Posttraumatic anterior-inferior instability of the shoulder: arthroscopic findings and clinical correlations

Glenoid track and subcritical Hill-Sachs lesion

Background

We have proposed the concept of glenoid track ("on-track/off-track" lesion) to evaluate the risk of engagement of the Hill-Sachs lesion with the glenoid after arthroscopic Bankart repair. This concept has been widely used and many clinical validation studies have been reported. To measure the glenoid track width, we have recommended to use 3-dimensional computed tomography (CT) images. However, the CT method has the issue of radiation exposure and involves time and effort to make 3-dimensional CT images from 2-dimensional images. For these reasons, there are several reports describing the measurement method using magnetic resonance imaging. Recently, the threshold of the critical glenoid bone loss becomes lower. A zone of bone loss below the critical size is called "subcritical bone loss", which might be related to deterioration of quality of life and bone grafting is recommended. We applied the concept of "subcritical bone loss" to the glenoid track. Patients with "on-track" lesions can be divided into 2 subgroups: those with a "peripheral-track" lesion (most medial 1/4) and those with a "central-track" lesion (the rest 3/4). More recently, similar evaluation methods to evaluate the risk of "off-track" lesions have been reported: ''distance to dislocation'' and "Hill-Sachs interval/glenoid track ratio". Also, similar concept to "peripheral-track" lesion, "near-track" lesion was reported. The concept of "peripheral-track" lesion is a concept of assessing an "on-track" lesion which is very close to the medial margin of the glenoid track (subcritical bone loss).

Methods

Similar evaluation methods to evaluate the risk of "off-track" or "peripheral-track" lesions were proposed in the literature. A review was performed by searching PubMed. Journal articles published between January 2014 and January 2023 were taken into account. They were compared and their differences were explained.

Results

The "near-track" lesion concept is similar to "peripheral-track" lesion. However, the cutoff value is different: Hill-Sachs occupancy ≥ 75% is the "peripheral-track" lesion, whereas "distance to dislocation" < 8 mm is the "near-track" lesion.

Conclusion

We introduced update of the glenoid track concept including the evaluation method, peripheral-track lesion, and its clinical application.

Infraspinatus function impairment after arthroscopic Bankart repair with Hill Sachs remplissage. Isokinetic, functional, and radiographic analysis

PURPOSE

Arthroscopic Bankart repair with Hill Sachs remplissage (BHSR) is an option for anterior shoulder instability with humeral defect. Our hypothesis was that infraspinatus capsulo-tenodesis is an effective solution, with good clinical results and no consequences on shoulder strength and ranges of motion.

METHODS

We performed a retrospective case-control study involving 22 patients operated with arthroscopic BHSR. We compared isokinetic evaluation of both shoulders using a dynanometer in concentric, eccentric force and endurance. Ranges of motion were measured using a goniometer and compared to the contralateral unaffected side. Functional assessment included Constant, Rowe, Walch and Duplay and WOSI scores. Healing and fatty degeneration were analyzed with magnetic resonance imaging.

RESULTS

At mean 37.2 months follow-up, 21 patients (95.4%) were satisfied or very satisfied with the intervention. Range of motion in external rotation of the affected side decreased by 10.8° in adduction and 6° at 90° of abduction (p<0.05). Deficit in external rotation strength of the affected side greater than 15% was found in all isokinetic tests (p<0.05). Walch and Duplay, Rowe, WOSI and adjusted Constant average scores were respectively 71.05±14.1 (40-90), 67.63±19.7 (15-100), 34.6%±19.9 (8.43-76.23) and 69.8±13.57 (36.7-101). Postoperative MRI showed good capsulo-tenodesis healing without infraspinatus muscle fatty degeneration.

CONCLUSION

Arthroscopic BHSR provides satisfactory functional outcomes but significant infraspinatus functional impairments in both strength and ranges of motion in external rotation.

LEVEL OF EVIDENCE

III; case-control study.

Bulk osteochondral allograft for massive Hill-Sachs defect combined with Latarjet procedure for bipolar bone loss in anterior instability

A proportion of patients with anterior glenohumeral instability present with bipolar bone loss comprising large Hill-Sachs lesions and substantial glenoid defect. These are surgically difficult cases to treat. We describe a novel surgical procedure of bulk size-matched osteochondral allograft reconstruction for massive Hill-Sachs lesions combined with the Latarjet procedure for these challenging cases.

How much force is acting on the shoulder joint to create a Hill-Sachs Lesion or reverse Hill-Sachs Lesion?

BACKGROUND

It has not been clarified yet how much force is acting on the shoulder joint to create Hill-Sachs/reverse Hill-Sachs lesions which are commonly observed in patients with anterior or posterior shoulder instability. The purpose of this study was to determine the magnitude of force to create these bony lesions using cadaveric shoulders.

METHODS

Fourteen fresh-frozen cadaveric shoulders were used. Compression tests were performed using the universal testing machine. The specimens were randomly divided into two groups. In group A, the posterior humeral head (the bare area and articular cartilage) was first compressed against the anterior glenoid rim to simulate a Hill-Sachs lesion, followed by the anterior humeral head being compressed against the posterior glenoid rim. In group B, the same procedure was repeated in the reverse order. X-ray microcomputed tomography (microCT) was also performed.

RESULTS

The maximum compression force to create a Hill-Sachs lesion was 771 ± 214 N (mean ± SD) on the articular cartilage of the posterior humeral head, which was significantly greater than the force of 447 ± 215 N to create it on the bare area (P = 0.0086). Regarding the reverse Hill-Sachs lesions, the maximum compression force was 840 ± 198 N when it was created on the articular cartilage of the anterior humeral head, which was significantly greater than the force of 471 ± 100 N when it was created at the footprint of the subscapularis tendon (P = 0.0238). MicroCT showed multiple breakage of the trabecular bone.

CONCLUSION

A force to create a Hill-Sachs lesion or a reverse Hill-Sachs lesion was significantly greater when it was created on the humeral articular cartilage than at the non-cartilage area. Also, the force to create a reverse Hill-Sachs lesion was significantly greater than the one to create a Hill-Sachs lesion.

Incidence of bony Bankart lesions in Sweden: a study of 790 cases from the Swedish fracture register

BACKGROUND

A bony Bankart lesion directly affects the stability of the shoulder by reducing the glenoid joint-contact area. The aim of this study was to report on the epidemiological data relating to bony Bankart lesions in Sweden using the Swedish fracture register. The purpose is to evaluate age and sex distribution in the population with bony Bankart lesions, its impact on treatment strategy and further to analyse patient-reported outcomes.

METHODS

This was an epidemiological descriptive study. The inclusion criteria were all patients with a unilateral bony Bankart lesion registered between April 2012 and April 2019. The patients' specific data (age, sex, type and time of injury, treatment option and patient-reported outcomes) were extracted from the Swedish fracture register database.

RESULTS

A total of 790 unilateral bony Bankart fractures were identified. The majority of the patients were male (58.7%). The median age for all patients at the time of injury was 57 years. Females had a higher median age of 66 years, compared with males, 51 years. Most of the bony Bankart lesions, 662 (91.8%), were registered as a low-energy trauma. More than two-thirds of all treatment registered cases, 509/734 patients (69.3%), were treated non-surgically, 225 (30.7%) were treated surgically, while, in 17 patients (7.5% of all surgically treated patients), the treatment was changed from non-surgical to surgical due to recurrent instability. Surgical treatment was chosen for 149 (35%) of the males and for 76 (25%) of the females. Patient quality of life decreased slightly in both surgically and non-surgically treated groups 1 year after bony Bankart injury.

CONCLUSION

This national register-based study provides detailed information on the epidemiology, choice of treatment and patient-reported outcomes in a large cohort of bony Bankart lesions. Most bony Bankart lesions affected males between 40 and 75 years after low-energy falls and non-surgical treatment dominated.

Assessing Bone Loss in the Unstable Shoulder: a Scoping Review

PURPOSE OF REVIEW

The aim of this scoping review is to identify and summarize findings published in the literature over the past 5 years related to methods for assessment of bone loss in anterior shoulder instability.

RECENT FINDINGS

Of the 113 clinical studies included in this review, 76 reported a cutoff for glenoid bone loss when determining the patients indicated for one of the many stabilization procedures investigated. Bone loss on the glenoid side was evaluated most commonly with three-dimensional computed tomography (3D CT), and either linear or surface area-based methods were employed with the use of a best-fit circle. When combined with plain CT, the two methods comprise up to 70% of the reported measurement techniques for glenoid bone loss (79 of 113 studies). On the humeral side, Hill-Sachs lesions were assessed more heterogeneously, though plain CT or 3D CT remained the methods of choice in the majority of studies (43 of 68, 63.2%). Lastly, the glenoid track was assessed by 27 of 113 studies (23.9%), again most commonly with 3D CT (13 studies) and plain CT (seven studies). The assessment of glenoid and humeral bone loss is essential to treatment decisions for patient with recurrent anterior shoulder instability. Glenoid bone loss is most commonly assessed using cross-sectional imaging, most often 3D CT, and some variation of a best-fit circle applied to the inferior portion of the glenoid. Hill-Sachs lesion assessment was also commonly done using three-dimensional imaging; however, there was more variability in assessment methods across studies and there is an obvious need to unify the approach to humeral bone loss assessment for the purposes of improving treatment decisions and to better assess on-track and off-track lesions.

Do Techniques for Hill-Sachs Remplissage Matter in Terms of Functional and Radiological Outcomes?

Background:

Different techniques are used for the remplissage procedure, including the double-pulley and mattress suture techniques. Both techniques have shown good results; however, it is unclear if one technique is superior.

