Arthroscopic Findings and Clinical Outcomes in Patients 40 Years of Age and Older With Recurrent Shoulder Dislocation

Outcomes of primary arthroscopic shoulder stabilization in active patients over 40-results at a mean follow-up of 7 years

Background

The purpose of this study is to report clinical outcomes, return to activity, redislocation rate, and rate of conversion to arthroplasty for active patients over age 40 undergoing primary arthroscopic shoulder stabilization.

Methods

Patients over 40 years of age who underwent arthroscopic capsulolabral repair for shoulder instability between December 2005 and January 2018 with a minimum of 2-year postoperative follow-up were enrolled in this retrospective, monocentric study. Clinical outcome scores including the 12-Item Short-Form Survey, American Shoulder and Elbow Surgeons (ASES), Quick Disabilities of the Arm, Shoulder, and Hand, Single-Assessment Numeric Evaluation, and visual analog scale pain were collected. Additionally, it was determined which patients reached the minimal clinically important difference and the patient-acceptable symptom state for the ASES score. Bivariate analysis was utilized to determine if there was any association between baseline demographic and clinical factors with the outcome scores.

Results

Of a total of 814 patients assessed for eligibility, an aggregate of 40 patients were included and 33 patients (8 females) were available for follow-up. The average age was 49.4 ± 7.6 years. At an average follow-up of 7.0 ± 3.6 years, all the outcome scores significantly improved compared to baseline. These included ASES (69.9 ± 19 to 95.8 ± 7.6, P < .001); the Quick Disabilities of the Arm, Shoulder, and Hand score (29.7 ± 17.7 to 3.9 ± 5.4, P < .002); Single Assessment Numeric Evaluation score (53.5 ± 29.3 to 91.6 ± 14.3, P < .003); the 12-Item Short-Form Survey (45.6 ± 8.8 to 55.2 ± 5.7, P < .001); and the visual analog scale (2.1 ± 2.1 to 0.3 ± 1, P < .002). The minimal clinically important difference was reached by 72.7% of the patients and 81.8% reached the patient-acceptable symptom state threshold for the ASES score. Postoperative shoulder stability improved substantially and significantly. Median postoperative satisfaction was 10/10 (range 1-10). Ninety-five-point-six percent of the patients returned to sport, with 91.0% of the patients able to return to preinjury level. One patient (3%) underwent revision surgery for osteoarthritis, in the form of comprehensive arthroscopic management procedure. The presence of cartilage defects cartilage defects Outerbridge grade >2 (P = .020) and posterior labral lesions (P = .03) at index surgery were significantly associated with inferior outcomes in the ASES score.

Conclusion

Active patients aged 40 years and older undergoing arthroscopic shoulder stabilization experienced favorable functional outcomes at a mean follow-up of 7 years, with low rates of revision surgery or of progression to clinically relevant osteoarthritis. However, the presence of high-grade cartilage lesions and the presence of a posterior labral tear were associated with inferior clinical outcomes.

Arthroscopic stabilization surgery for first-time anterior shoulder dislocations: a systematic review and meta-analysis

BACKGROUND

The optimal management of first-time anterior shoulder dislocations (FTASDs) remains controversial. Therefore, the purpose of this study was to assess the efficacy of arthroscopic stabilization surgery for FTASDs through a systematic review and meta-analysis of existing literature.

METHODS

MEDLINE, Embase, and Web of Science were searched from inception to December 18, 2022, for single-arm or comparative studies assessing FTASDs managed with arthroscopic stabilization surgery following first-time dislocation. Eligible comparative studies included studies assessing outcomes following immobilization for an FTASD, or arthroscopic stabilization following recurrent dislocations. Eligible levels of evidence were I to IV. Primary outcomes included rates of shoulder redislocations, cumulative shoulder instability, and subsequent shoulder stabilization surgery.

