Arthroscopic rotator interval closure in shoulder instability repair: a retrospective study

Editorial Commentary: Anterior Shoulder Stabilization Combining Arthroscopic Bankart and Inferior Capsular Shift Avoids Open Surgery in Athletes Without Critical Glenoid Bone Loss

Traumatic anterior shoulder dislocations can cause a myriad of injuries, each with their own unique set of challenges with respect to surgical management. The debate of whether open or arthroscopic management is the superior approach is one that predates most currently practicing orthopaedic surgeons yet remains one of the most actively researched areas of orthopaedics. Current trends favor arthroscopic management for anterior instability secondary to a Bankart lesion in patients without other risk factors for instability, such as critical glenoid bone loss. However, excellent results are not guaranteed following arthroscopic Bankart repair, particularly in athletes, due to high rates of recurrence. While the technique of inferior to superior capsular shift is not new, transitioning a historically open technique to the arthroscopic world may represent another tool in the glenohumeral instability management toolbox. While perspectives are evolving, more evidence supporting arthroscopic techniques like the capsular shift are needed to better identify appropriate patient populations.

Pediatric Shoulder Arthroscopy Case Volume Is Uniformly Low for Graduating Orthopaedic Residents

Purpose

To evaluate shoulder arthroscopy case volume for graduating United States orthopaedic surgery residents.

Methods

We used the Accreditation Council for Graduate Medical Education case log records to evaluate reports from academic years 2016 to 2020. Logs were queried for pediatric, adult, and total (pediatric and adult) cases. The 10th, 30th, 50th, and 90th percentiles of case volumes from 2016 to 2020 were presented to demonstrate case volume variability.

Results

There was a significant increase in the average number of total (70.7 ± 35 vs 81.8 ± 45; P < .001), adult (69 ± 34 vs 79.7 ± 44; P < .001), and pediatric (1.8 ± 2 vs 2.2 ± 3; P = .003) shoulder arthroscopy cases performed by orthopaedic surgery residents between the academic year 2016 and 2020. Residents were involved in more than 36 times the number of adult cases compared with pediatric cases in 2020 (79.7 ± 44 vs 2.2 ± 3; P < .001). The 90th percentile of residents performed 6 pediatric cases in 2020, compared with zero cases in the 30th percentile and lower.

Conclusions

Approximately one-third of orthopedic surgery residents graduate without having performed a pediatric shoulder arthroscopy.

Clinical Relevance

The findings from this study could help guide the revision of current Accreditation Council for Graduate Medical Education guidelines for orthopaedic surgery residents.

Management of Shoulder Instability in Patients with Underlying Hyperlaxity

PURPOSE OF REVIEW

Shoulder instability in patients with underlying joint hyperlaxity can be challenging to treat. Poorly defined terminology, heterogeneous treatments, and sparse reports on clinical outcomes impair the development of best practices in this patient population. This article provides a review of the current literature regarding optimal management of patients suffering from shoulder instability with concomitant hyperlaxity of the shoulder, from isolated shoulder joint hyperlaxity to congenital hypermobility spectrum disorders (HSD).

RECENT FINDINGS

Current research shows specialized physiotherapy protocols focused on strengthening of periscapular muscles and improvement of sensorimotor control are a promising non-surgical therapeutic avenue in certain patients, which can be augmented by device-based intervention in select cases. If surgical treatment is warranted, arthroscopic techniques such as pancapsular shift or plication continue to demonstrate favorable outcomes and are currently considered the benchmark for success. The long-term success of more recent innovations such as coracoid process transfers, conjoint tendon transfers, subscapularis tendon augmentation, and capsular reconstruction remains unproven. For patients affected by connective tissue disorders, treatment success is generally less predictable, and the entire array of non-operative and operative interventions needs to be considered to achieve the best patient-specific treatment results. In the treatment of shoulder instability and concomitant hyperlaxity, specialized physiotherapy protocols augmented by device-based interventions have emerged as powerful, non-operative treatment options for select patients. Successful surgical approaches have been demonstrated to comprehensively address capsular redundancy, labral lesions, and incompetence of additional passive stabilizers in a patient-specific fashion, respective of the underlying connective tissue constitution.

Inconsistencies in Controlling for Risk Factors for Recurrent Shoulder Instability After Primary Arthroscopic Bankart Repair: A Systematic Review

BACKGROUND

Failure rates after arthroscopic shoulder stabilization are highly variable in the current orthopaedic literature. Predictive factors for risk of failure have been studied to improve patient selection, refine surgical techniques, and define the role of bony procedures. However, significant heterogeneity in the analysis and controlling of risk factors makes evidence-based management decisions challenging.

