Evolution of lesions of the labrum-ligament complex in posttraumatic anterior shoulder instability: a prospective study

Type V superior labrum anterior to posterior repair: a systematic review

BACKGROUND

The purpose of this study is to systematically review the evidence in the literature to ascertain the functional outcomes, recurrence rates, and subsequent revision rates following type V superior labrum anterior to posterior (SLAP) repair.

METHODS

Two independent reviewers performed a literature search based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, utilizing the EMBASE, MEDLINE, and the Cochrane Library Databases. Studies were included if they had clinical outcomes on the patients undergoing type V SLAP repair. Statistical analysis was performed using SPSS (IBM, Armonk, NY, USA). A P value of <.05 was considered to be statistically significant.

RESULTS

Our review found 13 studies, including 451 shoulders meeting our inclusion criteria. The majority of patients were males (89.3%), with an average age of 25.9 years (range 15-58) and a mean follow-up of 53.8 months. The Rowe score was the most utilized functional outcome score, with a weighted mean of 88.5. Additionally, the mean Constant score was 91.0, the mean American Shoulder and Elbow Surgeons score was 88.3, the mean subjective shoulder value score was 85.5%, and the mean visual analog scale pain score was 1.2. The overall rate of return to play was 84.8%, with 80.2% returning to the same level of play. The overall reoperation rate was 6.1%, with a recurrent dislocation rate of 8.2%. In the studies comparing type V SLAP and isolated Bankart repair, there were statistically insignificant differences in visual analog scale pain scores (mean difference; 0.15, 95% confidence interval, -0.13 to 0.44, I2 = 0%, P = .29) and recurrence rates (risk ratio; 1.38, 95% confidence interval, 0.88-2.15, I2 = 0%, P = .16).

CONCLUSION

Arthroscopic repair of type V SLAP tears results in excellent functional outcomes, with high return to play rates in athletes. There are low rates of reoperations and recurrent dislocations. Additionally, in comparison to an isolated Bankart repair, SLAP repair does not increase recurrence rates or postoperative pain.

Kinematic analysis of damaged capsulolabral structure in patients with anterior shoulder instability using cine-magnetic resonance imaging

Background

We assessed damaged anterior capsulolabral motion during axial shoulder rotation in patients with anterior shoulder instability.

Methods

Twenty-nine shoulders of 28 patients with anterior shoulder instability who underwent cine-magnetic resonance imaging during axial rotation of the adducted arm were included. The motion was captured after an intra-articular injection of saline solution (10-20 mL). During imaging, the shoulder was rotated passively from maximum internal rotation to maximum external rotation in the first 10 s and then back to maximum internal rotation in the subsequent 10 s. We assessed the rotational angles of the damaged labrum during compressing and pulling the humeral head against the glenoid. Evaluation of the rotational angles was performed on a series of axial images through the humeral head center.

Results

The mean angles that damaged labrum compressed and pulled off against the glenoid were 12.0 ± 19.1° and 2.8 ± 21.2°, respectively. Additionally, seven of the 29 shoulders showed that the damaged labrum compressed on the glenoid rim before the rotational angle exceeded 0° during external rotation. In 13 shoulders, the damaged labrum could remain repositioned on the glenoid rim over the neutral position during internal rotation. In two shoulders, the damaged labrum was not compressed against the glenoid at the maximum external rotation. The injected saline moved from the posterior to the anterior side of the glenohumeral joint during internal rotation in each shoulder.

Conclusion

The damaged labrum could be positioned on the glenoid when the arm was in a traditional internal immobilization.

Glenohumeral Pathologies following Primary Anterior Traumatic Shoulder Dislocation-Comparison of Magnetic Resonance Arthrography and Arthroscopy

BACKGROUND

We assessed intraarticular injuries in patients after primary anterior traumatic shoulder dislocation by comparing magnetic resonance arthrography (MRA) results with concomitant arthroscopic findings.

METHODS

All patients with primary traumatic shoulder dislocation who underwent arthroscopic surgery between 2001 and 2020 with preoperative MRA were included in this study. MRA was retrospectively compared with arthroscopic findings. Postoperative shoulder function was prospectively assessed using the Disabilities of Arm, Shoulder and Hand score (quick DASH), the Oxford Shoulder Score (OSS), the Subjective Shoulder Value (SSV), as well as the rate of return to sports.

RESULTS

A total of 74 patients were included in this study. A Hill-Sachs lesion was consistently found in the corresponding shoulders on MRA and arthroscopy in 35 cases (p = 0.007), a Bankart lesion in 37 shoulders (p = 0.004), and a superior labrum from anterior to posterior (SLAP) lesion in 55 cases (p = 0.581). Of all cases, 32 patients were available for a clinical and functional follow-up evaluation. A positive correlation was found between the level of sport practiced and the Oxford Shoulder Score (redislocation subset) (p = 0.032) and between the age at the time of surgery and the follow-up SSV (p = 0.036). Conversely, a negative correlation was observed between the age at the time of surgery and the Oxford Instability Score (redislocation subset) (p = 0.038).

CONCLUSIONS

The results of this study show a good correlation between MRA and arthroscopy. Therefore, MRA is a valid tool for the detection of soft tissue pathologies after primary anterior traumatic shoulder dislocation and can aid in presurgical planning.

Bankart repair with subscapularis augmentation: A case control study

To examine the effect on functional shoulder scores of Bankart repair with arthroscopic subscapularis tendon augmentation applied to cases of anterior shoulder instability with < 25% glenoid defect and ligament-labral failure. A total of 83 patients underwent Bankart repair with subscapularis tendon augmentation between 2015 and 2021. The range of movement of the patients was measured by 2 doctors using a goniometer. The Constant Murley score, American Shoulder and Elbow Surgeons score, Rowe score, and the University of California at Los Angeles scores were recorded preoperatively and postoperatively. Statistically significant increases were determined in the postoperative functional scores compared to the preoperative values as mean 41.4 ± 2.08 unit increase in the Constant Murley score, mean 41.4 ± 1.8 unit increase in the American Shoulder and Elbow Surgeons score, mean 13.8 ± 1.45 unit increase in the University of California at Los Angeles and mean 49.3 ± 7.45 unit increase in the Rowe score (P = .001; P < .01). Compared with the preoperative evaluation, there was found to be a postoperative statistically significant unit decrease of 10.2 ± 1.47 in the external rotation measurement (P = .001; P < .01). The number of dislocations was determined to have a negative correlation with the internal rotation measurements (r = -0.305; P = .005; P < .01), and a weak negative statistically significant relationship with external rotation measurements (r = -0.329; P = .002; P < .01). Unlike other techniques, as this repair technique includes both the tendon and the capsule as a single piece, it was seen to be a sufficient and reliable technique that is easy-to apply.

Revision Arthroscopic Bankart Repair Results in High Failure Rates and a Low Return to Duty Rate Without Recurrent Instability

PURPOSE

The purpose of this study was to determine, in a military population without critical bone loss, the rate of recurrent instability after revision arthroscopic stabilization for failed primary arthroscopic Bankart repair.

METHODS

Forty-one revision arthroscopic stabilizations were performed at a single military institution between 2005 to 2016 for recurrent anterior shoulder instability after primary arthroscopic Bankart repair. Minimum follow-up was 2 years, and shoulders with glenoid bone loss >20% were excluded. The primary outcome of interest was the incidence of failure, defined by recurrent instability.

RESULTS

Age at revision surgery averaged 22.9 ± 4.3 years, and 88% were either service academy cadets or active duty combat arms soldiers. Mean follow-up was 7.8 years. Twenty-three patients (56%) returned to duty without recurrent instability after revision arthroscopic stabilization. Eighteen patients (44%) experienced recurrent instability after return to duty. Glenoid bone loss averaged 6.2% (95% confidence interval [CI], 3.2%-9.2%) in the successful group and 5.7% (95% CI, 3.1%-8.3%) in the failure group (P = .808).

CONCLUSIONS

Revision arthroscopic stabilization of failed primary arthroscopic Bankart repair has a failure rate of 44% in a young military population. The similar amounts of bone loss between groups indicates that bone loss is not the primary determinant of failure in revision arthroscopic stabilization.

LEVEL OF EVIDENCE

IV, Case Series.

Surgical Outcomes and Associated Injuries of Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) Lesions: A Systematic Review

Introduction

Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) lesions can lead to chronic shoulder instability and repetitive dislocations in active populations.

Objective

The purpose of this systematic review was to evaluate associated injuries and postoperative outcomes following ALPSA lesion repairs.

Methods

Medline, Embase, Cochrane, and Web of Science were searched through May 2022 for studies that investigated management and surgical outcomes of ALPSA lesion repair. Data was extracted on the following topics: surgical management, surgical complications, associated injuries, follow-up duration, and outcome parameters, including recurrence rates, functional outcome scores, range-of-motion (ROM), and return to activity.

Results

A total of 6 studies covering 202 patients met the inclusion criteria. In the included studies, 79% of patient were male with a mean age of 25.1 years. A total of 192 associated injuries were reported amongst 176 patients with the most common being Hill Sachs lesions (84, 43.8%), synovitis (35, 18.2%), SLAP tears (32, 16.7%) and glenoid erosions or lesions (30, 15.6%). All 202 patients were treated arthroscopically with no reported complications. 26 patients (12.9%) experienced operative failure as evidenced by recurrence of shoulder instability over a mean follow-up of 4.3 years. Various clinical outcome scores showed postoperative functional improvement and one study reported a 100% return to activity rate in 26 patients.

Conclusion

Our findings suggest a high 12.9 % risk of recurrence following ALPSA repair but satisfactory functional outcomes, both of which should be weighed by physicians when considering arthroscopic repair. Physicians should also be cognizant of co-pathologies when examining patients with suspected ALPSA lesions.

