1
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Watts V GJ, Tai R, Joshi G, Garwood E, Saha D. Reinjury Following Return to Play. Semin Musculoskelet Radiol 2024; 28:154-164. [PMID: 38484768 DOI: 10.1055/s-0043-1778022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Radiologists are frequently called on for guidance regarding return to play (RTP) for athletes and active individuals after sustaining a musculoskeletal injury. Avoidance of reinjury is of particular importance throughout the rehabilitative process and following resumption of competitive activity. Understanding reinjury risk estimation, imaging patterns, and correlation of clinical and surgical findings will help prepare the radiologist to identify reinjuries correctly on diagnostic imaging studies and optimize management for a safe RTP.
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Affiliation(s)
- George J Watts V
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, UMass Chan Medical School, Worcester, Massachusetts
| | - Ryan Tai
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, UMass Chan Medical School, Worcester, Massachusetts
| | - Ganesh Joshi
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, UMass Chan Medical School, Worcester, Massachusetts
| | - Elisabeth Garwood
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, UMass Chan Medical School, Worcester, Massachusetts
| | - Debajyoti Saha
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, UMass Chan Medical School, Worcester, Massachusetts
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2
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Rawal A, Eckers F, Lee OSH, Hochreiter B, Wang KK, Ek ET. Current Evidence Regarding Shoulder Instability in the Paediatric and Adolescent Population. J Clin Med 2024; 13:724. [PMID: 38337418 PMCID: PMC10856087 DOI: 10.3390/jcm13030724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 01/18/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
Paediatric and adolescent shoulder instability is caused by a unique combination of traumatic factors, ligamentous laxity, and pattern of muscle contractility. The multifactorial nature of its aetiology makes interpretation of the literature difficult as nomenclature is also highly variable. The purpose of this review is to summarize the existing literature and shed light on the nuances of paediatric and adolescent shoulder instability. The epidemiology, clinical features, imaging, and management of all forms of paediatric shoulder instability are presented. The main findings of this review are that structural abnormalities following a dislocation are uncommon in pre-pubertal paediatric patients. Young post-pubertal adolescents are at the highest risk of failure of non-operative management in the setting of traumatic instability with structural abnormality, and early stabilisation should be considered for these patients. Remplissage and the Latarjet procedure are safe treatment options for adolescents at high risk of recurrence, but the side-effect profile should be carefully considered. Patients who suffer from instability due to generalized ligamentous laxity benefit from a structured, long-term physiotherapy regimen, with surgery in the form of arthroscopic plication as a viable last resort. Those who suffer from a predominantly muscle patterning pathology do not benefit from surgery and require focus on regaining neuromuscular control.
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Affiliation(s)
- Aziz Rawal
- Melbourne Orthopaedic Group, Windsor, Melbourne, VIC 3181, Australia; (A.R.); (F.E.)
| | - Franziska Eckers
- Melbourne Orthopaedic Group, Windsor, Melbourne, VIC 3181, Australia; (A.R.); (F.E.)
- Orthopädie und Traumatologie, Universitätsspital Basel, 4031 Basel, Switzerland
| | - Olivia S. H. Lee
- Victorian Paediatric Rehabilitation Service, The Royal Children’s Hospital, Melbourne, VIC 3052, Australia;
| | - Bettina Hochreiter
- Melbourne Orthopaedic Group, Windsor, Melbourne, VIC 3181, Australia; (A.R.); (F.E.)
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, 8006 Zürich, Switzerland
| | - Kemble K. Wang
- Department of Orthopaedic Surgery, The Royal Children’s Hospital, Melbourne, VIC 3052, Australia;
| | - Eugene T. Ek
- Melbourne Orthopaedic Group, Windsor, Melbourne, VIC 3181, Australia; (A.R.); (F.E.)