PURPOSE

The goals of this systematic review were (1) to critically assess the consistency of reported risk factors for recurrent instability after arthroscopic Bankart repair, (2) to identify the existing studies with the most comprehensive inclusion of confounding factors in their analyses, and (3) to give recommendations for which factors should be reported consistently in future clinical studies.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of the literature was performed in accordance with the PRISMA guidelines. An initial search yielded 1754 titles, from which 56 full-text articles were screened for inclusion. A total of 29 full-text articles met the following inclusion criteria: (1) clinical studies regarding recurrent anterior shoulder instability; (2) surgical procedures performed including arthroscopic anterior labral repair; (3) reported clinical outcome data including failure rate; and (4) assessment of risk factors for surgical failure. Further subanalyses were performed for 15 studies that included a multivariate analysis, 17 studies that included glenoid bone loss, and 8 studies that analyzed the Instability Severity Index Score.

RESULTS

After full-text review, 12 of the most commonly studied risk factors were identified and included in this review. The risk factors that were most consistently significant in multivariate analyses were off-track lesions (100%), glenoid bone loss (78%), Instability Severity Index Score (75%), level of sports participation (67%), number of anchors (67%), and younger age (63%). In studies of bone loss, statistical significance was more likely to be found using advanced imaging, with critical bone loss thresholds of 10% to 15%. Several studies found predictive thresholds of 2 to 4 for Instability Severity Index Score by receiver operating characteristic or multivariate analysis.

CONCLUSION

Studies reporting risk factors for failure of arthroscopic Bankart repair often fail to control for known confounding variables. The factors with the most common statistical significance among 15 multivariate analyses are off-track lesions, glenoid bone loss, Instability Severity Index Score, level of sports participation, number of anchors, and younger age. Studies found significance more commonly with advanced imaging measurements or arthroscopic assessment of glenoid bone loss and with lower thresholds for the Instability Severity Index Score (2-4). Future studies should attempt to control for all relevant factors, use advanced imaging for glenoid bone loss measurements, and consider a lower predictive threshold for the Instability Severity Index Score.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

III.

High Variability of the Definition of Recurrent Glenohumeral Instability: An Analysis of the Current Literature by a Systematic Review

Purpose

To determine the definitions for recurrence used in the literature, assess the consensus in using these definitions, and determine the impact of these definitions on recurrence rates.

Methods

A literature search was performed in PubMed and EMBASE including studies from 2000 to 2020 reporting on recurrence rates after anterior arthroscopic shoulder instability surgery. Dislocation, apprehension, subluxation and recurrence rates were compared.

Results

Ninety-one studies were included. In 68% of the eligible studies, recurrence rates are not well defined. Thirty (33%) studies did not report on dislocations, 45 (49%) did not report on subluxations, and 58 (64%) did not report on apprehension. Seventeen different definitions for recurrence of instability, 4 definitions of dislocations, and 8 definitions of subluxation were used.

Conclusion

Recurrence rates are poorly specified and likely underreported in the literature, hampering comparison with results of other studies. This highlights the need for a consensus on definition of recurrence across shoulder instability studies. We recommend not using the definition recurrence of instability anymore. We endorse defining dislocations as a radiographically confirmed dislocation or a dislocation that is manually reduced, subluxations as the feeling of a dislocation that can be (spontaneously) reduced without the need for a radiographically confirmed dislocation, and a positive apprehension sign as fear of imminent dislocation when placing the arm in abduction and external rotation during physical examination. Reporting on the events resulting in a dislocation or subluxation aids in making an estimation of the severity of instability.

Level of Evidence

Level IV, systematic review.

A Multicenter Retrospective Study With a Minimum 5-Year Follow-up Comparing Arthroscopic Bankart Repair and the Latarjet Procedure

Background:

Arthroscopic Bankart repair (ABR) and the Latarjet procedure are surgical techniques commonly used to treat anterior shoulder instability. There is no consensus among shoulder surgeons regarding the indications for choosing one over the other.

