Failure of operative treatment for glenohumeral instability: etiology and management

Outcomes After Arthroscopic Revision Bankart Repair: An Updated Systematic Review of Recent Literature

PURPOSE

To provide an update of recent literature with a specialized focus on clinical outcomes following arthroscopic revision Bankart repair (ARBR) by performing a systematic review of all available literature published between 2013 and 2020.

METHODS

A literature search reporting clinical outcomes after ARBR was performed. Criteria for inclusion consisted of original studies; Level of Evidence of I-IV; studies focusing on clinical outcomes after ARBR published between January 1, 2013, and January 4, 2021; studies reporting recurrent dislocation or instability rate after ARBR; reoperation/revision following ARBR, return to sport rates following ARBR; and patient-reported outcomes. The primary outcomes of interest were failure defined as recurrent instability or dislocation, return to sport rates, and patient-reported outcomes at follow-up.

RESULTS

A large proportion of patients undergoing arthroscopic revision Bankart repair were male, ranging between 67.7% and 93.8%. Failure rate and return to sports rate ranged between 6.1% and 46.8% and 25.9% and 88.3%, respectively, when patients with significant or greater than 20% glenoid bone loss was excluded. Patient-reported outcome scores, which included American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale, saw significant improvement over mean follow-up of ranging 21.64 to 60 months.

CONCLUSIONS

Both the failure rate and RTS rates after ARBR had a wide range, given the heterogeneity of the studies included, which varied in patient selection criteria pertaining to patients with greater than 20% glenoid bone. Although there have been advancements in arthroscopic techniques and a trend favoring arthroscopic stabilization procedures, there is a lack of consensus in recent literature for careful patient selection criteria that would minimize failure rates and maximize RTS rates after ARBR.

LEVEL OF EVIDENCE

Level IV, a systematic review of Level III-IV studies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Bankart Repair With Subscapularis Augmentation in Athletes With Shoulder Hyperlaxity

PURPOSE

The purpose of this study was to demonstrate that arthroscopic Bankart repair with associated arthroscopic subscapularis augmentation (ASA) could be a valid surgical option in the treatment of anterior shoulder instability, in collision and contact sports athletes, affected by shoulder hyperlaxity.

METHODS

In total, 591 arthroscopic Bankart repairs plus ASA were performed in 6 shoulder centers from 2009 to 2017. Inclusion criteria were the following: collision and contact sports activities, recurrent anterior instability associated with hyperlaxity and glenoid bone loss (GBL) < 15%. Exclusion criteria were GBL > 15%, voluntary instability, multidirectional instability, pre-existing osteoarthritis and throwing athletes. The minimum follow-up was 24 months. Hyperlaxity was clinically evaluated according to Neer and Coudane-Walch tests. Before surgery, all patients underwent magnetic resonance imaging and computed tomography scanning. Pico area method was used to assess the percentage of GBL. Patients were operated on by 6 surgeons, and their functional outcomes were evaluated by 2 independent observers. The Western Ontario Shoulder Instability Index (WOSI), Rowe, American Shoulder and Elbow Surgeons (ASES) scores were used to assess results.

RESULTS

Overall, 397 patients with evidence of shoulder hyperlaxity (positive sulcus sign in ER1 position and Coudane-Walch test > 85°) met all inclusion criteria. The mean WOSI score was 321; the mean Rowe score rose from 68.5 to 92.5 (P = .037), and the ASES score rose from 71.5 to 97.4 (P = .041). Seven patients (1.6%) had atraumatic redislocation, and 9 patients (2.2%) had post-traumatic redislocation. At final follow-up the mean functional deficit of external rotation was 15° with the arm in adduction (ER1 position) and 10° in abduction (ER2 position).

CONCLUSIONS

The Bankart repair plus ASA has been demonstrated to be safe and effective for restoring joint stability in patients practicing collision and contact sports or affected by chronic anterior shoulder instability associated with GBL (<15%) and hyperlaxity, without compromising external rotation.

LEVEL OF EVIDENCE

Level IV, case series.

Revision Arthroscopic Bankart Repair Versus Arthroscopic Latarjet for Failed Primary Arthroscopic Stabilization With Subcritical Bone Loss

Background:

Limited evidence is available regarding the recommended technique of revision surgery for recurrent shoulder instability. Only 1 previous study has compared the results of soft tissue repair and the Latarjet technique in patients with persistent shoulder instability after primary surgical stabilization.

