Onlay Dynamic Anterior Stabilization With Biceps Transfer for the Treatment of Anterior Glenohumeral Instability Produces Good Clinical Outcomes and Successful Healing at a Minimum 1 Year of Follow-Up

Long head of biceps as an anterior dynamic sling for recurrent anterior shoulder dislocation

PURPOSE

To evaluate the functional outcomes of arthroscopic onlay dynamic anterior stabilization (DAS) using the long head of the biceps (LHB) tendon for treatment of anterior glenohumeral instability (AGI) with limited to subcritical glenoid bone loss (GBL).

METHODS

Twenty-five patients underwent arthroscopic DAS using LHB tendon between March 2022 and October 2022 for treatment of anterior glenohumeral instability (AGI) with limited to subcritical glenoid bone loss (GBL) were included in a prospective study with a minimum follow-up period of 2 years. The shoulder functional outcomes were assessed using the Rowe and the Quick Disabilities of Arm, Shoulder and Hand (Quick DASH) scores both preoperative and at 2 years follow-up. Magnetic resonance imaging (MRI) was done 6 months after surgery to evaluate LHB tendon healing to the anterior glenoid.

RESULTS

The study included 25 patients complaining of recurrent AGI. Twenty-one patients were males and four patients were females. The mean age of the patients at surgery was 22.75 ± 3.24 years. The mean duration between the first shoulder dislocation episode and surgery was 5.5 ± 2.13 months. The right shoulder was injured in 15 patients while the left shoulder was involved in 10 patients. The mean follow-up period was 24.25 ± 0.82 months. DAS using the long head of the biceps tendon resulted in a statistically significant improvement of the mean Rowe and the Quick DASH scores between preoperative and 2 years postoperative. Recurrent dislocation was reported in two (8%) patients during the follow-up period.

CONCLUSION

Arthroscopic onlay dynamic anterior stabilization using the long head of the biceps tendon is a safe and effective method for the treatment of recurrent anterior shoulder instability with GBL up to 25%.

LEVEL OF EVIDENCE

Level IV, case series study.

Inlay Dynamic Anterior Stabilization With the Long Head of the Biceps Tendon and Remplissage Procedure for Patients With Subcritical Glenoid Bone Loss and On-Track Hill-Sachs Lesion

Augmented Bankart with dynamic anterior stabilization (DAS) using the long head of the biceps tendon (LHBT) aims to address anteroinferior glenohumeral instability but does not specifically target Hill-Sachs lesions. The remplissage technique, "filling" the Hill-Sachs lesion, is popular for off-track lesions. The proposed combined approach seeks to stabilize the humeral head without sacrificing the coracoid, making it suitable for high-risk patients prone to recurrent shoulder instability, such as patients with subcritical glenoid bone loss. The operative technique includes patient preparation, creation of arthroscopic portals, confirmation of glenoid bone loss and other injuries, LHBT preparation and tenodesis to the anterior glenoid, and completion of the remplissage procedure. Postoperative protocols involve wearing a sling, self-mobilization, and gradual return to sports. The method aims to improve stability and outcomes in patients with complex shoulder instability issues. The DAS and remplissage is a rational choice for high-demand patients with subcritical glenoid bone loss and on-track Hill-Sachs lesions because it may provide better stability than isolated Bankart repair or Bankart plus remplissage procedures.

Dynamic anterior stabilization of the shoulder using buttons

Background

Surgical procedures to treat anterior shoulder instability are essentially divided into those for significant bone loss and those without relevant bone loss. However, there is a gray area between these procedures that would not require bone grafting but would benefit from improved stabilization mechanisms. This study evaluates a technique based on the triple soft tissue block, the dynamic anterior stabilization of the shoulder, using an adjustable button.

Methods

Twenty patients that underwent surgical procedure from September 2017 to March 2022 were prospectively evaluated. All were assessed with University of California-Los Angeles, American Shoulder and Elbow Surgeons scores, and measurement of external rotation of the shoulder before and 24 or more months after surgery, and the Rowe score at least 24 months postsurgery. The Rowe score was compared to the standard of 90, bone loss was also measured.

