[Recurrent instability and instability arthropathy]

A Novel Proportional Method for the Simplified Assessment of Glenoid Bone Loss in Patients With Anterior Shoulder Instability

BACKGROUND

Surgical planning for anterior shoulder instability (ASI) necessitates accurate measurements of glenoid bone defects, but current methods are either challenging or too complex for practical use. This underscores the need for a simplified, but precise, assessment technique for anterior glenoid bone defects.

PURPOSE

To introduce a new measurement technique that requires only computed tomography (CT) of the affected shoulder joint and simultaneously simplifies the assessment of bone defects in the anterior glenoid.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

CT scans of the glenoid from 285 healthy participants and 43 patients with unilateral ASI were collected and reconstructed in 3 dimensions. Initially, we established the proportional relationship between the maximum height and width in the superior-inferior and anterior-posterior directions of the glenoid as well as the location of their intersection (point O) in healthy participants. Subsequently, glenoid bone defects in patients with ASI were measured using the contralateral comparison method, the best-fit circle method, the CT-specific formula method, and our novel proportional method. We analyzed the differences in defect ratios and sizes as well as glenoid track calculations among the 4 methods.

RESULTS

The mean width-to-height ratio of the glenoid was determined to be 0.69 ± 0.04, allowing for the simplification of the calculation to width = 0.7 × height for clinical convenience. Point O was consistently located at the lower one-third of the glenoid height. There was no statistical significance noted in the measurements of bone defect size and bone defect ratio when comparing the novel proportional method, the contralateral comparison method, and the best-fit circle method; however, a significant increase in bone defect size and bone defect ratio was estimated with the CT-specific formula method (defect size: F = 19.20, P < .0001; defect ratio: F = 15.99, P < .0001).

CONCLUSION

We introduced a novel method for estimating the width of glenoid bone defects through the proportion of glenoid width to height, finding that 70% of the glenoid height at its lower one-third closely approximated its maximum width. This approach, requiring only CT data from the affected shoulder, simplified calculations and matched the accuracy of traditional methods. It offers potential clinical benefits in evaluating glenoid defects.

Low grade of osteoarthritis development after Latarjet procedure with a minimum 5 years of follow-up: a systematic review and pooled analysis

PURPOSE

The purpose of this systematic review and pooled analysis was to evaluate incidence and risk factors for glenohumeral osteoarthritis (OA) in patients who underwent Latarjet procedure with a minimum of 5-year follow-up.

METHODS

The PRISMA guidelines were followed to perform this systematic review. PubMed and EMBASE were searched up to February 29, 2020 for English, human in vivo studies that evaluated glenohumeral OA in patients undergoing Latarjet procedure at least 5 years after surgery. A pooled analysis on the included databases sent by authors was performed to evaluate the risk factors influencing the development or progression of dislocation arthropathy after the Latarjet procedure.

RESULTS

Four studies, including a total of 280 patients (213 males and 67 females), were analysed. In our study population, the median age at surgery was 25.0 years (range 20.8-32.6 years). and 92.1% were athletes. In 90% of the cases, the number of dislocations before surgery were fewer than 5. The recurrence of instability after Latarjet procedure was observed only in seven patients (2.5%). The position of the bone graft resulted flush to the anterior glenoid rim in 238 cases (85.3%), medial in 8 (2.9%) and overhanging in 33 (11.8%). Radiological signs of development or progression of shoulder OA were observed in 25.8% of the patients, of which 88.6% presented a grade 1 of OA according to Samilson and Prieto classification. The overhanging position of the bone graft resulted statistically significant for onset or worsening of OA. The age at surgery, the number of dislocations before surgery and the Hill-Sachs lesion were not significantly associated with joint degeneration. Instead, hyperlaxity showed a prevention role in the development of OA after open Latarjet procedure.

