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Batter's shoulder is characterized by posterior shoulder instability in the lead (front) shoulder of a batting athlete. This most commonly occurs as a discrete event, particularly a swing and miss at an outside pitch, which leads to an episode of shoulder subluxation. A thorough history and physical examination is key to diagnosis, with patients feeling pain and instability of the lead shoulder when attempting the baseball swing or during pushing-type activities, as well as positive posterior labral signs in tests such as the Kim, jerk, and modified dynamic labral shear tests. Magnetic resonance imaging can confirm the diagnosis of posterior labral tear and may show concomitant pathologies such as a reverse Hill-Sachs lesion. Nonsurgical treatment is directed at rotator cuff and scapular strengthening; however, arthroscopic posterior labral repair is often required for definitive stabilization. Overall, this is a relatively rare diagnosis, but outcomes of surgical repair are favorable with high satisfaction and rates of return to competition., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Shoulder glenohumeral joint dislocations and subluxations are a relatively common injury among athletic populations. Evaluating the patient both on the field initially and through early recovery helps to determine the best treatment strategies and predict the natural history of each unique injury., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

In the evaluation of shoulder instability, recognition of relevant pathology on imaging is critical to planning a surgical treatment that minimizes the risk for recurrent instability. The purpose of this review is to (1) discuss the use of radiography, computed tomography, and MRI in evaluating shoulder instability and (2) demonstrate how various imaging modalities are useful in identifying critical pathologies in the shoulder that are relevant for treatment., Competing Interests: Disclosure The authors report no relevant disclosures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

In-season management of anterior shoulder instability in athletes is a complex problem. Athletes often wish to play through their current season, though recurrent instability rates are high, particularly in contact sports. Athletes are generally considered safe to return to play when they are relatively pain-free, and their strength and range of motion match the uninjured extremity. If an athlete is unable to progress toward recovering strength and range of motion, surgical management is an option, though this is often a season-ending decision., Competing Interests: Disclosure B.R. Wolf is a board or committee member for the American Orthopedic Society for Sports Medicine, the American Board of Orthopedic Surgery, and the Mid-America Orthopedic Association. He is on the Editorial or Governing Board for the Orthopedic Journal of Sports Medicine. He receives IP royalties, is a paid consultant, or paid presenter/speaker for CONMED Linvatec. G.V. Christensen and O.C. O’Reilly certify that they have no disclosures., (Published by Elsevier Inc.)

Purpose: The Instability Severity Index (ISI) Score was developed to preoperatively assess the risk of recurrent shoulder instability after an arthroscopic Bankart repair. This study aims to validate the use of ISI Score for predicting the risk of recurrence after an arthroscopic Bankart repair in a heterogeneous population and proposes an appropriate cut-off point for treating patients with an arthroscopic Bankart repair or otherwise., Methods: This study analysed 99 shoulders after a traumatic dislocation that underwent arthroscopic Bankart repair with at least 3 years follow-up. Patients were divided into subcategories based on their respective ISI Score. Recurrence includes either a postoperative dislocation or perceived instability., Results: The overall recurrence rate was found to be 26.3%. A significant correlation was identified between ISI Score and the recurrence rate (odds ratio [OR]: 1.545, 95% confidence interval [CI]: 1.231-1.939, p < 0.001). Furthermore, ISI Score 4-6 (OR: 4.498, 95% CI: 1.866-10.842, p < 0.001) and ISI Score > 6 (OR: 7.076, 95% CI: 2.393-20.924, p < 0.001) both had a significantly higher risk of recurrence compared to ISI Score 0-3. In ISI Score subcategories 0-3, 4-6 and >6, the recurrence rate was, respectively, 15.4%, 40.7% and 71.4%., Conclusion: ISI Score has predictive value in determining the recurrence risk of shoulder instability following an arthroscopic Bankart repair in a heterogeneous population. Based on the findings of this study, we recommend using arthroscopic Bankart repair in patients with ISI Score 0-3. Clinical and shared decision-making are essential in the group with ISI Score 4-6, since the recurrence rate is significantly higher than in patients with ISI Score 0-3. Arthroscopic Bankart repair is not suitable for patients with ISI Score > 6., Level of Evidence: Level III., (© 2024 The Authors. Knee Surgery, Sports Traumatology, Arthroscopy published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

» Bony Bankart lesions are fractures of the anteroinferior glenoid rim, commonly associated with a traumatic anterior shoulder dislocation, and are diagnosed through radiological imaging and physical examination. Young male athletes playing contact sports are at highest risk of these injuries. Early diagnosis and treatment are crucial because, if left untreated, recurrent anterior shoulder instability and glenoid bone loss can occur. Both nonsurgical and surgical treatment options are available depending on the size of the lesion, with arthroscopic repair being the most common treatment method. After repair, patients typically have favorable outcomes with low rates of recurrent instability. This review aims to discuss the etiology, diagnosis, and treatment of bony Bankart lesions.» Bony Bankart lesions are fractures of the anteroinferior glenoid rim and occur in up to 22% of first-time anterior shoulder dislocations.» Young men involved in contact sports or combat training are at the highest risk of sustaining bony Bankart lesions.» Diagnosis and treatment of bony Bankart lesions are essential to prevent long-term shoulder instability.» Bony Bankart lesions can be treated either nonoperatively or operatively (arthroscopic vs open repair), with the size of the glenoid defect being the primary determinant of treatment., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/B89)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: The role of arthroscopic Latarjet as a revision surgery after failed arthroscopic Bankart repair has yet to be established., Purpose: To compare clinical outcomes, recurrences, and complication rates of arthroscopic Latarjet as a revision procedure after failed arthroscopic Bankart repair versus arthroscopic Latarjet as a primary procedure., Design: Cohort study; Level of evidence, 3., Methods: This is a retrospective study of prospectively collected data of patients who were diagnosed with anterior shoulder instability and underwent arthroscopic Latarjet stabilization between 2009 and 2018. Patients were separated into 2 groups depending on whether Latarjet was performed after a previous instability surgery (revision) or as a primary surgery (primary). Rowe score, Western Ontario Shoulder Instability Index (WOSI), Constant-Murley Shoulder Outcome (CMSO) score, and Single Assessment Numeric Evaluation (SANE) were assessed pre- and postoperatively with a minimum 24 months of follow-up. In addition, pre- and postoperative levels of sports activity, dislocations, subluxations, and complications were assessed., Results: A total of 97 patients (n = 62 revision; n = 35 primary), with a mean age of 31.0 ± 8.8 and 29.4 ± 7.6 years old in the revision and primary Latajet group, respectively, met the inclusion criteria. The mean follow-up in the revision group was 32 months (24-53) and 35.5 months (27.7-42.2) in the primary Latarjet group. No significant differences between groups were observed in Rowe score (revision = 91.4, primary = 94.1; P = .223), CMSO score (revision = 90.7, primary = 94; P = .105), and SANE (revision = 85.8, primary = 87.3; P = .683) postoperatively. However, the postoperative difference in the WOSI score between the revision and primary Latarjet groups was nearly significant (510 ± 334 vs 403 ± 343, respectively; P = .05). Four (6.4%) postoperative dislocations were reported in the revision and 1 (2.8%) in the primary Latarjet group ( P = .14). Patients in the revision group had a lower return to the previous level of sports participation ( P = .008) and decreased external rotation with the arm by the side compared with the primary Latarjet group ( P = .000)., Conclusion: Arthroscopic Latarjet as a revision surgery is a reasonable surgical option in failed Bankart repair cases. The decision to perform arthroscopic Latarjet stabilization as a revision surgery should not be influenced by the potential risk of future complications as it provides comparable clinical outcomes to the primary Latarjet procedure with a low postoperative recurrence rate. However, a decreased level of postoperative sports participation and external rotation with the arm by the side can be expected., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: E.C. has received consulting fees from DePuy Synthes, Smith & Nephew, and Stryker. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Introduction: Glenohumeral dislocations present a challenging management dilemma in austere settings where patient transport time may be prolonged. Expeditious reduction is preferable, but treatment is commonly expected to take place within a hospital or comparable facility. Through a novel shoulder injury program, professional ski patrollers trained as emergency medical technicians (EMTs) have diagnosed and reduced anterior shoulder dislocations using biomechanical techniques without sedation or analgesia for over 20 y. Summary records have been maintained to track the performance and safety of this program., Methods: Five hundred forty-six records of winter sports-related shoulder injuries from 2009-10 to 2019-20 were retrospectively analyzed to determine the assessment performance and dislocation reduction efficacy of EMTs, with the intent of ascertaining whether EMT-trained practitioners can reliably and safely diagnose and reduce anterior shoulder dislocations without premedication in a remote and resource-limited setting., Results: EMTs identified anterior shoulder dislocations with 98% sensitivity and 96% diagnostic accuracy. The overall success rate of reduction attempts was 86%, or 88% when limited to confirmed anterior dislocations. Two fracture-dislocations and 4 misdiagnoses were manipulated. No instances of iatrogenic harm were identified, and no patients who underwent successful reductions required ambulance transportation., Conclusions: With appropriate education and within a structured program, EMT-trained practitioners can reliably and safely diagnose and reduce anterior shoulder dislocations using biomechanical techniques without premedication in remote and resource-limited environments. Implementation of similar programs in austere settings has the potential to improve patient care. Further, using biomechanical reduction techniques may reduce reliance on procedural sedation irrespective of care setting., (Copyright © 2023 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

