Purpose The remplissage procedure may be performed as an adjunct to Bankart repair to address an engaging Hill-Sachs defect. Clinically, it has been reported that the remplissage procedure improves joint stability but that it may also restrict shoulder range of motion. The purpose of this biomechanical study was to examine the effects of the remplissage procedure on shoulder motion and stability. We hypothesized that the remplissage procedure would improve stability and prevent engagement but may have a deleterious effect on motion. Method Eight cadaveric forequarters were mounted on a custom biomechanical testing apparatus which applied simulated loads independently to the rotator cuff muscles and to the anterior, middle and posterior deltoid. The testing conditions included: intact shoulder, Bankart defect, Bankart repair, 2 Hill-Sachs defects (15%, 30%) with and without remplissage. Joint range of motion and translation were recorded with an optical tracking system. Outcomes measured were internal-external rotation range of motion in adduction and 90 combined abduction, extension range of motion and stability, quantified in terms of joint stiffness and engagement, in abduction. Results With a 15% Hill-Sachs defect, the remplissage significantly reduced internal-external rotation in adduction (15.111.1, p=0.039), but not in abduction (7.79.0, p=0.380). In a 30% Hill-Sachs defect, the remplissage procedure significantly reduced internal-external rotation in adduction (19.57.8, p=0.001), and in abduction (12.28.6, p=0.03). The remplissage procedure significantly enhanced stability in the 15% Hill-Sachs defect (4.74.0 N/mm, p=0.038), and in the 30% defect (3.93.2 N/mm, P=0.030) compared to the unrepaired defect. All of the unrepaired 30% defects engaged and the remplissage procedure successfully eliminated engagement in each case. However, impingement of the repair on the posterior glenoid with paradoxical posterior pivoting of the humeral head was observed in 50% of the specimens. Conclusion The remplissage procedure significantly augmented a Bankart repair in 15% and 30% Hill-Sachs defects and, in 30% Hill-Sachs defects, the remplissage successfully prevented engagement of the defect. The remplissage procedure, however, did significantly reduced shoulder internal-external rotation range of motion as reported clinically, and was also found to reduce extension in the two defect groups. During extension the intra-articular soft tissue bumper created by the remplissage procedure was found to impinge on the posterior glenoid rim and cause pivoting, which produced non-physiologic glenohumeral joint distraction. Therefore, the remplissage procedure stabilized the joint to a significantly greater degree than did a Bankart repair alone; however, it also significantly reduced shoulder range of motion.

The effect of the remplissage procedure on shoulder stability and range of motion: an in vitro biomechanical assessment

We performed a point-prevalence survey of 15,799 children, six to fourteen years old, who formed part of a prospective longitudinal study. Our purpose was to detect the prevalence of scoliosis and to investigate associated factors. On the basis of the initial screening, 934 children (5.9 per cent) were referred for additional clinical and radiographic examinations; 896 children returned for this second evaluation. A lateral spinal curve with a Cobb angle of more than 5 degrees was seen in 431 children (2.7 per cent of the 15,799 children). Only seventy-six children (0.5 per cent) had a curve that met our definition of idiopathic scoliosis (a curve of more than 10 degrees with concordant apical rotation). The point-prevalence rate was higher in girls, and it increased with age. The rate was 0.1 per cent (four of 5246) in the age-group of six to eight years, 0.3 per cent (sixteen of 5831) in the age-group of nine to eleven years, and 1.2 per cent (fifty-six of 4722) in the age-group of twelve to fourteen years old. With allowance for the fact that different definitions of idiopathic scoliosis have been used in earlier studies, our results suggest that the natural history of idiopathic scoliosis may be becoming more benign spontaneously.

Late-onset idiopathic scoliosis in children six to fourteen years old. a cross-sectional prevalence study

Adolescent Idiopathic Scoliosis (AIS) is a complex 3D structural disorder of the spine that has a significant impact on a person's physical and emotionalstatus. Thus, efforts have been made to identify the cause of the curvature and improve management outcomes. This comprehensive review looks at the relevant literature surrounding the possible aetio-pathogenesis of AIS, its clinical features, investigations, surgicalmanagement options, and reported surgical outcomes in anterior spinal fusion, posterior spinal fusion or combined approach in the treatment of AIS.

