Diagnosing the direction of shoulder instability in rugby players.

The muscular characteristics of rugby players may make diagnosing the direction of shoulder instability and labral pathology challenging. This study aimed to assess the accuracy of clinical examination and specifically instability tests, in diagnosing the direction of shoulder instability in rugby players. One-hundred-and-forty rugby players, who had undergone a shoulder stabilization procedure, over a 55-month period, were included in this study. The mean age was 21.5 years with 137 males. Data collected included clinical examination and intraoperative findings. The two were compared to calculate the diagnostic accuracy of special tests for instability. The Anterior Apprehension Test had good sensitivity (82.7%), specificity (100%) and PPV (100%) but poor NPV (55.8%). All posterior instability tests demonstrated a sensitivity of over 85%, but all had a specificity of 25% or less. In 83.6% of cases the direction of instability was correctly identified from history and examination. Anterior instability was correctly diagnosed in 78.9% of cases and posterior in 100.0%. The poor NPV of the anterior apprehension test suggests that clinicians should be suspicious of anterior instability in rugby shoulders even in the light of negative examination findings. Positive posterior instability tests are highly suggestive of posterior instability in rugby players.

In Vivo Randomized Controlled Study of the Bone Response of All-Suture Anchors and Biocomposite Anchors.

BACKGROUND: Suture anchors are widely used for labral reconstruction surgery. However, there has been some concern over the development of osteolysis around the anchor. This has been reported for both biocomposite and all-suture anchors, but they have not been compared directly in vivo. PURPOSE: To compare the bone response to 2 common suture anchors: a traditional biocomposite push-fit anchor and an all-suture anchor. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: Included in this study were 17 patients with a total of 37 unique suture anchors. Magnetic resonance imaging scans were performed at 3 weeks and 6 months postoperatively. A total of 38 senior radiologists and shoulder surgeons evaluated the images using a previously validated system for grading the bone response around suture anchors. The mean difference in grading at 3 weeks and 6 months was calculated using unpaired t tests, and the interrater reliability was evaluated with an intraclass correlation coefficient (ICC). RESULTS: At 3 weeks, there was no statistically significant difference in the degree of osteolysis surrounding each suture anchor type (P = .258), with little bone response. However, on the 6-month scans, there was a significantly lower level of osteolysis seen in the all-suture anchors compared with the biocomposite anchors (P = .040). Interrater reliability was excellent, with an ICC value of 0.975 (95% CI, 0.962-0.985). CONCLUSION: All-suture anchors cause significantly less osteolysis in glenoid bone at 6 months compared with biocomposite anchors.

Failed Latarjet surgery: why, how, and what next?

BACKGROUND: The Latarjet procedure is an established and popular procedure for recurrent anterior shoulder instability; however, to our knowledge, few studies have reported on the outcomes of revision for failed Latarjet surgery. We reviewed the causes and management of recurrent instability after previous Latarjet stabilization surgery. The outcomes of revision surgery were also evaluated. METHODS: A retrospective analysis of prospective data in patients undergoing revision surgery after failed Latarjet stabilization was conducted. Data were collected over a 5-year period and included patient demographics, clinical presentation, cause of recurrent instability, indications for revision surgery, intraoperative analysis, outcomes of revision surgery, and return to sport. RESULTS: We identified 16 patients (12 male and 4 female patients) who underwent revision surgery for recurrent instability after Latarjet stabilization. Of these patients, 11 were athletes: 9 professional and 2 amateur athletes. The mean age at revision was 29.9 ± 8.9 years (range, 17-50 years). The indications for revision were anterior instability in 11 patients, posterior instability in 4, and both anterior and posterior instability in 1. Of the anterior instability cases, 54.5% were due to coracoid nonunion and 36.4% were due to capsular failure (retear). All posterior instability cases had posterior capsulolabral injuries, and the mean Beighton score in this group was 6 or higher. One patient had a failed Latarjet procedure with coracoid nonunion and a posterior labral tear. CONCLUSION: Coracoid nonunion was the most common cause of recurrence after Latarjet stabilization, requiring an Eden-Hybinette procedure. The patients who returned with posterior instability had a high incidence of hypermobility and could be treated successfully by arthroscopic techniques.

