Recurrent Instability After Arthroscopic Bankart Repair in Patients With Hyperlaxity and Near-Track Lesions

Background

Recurrent anterior shoulder instability after arthroscopic Bankart repair presents a challenging clinical problem, with the primary stabilization procedure often portending the best chance for clinical success.

Purpose

To determine if capsuloligamentous laxity affects failure (recurrent dislocation, subluxation, and/or perceived instability symptoms) after arthroscopic Bankart repair in patients with near-track lesions (ie, those with smaller distance to dislocation [DTD]).

Study Design

Case-control study; Level of evidence, 3.

Methods

The authors retrospectively reviewed consecutive patients who underwent primary arthroscopic Bankart repair for recurrent anterior glenohumeral instability at a single institution between 2007 and 2019 and who had at least 2 years of follow-up data. Patients with glenoid bone loss >20%, off-track lesions, concomitant remplissage, or rotator cuff tear were excluded. Capsuloligamentous laxity, or hyperlaxity, was defined as external rotation >85° with the arm at the side and/or grade ≥2 in at least 2 planes with the shoulder at 90° of abduction. Near-track lesions were defined as those with a DTD <10 mm.

Results

Included were 173 patients (mean age, 20.5 years; mean DTD, 16.2 mm), of whom 16.8% sustained a recurrent dislocation and 6.4% had recurrent subluxations (defined as any subjective complaint of recurrent instability without frank dislocation), for an overall recurrent instability rate of 23.1%. The rate of revision stabilization was 15.6%. The mean time to follow-up was 7.4 years. Independent predictors of recurrent instability were younger age (P = .001), smaller DTD (P = .021), >1 preoperative instability episode (P < .001), and the presence of hyperlaxity during examination under anesthesia (P = .013). Among patients with near-track lesions, those with hyperlaxity had a recurrent instability rate almost double that of patients without hyperlaxity (odds ratio, 34.1; P = .04). The increased rate of failure and recurrent dislocation in the near-track hyperlaxity cohort remained elevated, even in patients with no bone loss.

Conclusion

Capsuloligamentous shoulder laxity was a significant independent risk factor for failure after primary arthroscopic Bankart repair without remplissage and was more predictive of failure in patients with versus without near-track lesions.

Posterior Labral Tear Extension Concomitant With Shoulder Bankart Injuries Is not Uncommon

Purpose

To identify the rate and risk factors of posterior labral involvement in operatively managed Bankart lesions and assess the effectiveness of MRI arthrogram for preoperative identification of such injury patterns.

Methods

A consecutive cohort of patients undergoing arthroscopic Bankart repair were retrospectively reviewed. All subjects underwent a prearthroscopy MRI arthrogram. Operative findings were used as the gold standard for posterior labral tear extension. Patient demographic and surgical data were then analyzed to identify independent factors associated with the presence of concomitant posterior labral injury.

Results

Of 124 patients undergoing arthroscopic Bankart stabilization, 23 (19%) were noted to demonstrate posterior labral injury on arthroscopic evaluation. Factors associated with injury to the posterior labrum included those sustaining two or fewer dislocations events (P =.001), an earlier average presentation (P = .001), and a reported “contact” mechanism of dislocation (P = .02). Posterior labral involvement did not correlate with surgical positioning (beach-chair versus lateral) or the need for revision surgery. On the basis of review of preoperative imaging, MRI arthrogram demonstrated a sensitivity of 83% and a specificity of 95% for detection of posterior labral injury.

Conclusions

Posterior propagation of Bankart lesions is relatively common following shoulder dislocations, with a rate of 18.5%. Risk factors for posterior labral extension include two or fewer dislocations, early presentation from the time of injury, and contact sports. On the basis of these findings, careful assessment of the posterior labrum on MRI arthrogram may reveal the majority, but not all, of these lesions.

Level of Evidence

Level III, retrospective case-controlled study.