Purpose/Hypothesis:

To evaluate the results of revision surgery in patients with previous surgical stabilization failure and subcritical glenoid bone defects, comparing repeated Bankart repair versus arthroscopic Latarjet technique. The hypothesis was that Latarjet would be superior to soft tissue procedures in terms of objective and subjective functional scores, recurrence rates, and range of movement.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Included were 45 patients (mean age, 29.1 ± 8.9 years) with subcritical bone loss (<15% of articular surface) who had undergone revision anterior shoulder instability repair after failed Bankart repair. Of these, 17 patients had arthroscopic Bankart repair and 28 had arthroscopic Latarjet surgery. Patients were evaluated at a minimum of 2 years postoperatively with the Rowe score, Western Ontario Shoulder Instability Index, and Subjective Shoulder Value. Subluxation or dislocation episodes were considered failures.

Results:

No statistically significant differences were found between groups in age, sex, sporting activity, preoperative Rowe score, or the presence of hyperlaxity or bony lesions. At revision arthroscopy, 20 shoulders showed a persistent Bankart lesion, 13 a medially healed labrum, and 6 a bony Bankart. In 6 patients, no abnormalities were present that could explain postoperative recurrence. In the Bankart repair group, 7 patients underwent isolated Bankart procedures; in the remaining 10 cases, a capsular shift was added. No significant differences were found between the Bankart and Latarjet groups in outcome scores, recurrence rate (11.8% vs 17.9%, respectively), or postoperative athletic activity level. The mean loss of passive external rotation at 0° and 90° of abduction was similar between groups.

Conclusion:

Arthroscopic Latarjet did not lead to superior results compared with repeated Bankart repair in patients with subcritical glenoid bone loss and recurrent anterior shoulder instability after Bankart repair.

Revision Arthroscopic Bankart Repair: A Systematic Review of Clinical Outcomes

Although the frequency of arthroscopic revision surgery is increasing in patients with recurrent dislocation after a primary shoulder stabilization, the literature describing arthroscopic revision Bankart repair has been limited. Preferred reporting items for systematic meta-analyses guidelines were followed by utilizing PubMed, EMBASE, Scopus, and Cochrane Library databases. Keywords included shoulder dislocation, anterior shoulder instability, revision surgery, stabilization, and arthroscopic Bankart repair. Quality assessments were performed with criteria from the methodological index for nonrandomized studies (MINORS). A total of 14 articles were included in this analysis. The mean MINORS score was 12.43. A total of 339 shoulders (337 patients) were included (281 males and 56 females). The mean follow-up period was 36.7 months. Primary surgeries were as follows: arthroscopic procedures (n = 172, 50.7%), open procedure (n = 87, 25.7%), and unknown (n = 80, 23.6%). The mean rate of recurrent instability after revision arthroscopic Bankart repair was 15.3% (n = 52), and an additional re-revision procedure was needed in 6.5% of cases (n = 22). Overall, there were 18.0% (n = 61) of complications reported. This systematic review suggests that arthroscopic revision Bankart repair can lead to an improvement in functional outcomes and reasonable patient satisfaction with proper patient selection.

No Sedation, No Traction, and No Need for Assistance: Analysis of New Prakash's Method of Shoulder Reduction

Materials and Methods

A total of 19 patients who were admitted to the emergency department with the diagnosis of anterior shoulder dislocation participated in this study. The diagnosis of shoulder dislocation was established in the emergency department with physical examination and anteroposterior shoulder radiography. The method was applied only once to the patients in the sitting position by the same physician without using any help, traction, anesthesia, analgesia, and myorelaxant.

Results

The mean age of the patients was 37.3 ± 13.1 years. Among them, 36.8% (n=7) were female and 63.2% (n=12) were male. Recurrent dislocations were observed in 21.1% (n=4) of the patients. The success rate of the method was 94.7% (n=18). No complication was noted in the patients. The mean procedure time was 243 ± 38 seconds.

Conclusion

Prakash's method is a safe method for anterior shoulder dislocations that can be quickly performed with no need for sedation, assistance, and traction and has a high success rate.

Anterior Instability: What to Look for

Most first-time anterior glenohumeral dislocations occur as the result of trauma. Many patients suffer recurrent episodes of anterior shoulder instability (ASI). The anatomy and biomechanics of ASI is addressed, as is the pathophysiology of capsulolabral injury. The roles of imaging modalities are described, including computed tomography (CT) and MR imaging with the additional value of arthrography and specialized imaging positions. Advances in 3D CT and MR imaging particularly with respect to the quantification of humeral and glenoid bone loss is discussed. The concepts of engaging and nonengaging lesions as well as on-track and off-track lesions are examined.