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.

Outcomes of Arthroscopic Anterior Labroligamentous Periosteal Sleeve Avulsion Lesions: A Minimum 2-Year Follow-up

BACKGROUND

Anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions can occur in recurrent anterior shoulder instability, which may lead to the labrum scarring medially to the glenoid. ALPSA lesions have also been associated with greater preoperative dislocations, larger Hill-Sachs lesions, and greater degrees of glenoid bone loss. Therefore, patients with these lesions have historically had a higher failure rate after repair, with nearly double the recurrent instability rate compared with those undergoing standard arthroscopic Bankart repair.

PURPOSE

To compare minimum 2-year outcomes of arthroscopic mobilization and anatomic repair of ALPSA lesions with those after standard arthroscopic Bankart repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Consecutive patients who underwent arthroscopic repair of ALPSA lesions were matched in a 1-to-3 fashion to patients who underwent standard Bankart repair by age, sex, number of previous ipsilateral shoulder instability surgical procedures, and number of anchors used. Patient-reported outcome (PRO) scores were compared preoperatively and postoperatively (American Shoulder and Elbow Surgeons [ASES]; 12-Item Short Form Health Survey [SF-12] Physical Component Summary [PCS]; Single Assessment Numeric Evaluation [SANE]; shortened version of Disabilities of the Arm, Shoulder and Hand; and satisfaction). Recurrent instability, on- versus off-track Hill-Sachs lesion, and reoperation rates were analyzed.

RESULTS

A total of 100 shoulders (25 ALPSA and 75 Bankart) with an overall mean age of 25.7 years were evaluated. Patients in the ALPSA group demonstrated significant improvements in the ASES (preoperative, 74.8; postoperative, 89.7; P = .041) and SF-12 PCS (preoperative, 46.9; postoperative, 53.4; P = .021) scores but not the SANE score (preoperative, 65.2; postoperative, 75.3; P = .311). Patients in the Bankart group had significant improvements in all outcome scores at final follow-up: ASES (preoperative, 67.1; postoperative, 90.3), SANE (preoperative, 58.0; postoperative, 85.7), and SF-12 PCS (preoperative, 45.3; postoperative, 52.9) (all P < .001). There were no significant differences in PRO scores between the groups preoperatively or postoperatively (P > .05). The median satisfaction for the ALPSA group was 10 of 10 and for the Bankart group it was 9 of 10 (P = .094). There was a significantly higher rate of recurrent dislocation in the ALPSA group (8/25 [32.0%]) compared with the Bankart group (10/75 [13.3%]) (P = .040). Additionally, 5 patients (20.0%) in the ALPSA group underwent revision surgery at a mean of 5.6 years, and 8 patients (10.7%) in the Bankart group underwent revision surgery at a mean of 4.4 years (P = .311).

CONCLUSION

Despite improvements in the recognition of and surgical techniques for ALPSA lesions, they still lead to significantly higher postoperative dislocation rates; however, no differences in PRO scores were found. These findings highlight the importance of early surgical interventions in anterior shoulder instability with the hope of lessening recurrent instability and the risk of developing an ALPSA lesion, as well as careful assessment of the quality of soft tissues and other risk factors for recurrence when considering what type of shoulder stabilization procedure to perform.

[Research progress on the relationship between shoulder instability and superior labrum anterior posterior lesion]

OBJECTIVE

To summarize the relationship between shoulder instability and superior labrum anterior posterior (SLAP) lesion.

METHODS

The characteristics of shoulder instability and SLAP lesion were analyzed, and the relationship between them in pathogenesis, clinical symptoms, and biomechanics was discussed by referring to relevant domestic and foreign literature.

RESULTS

Shoulder instability and SLAP lesion can occur both spontaneously and respectively. SLAP lesion destroys the superior labrum integrity and the long head of biceps tendon (LHBT) insertion, causing excessive humeral head displacement against glenoid, and leading to shoulder instability. While chronic repetitive or acute high-energy traumatic shoulder instability can in turn aggravate SLAP lesion, resulting in expansion and increased degree of the original lesion.

CONCLUSION

SLAP lesion destroys mechanisms of shoulder stability, while shoulder instability causes tears of the upper labrum and the LHBT, showing a connection between shoulder instability and SLAP lesion. However, the existing evidence can only demonstrate that shoulder instability and SLAP lesion induce and promote the development of each other, instead of a necessary and sufficient condition. Therefore, the specific causal relationship between the two remains unknown and needs to be further studied.

Associated Pathologies following Luxatio Erecta Humeri: A Retrospective Analysis of 38 Cases

Inferior shoulder dislocation in fixed abduction, also known as luxatio erecta humeri (LEH), is a rare injury with little data available. Therefore, the primary aim of this study was to evaluate and present our case series of this type of injury with special emphasis on associated pathologies; the secondary aim was to present diagnostic recommendations to detect for potential associated pathologies typically seen with this injury. A total of 38 patients (13 females, average age 72.8 years and 25 males, average age 41.4 years), who have been treated for inferior shoulder dislocation between 1992 and 2020, were included in this study. Associated pathologies after LEH were found in 81% of the cases. Twenty-one of these patients presented with secondary bony pathologies. Six patients revealed rotator cuff injuries diagnosed by magnetic resonance imaging (MRI). Seven patients exhibited pathological findings at the capsule-ligament complex. Eight patients presented with neurological findings. All neurologic symptoms except one axillary nerve palsy and a radialis paresis dissolved during the follow-up period. Five patients received surgical treatment of the affected shoulder. Inferior shoulder dislocation is a rare condition presenting with a high number of associated injuries. According to the findings of the present study, we want to raised awareness of the high rate of potential secondary shoulder pathologies associated with LEH. Beside a thorough clinical examination and immediate standard radiographs in two planes, we recommend to perform computed tomography scanning and an MRI of the shoulder as soon as possible. In the case of neurologic deficiencies, a determination of nerve conduction should be performed.

Capsulolabral Reconstruction During the Open Latarjet Procedure

Surgical treatment of anterior glenohumeral joint instability can be challenging and carries the inherent risk of recurrent instability, dislocation arthropathy, and postoperative loss of external rotation. In the current manuscript, a technique for combined reconstruction of anterior labrum and capsule, with concomitant reduction of the humeral head during anterior capsule reconstruction in open Latarjet procedure, is presented. Analogous to other techniques, the coracoid graft is fixed on the anteroinferior part of the glenoid between 3 and 5 o'clock. However, for this technique, reattachment of the labrum is performed between the native glenoid and the bone graft. Additionally, during the reconstruction of the anterior capsule on the coracoacromial ligament, while the operated arm is held in external rotation to avoid the postoperative rotational deficit, the humeral head is reduced posteriorly in the center of the glenoid during adduction, slight anterior forward flexion, and a posterior lever push. By doing so, the inherent theoretical risks of persistent instability and dislocation arthropathy are believed to be decreased. Further studies are needed to clarify the long-term consequences of this surgical technique in the clinical setting.

Bankart Repair With Subscapularis Augmentation in Athletes With Shoulder Hyperlaxity

PURPOSE

The purpose of this study was to demonstrate that arthroscopic Bankart repair with associated arthroscopic subscapularis augmentation (ASA) could be a valid surgical option in the treatment of anterior shoulder instability, in collision and contact sports athletes, affected by shoulder hyperlaxity.

METHODS

In total, 591 arthroscopic Bankart repairs plus ASA were performed in 6 shoulder centers from 2009 to 2017. Inclusion criteria were the following: collision and contact sports activities, recurrent anterior instability associated with hyperlaxity and glenoid bone loss (GBL) < 15%. Exclusion criteria were GBL > 15%, voluntary instability, multidirectional instability, pre-existing osteoarthritis and throwing athletes. The minimum follow-up was 24 months. Hyperlaxity was clinically evaluated according to Neer and Coudane-Walch tests. Before surgery, all patients underwent magnetic resonance imaging and computed tomography scanning. Pico area method was used to assess the percentage of GBL. Patients were operated on by 6 surgeons, and their functional outcomes were evaluated by 2 independent observers. The Western Ontario Shoulder Instability Index (WOSI), Rowe, American Shoulder and Elbow Surgeons (ASES) scores were used to assess results.

RESULTS

Overall, 397 patients with evidence of shoulder hyperlaxity (positive sulcus sign in ER1 position and Coudane-Walch test > 85°) met all inclusion criteria. The mean WOSI score was 321; the mean Rowe score rose from 68.5 to 92.5 (P = .037), and the ASES score rose from 71.5 to 97.4 (P = .041). Seven patients (1.6%) had atraumatic redislocation, and 9 patients (2.2%) had post-traumatic redislocation. At final follow-up the mean functional deficit of external rotation was 15° with the arm in adduction (ER1 position) and 10° in abduction (ER2 position).

CONCLUSIONS

The Bankart repair plus ASA has been demonstrated to be safe and effective for restoring joint stability in patients practicing collision and contact sports or affected by chronic anterior shoulder instability associated with GBL (<15%) and hyperlaxity, without compromising external rotation.

LEVEL OF EVIDENCE

Level IV, case series.

Epidemiology of Shoulder Instability in the National Football League

Background

Shoulder instability is a common and potentially debilitating injury among collision sport athletes that can lead to long-term damage of the glenohumeral joint. Limited data exist regarding instability among elite athletes in the National Football League (NFL).

Purpose

To describe the epidemiology of shoulder instability in the NFL from 2012 through 2017.

Study Design

Descriptive epidemiology study.

Methods

The NFL's injury database was reviewed for shoulder instability injuries resulting in missed time during the study inclusion dates. Injuries were classified by type and direction, as well as timing, setting, and mechanism. Median missed time was determined for the different types and directions of instability. Incidence rates for game-related injuries were calculated based on timing during the season and player position. Finally, the relationship between player position and instability direction was assessed.

