Arthroscopic Bankart Repair With Remplissage in Comparison to Bone Block Augmentation for Anterior Shoulder Instability With Bipolar Bone Loss: A Systematic Review

Arthroscopic Bankart Repair With Remplissage in Anterior Shoulder Instability Results in Fewer Redislocations Than Bankart Repair Alone at Medium-term Follow-up of a Randomized Controlled Trial

BACKGROUND

A multicenter, double-blinded randomized controlled trial comparing isolated Bankart repair (NO REMP) to Bankart repair with remplissage (REMP) reported benefits of remplissage in reducing recurrent instability at 2 years postoperative. The ongoing benefits beyond this time point are yet to be explored.

PURPOSE

To (1) compare medium-term (3 to 9 years) outcomes of these previously randomized patients undergoing isolated Bankart repair (NO REMP) or Bankart repair with remplissage (REMP) to manage recurrent anterior glenohumeral instability; (2) examine the failure rate, overall recurrent instability, and reoperation rate.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Recruitment and randomization for the original randomized trial occurred between 2011 and 2017. Patients ≥14 years diagnosed with recurrent traumatic anterior shoulder instability with an engaging Hill-Sachs defect of any size were included. Those with a glenoid defect >15% were excluded. In 2020, participants were contacted by telephone and asked standardized questions regarding ensuing instances of subluxation, dislocation, or reoperation on their study shoulder. "Failure" was defined as a redislocation, and "overall recurrent instability" was described as a redislocation or ≥2 subluxations. Descriptive statistics, relative risk, and Kaplan-Meier survival curve analyses were performed.

RESULTS

A total of 108 participants were randomized, of whom 50 in the NO REMP group and 52 in the REMP group were included in the analyses in the original study. The mean number of months from surgery to the final follow-up was 49.3 and 53.8 months for the NO REMP and REMP groups, respectively. Failure rates were 22% (11/50) in the NO REMP group versus 8% (4/52) in the REMP group. Rates of overall recurrent instability were 30% (15/50) in the NO REMP group versus 10% (5/52) in the REMP group. Survival curves were significantly different, favoring REMP in both scenarios.

CONCLUSION

For the treatment of traumatic recurrent anterior shoulder instability with a Hill-Sachs lesion and subcritical glenoid bone loss (<15%), a significantly lower rate of overall postoperative recurrent instability was observed with arthroscopic Bankart repair and remplissage than with isolated Bankart repair at a medium-term follow-up (mean of 4 years). Patients who did not receive a remplissage experienced a failure (redislocated) earlier and had a higher rate of revision/reoperation than those who received a concomitant remplissage.

REGISTRATION

NCT01324531 (ClinicalTrials.gov identifier).

Arthroscopic remplissage: history, indications, and clinical outcomes

Several surgical procedures have been proposed to address anterior glenohumeral instability, which is one of the most common complaints in the general population. The remplissage, first described in early 2000s, is a procedure performed simultaneously with the arthroscopic Bankart repair to correct large, engaging Hill-Sachs lesions (HSLs). This procedure stabilizes the joint by tenodesing the infraspinatus tendon into the HSL to fill and disengage the defect. This procedure gained popularity because it has relatively low risk and is able to improve shoulder stability while being less invasive than other bone-blocking procedures. The remplissage has become a valuable add-on technique that can substantially improve outcomes in unstable patients undergoing arthroscopic Bankart repair. Nevertheless, several studies in the literature have raised concerns regarding its efficacy in critically unstable patients and the potential range of motion limitations that can arise postoperatively. Additional comparative studies and trials should be conducted to appropriately establish the role of remplissage in treating anterior instability, especially in patients with critical bone loss.

Glenoid track revisited

The risk of Hill-Sachs lesion (HSL) to cause instability depends not only on the HSL but also on the glenoid size. Clinically, the only method to assess the risk of instability considering the dynamic interaction of both, the HSL together with the glenoid bone loss, is the glenoid track concept. Since it was introduced in a cadaveric study, its clinical efficacy and validity have been reported in the literature. Sometimes, the medial margin of the footprint (lateral margin of the glenoid track) is difficult to identify when a HSL is overriding the footprint. In such cases, we propose a method to draw an imaginary line connecting 2 landmarks. Although 3-dimensional computed tomography is the most accurate and widely used method to assess on/off-track lesions, our interest gradually is shifting toward magnetic resonance imaging (MRI), which has no radiation concern. The current magnetic resonance method is still under way. There are various risk factors influencing the recurrent instability after surgery. The glenoid track concept deals with only 1 of these factors, that is, instability caused by bony lesions. Therefore, the following 2 issues are important: 1) how to assess the glenoid track precisely and 2) how to incorporate other risk factors into consideration. The former can be achieved by obtaining the custom-made glenoid track width using not the fixed value of 83%, but more individualized value obtained by measuring the active horizontal extension angle of the opposite shoulder in the sitting position. At the same time, the gray zone (peripheral-track lesion) needs to be clearly defined. The latter can be achieved by incorporating the risk factors other than the bony lesions. One example is the Glenoid Track Instability Management Score (GTIMS), a combination of the glenoid track concept and the instability severity index score. This new scoring system is expected to increase the predictive potential of the scoring system, and accordingly to enhance clinical decision-making.

Clinical Outcomes and Graft Resorption After Metal-Free Bone Block Suture Tape Cerclage Fixation for Recurrent Anterior Shoulder Instability: A Computed Tomography Analysis

BACKGROUND

Glenoid reconstruction with a bone block for anterior glenoid bone loss (GBL) has shown excellent outcomes. However, fixation techniques that require metal implants are associated with metal-related complications and bone graft resorption.

HYPOTHESIS

Arthroscopic glenoid reconstruction using a tricortical iliac crest bone graft (ICBG) and metal-free suture tape cerclage fixation can safely and effectively restore the glenoid surface area in patients with recurrent anterior shoulder instability and anterior GBL.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Adult patients (≥18 years) of both sexes with recurrent anterior shoulder instability and anterior GBL ≥15% were enrolled. These patients underwent arthroscopic glenoid reconstruction with ICBGs and metal-free suture tape cerclage fixation. The effectiveness and clinical outcomes with this technique were evaluated at 24 months using functional scores. Resorption of the graft articular surface was assessed by computed tomography, with the graft surface divided into 6 square areas aligned in 2 columns. Descriptive analysis was conducted.