Arthroscopic Revision with Autologous Iliac Crest Bone Graft for Failed Anatomic Glenoid Reconstruction Using Distal Tibia Allograft

Recurrent instability after anterior shoulder stabilization surgery is not an uncommon complication, with variable rates of recurrences associated with different surgical procedures. The Latarjet procedure continues to be the gold standard in the management of anterior instability with significant glenoid bone loss, although a recent trend toward arthroscopic anatomic glenoid reconstruction (AAGR) with distal tibial allograft has been noted, with excellent short-term results and minimal complication rates. Arthroscopic revision stabilization for failed stabilization procedures is increasingly being performed, although it is technically more challenging than the primary stabilization procedure because of the anatomic rearrangements of the index surgery. In this article, we describe a revision arthroscopic technique for anatomic glenoid reconstruction using iliac crest autograft for a previous failed AAGR procedure secondary to nonunion of the graft. The graft is passed through the Halifax far-medial portal without splitting the subscapularis. Arthroscopic revision in the setting of a failed AAGR procedure is technically easier than after a Latarjet procedure, as the anatomy is relatively undisturbed in the former, facilitating easier identification of anatomic landmarks, accurate graft positioning, and decreased risk of neurovascular injuries. A Bankart capsulolabral repair is performed after graft fixation, making the graft extra-articular and providing additional stability.

Is the Instability Severity Index Score a Valid Tool for Predicting Failure After Primary Arthroscopic Stabilization for Anterior Glenohumeral Instability?

PURPOSE

To assess the validity of the Instability Severity Index Score in predicting the rate of recurrence of dislocation in patients undergoing arthroscopic Bankart repair.

METHODS

The inclusion criteria were recurrent anterior traumatic glenohumeral instability and a minimum follow-up of 5 years. According to the preoperative Instability Severity Index Score, patients were divided into the following groups: ≤3 points (A), 4 to 6 points (B), and >6 points (C). The recurrence rate was determined by telephone interviews. The estimated overall rate of success at 5 years was defined as the estimated overall percentage of patients free of recurrence at 5 years.

RESULTS

Six hundred seventy patients (572 men and 98 women) were included. The average age was 27 years (range, 18 to 39 years) at the time of surgery. One hundred fourteen of 670 patients had a recurrence of instability, with an overall recurrence rate of 17% (95% confidence interval [CI] 14.2%-19.9%). The Instability Severity Index Score had a significant association with recurrence. Compared with patients in group A, those in group B had double the risk of recurrence (hazard ratio [HR] = 2.43, 95% CI 1.38-4.28, P = .002), and patients in group C a 9 times greater risk of recurrence (HR = 9.42, 95% CI 5.20-17.7, P < .001). The estimated overall rate of success at 5 years was 84.8% (95% CI 81.8-87.3). The rate of success with an Instability Severity Index Score ≤3 points was 93.7% (95% CI 89.6-96.2), but it dropped to 85.7% (95% CI 81.7-88.9) in those with an Instability Severity Index Score of 4 to 6 points and became 54.6% (95% CI 42.8-64.9) in those with an Instability Severity Index Score >6 points. On multivariable analysis, the Instability Severity Index Score was found to significantly affect the risk of recurrence, corrected by type of sport and glenoid bone loss.

CONCLUSIONS

The Instability Severity Index Score is a validated tool with which to assess the recurrence rate of dislocation after arthroscopic surgery in patients with shoulder instability. Arthroscopic stabilization in patients with an Instability Severity Index Score ≤3 is associated with a significantly lower risk of recurrence of glenohumeral instability compared with that in patients with an Instability Severity Index Score >3 points.

LEVEL OF EVIDENCE

III, case-control study.

Surgical treatment outcomes after primary vs recurrent anterior shoulder instability

INTRODUCTION

The aim of this study is to compare the outcomes of surgical management after primary anterior shoulder dislocation to the outcomes of patients who have surgical stabilization after recurrent anterior shoulder instability.

METHODS

A Medline (PubMed) search was performed in November of 2016 using the following key terms: shoulder, labrum, Bankart, instability, repair, outcome, recurrent. In May 2017 a Cochrane search was performed using similar key terms to ensure we included all studies. Only level I and II studies were included.

RESULTS

There were three studies that compared primary repair to delayed repair. In all three studies, the rate of recurrence was higher in group R than group S. When pooled, there was not a statistically significant difference between these groups, but there was a slightly higher odds of recurrence in group R (pooled OR 2.08, CI 0.69-6.26, p = 0.19). No significant differences were appreciated in functional outcomes or complications in these two groups.

CONCLUSION

Further level I and level II studies to compare surgical treatment after first time and recurrent instability are needed. This study failed to find a statistically significant difference in recurrence rates in patients who had stabilization acutely after a single episode compared to patients with recurrent instability events, although results suggest there may be a small benefit in primary stabilization.

