Effect of subcritical glenoid bone loss on activities of daily living in patients with anterior shoulder instability

Remplissage May Decrease the Redislocation Rate After Arthroscopic Bankart Repair in Patients With an Engaging Hill-Sachs Defect: A Systematic Review and Meta-analysis of Studies With Minimal 2-Year Follow-up

BACKGROUND

The redislocation rate after arthroscopic Bankart repair (BR) among patients with a Hill-Sachs lesion (HSL) may be reduced with the use of remplissage.

PURPOSE

To investigate the outcomes of adding remplissage to an arthroscopic BR in patients with concomitant HSL.

STUDY DESIGN

Meta-analysis; Level of evidence, 3.

METHODS

PubMed and ScienceDirect databases were searched between February 2022 and April 2023 with the terms "remplissage" and "shoulder instability" according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The inclusion criteria were formed using the population, intervention, control, and outcome method; the investigation included studies that compared BR with and without remplissage and had ≥24 months of follow-up.

RESULTS

From 802 articles found during the initial search, 7 studies with a total of 837 patients-558 receiving isolated BR (BR group) and 279 receiving BR with remplissage (BR+REMP)-were included. The probability of recurrence of instability among patients with an engaging HSL was significantly diminished in the BR+REMP group compared with the BR group (odds ratio, 0.11; 95% CI, 0.05 to 0.24; P < .001). Regarding shoulder range of motion, the BR+REMP group achieved increased forward flexion (mean difference [MD], 1.97°; 95% CI, 1.49° to 2.46°; P < .001) and decreased external rotation in adduction (MD, -1.43°; 95% CI, -2.40° to -0.46°; P = .004) compared with the BR group. Regarding patient-reported outcome measures, the BR+REMP group had Rowe (MD, 2.53; 95% CI, -1.48 to 6.54; P = .21) and Western Ontario Shoulder Instability Index (WOSI) (MD, -61.60; 95% CI, -148.03 to 24.82; P = .162) scores that were comparable with those of the BR group.

CONCLUSION

Remplissage resulted in a 9-fold decrease in the recurrence of instability after arthroscopic BR in patients with HSL. Remplissage not only led to an increase in forward flexion but also only slightly limited patients' external rotation in adduction. WOSI and Rowe scores after remplissage at the final 24-month follow-up were comparable with those obtained after isolated Bankart repair.

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.

Glenoid track and subcritical Hill-Sachs lesion

Background

We have proposed the concept of glenoid track ("on-track/off-track" lesion) to evaluate the risk of engagement of the Hill-Sachs lesion with the glenoid after arthroscopic Bankart repair. This concept has been widely used and many clinical validation studies have been reported. To measure the glenoid track width, we have recommended to use 3-dimensional computed tomography (CT) images. However, the CT method has the issue of radiation exposure and involves time and effort to make 3-dimensional CT images from 2-dimensional images. For these reasons, there are several reports describing the measurement method using magnetic resonance imaging. Recently, the threshold of the critical glenoid bone loss becomes lower. A zone of bone loss below the critical size is called "subcritical bone loss", which might be related to deterioration of quality of life and bone grafting is recommended. We applied the concept of "subcritical bone loss" to the glenoid track. Patients with "on-track" lesions can be divided into 2 subgroups: those with a "peripheral-track" lesion (most medial 1/4) and those with a "central-track" lesion (the rest 3/4). More recently, similar evaluation methods to evaluate the risk of "off-track" lesions have been reported: ''distance to dislocation'' and "Hill-Sachs interval/glenoid track ratio". Also, similar concept to "peripheral-track" lesion, "near-track" lesion was reported. The concept of "peripheral-track" lesion is a concept of assessing an "on-track" lesion which is very close to the medial margin of the glenoid track (subcritical bone loss).

Methods

Similar evaluation methods to evaluate the risk of "off-track" or "peripheral-track" lesions were proposed in the literature. A review was performed by searching PubMed. Journal articles published between January 2014 and January 2023 were taken into account. They were compared and their differences were explained.

Results

The "near-track" lesion concept is similar to "peripheral-track" lesion. However, the cutoff value is different: Hill-Sachs occupancy ≥ 75% is the "peripheral-track" lesion, whereas "distance to dislocation" < 8 mm is the "near-track" lesion.

Conclusion

We introduced update of the glenoid track concept including the evaluation method, peripheral-track lesion, and its clinical application.

Cross-education effects on shoulder rotator muscle strength and function after shoulder stabilization surgery: a randomized controlled trial

HYPOTHESIS

This study aimed to investigate the effects of cross education (CE) on rotator cuff (RC) muscle strength recovery and shoulder function in patients who underwent arthroscopic anterior shoulder stabilization surgery.

METHODS

Twenty-eight patients who underwent shoulder stabilization surgery were included in the study (age, 25 ± 6 years; body mass index, 24.8 ± 3.6 kg/m2). The patients were randomly divided into either the CE group (n = 14) or the control group (n = 14). All patients received a standardized rehabilitation program until the end of the 12th postoperative week. The CE group also received isokinetic training of the nonoperative shoulder focusing on the RC muscles (twice a week, 3 sets of 10 repetitions). RC muscle strength was measured preoperatively and at 3 and 6 months postoperatively using an isokinetic dynamometer at 60°/s and 180°/s angular velocities. Shoulder function was assessed with the Closed Kinetic Chain Upper Extremity Stability Test and Y-Balance Test-Upper Quarter. Analyses of covariance were used for the statistical analyses.

