Non-operative Management of Posterior Shoulder Instability: An Assessment of Survival and Predictors for Conversion to Surgery at 1 to 13 Years After Diagnosis

Objectives: Among patients treated non-operatively for 1 year following a diagnosis of posterior shoulder instability (PSI), little is known about the the incidence of surgery between 1-13 years after injury. The purpose of this study is to define the frequency and evaluate the factors predictive for late surgical intervention of symptomatic PSI. Methods: This study included a population-based cohort of 115 patients (14 females, 101 males) diagnosed with PSI between January 1994 and July 2012 with a minimum 5-years follow-up (mean:13.9 years; range: 5-23 years). Landmark survival analysis was performed to evaluate incidence of surgery after 1 year. Survival was estimated using Kaplan Meier method and predictors of late surgical intervention were analyzed using Cox proportional hazards regression. Results: A total of 61/115 (53%) patients were treated non-operatively for 1 year following diagnosis of PSI. Of these, 24/61 (39%) converted to surgery for symptomatic PSI. The overall survival free of surgery at 1 and 5 years was 53.0% (95% CI 434.7-63.0) and 37.1% (95% CI 29.1-47.1), respectively. BMI >35 (p=0.04, HR 3.3) was predictive for late conversion to surgery. Age, gender, occupation, or history of glenohumeral dislocation were not significant. Assessing surgery as a time dependent covariate, a patient undergoing surgery was at an increased risk for radiographic progression of osteoarthritis (p=0.02, HR=4.0, 95% CI 1.2-13.2). Conclusion: Conservative management was performed for at least one year in over half of patients diagnosed with PSI. However, long-term follow-up demonstrates that nearly 40% of these patients eventually require surgery. Increased BMI was predictive for late failure of while age, gender, history of dislocation and occupation did not show an effect. Patients who underwent surgery were at an increased risk of radiographic progression of arthritis.

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Posterior Shoulder Instability After Infraclavicular Block for Outpatient Hand Surgery

Hand ◽

10.1177/15589447211065072 ◽

2021 ◽

pp. 155894472110650

Author(s):

Ajay C. Kanakamedala ◽

Jared S. Bookman ◽

David L. Furgiuele ◽

Jacques H. Hacquebord

Keyword(s):

Regional Anesthesia ◽

Shoulder Instability ◽

Case Reports ◽

Hand Surgery ◽

Orthopedic Procedures ◽

Postanesthesia Care Unit ◽

Posterior Shoulder Instability ◽

Posterior Shoulder Dislocation ◽

Posterior Shoulder ◽

Increased Risk

Regional blocks are being increasingly utilized for anesthesia for various orthopedic procedures. Several studies have shown that regional anesthesia has fewer side effects and improved postoperative pain relief compared to general anesthesia, but regional blocks are not without risks. We present case reports of 2 patients who experienced posterior shoulder instability, one of whom had a posterior shoulder dislocation, immediately in the postanesthesia care unit after undergoing hand surgery with regional anesthesia. This paper highlights the importance of being aware that patients might be at increased risk of shoulder instability after upper extremity regional anesthesia, and appropriate perioperative precautions should be taken.

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Incidence of and Risk Factors for Glenohumeral Osteoarthritis After Anterior Shoulder Instability: A US Population–Based Study With Average 15-Year Follow-up

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120962515 ◽

2020 ◽

Vol 8 (11) ◽

pp. 232596712096251

Author(s):

Bradley M. Kruckeberg ◽

Devin P. Leland ◽

Christopher D. Bernard ◽

Aaron J. Krych ◽

Diane L. Dahm ◽

...