Hypothesis:

The remplissage procedure using the double-pulley technique with 2 anchors would have superior functional and radiological outcomes compared with the mattress suture technique with a single anchor.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This study included patients with anterior shoulder instability who were treated using arthroscopic Bankart repair combined with remplissage between 2012 and 2017. A structured questionnaire was used to gather information on the following metrics: Instability Severity Index Score, hyperlaxity, Sugaya index, presence of a Hill-Sachs defect, number of dislocations before surgery, sports participation, radiological measurement of the Hill-Sachs lesion, postoperative range of motion in both shoulders, Rowe score, Walch-Duplay score, American Shoulder and Elbow Surgeons score, and Filling Index Score of Remplissage grade according to magnetic resonance imaging scans at the last follow-up.

Results:

There were 41 patients included with a mean age of 30 ± 7 years who underwent the Hill-Sachs remplissage procedure using the double-pulley technique with 2 anchors (n = 21; group DA) or the mattress suture technique with a single anchor (n = 20; group SA). At the final follow-up, there were no significant differences between the groups regarding the Instability Severity Index Score (P = .134), the Sugaya index (P = .538), sports participation (P = .41), the radiological measurement of the Hill-Sachs lesion (P = .803), or the Rowe score (P = .182). However, there were significant differences between the groups in the Walch-Duplay score (P = .012), American Shoulder and Elbow Surgeons score (P = .005), and Filling Index Score of Remplissage grade (P = .015), favoring group DA, as well as differences in external rotation in a neutral position (external rotation loss: 9° ± 3° [group SA] vs 12° ± 3° [group DA]; P = .003) and at 90° of abduction (external rotation loss: 8° ± 3° [group SA] vs 11° ± 3° [group DA]; P = .006), favoring group SA.

Conclusion:

In the remplissage procedure, the double-pulley technique provided better filling of the lesion and improvement in functional scores, but external rotation was limited compared with the mattress suture technique.

Glenoid erosion is a risk factor for recurrent instability after Hill-Sachs remplissage

AIMS

The aim of this study was to identify risk factors for recurrent instability of the shoulder and assess the ability to return to sport in patients with engaging Hill-Sachs lesions treated with arthroscopic Bankart repair and Hill-Sachs remplissage (ABR-HSR).

METHODS

This retrospective study included 133 consecutive patients with a mean age of 30 years (14 to 69) who underwent ABR-HSR; 103 (77%) practiced sports before the instability of the shoulder. All had large/deep, engaging Hill-Sachs lesions (Calandra III). Patients were divided into two groups: A (n = 102) with minimal or no (< 10%) glenoid bone loss, and B (n = 31) with subcritical (10% to 20%) glenoid loss. A total of 19 patients (14%) had undergone a previous stabilization, which failed. The primary endpoint was recurrent instability, with a secondary outcome of the ability to return to sport.

RESULTS

At a mean follow-up of four years (1.0 to 8.25), ten patients (7.5%) had recurrent instability. Patients in group B had a significantly higher recurrence rate than those in group A (p = 0.001). Using a multivariate logistic regression, the presence of glenoid erosion of > 10% (odds ratio (OR) = 35.13 (95% confidence interval (CI) 8 to 149); p = 0.001) and age < 23 years (OR = 0.89 (0.79 to 0.99); p = 0.038) were associated with a higher risk of recurrent instability. A total of 80 patients (78%) could return to sport, but only 11 athletes (65%) who practiced high-risk (collision or contact-overhead) sports. All seven shoulders which were revised using a Latarjet procedure were stable at a mean final follow-up of 36 months (11 to 57) and returned to sports at the same level.

CONCLUSION

Patients with subcritical glenoid bone loss (> 10%) and younger age (≤ 23 years) are at risk of failure and reoperation after ABR-HSR. Furthermore, following this procedure, one-third of athletes practicing high-risk sports are unable to return at their pre-instability level, despite having a stable shoulder. Cite this article: Bone Joint J 2021;103-B(4):718-724.

Arthroscopic Bankart Repair With Remplissage in Comparison to Bone Block Augmentation for Anterior Shoulder Instability With Bipolar Bone Loss: A Systematic Review

PURPOSE

The purpose of this systematic review is to examine the rates of postoperative recurrence of instability, functional outcomes, and complications after treatment with bone augmentation procedures or arthroscopic Bankart repair with remplissage for recurrent anterior shoulder instability in the setting of subcritical glenoid bone loss.

METHODS

EMBASE, PubMed, and MEDLINE were searched from database inception until June 2019 for articles examining either bone block augmentation to the glenoid or Bankart repair with remplissage (BRR) in the setting of subcritical glenoid bone loss. Search and data extraction were performed by 2 reviewers independently and in duplicate. A separate analysis was done for comparative studies.

RESULTS

Overall, 145 studies were identified, including 4 comparative studies. Across all studies, postoperative recurrence rates ranged from 0% to 42.8% for bone block augmentation and 0% to 15% for Bankart repair with remplissage. In comparative studies reporting subcritical glenoid bone loss, rates were 5.7% to 11.6% in the Latarjet group and 0% to 13.3% in the Bankart repair with remplissage group. However, in all studies reporting 10% to 15% mean glenoid bone loss, there was an increased rate of recurrent instability with arthroscopic soft tissue repair (6.1% to 13.2%) in comparison with bony augmentation (0% to 8.2%). Lastly, complication rates ranged from 0% to 66.7% for the bone block group and 0% to 2.3% for arthroscopic Bankart repair with remplissage.

CONCLUSION

Both bone block augmentation and Bankart repair with remplissage are effective treatment options for recurrent anterior shoulder instability in patients with bipolar bone loss but subcritical glenoid bone loss. Both have comparable functional outcomes, albeit bone block procedures carry an increased risk of complications. Arthroscopic BRR may be associated with a higher failure rate for preoperative glenoid bone loss >10%. Therefore, it may represent a stabilization procedure best suited for cases of recurrent anterior instability with glenoid bone loss <10% and the presence of a significant, off-track Hill-Sachs lesion.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II-IV studies.

Are there racial differences between patients undergoing surgery for shoulder instability? Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Group

BACKGROUND

The purpose of this study was to identify differences related to race in preoperative and intraoperative findings of patients undergoing operative treatment for shoulder instability.

METHODS

Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort were used. Of 1010 patients, 995 provided race and ethnicity information and were included in the analyses. Demographic characteristics, injury history, radiographic and intraoperative findings, and preoperative patient-reported instability, pain, and function were compared (1) between white and minority patients and (2) in a subgroup analysis between white patients and the 3 largest minority groups. The Distressed Communities Index (DCI) score was recorded for each patient's home ZIP code. Multiple logistic regressions were performed to determine whether models consisting of race/ethnicity, insurance carrier, and/or DCI score were predictive of bone and cartilage loss at the time of surgery.

RESULTS

Compared with white patients, a greater percentage of US minority patients had ≥2 dislocations (68.0% vs. 57.1%, P = .01), which corresponded with more frequent articular cartilage lesions (62.2% vs. 51.0%, P = .007) and increased frequencies of glenoid bone loss > 10% (16.2% vs. 8.7%, P = .03) and Hill-Sachs lesions (68.6% vs. 56.0%, P = .004). Specifically, when compared with white patients, African American and Asian patients showed significantly increased frequencies of glenoid bone loss > 10% (19.7% of African American patients, 18.4% of Asian patients, and 8.9% of white patients; P = .01) and Hill-Sachs lesions (65.6%, 71.7%, and 52.4%, respectively; P = .02). Race was an independent predictor of articular cartilage lesions (P = .04) and the presence of Hill-Sachs lesions (P = .01). A higher DCI score (P = .03) and race (P = .04) were both predictive of having glenoid bone loss > 10%.

CONCLUSION

We found that minority race was associated with increased number of preoperative dislocations and increased frequency of articular cartilage and Hill-Sachs lesions at the time of surgery, and both minority race and an increased DCI score were associated with glenoid bone loss > 10%. Further research is needed to understand the underlying reason for these differences and to optimize care for all patients with shoulder instability.

Arthroscopic management of anterior labrum periosteal sleeve avulsion (ALPSA) lesions: A case series with improved clinical outcomes using a modified technique

Introduction

Obejctive

Method

Results and conclusion

Anterior Shoulder Instability in the Professional Athlete: Return to Competition, Time to Return, and Career Length

Background:

Anterior shoulder instability is a common condition in professional athletes, yet little is known about the success of surgery. Return to competition (RTC) is a metric indicative of a successful outcome for professional athletes who undergo anterior shoulder stabilization surgery.

Purpose:

To determine the rate of RTC, time to RTC, recurrence rate, and length of career after surgery in professional athletes who had undergone surgical treatment for anterior shoulder instability.

Study Design:

Case series; Level of evidence, 4.

Methods:

We evaluated professional athletes who underwent surgical treatment for anterior shoulder instability by a single surgeon between 2007 and 2018. Data from patients’ medical records, a patient data registry, basic search engines, sports websites, and individual team websites were used to determine length of professional play before injury, duration of career after surgery, and RTC level.

Results:

Overall, 23 professional athletes (25 shoulders from 12 contact and 13 noncontact athletes) were identified. The mean age at the time of surgery was 24.3 ± 4.9 years (range, 16-35 years). Primary procedures included arthroscopic Bankart repair (76%; 19/25), open Latarjet (20%; 5/25), and bony Bankart repair (4%; 1/25). Of the 23 athletes, 22 returned to their previous level of competition (96%; 95% CI, 78%-100%). The mean time between surgery and RTC was 4.5 months (range, 3-8 months). There was no difference in time to RTC between contact and noncontact athletes (4.1 vs 4.4 months). There was no difference in RTC rates and time to return for players who received a Bankart repair versus a Latarjet procedure (4.6 vs 4.2 months). A total of 12 participants were still actively engaged in their respective sport at an average of 4.3 years since surgery, while 11 athletes went on to retire at an average of 4.8 years. Duration of play after surgery was 3.8 years for contact athletes and 5.8 years for noncontact athletes (P > .05).

