Clinical significance of the arthroscopic drive-through sign in shoulder surgery

Purpose: During arthroscopy of the shoulder, the ability to pass the arthroscope easily between the humeral head and the glenoid at the level of the anterior band of the inferior glenohumeral ligament is considered a positive drive-through sign. The drive-through sign has been considered diagnostic of shoulder instability and has been associated with shoulder laxity and with SLAP lesions. The goal of this study was to examine the prevalence of the drive-through sign in patients undergoing shoulder arthroscopy and to determine its relationship to shoulder instability, shoulder laxity, and to SLAP lesions. Type of Study: Case series. Methods: We prospectively studied 339 patients undergoing arthroscopy of the shoulder for a variety of diagnosis from 1992 to 1998. The drive-through sign was performed with the patients in a lateral decubitus position and under general anesthesia. The drive-through sign was correlated with preoperative physical findings, intraoperative laxity testing, and with intra-articular pathology at the time of arthroscopy. Results: The arthroscopic evaluation showed that drive-through sign was positive in 234 (69%) shoulders. For the diagnosis of instability, the drive-through sign had a sensitivity of 92%, a specificity of 37.6%, a positive predictive value of 29.9%, a negative predictive value of 94.2%, and an overall accuracy of 49%. There was an association between the drive-through sign and increasing shoulder laxity, but not with SLAP lesions. Conclusions: This study shows that a positive drive-through sign is not specific for shoulder instability but is associated with shoulder laxity. This arthroscopic sign should be incorporated with other factors when considering the diagnosis of instability.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 1 (January), 2001: pp 38–43     

Non-traumatic shoulder instability in an athletic patient with a periglenoidal cyst and a glenoid labral tear

A 34-year-old patient presented to our outpatient clinic with the chief complaint of shoulder instability, without any history of trauma. Physical examination revealed a painful apprehension test at 60 degrees, 90 degrees and 120 degrees but no objective sign of shoulder instability or hyperlaxity. MRI-scan showed a cyst over the anterior inferior glenoid rim. Arthroscopic findings were an enlarged capsule, a positive drive-through sign, a SLAP I lesion and a sublabral cyst at the anterior-inferior labrum. Detachment of the anterior labrum could be detected with a probe. The cyst's membrane was resected using a whisker shaver. The capsule and the anterior labrum were refixated with a suture anchor. Following capsular shrinking, there was no further laxity and the drive-through sign was diminished. After three months there was full range of active and passive motion. The patient had no subjective instability sensations. MRI showed no residuum of the cyst. Juxta-articular cysts are a known entity in large joints. There are different types of periarticular cysts. A ganglion cyst of the shoulder associated with glenohumeral instability has, to our knowledge, only been described twice. Our case suggests that mere excision of a juxtaglenoidal ganglion is not sufficient; reconstruction of the labrum must be performed to restore stability of the shoulder.     

Arthroscopic treatment of multidirectional instability.

Multidirectional instability of the shoulder, described by Neer and Foster, has been treated surgically with the inferior capsular shift procedure. The small number of reports on mid-term outcomes indicate that good to excellent results have been obtained in 75% to 100% of cases. Arthroscopic treatment of multidirectional instability has been previously described. The purpose of this study was to review the results of the arthroscopic capsular shift procedure with a minimum follow-up of 2 years. A retrospective study was performed on 25 patients who underwent an arthroscopic capsular shift performed with the transglenoid technique between January 1990 and December 1993. All patients had earlier not responded to an extensive course of physical therapy. Excluded from the study were patients who had undergone a previous arthroscopic capsular shift or any other procedure, arthroscopic or open, for the shoulder. Average patient age was 26.4 years. There were 20 male and 5 female patients. Sixteen of the affected shoulders involved the dominant extremity. All patients had a history of asymptomatic subluxation that slowly progressed to symptomatic subluxation. Eleven patients had a history of dislocation. Thirteen patients were athletes who were symptomatic in their chosen sport, whereas the other patients were symptomatic in activities of daily living. All patients were examined while they were under anesthesia and had positive results on the sulcus test in abduction with associated anterior instability, posterior instability, or both. Follow-up evaluation was performed with patient interview and examination. All 25 patients were available for follow-up, which occurred an average of 60 months (range 36 to 80 months) after operation. Three patients had episodes of instability after the operation. The average Bankart score was 95 (range of 50 to 100). All but 1 patient had regained full symmetric range of motion by follow-up. Twenty-one (88%) patients had a satisfactory result according to the Neer system. Results of treatment with the arthroscopic capsular shift procedure for multidirectional instability of the shoulder appear to be comparable to those of the open inferior capsular shift.     