CONCLUSION

The Latarjet procedure is a valid and safe surgical treatment in recurrent anterior shoulder instability with a low risk of developing moderate or severe OA also at long-term follow-up. The overhanging position of the bone graft represents the principal risk factor of joint degeneration, whereas the hyperlaxity seems to be protective. Finally, age, gender, time between first dislocation and surgery, and number of dislocations do not seem to affect the onset of OA after Latarjet procedure. Therefore, an accurate execution of the Latarjet procedure can be considered a valid treatment even in young and athletes thanks to the low recurrence rates and the low development of major long-term complications.

LEVEL OF EVIDENCE

IV.

Patients without re-dislocation in the short term after arthroscopic knotless Bankart repair for anterior shoulder instability may show residual apprehension and recurrence in the long term after 5 years

HYPOTHESIS

The aim of this study was to report the long-term results, residual instability, and recurrence rate of arthroscopic Bankart repair surgery without a re-dislocation event in the first 5 years.

METHODS

We performed a retrospective analysis of Bankart repairs performed in a single center, by a single surgeon, with a minimum of 5 years' follow-up. Patients without a re-dislocation in the first 5 years of surgery were included. Patients who underwent open repair, those who underwent revision surgery, and those with critical glenoid bone loss were excluded. A total of 68 shoulders in 66 patients (51 male and 15 female patients) were included. Patients were analyzed in 2 domains: (1) failures defined as re-dislocation and (2) failures defined as apprehension and re-dislocation combined (residual instability). Clinical outcomes were assessed using shoulder range of motion, the American Shoulder and Elbow Surgeons score, and the Western Ontario Shoulder Instability Index (WOSI) score. Pain, residual apprehension, re-dislocations, and additional surgical procedures were recorded.

RESULTS

The mean age of patients was 31.16 (range, 16-60 years), and the mean follow-up duration was 8.42 ± 2.1 years. The median number of dislocations was 3 (range, 1-20), and the median time from first dislocation to surgery was 16 months (interquartile range, 3-100.5 months). Five patients reported re-dislocations (7.4%) with a mean period of 6.54 ± 2.5 years (range, 5-10.8 years). Seven patients without re-dislocations and 2 patients with re-dislocations reported residual apprehension. Mean shoulder elevation and mean external rotation were 161.3° ± 12.4° and 39.2° ± 11°, respectively. The mean visual analog scale, American Shoulder and Elbow Surgeons, and WOSI scores were 0.5 ± 1.4, 91 ± 11.9, and 88 ± 12.1, respectively. Age was similar in patients with stable shoulders and those with shoulders with re-dislocation or residual instability. The WOSI score was lower in patients with re-dislocation and residual instability (P = .030 and P = .049, respectively).

CONCLUSIONS

Arthroscopic Bankart repair is a successful surgical option for anterior shoulder instability. The 7.4% re-dislocation rate after 5 years indicates there may be a deterioration of capsulolabral repair in certain patients. The long-term failure pattern may be underestimated in short- to mid-term projections.

Biceps Brachii Alterations Following the Latarjet Procedure: A Prospective Multicenter Study

Purpose: To prospectively investigate the postoperative forearm supination and elbow flexion strength of both upper extremities and popeye deformity in patients who underwent a mini-open Latarjet procedure for anterior shoulder instability. Methods: Patients who underwent a mini-open Latarjet procedure at two specialized shoulder centers were prospectively evaluated preoperatively (T0) and at least 6 months (T1) after surgery. Subjects were tested for elbow flexion and forearm supination strength of both upper extremities using an isometric dynamometer and customized torque dynamometer. Clinical outcome was assessed by the Constant Score (CS), American Shoulder and Elbow Score (ASES) and Simple Shoulder test (SST). Popeye deformity was defined as a distalization of the greatest circumference of the biceps muscle belly towards the lateral epicondyle of the elbow. Results: A total of 20 patients with a mean age of 27 ± 6 years were included in the study. At a mean follow-up of 10 ± 3 months, the elbow flexion strength was restored to the preoperative state (p = 0.240). Forearm supination strength significantly decreased at final follow-up, to 88 % in the surgical arm (p = 0.015) vs. 90 % in the non-surgical arm (p = 0.023). There was no statistical difference when comparing both arms concerning elbow flexion strength (p = 0.510) and forearm supination strength (p = 0.495). No significant popeye deformity was observed in both arms (p = 0.111 vs. p = 0.508). Clinical outcome scores improved significantly from 73 ± 18 to 82 ± 13 (p = 0.014) for CS and 76 ± 22 to 89 ± 12 (p = 0.008) for ASES score preoperatively to final follow-up. No difference in the SST was documented (p = 0.10). Conclusion: The Latarjet procedure showed to preserve elbow flexion strength and provided comparable forearm supination strength compared to the uninjured arm with reliable clinical outcome in this study population. However, a decrease of forearm supination strength in both arms was persistent at a mean of 10 months postoperatively. No popeye deformity was noted in the postoperative examinations. Level of evidence: Case series, Level III.

