Anterior shoulder instability: a review of pathoanatomy, diagnosis and treatment

Editorial Commentary: Arthroscopic Subscapular Sling Procedure for Anterior Glenohumeral Instability Has Limitations: Dynamic Anterior Stabilization Using Long Head of the Biceps Tendon May Represent a More Favorable Alternative

Anterior shoulder instability is common. Cases of mild glenoid bone loss are typically addressed with conventional arthroscopic Bankart repair procedures, whereas more critical glenoid bone loss often necessitates more invasive, bone-blocking procedures. Recently, for cases that fall between the need for arthroscopic repair and open procedures, surgeons have developed methods for using soft tissue grafts to create a "sling" effect and augment glenoid labral repair. The subscapular sling procedure aims to restore stability by introducing a semitendinosus autograft into the glenohumeral joint to reconstruct the torn labrum; the graft is wrapped around the subscapularis to create a suspensory sling. Limitations include harvest site morbidity; increased surgical time; subscapularis split, which can compromise the tendon integrity, resulting in loss of internal rotation; and a persistently positive apprehension test. Finally, the technique is complex, and similar alternatives with fewer limitations may include a dynamic anterior stabilization technique using the long head of the biceps tendon, which creates a stabilizing sling effect without graft harvest from the leg and has positive reported outcomes.

Young Collision Athletes Have High Rate of Return to Play and Good Clinical Outcomes Following Open Latarjet Procedure

PURPOSE

To evaluate return to play (RTP), clinical outcomes, and recurrence rates in collision athletes 20 years of age and younger who underwent open Latarjet for anterior shoulder instability.

METHODS

A retrospective review of collision athletes 20 years of age and younger, who underwent an open Latarjet procedure by a single surgeon between the years of 2010-2020 was carried out. Inclusion criteria were 1) collision athlete, 2) underwent open Latarjet procedure, 3) 16-20 years old, and 4) minimum 24-month follow-up. Exclusion criteria were 1) other pathology of the ipsilateral shoulder and 2) noncollision athlete. Rate of RTP, time to RTP, rate of return to preinjury level, the Shoulder Instability Return to Sport after Injury score (SIRSI) score, Subjective Shoulder Value (SSV), visual analogue scale (VAS) scores, and recurrence events were recorded. Quantitative statistical analysis was carried out.

RESULTS

The study included 105 male collision athletes with a mean age of 18.6 ± 1.0 years (range: 17-20). The mean follow-up for patients was 36 ± 26.2 months. A total of 93 (88.6%) RTP at a mean time of 6.3 ± 2.2 months, with 73 (69.5%) returning to their preinjury level of participation. The mean SIRSI score was 69.2 ± 21.8, the mean VAS score was 2.3 ± 2.1, and the mean SSV score was 84.1 ± 16.8. Five patients (4.8%) redislocated their shoulder, with 4 of these requiring a further surgery (3.8%). Two patients (1.9%) reported incidents of subluxation.

CONCLUSIONS

The open Latarjet procedure in young collision athletes results in high rates of RTP, excellent functional outcomes and low recurrence rates at mid-term follow-up. Additionally, complication rates are low in this cohort.

LEVEL OF EVIDENCE

Level IV, case series.

Demographics and Outcomes of Glenohumeral Dislocations in Individuals With Elevated Body Mass Index

INTRODUCTION

No specific study has investigated the characteristics and outcomes of anterior shoulder dislocations in morbidly obese individuals. The purpose of this study was to describe shoulder dislocations in patients with body mass index (BMI) greater than 40.

METHODS

A retrospective review was conducted to identify patients aged 18 years and older with a BMI ≥40 who presented with a shoulder dislocation in a single institution from 2000 to 2020. Dislocation patterns, associated injuries, treatment modalities, and associated complications were recorded.

RESULTS

A significant increase was noted in the number of patients with BMI greater than 40 presenting per year (r2 = -0.831, P < 0.01) over the past 20 years. A significant increase was noted in the average BMI per year in this population (r2 = 0.504, P = 0.028). Fifteen patients (19.5%) experienced at least one recurrent dislocation episode. Ten patients had a Bankart lesion that was associated with an elevated BMI (P = 0.04). Nine patients (11.7%) sustained an associated neurologic injury (no association with BMI).

CONCLUSIONS

Over time, there has been an increase in shoulder dislocations in morbidly obese individuals in the United States, alongside an overall increase in the average BMI of patients who present with shoulder dislocations.

The Arthroscopic Subscapular Sling Procedure Results in Low Recurrent Anterior Shoulder Instability at 24 Months of Follow-Up

PURPOSE

To analyze the results of the subscapular sling procedure developed for anterior shoulder instability in patients with less than 10% anterior glenoid bone loss.

METHODS

Patients were treated surgically with the arthroscopic subscapular sling procedure. A semitendinosus graft was used to reconstruct the anterior labrum and to establish a sling suspension around the upper part of the subscapularis tendon. The patients were followed up with radiographs (at 12 and 24 months). Magnetic resonance imaging (MRI) of the shoulder region and clinical examinations were performed at 3, 12, and 24 months. Recurrent dislocation was the primary endpoint. The Western Ontario Shoulder Instability Index (WOSI) and MRI results were secondary outcome measures. An independent physiotherapist assessed residual instability and range of motion.

RESULTS

Fifteen patients were included with a dislocation rate of 0% after 24 months follow-up. There was a significant clinical improvement of the WOSI score from 57% (904) at baseline to 88% (241) at 24 months (P < .001). The proportion of patients with an improvement in the WOSI Total score larger than the estimated minimal clinically important difference was 100% both at 12 and 24 months. MRI showed an intact sling in all patients. External rotation was not significantly reduced (52° at baseline vs 47° at 24 months, P = .211). Flexion and abduction were significantly improved from 152° to 174° (P = .001) and 141° to 170° (P < .001) after 24 months. The surgical procedures were completed without any intraoperative complications.

CONCLUSIONS

The subscapular sling procedure resulted in low recurrent shoulder instability and improved patient-reported outcome measures at 24 months of follow-up.

LEVEL OF EVIDENCE

Level IV, case series.

Management of a Failed Distal Tibial Allograft Procedure for Anterior Shoulder Instability in a Patient With Epilepsy: A Case Report

Shoulder instability episodes are observed in high-energy injuries, such as seizures. In this case report, we highlight the management of a failed distal tibial allograft procedure for recurrent shoulder instability in a patient with a bony Bankart lesion and epilepsy. The patient was treated with an iliac crest autograft and a proximal humerus osteochondral allograft procedure. To our knowledge, the use of an iliac crest autograft for glenoid bone loss and a proximal humerus osteochondral allograft after several failed shoulder instability procedures in a patient with epilepsy has not been reported.

A comprehensive comparison and evaluation of surgical techniques for anterior shoulder instability: a Bayesian network meta-analysis

BACKGROUND

Anterior shoulder instability is a common clinical problem; however, conflicting evidence exists regarding optimal treatment algorithms. We perform a comparative analysis of stabilization techniques used for recurrent anterior shoulder instability to identify the one associated with the lowest rate of recurrent instability. We additionally explore how glenoid bone loss and osseus lesions affect recurrence rates.

METHODS

PubMed, MEDLINE, Embase, and Cochrane databases were searched for clinical studies comparing surgical techniques for anterior shoulder instability. Two team members independently assessed all potential studies for eligibility and extracted data. Each included study underwent a risk of bias assessment using the Cochrane risk of bias summary tool. The primary outcome of interest was the rate of recurrent instability, which underwent a Bayesian network meta-analysis. Additional analyses were performed relating to the degree of glenoid bone loss and the presence of osseous lesions.

RESULTS

Of 2699 studies screened, 52 studies with 4209 patients were included. Patients who underwent open Latarjet demonstrated the overall lowest rate of recurrent instability [log odds ratio (LOR) 1.93], whereas patients who underwent arthroscopic Bankart repair demonstrated the highest (LOR 2.87). When glenoid bone loss was 10% to 20%, open Latarjet had significantly lower recurrent instability (P = .0016) compared to arthroscopic Bankart repair. When glenoid bone loss increased from 0%-10% to 10%-20%, arthroscopic Bankart repair had a significantly increased rate of recurrence (P = .021). In the presence of an engaging Hill-Sachs lesion, both open Latarjet (P = .01) and arthroscopic Bankart with remplissage (P = .029) had significantly reduced recurrence rates compared to arthroscopic Bankart repair. Finally, regardless of procedure, the presence of a Hill-Sachs or bony Bankart lesion was associated with an increased risk of recurrent instability (r = 0.44, P = .0003, and r = 0.40, P = .006, respectively).