Results

The mean University of California-Los Angeles score changed from 25.60 ± 2.83 before surgery to 34.60 ± 0.82 postsurgery P < .01; American Shoulder and Elbow Surgeons from 84.99 ± 8.94 before surgery to 97.34 ± 4.39 postsurgery P < .01; Rowe with an average of 98.00 ± 2.99 compared to the standard 90 of excellent results P < .01. The average loss of lateral rotation was 2.25° ± 2.55 (0°-5°), and the average bone loss in patients was 8% ± 2.48% (0%-20%).

Conclusion

The proposed procedure demonstrated safety and effectiveness in treating recurrent anterior glenohumeral instability.

Anterior Labrum Periosteal Sleeve Avulsion Lesions of the Shoulder: A Scoping Review

Background

Anterior labrum periosteal sleeve avulsion (ALPSA) lesion of the shoulder is defined as a labral avulsion with an intact periosteum of the glenoid neck resulting in medial malattachment of the labrum, which is both nonanatomic and nonfunctional. It is relatively rare compared with Bankart lesions, and its results are usually reported in combination with other anterior labroligamentous lesions in the literature.

Purpose

To (1) assess the size and scope of the literature on ALPSA lesions, (2) highlight the importance of this lesion, and (3) distinguish between ALPSA and Bankart lesions in diagnostic and treatment strategies.

Study Design

Scoping review; Level of evidence, 4.

Methods

The PubMed, Scopus, Embase, and Google Scholar databases were searched with the keywords "ALPSA,""anterior labrum periosteal sleeve avulsion,""anterior labral periosteal sleeve avulsion," and "anterior labroligamentous periosteal sleeve avulsion" lesion. Duplicate articles and those that did not meet the inclusion criteria were excluded, resulting in the identification of 42 relevant articles. Their references were analyzed for further data curation.

Results

This scoping review demonstrated that ALPSA lesions are difficult to clinically identify. Magnetic resonance angiography in the adduction internal rotation position is the most sensitive and specific imaging modality for identification. Optimal views are the anterosuperior portal for accurate identification and the anteroinferior portal for surgical repair during arthroscopy. Treatment begins with correctly identifying the labrum, in contradistinction to dense reactive fibrous tissue, and reattaching the labrum to the correct anatomic glenoid footprint. Chronic lesions with bone loss require either bone block or soft tissue augmentation procedures.

Conclusion

There is paucity of exclusive literature on ALPSA lesions. It is important to distinguish this lesion from the Bankart lesion as it is associated with worse outcomes. The higher failure rates of ALPSA lesion repair indicate that the current repair techniques require further refinement to improve the outcomes to the standard of Bankart lesions.

Editorial Commentary: For Patients With Shoulder Instability, On-Track Hill-Sachs Lesion Plus Subcritical Glenoid Bone Loss May Be the Best Indication for Dynamic Anterior Stabilization Using the Long Head of the Biceps Tendon

As the definition of shoulder glenoid critical bone loss has evolved and decreased from 25% to 17% to 13.5%, indications for bone block procedures for shoulder instability with glenoid bone loss have expanded. While the bone block procedure is an effective treatment for almost all cases of anterior shoulder instability, regardless of the amount of bone loss, many surgeons prefer to perform a bone block procedure only in cases of critical bone loss due to risk of complications. Thus, for cases of minimal (subcritical) bone loss, Remplissage has been recommended to enhance Bankart repair. As an alternative, dynamic anterior stabilization (DAS) using the long head of the biceps tendon has been recommended as a surgical option in patients with shoulder instability and subcritical bone loss. How do we decide? A biomechanical study shows DAS is an effective method for on-track Hill-Sachs lesions with subcritical bone loss, and Remplissage is more effective for off-track Hill-Sachs lesions. Clinical studies are required to complement biomechanical findings.

