Multiple Instability Events at Initial Presentation Are the Major Predictor of Failure of Nonoperative Treatment for Anterior Shoulder Instability

Comparing Recurrence Rates and the Cost-Effectiveness of Arthroscopic Labral Repair and Nonoperative Management for Primary Anterior Shoulder Dislocations in Young Patients: A Decision-Analytic Markov Model-Based Analysis

BACKGROUND

Value-based decision-making regarding nonoperative management versus early surgical stabilization for first-time anterior shoulder instability (ASI) events remains understudied.

PURPOSE

To perform (1) a systematic review of the current literature and (2) a Markov model-based cost-effectiveness analysis comparing an initial trial of nonoperative management to arthroscopic Bankart repair (ABR) for first-time ASI.

STUDY DESIGN

Economic and decision analysis; Level of evidence, 3.

METHODS

A Markov chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1000 simulated patients (mean age, 20 years; range, 12-26 years) with first-time ASI undergoing nonoperative management versus ABR. Utility values, recurrence rates, and transition probabilities were derived from the published literature. Costs were determined based on the typical patient undergoing each treatment strategy at the authors' institution. Outcome measures included costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER).

RESULTS

The Markov model with Monte Carlo microsimulation demonstrated mean (± standard deviation) 10-year costs for nonoperative management and ABR of $38,649 ± $10,521 and $43,052 ± $9352, respectively. Total QALYs acquired over the 10-year time horizon were 7.67 ± 0.43 and 8.44 ± 0.46 for nonoperative management and ABR, respectively. The ICER comparing ABR with nonoperative management was found to be just $5725/QALY, which falls substantially below the $50,000 willingness-to-pay (WTP) threshold. The mean numbers of recurrences were 2.55 ± 0.31 and 1.17 ± 0.18 for patients initially assigned to the nonoperative and ABR treatment groups, respectively. Of 1000 samples run over 1000 trials, ABR was the optimal strategy in 98.7% of cases, with nonoperative management the optimal strategy in 1.3% of cases.

CONCLUSION

ABR reduces the risk for recurrent dislocations and is more cost-effective despite higher upfront costs when compared with nonoperative management for first-time ASI in the young patient. While all these factors are important to consider in surgical decision-making, ultimate treatment decisions should be made on an individual basis and occur through a shared decision-making process.

Predicting recurrence of instability after a primary traumatic anterior shoulder dislocation

Aims

The risk factors for recurrent instability (RI) following a primary traumatic anterior shoulder dislocation (PTASD) remain unclear. In this study, we aimed to determine the rate of RI in a large cohort of patients managed nonoperatively after PTASD and to develop a clinical prediction model.

Methods

A total of 1,293 patients with PTASD managed nonoperatively were identified from a trauma database (mean age 23.3 years (15 to 35); 14.3% female). We assessed the prevalence of RI, and used multivariate regression modelling to evaluate which demographic- and injury-related factors were independently predictive for its occurrence.

Results

The overall rate of RI at a mean follow-up of 34.4 months (SD 47.0) was 62.8% (n = 812), with 81.0% (n = 658) experiencing their first recurrence within two years of PTASD. The median time for recurrence was 9.8 months (IQR 3.9 to 19.4). Independent predictors increasing risk of RI included male sex (p < 0.001), younger age at PTASD (p < 0.001), participation in contact sport (p < 0.001), and the presence of a bony Bankart (BB) lesion (p = 0.028). Greater tuberosity fracture (GTF) was protective (p < 0.001). However, the discriminative ability of the resulting predictive model for two-year risk of RI was poor (area under the curve (AUC) 0.672). A subset analysis excluding identifiable radiological predictors of BB and GTF worsened the predictive ability (AUC 0.646).

Conclusion

This study clarifies the prevalence and risk factors for RI following PTASD in a large, unselected patient cohort. Although these data permitted the development of a predictive tool for RI, its discriminative ability was poor. Predicting RI remains challenging, and as-yet-undetermined risk factors may be important in determining the risk.