- Department of Surgery, Monash University, Melbourne, VIC 3800, Australia
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3
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Delgado C, Luengo-Alonso G, Valencia M, Martínez-Catalán N, Calvo E. Association of Instability History and Off-Track Hill-Sachs Lesions in Anterior Shoulder Instability. Orthop J Sports Med 2023; 11:23259671231213858. [PMID: 38035218 PMCID: PMC10686021 DOI: 10.1177/23259671231213858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 06/21/2023] [Indexed: 12/02/2023] Open
Abstract
Background The glenoid track concept is now widely accepted, and its evaluation is considered essential for making decisions about surgery. Purpose To define preoperative descriptive data and clinical and functional features in patients with anterior glenohumeral instability according to glenoid track status and to analyze the influence of off-track Hill-Sachs (HS) lesions on preoperative shoulder function. Study Design Case-control study; Level of evidence, 3. Methods Preoperative magnetic resonance imaging or computed tomography scans were used to measure the glenoid track. Descriptive data and preoperative objective and subjective clinical and functional features were compared between patients with on-track HS lesions versus off-track HS lesions. Multivariate regression analysis was conducted to identify potential risk factors for off-track HS lesion development. Results A total of 235 patients (201 men, 34 women; mean age, 29.6 ± 8.6 years) were included- 134 shoulders (57%) with on-track HS lesions and 101 shoulders (43%) with off-track HS lesions. Age <20 years at first dislocation, number of dislocations, and ≥2 years between first dislocation and surgery were significantly different between the study groups (P = .005, P = .0001, and P = .01, respectively). Regarding these characteristics, the odds ratios for the risk of developing an off-track lesion were 2.67 (95% CI, 1.2-5.99)-1.2 times higher for each additional instability episode (95% CI, 1.025-1.14) and 2.42 times higher (95% CI, 1.176-4.608) for patients whose first dislocation was ≥2 years before surgery, respectively. Patients with off-track HS lesions had a significantly greater degree of instability (P = .04), worse Rowe scores (48.8 ± 15.3 vs 54.8 ± 28.3 for on-track HS lesions; P = .04), and lower Western Ontario Shoulder Instability scores (975 ± 454 vs 1179 ± 428 for on-track HS lesions; P = .01). Conclusion Characteristics related to a history of instability (age <20 years at first instability episode, larger number of dislocations, ≥2 years between first dislocation and surgery) were found to be risk factors for the development of an off-track HS lesion in this study. Off-track lesions led to a higher degree of instability and worse objective and subjective preoperative shoulder function versus on-track HS lesions.
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Affiliation(s)
- Cristina Delgado
- Shoulder and Elbow Reconstructive Surgery Unit, Department of Orthopedic Surgery and Traumatology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Gonzalo Luengo-Alonso
- Shoulder and Elbow Reconstructive Surgery Unit, Department of Orthopedic Surgery and Traumatology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Maria Valencia
- Shoulder and Elbow Reconstructive Surgery Unit, Department of Orthopedic Surgery and Traumatology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Natalia Martínez-Catalán
- Shoulder and Elbow Reconstructive Surgery Unit, Department of Orthopedic Surgery and Traumatology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Emilio Calvo
- Shoulder and Elbow Reconstructive Surgery Unit, Department of Orthopedic Surgery and Traumatology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
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4
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Kay J, Heyworth BE, Milewski MD, Kramer DE. Pediatric and Adolescent Shoulder Instability. Curr Rev Musculoskelet Med 2023:10.1007/s12178-023-09837-z. [PMID: 37067690 DOI: 10.1007/s12178-023-09837-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 04/18/2023]
Abstract
PURPOSE OF REVIEW Traumatic and atraumatic shoulder instability is common in pediatric and adolescent patients. It is well-established that young patients with anterior shoulder dislocation are at high risk of recurrent instability. This review assesses the current literature pertaining to management of both anterior instability and MDI in the pediatric and adolescent populations. RECENT FINDINGS Current research suggests that pediatric and adolescent patients with shoulder instability have excellent outcomes following arthroscopic Bankart repair; however, higher rates of recurrent instability requiring revision surgical management have been identified in patients with more than one dislocation episode pre-operatively, those with Hill-Sachs lesions and those under age 16. The addition of the remplissage procedure to an arthroscopic Bankart repair may be useful in preventing recurrent instability for patients with large Hill-Sachs lesions. Open procedures with bony glenoid augmentation may be indicated in patients with significant glenoid bone loss, or those who have failed primary surgical management, with promising outcomes reported following the Latarjet coracoid process transfer procedure in the adolescent population. Pediatric and adolescent patients with hyperlaxity, and those participating in swimming or gymnastics are more likely to have multidirectional instability (MDI). Non-surgical management with physical therapy is the mainstay of treatment for MDI with positive outcomes reported overall. In young patients with MDI who continue to have symptoms of instability and pain that effects daily activities or sports despite an adequate and appropriate course of rehabilitation, surgical management with capsulorrhaphy may be considered, with promising outcomes reported for both open and arthroscopic techniques. Attentive selection of timing and surgical procedure for pediatric and adolescent patients with anterior shoulder instability may help to prevent recurrent instability following shoulder stabilization. Although most pediatric and adolescent patients with MDI do well following non-surgical management alone, those that fail conservative management have good outcomes following arthroscopic or open capsulorrhaphy.
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Affiliation(s)
- Jeffrey Kay
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA.