RESULTS

At 6 months postoperatively, at 60°/s angular velocity, there was higher internal rotator strength in the CE group (P = .02) and similar external rotator strength (P = .62) between the groups. At 180°/s angular velocity, both internal rotator strength (P = .04) and external rotator strength (P = .02) were higher in the CE group. The Closed Kinetic Chain Upper Extremity Stability Test (P = .47), Y-Balance Test-Upper Quarter (P = .95), and Western Ontario Shoulder Instability Index (P = .12) scores were similar between the groups at 6 months after surgery.

CONCLUSIONS

CE in the early period of postoperative rehabilitation following stabilization surgery improves RC strength recovery. However, it has no effect on functional outcomes. Integrating a CE program into the postoperative rehabilitation protocol may help to improve dynamic shoulder stability but not functional capacity.

Glenoid Bone Loss in Recurrent Shoulder Instability After Arthroscopic Bankart Repair: A Systematic Review

BACKGROUND

Glenoid bone loss has been reported to occur in as many as 86% of patients with recurrent shoulder stability. This systematic review evaluated the amount of glenoid bone loss associated with recurrent shoulder dislocation or subluxation and with worse patient-reported outcomes after arthroscopic Bankart repair. We hypothesized that the percentage of glenoid bone loss associated with recurrent instability after arthroscopic Bankart repair is lower than the previously proposed critical value of 25%.

METHODS

The systematic review included 528 patients with glenoid bone loss from 3 clinical studies. The percentage of bone loss was the value quantified and reported in each study. Failure was defined as recurrent dislocation or subluxation. The percentage of glenoid bone loss associated with recurrent shoulder dislocation or subluxation after arthroscopic Bankart labral repair was analyzed with receiver operating characteristic (ROC) curve analysis.

RESULTS

Recurrent dislocation or subluxation occurred in 23.7% (125) of 528 patients in the pooled study cohort. There was a significant difference in age between those in whom the arthroscopic Bankart repair failed and those in whom it did not (22.9 versus 24.3 years; p = 0.009). The ROC curve analysis demonstrated that ≥16.0% glenoid bone loss was predictive of recurrent shoulder dislocation or subluxation (Youden index = 0.59, sensitivity = 80%, specificity = 80%). In patients who did not sustain a recurrent dislocation or subluxation, the ROC curve analysis demonstrated that 20.0% glenoid bone loss was predictive of a Single Assessment Numeric Evaluation (SANE) score of <85% (Youden index = 0.93, sensitivity = 93%, specificity = 100%).

CONCLUSIONS

The critical amount of glenoid bone loss associated with an increased risk of persistent instability was found to be less than previously reported. Glenoid bone loss of ≥16.0% was found to place patients at higher risk for recurrent shoulder dislocation or subluxation after treatment with arthroscopic Bankart repair alone.

LEVEL OF EVIDENCE

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

IODA-shoulder®, a 3-dimensional automated software for glenoid bone loss quantification in shoulder instability. A validation study

BACKGROUND

Glenoid bone loss (GBL) calculation in patients with shoulder instability has a wide variability in methods and their reliability. The purpose of this study was to describe and validate a new semi-automated software developed to improve GBL calculation using a 3D imaging modeling (IODA-shoulder) and to compare the method to the PICO area method.

PATIENTS AND METHODS

A semi-automated software to assess GBL was preliminarily developed and validated on 7 fresh frozen specimens (scapulae with artificially created glenoid defect), using water displacement method. Afterwards, the software was retrospectively used on CT images of 20 patients affected by recurrent shoulder dislocation. Inclusion criteria were: unilateral dislocation, minimum 2 dislocation episodes. Exclusion criteria were bone reconstruction of the glenoid, failed shoulder stabilization, bilateral dislocation, shoulder arthritis. Three-dimensional computed tomography images of bilateral shoulder were retrieved for each patient. Two methods to determine GBL were compared. The PICO surface area method and the new IODA method. We assessed the intra- and inter-rater reliability of the two methods with the Intraclass Correlation Coefficient (ICC), the Bland-Alman analysis, and Lin's concordance correlation coefficient (CCC).

RESULTS

We did not find a statistically significant difference between the mean volumes calculated with PICO and IODA methods, respectively 914 vs. 815 mm3, p=0.155. The analysis carried out by using the traditional PICO method showed a lower concordance rate among four observers than the higher concordance found using IODA method, regardless of the size and the location of the defect. The ICC agreement with PICO was significantly lower than with IODA (0.76 vs. 0.97). We found a poor CCC with PICO (from 0.65 to 0.81) and a substantial one with IODA (from 0.96 to 0.98).

DISCUSSION

The intra- and inter-rater reliability using IODA method is significantly better than PICO method. The assessment of GBL using IODA method is time saving, avoiding significant inter- and intra-observer variation, mainly due to individual skill and experience in the method.

LEVEL OF EVIDENCE

IV, experimental study.

