Outcome of the open Bankart procedure for shoulder instability and development of osteoarthritis: a 5- to 20-year follow-up study

Risk factors associated with glenohumeral arthritis before and after the Latarjet procedure: minimum follow-up of 5 years, using computed tomography imaging

BACKGROUND

Latarjet surgery has emerged as a prevalent option for managing anterior glenohumeral instability. Despite its efficacy, concerns persist regarding the development of postoperative osteoarthritis (OA), a significant complication. Understanding arthritis pathogenesis in patients undergoing this procedure proves challenging, as OA can manifest even in cases without surgical repair. Additionally, studies suggest correlation between inadequate surgical technique and the occurrence of postoperative arthritis. Traditional radiographic imaging may also underestimate the identification of early OA. Therefore, the objective of this study aimed to analyze the risk factors associated with glenohumeral arthritis before and after the Latarjet procedure, with a minimum follow-up of 5 years, using computed tomography imaging (CT).

METHODS

This retrospective study involved patients who underwent the Latarjet procedure between 2012 and 2017. Inclusion criteria were availability of preoperative and at least 5 years postoperative CT and physical examinations. The primary outcome studied was the presence of glenohumeral OA, classified preoperatively and postoperatively using CT scans. Risk factors for progression to pre and postoperative OA were assessed, including etiology, age at the initial injury, number of dislocation episodes before surgery, time interval from the initial injury to surgical stabilization, size of glenoid defect, position and presence of graft resorption, and screw position.

RESULTS

Fifty joints of 45 patients were included in the final analysis. The presence of preoperative OA was found in 21 of 50 cases (42%). The risk of osteoarthritis (OA) was significantly associated with both shoulder dislocation following a seizure disorder and a larger glenoid size defect (P < .05). Of the 29 shoulders without preoperative arthritis, 8 developed arthritis postoperatively (27.5%). Of those 21 cases with preoperative osteoarthritis, progression occurred in 11 cases (52.3%) (P = .25). When considering all cases with OA progression, significant risk factors were the presence of intraarticular screws and when both screws had angulation equal or above 16° (P < .06). When considering those patients with progression of OA above 1 grade, significant risk factors were lateral graft position, screw angulation, and the presence of intra-articular screws.

CONCLUSION

Our study reveals a higher incidence of osteoarthritis than reported in the literature, likely attributed to the imaging method employed. Preoperatively, risk factors for the presence of OA included cases resulting from seizure disorders and larger glenoid bone defects. Postoperatively, the only factors related to the progression of osteoarthritis were those associated with potential surgical technique issues.

Management of the in-season athlete with an anterior shoulder dislocation

BACKGROUND

Management of the in-season athlete presenting with an anterior shoulder dislocation is a nuanced process that continues to be refined. Options and pathways between nonoperative and operative treatment have undergone many iterations over a century of orthopedic research and advancement. It requires an understanding of sport-specific demands and the individual athlete's goals. The orthopedic surgeon must have mastery of the natural history, treatment options, and outcomes of anterior shoulder dislocations. Balance of these factors is delicate and highly individualized for each athlete, and is why management of the in-season athlete with an anterior shoulder dislocation remains an art for the orthopedic surgeon.

MATERIALS AND METHODS

A narrative review of the literature regarding the in-season athlete with anterior shoulder dislocation was conducted of the PubMed, Embase, and Cochrane databases. The findings are summarized in this article.

RESULTS

Multiple studies have investigated management of the in-season athlete with anterior shoulder dislocation. Treatment is highly individualized for each athlete and their respective circumstances. Nonoperative treatment remains the only option for athletes that seek to return to play in the same season, however with a high risk of recurrence. Operative treatment has a track record of success in terms of returning to high level of play and lower recurrence, but would preclude a return to competition in the same season.

CONCLUSIONS

Management of the in-season athlete with anterior shoulder dislocation remains a challenging issue without consensus recommendation among shoulder surgeons. Much has been done to understand the pathology and delineate indications for nonoperative treatment and surgical management. Although recurrence and return to play rates have improved with each iteration, recurrent instability and revision surgery continue to occur at high rates. Therefore, additional work remains to optimize return to play as well as long-term outcomes for athletes.

Global trends and current research in post-traumatic osteoarthritis: A bibliometric and visualization analysis from 2010 to 2024

BACKGROUND

To investigate global trends and current research on post-traumatic osteoarthritis (PTOA) from 2010 to 2024 using bibliometric and visualization techniques.

METHODS

A bibliometric analysis was conducted using data from the Web of Science Core Collection. The study examined publication trends, author contributions, institutional collaborations, keyword co-occurrence, and citation patterns, employing CiteSpace software to analyze key metrics such as publication frequency, centrality, and clustering.

RESULTS

A total of 3100 articles were published between 2010 and 2024, with a steady increase over the years, peaking at 320 articles in 2023. Most publications were from the USA (1141 articles), China (502), and Germany (268), with key fields being Orthopedics, Surgery, and Rheumatology. Early research focused on different types of osteoarthritis, while recent studies highlight therapeutic advances such as cartilage repair and oxidative stress. Co-citation analysis identified influential authors like Lohmander LS, and key research clusters include total hip arthroplasty and regenerative medicine.