Keyword(s):

Risk Factors ◽

Shoulder Instability ◽

The United States ◽

Anterior Shoulder Instability ◽

Geographic Population ◽

Increased Risk ◽

Modifiable Factors ◽

History Of ◽

Former Smokers

Background: The rate of osteoarthritis (OA) in patients with a history of previous anterior shoulder instability (ASI) varies within the literature, with the majority of studies investigating rates after surgical stabilization. ASI appears to lead to increased rates of OA, although risk factors for developing OA in cohorts treated nonoperatively and operatively are not well-defined. Purpose: To determine the incidence of clinically symptomatic OA and identify potential risk factors for the development of OA in patients younger than 40 years with a known history of ASI. Study Design: Case-control study; Level of evidence, 3. Methods: An established, geographically based database was used to identify patients in the United States who were younger than 40 years and were diagnosed with ASI between 1994 and 2014. Patient information, including demographic, imaging, and surgical details, was collected. Comparative analysis was performed between groups with and without OA at final follow-up as well as between patients who underwent surgical and nonsurgical management. Results: The study population consisted of 154 patients with a mean follow-up of 15.2 years (range, 5.1-29.8 years). The mean age at initial instability event was 20.9 years (95% CI, 19.9-22.0 years). Overall, 22.7% of patients developed clinically symptomatic glenohumeral OA. Multivariate analysis revealed that current or former smokers (odds ratio [OR], 4.3; 95% CI, 1.1-16.5; P = .030), hyperlaxity (OR, 10.1; 95% CI, 1.4-72.4; P = .020), laborer occupation (OR, 6.1; 95% CI, 1.02-36.1; P = .043), body mass index (BMI) (OR, 1.2; 95% CI, 1.03-1.3; P = .012), and age at initial instability (OR, 1.1; 95% CI, 1.02-1.2; P = .013) as potential independent risk factors when accounting for other demographic and clinical variables. Conclusion: In a US geographic population of patients younger than 40 years with ASI, approximately one-fourth of patients developed symptomatic OA at a mean follow-up of 15 years from their first instability event. When accounting for differences in patient demographic and clinical data, we noted a potentially increased risk for the development of OA in patients who are current or former smokers, have hyperlaxity, are laborers, have higher BMI, and have increased age at initial instability event. Smoking status, occupation, and BMI are modifiable factors that could potentially decrease risk for the development of symptomatic OA in these patients.

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A Prospective Analysis of Patients With Anterior Versus Posterior Shoulder Instability: A Matched Cohort Examination and Surgical Outcome Analysis of 200 Patients

The American Journal of Sports Medicine ◽

10.1177/0363546518819199 ◽

2019 ◽

Vol 47 (3) ◽

pp. 682-687 ◽

Cited By ~ 7

Author(s):

Andrew S. Bernhardson ◽

Colin P. Murphy ◽

Zachary S. Aman ◽

Robert F. LaPrade ◽

Matthew T. Provencher

Keyword(s):

