Long-term results of arthroscopic Bankart repair: Minimum 10 years of follow-up

Arthroscopic subscapularis augmentation of the classic Bankart repair leads to satisfactory clinical and functional mid-term outcomes in patients with recurrent anterior shoulder instability and less than a subcritical glenoid bone loss

PURPOSE

The long-term failure rate of the arthroscopic Bankart repair may reach unacceptable values, raising the need to augment this classic procedure. Arthroscopic subscapularis augmentation is the tenodesis of the upper part of the subscapularis tendon to the anterior glenoid rim. The aim of the study was to evaluate the mid-term clinical and functional outcomes of patients operated with arthroscopic subscapularis augmentation of the classic Bankart repair due to recurrent anterior shoulder instability.

METHODS

This is a retrospective single-centre case series study with prospectively collected data. All patients suffered from recurrent anterior shoulder instability and had glenoid bone loss less than 13.5% of the inferior glenoid diameter (subcritical glenoid bone loss). Patients with greater anterior glenoid bone defect, engaging Hill-Sachs lesions, multidirectional instability or subscapularis insufficiency were excluded. Postoperatively, all patients were evaluated for recurrence and apprehension. The patient's shoulder range of motion and functional scores were recorded.

RESULTS

The final study cohort included 34 patients with a mean age of 29.3 ± 10.2 years. The mean follow-up period was 42.4 ± 10.7 months (range, 24-62 months). Two out of 34 patients (5.8%) experienced a re-dislocation postoperatively, while one additional patient had a subjective feeling of apprehension. External rotation at the last follow-up was lower compared to preoperative values or the healthy side, but only one patient had restrictions in his sporting activities. The functional scores were significantly increased compared to the preoperative values. Twenty-two out of 26 patients (84.6%) returned to the same level of sporting activities, and 30/34 patients (88.2%) were highly satisfied with the results.

CONCLUSION

Arthroscopic subscapularis augmentation of the classic Bankart repair reduces the dislocation recurrence rate and leads to satisfactory clinical and functional mid-term outcomes in patients with recurrent anterior shoulder instability and less than a subcritical glenoid bone loss.

LEVEL OF EVIDENCE

Level IV.

Methodology and development of a machine learning probability calculator: Data heterogeneity limits ability to predict recurrence after arthroscopic Bankart repair

PURPOSE

The aim of this study was to develop and train a machine learning (ML) algorithm to create a clinical decision support tool (i.e., ML-driven probability calculator) to be used in clinical practice to estimate recurrence rates following an arthroscopic Bankart repair (ABR).

METHODS

Data from 14 previously published studies were collected. Inclusion criteria were (1) patients treated with ABR without remplissage for traumatic anterior shoulder instability and (2) a minimum of 2 years follow-up. Risk factors associated with recurrence were identified using bivariate logistic regression analysis. Subsequently, four ML algorithms were developed and internally validated. The predictive performance was assessed using discrimination, calibration and the Brier score.

RESULTS

In total, 5591 patients underwent ABR with a recurrence rate of 15.4% (n = 862). Age <35 years, participation in contact and collision sports, bony Bankart lesions and full-thickness rotator cuff tears increased the risk of recurrence (all p < 0.05). A single shoulder dislocation (compared to multiple dislocations) lowered the risk of recurrence (p < 0.05). Due to the unavailability of certain variables in some patients, a portion of the patient data had to be excluded before pooling the data set to create the algorithm. A total of 797 patients were included providing information on risk factors associated with recurrence. The discrimination (area under the receiver operating curve) ranged between 0.54 and 0.57 for prediction of recurrence.

CONCLUSION

ML was not able to predict the recurrence following ABR with the current available predictors. Despite a global coordinated effort, the heterogeneity of clinical data limited the predictive capabilities of the algorithm, emphasizing the need for standardized data collection methods in future studies.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Association of the Inlay Structure Used in the Modified Bristow Procedure With Accelerated Bone Union: Comparing the Cuistow and Modified Bristow Procedures

Background

The Chinese unique inlay Bristow (Cuistow) procedure is a modified Bristow surgery in which an inlay (mortise-and-tenon) structure is added to the contact surface between the coracoid tip and the glenoid. Patients who have undergone the Cuistow procedure have had satisfying clinical performance and excellent postoperative bone healing rates (96.1%).

Purpose

To compare the clinical and radiographic outcomes after the arthroscopic Cuistow procedure and the arthroscopic Bristow procedure.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 91 patients who underwent either the Cuistow or Bristow procedure between January 2017 and March 2018 were selected, and 69 patients (70 shoulders; 35 in the Cuistow group and 35 in the Bristow group) were included. Clinical assessment at minimum 24 months postoperatively, including the visual analog scale for pain and instability, American Shoulder and Elbow Surgeons score, Rowe score, subjective shoulder value score, and active range of motion, was completed by independent observers and compared with values collected preoperatively. Assessment with 3-dimensional computed tomography scans was performed preoperatively; immediately after the operation; at 3, 6, and 12 months postoperatively; and at the final follow-up.

Results

A total of 69 patients (70 shoulders) were included, with a mean follow-up duration of 34.41 ± 5.99 months (range, 24-50 months). Both groups saw significant improvement in visual analog scale for pain and instability, American Shoulder and Elbow Surgeons, Rowe, and subjective shoulder value scores at the final follow-up compared with the preoperative values (P < .001 for all), with no significant between-group differences on any clinical outcomes at the final follow-up. The 3-month postoperative graft union rate on computed tomography was significantly higher in the Cuistow group compared with the Bristow group (82.9% vs 51.4%, respectively, P = .003), although the graft union rate at the final follow-up was not significantly different (94.3% vs 85.7%, respectively; P = .449).

Conclusion

Patients receiving the Cuistow procedure had equivalent clinical outcomes and a significantly higher bone union rate at 3 months postoperatively than those in the Bristow group. The inlay structure used in the Cuistow procedure was found to be associated with accelerated bone union.

Treatment of race and ethnicity in shoulder and elbow research: An analysis of the most cited papers on rotator cuff repair

Background

This study examined the current approach to the inclusion of race and ethnicity among frequently referenced shoulder surgery literature and discussed guidance for best practices for the inclusion of race and ethnicity in shoulder research.

Methods

The shoulder literature were systematically reviewed for the most frequently cited studies discussing rotator cuff repair, total shoulder arthroplasty, and Bankart repair. All reviewed studies met the timeline criteria (2013-2022). Only studies with clinical outcomes were included. Review articles, meta-analyses, systematic reviews, basic science studies, or any manuscript that did not represent clinical outcomes research were excluded. Author, year issued, the journal in which the paper was published, study design, the number of subjects, duration of follow-up, independent variables, dependent variables, results, and conclusions were extracted from the articles that met the inclusion criteria. Whether race and/or ethnicity were included in the study design in any way was also recorded. For those studies in which race and ethnicity were included, a detailed analysis of the paper's treatment of race using the JAMA Updated Guidance on Reporting of Race and Ethnicity in Medical and Science Journals was performed and recorded.

Results

In the "rotator cuff repair" cohort of papers, there were 2 articles that mention race. Out of the 2 articles that mentioned race, neither included race appropriately using the JAMA Updated Guidance on Reporting of Race and Ethnicity in Medical and Science Journals. In the "Bankart repair" cohort of papers, each article lacked the mention of race among their patient population. The "total shoulder arthroplasty" manuscripts also did not include treatment of race and ethnicity in any way.

Discussion

Race and ethnicity and other social determinants of health can be used to understand the source of healthcare disparities. Unless a thoughtful and deliberate consideration of race and ethnicity is undertaken, their inclusion in clinical research can be a double-edged sword due to the potential race and ethnicity-centered treatment involvement can be rooted in fallacies. In shoulder surgery clinical research, race and ethnicity should be considered in concert with social factors that could exacerbate poor patient outcomes in our patient population.

Level of evidence

Level V.

High long-term failure rates after arthroscopic Bankart repair in younger patients with recurrent shoulder dislocations: A plea for early treatment

PURPOSE

To determine arthroscopic Bankart repair outcomes and recurrence risk factors at a minimum 5-year follow-up.

METHODS

Retrospective assessment of prospectively collected data, single-cohort study of patients who underwent arthroscopic Bankart repair with a minimum 5-year follow-up. Demographical and preoperative instability features were collected. Primary outcome was recurrent instability set as dislocation or subluxation. Secondary outcomes were revision surgery, postoperative instability degree according to Manta criteria, objective and subjective clinical and functional status, assessed by the Rowe, Western Ontario Shoulder Index (WOSI) and Subjective Shoulder Value (SSV) scores. Return to sport and postoperative sports activity at the final follow-up were also recorded.

RESULTS

One-hundred and seventy-two patients, 82% men, average age at surgery 29.5 ± 9.2 years, were included. At a mean follow-up of 8.3 ± 2.6 years, recurrent instability occurred in 53 of 172 patients (30.8%). Revision surgery was required in 23/53 (43.4%) of shoulder with recurrent instability. Recurrence occurred within the first 2 years postoperative in 49% of the shoulders, whereas 51% of recurrences occurred after this period. Recurrence took place after a traumatic event in 25% and 56%, respectively. Recurrence rates were higher in patients who underwent surgery after two or more dislocations (p = 0.029). Patients younger at the time of first dislocation, younger at surgery and those with a higher preoperative degree of instability also showed significantly higher rates of recurrence (p = 0.04, p = 0.02, p = 0.03). Postoperative ROWE, WOSI and SSV scores were significantly worse in patients with recurrent instability (p < 0.001). Return-to-sports rate was also lower in patients with postoperative recurrence (p < 0.001).