Surgical treatment of shoulder instability in active-duty service members with subcritical glenoid bone loss: Bankart vs. Latarjet

INTRODUCTION

Subcritical bone loss has been identified as a risk factor for potentially inferior outcomes following typical arthroscopic soft tissue repair. One alternative that has been presented as an option for patients with bone loss is the Latarjet, an ipsilateral coracoid transfer to the anteroinferior glenoid. The purpose of this study is to compare the outcomes between the arthroscopic Bankart repair and the open Latarjet for the treatment of anterior shoulder instability in patients with subcritical bone loss. We hypothesize that the open Latarjet will provide higher patient-reported outcome measure scores and lower rates of dislocation.

METHODS

A retrospective cohort comparison of patients with anterior glenohumeral instability procedures was performed. Inclusion criteria included symptomatic anterior shoulder instability, subcritical glenoid bone loss (13.5%-24%), surgical treatment with arthroscopic Bankart repair or open Latarjet, and minimum follow-up of 2 years. Outcomes included recurrent instability (defined as postoperative dislocation or subjective subluxation), permanent physical restrictions, Western Ontario Shoulder Index (WOSI), and Single Assessment Numeric Evaluation (SANE) scores.

RESULTS

Forty-seven patients were included, 25 of whom underwent an arthroscopic Bankart repair and 23 patients an open Latarjet. The average bone loss was 17.8% and 19.3%, respectively. Overall, 8 patients experienced recurrent instability, 6 in the arthroscopic Bankart group and 2 in the open Latarjet group (P = .162). The average postoperative SANE score for arthroscopic Bankart group was 48% and for the open Latarjet group, 84% (P < .001). The average postoperative WOSI score for the arthroscopic Bankart group was 53.6% and for the open Latarjet group, 67.9% (P = .069). There were significantly more patients placed on permanent physical restrictions in the arthroscopic Bankart repair group (16) compared with open Latarjet (3) (P < .001).

CONCLUSION

In patients with subcritical glenoid bone loss (defined as 13.5%-24%), patients treated with an open Latarjet have insignificantly higher SANE and WOSI scores and lower permanent physical restrictions than patients treated with an arthroscopic Bankart repair. We found no statistically significant difference in recurrent instability rates between the open Latarjet and arthroscopic Bankart repair (P = .162).

Long-term recurrence rate in anterior shoulder instability after Bankart repair based on the on- and off-track concept

BACKGROUND

Since its first proposal, the concept of on- and off-track lesions in anterior shoulder instability has gained clinical relevance as a tool to predict the failure rate of arthroscopic Bankart repair. Current literature only reports either short-term follow-up or long-term results of small sample sizes. The aim of this study was to provide a long-term evaluation of recurrent instability following arthroscopic Bankart repair in a large cohort using the on-track vs. off-track concept as a predictor for failure.

METHODS

We retrospectively analyzed 271 patients who underwent primary arthroscopic Bankart repair for anterior shoulder instability between 1998 and 2007. All patients with a minimum follow-up of 78 months and a preoperative computed tomographic (CT) or magnetic resonance imaging (MRI) scan were included into the study. Preoperative CT and/or MRI scans were used to determine the glenoid track and width of Hill-Sachs lesion. Recurrence of instability was defined as presence of instability symptoms (dislocation, subluxation, and/or apprehension) or revision surgery (stabilization procedure) and was assessed as the primary outcome parameter.

RESULTS

The glenoid track of 163 shoulders was assessed (female n = 51, male n = 112) with a mean follow-up of 124 months (99.4-145.6, standard deviation = 2.5) and a mean age of 24 years (20-34.). An off-track Hill-Sachs lesion was found in 77 cases (47%), and in 86 cases (53 %) it was on-track. The rate of recurrent instability in the off-track group was 74% (n = 57) compared with 27% (n = 23) in the on-track group (P < .001). The overall rate of revision surgery due to instability was 29% (n = 48) after a mean time of 50.9 months (±42.8) following Bankart repair. The rate of revision surgery in the off-track group was 48% (n = 37) after a mean of 53.5 months (±42.0) vs. 13% (n = 11) after 42.3 months (±46.3) in the on-track group (P < .001).

CONCLUSION

This study shows that the on- and off-track concept helps to distinguish patients for whom an isolated arthroscopic Bankart repair yields long-term benefits. Because of the high rate of recurrent instability in the off-track group, an off-track lesion should be treated surgically in such a way that the off-track lesion is converted into an on-track lesion.

First-time traumatic anterior shoulder dislocation: current concepts

The management of first-time traumatic anterior shoulder dislocations has been a topic of extensive study yet remains controversial. Development of a treatment plan requires an understanding of patient-specific considerations, including demographics, functional demands, and extent of pathology. Each of these can influence rates of recurrence and return to activity. The purpose of this review is to provide a framework for decision-making following a first-time anterior shoulder dislocation, with particular focus on the high-risk young and athletic population. A summary of surgical treatment options and their outcomes is outlined, along with future biomechanical and clinical perspectives.

High correlation between inner and outer glenoid circle diameters and its clinical relevance

PURPOSE

The majority of methods for measuring glenoid bone loss in shoulder instability use the best-fit circle following the inferior glenoid rim. However, there is no precise method on how to draw this circle, particularly in case of a missing rim segment. Defining the radius is a source of substantial error. It was hypothesized that there is a relationship between the best-fit inferior circle (inner circle), defined by Sugaya, and the circle tangent to the supra- and infra-glenoid tubercles (outer circle), defined by Itoi, thus allowing a more consistent appreciation of the paleo-glenoid.

