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Hemstock R, Sommer M, McRae S, MacDonald P, Woodmass J, Ogborn D. Characterizing the Practices of Canadian Orthopedic Surgeons in the Management of patients With Anterior Glenohumeral Instability. Clin J Sport Med 2023; 33:611-617. [PMID: 37185225 DOI: 10.1097/jsm.0000000000001155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 03/28/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE To determine the practice patterns of Canadian orthopedic surgeons in the management of patients with anterior glenohumeral instability (AGHI). DESIGN Cross-sectional survey. SETTING Canada. PATIENTS OR OTHER PARTICIPANTS Canadian orthopedic surgeons with membership in the Canadian Orthopedic Association or Canadian Shoulder and Elbow Surgeon group who had managed at least 1 patient with AGHI in the previous year. INTERVENTIONS A survey including demographics and questions on the management of patients with AGHI was completed. Statistical comparisons (χ 2 ) were completed with responses stratified using the instability severity index score (ISIS) in practice, years of practice, and surgical volumes. MAIN OUTCOME MEASURES Summary statistics were compiled, and response frequencies were considered for consensus (75%). Case series responses were stratified on use of the ISIS in practice, years of experience, and annual procedure volumes (χ 2 , P < 0.05). RESULTS Eighty orthopedic surgeons responded, with consensus on areas of diagnostic workup of AGHI, nonoperative management, and operative techniques. There was no consensus on indications for soft tissue and bony augmentation or postoperative management. There was no difference in practices based on the use of ISIS, years in practice, or surgical volumes. CONCLUSIONS Canadian orthopedic surgeons manage AGHI consistently with consensus achieved in preoperative diagnostics and operative techniques, although debate remains as to the indications for soft tissue and bony augmentation procedures.
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Affiliation(s)
- Riley Hemstock
- Department of Surgery, Orthopedic Section, University of Manitoba, Winnipeg, MB, Canada
| | - Micah Sommer
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Sheila McRae
- Department of Surgery, Orthopedic Section, University of Manitoba, Winnipeg, MB, Canada
- Pan Am Clinic Foundation, Winnipeg, MB, Canada; and
- Department of Physical Therapy, University of Manitoba, Winnipeg, MB, Canada
| | - Peter MacDonald
- Department of Surgery, Orthopedic Section, University of Manitoba, Winnipeg, MB, Canada
- Pan Am Clinic Foundation, Winnipeg, MB, Canada; and
| | - Jarret Woodmass
- Department of Surgery, Orthopedic Section, University of Manitoba, Winnipeg, MB, Canada
- Pan Am Clinic Foundation, Winnipeg, MB, Canada; and
| | - Dan Ogborn
- Department of Surgery, Orthopedic Section, University of Manitoba, Winnipeg, MB, Canada
- Pan Am Clinic Foundation, Winnipeg, MB, Canada; and
- Department of Physical Therapy, University of Manitoba, Winnipeg, MB, Canada
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Sudah SY, Menendez ME. Classifications in Brief: The Instability Severity Index Score for Predicting Recurrent Shoulder Instability After Arthroscopic Bankart Repair. Clin Orthop Relat Res 2023; 481:382-386. [PMID: 36006660 PMCID: PMC9831186 DOI: 10.1097/corr.0000000000002386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/09/2022] [Indexed: 02/04/2023]
Affiliation(s)
- Suleiman Y. Sudah
- Department of Orthopedics, Monmouth Medical Center, Long Branch, NJ, USA
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Cyst formation and bony ingrowth inside coil-type open-architecture anchors used for arthroscopic remplissage: a volumetric computed tomographic study of 50 anchors. J Shoulder Elbow Surg 2023; 32:333-339. [PMID: 36049702 DOI: 10.1016/j.jse.2022.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 07/06/2022] [Accepted: 07/10/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The use of anchors in the proximal humerus during arthroscopic surgery can cause localized bone loss due to osteolysis and cyst formation. The purpose of this study was to use computed tomography (CT) to evaluate the incidence of implant-related bone loss and cyst formation after implantation of polyetheretherketone (PEEK) coil-type open-architecture anchors during remplissage for the management of Hill-Sachs defects (HSDs) in patients with shoulder instability. METHODS This was a single-cohort, observational study with a minimum of 12 months of follow-up. Subjects undergoing arthroscopic instability surgery with HSD requiring remplissage were included. The volume of the bone defects and the degree of bony ingrowth into the anchor were measured on CT images. RESULTS