Conclusion:

In this series, professional athletes who underwent surgical shoulder stabilization for the treatment of anterior glenohumeral instability returned to their presurgical levels of competition at a high rate. No differences in RTC rate or time to RTC were observed for contact versus noncontact athletes or for those who received arthroscopic Bankart repair versus open Latarjet. However, contact athletes had shorter careers after surgery than did noncontact athletes.

Mechanism and patterns of bone loss in patients with anterior shoulder dislocation

BACKGROUND

Bony defects are common injuries associated with anterior shoulder dislocation. It is generally thought that these bony defects are created at the time of dislocation. However, there have been no biomechanical reports demonstrating the exact time point when these lesions occur. The purpose of this study was to clarify when, how, and which types of bony defects were created during experimental dislocation in cadaveric shoulders.

METHODS

Fifteen fresh-frozen cadaveric shoulders (mean age at the time of death, 79 years) were fixed in a custom testing machine. First, the glenohumeral joint was inspected by arthroscopy. Then, the arm was held at 60° of abduction and maximum external rotation and was manually extended horizontally under fluoroscopy until an anterior dislocation occurred. Next, a force of 800 N was applied to a Kirschner wire inserted in the humeral head in the direction of the pectoralis major with use of an air cylinder. We waited until the arm came to equilibrium under this condition. Finally, the glenohumeral joint was arthroscopically examined. We further performed x-ray micro-computed tomography and histologic examination in 1 shoulder with a bipolar lesion.

RESULTS

After the anterior dislocation, a Bankart lesion was created in 9 of 15 shoulders and a fragment-type glenoid defect (avulsion fracture) was created in 4. A Hill-Sachs lesion, on the other hand, was not observed after the dislocation. The equilibrium arm position was 40° ± 17° in flexion, 45° ± 22° in abduction, and 27° ± 19° in external rotation. In this arm position, newly created lesions were Hill-Sachs lesions in 6 shoulders and erosion-type glenoid defects (compression fracture) in 7. Micro-computed tomography, performed in a single specimen, showed a flattened anterior glenoid rim with collapse of trabecular bone. Histologic analysis of nondecalcified sections using hematoxylin-eosin staining indicated that the anterior rim of the glenoid was compressed and flattened. The cortex of the anterior glenoid rim could be clearly observed.

CONCLUSION

The fragment-type glenoid defect (avulsion fracture) was observed at the time of dislocation, whereas the erosion-type defect (compression fracture) was observed when the arm came to equilibrium in the midrange of motion. Hill-Sachs lesions were created not at the time of dislocation but after the arm came to equilibrium.

Accuracy of Currently Available Methods in Quantifying Anterior Glenoid Bone Loss: Controversy Regarding Gold Standard-A Systematic Review

PURPOSE

To determine the accuracy of glenoid bone loss-measuring methods and assess the influence of the imaging modality on the accuracy of the measurement methods.

METHODS

A literature search was performed in the PubMed (MEDLINE), Embase, and Cochrane databases from 1994 to June 11, 2019. The guidelines and algorithm of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) were used. Included for analysis were articles reporting the accuracy of glenoid bone loss-measuring methods in patients with anterior shoulder instability by comparing an index test and a reference test. Furthermore, articles were included if anterior glenoid bone loss was quantified using a ruler during arthroscopy or by measurements on plain radiograph(s), computed tomography (CT) images, or magnetic resonance images in living humans. The risk of bias was determined using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool.

RESULTS

Twenty-one studies were included, showing 17 different methods. Three studies reported on the accuracy of methods performed on 3-dimensional CT. Two studies determined the accuracy of glenoid bone loss-measuring methods performed on radiography by comparing them with methods performed on 3-dimensional CT. Six studies determined the accuracy of methods performed using imaging modalities with an arthroscopic method as the reference. Eight studies reported on the influence of the imaging modality on the accuracy of the methods. There was no consensus regarding the gold standard. Because of the heterogeneity of the data, a quantitative analysis was not feasible.

CONCLUSIONS

Consensus regarding the gold standard in measuring glenoid bone loss is lacking. The use of heterogeneous data and varying methods contributes to differences in the gold standard, and accuracy therefore cannot be determined.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV studies.

Reliability of humeral head measurements performed using two- and three-dimensional computed tomography in patients with shoulder instability

Purpose

The aim of the study was to compare two measurement methods of humeral head defects in patients with shoulder instability. Intra- and inter-observer reliability of humeral head parameters were performed with the use of 2D and 3D computed tomography.

Methods

The study group was composed of one hundred humeral heads measured with the use of preoperative 2D and 3D computed tomography by three independent observers (two experienced and one inexperienced). All observers repeated measurements after 1 week. The intra-class correlation coefficient (ICC) and the minimal detectable change with 95% confidence (MDC₉₅%) were used for statistical analysis of diagnostic agreement.

Results

For 3D inter-observer reliability, ICC values were “excellent” for all parameters and MDC₉₅% values were “excellent” or “reasonable.” All intra-observer ICC and MDC₉₅% values for 3D were “excellent” for experienced and inexperienced observers. For 2D-CT, ICC values were usually “good” or “moderate” with MDC₉₅% values higher than 10 or 30%.

Conclusions

Three-dimensional CT measurements are more reliable than 2D for humeral head and Hill-Sachs lesion assessment. This study showed that 2D measurements, even performed by experienced observers (orthopaedic surgeons), are burdened with errors. The 3D reconstruction decreased the risk of error by eliminating inaccuracy in setting the plane of the measurements.

Arthroscopic stabilisation for shoulder instability

Since its first description over 30 years ago arthroscopic stabilisation has evolved. With improvements in knowledge, surgical techniques and materials technology, arthroscopic bankart repair has become the most widely used method for treating patients with symptomatic anterior shoulder instability. These procedures are typically performed in a younger, high demand patient population after a primary dislocation or to treat recurrent instability. A thorough clinical evaluation is required in the clinic setting not only to fully understand the injury pattern but also consider patient expectations prior to embarking on surgery. Diagnostic imaging will aid the clinician in determining the soft tissue pathology as well as assessing bone loss, which facilitates surgical decision-making. Selected patients may benefit from adjunctive procedures such as a remplissage for an "engaging" Hill-sachs lesion. This review will focus on the indications, pre-operative considerations, surgical techniques and outcomes of arthroscopic stabilisation.

Arthroscopic Fixation of an Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) of the Shoulder

Anterior labroligamentous periosteal sleeve avulsions represent a diagnostic and treatment challenge. They are associated with a higher number of preoperative dislocations, as well as longer chronicity, and commonly result in a scarred and medialized labrum and periosteal sleeve complex. Anterior labroligamentous periosteal sleeve avulsion lesions therefore may be commonly overlooked. The complexity of the injury pattern has been associated with double the failure rate of standard Bankart lesions after arthroscopic repair. The purpose of this article is to describe our preferred arthroscopic technique for achieving full mobilization of the labral-periosteal complex and restore it to its anatomic location using a knotless, all-suture anchor construct.

In Which Arm Position Is a Hill-Sachs Lesion Created?

BACKGROUND

It has been believed that a Hill-Sachs lesion (HSL) is created with the arm in abduction and external rotation at the time of dislocation. However, no studies have clarified the arm position in which an HSL is created.

PURPOSE

To determine the arm position in which an HSL is created.

STUDY DESIGN

Descriptive laboratory study.

METHODS

The computed tomography images of 100 shoulders of 100 patients (72 males and 28 females; mean age, 30 years old) with recurrent anterior dislocation of the shoulder were investigated using an image analyzing software. Three-dimensional surface bone models of the scapula and humerus were created separately. The humerus was moved so that the HSL perfectly fit the anterior rim of the glenoid. This arm position was recorded 3-dimensionally.

RESULTS

Considering the scapulohumeral rhythm, the average arm position in which the HSL and the anterior glenoid rim best fit was 74° of abduction, 27° of external rotation, and 3° of horizontal flexion relative to the trunk.

CONCLUSION

The arm position when an HSL and the anterior glenoid rim best fit is 74° of abduction, 27° of external rotation, and 3° of horizontal flexion, which seems to be the arm position when the HSL has been created. This result suggests 2 possibilities: dislocation occurred in this midrange position or HSL was not created at the time of dislocation but later in the mid-range of motion. However, as we have no information on the arm position at the time of dislocation, we cannot conclude which of these possibilities is true in our study.

CLINICAL RELEVANCE

This study gives us a better understanding of the timing of HSL occurrence. Shoulder dislocation may occur at the end range of motion or in the mid-range of motion, but an HSL is created in the mid-range of motion.

Clinical and Image Outcomes of the Hill-Sachs Injury Approach by the Remplissage Technique on the Anterior Shoulder Instability

OBJECTIVE

To evaluate the functional outcome of the remplissage technique, the healing of the capsulotenodesis of the infraspinatus tendon in Hill-Sachs lesion, and the degree of fatty infiltration of the infraspinatus muscle and its postoperative strength.

METHODS

Twenty-five patients with recurrent anterior dislocation of the shoulder and Hill-Sachs lesion with a Hardy index > 20% who underwent the remplissage arthroscopic technique were evaluated with a minimum follow-up of 1 year. Patients underwent a clinical evaluation (Carter-Rowe and Walch-Duplay functional scores, measurement of range of motion and strength) and a magnetic resonance imaging (MRI) exam on the operated shoulder.