CONCLUSION

Over the past decade, PTOA research has expanded substantially, driven by contributions from Orthopedics and Surgery, and supported by growing international collaboration, particularly between the United States, China, and European countries. Future research directions should prioritize elucidating the molecular mechanisms underlying PTOA, advancing diagnostic methodologies, and developing innovative therapeutic approaches to improve patient outcomes. The interdisciplinary nature and international cooperation observed are essential to addressing the complex challenges posed by PTOA.

Arthroscopic Anterior and Inferior Labral Repair for Traumatic Shoulder Instability

Background

Anterior glenohumeral instability is common in the young and athletic population and can develop from a dislocation or subluxation event. Avulsion of the anterior inferior glenoid labrum (Bankart lesion) occurs in over 90% of these events. In patients who have unsuccessful conservative management or present with a high risk for redislocation, surgical intervention is indicated. This video presents our technique for arthroscopic anterior and inferior labral repair.

Indications

In addition to those patients who have unsuccessful conservative management, surgical management of anterior glenohumeral instability is indicated in patients who are at high risk for redislocation after an initial instability event. These patients include young age and participation in contact sports. Generally, glenoid bone loss over 25% warrants open bony augmentation, but arthroscopic bony augmentation techniques are evolving. Further, the management of "near-track" lesions, or "on-track" lesions with a small distance to dislocation value, remains controversial.

Technique Description

This procedure is performed in the lateral decubitus position. A second anterior portal is created distal and lateral to the first anterior portal, entering the shoulder joint just above the subscapularis. The anterior-inferior labrum is prepared with an arthroscopic elevator, followed by a rasp and superior labral anterior and posterior burr. A suture tape is then shuttled around the labrum and the anchor drilled in the appropriate position at the glenoid rim, not violating the cartilage. Anchor placement occurs from an inferior to a superior fashion until the entire labral injury is repaired.

Results

This video presents a technique to achieve arthroscopic fixation of an anterior-inferior labral tear in a young athlete with anterior glenohumeral instability. Patients are taken through 3 phases of rehabilitation before return to sport-specific activities, such as contact sports, around 6 months postoperatively. Return-to-sport rates for contact and collision athletes range from 80% to 100%, with recurrent rates ranging from 5% to 20%.

Discussion/Conclusion

Arthroscopic anterior-inferior labral repair is a useful technique for minimally invasive glenohumeral stabilization in indicated patients who have minimal glenoid bone loss. Portal placement, labral mobilization, and glenoid preparation are paramount in optimizing the healing potential of the fixation construct.

Patient Consent Disclosure Statement

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Long-term results of arthroscopic capsulolabral revision repair for failed anterior shoulder instability repair using suture anchors at a minimum of 10 years follow-up

INTRODUCTION

Arthroscopic revision anterior shoulder instability repair has been proposed, and early clinical results have been promising. However, long-term results after this procedure and the probable risk factors for failure have not been sufficiently discussed in the literature.

MATERIALS AND METHODS

Thirty-eight patients who were diagnosed with recurrent anteroinferior shoulder instability after failed Bankart repair, treated with ACRR between September 1998 and November 2003 and able to be contacted were included. Of these patients, 2 were excluded from the study due to the use of SureTak anchors for fixation, and 5 other patients refused to participate in the study due to lack of interest (3 patients) or lack of time (2 patients). The remaining shoulders were clinically examined at a minimum of ten years after surgery via the ASES, Constant, AAOS, Rowe, Dawson and VAS scores for pain and stability. Degenerative arthropathy was assessed with the modified Samilson-Prieto score.

RESULTS

All 31 remaining shoulders were evaluated at a mean time of 11.86 years (142.4 months) after surgery. Six patients (19.35%) reported redisolcation after the revision procedure, 4 of whom were affected by a new significant shoulder trauma. The ROWE and Constant scores improved significantly. Moderate to severe dislocation arthropathy was observed in 19.4% of patients. Five patients (16.2%) were not satisfied with the procedure.

CONCLUSION

Long-term follow-up after ACRR shows predictable results, with a high degree of patient satisfaction, good to excellent patient-reported outcome scores and minimal radiological degenerative changes. However, with an average recurrence rate of 19.3% after 11.86 years, the redislocation rate appears high. With careful patient selection, recurrence rates can be significantly reduced.

Determining the True Incidence of Glenohumeral Instability Among Players in the National Football League: An Epidemiological Study of Non-Missed Time Shoulder Instability Injuries

Background

Shoulder instability encompasses a spectrum of glenohumeral pathology ranging from subluxation to dislocation. While dislocation frequently leads to removal from play, athletes are often able to play through subluxation. Previous research on glenohumeral instability among athletes has largely focused on missed-time injuries, which has likely disproportionately excluded subluxation injuries and underestimated the overall incidence of shoulder instability.

Purpose

To describe the epidemiology of shoulder instability injuries resulting in no missed time beyond the date of injury (non-missed time injuries) among athletes in the National Football League (NFL).

Study Design

Descriptive epidemiology study.

