Return to Play After the Latarjet Procedure for Anterior Shoulder Instability: A Systematic Review

Return to Sport After Shoulder Stabilization Procedures: A Criteria-Based Testing Continuum to Guide Rehabilitation and Inform Return-to-Play Decision Making

The athlete with shoulder instability poses a unique challenge to the sports medicine team. Clinical studies support surgical intervention followed by a phased approach to rehabilitation. In the latter phases, it is important to tailor this program to the individual’s specific athletic needs, which requires ongoing qualitative assessment and objective measurement. Passing a return-to-sport testing battery has been shown to decrease the risk of recurrent instability. What is lacking in the literature is a consensus for how to best measure shoulder performance when the required athletic demands are widely varied by hand dominance, sport played, and playing position. Multiple upper-extremity tests have been described in the literature, but there is no consensus on which tests should be used to direct rehabilitation and to safely return the athlete to unrestricted athletic exposure. Using available evidence, we suggest a framework for return-to-play testing that integrates traditional rehabilitation phases with performance testing and graduated sports exposure.

Level of Evidence

Level V, expert opinion.

Both Open and Arthroscopic Latarjet Result in Excellent Outcomes and Low Recurrence Rates for Anterior Shoulder Instability

Purpose

The purpose of this study is to evaluate the patient-reported outcomes of open Latarjet (OL) compared to arthroscopic Latarjet (AL) for anterior shoulder instability.

Methods

A retrospective review of patients who underwent either OL or AL for anterior shoulder instability between 2011 and 2019 was performed. Recurrent instability, visual analog scale (VAS) score, Shoulder Instability-Return to Sport after Injury (SIRSI), Subjective Shoulder Value (SSV), Western Ontario Shoulder Instability (WOSI) score, patient satisfaction, willingness to undergo surgery again, and return to work/sport (RTW/RTS) were evaluated. A P value of < .05 was considered to be statistically significant.

Results

Our study included 102 patients in total; 72 patients treated with OL, and 30 treated with AL. There were no demographic differences between the two groups (P > .05 for all). At final follow up (mean of 51.3 months), there was no difference between those that underwent OL or AL in the reported WOSI, VAS, VAS during sports, SSV, and SIRSI scores, nor in patient satisfaction, or whether they would undergo surgery again (P > .05). Overall, there was no significant difference in the total rate of RTP (65% vs 60.9%; P = .74), or timing of RTP (8.1 months vs 7 months; P = .35). Additionally, there was no significant difference in the total rate of RTW (93.5% vs 95.5%; P = .75). Overall, 3 patients in the OL group and 2 patients in the AL group had recurrent instability events (6.9% vs 6.7%; P = .96), with no significant difference in the rate of recurrent dislocation (4.2% vs 3.3%; P = .84).

Conclusion

In patients with anterior shoulder instability, both the OL and AL are reliable treatment options, with a low rate of recurrent instability, and similar patient-reported outcomes.

Clinical outcomes of Gaelic Athletic Association athletes after surgical stabilization in the setting of anterior shoulder instability

Background

Gaelic Athletic Association (GAA) games are collision sports played at an amateur level, which represent the most popular sports played on the island of Ireland. Each year, many GAA players in Ireland require surgical stabilization with either arthroscopic Bankart repair (ABR) or open Latarjet (OL) procedures in the setting of anterior shoulder instability. The purpose of this study was to evaluate the clinical outcomes, recurrence, and return to play (RTP) in athletes who play GAA games having undergone surgical stabilization with either ABR or OL procedures in the setting of anterior shoulder instability.

Methods

A retrospective review of all patients with anterior shoulder instability whom had stabilization with either ABR or OL under a single surgeon between 2012 and 2018 was performed. Patients who were athletes partaking in GAA sports were followed up by chart review and telephone survey to assess their clinical outcomes including satisfaction, pain as measured on the visual analog scale score, the Subjective Shoulder Value, recurrence, complications, and revision surgeries. In addition, RTP rates, time to RTP, level of RTP, and Shoulder Instability–Return to Sport after Injury scores were evaluated.

Results

A total of 200 GAA athletes (194 males) with a mean age of 23.9 ± 6.1 years with mean follow-up of 50.4 ± 24 months were included in this study. A total of 98.1% patients were satisfied with their procedure at the latest follow-up, with an overall recurrence rate of 5%. A total of 6.5% of athletes required revision surgery, of whom 4% required revision stabilization (all of whom had recurrence). The overall rate of RTP was 88% at mean 6.0 ± 1.7 months postoperatively, with 75% of athletes returning at the same or higher levels than their preinjury level. There were no significant differences for all outcome measures analyzed between patients who had ABR or OL procedures.

Conclusion

GAA athletes with anterior shoulder instability treated with either ABR or OL procedures report excellent clinical outcomes at medium-term follow-up, with high satisfaction rates, excellent functional outcomes, and high rates of RTP. Furthermore, this cohort demonstrates low rates of recurrence after stabilization with few requiring revision surgery.

Arthroscopic Bankart Repair Versus Open Latarjet for Recurrent Shoulder Instability in Athletes

Background:

In athletes with recurrent shoulder instability, arthroscopic Bankart repair (ABR) and the open Latarjet procedure (OL) are commonly indicated to restore stability and allow them to return to play (RTP).

Purpose:

To compare the outcomes of ABR and OL in athletes with recurrent shoulder instability.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We performed a retrospective review of patients with recurrent shoulder instability who underwent ABR and OL and had a minimum 24-month follow-up. Indications for OL over ABR in this population were those considered at high risk for recurrence, including patients with glenohumeral bone loss. The patients were pair-matched in a 1:1 ratio (OL and ABR) by age, sex, sport, and level of preoperative play. We evaluated the rate, level, and timing of RTP, and the Shoulder Instability–Return to Sport after Injury (SIRSI) score between procedures. Additionally we compared the recurrence rate, visual analog scale (VAS) pain score, Subjective Shoulder Value (SSV), Rowe score, satisfaction, and whether patients would undergo the same surgery again.

Results:

Participants included 62 athletes who underwent ABR and 62 who underwent OL, with a mean follow-up of 47.7 months. There was no significant difference between ABR and OL in rate of RTP, return to preinjury level, time to return, SIRSI score, VAS score, SSV, or patient satisfaction. OL resulted in a significantly lower recurrence rate (1.6% vs 16.1% for ABR; P = .009) and a significantly higher Rowe score (mean ± SD, 90.5 ± 12.2 vs 82.2 ± 20.8 for ABR; P = .008). In collision athletes, there was no significant difference between ABR and OL regarding RTP rate (89.1% vs 94.5%; P = .489) or SIRSI score (70.4 ± 24.8 vs 73.8 ± 19.6; P = .426), but OL resulted in a lower recurrence rate (14.5% vs 1.8%; P = .031).

Conclusion:

ABR and OL resulted in excellent clinical outcomes, with high rates of RTP in athletes. However, lower recurrence rates were seen with OL.

