Long-Term Restoration of Anterior Shoulder Stability: A Retrospective Analysis of Arthroscopic Bankart Repair Versus Open Latarjet Procedure

No Difference in Outcome Scores or Persistent Instability After Latarjet Procedure for Anterior Instability in Patients With Shoulder Hyperlaxity Versus Those Without Hyperlaxity

BACKGROUND

The prevalence of hyperlaxity in patients with shoulder instability is high, and its management is challenging. Shoulder hyperlaxity denotes a redundant anterior capsule with an elongated or weak glenohumeral ligament that may be associated with worse functional outcomes after procedures for instability. The functional outcomes and postoperative recurrence after a Latarjet procedure for recurrent instability in shoulders with hyperlaxity versus those without hyperlaxity has not been studied.

QUESTIONS/PURPOSES

(1) What are the differences in functional outcomes (Rowe score and shoulder subjective value [SSV]) after a Latarjet procedure for unidirectional anterior instability in shoulder hyperlaxity versus no hyperlaxity, and what proportion of shoulders achieve the patient acceptable symptom state (PASS) in both groups? (2) What is the difference in the proportion of patients who experienced a recurrence after a Latarjet procedure for unidirectional anterior instability in shoulder hyperlaxity versus no hyperlaxity? (3) What are the differences in radiologic outcomes after a Latarjet procedure for unidirectional anterior instability in shoulder hyperlaxity versus no hyperlaxity?

METHODS

Between January 2014 and January 2022, one surgeon performed the Latarjet procedure for anterior shoulder instability in 155 patients. During that time, he performed the Latarjet for all patients with recurrent instability, with or without bone loss and with or without shoulder hyperlaxity. Of those who fit the prespecified inclusion criteria, 37% (48 of 131) had shoulder hyperlaxity (defined as external rotation [elbow adducted] ≥ 85° in the opposite normal shoulder) and 63% (83 of 131) had no hyperlaxity. A total of 90% (43 of 48) of the patients with shoulder hyperlaxity and 87% (72 of 83) of patients without hyperlaxity had a minimum follow-up time of 2 years and were evaluated for the first two study questions by comparing functional outcomes (SSV, Rowe scores, ROM) and the proportion of patients who experienced recurrent instability after a Latarjet procedure. We also compared the hyperlaxity group with a subgroup of 32 patients with no hyperlaxity who had ≥ 15% glenoid loss (defined as the "critical defect, no hyperlaxity" group). In addition, 84% (36 of 43) of patients in the hyperlaxity group and 81% (58 of 72) in the no hyperlaxity group had CT scans at a median (range) 3 years (1 to 7) after surgery, and this subset of patients was analyzed for radiologic outcomes. The PASS was defined as an SSV of 82.5%, per an earlier study. Recurrent instability after the procedure was defined as any overt instability (dislocation, subluxation) or anterior apprehension noted in the postoperative period. Subluxation was evaluated clinically based on the patient's history of a subjective instability event or a dislocation of the glenohumeral joint that could be self-reduced. The patients in the hyperlaxity group were younger (mean ± SD age 23 ± 4 years) and had a smaller preoperative glenoid defect (4% ± 7%) than those in the no hyperlaxity group (age 28 ± 7 years, p < 0.001; glenoid defect 11% ± 9%, p < 0.001) and those in the critical defect, no hyperlaxity group (age 27 ± 8 years, p = 0.01; glenoid defect 19% ± 6%, p < 0.001). A priori sample size calculation showed that at a power of 90% and an alpha value of 0.05, a total of 18 patients were needed in each group to detect a difference in SSV of 12 ± 11 points.

RESULTS

The hyperlaxity group did not differ from the no hyperlaxity group in terms of SSV (median [IQR] 85 [80 to 95] versus 90 [80 to 95], difference of medians -5; p = 0.17), Rowe score (median [IQR] 95 [90 to 100] versus 98 [88 to 100], difference of medians -3; p = 0.61), or Duplay-Walch score (median [IQR] 90 [86 to 100] versus 90 [80 to 100], difference of medians 0; p = 0.73). We found no difference between the hyperlaxity and the no hyperlaxity group in terms of the proportion of patients who achieved the PASS (56% [24 of 43] versus 71% [51 of 72], OR 0.5 [95% CI 0.23 to 1.14]; p = 0.10). The hyperlaxity group did not differ from the no hyperlaxity group in the proportion of patients who experienced postoperative instability (12% [5 of 43] versus 11% [8 of 72], OR 1.1 [95% CI 0.32 to 3.45]; p = 0.93). We found no difference between the hyperlaxity and the no hyperlaxity group in terms of bony healing (97% [35 of 36] versus 98% [57 of 58], OR 0.6 [95% CI 0.04 to 10.13]; p > 0.99). We found no difference between the hyperlaxity and the no hyperlaxity group in the proportion of patients who had major graft resorption at the superior screw level in the sagittal section (86% [31 of 36] versus 90% [52 of 58], OR 0.7 [95% CI 0.20 to 2.54]; p = 0.74), minor graft resorption at the inferior screw level in the sagittal section (100% [36 of 36] versus 97% [56 of 58], OR 3.2 [95% CI 0.15 to 69.2]; p = 0.45), and acceptable mediolateral graft positioning at the superior screw level (75% [27 of 36] versus 79% [46 of 58], OR 0.8 [95% CI 0.29 to 2.10]; p = 0.62) and the inferior screw level (75% [27 of 36] versus 86% [50 of 58], OR 0.5 [95% CI 0.17 to 1.39]; p = 0.18).

CONCLUSION

The Latarjet procedure for unidirectional shoulder instability does not result in inferior functional outcomes or higher postoperative recurrence in patients with preexisting shoulder hyperlaxity compared with patients without hyperlaxity. Therefore, our findings suggest that shoulder hyperlaxity may not necessarily be an exclusion criterion for performing the Latarjet procedure. Future studies may need to compare the functional outcomes and complications after the Latarjet procedure with those of capsular plication procedures in patients with hyperlaxity and shoulder instability.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Arthroscopic Trillat technique for chronic anterior shoulder instability: outcomes at 2-year follow-up in 74 at-risk sports patients

BACKGROUND

Chronic anterior shoulder instability affects a young and athletic population, with a high demand for functional recovery and return to sport. The arthroscopic Trillat dynamic stabilization technique has shown great results at 2 years in terms of stabilization and functional outcomes on the general population. The hypothesis is that it could do so in at-risk for dislocation athletic population for stabilization and return to sport, with results comparable to the reference techniques.

METHODS

This is a multicenter retrospective study of Walch-Duplay type 2, 3, and 4 at-risk sports patients treated by arthroscopic Trillat for chronic anterior shoulder instability between January 2012 and January 2021, at a 2-year follow-up. The primary endpoint was the occurrence of dislocation recurrence. Secondary endpoints were subluxation recurrence, functional outcomes, time and level of return to sport, functional scores, bony fusion, and complications.

RESULTS

A total of 74 patients were analyzed, with a mean age of 24.4 years (15-50 years). Sports levels were moderate risk of dislocation Walch-Duplay type 2 for n = 34 (46%), medium-risk Walch-Duplay type 3 for n = 19 (26%), and high-risk Walch-Duplay type 4 for n = 21 (28%). Dislocation recurred in 3 patients (4.1%). All patients (100%) returned to sport, with an average delay of 4.6 months, with 56 (76%) returning to the same previous level. The mean Constant score was 94.5 (79-100), the Rowe score was 94.7 (70-100), the Walch-Duplay score was 90.2 (50-100), and the Shoulder Subjective Value score was 90.5 (65-100). Subgroup analysis of athletes at moderate risk of dislocation recurrence (Walch-Duplay type 2) vs. medium and high risk of dislocation recurrence (Walch-Duplay types 3 and 4) revealed no statistically significant difference. One patient presented with asymptomatic pseudarthrosis.

CONCLUSIONS

Arthroscopic Trillat offers highly satisfactory results in the treatment of chronic anterior shoulder instability for athletes regardless of the type of sport practiced and the type of risk according to Walch-Duplay. This simple and quick technique enables a rapid return to sport and at the previous level in the majority of cases. After showing its effectiveness in the general population at 2 years, arthroscopic Trillat offers a reliable alternative to the reference procedures in young athletic patients.

Conversion to Arthroscopic Surgery for Anterior Shoulder Instability Does Not Significantly Increase Patient Out-of-Pocket Costs, But Both Conversion and Initial Arthroscopic Management Are Twice as Costly as Isolated Nonoperative Management

PURPOSE

The primary objective of this study is to elucidate patient out-of-pocket cost associated with arthroscopicand nonoperative treatment of anterior shoulder instability with a secondary aim to examine the costs of conversion from nonoperative to arthroscopic treatment within 12 months from initial shoulder instability diagnosis.

METHODS

The Merative MarketScan Commercial Claims and Encounters database was used to identify patients aged 18 to 40 with anterior shoulder instability using diagnosis codes from 2014 to 2017. Three cohorts were created: an operative cohort, a nonoperative cohort, and an operative conversion cohort. The operative cohort was initially treated with primary arthroscopic shoulder surgery. The nonoperative cohort was treated with physical therapy. The conversion cohort was initially treated nonoperatively and then converted to operative management. 81 failed arthroscopic patients were excluded. Open stabilization procedures were excluded as well. Patient out-of-pocket costs were calculated for each cohort and compared.

RESULTS

713 operative, 1,144 nonoperative, and 79 conversion cohort patients were identified. Approximately 6% (79/1,223) of patients failed initial nonoperative treatment. Patients in the operative cohort were more likely to be male (percentage of males: 78% vs 69% [p < 0.001]) and younger (median age: 21 vs 26 [p < 0.001]) than those in the nonoperative cohort. Nonoperative treatment had the lowest patient out-of-pocket cost (nonoperative: $998 vs. operative: $1,961 [p < 0.001]), and conversion to operative treatment had the highest patient cost (conversion: $2,230). The additional cost of physical therapy, when patients fail nonoperative treatment, played a significant role in this difference.

CONCLUSION

Among patients presenting for evaluation of anterior shoulder instability, converting from nonoperative to arthroscopic treatment does not significantly increase patient costs compared to initial arthroscopic intervention. However, both treatment pathways are roughly two times more costly to the patient than isolated nonoperative management.

CLINICAL RELEVANCE

This study demonstrates that nonoperative management of anterior shoulder instability is associated with the lowest patient out-of-pocket costs, while conversion from nonoperative to arthroscopic treatment results in the highest costs. These findings highlight the financial implications of treatment selection and the potential cost burden for patients who fail initial conservative management.

