Type V Superior-Labrum Anterior-Posterior (SLAP) Repair - A Systematic Review

BACKGROUND

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

METHODS

Two independent reviewers performed a literature search based on PRISMA guidelines, utilizing the EMBASE, MEDLINE, and The Cochrane Library Databases. Studies were included if they had clinical outcomes on the patients undergoing type V SLAP repair. Statistical analysis was performed using SPSS (IBM, Armonk, NY, USA). A P value of < 0.05 was considered to be statistically significant.

RESULTS

Our review found 13 studies, including 451 shoulders meeting our inclusion criteria. The majority of patients were male (89.3%), with an average age of 25.9 years (range 15-58) and a mean follow-up of 53.8 months. The Rowe score was the most utilized functional outcome score, with a weighted mean of 88.5. Additionally, the mean Constant score was 91.0, the mean ASES score was 88.3, the mean SSV score was 85.5%, and the mean VAS pain score was 1.2. The overall rate of return to play was 84.8%, with 80.2% returning to the same level of play. The overall reoperation rate was 6.1%, with a recurrent dislocation rate of 8.2%. In the studies comparing type V SLAP and isolated Bankart repair, there were statistically insignificant differences in VAS pain scores (MD; 0.15, 95% CI, -0.13 to 0.44, I2 = 0%, p = 0.29) and recurrence rates (RR; 1.38, 95% CI, 0.88 to 2.15, I2 = 0%, p = 0.16).

CONCLUSION

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

Higher Return to Sport and Lower Revision Rates when Performing Arthroscopic Bankart Repair with Remplissage for Anterior Shoulder Instability with a Hill-Sachs Lesion: A Meta-Analysis

BACKGROUND

Recurrent anterior shoulder instability remains the most common complication from a prior shoulder dislocation, especially among young and active individuals who engage in athletic activities. This instability can lead to repeated subluxation or dislocations of the humeral head from the glenoid fossa. The purpose of this study is to compare postoperative recurrence rates, instability-related revision and return to sport (RTS) rates between isolated arthroscopic Bankart repair (ABR) and ABR with remplissage (ABR+R) for anterior shoulder instability with subcritical glenoid bone loss (GBL) and a Hill-Sachs lesion (HSL).

METHODS

PubMed, Embase, and Web of Science were searched on June 2022. Studies sought were those comparing postoperative outcomes of ABR+R versus isolated ABR for subcritical GBL and an HSL. Study quality was evaluated using the revised Cochrane tool. Redislocations, instability-related revisions, and return to sport rates were extracted and pooled estimates were calculated using the random-effect model.

RESULTS

Twelve studies were included with a mean follow-up of 48.2 months for isolated ABR and 43.2 months for ABR+R. The meta-analytic comparison demonstrated that ABR+R resulted in statistically significant improvement in Rowe and American Shoulder and Elbow Surgeons scores by 6.5 and 2.2 points, respectively, however, the improvements in patient-reported outcomes were not clinically meaningful. ABR+R resulted in reduced external rotation at the side by 1˚ which was not clinically meaningful, and there was no significant difference in terms of forward elevation. ABR+R resulted in a statistically significant reduction of overall postoperative recurrences (odd ratio (OR): 9.36), postoperative dislocations (OR: 6.28) instability-related revision (OR: 3.46), and RTS to any level (OR: 2.85).

CONCLUSION

The addition of remplissage to ABR for recurrent anterior shoulder instability with subcritical GBL and HSL results in significantly lower postoperative instability recurrence, lower instability-related revisions, and higher RTS to any level.

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.

Return to play following operative management of anterior shoulder instability in overhead athletes-A systematic review

Background

The purpose of this study was to systematically review the rate and timing of return to play in overhead athletes following operative management of anterior shoulder instability.

Methods

A systematic literature search based on PRISMA guidelines, utilizing the EMBASE, MEDLINE, and The Cochrane Library Databases. Eligible for inclusion were clinical studies reporting on return to play among overhead athletes following arthroscopic Bankart repair, open Latarjet procedure or Remplissage procedure.

Results

There are 23 studies included with 961 patients. Among those undergoing arthroscopic Bankart repair, the rate of return to play was 86.2%, with 70.6% returning to the same level of play and the mean time to return to play was 7.1 months. Among those undergoing an open Latarjet procedure, the rate of return to play was 80.9%, with 77.7% returning to the same level of play and the mean time to return to play was 5.1 months. Among those undergoing a Remplissage procedure, the rate of return to play was 70.6%, with 70.0% returning to the same level of play or mean time to return to play.

Discussion

Overall, there were high rates of return to play following operative management of anterior shoulder instability in overhead athletes.

Complications following arthroscopic Bankart repair: a systematic review

BACKGROUND

Complications are rare after arthroscopic Bankart repair, and as a result, there is a lack of guidance over rates of complications that can be used to consent patients. The purpose of this study is to systematically review the literature to assess the complications after arthroscopic Bankart repair, other than recurrent instability.

METHODS

A literature search of MEDLINE, Embase, and the Cochrane Library was performed based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Clinical studies reporting on the complications after arthroscopic Bankart repair were included.

RESULTS

A total of 194 studies were included in the analysis, with 13,979 patients and 14,019 shoulders undergoing arthroscopic Bankart repair. The overall complication rate was 0.67%, with frozen shoulder being the most common complication occurring in 0.32%. Persistent pain occurred in 0.17%. The rates of nerve, hardware, and wound complications were 0.07%, 0.05%, and 0.03%, respectively.

CONCLUSION

The arthroscopic Bankart repair has a very low rate of complications. Frozen shoulder and persistent pain are the most frequently encountered complications.

A cadaveric study of the posterior band of the inferior glenohumeral ligament of the shoulder and its dynamic behaviour in different arm positions

Purpose

The inferior glenohumeral ligament (IGHL) is composed of three parts: the anterior branch or band (AB), the axillary pouch and the posterior band (PB). The latter has rarely been studied. We aim to describe the PB of the IGHL and its dynamic behaviour in different arm positions.

Methods

Twelve fresh cadaveric shoulders were used and the two bands (AB and PB) of the IGHL were dissected and isolated, taking away all muscle, ligaments and capsule. Characteristics of the bands were studied in five positions: maximum external rotation (ER1), abduction (ABD), internal rotation (IR), ABD external rotation (ER2) and anterior elevation-adduction-IR (Hawkins-Kennedy test position). Progressive and randomized sectioning of the bands and capsule with a scalpel was performed to study its impact on mobility and translation of the glenohumeral joint.

Results

The bands that tensioned first were in ER1, the AB at 97 ± 9° (80-110); in ER2, the AB at 81 ± 19° (30-100); in IR, the PB at 64 ± 9° (50-80); and in ABD, the PB at 87 ± 10° (70-105). Isolated sectioning of the AB had no effect on ABD, whilst isolated sectioning of the PB allowed greater ABD. In ER2, the AB limited anterior translation. After sectioning the AB, anterior translation remained limited by the PB, which wrapped around the humeral head and locked the joint by pressing the two joint surfaces tightly together. In Hawkins-Kennedy position anterior elevation-adduction-IR, the AB is the first constraint and the posterior translation was limited by the PB alone only in four cases.

Conclusions

When the IGHL is isolated, ligament limitation of glenohumeral ABD seems to be uniquely dependent on the PB. In the Hawkins and Kennedy position, the AB is the first constraint. In the case of an isolated lesion to the AB, the PB participates in anterior stabilization of the shoulder by wrapping around the humeral head that cannot dislocate. These findings confirm the role of the PB in glenohumeral joint stability.

Level of Evidence

Level IV.

Primary Latarjet procedure versus Latarjet in the setting of previously failed Bankart repair: a systematic review

OBJECTIVES

The purpose of this study is to systematically review the comparative studies in the literature to compare the outcomes of the Latarjet procedure in the setting of a previously failed Bankart repair versus those undergoing the Latarjet procedure as a primary surgery for anterior shoulder instability.

METHODS

A systematic search in Pubmed, EMBASE, and The Cochrane Library databases was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Cohort studies comparing outcomes in the Latarjet procedure as a primary surgery versus the Latarjet procedure in the setting of a previously failed Bankart repair were included.

RESULTS

Ten studies with 1913 patients were included. There was a significantly lower rate of recurrent instability in those with a Latarjet procedure as a primary surgery (4.8% vs 12.1%, p ​= ​0.007). There was also a significantly lower rate of complications with the Latarjet procedure as a primary surgery (6.2% vs 10.2%, p ​= ​0.03). Furthermore, there was a significant difference in the rate of revision surgery in favour of the Latarjet procedure as a primary surgery (4.8% vs 10.9%, p ​= ​0.02). However, there were similar rates of redislocations (2.8% vs 3.4%, p ​= ​0.82) and return to play (67.7% vs 78.5%, p ​= ​0.30) between the two cohorts.

CONCLUSION

This study found that the Latarjet procedure as a revision procedure for a previously failed Bankart repair resulted in higher rates of complications, recurrent instability, and revisions than the Latarjet procedure performed as a primary procedure.

LEVEL OF EVIDENCE

Level III, Systematic Review & Meta-Analysis of Level III studies.

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.

Global variations in treatment and outcomes reported for anterior shoulder instability: a systematic review of the literature

Background

Anterior shoulder instability is a common problem around the world, with a high risk for recurrence following the index dislocation. Surgical stabilization is commonly indicated for persistent instability, particularly in patients at high risk for recurrence, to minimize the risk of further labral injury and glenoid bone loss. However, there is little known about global geographic differences in the surgical management of anterior shoulder instability. As such, the purpose of this study was to evaluate and systematically review regional differences in the surgical treatment of anterior shoulder instability, particularly the indications for and outcomes from bony stabilization procedures compared to soft tissue procedures.

Methods

A systematic review, in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, was performed. Inclusion criteria consisted of level I and II evidence studies evaluating indications, techniques, and outcomes following operative management of anterior shoulder instability published from January 2000 to September 2021. Studies meeting inclusion criteria were grouped into four global regions (Asia, Europe, North America, South America) based on primary study location. Patient demographics, procedural details, patient reported outcomes, and complications (recurrence and reoperation rates) were compared between regions.