CONCLUSION

The open Latarjet has the overall lowest recurrent instability and significantly lower compared to arthroscopic Bankart repair in the setting of increasing glenoid bone loss. Bone loss between 0% and 10% results in similar outcomes across all procedures.

Fixation devices for anterior shoulder instability

PURPOSE

Over the past 40 years, advances in the development of anchors and sutures have contributed to the improvement in surgical outcomes for treatment of shoulder instability. Important choices in surgery when treating instability include the use of knotless versus knotted suture anchors, and bony versus soft tissue reconstruction techniques.

METHODS

A literature review was conducted to evaluate the history of instability of the shoulder and the results of specific fixation techniques including bony and soft tissue reconstructions as well as knotted and knotless suture anchors.

RESULTS

As knotless suture anchors have continued to grow in popularity since their development in 2001, many studies have compared this newer technique to that of the standard knotted suture anchors. In general, these studies have demonstrated no difference in patient-reported outcome measures between the two options. Additionally, the choice of bony versus soft tissue reconstructions is patient specific as it depends on the specific pathology or combination of injuries.

CONCLUSION

In each surgery performed for shoulder instability, it is vitally important that we try to restore normal anatomy. The normal anatomy is best established by knotted mattress sutures. However, loop laxity and tear through by the sutures in the capsule can eliminate this restoration, increasing risk of failure. Knotless anchors may allow better soft tissue fixation of the labrum and capsule to the glenoid, but without complete restoration of normal anatomy.

Osteoarthritis in the Upper Extremity

Osteoarthritis is a common cause of morbidity in an increasingly aging population. Although the weight-bearing joints of the leg and foot are frequently affected by osteoarthritis, degenerative changes in the joints of the upper extremity are likewise common and can be both particularly debilitating for affected individuals and uniquely challenging for the health care providers managing it. The present review seeks to overview the epidemiology, anatomy, diagnosis, and management of osteoarthritis in the joints of the shoulder, elbow, and hand with the intent of providing accessible and relevant information to the range of medical professionals involved in patient care.

Arthroscopic Bankart Repair With Remplissage as an Alternative to Latarjet for Anterior Glenohumeral Instability With More Than 15% Glenoid Bone Loss

BACKGROUND

Surgical management of anterior shoulder instability continues to evolve. The clinical effectiveness of arthroscopic Bankart repair with remplissage (REMP) in patients with increasing glenoid bone loss (GBL) has not been thoroughly compared with Latarjet.

PURPOSE/HYPOTHESIS

The purpose of this study was to compare 2-year outcomes of REMP versus open Latarjet in patients with >15% GBL. We hypothesized that there would be no difference.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A multicenter, retrospective study was performed on a consecutive series of patients who underwent primary REMP or Latarjet by 4 shoulder specialists between August 2013 and December 2019 for >15% GBL. Procedure performance was based on shared decision making between the surgeon and patient. Baseline and 2-year postoperative range of motion (ROM) and the following patient-reported outcomes (PROs) were collected: Western Ontario Shoulder Instability Index, Single Assessment Numeric Evaluation, and visual analog scale for pain. Return to sport, satisfaction, complications, recurrence, and revisions were reviewed.

RESULTS

A total of 47 patients were available for study, including 22 who underwent REMP and 25 who underwent Latarjet. Baseline demographic characteristics, ROM, and PROs were similar between the groups. Mean preoperative GBL (REMP 25.8% ± 7.8% vs Latarjet 25.1% ± 9.0%; P = .800) and off-track lesions (REMP 59.1% vs Latarjet 44.0%; P = .302) were similar. Postoperative change in external rotation favored Latarjet (10° ± 22° vs -4° ± 13°; P = .017). Postoperative PROs, return to the sports (86.4% vs 87.5%; P = .99), and satisfaction (95.5% vs 95.8%; P = .99) were similar between groups. There were no recurrent dislocations in either group. One infected hematoma was encountered in the Latarjet cohort.

CONCLUSION

At short-term follow-up, the hypothesis was upheld. REMP and Latarjet provided similar outcomes for patients with >15% GBL, although REMP patients experienced slightly decreased external rotation. Although larger series and longer-term follow-ups are required, remplissage may be considered in patients with >15% glenoid bone loss.

Remplissage Yields Similar 2-Year Outcomes, Fewer Complications, and Low Recurrence Compared to Latarjet Across a Wide Range of Preoperative Glenoid Bone Loss

PURPOSE

The purpose of this study was to compare functional outcome, return to sport, satisfaction, postoperative recurrence, and complications in patients undergoing primary arthroscopic Bankart repair with remplissage (ABR) to primary Latarjet.

METHODS

A multicenter retrospective study was performed on patients undergoing primary ABR or open Latarjet between 2013 and 2019 who had a minimum 2-year follow-up. Baseline and two-year range of motion (ROM), patient-reported outcomes (PROs: Western Ontario Shoulder Instability Index [WOSI], Single Assessment Numeric Evaluation [SANE], and visual analog scale [VAS] for pain) recurrence, return to sport, satisfaction, and complications were reviewed.

RESULTS

This study included 258 patients, including 70 ABRs and 188 Latarjet procedures. Baseline demographics, ROM, and PROs were similar. Mean preop glenoid bone loss (GBL) (12.3% ± 10.9% vs 7.6% ± 9%; P < .001) and off-track lesions (23% vs 13%; P = .046) were higher in the ABR group, while preoperative GBL range was similar (0-42% vs 0-47%). Changes in the VAS (1.9 vs 0.9; P = .019) and WOSI (1096 vs 805; P < .001) were improved in ABR. The percentage of patients who achieved a minimal clinically important difference was improved in WOSI for ABR and PASS for ABR in SANE, VAS, and WOSI scores. The ABR cohort reported worse changes in external rotation (ER) (-4° vs +19°; P < .001). Return to sport among overhead and contact athletes favored ABR (91.5% vs 72.7%; P = .007). Satisfaction and recurrent dislocation were similar. Surgical complications were observed in 0% of ABR cases, compared to 5.9% in the Latarjet group.

CONCLUSION

Primary ABR resulted in 2-year functional outcomes that were as good or superior to primary Latarjet, with higher return to sport for overhead and contact activities, fewer complications, and comparably low recurrence rates, even despite greater bipolar bone loss in the ABR cohort. However, this comes at the expense of decreased external rotation, which may be considered in individual patients.

LEVEL OF EVIDENCE

III, retrospective comparative study.

Impact of Prior Anterior Instability on Shoulder Arthroplasty Outcomes: A Systematic Review

Background

Anterior shoulder instability (ASI) is a frequently encountered pathology. Patients with a history of ASI have an increased rate of developing glenohumeral osteoarthritis and becoming candidates for shoulder arthroplasty. This systematic review aims to synthesize outcomes for patients undergoing shoulder arthroplasty with a history of ASI.

Methods

A comprehensive literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) using PubMed, Embase, OVID Medline, Scopus, CINAHL, Web of Science, and Cochrane databases for studies evaluating the impact of prior ASI on total shoulder arthroplasty (TSA), reverse TSA, and/or hemiarthroplasty outcomes, with a minimum follow-up of 12 months. Studies were graded by level of evidence and data concerning patient demographics and outcomes were extracted.

Results

Sixteen articles met the inclusion criteria, including 596 patients (413 male, 181 female). The average age of the control and prior ASI groups were 57.5 and 57.0 years, respectively. Overall, 251 patients were treated operatively, 132 nonoperatively, and 213 were controls without a history of prior ASI. Shoulder arthroplasty techniques included TSA (436 shoulders), reverse TSA (130 shoulders), and hemiarthroplasty (14 shoulders). Prior anterior stabilization management included soft tissue repair, bony augmentation, and nonoperative treatment. Almost all studies reported no significant difference in subjective and functional arthroplasty outcomes between control and prior ASI groups, or between patients with prior ASI treated nonoperatively vs. surgically.

Conclusion

Shoulder arthroplasty in the setting of prior ASI results in improved subjective and functional outcome scores that are comparable to patients without a history of instability.

Bankart Repair With Transferred Long Head of the Biceps Provides Better Biomechanical Effect Than Conjoined Tendon Transfer in Anterior Shoulder Instability With 20% Glenoid Defect

PURPOSE

To examine the biomechanical differences between labral repair with transferred conjoined tendon and transferred long head of the biceps tendon (LHBT) for anterior shoulder instability with 20% bone loss.

METHODS

Twelve cadaveric shoulders were tested in sequent 5 conditions: intact, 20% glenoid defect, Bankart repair, Bankart repair with transferred conjoined tendon (dynamic conjoined tendon sling, DCS), and with transferred LHBT (dynamic LHBT sling, DLS) at 60° of glenohumeral abduction and 60° of external rotation. The physiological glenohumeral joint load was created by forces applied to the rotator cuff, conjoined tendon, and LHBT. The glenohumeral compression force and range of motion were recorded before anteroinferior force application. The anterior, inferior, and total translations were measured with 20, 30, 40, and 50 N of anteroinferior force, respectively.