RESULTS

A total of 23 consecutive patients met inclusion criteria (22 male, 1 female; mean age, 30.5 ± 7.9 years). The mean preoperative GBL was 19.7% ± 3.4%, and there were 15 allograft and 8 autograft ICBGs. All patients exhibited graft union at 3 months. The median follow-up was 38.5 months (interquartile range, 24-45 months). The Western Ontario Shoulder Instability Index, Rowe, Constant-Murley, and Subjective Shoulder Value scores improved from preoperatively (35.1%, 24.8, 83.1, and 30.9, respectively) to postoperatively (84.7%, 91.1, 96.0, and 90.9, respectively) (P < .001). No differences in clinical scores were observed between the graft types. One surgical wound infection was reported, and 2 patients (8.7% [95% CI, 2.4%-26.8%]) required a reoperation. The mean overall glenoid surface area increased from 80.3% ± 3.5% to 117.0% ± 8.3% immediately after surgery before subsequently reducing to 98.7% ± 6.2% and 95.0% ± 5.7% at 12 and 24 months, respectively (P < .001). The mean graft resorption rate was 18.1% ± 7.9% in the inner column and 80.3% ± 22.4% in the outer column. Additionally, 3 patients treated with an allograft (20.0% [95% CI, 7.1%-45.2%]), including the 2 with clinical failures, exhibited complete graft resorption at the last follow-up.

CONCLUSION

Arthroscopic glenoid reconstruction using an ICBG and metal-free suture tape cerclage fixation was safe and effective, yielding excellent clinical outcomes. Resorption of the graft articular surface predominantly affected the nonloaded areas beyond the best-fit circle perimeter.

Managing severe bipolar bone loss in athletes: A comprehensive approach with open Latarjet and arthroscopic remplissage

Background

Severe bipolar bone loss (BBL) represents one of the toughest challenges when managing the instability of glenohumeral joints among athletes and more specifically the ones involved in overhead sports. It refers to the significant loss of the humeral head and the glenoid bone, with an increased risk of failure. The present study aimed to evaluate the functional outcomes of a combined open Latarjet and arthroscopic remplissage in such high-risk individuals.

Methods

A retrospective evaluation was carried out among athletes with antero-inferior loss of glenoid bone of more than 15 % and large off-track Hill-Sachs defect who underwent the Latarjet technique with iliac crest bone graft (ICBG) harvest used in combination with arthroscopic remplissage between 2021 and 2023. The University of California, Los Angeles (UCLA) score, constant-Murley score (CMS), and the range of motion (ROM; measured as forward flexion, external rotation, and abduction) were evaluated pre-operative and post-operative at the timepoint of 3-month, 6-month, and 1-year. Pre-operative magnetic resonance imaging scans (MRI) and computed tomography scans (CT) were obtained among the patients with severe glenohumeral BBL, and the glenoid track was calculated to identify on-track and off-track Hill-Sachs lesions. Post-operative MRI with filled Hill-Sachs defect post remplissage procedure and 3D CT scan was also done at 6-month to evaluate the union of the ICBG to the native glenoid bone.

Results

Overall, 11 patients underwent for the combined procedure for severe BBL. The UCLA score (31.18 ± 3.74), and the CMS (93.64 ± 8.38) at the time-point of 1-year post-operatively showed remarkable improvement in comparison with the preoperative scores (P < 0.0001); and the ROM including abduction, external rotation, and forward flexion were restored to near normality. All patients showed bony union at 6-month as confirmed by post-operative CT scan. No complications such as redislocation or subluxation were observed over 1-year. There were no neurological complications or complications related to graft (graft migration or graft breakage or resorption) as well. All the athletes returned to sports activities at an average duration of 6.8-month post-operatively, with 73 % returning to sports at the level of pre-injury.

Conclusion

The combined procedure of ICBG Latarjet and arthroscopic remplissage for the treatment of severe BBL in athletes achieved satisfactory outcomes over 1-year, with all athletes returning to sports activities.

Accuracy and Consistency of 3-Dimensional Magnetic Resonance Imaging Is Comparable With 3-Dimensional Computed Tomography in Assessing Glenohumeral Instability: A Systematic Review

PURPOSE

To compare the accuracy of 3-dimensional (3D) magnetic resonance imaging (MRI) with that of 3D computed tomography (CT) in evaluating glenoid bone loss (GBL).

METHODS

This review aligned with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. PubMed, the Cochrane Library, Embase, and Web of Science were obtained from data inception to August 28, 2023. The search term "glenoid bone loss" was extracted and analyzed via stringent inclusion and exclusion criteria. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 combined with the QUADAS-Comparative to assess the heterogeneity of included studies.

RESULTS

A total of 1,589 related studies were retrieved, and 10 studies were finally included, of which a total of 143 shoulders were evaluated. The index test in QUADAS-Comparative was low risk in 9 studies. 3D MRI measurements of GBL were primarily best-fit circles (n = 9). In both clinical and cadaveric studies, the mean percentages of GBL measured by 3D MRI were 0.38% to 2.19% and 0.25% to 6.1% when compared with 3D CT and standard reference values, respectively. Intraclass correlation coefficient agreement greater than 0.9 between GBL percentages measured by 3D CT and 3D MRI. 3D MRI also could accurately measure glenoid width, glenoid height, humeral head width, and height. 3D MRI reconstruction time was similar to that of 3D CT, which was mainly 10 to 15 minutes.

CONCLUSIONS

In both clinical and cadaveric studies, compared with 3D CT, 3D MRI is accurate and consistent in assessing glenohumeral bone, especially in measuring GBL, and the reconstruction time of 3D MRI is similar to 3D CT.