On-Track Lesions with a Small Distance to Dislocation Are Associated with Failure After Arthroscopic Anterior Shoulder Stabilization

BACKGROUND

Off-track lesions are strongly associated with failure after arthroscopic Bankart repair. However, on-track lesions with a small distance-to-dislocation (DTD) value, or "near-track lesions," also may be at risk for failure. The purpose of the present study was to determine the association of DTD with failure after arthroscopic Bankart repair.

METHODS

We performed a retrospective analysis of 173 individuals who underwent primary arthroscopic Bankart repair between 2007 and 2015. Glenoid bone loss and Hill-Sachs lesion size were measured with use of previously reported methods. Patients with failure were defined as those who sustained a dislocation after the index procedure, whereas controls were defined as individuals who did not. DTD was defined as the distance from the medial edge of the Hill-Sachs lesion to the medial edge of the glenoid track. Receiver operating characteristic (ROC) curves were constructed for DTD to determine the critical threshold that would best predict failure. The study population was subdivided into individuals ≥20 years old and <20 years old.

RESULTS

Twenty-eight patients (16%) sustained a recurrent dislocation following Bankart repair. Increased glenoid bone loss (p < 0.001), longer Hill-Sachs lesion length (p < 0.001), and decreased DTD (p < 0.001) were independent predictors of failure. ROC curve analysis of DTD alone demonstrated that a threshold value of 8 mm could best predict failure (area under the curve [AUC] = 0.73). DTD had strong predictive power (AUC = 0.84) among individuals ≥20 years old and moderate predictive power (AUC = 0.69) among individuals <20 years old. Decreasing values of DTD were associated with a stepwise increase in the failure rate.

CONCLUSIONS

A "near-track" lesion with a DTD of <8 mm, particularly in individuals ≥20 years old, may be predictive of failure following arthroscopic Bankart repair. When using the glenoid track concept as the basis for surgical decision-making, clinicians may need to consider the DTD value as a continuous variable to estimate failure instead of using a binary on-track/off-track designation.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

Predictive factors for failure of conservative management in the treatment of calcific tendinitis of the shoulder

Background

Calcific tendinitis of the shoulder is a painful condition characterized by the presence of calcium deposits within the tendons of the rotator cuff (RTC). When conservative management fails, arthroscopic surgery for removal of the calcium may be considered. Surgical removal is often followed by RTC repair to address the resulting tendon defect. This study was performed to assess predictive factors for failure of conservative management and to characterize the rate of RTC repair in the setting of calcific tendinitis. We hypothesize that larger calcific lesion would have a higher likelihood to fail conservative treatment.

Methods

A retrospective review of patients who were diagnosed with calcific tendinitis at our institution between 2009 and 2019 was performed. Demographics, comorbidities, pain score (visual analog scale), American Shoulder and Elbow Surgeons score, range of motion, and patient-reported quality of life measures were recorded and analyzed. All patients underwent a radiograph and magnetic resonance imaging. Size of the calcific lesion was measured based on its largest diameter on magnetic resonance imaging. Statistical analysis included chi-square test, independent t-test, and analysis of variance.

Results

Two hundred thirty-nine patients were identified in the study period; 127 (53.1%) were women. The mean age was 54 years, and body mass index was 29.2 with a mean follow-up of 6 months. One hundred and sixty had an intact RTC (67.2%) and 78 had a partial RTC tear (32.8%). Ninety-three of 239 (38.9%) patients failed conservative treatment after an average of 4.4 months, necessitating surgical management. Among patients who underwent surgery, the majority of patients (77 of 93 [82.8%]) required a concomitant RTC repair. Subanalysis demonstrates that calcific lesions >1 cm was significantly associated with failure of conservative treatment (odds ratio = 2.86, 95% confidence interval 1.25-6.29, P < .05). All patients who underwent surgery demonstrated significant improvements in pain scores (6.3 to 2.3 visual analog scale), American Shoulder and Elbow Surgeons score (47.9 to 90.49), forward flexion (133° to 146.8°), and external rotation (49.2° to 57.6°) (P < .05) postoperatively.