Purpose:

To compare the results of the Latarjet procedure with those of ABR for the treatment of anterior shoulder instability.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Data on all patients who were treated surgically for recurrent anterior shoulder instability between 2006 and 2011 were retrospectively collected at 4 medical centers. The minimum follow-up was 5 years. Data were retrieved from medical charts, and patients were interviewed to assess their level of satisfaction (range, 0-100), functional outcomes (using the American Shoulder and Elbow Surgeons shoulder score; the Subjective Shoulder Value; and the Disabilities of the Arm, Shoulder and Hand score), and quality of life (using the 12-Item Short Form Health Survey [SF-12]). Information on return to sports activities and postoperative level of activity compared with that of the preinjury state, complications, reoperations, and recurrent instability were recorded and evaluated.

Results:

A total of 242 patients were included. The Latarjet procedure was performed in 27 shoulders, and ABR was performed in 215 shoulders. Patients in the ABR group had significantly higher rates of redislocation (18.5%; P = .05) and subluxation (21.4%; P = .43) but a lower rate of self-reported apprehension (43.0%; P = .05) compared with patients in the Latarjet group (3.7%, 14.8%, and 63.0%, respectively). There were 5 patients in the ABR group who underwent reoperation with the Latarjet procedure because of recurrent instability. The functional scores in the Latarjet group were better than those in the ABR group. The SF-12 physical score was significantly better in the Latarjet group than in the ABR group (98.1 vs 93.9, respectively; P = .01). Patient satisfaction and subjective scores were similar in both groups.

Conclusion:

These results support recently published data on the Latarjet procedure that showed its superiority over ABR in midterm stability (dislocations or subluxations). The contribution of self-reported apprehension to the broad definition of stability is not clear, and apprehension rates were not correlated with satisfaction scores or the recurrence of dislocation or subluxation.

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

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

Variability of Reporting Recurrence After Arthroscopic Bankart Repair: A Call for a Standardized Study Design

Background

High recurrence rates have been reported after anterior shoulder dislocations, regardless of the treatment utilized. However, the definition of recurrent instability has been inconsistent, making a comparison between studies difficult.

Purpose

To report on the nature with which the rate of recurrent instability is reported after arthroscopic Bankart repair, across all levels of evidence, and to analyze factors that may affect the reported rate of recurrence.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic review of the literature was performed by searching PubMed, the Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov for studies published within the dates of January 2008 and September 2018. Studies in English that reported on the recurrence of instability after arthroscopic Bankart repair for anterior shoulder instability were considered for inclusion in this review. A meta-regression was performed to test for a linear association between the reported recurrence rate and several continuous covariates, including mean age at surgery, mean length of follow-up, attrition rate (loss to follow-up percentage), and percentage of male patients.

Results

A trim-and-fill meta-analysis yielded an estimated overall recurrence rate of 17.4% (95% CI, 14.3%-20.9%). There was a significant difference in the recurrence rate depending on the level of evidence (Q(3) = 10.98; P = .012). Significant associations were found with the recurrence rate through the meta-regression, including a negative association with mean age (P = .009), a positive association with mean follow-up time (P = .002), and a positive association with attrition rate (P = .035).

Conclusion

A call for standardization is necessary for reporting outcomes of anterior instability after arthroscopic Bankart repair, especially with regard to the reporting of recurrence/failure rates, with careful consideration of the effects that may occur from patient demographics and study design. With no current recommendations for deeming failure, we suggest that all forms of instability be accounted for when determining a failed treatment procedure, with future studies placing an emphasis on greater control of the study design.

Evaluation of the Instability Severity Index score in predicting failure following arthroscopic Bankart surgery in an active military population

BACKGROUND

The Instability Severity Index (ISI) score is a preoperative risk stratification tool used to identify patients at heightened risk of recurrent anterior instability after an arthroscopic Bankart procedure. The primary objective of this study was to validate the utility of the ISI score in predicting failure of primary arthroscopic Bankart surgery in an active-duty military population.

METHODS

A retrospective study was performed to compare all military service members undergoing primary arthroscopic Bankart repairs at a single military treatment facility between 2007 and 2014. The primary outcome of interest was surgical failure due to recurrent instability. The ISI framework was used to stratify each patient for recurrence, and multivariate analysis was performed to evaluate the composite ISI score and individual domains between patients with and patients without failed Bankart repairs.

RESULTS

A total of 131 patients were identified, with a mean patient age of 26.8 years (range, 19-47 years), among whom 42 patients (32%) were identified as having a higher-demand military occupation. At a minimum 2-year follow-up, 34 patients (26%) sustained recurrent anterior shoulder instability. The mean ISI score of patients in the failed Bankart repair group was not statistically different than that of patients with a successful repair (3.41 vs 3.5, P = .74), and no individual ISI domains were identified as independent risk factors for subsequent surgical failure or revision stabilization.