LEVEL OF EVIDENCE

Level Ⅲ, systematic review of Level Ⅱ-Ⅲ studies.

Anterior Labral Reconstruction With Biceps Autograft for Anterior Shoulder Instability

Shoulder instability is a common problem, with current research focused on understanding the implications of humeral and glenoid bone loss. Soft tissue injury, including damage to the anterior labrum, deformity of the capsule, and disruption of the inferior glenohumeral ligament, also contributes to the pathology of shoulder dislocation with implications for recurrent instability. Anatomic placement of the labral tissue and restoration of capsular tension are essential components of successful arthroscopic Bankart repair (ABR). Patients who meet criteria for ABR with a diminutive, ruptured, or absent anterior labrum at the time of arthroscopic stabilization present a significant challenge to repair. In this Technical Note, we demonstrate a technique using biceps autograft to reconstruct the anterior labrum.

Beyond guesswork: how accurate are surgeons at determining the degree of glenoid bone loss in instability surgery?

Background

Accurate measurement of glenoid bone loss (GBL) is critical to preoperative planning in cases of recurrent shoulder instability. The concept of critical bone loss has been established with a value of GBL >13.5% being associated with higher failure rate following arthroscopic Bankart Repair. Advanced imaging, such as magnetic resonance imaging (MRI) scans, can be used to quantify GBL prior to surgery using the best-fit circle technique. Surgeons have traditionally relied on visual inspection of the MRI scan preoperatively or on visual inspection of the glenoid at the time of arthroscopy to determine whether GBL is present. The purpose of this study is to determine if 3 fellowship-trained shoulder surgeons could adequately quantify GBL without using best-fit circle measurements on MRI.

Methods

A retrospective review was performed which included 122 patients over an 8-year period that had an arthroscopic Bankart repair performed by 3 fellowship-trained surgeons. In all patients, preoperative MRI scans were retrospectively measured using best-fit circle technique to determine true GBL and compare that to the surgeons' preoperative and intraoperative estimation of GBL.

Results

GBL was correctly identified in only 36% (18/50) of patients when the preoperative best-fit circle measurements were not made. Critical bone loss was missed in 9.8% (12/122) of patients in the study group. The estimated mean bone loss in that group by visual inspection was 11.3% compared to 16% true bone loss measured on MRI. Even in the 18 patients with some identified bone loss prior to surgery, critical bone loss was missed in 6 patients when using visual inspection of the MRI or intraoperative inspection alone.

Conclusion

Simple visual inspection of glenoid images on MRI scan and visual inspection of the glenoid at the time of surgery are inaccurate in determining the true extent of GBL especially in cases of subtle bone deficiency. Preoperative planning is dependent on the exact degree of bone deficiency and measurement on the MRI scan using the best-fit circle technique is recommended in all cases of instability surgery.

Clinical Outcomes, Union Rates, and Complications of Screw Versus Button Fixation in the Bristow-Latarjet Procedure for Anterior Shoulder Instability: A Systematic Review and Meta-Analysis

Background

The Latarjet procedure is a common procedure for treating critical glenoid bone loss in anterior shoulder instability. Implants such as the screw and cortical button are widely used. The aim of this study was to compare studies on screw versus button fixation techniques in the Bristow-Latarjet procedure for anterior shoulder instability in terms of clinical outcomes, union rates, and complications.

Methods

The PubMed, Scopus, and Embase databases were searched to find comparative studies that reported outcomes of using screw versus button fixation in the Bristow-Latarjet procedure following the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Studies that directly compared the screw and button fixation techniques and provided postoperative patient-reported outcomes, union rates, or complications were included. The Methodology Index for Non-Randomized Research (MINORS) criteria were used to assess the quality of the included studies. Odds ratios (ORs) were calculated for dichotomous outcomes whereas mean differences were calculated for continuous outcomes.

Results

Five articles included a total of 877 shoulders. All five studies had level 3 evidence. There was no statistically significant difference between the two techniques using the Walch-Duplay score, visual analog scale for pain, American Shoulder and Elbow Surgeons score, Simple Shoulder Test, range of motion, and graft union rates. However, the button fixation technique had statistically significantly higher recurrence rates than the screw fixation technique (OR, 0.24; 95% confidence interval, 0.10-0.58; p = 0.001).

Conclusions

The screw fixation technique had statistically significantly lower recurrence rates than the button fixation technique. However, there was no significant difference between screw and button fixation techniques regarding postoperative patient-reported outcomes, range of motion, graft union rates, nerve injury rates, infection rates, and reoperation rates.

The Arthroscopic Bristow Procedure Is Superior to the Arthroscopic Latarjet Procedure in Return to Sports but Inferior in Graft Healing: A Comparative Study With 3.4-Year Follow-Up

PURPOSE

To compare clinical and computed tomography outcomes between the arthroscopic Latarjet procedure and the arthroscopic Bristow procedure.

METHODS

Patients who underwent arthroscopic Latarjet or Bristow procedures with at least 2 years of follow-up were retrospectively reviewed. Thirty-eight shoulders were included in the Latarjet group, and 34 were included in the Bristow group. Recurrence of dislocation, clinical scores, rate of return to sports (RTS), and computed tomography assessment findings (position of transferred coracoid, graft healing, graft absorption, and glenohumeral degenerative osteoarthritis [OA]) were obtained at final follow-up.

RESULTS

No recurrent dislocation occurred in either group, and no significant differences in clinical scores were found between the 2 procedures, with a mean follow-up period of 3.4 years. The operative time in the Bristow group was significantly shorter than that in the Latarjet group (P < .001). The transferred coracoid had healed in 94.7% of the patients in the Latarjet group and 85.3% in the Bristow group at final follow-up (P = .01). No significant difference in graft absorption or the degree of glenohumeral OA was detected between the 2 groups. However, moderate to severe OA only occurred in the Latarjet group at final follow-up (4 of 38 shoulders, 10.5%). The postoperative external rotation angle and level of RTS favored the Latarjet procedure (P = .030 and P = .034, respectively).