Results

During the 6-year study period, 355 players sustained 403 missed-time shoulder instability injuries. Most injuries occurred during games (65%) via a contact mechanism (85%). The overall incidence rate of game-related instability was 3.6 injuries per 100,000 player-plays and was highest during the preseason (4.9 per 100,000 player-plays). The defensive secondary position accounted for the most injuries, but quarterbacks had the highest incidence rate in games (5.5 per 100,000 player-plays). Excluding unspecified events (n = 128; 32%), 70% (n = 192) of injuries were subluxations and 30% (n = 83) were dislocations; 75% of dislocations were anterior, while subluxations were more evenly distributed between the anterior and posterior directions (45% vs 52%, respectively). Players missed substantially more time after dislocation compared with subluxation (median, 47 days vs 13 days, respectively). When instability direction was known, the majority of instability events among quarterbacks and offensive linemen were posterior (73% and 53%, respectively), while anterior instability was most common for all other positions.

Conclusion

Shoulder instability is a common injury in the NFL and can result in considerable missed time. Dislocations occur less frequently than subluxations but lead to greater time lost. While most dislocations are anterior, more than half of subluxations are posterior, which is likely the result of repetitive microtrauma to the posterior capsulolabral complex sustained during sport-specific motions such as blocking. The risk of instability varies by player position, and position may also influence instability direction.

The 50 Most-Cited Papers on Bankart Lesions

Purpose

To analyze the 50 most-cited articles pertaining to “Bankart lesions,” also known as anteroinferior labral tears, by means of citation analysis as well as to provide analysis and summary of the origins and trends of research on Bankart lesions.

Methods

Scopus was used to query the literature on Bankart lesions. Included articles were related to Bankart lesions and the indications, risk factors, techniques, and outcomes of arthroscopic and open Bankart repair. The 50 most-cited articles were analyzed in the following areas: year of publication, citations in the most recent year, total citation count, contributing authors, institutions, countries, and journals, article classifications, and level of evidence.

Results

Years of publication ranged from 1938 to 2013. There were 608 total citations in the most recent year. Total citation count was 12,441. Regarding country, journal, and authorship, United States, R. A. Arciero, and Arthroscopy were the highest respective contributors. Rush University had the greatest number of publications. The most common article classification was clinical outcomes. Of 49 clinical articles, the most frequent Level of Evidence was IV. The majority of the top 50 Bankart literature consisted of case series and retrospective studies performed in the United States.

Conclusions

Our findings are consistent with the hypothesis that the 50 most-cited articles about Bankart lesions are predominantly U.S.-based, produced by academic orthopaedic groups, clinical outcomes articles, and of Level IV and V evidence. This list of articles should serve as a reference tool for any orthopaedist looking to review Bankart literature.

Are there racial differences between patients undergoing surgery for shoulder instability? Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Group

BACKGROUND

The purpose of this study was to identify differences related to race in preoperative and intraoperative findings of patients undergoing operative treatment for shoulder instability.

METHODS

Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort were used. Of 1010 patients, 995 provided race and ethnicity information and were included in the analyses. Demographic characteristics, injury history, radiographic and intraoperative findings, and preoperative patient-reported instability, pain, and function were compared (1) between white and minority patients and (2) in a subgroup analysis between white patients and the 3 largest minority groups. The Distressed Communities Index (DCI) score was recorded for each patient's home ZIP code. Multiple logistic regressions were performed to determine whether models consisting of race/ethnicity, insurance carrier, and/or DCI score were predictive of bone and cartilage loss at the time of surgery.

RESULTS

Compared with white patients, a greater percentage of US minority patients had ≥2 dislocations (68.0% vs. 57.1%, P = .01), which corresponded with more frequent articular cartilage lesions (62.2% vs. 51.0%, P = .007) and increased frequencies of glenoid bone loss > 10% (16.2% vs. 8.7%, P = .03) and Hill-Sachs lesions (68.6% vs. 56.0%, P = .004). Specifically, when compared with white patients, African American and Asian patients showed significantly increased frequencies of glenoid bone loss > 10% (19.7% of African American patients, 18.4% of Asian patients, and 8.9% of white patients; P = .01) and Hill-Sachs lesions (65.6%, 71.7%, and 52.4%, respectively; P = .02). Race was an independent predictor of articular cartilage lesions (P = .04) and the presence of Hill-Sachs lesions (P = .01). A higher DCI score (P = .03) and race (P = .04) were both predictive of having glenoid bone loss > 10%.

CONCLUSION

We found that minority race was associated with increased number of preoperative dislocations and increased frequency of articular cartilage and Hill-Sachs lesions at the time of surgery, and both minority race and an increased DCI score were associated with glenoid bone loss > 10%. Further research is needed to understand the underlying reason for these differences and to optimize care for all patients with shoulder instability.

Surgical stabilization of pediatric anterior shoulder instability yields high recurrence rates: a systematic review

PURPOSE

The purpose of this systematic review was to assess the surgical techniques, indications outcomes and complications for pediatric patients (≤ 19 years old) undergoing shoulder stabilization procedures for anterior shoulder instability.

METHODS

The electronic databases MEDLINE, EMBASE, CINAHL, and Web of Science were searched from data inception to March 14, 2019 for articles addressing surgery for pediatric patients with anterior shoulder instability. The Methodological Index for Non-randomized Studies (MINORS) tool was used to assess the quality of included studies.

RESULTS

Overall 24 studies, with a total of 688 patients (696 shoulders) and a mean age of 16.6 ± 2.5 years met inclusion criteria. Mean follow-up was 49 ± 26 months. The majority (59%) of studies only offered shoulder stabilization procedures to patients with more than one shoulder dislocation, however, three studies reported operating on pediatric patients after first time dislocations. Of the included patients 525 had arthroscopic Bankart repair (78%), 75 had open Bankart repair (11%), 34 had modified Bristow (5%), and 26 had Latarjet (4%) procedures. The overall complication rate was 26%. Patients undergoing arthroscopic Bankart repair experienced the highest recurrence rate of 24%. There were no significant differences in recurrent instability (n.s.) or loss of external rotation (n.s.) in pediatric patients treated with arthroscopic Bankart repair compared to open Latarjet. Patients had a 95% rate of return to sport at any level (i.e. preinjury level or any level of play) postoperatively (95%).

CONCLUSIONS

Pediatric patients are at high risk of recurrent instability after surgical stabilization. The majority of pediatric patients with anterior shoulder instability were treated with arthroscopic Bankart repair. Most studies recommend surgical stabilization only after more than one dislocation. However, given the high rates of recurrence with non-operative management, it may be reasonable to perform surgery at a first-time dislocation, particularly in those with other risk factors for recurrence. With the current evidence and limited sample sizes, it is difficult to directly compare the surgical interventions and their post-operative efficacy (i.e. re-dislocation rates or range of motion). There was an overall high rate of return to sport after surgical stabilization at final follow-up.

LEVEL OF EVIDENCE

IV.

Arthroscopic management of anterior labrum periosteal sleeve avulsion (ALPSA) lesions: A case series with improved clinical outcomes using a modified technique

Introduction

Obejctive

Method

Results and conclusion

The Arthroscopic Bankart Repair: State of the Art in 2020: Decision-making and Operative Technique

Traumatic anterior shoulder instability is prevalent among young athletes, and recurrent dislocations can result in compromised upper extremity function, increasing glenohumeral bone loss, and ultimately, posttraumatic arthritis. Although management algorithms have evolved in response to contemporary data and technical innovation, the arthroscopic Bankart repair continues to be a mainstay for the primary surgical management of first-time or recurrent anterior shoulder instability with marginal attritional glenoid bone loss (ie, <10% to 15%) and/or "on track" Hill-Sachs defects. The advantages of arthroscopic stabilization include its minimally invasive technique, high cost effectiveness, and relatively low recurrence rates and propensity for perioperative complications. The current article reviews contemporary indications/contraindications, management of the first-time dislocator, critical glenoid bone loss, surgical technique, and reported clinical outcomes of the arthroscopic Bankart repair.

Anterior Shoulder Instability in the Professional Athlete: Return to Competition, Time to Return, and Career Length

Background:

Anterior shoulder instability is a common condition in professional athletes, yet little is known about the success of surgery. Return to competition (RTC) is a metric indicative of a successful outcome for professional athletes who undergo anterior shoulder stabilization surgery.

Purpose:

To determine the rate of RTC, time to RTC, recurrence rate, and length of career after surgery in professional athletes who had undergone surgical treatment for anterior shoulder instability.

Study Design:

Case series; Level of evidence, 4.

Methods:

We evaluated professional athletes who underwent surgical treatment for anterior shoulder instability by a single surgeon between 2007 and 2018. Data from patients’ medical records, a patient data registry, basic search engines, sports websites, and individual team websites were used to determine length of professional play before injury, duration of career after surgery, and RTC level.

Results:

Overall, 23 professional athletes (25 shoulders from 12 contact and 13 noncontact athletes) were identified. The mean age at the time of surgery was 24.3 ± 4.9 years (range, 16-35 years). Primary procedures included arthroscopic Bankart repair (76%; 19/25), open Latarjet (20%; 5/25), and bony Bankart repair (4%; 1/25). Of the 23 athletes, 22 returned to their previous level of competition (96%; 95% CI, 78%-100%). The mean time between surgery and RTC was 4.5 months (range, 3-8 months). There was no difference in time to RTC between contact and noncontact athletes (4.1 vs 4.4 months). There was no difference in RTC rates and time to return for players who received a Bankart repair versus a Latarjet procedure (4.6 vs 4.2 months). A total of 12 participants were still actively engaged in their respective sport at an average of 4.3 years since surgery, while 11 athletes went on to retire at an average of 4.8 years. Duration of play after surgery was 3.8 years for contact athletes and 5.8 years for noncontact athletes (P > .05).