METHODS

Ninety-five normal dry scapulae were examined. The specimens were digitally photographed obtaining perpendicular images of the glenoid cavity. Using HOROS® imaging software, a best-fit inferior circle (inner circle) and a second circle fitting the most inferior and superior points of the glenoid (outer circle) were drawn by two investigators. The diameters and areas of the circles were recorded. Two-way random-effects intra-class correlation coefficients (ICC) were used to measure intra- and inter-observer agreement. A Bayesian measurement-error regression model was used to determine the relationship between outer and inner circle measurements.

RESULTS

The mean glenoid height was 35.1 mm and the glenoid width 25.6 mm. The mean diameter of the outer circle was 35.7 ± 4.2 mm and the mean diameter of the inner circle was 26.8 ± 3.2 mm. ICC showed excellent inter- and intra-observer agreement for both the outer circle diameter (ICC ≥ 0.95) and inner circle diameter (ICC ≥ 0.93). The two diameters demonstrated a very strong significant Pearson correlation (0.92, p < 0.001) and the regression showed excellent model fit R² = 0.87. The areas of the two circles were also highly and significantly correlated (r = 0.94; p < 0.001). The ratio of inner circle to outer diameters was 0.74.

CONCLUSION

There is a strong correlation between the inner and outer glenoid circle diameters. This study sets the base for the use the combined outer and inner circle and its ratio to better appreciate the paleo-glenoid morphology and thus obtain a more reliable bone loss estimation. Application of this method aids in a more reliable estimation bone loss with potential benefit in surgical decision-making.

Biomechanical analysis of anterior stability after 15% glenoid bone loss: comparison of Bankart repair, dynamic anterior stabilization, dynamic anterior stabilization with Bankart repair, and Latarjet

BACKGROUND

Dynamic anterior shoulder stabilization (DAS) with Bankart repair is a recently described stabilization technique thought to be more robust than an isolated Bankart repair while avoiding many coracoid transfer-related complications and technical demands. DAS involves transfer of the long head biceps through a subscapularis split to the anterior glenoid to create a sling effect. We hypothesize that DAS with Bankart repair will restore anterior stability in a human-cadaveric model with subcritical (15%) glenoid bone loss.

METHODS

Eight cadaveric shoulders were tested using an established shoulder simulator to record glenohumeral translations with an accuracy of ±0.2 mm. Shoulders were tested in 5 states-intact soft tissues, Bankart defect with 15% bone loss, isolated Bankart repair, DAS with Bankart repair, isolated DAS, and Latarjet. A 45 N anterior force was applied through the pectoralis major tendon, and translation of the humeral head was recorded and compared with repeated measures analysis of variance.

RESULTS

The anterior translation in the intact (native) glenoid was 4.7 mm at neutral position and 4.6 mm at 45° external rotation. Anterior translation significantly increased after introducing a Bankart defect with 15% glenoid bone loss to 9.1 mm (neutral, P = .002) and 9.5 mm (45° external rotation, P < .001). All repair conditions showed a significant decrease in anterior translation relative to Bankart defect. DAS with Bankart repair decreased anterior translation compared with the Bankart defect: 2.7 mm (neutral, P < .001) and 2.1 mm (45° external rotation, P < .001). DAS with Bankart repair significantly decreased anterior translation compared with the isolated Bankart repair (2.7 mm vs. 4.7 mm, P = .023) and the isolated DAS (2.7 mm vs. 4.3 mm, P = .041) in neutral position. The Latarjet procedure resulted in the greatest reduction in anterior translation compared with the Bankart defect: 1.2 mm (neutral, P < .001) and 1.9 mm (45° external rotation, P < .001).

CONCLUSIONS

DAS with Bankart repair is a viable alternative to restore anterior glenohumeral stability with a 15% glenoid defect at a greater degree than either DAS or Bankart repair alone. The Latarjet procedure was the most effective in reducing anterior translation but restrained the anterior translation significantly more than the native glenoid.

Early Treatment of Shoulder Pathology Is Necessary but Not Enough Is Being Performed

Delayed treatment of shoulder instability results in bone loss requiring more-complicated surgery, in turn resulting in less-optimal outcomes. Similarly, delayed treatment of repairable rotator cuff tears results in irreparable tears requiring more-complicated surgery and resulting in less-optimal outcomes. Delayed treatment of shoulder pathology is a problem. Solutions include education and research investigation.

The Short, 5-Item Shoulder Instability-Return to Sport After Injury (SIRSI) Score Performs as Well as the Longer Version in Predicting Psychological Readiness to Return to Sport

PURPOSE

To reduce the length of the Shoulder Instability-Return to Sport After Injury (SIRSI) scale and determine the predictive validity of the short version compared with the original form.

METHODS

This study included patients who underwent an arthroscopic Bankart repair or open Latarjet procedure between 2017 and 2019. One group was used for the SIRSI scale-reduction process, and a second group was used to test the predictive validity of the proposed short SIRSI scale. The Cronbach α value was used to evaluate internal consistency. Validity was determined by calculating the Pearson correlation coefficient with the Western Ontario Shoulder Instability Index scale. Predictive validity was assessed using receiver operating characteristic (ROC) curve statistics.