Posterior shoulder pain and anterior instability: a preliminary clinical study

Different clinical tests have been suggested in the literature as significant indicators of anterior shoulder instability. Sometimes patients with recurrent anterior shoulder instability may show some muscular guarding thus making the evaluation of specific clinical tests very difficult. These patients may also report a medical history with posterior shoulder pain that can be also elicited during some clinical manoeuvres. From September 2005 to September 2006 we prospectively studied patients who underwent an arthroscopic anterior capsuloplasty. Shoulder clinical examination was performed including anterior shoulder instability tests (drawer, apprehension and relocation tests). Furthermore the exam was focused on the presence of scapular dyskinesia and posterior shoulder pain. The patients were also evaluated with ASES, Rowe, SST (Simple Shoulder Test), Constant and UCLA (University of California at Los Angeles) scoring system preoperatively and at the latest follow-up time. In the period of this study we observed 16 patients treated for anterior gleno-humeral arthroscopic stabilisation, who preoperatively complained also of a posterior scapular pain. The pain was referred at the level of lower trapezium and upper rhomboids tendon insertion on the medial border of the scapula. It was also reproducible upon local palpation by the examiner. Four of these patients also referred pain in the region of the insertion of the infraspinatus and teres minor. After arthroscopic stabilisation the shoulder was immobilised in a sling with the arm in the neutral rotation for a period of 4 weeks. A single physician supervised shoulder rehabilitation. After a mean time of 6.8 months of follow-up, all the shoulder scores were significantly improved and, moreover, at the same time the patients referred the disappearance of the posterior pain. Posterior scapular shoulder pain seems to be another complaint and sign that can be found in patients affected by anterior shoulder instability. It can also be related to eccentric work of posterior stabilising muscles of scapula during the altered biomechanics observed in case of anterior shoulder instability. This pain responds positively to surgical intervention showing that re-centring the humeral head probably also re-establishes the periscapular muscle-firing pattern with a mechanism mediated by the proprioceptive system.     

Pectoralis major tendon transfer for subscapularis deficiency following multiple failed instability surgeries: A case report

Here, we report a case of a 30-year-old man with a diagnosis of complex shoulder instability, who was treated successfully by pectoralis major transfer following a series of failed instability correction surgeries. The patient was admitted to our outpatient clinic with an approximately 6-year history of chronic shoulder instability following several failed operations, including open Bankart repair, open capsular plication and Bankart repair, open capsule repair, arthroscopic Bankart repair, and Bristow-Latarjet procedure. Physical examination revealed persistent shoulder pain, weakness, and a limited range of motion. Imaging studies demonstrated complete subscapularis muscle atrophy with Goutallier grade 4 fatty infiltration. The decision for revision surgery was made owing to his shoulder findings and clinical symptoms. The intra-operative assessment revealed the subscapularis muscle to be fully atrophic and irreparable. The pectoralis major muscle was transferred from the intertubercular groove of the humerus to the lesser tuberosity. Postoperatively, the patient had 4 weeks of shoulder immobilization. Physical examination demonstrated an improved shoulder range of motion without evidence of recurrent shoulder instability. The authors encountered no sign of dislocation for 2.5 years of follow-up after the surgery. In conclusion, subscapularis muscle atrophy or insufficiency should be considered in the differential diagnosis of patients with failed shoulder instability surgeries. Pectoralis major tendon transfer may be successfully performed for the surgical treatment of such patients.     