High rate of return to sport in adolescent athletes following anterior shoulder stabilisation: a systematic review

Importance

Traumatic anterior shoulder instability remains common for the adolescent athletes.

Aim or objective

To perform a systematic review on the outcomes and return to sport (RTS) following Bankart repair in adolescent athletes.

Evidence review

A systematic review using the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines was conducted of studies reporting outcomes following open and/or arthroscopic Bankart repair using modern suture anchors following traumatic anterior shoulder dislocations in adolescent patients (ages 10-19 years). Quality assessment was evaluated with ROBINS-I and MINORS instruments. The outcomes analysed included RTS, timetable to unrestricted activity, recurrent instability and revision surgery.

Findings

This systematic review identified 11 studies comprising 461 adolescent athletes with a mean age of 15.7 years (range, 11-19 years) and an average follow-up of 48.8 months (range, 22-85.2 months). A total of 392 patients (400 shoulders) underwent arthroscopic Bankart repair, while the remaining 69 patients (69 shoulders) underwent an open procedure. The average MINORS score was 9.6 for non-comparative studies and 17 for comparative studies. ROBINS-I revealed six studies to have a moderate risk of bias, while the remaining five studies presented serious risk of bias. There was an overall 81.5% rate of RTS to preinjury levels of athletic competition at an average of 5.3 months following Bankart repair for traumatic anterior shoulder instability. The overall total mean incidence of recurrent instability was 18.5%, while the mean incidence of revision surgery was 12.1%. Contact athletes had a 31.1% and 13% rate of recurrence and revision surgery, respectively. In comparison, collision athletes were shown to have a 10.4% and 1.4% incidence of recurrent instability and revision surgery, respectively.

Conclusions and relevance

Adolescent athletes who undergo Bankart repair for traumatic anterior shoulder instability have an 81.5% rate of RTS to preinjury levels of play at an average of 5 months following surgery. The overall total mean incidence of recurrent instability in the adolescent population is 18.5%, while the mean incidence of revision surgery is 12.1%. The results of anterior shoulder stabilisation in contact athletes is much less predictable, with higher reported rates of recurrent instability and revision surgery.

Level of evidence

Level IV.

Arthroscopic Revision Surgery for Failure of Open Latarjet Technique

PURPOSE

To evaluate the efficacy in treating pain, limited range of motion, and continued instability of the Latarjet open technique via the use of arthroscopy.

METHODS

A retrospective review of patients who underwent arthroscopic capsule plication after failure of an open Latarjet technique was performed. Revision surgery was indicated in cases of recurrent instability and associated pain. Only patients with a glenoid defect <25% were considered. The Constant and Rowe scores were administered, whereas pain was assessed with a visual analog scale before the reoperation and at 24 months after operation. Radiographs, computed tomography, and CT arthrography scans were performed.

RESULTS

Twelve patients met the inclusion criteria. All patients had capsular distension and consequently were subjected to a capsuloplasty. Shoulder function, stability, and pain had all improved significantly at 24 months after arthroscopic revision (P < .0001). In particular, the Constant score increased from 44.9 (standard deviation [SD] 7.10) to 89.3 (SD 12.6) points, the Rowe score improved from 49.5 (SD 10.1) to 80.9 (SD 10.9), whereas the visual analog scale pain score decreased from 6.75 (SD 1.17) to 1.38 (SD 1.06).

CONCLUSIONS

Primary open Latarjet with a glenoid bone defect <25% that failed due to capsular redundancy is amenable to successful treatment with arthroscopic capsuloplasty.

CLINICAL RELEVANCE

Arthroscopic approaches can offer a good solution for treating previously failed open Latarjet procedures.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

All-Arthroscopic Revision Eden-Hybinette Procedure for Failed Instability Surgery: Technique and Preliminary Results

PURPOSE

To describe the technique of an all-arthroscopic Eden-Hybinette procedure in the revision setting for treatment of a failed instability procedure, particularly after failed Latarjet, as well as to present preliminary results of this technique.

METHODS

Between 2007 and 2011, 18 shoulders with persistent instability after failed instability surgery were treated with an arthroscopic Eden-Hybinette technique using an autologous bicortical iliac crest bone graft. Of 18 patients, 12 (9 men, 3 women) were available for follow-up. The average follow-up was 28.8 months (range, 15 to 60 months). A Latarjet procedure was performed as an index surgery in 10 patients (83%). Two patients (17%) had a prior arthroscopic Bankart repair.