CONCLUSION

Contrary to the findings of previous validation studies, the composite ISI score and its individual risk factors were not predictive of subsequent surgical failure after primary arthroscopic Bankart repair in an active military population.

Outcomes After Arthroscopic Rotator Interval Closure for Shoulder Instability: A Systematic Review

PURPOSE

(1) To systematically assess the clinical outcomes of arthroscopic rotator interval closure (RIC) procedures for shoulder instability and (2) to report the different technical descriptions and surgical indications for this procedure.

METHODS

Two independent reviewers searched 4 databases (PubMed, Embase, Web of Science, and Cochrane) from database inception until October 15, 2017. The inclusion criteria were studies that reported outcomes of shoulder stabilization using arthroscopic RIC as an isolated or adjunctive surgical procedure. The methodologic quality of studies was assessed with the Methodological Index for Non-Randomized Studies tool and Grading of Recommendations Assessment, Development and Evaluation system for randomized controlled trials.

RESULTS

Fifteen studies met our search criteria (524 patients). Of the studies, 12 were graded Level IV evidence; 2, Level III; and 1, Level II. Six different RIC technique descriptions were reported, with 2 studies not defining the details of the procedure. The most common method of RIC was arthroscopic plication of the superior glenohumeral ligament to the middle glenohumeral ligament (8 of 15 studies). The most commonly used patient-reported outcome measure was the Rowe score, with all studies reporting a minimum postoperative score of 80 points. The rate of return to preinjury level of sport ranged from 22% to 100%, and the postoperative redislocation rate ranged from 0% to 16%.

CONCLUSIONS

The indications for RIC were poorly reported, and the surgical techniques were inconsistent. Although most studies reported positive clinical results, the heterogeneity of outcome measures limited our ability to make definitive statements about which types of rotator interval capsular closure are warranted for select subgroups undergoing arthroscopic shoulder stabilization.

LEVEL OF EVIDENCE

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

Glenohumeral Instability Related to Special Conditions: SLAP Tears, Pan-labral Tears, and Multidirectional Instability

Glenohumeral instability is one of the more common conditions seen by sports medicine physicians, especially in young, active athletes. The associated anatomy of the glenohumeral joint (the shallow nature of the glenoid and the increased motion it allows) make the shoulder more prone to instability events as compared with other joints. Although traumatic dislocations or instability events associated with acute labral tears (ie, Bankart lesions) are well described in the literature, there exists other special shoulder conditions that are also associated with shoulder instability: superior labrum anterior/posterior (SLAP) tears, pan-labral tears, and multidirectional instability. SLAP tears can be difficult to diagnose and arthroscopic diagnosis remains the gold standard. Surgical treatment as ranged from repair to biceps tenodesis with varying reports of success. Along the spectrum of SLAP tears, pan-labral tears consist of 360-degree injuries to the labrum. Patients can present complaining of either anterior or posterior instability alone, making the physical examination and advanced imaging a crucial component of the work up of the patients. Arthroscopic labral repair remains a good initial option for surgical treatment of these conditions. Multidirectional instability remains one of the more difficult conditions for the sports medicine physician to diagnose and treat. Symptoms may only be reported as vague pain versus frank instability making the diagnoses particularly challenging, especially in a patient with overall joint laxity. Conservative management to include physical therapy is the mainstay initial treatment in patients without an identifiable structural abnormality. Surgical management of this condition has evolved from open to arthroscopic capsular shifts with comparable results.

Return to Play Criteria Following Surgical Stabilization for Traumatic Anterior Shoulder Instability: A Systematic Review

PURPOSE

To identify and describe in the existing literature any criteria used for return to play following surgical stabilization for traumatic, anterior shoulder instability.

METHODS

We performed a systematic review evaluating surgical stabilization for primary traumatic anterior shoulder instability in skeletally mature patients with a minimum of 1-year follow-up using Level I to IV studies in PubMed and EMBASE from January 1994 to January 2017.

RESULTS

Fifty-eight studies with at least 1 explicitly stated criterion for return to play were identified from a review of more than 5,100 published articles. Seven different categories of return to play criteria were identified, the most common of which were time from surgery (89.6%), strength (18.9%), and range of motion (13.8%). Pain, stability, proprioception, and postoperative radiographic evaluation were also used. As hypothesized, in 75.8% of the included studies (44/58), time was the only criterion explicitly used. The most commonly used time for return to play was 6 months.