- Division of Sports Medicine, Boston Children's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada.
| | - Benton E Heyworth
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
- Division of Sports Medicine, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Matthew D Milewski
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
- Division of Sports Medicine, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Dennis E Kramer
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
- Division of Sports Medicine, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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5
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Gouveia K, Harbour E, Athwal GS, Khan M. Return to Sport After Arthroscopic Bankart Repair With Remplissage: A Systematic Review. Arthroscopy 2023; 39:1046-1059.e3. [PMID: 36646363 DOI: 10.1016/j.arthro.2022.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 12/30/2022] [Accepted: 12/30/2022] [Indexed: 01/14/2023]
Abstract
PURPOSE To determine the return-to-sport rate following arthroscopic Bankart repair with remplissage (ABR), including overall rate of return to sport, rate of return to preinjury level of sport, and the rate of return for specific subgroups such as contact or throwing athletes. METHODS EMBASE, PubMed, and MEDLINE were searched from database inception until February 2022. Studies were screened by 2 reviewers independently and in duplicate for data regarding rates of return to sport following ABR. Data on return to sport and functional outcomes were recorded. Data are presented in a descriptive fashion. RESULTS Overall, 20 studies were included with a total of 736 patients (738 shoulders) who underwent ABR. These patients had a mean age of 28 years (range 14-72 years) and were 83% male. Mean follow-up time after surgery was 45 months (range 12-127 months). The rate of return to any level of sport ranged from 60% to 100%, whereas the rate of return to the preinjury level ranged from 63% to 100%. When we excluded those who underwent ABR as a revision procedure, the rate of return to any level of sport was 68% to 100%. Lastly, the return to sport rates for contact or collision athletes ranged from 80% to 100%, whereas for overhead or throwing athletes it was 46% to 79%. The rate of recurrence of instability postoperatively ranged from 0% to 20% in included studies. CONCLUSIONS For athletes with anterior shoulder instability, ABR led to a high rate of return to sport along with a low rate of recurrence of instability. Although most athletes are able to return to the same level of sport, certain groups such as throwing athletes may face greater difficulty. LEVEL OF EVIDENCE Level IV, systematic review of Level III and IV studies.
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Affiliation(s)
- Kyle Gouveia
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Eric Harbour
- School of Medicine, University of Limerick, Limerick, Ireland
| | - George S Athwal
- Hand and Upper Limb Centre, Western University, London, Ontario, Canada
| | - Moin Khan
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
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6
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Egger AC, Willimon SC, Busch MT, Broida S, Perkins CA. Arthroscopic Bankart Repair for Adolescent Anterior Shoulder Instability: Clinical and Imaging Predictors of Revision Surgery and Recurrent Subjective Instability. Am J Sports Med 2023; 51:877-884. [PMID: 36779584 DOI: 10.1177/03635465231151250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
BACKGROUND Multiple clinical and radiologic risk factors for recurrent instability after arthroscopic Bankart repair have been described. Humeral bone loss has gained more recent attention, particularly with respect to "off-track" lesions and increased rates of recurrent instability and revision surgery. PURPOSE To evaluate clinical and radiologic predictors of failure after arthroscopic Bankart repair in adolescents. STUDY DESIGN Case series; Level of evidence, 4. METHODS A single-institution retrospective study was performed in patients <19 years of age treated with arthroscopic Bankart repair from 2011 to 2017. Magnetic resonance imaging measurements of glenoid and humeral bone loss, the glenoid track, and the presence of off-track Hill-Sachs (HS) lesions were assessed. All patients had a minimum follow-up of 24 months and completed patient-reported outcome scores. Failure was defined as revision surgery or postoperative subjective instability. RESULTS A total of 59 patients (46 male, 13 female) with a median age of 16 years (range, 12-18 years) were included. Ten patients (17%) had revision surgery and 8 patients (14%) had subjective instability without revision surgery. No clinical or radiologic factors were significantly different between the failure cohort and the nonfailure cohort. Four patients (7%) measured off-track, and 2 of these patients experienced failure. A total of 38 patients (64%) were identified to have an HS defect. Subgroup analysis of these patients identified a greater HS interval (HSI) in patients who underwent revision surgery as compared with those patients who did not have revision surgery. Among patients with GT ratio ≥15 mm, there was a 50% rate of revision surgery. The Pediatric/Adolescent Shoulder Survey (PASS) and Single Assessment Numeric Evaluation (SANE) scores at the final follow-up were not significantly different among patients with or without revision surgery. However, those with subjective instability who had not undergone revision surgery had significantly lower PASS and SANE scores as compared with the remainder of the cohort. CONCLUSION Of the adolescents in this cohort, 31% either had revision surgery (17%) or reported subjective feelings of instability (14%) after arthroscopic Bankart repair. Off-track instability was identified in 7% of the cohort but was not predictive of failure. Among the subgroup of patients with an HS defect, those who underwent revision surgery had a significantly larger HSI.