RESULTS

Anteroinferior glenoid defect led to significant increase of humerus translation and decrease of glenohumeral compression force. DLS provided better resistance effect in both anterior-posterior and superior-inferior directions than DCS under high loading condition (40 N, P =.03; 50 N, P <.01). Both DCS and DLS procedures could further restore glenohumeral compression force with Bankart repair (Bankart repair: 32.1 ± 4.0 N; DCS: 36.7 ± 3.2 N, P < .01; DLS: 35.8 ± 3.6 N, P =.03). No range of motion restrictions were observed relative to the normal shoulder.

CONCLUSIONS

Both the DLS and DCS techniques could reduce the anterior-inferior translation and partially restore the glenohumeral stability in anterior shoulder instability with 20% anteroinferior glenoid defect compared with Bankart repair. Under greater loading conditions, DLS provides better stability than DCS.

CLINICAL RELEVANCE

Shoulder stability can be restored by DLS and DCS with low load. With greater shoulder stability requirements, DLS might be a better option than DCS for anterior shoulder instability with 20% bone loss.

Combined Bankart and SLAP repair: patient-reported outcome measurements after a minimum 5-year follow-up

BACKGROUND

Anterior shoulder instability is typically characterized by detachment of the anteroinferior labrum (Bankart lesion). Some patients also sustain a superior labrum anterior-to-posterior (SLAP) injury. The purpose of this study was to compare the medium-term clinical results of isolated anterior Bankart repairs (ABR) with those of combined Bankart and SLAP repair (ABR + SLAP).

METHODS

Data on all patients treated surgically for recurrent anterior shoulder instability between 2006 and 2011 were retrospectively collected from medical charts. The minimum follow-up was 5 years. Patients were interviewed to assess patient-reported outcome measurements (PROM) as determined by the American Shoulder and Elbow Surgeons Score (ASES), the Subjective Shoulder Score (SSV), and the Disabilities of the Arm, Shoulder, and Hand Score (DASH), as well as their quality of life (QOL: SF12 questionnaire). Information on complications, re-operations, and recurrent instability was recorded and evaluated as well.

RESULTS

A total of 150 patients (88% males) with a mean age 23.7 years (range 15-40) were included. Forty-two patients following ABR + SLAP repair were compared to 108 patients following ABR alone, with a mean follow-up of 7.8 years (range 5-10.7). The rate of re-dislocation was similar in both groups (26% for ABR + SLAP vs 20% for ABR, p = .44). There were no significant differences in functional outcome between the ABR + SLAP and the ABR alone groups (SSV 86.7 vs 86.5, p = .93, ASES 89.6 vs 86.5, p = .11, and DASH 4.9 vs 7, p = .17), or in QOL outcome (SF12 physical 95.6 vs 93.3, p = .27, SF12 mental 84.4 vs 85.7, p = .63).

CONCLUSION

Surgical repair for anterior shoulder instability and a coexisting SLAP lesion yields clinical results as good as those of isolated ABR, as evidenced by similar PROM and re-dislocation rates after medium-term follow-up.

LEVEL OF EVIDENCE

III.

Arthroscopic Latarjet Procedure Does Not Lead to Loss of Clinically Significant External Rotation at 0° and 90° of Shoulder Abduction

Background

Several reports have shown that shoulder stabilizing procedures lead to postoperative external rotation (ER) deficits. However, no study on arthroscopic Latarjet procedures has investigated the effect on ER when the arm is abducted at 0° (ER₀) and 90° (ER₉₀). This study examined the relationship between the arthroscopic Latarjet procedure and the subsequent effect on ER₀ and ER₉₀.

Methods

Patients who underwent an arthroscopic Latarjet procedure from December 2015 to April 2021 were retrospectively evaluated. Preoperative ER₀ and ER₉₀ values were obtained from the contralateral shoulder. ER₀ and ER₉₀ values from the operative side were collected at both 3 and 6 months postoperatively. A repeated measures ANOVA was performed to assess the mean preoperative and postoperative values.

Results

Forty-six patients met the inclusion criteria. Mean ER₀ for the 3- and 6-month time frames measured 44.2° and 54.6°, respectively. Mean ER₉₀ for the 3- and 6-month time frames measured 78.4° and 90.4°, respectively. Comparison to the contralateral arm at the 3-month follow-up period showed a deficit of 14.9° (P = .0001) and 17.2° (P = .0001) for ER₀ and ER₉₀, respectively. At the 6-month follow-up period, patients demonstrated an average decline in ER₀ and ER₉₀ of 4.57° (P = .063) and 5.11° (P = .008), respectively.

Conclusion

A nominal deficit in ER occurred for both ER₀ and ER₉₀ status post arthroscopic Latarjet procedure. Despite loss of ER₉₀ at 6 months achieving statistical significance, the clinical impact is arguably inconsequential. Such limited loss of ER provides more information regarding bony procedures being a more definitive treatment for glenohumeral instability and the ability to restore native motion.

Consideration May Be Given to Lowering the Threshold for the Addition of Remplissage in Patients With Subcritical Glenoid Bone Loss Undergoing Arthroscopic Bankart Repair

Purpose

Treatment for patients with anterior glenohumeral instability with subcritical bone loss is evolving. The purpose of this study was to compare 2-year outcomes of arthroscopic Bankart repair with and without Hill–Sachs remplissage in patients with <15% glenoid bone loss.

Methods

A multicenter retrospective study was performed on a consecutive series of patients who underwent primary isolated arthroscopic Bankart repair (IBR) or arthroscopic Bankart repair with remplissage (REMP) by 4 shoulder specialists between 2013 and 2019. Range of motion (ROM) and patient-reported outcomes (PROs) were collected at baseline and 2 years postoperative: Western Ontario Shoulder Instability Index, Single Assessment Numeric Evaluation, and visual analog scale for pain. Recurrence, return to sport, satisfaction, complications, and revisions also were reviewed.

Results

A total of 123 patients were available, including 75 IBR and 48 REMP. Baseline demographics, activity, ROM, and PROs were similar. Mean glenoid bone loss (2.5% vs 6.1%: P < .001) was greater in REMP, although the number of on-track lesions was similar (98.7% vs 93.8%: P = .298). WOSI scores were improved for REMP (196.5 vs 42.7: P = .004), but otherwise no difference in postoperative PROs or ROM. Differences between cohorts did not reach significance in return to sport (73% vs 83%: P = .203), recurrence (9.3% vs 2.1%: P = .148), or revisions (6.8% vs 2.1%: P = .403). For on-track lesions there were 6 recurrences in IBR (6 of 74; 8.1%) and 1 recurrence in REMP (1 of 45; 2.2%).

Conclusions

Despite slightly worse pathology, patients with subcritical bone loss who undergo REMP experience similar short-term postoperative function to isolated IBR. Recurrence, revision, and return to sport favored REMP but this study was underpowered to show statistical significance. Recurrence was common following IBR, despite subcritical glenoid bone loss and primarily on-track lesions, suggesting that REMP can be considered in on-track lesions.

Level of Evidence

III, retrospective comparative study.

Glenoid bony morphology along long diameter is associated with the occurrence of recurrent anterior shoulder dislocation: a case-control study based on three-dimensional CT measurements

PURPOSE

The purpose of our study is to compare the anatomic parameters of proximal humerus, glenoid, and glenohumeral joint between patients with recurrent anterior shoulder dislocation (RASD) and patients without RASD with the assistance of three-dimensional (3D) CT scans.

METHODS

Sixty patients were included in the study and divided into group RASD and group control. 3D-CT models of shoulder joint for each included patient were reconstructed and multiple anatomic parameters were measured.

RESULTS

There were no statistically significant differences between the two groups in morphological parameters of humerus and glenohumeral joints. Long diameter of glenoid was 3.50 ± 0.34 cm for patients in group RASD and 3.31 ± 0.32 cm in group control (p = 0.039). There was a statistically significant difference in the ratio of long to short diameter of glenoid (p < 0.001). Ratio of humeral head height to glenoid long diameter (Hhh/Gld) was 1.02 ± 0.07 in group RASD, significantly lower than 1.09 ± 0.08 in group control (p = 0.001). Longitudinal depth of glenoid was significantly higher in group RASD (p = 0.013).

CONCLUSION

The glenoid morphology along long diameter is closely correlated with the stability of glenohumeral joint, including glenoid long diameter and glenoid longitudinal depth. It is especially noteworthy that the value of Hhh/Gld decreases in patients with RASD. The difference of Hhh/Gld between the two groups reminds us that the correlation of bony structure along long diameter between glenoid and humeral head plays an important role in RASD.