CONCLUSION

The arthroscopic Bankart repair was associated with a high long-term recurrence rate, and its effectiveness decreased over time. The lowest recurrence rates in arthroscopic Bankart repair were achieved in older patients with only one prior instability episode and a lower instability degree.

LEVEL OF EVIDENCE

Level IV.

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

BACKGROUND

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

METHODS

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

CONCLUSION

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

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Risk factors for recurrence following arthroscopic Bankart repair: a systematic review

BACKGROUND

Recurrent instability remains a major source of morbidity following arthroscopic Bankart repair. Many risk factors and predictive tools have been described, but there remains a lack of consensus surrounding individual risk factors and their contribution to outcomes. The purpose of this study is to systematically review the literature to identify and quantify risk factors for recurrence following arthroscopic Bankart repair.

METHODS

A literature search was performed using the PubMed/MEDLINE databases based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Studies were included if they evaluated risk factors for recurrent instability following arthroscopic Bankart repair.

RESULTS

Overall, 111 studies were included in the analysis, including a total of 19,307 patients and 2750 episodes of recurrent instability with 45 risk factors described. Age at operation was reported by 60 studies, with 35 finding increased risk at younger ages. Meta-analysis showed a 2-fold recurrence rate of 27.0% (171 of 634) for patients <20 years old compared with 13.3% (197 of 1485) for older patients (P < .001). Seventeen studies completed multivariable analysis, 13 of which were significant (odds ratio 1.3-14.0). Glenoid bone loss was evaluated by 39 studies, with 20 finding an increased risk. Multivariable analysis in 9 studies found odds ratios ranging from 0.7 to 35.1; 6 were significant. Off-track Hill-Sachs lesions were evaluated in 21 studies (13 significant), with 3 of 4 studies that conducted multivariable analysis finding a significant association with odds ratio of 2.9-8.9 of recurrence. The number of anchors used in repair was reported by 25 studies, with 4 finding increased risk with fewer anchors. Pooled analysis demonstrated a 25.0% (29 of 156) risk of recurrence with 2 anchors, compared with 18.1% (89 of 491) with 3 or more anchors (P = .06). Other frequently described risk factors included glenohumeral joint hyperlaxity (46% of studies reporting a significant association), number of preoperative dislocations (31%), contact sport participation (20%), competitive sport participation (46%), patient sex (7%), and concomitant superior labral anterior-posterior tear (0%).

CONCLUSION

Younger age, glenoid bone loss, and off-track Hill-Sachs lesions are established risk factors for recurrence following arthroscopic Bankart repair. Other commonly reported risk factors included contact and competitive sports participation, number of fixation devices, and patient sex.

Glenohumeral morphological predictors of recurrent shoulder instability following arthroscopic Bankart repair

PURPOSE

The purpose of this study was to evaluate glenohumeral morphological features on a magnetic resonance arthrogram (MRA) to determine risk factors for recurrence of anterior shoulder instability following arthroscopic Bankart repair (ABR).

METHODS

A retrospective review of patients who underwent ABR between 2012 and 2017 was performed to identify patients who had recurrence of instability following stabilisation (Group 1). These were pair-matched in a 2:1 ratio for age, gender and sport with a control (Group 2) who underwent ABR without recurrence. Preoperative MRAs were evaluated for risk factors for recurrence, with glenoid bone loss and Hill-Sachs lesions also measured. Multilinear and multilogistic regression models were used to evaluate factors affecting recurrence.

RESULTS

Overall, 72 patients were included in this study, including 48 patients without recurrence and 24 patients with recurrent instability. There was a significant difference between the two groups in mean glenoid bone loss (Group 1: 7.3% vs. Group 2: 5.7%, p < 0.0001) and the rate of off-track Hill-Sachs lesions (Group 1: 20.8% vs. Group 2: 0%, p = 0.0003). Of the variables analysed in logistic regression, increased glenoid anteversion (p = 0.02), acromioclavicular (AC) degeneration (p = 0.03) and increased Hill-Sachs width were associated with increased risk of failure. Increased chondral version (p = 0.01) and humeral head diameter in the anteriorposterior view were found to be protective and associated with a greater likelihood of success.

CONCLUSION

Glenoid anteversion was a risk factor for recurrent instability, whereas increased chondral version and humeral head diameter were associated with higher rates of success following ABR. Glenoid bone loss, presence of an off-track Hill-Sachs lesion, increased Hill-Sachs width and AC degeneration were also associated with failure. These findings should be used by surgeons to stratify risk for recurrence following ABR.

LEVEL OF EVIDENCE

Level III.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Meta-analysis; Level of evidence, 3.

METHODS

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

RESULTS

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

CONCLUSION

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

Biomechanical comparison of open Bankart repair vs. conjoint tendon transfer in a 10% anterior glenoid bone loss shoulder instability model

BACKGROUND

The treatment of shoulder instability in patients with subcritical glenoid bone loss poses a difficult problem for surgeons as new evidence supports a higher failure rate when a standard arthroscopic Bankart repair is used. The purpose of this study was to compare a conjoint tendon transfer (soft-tissue Bristow) to an open Bankart repair in a cadaveric instability model of 10% glenoid bone loss.

METHODS

Eight cadaveric shoulders were tested using a custom testing system that allows for a 6-degree-of-freedom positioning of the glenohumeral joint. The rotator cuff muscles were loaded to simulate physiologic muscle conditions. Four conditions were tested: (1) intact, (2) Bankart lesion with 10% bone loss, (3) conjoint tendon transfer, and (4) open Bankart repair. Range of motion, glenohumeral kinematics, and anterior-inferior translation at 60° of external rotation with 20 N, 30 N, and 40 N were measured in the scapular and coronal planes. Glenohumeral joint translational stiffness was calculated as the linear fit of the translational force-displacement curve. Force to anterior-inferior dislocation was also measured in the coronal plane. Repeated measures analysis of variance with a Bonferroni correction was used for statistical analysis.

RESULTS

A Bankart lesion with 10% bone loss increased the range of motion in both the scapular (P = .001) and coronal planes (P = .001). The conjoint tendon transfer had a minimal effect on the range of motion (vs. intact P = .019, .002), but the Bankart repair decreased the range of motion to intact (P = .9, .4). There was a significant decrease in glenohumeral joint translational stiffness for the Bankart lesion compared with intact in the coronal plane (P = .021). The conjoint tendon transfer significantly increased stiffness in the scapular plane (P = .034), and the Bankart repair increased stiffness in the coronal plane (P = .037) compared with the Bankart lesion. The conjoint tendon transfer shifted the humeral head posteriorly at 60° and 90° of external rotation in the scapular plane. The Bankart repair shifted the head posteriorly in maximum external rotation in the coronal plane. There was no significant difference in force to dislocation between the Bankart repair (75.8 ± 6.6 N) and the conjoint tendon transfer (66.5 ± 4.4 N) (P = .151).

CONCLUSION

In the setting of subcritical bone loss, both the open Bankart repair and conjoint tendon transfer are biomechanically viable options for the treatment of anterior shoulder instability; further studies are needed to extrapolate these data to the clinical setting.

Editorial Commentary: Shoulder Bankart and Latarjet Procedures Show Different Complications at Different Time Periods

In patients with shoulder instability, arthroscopic Bankart procedure results in a high recurrence rate if there is associated bone loss, even small-to-moderate bone loss. The Latarjet procedure mitigates against recurrence in such cases but has greater short-term (30-day) complications than an arthroscopic Bankart and a greater rate of revision or reoperation. In truth, short-term complications are low with both procedures. That said, complications after arthroscopic Bankart are less likely to manifest in the short term, and possible future failure is generally not discovered until after a patient is released and returns to sports and/or greater levels of activity. The ultimate pros and cons of each procedure require long-term follow-up. That said, in the short term after Latarjet, surgeons should be mindful to monitor for early infection, hematoma, and hardware malposition or failure. In the long term after Latarjet, surgeons could monitor for graft resorption, nonunion of the graft, hardware prominence, and postsurgical arthritis.

Studies on Bankart Repair for Anterior Shoulder Instability Show Poor Reporting of Data and Reflect Low Level of Evidence: A Systematic Review

PURPOSE

To assess the quality and level of evidence of studies reporting on Bankart repair for anterior shoulder instability.

METHODS

A search was performed using the PubMed/Medline database for all studies that reported clinical outcomes on Bankart repair for anterior shoulder instability. The search term "Bankart repair" with all results were analyzed via strict inclusion and exclusion criteria. Two independent investigators scored each included study based on the 10 criteria of the Modified Coleman Methodology Score (CMS) out of 100 and gave each study a score out of 25 based on the Anterior Shoulder Instability (ASI) Methodology criteria.

RESULTS

Two hundred sixty-six studies were included in the analysis and encompassed a total of 19,156 patients and 19,317 surgical procedures for Bankart repair for shoulder instability. Overall, 81.6% of studies were Level III or IV evidence. The mean CMS score for the studies was 55.3 out of 100, and the mean ASI Methodology score for the studies was 12.1 out of 25. Weaknesses in the studies were identified in sample size, description of preoperative investigations and diagnoses, reporting of mean glenoid bone loss, nonsubjective clinical outcome reporting, and description of associated pathologies.

CONCLUSIONS

A large proportion of studies reporting the clinical outcomes of Bankart repair for anterior shoulder instability are of low methodological quality and have a low level of evidence.

