Outcomes of Bankart Repairs Using Modern Arthroscopic Technique in an Athletic Population

Immobilization in External Rotation Versus Arthroscopic Stabilization After Primary Anterior Shoulder Dislocation: A Systematic Review of Level 1 and 2 Studies

BACKGROUND

Arthroscopic stabilization has been established as a superior treatment option for primary glenohumeral instability when compared with immobilization in internal rotation. However, immobilization in external rotation (ER) has recently gained interest as a viable nonoperative treatment option for patients with shoulder instability.

PURPOSE

To compare the rates of recurrent instability and subsequent surgery in patients undergoing treatment for primary anterior shoulder dislocation with arthroscopic stabilization versus immobilization in ER.

STUDY DESIGN

Systematic review; Level of evidence, 2.

METHODS

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that'evaluated patients being treated for primary anterior glenohumeral dislocation with either arthroscopic stabilization or immobilization in ER. The search phrase used various combinations of the keywords/phrases "primary closed reduction,""anterior shoulder dislocation,""traumatic,""primary,""treatment,""management,""immobilization,""external rotation,""surgical,""operative,""nonoperative," and "conservative." Inclusion criteria included patients undergoing treatment for primary anterior glenohumeral joint dislocation with either immobilization in ER or arthroscopic stabilization. Rates of recurrent instability, subsequent stabilization surgery, return to sports, positive postintervention apprehension tests, and patient-reported outcomes were evaluated.

RESULTS

The 30 studies that met inclusion criteria included 760 patients undergoing arthroscopic stabilization (mean age, 23.1 years; mean follow-up time, 55.1 months) and 409 patients undergoing immobilization in ER (mean age, 29.8 years; mean follow-up time, 28.8 months). Overall, 8.8% of operative patients experienced recurrent instability at latest follow-up compared with 21.3% of patients who had undergone ER immobilization (P < .0001). Similarly, 5.7% of operative patients had undergone a subsequent stabilization procedure at latest follow-up compared with 11.3% of patients who had undergone ER immobilization (P = .0015). A higher rate of return to sports was found in the operative group (P < .05), but no other differences were found between groups.

CONCLUSION

Patients undergoing arthroscopic treatment for primary anterior glenohumeral dislocation with arthroscopic stabilization can be expected to experience significantly lower rates of recurrent instability and subsequent stabilization procedures compared with patients undergoing ER immobilization.

Post-operative rehabilitation following traumatic anterior shoulder dislocation: A systematic scoping review

Background

This systematic scoping review aimed to describe the content of post-operative rehabilitation programmes, and outcome measures selection following stabilisation surgery for traumatic anterior shoulder dislocation (TASD).

Methods

An electronic search of Medline, EMBASE, CINAHL and AMED was conducted (2000-2021). Any cohort or clinical trial of patients receiving post-operative TASD rehabilitation were included. Study selection, data extraction and quality appraisal were undertaken by two independent reviewers.

Results

Twelve studies including fourteen treatment programmes were eligible. Period of post-operative immobilisation ranged from 1 day to 6 weeks, with exercise introduced between 1 and 7 weeks. Strengthening exercises were introduced between 1 and 12 weeks. Two studies described "accelerated" rehabilitation programmes, differing in immobilisation period and exercise milestones. No increased recurrence was reported in professional footballers. Two studies compared rehabilitation programmes, one not randomised, the other 18 years old. There was variability in selected outcomes measures, with only 4 studies using a common measure.

Discussion

There is minimal evidence to guide post-operative rehabilitation, variability in immobilisation periods and when exercise is introduced. There is no consensus on the definition of accelerated rehabilitation, or outcome measure selection. Clinical consensus of standardised terminology and stages of rehabilitation is required prior to efficacy studies.

Outcomes After Arthroscopic Revision Bankart Repair: An Updated Systematic Review of Recent Literature

PURPOSE

To provide an update of recent literature with a specialized focus on clinical outcomes following arthroscopic revision Bankart repair (ARBR) by performing a systematic review of all available literature published between 2013 and 2020.

METHODS

A literature search reporting clinical outcomes after ARBR was performed. Criteria for inclusion consisted of original studies; Level of Evidence of I-IV; studies focusing on clinical outcomes after ARBR published between January 1, 2013, and January 4, 2021; studies reporting recurrent dislocation or instability rate after ARBR; reoperation/revision following ARBR, return to sport rates following ARBR; and patient-reported outcomes. The primary outcomes of interest were failure defined as recurrent instability or dislocation, return to sport rates, and patient-reported outcomes at follow-up.

RESULTS

A large proportion of patients undergoing arthroscopic revision Bankart repair were male, ranging between 67.7% and 93.8%. Failure rate and return to sports rate ranged between 6.1% and 46.8% and 25.9% and 88.3%, respectively, when patients with significant or greater than 20% glenoid bone loss was excluded. Patient-reported outcome scores, which included American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale, saw significant improvement over mean follow-up of ranging 21.64 to 60 months.

CONCLUSIONS

Both the failure rate and RTS rates after ARBR had a wide range, given the heterogeneity of the studies included, which varied in patient selection criteria pertaining to patients with greater than 20% glenoid bone. Although there have been advancements in arthroscopic techniques and a trend favoring arthroscopic stabilization procedures, there is a lack of consensus in recent literature for careful patient selection criteria that would minimize failure rates and maximize RTS rates after ARBR.

LEVEL OF EVIDENCE

Level IV, a systematic review of Level III-IV studies.

The arthroscopic Bankart operation: a 10-year follow-up study

INTRODUCTION

Traumatic shoulder instability most frequently occurs in young people often during sports events. Currently, the arthroscopic Bankart repair is the therapy of choice in the absence of extensive glenoid bone loss and has proved to be a safe and effective procedure. Nevertheless, we see recurrence of instability-especially if new trauma happens-and further data are needed to guide the right decision-making for these often young patients. The purpose of this study was to determine the long-term outcome 10 years after arthroscopic Bankart operation in terms of satisfaction of the patient, functional result, complications, recurrent instability, and development of osteoarthritis, and to look after possible risk factors for recurrence of instability and statistical proof of these.

MATERIALS AND METHODS

Thirty-nine out of 49 patients underwent physical examination of both shoulders. We could perform a postoperative shoulder a-p X-ray in 28 patients. According to Samilson, [24] the extent of osteoarthritis was measured. The Constant score and the postoperative ROWE score were determined for both shoulders as well as the WOSI Score. In 25 cases, we calculated the ISIS Score.