RESULTS

Eight patients (67%) obtained a good or excellent result, whereas 4 patients (33%) reported a fair or poor result. Seven patients (58%) returned to sport activities. A positive apprehension test persisted in 5 patients (42%), including 2 patients (17%) with recurrent subluxations. The Rowe score increased from 30.00 to 78.33 points (P < .0001). The Walch-Duplay score increased from 11.67 to 76.67 points (P < .0001). The Western Ontario Shoulder Instability Index score showed a good result of 28.71% (603 points). The average anterior flexion was 176° (range, 150° to 180°), and the average external rotation was 66° (range, 0° to 90°). Two patients (16.67%) showed a progression of glenohumeral osteoarthritic changes, with each patient increasing by one stage in the Samilson-Prieto classification. All 4 patients (33%) with a fair or poor result had a nonunion identified on postoperative computed tomography scan.

CONCLUSIONS

An all-arthroscopic Eden-Hybinette procedure in the revision setting for failed instability surgery, although technically demanding, is a safe, effective, and reproducible technique. Although the learning curve is considerable, this procedure offers all the advantages of arthroscopic surgery and allows reconstruction of glenoid defects and restoration of shoulder stability in this challenging patient population. In our hands, this procedure yields good or excellent results in 67% of patients. Successful outcome is correlated with bony healing of the iliac crest graft to the glenoid.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Shoulder Problems Motivate Innovative Solutions

Shoulder arthroscopic and related surgeons may require expertise in use of the 70° arthroscope, biologic patch augmentation, repair of massive rotator cuff tears, the Latarjet procedure and related glenoid bone augmentation, and reverse total shoulder arthroplasty.

Evaluation and treatment of failed shoulder instability procedures

Management of the unstable shoulder after a failed stabilization procedure can be difficult and challenging. Detailed understanding of the native shoulder anatomy, including its static and dynamic restraints, is necessary for determining the patient’s primary pathology. In addition, evaluation of the patient’s history, physical exam, and imaging is important for identifying the cause for failure after the initial procedure. Common mistakes include under-appreciation of bony defects, failure to recognize capsular laxity, technical errors, and missed associated pathology. Many potential treatment options exist for revision surgery, including open or arthroscopic Bankart repair, bony augmentation procedures, and management of Hill Sachs defects. The aim of this narrative review is to discuss in-depth the common risk factors for post-surgical failure, components for appropriate evaluation, and the different surgical options available for revision stabilization.

Level of evidence Level V.

First-time anterior shoulder dislocations: should they be arthroscopically stabilised?

The glenohumeral joint is inherently unstable because the large humeral head articulates with the small shadow glenoid fossa. Traumatic anterior dislocation of the shoulder is a relatively common athletic injury, and the high frequency of recurrent instability in young athletes after shoulder dislocation is discouraging to both the patient and the treating physician. Management of primary traumatic shoulder dislocation remains controversial. Traditionally, treatment involves initial immobilisation for 4-6 weeks, followed by functional rehabilitation. However, in view of the high recurrence rates associated with this traditional approach, there has been an escalating interest in determining whether immediate surgical intervention can lower the rate of recurrent shoulder dislocation, improving the patient's quality of life. This review article aims to provide an overview of the nature and pathogenesis of first-time primary anterior shoulder dislocations, the widely accepted management modalities, and the efficacy of primary surgical intervention in first-time primary anterior shoulder dislocations.

Glenoid Bone Loss Measurement in Recurrent Shoulder Dislocation: Assessment of Measurement Agreement Between CT and MRI

BACKGROUND

Shoulder instability can cause both soft tissue injury and bone defects, requiring both computed tomography (CT) and magnetic resonance imaging (MRI) for a thorough workup, which results in high patient costs and radiation exposure. Prior studies in cadaveric and nonclinical models have shown promise in assessing preoperative bone loss utilizing MRI.

PURPOSE

To evaluate the utility of MRI in detecting and evaluating glenoid bone defects in a clinical setting. The aim was to establish whether similar information could be determined by utilizing MRI and CT in a population with recurrent instability.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

CT and MRI scans of 22 shoulders were read by 4 orthopaedic surgeons. The CT images were obtained on a 2-dimensional CT scanner. Vertical measurements were taken from the superior glenoid tubercle and directed inferiorly along the glenoid; horizontal measurements were taken across the widest part of the face of the glenoid and were perpendicular within one-half of 1° to the vertical measurement. The same protocol was followed for MRI measurements. An intraclass correlation coefficient (ICC) was calculated.

RESULTS

There was a moderate amount of agreement between examiners for the height measurements on MRI (ICC, 0.53) and a substantial agreement for the CT images (ICC, 0.64). The width measurements for MRI had a moderate amount of agreement (ICC, 0.41), while the CT images had a fair agreement (ICC, 0.39). The height measurements between the measurements of MRI and CT images had an overall ICC of 0.43, while the width measurements had an overall ICC of 0.41, both of which were considered a moderate amount of agreement.