Postoperative recovery comparisons of arthroscopic Bankart to open Latarjet for the treatment of anterior glenohumeral instability

BACKGROUND

Recurrent anterior glenohumeral instability is a disabling pathology that can be successfully treated by arthroscopic Bankart repair or open Latarjet. However, there is a paucity of studies comparing the postoperative recovery. The purpose of this study is to evaluate the postoperative pain and functional recovery following arthroscopic Bankart versus open Latarjet.

METHODS

This is a retrospective analysis of a multicenter prospective outcomes registry database. Postoperative recovery outcomes of either a primary or revision arthroscopic Bankart and open Latarjet procedures were compared. A minimum of 1-year follow-up was required. Outcomes measures included pain visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) function score, ASES index score, and single assessment numeric evaluation (SANE) score. Overall, 787 patients underwent primary arthroscopic Bankart, 36 underwent revision arthroscopic Bankart and 75 underwent an open Latarjet procedure.

RESULTS

When compared to primary arthroscopic Bankart, open Latarjet demonstrated significantly lower VAS scores at 6 weeks (p = 0.03), 3 months (p = 0.01), and 2 years (p < 0.05). Medium-term outcomes for ASES scores and SANE score, at 1 and 2 years showed no difference. Latarjet demonstrated significantly lower (p < 0.05) preoperative early postoperative VAS pain scores with no difference at 1 year or 2 years when compared to primary Bankart. There was no difference in ASES function or index between Bankart and Latarjet. Revision Bankart provided inferior outcomes for VAS, ASES function, and ASES index when compared to primary Bankart and Latarjet at 1 year and 2 years.

CONCLUSIONS

Primary arthroscopic Bankart repair and open Latarjet provided nearly equivalent improvements in pain (VAS) and functional outcomes (ASES, SANE, VR-12) during the early recovery phase (2 years). This study supports the use of either procedure in the primary treatment of anterior glenohumeral instability. Revision arthroscopic Bankart repair demonstrated deteriorating outcomes at 1 and 2 years postoperatively.

Return to play following open Bankart repair in collision athletes aged 18 years or less

HYPOTHESIS

The purpose of this study was to evaluate clinical outcomes, return to play (RTP), and recurrence rates in patients aged 18 years or less who underwent open Bankart repair (OBR) for anterior shoulder instability.

METHODS

A retrospective review of collision athletes under 18 years old who underwent OBR by 2 surgeons between the years 2010 and 2019 was carried out. An OBR using a subscapularis split was performed in all patients. Recurrent instability, rate of RTP, and time to RTP were recorded. The Shoulder Instability Return to Sport after Injury score, Subjective Shoulder Value score, and visual analog scale scores were also evaluated.

RESULTS

The study included 34 male collision athletes with a mean age of 16.5 ± 1.3 years (range, 15-18 years). The mean follow-up for patients was 49.5 ± 30.7 months. A total of 30 patients (88.2%) returned to full sport at a mean time of 5.8 ± 2.2 months, with 27 (90%) managing to return at their preinjury level of participation. The mean Subjective Shoulder Value score for patients at the final follow-up was 86.8 ± 17.5, the mean Shoulder Instability Return to Sport after Injury score was 86.3 ± 22.6, and the mean visual analog scale score was 1.6 ± 1.8. Eight patients (23.5%) re-dislocated their shoulder, with 4 of them requiring a further surgery. Two patients (5.8%) reported having incidents of subluxation that did not require reduction.

CONCLUSION

This study found high rates of patient-reported satisfaction, excellent functional outcomes, and high rates of RTP in the medium term among young collision athletes aged 18 years or less who underwent OBR for anterior shoulder instability. However, there were high rates of recurrence with moderate rates of revision surgical stabilization in the medium term.

Comparison of Perioperative Complications Following Surgical Treatment of Shoulder Instability

Background

Surgical repair for shoulder instability includes arthroscopic Bankart, open Bankart, and Latarjet-Bristow.

Methods

This is a cohort study of patients who underwent arthroscopic Bankart, open Bankart, or Latarjet-Bristow procedures that were identified within the National Surgical Quality Improvement Program database (2007-2019). Unadjusted and adjusted analyses were performed (α = 0.05). Outcomes included 30-day adverse events, readmission, and operative time.

Results

This study included 10,955 patients (9128 arthroscopic Bankart, 1148 open Bankart, and 679 Latarjet-Bristow). Compared with arthroscopic Bankart, Latarjet-Bristow had longer operative times (129.96 [95% CI: 126.49-133.43] vs. 86.35 [85.51-87.19] minutes), along with a higher percentage of serious adverse events (2.5% vs. 0.4%), reoperation (1.9% vs. 0.1%), readmission (1.8% vs. 0.3%), thromboembolic complications (0.4% vs. 0.1%), and sepsis (0.4% vs. 0.0%) (P < .05 for all). Open Bankart had longer operative times (98.17 [95.52-100.82] vs. 86.35 [85.51-87.19] minutes) and a higher percentage of sepsis (0.2% vs. 0.0%) (P < .05 both). Latarjet-Bristow had increased odds of a serious adverse event (odds ratio [OR]: 7.68 [4.19-14.07]), reoperation (OR: 17.32 [7.58-39.56]), readmission (OR: 5.73 [2.84-11.54]), and deep wound complications (OR: 14.98 [3.92-57.23]) (P < .05 for all). In comparing the relative utilization of arthroscopic versus open Bankart, arthroscopic Bankart increased (83.4% to 91.2%) while open Bankart decreased (16.6% to 8.8%) from the 2011-2013 time period to 2017-2019 (P_trend < .001).

Conclusion

In addition to a low complication rate, the relative utilization of arthroscopic Bankart increased compared with open Bankart over the past decade. Furthermore, Latarjet-Bristow was associated with a higher incidence of serious adverse events than arthroscopic Bankart.

Clinical outcomes of revision arthroscopic Bankart repair for anterior shoulder instability: a systematic review of studies

BACKGROUND

The purpose of this study was to review the literature to ascertain the functional outcomes, recurrence rates, and subsequent revision rates following revision arthroscopic Bankart repair.

METHODS

Two independent reviewers performed a literature search based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines using the Embase, MEDLINE, and Cochrane Library databases. Studies in which arthroscopic Bankart repair was performed as a revision procedure were included. The clinical outcomes extracted and analyzed were functional outcomes, return to play, and recurrent instability.

RESULTS

Fourteen studies with 433 patients met the inclusion criteria. The majority of patients were male patients (63.7%); the average age was 26.1 years (range, 14-58 years), and the mean follow-up period was 37.6 months (range, 10-144 months). The mean Rowe score was 84.2, and 79.7% of patients had good to excellent outcomes. The rate of return to play was 78.5%, with 47.5% of patients returning to their preinjury level of play across 10 studies. The rate of recurrent instability was reported in 12 studies, with 328 shoulders demonstrating 86 instability events (26.2%). The rate of recurrent instability due to dislocation was reported in 7 studies (n = 176), with 19 events (10.8%), whereas the rate of subluxation was reported in 4 studies (n = 76), with 6 events (7.9%).

CONCLUSIONS

Revision arthroscopic Bankart repair for anterior shoulder instability was shown to result in a high rate of recurrent shoulder instability. There was a relatively poor rate of return to sport among athletes, and only about half of the patients were able to return at or above their preoperative level of ability.

Association Between Keratoconus and Shoulder Dislocation: A Cross-Sectional Study

Introduction Few studies have highlighted the correlation between shoulder dislocation and keratoconus (KC). This study aimed to examine the association between KC and shoulder dislocation using patients with KC and matched controls. Methods This cross-sectional study was conducted at Jordan University Hospital. We included patients diagnosed with KC from Jordan University Hospital's Ophthalmology Department between 2015 and 2018. We also included age- and sex-matched controls recruited randomly from fitness centers and shopping malls. All participants had complete ophthalmic and orthopedic assessments. KC was diagnosed by clinical examination followed by Pentacam (Scheimpflug Images, Oculyzer, WaveLight, Alcon, USA) confirmation. Results A total of 238 patients, with a mean age of 29.53 (±11.20) years, were included in this study. They were 144 (60.5%) men and 94 (39.5%) women. Moreover, 120 (50.4%) had KC while 118 (49.6%) did not have KC. Only 11 (4.6%) patients had previous shoulder dislocation. We did not find a significant difference in the frequency of shoulder dislocation between patients with and without KC (p = 0.512). Conclusion This study provides further evidence on the lack of association between shoulder dislocation and KC, an association that was presumed due to shared collagen characteristics.

