There is no simple method available to identify patients who will develop recurrent instability after an arthroscopic Bankart procedure and who would be better served by an open operation. We carried out a prospective case-control study of 131 consecutive unselected patients with recurrent anterior shoulder instability who underwent this procedure using suture anchors. At follow-up after a mean of 31.2 months (24 to 52) 19 (14.5%) had recurrent instability. The following risk factors were identified: patient age under 20 years at the time of surgery; involvement in competitive or contact sports or those involving forced overhead activity; shoulder hyperlaxity; a Hill-Sachs lesion present on an anteroposterior radiograph of the shoulder in external rotation and/or loss of the sclerotic inferior glenoid contour. These factors were integrated in a 10-point pre-operative instability severity index score and tested retrospectively on the same population. Patients with a score over 6 points had an unacceptable recurrence risk of 70% (p < 0.001). On this basis we believe that an arthroscopic Bankart repair is contraindicated in these patients, to whom we now suggest a Bristow-Latarjet procedure instead.

The instability severity index score: A SIMPLE PRE-OPERATIVE SCORE TO SELECT PATIENTS FOR ARTHROSCOPIC OR OPEN SHOULDER STABILISATION

J Bone Joint Surg [Br] 2007;89-B:1470-7. Received 27 November 2006; Accepted after revision 22 May 2007 There is no simple method available to identify patients who will develop recurrent instability after an arthroscopic Bankart procedure and who would be better served by an open operation. We carried out a prospective case-control study of 131 consecutive unselected patients with recurrent anterior shoulder instability who underwent this procedure using suture anchors. At follow-up after a mean of 31.2 months (24 to 52) 19 (14.5%) had recurrent instability. The following risk factors were identified: patient age under 20 years at the time of surgery; involvement in competitive or contact sports or those involving forced overhead activity; shoulder hyperlaxity; a Hill-Sachs lesion present on an anteroposterior radiograph of the shoulder in external rotation and/or loss of the sclerotic inferior glenoid contour. These factors were integrated in a 10-point pre-operative instability severity index score and tested retrospectively on the same population. Patients with a score over 6 points had an unacceptable recurrence risk of 70% (p < 0.001). On this basis we believe that an arthroscopic Bankart repair is contraindicated in these patients, to whom we now suggest a Bristow-Latarjet procedure instead.

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A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation

The second international consensus conference on the scapula was held in Lexington Kentucky. The purpose of the conference was to update, present and discuss the accumulated knowledge regarding scapular involvement in various shoulder injuries and highlight the clinical implications for the evaluation and treatment of shoulder injuries. The areas covered included the scapula and shoulder injury, the scapula and sports participation, clinical evaluation and interventions and known outcomes. Major conclusions were (1) scapular dyskinesis is present in a high percentage of most shoulder injuries; (2) the exact role of the dyskinesis in creating or exacerbating shoulder dysfunction is not clearly defined; (3) shoulder impingement symptoms are particularly affected by scapular dyskinesis; (4) scapular dyskinesis is most aptly viewed as a potential impairment to shoulder function; (5) treatment strategies for shoulder injury can be more effectively implemented by evaluation of the dyskinesis; (6) a reliable observational clinical evaluation method for dyskinesis is available and (7) rehabilitation programmes to restore scapular position and motion can be effective within a more comprehensive shoulder rehabilitation programme.

https://bjsm.bmj.com/content/bjsports/47/14/877.full.pdf

Clinical implications of scapular dyskinesis in shoulder injury: the 2013 consensus statement from the ‘scapular summit’

