Structural and clinical integrity of the rotator cuff in athletes after arthroscopic Bankart repair using the three-portal technique

Effectiveness of combined surgical and exercise-based interventions following primary traumatic anterior shoulder dislocation: a systematic review and meta-analysis

OBJECTIVE

To investigate the effectiveness, risk of recurrence and return to activity (RTA) of surgery combined with exercise-based interventions (EBI) versus EBI alone after traumatic anterior shoulder dislocation (ASD).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Systematic literature search (MEDLINE, Web of Science, Scopus, Google Scholar).

ELIGIBILITY

Studies focused on EBI or EBI as a part of postoperative care for adults with an ASD, written in English, and published after 1990. We excluded diagnostic, assessment-based studies on individuals experiencing recurrent shoulder dislocations, concomitant shoulder injury, animal or cadaveric studies. Primary outcomes were dislocation RTA. Secondary outcomes were self-reported outcome measures, strength and range of motion. Random-effects meta-analysis was used to estimate the effect of EBI (SMD; Hedges' g, RR). The Grading of Recommendations Assessment, Development and Evaluation approach was used to assess the certainty of evidence.

RESULTS

Sixty studies were included (n=3598); seven were meta-analysed (n=345). The mean age of participants in the included studies was 26.71±9.19 and 56% of those included were male. Of the 60 studies included in the systematic review, 29 were fair quality (48.3%), 15 studies were good quality (25%) and 16 studies were poor quality (26.7%), (k=0.66). Individuals who underwent EBI alone were 2.03 times more likely to experience recurrent instability than individuals who underwent EBI in conjunction with surgery (RR 2.03, 95% CI 1.03 to 3.97). Individuals who underwent EBI with surgery appeared 1.81 times more likely to RTA than those who underwent EBI alone, although results were not statistically significant (RR 1.81, 95% CI 0.96 to 3.43).

CONCLUSIONS

Surgery combined with EBI is more effective in reducing the risk of recurrence and possibly increasing RTA than EBI alone after traumatic ASD.

Arthroscopic Bankart repair: how many knotless anchors do we need for anatomic reconstruction of the shoulder?-a prospective randomized controlled study

PURPOSE

The optimal strategy for surgical repair of traumatic anterior shoulder instability remains controversial. While several study groups have reported that the clinical and radiological outcomes of arthroscopic procedures performed with two anchors are not fully adequate, these conclusions are not supported by the findings published in other studies. A prospective randomized study was conducted to compare the structural and clinical outcomes of surgical procedures involving two vs. three anchors.

METHODS

Patients who underwent arthroscopic Bankart repair were randomly assigned to either Group I, which underwent procedures involving two double-loaded 3.5-mm knotless anchors, or Group II, which underwent procedures involving three single-loaded 2.9-mm knotless anchors. All patients underwent bilateral MRI assessments at a minimum of 12 months and clinical assessment at a minimum of 24 months postoperatively. To evaluate the reconstruction of the labral capsular ligamentous complex (LCLC), the labrum-glenoid height index (LGHI), restored labral height (LH), and labral slope (LS) were measured for both shoulders. For clinical assessment, the redislocation rate and functional outcome scores (Constant score (CS), American Shoulder and Elbow Surgeon score (ASES), Walch Duplay score (WDS), and Rowe score (RS)) were evaluated at follow-up visits.

RESULTS

Bankart repair with two knotless anchors showed lower values for anterior reconstruction of the LCLC compared to the uninjured contralateral shoulder. Likewise, significant differences were noted when comparing these measurements to those from patients who underwent reconstruction with three anchors. No differences were demonstrated with regard to the reconstruction of the inferior LCLC. Clinical assessment showed good to excellent results in both groups. In total, three patients experienced redislocation of the shoulder: two in group I and one in group II. No significant differences were found with respect to clinical outcomes and redislocation rates.

CONCLUSION

Bankart repair with both two and three knotless anchors results in effective anatomical reconstruction of the labral capsular ligamentous complex. Although the two-anchor technique yields significantly lower values for the anterior portion compared with the contralateral side, none of these differences reach clinical relevance as per our original definition.

Outcome Measures After Shoulder Stabilization in the Athletic Population: A Systematic Review of Clinical and Patient-Reported Metrics

Background:

Athletic endeavor can require the “athletic shoulder” to tolerate significant load through supraphysiological range and often under considerable repetition. Outcome measures are valuable when determining an athlete’s safe return to sport. Few data are available to guide a clinician’s choice from the variety of measures available.