Thirty-one participants (28 males, 3 females; mean age 29.4 years, standard deviation [SD] 10.6) in whom 50 anchors (4.5-mm Healicoil PEEK double-loaded anchors) were used were evaluated with a CT performed at a mean of 14.1 (SD 3.74) months after surgery. Full bony ingrowth inside the anchor was found in 15 anchors (30%, range 17.8%-44.5%); clear ossification with a thin lucent rim was found in 10 anchors (20%, range 10.0%-33.7%); discontinuous ossification was found in 8 anchors (16%, range 7.2%-29.1%); and no ossification was observed inside 17 anchors (34%, range 21.2%-48.7%). Regarding bone defect size, no bone defect was identified in 15 anchors (30%, 95% CI 17.9%-44.6%), a partial bone defect was found in 17 anchors (34%, 95% CI 21.2%-48.7%), hole enlargement was found in 17 anchors (34%, 95% CI 21.2%-48.7%), and 1 anchor caused a cyst larger than twice the size of the hole made for anchor insertion (2%, 95% CI 0.1%-8.6%). At the 1-year evaluation, none of the participants presented recurrence or residual apprehension. CONCLUSION The use of PEEK coil-type open-architecture anchors for remplissage during instability surgery caused large cystic lesions in less than 10% of anchors. There was full bony ingrowth in one-third of anchors, and partial cancellous bone ingrowth occurred in another third of anchors.
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Trasolini NA, Dandu N, Azua EN, Garrigues GE, Verma NN, Yanke AB. Inconsistencies in Controlling for Risk Factors for Recurrent Shoulder Instability After Primary Arthroscopic Bankart Repair: A Systematic Review. Am J Sports Med 2022; 50:3705-3713. [PMID: 34591717 DOI: 10.1177/03635465211038712] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Failure rates after arthroscopic shoulder stabilization are highly variable in the current orthopaedic literature. Predictive factors for risk of failure have been studied to improve patient selection, refine surgical techniques, and define the role of bony procedures. However, significant heterogeneity in the analysis and controlling of risk factors makes evidence-based management decisions challenging. PURPOSE The goals of this systematic review were (1) to critically assess the consistency of reported risk factors for recurrent instability after arthroscopic Bankart repair, (2) to identify the existing studies with the most comprehensive inclusion of confounding factors in their analyses, and (3) to give recommendations for which factors should be reported consistently in future clinical studies. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS A systematic review of the literature was performed in accordance with the PRISMA guidelines. An initial search yielded 1754 titles, from which 56 full-text articles were screened for inclusion. A total of 29 full-text articles met the following inclusion criteria: (1) clinical studies regarding recurrent anterior shoulder instability; (2) surgical procedures performed including arthroscopic anterior labral repair; (3) reported clinical outcome data including failure rate; and (4) assessment of risk factors for surgical failure. Further subanalyses were performed for 15 studies that included a multivariate analysis, 17 studies that included glenoid bone loss, and 8 studies that analyzed the Instability Severity Index Score. RESULTS After full-text review, 12 of the most commonly studied risk factors were identified and included in this review. The risk factors that were most consistently significant in multivariate analyses were off-track lesions (100%), glenoid bone loss (78%), Instability Severity Index Score (75%), level of sports participation (67%), number of anchors (67%), and younger age (63%). In studies of bone loss, statistical significance was more likely to be found using advanced imaging, with critical bone loss thresholds of 10% to 15%. Several studies found predictive thresholds of 2 to 4 for Instability Severity Index Score by receiver operating characteristic or multivariate analysis. CONCLUSION Studies reporting risk factors for failure of arthroscopic Bankart repair often fail to control for known confounding variables. The factors with the most common statistical significance among 15 multivariate analyses are off-track lesions, glenoid bone loss, Instability Severity Index Score, level of sports participation, number of anchors, and younger age. Studies found significance more commonly with advanced imaging measurements or arthroscopic assessment of glenoid bone loss and with lower thresholds for the Instability Severity Index Score (2-4). Future studies should attempt to control for all relevant factors, use advanced imaging for glenoid bone loss measurements, and consider a lower predictive threshold for the Instability Severity Index Score.