CLINICAL RELEVANCE

This study emphasizes need for greater reporting of many variables such as body mass index, mean glenoid bone loss, and patient-reported outcomes and provides a framework for future studies reporting.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Level of Evidence

Level IV, therapeutic case-series.

Defining Critical Humeral Bone Loss: Inferior Craniocaudal Hill-Sachs Extension as Predictor of Recurrent Instability After Primary Arthroscopic Bankart Repair

BACKGROUND

The glenoid track concept for shoulder instability primarily describes the medial-lateral relationship between a Hill-Sachs lesion and the glenoid. However, the Hill-Sachs position in the craniocaudal dimension has not been thoroughly studied.

HYPOTHESIS

Hill-Sachs lesions with greater inferior extension are associated with increased risk of recurrent instability after primary arthroscopic Bankart repair.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

The authors performed a retrospective analysis of patients with on-track Hill-Sachs lesions who underwent primary arthroscopic Bankart repair (without remplissage) between 2007 and 2019 and had a minimum 2-year follow-up. Recurrent instability was defined as recurrent dislocation or subluxation after the index procedure. The craniocaudal position of the Hill-Sachs lesion was measured against the midhumeral axis on sagittal magnetic resonance imaging (MRI) using either a Hill-Sachs bisecting line through the humeral head center (sagittal midpoint angle [SMA], a measure of Hill-Sachs craniocaudal position) or a line tangent to the inferior Hill-Sachs edge (lower-edge angle [LEA], a measure of Hill-Sachs caudal extension). Univariate and multivariate regression were used to determine the predictive value of both SMA and LEA for recurrent instability.

RESULTS

In total, 176 patients were included with a mean age of 20.6 years, mean follow-up of 5.9 years, and contact sport participation of 69.3%. Of these patients, 42 (23.9%) experienced recurrent instability (30 dislocations, 12 subluxations) at a mean time of 1.7 years after surgery. Recurrent instability was found to be significantly associated with LEA >90° (ie, Hill-Sachs lesions extending below the humeral head equator), with an OR of 3.29 (P = .022). SMA predicted recurrent instability to a lesser degree (OR, 2.22; P = .052). Post hoc evaluation demonstrated that LEA >90° predicted recurrent dislocations (subset of recurrent instability) with an OR of 4.80 (P = .003). LEA and SMA were found to be collinear with Hill-Sachs interval and distance to dislocation, suggesting that greater LEA and SMA proportionally reflect lesion severity in both the craniocaudal and medial-lateral dimensions.

CONCLUSION

Inferior extension of an otherwise on-track Hill-Sachs lesion is a highly predictive risk factor for recurrent instability after primary arthroscopic Bankart repair. Evaluation of Hill-Sachs extension below the humeral equator (inferior equatorial extension) on sagittal MRI is a clinically facile screening tool for higher-risk lesions with subcritical glenoid bone loss. This threshold for critical humeral bone loss may inform surgical stratification for procedures such as remplissage or other approaches for at-risk on-track lesions.

Artificial Intelligence Can Define and Predict the "Optimal Observed Outcome" After Anterior Shoulder Instability Surgery: An Analysis of 200 Patients With 11-Year Mean Follow-Up

Purpose

The purpose of this study was to use unsupervised machine learning clustering to define the "optimal observed outcome" after surgery for anterior shoulder instability (ASI) and to identify predictors for achieving it.

Methods

Medical records, images, and operative reports were reviewed for patients <40 years old undergoing surgery for ASI. Four unsupervised machine learning clustering algorithms partitioned subjects into "optimal observed outcome" or "suboptimal outcome" based on combinations of actually observed outcomes. Demographic, clinical, and treatment variables were compared between groups using descriptive statistics and Kaplan-Meier survival curves. Variables were assessed for prognostic value through multivariate stepwise logistic regression.

Results

Two hundred patients with a mean follow-up of 11 years were included. Of these, 146 (64%) obtained the "optimal observed outcome," characterized by decreased: postoperative pain (23% vs 52%; P < 0.001), recurrent instability (12% vs 41%; P < 0.001), revision surgery (10% vs 24%; P = 0.015), osteoarthritis (OA) (5% vs 19%; P = 0.005), and restricted motion (161° vs 168°; P = 0.001). Forty-one percent of patients had a "perfect outcome," defined as ideal performance across all outcomes. Time from initial instability to presentation (odds ratio [OR] = 0.96; 95% confidence interval [CI], 0.92-0.98; P = 0.006) and habitual/voluntary instability (OR = 0.17; 95% CI, 0.04-0.77; P = 0.020) were negative predictors of achieving the "optimal observed outcome." A predilection toward subluxations rather than dislocations before surgery (OR = 1.30; 95% CI, 1.02-1.65; P = 0.030) was a positive predictor. Type of surgery performed was not a significant predictor.

Conclusion

After surgery for ASI, 64% of patients achieved the "optimal observed outcome" defined as minimal postoperative pain, no recurrent instability or OA, low revision surgery rates, and increased range of motion, of whom only 41% achieved a "perfect outcome." Positive predictors were shorter time to presentation and predilection toward preoperative subluxations over dislocations.

Level of Evidence

Retrospective cohort, level IV.

CT methods for measuring glenoid bone loss are inaccurate, and not reproducible or interchangeable

Aims

Glenoid bone loss is a significant problem in the management of shoulder instability. The threshold at which the bone loss is considered "critical" requiring bony reconstruction has steadily dropped and is now approximately 15%. This necessitates accurate measurement in order that the correct operation is performed. CT scanning is the most commonly used modality and there are a number of techniques described to measure the bone loss however few have been validated. The aim of this study was to assess the accuracy of the most commonly used techniques for measuring glenoid bone loss on CT.

Methods

Anatomically accurate models with known glenoid diameter and degree of bone loss were used to determine the mathematical and statistical accuracy of six of the most commonly described techniques (relative diameter, linear ipsilateral circle of best fit (COBF), linear contralateral COBF, Pico, Sugaya, and circle line methods). The models were prepared at 13.8%, 17.6%, and 22.9% bone loss. Sequential CT scans were taken and randomized. Blinded reviewers made repeated measurements using the different techniques with a threshold for theoretical bone grafting set at 15%.

Results

At 13.8%, only the Pico technique measured under the threshold. At 17.6% and 22.9% bone loss all techniques measured above the threshold. The Pico technique was 97.1% accurate, but had a high false-negative rate and poor sensitivity underestimating the need for grafting. The Sugaya technique had 100% specificity but 25% of the measurements were incorrectly above the threshold. A contralateral COBF underestimates the area by 16% and the diameter by 5 to 7%.

Conclusion

No one method stands out as being truly accurate and clinicians need to be aware of the limitations of their chosen technique. They are not interchangeable, and caution must be used when reading the literature as comparisons are not reliable.

Return to Preinjury-Level Sports After Arthroscopic Latarjet for Recurrent Anterior Shoulder Instability in Professional Athletes

Background

The Latarjet procedure is recommended to treat recurrent anterior shoulder instability with glenoid bone loss. Longer return-to-sport (RTS) times have been reported after the open Latarjet when compared with the arthroscopic Latarjet.

Purpose

To assess the clinical outcomes and RTS in athletes who underwent an arthroscopic Latarjet.

Study Design

Case series; Level of evidence, 4.

Methods

This study included 46 professional athletes with recurrent anterior shoulder instability who underwent an arthroscopic Latarjet between 2010 and 2016. Patients were divided by type of sport: noncollision and nonoverhead (n = 22), collision and martial arts (n = 13), and overhead (n = 11). Sport activity was evaluated with the Kerlan-Jobe Orthopaedic Clinic (KJOC) score, Subjective Patient Outcome for Return to Sports score, and RTS time. Clinical results were evaluated by Constant-Murley score, Walch-Duplay score, and range of external and internal rotation. Complication rates, recurrence of shoulder instability, and number of revision procedures were recorded. Correlation tests were used to assess the relationship between measured parameters.

Results

The mean ± SD patient age was 27.1 ± 7.3 years, and the mean follow-up was 50.7 ± 18 months. Overall, 44 patients (95.7%) returned to their previously practiced sports, and 40 (87%) returned to their preinjury levels. The RTS time was 5 ± 1.4 months, with no significant difference among sport types. KJOC and Subjective Patient Outcome for Return to Sports scores were 95.2 ± 5.6 and 9.5 ± 1, respectively. Significant pre- to postoperative improvement was seen on the Constant-Murley score (from 54.3 ± 9.4 to 87.9 ± 8.2; P = .001) and Walch-Duplay score (from 53.7 ± 7.3 to 88.1 ± 10.7; P = .001). Mean postoperative external and internal rotation was 72.8° ± 18.6° and 81.3° ± 11.3°. Procedure-related complications occurred in 10 patients (21.7%); recurrence of shoulder instability was observed in 4 (8.7%); and 4 (8.7%) underwent revision surgery. A worse Walch-Duplay score was significantly associated with longer RTS time (r = -0.39; P = .019) and lower KJOC score (r = 0.29; P = .03).

Conclusion

There was a 95.7% RTS rate after the arthroscopic Latarjet procedure, although the procedure was not free from complications.

Increased Failure Rates After Arthroscopic Bankart Repair After Second Dislocation Compared to Primary Dislocation With Comparable Clinical Outcomes

PURPOSE

The purpose of this study was to compare rates of recurrent dislocation and postsurgical outcomes in patients undergoing arthroscopic Bankart repair for anterior shoulder instability immediately after a first-time traumatic anterior dislocation versus patients who sustained a second dislocation event after initial nonoperative management.

