Recurrent posterior shoulder instability after rifle shooting

Arthroscopic Posterior Labral Repair in Active-Duty Military Patients: A Reliable Solution for an At-Risk Population, Regardless of Anchor Type

BACKGROUND

Active-duty servicemembers are a population at risk for the development of posterior shoulder instability. While short-term outcomes after arthroscopic posterior labral repair for posterior shoulder instability are promising, there is a paucity of longer term follow-up data for this procedure.

PURPOSES

The primary purpose was to report midterm outcomes after arthroscopic posterior labral repair in active-duty military patients for posterior shoulder instability without bone loss. The secondary purpose was to determine if outcomes varied between anchor types used.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Preoperative and postoperative outcomes, with a minimum 3-year follow-up, for a visual analog scale for pain, the Single Assessment Numeric Evaluation (SANE), the American Shoulder and Elbow Surgeons (ASES) score, and the Rowe score were collected and analyzed. A separate subgroup analysis was performed comparing the outcomes of patients who underwent repair with biocomposite anchors versus those who underwent repair with all-suture anchors.

RESULTS

A total of 73 patients with a mean follow-up of 82.55 ± 24.20 months met the inclusion criteria and were available for analysis. As a whole, the cohort demonstrated statistically and clinically significant improvements in outcome scores at final follow-up. Preoperative and postoperative range of motion did not vary significantly. While the difference in final outcome scores between the 2 anchor types did not reach statistical significance, a statistically significantly larger proportion of patients who underwent repair with all-suture anchors versus those who underwent repair with biocomposite anchors met the Patient Acceptable Symptom State for the SANE (97.14% vs 78.95%, respectively; P = .0180) and the ASES score (88.57% vs 68.42%, respectively; P = .0171). The proportion of patients who achieved the substantial clinical benefit or surpassed the minimal clinically important difference, however, did not vary by anchor type. Overall, 70 patients (95.89%) remained on active duty and were able to return to preinjury work and recreational activity levels. There were 3 patients (4.11%) who had recurrent posterior instability.

CONCLUSION

This population of active-duty servicemembers undergoing posterior labral repair for posterior labral instability without bone loss demonstrated a statistically and clinically significant improvement in midterm outcomes, a low recurrence rate, and a rate of return to active duty of 95.89%, regardless of the anchor type used.

Non-Operative Shoulder Dysfunction in the United States Military

INTRODUCTION

Recent epidemiological evidence shows that shoulder and upper-arm complaints impose a substantial burden on the armed forces of the United States and create significant challenges for all components of the physical fitness domain of total force fitness. Clinicians, epidemiologists, and health-services researchers interested in shoulder and upper-arm injuries and their functional limitations rarely have objective, validated criteria for rigorously evaluating diagnostic practices, prescribed treatments, or the outcomes of alternative approaches. We sought to establish and quantify patient volume, types of care, and costs within the Military Health System (MHS) in assessing and managing active duty members with nonoperative shoulder and upper-arm dysfunction.

MATERIALS AND METHODS

We performed a retrospective cohort study using data from the MHS Data Repository and MHS MART (M2) from fiscal year 2014 to identify active duty individuals with a diagnosis of shoulder and upper-arm injury or impairment defined by one of the International Classification of Disease Ninth Edition diagnosis codes that were selected to reflect nonoperative conditions such as fractures or infections. Statistical analyses include descriptive statistics on patient demographics and clinical visits, such as the range and frequency of diagnoses, number and types of appointments, and clinical procedure information following the diagnosis. We also examined treatment costs related to shoulder dysfunction and calculated the total cost to include medications, radiological, procedural, and laboratory test costs for all shoulder dysfunction visits in 2014 and the average cost for each visit. We further examined the category of each medication prescribed.