Acromioclavicular joint injuries and, more specifically, separations are commonplace both in general practice and during athletic participation. This article reviews the traditional classification as well as the clinical evaluation of patients with acute and chronic acromioclavicular joint separations. It also highlights many recent advances, principally in the anatomy and biomechanics of the acromioclavicular joint ligamentous complex. The concept of increases in superior translation as well as disturbances in horizontal translation with injuries to this joint and ligaments are discussed. This information, coupled with the unpredictable long-term results with the Weaver-Dunn procedure and its modifications, have prompted many recent biomechanical studies evaluating potential improvements in the surgical management of acute and chronic injuries. The authors present these recent works investigating cyclic loading and ultimate failure of traditional reconstructions, augmentations, use of free graft, and the more recent anatomic reconstruction of the conoid and trapezoid ligaments. The clinical results (largely retrospective), including acromioclavicular joint repair, reconstruction and augmentation with the coracoclavicular ligament, supplemental sutures, and the use of free autogenous grafts, are summarized. Finally, complications and the concept of the failed distal clavicle resection and reconstruction are addressed. The intent is to provide a current, in-depth treatise on all aspects of acromioclavicular joint complex injuries to include anatomy, biomechanics, benchmark studies on instability and reconstruction, clinical and radiographic evaluation, and to present the most recent clinical research on surgical outcomes.

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Evaluation and Treatment of Acromioclavicular Joint Injuries

Objectives To identify common recommendations for high-quality care for the most common musculoskeletal (MSK) pain sites encountered by clinicians in emergency and primary care (spinal (lumbar, thoracic and cervical), hip/knee (including osteoarthritis [OA] and shoulder) from contemporary, high-quality clinical practice guidelines (CPGs). Design Systematic review, critical appraisal and narrative synthesis of MSK pain CPG recommendations. Eligibility criteria Included MSK pain CPGs were written in English, rated as high quality, published from 2011, focused on adults and described development processes. Excluded CPGs were for: traumatic MSK pain, single modalities (eg, surgery), traditional healing/medicine, specific disease processes (eg, inflammatory arthropathies) or those that required payment. Data sources Four scientific databases (MEDLINE, Embase, CINAHL and Physiotherapy Evidence Database) and four guideline repositories. Results 6232 records were identified, 44 CPGs were appraised and 11 were rated as high quality (low back pain: 4, OA: 4, neck: 2 and shoulder: 1). We identified 11 recommendations for MSK pain care: ensure care is patient centred, screen for red flag conditions, assess psychosocial factors, use imaging selectively, undertake a physical examination, monitor patient progress, provide education/information, address physical activity/exercise, use manual therapy only as an adjunct to other treatments, offer high-quality non-surgical care prior to surgery and try to keep patients at work. Conclusion These 11 recommendations guide healthcare consumers, clinicians, researchers and policy makers to manage MSK pain. This should improve the quality of care of MSK pain.

https://bjsm.bmj.com/content/bjsports/54/2/79.full.pdf

What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review

BackgroundThere are not many reports in the literature about the long-term outcomes in terms of recurrence and degenerative changes after arthroscopic capsulolabral reconstruction for anterior shoulder instability.PurposeThe aim of this study was to evaluate long-term follow-up (minimum 10 years) of arthroscopic suture-anchor repair for traumatic unidirectional anterior instability, with special emphasis on the radiological evidence of arthritis and clinical outcome.Study DesignCase series; Level of evidence, 4.MethodsForty-two patients (43 shoulders) treated at our institute from 1995 to 1997 were included in the study. Thirty patients (31 shoulders) were available for clinical and radiological examination (71%). The mean follow-up was 10.9 years (range, 9.8-14.3 years). Patients were evaluated preoperatively and after surgery using the University of California, Los Angeles (UCLA), Simple Shoulder Test (SST), and Rowe score. Patient satisfaction was determined by asking the patients if they would do this...

Arthroscopic Bankart Suture-Anchor Repair Radiological and Clinical Outcome at Minimum 10 Years of Follow-up

Grade I and II acromioclavicular dislocations: results of conservative treatment.