METHODS

A retrospective chart review was performed of patients undergoing primary arthroscopic stabilization for anterior shoulder instability without concomitant procedures and minimum 2-year clinical follow-up. Primary outcome was documentation of a recurrent shoulder dislocation. Secondary clinical outcomes included range of motion, Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons Shoulder Score (ASES), and Shoulder Activity Scale (SAS).

RESULTS

Seventy-seven patients (mean age 21.3 years ± 7.3 years) met inclusion criteria. Sixty-three shoulders underwent surgical stabilization after a single shoulder dislocation, and 14 underwent surgery after 2 dislocations. Average follow-up was 35.9 months. The rate of recurrent dislocation was significantly higher in the 2-dislocation group compared to single dislocations (42.8% vs 14.2%, P = .03). No significant difference was present in range of motion, VAS, ASES, and SAS scores. The minimal clinically important difference (MCID) was 1.4 for VAS and 1.8 for SAS scores. The MCID was met or exceeded in the primary dislocation group in 31/38 (81.6%) patients for VAS, 23/31 (74.1%) for ASES, and 24/31 for SES (77.4%) scores. For the second dislocation cohort, MCID was met or exceeded in 7/9 (77.8%) for VAS, 4/7 (57.1%) for ASES, and 5/7 for SES (71.4%) scores.

CONCLUSION

Immediate arthroscopic surgical stabilization after a first-time anterior shoulder dislocation significantly decreases the risk of recurrent dislocation in comparison to those who undergo surgery after 2 dislocation events, with comparable clinical outcome scores. These findings suggest that patients who return to activities after a primary anterior shoulder dislocation and sustain just 1 additional dislocation event are at increased risk of a failing arthroscopic repair.

STUDY DESIGN

Retrospective comparative study; Level of evidence, 3.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Chronic posttraumatic shoulder instability]

Chronic posttraumatic shoulder instability is characterized by trauma-associated, recurrent dislocations. Surgical treatment is indicated in most cases but it remains controversial how risk factors should be weighted to decide between arthroscopic Bankart repair (ABR), Latarjet or alternative procedures. Known risk factors for recurrence are patient age, hyperlaxity, sports profile and bone loss. Surgical techniques are discussed in detail. The ABR leads to high patient satisfaction and return to sports; however, in association with risk factors, recurrent dislocations are seen even several years later. Latarjet or bone block procedures lead to high patient satisfaction, sustainable stability as a revision procedure, but can also be primarily indicated for chronic instability depending on risk factors. Early complications are more frequent but of a minor nature in most cases. All techniques are known for a serious learning curve. If performed well, they do not seem to increase the risk of arthritis, which is most affected by the number of lifetime dislocations and higher energy trauma.

Cross cultural adaptation and psychometric properties of the Finnish version of Western Ontario shoulder instability index (WOSI)

BACKGROUND

Western Ontario shoulder instability index (WOSI) is a widely used disease-specific self-assessment measurement tool for patients with shoulder instability. The main aim of this study was to translate and cross culturally adapt the WOSI into Finnish language and to test its measurement properties.

METHODS

WOSI was translated in Finnish and adapted into an electronic user interface. 62 male patients with traumatic anteroinferior shoulder instability, programmed for stabilizing shoulder surgery, answered the questionnaire twice preoperatively (2 and 0 weeks), and twice postoperatively (3 and 12 months). Additional scoring tools, such as satisfaction to treatment outcome, subjective shoulder value (SSV), Oxford shoulder instability index (OSIS) and Constant score (CS), were used as comparators. The reliability, validity and responsiveness of WOSI were investigated through statistical analysis.

RESULTS

Preoperative test-retest results were available for 49 patients, and 54 patients were available at final follow up. The mean WOSI was 57.8 (SD 20.3), 70.4 (SD 18.9), and 85.9 (SD 15.5), at baseline, 3, and 12 months, respectively. There was a statistically significant mean improvement of 28.8 (SD 24.5) in WOSI between baseline and 12 months (p < 0.0001). The intraclass correlation coefficient for the preoperative WOSI was excellent 0.91. At 12 months WOSI had an excellent Pearson's correlation coefficient both with SSV (0.69), OSIS (-0.81), and poor with CS (0.25) scores, confirming our a priori hypothesis. There were no detected floor nor ceiling effects for WOSI pre- or postoperatively. The calculated minimal detectable change was 9.2 and the estimated minimal clinically important difference 13.4 to 18.1.

CONCLUSION

Finnish version of WOSI is a reliable and valid tool for assessing health state and improvement after operative treatment of shoulder instability in young male patients.

A Case Series of Whether Arthroscopic Bankart Repair Following Primary Traumatic Anterior Shoulder Dislocation Versus Recurrent Dislocation in Soldiers Has Any Effect on the Postoperative Recurrence Rate

Background

Anterior traumatic shoulder dislocation is very common among soldiers or any young population following injury, which is invariably treated by closed reduction. The dislocation when treated nonsurgically has a 71% high rate of recurrence. There is not much data available on the rate of recurrence when primary dislocation (first time) was treated by arthroscopic Bankart repair and in those who have recurrent (multiple) dislocations before surgery.

Aim

This study aims to report the postoperative recurrence rate in soldiers with first-time dislocation versus those with recurrent dislocations before surgery.

Study design

The present study is a level IV case series treatment study.

Methods

In this prospective study, 143 soldiers were included, of which 82 patients had first-time dislocation (F group) and 61 patients had recurrent dislocation before surgery (R group). The patients were evaluated and followed up for over three years. Nonabsorbable PEEK suture anchors (Chetan Meditech, India) were used for arthroscopic Bankart repair. The recurrence rates, Rowe scores, visual analog scale (VAS) scores, subjective shoulder values (SSVs), and satisfaction were compared. We also used the Simple Shoulder Test (SST) score for evaluation. The scores were recorded preoperatively and at three-year follow-up. The range of motion, postoperative function, recurrence rates, and return to pre-injury state was evaluated.

Results

A total of 143 patients were included, providing 97.3% follow-up at an average of 36 months. The postoperative recurrence rate was 19.7% in the F group and 58.3% in the R group (P < 0.001). The odds of postoperative recurrence were five times higher in the recurrent dislocation group (odds ratio (OR): 5.23).

Conclusion

Patients who underwent repair after first-time dislocation show a lower postoperative recurrence rate as compared with those who had multiple dislocations before surgery. It is prudent to advise early repair even after the first dislocation especially in young active soldiers to reduce the risk of postoperative recurrence.

Long-Term Results of Arthroscopic Bankart Repair for Anterior Glenohumeral Instability: Does Associated Postero-inferior Capsulolabral Repair Still Have a Role?

PURPOSE

To compare the outcomes of arthroscopic anterior Bankart repair with and without associated postero-inferior capsulolabral repair as treatment of anterior glenohumeral instabiliy at minimun 10 year follow-up.

METHODS

A retrospective comparative study including patients who underwent arthroscopic anterior Bankart repair to treat anterior glenohumeral instability with glenoid bone-loss < 15% between January 2000 and February 2010 was performed. Outcomes were reported as recurrence rate, type of recurrence (dislocation or subluxation), need for revision surgery, range of motion, complications, and functional status. Outcomes were compared depending on whether a postero-inferior capsulolabral repair was added to the anterior Bankart repair.

RESULTS

70 shoulders [59 males, mean age 28.2 (range 14-56), mean follow-up 146.1 (range 120-208) months] were included. Recurrence occurred in 9 cases (12.8%), including 3 dislocations and 6 subluxations. Revision surgery was needed in 8 (11.4%). Mean Rowe score improved from 29.7 (11.6) preoperatively to 87.1 (12.3) postoperatively. 83.3% returned to previous sports activities. Mean forward flexion changed from 173.5° (19.2) to 168.4º(10.4) (P < 0.01), external rotation from 81.4° (18) to 75.7° (10.5) (P < 0.01), and internal rotation decreased from 66.2% reaching T12 to 14.1% (P < 0.01). Addition of postero-inferior capsulolabral repair did not influence any of the outcomes significantly.

CONCLUSION

Postero-inferior capsulolabral repair added to anterior Bankart repair as treatment of anterior glenohumeral instability in abscence of significant glenoid bone-loss did not influence the outcomes in terms of recurrence, range of motion, return to sports, or functional status, compared to isolated anterior Bankart repair at 12.2 year follow-up.

LEVEL OF EVIDENCE

Level III.

Cirurgia de Bankart artroscópica: Resultados clínicos com seguimento mínimo de 10 anos

Objective  To evaluate the functional outcome of patients submitted to arthroscopic Bankart repair in the long-term.

Methods  Retrospective evaluation of 41 patients (45 shoulders) operated between 1996 and 2009 followed-up for a mean period of 14.89 years. Functional scores were analyzed by the University of California, Los Angeles (UCLA) and Carter-Rowe scores, physical examination, and analysis of medical records.

Results  The Carter-Rowe score showed an average improvement of 46.11 points, with a final average of 85.89 points, and the UCLA score showed an average improvement of 31.33 points. Ten patients (22.22%) relapsed, with the number of preoperative dislocations being the most correlated factor.

Conclusion  It was demonstrated that the number of preoperative dislocations negatively influenced the failure rate.