Shoulder Instability ◽

Matched Cohort ◽

Arthroscopic Stabilization ◽

Mechanism Of Injury ◽

Posterior Shoulder Instability ◽

Anterior Instability ◽

Posterior Instability ◽

Medical Provider ◽

Posterior Shoulder

Background: Anterior and posterior shoulder instabilities are entirely different entities. The presenting complaints and symptoms vastly differ between patients with these 2 conditions, and a clear understanding of these differences can help guide effective treatment. Purpose: To compare a matched cohort of patients with anterior and posterior instability to clearly outline the differences in the initial presenting history and overall outcomes after arthroscopic stabilization. Study Design: Cohort study; Level of evidence, 2. Methods: Consecutive patients with either anterior or posterior glenohumeral instability were prospectively enrolled; patients were excluded if they had more than 10% anterior or posterior glenoid bone loss, multidirectional instability, neurologic injury, or prior surgery. Patients were assigned to anterior or posterior shoulder instability groups based on the history and clinical examination documenting the primary direction of instability, with imaging findings to confirm a labral tear associated with the specific direction of instability. Preoperative demographic data, injury history, and overall clinical outcome scores (American Shoulder and Elbow Surgeons [ASES], Single Assessment Numeric Evaluation [SANE], and Western Ontario Shoulder Index [WOSI]) were assessed and compared statistically between the 2 cohorts. Patients were indicated for surgery if they elected to proceed with surgical management or did not respond to a course of nonoperative management. Results: The study included 103 patients who underwent anterior stabilization (mean age, 23.5 years; range, 18-36 years) and 97 patients who underwent posterior stabilization (mean age, 24.5 years; range, 18-36 years). The mean follow-up was 39.7 months (range, 24-65 months), and there were no age or sex differences between the groups. No patients were lost to follow-up. The primary mechanism of injury in the anterior cohort was a formal dislocation event (82.5% [85/103], of which 46% [39/85] required reduction by a medical provider), followed by shoulder subluxation (12%, 12/103), and “other” (6%, 6/103; no forceful injury). No primary identifiable mechanism of injury was found in the posterior cohort for 78% (75/97) of patients; lifting and pressing (11%, 11/97) and contact injuries (10% [all football blocking], 10/97) were the common mechanisms that initiated symptoms. Only 10 patients (10.3%) in the posterior cohort sustained a dislocation. The most common complaints for patients with anterior instability were joint instability (80%) and pain with activities (32%). In the posterior cohort, the most common complaint was pain (90.7%); only 13.4% in this cohort reported instability as the primary complaint. Clinical outcomes after arthroscopic stabilization were significantly improved in both groups, but the anterior cohort had significantly better outcomes in all scores measured: ASES (preoperative: anterior 58.0, posterior 60.0; postoperative: anterior 94.2 vs posterior 87.7, P < .005), SANE (preoperative: anterior 50.0, posterior 60.0; postoperative: anterior 92.9 vs posterior 84.9, P < .005), and WOSI (preoperative: anterior 55.95, posterior 60.95; postoperative: anterior 92% of normal vs posterior 84%, P < .005). Conclusion: This study outlines clear distinctions between anterior and posterior shoulder instability in terms of presentation and clinical findings. Patients with anterior instability present primarily with an identifiable mechanism of injury and complaints of instability, whereas most patients with classic posterior instability have no identifiable mechanism of injury and their primary symptom is pain. Anterior instability outcomes in this matched cohort were superior in all domains versus posterior instability after arthroscopic stabilization, which further highlights the differences between anterior and posterior instability.

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Results of an open posterior bone block procedure for recurrent posterior shoulder instability after a short- and long-time follow-up

Knee Surgery Sports Traumatology Arthroscopy ◽

10.1007/s00167-014-3495-2 ◽

2015 ◽

Vol 24 (2) ◽

pp. 618-624 ◽

Cited By ~ 22

Author(s):

M. Struck ◽

M. Wellmann ◽

C. Becher ◽

M. F. Pastor ◽

T. Smith

Keyword(s):

Shoulder Instability ◽

Bone Block ◽

Posterior Shoulder Instability ◽

Posterior Shoulder ◽

Long Time ◽

Bone Block Procedure ◽

Posterior Bone Block

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Migraine and the risk of incident hypertension among women

Cephalalgia ◽

10.1177/0333102418756865 ◽

2018 ◽

Vol 38 (12) ◽

pp. 1817-1824 ◽

Cited By ~ 8

Author(s):

Pamela M Rist ◽

Anke C Winter ◽

Julie E Buring ◽

Howard D Sesso ◽

Tobias Kurth

Keyword(s):

