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BackgroundThe purpose of this study was to evaluate the results of arthroscopic treatment of traumatic unidirectional recurrent posterior subluxation of the shoulder.MethodsWe treated twenty-seven patients who had traumatic unidirectional recurrent posterior subluxation of the shoulder with arthroscopic labral repair and posterior capsular shift, and we evaluated them at a mean of thirty-nine months postoperatively. Patients who had posteroinferior instability, multidirectional instability, or an atraumatic onset or who were undergoing revision were excluded. There were twenty-five male and two female patients with a mean age of twenty-one years (range, fourteen to thirty-three years). All patients were involved in sports activity, and all had had a substantial injury prior to the onset of the instability. Results were assessed on the basis of stability, motion, and UCLA (University of California at Los Angeles), ASES (American Shoulder and Elbow Surgeons), and Rowe scores. Pain and function were also evaluated with visual analog scales.ResultsAll patients had one or more lesions in the posteroinferior aspect of the labrum and capsule. The most common finding was incomplete stripping of the posteroinferior aspect of the labrum (eighteen patients). At the arthroscopy, the posteroinferior aspect of the capsule appeared to be stretched in twenty-two patients. At the time of follow-up, all patients had improved shoulder function and scores (p < 0.01). All patients also had a stable shoulder according to subjective and objective measurements, except for one patient who had recurrent subluxation. Except for that patient, all patients were able to return to their prior sports activity with little or no limitation. Shoulder function was graded as >90% of the preinjury level in twenty-four patients. There were twenty-one excellent UCLA scores, five good scores, and one fair score. The average pain score improved from 4.5 points preoperatively to 0.2 point at the time of follow-up (p < 0.0001). The mean loss of internal rotation was one vertebral level. There were no operative complications.ConclusionsArthroscopic posterior labral repair and capsular shift to treat traumatic unidirectional recurrent posterior subluxation is a reliable procedure with respect to providing stability, pain relief, and functional restoration.Level of EvidenceTherapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Occupation ratio and fatty infiltration are important parameters for evaluating patients with rotator cuff tears. We analyzed the occupation ratio using a deep-learning framework and studied the fatty infiltration of the supraspinatus muscle using an automated region-based Otsu thresholding technique. To calculate the amount of fatty infiltration of the supraspinatus muscle using an automated region-based Otsu thresholding technique. The mean Dice similarity coefficient, accuracy, sensitivity, specificity, and relative area difference for the segmented lesion, measuring the similarity of clinician assessment and that of a deep neural network, were 0.97, 99.84, 96.89, 99.92, and 0.07, respectively, for the supraspinatus fossa and 0.94, 99.89, 93.34, 99.95, and 2.03, respectively, for the supraspinatus muscle. The fatty infiltration measure using the Otsu thresholding method significantly differed among the Goutallier grades (Grade 0; 0.06, Grade 1; 4.68, Grade 2; 20.10, Grade 3; 42.86, Grade 4; 55.79, p  < 0.0001). The occupation ratio and fatty infiltration using Otsu thresholding demonstrated a moderate negative correlation ( ρ  = − 0.75, p  < 0.0001). This study included 240 randomly selected patients who underwent shoulder magnetic resonance imaging (MRI) from January 2015 to December 2016. We used a fully convolutional deep-learning algorithm to quantitatively detect the fossa and muscle regions by measuring the occupation ratio of the supraspinatus muscle. Fatty infiltration was objectively evaluated using the Otsu thresholding method. The proposed convolutional neural network exhibited fast and accurate segmentation of the supraspinatus muscle and fossa from shoulder MRI, allowing automatic calculation of the occupation ratio. Quantitative evaluation using a modified Otsu thresholding method can be used to calculate the proportion of fatty infiltration in the supraspinatus muscle. We expect that this will improve the efficiency and objectivity of diagnoses by quantifying the index used for shoulder MRI.