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Affiliation(s)
| | - Navya Dandu
- Rush University Medical Center, Chicago, Illinois, USA
| | - Eric N Azua
- Rush University Medical Center, Chicago, Illinois, USA
| | | | | | - Adam B Yanke
- Rush University Medical Center, Chicago, Illinois, USA
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Zhou P, Shao H, Zhao M, Yang X, Hao Z, Chen Z, Li S, Zhang P. Suspension fixation of iliac bone grafts under arthroscopy is an effective method for the treatment of unstable bony Bankart disease of the shoulder joint in patients with joint relaxation. Knee Surg Sports Traumatol Arthrosc 2022; 31:1925-1931. [PMID: 36040509 PMCID: PMC10089981 DOI: 10.1007/s00167-022-07127-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/17/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the results of arthroscopic autologous iliac bone graft suspension fixation combined with the Remplissage procedure in the treatment of recurrent shoulder dislocation with bony Bankart lesions and joint hyperlaxity. METHODS From 2018 to 2020, 22 patients with joint laxity underwent arthroscopic autologous iliac bone graft suspension fixation and Bankart repair combined with the Remplissage procedure due to recurrent shoulder dislocation. Clinical assessment included range of motion (forward flexion, abduction, 90° external rotation, conventional external rotation, adduction, and internal rotation), visual analog scale (VAS) score, Rowe score, University of California Los Angeles (UCLA) score, and Western Ontario Shoulder Instability Index (WOSI) score. Post-operatively, the healing of the bone graft was evaluated with computed tomography (CT) scanning. RESULTS All 22 patients were followed up for a mean of 19.3 ± 4.1 months. CT imaging showed that the healing time of the bone graft was 6-8 weeks. The patient satisfaction rate was 100%, there were no cases of redislocation, all patients returned to their preinjury training state, and the fear test was negative. At the final follow-up, the UCLA, VAS, Rowe, and WOSI scores were 29.8 ± 2.1, 2.2 ± 0.8, 89.4 ± 4.2, and 482.3 ± 46.2, respectively (p < 0.001). CONCLUSION Arthroscopic autologous iliac bone graft suspension fixation and Bankart repair combined with the Remplissage procedure are effective in preventing recurrent instability with joint hyperlaxity. Furthermore, no patient had redislocation. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Peng Zhou
- Department of Sports Medicine, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Lanzhou, 730050, Gansu, China
| | - HongBin Shao
- Department of Sports Medicine, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Lanzhou, 730050, Gansu, China
| | - MaoSheng Zhao
- Department of Sports Medicine, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Lanzhou, 730050, Gansu, China
| | - XiaoJie Yang
- Department of Sports Medicine, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Lanzhou, 730050, Gansu, China
| | - Zuobin Hao
- Department of Hand Surgery, The Third People's Hospital of Jinan, Jinan, 250000, Shandong, China
| | - Zhao Chen
- The Third Department of Surgery, Qinghai Province Crops Hospital of Chinese People's Armed Police Forces, Xi'ning, 810000, China
| | - Shensong Li
- Department of Sports Medicine, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Lanzhou, 730050, Gansu, China.
| | - Peng Zhang
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, China.
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Ruiz Ibán MA, Vega Rodriguez R, Ruiz Díaz R, Pérez Expósito R, Zarcos Paredes I, Diaz Heredia J. Arthroscopic remplissage with all-suture anchors causes cystic lesions in the humerus: a volumetric CT study of 55 anchors. Knee Surg Sports Traumatol Arthrosc 2021; 29:2342-2347. [PMID: 33030611 DOI: 10.1007/s00167-020-06314-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 09/28/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE To evaluate with computed tomography (CT) the incidence of implant-related osteolysis after implantation of two types of all-suture anchors during remplissage for the management of Hill-Sachs lesions in shoulder instability. METHODS Single-cohort, observational study with a minimum of 12 months follow-up. Twenty-five participants (19 males and 6 females; mean age 37.4 years [SD: 11.6]) with Hill-Sachs lesions requiring remplissage were evaluated with a CT performed a mean of 14.1 [3.74] months