RESULTS

Eighty-eight percent and 92% of the patients had good or excellent scores in the functional assessments of the Carter-Rowe and Walch-Duplay scores, respectively. A mean difference of - 1 kg in the strength of the operated limb was observed when compared with the contralateral limb ( p  < 0.001), as well as a mean difference of 10° in external rotation 1 and 2 ( p  < 0.001), also compared with the contralateral side. All of the patients who underwent an MRI exam presented high-grade filling of the Hill-Sachs lesion by capsulotenodesis, as well as absence of or minimal fatty infiltration in the infraspinatus muscle.

CONCLUSION

The remplissage technique had good/excellent functional score results, despite the discrete, albeit statistically significant, loss of strength and of external rotation amplitude. Successful capsulotenodesis healing and filling of the Hill-Sachs defect were demonstrated.

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.

The role of bone in glenohumeral stability

Shoulder stability depends on several factors, either anatomical or functional. Anatomical factors can be further subclassified under soft tissue (shoulder capsule, glenoid rim, glenohumeral ligaments etc) and bony structures (glenoid cavity and humeral head).

Normal glenohumeral stability is maintained through factors mostly pertaining to the scapular side: glenoid version, depth and inclination, along with scapular dynamic positioning, can potentially cause decreased stability depending on the direction of said variables in the different planes. No significant factors in normal humeral anatomy seem to play a tangible role in affecting glenohumeral stability.

When the glenohumeral joint suffers an episode of acute dislocation, either anterior (more frequent) or posterior, bony lesions often develop on both sides: a compression fracture of the humeral head (or Hill–Sachs lesion) and a bone loss of the glenoid rim. Interaction of such lesions can determine ‘re-engagement’ and recurrence.

The concept of ‘glenoid track’ can help quantify an increased risk of recurrence: when the Hill–Sachs lesion engages the anterior glenoid rim, it is defined as ‘off-track’; if it does not, it is an ‘on-track’ lesion. The position of the Hill–Sachs lesion and the percentage of glenoid bone loss are critical factors in determining the likelihood of recurrent instability and in managing treatment.

In terms of posterior glenohumeral instability, the ‘gamma angle concept’ can help ascertain which lesions are prone to recurrence based on the sum of specific angles and millimetres of posterior glenoid bone loss, in a similar fashion to what happens in anterior shoulder instability.

Cite this article: EFORT Open Rev 2018;3:632-640. DOI: 10.1302/2058-5241.3.180028

Arthroscopic Bankart Repairs With and Without Remplissage in Recurrent Adolescent Anterior Shoulder Instability With Hill-Sachs Deformity

Background:

Recurrent shoulder dislocation after surgical intervention in adolescents with anterior instability is now understood to occur with a relatively high frequency. The remplissage procedure is successfully used in the adult population to mitigate the ability of a Hill-Sachs lesion to engage the anterior glenoid and can be used during an arthroscopic Bankart repair for anterior shoulder instability.

Purpose:

To compare the clinical outcomes in adolescent patients who underwent a Bankart repair with or without remplissage for treatment of recurrent anterior shoulder instability and associated Hill-Sachs defects.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective review was conducted on adolescents who underwent a remplissage procedure for recurrent anterior shoulder instability from 2009 to 2017 at a single institution. Controls were identified in a cohort of patients who underwent a Bankart repair only and were matched based on age, sex, and size of Hill-Sachs lesion. All patients were then contacted to determine instability recurrence as well as to complete the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) and the Pediatric Adolescent Shoulder Score (PASS) outcome surveys.

Results:

Twenty-one adolescents underwent a remplissage procedure, and 20 matched controls underwent only a Bankart procedure. A significantly higher rate of recurrence was noted in the Bankart-only patients (8/17) compared with remplissage patients (2/15) (P = .04). No statistical difference was found in patient-reported outcome scores between treatment groups or in range of motion measurements (P > .05). In a subset of patients in the remplissage group with pre- and postoperative surveys available, mean ± SD scores for PASS (77 ± 11) and QuickDASH (19 ± 12) improved when compared with preoperative scores (PASS, 54 ± 16; QuickDASH, 35 ± 28), but only the PASS score was statistically improved (PASS, P = .003; QuickDASH, P = .23).

Conclusion:

The addition of the remplissage procedure to a Bankart repair is a reasonable surgical option to treat a Hill-Sachs deformity in adolescents with anterior shoulder instability. The success of this additional procedure may be due to filling the Hill-Sachs defect, or perhaps it augments stability through a mechanism of posterior capsulorrhaphy. Either way, this young athletic population appears to have a lower rate of recurrence and improved patient-reported outcomes with a remplissage procedure to address the Hill-Sachs deformity.

The arthroscopic Bankart repair procedure enables complete quantitative labrum restoration in long-term assessments

PURPOSE

The restoration of the labrum complex and the influence on secondary osteoarthritis after arthroscopic Bankart repair on magnetic resonance imaging (MRI) remain unclear.

METHODS

Twenty-one patients were retrospectively followed after unilateral primary arthroscopic Bankart repair with knot-tying suture anchors (8.8 ± 2.5 years after surgery, age 25.3 ± 6.3 years). Bilateral structural MRI was performed to assess labrum-glenoid restoration by measurements of the labrum slope angle, height index, and labrum interior morphology according to the Randelli classification. Osteoarthritic status was bilaterally assessed by a modified assessment based on the Samilson-Prieto classification.

RESULTS

MRI assessment revealed full labrum-glenoid complex restoration with equivalent parameters for anterior slope angle (mean ± SD: 21.3° ± 2.6° after Bankart repair vs. 21.9° ± 2.6° control) and height index (2.34 ± 0.4 vs. 2.44 ± 0.4), as well as the inferior slope angle (23.1° ± 2.9° vs. 23.3° ± 2.1°) and height index (2.21 ± 0.3 vs. 2.21 ± 0.3) (all n.s.). The labrum morphology showed only for the anterior labrum significant alterations (1.4 ± 0.9 vs. 0.6 ± 0.7, p < 0.05), the inferior labrum occurred similarly (1.3 ± 0.8 vs. 0.8 ± 0.5, n.s.). Osteoarthritic changes were significantly increased after Bankart repair compared to the uninjured shoulder (4.8 ± 5.1 mm vs. 2.5 ± 1.0 mm; p < 0.05), with a significant correlation of osteoarthritis status between both shoulders (p < 0.05). Scores generally decreased after Bankart repair (constant 84.6 ± 9.5 vs. 94.5 ± 4.9 control, p < 0.05; Rowe 84.5 ± 6.5 vs. 96.2 ± 4.2, p < 0.05; Walch-Duplay 82.4 ± 7.0 vs. 94.3 ± 4.0, p < 0.05) with a strong correlation with osteoarthritis status (p < 0.05).

CONCLUSIONS

Arthroscopic Bankart repair enabled good clinical outcomes and complete quantitative labrum restoration parameters. Next to several well-known parameters, secondary osteoarthritis after arthroscopic Bankart repair significantly correlated with osteoarthritic status of the uninjured contralateral shoulder but was not influenced by quantitative labrum restoration. The recommendation for arthroscopic Bankart repair should be based on clinical parameters and not on prevention of secondary osteoarthritis.

STUDY DESIGN

Case series.

LEVEL OF EVIDENCE

IV.

Arthroscopic remplissage: Is it still an option?

Posterolateral humeral head defects can be large and engage on the anterior glenoid, and they usually contribute to anterior shoulder instability in 40% to 90% of cases.

The purpose of this study is to evaluate the results of the largest series of patients who underwent arthroscopic remplissage with Bankart repair for recurrent anterior shoulder instability due to associated Bankart lesions, with large and engaging (> 25% involvement) humeral Hill-Sachs defects (HSDs).

A total of 51 patients underwent arthroscopic Bankart repair with remplissage technique for the treatment of recurrent anterior glenohumeral instability with large and medial HSDs. Pre-operative imaging in all patients identified a Bankart lesion with an associated HSD that involved > 25% of the humeral head. The Rowe score was used to assess the patients clinically.

A total of 46 patients were male. The mean age of the patients was 28.7 years (18 to 43). The mean follow-up period was 31 months (20 to 39). At the final follow-up, three patients reported recurrence of instability (two dislocations and one subluxation). The mean Rowe score improved to 95.4 points (function, 45.5 of 50; stability, 26.4 of 30; motion, 8 of 10; pain, 8 of 10).

The arthroscopic remplissage technique with Bankart repair gave satisfactory results and is still considered to be an effective, safe and reliable procedure for treatment of glenohumeral instability in cases with large and medial HSDs.

Cite this article: EFORT Open Rev 2017;2:478–483. DOI: 10.1302/2058-5241.2.160070

Back to Sports After Arthroscopic Revision Bankart Repair

BACKGROUND

Recurrent instability following primary arthroscopic stabilization of the shoulder is a common complication. Young, athletic patients are at the greatest risk of recurring instability. To date, the literature contains insufficient description regarding whether return to sports is possible after revision arthroscopic Bankart repair.

HYPOTHESIS

Patients presenting with recurrent instability after primary arthroscopic stabilization should expect limitations in terms of their ability to partake in sporting activities after revision surgery.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Twenty athletes who underwent arthroscopic revision stabilization of the shoulder after failed primary arthroscopic Bankart repair were included in the study after completing inclusion and exclusion criteria surveys. Athletic Shoulder Outcome Scoring System (ASOSS), Shoulder Sport Activity Score (SSAS), and the Subjective Patient Outcome for Return to Sports (SPORTS) scores were determined to assess the participants' ability to partake in sporting activities. Furthermore, sport type and sport level were classified and recorded. To assess function and stability, Rowe, American Shoulder and Elbow Surgeons, Constant-Murley, and Walch-Duplay scores were measured and recorded.