Prospective evaluation of two diagnostic apprehension signs for posterolateral instability of the elbow

Posterolateral rotatory instability (PLRI) of the elbow occurs from attrition of the lateral ulnohumeral collateral ligament of the elbow after elbow dislocation. Diagnosis by physical examination can be difficult in the awake patient. The goals of this study were to define two active apprehension signs for the physical diagnosis of PLRI and to perform a prospective evaluation of the signs in a series of patients with PLRI. Eight patients with PLRI undergoing surgical reconstruction of the lateral ulnocollateral ligament of the elbow were prospectively included in this continuous case series. Preoperative evaluation consisted of physical examination with two active apprehension signs, the chair sign and the pushup sign, as well as the pivot-shift sign. Results were compared with repeat physical examination after reconstruction of the ligaments. Of 8 patients included in the series, 3 demonstrated a positive pivot-shift sign while awake, and all demonstrated a positive pivot-shift sign while under anesthesia. Seven patients demonstrated a positive chair sign, and seven demonstrated a positive pushup sign. At the 2-year follow-up evaluation, 7 patients remained stable and asymptomatic. The pushup sign, chair sign, and pivot-shift sign were negative in all 7 patients. The study demonstrated that both the pushup and chair signs are effective in aiding the diagnosis of PLRI. They are more sensitive than the pivot-shift sign in the awake patient and may be easily performed in the office environment.     

Perioperative morbidity following total knee arthroplasty among obese patients

To study the relationship between patient weight and perioperative morbidity, 512 total knee arthroplasties performed in 406 patients were reviewed. Patient height, weight, medical history, length of hospital stay, discharge destination (home versus rehabilitation facility), and all complications were recorded. Height and weight were used to calculate a body mass index (BMI) for each patient. Examination of patient data ordered by BMI established positive correlations between BMI and a cardiac history (P=.02), a history of diabetes mellitus (P=.006), postoperative hospital stays >7 days (P=.03), discharge to a rehabilitation facility (P=.02), and the risk of a postoperative complication (P=.004). Further statistical examination revealed the greatest differences in patient data exist between patients with a BMI >35 and patients with a BMI < or = 35. Patients with the greater BMI (>35) had significantly higher rates of cardiac conditions (56% versus 33%, P=.0001) and diabetes mellitus (10.5% versus 4.1%, P=.03) than patients with a lower BMI (< or = 35). Although there were no significant differences in the rates of specific complications between the two groups, patients in the heavier group were more likely to experience a complication (38% versus 25%, P=.002) and multiple complications (9.3% versus 6.2%, P=.03) than patients in the lighter group.     

Shoulder instability: classification and methods of clinical examination

The shoulder is a complex joint whose stability relies on both dynamic and static factors. Dysfunction of one of these components gives rise to shoulder problems. Diagnosis of shoulder instability depends on a detailed history and appropriate physical examination. Despite the presence of many tests, none has proved to be purely diagnostic for shoulder instability. Therefore, these tests should be regarded as a part of the diagnostic procedure rather than a referral to diagnosis itself. Tests performed to assess laxity and instability are different in nature; thus, positive laxity tests do not necessarily show instability unless supported by further evidence. The reliability of the tests for superior labrum anterior-posterior lesions has not been adequately validated by clinical studies and few anatomical studies have examined the effect of these tests on the superior labral complex.     