RESULTS

A total of 55,643 individuals met study criteria and accrued 193,455 shoulder-dysfunction-related clinical visits in fiscal year 2014. This cohort represents approximately 4.8% of the 1,155,183 active duty service members assigned to the United States and its territories during FY 2014. Most patients were male (85.32%), younger (85.25% were under 40 years old), and Caucasian/White (71.12%). The most common diagnosis code was 719.41 (pain in joint, shoulder region; 42.48%). The majority of the patients 42,750 (76.8%) had four or fewer medical visits during the study period and 12,893 (23.2%) had more than four visits. A total of 4,733 patients (8.5%) underwent arthrocentesis aspiration or injection. The total cost for all visits was $65,066,767.89. The average and median cost for each visit were $336.34 (standard deviation was $1,493.87) and $163.11 (range was from 0 to $84,183.88), respectively. Three out of four patients (75.3%) underwent radiological examinations, and 74.2% of these individuals had more than one radiological examination. Medications were prescribed to 50,610 (91.0%) patients with the three most common being IBUPROFEN (12.21%), NAPROXEN (8.51%), and OXYCODONE-ACETAMINOPHEN (5.04%), respectively.

CONCLUSIONS

Nearly 1 in 20 active duty military service members presented for nonoperative care of shoulder and/or upper-arm dysfunction during FY2014. Further examinations of the etiology and potential impact of shoulder/upper-arm dysfunction on force readiness are clearly warranted, as are additional studies directed at identifying best practices for preventing injury-related dysfunction and determining best practices for the treatment of shoulder dysfunction to optimize service member fitness and force readiness.

Posterior Shoulder Instability: What to Look for

Posterior shoulder instability is often hard to diagnose with clinical examination. Patients generally present with vague pain, weakness, and/or joint clicking but less frequently complaining of frank sensation of instability. Imaging examinations, especially MR imaging and magnetic resonance arthrography, have a pivotal role in the identification and management of this condition. This review describes the pathologic micro/macrotraumatic magnetic resonance features of posterior shoulder instability as well as the underlying joint abnormalities predisposing to this condition, including developmental anomalies of the glenoid fossa, humeral head, posterior labrum, and capsular and ligamentous structures.

Low Risk of Recurrence After Posterior Labral Repair of the Shoulder in a High-Risk United States Military Population

Purpose

To examine the results of isolated arthroscopic posterior labral repair of the shoulder in an active military population, looking specifically at the reoperation rate and rate of return to previous military activity with a minimum follow-up period of 2 years.

Methods

A retrospective case series was performed in active-duty military service members who underwent isolated, primary arthroscopic posterior labral repair at a single academic military treatment facility between 2009 and 2015 and had at least 2 years of follow-up. Patients were excluded if they were of non–active-duty status, had insufficient follow-up (<2 years), or had undergone a concurrent procedure. Injury presentation, demographic data, and surgical data (i.e., surgical positioning, number of anchors, and anchor placement location) were compiled manually. Outcomes including the rate of return to active duty, recurrence of symptoms, and need for revision surgery were evaluated.

Results

Sixty-five patients were included. After arthroscopic repair, a high rate of return to previous military duties (83%) was noted at short- to mid-term follow-up (mean ± standard deviation, 3.04 ± 1.30 years), with 1 patient (1.5%) requiring revision arthroscopic repair and 10 patients (15.5%) showing activity-limiting shoulder pain preventing a return to active duty. Intraoperative positioning (P = .17), a low anchor position (P = .27), and the number of anchors used (P = .62) were not found to be significant contributors to continued postoperative pain or recurrent instability.

Conclusions

Arthroscopic intervention resulted in a reliable rate of glenohumeral stability with a low rate of surgical revision and a high rate of return to military duty at short- to mid-term follow-up. However, 1 in 6 military service members showed significant, activity-limiting shoulder pain postoperatively that did not permit a return to previous military activities after surgical intervention.

Level of Evidence

Level IV, therapeutic case series.

Posterior Shoulder Instability

CONTEXT

Posterior shoulder instability has become more frequently recognized and treated as a unique subset of shoulder instability, especially in the military. Posterior shoulder pathology may be more difficult to accurately diagnose than its anterior counterpart, and commonly, patients present with complaints of pain rather than instability. "Posterior instability" may encompass both dislocation and subluxation, and the most common presentation is recurrent posterior subluxation. Arthroscopic and open treatment techniques have improved as understanding of posterior shoulder instability has evolved.