Outcomes of Shoulder Instability Surgery in Competitive Wrestlers: Outcomes, Reoperations, and Return to Play at 5 Years' Mean Follow-up

BACKGROUND

Wrestling is a physically demanding sport with young athletes prone to traumatic shoulder instability and a paucity of data evaluating the results of shoulder instability surgery (SIS).

PURPOSE

To assess reoperation rates, patient-reported outcomes, and return to wrestling (RTW) after SIS in a cohort of competitive wrestlers.

STUDY DESIGN

Case series; Level of evidence, 3.

METHODS

All competitive wrestlers with a history of shoulder instability and subsequent surgery at a single institution between 1996 and 2020 were identified. All directions of shoulder instability (anterior shoulder instability [ASI], posterior shoulder instability [PSI], and traumatic multidirectional shoulder instability [TMDI]) were analyzed. Exclusions included revision SIS and <2 years of follow-up. Athletes were contacted for determination of complications, RTW, and Western Ontario Shoulder Instability Index scores.

RESULTS

Ultimately, 104 wrestlers were included with a mean age at initial instability of 16.9 years (range, 12.0-22.7 years), mean age at surgery of 18.9 years (range, 14.0-29.0 years), and a mean follow-up of 5.2 years (range, 2.0-22.0 years). A total of 58 (55.8%) wrestlers were evaluated after a single shoulder instability event, while 46 (44.2%) sustained multiple events before evaluation. ASI was the most common direction (n = 79; 76.0%), followed by PSI (n = 14; 13.5%) and TMDI (n = 11; 10.6%). Surgical treatment was most commonly an arthroscopic soft tissue stabilization (n = 88; 84.6%), with open soft tissue repair (n = 13; 12.5%) and open bony augmentation (n = 3; 2.9%) performed less frequently. RTW occurred in 57.3% of wrestlers at a mean of 9.8 months. Recurrent instability was the most common complication, occurring in 18 (17.3%) wrestlers. Revision SIS was performed in 15 (14.4%) wrestlers. Across the entire cohort, survivorship rates free from recurrent instability and revision surgery were 90.4% and 92.5% at 2 years, 71.9% and 70.7% at 5 years, and 71.9% and 66.5% at 10 years, respectively. Preoperative recurrent instability was an independent risk factor for postoperative recurrent instability (hazard ratio, 3.8; 95% CI, 1.33-11.03; P = .012).

CONCLUSION

Competitive wrestlers with multiple dislocations before initial clinical evaluation were 3.8 times more likely to experience postoperative recurrent instability. Patients should be counseled that despite SIS, only 57.3% returned to wrestling after surgery.

Rehabilitation following shoulder arthroscopic stabilisation surgery: A survey of UK practice

Background

Optimal rehabilitation following arthroscopic shoulder stabilisation for traumatic anterior instability is unknown. The purpose of this study was to establish current UK practice for this patient group.

Methods

A self-administered online questionnaire was developed and distributed to UK surgeons and physiotherapists.

Results

138 responses were received. Routine immobilisation was reported in 79.7% of responses with a cross-body sling being the preferred position (63.4%). Duration of immobilisation and timescales to initiate movement were highly variable. Return to light work was advised when patients felt able (25.4%) or after 6 weeks (26.1%). 58.7% recommended waiting for 12 weeks to return to manual work. 56% recommended non-contact sport could be resumed after 12 weeks. For contact sport, recommendations varied from 6 weeks (3.8%) to 6 months (5.8%). Psychological readiness was the most frequently cited criteria for return to play (58.6%). Factors such as hyperlaxity (40.6%), age (32.6%) and kinesiophobia (28.3%) were not considered as relevant as reported quality of surgical fixation (50%).

Conclusion

There is no clear consensus regarding optimal post-operative rehabilitation following arthroscopic shoulder stabilisation. Further work is required to establish high value, personalised pathways for this patient group.