Results

Sixty (n = 60) studies (5480 patients) were identified. Eighty-six percent of all patients were male, with a mean age of 26.7 years. There was no difference in mean patient age, though patients undergoing bony stabilization procedures were older than those undergoing soft-tissue stabilization procedures (P = .0002) in all regions. The proportion of bony versus soft-tissue procedure groups did not differ significantly among regions. The indications for bony stabilization procedures varied significantly. Mean final follow-up was 3.5 years. Recurrent instability was 5.0% and did not vary across regions. However, recurrent instability occurred more frequently following soft-tissue compared to bony stabilization procedures (P = .017). South American studies utilized fewer anchors during soft tissue stabilization (P < .0001) and reported a higher reoperation rate compared to other regions (P = .009).

Conclusion

There is global variation in the reporting of outcomes following surgery for anterior shoulder instability. The proportion of bony and soft-tissue procedures is similar, irrespective of geographic region. Recurrent instability does not vary by region but occurs more frequently following soft-tissue compared to bony stabilization procedures. There are a number of potential medical and nonmedical factors that may affect global variation in the surgical treatment of anterior shoulder instability.

Patient perceptions after the operative and nonoperative treatment of shoulder instability: A qualitative focus group study

Background

Little evidence is available regarding patient perceptions of the treatment of shoulder instability. The aim of this study is to investigate patient perceptions regarding the operative and nonoperative treatment of anterior shoulder instability.

Methods

Patients who presented to the emergency department or outpatient clinic between 2016 and 2020 were retrospectively selected using diagnosis and procedure codes. Online focus groups and semistructured interviews were conducted, systematically recorded and subsequently transcribed to MaxQDA 2007 for qualitative analysis. Coded transcripts of all focus groups were subjected to a grounded theory-based analysis.

Results

Six focus groups and two semistructured interviews were hosted with 35 included patients. The mean age of included patients was 34.1 years (±11.5). Eight patients were female (23%), and 27 patients were male (77%). Fear of (recurrent) dislocation, preoperative counseling, communication between surgeon and physiotherapists and need for a consistent postoperative rehab protocol turned out to be important patient perceptions. The most crucial factor for discontent was a lack of communication from the surgeon.

Discussion

This patient-centered focus group study revealed that fear of (recurrent) dislocation, preoperative counseling, communication between surgeons and physiotherapists and the need for a consistent postoperative rehabilitation protocol was the most frequently discussed themes.

Current Concepts in the Measurement of Glenohumeral Bone Loss

PURPOSE

The extent of glenohumeral bone loss seen in anterior shoulder dislocations plays a major role in guiding surgical management of these patients. The need for accurate and reliable preoperative assessment of bone loss on imaging studies is therefore of paramount importance to orthopedic surgeons. This article will focus on the tools that are available to clinicians for quantifying glenoid bone loss with a focus on emerging trends and research in order to describe current practices.

RECENT FINDINGS

Recent evidence supports the use of 3D CT as the most optimal method for quantifying bone loss on the glenoid and humerus. New trends in the use of 3D and ZTE MRI represent exciting alternatives to CT imaging, although they are not widely used and require further investigation. Contemporary thinking surrounding the glenoid track concept and the symbiotic relationship between glenoid and humeral bone loss on shoulder stability has transformed our understanding of these lesions and has inspired a new focus of study for radiologists and orthopedist alike. Although a number of different advanced imaging modalities are utilized to detect and quantify glenohumeral bone loss in practice, the current literature supports 3D CT imaging to provide the most reliable and accurate assessments. The emergence of the glenoid track concept for glenoid and humeral head bone loss has inspired a new area of study for researchers that presents exciting opportunities for the development of a deeper understanding of glenohumeral instability in the future. Ultimately, however, the heterogeneity of literature, which speaks to the diverse practices that exist across the world, limits any firm conclusions from being drawn.

Epidemiology of shoulder instability procedures: A comprehensive analysis of complications and costs

Background

Recurrent shoulder instability is a debilitating condition that can lead to chronic pain, decreased function, and inability to return to activities or sport. This retrospective epidemiology study was performed to report 90-day postoperative complications and costs of Latarjet, anterior bone block reconstruction, arthroscopic, and open Bankart repair for shoulder instability.

Methods

Patients 18 years and older who underwent four primary shoulder surgeries from 2010 to 2019 were identified using national claims data. Patient demographics, comorbidities, and 90-day postoperative complications were analyzed using univariate analysis and multivariable logistic regression. Total and itemized 90-day reimbursements were determined for each procedure.

Results

The 90-day medical and surgery-specific complication rates were highest for anterior bone block reconstruction, followed by Latarjet. Arthroscopic Bankart repair had the highest 90-day costs and primary procedure costs compared to other procedures.

Conclusion

Anterior bone block reconstruction and Latarjet procedures were associated with the highest rates of 90-day medical and surgery-specific complications, while arthroscopic Bankart repair was associated with the highest costs.

Outcomes at Long-term Follow-up After Open Latarjet Versus Open Bankart Repair in Rugby Players

Background

Because rugby is a collision sport, it exposes players to a high risk of recurrence after anterior shoulder stabilization. Therefore, the choice of surgical procedure warrants close attention in order to optimize the time to return to sport and the stability of the shoulder throughout the player's career.

Hypothesis

The open Latarjet procedure would allow for a faster return to play and provide a lower rate of recurrence than the open Bankart repair at long-term follow-up.

Study Design

Cohort study; Level of evidence, 3.

Methods

The study retrospectively enrolled 62 competitive rugby players who had undergone an anterior shoulder instability procedure and had at least 5 years of follow-up data. A total of 32 players treated with an open Bankart repair (BK group) were compared with 30 players (31 shoulders) treated with an open Latarjet procedure (LT group). Outcomes between groups were compared with the Rowe score, Walch-Duplay score, recurrence rate, and osteoarthritis evaluation on plain radiograph (Samilson classification).

Results

The recurrence rate was significantly higher at 18.8% for the BK group (mean follow-up, 6.9 ± 1.7 years) compared with 3.3% for the LT group (mean follow-up, 6.2 ± 1.4 years) (P = .04). No postoperative complications occurred in the BK group, whereas 1 infection and 1 hematoma required a second surgery in the LT group (P = .14). In the BK and LT groups, 97% and 90% of players, respectively, were able to return to rugby at the same level or higher (P = .27), at a mean time of 8 and 6.3 months, respectively (P = .03). The mean Rowe and Walch-Duplay scores were not significantly different between the groups; however, the osteoarthritis rate was significantly higher in the BK versus the LT group (68% vs 38%, respectively; P = .03); 23% of patients, all in the BK group, had Samilson grade 2 osteoarthritis.

Conclusion

The open Latarjet procedure outperformed the open Bankart procedure in terms of stability, time to return to play, and radiological outcomes at long-term follow-up in competitive rugby players.

Anatomic risk factors for arthroscopic Bankart repair failure: A case-control study comparing failure and non-failure groups in an Asian population

Introduction

Post-arthroscopic Bankart repair failure/re-dislocation rates are influenced by several risk factors, including anatomic defects. There is limited evidence on the role of anatomic defects, especially for Hill-Sachs size in on-track lesions. This study aimed to assess glenoid bone loss, Hill-Sachs lesion and labral tear size and evaluate their contribution to post-operative instability after a primary repair.

Material and methods

Across 169 patients with on-track Bankart lesions who underwent primary arthroscopic Bankart repair from 2010 to 2015, this study matched 14 failure with 14 non-failure cases based on age/gender. Patient demographics, pre-operative radiological parameters (including size of glenoid bone loss and Hill-Sachs lesion) and labral tear size were compared between the failure and non-failure groups.

Result

All patients were male with a mean age of 21.01 ± 4.97. Significantly greater glenoid bone loss (p = 0.024) and labral tear size (p = 0.039) were found in the failure group. However, there was no significant difference in mean volume of Hill-Sachs lesion between the two groups (p = 0.739).

Conclusion

Extensive glenoid bone loss and labral tears are risk factors for post-arthroscopic Bankart failure. However, the size of Hill-Sachs lesion is not a risk factor for failure, in a specific group of on-track Hill-Sachs lesions.

Level of evidence

Retrospective Study, Level IV.

Current concepts in chronic traumatic anterior shoulder instability

Chronic traumatic anterior shoulder instability can be defined as recurrent trauma-associated shoulder instability requiring the assessment of three anatomic lesions: a capsuloligamentous and/or labral lesion; anterior glenoid bone loss and a Hill-Sachs lesion. Surgical treatment is generally indicated. It remains controversial how risk factors should be evaluated to decide between a soft-tissue, free bone-block or Latarjet-type procedure. Patient risk factors for recurrence are age; hyperlaxity; competitive, contact and overhead sports. Trauma-related factors are soft tissue lesions and most importantly bone loss with implications for treatment. Different treatment options are discussed and compared for complications, return to sports parameters, short- and long-term outcomes and osteoarthritis. Arthroscopic Bankart and open Latarjet procedures have a serious learning curve. Osteoarthritis is associated with the number of previous dislocations as well as surgical techniques. Latarjet-type procedures have the lowest rate of dislocation recurrence and if performed correctly, do not seem to increase the risk of osteoarthritis.

Pediatric and Adolescent Shoulder Instability

PURPOSE OF REVIEW

Traumatic and atraumatic shoulder instability is common in pediatric and adolescent patients. It is well-established that young patients with anterior shoulder dislocation are at high risk of recurrent instability. This review assesses the current literature pertaining to management of both anterior instability and MDI in the pediatric and adolescent populations.

RECENT FINDINGS

Current research suggests that pediatric and adolescent patients with shoulder instability have excellent outcomes following arthroscopic Bankart repair; however, higher rates of recurrent instability requiring revision surgical management have been identified in patients with more than one dislocation episode pre-operatively, those with Hill-Sachs lesions and those under age 16. The addition of the remplissage procedure to an arthroscopic Bankart repair may be useful in preventing recurrent instability for patients with large Hill-Sachs lesions. Open procedures with bony glenoid augmentation may be indicated in patients with significant glenoid bone loss, or those who have failed primary surgical management, with promising outcomes reported following the Latarjet coracoid process transfer procedure in the adolescent population. Pediatric and adolescent patients with hyperlaxity, and those participating in swimming or gymnastics are more likely to have multidirectional instability (MDI). Non-surgical management with physical therapy is the mainstay of treatment for MDI with positive outcomes reported overall. In young patients with MDI who continue to have symptoms of instability and pain that effects daily activities or sports despite an adequate and appropriate course of rehabilitation, surgical management with capsulorrhaphy may be considered, with promising outcomes reported for both open and arthroscopic techniques. Attentive selection of timing and surgical procedure for pediatric and adolescent patients with anterior shoulder instability may help to prevent recurrent instability following shoulder stabilization. Although most pediatric and adolescent patients with MDI do well following non-surgical management alone, those that fail conservative management have good outcomes following arthroscopic or open capsulorrhaphy.