CONCLUSIONS

This systematic review identifies 7 criteria that have been used in the available literature to determine when patients are ready to return to play; however, consistent with our hypothesis, 75% of studies used time from surgery as the sole listed criterion, with the most commonly used time point of 6 months postoperative. All of these criteria can be used in future research to develop a comprehensive checklist of functional criteria in hopes of reducing recurrent injury.

LEVEL OF EVIDENCE

Level IV, systematic review.

Recurrent Instability After Arthroscopic Bankart Reconstruction: A Systematic Review of Surgical Technical Factors

PURPOSE

Recurrent instability remains of concern after arthroscopic Bankart reconstruction. We evaluated various technical factors including anchor design, anchor material, number of anchors used, and interval closure on risk of recurrent instability after arthroscopic Bankart reconstruction.

METHODS

A systematic review of MEDLINE and Cochrane databases was conducted, following PRISMA guidelines. Extracted data were recorded on a standardized form. Methodological index for non-randomized studies (MINORS) and Newcastle-Ottawa Scale (NOS) were used to assess study quality and risk bias. Because of study heterogeneity and low levels of evidence, meta-analysis was not possible. Pooled weighted means were calculated and individual study evaluation and comparisons (qualitative analysis) were performed for systematic review.

RESULTS

Of 2097 studies identified, 26 met criteria for systematic review. Pooled weighted means revealed 11.4% versus 15% recurrent instability with 3 or more suture anchors versus fewer than 3 anchors, 10.1% versus 7.8% with absorbable versus nonabsorbable suture anchors, respectively, and 8.0% versus 9.4% with knotless versus standard anchors, respectively. Interval closure did not qualitatively decrease recurrent instability or decrease range of motion.

CONCLUSIONS

Our systematic review reveals that despite individual study, and previous systematic reviews pointing to the contrary, the composite contemporary published literature would support no difference in the risk of recurrent instability after arthroscopic Bankart reconstruction with rotator interval closure, differing numbers of anchors used for the repair, use of knotless versus standard anchors, or use of bioabsorbable versus nonabsorbable anchors. We recommend surgeons focus on factors that have been shown to modify the risk factors after arthroscopic Bankart reconstruction, such as patient selection.

LEVEL OF EVIDENCE

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

Recovery of Shoulder Rotational Muscle Strength After Arthroscopic Bankart Repair

Background:

Shoulder rotational muscles act as dynamic stabilizers of the glenohumeral joint, and the recovery of muscle strength plays an important role in stabilizing the joint during postoperative rehabilitation. However, temporal changes in muscle strength after arthroscopic Bankart repair have not been clarified.

Purpose:

To better understand the temporal recovery of shoulder rotational muscle strength after arthroscopic Bankart repair.

Study Design:

Case series; Level of evidence, 4.

Methods:

Isokinetic concentric shoulder rotational muscle strength was evaluated in 50 patients who were diagnosed with recurrent dislocations of the glenohumeral joint and treated with arthroscopic Bankart repair.

Results:

The mean peak torque/weight and total work were reduced significantly at 1.5 months after surgery (P < .0001) and returned to preoperative levels by 6 months for external rotation and 4.5 months for internal rotation. The contralateral peak torque ratios reached preoperative levels by 6 months after surgery. The ipsilateral peak torque ratios were reduced between 1.5 and 3 months after surgery and returned to preoperative levels at 6 months for external rotation and 4.5 months for internal rotation.

Conclusion:

Isokinetic shoulder rotational muscle strength after arthroscopic Bankart repair recovered to preoperative levels by 6 months for external rotation and 4.5 months for internal rotation.

Multidirectional Shoulder Instability: Treatment

Background:

The treatment of multidirectional instability of the shoulder is complex. The surgeon should have a clear understanding of the role of hiperlaxity, anatomical variations, muscle misbalance and possible traumatic incidents in each patient.

Methods:

A review of the relevant literature was performed including indexed journals in English and Spanish. The review was focused in both surgical and conservative management of multidirectional shoulder instability.

Results:

Most patients with multidirectional instability will be best served with a period of conservative management with physical therapy; this should focus in restoring strength and balance of the dynamic stabilizers of the shoulder. The presence of a significant traumatic incident, anatomic alterations and psychological problems are widely considered to be poor prognostic factors for conservative treatment. Patients who do not show a favorable response after 3 months of conservative treatment seem to get no benefit from further physical therapy.