Summary Objectives: To evaluate the results of retrograde percutaneous screw fixation (PSF) in minimally or undisplaced acetabular fractures in a geriatric population. Patients and method: Between July 1998 and July 2001, 21 consecutive patients with an acetabular fracture underwent fluoroscopic guided percutaneous fixation. The mean age was 81 years (range 67–90 years). In all cases, the fracture was minimally or undisplaced ( Results: Eighteen patients were reviewed at a mean of 3.5 years (range 2–5 years). Soft tissue dissection was minimal. There were no intraoperative or postoperative complications. At the latest follow-up there was no radiographical evidence of secondary displacement of fragments, degenerative changes, or screw failure. Fractures healed at a mean time of 12 weeks (range 8–15 weeks). Clinical results were satisfactory in 17 patients. Conclusion: Our results show that percutaneous screw fixation under fluoroscopic control is a safe technique to treat some pattern of acetabular fracture.

Percutaneous retrograde screwing for stabilisation of acetabular fractures.

Purpose: To evaluate the cause of recurrent pathologic instability after anterior cruciate ligament (ACL) surgery and the effectiveness of revision reconstruction using a quadriceps tendon autograft using a 2-incision technique. Type of Study: Retrospective follow-up study. Methods: Between 1999 and 2001, 31 patients underwent ACL revision reconstruction because of recurrent pathologic instability during sports or daily activities. Twenty-eight patients were reviewed after a mean follow-up of 4.2 years (range, 3.3 to 5.6 years). The mean age at revision surgery was 27 years (range, 18 to 41 years). The average time from primary procedure to revision surgery was 26 months (range, 9 to 45 months). A clinical, functional, and radiographic evaluation was performed. Also magnetic resonance imaging (MRI) or computed tomography (CT) scanning was performed. The International Knee Documentation Committee (IKDC), Lysholm, and Tegner scales were used. A KT-1000 arthrometer measurement (MEDmetric, San Diego, CA) by an experienced physician was made. Results: Of the failures, 79% had radiographic evidence of malposition of their tunnels. In only 6 cases (21%) was the radiologic anatomy of tunnel placement judged to be correct on both the femoral and tibial side. The MRI or CT showed, in 6 cases, a too-centrally placed femoral tunnel. After revision surgery, the position of tunnels was corrected. A significant improvement of Lachman and pivot-shift phenomenon was observed. In particular, 17 patients had a negative Lachman test, and 11 patients had a grade I Lachman with a firm end point. Preoperatively, the pivot-shift test was positive in all cases, and at last follow-up in 7 patients (25%) a grade 1+ was found. Postoperatively, KT-1000 testing showed a mean manual maximum translation of 8.6 mm (SD, 2.34) for the affected knee; 97% of patients had a maximum manual side-to-side translation Conclusions: There were satisfactory results after ACL revision surgery using quadriceps tendon and a 2-incision technique at a minimum 3 years' follow-up; 93% of patients returned to sports activities. Level of Evidence: Level IV, case series, no control group.

Revision anterior cruciate ligament reconstruction with quadriceps tendon-patellar bone autograft.

This article describes the anatomical two-incision reconstruction of anterior cruciate ligament (ACL) of knee. The major part of currently single incision tibial endoscopic techniques attempts to reproduce the most isometric anteromedial bundle of ACL. Often a relatively vertical femoral tunnel, respect to the notch, is drilled, which is not really efficacious in providing rotatory stability. The single incision technique was developed to obviate the necessity of the lateral femoral incision and dissection. This technical note describes a two-incision ACL reconstruction using an instrumentation, which avoids a large lateral femoral soft tissue dissection, and discusses the rational use of the two-incision ACL reconstruction technique.

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Raffaele Garofalo

Papers

Arthroscopic Bankart Suture-Anchor Repair Radiological and Clinical Outcome at Minimum 10 Years of Follow-up

Grade I and II acromioclavicular dislocations: results of conservative treatment.

Percutaneous retrograde screwing for stabilisation of acetabular fractures.

Revision anterior cruciate ligament reconstruction with quadriceps tendon-patellar bone autograft.

Anatomic anterior cruciate ligament reconstruction: the two-incision technique