Timothy S. Mologne

Arthroscopic Stabilization in Patients With an Inverted Pear Glenoid: Results in Patients With Bone Loss of the Anterior Glenoid

Background Recent literature has demonstrated that the success rates of arthroscopic stabilization of glenohumeral instability deteriorate in patients with an anteroinferior glenoid bone deficiency, also known as the “inverted pear” glenoid. Purpose This study was conducted to assess the outcomes of arthroscopic stabilization for recurrent anterior shoulder instability in patients with a mean anteroinferior glenoid bone deficiency of 25% (range, 20%-30%). Study Design Cohort study; Level of evidence, 3. Methods Twenty-one of 23 patients (91% follow-up) undergoing arthroscopic stabilization surgery and noted to have a bony deficiency of the anteroinferior glenoid of 20% to 30% were reviewed at a mean follow-up of 34 months (range, 26-47). The mean age was 25 years (range, 20-34); 2 patients were female and 19 were male. All patients were treated with a primary anterior arthroscopic stabilization using a mean of 3.2 suture anchors (range, 3-4). Eleven patients had a bony Bankart that was incorporated into the repair; 10 had no bone fragment and were considered attritional bone loss. Outcomes were assessed using the Rowe score, the American Shoulder and Elbow Surgeons (ASES) Score, the Single Assessment Numeric Evaluation (SANE), and the Western Ontario Shoulder Instability (WOSI) Index. Findings of recurrent instability and dislocation events were documented. Results Two patients (9.5%) experienced symptoms of recurrent subluxation, and 1 (4.8%) sustained a recurrent dislocation that required revision open surgery. The mean postoperative outcomes scores were as follows SANE = 88.1 (range, 65-100; standard deviation [SD] 9.0); Rowe = 85.2 (range, 55-100; SD 14.1); ASES Score = 93.1 (range, 78-100; SD 5.3); and WOSI Index = 398 (82% of normal; range, 30-1175; SD 264). No patient with a bony fragment experienced a recurrent subluxation or dislocation, and mean outcomes scores for patients with a bony fragment were better than those with no bony fragment (P = .08). No patient required medical discharge from the military for his or her shoulder condition. Conclusions Arthroscopic stabilization for recurrent instability, even in the presence of a significant bony defect of the glenoid, can yield a stable shoulder; however, outcomes are not as predictable especially in attritional bone loss cases. Longer-term follow-up is needed to see if these results hold up over time.

The Modified Bristow Procedure for Anterior Shoulder Instability 26-Year Outcomes in Naval Academy Midshipmen

Background Many procedures have been proposed for the correction of anterior shoulder instability. Some of these procedures address the problem anatomically, such as the Bankart procedure, and some prevent instability nonanatomically, such as the Bristow-Latarjet procedure. A modified Bristow procedure was the procedure of choice for anterior shoulder instability among midshipmen at the United States Naval Academy from 1975 to 1979. Hypothesis The modified Bristow procedure for anterior shoulder instability provides good shoulder function and stability in the long term. Study Design Case series; Level of evidence, 4. Methods There were 52 shoulders in 49 patients reviewed at a mean follow-up of 26.4 years. The Rowe score, Single Assessment Numeric Evaluation, and Western Ontario Shoulder Instability Index were used to assess outcomes. Results The mean Rowe score was 81.8 (range, 5-100), and the mean Single Assessment Numeric Evaluation score was 82.9 (range, 30-100), with an overall Single Assessment Numeric Evaluation of 71.2% (37 of 52 shoulders) rated as good and excellent. The mean Western Ontario Shoulder Instability Index was 376 of 2100 (range, 0-1560). Overall, recurrent instability occurred in 8 of 52 shoulders (15.4%), with recurrent dislocation in 5 shoulders (9.6%) and recurrent subluxation in 3 shoulders (5.8%). The mean time to recurrent dislocation was 7.0 years. Conclusion This study represents the longest follow-up in the literature of the modified Bristow procedure. The authors have shown nearly 70% good and excellent results and recurrent instability comparable with other long-term follow-up studies of open instability procedures.

Twenty-six-year results after broström procedure for chronic lateral ankle instability

Background The procedure described by Broström has been used to address chronic lateral ankle instability; the long-term results of this procedure have not been reported. Hypothesis The Broström procedure provides good results over the long term for active patients with chronic lateral ankle instability. Study Design Case series; Level of evidence, 4. Methods Thirty-one male patients (32 ankles) who underwent the Broström procedure for chronic lateral ankle instability while enrolled as students at the United States Naval Academy were identified. Each patient was mailed a questionnaire that included a functional outcome measure as described by Roos et al, a score described by Good et al, and a single-number ankle functional assessment. The mean age was 20.7 years (range, 18-23 years) at the time of operation. A functional outcome score was completed on each patient, with a mean follow-up of 26.3 years (range, 24.6-27.9 years). Results The follow-up included 22 of the 31 original patients. The mean numeric score for overall ankle function was 91.2 of 100 (standard deviation, 10.2). The foot and ankle outcome score (described by Roos et al) was 92.0 (92%; standard deviation, 12.8) averaged over 5 functional areas. Ninety-one percent of the patients described their ankle function as good or excellent using the scale devised by Good et al. Conclusion The long-term results of the Broström procedure for chronic lateral ankle instability are excellent with 26-year follow-up.