Shoulder arthroplasty for locked posterior dislocation of the shoulder

Currently, there are no published series with mid- to long-term results on patients undergoing shoulder arthroplasty for locked posterior dislocation of the shoulder. We reviewed the results of patients who underwent shoulder arthroplasty for locked posterior dislocation of the shoulder to determine the results, the risk factors for an unsatisfactory outcome, and the rates of failure. Twelve shoulder arthroplasties were performed at our institution, between January 1, 1980, and December 31, 1997, in 12 patients who had a locked posterior dislocation of the shoulder. All 12 patients were followed up for a minimum of 5 years (mean, 9.0 years) or until the time of revision surgery. There was significant pain relief (P <.001) as well as improvement in external rotation from -13 degrees to 28 degrees (P =.001). On the basis of a modified Neer result rating system, there was 1 excellent, 6 satisfactory, and 5 unsatisfactory results. Three patients underwent revision surgery for posterior instability (two) and component loosening (one). Recurrent instability occurred in two patients in the early postoperative period. There were no cases of recurrent instability greater than 1 year from the time of surgery. The data from this study suggest that shoulder arthroplasty for locked posterior dislocation provides pain relief and improved motion. Among those with recurrent posterior instability, it usually appears in the early postoperative period.     

Komplexe labrale Avulsionsverletzungen mit Extension in den SLAP-Komplex bei anteroinferiorer Schulterinstabilität

The Bankart-Perthes lesion is accepted as the pathognomonic finding for anterior inferior shoulder instability. Extensive injuries of the labral ring with involvement of the superior labrum anterior to posterior (SLAP) complex may occur. The aim of this study was to evaluate the prevalence of labral lesions with accompanying anteroinferior and superior extensions following anteroinferior shoulder instability. In addition the lesions were graduated according to common classification systems and the clinical as well as radiographic results were evaluated. Between January 2005 and November 2010 a total of 206 patients (40 female and 166 male, mean age 31.8?±?16.6 years) underwent primary arthroscopic surgery due to anteroinferior shoulder instability. Out of this cohort patients with anterior labral lesions that extended into the biceps tendon anchor were selected. For clinical evaluation the subjective shoulder value (SSV), Constant-Murley score (CMS), Rowe score (RS), Walch-Duplay score (WD), the Western Ontario shoulder instability index (WOSI), Melbourne instability shoulder score (MISS) and the long head of the biceps (LHB) score were documented. Furthermore, magnetic resonance imaging (MRI) was performed to evaluate the SLAP complex. Overall 15 patients (2 f?emale and 13 male, mean age 29.3?±?8.8 years) were evaluated revealing an additional lesion of the superior labrum with a prevalence of 7.3?%. In seven patients a SLAP V lesion, in two patients a SLAP IV and in six patients a SLAP III lesion with anteroinferior extension was observed. All of the bucked handle type lesions were reconstructed and nine patients could be completely evaluated using clinical and radiographic parameters. After an average follow-up of 59.5?±?12.1 months a mean SSV of 87?±?8?%, CMS 91.0?±?8.8 P, RS 83.3?±?11.2?%, WD 80.0?±?8.9 points, WOSI 73.1?±?23.5?%, MISS 81.5?±?10.5 points and LHB 94.0?±?9.7 points were evaluated. Recurrent dislocation was not obvious although one patient revealed a positive apprehension sign. On MRI an insufficiency of the SLAP reconstruction was not seen and the reconstructed bucket handle lesions seemed to be especially stable. Arthroscopic anterior shoulder stabilization in combination with a SLAP repair revealed good and excellent clinical results. The reconstruction of the biceps tendon anchor seems to be possible even in cases of complex pathologies.     

The effect of variation in definition on the diagnosis of multidirectional instability of the shoulder

