Outcomes of arthroscopic stabilization for recurrent instability are equal to stabilization after a primary event.

Aims: Extensive literature exists relating to the management of shoulder instability, with a more recent focus on glenoid and humeral bone loss. However, the optimal timing for surgery following a dislocation remains unclear. There is concern that recurrent dislocations may worsen subsequent surgical outcomes, with some advocating stabilization after the first dislocation. The aim of this study was to determine if the recurrence of instability following arthroscopic stabilization in patients without significant glenoid bone loss was influenced by the number of dislocations prior to surgery. Methods: A systematic review and meta-analysis was performed using the PubMed, EMBASE, Orthosearch, and Cochrane databases with the following search terms: ((shoulder or glenohumeral) and (dislocation or subluxation) and arthroscopic and (Bankart or stabilisation or stabilization) and (redislocation or re-dislocation or recurrence or instability)). Methodology followed the PRISMA guidelines. Data and outcomes were synthesized by two independent reviewers, and papers were assessed for bias and quality. Results: Overall, 35 studies including 7,995 shoulders were eligible for analysis, with a mean follow-up of 32.7 months (12 to 159.5). The rate of post-stabilization instability was 9.8% in first-time dislocators, 9.1% in recurrent dislocators, and 8.5% in a mixed cohort. A descriptive analysis investigated the influence of recurrent instability or age in the risk of instability post-stabilization, with an association seen with increasing age and a reduced risk of recurrence post-stabilization. Conclusion: Using modern arthroscopic techniques, patients sustaining an anterior shoulder dislocation without glenoid bone loss can expect a low risk of recurrence postoperatively, and no significant difference was found between first-time and recurrent dislocators. Furthermore, high-risk cohorts can expect a low, albeit slightly higher, rate of redislocation. With the findings of this study, patients and clinicians can be more informed as to the likely outcomes of arthroscopic stabilization within this patient subset.

The scapula spine may not be a suitable source of bone graft for glenoid reconstruction in critical bone loss.

AIMS: The hypothesis is that the scapula spine can provide a graft of suitable dimensions for use in cases of shoulder instability with critical bone loss. We aimed to investigate its utility with grafts of differing sizes. METHODS: The scapula spine was measured on CT scans of 50 patients who had undergone anterior stabilization. The theoretical ability to harvest a graft of either 2x1x1cm or 2x0.8x0.8cm was analyzed. RESULTS: Using the 2 x 1 x 1cm threshold, 36% of the scapulae had at least one zone from which a suitable graft could be obtained. 61% had only one zone from which a suitable graft could be obtained. Using the 2 x 0.8 x 0.8cm threshold, 72% had at least one zone from which a graft could be obtained. 47% met the threshold in one zone only. CONCLUSION: The scapula spine can be used as a source of autograft. Grafts up to 2 x 1 x 1cm can be harvested in some individuals, however the anatomy is very variable. TAKE HOME MESSAGE: The scapula spine can be used but we recommend that individualized preoperative planning is undertaken to ensure that a suitable graft can be harvested from the spine and to identify the exact location.

CT methods for measuring glenoid bone loss are inaccurate, and not reproducible or interchangeable.