Methods

The NFL's electronic medical record was retrospectively reviewed to identify non-missed time shoulder instability injuries during the 2015 through 2019 seasons. For each injury, player age, player position, shoulder laterality, instability type, instability direction, injury timing, injury setting, and injury mechanism were recorded. For injuries that occurred during games, incidence rates were calculated based on time during the season as well as player position. The influence of player position on instability direction was also investigated.

Results

Of the 546 shoulder instability injuries documented during the study period, 162 were non-missed time injuries. The majority of non-missed time injuries were subluxations (97.4%), occurred during games (70.7%), and resulted from a contact mechanism (91.2%). The overall incidence rate of game-related instability was 1.6 injuries per 100,000 player-plays and was highest during the postseason (3.5 per 100,000 player-plays). The greatest proportion of non-missed time injuries occurred in defensive secondary players (28.4%) and offensive linemen (19.8%), while kickers/punters and defensive secondary players had the highest game incidence rates (5.5 and 2.1 per 100,000 player-plays, respectively). In terms of direction, 54.3% of instability events were posterior, 31.9% anterior, 8.5% multidirectional, and 5.3% inferior. Instability events were most often anterior among linebackers and wide receivers (50% and 100%, respectively), while posterior instability was most common in defensive linemen (66.7%), defensive secondary players (58.6%), quarterbacks (100.0%), running backs (55.6%), and tight ends (75.0%).

Conclusion

The majority of non-missed time shoulder instability injuries (97.4%) were subluxations, which were likely excluded from or underreported in previous shoulder instability studies due to the inherent difficulty of detecting and diagnosing shoulder subluxation.

Dislocation Arthropathy of the Shoulder

Glenohumeral osteoarthrosis (OA) may develop after primary, recurrent shoulder dislocation or instability surgery. The incidence is reported from 12 to 62%, depending on different risk factors. The risk of severe OA of the shoulder following dislocation is 10 to 20 times greater than the average population. Risk factors include the patient’s age at the first episode of instability or instability surgery, bony lesions, and rotator cuff tears. For mild stages of OA, arthroscopic removal of intraarticular material, arthroscopic debridement, or arthroscopic arthrolysis of an internal rotation contracture might be sufficient. For severe stages, mobilization of the internal rotation contracture and arthroplasty is indicated. With an intact rotator cuff and without a bone graft, results for anatomical shoulder arthroplasty are comparable to those following primary OA. With a bone graft at the glenoidal side, the risk for implant loosening is ten times greater. For the functional outcome, the quality of the rotator cuff is more predictive than the type of the previous surgery or the preoperative external rotation contracture. Reverse shoulder arthroplasty could be justified due to the higher rate of complications and revisions of non-constrained anatomic shoulder arthroplasties reported. Satisfactory clinical and radiological results have been published with mid to long term data now available.

Large Drill Holes Are Still Present in the Long Term After Arthroscopic Bankart Repair With Absorbable Tacks: An 18-Year Randomized Prospective Study

BACKGROUND

Studies have demonstrated the development of an osseous reaction at the drill sites of anchors after arthroscopic shoulder surgery.

PURPOSE

To investigate the drill-hole size at 18 years after arthroscopic Bankart repair using either fast polygluconate acid (PGA) or slow polylevolactic acid (PLLA) absorbable tacks and to compare the functional outcomes and development of osteoarthritis.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

40 patients with unidirectional anterior shoulder instability, treated with arthroscopic Bankart repair, were randomized into the PGA group (n = 20) or the PLLA group (n = 20). Plain radiographs of both shoulders, as well as computed tomography (CT) images of the operated shoulder, were used to evaluate the drill-hole size, volume, and degenerative changes. Functional outcomes were assessed by use of the Rowe score, Constant score, and Western Ontario Shoulder Instability (WOSI) index.

RESULTS

Of the 40 patients, 32 patients returned for the follow-up (15 PGA and 17 PLLA). No significant differences were found in the population characteristics between the study groups. The mean follow-up time was 18 years for both groups. No significant differences were seen in range of motion, strength in abduction, or Constant, Rowe, and WOSI scores between the groups. Recurrence rate was 33% in the PGA group and 6% in the PLLA group during the follow-up period (P = .07). The drill-hole appearance on plain radiographs (invisible/hardly visible/visible/cystic) was 11/2/2/0 and 6/5/5/1 for the PGA and PLLA groups, respectively (P = .036). The mean ± SD drill-hole volume as estimated on CT images was 89 ± 94 and 184 ± 158 mm³ in the PGA and PLLA groups, respectively (P = .051). Degenerative changes (normal/minor/moderate/severe) on plain radiographs were 7/4/4/0 and 3/8/5/1 for the PGA and PLLA groups, respectively (P = .21), and on CT images were 5/7/3/0 and 2/6/6/3 for the PGA and PLLA groups, respectively (P = .030).

CONCLUSION

This long-term follow-up study demonstrated that the PLLA group had significantly more visible drill holes than the PGA group on plain radiographs. However, this difference was not evident on CT imaging, with both groups having several visible cystic drill holes and a substantial drill-hole volume defect. No significant differences were found between the study groups in terms of clinical outcomes.