Test-Retest reliability of the internal shoulder rotator muscles' stretch reflex in healthy men

Until now the reproducibility of the short latency stretch reflex of the internal rotator muscles of the glenohumeral joint has not been identified. Twenty-three healthy male participants performed three sets of external shoulder rotation stretches with various pre-activation levels on two different dates of measurement to assess test-retest reliability. All stretches were applied with a dynamometer acceleration of 10⁴°/s² and a velocity of 150°/s. Electromyographical response was measured via surface EMG. Reflex latencies showed a pre-activation effect (ƞ² = 0,355). ICC ranged from 0,735 to 0,909 indicating an overall "good" relative reliability. SRD 95% lay between ±7,0 to ±12,3 ms. The reflex gain showed overall poor test-retest reproducibility. The chosen methodological approach presented a suitable test protocol for shoulder muscles stretch reflex latency evaluation. A proof-of-concept study to validate the presented methodical approach in shoulder involvement including subjects with clinically relevant conditions is recommended.

Clinical Outcomes of the Traditional Latarjet Versus the Congruent Arc Modification for the Treatment of Recurrent Anterior Shoulder Instability: A Meta-analysis

Background:

Few studies have compared clinical outcomes between the traditional Latarjet procedure for anterior shoulder instability and the congruent arc modification to the Latarjet procedure.

Purpose:

To systematically evaluate the literature for the incidence of recurrent instability, clinical outcomes, radiographic findings, and complications for the traditional Latarjet procedure and the congruent arc modification and to compare results of each search.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review and meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We included studies published between January 1990 and October 2020 that described clinical outcomes of the traditional Latarjet and the congruent arc modification with a follow-up range of 2 to 10 years. The difference in surgical technique was analyzed using a chi-square test for categorical variables, while continuous variables were evaluated using a Student t test.

Results:

In total, 26 studies met the inclusion criteria: 20 studies describing the traditional Latarjet procedure in 1412 shoulders, and 6 studies describing the congruent arc modification in 289 shoulders. No difference between procedures was found regarding patient age at surgery, follow-up time, Rowe or postoperative visual analog scores, early or late complications, return-to-sport timing, or incidence of improper graft placement or graft fracture. A significantly greater proportion of male patients underwent glenoid augmentation using the congruent arc modification versus traditional Latarjet (P < .001). When comparing outcomes, the traditional Latarjet procedure demonstrated a lower incidence of fibrous union or nonunion (P = .047) and broken, loose, or improperly placed screws (P < .001), and the congruent arc modification demonstrated improved outcomes with regard to overall return to sport (P < .001), return to sport at the same level (P < .001), incidence of subluxation (P = .003) or positive apprehension (P = .002), and revision surgery for recurrent instability (P = .027).

Conclusion:

Outcomes after the congruent arc modification proved at least equivalent to the traditional Latarjet procedure in terms of recurrent instability and return to sport, although early and late complications were equivalent. The congruent arc procedure may be an acceptable alternative to traditional Latarjet for the treatment of anterior shoulder instability with glenoid bone loss; however, long-term outcomes of this procedure are needed.

Athletes With Anterior Shoulder Instability: A Prospective Study on Player Perceptions of Injury and Treatment

Background:

Many in-season athletes choose to delay or avoid surgery in order to continue playing and avoid downtime such as missed games or seasons.

Purpose:

To learn about the attitudes toward the injury and treatment of in-season shoulder instability in competitive athletes who have suffered a shoulder dislocation.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A study-specific questionnaire about athletes’ perceptions of injury and treatment was administered to injured players. Secondary outcomes included the American Shoulder and Elbow Surgeons (ASES) score and the Western Ontario Shoulder Instability Index (WOSI). Mean scores and standard deviations were calculated, and between-group analyses with t tests were performed to compare the ASES and WOSI scores. The Mann-Whitney U test was used for analyses performed on the following groups: early operative versus nonoperative management; age <18 versus ≥18 years; first-time dislocators versus recurrent dislocators; self-reducing subluxations versus dislocations requiring assistance; and dominant arm affected versus nondominant arm.

Results:

There were 45 patients included in this study (33 male, 12 female) with a mean age of 18 ± 2.8 years. Several sports were represented, with the most common being football, baseball, soccer, and rugby. In this study of in-season athletes with shoulder instability, 13 (28.9%) chose early surgery, 4 (8.9%) chose surgery at season’s end, while 28 (62.2%) chose physical therapy followed by a wait-and-see approach, with 13 (46.4%) of these patients ultimately requiring surgery. Athletes who chose nonoperative treatment were statistically more likely to believe that their shoulder would heal on its own (P < .001) or with physical therapy (P < .025); they were also more likely to agree that they would rather stop sports than undergo surgery (P < .04). Athletes with worse ASES and WOSI scores at injury were more likely to choose surgery (P < .03 and P < .05, respectively). Athletes with >1 dislocation were less likely to believe that the shoulder would heal without surgery (P < .025). Most athletes agreed that seasonal timing and recruitment prospects were an important factor in their decision in favor of surgery (P < .038), and most agreed that their doctor influenced their ultimate treatment decision (P < .006). Most athletes also agreed that a repeat dislocation would cause further injury to the shoulder.

Conclusion:

Treatment decisions were most strongly related to the athletes’ perceptions of injury severity and the influence of the treating surgeon.

Glenohumeral Joint Instability: A Review of Anatomy, Clinical Presentation, and Imaging

The glenohumeral joint is intrinsically predisposed to instability because of the bony anatomy but maintained in alignment by many important structures, including the glenoid labrum, glenohumeral ligaments (GHLs), and muscles and tendons. Trauma and overuse can damage these stabilizers, which may then lead to subluxation or dislocation and eventually recurrent instability. This is most common in the anterior direction, which has several recognizable patterns of injury on advanced imaging, including humeral Hill Sachs deformities, bony Bankart lesion of the anteroinferior glenoid, soft tissue Bankart lesions, Bankart variant lesions (Perthes and ALPSA lesions), and HAGL/GAGL lesions. Similar reverse lesions are seen, as well as unique posterior lesions, such as Bennett and Kim's lesions. When symptoms of apprehension and instability in more than one direction are seen, one should consider multidirectional instability, which often presents with a patulous joint capsule. Finally, owing to significant impacts of daily activities and quality of life, surgical correction of labral tears, bony Bankart defects, Hill Sachs defects, and capsular laxity, may be considered.

[Shoulder instability: review of current concepts of diagnosis and treatment]

OBJECTIVE

To conduct a systematic review of modern literature data on the modern approaches in diagnosis and treatment of shoulder instability.

MATERIAL AND METHODS

Searching for literature data was performed using the Pubmed and Google Scholar databases.

RESULTS

The authors analyzed the results of conservative treatment of patients with shoulder instability and emphasized higher risk of instability recurrence, degeneration of anatomical structures and functional impairment in these patients. Surgery is advisable to restore shoulder stability and normalize its function. Several methods for stabilizing the shoulder have been proposed.

The approaches to diagnosis and treatment of shoulder instability have been updated.

CONCLUSION

Successful treatment of shoulder instability is based on qualitative and complete assessment of soft tissues and bone structures. An individual approach considering bone tissue deficiency and individual needs of the patient is required.

Single Assessment Numeric Evaluation for instability as an alternative to the Rowe score

BACKGROUND

Several functional outcome scores have been proposed for the evaluation of shoulder instability. Most are multiple-item questionnaires, which can be time-consuming and difficult for patients to understand, as well as leading to lack of compliance. The Single Assessment Numeric Evaluation (SANE) score is a single question that has recently gained widespread acceptance based on its simplicity and correlation with more complex scoring systems. The purpose of this study was to assess the correlation of a new modified version of the SANE score, the SANE-instability score, with the Rowe score after treatment for shoulder instability.

MATERIALS AND METHODS

We prospectively evaluated a consecutive series of 253 patients (268 shoulders) treated surgically or nonoperatively for shoulder instability between November 2017 and November 2019, for whom the Rowe and SANE-instability scores were collected before treatment and/or after treatment. The SANE-instability score was assessed with the following question: "What is the overall percent value of your shoulder if a completely stable shoulder represents 100%?" Correlations were tested using the Pearson coefficient (r) and interpreted as very high (r = 0.90-1.00), high (r = 0.70-0.89), moderate (r = 0.50-0.69), low (r = 0.30-0.49), or negligible (r = 0.00-0.29). Subgroup analyses were also performed to observe correlation variations according to follow-up length (before treatment and at 6, 12, 26, 52, and 104 weeks after treatment), patient age (<20, 20-29, 30-39, or ≥40 years), and type of treatment (nonoperative or surgical).