Conclusion:

In this series, professional athletes who underwent surgical shoulder stabilization for the treatment of anterior glenohumeral instability returned to their presurgical levels of competition at a high rate. No differences in RTC rate or time to RTC were observed for contact versus noncontact athletes or for those who received arthroscopic Bankart repair versus open Latarjet. However, contact athletes had shorter careers after surgery than did noncontact athletes.

Time-sensitive ambulatory orthopaedic soft-tissue surgery paradigms during the COVID-19 pandemic

Purpose

Timing of surgery for orthopaedic injuries continues to evolve, as an improved understanding of biology, healing, and technological advances continues to challenge historical norms. With the growing COVID-19 pandemic stretching limited healthcare resources, postponing surgery becomes an inevitable and unenviable task for most orthopaedic surgeons, and a shift in outpatient paradigms is required to mitigate poor outcomes in patients.

Methods

A scoping review of five databases on surgical timing and orthopaedic soft-tissue injuries was performed. All randomized controlled trials, longitudinal cohort studies, retrospective case series, systematic reviews, meta-analyses, and expert opinions were included for review, with 65 studies meeting the inclusion criteria.

Results

Better outcomes appear to be associated with early surgery for subluxations (< 1 week), recurrent dislocations (> 2 episodes), ligamentous and tendinous injuries (< 2 weeks), and bony avulsion injuries (< 3 weeks). Spinal conditions with neurological compromise should be operated on within 24 hours and spinal instability within 72 hours to reduce the risk of complications and poor outcomes.

Conclusion

Most soft-tissue orthopaedic injuries can be managed with outpatient ambulatory surgery in a semi-elective setting. As the paradigm for outpatient surgery shifts due to technological advances and the COVID-19 pandemic, it is critical for surgeons to time their surgery appropriately to maintain the high standards of orthopaedic practice.

Arthroscopic stabilisation for shoulder instability

Since its first description over 30 years ago arthroscopic stabilisation has evolved. With improvements in knowledge, surgical techniques and materials technology, arthroscopic bankart repair has become the most widely used method for treating patients with symptomatic anterior shoulder instability. These procedures are typically performed in a younger, high demand patient population after a primary dislocation or to treat recurrent instability. A thorough clinical evaluation is required in the clinic setting not only to fully understand the injury pattern but also consider patient expectations prior to embarking on surgery. Diagnostic imaging will aid the clinician in determining the soft tissue pathology as well as assessing bone loss, which facilitates surgical decision-making. Selected patients may benefit from adjunctive procedures such as a remplissage for an "engaging" Hill-sachs lesion. This review will focus on the indications, pre-operative considerations, surgical techniques and outcomes of arthroscopic stabilisation.

Pan-labral tear of the shoulder joint in a non-athlete patient with six years history of recurrent shoulder subluxations and intraoperative findings of osteoarthritic changes: A case report

The hypermobility of the glenohumeral joint accounts for its anatomic predisposition for instability and dislocation. The stability of the shoulder joint is dependent on static and dynamic soft tissue structures, among which is the labrum. Circumferential labral tears are a rare pathological entity of shoulder instability that have not been commonly reported in the literature. A detailed history and physical examination are crucial for accurate diagnosis since MRIs have a poor sensitivity. A 40-year-old male patient with a history of atraumatic recurrent left shoulder subluxations for 6 years. On physical examination, there was no evidence of motor or sensory deficit. MR images were suggestive of Hills-Sachs lesion with intact rotator cuffs. Pan-labral tear repair via arthroscopy presents a unique challenge, even for the skilled orthopedic surgeon. Hence, the repair demands accessory portals and percutaneous techniques for the adequate placement of anchors. The purpose of this case is the rare presentation of a pan-labral tear repaired arthroscopically.

Concomitant Coracoid Process Fracture with Bony Bankart Lesion Treated with the Latarjet Procedure

Bony lesions of the glenoid and Hill-Sachs lesions are the most common injuries after a first-time traumatic shoulder dislocation. However, fracture of the coracoid process after traumatic shoulder dislocation is rare. A single, open surgical procedure could be performed by a Latarjet procedure using a fractured fragment of the coracoid process. If a fracture of the coracoid process is associated with a traumatic anterior shoulder dislocation, the Latarjet procedure may be the most appropriate surgical option.

Outcomes After Latarjet Procedure: Patients With First-Time Versus Recurrent Dislocations

BACKGROUND

The preoperative number of dislocations has been previously proved to be a major factor influencing the results after Bankart repair with more preoperative dislocations correlated with higher recurrence rates and more reoperations. This could possibly be because of the lower quality of the tissue repaired during the procedure after multiple dislocations. On the other hand, the Latarjet procedure does not "repair" but rather reconstructs and augments the anterior glenoid.

PURPOSE/HYPOTHESIS

The main objective was to report the clinical outcomes of patients undergoing a Latarjet procedure after 1 dislocation versus multiple (≥2) dislocations. The hypothesis was that the preoperative number of dislocations would not influence clinical results.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients older than 18 years who had undergone a primary Latarjet procedure for shoulder instability with at least 2 years of follow-up were included. Three different techniques were used: a mini-open technique using 2 screws, an arthroscopic technique using 2 screws, and an arthroscopic technique using 2 cortical buttons. Patients were evaluated and answered a questionnaire to assess the number of episodes of dislocation before surgery, the time between the first dislocation and surgery, recurrence of the dislocation, revision surgery, the Walch-Duplay score, the Simple Shoulder Test score, and the visual analog scale (VAS) score for pain.

RESULTS

A total of 308 patients were included for analysis with a mean follow-up of 3.4 ± 0.8 years. Of that, 83 patients were included in the first-time dislocation group and 225 in the recurrent dislocation group. At last follow-up, the rates of recurrence and reoperation were not significantly different between groups: 4.8% in the first-time dislocation group versus 3.65% in the recurrent dislocation group and 6.1% versus 4.0%, respectively. The overall Walch-Duplay scores at last follow-up were also comparable between the 2 groups, 67.3 ± 24.85 and 71.8 ± 25.1, even though the first-time dislocation group showed a lower pain subscore (15.0 ± 8.6 vs 18.0 ± 7.5; P = .003). The VAS for pain was also significantly higher in the first-time dislocation group compared with the recurrent dislocation group (1.8 ± 2.3 vs 1.2 ± 1.7; P = .03).

CONCLUSION

The number of episodes of dislocation before surgery does not affect postoperative instability rates and reoperation rates after the Latarjet procedure. However, patients with first-time dislocations had more postoperative pain compared with patients with recurrent dislocations before surgery.

Arthroscopic Circumferential Labral Repair for Patients With Multidirectional Instability: A Comparative Outcome Study

Background:

Circumferential tears of the glenohumeral labrum are an uncommon injury, comprising 2.4% of all labral lesions. Currently, the clinical outcomes of arthroscopic circumferential labral repair for patients with instability and combined anterior, posterior, and superior labral tears are not well-known.

Hypothesis:

Patients treated with arthroscopic circumferential shoulder labral repairs will have inferior clinical outcomes and higher failure rates compared with patients who have isolated arthroscopic anterior labral repairs.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective cohort study was performed to identify patients aged 18 years and older who underwent circumferential arthroscopic stabilization for recurrent instability as compared with an age-matched control group of arthroscopic primary anterior labral repairs. Age at surgery, American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form score, Simple Shoulder Test (SST) score, 12-Item Short Form Health Survey (SF-12) score (mental and physical), and overall patient satisfaction with surgery were assessed for each group.

Results:

A total of 35 consecutive patients (36 shoulders) who underwent an arthroscopic 360° circumferential labral repair were compared with a matched group of 31 patients who underwent an isolated arthroscopic anterior labral repair. The mean follow-up period was 34.3 and 56.8 months, respectively. No significant difference was found between the 2 groups for overall satisfaction with the surgery or recurrent instability. At the time of the follow-up survey, 22% of the patients experienced pain and 25% of the patients experienced instability in the circumferential repair group, whereas 15% of the patients experienced some level of pain and 30% of patients experienced a subjective sense of subtle instability in the isolated repair group. The ASES scores were 87.3 in the combined labral repair group and 93.3 in the isolated anterior group (P = .35), SST scores were 10.7 and 11.3 (P = .70), SF-12 mental scores were 54.6 and 56.8 (P = .80), SF-12 physical scores were 53.2 and 54.2 (P = .98), and age at time of the surgery was 26.7 and 24.6 years (P = .33), respectively. There was no difference between the 2 groups in pre- and postoperative range of motion (P > .05).

Conclusion:

There was no difference in shoulder stability and function in patients after 360° combined labral repairs versus anterior labral repair alone. With proper patient selection, patients can expect similar outcomes despite the more extensive surgical procedure and complex postoperative rehabilitation protocol for circumferential repairs.

Novel and effective arthroscopic extracapsular stabilization technique for anterior shoulder instability-BLS

PURPOSE

Arthroscopic Bankart repair for the treatment of anterior shoulder instability is associated with a high rate of recurrent instability. Extracapsular stabilization of the glenohumeral joint with enhancement of anterior wall soft tissues may be an effective alternative treatment technique. The aim of this study is to retrospectively assess clinical outcomes in the treatment of anterior shoulder instability using a novel technique of anterior extracapsular stabilization-"between glenohumeral ligaments and subscapularis tendon" (BLS).