CONCLUSIONS

Both the arthroscopic Latarjet and arthroscopic Bristow procedures led to good clinical scores with no new dislocation episodes. The Bristow group showed significantly less graft healing than the Latarjet group. However, the arthroscopic Bristow procedure took less operative time and showed a lower rate of early moderate to severe glenohumeral OA, better range of motion, and a higher rate of RTS.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Bankart repair with remplissage vs. Latarjet procedure on recurrence, postoperative pain scores, external rotation, and Rowe score in patients with a Hill-Sachs lesion. A systematic review

Background

Currently, recurrent anterior shoulder instability in patients with a Hill-Sachs lesion managed using the Bankart repair showed higher recurrent instability compared with the Latarjet technique. Addition of posterior capsulodesis with infraspinatus remplissage to the Bankart repair, known as Bankart with remplissage (BR), increases shoulder stability in patients with a Hill-Sachs lesion. BR can potentially match the low recurrence rates of the Latarjet procedure while being less invasive. This systematic review compares the Bankart repair with remplissage and Latarjet procedure on postoperative pain, external rotation range of motion, and recurrent instability in anterior shoulder instability patients with a Hill-Sachs lesion.

Methods

A systematic search of the PubMed, Web of Science, and Cochrane Library databases was performed. Studies comparing BR and Latarjet on recurrent instability and/or visual analogue scale (VAS) pain score in anterior shoulder instability patients with a Hill-Sachs lesion were included. Expert opinion, conference presentations, editorials, abstracts, case reports, and nonclinical studies were excluded. Records were initially screened by title and abstract, during the second screening full text was consulted. Study quality was examined using the Methodological Index for Nonrandomized Studies criteria. Risk ratios were calculated for recurrent instability, and standardized mean difference (Cohen's d) were calculated for VAS pain, external rotation, and Rowe score.

Results

Eight of the 146 studies were included in the analysis. The study population consisted of a total of 845 patients, of whom 450 patients underwent the Latarjet procedure and 395 patients underwent BR. Three studies included revision surgery patients; more revision surgery patients were allocated to the Latarjet group. Risk ratios for recurrent instability varied from 0.45 to 2.41. Effect size varied for VAS pain from -2.28 to 0.04, for external rotation from -1.44 to 1.12, and for Rowe score from -0.67 to 1.37. Limitations of the included studies were differences in baseline demographics and functional outcomes.

Conclusion

Recurrent instability seems equal between BR and Latarjet in patients with a Hill-Sachs lesion depth <10 mm. Latarjet showed superior external rotation than BR. Future research should examine patient demographics optimal for minimizing recurrent instability using BR.

Previously failed Bankart repair and the duration from first dislocation to surgery were the risk factors associated with the level of return to sports after coracoid transfer

PURPOSE

This study aims to determine the rate of different levels of return to sports (RTS) in athletes undergoing the modified arthroscopic Bristow procedure and the factors associated with the level of RTS.

METHODS

The study was performed retrospectively on patients with traumatic anterior shoulder instability who underwent the modified arthroscopic Bristow procedure with a minimum follow-up of 2 years. The RTS rate, the level of return and the timing of return were assessed. Additionally, factors such as preoperative basic information, clinical outcomes, graft position, graft healing and graft absorption were analysed to investigate their correlation with the level of RTS. Multivariate regression models were used to evaluate the factors affecting the level of RTS.

RESULTS

In total, this study included 182 shoulders of 177 athletes undergoing the modified arthroscopic Bristow procedure. Of these patients, 142 (78.0%) shoulders of 137 athletes were enrolled, with a mean of 3.3-year follow-up. At the final follow-up, 134 (94.4%) shoulders were able to RTS, 123 (86.6%) shoulders were able to RTS to the pre-injury level, 52 (36.6%) shoulders could be completely "forgotten" without any psychological barrier during exercise. The multivariate logistic regression analysis identified the variable associated with RTS at the pre-injury level as previously failed arthroscopic Bankart repair (p < 0.001). As for the "forgetting" operated shoulder, the duration from first dislocation to surgery was a significant independent predictor (p = 0.034).

CONCLUSION

Although a large majority of athletes were able to RTS at the pre-injury level after the modified arthroscopic Bristow procedure, about two-thirds of the athletes felt difference in shoulders on both sides and could not completely "forget" the operated shoulder during exercise. Previously failed Bankart repair and the duration from first dislocation to surgery were the risk factors associated with the level of RTS after the modified arthroscopic Bristow procedure.

LEVEL OF EVIDENCE

IV.

Epidemiology of shoulder instability procedures: A comprehensive analysis of complications and costs

Background

Recurrent shoulder instability is a debilitating condition that can lead to chronic pain, decreased function, and inability to return to activities or sport. This retrospective epidemiology study was performed to report 90-day postoperative complications and costs of Latarjet, anterior bone block reconstruction, arthroscopic, and open Bankart repair for shoulder instability.

Methods

Patients 18 years and older who underwent four primary shoulder surgeries from 2010 to 2019 were identified using national claims data. Patient demographics, comorbidities, and 90-day postoperative complications were analyzed using univariate analysis and multivariable logistic regression. Total and itemized 90-day reimbursements were determined for each procedure.

Results

The 90-day medical and surgery-specific complication rates were highest for anterior bone block reconstruction, followed by Latarjet. Arthroscopic Bankart repair had the highest 90-day costs and primary procedure costs compared to other procedures.

Conclusion

Anterior bone block reconstruction and Latarjet procedures were associated with the highest rates of 90-day medical and surgery-specific complications, while arthroscopic Bankart repair was associated with the highest costs.