RESULTS

The overall correlation between the SANE-instability and Rowe scores was high (r = 0.85, P < .001). Subgroup analyses revealed that the correlation between the 2 scores was high before treatment (r = 0.74); moderate at 6 and 12 weeks after treatment (r = 0.66 and r = 0.57, respectively); and then high at 26, 52, and 104 weeks after treatment (r = 0.75, r = 0.75, and r = 0.78, respectively) (P < .001). The correlation was high across all types of treatment (r = 0.76-0.85), high for patients aged ≥ 20 years (r = 0.80-0.86), and very high for patients aged < 20 years (r = 0.93) (P < .001).

CONCLUSION

This study demonstrated a significant correlation between the SANE-instability and Rowe scores before and after treatment, as well as across all patient age groups and treatments. Owing to its high simplicity, the SANE-instability score could be used as an alternative to the Rowe score for patient follow-up at various time points.

An exceptional case of posterior shoulder fracture dislocation in patient with recurrent anterior dislocation forming "Mirror Hill-Sachs lesion"

A posterior dislocation should be always kept in mind in a painful shoulder especially after trauma or seizure. Even in the presence of recurrent dislocation, the direction may be different from one episode to another.

Diagnosis and Management of Traumatic Anterior Shoulder Instability

Anterior shoulder instability is the most common form of shoulder instability and is usually because of a traumatic injury. Careful patient selection is key to a favorable outcome. Primary shoulder stabilization should be considered for patients with high risk of recurrence or for elite athletes. Soft-tissue injury to the labrum, capsule, glenohumeral ligament, and rotator cuff influence the outcome. Glenoid bone loss (GBL) and type of bone loss (on-track/off-track) are important factors when recommending treatment strategy. Identification and management of concomitant injuries are paramount. The physician should consider three-dimensional CT reconstructions and magnetic resonance arthrography when concomitant injury is suspected. Good results can be expected after Bankart repair in on-track Hill-Sachs lesions (HSLs) with GBL < 13.5%. Bankart repair without adjunct procedures is not recommended in off-track HSLs, regardless of the size of GBL. If GBL is 13.5% to 25% but on-track, adjunct procedures to Bankart repair should be considered (remplissage and inferior capsular shift). Bone block transfer is recommended when GBL > 20% to 25% or when the HSL is off-track. Fresh tibia allograft or lilac crest autograft are good treatment options after failed bone block procedure.

Return to Play after Arthroscopic Bankart Repair Combined with Open Subpectoral Biceps Tenodesis

Purpose

To evaluate the clinical outcomes and rate of return to play (RTP) in patients who underwent arthroscopic Bankart repair and open subpectoral biceps tenodesis.

Methods

A retrospective review of patients who underwent combined arthroscopic Bankart repair and open subpectoral biceps tenodesis by a single surgeon between 2012 and 2016 was performed. RTP, the level of return, and the timing of return were assessed. Visual analog scale for pain, Rowe score, Shoulder Instability-Return to Sport after Injury score, and Subjective Shoulder Value were evaluated.

Results

The study included 14 patients, with a mean follow-up of 34.2 ± 12.1 months. Of the 14 patients, 13 (92.9%) returned to sport at a mean of 4.8 ± 1.2 months and 9 (64.3%) returned to the same or higher level of sport. At final follow-up, the mean Rowe was 80.0 ± 16.3, the mean Subjective Shoulder Value was 81.0 ± 15.1, the mean Shoulder Instability-Return to Sport after Injury was 57.3 ± 25.6, and the mean visual analog scale score was 2.6 ± 1.5. One patient had a recurrent dislocation, whereas no patients underwent a further operation on the ipsilateral shoulder.

Conclusion

Patients undergoing arthroscopic Bankart repair combined with open subpectoral biceps tenodesis had a high rate of RTP with a low rate of recurrent instability.

Level of Evidence

IV, Therapeutic Case Series.

Return to Sport After Coracoid Bone Block Transfer for Shoulder Instability: A Systematic Review

BACKGROUND

Shoulder dislocations can be devastating for an athlete. Coracoid bone block transfer is often used for the treatment of recurrent shoulder instability.

QUESTIONS/PURPOSES

The primary purpose of this study was to determine the rate and mean time of return to sport in athletes after a coracoid bone block transfer at the pre-operative level of competition, a lower level, or a different level. We also sought to determine how return to sport rates after a coracoid bone block procedure compared with rates after several comparator interventions. Finally, we looked to determine the post-operative clinical outcomes and complications reported after a coracoid bone block procedure.

METHODS

We systematically searched three databases (PubMed, Embase, and MEDLINE) for studies reporting return to sport after a coracoid bone block procedure.

RESULTS

A total of 52 studies (with levels of evidence ranging from II to IV) evaluating 2953 shoulders in 2888 patients were included in this systematic review. The mean rate of return to sport at any level was 88.4% (2291 of 2592 patients). However, the rate of return to the pre-operative level was 70.3% (1387 of 1974 patients). The mean time to return to sport was 5.38 months (range 21 days to 36 months). The rate of return to sport was higher after the Latarjet procedure, as compared with Bankart repair (87.0% and 75.8%, respectively). All studies showed improvements in clinical outcome measures after coracoid bone block intervention. The cumulative complication rate was found to be 6.46% (158 of 2446 patients).

CONCLUSION

Coracoid bone block transfer allows for a high rate of return to sport, although the rate of return to sport at athletes' pre-operative level is lower. The rate of return to sport after Latarjet procedure is higher in comparison with Bankart repair. Additionally, coracoid bone block transfer is associated with improvements in a number of clinical outcome measures. Common post-operative complications include non-union between bone block and glenoid, hematoma, and infection.

The broken circle method: a novel technique that enhances detection of Hill-Sachs lesions on internal rotation shoulder radiographs

AIM

To describe and test a new method that increases the conspicuity of a Hill-Sachs lesion on internal rotation (IR) radiographs.

MATERIALS AND METHODS

This study had institutional review board approval. A retrospective search for patients with a prior shoulder dislocation and a Hill-Sachs lesion documented on magnetic resonance imaging (MRI) was performed over a 10-year period identifying 256 test patients. In Part 1, the IR radiographs from test cases were randomised with controls, and three readers scored them independently for the defect. The readers were then taught the Broken Circle (BC) method and re-scored the radiographs. In Part 2, 15 cases of Hill-Sachs lesions that were missed by all readers in Part 1 were randomised with controls, and were shown to 25 radiology residents before (pre-test) and after (post-test) learning the BC method. A paired t-test was used to compare the differences in sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

In Part 1, the sensitivity increased 19.7% (54.1%-73.8%; p<0.05) and NPV increased 10.8% (62.5%-73.3%; p<0.01). In Part 2, post-test sensitivity for residents increased 16.3% (55.2%-71.5%; p<0.0001), accuracy increased 13.4% (64%-77.4%; p<0.0001), and NPV increased 13.3% (40.8%-54.1%; p<0.0001) independent of the level of training. The change in accuracy was also statistically significant for every individual class.

CONCLUSION

The BC method was an effective technique that facilitated detection of a Hill-Sachs lesion at all levels of training, and was useful as a teaching tool.

Secondary frozen shoulder after traumatic anterior shoulder instability

Background

Secondary frozen shoulder after traumatic anterior shoulder instability is rare. The therapeutic management and clinical outcome of this condition are not well known. This study aimed to investigate the characteristics of such rare cases and verify treatment outcomes.

Methods

We reviewed the cases of 12 patients with secondary frozen shoulder after anterior shoulder dislocation or subluxation between April 2007 and March 2018. All patients underwent physical therapy along with an intra-articular injection. Patients with refractory stiffness received arthroscopic mobilization. The range of motion, Rowe score, and University of California, Los Angeles score were evaluated at the first and final visits. A telephone survey was performed to determine the long-term outcomes including recurrent instability, the Oxford Shoulder Score, and the Oxford Instability Score.

Results

The mean age of patients at the first visit was 42.5 years. Two patients underwent surgical treatment, which revealed scar-like tissue of the anteroinferior capsule. The range of motion, Rowe score, and University of California, Los Angeles score significantly improved at a mean follow-up of 15 months. At a mean follow-up of 82 months, the telephone survey revealed recurrent instability in 1 patient who was conservatively treated; the average Oxford Shoulder Score and Oxford Instability Score were 46.4 and 43.2, respectively.

Conclusions

The average patient age observed in this study was higher than the known peak age of traumatic anterior shoulder instability occurrence. Less activity, loss of capsule elasticity, or scarring after a capsular tear may lead to stiffness after traumatic anterior shoulder instability. Conservative treatment can be used as the first-line therapy, followed by effective arthroscopic mobilization when conservative treatment fails.