METHODS

Patients with anterior shoulder instability who underwent surgical treatment with a novel arthroscopic BLS technique between 2008 and 2016 were eligible for inclusion. According to the level of glenoid bone loss, patients were separated into four groups. Group 1 comprised patients with GBL equal to or less than 5%, group 2 patients with GBL 6-10%, group 3 patients with GBL 11-15%, and group 4 patients with GBL > 15%. A positive outcome in this study was defined as full restoration of joint stability. To evaluate clinical results, preoperative range of ER and IR measured in 90 degrees of abduction were compared with ER and IR measured at final follow-up. Additional outcome instruments used consisted of the Constant Score and the Walch-Duplay Score.

RESULTS

A total of 150 patients underwent arthroscopic BLS surgery. During the study period, 50 patients were lost to follow-up and 100 patients were available for final analysis. Mean patient age was 27.5 (± 10.3) years at the time of surgery. Mean duration of follow-up was 82.9 (± 29.4) months. At final assessment, 86 patients (86%) were categorized as having a positive outcome, with full restoration of joint stability. Recurrence of shoulder instability was observed in 14 (14%) patients, including 6 (6%) cases that were associated with major trauma. At final follow-up, the mean Constant Score was 88.2 ± 10.1, compared to 82.9 ± 9.1 preoperatively (p < 0.05). The mean final and mean preoperative Walch-Duplay Scores were 81.5 ± 18.9 and 52.2 ± 11.9, respectively (p < 0.05). There was no statistically significant limitation of external or internal rotation.

CONCLUSIONS

The BLS technique has been shown to be an effective method to anterior shoulder instability in patients without significant glenoid bone loss. It was shown that this technique provides significant improvement in shoulder function without reducing shoulder range of motion.

LEVEL OF EVIDENCE

IV.

Outcomes for Arthroscopic Repair of Combined Bankart/SLAP Lesions in the Treatment of Anterior Shoulder Instability: A Systematic Review and Meta-analysis

Background

Arthroscopic repair of combined Bankart/superior labral anteroposterior (SLAP) lesions is commonly performed to treat anterior shoulder instability, the clinical outcomes of which have not been widely studied.

Purpose

To compare the clinical outcomes for arthroscopic repair of combined Bankart/SLAP lesions in the treatment of anterior shoulder instability and to ascertain whether it is inferior to isolated Bankart repair.

Study Design

Systematic review; Level of evidence, 3.

Methods

A systematic review of the literature was performed through use of the MEDLINE, EMBASE, and Cochrane Library databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Study bias was assessed using the MINORS (Methodological Index for Non-Randomized Studies) scoring system. Randomized controlled trials, prospective or retrospective cohort studies, and case-control studies were included, whereas systematic reviews, literature reviews, conference abstracts, case reports, case series, and non-peer-reviewed studies were excluded to guarantee the quality of the study. Data on outcomes including recurrence rate, functional scores, and range of motion (ROM) were pooled, with statistical analysis performed. A P value of <.05 was considered statistically significant.

Results

The review included 7 studies with a total of 520 patients. The pooled recurrence rate after combined Bankart/SLAP repair was 6.47% (9/139). Significant improvements of postoperative versus preoperative functional scores were observed, including a reduction in the visual analog scale score for pain (mean ± SD: 0.99 ± 1.36 vs 4.13 ± 2.26; P < .00001) and an increase in mean Rowe score (89.56 ± 11.46 vs 43.16 ± 8.87; P < .00001) and mean Constant score (91.41 ± 7.57 vs 59.70 ± 5.63; P < .00001). In terms of ROM, no reduction was found in external rotation (66.56° ± 13.33° vs 67.22° ± 14.27°; P = .21), and a significant increase in abduction was found (157.67° ± 4.11° vs 144.18° ± 8.28°; P < .00001). No statistically significant difference was found between arthroscopic repair of combined Bankart/SLAP lesions and isolated Bankart repair regarding recurrence rate, functional scores, or ROM.

Conclusion

Of the pooled data, patients who underwent arthroscopic repair of combined Bankart/SLAP lesions in treatment of anterior shoulder instability showed a low recurrence rate, favorable functional scores, and no significant restriction on ROM, all of which were not significantly worse than outcomes of isolated Bankart repair. Therefore, combined repair was proven to be a viable option for extensive labral lesions.

Arthroscopic Treatment of First-Time Shoulder Dislocations in Younger Athletes

Background:

The glenohumeral joint is characterized by its large degree of movement and consequently is the most susceptible joint to dislocations. There are few studies on the first episode of a shoulder dislocation in younger athletes.

Purpose:

To report the results of arthroscopic treatment for the first episode of a glenohumeral dislocation in younger athletes.

Study Design:

Case series; Level of evidence, 4.

Methods:

In this retrospective study, 53 patients younger than 40 years (N = 54 shoulders) sustained their first anterior shoulder dislocation and underwent arthroscopic surgery. Surgery was undertaken in the lateral decubitus position. Standard posterior, anteroinferior, and anterosuperior portals were used, and the number of anchors and the degree of capsular plication were individualized and based on the arthroscopic findings of each patient. The minimum follow-up was 2 years (mean, 2.31 years), and patients were evaluated with the Rowe functional score, Athletic Shoulder Outcome Rating Scale (EROE; acronym in Portuguese), and visual analog scale (VAS) for pain.

Results:

The mean EROE score was 93.8, with 98% of results being good or excellent, and the mean Rowe score was 95.0, with 98% good or excellent results. The mean VAS pain score was <1.0. The rate of recurrence of dislocations was 2%. The return-to-sports rate was 83%; patients with associated superior labral anterior-posterior (SLAP) lesions had a lower return-to-sports rate (P = .001) and lower EROE (P = .017) and Rowe (P = .019) scores.

Conclusion:

The present study showed favorable results for arthroscopic surgical treatment after the first dislocation episode in young athletes. It was an effective and safe treatment option in this population.

Risk factors for anterior shoulder instability: a matched case-control study

BACKGROUND

Anatomic skeletal features of the shoulder play important roles in anterior shoulder dislocation. However, studies on the effect of the humeral structure are few. This case-control study aimed to analyze the risk factors of anterior shoulder instability, including glenoid and humeral factors.

METHODS

Anterior shoulder instability was found in 64 of 10,035 individuals who underwent magnetic resonance imaging. Propensity score matching was used to select controls matched for age, sex, height, and weight. We analyzed the glenoid and humeral structural data using conditional logistic regression analysis and identified cutoff points using receiver operating characteristic curve analysis.

RESULTS

Significant differences were found between the control and dislocation groups in the depth-to-width ratio (0.119 ± 0.034 vs. 0.105 ± 0.037, P = .021), height-to-width ratio (1.51 ± 0.13 vs. 1.67 ± 0.16, P < .001), humeral head diameter-to-glenoid fossa diameter ratio (1.56 ± 0.11 vs. 1.64 ± 0.20, P < .001), and humeral containing angle (67.3° ± 5.9° vs. 60.4° ± 5.9°, P < .001). The humeral containing angle (odds ratio, 0.95; P = .024) and the glenoid height-to-width ratio (odds ratio, 7.88; P = .002), adjusted for the depth-to-width ratio and diameter ratio, were associated with anterior shoulder instability. The cutoff point for the humeral containing angle was 64° and for the height-to-width ratio was 1.60.

CONCLUSIONS

This study revealed significant risk factors for shoulder instability in the Chinese Han population. The humeral containing angle and the glenoid height-to-width ratio were risk factors for anterior shoulder instability.

Recurrent Shoulder Instability: Do Morbidity and Treatment Differ Based on Insurance?

Background:

Patients with public insurance often face barriers to obtaining prompt orthopaedic care. For patients with recurrent traumatic anterior shoulder instability, delayed care may be associated with increasing bone loss and subsequently more extensive surgical procedures.

Purpose/Hypothesis:

The purpose of this study was to evaluate whether differences exist in patients undergoing treatment for shoulder instability between those with Medicaid versus non-Medicaid insurance. We hypothesized that at the time of surgery, Medicaid patients would have experienced greater delays in care, would have a more extensive history of instability, would have more bone loss, and would require more extensive surgical procedures than other patients.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients were identified who underwent surgical stabilization for traumatic anterior shoulder instability between January 1, 2011, and December 1, 2015, at a single sports medicine practice. Clinic, billing, and operative records were reviewed for each patient to determine age, sex, insurance type, total number of instability episodes, time from first instability episode to surgery, intraoperative findings, and procedure performed. Glenoid bone loss was quantified by use of preoperative imaging studies.

Results:

During this time period, 206 patients (55 Medicaid, 131 private insurance, 11 Tricare, 9 workers’ compensation) underwent surgical stabilization for traumatic anterior shoulder instability. Average wait time from initial injury to surgery was 1640 days (95% CI, 1155-2125 days) for Medicaid patients compared with 1237 days (95% CI, 834-1639 days) for others (P = .005). Medicaid patients were more likely to have sustained 5 or more instability events at the time of surgery (OR, 3.3; 95% CI, 1.64-6.69; P = .001), had a higher risk of having 15% or more glenoid bone loss on preoperative imaging (OR, 3.5; 95% CI, 1.3-10.0; P = .01), and had a higher risk of requiring Latarjet or other open stabilization procedures as opposed to an arthroscopic repair (OR, 3.0; 95% CI, 1.5-6.2; P = .002) when compared with other patients.

Conclusion:

Among patients undergoing surgery for traumatic anterior shoulder instability, patients with Medicaid had significantly more delayed care. Correspondingly, they reported a more extensive history of instability, were more likely to have severe bone loss, and required more invasive stabilization procedures.

Prospective Evaluation of Glenoid Bone Loss After First-time and Recurrent Anterior Glenohumeral Instability Events

BACKGROUND

Determining the amount of glenoid bone loss in patients after anterior glenohumeral instability events is critical to guiding appropriate treatment. One of the challenges in treating the shoulder instability of young athletes is the absence of clear data showing the effect of each event.