Purpose:

To describe the use of quantifiable objective outcome measures and patient-reported outcome tools after glenohumeral joint stabilization, specifically in an athletic population. The secondary aim of our study was to assess whether the method of measurement used was clearly described and standardized to aid clinical interpretation.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic search of MEDLINE, Scopus, SPORTDiscus, and Web of Science databases was performed in December 2018 based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. After the application of selection criteria, a full review of identified papers, and screening of reference lists, a total of 62 studies were included in the review. All studies were independently appraised for quality, predefined data fields were populated and cross-checked for accuracy, and results were then summarized from these data fields.

Results:

Of the 62 included studies, 94% used a quantifiable objective clinical outcome. A majority (85%) of the studies measured range of motion, 21% recorded muscle strength, 5% measured electromyographic activity, 5% examined shoulder kinematics, and 3% assessed joint proprioception after surgery. However, only 18% of the studies clearly described a standardized method of measuring the outcome. Nearly all (95%) of the studies used at least 1 patient-reported outcome measure. The Rowe score was most commonly used (35%).

Conclusion:

We must standardize and clearly describe the use of quantifiable objective outcome measures to aid clinical interpretation. A concerted effort should also be made to standardize the use of patient-reported outcome tools after shoulder stabilization in the athletic population.

Assessments of activities of daily living after arthroscopic SLAP repair with knot-tying versus knotless suture anchors

PURPOSE

The clinical influence of knot-tying or knotless anchor systems for the arthroscopic repair of SLAP lesions (superior labrum lesion from anterior to posterior) remain unclear.

MATERIALS AND METHODS

In a retrospective cohort analysis, 61 of 78 (78.2%) patients with isolated symptomatic SLAP II lesions were examined with a minimum of 24 months after arthroscopic SLAP repair compared to a control group: 28 patients with knot-tying anchors (group I, G1; 28.95 ± 9.48 years, 23 male/5 female), 33 with knotless anchors (group II, G2; 31 ± 10.09 years, 26 male/7 female) and 140 healthy volunteers (group III, G3; 30.9 ± 8.9 years, 109 male/31 female). The clinical assessment included an examination and estimated parameters of ADL (activities of daily living), the CS (Constant score), ASES (American Shoulder and Elbow score), DASH (disability of arm-shoulder hand) and the RS (Rowe score).

RESULTS

The ROM analysis recorded no significant differences for the external rotation in 0° abduction (G1 63.75° ± 15.55° versus = vs G2 65.30° ± 18.15°; p_{ERG1 vs G2} = 0.72). The clinical outcomes revealed significantly decreased pain status in G1 for the O'brien test and in G2 for the Palm-up test, whereas Yergason test showed similar pain levels (p_O'brien = 0.03; p_{palm up} = 0.02; p_yergason > 0.5). The pulley associated rotator cuff tests revealed a significantly inferior force status in G2 compared to G1 (p_lift-off = 0.005, p_Jobe = 0.02) whereas the further rotator cuff assessments were equal. In general, the intervention group showed increased pain level and functional deficits compared to the G3. The score analysis detected no significant differences with P_{CSG1 vs G2}, P_{ASESG1 vs G2}, P_{DASHG1 vs G2} and P_{RSG1 vs G2} all > 0.05 and significant impairments compared to G3 in all scores p_{G1/G2 vs G3} < 0.05 (CS_G1 = 88.28 ± 14.42, CS_G2=92.73 ± 9.24, CS_G3 = 96.2 ± 4.96; ASES_G1 = 81.10 ± 21.69, ASES_G2 = 85.35 ± 17.12, ASES_G3 = 94.95 ± 10.39,; DASH_G1= 35.75 ± 13.44, DASH_G2 = 36.03 ± 17.55, DASH_G3 = 27.13 ± 6.52; RS_G1 = 90.71 ± 9.88, RS_G2 = 88.33 ± 11.22, RS_G3= 92.96 ± 11.27).

CONCLUSIONS

The clinical assessment revealed for both anchor systems similar outcomes but showed general underestimated impairments after the SLAP repair surgery compared to the healthy control. The clinical status only marginally differed between both techniques, wherefore the present assessment of ADL allowed no recommendation of one of these two specific surgery technique for SLAP repair.

Return to sport after acute acromioclavicular stabilization: a randomized control of double-suture-button system versus clavicular hook plate compared to uninjured shoulder sport athletes

PURPOSE

Traumatic high-grade acromioclavicular joint (ACJ) separations can be surgically stabilized by numerous anatomic and non-anatomic procedures. The return to sport (Maffe et al. in Am J Sports Med 23:93-98, 1995] and remaining sport-associated impairments after acute ACJ stabilization has not yet been investigated.