Anterior Instability: What to Look for

Most first-time anterior glenohumeral dislocations occur as the result of trauma. Many patients suffer recurrent episodes of anterior shoulder instability (ASI). The anatomy and biomechanics of ASI is addressed, as is the pathophysiology of capsulolabral injury. The roles of imaging modalities are described, including computed tomography (CT) and MR imaging with the additional value of arthrography and specialized imaging positions. Advances in 3D CT and MR imaging particularly with respect to the quantification of humeral and glenoid bone loss is discussed. The concepts of engaging and nonengaging lesions as well as on-track and off-track lesions are examined.

Arthroscopic Bankart repair following traumatic recurrent shoulder dislocation: A prospective review of 30 cases

BACKGROUND

Literature on outcomes of arthroscopic Bankart repair at the intervening time intervals in traumatic recurrent dislocation of shoulder joint is limited.

STUDY DESIGN

Case series.

SUBJECTS AND METHODS

A prospective review of 30 shoulders, aged 20-40 years with clinically and magnetic resonance imaging established findings that were treated with primary arthroscopic Bankart repair and followed up for a minimum of 2 years. Outcomes were evaluated using Rowe score and University of California at Los Angeles (UCLA) scoring system.

RESULTS

The mean age was 26.40 years. All patients had definite trauma history. Average number of dislocation was 13.77 + 18.435 (range: 3-100). Time duration from first dislocation to surgery was an average of 4.80 + 3.576 years. The average size of the lesion was approximately 31% of the glenoid circumference. The number of suture anchors used for fixation did not correlate significantly with any of the scores. The mean Rowe and UCLA scores were 94.16 ± 9.7 and 33.83 ± 3.32, respectively, at final follow-up. The average duration of hospital stay was 7 days. Of the 30 patients, 2 (6.66%) had dislocation events post-operatively. Returns to pre-injury level were available for 27 (90%) of 30 patients. Multivariate analysis of independent Variables: age; side and number of dislocations, time to surgery, duration of surgery, size of lesion, number of anchors, and concurrent Hill-Sachs lesion, shown to have no significant relationship to outcomes.

CONCLUSION

Arthroscopic Bankart repair is an effective and safe technique for treating anterior glenohumeral instability in patients with recurrent traumatic shoulder dislocation.

An Algorithmic Approach to the Management of Shoulder Instability

The recurrence of anterior shoulder instability can be as high as 86.7% in high-risk patients who are treated nonoperatively after their first incident of instability. CT and MR arthrography are necessary for preoperative imaging and assessment of glenoid bone loss. Patient expectations in conjunction with appropriate preoperative imaging are critical for surgical planning. Arthroscopic shoulder stabilization is often sufficient in most cases where glenoid bone loss is minimal, with recurrent dislocation rates close to 4% in the literature. Open stabilization procedures are generally indicated in patients with greater than 20% glenoid bone loss.

Outcomes for Arthroscopic Repair of Combined Bankart/SLAP Lesions in the Treatment of Anterior Shoulder Instability: A Systematic Review and Meta-analysis

Background

Arthroscopic repair of combined Bankart/superior labral anteroposterior (SLAP) lesions is commonly performed to treat anterior shoulder instability, the clinical outcomes of which have not been widely studied.

Purpose

To compare the clinical outcomes for arthroscopic repair of combined Bankart/SLAP lesions in the treatment of anterior shoulder instability and to ascertain whether it is inferior to isolated Bankart repair.

Study Design

Systematic review; Level of evidence, 3.

Methods

A systematic review of the literature was performed through use of the MEDLINE, EMBASE, and Cochrane Library databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Study bias was assessed using the MINORS (Methodological Index for Non-Randomized Studies) scoring system. Randomized controlled trials, prospective or retrospective cohort studies, and case-control studies were included, whereas systematic reviews, literature reviews, conference abstracts, case reports, case series, and non-peer-reviewed studies were excluded to guarantee the quality of the study. Data on outcomes including recurrence rate, functional scores, and range of motion (ROM) were pooled, with statistical analysis performed. A P value of <.05 was considered statistically significant.

Results

The review included 7 studies with a total of 520 patients. The pooled recurrence rate after combined Bankart/SLAP repair was 6.47% (9/139). Significant improvements of postoperative versus preoperative functional scores were observed, including a reduction in the visual analog scale score for pain (mean ± SD: 0.99 ± 1.36 vs 4.13 ± 2.26; P < .00001) and an increase in mean Rowe score (89.56 ± 11.46 vs 43.16 ± 8.87; P < .00001) and mean Constant score (91.41 ± 7.57 vs 59.70 ± 5.63; P < .00001). In terms of ROM, no reduction was found in external rotation (66.56° ± 13.33° vs 67.22° ± 14.27°; P = .21), and a significant increase in abduction was found (157.67° ± 4.11° vs 144.18° ± 8.28°; P < .00001). No statistically significant difference was found between arthroscopic repair of combined Bankart/SLAP lesions and isolated Bankart repair regarding recurrence rate, functional scores, or ROM.

Conclusion

Of the pooled data, patients who underwent arthroscopic repair of combined Bankart/SLAP lesions in treatment of anterior shoulder instability showed a low recurrence rate, favorable functional scores, and no significant restriction on ROM, all of which were not significantly worse than outcomes of isolated Bankart repair. Therefore, combined repair was proven to be a viable option for extensive labral lesions.

Rotator interval closure: inconsistent techniques and its association with anterior instability. A literature review

The Rotator interval (RI) is an anatomic space in the anterosuperior part of the glenohumeral joint. An incompetent or lax RI has been implicated in various conditions of shoulder instability and therefore RI has been frequently touted as an area that is important in preserving stability of the shoulder. Biomechanical studies have shown that repair of RI ligamentous and capsular structures decreases glenohumeral joint laxity in various directions. Clinical studies have reported successful outcomes after repair or plication of these structures in patients undergoing shoulder stabilization procedures. Although varieties of methods have been described for its closure, the optimal surgical technique is unclear with various inconsistencies in incorporation of the closure tissue. This in particular makes the analysis of the RI closure very difficult. The purposes of this study are to review the structures of the RI and their contribution to shoulder instability, to discuss the biomechanical and clinical effects of plication of RI structures in particular to anterior glenohumeral instability, to delineate the differences between an arthroscopic and open RI closure. Additionally, we have proposed a new classification system describing various techniques used during RI closure.

Is CT scan a predictor of instability in recurrent dislocation shoulder?

PURPOSE

Glenoid bone defect and the defect on the posterior-superior surface of the humerus "Hill-Sachs lesion" are the commonly seen bony lesions in patients with recurrent dislocation shoulder. Computed tomography (CT) scan is considered as the best option in assessing the bony defects in the recurrent dislocation shoulder. The aim of this study was to assess the clinical and radiological co-relation in the patients with recurrent dislocation shoulder.

METHODS

Forty-four patients of recurrent dislocation shoulder who were evaluated between January 2015 and December 2017 at a tertiary care center, clinically and radiologically using CT scan and meeting the inclusion criteria, were included. The correlation between the clinical history of the number of dislocations and the bone loss using CT scan was evaluated. Two sided statistical tests were performed at a significance level of α = 0.05. The analysis was conducted using IBM SPSS STATISTICS (version 22.0).

RESULTS

All the patients were male with mean age of 25.95 (SD ± 4.2) years were evaluated. Twenty-four patients sustained injury in sporting activities while 20 patients sustained injury in training. There were an average of 4.68 (SD ± 3.1, range 2-15, median 3) episodes of dislocation. Forty-one patients had the glenoid bone loss while 40 had the Hill-Sachs lesions. The mean glenoid width defect was 10.80% (range 0-27%) while the mean Hill-Sachs defect was 14.27 mm (range 0-26.6 mm). The mean area of bone loss of the glenoid surface was 10.81% (range 0-22.4%). The lesions were on track in 34 patients and off track in 10 patients.

CONCLUSIONS

CT scan of the shoulder joint is an effective method for assessing the amount of bone loss. The number of dislocations are correlated significantly with off-track lesions and the amount of bone loss on the glenoid and Hill-Sachs lesion. The glenoid width bone loss of more than 9.80% or Hill-Sachs defect of more than 14.80 mm are the critical defects after which the frequency of dislocations increases.

ACR Appropriateness Criteria® Shoulder Pain-Atraumatic

Shoulder pain is one of the most common reasons for musculoskeletal-related physician visits. Imaging plays an important role in identifying the specific cause of atraumatic shoulder pain. This review is divided into two parts. The first part provides a general discussion of various imaging modalities (radiographs, arthrography, nuclear medicine, ultrasound, CT, and MRI) and their usefulness in evaluating atraumatic shoulder pain. The second part focuses on the most appropriate imaging algorithms for specific shoulder conditions including: rotator cuff disorders, labral tear/instability, bursitis, adhesive capsulitis, biceps tendon abnormalities, postoperative rotator cuff tears, and neurogenic pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Open Versus Arthroscopic Latarjet Procedure for Anterior Shoulder Instability: A Systematic Review and Meta-analysis

BACKGROUND

Anterior shoulder instability with significant glenoid bone loss is a challenging condition. The open Latarjet procedure is the established standard treatment method in this setting, but there is an increasing use of the arthroscopic technique.