PURPOSE

To prospectively determine the amount of bone loss associated with a single instability event in the setting of first-time and recurrent instability.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

The authors conducted a prospective cohort study of 714 athletes surveilled for 4 years. Baseline assessment included a subjective history of shoulder instability. Bilateral noncontrast shoulder magnetic resonance imaging (MRI) was obtained for all participants with and without a history of previous shoulder instability. The cohort was prospectively followed during the study period, and those who sustained an anterior glenohumeral instability event were identified. Postinjury MRI with contrast was obtained and compared with the screening MRI. Glenoid width was measured for each patient's pre- and postinjury MRI. The projected total glenoid bone loss was calculated and compared for patients with a history of shoulder instability.

RESULTS

Of the 714 athletes (1428 shoulders) who were prospectively followed during the 4-year period, 22 athletes (23 shoulders) sustained a first-time anterior instability event (5 dislocations, 18 subluxations), and 6 athletes (6 shoulders) with a history of instability sustained a recurrent anterior instability event (1 dislocation, 5 subluxations). On average, there was statistically significant glenoid bone loss (1.84 ± 1.47 mm) after a single instability event ( P < .001), equivalent to 6.8% (95% CI, 4.46%-9.04%; range, 0.71%-17.6%) of the glenoid width. After a first-time instability event, 12 shoulders (52%) demonstrated glenoid bone loss ≥5% and 4 shoulders, ≥13.5%; no shoulders had ≥20% glenoid bone loss. Preexisting glenoid bone loss among patients with a history of instability was 10.2% (95% CI, 1.96%-18.35%; range, 0.6%-21.0%). This bone loss increased to 22.8% (95% CI, 20.53%-25.15%; range, 21.2%-26.0%) after additional instability ( P = .0117). All 6 shoulders with recurrent instability had ≥20% glenoid bone loss.

CONCLUSION

Glenoid bone loss of 6.8% was observed after a first-time anterior instability event. In the setting of recurrent instability, the total calculated glenoid bone loss was 22.8%, with a high prevalence of bony Bankart lesions (5 of 6). The findings of this study support early stabilization of young active patients after a first-time anterior glenohumeral instability event.

10 Years of Arthroscopic Latarjet Procedure: Outcome and Complications

BACKGROUND

The treatment of anterior glenohumeral instability with a Bankart repair combined with a capsular plication is a frequently used arthroscopic technique. Latarjet created an open bone block procedure in 1954 for the treatment of anteroinferior glenohumeral instability. This procedure has been further developed by Lafosse in 2003 for arthroscopic surgery. The aim of this study is to evaluate the clinical outcome and complications of the latter procedure, most notably infection rate and nerve damage.

MATERIALS AND METHODS

132 shoulders (106 males/19 females, 68 right/64 left) were included in this retrospective study. Patients were included if treatment was performed for anterior instability and if the patient's instability severity index score was at least 4, or if a revision procedure was performed after a prior unsuccessful arthroscopic or open capsule and labral repair. Treatment included the arthroscopic transfer of the coracoid process for the anterior stabilization of the shoulder joint. The disabilities of the arm, shoulder, and hand score were evaluated postoperatively in 76 patients and compared with the results found in the literature. Mean followup was 20.1 [±14.09] months.

RESULTS

The rate of recurrent glenohumeral instability which needed revision surgery after the arthroscopic Latarjet procedure was 6.1% (n = 8). There were no severe neurovascular complications seen in our cohort. In 32 cases, re-operation was performed due to subjective discomfort because of screw impingement or postoperative shoulder stiffness.

CONCLUSION

The all-arthroscopic Latarjet procedure developed by Lafosse is a valid and reliable method for the treatment of shoulder instability. Our favorable results indicating that this procedure can prevent chronic shoulder luxation are repeatable, and the rate of postoperative recurrence is low.

The arthroscopic Bankart repair procedure enables complete quantitative labrum restoration in long-term assessments

PURPOSE

The restoration of the labrum complex and the influence on secondary osteoarthritis after arthroscopic Bankart repair on magnetic resonance imaging (MRI) remain unclear.

METHODS

Twenty-one patients were retrospectively followed after unilateral primary arthroscopic Bankart repair with knot-tying suture anchors (8.8 ± 2.5 years after surgery, age 25.3 ± 6.3 years). Bilateral structural MRI was performed to assess labrum-glenoid restoration by measurements of the labrum slope angle, height index, and labrum interior morphology according to the Randelli classification. Osteoarthritic status was bilaterally assessed by a modified assessment based on the Samilson-Prieto classification.

RESULTS

MRI assessment revealed full labrum-glenoid complex restoration with equivalent parameters for anterior slope angle (mean ± SD: 21.3° ± 2.6° after Bankart repair vs. 21.9° ± 2.6° control) and height index (2.34 ± 0.4 vs. 2.44 ± 0.4), as well as the inferior slope angle (23.1° ± 2.9° vs. 23.3° ± 2.1°) and height index (2.21 ± 0.3 vs. 2.21 ± 0.3) (all n.s.). The labrum morphology showed only for the anterior labrum significant alterations (1.4 ± 0.9 vs. 0.6 ± 0.7, p < 0.05), the inferior labrum occurred similarly (1.3 ± 0.8 vs. 0.8 ± 0.5, n.s.). Osteoarthritic changes were significantly increased after Bankart repair compared to the uninjured shoulder (4.8 ± 5.1 mm vs. 2.5 ± 1.0 mm; p < 0.05), with a significant correlation of osteoarthritis status between both shoulders (p < 0.05). Scores generally decreased after Bankart repair (constant 84.6 ± 9.5 vs. 94.5 ± 4.9 control, p < 0.05; Rowe 84.5 ± 6.5 vs. 96.2 ± 4.2, p < 0.05; Walch-Duplay 82.4 ± 7.0 vs. 94.3 ± 4.0, p < 0.05) with a strong correlation with osteoarthritis status (p < 0.05).

CONCLUSIONS

Arthroscopic Bankart repair enabled good clinical outcomes and complete quantitative labrum restoration parameters. Next to several well-known parameters, secondary osteoarthritis after arthroscopic Bankart repair significantly correlated with osteoarthritic status of the uninjured contralateral shoulder but was not influenced by quantitative labrum restoration. The recommendation for arthroscopic Bankart repair should be based on clinical parameters and not on prevention of secondary osteoarthritis.

STUDY DESIGN

Case series.

LEVEL OF EVIDENCE

IV.

Shoulder apprehension: A multifactorial approach

Shoulder apprehension is related to changes in functional cerebral networks induced by dislocations, peripheral neuromuscular lesions and persistent mechanical glenohumeral instability consisting of micro-motion.All the damage to the osseous and soft-tissue stabilizers of the shoulder, as well as neurologic impairment persisting even after stabilization, must be properly identified in order to offer the best possible treatment to the patient.There is growing evidence supporting the use of a global multimodal approach, involving, on the one hand, shoulder 'reafferentation', including proprioception, mirror therapy and even cognitive behavioural approaches, and, on the other hand, surgical stabilization techniques and traditional physical therapy in order to minimize persistent micro-motion, which may help brain healing. This combined management could improve return to sport and avoid dislocation arthropathy in the long term. Cite this article: EFORT Open Rev 2018;3:550-557. DOI: 10.1302/2058-5241.3.180007.

Traumatic Anterior Instability: Treatment Options for Initial Instability

Because of the lack of bony restraints and minimal articular contact, the glenohumeral joint can attain significant range of motion; however, this results in the propensity for instability. The most generic form of instability, traumatic anterior instability, reliably produces a series of pathoanatomic findings. While reliable, these findings contribute to the complexities of caring for patients after an initial instability event. Numerous studies have examined this issue and determined that careful consideration of patient factors can guide successful treatment, whether it be surgical or nonsurgical, after initial instability. Such forms of treatment have shown to provide a good functional outcome and decreases morbidity. To be able to provide successful treatment requires a thorough understanding of the pathoanatomic of an instability event and the intricacies of the evaluation of a patient after an initial instability event.

Early return to baseline range of motion and strength after anterior shoulder instability surgery: a Multicenter Orthopaedic Outcomes Network (MOON) shoulder group cohort study

BACKGROUND

Patients often return to higher-level activities and sports at 4 to 8 months after anterior shoulder stabilization procedures. It is unknown what percentage of patients have regained normal function at this time frame and what factors predict residual deficits, range of motion (ROM), and strength after anterior shoulder instability surgery.

METHODS

Ten participating sites throughout the United States enrolled patients in a prospective cohort study including primary, revision, arthroscopic, and open anterior stabilization procedures. Baseline demographic data and patient outcomes questionnaires were collected with initial physical examination, treatment, surgical findings, and surgical repair details. At the 6-month follow-up visit, ROM and strength measurements were collected and compared with preoperative measurements.

RESULTS

There were 348 patients identified who underwent surgical treatment for anterior shoulder instability. Of these, 259 patients (74.0%) returned to baseline, and 89 (26.0%) did not return to baseline shoulder ROM (≥20° loss of ROM) or strength. A higher Beighton score (P = .01) and number of dislocations (P < .01) were associated with failure to regain baseline ROM and strength at early follow-up. No surgical variables were found to influence return to baseline function, including open vs. arthroscopic surgery, primary vs. revision surgery, and number of suture anchors.

CONCLUSIONS

By 4 to 8 months postoperatively, 76% of patients return to baseline ROM, 98% return to baseline strength, and 74% return to both baseline ROM and strength. An increased number of dislocations and generalized joint laxity were associated with failure to return to baseline ROM and strength at early follow-up after anterior shoulder instability surgery.