Open Latarjet Procedure in Athletes Following Failed Prior Instability Surgery Results in Lower Rates of Return to Play

PURPOSE

The purpose of this study was to compare the outcomes of open Latarjet (OL) in competitive athletes with primary shoulder instability versus those with recurrent instability versus those undergoing OL for failed prior instability surgery.

METHODS

A retrospective review of patients who underwent OL with a minimum of 24-month follow-up was performed. Additionally, these were pair-matched in a 1:2:1 ratio for age, gender, sport, level of preoperative play, and follow-up length for primary instability, recurrent instability and failed prior instability surgery. Return to sport, the level of return and the timing of return were assessed. Additionally, recurrence, Visual Analogue Scale for pain (VAS), Subjective Shoulder Value (SSV), Rowe score, Shoulder Instability-Return to Sport after Injury (SIRSI) score, satisfaction, and whether they would undergo the same surgery again were compared.

RESULTS

After pair-matching, a total of 200 patients were included, with a mean age of 22.7 years and a mean follow-up of 38.8 months. Overall, there was no significant difference in any of the clinical outcome scores (VAS, Rowe, SIRSI, SSV) used for the 3 groups (P > 0.05 for all). However, there was a significantly lower rate of return to play for those undergoing OL because of failed prior instability surgery (88% vs 91% vs 64%, P < 0.0001) and for return at the same or a higher level (66% vs 78% vs 56%, P = 0.02). There was no significant difference in the rate of recurrent instability among the 3 groups (6% vs 5% vs 6%, P = 0.95).

CONCLUSION

OL results in excellent clinical outcomes and low recurrence rates for those with primary shoulder instability, those with recurrent instability and those undergoing OL for failed prior instability surgery. However, in those undergoing OL for failed prior stabilization surgery, there was a lower rate of return to play.

LEVEL OF EVIDENCE

Level III: Retrospective Comparative Study.

Arthroscopic Bankart Repair Versus Open Latarjet for First-Time Dislocators in Athletes

BACKGROUND

In athletes with a first-time shoulder dislocation, arthroscopic Bankart repair (ABR) and the open Latarjet procedure (OL) are the most commonly utilized surgical procedures to restore stability and allow them to return to play (RTP).

PURPOSE

To compare the outcomes of ABR and OL in athletes with a first-time shoulder dislocation.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We performed a retrospective review of patients with first-time shoulder dislocation who underwent primary ABR and OL and had a minimum 24-month follow-up. Indications for OL over ABR in this population were those considered at high risk for recurrence, including patients with glenohumeral bone loss. Patients who underwent ABR were pair-matched in a 2:1 ratio with patients who underwent OL by age, sex, sport, and level of preoperative play. The rate, level, and timing of RTP, as well as the Shoulder Instability-Return to Sport after Injury (SIRSI) score were evaluated. Additionally, we compared recurrence, visual analog scale pain score, Subjective Shoulder Value, Rowe score, satisfaction, and whether patients would undergo the surgery again.

RESULTS

Overall, 80 athletes who underwent ABR and 40 who underwent OL were included, with a mean follow-up of 50.3 months. There was no significant difference between ABR and OL in rate of RTP, return to preinjury level, time to return, or recurrent dislocation rate. There were also no differences between ABR and OL in patient-reported outcome scores or patient satisfaction. When collision athletes were compared between ABR and OL, there were no differences in RTP, SIRSI score, or redislocation rate.

CONCLUSION

ABR and OL resulted in excellent clinical outcomes, with high rates of RTP and low recurrence rates. Additionally, there were no differences between the procedures in athletes participating in collision sports.

The Latarjet Procedure Without Remplissage Is Effective to Restore Stability in Athletes With Glenoid Bone Defects Greater Than 25% and Off-Track Hill-Sachs Lesions

PURPOSE

There were 2 main purposes in this study: (1) to report on clinical outcomes of the Latarjet procedure without remplissage in athletes with glenoid bone defects greater than 25% and off-track Hill-Sachs lesions and (2) to determine whether the isolated Latarjet procedure converted off-track Hill-Sachs lesions to on-track Hill-Sachs lesions as measured on computed tomography (CT).

METHODS

During the study period, a total of 29 athletes who had anterior glenohumeral instability with glenoid bone defects greater than 25% and off-track Hill-Sachs lesions, who underwent Latarjet surgery, and who had a minimum follow-up period of 24 months were included in this study. The glenoid track was analyzed before and 3 months after the procedure using 3-dimensional CT. Return to sport and range of motion, as well as the Rowe score, visual analog scale score for pain during sports activity, and Athletic Shoulder Outcome Scoring System score, were used to assess functional outcomes. Recurrences were also evaluated.

RESULTS

The mean follow-up period was 35 months (standard deviation [SD], 6 months), and the mean age was 30 years (SD, 2 years). Of the patients, 27 (93%) were able to return to sports and 25 (86%) returned to the same level as before their injury. No significant difference in shoulder range of motion was found between preoperative and postoperative results. The Rowe, visual analog scale, and Athletic Shoulder Outcome Scoring System scores showed statistically significant improvements after surgery (P < .001). The mean width of the glenoid pathway changed significantly from 21.5 mm (SD, 2.54 mm) in the preoperative period to 35.1 mm (SD, 5.46 mm) at 3 months' follow-up. All the Hill-Sachs lesions remained on track, and no patient had recurrence of instability at the end of follow-up. No complications occurred in this series.

CONCLUSIONS

The Latarjet procedure was effective to restore stability in athletes with recurrent glenohumeral instability with glenoid bone defects greater than 25% and off-track Hill-Sachs lesions, avoiding recurrence in all patients after an average follow-up period of 35 months. Moreover, the Latarjet procedure converted all off-track Hill-Sachs lesions to on-track Hill-Sachs lesions as measured on CT.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Intra- and intersession reliability and agreement of the Unilateral Seated Shot-Put Test outcome measures in healthy male athletes

BACKGROUND

The Unilateral Seated Shot-Put Test (USSPT) consists of pushing an overweight ball as far as possible to assess upper extremity power unilaterally and bilateral symmetry. Literature however reports various body positions and upper limb pushing patterns to perform USSPT, demanding to provide additional guideline to achieve overweight ball push. This study therefore aimed at assessing the reliability and agreement of USSPT outcome measures when pushing an overweight ball in a horizontal direction.

METHODS

Twenty-seven healthy male athletes performed two sessions, one week apart, of three unilateral pushes per upper limb using a 3-kg medicine ball, for which the distances were measured. The intraclass correlation coefficient (ICC), standard error of measurement (SEM), minimum detectable change at a 95 % confidence level (MDC_95 %) and coefficient of variation (CV) were assessed for the pushing distances based on one, two or three trials per side to produce two outcome measures: the pushing distance per limb and USSPT Limb Symmetry Index (LSI) when dividing pushing distance of the dominant side by that of the non-dominant side.

RESULTS

The most reliable pushing distance per limb was obtained when averaging three pushing distances, normalized by body mass with the exponent 0.35. The mean USSPT LSI was 1.09 ± 0.10 for the first session and 1.08 ± 0.10 for the second session, highlighting good reliability and agreement (ICC = 0.82; SEM = 0.045; MDC_95 % = 0.124; CV = 5.02 %).