after surgery. Fifty-five all-suture anchors (19 2.3 mm Iconix and 36 1.7 mm Suturefix) were used. The volume of the bone defects was measured in the CT. Every anchor was classified into one of four groups: (1) no bone defect. (2) Partial bone defect (bone defects smaller than the drill used for anchor placement). (3) Tunnel enlargement (bone defect larger than the drill volume but smaller than twice that volume). (4) Cystic lesion (bone defect larger twice the drill volume). RESULTS No bone defect was identified in only two anchors (3.6%, 95% CI 0.4-12.5%). A partial bone defect was found in eight anchors (14.5%, 95% CI 6.5-26.7%). In 35 anchors (63.6%, 95% CI 49.6-76.2%), there was enlargement of the bone defect that was smaller than 200% the size of the drill used. Ten anchors caused bone defects larger than twice the size of the drill used (18.2%, 95% CI 9.1-30.9%). The defect size was a mean of 89 mm3 (SD: 49 mm3, minimum 0 mm3, maximum 230 mm3). CONCLUSION When using all-suture anchors in arthroscopic remplissage during instability surgery, relevant bone osteolytic defects are common at 1-year-follow-up. Cystic defects larger than twice the volume of the resected bone during implantation develop in one in six anchors and significant tunnel widening will develop in another three out of five anchors. This bone loss effectively increases the size and depth of the Hill-Sachs lesions but does not seem to affect short-term clinical outcomes. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
| | - Rosa Vega Rodriguez
- Hospital Universitario Ramón y Cajal, Cta Colmenar km 9,100, 28046, Madrid, Spain
| | - Raquel Ruiz Díaz
- Hospital Universitario Ramón y Cajal, Cta Colmenar km 9,100, 28046, Madrid, Spain
| | - Roque Pérez Expósito
- Hospital Universitario Ramón y Cajal, Cta Colmenar km 9,100, 28046, Madrid, Spain
| | - Irene Zarcos Paredes
- Hospital Universitario Ramón y Cajal, Cta Colmenar km 9,100, 28046, Madrid, Spain
| | - Jorge Diaz Heredia
- Hospital Universitario Ramón y Cajal, Cta Colmenar km 9,100, 28046, Madrid, Spain
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Ruiz Ibán MA, Vega Rodriguez R, Díaz Heredia J, Pérez Expósito R, Zarcos Paredes I, Ruiz Díaz R. Arthroscopic Bankart repair with all-suture anchors does not cause important glenoid bone osteolysis: a volumetric CT study of 143 anchors. Knee Surg Sports Traumatol Arthrosc 2021; 29:2152-2158. [PMID: 32754864 DOI: 10.1007/s00167-020-06192-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 07/27/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate with computed tomography (CT) the incidence of anchor-related osteolysis after implantation of two types of all-suture anchors for the management of labral lesions in shoulder instability. METHODS Single-cohort, observational study with 12-month follow-up. Thirty-three participants (27 males/6 females; age 38.3 years [SD 11.3]) with anterior labral lesions in which 143 all-suture anchors (71 Iconix 1.4 mm and 72 Suturefix 1.7 mm) were implanted were evaluated with a CT performed a mean of 15.4 [3.85] months after surgery. The volume of the bone defects was measured in the CT. Every anchor was classified into one of four groups: (1) no bone defect. (2) Partial bone defect (defects smaller than the drill used for anchor placement). (3) Tunnel enlargement (defects larger than the drill volume but smaller than twice that volume). (4) Cystic lesion (defects larger than twice the drill volume). RESULTS No bone defect was identified in 16 anchors (11.2%, [95% CI 6.5-17.5%]). A partial bone defect was found in 84 anchors (58.7% [50.2-66.9%]). Tunnel enlargement was found in 43 anchors (30.11% [22.6-37.6%]). No anchor caused cystic lesions (0% [0-2.5%]). The defect volume was a mean of 27.8 mm3 (SD 18.4 mm3, minimum 0 mm3, maximum 94 mm3). Neither the position in the glenoid nor the type of implant used had a significant effect in the type or size of the defects. CONCLUSION When using all-suture anchors in the glenoid during instability surgery, relevant bone osteolytic defects are rare at 1-year follow-up. Most anchor insertion tunnels will fill completely (11%) or partially (59%) with bone. Tunnel enlargement will develop in 30% of anchors. No cystic defects larger than 0.125 cm3 were observed. There is a low risk that all-suture anchors cause significant osteolytic bone defects in the glenoid. These implants can be used safely. Level of evidence IV.