Clinical and radiographic outcomes of open Latarjet procedure in patients aged 40 years or older

BACKGROUND

The Latarjet procedure is often used to treat shoulder instability in younger patients. Little is reported on the outcomes of this procedure in older (≥40 years) populations. The purpose of this study was to evaluate the clinical and radiographic outcomes of patients aged 40 years or older with recurrent anterior shoulder instability who underwent open Latarjet stabilization.

METHODS

A total of 168 patients aged 40 years or older were treated surgically for recurrent anterior shoulder instability with an open Latarjet procedure between 1988 and 2014. Bankart lesions or anteroinferior glenoid fractures were confirmed preoperatively with a computed tomography arthrogram. Outcomes were assessed with preoperative and postoperative physical examinations, clinical outcome scoring, and radiographic examinations.

RESULTS

Ninety-nine patients with complete data were available with a mean follow-up period of 13 years (range, 3-23 years). At the time of final follow-up, 94% of patients did not have recurrence of instability. Of the patients, 90% were satisfied or very satisfied with their outcomes and 54% returned to their preinjury level of activity. The overall complication rate was 21% (the most common complications being subjective apprehension [9%] and recurrent instability [6%]), with 9% of patients requiring reoperation. A full-thickness rotator cuff requiring repair was identified in 22% of patients.

CONCLUSIONS

The Latarjet procedure is an effective treatment option for older patients (aged ≥ 40 years) with recurrent anterior shoulder instability in the setting of an anteroinferior capsulolabral and/or bony injury.

Computed Tomography Features of Glenoid Osteophytes in Traumatic Anterior Shoulder Instability: Comparison Between Younger and Older Patients

Background:

Osteoarthritis that develops after traumatic anterior shoulder instability is known as dislocation arthropathy, but its frequency and characteristics are still unclear.

Purpose:

To evaluate glenoid osteophytes in shoulders with traumatic anterior instability by using computed tomography (CT) and to elucidate the influence of instability on the progression of dislocation arthropathy in different age groups.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

This study involved 214 unoperated patients with unilateral instability who underwent CT of both shoulders. The patients were divided into 2 groups according to age at the time of CT: ≤30 years (younger group; n = 172) and ≥31 years (older group; n = 42). Patient demographics as well as the presence, size, and location of glenoid osteophytes were compared between the 2 groups and also between patients with and without osteophytes. Furthermore, patients with osteophytes in the older group were divided into 2 subgroups according to age at the time of the initial injury: as a teenager (early-onset subgroup; n = 9) or at ≥31 years (late-onset subgroup; n = 14), and the same assessments were conducted.

Results:

Osteophytes were significantly more frequent on the affected side of the older group compared with the younger group (71.4% vs 13.9%, respectively; P < .001). In the younger group, patients with osteophytes had more multiple-instability events (P = .002) and a longer interval from injury to CT (P < .001) than those without osteophytes. Although there was no difference in osteophyte size between the 2 groups, most osteophytes were located at the anteroinferior part of the glenoid in the younger group, while osteophytes were usually circumferential around the glenoid in the older group. A comparison between the early- and late-onset subgroups in older patients with osteophytes revealed that the osteophytes were more frequently located at the anteroinferior glenoid region in the early-onset subgroup.

Conclusion:

CT allowed a detailed evaluation of glenoid osteophytes, revealing that osteophytes were not uncommon in younger patients. Instability itself might influence the progression of osteoarthritic changes in younger patients, while aging seems to have a greater effect in older patients.

Long-Term Results of a Monocentric Series of Soldiers After Latarjet Procedure for Anterior Shoulder Instability. Implications for the Assessment of Soldiers' Medical Ability

Introduction

Stabilizing surgery of the shoulder with a coracoid graft according to Latarjet is a recognized surgical treatment for anterior instability of the shoulder. This pathology frequently affects soldiers. Postoperatively, the potential risk of recurrence or of secondary shoulder arthritis can limit the practitioner in their ability assessment. The aim of this study is to analyze the long-term outcomes of this surgery in a military population, in order to assess the possible implications for French soldiers' medical ability.

Material and Methods

Twenty soldiers operated on the shoulder by Latarjet procedure by the same surgeon were retrospectively reviewed after more than 15 yr. All of them did regular physical activity for leisure or competitions. None had preoperative osteoarthritis injuries. The number of dislocation recurrences, the functional score, and the rate of radiographic osteoarthritis were assessed.

Results

After more than 16.3 yr (extremes: 15-24 yr), none displayed a dislocation recurrence. The average Rowe's score was 91.8 ± 9.9. The average subjective shoulder value was 89.2 ± 9.7. All patients had resumed sport. Three of them developed level 1 or 2 radiological signs of osteoarthritis according to Samilson. No level 3 or 4 osteoarthritis was found. Among all the patients, 14 still did regular physical activity.

Discussion

In view of our results and of those from the literature, the results of treatment for anterior shoulder instability with the Latarjet procedure are good, even very good in the long term. These data must be considered to favor this procedure for soldiers with shoulder instability and from a medico-administrative viewpoint for military patients in order to pursue their careers without any job restrictions.

Scapular muscles weakness in subjects with traumatic anterior glenohumeral instability

OBJECTIVE

To investigate possible alterations on scapular muscle strength in subjects with traumatic anterior glenohumeral instability.

DESIGN

Cross-sectional study.

SETTING

Laboratory setting.