RESULTS

Follow-up consultations were carried out after a mean of 28.7 months. The mean age at follow-up examination was 27.75 years. At the time of follow-up, 70% of the patients were able to return to their original sporting activities at the same level. However, 90% of patients described a limitation in their shoulder when participating in their sports. At 28.7 months after surgery, the mean ASOSS score was 76.8; the SSAS score decreased from 7.85 before first-time dislocation to 5.35 at follow-up (P < .005). The SPORTS score was 5.2 out of 10 at the follow-up consultation. Function- and instability-specific scores showed good to excellent results. The mean external rotational deficit for high external rotation was 9.25°, and for low external rotation it was 12°.

CONCLUSION

Patients can return to their original type and level of sport after arthroscopic revision Bankart repair, but they must expect persistent deficits and limitations to the shoulder when put under the strains of sporting activity. Patients with shoulder injuries who partake in sports that put greater demand on the shoulder show the smallest probabilities of returning to sporting activity.

Rotator cuff muscular integrity after arthroscopic revision of a Bankart repair

INTRODUCTION

Recurrent shoulder instability after arthroscopic Bankart repair is still a common complication. For primary Bankart repair studies have shown that the rotator cuff can recover completely. The ability of muscles to regenerate after arthroscopic revision Bankart repair (ARBR) has not been studied. Does the ARBR using a three-portal method allows complete muscle integrity compared with an uninjured imaging control group (ICG)?

MATERIALS AND METHODS

Twenty-two (1 female, 21 males) physically active patients (mean age at follow-up 28.5 ± 7.1 years; mean follow-up 27.5 months ± 8.5) were assessed. ARBR with a three-portal method was carried out in all patients according to previous primary arthroscopic stabilization of the shoulder (revision Bankart group). Muscle atrophy of the subscapularis muscle (SSC), supraspinatus muscle (SSP) and infraspinatus muscle (ISP) was assessed by making lateral and vertical measurements by magnetic resonance imaging (MRI). Fatty infiltration was detected by standardized assessment from variations in intensity. Detailed clinical examination of the rotator cuff was carried out. MRI assessment was compared with that of a control group of 22 healthy volunteers of same age and activity level (ICG).

RESULTS

For the SSC, no muscle impairment was noted compared with the ICG [superior atrophy index (sAI_SSC), p = 0.439; inferior atrophy index (iAI_SSC), p = 0.555; superior fatty infiltration index (sFDI_SSC), p = 0.294; inferior fatty infiltration index (iFDI_SSC), p = 0.62]. In investigation of the SSP and ISP, fatty infiltration was not shown (FDI_SSP, p = 0.454; sFDI_ISP, p = 0.504), though persistent muscle atrophy was found even > 2 years after surgery compared with the ICG (AI_SSP, p = 0.0025; sAI_ISP, p = 0.0009; iAI_ISP, p = 0.0004).

CONCLUSION

ARBR using a three-portal method allowed good muscular integrity compared with the ICG, but with persistent slight muscular atrophy of the SSP and ISP.

Natural History of Anterior Shoulder Instability

BACKGROUND

The shoulder is the most complex joint in the body. The large freedom of motion in this joint is the main cause of instability. Instability varies in its degree, direction, etiology and volition and there is a large spectrum of conditions.

METHODS

Based on literature research and also in our own experience, we propose to elucidate the reader about the natural history of instability and its importance for the appropriate management of this pathology, by answering the following questions: What happens in the shoulder after the first dislocation? Which structures suffer damage? Who are the patients at higher risk of recurrence? How does the disease evolve without treatment? Will surgical treatment avoid future negative outcomes and prevent degenerative joint disease? Who should we treat and when?

RESULTS

80% of anterior-inferior dislocations occur in young patients. Recurrent instability is common and multiple dislocations are the rule. Instability is influenced by a large number of variables, including age of onset, activity profile, number of episodes,delay between first episode and surgical treatment.

CONCLUSION

Understanding the disease and its natural evolution is determinant to decide the treatment in order to obtain the best outcome. It is crucial to identify the risk factors for recurrence. Delay in surgical treatment, when indicated, leads to worse results. Surgical technique should address the type and severity of both soft tissue and bone lesions, when present.

'On-track' and 'off-track' shoulder lesions

Shoulder stability depends on the position of the arm as well as activities of the muscles around the shoulder. The capsulo-ligamentous structures are the main stabilisers with the arm at the end-range of movement, whereas negative intra-articular pressure and concavity-compression effect are the main stabilisers with the arm in the mid-range of movement.

There are two types of glenoid bone loss: fragment type and erosion type. A bone loss of the humeral head, known as a Hill-Sachs lesion (HSL), is a compression fracture of the humeral head caused by the anterior rim of the glenoid when the humeral head is dislocated anteriorly in front of the glenoid. Four out of five patients with anterior instability have both Hill-Sachs and glenoid bone lesions, which is called a ‘bipolar lesion’.

With the arm moving along the posterior end-range of movement, or with the arm in various degrees of abduction, maximum external rotation and maximum horizontal extension, the glenoid moves along the posterior articular margin of the humeral head. This contact zone of the glenoid with the humeral head is called the ‘glenoid track’.

A HSL, which stays on the glenoid track (on-track lesion), cannot engage with the glenoid and cannot cause dislocation. On the other hand, a HSL, which is out of the glenoid track (off-track lesion), has a risk of engagement and dislocation. Clinical validation studies show that the ‘on-track/off-track’ concept is able to predict reliably the risk of a HSL being engaged with the glenoid. For off-track lesions, either remplissage or Latarjet procedure is indicated, depending upon the glenoid defect size and the risk of recurrence.

Cite this article: EFORT Open Rev 2017;2:343-351.

Intra-articular findings in symptomatic minor instability of the lateral elbow (SMILE)

PURPOSE

Lateral epicondylitis is generally considered an extra-articular condition. The role of minor instability in the aetiology of lateral elbow pain has rarely been considered. The aim of this study was to evaluate the correlation of lateral ligamentous laxity with aspects of intra-articular lateral elbow pathology and investigate the role of minor instability in lateral elbow pain.

METHODS

Thirty-five consecutive patients aged between 20 and 60 years with recalcitrant lateral epicondylitis who had failed conservative therapy and had no previous trauma or overt instability, were included. The presence of three signs of lateral ligamentous patholaxity and five intra-articular findings were documented during arthroscopy. The relative incidence of each of these was calculated, and the correlation between patholaxity and intra-articular pathology was evaluated.

RESULTS

At least one sign of lateral ligamentous laxity was observed in 48.6% of the studied cohort, and 85.7% demonstrated at least one intra-articular abnormal finding. Radial head ballottement was the most common sign of patholaxity (42.9%). Synovitis was the most common intra-articular aspect of pathology (77.1%), followed by lateral capitellar chondropathy (40.0%). A significant correlation was found between the presence of lateral ligamentous patholaxity signs and capitellar chondropathy (p = 0.0409), as well as anteromedial synovitis (p = 0.0408).

CONCLUSIONS

Almost one half of patients suffering from recalcitrant lateral epicondylitis display signs of lateral ligamentous patholaxity, and over 85% demonstrate at least one intra-articular abnormality. The most frequent intra-articular findings are synovitis and lateral capitellar chondropathy, which correlate significantly with the presence of lateral ligamentous patholaxity. The fact that several patients demonstrated multiple intra-articular findings in relation to laxity provides support to a sequence of pathologic changes that may result from a symptomatic minor instability of the lateral elbow (SMILE) condition.

LEVEL OF EVIDENCE

III.

Arthroscopic Findings in Anterior Shoulder Instability

Background:

In the last years, basic research and arthroscopic surgery, have improved our understanding of shoulder anatomy and pathology. It is a fact that arthroscopic treatment of shoulder instability has evolved considerably over the past decades. The aim of this paper is to present the variety of pathologies that should be identified and treated during shoulder arthroscopy when dealing with anterior shoulder instability cases.

Methods:

A review of the current literature regarding arthroscopic shoulder anatomy, anatomic variants, and arthroscopic findings in anterior shoulder instability, is presented. In addition, correlation of arthroscopic findings with physical examination and advanced imaging (CT and MRI) in order to improve our understanding in anterior shoulder instability pathology is discussed.

Results:

Shoulder instability represents a broad spectrum of disease and a thorough understanding of the pathoanatomy is the key for a successful treatment of the unstable shoulder. Patients can have a variety of pathologies concomitant with a traditional Bankart lesion, such as injuries of the glenoid (bony Bankart), injuries of the glenoid labrum, superiorly (SLAP) or anteroinferiorly (e.g. anterior labroligamentous periosteal sleeve avulsion, and Perthes), capsular lesions (humeral avulsion of the glenohumeral ligament), and accompanying osseous-cartilage lesions (Hill-Sachs, glenolabral articular disruption). Shoulder arthroscopy allows for a detailed visualization and a dynamic examination of all anatomic structures, identification of pathologic findings, and treatment of all concomitant lesions.

Conclusion:

Surgeons must be well prepared and understanding the normal anatomy of the glenohumeral joint, including its anatomic variants to seek for the possible pathologic lesions in anterior shoulder instability during shoulder arthroscopy. Patient selection criteria, improved surgical techniques, and implants available have contributed to the enhancement of clinical and functional outcomes to the point that arthroscopic treatment is considered nowadays the standard of care.