Out-of-hospital reduction of shoulder dislocations using the Campell method is recommended by the International Commission for Alpine Rescue and applied in the Bavarian Mountain Rescue Service (Bergwacht Bayern, BWB) protocols. This prospective observational study includes patients out-of-hospital with suspected shoulder dislocation and treated and evacuated by the BWB. Data were systematically collected using three questionnaires: one completed on-site by the rescuer, the second in hospital by the physician and the third within 28 (8-143) days after the accident by the patient. The suspected diagnosis of shoulder dislocation was confirmed in hospital in 37 (84%) of 44 cases. Concomitant injuries in other body regions were found in eight (16%) of 49 cases and were associated with incorrect diagnosis (p = 0.002). Younger age (p = 0.043) and first shoulder dislocation event (p = 0.038) were associated with a higher success rate for reduction attempts. Out-of-hospital reduction of shoulder dislocations leads to significant pain relief and no poorer long-term outcome. Signs that are associated with successful out-of-hospital reduction (younger age and first event), but also those that are associated with incorrect diagnosis (concomitant injuries) should be considered before trying to reduce shoulder dislocation on site. The considerable rate of incorrect first diagnosis on site should give rise to an intensive discussion around teaching and training for this intervention.Trial registration: This study is registered with the German Registry for Clinical Trials (DRKS00023377)., (© 2023. The Author(s).)

Traumatic anterior shoulder dislocation is a very common injury encountered in emergency rooms as well as in the primary health care physician's office. This injury occurs either in the setting of competitive or recreational sports injuries or as a high-energy injury during a fall or a road traffic accident. Common complications such as a recurrent dislocation can be predicted, monitored and prevented. Early appropriate treatment of associated cuff tears or fractures is associated with improved outcomes. There is a plethora of literature on the assessment and management of the primary anterior shoulder dislocation in specialised fields such as sports medicine, orthopaedic surgery and shoulder surgery. These studies are often highly technical, addressed to a particular subset of readers and often deal with one aspect of the management of the injury. This narrative aims to provide the reader with a simplified, evidence-based assessment and management approach for the first-time acute anterior shoulder dislocation. Emphasis is on closed reduction techniques, position and duration of immobilisation, and return to activities of life or sports. Risk factors for recurrence and other indications for primary referral to the orthopaedic surgeon are discussed. Other forms of shoulder instability such as posterior shoulder dislocation, inferior dislocation and multidirectional instability will not be the focus of this narrative.

Objectives: To assess the status at 13 to 17 years follow-up of a cohort of young male traumatic shoulder dislocators., Study Design: Prospective cohort study., Methods: A prospective study of first-time young male traumatic shoulder dislocators, began in 2004. Subjects were evaluated by the apprehension test after completing rehabilitation 6 to 9 weeks post dislocation. Between March 2021 and July 2022, a telephone questionnaire was administered to ascertain their current shoulder status. Subjects were questioned about avoidance of activities of daily living and sport, participation in sports, current instability, and self-assessed shoulder function by the SANE score., Results: 50/53 (94.3%) of the study subjects, mean age 20.4 years, completed a mean follow-up of 181.8 ± 12 months. The non-redislocation survival was 13% for those with a positive apprehension test and 49% for those with a negative test (p = 0.007). SANE scores were 64.3 ± 23.7 for those with a positive apprehension test and 83.7 ± 19.7 for those with a negative test (p = 0.001). In the year before the follow-up, 33.3% of those treated conservatively and 42.9% treated surgically experienced subluxation (p = 0.5). Fifty-seven percent of those who were treated conservatively and 56% of those who underwent surgery avoided some ADL or sports because of their shoulder., Conclusions: For young male first time traumatic shoulder dislocators a positive apprehension test after rehabilitation is associated with a high risk for reoccurrence and poorer long-term results. Most subjects were still dealing with shoulder symptoms at long-term follow-up., Competing Interests: Declaration of interest statement The authors declare that they have no competing interests., (Copyright © 2023 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

The shoulder joint is the most prone to dislocation in the whole body, and more than 95% of them are anterior dislocation. Improper treatment after the initial dislocation is easy to lead to recurrent anterior dislocation or anterior shoulder instability, and the outcomes following conservative treatment is poor. Anterior shoulder instability can damage the soft tissue structure and bone structure that maintain the stability of shoulder joint, among which bone structure is the most important factor affecting the stability of shoulder joint. Diagnosis should be combined with medical history, physical examination, and auxiliary examination. Currently, three-dimensional CT is the most commonly used auxiliary examination means. However, various bone defect measurement and preoperative evaluation methods based on three-dimensional CT and the glenoid track theory have their own advantages and disadvantages, and there is still a lack of gold standard. Currently, the mainstream treatment methods mainly include Bankart procedure, coracoid process transposition, glenoid reconstruction with free bone graft, Bankart combined with Remplissage procedure, and subscapular tendon binding tamponade, etc . Each of these procedures has its own advantages and disadvantages. For the diagnosis and treatment of anterior shoulder instability, there are still too many unknown, further research and exploration need to be studied.