CONCLUSIONS

When the overweight ball is pushed in a horizontal direction, averaging the distances of three trials for both the dominant and non-dominant limbs is advised to provide the most reliable USSPT distance per limb and USSPT LSI.

No difference in 90-day complication rate following open versus arthroscopic Latarjet procedure

The purpose of this study was to compare the 90-day complication rate between the open and arthroscopic Latarjet procedure. A retrospective review of patients who underwent an open or arthroscopic Latarjet procedure at NYU Langone Health between 2012 and 2019 was performed. The complications, readmissions, and reoperations within 90 days were assessed. Outcomes were compared between the two approaches, and a p value of < 0.05 was considered to be statistically significant. The study included 150 patients (open: 110; arthroscopic: 40), with no patients lost to follow-up within the first 90 days. Both cohorts were similar in terms of patient demographics. No intra-operative complications were observed in either group. Overall, there were 4 post-operative complications with the open approach and 2 with the arthroscopic approach (3.6% and 5.0%, respectively; n.s.) during the study period. Three patients required a readmission within the 90-day period; one patient in both groups required a revision Latarjet for graft fracture, and one patient in the open Latarjet required irrigation and debridement for deep infection (n.s.). With the open approach, there were 2 (2.3%) wound complications, 1 graft complication, and 1 (1.1%) nerve injury. With the arthroscopic approach, there was 1 (2.8%) wound complication and 1 (2.8%) hardware complication. The safety, and 90-day complication and readmission profile of arthroscopic Latarjet is similar to open Latarjet procedure. LEVEL OF EVIDENCE: Level III.

Failed Latarjet procedure: a systematic review of surgery revision options

Background

Revision surgery after the Latarjet procedure is a rare and challenging surgical problem, and various bony or capsular procedures have been proposed. This systematic review examines clinical and radiographic outcomes of different procedures for treating persistent pain or recurrent instability after a Latarjet procedure.

Methods

A systematic review of the literature was performed using the Medline, Cochrane, EMBASE, Google Scholar and Ovid databases with the combined keywords “failed”, “failure”, “revision”, “Latarjet”, “shoulder stabilization” and “shoulder instability” to identify articles published in English that deal with failed Latarjet procedures.

Results

A total of 11 studies (five retrospective and six case series investigations), all published between 2008 and 2020, fulfilled our inclusion criteria. For the study, 253 patients (254 shoulders, 79.8% male) with a mean age of 29.6 years (range: 16–54 years) were reviewed at an average follow-up of 51.5 months (range: 24–208 months).

Conclusions

Eden–Hybinette and arthroscopic capsuloplasty are the most popular and safe procedures to treat recurrent instability after a failed Latarjet procedure, and yield reasonable clinical outcomes. A bone graft procedure and capsuloplasty were proposed but there was no clear consensus on their efficacy and indication.

Level of evidence

Level IV

Trial registration PROSPERO 2020 CRD42020185090—www.crd.york.ac.uk/prospero/

Return to play criteria among shoulder surgeons following shoulder stabilization

PURPOSE

The purpose of this study was to survey the members of North American and European shoulder surgery and sports medicine societies to evaluate their criteria for deciding when an athlete can safely return to play (RTP) following shoulder stabilization surgery.

METHODS

A survey was sent to the members of the American Shoulder and Elbow Surgeons (ASES), American Orthopaedic Society for Sports Medicine (AOSSM), European Society for Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA), and European Society for Surgery of the Shoulder and the Elbow (SECEC). Surgeons were asked which criteria they used to determine when an athlete can return to play following the arthroscopic Bankart repair and Latarjet procedures, with additional questions on how time from surgery and participation in collision sports affect return.

RESULTS

Overall, 317 surgeons responded to the survey. Following arthroscopic Bankart repair, the most common criteria used were time (98.7%), strength (74.8%), and range of motion (70%). The most commonly reported time point was 4 months (43.8%), and the majority used an additional time period, most commonly 2 months (38.2%), before allowing a collision athlete to return to play (75.4%). Interestingly, the addition of a remplissage procedure did not affect decision making regarding RTP in most cases (92.1%). Following the Latarjet procedure, the most common criteria used were time (98.4%), strength (67.5%), and range of motion (65.9%). Less than half reported using imaging to assess for radiographic union before allowing patients to return to play (47%), and the most common modality was plain radiography (80%). The most common time point was 4 months (33.1%), and the majority reported waiting an additional period of time, most commonly by 2 months (25.9%), before allowing a collision athlete to return to play (59.6%).

CONCLUSION

Despite the absence of evidence-based guidelines on when athletes can safely return to play following shoulder stabilization surgery, there exists minimal variability in recommendations between North American and European shoulder surgeons. Further research is required to better define criteria for RTP after the arthroscopic Bankart repair and Latarjet procedures.

[Radiographic study of effect of lateral placement of bone graft on shoulder joint degeneration after modified arthroscopic Latarjet surgery with elastic fixation]

OBJECTIVE

To investigate the mid-term effect of lateral placement of bone graft on shoulder joint degeneration after modified arthroscopic Latarjet surgery with elastic fixation for recurrent anterior shoulder dislocation with an anterior glenoid bone defect.

METHODS

According to the inclusion and exclusion criteria, 18 patients with recurrent anterior shoulder dislocation and anterior glenoid bone defect who received the modified arthroscopic Latarjet surgery with elastic fixation between January 2015 and November 2016 were enrolled in this study. There were 12 males and 6 females with an average age of 26.2 years (range, 19-37 years). The number of shoulder dislocation ranged from 4 to 30 times (mean, 8.8 times). The disease duration was 8-49 months (mean, 23.8 months). The mean anterior glenoid bone defect was 25.2% of the glenoid surface (range, 20%-29%). The mean preoperative Instability Severity Index Score (ISIS) was 7.6 (range, 7-10). According to Samilson-Prieto classification, the shoulder joint degeneration was rated as grade 0 in 13 cases, grade Ⅰ in 3 cases, and grade Ⅱ in 2 cases. Before and after operation, the visual analogue scale (VAS) score, American Society of Shoulder and Elbow Surgery (ASES) score, Walch-Duplay score, Rowe score, and shoulder mobility were used to evaluate the effectiveness. Imaging examination was performed to observe the shoulder joint degeneration, the position of the bone graft, and the postoperative shaping of the scapular glenoid.