RESULTS

We could reach out to 89.6% of patients and 79.6% could be physically examined. The vast majority of 95.5% are either very satisfied or satisfied with the result at the time we ended the follow-up. The mean Constant score of 95.5 reflects this result. In contrast to this, we found at the same time in 15.3% ongoing clinical signs of instability of the concerning shoulder, even though 9.1% had to be re-operated for recurrent instability in between the follow-up timeline and we found in the X-rays (57.1% of all patients) in 35.7% at least moderate and in 10.7% severe signs of osteoarthritis. The Constant score but not the ROWE score differed significantly in patients with no or mild compared to those with moderate-to-severe osteoarthritis.

CONCLUSIONS

The arthroscopic Bankart stabilization procedure showed after 10 years to be a very safe operation and to be able to produce a satisfying and functional very good long-term result-reflected by the Constant score. We assume that the extent of osteoarthritis seems to be the determining factor of the very good functional result, even though ongoing instability was present in 15.3% of the patients.

Successful Outcomes and Return to Sport After Arthroscopic Bankart Repair in National Collegiate Athletic Association and National Football League Football Players

OBJECTIVE

To characterize recurrent instability, return to sport (RTS), and patient-reported outcomes (PROs) after arthroscopic Bankart repair for acute traumatic anterior shoulder instability in National Collegiate Athletic Association (NCAA) and National Football League (NFL) football players.

DESIGN

Case series.

SETTING

Orthopaedic and sports medicine clinic.

PARTICIPANTS

National Collegiate Athletic Association and NFL football athletes with traumatic anterior shoulder instability who underwent arthroscopic shoulder stabilization at a single institution with at least 2-year follow-up.

INTERVENTIONS OR ASSESSMENT OF RISK FACTORS OR INDEPENDENT VARIABLES

Arthroscopic Bankart repair.

MAIN OUTCOME MEASURES

Recurrent instability, RTS, patient satisfaction, the visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeons (ASES) score, and Rowe score.

RESULTS

Thirty-three players were included with a mean age of 23.8 years (range, 18-33 years) and a mean follow-up of 6.3 years (range, 4.1-9.3 years). One shoulder (3.0%) had a postoperative subluxation event, and 1 shoulder (3.0%) required revision surgery for issues other than instability; 93.3% of players were able to RTS at the same level or higher for at least 1 season. Mean satisfaction was 8.9 ± 2.3. Mean VAS was 1.0 ± 1.7, and mean ASES and Rowe scores were 90.7 ± 18.5 and 89.7 ± 15.2, respectively.

CONCLUSION

Arthroscopic Bankart repair is an effective surgical intervention for traumatic anterior shoulder instability in NCAA and NFL football players. At a mean 6-year follow-up, surgery restored stability in 97% of cases and 93.3% returned to their preinjury level of sport.

Surgical delay for traumatic recurrent shoulder dislocations leads to inferior functional outcomes

BACKGROUND

The effect of time interval between injury and surgery on outcomes of Bankart repair surgery has not been published previously. The purpose of this study was to assess the effect of surgical delay on functional outcomes after arthroscopic Bankart repair.

METHOD

One hundred and five athletes who underwent arthroscopic Bankart repair ± remplissage were enrolled in the study. Patients were divided into 2 groups depending upon the injury to surgery time- < 12 months (n = 19), and ≥12 months (n = 86). Depending upon the number of episodes of dislocation, patients were further categorized into 2 groups- <10 episodes (n = 66) and ≥10 episodes (n = 39). All patients were assessed post-operatively for functional outcomes (Modified Rowe's score, Constant Murley score) and return to sports at a minimum of 2 years of follow-up.

RESULTS

The mean injury to surgery time was 31.7 ± 23.1 months. The average number of episodes of dislocation before surgery were 10 (range 3-50). 49/105 (46.7%) patients returned to sports after a mean post-operative duration of 10.9 months. Athletes operated after a surgical delay of ≥12 months had inferior functional outcomes (Modified Rowe's score-89.5 ± 8.9 vs.77.4 ± 21.4; p = 0.02), lower rate of return to sports (14/19 vs. 35/86; p = 0.02) and higher mean time to return to sports (8.7 ± 1.9 vs. 11.5 ± 2.6; p < 0.05). Similarly, athletes who had ≥10 dislocations before surgery had inferior functional outcomes (Modified Rowe's score-84.5 ± 15.2 vs.72.9 ± 25.6; p = 0.004), lower rate of return to sports (37/66 vs. 12/39; p = 0.02) and higher mean time to return to sports (10.3 ± 2.4 vs. 12.6 ± 2.5; p < 0.05).

CONCLUSION

A delay in surgery (≥12 months) or dislocation episodes of ≥10 are associated with inferior functional outcomes, lower rate of return to sports and higher surgical failure rate.

LEVEL OF EVIDENCE

Level III; Prospective cohort study.

Trans-cuff portals heal by 6 weeks: an ultrasonography-based study

Background

Various arthroscopic portals have been described for repair of superior labrum anterior-posterior (SLAP) lesions. The difficulty in doing repair through the rotator interval and the problems in direction and placement of anchors still persist. Functional outcomes of the patients after treating them using trans-cuff portal are well established in literature, but the actual healing of the portal is not clear. We made a sincere effort to identify healing of the trans-cuff portal with ultrasound guidance and functional outcome using American Shoulder and Elbow Surgeons Shoulder Score (ASES score), Constant Shoulder Score, and Oxford Shoulder Score.

Material and methods

Twenty-two patients with SLAP or labral tears and normal contralateral shoulders were included. Surgery was performed using the trans-cuff portal as a viewing or working portal for biceps repair and labral repair. Rehabilitation was initiated from day 1 and followed up on 6 weeks, 3 months and, 6 months with a maximum follow-up duration of 2 years. Ultrasound was used to measure the depth of healing and graded at 6 weeks of follow-up postoperatively. Functional outcomes were measured using ASES score, Constant Shoulder Score, and Oxford Shoulder Score measured at 6 months.

Results

Seventeen patients were of grade 1 (complete healing); 1 patient was of grade 2 (more than 50% healing); 1 of grade 3 (less than 50% healing), and 3 were lost to follow-up. Fourteen patients out of 19 had excellent ASES scores, 4 patients had good scores, and 1 patient was considered as poor with an average ASES score of 84.51 (range 93-48) and standard deviation of 10.37. The ASES score indicated that healing of the rotator cuff portal is directly related to the functional outcome of the shoulder. The Constant Shoulder Score and Oxford Shoulder Score on the contrary were statistically not significant indicating no relation of the Oxford and Constant scores with healing of the rotator cuff portals.

Conclusion

Trans-cuff portal is safe, gives proper angle for insertion of anchors, and can be used for repair of SLAP lesions with ease. Ultrasonography helps in confirming the healing of portal.