Trends and Projections in Surgical Stabilization of Glenohumeral Instability in the United States from 2009 to 2030: Rise of the Latarjet and Fall of the Open Bankart

INTRODUCTION

Advances in surgical techniques have improved the ability to address recurrent glenohumeral instability via arthroscopic capsulolabral repair and bone restoring procedures such as Latarjet. Given the paucity of studies analyzing temporal trends in surgical management of glenohumeral instability, the purpose of this study was to assess trends in treatment of anterior, posterior, and multidirectional instability over a 10-year period and model projections to 2030.

METHODS

Using IBM Watson Marketscan national database, all patients that underwent glenohumeral instability procedures from 2009 to 2018 were identified. Procedures were identified using common procedural terminology (CPT) codes for open Bankart Repair, Latarjet, anterior bone block, posterior bone block, multidirectional capsular shift, and arthroscopic Bankart procedures. Sample weights provided by the database were utilized to calculate national estimates. The United States (U.S.) Census Bureau annual population data were utilized for calculating incidence. Future projections to 2030 were modeled using Poisson and linear regression.

RESULTS

There were an estimated 446,072 glenohumeral instability cases from 2009-2018. Per capita (per 100,000) incidence remained constant, from 14.8 in 2009 to 14.5 in 2018. Arthroscopic Bankart comprised the highest number of procedures throughout the study period, accounting for 89% of all procedures in 2009 and 93% in 2018. Open Bankart procedures decreased by 65% from 2009 to 2018, while there was a 250% increase in Latarjet procedures over the same period. Patient demographics did not change over the study period, and males aged 18-25 comprised the largest demographic group undergoing anterior instability procedures. Multidirectional instability procedures exhibited the least pronounced gender differences. Future modeling from 2018-2030 projected continued steady rise in arthroscopic Bankart (40,000-49,000 case/yr), rapid growth in Latarjet (1370-4300 cases/yr), and continued decline in open Bankart (1000-250 cases/yr) procedures.

CONCLUSIONS

Arthroscopic Bankart continues to be the most common glenohumeral instability procedure in the U.S. From 2009 to 2018, incidence of open Bankart procedures declined while Latarjet procedures markedly increased. Future projections to 2030 mirrored these findings. These data may provide an enhanced understanding of the evolution of surgical treatment of glenohumeral instability within the U.S. laying the foundation for continued prospective studies into the appropriate indications and advancements in surgical techniques.

Latarjet

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

"Nearly off-track lesions" or a short distance from the medial edge of the Hill-Sachs lesion to the medial edge of the glenoid track does not seem to be accurate in predicting recurrence after an arthroscopic Bankart repair in a military population: a case-control study

BACKGROUND

On-track lesions with a short distance from the medial edge of the Hill-Sachs lesion to the medial edge of the glenoid track (nearly off-track) may predispose recurrence after arthroscopic Bankart repair (ABR) in the general population. The aim of this study was to determine if a shorter distance between the medial edge of the Hill-Sachs lesion and the medial edge of the glenoid track could accurately predict recurrence after an ABR in a high-demand military population. It was hypothesized that a shorter distance would not accurately predict recurrence.

MATERIALS AND METHODS

A retrospective monocenter case-control study was performed at the Dutch Central Military Hospital. Patients with an on-track Hill-Sachs lesion who underwent a primary ABR between 2014 and 2019 with a minimal follow-up of 2 years and a preoperative magnetic resonance imaging (MRI) assessment received a questionnaire. The primary outcome was recurrence, defined as a complete dislocation or subluxation. Glenoid bone loss was assessed using a linear-based method on MRI. The distance from the medial edge of the Hill-Sachs lesion to the medial edge of the glenoid track was defined as the distance to dislocation (DTD). A receiver operating characteristic curve was created to determine the predictive value of the DTD for recurrence. Logistic regression was used to determine preoperative risk factors that predispose recurrence. Covariates were selected based on univariable analysis and included gender, body mass index, age at surgery and first dislocation, laterality, smoking habits, overhead shoulder activity during work, preoperative dislocations, sports type and level, bony or labral lesions on MRI, and DTD.

RESULTS

In total, 80 patients with an average follow-up of 4.8 ± 1.9 years completed the questionnaire and were included in the analyses. Seventeen patients (21%) experienced recurrence at the final follow-up. No difference in DTD was observed among patients who experienced recurrence (9 ± 4 mm) compared with patients who did not (9 ± 5 mm; P = .81). The receiver operating characteristic curve demonstrated no predictive power of DTD for recurrence (area under the curve = 0.49). Smoking at the time of surgery (odds ratio: 3.9; confidence interval: 1.2-12.7; P = .02) and overhead shoulder movement during work (odds ratio: 9.3; confidence interval: 1.1-78.0; P = .04) were associated with recurrence according to the logistic regression analysis.

CONCLUSION

A shorter DTD demonstrated no accuracy in predicting recurrence in a military population. Smoking at the time of surgery and overhead shoulder activity during work were associated with recurrence; however, these analyses were underpowered to draw valid conclusions.

Cost-effectiveness analysis of arthroscopic Bankart repair versus open Latarjet reconstruction in anterior shoulder instability

PURPOSE

The ideal surgical treatment for anterior shoulder instability is still under debate. In the healthcare setting, both clinical and economic factors must be considered for optimal resource allocation. From the clinical perspective, the Instability Severity Index Score (ISIS) is a helpful and validated tool for surgeons, although a gray area between 4 and 6 exists. In fact, patients with an ISIS < 4 and > 6 can be treated effectively with arthroscopic Bankart repair and open Latarjet, respectively. The purpose of this study was to conduct a cost-effectiveness analysis of arthroscopic Bankart repair versus open Latarjet in patients with an ISIS between 4 and 6.

METHODS

A decision-tree model was constructed to simulate the clinical scenario of an anterior shoulder dislocation patient with an ISIS between 4 and 6. Based on previously published literature, outcome probabilities and utility values in the form of Western Ontario Instability Score (WOSI) were assigned to each branch of the tree, alongside institutional cost. The primary outcome assessed was an Incremental cost-effectiveness ratio (ICER) of the two procedures. Eden-Hybbinette was also considered in the model as a salvage procedure for failed Latarjet. A two-way sensitivity analysis was performed to identify the most impactful parameters on the ICER upon their variation within a pre-determined interval.

RESULTS

Base case cost was 1245.57 € (1220.48-1270.65 €) for arthroscopic Bankart repair, 1623.10 € (1580.82-1665.39 €) for open Latarjet and 2.373.95 € (1940.81-2807.10 €) for Eden-Hybbinette. Base-case ICER was 9570.23 €/WOSI. Sensitivity analysis showed that the most impactful parameters were the utility of arthroscopic Bankart repair, the probability of success of open Latarjet, the probability of undergoing surgery after post-operative recurrence of instability and the utility of Latarjet. Of these, utility of arthroscopic Bankart repair and Latarjet had the most significant impact on the ICER.

CONCLUSION

From a hospital perspective, open Latarjet was more cost-effective than arthroscopic Bankart repair in preventing further shoulder instability in patients with an ISIS between 4 and 6. Despite its several limitations, this is the first study to analyze this subgroup of patients from a European hospital setting from both an economic and clinical perspective. This study can help surgeons and administrations in the decision-making process. Further clinical studies are needed to prospectively analyze both aspects to further delineate the best strategy.

Arthroscopic Bankart Repair for Adolescent Anterior Shoulder Instability: Clinical and Imaging Predictors of Revision Surgery and Recurrent Subjective Instability

BACKGROUND

Multiple clinical and radiologic risk factors for recurrent instability after arthroscopic Bankart repair have been described. Humeral bone loss has gained more recent attention, particularly with respect to "off-track" lesions and increased rates of recurrent instability and revision surgery.

PURPOSE

To evaluate clinical and radiologic predictors of failure after arthroscopic Bankart repair in adolescents.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A single-institution retrospective study was performed in patients <19 years of age treated with arthroscopic Bankart repair from 2011 to 2017. Magnetic resonance imaging measurements of glenoid and humeral bone loss, the glenoid track, and the presence of off-track Hill-Sachs (HS) lesions were assessed. All patients had a minimum follow-up of 24 months and completed patient-reported outcome scores. Failure was defined as revision surgery or postoperative subjective instability.

RESULTS

A total of 59 patients (46 male, 13 female) with a median age of 16 years (range, 12-18 years) were included. Ten patients (17%) had revision surgery and 8 patients (14%) had subjective instability without revision surgery. No clinical or radiologic factors were significantly different between the failure cohort and the nonfailure cohort. Four patients (7%) measured off-track, and 2 of these patients experienced failure. A total of 38 patients (64%) were identified to have an HS defect. Subgroup analysis of these patients identified a greater HS interval (HSI) in patients who underwent revision surgery as compared with those patients who did not have revision surgery. Among patients with GT ratio ≥15 mm, there was a 50% rate of revision surgery. The Pediatric/Adolescent Shoulder Survey (PASS) and Single Assessment Numeric Evaluation (SANE) scores at the final follow-up were not significantly different among patients with or without revision surgery. However, those with subjective instability who had not undergone revision surgery had significantly lower PASS and SANE scores as compared with the remainder of the cohort.

CONCLUSION

Of the adolescents in this cohort, 31% either had revision surgery (17%) or reported subjective feelings of instability (14%) after arthroscopic Bankart repair. Off-track instability was identified in 7% of the cohort but was not predictive of failure. Among the subgroup of patients with an HS defect, those who underwent revision surgery had a significantly larger HSI.

Shoulder Surgery Postoperative Immobilization: An International Survey of Shoulder Surgeons

BACKGROUND

There is currently no consensus on immobilization protocols following shoulder surgery. The aim of this study was to establish patterns and types of sling use for various surgical procedures in the United States (US) and Europe, and to identify factors associated with the variations.