The Incidence of Traumatic Posterior and Combined Labral Tears in Patients Undergoing Arthroscopic Shoulder Stabilization.

BACKGROUND: Posterior and combined shoulder instabilities have been reported as accounting for only 2% to 5% of cases. More recently, an increased incidence of posterior capsulolabral tear has been reported. PURPOSE: To assess the incidence of posterior and combined labral tears in a large cohort of patients with surgically treated shoulder labral tears. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This was a retrospective study that evaluated 442 patients who underwent an arthroscopic capsulolabral repair over a 3-year period. Patients were categorized according to the location of their labral tear and whether their injury was sustained during sporting or nonsporting activity. Proportions of labral tears between sporting and nonsporting populations were compared using the chi-square test. RESULTS: Patients had a mean age of 25.9 years and 89.6% were male. Isolated anterior labral tears occurred in 52.9%, with posterior and combined anteroposterior labral tears accounting for 16.3% and 30.8%, respectively. The frequency of posterior and combined lesions was greater in the sporting population compared with the nonsporting population (P = .013). CONCLUSION: Posterior and combined labral tears are more prevalent than previously reported, particularly in the sporting population.

The combined shoulder assessment: a convenient method for obtaining equivalent outcome scores.

BACKGROUND: Outcome scores are useful tools with respect to quantifying how pain and limitations in strength and movement affect the patient's functionality and lifestyle. Three shoulder outcome methods [Oxford, Constant and QuickDASH (Disability of the Arm, Shoulder and Hand)] are commonly used in practice but collectively consist of 34 questions, taking approximately 7 min to complete. We have developed a concise shoulder assessment to derive three equivalent outcome scores in a 12-item patient-reporting questionnaire. METHODS: Outcome scores from 1285 outpatients of an upper limb clinic were collected. The patient cohort consisted of 462 females and 823 males with a mean (SD) age of 47.2 (16.79) years (range 13 years to 90 years). Using a correlation matrix, a 12-item questionnaire was drafted. The combined shoulder assessment was validated by 227 patients; consisting of 101 females and 126 males with a mean (SD) age of 47.91 (16.63) years (range 13 years to 88 years). RESULTS: Agreement was achieved between the two methods, with an equivalent Oxford Shoulder Score intraclass correlation (ICC) of 0.930, equivalent Constant Shoulder Score ICC of 0.942 and equivalent QuickDASH ICC of 0.869. Bland-Altman analyses showed no systematic differences. Large effect sizes highlighted the responsiveness to change. CONCLUSIONS: The new combined shoulder assessment is a more convenient and patient-friendly method to obtain equivalent Oxford, Constant and QuickDASH shoulder outcome scores.

Surgical reconstruction of unrepairable pectoralis major rupture using tendo-achilles allograft.

Rupture of the pectoralis major remains an infrequent injury, although, recently, it has been reported more commonly as a result of the expansion and increasing popularity of competitive sports, as well as developments in sports medicine. A number of surgical repair techniques have been described for direct repair in the acute setting. However, on occasion, the pectoralis major muscle is so retracted that a tension-free direct repair is not possible. We describe a technique for allograft reconstruction of the pectoralis major, with our preliminary outcomes, where it is found or anticipated that a direct repair is not possible.

Recurrence After Arthroscopic Labral Repair for Traumatic Anterior Instability in Adolescent Rugby and Contact Athletes.