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Affiliation(s)
- Miguel Angel Ruiz Ibán
- Investigation Performed at Unidad de Hombro y Codo, Hospital Universitario Ramón y Cajal, Cta Colmenar km 9,100, 28046, Madrid, Spain.
| | - Rosa Vega Rodriguez
- Investigation Performed at Unidad de Hombro y Codo, Hospital Universitario Ramón y Cajal, Cta Colmenar km 9,100, 28046, Madrid, Spain
| | - Jorge Díaz Heredia
- Investigation Performed at Unidad de Hombro y Codo, Hospital Universitario Ramón y Cajal, Cta Colmenar km 9,100, 28046, Madrid, Spain
| | - Roque Pérez Expósito
- Investigation Performed at Unidad de Hombro y Codo, Hospital Universitario Ramón y Cajal, Cta Colmenar km 9,100, 28046, Madrid, Spain
| | - Irene Zarcos Paredes
- Investigation Performed at Unidad de Hombro y Codo, Hospital Universitario Ramón y Cajal, Cta Colmenar km 9,100, 28046, Madrid, Spain
| | - Raquel Ruiz Díaz
- Investigation Performed at Unidad de Hombro y Codo, Hospital Universitario Ramón y Cajal, Cta Colmenar km 9,100, 28046, Madrid, Spain
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Dyrna FGE, Ludwig M, Imhoff AB, Martetschläger F. Off-track Hill-Sachs lesions predispose to recurrence after nonoperative management of first-time anterior shoulder dislocations. Knee Surg Sports Traumatol Arthrosc 2021; 29:2289-2296. [PMID: 32740876 DOI: 10.1007/s00167-020-06176-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 06/11/2020] [Indexed: 01/27/2023]
Abstract
PURPOSE The purpose of this study was to evaluate whether the presence of an off-track Hill-Sachs lesion has an impact on the recurrence rate after nonoperative management of first-time anterior shoulder dislocations. METHODS A retrospective cohort study was planned with a follow-up via questionnaire after a minimum of 24 months. Fifty four patients were included in the study (mean age: 29.5 years; 16 female, 38 male). All of these patients opted for primary nonoperative management after first-time traumatic anterior shoulder dislocation, in some cases even against the clinician's advice. The glenoid track and the Hill-Sachs interval were evaluated in the MRI scans. The clinical outcome was evaluated via a shoulder-specific questionnaire, ASES-Score and Constant Score. Further, patients were asked to report on recurrent dislocation (yes/no), time to recurrent dislocation, pain, feeling of instability and satisfaction with nonoperative management. RESULTS In 7 (13%) patients, an off-track Hill-Sachs lesion was present, while in 36 (67%) the lesion was on-track and 11 (20%) did not have a structural Hill-Sachs lesion at all. In total, 31 (57%) patients suffered recurrent dislocations. In the off-track group, all shoulders dislocated again (100%), while 21 (58%) in the on-track group and 3 (27%) in the no structural Hill--Sachs lesion group had a recurrent dislocation, p = 0.008. The mean age in the group with a recurrence was 23.7 ± 10.1 years, while those patients without recurrent dislocation were 37.4 ± 13.1 years old, p < 0.01. The risk for recurrence in patients under 30 years of age was higher than in those older than 30 years (OR = 12.66, p < 0.001). There were no significant differences between patients with on- and off-track lesions regarding patients' sex, height, weight and time to reduction and glenoid diameter. Off-track patients were younger than on-track patients (24.9 ± 7.3 years vs. 29.6 ± 13.6 years). However, this difference was not statistically significant. CONCLUSION The presence of an off-track Hill-Sachs lesion leads to significantly higher recurrence rates compared to on-track or no structural Hill--Sachs lesions in patients with nonoperative management and should be considered when choosing the right treatment option. Therefore, surgical intervention should be considered in patients with off-track Hill-Sachs lesions. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Felix G E Dyrna
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Munich, Germany
| | - Marius Ludwig
- Department of Orthopaedic Sportsmedicine, Technical University, Munich, Germany
| | - Andreas B Imhoff
- Department of Orthopaedic Sportsmedicine, Technical University, Munich, Germany
| | - Frank Martetschläger
- Department of Orthopaedic Sportsmedicine, Technical University, Munich, Germany. .,German Center for Shoulder Surgery, ATOS Clinic Munich, Effnerstraße 38, 81925, München, Germany.