PARTICIPANTS

Fifty-two subjects of both sexes: 26 healthy and 26 with traumatic anterior glenohumeral instability.

MAIN OUTCOME MEASURES

Subjects performed maximal isometric and concentric isokinetic contractions of shoulder protraction and retraction in scapular and sagittal planes, at slow (12.2 cm/s) and fast (36.6 cm/s) speeds.

RESULTS

Subjects with glenohumeral instability presented lower peak force of protraction and retraction during isometric and fast speed tests in the scapular plane; and of isometric protraction in the sagittal plane.

CONCLUSIONS

People with traumatic anterior glenohumeral instability present muscle weakness of scapular protractors and retractors. Considering the importance of the scapulothoracic muscles for the dynamic stability of the glenohumeral joint, strengthening of these muscles is recommended for rehabilitation of traumatic anterior glenohumeral instability.

Anterior Glenohumeral Instability

Anterior shoulder dislocations, subluxations, and recurrent instability of the shoulder joint are common problems usually affecting a young active population. However, it can be a problem for patients up to the late decades in life and can lead to major shoulder arthropathy if left untreated or improperly treated. This article discusses the natural history, pathologic morphologic changes of the shoulder joint associated with anterior instability along with normal anatomic variants. We will also discuss current treatment recommendations and possible causes of the patient with recurrent instability despite prior stabilization procedures.

Patients' expectations of shoulder instability repair

PURPOSE

To analyze and compare patient expectations of primary and revision shoulder stabilization and to assess the factors associated with patients' expectations.

METHODS

Pre-operative patient expectations after shoulder instability repair were prospectively assessed using a self-designed questionnaire. The survey included questions on the expected level and type of return to sports, instability, pain, risk of osteoarthritis, and overall shoulder condition.

RESULTS

One-hundred and forty-five patients (99 primary; 46 revision repair) were included. A return to sport at the same level with slight to no restrictions was expected in 95%, a return to high-risk activities in 34%, to moderate in 58%, and to low-risk activities in 9%. No pain [instability] independent of the activity level was expected by 71% [79%] and occasional pain [instability] during contact and overhead activities by 25% [19%]. 61% expected to have no risk of glenohumeral osteoarthritis, 37% a slight, and 2% a significant risk. The overall expectation for the post-operative shoulder was indicated to be normal or nearly normal in 99% of patients. The revision group did not differ from the primary repair group in any variable. High pre-operative sport performance was positively correlated with post-operative sport expectations. The number of dislocations, the duration of instability, and the subjective instability level were negatively correlated with return to sport expectations.

CONCLUSION

Patient expectations for primary and revision shoulder instability repair are high. Realistic patient expectations regarding the surgical procedure are necessary to avoid low patient satisfaction, especially in pre-operatively highly active and demanding athletes. The surgeon must not solely base the treatment on the pathology and possible risk factors for failure but should also take the individual expectation of the patient into account.

LEVEL OF EVIDENCE

III.

Contraindications and complications of the Latarjet procedure

The Latarjet procedure is a well-known, safe and reliable technique to treat primary or recurrent anterior dislocations or subluxations, with or without hyperlaxity, with or without glenoid bone loss. Both the open and the arthroscopic methods produce excellent clinical results, with a low rate of recurrent instability. There have been concerns of a higher surgical complication rate associated with this procedure, however, large reviews reported an overall complication rate in the open Latarjet procedure of 15%. Meticulous surgical technique and a good understanding of the local anatomy can help to avoid the complications but postoperative shoulder arthritis and frequent bone block osteolysis remain unsolved additional challenges, which require further research. There are 2 main factors to further improve the clinical outcome and patient satisfaction: careful patient selection with good surgical indication, and reducing complications with adequate surgical techniques. The aim of this study is to provide the current overview of the contraindications and complications of the Latarjet procedure.

Long-term outcomes of the Bankart and Latarjet repairs: a systematic review

The most common surgical techniques for the treatment of recurrent anterior shoulder instability include the arthroscopic Bankart repair, the open Bankart repair and the open Latarjet procedure. The purpose of this study was to evaluate and compare the long-term outcomes following these procedures. A systematic review of modern procedures with a minimum follow-up of 5 years was completed. The objective outcome measures evaluated were post-operative dislocation and instability rate, the Rowe score, radiographic arthritis and complications. Twenty-eight studies with a total of 1652 repairs were analyzed. The estimated re-dislocation rate was 15.1% following arthroscopic Bankart repair, 7.7% following open Bankart repair and 2.7% following Latarjet repair, with the comparison between arthroscopic Bankart and open Latarjet reaching statistical significance (p<0.001). The rates of subjective instability and radiographic arthritis were consistently high across groups, with no statistical difference between groups. Estimated complication rates were statistically higher in the open Latarjet repair (9.4%) than in the arthroscopic Bankart (0%; p=0.002). The open Latarjet procedure yields the most reliable method of stabilization but the highest complication rate. There are uniformly high rates of post-operative subjective instability symptoms and radiographic arthritis at 5 years regardless of procedure choice.