Biceps tendon autograft augmentation for rotator cuff and instability procedures: a narrative review

Rotator cuff tears (RCT) and instability are the most common surgically treated shoulder pathologies. The concept of augmentation using the long head of the biceps tendon (LHBT) autograft was created to improve the results of surgical treatment of these pathologies, especially in cases of chronic and massive injuries. The popularity of using the LHBT for augmentation is evidenced by the significant number of publications on this topic published in the last 3 years; however, only one systematic review has been published regarding only LHBT augmentation for massive RCTs. Several studies comparing partial repair with partial repair and additional LHBT augmentation for RCT showed superior clinical outcomes and lower re-tear rates when LHBT augmentation was performed. There is a rising popularity of using LHBT as an autograft to perform superior capsule reconstruction (SCR) in case of irreparable rotator cuff tears. In recent years, shoulder stabilization by arthroscopic Bankart repair with biceps augmentation has been promoted with very promising short-term results. The evidence provided by studies appears to be sufficient to recommend the use of LHBT for augmentation whenever necessary; however, larger studies with long-term follow-up are needed.

Long head of the biceps tendon versatility in reconstructive shoulder surgery: a narrative review of arthroscopic techniques and their biomechanical principles with video presentation

The management of the long head of the biceps tendon (LHBT) during shoulder arthroscopy has been a subject of controversy for many years, with evolving discussions and trends. Despite long-standing debate, the nature of the surgical indication regarding how to treat concomitent LHBT injuries has undergone changes in recent years. It now extends beyond the timing of tenotomy to encompass considerations of alternative methods for preserving the LHBT, along with an ongoing exploration of how it can be effectively utilized in reconstructive shoulder surgery. Recent techniques describe approaches to using LHBT in a wide range of procedures, from shoulder instability to rotator cuff tears. Additionally, LHBT-based reconstructive techniques have surfaced for addressing what were formerly denoted as irreparable rotator cuff tears. While current literature provides detailed anatomical descriptions of the LHBT and many reports of novel, advanced techniques, there is still much debate regarding the decision-making process in each case. Because of the growing number of emerging techniques and the escalating debate in the subsequent paper, a decision has been made to present the current literature review concerning the potential utilization of LHBT in shoulder arthroscopy. In a dedicated video, we demonstrate the main arthroscopic techniques employed by the authors in their daily practice.

Biomechanical comparison of open Bankart repair vs. conjoint tendon transfer in a 10% anterior glenoid bone loss shoulder instability model

BACKGROUND

The treatment of shoulder instability in patients with subcritical glenoid bone loss poses a difficult problem for surgeons as new evidence supports a higher failure rate when a standard arthroscopic Bankart repair is used. The purpose of this study was to compare a conjoint tendon transfer (soft-tissue Bristow) to an open Bankart repair in a cadaveric instability model of 10% glenoid bone loss.

METHODS

Eight cadaveric shoulders were tested using a custom testing system that allows for a 6-degree-of-freedom positioning of the glenohumeral joint. The rotator cuff muscles were loaded to simulate physiologic muscle conditions. Four conditions were tested: (1) intact, (2) Bankart lesion with 10% bone loss, (3) conjoint tendon transfer, and (4) open Bankart repair. Range of motion, glenohumeral kinematics, and anterior-inferior translation at 60° of external rotation with 20 N, 30 N, and 40 N were measured in the scapular and coronal planes. Glenohumeral joint translational stiffness was calculated as the linear fit of the translational force-displacement curve. Force to anterior-inferior dislocation was also measured in the coronal plane. Repeated measures analysis of variance with a Bonferroni correction was used for statistical analysis.