RESULTS

Thirty-four studies with 2222 shoulder dislocations were included. Of these, 5 studies (n = 408 shoulders) were randomized trials comparing immobilization to arthroscopic Bankart repair (ABR) after a first dislocation. Another 16 studies were nonrandomized comparative studies assessing arthroscopic Bankart repair following first-time dislocation (ABR-F) to either immobilization (studies = 8, n = 399 shoulders) or arthroscopic Bankart repair following recurrent dislocations (ABR-R) (studies = 8, n = 943 shoulder). Mean follow-up was 59.4 ± 39.2 months across all studies. Cumulative loss to follow-up was 4.7% (range, 0%-32.7%). A composite rate of pooled redislocation, cumulative instability, and reoperations across ABR-F studies was 6.8%, 11.2%, and 6.1%, respectively. Meta-analysis found statistically significant reductions in rates of redislocation (odds ratio [OR] 0.09, 95% confidence interval [CI] 0.04-0.3, P < .001), cumulative instability (OR 0.05, 95% CI 0.03-0.08, P < .001), and subsequent surgery (OR 0.08, 95% CI 0.04-0.15, P < .001) when comparing ABR-F to immobilization. Rates of cumulative instability (OR 0.32, 95% CI 0.22-0.47, P < .001) and subsequent surgery rates (OR 0.27, 95% CI 0.09-0.76, P = .01) were significantly reduced with ABR-F relative to ABR-R, with point estimate of effect favoring ABR-F for shoulder redislocation rates (OR 0.59, 95% CI 0.19-1.83, P = .36). Return to sport rates to preoperative levels or higher were 3.87 times higher following ABR-F compared to immobilization (95% CI 1.57-9.52, P < .001), with limited ABR-R studies reporting this outcome. The median fragility index of the 5 included randomized controlled trials (RCTs) was 2, meaning reversing only 2 outcome events rendered the trials' findings no longer statistically significant.

CONCLUSION

Arthroscopic stabilization surgery for FTASDs leads to lower rates of redislocations, cumulative instability, and subsequent stabilization surgery relative to immobilization or arthroscopic stabilization surgery following recurrence. Although a limited number of RCTs have been published on the subject matter to date, the strength of their conclusions is limited by a small sample size and statistically fragile results.

Rotator Cuff Tears are Significantly More Frequent in Recurrent Shoulder Instability Patients With Initial Dislocation at Age 40 or Older

PURPOSE

To investigate and compare the pathologies and clinical outcomes of patients with traumatic anterior shoulder instability who underwent arthroscopic stabilization at 40 years or older between shoulders with initial dislocation before age 40 years and at 40 years or after.

METHODS

Shoulders that underwent arthroscopic stabilization for recurrent traumatic anterior shoulder instability at 40 years or older with a minimum of 2-year follow-up were included. The subjects were divided into 2 groups according to age at initial dislocation after propensity score matching to reduce potential bias: younger than 40 years (group 1) and 40 years or older (group 2). Radiographic findings, pathologies, clinical outcomes, and complications were compared between the groups.

RESULTS

Group 1 included 56 shoulders in 56 patients (26 men and 30 women) with a mean age of 51 years (range, 40-77 years). Group 2 included 28 shoulders in 28 patients (13 men and 15 women) with a mean age of 51 years (range, 40-77 years). Glenoid bone loss was greater in group 1 than in group 2 (P = .004). Rotator cuff tears were more frequently observed in group 2 than in group 1 (P < .001). Both groups showed significant improvement in the West Ontario Shoulder Instability Index score (P < .001 for each) and flexion (P < .001 for each). The recurrence rate was 4% in group 1 and 7% in group 2.

CONCLUSIONS

Rotator cuff tears are significantly more frequent in recurrent shoulder instability patients with initial dislocation at age 40 or older. Arthroscopic stabilization yielded a low recurrence rate and favorable outcomes with a good return-to-sport rate in patients 40 years or older.

LEVEL OF EVIDENCE

Level III, retrospective comparative prognostic trial.