Aims: Glenoid bone loss is a significant problem in the management of shoulder instability. The threshold at which the bone loss is considered "critical" requiring bony reconstruction has steadily dropped and is now approximately 15%. This necessitates accurate measurement in order that the correct operation is performed. CT scanning is the most commonly used modality and there are a number of techniques described to measure the bone loss however few have been validated. The aim of this study was to assess the accuracy of the most commonly used techniques for measuring glenoid bone loss on CT. Methods: Anatomically accurate models with known glenoid diameter and degree of bone loss were used to determine the mathematical and statistical accuracy of six of the most commonly described techniques (relative diameter, linear ipsilateral circle of best fit (COBF), linear contralateral COBF, Pico, Sugaya, and circle line methods). The models were prepared at 13.8%, 17.6%, and 22.9% bone loss. Sequential CT scans were taken and randomized. Blinded reviewers made repeated measurements using the different techniques with a threshold for theoretical bone grafting set at 15%. Results: At 13.8%, only the Pico technique measured under the threshold. At 17.6% and 22.9% bone loss all techniques measured above the threshold. The Pico technique was 97.1% accurate, but had a high false-negative rate and poor sensitivity underestimating the need for grafting. The Sugaya technique had 100% specificity but 25% of the measurements were incorrectly above the threshold. A contralateral COBF underestimates the area by 16% and the diameter by 5 to 7%. Conclusion: No one method stands out as being truly accurate and clinicians need to be aware of the limitations of their chosen technique. They are not interchangeable, and caution must be used when reading the literature as comparisons are not reliable.

Open fractures of the upper limb - do the BOAST guidelines need an update?

AIMS: This scoping review aims to explore the published literature on the current management strategies and outcomes of open upper limb injuries using the BOAST 4 guidelines as a structure. MATERIALS AND METHODS: A comprehensive search of the MEDLINE, EMBASE, Cochrane and OrthoSearch computerised literature databases (from January 2012 through April 2022) was performed. The medical subject headings used were "open fracture"/ "Gustilo Anderson" and "forearm" or "radius" or "ulna" or "elbow" or "humerus" or "clavicle" or "shoulder" or "scapula". Abstract titles were reviewed for relevance. If the article was deemed eligible, the article was retrieved and reviewed in full. RESULTS: The literature reveals lower rates of infection for upper limb injuries compared to their lower limb counterparts. Early antibiotic administration remains a key component of their management. Those without significant soft tissue injury (Gustilo Anderson 1) can often be treated as per their closed counterparts and timing to definitive fixation can be safely delayed in selected cases. DISCUSSION: There is limited high quality evidence available on the management of open upper limb injuries with guidelines built on borrowed principles from the more studied open tibia fractures. What the available evidence does show is that with lower infection rates and a more forgiving soft tissue envelope it may be safe to diverge from the current BOAST guidelines in certain cases. This has relevance in complex fracture patterns requiring specialist input where it is not possible to achieve definitive fixation in 72 h and when there are other life threatening injuries to manage. Despite this early antibiotic administration and debridement within 24 h remains a key component of the early management.

Platelet-rich plasma versus corticosteroid injections in the management of patients with rotator cuff disease: A systematic review and meta-analysis.

Platelet-rich plasma (PRP) is an alternative to corticosteroid (CS) injections in managing rotator cuff disease. This meta-analysis investigated differences between PRP and CS for function and pain scores in significance and minimal clinical important difference (MCID). A literature search of Ovid Cochrane Library, Medline, Embase, Epub, and Scopus was conducted from inception to October 28, 2021. Eligible studies reported patients older than 18 years with a diagnosis of rotator cuff disease. This review was registered in PROSPERO (ID: CRD42021278740). Twelve studies met eligibility criteria (n = 639) of patients receiving either PRP or CS. At short-term follow-up, a difference favored CS compared to PRP in baseline change for disability of arm, shoulder, and hand (DASH) score (MD = -5.08, 95% CI: -8.00, -2.15; p = 0.0007; I2 = 0%) and simple shoulder test (SST) (MD = 1.25, 95% CI: 0.33, 2.18; p = 0.008; I2 = 0%). At intermediate follow-up, a difference favored PRP to CS baseline change of the DASH score (MD = 3.41, 95% CI: 0.67, 6.15; p = 0.01; I2 = 0%). At medium-term, a difference favored PRP to CS baseline change of the American Shoulder and Elbow Surgeons Shoulder (ASES) score (MD = -4.42, 95% CI: -8.16, -0.67; p = 0.02; I2 = 0%). Both treatments achieved individual MCID for each score. Despite favoring CS at short-term follow-up and PRP at intermediate- and medium-term follow-up, functional and pain scores did not demonstrate any clinical difference between the two treatment modalities in management of rotator cuff disease at all follow-up periods.