Editorial Commentary: Glenoid Reconstruction With Autologous Tricortical Iliac Crest Represents an Alternative to Bankart Repair and Remplissage for Anterior Shoulder Instability With Subcritical Bone Loss

Traumatic anterior shoulder dislocations are estimated to occur in approximately 2% of the population, frequently with concomitant anterior-inferior labral tears and associated Hill-Sachs lesions of the humeral head. So-called bipolar (or engaging) lesions with attritional bone loss may be exacerbated by recurrent instability, in terms of both prevalence and severity. The glenoid track concept and distance to dislocation have offered context for evaluating bipolar lesions, and increasingly, options for bone block reconstruction are considered for definitive treatment. Recently, concerns have been raised regarding coracoid transfer or Latarjet treatment, particularly with screw constructs in which catastrophic failure, hardware breakage, and secondary arthritis may develop. The Eden-Hybinette procedure, or tricortical iliac crest autograft bone augmentation, may represent a promising alternative to existing options while also restoring native glenoid bone stock. Additionally, suture button fixation may obviate the traditional pitfalls of prior bone block procedures while also achieving reproducible functional outcomes and low rates of recurrence. However, this must be considered alongside other contemporary arthroscopic treatments, such as combined arthroscopic Bankart repair and remplissage.

Open Latarjet with Metal-Free Cerclage Fixation

Despite multiple modifications, the Latarjet is still the most popular procedure for recurrent anterior shoulder instability with glenoid bone loss. Partial or subtotal resorption of the graft is common, potentially leading to hardware prominence and risk of anterior soft-tissue impingement. To minimize the technical difficulties and morbidity associated with metallic implants, a coracoid and conjoint tendon transfer with a mini-open approach using Cerclage tape suture is described, as an alternative for the Latarjet procedure typically performed with metal screws and plates.

Latarjet procedure without capsular repair produces favorable clinical results and avoids limitation in external rotation

PURPOSE

This study aimed at analyzing the range of motion (ROM) and other clinical outcomes in patients with > 20% glenoid bone loss who underwent the Latarjet procedure with or without anterior capsule repair.

METHODS

This retrospective study included 47 patients with > 20% glenoid bone loss who underwent the classic Latarjet procedure from 2016 to 2021. Of these, 25 did not undergo capsular repair (no-capsular-repair group; group I) whereas 22 patients did (capsular-repair group; group II). The Rowe score, American Shoulder and Elbow Surgeons score, Visual Analogue Scale, ROM, recurrence, and complications were evaluated before and 3, 6, and 12 months after the surgery. A goniometer was used to measure the forward flexion and external rotation (arm adducted, 90° abducted) of both shoulders. The ROM deficit was measured as the difference from the contralateral healthy shoulder.

RESULTS

The external rotation in arm adduction at 3 and 6 months after surgery showed significantly better results in group I than group II(p = 0.002 at 3 months; p = 0.005 at 6 months). The deficit in external rotation with arm adduction was also significantly lower in group I at 3 months (p = 0.001) and 6 months (p = 0.001) after surgery. However, external rotation with arm adduction at 12 months after surgery did not significantly differ between the groups. Moreover, the ROM in external rotation with 90° arm abduction was significantly better in group I than that in group II at 3, 6, and 12 months postoperatively (p = 0.002, p = 0.001, and p = 0.005, respectively). The deficit in external rotation with 90° arm abduction gradually decreased with time after surgery and differed significantly between the groups. However, the difference in deficit between the two groups at 12 months after surgery did not exceed the measurement error. All clinical scores significantly improved after surgery compared to before surgery; however, the improvement did not significantly differ between the two groups.

CONCLUSION

The Latarjet procedure without capsular repair showed good laxity restoration and clinical results with less early postoperative external rotation limitation than that achieved by the same procedure with capsular repair. However, external rotation deficit at 1 year after surgery did not show a clinically relevant difference difference between the two groups.

LEVEL OF EVIDENCE

Level III.

The Glenoid Track Paradigm Does Not Reliably Affect Military Surgeons’ Approach to Managing Shoulder Instability

Purpose

To report the frequencies of surgical stabilization procedures performed by military shoulder surgeons and to use decision tree analysis to describe how bipolar bone loss affects surgeons' decision to perform arthroscopic versus open stabilization procedures.

Methods

The Military Orthopaedics Tracking Injuries and Outcomes Network (MOTION) database was queried for anterior shoulder stabilization procedures from 2016 to 2021. A nonparametric decision tree analysis was used to generate a framework for classifying surgeon decision making based on specified injury characteristics (labral tear location, glenoid bone loss [GBL], Hill-Sachs lesion [HSL] size, and on-track vs off-track HSL).

Results

A total of 525 procedures were included in the final analysis, with a mean patient age of 25.9 ± 7.2 years and a mean GBL percentage of 3.6% ± 6.8%. HSLs were described based on size as absent (n = 354), mild (n = 129), moderate (n = 40), and severe (n = 2) and as on-track versus off-track in 223 cases, with 17% (n = 38) characterized as off-track. Arthroscopic labral repair (n = 428, 82%) was the most common procedure, whereas open repair (n = 10, 1.9%) and glenoid augmentation (n = 44, 8.4%) were performed infrequently. Decision tree analysis identified a GBL threshold of 17% or greater that resulted in an 89% probability of glenoid augmentation. Shoulders with GBL less than 17% combined with a mild or absent HSL had a 95% probability of an isolated arthroscopic labral repair, whereas a moderate or severe HSL resulted in a 79% probability of arthroscopic repair with remplissage. The presence of an off-track HSL did not contribute to the decision-making process as defined by the algorithm and data available.

Conclusions

Among military shoulder surgeons, GBL of 17% or greater is predictive of a glenoid augmentation procedure whereas HSL size is predictive of remplissage for GBL less than 17%. However, the on-track/off-track paradigm does not appear to affect military surgeons' decision making.

Level of Evidence

Level III, retrospective cohort study.

A 2-Year Follow-up May Not be Enough to Accurately Evaluate Recurrences After Arthroscopic Bankart Repair: A Long-term Assessment of 272 Patients With a Mean Follow-up of 10.5 Years

BACKGROUND

There is a great discrepancy between the rates of recurrent instability reported after arthroscopic Bankart repair in relation to the follow-up time.

