Arthroscopically Assisted Coracoclavicular (CC) Stabilization Using a Suture Button Device for Lateral Clavicle Fractures with CC Ligament Injury.

Background: Lateral clavicle fractures represent approximately 10-15% of all clavicle fractures. However, controversy exists regarding the optimal surgical treatment because of instability associated with the coracoclavicular (CC) ligament injury and a small lateral fragment. The purpose of this study was to evaluate the radiological and clinical outcomes of arthroscopically assisted CC stabilization using a suture button device for lateral clavicle fractures accompanied by CC ligament injury. Methods: A retrospective observational study involved six patients with modified Neer type IIB fractures, which were treated with the technique and followed for 12 months. Postoperative range of motion (ROM) and X-rays were evaluated every 3 months. Shoulder functional scores (University of California Los Angeles score, Japanese Orthopedics Association score) and visual analog scale (VAS) scores for pain (at rest, at night, and during motion) and for satisfaction were analyzed 12 months after surgery. Results: Early phase ROM recovery and excellent outcomes were achieved. All patients achieved bone union. Slight superior clavicle displacement and bone hole dilation occurred with no critical complications. Conclusions: Arthroscopically assisted CC stabilization with a suture button device for unstable lateral clavicle fractures can produce satisfactory radiological and clinical results.

Glenoid Bone Loss Is a Risk Factor for Poor Clinical Results After Coracoid Transfer in Rugby Players With Shoulder Dislocations.

BACKGROUND: Although surgical shoulder stabilization via coracoid transfer in collision athletes is effective and has a low reinjury rate, the factors affecting poor clinical results and the superiority of the 2 stabilization procedures (Bristow and Latarjet) remain unclear. PURPOSE: To explore the factor(s) affecting poor clinical results of coracoid transfer in a large cohort of rugby players and to compare postoperative function between the Bristow and Latarjet procedures. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This study included 169 consecutive shoulders of 154 competitive male rugby players who underwent shoulder stabilization surgery (Bankart repair with coracoid transfer) between 2014 and 2018 and had a mean follow-up of 2.7 years (minimum follow-up, 2 years). The Bristow procedure was performed in the first 92 shoulders (84 players), and the Latarjet procedure was performed in the latter 77 shoulders (70 players). A poor clinical result was defined as a postoperative Rowe score of <70 and a postoperative Western Ontario Shoulder Instability Index (WOSI) score of >630. Multiple logistic regression analysis was conducted to identify the factors affecting postoperative functional failure. The postoperative scores and complication rates were also compared between the 2 procedures. RESULTS: In total, 92.3% of the rugby players returned to their preinjury competition level at a mean of 5.9 months postoperatively. The Rowe and WOSI scores showed that shoulder function was improved postoperatively compared with preoperatively. The number of rugby players with a poor clinical result was 18 (10.7%). Multiple logistic regression analysis demonstrated that a poor clinical result was associated with a preoperative glenoid bone defect of >20% of the glenoid width (odds ratio, 9.8), whereas the clinical result was unaffected by the type of coracoid transfer. There were no differences between the 2 procedures in any of the postoperative scores or complication rates. CONCLUSION: The present study indicated that the most effective predictor of postoperative functional scores was the degree of the glenoid bone defect and not the type of coracoid transfer. This information may be useful for the strategic treatment of shoulder dislocations in collision athletes.

The Number of Injury Events Associated With the Critical Size of Bipolar Bone Defects in Rugby Players With Traumatic Anterior Shoulder Instability.