Arthroscopic Remplissage for Moderate-Size Hill-Sachs Lesion

Humeral bone loss has been shown to be a risk factor for failure after arthroscopic treatment of instability. We present the arthroscopic remplissage technique originally described by Koo and Burkhart et al. with a modification in the percutaneous anchor placement and suture tying that is reproducible and effective. We percutaneously place 2 suture anchors, which require no additional suture passing across the tissue, to create a double pulley technique, filling the defect with posterior capsule and rotator cuff. Therefore, the Hill-Sachs defect becomes extra-articular, eliminating the potential engagement of the anterior glenoid and contribution to recurrence of instability. This technique is applicable broadly for most Hill-Sachs lesions that need addressing. By not having to pass or shuttle any suture through tissue after anchor placement and by eliminating the necessity to go subacromially to retrieve or tie suture, the technique saves time and improves reproducibility. The compression of tissue into the Hill Sachs surface area also is improved by double-reinforced suturing through the double-pulley technique. The combination of these advantages creates a sound and efficient technique for remplissage.

Midterm outcomes of arthroscopic remplissage for the management of recurrent anterior shoulder instability

PURPOSE

The purpose of the study was to present midterm results concerning the management of recurrent anterior shoulder instability with the remplissage technique in addition to the classic Bankart repair, in patients with engaging Hill-Sachs lesions.

METHODS

During a time period of 4 years (January 2007-December 2010), 48 patients with an average age of 28.9 ± 7.8 years were operated on in our department. They all had a positive apprehension sign pre-operatively and satisfied the inclusion criteria of this study. Seventy-nine per cent of these patients were involved in sport activities of different levels. The mean follow-up period was 37.2 ± 9.9 months.

RESULTS

Three patients (6.3 %) had suffered a new dislocation: one of them after a low-energy trauma and the two other after a high-energy trauma. The rest of the patients (93.7 %) were satisfied with the surgical result and returned to their previous everyday activities while 70.8 % continued to participate in sporting activities without restrictions. The ASES score increased from 67.7 ± 21.5 points pre-operatively to 90.8 ± 21.7 points post-operatively (p < 0.01), the modified Rowe score from 38 ± 17.3 to 93.8 ± 14.5 (p < 0.001) and the Oxford Instability score from 27.6 ± 11.1 to 45.1 ± 8.3 (p < 0.001). No significant restriction in shoulder range of motion was documented.

CONCLUSIONS

The outcome of the enhancement of the classic Bankart repair with tenodesis of the infraspinatus and posterior capsular plication is very good as far as the management of recurrent anterior shoulder instability is concerned, without significantly influencing the range of motion of the shoulder.

LEVEL OF EVIDENCE

Therapeutic study-case series with no comparison group, Level IV.

Structural and clinical integrity of the rotator cuff in athletes after arthroscopic Bankart repair using the three-portal technique

INTRODUCTION

Muscular recovery of structural integrity after arthroscopic Bankart repair using the para- and trans-musculotendinous three-portal technique has not been investigated.

MATERIALS AND METHODS

Twenty-seven athletes [mean age 26.9 years, (group 1; G1)] were prospectively and longitudinally monitored after arthroscopic Bankart repair using the three-portal technique by magnetic resonance imaging (MRI) and specific clinical muscular testing. The muscular integrity was assessed at the subscapularis (SSC) for the para-tendinous anteroinferior portal, the supraspinatus (SSP) for the trans-tendinous suprabicipital portal, and the infraspinatus (ISP) for the trans-tendinous posterior portal. Muscular atrophy was assessed by standardized ratios of transverse and vertical diameters for the SSC and ISP, as defined by cross-sectional area ratios for the SSP. Fatty infiltration was assessed by signal intensity analysis for the upper and lower SSC, SSP, and upper ISP as a ratio with the lower ISP. These parameters were analyzed for pre-operative (T0), 1-year (T1), and 2-year status (T2), and compared to 27 healthy volunteers [mean age 29.4 years, (group 2, G2)].

RESULTS

The structural integrity assessments were performed after 14.8 (T1) and 32.0 months (T2). The SSC analysis revealed no muscular impairments in the upper and lower portions between T0 and T2 or compared to G2. MRI analysis for SSP and ISP showed full muscular recovery without any changes between T0 and T2 or deficits compared to G2. The number of pre-operative dislocations had no influence on the muscular integrity. MR analysis detected signs of overuse syndrome in 15 % at T0, 41 % at T1, and 63 % at T2; 77, 22, and 26 % of patients at T0, T1, and T2, respectively, were symptomatic.

CONCLUSIONS

Arthroscopic Bankart repair using the three-portal technique prevents full muscular integrity for para-tendinous anteroinferior portals at the SSC, the trans-tendinous suprabicipital portal through the SSP, and the trans-tendinous portal through the ISP.

Remplissage, humeral osteochondral grafts, weber osteotomy, and shoulder arthroplasty for the management of humeral bone defects in shoulder instability: systematic review and quantitative synthesis of the literature

PURPOSE

The aim of this study was to evaluate clinical outcomes, rate of recurrence, complications, and range of movement after remplissage, Weber osteotomy, humeral allograft reconstruction, shoulder arthroplasty, and hemiarthroplasty in patients with anterior or posterior shoulder instability associated with humeral bone loss.

METHODS

A systematic review of published studies on the management of dislocation of the shoulder with humeral bony procedures was performed. A comprehensive search of the PubMed, Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane, Embase, and Google Scholar databases was performed using various combinations of the keywords "shoulder," "dislocation," "treatment," "remplissage," "hemiarthroplasty," "arthroplasty," "allograft," "osteotomy," "bone," "loss," "clinical," "outcome," and "Hill Sachs" since inception of the databases to 2014. The following data were extracted: demographic characteristics, bone defects and other lesions, type of surgery, outcome measurement, range of motion, recurrence of instability, and complications.

RESULTS

Twenty-six studies were included, in which 769 shoulders were evaluated. The mean value of the Coleman Methodology Score was 69.2 points. Preoperatively, the most detected injuries were Hill-Sachs and Bankart lesions. Shoulder arthroplasty procedures had the highest rate of postoperative recurrence and the lowest scores for postoperative clinical outcomes. The combination of remplissage and Bankart procedures was associated with a lower rate of recurrence when compared with Bankart repair alone (odds ratio, 0.05; 95% confidence interval, 0.01 to 0.25; P = .0002). A high heterogeneity (I(2) = 85%) across the study results was found.

CONCLUSIONS

Arthroscopic remplissage is the safest technique for the management of patients with shoulder instability with humeral bone loss. Remplissage-Bankart procedures are associated with a lower rate of recurrence when compared with Bankart repair alone. Weber osteotomy, humeral allograft reconstruction, shoulder arthroplasty, and hemiarthroplasty are characterized by a high rate of recurrence, complications, and poor outcome scores.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV studies.

Glenoid bone loss in the setting of an anterior labroligamentous periosteal sleeve avulsion tear

BACKGROUND

Glenoid bone loss is a factor that has been inversely associated with the success of shoulder instability repair. Recently, patients with an anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion have also been identified as having a higher failure rate after surgical repair.

PURPOSE

To determine differences in the amount of glenoid bone loss and to compare demographic factors of instability in patients with and without ALPSA tears.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Over a 3-year period, all patients (N = 83) who were treated for anterior shoulder instability at a single institution were reviewed retrospectively. A total of 39 (47%) were identified as having an ALPSA lesion and 44 (53%) as having no ALPSA tear. Glenoid bone loss was determined in 2 ways: (1) radiographically by 3-dimensional computed tomography (3D CT) (humeral head digitally subtracted by 3 blinded observers) and (2) with arthroscopic techniques at the time of surgery. Demographic data such as the time from the initial instability event to advanced imaging and surgery were noted. These data were then analyzed with the Student t test to determine any significant differences between the 2 groups.

RESULTS

The patients with an ALPSA lesion had more preoperative instability events than those without (8.2 vs 3.6, respectively; P = .04). The mean glenoid bone loss measured by 3D CT was 12.7% (range, 0%-22.3%) for those with ALPSA tears versus 6.25% (range, 0%-23.1%) for those without (P = .002). The mean duration of total instability for those with ALPSA tears was 42.9 months versus 46.3 months for those without (P = .95). Lastly, the mean bone loss based on arthroscopic measures was 11.4% for patients with ALPSA tears and 4.3% for those without ALPSA tears (P = .017). From the existing magnetic resonance imaging/arthrography scans reviewed, 82% of patients could be correctly identified as having an ALPSA lesion.

CONCLUSION

Patients with anterior shoulder instability who have an ALPSA lesion have nearly twice the amount of glenoid bone loss as those with a standard Bankart tear (no ALPSA lesion). Patients with ALPSA lesions had statistically more instability events, and this may be an additional factor in either developing an ALPSA lesion or glenoid bone loss or both.

Restoration of joint congruency and the glenoidal labrum after arthroscopic revision Bankart repair: a MRI match-paired analysis comparing primary Bankart repair and the uninjured labrum

PURPOSE

The restoration of joint congruency and labrum slope and height after arthroscopic revision Bankart repair (RB) compared to the primary arthroscopic Bankart repair (PB) remain unclear.

METHODS

Twenty-three consecutive patients after RB with minor glenoid deficits were matched to 23 patients after PB and retrospectively followed by a score system and native 1.5 T magnetic resonance imaging (MRI) assessment. Bankart repair surgeries were performed using double-loaded knotless suture anchors. The glenoidal (GAA) and labral articulation arc (LAA), labrum slope, height index and morphology were assessed separately for the anterior and inferior glenoid and compared to 23 healthy volunteers [radiologic control group (RC)].