RESULTS

All patients were followed up 55-62 months, with an average of 59.6 months. There was no neurovascular injuries, infections, fixation-related and bone graft-related complications. No re-dislocation and revision occurred. All patients returned to normal life, 17 of whom returned to sport. The VAS score was significantly decreased and ASES, Walch-Duplay, and Rowe scores were significantly improved at last follow-up ( P<0.05). No significant difference was found in range of motion of forward flexion, abduction, lateral rotation at 90° abduction, internal rotation at 90° abduction, or lateral rotation at 0° between pre- and post-operation ( P>0.05). Three-dimensional CT showed that the centers of all bone grafts were between 3∶30 and 4∶30 (right shoulder) or between 7∶40 and 8∶20 (left shoulder) and no bone grafts were positioned superiorly or inferiorly in the glenoid En-face view. All bone grafts were positioned lateral to the scapular glenoid with an average distance of 3.5 mm (range, 2.3-4.6 mm) in cross-sectional imaging by CT. Compared with the preoperative Samilson-Prieto classification results, all cases showed no progression of shoulder joint degeneration at 36, 48 months and last follow-up. All bone grafts remodeled to a steady state within 24 months after operation. The bone graft and glenoid finally remodeled analogous to the shape of the intact glenoid in the En-face view and became flush with the glenoid rim, remodeling to a curved shape congruent to the humeral head in cross-sectional imaging by CT. The shape of the remodeled glenoid at last follow-up was not significantly different from that at 24 months after operation.

CONCLUSION

The lateral placement of the bone graft during modified arthroscopic Latarjet surgery with elastic fixation do not accelerate the imaging changes of shoulder joint degeneration.

The S-STARTS Test: Validation of a Composite Test for the Assessment of Readiness to Return to Sport After Shoulder Stabilization Surgery

BACKGROUND

The time elapsed since surgery is the primary criterion for allowing athletes to return to sport after shoulder stabilization surgery using the Latarjet procedure. The objective assessment of shoulder functional status through the return-to-sport continuum demands a scoring instrument that includes psychological and physical dimensions. This study aimed to statistically validate the Shoulder-SanTy Athletic Return To Sport (S-STARTS) score in patients who have undergone primary shoulder stabilization surgery.

HYPOTHESIS

The S-STARTS score fulfils the criteria for statistical validation for assessing return-to-sport readiness after shoulder stabilization surgery.

STUDY DESIGN

Diagnostic study.

LEVEL OF EVIDENCE

Level 4.

METHODS

Fifty patients and 50 controls completed the Shoulder Instability-Return to Sport after Injury questionnaire and performed 4 physical performance tests, from which 8 outcome measures were extracted to provide a composite score, named S-STARTS, according to a scoring procedure. The statistical validation of the S-STARTS score was based on construct validity, discriminant validity, sensitivity to change, internal consistency, reliability, agreement, and feasibility.

RESULTS

The 8 components of the S-STARTS score provided additional information (0.01 ≤ |r| ≤ 0.59). The S-STARTS score exhibited good reliability (intraclass coefficient of correlation [3,k] = 0.74), no ceiling or floor effects, and high discrimination and sensitivity to change. The S-STARTS score was significantly lower in patients than in controls (13.5 ± 3.8 points vs 16.1 ± 2.7 points, respectively; P < 0.001). A significant increase was reported between 4.5 and 6.5 months postoperatively (12.8 ± 2.3 points vs 17.2 ± 2.4 points, respectively; P < 0.001).

CONCLUSIONS

The S-STARTS score meets statistical validation criteria for the assessment of shoulder functional status after shoulder stabilization surgery using the Latarjet procedure.

CLINICAL RELEVANCE

Using an S-STARTS score-based assessment to monitor an athlete's progression through the return-to-sport continuum may help clinicians and strength and conditioning coaches in return-to-sport decision-making.

Evolving Concepts in the Management of Shoulder Instability

BACKGROUND

Shoulder instability exists on a spectrum ranging from subtle subluxation and pain to dislocation and can be the result of a traumatic event or repetitive microtrauma. Shoulder instability can result in significant disability and often requires surgical intervention, especially amongst younger, active patient populations. The optimal treatment of shoulder instability depends on the degree of instability and concomitant pathology involving the labrum, capsule, and bony anatomy of the glenoid and humeral head. Even with surgical intervention, recurrent instability remains a relatively common and difficult problem to address.

PURPOSE

With a focus on anterior instability, the purpose of this review article is to discuss the current assessment and treatment of shoulder instability, and highlight current and future treatment modalities, as well as to identify current trends and deficiencies in our current management. We also provide an algorithm for the surgical treatment of anterior shoulder instability.

METHODS

Literature databases were extensively searched for recent articles related to the mechanism, diagnosis, and treatment of shoulder instability to comprise a comprehensive review.

CONCLUSION

Although there are multiple treatment modalities available for shoulder instability, such as nonoperative management, open and arthroscopic Bankart repair, Latarjet procedures, and remplissage, orthopaedic surgeons continue to learn about the most appropriate method of management as increasing long-term outcomes become available.

Traditional versus congruent-arc Latarjet anatomic and biomechanical perspective

The congruent-arc Latarjet (CAL) allows reconstruction of a greater percentage of glenoid bone deficit because the inferior surface of the coracoid is wider than the lateral edge of the coracoid used with the traditional Latarjet (TL).

Biomechanical studies have shown higher initial fixation strength between the graft and the glenoid with the TL.

In the TL, the undersurface of the coracoid, which is wider than the medial edge used with the CAL, remains in contact with the anterior edge of the glenoid, increasing the contact surface between both bones and thus facilitating bone consolidation.

The shorter bone distance around the screw with the CAL is potentially less tolerant of screw-positioning error compared to the TL. Moreover, the wall of the screw tunnel is potentially more likely to fracture with the CAL due to the minimal space between the screw and the graft wall.

CAL may be very difficult to perform in patients with very small coracoids such as small women or skeletally immature patients.

Radius of curvature of the inferior face of the coracoid graft (used with the CAL) is similar to that of the native glenoid. This may potentially decrease contact pressure across the glenohumeral joint, avoiding degenerative changes in the long term.

Cite this article: EFORT Open Rev 2021;6:280-287. DOI: 10.1302/2058-5241.6.200074

Variation in technique and postoperative management of the Latarjet procedure among orthopedic surgeons

BACKGROUND

The Latarjet procedure has become a treatment of choice for glenohumeral instability in the setting of large glenoid osseous defects (>20%) and for prior failed soft tissue repairs. However, surgical techniques and postoperative rehabilitation protocols vary among expert shoulder surgeons. The purpose of this survey study was to characterize the variation in current practice patterns among fellowship-trained orthopedic shoulder surgeons and identify factors related to variation.

METHODS

A 9-question survey was created (SurveyMonkey, San Mateo, CA, USA) and distributed to orthopedic surgeons who are active members of the American Shoulder and Elbow Surgeons or American Orthopaedic Society for Sports Medicine. The survey asked questions regarding surgeon experience with the Latarjet procedure, fellowship training, open vs. arthroscopic approach, method of coracoid-to-glenoid fixation, period of sling use postoperatively, and time before clearance to return to sport. Subgroup analysis was performed to determine whether further variation was evident between surgeons who completed sports medicine vs. shoulder and elbow fellowship training.

RESULTS

In total, 242 surgeons completed the survey. Of these, 55% indicated performing a sports medicine fellowship and 39% indicated completing a shoulder and elbow fellowship. Among all surgeons, the classic open Latarjet procedure was the strongly preferred technique (79%), followed by the open congruent-arc (17%) and all-arthroscopic (3%) techniques. With respect to fixation, 98% used screw fixation and only 1% indicated cortical button use. With respect to the postoperative course, >85% of surgeons preferred immobilization for 3-6 weeks after the procedure and 42% of respondents stated they waited ≥6 months prior to clearing their patients to return to sport. Subgroup analysis revealed that surgeons who completed a shoulder and elbow fellowship performed the classic open technique 89% of the time compared with 63% of those who completed a sports medicine fellowship (P < .001).