CONCLUSION

There is moderate correlation between MRI and CT scans when measuring the glenoid, indicating that taking the length-to-height ratio measurements across the glenoid is a promising way to estimate the glenoid defect. At present, a complete workup of a patient with shoulder instability includes both a CT scan and an MRI. Future research that establishes precisely how MRI misestimates CT measurements of the glenoid can perhaps obviate the need for 2 scans.

Rotator cuff tear and glenohumeral instability : a systematic review

BACKGROUND

The rotator cuff plays a significant role in the static and dynamic stability of the glenohumeral joint. Rotator cuff tears may occur after shoulder dislocations, whether in younger athletes or older patients with age-related tendon degeneration. Untreated tears may cause persistent pain, dysfunction, instability, and degenerative changes. A thorough understanding of when to look for rotator cuff tears after shoulder dislocations and how best to manage them may decrease patients' pain and improve function.

QUESTIONS/PURPOSES

We systematically reviewed the available literature to better understand (1) when a rotator cuff tear should be suspected after a dislocation, (2) whether surgical or nonsurgical approaches result in better scores for pain and satisfaction in patients with rotator cuff tears resulting from shoulder dislocations, and (3) whether intraarticular lesions, rotator cuff tears, or both should be addressed when surgery is performed.

METHODS

We systematically searched MEDLINE(®), CINAHL, and EMBASE for studies published from 1950 to 2012. We included studies reporting outcomes after treatment in patients with rotator cuff tears and shoulder dislocations. We excluded case reports, studies without any treatment, and studies about patients treated with arthroplasty. Five Level III and six Level IV studies were ultimately selected for review.

RESULTS

Patients with persistent pain or dysfunction after a shoulder dislocation often had a concomitant rotator cuff tear. Surgical repair resulted in improved pain relief and patient satisfaction compared to nonoperative management. Repair of the rotator cuff, along with concomitant capsulolabral lesions, helped restore shoulder stability. While these findings are based on Level III and IV evidence, better long-term studies with larger cohorts are needed to strengthen evidence-based recommendations.

CONCLUSIONS

Persistent pain and dysfunction after a shoulder dislocation should prompt evaluation of the rotator cuff, especially in contact or overhead athletes, patients older than 40 years, or those with nerve injury. Surgery should be considered in the appropriately active patient with a rotator cuff tear after dislocation. While the current literature suggests improved stability and function after surgical repair of the rotator cuff, higher-quality prospective studies are necessary to make definitive conclusions.

Primary versus revision arthroscopic reconstruction with remplissage for shoulder instability with moderate bone loss

PURPOSE

This study aims to evaluate our outcomes of arthroscopic remplissage in this setting.

METHODS

A retrospective review was performed to identify patients who underwent arthroscopic remplissage of an engaging Hill-Sachs lesion along with anterior capsulolabral reconstruction for anterior glenohumeral instability with moderate glenohumeral bone loss at our institution. Thirty-five patients, with a minimum of 2 years' follow-up, were identified. We assessed the American Shoulder and Elbow Surgeons score, incidence of recurrent instability, and postoperative Rowe instability score.

RESULTS

Follow-up was available for 30 patients (31 shoulders). The mean age was 24.6 years, with a mean follow-up period of 41 months. Prior instability surgery had failed in 11 patients, and they underwent capsulolabral reconstruction and remplissage ("revision surgery"). The failure rate in revision cases (36%) was significantly higher than the failure rate in primary surgery cases (0%) (P = .01). Failure resulted from trauma in all 4 patients, and none required further surgery. The mean American Shoulder and Elbow Surgeons score for all patients improved from 50 preoperatively to 91 postoperatively (P < .001), with no significant postoperative difference between primary and revision patients (P = .13). The patients with clinical failure showed nonsignificant improvement from 41 preoperatively to 72 postoperatively (P = .08). The mean postoperative Rowe score for the entire cohort was 90. The Rowe score was significantly lower in the 4 cases of failure than in the 27 non-failure cases (51 v 96, P < .001).

CONCLUSIONS

In our experience, aggressive capsulolabral reconstruction with remplissage in traumatic instability patients with moderate bone loss and engaging humeral Hill-Sachs lesions yields acceptable outcomes for primary instability surgery. However, a significantly higher failure rate occurred when arthroscopic reconstruction with remplissage was performed in the revision setting.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Recurrent instability after revision anterior shoulder stabilization surgery

PURPOSE

The purpose of this study was to perform a systematic review of the literature to compare outcomes of revision anterior stabilization surgeries based on technique. This study also sought to compare the impact of bone defects on outcomes.