Assessment of Primary Stability and Micromotion of Different Fixation Techniques for Scapular Spine Bone Blocks for the Reconstruction of Critical Bone Loss of the Anterior Glenoid-A Biomechanical Study

Anteroinferior shoulder dislocations require surgical intervention when related to critical glenoid bone loss. Scapular spine bone blocks have emerged as a promising alternative to traditional bone augmentation techniques. However, limited data exist on their biomechanical stability when using different suture-based fixation techniques. This study aimed to evaluate primary stability and micromotion after glenoid augmentation using a scapular spine bone block. A total of 31 fresh-frozen human shoulder specimens underwent bone block augmentation. The specimens were randomized into three groups: double-screw fixation (DSF), single-suture bone block cerclage (SSBBC), and double-suture bone block cerclage (DSBBC). Biomechanical testing was conducted using cyclic loading (5000 cycles at 1 Hz) and micromotion was analyzed using an optical 3D measurement system. Statistical analysis showed that medial irreversible displacement was significantly greater in the SSBBC group compared to DSF (p = 0.0386), and no significant differences were found in anterior or inferior irreversible displacements. A significant difference was noted in posterior reversible displacement (p = 0.0035), while no differences were found in inferior or medial reversible displacements. Between DSF and DSBBC, no significant differences were found in irreversible or reversible displacements in any direction. DSBBC provided stability comparable to DSF while offering a viable metal-free alternative. In contrast, SSBBC displayed inferior biomechanical properties, raising concerns about its clinical reliability.

Screw Fixation Has Better Outcomes, Lower Incidence of Redislocation, and Lower Bone Resorption Than Button Fixation for Arthroscopic Anatomic Glenoid Reconstruction With Distal Tibia Allograft: A Matched Cohort Analysis

PURPOSE

To compare the clinical outcomes between patients who received arthroscopic anatomic glenoid reconstruction (AAGR) using distal tibia allograft with button fixation versus screw fixation.

METHODS

A retrospective chart review was conducted for all patients who underwent AAGR with button or screw fixation between 2012 and 2021. Patients were matched at a 1:1 ratio on the basis of sex, type of surgery, and time since surgery. All patients who were included had a minimum clinical follow-up of 2 years. Study outcomes compared Western Ontario Shoulder Instability (WOSI) Index scores, recurrence of instability, incidence of revision surgeries, and computed tomography readings.

RESULTS

In total, 44 patients were included with 22 patients in each group. The preoperative glenoid bone loss was 22.57 ± 8.06% in the screw group and 22.92 ± 8.84% in the button group (P = .898). Both groups demonstrated a significant improvement in WOSI from preoperative to latest follow-up; however, patients in the screw group demonstrated significantly better WOSI scores at both 2-year (P = .003) and latest follow-up (P = .019) compared with the button group. Recurrent dislocation was observed in 9 patients (40.9%), all of whom underwent button fixation (P < .001). Two patients in the screw group experienced hardware complications (P = .488). Individuals who underwent button fixation were significantly more likely to undergo a revision surgery for recurrent instability (P = .011). Individuals in the button group demonstrated a significantly smaller mean graft anteroposterior diameter postoperatively (P < .001).

CONCLUSIONS

AAGR with both screw fixation results in significantly improved WOSI scores at minimum 2-year follow-up. Button fixation has a significantly greater incidence of redislocation. Radiographic findings suggest that on average, button fixation results in greater-grade bone resorption and subsequently smaller postoperative glenoid anteroposterior width than screw fixation.

LEVEL OF EVIDENCE

Level III, retrospective comparative case series.

Arthroscopic Bankart Repair Versus Arthroscopic Latarjet for Anterior Shoulder Instability: A Matched-Pair Long-Term Follow-up Study

Background

The Bankart and the Latarjet procedures are 2 of the most commonly utilized surgical techniques to treat anterior shoulder instability. However, the long-term outcomes after these procedures remain unclear, and there is not enough information regarding arthroscopic Latarjet.

Purpose

To analyze long-term outcomes of patients with anterior glenohumeral instability managed with an arthroscopic Bankart or Latarjet procedure.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients who underwent an arthroscopic Latarjet were matched-paired in a 1:1 ratio with patients who underwent an arthroscopic Bankart procedure at a single institution between 2007 and 2012. Recurrence at the time of follow-up as well as intraoperative and postoperative complications were recorded and compared between the 2 groups. Postoperative status was assessed at the final follow-up using the Rowe score, the Western Ontario Shoulder Instability Index (WOSI), the Subjective Shoulder Value, and the return-to-sport rate.

Results

A total of 80 patients, 40 patients in each group, were included (overall mean age, 26.5 ± 15.4 years). The mean follow-up was 13.2 years (range, 10-17 years). The recurrence rate was significantly higher in the Bankart group compared with the Latarjet group (35% vs 10%, respectively; P = .009). The mean estimate for the cumulative proportion of stable shoulders at 15-year follow-up was 64.4% in the Bankart group and 89.6% in the Latarjet group (P = .008). Revision surgery because of instability was necessary in 8 (20%) patients in the Bankart group and 2 (5%) in the Latarjet group (P = .41). There was no significant group difference in complication rate (15% in the Bankart group vs 17.5% in the Latarjet group; P = .48). The WOSI score was significantly better in patients treated with arthroscopic Latarjet (P = .004). More than half of the patients were able to completely return to their previous sport (52.5%), with no significant difference between groups.

Conclusion

Arthroscopic Latarjet was associated with a significantly lower recurrence rate and better postoperative WOSI score and sports activity level at long-term follow-up compared with arthroscopic Bankart, without any greater risk of complications.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Meta-analysis; Level of evidence, 3.

METHODS

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

RESULTS

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

CONCLUSION

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

Latarjet procedure versus iliac crest autograft transfer for anterior shoulder instability: a systematic review and meta-analysis of comparative studies

BACKGROUND

Anterior shoulder instability with glenoid bone loss presents a challenge in orthopedic surgery. The Latarjet and iliac crest bone graft transfer (ICBGT) procedures are commonly employed for its management, but direct comparative evidence is insufficient.

METHODS

Following PRISMA guidelines, a comprehensive search of PubMed, EMBASE, Cochrane Library, and Web of Science was conducted. Randomized controlled trials (RCTs) and cohort studies directly comparing the Latarjet and ICBGT procedures were included. Primary outcomes included postoperative recurrent instability, apprehension test, and complications, while secondary outcomes comprised Rowe score, Subjective Shoulder Value (SSV), pain level assessed by visual analogue scale (VAS), range of motion (ROM), and radiologic outcomes. Quality assessment was performed using RoB2 and MINORS tools. The weighted mean difference (WMD) for continuous variables and odds ratio (OR) for dichotomous variables were calculated, along with 95% confidence intervals (CIs). Meta-analysis was performed using RevMan 5.4.1 software.

RESULTS

A total of 6 studies with 409 patients were included. There was no significant difference in postoperative recurrent instability (OR, 1.33; 95% CI, 0.44 to 4.03; P = 0.61), positive apprehension test (OR, 0.78; 95% CI, 0.20 to 3.10; P = 0.73), revision surgery (OR, 2.06; 95% CI, 0.74 to 5.71; P = 0.16), mild complications (OR, 0.49; 95% CI, 0.23 to 1.06; 0.07), SSV (WMD, -1.94; 95% CI, -3.94 to 0.06; P = 0.06) or VAS score (WMD, 0.15; 95% CI, -0.17 to 0.47; P = 0.36) between the two procedures. The ICBGT group exhibited statistically superior Rowe scores (WMD, -3.10; 95% CI, -5.10 to -1.10; P = 0.002), as well as improved external (WMD, -5.32; 95% CI, -7.30 to -3.30; P < 0.001) and internal rotation (WMD, -5.11; 95% CI, -6.76 to -3.45; P < 0.001). However, these differences did not surpass the minimal clinically important difference (MCID). Radiological evaluations showed that the ICBGT procedure had statistically better outcomes in immediate glenoid augmentation, preservation and reduced fatty degeneration of the subscapularis (SSC) tendon, and graft remodeling at short-term follow-up.

CONCLUSIONS

The ICBGT procedure showed statistically superior Rowe scores and range of motion, but these differences may not be clinically significant. Both procedures had comparable outcomes in recurrent instability, apprehension test results, revision surgery, mild complications, SSV, and pain levels. ICBGT appears to offer advantages in glenoid augmentation and SSC preservation at short-term follow-up.

PROSPERO REGISTRATION ID

CRD42024586157.

A Technique to Augment Arthroscopic Bankart Repair With or Without a Metal Block: A Comparison

Introduction: Arthroscopic Bankart repair (ABR) is associated with an increased failure rate over time. The Recenter implant, a metal block, is designed to reinforce capsulolabral repair. The aim of this study was to evaluate whether the addition of the Recenter implant to ABR reduces the rate of recurrence in patients with glenohumeral anterior instability. Materials and Methods: This was a retrospective, multicentric case-control study focusing on patients surgically treated for anterior shoulder instability from February 2012 to November 2019. This study compared patients undergoing ABR augmented with the "Recenter" implant (augmented ABR group) against those receiving traditional ABR. Primary outcomes measured included recurrence rates. Secondary outcome measures included functional scores (Walch-Duplay and the subjective shoulder test [SST], the auto Rowe score, satisfaction, pain, and the presence or absence of subjective subluxation and apprehension), return to sports, the range of motion, as well as other complications. Results: Thirty-two patients with augmented ABR were compared to forty-eight patients in the traditional ABR group, with mean follow-up periods of 5.2 ± 1.3 years and 6.1 ± 1.5 years, respectively. Three patients (9.4%) experienced recurrence in the "Recenter" group, versus eight (16.7%) in the other group (p > 0.05). The Walch-Duplay score was 70.2 ± 8.2 in the "Recenter" group and 64.2 ± 8 in the control group (p > 0.05). The SST score out of 100 was, respectively, 84.6 ± 6 and 81.5 ± 5.5 (p = 0.05). There were no early complications in the implant group. No statistically significant differences were observed between the two groups for the other outcomes. Conclusions: ABR safely restores shoulder stability in selected patients with subcritical glenoid bone deficiency. However, the addition of the Recenter metal implant did not improve outcomes compared to traditional Bankart repair and introduced presumed significant surgical time, technical challenges, and additional costs.

Recurrence, Return to Sport, and Reoperation Rates Appear Similar Between Males and Females After Surgery for Anterior Shoulder Instability: Future Research Requires Disaggregation by Sex

PURPOSE

To evaluate sex-based disparities in outcomes following surgery for anterior shoulder instability and to assess the quality of the current literature on this topic.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a June 2023 database search (PubMed, Web of Science, Embase, Cinahl) identified Level I to III clinical studies on anterior shoulder instability (January 2003 to May 2023). Eligible studies included male and female outcomes after anterior shoulder stabilization. Systematic reviews, case reports, and case series were excluded. A meta-analysis examined sex-specific results: recurrence, reoperation, return to sport, American Shoulder and Elbow Surgeons (ASES) score, and Western Ontario Shoulder Instability (WOSI) index.