Differences in Patients' and Surgeons' Expectations before Shoulder Stabilization Surgery

Purpose: The primary goal of shoulder stabilization procedures is to re-establish stability and many surgeons measure the success after shoulder stabilization surgery only by the absence of re-dislocation. However, patients might also suffer from pain, loss of range of motion and strength as well as anxiety and stigmatization and therefore have other expectations from a stabilization surgery than just a stable shoulder. Purpose of this study was to analyze if surgeons know what their patients typically expect from a shoulder stabilization surgery. Furthermore, the aim was to analyze the influence of various factors on patients’ expectations. Materials and Methods: 204 patients with a diagnosis of shoulder instability scheduled for surgical treatment were included in this prospective multicentric study. Preoperatively, objective and subjective scores were obtained and patients were asked about their postoperative expectations. Additionally, 25 surgeons were interviewed with regard to what they think their patients expect from the surgery using standardized questions. Results: With regard to postoperative expectations surveyed by the Hospital for Special Surgery questionnaire (HSS), the most important goal to achieve for the patients was ‘stopping the shoulder from dislocation’, followed by ‘to improve the ability to exercise or participate in sports’ and ‘being the shoulder to be back the way it was before the issue started’. The ranking of factors for patients was ‘stability’ as the most important to achieve, followed by ‘movement’, ‘strength’, ‘pain’ and ‘cosmetics’. For surgeons, the order was ‘stability’ (p = 0.004 **), ‘movement’ (p = 0.225), ‘pain’ (p = 0.509), ‘strength’ (p = 0.007 **) and ‘cosmetics’ (p = 0.181). There was a significant difference between patients and surgeons with regard to gaining stability at the cost of movement (p = 0.001 **). Conclusion: Patients and surgeons expectations regarding outcome after surgical shoulder stabilization procedures are quite similar with limited topics of disagreement. Generally, surgeons tend to overrate the importance of stability at the costs of other factors.

Insufficient consensus regarding circle size and bone loss width using the ratio-"best fit circle"-method even with three-dimensional computed tomography

PURPOSE

Glenoid bone integrity is crucial for shoulder stability. The purpose of this study was to investigate a non-invasive method for quantifying bone loss regarding reliability and accuracy to detect glenoid bone deficiency in standard two-dimensional (2D) and three-dimensional (3D) computed tomography (CT) measurements at different time points. It was hypothesized that the diameter of the circle used would significantly differ between raters, rendering this method inaccurate and not allowing for an exact estimation of glenoid defect size.

METHODS

Fifty-two shoulder CTs from 26 patients (26 2D-CTs; 26 3D-CTs) with anterior glenoid bone defects were evaluated by 6 raters at time 0 (T0) and at least 3 weeks after (T1) to assess the glenoid bone defect using the ratio method ("best fit circle"). Inter- and intra-rater differences concerning circle dimensions (circle diameter), measured width of bone loss and calculated percentage of bone loss (length-width-ratio) were compared in 2D- versus 3D-CT scans. The intraclass coefficient (ICC) was used to determine the inter- and intra-rater agreement.

