. RESULTS: For some subjects, the UPs underperformed when simulated on a different coil from which they were derived, whereas FOCUS pulses still showed acceptable performance in that case. FOCUS inversion pulses outperformed adiabatic pulses when scaled to the same local SAR level. For the self-built coil, the use of VOPs showed reliable overestimation compared with the ground-truth EMF simulations, predicting about 52% lower local SAR for inversion pulses compared with per-channel power limits. CONCLUSION: FOCUS inversion pulses offer a low-SAR alternative to adiabatic pulses and benefit from using EMF-based VOPs for SAR estimation.

Artifact suppression in readout-segmented consistent K-t space EPSI (RS-COKE) for fast 1 H spectroscopic imaging at 7 T.

PURPOSE: Fast proton (1 H) MRSI is an important diagnostic tool for clinical investigations, providing metabolic and spatial information. MRSI at 7 T benefits from increased SNR and improved separation of peaks but requires larger spectral widths. RS-COKE (Readout-Segmented Consistent K-t space Epsi) is an echo planar spectroscopic imaging (Epsi) variant capable to support the spectral width required for human brain metabolites spectra at 7 T. However, mismatches between readout segments lead to artifacts, particularly when subcutaneous lipid signals are not suppressed. In this study, these mismatches and their effects are analyzed and reduced. METHODS: The following corrections to the data were performed: i) frequency-dependent phase corrections; ii) k-space trajectory corrections, derived from short reference scans; and iii) smoothing of data at segment transitions to mitigate the effect of residual mismatches. The improvement was evaluated by performing single-slice RS-COKE on a head-shaped phantom with a "lipid" layer and healthy subjects, using varying resolutions and durations ranging from 4.1 × 4.7 × 15 mm3 in 5:46 min to 3.1 × 3.3 × 15 mm3 in 13:07 min. RESULTS: Artifacts arising from the readout-segmented acquisition were substantially reduced, thus providing high-quality spectroscopic imaging in phantom and human scans. LCModel fitting of the human data resulted in a relative Cramer-Rao lower bounds within 6% for NAA, Cr, and Cho images in the majority of the voxels. CONCLUSION: Using the new reference scans and reconstruction steps, RS-COKE was able to deliver fast 1 H MRSI at 7 T, overcoming the spectral width limitation of standard EPSI at this field strength.

Combined acquisition of diffusion and T2*-weighted measurements using simultaneous multi-contrast magnetic resonance imaging.

OBJECT: In this work, we present a technique called simultaneous multi-contrast imaging (SMC) to acquire multiple contrasts within a single measurement. Simultaneous multi-slice imaging (SMS) shortens scan time by allowing the repetition time (TR) to be reduced for a given number of slices. SMC imaging preserves TR, while combining different scan types into a single acquisition. This technique offers new opportunities in clinical protocols where examination time is a critical factor and multiple image contrasts must be acquired. MATERIALS AND METHODS: High-resolution, navigator-corrected, diffusion-weighted imaging was performed simultaneously with T2*-weighted acquisition at 3 T in a phantom and in five healthy subjects using an adapted readout-segmented EPI sequence (rs-EPI). RESULTS: The results demonstrated that simultaneous acquisition of two contrasts (here diffusion-weighted imaging and T2*-weighting) with SMC imaging is feasible with robust separation of contrasts and minimal effect on image quality. DISCUSSION: The simultaneous acquisition of multiple contrasts reduces the overall examination time and there is an inherent registration between contrasts. By using the results of this study to control saturation effects in SMC, the method enables rapid acquisition of distortion-matched and well-registered diffusion-weighted and T2*-weighted imaging, which could support rapid diagnosis and treatment of acute stroke.

Inlay total shoulder arthroplasty for primary glenohumeral arthritis.