CONCLUSION

The results of our survey study indicate an overall strong preference for the open classic Latarjet technique as well as an overall strong preference for screw fixation of the coracoid graft to the glenoid among all surgeons. Shoulder and elbow fellowship-trained surgeons are significantly more likely to perform open surgery with a classic technique compared with sports medicine fellowship-trained surgeons. Furthermore, the significant variation in postoperative sling use and return to sport suggests that further research is needed to develop an evidence-based postoperative Latarjet rehabilitation protocol.

Arthroscopic Latarjet Procedure: Indications, Techniques, and Outcomes

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The proposed advantages of the arthroscopic approach in the Latarjet procedure for shoulder dislocation include improved visualization for accurate positioning of the coracoid graft, the ability to address any associated intra-articular pathologies, and the diminished potential for the formation of postoperative scar tissue and stiffness associated with an open procedure.

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Young age, the presence of glenoid and/or humeral bone loss, a history of dislocation, a history of failed arthroscopic stabilization surgery, and an active lifestyle are all associated with recurrent dislocation and are relative indications for an osseous augmentation procedure.

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Both the open and arthroscopic Latarjet procedures result in substantial improvements in patient function, with comparable rates of recurrent instability and complication profiles.

Recurrence and Revision Rates With Arthroscopic Bankart Repair Compared With the Latarjet Procedure in Competitive Rugby Players With Glenohumeral Instability and a Glenoid Bone Loss <20

BACKGROUND

There is a lack of evidence in the literature comparing outcomes between the arthroscopic Bankart repair and the Latarjet procedure in competitive rugby players with glenohumeral instability and a glenoid bone loss <20%.

PURPOSE

To compare return to sport, functional outcomes, and complications between the arthroscopic Bankart repair and the Latarjet procedure in competitive rugby players with glenohumeral instability and a glenoid bone loss <20%.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between June 2010 and February 2018, 130 competitive rugby players with anterior shoulder instability were operated on in our institution. The first 80 patients were operated on with the arthroscopic Bankart procedure and the other 50 with the open Latarjet procedure. Return to sport, range of motion (ROM), 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

In the total population, the mean follow-up was 40 months (range, 24-90 months) and the mean age was 24.2 years (range, 16-33 years). Ninety-two percent of patients were able to return to rugby, 88% at their preinjury level of play. Eighty-nine percent of patients in the Bankart group and 87% in the Latarjet group returned to compete at the same level (P = .788). No significant difference in shoulder ROM was found between preoperative and postoperative results. The Rowe and ASOSS scores showed statistical improvement after operation (P < .01). No significant difference in functional scores was found between the groups The Rowe score in the Bankart group increased from a preoperative mean (± SD) of 41 ± 13 points to 89.7 points postoperatively, and in the Latarjet group, from a preoperative mean of 42.5 ± 14 points to 88.4 points postoperatively (P = .95). The ASOSS score in the Bankart group increased from a preoperative mean of 53.3 ± 3 points to 93.3 ± 6 points postoperatively, and in the Latarjet group, from a preoperative mean of 53.1 ± 3 points to 93.7 ± 4 points postoperatively (P = .95). There were 18 recurrences (14%). The rate of recurrence was 20% in the Bankart group and 4% in the Latarjet group (P = .01). There were 15 reoperations (12%). The rate of reoperation was 16% in the Bankart group and 4% in the Latarjet group (P = .03). There were 6 complications (5%). The rate of complications was 4% in the Bankart group and 6% in the Latarjet group (P = .55). The proportion of postoperative osteoarthritis was 10% in the Bankart group (8/80 patients) and 12% (6/50 patients) in the Latarjet group (P = .55).

CONCLUSION

In competitive rugby players with glenohumeral instability and a glenoid bone loss <20%, both the arthroscopic Bankart repair and the Latarjet procedure produced excellent functional outcomes, with most athletes returning to sport at the same level they had before the injury. However, the Bankart procedure was associated with a significantly higher rate of recurrence (20% vs 4%) and reoperation (16% vs 4%) than the Latarjet procedure.

Latarjet procedure enables 73% to return to play within 8 months depending on preoperative SIRSI and Rowe scores

PURPOSE

Systematic reviews report return to play (RTP) within 5.8 months (range, 3-8) following the Latarjet procedure, but the factors that influence RTP remain unknown. The present study aimed to report the rate and time of return to play (RTP) during the first 8 months following the Latarjet procedure, and to determine the influence of sport type or patient characteristics.

METHODS

The authors retrospectively collected the records of patients that underwent Latarjet procedures for anterior shoulder instability between 2015 and 2017. Patients were excluded if they had any concomitant rotator cuff tendon lesions, or previous ipsilateral shoulder surgery. The authors retrieved patient demographics, time from injury to surgery, type of sport practiced (overhead/non-overhead, contact/non-contact), as well as pre- and postoperative Western Ontario Shoulder Instability index (WOSI), Shoulder Instability-Return to Sport After Injury index (SIRSI), and Rowe score.

RESULTS

A total of 217 patients (217 shoulders) were eligible for inclusion, comprising 184 males and 33 females, aged 26.8 ± 7.3 years at index surgery. The main sport practiced prior to surgery involved overhead (n = 173, 80%) and/or contact (n = 152, 70%) activities. By 8 month follow-up, 158 patients (73%) resumed their main sport, at a mean of 5.1 ± 1.5 months. Multivariable analysis revealed that RTP was more likely in patients with higher preoperative Rowe score (OR, 1.02; p = 0.024) and SIRSI score (OR, 1.02; p = 0.008).

CONCLUSIONS

By 8 months following the Latarjet procedure, 73% of patients had resumed their main sport. The likelihood of RTP was significantly associated with preoperative Rowe and SIRSI scores, but not with sport type.

LEVEL OF EVIDENCE

IV.

Return to Play After Arthroscopic Stabilization for Posterior Shoulder Instability-A Systematic Review

Purpose

To ascertain the rate and timing of return to play (RTP) and the availability of specific criteria for safe RTP after arthroscopic posterior shoulder stabilization.

Methods

Medline, EMBASE, and the Cochrane Library were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to find studies on arthroscopic posterior shoulder stabilization. Studies were included if they reported RTP data or rehabilitation protocols and excluded if concomitant procedures influenced the rehabilitation protocol. Rate and timing of RTP, along with rehabilitation protocols, were assessed.

Results

This review found 25 studies, including 895 cases, meeting the study’s inclusion criteria. The majority of patients were male (82.7%), with an age range of 14 to 66 years and a follow-up range of 4 to 148.8 months. The overall RTP rate ranged from 62.7% to 100.0%, and 50.0% to 100.0% returned to the same level of play. Among collision athletes, the overall rate of RTP was 80.0% to 100.0%, with 69.2%-100.0% returning to the same level of play. In overhead athletes, the overall rate of RTP was 85.2% to 100.0%, with 55.6% to 100.0% returning to the same level of play. Four studies (128 patients) specifically addressed the timing of RTP, and the range to RTP was 4.3 to 8.6 months. Specific RTP criteria were reported in a majority of studies (60%), with the most reported item being restoration of strength (44%).