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Affiliation(s)
| | | | | | - Sam Broida
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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7
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Bauer A, Engel G, Huth J, Mauch F. Fourteen years of follow-up after first arthroscopic Bankart repair in athletes: functional outcomes and magnetic resonance imaging findings. J Shoulder Elbow Surg 2023; 32:546-554. [PMID: 36273790 DOI: 10.1016/j.jse.2022.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 09/13/2022] [Accepted: 09/28/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The arthroscopic Bankart procedure is the most performed surgery for shoulder stabilization. Short-term to midterm results are well studied; however, long-term results over 10 years are rare. PURPOSE This study evaluates the long-term results and magnetic resonance imaging (MRI) findings in athletes at a mean follow-up of 14 years after an arthroscopic Bankart stabilization as well as risk factors for osteoarthritis. METHODS A total of 63 athletes had an arthroscopic Bankart repair between 2001 and 2008, of whom 46 patients (73.0%) participated in the final follow-up. The Constant, Rowe, and Western Ontario Shoulder Instability Index (WOSI) score and the rate of return to sports were evaluated. Glenohumeral osteoarthritis was assessed using the Samilson-Prieto classification. Known risk factors for osteoarthritis were analyzed. MRI findings (bone marrow edema, cysts, and joint effusion) were analyzed. RESULTS The average follow-up was 14 years. Assessment was performed on 46 athletes with an average age of 21.6 at the time of surgery. The overall redislocation rate was 21.7%. The Constant score was 96.7, the Rowe score was 83.4, and the Western Ontario Shoulder Instability Index score was 90.7 out of 100. A total of 84.8% of the athletes returned to their initial sports level. Glenohumeral osteoarthritis occurred in 28.1%. Known risk factors for osteoarthritis were confirmed. Further MRI findings were rare. CONCLUSIONS Arthroscopic Bankart repair in athletes shows good long-term clinical results. However, this is only in patients without osteoarthritis, which was rare, but was confirmed as a risk factor. We assume that resorption of anchors differs in patients. If it does have an impact on developing arthrosis, this should be confirmed in further studies.
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Affiliation(s)
- Anne Bauer
- Department of Sports Orthopaedics, Sportklinik Stuttgart GmbH, Stuttgart, Germany
| | - Guido Engel
- Department of Sports Orthopaedics, Sportklinik Stuttgart GmbH, Stuttgart, Germany
| | - Jochen Huth
- Department of Sports Orthopaedics, Sportklinik Stuttgart GmbH, Stuttgart, Germany.
| | - Frieder Mauch
- Department of Sports Orthopaedics, Sportklinik Stuttgart GmbH, Stuttgart, Germany
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8
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Orringer M, Lau J, Feeley B, Pandya N. Bone Bruise Patterns Associated With Pediatric and Adult Anterior Cruciate Ligament Tears Are Different. Arthrosc Sports Med Rehabil 2022; 5:e151-e157. [PMID: 36866294 PMCID: PMC9971902 DOI: 10.1016/j.asmr.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 11/08/2022] [Indexed: 12/29/2022] Open
Abstract
Purpose To describe differences in radiographic and magnetic resonance imaging (MRI) findings between adult and pediatric patients with known primary anterior cruciate ligament (ACL) injuries. Methods We performed a retrospective analysis of surgical patients with a history of ACL tears treated at our institution over a 7-year period. Patients were divided into 2 cohorts based on age (≤15 years and ≥21 years). Patients' radiographs and MRI studies were used to compare features including fracture incidence, bone bruise pattern, associated ligamentous injuries, and meniscal injuries between the 2 groups. Proportions of associated findings were analyzed using the 2-proportion z test. Results Within our cohorts of 52 sex-matched pediatric and adult patients, we found that pediatric patients were more likely to have radiographic evidence of fracture (P = .001) and MRI evidence of lateral femoral condylar bone bruising (P = .012). Adult patients had higher rates of medial femoral condylar bruising (P = .016) and medial proximal tibial bruising (P = .005), as well as popliteal fibular ligament injuries (P = .037), identified on MRI. Conclusions In this study, we identified differences in bone bruise patterns between pediatric and adult patients with primary ACL tears. Pediatric patients were more likely to have radiographic evidence of fracture and MRI evidence of lateral femoral condylar bone bruising. Adult patients were more likely to show medial femoral condylar and medial proximal tibial bone bruising, as well as popliteal fibular ligament injuries. Level of Evidence Level IV, prognostic case series.
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Affiliation(s)
- Matthew Orringer
- School of Medicine, University of California, San Francisco, San Francisco, California, U.S.A.,Address correspondence to Matthew Orringer, UCSF School of Medicine, 500 Parnassus Ave, San Francisco, CA 94143, U.S.A.
| | - Justin Lau
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California, U.S.A
| | - Brian Feeley
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California, U.S.A
| | - Nirav Pandya
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California, U.S.A
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9
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Evaluation and Management of the Contact Athlete's Shoulder. J Am Acad Orthop Surg 2022; 30:e584-e594. [PMID: 35171860 DOI: 10.5435/jaaos-d-20-01374] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 12/10/2021] [Indexed: 02/01/2023] Open
Abstract
Shoulder injuries are common in contact athletes and vary in severity because of the required complex interplay of shoulder stability and range of motion for proper function. Pathology varies based on sport but most commonly includes shoulder instability, acromioclavicular injuries, traumatic rotator cuff tears, and brachial plexus injuries. Acute management ranges from reduction of shoulder dislocations to physical examination to determine the severity of injury. Appropriate radiographs should be obtained to evaluate for alignment and fracture, with magnetic resonance imaging commonly being necessary for accurate diagnosis and management. Treatments range from surgical stabilization in shoulder instability to repeat examinations and physical therapy. Return-to-play decision making can be complex with avoidance of reinjury and player safety being of utmost concern. Appropriate evaluation and treatment are vital because repeat injury can lead to long-term effects due to the relatively high effectsometimes seen in contact sports.