Closed midshaft clavicle fractures : an evidence-based triage management algorithm.

AIMS: The management of mid-shaft clavicle fractures (MSCFs) has evolved over the last three decades. Controversy exists over which specific fracture patterns to treat and when. This review aims to synthesize the literature in order to formulate an appropriate management algorithm for these injuries in both adolescents and adults. METHODS: This is a systematic review of clinical studies comparing the outcomes of operative and nonoperative treatments for MSCFs in the past 15 years. The literature was searched using, PubMed, Google scholar, OVID Medline, and Embase. All databases were searched with identical search terms: mid-shaft clavicle fractures (± fixation) (± nonoperative). RESULTS: Using the search criteria identified, 247 studies were deemed eligible. Following initial screening, 220 studies were excluded on the basis that they were duplicates and/or irrelevant to the research question being posed. A total of 27 full-text articles remained and were included in the final review. The majority of the meta-analyses draw the same conclusions, which are that operatively treated fractures have lower nonunion and malunion rates but that, in those fractures which unite (either operative or nonoperative), the functional outcomes are the same at six months. CONCLUSION: With regard to the adolescent population, the existing body of evidence is insufficient to support the use of routine operative management. Regarding adult fractures, the key to identifying patients who benefit from operative management lies in the identification of risk factors for nonunion. We present an algorithm that can be used to guide both the patient and the surgeon in a joint decision-making process, in order to optimize patient satisfaction and outcomes.Cite this article: Bone Jt Open 2022;3(11):850-858.

Superior Capsule Reconstruction Is a Viable Option for Patients with Symptomatic, Isolated, and Irreparable Supraspinatus Tears.

Purpose: To evaluate the outcome of superior capsular reconstruction for isolated subscapularis tears using a decellularized porcine allograft as a superior capsular reconstruction. Methods: Patients who had symptomatic tears of supraspinatus who had failed to improve a conservative rehabilitation program were included. Previous surgery to the shoulder was not a bar to inclusion. Patients were assessed preoperatively and postoperatively with the Oxford Shoulder Score (OSS), the single assessment numeric evaluation (SANE) score, as well as clinically assessed for their shoulder range of motion (ROM). Patients were followed up with in-person clinic appointments for the first year, followed by a postal questionnaire and telephone consultation at a minimum of 2 years following surgery. Results: Twenty patients (11 males and 9 females) with a mean age of 67.5 years were included (range: 54-72 years). The average follow-up period was 31 months (24-50). The mean improvement in OSS was 14 points (P < .001), SANE score was 27 points (P < .01). Significant improvements in mean ROM were recorded (flexion 80.7°; P < .001; abduction: 81°; P < .001; external rotation: 31°; P < .001). Six patients suffered SCR failures diagnosed by magnetic resonance imaging, despite this they still recorded improvements in recorded OSS, SANE and ROM (excluding external rotation). Patient demographics for failed superior capsule reconstruction (SCR) highlighted smoking and revision surgery as risk factors. Conclusions: SCR appears to be a viable option for patients with symptomatic, isolated, and irreparable tears of the supraspinatus. Our results demonstrate that there are significant improvements in outcome scores and active range of motion, even in the subgroup in whom postoperative structural failure of the SCR was identified. We recommend caution in patients who have previously failed rotator cuff repair and in heavy smokers. Level of Evidence: Level IV, therapeutic case series.

CT estimation of glenoid bone loss in anterior glenohumeral instability : a systematic review of existing techniques.