Migraine With Aura ◽

Migraine Without Aura ◽

Proportional Hazards ◽

Past History ◽

Cox Proportional Hazards ◽

Incident Hypertension ◽

Cox Proportional Hazards Models ◽

Increased Risk ◽

History Of

Background Few studies have examined whether migraine is associated with an increased risk of incident hypertension. Methods We performed a prospective cohort study among 29,040 women without hypertension at baseline. Women were classified as having active migraine with aura, active migraine without aura, a past history of migraine, or no history of migraine. Incident hypertension was defined as new physician diagnosis or newly self-reported systolic or diastolic blood pressure ≥140 mmHg or ≥90 mmHg respectively. Cox proportional hazards models were used to evaluate the association between migraine and incident hypertension. Results During a mean follow-up of 12.2 years, 15,176 incident hypertension cases occurred. Compared to those with no history of migraine, women who experience migraine with aura had a 9% increase in their risk of developing hypertension (95% CI: 1.02, 1.18); women who experience migraine without aura had a 21% increase in their risk of developing hypertension (95% CI: 1.14, 1.28); and women with a past history of migraine had a 15% increase in their risk of developing hypertension (95% CI: 1.07, 1.23). Conclusions Women with migraine have a higher relative risk of developing hypertension compared to women without migraine.

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Acceptable Long-term Outcomes of Arthroscopic Bone Grafting for Recurrent Posterior Shoulder Instability: minimum follow-up of 5 years

Arthroscopy The Journal of Arthroscopic and Related Surgery ◽

10.1016/j.arthro.2020.10.052 ◽

2020 ◽

Author(s):

Roland Stefan Camenzind ◽

Javier Martin Becerra ◽

Louis Gossing ◽

Julien Serane-Fresnel ◽

Eric R. Wagner ◽

...

Keyword(s):

Shoulder Instability ◽

Bone Grafting ◽

Posterior Shoulder Instability ◽

Long Term Outcomes ◽

Posterior Shoulder

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Faster Transport Status and Mortality in Anuric Patients Undergoing Continuous Ambulatory Peritoneal Dialysis

Blood Purification ◽

10.1159/000433416 ◽

2015 ◽

Vol 40 (2) ◽

pp. 160-166 ◽

Cited By ~ 2

Author(s):

Liping Xiong ◽

Li Fan ◽

Qingdong Xu ◽

Qian Zhou ◽

Huiyan Li ◽

...

Keyword(s):

Peritoneal Dialysis ◽

Continuous Ambulatory Peritoneal Dialysis ◽

Proportional Hazards ◽

Cox Proportional Hazards ◽

Cox Proportional Hazards Models ◽

Increased Risk ◽

All Cause Mortality ◽

History Of ◽

The Relationship

Background: There are limited data regarding the relationship between transport status and mortality in anuric continuous ambulatory peritoneal dialysis (CAPD) patients. Methods: According to the dialysate to plasma creatinine ratio (D/P Cr), 292 anuric CAPD patients were stratified to faster (D/P Cr ≥0.65) and slower transport groups (D/P Cr <0.65). The Cox proportional hazards models were used to evaluate the association of transport status with mortality. Results: During a median follow-up of 22.1 months, 24% patients died, 61.4% of them due to cardiovascular disease (CVD). Anuric patients with faster transport were associated with an increased risk of all-cause mortality (HR (95% CI) = 2.16 (1.09-4.26)), but not cardiovascular mortality, after adjustment for confounders. Faster transporters with pre-existing CVD had a greater risk for death compared to those without any history of CVD. Conclusion: Faster transporters were independently associated with high all-cause mortality in anuric CAPD patients. This association was strengthened in patients with pre-existing CVD.

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Does Labral Reconstruction Prevent Osteoarthritis After Posterior Shoulder Instability: A Population-Based Study

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118s00154 ◽

2018 ◽

Vol 6 (7_suppl4) ◽

pp. 2325967118S0015

Author(s):

Julia Lee ◽

Jarret Murray Woodmass ◽

Isabella Wu ◽

Christopher L. Camp ◽

Diane L. Dahm ◽

...