Acute shoulder pain lasting less than six months is a common presentation to the primary care office. Shoulder injuries can involve any of the four shoulder joints, rotator cuff, neurovascular structures, clavicle or humerus fractures, and contiguous anatomy. Most acute shoulder injuries are the result of a fall or direct trauma in contact and collision sports. The most common shoulder pathologies seen in primary care are acromioclavicular and glenohumeral joint disease and rotator cuff injury. It is important to conduct a comprehensive history and physical examination to identify the mechanism of injury, localize the injury, and determine if surgical intervention is needed. Most patients with acute shoulder injuries can be treated conservatively using a sling for comfort and participating in a targeted musculoskeletal rehabilitation program. Surgery may be considered for treating middle third clavicle fractures and type III acromioclavicular sprains in active individuals, first-time glenohumeral dislocation in young athletes, and those with full-thickness rotator cuff tears. Surgery is indicated for types IV, V, and VI acromioclavicular joint injuries or displaced or unstable proximal humerus fractures. Urgent surgical referral is indicated for posterior sternoclavicular dislocations.

Bilateral posterior fracture-dislocation of the shoulder is an uncommon injury pattern usually caused by epileptic seizures. The cause of the seizure activity remains unknown in most cases, although the injury has been associated with several conditions. A 59-year-old man with uncontrolled hypertension presented with new-onset generalized tonic-clonic seizures. He was diagnosed with uremic encephalopathy and bilateral posterior fracture-dislocation of his shoulders. His medical condition required stabilization leading to a delay in definitive surgery and a subsequent poor outcome. This case highlights the previously unknown association between bilateral fracture-dislocation of the shoulders and seizures caused by uremic encephalopathy. In these complex situations with competing clinical priorities, it is important to initiate prompt treatment of the cause in any new-onset seizures, to facilitate expedient surgical management of the orthopaedic injury., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Purpose: The purpose of this study was to investigate the outcomes of conservative treatment for recurrent shoulder dislocation without subjective apprehension, despite the presence of a Bankart lesion or glenoid defect., Methods: A retrospective analysis was performed for 92 patients with recurrent shoulder dislocation treated with conservative treatment due to negative apprehension between 2009 and 2018. The failure of the conservative treatment was defined as a dislocation or subluxation episode or subjective feeling of instability based on a positive apprehension. The Kaplan-Meier method was used to estimate failure rates over time, and a receiver operating characteristic (ROC) curve was constructed to determine a cut-off value for a glenoid defect. The clinical outcomes were compared between patients who completed conservative treatment without recurrence of instability (Group A) and those who failed and subsequently underwent surgical treatment (Group B) using shoulder functional scores and sports/recreation activity level., Results: This retrospective study included 61 of 92 eligible patients with recurrent shoulder dislocation. Among the 61 patients, conservative treatment failed in 46 (75.4%) over the 2-year study period. The cut-off value for a glenoid defect was 14.4%. The association between glenoid defect size (≥ 14.4% or as a continuous variable) and survival was statistically significant (p = 0.039 and p < 0.001, respectively). The mean glenoid defect size in Group B increased from 14.6 ± 3.0% to 17.3 ± 3.1% (p < 0.001), and clinical outcomes for Group A were inferior to those for Group B at the 24-month follow-up., Conclusions: Conservative treatment for recurrent shoulder dislocation in patients without subjective apprehension showed a high failure rate during the study period, especially if the glenoid defect was ≥ 14.4% in size. Despite clinical improvement in patients who completed conservative treatment without recurrence, functional outcome scores and sport/recreation activity levels were better in the patients who underwent arthroscopic Bankart repair. Therefore, for recurrent anterior shoulder instability, even without subjective apprehension, surgical treatment is warranted over conservative treatment., Level of Evidence: Level IV., (© 2022. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Following anterior shoulder instability surgery, patients may present with new or recurrent symptoms. Postoperative imaging, including MR imaging, may be obtained for these patients to assess the integrity of the repaired tissues and orthopedic fixation hardware or grafts. Familiarity with different operative techniques and their expected normal appearances and complications helps in the appropriate interpretation of these imaging studies. This article provides an overview of the current treatment guidelines and surgery options for patients with anterior shoulder instability and reviews the normal and abnormal postoperative imaging appearances of the shoulder joint after treatment with the most common surgical stabilization techniques., Competing Interests: Disclosure None of the authors have any pertinent disclosures., (Copyright © 2022 Elsevier Inc. All rights reserved.)

After workers suffer electric shock, the ankylosis and contraction of muscle groups around the shoulder joint are more likely to lead to posterior dislocation and fracture, of which 80% are complicated with reverse Hill-Sachs injury of humeral head. This paper reports a case of bilateral posterior dislocation of shoulder joint combined with Hill-Sachs injury caused by electric shock in the Department of Orthopedics, Affiliated Huzhou Hospital, Zhejiang University School of Medicine in August 2020. The diagnosis of left posterior shoulder dislocation was clear, and the diagnosis of right posterior shoulder dislocation was missed. The patient successfully reconstructed the stability of the shoulder joint by actively performing shoulder arthroscopic surgery to repair the joint capsule. After 6 months of follow-up, there was no further dislocation and the function was good.

Objective: The present study describes the management of suspected shoulder dislocations in ski field clinics., Methods: Data were collected from two clinics in Queenstown, New Zealand. Suspected anterior shoulder dislocations, with no suspicion of significant fractures and without imaging, underwent attempted reduction., Results: Ninety percent (n = 49) of dislocations were successfully relocated. No short-term complications because of this procedure were observed., Conclusion: This short report raises the possibility that early anterior shoulder reduction in a ski field clinic can be safe without imaging, in select cases. Prospective studies including patient centred data are recommended., (© 2022 Australasian College for Emergency Medicine.)

Shoulder injuries are common in contact athletes and vary in severity because of the required complex interplay of shoulder stability and range of motion for proper function. Pathology varies based on sport but most commonly includes shoulder instability, acromioclavicular injuries, traumatic rotator cuff tears, and brachial plexus injuries. Acute management ranges from reduction of shoulder dislocations to physical examination to determine the severity of injury. Appropriate radiographs should be obtained to evaluate for alignment and fracture, with magnetic resonance imaging commonly being necessary for accurate diagnosis and management. Treatments range from surgical stabilization in shoulder instability to repeat examinations and physical therapy. Return-to-play decision making can be complex with avoidance of reinjury and player safety being of utmost concern. Appropriate evaluation and treatment are vital because repeat injury can lead to long-term effects due to the relatively high effectsometimes seen in contact sports., (Copyright © 2022 by the American Academy of Orthopaedic Surgeons.)