RESULTS

The initial search identified 7,028 studies, with 14 meeting inclusion criteria, totaling 1,262 patients (73.9% male, 26.1% female). Of the studies, 53% were excluded due to failure to disaggregate by sex. The meta-analysis found comparable outcomes by sex for recurrence (odds ratio [OR] = 1.05; 95% confidence interval [CI], 0.74-1.50; P = .77), reoperation rate (OR = 0.84; 95% CI, 0.69-1.02; P = .08), or return to sport (OR = 1.09; 95% CI, 0.54-2.22; P = .81) after arthroscopic Bankart, open Bankart, and open Latarjet procedures. Mean ASES scores were 91.08 ± 13.59 standard error of the mean (SEM) for males and 89.85 ± 16.73 SEM for females, while WOSI scores were 81.32 ± 19.23 SEM and 87.26 ± 14.09 SEM, respectively. Comparable outcomes were found in ASES (mean difference = -1.20; 95% CI, -4.28 to 1.88; P = .45) or WOSI scores (mean difference = 4.94; 95% CI, -0.31 to 10.00; P = .06).

CONCLUSIONS

Recurrence, return to sport, and reoperation rates were similar between males and females after arthroscopic Bankart, open Bankart, and open Latarjet procedures. Comparable outcomes were found in postoperative ASES and WOSI scores between sexes. Most relevant studies were excluded due to lack of disaggregation by sex, limiting the certainty of the conclusion and suggesting an opportunity to improve future research.

LEVEL OF EVIDENCE

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

Open Latarjet Results in Lower Recurrent Instability and Revision Rates Than Arthroscopic Bankart Repair at a 10-Year Follow-Up: A Systematic Review

PURPOSE

To compare arthroscopic Bankart repair versus the open Latarjet procedure at a minimum of a 10-year follow-up evaluating recurrence and arthropathy development rates.

METHODS

A systematic review was performed in concordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included if they reported on the arthroscopic Bankart repair or open Latarjet procedure with a minimum 10-year follow-up. Recurrent instability, revisions, and instability arthropathy were evaluated.

RESULTS

Overall, 40 studies met our criteria and were included, with 2,019 shoulders undergoing arthroscopic Bankart repair and 1,069 undergoing the open Latarjet procedure. The rate of recurrent instability was 0.0% to 22.6% (redislocations: 0.0%-9.6%) in those undergoing an open Latarjet procedure and 13.3% to 82.2% (redislocations: 9.6%-25.7%) among those undergoing arthroscopic Bankart repair. The rate of total revisions was 0.0% to 17.9% in those undergoing an open Latarjet procedure and 4.8% to 42.9% among those undergoing arthroscopic Bankart repair. The rate of overall arthritis was 10.3% to 71.4% in those undergoing an open Latarjet procedure and 16.7% to 89.3% among those undergoing arthroscopic Bankart repair.

CONCLUSIONS

There was a lower recurrent instability rate and revision rate in the open Latarjet group compared to the arthroscopic Bankart group at long-term follow-up. The rates of moderate to severe arthritis were comparable between the 2 procedures.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV studies.

Approach to shoulder instability: a randomized, controlled trial

Background

The significant rate of recurrent instability following arthroscopic stabilization surgery points to a need for an evidence-based treatment approach. The instability severity index Score (ISI score) is a point-based algorithm that may be used to assist clinicians in selecting the optimal treatment approach, but its efficacy compared with a traditional treatment algorithm has not been previously validated. The aim was to compare two surgical treatment algorithms: the ISI score and a conventional treatment algorithm (CTA).

Methods

This was a prospective, randomized controlled trial involving participants who were randomized to either the ISI score or CTA and were followed for 24 months postrandomization. In the ISI score cohort, patients underwent a Latarjet procedure if they presented with a score >3 points. Those scoring ISI score ≦3 points underwent an arthroscopic Bankart repair. Patients randomized to the CTA group underwent a Latarjet procedure if the glenoid bone loss was > 25%. The primary outcome was the Western Ontario Shoulder Instability Index. Secondary outcomes included the American Shoulder and Elbow Surgeons score as well as recurrence rates between groups.

Results

Sixty-three patients were randomized to ISI score (n = 31) or CTA (n = 32). At two years, the Western Ontario Shoulder Instability Index score was similar between groups (ISI score: 84.1 ± 16.9, CTA: 85.7 ± 12.5, P = .70). Similarly, no differences were detected in American Shoulder and Elbow Surgeons scores (ISI score: 93.2 ± 16.2, CTA: 92.6 ± 9.9, P = .89). Apprehension was reported in 18.5% for the ISI score group and 20% in the CTA group (P = 1.00). At a 24-month follow-up, there was no difference in redislocations: one in ISI score group and none in the CTA group (P = .48). There were two revision surgeries in the ISI score group and two in the CTA group.

Conclusion

This study did not demonstrate any differences in functional outcomes, the incidence of apprehension, or failure rates between the two treatment algorithms at 24-month follow-up.

Does high body mass index increase the risk of shoulder instability surgery? The LUXE prospective cohort study on 227 recurrent anterior shoulder instability

Background

The aim of this study was to determine whether body mass index (BMI) plays a role in overall morbidity following shoulder instability surgery and whether some surgical techniques are BMI-sensitive.

Methods

A prospective, multicenter database was created that included the following three surgical techniques: arthroscopic Bankart (AB), arthroscopic Bankart with remplissage (ABR), and Open Latarjet (OL). Patient data (demographic, strength, laxity and functional outcomes (Disability of the Arm, Shoulder, and Hand [QuickDASH]; Western Ontario Shoulder Instability Index; and QuickDASH Pain subscore) were compared at enrollment and last postoperative follow-up. Functional outcomes, complications, and postoperative outcomes were compared between the different groups and then subdivided by BMI. Follow-up radiographs were evaluated for graft position and complications for all patients who underwent OL.

Results

A total of 227 patients (164 men, 63 women) were included with at least 1-year follow-up (3.3y AB (n = 126), 4.5y ABR (n = 34), and 3y OL (n = 62)). At baseline, patients with high BMI (37(17%)) had significantly worse QuickDASH Pain subscores (2.9 ± 1.0, P value <.05) and QuickDASH (46.8 ± 21.6, P value < .001) scores compared to all other BMI groups. All BMI groups had similar QuickDASH (P value .22) and Western Ontario Shoulder Instability Index (P value .69) scores at last follow-up. Complication rates for patients with high BMI were significantly higher in ABR compared to AB (P value .042) and so were reoperation rates in patients with high BMI after OL compared to patients with high BMI after ABR (9.5%, P value .049).

Conclusion

Patients with high BMI showed significantly worse baseline functional scores but no difference was found in postoperative functional scores between BMI groups. Complication rates were significantly higher in patients with high BMI following ABR compared to AB, and so were reoperation rates in patients with high BMI undergoing Latarjet compared to AB.

Arthroscopic Bankart repair vs. Latarjet procedure for recurrent shoulder instability: a meta-analysis of clinical outcomes and complication rates in general and athletic populations

BACKGROUND

The Bankart repair and Latarjet procedure are both effective surgical methods for treating repeated recurrent anterior dislocation of the shoulder. However, there is still little consensus regarding the standard treatment for recurrent anterior instability of the shoulder. Typically, the choice of treatment has been influenced more by training and tradition rather than the existing evidence. This systematic review and meta-analysis aimed to compare patient-reported outcomes, recurrence, and complications between the 2 procedures, among both athletic and nonathletic cohorts.

METHODS

Relevant clinical trials were identified through a systematic search of databases in April 2023 including PubMed, Scopus, Web of Science, and Cochrane. Randomized controlled trials and cohort studies were included if they compared patient-reported outcomes or complication rates of open Latarjet procedure vs. arthroscopic Bankart repair. Continuous data, such as patient-reported outcomes were pooled as the weighted mean difference. For dichotomous data such as recurrence and revision rates, the pooled risk ratio (RR) with 95% confidence intervals (CIs) was calculated using random effects meta-analysis.

RESULTS

Twenty-one clinical studies (3 randomized controlled trials) were included in the meta-analysis involving a total of 13,176 operated shoulders. Arthroscopic Bankart showed a 3.08 times higher risk of recurrence and revision due to postoperative instability (RR = 3.08, 95% CI 2.03-4.68) compared with those who had the Latarjet approach. The Rowe score was higher in the Latarjet group by an average of 4.55 points (95% CI 2.41-6.68). This difference was more pronounced in athletes, with an increase of 5.47 points (95% CI 0.16-10.78), compared with the nonathletic population: 4.03 (95% CI 2.04-6.02). Return to sport time was shorter by 0.40 months (95% CI -0.75 to -0.05) in the Latarjet group. The total complication rate was approximately 47% lower in the Bankart group (RR = 0.53, 95% CI 0.31-0.90). Additionally, the risk of hematoma was 75% lower in patients undergoing the arthroscopic Bankart compared with the Latarjet procedure. External rotation, assessed both in abduction and adduction of the arm, as well as forward elevation, show no significant differences between the 2 groups.

CONCLUSION

Our results demonstrate that the Latarjet procedure has a lower recurrence rate, excels in patient-reported outcomes, and requires less time for return to sports. Thus, it may be a superior alternative to arthroscopic Bankart repair. However, it is still associated with a higher incidence of complications.

Arthroscopic Bankart repair with remplissage yields similar outcomes to open Latarjet for primary and revision stabilization in the setting of subcritical glenoid bone loss

BACKGROUND

Management of patients with recurrent anterior glenohumeral instability in the setting of subcritical glenoid bone loss (GBL), defined in this study as 20% GBL or less, remains controversial. This study aimed to compare arthroscopic Bankart with remplissage (ABR + R) to open Latarjet for subcritical GBL in primary or revision procedures. We hypothesized that ABR + R would yield higher rates of recurrent instability and reoperation compared to Latarjet in both primary and revision settings.

METHODS

A retrospective study was conducted on patients undergoing either arthroscopic ABR + R or an open Latarjet procedure. Patients with connective tissue disorders, critical GBL (>20%), <2 year follow-up, or insufficient data were excluded. Recurrent instability and revision were the primary outcomes of interest. Additional outcomes of interest included subjective shoulder value, strength, and range of motion (ROM) RESULTS: One hundred eight patients (70 ABR + R, 38 Latarjet) were included with an average follow-up of 4.3 ± 2.1 years. In the primary and revision settings, similar rates of recurrent instability (Primary: P = .60; Revision: P = .28) and reoperation (Primary: P = .06; Revision: P = 1.00) were observed between Latarjet and ABR + R. Primary ABR + R exhibited better subjective shoulder value, active ROM, and internal rotation strength compared to primary open Latarjet. However, no differences were observed in the revision setting.

CONCLUSION

Similar rates of recurrent instability and reoperation in addition to comparable outcomes with no differences in ROM were found for ABR + R and Latarjet in patients with subcritical GBL in both the primary and revision settings. ABR + R can be a safe and effective procedure in appropriately selected patients with less than 20% GBL for both primary and revision stabilization.