Keyword(s):

Shoulder Instability ◽

Radiographic Progression ◽

Glenohumeral Joint ◽

Population Based ◽

Posterior Shoulder Instability ◽

Cox Models ◽

Surgical Measures ◽

Glenohumeral Arthritis ◽

Posterior Shoulder ◽

Capsulolabral Reconstruction

Objectives: Diagnosis of and treatment for posterior shoulder instability (PSI) has improved with advances in surgical technique and radiographic imaging. It is unknown if PSI, or surgical measures to correct PSI, affect the progression of osteoarthritis in the glenohumeral joint. The purpose of this study is to evaluate the effect of posterior capsulolabral reconstruction (PCLR) and demographic risk factors on the rate of radiographic progression of osteoarthritis in shoulders with PSI. Methods: The study population included 115 patients (14 females, 101 males) diagnosed with PSI between January 1994 and July 2012 with an average follow up of 12.5years (range 5-23). Medical records were reviewed to evaluate patient demographics, surgical intervention, and radiographic progression of osteoarthritis. Kaplan Meier survival was used to estimate survival and Cox models were used to examine associations with osteoarthritis progression. Results: Overall, 16/115 (14%) patients had radiographic progression of glenohumeral arthritis with 5-year survival at 88.3% (95% CI 79.7%-97.3%). Age ≥30 at the time of instability was associated with arthritis progression (p<0.05). The number of previous dislocations, sport, and gender each did not affect progression (p>0.05). PCLR with at least one anchor along the posterior glenoid rim was performed in 56/115 (48%) of patients. There was no difference in the rate of radiographic arthritic progression in those who underwent PCLR and those who did not (7/56, 13% vs 10/59, 17%, p>0.05). One male patient who underwent PCLR progressed to end-stage arthritis, necessitating a shoulder arthroplasty at age 53. Conclusion: Radiographic progression of glenohumeral arthritis occurred 14% of patients with PSI. Age ≥30 at the time of initial instability was associated with radiographic progression of glenohumeral arthritis.

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Childhood Cancer and the Risk of ESKD

Journal of the American Society of Nephrology ◽

10.1681/asn.2020071002 ◽

2020 ◽

pp. ASN.2020071002

Author(s):

Ronit Calderon-Margalit ◽

Oren Pleniceanu ◽

Dorit Tzur ◽

Michal Stern-Zimmer ◽

Arnon Afek ◽

...

Keyword(s):

Cancer Survivors ◽

Childhood Cancer ◽

Military Service ◽

Benign Tumor ◽

Childhood Cancer Survivors ◽

Cox Proportional Hazards ◽

Benign Tumors ◽

Increased Risk ◽

History Of

BackgroundIncreasing cancer incidence among children alongside improved treatments has resulted in a growing number of pediatric cancer survivors. Despite childhood cancer survivors’ exposure to various factors that compromise kidney function, few studies have investigated the association between childhood cancer and future kidney disease.MethodsTo assess the risk of ESKD among childhood cancer survivors, we conducted a nationwide, population-based, retrospective cohort study that encompassed all Israeli adolescents evaluated for mandatory military service from 1967 to 1997. After obtaining detailed histories, we divided the cohort into three groups: participants without a history of tumors, those with a history of a benign tumor (nonmalignant tumor with functional impairment), and those with a history of malignancy (excluding kidney cancer). This database was linked to the Israeli ESKD registry to identify incident ESKD cases. We used Cox proportional hazards models to estimate the hazard ratio (HR) of ESKD.ResultsOf the 1,468,600 participants in the cohort, 1,444,345 had no history of tumors, 23,282 had a history of a benign tumor, and 973 had a history of malignancy. During a mean follow-up of 30.3 years, 2416 (0.2%) participants without a history of tumors developed ESKD. Although a history of benign tumors was not associated with an increased ESKD risk, participants with a history of malignancy exhibited a substantially elevated risk for ESKD compared with participants lacking a history of tumors, after controlling for age, sex, enrollment period, and paternal origin (adjusted HR, 3.2; 95% confidence interval, 1.3 to 7.7).ConclusionsChildhood cancer is associated with an increased risk for ESKD, suggesting the need for tighter and longer nephrological follow-up.

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