Background The effects of tranexamic acid (TXA) in the setting of shoulder arthroplasty are unclear. The objective of this study was to examine the effects of TXA in reducing the need for blood transfusions and blood loss in patients undergoing primary total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). Methods We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and retrospective cohort studies (RCS) that compared outcomes of patients who did and did not receive TXA during TSA or RTSA. We searched Cochrane Central Register of Controlled Trials, EMBASE, and MEDLINE for relevant studies. We assessed the risk of bias of the included studies and calculated pooled risk estimates. The primary outcome was transfusion rate, and secondary outcomes were changes in hemoglobin, estimated total blood loss (ETBL), blood loss via drainage, operative time, hospital stay, overall complications, and thromboembolic events. Results We identified 3 RCTs and 3 RCS including 677 patients with 680 shoulders (343 TXA and 337 non-TXA). The random-effects model meta-analysis showed that TXA group had a lower transfusion rate (risk ratio (RR) 0.34, 95% CI 0.14 to 0.79), less change in hemoglobin (mean difference (MD) -0.64 g/dl, 95% CI -0.81 to − 0.46), and reduced ETBL (MD -249.24 ml, 95% CI -338.74 to − 159.74). In patients with RTSA, the TXA group had a lower transfusion rate (RR 0.28, 95% CI 0.14 to 0.79), less ETBL (MD -249.15 ml, 95% CI -426.60 to − 71.70), less change in hemoglobin (MD − 0.64 g/dl, 95% CI -0.86 to − 0.42), and less blood loss via drainage (MD − 84.56 ml, 95% CI -145.72.14 to − 23.39) than non-TXA group. Conclusions The use of TXA in primary shoulder arthroplasty appears safe, and can reduce transfusion rate, changes in hemoglobin, and perioperative total blood loss, especially in patients with RTSA. Level of Evidence: Systematic Review and meta-analysis, III.

A transection (root tear or complete radial tear) injury of the medial meniscus posterior horn is not rare in the oriental area and needs to be repaired to restore the hoop tension and to reduce the extruded meniscus, which leads to osteoarthritis of the knee. In cases with transection of the medial meniscus posterior horn, the meniscus can be repaired by a pull out suture technique. However, it is difficult to manipulate a suture hook and drill a tibial tunnel in the narrow medial joint space using the traditional anterior arthroscopic technique. This article describes a new pull out suture technique for transection of the medial meniscus posterior horn using a posterior trans‐septal portal that provides a safe and wide field of vision. The handling of the suture hook and a guide may reduce the possibility of a chondral or meniscal injury.

Objectives To compare the accuracy of indirect magnetic resonance arthrography and noncontrast magnetic resonance imaging for diagnosing rotator cuff tears. Materials and methods In total, 333 patients who underwent noncontrast magnetic resonance imaging or indirect magnetic resonance arthrography were included retrospectively. Two musculoskeletal radiologists evaluated the images for the presence of supraspinatus-infraspinatus and subscapularis tendon tears. The overall diagnostic performance was calculated using the arthroscopic findings as the reference standard. Statistical differences between the diagnostic performances of the two methods were analyzed. Results Ninety-six and 237 patients who underwent noncontrast magnetic resonance imaging and indirect magnetic resonance arthrography were assigned into groups A and B, respectively. Sensitivity for diagnosing articular-surface partial-thickness supraspinatus-infraspinatus tendon tear was slightly higher in group B than in group A. Statistical significance was confirmed by multivariate analysis using the generalized estimating equation ( p  = 0.046). The specificity for diagnosing subscapularis tendon tear (85 % vs. 68 %, p  = 0.012) and grading accuracy (57 % vs. 40 %, p  = 0.005) was higher in group B than in group A; the differences were statistically significant for one out of two readers. Univariate analysis using the generalized estimating equation showed that the accuracy for diagnosing subscapularis tendon tear in group B was higher than in group A ( p  = 0.042). There were no statistically significant differences between the diagnostic performances of both methods for any other parameters. Conclusion Indirect magnetic resonance arthrography may facilitate more accurate diagnosis and grading of subscapularis tendon tears compared with noncontrast magnetic resonance imaging.