Isolated Primary Latarjet Procedures for Anterior Shoulder Instability Results in High Rates of Graft Resorption and Glenohumeral Degenerative Changes With Low Rates of Failure at a Minimum 2-Year Follow-Up: A Systematic Review

PURPOSE

To evaluate the incidence of postoperative complications after an isolated primary Latarjet procedure for anterior shoulder instability at a minimum 2-year follow-up.

METHODS

A systematic review was performed in accordance with 2020 PRISMA guidelines. EMBASE, Scopus, and PubMed databases were queried from database inception through September 2022. The literature search was limited to human clinical studies reporting on postoperative complications and adverse events after a primary Latarjet procedure with a minimum 2-year follow-up. Risk of bias was measured using the Newcastle-Ottawa Scale.

RESULTS

Twenty-two studies, consisting of 1,797 patients (n = 1,816 shoulders), with a mean age of 24 years were identified. The overall postoperative complication rate ranged from 0% to 25.7%, with the most common complication being persistent shoulder pain (range: 0%-25.7%). Radiological changes included graft resorption (range: 7.5%-100%) and glenohumeral degenerative changes (range: 0%-52.5%). Recurrent instability following surgery was documented in 0% to 35% of shoulders, while the incidence of bone block fractures ranged from 0% to 6% of cases. Postoperative nonunion, infection, and hematomas had a reported incidence rate ranging from 0% to 16.7%, 0% to 2.6%, and 0% to 4.4%, respectively. Overall, 0% to 7.5% of surgeries were reported failures, and 0% to 11.1% of shoulders required reoperation, with a revision rate ranging from 0% to 7.7%.

CONCLUSIONS

The incidence of complications following the primary Latarjet procedure for shoulder instability was variable, ranging from 0% to 25.7%. High rates of graft resorption, degenerative changes, and nonunion were present while failure and revision rates remained low at a minimum 2-year follow-up.

LEVEL OF EVIDENCE

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

Anteroinferior Glenoid Rim Fractures Are a Relatively Common Finding in Shoulder Instability Patients Aged 50 Years or Older but May Not Portend a Worse Prognosis

Purpose

To investigate the incidence of anteroinferior glenoid rim fractures (AGRFs) after anterior shoulder instability (ASI) in patients aged 50 years or older, identify risk factors for surgical intervention for AGRFs, compare initial treatment strategies, and compare clinical outcomes of patients with and without associated AGRFs.

Methods

An established geographic medical record system was used to identify patients aged 50 years or older with ASI between 1994 and 2016. Patients with radiographic evidence of AGRFs were identified and matched 1:1 to patients without AGRFs. Outcome measures included recurrent instability, recurrent pain events, conversion to arthroplasty, and osteoarthritis graded with the Samilson-Prieto classification for post-instability arthritis.

Results

Overall, 177 patients were identified, with a mean follow-up period of 10.8 years. Of these patients, 41 (23.2%) had AGRFs and were matched to 41 control patients without AGRFs. The average age was 58.6 and 58.2 years for the AGRF and control groups, respectively. Rates of surgical intervention (27% vs 49%), recurrent instability (12% vs 20%), progression of osteoarthritis (34% vs 39%), and conversion to arthroplasty (2% vs 5%) were similar between AGRF patients and controls. For patients with AGRFs, increased bone fragment size (odds ratio, 1.1) and increased body mass index (odds ratio, 1.2) correlated with an increased risk of surgery. The cutoff value for an increased risk of surgery in patients with AGRFs was a fragment size 33% of the glenoid width or greater.

Conclusions

Of patients aged 50 years or older at presentation of ASI, 23.2% presented with an associated AGRF. A fragment size 33% of the glenoid width or greater and a higher patient body mass index were significant factors for surgical intervention; however, most patients did not require surgery and still showed acceptable clinical outcomes, and the most common reason for surgical intervention was a rotator cuff tear. Overall, the presence of an AGRF did not portend a worse prognosis as treatment strategies and long-term outcomes including recurrent instability, progression of osteoarthritis, and conversion to arthroplasty were similar to those in patients without AGRFs.