Conclusion

Patients with calcific lesions >1 cm had a 2.8× increased likelihood to undergo operative treatment in the setting of calcific tendinitis of the shoulder. Most patients who undergo surgical management for removal of the calcific deposit required a concomitant RTC repair and had significant improvements in shoulder pain and function. This information can be helpful to guide orthopedic surgeons on preoperative planning and discussion when treating calcific tendinitis of the shoulder.

Preoperative Comorbidities and Postoperative Complications Do Not Influence Patient-Reported Satisfaction Following Humeral Head Resurfacing: Mid- to Long-term Follow-up of 106 Patients

Background

Humeral head resurfacing (HHR) has emerged as an alternative treatment for glenohumeral osteoarthritis. We investigated the outcomes of HHR using validated patient-reported outcome (PRO) measures.

Methods

A retrospective review was performed on 213 patients who underwent HHR. A PRO follow-up was performed by administering a questionnaire including the American Shoulder and Elbow Society (ASES) score, Brophy activity survey, short form of the Disabilities of the Arm, Shoulder and Hand (quickDASH) survey, and general shoulder function. PRO scores were stratified by comorbidities and complications.

Results

Survey responses were received from 106 patients (51%), with a mean follow-up of 5.6 ± 1.8 years (range: 9 months to 6.1 years). Preoperative comorbidities were associated with significantly higher quickDASH scores. Postoperative complications were associated with significantly higher rates of current pain, higher visual analog scale scores, night pain, lower subjective shoulder values, and lower ASES pain and total scores. No differences in patient satisfaction were identified between the cohorts with and without preoperative comorbidities and between the cohorts with and without postoperative complications.

Conclusion

In our cross-sectional analysis of mid- to long-term outcomes following HHR, preoperative comorbidities, or postoperative complications had no impact on patient-perceived postoperative satisfaction or most PROs. HHR is clinically viable in a wide variety of patients. Future work is necessary to compare the efficacy of HHR compared with more traditional total shoulder arthroplasty and stemmed hemiarthroplasty regarding long-term outcomes and appropriate indications.

Muscle cell-mediated gene delivery to the rotator cuff

Rotator cuff lesions are one of the most common causes of upper extremity disability. Surgical therapy addresses mostly the extrinsic etiology, but not intrinsic factors such as aging, structural changes, low vascularity, and inflammatory processes. In this study, genetically engineered, highly purified muscle-derived cells (MDCs) were characterized and injected into the supraspinatus tendons of nude rats. The injected cells were monitored for 3 weeks. In vitro, the engineered, highly purified MDCs do not express vimentin; 98% of them are positive for the beta-galactosidase marker gene, and 99% hybridize with the specific pancentromeric mouse probe. beta-Galactosidase marker gene expression of the injected cells was detected up to 21 days. From day 7 after injection, the cell nuclei became spindle shaped, cells were integrated into the tendon collagen bundles, and the cells showed differentiation into vimentin-expressing fibroblastic cells. The results indicate that the rotator cuff tendon matrix and its original cellular components modulated the injected MDCs toward a fibroblastic phenotype. The compatibility and ability of MDCs to differentiate into other cell lineages, such as fibroblasts, might have high potential utility in tissue-engineering applications for tendon healing. This approach facilitates the application of muscle-derived progenitor cells and ex vivo gene therapy for the treatment of rotator cuff lesions.

A clinical and comparative biomechanical evaluation of proximal femoral osteotomy fixation in children

This study compared the biomechanical characteristics of a 90 degrees infant blade plate construct and anteriorly applied 120 degrees angled plate construct in response to an axial compression load. The blade plate construct stiffness was three times greater than the angled plate construct (238.9 vs 85.7 N/deg). Four degrees failure load was also significantly higher for the blade plate. Despite inferior biomechanical characteristics, the 120 degrees angled plate functioned very satisfactorily in a retrospective clinical review of 21 proximal femoral varus osteotomies. The authors conclude that the 120 degrees angled plate has practical benefits in terms of ease of insertion and intraoperative adjustability which may outweigh its biomechanical inferiority.