Background: The aim was to improve the diagnosis of acromioclavicular joint dislocation by studying the capabilities and characteristics of clinical and instrumental diagnostic methods. The idea is expressed that modern clinical and instrumental diagnostic methods comprise a large number of techniques, but no single algorithm for diagnosing injury to the AC joint has been developed. A gold standard for investigating and diagnosing acute AC joint dislocation does not currently exist., Materials and Methods: A retrospective study of the characteristics and capabilities of clinical and instrumental diagnostic methods was performed in 152 patients with traumatic shoulder pathology. The patients were divided into two groups: Group I of 102 patients (67%) with acromioclavicular joint dislocation type III-VI according to Rockwood classification and Group II of 50 patients (33%) with a partial tear of the rotator cuff. Clinical and instrumental examinations involved specific provocative tests; the radiological diagnostics comprised conventional radiographs with the Zanca, axillary and Alexander views, and CT, MRI, and ultrasound examinations., Results: The characterization of examination methods was based on the records of patients in Group I and II. The most sensitive clinical test to establish Rockwood type V of acromioclavicular joint dislocation was the Paxinos test (91%). The lowest sensitivity across the tests used was observed with the active compression test to diagnose type IV of dislocation (50%). As regards the X-ray examination, the axial view was 100% sensitive for detecting type IV and VI AC joint dislocation. The Zanca view is highly sensitive for patients with Rockwood type V and Alexander view for Rockwood type III and V dislocations. The accuracy of ultrasound work-up in Group I was 95%, with 96% sensitivity and 93% specificity, while MRI accuracy was 97%, with 96% sensitivity and 98% specificity, and CT accuracy was 81%, with 83% sensitivity and 75% specificity., Conclusions: 1. Determination of the sensitivity and specificity of the X-ray examination revealed the absence of a 100% effective X-ray view for type III and V AC joint dislocation. 2. The accuracy and sensitivity of the ultrasound, MRI, and CT examinations are high. 3. There is currently no consensus on a protocol to view acute AC joint injuries. 4. Complete and timely early diagnosis of acromioclavicular dislocation allows for a diffe-rentiated approach to surgical treatment tactics, preventing possible complications and restoring the function of the injured shoulder joint to the fullest extent.

Purpose: The purpose of this study was to establish consensus statements via a modified Delphi process on the diagnosis, nonoperative management, and Bankart repair for anterior shoulder instability., Methods: A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability., Results: The independent factors identified in the 2 statements that reached unanimous agreement in diagnosis and nonoperative management were age, gender, mechanism of injury, number of instability events, whether reduction was required, occupation, sport/position/level played, collision sport, glenoid or humeral bone-loss, and hyperlaxity. Of the 3 total statements reaching unanimous agreement in Bankart repair, additional factors included overhead sport participation, prior shoulder surgery, patient expectations, and ability to comply with postoperative rehabilitation. Additionally, there was unanimous agreement that complications are rare following Bankart repair and that recurrence rates can be diminished by a well-defined rehabilitation protocol, inferior anchor placement (5-8 mm apart), multiple small-anchor fixation points, treatment of concomitant pathologies, careful capsulolabral debridement/reattachment, and appropriate indications/assessment of risk factors., Conclusion: Overall, 77% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the aspects of patient history that should be evaluated in those with acute instability, the prognostic factors for nonoperative management, and Bankart repair. Furthermore, there was unanimous consensus on the steps to minimize complications for Bankart repair, and the placement of anchors 5-8 mm apart. Finally, there was no consensus on the optimal position for shoulder immobilization., Level of Evidence: Level V, expert opinion., (Copyright © 2021 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the effect of the Nonoperative Instability Severity Index Score (NISIS) criteria on an established US-geographic population-based cohort of patients with anterior shoulder instability., Methods: An established geographically based medical record system was used to identify patients <40 years of age with anterior shoulder instability between 1994 and 2016. Medical records were reviewed to obtain patient demographics and instability characteristics. Patient-specific risk factors were individually incorporated into the 10-point NISIS criteria: age (>15 years), bone loss, type of instability (dislocation vs subluxation), type of sport (collision vs noncollision), male sex, and dominant arm involvement. High risk was considered a score of ≥7 points and low risk as <7 points. Failure was defined as either progression to surgery or recurrent instability diagnosed by a consulting physician at any point after initial consultation., Results: The study population consisted of 405 patients with a mean follow-up time of 9.6 ± 5.9 years. Failure was defined as recurrent instability or progression to surgery, and the overall failure rate was 52.8% (214/405). The rate of recurrent instability after initial consultation was 34.6% (140/405), and the rate of conversion to surgery was 37.8% (153/405). A total of 264 (65.2%) patients were considered low risk (NISIS < 7), and 141 (34.8%) patients were considered high risk (NISIS ≥ 7). Patients in the high-risk group were more likely to fail nonoperative management than those in the low-risk group (60.3% vs 48.9%; P = .028)., Conclusions: The NISIS has been proposed as a potentially useful tool in clinical decision-making regarding the appropriate use of nonoperative treatment in scholastic athletes. When applied to an established US-geographic population-based cohort consisting of competitive and recreational athletes under the age of 40 with longer-term follow-up, the NISIS high-risk cutoff was able to predict overall failure with 60.3% accuracy., Level of Evidence: III, retrospective observation trial., (Copyright © 2021 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

PURPOSE OF THE STUDY The purpose of this study is to remind of the specific features of diagnosis and therapy of dorsal dislocations of the glenohumeral joint to prevent frequent neglect or misdiagnosis during primary treatment. Also, we strived to present our experience and outcomes of posterior dislocation treatment by McLaughlin procedure and its modified version. MATERIAL AND METHODS We retrospectively evaluated 7 patients who had been treated at our department in the period 2015-2019 by McLaughlin procedure or its modification. The group consisted of 5 men and 2 women aged 33-79 years. In five patients, the dislocation occurred during an epileptic seizure, in two patients during an accident. The patients were treated by McLaughlin procedure or the Neer modification of McLaughlin procedure. The deltoideopectoral surgical approach was always used. Based on the preoperative planning, we decided, or intraoperatively changed our decision, as to whether mere transposition of the subscapularis is satisfactory or whether transposition of the lesser tuberosity to the defect, a bone graft and arthroplasty are necessary. Postoperatively, the operated limb was fixed for 6 weeks in neutral position, which was followed by rehabilitation. RESULTS We evaluated subjective and objective outcomes of the surgery, the radiological finding and in 2 patients also a control CT scan. The function of the shoulder was assessed using the Constant shoulder score and the OSIS scoring system. The resulting score: the mean OSIS was 55.7 points (92.8%) and the mean Constant score was 86.2 points (86.2%), which we regard as a very good result. All patients consider the surgery successful and are satisfied with the outcome. No patient reported recurrent dislocation. DISCUSSION When treating the posterior dislocation of the shoulder, vital is the shoulder reducibility and also the presence or the size of reverse Hill-Sachs defect. The transfer of the subscapularis tendon can be performed as an open procedure or arthroscopically. Inveterate irreducible posterior dislocation of the shoulder is quite a rare diagnosis, which is why even at our department the McLauglin procedure is performed in the order of units per year only. CONCLUSIONS The surgical solution of inveterate posterior dislocation of the shoulder is hardly ever uncomplicated. The reduction alone is often insufficient and some other way of shoulder stabilisation is necessary, often times addressing the humeral head defect. In our to date experience, the McLaughlin procedure or the Neer s modification is an elegant and safe method to treat posterior dislocation with a humeral head defect. The functional outcomes are very good and enable the patients to reengage in everyday activities. Thanks to this procedure shoulder joint arthroplasty can be avoided in younger patients. Nonetheless, in defects that are greater than 50% of the head the replacement is necessary. Due to frequently associated rotator cuff injuries, the most often procedure indicated by us is the reverse total shoulder replacement. Key words: posterior dislocation of the shoulder, reverse Hill-Sachs defect, McLaughlin procedure, Neer s modification.