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Editorial Commentary: Should We Condemn the Shoulder Instability Severity Index Scoring System? Not at All!... Can We Improve Its Radiographic Component? Yes, We Can! Arthroscopy 2021; 37:1392-1396. [PMID: 33896494 DOI: 10.1016/j.arthro.2021.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 02/02/2023]
Abstract
Is patient selection necessary in shoulder instability surgery? Absolutely. The risk-benefit discussion that the surgeon must have with the patient before proposing an arthroscopic Bankart repair remains crucial to provide informed consent. The most important preoperative risk factors are incorporated in the instability severity index (ISI) score to assist surgeons in the decision-making process. This 10-point score is based on factors derived from a preoperative questionnaire, physical examination, and simple plain radiographs. Using this score at the first visit, the surgeon can explain to the patient and family why a Bankart repair may be contraindicated and why other surgical options may be more suitable. A recent study found that the ISI score has no limited predictive value when applied in a preselected population of military patients without severe bone loss or hyperlaxity. This is not surprising because the authors analyzed a preselected patient population with lower risk than the general population. The value of the ISI scoring system relies on the fact that this tool has been developed after evaluation of arthroscopic Bankart repair in an unselected patient population and that there is no need for sophisticated imaging studies to make the decision. This scoring system should not be condemned but complemented with preoperative advanced imaging studies (computed tomography [CT] scanning or magnetic resonance imaging) to assess the severity of the bone lesions more accurately. Today, the choice of the surgical procedure depends not only on the clinical risk factors included in the ISI score (age, type of sports, level of practice, hyperlaxity) but also on the presence, location and size of bony lesions, as identified and measured on advanced CT scanning images.
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Loppini M, Borroni M, Delle Rose G. Editorial Commentary: Recurrence After Arthroscopic Bankart Repair: What the Instability Severity Index Score Will and Will Not Predict. Arthroscopy 2021; 37:1397-1399. [PMID: 33896495 DOI: 10.1016/j.arthro.2021.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 02/04/2021] [Indexed: 02/02/2023]
Abstract
The recurrence of shoulder instability is a challenging complication after anterior open or arthroscopic stabilization in patients with glenohumeral instability. Use of the arthroscopic Bankart procedure has increased over the last decade, because of its less invasiveness and low complication rates compared with the Latarjet procedure. However, arthroscopic repair has the possibility of a greater recurrent instability rate. The Instability Shoulder Index Score (ISIS) has been developed to predict the success of isolated arthroscopic Bankart repair for the management of recurrent anterior shoulder instability. The risk factors associated with the recurrence of instability are age, level and type of sports participation, shoulder hyperlaxity, and humeral and glenoid bony lesions. The ISIS is a validated tool to predict the recurrence of dislocation after arthroscopic surgery in patients with shoulder instability. The arthroscopic Bankart procedure can be performed in patients with ISIS ≤3 with a low risk of recurrence of glenohumeral instability. The Latarjet procedure should be recommended in patients with ISIS >6. The management of patients with ISIS between 4 and 6 is still controversial and ranges from arthroscopic Bankart procedure with the addition of remplissage to the Latarjet procedure. Because advanced imaging techniques, such as computed tomography scans, allow us to assess appropriately the glenoid and humeral bone defect, their use is recommended in addition to ISIS.
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Alkaduhimi H, Connelly JW, van Deurzen DFP, Eygendaal D, van den Bekerom MPJ. High Variability of the Definition of Recurrent Glenohumeral Instability: An Analysis of the Current Literature by a Systematic Review. Arthrosc Sports Med Rehabil 2021; 3:e951-e966. [PMID: 34195665 PMCID: PMC8220632 DOI: 10.1016/j.asmr.2021.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 02/11/2021] [Indexed: 12/12/2022] Open
Abstract
Purpose To determine the definitions for recurrence used in the literature, assess the consensus in using these definitions, and determine the impact of these definitions on recurrence rates. Methods A literature search was performed in PubMed and EMBASE including studies from 2000 to 2020 reporting on recurrence rates after anterior arthroscopic shoulder instability surgery. Dislocation, apprehension, subluxation and recurrence rates were compared. Results Ninety-one studies were included. In 68% of the eligible studies, recurrence rates are not well defined. Thirty (33%) studies did not report on dislocations, 45 (49%) did not report on subluxations, and 58 (64%) did not report on apprehension. Seventeen different definitions for recurrence of instability, 4 definitions of dislocations, and 8 definitions of subluxation were used. Conclusion Recurrence rates are poorly specified and likely underreported in the literature, hampering comparison with results of other studies. This highlights the need for a consensus on definition of recurrence across shoulder instability studies. We recommend not using the definition recurrence of instability anymore. We endorse defining dislocations as a radiographically confirmed dislocation or a dislocation that is manually reduced, subluxations as the feeling of a dislocation that can be (spontaneously) reduced without the need for a radiographically confirmed dislocation, and a positive apprehension sign as fear of imminent dislocation when placing the arm in abduction and external rotation during physical examination. Reporting on the events resulting in a dislocation or subluxation aids in making an estimation of the severity of instability. Level of Evidence Level IV, systematic review.
