Surgical versus conservative treatment of primary patellar dislocation. A systematic review and meta-analysis.

PURPOSE: The purpose of this study was to determine the efficacy of surgical and conservative treatment in the prevention of recurrence after primary patellar dislocation. METHODS: Studies were searched on MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and CINHAL from their inception to April 2015. All randomized controlled clinical trials comparing surgical versus conservative treatment after first patellar dislocation were included. Primary outcomes were: recurrent dislocation, subluxation, overall instability and subsequent surgery. Secondary outcomes included imaging, and subjective and objective clinical assessment tools. Methodological quality of the studies was assessed using Cochrane Collaboration's "Risk of Bias" tool. Pooled analyses were reported as risk ratio (RR) using a random effects model. Continuous data were reported as standardized mean difference (SMD) and 95 % confidence intervals (CIs). Heterogeneity was assessed using I². RESULTS: Nine studies were included in the meta-analyses. Methodological quality of the studies was moderate to low. Meta-analyses showed that surgical treatment significantly reduces the redislocation rate (RR = 0.62; 95% CI = 0.39, 0.98, p = 0.04) and provides better results on Hughston VAS score (SMD = -0.32; 95% CI = -0.61, -0.03; p = 0.03) and running (OR = -0.52; 95% CI = 0.31, 0.88; p = 0.01). Conservative treatment showed less occurrence of minor complications (OR = 3.46; 95% CI = 2.08, 5.77; p = 0.01) and better results in the figure-of-8 run test (SMD = 0.42; 95% CI = 0.06, 0.77; p = 0.02) and in the squat down test (SMD = -0.45; 95% CI = -0.81, -0.10; p < 0.00001). No other significant differences could be found. CONCLUSIONS: Based on the available data, surgical treatment of primary patella dislocation significantly reduces the risk of patella redislocation.

Magnetic resonance imaging criteria for the assessment of the rotator cuff after repair: a systematic review.

PURPOSE: The purpose of this systematic review was to detect the reliability of the currently available magnetic resonance imaging measurements used in the evaluation of repaired rotator cuff. METHODS: Search was performed using major electronic databases from their inception to February 2014. All studies reporting post-operative magnetic resonance assessment after rotator cuff repair were included. After the identification of available magnetic resonance criteria, reliability studies were further analysed. Descriptive statistics were used to summarize findings. Methodological quality was assessed using the Quality Appraisal of Reliability Studies checklist. RESULTS: One hundred and twenty studies were included in the review. Twenty-six different criteria were identified. Ten studies reported inter-observer reliability, and only two assessed intra-observer reliability of some of the identified criteria. Structural integrity was the most investigated criterion. The dichotomized Sugaya's classification showed the highest reliability (k = 0.80-0.91). All other criteria showed moderate to low inter-observer reliability. Tendon signal intensity and footprint coverage showed a complete discordance. Intra-observer reliability was high for the presence of structural integrity, and moderate to low for all other criteria. Methodological quality was high only for one study and moderate for three studies. CONCLUSIONS: Twenty-six different criteria described by multiple classification systems have been identified for the magnetic resonance assessment of rotator cuff after repair. Reliability of most of them has not been analysed yet. With the data available, only the presence of structural integrity showed good intra- and inter-observer agreement. LEVEL OF EVIDENCE: Systematic review of descriptive and qualitative studies, Level IV.

Reconstruction of the coracoclavicular and acromioclavicular ligaments with semitendinosus tendon graft: a pilot study.

PURPOSE: this study was conducted to assess the safety and efficacy of a new surgical technique for anatomical reconstruction of the coracoclavicular (CC) and acromioclavicular (AC) ligaments using one single-strand semitendinosus tendon graft. METHODS: eighteen patients affected by chronic type III-V AC joint dislocations were included in the present study between January 2010 and March 2012. All underwent the same surgical operation and rehabilitation protocol. The semitendinosus tendon was harvested from the ipsilateral knee. The CC and AC ligaments were reconstructed using the graft passed beneath the coracoid and through bone tunnels in the clavicle and in the acromion. The graft was secured with non-absorbable sutures. Radiographic recurrence of AC joint dislocation was the primary outcome. Clinical outcome was assessed using the DASH score and normalized Constant score. Wilcoxon's signed-rank test was used for comparison between pre- and postoperative results. Significance was set at p ≤ 0.05. RESULTS: the mean follow-up duration was 26.4±2.3 months (range: 24-30 months). On X-ray evaluation, only two patients (11%) showed asymptomatic recurrence of AC joint instability. Comparison between pre- and postoperative DASH and Constant scores showed significant clinical improvement (p<0.001). CONCLUSION: anatomical reconstruction of CC and AC ligaments using an autologous semitendinosus tendon graft for the treatment of AC joint dislocation provided good and reliable clinical and radiological results with a low failure rate at short-term follow-up. LEVEL OF EVIDENCE: level IV, therapeutic case series.

Generalized joint laxity and multidirectional instability of the shoulder.

Generalized joint laxity and shoulder instability are common conditions that exhibit a wide spectrum of different clinical forms and may coexist in the same patient. Generalized joint laxity can be congenital or acquired. It is fundamental to distinguish laxity from instability. Laxity is a physiological condition that may predispose to the development of shoulder instability. A high prevalence of generalized joint laxity has been identified in patients with multidirectional instability of the shoulder. Multidirectional instability is defined as symptomatic instability in two or more directions. The diagnosis and treatment of this condition are still challenging because of complexities in its classification and etiology. These complexities are compounded when multidirectional instability and laxity exist in the same patient. With an improved understanding of the clinical symptoms and physical examination findings, a successful strategy for conservative and/or surgical treatments can be developed. Conservative treatment is the first-line option. If it fails, different surgical options are available. Historically, open capsular shift has been considered the gold standard in the surgical management of these patients. Nowadays, advanced arthroscopic techniques offer several advantages over traditional open approaches and have shown similar outcomes. The correct approach to the management of failed stabilization procedures has not been yet defined.