METHODS

An online survey was sent to all members of the American Shoulder and Elbow Society (ASES) and European Society for Surgery of the Shoulder and Elbow (ESSSE). The survey gathered member data, including practice location and years in practice. It also obtained preferences for the type and duration of sling use after the following surgical procedures: arthroscopic Bankart repair, Latarjet, arthroscopic superior/posterosuperior rotator cuff repair (ARCR) of tears <3 cm and >3 cm, anatomic total shoulder arthroplasty (aTSA) and reverse TSA (rTSA), and isolated biceps tenodesis (BT). Relationships between physician location and sling type for each procedure were analyzed using Fisher's exact tests and post-hoc tests using Bonferroni-adjusted p-values. Relationships looking at years in practice and sling duration preferred were analyzed using Spearman's correlation tests.

RESULTS

In total, 499 surgeons with a median of 15 years of experience (IQR = 9-25) responded, with 54.7% from the US and 45.3% from Europe. US respondents reported higher abduction pillow sling use than European respondents for the following: Bankart repair (62% vs. 15%, p < 0.0001), Latarjet (53% vs. 12%, p < 0.001), ARCR < 3 cm (80% vs. 42%, p < 0.001) and >3 cm (84% vs. 61%, p < 0.001), aTSA (50% vs. 21%, p < 0.001) and rTSA with subscapularis repair (61% vs. 22%, p < 0.001) and without subscapularis repair (57% vs. 17%, p < 0.001), and isolated BT (18% vs. 7%, p = 0.006). European respondents reported higher simple sling use than US respondents for the following: Bankart repair (74% vs. 31%, p < 0.001), Latarjet (78% vs. 44%, p < 0.001), ARCR < 3 cm (50% vs. 17%, p < 0.001) and >3 cm (34% vs. 13%, p < 0.001), and aTSA (69% vs. 41%, p < 0.001) and rTSA with subscapularis repair (70% vs. 35%, p < 0.001) and without subscapularis repair (73% vs. 39%, p < 0.001). Increasing years of experience demonstrated a negative correlation with the duration of sling use after Bankart repair (r = -0.20, p < 0.001), Latarjet (r = -0.25, p < 0.001), ARCR < 3 cm (r = -0.14, p = 0.014) and >3 cm (r = -0.20, p < 0.002), and aTSA (r = -0.37, p < 0.001), and rTSA with subscapularis repair (r = -0.10, p = 0.049) and without subscapularis repair (r = -0.19, p = 0.022. Thus, the more experienced surgeons tended to recommend shorter durations of post-operative sling use. US surgeons reported longer post-operative sling durations for Bankart repair (4.8 vs. 4.1 weeks, p < 0.001), Latarjet (4.6 vs. 3.6 weeks, p < 0.001), ARCR < 3 cm (5.2 vs. 4.5 weeks p < 0.001) and >3 cm (5.9 vs. 5.1 weeks, p < 0.001), aTSA (4.9 vs. 4.3 weeks, p < 0.001), rTSR without subscapularis repair (4.0 vs. 3.6 weeks, p = 0.031), and isolated BT (3.7 vs. 3.3 weeks, p = 0.012) than Europe respondents. No significant differences between regions within the US and Europe were demonstrated.

CONCLUSIONS

There is considerable variation in the immobilization advocated by surgeons, with geographic location and years of clinical experience influencing patterns of sling use. Future work is required to establish the most clinically beneficial protocols for immobilization following shoulder surgery.

LEVEL OF EVIDENCE

Level IV.

Superior and Anterior Glenoid Labral Tears Are Associated With Increased Neurofilament Concentration

BACKGROUND

Pain is a common presentation after glenohumeral labral injuries. However, the source of that pain is undetermined.

PURPOSE/HYPOTHESIS

We aimed to determine if there is a differential expression of nerve fibers around the glenoid labrum and if torn labra have increased neuronal expression compared with untorn labra (rotator cuff repair labra). We hypothesized that the superior labrum would have a higher concentration of neurofilament than would the rest of the labrum and that the concentration of neurofilament would increase at the site of a labral tear.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Seven labra were sampled at the 3-, 5-, 9-, and 12-o'clock positions during total shoulder arthroplasty. Samples were also collected at the 3-, 5-, and 12-o'clock positions during rotator cuff repair (16 labra), anterior labral repair (6 labra), type II superior labral anterior to posterior (SLAP) repair (4 labra), and capsular release for idiopathic capsulitis (5 labra). Sections were immunostained with antibodies to neurofilament, a specific neuronal marker that is used to identify central and peripheral nerve fibers, and the concentration and intensity of immunostained-positive cells assessed.

RESULTS

The concentration of neurofilament staining was similar in the superior, anterior, posterior, and inferior glenoid labrum in untorn labra (8 neurofilament expressing cells per square millimeter; P = .3). Torn labra exhibited a 3- to 4-fold increase in neuronal expression, which was isolated to the location of the tear in SLAP (P = .09) and anterior labral tears (P = .02). The concentration of neurofilament expressing cells in torn glenoid labrum samples was comparable that in with the glenoid labrum of adhesive capsulitis samples (P = .7).

CONCLUSION

This study supports the hypothesis that after a tear of the anterior or superior labrum the labrum in that region becomes populated with new nerves fibers and that these fibers may be responsible for the pain noted by patients with superior (SLAP) and/or anterior labral (Bankart) tears.

CLINICAL RELEVANCE

This study suggests that neural infiltration contributes to the pain experienced by patients with labral tears. It may help with patient education and direct future management of labral lesions.

Bankart or Bankart-remplissage?]

INTRODUCTION

in patients with anterior glenohumeral (GH) instability together with an off-track or engaging Hill-Sachs (HS) defect, Bankart-remplissage (B-R) surgery reduces the recurrence rate when compared to Bankart (B) surgery alone. There is controversy regarding whether the recurrence rate also decreases in patients with on-track or non-engaging Hill-Sachs defects.

OBJECTIVE

to compare the recurrence rate and clinical evolution of patients with anterior glenohumeral instability with 'on-track' Hill-Sachs defect treated with either B or B-R surgery.

MATERIAL AND METHODS

non-randomized, retrospective, single-center cohort study of patients with anterior glenohumeral instability and on-track Hill-Sachs defect, operated between January 2010 and December 2018. Patients operated with B versus B-R were compared. Recurrence, complications and re-operation were recorded. In addition, VAS, SSV, WOSI and qDASH scores were obtained and compared in both groups.

RESULTS

of the 105 patients who met the inclusion criteria, 78 (74.3%) patients had a complete follow-up (52 B and 26 B-R, 4.3 years median follow-up). There was a higher recurrence rate in group B compared to B-R, with this difference not reaching statistical significance (17.3% vs 7.7%, p = 0.21). There were no significant differences in residual pain, feeling of instability, complications or VAS, qDASH, SSV or WOSI scores between both groups. In the subgroup analysis, patients who practiced contact sports and were operated with B showed higher recurrence rates (24.1% vs 0%, p = 0.08) and complications (41.4% vs 18.2%, p = 0.16) when compared to B + R, although these differences were not significant.

CONCLUSION

there were no significant differences in recurrence rates and functional evolution between patients with anterior glenohumeral instability operated with B or B-R surgery. Comparative, prospective studies should be performed to establish definitive recommendations.

Arthroscopic Bankart Repair With Remplissage as an Alternative to Latarjet for Anterior Glenohumeral Instability With More Than 15% Glenoid Bone Loss

BACKGROUND

Surgical management of anterior shoulder instability continues to evolve. The clinical effectiveness of arthroscopic Bankart repair with remplissage (REMP) in patients with increasing glenoid bone loss (GBL) has not been thoroughly compared with Latarjet.

PURPOSE/HYPOTHESIS

The purpose of this study was to compare 2-year outcomes of REMP versus open Latarjet in patients with >15% GBL. We hypothesized that there would be no difference.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A multicenter, retrospective study was performed on a consecutive series of patients who underwent primary REMP or Latarjet by 4 shoulder specialists between August 2013 and December 2019 for >15% GBL. Procedure performance was based on shared decision making between the surgeon and patient. Baseline and 2-year postoperative range of motion (ROM) and the following patient-reported outcomes (PROs) were collected: Western Ontario Shoulder Instability Index, Single Assessment Numeric Evaluation, and visual analog scale for pain. Return to sport, satisfaction, complications, recurrence, and revisions were reviewed.

RESULTS

A total of 47 patients were available for study, including 22 who underwent REMP and 25 who underwent Latarjet. Baseline demographic characteristics, ROM, and PROs were similar between the groups. Mean preoperative GBL (REMP 25.8% ± 7.8% vs Latarjet 25.1% ± 9.0%; P = .800) and off-track lesions (REMP 59.1% vs Latarjet 44.0%; P = .302) were similar. Postoperative change in external rotation favored Latarjet (10° ± 22° vs -4° ± 13°; P = .017). Postoperative PROs, return to the sports (86.4% vs 87.5%; P = .99), and satisfaction (95.5% vs 95.8%; P = .99) were similar between groups. There were no recurrent dislocations in either group. One infected hematoma was encountered in the Latarjet cohort.

CONCLUSION

At short-term follow-up, the hypothesis was upheld. REMP and Latarjet provided similar outcomes for patients with >15% GBL, although REMP patients experienced slightly decreased external rotation. Although larger series and longer-term follow-ups are required, remplissage may be considered in patients with >15% glenoid bone loss.

Microinstability characterised by small and easily overlooked anterior labral or Hill-Sachs lesions can be managed with arthroscopic anterior labral repair

PURPOSE

Some young individuals present with shoulder pain without a definite history or complaint of instability. However, careful history taking, physical examination, and high-quality magnetic resonance imaging may reveal evidence of instability of which the patient is unaware. Therefore, a clearer definition of these ambiguous patients is needed. This study aimed to report the characteristics and surgical outcomes of patients with microinstability compared to those of patients with classic recurrent anterior shoulder instability.