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Affiliation(s)
| | - James W Connelly
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | | | - Denise Eygendaal
- Orthopaedic Department, Amphia Ziekenhuis, Breda, the Netherlands.,Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Michel P J van den Bekerom
- Shoulder and Elbow Unit, Joint Research, Amsterdam, the Netherlands.,Amsterdam University Medical Centres, Amsterdam, the Netherlands
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Verweij LPE, van Spanning SH, Grillo A, Kerkhoffs GMMJ, Priester-Vink S, van Deurzen DFP, van den Bekerom MPJ. Age, participation in competitive sports, bony lesions, ALPSA lesions, > 1 preoperative dislocations, surgical delay and ISIS score > 3 are risk factors for recurrence following arthroscopic Bankart repair: a systematic review and meta-analysis of 4584 shoulders. Knee Surg Sports Traumatol Arthrosc 2021; 29:4004-4014. [PMID: 34420117 PMCID: PMC8595227 DOI: 10.1007/s00167-021-06704-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/13/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE Determining the risk of recurrent instability following an arthroscopic Bankart repair can be challenging, as numerous risk factors have been identified that might predispose recurrent instability. However, an overview with quantitative analysis of all available risk factors is lacking. Therefore, the aim of this systematic review is to identify risk factors that are associated with recurrence following an arthroscopic Bankart repair. METHODS Relevant studies were identified by searching PubMed, Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, CINAHL/Ebsco, and Web of Science/Clarivate Analytics from inception up to November 12th 2020. Studies evaluating risk factors for recurrence following an arthroscopic Bankart repair with a minimal follow-up of 2 years were included. RESULTS Twenty-nine studies met the inclusion criteria and comprised a total of 4582 shoulders (4578 patients). Meta-analyses were feasible for 22 risk factors and demonstrated that age ≤ 20 years (RR = 2.02; P < 0.00001), age ≤ 30 years (RR = 2.62; P = 0.005), participation in competitive sports (RR = 2.40; P = 0.02), Hill-Sachs lesion (RR = 1.77; P = 0.0005), off-track Hill-Sachs lesion (RR = 3.24; P = 0.002), glenoid bone loss (RR = 2.38; P = 0.0001), ALPSA lesion (RR = 1.90; P = 0.03), > 1 preoperative dislocations (RR = 2.02; P = 0.03), > 6 months surgical delay (RR = 2.86; P < 0.0001), ISIS > 3 (RR = 3.28; P = 0.0007) and ISIS > 6 (RR = 4.88; P < 0.00001) were risk factors for recurrence. Male gender, an affected dominant arm, hyperlaxity, participation in contact and/or overhead sports, glenoid fracture, SLAP lesion with/without repair, rotator cuff tear, > 5 preoperative dislocations and using ≤ 2 anchors could not be confirmed as risk factors. In addition, no difference was observed between the age groups ≤ 20 and 21-30 years. CONCLUSION Meta-analyses demonstrated that age ≤ 20 years, age ≤ 30 years, participation in competitive sports, Hill-Sachs lesion, off-track Hill-Sachs lesion, glenoid bone loss, ALPSA lesion, > 1 preoperative dislocations, > 6 months surgical delay from first-time dislocation to surgery, ISIS > 3 and ISIS > 6 were risk factors for recurrence following an arthroscopic Bankart repair. These factors can assist clinicians in giving a proper advice regarding treatment. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Lukas P. E. Verweij
- Amsterdam UMC, Department of Orthopedic Surgery, University of Amsterdam, Amsterdam Movement Sciences, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands ,Academic Center for Evidence-Based Sports Medicine (ACES), Amsterdam, The Netherlands ,Amsterdam Collaboration on Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, Netherlands
| | - Sanne H. van Spanning
- Department of Orthopedic Surgery, Shoulder and Elbow Unit, OLVG, Amsterdam, The Netherlands
| | - Adriano Grillo
- Department of Orthopedic Surgery, Shoulder and Elbow Unit, OLVG, Amsterdam, The Netherlands
| | - Gino M. M. J. Kerkhoffs
- Amsterdam UMC, Department of Orthopedic Surgery, University of Amsterdam, Amsterdam Movement Sciences, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands ,Academic Center for Evidence-Based Sports Medicine (ACES), Amsterdam, The Netherlands ,Amsterdam Collaboration on Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, Netherlands
| | | | | | - Michel P. J. van den Bekerom
- Department of Orthopedic Surgery, Shoulder and Elbow Unit, OLVG, Amsterdam, The Netherlands ,Faculty of Behavioural and Movement Sciences, Department of Human Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
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Chen KH, Yang TC, Chiang ER, Wang HY, Ma HL. The Hill-Sachs interval to glenoid track width ratio is comparable to the instability severity index score for predicting risk of recurrent instability after arthroscopic Bankart repair. Knee Surg Sports Traumatol Arthrosc 2021; 29:250-256. [PMID: 32253482 DOI: 10.1007/s00167-020-05955-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 03/23/2020] [Indexed: 01/02/2023]