Early Screw Fixation Versus Casting in the Treatment of Acute Jones Fractures

Background There is considerable variability in the literature concerning the optimal treatment of acute Jones fractures. Hypothesis Early surgical fixation of acute Jones fractures will result in shorter times to union and return to athletics compared with cast treatment. Study Design Randomized controlled clinical trial; Level of evidence, 1. Methods Eighteen patients were randomized to cast treatment, and 19 patients were randomized to screw fixation. Success of treatment and the times to union and return to sports were calculated for each patient. Results Mean follow-up was 25.3 months (range, 15-42 months). Eight of 18 (44%) in the cast group were considered treatment failures: 5 nonunions, 1 delayed union, and 2 refractures. One of 19 patients in the surgery group was considered a treatment failure. For the surgery group, the median times to union and return to sports were 7.5 and 8.0 weeks, respectively. For the cast group, the median times were 14.5 and 15.0 weeks, respectively. The Mann-Whitney test showed a statistically significant difference between the groups in both parameters, with P <. 001. Conclusion There is a high incidence (44%) of failure after cast treatment of acute Jones fractures. Early screw fixation results in quicker times to union and return to sports compared with cast treatment.

Arthroscopic Treatment of Posterior Shoulder Instability: Results in 33 Patients

Background Posterior shoulder instability is a relatively rare condition and a surgical challenge. Arthroscopic techniques have allowed for a potential improvement as well as diagnosis and management of this condition. Purpose To evaluate the outcomes of arthroscopic posterior shoulder stabilization and to evaluate preoperative and intraoperative variables as predictors of success. Study Design Case series; Level of evidence, 4. Methods Thirty-three consecutive patients with a mean age of 25 years (range, 19-34 years) who underwent posterior arthroscopic shoulder stabilization with suture anchors (mean, 3 anchors) or suture capsulolabral plication (mean, 5.3 stitches) or both were reviewed at a mean follow-up of 39.1 months (range, 22-60 months). Shoulder outcomes rating scores were determined using the American Shoulder and Elbow Surgeons Rating Scale, the Western Ontario Shoulder Instability Index, the Subjective Patient Shoulder Evaluation, and the Single Assessment Numeric Evaluation. Results There were 7 failures: 4 for recurrent instability and 3 for symptoms of pain. Overall, outcomes scores demonstrated mean values of the American Shoulder and Elbow Surgeons Rating Scale of 94.6, Subjective Patient Shoulder Evaluation of 20.0, Western Ontario Shoulder Instability Index of 389.4 (81.5% of normal), and Single Assessment Numeric Evaluation of 87.5. Patients with voluntary instability demonstrated worse outcomes (P=. 025), and those with prior surgery of the shoulder also did worse (P=. 02). Conclusion Arthroscopic treatment of posterior shoulder instability is an effective means to improve symptoms associated with recurrent posterior subluxation of the shoulder. It can provide predictable success in the setting of unidirectional, nonvoluntary posterior instability without prior surgery.

Posterior Instability of the Shoulder Diagnosis and Management

Recurrent posterior instability of the shoulder can be difficult to diagnose and technically challenging to treat. Although not as common as anterior instability, recurrent posterior shoulder instability is prevalent among certain demographic and sporting groups, and may be overlooked if one is not aware of the typical examination and radiographic findings. The diagnosis itself can be difficult as patients typically present with vague or confusing symptoms, and treatment has evolved from open to arthroscopic surgical techniques. This article is intended to review the anatomy and biomechanics associated with posterior shoulder instability, to discuss the pathogenesis and presentation of posterior instability, and to describe the variety of treatment options and clinical results.

The Addition of Rotator Interval Closure After Arthroscopic Repair of Either Anterior or Posterior Shoulder Instability Effect on Glenohumeral Translation and Range of Motion