METHODS

A systematic review of the electronic databases PubMed, Cochrane Central Register of Controlled Trials, and Scopus was performed in July 2012 and March 2013. Of 345 articles identified in the search, 17 studies with Level I to IV Evidence satisfied the inclusion criteria and were analyzed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Recurrent instability was defined as redislocation, resubluxation, or a positive apprehensive test after revision surgery. Procedures were categorized as arthroscopic Bankart repair, open Bankart repair, Bristow-Latarjet procedure, and other open procedures.

RESULTS

In total, 388 shoulders were studied. Male patients comprised 74.1% of patients, 66.7% of cases involved the dominant shoulder, the mean age was 28.2 years, and the mean follow-up period was 44.2 months. The surgical procedures classified as "other open procedures" had the highest rate of recurrent instability (42.7%), followed by arthroscopic Bankart repair (14.7%), the Bristow-Latarjet procedure (14.3%), and open Bankart repair (5.5%). Inconsistent reporting of bone defects precluded drawing significant conclusions.

CONCLUSIONS

A number of different procedures are used to address recurrent instability after a primary operation for anterior shoulder instability has failed. There is significant variability in the rate of recurrent instability after revision anterior shoulder stabilization surgery.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I to IV studies.

The interobserver reliability in diagnosing osseous lesions after first-time anterior shoulder dislocation comparing plain radiographs with computed tomography scans

BACKGROUND

Recurrence after first-time traumatic anterior shoulder dislocation is frequent. The prevalence of glenoid bone loss ranges from 41% after a first-time dislocation to 86% with recurrent dislocation. Postoperative recurrence can occur in up to 10% of cases. Thus, misdiagnosis of bony glenoid rim lesions has been assumed a major cause for failure. We evaluated the interobserver reliability of radiologic diagnoses after first-time traumatic shoulder dislocation based on radiographs and computed tomography (CT) images.

METHODS

Digital radiographs before and after reduction and CT images after reduction of 20 patients with a first-time shoulder dislocation were assessed by 6 observers. It was recorded whether they diagnosed a lesion at the greater tuberosity, a lesion at the glenoid rim, a Hill-Sachs lesion, or any other skeletal pathology. The average agreement among the investigators was evaluated, and radiographic diagnoses were compared with those based on CT images.

RESULTS

Of the 10 cases that presented with a glenoid rim fracture, each investigator had overlooked at least 1 fracture (range, 1-4) on the radiographs. No investigator had diagnosed all 8 Hill-Sachs lesions on the presented images. The average overall agreement among the investigators and corresponding sensitivity and specificity were calculated. Agreement of diagnoses based on radiographs with those based on CT images was lowest for glenoid rim fractures and Hill-Sachs lesions.

CONCLUSION

Radiographs seem inferior to CT scans for assessing osseous lesions especially at the glenoid rim. We suggest performing a CT scan of the shoulder after primary dislocation to apply the correct treatment early and potentially avoid further dislocations.

Revision arthroscopic Bankart repair

PURPOSE

Failed anterior shoulder stabilization procedures have traditionally been treated with open procedures. Recent advances in arthroscopic techniques have allowed for certain failed stabilization procedures to be treated by arthroscopic surgery. The aim of this systematic review was to determine the outcomes of revision arthroscopic Bankart repair.

METHODS

We searched Medline, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) for articles on revision arthroscopic Bankart repairs. Key words included shoulder dislocation, anterior shoulder instability, revision surgery, and arthroscopic Bankart repair. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data.

RESULTS

We included 16 studies comprising 349 patients. All studies were retrospective (1 Level II study and 15 Level IV studies). The mean incidence of recurrent instability after revision arthroscopic Bankart repair was 12.7%, and the mean follow-up period was 35.4 months. The most common cause for failure of the primary surgeries was a traumatic injury (62.1%), and 85.1% of patients returned to playing sports. The reasons for failure of revision cases included glenohumeral bone loss, hyperlaxity, and return to contact sports.

CONCLUSIONS

With proper patient selection, the outcomes of revision arthroscopic Bankart repair appear similar to those of revision open Bankart repair. Prospective, randomized clinical trials are required to confirm these findings.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II and Level IV studies.