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10
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Lim JR, Lee HM, Yoon TH, Lee HM, Chun YM. Association Between Excessive Joint Laxity and a Wider Hill-Sachs Lesion in Anterior Shoulder Instability. Am J Sports Med 2021; 49:3981-3987. [PMID: 34694163 DOI: 10.1177/03635465211049221] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Excessive general joint laxity, a negative prognostic factor in joint instability, has not been studied to determine its relationship with bipolar bone loss in anterior shoulder instability. PURPOSE/HYPOTHESIS This study aimed to investigate the characteristics of bipolar bone defects in the presence of excessive joint laxity and the clinical outcomes based on the on-track/off-track theory. We hypothesized that (1) patients with excessive joint laxity might have less significant bipolar bone defects compared with those without excessive joint laxity and (2) no significant difference would be found in the clinical outcomes, including recurrence rate. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS This study included 81 patients who had undergone arthroscopic Bankart repair, with (group L; n = 33) or without (group N; n = 48) excessive joint laxity. The presence of excessive joint laxity was defined as a score of ≥4 using Beighton and Horan criteria preoperatively. Bipolar bone lesions were assessed using preoperative 3-dimensional computed tomography. Additional remplissage was performed for cases with off-track or positive engagement test in borderline on-track lesions. The functional outcomes at the 2-year follow-up were assessed using the recurrence rate, Subjective Shoulder Value, Rowe score, University of California Los Angeles shoulder score, active range of motion, and the sports/recreation activity level. RESULTS No significant difference was found in the glenoid bone defect between groups (14.1%, group L; 14.4%, group N). Off-track lesions were identified in 39.4% (13/33) of group L and 14.6% (7/48) of group N (P = .011). The mean Hill-Sachs interval to glenoid track ratio was 83.1% in group L and 75.2% in group N (P = .021). Additional remplissage procedures were more frequently performed in group L (48.5%; 16/33) than in group N (16.7%; 8/48) (P = .002). However, no significant difference was observed in the shoulder functional scores and recurrence rates between the groups. CONCLUSION Patients with anterior shoulder instability and excessive joint laxity had significantly wider Hill-Sachs lesions and more off-track lesions than did those with normal joint laxity despite the lack of a significant difference in the glenoid bone defect. However, these differences in the Hill-Sachs lesion were not related to differences in the functional outcomes between the groups.
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Affiliation(s)
- Joon-Ryul Lim
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Severance Hospital, Seoul, Republic of Korea
| | - Hyung-Min Lee
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Severance Hospital, Seoul, Republic of Korea
| | - Tae-Hwan Yoon
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Severance Hospital, Seoul, Republic of Korea
| | - Hwan-Mo Lee
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Severance Hospital, Seoul, Republic of Korea
| | - Yong-Min Chun
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Severance Hospital, Seoul, Republic of Korea
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11
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Vopat ML, Hermanns CA, Midtgaard KS, Baker J, Coda RG, Cheema SG, Tarakemeh A, Peebles L, Vopat BG, Provencher MT. Imaging Modalities for the Glenoid Track in Recurrent Shoulder Instability: A Systematic Review. Orthop J Sports Med 2021; 9:23259671211006750. [PMID: 34159209 PMCID: PMC8182199 DOI: 10.1177/23259671211006750] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 02/28/2021] [Indexed: 11/16/2022] Open
Abstract
Background: The glenoid track (GT) concept illustrates how the degree of glenoid bone
loss and humeral bone loss in the glenohumeral joint can guide further
treatment in a patient with anterior instability. The importance of
determining which lesions are at risk for recurrent instability involves
imaging of the glenohumeral joint, but no studies have determined which type
of imaging is the most appropriate. Purpose/Hypothesis: The purpose of this study was to determine the validity and accuracy of
different imaging modalities for measuring the GT in shoulders with
recurrent anterior instability. We hypothesized that 3-dimensional computed
tomography (3D-CT) would be the most accurate imaging technique. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was performed according to the PRISMA (Preferred
Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using
PubMed, Scopus, Medline, and Cochrane libraries between database inception
and July 2019. We included all clinical trials or cadaveric studies that
evaluated imaging modalities for assessing the GT. Results: A total of 13 studies were included in this review: 1 study using
2-dimensional CT, 6 studies using 3D-CT, 4 studies using magnetic resonance
imaging (MRI), 1 study using magnetic resonance arthrography (MRA)/MRI, and
1 study combining CT and MRI. The mean sensitivity, specificity, and
accuracy for 2D-CT was 92%, 100%, and 96%, respectively. For MRI, the means
were 72.2%, 87.9%, and 84.2%, respectively. No papers included 3D-CT
metrics. The mean intraclass correlation coefficients (ICCs) for
intraobserver reliability were 0.9046 for 3D-CT and 0.867 for MRI. ICCs for
interobserver reliability were 0.8164, 0.8845, and 0.43 for 3D-CT, MRI, and
MRA/MRI, respectively. Conclusion: There is evidence to support the use of both CT and MRI imaging modalities in
assessing the GT. In addition, few studies have compared radiographic
measurements with a gold standard, and even fewer have looked at the GT
concept as a predictor of outcomes. Thus, future studies are needed to
further evaluate which imaging modality is the most accurate to assess the
GT.