Increased superior translation following multiple simulated anterior dislocations of the shoulder

PURPOSE

Recurrent shoulder dislocations can result in kinematic changes of the glenohumeral joint. The number of prior shoulder dislocations may contribute to increased severity of capsulolabral lesions. The kinematics of the glenohumeral joint following multiple dislocations remain poorly understood. The purpose of this study was to assess the kinematics of the glenohumeral joint during anterior dislocations of the shoulder, and more specifically, altered translational motion following multiple dislocations. The kinematics of the glenohumeral joint were hypothesized to change and correlate with the number of dislocations.

METHODS

Eight fresh-frozen cadaveric shoulders were dissected free of all soft tissues except the glenohumeral capsule. Each joint was mounted in a robotic testing system. At 60 degrees of glenohumeral abduction, an internal and external rotational torque (1.1 Nm) were applied to the humerus, and the resulting joint kinematics were recorded. Anterior forces were applied to the humerus to anteriorly dislocate the shoulder and the resulting kinematics were recorded during each dislocation. Following each dislocation, the same rotational torque was applied to the humerus, and the resulting joint kinematics were also recorded. A repeated-measures analysis of variance (ANOVA) was used to compare the kinematics following each dislocation.

RESULTS

During the 7th, 8th, 9th, and 10th dislocations, the humerus significantly translated superiorly compared with the shoulder during the 1st dislocation (p < 0.05). Following the 3rd, 4th, 5th, and 10th dislocations, the humeral head significantly translated superiorly compared with the shoulder following the 1st dislocation in the position of 60 degrees of abduction in response to external rotation torque (p < 0.05).

CONCLUSION

Multiple anterior shoulder dislocations lead to abnormal translational kinematics and result in increased superior translation of the humerus. This may contribute to pathologic superior extension of capsulolabral injuries. Superior translation of the humerus with overhead motion in the setting of recurrent instability may also place the shoulder at risk for extension of the capsulolabral injuries.

Natural History of First-Time Anterior Shoulder Dislocation in Patients Older Than 50 Years: A Study of 179 Patients With a Mean Follow-up of 11 Years

Background

There is a dearth of knowledge on anterior shoulder instability in older patients.

Purpose/Hypothesis

The purposes of this study were to describe the incidence and epidemiology, injury characteristics, and treatment and outcomes in patients ≥50 years old with first-time anterior shoulder instability. We also describe the historical trends in diagnosis and treatment. It was hypothesized that the rates of obtaining a magnetic resonance imaging (MRI) scan and surgical intervention have increased over the past 20 years.

Study Design

Descriptive epidemiology study.

Methods

An established geographic database was used to identify 179 patients older than 50 years who experienced new onset anterior shoulder instability between 1994 and 2016. Medical records were reviewed to obtain patient characteristics, imaging characteristics, and surgical treatment and outcomes, including recurrent instability. Comparative analysis was performed to identify differences between age groups. Mean follow-up time was 11 years.

Results

The incidence of first-time anterior shoulder dislocation in our study population was 28.8 per 100,000 person-years, which is higher than previously reported. Full-thickness rotator cuff tears were found in 62% of the 66 patients who underwent MRI scans. Of all patients, 26% progressed to surgery at a mean time of 1.6 years after injury; 57% of all surgical procedures involved a rotator cuff repair, and 17% included anterior labral repair. All patients who underwent a labral repair also underwent concomitant rotator cuff repair. The rate of recurrent instability for the cohort was 15% at a median of 176 days after the initial instability event. There were no instances of recurrent instability after operative intervention. At an average of 7.5 years after the initial instability event, 14% of patients developed radiographic progression of glenohumeral arthritis. The rate of surgical intervention within 1 year of initial dislocation increased from 5.1% in 1994 to 1999 to 52% in 2015 to 2016.

Conclusion

The incidence of first-time anterior shoulder instability in patients aged ≥50 years was 28.8 per 100,000 person-years. Full-thickness rotator cuff tears (62%) were the most common condition associated with anterior shoulder instability, followed by Hill-Sachs lesions (56%). The rate of recurrent instability for the entire cohort was 15%, with no instances of recurrent instability after operative intervention.