When conservative treatment fails, a surgical intervention is warranted. Both open capsular shift and arthroscopic capsular plication are considered to be the treatment of choice in these patients and have similar outcomes. Thermal or laser capsuloraphy is no longer recommended.

Conclusion:

Multidirectional instability is a complex problem. Conservative management with focus on strengthening and balancing of the dynamic shoulder stabilizers is the first alternative. Some patients will fare poorly and require either open or arthroscopic capsular plication.

Single anterior portal: A better option for arthroscopic treatment of traumatic anterior shoulder instability?

Objective

The aim of this study was to compare single and double anterior portal techniques in the arthroscopic treatment of traumatic anterior shoulder instability.

Methods

A total of 91 cases who underwent arthroscopic Bankart repair for anterior shoulder instability were reviewed. The patients were divided into 2 groups as Group 1 (47 male and 2 female; mean age: 25.8 ± 6.8) for arthroscopic single anterior portal approach and Group 2 (41 male and 1 female; mean age: 25.4 ± 6.6) for the classical anterior double portal approach. The groups were compared for clinical scores, range of motion, analgesia requirement, complications, duration of surgery, cost and learning curve according to a short questionnaire completed by the relevant healthcare professionals.

Results

No statistically significant difference was found between the 2 groups in terms of pre-operative and post-operative Constant and Rowe Shoulder Scores, range of motion and complications (p > 0.05). In Group 2 patients, the requirement for post-operative analgesics was significantly higher (p < 0.001), whereas the duration of surgery was statistically significantly shorter in Group 1 (p < 0.001). In the assessment of the questionnaire, it was seen that a single portal anterior approach was preferred at a higher ratio (p = 0.035). The cost analysis revealed that the cost was 5.7% less for patients with a single portal.

Conclusion

In the arthroscopic treatment of traumatic anterior shoulder instability accompanied by a Bankart lesion, the anterior single portal technique is as successful in terms of clinical results as the conventional double portal approach. The single portal technique has advantages such as less postoperative pain, a shorter surgical learning curve and lower costs.

Level of Evidence

Level III, Therapeutic study.

Rotator interval closure has no additional effect on shoulder stability compared to Bankart repair alone

PURPOSE

Arthroscopic Bankart repair (ABR) provides satisfactory results for recurrent anterior shoulder instability, but the high recurrence rate post-ABR remain a concern. One of the adjunct procedures proposed to improve ABR results is arthroscopic rotator interval closure (ARIC). This study prospectively evaluated the outcomes of ABRs alone compared to combined ABR + ARIC and identified risk factors related to failure of each procedure.

METHODS

Thirty-nine consecutive patients (mean age 23.1 (18.3-37.5) years; 37 males) underwent arthroscopic stabilization for recurrent anterior traumatic shoulder instability. Twenty patients underwent ABR alone and 19 underwent ABR + ARIC. Remplissage was added when glenoid engagement was observed during surgery. All patients were prospectively followed, and their postoperative courses were reviewed and functionally assessed at the last visit.

RESULTS

The re-dislocation rate was higher in the ABR + ARIC group compared to the ABR only group at a mean follow-up of 4.2 (2-5.6) years (3 vs. 0, P = 0.06). More subluxations were found in the ABR only group (2 vs. 1, respectively; P = 0.58). The final limitation of range of motion (ROM) compared with the preoperative ROM was similar in both groups. Remplissage procedures were performed more often in the ABR only group [12 (60%) vs. 4 (21%), P = 0.013].

CONCLUSIONS

ARIC performed as an adjunct to ABR showed no superiority in attaining value-added stability compared to ABR alone. Adding a remplissage procedure may achieve better stability.

LEVEL OF EVIDENCE

Level 2.

Biomechanical effects of rotator interval closure in shoulder arthroplasty

BACKGROUND

Subscapularis dysfunction remains a significant problem after shoulder arthroplasty. Published techniques have variable recommendations for placing a rotator interval closing suture in attempts to off-load the subscapularis repair site, the implications of which have yet to be examined in the literature. The goals of this study were to investigate the biomechanical benefit of the rotator interval closing suture on the subscapularis repair strength and to analyze the effect on shoulder range of motion.

METHODS

Sixteen matched cadaveric shoulders underwent a subscapularis tenotomy and shoulder arthroplasty. The subscapularis tenotomy was repaired, and motion at physiologic torsional force was recorded. One of each matched pair was randomly assigned to receive an additional rotator interval closure suture. Each specimen then underwent a standardized cyclic loading with measurement of gap formation and load to failure.