Conclusion

There is a high rate of return to sport after arthroscopic posterior shoulder stabilization, ranging from 4.3 to 8.6 months after surgery. Return to preinjury level is higher for collision athletes compared with overhead athletes. However, there is inadequate reporting of RTP criteria in the current literature, with no clear timeline for when it is safe to return to sport.

Level of Evidence

IV, systematic review of level II to IV studies

Immobilisation in external rotation after first-time traumatic anterior shoulder instability reduces recurrent instability: a meta-analysis

IMPORTANCE

Cadaveric and MRI findings have demonstrated significantly less labral separation and displacement when the shoulder is placed in external rotation as compared with internal rotation.

OBJECTIVE

The purpose of the current study is to meta-analyse the randomised controlled trials in the literature to compare immobilisation in external versus internal rotation after first-time anterior shoulder dislocation.

EVIDENCE REVIEW

A literature search of MEDLINE, EMBASE and the Cochrane Library was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomised controlled trials comparing immobilisation in external rotation versus internal rotation for first-time anterior shoulder dislocation were included.

FINDINGS

Nine randomised controlled trials with 795 patients were included. The mean age of included patients was 29 years, 82.4% were male and the mean follow-up was 25.5 months. As compared with immobilisation in internal rotation, compliance was significantly higher (74.5% vs 67.4%, p=0.01), and the rate of recurrent dislocations was significantly lower (22.2% vs 33.4%, p=0.02) with immobilisation in external rotation. Additionally, in patients 20-40 years old the rate of recurrent dislocations was significantly lower in those treated with immobilisation in external rotation than internal rotation (12.1% vs 31.4%, p=0.006). Immobilisation in external rotation also resulted in a higher rate of return to preinjury level of play (60.1% vs 42.6%, p=0.0001).

CONCLUSIONS AND RELEVANCE

Immobilisation of the shoulder in external rotation after a traumatic first-time anterior shoulder dislocation results in a higher compliance rate, a lower recurrent dislocation rate and a higher rate of return to play as compared with immobilisation in internal rotation.

LEVEL OF EVIDENCE

Level I.

Remplissage for anterior shoulder instability with Hill-Sachs lesions: a systematic review and meta-analysis

BACKGROUND

The purpose of this study was to perform a systematic review and meta-analysis of the current evidence in the literature to determine how arthroscopic Bankart repair (ABR) and remplissage compare with ABR alone and the open Latarjet procedure for anterior shoulder instability in patients with concomitant Hill-Sachs lesions.

METHODS

A literature search was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Studies comparing ABR and remplissage vs. ABR alone or the Latarjet procedure for anterior shoulder instability in patients with Hill-Sachs lesions were included. Clinical outcomes were compared, with all statistical analysis performed using Review Manager (version 5.3). P < .05 was considered statistically significant.

RESULTS

Twelve clinical trials were included. There was a significant difference between ABR plus remplissage and ABR alone in total recurrence rate (3.2% vs. 16.8%, P < .05) but not the rate of revision due to recurrence (1.7% vs. 8.5%, P = .06). There was no significant difference between the Latarjet procedure and ABR plus remplissage in total recurrence rate (7.0% vs. 9.8%, P = .39), total revision rate (3.7% vs. 5.7%, P = .41), and rate of revision due to recurrence (1.6% vs. 2.1%, P = .79). There was a significantly lower rate of complications with ABR and remplissage compared with the Latarjet procedure (0.5% vs. 8.6%, P = .003).

CONCLUSION

In patients with Hill-Sachs lesions and subcritical glenoid bone loss, ABR with remplissage resulted in lower rates of recurrent instability compared with ABR alone while resulting in similar recurrence rates, as well as similar patient-reported outcomes, with lower morbidity and fewer complications, compared with the Latarjet procedure.

LEVEL OF EVIDENCE

Level III; Systematic Review.

Clinical Outcomes of Patients With Anterior Shoulder Instability and Glenolabral Articular Disruption Lesions: A Retrospective Comparative Study

BACKGROUND

Anterior shoulder instability is a common clinical condition that often requires surgical stabilization. Glenoid labral tears are often associated with instability, with glenolabral articular disruption (GLAD) lesions occasionally being identified arthroscopically during repair, particularly in collision athletes.

PURPOSE

To evaluate the clinical outcomes and recurrence rates in patients who had GLAD lesions and underwent arthroscopic Bankart repair (ABR) and compare them with a control group without GLAD lesions.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective review of patients who underwent ABR with GLAD lesions, by a single surgeon between July 2012 and March 2017, was performed. Additionally, these were pair matched in a 2:1 ratio for age, sex, sport, and level of play with a control group who underwent ABR without GLAD lesions. Return to sport, the level of return, and the timing of return were assessed. The visual analog scale (VAS) for pain score, Rowe score, Shoulder Instability-Return to Sport after Injury (SIRSI) score, and Subjective Shoulder Value (SSV) were evaluated.

RESULTS

The study included a total of 66 patients (22 and 44 patients for the GLAD and control groups, respectively), with a mean age of 25.8 years and a mean follow-up of 66 months. Overall, there was no significant difference in any of the clinical outcome scores (VAS, Rowe, SIRSI, and SSV) utilized for the GLAD and control groups (P > .05 for all). Similarly, there was no significant difference in the total rate of return to play (90.9% vs 88.6%; P > .99) or return at the same/higher level (68.2% vs 72.7%; P = .78). There was no significant difference in timing of return to play (6.3 ± 6.6 months vs 6.4 ± 2.5 months; P = .98). There were 3 cases (13.6%) requiring further surgery (1 revision stabilization, 1 arthroscopic release, and 1 rotator cuff repair) in the GLAD group and 2 cases (4.5%) requiring further surgery (both revision stabilization) in the control group; the difference was not statistically significant (P = .32).

CONCLUSION

After arthroscopic repair, patients with GLAD lesions had similar midterm outcomes when compared with a control group without GLAD lesions.

Return to Play after Arthroscopic Bankart Repair Combined with Open Subpectoral Biceps Tenodesis

Purpose

To evaluate the clinical outcomes and rate of return to play (RTP) in patients who underwent arthroscopic Bankart repair and open subpectoral biceps tenodesis.

Methods

A retrospective review of patients who underwent combined arthroscopic Bankart repair and open subpectoral biceps tenodesis by a single surgeon between 2012 and 2016 was performed. RTP, the level of return, and the timing of return were assessed. Visual analog scale for pain, Rowe score, Shoulder Instability-Return to Sport after Injury score, and Subjective Shoulder Value were evaluated.