BACKGROUND: There currently is a wide variation in the definition of multidirectional instability of the shoulder in the literature. The purpose of this study was to determine if these variations influence the distribution of the diagnoses in a cohort of patients with shoulder instability. METHODS: A cohort of 168 patients who underwent shoulder surgery for instability of any type was studied. Statistical analysis was performed in two steps. First, the instability of the shoulder in each patient was classified with the use of four existing systems, and the number of patients classified as having multidirectional instability was compared among the classification systems. Second, the definition of multidirectional instability was modified so that the result of laxity testing was the criterion for making the diagnosis, and the changes in the distribution of patients with a diagnosis of multidirectional instability were analyzed. RESULTS: Classification with the four existing systems resulted in significant differences in the number of patients diagnosed as having multidirectional instability, with two (1.2%), seven (4.2%), thirteen (7.7%), and fourteen patients (8.3%) so diagnosed (p < 0.05). Modification of the definition of multidirectional instability so that it was based on laxity testing resulted in a wide variation in the number of patients diagnosed as having multidirectional instability; these numbers ranged from fourteen (8.3%) to 139 (82.7%) (p < 0.05). CONCLUSIONS: This study demonstrated that variations in the criteria used for the diagnosis of multidirectional instability significantly affect the distribution of patients with that diagnosis. The use of laxity testing tends to result in an overestimation of the number of patients with this condition. This observation is important because the results of studies may vary if patients with traumatic instability are considered to have multidirectional instability on the basis of laxity testing. Investigators studying patients with multidirectional instability should carefully define the inclusion criteria that they used.     

Shoulder proprioception in baseball pitchers

We examined proprioceptive differences between the dominant and nondominant shoulders of 21 collegiate baseball pitchers without a history of shoulder instability or surgery. A proprioceptive testing device was used to measure kinesthesia and joint position sense. Joint position sense was significantly (P =.05) more accurate in the nondominant shoulder than in the dominant shoulder when starting at 75% of maximal external rotation and moving into internal rotation. There were no significant differences for proprioception in the other measured positions or with kinesthesia testing. Six pitchers with recent shoulder pain had a significant (P =.04) kinesthetic deficit in the symptomatic dominant shoulder compared with the asymptomatic shoulder, as measured in neutral rotation moving into internal rotation. The net effect of training, exercise-induced laxity, and increased external rotation in baseball pitchers does not affect proprioception, although shoulder pain, possibly due to rotator cuff inflammation or tendinitis, is associated with reduced kinesthetic sensation.     

Acromioclavicular joint pain in patients with adhesive capsulitis: a prospective outcome study

Diagnosis of adhesive capsulitis is a clinical diagnosis based on history and physical examination. Afflicted patients exhibit active and passive loss of motion in all planes and a positive capsular stretch sign. The effect of adhesive capsulitis on acromioclavicular biomechanics leading to tenderness has not been documented in the literature. This study reports on the incidence of acromioclavicular tenderness in the presence of adhesive capsulitis. Furthermore, we note the natural history of such acromioclavicular joint pain in relation to that of adhesive capsulitis. Over a 2-year period (2005-2007), 84 patients undergoing initial evaluation for adhesive capsulitis were prospectively examined with the use of validated outcome measures and physical examination. Acromioclavicular joint tenderness results were compared and analyzed on initial evaluation and final follow-up of at least 1 year. Forty-eight patients (57%) with adhesive capsulitis had acromioclavicular joint pain on examination. At final follow-up, as range of motion improved, a significant increase in American Shoulder and Elbow Surgeons/Penn shoulder score and decrease in number of patients with acromioclavicular pain was noted with only 6 patients with residual pain (P<.05). In the presence of adhesive capsulitis, there is not only compensatory scapulothoracic motion but also acromioclavicular motion. This often results in transient symptoms at the acromioclavicular joint, which abate as the frozen shoulder resolves and glenohumeral motion improves. This is important to recognize to avoid unnecessary invasive treatment of the acromioclavicular joint when the patient presents with adhesive capsulitis.     

Macrophage accumulation within the cap of carotid atherosclerotic plaques is associated with the onset of cerebral ischemic events.