Does the immediate repair of Bankart lesion following first dislocation reduce the chances of recurrence after arthroscopic repair in soldiers?

PURPOSE

The study attempted to compare the effects of immediate and delayed arthroscopic Bankart repair on the shoulder dislocation recurrence.

METHODS

In total, 465 soldiers with first-time anterior shoulder dislocation were included in the study. Of the total, 285 soldiers underwent a quick arthroscopic Bankart repair procedure, whether 180 soldiers underwent a delayed repair procedure. The initial dislocation was traumatic in both groups and operated using the standard arthroscopic suture anchor repair technique. Patient's age, repair time since the first dislocation, number of dislocations before surgery, number of suture anchors used during the repair, duration of surgical procedure, duration from surgery to return to work, and recurrence of dislocation after surgery were recorded. Rowe score, Constant score, and American Shoulder and Elbow Surgeons score were used for clinical assessment.

RESULTS

The operating time and recurrence rate were higher in the group subjected to delayed repair procedure than in the group subjected to immediate repair procedure. Repair timing was found to be crucial for a successful outcome.

CONCLUSIONS

The findings suggest that Bankart repair must be performed immediately to minimize recurrence and other degenerative changes, which may require an additional surgical procedure for satisfactory repair. More studies are required to reach a definitive conclusion.

LEVELS OF EVIDENCE

Level III.

Postoperative Rehabilitation of Anterior Glenohumeral Joint Instability Surgery: A Systematic Review

Anterior glenohumeral instability is the most common form of shoulder instability. The systematic review summarizes the latest research on rehabilitation after Bankart repair. Inclusion criteria included postoperative rehabilitation and published in English between 2000 and 2019. Studies were excluded if they were addresses, comments, or editorials, or included other shoulder injuries or cadaver models. Two rounds of review using Rayyan QCRI software were performed for screening and full text search, and the articles were graded for levels of evidence. Of the 1982 articles, 14 articles were included with levels of evidence 1 through 4. Both arthroscopic and open Bankart repair have demonstrated improving functional outcomes and reducing recurrence rates of anterior shoulder instability. Accelerated postoperative rehabilitation may be comparable to a conventional protocol for arthroscopic repair, and the subscapularis musculature involvement during open repair can impact the timeframe. Strong evidence supports 4 phases of rehabilitation and future clinical trials are needed to compare different programs.

Evolving Concepts in the Management of Shoulder Instability

BACKGROUND

Shoulder instability exists on a spectrum ranging from subtle subluxation and pain to dislocation and can be the result of a traumatic event or repetitive microtrauma. Shoulder instability can result in significant disability and often requires surgical intervention, especially amongst younger, active patient populations. The optimal treatment of shoulder instability depends on the degree of instability and concomitant pathology involving the labrum, capsule, and bony anatomy of the glenoid and humeral head. Even with surgical intervention, recurrent instability remains a relatively common and difficult problem to address.

PURPOSE

With a focus on anterior instability, the purpose of this review article is to discuss the current assessment and treatment of shoulder instability, and highlight current and future treatment modalities, as well as to identify current trends and deficiencies in our current management. We also provide an algorithm for the surgical treatment of anterior shoulder instability.

METHODS

Literature databases were extensively searched for recent articles related to the mechanism, diagnosis, and treatment of shoulder instability to comprise a comprehensive review.

CONCLUSION

Although there are multiple treatment modalities available for shoulder instability, such as nonoperative management, open and arthroscopic Bankart repair, Latarjet procedures, and remplissage, orthopaedic surgeons continue to learn about the most appropriate method of management as increasing long-term outcomes become available.

Outcomes of the arthroscopic Bankart procedure in Irish collision sport athletes

BACKGROUND

While there is an abundance of research examining the outcomes of the arthroscopic Bankart repair in collision athletes, very few studies have involved the unique Irish collision sport athlete population. The previously held belief that collision athletes need to be treated with open surgery, due to the high traumatic forces the shoulder is subjected to in these sports, may no longer be true in the context of modern arthroscopic techniques and implants.

AIMS

To report the outcomes of the arthroscopic Bankart procedure in the unique Irish collision athlete population.

METHOD

Retrospective review conducted in 2018. Data was obtained from collision sport athletes using customised questionnaires and validated, standardised outcome measure tools. Participants were selected using inclusion and exclusion criteria.

RESULTS

Fifty-four patients were included in the study. The average age at primary injury was 19.9 years (range 13-35 years). The rate of recurrent dislocation was 21% (12/57) with a mean follow up time of 24 months (range 7 to 48 months). The mean patient reported outcome measure (PROM) scores were as follows: ASES = 90.8, WOSI = 316.4, SSV = 79%. Six patients failed to return to their sport. Eighty-seven percent of the cohort returned to their sport, with a mean time to return of 7.25 months. Patients who experienced recurrent instability after arthroscopic Bankart had a younger age at primary dislocation (P = 0.0005) and lower ASES (P = 0.0056) and WOSI scores (0.00132) at latest follow-up, compared to those who remained stable postsurgery.

CONCLUSION

The arthroscopic Bankart procedure has a high rate of recurrence of dislocation in Irish collision sport athletes. The current international literature suggests that the arthroscopic Bankart has similar rates of recurrence to the open procedure in collision athletes; however, this may not hold true for Irish collision sport athletes. Further research is required to determine the optimum surgical procedure for anterior shoulder instability in this population, particularly those patients with subcritical bone loss.

Double-loaded suture anchors in the treatment of anteroinferior glenohumeral instability

Hypothesis

The purpose of this study was to determine the clinical outcomes of arthroscopic labral repair for anteroinferior glenohumeral instability with the use of double-loaded suture anchors.

Methods

This study evaluated a series of consecutive patients treated after the senior author changed from single- to double-loaded suture anchors for the treatment of anteroinferior glenohumeral instability with a minimum follow-up period of 2 years. We collected the following outcomes at final follow-up: visual analog scale pain score, Simple Shoulder Test score, American Shoulder and Elbow Surgeons score, and instability recurrence data.

Results

A total of 41 consecutive patients underwent arthroscopic labral repair with double-loaded anchors, of whom 30 (71%) were able to be contacted at a minimum of 2 years postoperatively. These patients included 4 contact or collision athletes (13%). The patients had an average of 12 ± 13 prior dislocations over an average period of 56 ± 57 months preoperatively. Mean glenoid bone loss measured 16% ± 10%, and 67% (18 of 27 patients) had glenoid bone loss ≥ 13.5%. Intraoperatively, 3.2 ± 0.4 anchors were used. No posterior repairs or remplissage procedures were performed. At an average of 6.7 ± 2.7 years' follow-up, the visual analog scale pain score was 0.8 ± 1.4; Simple Shoulder Test score, 11 ± 2; and American Shoulder and Elbow Surgeons score, 90 ± 14. Patients with bone loss < 13.5% had a 0% redislocation rate and 11% subluxation rate, whereas those with bone loss ≥ 13.5% had a 6% reoperation rate, 22% redislocation rate, and 22% subluxation rate.