BACKGROUND: The size of a glenoid bone defect is responsible for reduction in shoulder stability and is correlated with the number of instability events. Biomechanical studies have suggested that it should be considered concomitantly with the Hill-Sachs lesion as "bipolar" bone defects for assessing structural degradation, but the definitive number of instability events associated with the critical size has not been investigated. PURPOSE: To (1) confirm that the number of instability events is the predictor of a critical size of bipolar bone defects and (2) demonstrate the cutoff value of the number of instability events for these defects in rugby players with traumatic anterior shoulder instability. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: One-hundred forty-four rugby players with anterior shoulder instability underwent morphologic evaluation for glenoid and Hill-Sachs lesions by computed tomography and determination of the critical (a glenoid bone defect of ≥25% or an off-track Hill-Sachs lesion) and subcritical (a glenoid bone defect of ≥13.5%) size of bipolar bone defects. In the primary analysis, the prevalence of the critical and subcritical size of bipolar bone defects was investigated. In the secondary analysis, the authors explored the predictors for these bone defects and determined the cutoff value correlating with the critical and subcritical size of bipolar bone defects by applying receiver operating characteristic curves. RESULTS: The primary analysis revealed that the prevalence of critical and subcritical size of bipolar bone defects was 20.8% and 61.8% of 144 shoulders, respectively. In the secondary analysis, multiple logistic regression analysis demonstrated that the total number of shoulder instability events and dominant shoulder were the significant factors associated with the critical and subcritical size of bipolar bone defects. The cutoff value for the number of instability events that correlated with critical bipolar bone defects was 6 for the dominant and 9 for the nondominant shoulder, whereas it was 4 for the dominant and 5 for the nondominant shoulder for subcritical bipolar bone defects. CONCLUSION: The number of shoulder instability events and the dominant shoulder were the predictors for the critical and subcritical size of bipolar bone defects for a shoulder with traumatic instability. Four injury events should herald caution when treating rugby players with shoulder instability.

Accelerated Return to Play for Professional Rugby Players After Facial Fractures.

BACKGROUND: Facial fractures may result in a significant time away from competition for professional rugby players. An understanding of the return-to-play times is an integral part of clinical decision making when treating professional athletes. A period of 8 to 12 weeks has been conventionally recommended for returning to collision sports after facial fractures. The conventional time to return to sports of 8 to 12 weeks is usually too long for professional players. However, the time of return to play after such facial fractures in elite athletes has not been well described. PURPOSE: To investigate the return to play after facial fractures in professional rugby players with an accelerated rehabilitation protocol. METHODS: Ten professional rugby players with facial fractures were identified and analyzed. The authors investigated the number of days required to return to training and full-contact play according to the trauma type. The authors also determined the presence or absence of refractures and sequelae. RESULTS: The average age of the patients was 26.9 years. Medial orbital wall fractures were the most represented pattern, followed by orbital floor fractures and zygomatic arch fractures. The players returned to jogging after 9.9 days, to sports-specific training after a mean of 10.8 days, and to full-contact training after 18.3 days. There were no cases of refractures and sequelae. CONCLUSION: Players were able to return to their regular rugby activities, earlier than the time commonly allowed to return to full activity.

Midterm Clinical Results in Rugby Players Treated With the Bristow Procedure.

BACKGROUND: Although surgical shoulder stabilization by coracoid transfer is effective for collision athletes and has a low reinjury rate, no reports have described the midterm results of this procedure in specific patient cohorts of sufficient number or provided subjective assessments of these patients. PURPOSE: To evaluate midterm results after treatment of shoulder instability with the Bristow procedure in a large cohort of rugby players. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This study included 176 shoulders of 152 competitive rugby players who underwent shoulder stabilization surgery (Bristow procedure with Bankart repair) with a mean follow-up of 4 years (minimum of 2 years) in our institute. The primary outcome measure was the difference in the presurgical and postsurgical functional Rowe score and Western Ontario Shoulder Instability index (WOSI) score and factors affecting these scores. Complication rates and associated factors were also investigated. RESULTS: In total, 176 shoulders of 152 patients underwent the Bristow procedure with Bankart repair, and 93.2% of the players returned to their preinjury competition level at a mean of 6.3 months postoperatively. All Rowe and WOSI scores were significantly improved after surgery. The numbers of shoulders with functional failure as indicated by the Rowe score, WOSI score, and inability to return to the previous level of play were 28 (15.9%), 54 (30.7%), and 12 (6.8%), respectively. Multiple logistic regression analyses demonstrated that reinjury after surgery (odds ratio [OR] = 35.1) and the number of shoulder dislocations (OR = 11.2-11.4) negatively affected the competition level after return to play, while reinjury (OR = 11.1-17.8), the number of shoulder subluxations (OR = 1.1-2.9), injury in the dominant shoulder (OR = 1.2-2.2), and large bone defects (OR = 1.1-11.5) negatively affected functional scores. Reinjury after shoulder stabilization occurred in 6 of 176 shoulders (3.4%). Multiple logistic regression analysis demonstrated that reinjury after surgery occurred more frequently in players at lower versus higher grade levels of competition (OR = 21.0). Although differences were not significant, a trend was noted toward higher postoperative reinjury rates in forward players, those in the upper categories (professional and college), and those with injury in the nondominant shoulder. CONCLUSION: The Bristow procedure provides good midterm outcomes for competitive collision athletes, while postsurgical reinjury, the number of preoperative dislocations and subluxations, and large bone defects negatively affect postsurgical shoulder function. This information may be useful for treatment of shoulder dislocations in collision athletes.