Recurrence of glenohumeral instability in patients with isolated rotator cuff repair after a traumatic shoulder dislocation

INTRODUCTION

The primary objective of this study was to assess the incidence of recurrent glenohumeral instability in patients over 40 years with isolated rotator cuff (RC) repair for traumatic shoulder dislocation. The secondary objectives were to identify risk factors for glenohumeral recurrence after RC repair and to describe the causes and incidences of re-intervention.

MATERIALS AND METHODS

In this retrospective cohort study, data of consecutive patients at a single trauma center between January 2014 and July 2019 were reviewed, and 84 patients with a mean age of 57 (range: 40-75) years and follow-up duration of 3.9 (2-6) years were included. The inclusion criteria were as follows: first traumatic anterior shoulder dislocation, reparable RC tear, primary arthroscopic RC repair, no labral or bony Bankart lesion repair, and at least 2 years of follow-up. Patients less than 40 years of age were excluded. Shoulder instability recurrences and surgical reinterventions were reviewed with medical records. Statistical analysis was performed for qualitative variables using the Chi-squared test. Statistical significance was set at P ≤ 0.05.

RESULTS

There was one patient with a redislocation episode (1.2%) at 2.5 years after surgery, who was surgically treated. Age, subscapular tears, bony Bankart injuries, humeral defects, and associated neurological injuries were not risk factors for recurrence in this study. Ten patients (11.9%) required reintervention. Nine patients (10.7%) re-tore their RCs.

CONCLUSIONS

Recurrent glenohumeral instability in active patients over 40 years with isolated RC repair after traumatic shoulder dislocation was infrequent, despite the incidence of significant Hill-Sachs defects, anterior glenoid defects, bipolar bone defects, size of the RC injury, and tendon re-tears. The incidence of re-interventions was 11.9%, with symptomatic RC retear as the main cause.

Primary traumatic shoulder dislocation associated with rotator cuff tear in the elderly

Introduction and importance

The shoulder is one of the most unstable joints of the body. Shoulder dislocation accounts for up to 60% of all major joint dislocations. This study reports two cases of primary traumatic shoulder dislocation and shows that in the elderly, primary traumatic shoulder dislocation is associated with a rotator cuff tear (RCT).

Case presentation

A case report and narrative review included two female patients, aged 63 and 100 years. Presenting symptoms were instability, pain, and restricted shoulder movement. Both were successfully treated by surgery. Arthroscopy was performed in the first patient and open reduction in the second patient.

Clinical discussion

In the first case, we found synovitis around the rotator interval, long head of the biceps tendinitis, and tears of the subscapularis tendon, supraspinatus tendon, and subacromial bursitis. The anterior labrum was normal. In the second case, complete detachment of the infraspinatus tendon was found. In both cases, rotator cuff repair was performed. Primary traumatic shoulder dislocation in the elderly is often associated with rotator cuff injury. Therefore, a detailed evaluation and management of the rotator cuff injury is essential. Rotator cuff injuries cause loss of dynamic stabilization of the shoulder, leading to recurrent shoulder dislocation and chronic shoulder instability.

Conclusion

The associated pathology of the primary traumatic shoulder dislocation in elderly are rotator cuff tear. The management of the rotator cuff tear in primary traumatic shoulder dislocation can prevent further shoulder instability events.

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Primary traumatic shoulder dislocation in the elderly is highly associated with rotator cuff tear.

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The rotator cuff acted as a dynamic shoulder stabilizer.

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Early identification and treatment of the associated rotator cuff tear can prevent further shoulder instability.

Advanced 3-Dimensional Characterization of Hill-Sachs Lesions in 100 Anterior Shoulder Instability Patients

PURPOSE

We sought to qualitatively and quantitatively describe characteristics of Hill-Sachs lesions (HSL) in a cohort of anterior shoulder instability patients using advanced 3-dimensional (3-D) modeling software and assess the impact of various HSL parameters on the HSL volume, location, and orientation in patients with anterior shoulder instability.