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Current concepts in the diagnosis and management of adolescent idiopathic scoliosis.

Background:  Adolescent idiopathic scoliosis (AIS) is one of the most common structural spinal deformities in adolescents, becoming apparent around the time of puberty. Schroth scoliosis-specific exercises have demonstrated promising results in reducing the progression of AIS. Objectives:  The aim of this study was to identify, critically appraise and establish the best available evidence for the effectiveness of Schroth exercises in comparison to non-surgical management to reduce the progression of AIS. Methodology:  Seven databases were searched in April 2018. Main key search terms included  AIS, Schroth exercises, physiotherapy, exercise, electrical stimulation, yoga, Pilates, tai chi  and  bracing . The quality of the trials was critically appraised according to the PEDro scale. Revman© Review Manager Software was used to pool the quality of life (QOL) results. Results:  Four randomised control trials with an average PEDro score of 6.75/10 were included in this study. Results indicated that Schroth exercises had a significant effect in decreasing the Cobb angle ( p  < 0.05) in comparison to non-surgical management. The pooled effect on QOL showed a significant result in favour of Schroth exercises at 12 weeks ( p  < 0.002) and at 24 weeks ( p  < 0.0004). Conclusion:  Level II evidence suggests that Schroth exercises have a significant effect on reducing the Cobb angle and improving QOL in adolescents with idiopathic scoliosis. Clinical implications:  This review’s findings should be considered with caution for physiotherapy practice because of the limited number of identified articles and their methodologic limitations. Based on the current available and limited evidence, clinicians could combine supervised Schroth exercises with conventional physiotherapy care (observation, exercise, bracing and manual therapy) when treating adolescents with idiopathic scoliosis.

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The effectiveness of Schroth exercises in adolescents with idiopathic scoliosis: A systematic review and meta-analysis

Fifteen moderate to severe acute slipped capital femoral epiphyses were manipulated in 15 patients to correct significant deformities ; in each case, torsion played a critical role in the reduction. Nine of 15 patients with acute slips underwent controlled, open reduction from the anterolateral approach, stabilizing the epiphysis while the metaphysis was internally rotated, flexed, and abducted ; none had osteonecrosis or chondrolysis. The other 6 acute slips were treated with traction using internal rotation to achieve closed reduction ; 2 of these 6 closed reductions progressed to osteonecrosis, and both were reduced in an uncontrolled situation. Of the 15 acute slips, 6 involved torsion as the primary force. Based on the importance of torsion in all the reductions and the prevalence of torsion as an etiologic factor in the initial slips, it is postulated that torsion is an important contributing component in the etiology of slipped capital femoral epiphysis. Despite 2 cases of osteonecrosis in unstable hips, these 15 manipulative reductions were 87% successful. If the 2 inadvertent closed reductions are eliminated, then the success rate is 100%.

The torsional basis for slipped capital femoral epiphysis : Splipped capital femoral epiphysis

Background:
Scoliosis refers to deviation of spine greater than 10 degrees in the coronal plane. Idiopathic Scoliosis is the most common spinal deformity that develops in otherwise healthy children. The sub types of scoliosis are based on the age of the child at presentation. Adolescent idiopathic scoliosis (AIS) by definition occurs in children over the age of 10 years until skeletal maturity.

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Adolescent Idiopathic Scoliosis

Background Defects to the articular surface of the humeral head have been known to be associated with shoulder dislocation since the 19th century. It wasn't until 1934 that the first description of the ubiquitous compression fracture of the posterolateral humeral head that occurs with traumatic anterior instability appeared. From 1940, this defect became referred to as a Hill-Sachs lesion after the investigators who reported the condition. The significance of, and therefore treatment of, these and other such bony defects around the shoulder joint has been hotly debated. Methods We reviewed the available current literature to determine and report on the most up to date concepts and treatment techniques being used to manage bony defects of the shoulder. Results Numerous surgical options have been proposed to manage bony defects of the shoulder, including a variety of defect-filling procedures, with good outcomes. However, the small numbers and diversity of case mix makes for difficult comparisons. Conclusion We are currently developing a greater appreciation of how both the humeral and glenoid defects interact and therefore should be assessed and addressed simultaneously in order to improve patient outcomes. More research and collaboration is needed to determine the optimal method of assessing and managing these patients.