EVIDENCE ACQUISITION

Electronic databases including PubMed and MEDLINE were queried for articles relating to posterior shoulder instability.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

In low-demand patients, nonoperative treatment of posterior shoulder instability should be considered a first line of treatment and is typically successful. Conservative treatment, however, is commonly unsuccessful in active patients, such as military members. Those patients with persistent shoulder pain, instability, or functional limitations after a trial of conservative treatment may be considered surgical candidates. Arthroscopic posterior shoulder stabilization has demonstrated excellent clinical outcomes, high patient satisfaction, and low complication rates. Advanced techniques may be required in select cases to address bone loss, glenoid dysplasia, or revision.

CONCLUSION

Posterior instability represents about 10% of shoulder instability and has become increasingly recognized and treated in military members. Nonoperative treatment is commonly unsuccessful in active patients, and surgical stabilization can be considered in patients who do not respond. Isolated posterior labral repairs constitute up to 24% of operatively treated labral repairs in a military population. Arthroscopic posterior stabilization is typically considered as first-line surgical treatment, while open techniques may be required in complex or revision settings.

Posterior Instability of the Shoulder: A Systematic Review and Meta-analysis of Clinical Outcomes

BACKGROUND

To date, there are no reports in the literature of a systematic review and meta-analysis for posterior instability of the shoulder.

PURPOSE

The primary objective was to systematically capture, critically evaluate, and perform a meta-analysis of all available literature on arthroscopic clinical outcomes to provide insight and clinical recommendations for unilateral posterior shoulder instability. The secondary objective was to use the same means to assess clinical outcome literature for open treatment, of which a subset of highly reported outcome measures were used to determine superiority of arthroscopic versus open procedures for unilateral posterior shoulder.

STUDY DESIGN

Systematic review, meta-analysis.

METHODS

A systematic search to obtain every available, published, level of evidence study reporting patient data for unidirectional posterior shoulder instability was performed by use of the Cochrane Database of Systematic Reviews, PubMed/Medline database, manual searches of high impact factor journals and conference proceedings, and secondary references appraised for studies meeting inclusion criteria.

RESULTS

The systematic search captured a total of 1035 publications. After initial exclusion criteria were applied, 607 abstracts were assessed for eligibility. Full-text articles were obtained for 324 articles, and a total of 53 unique publications (27 arthroscopic studies, 26 open studies) reporting clinical outcomes for unidirectional posterior shoulder instability met inclusion criteria and were included in the systematic review and meta-analysis.

CONCLUSION

Well-defined and uniform shoulder outcome measures to assess posterior shoulder instability are lacking throughout the literature. However, arthroscopic procedures are shown to be an effective and reliable treatment for unidirectional posterior glenohumeral instability with respect to outcome scores, patient satisfaction, and return to play. Despite similar results of outcome measures to the overall athletic population, throwing athletes are less likely to return to their preinjury levels of sport compared with contact athletes or the overall athletic population. Evidence also indicates that arthroscopic stabilization procedures using suture anchors result in fewer recurrences and revisions than anchorless repairs in young adults engaging in highly demanding physical activity. Furthermore, the literature suggests that patients treated arthroscopically have superior outcomes compared with patients who undergo open procedures with respect to stability, recurrence of instability, patient satisfaction, return to sport, and return to previous level of play.

Posterior shoulder instability in the contact athlete

Historically, posterior shoulder instability has been a challenging problem for contact athletes and orthopedic surgeons alike. A complete understanding of the normal shoulder anatomy and biomechanics and the pathoanatomy responsible for the instability is necessary for a successful clinical outcome. In addition, the surgeon must be familiar with the diagnostic imaging and physical examination maneuvers required for the correct diagnosis without missing any other concurrent abnormalities. This understanding will allow orthopedists to plan and execute the appropriate management, whether this may involve conservative or surgical intervention. The goal should always be to correct the abnormality and have the patient return to play with full strength and no recurrent instability.