BACKGROUND: Anatomic total shoulder arthroplasty with a nonspherical humeral head and inlay glenoid replacement has been introduced in the past; however, clinical evidence remains limited. We hypothesized that patients with advanced glenohumeral arthritis demonstrate significant improvements in pain and function. METHODS: Prospective patient-reported outcomes (PROs) included the American Shoulder and Elbow Surgeons score, a pain visual analog scale, and satisfaction. Range of motion was compared to the preoperative status. A sensitivity analysis examined responder rates and compared them to literature thresholds using the minimal clinically important difference and substantial clinical benefit. The preoperative glenoid morphology was determined using the Walsh classification. Zone-specific periprosthetic radiolucent lines were quantified at the last follow-up. RESULTS: Thirty-nine shoulders in 36 patients (3 bilateral) with a mean age of 65.9 years (26 males, 13 females) and a mean follow-up of 41.0 months were included. Ninety-three percent had grade III osteoarthritis, and 7% grade II. The glenoid Walsh classification included A1 (25%), A2 (25%), B1 (22%), B2 (25%), and C (3%). All PROs improved significantly (P < .001) with a mean American Shoulder and Elbow Surgeons score from 30.4 to 77.1, a pain visual analog scale from 8.1 to 1.5, and excellent (9.1/10) patient satisfaction. PRO-related responder rates for minimal clinically important difference and substantial clinical benefit were ≥85%. Forward elevation improved from 107° to 155°, and external rotation from 22° to 51°. One intraoperative glenoid rim fracture led to advanced radiolucency; no other clinically relevant lucency was observed. CONCLUSION: Treatment with inlay total shoulder arthroplasty demonstrated significant functional improvement, excellent pain relief, and patient satisfaction in patients with advanced shoulder arthritis and various glenoid morphology types. Our initial results provide further support for this new option in primary shoulder replacement.

Proximal Fifth Metatarsal Fractures in Athletes: Management of Acute and Chronic Conditions.

Proximal fifth metatarsal fractures are common in the athlete and can be a source of significant, temporary disability and missed playing time. The pattern of fracture can vary, and the type of fracture leads to a significantly different prognosis and treatment. Jones fractures of the fifth metatarsal are particularly common and difficult to treat in the athlete, can have recurrence and refracture, and require expertise to heal. Intramedullary screw fixation is currently the preferred method of fixation. Most other (non-Jones fractures and os vesalianum) proximal fifth metatarsal fractures can be treated successfully without surgery.

Distal Clavicle Fracture Repair: Clinical Outcomes of a Surgical Technique Utilizing a Combination of Cortical Button Fixation and Coracoclavicular Ligament Reconstruction.

BACKGROUND: When treated conservatively, unstable distal clavicle fractures demonstrate a high symptomatic nonunion rate. While a variety of surgical techniques have been described, many of these techniques are associated with high failure rates and hardware-related complications. The surgical technique used in this study has shown promising biomechanical results; however, long-term clinical results have not yet been described. PURPOSE: To assess the clinical and radiological outcomes of a surgical technique for fixing displaced distal clavicle fractures using a combination of cortical button fixation and coracoclavicular (CC) ligament reconstruction. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We conducted a retrospective review of 22 consecutive patients with displaced, unstable Neer type II or V distal clavicle fractures who underwent this surgical technique from 2012 to 2019. Primary outcome variables were radiographic union, patient satisfaction, and postoperative shoulder function. Preoperative and postoperative University of California, Los Angeles (UCLA), and American Shoulder and Elbow Surgeons (ASES) scores were compared. Secondary outcome variables included intraoperative complications, postoperative complications, time to radiographic union, and preoperative and postoperative CC distance. Quality of life was assessed using preoperative and postoperative 36-Item Short Form Health Survey (SF-36) scores. RESULTS: Nearly all (21/22) patients were available for a final review; 1 patient was lost to follow-up at 2 weeks. All 21 patients achieved radiographic union by 4 months (mean, 60.38 days; range, 41-84 days; 95% CI, 53.80-66.96 days). All patients were satisfied with the surgical procedure and their functional outcome. The mean UCLA score improved from 5.36 (95% CI, 4.14-6.60) preoperatively to 32.52 (95% CI, 30.56-34.48) postoperatively (mean difference, 27.14; P < .001). The mean ASES score improved from 16.23 (95% CI, 9.79-22.67) preoperatively to 88.11 (95% CI, 81.82-94.40) postoperatively (mean difference, 71.91; P < .001). Statistically significant improvements in SF-36 scores were seen in the physical functioning, role limitations due to physical health, pain, social functioning, and emotional well-being categories. There were 3 postoperative complications, including 1 patient with a minor complication secondary to hardware irritation, 1 patient with adhesive capsulitis, and 1 patient with wound dehiscence requiring wound closure. CONCLUSION: We describe a surgical technique for fixing displaced distal clavicle fractures using a combination of cortical button fixation and CC ligament reconstruction that resulted in a 100% union rate and excellent clinical outcomes with acceptable complications.