To compare the accuracy between a three-dimensional (3D) indirect isotropic T1-weighted fast spin-echo (FSE) magnetic resonance (MR) arthrography and a conventional two-dimensional (2D) T1-weighted sequences of indirect MR arthrography for diagnosing rotator cuff tears. The study was approved by our Institutional Review Board. In total, 205 patients who had undergone indirect shoulder MR arthrography followed by arthroscopic surgery for 206 shoulders were included in this study. Both conventional 2D T1-weighted FSE sequences and 3D isotropic T1-weighted FSE sequence were performed in all patients. Two radiologists evaluated the images for the presence of full- or partial-thickness tears in the supraspinatus-infraspinatus (SSP-ISP) tendons and tears in the subscapularis (SSC) tendons. Using the arthroscopic findings as the reference standard, the diagnostic performances of both methods were analyzed by the area under the receiver operating characteristic curve (AUC). Arthroscopy confirmed 165 SSP-ISP tendon tears and 103 SSC tendon tears. For diagnosing SSP-ISP tendon tears, the AUC values were 0.964 and 0.989 for the 2D sequences and 3D T1-weighted FSE sequence, respectively, in reader I and 0.947 and 0.963, respectively, in reader II. The AUC values for diagnosing SSC tendon tears were 0.921 and 0.925, respectively, for reader I and 0.856 and 0.860, respectively, for reader II. There was no significant difference between the AUC values of the 2D and 3D sequences in either reader for either type of tear. 3D indirect isotropic MR arthrography with FSE sequence and the conventional 2D arthrography are not significantly different in terms of accuracy for diagnosing rotator cuff tears.

Purpose: Hyaluronate-based anti-adhesive agents are expected to enhance rotator cuff healing; however, their effect on the incidence and extent of postoperative complications such as stiffness and retears has not been investigated. Methods: From July 2012 to February 2013, 80 patients undergoing arthroscopic rotator cuff repair surgery were prospectively enrolled. Forty patients were assigned to the control group, while the other 40 were assigned to the injection group and received a Guardix-sol injection immediately after surgery. Passive range of motion, pain visual analog scale, and functional score were assessed at 8 weeks, 6 months, and 24 months postoperatively. Gliding motion between the deltoid muscle and the greater tuberosity of the proximal humerus was evaluated using ultrasonography at 2 and 8 weeks postoperatively, and tendon integrity was evaluated using magnetic resonance imaging at 6 months postoperatively. Results: We found no significant difference between the groups regarding gliding motion at 2 weeks postoperatively. However, at 8 weeks, the incidence of poor gliding motion was 2.5% and 15% for the injected patients and control group, respectively, which was statistically significant. At 6 months after surgery, the retear rate between the two groups was not statistically significant. We found no statistically significant difference between the two groups regarding retear rate and clinical score throughout the follow-up period. We noted no complications related to the use of Guardix-sol. Conclusions: Patients who received the Guardix-sol injection showed improved gliding motion between the deltoid muscle and the greater tuberosity in the early postoperative period.