Incidence of Stingers in Young Rugby Players.

BACKGROUND: A stinger is a type of neurapraxia of the cervical roots or brachial plexus and represents a reversible peripheral nerve injury. The incidence of and major risk factors for stingers among young rugby players remain uninvestigated. PURPOSE: To investigate the incidence, symptoms, and intrinsic risk factors for stingers in elite rugby union teams of young players. STUDY DESIGN: Descriptive epidemiology study. METHODS: A total of 569 male rugby players, including 358 players from 7 high school teams and 211 players from 2 university teams, were investigated using self-administered preseason and postseason questionnaires. RESULTS: The prevalence of a history of stingers was 33.9% (95% CI, 30.3-37.9), and 20.9% (119/569) of players experienced at least 1 episode of a stinger during the season (34.2 [95% CI, 26.2-42.1] events per 1000 player-hours of match exposure). The reinjury rate for stingers per season was 37.3% (95% CI, 30.4-44.2). Using the multivariate Poisson regression method, a history of stingers in the previous season and the grade and position of the player were found to be risk factors for stingers during the current season. The mean severity of injury was 2.9 days, with 79.3% (191/241) of the players not losing any time from playing after sustaining a stinger injury and 5.8% (14/241) of the players recovering within more than 14 days. The most frequent symptom was numbness in the unilateral upper extremity, and the most severe symptom was weakness of grasping (mean severity, 6 days). A logistic regression analysis indicated that a history of stingers in the previous season and an injury with more than 3 symptoms, especially motor weakness, were correlated with the severity of injury. CONCLUSION: Young rugby players with a history of stingers have a significantly high rate of repeat injuries. Although nearly 80% of the players experienced only minimal (0-1 day) time loss injuries, neurological deficits sometimes last beyond 1 month. A history of stingers was identified to be the strongest risk factor for injuries and for lasting symptoms. This information may be useful for planning the proper treatment for stingers in young rugby players.

The incidence of and risk factors for developing atypical femoral fractures in Japan.

The long-term treatment with anti-resorptive drugs for osteoporotic patients is suggested to be associated with an increase in atypical femoral fractures (AFFs). However, their incidence, patient characteristics, and risk factors have not been fully elucidated especially in Asian countries. This retrospective observational cohort study found fourteen AFFs in ten patients (four bilateral fractures) among 2,238 hip and femoral shaft fractures treated in our associated hospitals between 2005 and 2010; this incidence (0.63%) was similar to Caucasians. Of the ten patients with AFFs, nine (90%) and six (60%) were using bisphosphonates (BPs) and glucocorticoids (GCs), respectively, compared to 14.3 and 8.6% for patients with typical femoral fractures who were using these agents. As comorbid conditions, five patients had collagen disease (CD) and two had diabetes. A fracture location-, age- and gender-matched (1:3) case-control study revealed that administration of BPs, GCs, and suffering from collagen disease (CD) were significant risk factors for developing AFFs [odds ratios 36.0 (95% confidence intervals 3.8-342.2), 13.0 (2.3-74.1) and 9.0 (1.6-50.3), respectively]. Interestingly, all of the patients with atypical subtrochanteric femoral fractures, defined as those within 5 cm of the lesser trochanter, were taking GCs due to CD, and the age of these patients (average of 54.8 years) was significantly younger than those with atypical diaphyseal femoral fractures (average of 77.2 years, p < 0.05). In conclusion, the incidence of AFFs in the Japanese population was similar to that of Caucasians, and taking BPs and GCs and suffering from CD were risk factors for developing AFFs.

Incidence of and risk factors for traumatic anterior shoulder dislocation: an epidemiologic study in high-school rugby players.