Conclusion

Arthroscopic labral repair with double-loaded anchors provides satisfactory clinical results at early to mid-term outcome assessment when glenoid bone loss is <13.5%.

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.

LATARJET PROCEDURE ON ANTERIOR SHOULDER INSTABILITY IN PROFESSIONAL SOCCER PLAYERS

Anterior glenohumeral instability is a frequent cause of professional soccer players’ removal, reduced performance, and prolonged recovery. Players are subjected to intense physical contact and high performance, thus demanding lower rates of recurrence after surgical correction so they can return to sport quickly.

A retrospective cohort analysis of arthroscopic Bankart repair with or without remplissage in patients with off-track Hill-Sachs lesion evaluated for functional outcomes, recurrent instability, and range of motion

BACKGROUND

Lone Bankart repair is associated with high rates of recurrence, especially in off-track Hill-Sachs (HS) lesion. The objective of the study was to assess the impact of remplissage in off-track HS lesion influencing the rate of redislocation and range of motion (ROM) of the shoulder.

MATERIAL AND METHOD

We retrospectively reviewed 136 patients for arthroscopic Bankart repair without remplissage (group 1, n = 77) or with remplissage (group 2, n =59) for recurrent anterior dislocation of the shoulder with glenoid bone loss of <25%. Further subgroups of on- and off-track HS lesion were based on computed tomographic assessment. At a minimum follow-up of 2 years; patients were evaluated for functional scores (Rowe, Constant-Murley, Western Ontario Shoulder Instability Index), redislocations, and ROM.

RESULTS

At a mean follow-up of 54 and 44 months in group 1 and 2, respectively, there was no difference in postoperative functional scores. There were significantly more dislocations in patients with Bankart repair with off-track lesion than in patients with Bankart repair with on-track lesion (P = .02). There were significantly fewer redislocations in patients with off-track lesion who underwent Bankart repair and remplissage than in those who did not undergo remplissage (P = .0007). Compared with group 1 patients, those in group 2 revealed a statistically significant loss of ROM.

CONCLUSIONS

Although a nonremplissaged off-track HS lesion remains an important risk factor for recurrent instability, remplissage also results in significant loss of shoulder ROM compared with those who do not undergo remplissage.

It's Not All About Redislocation: A Systematic Review of Complications After Anterior Shoulder Stabilization Surgery

BACKGROUND

The surgical treatment of recurrent shoulder instability has evolved in recent years to include a variety of soft tissue and bone block procedures, undertaken with either an open or arthroscopic approach. Although the utilization of such techniques has rapidly expanded, the associated risk of complications remains poorly defined. This information is vital for clinical decision making and patient counseling.

PURPOSE

To quantify the complication rate associated with all types of surgery for anterior glenohumeral joint dislocation.

STUDY DESIGN

Systematic review.

METHODS

A systematic search was undertaken of studies reporting complications from anterior shoulder stabilization surgery. Inclusion criteria were studies published in English between 2000 and 2017 with a minimum 2-year follow-up. Methodological quality of the included studies was assessed with the Methodological Index for Non-Randomized Studies criteria. Complication rates for all undesirable events contributing to the patient outcome were extracted and cumulative rates calculated.

RESULTS

Out of 1942 references, 56 studies were included, totaling 4362 procedures among 4336 patients. Arthroscopic soft tissue repair had a complication rate of 1.6% (n = 2805). When repair was combined with arthroscopic remplissage, the rate was 0.5% (n = 219). Open soft tissue repair had a complication rate of 6.2% (n = 219) and open labral repair with remplissage, a rate of 2.3% (n = 79). An open bone block procedure had a complication rate of 7.2% (n = 573) and an arthroscopic bone block procedure, a rate of 13.6% (n = 163).

CONCLUSION

This large systematic review demonstrates the overall complication rates (not purely recurrence rates) in modern shoulder stabilization surgery. With the growing interest in bone block stabilization procedures, including those performed arthroscopically, surgeons should be aware of the 10-fold increase in complications for these procedures over soft tissue arthroscopic surgery and counsel their patients accordingly.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

High rate of return to sport in adolescent athletes following anterior shoulder stabilisation: a systematic review

Importance

Traumatic anterior shoulder instability remains common for the adolescent athletes.

Aim or objective

To perform a systematic review on the outcomes and return to sport (RTS) following Bankart repair in adolescent athletes.

Evidence review

A systematic review using the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines was conducted of studies reporting outcomes following open and/or arthroscopic Bankart repair using modern suture anchors following traumatic anterior shoulder dislocations in adolescent patients (ages 10-19 years). Quality assessment was evaluated with ROBINS-I and MINORS instruments. The outcomes analysed included RTS, timetable to unrestricted activity, recurrent instability and revision surgery.

Findings

This systematic review identified 11 studies comprising 461 adolescent athletes with a mean age of 15.7 years (range, 11-19 years) and an average follow-up of 48.8 months (range, 22-85.2 months). A total of 392 patients (400 shoulders) underwent arthroscopic Bankart repair, while the remaining 69 patients (69 shoulders) underwent an open procedure. The average MINORS score was 9.6 for non-comparative studies and 17 for comparative studies. ROBINS-I revealed six studies to have a moderate risk of bias, while the remaining five studies presented serious risk of bias. There was an overall 81.5% rate of RTS to preinjury levels of athletic competition at an average of 5.3 months following Bankart repair for traumatic anterior shoulder instability. The overall total mean incidence of recurrent instability was 18.5%, while the mean incidence of revision surgery was 12.1%. Contact athletes had a 31.1% and 13% rate of recurrence and revision surgery, respectively. In comparison, collision athletes were shown to have a 10.4% and 1.4% incidence of recurrent instability and revision surgery, respectively.

Conclusions and relevance

Adolescent athletes who undergo Bankart repair for traumatic anterior shoulder instability have an 81.5% rate of RTS to preinjury levels of play at an average of 5 months following surgery. The overall total mean incidence of recurrent instability in the adolescent population is 18.5%, while the mean incidence of revision surgery is 12.1%. The results of anterior shoulder stabilisation in contact athletes is much less predictable, with higher reported rates of recurrent instability and revision surgery.

Level of evidence

Level IV.