RESULTS

A total of 158 patients participated in the scale-reduction process, and 137 patients participated in the predictive-validation process. The SIRSI scale was successfully reduced to a 5-item scale constructed by 1 underlying factor accounting for 60% of the variance. The short version showed good internal consistency (Cronbach α = 0.82) and was highly correlated with the Western Ontario Shoulder Instability Index scale and the long version. The short SIRSI scores were significantly different between patients who returned to sports and those who did not. The SIRSI scale had excellent predictive ability for return-to-sport outcomes (area under ROC curve of 0.84 for short version [95% confidence interval, 0.7-0.9] and 0.83 for long version [95% confidence interval, 0.7-0.9]).

CONCLUSIONS

A valid 5-item, short version of the SIRSI scale was successfully developed in our patient population. The short version was found to be as robust as the long scale for discriminating and predicting return-to-sport outcomes.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Relationship of the SIRSI Score to Return to Sports After Surgical Stabilization of Glenohumeral Instability

BACKGROUND

Literature is scarce regarding the influence of psychological readiness on return to sports after shoulder instability surgery.

PURPOSE

To evaluate the predictive ability of the Shoulder Instability-Return to Sport after Injury (SIRSI) score in measuring the effect of psychological readiness on return to sports and to compare it between athletes who returned to sports and athletes who did not return to sports.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A prospective analysis was performed of patients who underwent an arthroscopic Bankart repair or a Latarjet procedure between January 2019 and September 2020. Psychological readiness to return to play was evaluated using the SIRSI instrument. Preoperative and postoperative functional outcomes were measured by the Rowe, Athletic Shoulder Outcome Scoring System, and Western Ontario Shoulder Instability Index scores. The predictive validity of the SIRSI was assessed by the use of receiver operating characteristic (ROC) curve statistics. The Youden index was calculated and used to determine a SIRSI score cutoff point that best discriminated psychological readiness to return to sports. A logistic regression analysis was performed to evaluate the effect of psychological readiness on return to sports and return to preinjury sports level.

RESULTS

A total of 104 patients were included in this study. Overall, 79% returned to sports. The SIRSI had excellent predictive ability for return-to-sport outcomes (return to sports: area under ROC curve, 0.87 [95% CI, 0.80-0.93]; return to preinjury sports level: area under ROC curve, 0.96; [95% CI, 0.8-0.9]). A cutoff level of ≥55 was used to determine whether an athlete was psychologically ready to return to sports and to return to preinjury sports level (Youden index, 0.7 and 0.9, respectively). Of those who returned to sports, 76.8% were psychologically ready to return to play, with a median SIRSI score of 65 (interquartile range, 57-80). In comparison, in the group that did not return to sports, only 4.5% achieved psychological readiness with a median SIRSI score of 38.5 (interquartile range, 35-41) (P < .001). Regression analysis for the effect of SIRSI score on return to sports was performed. For every 10-point increase in the SIRSI score, the odds of returning to sports increased by 2.9 times. Moreover, those who did not achieve their preinjury sports level showed poorer psychological readiness to return to play and SIRSI score results.

CONCLUSION

The SIRSI was a useful tool for predicting whether patients were psychologically ready to return to sports after glenohumeral stabilization surgery. Patients who returned to sports and those who returned to their preinjury sports level were significantly more psychologically ready than those who did not return. Therefore, we believe that the SIRSI score should be considered along with other criteria that are used to decide whether the patient is ready to return to sports.

Remplissage in addition to arthroscopic Bankart repair for shoulder instability with on-track Hill-Sachs lesions reduces residual apprehension without external rotation limitation

PURPOSE

To evaluate the role of remplissage as an adjunct to Bankart repair in patients with recurrent anterior shoulder dislocation combined with on-track Hill-Sachs lesion.

METHODS

Arthroscopic Bankart repair with remplissage data (December 2018-2020) were collected (BR group). Inclusion criteria were (1) recurrent anterior shoulder dislocation, (2) on-track Hill-Sachs lesion, (3) minimal/subcritical glenoid bone loss (<17%), and (4) postoperative follow-up >1 year. Exclusion criteria were (1) revision surgery, (2) first dislocation with acute glenoid rim fracture, and (3) combined with other surgery. The control group was identified in Bankart repair-only cohort (B group). All patients were evaluated preoperatively, and at 3 weeks, 6 weeks, 3 months, 6 months, and then annually postoperatively. Visual analogue scale for pain, Self-Assessment Numerical Evaluation, American Shoulder and Elbow Surgeons Shoulder score, ROWE, and Western Ontario Shoulder Instability were evaluated at preoperative and final follow-up. Residual apprehension experience and external rotation deficit were evaluated. Patients, who were followed-up for more than 1 year, were asked how often they experienced any subjective apprehension in 4 grades (1: always, 2: frequently, 3: occasionally, 4: never). Patients who had a history of recurrent dislocation or revision surgery were investigated.

RESULTS

In total, 53 patients (B, 28; BR, 25) were included. At final follow-up, both groups showed improvement in 5 clinical scores postsurgery (P < .001). The BR group showed greater ROWE scores than the B group (B: 75.2 ± 13.6, BR: 84.4 ± 10.8; P = .009). Residual apprehension patient ratio (B: 71.4% [20/28], BR: 32% [8/25]; P = .004) and the mean subjective apprehension grade (B: 3.1 ± 0.6, BR: 3.6 ± 0.6; P = .005) showed statistically significant difference, whereas no patients in either group experienced external rotation deficit (B: 14.8 ± 12.9°, BR: 18.0 ± 15.2°, P = .420). Only 1 patient in the B group had not responded to surgery, with dislocation recurrence (P = .340).