Background Although the use of rotator interval closure is frequently advocated as a useful supplement to shoulder instability repairs, the addition of a rotator interval closure after arthroscopic instability repair has not been fully investigated. Purpose The objective of this study was to investigate whether a rotator interval closure improves glenohumeral stability in an anterior and posterior instability shoulder model. Study Design Controlled laboratory study. Methods Fourteen fresh-frozen cadaveric shoulder specimens were dissected free of soft tissues, leaving the rotator cuff intact with simulated cuff loading. All specimens were mounted in a custom testing apparatus using infrared sensors to document glenohumeral translation and rotation. The specimens were then tested for stability in the following order: vented/subluxated state, after arthroscopic anterior (Group 1; 7 specimens) or posterior (Group 2; 7 specimens) instability repair with suture anchors, and then after rotator interval closure. For each of the 3 testing conditions, the following were measured: (1) external and internal rotation at neutral, (2) external and internal rotation at 90° of abduction, (3) posterior and anterior translation at neutral rotation (15 N and 25 N), (4) anterior translation at 90° of abduction and external rotation (Group 1; 15 N and 25 N), (5) posterior translation at 90° of flexion and internal rotation (Group 2; 15 N and 25 N), and (6) sulcus testing in neutral (7.5 N). Results Posterior stability was only improved after anchor capsulolabral repair (8.0 to 5.0 mm; P = .017, 25 N), but there was no improvement after rotator interval closure (5.0 to 4.6 mm; P = .453). However, anterior stability was improved after capsulolabral repair (8.6 to 4.0 mm; P = .016, 25 N) and also improved further by rotator interval closure (4.0 to 2.4 mm; P = .007). The mean loss of external rotation was significantly increased by the addition of the rotator interval closure in both neutral and abducted glenohumeral positions, with a mean external rotation loss of 28° in neutral (P = .013). The addition of a rotator interval closure did not improve sulcus stability (P = .4). Conclusion The addition of an arthroscopic rotator interval closure after posterior capsulolabral repair did not improve posterior stability; however, anterior stability was improved further after a rotator interval closure. Inferior stability was not improved. Arthroscopic rotator interval closure significantly decreased external rotation at both neutral and abducted arm positions. Clinical Relevance Arthroscopic closure may be beneficial in certain cases of anterior shoulder instability; however, posterior instability was not improved. Predictable losses of external rotation after rotator interval closure are of concern.

Long-Term Evaluation of the Roux-Elmslie-Trillat Procedure for Patellar Instability A 26-Year Follow-up

Background Few published articles exist reporting the long-term evaluation of the Roux-Elmslie-Trillat procedure. Purpose To assess the long-term effect of the Roux-Elmslie-Trillat procedure in preventing recurrent subluxation and dislocation of the patella. Study Design Case series; Level of evidence, 4. Methods Eighteen patients who underwent the Roux-Elmslie-Trillat procedure for dislocation or subluxation of the patella were identified from a group previously evaluated at a mean follow-up of 3 years. The prevalence of recurrent subluxation or dislocation at a mean follow-up of 26 years was compared with the prevalence reported at the mean follow-up of 3 years. Although not the focus of this study, Cox functional scores were obtained from the smaller group and compared with the results at the 3-year follow-up. Results Seven percent (95% confidence interval, 0.00-0.32) of the patients had recurrent subluxation at 26 years compared with 7% (95% confidence interval, 0.03-0.13) of the study population reported at 3 years (P = 1.00). Fifty-four percent (95% confidence interval, 0.27-0.79) rated their affected knee as good or excellent at 26 years compared with 73% (95% confidence interval, 0.64-0.81) of the larger study population reported at 3 years (P = .14). Conclusion The prevalence of recurrent subluxation and dislocation in patients with patellofemoral malalignment who underwent the Roux-Elmslie-Trillat procedure for dislocation or subluxation of the patella is similar at 3 and 26 years after the procedure. The long-term functional status of the affected knee in patients who underwent the Roux-Elmslie-Trillat procedure declined.

Assessment of Failed Arthroscopic Anterior Labral Repairs Findings at Open Surgery

To assess capsulolabral lesions present in patients after unsuccessful arthroscopic procedures, we re viewed the records of 20 patients who had undergone open shoulder procedures after unsuccessful arthro scopic Bankart procedures for chronic shoulder insta bility. The Bankart lesion had initially been repaired arthroscopically by transglenoid sutures (N = 10), bio absorbable tacks (N = 7), suture anchors (N = 2), or arthroscopic screws (N = 1). Five of the 20 patients (25%) had reinjuries to the shoulder after the arthro scopic procedure. The average time from the arthro scopic to the open procedure was 17.9 months. Over all, 12 of the 20 patients (60%) had healed Bankart lesions at the time of open surgery. Eight of the 20 patients (40%) were found to have persistent Bankart lesions, and 15 of the 20 patients (75%) were found to have redundant anterior capsules. The presence of a persistent Bankart lesion significantly correlated with postarthroscopic dislocation, and the presence of cap sular laxity significantly correlated with postarthro scopic subluxation. We concluded that capsular laxity is difficult to quantify arthroscopically and is present in a significant percentage of patients with chronic trau matic shoulder instability. Failure to successfully treat either the Bankart lesion or capsular laxity at the time of an arthroscopic Bankart procedure may lead to post operative instability.

Newborn Clavicle Fractures

A prospective screening program of 9106 newborns identified 43 infants with clavicle fractures for a prevalence of 1 fracture in every 213 live births (0.5%). The fractures were equally distributed by right and left side involvement, and male and female sex. All fractures occurred during vaginal deliveries. None were breech presentation. Risk factors for fracture included large birth-weight, shoulder dystocia, mechanically assisted delivery, and prolonged gestational age. One in 11 newborns with a clavicle fracture also had a brachial plexus palsy.