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Affiliation(s)
- Matthew L Vopat
- University of Kansas School of Medicine--Wichita, Wichita, Kansas, USA
| | | | - Kaare S Midtgaard
- Steadman Philippon Research Institute, Vail, Colorado, USA.,The Steadman Clinic, Vail, Colorado, USA.,Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Jordan Baker
- University of Kansas School of Medicine--Kansas City, Kansas City, Kansas, USA
| | - Reed G Coda
- University of Kansas School of Medicine--Kansas City, Kansas City, Kansas, USA
| | - Sana G Cheema
- University of Kansas School of Medicine--Kansas City, Kansas City, Kansas, USA
| | - Armin Tarakemeh
- University of Kansas School of Medicine--Kansas City, Kansas City, Kansas, USA
| | - Liam Peebles
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Bryan G Vopat
- University of Kansas School of Medicine--Kansas City, Kansas City, Kansas, USA
| | - Matthew T Provencher
- Steadman Philippon Research Institute, Vail, Colorado, USA.,The Steadman Clinic, Vail, Colorado, USA
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12
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Parvaresh KC, Vargas-Vila M, Bomar JD, Pennock AT. Anterior Glenohumeral Instability in the Adolescent Athlete. JBJS Rev 2021; 8:e0080. [PMID: 32015270 DOI: 10.2106/jbjs.rvw.19.00080] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Glenohumeral instability is multifactorial and has both static and dynamic elements. The initial management of first-time dislocations has become increasingly controversial, although recent evidence supports operative treatment for adolescents who participate in contact sports. Risk factors for recurrent glenohumeral instability include adolescent age, hyperlaxity, glenoid bone loss, off-track Hill-Sachs lesions, and fixation with <=3 anchors. High rates of return to sport can be expected when the surgical plan is tailored to individual pathology.
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Affiliation(s)
| | | | | | - Andrew T Pennock
- University of California, San Diego, San Diego, California.,Rady Children's Hospital, San Diego, California
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13
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Vopat ML, Peebles LA, McBride T, Cirone I, Rider D, Provencher CMT. Accuracy and Reliability of Imaging Modalities for the Diagnosis and Quantification of Hill-Sachs Lesions: A Systematic Review. Arthroscopy 2021; 37:391-401. [PMID: 32798670 DOI: 10.1016/j.arthro.2020.08.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 04/24/2020] [Accepted: 08/11/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine the reliability and accuracy of different imaging modalities in assessing Hill-Sachs lesions within the setting of anterior shoulder instability. METHODS A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines using the PubMed, Scopus, Embase, and Cochrane Library databases. The inclusion criteria were clinical trials or cadaveric studies that assessed the accuracy of humeral head bone loss imaging or reliability and English-language articles. The exclusion criteria were animal studies; imaging studies without measures of accuracy, reliability, or clinical predictive power; studies of shoulder injuries without humeral head bone loss; editorials; abstracts; reviews; case reports; and surveys. The search terms included "imaging" OR "radiographic" OR "CT" OR "MRI" AND "Hill-Sachs" OR "humeral head bone loss." Assessment of the methodologic quality of the included studies was performed using the original Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. RESULTS Forty studies (2,560 shoulders) met the inclusion criteria and were assessed. For diagnosing the presence of Hill-Sachs lesions, computed tomography (CT) arthrography had the highest reported accuracy (median, 91%; range, 66%-100%). For the same assessment, CT arthrography also had the greatest reported sensitivity (median, 94%; range, 50%-100%). For the quantification of Hill-Sachs lesion parameters, reported intraobserver reliabilities were highest for 3-dimensional (3D) CT (intraclass correlation coefficient [ICC] range, 0.916-0.999), followed by 2-dimensional CT (ICC range, 0.858-0.861) and magnetic resonance imaging (MRI) (ICC range, 0.28-0.97). For the same quantification parameters, interobserver reliabilities were also reported for 3D CT (ICC range, 0.772-0.996), 2-dimensional CT (ICC range, 0.721-0.879), and MRI (κ range, 0.444-0.700). Intraobserver reliabilities for determining glenoid tracking were only reported for 3D CT (κ range, 0.730-1.00; ICC range, 0.803-0.901) and MRI (ICC range, 0.770-0.790). CONCLUSIONS This study shows that the current literature supports a variety of different imaging modalities that provide clinically acceptable accuracy in diagnosing and quantifying Hill-Sachs lesions, as well as determining whether they will cause persistent anterior shoulder instability. Furthermore, this systematic review justifies that further research is needed to help develop a treatment algorithm on the proper imaging modalities needed to help treat patients with anterior shoulder instability that is both reliable and financially acceptable. LEVEL OF EVIDENCE Level IV, systematic review of Level I through IV studies.