AIMS: Recurrent dislocation is both a cause and consequence of glenoid bone loss, and the extent of the bony defect is an indicator guiding operative intervention. Literature suggests that loss greater than 25% requires glenoid reconstruction. Measuring bone loss is controversial; studies use different methods to determine this, with no clear evidence of reproducibility. A systematic review was performed to identify existing CT-based methods of quantifying glenoid bone loss and establish their reliability and reproducibility. METHODS: A Preferred Reporting Items for Systematic reviews and Meta-Analyses-compliant systematic review of conventional and grey literature was performed. RESULTS: A total of 25 studies were initially eligible. Following screening, nine papers were included for review. Main themes identified compared 2D and 3D imaging, as well as linear- compared with area-based techniques. Heterogenous data were acquired, and therefore no meta-analysis was performed. CONCLUSION: No ideal CT-based method is demonstrated in the current literature, however evidence suggests that surface area methods are more reproducible and lead to fewer over-estimations of bone loss, provided the views used are standardized. A prospective imaging trial is required to provide a more definitive answer to this research question. Cite this article: Bone Jt Open 2022;3(2):114-122.

Reporting of glenoid bone loss measurement in clinical studies and the need for standardization : a systematic review.

AIMS: The amount of glenoid bone loss is an important factor in deciding between soft-tissue and bony reconstruction when managing anterior shoulder instability. Accurate and reproducible measurement of glenoid bone loss is therefore vital in evaluation of shoulder instability and recommending specific treatment. The aim of this systematic review is to identify the range methods and measurement techniques employed in clinical studies treating glenoid bone loss. METHODS: A systematic review of the PubMed, MEDLINE, and Embase databases was undertaken to cover a ten-year period from February 2011 to February 2021. We identified clinical studies that incorporated bone loss assessment in the methodology as part of the decision-making in the management of patients with anterior shoulder instability. The Preferred Reporting Items for Systematic Reviews (PRISMA) were used. RESULTS: A total of 5,430 articles were identified from the initial search, of which 82 studies met the final inclusion criteria. A variety of imaging methods were used: three studies did not specify which modality was used, and a further 13 used CT or MRI interchangeably. There was considerable heterogeneity among the studies that specified the technique used to quantify glenoid bone loss. A large proportion of the studies did not specify the technique used. CONCLUSION: This systematic review has identified significant heterogeneity in both the imaging modality and method used to measure glenoid bone loss. The recommendation is that as a minimum for publication, authors should be required to reference the specific measurement technique used. Without this simple standardization, it is impossible to determine whether any published paper should influence clinical practice or should be dismissed. Cite this article: Bone Joint J 2022;104-B(1):12-18.

The FAST Workstation Shows Construct Validity and Participant Endorsement.

PURPOSE: To determine in what way the proposed simulation-based intervention (SBI) is an effective intervention for use in basic arthroscopic skills training. METHODS: Twenty candidates were recruited and grouped according to experience. Performance metrics included the time to activity completion, errors made, and Global Rating Scale score. Qualitative data were collected using a structured questionnaire. RESULTS: Performance on the SBI differed depending on previous arthroscopic training received. Performance on the simulator differed between groups to a statistically significant level regarding time to completion. A difference was also present between participants with no previous training and those with previous training when assessed using the Global Rating Scale. The SBI was deemed acceptable, user-friendly, and realistic. Participants practicing at the expert level believe that such an SBI would be beneficial in developing basic arthroscopic skills. CONCLUSIONS: The results of this study provide evidence that the use of an SBI consisting of a benchtop workstation, laptop viewing platform, 30° arthroscope, and defined performance metrics can detect differences in the level of arthroscopic experience. This format of SBI has been deemed acceptable and useful to the intended user, increasing the feasibility of introducing it into surgical training. CLINICAL RELEVANCE: This study adds to the existing body of evidence supporting the potential benefits of benchtop SBIs in arthroscopic skills training. Improved performance on such an SBI may be beneficial for the purpose of basic arthroscopic skills training, and we would support the inclusion of this system in surgical training programs such as those developed by the Arthroscopy Association of North America and American Board of Orthopaedic Surgery.