Patients without re-dislocation in the short term after arthroscopic knotless Bankart repair for anterior shoulder instability may show residual apprehension and recurrence in the long term after 5 years

HYPOTHESIS

The aim of this study was to report the long-term results, residual instability, and recurrence rate of arthroscopic Bankart repair surgery without a re-dislocation event in the first 5 years.

METHODS

We performed a retrospective analysis of Bankart repairs performed in a single center, by a single surgeon, with a minimum of 5 years' follow-up. Patients without a re-dislocation in the first 5 years of surgery were included. Patients who underwent open repair, those who underwent revision surgery, and those with critical glenoid bone loss were excluded. A total of 68 shoulders in 66 patients (51 male and 15 female patients) were included. Patients were analyzed in 2 domains: (1) failures defined as re-dislocation and (2) failures defined as apprehension and re-dislocation combined (residual instability). Clinical outcomes were assessed using shoulder range of motion, the American Shoulder and Elbow Surgeons score, and the Western Ontario Shoulder Instability Index (WOSI) score. Pain, residual apprehension, re-dislocations, and additional surgical procedures were recorded.

RESULTS

The mean age of patients was 31.16 (range, 16-60 years), and the mean follow-up duration was 8.42 ± 2.1 years. The median number of dislocations was 3 (range, 1-20), and the median time from first dislocation to surgery was 16 months (interquartile range, 3-100.5 months). Five patients reported re-dislocations (7.4%) with a mean period of 6.54 ± 2.5 years (range, 5-10.8 years). Seven patients without re-dislocations and 2 patients with re-dislocations reported residual apprehension. Mean shoulder elevation and mean external rotation were 161.3° ± 12.4° and 39.2° ± 11°, respectively. The mean visual analog scale, American Shoulder and Elbow Surgeons, and WOSI scores were 0.5 ± 1.4, 91 ± 11.9, and 88 ± 12.1, respectively. Age was similar in patients with stable shoulders and those with shoulders with re-dislocation or residual instability. The WOSI score was lower in patients with re-dislocation and residual instability (P = .030 and P = .049, respectively).

CONCLUSIONS

Arthroscopic Bankart repair is a successful surgical option for anterior shoulder instability. The 7.4% re-dislocation rate after 5 years indicates there may be a deterioration of capsulolabral repair in certain patients. The long-term failure pattern may be underestimated in short- to mid-term projections.

Surgical delay for traumatic recurrent shoulder dislocations leads to inferior functional outcomes

BACKGROUND

The effect of time interval between injury and surgery on outcomes of Bankart repair surgery has not been published previously. The purpose of this study was to assess the effect of surgical delay on functional outcomes after arthroscopic Bankart repair.

METHOD

One hundred and five athletes who underwent arthroscopic Bankart repair ± remplissage were enrolled in the study. Patients were divided into 2 groups depending upon the injury to surgery time- < 12 months (n = 19), and ≥12 months (n = 86). Depending upon the number of episodes of dislocation, patients were further categorized into 2 groups- <10 episodes (n = 66) and ≥10 episodes (n = 39). All patients were assessed post-operatively for functional outcomes (Modified Rowe's score, Constant Murley score) and return to sports at a minimum of 2 years of follow-up.

RESULTS

The mean injury to surgery time was 31.7 ± 23.1 months. The average number of episodes of dislocation before surgery were 10 (range 3-50). 49/105 (46.7%) patients returned to sports after a mean post-operative duration of 10.9 months. Athletes operated after a surgical delay of ≥12 months had inferior functional outcomes (Modified Rowe's score-89.5 ± 8.9 vs.77.4 ± 21.4; p = 0.02), lower rate of return to sports (14/19 vs. 35/86; p = 0.02) and higher mean time to return to sports (8.7 ± 1.9 vs. 11.5 ± 2.6; p < 0.05). Similarly, athletes who had ≥10 dislocations before surgery had inferior functional outcomes (Modified Rowe's score-84.5 ± 15.2 vs.72.9 ± 25.6; p = 0.004), lower rate of return to sports (37/66 vs. 12/39; p = 0.02) and higher mean time to return to sports (10.3 ± 2.4 vs. 12.6 ± 2.5; p < 0.05).

CONCLUSION

A delay in surgery (≥12 months) or dislocation episodes of ≥10 are associated with inferior functional outcomes, lower rate of return to sports and higher surgical failure rate.

LEVEL OF EVIDENCE

Level III; Prospective cohort study.

A pilot multicenter randomized controlled trial comparing Bankart repair and remplissage with the Latarjet procedure in patients with subcritical bone loss (STABLE): study protocol

Introduction

Anterior dislocations, the most common type of shoulder dislocation, are often complicated by subsequent instability. With recurrent dislocations there often is attrition of the labrum and progressive loss of the anterior bony contour of the glenoid. Treatment options for this pathology involve either soft tissue repair or bony augmentation procedure. The optimal management remains unknown and current clinical practice is highly varied.

Methods and analysis

The Shoulder instability Trial comparing Arthroscopic stabilization Benefits compared with Latarjet procedure Evaluation (STABLE) is an ongoing multi-centre, pilot randomized controlled trial of 82 patients who have been diagnosed with recurrent anterior shoulder instability and subcritical glenoid bone loss. Patients are randomized to either soft tissue repair (Bankart + Remplissage) or bony augmentation (Latarjet procedure). The primary outcome for this pilot is to assess trial feasibility and secondary outcomes include recurrent instability as well as functional outcomes up to two years post-operatively.

Conclusions

This trial will help to identify the optimal treatment for patients with recurrent shoulder instability with a focus on determining which treatment option results in reduced risk of recurrent dislocation and improved patient outcomes. Findings from this trial will guide clinical practice and improve care for patients with shoulder instability.

Trial registration

This study has been registered on http://www.ClinicalTrials.gov with the following identifier: ClinicalTrials.gov Identifier: NCT03585491, registered 13 July 2018, https://www.clinicaltrials.gov/ct2/show/NCT03585491?term=NCT03585491&draw=2&rank=1.

Ethics and dissemination

This study has ethics approval from the McMaster University/Hamilton Health Sciences Research Ethics Board (REB) (approval #4942). Successful completion will significantly impact the global management of patients with recurrent instability. This trial will develop a network of collaboration for future high-quality trials in shoulder instability.

Arthroscopic Bankart versus open Latarjet as a primary operative treatment for traumatic anteroinferior instability in young males: a randomised controlled trial with 2-year follow-up

Objectives

To compare the success rates of arthroscopic Bankart and open Latarjet procedure in the treatment of traumatic shoulder instability in young males.

Design

Multicentre randomised controlled trial.

Setting

Orthopaedic departments in eight public hospitals in Finland.

Participants

122 young males, mean age 21 years (range 16–25 years) with traumatic shoulder anteroinferior instability were randomised.

Interventions

Arthroscopic Bankart (group B) or open Latarjet (group L) procedure.

Main outcome measures

The primary outcome measure was the reported recurrence of instability, that is, dislocation at 2-year follow-up. The secondary outcome measures included clinical apprehension, sports activity level, the Western Ontario Shoulder Instability Index, the pain Visual Analogue Scale, the Oxford Shoulder Instability Score, the Constant Score and the Subjective Shoulder Value scores and the progression of osteoarthritic changes in plain films and MRI.

Results

91 patients were available for analyses at 2-year follow-up (drop-out rate 25%). There were 10 (21%) patients with redislocations in group B and 1 (2%) in group L, p=0.006. One (9%) patient in group B and five (56%) patients in group L returned to their previous top level of competitive sports (p=0.004) at follow-up. There was no statistically significant between group differences in any of the other secondary outcome measures.

Conclusions

Arthroscopic Bankart operation carries a significant risk for short-term postoperative redislocations compared with open Latarjet operation, in the treatment of traumatic anteroinferior instability in young males. Patients should be counselled accordingly before deciding the surgical treatment.

Trial registration number

NCT01998048.

Glenoid track measurement using magnetic resonance imaging arthrography is predictive of recurrent instability following arthroscopic shoulder stabilisation

PURPOSE

The primary aim of this study was to investigate medium-term survivorship following arthroscopic Bankart repair (ABR) for anterior glenohumeral instability. The secondary aim was to determine whether the pre-operative magnetic resonance (MR) arthrography glenoid track measurement predicted recurrent instability following ABR.

METHODS

Over a 9-year period (2008-2017), 215 patients underwent ABR. Median age was 26 years (IQR 22-32.5; range 14-77). There were 173 males (81%). 175 patients (81%) had available pre-operative MR arthrography, which was used to determine the presence of "off-track" bone loss. Retrospective analysis was undertaken to determine recurrence of instability at a median follow-up of 76 months (range 21-125 months). Survivorship analysis was undertaken using Kaplan-Meier methodology: the endpoints examined were repeat dislocation, revision stabilisation, and symptomatic instability.

RESULTS

56 patients (26%) presented with further instability, including 29 patients with recurrent dislocation and 15 patients required revision stabilisation. Cumulative incidence of instability was 10% at 1 year, 27% at 5 years and 28% at 7 years. No significant difference in instability was seen between men and women 7 years after stabilisation (19% vs 17%; p = 0.87). Age at time of surgery did not predict recurrence. "Off-track" lesions were identified in 29 patients (16.1%). The incidence of redislocation was significantly higher in these patients (24% vs 3%; p = 0.01; relative risk 7.2; 95% CI 2.45-20.5; p = 0.001). Recurrent instability without frank redislocation was also significantly higher in this group (60% vs 18%; RR 3.33, 95% CI 2.02-5.20; p < 0.0001).