Importance: The Instability Severity Index (ISI) score was developed to evaluate a patient's risk of recurrent shoulder instability following arthroscopic Bankart repair. While patients with an ISI score of >6 were originally recommended to undergo an open procedure (ie, Latarjet) to minimise the risk of recurrence, recent literature has called into question the utility of the ISI score., Objective: The purpose of this systematic review was to evaluate the efficacy of the ISI score as a tool to predict postoperative recurrence among patients undergoing arthroscopic Bankart procedures., Evidence Review: Articles were included if study participants underwent arthroscopic Bankart repair for anterior shoulder instability and reported postoperative recurrence by ISI score at a minimum of 2 years of follow-up. Methodological study quality was assessed using the Methodological Index for Non-Randomized Studies criteria. Pearson's χ 2 test was used to compare recurrence rates among patients above and below an ISI score of 4. Sensitivity, specificity, mean ISI scores and predictive value of individual factors of the ISI score were qualitatively reviewed., Findings: Four studies concluded the ISI score was effective in predicting postoperative recurrence following arthroscopic Bankart repair; however, these studies found threshold values lower than the previously proposed score of >6 may be more predictive of recurrent instability. A pooled analysis of these studies found patients with an ISI score <4 to experience significantly lower recurrence rates when compared with patients with a score ≥4 (6.3% vs 26.0 % , p<0.0001). The mean ISI score among patients who experienced recurrent instability was also significantly higher than those who did not., Conclusions and Relevance: The ISI score as constructed by Balg and Boileau may have clinical utility to help predict recurrent anterior shoulder instability following arthroscopic Bankart repair. However, this review found the threshold values published in their seminal article to be insufficient predictors of recurrent instability. Instead, a lower score threshold may provide as a better predictor of failure. The paucity of level I and II investigations limits the strength of these conclusions, suggesting a need for further large, prospective studies evaluating the predictive ability of the ISI score., Level of Evidence: IV., Competing Interests: Competing interests: None declared., (© International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Anterior shoulder instability is a common complaint of young athletes. Posterior instability in this population is less well understood, and the standard of care has not been defined. The purpose of the study is to compare index frequency, treatment choice, and athlete disability following an incident of anterior or posterior shoulder instability in high school and collegiate athletes., Methods: A total of 58 high school and collegiate athletes (n=30 athletes with anterior instability; n=28 athletes with posterior instability) were included. Athletes suffering from a traumatic sport-related shoulder instability episode during a team-sponsored practice or game were identified by their school athletic trainer. Athletes were referred to the sports medicine physician or orthopedic surgeon for diagnosis and initial treatment choice (operative vs. nonoperative). Athletes diagnosed with traumatic anterior or posterior instability who completed the full course of treatment and provided pre- and post-treatment patient-reported outcome measures were included in the study. The frequency of shoulder instability was compared by direction, mechanism of injury (MOI), and treatment choice through χ 2 analyses. A repeated measures analysis of variance was used to compare the functional outcomes by treatment type and direction of instability (α = 0.05)., Results: Athletes diagnosed with anterior instability were more likely to report a chief complaint of instability (70%), whereas those diagnosed with posterior instability reported a primary complaint of pain interfering with function (96%) (P = .001). The primary MOI classified as a contact event was similar between anterior and posterior instability groups (77% vs. 54%, P = .06) as well as the decision to proceed with surgery (60% vs. 72%, P = .31). In patients with nonoperative care, athletes with anterior instability had significantly more initial disability than those with posterior instability (32±6.1 vs. 58±8.1, P = .001). Pre- and post-treatment Penn Shoulder Scores for athletes treated with early surgery were similar (P > .05). There were no differences in functional outcomes at discharge in those treated nonoperatively regardless of direction of instability (P = .24); however, change in Penn score was significantly greater in those with anterior (61±18.7) than those with posterior (27 ± 25.2) instability (P = .002)., Conclusion: Athletes with anterior instability appear to have different mechanisms and complaints than those with posterior instability. Among those that receive nonoperative treatment, athletes with anterior instability have significantly greater initial disability and change in disability than those with posterior disability during course of care., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Pigmented villonodular synovitis (PVNS) occurs most frequently in the knee and hand joints and is extremely rare in the shoulder joints. A 27-year-old women was admitted to our outpatient clinic with an abrupt-onset pain and limited range of motion of the left shoulder. On arthroscopic examination, localized PVNS surrounding the reactive synovitis in the posterior aspect of the subscapularis within the shoulder joint cavity. The mass was removed using a grasper and shaver. Symptomatic relief was achieved following surgical removal. In conclusion, although rare, localized PVNS of the shoulder joint should be kept in mind in patients with a sudden-onset shoulder joint subluxation and pseudoparalysis.

Background: Anterior shoulder dislocation is the most common shoulder injury in patients presenting to the emergency department (ED). Up to 25% of these injuries are fracture-dislocations. In general, the standard approach is to obtain plain radiographs before and after reduction. Fresno-Quebec Rules (FQR) are described to identify the patients who require an x-ray before reduction to reduce radiation exposure and delays in treatment. We aimed to evaluate the efficacy of clinical predictors used in the Fresno-Quebec algorithm for detecting a shoulder fracture-dislocation., Methods: Records of patients who presented to the Emergency Department with presumed shoulder dislocation were retrieved and retrospectively analyzed according to 'Fresno-Quebec Rule (FQR)'. Sensitivity, specificity, and predictive values of FQR for detecting associated injuries were calculated., Results: Eighty-nine (65.9%) men and 46 (34.1%) women were included. The mean age of patients was 46 years (16-89). Ninety-nine (73.3%) of the cases had their shoulder dislocated for the first time, whereas 36 (26.7%) patients had a recurrent dislocation. Fifty percent of the patients (18 cases) with recurrent dislocation presented with an atraumatic episode. The remaining 18 patients with a history of recurrent dislocations had their shoulder dislocated as a result of trauma, and four (22%) of them had fracture-dislocation. Using the Fresno-Quebec rules yielded 100% specificity for the diagnosis of fracture-dislocation. The severity of the injury mechanism was not predictive in traumatic but recurrent dislocations. Only one of four patients with a fracture-dislocation in the traumatic recurrent dislocation group had high energy trauma., Conclusion: FQR has 100% sensitivity in detecting fracture-dislocations in patients admitted to ED with anterior shoulder dislocation. It utilizes simple parameters that are easy to use and recall. Using these rules, 30% of unnecessary radiographs can be avoided, saving time and money and reducing radiation exposure in anterior dislocations.