PURPOSE

To systematically review the current evidence in the literature to ascertain if the open or arthroscopic Latarjet procedure resulted in improved patient outcomes.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A literature search of MEDLINE, EMBASE, and the Cochrane Library was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Cohort studies comparing the open and arthroscopic Latarjet procedures for anterior shoulder instability were included. Clinical outcomes were compared, with all statistical analysis performed using Review Manager (version 5.3). A P value of <.05 was considered statistically significant.

RESULTS

Six clinical trials with 896 patients were included. The open and arthroscopic Latarjet procedures resulted in a similar number of total recurrent instability (2.0% vs 2.4%; P = .75), revision procedures (2.4% vs 5.4%; P = .06), and total complications (13.8% vs 11.9%; P = .50), but the open procedure had a lower rate of persistent apprehension (10.2% vs 35.7%; P < .05). In addition, after the learning curve, the operative time was similar between the 2 procedures.

CONCLUSION

Both the open and arthroscopic Latarjet procedures result in significant improvements in patient function and outcome scores, with low rates of recurrent instability and similar complication rates. While technically challenging, the arthroscopic procedure has been shown to be a safe and viable alternative. However, there is a significant learning curve associated with the arthroscopic Latarjet procedure. The significant learning curve associated with this procedure suggests the arthroscopic procedure may be advisable to perform only in high-volume centers with experienced arthroscopists.

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

BACKGROUND

Anterior and posterior shoulder instabilities are entirely different entities. The presenting complaints and symptoms vastly differ between patients with these 2 conditions, and a clear understanding of these differences can help guide effective treatment.

PURPOSE

To compare a matched cohort of patients with anterior and posterior instability to clearly outline the differences in the initial presenting history and overall outcomes after arthroscopic stabilization.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Consecutive patients with either anterior or posterior glenohumeral instability were prospectively enrolled; patients were excluded if they had more than 10% anterior or posterior glenoid bone loss, multidirectional instability, neurologic injury, or prior surgery. Patients were assigned to anterior or posterior shoulder instability groups based on the history and clinical examination documenting the primary direction of instability, with imaging findings to confirm a labral tear associated with the specific direction of instability. Preoperative demographic data, injury history, and overall clinical outcome scores (American Shoulder and Elbow Surgeons [ASES], Single Assessment Numeric Evaluation [SANE], and Western Ontario Shoulder Index [WOSI]) were assessed and compared statistically between the 2 cohorts. Patients were indicated for surgery if they elected to proceed with surgical management or did not respond to a course of nonoperative management.

RESULTS

The study included 103 patients who underwent anterior stabilization (mean age, 23.5 years; range, 18-36 years) and 97 patients who underwent posterior stabilization (mean age, 24.5 years; range, 18-36 years). The mean follow-up was 39.7 months (range, 24-65 months), and there were no age or sex differences between the groups. No patients were lost to follow-up. The primary mechanism of injury in the anterior cohort was a formal dislocation event (82.5% [85/103], of which 46% [39/85] required reduction by a medical provider), followed by shoulder subluxation (12%, 12/103), and "other" (6%, 6/103; no forceful injury). No primary identifiable mechanism of injury was found in the posterior cohort for 78% (75/97) of patients; lifting and pressing (11%, 11/97) and contact injuries (10% [all football blocking], 10/97) were the common mechanisms that initiated symptoms. Only 10 patients (10.3%) in the posterior cohort sustained a dislocation. The most common complaints for patients with anterior instability were joint instability (80%) and pain with activities (32%). In the posterior cohort, the most common complaint was pain (90.7%); only 13.4% in this cohort reported instability as the primary complaint. Clinical outcomes after arthroscopic stabilization were significantly improved in both groups, but the anterior cohort had significantly better outcomes in all scores measured: ASES (preoperative: anterior 58.0, posterior 60.0; postoperative: anterior 94.2 vs posterior 87.7, P < .005), SANE (preoperative: anterior 50.0, posterior 60.0; postoperative: anterior 92.9 vs posterior 84.9, P < .005), and WOSI (preoperative: anterior 55.95, posterior 60.95; postoperative: anterior 92% of normal vs posterior 84%, P < .005).

CONCLUSION

This study outlines clear distinctions between anterior and posterior shoulder instability in terms of presentation and clinical findings. Patients with anterior instability present primarily with an identifiable mechanism of injury and complaints of instability, whereas most patients with classic posterior instability have no identifiable mechanism of injury and their primary symptom is pain. Anterior instability outcomes in this matched cohort were superior in all domains versus posterior instability after arthroscopic stabilization, which further highlights the differences between anterior and posterior instability.

Etiology of Shoulder Arthritis in Young Patients

The manifestation of glenohumeral arthritis in the young adult is a devastating occurrence that can be difficult to manage. This review details the many underlying etiologies including genetic causes, congenital abnormalities, glenohumeral instability, posttraumatic lesions, postcapsulorraphy arthropathy, osteonecrosis, intraarticular pain pump postoperative use, radiofrequency/thermal capsulorraphy treatments, septic arthritis/infection, and inflammatory arthropathies. Although each of these potential causes have been well-studied, their contributions to the development of glenohumeral arthritis in the young person has not been described extensively.

New concepts of radiologic preoperative evaluation of anterior shoulder instability: on-track and off-track lesions

The shoulder is the most frequently dislocated joint in the body due to a larger range of motion and a small area of articulation between the humeral and glenoid surfaces. Traumatic shoulder dislocations, especially those associated with injury to the labroligamentous or bony stabilizers of the joint, lead to further reduction of articular surface contact with resultant glenohumeral instability and recurrent shoulder dislocations. Imaging plays an increasingly important role in the preoperative evaluation of patients with traumatic shoulder instability by evaluating glenohumeral bone loss (uni- or bipolar), assessing soft tissue injuries and identifying patients at risk of postoperative recurrence. Quantification of bone loss is key to differentiate engaging vs. non-engaging Hill-Sachs lesions, while newer concepts of "on-track" vs. "off-track" lesions are being discussed that can determine the required surgical approaches. In this article, we review the preoperative imaging approaches, traditional treatments, outline the bone loss measurement strategies and review these new tracking concepts with relevant case examples.

Effect of Anterior Glenoid Labral Tears and Glenoid Bone Loss at the NFL Combine on Future NFL Performance

Background:

Anterior glenohumeral instability is a common abnormality in the young, athletic population, especially in those participating in contact or collision sports.

Purpose:

To examine the effect of anterior labral tears, their associated injuries, and their management on future National Football League (NFL) performance.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective review of all NFL Combine participants from 2009 to 2015 was performed using medical and imaging reports compiled at the NFL Combine. These notes and images were reviewed and analyzed for involved structures, associated injuries, and evidence of previous surgical interventions. The respective NFL draft position, number of NFL games played, number of NFL games started, and NFL snap percentage for each player’s first 2 seasons were collected and compared with a control group and within subgroups.

Results:

Of the 2285 players at the NFL Combine between 2009 and 2015, there were 206 (9%) anterior labral tears confirmed by magnetic resonance imaging, 20 of which were bilateral, for a total of 226 affected shoulders. There were 908 players who fit the criteria for inclusion in the control group. Overall, there were no significant differences between players with anterior labral tears and the control players in terms of draft position (P = .259), games played in their first 2 NFL seasons (P = .391), games started in their first 2 NFL seasons (P = .486), or snap percentage in their first (P = .268) and second (P = .757) NFL seasons. In general, sustaining a concomitant injury with an anterior labral tear (superior labrum from anterior to posterior [SLAP] tear, glenoid bone loss, Hill-Sachs lesion, rotator cuff tear, humeral avulsion of the glenohumeral ligament, and anterior tear combined with posterior tear) negatively affected a player’s NFL draft position when compared with those with an isolated anterior labral tear (P = .003). There was no significant difference between operative and nonoperative management for anterior labral tears in terms of any performance metric.

Conclusion:

A history of anterior labral tears was not significantly associated with future NFL performance. While players with isolated injuries were drafted significantly earlier than those with concomitant injuries, combined injuries did not affect players’ games played, games started, or snap percentage in their first 2 NFL seasons. Glenoid bone loss did significantly decrease draft position; however, the severity of bone loss did not affect draft position, and there were no significant associations between glenoid bone loss and games played, games started, or snap percentage.