Results of Arthroscopic Bankart Repair for Anterior-Inferior Shoulder Instability at 13-Year Follow-up

BACKGROUND

Anterior-inferior shoulder instability is a common injury in young patients, particularly those practicing overhead-throwing sports. Long-term results after open procedures are well studied and evaluated. However, the long-term results after arthroscopic repair and risk factors of recurrence require further assessment.

HYPOTHESIS

Arthroscopic Bankart repair results are comparable with those of open repair as described in the literature.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 180 shoulders with anterior-inferior shoulder instability were stabilized arthroscopically, met the inclusion criteria and the patients were able to be contacted at a minimum of 10-year follow-up. Of these patients, 143 agreed to participate in the study. Assessment was performed clinically in 104 patients using the American Shoulder and Elbow Surgeons score, Constant score, American Academy of Orthopaedic Surgeons score, Rowe score, and the Dawson 12-item questionnaire. The Samilson-Prieto score was used to assess degenerative arthropathy in radiographs available for 100 shoulders. Additionally, 15 patients participated through a specific questionnaire and 24 patients through a telephone survey.

RESULTS

The overall redislocation rate was 18.18%. Redislocation rates for the different types of fixation devices were as follows: FASTak/Bio-FASTak, 15.1% (17/112); SureTac, 26.3% (5/19); and Panalok, 33.3% (4/12). Concomitant superior labral anterior-posterior repair had no effect on clinical outcome. Redislocation rate was significantly affected by the patient's age and duration of postoperative rehabilitation. Redislocation rate tended to be higher if there had been more than 1 dislocation preoperatively ( P = .098). Severe dislocation arthropathy was observed in 12% of patients, and degenerative changes were significantly correlated with the number of preoperative dislocations, patient age, and number of anchors. The patient satisfaction rate was 92.3%, and return to the preinjury sport level was possible in 49.5%.

CONCLUSION

Clinical outcome at a mean follow-up of 13 years after arthroscopic repair of anterior-inferior shoulder instability is comparable with the reported results of open Bankart repair in the literature and allows management of concomitant lesions arthroscopically. Modifiable risk factors of postoperative redislocation and arthropathy must be considered. Stabilization after the first-time dislocation achieves better clinical and radiological outcomes than after multiple dislocations.

Review of current understanding of post-traumatic osteoarthritis resulting from sports injuries

Certain types of joint injuries, common in athletes, are known to have a high association with the development of osteoarthritis (OA). Post-traumatic osteoarthritis (PTOA) is especially debilitating due to its earlier onset than traditional OA, and its predisposition to affect a younger and more active population. Five common athletic injuries have been demonstrated to be risk factors for the development of OA. These include ACL rupture, meniscus tear, glenohumeral instability, patellar dislocation, and ankle instability. Though the mechanisms responsible for the development of PTOA are not entirely clear, certain kinematic, biologic, and mechanical factors have been implicated. In addition, there has been an increased emphasis on development of new methods to detect early OA changes in patients with known risk factors, as early intervention may prevent the development of end-stage OA. New imaging modalities as well as the identification of specific biomarkers may allow earlier detection. Though these developments hold promise, it is not entirely known what steps we can take today to prevent the future development of OA, even with early detection. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:397-405, 2017.

Mean Glenoid Defect Size and Location Associated With Anterior Shoulder Instability: A Systematic Review

BACKGROUND

There is a strong correlation between glenoid defect size and recurrent anterior shoulder instability. A better understanding of glenoid defects could lead to improved treatments and outcomes.

PURPOSE

To (1) determine the rate of reporting numeric measurements for glenoid defect size, (2) determine the consistency of glenoid defect size and location reported within the literature, (3) define the typical size and location of glenoid defects, and (4) determine whether a correlation exists between defect size and treatment outcome.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

PubMed, Ovid, and Cochrane databases were searched for clinical studies measuring glenoid defect size or location. We excluded studies with defect size requirements or pathology other than anterior instability and studies that included patients with known prior surgery. Our search produced 83 studies; 38 studies provided numeric measurements for glenoid defect size and 2 for defect location.

RESULTS

From 1981 to 2000, a total of 5.6% (1 of 18) of the studies reported numeric measurements for glenoid defect size; from 2001 to 2014, the rate of reporting glenoid defects increased to 58.7% (37 of 63). Fourteen studies (n = 1363 shoulders) reported defect size ranges for percentage loss of glenoid width, and 9 studies (n = 570 shoulders) reported defect size ranges for percentage loss of glenoid surface area. According to 2 studies, the mean glenoid defect orientation was pointing toward the 3:01 and 3:20 positions on the glenoid clock face.

CONCLUSION

Since 2001, the rate of reporting numeric measurements for glenoid defect size was only 58.7%. Among studies reporting the percentage loss of glenoid width, 23.6% of shoulders had a defect between 10% and 25%, and among studies reporting the percentage loss of glenoid surface area, 44.7% of shoulders had a defect between 5% and 20%. There is significant variability in the way glenoid bone loss is measured, calculated, and reported.

Anatomic and Biomechanical Comparison of Traditional Bankart Repair With Bone Tunnels and Bankart Repair Utilizing Suture Anchors

Background:

Traditional Bankart repair using bone tunnels has a reported failure rate between 0% and 5% in long-term studies. Arthroscopic Bankart repair using suture anchors has become more popular; however, reported failure rates have been cited between 4% and 18%. There have been no satisfactory explanations for the differences in these outcomes.