Glenohumeral instability is one of the most common conditions of the upper extremity, especially in athletes and active individuals. Over the past two decades, there has been a transformation of surgical treatment from traditionally open repair/reconstruction to arthroscopic management. This has especially been true with management of both anterior and posterior instability without significant bone loss. In this setting, and in certain patient populations (eg, contact/collision athletes), arthroscopic treatment may not be sufficient. Therefore, open techniques, such as coracoid bone transfer, also occupy an important role in management of glenohumeral instability. The goal of this review is to provide technical "pearls" in management of glenohumeral instability. Specifically, the review will highlight treatments such as arthroscopic anterior and posterior instability repair, posterior glenoid bone augmentation, and open coracoid transfer (Latarjet) for anterior instability with bone loss. We will also review management of complications related to coracoid transfer.

Anterior glenohumeral instability remains a common clinical problem in the athletic and working patient populations, and further, recurrence rates following stabilization surgery continue to be problematic. Over the past 5 years, there have been substantial improvements in the understanding of anterior shoulder instability. To better counsel and treat patients, it is imperative for surgeons to have a comprehensive understanding of the epidemiology of shoulder instability, the anatomy of the glenohumeral joint particularly as it relates to glenoid and humeral head bone loss, surgical indications, and surgical techniques. These critical topics are summarized in an effort to provide a complete guide to managing anterior shoulder instability in 2020.

Anterior shoulder instability commonly occurs in young and active individuals, particularly those participating in contact or collision sports. At the intercollegiate level, rates of anterior instability have been reported to be 0.12 events per 1000 athlete exposures. The treatment of in-season athletes with anterior instability presents a challenge for the team physician. The desire to return to play within the same season with nonoperative management must be weighed against the increased risk of recurrence as well as athlete and team specific demands. The purpose of this chapter is to discuss the key considerations for the management of the athlete with anterior shoulder instability that occurs within the competitive season.

The decision to manage first-time shoulder dislocations conservatively or operatively has become increasingly complex because of conflicting literature. Although shoulder dislocations have traditionally been managed with reduction and immobilization, recent evidence has suggested high rates of subsequent recurrence. Surgical intervention is thought to better restore stability and decrease recurrence rates; however, it also has the potential for additional morbidity and financial cost. As such, recent literature has sought to better define patient risk profiles to identify optimal candidates for both conservative and operative management. The purpose of the current review is to provide a comprehensive and evidence-based assessment of the most recent literature to better delineate an appropriate treatment algorithm for this challenging clinical scenario.

Traumatic anterior shoulder instability is prevalent among young athletes, and recurrent dislocations can result in compromised upper extremity function, increasing glenohumeral bone loss, and ultimately, posttraumatic arthritis. Although management algorithms have evolved in response to contemporary data and technical innovation, the arthroscopic Bankart repair continues to be a mainstay for the primary surgical management of first-time or recurrent anterior shoulder instability with marginal attritional glenoid bone loss (ie, <10% to 15%) and/or "on track" Hill-Sachs defects. The advantages of arthroscopic stabilization include its minimally invasive technique, high cost effectiveness, and relatively low recurrence rates and propensity for perioperative complications. The current article reviews contemporary indications/contraindications, management of the first-time dislocator, critical glenoid bone loss, surgical technique, and reported clinical outcomes of the arthroscopic Bankart repair.

Background: The management of the adolescent athlete after initial shoulder instability remains controversial., Hypothesis: Individual risk factors in athletes with shoulder instability who are managed nonoperatively can be integrated into a scoring system that can predict successful return to sport., Study Design: Retrospective cohort study., Level of Evidence: Level 4., Methods: A total of 57 scholastic athletes with primary anterior shoulder instability who were managed nonoperatively were reviewed. Success was defined as a return to index sport at the same level and playing at least 1 subsequent season without missed time as a result of the shoulder. Patient-specific risk factors were individually evaluated, and odds ratios were calculated. A 10-point Nonoperative Injury Severity Index Score (NISIS) incorporated the risk factors for failure. This score was then retrospectively applied with regression analysis and a chi-square analysis to determine the overall optimal score that predicted failure of nonoperative management., Results: In total, 6 risk factors for failure were included in the NISIS: age (>15 years), bone loss, type of instability, type of sport (contact vs noncontact), male sex, and arm dominance. Overall, 79% of patients treated nonoperatively were able to successfully return to sport. Nearly all (97%) low-risk patients (NISIS <7) successfully returned to sport, while only 59% of high-risk patients returned to sport, a relative risk of 12.2 ( P = 0.001). High-risk patients with unipolar bone loss successfully returned (100%), but 67% of high-risk patients with bipolar bone loss failed., Conclusion: The NISIS is a simple and effective clinical tool to determine successful nonoperative management following anterior shoulder instability and may be helpful in guiding decision making when presented with the unstable shoulder in the scholastic athlete.

Objective: The aims of this study were, first, to assess the loss of reduction after fixation of Rockwood type V acromioclavicular joint dislocation (ACJD) with the TightRope device (Arthrex, Naples, FL, USA) and, second, to present the functional and radiological outcomes of this treatment., Methods: We retrospectively reviewed the medical records of 15 patients (12 males; mean age=39.2 years; age range=23-61) with Rockwood type V ACJD who were treated by the TightRope fixation device. The mean follow-up period was 19.3 (range=12-30) months. Functional status was assessed using the Constant-Murley score (CMS) at the final follow-up examination. To determine the reduction loss of ACJ, we measured and compared the coracoclavicular (CC) distance using radiographs with Zanca view in the early postoperative period and at the final follow-up examination. The fixation procedures were performed with an open technique using the TightRope fixation device., Results: The mean CMS at the final follow-up was 93.2 (range=82-100) points. All the patients experienced full recovery of the shoulder's range of motion, were able to return to the activities of daily living, and were satisfied with the treatment. ACJ reduction was successfully achieved in all the patients using the TightRope technique. Postoperative radiographs revealed no reduction loss in the ACJ, and the CC distance was well maintained. The mean CC distance was 19.95 (range=13.1-28.3) mm before surgery. The mean CC distance was 7.47 (range=4.2-11.5) mm in the early postoperative radiographic measurements. This difference was statistically significant (p=0.001). The mean CC distance at the final follow-up examination was 7.70 (range=4.5-11.7) mm. At the final follow-up visit, the shoulders of all the patients were still completely reduced, with a mean difference in the CC of 0.23 (range=0-1.3) mm compared with that in the early postoperative period. The difference in the CC between the early postoperative and final follow-up intervals was not statistically significant (p=0.055). No patient experienced recurrence or required an operation for hardware removal., Conclusion: It seems that the TightRope device can provide anatomical restoration in patients with acute type V ACJD without subluxation at the final follow-up examination., Level of Evidence: Level IV, Therapeutic study.