Purpose: Although several cases of anatomical variants of the proximal portion of the long head of the biceps brachii tendon have been reported, most are case reports on single patients; few studies have investigated the classification and incidence of this phenomenon. We aimed to classify the variants of the long head of the biceps brachii tendon by their morphology and characterize them in regard to incidence, demography, and the relationship with biceps tendon or other shoulder diseases. Methods: We retrospectively reviewed 760 arthroscopic images spanning 31 months from October 2008 and found 45 variations of the proximal portion of the long head of the biceps brachii tendon. We classified the variants using Dierickx classification system and calculated the incidence of each subtype. We investigated age, gender, bicipital morbidity rate, procedure rate, and the frequency of related shoulder disease among the variant groups using patient data and compared the groups to normal patients. Results: The overall incidence of variants was 6.5% (67.4%, mesotenon; 32.6%, adherent; 0% split (SPL); and 0% absent (ABS) type). Morbidity and procedure rates of the long head of the biceps (LHB) tendon in the variant group (27.9% and 25.6%, respectively) were lower than in the normal group (40.5% and 38.9%, respectively), but the difference was not statistically significant (p = 0.102 and 0.082, respectively). Rotator cuff tear was significantly less common in the mesotenon (44.8%) group than in the normal group (62.4%; p = 0.004). Shoulder joint instability was more prevalent in the mesotenon (27.6%) group than in the normal group (14.9%), but the difference was not significant (p = 0.305). The distribution of other shoulder diseases in the adherent group was similar to that in the normal group. Conclusions: The incidence of variants of the long head of the biceps brachii tendon was 6.5%, and most variants were mesotenon or adherent type. The SPL and ABS types were rare. Morbidity and procedure rates of the LHB were not significantly different between the variant group and the normal group, and rotator cuff tear was less common in the mesotenon group.

Purpose: We aimed to evaluate the influence of the bony morphology of the bicipital groove on the stability of the long head of the biceps tendon (LHBT). Methods: Among the patients who underwent magnetic resonance imaging of the shoulder at our outpatient clinic in 2012, those aged >40 years were included. After excluding cases with complete tear or unclear positioning of the biceps tendon, 464 shoulders were analyzed according to the position of the LHBT with respect to the bicipital groove. Shoulders with subluxation or dislocation of the LHBT were labeled as having unstable LHBT, while those with the LHBT located in the bicipital groove were labeled as having stable LHBT. The bony morphology of the bicipital groove was measured in terms of opening angle, medial wall angle, and depth. A shallow bicipital groove was defined as having an opening angle >94°, concurrent with earlier studies. We compared shoulders with stable and unstable LHBT regarding bicipital bony morphology. We also compared shoulders with normal and shallow grooves regarding tendon stability. Results: Shoulders with stable and unstable LHBT differed significantly regarding bony morphology. Shoulders with unstable LHBT showed a shallower mean depth (by 0.3 mm; p = 0.008), a smaller mean medial angle (by 2.2°; p = 0.014), and a larger mean opening angle (by 3.7°; p = 0.016). Bony morphology characterized by a shallow groove was significantly associated with increased prevalence of instability defined as LHBT subluxation or dislocation (p = 0.011). Conclusion: A shallow bicipital groove, identified by the larger opening angle, smaller medial angle, and shallower depth, may represent a predisposing factor for biceps tendon instability.

Scapular stabilization is thought to have an important role in improving pain and dysfunction around the neck and shoulders, but evidence of this is lacking. We aim to systematically review the effect of a scapular stabilization exercise (SSE) on pain and dysfunction in patients with nonspecific chronic neck pain (NP). We searched the PubMed, EMBASE, CINAHL, and Cochrane Library databases using the terms (NP [MeSH] OR NP OR cervical pain OR neck ache OR cervicalgia) AND (scapular exercise OR periscapular exercise OR SSEs). We included suitable studies that met the study's inclusion criteria. Among the 227 studies identified by our search strategy, a total of four (three randomized controlled studies and one prospective study) met the inclusion criteria. The SSE was intense. It included three sets of 10 repetitions. In most of the studies, the exercises were conducted 3 times per week. Most studies reported that the SSE improved pain and dysfunction in patients with nonspecific chronic NP; however, the reviewed articles did not use the same variables for measurement. Additionally, the sample size was small. Although several studies show that SSE might improve NP and dysfunction, the effects of SSE on pain and dysfunction in the neck region remain unclear because the number of studies was small. Further high-quality studies are necessary to identify the detailed effects of SSE in patients with NP.