PURPOSE: Macrophage accumulation is associated with aortic and coronary plaque instability. The macrophage content of carotid plaques removed at carotid endarterectomy (CE) was assessed, and the relevance to the onset of ipsilateral cerebral ischemic events (CIE) was examined. METHODS: Carotid plaques from patients undergoing CE were examined (group I, symptomatic stenoses, n = 28; group II, high-grade asymptomatic stenosis, n = 7). The plaques were stained with monoclonal antimacrophage antibody (HAM56), and the interval since the last CIE was recorded. The percentage area of the cap, shoulder, and entire sclerotic region was quantified by computerized planimetry. RESULTS: The macrophage content of the cap, shoulder, and sclerotic region in all 35 plaques was 1.14% (interquartile range, 0.56 to 3.86), 1.03% (0.51 to 2.15), and 0.49% (0.27 to 0.63), respectively (cap vs sclerotic, P <.01; shoulder vs sclerotic, P <. 01; cap vs shoulder, P =.23). In 18 plaques that were removed less than 180 days after the last CIE, the macrophage content of the cap, shoulder, and entire sclerotic region was 2.41% (0.95 to 4.81), 0. 83% (0.40 to 2.52), and 0.53% (0.38 to 0.71), respectively (cap vs sclerotic, P =.01; cap vs shoulder, P =.01). The content in the cap of these plaques was greater than in plaques removed more than 180 days after symptoms, or asymptomatic plaques (n = 17; 0.62% [0.44 to 1.25], P =.01). The cap macrophage content was inversely related to the time since the last CIE (r = -0.414, P =.029). CONCLUSION: In patients requiring CE, macrophage accumulation was maximal within the cap of carotid plaques and greatest in plaques removed less than 180 days after the last CIE. These findings and the inverse relationship between macrophage content and the interval since symptoms support the hypothesis that macrophage accumulation is associated with plaque instability.     

Development of arthrosis following dislocation of the shoulder: a case-control study

The goal of this study was to document whether an association exists between shoulder dislocation and the development of arthrosis and to quantify this association, if present. Patients with osteoarthrosis who had undergone hemi-shoulder or total shoulder arthroplasty (TSA) were studied. Patients who had undergone total knee arthroplasty for arthrosis and who had no history of shoulder symptoms served as control subjects. All patients were asked if they had ever sustained a shoulder dislocation. Ninety-one TSA patients and 282 control subjects responded. The odds ratio for developing arthrosis after a shoulder dislocation was 19.3 (P =.000006). With the 5 patients who had shoulder surgery prior to TSA excluded, the odds ratio was 10.5 (P =.003). The risk of developing severe arthrosis of the shoulder is between 10 and 20 times greater for individuals who have had a dislocation of the shoulder.     

Subscapularis function following the latarjet coracoid transfer for recurrent anterior shoulder instability

The Latarjet procedure may be performed with both subscapularis splitting and subscapularis transecting approaches. The subscapularis splitting approach may better preserve subscapularis function and anatomy. The goal of this study was to determine the functional status of the subscapularis after the Latarjet procedure with a subscapularis splitting approach using the quantified belly press test. Thirty patients with traumatic anterior shoulder instability were prospectively enrolled in the study. All patients underwent a Latarjet procedure through a subscapularis splitting approach. Both operative and nonoperative extremities were tested preoperatively with a belly press test using an Isobex muscle strength analyzer (Medical Device Solutions AG, Oberburg, Switzerland). Fifteen patients returned for postoperative Isobex belly press testing at a minimum of 6 months. Average patient age was 23.3 years, and average follow-up interval was 13 months. We detected no significant differences in pre- vs postoperative subscapularis strength in the surgical shoulder (decreased by 0.3 kg [95% CI, -1.0 to 1.7 kg; P=.630]). There was no difference in control vs surgical arm at preoperative (control +0.3 kg stronger; 95% CI, -0.8 to 0.1 kg; P=.124) vs postoperative (control +0.3 kg stronger; 95% CI, -1.1 to 0.5 kg; P=.444) measurements. Neither sex (P=.593) nor surgery in the dominant arm (P=.459) had an effect on recovery of subscapularis strength. Finally, the surgical arm at follow-up was not significantly different from reported height- and weight-based normative values for either men (P=.481) or women (P=.298). This study suggests that subscapularis strength is not significantly altered by the Latarjet procedure with a subscapularis splitting approach.     