PURPOSE

To analyze the rate of recurrences after arthroscopic Bankart repair in the long term, emphasizing whether a minimum follow-up of 2 years is adequate to assess this outcome.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between January 2008 and April 2013, a total of 356 athletes underwent arthroscopic Bankart repair for anterior glenohumeral instability at our institution. Return to sports, the Rowe score, the Subjective Shoulder Value (SSV), and the Athletic Shoulder Outcome Scoring System (ASOSS) were used to assess functional outcomes. We analyzed the proportion of recurrences before and after 4 years of follow-up. Additionally, we performed a Kaplan-Meier analysis to evaluate recurrence-free time in patients with a recurrence.

RESULTS

The mean follow-up was 10.5 ± 1.6 years, and the mean age was 20.8 ± 3.9 years. In total, 90% of patients were able to return to sports; of these, 91% returned to their preinjury level of play. The Rowe, SSV, and ASOSS scores showed a statistical improvement after surgery (P < .01). The proportion of patients with a recurrence during the follow-up period was 25% (95% CI, 20%-31%; n = 70), and the mean time until a recurrence was 3.8 ± 2.6 years. Only 39% of the recurrences (95% CI, 30%-48%) occurred in the first 2 years after surgery, while 61% (95% CI, 50%-73%) occurred in the first 4 years after surgery.

CONCLUSION

In our study, the effectiveness of Bankart repair to stabilize the shoulder decreased significantly over time. Indeed, less than half of the recurrences occurred after 2 years of follow-up. Therefore, we propose that the recommended minimum follow-up should be 4 years; otherwise, it is very likely that the actual rate of recurrences will be significantly underestimated.

Arthroscopic Dynamic Anterior Stabilization Using Either Long Head of the Biceps or Conjoined Tendon Transfer for Anterior Shoulder Instability Results in a Similarly Low Recurrence Rate

PURPOSE

To compare the clinical outcomes of arthroscopic dynamic anterior stabilization (DAS) between transferring the long head of the biceps (DAS-LHB) and the conjoined tendon (DAS-CT) for anterior shoulder instability with <15% glenoid bone loss.

METHODS

From January 2016 to May 2019, a total of 63 patients who underwent DAS for recurrent anterior shoulder dislocation with <15% glenoid bone loss were included, comprising 33 patients in DAS-LHB group and 30 patients in DAS-CT group. Clinical outcomes were assessed preoperatively and at a minimum 3-year follow-up, including patient-reported outcomes, range of motion, and return to sports (RTS). Postoperative recurrent instability (including dislocation, subluxation, and subjective instability with a positive apprehension test), revisions and complications also were recorded.

RESULTS

No significant demographic characteristics difference was detected between the DAS-LHB (26.3 ± 7.9 years) and DAS-CT groups (26.0 ± 6.7 years). At the latest follow-up, there were no significant differences between the 2 groups in functional scores: Oxford Shoulder Instability Score (14.8 ± 2.8 vs 15.2 ± 3.6), Rowe score (95.9 ± 6.5 vs 93.2 ± 10.2), visual analog scale for pain (0.8 ± 1.2 vs 0.7 ± 1.7), and American Shoulder and Elbow Surgeons (95 ± 8.8 vs 95.2 ± 9.1) (all P > .218). No significant difference was detected between groups in the rates of RTS (90.1% vs 86.7%, P = .700) and RTS at previous level (78.7% vs 73.3%, P = .258), respectively. No recurrent dislocation occurred in either group. One patient felt occasional subluxation in the DAS-LHB group, and one was positive for the apprehension test in each group. One patient presented with postoperative shoulder stiffness and underwent a secondary arthroscopic debridement in the DAS-CT group.

CONCLUSIONS

Comparable rates of recurrence, complication, return to sports, and subjective shoulder function were observed between DAS-LHB and DAS-CT groups.

LEVEL OF EVIDENCE

Ⅲ; retrospective comparative therapeutic trial.

[Chronic posttraumatic shoulder instability]

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

Arthroscopic Bankart Repair With Remplissage as an Alternative to Latarjet for Anterior Glenohumeral Instability With More Than 15% Glenoid Bone Loss

BACKGROUND

Surgical management of anterior shoulder instability continues to evolve. The clinical effectiveness of arthroscopic Bankart repair with remplissage (REMP) in patients with increasing glenoid bone loss (GBL) has not been thoroughly compared with Latarjet.

PURPOSE/HYPOTHESIS

The purpose of this study was to compare 2-year outcomes of REMP versus open Latarjet in patients with >15% GBL. We hypothesized that there would be no difference.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A multicenter, retrospective study was performed on a consecutive series of patients who underwent primary REMP or Latarjet by 4 shoulder specialists between August 2013 and December 2019 for >15% GBL. Procedure performance was based on shared decision making between the surgeon and patient. Baseline and 2-year postoperative range of motion (ROM) and the following patient-reported outcomes (PROs) were collected: Western Ontario Shoulder Instability Index, Single Assessment Numeric Evaluation, and visual analog scale for pain. Return to sport, satisfaction, complications, recurrence, and revisions were reviewed.

RESULTS

A total of 47 patients were available for study, including 22 who underwent REMP and 25 who underwent Latarjet. Baseline demographic characteristics, ROM, and PROs were similar between the groups. Mean preoperative GBL (REMP 25.8% ± 7.8% vs Latarjet 25.1% ± 9.0%; P = .800) and off-track lesions (REMP 59.1% vs Latarjet 44.0%; P = .302) were similar. Postoperative change in external rotation favored Latarjet (10° ± 22° vs -4° ± 13°; P = .017). Postoperative PROs, return to the sports (86.4% vs 87.5%; P = .99), and satisfaction (95.5% vs 95.8%; P = .99) were similar between groups. There were no recurrent dislocations in either group. One infected hematoma was encountered in the Latarjet cohort.

CONCLUSION

At short-term follow-up, the hypothesis was upheld. REMP and Latarjet provided similar outcomes for patients with >15% GBL, although REMP patients experienced slightly decreased external rotation. Although larger series and longer-term follow-ups are required, remplissage may be considered in patients with >15% glenoid bone loss.