CONCLUSIONS

This study has reported a significant rate of recurrent instability in longer-term follow-up after ABR. It has also identified pre-operative MR arthrography as an important predictor of recurrent instability, which may be used to risk stratify patients with anterior instability in a typical UK population.

LEVEL OF EVIDENCE

III (cohort study).

Operative Versus Nonoperative Treatment Following First-Time Anterior Shoulder Dislocation

BACKGROUND

There is an ongoing debate about whether to perform operative or nonoperative treatment following a first-time anterior dislocation or wait for recurrence before operating. The aim of this systematic review is to compare recurrence rates following operative treatment following first-time anterior dislocation (OTFD) with recurrence rates following (1) nonoperative treatment (NTFD) or (2) operative treatment after recurrent anterior dislocation (OTRD).

METHODS

A literature search was conducted by searching PubMed (Legacy), Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, and Web of Science/Clarivate Analytics from 1990 to April 15, 2020, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The revised tool to assess risk of bias in randomized trials (RoB 2) developed by Cochrane was used to determine bias in randomized controlled trials, and the methodological index for non-randomized studies (MINORS) was used to determine the methodological quality of non-randomized studies. The certainty of evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach using GRADEpro software.

RESULTS

Of the 4,096 studies for which the titles were screened, 9 comparing OTFD and NTFD in a total of 533 patients and 6 comparing OTFD and OTRD in a total of 961 patients were included. There is high-quality evidence that OTFD is associated with a lower rate of recurrence (10%) at >10 years of follow-up compared with NTFD (55%) (p < 0.0001). There is very low-quality evidence that patients receiving OTFD had a lower recurrence rate (11%) compared with those receiving OTRD (17%) (p < 0.0001).

CONCLUSIONS

There is high-quality evidence showing a lower recurrence rate at >10 years following OTFD compared with NTFD (or sham surgery) in young patients. There is evidence that OTFD is more effective than OTRD, but that evidence is of very low quality.

LEVEL OF EVIDENCE

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

Anterior glenohumeral instability treated with arthroscopic Bankart operation - a retrospective 5-year follow-up study

BACKGROUND

This retrospective study investigated 5-year results of primary arthroscopic operation for anterior glenohumeral instability (AI) with special interest in patients aged<25 years and gender.

HYPOTHESIS

Recurrence of AI is higher in male patients aged<25 years than older patients or females.

PATIENTS AND METHODS

Primary arthroscopic Bankart repair was performed between January 2009 and December 2015 on 156 shoulders [154 patients, 104/156 (67%) males]. The mean follow-up was 5.6 (SD 2.1, range 0.4-8.9) years. Outcome measures, including re-dislocation, fear of dislocation, Western Ontario instability index, Subjective shoulder value and pain Numerical rating scale scores, the number of revision surgeries and satisfaction with the result of surgical treatment, were assessed for 130 shoulders [82/130 (63%) males]. AI recurrence was defined as a dislocation or a fear of such.

RESULTS

The Kaplan-Meier analysis estimates for the cumulative survival of stable shoulders were 28% at 8.8 years for patients aged<25 years (SE 0.4, CI 95% 5.5-7.2) and 53% at 8.9 years for patients aged ≥25 years (SE 0.2, CI 95% 7.2-8.0; p=0.005). The Kaplan-Meier estimates for the cumulative survival of stable shoulders were 50% at 8.9 years for males (SE 0.3, CI 95% 6.8-7.8) and 37% at 8.6 years for females (SE 0.3, CI 95% 6.5-7.7; p=0.8). Mean time to revision was 2.4 (SD 1.7, range 0.4-5.3) years.

DISCUSSION

Recurrence of AI was higher in the patients aged<25 years (p=0.005), but gender was not a risk factor. Re-operation rate due to recurrent AI was 10% in this 5-year follow-up.

LEVEL OF EVIDENCE

III; case-control study.

Editorial Commentary: Lower Return to Play After Failed Prior Instability Surgery: Should the Open Latarjet Be the Gold Standard for Anterior Shoulder Instability?

Anterior shoulder instability is common in contact athletes. Arthroscopic Bankart repair can result in good clinical outcomes, but high recurrence rates have been reported. The open Latarjet procedure can result in excellent functional outcomes with low rates of recurrent instability. Despite these encouraging results, there may be a lower return to play rate in athletes undergoing this procedure for a prior failed instability surgery. Due to the complexity of the procedure and high complication rate, the open Latarjet should continue to be reserved for cases of significant glenoid bone loss or revision settings.

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.

Optimization of the Algorithm for Choosing the Surgical Treatment of Anterior Recurrent Instability of the Shoulder Joint

Introduction. Chronic recurrent instability of the shoulder joint is a frequent outcome of conservative treatment oftraumatic dislocation of the shoulder (2.8–30 % of cases). Preoperative examination largely determines the outcome of surgical treatment of this pathology.

The aim of the study was to provide a clinical assessment of the developed algorithm for the surgical treatment of patients with recurrent anterior shoulder joint instability. Materials and methods. The results of treatment of 98 patients with recurrent anterior shoulder joint instability were studied. Preoperative examination included clinical tests, MRI or CT with calculation of bone loss. Fifty-six patients (57.1 %) underwent Bankart operation, 14 patients (14.3 %) – Latarjet operation. Twenty-three patients (23.5 %) underwent Bankart + Remplissage surgery, and 5 (5.1 %) – Latarjet + remplissage. The result was assessed on the ROWE scale.

Results. Bone defects significant in the formation of instability (“glenoid off track”) were found in 19.4 % of patients, and “glenoid on track” – in 80.6 %. According to the proposed algorithm for treating patients with anterior recurrent instability of the shoulder joint, the “glenoid off track” state was an indication for Latarjet surgery. When “glenoid on track” was used, indications for Bankart operation were displayed. The remplissage procedure was indicated in case of the presence of a Hill-Sachs grade 3 defect or the presence of hyperelasticity of the tissues of the shoulder joint. The mean ROWE score for the entire group of patients before surgery was 41.5 ± 12.8 points, and 15 months after sur gery – 94.9 ± 3.4 points. Two recurrent dislocations were revealed, one of which was associated with repeated trauma, and the other – with an incorrect choice of stabilization technique. One complication (axillary nerve neuropathy) was observed, which was arrested conservatively.

Conclusions. The proposed algorithm allowed us to obtain positive results in 97.9 % of cases. 

Optimization of the Algorithm for Choosing the Surgical Treatment of Anterior Recurrent Instability of the Shoulder Joint

Introduction. Chronic recurrent instability of the shoulder joint is a frequent outcome of conservative treatment oftraumatic dislocation of the shoulder (2.8–30 % of cases). Preoperative examination largely determines the outcome of surgical treatment of this pathology.

The aim of the study was to provide a clinical assessment of the developed algorithm for the surgical treatment of patients with recurrent anterior shoulder joint instability. Materials and methods. The results of treatment of 98 patients with recurrent anterior shoulder joint instability were studied. Preoperative examination included clinical tests, MRI or CT with calculation of bone loss. Fifty-six patients (57.1 %) underwent Bankart operation, 14 patients (14.3 %) – Latarjet operation. Twenty-three patients (23.5 %) underwent Bankart + Remplissage surgery, and 5 (5.1 %) – Latarjet + remplissage. The result was assessed on the ROWE scale.

Results. Bone defects significant in the formation of instability (“glenoid off track”) were found in 19.4 % of patients, and “glenoid on track” – in 80.6 %. According to the proposed algorithm for treating patients with anterior recurrent instability of the shoulder joint, the “glenoid off track” state was an indication for Latarjet surgery. When “glenoid on track” was used, indications for Bankart operation were displayed. The remplissage procedure was indicated in case of the presence of a Hill-Sachs grade 3 defect or the presence of hyperelasticity of the tissues of the shoulder joint. The mean ROWE score for the entire group of patients before surgery was 41.5 ± 12.8 points, and 15 months after sur gery – 94.9 ± 3.4 points. Two recurrent dislocations were revealed, one of which was associated with repeated trauma, and the other – with an incorrect choice of stabilization technique. One complication (axillary nerve neuropathy) was observed, which was arrested conservatively.

Conclusions. The proposed algorithm allowed us to obtain positive results in 97.9 % of cases. 

Comparison of anterior single- and standard two-portal techniques in arthroscopic Bankart repair

Objectives

This study aims to compare the outcomes of patients undergoing a single anterior portal or a standard two-portal arthroscopic procedure for Bankart repair.

Patients and methods

Between January 2015 and March 2018, a total of 71 consecutive patients (53 males and 18 females; mean age: 33.3±10.3 years; range, 17 to 56 years) who underwent arthroscopic Bankart repair with a minimum two-year follow-up period were included. The patients were divided into two groups according to the arthroscopic technique used: single anterior portal group (Group 1, n=32) and standard two-portal group (Group 2, n=39). Demographic and surgical characteristics of the patients were recorded. Pre- and postoperative clinical and functional outcomes were evaluated using the external rotation degree, as well as Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons (ASES), University of California at Los Angeles (UCLA) Shoulder Rating Scale, Constant-Murley Score (CMS), Oxford Shoulder Instability Score (OSIS), and Rowe scores. The clinical and functional outcomes and revision rates were compared between the groups.

