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Title: Posterior Bone Block Versus Arthroscopic Posterior Labral Repair for Primary Posterior Shoulder Instability Procedures
Background: Posterior instability is more common than reported in the past, and posterior shoulder instability procedures are becoming more frequent. A majority of primary posterior instability procedures are arthroscopic labral repairs. However, subcritical posterior bone loss is being recognized with greater frequency; and, not addressing this surgically has been shown to lead to higher failure rates. Therefore, many surgeons now have a lower threshold for proceeding with a posterior bone block procedure.
Purpose: The purpose of our study is to compare the results of arthroscopic posterior labral repair with posterior bone block procedures for primary posterior shoulder instability procedures performed at our institution.
Methods/ Results: A retrospective medical record review was performed of all posterior shoulder instability procedures performed by four shoulder surgeons at The Ohio State University between 2012 and 2024 with at least 2 year-follow up. We identified 451 patients who underwent arthroscopic posterior labral repair. We then identified 18 patients who had undergone a posterior bone block procedure with 12 of these cases being the primary surgery and 6 being a revision surgery. We will report on the patient reported outcomes and failure rates (recurrent subluxation or dislocation and reoperation). We will evaluate the outcomes for any statistically significant differences between arthroscopic posterior labral repair patients and posterior bone block patients. We will also evaluate for the presence and measure the degree of pre-operative posterior glenoid bone in each group and compare the degree of bone loss between the groups.
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Abstract
Objectives
Stemless total shoulder arthroplasty (TSA) is designed to reduce invasiveness compared with stemmed TSA, potentially improving recovery and preserving bone stock. While short-term outcomes suggest comparable function, long-term return-to-sport (RTS) rates and patient-reported outcomes (PROs) in active patients remain understudied. This study aimed to evaluate RTS rates, functional outcomes, and complications after stemless TSA at a minimum 1-year follow-up.
Methods
After institutional review board approval, we identified 401 patients who underwent primary stemless TSA by four board-certified sports medicine orthopedic surgeons at a single institution from January 2012 to December 2023. Inclusion criteria required a minimum 1-year follow-up and no prior shoulder surgery on the operative side. Patients were contacted by phone to provide informed consent and complete a validated RTS survey assessing sport type, level, and limitations. Retrospective chart review collected demographics, range of motion (ROM), strength (graded 0–5), and PROs, including Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES) score, and Visual Analog Scale (VAS) for pain, at preoperative, 3-, 6-, 12-, and 24-month intervals. PROs were available for 94 patients, with 29 including 24-month outcomes. Complications and reoperations were recorded.
Results
Of 401 patients, 167 (169 shoulders; mean age, 61.24 years; 130 males [78.3%], 30 females [18.1%]; follow-up range, 13.9-104.1 months) were enrolled. Pre-TSA, 157 patients participated in sports. Post-TSA, 141 (89.8%) returned to sport at a mean of 6.6 months. One patient-initiated sports post-TSA. RTS rates ranged from 0% (squash, 0/1) to 84.5% (gym, 82/97). Golf (53/69, 76.8%) and swimming (26/35, 74.3%) also had high RTS rates. Of returnees, 69 (48.9%) resumed at their preoperative level, 29 (20.9%) at a higher level, and 43 (30.2%) at a lower level; 43 (25.7%) reported persistent shoulder limitations (e.g., pain, weakness). SANE, ASES, and VAS scores improved significantly from preoperative to 24 months with an average improvement of 52.65, 46.34, and 5.03, respectively, in scores (p=<0.001); scores were better at each time period for the group who participated in sports post-TSA, compared to the non-sports participants post-TSA. ROM (forward flexion, abduction, external rotation) also significantly increased from preoperative to post-op (p=<0.001, <0.002, 0.002). Fourteen complications occurred in 12 patients (7.1%): 2 nerve injuries, 2 infections, 3 conversions to reverse TSA, 1 manipulation and capsular release for adhesive capsulitis, 2 thromboses (1 pulmonary embolism, 1 superficial vein thrombosis), 2 postoperative rotator cuff tears, and 2 proximal humerus fractures. Five patients (3.0%) required reoperation, including 2 for infection, 3 conversions to reverse (1 due to infection), and 1 manipulation and capsular release.