Level of Evidence

Level III, retrospective comparative study.

Nonoperative management of anterior shoulder instability can result in high rates of recurrent instability and pain at long-term follow-up

BACKGROUND

Data on the long-term outcomes of nonoperative treatment of anterior shoulder instability are lacking, particularly for the US population. The purpose was to (1) describe the characteristics of patients with anterior shoulder instability treated nonoperatively, (2) assess the long-term outcomes of nonoperative management in a US population, and (3) identify risk factors for poor outcomes following nonoperative management.

METHODS

A geographic cohort of >500,000 subjects was used to identify patients treated nonoperatively for anterior shoulder instability. Only patients aged <40 years at the time of initial instability with minimum 10-year follow-up were included. Medical records were reviewed to obtain demographic characteristics, physical examination findings, clinical history data, imaging results, treatment details, and clinical and/or radiographic progression. Recurrent pain, recurrent instability, and the development of symptomatic osteoarthritis (OA) were the primary outcomes evaluated.

RESULTS

The study included 254 patients (73% male) with a median age of 19 years (range, 16-26 years) at the time of initial instability. At median 17-year follow-up, 37.5% experienced recurrent instability, 58.4% had recurrent pain, and 12.2% had symptomatic OA development. Factors associated with recurrent pain at final follow-up were multiple instability events prior to presentation (hazard ratio [HR], 2.43; P < .01) and increased pain at the initial visit (HRs of 0.79 for mild, 1.74 for moderate, and 1.39 for severe; P < .01); patients with multiple instability events prior to presentation also had an increased risk of recurrence (P < .01). Factors increasing the risk of the development of symptomatic OA included increased pain at the initial visit (P = .05), seizure disorder (HR, 27.01; P < .01), and smoking (HR, 5.15; P < .01).

CONCLUSIONS

At long-term follow-up of 17 years, a high rate of poor outcomes was observed following nonoperative management of anterior shoulder instability. Overall, 37.5% of patients experienced recurrent shoulder instability, 58.4% had recurrent shoulder pain, and 12.2% had symptomatic OA development. Risk factors associated with adverse clinical outcomes included increased pain at the initial visit, recurrent instability prior to presentation, seizure disorder, and smoking.

Editorial Commentary: Management of First-Time Anterior Shoulder Instability Requires Risk Stratification and Surgery for Many, But Not All

The management of a patient with a first-time anterior shoulder dislocation has been the subject of longstanding debate among shoulder surgeons. A number of prognostic factors for recurrent instability have been proposed, including younger age, male sex, contact sports, and glenoid bone loss. Predictive tools and scores have been developed to assist in risk stratifying this patient population; however, no universally agreed upon, clinically validated algorithm exists. More recently, there has been emerging evidence favoring early surgical stabilization, as it has been shown to result in better overall outcomes compared with patients undergoing surgery following episodes of recurrent instability. With each subsequent dislocation or subluxation event, there is increased glenoid bone loss (and development of inverted-pear glenoid), a greater prevalence of engaging (i.e., off-track) Hill-Sachs lesions, more extensive labral tears, a greater risk of rotator cuff involvement (in the older patient), and increased plastic and/or permanent deformation, elongation, and compromise of the antero-inferior glenohumeral joint capsule and associated inferior glenohumeral ligament complex. Moreover, there is now sufficient evidence to suggest that recurrence comes at a cost, as it is a major risk factor for poor outcomes following arthroscopic stabilization. However, one risk is overtreatment, potentially exposing those individuals who would not have had another instability event due to an unnecessary procedure. We should continue to use the available evidence within the literature to help risk-stratify patients and develop an individualized treatment plan through a shared decision-making process with the patient.