Recurrence Rate of Instability After Remplissage for Treatment of Traumatic Anterior Shoulder Instability: A Systematic Review in Treatment of Subcritical Glenoid Bone Loss

PURPOSE

To report outcomes after arthroscopic remplissage in patients with anterior shoulder instability and subcritical glenoid bone loss, specifically regarding recurrence of instability, return to sport, and changes in range of motion.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to perform a search using the PubMed, Embase, Cochrane Library, and Scopus databases. Forest plots were used to evaluate the overall values for recurrent instability, change in external rotation, and return to sport after arthroscopic Bankart repair with or without remplissage. The Methodological Index for Non-randomized Studies and Risk of Bias in Nonrandomized Studies-Interventions checklist were used to evaluate bias.

RESULTS

Twenty-two articles met the inclusion and exclusion criteria. The Methodological Index for Non-randomized Studies and Risk of Bias in Nonrandomized Studies-Interventions checklists deemed studies as acceptable quality with low bias. Among 694 patients (522 male and 106 female patients) undergoing remplissage, the mean age was 28.3 ± 5.3 years and the mean duration of follow-up was 32.5 ± 13.9 months. The recurrence rate of instability ranged from 0% to 20%. The change in external rotation in 90° of abduction ranged from -11.3° to -1.0°, and the change in external rotation with the arm fully adducted ranged from -8.0° to +4.5°. The overall rate of return to sport ranged from 56.9% to 100% after remplissage. The rate of return to sport at the preinjury level ranged from 41.7% to 100%. In addition, arthroscopic remplissage in addition to Bankart repair had a reduced odds of recurrent instability developing, ranging from 0.07 to 0.88, when compared with isolated Bankart repair.

CONCLUSIONS

Arthroscopic remplissage combined with Bankart repair is an effective procedure in the treatment of patients with engaging Hill-Sachs lesions and minimal glenoid bone loss. Patients can expect favorable rates of recurrent instability with a negligible loss of external rotation when compared with isolated Bankart repair. Treatment algorithms may be updated to include this procedure for engaging Hill-Sachs lesions, measuring between 20% and 40% in volume, with subcritical (<20%) glenoid bone loss.

LEVEL OF EVIDENCE

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

Failure following arthroscopic Bankart repair for traumatic anteroinferior instability of the shoulder: is a glenoid labral articular disruption (GLAD) lesion a risk factor for recurrent instability?

BACKGROUND

Recurrent instability is a frequent complication following arthroscopic Bankart repair. The purpose of this study was to investigate risk factors for poor patient-reported clinical outcome scores and failure rates.

METHODS

Patients who underwent arthroscopic Bankart repair at least 2 years earlier were included. Preoperative and postoperative Single Assessment Numeric Evaluation; Quick Disabilities of the Arm, Shoulder and Hand; American Shoulder and Elbow Surgeons; and satisfaction scores were collected. The relationship of the following factors with outcomes and failure rates was assessed: (1) previous arthroscopic stabilization, (2) 3 or more dislocations prior to surgery, (3) glenoid labral articular disruption (GLAD) lesion, (4) concurrent superior labral anterior-to-posterior tear repair, and (5) concurrent biceps tenodesis.

RESULTS

The study included 72 patients with a median age of 23 years (range, 14-49 years). Subsequent revision was required in 9 (12.5%); 1 additional patient (1.4%) had recurrent dislocation. Outcome data were available at a median follow-up of 3 years (range, 2-9 years). All scores significantly improved from preoperatively to postoperatively (P <.05); the mean patient satisfaction score was 9, with a median of 10 (range, 1-10). None of the analyzed factors were associated with worse postoperative outcome scores. GLAD lesions were significantly associated with a higher rate of failure (P = .007). No other analyzed factors had a significant association with failure rates (P > .05).

CONCLUSIONS

Patients with arthroscopic Bankart repair for traumatic anteroinferior shoulder instability had excellent outcomes, even in the context of previous arthroscopic stabilization surgery, 3 or more dislocations prior to surgery, concurrent superior labral anterior-to-posterior tear repair, or concurrent biceps tenodesis. However, GLAD lesions were associated with higher rates of failure, and the presence of a GLAD lesion may herald the presence of changes in the articular version or other as-yet-undetermined factors that could predispose patients to failure.

Editorial Commentary: Using Bankart "Plus" Techniques to Tackle Anterior Shoulder Instability With Bone Loss: Can Newer Arthroscopic Adjuncts Provide Long-Term Stability?

The debate between arthroscopic Bankart repair versus the Latarjet technique for patients with anterior shoulder instability largely hinges on the argument between redislocation rate versus complication rate. This difference becomes more apparent when considering patients with bone loss. We believe that Bankart "plus" techniques, including arthroscopic anatomic bone grafting, create a stable shoulder with a low instability recurrence rate, while maintaining a complication rate comparable to the Bankart repair.

The Incidence of Glenohumeral Bone and Cartilage Lesions at the Time of Anterior Shoulder Stabilization Surgery: A Comparison of Patients Undergoing Primary and Revision Surgery

BACKGROUND

Intra-articular glenohumeral joint changes frequently occur after shoulder instability events.

PURPOSE

(1) To compare demographic characteristics, baseline patient-reported outcomes, and intraoperative findings for patients undergoing primary or revision shoulder stabilization surgery and (2) to determine the incidence of glenohumeral bone and cartilage lesions in this population while identifying factors independently associated with these lesions.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

The Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group shoulder instability database was used to identify all prospectively enrolled patients undergoing shoulder stabilization surgery for anterior instability between October 2012 and September 2016. Any patient who underwent surgery for posterior or multidirectional shoulder instability or concomitant rotator cuff repair surgery was excluded. Patient demographic characteristics, preoperative patient-reported outcomes, and intraoperative findings, including glenohumeral bone and cartilage lesions, were compared for patients undergoing primary and revision shoulder stabilization surgery. Additionally, patients with and without glenohumeral bone and cartilage lesions were compared and independent associations determined using multivariate analysis.

RESULTS

There were 545 patients available for analysis (461/545 [84.6%] primary; 84/545 [15.4%] revision). Patients undergoing revision surgery were older ( P = .001), were more frequently smokers ( P = .022), had a greater number of instability events before surgery ( P = .047), more frequently required reduction assistance ( P < .001), and had lower Short Form-36 (SF-36) Mental Component Summary ( P = .020) and Western Ontario Shoulder Instability Index (WOSI) ( P = .026) scores preoperatively. Additionally, patients undergoing revision surgery had a higher frequency of bone and cartilage lesions than those undergoing primary surgery (47.6% vs 18.4%, respectively; P < .001). Male sex, revision surgery, black race, increasing body mass index, increasing patient age, and lower preoperative SF-36 Physical Component Summary score were independently associated with the presence of glenohumeral bone and cartilage lesions at the time of shoulder stabilization surgery. Revision surgery was strongly associated with the presence of glenohumeral bone and cartilage lesions (odds ratio [OR], 4.381 [95% CI, 2.591-7.406]) and glenoid bone loss greater than 10% (OR, 9.643 [95% CI, 5.128-18.134]) or 20% (OR, 13.076 [95% CI, 5.113-33.438]) of the glenoid width.