METHODS

From 2005 to 2018, 35 patients with microinstability (group M) underwent arthroscopic anterior labral repair (AALR) and were compared to 35 sex- and age-matched patients with classic recurrent anterior shoulder instability (group C) who also underwent AALR. Baseline characteristics, preoperative apprehension test findings, preoperative imaging for the presence of anterior labral and Hill-Sachs lesions, preoperative and postoperative (over 2 years) range of motion (ROM) and functional scores, final complications, and patient satisfaction were analysed.

RESULTS

The most common chief complaints in groups M and C were pain (29/35) and both pain and instability (27/35), respectively. Only pain during the apprehension test was predominant in group M (M vs. C, 27 vs. 1, p < 0.001). High incidence of chronic repetitive injuries (26/35) and acute trauma (28/35) were observed in groups M and C, respectively. Over half of the patients in group M showed anterior labral lesions on magnetic resonance arthrography (MRA, 18/35), and 21 patients had Hill-Sachs lesions on MRA/three-dimensional computed tomography. Finally, 29 patients showed either anterior labral or Hill-Sachs lesions on preoperative imaging. The lesion severity was higher in group C than that in group M. All patients underwent AALR with/without the remplissage procedure, with no significant differences in final clinical outcomes, complications, and patient satisfaction between the groups.

CONCLUSIONS

Microinstability is diagnostically challenging and can be diagnosed in young patients with ambiguous shoulder pain during motion, without instability. Pain on anterior apprehension test and subtle labral and/or Hill-Sachs lesion on imaging study could be diagnostic clues. This condition can be managed with arthroscopic anterior labral repair with or without the remplissage procedure. The possibility of microinstability in young patients with shoulder pain should always be considered, and small anterior labral or Hill-Sachs lesions should be closely monitored.

LEVEL OF EVIDENCE

III.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Arthroscopic anatomic glenoid reconstruction has a lower rate of recurrent instability compared to arthroscopic Bankart repair while otherwise maintaining a similar complication and safety profile

OBJECTIVES

The primary purpose of this study was to determine the frequency and type of complications, including subluxation, infection, hardware complication, graft/glenoid fracture, chondrolysis, neurovascular deficits and stiffness following an Arthroscopic Bankart Repair (ABR) or an Arthroscopic Anatomic Glenoid Reconstruction (AAGR) using a distal tibia allograft for recurrent anterior shoulder instability. Secondary purposes were to determine the frank dislocation rate and the associations of post-operative complications with demographic patient factors.

METHODS

Demographic and clinical data were reviewed using means ± standard deviations or frequencies in patients with recurrent anterior shoulder instability who underwent either an ABR or an AAGR. Post-operative patient records were analysed to identify any post-operative complications. The numerical variables of the two groups were compared using the independent t-test or Mann-Whitney U test. Categorical variables and complications were tested using the chi-square test, Fisher's exact test, or the two-sided Monte Carlo test with a significance level of 0.05.

RESULTS

We included 174 patients in this cohort, with 61.5% of patients receiving ABR and 38.5% receiving AAGR. Most of our patients were male (70.1%) with an average age of 23.41 ± 8.26 years in the ABR group and 29.37 ± 13.54 years in the AAGR group (p = 0.001). The two groups were similar with respect to their post-operative complication rates when excluding frank dislocation (ABR: 11%, AAGR: 12%). The AAGR group had statistically significantly higher rates of hardware removal compared to the ABR group (p = 0.004). The ABR group had 25 post-operative frank dislocations, with none reported in the AAGR cohort (p < 0.001). The total complication rate for each procedure was found to be 35% for ABR and 12% for AAGR.

CONCLUSION

AAGR has a comparable safety profile to the ABR when assessing post-operative complications such as subluxation, infection, graft/glenoid fracture, chondrolysis, neurovascular deficits and stiffness. AAGR is superior to ABR with respect to rates of recurrent instability and should be considered as a first-line treatment in certain patients with specific risk factors such as younger age, competitive contact sports participation, and higher number of instability events pre-operatively.

LEVEL OF EVIDENCE

Level III.

Bony reconstruction after failed labral repair is associated with higher recurrence rates compared to primary bony reconstruction: a systematic review and meta-analysis of 1319 shoulders in studies with a minimum of 2-year follow-up

BACKGROUND

There is uncertainty with regard to the optimal revision procedure after failed labral repair for anterior shoulder instability. An overview of outcomes of these procedures with quantitative analysis is not available in literature. The aim of this review is (1) to compare recurrence rates after revision labral repair (RLR) and revision bony reconstruction (RBR), both following failed labral repair. In addition, (2) recurrence rates after RBR following failed labral repair and primary bony reconstruction (PBR) are compared to determine if a previous failed labral repair influences the outcomes of the bony reconstruction.

METHODS

Randomized controlled trials and cohort studies with a minimum follow-up of 2 years and reporting recurrence rates of (1) RBR following failed labral repair and PBR and/or (2) RLR following failed labral repair and RBR following failed labral repair were identified by searching PubMed, Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, and Web of Science/Clarivate Analytics.

RESULTS

Thirteen studies met the inclusion criteria and comprised 1319 shoulders. Meta-analyses showed that RBR has a significantly higher recurrence rate than PBR (risk ratio [RR] 0.51, P < .008) but found no significant difference in the recurrence rates for RLR and RBR (RR 1.40, P < .49). Also, no significant differences were found between PBR and RBR in return to sport (RR 1.07, P < .41), revision surgery (RR 0.8, P < .44), and complications (RR 0.84, P < .53). Lastly, no significant differences between RLR and RBR for revision surgery (RR 3.33, P < .19) were found.

CONCLUSION

The findings of this meta-analyses show that (1) RBR does not demonstrate a significant difference in recurrence rates compared with RLR and that (2) RBR has a significantly higher recurrence rate than PBR.

Variations in common operations in athletes and non-Athletes

Background

Achieving pre-injury activity level after an injury is the fundamental goal of any orthopedic treatment for an athlete. Unfortunately, pre-injury activity levels differ significantly in different patient categories, especially in athletes and non-athlete. Hence, an outcome suitable to a non-athlete may not be adequate for an athlete. This has led to variations in the surgical approach to the same injury in an athlete and non-athlete.There is plenty of literature published comparing the outcome in athletes and non-athletes after a particular surgery. Scattered discussion about variations in these surgeries based on functional demand was done in many publications. But there was a lack of a comprehensive narrative review summarizing variations in common operations among athletes and non-athletes.

Aim

This review attempted to summarize variations in common sports operations between high functional demand patients and low demand patients and discuss the variations from the author's perspective.

Methods

A review of all the relevant papers were conducted focusing on athletes and non-athletes. Most commonly performed sports surgeries were ACL reconstruction, Meniscal repair, PCL reconstruction, and Shoulder instability surgery. A literature search was done for each commonly performed surgery using relevant keywords in PubMed and Google Scholars. Summary of papers pertinent to athletes and non-athletes were compiled to prepare this narrative review.

Results

There is a lack of papers directly comparing results in athletes and non-athletes. However, many research papers discussed surgical variations in athletes (high demand) and non-athletes (low demand) patients. There are controversies in all commonly performed surgeries, and none of the papers gives a definitive guideline on the approach to athletes and non-athlete.

Conclusion

Rather than a common suggestion on surgical variation, an individualized approach would be appropriate to decide on variation in particular surgery in both athletes and non-athletes.

Safety, Efficacy, and Cost-Effectiveness of Simultaneous Bilateral Arthroscopic Bankart Repair for Bilateral Shoulder Instability

Background:

Bilateral shoulder instability and Bankart lesions are not rare and frequently require surgical treatment. Bilateral instability may be treated with either a single-stage, simultaneous bilateral Bankart repair or 2-stage surgery.

Purpose/Hypothesis:

To compare simultaneous bilateral arthroscopic Bankart repair to 2-stage repair in terms of clinical outcomes and hospitalization costs. It was hypothesized that simultaneous repair would provide clinical outcomes similar to those of 2-stage Bankart repair while yielding lower hospitalization costs.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients who underwent simultaneous bilateral arthroscopic Bankart repair (group 1) were matched by age, sex, and injury type to control patients who had unilateral Bankart repair (group 2). All patients were operated on by the same surgeon in the same institution between 2007 and 2017 and had a minimum follow-up duration of 24 months. Patients with inflammatory arthritis, metabolic/malignant disease, previous shoulder surgery, a glenoid bone loss ≥25%, or off-track Hill-Sachs lesion were excluded. The 2 groups were compared in terms of pre- and postoperative Western Ontario Shoulder Instability Index (WOSI) scores, hospitalization costs, complications, and recurrent instability. The hospitalization cost of group 2 was multiplied by 2 to create a projection of the estimated cost of 2 sequential unilateral Bankart repairs.

Results:

The study population comprised 48 patients (38 men [79.17%] and 10 women [20.83%]; mean age, 25.5 years at surgery and 22.75 years at first dislocation). Group 1 included 32 shoulders in 16 patients, while group 2 consisted of 32 shoulders in 32 patients. The mean hospitalization cost (in 2020 US dollars) was $26,010 ± $1455 for group 1 and $33,591 ± $1574 for group 2 (P < .001). Both groups had improved WOSI scores after surgery and achieved similar scores at the latest follow-up. There was 1 redislocation in each group (3.13%). No surgery- or anesthesia-related/medical complications were recorded in either group.

Conclusion:

For bilateral shoulder instability, clinical outcomes of simultaneous bilateral arthroscopic Bankart repair were similar to those of 2-stage repair; however, lower hospitalization costs were seen after simultaneous bilateral repair compared with 2-stage surgery.

Trends in utilization and patient demographics for shoulder instability procedures from 2010 to 2019

BACKGROUND

Improved techniques and increased surgeon experience have optimized surgical care in patients with recurrent shoulder instability. Several techniques are used for surgical repair of shoulder instability, yet there are limited data on how utilization has changed over the past decade. The aim of this study was to assess trends in the utilization rate and patient demographic characteristics (age and sex) from 2010 to 2019 for 4 shoulder instability procedures: coracoid transfer/Latarjet procedure (LP), anterior bone block (ABB), open Bankart repair (OBR), and arthroscopic Bankart repair (ABR).

METHODS

We identified >87,000 patients using an all-payer claims database. The utilization rate was defined as the number of cases of a procedure divided by the total number of surgical cases for shoulder instability for any given year. Age was divided into 3 groups: <25 years, 25-35 years, and >35 years. Trends were reported in terms of the compounded annual growth rate (CAGR).