Results

The mean follow-up was 32.0±7.4 months in Group 1 and 38.0±13.4 months in Group 2 (p=0.222). Good-to-excellent postoperative functional and clinical outcomes were achieved in both groups at the final follow-up, compared to baseline (p<0.001 for all). No significant difference was observed in the postoperative outcomes including daily sports activity, VAS, ASES, UCLA Shoulder Rating Scale, CMS, OSIS, and Rowe scores, and external rotation restriction degrees between the groups (p=0.270, p=0.190, p=0.313, p=0.248, p=0.125, p=0.203, p=0.318, p=0.083, respectively). The operative time in Group 1 was significantly lower than that in Group 2 (60.3±8.3 vs. 71.4±7.2, respectively; p=0.001). Four patients (5.6%) experienced recurrent dislocation with no significant difference between the groups (p=0.622). No significant complications occurred in the peri- or postoperative period. Fifty-eight (81.7%) patients returned to their preoperative sports activity level. The mean time to return to sports was 7.2±1.7 months.

Conclusion

Good-to-excellent clinical and functional outcomes can be obtained after arthroscopic Bankart repair, regardless of the use of a single or two anterior working portals. However, the single-portal technique is associated with reduced the operative time, compared to two-portal technique.

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.

Differences in Outcomes Between Anterior and Posterior Shoulder Instability After Arthroscopic Bankart Repair: A Systematic Review and Meta-analysis

Background:

The glenohumeral joint is one of the most frequently dislocated joints in the body, particularly in young, active adults.

Purpose:

To conduct a systematic review and meta-analysis to evaluate and compare outcomes between anterior versus posterior shoulder instability.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review was performed using the PubMed, Cochrane Library, and MEDLINE databases (from inception to September 2019) according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were included if they were published in the English language, contained outcomes after anterior or posterior shoulder instability, had at least 1 year of follow-up, and included arthroscopic soft tissue labral repair of either anterior or posterior instability. Outcomes including return-to-sport (RTS) rate, postoperative instability rate, and pre- and postoperative American Shoulder and Elbow Surgeons (ASES) scores were recorded and analyzed.

Results:

Overall, 39 studies were included (2077 patients; 1716 male patients and 361 female patients). Patients with anterior instability had a mean age of 23.45 ± 5.40 years (range, 11-72 years), while patients with posterior instability had a mean age of 23.08 ± 8.41 years (range, 13-61 years). The percentage of male patients with anterior instability was significantly higher than that of female patients (odds ratio [OR], 1.36; 95% CI, 1.04-1.77; P = .021). Compared with patients with posterior instability, those with anterior instability were significantly more likely to RTS (OR, 2.31; 95% CI, 1.76-3.04; P < .001), and they were significantly more likely to have postoperative instability (OR, 1.53; 95% CI, 1.07-2.23; P = .018). Patients with anterior instability also had significantly higher ASES scores than those with posterior instability (difference in means, 6.74; 95% CI, 4.71-8.77; P < .001). There were no significant differences found in postoperative complications between the anterior group (11 complications; 1.8%) and the posterior group (3 complications; 1.6%) (OR, 1.12; 95% CI, 0.29-6.30; P = .999).

Conclusion:

Patients with anterior shoulder instability had higher RTS rates but were more likely to have postoperative instability compared with posterior instability patients. Overall, male patients were significantly more likely to have anterior shoulder instability, while female patients were significantly more likely to have posterior shoulder instability.

Glenoid Pathology, Skeletal Immaturity, and Multiple Preoperative Instability Events Are Risk Factors for Recurrent Anterior Shoulder Instability After Arthroscopic Stabilization in Adolescent Athletes

PURPOSE

To identify risk factors for recurrent shoulder instability after arthroscopic stabilization in adolescent athletes.

METHODS

A retrospective case-control study was undertaken of all patients younger than 18 years undergoing arthroscopic shoulder stabilization for anterior instability between 2009 and 2016. Two patient cohorts were identified: (1) patients with recurrent instability (frank dislocations or subluxations) after arthroscopic stabilization and (2) an age- and sex-matched cohort of patients with no recurrent instability at a minimum of 2 years' follow-up from index surgery. Patient demographic, injury, radiographic, and surgical variables were recorded. Variables with P < .10 on univariate analysis were entered into a binary logistic multivariate regression analysis.

RESULTS

We identified 35 patients (20.5%) in whom arthroscopic stabilization failed at a mean of 1.2 ± 1.0 years after their index surgical procedure. A separate age- and sex-matched cohort of 35 patients with no evidence of recurrent instability was identified (mean follow-up, 5.4 ± 2.0 years; minimum follow-up, 2 years). Univariate analysis identified increased glenoid bone loss (P = .039), decreased glenoid retroversion (P = .024), and more than 1 instability event prior to surgery (P = .017) as significant risk factors for recurrent instability. Multivariate regression analysis revealed that glenoid retroversion less than 6°, skeletal immaturity, and more than 1 prior instability event significantly and independently predicted future recurrence. The risk of recurrence after arthroscopic stabilization was increased by 3 times in patients with 2 risk factors and by 4 times in patients with all 3 risk factors.

CONCLUSIONS

Anterior glenoid bone loss, glenoid version, skeletal immaturity, and multiple preoperative instability events are risk factors for failed arthroscopic stabilization in adolescent athletes with anterior instability.

LEVEL OF EVIDENCE

Level III, case-control study.

High Variability of the Definition of Recurrent Glenohumeral Instability: An Analysis of the Current Literature by a Systematic Review

Purpose

To determine the definitions for recurrence used in the literature, assess the consensus in using these definitions, and determine the impact of these definitions on recurrence rates.

Methods

A literature search was performed in PubMed and EMBASE including studies from 2000 to 2020 reporting on recurrence rates after anterior arthroscopic shoulder instability surgery. Dislocation, apprehension, subluxation and recurrence rates were compared.

Results

Ninety-one studies were included. In 68% of the eligible studies, recurrence rates are not well defined. Thirty (33%) studies did not report on dislocations, 45 (49%) did not report on subluxations, and 58 (64%) did not report on apprehension. Seventeen different definitions for recurrence of instability, 4 definitions of dislocations, and 8 definitions of subluxation were used.

Conclusion

Recurrence rates are poorly specified and likely underreported in the literature, hampering comparison with results of other studies. This highlights the need for a consensus on definition of recurrence across shoulder instability studies. We recommend not using the definition recurrence of instability anymore. We endorse defining dislocations as a radiographically confirmed dislocation or a dislocation that is manually reduced, subluxations as the feeling of a dislocation that can be (spontaneously) reduced without the need for a radiographically confirmed dislocation, and a positive apprehension sign as fear of imminent dislocation when placing the arm in abduction and external rotation during physical examination. Reporting on the events resulting in a dislocation or subluxation aids in making an estimation of the severity of instability.

Level of Evidence

Level IV, systematic review.

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.

Influential and Highest Cited Shoulder Instability Articles: A Bibliometric Analysis

Background

In orthopaedic surgery and other fields, the effect of influential journal articles has been evaluated by their citation counts and their correlation with methodological quality.

Purpose

To identify and characterize the 50 most cited articles on shoulder instability, examine trends in publication characteristics, and evaluate the correlation of citations with quality of evidence.

Study Design

Cross-sectional study.

Methods

The Web of Science and Scopus online databases were searched to identify the top 50 most cited articles on shoulder instability, based on the average number of citations from each database. Article characteristics were recorded, and level of evidence and methodological quality were assessed using the modified Coleman Methodology Score (mCMS), Jadad scale, and Methodological Index for Non-Randomized Studies (MINORS). Spearman correlation was used to evaluate relationships between citations or citation density (citations/y) and level of evidence or methodological scoring. Top cited articles from recent years were also aggregated.

Results

The top 50 most cited papers had a mean ± SD number of citations of 381.5 ± 166.7, with a mean of 15.0 ± 8.8 citations/y. Overall, 15 articles (30%) were biomechanical/cadaveric studies, and 15 (30%) were case series. Only 3 (6%) were considered to have level 1 evidence. The mean ± SD mCMS was 54.4 ± 12.7, mean ± SD Jadad score was 3.1 ± 1.4, and mean ± SD MINORS score was 10.5 ± 3.3. There were no significant correlations between citation rank or density and methodological assessments. There were weak correlations between citation rank and publication year (r _s = 0.32; P = .022) and between rank and level of evidence (r _s = -0.38; P = .047). The correlation between citation density and publication year was moderate (r _s = 0.70; P < .0001). There was no difference in citation density of the top 10 articles from 2010 to 2020 compared with the top 10 from the overall list (23.8 ± 5.3 vs 28.8 ± 9.5; P = .16).

Conclusion

Influential articles in shoulder instability included a high proportion of biomechanical/cadaveric studies. The majority of top cited articles had lower evidence levels and poorer methodological quality without strong correlation with citations or citation density. There was a moderate correlation between citation density and year of publication.

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

INTRODUCTION

Arthroscopic stabilization is a well-recognized 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 stabilization 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 recognized 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 favorable outcome, with a redislocation rate of 9% and low complication rate.

Glenoid Radius of Curvature and Humeral Head Volume Are Associated With Postoperative Dislocation After Arthroscopic Bankart Repair

Purpose

To measure bony morphologic parameters and identify their association with arthroscopic Bankart repair failure.

Methods

This was a retrospective comparative study. The inclusion criteria were primary arthroscopic Bankart repair, no prior shoulder surgery, traumatic cause, and had a Bankart (soft tissue and bony) lesion evident on magnetic resonance imaging (MRI). The exclusion criteria were posterior labral pathology, multidirectional instability, connective tissue disorder, rotator cuff pathology, and those who underwent concomitant shoulder procedures. Patients who had a postoperative redislocation (unstable group) were compared with matched patients who did not (stable group). Data were obtained by chart review and from preoperative MRI. Comparisons were made using the Student t test, Fisher exact test, or χ² test. Statistical significance was defined as P < .05. Inter-rater reliability was measured between reviewers.