CONCLUSION

Glenohumeral bone and cartilage lesions are common at the time of shoulder stabilization surgery, occurring more frequently in patients undergoing revision surgery as compared with primary surgery. On the basis of these findings, future prospective studies should aim to compare the clinical outcomes in these 2 groups.

Return to sport following arthroscopic Bankart repair: a systematic review

HYPOTHESIS AND BACKGROUND

The purpose of this systematic review was to determine the return-to-sport rate following arthroscopic Bankart repair, and it was hypothesized that patients would experience a high rate of return to sport.

METHODS

The MEDLINE, Embase, and PubMed databases were searched by 2 reviewers, and the titles, abstracts, and full texts were screened independently. The inclusion criteria were English-language studies investigating arthroscopic Bankart repair in patients of all ages participating in sports at all levels with reported return-to-sport outcomes. A meta-analysis of proportions was used to combine the rate of return to sport using a random-effects model.

RESULTS

Overall, 34 studies met the inclusion criteria, with a mean follow-up time of 46 months (range, 3-138 months). The pooled rate of return to participation in any sport was 81% (95% confidence interval [CI], 74%-87%). In addition, the pooled rate of return to the preinjury level was 66% (95% CI, 57%-74%) (n = 1441). Moreover, the pooled rate of return to a competitive level of sport was 82% (95% CI, 79%-88%) (n = 273), while the pooled rate of return to the preinjury level of competitive sports was 88% (95% CI, 66%-99%).

CONCLUSION

Arthroscopic Bankart repair yields a high rate of return to sport, in addition to significant alleviation of pain and improved functional outcomes in the majority of patients. However, approximately one-third of athletes do not return to their preinjury level of sports.

Open Latarjet Procedures Produce Better Outcomes in Competitive Athletes Compared With Recreational Athletes: A Clinical Comparative Study of 106 Athletes Aged Under 30 Years

BACKGROUND

In cases of shoulder stabilization for anterior instability, the main goals of the surgery are a rapid and efficient return to sports and excellent long-term outcomes without recurrence of dislocation, particularly in young and competitive athletes.

PURPOSE

To determine whether outcomes of open Latarjet procedure (OLPs) depend on the level of sports practiced by patients and to report clinical scores and complication rates for OLP at a minimum follow-up of 2 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective comparative study was conducted for all patients who underwent OLP by the senior author (J.B.) between July 2007 and December 2012. The indication for OLP at the authors' institution was a minimum of 2 episodes of dislocation and/or subluxation, a positive apprehension test result in the cocking position, an Instability Severity Index Score more than 2, and evidence of anterior instability lesions on computed tomography arthrograms. The 106 included patients (110 shoulders) with a mean follow-up of 46 months were compared in 2 groups depending on sport activities: 57 (54%) competitive athletes and 49 (46%) recreational athletes. The principal outcome measure was evidence of recurrent instability. The secondary outcome measures were clinical scores related to anterior instability and related to sport practice: Rowe score, Oxford Shoulder Instability Score (OSIS), Western Ontario Shoulder Instability Index, and level of satisfaction.

RESULTS

Of the 106 patients, 3 reported recurrence of shoulder dislocation: 2 competitive athletes (3.5%; 95% CI, 0.9%-11.2%) and 1 recreational athlete (2%; 95% CI, 0.4%-10.7%) ( P = .684). The persistent apprehension test result was positive in 7 competitive athletes (11.5%) and in 5 recreational athletes (10%) ( P = .566). The Rowe scores improved from 56.3 ± 13.2 (range, 30-80) preoperatively to 84.2 ± 16.4 (range, 30-100) postoperatively in competitive athletes and from 55.0 ± 11.0 (range, 35-80) to 69.5 ± 22.0 (range, 15-100) in recreational athletes ( P < .001). The net improvement in Rowe scores was significantly greater in competitive athletes (27.9 ± 21.7) compared with recreational athletes (14.5 ± 24.4) ( P = .006). The scores unrelated to sport activity (Oxford Shoulder Instability Score and Simple Shoulder Test) were similar for the 2 groups. All 57 (100%) competitive athletes and 34 (69.4%) recreational athletes resumed their previous sports practice, at the same level or higher than before their injury (respectively, 78.9% and 42.9%; P = .004).

CONCLUSION

The OLP could be considered for primary shoulder stabilization, particularly in competitive athletes, who have high functional demands and great risks of redislocation.

Clinical Outcomes Following the Latarjet Procedure in Contact and Collision Athletes

BACKGROUND

Few studies have evaluated the success of the Latarjet procedure for recurrent anterior glenohumeral instability in the contact or collision athlete. The purpose of this study was to evaluate the return-to-sport and functional results of the Latarjet procedure in this select group.

METHODS

One hundred and nine consecutive contact or collision athletes (112 shoulders) treated with an open Latarjet procedure for recurrent anterior glenohumeral instability were retrospectively identified. Seventy-three shoulders in 73 patients (67%) were evaluated at a mean follow-up of 52 months (range, 24 to 120 months). The average age at surgery was 25.8 years (range, 15 to 54 years). The primary outcomes were the scores on the Western Ontario Shoulder Instability Index (WOSI), the American Shoulder and Elbow Surgeons (ASES) questionnaire, a visual analog scale (VAS) for pain, and return to sport. Predictors of return to sport were analyzed.

RESULTS

Six (8%) of the 73 patients experienced ≥1 postoperative dislocations. Ten additional patients (14%) experienced a perception of instability without a dislocation. The median postoperative WOSI and ASES scores were 382 (range, 0 to 2,016) and 93.3 (range, 21.7 to 100), respectively. The median postoperative VAS pain score was 0 (range, 0 to 10). Forty-nine percent (36) of the 73 patients returned to their preoperative sports level, 14% (10) decreased their activity level in the same sport, 12% (9) changed sports, and 25% (18) decreased their level of activity and changed sports or stopped participating in sports altogether. Patients with ≥2 stabilization procedures prior to the Latarjet procedure demonstrated a lower likelihood of returning to their original sport (p = 0.019; relative risk = 2.84; 95% confidence interval = 1.34 to 6.06). The percentage of glenoid bone loss showed no association with the return-to-sport rate (p = 0.507).