Rehabilitation Following Surgery for Glenohumeral Instability

Shoulder dislocation and subsequent instability is a common problem in young athletes. Though it is not uncommon to attempt nonoperative rehabilitation in the early going, reinjury rates are high, particularly with contact sport athletes. As a result, many athletes will undergo a primary repair of one, or multiple, glenohumeral ligaments that make up the anterior shoulder capsule. This paper presents phases of rehabilitation from the preoperative stage up to returning to play. Criteria for phase progression are included, along with examples of common exercises and themes for each phase that allow the physical therapist to consider when working with patients who have had this type of shoulder surgery, allowing them to return to full function with low risk of reinjury.

Surgical stabilization for first-time shoulder dislocators: a multicenter analysis

BACKGROUND

Anterior shoulder dislocations in young patients are associated with high rates of recurrent instability. Although some surgeons advocate for surgical stabilization after a single dislocation event in this population, there is sparse research evaluating surgical treatment for first-time dislocators.

METHODS

Patients undergoing surgical stabilization for anterior shoulder instability were prospectively enrolled at multiple institutions from 2015-2017 and stratified by number of dislocations before surgery. Demographic data, preoperative patient-reported outcomes, imaging findings, surgical findings, and procedures performed were compared between groups. Analysis of variance, χ², and multivariate logistic regression were used for statistical analysis.

RESULTS

The study included 172 patients (mean age, 25.3 years; 79.1% male patients) for analysis (58 patients with 1 dislocation, 69 with 2-5 dislocations, 45 with >5 dislocations). There were no intergroup differences in demographic characteristics, preoperative patient-reported outcomes, or physical examination findings. Preoperative imaging revealed increased glenoid bone loss in patients with multiple dislocation events (P = .043). Intraoperatively, recurrent dislocators were more likely to have bony Bankart lesions (odds ratio [OR], 3.26; P = .024) and biceps pathology (OR, 6.27; P = .013). First-time dislocators more frequently underwent arthroscopic Bankart repair and/or capsular plication (OR, 2.22; P = .016), while recurrent dislocators were more likely to undergo open Bristow-Latarjet procedures (OR, 2.80; P = .049) and surgical treatment for biceps pathology (OR, 5.03; P = .032).

CONCLUSIONS

First-time shoulder dislocators who undergo stabilization are more likely to undergo an arthroscopic procedure and less likely to have bone loss or biceps pathology compared with recurrent dislocators. Future studies are needed to ascertain long-term outcomes of surgical stabilization based on preoperative dislocation events.

Concomitant SLAP repair does not influence the surgical outcome for arthroscopic Bankart repair of traumatic shoulder dislocations

BACKGROUND

Prior studies revealed the presence of superior labrum anterior-to-posterior (SLAP) injury together with Bankart lesions in some patients. The purpose of the study is to compare the clinical results of isolated Bankart repairs with the clinical results of Bankart repairs when performed with concomitant SLAP repairs.

METHODS

The patients who underwent arthroscopic surgery for treatment of anterior glenohumeral instability were evaluated retrospectively. Group 1 consisted of 19 patients who had arthroscopic SLAP repair together with Bankart repair. The mean age of the patients was 23. Group 2 consisted of 38 patients who underwent isolated Bankart repair. The mean age was 24. Knotless anchors were used in both groups.

RESULTS

The mean follow-up was 34 months (range: 26-72). In group 1, the mean preoperative Constant score was 84 (range: 74-90, standard deviation (SD): 5.91) and Rowe score was 64.1 (range: 40-70, SD: 8.14). In group 2, the preoperative Constant score was 84.4 (range: 70-96, SD: 5.88) and Rowe score was 60 (range: 45-70, SD: 7.95). In group 1, the postoperative mean Constant score raised to 96.8 (range: 88-100, SD: 2.91) and the mean Rowe score raised to 92.3 (range: 85-100, SD: 5.17). In group 2, the postoperative mean Constant score was 94.9 (range: 88-100, SD: 3.70) and the mean Rowe score was 94.2 (range: 80-100, SD: 4.71). The difference between the scores of two groups was insignificant ( p > 0.05). When the numbers of redislocations and range of motion were compared, no significant difference was found ( p > 0.05).

CONCLUSION

Accompanying SLAP repair in surgical treatment with Bankart repair for shoulder instability does not affect the results negatively. Properly repaired labral tears extending from anterior inferior to the posterior superior of the glenoid in instability treatment have the same outcome in overall results as repaired isolated Bankart lesions.

Arthroscopic Treatment of a Type II Superior Labrum Anterior to Posterior (SLAP) Lesion Combined with a Bankart Lesion: Comparative Study between Debridement and Repair of Type II SLAP Lesion by the Status of Lesion

Background

The purpose of this study is to evaluate results of superior labrum anterior to posterior (SLAP) repairs and debridement of type II SLAP lesions combined with Bankart lesions.

Methods

Between 2010 and 2014, total 58 patients with anterior shoulder instability due to a Bankart lesion combined with a type II SLAP lesion were enrolled. Patients were divided into two groups: group C consisted of 30 patients, each with a communicated Bankart and type II SLAP lesion and group NC consisted of 28 patients, each with a non-communicated Bankart and type II SLAP lesion. Bankart repairs were performed for all patients. SLAP lesions were repaired in group C and debrided in group NC. Clinical results were analysed to compare groups C and NC by using the visual analogue scale pain score, American Shoulder and Elbow Surgeons score, Constant scores, Rowe score for instability and range of motion assessments.

Results

The clinical scores were improved in both groups at final follow-up. Also, there were no differences between two groups. No significant difference was found in terms of the range of motion measured at the last follow-up. The number of suture anchors used was significantly higher in group C than in group NC (5.6 vs. 3.8; p=0.021).

Conclusions

In this study, it is considered that Bankart repair and SLAP debridement could be a treatment option in patients with a non-communicated type II SLAP lesion combined with a Bankart lesion (study design: IV, therapeutic study, case series).

Controversies in the Management of the First Time Shoulder Dislocation

Background:

Traditionally, initial management of first anterior shoulder dislocations consists of reduction of the glenohumeral joint followed by a period of immobilization and subsequent physical therapy to recover shoulder range of motion and strength. This traditional approach in management is now controversial due to the high rate of recurrence. The aim of this paper is to review and discuss the literature about the global management of patients presenting with first-time traumatic anterior glenohumeral dislocation, analyzing the factors that affect shoulder instability after the first episode of dislocation.

Methods:

Scientific publications about the management of first-time shoulder dislocations are reviewed. Pubmed is used for that and no limit in the year of publication are stablished. These papers and their conclusions are discussed.

Results:

Younger patients, patient´s activities and the kind of injury are the most important factors related to the shoulder instability after a first time traumatic dislocation. Authors that recommend surgical treatment after the first episode of dislocation argue that the possibilities of recurrence are high and therefore surgery should be performed before its occurrence. Other authors, however, argue that surgical treatment is demanding, and keep in mind that complications, such as recurrence, stiffness and pain after surgery, are still present.

Conclusion:

Currently, there is still no consensus in the literature with regard to the management of first episode of shoulder dislocation. It is necessary to analyze carefully every individual case to manage them more or less aggressive to obtain the best result in our practice.

Back to Sports After Arthroscopic Revision Bankart Repair

BACKGROUND

Recurrent instability following primary arthroscopic stabilization of the shoulder is a common complication. Young, athletic patients are at the greatest risk of recurring instability. To date, the literature contains insufficient description regarding whether return to sports is possible after revision arthroscopic Bankart repair.

HYPOTHESIS

Patients presenting with recurrent instability after primary arthroscopic stabilization should expect limitations in terms of their ability to partake in sporting activities after revision surgery.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Twenty athletes who underwent arthroscopic revision stabilization of the shoulder after failed primary arthroscopic Bankart repair were included in the study after completing inclusion and exclusion criteria surveys. Athletic Shoulder Outcome Scoring System (ASOSS), Shoulder Sport Activity Score (SSAS), and the Subjective Patient Outcome for Return to Sports (SPORTS) scores were determined to assess the participants' ability to partake in sporting activities. Furthermore, sport type and sport level were classified and recorded. To assess function and stability, Rowe, American Shoulder and Elbow Surgeons, Constant-Murley, and Walch-Duplay scores were measured and recorded.

RESULTS

Follow-up consultations were carried out after a mean of 28.7 months. The mean age at follow-up examination was 27.75 years. At the time of follow-up, 70% of the patients were able to return to their original sporting activities at the same level. However, 90% of patients described a limitation in their shoulder when participating in their sports. At 28.7 months after surgery, the mean ASOSS score was 76.8; the SSAS score decreased from 7.85 before first-time dislocation to 5.35 at follow-up (P < .005). The SPORTS score was 5.2 out of 10 at the follow-up consultation. Function- and instability-specific scores showed good to excellent results. The mean external rotational deficit for high external rotation was 9.25°, and for low external rotation it was 12°.

CONCLUSION

Patients can return to their original type and level of sport after arthroscopic revision Bankart repair, but they must expect persistent deficits and limitations to the shoulder when put under the strains of sporting activity. Patients with shoulder injuries who partake in sports that put greater demand on the shoulder show the smallest probabilities of returning to sporting activity.

Rotator cuff muscular integrity after arthroscopic revision of a Bankart repair

INTRODUCTION

Recurrent shoulder instability after arthroscopic Bankart repair is still a common complication. For primary Bankart repair studies have shown that the rotator cuff can recover completely. The ability of muscles to regenerate after arthroscopic revision Bankart repair (ARBR) has not been studied. Does the ARBR using a three-portal method allows complete muscle integrity compared with an uninjured imaging control group (ICG)?