创伤性肩关节前不稳定的临床研究

目的探讨创伤性肩关节前不稳定的诊断标准和治疗原则。方法根据４１例创伤性肩关节前不稳定患者发病机制、病程、症状及体征,肩关节Ｘ线片、气碘双重造影ＣＴ,以及基于关节囊、盂唇愈合机制,采用康复治疗和前关节囊修复成形术治疗的经验,提出诊断标准和治疗原则。结果创伤性肩关节前不稳定的诊断标准为：（１）外伤史;（２）肩前侧痛、无力、关节活动受限和肩周肌肉萎缩;（３）前惧痛征和前抽屉试验阳性;（４）Ｘ线片ＨｉｌＳａｃｈｓ骨缺损和气碘双重造影ＣＴ异常。治疗原则：（１）病程３个月内行康复治疗;（２）病程３个月以上、关节囊撕裂、康复治疗无效者,行手术治疗。治疗结果：４１例患者平均随访１６个月,临床效果满意。结论创伤性肩关节前不稳定诊断标准和治疗原则的提出,对提高肩部损伤的治疗水平以及相关理论的临床研究等,具有重要的参考价值     

Posterior shoulder instability: comprehensive analysis of open and arthroscopic approaches

Whether open surgery and arthroscopic repair of posterior shoulder instability have similar success rates remains unknown, but the literature suggests that arthroscopic soft-tissue stabilization procedures equal open surgery in managing posterior shoulder instability. A comprehensive PubMed computer search of the English-language literature from 1988 to 2004 was performed using the key phrase posterior shoulder instability. Studies included in our analysis addressed the surgical treatment of recurrent posterior instability and multidirectional instability with primarily a posterior component of instability; studies were excluded if their minimum follow-up was less than 1 year, if their patients had a history of habitual posterior shoulder instability, or if their patients had either bony procedures or thermal capsulorrhaphy. Data collected from each study included patient demographics, instability classifications (traumatic vs atraumatic), previous shoulder stabilizations, and clinical outcomes. After identifying and reviewing 283 abstracts, we found that 16 articles fulfilled the inclusion criteria--9 open studies (173 patients) and 7 arthroscopic trials (186 patients). The 2 treatment groups had similar sex distributions (P> .25). Mean age was 23 years for the open group and 26 years for the arthroscopic group (P< .02). Clinical outcomes were rated satisfactory by 72% of patients in the open group and 83% of patients in the arthroscopic group (P< .55), controlling for age. Eighty-five percent of patients treated with an open technique and 81% of patients treated arthroscopically returned to sports (P< .82). This study demonstrated no statistical difference in clinical outcomes for patients treated with either open or arthroscopic surgery for posterior shoulder instability.     

Ultrasound evaluation and clinical correlation of subscapularis repair after total shoulder arthroplasty

The purpose of this study was to document the subscapularis healing rate by use of postoperative ultrasound and correlate healing to physical examination findings. We included 23 patients (30 shoulders), who underwent total shoulder arthroplasty in the study. The evaluation included a standard history and physical examination, ultrasound evaluation, and outcome questionnaires. The postoperative examination included careful documentation of an abdominal-compression test to evaluate subscapularis function. All patients had an improvement in functional outcome scores and shoulder range of motion. Of 30 shoulders, 26 (87%) had an intact subscapularis as determined by ultrasound. By use of ultrasound as the gold standard, the abdominal-compression test had 7 false-positive results, 3 false-negative results, 19 true-negative results, and 1 true-positive result. The sensitivity of the abdominal-compression test was 25%, and the specificity was 73%. The negative predictive value was 86%, and the positive predictive value was 13%. The abdominal-compression test demonstrated a low sensitivity, specificity, and positive predictive value in this study for the assessment of subscapularis function after total shoulder arthroplasty. If a subscapularis tear is suspected in a patient after total shoulder arthroplasty, the abdominal-compression test is unreliable in predicting a subscapularis defect.