Suture Button Fixation in Shoulder Instability Surgery to Achieve Bone Healing: A Critical Analysis Review

» Suture button fixation has emerged as an effective surgical construct in arthroscopic and open Latarjet and anterior glenoid reconstruction with free autograft bone with high rates of bone block healing.» Biomechanical data suggest that screw and suture button mechanical fixation constructs provide similar load to failure and stability for the Latarjet procedure.» Preliminary bone healing models have identified that flexible fixation may exhibit a higher degree of bone callus maturation, whereas rigid fixation results in excessive callus hyperplasia» Mechanical tensioner use provides consistent tensioning of suture button constructs and improves bone-to-bone healing rates when used for anterior glenoid reconstruction surgery.» Evidence is lacking regarding the reliability of bone-to-bone healing of allografts to native bone with use of suture button constructs.» Suture button fixation provides good short- and mid-term clinical outcomes for the arthroscopic Latarjet and anterior glenoid reconstruction with free autograft bone.

Survivorship and outcomes of arthroscopic bankart repair for anterior shoulder dislocations: A minimum of 2 year follow-up

Background

This study aims to evaluate long-term survivorship of arthroscopic Bankart repair (ABR).

Methods

About 101 patients under a single surgeon were followed up for ≥2 years post-ABR. Primary outcome was survivorship, defined as re-dislocation post-surgery. Secondary outcomes included a range of motion, strength, pain, University of California-Los-Angeles shoulder score, Oxford shoulder score (OSS), Oxford Shoulder Instability Score (OSIS), Constant Murley Score, and satisfaction. Clinical factors were correlated.

Results

Eight patients experienced postoperative dislocation (5 high-energy trauma, 2 low-energy trauma, 1 atraumatic), with 2 patients requiring revision. The mean time to post-operative dislocation was 1.5 years (range 0.3-3.8). Competitive athletes demonstrated worse survivorship (p = 0.027) but greater isometric strength at 6 months (p = 0.041) compared to recreational players. Patients ≥25 years old experienced slower recovery of internal rotation at 3 months (p = 0.006). Patients with surgery >1 year after injury had slower recovery of external rotation (p = 0.006), worse Constant scores at 3 months (p = 0.036) and lesser improvements in isometric strength at 3 months (p = 0.032). Patients with single pre-operative dislocations (p = 0.036 OSS; p = 0.039 OSIS) and patients ≥25 years old (p = 0.044 OSS) had worse Oxford scores at 3 months.

Discussion

ABR demonstrates good outcomes with low recurrence. This study prognosticates long-term outcomes across various subgroups.

Bone formation of the coracoid bone graft after the Bristow procedure assessed using three-dimensional computed tomography

BACKGROUND

The Bristow procedure has been shown to be a reliable method to prevent recurrent anterior shoulder instability by compensating for glenoid bone loss and producing the sling effect. The degree of postoperative morphological change in the coracoid bone graft is speculated to influence glenohumeral joint stability; however, the details of these changes after the Bristow procedure remain unknown. This study was performed to quantify the postoperative change in the coracoid bone graft volume as assessed by three-dimensional computed tomography (3D-CT).

METHODS

The Bristow procedure was performed on 17 shoulders in 17 patients from August 2018 to January 2020. All patients were men, and their mean age at surgery was 17.9 years. The mean follow-up duration was 21.4 months. Within the first week after the operation (Time 0) and at the final follow-up, 3D-CT was used to determine the total coracoid bone graft volume. The clinical outcomes were evaluated using the Japanese Orthopaedic Association (JOA) shoulder score, the University of California Los Angeles (UCLA) shoulder score, and the Western Ontario Shoulder Instability Index (WOSI).

RESULTS

The mean volume of the total coracoid bone graft was 1.26 ± 0.29 cm3 at Time 0 and 1.90 ± 0.36 cm3 at the final follow-up (p < 0.0001). The mean JOA score, UCLA score, and WOSI were significantly better at the final follow-up than preoperatively (p < 0.001). No postoperative infection, neurovascular injury, or recurrent instability of the glenohumeral joint occurred.

CONCLUSIONS

In the Bristow procedure, the volume of the total coracoid bone graft as shown by 3D-CT was significantly greater at the final follow-up than at Time 0, and bone formation of the coracoid bone graft was found after the Bristow procedure.

Open Latarjet reduces residual apprehension, redislocation and possibility of dislocation arthropathy compared to arthroscopic Bankart repair despite greater bipolar bone loss in anterior glenohumeral instability

Background

Arthroscopic Bankart repair (ABR) and the open Latarjet (OL) procedure are the most frequently preferred methods in the treatment of anterior glenohumeral instability. The aim of this study was to compare patients who underwent ABR or OL due to anterior glenohumeral instability in terms of functional capacity, glenohumeral bone loss, residual apprehension, redislocation, and dislocation arthropathy.

Methods

A total of 56 patients who underwent ABR or OL due to anterior glenohumeral instability between January 2018 and December 2021 were evaluated retrospectively. There were 32 patients in the ABR group and 24 patients in the OL group. Patients' demographic characteristics, number of preoperative dislocations, and return-to-work, and follow-up periods were recorded. Glenoid bone loss, Hill-Sachs interval, and Hill-Sachs depth were measured from preoperative computed tomography sections. The American Shoulder and Elbow Surgeons score, the Western Ontario Shoulder Instability Index score, Rowe score, and joint range of motion were calculated. Patients were also asked about residual apprehension, postoperative redislocations, dislocation arthropathy, and surgery satisfaction.

Results

The mean age of the ABR group was 22.5 ± 3.9 years (28 men, 4 women), while that of the OL group was 25.0 ± 4.8 years (22 men, 2 women). The mean number of dislocations was 2.7 ± 1.3 in the ABR and 10.9 ± 5.5 in the OL (P = .001). Higher values of glenoid bone loss (%) (ABR: 6 ± 2; OL: 20 ± 4), Hill-Sachs interval (mm) (ABR: 8 ± 3; OL: 21 ± 3), and Hill-Sachs depth (mm) (ABR: 5 ± 2; OL: 8 ± 2) were measured in the OL (P = .001 for all), reflecting significantly more bone loss. Residual apprehension was detected in 10 patients in the ABR and 2 patients in the OL (P = .007). While 4 patients in the ABR had a history of redislocation, no redislocation occurred in the OL (P = .012). Dislocation arthropathy development was observed in 9 patients in the ABR and 4 patients in the OL (P = .038), according to the modified Samilson and Prieto classification. External rotation in adduction and external rotation in 90° abduction were approximately 5° higher in the OL (P = .011 and P = .016, respectively).

Conclusion

The ABR and OL methods both provide satisfactory outcomes in the treatment of anterior glenohumeral instability with appropriate indications. The OL procedure is preferred for patients with more dislocations and greater bipolar bone loss. Despite greater bipolar bone loss, the OL procedure provides lower rates of residual apprehension, redislocation, and dislocation arthropathy. Additionally, due to the stability it provides, there is less loss in external rotation.

Primary Open Latarjet Procedure Versus Revision to Open Latarjet Procedure for Anterior Shoulder Instability

BACKGROUND

Although the Latarjet operation may be performed as a revision surgery for anterior shoulder instability, the high recurrence rate of anterior shoulder instability after arthroscopic Bankart repair (ABR) has led some to advocate for performing the Latarjet procedure as a primary stabilization surgery. The purpose of this study was to compare the intermediate-term outcomes after primary open Latarjet (PLJ) and revision to open Latarjet (RLJ).

MATERIALS AND METHODS

This was a single-institution retrospective analysis of patients who underwent either PLJ or RLJ procedures for anterior shoulder instability between 2014 and 2023. Patients with less than 1 year of follow-up, seizure history, multidirectional instability, concurrent rotator cuff repair, or the absence of preoperative imaging were excluded. Glenoid bone loss (GBL), the width of Hill-Sachs lesions, recurrent dislocations, and reoperations were assessed.

RESULTS

The study included 29 patients, with 12 undergoing PLJ procedures and 17 undergoing RLJ procedures. The mean duration of follow-up was similar for the two groups (4.7 vs 4.6 years, P=.854). Patients undergoing PLJ procedures demonstrated a higher mean GBL (18.4%) compared with patients undergoing revision (10.5%; P=.035); however, there was no significant difference in Hill-Sachs lesion size (14.2 vs 10.4 mm, P=.374). After stratifying according to GBL, the groups undergoing PLJ and RLJ procedures had similar recurrent dislocation rates (8.3% and 11.8%, respectively; P=1.0) and reoperation frequency (25.0% and 23.5%, respectively; P=1.0).

CONCLUSION

The PLJ and RLJ groups had comparable rates of recurrent dislocations, complications, and reoperations, emphasizing the value of considering Latarjet procedures as revision surgery after unsuccessful primary arthroscopic stabilization. [Orthopedics. 2024;47(6):343-348.].

High Rate of Return to Sport in Contact and Collision Athletes After Arthroscopic Latarjet With Cortical Button Fixation

BACKGROUND

Contact and collision athletes face a higher risk of recurrent anterior shoulder instability after surgical stabilization. The Latarjet procedure is often preferred given the high incidence of bony lesions. However, this stabilizing procedure, performed either open or arthroscopically, is met with concerns regarding complications and revision surgery rates.

PURPOSE

To evaluate the return to sport (RTS) and assess complication and instability recurrence rates in contact/collision athletes undergoing the arthroscopic Latarjet procedure using a guided technique with suture buttons for coracoid fixations.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective analysis was conducted on contact/collision athletes who underwent the arthroscopic Latarjet procedure for recurrent anterior shoulder instability between January 2011 and March 2018. All patients were operated on arthroscopically using glenoid and coracoid guides and suture button fixation of the transferred coracoid. RTS was defined as the patient being able to participate in his or her activity without any restriction postoperatively. Two independent observers assessed patients using postoperative computed tomography (CT) scans to evaluate coracoid positioning and healing. A multivariate analysis was performed to identify predictive factors associated with persistent apprehension. A group comparison was performed to assess RTS failure risk factors.

RESULTS

In 136 contact/collision athletes (mean age, 25 ± 7 years), 93% were satisfied, and 98% achieved shoulder stability at a mean follow-up of 60 months (range, 24-117 months). No suture button-related complications or neurovascular issues were reported. Overall, 82% (112/136) returned to contact/collision sports. The mean time to RTS was 5.3 ± 1.2 months (range, 3-7.3 months). In a CT study performed 2 weeks after surgery, 87% (118/136) of bone grafts were positioned below the equator and 93% (126/136) were flush to the glenoid surface. At the 6-month postoperative CT examination, complete bone block healing was achieved in 84% (114/136). On clinical examination at the latest follow-up, 36 patients (26%) reported some anterior apprehension on testing. On multivariate analysis, patients with severe humeral bone defects (medium to large Hill-Sachs lesions, Calandra grade 2 or 3) had a higher risk of postoperative persistent apprehension. On group comparison, a visual analog scale score >3 and persistent anterior apprehension were found to be associated with failure of RTS.