Defining the Critical Elements of the Most Common Arthroscopic Procedures: A Consensus of Orthopaedic Sports Medicine Surgeons.

Objective To define the critical elements of common procedures in arthroscopic surgery. Methods A survey was administered to surgeons associated with the American Orthopaedic Society for Sports Medicine (AOSSM) to determine the critical elements for four common arthroscopic procedures: anterior cruciate ligament (ACL) reconstruction, knee arthroscopy with meniscal debridement or repair, rotator cuff repair (RCR), and capsulorrhaphy for anterior glenohumeral instability (Bankart repair). Respondents were asked which steps necessitated their direct supervision. The level of experience and practice demographics were also recorded. Results For all applicable procedures, patient positioning and closure were not considered critical steps. Establishing arthroscopic portals was critical for all procedures, except knee arthroscopy. Diagnostic arthroscopy was only critical in ACL reconstruction. Private practice surgeons considered every step of these common procedures to be critical elements. Less experienced surgeons were more likely to regard certain aspects of a procedure critical. Surgeons with >15 years of experience considered diagnostic arthroscopy critical to all procedures, whereas those with <15 years of experience did not. Unlike surgeons with a resident as first assist, surgeons with a physician assistant (PA) or nurse practitioner (NP) found every step of each procedure to be critical except closure and positioning. Conclusion Across all procedures, only patient positioning and closure were consistently regarded as non-critical elements. There were significant differences in responses according to experience and practice setting. Future research is necessary to determine the implications of these findings and guide the definition of the "critical portions" of surgery.

A biomechanical comparison of new techniques for distal clavicular fracture repair versus locked plating.

BACKGROUND: Unstable distal clavicular fractures treated surgically are associated with high failure rates and hardware-related complications. Newer techniques have shown promising early clinical results with fewer hardware complications; however, their biomechanical performance has not been assessed. This study biomechanically compared a distal-third locking plate with 3 newer techniques that incorporate coracoid fixation into the construct. METHODS: The study randomized 36 adult fresh frozen cadaveric shoulders to 4 groups: (1) distal-third locking plate (P); (2) distal-third locking plate with a coracoid button augmentation (P + CB); (3) coracoclavicular button (CB); and (4) coracoclavicular button with coracoclavicular ligament reconstruction using semitendinosus allograft (CB + CC). After fixation, each specimen was stressed in the coronal plane. Cyclic displacement, load at 10-mm displacement, and ultimate load to failure were measured. RESULTS: All 3 experimental groups biomechanically outperformed the locking plate. Mean load to failure was significantly higher in the CB (343 ± 76 N) and CB + CC (349 ± 94 N) groups compared with the P group (193 ± 52 N). There was also significantly less cyclic displacement in the CB (4.3 ± 1.9 mm) and CB + CC (4.4 ± 1.9 mm) groups compared with the P group (8.2 ± 2.9 mm). With respect to load at 10 mm of displacement, which essentially measures a clinical failure, the P + CB (235 ± 112 N), CB (253 ± 111 N), and CB+CC (238 ± 76 N) experimental groups significantly outperformed the P group (96 ± 29 N). CONCLUSIONS: CB and CB + CC techniques demonstrated more than 75% greater strength than the traditional locking plate alone. Coupled with greater overall construct strength and lower-profile hardware, these newer techniques may result in improved clinical outcome and fewer hardware-related complications.

Accelerated silent echo-planar imaging.