RESULTS

The rotator interval closing suture significantly increased the ultimate load to failure of the subscapularis repair (452 N vs. 219 N; P = .002) and decreased gap formation at the subscapularis repair site. Measurement of the shoulder motion showed no significant difference between shoulders with and without the rotator interval closing suture.

DISCUSSION

We report the additional biomechanical benefit that the rotator interval closing suture provides to the subscapularis repair site after shoulder arthroplasty. This suture acts to improve the load to failure of the subscapularis repair and to decrease gap formation under cyclic load. Furthermore, it does not detrimentally affect shoulder external rotation or overall arc of rotation. Our findings support the application of this off-loading technique after subscapularis repair during shoulder arthroplasty.

Arthroscopic Bankart repair: Have we finally reached a gold standard?

Traditionally, surgical stabilization of the unstable shoulder has been performed through an open incision. Arthroscopic Bankart repair with suture anchors is now widely considered the treatment of choice for anterior shoulder instability in patients who have failed conservative management. Many different factors have now been elucidated for adequate treatment of glenohumeral instability. Because of technical advances in instability repair combined with an increased understanding of factors that lead to recurrent instability, the outcomes following arthroscopic Bankart repair have significantly improved and approach those of open techniques.

The effect of the rotator interval on glenohumeral kinematics during abduction

Background

The rotator interval (RI) has been exploited as a potentially benign point of entry into the glenohumeral (GH) joint. Bounded by the supraspinatus, subscapularis and coracoid process of the scapula, the RI is believed to be important in the shoulder’s soft tissue balancing and function. However, the role of the RI in shoulder kinematics is not fully understood. The purpose of this study is to describe the effect of the RI on GH motion during abduction of the arm.

Methods

Six shoulders from three cadaveric torsos were studied to assess the impact of changes in the RI during abduction under four conditions: Intact (Baseline), Opened, Repaired (repaired with side-to-side tissue approximation, no overlap) and Tightened (repaired with 1 cm overlap). For each group, the GH translation and area under the Curve (AUC) were measured during abduction using an intact cadaveric shoulder (intact torso).

Results

GH kinematics varied in response to each intervention and throughout the entire abduction arc. Opening the RI caused a significant change in GH translation. The Repair and Tightened groups behaved similarly along all axes of GH motion.

Conclusions

The RI is central to normal GH kinematics. Any insult to the tissue’s integrity alters the shoulder’s motion throughout abduction. In this model, closing the RI side-to-side has the same effect as tightening the RI. Since suture closure may offer the same benefit as tightening the RI, clinicians should consider this effect when treating patients with shoulder laxity. This investigation provides an improved perspective on the role of the RI on GH kinematics during abduction. When managing shoulder pathology, surgeons should consider how these different methods of RI closure affect the joint’s motion. In different circumstances, the surgical approach to the RI can be tailored to address each patient’s specific needs.

Complications after arthroscopic labral repair for shoulder instability

Arthroscopic labral repair is a widely performed and safe technique for anterior or posterior shoulder instability; however, complications have been reported in the literature. Postoperative injection of local anesthetic via an intra-articular pain pump should be avoided to prevent chondrolysis of the glenohumeral joint. Postoperative stiffness of the shoulder can be treated with physiotherapy, and a surgical treatment is indicated in shoulders that failed a conservative treatment. Although nerve injury is relatively rare, the axillary nerve should be given careful attention. Recurrent shoulder instability is the most common complication after labral repair, but most reported rates of recurrent instability after arthroscopic Bankart repair are less than 10 %. Augmentations, such as rotator interval closure and Hill-Sachs remplissage, have a potential to reduce the rate of recurrence. A better understanding of these possible complications, including their pathology and treatment, is essential for optimization of outcomes after arthroscopic labral repair.

Identification and treatment of existing copathology in anterior shoulder instability repair

Recurrent anterior instability is a common finding after traumatic glenohumeral dislocation in the young, athletic patient population. A variety of concomitant pathologies may be present in addition to the classic Bankart lesion, including glenoid bone loss; humeral head bone loss; rotator interval pathology; complex/large capsular injuries including humeral avulsions of the glenohumeral ligaments (HAGL lesions), SLAP tears, near circumferential labral tears, and anterior labral periosteal sleeve avulsions (ALPSA lesions); and rotator cuff tears. Normal anatomic variations masquerading as pathology also may be present. Recognition and treatment of these associated pathologies are necessary to improve function and symptoms of pain and to confer anterior shoulder stability. This review will focus on the history, physical examination findings, imaging findings, and recommended treatment options for common sources of copathology in anterior shoulder instability repair.