CONCLUSION

The arthroscopic Latarjet procedure with suture button fixation allowed 82% of athletes with recurrent anterior shoulder instability to return to contact or collision sports. Patients with severe humeral bone defects have a higher risk of persistent anterior apprehension and decreased RTS. The arthroscopic-guided procedure with suture button fixation is safe; accurate, with a high rate of anatomic graft positioning and healing; and reliable, with a low recurrence rate.

The Top-20 Studies About Anterior Shoulder Instability From an Altmetric Analysis Had Higher Levels of Evidence Than Those From a Traditional Bibliometric Analysis

Purpose

To compare the characteristics of the top-20 studies about anterior shoulder instability according to the Altmetric Attention Score (AAS) with total citation counts.

Methods

Two separate searches were performed for articles related to anterior shoulder instability. The Altmetric search identified the top-20 articles according to AAS. A bibliometric search using Web of Science identified the top-20 most-cited articles. Altmetric criteria were applied to the bibliometric list and vice versa.

Results

The AAS from the Altmetric list ranged from 44 to 432. The highest AAS from the bibliometric search was 70. One study appeared in both lists. Most online mentions were from X (formerly Twitter). The geographical breakdown of X mentions saw 71 countries appearing in the Altmetric search versus 21 in the bibliometric search. The total citations in the bibliometric list ranged from 91 to 358 versus 0 to 121 for the Altmetric list. The Altmetric top-20 list contained 8 studies that were Level II or higher versus 3 in the bibliometric list.

Conclusions

The top-20 studies according to AAS or citation count are not the same. The top-20 studies by AAS are composed of studies at higher levels of evidence versus the top-20 studies when listed by citation count.

Clinical Relevance

Electronic searches are an important way to access information in the modern world. Different search options generate results according to different parameters and may generate different results for the same query. It is important to understand these differences so that users have a better understanding of where the most clinically useful information can be found, especially regarding medical conditions.

Splitting the subscapularis at the upper two-third and lower one-third junction or in the middle during the Latarjet-Walch procedure does not affect the external rotation range of motion

BACKGROUND

Our purpose was to investigate (1) the difference in external rotation range of motion (ROM) limitation between the two recommended subscapularis-splitting techniques (mid-split vs. upper 2/3rd -lower 1/3rd split) and (2) the differences in elevation ROM, internal rotation (IR) ROM, the functional outcomes and the IR strength between the two techniques in the Latarjet-Walch procedure.

MATERIAL AND METHODS

We conducted a prospective cohort study of patients with recurrent shoulder instability treated by the Latarjet-Walch procedure between January 2021 and January 2022. After a priori calculation of sample size, 32 patients were divided into two groups according to the type of intraoperative subscapularis split [upper 2/3rd -lower 1/3rd level split (LS group, n = 19) vs. mid-LS (MS group, n = 13)] performed in the Latarjet-Walch procedure.

RESULTS

The final external rotation with the arm adducted deficit (as compared to opposite normal shoulder) was not significantly different between the LS (9° ± 8°) and the MS (10° ± 8°, P = .8) groups. The final ER with the elbow abducted @ 90° (ER2) deficit was not significantly different between that of the LS (14° ± 12°) and the MS groups (12° ± 9°, P = .5). Only in the MS group were the final ER with the arm adducted deficit (P = .03) and the final ER with the elbow abducted @ 90° deficits (P = .05) significantly better (smaller) than the corresponding baseline values. The Rowe scores (P = .2) and the Shoulder Subjective Value (P = .7) were not significantly different between the two groups. There were no postoperative subluxations in either group. However, 3 patients tested positive in apprehension testing in the LS group compared to none in the MS group, the difference being statistically insignificant. The IR strength was 95% of the normal, unaffected shoulder in the LS group and 93% of the normal in the MS group (P = .6). Computed tomography scan evaluation showed that the transverse diameter index of subscapularis (upper subscapularis diameter/lower subscapularis diameter) was not different in the MS (0.9 ± 0.1) and the LS (0.9 ± 0.1, P = .3) groups.

CONCLUSION

We found no difference in final external rotation limitation between the upper 2/3rd - lower 1/3rd vs. mid-level subscapularis split techniques. The functional outcomes, the IR strength, subscapularis transverse diameter index, and fatty infiltration in the computed tomography scan were similar in both groups.

The Arthroscopically Guided Bristow-Latarjet Procedure With Cortical Button Fixation: A Minimum 10-Year Follow-up

BACKGROUND

Despite improved visualization, the use of arthroscopic surgery to perform the Latarjet procedure has not decreased the rates of complications and glenohumeral osteoarthritis (OA) in the long term. Many of the reported complications are related to the use of screws for bone block fixation with freehand drilling.

PURPOSE

To evaluate the long-term (at a minimum 10-year follow-up) clinical and radiological outcomes of the arthroscopic Bristow-Latarjet procedure using a posterior guided drilling technique and suture button for coracoid bone graft fixation.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Consecutive patients who underwent the arthroscopic Bristow-Latarjet procedure with suture button fixation between 2011 and 2013 were reviewed by 2 independent evaluators. Complications and revision surgery were recorded, and we evaluated patient-reported outcomes including subjective scores, recurrence of shoulder instability (dislocation or subluxation), range of motion limitations, and return to sports. Patients had radiographs taken at least 10 years after surgery to assess glenohumeral OA according to the Samilson-Prieto classification system and computed tomography scans to assess bone block positioning and healing.

RESULTS

A total of 65 consecutive patients (68 shoulders) with a mean follow-up of 135 months (range, 120-156 months) were included. The mean age at the time of surgery was 25 ± 8 years; 7 patients had previous failed Bankart repair. At follow-up, 94% (64/68) of the shoulders had no recurrence of instability. The 4 cases of instability recurrence were traumatic and occurred at 3 weeks (a fall), 4 months, 2 years, and 7 years after surgery. No hardware failures, coracoid fractures, or neurological complications were observed. Overall, 61 patients (94%) were still participating in sports, with 44 (68%) at the same or higher level. Range of motion showed nonsignificant restrictions in external rotation with the arm at the side (7° ± 9°) and with the arm at 90° of abduction (9° ± 10°) compared with the contralateral side. Additionally, 11 shoulders (16%) had some residual anterior apprehension on clinical examination. At last follow-up, 77% (47/61) of the shoulders had no OA development or progression. Previous failed Bankart repair was a risk factor for the development of OA. Patients with OA had significantly lower Subjective Shoulder Value scores (79% vs 91%, respectively; P = .01) and decreased external rotation with the arm at the side (40° vs 65°, respectively; P = .001) compared with patients with no or little OA.

CONCLUSION

The arthroscopically guided Bristow-Latarjet procedure with suture button fixation is a safe and durable surgical treatment method for recurrent anterior shoulder instability, allowing a high rate of return to sports without significant motion restrictions and no or little OA in the long term.

Surgical Variations of the Modified Latarjet Procedure: A Literature Review and Video-Illustrated Surgical Technique

The modified Latarjet procedure, otherwise known as the Walch-Boileau procedure, is a very successful management procedure for recurrent shoulder dislocation especially in patients with glenoid bone loss of less than 30 percent. Multiple variations of the surgical technique have been proposed over the years, some of which are still controversial. These variations include arthroscopic vs open technique, traditional versus congruent arc Latarjet procedure, subscapularis split versus L-shaped tenotomy, intra-articular versus extra-articular coracoid placement, capsular repair versus no repair, and the various modalities of coracoid fixation. The current evidence is based on a group of low-evidence heterogenous studies since some of these variations lack strong clinical comparative studies that control other variables. In this literature review, we present the evidence available for each of the above major variations. Furthermore, we present a video illustration of the surgical procedure done in our tertiary care center.

Instability Severity Index Score predicts recurrent shoulder instability after arthroscopic Bankart repair

PURPOSE

The Instability Severity Index (ISI) Score was developed to preoperatively assess the risk of recurrent shoulder instability after an arthroscopic Bankart repair. This study aims to validate the use of ISI Score for predicting the risk of recurrence after an arthroscopic Bankart repair in a heterogeneous population and proposes an appropriate cut-off point for treating patients with an arthroscopic Bankart repair or otherwise.

METHODS

This study analysed 99 shoulders after a traumatic dislocation that underwent arthroscopic Bankart repair with at least 3 years follow-up. Patients were divided into subcategories based on their respective ISI Score. Recurrence includes either a postoperative dislocation or perceived instability.

RESULTS

The overall recurrence rate was found to be 26.3%. A significant correlation was identified between ISI Score and the recurrence rate (odds ratio [OR]: 1.545, 95% confidence interval [CI]: 1.231-1.939, p < 0.001). Furthermore, ISI Score 4-6 (OR: 4.498, 95% CI: 1.866-10.842, p < 0.001) and ISI Score > 6 (OR: 7.076, 95% CI: 2.393-20.924, p < 0.001) both had a significantly higher risk of recurrence compared to ISI Score 0-3. In ISI Score subcategories 0-3, 4-6 and >6, the recurrence rate was, respectively, 15.4%, 40.7% and 71.4%.

CONCLUSION

ISI Score has predictive value in determining the recurrence risk of shoulder instability following an arthroscopic Bankart repair in a heterogeneous population. Based on the findings of this study, we recommend using arthroscopic Bankart repair in patients with ISI Score 0-3. Clinical and shared decision-making are essential in the group with ISI Score 4-6, since the recurrence rate is significantly higher than in patients with ISI Score 0-3. Arthroscopic Bankart repair is not suitable for patients with ISI Score > 6.

LEVEL OF EVIDENCE

Level III.

Arthroscopic Bankart Repair With Remplissage in Anterior Shoulder Instability Results in Fewer Redislocations Than Bankart Repair Alone at Medium-term Follow-up of a Randomized Controlled Trial

BACKGROUND

A multicenter, double-blinded randomized controlled trial comparing isolated Bankart repair (NO REMP) to Bankart repair with remplissage (REMP) reported benefits of remplissage in reducing recurrent instability at 2 years postoperative. The ongoing benefits beyond this time point are yet to be explored.

PURPOSE

To (1) compare medium-term (3 to 9 years) outcomes of these previously randomized patients undergoing isolated Bankart repair (NO REMP) or Bankart repair with remplissage (REMP) to manage recurrent anterior glenohumeral instability; (2) examine the failure rate, overall recurrent instability, and reoperation rate.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Recruitment and randomization for the original randomized trial occurred between 2011 and 2017. Patients ≥14 years diagnosed with recurrent traumatic anterior shoulder instability with an engaging Hill-Sachs defect of any size were included. Those with a glenoid defect >15% were excluded. In 2020, participants were contacted by telephone and asked standardized questions regarding ensuing instances of subluxation, dislocation, or reoperation on their study shoulder. "Failure" was defined as a redislocation, and "overall recurrent instability" was described as a redislocation or ≥2 subluxations. Descriptive statistics, relative risk, and Kaplan-Meier survival curve analyses were performed.