CONCLUSIONS

Remplissage with arthroscopic Bankart repair in on-track Hill-Sachs lesion has a role in reducing residual apprehension without external rotation limitation.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Effect of Anterior Glenoid Chondrolabral Defects on Anterior Glenohumeral Stability: A Biomechanical Study

Background:

It is well known that glenoid osseous defects >13.5% of the glenoid width critically destabilize the shoulder, as do labral tears. Chondrolabral defects often occur with anterior dislocation of the shoulder. It is unclear whether glenoid chondrolabral defects contribute to shoulder stability and, if so, at what size they become critical.

Purpose/Hypothesis:

The purpose of this study was to determine the effect of incremental chondrolabral defect sizes on anterior shoulder stability in the setting of labral deficiency. The hypothesis was that chondrolabral defects ≥13.5% of the glenoid width will decrease anterior shoulder stability.

Study Design:

Controlled laboratory study.

Methods:

This controlled laboratory study tested 12 fresh-frozen shoulders. Specimens were attached to a custom testing device in abduction and neutral rotation with 50-N compression applied to the glenoid. The humeral head was translated 10 mm anterior, anteroinferior, and anterosuperior with the conditions of intact cartilage and labrum and anterior full-thickness chondrolabral defects of 3-, 6-, and 9-mm width. Translation force was measured continuously. Peak translation force divided by 50-N compressive force defined the stability ratio. Data were analyzed using analysis of variance.

Results:

The anterior stability ratio decreased between the intact state (36% ± 7%) and all defects ≥3 mm (≤32% ± 8%; P ≤ .023). The anteroinferior stability ratio decreased between the intact state (52% ± 7%) and all defects ≥3 mm (≤47% ± 7%; P ≤ .006). The anterosuperior stability ratio decreased between the intact state (36% ± 4%) and all defects ≥6 mm (≤33% ± 4%; P ≤ .006). A 3-mm defect equated to 10% of the glenoid width. There were moderate to strong negative correlations between chondrolabral defect size and stability ratio in the anterior, anteroinferior, and anterosuperior directions (r = –0.79, –0.63, and –0.58, respectively; P ≤ .001). There were moderate to strong negative correlations between the percentage of glenoid chondrolabral defect size to the glenoid width and the stability percentage in all directions (r = –0.81, –0.63, and –0.61; P ≤ .001).

Conclusion:

An anterior glenoid chondrolabral defect ≥3 mm (>10% of the glenoid width) significantly decreased anterior and anteroinferior stability. Chondrolabral defect size negatively correlated with stability.

Clinical Relevance:

To fully restore glenohumeral stability, in addition to labral repair, it may be necessary to reconstruct chondrolabral defects as small as 3 mm (10% of the glenoid width).

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL RELEVANCE

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

A Ratio Estimating Glenoid Bone Loss

Background

Estimating glenoid bone loss when assessing the unstable shoulder can be challenging. The aim of this article was to describe a simple derived ratio to estimate glenoid bone loss.

Methods

When the glenoid is damaged and bone is damaged because of instability, the anterior aspect of the glenoid loses its normal curvature and becomes flattened. In geometry, this represents a chord. There are 3 assumptions for the calculations: (1) the lower glenoid is a circle; (2) there is a relationship between the glenoid height and the diameter of the glenoid circle; and (3) the length of the measured bone loss of the glenoid is a chord. Two measurements are required: glenoid height and length of the glenoid defect. The calculations involved in the ratio are reviewed.

Results

If the ratio of the length of the bone defect to the glenoid height is 0.5 (otherwise, 50% of the height), the estimated bone loss is 12%.

Conclusion

Glenoid bone loss can be estimated by measuring the length of the glenoid and the length of the defect.

Cartilage decisively shapes the glenoid concavity and contributes significantly to shoulder stability

PURPOSE

Glenohumeral joint injuries frequently result in shoulder instability. However, the biomechanical effect of cartilage loss on shoulder stability remains unknown. The aim of the current study was to investigate biomechanically the effect of two severity stages of cartilage loss in different dislocation directions on shoulder stability.

METHODS

Joint dislocation was provoked in 11 human cadaveric glenoids for 7 different directions between 3 o'clock (anterior) and 9 o'clock (posterior). Shoulder stability ratio (SSR) and concavity gradient were assessed in three states: intact, 3 mm and 6 mm simulated cartilage loss. The influence of cartilage loss on SSR and concavity gradient was statistically evaluated.

RESULTS

Both SSR and concavity gradient decreased significantly between intact state and 6 mm cartilage loss in every dislocation direction (p ≤ 0.038), except concavity gradient in 4 o'clock direction. Thereby, anterior-inferior dislocation directions were associated with the highest decrease in both SSR and concavity gradient of up to 59.0% and 49.4%, respectively, being significantly bigger for SSR compared with all other dislocation directions (p ≤ 0.040). Correlations between concavity gradient and SSR for pooled dislocation directions were significant in each separate specimen's state (p < 0.001).