Abstract
PURPOSE The purpose of this study was to clinically validate the Hill-Sachs interval to glenoid track width ratio (H/G ratio) compared with the instability severity index (ISI) score for predicting an increased risk of recurrent instability after arthroscopic Bankart repair. METHODS A retrospective evaluation was performed using data from patients with anteroinferior shoulder instability who underwent arthroscopic Bankart repair with a follow-up period of at least 24 months. A receiver operating characteristic (ROC) curve was used to determine the optimal cut-off values for the H/G ratio and the ISI score to predict an increased risk of recurrent instability. The area under the ROC curve (AUC) of the two methods and the sensitivity and specificity of their optimal cut-off values were compared. RESULTS A total of 222 patients were included, among whom 31 (14.0%) experienced recurrent instability during the follow-up period. The optimal cut-off values for predicting an increased risk of recurrent instability were an H/G ratio of ≥ 0.7 and ISI score of ≥ 4. There were no significant differences between the AUC of the two methods (H/G ratio AUC = 0.821, standard error = 0.035 and ISI score AUC = 0.792, standard error = 0.04; n.s.) nor between the sensitivity and specificity of the optimal cut-off values (n.s. and n.s., respectively). CONCLUSIONS The H/G ratio is comparable to the ISI score for predicting an increased risk of recurrent instability after arthroscopic Bankart repair. Surgeons are recommended to consider other strategies to treat anterior shoulder instability if H/G ratio is ≥ 0.7. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Kun-Hui Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Tzu-Cheng Yang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - En-Rung Chiang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsin-Yi Wang
- Department of Anaesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsiao-Li Ma
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan. .,Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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Hasebroock AW, Brinkman J, Foster L, Bowens JP. Management of primary anterior shoulder dislocations: a narrative review. SPORTS MEDICINE - OPEN 2019; 5:31. [PMID: 31297678 PMCID: PMC6624218 DOI: 10.1186/s40798-019-0203-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 06/24/2019] [Indexed: 01/20/2023]
Abstract
Abstract The recurrence rate following acute anterior shoulder dislocations is high, particularly in young, active individuals. The purpose of this paper is to provide a narrative overview of the best available evidence and results with regards to diagnostic considerations, comorbidities, position of immobilization, surgical versus conservative management, and time to return to play for the management of primary anterior shoulder dislocations. Three independent reviewers performed literature searches using PubMed, MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials. Randomized controlled trials and systematic reviews meeting inclusion criteria from 1930 to April 2019 were appraised and discussed with the intent to consolidate the best available evidence with regards to lowering recurrence rates. A majority of studies support early surgical intervention for individuals between 21 and 30 years of age following primary shoulder dislocations, as this group is particularly susceptible to recurrence. Conservative treatment plans favor 1–3 weeks of immobilization in internal rotation, followed by rehabilitation. Surgical methods are associated with longer time to return to play, but lower recurrence rates. Return to play time is best determined on an individualized basis, when subjective and objective function of both shoulders is determined to be symmetric. This paper broadly summarizes the best available evidence for the management of primary anterior shoulder dislocations. There remains a need for randomized studies to determine ideal long-term treatment following conservative or surgical management, as general timelines for returning to play following injury remain vague. Level of evidence IV, Narrative Review
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Affiliation(s)
- Andrew W Hasebroock
- Creighton University School of Medicine, 2500 California Plaza, Omaha, NE, 68105, USA
| | - Joseph Brinkman
- Creighton University School of Medicine, 2500 California Plaza, Omaha, NE, 68105, USA
| | - Lukas Foster
- Creighton University School of Medicine, 2500 California Plaza, Omaha, NE, 68105, USA.
| | - Joseph P Bowens
- Creighton University School of Medicine, 2500 California Plaza, Omaha, NE, 68105, USA
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