RESULTS

Although ABR was the most common shoulder instability procedure overall (91% utilization rate), the LP had the greatest increase in utilization from 2010 to 2019 (2.0% to 4.5%; CAGR, +9.8%). In comparison, the utilization of ABB procedures increased by 4.3% annually whereas that of OBR declined by 6.9% annually. The utilization of ABR showed minimal change. Notably, the LP was performed more frequently in younger patients over time. The percentage of patients aged < 25 years who underwent the LP increased from 30% to 41% from 2010 to 2019 (CAGR, +3.4%). There was a trend toward the performance of more LPs in men than in women (+1.2% vs. -3.5%, P < .05), although most cases (68%) were still performed in men.

CONCLUSION

ABR continues to account for most shoulder instability procedures. The LP had the greatest increase in the utilization rate from 2010 to 2019 and has now surpassed OBR in the utilization rate. ABB procedures are also being more frequently performed but only represent a minority of stabilization cases. During the course of the study period, a greater percentage of patients undergoing shoulder instability procedures were male individuals and were aged < 25 years.

Evaluation of factors associated with successful 5-year outcomes following arthroscopic Bankart repair in athletes

PURPOSE

The purpose of this study was to evaluate the outcomes of athletes 5-years post-operatively following arthroscopic Bankart repair, and to evaluate factors associated with satisfaction and shoulder function, as defined by subjective shoulder value.

METHODS

A retrospective review of athletes who underwent arthroscopic Bankart repair, with a minimum of 5-year follow-up was performed. Recurrence, Visual Analogue Scale (VAS) score, Subjective Shoulder Value (SSV), satisfaction, and whether they would undergo the same surgery again, and rate, level and timing of return to play, and Shoulder Instability-Return to Sport after Injury (SIRSI) score were evaluated. Multi-linear regression models were used to evaluate factors affecting postoperative Satisfaction, and SSV level.

RESULTS

Overall, 144 athletes who underwent arthroscopic Bankart repair were included, with a mean age of 26.9 years (SD: 8.1), 132 (91.7%) were males, and mean follow-up of 75.7 months. At final follow up, 82.6% were satisfied/very satisfied, and the mean SSV was 85.8 (SD: 14.4). Overall, the rate of return to play was 80.5%, with 63.9% returning at the same level at a mean of 6.2 months (SD: 2.7). Overall, there was 18 (12.5%) had recurrent instability, and a further procedure was performed in 15 (10.4%) patients. Linear regression revealed that the SIRSI score (p < 0.0001), SSV (p < 0.0001), VAS (p < 0.0031), no sleep trouble (p = 0.0129) was associated with satisfaction. Logistic regression revealed whether a patient required revision surgery (p = 0.0029), or had re-dislocation (p = 0.0031) was also associated with satisfaction. Linear regression revealed that the SIRSI score (p < 0.0001), VAS score (p < 0.0001), and no sleep trouble (p < 0.0001), were associated with SSV score.

CONCLUSION

There was a high rate of satisfaction at 5-year follow-up, with excellent patient-reported outcomes and a high rate of return to play among athletes. However, there was a moderate rate of recurrent instability and further revision surgery. This study identified that the SIRSI score, VAS score, no sleep trouble and ability to return to play at the same level were associated with both satisfaction and SSV score.

LEVEL OF EVIDENCE

III.

Ability to Retension Knotless Suture Anchors: A Biomechanical Analysis of Simulated Bankart Lesions

Background:

Knotless suture anchors are gaining popularity in arthroscopic glenohumeral labral repairs. The ability to retension knotless designs after initial anchor placement has been reported; however, no studies have quantified this claim or investigated the biomechanical consequence of retensioning.

Purpose/Hypothesis:

To determine whether knotless and knotted suture anchors have biomechanical or anatomic differences with regard to labral repairs and to determine whether retensioning of knotless suture anchors affects capsular tension, labral height, and capsular shift. We hypothesized that retensioning of knotless anchors would result in improved capsular tension compared with conventional knotted suture anchors.

Study Design:

Controlled laboratory study.

Methods:

A total of 18 fresh-frozen cadaveric shoulders with a mean age of 56 years were dissected to the capsule and disarticulated at the humeral capsular insertion. The scapula was potted and placed in a custom shoulder simulator to tension the capsule via braided sutures localized to the anteroinferior glenohumeral ligament. Specimens were randomized into 3 groups: (1) Knotted (KT), (2) Knotless with end retensioning (KL_end), and (3) Knotless with stepwise retensioning (KL_stepwise). All repairs were completed using all-suture anchors placed at the 5-, 4-, and 3-o’clock positions. KL_stepwise was used to simulate an intraoperative technique. Resultant mean capsular tension under 5 mm of displacement (subfailure loading) was measured for each anchor placement and retensioning step. Labral height and capsular shift were measured using a MicroScribe digitizer.

Results:

The intact, defect, 1-anchor, 2-anchor, and 3-anchor tensions were not significantly different between the KT and KL_end groups. For the latter, retensioning of all knotless anchors increased capsular tension by 2.1 N compared with its 3-anchor state, although this was not statistically significant (P = .081). The KL_stepwise group explored an alternative method to retension the capsule using knotless anchors, with similar final capsular tensions compared with the other groups. All repairs had similar improvements in capsulolabral height and superior capsular shift.

Conclusion:

Knotted and knotless suture anchors provided similar overall restorations in anteroinferior glenohumeral ligament tension. However, knotless devices were capable of small but statistically insignificant improvements in capsular tension with retensioning.

Clinical Relevance:

Retensioning of knotless anchors allows the surgeon to tighten regions of the glenohumeral capsule that remain lax after repair.

Postoperative Pain and Paresthesia in Labral Repairs of the Shoulder: Location Does Matter

Background:

Favorable outcomes have been reported regarding postoperative shoulder pain and function after repair of anteroinferior (Bankart) glenohumeral labral tears. However, the outcomes of patients after repair of isolated superior labral anterior-posterior (SLAP) tears are a contentious topic. The authors have also anecdotally noted that patients evaluated with labral tears complained of numbness and tingling in their ipsilateral hand.

Purpose:

To determine if there is a difference in the temporal outcomes of shoulder pain and hand paresthesia in patients with SLAP tears versus Bankart tears after arthroscopic repair.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Included were 66 consecutive patients who underwent arthroscopic labral repair at a single institution between August 2018 and February 2021. The prevalence and magnitude of shoulder pain as well as numbness and tingling of the hand were assessed using questions from the L’Insalata Shoulder Questionnaire and the Boston Carpal Tunnel Questionnaire preoperatively and at 1 week, 6 weeks, 12 weeks, and 6 months after surgery.

Results:

Preoperatively, patients with SLAP lesions reported a higher prevalence of shoulder pain during sleep compared with those with Bankart tears (P < .05). Postoperatively, patients who underwent SLAP repair reported a larger proportion and more severe magnitude of shoulder pain during rest, overhead activities, and sleep compared with those who underwent Bankart repair (P < .05). Only patients who underwent Bankart repair reported improvements in the prevalence and magnitude of their shoulder pain during rest, overhead activities, and sleep by 6 months postoperatively compared with preoperative levels (P < .05). Preoperatively, 30% of patients with Bankart repairs and 40% of patients with SLAP repairs reported hand tingling, while 35% and 50%, respectively, reported hand numbness. The prevalence and magnitude of hand tingling and numbness were not significantly different between groups at any time point.

Conclusion:

Study results indicated that patients who underwent SLAP repair experienced worse shoulder pain outcomes compared with those who underwent Bankart repair using the same anchor and surgical technique. Only patients who underwent Bankart repair reported improvements in their hand numbness after surgery. Therefore, labral tear location does matter with respect to shoulder pain and hand numbness.

High Incidence of Combined and Posterior Labral Tears in Military Patients With Operative Shoulder Instability

BACKGROUND

Anterior shoulder instability is the pattern most commonly reported in the civilian population, but military servicemembers may represent a unique population. At 1.7 per 1000 person-years, servicemembers not only have a higher incidence of instability events compared with civilians (reported rate of 0.2-0.8), but the distribution of labral tears in the military may differ significantly as well.

HYPOTHESIS

The incidence of combined and posterior labral tears in the military population will be greater than numbers previously reported.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

The Wounded, Ill, and Injured Registry, a Department of Defense patient reported outcomes data collection platform that includes all military branches, was queried retrospectively for all patients who had undergone a primary arthroscopic or open shoulder stabilization procedure (Current Procedural Terminology codes 29806, 23455, 23462) between October 2016 and January 2019. Demographic information was obtained through intake forms completed by patients at the time of enrollment into the Military Orthopaedics Tracking Injuries and Outcomes Network. Tear location was determined arthroscopically and labeled as anterior, inferior, posterior, superior, or any combination thereof. Chi-square analysis was used to compare the percentage of patients with isolated anterior, isolated posterior, isolated inferior, or combined labral tears in the current study cohort with those in a previously reported cohort of patients with operative shoulder instability at a single military treatment facility.

RESULTS

A total of 311 patients were included who had undergone primary shoulder stabilization during the study period. Of these patients, 94 (30.2%) had isolated anterior tears, 76 (24.4%) had isolated posterior tears, and 136 (43.7%) had combined tears. We observed a higher percentage of combined tears in our data set than in a data set from a single military treatment facility (χ²(2) = 48.2; P < .00001). Chi-square analysis demonstrated that significantly more female patients had an isolated anterior labral tear (51.2%) compared with male patients (27.1%; χ²(2) = 9.4; P = .009).

CONCLUSION

The incidence of combined and posterior labral tears in the military population is greater than numbers previously reported in both military and civilian populations.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

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

RESULTS

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

CONCLUSION

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

Athletes with primary glenohumeral instability demonstrate lower rates of bone loss than those with recurrent instability and failed prior stabilization

BACKGROUND

The purpose of this study was to compare the preoperative magnetic resonance arthrography findings in patients who underwent glenohumeral stabilization with a history of primary instability, recurrent instability, or failed stabilization.

METHODS

All patients who presented with glenohumeral instability and underwent stabilization performed by a single surgeon in our institution between 2008 and 2020 were considered for inclusion in this study. The magnetic resonance arthrography findings of all patients were recorded. Imaging findings were compared between patients with primary instability, those with recurrent instability, and those with failed prior stabilization. P < .05 was considered statistically significant.