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Affiliation(s)
- Matthew L Vopat
- University of Kansas School of Medicine-Wichita, Wichita, Kansas, U.S.A
| | - Liam A Peebles
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Trevor McBride
- Sidney Kimmel Medical College, Philadelphia, Pennsylvania, U.S.A
| | - Isaak Cirone
- Colorado State University, Fort Collins, Colorado, U.S.A
| | - Danielle Rider
- Wake Forest School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Capt Matthew T Provencher
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; The Steadman Clinic, Vail, Colorado, U.S.A..
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14
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Bois AJ, Mayer MJ, Fening SD, Jones MH, Miniaci A. Management of bone loss in recurrent traumatic anterior shoulder instability: a survey of North American surgeons. JSES Int 2020; 4:574-583. [PMID: 32939489 PMCID: PMC7479034 DOI: 10.1016/j.jseint.2020.04.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Management of bone loss in recurrent traumatic anterior shoulder instability remains a topic of debate and controversy in the orthopedic community. The purpose of this study was to survey members of 4 North American orthopedic surgeon associations to assess management trends for bone loss in recurrent anterior shoulder instability. Methods An online survey was distributed to all members of the American Shoulder and Elbow Surgeons, American Orthopaedic Society for Sports Medicine, and Canadian Orthopaedic Association and to fellow members of the Arthroscopy Association of North America. The survey comprised 3 sections assessing the demographic characteristics of survey respondents, the influence of prognostic factors on surgical decision making, and the operative management of 12 clinical case scenarios of varying bone loss that may be encountered in clinical practice. Results A total of 150 survey responses were returned. The age of the patient and quantity of bone loss were consistently considered important prognostic criteria. However, little consensus was reached for critical thresholds of bone loss and how this affected the timing (ie, primary or revision surgery) and type of bony augmentation procedure to be performed once a critical threshold was reached, especially in the context of critical humeral and bipolar bone loss. Conclusions Consistent trends were found for the management of recurrent anterior shoulder instability in cases in which no bone loss existed and when isolated critical glenoid bone loss was present. However, inconsistencies were observed when isolated critical humeral bone loss and bipolar bone loss were present.
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Affiliation(s)
- Aaron J Bois
- Section of Orthopaedic Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - Michelle J Mayer
- Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - Stephen D Fening
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - Morgan H Jones
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Anthony Miniaci
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
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15
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Management of Recurrent Anterior Shoulder Instability After Surgical Stabilization in Children and Adolescents. Curr Rev Musculoskelet Med 2020; 13:164-172. [PMID: 32076937 DOI: 10.1007/s12178-020-09612-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW Recurrent shoulder instability after stabilization is common in pediatric and adolescent athletes. The purpose of this review is to understand the risk factors that lead to failure of primary surgery and management principles in the setting of recurrent instability following surgical stabilization. RECENT FINDINGS Rates of recurrence after primary and revision surgical stabilization remain higher than desirable. Risk factors for failure in include glenoid and humeral bone loss, capsular or ligamentous laxity, and young age though few studies have focused specifically on the adolescent population. Arthroscopic, open, and bone block techniques have been described in this population similar to adults. Failure after a primary shoulder stabilization remains a common problem in adolescents in no small part because a high proportion of these athletes return to high levels of activity. A thorough understanding of the index procedure and patient-specific risk factors for failure are key to successful planning of revision surgery. The current literature does not allow for firm treatment recommendations in individual pediatric or adolescent athletes, but the guiding principles are similar to those in adults. Specifically, all bony and soft tissue pathology should be identified and assessed, with an understanding that simply repeating the steps of the index procedure typically results in poor outcomes, and often an "escalation" of surgical complexity is required at the time of revision. When appropriately indicated, arthroscopic or open soft tissue procedures and Latarjet coracoid transfer can be safely and successfully implemented for revision shoulder stabilization in young athletes.