CONCLUSIONS

The outcome of the Latarjet procedure in high-risk contact or collision athletes is variable. Patients who have fewer prior stabilization surgical procedures are more likely to successfully return to their original sport.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Biomechanical Comparison of Single- Versus Double-Row Capsulolabral Repair for Shoulder Instability: A Review

Background:

The glenohumeral joint is the most commonly dislocated joint in the body. Failure rates of capsulolabral repair have been reported to be approximately 8%. Recent focus has been on restoration of the capsulolabral complex by a double-row capsulolabral repair technique in an effort to decrease redislocation rates after arthroscopic capsulolabral repair.

Purpose:

To present a review of the biomechanical literature comparing single- versus double-row capsulolabral repairs and discuss the previous case series of double-row fixation.

Study Design:

Narrative review.

Methods:

A simple review of the literature was performed by PubMed search. Only biomechanical studies comparing single- versus double-row capsulolabral repair were included for review. Only those case series and descriptive techniques with clinical results for double-row repair were included in the discussion.

Results:

Biomechanical comparisons evaluating the native footprint of the labrum demonstrated significantly superior restoration of the footprint through double-row capsulolabral repair compared with single-row repair. Biomechanical comparisons of contact pressure at the repair interface, fracture displacement in bony Bankart lesion, load to failure, and decreased external rotation (suggestive of increased load to failure) were also significantly in favor of double- versus single-row repair. Recent descriptive techniques and case series of double-row fixation have demonstrated good clinical outcomes; however, no comparative clinical studies between single- and double-row repair have assessed functional outcomes.

Conclusion:

The superiority of double-row capsulolabral repair versus single-row repair remains uncertain because comparative studies assessing clinical outcomes have yet to be performed.

Arthroscopic Bankart Repair for the Management of Anterior Shoulder Instability: Indications and Outcomes

PURPOSE OF REVIEW

Arthroscopic Bankart repair is commonly utilized for shoulder stabilization in patients with anterior shoulder instability with minimum glenoid bone loss. The purpose of this review is to provide the indications, surgical technique, complications, and recent outcomes in arthroscopic Bankart repair for shoulder instability.

RECENT FINDINGS

Improvements in arthroscopic techniques have led to better patient outcomes, as well as an improved understanding of the pathoanatomy of instability. More recent studies have shown that one of the potential failures of primary arthroscopic repair may be due to unaddressed bone loss. This underscores the importance of evaluating glenoid bone loss and proper patient selection for this procedure to ensure successful outcome. When indicated, arthroscopic stabilization is the treatment of choice for many surgeons due to its lower morbidity and low overall complication rate. Future work must focus on longer-term outcomes in patients undergoing arthroscopic Bankart repair, as well as the clinical outcomes of new fixation techniques, augmentation techniques, and the effect of glenoid bone loss in outcome.

How Satisfied Are Patients with Arthroscopic Bankart Repair? A 2-Year Follow-up on Quality-of-Life Outcome

PURPOSE

To report general life and health satisfaction after arthroscopic Bankart repair in patients with post-traumatic recurrent anterior glenohumeral instability and to investigate postoperative time lost to return to work at 2-year follow-up.

METHODS

Between 2011 and 2013 patients treated with arthroscopic Bankart repair in the beach chair position for acute shoulder instability were included in this study. Questions on Life Satisfaction Modules (FLZ^M) and the Short Form 12 (SF-12) were used as quality-of-life outcome scales. Oxford Instability Score (OIS), Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), and self-reported American Shoulder and Elbow Surgeons (ASES) shoulder index were used as functional outcome scales. Return to work (months) was monitored and analyzed depending on physical workload. Data were assessed the day before surgery and prospectively monitored until 24 months postoperatively. Quality-of-life outcome was correlated with functional shoulder outcome and compared with normative age-adjusted data. Paired t-test, Wilcoxon test, Mann-Whitney U-Test, and Spearman's correlation coefficient were used for statistical analysis.

RESULTS

Fifty-three patients were prospectively included. The mean age at surgery was 29.4 years. Satisfaction with general life and satisfaction with health (FLZ^M) as well as physical component scale (SF-12) improved significantly to values above normative data within 6 to 12 months after surgery (each P < .001). OIS, QuickDASH, and ASES improved significantly from baseline until 24 months after surgery (each P < .001). For ASES, improvement above minimal clinically important difference was shown. There was a positive correlation between quality of life and functional outcome scores (P < .05; rho, 0.3-0.4). Mean time to return to work was 2 months (range, 0-10; standard deviation, 1.9), with significantly longer time intervals observed in patients with heavy physical workload (3.1 months; range, 0 to 10; standard deviation, 2.4; P = .002).

CONCLUSIONS

Following arthroscopic Bankart repair, quality of life was impaired during early course after surgery and increased significantly above preoperative levels within 6 to 12 months after the procedure. A steady state of excellent quality-of-life and functional outcomes was noted after 12 months of follow-up. Quality-of-life outcome scales correlated significantly with the functional outcome. Heavy physical workload must be considered as a risk factor for prolonged time lost to return to work.

LEVEL OF EVIDENCE

Level III, prospective noncomparative therapeutic case series.

Arthroscopic Stabilization After a First-Time Dislocation: Collision Versus Contact Athletes

BACKGROUND

There is no universally accepted definition of "contact" or "collision" sports in the literature. The few available studies evaluating contact and collision sports consider them to be synonymous. However, athletes in collision sports purposely hit or collide with each other or with inanimate objects with greater force and frequency than in contact sports, which could jeopardize functional outcomes.

PURPOSE

To compare the functional outcomes, return to sports, and recurrences in a series of contact and collision athletes with a first-time anterior shoulder dislocation treated using arthroscopic stabilization with suture anchors.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A total of 56 athletes were enrolled in this study, including 22 contact athletes and 34 collision athletes. All athletes underwent arthroscopic shoulder stabilization using suture anchors. Range of motion, the Rowe score, a visual analog scale (VAS) for pain, and the Athletic Shoulder Outcome Scoring System (ASOSS) were used to assess functional outcomes. Return to sports and recurrences were also evaluated.

RESULTS

The mean age at the time of surgery was 22.2 years, and the mean follow-up was 62.4 months (range, 36-94 months). No significant difference in shoulder motion was found between preoperative and postoperative results or between the contact and collision groups. The Rowe, VAS, and ASOSS scores showed statistical improvement in both groups after surgery (P = .001). Patients in the contact group returned to sports significantly faster than those in the collision group (5.2 vs 6.9 months, respectively; P = .01). In all, 43 athletes (76.8%) returned to near-preinjury sports activity levels (≥90% recovery) after surgery: 86.4% of patients in the contact group and 70.6% in the collision group (P = .04). The total recurrence rate was 8.9%. There were 5 recurrences (14.7%) in the collision group and no recurrences in the contact group (P < .01).