Purpose: Glenoid bony lesions play a role in approximately half of anterior shoulder instability cases. The purpose of this study is to see if the anatomy of the coracoid affects the location of glenoid rim defects. We hypothesized that a prominent coracoid (lower and lateral) would be more likely to cause an anterior-inferior glenoid lesion, and a less prominent coracoid more prone to cause an anterior lesion. The null hypothesis being the absence of correlation., Methods: Fifty-one shoulder CT-scans from a prospective database, with 3D reconstruction, were analyzed. The position of glenoid lesions was identified using the validated clock method, identifying the beginning and end time. The size of bony glenoid defects was calculated using the validated glenoid ratio method. The position of the coracoid tip was measured in three orthogonal planes., Results: Analysis included 25 right shoulders and 26 left shoulders in seven females and 41 males. The vertical position of the coracoid tip relative to the top of the glenoid was highly correlated to the location of the glenoid defect on the profile view (r = -0.625; 95% CI 0.423-0.768; p = 0.001). Thus, higher coracoids were associated with anterior lesions, while lower coracoids were associated with anterior-inferior lesions. A more laterally prominent coracoid was also correlated with anterior-inferior lesions (r = 0.433; 95% CI 0.179-0.633; p = 0.002)., Conclusion: This study shows that coracoid anatomy affects the location of bony Bankart defects in anterior shoulder instability. Lower and laterally prominent coracoids are associated with anterior-inferior lesions. This variation in anatomy should be considered during pre-op planning for surgeries involving bone graft., Level of Evidence: Level 4 basic science.

Objective: To assess the sensitivity, specificity, and validity of the Predicting Recurrent Instability of the Shoulder (PRIS) tool in people with a first-time traumatic anterior shoulder dislocation., Design: Prospective cohort study., Methods: People with first-time traumatic anterior shoulder dislocation (n = 85), aged 16 to 40 years, were recruited within 12 weeks of their shoulder dislocation and followed prospectively for 1 year post injury. We calculated the sensitivity, specificity, negative predictive value, and positive predictive value of the PRIS tool., Results: Of the 75 participants available for 1-year follow-up, 57 (76%) did not have recurrent shoulder instability. With the PRIS tool cut point set at 0.895, the tool's sensitivity was 39% (95% confidence interval [CI]: 17.3%, 64.3%) and its specificity was 95% (95% CI: 85.4%, 98.9%). The area under the curve was 0.69 (95% CI: 0.55, 0.84; P = .01). The PRIS tool correctly identified 54 of the 57 (95%) who did not have recurrent instability (accuracy, 81%; 95% CI: 70.7%, 89.4%). Negative and positive predictive values were 83% (95% CI: 77.2%, 87.7%) and 70% (95% CI: 40.2%, 89.0%), respectively., Conclusion: The PRIS tool can predict those who will not have further shoulder instability in the year following first-time traumatic anterior shoulder dislocation. The PRIS tool cannot accurately predict those who will have recurrent shoulder instability. J Orthop Sports Phys Ther 2020;50(8):431-437. doi:10.2519/jospt.2020.9284 .

Traumatic dislocation of the shoulder - a guide for medical practicioners Abstract. Traumatic dislocation of the shoulder joint is a common injury. Young patients suffer from dislocations usually during leisure and competitive activities, the elderly are prone for injuries because of falls. We provide an overview about state-of-the-art management in first traumatic shoulder dislocations. Besides an overview for mechanisms leading to injuries, we describe first line therapy as well as techniques to reposition the shoulder. First time traumatic glenohumeral dislocations can usually be treated without surgery, we elucidate the topic regarding the need for further imaging as well as possible injuries accompanying the dislocation.

The glenohumeral joint is prone to instability. Patients with instability should have a physical examination. Imaging studies can provide additional information. Classification schemes that into account soft tissue pathology, neuromuscular control, bone loss, and activity level. An arthroscopic Bankart repair is the mainstay for unidirectional instability. Bone block procedures are indicated for patients with bone loss or a failed attempt at stabilization surgery. The arthroscopic Latarjet is a promising option for these patients. For patients with multidirectional instability, prolonged rehabilitation is indicated, followed by capsular plication or inferior capsular shift if instability is unresponsive to physical therapy., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The arthroscopic method offers a less invasive technique of Bankart repair for traumatic anterior shoulder instability. The aim of the study is to determine the mid-/long-term functional outcome, failure rates and predictors of failure after primary arthroscopic Bankart repair for traumatic anterior shoulder instability., Methods: A total of 100 patients were primarily operated using arthroscopic Bankart repair after traumatic anterior shoulder instability. Medical records were retrospectively reviewed, and patients were assessed using postal questionnaire after a mean follow-up of 8.3 years [3-14]. Clinical assessment was performed using Constant score, Rowe score, and American Shoulder and Elbow Surgeons score., Results: The overall recurrence rate was 22%. The Kaplan-Meier failure-free survival estimates. were 80% at 5 years and 70% at 10 years. Nearly half (54.5%) of recurrences occurred at 2 years postoperative. Compared with normal shoulder, there were statistical differences in all 3 scores. Failure rate was significantly affected by age at the time of surgery with 86% of recurrence cases observed in patients aged 30 years or younger. Nevertheless, Younger age at the time of surgery (P = 0.007) as well age at the time of initial instability (P = 0.03) was found to correlate negatively with early recurrence within 2 years of surgery. Among those with recurrent instability, recurrence rate was found to be higher if there had been more than 5 instability episodes preoperatively (P = 0.01). Return to the preinjury sport and occupational level was possible in 41 and 78%, respectively., Conclusion: Failure-free survival rates dropped dramatically over time. Alternative reconstruction techniques should be considered in those aged ≤30 years due to the high recurrence rate.