CONCLUSION

From a biomechanical perspective, articular cartilage of the glenoid contributes significantly to the concavity gradient, correlating strongly with the associated loss in glenohumeral joint stability. The biggest effect of cartilage loss is observed in the most frequently occurring anterior-inferior dislocation directions, suggesting that surgical interventions to restore cartilage's surface and concavity should be considered for recurrent shoulder dislocations in presence of cartilage loss.

Managing Bone Loss in Shoulder Instability-Techniques and Outcomes: a Scoping Review

PURPOSE OF REVIEW

The aim of this scoping review is to provide an overview of the literature published over the past 5 years related to the management of bone loss in anterior shoulder instability.

RECENT FINDINGS

During recent years, there has been a focus on patients at high risk for failure following soft tissue anterior stabilization (Bankart repair). A growing body of evidence suggests that anterior capsulolabral repair is insufficient in the setting of subcritical glenoid bone loss with an off-track Hill Sachs lesion. In such cases, the addition of a remplissage procedure to a Bankart repair or a bone-block augmentation to the glenoid (Latarjet, for example) is often advocated to decrease the risk of recurrent instability. Recent studies have also evaluated the role of alternative bone-block procedures in comparison to the Latarjet, outcomes with arthroscopic and open techniques as well as various fixation methods and radiological outcomes (bone graft resorption, glenohumeral osteoarthritis). Advances in our understanding of subcritical glenoid bone loss and the glenoid track concept have significantly impacted clinical decision making and treatment selection. The development of arthroscopic techniques has allowed for minimally invasive and safe arthroscopic bone-block procedures as an alternative to open procedures. Further research related to free bone-block procedures will inform long-term outcomes between these procedures and the gold standard Latarjet. Additionally, high-quality evidence is lacking to identify the ideal treatment for patients with glenoid subcritical glenoid bone defect. Variability in outcome reporting suggests the need to standardize outcome measures for future instability trials.

What Is the Most Reliable Method of Measuring Glenoid Bone Loss in Anterior Glenohumeral Instability? A Cadaveric Study Comparing Different Measurement Techniques for Glenoid Bone Loss

BACKGROUND

Preoperative quantification of bone loss has a significant effect on surgical decision making and patient outcomes. Various measurement techniques for calculating glenoid bone loss have been proposed in the literature. To date, no studies have directly compared measurement techniques to determine which technique, if any, is the most reliable.

PURPOSE/HYPOTHESIS

To identify the most consistent and accurate techniques for measuring glenoid bone loss in anterior glenohumeral instability. Our hypothesis was that linear measurement techniques would have lower consistency and accuracy than surface area and statistical shape model-based measurement techniques.

STUDY DESIGN

Controlled laboratory study.

METHODS

In 6 fresh-frozen human shoulders, 3 incremental bone defects were sequentially created resulting in a total of 18 glenoid bone defect samples. Analysis was conducted using 2D and 3D computed tomography (CT) en face images. A total of 6 observers (3 experienced and 3 with less experience) measured the bone defect of all samples with Horos imaging software using 5 common methods. The methods included 2 linear techniques (Shaha, Griffith), 2 surface techniques (Barchilon, PICO), and 1 statistical shape model formula (Giles). Intraclass correlation (ICC) using a consistency model was used to determine consistency between observers for each of the measurement methods. Paired t tests were used to calculate the accuracy of each measurement technique relative to physical measurement.

RESULTS

For the more experienced observers, all methods indicated good consistency (ICC > 0.75; range, 0.75-0.88), except the Shaha method, which indicated moderate consistency (0.65 < ICC < 0.75; range, 0.65-0.74). Estimated consistency among the experienced observers was better for 2D than 3D images, although the differences were not significant (intervals contained 0). For less experienced observers, the Giles method in 2D had the highest estimated consistency (ICC, 0.88; 95% CI, 0.76-0.95), although Giles, Barchilon, Griffith, and PICO methods were not statistically different. Among less experienced observers, the 2D images using Barchilon and Giles methods had significantly higher consistency than the 3D images. Regarding accuracy, most of the methods statistically overestimated the actual physical measurements by a small amount (mean within 5%). The smallest bias was observed for the 2D Barchilon measurements, and the largest differences were observed for Giles and Griffith methods for both observer types.

CONCLUSION

Glenoid bone loss calculation presents variability depending on the measurement technique, with different consistencies and accuracies. We recommend use of the Barchilon method by surgeons who frequently measure glenoid bone loss, because this method presents the best combined consistency and accuracy. However, for surgeons who measure glenoid bone loss occasionally, the most consistent method is the Giles method, although an adjustment for the overestimation bias may be required.

CLINICAL RELEVANCE

The Barchilon method for measuring bone loss has the best combined consistency and accuracy for surgeons who frequently measure bone loss.