Outcomes of arthroscopic anterior shoulder instability in the beach chair versus lateral decubitus position: a systematic review and meta-regression analysis

PURPOSE

This study aimed to systematically review the clinical outcomes and recurrence rates after arthroscopic anterior shoulder stabilization in the beach chair (BC) and lateral decubitus (LD) positions.

METHODS

The authors performed a systematic review of multiple medical databases using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All English-language literature from 1990 to 2013 reporting clinical outcomes after arthroscopic anterior shoulder stabilization with suture anchors or tacks with a minimum 2-year follow-up period were reviewed by 2 independent reviewers. Data on recurrent instability rate, return to activity/sport, range of motion, and subjective outcome measures were collected. Study methodological quality was evaluated with the Modified Coleman Methodology Score (MCMS) and the Quality Appraisal Tool (QAT). To quantify the structured review of observational data, meta-analytic statistical methods were used.

RESULTS

Sixty-four studies (38 BC position, 26 LD position) met inclusion criteria. A total of 3,668 shoulders were included, with 2,211 of patients in the BC position (average age, 26.7 ± 3.8 years; 84.5% male sex) and 1,457 patients in the LD position (average age, 26.0 ± 3.0 years; 82.7% male sex). The average follow-up was 49.8 ± 29.5 months in the BC group compared with 38.7 ± 23.3 months in the LD group. Average overall recurrent instability rates were 14.65 ± 8.4% in the BC group (range, 0% to 38%) compared with 8.5% ± 7.1% in the LD group (range, 0% to 30%; P = .002). The average postoperative loss in external rotation motion (in abduction) was reported in 19 studies in the BC group and in13 studies in the LD group, with an average loss of 2.4° ± 1.0° and 3.6° ± 2.6° in each group, respectively (P > .05).

CONCLUSIONS

Excellent clinical outcomes with low recurrence rates can be obtained after arthroscopic anterior shoulder stabilization in either the BC or the LD position; however, lower recurrence rates are noted in the LD position. Additional long-term randomized clinical trials comparing these positions are needed to better understand the potential advantages and disadvantages of each position.

LEVEL OF EVIDENCE

Level IV, systematic review of studies with Level I through Level IV evidence.

Multidirectional instability of the shoulder: rotator interval dimension and capsular laxity evaluation using MR arthrography

OBJECTIVES

To compare the rotator interval and capsular dimension as measured on MR arthrography between patients with clinically diagnosed multidirectional instability (MDI) and control subjects with no instability.

MATERIALS AND METHODS

We retrospectively reviewed a consecutive series of 658 shoulders that had undergone MR arthrography between 2006 and 2010. Of these, 97 shoulders were included in the present study. These shoulders were divided into two groups according to the clinically established diagnoses. The MDI group comprised 47 shoulders with atraumatic multidirectional shoulder instability, and the control group comprised 50 shoulders with no instability. Two independent observers measured the width and depth of the rotator interval, and the capsular dimensions at the anterior, anteroinferior, inferior, posteroinferior, and posterior regions in the two groups using MR arthrography.

RESULTS

The rotator interval width and depth were significantly greater in the MDI group (width, observer 1, 17.7 mm, observer 2, 17.9 mm; depth, observer 1, 8.9 mm, observer 2, 8.8 mm) than in the control group (width, observer 1, 14.3 mm, observer 2, 14.5 mm; depth, observer 1, 5.9 mm, observer 2, 6.2 mm) (p < .001). The capsular dimensions at the inferior and posteroinferior regions were significantly larger in the MDI group (inferior, observer 1, 27.9 mm, observer 2, 27.8 mm; posteroinferior, observer 1, 27.0 mm, observer 2, 27.1 mm) than in the control group (inferior, observer 1, 25.7 mm, observer 2, 25.3 mm; posteroinferior, observer 1, 23.3 mm, observer 2, 23.6 mm) (p < .05). A width greater than 15.2 mm or a depth greater than 6.4 mm of the rotator interval, suggesting MDI, had sensitivities of 81 and 92 % for observer 1, and 79 and 94 % for observer 2, and specificities of 66 and 72 % for observer 1, and 62 and 66 % for observer 2, respectively.

CONCLUSIONS

Measurements of the rotator interval and the size of the distended inferior and posteroinferior joint capsule on MR arthrography are greater in shoulders with clinical MDI than in stable shoulders.