PURPOSE: The standard approach to Echo-Planar Imaging (EPI) is to use trapezoidal readout (RO) gradients with blipped phase-encoding (PE) gradients. Sinusoidal RO gradients with constant PE gradients can reduce acoustic noise. However, this sequence, originally introduced by Mansfield et al., constitutes major challenges for Cartesian parallel imaging techniques. In this study two alternatives to reconstruct a non-blipped EPI are proposed and evaluated. THEORY AND METHODS: The first method separates the acquired k-space data into odd and even echoes and applies Cartesian GRAPPA separately to each partial data set. Afterwards, the resulting reconstructed data sets for each echo are summed in image space. In the second method, an iterative parallel-imaging algorithm is used to reconstruct images from the highly non-Cartesian data samples. RESULTS: Compared to blipped-EPI, the first method reduces image SNR depending on the acceleration factor between 11% and 60%. For an acceleration factor of 3 folding artefacts appear. The second method produces slight fold-over artefacts although image SNR is on the same level as the blipped approach. CONCLUSION: In this study, we have introduced two new approaches to EPI that allow the use of Cartesian parallel imaging in conjunction with continuous data sampling. In addition to providing a reduction in acoustic noise compared to the standard blipped PE EPI sequence, the proposed techniques improve sampling efficiency, resulting in a reduction of the echo-spacing. Of the two methods, the second approach, based on an iterative image reconstruction, provides higher SNR, but requires a longer reconstruction time.

Injury Pattern in Ligamentous Lisfranc Injuries in Competitive Athletes.

BACKGROUND:: We report data on the largest cohort to date of patients who sustained a ligamentous Lisfranc injury during sport. To date, the prevalence of concurrent intercuneiform ligament injuries in the competitive athlete with subtle Lisfranc instability has not been reported. METHODS:: Eighty-two patients (64 males, 18 females) sustained an unstable Lisfranc injury (49 left, 33 right) and met inclusion criteria. Injuries were classified as traditional dislocation (TRAD, first to second TMT ligament tear), medial column dislocation (MCD, second TMT, and medial-middle cuneiform ligament tear), or proximal extension dislocation (PE, first, second, and medial-middle cuneiform ligament tear) and the injury pattern confirmed at surgery. All athletes underwent open reduction with internal fixation (ORIF) of each unstable midfoot segment. Fisher exact tests and 2-tailed t tests were used to analyze statistical significance according to injury pattern, sport, gender difference, hindfoot angle alignment, and injured side ( P < .05). RESULTS:: Average age of athletes was 21.0 ± 5.3 years old (range 12-40), and return to sports was 7.5 ± 2.1 months. Injury distribution was as follows: TRAD (n = 40), MCD (n = 17), and PE (n = 23). MCD trended toward a longer return to sport (8.4 ± 3.3 months, P = .074). Football was the most common sport at time of injury (n = 48). Wakeboard athletes (n = 5) were older (31.4 ± 3.2, P = .0002), and MCD tears were more prevalent among them ( P = .061). Basketball (n = 13) players were significantly younger (19.1 ± 2.5 years, P = .028) and returned to sports quicker (5.2 ± 0.7, P = .0002). Return to sport data indicated a typical population for athletes with Lisfranc injury in these sports. CONCLUSION:: Proximal extension disruption (intercuneiform ligament tear) occurred in 50% of these low-energy Lisfranc athletic injuries. MCD and PE may be more prevalent than previously understood. This is the first study to document the extent, pattern, and prevalence of associated intercuneiform ligament tears in the competitive athlete with a low-energy subtle, unstable Lisfranc injury. LEVEL OF EVIDENCE:: Level IV, retrospective case series.

Chronic Lateral Ankle Instability: Open Surgical Management.

Open surgical reconstruction for chronic lateral ankle instability is a proven and effective means of providing renewed stability. Ankle arthroscopy is recommended before reconstruction to address intra-articular pathology. The open procedure discussed is well researched and proven to restore stability and the ability to return to sport and daily activity. Anatomic shortening with reattachment into a bony trough allows return to full motion, reliable stability, and return to an active lifestyle without sacrificing any tendons or requiring a tenodesis. The authors' aggressive rehabilitation protocol is provided; the approach to athletes/patients with ligament laxity or cavovarus alignment is also addressed.

Proximal Adductor Avulsion Injuries: Outcomes of Surgical Reattachment in Athletes.