METHODS

A total of 100 recurrent anterior instability patients with evidence of HSL with a mean age of 27.2 years (range = 18 to 43 years) were evaluated. Three-dimensional models of unilateral proximal humeri were reconstructed from CT scans, and the volume, surface area (SA), width, and depth of identified HSLs were quantified along with their location (medial, superior, and inferior extent). Multiple angular orientation measures of HSLs were recorded, including Hill-Sachs rim (HSLr) angle in order to classify the level and location of potential humeral head engagement. Mann-Whitney U test assessed the relationship between measured parameters.

RESULTS

By volume, larger HSL had greater humeral head surface area (HH SA) loss (P = .001), HSL width (P = .001), were more medial (P = .015), and more inferior (P = .001). Additionally, more medial lesions had greater HSLr angles (P = 0.001). The mean depth, width, and volume of HSLs were 3.3 mm (range = 1.2-7.1 mm), 16.0 mm (range = 6.2-30.4 mm) and 449.2 mm³ (range = 62.0-1365.6 mm³), respectively. The medial border of the HSL extended to 17.2 ± 4.4 (range = 9.3-28.3 mm) off the most medial edge of the HH cartilage margin (medialization). The mean HSLr was 29.3 ± 10.5°.

CONCLUSION

There was a statistically significant association between HSL medialization and HSL volume, position, and orientation. More medialized HSL have larger volume, greater width, more SA loss and higher lesion angles and are more inferior in the humeral head. As it has been established that more medialized lesions have poorer clinical outcomes, this study highlights that HS lesions have varying angles and medialization, which may portend eventual treatment and outcomes.

LEVEL OF EVIDENCE

IV, case series.

Recurrent anterior shoulder instability in patients 40-60 years old. Accompanying injuries and patient outcomes of arthroscopic repair

BACKGROUND

Accompanying injuries are frequently seen in middle aged patients with recurrent instability. The aim of this study was to elucidate the associated injuries, report patient outcomes of the following arthroscopic instability surgery regarding 40-60 years old patients with recurrent shoulder instability.

METHODS

Patients that underwent arthroscopic instability surgery due to recurrent shoulder instability between February 2008 and November 2015, and which were 40-60 years old were included and evaluated retrospectively. Minimum follow-up duration was 24 months. Anterior-inferior labral injuries and accompanying pathologies such as rotator cuff tears and SLAP lesions were documented. Postoperative patient-reported outcome evaluation was made using Oxford Shoulder Instability Score.

RESULTS

Among 355 patients that underwent arthroscopic instability surgery, 88 patients which had pathology of recurrent instability were in the range of 40-60 years old. Patients who had previous shoulder surgery or fracture (n = 8) epileptic seizure history (n = 3), neurologic deficit (n = 2) were excluded from the study. 75 patients were included with a mean follow-up 69 ± 23 months (32-125). The percentage of middle-aged and elderly (40-60 years old) was 24.8% among recurrent shoulder instability patients. 44% had isolated Bankart lesion whereas 56% revealed multiple pathologies. Bankart + SLAP lesions were found in 32%, whereas Bankart + Rotator Cuff tears in 26.7% (13 isolated supraspinatus, 4 supraspinatus + subscapularis, 1 isolated subscapularis full-thickness and 2 partial-thickness supraspinatus tears). The mean Oxford Shoulder Instability Score was 38.4 ± 5.2 (26-48). The scores of patients which were treated with labrum and rotator cuff repair (median 42, range 30-48) were significantly better than the patients who were treated with isolated labrum repair (median 39, range 20-46) (p = 0.015). There was no difference regarding patients with or without SLAP repair (median 39 vs 39 and range 30-48 vs 20-48, respectively) (p = 0.702).

CONCLUSIONS

Arthroscopic repair of capsulolabral lesions is a safe and successful technique in 40-60 years old patients. Furthermore, the presence of repaired rotator cuff tears led to even superior results. Accompanying SLAP lesions did not affect the results.

STUDY DESIGN

Retrospective Case Series.

LEVEL OF EVIDENCE

4, Retrospective Case Series.