RESULTS

Arthroscopic revision Bankart repair showed 28.0 months post-operative equivalent anterior labral congruency (LAA, 9.3°/PB 9.9°/RC 10.1°) and inferior (LAA 9.9°/PB 9.6°/RC 10.5°). The anterior GAA remain decreased (54.6°/PB 55.7°/RC 58.0°) with an original inferior GAA (85.1°/PB 83.2°/RC 83.8°). The RB labrum was slightly decreased anteriorly (slope 22.9°/PB 23.9°/RC 24.6°; height index 2.4/PB 3.0/RC 3.2). The inferior portion had an equivalent labrum slope (23.8°/PB 24.7°/RC 25.1°), but a decreased height index (2.1/PB 2.2/RC 2.3). Morphologic labrum analysis revealed significant changes between all three groups. The clinical outcome after revision surgery was good-to-excellent, but inferior to the primary stabilization and without influence of joint congruency and labrum morphology to the clinical outcome.

CONCLUSION

A properly applied arthroscopic revision of a Bankart repair generates sufficient restoration of the anteroinferior labral joint congruency and good clinical results.

STUDY DESIGN

Case series.

Combined arthroscopic Bankart repair and remplissage for recurrent shoulder instability

PURPOSE

The objective of our study was to summarize the available clinical evidence pertaining to the combined arthroscopic Bankart repair and remplissage procedure (BRR) for the management of recurrent anterior glenohumeral instability.

METHODS

We searched Medline (1946 to the third week of November, 2012), the Cochrane Central Register of Controlled Trials, Embase (1947 to the 50th week of 2012), and PubMed for studies that reported clinical outcome data at a minimum of 1 year after BRR. Two independent reviewers selected studies for inclusion, assessed methodological quality, and extracted relevant data. Clinical outcome data were pooled and summarized.

RESULTS

Seven clinical studies with a total of 220 patients met the inclusion criteria. Mean patient age was 29 years and mean follow-up was 26 months. Among all studies, the pooled rate of recurrent dislocation after BRR was 3.4%. Compared with preoperative range of motion (ROM) and ROM after Bankart repair (BR) for similar pathologic conditions, there were no clinically significant losses in glenohumeral motion after BRR. Moreover, BRR resulted in favorable functional outcome scores and high patient satisfaction. Four studies reported on postoperative imaging and found high rates of healing and tissue fill-in at the site of infraspinatus tenodesis.

CONCLUSIONS

After BRR, the rate of recurrent dislocation is low and there are no clinically significant losses in glenohumeral ROM. Moreover, functional outcome scores are good and there is a high rate of patient satisfaction. Going forward, there is a need for high-level clinical studies to support the findings of this systematic review and to develop an evidence-based approach to the management of patients with recurrent glenohumeral instability in the setting of a Hill-Sachs defect (HSD).

The prevalence of a large Hill-Sachs lesion that needs to be treated

BACKGROUND

A large Hill-Sachs lesion has been considered a risk factor for postoperative recurrence of shoulder instability. However, there are few reports describing the prevalence of Hill-Sachs lesions that engage with the glenoid. The purpose of this study was to clarify the prevalence of engaging Hill-Sachs lesions using the concept of the glenoid track.

MATERIALS AND METHODS

The computed tomography images of 100 consecutive patients with unilateral recurrent anterior shoulder dislocations were assessed. An image in the plane perpendicular to the rotator cuff attachment was reconstructed from the DICOM (Digital Imaging and Communications in Medicine) data, and the maximum distance from the medial margin of the Hill-Sachs lesion to the medial margin of the rotator cuff footprint was measured. The location of the Hill-Sachs lesion in the glenoid track was assessed, and when the Hill-Sachs lesion extended medially over the glenoid track, it was defined as an "engaging Hill-Sachs lesion."

RESULTS

Engaging Hill-Sachs lesions were observed in 7 of 100 cases (7%). There were 2 types of Hill-Sachs lesions: a large and wide type (3 cases) and a narrow but medially located type (4 cases). All cases with an engaging Hill-Sachs lesion had a large bony defect of the glenoid at the same time.

CONCLUSIONS

In our series of consecutive 100 cases, the prevalence of engaging Hill-Sachs lesions was 7%. There were 2 types of Hill-Sachs lesions: a wide and large type and a narrow but medially located type.

Histopathologic evaluation of passive stabilizers in shoulder instability

BACKGROUND

The macroscopic pathomorphology in recurrent shoulder instability has been described. However, less is known regarding the histopathologic details of the affected structures. This study evaluates different histopathologic stages of shoulder instability by assessing biopsy specimens of static stabilizers for possible correlations with clinical parameters. Our hypothesis was that clinical parameters of shoulder instability correlate with histopathologic findings.

MATERIALS AND METHODS

Passive shoulder stabilizers (labrum, anterior bundle of the inferior glenohumeral ligament) were biopsied during arthroscopic shoulder stabilization. Samples were submitted to immunohistochemistry, in situ hybridization, and blinded evaluation. Clinical data, comprising age (<30 years or ≥30 years), total number of dislocations (1, 2-3, or >3), and period since initial dislocation (<6 months, 6 months to 6 years, or >6 years), were tested for statistical correlation with the following histopathologic parameters: inflammation, lipomatous changes, vascular proliferation, tissue fragmentation, and cellularity.

RESULTS

Standardized biopsies were performed in 30 consecutive patients (4 women and 26 men; mean age, 32.6 years) with anterior shoulder instability. Microscopic evaluation showed only small variations in histologic changes among all samples. Only limited variations in cell density, matrix swelling, and collagen fiber disruptions were found. Immunohistochemical analysis showed a similar expression of decorin in all samples. Clinical parameters (age, total number of dislocations, and period since initial dislocation) were statistically independent from histopathologic parameters (inflammation, lipomatous changes, vascular proliferation, tissue fragmentation, and cellularity). No correlation was found in patients with 1 dislocation versus those with more than 1 dislocation.

CONCLUSIONS

In contrast to macroscopic findings among different grades of shoulder instability, this study detected no correlation between clinical items (age, total number of dislocations, and period since initial dislocation) and histopathologic parameters. These clinical items seem to be independent from the tissue status of static stabilizers of the shoulder.

Bone loss in anterior instability

Bone loss is commonly observed in shoulders with anterior instability. The Latarjet procedure is commonly performed when a glenoid bony defect exists that is greater than 25 % of the glenoid width or when the risk of recurrent instability is higher (i.e., collision-sport athletes). Hill-Sachs lesions need to be assessed as well. For the purpose of assessing the bipolar lesions, the glenoid track concept is useful. A Hill-Sachs lesion that is located more medially than the medial margin of the glenoid track is defined as an engaging Hill-Sachs lesion. A potential treatment for such a condition is remplissage, but this procedure also decreases range of motion. Thus, its application in overhead athletes needs to be carefully considered.

Change in labrum height after arthroscopic Bankart repair: correlation with preoperative tissue quality and clinical outcome

HYPOTHESIS

Arthroscopic factors, such as labral and capsular tissue quality or anterior labral periosteal sleeve avulsion (ALPSA) lesion, affect postoperative labral height stability. Labral height stability has a correlation with clinical outcome.

METHODS

The study included 40 patients who underwent arthroscopic surgery for a Bankart lesion between August 2005 and May 2009. The mean follow-up and patient age were 29.1 ± 10.9 months (range, 15-60 months) and 24.7 ± 8.4 years (range, 12-55 years), respectively. Labral and capsular tissue quality, ALPSA lesions, Hill-Sachs lesions, glenoid erosion, and superior labrum anterior-posterior tears were identified by arthroscopic examination. Stepwise postoperative computed tomography arthrography to estimate the labral height was performed at 3 months and 1 year.

RESULTS

Correlation of postoperative 1 year Rowe scores with labral height maintenance was statistically significant (P < .01). Correlation of Rowe scores at 1 year postoperatively with labral height at 1 year postoperatively was also statistically significant (P < .01). The mean postoperative labral height at 3 months and at 1 year was 5.13 ± 1.56 mm (range, 2.9-8.8 mm) and 4.69 ± 1.75 mm (range, 1.6-8.5 mm), respectively (P < .01). The decrease in labral height at 1 year after surgery was significant in those patients with ALPSA lesions, Hill-Sachs lesions, and a poor labrum along with a poor capsule (P < .01).

CONCLUSIONS

The patients with less labral height decrease between 3 months and 1 year or higher labral height at 1 year postoperatively showed higher Rowe scores at 1 year postoperatively. Shoulders with ALPSA lesions, Hill-Sachs lesions, and a poor labrum with poor capsular tissue quality correlated more strongly with postoperative labral height decrease.

Anatomical and functional results after arthroscopic Hill-Sachs remplissage

BACKGROUND

Large osseous defects of the posterosuperior aspect of the humeral head can engage the glenoid rim and cause recurrent instability after arthroscopic Bankart repair for glenohumeral dislocation. Filling of the humeral head defect with the posterior aspect of the capsule and the infraspinatus tendon (i.e., Hill-Sachs remplissage) has recently been proposed as an additional arthroscopic procedure. Our hypothesis is that the capsulotenodesis heals in the humeral bone defect without a severe adverse effect on shoulder mobility, allowing return to preinjury sports activity.

METHODS

Of 459 patients operated on for recurrent traumatic anterior shoulder instability, forty-seven (10.2%) underwent arthroscopic Bankart repair combined with Hill-Sachs remplissage with use of suture anchors. All had a large Hill-Sachs lesion (Calandra grade III), engaging over the glenoid rim, without substantial glenoid bone loss. Nine patients had had prior unsuccessful surgery to address glenohumeral instability (three Bankart and six Bristow-Latarjet procedures). The average age at the time of surgery (and standard deviation) was 29 ± 5.4 years. Postoperatively, comparative shoulder motion was precisely measured with use of digital photographic images. Capsulotenodesis healing was assessed on a computed tomography (CT) arthrogram (n = 38) or magnetic resonance image (MRI) (n = 4). The mean duration of follow-up was twenty-four months.