RESULTS

A total of 108 participants were randomized, of whom 50 in the NO REMP group and 52 in the REMP group were included in the analyses in the original study. The mean number of months from surgery to the final follow-up was 49.3 and 53.8 months for the NO REMP and REMP groups, respectively. Failure rates were 22% (11/50) in the NO REMP group versus 8% (4/52) in the REMP group. Rates of overall recurrent instability were 30% (15/50) in the NO REMP group versus 10% (5/52) in the REMP group. Survival curves were significantly different, favoring REMP in both scenarios.

CONCLUSION

For the treatment of traumatic recurrent anterior shoulder instability with a Hill-Sachs lesion and subcritical glenoid bone loss (<15%), a significantly lower rate of overall postoperative recurrent instability was observed with arthroscopic Bankart repair and remplissage than with isolated Bankart repair at a medium-term follow-up (mean of 4 years). Patients who did not receive a remplissage experienced a failure (redislocated) earlier and had a higher rate of revision/reoperation than those who received a concomitant remplissage.

REGISTRATION

NCT01324531 (ClinicalTrials.gov identifier).

Minimum 10-year follow-up outcomes of arthroscopic Bankart's repair with metallic anchors: Reliable results with low redislocation rates

BACKGROUND

With stiff competition from alternative albeit more expensive counterparts, it has become important to establish the applicability of metallic anchors for shoulder instability in the modern era. This can be accomplished, in part, by analysing long-term outcomes.

AIM

To analyse minimum 10-year outcomes from 30 patients following arthroscopic anterior stabilisation using metallic anchors.

METHODS

Prospectively collected data from arthroscopic Bankart repairs performed using metal anchors during 2007P-2010 were retrospectively analysed in this single-surgeon study. Comprehensive data collection included historical and clinical findings, dislocation details, operative specifics, and follow-up radiological and clinical findings including shoulder scores. The primary outcomes were patient-reported scores (Constant, American Shoulder and Elbow Surgeons [ASES], and Rowe scores) and pain and instability on a visual analogue scale (VAS).

RESULTS

A 3% recurrence rate of dislocation was noted at the final follow-up. Total constant scores at 10 years postoperatively measured between 76 and 100 (mean 89) were significantly better than preoperative scores (mean 62.7). Congruous improvements were also noted in the Rowe and ASES scores and VAS at the 10-year review.

CONCLUSION

Reliable long-term outcomes with metallic anchors in surgery for shoulder instability can be expected. Our results provide additional evidence of their continued, cost-effective presence in the modern scenario.

Anterior shoulder dislocation: A bibliometric analysis in the past two decades (2003-2022)

Background

Anterior shoulder dislocation is the most common type of shoulder dislocation and is easy to develop into recurrent type, causing economic burden to society. This study uses the bibliometric method to analyze the global research status, hotspots and trends of anterior shoulder dislocation, aiming to promote the exploration of anterior shoulder dislocation.

Methods

The literature on anterior shoulder dislocation in the past two decades were retrieved and downloaded from the Web of Science Core Collection (WOSCC) database. CiteSpace, VOSviewer and bibliometrix package of R software were used to conduct scientific bibliometric analysis of the literature. Finally, some statistical graphics were performed in Graphpad Prism.

Results

A total of 3914 publications related to anterior shoulder dislocation from 2003 to 2022 were retrieved and screened from the WOSCC database. The ranking of the analysis results showed that Provencher MT was the author with the highest frequency of occurrence. Rush University was the most notable contributor. The American Journal of Sports Medicine was the most comprehensive journal. The United States was the most prominent country. Keywords related to surgical treatment were more significant than others.

Conclusion

In the past two decades, the research output on anterior shoulder dislocation have been increasing year by year. The focus has gradually shifted to surgical treatment. Surgical treatment may continue to be the research hotspots in this field in the future.

Arthroscopic Latarjet Versus Arthroscopic Free Bone Block Procedures for Anterior Shoulder Instability: A Proportional Meta-analysis Comparing Recurrence, Complication, and Reoperation Rates

BACKGROUND

Several arthroscopic glenoid bone augmentation techniques have been introduced to treat patients affected by anterior shoulder instability associated with critical bone loss. The efficacy of the different arthroscopic bony procedures has not been compared yet.

PURPOSE

To compare the recurrence, complication, and reoperation rates of the arthroscopic Latarjet (AL) and arthroscopic free bone block (ABB) procedures for anterior shoulder instability.

STUDY DESIGN

Meta-analysis and systematic review; Level of evidence, 4.

METHODS

A systematic search was conducted in MEDLINE/PubMed, Web of Science, and Embase to identify clinical studies reporting the outcomes of the AL and ABB procedures. The following search phrases were used: "Arthroscopic" AND "Bone Block" OR "Bone Graft," and "Arthroscopic" AND "Glenoid Augmentation" OR "Glenoid Reconstruction," and "Arthroscopic" AND "Latarjet" OR "Coracoid Graft" OR "Coracoid Transfer." Exclusion criteria were <24 months of minimum follow-up, sample size <10 cases, revision after previous glenoid bone grafting, epilepsy, and multidirectional instability. Data regarding the study design, patient characteristics, surgical technique, and outcomes were extracted and analyzed. A proportional meta-analysis was conducted to compare the complication, recurrence, and reoperation rates between the 2 groups. Multiple subgroup analyses were performed to analyze the incidence of each complication and assess the weight of different fixation methods (in the whole cohort) or different graft types (in the ABB group). The modified Coleman Methodology Score was used to assess the risk of bias.

RESULTS

Of 5010 potentially relevant studies, 18 studies regarding the AL procedure (908 cases) and 15 studies regarding the ABB procedure (469 cases) were included. The 2 groups were comparable in age (P = .07), sex (P = .14), glenoid bone loss (P = .14), number of preoperative dislocations (P = .62), proportion of primary and revision procedures (P = .95), length of follow-up (P = .81), modified Coleman Methodology Score (P = .21), and level of evidence (P = .49). There was no difference in the recurrence (P = .88), reoperation (P = .79), and complication (P = .08) rates. The subgroup analyses showed a higher rate of hardware-related complications for screw fixation compared with flexible fixation (P = .01).

CONCLUSION

The AL and ABB procedures had similar recurrence, reoperation, and complication rates. Screw fixation of the bone graft was related to an increased risk of complications compared with flexible fixation.

REGISTRATION

CRD42022368153 (PROSPERO).

The open Latarjet-Patte procedure for the treatment of anterior shoulder instability in professional handball players at a mean follow-up of 6.6 years

BACKGROUND

The popularity of team handball is increasing, with >10 million children playing this overhead throwing and collision sport with highest demands on the shoulder joint. Because of the risk of recurrent instability, the Latarjet-Patte (LP) procedure has been recommended to treat young competitive players. This is the first LP outcome study in professional handball players.

METHODS

We retrospectively included 20 shoulders (18 players [17 male patients]; mean age, 22.9 years [range, 17-35 years]; minimum follow-up period, 2 years; mean follow-up period, 6.6 years) operated on by 3 expert surgeons (2011-2020) with the Walch LP technique. We documented preoperative hyperlaxity (25%, n = 5), affected throwing arm (55%, n = 11), position (backcourt, winger, and goalkeeper, 22% each; full back and pivot, 17% each), >2 dislocations prior (20%, n = 4), >10 dislocations prior (5%, n = 1), previous failed Bankart or humeral avulsion of glenohumeral ligament (HAGL) repair (10%, n = 2), and large Hill-Sachs lesions (HSLs) (20%, n = 4). Clinical and radiographic outcomes, visual analog scale score, Subjective Shoulder Value, Walch-Duplay score, Rowe score, and return-to-sport (RTS) rate were recorded.

RESULTS

The RTS rate was 85% (17 of 20 shoulders); rate of RTS at the same level, 80% (16 of 20); and rate of RTS with no throwing pain, 73% (8 of 11). The time to training with a ball was 3.2 months, and the time to competition was 4.9 months. The mean Rowe score, Walch-Duplay score, and Subjective Shoulder Value were 90 points, 88 points, and 89%, respectively. Shoulder symptoms led players to give up handball in 2 cases (10%), whereas 1 player (5%) stopped playing handball for other reasons. We recorded 1 recurrent dislocation (5%) (non-throwing arm, winger, no recurrence after rehabilitation). Persistent apprehension occurred in 1 goalkeeper (5%). Residual pain was seen in 4 shoulders (20%); this was relieved by screw removal in 1. Resistant pain (throwing shoulder) was seen in 2 backcourt players (10%, 1 of whom had a large HSL) and 1 goalkeeper (5%; large HSL with >10 dislocations prior), all 3 of whom were aged > 30 years. Bone block positioning was correct (no lateral overhang) in all shoulders. At final follow-up, 1 shoulder (5%) showed mild arthritic changes (>10 dislocations, large HSL).

CONCLUSION

The open LP procedure is consistent in providing shoulder stability combined with return-to-throwing performance in professional handball players with a short time to RTS and high same-level RTS rate without increasing the risk of arthritic changes. Throwing shoulders of backcourt players, large HSLs, or age > 30 years may have an increased risk of persistent symptoms.

Long-term Effectiveness and Outcome-Determining Factors of Arthroscopic Bankart Repair for Recreational Sports Population: An Assessment of 100 Patients With a Mean Follow-up of 12.7 Years

BACKGROUND

A limited number of studies have reported the long-term effectiveness of and associated factors for recurrence of anterior shoulder instability after arthroscopic Bankart repair (ABR).

PURPOSE

To report the long-term clinical outcomes after ABR in a recreational sports population and identify the associated factors that influence the final instability status.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective study was performed in patients treated with ABR between 2007 and 2013 by a single surgeon. Patient data, magnetic resonance imaging measurements of bone loss and glenoid track, and intra- and perioperative factors were analyzed. After a minimum follow-up of 10 years, patient-reported outcomes including the Western Ontario Shoulder Instability Index score, the Rowe score, the visual analog scale for pain and function, the American Shoulder and Elbow Surgeons score, and sports activity were assessed. The current instability status was classified into 3 groups: stable, apprehensive, and redislocated. These groups were statistically compared with respect to outcomes and associated factors.

RESULTS

A total of 100 patients with a mean age of 22.4 ± 5.5 years and a mean follow-up of 12.7 ± 2.1 years were included. At the final follow-up, 38 patients (38%) showed recurrent symptoms: 19 patients (19%) with subjective apprehension and 19 patients (19%) with redislocation, including 10 patients (10%) with revision surgery. At the final follow-up, the redislocated group showed the lowest patient-reported outcomes and return to sports (both P < .001). The apprehensive group also showed a lower Western Ontario Shoulder Instability Index score (P = .011), Rowe score (P = .003), American Shoulder and Elbow Surgeons score (P = .027), and return to sports (P = .005) than the stable group. Participation in contact sports (P = .026), glenoid bone loss (P = .005), size of Hill-Sachs lesion (P = .009), and off-track lesions (P = .016) were all associated with recurrent symptoms, whereas age <20 years (P = .012), participation in contact sports (P = .003), and off-track lesions (P = .042) were associated with redislocation.