Results

The study included 14 patients, with a mean follow-up of 34.2 ± 12.1 months. Of the 14 patients, 13 (92.9%) returned to sport at a mean of 4.8 ± 1.2 months and 9 (64.3%) returned to the same or higher level of sport. At final follow-up, the mean Rowe was 80.0 ± 16.3, the mean Subjective Shoulder Value was 81.0 ± 15.1, the mean Shoulder Instability-Return to Sport after Injury was 57.3 ± 25.6, and the mean visual analog scale score was 2.6 ± 1.5. One patient had a recurrent dislocation, whereas no patients underwent a further operation on the ipsilateral shoulder.

Conclusion

Patients undergoing arthroscopic Bankart repair combined with open subpectoral biceps tenodesis had a high rate of RTP with a low rate of recurrent instability.

Level of Evidence

IV, Therapeutic Case Series.

Functional outcome and return to sports after the arthroscopic latarjet procedure in young and physically active patients

PURPOSE

The ideal treatment strategy for traumatic anterior shoulder instability with glenoid bone loss in young, physically active patients is still controversial. This study examines sporting activity, the ability to practice sports and the ability to return to sports after the arthroscopic Latarjet procedure.

METHODS

A total of 47 physically active patients with an average age of 24.5 ± 5.9 years were included in the study and evaluated at a minimum of two years after surgical treatment using shoulder and sport-specific scores. The shoulder sport activity score, Brophy marx activity score, Athletic shoulder outcome scoring system and the SPORTS score were used to assess the ability to practice sports, the sporting activity and the ability to return to sports. To assess functional outcome and shoulder stability, the evaluation was conducted using the Western Ontario shoulder instability index, the Constant score, the American shoulder and elbow surgeon score, and the Subjective shoulder value.

RESULTS

89.4% of the patients examined were able to perform the sport they had previously practiced after an average of 4.6 ± 2.0 months. Overhead athletes and martial arts athletes demonstrated a significantly lower return to sports rate than non-collision/non-overhead athletes (p = 0.01). With regard to sport-, instability-, or function-specific scores, no significant difference was found between patients after primary Latarjet procedure and patients after Latarjet procedure following a failed open or arthroscopic Bankart repair. All scores showed good to very good functional results on average. Two patients suffered a traumatic recurrent instability (4.1%) during the follow-up period and were therefore excluded from this study.

CONCLUSION

Arthroscopic Latarjet procedure presents a good surgical option, especially for young, physically active patients; it has very good clinical outcome, a high return to sports rate and a low probability of recurrent dislocation.

Similar Results in Return to Sports, Recurrences, and Healing Rates Between the Classic and Congruent-Arc Latarjet for Athletes With Recurrent Glenohumeral Instability and a Failed Stabilization

PURPOSE

To compare the return-to-sport rate, functional outcomes, and complications of the "classic Latarjet" surgery with those of the "congruent arc Latarjet" surgery in athletes with recurrent glenohumeral instability and failed previous stabilization procedures.

METHODS

All the included patients were operated between May 2009 and April 2017. The inclusion criteria were athletes with recurrent anterior glenohumeral instability, a glenoid bone defect greater than 20%, at least 1 previous failed stabilization surgery operated with the classic or the congruent-arc Latarjet procedures, and a minimum 2 years of follow-up. Return to sports, range of motion (ROM), the Rowe score, a visual analog scale for pain, and the Athletic Shoulder Outcome Scoring System score were used to assess functional outcomes. Complications were also evaluated.

RESULTS

A total of 135 athletes were included in the study (55 patients were operated with the classic technique and 80 with the congruent arc technique). The mean follow-up was 40.3 months (range, 24-88 months) and the mean age was 26.5 years (range, 18-45 years). Overall, 87% were able to return to sports and 92% returned at the same level. No significant difference regarding return to sports was found between the groups. No significant difference in shoulder ROM was found between preoperative and postoperative results. The Rowe, visual analog scale, and Athletic Shoulder Outcome Scoring System scores showed statistical improvement after operation (P < .001). No significant difference in shoulder ROM and functional scores was found between patients operated with the classic and congruent arc procedures. There were 6 recurrences (4%). There was no significant difference in the recurrence rate between groups. The bone block healed in 92% of the cases.

CONCLUSIONS

In athletes with recurrent anterior glenohumeral instability and a failed previous operative repair, the Latarjet procedure produced excellent functional outcomes and most athletes returned to sport at their preinjury level with a very low rate of recurrences, regardless of whether the Latarjet was performed with the classic or with the congruent arc technique.

LEVEL OF EVIDENCE

Retrospective comparative study; Level of evidence, 3.

Are the Classic and the Congruent Arc Latarjet Procedures Equally Effective for the Treatment of Recurrent Shoulder Instability in Athletes?

BACKGROUND

There is a lack of evidence in the literature comparing outcomes between the classic and the congruent arc Latarjet procedures in athletes.

PURPOSE

To compare return to sports, functional outcomes, and complications between the classic and the congruent arc Latarjet procedures in athletes with recurrent glenohumeral instability.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between June 2009 and June 2017, 145 athletes with recurrent anterior glenohumeral instability underwent surgery with the Latarjet as a primary procedure in our institution. The classic procedure was used in 66 patients, and the congruent arc method was used in 79 patients. Return to sports, range of motion (ROM), the Rowe score, a visual analog scale (VAS) for pain in sports activity, and the Athletic Shoulder Outcome Scoring System (ASOSS) were used to assess functional outcomes. Recurrences were also evaluated. The postoperative bone block position and consolidation were assessed with computed tomography.

RESULTS

In the total population, the mean follow-up was 41.3 months (range, 24-90 months) and the mean age was 25.3 years (range, 18-45 years). In total, 90% of patients were able to return to sports; of these, 91% returned at their preinjury level of play. No significant difference in shoulder ROM was found between preoperative and postoperative results. The Rowe, VAS, and ASOSS scores showed statistical improvement after operation (P < .001). The Rowe score increased from a preoperative mean of 42.8 points to a postoperative mean of 95.2 points (P < .01). Subjective pain during sports improved from 3.2 points preoperatively to 0.7 points at last follow-up (P < .01). The ASOSS score improved significantly from a preoperative mean of 46.4 points to a postoperative mean of 88.4 points (P < .01). No significant differences in shoulder ROM and functional scores were found between patients who received the classic vs congruent arc procedures. There were 5 recurrences (3.5%): 3 dislocations (2%) and 2 subluxations (1%). No significant difference in the recurrence rate was noted between groups. The bone block healed in 134 cases (92%).

CONCLUSION

In athletes with recurrent anterior glenohumeral instability, the Latarjet procedure produced excellent functional outcomes. Most athletes returned to sports at their preinjury level, and the rate of recurrence was very low, regardless of whether the patients received surgery with the classic or congruent arc technique.

Outcomes following arthroscopic Bankart repair in female patients

PURPOSE

The purpose of this study is to evaluate clinical outcomes and recurrence among women who have undergone an arthroscopic Bankart repair for recurrent anterior shoulder instability.

METHODS

A retrospective review of patients with anterior shoulder instability that have undergone an arthroscopic Bankart repair between 2012-2017 was performed. Patients were followed up to assess their visual analog scale (VAS) score, Rowe score, Shoulder Instability-Return to Sport after Injury (SIRSI), and the Subjective Shoulder Value (SSV) and their satisfaction level. Whether they were able to return to sport, the timing of return, and the level to which they returned were reported.