RESULTS

A Bankart lesion with 10% bone loss increased the range of motion in both the scapular (P = .001) and coronal planes (P = .001). The conjoint tendon transfer had a minimal effect on the range of motion (vs. intact P = .019, .002), but the Bankart repair decreased the range of motion to intact (P = .9, .4). There was a significant decrease in glenohumeral joint translational stiffness for the Bankart lesion compared with intact in the coronal plane (P = .021). The conjoint tendon transfer significantly increased stiffness in the scapular plane (P = .034), and the Bankart repair increased stiffness in the coronal plane (P = .037) compared with the Bankart lesion. The conjoint tendon transfer shifted the humeral head posteriorly at 60° and 90° of external rotation in the scapular plane. The Bankart repair shifted the head posteriorly in maximum external rotation in the coronal plane. There was no significant difference in force to dislocation between the Bankart repair (75.8 ± 6.6 N) and the conjoint tendon transfer (66.5 ± 4.4 N) (P = .151).

CONCLUSION

In the setting of subcritical bone loss, both the open Bankart repair and conjoint tendon transfer are biomechanically viable options for the treatment of anterior shoulder instability; further studies are needed to extrapolate these data to the clinical setting.

Dynamic Anterior Stabilization with Hill-Sachs Remplissage Can be Employed in Skeletally Immature Patients-Operative Technique

BACKGROUND

Numerous studies indicate that glenoid bony augmentation raises the risk of complications during and after surgery. On the other hand, repairing the labrum alone in cases with subcritical glenoid bone loss results in recurrent instability and persistent apprehension. As a result, recent advancements in shoulder instability surgery prioritize fully restoring the anterior shoulder restraint.

OPERATIVE TECHNIQUE

A novel method for treating recurrent anterior shoulder instability with subcritical glenoid bone loss and off-track Hill-Sachs lesion in skeletally immature patients is suggested: the use of dynamic anterior stabilization technique incorporating the long head of the biceps tendon onto the anterior glenoid rim via trans-subscapular transfer, in conjunction with Hill-Sachs remplissage. A practical, step-by-step surgical technique for a complete reconstruction of the anterior capsule-labral-ligamentous complex is provided. This involves utilizing a soft-tissue dynamic anterior sling, achieved through the trans-subscapularis transfer of the long head of the biceps tendon at the glenoid level. The procedure concludes with a Hill-Sachs remplissage to further prevent off-track events and alleviate apprehension.

CONCLUSION

Dynamic anterior stabilization is a suitable approach for addressing recurring anterior shoulder instability in skeletally immature patients who have subcritical glenoid bone loss and bipolar bone lesions.

Traumatic Anterior Shoulder Instability: A Systematic Review and Proposed Modern Classification System

Numerous surgical techniques have been developed to address recurrent anterior shoulder instability, with the Bankart repair and the Latarjet procedure emerging as dominant. With recent advancements in keyhole surgery, there's been a surge in popularity for all-arthroscopic procedures. Our systematic review aims to determine if there's justification for incorporating these techniques into a classification system for guiding treatment of traumatic anterior recurrent instability. We identified and analysed a variety of key studies, including 12 systematic reviews, three prospective studies, seven non-randomized prospective and retrospective studies, along with one biomechanical study. Our study sheds light on the wide range of procedures available to shoulder surgeons dealing with traumatic anterior recurrent instability. We introduce a novel classification system (BoTH) designed to simplify the decision-making process in this context.

Dynamic Anterior Stabilization of the Shoulder: Onlay Biceps Transfer to the Anterior Glenoid Using the Double Double-Pulley Technique

The treatment of anterior glenohumeral instability includes several surgical options, ranging from soft tissue to bony procedures-open or arthroscopic. In arthroscopic dynamic anterior stabilization (DAS) of the shoulder, the long head of the biceps is transferred to the anterior glenoid through a subscapularis tendon split. The biceps may be fixed either in an inlay or in an onlay position. Inlay DAS theoretically increases anterior glenohumeral stability through 3 different effects: the hammock effect, sling effect, and the tensioning effect. Onlay DAS may additionally increase stability through a labroplasty effect, produced by the onlay positioning of the biceps on the anterior glenoid rim. The current technical note presents tips and tricks, and pearls and pitfalls, to reproducibly perform onlay DAS using all-suture anchors and the double double-pulley technique.