RESULTS

The mean circle diameter difference in 2D-CT was 2.0 ± 1.9 mm versus 1.8 ± 1.5 mm in 3D-CT, respectively (p < 0.01). Mean width of bone loss in 2D-CT was 1.9 ± 1.7 mm compared to 1.7 ± 1.5 mm in 3D-CT, respectively (p < 0.01). The mean difference of bone loss percentage was 5.1 ± 4.8% in 2D-CT and 4.8 ± 4.5% in 3D-CT (p < 0.01). No significant differences concerning circle diameter, bone loss width and bone loss percentage were detected comparing T0 and T1. Circle diameter, bone loss width and bone loss percentage measurements in 3D-CT were significantly smaller compared to 2D-CT at T0 and T1 (p < 0.01). Agreement (ICC) was fair to good for all indicators of circle diameter (range 0.76-0.83), bone loss width (range 0.76-0.86) and percentage of bone loss (range 0.85-0.91). Overall, 3D-CT showed superior agreement compared to 2D-CT.

CONCLUSION

The ratio method varies in all glenoid parameters and is not valid for consistently quantifying glenoid bone defects even in 3D computed tomography. This must be taken into consideration when determining proper surgical treatment. The degree of glenoid bone loss alone should not be used to decide for or against a bony procedure. Rather, it is more important to define a defect size as "critical" and to also take other patient-specific factors into consideration so that the best treatment option can be undertaken. Application of the "best fitting circle" is a source of error when using the ratio method; therefore, care should be taken when measuring the circle diameter.

LEVEL OF EVIDENCE

III.

Arthroscopic glenoid labral lesion repair using all-suture anchor for traumatic anterior shoulder instability: short-term results

BACKGROUND

This study presents the preliminary clinical results of arthroscopic glenoid labral lesion repair using all-suture anchors in the treatment of recurrent traumatic anterior shoulder instability.

METHODS

Seventy patients who underwent arthroscopic shoulder stabilization for traumatic anterior shoulder instability were evaluated in this single center-based retrospective study. Patients with a glenoid defect greater than 20%, off-track engaging Hills-Sachs lesion, multidirectional instability, and generalized ligamentous laxity were excluded. The 62 included patients treated with arthroscopic glenoid labral lesion repair using all-suture anchors were evaluated. The Rowe and Constant scores were used to assess the results.

RESULTS

We evaluated 62 patients with a mean age of 26.7 ± 12 years. The mean Rowe and Constant scores were 35 ± 7.2 and 65 ± 6.3, respectively, preoperatively and increased to 93.6 ± 5.3 and 92 ± 4.3, respectively, postoperatively at the mean follow-up of 28.8 months (range, 24-48 months) (P < .001). The redislocation rate was 8.1%. Of the patients, 91.9% had good to excellent clinical scores. Younger age and contact sports were associated with a higher risk of recurrent dislocation (P = .012 and P = .041, respectively). The postoperative functional results were not significantly correlated with the findings concerning the number of dislocations, time until surgery, degree of anterior translation, and number of anchors.

CONCLUSION

The use of all-suture anchors for arthroscopic glenoid labral lesion repair for the treatment of recurrent traumatic anterior shoulder instability yields satisfactory clinical results and is a safe and effective option.

Arthroscopic Knotless, Tensionable All-Suture Anchor Bankart Repair

Surgical management for glenohumeral instability has advanced to provide stronger fixation and to be less invasive. Arthroscopic suture anchor repair has been the gold standard for isolated capsulolabral tears over the years. Despite the ability of the solid suture anchors to handle physiologic load, they can present challenges such as chondral damage due to anchor size and imperfect angulation, osteolysis, anchor breakage, revision drilling, difficulty of revision surgery with accompanied bone loss, and compromised postoperative magnetic resonance imaging quality. Recently, knotless all-suture anchors have been introduced as a technique to overcome these challenges. These anchors lack a rigid component and can be placed in a tunnel of smaller diameter, thereby allowing for maintenance of glenoid bone stock. The purpose of this Technical Note is to describe our preferred surgical technique with a minimally invasive approach for the fixation of capsulolabral tears using a knotless all-suture anchor construct.