Rotator Cuff Repair Improves Clinical Function and Stability in Patients Older Than 50 Years With Anterior Shoulder Dislocations and Massive Rotator Cuff Tears

Background:

Older patients with shoulder instability have a higher prevalence of rotator cuff tears and anterior capsular lesions. Simultaneous rotator cuff repair and labral repair are commonly performed to improve shoulder stability and function.

Purpose:

To investigate the clinical outcomes of arthroscopic rotator cuff repair for older patients with shoulder dislocations combined with massive rotator cuff tears and intact labral tissue.

Study Design:

Case series; Level of evidence, 3.

Methods:

A cohort consisting of 11 patients older than 50 years with shoulder dislocations and massive rotator cuff tears undergoing arthroscopic rotator cuff repair was identified between December 2015 and January 2018. Rotator cuff repair was performed after Bankart, superior labral anterior-posterior, and humeral avulsion of the glenohumeral ligament lesions were excluded during arthroscopic surgery. Preoperative and 12-month postoperative outcomes including modified University of California Los Angeles (UCLA), American Shoulder and Elbow Surgeons (ASES), Western Ontario Shoulder Instability Index (WOSI), and visual analog scale for pain scores as well as range of motion (ROM) were recorded.

Results:

The supraspinatus tendon was torn in all patients. Also, 36.4% of the patients had 3 rotator cuff tendons torn. For shoulder function, the preoperative UCLA score (12.1 ± 2.5 [range, 9-16]) and ASES score (35.4 ± 12.7 [range, 24-44]) significantly improved to 29.4 ± 4.3 (range, 24-35; P < .001) and 79.4 ± 16.0 (range, 45-95; P < .001), respectively, at 12 months postoperatively. None of the patients experienced shoulder redislocations at 12 months after surgery. For shoulder stability, the postoperative WOSI score (156.8 ± 121.0 [range, 45-365]) was significantly better than was the preoperative score (713.0 ± 238.6 [range, 395-1090]) (P < .001). For comparisons between preoperative and postoperative ROM, forward flexion, abduction, and external and internal rotation at the side significantly improved.

Conclusion:

For patients older than 50 years with shoulder dislocations combined with massive rotator cuff tears and an intact labrum, arthroscopic rotator cuff repair alone achieved satisfactory functional outcomes and ROM without the recurrence of dislocations.

[Short-term effectiveness of arthroscopically capsular vertical mattress suturing for shoulder recurrent anterior dislocation combined with joint laxity]

OBJECTIVE

To evaluate the short-term effectiveness of arthroscopically capsular vertical mattress suturing for shoulder recurrent anterior dislocation combined with joint laxity.

METHODS

A retrospective analysis was performed on 6 shoulder recurrent anterior dislocation patients combined with joint laxity treated with arthroscopically capsular vertical mattress suturing between January 2017 and December 2018. There were 5 males and 1 female with an average age of 20.8 years (range, 19-24 years). The number of shoulder dislocation was 3-18 times, with an average of 9.5 times. The disease duration ranged from 2 to 60 months, with an average of 25.3 months. The preoperative Beighton score was 4-7, with an average of 5.8; the Instability Severity Index Score (ISIS) was 2-5, with an average of 3.5. There were 5 cases of simple Bankart injury and 1 case of bony Bankart injury. The range of motion of shoulder joint (including active flexion and lifting, external rotation, abduction and external rotation, and internal ratation) was recorded before operation and at last follow-up; Oxford shoulder instability score, Rowe shoulder instability score, and Simple Shoulder Test (SST) score were used to evaluate shoulder joint function before operation, at 6 months after operation, and at last follow-up, and complications were recorded.

RESULTS

All patients were followed up 16-28 months (mean, 19.3 months). During the follow-up, all patients had satisfactory motor function, and no re-dislocation and postoperative neurovascular complications occurred. At last follow-up, the activities of active external rotation and abduction and external rotation were significantly improved when compared with those before operation ( P<0.05); the activities of active flexion and lifting and internal rotation were not limited before and after operation, and the difference was not significant ( P>0.05). The Oxford shoulder instability score, Rowe shoulder instability score, and SST score at 6 months after operation and at last follow-up were significantly improved when compared with those before operation ( P<0.05); there was no significant difference between at 6 months after operation and at last follow-up ( P>0.05).