Hypothesis:

Bone tunnels will provide increased coverage of the native labral footprint and demonstrate greater load to failure and stiffness and decreased cyclic displacement in biomechanical testing.

Study Design:

Controlled laboratory study.

Methods:

Twenty-two fresh-frozen cadaveric shoulders were used. For footprint analysis, the labral footprint area was marked and measured using a Microscribe technique in 6 specimens. A 3-suture anchor repair was performed, and the area of the uncovered footprint was measured. This was repeated with traditional bone tunnel repair. For the biomechanical analysis, 8 paired specimens were randomly assigned to bone tunnel or suture anchor repair with the contralateral specimen assigned to the other technique. Each specimen underwent cyclic loading (5-25 N, 1 Hz, 100 cycles) and load to failure (15 mm/min). Displacement was measured using a digitized video recording system.

Results:

Bankart repair with bone tunnels provided significantly more coverage of the native labral footprint than repair with suture anchors (100% vs 27%, P < .001). Repair with bone tunnels (21.9 ± 8.7 N/mm) showed significantly greater stiffness than suture anchor repair (17.1 ± 3.5 N/mm, P = .032). Mean load to failure and gap formation after cyclic loading were not statistically different between bone tunnel (259 ± 76.8 N, 0.209 ± 0.064 mm) and suture anchor repairs (221.5 ± 59.0 N [P = .071], 0.161 ± 0.51 mm [P = .100]).

Conclusion:

Bankart repair with bone tunnels completely covered the footprint anatomy while suture anchor repair covered less than 30% of the native footprint. Repair using bone tunnels resulted in significantly greater stiffness than repair with suture anchors. Load to failure and gap formation were not significantly different.

Prevalence of and Risk Factors for Dislocation Arthropathy: Radiological Long-term Outcome of Arthroscopic Bankart Repair in 100 Shoulders at an Average 13-Year Follow-up

BACKGROUND

Glenohumeral osteoarthritis is a well-documented, long-term complication of open stabilization procedures. However, there is a lack of knowledge about long-term radiographic outcome after arthroscopic Bankart procedures.

HYPOTHESIS

Glenohumeral osteoarthritis will develop less frequently in arthroscopic Bankart repair compared with open repairs reported in the literature.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The inclusion criteria for this study were (1) all-arthroscopic Bankart repair for a (2) symptomatic anteroinferior shoulder instability and (3) a minimum follow-up of 10 years. True anteroposterior and lateral radiographs were obtained to evaluate the prevalence and grade of osteoarthritis according to the Samilson classification. Patients were assessed by the Constant score and examined for passive external rotation deficits.

RESULTS

Of 165 shoulders that fulfilled the inclusion criteria, 100 were available for evaluation. The median Constant score at an average±SD 156.2±18.5 months after Bankart repair was 94 (range, 46-100). Twenty-one shoulders (21%) sustained a recurrent dislocation. Overall, 31% of shoulders showed no evidence of glenohumeral osteoarthritis; 41% showed mild, 16% moderate, and 12% severe degenerative changes. Osteoarthritis did not correlate with Constant score results (P=.427). The grade of osteoarthritis was significantly associated with the number of preoperative dislocations (P=.016), age at initial dislocation (P=.005) and at surgery (P=.002), and the number of anchors used (P=.001), whereas time from initial dislocation to surgery (P=.854) and external rotation deficit at 0° and 90° of abduction (P=.104 and .348, respectively) showed no significant correlation. Recurrent dislocation did not affect the presence or grade of osteoarthritis (P=.796 and .665, respectively).

CONCLUSION

At an average 13 years after arthroscopic Bankart repair, osteoarthritic changes are a common finding and, overall, are comparable with reports in the literature regarding open procedures as well as nonoperative treatment. The extent of trauma sustained during preoperative dislocations and the age of the patient seem to be more relevant for long-term dislocation arthropathy than the kind of treatment. Accordingly, the study hypothesis must be rejected. Avoiding preoperative dislocations is more important for the prevention of osteoarthritis than short-term treatment. The number of anchors used was found to be a predictor for long-term development of osteoarthritis.

Long-term results of the Latarjet procedure for anterior instability of the shoulder

BACKGROUND

The Latarjet procedure is effective in managing anterior glenohumeral instability in the short term, but there is concern for postoperative arthritis. The purpose of this study was to evaluate the long-term functional outcome after the Latarjet procedure and to assess the prevalence of and risk factors for glenohumeral arthritis after this procedure.

MATERIALS AND METHODS

A retrospective review was conducted of 68 Latarjet procedures at a mean of 20 years postoperatively. The mean age at surgery was 29.4 years. Functional outcome was determined by the Rowe score, subjective shoulder value, and recurrence of instability. Preoperative arthritis and postoperative radiographs were reviewed to evaluate the development or progression of arthritis.