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Managing Bony Defects of the Shoulder Joint that Occur in Association with Dislocation

INTRODUCTION Patients with scapulothoracic syndrome present with pain in the scapulothoracic area aggravated by overhead and repetitive shoulder movements. The aim of our study was to assess the outcome of scapulothoracic arthroscopic treatment in patients with painful snapping scapula in our institution. METHODS Fourteen patients underwent scapulothoracic arthroscopic treatment for painful snapping scapula. Pre-operatively, all these patients had a trial of conservative treatment modalities for at least 6 months. Two portals along the medial border of scapula were used for arthroscopy and instrumentation. In three cases a superior portal was also used. The arm was placed in the "chicken wing" position so that the scapula lifted up from the chest wall. Outcome was assessed using pre and postoperative pain visual analogue score and Oxford Shoulder Score. RESULTS Of the fourteen patients included in our study, ten were female and four were male patients. Mean age at the time of surgery was 27.6 years. Mean follow up was 35.7 months. Pain visual analogue score improved significantly from a mean of 8.8 preoperatively to 2.5 postoperatively (P value 0.00002). There was also a significant improvement in Oxford Shoulder Score from a mean of 10.8 to 40.9 (P= 0.00001). Mean crepitus score significantly decreased from 2.6 to 0.21 (p < 0.00001). Crepitus completely resolved in eleven patients. In three there was residual palpable crepitus but they had good pain relief. CONCLUSION Arthroscopic scapulothoracic treatment provides significant pain relief and functional improvement for painful snapping scapula symptoms not responding to non-surgical treatment modalities.

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Outcome of Scapulothoracic Arthroscopy for Painful Snapping Scapula.

Authors' response to the letter re: Evidence based treatment for unstable slipped upper femoral epiphysis: Systematic review and exploratory patient level analysis.

Background The position of the gastrocnemius tendon in relation to the leg length may be different in children with cerebral palsy as compared to normal children. The palpation of muscle bellies or previous experience of the operating surgeon is employed to place the surgical incision for lengthening of the gastrocnemius aponeurosis. Inaccurate localisation may cause incorrect incisions and a risk of iatrogenic damage to the vital structures (i.e. sural nerve). Objectives The aim of our study is to compare gastrocnemius length in-vivo between paretic and unaffected children and create a formula to localise the muscle-tendon junction accurately. Methods 10 children with di/hemiplegia (range 2-14y) were recruited. None of them had received any conventional medical treatment. An equal number of age/sex matched, typically developing children (range 4-14y) were recruited. Ultrasound scanning of the gastrocnemius muscle at rest was performed to measure the length of gastrocnemius bellies. We also measured the heights and leg lengths in all the children. Results The gastrocnemius medial muscles were shorter in Cerebral Palsy children when compared to similar aged normal children. In cerebral palsy children, the gastrocnemius muscle and leg ratio ranged between 35 to 50% (average ratio of 45%). Conclusion Using these figures, we created an average percentage for gastrocnemius muscle length that may be used clinically to identify the tendon for open/endoscopic lengthening and also to make simple and accurate localisation of gastrocnemius muscle-tendon junction for surgical access. This decreases the length of the surgical incision and may reduce the risk of iatrogenic injuries.

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Muhammad Naghman Choudhry

Papers

Adolescent Idiopathic Scoliosis

Managing Bony Defects of the Shoulder Joint that Occur in Association with Dislocation

Outcome of Scapulothoracic Arthroscopy for Painful Snapping Scapula.

Authors' response to the letter re: Evidence based treatment for unstable slipped upper femoral epiphysis: Systematic review and exploratory patient level analysis.

in vivo Gastrocnemius Muscle) Tendon Ratio in Patients with Cerebral Palsy.