Sex-specific differences in outcomes after anterior shoulder surgical stabilization: a meta-analysis and systematic review of literature

Background

Methods

Results

Conclusion

Anterior and posterior glenoid bone augmentation options for shoulder instability: state of the art

Bony lesions are highly prevalent in anterior shoulder instability and can be a significant cause of failure of stabilisation procedures if they are not adequately addressed. The glenoid track concept describes the dynamic interaction between the humeral head and glenoid defects in anterior shoulder instability. It has been beneficial for understanding the role played by bone defects in this entity. As a consequence, the popularity of glenoid augmentation procedures aimed to treat anterior glenoid bone defects; reconstructing the anatomy of the glenohumeral joint has risen sharply in the last decade. Although bone defects are less common in posterior instability, posterior bone block procedures can be indicated to treat not only posterior bony lesions, attritional posterior glenoid erosion or dysplasia but also normal or retroverted glenoids to provide an extended glenoid surface to increase the glenohumeral stability. The purpose of this review was to analyse the rationale, current indications and results of surgical techniques aimed to augment the glenoid surface in patients diagnosed of either anterior or posterior instability by assessing a thorough review of modern literature. Classical techniques such as Latarjet or free bone block procedures have proven to be effective in augmenting the glenoid surface and consequently achieving adequate shoulder stability with good clinical outcomes and early return to athletic activity. Innovations in surgical techniques have permitted to perform these procedures arthroscopically. Arthroscopy provides the theoretical advantages of lower morbidity and faster recovery, as well as the identification and treatment of concomitant pathologies.

Editorial Commentary: Improving Arthroscopic Bankart Repair Outcomes in Patients With Subcritical Bone Loss: Does Giving Up a Little (Cartilage), Give Us a Lot (of Stability)?

Over the past 3 decades, arthroscopic Bankart repair has become the gold standard for anterior shoulder instability in the absence of significant bone loss. Glenoid curettage may seem unusual in the setting of Bankart repair, but the advantage of a bleeding bony surface in reconstructive procedures is nearly universal in sports medicine, from cartilage restoration in the knee to rotator cuff repair. Intuitively, maximizing the surface of bleeding bone should improve healing, but is it really necessary to remove undamaged cartilage to create a healing response? Perhaps not in general, but in high-risk patients with subcritical bone loss curettage it could make sense. It has been well established that as the amount of bone loss drifts above 10%, recurrent instability after standard Bankart repair begins to rise. For many surgeons, the amount of glenoid and humeral bone loss in this patient population would encourage additional stabilizing measures in the form of Latarjet or Bankart repair with the addition of remplissage. Anterior glenoid cartilage curettage could be an additional tool when treating patients in subcritical bone loss. Removing 5 mm of glenoid cartilage may allow for anchor placement further posterior on the glenoid face, thus further closing off of the anterior glenohumeral joint space while providing potential added biologic benefit of increased bone to capsulolabral apposition. The addition of remplissage could further enhance stability and help hold the humeral head posteriorly and perhaps obviate the need for a bone block procedure.

High Rate of Return to Sports and Low Recurrences With the Latarjet Procedure in High-Risk Competitive Athletes With Glenohumeral Instability and a Glenoid Bone Loss <20

Purpose

To analyze return to sports, functional outcomes, and complications following the Latarjet procedure in competitive athletes with anterior glenohumeral instability and glenoid bone loss <20%.

Methods

All the included patients were operated between 2010 and 2016. The inclusion criteria were competitive athletes with anterior glenohumeral instability, a glenoid bone defect <20% who participated in contact sports, forced overhead sports, or had a previous failed Bankart repair and had a minimum 2 years’ follow-up. Return to sports, range of motion (ROM), the Rowe score, and the Athletic Shoulder Outcome Scoring System score were used to assess functional outcomes. Complications and bone consolidation were also evaluated.

Results

A total of 65 athletes were included in the study. The mean follow-up was 53 months (±13), and the mean age was 23.9 years (range, 16-31 years). Overall, 94% were able to return to sports and 84% returned at the same level. No significant difference in shoulder ROM was found between preoperative and postoperative results. The Rowe and Athletic Shoulder Outcome Scoring System scores showed statistical improvement after operation (P < .001). No significant difference in shoulder ROM and functional scores was found between primary and revision cases. The total complication rate was 11% and the revision rate was 1.5% The recurrence rate was 4.6%. The bone block healed in 95% of the cases.

Conclusions

In high-risk competitive athletes with anterior glenohumeral instability and glenoid bone loss <20%, the Latarjet procedure resulted in excellent functional outcomes, with most of the patients returning to sports and at the same level they had before injury with a low rate of recurrences

Level of Evidence

Therapeutic case series; Level of evidence, IV

How to handle minor and major bone loss in the shoulder? Current concepts

Anterior shoulder instability is a significant problem in orthopaedic surgery. It carries a heavy burden on quality of life, especially in young, active patients. Surgical treatment is therefore often carried out in this population. Several strategies can effectively address this issue. Yet, the consensus is lacking on the parameters which favour one technique over another, especially when bone loss is present. This is because of the complex, dynamic interplay between bone loss on the humeral side (ie, Hill-Sachs lesion) and glenoid bone loss, which is a common occurrence and defined as ‘bipolar’. There is an ongoing debate over the percentage of glenoid bone loss warranting bone block procedures: 13.5–15% is an indicator for such procedures (ie, Latarjet), although this value is still considered controversial and not uniformly accepted. A multitude of other factors (ie, age, sex, level of activity and so on) come into play alongside bipolar bone loss and the weight of each factor has yet to be fully elucidated. Also, refining the algorithm for the right procedure in the right patients will reduce the number of side effects stemming from initial, suboptimal treatment choice. Knowing how to manage previous surgical treatment failure is also key for the treating orthopaedic surgeon, who must be able to address the root cause of failure and react accordingly and effectively. This paper analyses key factors in treatment choice, the current stance of the literature on varying degrees of bone loss and choices on surgical treatment failure, lack of evidence and need for future research.