METHODS

73 consecutive athletes with acute high-grade ACJ separation were prospectively assigned into two groups (64.4% randomized, 35.6% intention-to-treat): open clavicular hook plate (cHP) implantation (GI) or arthroscopically assisted double double-suture-button (dDSB) implantation (GII). Patients were analyzed using shoulder sport-specific measurement tools for sport ability (ASOSS), sport activity (SSAS), and numerical analog scales: NAS_{pain during sport}, NAS_{shoulder function in sport}, and NAS_{re-achievement of sport level}. Four points of examination were established: preoperative evaluation (FU0) and first postoperative follow-up (FU1) at 6 months; FU2 at 12 months; and FU3 at 24 months after surgery. The control group (GIII) consisted of 140 healthy athletes without anamnesis of prior macro-injury or surgery.

RESULTS

After surgical stabilization, 29 of 35 athletes in GI (82.9%; 38.6 ± 9.9 years) and 32 of 38 in GII (82.9%; 38.6 ± 9.9 years) were followed up for 24 months (FU3) (loss 17.8%). All operated athletes showed significantly increased scores compared to FU0 (p < 0.05). Compared to GI, GII showed significantly superior outcome data for sporting ability as well as for NAS_{re-achievement of sport level} (p < 0.05). While GII re-achieved GIII-comparable SSAS and ASOSS levels, GI remained at a significantly inferior level. Athletes after ACJ injury of Rockwood grade IV/V and overhead athletes benefited significantly from the dDSB procedure.

CONCLUSION

The dDSB procedure enabled significantly superior sport-specific outcomes compared to the cHP procedure. Athletes after dDSB surgeries re-achieved the sporting ability and the sport activity levels of healthy athletes, whereas athletes after cHP implantation remained at significantly inferior levels. The more extensive dDSB procedure and the more restrictive rehabilitation are recommended for treatment of acute high-grade ACJ separations of functionally high-demanding athletes.

LEVEL OF EVIDENCE

I.

The arthroscopic Bankart repair procedure enables complete quantitative labrum restoration in long-term assessments

PURPOSE

The restoration of the labrum complex and the influence on secondary osteoarthritis after arthroscopic Bankart repair on magnetic resonance imaging (MRI) remain unclear.

METHODS

Twenty-one patients were retrospectively followed after unilateral primary arthroscopic Bankart repair with knot-tying suture anchors (8.8 ± 2.5 years after surgery, age 25.3 ± 6.3 years). Bilateral structural MRI was performed to assess labrum-glenoid restoration by measurements of the labrum slope angle, height index, and labrum interior morphology according to the Randelli classification. Osteoarthritic status was bilaterally assessed by a modified assessment based on the Samilson-Prieto classification.

RESULTS

MRI assessment revealed full labrum-glenoid complex restoration with equivalent parameters for anterior slope angle (mean ± SD: 21.3° ± 2.6° after Bankart repair vs. 21.9° ± 2.6° control) and height index (2.34 ± 0.4 vs. 2.44 ± 0.4), as well as the inferior slope angle (23.1° ± 2.9° vs. 23.3° ± 2.1°) and height index (2.21 ± 0.3 vs. 2.21 ± 0.3) (all n.s.). The labrum morphology showed only for the anterior labrum significant alterations (1.4 ± 0.9 vs. 0.6 ± 0.7, p < 0.05), the inferior labrum occurred similarly (1.3 ± 0.8 vs. 0.8 ± 0.5, n.s.). Osteoarthritic changes were significantly increased after Bankart repair compared to the uninjured shoulder (4.8 ± 5.1 mm vs. 2.5 ± 1.0 mm; p < 0.05), with a significant correlation of osteoarthritis status between both shoulders (p < 0.05). Scores generally decreased after Bankart repair (constant 84.6 ± 9.5 vs. 94.5 ± 4.9 control, p < 0.05; Rowe 84.5 ± 6.5 vs. 96.2 ± 4.2, p < 0.05; Walch-Duplay 82.4 ± 7.0 vs. 94.3 ± 4.0, p < 0.05) with a strong correlation with osteoarthritis status (p < 0.05).

CONCLUSIONS

Arthroscopic Bankart repair enabled good clinical outcomes and complete quantitative labrum restoration parameters. Next to several well-known parameters, secondary osteoarthritis after arthroscopic Bankart repair significantly correlated with osteoarthritic status of the uninjured contralateral shoulder but was not influenced by quantitative labrum restoration. The recommendation for arthroscopic Bankart repair should be based on clinical parameters and not on prevention of secondary osteoarthritis.

STUDY DESIGN

Case series.

LEVEL OF EVIDENCE

IV.