BACKGROUND: Sports-related groin injuries are common among athletes. However, traumatic proximal adductor avulsion injuries are relatively rare groin injuries in the athletic population, with limited case reports describing suture anchor repair. PURPOSE: To report on the outcomes of surgical reattachment of proximal adductor avulsion injuries in athletes utilizing a suture anchor repair technique. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Prospective data were collected on patients undergoing surgical reattachment of proximal adductor avulsion injuries from December 2012 to May 2015 by a single surgeon. Six athletes presented after a traumatic sports-related injury with disabling groin pain, adductor weakness, and magnetic resonance imaging confirmation of fibrocartilage avulsion of the proximal adductor with retraction. Patient-reported outcomes (Hip Outcome Score-Activities of Daily Living [HOS-ADL] and Hip Outcome Score-Sport Specific [SS] subscales, modified Harris Hip Score [mHHS], and visual analog scale [VAS] for pain) were collected preoperatively and at a minimum 2-year follow-up. RESULTS: The latest follow-up of each patient averaged 33.4 months postoperatively (range, 25-42.5 months). All patients returned to sporting activities, with 1 minor wound complication that resolved. Paired-samples t tests indicated that the mean latest postoperative scores for all patients were significantly better than their mean preoperative scores (HOS-ADL: 99.0 vs 43.2, HOS-SS: 98.9 vs 8.3, and mHHS: 97.1 vs 44.6, respectively; P < .001 for all). Similarly, there was a significant improvement in mean postoperative VAS scores for all patients (from 89.2 to 2.2; P < .001). CONCLUSION: Patient-reported outcomes offer an objective measure of hip function and pain control. Surgical reattachment utilizing a multiple suture anchor technique is a successful procedure that allows for a safe return to athletic performance and a predictable return to sport.

Distal Clavicle Fracture Repair Using Cortical Button Fixation With Coracoclavicular Ligament Reconstruction.

Management of distal clavicle fractures remains controversial. Various treatment options have been described including open reduction and internal fixation with hook plate fixation, tension band wiring, screw fixation, and distal locking plates. Many of these techniques are associated with a high perioperative complication rate. We describe a surgical technique that allows indirect fixation of distal clavicle fractures and reconstruction of the CC ligaments without the use of prominent hardware.

Effect of Intraoperative Platelet-Rich Plasma Treatment on Postoperative Donor Site Knee Pain in Patellar Tendon Autograft Anterior Cruciate Ligament Reconstruction: A Double-Blind Randomized Controlled Trial.

BACKGROUND: Donor site morbidity in the form of anterior knee pain is a frequent complication after bone-patellar tendon-bone (BPTB) autograft anterior cruciate ligament (ACL) reconstruction. Hypothesis/Purpose: The purpose was to examine the effect of the intraoperative administration of platelet-rich plasma (PRP) on postoperative kneeling pain. It was hypothesized that PRP treatment would reduce knee pain. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: Fifty patients (mean ± SD age, 30 ± 12 years) undergoing BPTB ACL autograft reconstruction were randomized to the PRP (n = 27) or sham (n = 23) treatment. In either case, 10 mL of venous blood was drawn before the induction of anesthesia and either discarded (sham) or processed (PRP) for preparation of a PRP gel to be later mixed with donor site bone chips and inserted into the patellar defect. At 12 weeks, 6 months, 1 year, and 2 years after surgery, patients completed International Knee Documentation Committee (IKDC) forms and visual analog scale pain scores for activities of daily living and kneeling. Healing indices at the donor site were assessed by routine noncontrast magnetic resonance imaging (MRI) at 6 months. Mixed-model analysis of variance was used to assess the effect of PRP on patient symptoms and MRI indices of donor site healing, as measured by the width of the donor site defect. RESULTS: Kneeling pain, pain with activities of daily living, and IKDC scores were not different between treatment groups at any of the time intervals ( P = .08-.83). Kneeling pain improved from 12 weeks to 6 months and from 1 to 2 years ( P < .05). IKDC scores improved substantially from 12 weeks to 6 months ( P < .001) and continued to improve to 2 years (PRP, 86 ± 19; sham, 89 ± 10). MRI indices of donor site healing were not different between treatment groups ( P = .53-.90). CONCLUSION: Whether randomized to receive PRP in their patellar defect or not, patients continued to have similar levels of kneeling pain and patellar defect sizes after autograft BPTB ACL reconstruction. Registration: NCT01765712 ( ClinicalTrials.gov identifier).

In-Hospital Acute Kidney Injury After TKA Revision With Placement of an Antibiotic Cement Spacer.