MATERIALS AND METHODS

Twenty-two (1 female, 21 males) physically active patients (mean age at follow-up 28.5 ± 7.1 years; mean follow-up 27.5 months ± 8.5) were assessed. ARBR with a three-portal method was carried out in all patients according to previous primary arthroscopic stabilization of the shoulder (revision Bankart group). Muscle atrophy of the subscapularis muscle (SSC), supraspinatus muscle (SSP) and infraspinatus muscle (ISP) was assessed by making lateral and vertical measurements by magnetic resonance imaging (MRI). Fatty infiltration was detected by standardized assessment from variations in intensity. Detailed clinical examination of the rotator cuff was carried out. MRI assessment was compared with that of a control group of 22 healthy volunteers of same age and activity level (ICG).

RESULTS

For the SSC, no muscle impairment was noted compared with the ICG [superior atrophy index (sAI_SSC), p = 0.439; inferior atrophy index (iAI_SSC), p = 0.555; superior fatty infiltration index (sFDI_SSC), p = 0.294; inferior fatty infiltration index (iFDI_SSC), p = 0.62]. In investigation of the SSP and ISP, fatty infiltration was not shown (FDI_SSP, p = 0.454; sFDI_ISP, p = 0.504), though persistent muscle atrophy was found even > 2 years after surgery compared with the ICG (AI_SSP, p = 0.0025; sAI_ISP, p = 0.0009; iAI_ISP, p = 0.0004).

CONCLUSION

ARBR using a three-portal method allowed good muscular integrity compared with the ICG, but with persistent slight muscular atrophy of the SSP and ISP.

Return to Sports After Shoulder Stabilization Surgery for Anterior Shoulder Instability

PURPOSE OF REVIEW

Young athletes continue to experience traumatic shoulder instability and are often plagued by recurrent instability, limiting their return to sport. The purpose of this paper was to review return to sport in athletes after shoulder stabilization surgery for anterior shoulder instability.

RECENT FINDINGS

Athletes managed nonoperatively demonstrate unacceptably high rates of recurrent instability and are less likely to successfully return to sport. Operative management includes capsuloligamentous repair (arthroscopic versus open) and bone augmentation techniques. While modern arthroscopic techniques have provided favorable outcomes, open techniques have demonstrated lower recurrence rates among young collision athletes. A subset of athletes continue to experience recurrent instability, leading to further investigation of concomitant pathologies, which may put patients at risk of failure following Bankart repair. Bony augmentation procedures remain favorable for patients with glenoid bone loss; however, what constitutes critical bone loss in the decision between anterior labral repair versus bone augmentation has recently been questioned. Operative management of anterior shoulder instability provides superior results, including lower recurrent instability and return to sport. Future research on patient-specific risk factors may aid surgical decision-making and optimization of outcomes.

Natural History of Anterior Shoulder Instability

BACKGROUND

The shoulder is the most complex joint in the body. The large freedom of motion in this joint is the main cause of instability. Instability varies in its degree, direction, etiology and volition and there is a large spectrum of conditions.

METHODS

Based on literature research and also in our own experience, we propose to elucidate the reader about the natural history of instability and its importance for the appropriate management of this pathology, by answering the following questions: What happens in the shoulder after the first dislocation? Which structures suffer damage? Who are the patients at higher risk of recurrence? How does the disease evolve without treatment? Will surgical treatment avoid future negative outcomes and prevent degenerative joint disease? Who should we treat and when?

RESULTS

80% of anterior-inferior dislocations occur in young patients. Recurrent instability is common and multiple dislocations are the rule. Instability is influenced by a large number of variables, including age of onset, activity profile, number of episodes,delay between first episode and surgical treatment.

CONCLUSION

Understanding the disease and its natural evolution is determinant to decide the treatment in order to obtain the best outcome. It is crucial to identify the risk factors for recurrence. Delay in surgical treatment, when indicated, leads to worse results. Surgical technique should address the type and severity of both soft tissue and bone lesions, when present.

Successful Return to Sport After Arthroscopic Shoulder Stabilization Versus Nonoperative Management in Contact Athletes With Anterior Shoulder Instability: A Prospective Multicenter Study

BACKGROUND

The debate continues regarding the optimal treatment of intercollegiate contact athletes with in-season anterior shoulder instability.

PURPOSE

To examine return to sport and recurrent instability in the season after the index in-season anterior instability event.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Forty-five contact intercollegiate athletes treated nonoperatively or with arthroscopic stabilization were prospectively followed in a multicenter observational study to evaluate return to play (RTP) and recurrent instability in the season after an initial in-season anterior glenohumeral instability event. Baseline data collection included sport played, previous instability events, direction of instability, type of instability (subluxation or dislocation), and treatment method (nonoperative management or arthroscopic stabilization). All nonoperatively treated athletes underwent a standardized accelerated rehabilitation program without shoulder immobilization. Surgical stabilization was performed arthroscopically in all cases, and successful RTP was evaluated during the next competitive season after complete rehabilitation.

RESULTS

Thirty-nine of 45 intercollegiate contact athletes had remaining National Collegiate Athletic Association eligibility and were followed through the subsequent competitive season after the index instability event. Of the 10 athletes electing nonoperative treatment, 4 (40%) successfully returned to play without recurrence during the subsequent season. Of the 29 athletes treated surgically, 26 (90%) were able to successfully return to play without recurrence the following season (recurrence: n = 1; inadequate function: n = 2). Athletes who underwent surgical reconstruction before the next season were 5.8 times (95% CI, 1.77-18.97; P = .004) more likely to complete the subsequent season without recurrent instability. Of the 29 athletes electing surgical stabilization, there was no difference (risk ratio, 0.95; 95% CI, 0.10-9.24; P > .99) in RTP between the 9 stabilized after a single instability event (90% RTP rate) and the 20 stabilized after multiple in-season recurrent instability events (89% RTP rate).

CONCLUSION

Collegiate contact and collision athletes with in-season anterior shoulder instability are significantly more likely to successfully return to sport without subsequent instability events the next season if they undergo surgical repair in the off-season.

The "triple dislocation fracture": anterior shoulder dislocation with concomitant fracture of the glenoid rim, greater tuberosity and coracoid process-a series of six cases

BACKGROUND

A combined fracture of the glenoid rim, greater tuberosity, and coracoid process after anterior shoulder dislocation is a rare event. Only 1 patient has been reported in the literature.

METHODS

All patients with a first-time traumatic anterior shoulder dislocation in a level A trauma center were retrospectively reviewed. Among the 2068 patients treated between 1998 and 2013, we identified 6 patients (0.3%; 1 female, 5 male) with "triple dislocation fracture" (anterior shoulder dislocation with concomitant fracture of the glenoid rim, greater tuberosity, and coracoid process). All patients underwent surgery and had computed tomography scans before surgery and the first postoperative day. Mean follow-up time was 59 months. Clinical and radiographic evaluation, Constant-Murley Score, Simple Shoulder Test, and Subjective Shoulder Value were performed at the final follow-up.

RESULTS

Surgery was determined individually according to the radiologic findings, patient's age, and personal demands. Glenoid reconstruction was performed in all 6 patients, greater tuberosity refixation in 4 patients, and coracoid process refixation in 3. Two patients needed revision surgery due to loss of reduction. At the final follow-up, mean abduction was 133°, mean anterior flexion was 138°; the mean Constant-Murley Score was 72 points; the mean Simple Shoulder Test was 9 points; and the mean Subjective Shoulder Value was 72%. No recurrent instability occurred.

CONCLUSIONS

A "triple dislocation fracture," especially coracoid process fractures, can easily be overlooked in radiographs. Computed tomography scans are strongly recommended in patients with a first-time traumatic shoulder dislocation. Because recurrent joint instability and secondary arthropathy are serious complications after anterior shoulder dislocation, surgery should be considered and provides satisfying to excellent results.

The Effect of Subcritical Bone Loss and Exposure on Recurrent Instability After Arthroscopic Bankart Repair in Intercollegiate American Football

BACKGROUND

There is no consensus on the optimal method of stabilization (arthroscopic or open) in collision athletes with anterior shoulder instability.

PURPOSE

To examine the effect of "subcritical" bone loss and football-specific exposure on the rate of recurrent shoulder instability after arthroscopic stabilization in an intercollegiate American football population.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Fifty intercollegiate football players underwent primary arthroscopic stabilization for anterior shoulder instability and returned to football for at least a single season. Preoperatively, 32 patients experienced recurrent subluxations, and 18 patients experienced a single or recurrent dislocation. Shoulders with glenoid bone loss >20%, an engaging Hill-Sachs lesion, an off-track lesion, and concomitant rotator cuff repair were excluded from the study. The primary outcome of interest was the ability to return to football without subsequent instability. Patients were followed for time to a subsequent instability event after return to play using days of exposure to football and total follow-up time after arthroscopic stabilization.

RESULTS

Fifty consecutive patients returned to American football for a mean 1.5 seasons (range, 1-3) after arthroscopic stabilization. Three of 50 (6%; 95% CI, 1.3%-16.5%) patients experienced recurrent instability. There were no subsequent instability events after a mean 3.2 years of military service. All shoulders with glenoid bone loss >13.5% (n = 3) that underwent arthroscopic stabilization experienced recurrent instability upon returning to sport, while none of the shoulders with <13.5% glenoid bone loss (n = 47) sustained a recurrent instability event during football ( X² = 15.80, P < .001). Shoulders with >13.5% glenoid bone loss had an incidence rate of 5.31 cases of recurrent instability per 1000 athlete-exposures of football. In 72,000 athlete-exposures to football with <13.5% glenoid bone loss, there was no recurrent instability. Significantly more anchors were used during the primary arthroscopic stabilization procedure in patients who experienced multiple preoperative instability events ( P = .005), and lesions spanned significantly more extensive portions along the circumference of the glenoid ( P = .001) compared with shoulders having a single preoperative instability event before surgical stabilization.

CONCLUSION

Arthroscopic stabilization of anterior shoulder instability in American football players with <13.5% glenoid bone loss provides reliable outcomes and low recurrence rates.