RESULTS

Overall, 871 patients were included, of whom 814 (93.5%) were male patients; the mean age was 23.1 years (range, 13-57 years). There were 200 patients with primary instability, 571 with recurrent instability, and 100 who required revision stabilization surgery, with no significant differences in demographic characteristics between the groups. A significantly higher amount of glenoid bone loss was noted in patients with recurrent instability (43.4%) and failed prior stabilization (56%) than in those with primary instability (26.5%) (P < .0001). Additionally, a significantly higher number of Hill-Sachs lesions were observed in patients with recurrent instability (70.1%) and failed prior stabilization (89%) than in those with primary instability (67.5%) (P < .0001). We found no significant differences between the groups regarding articular cartilage damage, glenolabral articular disruption, anterior labral periosteal sleeve avulsion, humeral avulsion of the glenohumeral ligaments, or superior labral anterior-posterior tears (P > .05).

CONCLUSION

Patients presenting for stabilization with recurrent instability or following a failed stabilization procedure have higher rates of glenohumeral bone loss than those with primary instability. Therefore, stabilization of primary instability, particularly in high-functioning athletes with a view to preventing recurrence, may reduce the overall progression of glenohumeral bone loss and potential subsequent inferior clinical outcomes.

Long-term outcomes of arthroscopic Bankart repair and Hill-Sachs remplissage for bipolar bone defects

PURPOSE

To evaluate long-term results after arthroscopic Bankart repair and Hill-Sachs remplissage (BHSR) in bipolar bone defects with less than 20% of glenoid bone loss (GBL) and to analyse risk factors for recurrent dislocation.

METHODS

From 2009-2012, 43 patients with recurrent anterior shoulder instability were treated with BHSR. Inclusion criteria were GBL < 20% and minimum of 4-yearfollow-up. There were 35 males and 8 females with a mean age of 29 years (range 16-53). The mean ISIS score was 3.6 (range 2-6). Patients were evaluated for recurrence, range of motion and functional outcomes (Walch-Duplay and Rowe score). Post-operative MRI was performed at least 6 months after surgery to evaluate infraspinatus capsulotenodesis healing. Glenoid track was assessed retrospectively from pre-operative computed tomography. Mean follow-up was 7.3 years (range 4-11).

RESULTS

At the last follow-up, good to excellent outcomes were reported in 86% of patients. Average post-operative Walch-Duplay was 87.9 (range 75-100) and ROWE 93.7 (range 70-100). Infraspinatus capsulotenodesis healing was achieved in 86%. The rate of recurrence and revision surgery was 9.3% and 13.9%, respectively. Recurrence was associated with higher ISIS score (p = 0.0191) and lower age at surgery (p = 0.0227). Four (9.3%) Hill-Sachs lesions were considered off-track. The presence of off-track Hill-Sachs was associated with higher risk of recurrence (p < 0.00001).

CONCLUSION

Arthroscopic BHSR improves shoulder instability in the setting of bipolar bone defects with less than 20% of GBL. Patient-related factors and pre-operative glenoid track should be taken into consideration to reduce the risk of recurrence.

Clinical Outcomes in Patients With Humeral Avulsion Glenohumeral Ligament Lesions in the Setting of Anterior Shoulder Instability: A Retrospective Comparative Study

BACKGROUND

Humeral avulsion glenohumeral ligament (HAGL) lesions are often underreported but have been shown to occur in up to 10% of cases of anterior shoulder instability.

PURPOSE

To compare clinical outcomes and recurrence rates of patients with HAGL lesions undergoing open stabilization for anterior shoulder instability versus a pair-matched control.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective review of all patients who underwent both arthroscopic and open stabilization procedures with a minimum 24-month follow-up was performed. Patients with HAGL lesions were pair-matched in a 1:6 ratio for age, sex, sport, level of preoperative play, and follow-up length with those without HAGL lesions who underwent arthroscopic Bankart repair alone. Return to play (RTP), the level of return, and the timing of return were assessed. In addition, recurrence, visual analog scale for pain (VAS), Subjective Shoulder Value (SSV), Rowe score, satisfaction, and whether they would undergo the same surgery again were compared.

RESULTS

A total of 15 patients with HAGL lesions who underwent shoulder stabilization procedures were included, with a mean age of 21.5 ± 4.1 years and mean follow-up of 53.5 ± 17.4 months, and were pair-matched to 90 patients without HAGL lesions. Overall, there was no significant difference in any of the clinical outcome scores (VAS, Rowe, SSV, satisfaction) used between the 2 groups (1.6 vs 1.7, P = .86; 83.4 vs 88.0, P = .06; 85.7 vs 87.2, P = .76; and 86.7% vs 94.5%, P = .26, respectively). In addition, there were no significant differences in terms of overall rates, levels, and timing of RTP between the 2 groups (93.3% vs 90.0%, P > .99; 80.0% vs 78.9%, P > .99; and 5.3 ± 2.2 vs 5.9 ± 2.9 months, P = .45, respectively). There was no significant difference in the rates of apprehension, subluxation, and recurrent instability between the HAGL and pair-matched control groups (26.7% vs 26.7%, P > .99; 6.7% vs 3.3%, P = .47; and 13.3% vs 6.7% months, P = .32, respectively).

CONCLUSION

Patients with anterior shoulder instability undergoing surgical stabilization with open HAGL repair demonstrate excellent functional outcomes and high rates of RTP, with low rates of recurrence in the medium term compared with a control group without HAGL lesions who underwent arthroscopic Bankart repair alone.

Clinical outcomes of revision arthroscopic Bankart repair for anterior shoulder instability: a systematic review of studies

BACKGROUND

The purpose of this study was to review the literature to ascertain the functional outcomes, recurrence rates, and subsequent revision rates following revision arthroscopic Bankart repair.

METHODS

Two independent reviewers performed a literature search based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines using the Embase, MEDLINE, and Cochrane Library databases. Studies in which arthroscopic Bankart repair was performed as a revision procedure were included. The clinical outcomes extracted and analyzed were functional outcomes, return to play, and recurrent instability.

RESULTS

Fourteen studies with 433 patients met the inclusion criteria. The majority of patients were male patients (63.7%); the average age was 26.1 years (range, 14-58 years), and the mean follow-up period was 37.6 months (range, 10-144 months). The mean Rowe score was 84.2, and 79.7% of patients had good to excellent outcomes. The rate of return to play was 78.5%, with 47.5% of patients returning to their preinjury level of play across 10 studies. The rate of recurrent instability was reported in 12 studies, with 328 shoulders demonstrating 86 instability events (26.2%). The rate of recurrent instability due to dislocation was reported in 7 studies (n = 176), with 19 events (10.8%), whereas the rate of subluxation was reported in 4 studies (n = 76), with 6 events (7.9%).

CONCLUSIONS

Revision arthroscopic Bankart repair for anterior shoulder instability was shown to result in a high rate of recurrent shoulder instability. There was a relatively poor rate of return to sport among athletes, and only about half of the patients were able to return at or above their preoperative level of ability.

The Outcomes of Soft-Tissue Repair for Posterior Shoulder Instability Surgery

BACKGROUND

This study aimed to assess the results after soft-tissue posterior instability surgery and address possible challenges during these operations.

METHODS

The databases of two tertiary hospitals were reviewed to identify patients treated for posterior shoulder instability between 2000 and 2015. Out of 198 treated patients, 19 cases underwent surgery with a mean follow-up of 35 months. Chart review was performed to obtain recurrence rates, revision rates, return to sport, persistent pain, subjective instability, subjective feeling of being better, complications, and range of motion after operative treatment of posterior shoulder instability. These outcomes were compared using the Fisher's exact and Mann-Whitney U tests.

RESULTS

After surgery, 6 (32%) patients had a recurrent subluxation, and 11 (58%) cases had persistent pain; moreover, 5 (26%) patients had a persistent feeling of instability, and 10 (53%) cases did not feel improvement after the operation. Furthermore, 10 (53%) patients required a revision, and there were 7 (37%) cases with a complication. Postoperatively, 75% of the patients had a full forward flexion, and 93% of the cases had full internal rotation; however, 64% of them had restrictions in external rotation.

CONCLUSION

There is a high rate of recurrent instability, need for revision, and complications after soft-tissue posterior instability surgery. Postoperative external rotation was impaired in most patients. Patients should be informed about these unsatisfactory results.

Preoperative psychometric properties of Patient-Reported Outcomes Measurement Information System Upper Extremity, Pain Interference, and Depression in Bankart repair and rotator cuff repair

BACKGROUND

We aimed to examine the preoperative performance of Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE, versions 1.2 and 2.0), Pain Interference (PI, version 1.1), and Depression (version 1.0) testing across multiple orthopedic procedures for the upper extremity and define its susceptibility to preoperative floor and ceiling effects.

METHODS

We conducted a retrospective analysis of prospectively collected patient-reported outcome measures using an electronic outcome registry for procedures performed between May 2017 and April 2019. Current Procedural Terminology (CPT) codes were used to examine cohorts for 2 upper-extremity orthopedic procedures: Bankart repair and arthroscopic rotator cuff repair (ARCR). Shapiro-Wilk normality testing was used to assess score distributions for normalcy; given non-normal score distributions, Spearman correlation coefficients were calculated for preoperative patient-reported outcome scores. Absolute floor and ceiling effects were calculated for preoperative time points based on CPT code.

RESULTS

A total of 488 patients were included across the Bankart repair cohort (n = 109; mean age, 29.3 ± 12.5 years) and ARCR cohort (n = 379; mean age, 57.5 ± 9.5 years). In the Bankart repair cohort, the PROMIS PI score demonstrated strong correlations with the American Shoulder and Elbow Surgeons score (r = -0.63), Constant score (r = -0.75), PROMIS UE score (r = -0.75), and Veterans RAND-6 Domain score (r = -0.61). The PROMIS Depression score (r = 0.23 and r = 0.17, respectively), Short Form 12 Mental Composite Scale score (r = 0.34 and r = 0.11, respectively), and Veterans RAND 12-item health survey Mental Composite Scale score (r = 0.44 and r = 0.15, respectively) exhibited poor correlations with the PROMIS PI and UE scores. In the ARCR cohort, the PROMIS PI score demonstrated a good correlation with the PROMIS UE score (r = 0.61). The Constant score (r = 0.58 and r = 0.67, respectively), Veterans RAND 12-item health survey Physical Composite Scale score (r = 0.58 and r = 0.47, respectively), and Veterans RAND-6 Domain score (r = 0.67 and r = 0.53, respectively) exhibited good correlations with the PROMIS PI and UE measures. No significant absolute floor or ceiling effects were observed for the PROMIS instruments except the PROMIS Depression measure: An absolute floor effect was noted for both the Bankart repair (n = 12, 30%) and ARCR (n = 38, 14.7%) groups.