Arthroscopic Remplissage for the Treatment of Anterior Shoulder Instability: Current and Evolving Concepts

➢

A Hill-Sachs lesion (HSL) is a compression fracture on the posterolateral humeral head that can increase the risk of recurrent shoulder instability after isolated arthroscopic Bankart repair.

➢

Remplissage involves capsulotenodesis of the infraspinatus tendon and posterior capsule into the HSL to prevent its engagement with the glenoid rim through extra-articular conversion and restraint against humeral head anterior translation.

➢

The glenoid track concept can be applied preoperatively and intraoperatively to evaluate risk of recurrence and help direct clinical management options for recurrent shoulder instability.

➢

Recent literature supports expanding indications for remplissage to include patients with on-track HSLs who are at increased risk of recurrence including collision athletes, military personal, and patients with joint hyperlaxity.

➢

New techniques and suture constructs have demonstrated improved biomechanical strength while avoiding the need to access the subacromial space.

Arthroscopic Autologous Scapular Spine Bone Graft for Recurrent Anterior Shoulder Dislocation With Subcritical (10%-15%) Glenoid Bone Loss

For anterior shoulder instability with subcritical glenoid bone loss (10%-15%), there is no consensus on the optimal treatment. Now, we describe the technique of using autogenous scapular spine bone graft for recurrent anterior shoulder dislocation. This procedure can effectively increase the anterior bone barrier and strengthen the effect of Bankart repair. In addition, this procedure not only avoids coracoid or iliac crest transfer, but also adopts nonrigid fixation, which makes it safer and more convenient. We believe that this technique will provide a promising alternative to the surgical treatment of recurrent anterior shoulder dislocation in subcritical glenoid bone loss (10%-15%).

Arthroscopic Remplissage Using Knotless, All-Suture Anchors

Glenohumeral bone loss is a significant risk factor for recurrent instability after shoulder dislocation. The Hill-Sachs lesion is an osseous defect of the posterior humeral head that is commonly recognized after anterior shoulder dislocation. Several procedures exist to address humeral-sided bone loss, including soft tissue filling procedures, osteoarticular allografts, bone plugs, rotation osteotomies, and humeral head replacements. However, among the most common of these procedures is the arthroscopic remplissage. This technique involves capsulotenodesis of the posterior shoulder capsule and infraspinatus tendon into a Hill-Sachs lesion. Previously described techniques use knotted suture anchors. In this report, we describe a modified technique for remplissage using knotless, all-suture anchors to perform capsulotenodesis of a Hill-Sachs lesion. Benefits of this technique include a single skin incision, improved bone preservation, and easier facilitation of revision surgery if required.

Evaluation and Management of the Contact Athlete's Shoulder

Shoulder injuries are common in contact athletes and vary in severity because of the required complex interplay of shoulder stability and range of motion for proper function. Pathology varies based on sport but most commonly includes shoulder instability, acromioclavicular injuries, traumatic rotator cuff tears, and brachial plexus injuries. Acute management ranges from reduction of shoulder dislocations to physical examination to determine the severity of injury. Appropriate radiographs should be obtained to evaluate for alignment and fracture, with magnetic resonance imaging commonly being necessary for accurate diagnosis and management. Treatments range from surgical stabilization in shoulder instability to repeat examinations and physical therapy. Return-to-play decision making can be complex with avoidance of reinjury and player safety being of utmost concern. Appropriate evaluation and treatment are vital because repeat injury can lead to long-term effects due to the relatively high effectsometimes seen in contact sports.

Clinical and Radiographic Outcomes After Arthroscopic Inlay Bristow Surgery With Screw Versus Suture Button Fixation: A Comparative Study of 117 Patients With 3.3-Year Follow-up

Background:

Some studies have advocated the use of suture button fixation during Bristow-Latarjet surgery to reduce complications associated with screw fixation. However, data comparing these fixation methods are relatively incomplete.

Purpose:

To investigate the efficacy of modified arthroscopic Bristow-Latarjet surgery and compare the clinical and radiographic outcomes using screw versus suture button fixation.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We evaluated 136 patients with traumatic anterior shoulder instability who underwent the modified arthroscopic Bristow-Latarjet surgery between June 2015 and February 2018. Of these patients, 117 who met the inclusion criteria were enrolled at a mean follow-up of 3.3 ± 0.7 years. Shoulders were separated into 2 groups based on fixation technique: screw fixation (group A; n = 63) or suture button fixation (group B; n = 54). Computed tomography imaging findings and clinical results were assessed preoperatively; immediately after operation; and postoperatively at 3 months, 6 months, 1 year, and final follow-up.

Results:

There were no significant differences between the groups in terms of postoperative clinical scores, the level of return to sports, range of motion, graft position, or reoperation rates. Bone healing was observed in 97.4% of the cases overall (114/117), with 98.4% bone union in group A and 96.3% in group B at final follow-up. Bone absorption was more common in group A (n = 30; 47.6%) compared with group B (n = 10; 18.5%) (P = .003). There were no hardware-related complications in group B, compared with 7.9% of patients in group A (P = .034). One patient in group B had a recurrent dislocation due to an unexpected event, and there were no recurrent dislocations in group A.

Conclusion:

After the modified arthroscopic Bristow-Latarjet procedure, both suture button and screw fixation methods demonstrated high bony healing rates and low risk of recurrence. Less coracoid graft resorption and no hardware-related complications were seen with suture button fixation.

Managing Bone Loss in Shoulder Instability-Techniques and Outcomes: a Scoping Review

PURPOSE OF REVIEW

The aim of this scoping review is to provide an overview of the literature published over the past 5 years related to the management of bone loss in anterior shoulder instability.