Outcome after modified Putti-Platt procedure for recurrent traumatic anterior shoulder dislocations

Most recent studies on procedures for stabilizing the glenohumeral joint focus on arthroscopic techniques. A relatively simple open procedure is the modified Putti-Platt procedure. The aim of these retrospective case series was to evaluate the functional outcome, patient satisfaction, and quality of life of patients who underwent this procedure. After a median follow-up time of 4.7 (P₂₅–P₇₅ 1.7–6.8) years, fifty-one patients could be enrolled with a mean age of 25 (21–39) years. Five patients (10 %) reported re-dislocations. The median Constant score for the affected side was 84 (P₂₅–P₇₅ 75–91). Median loss of motion in abduction, elevation, external rotation, and external rotation in 90° of abduction did not exceed 10° when compared to the healthy shoulder. A median Rowe score of 92 (P₂₅–P₇₅ 75–95) was measured. The WOSI score and SF-36 showed excellent quality of life. The VAS proved high patient satisfaction with the outcome; 7.9 (6.8–9.5). We concluded that the modified Putti-Platt procedure leads to excellent outcome scores and only marginal restriction in range of motion combined with a high patient satisfaction. Our data prove that excellent results can be obtained with a relatively simple open procedure.

[Results of revision after failed surgical treatment for traumatic anterior shoulder instability]

INTRODUCTION AND OBJECTIVES

Persistent or recurrent glenohumeral instability after a previous operative stabilization can be a complex problem. Our aim is to establish the incidence of recurrence and its revision surgery, and to analyse the functional results of the revision instability surgery, as well as to determine surgical protocols to perform it.

MATERIALS AND METHODS

A retrospective analysis was conducted on 16 patients with recurrent instability out of 164 patients operated on between 1999 and 2011. The mean follow-up was 57 months and the mean age was 29 years. To evaluate functional outcome we employed Constant, Rowe, UCLA scores and the visual analogue scale.

RESULTS

Of the 12 patients who failed the initial arthroscopic surgery, 6 patients underwent an arthroscopic antero-inferior labrum repair technique, 4 using open labrum repair techniques, and 2 coracoid transfer. The two cases of open surgery with recurrences underwent surgery for coracoid transfer. Results of the Constant score were excellent or good in 64% of patients.

CONCLUSIONS

Surgical revision of instability is a complex surgery essentially for two reasons: the difficulty in recognising the problem, and the technical demand (greater variety and the increasingly complex techniques).

Risk factors for recurrence after Bankart repair a systematic review

PURPOSE

Arthroscopic Bankart repair of anterior shoulder instability is a common practice in orthopedics. The aim of this study was to evaluate pre-operative risks factors associated with recurrent instability and to delineate possible indications for revision surgery.

METHODS

A systematic review was performed including the following keywords: arthroscopy, Bankart repair, anterior shoulder instability, recurrence of instability, suture anchors and treatment outcome. Studies eligible for inclusion in the review were clinical trials published in the last 10 years investigating patients with anterior shoulder instability managed by an arthroscopic repair technique with suture anchors. The studies had to report data about recurrence of instability and investigational parameters (risk factors) that influenced the results referred to the rate of recurrence. Twenty-four articles were identified that met the inclusion criteria and underwent further review. Data from these studies were collected, and the risk of treatment failure was statistically recalculated. An estimate of the overall recurrence rate was obtained by pooling data about failure from the trials.

RESULTS

The rate of recurrent instability at 10 years of follow-up ranged from 3.4 to 35 %. Epidemiological parameters significantly associated with the recurrence of instability were age below 22 years old, male gender, the number of preoperative dislocations and participation in competitive sports. Surgical parameters significantly associated with recurrence of instability were repair with fewer than three anchors and the use of knotless anchors. The patho-anatomical factors significantly associated with recurrences were substantial associated glenoid or humeral head bone loss and the presence of anterior labroligamentous periosteal sleeve avulsion.

CONCLUSIONS

Knowledge of risk factors for post-operative outcomes allows surgeons to provide appropriate preoperative counselling to patients and support more realistic expectations. An accurate analysis of causes of failure should enable the correct revision strategy to be adopted.

LEVEL OF EVIDENCE

II.

Area-based determination of bone loss using the glenoid arc angle

In patients with anterior glenohumeral instability, the most commonly observed osseous defect involves the anterior portion of the inferior glenoid. The amount of glenoid bone loss guides surgical treatment, with progressively larger defects not being amenable to arthroscopic soft-tissue procedures. Currently, there is no universally accepted method of quantifying glenoid bone loss. Two-dimensional area-based methods and 1-dimensional methods of measuring bone loss have both been described but cannot be used interchangeably. The surface area of a glenoid bony defect is a more comprehensive descriptor of its magnitude than the 1-dimensional width of the defect. Calculating surface area can be challenging. We describe a method of quantifying glenoid bone loss using a glenoid arc angle that corresponds to the surface area of the defect. The arc angle is easily measured by use of commonly used imaging software tools and is independent of the size of the glenoid or defect orientation. This method may prove valuable in preoperative planning for patients with anterior glenohumeral instability.