BACKGROUND: The incidence of reinjuries due to glenohumeral instability and the major risk factors for primary anterior shoulder dislocation in youth rugby players have been unclear. PURPOSE: The purpose of this study was to investigate the incidence, mechanisms, and intrinsic risk factors of shoulder dislocation in elite high-school rugby union teams during the 2012 season. METHODS: A total of 378 male rugby players from 7 high-school teams were investigated by use of self-administered preseason and postseason questionnaires. RESULTS: The prevalence of a history of shoulder dislocation was 14.8%, and there were 21 events of primary shoulder dislocation of the 74 overall shoulder injuries that were sustained during the season (3.2 events per 1000 player-hours of match exposure). During the season, 54.3% of the shoulders with at least one episode of shoulder dislocation had reinjury. This study also indicated that the persistence of glenohumeral instability might affect the player's self-assessed condition, regardless of the incidence during the current season. By a multivariate logistic regression method, a history of shoulder dislocation on the opposite side before the season was found to be a risk factor for contralateral primary shoulder dislocation (odds ratio, 3.56; 95% confidence interval, 1.27-9.97; P = .02). CONCLUSIONS: High-school rugby players with a history of shoulder dislocation are not playing at full capacity and also have a significant rate of reinjury as well as a high risk of dislocating the other shoulder. These findings may be helpful in deciding on the proper treatment of primary anterior shoulder dislocation in young rugby players.

Do stingers affect scapular kinematics in rugby players?

BACKGROUND: Scapular dyskinesis is observed in subjects with pathologic conditions of the shoulder; however, there is limited information about the factors related to scapular dyskinesis among participants in rugby. The purpose of this study was to investigate the incidence, reliability, and relationships between scapular dyskinesis and variables related to the shoulder in high-school rugby players. METHODS: A total of 164 Japanese high-school rugby players were evaluated with questionnaires, physical examinations, and a video analysis during their preseason. After evaluation of the inter-rater reliability of a classification of scapular dyskinesis, the outcomes were analyzed to assess the relationships between scapular dyskinesis and other variables during the preseason. The data were assessed with a logistic regression analysis calculating the odds ratios (OR). RESULTS: The inter-rater reliability among 3 blinded observers based on the Fleiss κ value and percentage agreement was .52 and 79.0%, respectively, which indicates that the method is moderately reliable. Scapular dyskinesis was identified in 16 (10.1%) shoulders among 159 players, with type I being prominent. A multivariate logistic regression analysis revealed that a type I dyskinesis was significantly associated with a past history of stingers with projected pain to the affected side of the shoulder (OR, 3.7) and the player's competitive grade at the time of the survey (OR, 3.9). CONCLUSIONS: Scapular dyskinesis is significantly associated with a past history of stingers. This suggests that stingers are a causative factor of scapular dyskinesis in the rugby population. Our method of evaluating scapular dyskinesis in collision athletes exhibits moderate reliability.

The fracture sites of atypical femoral fractures are associated with the weight-bearing lower limb alignment.

PURPOSE: Atypical femoral fractures (AFFs) are stress-related fractures that are speculated to associate with long-term treatment with bisphosphonates for osteoporosis. A history of AFF is a high risk factor for the development of a subsequent AFF in the same location of the contralateral femur, suggesting that a patient's individual anatomical factor(s) are related to the fracture site of AFFs. In this study, we investigated the radiographs of fourteen AFFs (four bilateral fractures among ten patients) treated at six hospitals associated with our university between 2005 and 2010. The fracture site and standing femorotibial angle (FTA), which reflects the mechanical axis of the lower limb, were measured on weight-bearing lower limb radiographs. The fracture site and FTA of patients with typical femoral fractures (TFF) were compared to those of patients with AFFs. The correlations were examined using Spearman's rank correlation coefficients. The fracture locations in the femora were almost the same in the patients with bilateral AFFs. There was a positive correlation between the fracture site and the standing FTA in the patients with AFFs (r=0.82, 95% confidence interval; 0.49 to 0.94), indicating that the larger the standing FTA (varus alignment), the more distal the site of the fracture in the femur. The FTA of the patients with atypical diaphyseal femoral fracture were significantly larger compared to that of those with not only atypical subtrochanteric fractures but also TFFs. In conclusion, the fracture sites of AFFs are associated with the standing lower limb alignment, while those of TFFs are not.

Computed tomography osteoabsorptiometry for assessing the density distribution of subchondral bone as a measure of long-term mechanical stress in the "rugby shoulder".