Outcome of arthroscopic SLAP repair using knot-tying-suture anchors compared with knotless-suture anchors in athletes

INTRODUCTION

Arthroscopic repair is one option for the surgical treatment of type II superior labrum tears from anterior to posterior (SLAP) lesions in athletes' shoulders.

MATERIALS AND METHODS

Sixty-one of 78 (78.2%) athletes were retrospectively examined after isolated arthroscopic SLAP repair (group 1/G1: 28x knot-tying anchors; group 2/G2: 33 knotless anchors; follow-up 24 months) and compared to two specific, separate matched volunteer athlete control groups (group 3/G3: 28 athletes matched to G1; group 4/G4: 33 athletes matched to G2). The assessment of G1-4 included numerical analogue scales (NASs: 1-15 scales) and the Athletic Shoulder Outcome Scoring System (ASOSS) score, and the Shoulder Sport Activity Score (SSAS). The preinjury status (FU-1), the status before surgery (FU0), and at follow-up (FU1) were assessed.

RESULTS

High external rotation at abduction (hER) was significantly worse in G1 than G2 (FU1: G1, 86.6° ± 7.7° versus = vs G2, 91.1° ± 10.7°; p = 0.03). The ASOSS and SSAS revealed significant impairment in G1-2 compared to G3-4 (ASOSS FU1: 83.9 ± 19.9 G1 vs 94.6 ± 7.7 G3; p = 0.002 and 80.3 ± 17.7 G2 vs 91.8 ± 9.1 G4; p = 0.002; SSAS 5.9 ± 2.7 G1 vs 6.9 ± 1.8 G3; p = 0.02 and 6.3 ± 2.5 G2 vs 7.4 ± 1.4 G4; p = 0.06), with 17-20% loss on ASOSS and 23-25% deficits on SSAS. The NAS analysis detected for pain (4 ± 3.5 vs 3.2 ± 2.6), satisfaction (2 ± 0.8 vs 1.8 ± 0.9), reduction of function (4.6 ± 3.9 vs 3.9 ± 3.8) and proficiency (9.6 ± 4.7 vs 10.9 ± 3.9) similar impairments in G1-2 (p > 0.05) and better results in G3 and G4 (all p < 0.001).

CONCLUSIONS

After SLAP repair, athletes showed underestimated impairment of shoulder sport resumption and proficiency with high rates of shoulder sports cessation. The present data favor the knotless fixation technique, because this fixation technique allowed bilaterally equivalent ranges of motions. The uninjured shoulder athletes also showed functional deficits with significant shoulder sport impairments, which must be considered in outcome analysis and for the rehabilitation program.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Rotator cuff muscular integrity after arthroscopic revision of a Bankart repair

INTRODUCTION

Recurrent shoulder instability after arthroscopic Bankart repair is still a common complication. For primary Bankart repair studies have shown that the rotator cuff can recover completely. The ability of muscles to regenerate after arthroscopic revision Bankart repair (ARBR) has not been studied. Does the ARBR using a three-portal method allows complete muscle integrity compared with an uninjured imaging control group (ICG)?

MATERIALS AND METHODS

Twenty-two (1 female, 21 males) physically active patients (mean age at follow-up 28.5 ± 7.1 years; mean follow-up 27.5 months ± 8.5) were assessed. ARBR with a three-portal method was carried out in all patients according to previous primary arthroscopic stabilization of the shoulder (revision Bankart group). Muscle atrophy of the subscapularis muscle (SSC), supraspinatus muscle (SSP) and infraspinatus muscle (ISP) was assessed by making lateral and vertical measurements by magnetic resonance imaging (MRI). Fatty infiltration was detected by standardized assessment from variations in intensity. Detailed clinical examination of the rotator cuff was carried out. MRI assessment was compared with that of a control group of 22 healthy volunteers of same age and activity level (ICG).

RESULTS

For the SSC, no muscle impairment was noted compared with the ICG [superior atrophy index (sAI_SSC), p = 0.439; inferior atrophy index (iAI_SSC), p = 0.555; superior fatty infiltration index (sFDI_SSC), p = 0.294; inferior fatty infiltration index (iFDI_SSC), p = 0.62]. In investigation of the SSP and ISP, fatty infiltration was not shown (FDI_SSP, p = 0.454; sFDI_ISP, p = 0.504), though persistent muscle atrophy was found even > 2 years after surgery compared with the ICG (AI_SSP, p = 0.0025; sAI_ISP, p = 0.0009; iAI_ISP, p = 0.0004).

CONCLUSION

ARBR using a three-portal method allowed good muscular integrity compared with the ICG, but with persistent slight muscular atrophy of the SSP and ISP.