RECENT FINDINGS

During recent years, there has been a focus on patients at high risk for failure following soft tissue anterior stabilization (Bankart repair). A growing body of evidence suggests that anterior capsulolabral repair is insufficient in the setting of subcritical glenoid bone loss with an off-track Hill Sachs lesion. In such cases, the addition of a remplissage procedure to a Bankart repair or a bone-block augmentation to the glenoid (Latarjet, for example) is often advocated to decrease the risk of recurrent instability. Recent studies have also evaluated the role of alternative bone-block procedures in comparison to the Latarjet, outcomes with arthroscopic and open techniques as well as various fixation methods and radiological outcomes (bone graft resorption, glenohumeral osteoarthritis). Advances in our understanding of subcritical glenoid bone loss and the glenoid track concept have significantly impacted clinical decision making and treatment selection. The development of arthroscopic techniques has allowed for minimally invasive and safe arthroscopic bone-block procedures as an alternative to open procedures. Further research related to free bone-block procedures will inform long-term outcomes between these procedures and the gold standard Latarjet. Additionally, high-quality evidence is lacking to identify the ideal treatment for patients with glenoid subcritical glenoid bone defect. Variability in outcome reporting suggests the need to standardize outcome measures for future instability trials.

Arthroscopic Autologous Scapular Spine Bone Graft Combined With Bankart Repair for Anterior Shoulder Instability With Subcritical (10%-15%) Glenoid Bone Loss

PURPOSE

The purpose of our study is to prove that the autologous scapular spine bone graft is an alternative for the treatment of anterior shoulder instability and the clinical and radiological results are promising.

METHOD

From July 2016 to August 2018, patients who were diagnosed as having anterior shoulder instability with subcritical (10%-15%) glenoid bone loss were treated by arthroscopic repair with autologous scapular spine bone graft. The inclusion criteria were (1) anterior shoulder instability underwent arthroscopic autologous scapular spine bone graft; (2) glenoid bone loss was within 10% to 15% (measured by Sugaya's method); (3) three complete sets of computed tomography (CT) scans (preoperative, 1 week after surgery, and 1 year after surgery) available; and (4) clinical follow-up time was at least 2 years. The exclusion criteria were (1) concomitant rotator cuff tear; (2) concomitant remplissage or SLAP repair; (3) previous surgery of the affected shoulder; (4) open surgery; and (5) incomplete radiological or clinical follow-up. The preoperative and postoperative Constant-Murley score, dietary approaches to stop hypertension (DASH) score, visual analog scale (VAS) score, and range of motion (ROM) were recorded. CT scans with 3-dimensional reconstruction were obtained at the first week after operation and at 1 year after operation; the graft resorption rate was consequently calculated.

RESULTS

Twenty-seven patients were qualified and enrolled in the study. No severe complication was recorded during follow-up. No redislocation or subluxation was found, and the apprehension tests were all negative. At the last follow-up, the mean Constant-Murley score was 89.74 ± 3.71, the mean DASH score was 9.77 ± 5.31, the mean VAS score was 0.74 ± 0.64, which are all improved significantly compared with preoperative scores (P = .00,.00,.00, respectively). At the last follow-up, the ROM including anterior flexion, external rotation by side, and the internal rotation were well restored without significant difference compared with the contralateral shoulder (P =.48, .08, .47, respectively). At 1 year after operation, the resorption rate of the bone graft was 19.4%.

CONCLUSION

This study found that anterior shoulder instability with subcritical (10%-15%) glenoid bone loss treated with arthroscopic autologous scapular spine bone graft with suture anchor fixation is safe and could achieve satisfactory result at short-term follow-up.

LEVEL OF EVIDENCE

Therapeutic case series.

A lower Instability Severity Index score threshold may better predict recurrent anterior shoulder instability after arthroscopic Bankart repair: a systematic review

Importance

The Instability Severity Index (ISI) score was developed to evaluate a patient’s risk of recurrent shoulder instability following arthroscopic Bankart repair. While patients with an ISI score of >6 were originally recommended to undergo an open procedure (ie, Latarjet) to minimise the risk of recurrence, recent literature has called into question the utility of the ISI score.

Objective

The purpose of this systematic review was to evaluate the efficacy of the ISI score as a tool to predict postoperative recurrence among patients undergoing arthroscopic Bankart procedures.

Evidence review

Articles were included if study participants underwent arthroscopic Bankart repair for anterior shoulder instability and reported postoperative recurrence by ISI score at a minimum of 2 years of follow-up. Methodological study quality was assessed using the Methodological Index for Non-Randomized Studies criteria. Pearson’s χ2 test was used to compare recurrence rates among patients above and below an ISI score of 4. Sensitivity, specificity, mean ISI scores and predictive value of individual factors of the ISI score were qualitatively reviewed.

Findings

Four studies concluded the ISI score was effective in predicting postoperative recurrence following arthroscopic Bankart repair; however, these studies found threshold values lower than the previously proposed score of >6 may be more predictive of recurrent instability. A pooled analysis of these studies found patients with an ISI score <4 to experience significantly lower recurrence rates when compared with patients with a score ≥4 (6.3% vs 26.0%, p<0.0001). The mean ISI score among patients who experienced recurrent instability was also significantly higher than those who did not.

Conclusions and relevance

The ISI score as constructed by Balg and Boileau may have clinical utility to help predict recurrent anterior shoulder instability following arthroscopic Bankart repair. However, this review found the threshold values published in their seminal article to be insufficient predictors of recurrent instability. Instead, a lower score threshold may provide as a better predictor of failure. The paucity of level I and II investigations limits the strength of these conclusions, suggesting a need for further large, prospective studies evaluating the predictive ability of the ISI score.

Level of evidence

IV.

Editorial Commentary: Augmented Bankart Could Be the Right Option for Subcritical Bone Loss

The suitable treatment for recurrent anterior shoulder instability with subcritical glenoid bone loss remains controversial. Although the Latarjet procedure is one of the most successful surgery for shoulder instability, it has been associated with potential complications in my patients with limited bone loss and poor soft-tissue conditions, which motivated me to further investigate Bankart augmentation techniques. A myriad of them have been devised and proposed for this specific group of patients; however, there are no sufficient clinical data reported in the literature to support one of them particularly or clarify in which situation they should be used. Further comparative and prospective studies are therefore needed to build an evidence-based decision tree to help us treating our patients and better match their expectations. That said, current literature and my experience have resulted in a shift in my treatment paradigm undertaken 3 years ago to augmented Bankart in case of subcritical glenoid bone loss.