RESULTS

The mean Rowe score increased from 37.9 preoperatively to 89.6 at final follow-up (P < .001). The mean subjective shoulder value was 90.9% at final follow-up. The postoperative rate of recurrence was 5.9%. Of the 60 shoulders without arthritis preoperatively, 12 (20%) had developed arthritis at final follow-up. Among the 8 shoulders with preoperative arthritis (all stage 1), 4 (50%) demonstrated progression of arthritis at final follow-up. Overall, postoperative arthritis was stage 1 in 14.7%, stage 2 in 5.9%, and stage 3 in 8.8% of cases; no stage 4 arthritis was observed. Risk factors for postoperative arthritis were older age, high-demand sports activity, and lateral overhang of coracoid bone graft.

CONCLUSION

The Latarjet procedure provides excellent long-term outcomes in the treatment of recurrent anterior glenohumeral instability. Twenty years after the Latarjet procedure, arthritis may develop or progress in 23.5% of cases, but the majority of arthritis is mild.

Long-term outcomes after Bankart shoulder stabilization

PURPOSE

The purposes of this study were (1) to analyze long-term outcomes in patients who have undergone open or arthroscopic Bankart repair and (2) to evaluate study methodologic quality through validated tools.

METHODS

We performed a systematic review of Level I to IV Evidence using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Clinical outcome studies after open or arthroscopic Bankart repair with a minimum of 5 years' follow-up were analyzed. Clinical and radiographic outcomes were extracted and reported. Study methodologic quality was evaluated with Modified Coleman Methodology Scores and Quality Appraisal Tool scores.

RESULTS

We analyzed 26 studies (1,781 patients). All but 2 studies were Level III or IV Evidence with low Modified Coleman Methodology Scores and Quality Appraisal Tool scores. Patients analyzed were young (mean age, 28 years) male patients (81%) with unilateral dominant shoulder (61%), post-traumatic recurrent (mean of 11 dislocations before surgery) anterior shoulder instability without significant glenoid bone loss. The mean length of clinical follow-up was 11 years. There was no significant difference in recurrence of instability with arthroscopic (11%) versus open (8%) techniques (P = .06). There was no significant difference in instability recurrence with arthroscopic suture anchor versus open Bankart repair (8.5% v 8%, P = .82). There was a significant difference in rate of return to sport between open (89%) and arthroscopic (74%) techniques (P < .01), whereas no significant difference was observed between arthroscopic suture anchor (87%) and open repair (89%) (P = .43). There was no significant difference in the rate of postoperative osteoarthritis between arthroscopic suture anchor and open Bankart repair (26% and 33%, respectively; P = .059). There was no significant difference in Rowe or Constant scores between groups (P > .05).

CONCLUSIONS

Surgical treatment of anterior shoulder instability using arthroscopic suture anchor and open Bankart techniques yields similar long-term clinical outcomes, with no significant difference in the rate of recurrent instability, clinical outcome scores, or rate of return to sport. No significant difference was shown in the incidence of postoperative osteoarthritis with open versus arthroscopic suture anchor repair. Study methodologic quality was poor, with most studies having Level III or IV Evidence.

LEVEL OF EVIDENCE

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

Dislocation arthropathy and drill hole appearance in a mid- to long-term follow-up study after arthroscopic Bankart repair

PURPOSE

The aim of this study was to perform a prospective mid- to long-term clinical and radiographic follow-up after arthroscopic Bankart repair using absorbable tacks with special emphasis on the development of dislocation arthropathy.

METHODS

Thirty-four shoulders in 32 patients with post-traumatic shoulder instability were included in the study. Clinical and radiographic follow-ups took place after approximately 2 and 8 years.

RESULTS

Thirty-four of 34 (100 %) shoulders in 32 patients returned for the follow-up examination after 95 (53-129) months. Pre-operatively, none of the shoulders had any arthropathy changes. At follow-up, 8/34 (24 %) had minor changes, 6/34 (18 %) had moderate changes, and none had severe arthropathy changes, a significant increment compared with the pre-operative figures (p = 0.005). At follow-up, the drill holes in 24 % of the shoulders still had not healed radiographically. The failure rate in terms of stability was 3/34 (9 %) re-dislocations and 3/34 (9 %) subluxations.

CONCLUSION

Eight years after arthroscopic Bankart repair using absorbable tacks, 41 % of the shoulders displayed some degree of radiographic arthropathy changes and in 24 % the drill holes had not yet radiographically healed. There was no correlation between clinical outcome or drill hole appearance and the development of arthropathy changes.

LEVEL OF EVIDENCE

III.

Management of mid-season traumatic anterior shoulder instability in athletes

Shoulder dislocation and subluxation injuries are common in young athletes and most frequently occur during the competitive season. Controversy exists regarding optimal treatment of an athlete with an in-season shoulder dislocation, and limited data are available to guide treatment. Rehabilitation may facilitate return to sport within 3 weeks, but return is complicated by a moderate risk of recurrence. Bracing may reduce the risk of recurrence, but it restricts motion and may not be tolerated in patients who must complete certain sport-specific tasks such as throwing. Surgical management of shoulder dislocation or subluxation with arthroscopic or open Bankart repair reduces the rate of recurrence; however, the athlete is unable to participate in sport for the remainder of the competitive season. When selecting a management option, the clinician must consider the natural history of shoulder instability, pathologic changes noted on examination and imaging, sport- and position-specific demands, duration of treatment, and the athlete's motivation.