CONCLUSION

The treatment of shoulder recurrent anterior dislocation combined with joint laxity by arthroscopically vertical matress suturing can achieve good short-term effectiveness.

Concomitant rotator cuff repair and instability surgery provide good patient-reported functional outcomes in patients aged 40 years or older with shoulder dislocation

Background

Recurrent anterior shoulder dislocation in patients aged ≥ 40 years is not as rare as once thought. The mechanism of instability in this patient population is different—more likely to be attributed to rotator cuff pathology—compared with that in younger individuals. With an increasingly aging active population, surgical management has a rising role in preventing morbidity associated with recurrent instability. Our purpose was to evaluate outcomes of anterior shoulder instability repair (ie, Bankart or bony Bankart repair) with and without rotator cuff repair (RCR) in patients aged ≥ 40 years.

Methods

We conducted a retrospective chart review of all patients aged ≥ 40 years who underwent surgical repair for anterior shoulder instability from 2008-2016. Patients were categorized into 4 cohorts: Bankart repair only, bony Bankart repair only, Bankart repair with concomitant RCR, and bony Bankart repair with concomitant RCR. Demographic and history-of-instability data were collected. Clinical and functional outcomes assessed included the Single Assessment Numeric Evaluation score, American Shoulder and Elbow Surgeons score, Penn Shoulder Score, visual analog scale score for pain, Western Ontario Shoulder Instability Index score, and patient satisfaction score.

Results

A total of 146 patients were included in this study, with 103 patients (71%) having ≥2-year outcome scores. Outcome scores were not significantly different among groups. For patients who underwent Bankart repair only, bony Bankart repair only, Bankart repair with RCR, and bony Bankart repair with RCR, the Single Assessment Numeric Evaluation scores were 80.8 ± 19.7, 90.0 ± 10.7, 79.3 ± 29.4, and 87.2 ± 10.6, respectively (P = .284); American Shoulder and Elbow Surgeons scores, 83.8 ± 19.7, 92.4 ± 17.4, 82.5 ± 25.6, and 85.6 ± 12.7, respectively (P = .114); Penn Shoulder Scores for function, 84.5 ± 17.9, 90.9 ± 15.3, 83.6 ± 25.1, and 95.7 ± 13.0, respectively (P = .286); and Western Ontario Shoulder Instability Index scores, 481.0 ± 519.5, 292.1 ± 414.3, 548.9 ± 690.5, and 320.6 ± 258.7, respectively (P = .713). Age at the time of surgery significantly differed between cohorts (P < .001). No patients had recurrence of instability during the study period.

Conclusion

Similar functional outcomes can be achieved in the surgical management of anterior instability in patients aged ≥ 40 years. Rotator cuff tears should be suspected and repaired in patients with anterior instability, especially those aged ≥ 50 years.

Anterior Shoulder Instability in the Aging Population: MRI Injury Pattern and Management