Results

A total of 45 patients experienced a postoperative dislocation and were matched to 90 patients without a postoperative dislocation. There were no differences in demographic and radiographic variables. The radius of curvature (ROC) of the glenoid was larger (shallower) in the unstable group (23.6 mm vs 22.6 mm, P = .05). The humeral head volume (HHV) trended higher in the unstable group (68.9 mL vs 62.9 mL, P = .06). The glenoid volume was not significantly different. A greater percentage of patients with a glenoid ROC of 24.5 mm or greater (62.1% vs 26.4%, P = .0003) and an HHV of 80 mm³ or greater (60.8% vs 28.9%, P = .003) experienced a redislocation compared with patients without these factors. Patients with a glenoid ROC of 24.5 mm or more and an HHV of 80 mm³ or more had greater than 4 times the odds of redislocation (odds ratio, 4.56; 95% confidence interval, 1.44-14.43; P = .0098). Strong inter-rater reliability was found for the HHV, glenoid volume, glenoid ROC, and humeral head ROC measurements (r = 0.94, r = 0.88, r = 0.89, and r = 0.95, respectively).

Conclusions

This study shows that large ROC (shallow) glenoids in conjunction with large humeral heads may predispose patients to failure after arthroscopic Bankart repair.

Level of Evidence

Level III, retrospective comparative trial.

The Bankart repair: past, present, and future

Arthur Sidney Blundell Bankart was a London-based orthopedic surgeon who discovered the essential lesion in recurrent anterior shoulder instability in 1923. He pioneered a technique, the Bankart repair, to re-establish stability to the glenohumeral joint, without sacrificing native joint motion. In this article, the original Bankart repair is compared to the modern arthroscopic Bankart repair, accompanied by a surgical video of Blundell Bankart performing the Bankart repair in 1951, shortly before his death. Bankart's original description included an open repair with a coracoid osteotomy and subscapularis tenotomy and repair. The history of the technique, its utility in present day, and the future of the Bankart repair are discussed.

Functional outcome and tendon integrity of rotator cuff reconstruction after primary traumatic glenohumeral dislocation

INTRODUCTION

Rotator cuff tears (rct) subsequent to glenohumeral dislocation are relevant concomitant injuries, can lead to impaired shoulder function and increase risk of recurrent dislocation.

AIM

The aim of this study was to determine the functional outcome, recurrent dislocation rate and tendon integrity after rotator cuff repair after primary traumatic shoulder dislocation.

MATERIALS AND METHODS

In this retrospective case series, 23 patients (age 56.4 years ± 6.3) who underwent a rotator cuff reconstruction after primary traumatic shoulder dislocation with confirmed combination of full-thickness RCT and Bankart lesion were enrolled after a minimum follow-up of 2 years. Clinical outcome (age and gender adjusted Constant Murley Score (CMS), DASH, Rowe Score) (n = 23) and sonographic tendon integrity (n = 19) were studied.

RESULTS

After a mean follow-up of 58 ± 32 months, a CMS of 85.1% ± 14.7, DASH of 14.2 ± 20.5, and Rowe Score of 82.4 ± 15.2 indicated good functional outcome. In 4 of 19 patients (21.1%) a re-tear was found during sonographic evaluation. In 3 cases (13%), a revision was performed (2 × stiff shoulder, 1 × postoperative infection). One patient had a single traumatic re-dislocation (4.3%).

CONCLUSIONS

Patients undergone reconstruction of the rotator cuff following a primary traumatic shoulder dislocation can achieve good functional results and a low rate of recurrent dislocation. Postoperative tendon integrity is comparable with known data about non traumatic tears.

Influence of Glenoid Labral Bumper Height and Capsular Volume on Clinical Outcomes After Arthroscopic Bankart Repair as Assessed With Serial CT Arthrogram: Can Anterior-Inferior Volume Fraction Be a Prognostic Factor?

BACKGROUND

Arthroscopic labral repair combined with capsular plication decreases joint volume and restores glenoid labral bumper height; thus, the procedure helps decrease capsular redundancy. However, the decreased volume and restored glenoid labral bumper height could change over time, which could influence the outcome of the operation.

PURPOSE

To (1) measure glenoid labral bumper height and capsular volume quantitatively in serial computed tomography arthrography (CTA) and evaluate the relationship between bumper height and joint volume and (2) compare the difference in bumper height and joint volume between groups with and without apprehension after arthroscopic Bankart repair.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Patients who had undergone arthroscopic Bankart repair between January 2012 and June 2016, and were assessed by CTA 3 to 6 months and 12 to 18 months after the operation were included. An image reconstruction program (3-dimensional slicer) was used to calculate inferior, anterior-inferior, and posterior-inferior joint volumes; the ratio of the anterior-inferior volume to the inferior volume was defined as the anterior-inferior volume fraction (VF_AI). We also measured glenoid labral bumper height at the 5-, 4-, and 3-o'clock positions.

RESULTS

A total of 50 patients were enrolled as study participants (mean age, 25.2 ± 9.29 years). Of these, 10 patients had either redislocation or apprehension, and 40 patients had neither. A significant correlation was observed between 5-o'clock glenoid labral bumper height and VF_AI on early CTA (3-6 months) and late CTA (12-18 months) (early CTA: Pearson coefficient, -0.335, P = .040; late CTA: Pearson coefficient, -0.468, P = .003). VF_AI at the early CTA was 42.20 ± 10.15 in the group with apprehension and 33.49 ± 9.66 in the group without apprehension; a significant difference was observed. VF_AI at the late CTA was 45.84 ± 11.97 in the group with apprehension and 37.65 ± 9.70 in the group without apprehension and thus showed a significant difference between the 2 groups. However, the 3-, 4-, and 5-o'clock glenoid labral bumper heights on early and late CTAs did not show a statistically significant difference between the 2 groups.

CONCLUSION

Early postoperative VF_AI is related to postoperative apprehension and redislocation and might be reduced by increasing the 5-o'clock glenoid labral bumper height.

Arthroscopic stabilisation for shoulder instability

Since its first description over 30 years ago arthroscopic stabilisation has evolved. With improvements in knowledge, surgical techniques and materials technology, arthroscopic bankart repair has become the most widely used method for treating patients with symptomatic anterior shoulder instability. These procedures are typically performed in a younger, high demand patient population after a primary dislocation or to treat recurrent instability. A thorough clinical evaluation is required in the clinic setting not only to fully understand the injury pattern but also consider patient expectations prior to embarking on surgery. Diagnostic imaging will aid the clinician in determining the soft tissue pathology as well as assessing bone loss, which facilitates surgical decision-making. Selected patients may benefit from adjunctive procedures such as a remplissage for an "engaging" Hill-sachs lesion. This review will focus on the indications, pre-operative considerations, surgical techniques and outcomes of arthroscopic stabilisation.

Labral Morphology and Number of Preoperative Dislocations Are Associated With Recurrent Instability After Arthroscopic Bankart Repair

PURPOSE

To develop a method to measure capsule and labral volume on preoperative magnetic resonance imaging to predict surgical failure after primary Bankart repair.

METHODS

A retrospective case-control study was conducted on patients undergoing primary anterior arthroscopic shoulder stabilization. Surgical failure was defined as a recurrent dislocation event. Cases were matched to controls based on age and sex in a 1:2 ratio. Preoperative magnetic resonance (MR) arthrograms were analyzed by 2 trained reviewers using Vitrea software to measure labral and capsular volume with a 3-dimensional model. Labral size was also qualitatively measured on axial images. A "diffusely small" labrum was defined as labral height less than the width of the glenoid tidemark cartilage.

RESULTS

Of the 289 patients who had an arthroscopic Bankart repair from 2006 to 2015, 33 who had a postoperative dislocation met the inclusion criteria and were matched to 62 control patients who did not. There was no difference between groups with regard to age (P = .88), sex (P = .82), contact sport participation (P = .79), proportion of overhead athletes (P = .33), proportion of throwers (P = 1), surgical positioning in lateral decubitus (P = .18), or number of repair anchors used (P = .91). The average number of preoperative dislocations was significantly higher in the failure group (3.2 vs. 2.0, P < .0001). In patients with normal labrum morphology, the odds of having surgical failure increased by 26% for a 1-unit increase in the number of prior dislocations (odds ratio [OR] 1.26, 95% confidence interval [CI] 1.02 to 1.55). The case and control groups had similar labral and capsular volume as measured in Vitrea. The failure group had a significantly higher proportion of patients with a diffusely small labral morphology (47% vs. 17%, P = .03). Controlling for number of preoperative dislocations, the odds of having a diffusely small labral morphology was 3.2 times more likely in the case group than the control group (95% CI 1.259 to 8.188). Interrater reliability between 2 independent reviewers was excellent for measurement of capsule volume (r = 0.91) and good for measurement of labral volume (r = 0.74).

CONCLUSIONS

This study presents a novel method of measuring labral and capsule volume with high interrater reliability. An increased number of recurrent dislocations prior to primary Bankart repair was associated with increased odds of recurrent instability after surgery. The OR for failure also increased with increasing number of preoperative dislocations. Diffusely small labral morphology was associated with having a postoperative redislocation.

LEVEL OF EVIDENCE

III (case-control study).