Background: A high incidence of missed posterior shoulder dislocations is widely recognised in the literature. Concern was raised by the upper limb multidisciplinary team at a London major trauma centre that these missed injuries were causing serious consequences due to the need for surgical intervention and poor functional outcome., Objective: To identify factors contributing to missed diagnosis and propose solutions., Methods: A local quality improvement report was performed investigating time from admission to diagnosis of simple posterior dislocations and fracture dislocations over a 5-year period. Factors contributing to a delayed diagnosis were analysed., Results: The findings supported current evidence: a posterior shoulder dislocation was more often missed if there was concurrent fracture of the proximal humerus. Anteroposterior and scapular Y view radiographs were not always diagnostic for dislocation. Axial views were more reliable in assessment of the congruency of the joint and were associated with early diagnosis and appropriate treatment of the injury., Discussion: As a result of these findings a new protocol was produced by the orthopaedic and radiology departments and distributed to our emergency department practitioners and radiography team. The protocol included routine axial or modified trauma axial view radiographs for all patients attending the emergency department with a shoulder injury, low clinical suspicion for dislocation and a low threshold for CT scan. Reaudit and ongoing data collection have shown significant increase in axial view radiographs and improved diagnosis., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To describe the posterior labral lesions and labrocapsular abnormalities of the shoulder on sonoarthrography and to compare these findings with MR arthrography results., Methods: 82 shoulders were initially evaluated with ultrasonography and MRI and then were examined with sonoarthrography and MR arthrography following intraarticular injection of diluted gadolinium solution. The ultrasonography images were prospectively evaluated for the presence of posterior labral tear, sublabral cleft, and posterior capsular abnormalities by two radiologists. The diagnostic accuracy of sonoarthrography in the detection of posterior labral tears and posterior labrocapsular variants was compared with that of MR arthrography., Results: In sonoarthrographic examinations of 82 shoulders, 5 and 6 posterior labral tears were identified by Observer 1 and 2, respectively. Moreover, 6 and 7 posterior sublabral clefts, and 2 and 3 posterior synovial folds were identified by Observer 1 and 2, respectively. All the 82 patients were examined with MR arthrography; however, only 14 patients underwent arthroscopic examination. No significant difference was found among the 82 patients with regard to age, gender, and the prevalence of posterior labral tear, posterior labral cleft, and posterior synovial fold ( p > 0.05). Interobserver variability showed substantial agreement between the sonoarthrographic and MR arthrographic results of the posterior labrocapsular structures (κ = 0.71, p < 0.05)., Conclusion: Posterior labral tears and posterior synovial folds of the shoulder joint can be evaluated non-invasively by sonoarthrography., Advances in Knowledge: Variations and pathologies of posterior labrocapsular structures of the glenohumeral joint are relatively uncommon.Direct (MR) arthrography is the gold-standard imaging modality to evaluate of posterior labrocapsular abnormalities of the glenohumeral joint.Sonoarthrography of the glenohumeral joint may be utilized in clinical practice in patients with contraindications to (MRI).

Background: Hook plates are widely used for repair of acromioclavicular joint (ACJ) dislocations. However, it is unclear whether repair of torn coracoclavicular (CC) ligament is necessary. The purpose of this study was to evaluate the outcomes of the hook plate fixation with direct CC ligament repair for acute ACJ dislocation in comparison with the hook plate fixation without direct CC ligament repair., Methods: The study included 120 patients with acute ACJ dislocations who underwent surgery. The patients were divided into 73 patient groups with Arbeitsgemeinschaft für Osteosynthesefragen (AO) hook plate fixation and direct CC ligament repair and 47 patient groups without direct CC ligament repair. For clinical assessments, the American Shoulder and Elbow Surgeons score, constant score, and time for implant removal were recorded. The corcoclavicular distance (CCD) and the CCD ratio were used for the evaluation of reduction. Typical reported complications, such as secondary dislocation, implant failure or loosening, peri-implant fracture, acromion osteolysis, and postoperative ACJ arthrosis, were also analyzed., Results: There were no differences in the clinical outcomes between the two groups. There was no difference in the timing of implant removal between the two groups. The last follow-up CCD was not statistically significant between group with direct CC ligament repair and without repair (9.1 ± 3.3 vs. 9.0 ± 2.8, respectively, p > 0.05). The last follow-up CCD ratio showed significant differences between the two groups (12.6 ± 25.5% vs. 26.3 ± 39.7, respectively, p < 0.05). There was no statistically significant difference in the complication rate between the two groups., Conclusion: The hook plate fixation with direct CC ligament repair group was better for maintenance of reduction than that of the hook plate fixation without direct CC ligament repair group. Although, there were no differences of clinical outcomes and complications between two groups., Level of Evidence: Level III, Retrospective Study.

Background: Multiple published studies quantitatively analysing the diagnostic value of MRI, MR arthrography (MRA) and CT arthrography (CTA) for labral lesions of the shoulder have had inconsistent results. The aim of this meta-analysis was to systematically compare the diagnostic performance of MRI, MRA, CTA and CT., Methods: Two databases, PubMed and EMBASE, were used to retrieve studies targeting the accuracy of MRI, MRA, CTA and CT in detecting labral lesions of the shoulder. After carefully screening and excluding studies, the studies that met the inclusion criteria were used for a pooled analysis, including calculation of sensitivity and specificity with 95% confidence intervals (CIs) and the area under the hierarchical summary receiver operating characteristic (HSROC) curves., Results: The retrieval process identified 2633 studies, out of which two reviewers screened out all but 14 studies, involving a total of 1216 patients who were deemed eligible for inclusion in the meta-analysis. The results assessing the diagnostic performance of MRI vs. MRA for detecting labral lesions showed a pooled sensitivity of 0.77 (95% CI 0.70-0.84) vs. 0.92 (95% CI 0.84-0.96), a specificity of 0.95 (95% CI 0.85-0.98) vs. 0.98 (95% CI 0.91-0.99), and an area under the HSROC curve of 3.78 (95% CI 2.73-4.83) vs. 6.01 (95% CI 4.30-7.73), respectively., Conclusion: MRA was suggested for use in patients with chronic shoulder symptoms or a pathologic abnormality. MRI is by far the first choice recommendation for the detection of acute labral lesions. CT should be a necessary supplemental imaging technique when there is highly suspected glenoid bone damage.

Background : Cycling is a popular source of recreation and physical activity for children and adults. With regard to the total number of sports injuries, cycling has the highest absolute number of injuries per year in the United States population. Cycling injuries can be classified into bicycle contact, traumatic, or overuse injuries. Aim of this study: The aims of this case report are to report a rare clinical complication of glenohumeral joint anterior dislocation that resulted in a patient experiencing continuous GHJ dislocations secondary to involuntary violent muscular spasms and emphasize the role of the physical therapist's differential diagnosis and clinical decision-making process in a patient following direct access referral. Case presentation: A professional 23-year-old cyclist presented to a physical therapist with spontaneous multidirectional dislocations to the right shoulder after the recurrence of trauma occurred during a recent cycling race. The dislocations do not occur at night, but occur during the day, randomly, and mostly associated with changes in the patient's psychological conditions. Directly from the clinical history, the physical therapist identified a neuro-physiological orange flag as well as an orthopedic red flag and, therefore, decided it was appropriate to refer the patient to a neurologist. It was determined by the physical therapist to be a priority to focus on the patient's neurologic status and then to evaluate the orthopedic problem. The neurological examination revealed a condition of spontaneous multidirectional dislocation associated with recurrent antero-posterior pain spasms of the shoulder joint. The neurologist prescribed medication. Following the second cycle of medication assumption, the patient was able to continue physiotherapy treatment and was referred to the orthopedic specialist to proceed with shoulder stabilization surgery. Discussion and conclusion : Currently, the diagnosis of this unusual clinical condition is still unclear. It is a shared opinion of the authors that the trauma during the past bicycle race awakened an underlying psychological problem of the patient that resulted in a clinical condition of weakness of all the structures of the shoulder, such that these spasms could result in multiple multidirectional dislocations.