Long-term clinical outcome of arthroscopic Bankart repair with suture anchors

BACKGROUND

The most common surgical technique in traumatic anterior shoulder instability is the arthroscopic Bankart repair, which has excellent short-term results. The long-term results of the arthroscopic Bankart repair are less frequently studied, with a high recurrence rate of 23% to 35%. The aim of this study was to evaluate the medium-term to long-term results of arthroscopic Bankart repair using suture anchors and to identify specific risk factors for recurrent instability.

METHODS

Included were 147 patients after traumatic anterior shoulder dislocation who underwent an arthroscopic Bankart repair. The primary outcome was recurrent instability, defined as dislocation or subluxation as perceived by the patients. The secondary outcome was subjective shoulder stability and function as well as quality of life, evaluated using the Western Ontario Shoulder Instability Index, the Simple Shoulder Test, and the 12-Item Short Form Health Survey. Prognostic factors for recurrent instability were analyzed.

RESULTS

Recurrent instability occurred in 22% of patients with a mean follow-up of 6.3 years. Survival at 5 and 10 years without recurrent instability was 79% and 78%, respectively (95% confidence interval, 72%-85% and 71%-85%, respectively). The Western Ontario Shoulder Instability Index score, the Simple Shoulder Test score, and the 12-item Short Form Physical Component Summary improved significantly in the nonrecurrence group (P < .001, P = .004, and P = .002, respectively). Younger age and use of fewer than 3 anchors were associated with a higher risk of recurrent dislocation (P = .008 and P = .039, respectively).

CONCLUSION

We found an overall recurrent instability rate of 22% (dislocation or subluxation). Good long-term results were observed after arthroscopic Bankart repair in patients older than 20 years with 3 or more suture anchors used.

Long-term outcome of arthroscopic remplissage in addition to the classic Bankart repair for the management of recurrent anterior shoulder instability with engaging Hill-Sachs lesions

PURPOSE

The evaluation of the long-term outcome of the arthroscopic remplissage performed in addition to the classic Bankart repair for the primary management of recurrent anterior shoulder instability with engaging Hill-Sachs lesion without inverted pear appearance of the glenoid during arthroscopy.

METHODS

During a 6-year period, from 2007 to 2012, 65 patients whose average age was 30.1 ± 7.6 years were operated on in our department and satisfied the inclusion criteria of this study. They all had a positive apprehension sign preoperatively. Among them, 51 patients (82%) were available for long-term evaluation. The mean follow-up period was 8.1 ± 1.8 years (range 5.6-10.6).

RESULTS

Three patients (5.6%) had suffered a new dislocation. The remaining patients (94.4%) were satisfied with the surgical result and returned to their previous daily activities, whereas 71% continued to participate in sports without restrictions. The ASES score increased from 72.5 (range 18-100) preoperatively to 100 (range 85-100) postoperatively (p < 0.01). The modified Rowe score increased from 40 (range 15-70) to 100 (range 70-100) (p < 0.001), and the Oxford Instability score from 29 (range 9-47) to 48 (range 36-48) (p < 0.001). No significant restriction in the shoulder range of motion was documented.

CONCLUSIONS

The combination of the arthroscopic remplissage with the classic Bankart repair was proven to be a safe and effective procedure for the treatment of "engaging" Hill-Sachs lesions without inverted pear appearance of the glenoid. This combination has long-term outcomes in terms of the recurrence rate and does not significantly influence the range of motion of the shoulder.

LEVEL OF EVIDENCE

Therapeutic Study-Case series with no comparison group, Level IV.

Surgical technique and clinical outcome of arthroscopic shoulder stabilization via suture anchors using the lasso-loop stitch

During arthroscopic Bankart-repair the lasso-loop-stitch can be used. The clinical outcome of this technical modification to a broadly used procedure is not known. We followed-up 24 patients treated with this technique over 30 months. We found an excellent clinical outcome in 96% of all cases. The average Rowe-score was 96.3 points. The mean QuickDash was 2.8 points. Using the lasso-loop-stitch in arthroscopic Bankart-repair is safe and results in very good clinical outcomes. It might lead to an accentuated labral bump and enables secure knot-tying with knot-positioning away from the articular cartilage while avoiding the suture cutting through the tissue.