BACKGROUND: Traumatic glenohumeral dislocation of the shoulder is one of the most common shoulder injuries, especially among adolescent athletes. The treatment of instability for young athletes continues to be controversial owing to high recurrence rates. PURPOSE: To investigate the recurrence rate of shoulder instability after arthroscopic capsulolabral repair for adolescent contact and collision athletes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Sixty-seven patients aged <18 years underwent an arthroscopic labral repair over a 5-year period. The mean ± SD age of the cohort was 16.3 ± 0.9 years (range, 14-17 years) and consisted of 1 female and 66 males. All patients were contact athletes, with 62 of 67 playing rugby. Demographic, clinical, and intraoperative data for all patients with shoulder instability were recorded in our database. Recurrence rates were recorded and relative risks calculated. RESULTS: At a follow-up of 33 ± 20 months, 34 of 67 patients had recurrent instability for an overall recurrence rate of 51% among adolescent contact athletes after arthroscopic labral repair surgery. The mean time to recurrence was 68.1 ± 45.3 weeks. All recurrences occurred as a result of a further sporting injury. Relative risk analysis demonstrated that athletes aged <16 years had 2.2 (95% CI, 1.2-2.1) times the risk of developing a further instability episode as compared with athletes aged ≥16 years at the time of index surgery ( P = .0002). The recurrence rate among adolescent athletes after bony Bankart repairs was 57.9% versus 47.9% for soft tissue labral repairs ( P = .4698). The incidence of Hill-Sachs lesions ( P = .0002) and bony Bankart lesions ( P = .009) among adolescent athletes was significantly higher than among adult controls ( P = .002). The presence of bone loss did not lead to a significant increase in recurrence rate over and above the effect of age. CONCLUSION: Adolescent contact athletes undergoing arthroscopic labral repair have an overall recurrence rate of 51%. Rugby players who undergo primary arthroscopic shoulder stabilization aged <16 years have 2.2 times the risk of developing a further instability episode when compared with athletes aged ≥16 years at the time of index surgery, with a recurrence rate of 93%.

Arthroscopic repair of bony Bankart lesions in collision athletes.

BACKGROUND: The present study aimed to report the outcomes of acute and subacute arthroscopic bony Bankart repairs in collision athletes. METHODS: We reviewed 22 consecutive rugby players with traumatic anterior glenohumeral instability who underwent arthroscopic bony Bankart repair within 4 months of injury over a 2-year period. All lesions were less than 25% of the glenoid bony area. RESULTS: A significant improvement was noted at three months and was maintained at 28 months postoperatively. The mean Constant score improved from 61.5 to 84.1, the mean Oxford shoulder score decreased from 26.3 to 13.6 and the mean Oxford instability score decreased from 42.9 to 13.5. The mean satisfaction score was 8.3 out of 10 at final follow-up. All patients returned to their pre-injury sporting level. Twenty patients (91%) remained stable and asymptomatic, although two (9%) had recurrent instability after further traumatic sports injuries. One required a modified Latarjet procedure, whereas the other patient sustained a soft tissue Bankart lesion and had a revision arthroscopic repair. CONCLUSIONS: Acute and sub-acute bony Bankart lesions in collision athletes can be addressed through arthroscopic repair with a satisfactory outcome and return to pre-injury level of sport.

Shoulder Injuries in Canoeing and Kayaking.

OBJECTIVE: We report the largest case series of shoulder injuries among paddlers so far to establish common mechanisms and patterns of injury. We also discuss how these injuries were managed and report the proportion of paddlers that return to paddlesport. DESIGN: Case series. SETTING: Upper Limb Unit, Wrightington Hospital, United Kingdom. Manchester Arm Clinic, United Kingdom. PATIENTS: Fifty-seven shoulder injuries to professional and recreational paddlers were reviewed at a mean follow-up time of 55 months from the first consultation. The patient cohort had a mean age of 36 years and consisted of 56% males. ASSESSMENT OF RISK FACTORS: Sex, mechanism of injury, acute/nonacute injury, and level of sport participation. MAIN OUTCOME MEASURES: Patient data were analyzed with regards to Constant score, QuickDASH score, and VAS satisfaction score before and after treatment. RESULTS: The most common mechanism of injury was a capsize which accounted for 15 (26%) injuries. Ten injuries caused by a capsize were labral tears all of which needed surgery. A significant improvement in patient outcome scores was noted. Patients were able to return to a high level of paddling such as 3 slalom paddlers who returned to international competition; one of whom had bilateral surgery. CONCLUSIONS: Paddlers most commonly injure their shoulder when preventing a capsize, during a capsize or while rolling. The paddles strokes performed at these times often require paddlers to place their shoulder in a dangerous abducted and externally rotated position. We believe this is one of the commonest causes of serious shoulder injuries to paddlers.

Low-grade infections in nonarthroplasty shoulder surgery.