CONCLUSION

After long-term follow-up in a recreational sports population, ABR demonstrated a 19% rate of subjective apprehension and 19% rate of redislocation, with a gradual decline in clinical outcomes and sports activity over time. Therefore, candidates for ABR should be selected based on consideration of risk factors such as off-track lesions, age <20 years, and participation in contact sports.

Patients Have a 15% Redislocation Rate After Arthroscopic Bankart Repair With a Knotless Technique

Purpose

To evaluate the redislocation rate after arthroscopic Bankart repair (ABR) with a standardized knotless anchor technique in a consecutive series of patients with anterior glenohumeral instability.

Methods

Inclusion criteria were patients who underwent ABR by a single surgeon between January 2008 and December 2018 with a minimum follow up of 2 years. We collected data through phone interviews, Western Ontario Shoulder Instability Index, and review of patient records. The primary outcome was redislocation and secondary outcomes were recurrent subluxations, reoperation, postoperative complications, patient satisfaction, and functional outcomes. We also performed survival analysis and risk factor analysis.

Results

Of 88 patients (91 shoulders) who underwent ABR during the inclusion period, 70 patients (73 shoulders) were included (follow-up rate 80%). The mean follow-up was 7.5 years (range 2-12 years). Redislocation occurred in 15% (95% confidence interval [CI] 7.8%-25.4%) of patients at a mean of 41 months after surgery (range 6-115 months). The reoperation rate for recurrent redislocation was 4.1%. Overall, 90.4% reported being currently satisfied with their shoulder and the mean Western Ontario Shoulder Instability Index score at follow-up was 73.8% (range 8.3%-99.9%). Patients with redislocation were younger at primary operation than patients with no redislocation (mean 21 years vs 28 years; P = .023) and adjusted hazard ratio for age was 0.86 (95% CI 0.74-0.99; P = .033). It was more common to have less than 3 anchors in patients with redislocation (P = .024), but adjusted hazard ratio was 4.42 (95% CI 0.93-21.02; P = .061).

Conclusions

The redislocation rate after ABR with a standardized knotless anchor technique in a consecutive series of patients with anterior glenohumeral instability was found to be 15% after a minimum 2-year follow-up (mean 7.5).

Level of Evidence

Level IV, therapeutic case-series.

Majority of Studies Show Similar Rates of Return to Play After Arthroscopic Bankart Repair or Latarjet Procedure: A Systematic Review

PURPOSE

To systematically review the current evidence in the literature to compare return to play following arthroscopic Bankart repair versus open Latarjet procedure for the treatment of anterior shoulder instability.

METHODS

A literature search was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Comparative studies reporting return to play following arthroscopic Bankart repair versus open Latarjet procedure were included. Return to play was compared, with all statistical analysis performed using Review Manager, Version 5.3.

RESULTS

Nine studies with 1,242 patients (mean age: 15-30 years) were included. The rate of return to play was 61% to 94.1% among those undergoing arthroscopic Bankart repair and 72% to 96.8% in those undergoing an open Latarjet procedure. Two studies (Bessiere et al. and Zimmerman et al.) found a significant difference in favor of the Latarjet procedure (P < .05 for both, I2 = 37%). The rate of return to play at preinjury level was 9% to 83.8% among those undergoing arthroscopic Bankart repair and 19.4% to 80.6% in those undergoing an open Latarjet procedure, with no study finding a significant difference (P > .05 for all, I2 = 0%). The mean time of return to play was 5.4 to 7.3 months among those undergoing arthroscopic Bankart repair and 5.5 to 6.2 months in those undergoing an open Latarjet procedure, with no study finding a significant difference (P > .05 for all, I2 = 39%).

CONCLUSIONS

Overall, the majority of studies showed no significant difference in rates of return to play or timing following arthroscopic Bankart repair or open Latarjet procedure. Furthermore, no study has found a significant difference in rate of return to play at pre-injury level, or rate of return to play among collision athletes.

LEVEL OF EVIDENCE

Level III, systematic review of Level I-III studies.

Isolated Primary Latarjet Procedures for Anterior Shoulder Instability Results in High Rates of Graft Resorption and Glenohumeral Degenerative Changes With Low Rates of Failure at a Minimum 2-Year Follow-Up: A Systematic Review

PURPOSE

To evaluate the incidence of postoperative complications after an isolated primary Latarjet procedure for anterior shoulder instability at a minimum 2-year follow-up.

METHODS

A systematic review was performed in accordance with 2020 PRISMA guidelines. EMBASE, Scopus, and PubMed databases were queried from database inception through September 2022. The literature search was limited to human clinical studies reporting on postoperative complications and adverse events after a primary Latarjet procedure with a minimum 2-year follow-up. Risk of bias was measured using the Newcastle-Ottawa Scale.

RESULTS

Twenty-two studies, consisting of 1,797 patients (n = 1,816 shoulders), with a mean age of 24 years were identified. The overall postoperative complication rate ranged from 0% to 25.7%, with the most common complication being persistent shoulder pain (range: 0%-25.7%). Radiological changes included graft resorption (range: 7.5%-100%) and glenohumeral degenerative changes (range: 0%-52.5%). Recurrent instability following surgery was documented in 0% to 35% of shoulders, while the incidence of bone block fractures ranged from 0% to 6% of cases. Postoperative nonunion, infection, and hematomas had a reported incidence rate ranging from 0% to 16.7%, 0% to 2.6%, and 0% to 4.4%, respectively. Overall, 0% to 7.5% of surgeries were reported failures, and 0% to 11.1% of shoulders required reoperation, with a revision rate ranging from 0% to 7.7%.

CONCLUSIONS

The incidence of complications following the primary Latarjet procedure for shoulder instability was variable, ranging from 0% to 25.7%. High rates of graft resorption, degenerative changes, and nonunion were present while failure and revision rates remained low at a minimum 2-year follow-up.

LEVEL OF EVIDENCE

Level III, systematic review of Level I-III studies.

Outcomes of primary Latarjet vs. revision Latarjet after prior surgery for anterior shoulder instability: a systematic review and meta-analysis

BACKGROUND

Latarjet has become an increasingly popular treatment option for recurrent anterior shoulder instability. With the reported complication rates for primary Latarjet surgery, there are concerns about the complications of Latarjet as a revision surgery. It remains unclear if poor results after previous surgical management can be improved with revision Latarjet as well as with primary Latarjet. The aim of this systematic review and meta-analysis is to compare the outcomes of primary Latarjet and revision Latarjet for the treatment of anterior shoulder instability.

METHODS

A systematic search was performed on 3 databases for studies that compared primary Latarjet with revision Latarjet used after failed arthroscopic stabilization or failed free bone block procedures. From the included studies, demographic data, clinical outcome scores, range of motion measurements, and postoperative complications were obtained.

RESULTS

A total of 11 studies were included for data analysis. Compared with the primary Latarjet cohort, revision Latarjet cohorts had a higher infection rate (1.2% vs. 2.6%; RR 0.46, P = .039). The primary Latarjet group showed a greater rate of return to sport (89.7% vs. 80.5%; RR 1.12, P = .41) and less subjective feeling of instability (12.6% vs. 20.9%; RR 0.60, P = .085) compared with the revision Latarjet group; however, this was not statistically significant. There were no significant differences in complication rates, reoperation, recurrence, and range of motion between primary Latarjet and revision Latarjet groups. Clinical outcome scores such as visual analog scale and Rowe scores were not significantly different between the cohorts.

CONCLUSION

Based on the current evidence, primary Latarjet presents reduced infection rates but similar clinical outcome measures, overall complication, and range of motion measurements than revision Latarjet performed after failed prior operative treatment.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Intra-articular soft arthroscopic Latarjet technique as a Bankart-plus procedure for type V superior labrum anterior-posterior lesion: lower rate of instability recurrence and better functional outcomes of a prospective cohort study

BACKGROUND

Intra-articular soft arthroscopic Latarjet technique (in-SALT) involves augmentation of arthroscopic Bankart repair (ABR) with soft tissue tenodesis of long head of biceps to upper subscapularis. This study was conducted to investigate superiority of outcomes of in-SALT-augmented ABR over those of concurrent ABR and anterosuperior labral repair (ASL-R) in management of type V superior labrum anterior-posterior (SLAP) lesion.

METHODS

This prospective cohort study (conducted between January 2015 and January 2022) included 53 patients with arthroscopic diagnosis of type V SLAP lesion. Patients were allocated into 2 consecutive groups: group A of 19 patients managed with concurrent ABR/ASL-R and group B of 34 patients managed with in-SALT-augmented ABR. Outcome measurements included 2-year postoperative pain, range of motion, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and Rowe instability scores. Failure was defined as frank/subtle postoperative recurrence of glenohumeral instability or objective diagnosis of Popeye deformity.

RESULTS

The statistically matched studied groups showed significant postoperative improvement in outcome measurements. However, group B demonstrated significantly better 3-month postoperative visual analog scale score (3.6 vs. 2.6, P = .006) and 24-month postoperative external rotation at 0° abduction (44° vs. 50°, P = .020) and ASES (84 vs. 92, P < .001) and Rowe (83 vs. 88, P = .032) scores. Rate of postoperative recurrence of glenohumeral instability was relatively lower in group B (10.5% vs. 2.9%, P = .290). No Popeye deformity was reported.

CONCLUSION

For management of type V SLAP lesion, in-SALT-augmented ABR yielded a relatively lower rate of postoperative recurrence of glenohumeral instability and significantly better functional outcomes compared with concurrent ABR/ASL-R. However, currently reported favorable outcomes of in-SALT should be validated via further biomechanical and clinical studies.

Anterior Shoulder Instability and Open Procedures: History, Indications, and Clinical Outcomes

The shoulder, being the most mobile joint in the human body, is often susceptible to dislocations and subluxations more so than other joints. As such, shoulder instability constitutes a common complaint among patients worldwide, especially those who are young, participate in contact sports, and have increased innate flexibility in their joints. Management options in the setting of instability vary between conservative and surgical options that aim to mitigate symptoms and allow return of function. Surgical options can be arthroscopic and open, with a general shift among surgeons towards utilizing arthroscopic surgery in the past several decades. Nevertheless, open procedures still play a role in managing shoulder instability patients, especially those with significant bone loss, recurrent instability, coexisting shoulder pathologies, and high risk of failure with arthroscopic surgery. In these clinical settings, open procedures, like the Latarjet procedure, open Bankart repair, glenoid bone augmentation using iliac crest autograft or distal tibial allograft, and salvage options like glenohumeral arthrodesis and arthroplasty may show good clinical outcomes and low recurrence rates. Each of these open procedures possesses its own set of advantages and disadvantages and entails a specific set of indications based on published literature. It is important to cater treatment options to the individual patient in order to optimize outcomes and reduce the risk of complications. Future research on open shoulder stabilization procedures should focus on the long-term outcomes of recently utilized procedures, investigate different graft options for procedures involving bone augmentation, and conduct additional comparative analyses in order to establish concrete surgical management guidelines.