CONCLUSION

Arthroscopic stabilization for anterior instability of the shoulder is a reliable procedure with respect to shoulder function, range of motion, and postoperative return to sports in contact and collision athletes. Compared with the contact group (0%), the collision group yielded a higher failure rate (14.7%). Moreover, patients in the contact group returned significantly faster (5.2 vs 6.9 months, respectively) and to and more returned to preinjury or near-preinjury activity levels (86.4% vs 70.6% of patients, respectively) than patients in the collision group.

Bankart Repair Using Modern Arthroscopic Technique

As technology continues to improve, surgeons must regularly re-evaluate techniques to improve efficacy and outcomes. The Bankart repair for shoulder instability has evolved from open reconstruction to minimally invasive arthroscopic techniques, which have the benefit of less pain and morbidity. This technical description and video present a modern arthroscopic technique for Bankart repair used at our institution with high success in an athletic population.

Arthroscopic Subscapularis Augmentation of Bankart Repair in Chronic Anterior Shoulder Instability With Bone Loss Less Than 25% and Capsular Deficiency: Clinical Multicenter Study

PURPOSE

To assess the short-term outcomes of the arthroscopic subscapularis augmentation (ASA) technique, consisting of a tenodesis of the upper third of the subscapularis tendon and a Bankart repair, and its effect on shoulder external rotation.

METHODS

Patients selected for this study were involved in contact sports, with a history of traumatic recurrent shoulder dislocations and a minimum of 2-year follow-up. Inclusion criteria were patients with glenoid bone loss (GBL) ranging from 5% to 25%, anterior capsular deficiency, and Hill-Sachs lesion who underwent ASA technique. Exclusion criteria were GBL >25%, multidirectional instability, preexisting osteoarthritis, and overhead sports activities. Visual analog scale (VAS) scale for pain, Rowe score, and American Shoulder and Elbow Surgeons (ASES) scores were used to assess results. Loss of shoulder external rotation was measured with the arm at the side (ER1 position) or 90° in abduction (ER2 position). Analysis of variance and Fisher tests were used for data evaluation. Significance was established at P ≤ .05.

RESULTS

One hundred ten patients (84 men and 26 women, mean age 27 years) were evaluated with a mean follow-up of 40.5 months (range: 24 to 65 months). In 98 patients, a Hill-Sachs lesion was observed and in 57 patients a capsular deficiency was present. Three patients (2.7%) had a traumatic redislocation. At final follow-up, the mean scores were as follows: VAS scale decreased from a mean of 3.5 to 0.5 (P = .015), Rowe score increased from 57.4 to 95.3 (P = .035), and ASES score increased from 66.5 to 96.5 (P = .021). The mean deficit of external rotation was 8° ± 2.5° in the ER1 position and 4° ± 1.5° in the ER2 position.

CONCLUSIONS

The ASA procedure has been shown to be effective in restoring joint stability in patients practicing sports, affected by chronic anterior shoulder instability associated with anterior GBL (<25%), capsular deficiency, and Hill-Sachs lesions, with mild restriction of external rotation.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Outcomes After Arthroscopic Bankart Repair in Adolescent Athletes Participating in Collision and Contact Sports

Background:

Literature on arthroscopic stabilization in adolescent patients participating in collision and contact sports is limited, as most studies include adolescents within a larger sample group comprised primarily of adults.

Purpose:

To review the outcomes of arthroscopic Bankart repair for anterior shoulder instability in an adolescent population participating in collision and contact sports.

Study Design:

Case series; Level of evidence, 4.

Methods:

This retrospective review included 39 shoulders in 37 adolescent (≤19 years) athletes who underwent primary arthroscopic Bankart repair using suture anchors with at least 2-year follow-up. All patients had a history of trauma to their shoulder resulting in an anterior dislocation. Outcome measures included patient satisfaction, the visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeons (ASES) score, and Rowe score. Recurrence of dislocation and return to sporting activity were also assessed.

Results:

The mean age at the time of surgery was 16.9 years (range, 15-19 years), and the mean follow-up was 6.3 years (range, 4.3-10.0 years); 58.6% of patients participated in collision sports. Time to surgery after the initial dislocation episode was 9.2 months (range, 0.5-36.2 months). Four shoulders (10.3%) had dislocation events postoperatively. The majority (78.1%) of patients returned to sports at the same level of competition. Mean VAS was 0.49 ± 1.0, and the mean ASES and Rowe scores were 92.8 ± 12.6 and 85.0 ± 24.2, respectively. Univariate analyses demonstrated that subjective functional outcomes were negatively correlated with recurrence (ASES, P = .005; Rowe, P = .001) and failure to return to sport (ASES, P = .016; Rowe, P = .004). Independent variables shown to have no significant relationship to functional outcomes included age, follow-up, number of preoperative dislocations, time to surgery, sport classification, competition level, tear extent, number of anchors, concurrent Hill-Sachs lesion, and repair of a superior labral anterior-posterior (SLAP) lesion.

Conclusion:

Arthroscopic Bankart repair is an effective surgical option for traumatic shoulder instability in adolescents participating in collision and contact sports. At a minimum 4-year follow-up, arthroscopic Bankart repair effectively restored stability in 90% of cases; 80% returned to their preinjury level of sport.

Arthroscopic treatment of shoulder instability in professional athletes

BACKGROUND

Post-traumatic shoulder instability is a common disease, especially in sportsmen. If inadequately or late treated, it may be responsible for an articular biomechanics alteration, with serious problems. This is much more obvious for professionals athletes, because corporate and market needs force them to a premature return to sport. The purpose of this retrospective study is to evaluate if arthroscopic approach may be better than the open one and allowing a shoulder function rapid recovery, with fast return to sport.

MATERIALS AND METHODS

From January 2003 to January 2014, 46 professional athletes underwent surgical treatment for post traumatic shoulder instability. Two groups were made: 25 athletes treated arthroscopically and 21 treated with open approach. Patients were followed up from 36 to 92 months, according to Rowe Score for Instability and VAS scoring system.

RESULTS

Patients in the open group returned later than the first one to sport. Moreover, pain in postoperative period and during rehabilitation, was lower in the arthroscopic group. There was only one recurrence in the open group.

CONCLUSIONS

Arthroscopic surgical approach appears to be excellent in shoulder instability management, reducing recovery time, allowing a faster return to sport, with less pain, if compared with open surgery.

LEVEL OF EVIDENCE

III, a case control-study.