CONCLUSION

The PROMIS PI and UE instruments perform favorably compared with legacy outcome instruments in patients receiving Bankart repair, as well as those undergoing ARCR. Furthermore, in both populations, the PROMIS Depression instrument exhibits absolute floor effects whereas the PROMIS PI and UE instruments fail to demonstrate any absolute floor or ceiling effects.

Current concepts in anterior glenohumeral instability: diagnosis and treatment

The glenohumeral joint is the most dislocated articulation, accounting for more than 50% of all joint dislocations. The reason behind shoulder instability should be investigated in detail for successful management, and the treatment plan should be individualized for all patients. Several classification systems have been proposed for glenohumeral instability. A physical exam is mandatory no matter what classification system is used. When treating patients with anterior shoulder instability, surgeons need to be aware of the critical size of the bone loss, which is commonly seen. The glenoid track concept was clinically adopted, and the measurement of the glenoid track for surgical decision-making is recommended. Detailed assessment of existing soft tissue injury to the labrum, capsule, glenohumeral ligaments, and rotator cuff is also mandatory as their presence influences the surgical outcome. Rehabilitation, arthroscopic repair techniques, open Bankart procedure, capsular plication, remplissage, Latarjet technique, iliac crest, and other bone grafts offer the surgeon different treatment options according to the type of patient and the lesions to be treated. Three-dimensional (3D) technologies can help to evaluate glenoid and humeral defects. Patient-specific guides are low-cost surgical instruments and can be used in shoulder instability surgery. 3D printing will undoubtedly become an essential tool to achieve the best results in glenohumeral instability surgery.

Evaluation of the subscapularis split created with passive rotation during arthroscopic dynamic anterior stabilization (DAS): A cadaveric study

INTRODUCTION

The purpose of the present study was to analyze the ability to create a subscapularis split by passive rotation of the arm during dynamic anterior stabilization (DAS) and to analyze the new geometry of the long head of the biceps LHB.

HYPOTHESIS

The hypothesis was that this passive simple technique can create subscapularis split without additional dissection giving rise to new position of LHB with a new stabilization function.

MATERIAL AND METHODS

A technique of subscapularis split using the LHB was used in 12 fresh-frozen human cadaveric shoulders. A subscapularis split was created by passive rotation of the arm after the LHB is shuttled into the joint during DAS. The length of the subscapularis split, post-DAS position and length of the LHB, and the angulation of the LHB relative to bicipital groove were measured after DAS and if this new geometry can give a new dynamic effect on subscapularis muscle.

RESULTS

The mean length of the subscapular split after maximal rotation was 20.4±6.0mm (range: 10-32mm). The mean elongation of the LHB was 0.6±1.4mm (range: -1 to +3mm). The final angle of the LHB relative to the bicipital groove was 45±5 degrees (range: 41 to 55 degrees).

DISCUSSION

There is no need to create a distinct split prior to DAS. Additionally, DAS maintains the length-tension relationship of the LHB. The post-procedure medial angulation of the LHB relative to the bicipital groove may provide a lowering of the subscapularis, helping explain the anterior reinforcement of this technique.

LEVEL OF EVIDENCE

Basic science study, cadaver study.

Evaluating the results of Bankart repair in recurrent traumatic anterior shoulder dislocation

INTRODUCTION

Bankart procedure is considered a safe and effective technique in the management of traumatic shoulder dislocation. Various studies have evaluated the results of Bankart Repair in different populations. The aim of the current study is to evaluate and report the outcomes of Bankart capsulorrhaphy in patients with recurrent shoulder dislocation in Iran.

METHODS

This is a clinical trial without a control group that was performed in 2021. The study population consisted of all patients diagnosed with recurrent anterior shoulder dislocation and Bankart lesion that were candidates for Bankart capsulorrhaphy in 2012-2020. All patients that met the inclusion criteria entered the study using census method. We assessed variables including shoulder range of motion (ROM), shoulder joint symptoms using Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, Rowe score, Constant Shoulder Score and patient's quality of life using 36-Item Short Form Survey Instrument (SF-36) before surgeries and within 2 months, 6 months and 1 year after surgeries.

RESULTS

Data of 300 patients were analyzed. All patients underwent Bankart capsulorrhaphy. Patients were followed up for minimum of 1 year after surgery. These data showed improvements in external rotation, abduction, DASH score, Rowe score and SF-36 in patients (P < 0.05 for all items). No significant changes were observed within 1 year in forward elevation (P = 0.07), internal rotation (P = 0.125) and Constant Shoulder Score (P = 0.082).

CONCLUSION

Bankart surgery is an effective method for reducing pain and recurrence of shoulder dislocation. Based on our results, using Bankart surgery led to significantly increased shoulder functions among patients.

Reasons Why Athletes Do Not Return to Sports After Arthroscopic Bankart Repair: A Comparative Study of 208 Athletes With Minimum 2-Year Follow-up

Background:

There is a lack of information regarding the reasons why patients do not return to sports after an arthroscopic Bankart repair and whether there is a relationship between return to sports and functional outcomes.

Purpose:

To evaluate the reasons why competitive athletes who underwent arthroscopic Bankart repair did not return to sports and whether there was a relationship between returning to sports and postoperative outcome scores and complications.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Of 217 competitive athletes who underwent arthroscopic Bankart repair for isolated anterior glenohumeral instability between June 2014 and December 2017, a total of 208 athletes (96%) were evaluated at minimum 2-year follow-up. Return to sports, the level of sports achieved, and the time between surgery and return to competition were assessed, and patients who did not return to sports were asked to provide the reasons for cessation. The Rowe score and the Athletic Shoulder Outcome Scoring System (ASOSS) were used to assess functional outcomes. Recurrences, reoperations, and complications were also evaluated.

Results:

The mean patient age was 24 years (range, 18-30 years), and the mean follow-up was 44 months (range, 24-90 months). Of the 208 athletes, 73% were able to return to sports (65% returned to their preinjury level), and 27% did not return to sports. Of those who did not return, the most frequent reasons were fear of reinjury (44%), lack of confidence in their shoulder (12%), and concern about a new rehabilitation process in case of recurrence (10%). The Rowe and ASOSS scores showed significant postoperative improvement in all patients (P < .001), with no significant differences between the 2 study groups at the final follow-up. There were 21 recurrences (10%) and 5 complications (2.4%), and 11 patients (5.3%) underwent revision surgery, with no significant differences in these rates between the groups.

Conclusion:

Of patients who did not return to sports, 74% left for a reason independent of shoulder function, with the most frequent causes being fear of reinjury and a concern about new rehabilitation process. Neither outcome scores nor complications varied significantly between patients who returned and those who did not return to sports.

Type V superior labral anterior-posterior tears results in lower rates of return to play

PURPOSE

The purpose of this study was to evaluate the rate of return to play (RTP) in patients who underwent Type V superior labrum anterior-posterior (SLAP) repair compared to patients who underwent isolated Bankart repair in the setting of traumatic anterior shoulder instability.

METHODS

A retrospective review of patients who underwent arthroscopic Bankart repair and SLAP repair by a single surgeon between 2012 and 2017 was performed. Additionally, these were pair-matched in a 1:2 ratio for age, sex, sport and level of pre-operative play, with those undergoing isolated arthroscopic Bankart repair alone as a control group. RTP, level of RTP and the timing of RTP were assessed.

RESULTS

The study included a total of 96 patients, with 32 in the study group and 64 in the control group, and a mean follow-up of 59 months. Overall, there was no significant difference in the overall rate of return to play (26/32 (81.3%) vs 56/64 (87.5%), n.s), but there was a significantly higher rate of RTP at the same/higher level in the control group (14/32 (43.6%) vs 43/64 (67.2%), p = 0.0463). There was no significant difference in timing of RTP between the groups (n.s). There was no significant difference in recurrent instability (6/32 (18.8%) vs 5/64 (7.8%), n.s) but there was a significant difference in revision rates (5/32 (15.6%) vs. 2/64 (3.1%), p = 0.0392) between the Type V SLAP repair group and the control group.

CONCLUSION

Following arthroscopic repair, patients with Type V SLAP tears had a similar overall rate of RTP when compared directly to a control group of patients who underwent arthroscopic Bankart repair alone. However, those who underwent Type V SLAP repair reported significantly lower rates of RTP at the same or higher level compared to the control group.

LEVEL OF EVIDENCE

III.

Arthroscopic bankart repair for the management of anterior shoulder instability: Mid- and long-term results

INTRODUCTION

Arthroscopic stabilisation is a well-recognised surgical technique with a variable rate of failure reported between 0-35%. The aim of this study was to evaluate the outcome of this technique and our second aim was to identify risk factors that could be associated to recurrence rate.

MATERIAL AND METHODS

41 patients that underwent arthroscopic shoulder stabilisation for glenohumeral instability between 2001-2015 were included. Different items such as epidemiologic, recurrence, age at first dislocation, preoperative sport practice, and number of fixation devices used were collected. The results were evaluated using functional scales (WOSI, Rowe y Walch-Duplay) and radiological study was assessed using the Samilson-Prieto score. Data from the medical history were recognised in order to assess possible risk factors.

RESULTS

The overall redislocation rate was 9.4%. The average follow-up was 83 months. The 54.3% of the patients achieved excellent/good results in the functional assessment scales. The range of motion was complete in 90% of the cases. On the radiographs, only 4.88% of the patients present advanced osteoarthritis. It was not possible to identify risk factors related to a worse outcome after surgery.

CONCLUSION

The arthroscopic Bankart repair with suture anchors is considered the gold standard for treatment of anterior glenohumeral instability. The long-term follow-up shows a favourable outcome, with a redislocation rate of 9% and low complication rate.