BACKGROUND: Rugby is a collision sport with a high risk of shoulder injury. Although traumatic anterior shoulder instability is common, the long-term effects of rugby and joint instability on the shoulder have not been described; thus, this study assessed the effects of rugby itself, and joint instability, on the glenoid cavity. MATERIALS AND METHODS: Both sides of the shoulders from 25 rugby players and 17 control patients with unilateral shoulder instability were prospectively evaluated by means of computed tomography osteoabsorptiometry, which represents the distribution of mineralization in subchondral bone plate (DMSB) as a marker of the long-term loading history of a joint. For the quantitative analysis, intergroup differences of maximum Hounsfield unit (HU) values in 7 areas on the glenoid were assessed in the uninjured intact shoulder to characterize the influence of rugby. Side-to-side differences of the HUs in each area were assessed in each participant to characterize the effects of shoulder instability. For the qualitative analysis, associations between the patterns of each DMSB and each group were assessed by means of correspondence analysis. RESULTS: All examined areas on the glenoid had a significantly higher HUs in rugby players. Shoulder instability affected the HUs in both groups. A qualitative analysis demonstrated that the maximum HU tended to be shifted more inferiorly in rugby players and in the unstable shoulders. CONCLUSIONS: Rugby affects the shoulder joint, regardless of any history of instability, suggesting that "rugby shoulder" tends to involve degenerative changes, such as osteoarthritis or labral tears.

Does scapular dyskinesis affect top rugby players during a game season?

BACKGROUND: Scapular dyskinesis represents a considerable risk of shoulder injury to overhead athletes; however, there is a shortage of detailed epidemiologic information about scapular dyskinesis among the participants in collision sports. PURPOSE: To describe the incidence and relationship of scapular dyskinesis to shoulder discomfort and variables related to the shoulder in top rugby players. METHODS: One hundred twenty top rugby football players in Japan were evaluated by means of questionnaires, physical examinations, and a video analysis during their preseason. Data were assessed by a logistic regression analysis calculating odds ratios. The primary outcome was processed to assess the relationship between scapular dyskinesis and other variables at the preseason. The secondary outcome was processed to assess an influence of scapular dyskinesis to shoulder discomfort during their regular season that were reassigned by second questionnaires. RESULTS: Scapular dyskinesis was identified in 33 (32%) shoulders, and type III was prominent. Scapular dyskinesis was significantly associated with shoulder discomfort (OR [odds ratio] = 4.4), and was also associated with variables of the affected shoulder. In addition, the players with asymptomatic scapular dyskinesis at the preseason would have high incident with shoulder discomfort during their regular season (OR = 3.6). CONCLUSIONS: Scapular dyskinesis was associated significantly with both subjective and objective symptoms of the affected shoulder. These appearances may be of particular relevance in the early screening of chronic shoulder disorders in the rugby population. Further study to investigate and evaluate its reliability is needed to characterize its impact on the participants in collision sports.

Potential involvement of p53 in ischemia/reperfusion-induced osteonecrosis.

Idiopathic osteonecrosis of the femoral head (ION) is a devastating pathological condition of unknown etiology. In this study, we developed a simple murine model of osteonecrosis and investigated the underlying molecular mechanisms. In this model, the central portion of the tails of male C57BL/6 mice were tightly ligated to produce ischemic regions at sites distal to the ligatures. The occlusive ligatures were maintained for the indicated periods and then removed to induce reperfusion. The tails were histologically examined, and gene expression was analyzed by PCR array. The effect of p53 expression on osteocytes apoptosis was examined using preosteocytic MLO-A5 cells. In addition, the expression of p53 was analyzed in the femoral head samples obtained from hip osteoarthritis (OA) patients and ION patients. Caudal vertebrae distal to the ligatures (distal region) exhibited histological changes mimicking those observed in ION. Expression of p53 was increased in the distal region, and overexpression of p53 induced apoptosis in MLO-A5 cells. Treatment with a p53 inhibitor suppressed osteocyte apoptosis in the distal region. Strong p53 immunostaining was observed in osteocytes, vascular endothelial cells, and bone marrow cells in the femoral heads from ION patients but not from OA patients. Ischemia/reperfusion of the caudal vertebrae is a useful murine model of osteonecrosis, mimicking the histological changes found in ION. Using this model, we found the possible involvement of p53 in the osteocyte apoptosis observed in ION. Therapeutics targeting p53 might be a useful approach to ameliorating or even preventing osteonecrosis in ION patients.