RESULTS

Healing of the posterior aspect of the capsule and the infraspinatus tendon into the humeral defect was observed in all forty-two patients who underwent postoperative imaging, and thirty-one (74%) had a remplissage of ≥75%. Compared with the normal (contralateral) side, the mean deficit in external rotation was 8° ± 7° with the arm at the side of the trunk and 9° ± 7° in abduction at the time of the last follow-up. Of forty-one patients involved in sports, thirty-seven (90%) were able to return postoperatively and twenty-eight (68%) returned to the same level of sports, including those involving overhead activities. Ninety-eight percent (forty-six) of the forty-seven patients had a stable shoulder at the time of the last follow-up.

CONCLUSIONS

Arthroscopic Hill-Sachs remplissage, performed in combination with a Bankart repair, is a potential solution for patients with a large engaging humeral head bone defect but no substantial glenoid bone loss. The posterior capsulotenodesis heals predictably in the humeral defect. The slight restriction in external rotation (approximately 10°) does not significantly affect return to sports, including those involving overhead activities. The procedure, which may also be useful for revision of previous failed glenohumeral instability surgery, is not indicated for patients with glenoid bone deficiency.

Shoulder sport-specific impairments after arthroscopic Bankart repair: a prospective longitudinal assessment

BACKGROUND

Reports of return to shoulder-dependent sport after surgical stabilization previously underestimated impairments, which were not reflected in the score systems used.

HYPOTHESIS

Return to shoulder-dependent sport depends on the type of sport performed.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Forty-seven athletes (26.9 years of age at surgery) who underwent isolated arthroscopic Bankart repair were longitudinally monitored by shoulder-dependent sport-specific activity (Shoulder Sport Activity Score [SSAS]) and ability (Athletic Shoulder Outcome Scoring System [ASOSS]) scores and visual analog scales for reachieved proficiency level, sport-specific shoulder pain, and functional deficits. Data were assessed at 4 points of treatment: preoperatively, and postoperatively after 6, 16, and 32 months (P0-P3). Athletes were analyzed separately according to shoulder sport: noncollision/nonoverhead (G1), collision (G2), overhead (G3), and martial arts (G4).

RESULTS

The G1 and G2 athletes had re-achieved the preinjury sport activity and sport proficiency status and excellent ASOSS scores after 32 months (SSAS(G1) = 7.2, SSAS(G2) = 8.1, ASOSS(G1) = 94.4, ASOSS(G2) = 95.2), whereas G3 and G4 athletes remained at an inferior activity level (SSAS(G3) = 8.0, SSAS(G4) = 8.3) and proficiency level. The ASOSS documented a prolonged period of shoulder rehabilitation for G3 and G4 athletes to reach a good shoulder-dependent sport ability outcome after 32 months (ASOSS(G3) = 89.0, ASOSS(G4) = 93.1). All groups recorded persisting limitations in visual analog scales for sport-specific shoulder function and pain. The established scores (Rowe = 95.9, Walch-Duplay = 93.3, Constant = 94.0) did not reflect these sport-specific impairments. Athletes with 5 or more preoperative dislocations had significantly longer surgery-to-sport resumption intervals with a prolonged proficiency recovery.

CONCLUSION

The athletes' shoulder stabilization resulted in a prolonged rehabilitation depending on the functional demand of the performed shoulder-dependent sport, as shown by the specific shoulder sport score systems.

MRI assessment of the structural labrum integrity after Bankart repair using knotless bio-anchors

PURPOSE

Adequate labral restorations after Bankart repair have been demonstrated in cadaver models for knot-tying and knotless anchors and in vivo by magnetic resonance imaging for knot tying. The influence of glenoidal bio-degradation on clinical outcome, and conclusions regarding drill hole enlargement and foreign body reactions remain controversial.

METHODS

The labrum was analyzed in magnetic resonance images for 37 consecutive patients with Bankart repair using knotless PLLA anchors and for 31 volunteers as radiologic controls. The labrum was assessed regarding slope, height index (quotient between labral height to the glenoid height), and labrum morphology in axial and coronal T2 images. Glenoidal bio-degradation was graded in terms of the drill hole configuration in T1 images and the corresponding osseous reaction in T2 images. Constant-Murley, Walch-Duplay, and Rowe scoring were carried out preoperatively and at follow-up.

RESULTS

At 15 months after arthroscopy, the anterior slope (24.8°), height index (3.0), inferior slope (25.4°), and height index (2.5) were not significantly different from control values. Morphologic analysis revealed significant changes in the Bankart group (P < 0.05) that were influenced by the number of preoperative dislocations. Bio-degradation proceeded slowly with no evidence of drill hole enlargement. Osseous reactions were significantly greater in inferior compared to superior implants. The clinical scores were excellent and were not influenced by bio-degradation.

CONCLUSIONS

Knotless anchors facilitate labral restoration that is comparable to the knot-tying approach. Bio-degradation proceeds slowly without clinical or radiologic evidence of foreign body reactions.

LEVEL OF EVIDENCE

III.

Arthroscopic anatomy, variants, and pathologic findings in shoulder instability

Shoulder instability is a common diagnosis that often requires surgical treatment. A detailed knowledge of the shoulder anatomy and its stabilizing structures is of utmost importance for successful treatment of shoulder instabilities. Identifying anatomic variants (e.g., sublabral hole, meniscoid labrum, cordlike middle glenohumeral ligament, and Buford complex) and distinguishing them from pathologic findings may be especially difficult, as shown by the high interobserver variability. Over the last decade, basic research and arthroscopic surgery have improved our understanding of the shoulder anatomy and pathology. In the context of shoulder instability, injuries of the glenoid (bony Bankart), injuries of the glenoid labrum superiorly (SLAP) or anteroinferiorly (e.g., Bankart, anterior labroligamentous periosteal sleeve avulsion, and Perthes), capsular lesions (humeral avulsion of the glenohumeral ligament), accompanying cartilage lesions (Hill-Sachs, glenolabral articular disruption), and rotator interval and pulley lesions, as well as signs of dynamic instability impingement (posterior-superior impingement, anterior-superior impingement) can be exactly diagnosed (magnetic resonance imaging with intra-articular gadolinium, arthroscopy) and treated (arthroscopy). Therefore the purpose of this article is to review the current literature concerning shoulder anatomy/pathology related to shoulder stability/instability to improve clinical diagnosis and surgical treatment of our patients.

Anterior labroligamentous periosteal sleeve avulsion lesion in arthroscopic capsulolabral repair for anterior shoulder instability

PURPOSE

This study aims to compare the associated lesions, clinical results, and postoperative recurrence rates in patients with ALPSA lesions (ALPSA group) versus those with Bankart lesions or Perthes lesions (Bankart group) in arthroscopic capsulolabral repair for anterior shoulder instability.

METHODS

Two hundred and twenty-two patients (227 shoulders) who had been followed for a minimum of 1 year were enrolled for this study. Mean age at the time of first dislocation was 19.5 ± 4.8 years. Mean age at the time of operation was 23.3 ± 4.6 years. One hundred and seventy-four shoulders were included in the Bankart group and fifty-three shoulders in the ALPSA group.

RESULTS

The mean preoperative number of dislocations was significantly higher in the ALPSA group with 12.3 ± 6.2 times than in the Bankart group with 6.9 ± 5.7 times. No statistically significant differences were found in final clinical results except postoperative loss of external rotation (P < 0.01) between the two groups. The ALPSA group had significantly higher rates of the lesion extended to the superior part of the 2 o'clock position (P < 0.01), synovitis (P < 0.01), glenoid erosion (P < 0.01), large Hill-Sachs lesions (P < 0.01), and engaging Hill-Sachs lesions (P = 0.03). The recurrence rate was 15.1% in the ALPSA group, more than twice the rate in the Bankart group with 7.4% (P = n.s.). The size and engagement of Hill-Sachs were significantly associated with redislocation (P < 0.01, P = 0.02).

CONCLUSIONS

Compared with the Bankart group, the ALPSA group showed a significantly higher number of preoperative dislocations, an associated larger-sized Hill-Sachs lesion, and a higher tendency to develop into an engaging Hill-Sachs lesion. In addition, the ALPSA group presented a higher tendency to redislocate and significant postoperative loss of external rotation after capsulolabral repair.

Outcomes of arthroscopic "remplissage": capsulotenodesis of the engaging large Hill-Sachs lesion

Background

A Hill-Sachs lesion of the humeral head after a shoulder dislocation is clinically insignificant in most cases. However, a sizable defect will engage with the anterior rim of the glenoid and cause instability even after anterior glenoid reconstruction. The purpose of this study was to evaluate the outcome of arthroscopic capsulotenodesis of the posterior capsule and infraspinatus tendon ("remplissage") to seal a large engaging Hill-Sachs lesion in an unstable shoulder.

Methods

This was a prospective follow-up study of patients who underwent arthroscopic surgery for recurrent shoulder instability with a large engaging Hill-Sachs lesion from 2007 to 2009. The clinical results were measured preoperatively and postoperatively with the Simple Shoulder test (SST) and the Rowe score for instability.

Results

Eleven patients met the inclusion criteria of this study. The mean follow-up time was 30 months (range 24 to 35 months). At the last follow-up, significant improvement was observed in both scores with no recurrent dislocations. The mean SST improved from 6.6 to 11 (p < 0.001). The mean Rowe Score improved from 10.6 to 85 points (p < 0.001). On average patients regained more than 80% of shoulder external rotation.

Conclusions

Arthroscopic remplissage for shoulder instability is an effective soft tissue technique to seal a large engaging Hill-Sachs lesion with respect to recurrence rate, range of motion and shoulder function.