BACKGROUND: There is mounting evidence that treatment of periprosthetic joint infection of the knee with an antibiotic cement spacer (ACS) may increase risk for acute kidney injury (AKI). We sought to determine the incidence, as well as potential risk factors, of in-hospital AKI in this cohort. METHODS: We retrospectively identified 75 patients that received either a static or articulating ACS at a single institution. In-hospital AKI was defined by a more than 50% rise in serum creatinine from preoperative baseline to at least 1.4 mg/dL. Our secondary outcome was percent change in creatinine from preoperative to peak postoperative value. Variables were analyzed for the outcome of AKI with univariate logistic regression. A final multivariate model for percent change in creatinine was formed while controlling for age, gender, body mass index, and baseline creatinine. RESULTS: The incidence of AKI was 14.6%, occurring at a mean of 6.3 days (2-8 days). A lower preoperative hemoglobin (odds ratio = 1.82, P = .015) significantly increased risk for AKI on univariate analysis. Diagnosis of either hypertension or diabetes also showed a strong statistical trend (P = .056). On multivariate regression, lower preoperative hemoglobin significantly correlated with a greater percent rise in creatinine postoperatively (ß = 0.30, P = .015). CONCLUSION: The incidence of AKI in patients who receive ACS is relatively high, raising clinical concern in the care of periprosthetic joint infection patients. Our results suggest that a lower baseline hemoglobin may be involved in the etiology of AKI in this population. Therefore, it may be clinically appropriate to monitor anemic patients for AKI when implanting an ACS.

Fifth Metatarsal Jones Fractures in the Athlete.

Fifth metatarsal fractures, otherwise known as "Jones" fractures, occur commonly in athletes and nonathletes alike. While recent occurrence in the popular elite athlete has increased public knowledge and interest in the fracture, this injury is common at all levels of sport. This review will focus on all three types of Jones fractures. The current standard for treatment is operative intervention with intramedullary screw fixation. Athletes typically report an acute episode of lateral foot pain, described as an ache. Radiographic imaging with multiple views of the weightbearing injured foot are needed to confirm diagnosis. If these images are inconclusive, further magnetic resonance imaging (MRI) or computed tomography (CT) is used. Nonoperative treatment is not commonly used as the sole treatment, except when following reinjury of a stable screw fixation. While screw selection is still controversial, operative treatment with intramedullary screw fixation is the standard approach. Technical tips on screw displacement are provided for Torg (types I, II, III) fractures, cavovarus foot fractures, recurrent fractures, revision surgery, occult fractures/high-grade stress reactions, and Jones' variants. Excellent clinical outcomes can be expected in 80% to 100% of patients when using the intramedullary screw fixation to "fit and fill" the medullary canal with threads across the fracture site. Most studies show the timing for return to sports with optimal healing to be seven to twelve weeks after fixation. LEVEL OF EVIDENCE: Level V, expert opinion.

Arthroscopic Treatment of Osseous Instability of the Shoulder.

BACKGROUND: Bony deficiency of the anteroinferior glenoid rim as a result of a dislocation can lead to recurrent glenohumeral instability. These lesions, traditionally treated by open techniques, are increasingly being treated arthroscopically as our understanding of the pathophysiology and anatomy of the glenohumeral joint becomes clearer. Different techniques for arthroscopic management have been described and continue to evolve. While the success of the repair is surgeon dependent, the recent advances in arthroscopic shoulder surgery have contributed to the growing acceptance of arthroscopic reconstruction of glenoid bone defects to restore stability. QUESTIONS/PURPOSES: The purpose of this study was to describe arthroscopic surgical management options for patients with glenohumeral osseous lesions and instability. METHODS: A comprehensive search of PubMed, Cochrane, and Medline was conducted to identify eligible studies. The reference lists of identified articles were then screened. Both technique articles and long-term outcome studies evaluating arthroscopic management of glenohumeral lesions were included. RESULTS: Studies included for final analysis ranged from Level II to V evidence. Technique articles include suture anchor fixation of associated glenoid rim fractures, arthroscopic reduction and percutaneous fixation of greater tuberosity fractures, arthroscopic filling ("remplissage") of the humeral Hill-Sachs lesion, and an all-arthroscopic Latarjet procedure. The overall redislocation rate varied but was consistently <10% with a low complication rate. CONCLUSION: Management of glenohumeral instability can be challenging but more recent advances in arthroscopic techniques have provided improved means of treating this diagnosis. This manuscript provides a comprehensive review of the arthroscopic treatment of osseous instability of the shoulder. It provides an in depth look at the various treatment options and describes techniques for each.