RESULTS

Our study included 31 female patients (34 shoulders), with a mean follow-up of 51.9 months. Overall, 82.4% (28/34 shoulders) were satisfied/very satisfied with their surgery. The mean scores were as follows: Rowe, 79.2; SIRSI, 53.9; SSV, 81.9; and VAS, 1.9. Of the 29 patients (32 shoulders) who played sport prior to surgery, 24 returned to play and 17 returned to the same or higher level. One patient suffered a recurrent dislocation and 2 patients suffered recurrent subluxation. No patients underwent a revision procedure.

CONCLUSION

Female patients with anterior shoulder instability treated with arthroscopic Bankart repair have low recurrence rates, with good patient-reported outcomes and high satisfaction rates. Of those participating in sport prior to surgery, there was a high rate of return to play. The overall rate of complications was low, with a low rate of revision surgery.

Return to Sport Following Arthroscopic Repair of 270° Labral Tears

PURPOSE

To evaluate the rate of return to sport following arthroscopic repair of 270° labral tears.

METHODS

We performed a retrospective review of patients with 270° labral tears treated arthroscopically between 2013 and 2017 by a single surgeon. Patients were followed-up to assess whether they were able to return to sport, the level to which they returned and the timing of return. Complications, the Visual Analogue Scale for pain (VAS), the Rowe score, the Shoulder Instability-Return to Sport after Injury (SIRSI) score, and the Subjective Shoulder Value (SSV) were recorded.

RESULTS

The study included 25 patients, with a mean follow-up of 42.2 ± 16.5 months. Of the 25 patients, 19 (76.0%) returned to sport at a mean of 6.8 ± 2.6 months, while 15 (60%) returned at the same or a higher level. At final follow-up, the mean Rowe score was 80.6 ± 14.2; the mean SIRSI score was 61.8 ± 25.4; the mean SSV was 86.4 ± 15.2; and the mean VAS score was 2.2 ± 2.0. One patient reported recurrent subluxation, but no patients suffered a recurrent dislocation during the study period. No revision surgeries were performed within the study period.

CONCLUSION

Patients with 270° labral tears who were treated with arthroscopic repair showed an overall high rate of return to sport. Despite a low rate of recurring instability, not all patients were able to return to their previous levels of sports.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Are Patients Who Undergo the Latarjet Procedure Ready to Return to Play at 6 Months? A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group Cohort Study

BACKGROUND

The Latarjet procedure is growing in popularity for treating athletes with recurrent anterior shoulder instability, largely because of the high recurrence rate of arthroscopic stabilization, particularly among contact athletes with bone loss.

PURPOSE

(1) To evaluate return of strength and range of motion (ROM) 6 months after the Latarjet procedure and (2) to determine risk factors for failure to achieve return-to-play (RTP) criteria at 6 months.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A total of 65 athletes (83% contact sports, 37% overhead sports; mean ± SD age, 24.5 ± 8.2 years; 59 male, 6 female) who enrolled in a prospective multicenter study underwent the Latarjet procedure for anterior instability (29% as primary procedure for instability, 71% for failed prior stabilization procedure). Strength and ROM were assessed preoperatively and 6 months after surgery. RTP criteria were defined as return to baseline strength and <20° side-to-side ROM deficits in all planes. The independent likelihood of achieving strength and motion RTP criteria at 6 months was assessed through multivariate logistic regression modeling with adjustment as needed for age, sex, subscapularis split versus tenotomy, preoperative strength/motion, percentage bone loss, number of prior dislocations, preoperative subjective shoulder function (American Shoulder and Elbow Surgeons and Western Ontario Shoulder Instability Index percentage), and participation in contact versus overhead sports.

RESULTS

Of the patients, 55% failed to meet ≥1 RTP criteria: 6% failed for persistent weakness and 51% for ≥20° side-to-side loss of motion. There was no difference in failure to achieve RTP criteria at 6 months between subscapularis split (57%) versus tenotomy (47%) (P = .49). Independent risk factors for failure to achieve either strength or ROM criteria were preoperative American Shoulder and Elbow Surgeons scores (per 10-point decrease: adjusted odds ratio [aOR], 1.61; 95% CI, 1.14-2.43; P = .006), Western Ontario Shoulder Instability Index percentage (per 10% decrease: aOR, 0.61; 95% CI, 0.38-0.92; P = .01), and a preoperative side-to-side ROM deficit ≥20° in any plane (aOR, 5.01; 95% CI, 1.42-21.5; P = .01) or deficits in external rotation at 90° of abduction (per 10° increased deficit: aOR, 1.64; 95% CI, 1.06-2.88; P = .02).

CONCLUSION

A large percentage of athletes fail to achieve full strength and ROM 6 months after the Latarjet procedure. Greater preoperative stiffness and subjective disability are risk factors for failure to meet ROM or strength RTP criteria.

What Are the Effects of Remplissage on 6-Month Strength and Range of Motion After Arthroscopic Bankart Repair? A Multicenter Cohort Study

BACKGROUND

Patients who have undergone shoulder instability surgery are often allowed to return to sports, work, and high-level activity based largely on a time-based criterion of 6 months postoperatively. However, some believe that advancing activity after surgery should be dependent on the return of strength and range of motion (ROM).

HYPOTHESIS

There will be a significant loss of strength or ROM at 6 months after arthroscopic Bankart repair with remplissage compared with Bankart repair alone.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A total of 38 patients in a prospective multicenter study underwent arthroscopic Bankart repair with remplissage (33 males, 5 females; mean age, 27.0 ± 10.2 years; 82% with ≥2 dislocation events in the past year). Strength and ROM were assessed preoperatively and at 6 months after surgery. Results were compared with 104 matched patients who had undergone Bankart repair without remplissage, although all had radiographic evidence of a Hill-Sachs defect.

RESULTS

At 6 months, there were no patients in the remplissage group with anterior apprehension on physical examination. However, 26% had a ≥20° external rotation (ER) deficit with the elbow at the side, 42% had a ≥20° ER deficit with the elbow at 90° of abduction, and 5% had persistent weakness. Compared with matched patients who underwent only arthroscopic Bankart repair, the remplissage group had greater humeral bone loss and had a greater likelihood of a ≥20° ER deficit with the elbow at 90° of abduction (P = .004). Risk factors for a ≥20° ER deficit with the elbow at 90° of abduction were preoperative stiffness in the same plane (P = .02), while risk factors for a ≥20° ER deficit with the elbow at the side were increased number of inferior quadrant glenoid anchors (P = .003), increased patient age (P = .02), and preoperative side-to-side deficits in ER (P = .04). The only risk factor for postoperative ER weakness was preoperative ER weakness (P = .04), with no association with remplissage (P = .26).

CONCLUSION

Arthroscopic Bankart repair with remplissage did not result in significant strength deficits but increased the risk of ER stiffness in abduction compared with Bankart repair without remplissage at short-term follow-up.