BACKGROUND: Recent studies have identified the diagnostic challenge of low-grade infections after shoulder arthroplasty surgery. Infections after nonarthroplasty procedures have not been reported. This study assessed patient-related risk factors, outcomes, and clinical presentation of low-grade infection after open and arthroscopic nonarthroplasty shoulder surgery. METHODS: The cases of 35 patients presenting with suspected low-grade infection were reviewed. Biopsy specimens taken at revision surgery were cultured in the sterile environment of a class II laminar flow cabinet and incubated for a minimum of 14 days at a specialist orthopedic microbiology laboratory. Patient-related factors (age, occupation, injection), index surgery, and infection characteristics (onset of symptoms, duration to diagnosis, treatment) were analyzed. RESULTS: Positive cultures were identified in 21 cases (60.0%), of which 15 were male patients (71%). Of all patients with low-grade infection, 47.6% were male patients between 16 and 35 years of age. Propionibacterium acnes and coagulase-negative staphylococcus were the most common organisms isolated (81.1% [n = 17] and 23.8% [n = 5], respectively). Of 14 negative culture cases, 9 were treated with early empirical antibiotics (64.3%); 7 patients reported symptomatic improvement (77.8%). Of 5 patients treated with late empirical antibiotics, 4 stated improvement. Patients presented with symptoms akin to resistant postoperative frozen shoulder (persistent pain and stiffness, unresponsive to usual treatments). CONCLUSION: Young male patients are at greatest risk for low-grade infections after arthroscopic and open nonarthroplasty shoulder surgery. P. acnes was the most prevalent organism. Patients presented with classic postoperative frozen shoulder symptoms, resistant to usual treatments. Interestingly, 78.6% of patients with negative cultures responded positively to empirical treatment.

Neuralgic amyotrophy is not the most common neurologic disorder of the shoulder: a 78-month prospective study of 60 neurologic shoulder patients in a specialist shoulder clinic.

BACKGROUND: Neuralgic amyotrophy (NA) was first described in 1948. Traditional literature describes a painful attack with sudden onset, followed by paresis, with varied outcomes. Recent studies have suggested NA is currently underdiagnosed. However, a large number of studies detailing NA originate from a small group of sources. Our study compared the onset, diagnosis, investigation, and treatment of all neurologic shoulder conditions to provide comparable data for these studies. METHODS: Data were collected from 60 patients (81.6% male; median age, 41.5 years) during a 78-month period. Patients with a diagnosis of a neurologic disorder of the shoulder with confirmatory electromyogram (EMG) studies were included. RESULTS: NA was diagnosed in 18 patients before the EMG investigation. Of the clinically diagnosed NA patients, only 5 (27.8%) had EMG findings supportive of NA. A further 5 patients with a clinical diagnosis other than NA were diagnosed with NA after EMG findings. Overall, 10 patients (16.6%) in our study were diagnosed with NA after EMG studies. Only 4 (40.0%) reported a sudden onset attack associated with NA. Supraspinatus and infraspinatus were involved in 9 patients (90.0%), suggesting a predictable distribution of muscle involvement. CONCLUSIONS: These results suggest that NA is overdiagnosed and does not warrant the increased attention suggested by recent articles. The current study also highlights a necessity to perform EMG investigations in all cases of suspected NA because the accuracy of the clinical assessment is poor.

MKP-2: out of the DUSP-bin and back into the limelight.

The MKPs (mitogen-activated protein kinase phosphatases) are a family of at least ten DUSPs (dual-specificity phosphatases) which function to terminate the activity of the MAPKs (mitogen-activated protein kinases). Several members have already been demonstrated to have distinct roles in immune function, cancer, fetal development and metabolic disorders. One DUSP of renewed interest is the inducible nuclear phosphatase MKP-2, which dephosphorylates both ERK (extracellular-signal-regulated kinase) and JNK (c-Jun N-terminal kinase) in vitro. Recently, the understanding of MKP-2 function has been advanced due to the development of mouse knockout models, which has resulted in the discovery of novel roles for MKP-2 in the regulation of sepsis, infection and cell-cycle progression that are distinct from those of other DUSPs. However, many functions for MKP-2 still await to be characterized.