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Verweij LP, van Deurzen DF, Kerkhoffs GM, van den Bekerom MP. A Clinical Comparison of Linear- and Surface Area-Based Methods of Measuring Glenoid Bone Loss: Letter to the Editor. Am J Sports Med 2019; 47:NP28-NP29. [PMID: 30870028 PMCID: PMC6587360 DOI: 10.1177/0363546519825635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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17
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Magnetic resonance imaging predictors of shoulder instability in adolescents. Pediatr Radiol 2019; 49:365-371. [PMID: 30564903 DOI: 10.1007/s00247-018-4318-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 09/18/2018] [Accepted: 11/30/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Managing recurrent shoulder instability in an athlete of any age is challenging. The pediatric literature regarding recurrence of instability is difficult to interpret because of the variable treatment protocols and varying ages. The adult literature suggests that bone loss on the humerus, glenoid or both, as detected by CT, has high rates of recurrence following surgical intervention. OBJECTIVE The purpose of this study was to evaluate risk factors for recurrence following arthroscopic capsulorrhaphy in adolescent athletes using preoperative MR arthrograms. MATERIALS AND METHODS We reviewed a retrospective shoulder instability database for adolescents (age ≤18 years), who underwent an isolated arthroscopic capsulorrhaphy from 2006 to 2011. We recorded preoperative MRI measurements regarding the dimensions of the glenohumeral joint, as well as glenoid, humeral and labral pathologies. We performed statistical analysis to determine MRI findings that might have predicted recurrence of shoulder instability following capsulorrhaphy. RESULTS We reviewed a total of 50 patients (13-18 years) and found 22 patients (44%) to have recurrent instability following capsulorrhaphy. Presence of glenoid bone loss or a bipolar bone lesion (defined as bone loss on both the glenoid and humerus) significantly predicted recurrence of shoulder instability (both P=0.03). There was not a threshold size of glenoid bone loss or bipolar lesion that predicted recurrence. All remaining glenohumeral dimensions or presence or size of an isolated Hill-Sachs did not significantly predict recurrence of instability. CONCLUSION Athletes ≤18 years old have a high rate of failure following arthroscopic capsulorrhaphy in the presence of glenoid bone loss or a bipolar lesion on MRI. Surgeons should consider addressing these lesions in adolescent athletes with shoulder instability. Additionally, MRI is a valid imaging tool to diagnose and measure osseous lesions of the shoulder.
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Lee SH, Lim KH, Kim JW. Risk Factors for Recurrence of Anterior-Inferior Instability of the Shoulder After Arthroscopic Bankart Repair in Patients Younger Than 30 Years. Arthroscopy 2018; 34:2530-2536. [PMID: 30173793 DOI: 10.1016/j.arthro.2018.03.032] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 03/17/2018] [Accepted: 03/19/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To identify the risk factors for recurrent instability after arthroscopic Bankart repair and evaluate the recurrence rate and functional outcomes. METHODS A retrospective review was performed of patients with anterior-inferior shoulder instability who underwent arthroscopic Bankart repair between 2008 and 2014. Patients below 30 years of age who were available for follow-up at least for 2 years were sorted into 2 groups according to the presence of recurrent instability. Furthermore, statistical analysis by binary logistic regression analysis included the significance of various risk factors including gender, demographic factors, number of preoperative dislocations, time interval between the first dislocation and the surgery (shorter than 6 months or not), generalized hyperlaxity, concomitant injury, bony Bankart, and off-track lesion. The functional outcomes were assessed with the Rowe and Walch-Duplay scores. RESULTS A total of 170 shoulders were included (without-recurrence group: 138, recurrent group: 32). The overall postoperative recurrent instability rate was 18.8%. SLAP repair, interval closure, and capsular plication were performed when necessary. However, these additional procedures were not influenced by recurrence (P = .37). The 2 groups showed significant differences in the number of preoperative dislocations (P = .048; adjusted odds ratio [OR] 2-5 times, 6.41; more than 5 times, 8.77), time interval between the first dislocation and surgery (P = .003, adjusted OR 5.62), and off-track Hill-Sachs lesion (P = .04, adjusted OR 4.31). There was significant improvement in the mean Rowe and Walch-Duplay scores at 2 years postoperatively (P < .001 in both cases), but the mean scores were lower in the group with recurrence than in the group without (P = .021 and .014, respectively). CONCLUSIONS The overall results suggest that surgery within 6 months of the first dislocation should be considered, with meticulous attention in patients with a high number of preoperative dislocations or off-track Hill-Sachs lesions. LEVEL OF EVIDENCE Level III, retrospective case-control study.
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Affiliation(s)
- Sung Hyun Lee
- Department of Orthopedic Surgery, Wonkwang University Hospital, Iksan, Republic of Korea
| | - Kyeong Hoon Lim
- Department of Orthopedic Surgery, Wonkwang University Hospital, Iksan, Republic of Korea
| | - Jeong Woo Kim
- Department of Orthopedic Surgery, Wonkwang University Hospital, Iksan, Republic of Korea.
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Burkhart SS. Editorial Commentary: Off-Track Hill-Sachs Lesions in Adolescents With Multiple Anterior Dislocations: The Case for Stabilizing Adolescent First-Time Dislocators. Arthroscopy 2017; 33:1762-1763. [PMID: 28969811 DOI: 10.1016/j.arthro.2017.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 06/03/2017] [Indexed: 02/02/2023]
Abstract
Recurrent anterior dislocations in adolescents reveal a high rate of off-track Hill-Sachs lesions, much higher than in adults. This new information makes a strong case in favor of arthroscopic Bankart repair for adolescents with a first-time anterior dislocation of the shoulder.
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