Conclusion
Stemless TSA facilitates a high RTS rate (89.8%) within 7 months, with nearly 70% of patients returning to their preoperative or higher sport level. Improvements in PROs and ROM in sports participants support its efficacy for active patients with shoulder pathology. However, 25.7% of patients reported ongoing limitations during sports, and the 9.0% complication rate highlights the importance of patient selection and postoperative rehabilitation. These findings suggest stemless TSA is a viable option for sports medicine populations but warrant further comparison with stemmed TSA to optimize outcomes.
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Introduction: Improving patient access to care is one of the most important issues in the Canadian Healthcare System.
Purpose: 1. Develop a tool to triage, screen and diagnose shoulder conditions on-line. The Shoulder trIaGe, screeNing and diAgnostic tooL (SIGNAL)
2. To measure intra and inter-rater reliability of this tool using multiple observers.
3. To apply the tool prospectively using different observers to evaluate diagnostic agreement in a busy shoulder clinic setting.
Methods:
1. A shoulder specific tool was developed through adaptation of a validated knee injury on-line assessment tool and with an experienced consensus group to establish face and content validity.
2. Four clinicians retrospectively and independently evaluated the tool on 205 patients with shoulder complaints. Intra and inter-rater reliability were assessed on a sample of randomly selected patients (N=103). Diagnostic agreement was determined for each clinician with the final diagnosis. The tool was modified and then prospectively evaluated in a second cohort of patients presenting with shoulder complaints.
3. The on-line tool was implemented in a patient self-referral clinic. Information from the SIGNAL was independently assessed by both two-person clinical team a Physician (MD) and Non-Physician Expert (NPE). Diagnostic agreement between observers, at three stages was measured. Stage one looking at only on-line information to determine the diagnosis. Stage 2 compared the on-line diagnosis to the in-person team (MD and NPE) assessment which included the physical examination +/- diagnostic investigations. Stage 3 analysed the agreement between the MD, the NPE and the team diagnoses compared to the reference final diagnosis.
4. All patients were asked to respond to a Patient-Reported Experience Measure.
Results: Intra-rater reliability was Moderate (0.5) to Substantial 0.7) Inter-rater reliability Fair at 0.4. The diagnostic agreement averaged 77% in the retrospective cohort. 432 patients consented to be part of the prospective cohort study. The average age was 53 with 62% males. The diagnostic agreement between the Physician and Non-Physician Expert (NPE) was 76.5% on the initial SIGNAL information. The NPE agreed with the final diagnosis 75% of the time with the physician 77% of the time. Overall, the team assessment agreed with the final diagnosis 98% of the time. Patient experience strongly agreed with recommending this type of clinic at 89%, with confidence in the providers at 91%, felt they were informed of their diagnosis and care plan at 87% and that the providers took time to understand their clinical condition at 90%.
Discussion: This study demonstrates consistency with respect to multiple provider clinicians being able to utilize on-line information to diagnose patients presenting with shoulder conditions. The self-referral process provides direct access for patients, and the SIGNAL on-line tool likely improves efficiency for the clinical team while still providing a highly effective patient experience.
Conclusions: This study provides strong evidence to support a new model of healthcare delivery for patients with shoulder complaints. This model includes patient self-referral, with an on-line clinical tool to provide relevant and diagnostically valid information to support a clinical team approach to care.
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Tendon augmentation is needed in Lower Trap Transfer rectus femoralis is an easy tendon to harvest with low morbitity
Description of a new technique
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We encountered a central glenoid cartialge tear (20 x 20 cm) in a 19 YO collegiate baseball catcher who could no longer throw or participate in baseball. No history of instability or labral damage. This was treated with arthroscopic curratage bone grafting and cartialge repair fibrin glue with return to baseball 6 months post-op.
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