BACKGROUND. Literature on glenohumeral dislocations has focused on younger patient populations because of high recurrence rates. However, the spectrum of injuries sustained in younger versus older patient populations is reported to be quite different. OBJECTIVE. The purpose of this article is to describe MRI findings and management of anterior shoulder instability in the aging (≥ 60 years) population. METHODS. Shoulder MRI examinations of anterior glenohumeral dislocations in patients 40 years old and older were subdivided into groups younger than 60 years old or 60 years old and older and reviewed by two musculoskeletal radiologists for a Hill-Sachs lesion, other fracture, glenoid injury, capsulolabral injury, rotator cuff tear, muscle atrophy, and axillary nerve injury. Fischer exact test and logistic regression was evaluated for significant differences between cohorts, and interreader agreement was assessed. Surgical management was recorded, if available. RESULTS. A total of 104 shoulder MRI examinations (age range, 40-79 years; mean age, 58.3 years; 52 women, 52 men) were reviewed (54 examinations < 60 years; 50 examinations ≥ 60 years). Acute high-grade or full-thickness supraspinatus (64.0% vs 37.0%; p = .001), infraspinatus (28.0% vs 14.8%; p = .03), and subscapularis (22.0% vs 3.7%; p = .003) tears were more common in the group 60 years old and older. Hill-Sachs lesions were more common in the younger group (81.5% vs 62.0%; p = .046). Greater tuberosity fractures were seen in 15.4% of the overall cohort, coracoid fractures in 4.8%, and acute axillary nerve injuries in 9.6%. Interreader concordance was 88.5-89.4% for rotator cuff tears and 89.4-97.1% for osseous injury. In the group younger than 60 years old, 11 of 37 subjects (29.7%) had rotator cuff repair and 11 of 37 (29.7%) had labral repair, whereas 17 of 36 (47.2%) of the older group underwent rotator cuff repair, six of 36 (16.7%) underwent reverse shoulder arthroplasty, and six of 36 (16.7%) underwent labral repair. CONCLUSION. Radiologists should have a high index of suspicion for acute rotator cuff tears in anterior shoulder instability, especially in aging populations. Greater tuberosity or coracoid fractures and axillary nerve injury occur across all ages, whereas Hill-Sachs injuries are more common in younger patients. CLINICAL IMPACT. Acute high-grade or full-thickness rotator cuff tears are seen with higher frequency in older populations after anterior glenohumeral dislocation. Osseous and nerve injuries are important causes of patient morbidity that if not carefully sought out may be overlooked by the interpreting radiologist on routine imaging.

Risk Factors for Postoperative Opioid Use in Arthroscopic Shoulder Labral Surgery

PURPOSE

To determine the correlation between preoperative and postoperative opioid use in patients undergoing arthroscopic shoulder labral repair, as well as patient risk factors associated with increased postoperative opioid use after the procedure.

METHODS

A retrospective review of all patients undergoing arthroscopic shoulder labral surgery at a single institution between August 2013 and November 2017 was performed. Patients were stratified as opioid nonusers, acute users, or chronic users based on preoperative consumption. Patient demographic characteristics, injury characteristics, surgical interventions, and postoperative opioid use for the first 12 months after surgery were then analyzed.

RESULTS

A total of 340 patients were included in this study. The average age was 26.3 years (range, 13-68 years), and the average body mass index was 27.5 (range, 18.4-45.0). Preoperative opioid users (acute and chronic) were found to continue to receive opioid medications at extended time points beyond 2 months postoperatively compared with nonusers (P < .001). Patients with intraoperatively identified SLAP tears experienced more preoperative pain and required more postoperative opioid prescriptions (P = .018). On stratification for other common shoulder instability injury patterns, no differences were found between the number of postoperative opioid prescriptions filled and the presence of Bankart lesion, Hill-Sachs lesion, reverse Hill-Sachs lesion, anterior labroligamentous periosteal sleeve avulsion, glenolabral articular disruption, or humeral avulsion of the glenohumeral ligament (P > .05).

CONCLUSIONS

In patients undergoing arthroscopic labral surgery, the chronicity of preoperative opioid use, number of concomitant procedures at the time of initial surgery, and presence of biceps tenodesis were found to significantly increase postoperative opioid demand. Orthopaedic surgeons should recognize risk factors for increased opioid use postoperatively and adapt treatment strategies and patient counseling accordingly.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Editorial Commentary: Middle-Age Does Not Confer Immunity From Recurrent Instability After Arthroscopic Bankart Repair

Recurrent anterior shoulder instability remains a challenge to treat with arthroscopy, as the rate of postoperative instability remains high in certain patient populations. Indications for performing an "anatomic" arthroscopic reconstruction (isolated Bankart repair) are narrowing as surgeons identify risk factors for failure with this approach. In particular, the presence of certain bone loss patterns that occur with high numbers of instability events should prompt consideration for nonanatomic reconstruction, such as Latarjet or Hill-Sachs remplissage, to reduce the rate of postoperative recurrent instability.