Arthroscopic Anterior Shoulder Capsular Reconstruction Using Human Acellular Dermal Graft in Conjunction With Anatomic Glenoid Reconstruction

Capsular insufficiency of the shoulder associated with glenoid bone loss poses a major challenge to orthopaedic surgeons in the management of recurrent anterior instability. Multiple surgical techniques have been described in the literature with varying rates of success, and the majority of these are open techniques. We present a complete arthroscopic technique for anterior capsular reconstruction using acellular human dermal allograft patch in conjunction to an anatomic glenoid reconstruction using a distal tibial allograft in the lateral decubitus position. If the capsular insufficiency is determined irreparable after glenoid reconstruction, the acellular human dermal graft patch is prepared, inserted into the shoulder joint, and appropriately fixed using suture anchors on both glenoid and humerus, all through arthroscopic portals.

Coracoid graft resorption after the Latarjet procedure does not depend on the preoperative glenoid defect

BACKGROUND

The primary purpose was to compare coracoid graft resorption after the Latarjet procedure in patients without preoperative glenoid bone loss vs. those with more than critical glenoid loss. The secondary purposes were to compare the functional outcomes and to investigate the association of graft position, angle of the screws, preoperative glenoid defect, age at surgery, and smoking status with graft resorption.

METHODS

Sixty consecutive patients with recurrent anterior instability were treated by the Latarjet procedure as the index procedure, irrespective of the glenoid bone loss between 2018 and 2021. Fifty-five patients were evaluated via computed tomography scans after a minimum of 1 year after surgery (range: 1-4 years). Twenty-five patients had no prior glenoid defect (No-defect group), 24 patients had preoperative glenoid defects ≥15% (Critical defect group), and 6 patients had glenoid defects between 5% and 15%. The No-defect group (n = 25) was compared with the Critical defect group (n = 24). Multivariate logistical regression was performed to evaluate the association of independent factors with the grade of resorption for all 55 patients in the cohort.

RESULTS

Major graft resorption at the level of the superior screw was observed in 72%-84% of patients in the No-defect group (n = 25) and in 75%-83% of patients in the Critical defect group (n = 24) (P = 1, P = 1; no significant difference). No to mild resorption at the level of the inferior screw was observed in 96% of patients in the No-defect group and 100% of patients in the Critical defect group (P = 1; no significant difference). Postoperative Rowe scores (100 [95-100] vs. 100 [95-100]; P = .8) and shoulder subjective value (87 [11] vs. 86 [9]; P = .9) were not significantly different between the 2 groups. None of the independent factors, including the corresponding screw angle, the mediolateral graft positioning, prior glenoid defect, age, and smoking status, were associated with graft resorption in multivariate logistical regression.

CONCLUSIONS

Graft resorption after the Latarjet procedure does not depend on the preoperative glenoid defect. The coracoid graft may be mostly resorbed around the superior screw but mildly or none at the level of the inferior screw, but this graft resorption is not dependent on the smoking status, age, prior glenoid defect, mediolateral graft positioning, and the angle of the screws.

Fourteen years of follow-up after first arthroscopic Bankart repair in athletes: functional outcomes and magnetic resonance imaging findings

BACKGROUND

The arthroscopic Bankart procedure is the most performed surgery for shoulder stabilization. Short-term to midterm results are well studied; however, long-term results over 10 years are rare.

PURPOSE

This study evaluates the long-term results and magnetic resonance imaging (MRI) findings in athletes at a mean follow-up of 14 years after an arthroscopic Bankart stabilization as well as risk factors for osteoarthritis.

METHODS

A total of 63 athletes had an arthroscopic Bankart repair between 2001 and 2008, of whom 46 patients (73.0%) participated in the final follow-up. The Constant, Rowe, and Western Ontario Shoulder Instability Index (WOSI) score and the rate of return to sports were evaluated. Glenohumeral osteoarthritis was assessed using the Samilson-Prieto classification. Known risk factors for osteoarthritis were analyzed. MRI findings (bone marrow edema, cysts, and joint effusion) were analyzed.

RESULTS

The average follow-up was 14 years. Assessment was performed on 46 athletes with an average age of 21.6 at the time of surgery. The overall redislocation rate was 21.7%. The Constant score was 96.7, the Rowe score was 83.4, and the Western Ontario Shoulder Instability Index score was 90.7 out of 100. A total of 84.8% of the athletes returned to their initial sports level. Glenohumeral osteoarthritis occurred in 28.1%. Known risk factors for osteoarthritis were confirmed. Further MRI findings were rare.

CONCLUSIONS

Arthroscopic Bankart repair in athletes shows good long-term clinical results. However, this is only in patients without osteoarthritis, which was rare, but was confirmed as a risk factor. We assume that resorption of anchors differs in patients. If it does have an impact on developing arthrosis, this should be confirmed in further studies.

Arthroscopic Latarjet procedure and suture-button fixation: can we predict nonunion early?

BACKGROUND

The arthroscopic Latarjet procedure is a technically challenging technique that provides well-known results. The first series reported fixation with screws. An alternative fixation technique has been proposed, using a button, to improve the reproducibility and to decrease the complications due to screws. The first reports using this fixation technique have yielded comparable rates of fusion. The objective of this study was to assess the fusion rate and bone modifications with this type of fixation.

METHODS

Two hundred sixteen patients were included in this prospective study. An arthroscopic Latarjet procedure, fixed with 1 button according to the Smith & Nephew technique, was performed by a single surgeon for the treatment of anterior instability. The radiographic protocol consisted of computed tomography scans at 3, 12, and 24 weeks postoperatively. We measured the coronal and sagittal positions of the bone block, distance between the bone block and the glenoid, diameter of the glenoid tunnel, fusion rate, and time to fusion.

RESULTS

The position was deemed flush in 92.6% of cases in the coronal plane and under the equator in 87.5% of cases in the sagittal plane. At last follow-up, we observed 9 cases of nonunion (4%), as well as 18 cases of delayed fusion. The fusion rate was 92% at 3 months and 96% at 6 months. For bone blocks that ultimately healed, the diameter of the glenoid tunnel was <2 mm in 62% of cases at 3 weeks and <1 mm in 90% of cases at 3 months. Conversely, the diameter of this tunnel significantly increased and was >3 mm in all cases of delayed union or nonunion.

CONCLUSION

The described technique achieved a reliable position of the bone block and a very good fusion rate with a new type of fixation. The time to obtain fusion can be lengthy, occurring between the third and sixth months. The diameter of the glenoid tunnel was the best predictive factor for fusion. Widening of the glenoid tunnel diameter >3 mm during the first 3 weeks was the most predictive factor for delayed union or nonunion of the bone block. This finding is probably explained by a sliding effect of the sutures through this tunnel, comparable to the bungee effect in anterior cruciate ligament repair in the knee.

A 2-Year Follow-up May Not be Enough to Accurately Evaluate Recurrences After Arthroscopic Bankart Repair: A Long-term Assessment of 272 Patients With a Mean Follow-up of 10.5 Years

BACKGROUND

There is a great discrepancy between the rates of recurrent instability reported after arthroscopic Bankart repair in relation to the follow-up time.

PURPOSE

To analyze the rate of recurrences after arthroscopic Bankart repair in the long term, emphasizing whether a minimum follow-up of 2 years is adequate to assess this outcome.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between January 2008 and April 2013, a total of 356 athletes underwent arthroscopic Bankart repair for anterior glenohumeral instability at our institution. Return to sports, the Rowe score, the Subjective Shoulder Value (SSV), and the Athletic Shoulder Outcome Scoring System (ASOSS) were used to assess functional outcomes. We analyzed the proportion of recurrences before and after 4 years of follow-up. Additionally, we performed a Kaplan-Meier analysis to evaluate recurrence-free time in patients with a recurrence.

RESULTS

The mean follow-up was 10.5 ± 1.6 years, and the mean age was 20.8 ± 3.9 years. In total, 90% of patients were able to return to sports; of these, 91% returned to their preinjury level of play. The Rowe, SSV, and ASOSS scores showed a statistical improvement after surgery (P < .01). The proportion of patients with a recurrence during the follow-up period was 25% (95% CI, 20%-31%; n = 70), and the mean time until a recurrence was 3.8 ± 2.6 years. Only 39% of the recurrences (95% CI, 30%-48%) occurred in the first 2 years after surgery, while 61% (95% CI, 50%-73%) occurred in the first 4 years after surgery.

CONCLUSION

In our study, the effectiveness of Bankart repair to stabilize the shoulder decreased significantly over time. Indeed, less than half of the recurrences occurred after 2 years of follow-up. Therefore, we propose that the recommended minimum follow-up should be 4 years; otherwise, it is very likely that the actual rate of recurrences will be significantly underestimated.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Arthroscopic Dynamic Anterior Stabilization Using Either Long Head of the Biceps or Conjoined Tendon Transfer for Anterior Shoulder Instability Results in a Similarly Low Recurrence Rate

PURPOSE

To compare the clinical outcomes of arthroscopic dynamic anterior stabilization (DAS) between transferring the long head of the biceps (DAS-LHB) and the conjoined tendon (DAS-CT) for anterior shoulder instability with <15% glenoid bone loss.

METHODS

From January 2016 to May 2019, a total of 63 patients who underwent DAS for recurrent anterior shoulder dislocation with <15% glenoid bone loss were included, comprising 33 patients in DAS-LHB group and 30 patients in DAS-CT group. Clinical outcomes were assessed preoperatively and at a minimum 3-year follow-up, including patient-reported outcomes, range of motion, and return to sports (RTS). Postoperative recurrent instability (including dislocation, subluxation, and subjective instability with a positive apprehension test), revisions and complications also were recorded.

RESULTS

No significant demographic characteristics difference was detected between the DAS-LHB (26.3 ± 7.9 years) and DAS-CT groups (26.0 ± 6.7 years). At the latest follow-up, there were no significant differences between the 2 groups in functional scores: Oxford Shoulder Instability Score (14.8 ± 2.8 vs 15.2 ± 3.6), Rowe score (95.9 ± 6.5 vs 93.2 ± 10.2), visual analog scale for pain (0.8 ± 1.2 vs 0.7 ± 1.7), and American Shoulder and Elbow Surgeons (95 ± 8.8 vs 95.2 ± 9.1) (all P > .218). No significant difference was detected between groups in the rates of RTS (90.1% vs 86.7%, P = .700) and RTS at previous level (78.7% vs 73.3%, P = .258), respectively. No recurrent dislocation occurred in either group. One patient felt occasional subluxation in the DAS-LHB group, and one was positive for the apprehension test in each group. One patient presented with postoperative shoulder stiffness and underwent a secondary arthroscopic debridement in the DAS-CT group.

CONCLUSIONS

Comparable rates of recurrence, complication, return to sports, and subjective shoulder function were observed between DAS-LHB and DAS-CT groups.

LEVEL OF EVIDENCE

Ⅲ; retrospective comparative therapeutic trial.